Note: Descriptions are shown in the official language in which they were submitted.
2096196 RAN_4051~2~
The present invention is coneerned with pharmaceutical
preparations containing 9-cis- or 13-cis-retinoic acid or acitretin
(all(E)-9-(4-methoxy-2,3,6-trimethylphenyl)-3,7-dimethyl-2,4,6,8-
nonatetraenoic acid), a pharmaceutically usable salt or ester thereof
5 and a vitamin D derivative. it has been found that such preparations
can be used for the treatrnent of psoriasis, of osteoporosis, of
precanceroses and of tumours, as well as for the treatment of
pathological or undesired immune reactions. The invention is
therefore also concerned with the use of 9-cis-or 13-cis-retinoic
10 acid or acitretin9 pharmaceutically usable salts or esters thereof
for the combined use with vitamin D derivatives in the treatment of
the said diseases and anomalies. Finally, the invention is concerned
with the use of 9-cis-or 13-cis-retinoic acid or acitretin, pharma-
ceutically usable salts or esters thereof in the manufacture of
~5 pharmaceutical preparations for the combined use with vitamin D
derivatives in the treatment of ~he aforementioned diseases and
anomalies.
Examples of pharmaceutically usable salts of 9-cis- or 13-
ao cis-retinoic acid or acitretin are alkali salts such as the Na and K
salt, alkaline earth metal salts such as the Ca and Mg salt; as well
as the ammonium salt and alkylammonium salts. Examples of esters
are lower-alkyl esters such as the methyl and ethyl ester such as
etretinate, and aromatic esters such as the benzyl es~er.
'
Examples of vitamin D derivatives which can be used in
accordance with the invention are hydroxylated vitamin D3
derivatives such as la-hydroxy-vitamin D3, 1,25-dihydroxy-
vitamin D3 (calcitriol), la,25,26-trihydroxy-vitamin D3, la,23,25-
30 trihydroxy-vitamin D3, 24-fluoro-1 a,25-dihydroxy-vitamin D3,
24,24-difluoro-1 a,25-dihydroxy-vitamin D3, 26,26,26-trifluoro-
1 a,~5-dihydroxy-vitamin D3, 26,26,26,27,27,27-hexafluoro-1 a,25-
dihydroxy-vitamin D3; 1a,Z5-dihydroxy-22,23-dehydro-vitamin D3,
26,26,26-trisdeutero-22,23-dehydro-1 a,25-dihydroxy-vi~amin D3,
35 26,26,26,27,27,27 hexakisdeutero-22,23-dehydro-1 a,25-dihydroxy-
Grn/29.3.93
- - :
,
.. . . . ... . . . . .
2096196
- 2 -
vitamin D3, 26,26,26-trifluoro-1 cc,25-dihydroxy-22,23-dehydro-
vitamin D3, 26,26,26,27,27,27-hexafluoro-la,25-dihydroxy-22,23-
dehydro-vitamin D3, 26,26,26,27,27,27-hexafluoro-1 a,25-
dihydroxy-23,24-dehydro-vitamin D3, la,25-dihydroxy-vitamin D2,
5 26,26,26,27,27,27-hexakisdeutero-1oc,25-vitamin D2, la,25-
dihydroxy-27-nor-vitamin Dz, 1a,25,26-trihydroxy-22,23-dehydro-
vitamin D3, la,25,26-trihydroxy-vitamin D2, la,25-dihydroxy-
23,24-didehydro-vi~amin D3, 1 oc,25-dihydroxy-16,17-dehydro-
vitamin D3, 1 a,25-dihydroxy-16,17;23,24-bisdehydro-vitamin D3,
10 1 a,25-dihydroxy-16,17-dehydro-23,24-didehydro-vitamin D3,
26,26,26,27,27,27-hexafluoro-1 a,25-dihydroxy-16,17-dehydro-
23,24-didehydro-vitamin D3,1a,26,26,26,27,27,27-heptafluoro-2~-
hydroxy-23,24-didehydro-vitamin D3, 1 oc,25-dihydroxy-3-deoxy-
23,24-didehydro-vitamin D3 and 25-hydroxy-23,24-didehydro-
l5 vitamin D2-
The aforementioned vitamin D derivatives and theirpreparation are known, see, e.g., the US patent specifications
3 993 675, 4 022 768, 4 407 7S4,4 421 690, 4 594 432,
2~ 4 594 346,4 612 308,4 613 ~94,4 6~2 405,4 749 710,
4 804 502,4 898 855,4 906 785,4 929 609, S 087 619 and
5 120 722.
26,26,Z6,27,27,Z7-Hexafluoro-l a,25-dihydroxy-16,17-
25 dehydro-23,24-didehydro vitamin D3 has not yet been described and
can be ob~ained as follows:
A. To 522 mg of [3aS-[3(S*),3aa,7a,7a~]]-[[3a,4,5,6,7,7a-
hexahydro-3a-methyl-3-(1-methyl-3-butynyl~-1 H-inden-7-
30 yl~oxy]trimethylsilane in 15 ml of anhydrous tetrahydrofuran,1.85 ml of 1.6M solution of n-butyllithium in hexane was added
dropwise after cooling at -75C over 5 minutes and the mixture was
stirred at -75C for 30 min. Then a stream of hexafluoroacetone was
bubbled into the mixture for 15 min with temperature maintained at
35 -75C. The reaction mixture was stirred for one additional hour, and
then quenched with 1 :1 mixture of 2M KHC03 and 1 M Roche!le salt
added dropwise. The mixture was stirred at room temperature for
one hour and then dilu~ed with 25 ml of the same salt solution. After
.' . -.
- :
.... . .
2~9~6
- 3 -
extraction with CH2CI2, the organic phase was washed with 50 ml of
the same salt solution, dried and evaporated. The residue was
azeotroped with benzene to give 2.38 g of crude oily product.
Purification was performed by flash chromatography (EtOAc-hexane
5 1:9) to give 817 mg of [3aS-[3(S*),3[3aa,7a,7a~]]-1,1,1-trifluoro-
6[3a,4,5,6,7,7a-hexahydro-3a-methyl-7-[(trimethylsilyl)oxy]-1 H-
inden-3-yl]-2-(trifluoro-methyl)-3-heptyn-2-ol.
B. To a solution of 812 mg of [3aS-[3(S*),3aa,7a,7a~]3-1,1,1-
10 trifluoro-6[3a,4,5,6,7,7a-hexahydro-3a-methyl-7-[(trimethylsilyl)-
oxy]-1 H-inden-3-yl]-2-(trifluoromethyl)-3-heptin-2-ol in 18 ml of
anhydrous tetrahydrofuran there was added 5.34 ml of tetra-butyl-
ammonium fluoride in tetrahydrofuran, and the mixture was stirred
at room temperature under argon for 8û min. The reaction was then
15 quenched by addition of 9 ml of half-saturated NaHC03 and stirred at
room temperature for an additional 20 min. Excess of tetrahydro-
furan was removed by evaporation and additional 9 ml of bicarbonate
was added. The mixture was extracted with ethyl acetate, the ~-
extract was washed with brine~ dried and evaporated. Af~er
ao purification by flash chromatography (EtOAc-hexane 1:2), it gave
690 mg of [3aR-~1(R*),3aa,4~B,7a,B]]-3,3a,5,6,7,7a-hexahydro-7a-
methyl-1 -[6,6,6-trifluoro-5-hydroxy-1 -methyl-5-(trifluoro-
methyl~-3-hexynyl] -4H-inden-4-ol.
25 C. To a solution of 100 mg of [3aR,-[1(R*),3aa,4~,7a~]-
3,3a,5,6,7,7a-hexahydro-7a-methyl-1 -[6,6,6-trifluoro-5-hydroxy-
1-methyl-5-(trifluoromethyl)-3-hexynyl]-4H-inden-4-ol in 6 ml of
anhydrous CH2CI2 there was added at room temperature, 176 mg of
pyridinium chlorochromate, and the mixture was stirred at room
30 temperature for 50 min under argon. To this mixture there was added
9 ml of ether under stirring, then it was filtered and the filtrate
evaporated to dryness. The crude product thus obtained was purified
by chromatography on silicagel column with ethyl acetate-hexane
1:3 to give [3aR-[1(R*),3aa,7a~]]-3,3a,5,6,7,7a-hexahydro-7a-
35 methyl-1-[6,6,6-trifluoro-5-hydroxy-1-methyl-5-(trifluoro-
methyl)-3-hexinyl~-4H-inden-4-one.
.
.. , ~ , . ' . ,. ' .
... - ', '' ' . . , - ~ : : .-'
.
.
209~
- 4 -
n To a solution of 333 mg of [35-(30c,5~,Z)]-2-~2-[2-methylene-
3, 5 -bis [ [( 1 ,1 -dimethylethyl)dimethylsilyl]oxy~cyclohexylidene]-
ethyl]diphenyl phosphine oxide in 7 ml anhydrous tetrahydrofuran
there was added at -75C, 0.325 ml of 1.6M n-butyllithium in hexane
5 under argon. After stirring for 6 min, a solution of 73 mg of ~3aR-
[1 (R*),3aa,7a~]]-3,3a,5,6,7,7a-hexahydro-7a-methyl-1-L6,6,6-
trifluoro-5 -hydroxy- 1 -methyl-5-~trifluoromethyl)-3-hexiny]-4H-
inden-4-one in 5 ml anhydrous tetrahydrofuran was added dropwise.
The reaction mixture was stirred for 1 hour at -75C, and then
10 quenched with 2.6 ml of 1:1 mixture of 2N Rochelle salt and 2N
K~C03 solutions and was allowed to warm to room temperature. It
was then diluted with 10 ml of the same salt solution and extracted
with Pthyl acetate. The extract was washed with brine, dried and
evaporated. The crude intermediate was purified by flash chromato-
graphy on silica gel column wi~h ethyl acetate-hexane 1:5 to give
disilyl-protected 1 ,25-dihydroxy-1 6-ene-23-yne-26,27-hexafluoro-
cholecalciferol.
E. To 92 mg of the disilyl protected 1,25-dihydroxy 16-ene-23-
ao yne-26,27-hexafluoro-cholecalciferol in 5 ml anhydrous ~etrahydro-
furan in a dark wall flask there was added 0.89 ml of lM tetrabutyl-
ammonium fluoride in tetrahydrofuran, and the mixture was stirred
for 16 hrs under argon. The reaction was then quenched with 3 ml of
half-saturated NaHC03 and stirred at room temperature. It was then
25 extracted with ethyl acetate. The extract was washed with half-
saturated NaHC03 and brine, then dried and evaporated. The crude
product was purified by flash chromatography with ethyl-acetate
4:1, to give 1 ,25-dihydroxy-1 6-ene-23-yne-26,27-hexafluoro-
cholecalciferol as a foamy glass; [a]25 = +59.1 (c 0.11, CH30H).
In accordance with the invention the 9-cis- or 13-cis-retinoic
acid or acitretin or a salt or ester thereof can be used in the form of
pharmaceutical preparations which also contain a vitamin D
derivative or as preparations which contain an ad hoc combination
35 with vitamin D derivatives.
2~9~196
- 5 -
The use o~ 9-cis-retinoic acid, pharrnaceutically usable salts
or esters thereof and vitamin D derivatives, especially 9-cis-
retinoic acid and calciferol is preferred.
The active substances can be administered ~opically or orally
for the treatment of psoriasis. Topical prepara~ions can be present
as creams, ointments, lotions, tinctures or gels which contain the
ac~ive substances together with carriers which are usual in such
preparations. The content of 9-cis- or 13-cis-retinoic acid or
10 acitretin, salts or esters thereof in these preparations can be about
0.001-0.1 wt.%, preferably 0.003-0.03 wt.%. The content of
vitamin D derivative in such preparations can be about 1 ~lg/g to
about 100 llg/g. These preparations are applied to ~he diseased site
on the skin according to the requirements of the patien~, e.g. once or
twice per day.
Preparations for oral administration can be present in the
form of tablets, capsules, solutions or emulsions. For the treatment
of psoriasis, such preparations can be administered in dosages of
ao about 0.01 mg to about 3 m~ of 9-cis-or 13-cis-re~inoic acid or
acitretin or salt or ester thereof per kg body weight per day,
preferably about 0.025 mg/kg to about 1.5 mg/kg per day; and about
0.001 ~lg/kg to about 0.1 llg/kg of vitamin D derivative, preferably
about O.OOS ~lg/kg to about 0.05 ~lg/kg, per day. Solid dosage forms
25 such as tablets and capsules conveniently contain per dosage unit
about 1 mg to about 50 rng of 9-cis- or 13-cis-retinoic acid or
acitretin and, respectively, about 0.1 1l9 to about 1 1l9 of vitamin D
derivative.
For the treatment and prevention of tumours, the active
substances or the preparations in accordance with the invention can
be administered enterally, parenterally or topically. Fxamples of
tumours which can be treated with the preparations in accordance
with the invention or the active substance combination in
35 accordance with the invention are haematological tumours such as
leukaemia, especially acute promyelocy~aric leukaemia and
Iymphomas. Furthermore precancerous lesions of the epitheliai
tissue such as actinic keratoses of the skin, oral leukoplakias,
- , . ~ .. ..
,, ~, . - . . ~ . .. -. . .
2~6~6
- 6 -
dysplasias of the larynx, bronchi and cervix; as well as carcinornas
of the skin, buccal cavity, the bronchi, the larynx, pharynx, stomach,
colon, uterus, pancreas, the bladder, breast and pros~ate can be
treated by the administration of an effective amount of the
5 preparations or active substance combination in accordance with the
invention.
Examples of pathological or undesired immune reactions are
autoimmune diseases such as rheumatoid arthritis, multiple
sclerosis, insulin-dependent diabetes, ~upus erythematosus,
pemphigus vulgaris, pemphi~us foliaceus, myasthenia gravis,
ankylosing spondylitis, autoimmune diseases of the thyroid gland
such as Hashimoto's disease and primary thyroid gland failure;
scleroderma, uveitis, Behcet's disease, Crohn's disease, auto-
immune-conditioned myocarditis and autoimmune-conditioned poly-
glandular syndrome; as well as allergies such as ailergic rhinitis,
atopic dermatitis, asthma and celiaca. Other indications are
undesired immune reactions in organ or cell transplants suoh as
kidney, heart, pancreas beta-islet cell, bone marrow and liver
ao transplants.
A further aspect of the invention is concerned with the use of
the preparations and, respectively, active substance combination in
accordance with the invention for the preferably emeral or
25 parenteral treatrnent and prevention of osteoporosis. In all of these
indications the active substances can be used in the dosage ranges
given above, whereby the individual dosage will depend on the nature
of the disease to be treated and on the age and condi~ion of the
patient and can be determined within the framework of medical
30 expertise. The invention is illustrated in more detail by the
following Examples.
- - ' - . . .
.
. , : . . - ~, . - ,
.
.
:, : -,
2 0 ~ 6
Example ~
Ca~ules containing 9-cis-retinoic_~$id ~ -
9-cis-Retinoic acid 20.0 mg
Gelatine ~BIoom number 30) 70.0 mg
Maltodextrin 108.0 mg
dl-a-Tocopherol 2.0 mg
Na ascorbate 10.0 mg
Microcrystalline cellulose 48.0 mg
Mg stearate 2.0 mg
Total 260 mg
-The active substance is wet-ground in a soiution of gelatine,
5 maltodextrin, tocopherol and Na ascorbate and the suspension
obtained is spray-dried. Thereafter, the cellulose and the Mg
stearate are admixed and 260 mg aliquots of the mixture are filled
into hard gelatine capsules.
Capsules cQntainina calcitriol
Calcitriol 0.25 ~lg
Butylated hydroxytoluene 0.016 mg
Buylated hydroxyanisole 0.016 mg
Fractionated coconut oil ad 160.0 mg
The ingredients are mixed and the oily solution is filled under
an inert gas into soft gelatine capsules each containing 160 mg.
,5
.. . - - .. - . - , . ~
. .: . . - : ' . . '' . . :-, ,
. . - - . . . . . . .
... . ~ . . :
,. - . .... : .
- . . ~ . .. . .
2~9~1~6
Ex~le 3
Capsules ~ontaining 9-cis-retinoic acid and calcitri~!
Calcitriol 0.25 ~g
9-cis-Retinoic acid 20 mg
Polyethylene glycol 400 200 mg
Butylated hydroxyanisole 0~1 mg
The ingredients are mixed and filled under an inert gas into
s soft gelatine capsules having a fill weight of 220 mg.
Example 4
Cre~m ~on~i~ing ~-cis-retinoic acid and calci~riol
Calcitriol 2 mg
9-cis-Retinoic acid 30 mg
Cetyl alcohol 1.5 mg
Stearyl alcohol 2.5 mg
Sorbitan monostearate 2.0mg
Glyceryl monostearate and polyoxyethylene
glycolsteara~e 4.0 mg
Polysorbate 60 l.Omg
Mineral oil 4.0 mg
Propylene glycol 5.0mg
Propylparaben 0.05 mg
Butylated hydroxyanisole 0.05 mg
Sorbitol solution 2.0 mg
Na EDTA 0.01 mg
Methylparaben 0.18 mg
Dist. water q.s. ad 100 9
Example 5
The activity of the combination in accordance with the
invention of 9-cis-retinoic acid and calcitriol on the differentiation
of hurnan promyelocytic leukaemia cells (HL-60) can be
. . .
,. , . . ~
-
..
.. ~.. . ~.
209~96
g
demonstrated in vitro in the tes~ procedure described in Cancer
Research 45, 4244 (1985). The effects obtained with various
concentrations of the active substances on cell differentiation
(measured by detecting the reduction effect on nitroblue-tetra-
5 zolium, NBT) can be concluded from Figure 1. The measurement ofthe NBT reduction was effected according to a modified method of
Pick et al. in J. Reticul. Soc. 30, 581 (1981). In each case, 3.104
cells in 200 ,ul were incubated for 48 hours with the active
substances. The cells were centrifuged off and treated with in each
10 case 100 1ll of pre-warmed NBT solution (1 mg~ml, diluted with
Dulbeccos PBS) and PMA (123 mg/ml in DMSO) and incubated at 37~C
for 1 hour. After cen~rifugation, 100 1ll of 90% DMF, diluted with
10% SDS, were added, the mixture was incubated at 37C and the
extinction (OD) was measured at 550 mm.
The curves in Fig. 1 show the effect of calcitriol alone and of
combinations of varying amounts of calcitriol with (from above
downwards) 80 nM, 16 nM and 3.2 nM 9-cis-retinoic acid.
ExamplQ 6
Patients with multiple actinic keratoses were treated -
topically with 9-cis-retinoic acid and calcitriol. 9-cis-retinoic acid
was applied as a 0.01% (v/v) solution in ethanol/propylene glycol
2s (50:50). Calcitriol was applied as a 0.0025% (w/w) cream.
Treatment was carried out for 4-16 weeks with adminis~ration of
the preparations to the skin once daily. 9-cis-retinoic acid was
applied first, followed, after drying (3 minutes~, by calcitriol cream.
Occlusive dressing was not used.
The following results were obtained with various patient
groups:
,
.- . :
.
2 ~
- lo -
A. Patient group: 16 patients
Duration of treatment: 4 weeks
Result of treatment:
6 patients: slight improvement
5 patients: moderate improvement
5 patients: marked irnprovement
B. Patient group: 16 pa~ients
Duration of treatment: 8 weeks
Result of treatment:
3 patients: slight improvement
4 patients: moderate improvement
9 patients: marked improvement
C. Patient group: 7 patients
Duration of treatment: 1Z weeks
Result of treatment:
in all 7 patients: marked improYement
ao D. Patient group: 3 patients
Duration of treatment: 16 weeks
Result of treatment:
in all 3 patients: marksd improvement
In all cases, slight erythema but no disturbing symptoms
(burning, itching) developed.
.
- : : .:
. . . .
, , . ~ .
