Note: Descriptions are shown in the official language in which they were submitted.
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ORAL INSULIN THERAPIES AND PROTOCOL
FIELD OF THE INVENTION
[0001] This invention relates to the oral delivery of insulin in a
therapeutically effective amount to
the bloodstream as part of a therapeutic regimen for the treatment of
diabetes. This invention also
relates to oral administration of compositions of insulin and a delivery agent
that facilitates insulin
transport in a therapeutically effective amount to the bloodstream for the
treatment of diabetes. The
present invention is also directed to therapies and protocols for
administration of oral
pharmaceutical dosage forms of insulin on a chronic basis to pre-diabetics,
including those with
impaired glucose tolerance and/or insulin resistance, to early stage
diabetics, and to late stage
diabetics. The present invention further relates to methods for reducing
adverse effects and the
incidence of diseases that are associated with systemic hyperinsulinemia and
hyperglycemia.
especially to the 0-cells of the pancreas.
BACKGROUND OF THE INVENTION
[0002] Proteins, peptides and other biological molecules ("biological
macromolecules", namely
biological polymers such as proteins and polypeptides) are increasingly being
use in many diverse
areas of science and technology. For example, proteins are employed as active
agents in the fields
of pharmaceuticals, vaccines and veterinary products. Unfortunately, the use
of biological
macromolecules as active agents in pharmaceutical compositions is often
severely limited by the
presence of natural barriers of passage to the location where the active agent
is required. Such
barriers include the skin, lipid bi-layers, mucosal membranes, severe pH
conditions and digestive
enzymes.
[0003] There are many obstacles to successful oral delivery of biological
macromolecules. For
example, biological macromolecules are large and are amphipathic in nature.
More importantly, the
active conformation of many biological macromolecules may be sensitive to a
variety of
environmental factors, such as temperature, oxidizing agents, pH, freezing,
shaking and shear
stress. In planning oral delivery systems comprising biological macromolecules
as an active agent
for drug development, these complex structural and stability factors must be
considered. In
addition, in general, for medical and therapeutic applications, where a
biological macromolecule is
being administered to a patient and is expected to perform its physiologic
action, delivery vehicles
can be used to facilitate absorption through the gastro-intestinal tract.
These delivery vehicles must
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ye avie io release active molecules at a rate that is consistent with the
needs of the particular patient
or the disease process.
[0004] One specific biological macromolecule, the hormone insulin, contributes
to the normal
regulation of blood glucose levels through its release by the pancreas, more
specifically by the
0-cells of a major type of pancreatic tissue (the islets of Langerhans), so
that the glucose can be
used as a source of energy. Insulin secretion is a regulated process that, in
normal subjects,
provides stable concentrations of glucose in blood during both fasting and
feeding. In healthy
humans, insulin is secreted from the pancreas into the portal vein, which
carries the insulin to the
liver. The liver utilizes and/or metabolizes a large portion of the insulin
that it receives from the
portal circulation. In very basic terms, the liver plays a key role in the
metabolism of glucose as
follows: in the presence of excess insulin, excess glucose, or both, the liver
modulates the
production of glucose released into the blood; and, in the absence of insulin
or when the blood
glucose concentration falls very low, the liver manufactures glucose from
glycogen and releases it
into the blood. The liver acts as a key blood glucose buffer mechanism by
keeping blood glucose
concentrations from rising too high or from falling too low.
[0005] Blood glucose concentration is the principal stimulus to insulin
secretion in healthy
humans. The exact mechanism by which insulin release from the pancreas is
stimulated by
increased glucose levels is not fully understood, but the entry of glucose
into the )3-cells of the
pancreas is required. Glucose enters the pancreatic 0-cells by facilitated
transport and is then
phosphorylated by glucokinase. Expression of glucolcinase is primarily limited
to cells and tissues
involved in the regulation of glucose metabolism, such as the liver and the
pancreatic 0-cells. The
capacity of sugars to undergo phosphorylation and subsequent glycolysis
correlates closely with
their ability to stimulate insulin release. It is noted that not all tissues
are dependent on insulin for
glucose uptake. For example, the brain, kidneys and red blood cells are
insulin independent tissues,
while the liver, adipose and muscle are insulin dependent tissues.
[0006] When evoked by the presence of glucose (e.g., after a solid meal is
ingested) in a non-
diabetic individual, insulin secretion is biphasic: shortly after ingesting
food, the pancreas releases
the stored insulin in a burst, called a first phase insulin response, and then
approximately 15-20
minutes later outputs further insulin to control the glycemic level from the
food. The first phase
insulin response reaches a peak after 1 to 2 minutes and is short-lived,
whereas a second phase of
secretion has a delayed onset but a longer duration. Thus, secretion of
insulin rises rapidly in
normal human subjects as the concentration of blood glucose rises above base
levels (e.g., 100
mg/100m1 of blood), and the turn-off of insulin secretion is also rapid,
occurring within minutes
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after reduction in blood glucose concentrations back to the fasting level.
[0007] In healthy human subjects, insulin secretion is a tightly regulated
process that maintains
blood concentrations of glucose within an acceptable range regardless of
whether or not the subject
has ingested a meal (i.e., fasting and fed states). Insulin facilitates (and
increases the rate of)
glucose transport through the membranes of many cells of the body,
particularly skeletal muscle and
adipose tissue. Insulin has three basic effects: the enhanced rate of glucose
metabolism, the
promotion of increased glycogen stores in muscle and adipose tissue, and
decreased circulating
blood glucose concentration.
[0003] Diabetes Mellitus ("diabetes") is a disease state in which the pancreas
does not release
insulin at levels capable of controlling blood glucose and/or in which muscle,
fat and liver cells
respond poorly to normal insulin levels because of insulin resistance.
Diabetes thus can result from
a dual defect of insulin resistance and "burn out" of the 0-cells of the
pancreas. Diabetes Mellitus is
classified into two types: Type 1 and Type 2. Approximately 5 to 10% of
diagnosed cases of
diabetes are attributed to Type 1 diabetes, and approximately 90% to 95% are
attributed to Type 2
diabetes.
[0009] Type 1 diabetes is diabetes that is insulin dependent and usually first
appears in young
people. In Type 1 diabetes, the islet cells of the pancreas stop producing
insulin mainly due to
autoimmune destruction, and the patient must self-inject the missing hormone.
For type 1 diabetics,
insulin therapy is essential and is intended to replace the absent endogenous
insulin with an
exogenous insulin supply.
[0010] Type 2 diabetes is commonly referred to as adult-onset diabetes or non-
insulin dependent
diabetes and may be caused by a combination of insulin resistance (or
decreased insulin sensitivity)
and, in later stages, insufficient insulin secretion. This is the most common
type of diabetes in the
Western world. Close to 6% of the adult population of various countries around
the world,
including the United States, have Type 2 diabetes, and about 30% of these
patients will need
exogenous insulin at some point during their lifespans due to secondary
pancreatic exhaustion and
the eventual cessation of insulin production. For type 2 diabetics, therapy
has consisted first of oral
antidiabetic agents, which increase insulin sensitivity and/or insulin
secretion, and only then insulin
if, and when, the oral agents fail.
[0011] Diabetes is the sixth leading cause of death in the United States and
accounted for more
than 193,000 deaths in 1997. However, this figure is an underestimate because
complications
resulting from diabetes are a major cause of morbidity in the population.
Diabetes is associated
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with considerable morbidity and mortality in the form of cardiovascular
disease, stroke, digestive
diseases, infection, metabolic complications, ophthalmic disorders,
neuropathy, kidney disease and
failure, peripheral vascular disease, ulcerations and amputations, oral
complications, and
depression. Thus, diabetes contributes to many deaths that are ultimately
ascribed to other causes.
(00121 The main cause of mortality with Diabetes Mellitus is long term micro-
and macro-
vascular disease. Cardiovascular disease is responsible for up to 80% of the
deaths of type 2
diabetic patients, and diabetics have a two- to four-fold increase in the risk
of coronary artery
disease, equal that of patients who have survived a stroke or myocardial
infarction. In other words,
heart disease, high blood pressure, heart attacks and strokes occur two to
four times more frequently
in adult diabetics than in adult non-diabetics. This increased risk of
coronary artery disease
combined with an increase in hypertensive cardiomyopathy manifests itself in
an increase in the risk
of congestive heart failure. These vascular complications lead to
neuropathies, retinopathies and
peripheral vascular disease. Diabetic retinopathy (lesions in the small blood
vessels and capillaries
supplying the retina of the eye, i.e., the breakdown of the lining at the back
of the eye) is the leading
cause of blindness in adults aged 20 through 74 years, and diabetic kidney
disease, e.g.,
nephropathy (lesions in the small blood vessels and capillaries supplying the
kidney, which may
lead to kidney disease, and the inability of the kidney to properly filter
body toxins), accounts for
40% of all new cases of end-stage renal disease (kidney failure). Furthermore,
diabetes is also the
leading cause for amputation of limbs in the United States. Diabetes causes
special problems
during pregnancy, and the rate of congenital malformations can be five times
higher in the children
of women with diabetes.
[0013] Poor glycemic control contributes to the high incidence of these
complications, and the
beneficial effects of tight glycemic control on the chronic complications of
diabetes are widely
accepted in clinical practice. However, only recently has it been firmly
established that elevated
blood glucose levels are a direct cause of long-term complications of
diabetes. The Diabetes
Control and Complications Trial and the United Kingdom Prospective Diabetes
Study both showed
that control of blood glucose at levels as close to normal as possible
prevents and retards
development of diabetic retinopathy, nephropathy, neuropathy and microvascular
disease.
10014] Insulin resistance (or decreased insulin sensitivity) is also prevalent
in the population,
especially in overweight individuals, in those with risk of diabetes (i.e.,
pre-diabetic, wherein blood
glucose levels are higher than normal but not yet high enough to be diagnosed
as diabetes) and in
individuals with type 2 diabetes who produce enough insulin but whose tissues
have a diminished
ability to adequately respond to the action of insulin. When the liver becomes
insulin-resistant, the
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mechanism by which insulin affects the liver to suppress its glucose
production breaks down, and
the liver continues to produce glucose, even under hyperinsulinemic conditions
(elevated plasma
insulin levels). This lack of suppression can lead to a hyperglycemia
(elevated blood glucose
levels), even in a fasting state.
[0015] In order to compensate and to overcome the insulin resistance, the
pancreatic 0-cells
initially increase their insulin production such that insulin resistant
individuals often have high
plasma insulin levels. This insulin is released into the portal vein and
presented to the liver
constantly or almost constantly. It is believed that the liver's constant
exposure to high levels of
insulin plays a role in increased insulin resistance and impaired glucose
tolerance. After a period of
high demand placed on the pancreatic 13-cells, the cells start to decompensate
and exhaust, and
insulin secretion, or insulin secretory capacity, is reduced at later stages
of diabetes. It is estimated
that, by the time an individual is diagnosed with type 2 diabetes, roughly 50%
of the 13-cells have
already died due to increased demand for insulin production.
100161 Insulin resistance plays an important role in the pathogenesis of
hyperglycemia in type 2
diabetes, eventually inducing the development of diabetic complications.
Furthermore, insulin
resistance ostensibly plays a role in the pathogenesis of macrovascular
disease, cardiovascular
diseases and microvascular disease. See, for example, Shinohara K. et al.,
Insulin Resistance as an
Independent Predictor of Cardiovascular Mortality in Patients With End-Stage
Renal Disease, J.
Am. Soc. Nephrol., Vol. 13, No. 7, July 2002, pp. 1894-1900. Research
currently shows that insulin
resistance reaches a maximum and then plateaus. Once the insulin resistance
plateaus, it is believed
to not get appreciably worse, but can improve.
[0017] Diabetes or insulin resistance can be diagnosed in many ways, as is
known to those in the
art. For example, the initial diagnose may be made from a glucose tolerance
test (OTT), where a
patient is given a bolus of glucose, usually orally, and then the patient's
blood glucose levels are
measured at regular time intervals for approximately 2 hours, or as many as 6
hours in the case of
an extended GTT. Another method of testing for diabetes or insulin resistance
is a test of the
patients fasting or postprandial glucose. Other tests, such as Glycosolated
Hemoglobin, often
reported as Hemoglobin Alc (HbAic) can be used to assess blood glucose over 2-
3 months.
[001J Several methods to assess insulin resistance are currently available,
including the
euglycemic-hyperinsulinemic clamp, fasting plasma insulin, homeostasis model
assessment
(HOMA) of insulin resistance (HOMA-1R), the fasting glucose-to-insulin ratio
method and
quantitative insulin sensitivity check index (QUICKI). Except for the
euglycemic-hyperinsulinemic
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clamp method, the others are surrogate indices and are indirect methods of
assessing insulin
resistance. For example, the HOMA-IR is calculated from fasting plasma glucose
(FPG) and
fasting immunoreactive insulin (FIR]) with the formula HOMA-M = FIRI in mU/1 x
FPG in
mg/d1/405. In addition, the reciprocal index of homeostasis model assessment
(1/HOMA-IR) is
also calculated. Similarly, QUICK1 is derived from logarithmic-transformed FPG
and insulin levels
as calculated from FPG and FIRI levels with the formula QUICKI = 1/(log [FIRI
in mU/1] + log
[FPG in mg/di]),
[0019] Several oral hypoglycemic agents have been developed for specifically
improving a
patient's insulin resistance, such as thiazolidinediones, which make the
patient more sensitive to
insulin, and biguanides, which decrease the amount of glucose made by the
liver, and these are
currently available clinically for patients with diabetes and insulin
resistance. In addition,
sulfonylureas stimulate the pancreas to make more insulin, alpha-glucosidase
inhibitors slow the
absorption of the starches eaten by an individual, meglitinides stimulate the
pancreas to make more
insulin, and D-phenylalanine derivatives help the pancreas make more insulin
quickly. Present
treatment of insulin resistance involves sensible lifestyle changes, including
weight loss to attain
healthy body weight, 30 minutes of accumulated moderate-intensity physical
activity per day and
diet control, including increased dietary fiber intake and regulation of blood
sugar levels and of
caloric intake. In addition, Metformin, which has been used successfully for
some time to treat
diabetes because it increases insulin sensitivity, is also being studied as a
treatment.
[0020] The aim of insulin treatment of diabetics is typically to administer
enough insulin such that
the patient will have normal carbohydrate metabolism throughout the day.
Because the pancreas of
a diabetic individual does not secrete sufficient insulin throughout the day,
in order to effectively
control diabetes through insulin therapy, a long-lasting insulin treatment,
known as basal insulin,
must be administered to provide the slow and steady release of insulin that is
needed to control
blood glucose concentrations and to keep cells supplied with energy when no
food is being
digested. Basal insulin is necessary to suppress glucose production between
meals and overnight,
and preferably mimics the patient's normal pancreatic basal insulin secretion
over a 24-hour period.
Thus, a diabetic patient may administer a single dose of a long-acting insulin
each day
subcutaneously, with an action lasting about 24 hours.
[0021] Furthermore, in order to effectively control diabetes through insulin
therapy by dealing
with post-prandial rises in glucose levels, a bolus, fast-acting treatment
must also be administered.
The bolus insulin, which has generally been administered subcutaneously,
provides a rise in plasma
insulin levels at approximately 1 hour after administration, thereby limiting
hyperglycemia after
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meals. Thus, these additional quantities of regular insulin, with a duration
of action of, e.g., 5-6
hours, may be subcutaneously administered at those times of the day when the
patient's blood
glucose level tends to rise too high, such as at meal times. Alternative to
administering basal
insulin in combination with bolus insulin, repeated and regular lower doses of
bolus insulin may be
administered in place of the long-acting basal insulin, and bolus insulin may
be administered
postprandially- as needed.
[0022] The problem of providing bioavailable unmodified human insulin, in a
useful form, to an
ever-increasing population of diabetics has occupied physicians and scientists
for almost 100 years.
Many attempts have been made to solve some of the problems of stability and
biological delivery of
this peptide. Because insulin is a peptide drug (MW approx. 6000 Da) that is
not absorbed intact in
the gastrointestinal tract, it ordinarily requires parenteral administration
such as by subcutaneous
injection. Thus, most diabetic patients self-administer insulin by
subcutaneous injections, often
multiple times per day. However, the limitations of multiple daily injections,
such as pain,
inconvenience, frequent blood glucose monitoring, poor patient acceptability,
compliance and the
difficulty of matching postprandial insulin availability to postprandial
glucose-control requirements,
are some of the shortcomings of insulin therapy.
[0023] Currently, regular subcutaneously injected insulin is recommended to be
dosed at 30 to 45
minutes prior to mealtime. As a result, diabetic patients and other insulin
users must engage in
considerable planning of their meals and of their insulin administrations
relative to their meals.
Unfortunately, intervening events that may take place between administration
of insulin and
ingestion of the meal may affect the anticipated glucose excursion.
Furthermore, there is also the
potential for hypoglycemia if the administered insulin provides a therapeutic
effect over too great a
time, e.g., after the rise in glucose levels that occur as a result of
ingestion of the meal has already
been lowered.
[0024] Despite studies demonstrating the beneficial effects of tight glycemic
control on chronic
complications of diabetes, clinicians do not often recommend aggressive
insulin therapy,
particularly in the early stages of the disease, and this is widely accepted
in clinical practice. The
unmet challenge of achieving tight glycemic control is due, in part, to the
shortcomings of frequent
blood glucose monitoring, the available subcutaneous route of insulin
administration and the fear of
hypoglycemia. In addition to the practical limitations of multiple daily
injections discussed above,
the shortcomings of the commonly available subcutaneous route of insulin
administration have
resulted in the generally inadequate glycemic control believed to be
associated with many of the
chronic complications (comorbidities) associated with diabetes. Thus, while
intensive insulin
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therapy may reduce many of the complications of diabetes, the treatment also
increases the risk of
hypoglycemia and often results in weight gain, as reported in Diabetes Care,
Volume 24, pp. 1711-
21(2001).
[0025] In addition, hyperinsulinemia (elevated blood concentrations of
insulin) can also occur,
such as by the administration of insulin in a location (and manner) that is
not consistent with the
normal physiological route of delivery. Insulin circulates in blood as the
free monomer, and its
volume of distribution approximates the volume of extracellular fluid. Under
fasting conditions,
the concentration of insulin in portal blood is, e.g., about 2-4 ng/mL,
whereas the systemic
(peripheral) concentration of insulin is, e.g., about 0.5 ng/mL, in normal
healthy humans, translating
into, e.g., a 5:1 ratio. In human diabetics who receive insulin via
subcutaneous injection, the portal
vein to periphery ratio is changed to about 0.75:1. Thus, in such diabetic
patients, the liver does not
receive the necessary concentrations of insulin to adequately control blood
glucose, while the
peripheral circulation is subjected to higher concentrations of insulin than
are found in healthy
subjects. Elevated systemic levels of insulin may lead to increased glucose
uptake, glycogen
synthesis, glycolysis, fatty acid synthesis, cortisol synthesis and
triacylglycerol synthesis, leading to
the expression of key genes that result in greater utilization of glucose.
[00261 One aspect of the physiological response to the presence of insulin is
the stimulation of
glucose transport into muscle and adipose tissue. It has been reported that
hyperglycemia and/or
hyperinsulinemia is related to vascular diseases associated with diabetes.
Impairment to the
vascular system is believed to be the reason behind conditions such as
microvascular complications
or diseases, such as retinopathy, neuropathy (impairment of the function of
the autonomic nerves,
leading to abnormalities in the function of the gastrointestinal tract and
bladder and loss of feeling
in lower extremities) and nephropathy, or macrovascular complications or
diseases, such as
cardiovascular disease, etc.
[0027] In the field of insulin delivery, where multiple repeated
administrations are required on a
daily basis throughout the patient's life, it is desirable to create
compositions of insulin that do not
alter physiological clinical activity and that do not require injections. Oral
delivery of insulin is a
particularly desirable route of administration, for safety and convenience
considerations, because it
can minimize or eliminate the discomfort that often attends repeated
hypodermic injections. It has
been a significant unmet goal in the art to imitate normal insulin levels in
the portal and systemic
circulation via oral administration of insulin.
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100281 Oral delivery of insulin may have advantages beyond convenience,
acceptance and
compliance issues. Insulin absorbed in the gastrointestinal tract is thought
to mimic the physiologic
route of insulin secreted by the pancreas because both are released into the
portal vein and carried
directly to the liver before being delivered into the peripheral circulation.
Absorption into the portal
vein maintains a peripheral-portal insulin gradient that regulates insulin
secretion. In its first
passage through the liver, roughly 60% of the insulin is retained and
metabolized, thereby reducing
the incidence of peripheral hyperinsulinemia, a factor linked to complications
in diabetes.
100291 However, insulin exemplifies the problems confronted in the art in
designing an effective
oral drug delivery system for biological macromolecules. Insulin absorption in
the gastrointestinal
tract is prevented presumably by its molecular size and its susceptibility for
enzymatic degradation.
The physicochemical properties of insulin and its susceptibility to enzymatic
digestion have
precluded the design of a commercially viable oral or alternate delivery
system.
100301 Emisphere Technologies, Inc. has developed compositions of insulin that
are orally
administrable, e.g., absorbed from the gastrointestinal tract in adequate
concentrations, such that the
insulin is bioavailable and bioactive following oral administration and
provide sufficient absorption
and pharmacokinetic/pharmacodynamic properties to provide the desired
therapeutic effect, i.e.,
cause a reduction of blood glucose, as disclosed in U.S. Patent Applications
Nos. 10/237,138,
60/346.746, 60/347,312, 60/368,617, 60/374,979, 60/389,364, 60/438,195,
60/438,451, 60/578,967,
60/452,660, 60/488,465, 60/518,168, 60/535,091 and 60/540,462, as well as in
International Patent
Application Publications Nos. WO 03/057170, WO 03/057650 and WO 02/02509 and
International
Patent Application No. PCT/US04/00273, all assigned to Emisphere Technologies,
Inc.
100311 The novel drug delivery technology of Emisphere Technologies, Inc. is
based upon the
design and synthesis of low molecular weight compounds called "delivery
agents." When
formulated with insulin, the delivery agent, which is in a preferred
embodiment sodium N-[4-(4-
chloro-2 hydroxybenzoyDamino]butyrate (4-CNAB), enables the gastrointestinal
absorption of
insulin. It is believed that the mechanism of this process is that 4-CNAB
interacts with insulin non-
covalently, creating more favorable physical-chemical properties for
absorption. Once across the
gastrointestinal wall, insulin disassociates rapidly from 4-CNAB and reverts
to its normal,
pharmacologically active state. 4-CNAB is not intended to possess any inherent
pharmacological
activity and serves only to increase the oral bioavailability of insulin by
facilitating the transport of
insulin across the gastrointestinal wall. The pharmacology of insulin is the
desired therapeutic
effect and is well characterized.
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[0032] Insulin/4-CNAB capsules were evaluated by Emisphere Technologies, Inc.
in a nonclinical
program that included pharmacological screening, pharmacokinetic and metabolic
profiles, and
toxicity assessments in rats and monkeys. These studies in rats and monkeys
showed that 4-CNAB
is absorbed rapidly following oral administration and that, over the range
tested, insulin absorption
increased with increasing doses of 4-CNAB. Similarly, for a fixed oral dose of
4-CNAB, insulin
absorption increased with increasing doses of insulin. Preclinical
pharmacokinetie studies in rats
and monkeys showed that both insulin and 4-CNAB were absorbed and eliminated
rapidly
following oral administration. Receptor binding screening assays revealed that
4-CNAB did not
possess any inherent pharmacological activity and serves only to facilitate
the oral bioavailability of
insulin.
[0033] Toxicology studies were also conducted in rats and monkeys to assess
the potential
toxicity of 4-CNAB, alone or in combination with insulin. Based on the 14-day
oral repeated dose
toxicity studies, the NOAEL (No-Adverse Effect Level) was estimated to be 500
mg/kg in Sprague-
Dawley rats, and 400 mg/kg in rhesus monkeys. In the 90-day oral repeated dose
toxicity studies,
NOAELs of 250 mg/kg and 600 mg/kg were observed in rats and monkeys,
respectively. Four
genotoxicity studies have also been conducted with 4-CNAB, with no positive
findings.
Developmental and reproductive toxicology studies have not yet been conducted.
[0034] Oral insulin/4-CNAB capsules were also evaluated by Emisphere
Technologies, Inc. in
clinical human studies for safety, pharmacokinetics, pharmacodynamics, and the
effect of food on
the absorption of insulin/4-CNAB. In these studies, 4-CNAB was shown to
enhance the
gastrointestinal absorption of insulin following oral administration in
diabetic patients and healthy
subjects. Oral administration of Insulin/4-CNAB capsules resulted in rapid
absorption (trnax ¨ 20-
30 minutes) of both insulin and 4-CNAB, and the insulin absorbed orally in
combination with
4-CNAB was pharmacologically active, as demonstrated by a reduction of blood
glucose in healthy
and diabetic subjects and by a blunting of postprandial glucose excursion in
diabetic patients.
These studies suggest that oral administiation of a formulation of insulin/4-
CNAB is well-tolerated
and reduces blood glucose concentrations in both healthy subjects and diabetic
patients.
[0035] Whereas traditional subcutaneous insulin dosing shifts the point of
entry of insulin into the
systemic circulation from the natural site (the portal vein), the oral dosing
method developed by
Emisphere Technologies, Inc. is thought to mimic natural physiology, namely,
the ratio of
concentration of insulin in the portal circulation to that in the systemic
circulation approaches the
normal physiological ratio, e.g., from about 2:1 to about 6:1. The effect of
this route of dosing is
two fold. First, by targeting the liver directly, a greater control of glucose
may be achieved.
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Various studies have shown that intraportal delivery of insulin can yield a
comparable control of
glucose at infusion rates lower than those required by peripheral
administration. Because the
orally-administered insulin will undergo substantial (¨ 50%) first-pass
metabolism prior to entering
the systemic circulation, a lower plasma concentration and total exposure is
achieved compared to
an subcutaneous equivalent dose. This may, in turn, alleviate any detrimental
effects of insulin on
non-target tissues,
[0036] Thus, the oral insulin formulations of Emisphere Technologies, Inc.
provide an advantage
over subcutaneously administered insulin that is currently the state of the
art, beyond the benefit of
ease of administration, pain-free administration, and the potential for
improved patient compliance.
Because subcutaneously administered insulin is delivered peripheral to the GI
tract and portal vein,
and absorption of large biomolecules from the subcutaneous space is generally
more prolonged, the
first-phase insulin response is not well-replicated by subcutaneous insulin
administration. By
administration of the oral insulin formulations of the present invention, the
plasma levels of insulin
that occur upon the first (acute) phase of insulin secretion by the pancreas
can be simulated by
rapid, direct absorption from the GI tract.
[0037] In normal physiology, first-phase insulin secretion takes place 5 to 20
minutes after the
start of a meal, and this effect has a well-known impact on prandial glucose
homeostasis. The first
phase of insulin secretion, while of short duration, has an important role in
priming the liver to the
metabolic events ahead (meal). The loss of first-phase insulin secretion is a
characteristic feature of
Type 2 diabetic patients in the early stages of the disease, and it is also
observed in prediabetic
states, namely individuals with impaired glucose tolerance. In the absence of
first-phase insulin
secretion, the stimulatory effect of glucagon on gluconeogenesis is not
suppressed and may
contribute to the development of prandial hyperglycemia. In the basal state as
well as in the
prandial phase, plasma glucose concentrations are correlated with hepatic
glucose output.
Therefore, restoration of first-phase insulin secretion at the time of meal
ingestion should suppress
prandial hepatic glucose output and subsequently improve the blood glucose
profile.
[00381 Several approaches have been undertaken to prove this hypothesis.
However, the
therapeutic regimens were either too dangerous for a long-term treatment (such
as intravenous
administration of regular human insulin) or pharmacologically unsuitable (fast-
acting insulin
analogues). In addition, restoration of first phase insulin response appears
to be difficult in patients
with a long-standing history of diabetes who have lost most or all of their
endogenous insulin
secretion capacity. Furthermore, certain short acting insulin formulations,
because of the speed
with which the insulin provides a blood glucose lowering effect, may, between
the time of
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administration of insulin and the time of ingestion of the meal, contribute to
a lowering of blood
glucose to a level that could range from subclinical hypoglycemia to more
undesirable effects.
[0039] The rapid onset and the short duration of action of oral Insulin/4-CNAB
following single
dose administration in humans suggests that oral Insulin/4-CNAB may be well-
suited for
supplementation of first phase insulin secretion in subjects with type 2
diabetes. In a previous
study, as set forth in International Patent Application No. PCTTUS04/00273,
patients with type 2
diabetes were administered a single doses of Insulin (300 U)/4-CNAB (400 mg)
at or shortly before
bedtime. Substantial decrease in insulin, C-peptide, and fasting blood glucose
levels were
observed. Insulin sensitivity, as assessed with the HOMA-model, was also
significantly improved.
This suggests that even a short-term treatment with pre-prandial Insulin/4-
CNAB may be able to
improve insulin sensitivity and, thereby, metabolic control.
[0040] It is, therefore, desirable to provide a pharmaceutical compositions of
insulin that can be
administered closer to as meal than previously known and to provide a protocol
for insulin
treatment for patients with impaired glucose tolerance or with early stage or
late stage diabetes,
which treatment can be administered orally multiple times daily, such as at or
shortly prior to
mealtime and/or at or shortly prior to bedtime, has a short duration of
action, and has positive and
long lasting effects on the patient's glucose tolerance, glycemic control,
insulin secretory capacity
and insulin sensitivity, but does not increase the risk of hypoglycemia,
hyperinsulinemia and weight
gain that are normally associated with insulin therapy treatments.
SUMMARY OF THE INVENTION
[0041] It is an object of the present invention to provide a therapeutic
insulin treatment for
patients with impaired glucose tolerance or with early stage or late stage
diabetes to provide
therapeutic effects to the patient greater than or unseen in current
parenteral insulin therapy.
[0042] It is another object of the present invention to provide a therapeutic
insulin treatment for
patients with impaired glucose tolerance or with early stage or late stage
diabetes to provide
positive therapeutic effects on the patient's glucose tolerance and glycemic
control.
10043] It is an object of the present invention to provide a therapeutic
insulin treatment for
patients with impaired glucose tolerance or with early stage or late stage
diabetes to provide long
lasting therapeutic effects on the patient's glucose tolerance and glycemic
control.
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101144] It is another object of the present invention to provide a therapeutic
insulin treatment for
patients with impaired glucose tolerance or with early stage or late stage
diabetes to improve the
patient's endogenous capacity to handle sugar load.
[0045] It is additionally an object of the present invention to provide a
therapeutic insulin
treatment for patients with impaired glucose tolerance or with early stage or
late stage diabetes to
provide for the patient an improved glucose profile, a decrease in glucose
excursion or a decreased
AUC of blood glucose, measured following a glucose load such as a meal or oral
glucose tolerance
test.
[0046] It is a further object of the present invention to provide a
therapeutic insulin treatment for
patients with impaired glucose tolerance or with early stage or late stage
diabetes to provide for the
patient a decreased fasting blood glucose concentration when compared with the
patient's own
baseline level prior to starting the treatment.
[0047] It is still another object of the present invention to provide a
therapeutic insulin treatment
for patients with impaired glucose tolerance or with early stage or late stage
diabetes to provide for
the patient a decreased serum fructosamine level.
[0048] It is yet another object of the present invention to provide a
therapeutic insulin treatment
for patients with impaired glucose tolerance or with early stage or late stage
diabetes to improve the
insulin utilization of the patient's body.
[0099] It is yet another object of the present invention to provide a
therapeutic insulin treatment
for patients with impaired glucose tolerance or with early stage or late stage
diabetes to improve the
insulin sensitivity of the patient's body.
[0050] It is still a further object of the present invention to provide a
therapeutic insulin treatment
for patients with impaired glucose tolerance or with early stage or late stage
diabetes to improve the
insulin secretion capacity of the patient's body.
[0051] It is yet a further object of the present invention to provide a
therapeutic insulin treatment
for patients with impaired glucose tolerance or with early stage or late stage
diabetes without the
negative side effects currently seen in parenteral insulin therapy.
[0052] It is another object of the present invention to provide a therapeutic
insulin treatment for
patients with impaired glucose tolerance or with early stage or late stage
diabetes without inducing
hypoglycemia.
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[0053] It is a further object of the present invention to provide a
therapeutic insulin treatment for
patients with impaired glucose tolerance or with early stage or late stage
diabetes without inducing
hyperinsulinemia.
[0054] In yet another object of the present invention to provide a therapeutic
insulin treatment for
patients with impaired glucose tolerance or with early stage or late stage
diabetes without the
weight gain commonly associated with parenteral insulin therapy,
[0055] It is yet a further object of the present invention to provide a
therapeutic insulin treatment
for patients with impaired glucose tolerance or with early stage or late stage
diabetes that reduces
the need for frequent monitoring of blood sugar levels currently needed with
current insulin therapy
regimens.
[0056] It is another object of the present invention to provide a therapeutic
insulin treatment for
patients with impaired glucose tolerance or with diabetes from its earliest
stages to its latest stages.
[0057] It is a further object of the present invention to provide a method of
reversing impaired
glucose tolerance or diabetes by administration of a therapeutic insulin
treatment.
[0058] It is another object of the present invention to provide a therapeutic
insulin treatment for
patients who are failing dual or multiple therapy with sulfonureas and insulin
sensitizers.
[0059] It is an object of the present invention to provide pharmaceutical
compositions for oral
administration comprising insulin and a delivery agent that facilitates
insulin transport in a
therapeutically effective amount to the bloodstream, which compositions are
therapeutically and
quickly effective.
[0060] It is another object of the present invention to provide
therapeutically effective
pharmaceutical compositions comprising insulin and a delivery agent for oral
administration to
patients with impaired glucose tolerance or with early stage or late stage
diabetes to provide longer
lasting therapeutic effects on the patient's glucose tolerance and glycemic
control without the risks
of hypoglycemia, hyperinsulinemia and weight gain that are normally associated
with insulin
therapy treatments.
[0061] It is a further object of the present invention to provide compositions
for oral
administration of insulin and a delivery agent that facilitates insulin
transport in a therapeutically
effective amount to the bloodstream for the treatment of diabetes, for the
treatment of impaired
glucose tolerance, for the purpose of achieving glucose homeostasis, for the
treatment of early stage
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diabetes, for the treatment of late stage diabetes, and/or to serve as
replacement therapy for type I
diabetic patients to provide longer lasting effects on the patient's glucose
tolerance and glycemic
control without the risks of hypoglycemia, hyperinsulinemia and weight gain
that are normally
associated with insulin therapy treatments.
[0062] It is still a further object of the present invention to provide
methods of treating mammals
with impaired glucose tolerance, early stage diabetes or late stage diabetes,
for achieving glucose
homeostasis in mammals, for prophylactically sparing pancreatic 0-cell
function, for preventing
0-ce1l death or dysfunction, for long term protection of a mammal from
developing overt or insulin
dependent diabetes, for delaying the onset of overt or insulin dependent
diabetes in a mammal that
has impaired glucose tolerance or early stage diabetes, and for reducing the
incidence and/or
severity of systemic hyperinsulinemia associated with chronic dosing of
insulin or of one or more
disease states associated with chronic dosing of insulin.
[0063] In accordance with these and other objects, the invention provides a
method for treating a
mammal with impaired glucose tolerance or with early or late stage diabetes,
and of achieving
glucose homeostasis in mammals, comprising orally administering to a mammal a
therapeutically
effective dose of a pharmaceutical formulation comprising insulin such that
the mammal achieves
improved glucose tolerance and glycemic control as compared with baseline
levels prior to
treatment.
[0064] The invention also provides a method for treating a mammal with
impaired glucose
tolerance or with early or late stage diabetes, comprising orally
administering to a mammal a
therapeutically effective dose of a pharmaceutical formulation comprising
insulin such that the
mammal achieves improved glucose tolerance and glycemic control as compared
with baseline
levels prior to treatment without any statistically significant weight gain by
the mammal over the
treatment period.
[0065] The invention also provides a method for treating a mammal with
impaired glucose
tolerance or with early or late stage diabetes, comprising orally
administering to a mammal a
therapeutically effective dose of a pharmaceutical formulation comprising
insulin such that the
mammal achieves improved glucose tolerance and glycemic control as compared
with baseline
levels prior to treatment without any statistically significant risk of
hypoglycemia in the mammal
over the treatment period.
[0066] The invention also provides a method for treating a mammal with
impaired glucose
tolerance or with early or late stage diabetes, comprising orally
administering to a mammal a
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therapeutically effective dose of a pharmaceutical formulation comprising
insulin such that the
mammal achieves improved glucose tolerance and glycemic control as compared
with baseline
levels prior to treatment without any statistically significant risk of
hyperinsulinemia in the mammal
over the treatment period.
100671 In certain preferred embodiments, the improved glucose tolerance is
demonstrated by
better endogenous capacity of the mammal to handle sugar load as measured by
blood glucose
concentration, following a sugar load, that is reduced by a statistically
significant amount as
compared with baseline blood glucose concentration, following a glucose load,
prior to treatment.
Preferably, the statistically significant amount is a mean of about 10-20%,
preferably about 15%.
[0068] In certain preferred embodiments, the improved glucose tolerance is
demonstrated by
better endogenous capacity of the mammal to handle sugar load as measured by
an AUC of blood
glucose excursion, following a glucose load, that is reduced by a
statistically significant amount as
compared with AUC of blood glucose excursion, following a glucose load, prior
to treatment.
Preferably, the statistically significant amount is a mean of about 10-30%,
preferably about 20%.
[0069] In certain preferred embodiments, the improved glycemic control is
demonstrated by
decreased fasting blood glucose levels as measured by fasting blood glucose
concentration that is
reduced by a statistically significant amount as compared with baseline
fasting blood glucose
concentration prior to treatment. Preferably, the statistically significant
amount is a mean of about
10-30%, preferably about 19%.
[0070] In certain preferred embodiments, the improved glycemic control is
demonstrated by
decreased serum fructosamine levels, as measured by serum fructosamine assay,
that is reduced by
a statistically significant amount as compared with baseline serum
fructosamine levels prior to
treatment. Preferably, the statistically significant amount is a mean of about
5-20%, preferably
about 9%.
[0071] In certain preferred embodiments, the improved glycemic control is
demonstrated by
improved HbAl c levels after treatment compared with baseline levels prior to
treatment.
Preferably, the improved HbAl c levels are measured by a statistically
significant decline in HbAl c
levels. More preferably, administration of the pharmaceutical formulation of
the present invention
can preferably be made to a mammal with impaired glucose tolerance or with
early or late stage
diabetes having an HbAie level ranging from normal to elevated prior to
treatment. In one
embodiment, the mammal may have an HbAi, level preferably of less than about
8.0 prior to
treatment.
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[0072] In certain further preferred embodiments, the improved glucose
tolerance and glycemic
control are achieved without the need for monitoring the mammal's blood
glucose concentrations or
HbAi, levels over the treatment period.
[0073] In certain preferred embodiments, the mammal achieves improved insulin
utilization and
insulin sensitivity after the treatment as compared with baseline levels prior
to treatment.
Preferably, the improved insulin utilization and insulin sensitivity are
measured by a statistically
significant decline in HOMA (Homeostasis Model Assessment).
[0074] In certain preferred embodiments, the mammal achieves improved insulin
secretion
capacity after the treatment as compared with baseline levels prior to
treatment. Preferably, the
improved insulin secretion capacity is measured by a statistically significant
decline in Stumvoll
first-phase insulin secretion capacity index.
[0075] The invention is also directed in part to an oral solid dosage form
comprising a dose of
insulin that achieves a therapeutically effective reduction in blood glucose
after oral administration
to a human diabetic patient, and which maintains a physiological
(portal/peripheral) gradient, and in
certain embodiments provides a ratio of portal vein insulin concentration to
peripheral blood insulin
concentration from about 2.5:1 to about 6:1, and preferably from about 4:1 to
about 5:1.
[0076] The invention is further directed in part to an oral dosage form
comprising a
therapeutically effective amount of insulin, said dosage form upon pre-
prandial oral administration
to diabetic patients causing the post prandial blood glucose concentration in
said patients to be
reduced for the first hour after oral administration relative to a post-
prandial blood glucose
concentration without treatment or following subcutaneous insulin
administration or other standard
treatment regimen.
[0077] The invention is further directed in part to an oral dosage form
comprising a
therapeutically effective amount of insulin, said oral dosage form upon pre-
prandial oral
administration provides a mean plasma glucose concentration which does not
vary by more than
about 40% (and more preferably not more than 30%) for the first hour after
oral administration,
relative to a mean baseline (fasted) plasma glucose concentration in said
patients, where a meal is
eaten by said patients within about one half hour of oral administration of
said dosage form.
[00731 In certain preferred embodiments, the administration of the oral
insulin formulation of the
present invention achieves a reduction in blood glucose concentration in human
diabetic patients
comparable to a subcutaneous insulin injection in those patients, while
providing a lower (e.g., 20%
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or greater) total exposure of insulin to the peripheral blood circulation
under acute, sub-acute and
chronic conditions as compared to the peripheral blood insulin exposure
achieved via subcutaneous
injection.
100791 The present invention provides methods of treating mammals with
impaired glucose
tolerance, early stage diabetes and late stage diabetes; for achieving glucose
homeostasis; for
reducing the incidence and/or severity of systemic hyperinsulinemia associated
with chronic dosing
of insulin. It is believed that the present invention also provides methods
for reducing the incidence
and/or severity of one or more disease states associated with chronic dosing
of insulin; for
prophylactically sparing 0-cell function or for preventing 0-cell death or
dysfunction, in a mammal
which has impaired glucose tolerance or early stage diabetes mellitus; and for
long-term protection
from developing overt or insulin dependent diabetes, or for delaying the onset
of overt or insulin
dependent diabetes, in a mammal which has impaired glucose tolerance or early
stage diabetes.
[0080] In a preferred embodiment of the invention, such methods comprise
orally administering a
therapeutically effective dose of a pharmaceutical formulation comprising
insulin and a delivery
agent that facilitates the absorption of the insulin from the gastrointestinal
tract, to provide a
therapeutically effective reduction in blood glucose and a plasma insulin
concentration, to provide a
therapeutically effective reduction and/or control in blood glucose
concentration and a plasma
insulin concentration that is reduced relative to the plasma insulin
concentration provided by a
therapeutically equivalent dose of subcutaneously injected insulin. The
determination of insulin
concentration obtained in patients who have been administered subcutaneous
insulin are well
known to those skilled in the art.
[0081] In a preferred embodiment, administration of the pharmaceutical
formulation takes place
multiple times daily, preferably at bedtime and preprandially during the day
time, e.g., preprandially
for breakfast, lunch and dinner. More preferably, administration of the
pharmaceutical formulation
is at or shortly prior to bedtime and concurrently with or shortly prior to
ingestion of a meal, i.e.,
within about 15 minutes or less of ingestion of the meal.
[0082] In another preferred embodiment of the invention, the oral
pharmaceutical formulation will
be administered about once daily to about four times daily, preprandially
and/or at bedtime,
depending upon the extent of the patient's impaired glucose tolerance and need
for exogenous
glycemic control. If the patient has a need for fasting glycemic control, the
oral pharmaceutical
formulation will be administered only at or shortly prior to bedtime. If the
patient has a need for
post-prandial glycemic control, the oral pharmaceutical formulation will be
administered
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preprandially for all meals. If the patient has a need for comprehensive
glycemic control, the oral
pharmaceutical formulation will be administered preprandially for all meals
and at or shortly prior
to bedtime.
[0083] Preferably, the dosage form of the present invention will be
administered for at least one
day, more preferably on a chronic basis, and can be administered for the life
of the patient. Most
preferably, the dosage form of the present invention will be administered on a
chronic basis, e.g.,
for at least about two weeks.
[0084] Preferably, the therapeutic insulin treatment of the present invention
will be administered
to patients having some form of impaired glucose tolerance. This can range
from insulin resistance
seen in pre-diabetics and early stage Type 2 diabetics to failure of insulin
production by the
pancreas seen in Type 1 diabetes and late stage Type 2 Diabetes. In certain
embodiments, the
resulting improved insulin utilization or insulin sensitivity of the patient's
body is measured by
HOMA (Homeostasis Model Assessment). In certain embodiments, the resulting
improved insulin
secretion capacity of the patient's body is measured by Stuinvoll first-phase
insulin secretion
capacity index.
[0085] Further, the therapeutic insulin treatment of the present invention can
be administered to a
mammal with an HbAic ranging from normal to elevated levels. More
particularly, the treatment
can be administered to anyone in the range of normal glycemic control to
impaired glycemic control
to late stage type 2 diabetes or type 1 diabetes. In certain embodiments, the
resulting improved
glycemic control in the patient's body is measured by a reduced serum
fructosamine concentration.
Preferably the average decline will be about 8.8% after at least two weeks of
treatment with the
present invention.
[0086] In preferred embodiments of the oral dosage forms of the invention
described above, the
oral dosage form is solid, and is preferably provided incorporated within a
gelatin capsule or is
contained in a tablet.
[0087] In certain preferred embodiments, the dose of unmodified insulin
contained in one or more
dosage forms is from about 50 Units to about 600 Units (from about 2 to about
23 mg), preferably
from about 100 Units (3.8 mg) to about 450 Units (15.3 mg) insulin, more
preferably from about
200 Units (7.66 mg) to about 350 Units (13.4 mg), and still more preferably
about 300 Units (11.5
mg), based on the accepted conversion of factor of 26.11 Units per mg.
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[0088] In certain preferred embodiments of the invention, the dosage forms
begin delivering
insulin into the systemic circulation via the portal vein (via absorption
through the mucosa of the
gastrointestinal tract) to achieve peak levels within about 30 minutes or
less.
[0089] In certain preferred embodiments, the dosage forms of the invention
provide a trnaõ for
insulin at from about 5 minutes to about 30 minutes, and more preferably at
from about 10 minutes
to about 25 minutes after oral administration to diabetic patients. In certain
preferred embodiments
of the invention, the dosage forms begin delivering insulin into the systemic
circulation to produce
a peak plasma insulin concentration at about 10 to about 20 minutes post oral
administration and in
further preferred embodiments, a peak plasma insulin concentration at about 10
minutes to about 15
minutes post oral administration to patients who ingested the dosage at about
0 or about 10 minutes
prior to ingestion of a meal.
[0090] The invention is also directed in part to an oral dosage form
comprising a dose of
unmodified insulin that achieves a therapeutically effective control of post
prandial blood glucose
after oral administration to human diabetic patients in tablet form at or
shortly before mealtime, the
oral solid dosage form providing an insulin tin at a time point from about 10
minutes to about 15
minutes after oral administration to said patients, at least about 30% of the
blood glucose
concentration reduction caused by said dose of insulin occurring within about
less than 1 hour after
oral administration of said dosage form. In preferred embodiments of this
invention, the oral
dosage form is a tablet.
[0091] In certain preferred embodiments, the composition provides a tin., for
maximum control of
glucose excursion at about 0.25 to about 1.5 hours, more preferably at about
0.75 to about 1.25
hours, after oral administration. In certain preferred embodiments, the tn,,,
for post-prandial
glucose control occurs preferably at less than about 120 minutes, more
preferably at less than about
80 minutes, and still more preferably at about 45 minutes to about 60 minutes,
after oral
administration of the composition.
[0092] In certain preferred embodiments, the pharmaceutical composition
contained in one or
more dosage forms comprises from about 5 mg to about 800 mg of delivery agent,
preferably about
20 mg to about 600 mg, more preferably from about 30 mg to about 400 mg, even
more preferably
from about 40 mg to about 200 mg, most preferably about 40 mg, 80 mg or 160
mg. In certain
embodiments, the composition provides a peak plasma delivery agent
concentration Crnaõ, from
about 3,000 to about 15,000 ng/mL, and a trna, at about 10 minutes to about 35
minutes. More
preferably, the composition provides a peak plasma delivery agent
concentration within about 15
CA 02518216 2016-06-06
minutes to about 35 minutes after oral administration and more preferably
within about 20
minutes after oral administration to fed diabetic patients.
[0093] For purposes of the present invention, a preferred delivery agent is
identified via
chemical nomenclature as 4-[(4-chloro, 2-hydroxybenzoyl)amino]butanoic acid.
In certain
preferred embodiments, the delivery agent is a sodium salt, preferably
monosodium salt.
Alternatively, the same compound is identified by the alternative nomenclature
monosodium
N-(4-chlorosalicyloy1)-4-aminobutyrate, or by the short name "4-CNAB".
[0093a] In a broad aspect, then, the present invention relates to insulin
for oral use in a solid
dosage tablet comprising 300 Units insulin and 160 mg of a delivery agent
consisting of 4-[(4-
chloro,2-hydroxybenzoyl) amino] butanoic acid or a pharmaceutically effective
salt thereof, for
post-prandial glycemic control with a reduction in blood glucose after use and
a maximum
plasma concentration of insulin 5 to 30 minutes after use, and reduced risk of
hyperinsulinemia,
in a human suffering from type 2 diabetes, from 30 minutes prior to ingestion
of each meal to
concurrently with ingestion of the meal, and at bedtime, for at least two
weeks.
[0094] The following terms will be used throughout the application as
defined below:
[0095] Patient -- refers to any mammal in whom there is determined to be.
[0096] Diabetic patient -- refers to a mammal with a form of pre-diabetes
or diabetes, either
diagnosed or undiagnosed, and/or with a condition that would respond to an
anti-diabetic and/or
insulin treatment.
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[0097] Mammal -- includes but is not limited to rodents, aquatic mammals,
domestic animals
such as dogs and cats, farm animals such as sheep, pigs, cows and horses, and
preferably
humans.
[0098] Diabetes or Diabetes Mellitus -- is deemed to encompass type 1 and
type 2 diabetes
mellitus, unless specifically specified otherwise.
[0099] Overt Diabetes -- is deemed to encompass type 1 and type 2 diabetes
mellitus that is
insulin dependent.
[00100] Early stage diabetes -- refers to a condition of impaired glycemic
control, absent
treatment, wherein the function of the islet cells of the pancreas still
exist, although in an
impaired state, also including impaired glucose tolerance (IGT) and impaired
fasting blood
glucose (IFG), e.g., the patient's endogenous insulin production is
insufficient to provide a first
phase insulin response following ingestion of a meal but is sufficient to
provide a second phase
insulin response following ingestion of a meal.
[00101] Late stage diabetes -- refers to a condition of impaired glycemic
control, absent
treatment, wherein the islet cells of the pancreas are approaching or have
reached total failure,
e.g., the patient's endogenous insulin production is insufficient to provide a
first or a second
phase insulin response following ingestion of a meal.
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tutu 01] treatment -- when used herein with respect to diabetes is deemed to
include prevention of
diabetes, delay of the onset of diabetes, delay of worsening of diabetic
conditions and delay of
progression from an earlier stage of diabetes to a later stage of diabetes,
unless specifically specified
otherwise.
[00103] Delivery agent -- refers to carrier compounds or carrier molecules
that are effective in the
oral delivery of therapeutic agents, and may be used interchangeably with
"carrier".
[00104] Therapeutically effective amount of insulin -- refers to an amount of
insulin included in the
dosage forms of the invention which is sufficient to achieve a clinically
relevant control of blood
glucose concentrations in a human diabetic patient either in the fasting state
or in the fed state
effective, during the dosing interval.
[00105] Effective amount of delivery agent -- refers to an amount of the
delivery agent that has
been shown to deliver the drug following oral administration by measurement of
phannacokinetic
and/or pharmacodynamic endpoints.
[00106] Organic solvents -- refers to any solvent of non-aqueous origin,
including liquid polymers
and mixtures thereof. Organic solvents suitable for the present invention
include: acetone, methyl
alcohol, methyl isobutyl ketone, chloroform, 1-propanol, isopropanol, 2-
propanol, acetonitrile, 1-
butanol, 2-butanol, ethyl alcohol, cyclohexane, dioxane, ethyl acetate,
dimethylforrnamide,
dichloroethane, hexane, isooctane, methylene chloride, tert-butyl alchohol,
toluene, carbon
tetrachloride, or combinations thereof.
[00107] Peptide -- refers to a polypeptide of small to intermediate molecular
weight, usually 2 or
more amino acid residues and frequently but not necessarily representing a
fragment of a larger
protein.
[00108] Protein -- refers to a complex high polymer containing carbon,
hydrogen, oxygen, nitrogen
and usually sulfur and composed of chains of amino acids connected by peptide
linkages. Proteins
in this application refer to glycoproteins, antibodies, non-enzyme proteins,
enzymes, hormones and
sub-units of proteins, such as peptides. The molecular weight range for
proteins includes peptides
of 1000 Daltons to glycoproteins of 600 to 1000 IdloDaltons.
[00109] Reconstitution -- refers to dissolution of compositions or
compositions in an appropriate
buffer or pharmaceutical composition.
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1001101 Unit-Dose Forms refers to physically discrete units suitable for
human and animal
subjects and packaged individually as is known in the art. It is contemplated
for purposes of the
present invention that dosage forms of the present invention comprising
therapeutically effective
amounts of insulin may include one or more unit doses (e.g., tablets,
capsules, powders, semisolids
(e.g. gelcaps or films), liquids for oral administration, ampoules or vials
for injection, loaded
syringes) to achieve the therapeutic effect. It is further contemplated for
the purposes of the present
invention that a preferred embodiment of the dosage form is an oral dosage
form.
1001111 The term "multiple dose" means that the patient has received at least
two doses of the drug
composition in accordance with the dosing interval for that composition.
1001121 The term "single dose" means that the patient has received a single
dose of the drug
composition or that the repeated single doses have been administered with
washout periods in
between.
1001131 Unless specifically designated as "single dose" or at "steady-state"
the pharmacokinetic
parameters disclosed and claimed herein encompass both single dose and
multiple-dose conditions.
1001141 Unmodified insulin¨refers to insulin prepared in any pharmaceutically
acceptable
manner or from any pharmaceutically acceptable source which is not conjugated
with an oligomer
such as that described in U.S. Patent No. 6,309,633 and/or which not has been
subjected to
amphiphilic modification such as that described in U.S. Patent Nos. 5,359.030;
5,438,040; and/or
5.681,811.
1001151 The phrase "equivalent therapeutically effective reduction" as used
herein means that a
maximal reduction of blood glucose concentration achieved by a first method of
insulin
administration (e.g. via oral administration of insulin in a patient(s)) is
not more than 20%, and
preferably not more than 10% and even more preferably not more than 5%
different from a
maximal reduction of blood glucose concentration after administration by a
second method (e.g.,
subcutaneous injection) in the same patient(s) or a different patient
requiring the same reduction in
blood glucose level. The phrase may also mean the dose required to approximate
normoglycemia
by any method of administration, normoglycemia being defined as variability
from a subject's
baseline blood glucose of not more than 20%, preferably 10%, more preferably
5%, in the fasted
state.
1001161 The term "meal" as used herein means a standard, ADA and/or a mixed
meal.
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[00117] The term "mean", when preceding a pharmacoldnetic value (e.g., mean
tmax), represents
the arithmetic mean value of the pharmacoldnetic value unless otherwise
specified.
[00118] The term "mean baseline level" as used herein means the measurement,
calculation or
level of a certain value that is used as a basis for comparison, which is the
mean value over a
statistically significant number of subjects, e.g., across a single clinical
study or a combination of
more than one clinical study.
[00119] The term "Cmax" as used herein is the highest plasma concentration of
the drug or delivery
agent observed within the sampling interval.
1001201 The term "tma" as used herein is the time post-dose at which Cm ax is
observed.
[00121] The term "AUC" as used herein means area under the plasma
concentration-time curve, as
calculated by the trapezoidal rule over the complete sample collection
interval.
[00122] The term "AUCo-laso" as used herein means the area under the plasma
concentration-time
curve using linear trapezoidal summation from time zero (dosing) to the time
of the last
quantifiable concentration post-dose.
[00123] The term "AUC(04)" as used herein means the area under the plasma
concentration-time
curve using linear trapezoidal summation from time zero (dosing) to time t
post-dose, where t is any
quantifiable time point.
[00124] The term "AUC(0.4m)" as used herein means an estimate of the area
under the plasma
concentration-time curve from time zero (dosing) to infinity.
[00125] The term "CL/F" as used herein means the apparent total body clearance
calculated as
Dose/AUC(o-ini), uncorrected for absolute bioavailability.
[00126] The term "Vd/F" as used herein means the apparent volume of
distribution calculated as
(CL/F)/Kni, uncorrected for absolute bioavailability.
[00127] The term "Eb" as used herein means the maximum observed effect
(baseline subtracted)
prior to intervention for hypoglycemia.
[00128] The term "Emax" as used herein means the maximum observed effect
(baseline subtracted).
[00129] Kei is the terminal elimination rate constant calculated by linear
regression of the terminal
linear portion of the log concentration vs. time curve
24
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WO 2004/080401 PCT/US2004/006943
[00130] The term "tvõ" as used herein means the terminal half-life calculated
as ln(2)/Kel.
[00131] The term "BMI" as used herein means the body mass index, calculated as
weight in kg
divided by the squared height in m.
[00132] The term "Bioavailability" as used herein means the degree or ratio ,
0, (cv .1 XI which a drug OT
agent is absorbed or otherwise available to the treatment site in the body
relative to a parenteral
route. This is calculated by the formula
Dose SC AUC Oral
Relative Bioavailability (%) ¨ X ___________ X 100
Dose Oral AUC SC
[00133] The term "Biopotency" as used herein means the degree or ratio (%) to
which a drug or
agent is effective relative to a parenteral route. This is calculated by the
formula
Dose SC AUC Oral
Relative Biopotency (%) = ___________ X X 100
Dose Oral AUC SC
[00134] The term "nighttime" or "bedtime" as used herein means a time before
the patient goes to
sleep and is not limited to clock time or cycles of light and dark, and
alternately refers to a time
during a day or night of longest fast, a period without external glucose
source.
[00135] For the purposes of the present specification, as used herein, the
phrase administered "at
nighttime" or "at or shortly before (prior to) bedtime" means administered
less than about 3 hours,
preferably less than about 2 hours and more preferably less than about 1 hour
prior to a prolonged
period of sleep, or relative physical and/or mental inactivity, and fast,
e.g., overnight. Whereas
overnight typically means from the late night (p.m.) hours to the early
morning (a.m.) hours, it
could mean any period of a sleep-wake cycle during which a person obtains
his/her necessary
period of sleep. For the purposes of the present specification, administration
should also occur at
least about one hour, preferably at least about 1.5 hours, more preferably at
least about 2 hours and
still more preferably at least about 2 to about 3 hours after the last meal of
the day.
[00136] For the purposes of the present specification, as used herein, the
phrase administered "at
mealtime" or -at or shortly before (prior to) ingestion of a meal" means
administered within about
30 minutes prior to the meal. For the purposes of the present specification,
the administration is
preferably within about 25 minutes, more preferably within about 20 minutes,
even more preferably
within about 15 minutes, still more preferably within about 10 minutes,
further more preferably
CA 02518216 2011-07-27
within about 5 minutes of ingestion of the meal, and most preferably
administered concurrently
with ingestion of the meal (within about 0 minutes).
1001371 As used herein and in the appended claims, the singular forms "a,"
"an," and "the,"
include plural referents unless the context clearly indicates otherwise. Thus,
for example, reference
to "a molecule" includes one or more of such molecules, "a reagent" includes
one or more of such
different reagents, reference to "an antibody" includes one or more of such
different antibodies, and
reference to "the method" includes reference to equivalent steps and methods
known to those of
ordinary skill in the art that could be modified or substituted for the
methods described herein.
1001381 Unless defined otherwise, all technical and scientific terms used
herein have the same
meaning as commonly understood by one of ordinary skill in the art to which
the invention belongs.
Although any methods, compositions, reagents, cells, similar or equivalent to
those described
herein can be used in the practice or testing of the invention, the preferred
methods and materials
are described herein.
1001391 The publications discussed above are provided solely for their
disclosure before the filing
date of the present application. Nothing herein is to be construed as an
admission that the invention
is not entitled to antedate such disclosure by virtue of prior invention.
Throughout this description,
the preferred embodiment and examples shown should be considered as exemplars,
rather than as
limitations on the present invention.
BRIEF DESCRIPTION OF THE DRAWINGS
Figures From 1015p Example 7 - Study 175A-C-04 (Profit II) (Food effect Type
2)
1001401 Figure 1 shows a plot of the arithmetic means of postprandial blood
glucose excursions for
all subjects.
1001411 Figure 2 shows a plot of 4-CNAB plasma concentrations (ng/mL) vs. time
(arithmetic
means).
1001421 Figure 3 shows a plot of the postprandial blood glucose excursion
(blood glucose
concentration (SuperGL) (mg/dl) vs. time) for Type 2 Diabetic subject no. 116
after oral or
subcutaneous administration of insulin or insulin/4-CNAB 30 minutes prior to a
standard meal
(meal at time = 0).
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1001431 Figure 4 shows a plot of the postprandial blood glucose excursion
(blood glucose
concentration (SuperGL) (mg/di) vs. time) for Type 2 Diabetic subject no. 117
after oral or
subcutaneous administration of insulin or insulin/4-CNAB 30 minutes prior to a
standard meal
(meal at time = 0).
[00144] Figure 5 shows a plot of insulin plasma concentrations (pmo1/1) vs.
time (arithmetic
means).
[001451 Figure 6 shows a plot of C-peptide plasma concentrations (nmo1/1) vs.
time (arithmetic
means).
[00146] Figure 7 shows a plot of insulin plasma concentration (pmo1/1) vs.
time for Type 2 Diabetic
subject no. 116 after oral or subcutaneous administration of insulin or
insulin/4-CNAB 30 minutes
prior to a standard meal (meal at time = 0).
[00147] Figure 8 shows a plot of insulin plasma concentration (pmo1/1) vs.
time for Type 2 Diabetic
subject no. 117 after oral or subcutaneous administration of insulin or
insulin/4-CNAB 30 minutes
prior to a standard meal (meal at time = 0).
Figures From 1016p- Study 175A-C-07 (Hadassah III) nighttime
[00148] Figure 9 is a bar graph showing the effect of nighttime dosing of
insulin and 4-CNAB on
blood glucose concentration.
[00149] Figure 10 is a bar graph showing the effect of nighttime dosing of
insulin and 4-CNAB on
blood C-peptide concentration.
[00150] Figure 11 is a bar graph showing the effect of nighttime dosing of
insulin and 4-CNAB on
blood insulin concentration.
Figures From 1019p Study 175A-C-11 (Profil) mealtime tablets
[00151] Figure 12 is a plot of Preliminary Mean +/- SD % Change in Baseline
Blood Glucose
(SuperGL) Following Oral Administration of Insulin/4-CNAB Tablets to Fed of
Fasted Type 2
Diabetic Patients.
[00152] Figure 13 is a plot of Preliminary Mean +/- SD % Change in Blood
Glucose (SuperGL)
Following Oral Administration of Insulin/ 4-CNAB Tablets to Type 2 Diabetic
Patients with a
Standard Meal.
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WO 2004/080401 PC T/US2004/006943
[00153] Figure 14 is a plot of Preliminary Mean +/- SD % Change in Blood
Glucose (SuperGL)
Following Oral Administration of Insulin/ 4-CNAB Tablets to Type 2 Diabetic
Patients with or
without a Meal.
[00154] Figures 15-22 are plots of Preliminary Percent Change in Blood
(SuperGL) Glucose for
Subjects 101-108, respectively.
[00155] Figure 23 is a plot of Preliminary Mean +/- SD Plasma Glucose Change
(%) Following
Oral Tablet Administration of Insulin/ 4-CNAB to Type 2 Diabetic Patients with
or without a Meal.
[00156] Figure 24 is a plot of Preliminary Mean +/- SD Plasma Glucose
concentration Following
Oral Administration of Insulin/4-CNAB Tablets to Type 2 Diabetic Patients with
or without a Meal.
[00157] Figure 25 is a plot of Preliminary Mean +/- SD Blood (SuperGL) Glucose
concentration
Following Oral Administration of Insulin/ 4-CNAB Tablets to type 2 diabetic
patients with or
without a Meal.
[00158] Figures 26-33 are plots of Preliminary Blood (SuperGL) Glucose
concentrations for
Subjects 101-108, respectively.
[00159] Figure 34 is a plot of Mean +/- SD Serum Insulin Concentration
Following a Single Oral
Administration of Insulin/ 4-CNAB Tablets to Fasted or Fed Type 2 Diabetic
Patients.
[00160] Figure 35 is a plot of Mean +/- SD Serum Insulin Concentration
Following a Single Oral
Administration of Insulin/ 4-CNAB Tablets to Fasted or Fed Type 2 Diabetic
Patients.
[00161] Figures 36-43 are plots of Serum Insulin Concentration Following a
Single Oral
Administration of Insulin/ 4-CNAB Tablets to Fasted Type 2 Diabetic Patients
Subjects 101-108,
respectively.
[00162] Figure 44 is a plot of Mean +/- SD Plasma 4-CNAB Concentration
Following a Single
Oral Tablet Administration of Insulin/4-CNAB to Fed or Fasted Type 2 Diabetic
Patients.
[00163] Figure 45 is a plot of Mean +/- SD Plasma C-Peptide Concentration
Following a Single
Oral Administration of Insulin/4-CNAB Tablets to Fed or Fasted Type 2 Diabetic
Patients.
[00164] Figure 46 is a prior art graph showing mean change in plasma glucose
concentration from
baseline for administration of placebo, glipizide, nateglinide, and glipizide
plus nateglinide.
Figures From 1022p - Study 175A-C-10 (Profil) Multidose
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WO 2004/080401 PCT/US2004/006943
100165] Figure 47 is a curve showing PRELIMINARY Mean (n=6 or 7, SD) Blood
(SuperGL)
Glucose Following Oral Glucose Tolerance Test on Day 0 and Day 15 Following 14
Days of Daily
Q1D Administration of 30015 Insulin/160mg 4-CNAB OR 200mg 4-CNAB alone.
10016611 Figures 48A and 48B are curves showing PRELIMINARY Mean and
Individual Fasting
Blood Glucose Prior to Oral Glucose Tolerance Test at Screening and on Day 15
Following 14
Days of Daily QED Administration of 30015 Insulin/160mg 4-CNAB to Type 2
Diabetic Subjects
(48A) and 200mg 4-CNAB Alone to Type 2 Diabetic Subjects (48B).
[00167] Figures 49A and 49B are curves showing PRELIMINARY Mean and Individual
Blood
Glucose AUCO-240min Following Oral Glucose Tolerance Test At Screening and on
Day 15
Following 14 Days of Daily QLD Administration of 300U Insulin/160mg 4-CNAB to
Type 2
Diabetic Subjects (49A) and 200mg 4-CNAB Alone to Type 2 Diabetic Subjects
(49B).
[00168] Figures 50A and 50B are curves showing PRELIMINARY Mean and Individual
Blood
Glucose 2 Hours Following Oral Glucose Tolerance Test at Screening and on Day
15 Following 14
Days of Daily QED Administration of 30015 Insulin/160mg 4-CNAB to Type 2
Diabetic Subjects
(50A) and 200mg 4-CNAB Alone to Type 2 Diabetic Subjects (50B).
[00169] Figure 51 is a curve showing PRELIMINARY Mean (SD, n=6 or 7) Plasma
Insulin
Concentration Following OGTT at Baseline and on Day 15 Following 14 Days of
Daily QED Oral
Doses of 300U Insulin/160mg 4-CNAB OR 200mg 4-CNAB alone.
[00170] Figures 52A and 52B are curves showing PRELIMINARY Mean and Individual
Plasma
Insulin AUC0-240min Following Oral Glucose Tolerance Test At Screening and on
Day 15 Following
14 Days of Daily QID Administration of 30015 Insulin/160mg 4-CNAB to Type 2
Diabetic Subjects
(52A) and 200mg 4-CNAB Alone to Type 2 Diabetic Subjects (52B).
[00171] Figures 53A and 53B are bar graphs showing PRELIMINARY Mean and
Fasting Blood
Glucose and Plasma Insulin Prior to Oral Glucose Tolerance Test At Screening
and on Day 15
Following 14 Days of Daily QlD Administration of 300U Insulin/160mg 4-CNAB to
Type 2
Diabetic Subjects (53) and 200mg 4-CNAB Alone to Type 2 Diabetic Subjects
(53B).
[00172] Figures 54A and 54B are bar graphs showing PRELIMINARY Mean Blood
Glucose and
Plasma Insulin 2 Hours Following Oral Glucose Tolerance Test at Screening and
on Day 15
Following 14 Days of Daily QID Administration of 300U Insulin/160mg 4-CNAB to
Type 2
Diabetic Subjects (54A) and 200mg 4-CNAB Alone to Type 2 Diabetic Subjects
(54B).
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WO 2004/080401 PCT/US2004/006943
[00173] Figure 55 is a curve showing PRELIMINARY Mean (N=6 or 7, SD) Blood
Glucose
Concentration Following Daily Mealtime Doses of Oral 300U insulin/160mg 4-CNAB
OR 200mg
4-CNAB Alone to Type 2 Diabetic Subjects.
[00174] Figure 56 is a curve showing PRELIMINARY Mean (N=6 or 7, SD) Blood
Glucose
Concentration Following Daily Mealtime Doses of Oral 300U Insulin/160mg 4-CNAB
OR 200mg
4-CNAB Alone to Type 2 Diabetic Subjects.
[00175] Figure 57 is a curve showing PRELIMINARY Mean (N=6 or 7, SD) Blood
Glucose
Concentration Following Daily Mealtime Doses of Oral 300U Insulin/160mg 4-CNAB
OR 200mg
4-CNAB Alone to Type 2 Diabetic Subjects.
[00176] Figure 58 is a curve showing PRELIMINARY Mean (n=6 or 7, SD) Plasma
Insulin
Concentration on Days 0 (baseline), 1 and 14 Following Daily QID Doses of Oral
300U
Insulin/160mg 4-CNAB OR 200mg 4-CNAB alone.
[00177] Figures 59A and 59B are curves showing PRELIMINARY Serum Fructosamine
on Days 0
and 15 Following 14 Days of Daily QID Administration of 300U Insulin/160mg 4-
CNAB to Type 2
Diabetic Subjects (59A) and 200mg 4-CNAB alone (control) to Type 2 Diabetic
Subjects (59B).
DETAILED DESCRIPTION OF THE INVENTION
[00178] Because insulin entry into the bloodstream produces a decrease in
blood glucose levels,
oral absorption of insulin may be verified by observing the effect on a
subject's blood glucose
following oral administration of the composition. In a preferred embodiment of
the invention, the
oral dosage forms of the invention facilitate the oral delivery of insulin,
and after insulin is
absorbed into the bloodstream, the composition produces a maximal decrease in
blood glucose in
treated type 2 diabetic patients from about 5 to about 60 minutes after oral
administration. In
another embodiment of the present invention, the pharmaceutical composition
produces a maximal
decrease in blood glucose in treated type 2 diabetic patients from about 10 to
about 50 minutes post
oral administration. More particularly, the pharmaceutical composition
produces a maximal
decrease in blood glucose in treated type 2 diabetic patients within about 20
to about 40 minutes
after oral administration.
[00179] The magnitude of the decrease in blood glucose produced by insulin
absorbed into the
bloodstream following entry into the gastrointestinal tract varies with the
dose of insulin_ In certain
embodiments of the invention, type 2 diabetic diabetic patients show a maximal
decrease in blood
glucose by at least 10% within one hour post oral administration. In another
embodiment, type 2
CA 02518216 2005-09-06
WO 2004/080401 PCT/US2004/006943
diabetic diabetic patients show a maximal decrease in blood glucose by at
least 20% within one
hour post oral administration, alternatively, at least 30% within one hour
post oral administration.
[00180] Normal levels of blood glucose vary throughout the day and in relation
to the time since
the last meal. One goal of the present invention is to provide oral
compositions of insulin that
facilitate achieving close to normal levels of blood glucose throughout the 24-
hour daily cycle. In a
preferred embodiment of the invention, the pharmaceutical composition includes
insulin or an
insulin analog as the active agent and a delivery agent in an amount effective
to achieve a fasting
blood glucose concentration from about 90 to about 115 mg/d1. In another
preferred embodiment of
the invention, the pharmaceutical composition includes insulin or an insulin
analog as the active
agent and a delivery agent in an amount effective to achieve a fasting blood
glucose concentration
from about 95 to about 110 mg/di, more preferably, the subject manifests
fasting blood glucose
concentrations at about 100 mg/d1.
[00181] In the time after a meal is consumed, blood glucose concentration
rises in response to
digestion and absorption into the bloodstream of carbohydrates derived from
the food eaten. The
present invention provides oral compositions of insulin that prevent or
control very high levels of
blood glucose from being reached and/or sustained. More particularly, the
present invention
provides compositions which facilitate achieving normal levels of blood
glucose after a meal has
been consumed, i.e., post-prandial. In a preferred embodiment of the
invention, the pharmaceutical
composition includes insulin as the active agent and a delivery agent in an
amount effective to
achieve a post-prandial blood glucose concentration from about 130 to about
190 mg/d1. In another
preferred embodiment of the invention, the pharmaceutical composition includes
insulin or an
insulin analog as the active agent and a delivery agent in an amount effective
to achieve a post-
prandial blood glucose concentration from about 150 to about 180 mg/di, more
preferably, the
subject manifests fasting blood glucose concentrations at less than about 175
mg/d1.
[00182] The present invention provides pharmaceutical compositions for oral
administration which
includes insulin or an insulin analog as the active agent and a delivery agent
in an amount effective
to achieve pre-prandial (before a meal is consumed) blood glucose
concentration from about 90 to
about 125 mg/t1.1. In a preferred embodiment, the present invention provides
pharmaceutical
compositions for oral administration which includes insulin or an insulin
analog as the active agent
and a delivery agent in an amount effective to achieve pre-prandial blood
glucose concentration
from about 100 to about 115 mg/d1.
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[00183] The present invention provides pharmaceutical compositions for oral
administration which
include insulin as the active agent and a delivery agent in an amount
effective to achieve blood
glucose concentrations within the normal range during the evening period from
about 70 to about
120 mg/d1. In a preferred embodiment, the present invention provides
pharmaceutical compositions
for oral administration which include insulin or an insulin analog as the
active agent and a delivery
agent in an amount effective to achieve blood glucose concentrations at about
4 hours after bed time
from about 80 to about 120 mg/dl.
[00134] In general, the present invention provides a method of administering
insulin and
pharmaceutical compositions useful for administering insulin such that the
insulin is bioavailable
and biopotent. The delivery agent enables insulin to be orally absorbable
through the mucosa of the
stomach and facilitates the absorption of insulin administered therewith
(either in the same dosage
form, or simultaneously therewith), or sequentially (in either order, as long
as both the delivery
agent and insulin are administered within a time period which provides both in
the same location,
e.g., the stomach, at the same time). Following oral administration of the
pharmaceutical
compositions of the present invention, the delivery agent passes though the
mucosal barriers of the
gastrointestinal tract and is absorbed into the blood stream where it can be
detected in the plasma
and/or blood of subjects. The level of delivery agent in the bloodstream as
measured in the plasma
and/or blood is dose-dependent.
[00185] By virtue of the present invention, the ratio of portal (unmodified)
insulin concentration to
systemic (unmodified) insulin concentration approaches in human diabetic
patients approaches that
which is obtained in normal healthy humans. The chronic administration of oral
dosage forms of
the present invention result in a higher portal insulin concentration and
lower systemic insulin
concentration over time than that obtained with an equi-effective dose of
insulin administered
subcutaneously (i.e., which provide similar control of blood glucose levels).
Transient peaks in
insulin levels that may occur by virtue of the oral administration of insulin
in accordance with the
present invention is not believed to be associated with vascular diseases.
[00186] By virtue of the chronic administration of oral dosage forms of the
present invention
instead of equi-effective subcutaneous doses of insulin, lower levels of
hyperinsulinemia are
obtained, e.g., systemic insulin concentrations are at least about 20% lower
when compared to a
comparably effective subcutaneous dose of insulin. Therefore, the present
invention provides a
method for reducing the incidence and/or severity of systemic hyperinsulinemia
associated with
chronic dosing of insulin, and it is believed that the present invention also
provides a method for
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WO 2004/080401 PCT/US2004/006943
reducing the incidence and/or severity of one or more disease states
associated with chronic dosing
of insulin.
1001871 By virtue of the chrome administration of oral dosage forms of the
present invention, the
patient achieves improved glucose tolerance and glycemic control as compared
with baseline levels
prior to treatment, even without any statistically significant increase in
weight, risk of hypoglycemia
or risk of hyperinsulinemia over the treatment period. Further, by virtue of
the chronic
administration of oral dosage forms of the present invention, the patient
achieves improved insulin
utilization, insulin sensitivity insulin secretion capacity and HbAic levels
as compared with
baseline levels prior to treatment.
[00183] It is also believed that the chronic administration of oral dosage
forms of the present
invention to replace the endogenous insulin production in a mammal with
impaired glucose
tolerance or early stage diabetes mellitus will result in prophylactically
sparing the function of the
mammal's 0-cells or will prevent death or dysfunction of the mammal's 0-cells,
and will thereby
provide long-term protection to the mammal from developing overt or insulin
dependent diabetes,
or will delay the onset of overt or insulin dependent diabetes in the mammal.
[00189] The preferred pharmaceutical compositions of the invention comprise a
combination of
insulin and a delivery agent in a suitable pharmaceutical carrier or excipient
as understood by
practitioners in the art. The means of delivery of the pharmaceutical
composition can be, for
example, a capsule, compressed tablet, pill, solution, freeze-dried, powder
ready for reconstitution
or suspension suitable for administration to the subject.
[00190] Thus, in certain preferred embodiments of the present invention, the
oral insulin
formulations of the invention may be administered to a patient at meal time,
and preferably slightly
before (e.g., about 10-30 minutes before) ingestion of a meal, such that the
peak plasma insulin
concentrations are attained at or about the time of peak blood glucose
concentrations resulting from
the meal. As a further advantage in certain preferred embodiments, the
administration of a
relatively short-acting insulin (e.g., such as the insulin used to prepare the
capsules administered in
the clinical studies reported in the appended examples) will further result in
plasma insulin levels
returning to baseline levels within about 4 hours (and preferably within about
3 hours or less) after
oral administiation of the insulin formulations of the present invention.
[00191] As used herein, "insulin" refers to insulin from a variety of sources.
Naturally occurring
insulin and structurally similar bioactive equivalents (insulin analogues
including short acting and
analogues with protracted action) can be used. Insulin useful in the invention
can be may be
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WO 2004/080401 PCT/US2004/006943
obtained by isolating it from natural source, such as different species of
mammal. For example,
animal insulin preparations extracted from bovine or porcine pancreas can be
used. Insulin
analogues, fragments, mimetics or polyethylene glycol (PEG)-modified
derivatives of these
compounds, derivatives and bioequivalents thereof can also be used with the
invention.
[00192] The insulin used in the present invention may be obtained by
chemically synthesizing it
using protein chemistry techniques such as peptide synthesis, or by using the
techniques of
molecular biology to produce recombinant insulin in bacteria or eukaryotic
cells. The physical form
of insulin may include crystalline and/or amorphous solid forms. In addition,
dissolved insulin may
be used. Other suitable forms of insulin, including, but not limited to,
synthetic forms of insulin,
are described in U.S. Patents Nos. 4,421,685, 5,474,978, and 5,534,488, the
disclosure of each of
which is hereby incorporated by reference in its entirety.
[00193] The most preferred insulin useful in the pharmaceutical compositions
and methods of the
present invention is human recombinant insulin optionally having counter ions
including zinc,
sodium, calcium and ammonium or any combination thereof. Human recombinant
insulin can be
prepared using genetic engineering techniques that are well known in the art.
Recombinant insulin
can be produced in bacteria or eukaryotic cells. Functional equivalents of
human recombinant
insulin are also useful in the invention. Recombinant human insulin can be
obtained from a variety
of commercial sources. For example, insulin (Zinc, human recombinant) can be
purchased from
Calbiochem (San Diego, CA): Alternatively, human recombinant Zinc-Insulin
Crystals: Proinsulin
Derived (Recombinant DNA Origin) USP Quality can be obtained from Eli Lilly
and Company
(Indianapolis, IN). All such fon-ns of insulin, including insulin analogues
(including but not limited
to Insulin Lispro, Insulin Aspart, Insulin Glargine, and Insulin Detemir) are
deemed for the
purposes of this specification and the appended claims are considered to be
encompassed by the
term "insulin." The present invention also provides compositions of
recombinant human zinc
insulin and a delivery agent as a drug for oral administration of insulin in
humans.
[00194] In other preferred embodiments of the invention, the insulin is a
modified insulin, such as
that conjugated with an oligomer such as that described in U.S. Patent No.
6,309,633 and/or which
not has been subjected to amphiphilic modification such as that described in
U.S. Patent Nos.
5,359,030; 5,438,040; and/or 5,681,811. The conjugated (modified) insulin may
be incorporated
into the oral formulations of the present invention in addition to or in the
absence of any of the
types of insulin described above, as well as with other insulin analogues. In
such embodiments, the
oral formulations include the modified insulin either with or without a
pharmaceutically acceptable
delivery agent that facilitates absorption of said insulin from the
gastrointestinal tract.
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[UU1,95.1 Ube total amount of insulin to be used can be determined by those
skilled in the art. It is
preferable that the oral dosage form comprise a therapeutically effective
amount of insulin, i.e., a
pharmacologically or biologically effective amount, or an amount effective to
accomplish the
purpose of insulin. The dose of insulin administered should preferably be in
such an amount that,
upon oral administration, it results in a measurable and statistically
significant reduction in blood
glucose levels in normal healthy human subjects.
[001961 However, the amount can be less than a pharmacologically or
biologically effective
amount when the composition is used in a dosage unit form, such as a tablet,
because the dosage
unit form may contain a multiplicity of delivery agent/biologically or
chemically active agent
compositions or may contain a divided pharmacologically or biologically
effective amount. The
total effective amounts can then be administered in cumulative units
containing, in total,
pharmacologically, biologically or chemically active amounts of biologically
or pharmacologically
active agent.
[00197] It has been found that the use of the presently disclosed delivery
agent provides extremely
efficient delivery of insulin. Preferred insulin doses contained in one or
more dosage forms, when
dosed in combination with the delivery agents described herein, are about 50
to about 600 insulin
Units USP (from about 2 to about 23 mg), preferably from about 100 Units (3.8
mg) to about 450
Units (15.3 mg), more preferably from about 200 Units (7.66 mg) to about 350
Units (13.4 mg), and
still more preferably about 300 Units (11.5 mg), based on the accepted
conversion of factor of 26.11
Units per mg.
[00198] Presently, different forms of typically subcutaneously-administered
insulin preparations
have been developed to provide different lengths of activity (activity
profiles), often due to
ingredients administered with insulin, ranging from short or rapid activity
(e.g., solutions of regular,
crystalline zinc insulin for injection; semilente insulin (prompt insulin zinc
suspension);
intermediate activity (e.g., NPH (isophane insulin suspension; lente (insulin
zinc suspension; lente
is a mixture of crystallized (ultralente) and amorphous (semilente) insulins
in an acetate buffer); and
slow activity (ultralente, which is extended insulin zinc suspension;
protamine zinc). Short-acting
insulin preparations that are commercially available in the U.S. include
regular insulin and rapid-
acting insulins. Regular insulin has an onset of action of 30-60 minutes, peak
time of effect of 1.5
to 2 hours, and a duration of activity of 5 to 12 hours. Rapid acting
insulins, such as aspart
(Humalog )/lispro (Novologe), have an onset of action of 10-30 minutes, peak
time of effect of 30-
60 minutes, and a duration of activity of 3 to 5 hours. Intermediate-acting
insulins, such as NPH
(neutral protamine Hagedorn) and Lente insulins (insulin zinc suspension),
have an onset of action
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of 1-2 hours, peak time of effect of 4 to 8 hours, and a duration of activity
of 10 to 20 hours. In the
case of long-acting insulins, Ultralente insulin has an onset of action of 2-4
hrs, peak time of effect
of 8-20 hours, and a duration of activity of 16 to 24 hours, while Glargine
insulin has an onset of
action of 1 to 2 hours, a duration of action of 24 hours but no peak effect.
[00199] There are over 180 individual insulin preparations available world-
wide. Approximately
25% of these are soluble insulin (unmodified form); about 35% are basal
insulins (mixed with NPH
or Lente insulins, increased pI, or isoelectric point (insulin glargine), or
acylation (insulin detemir);
these forms have reduced solubility, slow subcutaneous absorption and long
duration of action
relative to soluble insulins); about 2% are rapid-acting insulins (e.g., which
are engineered by
amino-acid change, and have reduced self-association and increased
subcutaneous absorption); and
about 38% pre-mixed insulins (e.g., NPH/soluble/rapid-acting insulins; these
preparations have the
benefit, e.g., of reduced number of daily injections). In many cases, regimens
that use insulin in the
management of diabetes combine long-acting and short-acting insulin.
[00200] It is contemplated that the oral insulin formulations of the present
invention, which include
insulin preferably together with a pharmaceutically acceptable delivery agent
that facilitates
absorption of said insulin from the gastrointestinal tract, may be utilized in
combination therapy to
include an insulin that has rapid action, intermediate action, and/or slow
action, as described above,
in order to provide effective basal insulin levels in the diabetic patient.
The rate of action of the
insulin may be caused by virtue of its solubility, and/or by virtue of its
half-life, etc. Thus, in
alternative embodiments, the oral formulations of the present invention may be
designed to provide
the intermediate activity which is found with, e.g., a subcutaneously
administered NPH insulin, or a
slow action which is found with protamine zinc insulin. In each case, the oral
formulations of the
invention, which preferably include a pharmaceutically acceptable delivery
agent which facilitates
absorption of the insulin (as described herein) provide effective control of
blood glucose levels,
albeit for different time periods and with different plasma glucose time
curves.
[00201] Intermediate-acting and long-acting insulin may be prepared using
methodologies known
to those skilled in the art to provide a continuous level of insulin, similar
to the slow, steady (basal)
secretion of insulin provided by the normal pancreas. For example, Lantus ,
from Aventis
Pharmaceuticals Inc., is a recombinant human insulin analog that is a long-
acting, parenteral blood-
glucose-lowering agent whose longer duration of action (up to 24 hours) is
directly related to its
slower rate of absorption. Lantus is administered subcutaneously once a day,
preferably at
bedtime, and is said to provide a continuous level of insulin, similar to the
slow, steady (basal)
secretion of insulin provided by the normal pancreas. The activity of such a
long-acting insulin
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results in a relatively constant concentration/time profile over 24 hours with
no pronounced peak,
thus allowing it to be administered once a day as a patient's basal insulin.
Such long-acting insulin
has a long-acting effect by virtue of its chemical composition, rather than by
virtue of an addition to
insulin when administered.
[00202] In a preferred embodiment, administration of the pharmaceutical
formulation comprising
long-acting insulin is once or twice a day. In a preferred embodiment,
administration of the dosage
form providing short-acting insulin effect can be once, twice, three times,
four times or more than
four times daily, and can be at nighttime, in the morning and/or
preprandially. In a more preferred
embodiment, administration of the dosage form is preferably at nighttime or
morning and three
times preprandially, and more preferably is at nighttime and preprandially for
breakfast, lunch and
dinner. Preferably, the insulin formulations are administered to such human
patients on a chronic
basis, e.g., for at least about 2 weeks.
[00203] In other embodiments of the invention, the oral formulations include
an insulin conjugated
with an oligomer such as that described in U.S. Patent No. 6,309,633 and/or
which not has been
subjected to amphiphilic modification such as that described in U.S. Patent
Nos. 5,359,030;
5,438,040; and/or 5,681,811. The conjugated (modified) insulin may be
incorporated into the oral
formulations of the present invention in addition to or in the absence of any
of the types of insulin
described above, as well as with other insulin analogues. In such embodiments,
the oral
formulations preferably include the modified insulin together with a
pharmaceutically acceptable
delivery agent which facilitates absorption of said insulin from the
gastrointestinal tract.
[00204] Oral administrable drugs currently available for management of type 2
diabetes fall into
two general categories: those that increase insulin supply (sulfonylureas,
other secretagogues and
insulin itself) and those that decrease insulin resistance or improve its
effectiveness (biguanides,
thiazolidinediones). See The Medical Letter, Volume 1, Issue 1, September
2002, Treatment
Guidelines, Drugs for Diabetes. Oral sulfonylurea secretagogues include the
first and second
generation insulin secretagogues which are believed to interact with ATP-
sensitive potassium
channels in the beta cell membrane to increase secretion of insulin. The more
commonly used
second-generation agents (glyburide, glipizide, and glimepiride), which are
more potent than the
first-generation drugs (acetohexamide, chlorpropamide, tolbutamide, and
tolammide), are similar to
each other in efficacy, but differ in dosage and duration of action.
1002051 Typically, such secretagogues are useful for increasing insulin levels
sufficiently to
achieve desired basal insulin levels in patients with early stages of type II
diabetes, who are still
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able to produce their own insulin. However, it is unlikely that such
secretagogues would be useful
for increasing insulin levels sufficiently to achieve desired basal insulin
levels in patients with later
stages of type la diabetes, who have very little pancreatic function left and
produce very little insulin
endogenously. In such patients, the basal insulin levels are achieved, e.g.,
via the use of
subcutaneous injections of insulin (such as a long-acting insulin, for example
Lantus ).
[00206] In certain embodiments of the present invention, the oral insulin
formulations include one
or more of the various types of secretagogues mentioned above in addition to a
type of insulin as
described above. For example, with respect to the first generation
sulfonylureas, tolbutamide
(Orinase ) has an onset of action of one (1) hour and a duration of action of
6-12 hours, and is
usually given in a dose of 1000 mg to 2000 mg in divided daily doses (maximum
daily dose, 3000
mg/day). Tolazamide (Tolinase ) has an onset of action of 4-6 hours and a
duration of action of
10-14 hours, and is usually given in a dose of 250 mg to 500 mg either once or
in divided daily
doses (1000 mg/day). Acetohexamide (Dymelor ) has an onset of action of one
(1) hour and a
duration of action of 10-14 hours, and is usually given in a dose of 500 mg to
750 tug either once or
in divided daily doses (maximum daily dose 1500 mg/day). Chlorpropamide
(Diabinese ) has an
onset of action of one hour and a duration of action of 72 hours, and is
usually given in a dose of
250 mg to 375 mg once a day (maximum daily dose, 750 mg/day).
1002071 With respect to the second generation sulfonylureas, glyburide
(DiaBeta ); Micronase ;
Glynase ) has an onset of action of 1.5 hours and a duration of action of 18-
24 hours. It is usually
given in a dose of 5 to 20 mg either once or in divided daily doses (maximum
daily dose, 20
mg/day). Glipizide (Glucotrol ) has an onset of action of one hour and a
duration of action of 10-
24 hours. It is usually given in a dose of 10 to 20 mg either once or in
divided daily doses
(maximum daily dose, 40 mg/day). Glimepiride (Amarye) has an onset of action
of 2 hours and a
duration of action of 18-28 hours. It is usually administered in a dose of 1
to 4 mg once a day
(maximum daily dose, 8 mg/day). Lastly, gliclazide (Diamicron ) is usually
administered in a dose
of 40 to 80 mg per day (maximum daily dose, 320 mg).
100208] Oral non-sulfonylurea secretagogues, such as repaglinide and
nateglinide, although
structurally different from the sulfonylureas, also bind to ATP-sensitive
potassium channels on
beta-cells and increase insulin release. See The Medical Letter, Volume 1,
Issue 1, September
2002, Treatment Guidelines, Drugs for Diabetes. Both repaglinide and
nateglinide are rapidly
absorbed, resulting in plasma levels of insulin that peak within 30 to 60
minutes and return to
baseline before the next meal. These drugs must be taken before each meal; if
a meal is missed, the
drug should be omitted. Repaglinide and nateglinide are much more expensive
than sulfonylureas,
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but repaglinide may be a useful alternative to a sulfonylurea in patients with
renal impairment
(because it is cleared primarily by hepatic metabolism) or in patients who eat
sporadically.
Hypoglycemia may be slightly less frequent with nateglinide and repaglinide
than with
sulfonylureas, but data are limited. Nateglinide (Starlix419) stimulates
pancreatic insulin secretion
within 20 minutes of oral administration. Following oral administration
immediately prior to a
meal, nateglinide is rapidly absorbed with a mean peak plasma drug
concentration (Ca.) generally
occurring within one hour (tma.) after dosing. When nateglinide is dosed three
times daily before
meals, there is a rapid rise in plasma insulin, with peak levels approximately
one (1) hour after
dosing and a fall to baseline by four (4) hours after dosing. Nateglinide is
usually administered in a
dose of 60 to 120 mg three times daily before meals (maximum daily dose. 360
mg/day). When
given with or after meals, the extent of nateglinide absorption (AUC) remains
unaffected.
However, there is a delay in the rate of absorption characterized by a
decrease in Cmax and a delay
in time to peak plasma concentration (tma.). Similarly, repaglinide (Prandie)
is rapidly and
completely absorbed from the gastrointestinal tract following oral
administration. After single and
multiple oral doses in healthy subjects or in patients, peak plasma drug
levels (Cm) occur within 1
hour (tmõ). Repaglinide is usually administered in a dose of 1 to 4 mg three
times a day before
meals (maximum daily dose, 16 mg/day). When repaglinide was given with food,
the mean tma.
was not changed, but the mean Cma. and A-UC (area under the time/plasma
concentration curve)
were decreased 20% and 12.4%, respectively.
[002091 In addition, long-term administration of specific inhibitors of
dipeptidyl peptidase IV (DP
IV), so as to enhance circulating active potent insulin secretagogues glucose-
dependent
insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) levels,
has been shown to
improve glucose tolerance and beta-cell glucose responsiveness and to reduce
hyperinsulinemia in
the Vancouver diabetic fatty (VDF) rat model of type 2 diabetes.[Long-term
treatment with
dipeptidyl peptidase IV inhibitor improves hepatic and peripheral insulin
sensitivity in the VDF
Zucker rat: a euglycemic-hyperinsulinemic clamp study. Diabetes 2002 Sep;
51(9):2677-2683.
Pospisilik JA, Stafford SG, Demuth HU, McIntosh CH, Pederson RA.] Upon release
into the
circulation, GIP and GLP-1 are rapidly cleaved and inactivated by the enzyme
DP IV.
[00210] With respect to anti-diabetic drugs currently available for management
of type 2 diabetes
that decrease insulin resistance or improve its effectiveness, biguanides,
which decrease the amount
of glucose made by the liver, and thiazolidinediones, which make the patient
more sensitive to
insulin, are oral hypoglycemic agents that are currently used clinically for
improving insulin
resistance. Biguanides, such as Metformin (Glucophage and Glucophage XR by
Bristol-Myers
Squibb Company of Princeton, NJ), which is the only biguanide available for
therapeutic use,
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decreases hepatic glucose production (gluconeogenesis), decreases intestinal
absorption of glucose
and improves insulin sensitivity by increasing peripheral glucose uptake and
utilization. There is
no fixed dosage of Glueophage for the management of hyperglycemia, and dosage
must be
individualized based upon effectiveness and tolerance, while not exceeding the
maximum
recommended daily dose of 2550 mg in adults and 2000 mg in pediatric patients,
once or in divided
doses. In general, clinically significant results are not seen at doses below
1500 mg per day.
However, a lower recommended starting dose and gradually increased dosage is
advised in order to
minimize gastrointestinal symptoms.
[00211] Thiazolidinediones improve sensitivity to insulin in muscle and
adipose tissue and inhibit
hepatic gluconeogenesis, and thus depend on the presence of insulin for their
action. The two
currently approved thiazolidinedione compounds are pioglitazone (Actose by
Takeda
Pharmaceuticals America, Inc. of Lincolnshire, IL) and rosiglitazone (Avandiae
by
GlaxoSmithKline of Research Triangle Park, NC). Actose also improves hepatic
sensitivity to
insulin and improves dysfunctional glucose homeostasis. Actos is first
measurable in serum,
following oral administration in the fasting state, within 30 minutes, with
peak concentrations
observed within 2 hours. Food slightly delays the time to peak serum
concentration to 3 to 4 hours
but does not alter the extent of absorption. Actose is usually given once
daily without regard to
meals, and dosage must be individualized based upon HbAl, for a period of time
adequate to
evaluate changes in HbAlc. Monotherapy dosage in patients not adequately
controlled with diet and
exercise may be initiated at 15 mg or 30 mg and can be increased incrementally
up to 45 mg
(maximum dose 45 mg per day). Avandiae reaches peak plasma concentrations
within about 1
hour after dosing, and administration with food results in no change in
overall exposure (AUC) but
results in a 28% decrease in maximum plasma concentrations and a delay of the
time to reach peak
plasma concentrations to about 1.75 hours after dosing. Dosage of Avandiae
must be
individualized, and Avandiae may be administered either at a starting dose of
4 mg as a single daily
dose or divided and administered twice a day with or without food. For
patients who respond
inadequately, as determined by reduction in fasting blood glucose, the dose
may be increased to 8
mg daily (maximum dose 8 mg per day).
[00212] In certain preferred embodiments of the invention, the oral
formulations of the invention
provide two forms of insulin having different activity rates in order to
simulate the biphasic release
of insulin in non-diabetic humans. For example, such oral formulations may
include a rapid-acting
form of insulin together with a slow acting form of insulin so as to provide a
first peak of insulin
which occurs rapidly and is short-lived, followed by a second peak of insulin
which occurs at a later
time, but which preferably has a longer duration.
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[00213] In further alternatively preferred embodiments of the invention, the
oral formulations of
the invention include a rapid-acting form of insulin together with a
secretagogue that promotes the
secretion of insulin from the beta-cells at a time and to an extent which
mimics the second phase
release of insulin in non-diabetic humans.
1002141 In alternatively preferred embodiments of the invention, the methods
of insulin
administration of the invention provide two separate forms of insulin having
different activity rates
in order for the regimen to simulate the biphasic release of insulin in non-
diabetic humans. For
example, the oral formulations may include a rapid-acting form of insulin so
as to provide a first
peak of insulin which occurs rapidly and is short-lived. Such fast-acting
effect may be provided by
the delivery agent that facilitates the absorption of insulin from the
gastrointestinal tract. The slow
acting form of insulin provides a second peak of insulin that occurs at a
later time but that
preferably has a longer duration. Such slower acting insulin may be provided
by a separate dosage
form, which may be administered orally or subcutaneously.
[00215] In further embodiments of the present invention, the oral dosage forms
described herein
are orally administered as described herein in combination with an additional
therapy to treat
diabetes, impaired glucose tolerance, or to achieve glucose homeostasis, said
additional therapy
comprising, for example, an additional drug such as a sulfonylurea, a
biguanide (such as
Metformin), an alpha-glucosidase, insulin delivered via a different pathway
(e.g., parenteral
insulin), and/or an insulin sensitizer such as thiazolidinedione.
[00216] In further embodiments of the invention, the oral dosage forms
described herein reduce the
likelihood of hypoglycemic events. Hypoglycemia usually results from a
mismatch between insulin
levels and degree of glycemia, e.g., when the administration of insulin and
the ingestion of the meal
are not timed such that the insulin peak occurs at peak glycemia, and
administration of insulin
shortly before a meal is more practical for a patient and is also safer,
because glucose is ingested
soon thereafter. The risk of hypoglycemia is lowered mainly due to the portal-
physiologic route of
administration of oral insulin. One cannot hyperinsulinize the liver, because,
even under
hyperinsulinemic condition, the uptake of glucose by the liver will be
unchanged. Unlike the
peripheral tissue, the pancreas will not sequester additional glucose but
rather will only cease
producing endogenous insulin. Second, the brief peak of insulin that results
from the oral
composition described herein shows that, even if insulin were to reach high
peripheral levels, the
peak quickly drops precipitously.
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[00217] In addition, further embodiments of the oral dosage forms described
herein avoid the risk
of hypoglycemic events that may occur in certain short acting insulin
formulations, which may,
between the time of administration of insulin and the time of ingestion of the
meal, contribute to a
lowering of blood glucose to a level that could range from undesirable to
clinically hypoglycemic.
In the oral dosage forms disclosed herein, dosing closer to a meal eliminated
the dip in blood
glucose levels, which was precarious by itself. The effect seems to have also
translated to lowering
of the subsequent glucose excursion
[00218] In preferred embodiments of the dosage forms described herein, in the
absence of a
delivery agent, the dose of insulin is not sufficiently absorbed when orally
administered to a human
patient to provide a desirable therapeutic effect but said dose provides a
desirable therapeutic effect
when administered to said patient by another route of achninistratiOn.
Previous disclosures by
Emisphere Technologies, Inc. solved the problem of oral absorption of insulin
by providing
delivery agents that facilitate transport of insulin through the gut wall and
into the bloodstream
where the insulin can perform its biological function. As a result, effective
oral drug delivery
methods are provided to increase the oral bioavailability and absorption of
insulin, which is
currently administered parenterally.
[00219] The invention is thus directed to an methods involving oral
administration of a dosage
form comprising insulin together with a pharmaceutically acceptable delivery
agent that serves to
render the insulin orally absorbable through the gastrointestinal mucosa, the
delivery agent being
present in an amount effective to facilitate the absorption of said insulin,
such that a therapeutically
effective amount of said dose of insulin is absorbed from the gastrointestinal
tract of human
diabetic patients. This allows the oral dosage form to be dosed much closed to
a meal than was
previously taught.
[00220] In preferred embodiments, the oral dosage forms of the present
invention comprise a
mixture of insulin and a delivery agent, e.g., monosodium N-(4-
chlorosalicyloy1)-4-aminobutyrate
(4-CNAB), a novel compound discovered by Emisphere Technologies, Inc., or
separately
containing insulin and the delivery agent.
[00221] In other preferred embodiments, the delivery agents used in the
invention have the
following structure:
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OH 0
X
wherein X is one or more of hydrogen, halogen, hydroxyl or C1-C3 alkoxy, and R
is substituted or
unsubstituted C1-C3 alkylene, substituted or unsubstituted C1-C3 alkenylene.
[00222] In certain preferred embodiments, the delivery agents of the invention
preferably have the
following structure:
OH 0
OH
4011 HNI
0
X
wherein X is halogen, and R is substituted or unsubstituted Ci-C3 alkylene,
substituted or
unsubstituted C1-C3 alkenylene.
[00223] In a preferred embodiment of the present invention, the pharmaceutical
composition
includes a delivery agent wherein X is chlorine and R is C3 alkylene. In
another preferred
embodiment of the present invention, the pharmaceutical composition includes
the compound 4-
[(4-chloro, 2-hydroxybenzoyDaminolbutanoic acid as a delivery agent for the
oral delivery of
insulin, preferably the monosodium salt thereof. In preferred embodiments, the
oral dosage forms
of the present invention comprise a mixture of insulin and a delivery agent,
e.g., monosodium N-(4-
chlorosalicyloy1)-4-aminobutyrate (4-CNAB), a novel compound discovered by
Emisphere
Technologies, Inc., or separately containing insulin and the delivery agent.
[002241 The delivery agents may be in the form of the carboxylic acid or salts
thereof. Suitable
salts include, but are not limited to, organic and inorganic salts, for
example alkali-metal salts, such
as sodium, potassium and lithium; alkaline-earth metal salts, such as
magnesium, calcium or
barium; ammonium salts; basic amino acids, such as lysine or arginine; and
organic amines, such as
dimethylamine or pyridine. Preferably, the salts are sodium salts. The salts
may be mono- or multi-
43
CA 02518216 2011-07-27
valent salts, such as monosodium salts and di-sodium salts. The salts may also
be solvates,
including ethanol solvates, and hydrates.
1002251 Other suitable delivery agents that can be used in the present
invention include those
delivery agents described United States Patents Nos. 5,650.386, 5,773,647,
5,776,888, 5,804,688,
5,866,536, 5,876,710, 5,879,681, 5,939,381, 5,955,503, 5,965,121,5,989,539,
5,990,166, 6,001,347,
6,051,561, 6,060,513. 6,090,958, 6,100,298, 5,766,633, 5,643,957, 5,863,944,
6,071,510 and
6,358,504. Additional suitable delivery agents are also described in
International Publications Nos.
WO 01/34114, WO 01/21073, WO 01/41985, WO 01/32130, WO 01/32596, WO 01/44199,
WO
01/51454, WO 01/25704, WO 01/25679, WO 00/50386, WO 02/02509, WO 00/47188, WO
00/07979, WO 00/06534. WO 98/25589, WO 02/19969, WO 00/59863, WO 95/28838, WO
02/19969, WO 02/20466, WO 02/069937 and WO 02/070438.
1002261 Salts of the delivery agent compounds of the present invention may be
prepared by
methods known in the art. For example, sodium salts may be prepared by
dissolving the delivery
agent compound in ethanol and adding aqueous sodium hydroxide.
1002271 The compounds described herein may be derived from amino acids and can
be readily
prepared from amino acids by methods known by those with skill in the art
based upon the present
disclosure and the methods described in International Publications Nos. WO
96/30036, WO
97/36480, WO 98/34632 and WO 00/07979, and in United States Patents Nos.
5,643,957 and
5,650,386. For example, the compounds may be prepared by reacting the single
amino acid with the
appropriate acylating or amine-modifying agent, which reacts with a free amino
moiety present in
the amino acid to form amides. Protecting groups may be used to avoid unwanted
side reactions as
would be known to those skilled in the art.
1002281 The delivery agents may also be prepared by the methods of
International Patent
Publications Nos. WO 02/02509 and WO 03/057170.
1002291 The delivery agents may also be prepared by alkylation of the
appropriate salicylamide
according to the methods of International Publication No. WO 00/46182. The
salicylamide may be
prepared from salicylic acid via the ester by reaction with sulfuric acid and
ammonia.
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[00230] In addition, polyamino acids and peptides comprising one or more of
these compounds
may be used. An amino acid is any carboxylic acid having at least one free
amine group and
includes naturally occurring and synthetic amino acids. Poly amino acids are
either peptides (which
are two or more amino acids joined by a peptide bond) or are two or more amino
acids linked by a
bond formed by other groups which can be linked by, e.g., an ester or an
anhydride linkage.
Peptides can vary in length from dipeptides with two amino acids to
polypeptides with several
hundred amino acids.
[00231] The delivery agent compound may be purified by recrystallization or by
fractionation on
one or more solid chromatographic supports, alone or linked in tandem.
Suitable recrystallization
solvent systems include, but are not limited to, ethanol, water, heptane,
ethyl acetate, acetonitrile,
methanol and tetrah3rdrofuran and mixtures thereof. Fractionation may be
performed on a suitable
chromatographic support such as alumina, using methanol/n-propanol mixtures as
the mobile
phase; reverse phase chromatography using trifluoroacetic acid/ acetonitrile
mixtures as the mobile
phase; and ion exchange chromatography using water or an appropriate buffer as
the mobile phase.
When anion exchange chromatography is performed, preferably a 0-500 mM sodium
chloride
gradient is employed.
[00232] Following oral administration of the pharmaceutical compositions of
the present invention,
the delivery agent passes though the mucosal barriers of the GI tract and is
absorbed into the blood
stream where it can be detected in the plasma of subjects. The delivery agent
facilitates the
absorption of the drug (active agent) administered therewith (either in the
same dosage form, or
simultaneously therewith), or sequentially (in either order, as long as both
the delivery agent and the
drug are administered within a time period which provides both in the same
location, e.g., the
stomach, at the same time). The mechanism by which 4-CNAB facilitates the
gastrointestinal
absorption of insulin has not yet been fully elucidated. The current working
hypothesis is that 4-
CNAB interacts with insulin non-covalently, creating more favorable
physicochemical properties
for absorption. This working hypothesis is provided for explanation purposes
only and is not
intended to limit the present invention or the appended claims in any way.
[00233] The amount of delivery agent in the present composition is a delivery
effective amount and
can be determined for any particular delivery agent/insulin combination by
methods known to those
skilled in the art. The amount of delivery agent necessary to adequately
deliver the therapeutic
amount of insulin into the blood stream of a subject needing the therapeutic
effect of insulin may
vary depending on one or more of the following; the chemical nature of
insulin; the chemical
structure of the particular delivery agent; the nature and extent of
interaction between insulin and
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delivery agent; the nature of the unit dose, i.e., solid, liquid, tablet,
capsule or suspension; the
concentration of delivery agent in the GI tract; the feeding state of the
subject; the diet of the
subject; the health of the subject and the ratio of delivery agent to insulin.
In certain preferred
embodiments of the invention, the amount of the delivery agent preferred for
the pharmaceutical
composition and contained in one or more dosage forms is from about 1 mg to
about 2,000 mg,
more preferably from about 5 mg to about 800 mg, more preferably about 20 mg
to about 600 mg,
even more preferably from about 30 mg to about 400 mg, still more preferably
from about 40 mg to
about 200 mg, most preferably about 40 mg, 80 mg or 160 mg.
[00234] The time it takes for the delivery agent to reach a peak in the
bloodstream (tõ) may
depend on many factors such as the following: the nature of the unit dose,
i.e., solid, liquid, tablet,
capsule, suspension; the concentration of delivery agent in the GI tract; the
feeding state of the
subject; the diet of the subject; the health of the subject and the ratio of
delivery agent to the active
agent. The delivery agents of the present invention are rapidly absorbed from
the gastrointestinal
tract when orally administered in an immediate release dosage form, preferably
in tablet form, and
preferably provide a peak plasma delivery agent concentration within about 5
minutes to about 40
minutes after oral administration, and preferably at about 10 minutes to about
35 minutes after oral
administration. In a preferred embodiment of the invention, wherein the
pharmaceutical
composition includes the compound 4-CNAB as the delivery agent for insulin,
the composition
provides a peak plasma delivery agent concentration within about 25 minutes to
about 35 minutes
after oral administration to fasting diabetic patients and within about 15
minutes to about 25
minutes after oral administration to fed diabetic patients.
[00235] In certain preferred embodiments of the invention, a peak plasma
concentration (Cm.) of
the delivery agent achieved after oral administration is preferably from about
10 to about 250,000
ng/ml, after oral administration, preferably from about 100 to about 125,000
ng/ml, and preferably
the peak plasma concentration of the delivery agent is from about 1,000 to
about 50,000 ng/ml,
after oral administration. More preferably, the peak plasma concentration of
the delivery agents of
the present invention is from about 3,000 to about 15,000 ng/ml after oral
administration.
[00236] In a preferred embodiment of the invention, wherein the pharmaceutical
composition
includes the compound 4-CNAB as the delivery agent and insulin as the active
agent, the
composition provides a peak plasma 4-CNAB concentration within about 0.1 to
about 3 hours after
oral administration. In certain preferred embodiments where the pharmaceutical
composition
includes the compound 4-CNAB as the delivery agent and insulin as the active
agent, the peak
plasma concentration of delivery agent attained is from about 8,000 to about
37,000 ng/ml.
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[002371 Since the amount of delivery agent required to deliver a particular
active agent is variable
and the amount of active agent required to produce a desired therapeutic
effect is also a variable, the
ratio of active agent to delivery agent may vary for different active
agent/delivery agent
combinations. In certain preferred embodiments of the invention where the oral
pharmaceutical
composition includes insulin as the active agent and the delivery agent is the
compound 4-CNAB,
the amount of the delivery agent included in the pharmaceutical composition
may be from about 20
mg to about 600 mg of said delivery agent.
[002381 The optimum ratio of insulin to delivery agent can vary depending on
the delivery agent
and the formulation. Optimizing the ratio of insulin to delivery agent is
within the knowledge of
one skilled in the art. In certain preferred embodiments of the invention, the
pharmaceutical
composition includes insulin as the active agent and the delivery agent is the
monosodium salt of 4-
CNAB, the ratio of insulin [Units] to delivery agent [mg] ranges from 10:1
[Units/mg] to 1:10
[Units/mg], preferably, the ratio of insulin [Units] to delivery agent [mg]
ranges from 5:1
[Units/mg] to 0.5:1 [Units/mg].
[00239] Preferred insulin doses in a single administration are about 5 to
about 1000 insulin units
USP, preferably from about 50 to about 400, more preferably from about 150 to
about 400, and still
more preferably from about 150 to about 300 units.
[00240] Absorption of insulin can be detected in subjects treated with the
pharmaceutical
compositions of the present invention by monitoring the plasma levels of
insulin after treatment.
The time it takes for an active agent to reach a peak in the bloodstream
(tn.() may depend on many
factors such as the following: the nature of the unit dose, i.e., solid,
liquid, tablet, capsule,
suspension; the concentration of active agent and delivery agent in the GI
tract; the feeding state of
the subject; the diet of the subject; the health of the subject and the ratio
of active agent to the
delivery agent.
[00241] hi a preferred embodiment of the invention, wherein the pharmaceutical
composition
includes the compound 4-CNAB as the delivery agent and insulin as the active
agent, the
composition provides a peak plasma insulin concentration from about 0.1 to
about 1 hour after oral
administration. In another embodiment, the composition provides a peak plasma
insulin
concentration from about 0.2 to about 0.6 hours after oral administration. In
a preferred
embodiment, the composition provides a peak plasma insulin concentration from
about 0.3 to about
0.4 hours after oral administration. In another embodiment, the composition
provides a peak
plasma insulin concentration within about 1 hour after oral administration. In
certain preferred
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embodiments, the pharmaceutical composition comprises insulin and the compound
4-CNAB as a
delivery agent to facilitate the oral delivery of insulin, and after insulin
is absorbed into the
bloodstream, the plasma insulin levels in treated patients peak at about 20
minutes post oral
administration with a second peak at about 105 minutes.
[00242] The effect of absorption of insulin is manifested in human patients
treated with the
pharmaceutical compositions of the present invention by observing reductions
in C-peptide
concentration following oral treatment. For example, in one embodiment of the
invention, the
pharmaceutical composition comprises insulin and the compound 4-CNAB as a
delivery agent to
facilitate the oral delivery of insulin, and, after insulin is absorbed into
the bloodstream, the
composition produces a maximal decrease in C-peptide concentration in treated
patients from about
80 and about 120 minutes post oral administration. More particularly, the
composition produces a
maximal decrease in 0-peptide concentration in treated patients from about 90
and about 110
minutes post oral administration.
[00243] In previous patent applications, such as those enumerated above that
have been
incorporated herein by reference, Emisphere Technologies, Inc. disclosed
structures of various
delivery agents, comparisons of their effectiveness of absorption and
effectiveness of delivery, the
preparation of the preferred delivery agent 4-CNAB, its preparation for human
studies, and data
regarding previous non-clinical and clinical studies involving the delivery
agent 4-CNAB.
[00244] The delivery agent may be used directly by mixing with the unmodified
insulin prior to
administration, either in dry powder form or wet granulated together. To this
mixture, other
pharmaceutically acceptable excipients may be added. The mixture may be then
tableted or placed
into gelatin capsules containing a unit dose of the active agent and the
delivery agent.
Alternatively, the delivery agent/insulin mixture may be prepared as an oral
solution or suspension.
The delivery agent and insulin do not need to be mixed together prior to
administration, such that,
in certain embodiments, the unit dose of insulin (with or without other
pharmaceutically acceptable
excipients) is orally administered without the delivery agents of this
invention, and the delivery
agent is separately orally administered (with or without other
pharmaceutically acceptable
excipients) before, after, or simultaneously with the insulin.
100245] In certain preferred embodiments, the oral dosage forms of the present
invention are solid.
The insulin in dry powder form is stable, and in certain preferred embodiments
is simply mixed in
a desirable ratio with the delivery agent. The dry powder mixture may then be
filled into gelatin
capsules, with or without optional pharmaceutical excipients. Alternatively,
the insulin in dry
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powder form may be mixed with the delivery agent together with optional
pharmaceutical
excipients, and the mixture may be tableted in accordance with standard
tableting procedures
known to those having ordinary skill in the art.
[00246] The dosage forms of the present invention may be produced by first
dissolving insulin and
the delivery agent into one solution or separate solutions. The solvent will
preferably be an aqueous
solution, but organic solvents or aqueous organic solvent mixtures may be used
when necessary to
solubilize the delivery agent. If two solutions are used, the proportions of
each necessary to provide
the correct amount of either insulin or delivery agent are combined and the
resulting solution may
be dried, by lyophilization or equivalent means. In one embodiment of the
invention, the oral
dosage form may be dried and rehydrated prior to oral administration.
[00247] The administration mixtures may be prepared, e.g., by mixing an
aqueous solution of the
delivery agent with an aqueous solution of insulin just prior to
administration. Alternatively, the
delivery agent and insulin can be admixed during the manufacturing process.
The solutions may
optionally contain additives such as phosphate buffer salts, citric acid,
acetic acid, gelatin, and gum
acacia.
[00248] In preferred embodiments of the oral dosage forms of the invention
described above, the
oral dosage form is solid, and is preferably provided incorporated within a
gelatin capsule or is
contained in a tablet.
[00249] Stabilizing additives may be incorporated into the delivery agent
solution. With some
drugs, the presence of such additives promotes the stability and
dispersibility of the agent in
solution. The stabilizing additives may be employed at a concentration ranging
from about 0.1 and
5% (W/V), preferably about 0.5% (WN). Suitable, but non-limiting, examples of
stabilizing
additives include gum acacia, gelatin, methyl cellulose, polyethylene glycol,
carboxylic acids and
salts thereof, and polylysine. The preferred stabilizing additives are gum
acacia, gelatin and methyl
cellulose.
[00250] The oral dosage forms of the present invention, containing a mixture
of the active agent,
e.g., insulin and the delivery agent, e.g., 4-CNAB or separately containing
the active agent and the
delivery agent, may include additional materials known to those skilled in the
art as pharmaceutical
excipients. Any excipient or ingredient, including pharmaceutical ingredients
or excipients. Such
pharmaceutical excipients include, for example, the following: Acidifying
agents (acetic acid,
glacial acetic acid, citric acid, fumaric acid, hydrochloric acid, diluted
hydrochloric acid, malic acid,
nitric acid, phosphoric acid, diluted phosphoric acid, sulfuric acid, tartaric
acid); Aerosol
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propellants (butane, dichlorodifiuoro-methane, dichlorotetrafluoroethane,
isobutane, propane,
trichloromonofluoromethane); Air displacements (carbon dioxide, nitrogen);
Alcohol denaturants
(denatonium benzoate, methyl isobutyl ketone, sucrose octacetate); Alkalizing
agents (strong
ammonia solution, ammonium carbonate, dietha-nolamine, diisopropanolamine,
potassium
hydroxide, sodium bicarbonate, sodium borate, sodium carbonate, sodium
hydroxide, trolamine);
Anticaking agents (see glidant); Antifoaming agents (dimethicone,
simethicone); Antimicrobial
preservatives (benzalkonium chloride, benzalkonium chloride solution,
benzelthonium chloride,
benzoic acid, benzyl alcohol, butylparaben, cetylpyridinium chloride,
chlorobutanol, chlorocresol,
cresol, dehydroacetic acid, ethylparaben, methylparaben, methylparaben sodium,
phenol,
phenylethyl alcohol, phenylmercuric acetate, phenylmercuric nitrate, potassium
benzoate,
potassium sorbate, propylparaben, propylparaben sodium, sodium benzoate,
sodium
dehydroacetate, sodium propionate, sorbic acid, thimerosal, thymol);
Antioxidants (ascorbic acid,
acorbyl palmitate, butylated hydroxyanisole, butylated hydroxytoluene,
hypophosphorous acid,
monothioglycerol, propyl gallate, sodium formaldehyde sulfoxylate, sodium
metabisulfite, sodium
thiosulfate, sulfur dioxide, tocopherol, tocopherols excipient); Buffering
agents (acetic acid,
ammonium carbonate, ammonium phosphate, boric acid, citric acid, lactic acid,
phosphoric acid,
potassium citrate, potassium metaphosphate, potassium phosphate monobasic,
sodium acetate,
sodium citrate, sodium lactate solution, dibasic sodium phosphate, monobasic
sodium phosphate);
Capsule lubricants (see tablet and capsule lubricant); Chelating agents
(edetate disodium,
ethylenediaminetetraacetic acid and salts, edetic acid); Coating agents
(sodium
carboxymethylcellulose, cellulose acetate, cellulose acetate phthalate,
ethylcellulose, gelatin,
pharmaceutical glaze, hydroxypropyl cellulose, hydroxypropyl methylcellulose,
hydroxypropyl
methylcellulose phthalate, methacrylic acid copolymer, methylcellulose,
polyethylene glycol,
polyvinyl acetate phthalate, shellac, sucrose, titanium dioxide, camauba wax,
mic-rocystalline wax,
zein); Colorants (caramel, red, yellow, black or blends, ferric oxide);
Complexing agents
(ethylenediaminetetraacetic acid and salts (EDTA), edetic acid, gentisic acid
ethanolmaide,
oxyquinoline sulfate); Desiccants (calcium chloride, calcium sulfate, silicon
dioxide); Emulsifying
and/or solubilizing agents (acacia, cholesterol, diethanolamine (adjunct),
glyceryl monostearate,
lanolin alcohols, lecithin, mono- and di-glycerides, monoethanolamine
(adjunct), oleic acid
(adjunct), oleyl alcohol (stabilizer), poloxamer, polyoxyethylene 50 stearate,
polyoxyl 35 caster oil,
polyoxyl 40 hydrogenated castor oil, polyoxyl 10 oleyl ether, polyoxyl 20
cetostearyl ether,
polyoxyl 40 stearate, polysorbate 20, polysorbate 40, polysorbate 60,
polysorbate 80, propylene
glycol diacetate, propylene glycol monostearate, sodium lauryl sulfate, sodium
stearate, sorbitan
monolaurate, soritan monooleate, sorbitan monopahnitate, sorbitan
monostearate, stearic acid,
trolamine, emulsifying wax); Filtering aids (powdered cellulose, purified
siliceous earth); Flavors
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and perfumes (anethole, benzaldehyde, ethyl vanillin, menthol, methyl
salicylate, monosodium
glutamate, orange flower oil, peppermint, peppermint oil, peppermint spirit,
rose oil, stronger rose
water, thymol, tolu balsam tincture, vanilla, vanilla tincture, vanillin);
Glidants and/or anticaking
agents (calcium silicate, magnesium silicate, colloidal silicon dioxide,
talc); Humectants (glycerin,
hexylene glycol, propylene glycol, sorbitol); Plasticizers (castor oil,
diacetylated monoglycerides,
diethyl phthalate, glycerin, mono- and di-acetylated monoglycerides,
polyethylene glycol, propylene
glycol, triacetin, triethyl citrate); Polymers (e.g., cellulose acetate, alkyl
celloloses,
hydroxyalkylcelloloses, acrylic polymers and copolymers); Solvents (acetone,
alcohol, diluted
alcohol, amylene hydrate, benzyl benzoate, butyl alcohol, carbon
tetrachloride, chloroform, corn oil,
cottonseed oil, ethyl acetate, glycerin, hexylene glycol, isopropyl alcohol,
methyl alcohol,
methylene chloride, methyl isobutyl ketone, mineral oil, peanut oil,
polyethylene glycol, propylene
carbonate, propylene glycol, sesame oil, water for injection, sterile water
for injection, sterile water
for irrigation, purified water); Sorbents (powdered cellulose, charcoal,
purified siliceous earth);
Carbon dioxide sorbents (barium hydroxide lime, soda lime); Stiffening agents
(hydrogenated
castor oil, cetostearyl alcohol, cetyl alcohol, cetyl esters wax, hard fat,
paraffin, polyethylene
excipient, stearyl alcohol, emulsifying wax, white wax, yellow wax);
Suspending and/or viscosity-
increasing agents (acacia, agar, alginic acid, aluminum monostearate,
bentonite, purified bentonite,
magma bentonite, carbomer 934p, carboxymethylcellulose calcium,
carboxymethylcellulose
sodium, carboxymethycellulose sodium 12, carrageenan, microcrystalline and
carboxymethylcellulose sodium cellulose, dextrin, gelatin, guar gum,
hydroxyethyl cellulose,
hydroxypropyl cellulose, hydroxypropyl methylcellulose, magnesium aluminum
silicate,
methylcellulose, pectin, polyethylene oxide, polyvinyl alcohol, povidone,
propylene glycol alginate,
silicon dioxide, colloidal silicon dioxide, sodium alginate, tragacanth,
xanthan gum); Sweetening
agents (aspartame, dextrates, dextrose, excipient dextrose, fructose,
mannitol, saccharin, calcium
saccharin, sodium saccharin, sorbitol, solution sorbitol, sucrose,
compressible sugar, confectioner's
sugar, syrup); Tablet binders (acacia, alginic acid, sodium
carboxymethylcellulose, microcrystalline
cellulose, dextrin, ethylcellulose, gelatin, liquid glucose, guar gum,
hydroxypropyl methylcellulose,
methycellulose, polyethylene oxide, povidone, pregelatinized starch, syrup);
Tablet and/or capsule
diluents (calcium carbonate, dibasic calcium phosphate, tribasic calcium
phosphate, calcium
sulfate, rnicrocrystalline cellulose, powdered cellulose, dextrates, dextrin,
dextrose excipient,
fructose, kaolin, lactose, mannitol, sorbitol, starch, pregelatinized starch,
sucrose, compressible
sugar, confectioner's sugar); Tablet disintegrants (alginic acid,
microcrystalline cellulose,
croscarmellose sodium, corspovidone, polacrilin potassium, sodium starch
glycolate, starch,
pregelatinized starch); Tablet and/or capsule lubricants (calcium stearate,
glyceryl behenate,
magnesium stearate, light mineral oil, polyethylene glycol, sodium stearyl
fumarate, stearic acid,
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purified stearic acid, talc, hydrogenated vegetable oil, zinc stearate);
Tonicity agent (dextrose,
glycerin, tnannitol, potassium chloride, sodium chloride); Vehicle: flavored
and/or sweetened
(aromatic elixir, compound benzaldehyde elixir, iso-alcoholic elixir,
peppennint water, sorbitol
solution, syrup, tolu balsam syrup); Vehicle: oleaginous (almond oil, corn
oil, cottonseed oil, ethyl
oleate, isopropyl myristate, isopropyl pahnitate, mineral oil, light mineral
oil, myristyl alcohol,
uctyldodecanol, olive oil, peanut oil, persic; oil, seame oil, soybean oil,
squalane); Vehicle: solid
carrier (sugar spheres); Vehicle: sterile (bacteriostatic water for injection,
bacteriostatic sodium
chloride injection); Viscosity-increasing (see suspending agent); Water
repelling agent
(cyclomethicone, dimethicone, simethicone); and Wetting and/or solubilizing
agent (benzalkonium
chloride, ben.zethonium chloride, cetylpyridinium chloride, docusate sodium,
nonoxynol 9,
nonoxynol 10, octoxynol 9, poloxamer, polyoxyl 35 castor oil, polyoxyl 40,
hydrogenated castor
oil, polyoxyl 50 stearate, polyoxyl 10 oleyl ether, polyoxyl 20, cetostearyl
ether, polyoxyl 40
stearate, polysorbate 20, polysorbate 40, polysorbate 60, polysorbate 80,
sodium lauryl sulfate,
sorbitan monolaureate, sorbitan monooleate, sorbitan monopalmitate, sorbitan
monostearate,
tyloxapol). This list is not meant to be exclusive, but instead merely
representative of the classes of
excipients and the particular excipients which may be used in oral dosage
forms of the present
invention.
[00251] The stability of insulin has been well documented, and temperature, pH
and moisture are
some of the factors that affect the stability of insulin formulations.
Likewise, the influence of
pharmaceutical excipients on the stability of insulin has been well
documented. The present
specification discloses oral pharmaceutical formulations in tablet form that
exhibit evidence of
sufficient stability to warrant long term storage at room temperature, as
demonstrated by a stability-
indicating High Performance Liquid Chromatography (HPLC) assay methodology.
Some of the
factors that are believed to contribute to insulin stability in this
formulation are:
reduced surface area exposure to atmospheric conditions (only the outside
surface of the
tablet is exposed; while the inner tablet core is not);
formulation of the tablet to provide an "insulin-friendly" local pH, perhaps
in part due to the
presence of dicalcium phosphate; and
low moisture content (anhydrous excipients were used whenever possible, and 4-
CNAB is
not hygroscopic(residual moisture content < 0.5%) below 75% RH and has
moisture content below
0.5% w/w).
[00252] There are several ways to assess the stability of insulin. One way is
an HPLC stability-
indicating assay: This method determines the amount of intact insulin
molecules present in a
sample, but does not determine whether these molecules are in a bioactive
conformation, which is
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necessary in order to have an effective product. Other methods are measurement
of related
substances (impurities) by HPLC and assessing the bioactivity of the product,
which could be an in
vivo assay or an in vitro predictor of in vivo performance.
[00253] Following administration, the insulin present in the dosage unit form
is absorbed into the
circulation. The circulating levels of the insulin itself can be measured
directly. Similarly, levels of
4-CNAB delivery agent in the blood can be measured. The bioavailability of the
insulin is readily
assessed by measuring a known pharmacological activity in blood, e.g.,
decreased blood glucose.
Further physiologic effects of the insulin can be measured using tests, for
example, measurement of
plasma C-peptide concentration as a measure of endogenous insulin production.
[00254] In addition, a fructosamine assay can be performed to determine the
measure of the
diabetic patient's glycemic control over the previous period of two to three
weeks. Fructosamine is
formed by a non-enzymatic reaction between glucose and amino acid residues of
proteins, and
serum fructosamine levels are elevated in diabetic patients with elevated
blood glucose
concentration. Whereas blood glucose concentration is a short-term indicator
of diabetes control,
fructosamine is a short- to medium-term indicator of diabetes control that
correlates well with both
fasting and mean blood glucose over a 2-week period.
[00255] In the present invention, the methods for treating a mammal with
impaired glucose
tolerance or with early or late stage diabetes comprise orally administering
to the mammal a
pharmaceutical formulation that includes a therapeutically effective amount of
insulin or an insulin
analog and a delivery agent in an amount effective to facilitate the
absorption of the insulin from the
gastrointestinal tract. It is preferred that the administration be on a
chronic basis, e.g., for at least
two weeks, and be preprandially and at bedtime such that, after two weeks of
treatment, the
mammal achieves improved glucose tolerance and glycemic control, as well as
improved insulin
utilization, insulin sensitivity, insulin secretion capacity and HbAtc levels,
as compared with
baseline levels prior to treatment.
[00256] Improved glucose tolerance can be demonstrated by better endogenous
capacity of the
mammal to handle sugar load as measured by blood glucose concentration,
following a sugar load,
that is reduced by a statistically significant amount as compared with
baseline blood glucose
concentration, following a glucose load, prior to treatment. Preferably, the
statistically significant
reduction in blood glucose concentration is a mean of about 10-20%, preferably
about 15%.
[00257] Improved glucose tolerance and better endogenous capacity of the
mammal to handle
sugar load can also be measured by an AUC of blood glucose excursion,
following a glucose load,
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that is reduced by a statistically significant amount as compared with AUC of
blood glucose
excursion, following a glucose load, prior to treatment. Preferably, the
statistically significant
reduction in AUC of blood glucose excursion is a mean of about 10-30%,
preferably about 20%.
[00258] Improved glycemic control can be demonstrated by decreased fasting
blood glucose levels
as measured by fasting blood glucose concentration that is reduced by a
statistically significant
amount as compared with baseline fasting blood glucose concentration prior to
treatment.
Preferably, the statistically significant reduction in fasting blood glucose
concentration is a mean of
about 10-30%, preferably about 19%.
[00259] Improved glycemic control can also be demonstrated by decreased serum
fructosamine
concentrations, as measured by serum fructosamine assay, that is reduced by a
statistically
significant amount as compared with baseline serum fructosamine concentrations
prior to treatment.
Preferably, the statistically significant reduction in serum fructosamine
concentrations is a mean of
about 5-20%, preferably about 9%.
[00260] Improved glycemic control can also be demonstrated by improved HbAl c
levels after
treatment compared with baseline levels prior to treatment. Preferably, the
improved HbAl c levels
are measured by a statistically significant decline in HbAl c levels. When
treating a mammal with
impaired glucose tolerance or with early or late stage diabetes,
administration of the pharmaceutical
formulation of the present invention can preferably be made to a mammal having
an HbAl, level
ranging from normal to elevated prior to treatment. In one embodiment, the
mammal may have an
HbAi, level preferably of less than about 8.0 prior to treatment.
[00261] Improved insulin utilization and insulin sensitivity of the patient's
body can be measured
by a statistically significant decline in HOMA (Homeostasis Model Assessment),
and the improved
insulin secretion capacity of the patient's body is measured by Stumvoll first-
phase insulin secretion
capacity index.
[00262] In preferred embodiments of the invention, by virtue of the chronic
administration of oral
dosage forms of the present invention, the patient achieves improved glucose
tolerance and
glycemic control as compared with baseline levels prior to treatment even
without any statistically
significant increase in weight, any statistically significant increase in risk
of hypoglycemia or any
statistically significant increase in risk of hyperinsulinemia in the mammal
over the treatment
period, and without the need for monitoring the mammal's blood glucose
concentrations or HbAi c
levels. Further, by virtue of the chronic administration of oral dosage forms
of the present
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invention, the patient achieves improved insulin utilization, insulin
sensitivity insulin secretion
capacity and HbAlc levels as compared with baseline levels prior to treatment.
[00263] It is preferred that the administration of the oral pharmaceutical
formulation will be about
once daily to about four or more times daily, preprandially and/or at bedtime.
In one embodiment
of the invention, administration of the pharmaceutical formulation takes place
once daily, either at
bedtime or preprandially for one meal during the day time, e.g., for
breakfast, lunch or dinner. In
another embodiment, administration of the pharmaceutical formulation takes
place multiple times
daily, preferably at bedtime and preprandially for one meal during the day
time, e.g., for breakfast,
lunch or dinner. In a further embodiment, administration of the pharmaceutical
formulation takes
place multiple times daily, preferably at bedtime and preprandially for more
than one meal during
the day time. Administration of the pharmaceutical formulation can also be is
at or shortly prior to
bedtime and concurrently with or shortly prior to ingestion of each meal,
i.e., within about 15 ,
minutes or less of ingestion of each meal.
[00264] Preferably, the insulin formulations are administered to such human
patients on a chronic
basis, e.g., for at least about two weeks. The dosage form of the present
invention can be
administered for at least one day, for one week, for two weeks, for longer
periods, for alternating
on-off time periods, or for the life of the patient.
[00265] It is believed that the frequency of administration of the oral
pharmaceutical formulation,
on a daily basis (i.e., how often during one day-night period) and on a
chronic basis (i.e., for how
many days), will depend upon the patient's position along a "diabetes
continuum", i.e., the extent of
the patient's impaired glucose tolerance, the patient's stage of diabetes and
the patient's need for
exogenous glycemic control. This continuum ranges from normal glycemic
control, to simple
impaired glucose tolerance and insulin resistance seen in pre-diabetics or
early stage type 2
diabetics, to failure of insulin production by the pancreas seen in type 1
diabetics and late stage type
2 diabetics. This can also be measured by the patient's HbAi c concentration,
ranging from normal
to elevated levels.
[00266] For example, if the patient has a need for fasting glycemic control,
the oral pharmaceutical
formulation should preferably be administered only at or shortly prior to
bedtime. If the patient has
some need for post-prandial glycemic control, the oral pharmaceutical
formulation should
preferably be administered preprandially for some meals. If the patient has a
need for total post-
prandial glycemic control, the oral pharmaceutical formulation should
preferably be administered
preprandially for all meals. If the patient has a need for comprehensive
glycemic control, the oral
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pharmaceutical formulation should preferably be administered preprandially for
all meals and at or
shortly prior to bedtime.
[00267] Similarly, it is also believed that depending upon the patient's
position along the "diabetes
continuum", the oral insulin formulations of the present invention may be
utilized in combination
therapy, and may also include an additional treatment, either oral or
subcutaneously administered,
such as an anti-diabetic drug or insulin that has rapid action, intermediate
action and/or slow action.
It is believed that, in certain preferred embodiments of the present
invention, the oral dosage forms
described herein can be orally administered as described herein in combination
with an additional
yet separate therapy to treat diabetes or impaired glucose tolerance or to
achieve glucose
homeostasis, such as an additional drug such as sulfonylurea, a biguanide, an
alpha-glucosidase,
insulin delivered via a different pathway (e.g., parenteral insulin), an
insulin sensitizer such as
thiazolidinedione, and/or an insulin secretagogue.
[00268] In alternatively preferred embodiments of the invention, the
additional treatment may
comprise a second form of insulin, so as to provide the patient with two
separate forms of insulin
having different activity rates in order for the regimen to simulate the
biphasic release of insulin in
non-diabetic humans. For example, the oral formulations may include a rapid-
acting form of
insulin so as to provide a first insulin peak that occurs rapidly and is short-
lived, and the fast-acting
effect may be provided by the delivery agent that facilitates the absorption
of insulin from the
gastrointestinal tract. The slow acting form of insulin provides a second
insulin peak that occurs
later but has a longer duration. Such slower acting insulin may be provided by
the same oral
formulation as the rapid-acting insulin or by a separate dosage form that may
be administered orally
or subcutaneously.
[00269] It is further believed that the particular combination therapy and its
frequency of
administration, on a daily basis and on a chronic basis, will depend upon the
patient's position
along the "diabetes continuum". For example, if the patient has a need for
fasting glycemic control,
the oral pharmaceutical formulation should be administered only at or shortly
prior to bedtime. If
the patient has some need for post-prandial glycemic control, the oral
pharmaceutical formulation
should be administered preprandially for meals. If the patient has a need for
basal insulin, as in late
stage type 2 diabetes or type 1 diabetes, the supplemental slow-acting insulin
or anti-diabetic drug
should be administered daily. If the patient has a need for comprehensive
glycemic control, the oral
pharmaceutical formulation should preferably be administered preprandially for
all meals and at or
shortly prior to bedtime in combination with the slow-acting insulin or anti-
diabetic drug.
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[00270] It is also believed that the invention provides a method of achieving
glucose homeostasis
in mammals, comprising orally administering to a mammal a pharmaceutical
formulation
comprising a therapeutically effective amount of insulin or an insulin analog
and a delivery agent in
an amount effective to facilitate the absorption of the insulin from the
gastrointestinal tract It is
preferred that the administration be on a chronic basis, e.g., for at least
two weeks, and be
preprandially and at bedtime such that, after two weeks of treatment, the
mammal achieves
improved glucose tolerance and glycemic control as compared with baseline
levels prior to
treatment.
[00271] It is further believed that the chronic administration of the oral
dosage forms of the present
invention will reduce the incidence and/or severity of systemic
hyperinsulinemia associated with
chronic dosing of insulin or of one or more disease states associated with
chronic dosing of insulin
in a mammal that has impaired glucose tolerance or early stage diabetes.
[00272] The chronic administration of oral dosage forms of the present
invention result in a higher
portal insulin concentration and lower systemic insulin concentration over
time than that obtained
with an equi-effective dose of insulin administered subcutaneously (i.e.,
which provide similar
control of blood glucose levels). Transient peaks in insulin levels that may
occur by virtue of the
oral administration of insulin in accordance with the present invention are
not believed to be
associated with vascular diseases. By virtue of the chronic administration of
oral dosage forms of
the present invention instead of equi-effective subcutaneous doses of insulin,
lower levels of
hyperinsulinemia are obtained, e.g., systemic insulin concentrations are at
least about 20% lower
when compared to a comparably effective subcutaneous dose of insulin.
[00273] The present invention thus provides methods for reducing the incidence
and/or severity of
systemic hyperinsulinemia associated with chronic dosing of insulin, and it is
believed that the
present invention also provides a method for reducing the incidence and/or
severity of one or more
disease states associated with chronic dosing of insulin.
[00274] Such methods also comprise orally administering a therapeutically
effective dose of a
pharmaceutical formulation comprising insulin and a delivery agent that
facilitates the absorption of
the insulin from the gastrointestinal tract, to provide a therapeutically
effective reduction and/or
control in blood glucose concentration and a plasma insulin concentration that
is reduced relative to
the plasma insulin concentration provided by a therapeutically equivalent dose
of subcutaneously
injected insulin. Such methods also achieve a reduction in blood glucose
concentration in human
diabetic patients comparable to a subcutaneous insulin injection in those
patients, while providing a
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lower (e.g., 20% or greater) total exposure of insulin to the peripheral blood
circulation under acute,
sub-acute and chronic conditions as compared to the peripheral blood insulin
exposure achieved via
subcutaneous injection. The determinations of blood or insulin concentration
obtained in patients
who have been administered subcutaneous insulin are well known to those
skilled in the art.
[00275] It is still further believed that the chronic administration of oral
dosage forms of the
present invention to replace the endogenous insulin production in a mammal
with impaired glucose
tolerance or early stage diabetes mellitus will result in prophylactically
sparing the function of the
mammal's 0-cells or will prevent death or dysfunction of the mammal's 0-cells,
and will thereby
provide long-term protection to the mammal from developing overt or insulin
dependent diabetes,
or will delay the onset of overt or insulin dependent diabetes in the mammal.
The rationale for this
belief is as follows.
100276] A two year observational study with SC insulin therapy initiated early
in type 2 diabetic
patients, as reported in Kalfhaus J and Berger M, Insulin Treatment With
Preprandial Injections of
Regular Insulin in Middle-Aged Type 2 Diabetic Patients: A Two Years
Observational Study,
Diabetes Metab, Volume 26, pp. 197-201 (2000), showed that a subcutaneous
insulin treatment
regimen is safe (with a very low incidence of hypoglycemia), and highly
effective in terms of
establishing long-term metabolic control by the preservation of 0-cell
function. Insulin/4-CNAB
may have the potential to show similar or even better results, because, as an
oral therapy, it will be
much more easily accepted by patients.
[00277] The clinical studies with oral insulin in type 2 diabetic patients
reported previously by
Emisphere Technologies, Inc. and herein demonstrated a hypoglycemic effect of
short duration,
probably indicating that the half-life of systemic circulating insulin
provided by oral administration
is short to affect peripheral glucose disposal. It was hypothesized that
orally administered insulin as
set forth herein may, however, due to its portal delivery, have a more
profound effect on hepatic
glucose production, which is responsible for the fasting blood glucose levels.
[00278] In a non-diabetic individual, during times of fasting, such as during
sleeping hours or
between meals, the pancreas is able to store insulin for future use and is
given a rest from secretion.
In a diabetic or insulin resistant patients, the pancreas continues to secrete
insulin without allowing
a proper insulin store to be achieved. It is believed that one of the first
defects of the pancreas in
insulin resistance and type 2 diabetes is this defect in insulin storage.
[00279] In type 2 diabetics, blood glucose levels are often elevated after an
overnight fast,
presumably because of unrestrained glucose production by the liver as a result
of a combination of
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insulin resistance and insufficient insulin secretion, which is the hallmark
of the diabetes disease.
Elevated blood glucose levels can lead to a vicious cycle to perpetuate the
severity of a diabetic's
condition because, if blood glucose concentration is elevated for an extended
period of time, a
corresponding "wear and tear" on the cells in the pancreas that secrete
insulin to regulate blood
glucose levels is possible. It is believed that hyperglycemia is toxic to the
0-cells of the pancreas.
Current literature shows that patients in the United States with type 2
diabetes are being diagnosed
8-10 years after the diabetic process has begun. The current American Diabetes
Association
guideline for diagnosing diabetes is two consecutive fasting blood glucose
levels above 110 mg/dL.
It is believed that, by the time of diagnosis, a diabetic patient has already
lost function of about
50% of his islet cells.
[00280] In insulin resistant and early stage diabetic patients, the first
phase insulin response is lost
or impaired, depending on the stage of the disease. In addition, this lack of
rest by the pancreas,
especially the 0-cells, can cause these cells to become dysfunctional or die
from exhaustion. Thus,
if a treatment were to spare insulin producing cell function, this "rest" to
the cells may provide for
long-term protection to develop overt diabetes.
[00281] In a study reported in International Patent Application No.
PCT/US04/00273 and also
discussed below, it was shown that administration of exogenous insulin at
nighttime had an effect
on hepatic glucose production and hence FBG (free blood glucose), thereby
presumably allowing
the patients' (3-cells to rest and produce less insulin to achieve the same
glycemic level. The
suggested clinical implication is that, if nighttime oral insulin treatment
were to be given alone, it is
likely to spare 0-cell function. This significance is supported by several
reported studies that have
shown that, by intervening "aggressively" with insulin at early stages of the
disease (such as at the
impaired glucose tolerance stage) by giving insulin even for a short time such
as two week duration,
the resulting rest to the 0-cells may provide long term protection from
developing overt diabetes. It
is thus believed that a boost of exogenous insulin at nighttime can also be
useful through the
progression of the diabetes from a healthy state, to a pre-diabetic state and
finally to a diabetic state.
[00282] It is believed that therapy can be initiated at an early stage to
prophylactically spare 0-cell
function and aid in preventing (3-cell death and the progression to overt
diabetes. Many factors may
be taken into account when therapy becomes necessary or desirable including,
but not limited to:
defects in GTT indicating signs of insulin resistance, reactive hypoglycemia,
or early 43-cell
dysfunction, elevated fasting or postprandial blood glucose levels, family
history for diabetes,
obesity, HbAi c above approximately 6.5 or an elevation of HbAi, of more than
about 10% over
patient's past values, even if still within normal ranges. In accordance with
the present invention, it
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is believed that a mammal at this early stage can be treated, prophylactically
sparing 0-cell function,
aiding in preventing 0-cell death and/or the progression to overt diabetes, by
administering one time
daily an effective dose of a pharmaceutical formulation, preferably an oral
formulation, comprising
insulin (as described herein) at nighttime, in the morning or preprandially,
preferably at nighttime or
in the morning. Preferably, the insulin formulation is administeied to such
human patients on a
chronic basis, e.g., for at least about two weeks.
1002031 It is believed that, as the diabetes progresses, the patient may no
longer be able to control
his blood glucose at breakfast, even with the once a day dose as described
above. This progression
can be diagnosed using any method known in the art including but not limited
to noting: further
defects in the MT, elevated fasting or postprandial blood glucose levels,
HbAie above
approximately 6.5 or an elevation of Ai, of more than about 10% over patient's
past values, even
if still within normal ranges, or no noticeable decrease in patients elevated
HbALc as described
above despite treatment. In accordance with the present invention, it is
believed that a mammal at
this early stage of impaired glucose tolerance or early stage diabetes
mellitus can be treated,
prophylactically sparing remaining 0-cell function, aiding in preventing 0-
cell death and/or the
progression to overt diabetes and treating the current level of glycemic
control dysfunction, by
administering an effective dose of a pharmaceutical formulation, preferably an
oral formulation,
twice daily comprising insulin (as described herein) at nighttime, in the
morning and/or
preprandially, preferably at nighttime or morning and preprandially, more
preferably at nighttime
and preprandial for breakfast. Preferably, the insulin formulation is
administered to such human
patients on a chronic basis, e.g., for at least about two weeks.
[00284] Alternatively, it is believed that, even at this stage of impaired
glucose tolerance or early
stage diabetes, the patient can be treated, prophylactically sparing remaining
0-cell function, aiding
in preventing 0-cell death and/or the progression to overt diabetes and
treating the current level of
glycemic control dysfunction, by administering an effective dose of a
pharmaceutical formulation,
preferably an oral formulation, three times daily comprising insulin (as
described herein)
preprandially or postprandially. This treatment regime can be carried through
to later stages of the
diabetes. Preferably, the insulin formulation is administered to such human
patients on a chronic
basis, e.g., for at least about two weeks,
1002051 It is believed that, as the diabetes progresses even further, the
patient may no longer be
able to control his blood glucose at lunch, even with the twice a day dose as
described above. This
progression can be diagnosed using any method 'known in the art including but
not limited to
noting: further defects in the G'TT or defects in a lunchtime GTT, elevated
fasting or postprandial
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blood glucose levels, HbAl, above approximately 6.5 or an elevation of HbAi,
of more than about
10% over patient's past values, even if still within normal ranges, or no
noticeable decrease in
patients elevated HbA.1, as described above despite treatment. In accordance
with the present
invention, it is believed that a mammal at this stage of impaired glucose
tolerance or diabetes
mellitus can be treated, prophylactically sparing remaining function,
aiding in preventing /3-
cell death and/or the progression to overt diabetes and treating the current
level of glycemic control
dysfunction, by administering an effective dose of a pharmaceutical
formulation, preferably an oral
formulation, three times daily comprising insulin (as described herein) at
nighttime, in the morning
and/or preprandially, preferably at nighttime or morning and twice
preprandially, more preferably at
nighttime and preprandial for breakfast and lunch. Preferably, the insulin
formulation is
administered to such human patients on a chronic basis, e.g., for at least
about two weeks.
100286] It is believed that, as the diabetes progresses yet further, the
patient may no longer be able
to control his blood glucose at dinner, even with the three times a day dose
as described above.
This progression can be diagnosed using any method known in the art including
but not limited to
noting: further defects in the G Fl, or defects in a dinnertime GTT, elevated
fasting or postprandial
blood glucose levels, HbAie above 6.5 or an elevation of Hb261.1, of more than
about 10% over
patients past values, even if still within normal ranges, or no noticeable
decrease in patients
elevated HbAic as described above, even with treatment. In accordance with the
present invention,
it is believed that a mammal at this stage of impaired glucose tolerance or
diabetes mellitus can be
treated, prophylactically sparing remaining 0-cell function, and/or aiding in
preventing 0-cell death
and treating the current level of glycemic control dysfunction, by
administering an effective dose of
a pharmaceutical formulation, preferably an oral formulation four times daily
comprising insulin (as
described herein) at nighttime, in the morning and/or preprandially,
preferably at nighttime or
morning and three times preprandially, more preferably at nighttime and
preprandially for breakfast,
lunch and dinner. Preferably, the insulin formulation is administered to such
human patients on a
chronic basis, e.g., for at least about two weeks.
1002871 It is believed that, as the diabetes progresses still further, the
patient may no longer be able
to control his blood glucose endogenously at all, even with the four time a
day dose as described
above. In accordance with the present invention, it is believed that a inammal
at this stage of
diabetes mellitus can be treated, prophylactically sparing any remaining 0-
cell function, and/or
aiding in preventing death and
treating the current level of glycemic control dysfunction, by
administering an effective dose of a pharmaceutical formulation, preferably
oral, comprising long-
acting insulin; and an effective dose of a pharmaceutical formulation,
preferably an oral
formulation, four times daily comprising insulin (as described herein) at
nighttime, in the morning
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and/or preprandially, preferably at nighttime or morning and three times
preprandially, more
preferably at nighttime and preprandially for breakfast, lunch and dinner.
Preferably, the insulin
formulations are administered to such human patients on a chronic basis, e.g.,
for at least about two
weeks.
[002831 It is believed that, if it is determined that the pancreas has ceased
to function, in
accordance with the present invention, a mammal at this stage of diabetes
mellitus can be treated by
administering an effective dose of a pharmaceutical formulation, preferably
oral, comprising long-
acting insulin; and an effective dose of a pharmaceutical formulation,
preferably an oral
formulation, three or four times daily comprising insulin (as described
herein) at nighttime, in the
morning and/or preprandially, preferably nighttime, or in the morning and
three preprandially,
preferably at nighttime and three times preprandially. If three times a day
dosing is chosen, it is
believed that in addition to the long acting formulation described above, an
effective dose of a
pharmaceutical formulation of should be dosed, preferably preprandially.
Preferably, the insulin
formulations are administered to such human patients on a chronic basis, e.g.,
for at least about two
weeks.
[00289) In another embodiment of the invention, a continuum of development of
diabetes is
identified comprising a pre-diabetic stage, an early stage diabetes and late
stage diabetes, and the
invention comprises identifying a patient's stage along the continuum of
development of diabetes.
A preferred embodiment of the invention comprises a method for treating a
patient in accordance
with his/her stage of development of diabetes comprising: identifying a
patient's stage along the
continuum of development of diabetes, devising a course of treatment for that
patient in accordance
with his stage along the continuum of development of diabetes and
administering the treatment to
the patient.
[00290] In order that this invention may be better understood, the following
examples are set forth.
These examples are for the purpose of illustration only and are not to be
construed as limiting the
scope of the invention in any manner.
EXAMPLE 1
Comparison between Oral Insulin and SC Short Acting PosVrandial Blood Glucose
Excursions
[00291] A randomized, 3-period crossover, double-blind, double-dummy study was
conducted in
order to compare the effect (i.e., the postprandial pharrnacokinetic and
pharmacodynamic profiles)
of an oral insulin formulation with that of subcutaneously administered short
acting insulin on
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postprandial blood glucose excursions in type 2 diabetic subjects without any
antidiabetic
medication.
[00292] A primary objective of this study was to compare the effect of an oral
insulin formulation
(300 U insulin combined with 400 mg 4-CNAB in 2 capsules, each capsule
containing 150 U
insulin/200 mg 4-CNAB) with that of 12 U subcutaneous (SC) injected short
acting insulin
[Humaloe injection 100 Um] from Eli Lilly and Company] on postprandial blood
glucose
excursions. The postprandial blood glucose excursions were assessed after a
standardized breakfast
intake.
[00293] Fifteen male subjects between 35 and 70 years old, inclusive, with
type 2 diabetes mellitus
as defined by the American Diabetes Association (1998 Diabetes care, 21: S5-
S19) for more than
one year were chosen. Subjects included in the study had BMI < 36 kg/m2, had
stable glycemic
control (HbAi c < 11%), were off all oral hypoglycemic agents 24 hours prior
to each study dosing
day and off any investigational drug for at least four (4) weeks prior to
Visit 1, refrained from
strenuous physical activity beginning 72 hrs prior to admission and through
the duration of the
study, and were confined to the clinical research unit as required by the
protocol. Subjects
maintained a constant body weight (+/- 2kg).
[00294] All patients received the same oral and SC injection treatments in a
randomized sequence.
At visit 1, each patient was randomized to one of six possible treatment
sequences (see Table 1).
On four separate occasions, patients received one of the four possible
treatments prior to a
standardized breakfast: 300 U oral Insulin/400 mg 4-CNAB (2 capsules, each
capsule containing
150 U Insulin/200 mg 4-CNAB), 150 U oral Insulin/200 mg 4-CNAB (one capsule),
12 U SC short-
acting insulin (Humaloe), and no supplemental insulin (placebo). During the
first three treatment
periods, 300 U oral, 12 U SC and placebo insulin were administered in random
order and under
blinded conditions (double-dummy technique). During the fourth treatment
period, the patients
received 150 U oral insulin in an open fashion. The overall study design is
illustrated in Table 1
below.
Table 1: Overall Study Design
Randomization
4-
Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6
Visit 7 Visit 8*)
Screening Session 1 Session 2 Session
3 Final Screening Session 4 Final
Visit Vise)
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300 U oral insulin.or 12 U SC or ' 150 U
placebo i oral
[00295] *) For all patients, Visits 7 and 8 were combined (i.e., final
examination was performed at
Visit 7, immediately after finishing experimental procedures).
[00296] The SC insulin dose of 12 U was selected to fall within a range
typical for type 2 diabetic
patients. The oral dose of 300 U insulin (in combination with 400 mg 4-CNBA)
had been shown to
be effective in Example 5 above. The oral dose of 150 U insulin (in
combination with 200 mg 4-
CNBA) was chosen to investigate whether or not an effect on hepatic glucose
production could be
achieved also by a lower insulin dose.
[00297] The time point of study drug administration (SC injection: 15 minutes
prior to meal intake;
oral administration: 30 minutes prior to meal intake) was selected in order to
match the PK and PD
properties of the administered insulin formulations with the postprandial rise
of blood glucose. The
wash-out period between the first three treatment sessions was 1-20 days. The
duration of each
session was approximately 8-9 hours, and all experiments were performed after
an overnight fast of
approx. 12 hours.
[00298] At Visit 1 (screening visit), the patients came to the clinical
research unit in a fasted state
(i.e., not having had any caloric intake for at least 12 hours). The patients'
physical statistics,
medical history and social habits recorded, and a physical examination
performed. Not more than
14 days later, at Visit 2, each patient was randomized to one of six treatment
sequences shown in
Table 2 below and received either one of the two active treatments (300 U oral
Insulin/400 mg 4-
CNAB or 12 U short-acting SC insulin) or no supplemental insulin (placebo).
Thirty minutes after
oral and fifteen minutes after SC drug administration, the patients ate a
standardized breakfast, and
postprandial blood glucose concentrations were monitored for six hours. Serial
blood samples were
also collected in regular intervals for measurement of plasma insulin, 4-CNAB,
and C-peptide
concentrations. The study patients were released from the institute at the end
of the treatment
session.
[00299] At Visits 3 and 4, the study patients returned to the clinical unit to
receive the alternative
treatments in conjunction with the test meal according to their treatment
sequence. All
experimental procedures and measurements were identical with those of the
preceding treatment
days. A final examination (Visit 5) was perfonned after Visit 4, preferably
immediately after the
experimental procedures were completed, but no longer than fourteen days after
Visit 4.
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[00300] The patients were invited to attend a fourth treatment session (Visit
7) with a single oral
administration of 150 U Insulin/200 mg 4-CNAB thirty minutes prior to a test
meal. All
experimental procedures and measurements were the same as on the preceding
treatment days.
Patients attended a screening (Visit 6), no more than twenty days prior to the
additional session, as
well as a final examination (Visit 8), preferably immediately after the
experimental procedures of
Visit 7 were completed, but no longer than fourteen days thereafter. Visits 7
and 8 were generally
combined (i.e., for all patients final examination was performed at Visit 7,
immediately after
completion of experimental procedures).
[00301] The patients were randomly assigned to one of the following treatment
sequences:
Table 2: Treatments Administered
Treatment Treatment Period
Sequence 1 (Visit 2) 2 (Visit 3) 3 (Visit 4) 4 (Visit
7)
1 300 U Oral 12 U SC Placebo 150 U Oral
2 300U Oral Placebo 12 U SC 150U Oral
3 12 U SC 300 U Oral Placebo 150 U Oral
4 12 U SC Placebo 300 U Oral 150 U
Oral
Placebo 12 U SC 300 U Oral 150 U Oral
6 Placebo 300 U Oral 12 U SC 150U Oral
[00302] According to the double-dummy technique, each patient received on the
first three
treatment sessions (Visits 2-4), in addition to his scheduled treatment
administration (oral or SC),
the alternative administration (SC or oral) as placebo preparation. On
sessions without
supplemental insulin, both treatments (oral and SC) were placebo preparations.
On the last
treatment session (Visit 7), all patients received in an open fashion one oral
dose of 150 U
Insulin/200 mg 4-CNAB.
[00303] Based on the six sequences shown above, the following treatments were
administered
during the study:
[00304] Sequence 1:
- Visit 2: Two insulin capsules 30 minutes, one SC placebo injection 15
minutes before meal.
- Visit 3: Two placebo capsules 30 minutes, one SC insulin injection 15
minutes before meal
- Visit 4: Two placebo capsules 30 minutes, one SC placebo injection 15
minutes before meal
- Visit 7: One insulin capsule 30 minutes before meal
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[00305] Sequence 2:
- Visit 2: Two insulin capsules 30 minutes, one SC placebo injection 15
minutes before meal.
- Visit 3: Two placebo capsules 30 minutes, one SC placebo injection 15
minutes before meal
- Visit 4: Two placebo capsules 30 minutes, one SC insulin injection 15
minutes before meal
- Visit 7: One insulin capsule 30 minutes before meal
[00306] Sequence 3:
- Visit 2: Two placebo capsules 30 minutes, one SC insulin injection 15
minutes before meal.
- Visit 3: Two insulin capsules 30 minutes, one SC insulin injection 15
minutes before meal
- Visit 4: Two placebo capsules 30 minutes, one SC placebo injection 15
minutes before meal
- Visit 7: One insulin capsule 30 minutes before meal
1003071 Sequence 4:
- Visit 2: Two placebo capsules 30 minutes, one SC insulin injection 15
minutes before meal.
- Visit 3: Two placebo capsules 30 minutes, one SC placebo injection 15
minutes before meal
- Visit 4: Two insulin capsules 30 minutes, one SC placebo injection 15
minutes before meal
- Visit 7: One insulin capsule 30 minutes before meal
[00308] Sequence 5:
- Visit 2: Two placebo capsules 30 minutes, one SC placebo injection 15
minutes before meal.
- Visit 3: Two placebo capsules 30 minutes, one SC insulin injection 15
minutes before meal
- Visit 4: Two insulin capsules 30 minutes, one SC placebo injection 15
minutes before meal
- Visit 7: One insulin capsule 30 minutes before meal
[00309] Sequence 6:
- Visit 2: Two placebo capsules 30 minutes, one SC placebo injection 15
minutes before meal.
- Visit 3: Two insulin capsules 30 minutes, one SC placebo injection 15
minutes before meal
- Visit 4: Two placebo capsules 30 minutes, one SC insulin injection 15
minutes before meal
- Visit 7: One insulin capsule 30 minutes before meal
[00310] The 4-CNAB used for the capsules was manufactured under GMP
compliance. The
Insulin used to prepare the capsules was Zinc-Insulin Crystals Human:
Proinsulin Derived
(Recombinant DNA Origin) US? Quality obtained from Eli Lilly and Company
(Indianapolis, IN).
The hasulin/4-CNAB capsules contained 150 Insulin Units US? and 200 mg 4-CNAB.
The
insulin/4-CNAB capsules were prepared by AAI Pharma Inc., Wilmington NC.
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[00311] Insulin/4-CNAB capsules were provided in HDPE bottles, each of which
contained 40
capsules and a polyester coil. Each bottle had a heat-induction seal and a
child-resistant cap, and
were stored frozen at or less than minus 10 C. On the day of dosing, the
appropriate number of
capsules was removed from the freezer and brought to room temperature (between
15 and 30 C) for
about one hour. Capsules were used within four hours of dispensing, and
unopened bottles were
not left at room temperature for more than four hours.
[003121 The subjects ingested the meal thirty minutes after oral insulin
administration. Blood
glucose concentrations were monitored for six hours after glucose ingestion,
and serial blood
samples were collected in regular intervals for measurement of insulin
concentration, 4-CNAB
concentration, C-peptide, and blood glucose, providing information for
pharmacolcinetic and
pharmacodynamic determinations. Blood glucose concentrations were determined
immediately
after sample collection and documented. All experiments were identical in
their sample collections
and monitoring period for all visits. The experimental procedure after the
meal intake lasted for six
hours (+ 1 hour baseline period for stabilization of blood glucose
concentrations at the desired
preprandial blood glucose level).
[00313] During each treatment session, blood samples were collected for
determination of plasma
concentrations of 4-CNAB, insulin and C-peptide, and for blood glucose
concentration. Sampling
started 1 hour before intake of the test meal and continued until 6 hours
thereafter. Blood samples
were drawn via a venous cannula and collected related to the start of the test
meal at time point 0.
The timing of scheduled samples could be adjusted according to clinical needs
or needs for
pharmacokinetic data. The duration of each session was approximately 8-9
hours. All experiments
were performed after an overnight fast of approximately 12 hours.
[00314] The studies started in the morning. A 17-gauge PTFE catheter was
inserted into an arm
vein for blood sampling for measurement of blood glucose, and for plasma
insulin, 4-CNAB and
C-peptide concentrations. The line was kept patent with 0.15-mon (0.9%)
sterile saline.
[00315] At time-point -15, exogenous insulin was administered by oral insulin
administration or by
subcutaneous injection at two of the three experimental days. At time point 0,
subjects ingested a
standardized breakfast at every study day (visits 2-4 and 7). The oral
treatments (Insulin/4-CNAB
capsules and placebo capsules) were administered 30 minutes, and the
injections (short-acting
insulin and placebo solution) 15 minutes, before start of meal intake. The
pharmacodynamie
response elicited was studied by measurements of blood glucose concentrations
in 5 minute
intervals for another six hours, and no food intake was allowed during this
period, although water
67
CA 02518216 2005-09-06
WO 2004/080401 PCT/11S2004/006943
was consumed as desired.
[00316] Blood samples for blood glucose determination (0.25 mL per sample)
were taken at ¨1
min (baseline), 5 minutes after start of meal intake and thereafter in 5
minute intervals until 120
Minutes, 10 minute intervals until 240 minutes, and 15 minute intervals until
360 minutes after start
of meal intake (45 samples per session). Blood glucose concentrations were
measured immediately
after sample collection using an automated GOD method (Super GL Ambulance
Glucose Analyzer,
Ruhrtal Labortechnik, Delecke-Mohnesee, Germany).
1003171 Blood samples for determination of 4-CNAB plasma concentrations (2 mL
in sodium
heparin tube) were drawn 10, 20, 30, 40, 60, 90, 120, 240 and 360 minutes
after start of meal intake
(9 samples per session). Blood samples for determination of insulin and C-
peptide plasma
concentrations (5 mL in sodium heparin tube) were drawn at -60 and -30
minutes, at time 0 (start of
meal intake), and after 10, 20, 30, 40, 50, 60, 75, 90, 105, 120, 150, 180,
210, 240, 300, and 360
minutes (19 samples per session). Plasma concentrations of insulin were
determined by a GLP-
validated microparticle enzyme immunoassay (MEIA).
[00318] In case of a hypoglycemia (defined as blood glucose concentrations
below 60 mg/di), a
blood glucose concentration of 60 mg/di was maintained by means of a variable-
rate intravenous
infusion of 20% glucose. The glucose infusion rate was adopted, if necessary,
in relation to the
blood glucose concentrations measured to maintain this blood glucose level. In
case of blood
glucose values exceeding 350 mg/di for more than 60 minutes, the experiments
were aborted and
the subject was treated with additional s.c. insulin to normalize his blood
glucose concentrations.
[00319] Blood samples for the determination of plasma concentrations of
insulin, 4-CNAB and
C-peptide were collected at defined intervals, as discussed above. Plasma
samples were stored at
approximately -20 C (4-CNAB at -70 C) until determination by immunoassay is
performed. After
the end of the sampling period, the study subjects were released from the
clinic.
[00320] Inter-subject variability for selected pharmacodynamic and
pharmacoldnetic parameters
was assessed. Incidence of postprandial hypoglycemia was assessed for each
subject and across the
study population.
[00321] Blood glucose excursions (i.e., differences between pre-prandial and
postprandial blood
glucose concentrations) registered after the ingestion of the meal were used
to evaluate
pharmacodynamic parameters of the two insulin administration routes and
compared with the same
data obtained for the study day without any supplemental insulin. From these
measurements, the
68
CA 02518216 2005-09-06
WO 2004/080401 PCT/US2004/006943
area under the glucose infusion rate versus time curve from 0-6 hours (and
other time intervals), the
maximal blood glucose excursion (Cmax) and time to the maximal blood glucose
excursion (tmax)
were analyzed.
[00322] For pharmacodynamic assessment, the following parameters were
calculated: Maximal
blood glucose excursion (BGmax), time to BGmax (tBG max), Area under the blood
glucose excursion
curve in defined time-intervals (AUCBG 0-1 h. AUCBG 0-2h, AUCBG 0-3h, AUCBG
04h, AUCBG 0-6h),
maximal absolute blood glucose concentrations (BGabsma,), time to BGabsm
(tBGabsmax).
[00323] For pharmacokinetic assessment the following parameters were
calculated: Maximal
plasma insulin concentrations (INS,,aõ), time to INSmax (tiNs ), Area under
the glucose infusion
rates in defined time-intervals (AUCths 0-1h, AUChn 0-2b, AUChis 0-3h, AUCins
0-45, AUCihs o-6h) and
maximum reduction of C-peptide concentrations
[00324] Plasma insulin concentrations were subjected to appropriate
pharmacokinetic analyses.
Parameters determined include Cax, tinax, and the area under the plasma
concentration versus time
curve from the time of dosing until a return to the baseline measurement
(AUC04, where t' is the
time that the level of plasma insulin concentration returns to the baseline.
In addition, other
pharmacokinetic parameters, such as tyõ elimination rate constant (2,z) and
partial AUC values, were
calculated, if considered appropriate, for each individual subject enrolled
within the study.
Pharmacodynamics
[003251 As measurement of a pharrnacodynamic effect of oral Insulin/4-CNAB
capsules, the blood
glucose excursions measured over 6 hours were considered, and the area under
the blood glucose
excursion vs. time curve in the first two hours after start of meal intake
(AUC0_25) was defined as
primary pharmacodynamic endpoint.
[00326] From the blood samples taken, the individual blood glucose
concentrations were
determined, and summary concentration vs. time tables were prepared and
profiles were plotted, as
set forth in Tables 3-20 below.
69
CA 0251 821 6 2005-0 9-0 6
WO 2004/080401
PCT/US2004/006943
TABLE 3:
Patient Number 101
Treatment
Time
(min) Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting
insulin .
Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
glucose excursion glucose excursion glucose excursion glucose excursion
(m/dl) (mold1) (m/dl) (mold1) (mq/d1) (moidll ,
(m9/d1) (m/dl)
-120 NA NA NA
-105 NA NA NA .,
-90 NA NA _ NA
_
-75 NA NA NA .
-60 134 149 140
-45 .., 135 152 141
-30 130 . 150 144
-16 124 146 139
-1 127 0 144 0 140 0
126 -1 144 0 134 -6
123 -4 141 -3 116 -24
121 -6 142 , -2 138 -2
127 0 148 4 136 -4
129 2 158 14 145 5
, =i
139 12 164 20 166 26
140 13 169 25 171 31
, 40 150 23 179 35 183 43
_
153 26 179 35 198 58 _
163 36 184 , 40 , 195 55
170 43 185 41 209 69
178 51 186 42 206 66
185 58 193 49 211 71
49 222 82
_
204 77 193 . . .
215 88 197 53 223 83
218 91 213 69 225 85
221 94 210 66 224 84
225 98 210 66 222 82
r ,
225 98 204 60 229 89
100 231 104 211 67 231 91
_
105 231 1104 209 65 214 74
¨ _
110 229 102 199 55 231 91
_
115 226 99 202 58 223 83
' 120 215 , 88 208 64 204 64
130 207 80 201 57 202 62
140 211 84 182 _ 38 192 52
150 , 208 81 173 29 '175 35
160 188 61 164 20 177 37
170 176 49 153 9 165 25
180 169 42 141 -3 169 29 _
190 157 30 126 -18 154 14 .
200 148 21 130 -14 162 22
210 142 15 117 -27 155 15
220 141 14 116 -28 160 20
230 141 14 114 -30 159 19
240 134 7 105 -39 155 15
255 132 5 101 -43 135 -5 _
270 131 4 95 -49 131 -9
285 117 -10 91.7 -52.3 128 -12
,
300 118 -9 86.1 -57.9 123 -17
_ 315 105 -22 83.6 -60.4 114 -26
330 105 -22 . 83 -61 118 -22 _
345 101 -26 78.3 -65.7 113 -27
0 360 99.9 -27.1 83.8 -60.2 110 -30
CA 0251 821 6 2005-0 9-0 6
WO 2004/080401 PCT/US2004/006943
TABLE 4:
Patient Number 102
Treatment
Time
(min) Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
glucose excursion glucose excursion glucose excursion glucose e2:.curzion
(mg/dl) (mak11) (mp/d1) (mg/dI) (maid I) (mg/d1)
(timid I) (mq/d1)
-120 NA NA NA
-105 NA NA NA
-90 NA NA NA
-75 NA _ NA NA
-60 135 _ 149 164
-45 147 157 181
-30 139 _ 161 169
-16 _ 144 _ 164 177
-1 146 0 151 0 172 0
_ _
5- 157 11 157 6 177 5
_ -
154 _ 8 155 4 178 6
152 _ 6 158 7 180 8
154 8 167 16 167 -5
_
159 13 164 _ 13 174 2
175 29 160 9, 184 12
182 36 179 28 184 12
191 45 184 33 199 27
_
206 60 167 16 208 36
_
202 56 177 26 217 45
, 209 _ 63 175 24 223 51 .
217 71 168 17 234 62
239 , 93 188 37 252 80
247 101 188 37 239 67
241 95 194 43 260 88
246 100 194 43 279 107
249 103 213 62 271 99
255 109 196 45 255 83
253 107 211 60 275 103
100 261 115 197 46 256 84
105 258 112 214 63 279 107
110 276 130 209 58 264 92
,
115 270 124 201 50 270 98
120 275 129 198 47 270 98
130 265 119 199 48 281 109
140 266 120 190 39 295 123
150 271 , 125 186 35 254 82
, 160 252 , 106 194 , 43 275 103
170 254 , 108 188 37 259 87
180 249 103 184 33 251 79
190 243 97 172 21 252 80
200 ' 247 101 171 20 247 75
210 243 97, 180 29 248 76
220 244 98 170 19 227 55
230 245 99 170 19 231 59
240 233 87 163 12 226 54
255 225 79 162 11 222 50
270 218 72 153 9 223 51
285 219 73 _ 158 7 212 40
300 213 67 147 -44 219 40
315 210 64 129 -22 205 33
330 210 64 145 -6 196 24
345 204 58 105 -46 199 97
360 I 199 53 130 -21 1 204 1 32 I
71
CA 02518216 2005-09-06
WO 2004/080401 PCTALIS2004/006943
TABLE 5:
Patient Number 103
Treatment
Time
(min) Oral 150 U Insulin/ Oral 300 U Insulin/ Sc 12 U
Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
glucose excursion glucose eneursion glucose eneursion glucose e;-.cursion
(mg/d1) (mci/dl) (mg/d1) (m/d11 (mg/d1) (rno/d11
(rno/d1) (mo/d1)
-120 NA NA NA NA
-105 NA NA NA NA
-90 NA NA NA NA
-75 NA NA NA NA
-60 162 172 177 170
-45 144 . 177 175 167
-30 146 174 179 165
-16 139 162 166 164
-1 137 0 169 0 162 0 160 0
135 -7 167 -2 166 4 159 -1
135 -2 165 -4 159 -3 159 -1
137 0 161 -8 164 2 160 0
150 13 166 -3 159 -3 167 7
. 25 161 24 170 1 175 13 174 14
180 43 168 -1 179 17 188 28
172 35 186 17 184 22 188 28
187 50 198 29 188 26 202 42
190 53 203 34 190 , 28 201 41
216 79 203 34 194 32 209 49
207 70 214 45 199 37 215 55
218 81 219 50 200 38 214 54
223 86 224 55 201 39 203 43
222 85 228 59 209 47 225 65
216 79 205 36 205 43 226 66
229 92 229 60 204 42 214 54
228 91 233 64 196 34 217 57 ..
226 89 250 81 193 31 214 54
238 101 246 77 190 28 219 59
100 227 90 244 75 189 27 209 49
105 235 98 248 79 186 24 217 57
110 233 96 231 62 179 17 216 56
115 220 83 249 80 172 10 222 62
120 225 88 254 85 172 10 214 54
130 204 67 245 76 157 -5 217 57
140 215 78 249 80 156 -6 216 56
150 215 78 246 77 146 -16 199 39
160 222 85 248 79 151 -11 194 34
170 220 83 257 88 147 -15 200 40
180 212 75 250 81 144 -18 199 39
190 204 67 248 79 144 -18 192 32
200 193 56 235 66 145 -17 188 28
210 168 31 240 71 129 -33 187 27
220 188 51 205 36 127 -35 188 28
230 189 52 222 53 116 -46 181 21
240 178 41 217 48 112 -50 185 25
255 189 52 204 35 112 -50 175 15
270 151 14 192 23 106 -54 163 3
285 142 5 181 12 106 -56 157 -3
300 135 -2 178 9 101 -61 155 -5
315 135 -2 170 1 101 -61 148 -12
330 122 -15 161 -8 99.8 -62.2 140 -20
345 111 -26 164 -5 96.6 -65.4 136 -24
360 104 -33 157 -12 ( 92.8 -69.2 136 -24 I
72
CA 0251 821 6 2005-0 9-0 6
WO 2004/080401 PCT/US2004/006943
TABLE 6:
Patient Number 104
Treatment
Time
(min) Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Placebo
200 mg 4-CNAB 400 mg 4-CMAB Short-acting insulin ,
Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
glucose excursion glucose 8NCUrzion glucose iwzcursion glucose c;[cursion
(mp/d1) (inci/d1) (iug/d1) (mci/d1) (mo/dh (mpidh_
(ma/d1) (muidl)
-120 NA NA NA NA
-105 NA NA NA NA
-90 NA NA NA NA
-75 NA NA NA NA
-60 164 166 149 184
-45 164 137 135 180
-30 165 177 139 178
-16 163 135 168 185
-1 164 0 157 0 , 173 0 183 0
-
161 -3 154 -3 182 9 172 -11
,
161 -3 , 151 -6 178 5 173 -10
159 -5 118 -39 190 17 169 -14
164 0 150 -7 195 22 192 9
163 -1 163 6 193 , 20 202 19
170 6 164 7 208 35 213 30
177 13 171 14 208 35 214 31
179 15 176 19 214 41 220 37
185 21 184 27 218 45 224 41
196 32 195 38 193 20 235 52
189 25 207 50 211 38 251 68
203 39 224 67 213 40 229 46
206 42 214 57 216 43 262 79
211 47 228 71 213 40 267 84
223 59 240 83 198 25 267 84
232 68 220 63 210 37 267 84
220 56 238 , 81 207 34 263 80
212 48 248 91 198 25 271 88
213 49 242 85 189 16 282 99
100 218 54 265 108 191 18 284 101
105 205 41 250 93 183 10 259 76
110 207 43 253 96 194 21 276 93
115 208 44 246 89 188 15 281 98
120 207 43 244 87 188 15 256 73
130 204 40 238 81 179 6 240 57
140 209 45 250 93 185 12 228 45
150 220 56 249 92 164 -9 239 56
160 220 56 241 84 165 -8 252 69
170 216 52 246 89 153 -20 251 68
180 220 56 218 61 145 -28 252 69
190 225 61 228 71 152 -21 256 73
200 228 64 213 56 162 -11 268 85
210 224 60 203 46 160 -13 264 81
, 220 230 66 217 60 155 -18 237 -- 54
230 218 54 218 61 151 -22 271 88
240 226 62 211 54 150 -23 252 69
255 227 63 195 38 138 -35 234 51
270 215 51 196 39 135 -38 227 44
285 218 54 176 19 128 -45 225 42
300 213 49 175 18 131 -42 218 35
_ 315 206 42 171 14 132 -41 195 12
330 200 36 160 3 129 -44 201 18
345 188 24 159 2 133 -40 195 19
360 172 8 156 -1 130 -43 184 1 I
73
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TABLE 7:
Patient Number 105
Treatment
Time
(min) Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
Placebo
200 mg 4-C NAB 400 mg 4-CNAB Short-acting
insulin .
Blood Postprandia Blood Postprandia Blood Postprandia Blood Postprandia
glucose I e2:cursion glucose i e:mursion glucose I e:xursion glucose I
eNcursion
(mq/d1) (mg/d1) (m/dl) (mo/dI) (mg/d1) (mo/dI)
(rrap/d1) (mg/d1)
-120 NA NA NA NA
-105 NA NA , NA NA
-90 NA NA NA NA
-75 NA NA NA NA
-60 131 114 , 111 125
-45 111 108 112 _ 114 .
-30 116 109 110 98.6 ,
-16 109 106 105 84.2
-1 99.1 0 107 0 106 0 93.1 , 0
95.5 -3.6 105 µ -2 102 -4 96.1 3
96.8 -2.3 99.9 -7.1 99.7 -6.3 95.2 2.1
108 8.9 92.1 -14.9 104 -2 92.8 -0.3
111 11.9 112 5 107 1 99.6 õ 6.5
137 37.9 107 o 120 14 118 24.9
149 49.9 118 11 119 , 13 120 26.9
157 57.9 120 13 120 14 119 25.9
156 56.9 126 19 133 27 117 23.9
176 76.9 119 12 130 24 102 8.9
178 78.9 136 29 133 27 144 50.9
184 84.9 119 12 126 20 151 57.9
186 86.9 133 26 137 31 160 66.9
179 79.9 133 26 138 32 160 66.9
182 82.9 157 50 140 34 147 53.9
185 85.9 155 48 138 32 161 67.9
190 90.9 156 49 130 24 162 68.9
178 78.9 167 60 141 35 , 147 53.9
181 81.9 154 47 134 28 161 67.9
164 64.9 155 48 147 41 159 65.9
100 162 62.9 156 49 146 40 161 67.9
105 152 52.9 168 61 147 41 159 65.9
110 139 39.9 168 61 139 33 165 71.9
115 133 33.9 168 61 138 32 158 64.9
120 120 20.9 178 71 148 42 157 63.9
130 112 12.9 171 64 132 26 156 62.9
140 106 6.9 159 52 137 31 159 65.9
150 , 97.3 -1.8 153 46 135 29 158 64.9
160 102 2.9 146 39 117 11 143 49.9
170 101 1.9 147 40 119 13 145 51.9
180 109 9.9 143 36 108 2 132 38.9
190 116 16.9 138 31 93.7 -12.3 132 38.9
200 113 13.9 127 20 85.1 -20.9 127 33.9
210 108 8.9 132 25 77.6 -28.4 119 25.9
220 109 9.9 132 25 70.3 -35.7 117 23.9
230 101 1.9 113 6 67.4 -38.6 109 15.9
240 90.6 -8.5 110 3 62.5 -43.5 102 8.9
255 79.6 -19.5 123 16 64.5 -41.5 94.1 1
270 75 -24.1 95.7 -11.3 68.3 -37,7 92.9 -0.2
285 71.4 -27.7 81.1 -25.9 72.8 -33.2 82.3 -10.8
300 70.9 -28.2 87.9 -19.1 66.9 -39.1 76.2 -16.9
315 68 -31.1 85.4 -21.6 67.6 -38.4 74.1 -19
330 68.7 -30.4 80.4 -26.6 66.9 -39.1 69.2 -23.9
345 68.9 -30.2 74.5 -32.5 73.7 -32.3 69.9 -23.2
360 69.1 -30 80.4 -26.6 72.5 -33.5 71 I -22.1
74
CA 02518216 2005-09-06
WO 2004/080401 PCT/US2004/006943
TABLE 8:
Patient Number 106
Time Treatment
(mm)
Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
(pmo1/1) _ (nmo1/1) (pmo1/1) (nmo1/1) , (pmo1/1) ,
(nmoUl) (pmo1/1) (nmo1/11
-60 65 0.82 42 0.71 24 0.51 24 . 0.69
-30 55 0.86 , 30 0.74 19 0.49 24 0.58
0 62 0.71 48 0.61 26 0.55 32 0.66
46 0.75 48 ' 0.66 38 0.61 39 0.68
38 0.76 27 0.58 52 0.75 71 0.81
_
82 _ 0.88 33 0.57 69 0.76 90 0.93 _
106 1.00 49 0.68 39 0.74 122 1.12
123 1.33 55 0.74 63 0.77 136 1.32
118 1.39 78 0.82 58 0.72 130 1.63
75 94 _ 1.44 53 0.77 BLQ* 0.51* 155 1.76
90 127 _ 1.42 121 1.22 BLQ 0.43" 173 1.96
105 123 , 1.90 62 1.05 BLQ , 0.34 166 2.30
120 140 2.10 73 1.09 _ 13 0.32 159 2.40
150 155 , 2.30 88 , 1.36 17 0.35 97 1.91
180 121 _ 2.50 146 1.58 26 0.46 108 1.73 _
210 84 1.98 135 2.10 12* , 944* 104 1.75
240 112 2.00 137 2.20 31 0.50 90 1.90
300 87 1.68 51 1.30 _ BLQ" 0.41* 22 0.84 ,
360 35 0.88 30 0.70 131-0 0.31 18 0.57
TABLE 9:
Patient Number 107
Treatment
Time
(min) Oral 150 U Insulin/ Oral 300 U insulin/ SC 12 U Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin ..
Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
glucose excursion glucose excursion glucose excursion glucose excursion
(mg/di) (mg/d1) (mg/di) (mg/di) (mg/di) (mg/di) (mg/dl)
(mg/d1)
-120 NA NA NA NA
-105 NA NA , NA NA
-90 , NA .NA NA NA
-75 NA NA NA NA ,
_
-60 145 140 147 139 .
-45 , 145 136 154 138
_
-30 142 151 , 147 141
-16 129 141 145 136
_
-1 123 0 130, 0 140 0 128 0
5 120 -3 125 -5 141 1 131 3
10 114 -9 140 10 139 -1 128 " 0
15 114 -9 136 , 6 141 1 124 -4
20 119 -4 142 12 141 1 126 -2
25 140 17 144, 14 147 7 127 -1
30 141 18 156 26 152 12 140 12
35 151 28 162 32 159 19 142 14
40 155 32 164 34 149 9 152 24
45 163 40 164 34 154 14 _ 164 36
50 166 43 179 42 156 18 165 37
55 174 51 167 37 154 14 170 42
60 174 51 170 40 160 20 171 43
176 53 171 41 164 24 176 48
_ 186 63 172 42 168 28 , 173 45
183 60 188 58 164, 24 187 59
BO 175 52 167 57 162 22 184 56
CA 02518216 2005-09-06
WO 2004/080401
PCT/US2004/006943
85 181 , 58 175 45 169 29 184 56
90 181 58 197 , 67 170 30 185 57
95 179 56 189 59 166 26 185 57
-
100 174 51 180 50 169 29 184 56
. 105 176 53 192 62 165 25 , 183 55
110 175 59 187 57 165 25 180 52
¨
115 175 52 183 53 . 167 27 183 55
_
120 182 59 189 59 160 20 _ 185 57
130 178 55 181 , 51 154 14 186 58
140 167 44 183 , 53 157 17 182 54
150 156 33 190 60 141 1 174 46
160 152 29 182 52 133 -7 170 42
170 _ 148 25 173 43 , 130 -10 170 42
_
180 149 26 169 39 128 _ -12 170 42
190 146 23 162 32 121 -19 170 42
200 149 26 150 20 120 _ -20 168 40
210 146 23 137 7 115 -25 162 34
220 -141 18 197
_ - -3 112 -28 155 27
_
230 147 24 140 10 107 -33 149 21
240 140 17 126 -4 102 -38 147 19
_
255 139 16 113 -17 101 -39 135 7
270 138 15 115 -15 98.6 -41.4 120 -8
285 136 13 106 -24 97.9 -421 111 -17
_
300 127 4 102 -28 99.2 -40.8 104 -24
315 120 -3 97 -33 100 -40 98.3 -29.7
330 117 -6 100 -30 98.8 -41.2 94.4 -33.6
345 111 -12 99.5 -30.5 101 -39 95.5 -32.5
360 108 -15 88.5 -41.5 95.8 -44.2 92.1 -35.9
TABLE 10:
Patient Number 108
Treatment
Time ___________________________________________________________
(min) Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
glucose excursion glucose excursion glucose excursion glucose excursion
(mg/di) (mg/d1) (mg/di) (mg/dl) , (mg/d1) (mg/di) _
(mg/di) (mg/di)
-120 NA NA NA NA
-105 NA NA NA NA .
-90 , NA NA NA NA ,
-75 NA NA NA NA
-60 150 148 150 162
_ _ -
-45 146 148 154 163
_
-30 147 147 151 156
¨
-16 154 . 151 151 158
-1 144 0 129 0 147 0 150 0
142 -2 122 -7 151 4 151 1
139 -5 123 -6 148 , 1 152 2
142 -2 118 -11 146 -1 151 1
164 20 119 -10 148 1 158 8
170 26 113 -16 155 8 r 179 29
200 56 133 4 166 19 200 50
205 61 137 8 172 25 210 _ 60
, 212 68 168 39 177 30 227 77
213 69 179 50 184 37 221 71
223 79 196 67 184 37 219 69
215 71 189 60 186 39 219 69
222 78 200 71 194 47 238 88
231 87 197 68 194 47 242 92
238 94 207 78 209 62 239 89
238 94 214 85 219 72 256 106
256 112 214 85 213 66 257 107
262 118 222 93 220 73 244 94
76
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WO 2004/080401 PCT1US2004/0069-13
90 268 124 211 82 222 75 _ 252 102
95 277 133 208 79 228 81 256 106
100 273 129 223 94 219 72 251 101
105 280 136 228 99 226 79 249 99
110 281 137 220 _ 91 222 75 246 96
115 277 133 212 83 226 79 244 94
120 270 126 214 85 231 84 , 241 91
130 284 140 208 79 220 73 244 94
140 294 150 213 84 227 80 241 91
150 298 154 214 85 235 88 255 105
160 252 108 225 96 231 84 264 114
170 293 _ 149 227 98 233 86 257 107
180 286 142 214 85 224 77 252 102
190 281 137 211 82 232 85 252 102
. 200 288 144 213 84 234 87 255 105
210 270 126 204 75 232 85 230 80
220 254 110 198 69 _ 219 72 234 84
_
230 244 100 193 64 212 65 218 68
240 236 92 184 55 _ 202 55 208 58
255 225 81 172 43 197 50 198 48
270 212 68 171 42 158 11 195 45
285 207 63 161 32 149 2 179 29
300 189 45 153 24 141 -6 170 20
315 178 34 147 18 128 -19 159 9
330 168 24 139 10 123 -24 152 2
345 158 14 133 4 113 -34 142 -8
360 140 -4 121 -8 103 -44 134 -16
TABLE 11:
Patient Number 109
Treatment
lime
(min) Oral 150 U Insulin/ Oral 300 U Insulin/ Sc 12 U
Placebo
200 mg 4-C NAB 400 mg 4-CNAB Short-acting insulin
Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
glucose excursion glucose excursion glucose excursion glucose excursion
(mgfc11) (mg/di) (mg/di) (mg/di) (mg/di) (mg/di)
(mg/d1) (mg/dl)
-120 NA NA NA NA
-105 NA NA NA NA
-90 NA NA NA NA _
-75 NA NA NA NA
-60 171 187 171 179
_ -45 182 195 171 179
-30 176 193 170 169
-16 172 185 168 177
-1 172 0 175 0 166 0 173 0
170 -2 170 -5 170 4 171 -2
_ 10 171 -1 170 -5 166 0 171 -2
174 2 171 -4 165 -1 171 -2
187 15 164 -11 179 13 177 4
195 23 180 5 188 22 186 13
206 34 190 15 201 35 199 26
210 38 193 18 209 43 202 29
234 62 202 27 216 50 220 47
237 65 211 36 208 42 221 48
239 67 213 38 211 45 225 52
246 74 196 21 200 34 227 54
258 86 208 33 213 47 233 60
255 83 199 24 220 54 247 74
256 84 221 46 223 57 249 76
256 84 232 57 226 60 243 70
258 86 233 58 227 61 239 66
266 94 241 66 226 60 226 53
266 94 230 55 217 51 230 57
77
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WO 2004/080401 PCT/US2004/006943
95 273 101 245 70 220 54 228 , 55
100 275 103 252 77 218 52 236 63 -
105 280 108 256 81 206 _ 40 233 60
. -
110 275 103 262 87 184 18 242 69
-
115 264 92 249 74 189 23 235 62
120 262 90 240 65 191 25 225 52
-
130 250 78 247 72 195 29 228 55 ,
140 256 84 251 _ 76 196 30 219 46
150 253 81 267 92 _ 195 99 213 40
160 253 81 267 92 187 21 924 51
-
170 244 72 268 93 188 92 , 211 38
180 257 85 265 90 190 94 206 33
190 267 95 262 87 171 5 195 22
200 273 101 256 81 166 0 197 24
210 285 113 239 64 173 7 189 16
H220 280 108 245 70 148 -18 185 12
230 268 96 234 59 153 -13 178 5
240 255 83 232 57 148 -18 177 4
_ 255 246 74 211 36 135 -31 164 -9
270 232 60 231 56 132 -34 154 -19 _
285 224 52 222 47 131 -35 153 -20
300 219 _ 47 225 50 118 -48 146 -27
-
315 214 42 222 47 117 -49 143 -30
330 192 20 212 37 111 -55 137 -36
345 189 17 211 36 111 -55 127 -46
360 181 9 210 35 107 -59 119 -54
TABLE 12:
Patient Number 110
Treatment
Time
(min) Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
Placebo
200 mg 4-CNAB 400 mg 4CNAB Short-acting insulin
Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
glucose excursion glucose excursion glucose excursion glucose excursion
(mg1d1) (mg/d1) (mgidl) (mg/dl y (mg/di) (mg/di) (mg/di)
(mg/di)
-120 NA NA NA , NA
-105 NA NA NA NA
-90 NA NA NA NA
-75 NA NA NA NA
-60 142 142 151 141 _
¨
-45 141 , 138 148 141
-30 143 _ 141 117 143
-16 136 140 144 141
-1 131 0 121 0 141 0 139 0
128 -3 84.8 -36.2 133 -8 135 -4
135 4 80 -41 129 -12 134 -5
138 7 68.8 -52.2 132 , -9 144 5
144 13 79.2 -41.8 134 -7 150 11
149 18 73.9 -47.1 145 4 162 23
154 23 75.8 -45.2 147 6 176 37
149 18 73.9 -47.1 147 6 181 42
158 27 80 -41 145 4 191 52
156 25 87.3 -33.7 146 5 191 52
168 37 88.4 -32.6 , 151 10 188 49
162 31 93.5 -27.5 144 3 189 50 _
164 33 113 -8 151 10 190 51
F 65 156 25 110 -11 156 15 186 47
160 29 120 -1 155 14 189 50
_
169 38 130 9 156 15 194 55
165 34 135 14 161 20 199 60 _
170 39 142 21 164 23 199 60
170 39 142 21 158 17 196 57
176 45 139 18 156 15 197 58
78
CA 0251 821 6 2 005-0 9-0 6
WO 2004/080401 PCT/US2004/006943
100 171 40 139 18 161 e-
20 191 _ 52
105 176 45 137 16 155 14 196 , 57 _
110 185 54 137 16 159 18 185 46
,
,
115 172 41 _ 142 21 136 -5 189 50
120 180 49 ' 143 22 135 -6 197 58
130 186 55 151 30 144 3 , 188 49
140 186 55 138 17 119 -22 188 49 .
150 191 60 144 23 116 -25 180 41
160 181 50 142 21 113 -28 , 170 31
170 186 55 145 24 102 -39 159 20
180 183 59 146 25 104 -37 158 19
190 181 50 148 27 95.9 -45.1 , 160 21
200 177 46 139 18 90.1 -50.9 158 19
210 171 40 139 18 83.4 -57.6 153 14
220 154 23 134 13 , 83.8 -57.2 146 7
230 130 -1 127 6 , 81.8 -59.2 142 3 .
240 126 -5 126 5 82.4 -58.6 137 -2
255 127 -4 111 -10 78.9 -62.1 133 -6
270 122 -9 109 -12 78.8 -62.2 129 -10
285 122 -9 103 -18 80.9 -60.1 124 -15
300 130 -1 99 -22 79 -62 , 120 -19
315 124 -7 99 -22 79.9 -61.1 117 -22
330 123 -8 97 -24 77.7 -63.3 115 -24
345 113 -18 96 -25 79.7 -61.3 109 -30
360 104 -27 92.1 -28.9 80.4 -60.6 104 -35 .
TABLE 13:
Patient Number 111
Treatment
Time
(min) Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
glucose excursion glucose excursion glucose excursion glucose excursion
(mg/di) (mg/d1) (mg1d1) (mg/d1) (mg/d1) (mg/d1)
(ing/d1) (mg/d1)
-120 NA NA NA , NA
-105 NA NA NA NA
-90 NA NA NA NA
-75 NA NA NA NA
-60 109 110 134 129
-45 117 113 132 127
-30 118 , , 112 142 127
-16 122 120 141 126
-1 106 0 109 0 138 0 118 0
112 6 96.2 -12.8 138 0 , 127 9
124 18 90.5 -18.5 138 0 128 10
108 2 80.6 -28.4 135 -3 _ 127 9
108 2 92.1 -16.9 138 . 0 _ 136 _ 18
114 8 106 -3 149 11 _ 142 24
119 13 110 1 147 9_ 144 _ 26
121 15 127 18 161 23 NA
129 23 120 11 165 27 160 42
154 48 144 35 174 T 36 165 47
_ -
144 38 146 37 166 28 168 50
, 147 41 134 25 181 43 18.3 65
156 50 157 48 137 -1 183 65
154 48 161 52 155 17 176 58
-
146 40 154 45 165 , 27 183 _ 65
153 47 161 52 165 27 191 73
150 44 147 38 150 12 184 66
160 54 159 50 147 9 183 _ 65
152 46 142 33 135 -3 191 73 _
, 153 47 160 51 119 _
-19 189 71
100 153 , 47 146 37 142 4 194 76
79
CA 02518216 2005-09-06
WO 2004/080401 PCT/US2004/006943
105 150 44 149 40 133 -5 195 77
110 151 , 45 143 ,. 34 147 9 191 73
115 160 54 137 28 134 -4 , 188 70
120 160 54 146 37 77.6 -60.4 180 62
130 163 57 145 36 117 -21 , 176 58
140 155 49 134 25 131 -7 167 49
- _
150 164 58 143 34 134 -4 183 65
160 152 46 151 42 , 135 -3 176 58 -
170 156 50 129 20 145 7 165 47
180 149 43 118 9 152 14 183 65
190 154 48 153 44 147 9 154 36
200 147 41 148 39 145 7 154 36
210 139 33 148 39 152 14 161 43
220 138 32 137 28 142 4 145 27
230 133 27 150 41 119 -19 130 12
240 142 36 152 43 144 6 131 13
255 147 41 133 24 138 0 121 3
270 133 27 122 13 118 -20 118 0
285 134 28 124 15 112 -26 111 -7
300 121 15 118 , 9 108 -30 114 -4
315 96.7 -9.3 120 11 99.6 -38.4 108 -10
330 110 4 111 2 97.4 -40.6 107 -11
345 107 1 107 -2 95.1 -42.9 106 -12
360 105 -1 108 -1 91.6 -46.4 105 -13
TABLE 14:
Patient Number 112
Treatment
Time
(min) Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
glucose excursion glucose excursion glucose excursion glucose excursion
(mg/di) (mg/di) (mg/di) (mg/di) (mg/dl) (mg/di) (mg/d1)
(mg/di)
-120 NA NA NA NA
-105 NA NA NA NA
_
-90 NA NA NA NA
-75 NA NA NA NA
-60 108 112 120 117
-45 108 108 117 116
-30 92.6 111 , 117 116
-16 101 105 109 112
-1 99.3 0 86.6 0 104 0 110 0
96.7 -2.6 76.6 -10 , 106 2 107 -3
96.7 -2.6 74.3 -12.3 103 -1 107 -3
98.4 -0.9 60.1 -26.5 101 -3 111 1
93.3 -6 81.1 -5.5 98 -6 120 10
96 -3.3 84.6 -2 101 -3 128 18
103 3.7 84.9 -1.7 109 5 132 22
109 9.7 95 8.4 111 7 134 24
108 8.7 99.1 12.5 109 5 141 31
118 18.7 106 19.4 107 3 138 28
125 25.7 101 14.4 112 8 137 27
129 29.7 107 20.4 100 -4 137 27
137 37.7 107 20.4 NA 144 34
140 40.7 111 24.4 117 13 144 34
143 43.7 116 29.4 108 4 137 27
146 46.7 120 33.4 109 5 i 37 27
151 51.7 121 34.4 102 -2 144 34
147 47.7 120 33.4 99.9 -4.1 137 97
143 43.7 132 45.4 104 0 136 26
,.
139 39.7 133 46.4 105 1 140 30
100 143 43.7 129 42.4 112 8 141 31
105 147 47.7 134 47.4 110 6 138 28
CA 02518216 2005-09-06
WO 2004/080401 PCT/US2004/006943
110 148 48.7 127 40.4 105 1 143 33
115 145 45.7 125 38.4 110 6 141 31
120 141 41.7_ 13B 51.4 108 4 141 31
130 139 39.7 130 43.4 99.2 -4.8 136 26
140 134 34.7 121 34.4 96.2 -7.8 144 34
150 124 24.7 119 32.4 100 4 147 37
160 91 -8.3 129 42.4 87.6 -16.4 143 33
170 90.3 -9 129 42.4 92.9 -11.1 114 4
180 96.8 -2.5 143 56.4 83.5 -20.5 111 1
190 96.6 -2.7 139 52.4 85.7 -18.3 113 3
200 100 0.7 126 39.4 86.1 -17.9 124 14
210 88.9 -10.4 108 21.4 84.1 -19.9 119 9
220 96.6 -2.7 111 24.4 87.7 -16.3 120 10
, 230 96.7 -2.6 118 31.4 96.1 -7.9 120 10
240 97.3 -2 121 34.4 101 -3 120 10
255 90.4 -8.9 115 28.4 104 0 110 0
270 86.2 -13.1 109 22.4 102 -2 109 -1
285 , 79.4, -i 9.9 111 24,4 102 -2 , 96.2 -13.8
300 75.3 -24 , 105 18.4 97.9 -6.1 96.5 -13.5
315 72.1 -27.2 105 18.4 93.6 -10.4 94.8 -15.2
330 81.4 -17.9 103 16.4 87.7 -16.3 91.8 -18.2
345 83.7 -15.6 101 14.4 84.1 -19.9 85.9 -24.1
360 78.8 -20.5 95.6 9 82.6 -21.4 82.7 -27.3
TABLE 15:
Patient Number 113
Treatment
Time
(min) Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
Placebo
200 m9 4-CNAB 400 mg 4-CNAB Short-acting insulin
Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
glucose excursion glucose excursion glucose excursion glucose excursion
.
(m gld1) (mg/dl) (mgfdl) (mg/di) (mgfdl) (mg/di)
(mgld1) (mg/dl)
-120 NA NA NA NA
-105 NA NA NA NA
-90 NA NA NA , NA
-75 NA NA NA NA
-60 110 144 174 115
-45 108 139 174 113
-30 103 136 171 106
-16 103 130 _ 164 115
-1 99.2 0 129 0 168 0 111 0
98.8 -0.4 123 -6 168 , 0 102 -9
98.8 -0.4 120 -9 168 0 107 -4
96.1 -3.1 125 -4 153 -15 100 -11
97.5 -1.7 123 -6 164 -4 104 -7
102 2.8 122 -7 168 0 113 2
112 12.8 128 -1 174 6 108 -3
119 19.8 129 0 184 16 116 5
, 40 128 28.8 144 15 184, 16 123 12
127 27.8 144 15 188 20 131 26
138 38.8 156 27 179 11 132 21
146 46.8 153 24 188 20 129 18
156 56.8 156 27 201 33 131 20
159 59.8 185 56 224 56 139 28
166 66.8 183 54 219 51 141 30
168 68.8 187 58 228 60 136 25
BO 165 65.8 197 68 236 . 68 148 37
168 68.8 194 65 223 55 157 46
163 63.8 195 66 231 63 167 56
169 69.8 188 59 222 54 168 57
100 171 71.8 199 70 222 61 162 Si
105 170 70.8 200 71 229 61 187 76
110 171 71.8 204 75 233 65 176 65
81
CA 02518216 2005-09-06
WO 2004/080401 PCT/U82004/006943
115 174 74.8 212 83 238 70 177 66 _
120 173 73.8 206 77 237 69 199 88
130 176 76.8 215 86 232 64 190 79 _
140 186 86.8 220 91 234 66 178 67
.. _
150 195 95.8 219 90 241 73 198 87
160 199 99.8 207 78 269 101 187 76
-
170 204 104.8 218 89 241 73 184 73
180 210 110.8 224 95 245 77 195 84
190 223 123.8 291 92 236 68 178 67
200 226 125.8 226 97 243 75 176 65
210 220 120.8 227 98 224 56 164 53 I
220 216 116.8 241 112 220 52 180 69 I
230 219 119.8 222 93 213 45 176 65
240 211 111.8 224 95 210 42 184 73
255 215 115.8 _ 228 99 192 24 179 68
270 221 121.8 228 99 187 19 187 76
285 218 118.8 231 102 179 11 168 57
300 218 118.8 218 89 174 6 165 54
315 211 , 111.8 210 81 170 2 152 41
330 209 109.8 210 81 164 -4 170 59
345 204 104.8 201 72 167 -1 156 45
360 198 98.8 200 71 _ 154 -14 147 36 I
TABLE 16:
Patient Number 114
Treatment
-
Time
(mm) Oral 150 U Insulin/ Oral 300 U Insulin/ Sc 12 U
Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
glucose excursion glucose excursion glucose excursion glucose excursion
(mg/di) (mg/di) (mg/di) (mg/dl) , (mg/dI) (mg/di) (mg/di)
(mg/di)
-120 NA NA NA
-105 , NA NA NA
-90 NA NA NA
-75 NA NA NA
-60 141 140 142
-45 144 138 154
-30 138 140 156
-16 133 138 157 .
-1 94 0 132 0 135 0
70.4 -23.6 131 -1 151 16
65.9 -28.1 125 -7 143 8
67.9 -26.1 126 -6 142 7
79.6 -14.4 136 4 157 22
90.4 -3.6 141 9 172 37
( 98.9 4.9 148 16 172 37
110 16 155 23 154 19
125 31 157 25 205 70
127 33 152 20 200 65 ,
135 41 156 24 161 26
144 50 149 17 204 69
143 49 142 10 225 90
162 68 156 24 200 65
172 78 143 11 212 77
189 95 140 8 224 89
199 105 138 6 223 88
190 96 134 2 179 44
194 100 130 -9 222 87
186 92 126 -6 226 91
100 186 99 123 -2 203 68
105 177 83 115 -17 207 72
110 177 83 _ 112, -20 177 42
115 178 84 114 -18 218 83
82
CA 02518216 2005-09-06
WO 2004/080401
PCTIUS2004/006943
120 185 91 109 -24 225 j 90
130 195 101 119 -13 204 j 69 _
140 195 101 120 -12 185 50 .
150 193 99 123 , -9 194 59
-
160 - 185 91 127 -5 167 32 -
170 183 89 127 -5 195 60
180 176 82 111 -21 155 20
190 166 72 93 -39 , 159 24
200 169 75 73 -59 150 15 ,
210 _ 167 73 65.5 -66.5 159 24
220 164 70 57.9 -74.1 . 161 26
230 153 59 65.1 -66.9 _ 142 7
240 136 42 54.1 -77.9 136 1
255 134 40 80.7 -51.3 131 -4
270 127 . 33 67.7 -64.3 137 2
265 117 23 65.9 -66.1 _ 130 -5
300 111 17 68.2 -63.8 128 -7
315 112 18 70.5 -61.5 119 -16
330 112 18 82 -50 119 -16
345 108 _ 14 84 , -48 115 -20
360 111 17 87.1 -44.9 114 -21
TABLE 17:
Patient Number 115
Treatment
Time
(min) Oral 150 U Insulin/ Oral 300 U Insulin/ Sc 12 U
Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
glucose excursion glucose excursion glucose excursion glucose excursion
(mg/di) (mg/di) (mg/d1) (mg/di) (mg/d1) (mg/di) (mg/d1) (mg/di) ,
-120 NA NA NA
-105 NA NA NA -
-90 NA NA NA
-75 NA NA NA
-60 136 175 176
-45 136 170 176
-30 135 166 174 .
-16 136 169 170 _
-1 126 0 168 0 174 0
123 -3 165 -3 180 6
111 -15 161 -7 175 1
105 -21 161 -7 179 , 5
104 -22 162 -6 169 _ -5
103 -23 162 -6 175 1
114 -12 170 2 191 17
122 -4 168 0 189 15
135 9 203 35 219 45
143 17 203 35 228 54
147 21 193 25 235 61
168 42 184 16 249 75
172 46 194 26 231 57
171 45 194 26 251 77
173 47 199 31 274 100
183 57 198 30 284 110
196 70 203 35 275 101
184 58 204 36 286 112
206 80 212 44 286 112
_ 95 200 74 212 44 283 109
100 204 78 210 _ 42 281 107
105 213 87 214 46 287 113
110 217 91 221 53 298 124
115 I 210 84 230 62 291 117
120 222 96 230 62 300 126
83
CA 0251 821 6 2005-0 9-0 6
WO 2004/080401
PCT/US2004/006943
130 218 92 222 54 , 308 134
_ -
,
_
140 217 91 214 46 302 128
150 224 ., 98 202 34 , 302 128
160 239 113 183 15 302 128 ,
170 233 107 160 -8 281 107 .
180 235 109 149 -19 276 102
190 239 113 122 -46 , 278 104
, 200 ' 238 112 112 -56 271 97
210 243 117 98.6 -69A 270 96
220 236 110 97.7 -70.3 _ 268 94
230 231 105 89.9 -78.1 260 , 86 .
240 236 110 84.4 -83.6 253 79
255 239 113 73.5 -94.5 254 80
-270 234 108 64.2 _ -104 _ 249 75
_ 285 224 98 68.5 -99.5 237 63
300 217 91 73 -95 230 56
315 208 82 78.9 -89.1 223 49
330 206 80 77.7 -90.3 218 44
345 194 68 80.1 , -87.9 216 42
360 184 58 77.6 -90.4 196 22 I
TABLE 18:
Patient Number 116
Treatment
Time
(min) Oral 150 U Insulin/ Oral 300 U Insulin/ Sc 12 U
Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
glucose excursion glucose excursion glucose excursion glucose excursion
(mg/c11) (mg/dl) (mg/di) (mg/di) (mg/di) (mg/di) (mg/di) (mg/d1) .
-120 NA NA NA NA .
-105 NA NA NA NA
-90 NA NA NA NA
-75 NA NA NA NA _
-60 113 107 106 117
-45 117 104 115 115 .
-30 117 98.3 110 118
-16 105 92.2 102 117 .
-1 112 0 72.2 0 108 0 111 0 -
111 -1 57.4 -14.8 107 -1 124 13
111 -1 44.7 -27.5 105 -3 105 -6 _
116 4 41.7 -30.5 105 -3 113 2
119 7 50.7 -21.5 107 -1 131 20
137 25 61.8 -10.4 127 19 130 19
160 48 79.4 7.2 131 23 NA -
169 57 112 39.8 _ 141 33 NA
197 85 125 52.8 155 47 166 55
216 104 136 63.8 156 48 165 54
219 107 136 63.8 164 56 205 94
220 108 153 80.8 159 51 222 111
233 121 154 81.8 192 84 206 95
, 248 136 163 90.8 181 73 212 101
I 242 130 157 84.8 179 71 205 94 ,
239 127 165 92.8 176 68 199 88
244 132 182 109.8 170 52 NA
252 140 186 113.8 177 69 203 92
260 148 186 113.8 165 57 203 92
263 151 187 114.8 165 57 194 83
100 244 132 188 115.8 163 55 200 89
105 241 129 184 111.8 175 67 184 73
110 248 136 178 105.8 158 50 188 77
115 248 136 172 99.8 157 49 181 70
120 ! 235 123 177 104.8 162 54 174 63
130 I 219 107 180 107.8 150 42 172 61
84
CA 02518216 2005-09-06
WO 2004/080401 PCT/US2004/006943
140 205 93 156 83.8 , 138 30 169 58
-
150 175 63 134 61.8 127 19 157 46 .
160 167 55 132 59.8 112 4 136 25
170 171 59 117 44.8 105 -3 138 27
-
180 151 39 115 42.8 89.2 -18.8 130 19
190 119 7 108 35.8 73.3 -34.7 111 0
200 104 -8 97.5 25.3 69.3 -45.7 93.8 -17.2
210 91 -21 .. 98.5 26.3 57.8 -50.2 85.7 -25.3 _
220 94.2 -17.8 94.5 22.3 53.6 -54.4 74 -37
230 91.6 -20.4 83.8 11.6 73.9 -34.8 75.9 -35.1
240 86.4 -25.6 78.7 6.5 77.8 -30.9 73.5 -37.5
255 81 -31 80.3 8.1 73.1 -34.9 70.5 -40.5 .
270 80.8 -31.2 75 2.8 72.9 -35.1 õ 73.1 -37.9
285 77.7 -34.3 78.7 6.5 69.3 -38.7 71.1 -39.9
300 77.8 -34.2 79.4 7.2 75 -33 70.8 -40.2
_
, 315 71.4 -40.6 76.2 4 77.7 -30.3 69.1 -41.9
330 74.5 -37.5 76.2 , 4 77.1 -30.9 72.3 -38.7
345 78.5 -33.5 75.8 3.6 75.8 -32.2 73.3 -37.7
_
360 78.5 -33.5 76.8 4.6 85.6 -22.4 75.9 -35.1
TABLE 19:
Patient Number 117
Treatment
Time
(min) Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
glucose excursion glucose excursion glucose excursion glucose excursion
(mg/dl) (mg/di) (mg/di) (mg/di) (mg/di) (mg/di) (mg1d1)
(mg/di)
-120 NA NA NA
-105 NA NA NA
-90 NA NA NA
-75 NA NA , NA
-60 160 133 145
. -45 161 = 139 140
-30 157 135 146
-16 156 135 140
-1 142 0 134 0 138 0
139 -3 134 0 140 2
125 -17 132 -2 141 3
119 -23 130 -4 138 0
125 -17 136 2 141 3
_ 25 129 -13 147 13 160 22 .
146 4 155 21 170 32
157 15 165 31 179 41
172 , 30 168 34 193 55
182 40 166 32 191 53
199 57 163 29 207 69
203 61 175 41 213 75
,
221 79 170 36 221 83
215 73 184 50 220 82 ,
230 88 184 50 õ. 222 84
222 80 178 44 234 96
227 85 196 62 237 99
227 85 191 57 238 100
216 74 181 47 250 112
221 79 187 53 254 116
100 228 86 179 45 258 120
105 229 87 184 50 267 129
110 226 84 180 46 269 131
115 226 84 173 39 270 132
120 230 88 165 31 269 131
130 228 86 176 42 267 129
140 231 89 176 42 270 132
CA 0251 821 6 2005-0 9-0 6
WO 2004/080401 PCT/US2004/006943
150 , 232 90 175 41 268 130
160 223 81 155 21 255 117
170 213 71 137 3 249 111 -
180 209 67 124 -10 255 , 117 _
190 220 78 118 -16 259 121 .
200_ 228 86 121 -13 263 125
210 237 95 129 -5 260 122
220 223 81 139 5 256 118
230 214 _ 72 137 3 249 111 _
740 _ 214 72 138 4 242 104
255 218 76 136 2 233 95
270 225 83 133 -1 228 90
285 217 75 124 -10 214 76
-
300 211 69 123 -11 209 71 -
315 194 52 119 -15 202 64
330 191 ,, 49 109 -25 184 , 46
345 187 45 123 -11 178 40
360 169 27 118 -16 165 27
TABLE 20:
Patient Number 118
Time Treatment
Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Placebo
200 mg 4-CNAB 400 mg 4-C NAB Short-acting insulin
Blood Postprandial Blood Postprandial Blood Postprandial Blood Postprandial
glucose excursion glucose excursion glucose excursion glucose excursion
(mg/di) (mg/c11) (mg/dl) (mgld1) (mgldh (mg/di)
(mgldh (mg/d1)
-120 NA
-105 NA _
_ -90 NA ,
_ -75 NA
_ -60 175 .
-45 181
-30 , 181
-16 184
-1 190 0
193 3 .
191 1
1
185 -5
184 -6
-
185 -5
,
190 0
202 12 .
201 11 .
_ 210 20
215 25
227 37
214 24
228 38
,
233 43
239 49
218 28
211 21
, 224 34
_
223 33
100 233 43
105 225 35
110 226 36
115 226 36
120 225 35
130 215 95
_ 140 212 22
. _
150 214 24
86
CA 02518216 2005-09-06
WO 2004/080401 PCT/US2004/006943
160 214 24
170 205 15
180 201 11
190 192 2
200 - 189 -1 _
210 188 -2
220 176 -14 _
230 179 -11
240 _ 177 -13
255 167 -23
270 148 -42
285 138 -52
300 136 -54 _
315 136 -54
330 136 -54
345 125 -65 _
360 129 -61
[003271 Based upon individual blood glucose excursion data, the mean time data
(with standard
deviation) of the blood glucose excursions per treatment were calculated.
Table 21 below presents
the mean time profiles (with standard deviation) of the blood glucose
excursions per treatment.
Table 21: Statistics on Blood Glucose Excursions (mg/dL) versus Time
Treatment
Oral 150 U Oral 300 U SC 12 U Placebo
Time Insulin/200 mg Insulin/400 mg Short-acting
4-CNAB 4-CNAB insulin
MEAN STD Mean STD Mean STD Mean STD
-1 min 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00
min -1.88 2.85 -10.28 9.82 0.83 3.90 1.26
7.21
min -0.94 6.82 -14.32 12.79 -2.02 4.12 -1.34
7.73
min -0.90 6.60 -20.80 15.85 -1.83 6.65 0.67
6.27
min 5.17 9.34 -13.10 12.28 2.00 7.99 6.36 8.95
min 14.45 13.65 -7.73 15.37 8.78 8.34 15.98
10.94
min 25.78 19.53 0.96 16.45 13.94 10.32 25.04
12,13
min 30.03 19.59 9.65 20.71 20.22 11.84 27.17
13.77
min , 38.70 25.11 19.44 22.26 25.61 14.29 42.09
16.75
min 46,62 28.06 27.22 23.02 25.39 14.72 44.27
15.74
min 53.20 28.13 34.15 25.35 ' 25.17 14.72 50.21
17.62
min 53.78 28.10 36.32 26.55 25.23 18.21 59.15
20.77
min 61.53 29.36 45.12 25.43 28.61 22.60 60.68
20.18
min 62.95 33.22 47.66 26.40 34.27 20.98 64.92
20.20
rain 65.28 31.71 53.43 25.78 34.80 23.89 67.21
21.48
mm i 67.03 29.53 60.82 26.01 35.18 24.69 73.09
24.03
min 71.62 31.52 63.58 28.07 34.76 27.55 72.98
23.59
87
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85 min 72.78 33.07 65.35 27.24 34.84 28.91 70.15
23.72
90 min 72.45 35.93 66.43 27.65 31.73 28.64 74.27
23.37
95 min 73.95 38.85 65.43 26.86 30.77 32.19 77.04
24.40
100 min 72.03 33.65 68.82 31.37 31.89 29.45 73.86
24.91
105 min 71.70 36.28 70.05 28.56 30.43 34.39 74.98
24.90
110 min 72.53 36.31 68.66 29.11 28.94 29.69 74.21
27.63
115 min 69.95 34.89 66.82 25.86 27.78 30.69 75.51
26.02
120 min 67.62 33.17 68.74 26.84 24.39 38.20 73.09
27.51
130 min 64.20 33.66 69.66 26.29 23.58 29.38 69.92
30.50
140 min 64.12 36.90 67.05 29.96 21.13 29.04 65.21
34.05
150 min 61.81 39.39 69.82 27.52 18.24 30.41 63.09
33.30
160 min 52.45 36.58 69.89 26.44 14.70 33.22 60.04
35.19
170 min 56.14 43.50 66.58 29.68 8.18 31.08 54.62
33.10
180 min 53.43 43.74 63.05 29.07 2.46 32.61 52.51
34.37
190 min 52.50 46.66 65.51 25.89 -5.92 35.08 47.62
36.83
200 min 51.87 49.16 61.24 30.87 -7.98 38.93 47.20
38.33
210 min 43.86 50.96 56.55 34.19 -11.50 40.57 42.43
37.39
220 mm 44.02 46.33 54.32 35.95 -16.28 38.64 38.04
37.33
230 tnin 39.06 45.66 51.03 30.63 -18.03 36.67 34.38
38.38
240 min 35.81 43.81 47.56 33.31 -19.99 37.25 30.18
36.50
255 rnin 34.03 45.16 38.68 38.20 -23.24 34.66 21.01
37.12
270 min 25.78 44.25 37.74 39.55 -30.94 31.16 17.26
38.00
285 min 22.66 44.50 32.02 39.22 -33.17 29.93 9.15
34.35
300 min 17.62 42.95 27.00 37.62 -36.51 27.14 5.46
33.57
315 min 9.72 42.22 22.73 34.64 -38.84 23.55 -1.79
31.13
330 min 6.50 39.10 19.07 34.40 -40.00 22.81 -3.87
30.70
345 min 2.29 37.43 15.57 31.59 -42.37 22.24 -7.80
29.53
360 min -3.60 36.03 10.60 31.52 -42.68 21.48 -
12.44 26.69
[00328] Based upon individual blood glucose excursion data, the mean time
profiles (with standard
deviation) of the blood glucose excursions per treatment were plotted. Figure
1 shows a plot of the
arithmetic means of postprandial blood glucose excursions (mg/dL) vs. time for
all subjects. As
indicated in Figure 1, mean blood glucose excursions of the different
treatments reach their maxima
between 1 and 2 hours after start of meal intake and then return towards
baseline. The time to
maximal glucose excursion (median) was 1.3 hours for SC 12 U short-acting
insulin, 1.7 hours for
placebo, 1.8 hours for oral 150 U Insulin/200mg 4-CNAB, and 2.2 hours for oral
300 U Insulin/400
mg 4-CNAB.
88
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100329] The lowest overall excursions were achieved with the 12 U SC short-
acting insulin
injection. Compared to both oral insulin treatments and placebo, blood glucose
excursions after SC
injection are markedly lower during the period from 45 to 360 minutes and,
after crossing the
baseline at about 180 minutes, values become increasingly negative until 360
minutes after meal
intake.
[00330] After oral 300 U Insulin/400 mg 4-CNAB, a sharp decline from baseline
can be seen until
-20.8 mg/dL at 15 minutes, followed by a return to baseline at 30 minutes.
Thus, during
approximately the first hour, the dose of 300 U oral Insulin/400mg 4-CNAB led
to lower excursions
even when compared to injection. Thereafter, rise and subsequent decline of
the curve follows the
pattern seen for oral 150 U Insulin/200 mg 4-CNAB dosage and no treatment
(placebo). No
differences could be seen between 150 U oral Insulin/200mg 4-CNAB and no
treatment (placebo).
[00331] Based on the profiles, the derived parameters, AUCo-ih, AUCo-m, AUCo-
3h, AUCo-4h,
AUC0_6h and C. were calculated, as presented in Table 22 below.
Table 22;
Treatment
Oral 150 U Oral 300 U SC 12 U Placebo
Parameter Insulin/200 mg Insulin/400 mg Short-acting
4-CNA]3 4-CNAB insulin
Mean STD Mean STD Mean STD Mean STD
AUCo_th (h*mg/dL) 24.5 15.2 6.9 15.0 13.1 8.5 25.3
9.1
AUCo-21, (h*mg/dL) 94.3 46.3 69.8 38.0 44.9 32.8 97.8
28.5
AUC0_3h (h*mg/dL) 154.1 74.1 138.2 60.4 61.4 57.5 160.2
54.0
AUCo-th (h*mg/dL) 200.1 105.9 195.2 81.4 50.0 83.6
202.1 84.9
AUC0.6h (h*mg/dL) 233.9 164.3 250.8 140.6 -21.1 119.4
214.2 143.7
(mg/dL) 90.5 38.1 85.8 28.3 I 50.7 25.8 88.3
27.7
[003321 This data indicates that AUCo_ih is lowest following the 300 U oral
Insulin/400 mg
4-CNAB dosage. Up to 2 hours and 3 hours, the AUCs are still smaller than the
AliCs of 150 U
oral Insulin/200 mg 4-CNAB and no treatment (placebo), but larger than the
AUCs of 12 U SC
short-acting insulin. However, for 4 hours and 6 hours, no difference can be
seen between the oral
applications and no treatment. For 150 U oral Insulin/200 mg 4-CNAB, all AUCs
are more or less
equal to those obtained under no treatment. Mean maximum blood glucose
excursions (Cmax) after
both oral insulin administrations and after no treatment are similar and
clearly higher than C. after
the SC injection.
89
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[003331 Figures 3 and 4 show the blood glucose concentration vs. time curves
for subjects 116 and
117, respectively. Subject 116 was chosen because he was a Type II diabetic in
an early stage of the
disease, i.e., was able to produce his own insulin, and the glucose curve for
subject 1.16 shown in
Figure 3 paralleled that of healthy (normal) non-diabetic humans. By contrast,
subject 117 was a
type 11 diabetic in an advanced stage of the disease, i.e., having very little
pancreatic function left
and producing very little endogenous insulin. Accordingly, as shown in the
glucose curve of Figure
4 for subject 117, it took much longer to lower the glucose level for this
subject back to a level
found in healthy (normal) non-diabetic humans.
1003341 The test results can be summarized as follows: When Cm, and AUCs for 3
hours and more
are considered, no statistically significant differences of the oral
treatments compared to no
treatment (placebo) could be established. On the other hand, both oral
treatments differ
significantly from SC insulin injection, with oral treatments leading to
higher mean values.
[00335] With regard to the primary endpoint AUC0_2h, a single oral dose of 300
U Insulin/400mg 4-
CNAB, administered 30 minutes prior to a standardized test meal, caused a
statistically significant
reduction of postprandial blood glucose excursions in comparison to no
treatment (placebo).
However, the effect was significantly lower than after SC injection of 12 U
short-acting insulin.
The effect of 150 U oral Insulin/200 mg 4-CNAB was not significantly different
from no treatment
(placebo).
Pharmacolcinetics
[00336] From the blood samples taken, the individual plasma concentrations of
4-CNAB, insulin
and C-peptide were also determined, and summary concentration vs. time tables
were prepared and
profiles were plotted, as set forth in Tables 23-40 for insulin and C-peptide
concentrations below.
Table 23:
Patient Number 101
Time Treatment
(min)
Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
Insulin 6-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
(pmo1/1) (nmollh (pmolil) (nmoill) (pmo111) (nmo1/1)
(pmo1/1) (nmo)/1)
-60 63 0.73 134 0.97 72 0.85
-30 78 0.80 66 0.76 95 0.90 _
0 277 0.76 112 0.90 74 0.81
334 0.81 111 0.98 105 0.98
159 0.85 140 1.13 136 1.15
222 1.19 280 1.58 229 1.53
202 1.17 339 1.66 281 1.71
222 1.27 281 1.73 322 1.96
CA 02518216 2005-09-06
WO 2004/080401 PCT/US2004/006943
60 311 1.70 270 1.66 338 2.20
75 311 1.95 349 1.98 352 2.30 _
90 339 2.10 384 2.20 430 2.50
105 386 2.40 397 2.30 _ 349 2.50
120 433 2.70 501 2.60 441 2.90 _
150 452 2.90 _ 395 2.70 299 2.60
180 285 2.60 252 2.30 192 2.30
210 220 2.20 186 1.88 273 2.60
240 165 2.10 93 1.32 175 2.20
..
300 95 1.42 68 0.93 98 1.51 I
-
360 102 1.14 43 0.71 67 0.86 1
TABLE 24:
=
Patient Number 102
Time Treatment
Oral 150 U Insulin/ Oral 300 U Insulin/ Sc 12 U Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
(pmo1/1) (nmo1/1) (pmo1/1) (nmo1/1) _ (pmo1/1)
(nmo1/1) (pmo1/1) (nmo1/1)
-60 44 0.78 . 30 0.55 51 0.71
-30 35 0.69 _ 23 0.50 47 0.76
0 52 0.68 48 0.59 45 0.69
68 _ 0.72 60 0.62 67 0.76
, _ 54 _ 0.70 50 0.60 66 0.75
113 0.93 41 0.85 128 0.93
169 1.16 212 1.22 153 1.13
250 1.47 163 1.14 264 1.47
256 1.50 153 1.15 282 1.61
75 336 2.00 300 1.71 322 1.88
90 362 2.20 128 1.53 556 2.70
,
105 343 2.40 267 1,73 602 2.80
120 344 2.50 209 1.72 763 3.20
150 213 2.30 162 1.61 488 3.10
180 142 1.83 139 1.52 416 3.00
210 _ 135 2.10 219 1.70 281 2.70
240 95 1.49 108 1.38 213 2.20
300 83 1.28 70 1.01 140 1.61
360 83 1.24 56 0.88 86 1.35
TABLE 25:
Patient Number 103
Time Treatment
(min) ____________________________________________________
Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
(pmo1/1) (nmo1/1) (pmo1/1) (nmo1/1) (pmo1/1) (nmo1/1)
(pmo1/1) (nmo1/1)
-60 70 0.88 35 1.11 77 1.01 58 1.01
-30 70 0.83 79 1.09 65 1.00 25 0.97
0 68 0.85 . 95 0.97 61 0.94 78 1.00
10 89 0.90 73 1.13 84 1.05 80 1.16
20 101 0.99 84 1.17 81 1.07 120 1.26
30 132 1.12 147 1.41 150 1.25 152 1.44 1
40 174 1.38 178 1.46 191 1.41 73 1.59
50 253 1.69 180 1.63 208 1.52 196 1.77
60 275 1.74 237 1.84 249 1.68 271 1.87
75 350 9.40 305 1.99 291 1.94 274 2.20
90 483 2.80 271 2.30 343 2.10 278 . 2.50
105 530 3.60 173 ._ 2.40 301 2.20 96* 2.50
120 558 3.90 227 2.70 , 318 2.20 , 320 2.70
91
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150 596 4.30 260 2.70 211 2.10 _ 292 2.80 ,
180 469 4.80 288 2.90 148 _ 1.82 256 3.00
210 410 4.40 164 3.00 100 1.55 224 - 2.90
, 240 , 304 3.90 126 2.10 68 1.33 122 2.40 _
300 167 2.50 119 1.90 74 1.12 93 1.74
_
360 93* 2.10 122 1.88 61 1.00 44* 1.43
TABLE 26:
Patient 11 um ber 104
Time Treatment
(min)
Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
(pmo1/1) (nmo1/1) (pmo1/1) (nmo1/1) (pmo1/1)
(nmo1/1) (pmo1/1) (nmo1/1)
-60 22 0.48 BLQ 0.52 27 0.55 23 0.52 _
-30 23 _ 0.51 15 0.47 BLQ BLQ 14 0.47
0 62 0.59 47 0.50 25 0.53 31 0.60
95 0.83 35 0.53 24 0.54 53 0.73
_
130 1.14 61 0.77 84 0.78 100 0.94
, 94 0.99 56 0.72 71 0.76 73 0.92
50* 0.95 BLQ BLQ 112 0.83 89 1.05
108 1.11 64 0.82 124 0.98 14 1.23
141 1.34 65 1.04 114 0.94 98 1.37
75 135 1.39 113 1.23 82 0.90 22 1.65
90 ., 115 1.36 129 1.18 51 0.91 117 1.67
105 83 1.45 142 1.75 85 1.07 117 1.70
120 107 1.54 162 2.00 82 0.94 98 1.80
150 117 1.57 158 2.30 54 0.83 74 1.46
180 116 1.58 118 2.00 32 0.75 44 1.43 .
210 94 , 1.53 89 1.96 42 0.71 64 1.64
240 122 1.63 77 1.76 27 . 0.61 56 , 1.38
300 48 1.41 35 1.19 14 0.47 40 1.01
360 43 1.01 28 0.91 19 0.43 23 0.78
TABLE 27:
Patient Number 105
Time Treatment
(min) ____________________________________________________
Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
, (pmo1/1) (nmo1/1) (pmo1/1) (nmo1/1) (pmo1/1)
(nmo1/1) (pmo1/1) (nmo1/1)
-60 44 0.95 36 0.79 23 0.72 23 0.76
-30 40 1.04 39 0.85 19 0.72 23 0.73
0 38 1.01 76 0.82 25 0.70 22 0.71
10 48 1.03 114 0.83 40 0.76 42 0.83
20 53 1.03 61 0.79 38 0.75 43 0.77 .
30 146 1.65 98 1.01 106 1.10 100 1.12
40 165 1.78 95 1.19 120 1.10 135 1.30
50 193 1.83 97 1.05 . 122 1.11 144 , 1.18
60 49* 2.60* 111 1.22 119 1.24 148 , 1.43
75 360 3.20 149 1.57 159 1.62 239 2.00
90 245* 370 148 1.68 170 _ 1.75 283 2.30 .
105 498 3.80 233 2.00 197 2.20 289 2.50
120 430 4.30 232 2.10 , 193 1.81 321 2.60
150 188 3.00 286 2_40 207 2.30 260 2.80
180 244 3.10 281 2.50 135 1.99 213 2.60
210 121 3.20 229 2.50 40 1.28 134' 2.40
240 103 1.90 169 2.40 18 0.83 84 1.97
300 28 1.26 48 1.29 14 0.74 32 1.11
360 25 0.91 34 0.92 BLQ 0.58 25 0.86
92
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TABLE 28:
Patient Number 106
Time Treatment
(min) ____________________________________________________
Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Placebo
200 mg 4-CRIAE 400 mg 4-C Short-actina insulin
Insulin C-Peptide In.sulin C-Peptide Insulin c;-Peptide Irt..-milin C-Pepdde
(pmo1/1) (nmo1/1) (pmo1/1) (nmo1/1) (pmo1/1) (nmo1/1)
(pmo1/1) (nrno1/1)
-
-60 65 0.82 42 0.71 24 _ 0.51 24 0.69
-30 55 0.86 30 0.74 19 , 0.49 , 24 0.58
0 62 0.71 48 . 0.61 26 0.55 32 0.66 .
46 0.75 48 0.66 38 0.61 39 0.68
- 20 38 0.76 27 0.58 52 0.75 71 0.81
30 82 , 0.88 33 0.57 69 0.76 90 , 0.93
40 106 1.00 , 42 0.68 39 0.74 122 , 1.12
50 123 1.33 55 0.74 63 0.77 136 1.32 .
60 118 1.39 78 0.82 58 , 0.72 130 1.63
75 94 1.44 53 0.77 BLQ* 0.51* 155 1.76
90 127 . 1.42 121 1.22 BLQ* 0.43* 173 1.96
105 123 , 1.90 62 1.05 BLQ 0.34 166 2.30
120 140 , 2.10 73 . 1.09 13 0.32 159 2.40
_ ________________________________________________________________
150 155 2.30 88 , 1.36 17 0.35 97 1.91
180 121 2.50 146 1.58 26 0.46 108 1.73 _
210 84 1.98 135 2.10 12* _ 0.44* 104 1.75
240 112 2.00 137 2.20 ._ 31 0.50 90 1.90
300 87 1.68 51 1.30 BLQ* 0.41* 22 0.84
360 35 0.88 30 0.70 BLQ 0.31 18 0.57
TABLE 29:
Patient Number 107
Time Treatment
(min)
Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
-
Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
(pmo1/1) (nmo1/1) , (pmo1/1) (nmo1/1) (pmo1/1)
(nmo1/1) (pmo1/1) (nmo1/1)
-60 42 0.76 43 0.73 38 0.70 36 0.74
-30 43 _ 0.77 43 0.74 46 0.77 40 0.75
0 134 0.85 98 0.94 52 0.81 53 0.84
10 86 0.84 163 1.30 103 1.08 83 1.01
145 1.28 143 1.35 135 1.22 70 0.92
153 1.37 221 _ 1.55 220 1.46 138 1.26
163 1.37 217 1.58 184 1.48 258 1.48
214 1.63 190 1.60 184 1.49 235 1.49
245 1.95 210 1.86 219 1.66 203 1.78
75õ 306 2.30 263 2.10 330 2.10 326 2.10
90 306 2.50 _ 268 2.20 260 2.10 455 2.50
105 , 251 2.40 261 2.20 273 2.20 346 2.50
120 275 2.70 269 2.50. 253 2.10 386 2.80
150 229 2.50 40" 2.30* 159 2.00 280 2.60
180 172 2.30 148 2.00 111 1,67 237 2.50
210 87 1.97 114 1.75 86 1.54 165 2.40
240 98 1.80 156 1.96 59 1.28 191 2.00
300 56 1.30 65 1.05 33 0.96 55 1.29
360 50 1.15 50 0,92 28 0.76 38 0.86
93
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TABLE 30:
Patient Number 108
Time Treatment
(min) ____________________________________________________
Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Placebo
200 mg 4-CNAB 400 m4-CNAB Short-acting insulin
Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
(pmo1/1) (nmo1/1) (pmo1/1) (nmo1/1) (pmo1/1)
(nmo1/1) (pmo1/1) , (nmo1/11
-60 158 1.62 71 0.88 92 1.00 134 1.12
-30 128 1.43 BLO* 0.83' 90 0.87 91 1.06 .
0 313 1.43 330 0.72 , 143 1.20 120 1.20
247 1.58 155 0.82 138 1.21 130 1.28 ..
364 2.20 144 0.98 242 1.49 419 , 2.20
379 2.20 137 1.03 , 192 1.58 616 , 2.60
438 2.40 224 1.38 332 1.71 533 2.30
467 2.60 297 1.81 337 1.83 458 2.90
559 2.80 260 1.79 369 2.00 489 3.20 .
75 573 3.20 141 1.80 403 2.10 518 3.50
90 515 3.70 254 2.00 473 2.40 441 2.60
105 657 3.80 66* 2.00 414 2.50 388 3.30
120 586 3.90 209 2.00 389 2.40 386 3.60
150 853 5.30 235 2.10 268 2.60 463 2.60
180 569 4.90 241 3.00 281 2.40 364 3.30 ,
210 540 3.10 341 3.10 352 2.50 240 3.00
240 481 3.70 204 2.20 225 2.20 290 3.40
300 391 2.90 141 1.82 116 1.73 196 2.20
' 360 229 2.00 126 1.70 95 1.07 109 1.77
TABLE 31:
Patient Number 109
Time Treatment
(min)
Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
Insulin C-Peptide Insulin C-PeptIde Insulin C-Peptide Insulin C-Peptide
(pmo1/1) (nmo1/1) (pmo1/1) (nmo1/1) (pmo1/1) (nmo1/1)
(pmo1/1) (nmo1/1)
-60 82 0.89 64 1.18 69 , 1.18 36 0.66
1
-30 82 0.97 59 1.38 38 0.86 36 0.63
0 83 0.95 273 1.19 63 1.17 63 0.77
10 47* 0.96" 114 1.04 81 1.36 61 0.76
20 149 1.27 74 0.83 101 1.34 141 1.01
30 595 2.30 302 1.43 460 2.60 222 1.45
40 388 2.00 303 2.10 436 , 3.40 362 1.88
50 482 2.30 265 1.94 276 2.70 416 2.00
60 406 2.20 174 1.69 418 2.70 379 2.10
75 415 2.20 225 2.20 457 3.80 569 2.50
90 511 2.60 329 2.50 499 4.10 416 2.30
105 582 3.30 475 2.70 352 3.30 635 3.00
120 470 3.00 408 2.70 265 2.60 594 3.00
150 565 3.40 375 2.50 494 4.70 514 3.30
180 435 3.10 321 2.40 240 3.80 333 2.50
210 447 3.40 196 3.20 140 2.50 183 2.40
240 271 2.70 203 2.70 92 2.10 122 1.93
300 204 2.30 137 2.20 57 1.81 62 1.37
360 98 1.54 93 1.87 39 1.01 76 1.32
94
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TABLE 32:
Patient Number 110
Time Treatment
(min)
Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
Placebo
200 mu 4-CNAB 400 mg 4-CNAB Short-acting insulin
Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide. Inzulin C-Peptlde
(pmo1/1) (nmo1/1) (pmo1/1) Irimal/0 (pmol/1) (nmo1/1)
(pmoUl) (nmo1/1) ,
-60 59 0.62 24 0.44 36 0.50 37 0.57
-30 40 0.55 24 0.43 39 0.54 27 0.55
0 51 0.60 1803 0.52 50 0.61 32 0.56
219 1.21 890 0.64 67 0.67 153 0.94
227 1.24 351 0.78 271 1.26 348 1.57
-
270 1.27 197 0.73 275 1.22 473 2.00
242 1.42 189 0.79 275 1.28 511 2.20
348 1.81 184 0.87 348 1.58 445 2.20
359 '1.86 171 0.99 471 1.74 356 2.10
75 477 2.30 153 1.08 455 1.89 _ 383 2.20
90 411 2.40 161 1.20 427 2.10 422 2.60
105 396 2.40 112 1.14 461 2.10 329 2.60
120 375 2.40 223 1.61 252 1.72 492 3.00
150 437 2.80 165 1.67 248 1.75 233 2.40
180 444 2.90 152 1.47 , 76 1.27 .. 174 2.20
210 342 2.60 139 , 1.56 , 51 0.81 , 142 2.00
240 179 1.97 59 1.16 42 0.63 96 1.63
300 149 1.57 35 0.63 , 27 0.47 44 1.00
360 51 0.96 24 0.51 22 0.37 33 0.62
TABLE 33:
Patient Number 111
Time Treatment
(min)
Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
(pmo1/1) (nmo1/1) (pmo1/1) (nmo1/1) (pmo1/1) (nmoUl)
(pmo1/1) (nmo1/1)
-60 78 1.29 68 1.11 131 1.53 _ 87 1.12
-30 83 1.19 71 1.11 108 1.38 51 0.99
0 67 1.07 373 1.02 142 1.27 43 0.78
10 62 1.02 127 0.97 105 1.38 46 0.80
20 83 1.10 85 0.89 BLQ BLQ 51 0.85
30 242 1.84 221 ,. 1.43 215 1.77 137 1.17
40 330 2.10 292 1.80 305 1.94 129 1.25
50 257 1.91 351 2.00 383 2.10 234 1.66
60 309 2.20 329 1.93 482 2.50 131 1.95
75 312 2.40 407 2.50 507 2.70 296 2.40
90 281 2.30 550 2.80 _ 384 2.30 332 2.60
105 266 2.40 398 2.80 409 2.40 409 3.00
120 356 2.70 408 1 2.90 296 1.86 361 3.00
150 407 3.40 380 3.20 221 2.00 324 3.70
180 325 3.60 384 2.80 291 2.30 455 4.40
210 275 3.20 303 2.90 529 2.30 244 3.00
240 352 3.90 210 2.20 197 1.95 148 2.30
300 191 3.00 73 1.42 40 1.04 85 1.46
360 93 1.92 63 1.19 44 0.81 64 1.06
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TABLE 34:
Patient Number 112 ,
Time Treatment
(min) _____________________________________________________
Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U
Placebo
200 mg 4-C NAB 400 mg 4-CNA13 Short-acting
insulin
Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
(pmol/l) (nmo1/1) (pmo1/1) (nmo1/1) (pmo1/1) (nmo1/1)
(prno1/1) (nmo1/1)
-60 74 0.88 42 0.67 37" , 0.64 79 0.74
-30 66 0.90 47 0.70 40 0.64 54 0.64
0 63 0.89 241 0.61 49 0.62 52 0.69 1
71 0.89 13* 0.54* 57 0.67 44 0.67
68 0.90 38 0.55 40 0.63 149 0.87
76 0.94 _ 82 0.69 149 0.91 246 1.99
. 40 219 1.49 106 0.82 916 1.05 270 1.59
50 239* 1.81* 100 0.85 216 1.22 281 1.34
60 293 1.99 85 0.87 200 1.25 304 1.71 -
75 383 2.30 83 0.95 201 1.33 272 1.74
' 90 372 2.60 96 1.21 188 1.49 260 1.87
105 407 2.80 87 1.40 189 1.48 298 2.00
120 484 3.60 103 1.57 176 1.47 308* 2.40*
150 470 4.00 142 1.95 156 1.56 , 417* 3.30*
180 402 3.70 212 2.50 103 1.27 370 3.00
210 327 2.90 126 2.50 62 0.99 335 3.10
-
240 279 3.10 189 2.90 72 0.96 362 3.30
300 91 1.96 101 1.94 56 0.94 132 2.20
360 62 1.26 54 1.33 25 0.63 41 1.15
TABLE 35:
Patient Number 113
Time Treatment
(min)
Oral 150 U Insulin/ Oral 300 U insulin/ SC 12 U
Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
Insulin C-Peptide
(pmo1/1) (nmo1/1) (pmolA) (nmo1/1) (pmo1/1) (nmo1/1)
(pmo1/1) (nmo1/1)
-60 89 1.68 56 1.20 BO 1.66 63 1.18
-30 79 1.60 60 . 1.15 72 1.63 37 1.12
0 80 1.46 166 1.19 82 1.72 58 1.08
10 89 1.59 62 1.21 98 1.74 55 1.16 _
20 95 1.62 72 1.21 97 1.72 63 1.16
30 126 1.77 75 1.17 135 1.87 99 1.29
189 1.93 179 , 1.40 201 2.10 131 1.48
157 2.00 168 1.62 187 2.10 146 1.64
223 2.30 230 1.72 216 2.30 163 1.68
75 236 2.50 197 1.95 221 2.50 158 1.82
90 199 2.40 246 2.20 232 2.60 200 2.20
105 202 2.60 241 2.30 91 2.60 230 2.40
120 167 2.60 241 2.50 245 2.80 241 2.60
150 197 2.80 221 2.70 226 3.10 400 2.80
180 280 3.20 226 3.00 179 3.20 218 3.40
- 210 252 3.60 222 3.20 184 3.10 141 3.10
240 193 3.60 169 3.70 123 2,40 161 3.10
300 232 4.10 163 3.60 106 2.20 113 3.00
360 196 3.80 148 2.70 88 2.00 83 2.70
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TABLE 36:
Patient Number 114
Time Treatment
(min) -
Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
Insulin C-Peptide insulin C-Peptide Insulin C-PeptIde Insulin C-Peptide
(pmo1/1) _ (nmo1/0 (pmo1/1) (runo1/1) (pmo1/1)
(nmo1/1) , (pmo1/1) (nmo1/1)
-60 19 0,51 20 0.55 153 0.53
-30 BLQ _ 0.49 16 0.58 28 0.61
0 , BLQ BLQ 21 0.54 103 0.59
, 63 0.39 35 0.70 125 1.22
56 0.47_ 95 0.85 121 1.37
71 0.59 148 1.09 128 1.42 .
99 0.76 299 1.24 121 1.54
117 0.88 240 1.69 154 1.52
115 '1.09 257 1.72 218 2.20
_
75 152 1.43 250 1.88 BLQ* 2,10"
90 113 1.70 191 1.82 246 2.40
-
105 107 1.63 126 1.66 172 2.50
120 181 2.20 125 1.70 209 2.60
150 154 2.20 105 _ 1.56 224 2.80
180 119 2.10 70 1.40 48" 2.40"
210 71 1.89 23 0.80 48 1.94
240 45 1.44 BLQ 0.51 26 1.35
300 23 0.84 BLQ 0.30 17 0.83
360 15 0.64* BLQ 0.25 BLQ* 0.62* ,
TABLE 37:
Patient Number 115
Time Treatment
'
(min)
Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin
Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
(pmo1/1) (nmo1/1) (pmo1/1) (nmo1/1) (pmo1/1) (nmo1/1)
(pmo1/1) (nmo1/1)
-60 31 0.66_ 47 0.72 42 0.67
-30 31 0.67 27 0.75 38 0.74
0 199 0.70 41 0.75 , 37 0.75
10 71 0.67 24 0.83 45 0.80
20 47 0.65 140 0.76 43 0.71
30 62 0.81 113 0.93 81 0.87
, 40 66 0.86 470 1.02 102 1.17
50 61 0.84 75 1.01 95 1,20
60 58 0.87 164 1.11 82 1.19
75 67 0.97 159 1.15 97 1.43
90 67 1.07 266 1.35 107 1.81
10565 1.03 89 1.49 101 , 1.83
120 - , 77 1.17 112 1.59 89 1.74
150 69 1.32 84 1.64 86 2.20
180 87 1.51 82 1.34 103 2.40
210 87 1.56 64 1.51 108 2.50
240 99 1.83 76 1.24 82 1.82 .
300 65 1.62 24 0.74 52 1.52
360 - 68 1.58 45 0.56 36* 1.42*
97
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TABLE 38:
Patient Number 116
Time Treatment
(min) ____________________________________________________
Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Placebo
200 mg 4-CNAB 400 mg 4-CNAB Short-acting insulin ..
Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
(pmo1/1) (nmo1/1) (pmo1/1) (nmo1/1) (pmo1/1) (nmo1/1)
(pmo1/1) = , (nmo1/1) _
-60 36 0.66 30 0.49 41 0.55 31 0.48
-30 39 0.65 97 0.49 34 0.58 97 0.48
_
0 45 0.68 538 0.34 30 0.53 26 0.46
_
54 0.62 66 0.26 46 0.64 19 0.52'
45 0.67 52 0.31 88 0.69 BLQ BLQ
122 0.93 96 0.52 161 1.05 BLQ BLQ
206 1.26 115 0.70 245 1.52 129 0.94
249 1.76 137 0.86 271 1.68 247 1.40
310 2.00 161 1.21 342 2.10 987 1.78
75 473 2.90 219 1.55 366 2.30 358 2.80
90 602 3.70 206 1.86 388 2.80 410 2.80
105 643 4.60 270 2.30 418 2.70 403 4.20
120 746 4.20 291 2.70 409 2.80 423 5.50
150 , 632 4.30 357 3.10 343 2.80 441 4.10
180 386 3.50 _ 162 2.50 122 1.74 315 3.20
210 140 , 2.20 111 1.61 42 0.97 70 1.89
240 76 1.51 39 0.90 50 0.89 42 1.26
300 46 0.97 37 0.72 24 0.56 , 38 0.81
360 36 0.72 25 0.51 23 0.41 34 0.62
TABLE 39:
Patient Number 117
Time Treatment
(min)
Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Placebo
200 mg 4-CNAB 400 mg 4-CNAB , Short-acting
insulin
Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
(pmo1/1) (nmo1/1) (pmo1/1) (nmol/1) (pmo1/1) (nmo1/1)
(pmo1/1) (nmo1/1)
-60 41 0.81 37 0.90 46 1.19
-30 45 0.90 30 0.89 80 1.17
0 559 0.79 45 0.90 45 1.06
10 188 0.81 65 0.86 61 1.14
20 81 0.85 67 0.80 56 1.10
30 85 0.91 97 1.03 104 1.29
40 101 0.97 127 1.15 100 1.30
50 74 0.99 , 134 1.01 107 1.43
60 113 , 1.17 112 1.34 127 1.48
75 102 1.27 131 1.38 117 1.51
90 94 1.46 161 1.30 , 186 1.91
105 93 1.67 112 1.47 142 2.10
120 88 1.73 71 1.39 134 2.20
150 101 1.96 106 1.55 165 2.60 _
180 74 1.73 48 1.01 155 2.60
210 112 2.10 44 0.97 173 2.40
240 90 2.10 55 0.92 155 2.20
300 , 106 2.20 41 0.97 124 1.99
360 59 1.70 46 0.92 73 1.61
98
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TABLE 40:
Patient Number 118
Time Treatment
(mm) _____________________________________________________
Oral 150 U Insulin/ Oral 300 U Insulin/ SC 12 U Placebo
200 mu 4-CNAIS 400 mg 4-CNAB Short-acting insulin
Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide Insulin C-Peptide
ipmo1/1) (nmo1/1) (pmo1/1) (nmo1/1) (pmo1/1)
(nmo1/1) (pmall1) (nmo1/1)
-60 23 0.53
-30 29 0.47
32" 0.58*
41 0.64
45 0.65
40 0.77
BLQ* 0.82*
67 0.90
72 0.82
75 66 0.96
90 65 0.94
105 52 0.96
120 43 0.92
150 68 0.92
180 64 0.75
210 56 0.82
240 57 0.66
300 46 0.59
360 46 0.55
* denotes samples that were hemolyzed
[00337] Table 41 below presents the mean time data (with standard deviation)
of the plasma 4-
CNAB concentrations for the two treatments involving 4-CNAB.
Table 41: Statistics on 4-CNAB Concentration (ng/mL) vs. Time
Treatment
Oral 150 U Oral 300 U
Insulin/200 mg 4-CNAB Insulin/400 mg 4-CNAB
Time Mean STD Mean STD
10 min 5031.01 1979.06 11005.11 4611.76
20 min 3449.44 1612.48 7216.69 1858.48
30 min 2528.54 986.25 5077.03 1401.94
40 min 1587.28 561.28 3576.83 1001.72
60 min 1198.71 858.55 2310.03 787.86
90 min 604.81 395.73 1389.54 406.35
120 min 348.73 178.14 963.92 273.23
240 min 126.13 50.55 385.42 169.62
360 min 111.86 44.91 281.18 151.58
1003381 Figure 2 shows profiles of 4-CNAB plasma concentrations (ng/mL) vs.
time (arithmetic
99
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WO 2004/080401 PCT/US2004/006943
means) for the two treatments involving 4-CNAB. As seen in Figure 2, plasma 4-
CNAB
concentrations show a rapid decline within the first two hours after start of
meal intake. After 2
hours, concentrations are less than 10% of the levels seen after 10 minutes.
The results indicate that
markedly higher concentrations might have been reached in the time between
intake of the
Insulin/4-CNAB capsules and the first measurement 10 minutes after start of
meal intake.
Concentrations after intake of 400 mg 4-CI\TAB are approximately twice as high
as after intake of
200 mg.
[00339] Table 42 below presents the mean time data (with standard deviation)
of the plasma
insulin concentrations per treatment.
Table 42: Statistics on Insulin Concentration (pmol/L) vs. Time Profiles
Time Treatment
Oral 150 U Oral 300 U SC 12 U Placebo
Insulin/200 mg Insulin/400 mg Short-acting insulin
4-CNAB 4-CNAB
Mean STD Mean STD Mean STD Mean STD
-60 min 67.67 35.07 44.25 17.21 53.67 35.86
58.53 37.49
-30 min 62.33 28.59 41.09 17.39 44.76 26.55
43.35 24.18
0 min 88.83 74.69 389.58 476.10 58.17 38.02
53.76 27.05
min 95.50 66.76 153.46 227.65 67.61 33.18 71.06
36.99
min 124.83 92.52 94.69 84.76 103.88 66.49
124.81 107.93
min 201.42 152.72 126.00 82.65 162.33 102.91
188.50 150.82
rein 222.50 112.69 161.08 85.98 236.82 113.90
205.82 143.56
min 257.50 120.42 158.69 96.27 204.39 97.98
229.06 126.39
min 273.92 136.46 157.62 82.77 238.06 131.97
235.65 114.90
75 min 342.83 139.45 167.31 96.64 278.06 134.82
278.63 147.21
90 min 347.25 160.66 202.62 131.93 271.18 139.21
312.47 132.36
105 min 386.50 199.81 183.00 135.58 249.00 141.18
298.35 161.63
120 min 392.83 192.71 210.23 113.84 219.56 133.35
336.76 179.17
150 min 403.83 230.87 191.15 116.15 195.78 124.00
297.47 141.51
180 min 330.25 145.58 183.85 90.79 133.28 83.95
235.35 125.05
210 min 259.92 156.54 157.38 84.46 124.00 133.24
172.29 83.22
240 min 214.17 124.78 129.00 63.79 81.94 56.35
137.94 86.82
300 min 140.83 104.91 79.38 46.06 50.63 30.36
79.00 49.57
360 min 84.25 65.03 60.23 40.69 45.33 22.59
53.13 26.81
[00340] Figure 5 shows profiles of insulin plasma concentrations (pmolfl) vs.
time (arithmetic
100
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WO 2004/080401 PCT/US2004/006943
means). As shown in Figure 5 and in Table B above, highest mean insulin plasma
concentrations
are reached after the 150 U oral dose, followed by 300 U oral, placebo, and 12
U SC injection. The
curve of oral 300 U Insulin/400 mg 4-CNAB shows two maxima, the first at 0 min
and the second
at 120 mm. The peak at 0 mm is due to one particular patient who contributed
with a value of 1803
pmol/L the most to this marked shift of mean insulin concentration. Almost all
patients showed a
more or less marked isolated increase of insulin concentrations at time 0 but
not to such an extent as
that patient. In addition, the rise of insulin concentrations under placebo is
explained by the
patients' endogenous insulin production, induced by the meal intake.
[00341] Figures 7 and 8 show the insulin plasma concentration vs. time curves
for subjects 116 and
117, respectively. For subject 116, who was an early stage Type It diabetic
who produced his own
insulin, the insulin plasma concentration vs. time curve shown in Figure 7
mimicked that of healthy
(normal) non-diabetic humans, i.e., it had the same biphasic secretion time
curve shape, although
the insulin peaks occurred slightly earlier than normal. For subject 117, who
was an advanced stage
Type 11 diabetic who produced very little endogenous insulin, the insulin
plasma concentration vs.
time curve shown in Figure 8 shows levels of insulin after the initial peak
that are lower that those
for normal, non-diabetic humans and shows that no second peak of plasma
insulin concentration
occurred. This is an indication that this subject would also need to be
administered basal long
lasting insulin in order to maintain normal insulin plasma concentration and
blood glucose levels.
[00342] Table 43 below presents the mean time data (with standard deviation)
of the plasma
C-peptide concentrations per treatment.
Table 43: Statistics on C-peptide Concentration (nmol/L) vs. Time
Time Treatment
Oral 150 U Oral 300 U SC 12 U Placebo
Insulin/200 mg Insulin/400 mg Short-acting Insulin
4-CNAB 4-CNAB
Mean STD Mean STD Mean STD , Mean STD
-60 min 0.96 0.38 0.76 0.26 0.82 0.35 0.80 0.24
-30 min 0.94 0.33 0.78 0.29 0.79 0.31 0.77 0.22
0 min 0.92 0.29 0.76 0.27 0.83 0.33 0.78 0.20
min 1.02 0.30 0.76 0.31 0.91 0.33 0.91 0.22 _
min 1.18 0.41 0.79 0.29 0.97 0.34 1.09 0.38
min 1.44 0.50 0.93 0.36 1.25 0.48 1.34 0.44
mm 1.59 0.45 1.15 0.48 1.43 0.62 1.47 0.38
min 1.82 0.39 1.22 0.49 1.48 0.51 1.63 0.44
101
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60 min 2.03 0.43 1.31 0.42 1.59 0.57 1.84 0.46 ,
75 min 2.38 0.57 1.52 0.54 1.82 0.76 2.11 0.51
90 min 2.62 0.78 1.74 0.57 1.90 0.83 2.31 0.35 .
105 min 2.92 0.91 1.84 0.60 1.93 0.72 2.57 0.59
120 min 3.08 0.89 2.05 0.59 1.83 0.68 2.83 0.83
-
150 min 3.31 1.03 2.20 0.58 2.00 0.98 2.77 0.63
180 min 3.27 0.95 2.20 0.54 1.72 0.85 2.71 0.68
210 min 2.84 0.82 2.26 0.64 1.47 0.74 2.45 0.48
_
240 min 2.64 0.95 2.08 0.74 1.21 0.60 2.14 , 0.63
300 min 2.08 0.92 1.58 0.80 0.94 0.51 1.50 0.59
360 min 1.52 0.86 1.25 0.65 0.74 0.40 1.15 0.55
_
[00343] Figure 6 shows profiles of C-peptide plasma concentrations (nmo1/1)
vs. time (arithmetic
means). Mean plasma concentrations of C-peptide, the indicator of endogenous
insulin production,
increased after all treatments. Decreasing, or more or less constant C-peptide
concentrations, were
seen only in a few patients and only after SC injection of short-acting
insulin. This may reflect the
fact that in most of the patients the ability to produce endogenous insulin
was still maintained. As
expected, the 150 U oral insulin dose and placebo show the most marked
increase, whereas the
increases after the 300 U oral dose and the 12 U SC injection are clearly
lower.
[00344] Based on the insulin concentration vs. time profiles, the parameters
C., tinax and AUC
from time 0 to the time when the baseline insulin level was reached again
(AUC0..1*) were
calculated, as presented in Table 44 below.
Table 44:
Treatment AUCO-t* Cm ax tmax
(h*pmol/L) (pmol/L) (h)
Mean STD Mean , STD Median MIN MAX
Oral 150 U Insulin/ 1469.42 684.92 461.50 219.29
2.00 0.50 3.00
200 mg 4-CNAB
Oral 300 U Insulin/
400 mg 4-CNAB 866.45 372.85 439.23 437.80 1.50 0.00
3.50
SC 12 U Short- 791.52 417.95 315.83 155.09 1.38 0.50 3.50
acting insulin ,
Placebo 1093.47 466.46 388.53 185.82 2.00 0.50 3.50
[00345] t* denotes time when baseline insulin level is reached again, or last
data point (360 min)
[00346] This data indicates that mean insulin plasma concentration vs. time
profiles showed the
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WO 2004/080401 PCT/US2004/006943
highest AUC after 150 U oral insulin, followed by placebo, 300 U oral insulin,
and 12 U SC
injection. Highest mean Cni. was reached after 150 U oral insulin, followed by
300 U oral insulin,
placebo, and 12 U SC injection. The median time until C.. (tm.) was longest
for 150 U oral
insulin and placebo, followed by 300 U oral insulin and 12 U SC injection.
Conclusions
[00347] The primary objective of this study was to compare the effect of
orally administered 300 U
Insulin/400 mg 4-CNAB with that of 12 U subcutaneously injected short-acting
insulin (Humaloe)
on postprandial blood glucose excursions after a standardized breakfast. With
respect to AUC0..21, as
main parameter for pharmacodynamic evaluation, the highest effect on blood
glucose excursions
was found for 12 U SC short-acting insulin, followed by oral 300 U Insulin/400
mg 4-CNAB, oral
150 U Insulin/200 mg 4-CNAB and placebo, and the effects of the two latter
appeared more or less
equal. However, these results were not consistent for all calculated AUCs.
During the first hour,
300 U oral insulin were superior to 12 U SC, and this order changed when the
AUCs for more than
2 hours were compared: both oral treatments were no longer significantly
different from no
treatment (placebo), but the 12 U SC injection showed still a significant
difference and clearly
smaller AUCs.
[00348] After the 300 U oral insulin dose, mean blood glucose excursions
turned (until -20.8
mg/dL at 15 minutes after start of meal intake) and returned to baseline at 30
minutes. This
transient decline could be seen in most of the patients, but only in one
particular with a baseline
blood glucose below 80 mg/dL did it lead to a hypoglycemic episode. These
findings may indicate
a rapid onset of action of orally administered 300 U Insulin/400 mg 4-CNAB
prior to considerable
absorption of carbohydrates from the test meal. Therefore, a time span of 30
minutes between dose
administration and start of meal intake might be too long.
[00349] Mean fasting blood glucose values at baseline (-1 minute) which served
as reference for
the calculation of excursions, were 124.38 mg/dL (99.10-172.00) for oral 150 U
Insulin/200 mg 4-
CNAB, 120.26 mg/dL (72.20-175.00) for oral 300 U Insulin/400 mg 4-CNAB, 143.11
rng/dL
(104.00-190.00) for 12 U SC short-acting insulin, and 137.32 mg/dL (93.10-
183.00) for placebo.
With regard to these baseline values, the four treatments were split into two
groups: the two oral
treatments with values around 120 mg/dL, and the SC injection together with
placebo showing
values around 140 mg/dL. This finding may be explained by early action of the
oral insulin
formulations in the time between dose administration and start of meal intake,
which is not covered
by the profiles. However, the described non-homogeneity is not considered to
impair the quality of
103
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the results.
[00350] The concentration vs. time profiles for 4-CNAB display only the
elimination of the
substance from plasma. The absorption phase and the maximum concentrations are
missed. In the
time between -30 and +10 minutes, a rapid rise followed by a rapid decline can
be assumed, and the
achieved maximum concentrations should be markedly higher than the values seen
at 10 minutes
after start of meal intake. Therefore, further investigations of 4-CNAB
pharmacokinetics should
include an appropriate number of samples from the first hour following dose
administration.
[003511 The insulin profiles showed the highest AUC after 150 U oral insulin,
followed by
placebo, 300 U oral insulin, and 12 U SC short-acting insulin. The marked
increase of mean
plasma insulin concentrations after placebo indicates that the patients'
ability of endogenous insulin
production, induced by meal intake, was still maintained. Also the high AUC
for 150 U oral insulin
probably reflects mainly endogenous insulin production, and also the curves of
the other treatments
may account for a certain amount of endogenous insulin.
[00352] The C-peptide plasma concentration profiles confirm this view and also
indicate the
release of considerable amounts of endogenous insulin. The levels were highest
after 150 U oral
insulin, followed by placebo, 300 U oral insulin, and 12 U SC short-acting
insulin. As expected,
the 150 U oral dose and placebo led to the most marked increase, whereas the
increase after the 300
U oral dose and the 12 U SC injection was clearly lower, and these findings
correlate with the blood
glucose lowering effect seen for the different treatments: the lower the
effect of the external insulin
dose, the higher were the amounts of C-peptide as indicator of endogenous
insulin production.
[00353] The insulin concentration vs. time profiles seen for both oral doses
in this study are
considerably different from those obtained in Example 6 of International
Publication No.
WO 03057170, where mean insulin concentrations were back to baseline after
approximately two
hours and where maximum concentrations occurred after about half an hour.
These differences
might be due to the influence of the meal, stimulating endogenous insulin
release and also possibly
interfering with the resorption of the oral insulin preparations. In Example 6
of WO 03057170,
patients fasted during the entire experiment, and endogenous insulin
production was suppressed by
a constant low-dose insulin infusion. Therefore, the concentration vs. time
curves of Example 6 of
WO 03057170 represent more the pure pharmacokinetics of the administered
exogenous insulin,
whereas in the present study the effects of exogenous and endogenous insulin
are overlapping.
[00354] No adverse events were reported in this study. There were no treatment
related findings of
clinical laboratory safety parameters, vital signs, ECG or physical
examination. The five
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hypoglycemic episodes that occurred in four patients remained symptomless due
to immediate
intervention with intravenous glucose infusion. Only one of the episodes was
due to oral 300 U
Insulin/400 mg 4-CNAB, and the majority (4/5) occurred after 12 U SC short-
acting insulin
injection. Accordingly, all study treatments were well tolerated.
[00355] Overall, the study results suggest (based on the primary endpoint AUCo-
21) that orally
administered 300 U Insulin/400 mg 4-CNAB are effective in lowering the
postprandial rise of blood
glucose in type 2 diabetic patients. However, the effect is smaller than after
injection of 12 U SC
short-acting insulin, which is significantly superior to both oral
administrations. The oral dose of
150 U Insulin/200 mg 4-CNAB is similar effective as no treatment (placebo). At
both doses, orally
administered Insulin/4-CNAB seems to be well tolerated.
EXAMPLE 2
[00356] In this example, as also set forth in International Patent Application
No. PCT/US04/00273,
oral insulin capsule(s) described herein were orally administered to twenty
human subjects with
diabetes at night before going to sleep.
[00357] An open-label, single-dose, crossover study was conducted in order to
compare the safety
of orally administered 4-CNAB/Insulin formulation with that of subcutaneously
injected insulin in
two groups of subjects with type 2 diabetes mellitus -- one in the fasting
state and one after a
standard meal. The objectives were (1) to compare the safety, pharmacokinetics
and
pharmacodynamics of orally administered 4-CNAB/insulin with that of
subcutaneously injected
regular insulin in fasting type 2 diabetic subjects, and (2) to compare blood
glucose, insulin and
C-peptide levels after a standard meal with regular medication with blood
glucose, insulin and
C-peptide levels after a standard meal with 4-CNAB/insulin.
[00358] The focus of this study is the assessment of the safety of insulin/4-
CNAB, administered
orally at bedtime, to type 2 diabetic subjects. The purpose of the study was
to determine if the
administration of oral insulin at bedtime could exert effects on overnight-
fasting glucose
homeostatsis and insulin secretion. The postulated mode of action (e.g.,
suppressing the liver
production of glucose, and thus preventing 13-cell death or dysfunction of
insulin producing) was the
basis for the design of the study.
[00359] Twenty-four human subjects (patients) of age 35-70 years with elevated
fasting blood
glucose levels (type 2 diabetes), but in otherwise good general health on the
basis of a medical
history, physical examination, clinical laboratory studies, participated in
the study and were studied
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in the overnight-fasted state on two occasions, separated by an interval of at
least 7 days. The
following treatment conditions were studied:
Group 1: twelve (12) type 2 diabetic subjects: (a) oral insulin/4-CNAB ¨
fasted subjects,
and (b) empty capsule ¨ fasted subjects.
Group 2: twelve (12) type 2 diabetic subjects: (a) standard meal with regular
medication,
and (b) standard meal with oral human insulin/4-CNAB.
[00360] A total of twenty subjects participated in the second part of the
study, relating to the safety
of insulin/4-CNAB administered orally at bedtime, an additional four subjects
not being included
due to logistical considerations. These twenty subjects took an oral insulin
capsule(s) at night
before going to sleep. The trial took place at the home of the subject under
the supervision of a
bedside private duty nurse. The rationale to conduct the trial at the patient
own environment was
based on the fact that glucose homeostasis is best reflected when conducted in
a familiar
environment and changes significantly with hospitalization.
[00361] Fasting blood glucose, insulin and C-peptide levels were measured at
7:00 a.m. for three
days to establish baseline levels. On two successive nights and mornings
before taking the capsule,
the subjects measured their glucose levels with a glucometer (supplied). If
the subject's glucose
levels were >120 mg/dL on the first two mornings (fasting), on the 3rd night,
the subject took the
insulin capsule(s). If, on the first two successive mornings, the patient's
fasting blood glucose was
not greater than 120 mg/dL, then the patient was dismissed from the study and
all final study
procedures were performed as per the protocol. The subjects ate their regular
dinner at home, as
every evening, between the hours of 7:00 and 8:00 P.M. If the subjects usually
took medication for
the diabetes (metformin or acarbose) in the evening, they took their usual
dose.
[00362] At 11:00 p.m. (at least two hours after dinner), the subjects took one
oral insulin dose that
contained the following ingredients: 300 mg 4-CNAB and insulin according to
the dose (200-400
U) that the subject received during the first phase of the trial. If the
subject had received 200 U
insulin in the first phase of the trail and there was no drop in blood glucose
level (<15% reduction),
he now received 300 U of insulin. If the subject had received 300 U insulin in
the first phase of the
trail and there was no drop in blood glucose level (<15% reduction), he now
received 400 U of
insulin. None of the subjects received more than 400 U of insulin. The
capsules were prepared by
AAJ and have shown stability.
[00363] A nurse was present at the home of the subjects when they took the
oral insulin capsules
and throughout the night. The nurse checked the blood glucose level with a
glucometer before the
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subjects took the medication. In addition, blood was taken for further blood
glucose levels, insulin
and C-peptide. Orange juice was readily available for treatment in the
unlikely event of
hypoglycemia. During sleep the subjects wore a Glucowatch (which is a monitor
of blood glucose
and measures and records blood glucose levels at regular intervals). The
Glucowatch is equipped
with an alarm triggered when blood glucose levels reach predetermined blood
glucose levels
(hypoglycemic levels) determined by the investigator or patient. The bedside
private duty nurse
was also present during the night to monitor the patient. in the morning, when
the subjects woke up
(e.g., at 7:00 a.m.), the nurse checked their blood glucose level with the
glucometer. Additional
blood samples were taken for further blood glucose levels, insulin and C-
peptide. The blood
samples from the night before were stored in the refrigerator at home and in
the morning the nurse
brought the samples of blood (from the night and the morning) to the lab for
analysis.
[00364) There were no serious adverse effects in the course of the study. The
results of the
nighttime oral insulin study reported as the example herein (fasting blood
glucose, insulin and C-
peptide measured at approximately 7:00 a.m. and compared to the patient's own
baseline levels) are
set forth in Figures 9-12. The data (blood glucose, insulin and C-peptide)
collected in the morning
after nighttime dosing of insulin and 4-CNAl3 for each subject compared to
that subject's own
baseline levels is reported by patient in Table 45 (1LLTU/mL), and is
graphically represented in
Figures 9-11.
Table 45:
C-peptide Insulin Glucose
Subject # Control p.m. Control p.m. control p.m.
insulin insulin insulin
1 3.6 1.3 20.0 7.0 117 93
2 3.1 2.3 24.0 12.0 136 179
3 3.4 2.6 11.8 10.0 104 87
4 2.7 2.0 8.8 7.0 117 96
2.5 2.5 6.5 5.0 221 207
6 2.1 1.6 1 7.0 5.0 210 226
7 1.8 1.6 ! 11.0 7.0 78 100
8 1.9 2.0 8.8 8.0 199 137
9 3.8 2.8 16.5 16.0 112 126
0.9 1.2 5.0 6.0
11 2.7 2.2 17.0 12.0
12 3.0 1.4 13.0 7.0 125 107 '
13 2.9 2.3 18.0 10.0 124 103
14 1.4 1.3 9.3 5.0 123 104
2.6 1.3 ' 17.0 5.0 93 78
16 I 4.9 3.3 , 99.0 23.0 156 173
17 9.6 2.0 ! 19.8 12.0 144 125
18 2.3 1.3 ! 16.0 8.0 142 121
19 I 2.6 1.9 14.0 8.0 84 84
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20 2.9 3.8 5.5 14.0 123 118
Average 2.69 2.04 13.90 9.35 133.78 125.78
Std Dev 0.88 0.71 6.44 4.52 40.53 42.99
Std Error 0.20 0.16 1.44 1.01 9.55 10.13
Mean
Ttest 0.00079 0.00073 0.16806
0.00039 0.00036 0.08403
[00365] The overnight study demonstrated that the metabolic effect of a single
dose of oral insulin
was still apparent in the morning, i.e., about eight hours after
administration. As a result, there was
a decrease in blood glucose output from the liver. As shown in Figure 9
(effect on blood glucose),
there was no statistically significant difference between the baseline blood
glucose levels and the
blood glucose levels in the patients after administration of the nighttime
oral insulin capsules.
Blood glucose measured the morning after administration decreased by 6% from
baseline levels,
i.e., from 133.78 40.53 mg/dL to 125.78 42.99 (p=0.017).
[00366] On the other hand, in all patients, a statistically significant
reduction in C-peptide and
insulin was detected in the morning (while the glucose levels were somewhat
unchanged). A
consistent compensatory decline in C-peptide levels from baseline by a mean of
24%, i.e., from
2.69 0.88 ng/mL to 2.04 0.71 (p<0.001) indicated that there was less
activity in the 3-cells that
secrete endogenously produced insulin. Plasma insulin levels were reduced by a
mean of 33%, i.e.,
from 13.90 6.44 tzU/mL to 9.35 4.52 (p<0.001). These results are
graphically depicted in
Figures 3 and 4, respectively.
[00367] The interpretation of these results is that a "boost" of exogenous
insulin at nighttime
allows the patients' 3-cells to rest and produce less insulin to achieve the
same glycemic level. The
suggested clinical implication is that, if such treatment were to be given
(bedtime oral insulin)
alone, it is likely to spare 13-cell function as these cell become
dysfuctional or die from exhaustion.
This significance is supported by several reported studies which have shown
that by intervening
"aggressively" with insulin at early stages of the disease (such as IGT or
"impaired glucose
tolerance" stage), by giving insulin even for a short time such as two week
duration, that this "rest"
to the cells may provide for long tenn protection to develop overt diabetes.
[00368] It was further seen in this study that none of the patients had a
clinically significant
hypoglycemic episode, despite that the insulin was administered to the
patients in the fasting state
and with continued fasting. This result supports the conclusion that the
administration of oral
insulin formulations as described herein will be safe in terms of
hypoglycemia.
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EXAMPLE 3
Preparation of Insulin/4-CNAB (75U/100mg) Tablets
[00369] This example describes the manufacturing procedure for Insulin/4-CNAB
tablets. Each
tablet contained about 75 units of insulin USP (equivalent to about 2.82 mg of
recombinant human
insulin with an as-is potency of about 26.6 U/mg) and about 100 mg of 4-CNAB
monosodium salt.
Composition of formulation (theoretical, all numbers are approximate):
Component Weight (mg)/ tablet
4-CNAB, monosodium salt 100
Insulin 2.82
Povidone 0.41
Anhydrous Emcompress (extragranular) 45.27
Magnesium Stearate (extragranular) 1.5
Total 150
[00370] 4-CNAB and povidone (KOLLIDON 90F (BASF Corporation, Mount Olive,
NJ)) were
weighed. KOLLIDON 90F was dissolved in 15% w/w water. Insulin (obtained from
Diosynth,
Inc.) was suspended in the KOLLIDON solution, and then 4-CNAB was granulated
using the
insulin suspension as granulation media. Granulation was completed with
additional water, as
required. Granules were dried in a vacuum oven at about 50 C. Partly dried
granules (about 0-10%
w/w, preferably about 2-3% w/w moisture) were milled through about 0.02 inch
screen using
hammer mill. Drying was continued to a final moisture content of less than
about 0.6% w/w.
[00371] Dried granules were assayed for insulin and 4-CNAB. Based on the assay
results, amounts
of excipients (Anhydrous EMCOMPRESS (dicalcium phosphate (JRS Pharma LP,
Paterson, NY)
and magnesium-stearate) were calculated and weighed. Insulin/4-CNAB granules
and anhydrous
EMCOMPRESS were blended in a V-blender for about 15 minutes. Samples were
analyzed for
blend uniformity. If samples passed blend uniformity specifications, magnesium
stearate was
blended for about 3 minutes. If samples did not pass blend uniformity
specifications, then the mix
was blended for an additional about 5 minutes, and the assay and analysis
steps were repeated.
Tablets were compressed on an EK-0 single station press with a hardness of
about 71(P.
[00372] The resulting tablet had a hardness of about 7.6 kP, a thickness of
about 2.8 mm, a
diameter of about 7.1 mm, a friability of 0.00% and a disintegration time of
about 5 minutes. The
dose for this preparation was about four tablets per patient, as described in
Example 3 below.
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Preparation of Insulin/4-CNAB (75U/100mg) Tablets
[00373] The resulting tablets were studied to determine whether they would
remain within
specification when stored under recommended storage conditions in order to
provide evidence on
how the product quality varies with time under the influence of temperature
and humidity. The
stability tests were conducted in compliance with the U.S. Federal Drug
Administration current
Good Manufacturing Practice Standards, 21 C.F.R. 210 and 211, and the
International Conference
on Harmonization (ICH) Guidance, ICH Q1A (R2), using qualified equipment, test
methods and
personnel.
[00374] Tablet samples were packaged in a number of closed containers that
were then placed in
controlled temperature and humidity chambers. For room temperature stability
tests, the containers
were stored at 25 C 2 C / 60% 5 % Relative Humidity. Samples were then
drawn from these
chambers at specified time intervals and tested for conformance to the product
stability
specifications with regard to appearance (method No. AM001v2), insulin assay
(method no.
AM018), 4-CNAB assay (method no. AM018), moisture (method no. USP<921>),
disintegration
(method no. USP <701>) and, in some cases, microbial testing (method no. USP
<1111>).
[00375] The following Table 46 shows the stability data for tablets of 75 U
Insulin/100 mg
4-CNAB under 25 C 2 C 160% 5 % Relative Humidity conditions.
Table 46:
TIME (months)
D.5 1 2 3 6
TEST METHODS SPECIFICATIONS Bulk Release
(8/20/03) (9122103) (12/19/03)
APPEARANCE (visual) White, off-white or tan tablets Conforms Conforms
Conforms Conforms Conforms Conforms
DISINTEGRATION Report the time required for
mm. 5.25 min 5 min 5 mm, 5 min. 5.5
mm
(USP) disintegration of six tablets
MOISTURE CONTENT Report result 1.2% 2.8% 2.6% 3.6% 1.7%
1.1%
INSULIN ASSAY
90.0¨ 110.0% Label Claim 100.1% 96.4% 96.7% 92.0% 87.6%
83.3%
(HPLC)
4-CNAB ASSAY 90.0¨ 110.0% Label Clain
96.9% 97.1% 96.8% 98.6% 97.2%
98.6%
(HPLC)
Total Bacterial Count NMT 1000 CFLlig <100 N/A N/A N/A N/A
N/A
Total Mold and Yeast NMT 100 CFU/g <100 N/A N/A N/A N/A
N/A
Staphylococcuc
aureus Absent Absent
Pseudomonas Absent Absent
aeruginosa Absent Absent N/A NIA N/A NIA N/A
Salmonella Absent Absent
=
Esc/mar/chin co/i WIT 100/g I Absent
Enterobecterio
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[00376] The insulin molecule appears to be stable (>90%) in the 75 U
Insulin/100 mg 4-CNAB
insulin tablet formulation when stored for two months at 25 degrees C and 60%
Relative Humidity
(25/60).
EXAMPLE 4
Pre_paration of Insulin/4-CNAB (150U/80mg) Tablets
[00377] This example describes the manufacturing procedure for Insulin/4-CNAB
tablets. Each
tablet contained about 150 units of insulin USP (equivalent to about 5.64 mg
of recombinant human
insulin with an as-is potency of about 26.6 U/mg) and about 80 mg of 4-CNAB
monosodium salt.
The insulin used in this study was obtained from Diosynth, Inc. and met the
specifications for
Human Insulin as described in the United States Pharmacopoeia.
Composition of formulation (theoretical, all numbers are approximate):
Component Weight (mg)/ tablet
4-CNAB, monosodium salt 80
Insulin 5.64
Povidone 0.35
Anhydrous EMCOMPRESS 37.76
Magnesium Stearate 1.25
Total 125
[00378] 4-CNAB and KOLLIDON 90F were weighed. KOLLIDON 90F was dissolved in
water. The amount of water used in this step was about 1-50%, preferably about
15% w/w of the
amount of material used in the granulation. Insulin (obtained from Diosynth,
Inc.) and 4-CNAB
were geometrically blended and charged to the 5L bowl of a Key Instruments KG-
5 high shear
granulator. The insulin/4-CNAB blend was then granulated using the KOLLIDON
solution. The
granulation was finished with additional water as required. Granules were
dried in a vacuum oven
at about 20-80 C, preferably about 50 C. Partly dried granules (about 0-10%
w/w, preferably about
2-3% w/w moisture) were milled through about 0.02 inch screen using hammer
mill. Drying was
continued to a final moisture content of less than about 0.6% w/w.
[00379] Dried granules were assayed for insulin and 4-CNAB. Based on the assay
results, the
amounts of excipients (Anhydrous EMCOMPRESS and magnesium stearate) were
calculated and
weighed. Insulin/4-CNAB granules and anhydrous EMCONTPRESS were blended in a
V-blender
for about 10-20 minutes, preferably about 15 minutes. Samples were analyzed
for blend
uniformity. If samples passed blend uniformity specifications, magnesium
stearate was blended for
about 1-5 minutes, preferably about 3 minutes. If samples did not pass blend
uniformity
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specifications, then the mix was blended for an additional about 1-10 minutes,
preferably about 5
minutes, and the assay and analysis steps were repeated. Tablets were
compressed on an EK-0
single station press with a hardness of about 5KP-10KP, preferably about 7KP.
The resulting tablet
had a hardness of about 7.8 IS, a thickness of about 2.8 mm, a diameter of
about 6.5 mm, a
friability of 0.02% and a disintegration time of about 6 minutes.
Preparation of Insulin/4-CNAB (150U/80mg) Tablets
[00380] The resulting tablets were studied to determine whether they would
remain within
specification when stored under recommended storage conditions in order to
provide evidence on
how the product quality varies with time under the influence of temperature
and humidity. The
stability tests were conducted in compliance with the U.S. Federal Drug
Administration current
Good Manufacturing Practice Standards, 21 C.F.R. 210 and 211, and the
International Conference
on Harmonization (ICH) Guidance, ICH Q1A (R2), using qualified equipment, test
methods and
personnel.
[00381] Tablet samples were packaged in a number of closed containers that
were then placed in
controlled temperature and humidity chambers. For room temperature stability
tests, the containers
were stored at 25 C 2 C / 60% 5 % Relative Humidity. Samples were then
drawn from these
chambers at specified time intervals and tested for conformance to the product
stability
specifications with regard to appearance (method No. AM001v2), insulin assay
(method no.
AM018), 4-CNAB assay (method no. AM018), moisture (method no. USP<921>),
disintegration
(method no. USP <701>) and, in some cases, microbial testing (method no. USP
<1111>).
[00382] The following Table 47 shows the stability data for tablets of 150 U
Insulin/80 mg
4-CNAB under 25 C 2 C / 60% 5 % Relative Humidity conditions.
TIME (months)
TEST METHODS SPECIFICATIONS Bulk Release 0.5 1 2 3 6
(6/20/03) (7/7/03) (7/21/03) (8/20/03) (9/22/03) (12/19/03)
APPEARANCE (visual) White, off-white or tan tablets Conforms Conforms
Conforms Conforms Conforms Conforms
Report the time required for
DISINTEGRATION (USP)5 min. 4.5 min 4.5 min 4.5 mm. 4.5
mm. 5 min.
disintegration of six tablets
MOISTURE CONTENT Report result 1.2% 4.2% 3.5% 4.3% 3.3%
2.2%
INSULIN ASSAY (HPLC) 90.0- 110.0% Label Claim 100.1% 104.5% 106.4%
103.3% 102.0% 99.1%
90.0 - 110.0% Label Claim
4-CNAB ASSAY (HPLC) 96.9% 104.7% 101.9% 104.0% 103.0%
104.2%
Total Bacterial Count NMT 1000 Cake <100 N/A N/A N/A
N/A N/A
Total Mold and Yeast NMT 100 CFU/g <100 N/A N/A N/A
N/A N/A
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Staphylococcus aureus
Absent Absent
Pseudomonas
Absent Absent
aeruginosa
Absent Absent N/A N/A N/A N/A N/A
Salmonella
Absent Absent
Escherichia coli
NMT 100/g Absent
Enterobacteria
1003831 The insulin molecule appears to be stable (>90%) in the 150 U
Insulin/80 mg 4-CNAB
insulin tablet formulation when stored for six months at 25 degrees C and 60%
Relative Humidity
(25/60). By comparison, a 150 Insulin/200 mg 4-CNAB capsule formulation
yielded spurious
HPLC data after two months, and a result below 90% after three months. The
differences between
the capsule and tablet formulations are that capsules allow higher surface
area exposure to
atmosphere, had a higher level of 4-CNAB, contained hydrous rather than
anhydrous dicalcium
phosphate, and contained sodium lauryl sulfate (a potential insulin
denaturant).
EXAMPLE 5
Preparation of 4-CNAB (100mg) Tablets
This example describes the manufacturing procedure for 4-CNAB tablets. Each
tablet
contains about 100 mg of 4-CNAB monosodium salt.
Composition of formulation (theoretical, all numbers are approximate):
Component Weight (mg)/ tablet
4-CNAB, monosodium salt 100
Povidone 0.4
Anhydrous EMCOMPRESS 48.1
Magnesium Stearate 1.5
Total 150
1003841 4-CNAB and povidone (KOLLIDON 90F (BASF Corp., Mount Olive, NJ)) were
weighed. KOLLMON 90F was dissolved in water. The amount of water used in this
step should
be about 1 ¨ 50%, preferably about 15% w/w of the amount of material used in
the granulation. 4-
CNAB was granulated using the KOLLIDON4 solution as granulation media.
Granulation was
completed with additional water, as required. Granules were dried in a vacuum
oven at about 20-
80 C, preferably about 50 C. Partly dried granules (about 0-10% w/w,
preferably about 2-3% w/w
moisture) were milled through about 0.02 inch screen using hammer mill. Drying
was continued to
a final moisture content of less than about 1.0%, preferably less than about
0.6% w/w. Based on
final moisture content, amounts of excipients (anhydrous EMCOMPRESSQT
(dicalcium phosphate
(IRS Pharma PL,Patterson, New Yorl())and magnesium stearate) were calculated,
weighed and
screened. 4-CNAB granules and anhydrous EMCOMPRESS' were blended in a V-
blender for
about 10-20 minutes, preferably about 15 minutes. Magnesium stearate was added
and blended for
about 1-5 minutes, preferably about 3 minutes. Tablets were compressed on an
EK-0 single station
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press with a hardness of about 5KP-101CP, preferably about 7KP.
EXAMPLE 6
100385] In this example, a single-blind, crossover study was done in order to
assess the safety,
tolerability, pharmacokinefics and pharmacodynamics of oral Insulin/4-CNAB
tablets in fasted and
pre-prandial type 2 diabetic patients. A crossover design was selected for
this study so as to reduce
the inter-subject variability and to allow maximum use of the limited sample
size, and a blinded
study design was selected in order to reduce the bias from the patient side.
[00386] Eight (8) male subjects. aged 30 to 65 inclusive and having a body
mass index <32 kg/n2,
with clinically documented diet-controlled type 2 diabetes and a fasting blood
glucose level of
<150 mg/dL, were chosen for this study. These patients were generally in good
health, evidenced
by lack of significant findings in medical history, physical examination,
clinical laboratory tests,
vital signs and ECG, and liver and kidney laboratory evaluations within normal
limits. These
patients had neither current nor past use of insulin to control their
diabetes, and no clinically
significant disease or abnormal condition of the liver, kidneys, or
gastrointestinal system.
1003871 The subjects fasted for at least 8 hours overnight prior to
administration of each dosage,
and each study drug was administered with exactly 150 mL of water and followed
by a 72 hour
wash-out period in order to eliminate pharmacological treatment interactions.
An indwelling
catheter was inserted for pharmacoldnetic, pharmacodynamic and clinical blood
sample collection.
The study drug regimen was as follows:
- Period 1: Subjects were administered four 4 tablets of 75 U Insulin/100 mg 4-
CNAB (total dose
300 U Insulin/400 mg 4-CNAB) in the morning and remained in a fasted state for
4.5 hours.
- Period 2: Subjects were administered four tablets of 75 U Insulin/100 mg
4-CNAB (total dose 300
U Insulin/400 mg 4-CNAB) exactly 10 minutes before receiving a standard ADA
breakfast.
- Period 3: Subjects were administered two tablets of 150 U Insulin/80 mg 4-
CNAB (total dose 300
U Insulin/160 mg 4-CNAB) in the morning and remained in a fasted state for 4.5
hours.
- Period 4: Subjects were administered two tablets of 150 U Insulin.! 80 mg
4-CNAB (total dose 300
U Insulin/160 mg 4-CNAB) exactly 10 minutes before receiving a standard ADA
breakfast.
- Period 5: All the subjects were administered 300 U Insulin with 160 mg of 4-
CNAB (2 tablets).
Three patients were administered one tablet containing 150 U insulin/80 mg 4-
CNAB exactly 10
minutes before breakfast and one tablet containing 150 U Insulin/80 mg 4-CNAB
exactly 0 minutes
before breakfast. Five patients were administered two tablets containing a
total of 300 U Insulin/
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WO 2004/080401 PCT/US2004/006943
160 mg 4-CNAB exactly 0 minutes before breakfast (N=5)
- Period 6: Subjects were administered two tablets of 100 mg 4-CNAB (total
dose 200 nig
4 CNAB) exactly 10 minutes before receiving a standard ADA breakfast.
[003881 The dose levels for this study were selected based upon previous human
experience in both
healthy and diabetic subjects, wherein up to 450 U Insulin/600 mg 4-CNAB has
been safely
tolerated in Diabetes Type 1 and Type 2 patients. The formulation and dose
ratio of insulin to
4-CNAB were chosen to investigate a drug/carrier ratio-response relationship
for formulation
optimization. The 75 U Insulin/100 mg 4-CNAB tablets and the 150 U Insulin/80
mg 4-CNAB
tablets were manufactured as described in Examples 1 and 2 above,
respectively.
[00389] Blood samples for pharmacoldnetie analysis of 4-CNAB, insulin and C-
peptide and for
pharmacodynamic analysis of insulin and glucose were collected at each period
at the following
times (except that 4-CNAB was not measured after the sixth period):
- 4-CNAB (12 samples): 5 minutes pre-study dose; and 5, 10 ,15, 20, 25, 30,
40, 50 and 60 minutes,
and 2 and 4 hours post-study dose.
- Insulin (13 samples): 15 and 5 minutes pre-study dose; and 5, 10, 15, 20,
25, 30, 40, 50 and 60
minutes, and 2 and 4 hours post-study dose.
- C-peptide (9 samples): 15 and 5 minutes pre-study dose; and 10, 20, 30, 40
and 60 minutes, and 2
and 4 hours post study dose.
- Plasma or blood glucose (13 samples): 15 and 5 minutes pre-study dose; and
5, 10, 15, 20, 25, 30,
40, 50 and 60 minutes, and 2 and 4 hours post-study dose (blood glucose used
the SuperGL
equipment; plasma used an Elisa assay).
[00390] The pharmacokinefic parameters determined or calculated from the
plasma concentration
time data for 4-CNAB were C., t, t%, AUCNast, AUCirth AUCo-t, and CL/F. The
pharmacolcinetic parameters determined or calculated from the plasma
concentration time data for
insulin and C-peptide were Cmax, tmax, AUCO-t (for t = 1, 2), AUCNast and AUC0-
int=
[00391] The pharmacodynamic parameters computed from the plasma concentration-
time data of
glucose were percent decrease from baseline, absolute blood glucose
concentration, Emax, te,,,x and
EAUClast=
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Pharmacolcinetic/Pharrnacodynamie Evaluation
[00392] Data collected following administration of oral Insulin/4-CNAB
tablets, namely, the
concentrations of 4-CNAB, insulin, C-peptide and glucose, in fasted and pre-
prandial type 2
diabetic patients will now be presented.
[00393] Table 48 below sets forth the data for mean blood glucose change vs.
time:
Table 43: Mean Percent Change from Baseline Blood Glucose vs. Time
1 ______________________________________________________________________
4-CNTAB
30011/400mg 300U/160mg 150U/80mg -10min
300U/160mg alone 10
time 300U/400mg 10 min meal I 300U/160mg 10 win meal +150U/80mg @0 0
min meal min meal
(min) fasted (N=8) (1N=8) I fasted (N=3) (N=8) min w/
meal (N=3) (11=5) 01=7)
Mean (%)
0 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
-1.6% 3.2% . -0.3% -1.0% -1.0% -0.4% -0.6%
-3.5% 0.8% 1 -2.1% -2.2% -2.7% 0.5% -1.9% _
-3.7% -1.3% -2.8% -2.6% -3.9% 4.6% -0.6%
-4.7% -4.1% -4.8% -4.5% -7.0% 7.7% 0,4%
-7.4% -0.1% -6.5% -1.5% -0.1% 13.1% 6.4%
-
-9.3% 5.4% -9.4% 3.5% 4.9% 19.1% 18.6%
-13.1% 18.3% -14.9% 10.4% 16.8% 30.3% 33.3%
-17.0% 26.9% ' -16.9% 15.9% 45.7% 35.9% 47.4%
-16.0% 32.7% -16.9% 21.1% 49.1% 35.8% 49.5%
90 -13.0% 37.4% -11.8% 23.0% 57.8% 33.3% 49.5%
120 -7.7% 28.3% -6.5% 22.0% 50.8% 27.5% 44.9%
150 -11.7% 15.2% -5.8% 13.4% 26.4% 14.3% 28.9%
180 -8.3% 4.3% -3.1% 8.2% 6.2% 4.8% 20.1%
210 -9.4% -4.0% -4.5% -1.0% -4.4% -5.7% 11.1%
240 -9.2% -4.7% , -5.4% -3.5% -9.4% -11.3% 2.0%
Standard Deviation (SD)
0 0.00% , 0.00% 0.00% 0.00% 0.00% 0.00% I 0.00%
5 4.78% 8.87% 2.85% 2.95% 1.89% 3.26% ; 3.05%
10 3.77% 6.64% 1 2.59% 3.08% 4.86% 3.84% 4.87%
15 6.19% 5.84% 2.05% 2.90% 2.20% 7.96% 5.23%
20 5.53% 7.98% 1 2.87% 3.87% 1.57% 10.28% 7.28%
25 5.49% 7.54% 4.33% 4.65% 6.82% 4.95% 11.65%
30 5.63% 12.11% 6.87% 3.87% 14.96% 4.93% 14.10%
40 8.12% 14.58% 10.52% 5.52% 18.98% 3.71% 18.58%
50 11.59% 17.06% 1 12.63% 5.42% 20.84%1.75% 1 23.62%
60 13.54% 18.72% 1 13.48% 5.41% 22.51% 6.84% 1 20.86%
90 13.06% 18.69% . 6.71% 6.73% 17.22% 12.49% 16.85%
120 10.53% 23.90% 6.11% 5.39% 26.58% 16.76% 13.15%
= 150 13.68% 22.17% 5.80% 6.10% 12.97% 17.34%
10.48%
180 9.31% 20.37% 6.38% 9.01% 11.04% 14.88% 13.00%
210 11.74% 19.78% 5.20% 9.30% 8.55% 14.22% 10.21%
240 8.89% 14.05% 5.17% 10.12% 6.82% 10.41% 1 8.62%
[00394] Figure 12 shows graphs of mean (for all eight subjects) percent change
in blood glucose
concentration from baseline levels following oral administration of the
various Insulin/4-CNAB
tablet combinations and control described above to Type 2 diabetic patients,
both with and without
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a meal. The mean Figure 12 is based upon Figures 15-22, which show percent
change in blood
glucose concentrations from baseline levels for subjects 101-108 following
oral administration of
the various Insulin/4-CNAB tablet combinations described above. The oral
insulin/4-CNAB tablets
appeared to be well-tolerated in Type 2 diabetes patients.
[00395] These figures show that the oral insulin tablets exhibited a fast on-
set of action and
produced significant reduction is glucose excursion in Type 2 diabetes
patients when compared to
the control (4-CNAB alone). This is shown clearly in Figure 2, which shows a
comparison of
graphs of the mean percent change in blood glucose concentration following
oral administration of
Insulin/4-CNAB tablet combinations vs. control, all taken with a meal. It can
be seen that all
Insulin/4-CNAB tablet formulations provided a significant (p<0.0005) reduction
in post-prandial
glucose excursions when compared to the formulation without insulin (control,
4-CNAB alone).
(There was no significant difference in fasting glucose excursion reduction
between the
formulations.)
[00396] Figure 13 also shows that the 300U insulin/160 mg 4-CNAB ratio
appeared to have been
more effective at delivering insulin than was the 3001J insulin/400 mg 4-CNAB
ratio, because the
300U insulin/160 mg 4-CNAB ratio produced a slightly greater decrease in blood
glucose when
administered 10 minutes prior to a meal than did the 300U insulin/400 mg 4-
CNAB ratio.
Therefore, at controlling post-prandial glucose excursion, the 3001J
insulin/160 mg 4-CNAB ratio
appeared to be at least as effective as, if not more effective than, the 300U
insulin/400 mg 4-CN_AB
ratio.
[00397] Figure 13 also indicated that the 300U insulin/160 mg 4-CNAB ratio,
when administered 0
minutes prior to a meal (N=5), showed a lower blood glucose excursion profile
than did the control
(4-CNAB alone) when administered 10 minutes prior to a meal. This shows that
the 300U
insulin/160 mg 4-CNAB tablet dose was t absorbed and produced a desired effect
when
administered at mealtime.
[00398] For the 300U Insulin/160 mg 4-CNAB tablets, whose ratio appears in
this study to perform
best at lowering glucose excursions, Figure 3 shows a comparison of the mean
(for all eight
subjects) percent change in blood glucose concentration following oral
administration at 10 minutes
before a meal and fasting (compared to the control at 10 minutes before a meal
n=7).
[00399] Figure 23 shows graphs of mean (for all eight subjects) percent change
in plasma glucose
concentration from baseline levels following oral administration of the
various Insulin/ 4-CNA13
tablet combinations described above to type 2 diabetic patients, both with and
without a meal.
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,
figure 24 shows a comparison of the mean (for all eight subjects) percent
change in plasma glucose
concentration for only the 300U Insulin/160 mg 4-CNAB tablets and the 4-CNAB
alone tablets, in
both cases 10 minutes before a meal. These figures are similar to Figures 12
and 14, except that
plasma glucose concentration, instead of blood glucose concentration, was
measured.
1004001 Table 49 below sets forth the data for mean absolute blood glucose
concentration vs. time:
Table 4.9: Mean Blood Glucose Concentration vs. Time
, ___________________________________________________________________________
4-CNAB
30011/400mg 3001J/160mg 15011/80mg -
10min 300U/160mg alone 10
time 30013/400mg 10 min meal 300U/160mg 10 mm meal + 150U/80mg @ 0
0 min meal min meal
(min) fasted (N=8.1 (N=8) fasted (N=8) (N=8)
min iv/ meal (1'i=3) (N=51 (N=7)
Mean (ing/t1L)
-15 134 128 128 130 134 127 133
_
, ___________________________________________________________________________
-5 135 130 129 129 135 127 133
, 132 134 128 127 133 126 132
130 130 124 125 131 127 131
-
130 127 123 _ 124 129 132 132
128 123 119 120 I 125 137 133
_ 25 125 129 115 126 134 144 141
122 137 109 136 140 152 157
-
117 156 98 150 155 166 176
112 168 94 161 192 172 195
113 176 94 172 197 172 197
90 117 183 105 175 209 169 198
_ 120 124 170 _ 115 173 198 162
192
-
150 115 151 117 156 170 145 171
180 124 135 122 146 , 143 133 158
210 123 123 119 127 129 119 147
240 121 122 117 122 122 112 136
-
Standard Deviation (SD) .
-15 21.0 18.5 13.0 23.9 28.1 16.9
29.2
-5 21.6 15.5 I 17.6 26.6 27.8
16.9 29.3
5 21.2 18.1 18.5 25.1 27.6 16.0
28.1
10 24.2 18.7 15.9 24.4 28.5 15.1
28.7
15 22.6 16.6 15.3 21.3 24.4 14.4 ,
29.4
_ 20 21.7 16.1 14.3 22.1 24.3 21.2
27.7
25 18.2 20.8 13.9 25.0 26.2 19.8
26.4
30 18.0 27.8 16.5 24.8 27.0 25.1
32.3
40 , 20.4 27.4 20.0 28.9 25.1 25.1 36.3
_
50 21.1 28.3 23.8 28.7 16.1 21.4
41.4
60 23.4 1 31.0 25.9 24.4 15.7
18.6 37.5
90 23.4 30,4 16.2 29.9 24.4 24.1
40.3
120 25.4 36.1 19.6 25.8 17.4 29.1
40.6
150 22.1 30.1 20.8 28.2 37.6 30.3
36.4
180 25.7 29.2 22.3 32.6 36.0 26.9
30.7
210 29.0 28.4 22.8 27.7 33.1 19.4
32.5
240 26.5 24.3 I 21.3 27.3 25.0
13.5 32.9
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[00401] Figure 25 shows graphs of mean (for all eight subjects) blood glucose
concentration
following oral administration of the various Insulin/4-CNAB tablet
combinations described above
to type 2 diabetic patients, both with and without a meal. The mean Figure 25
is based upon
Figures 26-33, which show blood glucose concentration vs. time curves for
subjects 101-108
following oral administration of the various Insulin/4-CNAB tablet
combinations described above.
[00402] Table 50 below sets forth the data for mean serum insulin
concentration vs. time:
Table 50: Mean Serum Insulin Concentration vs. Time
I 4-CNAB
300U/400mg 3000160ing 150U/80mg -10min 300U/160mg
alone 10
time 300U/400mg 10 inin meal 300U/160mg 10 mm meal
+150U/80mg @ 0 0 min meal min meal
(min) fasted (N=8) (N=8) fasted P4=8) (N=8) min w/ meal
(N=3) (N=5) (Iv=7)
Mean (nghnL)
-15 18.9 23.2 22.2 21.6 /1.7 17.0 19.7
-5 19.6 21.7 18.6 20.1 17.1 20.3 18.7
22.1 24.9 25.8 31.3 16.8 26.7 15.3
42.2 56.3 100.4 62.4 40.5 42.7 17.9
81.7 78.5 168.0 65.9 63.2 47.4 24.8
90.1 61.6 147.9 53.0 72.3 50.7 28.7
66.3 50.3 , 119.7 51.7 81.4 51.9 33.0
49.9 54.3 84.8 52.1 95.0 55.3 45.2
29.2 57.4 42.7 56.0 98.5 66.4 58.6
20.5 61.6 25.4 66.4 106.1 74.4 66.0
29.4 73.9 20.5 73.1 113.4 83.3 78.7
120 17.3 71.6 12.1 83.6 104.9 93.4 83.9
240 15.9 25.2 15.0 47.9 18.2 69.1 24.9
Standard Deviation (SD)
-15 11.04 19.45 16.74 19.31 8.21 14.09 15.78
-5 9.63 11.65 8.50 16.51 5.39 12.01 14.51
5 10.60 14.30 15,27 20.42 5.77 12.07 7.80
10 31.64 23.07 64.02 29.82 6.13 24.88 13.74
15 58.49 37.67 117.46 26.96 2293 21.72 11.95
20 75.06 26.64 94.77 30.10 33.52 18.23 14.36
25 45.23 18.65 94.68 30.23 42.76 17.23 21.17
_
30 . 33.72 30.31 61.13 36.87 65.55 22.10
27.94
40 19.17 40.97 27.22 37.80 78.31 45.79 43.33
50 9.20 51.21 13.22 50.09 I 59.32 56.60 1 46.39
60 30.81 59.88 9.31 54.07 58.8371.24 57.68
120 9.12 32.46 5.64 89.48 32.72 63.82 47.49
240 6.95 21.15 6.37 84.60 8.25 91.69 I 18.01
[00403] Figure 34 shows curves of mean (for all eight subjects) serum insulin
concentration
following oral administration of the various Insulin/4-CNAB tablet
combinations described above
to type 2 diabetic patients, both with and without a meal. The mean Figure 34
is based upon
Figures 36-43, which show graphs of serum insulin concentration vs. time
following oral
administration of the various Insulin/4-CNAB tablet combinations described
above for subjects
101-108, both with and without a meal.
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[00404] Figure 35 shows a comparison of graphs of mean (for all eight
subjects) serum insulin
concentration vs. time for only the 300U Insulin/160 mg 4-CNAB tablets (both
fasted afterwards
and at 10 minutes before a meal) and the control (4-CNAB alone) 10 minutes
before a meal.
1004051 The C. was somewhat higher, and the trna, was somewhat later, for the
fasted state than it
was for the prandial state (administration 0 or 10 minutes prior to a meal) in
both the 300U
insulin/160 mg 4-CNAB ratio group and the 300U insulin/400 mg 4-CNAB ratio
group. For
example, for the 300U insulin/160 mg 4-CNAB ratio tablet, mean fasted C. was
about 170
p.U/mL and mean fasted t,,,,,, was at about 20 minutes post administration,
and mean Cõ,aõ was about
65 uU/mL and mean t.; was at about 15 minutes post administration when
administered 10
minutes prior to a meal. Similarly, for the 300U insulin/400 mg 4-CNAB ratio
tablet, mean fasted
Cmax was about 90 U/mL and mean fasted tma,, was at about 20 minutes post
administration, and
mean Cma, was about 75 uIJ/mL and mean tmax was at about 15 minutes post
administration when
administered 10 minutes prior to a meal.
[00406] Table 51 below sets forth the data for mean plasma 4-CNAB
concentration vs. time:
Table 51: Mean Plasma 4-CNAB Concentration vs. Time
300U/400mg 300U/160mg 150U/80mg 10min meal + 300U/160mg
0
time 300U/400mg 10 mm meal 300U/160mg 10 min meal 150U/80mg 0
min meal min meal
(min) , fasted (N=8) (N=8) fasted (N=8) (N=8) (N=3) (N=5)
Mean (tig/nzL)
0 0 1,680 1 177 0 0 0
1,703 1,445 1 716 772 223 488
4.903 9,274 2,416 3,181 990 2283
8.081 12,134 1 4,459 5.109 2,622 3,590
9.468 14,489 5,461 4,564 5,593 4,230
11.184 13,875 5,460 4.650 5,743 4,010
12,969 11.519 4,624 3,808 5,550 4,014
11,340 7,469 3,098 2,607 4,647 2,598
7,270 4,815 2,273 1.641 2,810 2,106 1
5,245 3,598 1,789 1.197 2,147 1,539
i 120 2,513 1,653 1,199 607 662 820
240 344 732 145 303 224 243
Standard Deviation (SD)
0 0.0 0.0 0.0 0.0 0.0 0.0 1
5 2,494.0 749.2 572.8 856.2 210.0 290.8
10 3,523.6 8,713.2 1,495.1 2,684.1 1,010.5 361.0
15 4,394.9 6,250.0 3,881.1 3,846.0 1,421.3 2,544.2
20 4,930.2 6,734.3 4,492.7 3,890.2 987.6 7,035.0
25 6,337.2 9,503.9 3.787.1 2,899.7 1,682.0
6,457.8
30 6,952.6 6,393.7 2.270.2 2,095.7 1,980.6 5,359.2
40 6,877.7 3,483.1 1,227.4 1,007.7 1,657.5 3,256.2
50 3,250.3 2,041.4 613.5 572.0 1,061.3 155.2 i
60 1,870.0 1,289.1 604.3 408.1 684.1 484.0 1
120 2,823.8 523.9 1,071.5 256.1 667.9261.2 1
240 134.7 722.1 72.6 253.2 197.6 160.0 1
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[00407] Figure 33 shows graphs of mean (for all eight subjects) plasma 4-CNAB
concentration vs.
time following oral administration of the various Insulin/4-CNAB tablet
combinations described
above to type 2 diabetic patients, both with and without a meal.
[00408] For the 300IJ insulin/160 mg 4-CNAB ratio tablet, mean fasted tma,,,
was at about 20-25
minutes post administration, and mean tn., was at about 15 minutes post
administration when
administered 10 minutes prior to a meal. For the 300U insulin/400 mg 4-CNAB
ratio tablet, mean
fasted tmax was at about 30 minutes post administration, and mean t, was at
about 20 minutes post
administration when administered 10 minutes prior to a meal.
[00409] Table 52 below sets forth the data for mean plasma C-peptide
concentration vs. time:
Table 52; Mean Plasma C-Peptide Concentration vs. Time
4-CNAB
300U/400mg 3001.1/160mg 1 150U/80mg
-10min 300U/160mg alone 10
time 300U/400mg 10 min meal 300U/160mg 10 min meal 1 +150U/80mg
@ 0 0 min meal min meal
(min) fasted (N=8) (N=8) fasted (N=8) (N=8) min w/ meal
(N=3) (N=5) (N=7)
Mean (ng/mL)
I -15 2.61 4.62 3.45 3.50 4.27 4.32 2.96
-5 2.65 4.46 3.53 3.54 , 1 4.16 4.20 2.88
2.58 4.32 3.56 4.06 4.12 4.73 2.79
2.57 4.48 3.33 3.98 4.43 5.04 3.33
2.42 _ 5.19 3.06 4.65 5.64 5.50 3.88
_
2.20 6.02 2.80 5.04 6.40 6.57 4.31
60 2.24 6.83 2.71 5.96 8.16 8.85 5.16
120 _ 2.27 9.47 2.65 , 7.62 10.60 9.53
6.85
240 2.31 i 5.34 2.72 5.91 4.71 6.39 4.42
Standard Deviation (Sp)
-15 1.045 1.781 1.694 . 2.101 1.426 0.700
2.424
..5 1.028 1.776 1.420 2.127 1.393 0.821 2.227
10 1.259 1.762 1.378 2.546 , 1.369 0.501 2.163
20 1.068 1.667 1.121 2.295 ' 1.472 0.318 2.195
30 1.071 2.210 1.269 1.860 1.731 1.020 2.556
40 , 0.904 2.942 1.354 2.556 3.602 _ 1.640 2.881
60 0.981 3.320 1.531 2.616 3.706 2.903 3.390
120 1.121 2.848 1.569 4.361 1 5.088 , 3.584 4.031
240 0.835 2.702 1.110 4.804 4.059 1.724 3.390
[00410] Figure 45 shows graphs of mean (for all eight subjects) plasma C-
Peptide concentration vs.
time following oral administration of the various Insulin/4-CNAB tablet
combinations described
above to type 2 diabetic patients, both with and without a meal.
[00411] In addition, when compared to drugs that enhance insulin secretion
from the pancreatic
beta cells, also called insulin secretagogues, the oral insulin formulation
disclosed herein has the
same effect on glucose suppression after a standard meal as observed with the
secretagogues. This
can be seen by comparing glucose excursion profiles shown in Figures 14 and
46. In Figure 3, the
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change in blood glucose concentration from baseline of 30015 insulin/160 mg 4-
CNAB
administered 10 minutes before a meal is compared with that for 4-CNAB alone
administered 10
minutes before a meal (control). Here, the oral insulin dose resulted in about
a 30% reduction in
the post-prandial glucose excursion for about 60 minutes. In Figure 46, which
is taken from MY.
Carrol et at, Control of PosVandial Hyperglycemia, Diabetes Care, Vol. 25,
page 2152 (2002), the
change in plasma glucose concentration from baseline is shown for placebo, for
glipizide, for
nateglinide, and for glipizide plus nateglinide. Here, the secretagogues
resulted in about a 30%
reduction sustained for about 60 minutes. Thus, the reduction in glucose
excursion (about 25% to
30%) and the duration of action (sustained for about 60 minutes) was similar
in both the oral insulin
fon-nulation and the secretagogues, evidence that secretagogues have same
magnitude and duration
of action as does oral insulin,
[00412] These results demonstrated a substantial enhancement of key attributes
that were shown
previously with an oral insulin capsule formulation. The tablet formulations
disclosed herein,
therefore, are suitable for oral administration at or shortly prior to
mealtime in order to treat
diabetes and other insulin-related dependencies. The current oral insulin
tablet formulation
represents the prospect of a convenient and effective oral insulin product
that could be dosed very
close to, i.e., within 10 minutes of, mealtime or immediately prior to
mealtime.
EXAMPLE 7
[00413] The aim of this study was to evaluate the safety, tolerability and
pharmacoldnetics of oral
Insulin/4-CNAB following two weeks of preprandial and bedtime administration
and to investigate
the effect on glycemic control, insulin secretion capacity, insulin
sensitivity and glucose tolerance
in diet-treated type 2 diabetic subjects in good to moderate metabolic
control. This was a single
center, double-blind, randomized, controlled, parallel-group study in diet-
controlled type 2 diabetic
patients to determine whether repeated dosing of oral insulin can exert a
sustained therapeutic effect
in patients with type 2 diabetes.
[00414] More particularly, this study was to evaluate whether repeated dosing
of oral insulin
multiple times daily can exert a sustained therapeutic effect in patients with
type 2 diabetes. The
information gained in this study is to provide further insight into the
beneficial effects of a
preprandial treatment with oral insulin/4-CNAB in early phase type 2 diabetic
patients.
[004151 Thirteen male and female patients, aged 30 to 75 years, with a Body
Mass Index < 32
kg/m2 and HbAic between 6.1% and 7.8%, completed the study (out of the
original fourteen
patients who were enrolled). All the patients were diagnosed with type 2
diabetes for more than
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one year as defined by the American Diabetes Association and controlled their
diabetes with diet
only, not with any oral antidiabetic agents and/or insulin. These patients
were generally in good
health, evidenced by lack of significant findings in medical history, physical
examination, clinical
laboratory tests, vital signs and ECG, and had liver and kidney laboratory
evaluations within normal
limits.
1004161 During the screening phase of this study, patients were evaluated for
study eligibility. An
oral glucose tolerance test (OGTT) was also performed, wherein patients drank
300 mL of a
glucose solution (75 g Glucose, Dextro 0.G-T. Saft, Hoffmann La Roche,
Grenzach-Wyhlen,
Germany) within a 10 minute period. Ten blood samples, consisting of fasting
glucose. C-peptide,
insulin and pro-insulin, were taken during this four-hour test.
[00417] On the evening prior to the first day of the treatment phase of the
study, the patients had
their last food intake no later than 10 p.m. and arrived at the
investigational site in a fasting state in
the morning. Blood samples for the determination of blood glucose
concentrations, insulin, pro-
insulin, and C-peptide were drawn at regular intervals over the next 24 hours,
first at 30 minutes
before a standard breakfast is served, and later throughout lunch, dinner, at
bedtime, and the
following morning. In addition, a fasting blood sample for fructosamMe was
taken, and a 24-hour
urine collection for the determination of C-peptide was obtained.
[00418] Patients were randomized to one of two treatment groups to receive an
active dose of
Insulin/4-CNAB or a control dose of 4-CNAB alone for a two-week period four
times daily, 10
minutes before breakfast, lunch and dinner and at bedtime). The seven patients
in the active group
were to be treated with two tablets totaling 300 U insulin/I 60 mg 4-CNAB, and
the six patients in
the control group were treated with two tablets totaling 200 mg 4-CNAB. Those
chosen for active
treatment had HbAic between 6.1% and 7.7%, with a mean HbAic of 6.5%, meaning
that they were
early stage type 2 diabetics. Those chosen for active treatment also had a
body weight between 71.3
kg and 101.4 kg, with a median of 96.9 kg and a mean of 92.4 kg.
[00419] During the first three days of the treatment phase, patients remained
at the research site
and were administered study medication before breakfast, lunch, and dinner and
at bedtime.
Thereafter, patients were given study medication to be taken on an out-patient
basis for the
remainder of the treatment phase. The doses of study medication were
administered 10 minutes
before every meal and before bedtime with 150 mL of water. Glucose readings
were obtained from
the patients at mid-night and at 3 a.m. Blood samples for the determination of
blood glucose
concentrations, insulin, pro-insulin, C-peptide and 4-CNAB were drawn at
regular intervals over
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the first 24 hours beginning before the first dose of study dose, i.e.,
immediately before breakfast is
served, and throughout lunch and dinner, at bedtime, and the following
morning.
[00420] Patients were instructed to self-monitor blood glucose while on out-
patient medication and
to record their data in a diary. Thereafter, when dosing occurred at home, the
patients self-
monitored their blood glucose concentrations and visited the investigational
site on three of the days
for measurement of blood glucose, insulin, pro-insulin, C-peptide and 4-CNAB
concentrations.
[00421] On the evening prior to the final day, the patients had their last
food intake no later than 10
p.m. and arrived at the investigational site in a fasting state in the
morning. Blood samples for
determination of blood glucose concentrations, insulin, pro-insulin, C-
peptide, and 4-CNAB were
drawn at the same specified interval time points as in the first treatment day
1 over a 24 hour
period, while patients continued to take their study medication 10 minutes
prior to each meal and at
bedtime. In addition, urine was collected over 24 hours for the determination
of C-peptide. At the
end of the 24-hour blood sampling period, a fasting blood sample was drawn for
the evaluation of
fi-uctosamine, and an oral glucose tolerance test was performed as discussed
above with ten blood
samples being drawn over a 4 hour period for fasting glucose, C-peptide,
insulin and pro-insulin.
[00422] At each follow-up visit, vital signs (heart rate, blood pressure,
temperature) were
measured, and a fasting blood samples were drawn for blood glucose, insulin, C-
peptide and pro-
insulin concentrations. In addition, patients will be asked about potential
adverse events, and a
follow up of any adverse events previously reported will be performed.
[00423] All blood samples were collected via a venous cannula. For insulin
assays, 1.5 mL of
blood was drawn and collected in sodium-heparin tubes, from which the
resulting plasma samples
were kept at -70 C. Plasma concentrations of insulin were determined from
approximately 0.5 ml
of plasma at Huntingdon Life Sciences by means of a GLP validated RIA assay.
Blood glucose
concentrations were measured immediately after sample collection using a
laboratory method
(Super GL Ambulance glucose analyzer, Ruhrtal Labortechnik, Delecke-Malmesee,
Germany)
based on the glucooxidRse-reaction.
[00424] Plasma C-peptide was measured from 0.5 ml serum, obtained from a 3 ml
blood sample,
which was kept at -70 C. An evaluated RIA-Assay with double determinations
was used for the
measurements. Urinary C-peptide was measured by liquid chromatography-tandem
mass
spectrometry with a stable isotopically-labeled internal standard. Plasma
proinsulin was measured
from 1 ml serum obtained from the same sample as C-peptide, and an evaluated
R1A-Assay with
double determinations was used for the measurements.
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[00425] Serum fructosamine was measured from 0.5 mL serum obtained from a 1 mL
blood
sample collection, which was kept at - 70 C until assayed. Plasma 4-CNAB was
measured from
0.5 mL plasma obtained from a 1 mL blood sample collected into a sodium
heparin tube and stored
frozen at - 70 C until shipment to Huntingdon Life Science Laboratories for
analysis by a validated
LC/MS/MS assay.
Data Analysis
[00426] In order to assess and compare the biological effect of the treatment
formulations, several
characteristics were derived from the preliminary and unaudited
pharmacoldnetic and
pharmacodynamic data, and were calculated for each patient and evaluated with
standard numeric
and descriptive statistical procedures.
[00427] The pliannacokinetic values of insulin and 4-CNAB and the
pharmacodynamic values of
glucose were compared at Study Day 1 and Day 14. The following PK/PD
parameters were
evaluated for 4-CNAB: Cma,õ trnaõ, AUCk,st, AUC,,f, ty,, CL/f and Vd. The
following PK/PD
parameters were evaluated for insulin and C-Peptide: Cmax, tmax, AUC(0-1),
AUC(0-2), AUC(0-3))
AUC(0-last) and AUC03-int).
[00428] Areas under the curve (AUC) were calculated for the glucose
concentrations after
ingestion of the oral glucose solution (AUCBG) for the time intervals 0-60
min, 0-120 mm, 0-180
min, 0-240 min, 0-300 min and 0-360 mm (AUCB00-60, AUCB00-1205 etc.) and were
compared
between the two treatment groups (see Figures 49A and 49B). Likewise, AUCs
were calculated for
insulin (AUCNs), proinsulin (AUCpR0), and C-peptide (AUCcp) but only for the
first two hours, six
hours and the total duration of the experiments (AUC0.120, AUC0-360, and AUCo-
14-4o) (see Figures
52A and 52B for insulin AUC). All AUCs were calculated as incremental AUCs,
i.e., area under
the curve of the absolute values minus the baseline values, with the
trapezoidal rule. In case of
many negative incremental AUCs (which occur when baseline values are higher
than subsequent
values), absolute AUCs were calculated additionally. All AUCs were compared
between the
treatment arms.
[00429] In addition, mean concentrations for each timepoint and maximal
concentrations were
calculated for glucose (CBG max), insulin (Chs max); proinsuhn (CPro max) and
C-peptide (CCP max). The
time point of maximal concentration (tmaõ) was also calculated for all these
parameters.
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1004301 Insulin sensitivity was assessed on previously described parameters
derived from insulin
and blood glucose values during the oral glucose tolerance tests. The
following indices for insulin
sensitivity (IS) were calculated:
AUG-Ratio: IS =AUC(BG)
AUC(Ins)
Belfiore: /S 2
(AUC(Ins) 0 AUC(BG)+1
10,000
Composite Index: IS =
V[Ins(0)c BG(0)10[Ins(OGIY)c BG(OGTT)]
Stumvoll: IS = 0.226¨ 0.0032* B/14/ ¨0.0000645 e /NS(120)¨ 0.0037* BG(90)
IS = 22.5*
HOMA:
Ins(0)
2
IS 5
BG(0)= Ins(0)
wherein
- AUC(BG)/AUC(Ins): area under the blood glucose (BG) or insulin (INS)
concentration curve.
- BG/Ins(0): blood glucose (BG) or insulin (INS) concentration at time
point 0, i.e., immediately
before ingestion of the oral glucose load.
- BG/Ins(OGTT): mean blood glucose (BG) or insulin (INS) concentrations during
the oral glucose
tolerance test.
- INS(120): insulin concentration 120 minutes after ingestion of the oral
glucose load.
- BG(90): blood glucose concentration 90 minutes after ingestion of the
oral glucose load.
1004311 The following indices for insulin secretion capacity (ISC) were
calculated:
HOMA: /SC = 20. _____
B G(0) ¨ 3.5
Stumvoll 1St phase: /SC =1283+1.829. Ins(30)
¨138.7 = BG(90) Ins(0)
Stumvoll 2' phase: /SC = 287 +0.4164* /72s(30)¨ 26.07* BG(30)+ 0.9226 = Ins(0)
Ins (30) ¨ /n.s(0)
Insulinogenic(30): /SC =
BG(30)¨BG(0)
MUC(Ins)
Insulinogenic(120): /SC =
ZitlUC(BG)
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The HOMA and the FM indices will be calculated not only from the OGTT
experiments, but also
from the fasting samples drawn at the ambulatory and the follow-up visits.
[00432] The primary efficacy parameters assess the effect of a two week
treatment with an oral
insulin/4-CNAB tablet formulation on insulin secretion capacity, insulin
sensitivity, and glucose
tolerance in diet-treated patients with type 2 diabetes. As the main
parameter, the Stumvoll indices
of insulin secretion and first phase insulin secretion were determined.
[00433] The secondary efficacy parameters assess the effect of a two week
treatment with an oral
insulin formulation on glycemic control in diet-treated patients with type 2
diabetes. Glycemic
control was assessed by the measurement of fructosanaine and 24-hour blood
glucose profiles. To
assess glycemic control, the absolute concentrations at the scheduled time-
points as well as the
maximal concentrations, time of maximal concentrations, and the area under the
curves for various
time-intervals were determined. All other parameters of insulin sensitivity
and insulin secretion,
and the AUCs and maximal concentrations of insulin, C-peptide and proinsulin
are regarded as
secondary outcome parameters.
[00434] The safety parameters to be assessed are: physical examination,
electrocardiograms, vital
signs, clinical labs (chemistry, hematology, urinalysis), and continuous
glucose monitoring.
[00435] At the end of the study, those chosen for active treatment had a body
weight between 70.3
kg and 99.2 kg, with a median of 94.3 kg, down from a median of 96.9 prior to
the study.
Conclusions
100436] As a result, the following conclusions may be drawn. In general,
patients receiving oral
insulin tablets for two weeks showed improvements versus baseline on key
parameters, including:
- reduced fasting blood glucose;
- reduced average blood glucose, as evidenced by a decrease in the AUC (area
under the curve)
following an oral glucose tolerance test (OG ri ) at Day 15;
- decreased two-hour, post-load blood glucose following an OGTT at Day 15;
- reduced serum fructosamine levels (an indicator of average glycemic
control over approximately
the previous two weeks); and
- improved insulin secretion capacity and sensitivity based on at least two
widely used indices (the
Stumvoll first-phase insulin secretion capacity index and the Homeostasis
Model Assessment, or
ROMA, index).
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11/04.37.1 As shown in Figure 47, patients receiving oral insulin tablets for
two weeks showed clear
improvements versus baseline levels on reduced fasting blood glucose by
lowered levels of glucose
excursion after an oral glucose tolerance test. As shown in Figure 48A, there
were clinically
relevant decreases in fasting blood glucose concentrations versus baseline
levels after an oral
glucose tolerance test at Day 15 (mean 19%). Thus, after two weeks of
treatment, the patients
achieved improved glycemic control compared with baseline levels prior to
treatment.
[00433] In addition, as shown in Figure 49A, which shows blood glucose AUC of
Figure 48A after
an oral glucose tolerance test, patients receiving oral insulin tablets for
two weeks showed
significantly lower exposure to glucose versus baseline levels based upon
reduced average blood
glucose concentration, as evidenced by a decrease in the AUC (mean 21%)
following an oral
glucose tolerance test at Day 15. Furthermore, as shown in Figure 50A,
patients receiving oral
insulin tablets for two weeks showed decreased two-hour, post-load blood
glucose concentration
versus baseline levels (mean 16%) following an oral glucose tolerance test at
Day 15. Thus, after
two weeks of treatment, the patients achieved improved glucose tolerance and a
better capacity to
handle a sugar load compared with baseline levels prior to treatment. In
addition, because a
patient's two-hour post-load glucose is a standard clinical marker for
assessing a patient's diabetic
disease state, lowering of this marker, especially by a mean of 16%, is
perhaps an indication of a
reversal of the patients' diabetic disease states.
[00439] Oral insulin absorption was evident, by the clear insulin peaks that
were observed at 15-20
minutes post-dose, as shown in Figure 58. In addition, the oral insulin was
safe and well-tolerated,
as there was no hypoglycemia in diet-controlled subjects and there were no
serious adverse effects.
As seen in Figures 51 and 52A, patients receiving oral insulin tablets for two
weeks showed no
increase in systemic plasma insulin exposure versus baseline levels, as well
as no increase in
average blood glucose concentration versus baseline levels, following an oral
glucose tolerance test
at Day 15. Similarly, the data showed that there were no significant
differences in fasting or post-
load plasma insulin concentration in the active group. These results show
that, even in a diabetic
population with HbAlc ¨6.5 (range of HbAi c 6.1 to 7.5), which is generally
considered to be
impaired glucose tolerance to with early to moderate stage diabetes, who do
not suffer from an
inability to produce endogenous insulin, oral administration of additional
insulin by the
formulations disclosed herein does not result in hyperinsulinemia.
[00440] These results are especially remarkable given the amount of insulin
that was administered
over the two-week period and the marked improvement in glucose control. As
graphically shown
in Figure 53A, patients receiving oral insulin tablets for two weeks showed
reduced fasting blood
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glucose concentrations versus baseline levels after an oral glucose tolerance
test at Day 15 but
without any increase in plasma insulin concentration. Similarly, as
graphically shown in Figure
54A, patients receiving oral insulin tablets for two weeks showed decreased
two-hour, post-load
blood glucose concentration versus baseline levels after an oral glucose
tolerance test at Day 15 but
without any increase in plasma insulin concentration. Accordingly, this study
showed improved
sensitivity of the patients' livers to insulin or the improved ability of the
patients' pancreas to
produce insulin and to thereby control overnight glucose concentrations, as
seen from the
significant decrease in fasting and two-hour, post-load blood glucose
concentration versus baseline
levels.
[00441] The improved insulin secretion capacity and insulin sensitivity based
on at least two
widely used indices (the Stumvoll first-phase insulin secretion capacity index
and the Homeostasis
Model Assessment, or HOMA, indices). Using the HOMA index as a benchmark for
insulin
sensitivity, it was determined that patients receiving oral insulin tablets
for two weeks showed a
significant increase in insulin sensitivity from baseline (mean 0.010) to day
14 (mean 0.018) of the
treatment. Using the Strumvoll first phase index as a benchmark for insulin
secretion capacity, it
was again determined that patients receiving oral insulin tablets for two
weeks showed a significant
increase in insulin secretion capacity from baseline (mean -37594) to day 14
(mean -30264). (The
HOMA index as a benchmark for insulin secretion capacity, however, showed a
slight decrease in
insulin secretion capacity from baseline (mean 2.328) to day 14 (mean 2.134).)
[00442] With regard to post-prandial effect, oral insulin efficacy was
observed in the "real-life"
outpatient dosing design. As shown in Figures 55 and 56, patients receiving
oral insulin tablets for
two weeks showed a significant decrease in post-prandial glucose excursion
from baseline to day 1
of the treatment to day 14 of the treatment. Likewise, post-prandial
(breakfast) glucose Cr,õ
declined from a baseline level of 209 ing/dL to 194 after one day of treatment
and further declined
to 186 mg/dL after two weeks of treatment. Figure 57 shows a comparison post-
prandial glucose
excursion from day 1 of the treatment to day 14 of the treatment, in order to
demonstrate the
continuing and cumulative impact of the two-week treatment on post-prandial
glucose excursion,
i.e., that the lowered post-prandial glucose excursion on day 14 was not due
to that day's dosage but
rather was even lower than the post-prandial glucose excursion of day 1,
evidencing a cumulative
effect of the two-week treatment on lowering post-prandial glucose excursions.
[00443] As shown in Figure 58, post-prandial insulin absorption did not reach
higher levels than
baseline levels, indicating that no hyperinsulinemia resulted from the two-
week treatment. In fact,
post-prandial insulin absorption was lower, as evidenced by the decline in
post-prandial (breakfast)
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insulin Cmax from a baseline level of 129.1 kiU/ml, to 123.7 AU/mL after one
day of treatment and a
further decline to 105.4 AU /mL after two weeks of treatment Accordingly, this
study showed that
administering to patients oral insulin tablets for two weeks provided them
with improved post-
prandial glycemic control, as seen from the significant decrease in post-
prandial glucose excursion
and the fact that there was no hyperinsulinemia associated with the improved
glycemic control.
[00444] Accordingly, the two weeks of oral insulin resulted in improved post-
prandial glycemic
control, evidenced by significantly lower Cm ax values on Day 14 as compared
to baseline values (an
11% decrease in mean maximum blood glucose), as well as significantly lower
glucose AUC values
on Day 14 as compared to baseline (12% decrease in mean glucose AUC). In
addition, the two
weeks of oral insulin resulted in no hyperinsulinemia, as evidenced by no
significant differences in
insulin C,,,õ and no significant differences in insulin AUC (there was, in
fact, slightly lower mean
AUC values from Day 0 to Day 14). Furthermore, none of the patients receiving
oral insulin tablets
for two weeks had episodes of hypoglycemia, and no subject required rescue
throughout the study.
[00445] Thus, even in a diabetic population with HbAtc ¨6.5 (range of HbAic
6.1 to 7.5), which is
generally considered to be impaired glucose tolerance to with early to
moderate stage diabetes, oral
administration of additional insulin by the formulations disclosed herein
provided improved post-
prandial glycemic control without any hypoglycemia. Significantly, even at day
14, when the
patients' HbAlc was at their lowest, no hypoglycemic events occurred. As a
result, this insulin
therapy may be administered to patients with impaired glucose tolerance or
with early or late stage
diabetes without the need for frequent monitoring of the patients' blood
glucose concentrations and
HbAic levels.
1004461 The treatment also provided the patients with demonstrably improved
glycemic control
over the previous period of two weeks, as evidenced by serum fructosamine
levels. As shown in
Figure 59, based upon fructosamine assay, patients receiving oral insulin
tablets for two weeks
(mean baseline HbAle of 6.5%) showed a mean 8.8% decrease in fructosamine
levels versus
baseline levels, meaning that the patients had a better average glycemic
control over approximately
the two week study period. Thus, by lowering the patients' fructosamine
levels, there was
approximately a 9% decrease in fructosamine levels in the diabetic population
with HbAic ¨6.5
(range of HbAi c 6.1 to 7.5), suggesting that the oral insulin therapy
discussed herein may be
effective to actually reduce, or even reverse, diabetic and pre-diabetic
conditions.
[00447] At the end of the study, those chosen for active treatment had a body
weight between 70.3
kg and 99.2 kg, with a median of 94.3 kg, down from a median of 96.9 prior to
the study. Thus,
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patients receiving oral insulin tablets for two weeks did not show any weight
increase, as usually
accompanies conventional diabetes therapy. Accordingly, this study showed that
administering
patients oral insulin tablets for two weeks provided them with improved post-
prandial glycemic
control, without the weight gain normally associated with insulin therapy.
[00443] Thus, in patients with type 2 diabetes, more particularly those with
impaired glucose
tolerance or with early or late stage diabetes, treatment for two weeks with
oral insulin/4-CNAB
before meals and at bedtime briefly augments systemic insulin concentrations
shortly after each
dose (-20 mm) but lowers fasting blood glucose and improves 24-hour glycemic
control, without
systemic hyperinsulinemia, hypoglycemia and weight gain. This treatment also
improves oral
glucose tolerance after the treatment has been stopped
[004491 It should also be noted that the control group also experienced some
improvements in
certain key parameters. For example, patients receiving tablets containing
only delivery agent
showed somewhat lowered levels of glucose excursion, decreased fasting blood
glucose
concentrations versus baseline levels (mean 13%), lower exposure to glucose to
glucose (AUC)
versus baseline levels (mean 11%) and decreased two-hour post-load glucose
concentrations versus
baseline levels (mean 5%) following a glucose tolerance test at Day 15. In
addition, patients
receiving tablets containing only delivery agent showed somewhat improved
insulin sensitivity and
insulin secretion capacity based on statistically significant increase in the
HOMA index for insulin
sensitivity (0.015 to 0.021) and in the Strumvoll first phase index benchmark
for insulin secretion
capacity (-38371 to -35815). However, most improvements were not considered
overall to be
statistically significant compared with baseline levels. These changes were
instead attributed to the
fact that patients in this group likely better regulated their diet and made
other lifestyle
modifications based on their glucose monitoring results and mandatory diary
keeping practices,
such that improvement in this group was to be expected as is typically
observed within the first two
weeks of studies in diabetics. By contrast, in the active group, it was
observed that, for all key
parameters for which a change was desired, the marked improvements from
baseline were
consistent and statistically significant (p<0.05 using a paired parametric T-
test), and in all cases
were of greater magnitude than in the control group. However, the study was
not powered to
demonstrate statistical significance between the active and control groups. A
larger sample size
would be required to evaluate statistically significant differences between
the active and the control
groups.
[00450] The oral insulin tablets proved to be safe and tolerable to the
patients receiving them,
based upon no hypoglycemic events even in patients with tight glycemic control
(HbAlc ¨6.5%), as
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well as no serious adverse events and a low incidence of mild to moderate
adverse events (of which
two were deemed potentially related to the study drug).
1004511 It is contemplated that the invention may be characterized by any
aspect of any of the in-
vivo clinical (human) data set forth herein, as well as any combination
thereof. Thus, for example,
the invention is deemed to encompass (i) patentable aspects of the efficacy
values, onset and
duration obtained for the tested formulations with respect to direct
measurements of insulin levels,
glucose levels and C-peptide levels (including but not limited to tmax, Cmax,
shape of the plasma
concentration curve (e.g., plasma insulin levels); (ii) any combination of the
various direct
measurements of the treatment efficacy characteristics set forth in the above
specification and/or as
demonstrated by the appended examples; (iii) any combination of any of the
above-mentioned
characteristics of the invention together with aspects of the contemplated
formulations themselves,
including but not limited to the method of manufacture of the formulation, the
drug load, the
delivery agent load, the drug and form of the drug used (e.g., unmodified
insulin), the delivery
agent used, the ratio of drug to the total weight of the formulation, the
ratio of drug to delivery
agent, the actual amounts of drug with or without optional delivery agent
used;etc.
[00452] While certain preferred and alternative embodiments of the invention
have been set forth
for purposes of disclosing the invention, modifications to the disclosed
embodiments may occur to
those who are skilled in the art. Accordingly, the appended claims are
intended to cover all
embodiments of the invention and modifications thereof that do not depart from
the spirit and scope
of the invention.
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