Patent Application
20170049716
The invention relates to nitisinone (2-[2-nitro-4-(trifluoromethyl)benzoyl]-1,3-cyclohexanedione) for use in the treatment of alkaptonuria, wherein nitisinone is administered in a dose of at least 4 mg per day. The invention also relates to a pharmaceutical composition comprising nitisinone for use in the treatment of alkaptonuria, wherein nitisinone is administered in a dose of at least 4 mg per day.
Alkaptonuria (AKU) is an autosomal recessive disorder caused by a deficiency of the enzyme homogentisate 1,2-dioxygenase (HGD). It is a rare disease affecting approximately one in every 250,000 to 1 million people. Due to the absence of HGD, alkaptonuria patients are unable to fully metabolize the amino acid tyrosine, which results in high plasma (or serum) levels of homogentisic acid (HGA). Despite efficient and marked urinary excretion of much of the HGA formed in AKU patients, some of it is oxidized to a melanin-like polymeric pigment via benzoquinone acetic acid (BQA). This pigment polymer is deposited in connective tissues (particularly cartilage) in a process termed ochronosis. This leads to severe arthritis of the spine and synovial joints with an early onset. Until the late 20s or early 30s, there are few clinical features aside from dark urine. Thereafter, progressive arthritic pain begins, affecting the spine and all synovial joints. The high levels of HGA further cause damage to heart valves and lead to the formation of kidney stones, as well as prostate stones in men.
There is currently no approved pharmacological treatment available for lowering HGA in patients with AKU and treatment options are limited to treatment of the disease sequelae as they arise, including physiotherapy, surgery and analgesia. Treatment with vitamin C, to inhibit the oxidative conversion of HGA to melanin-like polymeric pigment, has not proven helpful (La Du. Alkaptonuria. In: Scriver, Beaudet, Sly, Valle and Vogelstein (eds), The Metabolic and Molecular Bases of Inherited Disease. McGraw-Hill, New York, 2001, vol. 2, p. 2109-2123). Dietary therapy restricting the intake of phenylalanine and tyrosine has not shown to be effective in sufficiently reducing HGA in adults and has had no demonstrable efficacy in improving the symptoms of AKU (de Haas et al., J. Inherit. Metab. Dis. 1998, vol. 21, no. 8, p. 791-798). Such dietary restrictions are furthermore difficult to maintain.
Nitisinone has been shown to reduce plasma/serum HGA levels and urinary excretion in patients with AKU (Phornphutkul et al., N. Engl. J. Med. 2002, vol. 347, no. 26, p.2111-2121; Suwannarat et al., Metabolism 2005, vol. 54, p.719-728; Introne et al., Mol. Genet. Metab. 2011, vol. 103, no. 4, p.307-314).
Nitisinone (2-[2-nitro-4-(trifluoromethyl)benzoyl]-1,3-cyclohexanedione) is a competitive inhibitor of the enzyme 4-hydroxyphenylpyruvate dioxygenase (HPPD). Under the brand name Orfadin®, it is used in the treatment of hypertyrosinaemia type 1 (HT-1) where it acts by blocking the metabolic degradation of 4-hydroxyphenylpyruvate. Nitisinone thereby prevents the formation of HGA and the accumulation of the toxic intermediates maleylacetoacetate (MAA) and fumarylacetoacetate (FAA) in HT-1 patients (see scheme 1).
Nitisinone has also been investigated for the treatment of AKU in a long-term (36 months) clinical trial in a dose of 2 mg/day. Although the urinary excretion of nitisinone was reduced by about 95% on average, compared to pre-treatment levels, the trial failed to show an effect on the primary efficacy variable, hip rotation (Introne et al., Mol. Genet. Metab. 2011, vol. 103, no. 4, p. 307-314).
There is therefore a continued need for improved treatment of AKU.
The inevitable consequence of treatment with nitisinone is the elevation of tyrosine levels. In the treatment of HT-1, it is therefore recommended that a more restricted tyrosine and phenylalanine diet should be implemented to keep plasma tyrosine levels below 500 μmol/L. In a 3-year study of nitisinone in alkaptonuria, where no diet restrictions were applied, tyrosine levels in untreated patients were approximately 60 μM, whereas the 20 patients on nitisinone 2 mg daily had tyrosine levels of 332-1528 μM, with an average of 800 μM (Introne et al., supra). Stable but variably increased plasma tyrosine concentrations were seen by 3-4 weeks post-nitisinone. It is thus difficult to keep the tyrosine concentrations at or below an acceptable level without diet restrictions.
One of the clinical consequences of high serum tyrosine levels is the precipitation of tyrosine crystals in the eye, leading to corneal irritation or pain. Patients may also experience vision problems such as blurred or impaired vision. Although these symptoms disappear after discontinuation of the treatment, they recur when treatment is restarted. Another clinical consequence of the high serum tyrosine concentrations is the negative effect on cognitive function. In a recent study (Bendadi et al., J. Pediatr. 2014, vol. 164, no. 2, p.398-401), it was found that the IQ of children treated with nitisinone was considerably lower than their unaffected siblings. Another study (Masurel-Paulet et al., J. Inherit. Metab. Dis. 2008, vol. 31, no. 1, p. 81-87) reported cognitive impairment causing schooling difficulties in eight out of 23 school-age patients with HT-1 that were treated with nitisinone. In six out of these eight patients major cognitive disturbances (memory and concentration difficulties, slowness) were noted.
In view of these side effects, it is of great importance that the serum tyrosine levels are kept as low as possible. In healthy individuals, serum tyrosine levels are normally between about 40 and 90 μmol/L, and levels higher than 500 μmol/L should generally be avoided. However, at a nitisinone dose of only 2 mg/day, serum tyrosine levels already are between 600 and 1000 μmol/L.
The increase in serum tyrosine levels is a consequence of the inhibition of HPPD with nitisinone (see scheme 1). It was therefore assumed that any decrease in serum or urine HGA would be mirrored by a simultaneous increase of serum tyrosine. With respect to the high serum tyrosine levels observed at a nitisinone dose of only 2 mg/day, it was thus believed that it would not be possible to use higher doses of nitisinone as this would cause even higher tyrosine levels and an increased risk of serious side effects related to tyrosinaemia.
During the study that forms the basis for this invention, it has been found that with increasing doses of nitisinone, the urinary excretion of HGA during 24 hours (u-HGA24) decreased in a clear dose-related manner. However, despite a slight increase in mean serum concentrations of tyrosine (s-Tyr) with increasing doses of nitisinone, the dose-response relationship for tyrosine was less distinct than what was seen for the urinary excretion of HGA. With one exception, a nitisinone dose of 2 mg or higher per day resulted in u-HGA24 values of less than 2000 μmol. No correlation could be seen between s-Tyr and u-HGA24 values when the latter was decreased to below 2000 μmol.
It has thus surprisingly been discovered that administration of nitisinone at considerably higher doses than previously used in the treatment of alkaptonuria may suppress the formation of HGA to more than 99%, while only marginally further increasing the tyrosine level in serum. In other words, the dose of nitisinone can be increased without an increased risk of for example tyrosine-related side-effects.
Thus, in a first aspect, the invention relates to nitisinone for use in the treatment of alkaptonuria, wherein nitisinone is administered in a dose of at least 4 mg per day.
The daily dose of nitisinone as disclosed herein represents a fixed daily dose. This means that the dose is not adjusted based on e.g. body weight of the patient. A dose of at least 4 mg nitisinone per day thus represents the minimum level of a fixed daily amount of nitisinone administered to a patient.
In a preferred embodiment of the invention, nitisinone is administered in a dose of at least 6 mg per day. In a more preferred embodiment, nitisinone is administered in a dose of at least 8 mg per day. In a yet more preferred embodiment, nitisinone is administered in a dose of at least 10 mg per day.
It has been found that administration of nitisinone in a dose of 8 mg per day decreases the urinary excretion of HGA up to more than >99%. It is estimated that a dose of 10 mg per day should be sufficient to suppress the formation of HGA almost completely. Thus, in another preferred embodiment, nitisinone is administered in a dose of 8-12 mg per day. In a most preferred embodiment, nitisinone is administered in a dose of 10 mg per day.
In order to limit the risk of side effects, the dose of nitisinone should not exceed 15 mg per day. It can be estimated by extrapolation that such a dose should be sufficient to decrease u-HGA by about 99.9% in a majority of patients. Thus, in one embodiment, nitisinone is administered in a dose of at least 4 and up to 15 mg per day. In another embodiment, nitisinone is administered in a dose of at least 6 and up to 15 mg per day. In yet another embodiment, nitisinone is administered in a dose of at least 8 and up to 15 mg per day. In yet another embodiment, nitisinone is administered in a dose of at least 10 and up to 15 mg per day.
The invention also relates to the use of nitisinone in the manufacture of a medicament for the treatment of alkaptonuria, wherein the nitisinone is administered in the doses described above. The invention also relates to a method of treating alkaptonuria, comprising administering nitisinone to a patient in need of such treatment in the doses described above.
In another embodiment, the invention relates to nitisinone for use in the treatment of alkaptonuria as disclosed herein, wherein nitisinone is administered as a pharmaceutical composition which comprises nitisinone in admixture with one or more pharmaceutically acceptable excipients.
In another aspect, the invention relates to a pharmaceutical composition comprising nitisinone for use in the treatment of alkaptonuria, wherein nitisinone is administered in a dose of at least 4 mg per day. In a preferred embodiment, nitisinone is administered in a dose of at least 6 mg per day. In a more preferred embodiment, nitisinone is administered in a dose of at least 8 mg per day. In a most preferred embodiment, nitisinone is administered in a dose of 8-12 mg per day, such as 10 mg per day. In another embodiment, nitisinone is administered in a dose of at least 4 and up to 15 mg per day. In another embodiment, nitisinone is administered in a dose of at least 6 and up to 15 mg per day. In yet another embodiment, nitisinone is administered in a dose of at least 8 and up to 15 mg per day. In yet another embodiment, nitisinone is administered in a dose of at least 10 and up to 15 mg per day. The pharmaceutical composition comprising nitisinone may additionally comprise one or more pharmaceutically acceptable excipients.
The daily dose of nitisinone may be a single dose that is administered once a day, or may be divided into two or more smaller doses that are administered several times a day. The frequency of administration can remain constant or be variable during the duration of the treatment. Preferably, nitisinone is administered once daily as a single dose.
In one embodiment, nitisinone is administered orally.
Nitisinone can be administered in a composition comprising a therapeutically effective amount of the active ingredient, in admixture with one or more pharmaceutically acceptable excipients. A composition comprising nitisinone can be formulated as, e.g., capsules, tablets, solutions and oral dispersions. A suitable liquid pharmaceutical composition for oral administration is disclosed in WO 2012/177214. Said liquid pharmaceutical composition comprises a suspension of an effective amount of micronized nitisinone and citric acid buffer having a pH in the range of 2.5 to 3.5, preferably pH 3.0.
The invention is further illustrated by means of the following examples, which do not limit the invention in any respect. All cited documents and references are incorporated herein by reference.
Abbreviations
AKU alkaptonuria
Cav average serum concentrations over the 24-hour dosage interval
FAA fumarylacetoacetate
FAH fumarylacetoacetate hydrolase
HGA homogentisic acid
HGD homogentisate 1,2-dioxygenase
HPPA 4-hydroxyphenylpyruvic acid
HPPD 4-hydroxyphenylpyruvate dioxygenase
HT-1 hereditary hypertyrosinaemia type 1
LLOQ lower limit of quantitation
MAA maleylacetoacetate
s-HGA serum concentrations of HGA
s-Tyr serum concentrations of tyrosine
u-HGA24 urinary excretion of HGA during 24 hours
Dose-Response Study of Nitisinone
Methods
Study Design
A randomized, open-label, parallel-group dose-response study with a no-treatment control group was performed. Patients with AKU were randomized to receive either 1 mg, 2 mg, 4 mg or 8 mg nitisinone once daily (oral administration) or no treatment (control). Forty patients were randomized, equally distributed amongst the five groups (8 patients per group).
Patients
Inclusion Criteria
A patient had to fulfill the following criteria in order to be included in the study:
Exclusion Criteria
The presence of any of the following excluded a patient from inclusion in the study:
Treatments
Nitisinone was administered as an oral suspension containing 4 mg/mL. The following dose volumes were administered once daily, in the morning:
Each dose was given to a group of 8 patients, and there was an untreated control group also consisting of 8 patients.
Assessments
Urinary HGA
Urinary excretion of HGA over a 24-hour period (u-HGA24) was assessed at weeks 0, 2 and 4. Urine was collected into 2.5-L bottles containing 30 mL of 5N H2SO4. The exact length of the collection interval and the volume of the collected urine were recorded. The concentration of HGA in the urine was measured by liquid chromatography tandem mass spectrometry (LCMSMS). The 24-hour excretion of HGA was calculated by multiplying the concentration with the volume of the collected urine, and correcting for any deviation from a 24-hour collection period. (There were no reports of missed samples within the collection interval.)
Serum Tyrosine and HGA
Measurements of serum HGA (s-HGA) and tyrosine (s-Tyr) concentrations were performed at weeks 0, 2 and 4. At all visits a full 24-hour profile was determined at the following time-points: pre-dose (immediately after breakfast) and 0.5, 1,2, 3, 4, 6, 8, 10, 12, 15, 18,24 hours post-dose.
The concentrations of HGA and tyrosine in the serum were measured by liquid chromatography tandem mass spectrometry (LCMSMS). The lower limit of quantification (LLOQ) for HGA was 3.1 μmol/L.
Maximum and daily average serum concentrations of HGA and tyrosine were determined. The daily average concentrations were determined by dividing the area under the concentration vs. time curves, calculated by means of the trapezoidal rule, by 24.
Statistics
All data are presented with descriptive statistics, including mean, standard deviation, median, minimum and maximum values.
Results
Demographics and Baseline Characteristics
Patient baseline data are presented in Table 1.
Overall, there were 13 females and 27 males participating in the study. All included patients completed the study and there were no protocol deviations affecting the results of the study.
Urinary Excretion of HGA During 24 Hours (u-HGA)
Urinary excretion of HGA at baseline and week 4 are presented in Table 2. The relative decrease in u-HGA24 is presented in Table 3.
The results are presented graphically in
Serum HGA
A total of 14 patients had HGA concentrations below the lower limit of quantification (3.1 mmol/L) in all samples and it was therefore not possible to calculate all statistics for this variable, nor to include the data for these 14 individuals in a graph. The average serum concentrations of HGA, over a 24-hour sampling period at baseline and week 4 are presented, as far as possible in Table 4.
The data in Table 4 do not allow any definite conclusion to be drawn regarding the dose-response relationship for serum HGA, since many patients had concentrations below the LLOQ. However, the increasing number of patients with HGA concentrations below the LLOQ indicates that there was a dose-response relationship also for this variable. There were 3 patients on 2 mg, 4 on 4 mg and 7 on 8 mg with no quantifiable concentrations in any of the samples collected over the 24-hour dosage interval.
Serum Tyrosine
The average serum concentrations of tyrosine, measured over a 24-hour period, are presented for baseline and week 4 in Table 5.
Correlation Between u-HGA24 and Serum Tyrosine
In order to illustrate how tyrosine concentrations increase when serum HGA concentrations or urinary excretion decrease, these variables are presented together in a series of figures shown below.
The decrease in u-HGA24 and simultaneous increase in serum tyrosine are shown for all patients in
It can be seen from these figures that the urinary excretion of HGA decreases in a clear dose-related manner with increasing doses of nitisinone (up to more than >99% for the highest dose). The inter-individual variability of u-HGA24 also decreases with increasing doses of nitisinone.
At the same time, the dose-response relationship for serum concentrations of tyrosine is less distinct than observed for u-HGA24. There is a slight increase in mean s-Tyr with increasing doses of nitisinone, but the increase between the lowest (1 mg) and the highest dose (8 mg) is only moderate. Furthermore, the inter-individual variability in s-Tyr is of the same magnitude for all doses.
The relationship between u-HGA24 and serum tyrosine is also illustrated in
| Number | Date | Country | Kind |
|---|---|---|---|
| 1450521-8 | Apr 2014 | SE | national |
| Filing Document | Filing Date | Country | Kind |
|---|---|---|---|
| PCT/EP2015/059352 | 4/29/2015 | WO | 00 |
