Note: Descriptions are shown in the official language in which they were submitted.
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HIGH DOSE PROTEASE FORMULATION
FIELD OF THE INVENTION
The invention concerns a new protease formulation useful in the treatment
of pancreatic disorders.
BACKGROUND OF THE INVENTION
Chronic pancreatitis is characterized by episodes of severe epigastric and
back pain, which often requires regular doses of narcotics. During these
episodes, the pain lasts for hours and occurs every day. Moreover, it
recurs periodically for years. Pain is usually epigastric, sometime also felt
in the left upper quadrant with radiation to the back between T12 and L2
or to the left shoulder (Pitchumoni 199$). Many patients are chronically
debilitated because of the pain. It can be quite frustrating to take care of
these patients because they return again and again to the emergency
room with severe pain, some of them intoxicated, others denying any
ongoing alcoholism, others addicted to narcotics. Excessive alcohol
consumption causes about 70% of all cases of chronic pancreatitis while
10-40% is idiopathic (Ectors et al 1997).
The only prospective study on the incidence and prevalence of chronic
pancreatitis was performed in Copenhagen in 1978 and 1979. ft showed
an incidence of 8.2 new cases/100,000 inhabitants per year and a
prevalence of 26.4 cases/100,000 inhabitants. Alcohol consumption is
considered to be a major factor in the development of chronic pancreatitis.
Japan has traditionally had a very low alcohol intake, which may well
explain the low incidence (rate) of chronic pancreatitis. Environmental or
hereditary factors may influence the susceptibility to alcohol-induced
pancreatitis. Alternatively, this may be related to regional differences in
diagnostic criteria for chronic pancreatitis. Thus, the figures for frequency
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of chronic pancreatitis differ markedly from one center to another. Most
likely, this does not reflect a real difference in frequency but point
strongly
to regional differences in patient selection and diagnostic criteria. Valid
and comparable figures for incidence and prevalence of chronic
pancreatitis are pending for careful prospective epidemiologic studies
based on uniformly accepted diagnostic criteria.
In chronic pancreatitis, the gland usually undergoes extensive atrophy
with fibrosis and inflammatory cell infiltration. Somewhere along the
evolution of the atrophy of the gland, there is an increase in protein
secretion associated with protein precipitation in the smaller ductules, the
formation of protein plugs, and the subsequent blockage of the smaller
ductules. As the disease progresses, blockage of the larger ductules and
central ducts takes place and stone formation and calcification can occur.
Many of these changes probably involve the production of pain, as we
know it in the syndrome of chronic pancreatitis.
The treatment of chronic pancreatitis is usually influenced by the presence
of large or small duct disease. Patients with large duct disease should be
referred for an attempt at endoscopic or surgical drainage. On the other
hand, small duct disease is often characterized by minimal changes on X-
rays, ultrasounds, and CT-scans (Hayakawa 1992, Walsh 1992). The
exocrine function may be intact or only partially diminished (Hayakawa
1992). Since there is no effective way to treat these patients, one should
proceed from the least invasive to the most invasive approach.
The American Gastroenterological Association (AGA 1998) has
published guidelines for the treatment of chronic pancreatitis. The first
step is to avoid the use of any type of irritant for the pancreas, such as
alcohol, and to prescribe a low-fat diet and non-narcotic analgesics, such
as acetaminophen. Secondly, when the patient suffers from refractory
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pains, the use of high dose pancreatic enzymes plus acid suppression is
advocated.
These new guidelines confirm the increasing evidences that chronic
pancreatitis can be managed by the use of large doses of pancreatic
enzymes, especially to relieve the pain associated with this condition.
The mechanism seems to involve a reduction in the secretion of
pancreatic enzymes mediated by the presence of ingested enzymes in
the duodenum, a process called negative feedback inhibition. The ability
of ingested enzymes to initiate changes in pancreatic exocrine secretion,
and therefore, possibly modify pain, appears to involve a peptide in the
mucosa of the small intestine, called CGK-releasing peptide (CCK-RP),
that releases CCK into the circulation.
Trypsin is capable of denaturing this peptide and thereby prevents the
release of CCK.
In the fasting state, basal pancreatic secretion supplies just enough
enzyme to denature CCK-RP and thus limits the steady state of release
of CCK to small amounts.
In chronic pancreatitis, trypsin out-put is diminished. As a result, CCK-
RP is not denatured and is available to release excessive amounts of
CCK. The pancreas remains under strong stimulation from this hormone
and this mechanism is thought to cause pancreatic pain. However, the
mechanism remains to be elucidated. Oral enzyme therapy provides
increased trypsin within the duodenum and trypsin denatures CCK-RP,
thereby reducing CCK release. The result is a decrease in pancreatic
stimulation and less pain. Oral enzyme also reduces CCK release in
response to food.
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There are several published studies on the use of pancreatic enzymes
for the relief of pain associated with chronic pancreatitis and one meta-
analysis. Most of these studies were carried out and suggested that
non-coated enzymes preparation should be useful in the treatment of
painful chronic pancreatitis.
Moreover, the active component of these preparations is the protease
fraction, more specifically trypsin and chymotrypsin, which can denature the
CCK releasing peptide. It is then logical to think that enzymes preparations
that would contain only proteases would be ideal to treat chronic, painful
pancreatitis.
Thus; there is a need to develop a new non-enteric coated formulation
having a high content of protease.
SUMMARY OF THE INVENTION
An object of the present invention is to provide a formulation having a high
content of protease.
Another object of the invention is to provide a non-enteric coated
formulation having a high content of protease.
A further object of the present invention is the use of the above-mentioned
new formulation for the treatment of pancreatic disorders.
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BRIEF DESCRIPTION OF THE DRAWINGS
Figure 1 is flowchart illustrating a process for manufacturing a high
protease content formulation according to a preferred embodiment of the
present invention;
5 Figure 2 is a table summarizing the pH values that may be used in the
process of Figure 1.
DETAILED DESCRIPTION OF THE INVENTION
The present invention is concerned with a pancreatin or pharmaceutical
formulation comprising protease which has a residual protease activity of at
least 100 000 Uusp/g. Preferably, such formulation has a residual protease
activity ranging from about 150 000 Uusp/g to 300 000 Uusp/g.
The formulation according to the present invention may also contain
amylase and lipase. The feasible ratio of protease/lipase is around 3 to 10
in the final product. The lipase will then be between 25,000 to 35,000
Uusp/g. The residual lipase activity is about 2,000 Uusp/g for pancreatine
and for pancrelipase, 24,000 Uusp/g.
The pH shift between 5 and 6, between 0 and 60 minutes. The residual
lipase activity varies from 20,000 to 40,000 Uusp/g. The residual amylase
activity is greater than 75,000 Uusp/g. The residual protease activity varies
from 150,000 to 300,000 Uusp/g.
The pancreatin formulation according to the present invention may be
prepared by a process comprising:
a) a grinding step which comprises grinding a predetermined amount
of a frozen pancreas gland;
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b) an autolysis step which comprises mixing the pancreas gland
obtained in a) with water, isopropanol, sodium bicarbonate and
trypsin, thereby obtaining a first mixture;
c) a separation step which comprises pumping the first mixture into a
screening kettle thereby seperating the insoluble fibers thereby
obtaining a filtrate;
d) a precipitation step which comprises mixing the filtrate with
isopropanol thereby forming a second mixture, and allowing the
second mixture to settle thereby obtaining a precipitate;
e) a purification step which comprises washing the precipitate with
isopropanol; and
f) an isolation step which comprises isolating the precipitate obtained
in e) by filtration.
The pancreatin or pharmaceutical formulation according to the present
invention may be used for the treatment of digestive deficiencies and
pancreatic disorders such as chronic pancreatitis and non- ulcerous
dyspepsia.
Dyspepsia is a common clinical symptom, associated with a potentially
profound impact on health care resource utilization and patient quality of
life. There are many possible causes for dyspepsia including acid-related
disease, motility disturbances, abnormal visceral sensitivity, and neoplastic
disorders of the esophagus, stomach, and duodenum. However, the
majority of patients with dyspepsia have no identifiable upper
gastrointestinal pathology after standard test (1-8). Furthermore, whether or
not structural or functional abnormalities are documented, symptoms
persist in >50% patients despite treatment with potent acid suppressants,
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prokinetics, drugs affecting visceral pain thresholds, and/or antibiotics
against H, pyroli. (9-10) Biliary tract disease may account for symptoms in
some patients with dyspepsia, but it is well known that cholecystectomy
and/or biliary sphincterotomy often fail to relieve symptoms in patients
without classic biliary colic or objective evidence of biliary obstruction.
The role of pancreatic disease in dyspepsia is unclear. A number of studies
have documented abnormal pancreatic function in patients with dyspepsia.
Lundh meal tests were abnormal in 20/72 (28%) uninvestigated dyspeptics
studied by Schulze et al. (11) and in 159/460 (35%) studied by Anderson et
al. (12) Smith et al. also found significantly reduced mean tryptic activity
after a Lundh test meal in 6127 (27°/A) patients with endoscopically
confirmed non ulcer dyspepsia (13) and Skude et al. found abnormal serum
pancreatic isoamylase levels in 7/36 (19%) consecutive males seeking
primary care for dyspepsia (14).
Mild pancreatic disease is difficult to diagnose since duodenal intubation
tests may be impractical to perform outside of referral centers and because
endoscopic retrograde pancreatography may be considered too invasive.
Some authors have suggested that mild pancreatic disease may present as
dyspepsia (15) and abnormal pancreatic function has been found in up to
35% of patients with dyspepsia (11-14). 'There are no published data on
pancreatographic finding in patients classified prospectively as suffering
from dyspepsia.
EXAMPLES
1.0) Manufacturing process for pancreatin formula for 235 to 370 kg*
Material I Mass ~ Addition
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Pancreas glands2,000-3,000 at step 1 Mincing: frozen
kg material is
minced
Sodium 25-40 kg at step 2 Autolysis: as buffer
bicarbonate substance
Simethicone 0-12 kg at step 2 Autolysis: in case
of foaming
emulsion
Pancreatin for 40-80 Mio at step 2 Autolysis: to activate
FIP- Trypsin
starting Units for autolysis
Isopropanol 250-350 L at step 2 Autolysis (start)
88% to reduce
(vw) microbiological contamination
' at step 2 Autolysis (end)
to dissolve fat
1,500-1,700
L r
ci
itate
i
ti
t
4 P
it
t
t
p
p
on
o p
e
rec
a
s
ep
a
' pancreatin
6,500-7,500
L i
II; at step 5 Purification
to wash
4,000-6,000
L
i pancreatin and to reduce
microbiological contamination
I
Drinking water 600-750 L at step 2 Autolysis: to dissolve
buffer
and pancreas glands
I
* Batch size is 470 to 740 Kg after addition of two sub-batches of this size
to step 8 shredding.
1 1 ) Detailed description of the process
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Step 1: Mincing
2,500 kg (2,000 to 3,000 kg) of deep frozen Porcine Pancreas Glands are
minced with a meat grinder.
Step 2: Autolysis
The minced material is pumped with 500 L of drinking water to a stirred
mixture of 300 L (250 to 350 L) of Isopropanol 88%, 150 L (100 to 250 L) of
drinking water and 32.5 kg (25 to 40 kg) of Sodium bicarbonate in a
autolysis kettle. Then 40 to 80 million FIP trypsin units and 0 to 1.2 kg of
Simethicone emulsion (if foaming occurs) are added.
This mixture is heated in stages to a maximum of 25°C, while
stirring.
Samples are taken to determine the end of autolysis. To stop the autolysis
(after 12 to 96 h) 1,600 L (1,500 to 1,700 L) of Isopropanol 88% (v/v) is
added, while stirring.
Step 3: Separation
The mixture is pumped into the screening kettle and insoluble fibers are
separated by sieving.
Step 4: Precipitation
The filtrate is charged to 7,000 L (6,500 to 7,500 L) of isopropanol 88%
(v/v) in the precipitation kettle and stirred for a minimum of 30 minutes. The
precipitate is allowed to settle during a minimum of 30 minutes and the
upper layer of solvent is removed.
This solvent is distilled to recycle isopropanol.
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Step 5: Purification
The remaining precipitate is stirred with 4,000 to 6,000 L of isopropanol
88% (v/v) at a maximum temperature of 25°C for a minimum of 60 minutes.
Step 6: Isolation
5 The purified product is isolated by filtration on a filter press.
Step 7: Cold storage
In a cold storage room the product is stored in closed containers at a max
temperature of 0°C.
Step 8: Shredding
10 The wet filter cake of two autolysis sub-batches, produced as described
above, are combined and shredded in a screw-type extruder.
Step 9: Drying
The sized product is dried in a vacuum double-cone dryer. The drying of
pancreatin is performed in vacuum at temperatures between 0 and 85°C
over a period of minimum 16 h, at least 1 h with a minimum temperature of
60°C.
Step 10: Milling
The dried product is milled in a cylinder mill and sieved.
Step 11: Sifting
To remove residual fibers the material is sieved on a 0.6 mm sifting system.
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Step 12: Homogenizing
Before taking samples for analysis the material is collected in an aluminum
container and homogenized with the container mixer.
Step 13: Quarantine Storage
The drug substance is stored in aluminum containers until released by
Quality Control.
Optional: Standardizing
The digestive power of the drug substance can be standardized to
customer requirements by blending material in a container mixer with a
higher digestive power with material of a lower digestive power.
Step 14: Packaging and Labelling
Pancreatin / Pancrelipase is weighed into PE bags, sealed up tightly
together with a desiccant in an AI-laminated foil and packaged in a
corrugated cardboard box.
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REFERENCES
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1995;109:6
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13. Smith RC, Talley NJ, Dent OF, Jones M.'.Waller SL.. Exocrine pancreatic
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