Patent Application
20110218246
Pain management continues to be a challenge for medical practitioners. Many pain medications have unfavorable side effects. In addition, patients can develop tolerance to pain medications and require larger doses to reach a previously achieved level of pain relief.
Pain is generally classified as either nociceptive pain or non-nociceptive pain. Nociceptive pain arises from the stimulation of pain receptors (i.e., nociceptive receptors) to heat, cold, vibration, stretch, and chemical stimulus from damaged cells. Somatic pain (i.e., muscoskeletal pain, such as pain specific to skin, muscle, joints, bones, and ligaments) and visceral pain (i.e., pain specific to the internal organs and main body cavities) are the two types of nociceptive pain. Nociceptive pain is usually time-limited and thus, when the tissue heals, the pain is resolved. During periods of pain, nociceptive pain responds well to treatment with opioids.
Non-nociceptive pain arises from within the peripheral and central nervous system, where there are no pain receptors. The pain associated with non-nociceptive pain is generated from nerve cell dysfunction. Non-nociceptive pain includes neuropathic pain and sympathetic pain.
Neuropathic pain originates in the peripheral nervous system (the nerves between the tissue and the spinal cord) or the central nervous system (the nerves between the spinal cord and the brain). Neuropathic pain may be caused by nerve degeneration (e.g., by multiple sclerosis), nerve pressure (e.g., from a trapped nerve); nerve inflammation (e.g., from a torn or slipped disc), or nerve infection (e.g., from shingles or other viral infections). With neuropathic pain, the injured nerves become electrically unstable firing of signals in an inappropriate, random, and disordered fashion. Neuropathic pain is characterized by nerve malfunctions such as hypersensitivity to touch, vibrations, and extreme temperatures and is often described as burning, lancinating, and shooting pain.
Sympathetic pain is caused from possible over activity of the sympathetic system, which controls blood flow to tissues such as skin and muscle, sweating by the skin, and the speed and responsiveness of the peripheral nervous system. Sympathetic pain occurs most commonly after fractures and soft tissue injuries of the arms and legs. Sympathetic pain is characterized by extreme sensitivity in the skin surrounding the site of injury and peripherally in the afflicted limb, which may become so painful that the patient will refuse to use it causing secondary problems with the limb due to non-use.
Unlike nociceptive pain, non-nociceptive pain is not time limited and is not easily treatable. Non-nociceptive pain is generally treated with anti-depressants, anti-convulsants (i.e., anti-epileptic drugs), and anti-arrhythmics; however, to date, there is no effective treatment for non-nociceptive pain. In commonly owned U.S. patent application Ser. No. 10/280,309, the present inventors disclosed a gastric-retentive form of gabapentin and the use of the drug for the treatment of neuropathic pain, which is a non-nociceptive pain state,
Gabapentin (1-(aminomethyl) cyclohexane acetic acid) was approved in the United States in 1994 as NEURONTIN® (Pfizer Inc., New York, N.Y.; NEUROTIN® is an immediate release dosage form of gabapentin) for use as adjunctive therapy in the treatment of partial seizures in children and adults and for treatment of post-herpetic neuralgia (PI-IN) in adults. Gabapentin is currently available as immediate release NEURONTIN® in 100 mg, 300 mg, and 400 mg hard shell capsules; 600 mg and 800 mg film-coated tablets; and in a liquid formulation having 250 mg/5 mL. The recommended dosage for gabapentin is a total daily dose of 900 mg to 1800 mg t.i.d. (i.e., three times daily). The oral bioavailability is dose-dependent, with approximately 60% bioavailability for a dose in the range of 300-400 mg, but with only 35% bioavailability for a dose of 1600 mg (Bourgeois, Epilepsia 36 (Suppl. 5):S1-S7 (1995); Gram, Epilepsia 37 (Suppl. 6):S12-S16 (1996)). The decrease in bioavailability with dose of the immediate release tablet has been attributed to carrier-mediated absorption (Stewart, et al., Pharmaceutical Research 10(2):276-281 (1993).
In early work with rats. Vollmer, et al, Arzneim-Forsch/Drug Research 36(1, Nr. 5):781-892 (1986) found that the absorption site for gabapentin in rats was the duodenum. In humans, gabapentin is absorbed throughout the small intestine with diminished absorption in the colon. The absorption of gabapentin occurs relatively slowly with the peak plasma concentration occurring approximately 2 to 6 hours after dosing (Bourgeois, supra). The elimination of gabapentin is exclusively through renal pathways (Chadwick; Lancet 343:89-91 (1994); Vollmer, supra; Thomson, et al., Pharmacokinet. 23(3):216-230 (1992); and Riva, et al., Clin. Pharmacokinet. 31(6):470-493 (1996)) with reported half-lives of 5 to 7 hours (Chadwick, supra) and 6 to 7 hours (Gram, supra).
Following oral administration of the immediate release form of gabapentin, peak plasma concentrations arc observed within 2 to 3 hours. The absorption of gabapentin is dose-dependent. However, as the dose increases, the bioavailability of the drug decreases (Drugs of Today 31:613-9:975-82 (1995); Neurology 44(Supple 5): S17-S32 (2003). Food has only a small effect on the rate and extent of immediate release gabapentin absorption and less than 3% of gabapentin circulates bound to plasma proteins. Gabapentin is not appreciably metabolized in humans, does not induce hepatic enzymes, and is eliminated unchanged by renal excretion with a half-life of 5-7 hours which is unaffected by dose or multiple dosing.
Because gabapentin is administered t.i.d., compliance is an issue. In this respect, a once- or twice-daily dosage form of gabapentin would be expected to improve compliance with the drug; thus, from a compliance perspective, a controlled release dosage form of gabapentin would provide an advantage over the conventional immediate release dosage form. In addition to the foregoing, a controlled release dosage form of gabapentin would also serve to lower the maximum blood plasma concentration of the drug, which would result in reduced side effects fir patients taking the drug. Since gabapentin is absorbed high in the gastrointestinal tract (“GI tract”), a gastric retentive dosage form of gabapentin is particularly beneficial for delivery of gabapentin since the dosage form would be able to keep the drug in the region of absorption for a longer period of time thus improving the bioavailability of the drug by virtue of the slower release rate.
An osmotic dosage form has been described for delivery of gabapentin prodrugs. U.S. Pat. No. 6,683,112 to Chen et al. describes sustained release formulations that deliver gabapentin prodrugs by means of the push-pull osmotic pump system described in U.S. Pat. No. 4,612,008 to Wong et al. This system however, is not a gastric retentive dosage form and would be expected to deliver the drug with poor bioavailability.
The present invention overcomes the need in the art for a more effective gabapentin dosage form that will increase patient compliance and provide for extended effective plasma levels so that patients suffering from a non-nociceptive pain state may be able to more effectively use gabapentin for treatment of in symptoms.
The present invention overcomes the need in the aforementioned need in the art by providing gastric retentive dosage forms of gabapentin that may be administered to a patient suffering from a pain state in once or twice daily administrations. The pain states that may be treated by the gastric retentive dosage forms of the present invention include non-nociceptive pain states, such as neuronathic pain or sympathetic pain or pain states that include a combination of non-nociceptive pain and nociceptive pain.
In one embodiment of the invention, there is provided a method of treating a patient suffering from a pain state comprising administering to the patient a gastric retentive dosage form comprised of a therapeutically effective amount of gabapentin, wherein the dosage form is administered to the patient in a once-daily dosing regimen within a single 24-hour period.
In another embodiment of the invention, there is provided a method of treating a patient suffering from a pain state comprising administering to the patient a gastric retentive dosage form comprised of a therapeutically effective amount of gabapentin, wherein the dosage form is administered to the patient in a twice-daily dosing regimen within a single 24-hour period.
With both the once-daily and twice-daily dosing regimens, upon administration of the gastric retentive dosage form to the patient, bioavailability (AUC) of the gabapentin is approximately 70% to approximately 130% greater than AUC for a comparable dose of immediate release gabapentin; the patient's blood plasma exhibits a maximum concentration (Cmax) of gabapentin that is approximately 35% to approximately 85% less than Cmax for a comparable dose of immediate release gabapentin; and time to Cmax (Tmax) is approximately 1.5 to approximately 5 hours longer than Tmax for a comparable dose of immediate release gabapentin.
Definitions
Before describing the present invention in detail, it is to be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting.
It must be noted that as used in this specification and the appended claims, the singular forms “a,” “an” and “the” include plural referents unless the context clearly dictates otherwise; thus, for example, reference to “an active agent” or “a pharmacologically active agent” includes a single active agent as well a two or more different active agents in combination, reference to “a polymer” includes mixtures of two or more polymers as well as a single polymer, and the like.
In describing and claiming the present invention, the following terminology will be used in accordance with the definitions set out below.
Within the context of the present invention, the term “pain” as used herein refers to a pain state experienced by a human individual (also referred to as a “patient” herein) that includes a non-nociceptive pain, i.e., a neuropathic pain, a sympathetic pain, or both. As used herein, the term “pain” is also intended to include a mixed pain syndrome that includes a nociceptive pain state in addition to a non-nociceptive pain state. Examples of neuropathic pain include, without limitation, diabetic neuropathy, HIV sensory neuropathy, post-heretic (or post-shingles) neuralgia, post-thoracotomy pain, trigeminal neuralgia, radiculopathy, neuropathic pain associated with chemotherapy, reflex sympathetic dystrophy or causalgia also known as nerve damage (for example carpal tunnel syndrome), back pain, peripheral neuropathy (known as widespread nerve damage experienced in the limbs and regions extending from the central nervous system), entrapment neuropathy (e.g., carpel tunnel syndrome), phantom limb pain, and complex regional pain syndrome. As previously noted, sympathetic pain occurs most commonly after fractures and soft tissue injuries of the arms and legs. Because pain is difficult to define and characterize, it is to be understood that a patient being treated for a particular non-nociceptive pain state, such as the neuropathic pain condition of neuralgia, may also be experiencing a sympathetic pain condition or a nociceptive pain condition. In this respect, the term “pain” as used herein is used to include a mixed syndrome pain that includes mixed syndrome non-nociceptive pain (i.e., pain that includes both neuropathic and sympathetic pain) or a nociceptive pain that accompanies a non-nociceptive pain state. Examples of mixed syndrome non-nociceptive pain are pain associated with post-menopausal symptoms, or pain associated with chronic pelvic pain syndrome. A migraine headache is considered to be one example of a mixed syndrome pain state that is a mixture of neuropathic and somatic, (i.e., nociceptive) pain).
With respect to pain, the terms “treating” and “treatment” as used herein refer to reduction in severity and/or frequency of pain symptoms, elimination of pain symptoms and/or the underlying cause for pain symptoms, prevention of the occurrence of pain symptoms and/or their underlying cause, and the improvement or remediation of damage caused by the pain symptoms. With respect to other conditions or diseases, the terms “treating” arid “treatment” includes the following actions: (i) preventing the disease from occurring in a subject, which may be predisposed to the disease, but has not yet been diagnosed as having it; (ii) inhibiting the disease, i.e., arresting its development; or (iii) relieving the disease, i.e., causing regression of the disease.
The terms “effective amount” or a “therapeutically effective amount” refer to the amount of drug or pharmacologically active agent to provide the desired effect without toxic effects.
The terms “drug,” “active agent,” and “pharmacologically active agent” are used interchangeably herein to refer to any chemical compound, complex or composition that is suitable for oral administration and that has a beneficial biological effect, preferably a therapeutic effect in the treatment of a disease or abnormal physiological condition. The terms also encompass pharmaceutically acceptable, pharmacologically active derivatives of those active agents specifically mentioned herein, including, hut not limited to, salts, esters, amides, prodrugs, active metabolites, analogs, and the like. When the terms “active agent,” “pharmacologically active agent,” and “drug” are used, then, or when a particular active agent is specifically identified, it is to be understood that applicants intend to include the active agent per se as well as pharmaceutically acceptable, pharmacologically active salts, esters, amides, prodrugs, metabolites, analogs, etc.
The term “dosage form” refers to the physical formulation of the drug for administration to the patient. Dosage forms include without limitation, tablets, capsules, caplets, liquids, syrups, lotions, lozenges, aerosols, patches, enemas, oils, ointments, pastes, powders for reconstitution, sachets, solutions, sponges, and wipes. Within the context of the present invention, the gabapentin formulation will generally be administered to patients in the form of tablets or capsules, although a liquid formulation is also contemplated under the invention.
The term “dosage unit” refers to a single unit of the dosage form that is to be administered to the patient. The dosage unit will be typically formulated to include an amount of drug sufficient to achieve a therapeutic effect with a single administration of the dosage unit although where the size of the dosage form is at issue, more than one dosage unit may be necessary to achieve the desired therapeutic effect. For example, a single dosage unit of a drug is typically, one tablet, one capsule, or one tablespoon of liquid. More than one dosage unit may be necessary to administer sufficient drug to achieve a therapeutic effect where the amount of drug causes physical constraints on the size of the dosage form. For example, within the context of the gastric retentive gabapentin dosage form of the present invention, where the therapeutic effective amount of gabapentin is 1800 mg, the patient would be required to take multiple dosage units of gabapentin because a single dosage unit of 1800 mg of gabapentin would be too large for a patient to swallow without discomfort. In such a situation, the patient would take three 600 mg tablets or capsules or two 900 mg tablets or capsules of the gabapentin in order to achieve the 1800 mg therapeutic dose. It is to be understood that the dosage units of the gastric retentive gabapentin of the present invention is not restricted to any particular size dosage unit (such as the 600 and 900 mg tablets or capsules discussed above) and that any dosage unit of a size that would not be restrictive for comfortable ingestion is contemplated under the present invention. As an alternative to administering a plurality of 300-900 mg tablets or capsules, a large dose of gabapentin could be prepared in a single large dosage unit that is cut in half at the time of administration. Thus, with the 1800 mg therapeutic dose, a tablet of 1800 mg could be prepared that could be cut in half or in thirds in order to make the 1800 mg dosage unit more easily ingested.
“Total daily dose” is the total amount of drug administered to the patient in one 24-hour period, regardless of whether the protocol calls for a once-daily, twice-daily, or thrice-daily administration of the drug. Thus, the total amount of drug is summed for a given 24-hour period to determine how much total drug the patient is to be administered in a given day. For gabapentin, the maximum daily total dose deemed reasonable is about 9600 mg with the most common daily doses of gabapentin being in the range of 1800 mg to 2400 mg daily; however, it is to be understood that the amount of gabapentin to be administered to a particular patient will vary due to the pain state requiring treatment, the patient's tolerance for gabapentin or drugs in general, the size of the patient, and various other factors that one of ordinary skill in the art must take into consideration.
The term “asymmetric dose” refers to the administration of two unequal doses of a particular drug in a 24-hour period. Asymmetric doses are typically administered as a small dose in the morning and a proportionally larger dose in the evening. Within the context of the present invention, a morning dose of the gastric retentive gabapentin of the present invention may be about one-half, one-third, or one-fourth the evening dose. Exemplary asymmetrical doses of the gastric retentive gabapentin of the present invention may be 600 mg in the morning and 1200 mg in the evening (1800 total daily dose), 800 mg in the morning and 1500 mg in the evening (2300 total daily dose), 1000 mg in the morning and 2400 mg in the evening (3400 total daily dose), 800 mg in the morning and 3600 mg in the evening (4800 total daily dose), or 600 mg in the morning and 6000 mg in the evening (6600 total daily dose). While an asymmetric dosing regimen for gabapentin will generally be administered with the smaller dose in the morning and the larger dose in the evening, there may be situations where the morning dose may need to exceed the evening dose for reasons based on the needs of the patient, the patient's state of pain, and other factors determined by the patient's physician. By contrast, the term “symmetric dose” refers to the administration of two equal doses in a 24-hour period, such as for example, 300 mg of a given drug in the morning and 300 mg in the evening.
“Titration” is the process of ramping up the total daily amount of drug administered to the patient. “Titration” allows the patient's body to get used to the higher dose, and ensures that the patient is prepared for subsequent higher doses of the drug through a succession of daily doses that are of increasing amount. For example, with gabapentin, where the maintenance dose is 1500 mg, the titration protocol might be 300 mg the first day, 600 mg the second say, 900 mg the third day, 1200 mg the fourth day, and 1500 mg the fifth day. In this way, a titration schedule of 5 days can serve to adjust the patient to a maintenance dose of 1500 mg.
“Weaning” is the process of reducing the daily total dose a patient is receiving from the maintenance dose to a lesser dose. “Weaning” occurs when a patient is experiencing less pain, or the treating physician would like to test whether the patient can reduce a maintenance dose. Weaning is effectively the opposite of titration, and occurs by successively reducing a daily maintenance dose to a lower level. Weaning can occur down to 0 mg of drug, depending on whether the patient is in fact ready to completely stop the pain medication.
“Maintenance” is the dosage amount that the patient needs to reach and maintain a desired level of pain relief. The maintenance dose is generally a daily dosage amount, such as, for example 1200 mg, 1500 mg, 1800 mg, or 2400 mg. The maintenance dose is generally titrated to and maintained for a designated period of time. As discussed above, maintenance doses may also be diminished by weaning. As is known by those of ordinary skill in the art, maintenance doses should be set to minimize any side effects of the drug.
The term “controlled release” is intended to refer to any dosage form in which release of the drug is not immediate, i.e., with a “controlled release” formulation, oral administration does not result in immediate release of the drug into an absorption pool. The term is used interchangeably with “nonimmediate release” as defined in Remington: The Science and Practice of Pharmacy, 20th edition (Lippincott Williams & Wilkins, 2000). Examples of controlled release dosage forms include “delayed release,” “sustained or extended release,” and “modified release” dosage forms. As discussed therein, immediate and non-immediate release can be defined kinetically by reference to the following equation:
The “absorption pool” represents a solution of the drug administered at a particular absorption site, and kr, ka and ke, are first-order rate constants for (1) release of the drug from the formulation, (2) absorption, and (3) elimination, respectively. For immediate release dosage forms, the rate constant for drug release kr is far greater than the absorption rate constant ka. For controlled release formulations, the opposite is true, i.e., kr<<ka, such that the rate of release of drug from the dosage form is the rate-limiting step in the delivery of the drug to the target area. It should be noted that this simplified model uses a single first order rate constant for release and absorption, and that the controlled release kinetics with any particular dosage form may be much for complicated. In general, however, the term “controlled release” as used herein includes any nonimmediate release formulation.
“Delayed release” dosage forms are a category of controlled release dosage forms in which the release of the drug is delayed after oral administration for a finite period of time after which release of the drug is unhindered. Delayed release dosage forms are frequently used to protect an acid-labile drug from the low pH of the stomach or where appropriate to target the GI tract for local effect while minimizing systemic exposure.
The terms “sustained release” and “extended release” are used interchangeably herein to refer to a dosage form that provides for gradual release of a drug over an extended period of time. With extended release dosage forms, the rate of release of the drug from the dosage form is reduced in order to maintain therapeutic activity of the drug for a longer period of time or to reduce any toxic effects associated with a particular dosing of the drug. Extended release dosage forms have the advantage of providing patients with a dosing regimen that allows for less frequent dosing, thus enhancing compliance. Extended release dosage forms can also reduce peak-related side effects associated with some drugs and can maintain therapeutic concentrations throughout the dosing period thus avoiding periods of insufficient therapeutic plasma concentrations between doses.
The “gastric retentive” oral dosage forms described herein are a type of extended elease dosage form. Gastric retentive dosage forms are beneficial for the delivery of drugs with reduced absorption in the lower GI tract or for local treatment of diseases of the stomach or upper GI tract. With gastric retentive oral dosage forms of the present invention, the dosage form swells in the gastric cavity and is retained in the gastric cavity of a patient in the fed med so that the drug may be released for heightened therapeutic effect. See, Hou et al., Crit. Rev. Ther. Drug Carrier Syst. 20(6):459-497 (2003)
The term “modified release” refers to a dosage form that includes both delayed and extended release drug products. The manufacture of delayed, extended, and modified release dosage forms are known to ordinary skill in the art and include the formulation of the dosage forms with excipients or combinations of excipients necessary to produce the desired active agent release profile for the dosage form. For example, enteric coating is frequently used to manufacture delayed release dosage forms.
The term “AUC” (literally “area under the curve,” “area under the concentration curve”, or “area under the concentration-time curve”) is a pharmacokinetic term used to refer a method of measurement of bioavailability or extent of absorption of a drug based on a plot of an individual or pool of individual's blood plasma concentrations sampled at frequent intervals; the AUC is directly proportional to the total amount of unaltered drug in the patient's blood plasma. For example, a linear curve (i.e., straight ascending line) indicates that the drug is being released slowly into the blood stream and is providing a steady amount of drug to the patient; the AUC measured from a linear curve generally represents optimal delivery of the drug into the patient's blood stream. By contrast, a non-linear curve indicates rapid release of drug that is not absorbed or metabolized before entering the blood stream; the AUC measured from a non-linear curve may indicate that the drug is not being absorbed or broken down before entering the plasma for a sufficient period of time to extend a therapeutic effect. Within the context of the present invention,
The term “Cmax” (literally “maximum concentration”) is a pharmacokinetic term used to indicate the peak concentration of a particular drug in the blood plasma of a patient. Within the context of the present invention, for immediate release formulations of gabapentin, the Cmax is generally higher than the Cmax of gastric retentive gabapentin because the latter releases the drug more slowly than the former and thus, the gastric retentive gabapentin does not achieve a peak concentration as high as the immediate release gabapentin. As shown in
The term “Tmax” (literally “time of maximum concentration” or “time of Cmax”) is a pharmacokinetic term used to indicate the time at which the Cmax, is observed during the time course of a drug administration. Within the context of the present invention, Tmax is also reduced for gastric retentive gabapentin when compared to immediate release gabapentin. As shown in
The term “half-life” is a pharmacokinetic term used to indicate the length of time necessary to eliminate 50% of the remaining amount of drug present in the body.
By “pharmaceutically acceptable,” such as in the recitation of a “pharmaceutically acceptable carrier,” or a “pharmaceutically acceptable acid addition salt,” is meant a material that is not biologically or otherwise undesirable, i.e., the material may be incorporated into a pharmaceutical composition administered to a patient without causing any undesirable biological effects or interacting in a deleterious manner with any of the other components of the composition in which it is contained. “Pharmacologically active” (or simply “active”) as in a “pharmacologically active” derivative, refers to a derivative having the same type of pharmacological activity as the parent compound and approximately equivalent in degree. When the term “pharmaceutically acceptable” is used to refer to a derivative (e.g., a salt) of an active agent, it is to be understood that the compound is pharmacologically active as well. When the term, “pharmaceutically acceptable” is used to refer to an excipient, it implies that the excipient has met the required standards of toxicological and manufacturing testing or that it is on the Inactive Ingredient Guide prepared by the FDA.
The term “soluble” as used herein refers to a drug having an aqueous solubility (measured in water at 20° C.) greater than 10%, preferably greater than 20%, by weight. The terms “slightly soluble” and “sparingly soluble” refer to a drug having an aqueous solubility (measured at 20° C.) in the range of 2% to 10% by weight, while drugs having an aqueous solubility in the range of 0.001% to less than 2% by weight are referred to as “substantially insoluble.”
The terms “hydrophilic” and “hydrophobic” are generally defined in terms of a partition coefficient P, which is the ratio of the equilibrium concentration of a compound in an organic phase to that in an aqueous phase. A hydrophilic compound has a P value less than 1.0, typically less than about 0.5, where P is the partition coefficient of the compound between octanol and water, while hydrophobic compounds will generally have a P greater than about 1.0, typically greater than about 5.0. The polymeric carriers herein are hydrophilic, and thus compatible with aqueous fluids such as those present in the human body.
The term “polymer” as used herein refers to a molecule containing a plurality of covalently attached monomer units, and includes branched, dendrimeric, and star polymers as well as linear polymers. The term also includes both homopolymers and copolymers, e.g., random copolymers, block copolymers and graft copolymers, as well as uncrosslinked polymers and slightly to moderately to substantially crosslinked polymers.
The term “vesicle” as used herein refers to a small (e.g., 0.01 to 1.0 mm), usually spherical structure that may contain or be composed of either lipoidal or aqueous material, or both. Suitable vesicles include, but are not limited to, liposomes, nanoparticles, and microspheres composed of amino acids. While vesicles are usually membrane-bound, they need not necessarily be membrane bound and within the context of the present invention, the term “vesicle” includes both membrane-bound and non-membrane-bound structures.
The terms “swellable” and “bioerodible” (or simply “erodible”) are used to refer to the polymers used in the present dosage forms, with “swellable” polymers being those that are capable of absorbing water and physically swelling as a result, with the extent to which a polymer can swell being determined by the degree of crosslinking, and “bioerodible” or “erodible” polymers referring to polymers that slowly dissolve and/or gradually hydrolyze in an aqueous fluid, and/or that physically erodes as a result of movement within the stomach or GI tract.
The in vivo “release rate” and in vivo “release profile” refer to the time it takes for the orally administered dosage form, or the active agent-containing layer of a bilayer or multilayer tablet (administered when the stomach is in the fed mode) to be reduced to 0-10%, preferably 0-5%, of its original size, as may be observed visually using NMR shift reagents or paramagnetic species, radio-opaque species or markers, or radiolabels. Unless otherwise indicated herein, all references to in vivo tests and in vivo results refer to results obtained upon oral administration of a dosage form with food, such that the stomach is in the fed mode.
The term “fed mode,” as used herein, refers to a state which is typically induced in a patient by the presence of food in the stomach, the food-giving rise to two signals, one that is said to stem from stomach distension and the other a chemical signal based on food in the stomach. It has been determined that once the fed mode has been induced, larger particles are retained in the stomach for a longer period of time than smaller particles. Thus, the fed mode is typically induced in a patient by the presence of food in the stomach.
In the normal digestive process, the passage of matter through the stomach is delayed by a physiological condition that is variously referred to as the digestive mode, the postprandial mode, or the “fed mode.” Between fed modes, the stomach is in the interdigestive or “fasting” mode. The difference between the two modes lies in the pattern of gastroduodenal motor activity.
In the fasting mode, the stomach exhibits a cyclic activity called the interdigestive migrating motor complex (“IMMC”). This activity occurs in four phases:
Phase I, which lasts 45 to 60 minutes, is the most quiescent, with the stomach experiencing few or no contractions;
Phase II, characterized by sweeping contractions occurring in an irregular intermittent pattern and gradually increasing in magnitude;
Phase III, consisting of intense bursts of peristaltic waves in both the stomach and the small bowel, lasting for about 5 to 15 minutes; and
Phase IV is a transition period of decreasing activity which lasts until the next cycle begins.
The total cycle time for all four phases is approximately 90 minutes. The greatest activity occurs in Phase III, when powerful peristaltic waves sweep the swallowed saliva, gastric secretions, food particles, and particulate debris, out of the stomach and into the small intestine and colon. Phase III thus serves as an intestinal housekeeper, preparing the upper tract for the next meal and preventing bacterial overgrowth.
The fed mode is initiated by nutritive materials entering the stomach upon the ingestion of food. Initiation is accompanied by a rapid and profound change in the motor pattern of the upper GI tract, over a period of 30 seconds to one minute. The change is observed almost simultaneously at all sites along the GI tract and occurs before the stomach contents have reached the distal small intestine. Once the fed mode is established, the stomach generates 3-4 continuous and regular contractions per minute, similar to those of the fasting mode but with about half the amplitude. The pylorus is partially open, causing a sieving effect in which liquids and small particles flow continuously from the stomach into the intestine while indigestible particles greater in size than the pyloric opening are retropelled and retained in the stomach. This sieving effect thus causes the stomach to retain particles exceeding about 1 cm in size for approximately 4 to 6 hours.
Active Agents
The active ingredient in the method of the invention is gabapentin. Gabapentin is preferably used in the free amphoteric form. Pharmaceutically acceptable salt forms that retain the biological effectiveness and properties of gabapentin and are not biologically or otherwise undesirable can also be used and may show superior bioavailability. As used herein, the term “gabapentin” is intended to include the agent itself, as well as its pharmaceutically acceptable salts.
Pharmaceutically acceptable salts may be amphoteric and may be present in the form of internal salts. Gabapentin may form acid addition salts and salts with bases. Exemplary acids that can be used to form such salts include, by way of example and not limitation, mineral acids such as hydrochloric, hydrobromic, sulfuric or phosphoric acid or organic acids such as organic sulfonic acids and organic carboxylic acids. Salts formed with inorganic bases include, for example, the sodium, potassium, lithium, ammonium, calcium, and magnesium salts. Salts derived from organic bases include, for example, the salts of primary, secondary and tertiary amines, substituted amines including naturally-occurring substituted amines, and cyclic amines, including isopropylamine, trimethylamine, diethylamine, triethylamine, tripropylamine, ethanolamine, 2-dimethyl aminoethanol, tromethamine, lysine, arginine, histidine, caffeine, procaine, hydrabamine, choline, betaine, ethylenediamine, glucosamine, N-alkylglucamines, theobromine, purines, piperazine, piperidine, N-ethylpiperidine, fumarate, maleate, succinate, acetate and oxalate. The invention also contemplates administering one or more additional therapeutic agents with the gabapentin treatment. The selection of these additional therapeutic agents will depend upon the specific pain or disease state being treated.
Additional therapeutic agents that can be used with the gastric retentive gabapentin of the present invention to treat any of the various pain states described above, include anticonvulsants, tricyclic antidepressants, opioids, and secondary analgesics. Examples of suitable anticonvulsants include carbamazepine, phenytoin, and lamotrigine. Examples of suitable tricyclic antidepressants include amitriptyline, imipramine, clomipramine, and desipramine. Examples of suitable opioids include oxycodone and tramadol.
For those embodiments of the invention where the gabapentin gastric retentive dosage form is administered for prophylactic treatment of migraine headaches, such additional therapeutic agents can be selected from the group consisting of tricyclic antidepressants (amitriptyline, doxepin, imipramine, maprotiline, protriptyline, desipramine), SSRI (fluoxetine), triptine (sumatriptan, etc.), and ergotamine.
Where the additional therapeutic agent is a secondary analgesic, any analgesic that would complement the treatment protocol of the gastric retentive gabapentin of the present invention can be administered with gabapentin, either at the same time or at different times in order to treat the pain condition at hand. The secondary analgesic would typically be administered at least once in a 24-hour period, and can be any analgesic effective for treatment of pain. One type of analgesic that may be used in conjunction with the gastric retentive gabapentin of the present invention are non-steroidal anti-inflammatory drugs (“NSAIDs”),
Methods of Treatment
The present invention relates to a method of treating a pain state, comprising administering a therapeutically effective amount of gabapentin, or a pharmaceutically acceptable salt thereof, to a patient in need of such treatment in a gastric retentive dosage form that is administered to the patient in a once-daily or twice-daily dosing regimen. The method of the present invention is useful for treating numerous pain states that are currently being treated with conventional immediate release formulations of gabapentin and include, by way of illustration and not limitation, pain states exhibiting neuropathic pain, sympathetic pain, a mixture of neuropathic pain and sympathetic pain, or a mixture of neuropathic pain or sympathetic pain with nociceptive pain.
Generally, the frequency of administration of a particular dosage form is determined to provide the most effective results in an efficient manner without overdosing and varies according to the following criteria: (1) the characteristics of the particular drug, including both its pharmacological characteristics and its physical characteristics, such as solubility; (2) the characteristics of the swellable matrix, such as its permeability; and (3) the relative amounts of the drug and polymer. In most cases, the dosage form is prepared such that effective results are achieved with administration once every eight hours, once every twelve hours, or once every twenty-four hours. As previously discussed, due to the physical constraints placed on a tablet or capsule that is to be swallowed by a patient, most dosage forms can only support a limited amount of drug within a single dosage unit.
Within the context of the present invention, the gastric retentive gabapentin of the present invention has the advantage of improving patient compliance with gabapentin administration protocols because the drug is administered in a once-daily or twice-daily dosing regimen, rather than the multiple dosing administrations necessary for the immediate release dosage forms of gabapentin in order to maintain a desired level of pain relief. When administered in the fed mode, the gastric retentive gabapentin dosage forms of the present invention are retained for a period of time in the stomach and the release of the drug is extended beyond the release time of an immediate release dosage form. One embodiment of the invention relates to a method of administering a therapeutically effective amount of gabapentin to a patient in need thereof, comprising administering gabapentin or a pharmaceutically acceptable salt thereof, in a gastric retentive dosage form once in the morning or evening in a once a day daily regime. Another embodiment comprises administering gabapentin or a pharmaceutically acceptable salt thereof, in a gastric retentive dosage form twice a day, for example once in the morning and once in the evening in a twice a day daily dosage regime.
In addition to the foregoing, the gastric retentive gabapentin dosage forms of the present invention can lower the maximum plasma concentration of the drug in a patient's blood thereby reducing any side effects from the drug while maintaining a heightened level of pain relief. Since gabapentin is absorbed high in the GI tract by means of a saturable transport mechanism, a gastric retentive dosage form is particularly beneficial for delivery of gabapentin since the dosage form can keep the drug in the region of absorption for an extended period of time and consequently improve bioavailability of the drug. By virtue of the slower release rate of the gastric retentive gabapentin of the present invention, saturation of the carrier-mediated transport of conventional dosages is avoided. The gastric retentive dosage form of the present invention is particularly beneficial for delivery of gabapentin due to its prolonged transit in the upper GI tract, which allows the drug to be absorbed adequately in the preferred region of absorption. Further, as shown in
In one embodiment of the present invention, the gastric retentive gabapentin is administered in a once-daily dosing regimen with a total daily dose of gabapentin ranging from about 300 mg/day to about 9600 mg/day, depending on the pain state of the individual.
In another embodiment of the invention, the gastric retentive gabapentin is administered in the morning and evening in a twice a day daily regime with a total daily dose of gabapentin ranging from about 300 mg/day to about 9600 mg/day,
Where the total daily dose of gabapentin is 1000 mg or greater, the patient is preferably titrated up to the maximum maintenance dose that the patient is capable of tolerating. Titration is preferable with both the once-daily and twice-daily dosing regimens.
With the twice-daily dosing regimen, the two dosings may be administered in a symmetric or asymmetric dosing regimen. With a symmetric dosing regimen, the morning dose is the same as the evening dose. Thus, a symmetric dosing regimen may consist of 300 mg of gabapentin in the morning and 300 mg of gabapentin in the evening for a total daily dose of 600 mg of gabapentin for a single 24-hour period. With gabapentin, symmetric dosing regimens are best used where lower dosages of gabapentin are being used for pain management. When the twice-daily dosing regimen in an asymmetric dosing regimen, the morning and evening doses will not be the same. Where high doses of gabapentin are necessary to manage pain, asymmetric dosing regimens are preferred. Examples of asymmetric dosage regime can be, for example, 300 mg in the morning and 1200 mg in the evening for a total daily dose of 1500 mg/day; 600 mg in the morning and 3600 mg in the evening for a total daily dose of 4200 mg/day; or 900 mg in the morning and 6000 mg in the evening for a total daily dose of 6900 mg/day.
Individual dosage units for both the once-daily and twice-daily dosing regimens will generally contain from about 100 mg to about 1800 mg of gabapentin per dosage unit. Presently, any dosing regimen for the gastric retentive gabapentin of the present invention must take into consideration both the amount of the gabapentin in a single dosage unit and the number of tablets or capsules that can be consumed together to reach the desired daily dose and/or maintenance dose. For example, for a dosing regimen comprised of a once-daily dosing of 1800 mg of gastric retentive gabapentin, three 600 mg tablets or a 1200 mg tablet or capsule may be taken together with a 600 mg tablet at the evening meal. If the patient finds that the 1200 mg tablet is too large, then the patient may take two 600 mg tablets or three 400 mg tablets. For a dosing regimen comprised of a twice-daily dosing of 1800 mg of gastric retentive gabapentin, 600 mg may be taken with a morning meal and 1200 mg (in one or multiple dosage units) may be taken with an evening meal.
For all modes of administration, the gastric retentive gabapentin dosage forms of the present invention are preferably administered in the fed mode, i.e., with or just after consumption of a small meal. Because two of the side effects of gabapentin are dizziness and somnolence, it is preferable, when possible, for the patient to take the once-daily dose or the larger of the twice-daily doses with an evening meal. In this way, the patient may avoid the side effects by sleeping through the side effects, thus permitting better compliance and optimization of the dosing regimen. When administered in the evening fed mode, the gastric retentive gabapentin of the present invention will provide the patient with continued relief from pain through the night and into the next day. The gastric retentive gabapentin dosage form of the present invention is able to provide pain relief for an extended period of time because the dosage form allows for both extended release of the gabapentin and the superior absorption of the drug in the GI tract.
As previously discussed, with both the once-daily and twice-daily dosing regimens described herein, the total daily dose of gabapentin may be titrated up to a maximum amount per day, also called the maintenance dose. The length of time for the titration process will vary with the individual patients, but will generally range from approximately two days to approximately two weeks. Likewise, where a patient is nearing the completion of a pain management course, the patient may be weaned off the maintenance dose over a period of days or weeks so that the patient's body has a chance to adjust to the reduction of pain medication slowly.
That the gastric retentive gabapentin dosage form of the present invention may be administered in once-daily or twice-daily dosing regimens as described herein is particularly surprising and unexpected when compared to the behavior of immediate release gabapentin. Specifically, while immediate release gabapentin is absorbed in the colon with such a short half-life that it must be administered at least three times a day in order to achieve a desired level of pain relief, the slower absorption of the gastric retentive gabapentin of the present invention allows for administration of the drug in a once or twice daily dosing regimen with improved pain relief and without exacerbation of the incidence of adverse side effects.
In addition to a decrease in Cmax, the gastric retentive dosage forms of the present invention also show increased Tmax (
A further surprising and unexpected feature of the gastric retentive gabapentin dosage forms of the present invention is that the gastric retentive dosage forms enable greater bioavailability of the higher doses of gabapentin when compared to a comparable dose of immediate release gabapentin. Specifically, the bioavailability of a total daily dose of the gastric retentive gabapentin of the present invention is approximately 70% to approximately 130% greater than the bioavailability of a comparable total daily dose of immediate release gabapentin.
Further, as gabapentin is known to exhibit saturable absorption (i.e., where a drug is absorbed only to the amount of saturation), it is also surprising and unexpected that the gastric retentive gabapentin of the present invention is capable of being administered in doses that are two to six times the doses administered for immediate release gabapentin while retaining sufficient bioavailability to attain effective pain relief. As shown in
A particularly beneficial advantage of the once or twice daily dosing regimens for the gastric retentive gabapentin of the present invention is that when the once-daily dosing is administered in the evening, or when the larger of the twice-daily dosing is administered in the evening, the patient is able to experience pain relief throughout the night. As a result of the linear absorption of the drug in the gastric retentive dosage form, the gabapentin is released continuously throughout the night thus providing continuous in relief. The lasting pain relief experienced with the gastric retentive gabapentin of the present invention is in contrast to the pain relief experienced with immediate release gabapentin, which is short-lived and which frequently results in patients awakening during the night when the effects of the immediate release gabapentin wear off and pain ensues.
Another beneficial advantage of the gastric retentive gabapentin of the present invention is that when it is administered at a sufficiently high dose with an evening meal, the sedation, drowsiness, and dizziness typically associated with higher dosages of gabapentin are ameliorated with the nighttime sleep. Another advantage of administering a high evening dose of gastric retentive gabapentin is that the dosage form will allow for continued pain relief upon waking and potentially throughout the next day until the next evening administration. Where appropriate and if necessary, a small morning dosing (e.g., 300 mg) may be administered to supplement the larger evening dosages.
As previously noted, the patient may be titrated up to the maintenance dose (i.e., the highest maximum dose allowable or preferred for a patient). Titration may occur over a period of days or weeks, depending on the patient's needs for pain relief, the magnitude of the maintenance dose, and the patient's apparent tolerance for gabapentin. Titration will generally be determined by the administrating practitioner.
Likewise the patient may be weaned from the high maintenance dose down to a zero dose in a gradual process that allows the patient's body to adjust to reduced medication and to determine whether the pain relief is sufficient at the lower dose.
When the administration of an additional therapeutic agent in addition to the gabapentin is desired, the additional active agent may be administered at the same time or at a different time than gabapentin. For purposes of facilitating patient compliance, administration of any of the aforementioned additional agents at the same time is preferred.
Drug Delivery Systems
There are several drug delivery systems that are suitable for use in delivering gabapentin in the method of the invention as they are particularly tailored to be gastric-retentive dosages, such as the swellable bilayer described in U.S. Pat. No. 5,232,704 to Franz et al.; the multilayer tablet with a band described in U.S. Pat. No. 6,120,803 to Wong et al.; the membrane sac and gas generating agent described in U.S. Pat. No. 4,996,058 to Sinnreich; the swellable, hydrophilic polymer system described in U.S. Pat. No. 5,972,389 to Shell et al. and WO 98/55107 to Shell et al.; all of which are incorporated herein by reference.
Of particular interest are gastric retentive dosage forms that contain hydrophilic polymers that swell to a size such that the dosage form is retained in the fed mode. For example, the gastric retentive dosage form can contain polymers with a high swelling capacity such as polyethylene oxide, hydroxyethylcellulose, and hydroxypropylmethylcellulose. The polymers are preferably of a moderate to high molecular weight (4×103 to greater that 107) to enhance swelling and provide control of the release of gabapentin. In one embodiment of the invention, a hydroxypropylmethylcellulose polymer of such molecular weight is utilized so that the viscosity of a 1% aqueous solution is about 4000 cps to greater than 100,000 cps. An example of suitable polyethylene oxide polymers are those having molecular weights (viscosity average) on the order of 2-7 million. A typical dosage form should swell to approximately 115% of its original volume within one hour after administration, and at a later time should swell to a volume that is 130% or more of the original volume. Fillers, binders, lubricants and other additives may also be included in the gastric retentive dosage form, such as are well known to those of skill in the art.
A typical dosage form would provide for a drug delivery profile such that gabapentin both on an in vivo and in vitro basis is delivered for at least 5 hours, and typically over a time period of about 8-10 hours. In order to provide for sustained delivery, it is preferable that at least 40 wt. % of gabapentin is retained in the dosage form after 1 hour, i.e., no more than 60 wt % of the drug is administered in the first hour. In addition, it may be desired to utilize a dosage form that provides for substantially all of the gabapentin to be delivered over the intended duration, which is typically about 6-12 hours, where substantially all is taken to mean at least about 85 (generally the art teaches that substantially all is 80) wt % of the gabapentin is administered.
In one embodiment of the invention, the gastric retentive dosage form of gabapentin is a capsule dosage form that allows for the extended release of gabapentin in the stomach and comprises: (a) at least one component that expands on contact with gastric juice and contains an agent capable of releasing carbon dioxide or nitrogen, gabapentin or a pharmaceutically acceptable salt thereof; (b) at least one hydrophilic membrane in the form of a sachet which contains component (a), expands by inflation, floats on the aqueous phase in the stomach and is permeable to gastric juice and; (c) capsule dosage form which contains components (a) and (b) and which disintegrates without delay in the stomach under the action of gastric juice. Component (a) may also contain a pharmaceutically acceptable hydrophilic swelling agent such as lower alkyl ethers of cellulose, starches, water-soluble aliphatic or cyclic poly-N-vinylamides, polyvinyl alcohols, polyacrylates, polymethacrylates, polyethylene glycols and mixtures thereof, as well as other materials used in the manufacture of pharmaceutical dosage forms. Further details regarding an example of this type of dosage form can be found in U.S. Pat. No. 4,996,058 to Sinnreich.
In another embodiment of the invention, the gastric retentive dosage form of gabapentin is an extended release oral drug dosage form for releasing gabapentin into the stomach, duodenum and small intestine of a patient, and comprises: a single or a plurality of solid particles consisting of gabapentin or a pharmaceutically acceptable salt thereof dispersed within a polymer that (i) swells unrestrained dimensionally by imbibing water from gastric fluid to increase the size of the particles to promote gastric retention in the stomach of the patient in which the fed mode has been induced; (ii) gradually the gabapentin diffuses or the polymer erodes over a time period of hours, where the diffusion or erosion commences upon contact with the gastric fluid; and (iii) releases gabapentin to the stomach, duodenum and small intestine of the patient, as a result of the diffusion or polymeric erosion at a rate corresponding to the time period. Exemplary polymers include polyethylene oxides, alkyl substituted cellulose materials and combinations thereof, for example, high molecular weight polyethylene oxides and high molecular weight or viscosity hydroxypropylmethylcellulose materials. Further details regarding an example of this type of dosage form can he found in U.S. Pat. No. 5,972,389 to Shell et al. and WO 9855107 to Shell et al.
In yet another embodiment, a bi-layer tablet releases gabapentin to the upper GI tract from an active containing layer, while the other layer is a swelling or floating layer. Details of this dosage may be found in U.S. Pat. No. 5,232,704 to Franz et al. This dosage form may be surrounded by a band of insoluble material as described in U.S. Pat. No. 6,120,803 to Wong et al.
Another embodiment of the invention uses a gastric retentive swellable, sustained-release tablet having a matrix comprised of poly(ethylene oxide) and hydroxypropylmethylcellulose. This dosage form is illustrated in Example 1 and further details may be found in U.S. Patent Application Publication No. 20030104053 to Gusler et al.
Yet another embodiment of the invention relates to a dosage form that is formulated to have a large enough size so as to provide for prolonged transit in the upper GI tract. Such tablets would contain at least 800 mg of gabapentin, typically 800-1200 mg. Typically such a dosage form will be a film coated dosage form or a capsule dosage form that allows for the controlled and extended release of gabapentin in the stomach. In a preferred embodiment, the dosage form is a drug-containing core surrounded by a controlled release film coating that provides for controlled or sustained drug release, i.e., continuous diffusion of drug from the core into the upper GI tract.
Numerous materials useful for manufacturing these large-sized dosage forms are described in Remington: The Science and Practice of Pharmacy, 20th edition (Lippincott Wilkins, 2000) and Ansel et al., Pharmaceutical Dosage Forms and Drug Delivery Systems, 6th Ed. (Media, Pa.: Williams & Wilkins, 1995). Along with gabapentin, the core may contain pharmaceutically acceptable additives or excipients to facilitate manufacturing. These include binders (e.g., ethyl cellulose, gelatin, gums, polyethylene glycol, polyvinylpyrrolidone, polyvinylalcohol, starch, sugars, waxes), coloring agents, diluents (e.g., calcium sulfate, cellulose, dicalcium phosphate, kaolin, lactose, mannitol, microcrystalline cellulose, sodium chloride, sorbitol, starch, sucrose), flavoring agents, glidants colloidal silicon dioxide, talc), and lubricants (e.g., calcium stearate, glyceryl behenate, hydrogenated vegetable oils, magnesium stearate, polyethylene glycol, sodium stearyl fumarate, stearic acid, stearyl behenate, talc). The core may also contain pharmaceutically acceptable additives or excipients that serve to provide desirable physical characteristics to the dosage form. These include sweeteners, polymers, waxes, and solubility-retarding materials. These dosage forms can be made by techniques that are well established in the art, including wet granulation, fluid-bed granulation, dry granulation, direct compression, and so forth.
The controlled release film coating can also be applied by techniques that are well established in the art, for example, by dissolving the material in an appropriate solvent such as acetone or methylene chloride and is then applying the coating to the dosage form core by molding, air spraying, dipping or brushing a solvent-based solution of the material onto the core. Materials suitable for use in controlled release film coatings include by way of illustration, and not limitation, mixtures of waxes such as beeswax and carnuba wax, shellac, and zein, celluloses such as ethyl cellulose, acrylic resins, cellulose acetates including diacetates and triacetates and other cellulose esters, and silicone elastomers. Additional examples arc set forth below.
Of particular interest are controlled release film coating materials that can form a semipermeable membrane or coating, which can be porous or non-porous, and which are permeable to external fluid, and substantially impermeable to the unsolubilized drug contained within the core. Typically, external fluids are aqueous fluids or biological fluids in the environment of use, such as the upper GI tract. External fluid passes through the semipermeable membrane into the core, where it solubilizes the drug. The solubilized drug then moves from the core through the membrane into the GI tract.
After application of the controlled release film coating to the core, a drying step is required and, then, a suitable exit means for the gabapentin must be formed through the semipermeable membrane. Depending on the properties of the gabapentin and other ingredients within the internal compartment and the desired release rate for the dosage form, one or more orifices for gabapentin delivery can be formed through the membrane by mechanical drilling, laser drilling, or the like. The orifice(s) may range in size from a single large orifice containing substantially an entire surface of the dosage form to one or more small orifices selectively located on the surface of the semipermeable membrane. One specific embodiment of a semipermeable membrane-coated core is the elementary osmotic pump. The membrane is provided with one or more delivery orifices, e.g., pierced with a laser to create one or more delivery orifices. Fluid passing through the membrane into the core generates an osmotic pressure that serves to “pump” the solubilized drug through the delivery orifice(s). See for example, U.S. Pat. No. 3,845,770 to Theeuwes et al. and U.S. Pat. No. 3,977,404 to Theeuwes.
The materials used in forming the semipermeable membrane can be substantially insoluble in the external fluid or they can erode after a predetermined period of time with erosion taking place at the end of the gabapentin release period. Suitable materials include, by way of illustration and not limitation: acetaldehyde dimethyl acetate and acetaldehyde dimethylcellulose acetate; agar acetate; alkylene oxide and alkyl glycidyl ether copolymers; amylose triacetate; beta glucan acetate and beta glucan triacetate; cellulosic materials, which include cellulose esters (e.g., mono-, di- and tricellulose acetates, cellulose acetate butyl sulfonate, cellulose acetate butyrate, cellulose acetate chloroacetate, cellulose acetate dimethylaminoacetate, cellulose acetate ethyl carbamate, cellulose acetate ethyl carbonate, cellulose acetate ethyl oxalate, cellulose acetate laurate, cellulose acetate methyl carbamate, cellulose acetate methyl sulfonate, cellulose acetate octate, cellulose acetate phthalate, cellulose acetate propionate, cellulose acetate succinate, cellulose acetate p-toluene sulfonate, cellulose acetate valerate, cellulose propionate, cellulose propionate succinate, dimethyl cellulose acetate, mono-, di- and tricellulose acrylates, mono-, di- and tricellulose alkanylates, mono, di and tricellulose aroylates, cellulose triacylates such as cellulose trilaurate, cellulose tripalmitate, cellulose trisuccinate and cellulose trivalerate, and cellulose diacylates such as cellulose dicaprylate, cellulose dioctanoate, cellulose dipalmatate, cellulose dipentanlate and cellulose disuccinate), cellulose ethers (e.g., ethyl cellulose, hydroxyethylcellulose, hydroxypropylcellulose, and methylcellulose), cellulose ester-ether polymers, mono-, di- and tricellulose acrylates, mono-, di- and tricellulose alkenylates; hydroxylated ethylene-vinyl acetate; perm-selective aromatic nitrogen containing polymeric membranes that exhibit water permeability and essentially no solute permeability; polyamides; polyalkylene oxides such as crosslinked and non-crosslinked polyethylene oxide; polyether and polyamide copolymers; polyglycolic acid and polylactic acid and derivatives thereof; polymeric epoxides; poly(methacrylate) copolymer salts such as poly(ammonium methacrylate) copolymer, poly(ammonium methacrylate copolymer, poly(aminoalkyl methacrylate) copolymer, and (ethyl acrylate)-(methyl methacrylate)-[(trimethylammonium)-ethylmethacrylate] (1:2:0.2) copolymer; cross-linked poly(sodium styrene sulfonate); crosslinked polystyrenes; polyurethanes; polyvinyl alcohol; crosslinked poly(vinylbenzyltrimethyl ammonium chloride); polyvinyl chloride; poly(vinylmethyl ether) copolymers; polyvinylpyrrolidone; propylcarbamate; sulfonated polystyrenes; triacetate of locust gum bean; and so forth; and combinations thereof.
Preferred materials for use in forming the semipermeable membrane include, by way of illustration and not limitation: cellulose esters, cellulose ethers, polyvinylpyrrolidone, polyvinyl alcohol, polyalkylene oxides, and combinations thereof.
The semipermeable membrane may also include one or more plasticizers, including: acetylated monoglycerides; dibutyl phthalate, diethyl phthalate, isopropyl phthalate, dimethyl phthalate, and dactyl phthalate; dibutyl sebacate and dimethyl sebacate; esters such as acetyl triethyl citrate, acetyl tributyl citrate, citrate ester, dibutyl sebacate, tetraethyl acetate, triethyl citrate and other citrate esters; fatty acids such as stearic acid; glyceryl behenate; glycols such as 1,2-butylene glycol, 2,3-butylene glycol, diethylene glycol, ethylene glycol, propylene glycol, tetraethylene glycol, triethylene glycol and polyalkylene glycols such as polyethylene glycol; oils such as castor oil and fractionated coconut oil; glycerin; glycerol and glycerol monostearate; triacetin; and so forth; and combinations thereof.
Preferred plasticizers include esters and fatty acids.
A particularly well-suited example of a core/coating system that can be used with gabapentin to provide for a gastric retentive dosage form is the delayed release tablet described in U.S. Pat. No. 6,350,471 to Seth, which comprises a drug/excipient core and a coating of a water-insoluble, water-permeable film-forming polymer such as ethyl cellulose, a plasticizer such as stearic acid, and a water-soluble polymer such as polyvinylpyrrolidone or hydroxypropylcellulose.
Another suitable core/coating system has a polyvinyl alcohol coating, which is either a water-soluble polyvinyl alcohol blended with a water insoluble polyvinyl alcohol, or a polyvinyl alcohol that has been crosslinked with a material such as boric acid or sodium borate. Such a coating may also include one or more plasticizers.
For those embodiments of the invention that include further administering additional therapeutic agents simultaneously with gabapentin, these agents can either be administered in the gastric retentive dosage form that includes gabapentin or can be administered in a dosage form that is separate from gabapentin; such dosages can be any suitable formulation as are well known in the art. Where appropriate, the additional therapeutic agent may be contained in a vesicle within the dosage form or as one layer of a bilayer or multilayer dosage form.
For those additional agents where controlled release is desirable, the agent may be incorporated in the gabapentin gastric retentive dosage form or be administered in a separate gastric retentive or other controlled release formulation dosage form. For those additional agents where immediate release is desirable, the agent may be incorporated in a coating around the gabapentin gastric retentive dosage form or in a separate layer of a bilayer tablet, the agent may be simply enclosed in the capsule of the aforementioned gabapentin gastric retentive capsule dosage form, or the agent may be administered in a separate immediate release dosage form.
Typically, dosage forms contain the additional agent another analgesic or antineuralgic anticonvulsant agent) in combination with one or more pharmaceutically acceptable ingredients. The carrier may be in the form of a solid, semi-solid, or liquid diluent, or a capsule. Usually the amount of active agent is about 0.1-95 wt %, more typically about 1-50 wt %. Actual methods of preparing such dosage forms are known, or will be apparent, to those skilled in this art (see, e.g., Remington: The Science and Practice of Pharmacy, 20th edition (Lippincott Williams & Wilkins, 2000)). The dosage form to be administered will, in any event, contain a quantity of the additional therapeutic agent(s) in an amount effective to alleviate the symptoms of the subject being treated,
In the preparation of pharmaceutical formulations containing the additional therapeutic agent in the form of dosage units for oral administration the agent may be mixed with solid, powdered ingredients, such as lactose, microcrystalline cellulose, maltodextrin, saccharose, sorbitol, mannitol, starch, amylopectin, cellulose derivatives, gelatin, or another suitable ingredient, as well as with disintegrating agents and lubricating agents such as magnesium stearate, calcium stearate, sodium stearyl fumarate, and polyethylene glycol waxes. The mixture is then processed into granules or pressed into tablets such as chewable and oral disintegrating tablets.
Soft gelatin capsules may be prepared by mixing the active agent and vegetable oil, fat, or other suitable vehicle. Hard gelatin capsules may contain granules of the active agent, alone or in combination with solid powdered ingredients such as lactose, saccharose, sorbitol, mannitol, potato starch, cornstarch, amylopectin, cellulose derivatives, or gelatin.
Liquid preparations for oral administration may be prepared in the form of syrups or suspensions, e.g. solutions or suspensions containing about 0.2-20 wt % of the active agent and the remainder consisting of sugar or sugar alcohols and a mixture of ethanol, water, glycerol, propylene glycol and polyethylene glycol. If desired, such liquid preparations may contain coloring agents, flavoring agents, saccharin and carboxymethyl cellulose or other thickening agents. Liquid preparations for oral administration may also be prepared in the form of a dry powder to be reconstituted with a suitable solvent prior to use.
When the method of the invention includes administering another agent, such as secondary analgesics, anticonvulsant agents, antidepressants, or opioids, the additional agent may be obtained from a commercial source in a variety of dosage forms (e.g., tablets, capsules, oral suspensions, and syrups). The additional agent may be administered as a separate dosage form or the gastric retentive gabapentin dosage form of the present invention may be designed to include the additional agent. Additional analgesic agents may be selected from among the many available NSAIDs on the market. Examples of suitable commercially available anti-convulsants include TEGRETOL® (carbamazepine; Novartis, Summit, N.J.), DILANTIN® (Pfizer Inc., New York, N.Y.), and LAMICTAL® (lamotrigine (GlaxoSmithKline, Philadelphia, Pa.). Suitable antidepressants include the tricyclic antidepressants LIMBITROL® (amitriptyline; Hoffmann-LaRoche, Nutley, TOFRANIL® (imipramine; Tyco Healthcare, Mansfield, Mass.), ANAFRANIL® (clomipramine; Tyco Healthcare, Mansfield, Mass.), and NORPRAMIN® (desipramine; Sanofi-Aventis, Bridgewater, N.J.). Examples of suitable commercially available opioids include PERCOCET® (oxycodone; Dupont Merck Pharmaceuticals, Wilmington, Del.), ULTRACET® (tramadol; Johnson & Johnson, New Brunswick, N.J.), and CLONOPIN™ (clonazepam; Hoffmann-LaRoche, Nutley, N.J.).
All patent applications, patents, publications, and other published documents mentioned or referred to in this specification are incorporated herein by reference in their entireties, to the same extent as if each individual patent application, patent, publication, and other published document was specifically and individually indicated to be incorporated by reference.
The general methods of the invention are best understood with reference to the following examples which are intended to enable those skilled in the art to more clearly understand and to practice the present invention. The following examples are not intended, nor are they to be construed, as limiting the scope of the invention, but are merely intended to be illustrative and representative of the invention.
The practice of the present invention will use, unless otherwise indicated, conventional techniques of pharmaceutical formulation, medicinal chemistry and the like, which are within the skill of the art. Such techniques are explained fully in the literature. Preparation of various types of pharmaceutical formulations are described, for example, in Remington: The Science and Practice of Pharmacy, 20th edition (Lippincott Williams & Wilkins, 2000) and Ansel et al., Pharmaceutical Dosage Forms and Drug Delivery Systems, 6th Ed. (Media, Pa.: Williams & Wilkins, 1995).
In all human clinical trials described in the examples, all investigators involved in the studies conducted the clinical trials in accordance with the United States IND regulations (21 C.F.R. §§50, 54, and 56), the International Conference on Harmonization Harmonized Tripartite Guideline for Good Clinical Practice, the Guidelines of the Declaration of Helsinki, Finland, 1964, and its subsequent amendments (Tokyo, Japan, 1975; Venice, Italy, 1983; Hong Kong, 1989; Republic of South Africa, 1996; and Scotland, 2000), and all national, state, and local laws of the pertinent regulatory authorities. All patients provided written Informed Consent before any study-related procedures were undertaken.
In the Examples that follow, gabapentin was obtained from Plantex U.S.A. (Englewood Cliffs, N.J.). METHOCEL® brand hydroxypropyl methylcellulose (also known as hypromellose), and SENTRY® POLYOX® brand polyethylene oxide were obtained from Dow Chemical (Midland, Mich.). METHOCEL® E5, premium is a USP type 2910 hydroxypropyl methylcellulose with number average molecular weight of on the order of 6000-8000 and a viscosity of 5 cps as a 2% aqueous solution at 20° C. METHOCEL® K4M and METHOCEL® K15M are USP type 2208 hydroxypropyl methylcellulose with viscosities of 4000 cps and 15,000 cps, respectively, as a 2% aqueous solution at 20° C., and number average molecular weights on the order of 80,000 and 100,000, respectively. SENTRY® POLYOX® WSR 301, NE FP, SENTRY® POLYOX® WSR Coagulant, NF FP and SENTRY® POLYOX® WSR 303, NE FP have viscosity-average molecular weights of approximately 4,000,000, 5,000,000 and 7,000,000, respectively. Avicel PH-10I, NE is microcrystalline cellulose supplied by FMC Corporation (Philadelphia, Pa.). Magnesium stearate, NF was supplied by Spectrum Quality Products (New Brunswick, N.J.).
Gastric retentive gabapentin tablets were manufactured using a dry blend process, and hand made on a Carver Auto C Press (Fred Carver, Inc., Indiana). The dry blend process consisted of blending all of the ingredients in a plastic bag, and compressing into a 1000 mg tablet (600 mg gabapentin dose) using a 0.7086″×0.3937″ Mod Oval die (Natoli Engineering, St. Charles, Mo.). The parameters for the operation of the Carver ‘Auto C’ Press were as follows: 4000 lbs force, 0-second dwell time (the setting on the Carver Press), and 100% pump speed. The formulation for the tablets is set froth in Table 1:
The dissolution was determined in USP apparatus I (40 mesh baskets), 100 rpm, in deionized water. Samples, 5 ml at each time-point, were taken without media replacement at 1, 4, and 8 hours. The resulting cumulative dissolution profile, based upon a theoretical percent active added to the formulations is set forth in Table 2:
Gastric retentive gabapentin tablets were manufactured using a dry blend process, and hand made on a Carver ‘Auto C’ Press (Fred Carver, Inc., Indiana). The dry blend process consisted of blending all of the ingredients in a plastic bag, and compressing into a 600 mg tablet (300 mg gabapentin) using a 0.6299″×0.3937″ Mod Oval die (Natoli Engineering, St. Charles, Mo.). The parameters for the operation of the Carver ‘Auto C’ Press were as follows: ˜2000-2500 lbs. force, 0-second dwell time (the setting on the Carver Press), and 100% pump speed. The formulation for the tablets is set froth in Table 3:
The dissolution was determined in USP apparatus 1 (40 mesh baskets), 100 rpm, in deionized water. Samples, 5 ml at each time-point, were taken without media replacement at 1, 2, 4, and 8 hours. The resulting cumulative dissolution profile, based upon a theoretical percent active added to the formulation is set forth in Table 4:
Three gastric retentive gabapentin formulations were manufactured utilizing a standard granulation technique. The formulations manufactured are shown Table 5.
The dissolution profiles, as determined by USP Apparatus 1 (100 rpm) in modified simulated gastric fluid, for three prototypes formulations are shown in
The pharmacokinetic profiles of the three gastric retentive (“GR”) formulations described in Example 3, administered as a 600-mg dose, were compared to NEURONTIN® immediate release 300-mg capsule in a randomized four-way cross-over experiment involving 15 healthy volunteers. Each subject was administered treatment of 600-mg gabapentin as one of the three formulations (1×600-mg tablet or 2×300-mg tablet) or NEURONTIN© capsules (2×300-mg) within 5 minutes of completing a high fat breakfast (FDA breakfast). Plasma samples were taken up to 48 hours post-dose.
As demonstrated in
A gastric retentive tablet containing 900 mg of gabapentin is prepared by granulation with 90 mg of polyvinylpyrrolidone and 10 mg of magnesium stearate and then tableted as a 1000 mg tablet on a Carver press with 4000 lbs force, 0-second dwell time. These tablet cores are then coated from an alcohol-water solution that dries with approximately 2% dry coat weight of 10 mg ethyl cellulose, 7 mg Povidone (PVP), and 3 mg stearic acid.
A gastric retentive tablet containing 1200 mg of gabapentin is prepared by granulation with 120 mg of polyvinylpyrrolidone and 10 mg of magnesium stearate and then tableted as a 1330 mg tablet on a Carver press with 4000 lbs force, 0-second dwell time. These tablet cores are then coated from an alcohol-water solution that dries with approximately 25 mg dry coat weight of 10 mg ethyl cellulose, 10 mg hydroxypropylcellulose, and 5 mg glyceryl behenate.
A gastric retentive tablet containing 900 mg of gabapentin is prepared by granulation with 90 mg of polyvinylpyrrolidone and 10 mg of magnesium stearate and then tableted as a 1000 mg tablet on a Carver press with 4000 lbs force, 0-second dwell time. These tablet cores are then coated from an aqueous solution that dries with approximately 2% dry coat weight of 15 mg polyvinyl alcohol (PVA), 5 mg Povidone (PVP), and 3 mg stearic acid. The coated tablets are then sprayed with an aqueous solution of 1% sodium borate to crosslink the PVA and dried.
A gastric retentive tablet containing 900 mg of gabapentin is prepared by granulation with 90 mg, of polyvinylpyrrolidone, 250 mg microcrystalline cellulose, and 10 mg of magnesium stearate and then tableted as a 1250 mg tablet on a Carver press with 4000 lbs force, 0-second dwell time. These tablet cores are then coated from an alcohol-water solution that dries with approximately 2% dry coat weight of 10 mg ethyl cellulose, 7 mg Povidone (PVP), and 3 mg stearic acid.
To study the rate and extent of absorption of the gastric retentive gabapentin dosage forms of the present invention, a four-arm, non-randomized, open-label, single dose, fed designed study was conducted on 24 healthy non-smoking males.
The objective of the study was to compare the rate and extent of absorption of gabapentin following administration of four escalating doses of a test formulation of 600 mg tablets of gastric retentive gabapentin (Depomed Inc., Palo Alto, Calif.) administered once daily under fed condition.
The subjects of the study were 24 nonsmoking males in the are range of 18-65 years old. The 24 subjects were separated into four treatment groups of six subjects per group. The drug administration protocol was as follows:
TREATMENT GROUP A—following an overnight fast of at least 10 hours, one 600 mg gastric retentive gabapentin tablet with 240 mL of ambient temperature water was administered 20 minutes after the start of a standardized moderate fat content meal. Treatment dose was 600 mg.
TREATMENT GROUP B—following an overnight fast of at least 10 hours, two 600 mg gastric retentive gabapentin tablets with 240 mL of ambient temperature water were administered 20 minutes after the start of a standardized moderate fat content meal. Treatment dose was 1200 mg.
TREATMENT GROUP C—following an overnight fast of at least 10 hours, three 600 mg gastric retentive gabapentin tablets with 240 mL of ambient temperature water were administered 20 minutes after the start of a standardized moderate fat content meal. Treatment dose was 1800 mg.
TREATMENT GROUP D—following an overnight fast of at least 10 hours, four 600 mg gastric retentive gabapentin tablets with 240 mL of ambient temperature water were administered 20 minutes after the start of a standardized moderate fat content meal. Treatment dose was 2400 mg.
The meals for all the treatment groups were a 500-600 calorie meal with moderate fat (about 40% fat), with approximately 80 calories from protein. 252 calories from carbohydrates, and about 207 calories from fats. As noted above, the meals were provided after an overnight fast of at least 10 hours. Additional moderate fat meals meals with beverages were provided for the subjects at 4.5 and 9.5 hours post-dose and a standardized snack was provided 13,5 hours post-dose. All meals and beverages were free of alcohol, grapefruit products, xanthine, and caffeine and were identical during the study periods.
The length of the study was four three-day periods separated by at least one-week washout period between treatments. Eighteen blood samples of 4 ml., each were drawn in each three-day-period according to the following schedule (in hours): 0.0 (pre-dose), 0.5, 1.0, 2.0, 3.0, 4.0, 5.0, 6.0, 7.0, 8.0, 10.0, 12.0, 14.0, 16.0, 24.0, 35.0, and 36.0 hours post-dose. The total blood volume was 315 mL. Vital signs (blood pressure, temperature, respiration rate, and heart rate) were measured at the following time periods: 0.0 (predose), 2.0, 4.0, 8.0, 12.0, and 24.0 hours post dose. Data obtained from the study is shown in Tables 7 and 8 and in
As shown in Table 7, a comparison of gastric retentive gabapentin versus immediate release gabapentin shows that 2400 mg of gastric retentive gabapentin achieves lower peak blood plasma concentrations (Cmax) than does 800 mg of immediate release gabapentin in the same period of time. This data indicates that gastric retentive gabapentin is capable of delivering significantly more drug to a patient over a longer period of time when compared against immediate release gabapentin.
To determine the rate and extent of absorption of the gastric retentive gabapentin dosage forms, the pharmacokinetic measurements obtained for the AUC (in ng-h/mL) for each treatment group at 24 hours (Table 8) was plotted against the amount of drug administered to each group (i.e., the 600 mg, 1200 mg, 1800 mg, and 2400 mg gastric retentive dosages, which were administered in once-daily dosings as set forth above) (
When compared against the AUC (ng-h/mL) for a single dosing of the immediate release gabapentin dosage form NEURONTIN® calculated at 8 hours for dosages of 400 mg, 800 mg, 1200 mg, and 1600 mg (
The difference in bioavailability of gastric retentive and immediate release gabapentin depicted in
To study the efficacy of once-daily versus twice-daily administration of gastric retentive gabapentin, a randomized, double-blind multi-center trial was conducted on 158 patients (consisting of both males and females older than 18 years of age) with post herpetic neuralgia (“PHN”). The aim of the study was to determine if the gastric retentive gabapentin dosage forms was successful in reducing the patients' mean daily pain scores from the baseline week to end of the efficacy treatment period (Treatment Week 4). Secondary efficacy measures included changes from baseline in mean weekly sleep interference scores, Short-Form McGill Pairs Questionnaire (SF-MPQ), the Neuropathic Pain Scale (NPS), Patient Global Impression of Change (PGIC), and Investigator-rated Clinical Global Impression of Change (CGIC).
Patients suffering from PHN were eligible for the study if they had experienced pain for at least three months after the healing of an acute herpes zoster skin rash with a pain intensity of at least 4 on the 11-point Lickert scale (i.e., 0-10) at screening. Baseline pain values for all eligible patients were determined during a one-week pretreatment period where the patients were to base their pain during this week on the 11-point Lickert scale; patients who recorded at least a 4 on the 11-point scale together with the completion of at least 4 days of diary entries were deemed eligible to participate in the study. All patients were required to undergo 7-day washout for medications prescribed for PHN and a 14-day washout (tapered appropriately) for strong opiates (i.e., morphine or fentanyl). Patients were permitted to take acetaminophen or acetaminophen with hydrocodone (if required for treatment of pain during the study).
The 158 patients selected for the study were randomly assigned to treatment with 1800 mg of gastric retentive gabapentin dosed once daily following the evening meal (55 patients), or dosed twice daily with 600 mg in the morning and 1200 mg in the evening (52 patients) against a placebo (51 patients). The course of the study was five weeks. Patients randomized to active treatment were gradually titrated over a two-week period to a total daily dose of 1500 mg, followed by an additional two-week period at the 1800 mg/day maintenance dose. All patients, regardless of treatment, took the same number of tablets of identical appearance each day to maintain the study blind; accordingly, patients assigned to placebo received no drug, but took the same number of tablets each day as those patients assigned to active treatments. A one week blinded tapering period followed the four-week efficacy treatment period. End of study safety assessments were completed at the Week 5 visit.
The gastric retentive gabapentin dosage units prepared for administration to the patients were 300 mg and 600 mg white film coated, modified oval-shaped tablets with a total mass of 714 mg and 1020 mg, respectively. In addition to gabapentin, the tablets included the following inactive ingredients: polyethylene oxide, hypromellose, magnesium stearate, and coating. The placebo tablets were comprised of lactose, microcrystalline cellulose, and polyethylene oxide in place of gabapentin, and contained the same excipients as the active product.
Patients assigned to placebo randomly took the required number of placebo tablets each morning and evening to match the dosing of patients assigned to the two active treatment groups.
The results of the study are shown in Tables 9-13. In all tables, patients who had both baseline and endpoint values were included in the data analysis. In accordance with standard statistical analyses, a lower p-value represents stronger evidence against the null hypothesis of no effect in the population being tested (p=1.00)
In Tables 9, 12, and 13 the “p-values” (both overall and vs. placebo) are based on a Type III sum of squares statistical analysis; the LS mean and SEM values for the Baseline are estimated from the ANOVA model that includes treatment, center, and treatment by center interaction factor; and the LS mean and SEM values for the Endpoint and Change from Baseline to Endpoint are estimated from the ANCOVA model that includes, treatment, center, treatment by center interaction factor, and baseline value as a covariate.
In Table 10, the “responders” are defined as patients with at least 50% reduction in LOCF average daily pain score from baseline; the “overall p-value” is based on a Cochran-Mantel-Haenszel test for the general association stratified by the baseline pain score category (less than 8 vs. at least 8); and the “p-value vs. placebo” is based on the Z test for the difference in proportions between the two groups (i.e., the treatment groups and the placebo group).
The Overall Treatment p-values in Table 9 show that the group as a whole experienced a statistically significant decrease in pain from Baseline to LOCF. While Table 9 shows a relatively large placebo effect, most likely due to self-administration of acetaminophen (with or without hydrocodone) during the course of the study, the p-values (vs. placebo) for the two gabapentin treatment groups indicate a statistically significant decrease in the pain experienced by the patients from Baseline to LOCF (see, p-values (vs. placebo) at Baseline and for GR Gabapentin minus Placebo). Between the two treatment groups, patients administered the twice-daily gastric retentive gabapentin showed more pain reduction than did the patients on the once-daily dosing regimen; however, the difference was not great (see, values for LOCF Endpoint and Changes from Baseline to LOCF Endpoint).
Table 10 shows that 25.5% of the patients following the once-daily dosing regimen and 28.8% of the patients following, the twice-daily dosing regimen experienced a 50% reduction in pain from Baseline to LOCF and Table 11 outlines the pain reduction from 0% Decrease to 100% Decrease for each of the patients in each of the Treatment Groups. Within the once-daily Treatment Group, two patients reported a 90% decrease in pain and within the twice-daily Treatment Group, three patients reported a 100% decrease.
Table 12 sets forth the LOCF Average Daily Pain Score from Table 9 for those patients at least 65 years of age. The data from Table 12 shows statistical differences from placebo in pain management between the patients on the once-daily dosing regimen and the twice-daily dosing regimen (see, p-value (vs. placebo) for GR Gabapentin minus Placebo) and is more consistent than for the complete age group (Table 9).
This application is a continuation of U.S. Ser. No. 11/322,448, filed Dec. 29, 2005, the disclosure of which is incorporated herein by reference in its entirety.
| Number | Date | Country | |
|---|---|---|---|
| Parent | 11322448 | Dec 2005 | US |
| Child | 13110522 | US |
