WO2011149337A1

WO2011149337A1 - New combination treatment for type 2 diabetes and other disorders related to insulin resistance

Info

Publication number: WO2011149337A1
Application number: PCT/NL2010/050326
Authority: WO
Inventors: Adriaan Kooy
Original assignee: Bethesda Diabetes Research Centrum B.V.
Priority date: 2010-05-28
Filing date: 2010-05-28
Publication date: 2011-12-01
Also published as: EP2588139A1

Abstract

The invention relates to a new pharmaceutical composition comprising metformin, vitamin B12 (α-(5,6-dimethylbenzimidazolyl) cobamidcyanide or cyanocobalamin) or a vitamin B12 equivalent, vitamin B1 (thiamine) or a vitamin B1 equivalent, and optionally vitamin D (25-OH D₃) or a vitamin D equivalent, further optionally calcium, and further optionally chromium, and the use of such a composition in the treatment of type 2 diabetes, prediabetes, insulin resistance, metabolic syndrome, cancer, high risk patients for cardiovascular disease, NASH, gestational diabetes, Poly Cystic Ovary Syndrome, type 1 diabetes and patients with (a high risk to develop) cancer.

Description

New combination treatment for type 2 diabetes and other disorders related to insulin resistance.

FIELD OF THE INVENTION

The invention relates to the field of pharmacology, more specifically to the field of treatment of diabetes, more particularly type 2 diabetes and other disorders related to insulin resistance.

INTRODUCTION

Type 2 diabetes has been characterized as one of the most important and widespread current diseases and its prevalence will only grow during the 21^st century. In 2005, people with diabetes were estimated to account for 7% of the US population, or approximately 20.8 million people. Of these 20.8 million people, 14.6 million have a diagnosis of diabetes, and diabetes is undiagnosed in another 6.2 million. Approximately 8-10% have type 1 diabetes, and about 90% have type 2. A small rest group consists of rare (hereditary) variants of diabetes. Additionally, an estimated 54 million people in the US have prediabetes. Pre-diabetes, as defined by the American Diabetes Association, is that state in which blood glucose levels are higher than normal but not high enough to be diagnosed as diabetes. The fraction of type 2 diabetics of the total population is impressively growing worldwide, especially in Africa and Asia, at least due to changes in food intake and lifestyle. Diabetes affects over 150 million people worldwide and this number is expected to double by 2025.

Type 2 diabetes mellitus was once called diabetes of old age. Now, because of the epidemic of obesity and inactivity in adolescents and children, type 2 diabetes mellitus is occurring at younger and younger ages. Although type 2 diabetes mellitus typically affects individuals older than 40 years, it has been diagnosed in children as young as 2 years of age who have a family history of diabetes. Type 2 diabetes is characterized by peripheral insulin resistance with a varying, but progressive insulin- secretory defect of the 6-cells, seated in the islets of Langerhans of the pancreatic tail. For type 2 diabetes mellitus to develop, both defects must exist: all overweight individuals have insulin resistance, but only those with an inability to increase insulin secretion develop diabetes. During the course of type 2 diabetes, defects in the system of 'gut hormones' (= incretins), essential regulators of the meal-related insulin release, are involved in the further deterioration of 6-cell function. Metformin, primarily used as an insulin sensitizing drug, also counteracts these detrimental defects of the incretin system affecting β-cell function, by inhibiting DPP-4 and increasing GLP-1 production, which could explain metformin's weight neutral effect (Bailey CJ, Wilcock C, Scarpello JH (2008), Diabetologia 51: 1552-1553; Lindsay JR, Duffy NA, McKillop AM et al. (2005), Diabet Med 22: 654-657; Mannucci E, Tesi F, Bardini G et al. (2004), Diabetes Nutr Metab 17: 336-342; Mannucci E, Ognibene A, Cremasco E et al. (2001), Diabetes Care 24:489-494; Tahrani AA, Piya MK, Kennedy A, Barnett AH (2010), Pharmacology & Therapeutics 125: 328-361).

In the progression from normal glucose tolerance to abnormal glucose tolerance, postprandial glucose levels first increase. Eventually, fasting hyperglycemia develops as insulin-induced inhibition of hepatic gluconeogenesis declines because of hepatic insulin resistance.

Diabetes mellitus type 2 is a chronic, progressive disease that has no established cure, but does have well-established treatments which can delay or prevent entirely the formerly inevitable consequences of the condition. Often, the disease is viewed as progressive since poor management of blood sugar leads to a myriad of steadily worsening complications. However, if blood sugar is properly maintained, then the disease is effectively cured - that is, patients are not anymore exposed to the effects of glucotoxicity leading to neuropathy, blindness, or any other high blood sugar complication. However, other harmful phenomena related to insulin resistance persist, if left untreated: high blood pressure, low levels of protective HDL cholesterol, high levels of triglycerides, toxic change of LDL cholesterol, activated coagulation, and endothelial dysfunction. All these phenomena act in concert accelerating the processes of atherothrombosis and atherosclerosis leading to the so-called macrovascular complications of diabetes: myocardial infarction, stroke, ischemic bowl disease, and peripheral arterial vessel disease potentially leading to amputation. So, type 2 diabetes with insulin resistance is far more than a disorder of glucose metabolism. In fact, it is a vascular disease with major impact on morbidity, quality of life and life expectancy. At present, three out of four patients with type 2 diabetes die of cardiovascular disease. Additionally, insulin resistance itself is related to an increased risk to develop cancer.

Actually, the different treatments of type 2 diabetes and related disorders have two main goals:

1. reduction of advanced mortality and concomitant morbidity (from

assorted diabetic complications);

2. preservation of quality of life .

The first goal can be achieved through close glycemic control (i.e., to near 'normal' blood glucose levels), as well as through broadly oriented cardiovascular risk management - particularly in type 2 diabetes - by treating the disturbances related to insulin resistance mentioned above. The actual suboptimal effectiveness of treatments with reduction in severity of diabetic side effects has been very well demonstrated in several large clinical trials and is established beyond controversy. The second goal is often addressed (in developed countries) by support and care from teams of diabetic health professionals (usually physician, PA, nurse, dietitian or a certified diabetic educator). Endocrinologists, family practitioners, and general internists are the physician specialties most likely to treat people with diabetes.

Knowledgeable patient participation is vital to clinical success, and so patient education is a crucial aspect of this effort. Type 2 diabetes is initially treated by adjustments in diet and exercise, and by weight loss, most especially in obese patients. The amount of weight loss which improves the clinical picture is sometimes modest (2-5 kg or 4.4-11 lb); this is almost certainly due to currently poorly understood aspects of fat tissue activity, for instance chemical signaling (especially in visceral fat tissue in and around abdominal organs). In many cases, such initial efforts can substantially restore insulin sensitivity. In some cases strict diet can adequately control the glycemic levels and improve insulin sensitivity.

Because patients with type 2 diabetes have both insulin resistance and β-cell dysfunction, oral medication to increase insulin sensitivity (e.g., metformin or a thiazolidinedione [TZD]) is often given with an intermediate- acting insulin at bedtime or a long-acting insulin given once daily. An insulin secretagogue, such as a sulfonylurea agent, can also be given to increase preprandial insulin secretion. Metformin, in fact the cornerstone of treatment, can be beneficially continued from the beginning till the end of the diagnosis (Kooy A, De Jager J, Lehert P et al. (2009) Arch Int Med 169: 616-625; Kooy A (2009) BMJ 339: b4227; 1093-1094).

Metformin improves hyperglycemia primarily through its suppression of hepatic glucose production (hepatic gluconeogenesis). The "average" person with type 2 diabetes has three times the normal rate of gluconeogenesis; metformin treatment reduces this by over one third.

Metformin activates AMP-activated protein kinase (AMPK), a liver enzyme that plays an important role in insulin signaling, whole body energy balance, and the metabolism of glucose and fats; activation of AMPK is required for metformin's inhibitory effect on the production of glucose by liver cells.

Research published in 2008 further elucidated metformin's mechanism of action, showing that activation of AMPK is required for an increase in the expression of SHP, which in turn inhibits the expression of the hepatic gluconeogenic genes PEPCK and Glc-6-Pase. Metformin is frequently used in research along with AICAR as an AMPK agonist. Interestingly, through the same mechanism, metformin also blocks mTOR (= 'mammalian Target Of Rapamycin'), the master regulator compound of cellular protein synthesis, being activated in progressive malignancies like breast cancer (Zhou G, Myers R, Li Y et al. (2001) J Clin Invest 108: 1167-1174; Towler MC, Hardie DG. (2007) Circulation Res 100: 328-341). Therefore, the use of metformin may be favorable in different malignancies due to its anti-cancer potency. Recent emerging evidence indicates convincingly such a potency of metformin

(Alimova IN, Liu B, Fan Z et al. (2009) Cell Cycle 8: 909-915; Ben Sahra I, Laurent K, Loubat A et al. (2008) Oncogene 27: 3576-3586; Jiralerspong S, Palla SL, Giordano SH et al. (2009) J Clin Oncol 27: 3297-3302; Li D, Yeung S- CJ, Hassan MM et al. (2009) Gastroenterology 137: 482-488). The mechanism by which the biguanide metformin increases the activity of AMPK remains uncertain; however, research suggests that metformin increases the amount of cytosolic AMP (as opposed to a change in total AMP or total AMP/ATP).

In addition to suppressing hepatic glucose production, metformin increases insulin sensitivity, enhances peripheral glucose uptake, increases fatty acid oxidation, and decreases absorption of glucose from the

gastrointestinal tract. Increased peripheral utilization of glucose may be due to improved insulin binding to insulin receptors. AMPK probably also plays a role, as metformin administration increases AMPK activity in skeletal muscle. AMPK is known to cause GLUT4 translocation, resulting in insulin- independent glucose uptake. Some metabolic actions of metformin do appear to occur by AMPK-independent mechanisms; a 2008 study (Saeedi R, Parsons HL, Wambolt RB, et al. (2008) Am J Physiol Heart Circ Physiol 294 (6):

H2497-506) found that "the metabolic actions of metformin in the heart muscle can occur independent of changes in AMPK activity and may be mediated by p38 MAPK- and PKC-dependent mechanisms."

Metformin is absorbed mainly from the small intestine. It is stable, does not bind to plasma proteins and is excreted unchanged in the urine. It has a half- life of 1.3 to 4.5 hours. The maximum recommended daily dose of metformin is 3 g, taken in three doses with meals.

Combinations of other drugs with metformin are available on the market. Metformin is often prescribed to type 2 diabetes patients in

combination with other drugs, like thiazolidinediones, such as pioglitazone and rosiglitazone. These drugs actively reduces insulin resistance, complementing the action of the metformin. In 2002, metformin + rosiglitazone were combined into a single product, Avandamet®, marketed by GlaxoSmithKline. In the United States, metformin is also available in combination with pioglitazone (trade name Actoplus Met®), the sulfonylureas glipizide (trade name

Metaglip®) and glibenclamide (known as glyburide in the United States, trade name Glucovance®), the dipeptidyl peptidase-4 inhibitors sitagliptin (trade name Janumet®) and vildagliptin (trade name Eucreas®), and the meglitinide repaglinide (PrandiMet®). Generic formulations of metformin/glipizide and metformin/glibenclamide are available. A generic formulation of

metformin/rosiglitazone from Teva has received tentative approval from the FDA, and is expected to reach the US market in early 2012. However, the thiazolidinediones - rosiglitazone in particular - have been recently criticized, because of unexpected (cardiovascular) side effects.

Metformin interferes with vitamin B12 absorption (an effect that is likely to be exaggerated in the elderly) and reduces serum vitamin B12 (B12) levels. This is a factor in the elevated levels of homocystein (Hey) which develop during treatment with metformin: the metabolism of Hey depends on the vitamins B6, B12 and folate. More importantly, low plasma levels of B12 develop over time during the treatment with metformin, and will induce signs of B12-related neuropathy, potentially being misdiagnosed as diabetic neuropathy (Wulffele MG, Kooy A, Lehert P et al. (2003) J Int Med 254: 455-463; De Jager J, Kooy A, Lehert P et al. (2010) BMJ: in press). To prevent this side effect, a combination therapy of metformin and vitamin B12 has been proposed (see Braza, M. et al., 69th Scientific Sessions of the American Diabetes Association June 5 - 9, 2009, New Orleans, Louisiana, U.S.A., Abstract 569-P).

However, metformin therapy still can be improved by combinations with other drugs or beneficial compounds to alleviate the symptoms of type 2 diabetes and/or to accommodate for any side-effects of metformin therapy.

SUMMARY OF THE INVENTION

The inventors from the Bethesda Diabetes Research Center, Hoogeveen, The Netherlands, now have found a therapeutic regimen that is especially beneficial for patients with type 2 diabetes. :

Accordingly, the invention comprises a new pharmaceutical composition comprising metformin, vitamin B12 (a-(5,6- dimethylbenzimidazolyl) cobamidcyanide or cyanocobalamin) or a vitamin B12 equivalent, vitamin Bl (thiamine) or a vitamin Bl equivalent, and optionally vitamin D (25-OH D3) or a vitamin D equivalent, further optionally calcium, and further optionally chromium. Preferably said composition comprises metformin, vitamin B12 (a-(5,6-dimethylbenzimidazolyl) cobamidcyanide or cyanocobalamin) or a vitamin B12 equivalent, vitamin Bl (thiamine) or a vitamin Bl equivalent, vitamin D (25-OH D3) or a vitamin D equivalent, calcium, and chromium. More preferably, in said composition the vitamin B12 equivalent is hydroxycobalamin, methylcobalamin or adenosylcobalamin. Also preferred for the vitamin Bl equivalent is benfotiamine.

More specifically, the pharmaceutical composition consists of the active ingredients metformin, vitamin B12 or a vitamin B12 equivalent, and vitamin Bl or a vitamin Bl equivalent, and pharmaceutically acceptable excipients. Alternatively, the pharmaceutical composition consists of the active ingredients metformin, vitamin B12 or a vitamin B12 equivalent, vitamin Bl or a vitamin Bl equivalent, vitamin D (25-OH D3) and pharmaceutically acceptable excipients. Further, alternatively, the composition consists of the active ingredients metformin, vitamin B12 or a vitamin B12 equivalent, vitamin Bl or a vitamin Bl equivalent, vitamin D (25- OH D3), calcium and pharmaceutically acceptable excipients.

In yet a further alternative embodiment the pharmaceutical composition consists of the active ingredients metformin, vitamin B12 or a vitamin B12 equivalent, vitamin Bl or a vitamin Bl equivalent, vitamin D (25- OH D3), calcium, chromium and pharmaceutically acceptable excipients.

The invention also relates to a kit comprising one or more unity doses of a pharmaceutical composition according to the invention, and one or more unity doses of insulin.

Further part of the invention is a combination of metformin, vitamin

B12 or a vitamin B12 equivalent, and vitamin Bl or a vitamin Bl equivalent, for the simultaneous, separate or sequential use in the treatment of type 2 diabetes, prediabetes, insulin resistance, metabolic syndrome, cancer, high risk patients for cardiovascular disease, NASH, PCO syndrome, gestational diabetes, type 1 diabetes, patients with a high risk to develop cancer,. More specifically in said combination metformin, vitamin B12 or a vitamin B12 equivalent, and vitamin Bl or a vitamin Bl equivalent are present in one single pharmaceutical composition; or, alternatively, in separate

pharmaceutical compositions.

Further part of the invention is the use of the combination of the active ingredients metformin, vitamin B12 or a vitamin B12 equivalent, and vitamin Bl or a vitamin Bl equivalent, for preparing a medicament for treating type 2 diabetes, prediabetes, insulin resistance, metabolic syndrome, cancer, high risk patients for cardiovascular disease, NASH, PCO syndrome, gestational diabetes, type 1 diabetes, patients with a high risk to develop cancer, wherein said treatment comprises simultaneous or sequential administration of said active ingredients. Preferably in such a use, the active ingredients are to be administered orally. More preferably, the treatment further comprises administration of insulin. Alternatively, the insulin is to be administered parenterally, preferably by injection. In yet another embodiment, the invention relates to a method for the treatment of type 2 diabetes, prediabetes, insulin resistance, metabolic syndrome, cancer, high risk patients for cardiovascular disease, NASH, PCO syndrome, gestational diabetes, type 1 diabetes, patients with a high risk to develop cancer, wherein to a patient in need thereof a combination of the active ingredients metformin, vitamin B12 or a vitamin B12 equivalent, and vitamin Bl or a vitamin Bl equivalent, is administered simultaneously, or subsequently in any order. Preferably in such a method further insulin is administered.

DETAILED DESCRIPTION

In this application "unit dosage form" refers to a composition intended for a single administration to treat a subject suffering from a disease or medical condition. Each unit dosage form may comprise one or more active ingredients and typically comprises each of the active ingredients of this invention plus pharmaceutically acceptable excipients. Examples of unit dosage forms are individual tablets, individual capsules, bulk powders, and liquid solutions, emulsions or suspensions. Treatment of the disease or condition may require periodic administration of unit dosage forms, for example one or two unity dosage forms once, twice or more times a day, one or two with each meal, one or two every four hours or other interval, or only one per day.

An "active agent" or "active ingredient" (i.e. metformin, vitamins Bl, B12, and 25-OH D3) is a component of a dosage form that performs a biological function when administered or induces or affects (enhances or inhibits) a physiological process in some manner. "Activity" is the ability to perform the function, or to induce or affect the process. Active agents and ingredients are distinguishable from excipients such as carriers, vehicles, diluents, lubricants, binders, fillers, and other formulating aids, and encapsulating or otherwise protective components.

A "delivery vehicle" is a composition, which comprises one or more active ingredients, and is designed to release the active agent in a particular fashion, either by dispersing the active ingredient(s) in the digestive system, or by releasing the active ingredient(s) in a slow sustained fashion. The term encompasses porous microspheres, microcapsules, cross-linked porous beads, and liposomes that contain one or more active ingredients sequestered with internal cavities or porous spaces. The term also includes osmotic delivery systems, coated tablets or capsules that include non-porous microspheres, microcapsules, and liposomes, and active ingredients dispersed within polymeric matrices. A dosage form can include one or more delivery vehicles.

"Controlled" or "sustained" release are equivalent terms that describe the type of active agent delivery that occurs when the active agent is released from a delivery vehicle at an ascertainable and manipulatable rate over a period of time, which is generally on the order of minutes, hours or days, typically ranging from about thirty minutes to about 3 days, rather than being dispersed immediately upon entry into the digestive tract or upon contact with gastric fluid. Factors influencing the rate of delivery in controlled release include the particle size, composition, porosity, charge structure, and degree of hydration of the delivery vehicle and the active ingredient(s), the acidity of the environment (either internal or external to the delivery vehicle), and the solubility of the active agent in the physiological environment, i.e. the particular location along the digestive tract.

In the present invention, the term "additive effect" means that, in a test, an effect of two or more active ingredients administered in combination (the difference between the value of a combination treatment group and that of a control group) does not exceed the sum of effects shown in the respective test results of single active ingredients (the difference between the value of a single drug treatment group and that of a control group).

In the present invention, the term "synergistic effect" means that, in a test, an effect of two or more active ingredients administered in combination (the difference between the value of a combination treatment group and that of a control group) exceeds the sum of effects shown in the respective test results of single drugs (the difference between the value of a single drug treatment group and that of a control group). This case is referred to as a synergistic effect even though no statistically significant difference is observed.

Preferably, however, a synergistic effect is shown with a statistically

significant difference. A synergistic effect with a statistically significant difference can be shown e.g. by two-way analysis of variance.

The inventors have shown - in 390 patients with type 2 diabetes enrolled in a placebo controlled randomized trial with a follow up period of 4 years and 4 months - that metformin has crucial benefits even late in the course of type 2 diabetes, during the (longest) phase of the disease in which insulin therapy is inevitable (Wulffele MG, Kooy A, Lehert P et al. (2002), Neth J Med 60: 249-252; Wulffele MG, Kooy A, Lehert P et al. (2002), Diabetes Care 25: 2133-2140; De Jager J, Kooy A, Lehert P et al. (2005), J Int Med 257: 100- 109; Kooy A, De Jager J, Lehert P et al. (2009), Arch Int Med 169: 616-625; Kooy A (2009), BMJ 339: b4227; 1093-1094; De Jager J, Kooy A, Lehert P et al. (2010), submitted for publication). Addition of metformin versus placebo to intensive insulin therapy resulted into sustained beneficial effects: an improved glycemic control (HbAlc decreased by 0,4%point without an increase of hypoglycemia), with 30% less insulin, 4 kg less weight gain, and 39% less macrovascular end points, with a clear improvement of endothelial functions in the short term, as well as in the long term. The number needed to treat to prevent one macrovascular end point was 16. Moreover, they showed in this trial a significant metformin-induced reduction of plasma B12 levels (De Jager J, Kooy A, Lehert P et al. (2010) BMJ: in press). The addition of B12 - orally given - to metformin therapy prevents the metformin-induced lowering of B12, and the related harmful neuropathy in type 2 diabetes (Kooy A et al. (2010) unpublished results).

Additionally, two vitamins are of special interest in prediabetes and diabetes: vitamin Bl (thiamine or its lipophilic derivative benfotiamine) and vitamin 25-OH D3 (colecalciferol).

Vitamin Bl is an essential cofactor and is required in intracellular glucose metabolism. Lack of thiamine can cause a number of severe disorders. Thiamine acts as a coenzyme for transketolase (TK) and for the pyruvate dehydrogenase and alpha-ketoglutarate dehydrogenase complexes, enzymes which play a fundamental role for intracellular glucose metabolism. In particular, TK is able to shift excess fructose- 6-phosphate and glycerhaldeyde- 3-phosphate from glycolysis into the pentose-phosphate shunt, thus

eliminating these potentially damaging, vasculotoxic metabolites from the cytosol (Beltramo E, Berrone E, Tarallo S, Porta M (2008) Acta Diabetol 45: 131-141). Diabetes might be considered a thiamine- deficient state, at least relative to the increased requirements deriving from accelerated glucose metabolism in non-insulin dependent tissues that, like the vessel wall, are prone to complications. A thiamine/TK activity deficiency has been described in diabetic patients, the correction of which by thiamine and/or benfotiamine, has been demonstrated in vitro to counteract the damaging effects of hyperglycaemia on vascular cells. Little is known, however, on the positive effects of thiamine/benfotiamine administration in diabetic patients, apart from the possible amelioration of neuropathic symptoms. Clinical trials on diabetic patients would be necessary to test this vitamin as an inexpensive approach to the prevention and treatment of diabetic vascular complications.

Vitamin 25 OH D3 favours insulin sensitivity (Teegarden D, Donkin SS (2009) Nutr Res Rev 22: 82-92; Alvarez JA, Ashraf A, et al. (2010) Int J Endocrinol: 2010:351-385), and prevents cardiovascular morbidity (Lee JH, O'Keefe JH, Bell D et al. (2008) J Am Coll Cardiol 52: 1949-1956).

The inventors now have developed a new pharmaceutical composition, also denominated as Compound Metformin Plus (= Metformin + Bl + B12 + D + additives) to deliver metabolic, vascular and oncologic benefits versus metformin and/or placebo in the following groups: (1) patients with metabolic syndrome and prediabetes, (2) patients with type 2 diabetes, (3) patients with type 1 diabetes, (4) patients with an otherwise high

cardiovascular risk, (5) women with gestational diabetes, (6) women with PolyCystic Ovary (= PCO) syndrome and / or subfertility (Leeman L, Acharya U (2009), J Obstet Gynaecol 29: 467-472; Diamanti-Kandarakis E, Christakou CD, Kandaraki E, Economou FN (2010), Eur J Endocrinol 162:193-212; Tang T, Lord JM, Norman RJ, Yasmin E, Balen AH (2010) Cochrane Database Syst Rev 20: CD003053. (7) women with hair loss (Camacho-Martinez FM (2009), Semin Cutan Med Surg 28:19-32. (8) patients with Non-Alcoholic Steatosis

Hepatis (= NASH), an expression of insulin resistance, (9) high-risk patients to develop malignancies, and (10) patients with one or more malignancies.

Metabolic benefits of Compound Metformin Plus are summarized as (1) improvements of insulin sensitivity and its related effects, (2) glycemic control, (3) vitamin Bl status, (4) vitamin B12 status, (5) vitamin D status, (6) decrease of glucotoxicity, (7) prevention of weight gain, (8) improvement of fibrinolysis, (9) improvement of metabolic markers of endothelial function, (10) improvement of metabolic markers of Hey metabolism, and (11) improvement of lipid metabolism.

Vascular benefits of Compound Metformin Plus are summarized as

(1) deceleration - or even regression - of atherosclerosis and atherothrombosis, measured through surrogate endpoints, like intima media thickness (IMT), (2) improvement of vascular and vasomotor function, (3) prevention of

macrovascular endpoints, like myocardial infarction, stroke and peripheral arterial occlusion, (4) prevention of microvascular endpoints, like retinopathy, nephropathy and neuropathy, (5) improvement of quality of life related to the prevention and/or treatment of vascular disease, and (6) improvement of life expectancy related to the prevention and/or treatment of vascular disease.

Oncologic benefits of Compound Metformin Plus are summarized as (1) prevention of the development of malignancies, (2) improvement of responses to registered oncolytical therapies, (3) intrinsic, antitumor effects in malignancies, (4) improvement of quality of life related to the prevention and/or treatment of oncologic disease, and (5) improvement of life expectancy related to prevention and/or treatment of oncologic disease.

The invention relates to a new therapy, effective in type 2 diabetes and related syndromes, such as insulin resistance and metabolic syndrome, wherein the therapy consists of administration of a combination of metformin, a vitamin B12 and a vitamin Bl. A combination treatment with metformin and vitamin B12 is already suggested by the inventors in the literature (Wulffele MG, Kooy A, Lehert P et al. (2003), J Int Med 254: 455-463; De Jager, Kooy A, Lehert P et al. (2010), BMJ: in press) but no reports are yet available of actual treatments with this combination. The combination of metformin and vitamin B12 is mainly important because vitamin B12 can be used to prevent two clusters of common side-effects of metformin treatment, i.e. (1) high levels of homocystein (Hey) caused by vitamin B12 deficiency, and (2) neuropathy due to B12 deficiency. Increased total plasma Hey is an accepted risk factor for premature cardiovascular disease (CVD) and stroke risk in healthy

populations. Experimental studies have shown that high plasma

concentrations of Hey may cause vascular damage and alteration in the coagulation process, where it is estimated that 10% of the risk of coronary artery disease is attributable to an increase in Hey levels (Boushey CJ et al. (1995), J Am Med Assoc 274:1049-1057). Further effects of increased levels of Hey in pregnancy on neural tube defects and other congenital defects, spontaneous miscarriages and intra-uterine growth retardation have been described (de la Calle M et al. (2003), Eur J Obstet Gynecol Reprod Biol

107:125-134). B12 deficiency can also cause neuropathy, which in many cases is misdiagnosed as diabetic neuropathy, and then is destined to remain causally untreated.

Although vitamin Bl (thiamine and its lipophilic derivative benfotiamine) has been mentioned to counter the assumed biguanide-induced lactic acidosis, to the inventor's knowledge there is no suggestion in the prior art to use thiamine in a pharmaceutical combination with metformin and vitamin B12. Nevertheless, thiamine has many effects that could assist in therapy of type 2 diabetes. First of all, thiamine is important in the synthesis of insulin, such that its deficiency reduces insulin secretion. It is believed that by administration of thiamine, glucose deficiency is improved, resulting in a lowering of blood glucose levels. Benfotiamine (a synthetic derivative of thiamine) has been reported to inhibit three major pathways (the hexosamine pathway, the advanced glycation end product (AGE) formation pathway and the diacylglycerol (DAG) -protein kinase C (PKC) pathway) implicated in the pathogenesis of hyperglycemia induced vascular damage (Hammes HP et al. (2003), Nat Med 9: 94-299). The authors of this paper suggest that this property of benfotiamine might be clinically useful in preventing the development and progression of diabetic complications. Further, increased long-term high blood glucose levels can be the cause of microvascular disease, such as nephropathy, retinopathy and neuropathy. In the same report Hammes et al. showed that diabetic retinopathy could be prevented or reversed by benfotiamine. Others showed favourable effects of benfotiamine on peripheral diabetic neuropathy(Winkler G et al. (1999), Arzneimittelforschung 49: 220-224; Simeonov S et al. (1997), Folia Med 39: 5-10; Stracke H et al. (1996), Exp Clin Endocrinol Diabetes 104: 311-316). In some of the above mentioned studies, benfotiamine was co-administered with other vitamins of the B-complex, including vitamin B12. However, although the above (and other) beneficial results of vitamin Bl and/or benfotiamine on the one hand and of metformin, supposedly complemented with vitamin B12, are known already for some time, it has never been proposed to combine the therapeutic properties of these compounds into one therapy for type 2 diabetes. The only attempt to suggest multi- component pharmaceutical compositions including metformin useful in diabetes type 2 therapy comes from Pearson and Richardson (US

2003/0078269). In this document several components, amongst which thiamine and vitamin B12, are suggested for combination with biguanide (metformin) or sulfonylurea treatment of diabetes. However, close reading of this document reveals that no composition comprising metformin and both thiamine and vitamin B12 has been suggested or disclosed.

The components of the proposed pharmaceutical combination(s) (among which the combination indicated as Compound Metformin Plus, see Example 1) synergistically improve the microvascular and macrovascular outcome of diabetes for several reasons. First, considering that a metformin- induced B12 deficiency will have vasculotoxic and neurotoxic effects through different pathways, addition of B12 will synergistically strengthen the metformin-related beneficial effects in preventing diabetic complications. Second, vitamin Bl lowers glucotoxicity through mechanisms - as discussed above - independently of the mechanisms by which metformin exert its protective effects, and synergistically improves the metformin-related beneficial effects in preventing diabetic complications. Third, as unraveled so far, 25-OH vitamin D3 improves insulin sensitivity and lowers cardiovascular risk through mechanisms independently of metformin, and synergistically improves the metformin related beneficial effects in preventing diabetic complications.

The major biologic function of vitamin D is to maintain normal blood levels of calcium and phosphorus. Vitamin D aids in the absorption of calcium, helping to form and maintain strong bones. Recently, research also suggests vitamin D may provide protection from osteoporosis, hypertension (high blood pressure), cancer, and several autoimmune diseases.

In children, vitamin D deficiency causes rickets, which results in skeletal deformities. In adults, vitamin D deficiency can lead to osteomalacia, which results in muscular weakness in addition to weak bones. Populations who may be at a high risk for vitamin D deficiencies include the elderly, obese individuals, exclusively breastfed infants, and those who have limited sun exposure. Also, individuals who have fat malabsorption syndromes (e.g., cystic fibrosis) or inflammatory bowel disease (e.g., Crohn's disease) are at risk.

Colecalciferol (25-OH D3) improves insulin secretion and sensitivity

(Alvarez JA, Ashraf A (2010), Int J Endocrinol 2010: ID 351385) additionally to its well-known functions.

According to the present invention, supplementation of vitamin 25- OH D3 is expected to improve insulin sensitivity and cardiovascular outcome in type 2 diabetes.

The active ingredients of the invention can be combined into one unit dosage form or they can be given separately as two or three unit dosage forms. This also implies that different dosage schemes can be used for the different active ingredients. In such a way a first active ingredient may be administered once a day, a second active ingredient may be administered twice a day, and a third active ingredient may be administered three times a day. Also the times of the day when the unit dosage forms are ingested may differ for the different active ingredients, and further the administration route may differ. However, preferably all three active ingredients are contained within one unit dosage form and thus follow the same dosage schedule and route of administration. In any case, the daily dose of an active ingredient should be a therapeutically effective amount.

The route of administration of the unit dosage forms can be any route of administration selected form orally (including delayed or sustained release unit dosage forms), rectally, intramuscularly, intraperitoneally and intravenously. Preferably, the unit dosage forms are administered orally.

According to the present scientific knowledge, preferably two possible dose schedules are envisaged: (1) 2-3 times daily, orally given during the meals, and (2) once daily Slow Release orally given at bedtime. For slow release, unit dosage forms can be developed e.g. by enteric coating of tablets. It is well within the knowledge of the skilled person to develop pharmaceutical formulations which accommodate the above mentioned - or any other - dose schedules.

The term "therapeutically effective amount" as used herein refers to an amount of a therapeutic, viz. an active ingredient used in the composition according to the present invention, to aid in the therapy of type 2 diabetes and/or to prevent the undesired side-effects of metformin. The precise effective amount for a subject will depend upon the subject's size and health, the nature and extent of the condition, and the therapeutics or combination of

therapeutics selected for administration. Thus, it is not useful to specify an exact effective amount in advance. However, the effective amount for a given situation can be determined by routine experimentation and is within the judgment of the clinician or experimenter. Specifically, the compositions of the present invention can be used to reduce or prevent type 2 diabetes and/or accompanying biological or physical manifestations, such as microvascular diseases. Methods that permit the clinician to establish initial dosages are known in the art. The dosages determined to be administered must be safe and efficacious. However, treatments with the individual active ingredients of the composition of the invention are already known in the art and doses and treatment schedules used in these individual treatments can be maintained with the compositions of the present invention.

For purposes of the present invention, an effective dose of metformin will be about 300 to 3000 mg/day, preferably 1000 to 2000 mg/day, preferably given as a one to three times a day treatment of a unit dose of 500 or 1000 mg. Solo therapy of vitamin B12 has been used for various reasons, one of the most common reasons being supplementation of any (suspected) vitamin B12 deficiency. There are several different galenic forms of vitamin B12.

Injectable vitamin B12 and vitamin B12 nasal spray (CaloMist™, Nascobal^®) are prescription-only medications that have been proven safe and effective. Tablets, sublingual ("under the tongue") tablets, capsules, and liquids are alternative forms that are available as non-prescription dietary supplements. Lastly, a vitamin B12 patch is available, but there is little evidence to suggest that this vitamin can be absorbed through the skin. The dosages for the oral and nasal forms are much higher than for the injectable form, since only a small percentage of the dose for oral or nasal forms actually reaches the bloodstream. For preventing vitamin B12 deficiency caused by metformin treatment, as contemplated in the present invention, an effective dose would be in the range of 100 microgram.

Vitamin B12 derivatives or equivalents are available, such as nitrosyl-cobinamide, hydroxycobalamin, cyanocobalamin, benzimidazole, 2,5- dimethylbenzimidazole, 5,6-dimethylbenzimidazole, a-ribasole, 6-ribasole, adenosylcobalamin, methylcobalamin, the vitamin B12 derivatives disclosed in US 5510479, and heptamethyl cobyrinate perchlorate. Cyanocobalaminis preferred.

Vitamin Bl is a water soluble vitamin that readily enters and exits the body daily so it must be taken internally on a daily basis. Vitamin Bl is a crystalline, yellow-white, water-soluble compound that is heat and alkali reactive when placed in solution. Thiamine is available in nutritional supplements in the form of thiamine hydrochloride and thiamine nitrate.

These are also the forms used for food fortification. Thiamine pyrophosphate or cocarboxylase may also be available in some products. Daily needs for thiamine are based on the amount of calories taken in each day. The recommended dietary intake (RDI) for Vitamin Bl is 1.1 mg per day for adult males and 0.8 mg per day for adult females, although women that are pregnant require an additional 0.2 mg per day and those that are lactating require and additional 0.4 mg. To correct deficiency, larger daily doses are given, sometimes using intramuscular injections. Pre- and postnatal supplements typically deliver a thiamine dose of 3 milligrams daily. There is little danger of thiamine toxicity when it is taken orally.

There are various thiamine derivatives that can be used in the present invention, such as benfotiamine (S-benzoylthiamine-O- monophosphate), fursultiamin (thiamintetrahydrofurfuryl disulfide) or thiaminedisulfide, The derivative benfotiamine, which is preferably used in the present invention, has therapeutic effects given at 50 mg/week for preventing vitamin Bl deficiency, to about 1000 mg/day given with severe neuropathy. More preferably, a dose between 25 and 500 mg daily is used in the present invention, most preferably, a dose of 100-200 mg/day.

The optimal daily dose of colecalciferol to exerts its effects described is in the range of 800 IU (= 20 microgram) to 2000 IU.

The preferred pharmaceutical composition of the present invention (Compound Metformin Plus) comprises 2 additional important minerals: calcium and chromium (1 mg). Calcium is added because of its counteracting effect on the metformin-induced malabsorption of B12 (Bauman WA, Shaw S, Jayatilleke E et al. (2000), Diabetes Care 23: 1227-1231; De Jager, Kooy A, Lehert P et al. (2010), BMJ: in press). Chromium is added, because of its insulin sensitizing effect in the more pronounced insulin resistant patients with type 2 diabetes (Cefalu WT, Rood J, Pinsonat P et al. (2010), Metabolism 59: 755-762).

Calcium preferably is added in a daily dose of 1000 mg, while chromium is preferably added in a daily dose of 1 mg. The amounts that are maintained in a unit dose form according to the invention reflect these daily doses and is dependent on the amount and type of single dose units given to a patient per day. Dosages for achieving the therapeutic effects of the pharmaceutical composition described herein may easily be determined by the skilled person.

Preferably the pharmaceutical composition according to the present invention is a composition comprising the six above mentioned components, as is further illustrated in Example 1.

Although it is possible to include other active ingredients in the composition, which active ingredients would be useful in treating and/or preventing type 2 diabetes and/or adverse effects caused by this disease, such as microvascular disorders, like diabetic neuropathies, in a preferred embodiment of the present invention there are only four active ingredients combined with two minerals in a composition or therapy according to the present invention: metformin, vitamin B12 (or a derivative or equivalent thereof), vitamin Bl (or a derivative or equivalent thereof), vitamin D (or a derivative or equivalent thereof), calcium and chromium. However, the compositions of the present invention may further contain conventional pharmaceutical additives and adjuvants, excipients or diluents, including, but not limited to, water, gelatine of any origin, vegetable gums, ligninsulfonate, talc, sugars, starch, gum arabic, vegetable oils, polyalkylene glycols, flavoring agents, preservatives, stabilizers, emulsifying agents, buffers, lubricants, colorants, wetting agents, fillers, and the like. The carrier material can be organic or inorganic inert carrier material suitable for

oral/parenteral/injectable administration.

The pharmaceutical compositions according to the present invention may be in any galenic form that is suitable for administrating to the animal body including the human body, especially in any form that is conventional for oral administration, e.g. in solid form such as tablets, pills, granules, dragees, capsules, and effervescent formulations such as powders and tablets, or in liquid form such as solutions, emulsions or suspensions as e.g. pastes and oily suspensions. The pastes may be filled into hard or soft shell capsules, whereby the capsules feature e.g. a matrix of (fish, swine, poultry, cow) gelatin, plant proteins or ligninsulfonate. Examples for other application forms are forms for transdermal, parenteral or injectable administration. The pharmaceutical compositions may be in the form of controlled (delayed) release formulations, e.g. being provided with an enteric coating to prevent degradation in the stomach.

In a further embodiment of the present invention, the compositions of the invention are co-administered with insulin. Insulin treatment, of course, is one of the major treatments in type 2 diabetes and, although e.g. metformin can be provided as a single treatment for this disease, often a combination treatment of insulin and metformin is performed. In such a combination treatment, insulin may be administered in a normal fashion, which in most cases will be as injectable. As discovered by the inventors, addition of metformin to insulin therapy reduces the daily need of insulin by about 30% resulting in a sustained lower daily dose of insulin (Wulffele MG, Kooy A, Lehert P et al. (2002), Diabetes Care 25: 2133-2140; Kooy A, De Jager J, Lehert P et al. (2009), Arch Int Med 169: 616-625)

The invention will now be illustrated by one or more examples, which only prevent guidance for the skilled practitioner and which should not be taken to limit the invention in any way.

EXAMPLES

Example 1

In a stable pharmacological form Compound Metformin Plus (tablet

- normal and slow release - or powder) with a composition as described in Table 1 is tested as basal therapy (BT) or as additional therapy (AT) versus metformin / placebo / insulin in the following groups of individuals:

1. patients with metabolic syndrome and prediabetes (BT

versus metformin / placebo), 2. patients with type 2 diabetes (BT versus metformin, and AT to insulin),

3. patients with type 1 diabetes (AT to insulin),

4. patients with an otherwise high cardiovascular risk (BT),

5. women with gestational diabetes (BT versus metformin / insulin, AT to insulin),

6. patients with Non-Alcoholic Steatosis Hepatis (= NASH), an expression of insulin resistance (BT),

7. high-risk patients to develop malignancies (BT), and

8. patients with one or more malignancies (AT to standard oncolytical therapy)

9. high-risk patients to develop malignancies (BT), and

10. patients with one or more malignancies (AT to standard oncolytical therapy).

Composition of the Compound Metformin Plus, developed by the inventors consists of 6 components with the details given in Table 1.

Formulation of the unit dosage form(s) for the experiment is achieved through normal galenic procedures, as will be known to the skilled person.

Table 1. Composition of Compound Metformin Plus

Component Daily Dosage form and dose Number of

Dose per tablet or powder tablets a day

Normal Slow Release Normal Slow Release Release Release

Metformin¹ 1000 mg 500 mg 1000 mg 2 1

2000 mg 1000 mg 2000 mg 2 1

Bl 200 mg 100 mg 200 mg 2 1

B12 100 pg 50 pg 100 pg 2 1

25-OH D3 20 pg (800 IE) 10 pg (400 IE) 20 pg (800 IE) 2 1

Calcium 1000 mg 500 mg 1000 mg 2 1

Chromium 1 mg 0,5 mg 1 mg 2 1

Results: it appears that Compound Metformin Plus shows a synergistic effect on the severity of insulin resistance and the development and/or severity of related disease symptoms.

¹ The daily dose of metformin depends on individual tolerance and need (mg): 500, 1000, 1500 (500- 1000), 2000 (1000-1000); BMI > 35 kg/m²: 2.500 (1000-500-1000), 3000 (1000-1000-1000).

Claims

Pharmaceutical composition comprising metformin, vitamin B12 (a- (5,6-dimethylbenzimidazolyl) cobamidcyanide or

cyanocobalamin) or a vitamin B12 equivalent, vitamin Bl (thiamine) or a vitamin Bl equivalent, and optionally vitamin D (25-OH D3) or a vitamin D equivalent, further optionally calcium, and further optionally chromium.

cyanocobalamin) or a vitamin B12 equivalent, vitamin Bl (thiamine) or a vitamin Bl equivalent, vitamin D (25-OH D3) or a vitamin D equivalent, calcium, and chromium.

Pharmaceutical composition according to claim 1 or 2, wherein the vitamin B12 equivalent is hydroxycobalamin, methylcobalamin or adenosylcobalamin.

Pharmaceutical combination according to any of the previous claims, wherein the vitamin Bl equivalent is benfotiamine.

Pharmaceutical composition according to claim 1, wherein the

composition consists of the active ingredients metformin, vitamin B12 or a vitamin B12 equivalent, and vitamin Bl or a vitamin Bl equivalent, and pharmaceutically acceptable excipients.

Pharmaceutical composition according to claim 1, wherein the composition consists of the active ingredients metformin, vitamin B12 or a vitamin B12 equivalent, vitamin Bl or a vitamin Bl equivalent, vitamin D (25-OH D3) and

pharmaceutically acceptable excipients.

Pharmaceutical composition according to claim 1, wherein the composition consists of the active ingredients metformin, vitamin B12 or a vitamin B12 equivalent, vitamin Bl or a vitamin Bl equivalent, vitamin D (25-OH D3), calcium and pharmaceutically acceptable excipients.

Pharmaceutical composition according to claim 1 or 2, wherein the composition consists of the active ingredients metformin, vitamin B12 or a vitamin B12 equivalent, vitamin Bl or a vitamin Bl equivalent, vitamin D (25-OH D3), calcium, chromium and pharmaceutically acceptable excipients.

Kit comprising one or more unity doses of a pharmaceutical

composition according to any of claims 1 -8, and one or more unity doses of insulin.

The combination of metformin, vitamin B12 or a vitamin B12

equivalent, and vitamin Bl or a vitamin Bl equivalent, for the simultaneous, separate or sequential use in the treatment of type 2 diabetes, prediabetes, insulin resistance, metabolic syndrome, cancer, high risk patients for cardiovascular disease, NASH, PCO syndromegestational diabetes, type 1 diabetes, patients with a high risk to develop cancer,. .

11. The combination of claim 10, wherein metformin, vitamin B12 or a vitamin B12 equivalent, and vitamin Bl or a vitamin Bl equivalent are present in one single pharmaceutical composition.

12. The combination of claim 10, wherein metformin, vitamin B12 or a vitamin B12 equivalent, and vitamin Bl or a vitamin Bl equivalent are present in separate pharmaceutical compositions.

13. Use of the combination of the active ingredients metformin, vitamin

B12 or a vitamin B12 equivalent, and vitamin Bl or a vitamin Bl equivalent, for preparing a medicament for treating type 2 diabetes, prediabetes, insulin resistance, metabolic syndrome, cancer, high risk patients for cardiovascular disease, NASH, PCO syndrome gestational diabetes, type 1 diabetes, patients with a high risk to develop cancer, wherein said treatment comprises simultaneous or sequential administration of said active ingredients.

14. The combination of claim 10 or the use of claim 13, wherein the

active ingredients are to be administered orally.

15. The combination of claim 10 or the use of claim 13, wherein the

treatment further comprises administration of insulin.

16. The combination of claim 10 or the use of claim 15, wherein the

insulin is to be administered parenterally, preferably by injection.

17. Method for the treatment of type 2 diabetes, prediabetes, insulin resistance, metabolic syndrome, cancer, high risk patients for cardiovascular disease, NASH, PCO syndromegestational diabetes, type 1 diabetes, patients with a high risk to develop cancer, wherein to a patient in need thereof a combination of the active ingredients metformin, vitamin B12 or a vitamin B12 equivalent, and vitamin Bl or a vitamin Bl equivalent, is administered simultaneously, or subsequently in any order.

Method according to claim 17, wherein further insulin

administered.