Note : Les descriptions sont présentées dans la langue officielle dans laquelle elles ont été soumises.
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ALKYLATE:D RAPAMYCIN DERIVATIVES
This invention relates to compounds of formula I below or pharm~eutir~l1y
acceptable salts thereof which possess immunosuppressive and/or anti tumor and/or
s antiinflamrnatory activity in vivo and/or inhibit thymocyte proliferation in vilro. These
compounds are therefore useful in the treatment of transplantation rejection,
autoimmune diseases such as lupus, rheumatoid arthritis, diabetes mellitus, multiple
sclerosis, the treatn1ellt of Candicia ~1lbicans infectiolls, treatment of diseases of
inflammation neatment of hyperproliferative vascular disease (restenosis) and in the
treatrnent of certain human tumors.
BACKGROUND OF THE INVENTION
Rapamycin is a macrocyclic triene antibiotic produced by Streptomyces
hygroscopicus, which was follnd to have antifungal activity, particularly against
Candida albicans, both in vitro alld in vlvo ~C. Vezina et al., J. Antibiot. 28, 721
(1975); S.N. Seghal et al., J. Antibiot. 28, 727 (1975); H. A. Baker et al., J. Antibiot.
31, 539 (197~); U.S. Patent 3,929,992; and U.S. Patent 3,993,749].
,~- OCH3
4% ~37 26 ,48
8 [~ 2~OH
~0 ~ CH30- ~
HO ~J~4 - 34
46--~ 013 OCH3 5(~ ~ 35
/36
~ 1 4 2
4; 51
20Rap~mycin
(Positions numbered accordillg to Chemical Abstract~s)
Rapamycin alone (U.S. Patent 4,885,171) or in combination with picibanil
(U.S. Patent 4,401,653) has been shown to have antitumor activity. R. Martel et al.
I
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[Can. J. Physiol. Ph~rmacol. 55, 48 (1977)1 disclosed that rapamycin is effective in
the experimental allergic encephalomyelitis model, a model for multiple sclerosis; in the
adjuvant arthritis model, a model for rheumatoid arthritis; and effectively inhibited the
formation of IgE-like antibodies.
s The immunosuppressive effects of rapamycin have been disclosed in FASEB 3,
3411 (19~9). Rapamycin has been shown to be effective in inhibiting transplant
rejection (U.S. Patent 5,10(),899). Cyclosporin A and FK-506, other macrocyclic
molecules, also have been shown to be effective as immunosuppressive agents,
therefore useful in preventing transplant rejection IFASEB 3, 3411 (1989); FASEB 3,
o 5256 (1989); and R. Y. Calne et al., Lancet 1183 (1978)]. U. S. patent 5,321,009
discloses a method of prophylactica]ly preventing the onset, preventing the
development, and arresting the progression of insulin-dependent diabetes mellitus by
administration of rapamycin. U. S. patellt 5,2~,711 discloses a method of preventing
or treating hyperproliferative vascular disease by administration of a combination of
s rapamycin and heparin. U. S. patent 5,2~6,730 discloses a method of treatingimmunoinflammatory disease by treatlllent with rapamycin alone or in combination with
cyclosporin A. U. S. patent 5,2~6,731 provides a method of treating
immunoinflammatory bowel disease by administration of rapamycin alone or in
combination with cyclosporin A.
Various structural features of rapamycin have been modified in efforts to
increase the potency or specificity of phamlacological action. For instance, a number
of U. S. patents disclose compounds where one or more of the hydroxy groups having
normal stereochemistry at positions 14, 31, and 42 have been converted into acylesters, sulfonyl esters, and carballlates. U. S. patent 5,023,263 discloses 42-oxo
2s rapamycin. V. S. patent 5,258,389 discloses 31 and/or 42 O-alkyl, O-aryl, O-alkenyl,
and O-alkynyl ethers of rapamycin having normal stereochemistry at the 42 position.
The PCI' published applicatioll WO 94/~)9()1() discloses 31 and/or 42 O-alkylated
rapamycin analogs wherein the keto groups at positions 15 and 33 may be reduced to a
hydroxyl group or a methylene group.
SUMMARY OF THE INVENTION
The compounds of this invention are represented by the following chemical
formula and are novel. While a number of rapamycin analogs substituted at positions
3s 31 and 42 have been disclosed, substitution at position 29 has not been heretofore
disclosed.
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The compounds useful in this invention are represented by the formula below:
~3 W
38 ' ~ - OCH3
3 ~ ~ z~ Z y
~~o ~ CH303 33~
HO~I~4 134
46 ~ 013 OCH3 5( ~ > 35
11 ~ ' ~ 36
8 1 4 2
4~ 51
wherein W and Y are ORl and X and Z together form a bond or W and X are oR2 and
Y and Z together fonn ,t bond, wherein
R1 is selected from -(CH2)n-Ar where Ar is not phenyl,
-(CH2CH2O~nCH3 where n is not 1,
I O -CH2CH2CH20(CH2CH20)m-CH3,
~(CH2)n-CH2CH(oR3)cH2oR4 where R3 ;~nd R4 are H, Cl-Clo alkyl, or R3
and R4 together ale ethylene, metl~ylene or dimethylmethylene;
~CH2(CH2)n-oR3 where R3 is not H, Cl-Cl() alkyl, or C(O)C1-CIo alkyl,
and -CH2(CH2)n-X where X is F, Cl, Br or l;
R2 is selected from H, Cl-Clo alkyl, Ar(CH2)n-, C3-CIo alkenyl, -(CH2CH2O)nCH3,
-CH2CH2CH20(CH2CH20)m-CH3, ~CH2(CH2)n-oR3~ -CH2(CH2)n-X
where X is F, Cl, Br or ~;
and -(CH2)n-CH~CH(ORS)CH2OR6 where RS and R6 are selected
independently from H, Cl-Cl() alkyl, -(CH2)n-Ar, -CONH(CH2)n-Ar
or COC(CH3)2-(CH2)n-Ar, -CoR7 and -Co2R7~ where R7 is Cl-C6
alkyl, C2-C6 alkellyl, or Ar;
n= 1-10 indepelldelltly: and
2s
. _
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m= 1-5 independently;
In the above definitions of variable substituents, the term alkyl includes straight
and branched chain hydrocarbons and the aryl groups (Ar) are selected independently
s from phenyl, pyridinyE, quinolinyl, indolyl, furanyl, 1, 2, 3-triazolyl and tetrazolyl.
This invention also encompasses the pharmaceutica]ly acceptable acid addition salts
where ehey can be formed.
The compounds of this invention exhibit immunosuppressive and/or antifungal
and/or antitumor and/or antiinflammatory activity in vivo and/or inhibit thymocyte
o proliferation in vitro and are therefore useful in the ùeatment or inhibition of organ or
tissue transplantatioll rejection or host vs. graft disease, proliferative diseases such as
restenosis following angioplasty procedures, autoimmune diseases such as lupus,
rheumatoid arthritis, diabetes mellitus, and multiple sclerosis; fungal infections, and
diseases of inflamm.ltioll such as psoriasis, exzema, sebolThea, inflammatory bowel
disease and pulmonary inflammation such ;lS asthma, chronic obstructive pulmonary
disease, emphysema, brollchitis and the like. An invention compound was found toinhibit the growth of human breast, colon and ovarian cancer cell lines in
submicromolar concentration and it is therefole expected that the invention compounds
will be useful in inhibiting these and other tumors in humans.
Detailed Description of the Invention
The compounds of this invention can be prepared by standard literature
procedures as outlined below. Other suitable bases may be used in place of the 2,6-di-
tert-butyl-4-methylpyridine and may include pyridine, lutidine, co]lidine, sodium
hydride, or sodiulll carbonate.
f ~0 H ~O R
~ OMe ~~ OMe
~, '2 6 di(t buRty~l) 4-2rnetnylpyridine
CH2cl2 ~ I n ¦l
SSlr~ ~ ~;0 or ROC(=NH)CCI3, catalytic SSlr ~31
M e O J~ CF3SO3H, benzene o M e O' ~ ~
+ 31-substituted product and
31,42-disubstituted product
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Also, unexpectedly, a product was i.solated (1,3-allyl rearrangement) via
triflation at C-28 followed by attack by external nucleophile.
OH ~OH
'J~ OMe ~ OMe
, ~2,6-di(t-butyl)-4-methylpyridine ~" ~O R
n 1l CH2CI2 I n ~ 1
SSlr ~31or ROC(=NH)CCI3, catalytic Ss~r ~
M e O ~CF3SO3H, benzene o M e O~ J~~
~ss ~ss
The compounds of this invention exhibit immunosuppressive and/or antifungal
and/or antitumor and/or antiinflammatory activity in vivo andJor inhibit thymocyte
proliferation in vitro and are therefore useful in the treatment of transplantation
rejection, autoimmul1e dise~ces (i.e. Iupus, rheumatoid arthritis, diabetes mellitus,
multiple sclerosis), Candida al~ica~Ls infections, and diseases of inflammation. An
invention compound inhibits in vitro in sub-micron-olar concentrations, the growth of
certain human tumor cell lines, including colon (MIP 101), breast (T47D, SKBR-3),
and ovarian (A2780S) cells and therefore it is expected that compounds of this inventon
will be useful in the treatment of these and other tumors.
The following procedllres are included to exemplify the preparation of inventioncompounds and employ stand.ud labor.ltory techniq~les known to those skilled in the art
of organic systhesis.
Example ].
29-O-Ben~,ylI apamycin
Toasolution of triflic anhydride (0.19 n-L, 1.13 mmol) in dichloromethane (5.0 rnL)
in a round bottom flask (50 mL, flame dried) equipped with a magnetic stirrer at 0 ~C
was added 2,6-di-t-butyl-4-methyl pyridine (().253 g, 1.23 mmol) portionwise. The
2s reaction mixture was deg.lssed, and purged with nitrogen. To the solution was added a
solution of benzyl alcohol (().1] mL, 1.06 mmol, diluted in 3 mL dichloromethane)
dropwise. The solutioll became a pale white suspensioIl. The reaction was stirred at 0
~C for 30 min. TLC analysis indicated no residllal benzyl alcohol remained. To the
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suspension was added another portion of 2,6-di-t-butyl-4-methyl pyridine (0.335 g,
1.63 mmol) portionwise, followed by a solution of rapamycin (0.855 g, 0.94 mmol, in
3 mL dichloromethalle) dropwise. The reaction was stirred at 0 ~C for 30 min, and
warmed up to room temperature and stirred overnight. The reaction was quenched with
saturated aqueous NaHC03, and the organic and aqueous layers were separated. Iheaqueous layer was extracted three times with ethyl acetate. The organic layers were
combined, washed with brine, and dried over sodium sulfate. The solution was filtered
and concentrated ln vac~o to afford a pale yellow foam. The product rnixture wasseparated by HPLC (40 % EtOAc/hexane, Dynan1ax 2" silica colun1n, 20 mL/min), and
o four fractions were collected. The second fraction which was obtained in 12 % yield
was identified as 42-O-benzylrapamycin. The third fraction which was obtained in 14
% yield was identified as the dihydr;lte of the title compound.
H NMR (4()() MHz, DMSO-d6) ~ 7.3~ (m, 5 H, PhCH2O-), 6.]() - 6.42 (m, 4 H,
S vinylic), 5.48 (q, 1 H, vinylic), 4.95 (m, 2 H, PhCH20-), 3.32 (s, 3 H, -OC~13), 3.18
(s, 3 H, -OC~3), 3.()5 (s, 3 H, -OCH3); IR (KBr, cm~l): 3420, 2920, 1730, 1645,
1445; MS (neg. FAB): 1()03.4 lMl-, 652, 59(), 349; Anal. Calcd. for Cs3H83Nol3. 2
H2O: C 66.98 %, H 8.56 %, N 1.39 %; Found: C 66.53 %, H 8.51 %, N 1.70 %.
Preparation of substituted alkyl triflates.
To a solution of substituted alkanol (l.()() mmol) in dichloromethane (15.0 mL) in a
round bottom flask (25 mL, flame dried) equipped with a magnetic stirrer at roomtemperature was added 2,~-di-t-butyl-4-metllyl pyridine (0.~50 g, 2.92 mmol). The
2s reaction mixture was degassed, purged with nitrogen, and cooled to -78 ~C. To the
solution was added dropwise trifluoromethanes-llfonic anhydride (0.170 mL, 0.282 g,
1-.00 mmol) over a period of 5 minutes. The solution became a suspension. The
reaction was stirred at () ~C for 3() minutes, then wamled up to room t~lllpe.dlul~. TLC
analysis showed completion of ttle reaction.
General Procedure for the Preparatioll of 42-substituted Derivatives of
Rapamycin via Nucleophilic Substitution.
To the solution of substituted alkyl-triflate prep~ared from 1 mmol of alkanol was added
at room temperature (unless otherwise noted) rap~mycin (914 mg, 1 mmol). The
mixture was stirred between 4 and 12() h (monitoring of the extent of the reaction was
~,
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carried out by TLC). When desired convelsioll has been achieved the reaction wasquenched with saturated aqueous NaHCO3, and the organic and aqueous layers were
separated. The aqueous layer was extracted three times with ethyl acetate. The organic
layers were combined, washed with brine, and dried over sodium sulfate. The solution
s was filtered and concen~ated i~ vacuo to afford a product. Pure products were
isolated by HPLC (norrnal phase- Dynamax 2" silica column, eluent EtOAc: hexane,20 mL4min; reversed ph~se -Dynamax 2" C18 column, eluent MeCN: water, 20
mL/min. Spectroscopic analyses were used to confirm the structures.
0 Example 2.
42-0-(4-chlorobutyl )rapamycin
Method A. Alkanol used: 1()8 mg (I mmol) of l-chloro-butane-4-ol. Reaction tirne:
S 72 h at 25 ~C. Separatioll tech~ u~ en1ployed: 2" Dynal~ x silica column, eluent 40%
EtOAc: hexane,20 mL/min. Yield of product: 18() mg (18 %).
Spectral data follows: IH NMR (400 MHz, DMSO-d6 ~ 6.08-6.45 (m, 4 H), 3.4-3.7
(m, 8 H), 3.1S (s, 3H), 3.04 (s, 3 H). IR (KBr, cm~l) 3420, 2930, 1715, 1650,
1620, 1460. MS (neg. FAB) 1003.4 ~MI-, 590.2, 411.2. Anal. calcd. for
CssHg6NO13CI: C 65.75 %, H 8.63 %, N 1.39 %; Found: C 65.14 %, H 8.64 %,
N 1.18 %.
Example 3.
2s
42-0-(2-[2-(2-methoxy etho~y)-ethoxy]-ethyl)-l apamycin
Method A. Alkanol used: 165 mg (I mmol) of triethylenegycol monomethyl ether.
Reaction time: 12() h ~I 1() ~C. Separation techni~lue employed: 2" Dynamax silica
column, eluent 7()~c EtOAc: hexane,2() mL/min. Yield of product: 210 mg (19 %).
Spectral data follows: ~H NMR (4()() MHz, DMSO-d6 ~ 6.()5-6.45 (m, 4 H), 3.4-
3.65 (m, 12 H), 3.23 (s, 3 H), 3.14 (s, 3 H), 3.()4 (s, 3 H). IR (KBr, cm~l ) 3420,
2925, 1720, 1645, 145(); MS (neg. FAB) 1()59.4 IM]-, 590.2, 467.2. Anal. Calcd.
3s for C5XHg3NOl6. H~O C 64.6() %, H 8.81 %, N 1.28 %; Found: C 63.96 %, H
8.64 %, N 1.15 %.
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Pharmacolo~y
Immunosuppressive activity was evalu~ted in an in vitro standard
s pharmacological test procedllre to measure Iymphocyte proliferation (LAF), in an in
vivo procedure to evaluate the survival time of a pinch skin graft, and in an in vivo
procedure to determine inhibition of T-cell mediated inflammatory response (adjuvant
arthritis).
The comitogen-induced thymocyte proliferation procedure (LAF) was used as
o an in vilro measure of tl-e immunos~lpplessive effects of representative compounds.
Briefly, cells from the thymus of normal BALB/c mice are cultured for 7'~ hours with
PHA and IL-I and pulsed with tritiated thymidine during the last six hours. Cells are
cultured with and without various concentrations of rapamycin, cyclosporin A, or test
compound. Cells are halvested and incolporated; radioactivity is determined.
Inhibition of Iymphoproliferation is assessed in percent change in counts per minute
from non-drug treated controls. T}-e results are expressed by the following ratio, or as
the percent hlhibition of Iymphoproliferation of 1 ~lM.
3H-control thymus cells - H3-rap.lmycin-trellted thymus cells
3H-control thymus cells - H3-test compound-treated cells
The results for the rap;mlycin analog (ICsoallalog) alld r.tp;mlycin (ICsorapa) as well as
the ratio of the IDs()s of rapamycin to the analog (R/A) are given in the table below. A
ratio less than l.0 means the analog is less potent than rapamycin.
2s The in vivo test procedure is designed to determine the survival time of pinch
skin graft from male DBA/2 donors tr;ulsplanted to male BALB/c recipients. The
method is adapted from Billingh;ml R.E. and Medawar P.B., J. Exp. Biol. 2~:385-
402, (1951). Briefly, a pinch skin graft from the donor is grafted on the dorsum of the
recipient as a homograft, and an autograft is used as control in the same region. The
recipients are treated with either varying concentrations of cyclosporin A as test control
or the test compoulld, intrapelitone.llly. Untleated recipients serve as rejection control.
The graft is monitored daily and observations ale recorded until the graft becomes dry
and forms a blackened scab. This is considel-ed as the rejection day. The mean graft
survival time (MST -number of days + S.D.) of the drug treatment group is compared
with the control group. Rap;lmycill tre.ltlllellt provides a meall graft survival (MST) of
12.0~ 1.7 days.
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The in vivo adjuvant arthritis standard pharm.lcological test procedure measuresthe ability of test compo-~nds to prevent immune mediated inflammation and inhibit or
treat rheumatoid arthritis. The following briefly describes the test procedure used. A
group of rats (male inbred Wistar Lewis rats) are pre-treated with the compound to be
s tested (lh prior to antigen) and then injected with Freund's Complete Adjuvant (FCA)
in the right hind paw to induce arthritis. The rats are then orally dosed on a Monday,
Wednesday, Friday schedule from day 0-14 for a total of 7 doses. Both hind paws are
measured on days 1~, 23 and 3(). The difference in paw volume (mL) from day 16 to
day 0 is determined and a percent change frolll control is obtained. The left hind paw
o (uninjected paw) inflammation is caused by T-cell mediated inflammation and isrecorded as percent change from control. The right hind paw inflammation, on theother hand, is caused by non-specific inflammation. Compounds were tested at a dose
of 2 mg/kg. The results ~ue expressed as the percent change in the uninjected paw at
day 16 versus control; the more negative the percent change, the more potent thecompound. Rapamycin provides between -7()~o and -90% change versus control,
indicating that rapamycin treated rats h,lve between 70-90% less immune-induced
inflammation than control rats.
The following table summarizes tlle results of the compounds of this invention
in these three standard test procedures.
g
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Table 1: Summ~try of Pharmacological Test Results
EvaluatiolI of ImmulIosllpplessive Activity
LA F Skin G raft Adjuvant
Arthritis
Example ICs() analog _50 rapa R/A MST + S.D. % Change
4.2 0.5 0.12 7.2 0.04
2 2.4 0.00
3 l .47 1 . l 0.75 9.8 0.8 -88
0 3.10 0.8 ().26 9.7 0.5
The results of these standard pharnIacological test procedures demonstrate
immunosuppressive activity both in vitro and in vivo for the compounds of this
invention. Positive ratios in the LAF test procedure indicate suppression of T cell
proliferation. As tralIsplallted pillCh skhI grafts are typically rejected with 6-7 days
without the use of an imllIullosupplessive a$elIt, the increased survival time of the skin
graft when treated with the compoulIds of this invention further demonstrates their
utility as immunosuppressive agents. The reduction of infl~mlmatory joint swelling in
the adjuvant rat model demonstrates their utility in the treatment of inflammatory
diseases.
}nhibition of growtll of human tumors in VitlO by rapamycin analogs
The compound of Example 3 was shown to inhibit in submicromolar
concentrations breast (T47D), colon (MIP 1()1), and ovarian (A 2780S) cancer cell
lines according to the following assay procedure:
Human tumor cell lines were plated in 96-well plates (250 IlL/well, 1-6 x 104
cells/mL) in RPMI 164() medium, colItaillillg ~'J/o FBS (Fetal Bovine Serum). Twenty-
four hours after plating, drugs were added at five log concentrations ~0.01-100
~g/mL). After 48 hours exposure to dr-lgs, cells were fixed with trichloroacteic acid,
and stained with Sulfolhod;tllline B. After washing with trichloroacetic acid, bound
dye was solubili~ed in 1() mM Tris base alld Optical Density was detennined using a
plate reader. Under conditions of the ass;ly, the optical density is proportional to the
number of cells hl the well. IC5()s (concelItr;ltions causing 50% inhibition of cell
growth) were detemlilIed fiom the growth hIhibition plo~s. The assay is described in
3s details by Philip SkehalI et al., J. Nation;ll Cancer Institute X2, 1107-1112, 1990.
Based on the results of these stalIdald ph;lrl1lacological test procedures, the
compounds are useful in the treatment of transphlntation rejection such as, heart,
kidney, liver, bone marlow, and skin tr.lnsplants; autoimmune diseases such as lupus,
rheumatoid arthritis, dhlbetes mellitus, myastheni;l gravis, and multiple sclerosis; and
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,
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diseases of inflammation such as, psoriasis, dermatitis, eczema, seborrhea,
infla,~ laloly bowel disease and pulnlollary inflammation such as asthma, chronic
obstructive pulmon.try disease, emphysema, bronchitis and the like; proliferative
diseases such as restenosis following angioplasty procedures, and fungal infections.
s The compounds are also expected to be useful in the treatrment of breast, colon, or
ovarian cancers in humans.
Pharm~ceutic~1 Composition
0 The compounds may be administered neat or with a pharrnaceutical carrier to a
mammal in need thereof. The ph;tml;tceutic;tl carrier may be solid or liquid and the
active compound shall be a therapeutic;tlly effective amount.
A solid c;trrier can include one or more substances which may also act as
flavoring agents, lubricants, solubilizers, suspending agents, fillers, glidants,
s compression aids, binders or tablet-disintegrating agents; it can also be an encapsulating
material. In powders, the carrier is a finely divided solid which is in admixture with the
finely divided active ingrediellt. In tablets, the active ingredient is mixed with a carrier
having the necessary complession properties in suitable proportions and compacted in
the shape and size desired. The powders and tablets preferably contain up to 99% of
2n the active ingredient. Suitable solid carliers include, for example, calcium phosphate,
magnesium ste;uate, talc, sugars, lactose, dextrill, starch, gelatin, cellulose, methyl
cellulose, sodium carboxymethyl cellulose, polyvinylpyrrolidine, low melting waxes
and ion exchange resins.
Liquid carriers are used in prep;uing solutions, suspensions, eMulsions,
2s syrups, elixirs and pressurized compositions. The active ingredient can be dissolved or
suspended in a pharmaceutic;tlly acceptable liquid carrier such as water, an organic
solvent, a mixture of both or phalmaceutic,llly acceptable oils or fats. The liquid carrier
can contain other suitable phamlaceutic.ll additives such as solubilizers, emulsifiers,
buffers, preservatives, sweeteners, flavoring agents, suspending agents, thickening
agents, colors, viscosity regulators, stabilizers Ol osmo-regulators. Suitable examples
of liquid carriers for oral and palentelal administration incltlde water (partially
containing additives as above, e.g. cellulose derivatives, preferably sodium
carboxymethyl cellulose solutiol1), alcohols (including monohydric alcohols and
polyhydric alcohols, e.g. glycols) and ti1eil deriv;ltives, and oils (e.g. fractionated
3s coconut oil and ar,lchis oil). For palentel;ll admil1istlation, the car~ier can also be an
oily ester such as ethyl oleate and isopropyl myristate. Sterile liquid carriers are useful
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in sterile liquid fo~m compositions for p.uentel;ll administr.ltion. The liquid carrier for
pressurized compositions can be halogenated hydrocarbon or other pharmaceutically
acceptable propellant.
Liquid phamlaceutical compositions which are sterile solutions or suspensions
s can be utilized by, for example, intramuscular, intraperitoneal or subcutaneous
injection. Sterile solutions can also be administered intravenously. The compound can
also be administered orally either in liquid or solid composition form. The form~ teA
compound can further be administered intr.masally through insuMation of a powderformulation, rectally or vaginally via suppositories, and topically or transdermally.
0 Furthermore, the formulated invention compound can be administered alone or
in combination with one or more addidional immunoregluatory agents such as a
corticosteroid, cyclophosphamide, r,lpalllyLIcin, cyclosporin A, FK-506, OKT-3 or
ATG as established by Stepkowski, Transplantation Proceedings 23: 5()7 (1991).
Preferably, the ph.umaceutical composition is in unit dosage form, e.g. as
tablets or capsules. In such foml, the composition is sub-divided in unit doses
containing appropriate quantities of the active ingredient; the unit dosage forms can be
packaged compositions, for example, packeted powders, vials, ampoules, prefilledsyringes or sachets contaillillg liquids. The unit dosage form can be, for example, a
capsule or tablet itself, or it can be the appropriate number of any such compositions in
package form. The dosage to be used in the treatmellt must be subjectively deterrnined
by the attending physician.
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