Note: Descriptions are shown in the official language in which they were submitted.
1~787~8
1125X
PHARMACEUTICAL COMPOSITION FOR COMBINATION THERAPY
OF HORMONE DEPENDENT CANCERS
This invention relates to a combination
therapy of sex steroid dependent cancers in susceptible
warm-blooded animals including humans comprising
administering to such animals whose hormone output of
their testes or ovaries respectively is blocked a
pharmaceutically effective amount of an antiandrogen
and/or an antiestrogen and/or at least one inhibitor of
sex steroid biosynthesis to the animal whose hormone
output of the testes or ovarles, respectively, is
blocked, wlth the provlso that the method of treating
prostate cancer comprises admlnistering
pharmaceutically effective amounts of an antiandrogen
and at least one inhibitor of sex steroid biosynthesis
and the method of treating breast cancer comprises
administering a pharmaceutically effective amount of an
antiandrogen or of at least one inhibitor of sex
steroid biosynthesis or of an antiandrogen and an
antiestrogen or of an antiandrogen and at least one
inhibitor of sex steroid biosynthesis or of an
antiestrogen and at least one inhibitor of sex steroid
biosynthesis or of an intiandrogen and an antiestrogen
and at least one inhibitor of sex steroid
biosynthesis. In the therapy of sex steroid dependent
l~7s7~a
cancers such as testicular cancer, ovarian cancer,
colon-rectal cancer, renal cancer, pancreatic cancer,
liver cancer, stomach cancer, skin cancer, uterine
cancer, brain cancer and larynx cancer all above listed
combinations are applicable. The hormone output of the
animal's testes or ovaries, respectively, can be
blocked by surgical or chemical means. (In post-
menopausal women~ the attending clinicians may decide
that the hormone output of the ovaries need not be
blocked.)
While various investigators have been
studying hormone~dependent breast and prostate cancer,
none have proposed the combination therapy of this
invention.
A. V. Schally et al., Cancer Treatment
Reports, 68, (No. 1) 281-289 tl984), summarize the
results of animal and clinical studies on growth
inhibition of hormone-dependent mammary and prostate
tumors by use of analogues of luteinizing hormone-
releasiny hormones, the so-called LH-RH agonists and
suggest that LH-RH analogs and/or antagonists may have
potential for treating breast cancer.
T. W. Redding and A. V. Schally, Pro. Natl~
Acad. Sci. USA, R0, 14S9-1462 ~1983), disclose
reduction of estrogen-dependent mammary tumors in rats
and mice by use of an LH-RH agonist, [D-Trp6]LH-RH or
of two specific antagonists and inhibition of prostate
tumor growth in rats of chronic use of an LH-RH
agonist, [D-Trp6] LH-RH.
In U.S. Patent 4,071,622, it is disclosed
that use of certain LH-RH agonists causes regression of
DMBA-induced mammary carcinoma in rats.
In U.S. Patent 4,472,382, it is disclosed
that prostate adenocarcinoma, benign prostate
1'~787~L8
--3--
hypertrophy and hormone-dependent mammary tumors may be
treated with various LH-RH agonists and that prostate
adenocarcinoma and benign hypertrophy may be treated by
use of various LH-RH agonists and an antiandrogen.
However, there is no suggestion or disclosure of the
present invention.
Some clinical improvement in premenopausal
women with breast cancer by use of the two LH-RH
agonists, Buserelin and Leuprolide, is also reported by
H.A. Harvey et al. "LH-RH analogs in the treatment of
human breast cancer", LH-RH and its Analogs - A New
Class of Contraceptive and Therapeutic Aqents (B.H.
Vickery and J.J. Nestor, Jr., and E.S.E. Hafez, eds)
Lancester, MTP Press, ~1984) and by J.G.M. Klijn et al.
"Treatment with luteinizing hormone releasing hormone
analogue (Buserelin) in premenopausal patients with
metastatic breast cancer", Lancet, 1, 1213-1216 (1982).
Treatment of advanced breast cancer with
aminoglutethimide after therapy with the antiestrogen,
Tamoxifen is clisclosed by A.V. Buzdar et al., Cancer,
50, 170~-1712 (1982).
Il. Flax et al., Lancet, l204-1207, (1973),
suggest some women's br~st cancers are androgen-
dependent.
In U.S. Patent 4,329,364, it is disclosed
that the antiandrogen, 4'-nitro-3'-trifourormethyl
isobutyranilide may be used for treatment of prostatic
cancer.
Some clinical improvement in men with
prostate cancer by use of the two LH-RH agonists,
Buserelin and Leuprolide, is also reported by N. Faure
et al. at pages 337-350 and by R.J. Santen et al. at
pages 351-364, respectively, LH-RH and its Analogs - A
New Class of Contraceptive and Therapeutic Aqents (B.H.
l~7a7~s
--4--
Vickery and J.J. Nestor, Jr., and E.S.E. Hafez, eds)
Lancester, MTP Press, (1984).
R. Santen et al., The Journal of Steroid
Biochemistry, Volume 20, No 6B, at page 1375 (1984),
disclose that use of ketoconazole in combination with
chronic administration of Leuprolide in rodents
decreased basal and Leuprolide stimulated testosterone
levels.
D. Kerle et al., The IJournal of Steroid
Biochemistry, Volume 20, No 6B, at page 1395 (1984)
disclose that the combined use of a LH-RH analogue and
ketoconazole produced objective responses in some
prostate cancer patients who have relapsed or failed to
respond to treatment with a LH-RH analogue alone.
F. Labrie et al., Abstracts of 7th
International Congress of Endrocrinology, Excerpta
~1edica (1984) at page 98 discloses that treatment of
prostate cancer patients with LH-RH agonists alone
causes a transient increase in serum androgen levels
lasting for 5 to 15 days before castration levels are
reached. While F. Labrie et al. recommends that
orchiectomy, estrogen and LH-RH agonists alone should
not be further used for treatment of prostate cancer in
the absen~e of a pure antiandrogen, there still is a
need fo~ a method of treatment of prostate canceL that
effects mOLe complete androgen blockage at the start as
well as during the full period of treatment.
F. Labrie et al., The Prostate, 4, 579-594
~1983), disclose that use of a combination therapy of
an LH-RH agonist (Buserelin) and an antiandrogen
(Anandron) to treat advanced prostate cancer in
previously untreated patients effects simultaneous
inhibition of androgens of both testicular and adrenal
origin.
l~7a~s
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F. Labrie et al., J. Steroid Biochem., 19,
99-1007 (1983), disclose the treatment of prostate
cancer by the combined administration of an LH-RH
agonist and an antiandrogen. Labrie et al. disclose
animal and clinical data in support of the proposition
that the combined LH-RH/antiandrogen treatment
neutralizes the stimulatory influence of all androgens
on the development and growth of androgen-dependent
prostatic cancer.
In U.S. Patent 4~,094,994, it is disclosed
that the use of antiestrogens such as meso-3,4-bis(3'-
hydroxyphenyl)hexane inhibits MCF7 human breast tumor
cells. In fact, the inhibitory activity of the anti-
estrogen was antagonized by estradiol.
H. Mouridsen et al,. Cancer Treatment Review
5, 131-141, (1978), disclose that Tamoxifen, an
antiestrogen is effective in remission of advanced
breast cancer in about 30~ of the patients treated.
J.G.M. Klijn et al., ~J. Steroid Biochem,
Vol. 20 l~o. 6B), 1381 ~198~), disclosed the combined
use of the antiestrogen, Tamoxif0n, and the LH-RH
agonist, Buscrelin, for tr0atment of breast cancer is
krlown, but obj0etiv~ remiss;on of such cancers remains
low ~35'~).
The present invention provides a new
combination therapy of sex steroid dependent cancers
which inhibits tumor growth and metastases and causes
in some instances complete remission. The invention is
exemplified by detailed discussion of the therapy of
breast cancer and prostate cancer. The therapy of
other sex steroid dependent cancers (listed above) is
carried out analogously.
In one aspect, the invention provides a
method of treating sex steroid dependent cancers such
l~7874a
--6--
as, for example, breast cancer in a warm-blooded female
animal in need of such treatment which comprises
administering to said animal whose hormone output of
the ovaries is blocked, a therapeutically effective
amount of an antiandrogen or a pharmaceutical
composition thereof. The ovarian hormonal secretions
of said animal can be blocked by surgical or chemical
means. In one aspect, the invention provides a method
of treating sex steroid dependent cancers such as, for
example, breast cancer in a castrated warm-blooded
female animal, i.e., such a female animal whose ovaries
are blocked by surgical or chemical means from
secreting estrogen, which comprises administering to
such a female in need of such treatment an antiandrogen
in association with at least one inhibitor of sex
steroid biosynthesis and, optionally, an antiestrogen,
or pharmaceutical compositions thereof, in amounts
sufficient to treat such cancers, e.g., breast
cancer. In another aspect, the invention provides a
method of treating sex steroid dependent cancers such
as, for examplo, breast cancer in a warm-blooded animal
in need of such treatment which comprises blocking the
ovarian hormonal secretions of said animal hy surgical
or chemical means and administering to said animal
therapeutically effective amounts of an antiestrogen in
association with at least one inhibitor of sex steroid
biosynthesis, or pharmaceutical compositions thereof.
In one aspect, the invention provides a method of
treating sex steroid dependent cancers such as, for
example, breast cancer in a warm-blooded animal whose
ovaries are blocked by surgical or chemical means from
secreting estrogen, which comprises administering to an
animal in need of such treatment an antiandrogen and an
antiestrogen, or pharmaceutical compositions thereof,
1-~787~8
--7--
in amounts sufficient to treat such cancers, e.g.,
breast cancer.
By completely bloclcing sex steroids
~androgens and estrogens) production and/or action, the
present invention provides a method of inhibiting the
growth of sex steroid-sensitive tumors, e.g., breast
tumors in warm-blooded animals having such tumors.
In female mammals, the ovaries may be surgic-
ally removed ~oophorectomy) but preferably the
secretion of estrogens from the ovaries is blocked by
chemical castration by administering an effective
amount of an LH-RH agonist or antagonist. Thus, in a
preferred aspect, the present invention provides a
method of treating sex steroid dependent cancers such
as, for example, breast cancer in a warm-blooded female
animal, which comprises administering to such a female
in need of such treatment an LH-RH agonist or
antagonist, in association with an antiandrogen and/or
an antiestrogen and/or at least one inhihitor of sex
steorid biosynthesis according to the invention,
preferably an antiandrogen. Preferably in this
treatment at least one inhibitor of sex steroid
biosynthesis, or pharmaceutical compositions thereof,
and/or antiestrogen is administered.
In its preferred aspect, the LH-RH agonist is
administered parenterally ~subcutaneously or intra-
muscularly or intranasal) and, in association there-
with, the antiandrogen and the inhibitor of sex steroid
biosynthesis and/or antiestrogen are each administered
orally.
Thus, this invention provides a novel method
for effective treatment of sex steroid dependent
cancers such as, for example, female breast cancer, in
the absence of antiestrogen. In addition, the amounts
l~7s7~a
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of antiestrogen required when administered in
association with this combined therapy are lower than
normally used in prior art methods, e.g., J.G.M. Klijn
et al., J. Steroid Biochem. 20 (No. 6B) 1381 ~1984), to
treat breast cancer, and thus, the harmful effects of
relatively large doses of antiestrogen are minimized.
In one preferred aspect, the present
invention provides an effective method of treating sex
steroid dependent cancers such as, for example, breast
cancer in warm-blooded female animals in need of such
treatment by administering an LH-RH agonist or
antagonist, in association with an antiandrogen and an
inhibitor of sex steroid biosynthesis or pharmaceutical
compositions thereof in amounts sufficient to inhibit
tumor growth. These active compounds can be
administered together or in any order as discussed
hereinafter.
To assist in determining the effect of the
treatment, blood plasma concentrations of the sex
steroids of adrenal and ovarian origin, i.e., precursor
steroids, androgens and estrogens, and tumor size are
measured. Lowered concentrations of sex steroids and
reduction in tumor size are indicative of successful
treatment, e.g. inhibition of tumor growth using active
compounds described herein in accordance with the
present invention. The concentrations of adrenal
androgens and estrogens such as dehydroepiandrosterone
(DHEA), DHEA-sulfate tDHEAS), androst-5-ene-3R,17B-diol
(~5-diol) and, the ovarian estrogen, 17B-estradiol (E2)
are measured by standard methods well known to those
skilled in the art, see for example F. Labrie et al.,
The Prostate, _, 579-594 (1983).
The change in tumor size is measured by
standard physical methods well known to those skilled
l~7~74a
in the art, e.g., bone scan, chest X-ray, skeletal
survey, ultrasonography of the liver and liver scan (if
needed), CAT-scan and physical examination.
While a LH-RH agonist or a LH-RH antagonist
may be used in one preferred aspect of the present
invention, the use of a LH-RH agonist is more
preferred.
In another aspect, the invention provides a
method of treating sex steroid dependent cancers
(excluding prostate cancer) such as, for example,
breast cancer in a warm-blooded male animal in need of
such treatment which comprises blocking the testicular
hormonal secretions of said animal by surgical or
chemical means and administering to said animal a
therapeutically effective amount of an antiandrogen, or
a pharmaceutical composition thereof. In another
aspect, the invention provides a method of treating sex
steroid dependent cancers (excluding prostate cancer)
such as, for example, breast cancer in a castrated
warm-blooded mal0 animal, i.e., such a male animal
whose teste~s are blockod by surg;cal or chemical means
from secreting andro~en, which comprises administering
to an animal in neod o such treatment therapeutically
effective amounts of an antiandrogen in assocciation
with at least one inhibitor of sex steroid
biosynthesis, or a pharmaceutical composition thereof,
in an amount sufficient to treat the cancer. In
another aspect, the invention provides a method of
testing sex steroid dependent cancers (excluding
prostate cancer) such as, for example, breast cancer in
a castrated warm-blooded male animal, which comprises
administering to an animal in need of such treatment
therapeutically effective amounts of an antiandrogen
and an antiestrogen, optionally in association with at
3',~787~La
--10--
least one inhibitor of sex steroid biosynthesis. By
simultaneously blocking sex-steroids (androgens and
estrogens of testicular and adrenal origin) production
and/or action, the present invention provides a method
of inhibiting the growth of sex steroid-sensitive
~breast) tumors in warm-blooded male animals having
such tumors.
In male mammals, the removal of testicular
androgens may be achieved by surgical castration but
preferably the secretion of androgens from the testes
is blocked by chemical castration by administering to
the warm-blooded male animal, an effective amount of an
LH-RH agonist or antagonist. Thus, in a preferred
aspect, the present invention provides a method of
treating sex steroid dependent cancers (excluding
prostate cancer) such as, for example, breast cancer in
a warm-blooded male animal, which comprises
administering to an animal in need of such treatment an
LH-RH agonist or antagonist in association with an
antiandroyen and/or an antiestrogen and/or at least one
inhibitor of sex steroid biosynthesis as discussed in
the preceding paragraph, preferably in association with
an antiAndrogen, or a pharmaceutical composition
thereof, in amounts sufficient to treat the cancer.
In its preferred aspect, the LH-RH agonist or
antagonist is administered parenterally (sub-
cutaneously or intramuscularly) and the antiandrogen,
the antiestrogen and the inhibitor(s) of sex steroid
biosynthesis (if used) are administered orally.
In one preferred aspect, the present
invention provides an effective method of treating sex
steroid dependent cancers ~excluding prostate cancer)
such as, for example, breast cancer in warm-blooded
male animals in need of such treatment by administering
~7874a
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a LH-RH agonist or antagonist in association with an
antiandro~en or pharmaceutical compositions thereof in
amounts sufficient to inhibit tumor growth. The use of
an LH-RH agonist in association with an antiandrogen
produced almost complete blockage of testicular steroid
secretion while simultaneously blocking about 25 to 60%
of the precursor sex steroids ~androgens and estrogens)
of adrenal origin. See Figure 3 and Example 1. In
still another preferred aspect, at least one inhibitor
of sex steroid biosynthesis is administered to warm-
blooded male animals having sex steroid dependent
cancers (excluding prostate cancer) such as, for
example, breast cancer in association with surgical
castration or chemical castration (by use of an LH-RH
agonist or antagonist) and the antiandrogen. These
active compounds can be administered together or in any
order as discussed hereinafter.
To assist in determining the effect of the
treatment, blood plaYma concentrations of the testical
and adrenal androgens and estrogens and tumor size are
measured. Lowered concentrations of sex steroids and
precurso~s and reduction in tumor size are indicative
of successful treatment, e.g. lnhibition Oe tumor
growth. The concentratlons of adrenal androgens and
estrogens such as dehydroepLandrosterone ( DHEA), DHEA-
sulfate ( DHEAS ), androst-5-ene-3~,17~-diol ~5-diol)
and, the estrogen, 17~-estradiol ~E2) are measured by
standard methods well known to those skilled in the
art, see for example F. Labrie et al., The Prostate, 4,
579-594 (1983).
The active compounds described herein and
used in accordance with the present invention exhibited
tumor growth inhibition and lowered concentrations of
sex steroids when tested in warm-blooded male animals
~,~7a~8
-12-
including man. See Figure 1-2 and 3 and the
descriptions thereof in Example l.
The change in tumor size is measured by
standard physical methods well known to those skilled
in the art, e.g., bone scan, chest X-ray, skeletal
survey, ultrasonography of the liver and liver scan (if
needed), CAT-scan and physical examination.
While a LH-RH agonist or a LH-RH antagonist
may be used in one preferred aspect of the present
invention, the use of a LH-RH agonist is more
preferred.
In another aspect, the invention provides a
method of treating sex steroid dependent cancers such
as, for example, pLOState cancer in a warm-blooded male
animal including humans in need of such treatment which
comprises blocking the testicular hormonal secretions
of said animal by surgical or chemical means and
administering to said animal a therapeutically
effective amount of an antiandrogen in association with
at least one inhibitor of sex steroid biosynthesis, or
pharmaceutical compositions thereof. By simultaneously
blockin(~ androgens o testicular and adLenal origin
production and/or actlon, the present inventlon
provides a method of inhibiting the growth of sex
steroid-sensitive carcinomas in warm-blooded male
animals having such carcinomas.
In male mammals, the removal of testicular
androgens may be achieved by surgical castration
torchiectomy) but preferably the secretion of androgens
from the testes is blocked by chemical castration by
administering to warm-blooded male animal, an effective
amount of an LH-RH agonist or antagonist. In a
preferred aspect, the present invention provides a
method of treating sex steroid dependent cancers such
1~78~48
-13-
as, for example, prostate cancer in a warm-blooded male
animal having such cancer, which comprises
administering to said animal therapeutically effective
amounts of an LH-RH agonist or antagonist in
association with ar antiandroyen and at least one
inhibitor of sex steroid biosynthesis, or
pharmaceutical compositions thereof.
In its preferred aspect, the LH-RH agonist is
administered parenterally (subcutaneously or intra-
muscularly) and the antiandrogen and the inhibitor(s)
or inhibitors of sex steroid biosynthesis are each
administered orally.
In one preferred aspect, the present
invention provides an effective method of treating sex
steroid dependent cancers such as, for example,
prostate cancer in warm-blooded male animals in need of
such treatment by administering a LH-RH agonist or
antagonist in association with an antiandrogen and an
inhibitor of sex steroid biosynthesis of testicular
origin or pharmaceutical compositlon~ thereo in
amounts suf~ici0nt to inhibit such cancer. ~y use of
an inhibito~ of te~ticular s0x steroid biosynthesis in
association with an antiandro~J~n and a Ltl-RH ayonist or
antagonist more complete androgen blockage is effected
at an early stage in the treatment o such
(particularly prostate) cancer than achieved by prior
art methods. If an inhibitor of sex steroid
biosynthesis of both testicular and adrenal origin
(such as, for example, aminogluethimide) is used, the
administration of the inhibitor is started on the first
day o treatment and continued thereafter to block
adrenal steroid synthesis.
In another preferred aspect, the use of an
LH-RH agonist or antagonist in association with an
7~74l3
-14-
antiandrogen and two inhibitors of sex steroid
biosynthesis, e.g an inhibitor of adrenal sex steroid
biosynthesis such as aminoglutethimide and an inhibitor
of testicular sex steroid biosynthesis such as
ketoconazole, produced almost complete blockage of
testicular steroid secretion while simultaneously
blocking the precursor sex steroids ~androgens and
estrogens) of adrenal origin at an early stage of the
treatment. While such complete blockage of androgen
secretion and/or action has not been achieved by prior
art methods, such complete blockage can be achieved and
maintained throughout the period of treatment in
accordance with the present invention. These active
compounds can be administered together or in any order
as discussed hereinafter.
To assist in determining the effect of the
treatment, blood plasma concentrations of the adrenal
and testical androgens and estrogens and parameters of
cancer evolution are measured according to known
methods. Lowe~ed concentrations of sex steroids and
reduction in pro.state or metastatic tumor size are
indicative Oe successEul treatment, e,g. inhibition of
prostatic cancer eell growth. The concentrations of
adrenal steroids such as dehydroepiandrosterone ~DHEA),
DHEA-sulfate ~DHEAS), androst-5-ene-3~,17~-diol (~5-
diol) and, the estroyen, 17~-estradiol ~E2) are
measured by standard methods well known to those
skilled in the art, see for example F. Labrie et al.,
The Prostate, 4, 579-594 (1983).
P~ostatic size is measured by rectal
examination and by transrectal ultrasonography.
Objective assessment of the effect of the treatment is
also measured by standard physical methods well known
to those skilled in the art, e.g., bone scanning, X-
l~7s7~a
-15-
ray, skeletal survey, intravenous pyelography, CAT-scan
and physical examination. The response criteria for
prostate cancer developed by the U.S.A. National
Prostate Cancer Project (The Prostate, 1, 375-382) may
also be used.
The use of therapeutically effective amounts
of the inhibitor of testicular sex steroid biosynthesis
such as ketoconazole or aminoglutethimide in associa-
tion with the antiandrogen and the LH-RH agonist or LH-
RH antagonist in accordance with the present invention
effectively surpresses the serum sex steroid levels,
especially serum testosterone and dihydrotestosterone
concentrations stimulated by treatment with LH-RH
ayonist at the start of the treatment even in the
presence of an antiandrogen.
While a LH-RH agonist or a LH-RH antagonist
may be used in one preferred aspect of the present
invention, the use of a LH-RH agonist is more
preferred.
The components used in the above described
aspects oE the inventlon are descrlbe~ in more detail:
Hy the term "LH-RH agonist" is meant
synthetic analogues of the natural luteinizing hormone-
releasin(~ hormone ~LH-RH), a decapeptide of the
structure:
L-pyroylutamyl-L-histidyl-L-tryptophyl-L-seryl-L-
tyrosyl-ylycyl-L-leucyl-L-arginyl-L-prolylglycyl-
NH2
Typical suitable LH-RH agonists include
nonapeptides and decapeptides represented by the
formula:
L-pyroglutamyl-L-histidyl-L-tryptophyl-L-seryl-
L-tyrosyl-X-Y-L-arginyl-L-prolyl-Z
1~7B7~3
-16-
wherein X is D-tryptophyl, D-leucyl, D-alanyl,
iminobenzyl-D-histidyl, 3-(2-naphthyl)-D-alanyl, O-
tert-butyl-D-seryl, D-tyrosyl, D-lysyl, D-phenylalanyl
or N-methyl-D-alanyl and Y is L-leucyl, D-leucyl, N-
methyl D-leucyl, Na-methyl-L-leucyl or D-alanyl and
wherein Z is glycyl-NHRl or NHRl wherein Rl is H, lower
alkyl or lower haloalkyl. Lower alkyl includes
straight or branched chain alkyls having 1 to 6 carbon
atoms, e.g., methyl, ethyl, propyl, pentyl or hexyls,
iso-butyl, neopentyl and the like. Lower haloalkyl
includes straight and branched chain alkyls of 1 to 6
carbon atoms having a halogen substituent, e.g., -CF3,-
CH2CF3, -CF2CH3. Halogen means F, Cl, B~, with F being
preferred.
Preferred nonapeptides wherein Y is L-leucyl
and X is an optically active D-form of selected amino
acids and ~ is NHC2H5 are [D-Trp6, des-gly-NH210]-LH-RH
ethylamide (X = D-Trp6); [D-Ser-~t-BuO~6, des-gly-
NH210]- LH-RH ethylamide [X = D-Ser(t-BuO6)]; [D-Leu6,
des-gly-NI-I210]-LH-REI ethylamide (X = D-Leu6), [D-
His(i~z1)6, des-gly-NH210¦LH-RH ethylamide (X =
iminobenzyl-l)-liis6) and [i)-AIa6, des-gly-NH210]-LEI-RH
ethylamide ~X - D-Ala6).
PLeferred decapeptides include [D-Trp6]-LM-RH
wherein X = D-Trp, Y = L-leucyl, Z = glycyl-NH2,
[D-Phe6]-LH-RH wherein X = D-phenylalanyl, Y = L-leucyl
and Z = glycyl-HN2) or [D-Nal(2)6]LH-RH which is [(3-
~2-naphthyl)-D-Ala6]LH-RH wherein X = 3-~2-naphthyl)-D-
alanyl, Y = L-leucyl and Z = glycyl-NH2.
Other LH-RH agonists useful within the scope
of this invention are the a-aza analogues of the
natural LH-RH, especially, [D-Phe6,Azglyl0]-LH-RH, [D-
Tyr~Me)6, Azglyl0]-LH-RH, and [D-Ser-~t-BuO)6,
1 ~787~
-17-
Azgly10]-LH-RH disclosed by A.S. Dutta et al. in J.
Med. Chem., 21, 1018 (1978) and US Patent 4,100,274 as
well as those disclosed in U.S. Patent Nos. 4,024,248
and 4,118,483.
Typical suitable LH-RH antagonists include
[N-Ac-D-p-Cl-Phel'2, D-Phe3, D-Arg6, D-Ala10]-LH-RH
disclosed by J. Ercheggi et al., Biochem. ~iophys.
Res. Commun. 100, 915-920, ~1981); [N-Ac-D-p-Cl-Phel'2,
D-Trp3, D-Arg6, D-Ala10] LH-RH disclosed by D.H. Coy et
al., Endocrinology, 110: 1445-1447, (1982); [N-Ac-D-
~3-(2-naphthyl)-Ala)l, D-p-Cl-Phe2, D-Trp3, D-
hArg(Et2)6,D-Ala10]-LH-RH and [N-Ac-Prol, D-p-F-Phe2,
D-~3-~2-naphthyl)Ala3'6]-LH-RH disclosed by J.J. Nestor
et al. J. Steroid Biochem., 20 (No. 6B), 1366 (1984);
the nona - and decapeptides analogs of LH-RH useful as
LH-RH antagonists disclosed in U.S. Patent 4,481,190
(J.J. Nestor et al.); analogs of the highly constrained
cyclic antagonist, cycle [~3 Prol, D-p-Cl-Phe2, D-
Trp3'6, N-Me-Leu7, R-Ala10]-LH-RH disclosed by J.
Rivier, J. Steroid Biochem., 20, ~No. 6B), 1365 ~1984),
and [N-Ac-D- ~ 3-~2-naphthyl)-Alal, D-p-F-Phe2, D-Trp3~
D-Arg6J-Lil-Rii disclosed by A. Corhin et al., J. Steroid
Biochem. 2() ~No. 6B) 1369 ~1984).
Other LH-RH agonist and antagonist analogs
are disclosed in LH-~H and Its Analogs, B.H. Vickory et
al. editoL~s at pages 3-10 ~J.J. Nestor), 11-22 ~J.
Rivier et al.) and 23-33 ~J.J. Nestor et al.)
The LH-RH agonists and antagonists useful in
this invention may conveniently be prepared by the
method described by Stewart et al. in "Solid Phase
Peptide Synthesis" ~published in 1969 by Freeman ~ Co.,
San Francisco, page 1) but solution phase synthesis may
also be used.
The nona- and decapeptides used in this
~787~3
-18-
invention are conveniently assembled on a solid resin
support, such as 1% cross-linked Pro-Merrifield resin
by use of an automatic peptide synthesizer. Typically,
side-chain protecting groups, well known to those in
the peptide arts, are used during the
dicyclohexylcarbodiimide-cataylzed coupling of a tert-
butyloxycarbonylamino acid to the growing peptide
attached to a benzhydrylamine resin. The tert-
butyloxycarbonyl protecting groups are removed at each
stage with trifluoroacetic acid. The nona- or
decapeptide is cleaved from the resin and deprotected
by use of HF. The crude peptide is purified by the
usual techniques, e.g., gel filtration, HPLC and
partition chromatography and optionally
lyophilization. See also D. H. Coy et al., J. Med.
Chem. _, pages 423-425, (197fi).
Typical suitable antiandrogens include non-
steroidal antiandrogens such as the imidazolidines,
especially 1-~3'-trifluoromethyl-4'-nitrophenyl)-4,4-
dimethyl-imida2O1ine-2,5-dion~ ~also called Anandron)
described in U.S. Patent No. 4,097,578, or 4'-nitro-3'-
trifluoromethylisobutyranilide ~also called flutamide)
described in U.S. Patent 4,329,364 as well as the N-
(phenylalkanoyl)aniline derLvatives disclosed in U.S.
Patent 4,386,080 and the 3,4-disubstituted - branched-
chain acylanilides disclosed in U.S. Patent 4,239,776
(A.T. Glen et al). Flutamide is the preferred
antiandrogen.
Typical suitable steroidal antiandrogens
include 6-chloro-1,2-dihydro-17-~acetyloxy)-3'H-
cyclopropa[l,2]pregna-1,4,6-triene-3,20-dione,
available under the trademark of Androcur from Schering
A.G., ~. ~erlin and 17-acetyloxy-6-methylpregna-4,6-
diene-3,20-diene, also called meg~strGl aceta~ and
~ S'i
~ 7s7~a
--19--
available from Mead Johnson & Co., Evansille, Ind.
under the trademark of Megace.
Typical suitable antiestrogens include those
steroidal and non-steroidal antiestrogens such as
(lRS,2RS)-4,4'-diacetoxy-5,5'-difluoro-(1-ethyl-2-
methylene)di-m-phenylenediacetate, which is available
from Biorex under the tradename of Acefluranol, 6a-
chloro-16a-methylpregn-4-ene-3,20-dione which is
available from Eli Lilly & Co., Indianapolis, Ind.
under the tradename of Clometherone, 6-chloro-17-
hydroxypregna-1,4,6-triene-3,20-dione which is
available as the acetate salt from Syntex Labs, Palo
Alto, Cal. as Delmadione Acetate, 17-hydroxy-6-methyl-
l9-norpregna-4,6-diene-3,20-dione which is available
from Theramex under the name of Lutenyl, 1-[2-[4-[1-(4-
methoxyphenyl)-2-nitro-2-phenylethenyl]phenoxy]ethyl]-
pyrrolidine which is available as the citrate salt from
Parke-Davis Div. of Warner-Lambert Co., Morris Plains,
N.J. under the name Oe Nitromifene Citrate, substituted
aminoalkoxyphenylalkenes such as (Z)-2-[4-(1,2-
diphenyl-l-butenyl)phenoxy]-N,N-dimethylethanamine
which is available as the citrate salt from Stuart
Pharmaceuticals, Wilmington, Del. as Tamoxifen Citrate
(see also Belgian Patent 637,389, March 1964), 3,4-
dihydro-2-(p-methoxyphenyl)-1-naphthyl p-[2-(1-
pyrrolidinyl)ethoxy]phenyl ketone which is available as
the methane sulfonate salt from Eli Lilly & Co. under
the tradename of Trioxifene Mesylate, 1-[4'-(2-
dimethylaminoethoxy)-phenyl)-l-(3'-hydroxyphenyl)-2-
phenyl-but-l-ene, which is available from Klinge
Pharma, 6-hydroxy-2-(p-hydroxyphenyl)-benzo(b)thien-3-
yl[2-(1-pyrrolidinyl)-ethoxyphenyl]ketone which is
available from Eli Lilly & Co. (LY-117~18), [6-hydroxy-
2-(4-hydroxyphenyl)benæo(h!thien-3-yl]-~4-(2-(1-
l~7~ 4a
-20-
piperdinyl)-ethoxy)phenyl]methanone, which is available
from Eli Lilly & Co. as the hydrogen chloride salt (LY-
156758) and meso-3,4-bis(3'-hydroxyphenyl)hexane as
well as the dimethyl, dipropyl and 3'-acetoxyphenyl
analogues which are described in U.S. Patent 4,094,994
and a series of l-phenyl-alkane and -alkenes, e.g. (E)-
3-cyclopentyl-1-(4-hydroxyphenyl)-1-phenyl-1-butene and
2-cyclopentyl-1-[4-hydroxy-or methoxyphenyl]-3-phenyl-
2-propen-1-ol and FC-1157 which is available as the
citrate salt from Farmos Group, Ltd., Turku, Finland
(see also Eur. Pat. Appln. EP 7~,158). It is preferred
to use an antiestrogen which shows minimal partial
estrogen agonism. FC-1157, LY-117018,` LY-156578 and
Tamoxifen are the preferred antiestrogens.
The inhibitors of sex steroid biosynthesis
found useful in the present invention include those
compounds which inhibit biosynthesis of sex steroids
and precursor sex steroids of adrenal origin, and/or
ovarian (or testicular respectively) preferably of
ovarian (or testicular respectively) and adrenal
origin.
Typical suitable inhibitors of sex steroid
biosynthesis include 3-~4-aminophenyl)-3-ethyl-2,6-
piperidinedione which is commonly called aminoglute-
thimide, which is an inhibitor of sex steroid
biosynthesis of adrenal but also ovarian and testicular
origin and which is available from Ciba Pharmaceutical
Co., Summit N.J. under trademark Cytadren, or
ketoconazole an effective testicular but also adrenal
sex steroid biosynthesis inhibitor which is available
from Janssen Pharmaceutica, Piscataway, N.J. under the
trademark Nizoral.
When an inhibitor of adrenal sex steroid bio-
synthesis, e.g., aminoglutethimide is adm1nisteredf
87~3
-21-
cortisol biosynthesis is blocked. Accordingly, hydro-
cortisone is administered in physiological amounts
sufficient to maintain normal glucocorticoid levels.
In this invention, the LH-RH agonist or
antagonist and antiandrogen and, where applicable, the
inhibitor of steroid biosynthesis, hydrocortisone and
antiestrogen are administered as pharmaceutical
compositions via topical, parenteral or oral means.
The LH-RH agonist or antagonist is administered
parenterally, i.e., intramuscularly, subcutaneously or
intravenously by injection or infusion by nasal drops
or by suppository, where applicable intra-vaginally.
The LH-RH agonist or antagonist also may be
microencapsulated in or attached to a biocompatable,
biodegradable polymer, e.g., poly~d,l-lactide-co-
glycolide) and subcutaneously or intramuscularly
injected by a techni~ue called subcutaneous or
intramuscular depot to provide continuous, slow release
of the LH-RH agonist or antagonist over a period of 30
days or longer. The most preferred route of
administration of the LH-RH agonist or antagonist is
subcutaneous depot injection. Preferably the
antiandrogen will be administered orally. Preferably,
the inhibitors of sex steroid biosynthesis such as
aminoglutethimide and ketoconazole, and anti-estrogen
when used, are administered orally.
The amount of each component administered is
determined by the attending clinicians taking into
consideration the etiology and severity of the disease,
the patient's condition and age, the potency of each
component and other factors. In the combination
therapy of sex steroid dependent cancers, such as
prostate cancer, breast cancer, testicular cancer,
ovarian cancer, colon-rectal cancer, renal cancer,
8748
-22-
pancreatic cancer, liver cancer, stomach cancer, skin
cancer, uterine cancer, brain cancer and larynx cancer
especially prostate and breast cancer, according to
this invention, the following dosage ranges are
suitable.
The LH-RH agonist or antagonist is generally
administered at from about 10 to 5000 ~g per day, with
contemplated dosage ranges of about 10 to 1500 ~g per
day and about 250 ~preferably 200 ~g in the therapy of
female breast cancer using the combination with sex
hormone biosynthesis inhibitor) to 500 ~g per day for
the LH-RH agonist and to about 50 to 5000 ug per day
for the LH-RH antagonist being preferred.
In the most preferred embodiment of this
invention, the LH-RH agonist or antagonist is
administered subcutaneously in a daily dose of 500 ug
for the first 30 days and thereafter subcutaneously in
a daily dose of 250 ~g regardless of the patients' body
weight. When the LH-RH agonist or antagonist is
administered, once every 30-day period or even longer,
by intram~lscular or subcutaneous d0pot injection, a
dose from about 300 to lSO,OnO ~g per 30-day period is
ust-~d, with a tiose of 750 to 15,000 ~Ig per 30-day period
being prefe L red.
The antiandrogen compositions are generally
administe~etl in a dosage range of about 0.20 to 40
mg/kg (body weight) per day with 750 mg per day in
three equally divided doses being preferred.
The aminoglutethimide compositions (when
used) are administered initially in a dosage of 250 mg
given at 8-hour intervals and the dosage may be
increased in increments of 250 mg daily up to a total
daily dose of 2 grams.
~ 787~8
-23-
The ketoconazole compositions ~when used) are
administered orally in a dose of 250 mg given at 8-hour
intervals and may be increased to a daily dose of 2
grams.
Other inhibitors of sex steroid biosynthesis
are preferably administered in dosages being equivalent
to the dosages given for aminoglutethimide and
ketoconazole.
The antiestrogen compositions (when used) are
administered in a dosage range of about 0.1 to 10 mg/ky
body weight per day, with 10 mg, especially 20 mg, in
two equally divided doses being preferred.
The glucocorticoide, especially
hydrocortisone compositions (when used) are
administered orally in a dosage range of about 0.1 to
20 mg/kg body weight per day. Preferably, the
hydrocortisone is administered orally at the dose of
about 10 mg in the morning and about 5 mg doses in the
afternoon and in the evening.
The LH-RH agonist or antagonist and anti-
androgen and inhibitor of sex steroid bisoynthesis and
antiestrogen ~when used) each may be administered
separately or when the modes of administration are the
same, all or at lea~t two of them may be administered
in the same composition, but in any case the preferred
ratio of LH-I~H agonist to antiandrogen to antiestrogen
~when used) to inhibitor of sex steroid biosynthesis
~when used) administered daily will be about 250 ~9 of
LH-RH agonist to about 750 mg of antiandrogen to about
15 mg, especially 20 mg, of anti-estrogen to about 750
mg of inhibitor of sex steroid biosynthesis.
In the therapy of sex steroid dependent
cancers such as, for example, female breast cancer
combining the administration of an LH-RH agonist or
~'~7a7~L8
-24-
antagonist, an antiandrogen and an antiestrogen the
dosages preferable are as follows: The LH-RH agonist
or antagonist is generally administered at rom about
10 to 2000 ~g per day, with contemplated dosage ranges
of 10 to 500 ~g per day, 50-250 ~g per day and 250 to
500 ~g per day being preferred. In the most preferred
embodiment of this aspect of the invention, the LH-RH
agonist or antagonist is administered subcutaneously in
a daily dose of 500 ~g for the first 30 days and
thereafter subcutaneously in a daily dose of 250 ~g
regardless of the patients' body weight. When the LH-
RH ayonist or antagonist is administered, once every
30-day period, by intramuscular or subcutaneous depot
injection, a dose from about 300 to 60000 (occasionally
15000) ~g per 30-day period is used, with a dose of 750
to 6000 ~g per 30-day period being preferred. The
antiandrogen compositions are generally administered in
a dosage range of about 0.20 to 20 preferably 40 mg/kg
~body weight) per day with 375 especially 750 mg per
day in th~ee equally divlded doses being preferred.
The antlestroyen compositions are administered in a
dosage range of about 0.1 to 10 mg/kg body weight per
day, with 15 mg in three, prefeLably with 20 mg in two,
equally divided doses being preferred. The
aminoglutethimide compositions when used are
administe~ed initially in a dosage of 250 mg given at
6-hour, preferably 8-hour, intervals and the dosage may
be increased in increments of 250 mg daily up to a
total daily dose of 2 grams. The ketoconazole
compositions when used are administered orally in a
dose of 200 mg once per day and may be increased to 800
mg once peL day.
The LH-RH agonist or antagonist and
antiandrogen and antiestrogen each may be administered
1.~787~8
-25-
separately or when the modes of administration are the
same, all or two of them may be administered in the
same composition, but in any case the preferred ratio
of LH-RH agonist to antiandrogen to antiestrogen
administered daily will be about 250 ~g of LH-RH
agonist to about 375 especially 750 mg of antiandrogen
to about 15, preferably 20, mg of antiestrogen.
In the therapy of sex steroid dependent
cancers, especially such as prostate and breast cancer,
according to this invention, it is preferred that the
LH-RH agonist is [D-Trp6,des-Gly NH210] LH-RH ethylamide
which is administered subcutaneously in single daily
dose of 500 ~9 for the first thirty ~30) days of
treatment and thereafter in a single daily dose of
250 ~g; the antiandrogen is 4'-nitro-3'-
trifluoromethyl-isobutyranilide, i.e. flutamide, which
is administered orally in three equally divided daily
doses of 2S0 mg each; and the lnhibltor of sex steroid
biosynthesis is ketoconaxole and/or aminoglutethimide,
each of which is administered orally in three equally
divided doses of 250 mg ~very ~ hours; and the
hydrocortison~ ~i ~Ised) is administered orally at a
dose of about 10 mg in the morning and two equally
divided doses of about 5 mg, ~ and 16 hours thereafter;
and the antiestrogen, when used, is ~Z)-2-[p-~1,2-
diphenyl-l-hutenyl)phenoxy]-N,N-dimethyl ethylamine
~Tamoxifen) which is administered orally in two equally
divided doses of about 10 mg every 12 hours. In the
therapy of, for example, female breast cancer using the
combination of the LH-RH agonist, the antiandrogen and
antiestrogen discussed here, it is also useful to
administer the antiandrogen ~flutamide) orally in three
equally divided doses of 125, preferably 250 mg.
~'~7S7~
-26-
In the combination therapy of sex steroid
dependent cancers according to this invention the
administration of the antiandrogen, antiestrogen,
inhibitor(s) of steroid biosynthesis, hydrocortisone
and LH-RH agonist or LH-RH antagonist can be started in
any order of sequence. Preferably the administration
of the antiandrogen and/or the antiestrogen is started
before (preferably one day before) the administration
of the LH-RH agonist or LH-RH antagonist is started.
Preferably the administration of the inhibitor(s) of
sex steroid biosynthesis is started on the same day as
the administration of the LH-RH agonist or LH-RH
antagonist. However, the attending clinician may elect
to start administration of the LH-RH agonist or
antagonist on the first day of treatment.
When patients whose testes or ovaries
respectively have already been surgically removed are
treated according to this invention, the administration
and dosage o~ the antlandrogen and the other components
of the therapy (except the LH-RH agonist or antagonist)
are the same as indicated for the therapy in which the
LH-RH agonis~ or antagonist is used.
Normally, an lnhibitoL of testicular sex
steroid biosynthesis such as ketoconazole may be
administered to chemically but not surgically castrated
patients.
Generally, the inhibitor of testicular sex
steroid biosynthesis (when used), e.g., ketoconazole
will be administered until the serum levels of T and
DHT stimulated by the administration of the LH-RH
agonist are effectively suppressed, normally for one to
three weeks. The inhibitor of adrenal sex steroid
biosynthesis, e.g., aminoglutethimide may be
administered at the start of treatment in the presence
~7a~748
or absence of the inhibitor of testicular sex steroid
biosynthesis and thereafter continued throughout the
period of treatment.
The LH-RH agonists or antagonists useful in
the present invention are typically amorphous solids
which are freely soluble in water or dilute acids,
e.g., HCl, H2S04, citric, acetic, mandelic or
fumaric. The LH-RH agonist or antagonist for
subcutaneous injection is supplied in vials containing
5 mL of sterile solution with the LH-RH agonist or
antagonist at a concentration of about 1.0 mg/mL.
A typical pharmaceutical composition of the
LH-RH agonist or antagonist include the LH-RH agonist
or antagonist or a pharmaceutically acceptable acid
salt thereof, benzyl alcohol, a phosphate buffer
(pH=6.9-7.2) and sterile water.
The LH-RH agonist or antagonist for intra-
muscular or subcutaneous depot injection may be
microencapsulated in a biocompatible, biodegradable
polymer, e.g., poly ~d,l-lactide-co-glycolide~ by a
phase separation process or foLmed into a pellet. The
microspheLes may then be suspended in a carrier to
provide an injectable preparation or the depot may be
injected in the form of a pellet. See also European
Patent Application EPA 58,481 published August 25, 1982
for solid compositions for subdermal injection or
implantation or liquid formulations for intramuscular
or subcutaneous injections; containing biocompatible,
biodegradeable polymers such as lactide-glycolide
copolymer and an LH-RH agonist, e.g., D-Ser-t-BuO6,
Azglyln-LH-RH .
The inhibitors of sex steroid biosynthesis,
e.g., aminoglutethimide and ketoconazole and the
glucocorticoide, e.g., hydrocortisone (when used) are
~78~48
-28-
typically compounded in custornary ways for oral
administration, e.g., in tablets, capsules and the
like.
The antiandrogens useful in the present
invention are typically formuLated with conventional
pharmaceutical excipients, e.g., spray dried lactose
and magnesium stearate into tablets or capsules for
oral administration. The antiestrogens, when used with
the invention, are typically compounded in customary
ways for oral administration, e.g., in capsules,
tablets, as dragees or even in liquid form, e.g.,
suspensions or syrups. One or more of the active
substances, with or without additional types of active
agents, can be worked into tablets or dragee cores by
being mixed with solid, pulverulent carrier substances,
such as sodium citrate, calcium carbonate or dicalcium
phosphate, and binders such as polyvinyl pyrrolidone,
gelatin or cellulose derivatives, possibly by adding
also lubricants such as magnesium stearate, sodium
lauryl sulEate, "Carbowax" or polyethylene glycols. Of
course, taste-improvlng ~ubstances can be added in the
case of oral-administration forms.
The therapeutically active antiestrogen
compound should be present in a concentration of about
0.5-90~ by welght of the total mixture, i.e., in
amounts that are sufficient for maintaining the above-
mentioned dosage range.
As further forms of administration, one can
use plug capsules, e.g., of hard gelatin, as well as
closed soEt-gelatin capsules comprising a softener or
plasticizer, e.g., glycerine. The plug capsules
contain the active substance preferably in the form of
granulate, e.g., in mixture with fillers, such as
lactose, saccharose, mannitol, starches, such as potato
87~8
-29-
starch or amylopectin, cellulose derivatives or highly-
dispersed silicic acids. In soft-gelatin capsules, the
active substance is preferably dissolved or suspended
in suitable liquids, such as vegetable oils or liquid
polyethylene glycols.
In place of oral administration, the active
compounds may be administered parenterally. In such
case, one can use a solution of the active substance,
e.g., in sesame oil or olive oil.
Following the above treatment using the
described regimen, tumor growth and bone metastases of
sex steroid dependent cancers is inhibited and in some
instances complete remission occurs.
The invention also provides kits or single
packages combining the pharmaceutical compositions
useful for the combination treatment of sex-steroid
dependent cancers discussed above. The kits or
packages may also contain instructions to use the
pharmaceutical compositions in accordance with the
present invention. This aspect of the invention is
exemplified by the following discussions: For the
treatment of female breast cancer a two component kit
provides the antiandrogen oral pharmaceutical
composition and the LH-RH agonist or LM-RM antagonist
parenteral compo~ition or the antiandrogen oral
pharmaceutical composition and the antiestrogen oral
composition or the oral compositions of the
antiandroyen or antiestroyen and the inhibitor of sex
steroid biosynthesis; a three component kit provides
the LH-RH agonist or antagonist parenteral
pharmaceutical composition, or the oral compositions of
the antiandrogen, the antiestrogen and the inhibitor of
sex steroid biosynthesis; the antiandrogen and the
antiestrogen oral pharmaceutical composition, a four
'11'~7~37~3
-30-
component kit provides the LH-RH agonist or LH-RH
antagonist parenteral pharmaceutical composition, the
antiandrogen oral pharmaceutical composition, the sex
steroid biosynthesis inhibitor oral pharmaceutical
composition and the hydrocortisone oral pharmaceutical
composition; and a five component kit provides the LH-
RH agonist or LH-RH antagonist parenteral
pharmaceutical composition, the antiandrogen oral
pharmaceutical composition, the antiestrogen oral
pharmaceutical composition, the sex steroid
biosynthesis inhibitor oral composition and the
hydrocortisone oral pharmaceutical composition.
Further kits are provided in accordance with the
combination therapy of this invention.
For the treatment of prostate cancer, a three
component kit provides the antiandrogen oral
pharmaceutical composition, the LH-RH agonist or LH-RH
antagonist parenteral composition and the sex steroid
biosynthesis inhibitor oral pharmaceutical composition;
a four component kit provides the LH-RH agonist or LH-
RH antagonist parenteral pharmaceutical composition,
the antlandro~en oral pharmaceutical composition, the
adrenal sex steroid blosynthesLs inhihitor oral
pharmaceutical composition and the hydrocortisone oral
pharmaceutical composition; and a five component kit
provides the LH-RH agonist or LH-RH antagonist
parenteral pharmaceutical composition, the antiandrogen
oral pharmaceutical composition and the testicular sex
steroid biosynthesis inhibitor oral pharmaceutical
composition, the adrenal sex steroid biosynthesis
inhibitor oral pharmaceutical composition and the
hydrocortisone oral pharmaceutical composition.
Further kits are provided in accordance with the
combination therapy of this invention.
7~7'~8
-31-
For the treatment of other sex steroid
dependent cancers analogous kits are provided according
to this invention. The kits may also contain
pharmaceutical compositions which contain more than one
component of the combination treatment.
The following examples illustrate the
invention.
~7~7~8
-32-
EXAMPLE 1
Figures l to 3 show the result of the
combination therapy of a male patient having breast
cancer according to the invention.
Figure l is a bone scintigraph showing
multiple bone metastases in a male patient having
breast cancer prior to treatment in accordance with an
aspect of the present invention.
Figure 2 is a bone scintigraph of the same
male patient after treatment for six and a half months
in accordance with an aspect of the present invention.
Figure 3 graphically displays serum levels of
testicular and adrenal steroids in the male patient
treated in accordance with an aspect of the present
invention.
Twelve months after modified radical
mastectomy with axillary dissection ~4 out of 13
positive nodes) in a 66-year old man, bone scintigraphy
~Fig. l) ~howed multiple bone metastatic lesions in the
third and fo~lrth cervical vertebrae, in the first,
third and twelth thoracic vertebrae, in the third,
fourth and fifth lumbar vertebrae, in both sacro-iliac
areas, in both shoulders and in the anterior part of
the second L ight rib. Chest X-Ray and abdominal
echogram did not show evidence of additional extension
of the disease. The pituitary ~LH, FSH and prolactin)
as well as steroid [pregnenolone, 17-OH pregnenolone,
dehydroepiandrosterone ~DHEA), DHEA-sulfate, androst-5-
ene-38,17R-diol~5-diol), progesterone, 17-OH-
progesterone, androstenedione~4-dione), testosterone
(T), dihydrotestosterone (DHT), androstane-3~,17R-diol,
androstane-3B,17R-diol, androsterone and cortisol]
hormones were within normal limits. Hormone
7~8
-33-
measurements and calculations were performed according
to known methods. The serum concentration of
carcinoembryonic antigen (CEA) as well as a series of
laboratory analyses, including complete blood count,
sequential multiple analyzer (SMA-12) and urinalysis
were normal.
Combined antihormonal treatment with the LH-
RH agonist [D-Ser-(tBuO)6, des-gly-NH210~LH-RH
ethylamide (500 ~9 daily, s.c.) in combination with the
pure antiandrogen Flutamide (250 mg orally every 8h)
was started. Six and a half months later bone
scintigraphy showed a complete disappearance of
increased uptake in all the areas identified 6 1/2
months earlier with no appearance of new lesion (Fig.
2). X-Ray, ultrasonography and clinical examination
revealed no sign of any lesion. As illustrated in Fig.
3, the combined treatment caused 95~ reduction
(compared to control) in serum testosterone (T) and a
25 to 60~. fall in the serum levels of adrenal steroids,
namely DHEA, DHEAS, Q4-dione and Q5-diol while not
affecting cortisol signlEicantly. S0rum levels of DHT
anA E2 were also d0creased by ~0 to 4n~. During
hormonal therapy, no cllnical sign of the disease could
be detected. The only side-effects were related to
hypoandrogenicity. Thus, after four months of
treatment, the patient developed mild climateric-like
vasomotor phenomena consisting of perspiration and hot
flushes, which did not require treatment. He also
complained of loss of libido and sexual potency after
two months of treatment.
The present data show a rapid and complete
regression of bone metastases in a patient having wide-
spread bone metastases from breast-cancer. A complete
response could be seen within 6 1/2 months after
~.~'78748
-34-
starting the combined treatment with an LH-RH agonist
and a pure antiandrogen.
EXAMPLE 2
INHIBITORY EFFECT OF AMIN~GLUTETHIMIDE OR
KETOCONAZOLE ON LHRH AGONIST-IND~CED SERUM
TESTOSTERONE IN THE DOG
Figures 4 to 6 show the result of the test.
Fig. 4. Serum levels of testosterone during
the first 19 days of treatment of dogs with daily
administration of 50 ~g of [D-Trp6]LHRH ethylamide.
Fig. 5. Serum levels of testosterone during
the first 19 days o treatment of dogs with daily
administration to 50 ~9 of [D-Trp6]LHRH ethylamide in
association with ketoconazole.
Fig. 6. Serum levels of testosterone during
the first 19 dàys of treatment of dogs with daily
administration of 50 ~9 of [D-Trp6]LHRH ethylamide in
association with amlnoglutethimide.
~ hile LH~H flgonists achieve castration levels
of androgens during chronlc treatment in men, the first
5 to 10 days of administration of the peptide are
associated with increased serum levels o testosterone
and dihydrotestosterone ~Labrie et al., J. Androl. 1:
209-228, 1980). These increased levels of testicular
androgens are accompanied by an exacerbation of the
symptoms and signs of prostate cancer in significant
proportion of cases ~Kahan et al., The Lancet i, 971-
972, 1984).
The following experiment shows that the LHRH
agonist-induced rise in serum testosterone can be
prevented by simultaneous administration of the steroid
78q4~
-35-
biosynthesis inhibitors aminoglutethimide or
ketaconazole.
Eighteen mongrel dogs weighing between 20-30
kg were randomly divided into three groups. The
animals were housed one per cage and fed Purina Dog
Chow and tap water ad libitum.
The animals of group 1 were injected daily
~at 0700h) with 50 ~g of the LHRH agonist [D-Trp6, des-
Gly-NH210]LHRH ethylamide (LHRH-A). In group 2, the
animals were also injected daily with 50 ~g of LHRH-A
and took in addition 200 mg of ketoconazole per os at
0700h, 1500h and 2300h. The animals of group 3
received daily 50 ~g of LHRH-A and 125 mg of
aminoglutethimide per os at 0700h, 1500h, 2300h plus 10
mg of hydrocortisone twice daily.
Blood samples were collected at 0700h, O900h,
llOOh and 1500h one day before treatment and every day
during the treatment. Plasma was extracted with
diethyl ether and testosterone was separated on LH-20
columns before RIA mea~urements.
Fig. 4 shows that on one to six days
following the start of treatment with the dailty
injection of 50 ~g of the LHRH agonist ~D-Trp6]LHRH
ethylamide, there is an increase in serum testosterone
up to approximately 500% above control. Thereafter,
there is a decrease of the level of this androgen which
reaches near-castration levels on day 19. It can be
seen in Fig. 5 and 6 that the simultaneous
administration of the steroid inhibitors ketoconazole
or aminoglutethimide almost completely prevented this
rise in serum testosterone which occur during the first
days of treatment with a peptide.
These data clearly indicate the usefulness of
the combined administration of inhibitors of steroid
L8
-36-
blosynthesis in order to pr~vent the rise of testicular
serum androgens during the first days of treatment with
LHRH agonist~.
Since dogs do not have adre~al p~odu~tlon of
androgens the influence of the admlnistration o~ an
antiand~ogen in combination with the ad~lnistratlon of
the LH-RH a~onist and the inhLbitor~ of ~3ex steroid
biosynthesis cannot be demonstrated in thi~ species.
Howeve~, it can be concl~ded from the te~t results that
in men the admini6tration of an antiandrogen
(especially flutamide) in combin~tion with the LH-RH
agonist or antagonist And the inhibitors of sex steroid
biosynthesls which lnhibit the s~cretion of precursor
adrenal androgens substantially or comp1etely decr~ases
the content of andro~ens in the sy~tem and t`nus
cont~-ibutes to the inhibition of and~ogen 5ensitive
cancer ~rowth.
The ilnportant aspect~ of ~his lnvention can
be summarized ~ follows:
The invcn~ion provid~s:
l~ A method of treating sex st~roid dependent cancers
in a warm-bloodcd animal which comprises admlnistering
a phar~aceutically efective amount oi an ant~androgen
and/or an antiestrogen and~or at lea~t one ~nhibitor of
sex ~teroid biosynthesi~ to the animal whose hormone
output o~ the testes or ovaries, is blocked, with the
proviso that ~he method of treating prostate cancer
ccmprises administering pharmace~tically e~fective
a~ounts o~ an anti~ndrogen and at least one inhibitor
of sex steroid biosynthesis and the method of treating
breast cancer comprises a~ministering a pharmaceu-
tically effective a~ount (l) of an an~landrogen o~ (2)
of at least one inhibitor of sex steroid biosynthesls
~ ~7~8
-37-
or (3) of an antiandrogen and an antiestrogen or (4) o~
an antiandrogen and at least one inhibitor of sex
steroid biosynthesls or t5~ of an antiestrogen and at
least one inhibitor of sex steroid biosynthesis or (6)
of an antiandrogen and an antiestrogen and at least one
inhibitor of sex steroid biosynthesis.
~) A kit c~mprislng a combination of pharmaceutical
composition~ for combination therapy of sex steriod
dependent cancers in a warm-blooded animal whose
hormone output of the testes or ovaries, is blocked,
the combination consisting Oe pharmaceuti~al
compositions co~p~ising (1) an antiandro~ein and ~n
antiestrogen or (2) an antiand~ogen and at least one
inhibitor of sex ste~old blosynthesi~ or (3) an
antie.st~ogen and at least one inhi~itor of sex ~teroid
biosynthesis ot (4) an antiandror~en ~nd an anties~rogen
and at l~ast on~ inhibitor Of ~ex ~teroid b.iosynthesis.
3~ A kit comprising a pharmaccutic~l composition
comprising fln ar~ti~ndro~en an~/or ~ ~harmaceutical
composition comprising ~n ~nties~rogerl and/or one or
mOre phar~ac~utical composi~ion(s) comprisiny an
inhi~itor of sex steroid ~iosynthesis co~ether with
instructions for `using the composition(s) or each of
these compositions for the tr~atment o~ sex steroid
dependent cancer.s in a warm-blooded animal by a
combination therapy involvlng administering a
pharmaceutically e~fective a~ount of an antiandrogen
and/or an antiestrogen and/ot at least o.ne inhibitor of
sex steroid biosynthesis to the animal whose hormone
output of the testes or ovarie.s, is blocked, w~th the
proviso that the instructions for treating prostate
cancer recommend administerlng pharmaceutically
-38-
effective a~ounts of an antiandrogen and at least one
~nhibltor of sex steroid biosynthesis and the
instructions for treating beeast: cancer recommend
administering a pharma~eutically effective amount (1)
of an anttandror~en or (2) of at least one inhibitor of
sex ster~id bio~ynthesiS or (3) of an antiandro~en and
an antiestro~en or (4) of an antiandrogen and at least
one inhibitor of sex steroid biosynthesis or (5) of an
antiestrogen and at least one inhibitor of sex steroid
biosynthesis or (6) of an antiandrogen and an
antiesttogen and at least one inhibitor of sex steroi~
biosyntl-esis.
4) Use of a~ antiandro~en and~or an anties~royen
and/or at least one inhibitor o sex steroid
bio.synthesis for treating sex steroid dependent eancers
in a warm-blooded animal by administering a
pharmaceutically ef~ective amount of an antiandrogen
and/or an antiestrogen and/or at le~t one inhibitor of
sex steroi~ biosyntheSis to the animal whose hormone
output o~ t~ teste~ or ovaries is blocked with the
proviso that tre~ting prostate cancet comprises
administering pharma~eutically ef~ective amounts of an
antiandro~en and at least one inhibito~ of sex steroid
hiosynthesis and treating breast cancer ~o~prises
administering a p~larmace~tieally e~fective amount (1)
of a~ a~tiandro-~en or (2) of at least one inhibit~r of
sex steroid hiosynthesis or (3) of an antiand~ogen and
an antiestrogen or (4~ of an antiandro~en and at least
one lnhibitor of sex steroid biosynth~is or (5) of an
antiestrogen and at least one inhibitor of sex steroid
biosynthesis or (6~ of an antiandrogen and an
antiestrogen and at least one inhibito~ of sex steroid
biosynthesis,
-39-
~7874~3
5) The use of an antiandrogen and/or an antiestrogen
and/or at least one inhibitor of sex steroid biosyn-
thesis for the manufacture of a medicament for
combination therapy of sex steroid dependent cancers
in a warm-blooded animal which therapy comprises
adminis-tering a pharmaceutically effective amount of
an antiandrogen and/or an antiestrogen and/or at
least one inhibi-tor of sex steroid biosynthesis to
the animal whose hormone output of the testes or
ovaries is blocked, with the proviso that the therapy
of prostate cancer comprises administering pharmaceu-
tically effective amounts of an antiandrogen and at
least one inhibitor of sex steroid biosynthesis and
the therapy of breast cancer comprises administering
a pharmaceutically effective amount (1) of an anti-
androgen or (2) of at least one inhibitor of sex
steroid biosynthesis or (3) of an antiandrogen and an
antiestrogen or (4) of an antiandrogen and at least
one inhibitor of sex steroid biosynthesis or (5) of
an antiestrogen and at least one inhibitor of sex
steroid biosynthesi.s or (6) of an antiandrogen and an
anti.estroyen and at least one :inhibitor of sex
steroi.d biosyntllesis.
6) A combination of pha.rmaceuti.cal composit:Lons for
combi.nation therapy of sex steroid dependent cancers
in a warm-blooded an:imal whose hormone output of the
testes or ovaries is blocked, the combination
consisting of pharmaceutical compositions comprising
an antiandrogen and antiestrogen or an antiandrogen
and at least one inhibitor of sex steroid biosyn-
thesis or an antiestrogen and at least one inhibitor
of sex steroid biosynthesis or an antiandrogen and an
antiestrogen and at least one inhibitor of sex
steroid biosynthesis.
~787~
-40-
Prefer~ed aspects of the invention can be
su.~narized as follows:
a) For trea~ing testicular cancer, ovarian cancer,
colon-~eotal cancer, renal cancer, pa~creatic cancer,
liver cancer, stomach cancer, ski~ cancer, uteri~e
cancer, braln cancer and lary?x cance~: admi.~isterlng
an antiandrogen ~nd/or an antiestrogen and/or at least
on* inhibitor of sex steroid biosynthesis.
b) ~or ~reati~g breast ca~cer, testicular cancer~
ovarian cancer, colon-rectal c~ncer, L-enal cancer,
pancreatic cance~, liver CaneeL-, s~omaoh cancer, skin
cancet, uterine ca~cer, brain cancer and larynx
cancer: a~ministtation of an antiandro~e? vr of an
antiandro~en an~ an a~tiestro~en or of ~n antian,~rogen
and at leas~ one inhibitor of sex steroid biosynthesis
or of an antiestro~en an~ at least one inhibitor o~ sex
steroid biosynthe~is or o~ an ~n~iandrogen and ~n
antiestrogen and at lea~t o~e inhibitor of sex steroid
biosynthesis.
c) Ad~inist.r~tion of the a~tiandrogen and/or the
a.~tiestroge.? and/oc at le~st one inhibitor of .sex
steroid biosy~thesis and, if used, the glucocorticoid
such ~s hydtocorti~one, to an animal who~e hormone
output of tll~ testes or ovaries, has been blocked by
su~-yical ren)oval thereof.
d) Admini~stration of ~he a~?tia~dro(~e., and/or the
a~tiestroge, and/ or at least one i;?hibitor of sex
steroid bios~:lthesis a~d, if use~, the glucocorticoid,
such as hydrocortisone to an anim~l whose hormone
output of the testes or ova~-ies, is blo~ke-~ by chemical
1'~7~
--ql--
mean~ such as ~y an LH-RH agon~st or L~-RH antagonist
of whlch a pharmace~tically ef~ective amount is
adminl~tered ~o the animal in a~sociatlon with ~he
antlandrogen and/or the ~tiestrogen and/or the
inhibi~orts) of s~eroid biosy~thesi~ and/or the
glucoc~Itlcoid.
e) Admlni~tratlon of the antiandrogen, the
a~tiestrogen, the inhibitor(s) of sex ste~old
biosynthesis, the LH-RH agonist or LH-RH antagonist and
the gluco~orticoid (if appli~able) in the form of
individual eompositions.
~) Pre~erably the antiandrogen a~d/or the a~tiestro~en
i~ started one day before the administration of tha LH-
RH agonist o~ LH-RH antagonist and of the inhibitoL-(s)
of sex ste~oid biosynthesis ~i used) and the
~lucocortiooid tif used).
g) Admin~stratlon of the ~-RH a~onist or l.H-RH
ant~yonist in the orm of a p~nt~ral compo.sition.
h~ Administration o~ the a~.ia~ro~en, antiestroye."
the inhi~itor(~) of sex steroid biosynthesis a~d the
glucocorticoid Quch a~ the hydroco~tisone in the for~
of oral compositions.
1) The preferred antiandrogen is 4'-nitro-3'-tri-
fl~oromethylisobutyranilide or 1-~3'-tri~luorometh~l-
4'-nitrophe,yl)-4,4-dimethylimidazoline-2,S-dione.
j) The preferred LH-RH a~onist is a nonapeptide or a
decapeptide represented by the formula : L-pyto-
glutamyl-L-histi~yl-L-tryptophyl-L-seryl-L-~yrosyl-X-Y-
1~7~
-42-
L-arginyl~~-prolyl-z~ wherein X ls D-tryptophyl, D-
leucyl, ~-alanyl, iminoben~yl-D-histidyl, 3-(2-naph-
thyl)-D-alanyl~ 0-tert-butyl-D-seryl, D-tyrosyl, ~-
lysyl, D-phenylal~nyl or N-methyl-D-alanyl and wherein
Y is L-leucyl, ~-methyl-L-leucyl, D-leucyl, N-methyl-
D-le~cyl, or D alanyl and wh~rein ~ is glycyl-NHRl o~
N~Rl wherein Rl is H, lower alkyl or haloloweralkyl.
k) Preferably aminoglutethimide and/or ketokona201e
is/are u~ed ~s in~ibitors of~sex steroid biosynthes1s.
1) The preferted antiestrogen i~ (z)-2-~4-(1,2-
diphenyl-l-b~tenyl)phenoxy~-~,N-dimethylethanamlne or
LY-117018.
Rel~ing to these pre~erred aspe~ts the
inventio~ ~rovides kits compri~ing compositions
containing the relevant ac~ive ~ul)stance~, possibiy
together with ingtruction to use them.
P/PASP0289
