Note: Descriptions are shown in the official language in which they were submitted.
CA 02899746 2015-07-30
Alfred E. Tiefenbacher (GmbH & Co. KG), Hamburg; medac GmbH, Wedel
Pharmaceutical Composition comprising Leflunomide
Technical Field:
The present invention relates to an inventive pharmaceutical composition
comprising 14 to 17.5 mg
leflunomide arranged in a single dose and the uses thereof.
Prior Art:
The pharmaceutically active agent leflunomide (formula I) with the chemical
name 5-methyl-N-[4-
(trifluoromethyl)phenyI]-1,2-oxazole-4-carboxamide is for some time now being
used as a disease
modifying antirheumatic drug (also abbreviated as: DMARDs = disease modifying
antirheumatic
drugs) from the group of isoxazoles. Besides the use as an antirheumatic drug
in the treatment of
rheumatoid arthritis and/or psoriasis arthritis the efficacy of leflunomide is
presently being exam-
ined in the treatment of further autoimmune diseases, in particular lupus
nephritis, systemic lupus
erythematosus, uveitis, myasthenia gravis and/or granulomatosis with
polyangiitis (Wegener's
granulomatosis); in the course of solid organ transplantation, in particular
transplantation of kidney
and liver; oncologic diseases, in particular melanoma, sarcoma, glioma,
prostate carcinoma, brain-
and/or CNS tumors; and/or of diseases correlated with the human immune
deficiency virus (HIV).
,0 =
N\icx H
1
N
N
. 101
0 0
CF3 CF3
Leflunomide itself represents a prodrug, which is after oral application
metabolized in the intestinal
wall, but also in the liver by opening the isoxazole ring to the active malono
nitril amide metabolite
and active agent teriflunomide (formula II, also known as A77 1726), with
immunomodulatory
properties. Concentrations of leflunomide following oral application are
detectable in vivo only in
very low concentrations. The mode of action of leflunomide is essentially
based on the effective-
CA 02899746 2015-07-30
2
ness of the active metabolite teriflunomide, which according to the present
state of art on the one
hand inhibits dihydroorotate dehydrogenase and on the other hand shows anti
proliferative and/or
anti-inflammatory properties.
The maximum blood concentration of teriflunomide can be measured 6 to 12 hours
after oral appli-
cation. Due to the relatively long half-life of teriflunomide (appr. 2 weeks)
steady state blood con-
centrations can be measured after approximately 2 months for a once daily
application of 10 or 20
mg leflunomide respectively. As reliable propositions on the individual
efficacy of le-
flunomide/teriflunomide and a possible adaptation by increase or reduction of
the dose can only be
conducted after entering the steady state concentration, attempts have been
made to reduce the
time until entering the steady state concentration.
By oral application of 100 mg leflunomide once daily for 3 days (loading dose)
and subsequent
application of 20 mg or 10 mg leflunomide once daily (maintenance dose)
respectively, the time
span until entering the steady state concentration can be reduced from
approximately 2 months to
approximately 2 weeks, wherein the therapeutic efficacy can generally be
expected after 4 to 6
weeks and can even increase during the following 4 to 6 months.
According to the prescribing information of Arava , a commercially available
pharmaceutical prepa-
ration of leflunomide tablets with 10 mg, 20 mg and 100 mg leflunomide, it is
thus recommended to
start the respective treatments of active rheumatoid arthritis or active
psoriasis arthritis with a
loading dose of 100 mg once daily for 3 days. In case of treating active
rheumatoid arthritis, the
maintenance dose shall subsequently range from 10 to 20 mg leflunomide once
daily depending
on the severity (activity) of the disease; when treating active psoriasis
arthritis 20 mg leflunomide
shall be applied as the subsequent maintenance dose. Side effects have been
observed for the
respective dose regime, wherein the following side effects have been observed
often: increase of
blood pressure, leukopenia, paresthesia, headaches, dizziness,
gastrointestinal disorders, such as
diarrhoea, nausea, vomitus, diseases of the oral mucosa, and/or abdominal
pain, increased hair
loss, eczema, skin eruption, pruritus, dry skin, tenosynovitis, increase of
creatinine kinase (CK),
loss of appetite, weight loss, asthenia, light allergic reactions and
increased liver values (transami-
nases, gamma-GT, alkaline phosphatases, bilirubin). Based on one or more of
these side effects,
in particular with hematotoxic and/or hepatotoxic and/or gastrointestinal
effects the therapy may be
discontinued or the active agent may be changed within 12 months following
start of therapy.
In addition, some publications discuss the influence of inflammatory
reactions, which are present,
e.g., with rheumatoid arthritis on the pharmacokinetic of the active agents.
As an example for being
influenced by inflammatory reactions, metabolising enzymes, transporter
proteins and/or plasma
binding proteins are mentioned. For chronic inflammatory reactions the
metabolic system of the
CA 02899746 2015-07-30
3
liver can be overloaded or saturated with inflammatory products, so that this
can amend the me-
tabolism of an active agent and can, e.g., result in a reduction of the
metabolism of the active
agent and in an increase of the plasma level of the active agent.
It is now the aim of the present invention to provide a pharmaceutical
composition comprising
leflunomide, which in comparison to an application of 20 mg or 10 mg
leflunomide once daily re-
spectively
= shows a comparable or enhanced efficacy in the prophylaxis and/or
treatment of autoimmune
diseases, preferably of rheumateid arthritis, psoriasis arthritis, arthritis
as complication of
cystic fibrosis, lupus nephritis, systemic lupus erythematosus, uveitis,
myasthenia gravis
and/or granulomatosis with polyangiitis (Wegener's granulomatosis); and/or in
the prophylax-
is and/or treatment in the course of organ transplantations, preferably of
kidney transplanta-
tion and/or liver transplantation; and/or in the prophylaxis and/or treatment
of oncologic dis-
eases, preferably melanomas, sarcomas, gliomas, prostate carcinomas, brain
and/or CNS
tumors; and/or in the prophylaxis and/or treatment of diseases correlated with
the human
immune deficiency virus (HIV) and/or
= provides a reduction in one or more of the aforementioned side effects,
preferably one or
more hematotoxic and/or hepatotoxic and/or gastrointestinal side effects
and/or
= provides a reduction of discontinuation of leflunomide treatment or a
change to alternative ac-
tive agents.
Short Description of the Invention:
One or more of the aforementioned advantages of the inventive problem are
solved by the in-
ventive subject matter of the claims. Advantageous embodiments are disclosed
in the dependent
claims as well as in the following description.
Accordingly, the first inventive aspect relates to a pharmaceutical
composition comprising
leflunomide, characterized in that the composition is arranged as a single
dose with 14 to 17.5 mg,
preferably 15 to 17.5 mg, more preferably 15 mg leflunomide.
A second inventive aspect relates to the use of leflunomide in the prophylaxis
and/or treatment of
of an autoimmune disease, preferably of rheumatoid arthritis, psoriasis
arthritis, arthritis as compli-
cation of cystic fibrosis, lupus nephritis, systemic lupus erythematosus,
uveitis, myasthenia gravis
and/or granulomatosis with polyangiitis (VVegener's granulomatosis); and/or in
the prophylaxis
and/or treatment in the course of an organ transplantation, preferably of
kidney transplantation
CA 02899746 2015-07-30
4
and/or liver transplantation; and/or in the prophylaxis and/or treatment of
oncologic diseases,
preferably melanomas, sarcomas, gliomas, prostate carcinomas, brain and/or CNS
tumors; and/or
in the prophylaxis and/or treatment of diseases correlated with the human
immune deficiency virus
(HIV), characterized in that leflunomide is arranged or arrangeable as single
dose of a pharmaceu-
tical composition with 14 to 17.5, preferably 15 to 17.5, more preferably 15
mg leflunomide and is
applied once, twice, three or four times daily.
The inventive aspects as disclosed hereinbefore can comprise - in case it is
reasonable for a per-
son skilled in the art - any combination of the preferred inventive
embodiments, which are dis-
closed hereinafter and in particular in the dependent claims.
Detailed Description of the invention:
The inventors of the present invention have surprisingly found out, that an
inventive pharmaceuti-
cal composition based on the single dose comprising 14 to 17.5 mg, preferably
15 to 17.5 mg,
more preferably 15 mg leflunomide per pharmaceutical formulation and a
respective once, twice,
three or four times daily (simultaneous or subsequent) application in the
prophylaxis and/or treat-
ment of autoimmune diseases, preferably of rheumatoid arthritis, psoriasis
arthritis, arthritis as
complication of cystic fibrosis, lupus nephritis, systemic lupus
erythematosus, uveitis, myasthenia
gravis and/or granulomatosis with polyangiitis (Wegener's granulomatosis);
and/or in the prophy-
laxis and/or treatment in the course of an organ transplantation, preferably
of kidney transplanta-
tion and/or liver transplantation; and/or in the prophylaxis and/or treatment
of oncologic diseases,
preferably melanomas, sarcomas, gliomas, prostate carcinomas, brain and/or CNS
tumors; and/or
in the prophylaxis and/or treatment of diseases correlated with the human
immune deficiency virus
(HIV)
= shows a comparable or enhanced efficacy when compared to the standard
therapy with 20
mg or 10 mg leflunomide respectively arranged as a single and/or
= provides a reduction in one or more of the aforementioned side effects, in
particular increase
of blood pressure; hematotoxic side effects, such as, e.g., leukopenia;
paresthesia; head-
aches; dizziness; gastrointestinal disorders, such as diarrhea, nausea,
vomitus, diseases of
the oral mucosa, and/or abdominal pain; increased hair loss; dermatologic side
effects, such
as, e.g., eczema, skin eruption, pruritus and/or dry skin; tenosynovitis;
increase of creatinine
kinase (CK); loss of appetite; weight loss; asthenia; light allergic reactions
and/or hepatotoxic
side effects, preferably characterized by increased liver values
(transaminases, gamma-GT,
alkaline phosphatases, bilirubin), more preferably a reduction of one or more
hematotoxic
and/or hepatotoxic and/or gastrointestinal side effects and/or
CA 02899746 2015-07-30
= Provides a reduction of discontinuation of leflunomide treatment or a
reduction of change to
alternative active agents.
The application of the inventive pharmaceutical composition can thus also lead
to an enhanced
patient compliance.
5 Although the underlying mechanisms are presently not fully understood,
the aforementioned ad-
vantageous properties of the inventive subject matter are somewhat surprising
to a person skilled
in the art, as until now he assumed that the dose-response-relationship would
be linear, in particu-
lar for the autoimmune diseases, such as for rheumatoid arthritis, psoriasis
arthritis, arthritis as
complication of cystic fibrosis, lupus nephritis, systemic lupus
erythematosus, uveitis, myasthenia
gravis and/or granulomatosis with polyangiitis (Wegener's granulomatosis);
i.e. that a higher
leflunomide dose correlates with a higher efficacy and, thus, it would be
expected that a dose
reduction from 20 mg to 14 to 17.5 mg, preferably 15 to 17.5 mg, most
preferably 15 mg
leflunomide would result in a reduction of efficacy.
Inventive pharmaceutical compositions, which comprise 14 to 17.5 mg,
preferably 15 to 17.5 mg,
more preferably 15 mg leflunomide in a single dose and are applied once daily,
surprisingly show a
similar or enhanced efficacy in particular in the prophylaxis and/or treatment
of autoimmune dis-
eases, preferably rheumatoid arthritis, psoriasis arthritis, arthritis as
complication of cystic fibrosis,
lupus nephritis, systemic lupus erythematosus, uveitis, myasthenia gravis
and/or granulomatosis
with polyangiitis (Wegener's granulomatosis) when compared to pharmaceutical
compositions,
which comprise 20 mg leflunomide in a single dose and are applied once daily.
Inventive pharmaceutical compositions, which comprise 14 to 17.5 mg,
preferably 15 to 17.5 mg,
more preferably 15 mg leflunomide in a single dose and which are applied once,
twice, three times
or four times daily dependent on the severity of the disease, show in addition
surprisingly the same
or an enhanced efficacy in comparison to the presently known recommendations
for therapy in
particular for the prophylaxis and/or treatment in the course of an organ
transplantation, preferably
kidney transplantation or liver transplantation; and/or of oncologic diseases,
preferably melanomas,
sarcomas, gliomas, prostate carcinomas, brain and/or CNS tumors; and/or of
diseases correlated
with the human immunodeficiency virus (HIV).
Cumulatively or alternatively to the aforementioned advantages the number of
aforementioned side
effects in particular hematotoxic and/oi' hepatotoxic and/or gastrointestinal
side effects and/or the
severity of side effects can be reduced by once daily application of the
inventive pharmaceutical
single dose composition of 14 to 17.5 mg, preferably 15 to 17.5 mg more
preferably 15 mg
leflunomide e.g. in the prophylaxis and/or treatment of autoimmune diseases,
preferably rheuma-
toid arthritis, psoriasis arthritis, arthritis as complication of cystic
fibrosis, lupus nephritis, systemic
lupus erythematosus, uveitis, myasthenia gravis and/or granulomatosis with
polyangiitis (VVegen-
CA 02899746 2015-07-30
6
er's granulomatosis) in comparison to the single dose of 20 mg or 10 mg
leflunomide respectively,
whereby also the number of discontinuations of therapy or change of therapy
can be reduced. The
reduction of side effects and/or the severity of side effects is all the more
amazing, as the prior art
shows that an increase from 10 mg leflunomide single dose to 20 mg leflunomide
single dose
leads to a significant increase in (severe) side effects and thus also to an
increase in discontinua-
tions in therapy (Po6r, G õEfficacy and safety of leflunomide 10 mg versus 20
mg once daily in
patients with active rheumatoid arthritis: multinational double-blind,
randomized trial" Rheumatolo-
gy 2004; 43: 744-749).
Surprisingly it can additionally be observed that an inventive pharmaceutical
composition compris-
ing 14 to 17.5 mg, preferably 15 to 17.5, more preferably 15 mg leflunomide
single dose can lead
to a faster adjustment of the steady state concentration in the prophylaxis
and/or treatment of
autoimmune diseases, preferably rheuratoid arthritis, psoriasis arthritis,
arthritis as complication of
cystic fibrosis, lupus nephritis, systemic lupus erythematosus, uveitis,
myasthenia gravis and/or of
granulomatosis with polyangiitis (Wegener's granulomatosis); and/or in the
course of an organ
transplantation, preferably kidney transplantation and/or liver
transplantation; and/or oncologic
diseases, preferably melanomas, sarcomas, gliomas, prostate carcinomas, brain
and/or CNS
tumors; and/or diseases correlated with human immune deficiency virus (HIV) in
comparison to the
single dose comprising 20 mg and/or 10 mg leflunomide, so that an assessment
of the therapeutic
efficacy can be taken earlier and, thus, if necessary the respective dose can
be adapted earlier, i.e.
dose reduction or increase can be conducted earlier and under doses and/or
side effects can be
prevented.
The provision of an inventive pharmaceutical composition comprising 14 to 17.5
mg, preferably 15
to 17.5 mg, more preferably 15 mg leflunomide single dose can facilitate an
(enhanced) personal-
ized therapy in the prophylaxis and/or treatment of autoimmune diseases,
preferably rheumatoid
arthritis, psoriasis arthritis, arthritis as complication of cystic fibrosis,
lupus nephritis, systemic lupus
erythematosus, uveitis, myasthenia gravis and/or of granulomatosis with
polyangiitis (Wegener's
granulomatosis); and/or in the course of an organ transplantation, preferably
kidney transplantation
and/or liver transplantation; and/or oncologic diseases, preferably melanomas,
sarcomas, gliomas,
prostate carcinomas, brain and/or CNS tumors; and/or diseases correlated with
human immune
deficiency virus (HIV).
The application of an inventive pharmaceutical composition comprising 14 to
17.5 mg, preferably
15 to 17.5 mg, more preferably 15 mg leflunomide single dose according to the
first aspect of the
invention can in addition be of advantage for special patient populations in
comparison to the
commercially available single dose of 20 mg leflunomide, in case an individual
disadvantageous
risk-benefit profile exists based on a side effect or toxicity of leflunomide.
Such a disadvantageous
risk-benefit profile in the treatment of rheumatoid arthritis and in
particular in a therapy regime with
CA 02899746 2015-07-30
7
one or more further autoimmune active agents can be based on polymorphisms of
genes, which
code for proteins, which in particular respectively intervene in metabolism
reactions, preferably in
the transport or the uptake from the gastro intestinal tract, the distribution
in the body (plasma
level) or the excretion of leflunomide and/or its metabolites, preferably its
active metabolite
teriflunomide.
According to a preferred inventive embodiment the inventive composition of the
first inventive
aspect is applied to patients, preferably humans, which show a polymorphism at
enzyme cyto-
chrome P 450 2C19 (CYP2C19) and are in particular poor to intermediate
metabolizers (see Wiese
et al.: Polymorphisms in cytochrome P450 2C19 enzyme and cessation of
leflunomide in patients
with rheumatoid arthritis. Arthritis Research & Therapy 2012 14:R163). Poor
CYP2C19 metaboliz-
ers are generally characterized in accordance with Wiese et al. in that they
have 2 alleles with loss
of function, whereas intermediate metabolizers have 1 allele with loss of
function and one wild type
allele. Patients, who are poor or intermediate CYP2C19 metabolizers have a
disadvantageous risk-
benefit profile concerning the toxicity of leflunomide and discontinue with a
higher likelihood the
leflunomide therapy, in particular for rheumatoid arthritis and in particular
in a therapy regime with
further autoimmune active agents. An application of an inventive composition
comprising 14 to
17.5 mg, preferably 15 to 17.5 mg, more preferably 15 mg leflunomide single
dose according to the
first aspect of the invention can, in particular when treating rheumatoid
arthritis, lead to a reduction
of toxicity and, thus, a reduction of discontinuations of therapy in
particular when applying further
autoimmune active agents, which is based on the reduction of the leflunomide
content.
According to a further cumulatively or alternative preferred inventive
embodiment the inventive
composition of the first inventive aspect is applied to patients, preferably
humans, which show a
polymorphism at the ATP binding cassette sub-family G member 2 (ABCG2), also
known as breast
cancer resist protein (BCRP) (see Wiese et al.: Polymorphisms in cytochrome
P450 2C19 enzyme
and cessation of leflunomide in patients with rheumatoid arthritis. Arthritis
Research & Therapy
2012 14:R163). Patients with such a respective ABCG2 genotype or BCRP genotype
have a dis-
advantageous risk-benefit-profile concerning the side effect diarrhea and
discontinue with a higher
likelihood the leflunomide therapy, in particular when treating rheumatoid
arthritis and in particular
in therapy with further active agents. An application of an inventive
composition comprising 14 to
17.5 mg, preferably 15 to 17.5 mg, more preferably 15 mg leflunomide single
dose according to the
first aspect of the invention can in particular when treating rheumatoid
arthritis lead to a reduction
of the incidence and/or severity of diarrhea and, thus, a reduction of
discontinuation of therapy in
particular when applying leflunomide and further autoimmune active agents.
The application of an inventive pharmaceutical composition comprising 14 to
17.5 mg, preferably
15 to 17.5 mg, more preferably 15 mg leflunomide single dose according to the
first aspect of the
invention can furthermore be advantageous in comparison to the commercially
available 20 mg
CA 02899746 2015-07-30
8
leflunomide single dose, in case the steady state level of leflunomide and/or
its metabolites, pref-
erably teriflunomide shall be reached earlier. A respective advantageous risk-
benefit profile can
preferably be advantageous in the treatment of rheumatoid arthritis and in
particular in a therapy
regime with one or more further autoimmune active agents and can, e.g., be
based on the satura-
tion of transporter proteins, which in particular respectively intervene in
the uptake from the gastro-
intestinal tract, the distribution in the body (plasma level) and/or in the
excretion (e.g. biliary) of
leflunomide and/or its metabolites, preferably teriflunomide.
In accordance with a further preferred inventive embodiment the inventive
composition of the first
inventive aspect is preferably applied in the treatment of rheumatoid
arthritis and in particular in
io therapy regimes with one or more further autoimmune active agents to
patients, preferably hu-
mans, who show a polymorphism of the ABCG2/BCRP transporter. For
simplification reasons, it is
essentially referred to BCRP, wherein this is used synonymously for ABCG2 in
the context of the
present invention. Such transporter proteins play an important role in the
absorption, distribution,
metabolism and/or excretion of leflunomi0e and/or its metabolites, preferably
teriflunomide.
BCRP is one of the most important efflux transporters of the cells of the endo-
and epithelium. In
vitro studies show, that in particular leflunomide and its metabolite
teriflunomide show as sub-
strates a high binding affinity to the BCRP transporter [Bartlett, R.R., et
al., Effects of leflunomide
on immune responses and models of inflammation. Springer Semin Immunopathol,
1993. 14(4): p.
381-94]. Thus, the saturation of the BCRP transporter plays an important role
i) in reaching thera-
peutically active plasma levels of leflunomide and/or its metabolites,
preferably teriflunomide, in
particular in view of the induction phase as well as ii) in the time span for
reaching the steady state
levels of leflunomide and/or its metabolites, preferably teriflunomide, as
leflunomide and/or its
metabolites, preferably teriflunomide represent a substrate for the BCRP
transporter.
An application of an inventive composition comprising 14 to 17.5 mg,
preferably 15 to 17.5 mg,
more preferably 15 mg leflunomide single dose according to the first aspect of
the invention can
lead preferably when treating rheumatoid arthritis and in particular in a
therapy regime with one or
more further autoimmune active agents to a
= modified ratio of the plasma level of leflunomide in comparison to the
plasma level of its me-
tabolites, preferably teriflunomide and/or
= modified time window within which the steady state level of leflunomide
and/or its metabolites
preferably teriflunomide is reached
and thereby can lead to a more rapid onset of the therapeutic active effects
and/or to a reduction of
the toxicity of leflunomide and/or its metabolites, preferably teriflunomide.
CA 02899746 2015-07-30
9
Patients showing a c.421CA genotype and a polymorphism of the BCRP transporter
protein gen-
erally show in comparison to patients without such a polymorphism a higher
plasma level of
leflunomide metabolites, preferably teriflunomide, which is why this
polymorphism leads to an inter-
individual variability of the plasma level of leflunomide metabolites in the
treatment of rheumatoid
arthritis and in particular in the therapy regime with one or more further
autoimmune active agents
[Williams, J.W., et al., lmmunosuppressive effects of leflunomide in a cardiac
allograft model.
Trans-plant Proc, 1993. 25(1 Pt 1): p. 745-6]. This factor is in particular
then particularly relevant, in
case one or more of the further autoimmune active agents themselves and/or its
metabolites rep-
resent in the combination therapy regime substrates for this BCRP transporter
protein.
Thus, saturation and polymorphism of the BCRP transporter proteins play an
important role, pref-
erably when treating rheumatoid arthritis and in particular in a therapy with
one or more further
autoimmune active agents, as due to the saturation or the polymorphism of the
BCRP transporter
protein the plasma level and/or the time span, which is necessary to reach the
steady state level of
leflunomide and/or its metabolites, preferably teriflunomide, and/or the time
span until reaching
therapeutic efficacy and/or the toxicit'l level of leflunomide and/or its
metabolites, preferably
teriflunomide can be altered. This factor is in particular then particularly
relevant, in case in the
combination therapy regime one or more of the further autoimmune active agents
themselves
and/or its metabolites represent substrates for this PCRP transporter protein.
Thus, due to an altered ratio of the plasma level of leflunomide in comparison
to its metabolites an
application of an inventive composition comprising 14 to 17.5 mg, preferably
15 to 17.5 mg, more
preferably 15 mg leflunomide single dose according to the first aspect of the
invention and in par-
ticular when treating rheumatoid arthritis can lead to a reduction of toxicity
and accordingly to a
reduction of therapy discontinuations under leflunomide in particular in
combination with one or
more further autoimmune active agents.
According to the first inventive aspect the pharmaceutical composition
comprising leflunomide is
characterized in that the composition is arranged or arrangeable as single
dose with 14 to 17.5 mg,
preferably 15 to 17.5 mg, more preferably 15 mg leflunomide.
According to a preferred embodiment the inventive pharmaceutical compositions
of the first in-
ventive aspect are preferably characterized in that the compositions are in
solid or liquid form and
are suitable for oral application. Preferred solid inventive pharmaceutical
compositions for oral
application are selected from the group consisting of powders, pellets,
globuli, granulates, tablets
and/or capsules, in particular preferred are tablets and further particularly
preferred are film coated
tablets. Preferred liquid inventive pharmaceutical composition for oral
application are selected from
the group consisting of elixirs, solutions, suspensions, emulsions, mixtures,
syrups, juices and/or
CA 02899746 2015-07-30
drops. The inventive pharmaceutical compositions of the first inventive aspect
can be inventively
used in retarded or non-retarded formulation.
According to the present invention for the production of inventive
compositions according to the
first inventive aspect all of the pharmaceutically acceptable excipients
generally known for the
5 respective pharmaceutical formulations can be used.
When producing tablet formulations as inventive pharmaceutical compositions
according to first
inventive aspect, pharmaceutical acceptable excipients can depending on the
mode of forming
tablets (direct tableting, dry or wet granulation) be selected from the group
of respectively suitable
excipients consisting of i) filler materials, preferably starch or starch
derivatives, in particular pref-
-io erably potato, wheat and/or maize starch (derivatives), lactose,
lactose monohydrate, mannitol,
sorbitol, calcium carbonate, laevulose, glucose, cellulose, microcrystalline
cellulose,
hydroxypropylcellulose, and/or calcium phosphates, in particular preferred
dicalcium phosphate,
particularly preferred filler materials are selected from the group consisting
of lactose, lactose
monohydrate, dicalcium phosphate, and/or hydroypropylcellulose, preferably
lactose monohydrate;
ii) disintegrants, preferably starch or starch derivatives, in particular
potato, and/or maize starch
(derivatives), pectin, alginates, alginic acid, microcrystalline cellulose,
crosslinked sodium
carboxymethylcellulose, crosslinked polyvinylpyrrolione, such as crospovidone
(polyplastone)
and/or croscaramellose; iii) binding agents or adhesives (in particular for
wet granulation), prefera-
bly sugar, starch, starch paste and/or starch derivatives, in particular
preferred are potato, wheat
and/or maize starch (derivatives), gelatin, cellulose derivatives, in
particular preferred (low substi-
tuted) hydroxpropylcellulose, hydroxyethylcellulose and/or
hydroxyporpylmethylcellulose, micro-
crystalline cellulose, Arabic gum, tragacanth, polyethylene glycol, and/or
polyvinylpyrrolidone,
and/or collidone, a particular preferred binding agent or adhesive is (low
substituted)
hydroxypropylcellulose; iv) dry binding agents (in particular for dry
granulation), preferably micro-
crystalline cellulose, lactose, lactose monohydrate, saccharose, mannitol,
sorbitol, calcium car-
bonate, polyvinylpyrrolidone, collidone, and/or polyethylene glycol v)
glidants or drying agents,
preferably highly dispersed silicium dioxide; and/or vi) lubricants,
preferably talc, siliconized talc,
stearic acid, palmitic acid, calcium, aluminum and/or magnesium stearate,
calcium behenate (mix-
ture of calcium salts of higher fatty acids, preferably behenic acid), starch,
aerosol, (colloidal)
silicium dioxide, polyethylene glyclol, hydroxypropylcellulose, stearyl, cetyl
and/or myristyl alcohol,
paraffin, hydrated fats and/or magnesium trisilicate, preferred lubricants are
in particular selected
from the group consisting of magnesium stearate and/or hydroxypropylcellulose,
further preferred
is magnesium stearate; and/or further suitable excipients, such as wetting
agents, such as sodium
lauryl sulfate or polysorbate, particularly preferred is sodium lauryl
sulfate, and excipients for the
production of film coatings, e.g., film binding agents, pigments, filler
materials, softeners and/or
stabilizers, preferably selected from th group consisting of polydextrose
(E1200), hypromellose,
CA 02899746 2015-07-30
11
triacetin, macrogol, iron oxides (e.g., red and/or yellow), polyvinyl alcohol,
titan dioxide, talc, leci-
thin (preferably derived from soy beans), xanthan gum and/or suitable
polyacrylic acid derivatives
and/or (soluble) collidones.
The inventive pharmaceutical compositions preferably as solid or liquid oral
formulation preferably
further comprise according to a cumulative or alternative preferred embodiment
of the first in-
ventive aspect a pH regulating agent, in particular preferred are monobasic
organic or inorganic
acids or organic or inorganic polyacids, wherein the inorganic acids are
preferably selected from
the group consisting of phosphoric acid, sulfuric acid, their acidic reacting
salts, such as
dihydrogen phosphates and hydrogen sulfates as well as their condensates, such
as
polyphosphoric acid, and/or inorganic buffer systems, which react in aqueous
solution to a pH of 7
or lower; and wherein the organic acids are preferably selected from the group
consisting of car-
bonic acids, preferably tartaric acid, malic acid, fumaric acid, citric acid,
malonic acid, maleic acid
as well as methane, ethane and/or p-toluene sulfonic acid, further preferred
tartaric acid, malic
acid, fumaric acid, citric acid, malonic acid, maleic acid and/or organic
buffer systems, which react
in aqueous solution to a pH of 7 or lower (e.g., citric acid/citrate buffer
and/or acetic acid/acetate
buffer). Respective inventive pharmaceutical compositions are in particular
preferred, as they can
increase the shelf life of leflunomide, LEI. reduce the transformation of
leflunomide to teriflunomide
during storage, in the inventive pharmaceutical composition in comparison to
pharmaceutical
compositions comprising leflunomide without acidic addition.
zo According to an in particular preferred embodiment of the first
inventive aspect the inventive com-
position as tablet comprises in addition to the content of 14 to 17.5 mg,
preferably 15 to 17.5 mg,
more preferably 15 mg leflunomide the following excipients in suitable
amounts, namely a) lactose
monohydrate, low substituted hydroxypropylcellulose, a pH regulating agent,
preferably selected
from organic acids, particularly preferred tartaric acid or citric acid,
sodium lauryl sulfate and mag-
nesium stearate or b) maize starch, povidone (1201), crospovidon (1202),
highly dispersed silicium
dioxide, magnesium stearate (E470b) and lactose monohydrate. In case of film
coated tablets the
inventive pharmaceutical compositions comprise preferably suitable amounts of
the following
excipient, namely a) polyvinyl alcohol, titan dioxide, talc, lecithin, xanthan
gum or b) talc (E553b),
hypromellose (E464), titan dioxide (E171), macrogol 8000 and optionally iron
(III) hydroxide oxides
(E172).
According to a further cumulatively or alternatively preferred embodiment of
the first inventive
aspect the inventive pharmaceutical compositions are applied in the
prophylaxis and/or treatment
of autoimmune diseases, preferably selected from the group consisting of
rheumatoid arthritis,
psoriasis arthritis, arthritis as complication of cystic fibrosis, lupus
nephritis, systemic lupus
erythematosus, uveitis, myasthenia gravis, granulomatosis with polyangiitis
(Wegener's
granulomatosis); in the course of organ transplantations, preferably selected
of the group consist-
CA 02899746 2015-07-30
12
ing of kidney transplantation and/or liver transplantation; of oncologic
diseases, preferably selected
of the group consisting of melanomas, sarcomas, prostate carcinomas, brain
and/or CNS tumors;
and/or of diseases correlated with the human immune deficiency virus (HIV); in
particular preferred
in the prophylaxis and/or treatment of rheumatoid arthritis, psoriasis
arthritis and/or arthritis as
complication of cystic fibrosis. Generally, the inventive pharmaceutical
compositions comprising 14
to 17.5 mg, preferably 15 to 17.5 mg, in particular preferred 15 mg
leflunomide is applied once
daily or depending on the kind and/or severity of diseases (simultaneously or
sequentially) twice,
three or four time daily in the prophylaxis and/or treatment of the
aforementioned diseases.
In the context of the present invention the term "simultaneous" application
refers according to the
lo first inventive aspect to a twice, three or four times daily application
of an inventive pharmaceutical
composition comprising leflunomide arranged as single dose of 14 to 17.5 mg,
preferably 15 to
17.5 mg, more preferably 15 mg leflunomide and means that the inventive
pharmaceutical compo-
sition is taken by a patient simultaneously, i.e. in narrow time sequence,
generally within a time
period of up to 10 minutes, preferably up to 5 minutes, more preferably up to
1 minute.
In the context of the present invention the term "sequential" application
refers according to the first
inventive aspect to a twice, three or four times daily application of an
inventive pharmaceutical
composition comprising leflunomide arranged as single dose of 14 to 17.5 mg,
preferably 15 to
17.5 mg, more preferably 15 mg leflunumide and means that the inventive
pharmaceutical compo-
sition is taken by a patient sequentially, i.e. in a temporary offset,
generally with a time lag in par-
ticular for a twice daily application in a sequence of approximately 12 hours,
in particular for a three
times daily application in a sequence of approximately 8 hours and/or in
particular for a four times
daily application in a sequence of approximately 6 hours.
Generally, the intake of the inventive pharmaceutical compositions according
to the first inventive
aspect can be conducted at all day and night times as well as prior, during
and after meals, prefer-
ably in a time sequence prior to the meal.
In the context of the prophylaxis and/or treatment of autoimmune diseases,
preferably selected
from a group consisting of rheumatoid arthritis, psoriasis arthritis,
arthritis as complication of cystic
fibrosis, lupus nephritis, systemic lupus erythematosus, uveitis, and/or
myasthenia gravis, and/or
the prophylaxis and/or treatment of diseases correlated with the human immune
deficiency virus
(HIV) the inventive pharmaceutical composition comprising 14 to 17.5 mg,
preferably 15 to 17.5
mg, in particular preferred 15 mg leflunomide single dose is generally applied
once or twice (simul-
taneously or sequentially) daily, more preferably once daily to achieve the
inventive advantages, in
particular an optimized effect-side effect profile.
In the context of the prophylaxis and/or treatment of granulomatosis with
polyangiitis (Wegener's
granulomatosis) the inventive pharmaceutical composition comprising 14 to 17.5
mg, preferably 15
CA 02899746 2015-07-30
13
to 17.5 mg, more preferably 15 mg leflunomide arranged as single dose is
generally applied once,
twice or three times (simultaneously or sequentially) daily, more preferred
twice or three time (sim-
ultaneously or sequentially) daily, to achieve the inventive advantages, in
particular an optimized
effect-side effect profile.
In the context of the prophylaxis and/or treatment of organ transplantations,
preferably selected
from the group consisting of kidney transplantation and/or liver
transplantation; and/or oncologic
diseases, preferably selected from the group consisting of melanoma, sarcoma,
glioma, prostate
carcinomas and/or brain and/or CNS tumors, the inventive pharmaceutical
composition comprising
14 to 17.5 mg, preferably 15 to 17.5 mg, in particular preferred 15 mg
leflunomide single dose is
generally applied once, twice, three or four times daily (simultaneously or
sequentially), more
preferred twice, three or four time daily (simultaneously or sequentially), in
particular preferred
three or four times daily (simultaneously or sequentially), to achieve the
inventive advantages, in
particular an optimized effect-side effect profile.
According to a further advantageous embodiment of the present invention the
inventive pharma-
ceutical composition according to the first inventive aspect is preferably
applied to a patient of
equal or more than 45 years of age, more preferably equal or more than 55
years of age, even
more preferred equal or more than 65 years of age, even more preferred equal
or more than 70
years of age, to achieve optimized results concerning the advantageous
inventive effects in par-
ticular concerning the equal or enhan, .-d efficacy, the reduced side effects
and the reduction in
therapy discontinuations or the change to other active agents.
The second inventive aspect relates to the use of leflunomide in the
prophylaxis and/or treatment
of autoimmune diseases, preferably of rheumatoid arthritis, psoriasis
arthritis, arthritis as complica-
tion of cystic fibrosis, lupus nephritis, systemic lupus erythematosus,
uveitis, myasthenia gravis
and/or granulomatosis with polyangiitis (Wegener's granulomatosis); and/or in
the prophylaxis
and/or treatment in the course of an organ transplantation, preferably kidney
transplantation and/or
liver transplantation; and/or in the prophylaxis and/or treatment of oncologic
diseases, preferably
melanomas, sarcomas, gliomas, prostate carcinomas, brain and/or CNS tumors;
and/or in the
prophylaxis and/or treatment of diseases correlated with the human immune
deficiency virus (HIV),
characterized in that leflunomide is arranged or arrangeable as single dose of
an pharmaceutical
composition with 14 to 17.5 mg, preferably 15 to 17.5 mg, more preferably 15
mg leflunomide and
is applied once, twice, three or four times daily. The preferred embodiments
according to the inven-
tion, which have been discussed in the present application with respect to the
first inventive aspect
are to be applied alternatively or cumulatively also to the second inventive
aspect.
According to the present invention the term "leflunomide is arranged as single
dose of an pharma-
ceutical composition with 14 to 17.5 mg, preferably 15 to 17.5 mg, more
preferably 15 mg
CA 02899746 2015-07-30
14
leflunomide" means that the commercially available inventive pharmaceutical
composition is al-
ready present in such a separated form, that one or more single dose
formulations with 14 to 17.5
mg, preferably 15 to 17.5 mg, more preferably 15 mg leflunomide are comprised.
According to the present invention the term "leflunomide is arrangeable as
single dose of an phar-
maceutical composition with 14 to 17.5 mg, preferably 15 to 17.5 mg, more
preferably 15 mg
leflunomide" means that the commercially available inventive pharmaceutical
composition does not
already comprise the single dose with 14 to 17.5 mg, preferably 15 to 17.5 mg,
more preferably 15
mg leflunomide in separated form, however can be separated in particular by
the patients in such a
way, that an inventive pharmaceutical single dose formulation with 14 to 17.5
mg, preferably 15 to
17.5 mg, more preferably 15 mg leflunomide can be arranged. In case the
inventive pharmaceuti-
cal compositions for oral consumption is present in liquid form, such a single
dose formulation can,
e.g., be arranged by measuring the liquid by means of a measuring cup or
measuring spoon or by
means of counting of drops or any other suitable method. In case the inventive
pharmaceutical
compositions for oral consumption is present in solid form, such a single dose
formulation can,
e.g., be arranged by breaking a (film coated) tablet, preferably a (film
coated) tablet with a score
line, counting of pellets, globuli or granulates or any other suitable method.
The present invention will be described in the following by use of exemplary
embodiments, which
shall rather be regarded as examples and shall not limit the scope of
protection of the present IP
right.
CA 02899746 2015-07-30
Examples: ,
A: Production of inventive pharmaceutical compositions
The production described in the following discloses one possibility of
producing the inventive oral
pharmaceutical compositions, in particular as inventive film coated tablets
comprising leflunomide
5 listed in the following table:
Ingredients (in mg/ tablet) Fl F2 F3 F4 F5
Tablet Core
Leflunomide (Ph. Eur.) 14.000 15.000 16.000 17.000
17.500
Lactose Monohydrate (Ph. Eur.) 50.000 - 45.000 215.000
106.500
Microcrystalline Cellulose (Ph. Eur.) 45.000 25.000 85.000
55.000 35.000
Dicalcium phosphate, anhydrous
- 80.000 - - 10.500
(DI-CAFOS, Ph. Eur.)
Copovidone (Ph. Eur.) - - 10.000 -
9.000
Maize starch (Ph. Eur.) 15.000 - -
Crospovidone (Ph. Eur.) - 12.000 5.500 3.000 -
Croscarmellose (Ph. Eur.) - 15.000 5.500 -
8.500
Tartaric Acid (Ph. Eur.) - 3.350 - - .
Citric acid, anhydrous (Ph. Eur.) 3.500 . - - -
-
Sodium lauryl sulfate (Ph. Eur.) - 0.650 - - -
Polysorbate 80 (Ph. Eur.) 0.500 - - -
Highly dispersed silicon dioxide (Ph.
- - 3.000 - 5.000
Eur.)
Magnesium stearate (Ph. Eur.) 2.000 3.000 - 3.000
2.000
'
Calcium behenate (Ph. Eur.) - 2.500 -
Purified water (Ph. Eur.) q.s. q.s. - - -
Weight Tablet Core (mg) 130.000 154.000 172.500
293.000 194.000
Filmcoating
Polydextrose (E1200) 0.960 0960 - -
Hypromellose (Ph. Eur.) 1.461 1.461 5.200
0.250
silia - - -
2.650
Triacetin (Ph. Eur.) 0.240 0.240 - -
Macrogol (Ph. Eur.) 0.080 0.080 0.600
0.150
Iron oxide yellow (E172) 0.009- N/A - -
Iron oxide red (E172) - 0.009 - -
Polysorbate 80 (Ph. Eur.) - - 0.090 -
Titanium dioxide (Ph. Eur.) 1.250 1.250 2.110 -
Ethanol 96 % (Ph. Eur.) - - -
q.s.
Purified water (Ph. Eur.) q.s. q.s. q.s.
q.s.
Weight Film Coated Tablet (mg) 134.000 158.000 N/A
301.000 197.050
CA 02899746 2015-07-30
16
__________________________ , _________________________________________
Ingredients (in mg/ tablet) F6 F7 F8 F9 F10
Tablet Core
Leflunomide (Ph. Eur.) 14.000 15.000 16.000 17.000
17.500
Lactose Monohydrate (Ph. Eur.) 80.000 120.000 55.000 - 36.500
Microcrystalline Cellulose (Ph. Eur.) - - 25.000 180.00
63.000
Mannitol (Ph. Eur. - - - 155.00 -
Hypromellose (Ph. Eur.) - - - - 10.500
Hydroxypropylcellulose, low substi-
15.000 7.500 - - -
tuted (NF)
Maize starch (Ph. Eur.) 15.000 - 9.000 -
-
Sodium carboxyl nnethylstarch (Ph.
- - 18.500 -
-
Eur.)
Croscaramellose (Ph. Eur.) 10.000- - - 12.000
Tartaric acid (Ph. Eur.) 5.000 4.500 - - -
Citric acid, anhydrous (Ph. Eur.) - - 2.300 2.000 -
Sodium lauryl sulfate (Ph. Eur.) 1.500 0.750 - - -
Polysorbate 80 (Ph. Eur.) 2.000 - 0.750 -
-
Highly dispersed silicon dioxide
- -
1.200
-
(Ph. Eur.)
Magnesium stearate (Ph. Eur.) - 2.250 0.500 - 1.500
Calcium behenate (Ph. Eur.) 2.500 - 1.200 -
-
Purified water (Ph. Eur.) q.s. q.s. q.s. q.s. -
Sodium stearyl fumarate (Ph. Eur.) - - 9.000 q.s.
Weight Tablet Core (mg) 145.000 150.000 129.450 363,000
141.000
Film Coating
Polydextrose (E1200) - - -
Hypromellose (Ph. Eur.) - - 2.500 -
Triacetin (Ph. Eur.) - - - -
Macrogol (Ph. Eur.) 0.200- 0.810 0.215
Iron oxide yellow (E172) - - 0.040 0.035
Iron oxide red (E172) - - 0.050
N/A -
Polyvinyl alcohol (Ph. Eur.) 1.500 2.048 - 1.460
Titanium dioxide (Ph. Eur.) 2.300 1.440 1.200 1.540
Talc (Ph. Eur.) - 0.900 0.450 -
Lecithin (from soy beans) (NF) - 0.090 - -
Xanthan gum (Ph. Eur.) - 0.022 - -
Purified water (Ph. Eur.) q.s. q.s. q.s. q.s.
Weight Film Coated Tablet (mg) 149.000 154.500 134.500 N/A
144.250
CA 02899746 2015-07-30
17
Ingredients (in mg/ tablet) F11 F12 F13 F14
Tablet Core
Leflunomide (Ph. Eur.) 14.000 15.000 15.000 17.500
Lactose Monohydrate (Ph. Eur.) 80.000 105.000 118.000 100.000
Microcrystalline Cellulose (Ph. Eur.) - - - 51.500
Hydroxypropylcellulose, low substi-
- - 8.000 -
tuted (NF)
Maize starch (Ph. Eur.) - 18.000 6.300 25.000
Povidone (Ph. Eur.) 6.000 4.750 - 4.000
Crospovidone (Ph. Eur.) - 12.000 - 6.000
Sodium carboxyl methylstarch (Ph.
12.000 - 5.000 -
Eur.)
Tartaric acid (Ph. Eur.) - - 4.000 -
Citric acid, anhydrous (Ph. Eur.) - - - -
Sodium lauryl sulfate (Ph. Eur.) - - - 3.500
Polysorbate 80 (Ph. Eur.) - - - -
Highly dispersed silicon dioxide
1.500 2.000 - 4.500
(Ph. Eur.)
Talc (Ph. Eur.) - 1.000 - -
Magnesium stearate (Ph. Eur.) - 1.250 2.200 3.500
Calcium behenate (Ph. Eur.) 1.500 - - -
Purified water Ph. Eur.) q.s. q.s. q.s. q.s.
Weight Tablet Core (mg) 115.000 159.000 158.500 215.500
Film Coating
Polydextrose (E1200) - - - -
Hypromellose (Ph. Eur.) - 2.500 2.200 -
Triacetin (Ph. Eur.) - - - -
Macrogol (Ph. Eur.) - 0.810 0.700 -
Iron oxide yellow (E172) - 0.040 - 0.050
Iron oxide red (E172) - - - 0.050
Polyvinyl alcohol (Ph. Eur.) 2.200 - - 2.800
Titanium dioxide (Ph. Eur.) 1.320 1.200 1.650 1.400
Talc (Ph. Eur.) 0.300 0.450 0.450 0.400
Lecithin (from soybeans) (NF) 0.090 - - 0.100
Xanthan gum (Ph. Eur.) 0.090 - - 0.200
Purified water (Ph. Eur.) q.s. q.s. q.s. q.s.
Weight Film Coated Tablet (mg) 119.00 164.000 163.500 220.500
CA 02899746 2015-07-30
18
According to the invention the individual features of the exemplary
embodiments of the inventive
pharmaceutical composition as disclosed hereinbefore can respectively be
separately combined
with features of the further exemplary embodiments or with the general
description of the invention.
The advantages of the application of the inventive pharmaceutical composition
comprising 14 to
17.5 mg, preferably 15 to 17.5 mg, more preferably 15 mg leflunomide single
dose according to the
first inventive aspect as well as its inventive use according to the second
inventive aspect, prefera-
bly in the treatment of rheumatoid arthritis and in particular in therapy
regimes with one or more
further autoimmune active agents can be demonstrated in comparison to
commercially available
single doses of 10 mg and 20 mg leflunomide in animal models. Such animal
models allow exami-
nations of autoimmune diseases, in particular of chronic diseases such as
rheumatoid arthritis
(RA). Respective animal models comprise in particular, but are not limited to,
the collagen-induced
arthritis (CIA) animal model, the adjuvant-induced-arthritis (AIA) animal
model and the experi-
mental allergic encephalomyelitis (EAE) animal model as well as animal models
concerning graft-
versus-host disease or reactions concerning graft rejection. In addition
animal models suitable for
the examination of other autoimmune diseases, such as, e.g., psoriasis
arthritis, arthritis as com-
plication of cystic fibrosis, lupus nephritis, systemic lupus erythematosus,
uveitis, myasthenia
gravis and/or granulomatosis with polyangiitis (Wegener's granulomatosis) can
be used. Alterna-
tively, animals models can be used, which allow the examination of organ
transplantations, prefer-
ably of kidney transplantations and/or liver transplantations, and/or the
examination of oncologic
diseases, preferably melanomas, sarcomas, gliomas, prostate carcinomas, brain
and/or CNS
tumors; and/or the examination of diseases correlated with the human immune
deficiency virus
(HIV).
Safety and toxicity studies with leflunomide in naive, untreated animals
(dogs, rats) showed that
side effects occurred, which also are present in patients under leflunomide
treatment. Such are,
e.g., hematotoxic side effects, gastrointestinal side effects, creatinine
kinase (CK) increase, body
weight reduction and/or hepatotoxic side effects.
Animal models for chronic autoimmune diseases, in particular animal models for
rheumatoid arthri-
tis showed similar side effects such as altered metabolization and/or
pharmacokinetic and/or
pharmacodynamics of the active agents in the treatment of patients with
autoimmune diseases,
such as rheumatoid arthritis, psoriasis arthritis, arthritis as complication
of cystic fibrosis, lupus
nephritis, systemic lupus erythematosus, uveitis, myasthenia gravis and/or
granulomatosis with
polyangiitis (Wegener's disease).
Therefore, the animal models discussed hereinbefore are suitable to study the
risk-benefit ratio of
the respective active agents, preferably leflunomide and/or its metabolites,
such as preferably
teriflunomide. Safety studies treating naïve, untreated animals with
leflunomide have been pub-
CA 02899746 2015-07-30
19
lished up to now. Aforementioned animal models can represent patient
situations and allow draw-
ing conclusions concerning the risk-benefit-ratio without impairing the safety
of humans.
The inventors of the present invention have surprisingly discovered that due
to the content of 14 to
17.5 mg, preferably 15 to 17.5 mg, in particular preferably 15 mg leflunomide
per pharmaceutical
formulation of an inventive pharmaceut:cal composition according first
inventive aspect as well as
its use according to the second inventive aspect show in one or more animal
models of these
diseases, e.g. but not limited to, the collagen induced arthritis (CIA) RA
animal model
= a comparable or enhanced efficacy in the prophylaxis and/or treatment of
autoimmune dis-
eases, preferably of rheumatoid arthritis, psoriasis arthritis, arthritis as
complication of cyst-
ic fibrosis, lupus nephritis, systemic lupus erythematosus, uveitis,
myasthenia gravis and/or
granulomatosis with polyangiitis (Wegener's granulomatosis); and/or in the
prophylaxis
and/or treatment in the course of an organ transplantation, preferably kidney
transplantation
and/or liver transplantation; and/or in the prophylaxis and/or treatment of
oncologic diseas-
es, preferably melanomas, sarcomas, gliomas, prostate carcinomas, brain and/or
CNS tu-
mors; and/or in the prophylaxis and/or treatment of diseases correlated with
human im-
mune deficiency virus (HIV) in comparison to the standard therapy with 20 mg
and/or 10
mg leflunomide arranged as single dose and/or
= a reduction of one or more of the side effects, preferably one or more
hematotoxic and/or
hepatotoxic and/or gastro intestinal side effects and, thus, an enhanced
safety in compari-
son to the standard therapy with 20 mg and/or 10 mg leflunomide arranged as
single dose
and/or
= a reduction of therapy discontinuations with leflunomide or changes to
other therapeutic ac-
tive agents in comparison to the standard therapy with 20 mg and/or 10 mg
leflunomide ar-
ranged as single dose.
The inventive film coated tablets can be produced in accordance with common
production pro-
cesses (direct tableting, dry or wet granulation). According to a preferred
embodiment all or a part
of the constituents of the tablet core can be grouted in the wet granulation
process to a tablet core.
In a suitable equipment the tablet cores can subsequently be coated with the
constituents of the
film coating and can optionally subsequently be dried.
In the following a choice of assessment possibilities are described, to proof
the efficacy and safety
of leflunomide and/or its active metabolite (A77 1726) teriflunomide according
to the inventive
pharmaceutical composition in particular rheumatoid arthritis.
CA 02899746 2015-07-30
B: Non clinical studies for the analysis of efficacy of leflunomide
Rheumatoid arthritis is a chronic inflammatory disease, which is characterized
by a symmetrical
polyarticular synovitis with defects in cartilage and bone. Generally, many
rat models imitating RA
can be used, including the collagen type II induced arthritis (CIA), the
pristane (2, 6, 10, 14-
5 tetramethyl pentadecane) induced arthritis (PIA), adjuvant induced
arthritis, oil induced arthritis,
avridine induced arthritis, collagen type XI induced arthritis and the
oligomer matrix protein induced
arthritis of the cartilage.
CIA is one of the most used models of the RA and can easily be induced in
sensitive rats and mice
by intradermal injection of autologous or heterologous collagen type II (CII)
with incomplete
10 Freund's adjuvant. Another commonly used model for RA is PIA, which is
induced by a single
injection of pristane. The course of disease is followed over 28 days in the
PIA model, wherein the
symptoms generally begin 14 days post pristane injection. The peak of the
disease systems is
generally reached 21 days post disease induction. In contrast thereto the
disease symptoms gen-
erally start in the CIA 18 days post CII application, wherein the peak of the
disease symptoms is
15 reached approximately 28 days post disease induction.
Materials and methods
All human and animal materials of the models described hereinbefore underlie
the ethical require-
ments or will be gained for the respective use after permission of the ethical
commission.
Animals
In accordance with the models described hereinbefore Dark Argouti (DA) rats of
Taconic Europa
(DK) can be used as animals, wherein the animals are preferably kept in a
specific pathogen free
condition and in a 12 h light-dark cycle.
Preparation of CII
CII will generally be produced by the pepsin digestion process from the
cartilage of the xiphoid
process of the DA rat (s. LU et al: Die Immunisierung von Ratten mit homologen
Typ XI Kollagen
fLihrt zu chronischer und rezidivierender Arthritis, mit unterschiedlicher
Genetik und
Gelenkpathologie, als mit homologen Typ-II-Kollagen induzierte Arthritis. J
Autoimmun 2002; 18:
199-211).
Generally the preparation will be extracted in buffer (1.0 M NaCl/ 50 mM Tris
/ pH 7.5) after cleav-
age by pepsin. Subsequently, 0.9 M NaCI can be used to precipitate C II. The
collagen will gener-
CA 02899746 2015-07-30
21
ally be lyophilized, weighted and then dissolved and kept in 0.1 M acetic acid
until use. The purity
of the CII can be proved by Coonnassie Blue Staining after SDS PAGE analysis.
Induction of arthritis
In the CIA model, rats are generally immunized, i.e. the disease is induced by
a single intradermal
injection of 150 pl emulsion comprising 10 pg C 11 dissolved in 75 pL 0.1
mo1/1 acetic acid and 75
pL incomplete Freund's adjuvant (Sigma-Aldrich, USA).
In the PIA model, 150 pL pristane (Arcos Organics, Belgium) is generally
injected at the tail bases
of the rats, to induce the disease pattern.
io Rats
of the control group generally receive a subcutaneous injection of 150 pL
phosphate buffered
sodium chloride solution.
Clinical evaluation of the arthritis
Generally a macroscopic evaluation system is used, to monitor the development
of the arthritis in
all 4 extremities. Within this evaluation system generally
(i) one point is awarded for each swollen Or
red
metacarpophalangeal/metatarsophalangeal joint,
(ii) One point is awarded for swollen or red interphalangeal (IP) joints of
each single toe,
and
(iii) Five
points at maximum are awarded for each wrist or ankle (1, slight red; 2,
swollen
joint at inside, outside or central; 3, moderate swelling / redness; 4,
strong, but incom-
plete joint swelling; 5, complete joint swelling / redness).
The maximum point number for each paw is 15. Rats are generally examined 3
times per week
post induction of the disease.
Pathological evaluation of the arthritis
The left hindpaw of the rats are generally removed and fixed and then
discalcified for 4 weeks in
12.5 % EDTA (ethylenediaminetetraacetic acid) solution. During this time the
solution is generally
changed every second day.
The discalcified samples are subsequently embedded in paraffin and sliced in 6
pm big tissue
segments, which are then stained with hematoxylin and eosin (H & E).
CA 02899746 2015-07-30
22
A pathologic evaluation system is generally used to evaluate the severity of
the arthritis. Synovitis
is thereby evaluated according to the number of synovial cell layer areas,
areas of the pannus
bearing area, infiltration of synovial inflammatory cells and novel
vascularization. For each index 0
to 3 points are awarded. Destruction of the joint by degradation of the
cartilage, bone erosion,
synarthrophysis and joint structure are rated with 0 to 4 points. Damage
repair by building of new
cartilage and bone is rated with 0 to 3 points.
Pathological evaluation of further organs
Gastrointestinal tract, liver, inguinal lymph nodes and popliteal lymph nodes
can be sampled from
the rat and can be weighted after sampling. The pathological modifications in
the sampled tissues
of both, the control and the PIA animals can be identified and evaluated after
fixation with para-
formaldehyde and H & E staining.
Measuring the A77 1726 level
The measuring of the A77 1726 level can be conducted as described in Rakhila
et al. (2011) J.
Pharm. Biomed. Anal. 5; 55 (2), S. 325-31.
Interaction of leflunomide and/or its metabolite with cytochrome P450 enzymes
The cytochrome P450 level can be measured by commercially available ELISA kits
specific for
rats.
Measuring the active agent transporter protein level
The amount on mRNA of the ATP binding cassette sub family G member 2 (ABCG2),
also known
as breast cancer resistance protein (BCRP), can be measured as described in
Takara et al. (2003)
Drug Metab Dispos 31:1235-1239 und Takara et al. (2007) EXCLI Journal 6:138-
144 Takara et al.
(2003) Drug Metab Dispos 31:1235-1239 und Takara et al. (2007) EXCLI Journal
6:138-144.
Measuring the DHODH level / activity
The DHODH level can be measured by use of a commercially available ELISA kit
specific for rats.
CA 02899746 2015-07-30
23
Measuring the kinase level / activity
Identifying kinases, which have been activated by leflunomide and/or A77 1726
A kinase scan can be conducted as described in Fabian, M.A. et al. (A small
molecule-kinase
interaction map for clinical kinase inhibitors. Nat. Biotechnol. 23, 329-336;
2005) and Wodicka,
L.M. et al. (Activation state-dependent binding of small molecule kinase
inhibitors: structural in-
sights from biochemistry. Chem. Biol. 17, 1241-1249; 2010). Kinases fused to
T7 phages are
produced in an E. coli host, which is generally produced from the strain BL21.
E. coli is accordingly
generally cultivated up to the log phase and then infected with T7phages and
incubated under
agitation at 32 C until lysis. The lysates are centrifuged and filtrated to
remove the cell fractions.
The remaining kinases are expressed in fusion with NF KB in HEK-293 cells. The
constructs are
subsequently marked with DNA for a PCR analysis.
Streptavidin coated magnetic pearls can be treated for 30 minutes at room
temperature with small
molecule ligands comprising biotin, to generate affinity resins for the kinase
assay. Here, the pearls
comprising ligands are generally blocked with excess biotin and are washed
with blocking buffer
(Seablock (Pierce), 1% BSA, 0,05% Tween 20, 1 mM DTT), to remove unbound
ligands and to
avoid nonspecific bindings.
Status / activity of phosphorylation
In use of standard techniques freshly isolated tissue is generally washed and
homogenized in ice
cold homogenization buffer.
Lysed tissue is generally incubated with commercially available primary
antibodies, which specifi-
cally bind the respective kinases. These are activated by leflunomide and/or
teriflunomide. The
presence of phosphorylated and complete kinases are measured by use of cell
based ELISA in
accordance to the producer instructions.
Localizing leflunomide and/or A77 1726 activated kinases in situ
The phosphorylation of kinases in situ ,:;an be examined in use of standard
immunohistochemical
(INC) techniques and in use of commercially available phosphor antibodies (BD
Biosciences).
Monoclonal antibodies for kinases, which are activated by leflunomide and/or
teriflunomide (kinase
scan), are generally used here, to localize the activity on cellular base.
CA 02899746 2015-07-30
24
C: In vitro studies with leflunomide and its metabolites
Example 1: Kinome Scan of leflunomide an A77 1726
Binding reactions can be conducted by combining kinases and ligand affinity
pearls for leflunomide
and its active metabolite A77 1726 (teriflunomide). The kinase concentration
in the eluates are
generally measured with quantitative PCR.
Example 2: proliferation assay in use of mitogen induced peripheral blood
cells (human and
rat)
Heparinized full blood, buffy coat or leukocyte filter fraction of healthy
volunteers (human) are used
for the isolation of human peripheral blood mononuclear cells. Heparinized
full blood or spleen are
removed of female or male DA rats (Taconic Europa, DK).
Human peripheral blood mononuclear cells (PBMCs) can be isolated from
heparinized venous
blood of healthy volunteers by centrifugation on a Ficoll Paque gradient
(Amersham Biosciences
AB). Here the white cells are sampled from the Ficoll plasma intermediate
phase and are washed
twice with fresh phosphate buffered sodium chloride solution (PBS).
Erythrocytes remaining in the cellular pellet are lysed with distilled H20 and
the reaction is stopped
by the addition of the same volume of 1.8 % NaCI, to restore the isotonicity.
Isolated cells are
resuspended in sterile complete media R10 (RPM! 1640 with HEPES buffer 25 mM,
Glutamax I,
10% fetal bovine sera and penicillin streptomycin (5 ml penicillin 5000IU/mL +
streptomycin
5000pg/mL). The cells are generally plated on 96 well plates with a density of
1 x 106 cells / ml
and are incubated for an hour with A771726 (concentration 1 x 10-9¨ 1 x 10-4
M).
Subsequently the cells are generally stimulated either with anti CD3 (10
ng/ml), PHA (1pg/m1) or
with ConA (10 pg/ml) and are cultivated at 27 C, 5% CO2, 90% relative
humidity (RH) for 24, 48 or
72 hours.
The cells are generally pulsed one hour prior to the harvest with BrdU (30 pM)
(for measurement of
the proliferative capacity). At time of harvest the supernatants are sampled
and stored at ¨ 80 C
for further analysis.
The cells are generally stained with surface marking agents for identification
of the relevant popula-
tions of leukocytes and T cells with anti CD3, anti CD4, anti CD8, B cells
with anti CD19 and mon-
ocytes as well as neutrophils. The cells are generally subsequently fixed,
permeabilized and
stained for presence of nuclear BrdU. Subsequently, the cells are generally
analyzed in use of
CA 02899746 2015-07-30
FACS Calibur and BrdU positive cells and are recorded within the respective
leucocyte populations
as indication of proliferative activity.
The cells, which have been incubated with teriflunomide and then stimulated
with mitogen, are
generally analyzed on DHODH and selected tyrosine kinase activity, to study
the concentration-
5 efficacy relationship.
White blood cells of the rat are isolated from the spleen of the control and
the pristane treated rats
and are gently homogenized to generate a single cell suspension. The spleen
cells are generally
obtained in PIA rats at peak of the inflammation and are set on Ficoll Paque.
Subsequently, the
spleen cells can be prepared in the same manner as described for human PBMC
only in use of rat
10 specific antibody for leukocyte subpopulation. The cells, which have
been incubated with
teriflunomide and the stimulated as described with mitogen can also be
analyzed on DHODH and
selected tyrosine kinase activity, to study the concentration efficacy
relationship.
D: In vivo studies with leflunomide
15 Example 3: Influence of the Inflammation on the dose exposure
relationship leflunomide
Male DA rats at the age of 8 to 12 weeks are randomly divided in 2 groups: One
PIA group and
one control group. Each group is further divided into dose groups (n = 3-4)
and receive a single
dose formulation of leflunomide (e.g., 5 different doses). To determine
pharmacokinetic profiles,
blood samples are generally taken at 7 to 10 time points after application for
measuring the plasma
20 concentration of an active leflunomide metabolite, (A77 1726)
teriflunomide. Animals showing an
inflammation, the dosing and blood sample taking follows at the peak of the
inflammation.
Preferably each group contains a subgroup, which is not treated.
These animals are generally used to confirm the influence of the inflammation
on systems under
involvement of the liver active agent clearance, e.g., expression / activity
of the cytochrome P450
25 (CYP) and of influx / efflux transporters, and are sacrificed at the
peak of the inflammation. The
livers are taken from the animals. One part of the liver is prepared and used
for
immunohistochemical analysis, to study the expression level of the transporter
proteins. The re-
maining liver tissue is homogenized and plasmosomes are isolated by use of
differential centrifu-
gation.
The complete CYP expression in plasmosomes can be measured (carbon monoxide
differential
spectra) and activities of the CYP isoforms can be determined by quantifying
the metabolization of
testosterone.
CA 02899746 2015-07-30
26
Example 4: Effect of inflammation on the efficacy and toxicity dose
relationship of
leflunomide
Male DA rats at the age of 8 to 12 weeks are randomly divided in 2 groups: One
PIA group and
one control group.
Each group is further divided in treatment groups (preferably n = 10), which
receive leflunomide
once daily (e.g., 4 different doses or vehicles) over 3-4 weeks.
To establish the toxic kinetic, blood samples are generally taken at 7 to 10
time points on day 1
and on the day of the peak of the disease for animals with inflammation for
measuring the plasma
concentrations of active leflunomide m'Otabolite, (A77 1726) teriflunomide.
Blood samples, which
are taken at the peak of the disease, can further be analyzed for clinical
chemistry, hematology
and plasma marker, e.g., cytokines. During the study disease scores and
general health parameter
(weight, behavior) are measured. After taking the second blood sample, the
animals are generally
sacrificed and the efficacy, toxicity parameter as well as histopathology of
the relevant tissue
(joints, liver, GI tract, lymphatic organs) is obtained. The pathological
evaluation of leflunomide
treated PIA and healthy control rats enables the determination of the dose
toxicity and the dose
efficacy relationship for leflunomide.
E: Ex vivo studies with leflunomide
Example 5: Ex vivo measurement of DHODH activity
Tissue samples, which have been taken in example 4 for the ex vivo
measurement, can be used to
establish the DHODH activity ex vivo.
Example 6: Ex vivo measurement of the kinase activity
Tissue samples, which have been taken in example 4 for the ex vivo
measurement, can be used to
establish the kinase activity ex vivo.
The status / activity of phosphorylation selected kinases, which have been
identified in the kinase
scan (example 1), can be quantified in homogenized tissue by use of an ELISA
based assay and
its cellular base in the tissue can be localized by use of
immunohistochemistry.
