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  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K33/00—Medicinal preparations containing inorganic active ingredients
  • A61K33/24—Heavy metals; Compounds thereof
• • A—HUMAN NECESSITIES
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  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/41—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with two or more ring hetero atoms, at least one of which being nitrogen, e.g. tetrazole
  • A61K31/4164—1,3-Diazoles
  • A61K31/4184—1,3-Diazoles condensed with carbocyclic rings, e.g. benzimidazoles
• • A—HUMAN NECESSITIES
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  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K38/00—Medicinal preparations containing peptides
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  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
  • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
• • A—HUMAN NECESSITIES
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  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/14—Particulate form, e.g. powders, Processes for size reducing of pure drugs or the resulting products, Pure drug nanoparticles
  • A61K9/16—Agglomerates; Granulates; Microbeadlets ; Microspheres; Pellets; Solid products obtained by spray drying, spray freeze drying, spray congealing,(multiple) emulsion solvent evaporation or extraction
• • A—HUMAN NECESSITIES
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  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P13/00—Drugs for disorders of the urinary system
  • A61P13/12—Drugs for disorders of the urinary system of the kidneys
• • A—HUMAN NECESSITIES
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  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P3/00—Drugs for disorders of the metabolism
  • A61P3/12—Drugs for disorders of the metabolism for electrolyte homeostasis
• • A—HUMAN NECESSITIES
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  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P43/00—Drugs for specific purposes, not provided for in groups A61P1/00-A61P41/00
• • 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
  • A61P5/38—Drugs for disorders of the endocrine system of the suprarenal hormones
  • A61P5/40—Mineralocorticosteroids, e.g. aldosterone; Drugs increasing or potentiating the activity of mineralocorticosteroids
• • 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
  • A61P7/12—Antidiuretics, e.g. drugs for diabetes insipidus
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P9/00—Drugs for disorders of the cardiovascular system
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P9/00—Drugs for disorders of the cardiovascular system
  • A61P9/04—Inotropic agents, i.e. stimulants of cardiac contraction; Drugs for heart failure
• • C—CHEMISTRY; METALLURGY
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  • C01B—NON-METALLIC ELEMENTS; COMPOUNDS THEREOF; METALLOIDS OR COMPOUNDS THEREOF NOT COVERED BY SUBCLASS C01C
  • C01B39/00—Compounds having molecular sieve and base-exchange properties, e.g. crystalline zeolites; Their preparation; After-treatment, e.g. ion-exchange or dealumination
• • Y—GENERAL TAGGING OF NEW TECHNOLOGICAL DEVELOPMENTS; GENERAL TAGGING OF CROSS-SECTIONAL TECHNOLOGIES SPANNING OVER SEVERAL SECTIONS OF THE IPC; TECHNICAL SUBJECTS COVERED BY FORMER USPC CROSS-REFERENCE ART COLLECTIONS [XRACs] AND DIGESTS
  • Y02—TECHNOLOGIES OR APPLICATIONS FOR MITIGATION OR ADAPTATION AGAINST CLIMATE CHANGE
  • Y02A—TECHNOLOGIES FOR ADAPTATION TO CLIMATE CHANGE
  • Y02A50/00—TECHNOLOGIES FOR ADAPTATION TO CLIMATE CHANGE in human health protection, e.g. against extreme weather
  • Y02A50/30—Against vector-borne diseases, e.g. mosquito-borne, fly-borne, tick-borne or waterborne diseases whose impact is exacerbated by climate change

Definitions

• the present invention relates to combination therapy and co-therapy methods for the treatment of diseases and/or disorders associated with excess cation levels using microporous zirconium silicate and diuretic compounds.
• the present invention can be used in the treatment of various disorders associated with excess potassium, including but not limited to hyperkalemia.
• the present invention can also be used in the treatment of chronic kidney and chronic heart disease.
• the invention provides a safe way to lower potassium levels in patients prone to or at risk to develop high potassium levels due to the use of therapies that include diuretics.
• the invention mitigates the negative systemic effects of such therapies without incurring the risk of hyperkalemia.
• the invention also relates to treatment of other conditions including hyperphosphatemia that can occur either alone or in connection with hyperkalemia, chronic kidney disease, and/or chronic heart disease.
• Acute hyperkalemia is a serious life threatening condition resulting from elevated serum potassium levels.
• Potassium is a ubiquitous ion, involved in numerous processes in the human body. It is the most abundant intracellular cation and is critically important for numerous physiological processes, including maintenance of cellular membrane potential, homeostasis of cell volume, and transmission of action potentials. Its main dietary sources are vegetables (tomatoes and potatoes), fruit (oranges, bananas) and meat.
• the normal potassium levels in plasma are between 3.5-5.0 mmol/L with the kidney being the main regulator of potassium levels.
• the renal elimination of potassium is passive (through the glomeruli) with active reabsorption in the proximal tubule and the ascending limb of the loop of Henle. There is active excretion of potassium in the distal tubules and the collecting duct, both of these processes are controlled by aldosterone.
• Hyperkalemia may develop when there is excessive production of serum potassium (oral intake, tissue breakdown). Ineffective elimination, which is the most common cause of hyperkalemia, can be hormonal (as in aldosterone deficiency), pharmacologic (treatment with ACE-inhibitors or angiotensin-receptor blockers) or, more commonly, due to reduced kidney function or advanced cardiac failure. The most common cause of hyperkalemia is renal insufficiency, and there is a close correlation between degree of kidney failure and serum potassium (“S-K”) levels. In addition, a number of different commonly used drugs cause hyperkalemia, such as ACE-inhibitors, angiotensin receptor blockers, potassium-sparing diuretics (e.g.
• beta-receptor blocking agents digoxin or succinylcholine are other well-known causes of hyperkalemia.
• advanced degrees of congestive heart disease, massive injuries, burns or intravascular hemolysis cause hyperkalemia, as can metabolic acidosis, most often as part of diabetic ketoacidosis.
• Symptoms of hyperkalemia are somewhat non-specific and generally include malaise, palpitations and muscle weakness or signs of cardiac arrhythmias, such as palpitations, brady- tachycardia or dizziness/fainting. Often, however, the hyperkalemia is detected during routine screening blood tests for a medical disorder or after severe complications have developed, such as cardiac arrhythmias or sudden death. Diagnosis is obviously established by S- K measurements.
• Treatment depends on the S-K levels. In milder cases (S-K between 5-6.5 mmol/1), acute treatment with a potassium binding resin (Kayexalate®), combined with dietary advice (low potassium diet) and possibly modification of drug treatment (if treated with drugs causing hyperkalemia) is the standard of care; if S-K is above 6.5 mmol/1 or if arrhythmias are present, emergency lowering of potassium and close monitoring in a hospital setting is mandated.
• the following treatments are typically used: • Kayexalate , a resin that binds potassium in the intestine and hence increases fecal excretion, thereby reducing S-K levels.
• Kayexalate ® has been shown to cause intestinal obstruction and potential rupture. Further, diarrhea needs to be simultaneously induced with treatment. These factors have reduced the palatability of treatment with Kayexalate ® .
• Insulin IV (+ glucose to prevent hypoglycemia), which shifts potassium into the cells and away from the blood.
• Calcium supplementation Calcium does not lower S-K, but it decreases myocardial excitability and hence stabilizes the myocardium, reducing the risk for cardiac arrhythmias.
• Bicarbonate The bicarbonate ion will stimulate an exchange of K+ for Na+, thus leading to stimulation of the sodium-potassium ATPase.
• ZS or titanium silicate microporous ion exchangers to remove toxic cations and anions from blood or dialysate is described in U.S. Patent Nos. 6,579,460, 6,099,737, and 6,332,985, each of which is incorporated herein in their entirety. Additional examples of microporous ion exchangers are found in U.S. Patent Nos. 6,814,871, 5,891,417, and 5,888,472, each of which is incorporated herein in their entirety.
• the inventors have found that known ZS compositions may exhibit undesirable effects when utilized in vivo for the removal of potassium in the treatment of hyperkalemia.
• ZS molecular sieve compositions have been associated with an incidence of mixed leukocyte inflammation, minimal acute urinary bladder inflammation and the observation of unidentified crystals in the renal pelvis and urine in animal studies, as well as an increase in urine pH. Further, known ZS compositions have had issues with crystalline impurities and undesirably low cation exchange capacity.
• the inventors disclosed novel ZS molecular sieves to address the problem associated with existing hyperkalemia treatments, and novel methods of treatment for hyperkalemia utilizing these novel compositions. See U.S. Patent Application No. 13/371,080 (U.S. Pat. Application Pub. No. 2012-0213847 Al).
• the present inventors have disclosed novel processes for producing ZS absorbers with an improved particles-size distribution that can be prepared with methods avoid and/or reduce the need to screen ZS crystals. See U.S. Provisional Application No. 61/658,117.
• novel divalent cation e.g., calcium and/or magnesium
• the calcium loaded forms of ZS disclosed in the '415 provisional may include magnesium in addition or as a substitute for calcium.
• CVD is well known to be common and often fatal in people with CKD.
• plasma aldosterone levels are associated with increased cardiovascular morality. Accordingly, reduction of aldosterone levels without side effects associated with aldo blockers would be desirably in the treatment of patients diagnosed with CKD and/or CVD.
• microporous zirconium silicate is associated with an improved GFR and when co administered with therapies that include diuretics desirably reduced the risk of developing hyperkalemia.
• the present invention involves administration of a suitable dose of microporous zirconium silicate to a patient who has been diagnosed with chronic kidney disease.
• the present invention involves administration of a suitable dose of microporous zirconium silicate to a patient who has been diagnosed with cardiovascular disease or after a myocardial infarction.
• the patient is diagnosed with both CKD and CVD.
• the dosage of the composition may range from approximately 1-20 grams of ZS, preferably 8-15 grams, more preferably 10 grams. In another embodiment, the composition is administered at a total dosage range of approximately 1-60 gram, preferably 24-45 grams, more preferably 30 grams.
• the composition comprises a microporous structure composed of Zr0 3 octahedral units and at least one Si0 2 tetrahedral units and Ge0 2 tetrahedral units. These structures have the empirical formula:
• ApMxZr 1 -xSinGeyOm where A is an exchangeable cation selected from potassium ion, sodium ion, rubidium ion, cesium ion, calcium ion, magnesium ion, hydronium ion or mixtures thereof, M is at least one framework metal selected from the group consisting of hafnium (4+), tin (4+), niobium (5+), titanium (4+), cerium (4+), germanium (4+), praseodymium (4+), and terbium (4+), "p” has a value from about 1 to about 20, “x” has a value from 0 to less than 1, "n” has a value from about 0 to about 12, “y” has a value from 0 to about 12, “m” has a value from about 3 to about 36 and 1 ⁇ n + y ⁇ 12.
• the germanium can substitute for the silicon, zirconium or combinations thereof. Since the compositions are essentially insoluble in bodily fluids (at neutral or basic
• the compositions preferably have an elevated cation exchange capacity, particularly potassium exchange capacity.
• the elevated cation exchange capacity is achieved by a specialized process and reactor configuration that lifts and more thoroughly suspends crystals throughout the reaction as described in U.S. Patent Application No. 13/371,080 (U.S. Pat. Application Pub. No. 2012-0213847 Al).
• the improved ZS- 9 crystal compositions i.e., compositions where the predominant crystalline form is ZS-9) had a potassium exchange capacity of greater than 2.5 meq/g, more preferably between 2.7 and 3.7 meq/g, more preferably between 3.05 and 3.35 meq/g.
• ZS-9 crystals with a potassium exchange capacity of 3.1 meq/g have been manufactured on a commercial scale and have achieved desirable clinical outcomes. It is expected that ZS-9 crystals with a potassium exchange capacity of 3.2 meq/g will also achieve desirable clinical outcomes and offer improved dosing forms.
• the targets of 3.1 and 3.2 meq/g may be achieved with a tolerance of ⁇ 15%, more preferably ⁇ 10%, and most preferably ⁇ 5%. Higher capacity forms of ZS-9 are desirable although are more difficult to produce on a commercial scale.
• Such higher capacity forms of ZS-9 have elevated exchange capacities of greater than 3.5 meq/g, more preferably greater than 4.0 meq/g, more preferably between 4.3 and 4.8 meq/g, even more preferably between 4.4 and 4.7 meq/g, and most preferably approximately 4.5 meq/g.
• ZS-9 crystals having a potassium exchange capacity in the range of between 3.7 and 3.9 meq/g were produced in accordance with Example 14 below.
• the composition exhibits median particle size of greater than
• 3 microns and less than 7% of the particles in the composition have a diameter less than 3 microns.
• less than 5% of the particles in the composition have a diameter less than 3 microns, more preferably less than 4% of the particles in the composition have a diameter less than 3 microns, more preferably less than 3% of the particles in the composition have a diameter of less than 3 microns, more preferably less than 2% of the particles in the composition have a diameter of less than 3 microns, more preferably less than 1% of the particles in the composition have a diameter of less than 3 microns, more preferably less than 0.5% of the particles in the composition have a diameter of less than 3 microns.
• none of the particles or only trace amounts has a diameter of less than 3 microns.
• the median and average particle size is preferably greater than 3 microns and particles reaching a sizes on the order of 1,000 microns are possible for certain applications.
• the median particle size ranges from 5 to 1000 microns, more preferably 10 to 600 microns, more preferably from 15 to 200 microns, and most preferably from 20 to 100 microns.
• the composition exhibiting the median particle size and fraction of particles in the composition having a diameter less than 3 micron described above also exhibits a sodium content of below 12% by weight.
• the sodium contents is below 9% by weight, more preferably the sodium content is below 6% by weight, more preferably the sodium content is below 3% by weight, more preferably the sodium content is in a range of between 0.05 to 3% by weight, and most preferably 0.01% or less by weight or as low as possible.
• the invention involves administering to a CKD and/or a CVD patient an individual pharmaceutical dosage comprising the composition in capsule, tablet, or powdered form.
• the pharmaceutical product is packaged in a kit in individual unit dosages sufficient to maintain a lowered serum potassium level.
• the dosage may range from approximately 1-60 grams per day or any whole number or integer interval therein.
• Such dosages can be individual capsules, tablets, or packaged powdered form of 1.25-20 grams of the ZS, preferably 2.5-15 grams of ZS, more preferably 5-10 grams of ZS.
• the ZS may be a single unit dose of approximately 1.25-45 gram capsule, tablet or powdered package.
• the product may be consumed once a day, three times daily, every other day, or weekly.
• the invention involves administering to a CKD and/or CVD patient a combination comprising a therapy that includes diuretic and a zirconium silicate.
• the zirconium silicate can be a ZS-9 as described herein.
• the diuretic can be a loop diuretic, a thiazine diuretic and/or a potassium sparing diuretic.
• a method of treating a CKD and/or CVD comprises administering therapies that include diuretics and a zirconium silicate of the present invention.
• the treatment of CKD and/or CVD using diuretics and zirconium silicate may further comprise angiotensin converting enzyme inhibitors (ACE) or angiotensin receptor blockers (ARB).
• ACE angiotensin converting enzyme inhibitors
• ARB angiotensin receptor blockers
• Fig. 1 is a polyhedral drawing showing the structure of microporous ZS
• Fig. 2 shows particle size distribution of ZS-9 lot 5332-04310-A in accordance with Example 8.
• FIG. 3 shows particle size distribution of ZS-9 lot 5332-15410-A in accordance with Example 8.
• Fig. 4 shows particle size distribution of ZS-9 preclinical lot in accordance with
• FIG. 5 shows particle size distribution of lot 5332-04310A w/o screening in accordance with Example 9.
• Fig. 6 shows particle size distribution of lot 5332-04310A 635 mesh in accordance with Example 9.
• Fig. 7 shows particle size distribution of lot 5332-04310A 450 mesh in accordance with Example 9.
• Fig. 8 shows particle size distribution of lot 5332-04310A 325 mesh in accordance with Example 9.
• Fig. 9 shows particle size distribution of lot 5332-04310A 230 mesh in accordance with Example 9.
• Fig. 10 XRD plot for ZS-9 prepared in accordance with Example 12.
• FIG. 11 FTIR plot for ZS-9 prepared in accordance with Example 12.
• Fig. 12 XRD plot for ZS-9 prepared in accordance with Example 14.
• Fig. 13 FTIR plot for ZS-9 prepared in accordance with Example 14.
• Fig. 14 Example of the Blank Solution Chromatogram
• Fig. 15 Example of the Assay Standard Solution Chromatogram.
• Fig. 16 Exemplary Sample Chromatogram.
• Fig. 17 Reaction vessel with standard agitator arrangement.
• Fig. 18 Reaction vessel with baffles for production of enhanced ZS-9
• Fig. 19 Detail of baffle design for 200-L reaction vessel for production of enhanced ZS-9
• Fig. 20 Treatment Period of ZS-9 in comparison to placebo over 48 hours after ingestion.
• Fig. 21 Comparison of time of serum K decrease.
• Fig. 22 Comparison of serum K increase following treatment.
• Fig. 23 Rate of K excretion in urine.
• Fig. 24 Daily urinary sodium excretion.
• Fig. 25 XRD plot for H-ZS-9 prepared according to Example 20 batch 5602- 26812
• Fig. 26 XRD plot for H-ZS-9 prepared according to Example 20 batch 5602- 28312
• Fig. 27 XRD plot for H-ZS-9 prepared according to Example 20 batch 5602- 29112
• Fig. 28 XRD plot for H-ZS-9 prepared according to Example 20 batch 5602- 29812
• Fig. 29 XRD data for ZS crystals produced accoridng to Example 20.
• Fig. 30 XRD data showing ZS-8 impurities. DETAILED DESCRIPTION OF THE EMBODIMENTS OF THE INVENTION
• ZS has a microporous framework structure composed of Zr0 2 octahedral units and Si0 2 tetrahedral units.
• Figure 1 is a polyhedral drawing showing the structure of microporous ZS Na2.19ZrSi3.01O9.11 . ⁇ 2.71H20 (MW 420.71)
• the dark polygons depict the octahedral zirconium oxide units while the light polygons depict the tetrahedral silicon dioxide units. Cations are not depicted in Fig. 1.
• the microporous exchanger of the invention has a large capacity and strong affinity, i.e., selectivity, for potassium or ammonium.
• Eleven types of ZS are available, ZS-1 through ZS-11, each having various affinities to ions have been developed. See e.g., U.S. Patent No. 5,891,417.
• UZSi-9 (otherwise known as ZS-9) is a particularly effective ZS absorber for absorbing potassium and ammonium. These ZS have the empirical formula:
• A is an exchangeable cation selected from potassium ion, sodium ion, rubidium ion, cesium ion, calcium ion, magnesium ion, hydronium ion or mixtures thereof
• M is at least one framework metal selected from the group consisting of hafnium (4+), tin (4+), niobium (5+), titanium (4+), cerium (4+), germanium (4+), praseodymium (4+), and terbium (4+)
• p has a value from about 1 to about 20
• "x” has a value from 0 to less than 1
• n has a value from about 0 to about 12
• y has a value from 0 to about 12
• m has a value from about 3 to about 36 and 1 ⁇ n + y ⁇ 12.
• the germanium can substitute for the silicon, zirconium or combinations thereof. It is preferred that x and y are zero or both approaching zero, as germanium and other metals are often present in trace quantities. Since the compositions are essentially insoluble in bodily fluids (at neutral or basic pH), they can be orally ingested in order to remove toxins in the gastrointestinal system.
• the inventors of the present invention have noted that ZS-8 has an increased solubility as compared to other forms of ZS (i.e., ZS-l-ZS-7, and ZSi-9-ZS-l l).
• ZS-8 has an increased solubility as compared to other forms of ZS (i.e., ZS-l-ZS-7, and ZSi-9-ZS-l l).
• the presence of soluble forms of ZS including ZS-8 are undesirable since soluble forms of ZS may contribute to elevated levels of zirconium and/or silicates in the urine.
• Amorphous forms of ZS may also be substantially soluble
• the zirconium metallates are prepared by a hydrothermal crystallization of a reaction mixture prepared by combining a reactive source of zirconium, silicon and/or germanium, optionally one or more M metal, at least one alkali metal and water.
• the alkali metal acts as a templating agent. Any zirconium compound, which can be hydrolyzed to zirconium oxide or zirconium hydroxide, can be used.
• these compounds include zirconium alkoxide, e.g., zirconium n-propoxide, zirconium hydroxide, zirconium acetate, zirconium oxychloride, zirconium chloride, zirconium phosphate and zirconium oxynitrate.
• the sources of silica include colloidal silica, fumed silica and sodium silicate.
• the sources of germanium include germanium oxide, germanium alkoxides and germanium tetrachloride.
• Alkali sources include potassium hydroxide, sodium hydroxide, rubidium hydroxide, cesium hydroxide, sodium carbonate, potassium carbonate, rubidium carbonate, cesium carbonate, sodium halide, potassium halide, rubidium halide, cesium halide, sodium ethylenediamine tetraacetic acid (EDTA), potassium EDTA, rubidium EDTA, and cesium EDTA.
• the M metals sources include the M metal oxides, alkoxides, halide salts, acetate salts, nitrate salts and sulfate salts.
• M metal sources include, but are not limited to titanium alkoxides, titanium tetrachloride, titanium trichloride, titanium dioxide, tin tetrachloride, tin isopropoxide, niobium isopropoxide, hydrous niobium oxide, hafnium isopropoxide, hafnium chloride, hafnium oxychloride, cerium chloride, cerium oxide and cerium sulfate.
• the hydrothermal process used to prepare the zirconium metallate or titanium metallate ion exchange compositions of this invention involves forming a reaction mixture which in terms of molar ratios of the oxides is expressed by the formulae:
• reaction mixture is prepared by mixing the desired sources of zirconium, silicon and optionally germanium, alkali metal and optional M metal in any order to give the desired mixture. It is also necessary that the mixture have a basic pH and preferably a pH of at least 8. The basicity of the mixture is controlled by adding excess alkali hydroxide and/or basic compounds of the other constituents of the mixture.
• reaction mixture Having formed the reaction mixture, it is next reacted at a temperature of about 100°C to about 250°C for a period of about 1 to about 30 days in a sealed reaction vessel under autogenous pressure. After the allotted time, the mixture is filtered to isolate the solid product which is washed with deionized water, acid or dilute acid and dried. Numerous drying techniques can be utilized including vacuum drying, tray drying, fluidized bed drying. For example, the filtered material may be oven dried in air under vacuum.
• the different structure types of the ZS molecular sieves and zirconium germanate molecular sieves have been given arbitrary designations of ZS-1 where the " 1" represents a framework of structure type "1". That is, one or more ZS and/or zirconium germanate molecular sieves with different empirical formulas can have the same structure type.
• the X-ray patterns presented in the following examples were obtained using standard X-ray powder diffraction techniques and reported in U.S. Patent No. 5,891,417.
• the radiation source was a high-intensity X-ray tube operated at 45 Kv and 35 ma.
• the diffraction pattern from the copper K-alpha radiation was obtained by appropriate computer based techniques.
• Flat compressed powder samples were continuously scanned at 2° (2 ⁇ ) per minute.
• Interplanar spacings (d) in Angstrom units were obtained from the position of the diffraction peaks expressed as 2 ⁇ where ⁇ is the Bragg angle as observed from digitized data.
• Intensities were determined from the integrated area of diffraction peaks after subtracting background, "I 0 " being the intensity of the strongest line or peak, and "I" being the intensity of each of the other peaks.
• the determination of the parameter 2 ⁇ is subject to both human and mechanical error, which in combination can impose an uncertainty of about ⁇ 0.4 on each reported value of 2 ⁇ . This uncertainty is, of course, also manifested in the reported values of the d-spacings, which are calculated from the ⁇ values. This imprecision is general throughout the art and is not sufficient to preclude the differentiation of the present crystalline materials from each other and from the compositions of the prior art. In some of the X-ray patterns reported, the relative intensities of the d-spacings are indicated by the notations vs, s, m and w which represent very strong, strong, medium, and weak, respectively.
• the purity of a synthesized product may be assessed with reference to its X-ray powder diffraction pattern.
• a sample is stated to be pure, it is intended only that the X-ray pattern of the sample is free of lines attributable to crystalline impurities, not that there are no amorphous materials present.
• the crystalline compositions of the instant invention may be characterized by their X-ray powder diffraction patterns and such may have one of the X-ray patterns containing the d-spacings and intensities set forth in the following Tables.
• ZS The formation of ZS involves the reaction of sodium silicate and zirconium acetate in the presence of sodium hydroxide and water.
• the reaction has typically been conducted in small reaction vessels on the order of 1-5 Gallons.
• the smaller reaction vessels have been used to produce various crystalline forms of ZS including ZS-9.
• the inventors recognized that the ZS-9 being produced in these smaller reactors had an inadequate or undesirably low cation exchange capacity (“CEC").
• baffle-like structure in relation to the agitator within the crystallization vessel produces a ZS-9 crystal product exhibiting crystalline purity (as shown by XRD and FTIR spectra) and an unexpectedly high potassium exchange capacity.
• cooling coils were positioned within the reactor to provide a baffle-like structure. The cooling coils were not used for heat exchange.
• serpentine-type coils which snake along the inside wall of the reactor vessel.
• the baffles and agitator improved the reaction conditions by creating forces within the reactor that lift the crystals within the vessel allowing for the necessary heat transfer and agitation to make a high purity form of ZS-9.
• the baffles in combination with the agitator may be configured such that it provides sufficient lift throughout the entire volume regardless of the size of the reactor used. For example, if the reactor size is enlarged (e.g., 200 liter reactor) and the reaction volume is increased, the baffles will also be resized to accommodate the new reactor volume.
• Figs. 12-13 show XRD and FTIR spectra of high purity ZS-9 crystals. As shown in Table 3 below, these crystals exhibit significantly higher levels of potassium exchange capacity (“KEC”) than the less pure ZS-9 compositions.
• the ZS-9 crystals had a potassium exchange capacity of between 2.7 and 3.7 meq/g, more preferably between 3.05 and 3.35 meq/g.
• ZS-9 crystals with a potassium exchange capacity of 3.1 meq/g have been manufactured on a commercial scale and have achieved desirable clinical outcomes. It is expected that ZS-9 crystals with a potassium exchange capacity of 3.2 meq/g will also achieve desirable clinical outcomes and offer improved dosing forms.
• the targets of 3.1 and 3.2 meq/g may be achieved with a tolerance of ⁇ 15%, more preferably ⁇ 10%, and most preferably ⁇ 5%. Higher capacity forms of ZS-9 are desirable although are more difficult to produce on a commercial scale.
• Such higher capacity forms of ZS-9 have elevated exchange capacities of greater than 3.5 meq/g, preferably greater than 4.0 meq/g, more preferably between 4.3 and 4.8 meq/g, even more preferably between 4.4 and 4.7 meq/g, and most preferably approximately 4.5 meq/g.
• ZS-9 crystals having a potassium exchange capacity in the range of between 3.7 and 3.9 meq/g were produced in accordance with Example 14 below.
• the microporous compositions of this invention have a framework structure of octahedral Zr0 3 units, at least one of tetrahedral Si0 2 units and tetrahedral Ge0 2 units, and optionally octahedral M0 3 units.
• This framework results in a microporous structure having an intracrystalline pore system with uniform pore diameters, i.e., the pore sizes are crystallographically regular. The diameter of the pores can vary considerably from about 3 angstroms and larger.
• the microporous compositions of this invention will contain some of the alkali metal templating agent in the pores. These metals are described as exchangeable cations, meaning that they can be exchanged with other (secondary) A' cations. Generally, the A exchangeable cations can be exchanged with A' cations selected from other alkali metal cations (K , Na , Rb , Cs ), alkaline earth cations (Mg , Ca , Sr , Ba ), hydronium ion or mixtures thereof. It is understood that the A' cation is different from the A cation.
• the methods used to exchange one cation for another are well known in the art and involve contacting the microporous compositions with a solution containing the desired cation (usually at molar excess) at exchange conditions.
• exchange conditions include a temperature of about 25°C to about 100° C and a time of about 20 minutes to about 2 hours.
• the use of water to exchange ions to replace sodium ions with hydronium ions may require more time, on the order of eight to ten hours.
• the particular cation (or mixture thereof) which is present in the final product will depend on the particular use and the specific composition being used.
• One particular composition is an ion exchanger where the A' cation is a mixture of Na + , Ca +2 and H + ions.
• ZS-9 form.
• the sodium content of Na-ZS-9 is approximately 12 to 13% by weight when the manufacturing process is carried out at pH greater than 9.
• the Na-ZS-9 is unstable in concentrations of hydrochloric acid (HCl) exceeding 0.2 M at room temperature, and will undergo structural collapse after overnight exposure. While ZS-9 is slightly stable in 0.2 M HCl at room temperature, at 37°C the material rapidly loses crystallinity. At room temperature, Na- ZS-9 is stable in solutions of 0.1M HCl and/or a pH of between approximately 6 to 7. Under these conditions, the Na level is decreased from 13% to 2% upon overnight treatment.
• HCl hydrochloric acid
• the conversion of Na-ZS-9 to H-ZS-9 may be accomplished through a combination of water washing and ion exchange processes, i.e., ion exchange using a dilute strong acid, e.g., 0.1 M HCl or by washing with water. Washing with water will decrease the pH and protonate a significant fraction of the ZS, thereby lowering the weight fraction of Na in the ZS. It may be desirable to perform an initial ion exchange in strong acid using higher concentrations, so long as the protonation of the ZS will effectively keep the pH from dropping to levels at which the ZS decomposes. Additional ion exchange may be accomplished with washing in water or dilute acids to further reduce the level of sodium in the ZS.
• a dilute strong acid e.g., 0.1 M HCl
• the ZS made in accordance with the present invention exhibits a sodium content of below 12% by weight.
• the sodium contents is below 9% by weight, more preferably the sodium content is below 6%) by weight, more preferably the sodium content is below 3% by weight, more preferably the sodium content is in a range of between 0.05 to 3% by weight, and most preferably 0.01% or less by weight or as low as possible.
• protonated (i.e., low sodium) ZS is prepared in accordance with these techniques, the potassium exchange capacity is lowered relative to the un-protonated crystals.
• the ZS prepared in this way has a potassium exchange capacity of greater than 2.8.
• the potassium exchange capacity is within the range of 2.8 to 3.5 meq/g, more preferably within the range of 3.05 and 3.35 meq/g, and most preferably about 3.2 meq/g.
• a potassium exchange capacity target of about 3.2 meq/g includes minor fluctuations in measured potassium exchange capacity that are expected between different batches of ZS crystals.
• the ion exchanger in the sodium form e.g., Na-ZS-9
• the ion exchanger in the sodium form is effective at removing excess potassium ions from a patient's gastrointestinal tract in the treatment of hyperkalemia.
• hydronium ions replace sodium ions on the exchanger leading to an unwanted rise in pH in the patient's stomach and gastrointestinal tract. Through in vitro tests it takes approximately twenty minutes in acid to stabilize sodium ion exchanger.
• the hydronium form typically has equivalent efficacy as the sodium form for removing potassium ions in vivo while avoiding some of the disadvantages of the sodium form related to pH changes in the patient's body.
• the hydrogenated form has the advantage of avoiding excessive release of sodium in the body upon administration.
• compositions lacking added calcium can serve to withdraw excess calcium from patients which makes these compositions useful in the treatment of hyperkalemia in hypercalcemic patents as well as for the treatment of hypercalcemia.
• the calcium content of compositions prepared according to the process described in U.S. Provisional Application 61/670,415, incorporated by reference in its entirety, is typically very low— i.e., below 1 ppm.
• treatment of hyperkalemia with these compositions is also associated with removal of significant quantities of calcium from the patient's body. Therefore, these compositions are particularly useful for the treatment of hypercalcemic patients or hypercalcemic patients suffering from hyperkalemic.
• compositions of the present invention may be prepared by pre-loading the above-described ZS compositions with calcium ions.
• the pre-loading of the compositions with calcium results in a composition that will not absorb calcium when administered to patients.
• the ZS compositions may also be pre-loaded with magnesium.
• the pre-loading of ZS with calcium (and/or magnesium) is accomplished by contacting the ZS with a dilute solution of either calcium or magnesium ions, preferably having a calcium or magnesium concentration range of about 10-100 ppm.
• the pre-loading step can be accomplished simultaneously with the step of exchanging hydronium ions with sodium ions as discussed above.
• the pre-loading step can be accomplished by contacting ZS crystals at any stage of their manufacture with a calcium or magnesium containing solution.
• the ZS compositions comprise calcium or magnesium levels ranging from 1 to 100 ppm, preferably from 1 to 30 ppm, and more preferably between 5 and 25 ppm.
• protonated ZS may be linked to hydroxyl-loaded anion exchanger such as zirconium oxide (OH-ZO), which help in the removal of sodium, potassium, ammonium, hydrogen and phosphate.
• OH-ZO zirconium oxide
• the hydrogen released from the protonated ZS and hydroxide released from OH-ZO combine to form water, thus diminishing the concentration of "counter-ions" which diminish binding of other ions.
• the binding capacity of the cation and anion exchangers should be increased by administering them together.
• ZS of this form are useful for the treatment of many different types of diseases.
• the compositions are used to remove sodium, potassium, ammonium, hydrogen and phosphate from the gut and from the patient with kidney failure.
• the ZS-9 crystals have a broad particle size distribution. It has been theorized that small particles, less than 3 microns in diameter, could potentially be absorbed into a patient's bloodstream resulting in undesirable effects such as the accumulation of particles in the urinary tract of the patient, and particularly in the patent's kidneys.
• the commercially available ZS are manufactured in a way that some of the particles below 1 micron are filtered out. However, it has been found that small particles are retained in the filter cake and that elimination of particles having a diameter less than 3 microns requires the use of additional screening techniques.
• the inventors have found that screening can be used to remove particles having a diameter below 3 microns and that removal of such particles is beneficial for therapeutic products containing the ZS compositions of the invention.
• Many techniques for particle screening can be used to accomplish the objectives of the invention, including hand screening, air jet screening, sifting or filtering, floating or any other known means of particle classification.
• ZS compositions that have been subject to screening techniques exhibit a desired particle size distribution that avoids potential complications involving the therapeutic use of ZS. In general, the size distribution of particles is not critical, so long as excessively small particles are removed.
• the ZS compositions of the invention exhibit a median particle size greater than 3 microns, and less than 7% of the particles in the composition have a diameter less than 3 microns.
• less than 5% of the particles in the composition have a diameter less than 3 microns, more preferably less than 4% of the particles in the composition have a diameter less than 3 microns, more preferably less than 3% of the particles in the composition have a diameter of less than 3 microns, more preferably less than 2% of the particles in the composition have a diameter of less than 3 microns, more preferably less than 1% of the particles in the composition have a diameter of less than 3 microns, more preferably less than 0.5% of the particles in the composition have a diameter of less than 3 microns.
• none of the particles or only trace amounts have a diameter of less than 3 microns.
• the median particle size is preferably greater than 3 microns and particles reaching a sizes on the order of 1,000 microns are possible for certain applications.
• the median particle size ranges from 5 to 1000 microns, more preferably 10 to 600 microns, more preferably from 15 to 200 microns, and most preferably from 20 to 100 microns.
• the particle screening can be conducted before, during, or after an ion exchange process such as described above whereby the sodium content of the ZS material is lowered below 12%.
• the lowering of sodium content to below 3% can occur over several steps in conjunction with screening or can occur entirely before or after the screening step.
• Particles having a sodium content below 3% may be effective with or without screening of particles sizes as described herein.
• the desired particle size distribution may be achieved using a granulation or other agglomeration technique for producing appropriately sized particles.
• the ZS compositions may further comprise atoms or molecules attached onto their surfaces to produced grafted crystals.
• the grafted atoms or molecules are attached to the surface of the ZS, preferably through stable covalent bonds.
• an organosilicate moiety is grafted onto the surface of the ZS composition through reacting active groups such as silanols ( ⁇ Si-0-H) on the surface of crystals. This may be accomplished, for example by using aprotic solvents.
• an alkoxysilane may be grafted and would require the use of a corresponding alcohol to perform the reaction. Identifying free silanol groups on the surface can done through, for example by, Infrared spectroscopy.
• the ZS compositions may further comprise tagging the composition with radioactive isotopes, such as but not limited to C or Si.
• the ZS compositions may also comprise non-exchangeable atoms, such as isotopes of Zr, Si, or O, which may be useful in mass-balance studies.
• microporous ion exchange compositions can be used in powder form or can be formed into various shapes by means well known in the art. Examples of these various shapes include pills, extrudates, spheres, pellets and irregularly shaped particles. It is also envisioned that the various forms can be packaged in a variety of known containers. These might include capsules, plastic bags, pouches, packets, sachets, dose packs, vials, bottles, or any other carrying device that is generally known to one of skill in the art.
• the microporous ion exchange crystals of this invention may be combined with other materials to produce a composition exhibiting a desired effect.
• the ZS compositions may be combined with foods, medicaments, devices, and compositions that are used to treat a variety of diseases.
• the ZS compositions of the present invention may be combined with toxin reducing compounds, such as charcoal, to expedite toxin and poison removal.
• the ZS crystals may exist as a combination of two or more forms of ZS of ZS-1 to ZS-11.
• the combination of ZS may comprise ZS-9 and ZS-11, more preferably ZS-9 and ZS-7, even more preferably ZS-9, ZS-11, and ZS-7.
• the ZS composition may comprise a blend or mixture of ZS-9, wherein ZS-9 is present at greater than at least 40%, more preferably greater than at least 60%, even more preferably greater than or equal 70%, where the remainder may comprise mixtures of other forms of ZS crystals (i.e., ZS-1 to ZS-11) or other amorphous forms.
• the blend of ZS-9 may comprise greater than about between 50%> to 75% ZS-9 crystals and greater than about 25% to about 50% ZS-7 crystals with the remainder being other forms of ZS crystals, wherein the remainder of the ZS crystals does not include ZS-8 crystals.
• compositions have particular utility in adsorbing various toxins from fluids selected from bodily fluids, dialysate solutions, and mixtures thereof.
• bodily fluids will include but not be limited to blood and gastrointestinal fluids.
• bodily is meant any mammalian body including but not limited to humans, cows, pigs, sheep, monkeys, gorillas, horses, dogs, etc. The instant process is particularly suited for removing toxins from a human body.
• the zirconium metallates can also be formed into pills or other shapes which can be ingested orally and pickup toxins in the gastrointestinal fluid as the ion exchanger transits through the intestines and is finally excreted.
• the ZS compositions may be made into wafer, a pill, a powder, a medical food, a suspended powder, or a layered structure comprising two or more ZS.
• the shaped articles may be coated with various coatings which will not dissolve in the stomach, but dissolve in the intestines.
• the ZS may be shaped into a form that is subsequently coated with an enteric coating or embedded within a site specific tablet, or capsule for site specific delivery.
• A exchangeable cations
• ⁇ ' secondary cations
• preferred cations are sodium, calcium, hydronium and magnesium.
• Preferred compositions are those containing sodium and calcium, sodium and magnesium sodium, calcium and hydronium ions, sodium, magnesium, and hydronium ions, or sodium calcium, magnesium, and hydronium ions.
• the relative amount of sodium and calcium can vary considerably and depends on the microporous composition and the concentration of these ions in the blood. As discussed above, when sodium is the exchangeable cation, it is desirable to replace the sodium ions with hydronium ions thereby reducing the sodium content of the composition.
• ZS crystals as described in related U.S. Application 13/371,080, which is incorporated by reference in its entirety, have increased cation exchange capacities or potassium exchange capacity. These increased capacity crystals may also be used in accordance with the present invention.
• the dosage utilized in formulating the pharmaceutical composition in accordance to the present invention will be adjusted according to the cation exchange capacities determined by those of skill in the art. Accordingly, the amount of crystals utilized in the formulation will vary based on this determination. Due to its higher cation exchange capacity, less dosage may be required to achieve the same effect.
• compositions of the present invention may be used in the treatment of diseases or conditions relating to elevated serum potassium levels. These diseases may include for example chronic or acute kidney disease, chronic, acute or sub-acute hyperkalemia.
• diseases may include for example chronic or acute kidney disease, chronic, acute or sub-acute hyperkalemia.
• the product of the present invention is administered at specific potassium reducing dosages.
• the administered dose may range from approximately 1.25-15 grams (-18-215 mg/Kg/day) of ZS, preferably 8-12 grams (-100-170 mg/Kg/day), more preferably 10 grams (-140 mg/Kg/day) three times a day.
• the total administered dose of the composition may range from approximately 15-45 gram (-215-640 mg/Kg/day), preferably 24-36 grams (-350- 520 mg/Kg/day), more preferably 30 grams (-400 mg/Kg/day).
• the composition of the present invention is capable of decreasing the serum potassium levels to near normal levels of approximately 3.5-5 mmol/L.
• the molecular sieves of the present product is capable of specifically removing potassium without affecting other electrolytes, (i.e., no hypomagnesemia or no hypocalcemia).
• the use of the present product or composition is accomplished without the aid of laxatives or other resins for the removal of excess serum potassium.
• Acute hyperkalemia requires an immediate reduction of serum potassium levels to normal or near normal levels.
• Molecular sieves of the present invention which have a KEC in the range of approximately 1.3-2.5 meq/g would be capable of lowering the elevated levels of potassium to within normal range in a period of about 1-8 hours after administration.
• the product of the present invention is capable of lowering the elevated levels in about at least 1, 2, 4, 6, 8, 10 hours after administration.
• the dose required to reduce the elevated potassium levels may be in the range of about 5-15 grams, preferably 8-12 grams, more preferably 10 grams.
• Molecular sieves having a higher KEC in the range of approximately 2.5- 4.7 meq/g would be more efficient in absorbing potassium.
• the dose required to reduce the elevated potassium levels may be in the range of about 1.25-6 grams.
• the schedule of dose administration may be at least once daily, more preferably three times a day.
• the treatment of chronic and sub-acute hyperkalemia will require maintenance dosing to keep potassium levels near or within normal serum potassium levels.
• the administration of the product of the present invention will be lower than that prescribed to patients suffering from acute hyperkalemia.
• compositions comprising molecular sieves having KEC in the range of approximately 2.5-4.7 meq/g will be scheduled for a dose in the range of approximately 1-5 grams, preferably 1.25-5 grams, preferably 2.5-5 grams, preferably 2-4 grams, more preferably 2.5 grams.
• compositions comprising molecular sieves having a KEC in the range of approximately 2.5-4.7 meq/g will receive less and will be scheduled for a dose in the range of approximately 0.4-2.5 grams, preferably 0.8-1.6 grams, preferably 1.25-5 grams, preferably 2.5-5 grams, more preferably 1.25 grams. Compliance in this subset of patients is a major factor in maintaining normal potassium levels. As such, dosing schedule will therefore be an important consideration. In one embodiment, the dose will be given to patients at least three times a day, more preferably once a day.
• One preferred aspect of the invention is its use of microporous zirconium silicate in the treatment of chronic kidney disease and/or chronic heart disease.
• therapies comprising diuretics is common place in the treatment of chronic kidney disease and/or chronic heart disease.
• Prior attempts to treat these conditions by using therapies comprising diuretics led to undesirable effects such as hyperkalemia.
• the inventors have observed that administration of microporous zirconium silicate to patients suffering from chronic kidney disease and being administered therapies that included diuretics, experienced significant reduction in potassium levels without the negative effects. These negative effects were observed when therapies comprising diuretics were used in connection with ACE inhibitors and ARB therapy.
• the inventors have also unexpectedly observed that systemic aldosterone reduction is achieved through administration of microporous zirconium silicate without the negative effects of the aldosterone blockers.
• zirconium silicate according to the present invention will be effective in treating patients suffering from chronic kidney disease.
• Administration of microporous zirconium silicate to these patients currently on therapies that include diuretics reduces the risk of developing hyperkalemia and also reduces aldosterone without inducing hyperkalemia.
• the zirconium silicate can be administered alone or in combination with existing treatments that include diuretics or diuretics and ACE inhibitors and/or ARB therapy.
• microporous zirconium silicate in conjunction with these therapies is expected to improve the effects upon the renin-angiotensin-aldosterone system (RAAS) and further mitigate the negative effects of aldosterone on CKD and CVD.
• RAAS renin-angiotensin-aldosterone system
• the different mechanisms and independent aldosterone-lowering ability of microporous zirconium silicate are expected to result in at least additive and possibly synergistic interaction between the combined therapies.
• the diuretics may include any diuretic selected from the three general classes of thiazine or thiazine-like, loop diuretics, or potassium sparing diuretics.
• the diuretic is potassium sparing diuretic, such as spironolactone, eplerenone, canrenone (e.g., canrenoate potassium), prorenone (e.g., prorenoate potassium), and mexrenone (mextreoate potassium), amiloride, triamterene, or benzamil.
• microporous zirconium silicate furosemide, bumetanide, torsemide, etacrynic acid, etozoline, muzolimine, piretanide, tienilic acid, bendroflumethiazide, chlorthiazide, hydrochlorthiazide, hydroflumethiazide, cyclopenthiazide, cyclothiazide, mebutizide, hydroflumethiazide, methyclothiazide, polythiazide, trichlormethiazide, chlorthalidone, indapamide, metolazone, quinethazone, clopamide, mufruside, clofenamide, meticrane, xipamide, clorexidone, fenquizone.
• ACE inhibitors that can be used in combination with microporous zirconium silicate according to the invention: sulfhydryl-containing agents including captopril or zofenopril; dicarboxylate-containing agents including enalapril, ramipril, quinapril, perindopril, lisinopril, benazepril, imidapril, zofenopril, trandolapril; phosphate- containing agents including fosinopril; and naturally-occuring ACE inhibitors including casokinins and lactokinins.
• ARBs that can be used in combination with microporous zirconium silicate according to the present invention: valsartan, telmisartan, losartan, irbesartan, azilsartan, and olmesartan. Combinations of the above are particularly desirable.
• a preferred method of treating CKD and/or CVD includes administration of microporous zirconium silicate, ramapril (ACE inhibitor) and telmisartan (ARB).
• the invention may involve administration of microporous zirconium silicate in conjunction with combination therapy of ramapril/telmisartan to a patient diagnosed with chronic kidney disease.
• the ACE inhibitors and ARBs may be administered at their standard dose rates for the treatment of CKD, and in some instances at lower doses depending on the degree of synergy between the ACE inhibitor/ ARBs in combination with microporous zirconium silicate.
• microporous zirconium silicate with an aldosterone antagonist, i.e., an anti-mineralocorticoid. These agents are often used in adjunctive therapy for the treatment of chronic heart failure. Based on the observations of the inventor regarding the effects of microporour zirconium silicate on aldosterone, the combination of microporous zirconium silicate with an aldosterone antagonist may provide for additive and/or synergistic activity.
• Suitable aldosterone antagonists include spironolactone, eplerenone, canrenone (e.g., canrenoate potassium), prorenone (e.g., prorenoate potassium), and mexrenone (mextreoate potassium).
• the composition or product of the present invention may be formulated in a manner that is convenient for administration.
• the composition of the present invention may be formulated as a tablet, capsule, powder, granule, crystal, packet, or any other dose form that is generally known to one of skill in the art.
• the various forms can be formulated as individual dosages comprising between 5-15 grams, preferably 8-12 grams, or more preferably 10 grams for multiple administrations per day, week or month; or they may be formulated as a single dosage comprising between 15-45 grams, preferably 24-36 grams, or more preferably 30 grams.
• the individual dosage form can be at least greater than 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 20, 30, or 40 grams.
• the dosage form is tablet, it may be formulated as a granule, granule-like, or as an extended release form. Capsules may be formulated for administration three times a day, as a sprinkle, an extended release sprinkle, or a dose pack. Powders may be formulated for reconstitution, contained in plastic bags or packets.
• the administration of the composition of the present invention at the specifically described dosing of approximately 10 grams (-140 mg/Kg/day) three times a day (i.e., 30 grams (-400 mg/Kg/day) total) is capable of reducing potassium levels in the serum for an extended duration of time.
• the inventors have found that when the product or composition of the present invention is administered at a dosage of approximately 10 grams three times a day, the effects of lowering serum potassium levels to within normal levels is sustained for 5 days after 2 days of acute therapy. It was expected, however, that the product of the present invention would be expelled in a relatively quick manner.
• the ZS of the present invention may be modified and/or combined with other drugs or treatments if multiple conditions or diseases are present in a subject.
• a subject may present with both hyperkalemia and chronic kidney disease, in which Na-ZS compositions may be used.
• the ZS compositions used to treat chronic kidney disease may further comprise sodium bicarbonate in combination with protonated forms of the ZS.
• subjects presenting with hyperkalemia and chronic heart failure may require the use of protonated ZS compositions.
• the treatment of hyperkalemia and chronic heart disease will require no more than 10% sodium present in the ZS, more preferably less than 2% sodium.
• the ZS described herein may be further combined with activated carbon.
• the activated carbon has the effect of attracting organic molecules circulating within the system of a subject. See,Q.g., HSGD Haemosorbents for Medical Device Applications, Nikolaev V.G. Presentation, London.
• the combination of activated carbon with a ZS will act as a combination product having the ability to remove both excess potassium, and organic molecules.
• the activated carbon will comprise a multiplicity of adsorption pores of ranging from about 8 angstroms to about 800 angstroms in diameter, preferably at least about 50 angstroms in diameter.
• the ZS combined with activated carbon of the present invention will be useful in the treatment of many diseases and/or conditions requiring the removal of excess organic materials, such as but not limited to, lipids, proteins, and toxins.
• the carbon containing ZS compositions of the present invention will be useful in the removal of pyrimidines, methylguanidines, guanidines, o-hydroxyhippuric acid, p- hydroxyhippuric acid, parathormone, purines, phenols, indols, pesticides, carcinogenic heterocyclic amines, conjugates of ascorbic acids, trihalomethanes, dimethylarginine, methylamines, organic chloramines, polyamines, or combinations thereof.
• the activated carbon combined with ZS will also be useful in adsorbing elevated levels of bile acids, albumin, ammonia, creatinine and bilirubin.
• the composition may be further coated with an albumin layer, a lipid layer, a DNA layer, a heparin layer, resulting in additional adsorption efficiencies ranging from about 12% to about 35%.
• the activated carbon and ZS compositions will be useful in treating a subject presenting with multiple diseases or conditions, such as hyperkalemia, acute and chronic esogastritis, acute and chronic intestinal catarrhus, hyperacid gastritis, summer diarrhea, catarrhal jaundice, food related toxicoinfections, kidney disease, dysentery, choloera, typhoid, intestinal bacilli-carrier, heartburn, nausea, acute viral hepatitis, chronic active hepatitis and cirrhosis, concomitant hepatitis, mechanical jaundice, hepato-renal failure, hepatic coma, or combinations thereof.
• diseases or conditions such as hyperkalemia, acute and chronic esogastritis, acute and chronic intestinal catarrhus, hyperacid gastritis, summer diarrhea, catarrhal jaundice, food related toxicoinfections, kidney disease, dysentery, choloera, typhoid, intestinal bacilli-
• the ZS compositions described herein may be used in a variety of methods comprising administering to a subject in need thereof a composition described herein to remove excess levels of potassium.
• the method may include the administration of a combination of the ZS described herein and may further comprise additional compositions to aid in the removal of potassium while simultaneously removing other substances, such as but not limited to toxins, proteins, or ions, from the subject.
• a solution was prepared by mixing 2058 g of colloidal silica (DuPont Corp. identified as LudoxTM AS-40), 2210 g of KOH in 7655 g H 2 0. After several minutes of vigorous stirring 1471 g of a zirconium acetate solution (22.1 wt. % Zr0 2 ) were added. This mixture was stirred for an additional 3 minutes and the resulting gel was transferred to a stainless steel reactor and hydrothermally reacted for 36 hours at 200°C. The reactor was cooled to room temperature and the mixture was vacuum filtered to isolate solids which were washed with deionized water and dried in air.
• the solid reaction product was analyzed and found to contain 21.2 wt. % Si, 21.5 wt. % Zr, K 20.9 wt. % K, loss on ignition (LOI) 12.8 wt. %, which gave a formula of K 2 . 3 ZrSi 3 . 2 0 9 .5*3.7H 2 0. This product was identified as sample A.
• a solution was prepared by mixing 121.5 g of colloidal silica (DuPont Corp. identified as Ludox ® AS-40), 83.7 g of NaOH in 1051 g H 2 0. After several minutes of vigorous stirring 66.9 g zirconium acetate solution (22.1 wt. % Zr0 2 ) was added. This was stirred for an additional 3 minutes and the resulting gel was transferred to a stainless steel reactor and hydrothermally reacted with stirring for 72 hours at 200°C. The reactor was cooled to room temperature and the mixture was vacuum filtered to isolate solids which were washed with deionized water and dried in air. [00112] The solid reaction product was analyzed and found to contain 22.7 wt. % Si, 24.8 wt. % Zr, 12.8 wt. % Na, LOI 13.7 wt. %, which gives a formula Na 2 .oZrSi3.o0 9 .o *3.5H 2 0. This product was identified as sample B.
• the solid reaction product was analyzed and found to contain 20.3 wt. % Si, 15.6 wt. % Zr, 20.2 wt. % K, 6.60 wt. % Nb, LOI 9.32 wt. %, which give a formula of K 2 .i 4 Zr 0 .7iNbo. 2 9 Si 3 Oc). 2 *2.32H 2 0.
• batch- wise ion exchange with a dilute strong acid is capable of reducing the sodium content of a NA-ZS-9 composition to within a desired range.
• EXAMPLE 7 [00119] Approximately 85 gram (non- volatile-free basis, lot 0063-59-26) of Na-ZS-9 was washed with approximately 31 Liters of DI water at 2 Liter increments over 3 days until the pH of the rinsate reached 7. The material was filtered, dried and washed with DI water. The pH of the resulting material was 7. The H-ZS-9 powder resulting from batch-wise ion exchange and water wash has ⁇ 12% Na.
• water washing is capable of reducing the sodium content of a NA-ZS-9 composition to within a desired range.
• the resulting particle size distribution of the ZS-9 crystals screened using different size screens was analyzed. As illustrated in the following figures, the fraction of particles having a diameter below 3 microns can be lowered and eliminated using an appropriate mesh size screen. Without screening, approximately 2.5% percent of the particles had a diameter of below 3 microns. See Fig. 5. Upon screening with a 635 mesh screen, the fraction of particles having a diameter below 3 microns was reduced to approximately 2.4%. See Fig. 6. Upon screening with a 450 mesh screen, the fraction of particles having a diameter below 3 microns was reduced further to approximately 2%. See Fig. 7. When a 325 mesh screen is used, the fraction of particles having a diameter below 3 microns is further reduced to approximately 0.14%. See Fig. 8. Finally, a 230 mesh screen reduces the fraction of particles below 3 microns to 0%>. See Fig. 9.
• the screening techniques presented in this example illustrate that particle size distributions may be obtained for ZS-9 that provide little or no particles below 3 microns. It will be appreciated that ZS-9 according to Example 5 or H-ZS-9 according to Examples 6 and 7 may be screened as taught in this example to provide a desired particle size distribution. Specifically, the preferred particle size distributions disclosed herein may be obtained using the techniques in this example for both ZS-9 and H-ZS-9.
• a 14-Day repeat dose oral toxicity study in Beagle Dogs with Recovery was conducted. This GLP compliant oral toxicity study was performed in beagle dogs to evaluate the potential oral toxicity of ZS-9 when administered at 6 h intervals over a 12 h period, three times a day, in food, for at least 14 consecutive days.
• ZS-9 was administered to 3/dogs/sex/dose at dosages of 0 (control), 325, 650 or 1300 mg/kg/dose.
• An additional 2 dogs/sex/dose, assigned to the Recovery Study received 0 or 1300 mg/kg/dose concurrently with the Main study animals and were retained off treatment for an additional 10 days.
• a correction factor of 1.1274 was used to correct ZS-9 for water content.
• Dose records were used to confirm the accuracy of dose administration.
• dogs were trained to eat 3 portions of wet dog chow at 6 h intervals.
• the requisite amount of test article (based on the most recently recorded body weight) was mixed with ⁇ 100g of wet dog food and offered to the dogs at 6 h intervals. Additional dry food was offered following consumption of the last daily dose.
• Each dog received the same amount of wet dog feed.
• Body weights were recorded at arrival and on Days -2, -1, 6, 13 and 20. Clinical observations were performed twice daily during the acclimation, treatment and recovery periods. Wet and dry food consumption was measured daily during the treatment period.
• Plasma samples for analysis of serum chemistry, hematology, coagulation and urinalysis parameters were collected pretest (Day -1) and Day 13.
• Ophthalmologic examinations were performed pretest (Day -6/7) and on Day 7 (females) or 8 (males).
• Electrocardiographic assessments were performed pretest (Day -1) and on Day 11.
• necropsy examinations were performed, protocol specified organ weights were weighed, and selected tissues were microscopically examined.
• urinary pH was elevated compared to control and it was postulated that the change in urinary pH and/or urinary composition affected urine solute solubility resulting in crystal formation that caused urinary tract irritation and/or increased susceptibility to urinary tract infections (UTIs).
• UTIs urinary tract infections
• Crystals of ZS-9 are prepared and designated "ZS-9 Unscreened.” Screening in accordance with the procedures of Example 10 is conducted on a sample of ZS-9 crystals and the screened sample is designated "ZS-9 >5 ⁇ .” Another sample of Crystals of ZS-9 undergo an ion exchange in accordance with the procedures of Example 6 above and are then screened in accordance with the procedures of Example 10. The resulting H-ZS-9 crystals are designated "ZS-9 + >5 ⁇ .”
• the following 14-day study is designed to show the effect of particle size and particle form on the urinary pH and presence of crystals in the urine.
• the compounds above are administered to beagles orally by mixing with wet dog food.
• the regimen is administered 3 times a day at 6 hour intervals over a 12 hour period in the following manner:
• Dose Formulation Analysis Dose records will be used to confirm dosing. Weight of any remaining wet food will be recorded.
• test articles ZS-9 unscreened, ⁇ 8-9>5 ⁇ , and ZS-9 + >5 ⁇ , were administered three times daily at 6 hour intervals over a 12-hour period for 14 consecutive days via dietary consumption utilizing a wet food vehicle.
• the dose levels were 100 or 600 mg/kg/dose.
• ZS-9 related findings were limited to an increase in the fractional excretion of sodium and an increase in urinary pH in animals receiving screened or unscreened ZS-9 at a dose of 6000 mg/kg/dose, and deceases in the fractional excretion of potassium and the urinary urea nitrogen/creatinine ratio in animals dosed at 600 mg/kg/dose ZS- 9 unscreened, ⁇ 8-9>5 ⁇ , and ZS-9 + >5 ⁇ .
• urea nitrogen/creatinine ratio was mildly increased relative to predose intervals in all groups including controls. There were mild decreases in urea nitrogen/creatinine ratios on Days 7 and 13 in animals receiving 600 mg/kg/dose ZS-9 unscreened, ⁇ 8-9>5 ⁇ , and ZS-9 + >5 ⁇ relative to controls (up to 26%). Most of the changes observed in these four groups reached statistical significance compared to controls for Days 7 and 13 although group mean values did not differ appreciably when compared to their respective pretest values. These findings were considered test article-related. Although there were occasional statistically significant differences among other endpoints, no test article-related effects on creatinine clearance, calcium/creatinine ratio, magnesium/creatinine ratio, or urine osmolality were identified in any treatment group.
• Test article related microscopic findings in the kidney were observed at the 600 mg/kg/dose.
• the most common findings were minimal to mild mixed leukocyte infiltrates (lymphocytes, plasma cells, macrophages and/or neutrophils), and minimal to mild renal tubular regeneration (slightly dilated tubules lined by attenuated epithelial cells, epithelial cells with plump nucleus and basophilic cytoplasm).
• Minimal pyelitis infiltration of neutrophils, lymphocytes and plasma cells in the submucosa of the renal pelvis
• minimal renal tubular degeneration/necrosis tubules lined by hypereosinophilic cells with either pyknotic or karyorrhectic nucleus and containing sloughed epithelial cells and/or inflammatory cells in the lumen
• Minimal pyelitis and mixed leukocyte infiltration in the urethra or ureter were also present in some dogs given ⁇ -9>5 ⁇ .
• the changes in the kidney were mostly present in the cortex and occasionally in the medulla with a random, focal to multifocal (up to 4 foci) distribution. These foci were variably sized, mostly irregular, occasionally linear (extending from the outer cortex to the medulla), and involved less than 5% of the kidney parenchyma in a given section. Most of these foci consisted of minimal to mild infiltration of mixed leukocytes with minimal to mild tubular regeneration, some foci had only minimal to mild tubular regeneration without the mixed leukocyte infiltrate.
• a few of these foci contained a small number of tubules with degeneration/necrosis. Pyelitis was present in four dogs (one given ZS-9 unscreened 600 mg/kg/dose and three dogs given ZS- 9>5 ⁇ at 600 mg/kg/dose).
• the infiltration of mixed leukocytes was also present in the submucosa of both ureters in dogs given 600 mg/kg/dose ⁇ -9>5 ⁇ and the submucosa of the urethra in animals given 600 mg/kg/dose ZS-9 unscreened, 600 mg/kg/dose ⁇ 8-9>5 ⁇ .
• the incidence and/or severity of mixed leukocyte infiltrates in the kidney parenchyma were higher in dogs with pyelitis compared to the dogs without pyelitis.
• kidneys in two of the three dogs were affected with one or more of the aforementioned findings. All three dogs given ⁇ 8-9>5 ⁇ at 600 mg/kg/dose had kidney lesions including pyelitis and mixed leukocyte infiltrates in the submucosa of urethra or ureters. Dogs given ZS-9 + >5 ⁇ at 600 mg/kg/dose, minimal mixed leukocyte infiltrate with tubular regeneration was present in only the left kidney in one dog while another dog had a few foci of minimal tubular regeneration.
• Test article-related findings were not present in female dogs given ZS- 9 unscreened at 100 mg/kg/dose (ZS-9, ⁇ 8-9>5 ⁇ , ZS-9 +>5 ⁇ ).
• ZS-9, ⁇ 8-9>5 ⁇ , ZS-9 +>5 ⁇ An occasional focus or two of minimal tubular regeneration were present in three of the animals without an evidence of mixed leukocyte infiltrate or tubular degeneration/necrosis. Similar focus/foci of tubular regeneration were also present in a control female dog.
• the foci of tubular regeneration observed in female dogs given lower doses of ZS-9 unscreened were slightly smaller and were not associated with either mixed leukocyte infiltrates or tubular degeneration/necrosis. There was no evidence of crystals in any of the sections examined.
• Tubular mineralization in the papilla and glomerular lipidosis are background findings in beagle dogs and were not considered test article-related.
• the no-observable-effect-level was 100 mg/kg/dose ZS-9 unscreened, ⁇ 8-9>5 ⁇ , and ZS-9 + >5 ⁇ .
• the no-observable-adverse-effect-level (NOAEL) was established for ZS-9 unscreened at 600 mg/kg/dose, screened ZS-9 ( ⁇ 8-9>5 ⁇ ) at 600 mg/kg/dose, and screened and protonated ZS-9 (ZS-9 + >5 ⁇ ) at 600 mg/kg/dose.
• the reactants were prepared as follows. A 22-L Morton flask was equipped with an overhead stirrer, thermocouple, and an equilibrated addition funnel. The flask was charged with deionized water (3.25 L). Stirring was initiated at approximately 100 rpm and sodium hydroxide (1091 g NaOH) was added to the flask. The flask contents exothermed as the sodium hydroxide dissolved. The solution was stirred and cooled to less than 34 °C. Sodium silicate solution (5672.7 g) was added. To this solution was added zirconium acetate solution (3309.5 g) over 43 minutes. The resulting suspension was stirred for another 22 minutes. Seed crystals of ZS-9 (223.8 g) were added to the reaction vessel and stirred for approximately 17 minutes.
• the mixture was transferred to a 5-G Parr pressure vessel with the aid of deionized water (0.5 L).
• the vessel had smooth walls and a standard agitator.
• the reactor did not have a cooling coil present.
• the vessel was sealed and the reaction mixture was stirred at approximately 275-325 rprn and heated to 185 +/- 10 °C over 4 hours, then held at 184-186 °C and soaked for 72 hours. Finally, the reactants were then cooled to 80 °C over 12.6 hours.
• the resulting white solid was filtered with the aid of deionized water (18L).
• the solids were washed with deionized water (125 L) until the pH of the eluting filtrate was less than 11 (9.73).
• the wet cake was dried in vacuo (25 inches Hg) for 48 hours at 95-105 °C to give 2577.9 g (107.1%) of ZS-9 as a white solid.
• FTIR plot of this material is shown in Fig. 11.
• These XRD and FTIR spectra are characterized by the presence of absorption peaks typically associated with the ZS-11 crystalline form.
• the peaks that are associated with ZS-9 exhibit significant spreading due to crystal impurities (e.g. the presence of ZS-11 crystals in a ZS-9 composition).
• the FTIR spectra shows significant absorption around 764 and 955 cm "1 .
• the XRD plot for this example exhibits significant noise and poorly defined peaks at 2-theta values of 7.5, 32, and 42.5.
• a hydrochloric acid solution is prepared comprising the steps of charging the carboy with deionized water (48 L) followed by hydrochloric acid (600 ml). To the 100 L reaction vessel, the hydrochloric acid solution is charged over a period of 1.5-2 hours. Hydrochloric acid solution was added to the reaction mixture until the pH reached a range of approximately 4.45-4.55. The reaction mixture was continually mixed for an additional period of 30-45 minutes. If the pH was greater than 4.7, additional hydrochloride solution was added until the pH was in the range of approximately 4.45-4.55. The reaction was allowed to stir for an additional 15-30 minutes.
• the protonated ZS-9 crystals were filtered through Buchner funnel fitted with a 2 micron stainless steel mesh screen of approximately 18 inches in diameter.
• the filter cake formed was rinsed three times with approximately 6 L of deionized water to remove any excess hydrochloric acid.
• the filter cake containing the protonated crystals were dried in an vacuum oven at approximately 95-105 °C for a period of 12-24 hours. Drying was continued until the percent difference in net weight loss is less than 2% over greater than a 2 hour period. Once the product achieved appropriate dryness, the crystals were samples for quality.
• the reactants were prepared as follows. A 22-L Morton flask was equipped with an overhead stirrer, thermocouple, and an equilibrated addition funnel. The flask was charged with deionized water (8,600 g, 477.37 moles). Stirring was initiated at approximately 145-150 rpm and sodium hydroxide (661.0 g, 16.53 moles NaOH, 8.26 moles Na20) was added to the flask. The flask contents exothermed from 24 °C to 40 °C over a period of 3 minutes as the sodium hydroxide dissolved. The solution was stirred for an hour to allow the initial exotherm to subside.
• the mixture was transferred to a 5-G Parr pressure vessel Model 4555 with the aid of deionized water (500g, 27.75 moles).
• the reactor was fitted with a cooling coil having a serpentine configuration to provide a baffle-like structure within the reactor adjacent the agitator.
• the cooling coil was not charged with heat exchange fluid as it was being used in this reaction merely to provide a baffle-like structure adjacent the agitator.
• baffles provide added turbulence which lifts the solids (i.e., crystals) and results in a more even suspension of crystals within the reaction vessel while the reaction is ongoing. This improved suspension allows for more complete reaction to the desired crystalline form and reduces the presence of unwanted crystalline forms of ZS in the end product.
• the KEC of ZS was determined according to the following protocol.
• This test method used a HPLC capable of gradient solvent introduction and cation exchange detection.
• the column was an IonPac CS 12A, Analytical (2 x 250 mm).
• the flow rate was 0.5 mL/minute with a run time of approximately 8 minutes.
• the column temperature was set to 35 °C.
• the injection volume was 10 ⁇ , and the needle wash was 250 ⁇ .
• the pump was operated in Isocratic mode and the solvent was DI water.
• a stock standard was prepared by accurately weighing and recording the weight of about 383 mg of potassium chloride (ACS grade), which was transferred into a 100-rnL plastic volumetric flask. The material was dissolved and diluted to volume with diluent followed by mixing. The stock standard had a K + concentration of 2000 ppm (2mg/mL). Samples were prepared by accurately weighing, recording, and transferring about 1 12 mg of ZS-9 into a 20 mL plastic vial. 20.0 mL of the 2000 ppm potassium stock standard solution was pipetted into the vial and the container was closed. The sample vials were placed onto a wrist action shaker and were shook for at least 2 hours but not more than 4 hours.
• the sample preparation solution was filtered through a 0.45 pm PTFE filter into a plastic container. 750 pL of the sample solution was transferred into a 100-mL plastic volumetric flask. The sample was diluted to volume with DI water and mixed. The initial K + concentration was 15 ppm (1 SpglmL).
• the samples were injected into the HPLC.
• Fig. 14 shows an example of the blank solution chromatogram.
• Fig. 15 shows an example of the assay standard solution chromatogram.
• Fig. 16 shows an exemplary sample chromatogram.
• the potassium exchange capacity was calculated using the following formula: KEC is the potassium exchange capacity in mEq/g.
• the initial concentration of potassium (ppm) is IC.
• the final concentration of potassium (ppm) is FC.
• the equivalent weight (atomic weight/valence) is Eq wt.
• the volume (L) of standard in sample preparation is V.
• the weight of ZS-9 (mg) used for sample preparation is Wt spl .
• the percent (%) of water content (LOD) is % water.
• the high capacity ZS prepared in accordance with Example 14 will, upon protonation using the techniques of Example 13, have a slightly lower potassium exchange capacity.
• the protonated ZS prepared in this way has been found to have a potassium exchange capacity of about 3.2 meq/g. Accordingly, the high capacity ZS has been found to increase the capacity of the protonated form prepared using this process.
• protonated ZS can be prepared having a potassium exchange capacity within the range of 2.8 to 3.5 meq/g, more preferably within the range of 3.05 and 3.35 meq/g, and most preferably about 3.2 meq/g.
• the inventors have designed a reactor for larger-scale production of high purity, high-KEC ZS-9 crystals. Large-scale reactors typically utilize a jacket for achieving heat transfer to the reaction chamber rather than coils suspended within the reaction chamber.
• a conventional 200-L reactor 100 is shown in Fig. 17.
• the reactor 100 has smooth walls and an agitator 101 extending into the center of the reaction chamber.
• the reactor 100 also has a thermowell 102 and a bottom outlet valve 103.
• the inventors have designed an improved reactor 200, Fig. 18, which also has an agitator 201, thermowell 202, and bottom outlet valve 203.
• the improved reactor 200 has baffle structures 204 on its sidewalls, which in combination with the agitator 201 provide significant lift and suspension of the crystals during reaction and the creation of high purity, high KEC ZS-9 crystals.
• the improved reactor can also include a cooling or heating jacket for controlling the reaction temperature during crystallization in addition to the baffle structures 204.
• the details of an exemplary and non- limiting baffle design is shown in Fig. 19.
• the reactor has a volume of at least 20-L, more preferably 200-L or more, or within the range of 200-L to 30,000-L.
• the baffle design may be configured to extend the
• EXAMPLE 17 The several dosages of ZS-9 were studied in the treatment of human subjects suffering from hyperkalemia. A total of 90 subjects were enrolled in the study. The study involved three stages with dose escalation of the ZS in each stage. The ZS-9 used in these studies was prepared in accordance with Example 12. The ZS-9 crystals of an appropriate size distribution were obtained by air fractionation to have a distribution of crystals where greater than or equal to 97% are larger than 3 microns. The screening is such that the ZS crystals exhibit a median particle size of greater than 3 microns and less than 7% of the particles in the composition have a diameter less than 3 microns. The ZS-9 crystals were determined to have a KEC of approximately 2.3 meq/g. The protonation is such that the ZS crystals exhibit a sodium content below 12% by weight. The study utilized 3g silicified microcrystaline cellulose, which are indistinguishable from ZS as the placebo.
• Each patient in the study received either a 3 g dose of either the placebo or ZS three times daily with meals. Both ZS and Placebo were administered as a powder in water suspension that was consumed during meals. Each stage of the study had a 2:1 ratio between the number of subjects in the ZS cohort and placebo. In stage I, 18 patients were randomized to receive three daily doses of 0.3 g ZS or placebo with meals. In Stage II, 36 patients were randomized to receive three daily doses of 3 g ZS or placebo with meals. In Stage III, 36 patients were randomized to receive three daily doses of 10 g ZS placebo with meals. Altogether there were 30 patients that received placebo and 60 patients that received various doses of ZS. Diet was essentially unrestricted, and patients were allowed to choose which food items they wished from a variety of local restaurants or the standard in-house diet of the clinic.
• the screening value for potassium was established on day 0 by measuring serum K three times at 30-minute intervals and calculating the mean (time 0, 30 and 60 minutes). The baseline K level was calculated as the mean of these values and the serum K on day one just before ingestion of the first dose. If the screening K value was less than 5.0 meq/1 the subject was not included in the study.
• the primary efficacy endpoint of the study was the difference in the rate of change in potassium levels during the initial 48 hours of study drug treatment between the placebo treated subjects and the ZS treated subjects.
• Table 4 provides the p-values of the various cohorts at the 24 and 48 hour endpoints. Patients receiving 300 mg of the ZS three times daily had no statistical difference relative to placebo at either of the 24 and 48 hour endpoints. Patients receiving 3 grams of ZS demonstrated a statistical difference at only the 48 hour time period, suggesting that this particular dosing was relatively effective at lowering serum potassium levels. Unexpectedly, those patients receiving 10 grams of ZS three times daily demonstrated the greatest reduction in potassium levels in both concentration and in rate. The decrease in potassium was considerable in magnitude, with an approximate 0.5 meq/g reduction at the 3 gram dose and approximately 0.5-1 meq/g reduction at the 10 gram dosing.
• BUN Blood Urea Nitrogen
• SPS Oral sodium polystyrene sulfonate
• K hydrogen, calcium, magnesium, etc.
• ZS is loaded partly with sodium and partly with hydrogen, to produce a near physiologic pH (7 to 8)). At this starting pH, there is little release of sodium and a some absorption of hydrogen during binding of K. Urinary excretion of sodium does not increase during ingestion of ZS and thus ZS use should not contribute to sodium excess in patients.
• microporous zirconium silicate can be utilized in the treatment of hyperphosphatemia.
• High capacity ZS (ZS-9) is prepared in accordance with Example 14.
• the material is protonated in accordance with the techniques described in Example 13.
• the material has been screened such that the ZS crystals exhibit a median particle size of greater than 3 microns and less than 7% of the particles in the composition have a diameter less than 3 microns.
• the ZS crystals exhibit a sodium content below 12% by weight.
• the dosage form is prepared for administration to patients at a level of 5g, lOg, and 15g per meal.
• the ZS in this example has an increased potassium exchange capacity of greater than 2.8.
• the potassium exchange capacity is within the range of 2.8 to 3.5 meq/g, more preferably within the range of 3.05 and 3.35 meq/g, and most preferably about 3.2 meq/g.
• a potassium exchange capacity target of about 3.2 meq/g includes minor fluctuations in measured potassium exchange capacity that are expected between different batches of ZS crystals.
• ZS-9 has an improved KEC, the dosing administered to the subject in need thereof will be lowered to account for the increased cation exchange capacity.
• approximately 1.25, 2.5, 5, and 10 grams of the ZS-9 will be administered three times daily.
• ZS (ZS-2) is prepared in accordance with known techniques of U.S. Patent Nos.
• the x-ray diffraction pattern for the ZS-2 has the following characteristics d- spacing ranges and intensities:
• the ZS-2 crystals are prepared using the reactor with baffles described in Example 14.
• the material is protonated in accordance with the techniques described in Example 13.
• the material has been screened such that the ZS crystals exhibit a median particle size of greater than 3 microns and less than 7% of the particles in the composition have a diameter less than 3 microns.
• the ZS crystals exhibit a sodium content below 12% by weight.
• the dosage form is prepared for administration to patients at a level of 5g, lOg, and 15g per meal.
• the ZS-2 crystals prepared in accordance with this example are beneficial for reducing serum potassium and can be manufactured using the alternative techniques for making ZS-2. These alternative manufacturing techniques may provide advantages under certain circumstances.
• the reactants were prepared as follows. To a 200-L reactor, as shown in Fig. 17, sodium silicate (56.15 kg) was added and charged with deionized water (101.18 kg). Sodium hydroxide (7.36 kg) was added to the reactor and allowed to dissolve in the reactor in the presence of rapid stirring over a period of greater than 10 minutes until there was complete dissolution of the sodium hydroxide. Zirconium acetate (23 kg) was added to the reactor in the presence of continuous stirring and allowed to stir over a period of 30 minutes. The reactants were mixed at a rate 150 rpm with the reactor set to 210°C ⁇ 5°C for a period of > 60 hours.
• Phase quantification to determine the diffraction pattern of the various batches of protonated ZS crystal samples were also performed using the Rietveld method in a Rigaku MiniFlex600. Manufacturing procedures using the 200-L reactor produced the phase composition described in Table 8 and XRD data described in Figs. 25-29.
• ZS-7 crystals in additional to a series of amorphous crystals. It was found that ZS crystals made in the larger 200 L reactor according to the above processes resulted in no detectable levels of ZS-8 crystals and lower levels of amorphous material than previously produced. The absence of ZS-8 crystals is highly desirable due to the undesirably higher solubility of ZS-8 crystals and their attendant contribution to elevated levels of zirconium in urine. Specifically, levels of zirconium in the urine are typically around 1 ppb. Administration of zirconium silicate containing ZS-8 impurities has led to zirconium levels in the urine between 5 to 50 ppb. The presence of ZS-8 can be confirmed by XRD as shown in Fig. 30. The ZS-9 crystals according to this embodiment are expected to lower levels of zirconium in the urine by eliminating impurities of soluble ZS-8 and minimizing the amorphous content. EXAMPLE 21
• the batches of protonated zirconium crystals described in Example 20 were used in studies to treat human subjects suffering from hyperkalemia.
• the ZS compositions were generally characterized as having a mixture of ZS-9 and ZS-7, where the ZS-9 was present at approximately 70% and the ZS-7 was present at approximately 28% (hereafter ZS-9/ZS-7). All of the characterized ZS-9/ZS-7 crystals lack detectable quantities of ZS-8 crystals.
• Subjects were administered the ZS-9/ZS-7 composition according the method described in Example 17.
• GFR glomerular filtration rate
• ZS-9/ZS-7 composition were unexpectedly higher relative to the patient's baseline. Without being bound to any particular theory, the inventors posit that the improved GFRs and lowered creatinine levels (see Table 9 above) are due to absence of the ZS-8 impurities in the ZS-9/ZS-7 composition. As is generally known in the prior art, ZS-8 crystals have been characterized as being more reactive and therefore able to "leach" into the system.
• the zirconium silicate according to this example had a content of 94% ZS-9, 4% ZS-7, and 2% amorphous zirconium silicate.
• RAASi cardio- and reno-protective renin-angiotensin-aldosterone system inhibitors
• RAASi cardio- and reno-protective renin-angiotensin-aldosterone system inhibitors
• ZS-9 a nonabsorbed cation exchanger designed to specifically entrap excess potassium (K ), significantly reduced serum K vs placebo over 48 hr with excellent tolerability in patients with chronic kidney disease (CKD) and hyperkalaemia (Ash 2013).
• K entrap excess potassium
• CKD chronic kidney disease
• Ash 2013 hyperkalaemia
• TID placebo thrice daily
• GI AEs The most common (>2% in any treatment group) GI AEs in the acute phase were diarrhea and constipation.
• SAE placebo
• the proportion of patients with >1 AE and >1 GI AE in the extended-treatment phase is shown in the Figure.
• the number of patients with SAEs was low and similar for ZS-9 (3, 4, 3, and 0 patients each on ZS-9 1.25g, 2.5g, 5g and lOg, respectively) and placebo (5 patients) with extended treatment.
• Extended Phase % of patients with
• RAAS renin-angiotensin-aldosterone
• ZS-9 is a novel, nonabsorbed cation exchanger designed to specifically entrap excess K + .
• ZS-9 was effective in decreasing K after 3 days of TID treatment and maintaining K + levels with QD dosing in patients receiving RAAS therapy, results consistent with those in patients not on RAAS inhibitors.
• ZS-9 may become an important treatment for both correcting hyperkalaemia and importantly maintaining normokalaemia in a safe and well-tolerated manner.
• ZS-9 may enable optimal use of cardio- and reno-protective RAAS inhibitors in patients who may benefit from them.

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