|Title of Invention||
A UNIT DOSAGE FORM COMPRISING PER DOSAGE SULODEXIDE
|Abstract||A unit dosage form comprising per dosage unit 200 mg sulodexide or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier, or excipients, which composition is suitable for oral administration.|
|Full Text||"A UNIT DOSAGE FORM COMPRISING PER DOSAGE SULODEXIDE"
FIELD OF mv. TNVENTTQN
The present invention relates to a unit dosage form comprising Sulodexide in specific dosages and methods of using specific dosages of Sulodexide for the treatment of pati;its with diabetic nq>hropathy and albuminuria caused by, for example, insulin dsgesadeat or non-insulin dependrait Diabetes Mellitus.
BACKGROUND OF THE INVENTION
The use of glycosaminoglycans, such as heparin, in various anticoagulant and antithrombotic thenq)ies is well known. Sulodexide is a glycosaminoglycan of natural origin extracted fix>m mammalian intestinal mucosa that posses an anticoagulant activity. Sulodexide has a sulfation degree low; than those of heparin, as shown by Radhakrishnamurthy B. et al.. Atherosclerosis. 31,217-229 (1978). The preparation of Sulodexide is described in U.S. Patent 3,936,351,(incorporated herein by reference in its aitirety).
Sulodexide is mariceted in Europe und; the ttademark VESSEL DUE F(R) and is prescribed for the treatment of vascular pathologies with flfforabotic risk such as peripheral occlusive arterial disease (POAD), healing of venous leg ulcers and intermittent claudication (See Harenberg J. Med. Res. Rev, vol.18,1-20 (1998), Crepaldi G. et al.. Atherosclerosis. 81,233, (1990)), cardiovasculopathies, as described by Tramarin R. et al. Medical Praxis. 8,1, (1987), cerebrovasculopafliies as described by Sozzi C, Eur. Rev. Med. Pharmacol Sci. 6,295, (1984) and voious pathologies of the lower limbs, as described by Cospite M. et al, ActaTherapeutica. 18,149, (1992).
Diabetic nephropathy is a common and serious con;Iication of the disease Diabetes Mellitus and is the leading cause of chronic renal failure (CRF) in the U.S., being responsible for one third of all CFR cases. The precise cause of the changes produced by diabetes in the kidney are not all known. However, it is known that a hallmark of diabetic throaty is the presence of protein in fibs urine proteinuria) of patioits. The protein albumin, which is normally present in plasma, is excreted in the urine of patients with diabetic nephropathy. This is referred to as albuminuria. The rate of excretion of this protein is a good indicator of the extent of the reual pathology. High levels of albumin excretion strongly predict accelerated diminution in glomerular filtration rate (GFR) and eventual renal failure. The degree of albumin excretion is used to divide patients into two groups;
those with microalbuminuria (excretion of 200 mcg/min or less), and those with macroalbuminuria (excretion of more than 200 mcg/min).
The antihypertension drugs known as ACE inhibitors (ACEI) decrease albuminuria in diabetic nephropathy but the pathological changes in the kidney and renal functional deterioration may continue toward end stage renal disease (ESRD). ACEI are also less effective in type 2 or non-insulin dependent diabetic (DM2) nephropathy as compared to that seen in type 1 or insulin dependent diabetes (DM1). Salvetti A. et al. Drugs 57(5):665-693 (1999).
Diabetic nqphropathy is a clinically well defined pathological condition characterized by proteinuria, hypertension, edema and renal insufficiency and generally occurs in patiotits suffering firom diabetes for more than ten years. Diabetic nephropathy causes a number of structural changes in the kidney, the most characteristic of which is the glomerular injury detectable by the enlargement of the mesangimn and by the thickening of the basement membrane in the glomerulus. (See Cecil Textbook of Medicine (pages 1281-1283), Edited by Goldman L. and Claude Bennett J., 21=* Edition (2000), W.B. Saunders, Philadelphia).
Glycosaminoglycans such as Sulodexide are known to decrease albumin excretion ui patiehis wiili diabetic nephropathy. The precise mechanism is not known but may include the following:
1) Restoration of the physiologic glomerular membrane anionic charge barrier via enhanced synthesis and sulfation of heparan sulfate in renal vascular membranes, and direct replenishment of renal hepar; sulfete,
2) Inhibition of Transforming Growfli Factor beta-1 (TGFbeta-1)** mediated mesangial matrix overproduction,
3) Inhibition of endothehn mediated tubulo-interstitial fibrosis, and
4) Inhibition of mesangial cell hyperplasia
(See Harenberg J., Med. Res. Rev, vol. 18,1-20 (1998), Gambaro G. and Van Der Woude, J. Am. Soc. Neplirol. 11:359-368 (2000))
Kanwar Y.S. et al., Sem. Nephrol. 5,307, (1985) and Groggel G.C. et al.. Kidney Int. 33, 517. (1988), have produced evidence of the probable role of glycosaminoglycans in helping the integrity and the functioning of the renal cells.
Moreover, Canfield J.P. et al.. Lab. Invest., 39, 505, (1978), previously showed a decrease of glycosaminoglycans in the glomerular basement membrane in many
conditions of nephropathy, while Baggio B. et al., Nephron.. 43,187, (1986) showed an inCTeased urinary elimination of glycosaminoglycans in diabetic, non-albuminuric, patients. This increased excretion of glycosaminoglycans in diabetic nephropathies was shown also by Partasarathy N. et al., Diabetes, 31,738, (1982).
In addition, Diamond J.R. et al.. Renal Physiol.. 9,366, (1986) and Parkerson M.B. et al., J. Clin. Invest, 81,69, (1988), showed in animals the potential protective effect of heparin and its derivatives in models of experimental nephropathy not related to diabetic nephropathy, like chronic nephrosis from aminoglycosides and renal pathologies resulting from the subtotal renal ablation in the rat.
The use of heparin, low molecular weight heparin fractions, chemically modified heparins or low molecular weight dermatan sulfate in the treatment of both diabetic nephropathy and neuropathy has been investigated in the European Patent Pubhcation EP 0513513 and U.S. Patent No. 5,236,910 (incorporated herein by reference in its entirety). The possibihty of therapeutic use was shown by means of pharmacological tests in animals: diabetes was caused by streptozotocin in Sprague Dawley male albino rats and the diabetic rats were treated with the above mentioned glycosaminoglycans. The effectiveness of treatment in animals was determined on the basis of the diminution of albuminuria and of the reduction of the thickness of the basal glomerular membrane and the increase of the glomerular anionic charges.
The use of Sulodexide to freat diabetic nephropathy is described in U.S. Patent No. 5,496,807;;co;pofated herein by reference in its entirety). This patent describes tiie effectiveness of Sulodexide in two clinical studies in which diabetic patients, some with microalbuminuria and some with macroalbuminuria, were given doses of Sulodexide. In one study Sulodexide was administered at the then recognized safe and effective dose of 1000 lipoproteinUpase releasing units/day (LRU"s/day) (equivalent tolOO mg/day). This daily dose required two 250 LRU capsules of VESSEL DUE F(R) administrated twice a day. After 60 days, 8 out of 10 diabetic patients, 4 with microalbuminuria and 4 with macroalbuminuria showed an average decrease of 44% and 35% in albimiin excretion respectively. Two ofthe patients with microalbuminia did not get any improvement. In addition, no substantial change in the glomerular filtration rate of any ofthe patients was noted at follow-up four months after the end of treatment
The second clinical trial described in U.S. Patent No. 5,496,807 involved three microalbuminuric and two macroalbuminuric diabetic patients administered 600 LRU/day of Sulodexide by intramuscular route for 21 days. All five of these patients showed a significant lowering of albumin excretion.
In neither of these studies, disclosed in the "807 patent, was the improvement in albumin excretion shown to be maintained after the Sulodexide administration ended. The dose range disclosed in this patent specification and the claims was 500 to 1500 L.R.U."s or 50 to 150mg./day.
Recently, the use of glycosaminoglycans, including Sulodexide, in the treatment of diabetic nephropathy has beoti reviewed by Gambaro G. and Van Der Woude in J. Am.Soc. Nephrol. 11:359-368 (2000). In this review Sulodexide is described as being active in preventing diabetic nephropathy in an experimental animal model, Gambaro et al. Kidney Int. 42: 285-291,1992. In addition, Sulodexide is said to have been shown to reduce albuminuria in both insulin dependent diabetes mellitus (IDDM) and non-insuhn dependent diabetes meUitus (NIDDM). (See Skiha J. et al. Diabetes Res. Clin. Pract. 38:25-51 (1997), Solini a. et al. Diabetes Nutr. Metab. 7: 304-307, (1994), Poplawska A. et al. Diabetes Res Chn. Pract. 38: 109-114, (1997), Dedov. I. et al. Nephrol Dial Transplant 12:2295-2300, (1997) and Szelanowska M. et al. Curr Med. Res. Opin. 13:539-545, (1997)).
hi these studies Sulodexide treatment in IDDM was found to be consistently effective in reducing microalbuminuria. However this hypoalbuminuric effect was observed in only 30 to 50% of NEDDM patient, and at most the effect lasted only several weeks after the withdrawal of the Sulodexide. In the studies reviewed by Gambaro the maximum dose of Sulodexide used was 100 mg/day orally and more typically doses of only 60 mg/day were used either by the oial route or by intra muscular injection. Previous experience in using Sulodexide to treat other pathological conditions had shown that doses of 25-100 mg/day (250-1000 LRU"s) were considered clinically effective.
hi addition, another reason for the use of such low doses was the concem over possible risks and side effects of a drug such as Sulodexide. For example Sulodexide is known to have antithrombotic activity equal to that of hq)arin, Thomas D.P. et al. Ann. N.Y. Acad. Sci.. 556,313 (1989) and to completely prevent clot formation at high doses. In primates the oral administration of 10 mg/kg of Sulodexide increased tissue plasminogen activator (TPA) from 5 to 10 ng/ml and produced an increase of U-PA from 3 to 6.5 ng/ml. This suggests that Sulodexide is a strong anticoagulant, antithrombotic and profibromolytic agent. Callas D.D. et aL, Thromb. Hemost.. 19 (Suppl. 1), 49 (1993).
Effective oral doses of Sulodexide have been in the range of 25-100 mg/day or 250-1000 LRU/day for tiie treatment of vascular pathologies Harenberg J., Med. Res. Rev, vol.18,1-20 (1998). The largest dose reported in flie Uterature to our knowledge for the treatment of diabetic nephropathy was an oral dose of 1000 LRU/day or 100 mg/day. This dose did decrease the rate of albumin excretion in patients with NIDDM (type II
diabetes or DM2) but the albumin excretion rate was found again increased four months after cessation of treatment Solina A. Diab. Nutr. Metabo.. 7,304 (1994).
The art concerning the use of Sulodexide to treat vascular conditions teaches that doses of 100 mg/day or 1000 LRU"s or less are effective and that higher doses may produce unwanted or dangerous heparin like efifects. However, doses in the range of 100 mg./day (lOOOLRU"s) or less, have not proved effective in all subjects with diabetic nephropathy and have not been shown to produce lasting improvement in the albumin excretion rate in treated patients. (See Harenberg J. Med. Res. Rev, vol.18,1-20 (1998) and Gambaro G, and Van Der Woude, J. Am. Soc. Nephrol. 11:359-368 (2000)). Furthermore, oral administration is much more desirable and less problematic to the patient as compared to intramucular administration.
For these reasons there is a need for oral formulations of Sulodexide in dosage formulations adapted to adequately treat diabetic nephropathy in both macro and micro albuminic patients and to produce lasting improvement in albumin excretion rate in diabetic patients.
SUMMARY OF THE INVENTION
The present invention is directed to pharmaceutical compositions of Sulodexide in unit dosages particularly well suited for the treatment of diabetic nephropathies. These pharmaceutical compositions or formulations comprise effective and non-toxic amounts of Sulodexide or a phannaceutically acceptable salt thereof within the range from about 100mg.(1000 LRU) to about 1000mg.(10,000 LRU); and a phannaceutically acceptable carrier, diluent or excipient.
The compositions are preferably pharmaceutical preparations suitable for oral administration, comprising an amount of Sulodexide sufficient to produce a substantial reduction in the albmnin excretion rate (AER) in patients with diabetic nephropathy who have micro or macro albuminuria as a result of diabetes induced changes in renal fiinctioning, together with a pharmaceutical excipient, diluent, or carrier.
The present invention encompasses single unit dosage forms comprising an amount of Sulodexide sufficient to produce an immediate and lasting reduction in AER without significant adverse side effects.
In addition, this invention encompasses methods of treating patients with diabetic nephropathy using these specific dosage formulations.
The doses of Sulodexide disclosed in the present invention are novel in the treatment of diabetic nephropathy and are based, at least in part, on the discovery that such
doses produce lasting improvement in albumin excretion rate and do not produce the expected toxic effects.
These and other features, aspects and advantages of the present invention will become better understood with reference to the following description, figure and appended claims.
BRIEF DESCRIPTIONS OF THE DRAWINGS
Fig. 1 shows the percent albumin excretion rate (AER) reduction in DM2 patients (micro and macro albuminuric patients combined).
DETAILED DESCRIPTION OF THE INVENTION
The present invention encompasses pharmaceutical compositions for the treatment of a human suflFering from diabetic nephropathy with micro or macro albuminuria which encompasses an amount of Sulodexide, preferably in orally administratable form, said amount of Sulodexide being sufficient to significantly decrease the amount of albumin excreted in the urine of a patient with diabetic nephropathy.
Sulodexide is available commercially imder the trademark VESSEL DUE F(r), and it can be made by the methods disclosed in U.S. Patent 3,936,351.
This invention is based in part on the discovery of unexpected benefits of using doses of Sulodexide in humans much higher than previously used, including the absence of expected adverse side efiEects at the higher dose levels. The unexpected benefits of the higher doses are demonstrated in patients given oral Sulodexide for the treatment of diabetic nephropathy.
The effectiveness of these hi;er doses is unexpected because in the treatment of conditions other than diabetic nephropathy much lower doses of Sulodexide have been used and found clinically effective. Even in the treatmrait of diabetic nephropathy doses of Sulodexide larger than 100 mg/day or 1000 LRU"s have nevar been reported and to our knowledge the art does not teach that hi;er doses would be effective and non-toxic. In addition, the possibility of adverse heparin like side efifects was well known and this constituted teaching away from the use of tiiese higher doses of Sulodexide.
The present invention enconq)asses a method for treating diabetic nephropathy in a human which comprises administering to said htunan an amount of Sulodexide or a pharmaceutically acceptable salt thereoi; of from about lOOmg. (1000 LRU) to lOOOmg. (10,000 LRU) in a sohd unit dosage form, said amount being administered one or more times per day and said amount being sufficient to reduce the albumin excretion rate
but insufficient to cause adverse side effects. In addition, the present invention encompasses unit dose forms of Sulodexide of about; lOOmg, 125mg, 150mg, 175mg, 200mg, 225mg, 250mg, 275mg, SOOmg, 325mg, 350mg, 375mg, 400mg, 425mg, 450mg, 475mg, 500mg, 525mg, 550mg, 575mg, 600mg, 625mg, 650mg, 675mg, 700mg, 725mg, 750mg, 775mg, 800mg, 825mg, 850mg, 875mg, 900mg, 925mg, 950mg, 975mg, and lOOOmg.
The therapeutic effectiveness of Sulodexide at high doses has been evaluated in a placebo controlled double-blind study. The results of this study reported in the example show below compared placebo treatment with 200 mg/day of Sulodexide and showed a 70% reduction in AER in patients with IDDM (DM1) and 77% reduction in AER in patients with NIDDM (DM2) compared to a 48% reduction and 52% in patients treated with a 100 mg/day dose for four months. Even more dramatic was the improvement in albumin excretion rate shown at follow-up, four months post treatment. In this follow up portion of the study the 200 mg/day dose produced a 62% reduction in AER in DM1 patients and a 63% reduction in AER in DM2 patient compared to 38% and 18% reductions respectively in patients receiving 100 mg/day.
Thus, patients with DM2 receiving 200 mg/day of Sulodexide showed more than three times the reduction in albumin excretion at a point four months post treatment as compared to the patients receiving 100 mg/day. This dramatic non-linear effect of high dose Sulodexide was highly significant clinically and unexpected.
The following example is given to illustrate the invention and caimot be taken on a limitation of the invention itself.
Oral Treatment of Albimiinuria in Nepbropathic Diabetic Patients with Sulodexide.
The objective of this study was to evaluate the efficacy of three dose regimens of oral Sulodexide versus placebo, in both DM1 and DM2 patients with diabetic nephropathy and albuminuria.
The experimental methodology was to randomly divide 240 patients with ■diabetic nephropathy and albununuiia into four groups. Tliese groups received treatment with placebo or with oral Sulodexide at doses of 50,100 or 200 mg per day. The active treatment phase was four months long and this was followed by an additional post treatment foUow up after four mouths. The assignment and treatment of the patients was done in a double blind fashion.
hiclusion criteria for the study required a stable blood pressure of less than l60/90y a serum creatinine of less than 150 fimol/L, proteinuria of less than 3 g/day and stable HgBAlC.
The primary end point changes in albumin excretion rate (AER) were determined by three overnight urine collections (analysis by ANTCOVA adjusting for the baseline value of log AER).
The results demonstrated that the percent reduction in AER after 4 months treatment with Sulodexide was significantly different fi:om placebo, and approximately linear to dose increments. The group receiving Sulodexide at 50 mg/day had a 31% reduction in AER (p = 0. 0026), the 100 mg/day group, a 50% reduction (p = 0.0001), and the 200 mg/day group a 75% reduction (p = 0.0001). After 4 months follow-up, the Sulodexide 100 mg group maintained a 28% AER reduction compared to placebo (p = 0.0179), and the 200 mg group maintained a 65% reduction (p = 0.0001). Sub-analysis by type of diabetes (DM1 vs. DM2), micro vs. macroalbuminuria, and patients treated with or without ACE inhibitors demonstrated similar reductions in AER. Sulodexide at all dose levels was well tolerated. There were no significant changes in hemotologic, coagulation, and liver fiction parameters among the four groups. No deaths were recorded.
The conclusions were that oral Sulodexide reduces AER in patients with diabetic nephropathy caused by both DM1 and DM2 who are demonstrating micro or caacroalbuminuria. The study showed no evidence of a plateau effect with the maximum doses used in this study. This was very significant and unexpected because the maximum dose used in this study was twice the maximum dose of Sulodexide used in any prior studies.
In addition, the about of oral Sulodexide to reduce albuminuria persisted following a four month cessation of treatment This effect was a dramatic and unexpected finding and demonstrated a lasting beneficial effect of Sulodexide at hi; doses. This may be due to replenishment of the glomerular membrane electrostatic charge barrier or some other about of hi; dose Sulodexide to produce a "healing" effect.
The additional efficacy of high dose Sulodexide was observed even in diabetic nephropathy patients already taking ACE inhibitors.
These findings show the apathy of Sulodexide to lower albuminuria in nephropathic diabetic patients on a long ten basis, beyond improvements achieved with ACE inhibitors. This may be of particular important in NIDDM or DM2 nephropathic patients, who respond less well to ACE inhibitors and who compromise the fastest growing group of patients with ESRD.
The pharmaceutical compositions of tiie present invention comprise Sulodexide as tiie active ingredient, and may also contain a pharmaceutically acceptable carrier, excipient or diluents and optionally other therapeutic ingredients.
Any formulation suitable for oral administration may be used in the present invention. These dosage forms include tablets, coated tablets, caplets, hard gelatin casuals, soft gelatin capsules, troches, draggers, dispersions, suspensions, solutions, patches and the like, including sustained release formulations well known in the art See, e.g.. Introduction to Pharmaceutical Dosage Forms, 1985, Ansel, H.C., Lea and Feigner, Philadelphia, PA; Remington"s Pharmaceutical Sciences. 1995, Mack Pub. Co., Easton, PA.
In practical use, the active agent (Sulodexide) in the pharmaceutical compositions of the invention can be combined as the active ingredient in intimate admixture witan a pharmaceutically acceptable carrier according to conventional pharmaceutical compounding techniques. The carrier may take a wide variety of forms and comprises a number of components depending on the form of preparation desired for administration. The compositions of the present invention include, but are not limited to, suspensions, solutions and ehxirs; aerosols; or excipients, including, but not limited to.
WE CLAIM :
1. A unit dosage form comprising per dosage unit 200 mg sulodexide or a
pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable
carrier, diluents or recipients, which composition is suitable for oral
2. The unit dosage form as claimed in claim 1, wherein the medicament is
administered orally as a tablet, a capsule or a liquid suspension.
3. The unit dosage form as claimed in claim 1 or claim 2, wherein the
medicament is administered in one to four unit doses per day.
4. The unit dosage form as claimed in claim 1, wherein the medicament
administered orally as a tablet, coated tablet, caplet, hard gelatin capsule,
soft gelatin capsule, troche, dragger, dispersion, suspension or solution.
|Indian Patent Application Number||2/CHENP/2003|
|PG Journal Number||13/2008|
|Date of Filing||01-Jan-2003|
|Name of Patentee||ALFA WASSERMANN, INC|
|Applicant Address||4 Henderson Drive, West Caldwell, NJ 07006,|
|PCT International Classification Number||A61K 31/726|
|PCT International Application Number||PCT/US2001/018411|
|PCT International Filing date||2001-06-06|