Note: Descriptions are shown in the official language in which they were submitted.
WO 94/14455 PCT/US93/12302
2~12~
,,. TITLE OF THE INVENTION
BISPHOSPHONATE/ESTROGEN THERAPY FOR TREATING AND
PREVENTING BONE LOSS
5 FIELD QF THE INVENTION
The instant invention relates generally to the combination
of estrogen and bi,sphosphonate.s and their use in bone growth and
maturation. Specifically, the invention relates to the use of estrogen and
bisphosphonates to inhibit bone resorption and promote net bone
formation. Thi,s therapeutic combination will result in a decreased rate
of bone resorption with either an increase or stabilization of bone mass.
BACKGROUND OF THE INVENTION
The normal bones are living tissues undergoing constant
resorption and redeposition of calcium, with the net effect of
m~intenance of a constant mineral balance. The dual process is
commonly called "bone turnover". In normal growing bones, the
mineral deposition exceeds the mineral resorption, whereas in certain
pathological conditions, bone resorption exceeds bone deposition, for
instance due to malignancy or primary hyperparathyroidism, or in
o.steoporosi.s. ln other pathological conditions the calcium deposition
may take place in undesirable amounts and areas leading to e.g.
heterotopic calcification, osteoarthriti.s, kidney or bladder .stones,
atherosclerosis, and Paget's disease which is a combination of an
abnormal high bone resorption followed by an abnormal calcium
deposition.
Most of the currently available therapeutic agents for the
treatment of osteoporosis, e.g. estrogens, act by reducing bone
resorption in the osteoporotic patient. See the review article, British
Medical Bulletin 46 (I ), p. 94-1 12 (1990).
Bisphosphonates are also known in the art as bone
resorption inhibitors.
WO 94/14455 PCT/US93/12302 ~
21~ 2~Q
Alendronate, 4-amino- 1 -hydroxybutylidene- 1, I - ,,
bispho,sphonic acid monosodium trihydrate, is described as ~
composition, method of use and synthesis in US Patents 4,621,077
(Gentili); 4,922,007 and 5,019,651 (Merck).
Clodronate, (dichloromethylene)bisphosphonic acid
disodium salt (Proctor and Gamble, is described in Belgium Patent
672,205 (1966) and J. Org. Chem 32, 4111 (1967) for it~ preparation.
Tiludronate, (1(4-chlorophenyl)thiomethylenel-
bisphosphonic acid) (Sanofi) i~s described in U.S. Patent 4,~s76,24g
issued October 24, 19~S9.
YM 175 ([(cycloheptylamino)methylenelbisphosphonic
acid, disodium salt) by Yamanouchi is described in U.S. Patent
4,970,335 issued November 13, 1990.
BM 210995 (1-Hydroxy-3-(methylpentylamino)-
propylidene-bisphosphonate) by Boehringer-Mannheim - is described in
U.S. Patent 4,927,~ 14 issued May 22, 1990.
A study by Proctor and Gamble (Norwich Eaton
Pharmaceuticals) using risendronate, whose chemical name is sodium
trihydrogen [l-hydroxy-2-(3-pyridinyl)ethylidene]bisphosphonate, in
combination with estrogen showed a positive effect on bone lo.ss in
ovaricetomized rats (published in Abstracts 731 and 732 at the Fall 1992
ASBMR meeting in Minnesota.
The article, J. Clin. lnvest., Jan. 1992, ~9 (1), p. 74-7~ by
J. Chow et al., describes the effect of estrogen on ovariectomized rats in
which bone resorption was suppressed by parnidronate. They concluded
that estrogen inhibits bone resorption and also stimulates bone
formation.
The article, J. Bone Miner. Res. (USA) 1991, p. 3~7-394
by T.J. Wron.ski et al., describes studies in rats with estrogen and the
bisphosphonates etidronate and risedronate. The studies showed that
etidronate, (l-hydroxyethylidene)bisphosphonic acid, disodium salt,
(Proctor and Gamble) has long term adver.se effects on bone
mineralization.
~0 94/1445~ PCT/US93/12302
~ ~5~2~0
- However, these studies did not sugge,st the use of other
bispho,sphonate,s including alendronate.
There are situation,s where a female patient is undergoing
estrogen therapy for a menopau,sal or postmenopau,sal-related condition,
(e.g., vasomotor symptoms, atrophy of the vaginal mucosa, increased
cardiovascular risk, etc.) and is also discovered to be suffering from
osteoporosi,s (i.e. rarefaction of bone) or to be at ri,sk for developing
osteoporosi,s.
0 Although e,strogens/hormone replacement therapy (HRT)
are known to help prevent the development of o,steoporosis, there are
instances, which are not at all uncommon, where HRT or a weak
estrogen is prescribed at dosage.s which do not provide adequate
protection against osteoporosi,s. There are also some women who
continue to lose bone mass despite treatment with higher estrogen/HRT
doses or who have established osteoporosi,s but fail to increase their
bone mass on estrogen/HRT alone.
What is de,sired in these cases is a therapy to optimally treat
both the menopausal and postmenopausal-related conditions and the
development of osteoporosis or osteoporosis n,sk concurrently.
SUMMARY OF THE INVENTION
The present invention di,scloses a combination method for
treating and/or preventing bone loss in a subject by the combination
therapy of pharmaceutically effective amounts of estrogen and of a
bisphosphonate selected from: alendronate, clodronate, tiludronate, YM
175, BM 210995, or mixture thereof.
Also described is a pharmaceutical composition containing
the combination described above in a pharmaceutically acceptable
3 o Carrler.
WO 94/14455 PCT/US93/12302
2~12~ --
DETAILED DESCRIPTION OF THE INVENTION AND
PREFERRED EMBODIMENTS
By the term "e.strogen" as u,sed herein is meant " 17-beta
estradiol" and includes those equivalent material~ contained in the
MERCK INDEX - Eleventh Edition (19~s9). E,strogens, e.g. estradiol
and its steroidal and non-steroidal e~uivalent~ which can be used herein
include (page numbers taken from the above indicated MERCK
INDEX):
ESTROGEN
Nonsteroidal
Benzestrol, 10~2
Broparoestrol, 143~
Chlorotrianisene, 2173
Dienestrol, 3094
Diethylstilbe~strol, 311 g
Diethylstilbestrol Dipropionate, 3119
Dimestrol, 319g
Fosfestrol, 416~S
Hexestrol, 4621
Methallenestril, 5~56
Methestrol, 5~
Tamoxifen, 9019
Steroidal
Colpormon, 24g5
Conjugated Estrogenic Horrnones, 2504
Equilenin, 35~1
Equilin, 35~2
Estradiol, 3653
Estradiol Benzoate, 3655
Estradiol 17~-Cypionate, 3656
Estriol, 3659
~WO 94/14455 PCT/US93/12302
21~4~
Estrone, 3660
Ethinyl Estradiol, 36~9
Me.stranol, 5~19
Moxestrol, 6203
Mytatrienediol, 6254
Progesterone, 77~S3
Quinestradiol, ~065
Quinestrol, ~s066
and including estrogen/progestin combinations.
By the term "bisphosphonates" as used herein is meant
bisphosphonates of the structure:
R2 - C (P03H)2
Rl
irl which R 1 is OH or H and R2 is an C 1 -C5 linear, branched or cyclic
alkyl or alkylidene which can be substituted by an terminal amino,
substituted amino, e.g. dimethylamino, methylamino, ethylamino,
heterocyclic amino, and the like. Also included within the term
"bisphosphonates" are the bisphosphonates described above, and those in
the US Patents 4,732,99~; 4,~70,063; 5,130,304 to Leo Pharmaceuticals.
Excluded from this category is risedronate.
The method can be used to treat subjects in general,
including sport, pet, and farm ~nim~l~, and humans.
The term "inhibition of bone resorption" refers to
prevention of bone loss, especially the inhibition of removal of existing
bone either from the mineral phase and/or the organic matrix phase,
30 through direct or indirect alteration of osteoclast formation or activity.
Thus, the term "inhibitor of bone resorption" as used herein refers to
agents that prevent bone loss by the direct or indirect alteration of
osteoclast formation or activity.
WO 94/14455 PCT/US93/12302 ~
2~ ~12~
The term "osteogenically effective" means that amount
which effects the turnover of mature bone. As used herein, an
osteogenically effective dose is al,so "pharmaceutically effective."
The term "subject" as used herein refer.s to a living
vertebrate ~nim~l such as a m~mm~l or bird in need of treatment, i.e.,
in need of bone repair or replacement. Such need arises locally in c~ses
of bone fracture, non-union, defect, prosthesi~i implantation, and the
like. Such need also ari.ses in cases of systemic bone disease, as in
osteoporosis, osteoarthritis, Paget's disea.se, o.steomalacia, multiple
myeloma and other forms of cancer, steroid therapy, and age-related
loss of bone mass. Particularly preferred is a human female subject.
The term "treatment" or "treating" as used herein shall
mean (1) providing a subject with an amount of a substance sufficient to
act prophylactically to prevent the development of a weakened and/or
unhealthy state; and/or (2) providing a subject with a sufficient amount
of a substance so as to alleviate or elimin~te a disease state and/or the
,symptoms of a disease state, and a weakened and/or unhealthy state.
METHOD OF USE
Drugs which prevent bone loss and/or add back lo,st bone
may be evaluated in the ovariectomized rat. This ~nim~l model is well
established in the art (see, for example, Wronski, et al. (19~5) Calcif.
Tissue Int. 37:324-32~; Kimmel, et al. (1990) Calcif. Tissue Int.
46:101-110; and Durbridge, et al. (1990) Calcif. Tissue Int 47:383-387;
these references are hereby incorporated in their entirety). Wronski, et
al. ((19g5) Calcif. Tissue lnt. 43:179-183)) describe the association of
bone loss and bone turnover in the ovariectomized rat.
Pharmaceutical formulations of the invention which include
a bone growth factor and/or an inhibitor of bone resorption for
~lmini~tration will generally include an osteogenically effective amount
of the bone growth factor to promote bone growth, in addition to a
pharmaceutically acceptable excipient. Suitable excipients include most
carriers approved for parenteral ~ministration, including water, ,saline,
Ringer's solution, Hank's solution, and solutions of glucose, lactose,
~WO 94/14455 ~CT/US93/12302
2 1 5 ~
r dextrose, ethanol, glycerol, albumin, and the like. These compo.sitions
may optionally include .stabilizer~, antioxidants, antimicrobial~,
preservatives, buffering agents, .surfactants, and other acce.ssory
additives. The inhibitor of bone resorption may also be delivered in
sustained release form from a suitable carrier.
A presently preferred vehicle comprises about 1 mg/ml
serum albumin (species-specific) in phosphate-buffered saline (P~S) or
isotonic citrate buffer. A thorough di.scussion of suitable vehicles for
parenteral ~clministration may be found in E. W. Martin. "Remington'~
Pharmaceutical Science,s" (Mack Pub. Co., current edition section~
relating to the excipient vehicles and formulating being incorporated
herein by reference to disclo.se such). Such formulations are generally
known to those skilled in the art and are a-lministered systemically to
provide systemic treatment.
The estrogen and bisphosphonate may be ~lmini.stered
sequentially or concurrently in separate dosages or as a single
composition to the subject. If administered sequentially, the period
between the ~lmini~tration of the estrogen and bisphosphonate will
typically be one week to one year, and optimally, one week to six
months.
If the estrogen and bisphosphonate are ~lmini~tered a.s a
single composition, the molar ratio of the estrogen and bisphosphonate
will be about 50:1 to 1:50, preferably, 5:1 to 1:5. The optimal ratio is
expected to vary from compound to compound. Furthermore, if
~mini~tered as a single composition the estrogen and bisphosphonate
may be separate components of the composition, or they may be
conjugated to each other. Methods for conjugating bone growth factor~
to other agents are described above.
The precise dosage necessary will vary with the age, size,
sex and condition of the subject, the nature and severity of the disorder
to be treated, and the like; thus, a precise effective amount cannot be
specified in advance and will be determined by the caregiver. However,
appropriate amounts may be determined by routine experimentation
with ~nim~l models, as described below. In general terms, an effective
WO 94/14455 PCT/US93/12302 ~
~ 21~112~
dose of estrogen for systemic treatment will range from about 0.001
!lg/kg to about 50 ~g/kg of body weight and preferably about 30 ~g/kg
of body weight. An effective dose for biphosphonate is about 1.5 to
3000 !lg/kg of body weight and preferably about 10 ,ug/kg to about 200
g/kg of body weight.
Effective doses for local ~lministration would be about
0.001 ,ug to 1 mg per application site.
The methods and composition,s of the invention are useful
o for treating bone fractures defects and disorders which result in
weakened bones such as osteoporosis, osteoarthritis, Paget's disease,
osteohalisteresis, osteomalacia, bone loss resulting from multiple
myeloma other forms of cancer, bone lo,ss resulting from side effect,s of
other medical treatment (such a,s steroids), and age-related los,s of bone
1 5 mass.
In accordance with one method of use the estrogen and
bisphosphonate may be ~lmini.~tered systemically either orally and/or
parenterally, including subcutaneous or intravenous injection.
Additionally, the estrogen and bisphosphonate make be delivered in
.slow release form from a suitable carrier.
In accordance with another method of use, the estrogen
may be ~lmini~tered locally to a specific area in need of bone growth or
repair, with either the concomitant ~lmini~tration of the bi.sphosphonate
at the site, or the ~lmini~tration of the bisphosphonate in a separate
2 vehicle, or the inhibitor of bone resorption may be provided locally
with the ~lmini~tration of the estrogen in a separate vehicle. Thus, the
estrogen and/or bisphosphonate may be implanted directly at the site to
be treated, for example, by injection or surgical implantation in a
sustained-release carrier. Suitable carrier.s include hydrogels,
controlled- or sustained-relea,se devices (e.g., an Alzet(~) minipump), f
polylactic acid, and collagen matrice.s. Presently preferred carriers are
formulations of atelopeptide collagen cont~ining particulate calcium
phosphate mineral components, such combinations of homologous or
xenographic fibrillar atelopeptide collagen (for example Zyderm(~
Collagen Implant, available from Collagen Corporation, Palo Alto,
_WO 94/14455 PCT/US93/12302
-- ~ 21~2~
Calif.) with hydroxapatitetricalcium phosphate (HA-TCP, available
from Zimmer, Inc., Warsaw, ln.). It is presently preferred to
a(lminicter implant compositions cont~ining and/or an bi.sphosphonate in
5 a collagen/mineral mixture implant.
Estrogen and/or an bisphosphonate delivered in sustained-
relea.se vehicles is also particularly useful for improving implant
fixation, for example for improving in growth of new bone into a metal
pro.sthesis in joint reconstruction and dental or orthopedic implants.
o Alternatively, the estrogen may be delivered in the implant, with the
bisphosphonate delivered in a separate vehicle, and vice-versa.
Dental and orthopedic implants can be coated with estrogen
in combination with an bisphosphonate to enhance attachment of the
implant device to the bone. Alternatively, the estrogen can be used to
15 coat the implant, and the bisphosphonate can be ~mini~tered
concomitantly or sequentially in a separate vehicle, and vice-versa.
In general, irnplant devices may be coated with a estrogen
and/or an bisphosphonate as follows. The estrogen and the
bisphosphonate if desired is dissolved at a concentration in the range of
20 0.01 ~lg/ml to 200 mg/ml in phosphate-buffered saline (PBS) con~ining
2 mg/ml serum albumin. The porous end of an implant is dipped in the
solution and is airdried (or Iyophilized) or implanted imrnediately into
the bony site. The viscosity of the coating solution is increased, if
desired, by ~ ling hyaluronate at a final concentration of 0.1 mg/ml to
25 100 mg/ml or by ~ ling other pharmaceutically acceptable excipients.
Alternatively, the solution cont~ining the estrogen (and the
bisphosphonate, if desired) is mixed with collagen gel or hllm~n
collagen (e.g. Zyderm~) Collagen Implant, Collagen Corp., Palo alto,
Calif.) to a final collagen concentration of 2 mg/ml to 100 mg/ml to
30 form a paste or gel, which is then used to coat the porous end of the
implant device. The coated implant device is placed into the bony site
immediately or is airdried and rehydrate with PBS prior to implanting,
with the objective of maximi7ing new bone formation into the implant
while minimi7.ing the ingrowth of soft tissue into the implant site.
W O 94/14455 PCTrUS93/12302 ~
2 1 3 1 2 ~ ~
- - 10 -
The pharmaceutical composition,s according to the present
invention containing, e.g., both alendronate and estradiol, may be
prepared for use in the form of capsules or tablets or in solution for
oral ~lmini~tration or for sy.stemic use. The compo.sition.s are
advantageously prepared together with inert carriers such as sugars
(saccharose, glucose, lactose), starch and derivatives, cellulose and
derivatives, gums, fatty acid.s and their salts, polyalcohols, talc, aromatic
esters.
Some typical pharmaceutical formulations cont~ining 4-
amino-l-hydroxybutane-l,l-diphosphonic acid monosodium salt
trihydrate are shown here below:
TABLE
1 2
OPERCOLATE~ (~APSULES
4-amino-1-hydroxybutan-1,1- mg 6.5 mg 2.5
biphosphonicacid, sodium salt
trihydrate
Estradiol 3.0 2.0
Lactose 11 0.0 11 0.0
Avucek PhlOl 80.0 80.0
Aldisol~ Type A 2.0 2.0
Magnesium Stearate 1.0 1.0
Total Total
Weight 202.5 Weight 197.5
WO 94/14455 PCT/US93/12302
I I _
EFFERVESCENT
GRANULATES
4-amino- 1 -hydroxybutan- 1,1- mg 5.0 mg10.0
biphosphonic acid
Estradiol 3.0 3.0
Anhydrous Sodium Carbonate 12.0 12.0
Sodium Bicarbonate 63.0 63.0
Anhydrous Citric Acid 110.0 110.0
SodiumSaccharinate 5.0 5.0
Saccharose 493.0 493.0
Dehydrated Lemon Juice 55.0 55.0
Natural Essence of Lemon 2.0 2.0
Total Weight 74~s 753
FORMULATIONS
SUITABLE FOR ~NJECTION
4-amino- 1 -hydroxybutan- 1,1- mg 0.5 mg 1.00
biphosphonic acid
Estradiol 0.42 0.84
Sodium Hydroxide 0.25 0.25
Sodium Chloride 8.40 16.30
Purified Water q h ml 1.0 ml 12.0
-
