Patent Application
20160317525
Multiple Sclerosis (MS) is a neurological disease affecting more than 1 million people worldwide. It is the most common cause of neurological disability in young and middle-aged adults and has a major physical, psychological, social and financial impact on subjects and their families, friends and bodies responsible for health care (EMEA Guideline, 2006).
A clinically isolated syndrome (CIS) is a single monosymptomatic attack suggestive of MS, such as optic neuritis, brain stem symptoms, and partial myelitis. Patients with CIS that experience a second clinical attack are generally considered to have clinically definite multiple sclerosis (CDMS). Various MS disease stages and/or types are described in Multiple Sclerosis Therapeutics (Duntiz, 1999). Among them, relapsing-remitting multiple sclerosis (RRMS) is the most common form at the time of initial diagnosis. Many subjects with RRMS have an initial relapsing-remitting course for 5-15 years, which then advances into the secondary progressive MS (SPMS) disease course. There are currently a number of disease-modifying medications approved for use in relapsing MS (RMS), which includes RRMS and SPMS (The Disease Modifying Drug Brochure, 2006). These include interferon beta 1-a (Avonex® and Rebif®), interferon beta 1-b (Betaseron®), glatiramer acetate (Copaxone®), mitoxantrone (Novantrone®), natalizumab (Tysabri®) and Fingolimod (Gilenya®). Immunosuppressants or cytotoxic agents are used in some subjects after failure of conventional therapies. However, the relationship between changes of the immune response induced by these agents and the clinical efficacy in MS is far from settled (EMEA Guideline, 2006).
Other therapeutic approaches include symptomatic treatment which refers to all therapies applied to improve the symptoms caused by the disease (EMEA Guideline, 2006) and treatment of acute relapses with corticosteroids. While steroids do not affect the course of MS over time, they can reduce the duration and severity of attacks in some subjects.
Teriflunomide (trade name Aubagio) is approved by the FDA as a tablet of 7 mg or 14 mg administered once daily for the treatment of adults with relapsing forms of multiple sclerosis (MS). (www.accessdata.fda.gov/drugsatfda_docs/label/2012/202992s0001b1.pdf). The use of teriflunomide for treating multiple sclerosis was disclosed in U.S. Pat. No. 6,794,410. Teriflunomide has the following structure:
IUPAC: (2Z)-2-cyano-3-hydroxy-N-[4-(trifluoromethyl) phenyl]but-2-enamide
It has been suggested that teriflunomide induces the noncompetitive reversible inhibition of mitochondrial enzyme diydro-orotate dehydrogenase, decreases T-cell proliferation, activation, and cytokine production. The mechanism of action in multiple sclerosis was suggested to involve a reduction of the number of pro-inflammatory activated T-cells infiltrating into the Central Nervous System (CNS) (Zeyda 2005).
Several adverse effects have been identified for teriflunomide including ALT elevations, nasopharyngitis, alopecia, nausea, diarrhea, paresthesias, back pain, limb pain and arthralgias. Teriflunomide has also been found to influence hepatic metabolism, inhibit CYP2C9, enhance warfarin effects but has no PK interaction. Further, teriflunomide was found teratogenic in animal studies. Therefore, washout with cholesyramine/activated charcoal and confirmation of plasma level of <0.02 mg/L is recommended before conception (O'Connor et al. 2006 and Warneke et al. 2009).
Two doses of teriflunomide were investigated in a Phase III clinical trial (TEMSO) as a medication for relapsing multiple sclerosis. Teriflunomide was shown to reduce the annualized relapse rate versus the placebo at 7 mg/day and 14 mg/day (O'Connor et al. 2011).
Laquinimod (TV-5600) is a novel synthetic compound with high oral bioavailability which has been suggested as an oral formulation for the treatment of Multiple Sclerosis (MS) (Polman, 2005; Sandberg-Wollheim, 2005; Comi et al 2008). Laquinimod and its sodium salt form are described, for example, in U.S. Pat. No. 6,077,851. The mechanism of action of laquinimod is not fully understood.
Animal studies show it causes a Th1 (T helper 1 cell, produces pro-inflammatory cytokines) to Th2 (T helper 2 cell, produces anti-inflammatory cytokines) shift with an anti-inflammatory profile (Yang, 2004; Bruck, 2011). Another study demonstrated (mainly via the NFkB pathway) that laquinimod induced suppression of genes related to antigen presentation and corresponding inflammatory pathways (Gurevich, 2010). Other suggested potential mechanisms of action include inhibition of leukocyte migration into the CNS, increase of axonal integrity, modulation of cytokine production, and increase in levels of brain-derived neurotrophic factor (BDNF) (Runström, 2006; Brück, 2011).
Laquinimod showed a favorable safety and tolerability profile in two phase III trials (Results of Phase III BRAVO Trial Reinforce Unique Profile of Laquinimod for Multiple Sclerosis Treatment; Teva Pharma, Active Biotech Post Positive Laquinimod Phase 3 ALLEGRO Results).
IUPAC: 5-chloro-N-ethyl-4-hydroxy-1-methyl-2-oxo-N-phenyl-1,2-dihydroquinoline-3-carboxamide
The administration of two drugs to treat a given condition, such as multiple sclerosis, raises a number of potential problems. In vive interactions between two drugs are complex. The effects of any single drug are related to its absorption, distribution, and elimination. When two drugs are introduced into the body, each drug can affect the absorption, distribution, metabolism and elimination of the other and hence, alter the effects of the other. For instance, one drug may inhibit, activate or induce the production of enzymes involved in a metabolic route of elimination of the other drug (Guidance for Industry, 2012). In one example, combined administration of fingolimod and interferon (IFN) has been experimentally shown to abrogate the clinical effectiveness of either therapy. (Brod 2000) In another experiment, it was reported that the addition of prednisone in combination therapy with IFN-β antagonized its up-regulator effect. Thus, when two drugs are administered to treat the same condition, it is unpredictable whether each will complement, have no effect on, or interfere with, the therapeutic activity of the other in a human subject.
Not only may the interaction between two drugs affect the intended therapeutic activity of each drug, but the interaction may increase the levels of toxic metabolites (Guidance for Industry, 2012). The interaction may also heighten or lessen the side effects of each drug. Hence, upon administration of two drugs to treat a disease, it is unpredictable what change will occur in the negative side profile of each drug. In one example, the combination of natalizumab and interferon β-1a was observed to increase the risk of unanticipated side effects. (Vollmer, 2008; Rudick 2006; Kleinschmidt-DeMasters, 2005; Langer-Gould 2005).
Additionally, it is difficult to accurately predict when the effects of the interaction between the two drugs will become manifest. For example, metabolic interactions between drugs may become apparent upon the initial administration of the second drug, after the two have reached a steady-state concentration or upon discontinuation of one of the drugs (Guidance for Industry, 2012).
Therefore, the state of the art at the time of filing is that the effects of combination therapy of two drugs, in particular laquinimod and teriflunomide, cannot be predicted.
The subject invention provides a method of treating a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome comprising administering to the subject an amount of laquinimod and an amount of teriflunomide, wherein the amount of teriflunomide is greater than a minimal effective dose of teriflunomide.
The subject invention also provides a package comprising: a) a first pharmaceutical composition comprising an amount of laquinimod and a pharmaceutically acceptable carrier; b) a second pharmaceutical composition comprising an amount of teriflunomide and a pharmaceutically acceptable carrier, wherein the amount of teriflunomide is greater than a minimal effective dose of teriflunomide; and c) instructions for use of the first and second pharmaceutical compositions together to treat a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome.
The subject invention also provides laquinimod for use as an add-on therapy or in combination with a greater than a minimal effective dose of teriflunomide in treating a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome.
The subject invention also provides a greater than a minimal effective dose of teriflunomide for use as an add-on therapy or in combination with laquinimod in treating a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome.
The subject invention also provides a pharmaceutical composition comprising an amount of laquinimod and an amount of teriflunomide for use in treating a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome, wherein the laquinimod and the teriflunomide are prepared to be administered simultaneously, contemporaneously or concomitantly, and the amount of teriflunomide is greater than a minimal effective dose of teriflunomide.
The subject invention also provides a pharmaceutical composition comprising an amount of laquinimod and an amount of teriflunomide, wherein the amount of teriflunomide is greater than a minimal effective dose of teriflunomide.
The subject invention also provides use of an amount of laquinimod and a greater than minimal effective dose of teriflunomide in the preparation of a combination for treating a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome wherein the laquinimod and the teriflunomide are prepared to be administered simultaneously, contemporaneously or concomitantly.
The subject invention also provides a pharmaceutical composition comprising an amount of laquinimod for use in treating a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome as an add-on therapy or in combination with a greater than minimal effective dose of teriflunomide.
The subject invention also provides a pharmaceutical composition comprising a greater than minimal effective dose of teriflunomide for use treating a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome as an add-on therapy or in combination with laquinimod.
The subject invention also provides a pharmaceutical composition comprising an amount of laquinimod for use in treating a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome simultaneously, contemporaneously or concomitantly with a greater than minimal effective dose of teriflunomide.
The subject invention also provides a pharmaceutical composition comprising a greater than minimal effective dose of teriflunomide for use treating a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome simultaneously, contemporaneously or concomitantly with laquinimod.
The subject invention also provides a therapeutic package for dispensing to, or for use in dispensing to, a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome, which comprises: a) one or more unit doses, each such unit dose comprising: i) an amount of laquinimod and ii) an amount of teriflunomide which is greater than a minimal effective dose of teriflunomide, wherein the respective amounts of said laquinimod and said teriflunomide in said unit dose are effective, upon concomitant administration to said subject, to treat the subject, and b) a finished pharmaceutical container therefor, said container containing said unit dose or unit doses, said container further containing or comprising labeling directing the use of said package in the treatment of said subject.
The subject invention also provides a pharmaceutical composition in unit dosage form, useful in treating a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome, which comprises: a) an amount of laquinimod; b) an amount of teriflunomide which is greater than a minimal effective dose of teriflunomide, wherein the respective amounts of said laquinimod and said teriflunomide in said composition are effective, upon concomitant administration to said subject of one or more of said unit dosage forms of said composition, to treat the subject.
The subject invention provides a method of treating a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome comprising administering to the subject an amount of laquinimod and an amount of teriflunomide, wherein the amount of teriflunomide is greater than a minimal effective dose of teriflunomide.
In an embodiment of the present invention the method comprises periodically administering to the subject an amount of laquinimod and an amount of teriflunomide, wherein the amount of laquinimod and the amount of teriflunomide when administered together is more effective to treat the subject than when each agent at the same amount is administered alone.
In an embodiment of the present invention, the multiple sclerosis is relapsing multiple sclerosis. In another embodiment, the relapsing multiple sclerosis is relapsing-remitting multiple sclerosis.
In one embodiment, the amount of laquinimod and the amount of teriflunomide when taken together is effective to reduce a symptom of multiple sclerosis in the subject. In another embodiment, the symptom is a MRI-monitored multiple sclerosis disease activity, relapse rate, accumulation of physical disability, frequency of relapses, decreased time to confirmed disease progression, decreased time to confirmed relapse, frequency of clinical exacerbation, brain atrophy, neuronal dysfunction, neuronal injury, neuronal degeneration, neuronal apoptosis, risk for confirmed progression, deterioration of visual function, fatigue, impaired mobility, cognitive impairment, reduction of brain volume, abnormalities observed in whole Brain MTR histogram, deterioration in general health status, functional status, quality of life, and/or symptom severity on work.
In one embodiment, the amount of laquinimod and the amount of teriflunomide when taken together is effective to decrease or inhibit reduction of brain volume. In another embodiment, brain volume is measured by percent brain volume change (PBVC).
In one embodiment, the amount of laquinimod and the amount of teriflunomide when taken together is effective to increase time to confirmed disease progression. In another embodiment, the time to confirmed disease progression is increased by 20-60%. In yet another embodiment, the time to confirmed disease progression is increased by at least 50%.
In one embodiment, the amount of laquinimod and the amount of teriflunomide when taken together is effective to decrease abnormalities observed in whole Brain MTR histogram.
In one embodiment, the accumulation of physical disability is measured by Kurtzke Expanded Disability Status Scale (EDSS) score. In another embodiment, the accumulation of physical disability is assessed by the time to confirmed disease progression as measured by Kurtzke Expanded Disability Status Scale (EDSS) score. In another embodiment, the subject had an EDSS score of 0-5.5 at baseline. In another embodiment, the subject had an EDSS score of 1.5-4.5 at baseline. In another embodiment, the subject had an EDSS score of 5.5 or greater at baseline. In another embodiment, confirmed disease progression is a 1 point increase of the EDSS score. In yet another embodiment, confirmed disease progression is a 0.5 point increase of the EDSS score.
In one embodiment, impaired mobility is assessed by the Timed-25 Foot Walk test. In another embodiment, impaired mobility is assessed by the 12-Item Multiple Sclerosis Walking Scale (MSWS-12) self-report questionnaire. In another embodiment, impaired mobility is assessed by the Ambulation Index (AI). In another embodiment, impaired mobility is assessed by the Six-Minute Walk (6MW) Test. In another embodiment, impaired mobility is assessed by the Lower Extremity Manual Muscle Test (LEMMT) Test.
In one embodiment, the amount of laquinimod and the amount of teriflunomide when taken together is effective to reduce cognitive impairment. In another embodiment, cognitive impairment is assessed by the Symbol Digit Modalities Test (SDMT) score.
In one embodiment, general health status is assessed by the EuroQoL (EQ5D) questionnaire, Subject Global Impression (SGI) or Clinician Global Impression of Change (CGIC). In another embodiment, functional status is measured by the subject's Short-Form General Health survey (SF-36) Subject Reported Questionnaire score. In another embodiment, quality of life is assessed by SF-36, EQ5D, Subject Global Impression (SGI) or Clinician Global Impression of Change (CGIC). In another embodiment, the subject's SF-36 mental component summary score (MSC) is improved. In another embodiment, the subject's SF-36 physical component summary sore (PSC) is improved. In another embodiment, fatigue is assessed by the EQ5D, the subject's Modified Fatigue Impact Scale (MFIS) score or the French valid versions of the Fatigue Impact Scale (EMIF-SEP) score. In another embodiment, symptom severity on work is measured by the work productivity and activities impairment General Health (WPAI-GH) questionnaire.
In an embodiment, laquinimod is laquinimod sodium. In another embodiment, teriflunomide is a pharmaceutically acceptable salt thereof.
In one embodiment, the laquinimod and/or the teriflunomide is administered via oral administration. In another embodiment, the laquinimod and/or the teriflunomide is administered by injection.
In an embodiment, the laquinimod and/or the teriflunomide is administered periodically. In an embodiment, the laquinimod and/or the teriflunomide is administered daily. In another embodiment, the laquinimod and/or the teriflunomide is administered more often than once daily. In another embodiment, the laquinimod and/or the teriflunomide is administered less often than once daily. In yet another embodiment, the frequency of periodic administration is twice daily, three times daily, four times daily, weekly, twice weekly, three times weekly, etc.
In one embodiment, the ratio by weight of the daily dose of teriflunomide to laquinimod is in the range 95:1 to 1333:1. In another embodiment, the ratio by weight of the daily dose of teriflunomide to laquinimod is in the range 142:1 to 2000:1. In another embodiment, the ratio by weight of the daily dose of teriflunomide to laquinimod is greater than 0.6:1.
In an embodiment, the amount laquinimod administered is less than 0.6 mg/day. In another embodiment, the amount laquinimod administered is 0.1-40.0 mg/day. In another embodiment, the amount laquinimod administered is 0.1-2.5 mg/day. In another embodiment, the amount laquinimod administered is 0.25-2.0 mg/day. In another embodiment, the amount laquinimod administered is 0.5-1.2 mg/day. In another embodiment, the amount laquinimod administered is 0.25 mg/day. In another embodiment, the amount laquinimod administered is 0.3 mg/day. In another embodiment, the amount laquinimod administered is 0.5 mg/day. In another embodiment, the amount laquinimod administered is 0.6 mg/day. In another embodiment, the amount laquinimod administered is 1.0 mg/day. In another embodiment, the amount laquinimod administered is 1.2 mg/day. In another embodiment, the amount laquinimod administered is 1.5 mg/day. In yet another embodiment, the amount laquinimod administered is 2.0 mg/day.
In one embodiment, the amount teriflunomide is greater than 7 mg/day. In yet another embodiment, the amount teriflunomide administered is greater than 14 mg/day.
In one embodiment, the amount teriflunomide is 7 mg/day. In another embodiment, the amount teriflunomide administered is 8 mg/day. In another embodiment, the amount teriflunomide administered is 9 mg/day.
In another embodiment, the amount teriflunomide administered is 10 mg/day. In another embodiment, the amount teriflunomide administered is 11 mg/day. In another embodiment, the amount teriflunomide administered is 12 mg/day. In another embodiment, the amount teriflunomide administered is 13 mg/day. In another embodiment, the amount teriflunomide administered is 14 mg/day.
In an embodiment of the present invention, a loading dose of an amount different form the intended dose is administered for a period of time at the start of the periodic administration. In another embodiment, the loading dose is double the amount of the intended dose.
In an embodiment of the present invention, the subject is receiving laquinimod therapy prior to initiating teriflunomide therapy. In another embodiment, the administration of laquinimod substantially precedes the administration of teriflunomide. In another embodiment, the subject is receiving teriflunomide therapy prior to initiating laquinimod therapy. In another embodiment, the administration of teriflunomide substantially precedes the administration of laquinimod.
In an embodiment, the subject is receiving teriflunomide therapy for at least 8 weeks prior to initiating laquinimod therapy. In another embodiment, the subject is receiving teriflunomide therapy for at least 10 weeks prior to initiating laquinimod therapy. In another embodiment, the subject is receiving teriflunomide therapy for at least 24 weeks prior to initiating laquinimod therapy. In another embodiment, the subject is receiving teriflunomide therapy for at least 28 weeks prior to initiating laquinimod therapy. In another embodiment, the subject is receiving teriflunomide therapy for at least 48 weeks prior to initiating laquinimod therapy. In yet another embodiment, the subject is receiving teriflunomide therapy for at least 52 weeks prior to initiating laquinimod therapy.
In one embodiment, the method further comprises administration of nonsteroidal anti-inflammatory drugs (NSAIDs), salicylates, slow-acting drugs, gold compounds, hydroxychloroquine, sulfasalazine, combinations of slow-acting drugs, corticosteroids, cytotoxic drugs, immunosuppressive drugs and/or antibodies.
In an embodiment, the periodic administration of laquinimod and teriflunomide continues for at least 3 days. In another embodiment, the periodic administration of laquinimod and teriflunomide continues for more than 30 days. In another embodiment, the periodic administration of laquinimod and teriflunomide continues for more than 42 days. In another embodiment, the periodic administration of laquinimod and teriflunomide continues for 8 weeks or more. In another embodiment, the periodic administration of laquinimod and teriflunomide continues for at least 12 weeks. In another embodiment, the periodic administration of laquinimod and teriflunomide continues for at least 24 weeks. In another embodiment, the periodic administration of laquinimod and teriflunomide continues for more than 24 weeks. In another embodiment, the periodic administration of laquinimod and teriflunomide continues for 6 months or more.
In one embodiment, the administration of laquinimod and teriflunomide inhibits a symptom of relapsing multiple sclerosis by at least 20%. In another embodiment, the administration of laquinimod and teriflunomide inhibits a symptom of relapsing multiple sclerosis by at least 30%. In another embodiment, the administration of laquinimod and teriflunomide inhibits a symptom of relapsing multiple sclerosis by at least 50%. In another embodiment, the administration of laquinimod and teriflunomide inhibits a symptom of relapsing multiple sclerosis by at least 70%. In another embodiment, the administration of laquinimod and teriflunomide inhibits a symptom of relapsing multiple sclerosis by more than 100%. In another embodiment, the administration of laquinimod and teriflunomide inhibits a symptom of relapsing multiple sclerosis by more than 300%. In another embodiment, the administration of laquinimod and teriflunomide inhibits a symptom of relapsing multiple sclerosis by more than 1000%.
In one embodiment, each of the amount of laquinimod or pharmaceutically acceptable salt thereof when taken alone, and the amount of teriflunomide when taken alone is effective to treat the subject.
In another embodiment, the amount of laquinimod or pharmaceutically acceptable salt thereof when taken alone is not effective to treat the subject.
In another embodiment, the subject is a human patient.
The subject invention also provides a package comprising: a) a first pharmaceutical composition comprising an amount of laquinimod and a pharmaceutically acceptable carrier; b) a second pharmaceutical composition comprising an amount of teriflunomide and a pharmaceutically acceptable carrier, wherein the amount of teriflunomide is greater than a minimal effective dose of teriflunomide; and c) instructions for use of the first and second pharmaceutical compositions together to treat a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome.
In an embodiment of the present invention, the first pharmaceutical composition, the second pharmaceutical composition, or both the first and the second pharmaceutical composition are in an aerosol, an inhalable powder, an injectable, a liquid, a solid, a capsule or a tablet form. In another embodiment, the first pharmaceutical composition, the second pharmaceutical composition, or both the first and the second pharmaceutical composition are in a liquid or a solid form. In another embodiment, the first pharmaceutical composition, the second pharmaceutical composition, or both the first and the second pharmaceutical composition are in capsule form or in tablet form.
In an embodiment, the tablets are coated with a coating which inhibits oxygen from contacting the core. In another embodiment, the coating comprises a cellulosic polymer, a detackifier, a gloss enhancer, or pigment.
In one embodiment, the first pharmaceutical composition further comprises mannitol. In another embodiment, the first pharmaceutical composition further comprises an alkalinizing agent. In another embodiment, the alkalinizing agent is meglumine. In another embodiment, the first pharmaceutical composition further comprises an oxidation reducing agent.
In one embodiment, the first pharmaceutical composition is stable and free of an alkalinizing agent or an oxidation reducing agent. In another embodiment, the first pharmaceutical composition is free of an alkalinizing agent and free of an oxidation reducing agent.
In one embodiment, the first pharmaceutical composition is stable and free of disintegrant. In another embodiment, the first pharmaceutical composition further comprises a lubricant. In another embodiment, the lubricant is present in the composition as solid particles. In another embodiment, the lubricant is sodium stearyl fumarate or magnesium stearate.
In one embodiment, the first pharmaceutical composition further comprises a filler. In another embodiment, the filler is present in the composition as solid particles. In another embodiment, the filler is lactose, lactose monohydrate, starch, isomalt, mannitol, sodium starch glycolate, sorbitol, lactose spray dried, lactose anhydrouse, or a combination thereof. In another embodiment, the filler is mannitol or lactose monohydrate.
In an embodiment, the package further comprises a desiccant. In another embodiment, the desiccant is silica gel.
In an embodiment, the first pharmaceutical composition is stable and has a moisture content of no more than 4%. In another embodiment, laquinimod is present in the composition as solid particles. In another embodiment, the package is a sealed packaging having a moisture permeability of not more than 15 mg/day per liter.
In an embodiment, the sealed package is a blister pack in which the maximum moisture permeability is no more than 0.005 mg/day. In another embodiment, the sealed package is a bottle. In another embodiment, the bottle is closed with a heat induction liner. In another embodiment, the sealed package comprises an HDPE bottle. In another embodiment, the sealed package comprises an oxygen absorbing agent. In another embodiment, the oxygen absorbing agent is iron.
In one embodiment, the amount of laquinimod in the first composition is less than 0.6 mg. In another embodiment, the amount of laquinimod in the first composition is 0.1-40.0 mg. In another embodiment, the amount of laquinimod in the first composition is 0.1-2.5 mg. In another embodiment, the amount of laquinimod in the first composition is 0.25-2.0 mg. In another embodiment, the amount of laquinimod in the first composition is 0.5-1.2 mg. In another embodiment, the amount of laquinimod in the first composition is 0.25 mg. In another embodiment, the amount of laquinimod in the first composition is 0.3 mg. In another embodiment, the amount of laquinimod in the first composition is 0.5 mg. In another embodiment, the amount of laquinimod in the first composition is 0.6 mg. In another embodiment, the amount of laquinimod in the first composition is 1.0 mg. In another embodiment, the amount of laquinimod in the first composition is 1.2 mg. In another embodiment, the amount of laquinimod in the first composition is 1.5 mg. In another embodiment, the amount of laquinimod in the first composition is 2.0 mg.
In one embodiment, the amount of teriflunomide is greater than 7 mg. In another embodiment, the amount of teriflunomide is greater than 14 mg.
In one embodiment, the amount teriflunomide is 7 mg. In another embodiment, the amount teriflunomide administered is 8 mg. In another embodiment, the amount teriflunomide administered is 9 mg. In another embodiment, the amount teriflunomide administered is 10 mg. In another embodiment, the amount teriflunomide administered is 11 mg. In another embodiment, the amount teriflunomide administered is 12 mg. In another embodiment, the amount teriflunomide administered is 13 mg. In another embodiment, the amount teriflunomide administered is 14 mg.
In one embodiment of the present invention, the amount of laquinimod and the amount of teriflunomide are prepared to be administered simultaneously, contemporaneously or concomitantly.
The subject invention also provides laquinimod for use as an add-on therapy or in combination with a greater than minimal effective dose of teriflunomide in treating a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome, and a greater than minimal effective dose of teriflunomide for use as an add-on therapy or in combination with laquinimod in treating a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome.
The subject invention also provides a pharmaceutical composition comprising an amount of laquinimod and an amount of teriflunomide for use in treating a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome, wherein the laquinimod and the teriflunomide are prepared to be administered simultaneously, contemporaneously or concomitantly, and the amount of teriflunomide is greater than a minimal effective dose of teriflunomide.
The subject invention also provides a pharmaceutical composition comprising an amount of laquinimod and an amount of teriflunomide, wherein the amount of teriflunomide is greater than a minimal effective dose of teriflunomide.
In one embodiment, the ratio of teriflunomide to laquinimod by weight is in the range 95:1 to 1333:1. In another embodiment, the ratio of teriflunomide to laquinimod by weight is in the range 142:1 to 2000:1.
In another embodiment, the ratio of teriflunomide to laquinimod by weight is greater than 0.6:1.
In another embodiment, laquinimod is laquinimod sodium. In another embodiment, teriflunomide is a pharmaceutically acceptable salt thereof.
In an embodiment, the pharmaceutical composition is in an aerosol, an inhalable powder, an injectable, a liquid, a solid, a capsule or a tablet form. In another embodiment, the pharmaceutical composition is in a liquid or a solid form. In another embodiment, it is in capsule form or in tablet form.
In one embodiment, the tablets are coated with a coating which inhibits oxygen from contacting the core. In another embodiment, the coating comprises a cellulosic polymer, a detackifier, a gloss enhancer, or pigment.
In an embodiment, the pharmaceutical composition further comprises mannitol. In another embodiment, the pharmaceutical composition further comprises an alkalinizing agent. In another embodiment, the alkalinizing agent is meglumine. In another embodiment, the pharmaceutical composition further comprises an oxidation reducing agent.
In one embodiment, the pharmaceutical composition is free of an alkalinizing agent or an oxidation reducing agent. In an embodiment, the pharmaceutical composition is free of an alkalinizing agent and free of an oxidation reducing agent.
In one embodiment, the pharmaceutical composition is stable and free of disintegrant. In another embodiment, the pharmaceutical composition further comprises a lubricant. In another embodiment, the lubricant is present in the composition as solid particles. In another embodiment, the lubricant is sodium stearyl fumarate or magnesium stearate.
In one embodiment, the pharmaceutical composition further comprises a filler. In another embodiment, the filler is present in the composition as solid particles. In another embodiment, the filler is lactose, lactose monohydrate, starch, isomalt, mannitol, sodium starch glycolate, sorbitol, lactose spray dried, lactose anhydrouse, or a combination thereof. In another embodiment, the filler is mannitol or lactose monohydrate.
In one embodiment, the amount of laquinimod in the composition is less than 0.6 mg. In another embodiment, the amount of laquinimod in the composition is 0.1-40.0 mg. In another embodiment, the amount of laquinimod in the composition is 0.1-2.5 mg. In another embodiment, the amount of laquinimod in the composition is 0.25-2.0 mg. In another embodiment, the amount of laquinimod in the composition is 0.5-1.2 mg.
In another embodiment, the amount of laquinimod in the composition is 0.25 mg. In another embodiment, the amount of laquinimod in the composition is 0.3 mg. In another embodiment, the amount of laquinimod in the composition is 0.5 mg. In another embodiment, the amount of laquinimod in the composition is 0.6 mg. In another embodiment, the amount of laquinimod in the composition is 1.0 mg. In another embodiment, the amount of laquinimod in the composition is 1.2 mg. In another embodiment, the amount of laquinimod in the composition is 1.5 mg. In yet another embodiment, the amount of laquinimod in the composition is 2.0 mg.
In an embodiment, the amount of teriflunomide in the composition is greater than 7 mg. In another embodiment, the amount of teriflunomide in the composition is greater than 14 mg.
In one embodiment, the amount teriflunomide is 7 mg. In another embodiment, the amount teriflunomide administered is 8 mg. In another embodiment, the amount teriflunomide administered is 9 mg. In another embodiment, the amount teriflunomide administered is 10 mg. In another embodiment, the amount teriflunomide administered is 11 mg. In another embodiment, the amount teriflunomide administered is 12 mg. In another embodiment, the amount teriflunomide administered is 13 mg. In another embodiment, the amount teriflunomide administered is 14 mg.
The subject invention also provides use of a greater than minimal effective dose of laquinimod and an amount of teriflunomide in the preparation of a combination for treating a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome wherein the laquinimod and the teriflunomide are prepared to be administered simultaneously, contemporaneously or concomitantly.
The subject invention also provides a pharmaceutical composition comprising an amount of laquinimod for use in treating a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome as an add-on therapy or in combination with a greater than minimal effective dose teriflunomide.
The subject invention also provides a pharmaceutical composition comprising a greater than minimal effective dose of teriflunomide for use treating a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome as an add-on therapy or in combination with laquinimod.
The subject invention also provides a pharmaceutical composition comprising an amount of laquinimod for use in treating a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome simultaneously, contemporaneously or concomitantly with a greater than minimal effective dose teriflunomide.
The subject invention also provides a pharmaceutical composition comprising a greater than minimal effective dose of teriflunomide for use treating a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome simultaneously, contemporaneously or concomitantly with laquinimod.
The subject invention also provides a therapeutic package for dispensing to, or for use in dispensing to, a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome, which comprises; a) one or more unit doses, each such unit dose comprising: i) an amount of laquinimod and ii) an amount of teriflunomide which is greater than a minimal effective dose of teriflunomide, wherein the respective amounts of said laquinimod and said teriflunomide in said unit dose are effective, upon concomitant administration to said subject, to treat the subject, and b) a finished pharmaceutical container therefor, said container containing said unit dose or unit doses, said container further containing or comprising labeling directing the use of said package in the treatment of said subject.
In one embodiment, the respective amounts of said laquinimod and said teriflunomide in said unit dose when taken together is more effective to treat the subject than when compared to the administration of said laquinimod in the absence of said teriflunomide or the administration of said teriflunomide in the absence of said laquinimod.
The subject invention also provides a pharmaceutical composition in unit dosage form, useful in treating a subject afflicted with multiple sclerosis or presenting a clinically isolated syndrome, which comprises: a) an amount of laquinimod; b) an amount of teriflunomide which is greater than a minimal effective dose of teriflunomide, wherein the respective amounts of said laquinimod and said teriflunomide in said composition are effective, upon concomitant administration to said subject of one or more of said unit dosage forms of said composition, to treat the subject.
In one embodiment, the respective amounts of said laquinimod and said teriflunomide in said unit dose when taken together is more effective to treat the subject than when compared to the administration of said laquinimod in the absence of said teriflunomide or the administration of said teriflunomide in the absence of said laquinimod.
For the foregoing embodiments, each embodiment disclosed herein is contemplated as being applicable to each of the other disclosed embodiment. For example, the elements recited in the method embodiments can be used in the composition and package embodiments described herein and vice versa.
Teriflunomide can be administered by way of oral, sublingual, injection including subcutaneous, intramuscular and intravenous, topical, intratracheal, intranasal, transdermal or rectal administration. Teriflunomide may be administered in admixture with conventional pharmaceutical carriers. The appropriate unit forms of administration include forms for oral administration, such as tablets, gelatin capsules, powders, granules and solutions or suspensions to be taken orally.
Laquinimod mixtures, compositions, and the process for the manufacture thereof are described in, e.g., U.S. Pat. No. 6,077,851, U.S. Pat. No. 7,884,208, U.S. Pat. No. 7,989,473, U.S. Pat. No. 8,178,127, U.S. application publication No. 2010-0055072, U.S. Application Publication No. 2012-0010238, and U.S. Application Publication No. 2012-0010239, each of which is hereby incorporated by reference in its entireties into this application.
Use of laquinimod for treatment of various conditions, and the corresponding dosages and regimens, are described in U.S. Pat. No. 6,077,851 (multiple sclerosis, insulin-dependent diabetes mellitus, systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, psoriasis, inflammatory respiratory disorder, atherosclerosis, stroke, and Alzheimer's disease), U.S. Application Publication No. 2011-0027219 (Crohn's disease), U.S. Application Publication No. 2010-0322900 (Relapsing-remitting multiple sclerosis), U.S. Application Publication No. 2011-0034508 (brain-derived neurotrophic factor (BDNF)-related diseases), U.S. Application Publication No. 2011-0218179 (active lupus nephritis), U.S. Application Publication No. 2011-0218203 (rheumatoid arthritis), U.S. Application Publication No. 2011-0217295 (active lupus arthritis), and U.S. Application Publication No. 2012-0142730 (reducing fatigue, improving quality of life, and providing neuroprotection in MS patients), each of which is hereby incorporated by reference in its entireties into this application.
A pharmaceutically acceptable salt of laquinimod as used in this application includes lithium, sodium, potassium, magnesium, calcium, manganese, copper, zinc, aluminum and iron. Salt formulations of laquinimod and the process for preparing the same are described, e.g., in U.S. Pat. No. 7,589,208 and PCT International Application Publication No. WO 2005/074899, which are hereby incorporated by reference into this application.
Laquinimod can be administered in admixture with suitable pharmaceutical diluents, extenders, excipients, or carriers (collectively referred to herein as a pharmaceutically acceptable carrier) suitably selected with respect to the intended form of administration and as consistent with conventional pharmaceutical practices. The unit can be in a form suitable for oral administration.
Laquinimod can be administered alone but is generally mixed with a pharmaceutically acceptable carrier, and co-administered in the form of a tablet or capsule, liposome, or as an agglomerated powder. Examples of suitable solid carriers include lactose, sucrose, gelatin and agar. Capsule or tablets can be easily formulated and can be made easy to swallow or chew; other solid forms include granules, and bulk powders.
Tablets may contain suitable binders, lubricants, disintegrating agents, coloring agents, flavoring agents, flow-inducing agents, and melting agents. For instance, for oral administration in the dosage unit form of a tablet or capsule, the active drug component can be combined with an oral, non-toxic, pharmaceutically acceptable, inert carrier such as lactose, gelatin, agar, starch, sucrose, glucose, methyl cellulose, dicalcium phosphate, calcium sulfate, mannitol, sorbitol, microcrystalline cellulose and the like. Suitable binders include starch, gelatin, natural sugars such as glucose or beta-lactose, corn starch, natural and synthetic gums such as acacia, tragacanth, or sodium alginate, povidone, carboxymethylcellulose, polyethylene glycol, waxes, and the like. Lubricants used in these dosage forms include sodium oleate, sodium stearate, sodium benzoate, sodium acetate, sodium chloride, stearic acid, sodium stearyl fumarate, talc and the like. Disintegrators include, without limitation, starch, methyl cellulose, agar, bentonite, xanthan gum, croscarmellose sodium, sodium starch glycolate and the like.
Specific examples of the techniques, pharmaceutically acceptable carriers and excipients that may be used to formulate oral dosage forms of the present invention are described, e.g., in U.S. Pat. No. 7,589,208, PCT International Application Publication Nos. WO 2005/074899, WO 2007/047863, and 2007/146248.
General techniques and compositions for making dosage forms useful in the present invention are described in the following references: Modern Pharmaceutics, Chapters 9 and 10 (Banker & Rhodes, Editors, 1979); Pharmaceutical Dosage Forms: Tablets (Lieberman et al., 1981); Ansel, Introduction to Pharmaceutical Dosage Forms 2nd Edition (1976); Remington's Pharmaceutical Sciences, 17th ed. (Mack Publishing Company, Easton, Pa., 1985); Advances in Pharmaceutical Sciences (David Ganderton, Trevor Jones, Eds., 1992); Advances in Pharmaceutical Sciences Vol 7. (David Ganderton, Trevor Jones, James McGinity, Eds., 1995); Aqueous Polymeric Coatings for Pharmaceutical Dosage Forms (Drugs and the Pharmaceutical Sciences, Series 36 (James McGinity, Ed., 1989); Pharmaceutical Particulate Carriers: Therapeutic Applications: Drugs and the Pharmaceutical Sciences, Vol 61 (Alain Rolland, Ed., 1993); Drug Delivery to the Gastrointestinal Tract (Ellis Horwood Books in the Biological Sciences. Series in Pharmaceutical Technology; J. G. Hardy, S. S. Davis, Clive G. Wilson, Eds); Modern Pharmaceutics Drugs and the Pharmaceutical Sciences, Vol. 40 (Gilbert S. Banker, Christopher T. Rhodes, Eds). These references in their entireties are hereby incorporated by reference into this application.
Disclosed is a method for treating a subject, e.g., human patient, afflicted with multiple sclerosis, e.g., relapsing multiple sclerosis or presenting a CIS using laquinimod with a minimal effective dose of teriflunomide which provides a more efficacious treatment than each agent alone. The use of laquinimod for multiple sclerosis had been previously suggested in, e.g., U.S. Pat. No. 6,077,851. However, the inventors have surprisingly found that the combination of laquinimod and a greater than minimal effective dose of teriflunomide is particularly effective for the treatment of a subject afflicted with MS or presenting a CIS as compared to each agent alone. In particular, the combination of laquinimod and a greater than a minimal effective dose of teriflunomide provides improved relapse rate reduction, improved preservation of brain tissue, improved reduction in disability progression and improved safety profile, as compared to each agent alone at the same dose.
As used herein, and unless stated otherwise, each of the following terms shall have the definition set forth below.
As used herein, “laquinimod” means laquinimod acid or a pharmaceutically acceptable salt thereof.
As used herein, “teriflunomide” means teriflunomide or a pharmaceutically acceptable salt thereof.
As used herein, an “amount” or “dose” of laquinimod or teriflunomnide as measured in milligrams refers to the milligrams of laquinimod acid or teriflunomide base present in a preparation, regardless of the form of the preparation. A “dose of 0.6 mg laquinimod” means the amount of laquinimod acid in a preparation is 0.6 mg, regardless of the form of the preparation. Thus, when in the form of a salt, e.g. a laquinimod sodium salt, the weight of the salt form necessary to provide a dose of 0.6 mg laquinimod would be greater than 0.6 mg (e.g., 0.64 mg) due to the presence of the additional salt ion. Similarly, when in the form of a salt, the weight of the salt form necessary to provide a dose of 14 mg teriflunomide would be greater than 14 mg due to the presence of the additional salt ion.
As used herein, a “unit dose”, “unit doses” and “unit dosage form(s)” mean a single drug administration entity/entities.
As used herein, “about” in the context of a numerical value or range means±10% of the numerical value or range recited or claimed.
As used herein, a composition that is “free” of a chemical entity means that the composition contains, if at all, an amount of the chemical entity which cannot be avoided although the chemical entity is not part of the formulation and was not affirmatively added during any part of the manufacturing process. For example, a composition which is “free” of an alkalizing agent means that the alkalizing agent, if present at all, is a minority component of the composition by weight. Preferably, when a composition is “free” of a component, the composition comprises less than 0.1 wt %, 0.05 wt %, 0.02 wt %, or 0.01 wt % of the component.
As used herein, “alkalizing agent” is used interchangeably with the term “alkaline-reacting component” or “alkaline agent” and refers to any pharmaceutically acceptable excipient which neutralizes protons in, and raises the pH of, the pharmaceutical composition in which it is used.
As used herein, “oxidation reducing agent” refers to a group of chemicals which includes an “antioxidant”, a “reduction agent” and a “chelating agent”.
As used herein, “antioxidant” refers to a compound or molecule that inhibits the oxidation of other molecules. Examples of antoxidants include tocopherol, methionine, glutathione, tocotrienol, dimethyl glycine, betaine, butylated hydroxyanisole, butylated hydroxytoluene, turmerin, vitamin E, ascorbyl palmitate, tocopherol, deteroxime mesylate, methyl paraben, ethyl paraben, butylated hydroxyanisole, butylated hydroxytoluene, propyl gallate, sodium or potassium metabisulfite, sodium or potassium sulfite, alpha tocopherol or derivatives thereof, sodium ascorbate, disodium edentate, BHA (butylated hydroxyanisole), a pharmaceutically acceptable salt or ester of the mentioned compounds, and mixtures thereof.
The term “antioxidant” as used herein is also exemplified by Flavonoids such as those selected from the group of quercetin, morin, naringenin and hesperetin, taxifolin, afzelin, quercitrin, myricitrin, genistein, apigenin and biochanin A, flavone, flavopiridol, isoflavonoids such as the soy isoflavonoid, genistein, catechins such as the tea catechin epigallocatechin gallate, flavonol, epicatechin, hesperetin, chrysin, diosmin, hesperidin, luteolin, and rutin.
As used herein, “reduction agent” refers to a compound exemplified by the group consisting of thiol-containing compound, thioglycerol, mercaptoethanol, thioglycol, thiodiglycol, cysteine, thioglucose, dithiothreitol (DTT), dithio-bis-maleimidoethane (DTME), 2,6-di-tert-butyl-4-methylphenol (BHT), sodium dithionite, sodium bisulphite, formamidine sodium metabisulphite, and ammonium bisulphite.”
As used herein, “chelating agent” refers to a compound exemplified by the group consisting of penicillamine, trientine, N,N′-diethyldithiocarbamate (DDC), 2,3,2′-tetraamine (2,3,2′-tet), neocuproine, N,N,N′,N′-tetrakis(2-pyridylmethyl)ethylenediamine (TPEN), 1,10-phenanthroline (PHE), tetraethylenepentaminc, triethylenetetraamine and tris(2-carboxyethyl) phosphine (TCEP), ferrioxamine, CP94, EDTA deferoxainine B (DFO) as the methanesulfonate salt (also known as desferrioxanilne B mesylate (DFOM)), desferal from Novartis (previously Ciba-Giegy), and apoferritin.
As used herein, a pharmaceutical composition is “stable” when the composition preserves the physical stability/integrity and/or chemical stability/integrity of the active pharmaceutical ingredient during storage. Furthermore, “stable pharmaceutical composition” is characterized by its level of degradation products not exceeding 5% at 40° C./75% RH after 6 months or 3% at 55° C./75% RH after two weeks, compared to their level in time zero.
As used herein, “combination” means an assemblage of reagents for use in therapy either by simultaneous or contemporaneous administration. Simultaneous administration refers to administration of an admixture (whether a true mixture, a suspension, an emulsion or other physical combination) of the laquinimod and the teriflunomide. In this case, the combination may be the admixture or separate containers of the laquinimod and the teriflunomide that are combined just prior to administration. Contemporaneous administration refers to the separate administration of the laquinimod and the teriflunomide at the same time, or at times sufficiently close together that a synergistic activity relative to the activity of either the laquinimod or the teriflunomide alone is observed.
As used herein, “concomitant administration” or administering “concomitantly” means the administration of two agents given in close enough temporal proximately to allow the individual therapeutic effects of each agent to overlap.
As used herein, “add-on” or “add-on therapy” means an assemblage of reagents for use in therapy, wherein the subject receiving the therapy begins a first treatment regimen of one or more reagents prior to beginning a second treatment regimen of one or more different reagents in addition to the first treatment regimen, so that not all of the reagents used in the therapy are started at the same time. For example, adding laquinimod therapy to a patient already receiving teriflunomide therapy.
As used herein, “effective” when referring to an amount or dose of laquinimod and/or teriflunomide refers to the quantity of laquinimod and/or teriflunomide that is sufficient to yield a desired therapeutic response. Efficacy can be measured by an improvement of a symptom of multiple sclerosis. Such symptoms can include a MRI-monitored multiple sclerosis disease activity, relapse rate, accumulation of physical disability, frequency of relapses, time to confirmed disease progression, time to confirmed relapse, frequency of clinical exacerbation, brain atrophy, neuronal dysfunction, neuronal injury, neuronal degeneration, neuronal apoptosis, risk for confirmed progression, visual function, fatigue, impaired mobility, cognitive impairment, brain volume, abnormalities observed in whole Brain MTR histogram, general health status, functional status, quality of life, and/or symptom severity on work.
A “minimal effective dose” of teriflunomide as used herein means the minimum dose of teriflunomide which has been experimentally determined to be effective, which experimental results are consistent and statistically significant. In a study by Merill et al. (Merill et al., 2009), the minimal effective dose in mice was determined to be 3 mg/kg. In an embodiment, the human dose of teriflunomide is 7 mg/day, greater than 7 mg/day, 8 mg/day, 9 mg/day, 10 mg/day, 11 mg/day, 12 mg/day, 13 mg/day, 14 mg/day or greater than 14 mg/day.
In an embodiment, an effective amount is an amount that is sufficient to reduce relapse rate, preserve brain tissue, decrease or inhibit reduction of brain volume (optionally brain volume is measured by percent brain volume change (PBVC)), increase time to confirmed disease progression (e.g., by 20-60% or at least 50%), reduce disability progression, decrease abnormalities observed in whole Brain MTR histogram, decrease the accumulation of physical disability (optionally measured by Kurtzke Expanded Disability Status Scale (EDSS) score, e.g., wherein the accumulation of physical disability is assessed by the time to confirmed disease progression as measured by Kurtzke Expanded Disability Status Scale (EDSS) score), improve impaired mobility (optionally assessed by the Timed-25 Foot Walk test, the 12-Item Multiple Sclerosis Walking Scale (MSWS-12) self-report questionnaire, the Ambulation Index (AI), the Six-Minute Walk (6MW) Test, or the Lower Extremity Manual Muscle Test (LEMMT) Test), reduce cognitive impairment (optionally assessed by the Symbol Digit Modalities Test (SDMT) score), improve general health (optionally assessed by the EuroQoL (EQ5D) questionnaire, Subject Global Impression (SGI) or Clinician Global Impression of Change (CGIC)), improve functional status (optionally measured by the subject's Short-Form General Health survey (SF-36) Subject Reported Questionnaire score), improve quality of life (optionally assessed by SF-36, EQ5D, Subject Global Impression (SGI) or Clinician Global Impression of Change (CGIC)), improve the subject's SF-36 mental component summary score (MSC) and/or SF-36 physical component summary sore (PSC), reduce level of fatigue (optionally assessed by the EQ5D, the subject's Modified Fatigue Impact Scale (MFIS) score or the French valid versions of the Fatigue Impact Scale (EMIF-SEP) score), or improve symptom severity on work (optionally measured by the work productivity and activities impairment General Health (WPAI-GH) questionnaire).
“Administering to the subject” or “administering to the (human) patient” means the giving of, dispensing of, or application of medicines, drugs, or remedies to a subject/patient to relieve, cure, or reduce the symptoms associated with a condition, e.g., a pathological condition. The administration can be periodic administration. As used herein, “periodic administration” means repeated/recurrent administration separated by a period of time. The period of time between administrations is preferably consistent from time to time. Periodic administration can include administration, e.g., once daily, twice daily, three times daily, four times daily, weekly, twice weekly, three times weekly, four times weekly and so on, etc.
“Treating” as used herein encompasses, e.g., inducing inhibition, regression, or stasis of a disease or disorder, e.g., Relapsing MS (RMS), or alleviating, lessening, suppressing, inhibiting, reducing the severity of, eliminating or substantially eliminating, or ameliorating a symptom of the disease or disorder. “Treating” as applied to patients presenting CIS can mean delaying the onset of clinically definite multiple sclerosis (CDMS), delaying the progression to CDMS, reducing the risk of conversion to CDMS, or reducing the frequency of relapse in a patient who experienced a first clinical episode consistent with multiple sclerosis and who has a high risk of developing CDMS.
“Inhibition” of disease progression or disease complication in a subject means preventing or reducing the disease progression and/or disease complication in the subject.
A “symptom” associated with MS or RMS includes any clinical or laboratory manifestation associated with MS or RMS and is not limited to what the subject can feel or observe.
As used herein, “a subject afflicted with multiple sclerosis” or “a subject afflicted with relapsing multiple sclerosis” means a subject who has been clinically diagnosed to have multiple sclerosis or relapsing multiple sclerosis (RMS), which includes relapsing-remitting multiple sclerosis (RRMS) and Secondary Progressive multiple sclerosis (SPMS).
As used herein, a subject at “baseline” is as subject prior to administration of laquinimod.
A “patient at risk of developing MS” (i.e. clinically definite M5) as used herein is a patient presenting any of the known risk factors for MS. The known risk factors for MS include any one of a clinically isolated syndrome (CIS), a single attack suggestive of MS without a lesion, the presence of a lesion (in any of the CNS, PNS, or myelin sheath) without a clinical attack, environmental factors (geographical location, climate, diet, toxins, sunlight), genetics (variation of genes encoding HLA-DRB1, IL7R-alpha and IL2R-alpha), and immunological components (viral infection such as by Epstein-Barr virus, high avidity CD4+ T cells, CD8+ T cells, anti-NF-L, anti-CSF 114(Glc)).
“Clinically isolated syndrome (CIS)” as used herein refers to 1) a single clinical attack (used interchangeably herein with “first clinical event” and “first demyelinating event”) suggestive of MS, which, for example, presents as an episode of optic neuritis, blurring of vision, diplopia, involuntary rapid eye movement, blindness, loss of balance, tremors, ataxia, vertigo, clumsiness of a limb, lack of co-ordination, weakness of one or more extremity, altered muscle tone, muscle stiffness, spasms, tingling, paraesthesia, burning sensations, muscle pains, facial pain, trigeminal neuralgia, stabbing sharp pains, burning tingling pain, slowing of speech, slurring of words, changes in rhythm of speech, dysphagia, fatigue, bladder problems (including urgency, frequency, incomplete emptying and incontinence), bowel problems (including constipation and loss of bowel control), impotence, diminished sexual arousal, loss of sensation, sensitivity to heat, loss of short term memory, loss of concentration, or loss of judgment or reasoning, and 2) at least one lesion suggestive of MS. In a specific example, CIS diagnosis would be based on a single clinical attack and at least 2 lesions suggestive of MS measuring 6 mm or more in diameter.
“Relapse Rate” is the number of confirmed relapses per unit time. “Annualized relapse rate” is the mean value of the number of confirmed relapses of each patient multiplied by 365 and divided by the number of days that patient is on the study drug.
“Expanded Disability Status Scale” or “EDSS” is a rating system that is frequently used for classifying and standardizing the condition of people with multiple sclerosis. The score ranges from 0.0 representing a normal neurological exam to 10.0 representing death due to MS. The score is based upon neurological testing and examination of functional systems (FS), which are areas of the central nervous system which control bodily functions. The functional systems are: Pyramidal (ability to walk), Cerebellar (coordination), Brain stem (speech and swallowing), Sensory (touch and pain), Bowel and bladder functions, Visual, Mental, and Other (includes any other neurological findings due to MS) (Kurtzke J F, 1983).
A “confirmed progression” of EDSS, or “confirmed disease progression” as measured by EDSS score is defined as a 1 point increase from baseline EDSS if baseline EDSS was between 0 and 5.0, or a 0.5 point increase if baseline EDSS was 5.5. In order to be considered a confirmed progression, the change (either 1 point or 0.5 points) must be sustained for at least 3 months. In addition, confirmation of progression cannot be made during a relapse.
“Adverse event” or “AE” means any untoward medical occurrence in a clinical trial subject administered a medicinal product and which does not have a causal relationship with the treatment. An adverse event can therefore be any unfavorable and unintended sign including an abnormal laboratory finding, symptom, or diseases temporally associated with the use of an investigational medicinal product, whether or not considered related to the investigational medicinal product.
“Gd-enhancing lesion” refers to lesions that result from a breakdown of the blood-brain barrier, which appear in contrast studies using gandolinium contrast agents. Gandolinium enhancement provides information as to the age of a lesion, as Gd-enhancing lesions typically occur within a six week period of lesion formation.
“Magnetization Transfer imaging” or “MTI” is based on the magnetization interaction (through dipolar and/or chemical exchange) between bulk water protons and macromolecular protons. By applying an off resonance radio frequency pulse to the macromolecular protons, the saturation of these protons is then transferred to the bulk water protons. The result is a decrease in signal (the net magnetization of visible protons is reduced), depending on the magnitude of MT between tissue macromolecules and bulk water. “MT” or “Magnetization Transfer” refers to the transfer of longitudinal magnetization from the hydrogen nuclei of water that have restricted motion to the hydrogen nuclei of water that moves with many degrees of freedom. With MTI, the presence or absence of macromolecules (e.g. in membranes or brain tissue) can be seen (Mehta, 1996; Grossman, 1994).
“Magnetization Resonance Spectroscopy” or “MRS” is a specialized technique associated with magnetic resonance imaging (MRI). MRS is used to measure the levels of different metabolites in body tissues. The MR signal produces a spectrum of resonances that correspond to different molecular arrangements of the isotope being “excited”. This signature is used to diagnose certain metabolic disorders, especially those affecting the brain, (Rosen, 2007) as well as to provide information on tumor metabolism (Golder, 2007).
As used herein “mobility” refers to any ability relating to walking, walking speed, gait, strength of leg muscles, leg function and the ability to move with or without assistance. Mobility can be evaluated by one or more of several tests including but not limited to Ambulation Index, Time 25 foot walk, Six-Minute Walk (6MW), Lower Extremity Manual Muscle Test (LEMMT) and EDSS. Mobility can also be reported by the subject, for example by questionnaires, including but not limited to 12-Item Multiple Sclerosis Walking Scale (MSWS-12). Impaired Mobility refers to any impairment, difficulty or disability relating to mobility.
“T1-weighted MRI image” refers to an MR-image that emphasizes T1 contrast by which lesions may be visualized. Abnormal areas in a T1-weighted MRI image are “hypointense” and appear as dark spots. These spots are generally older lesions.
“T2-weighted MRI image” refers to an MR-image that emphasizes T2 contrast by which lesions may be visualized. T2 lesions represent new inflammatory activity.
The “Six-Minute Walk (6MW) Test” is a commonly used test developed to assess exercise capacity in patients with COPD (Guyatt, 1985). It has been used also to measure mobility in multiple sclerosis patients (Clinical Trials Website).
The “Timed-25 Foot Walk” or “T25-FW” is a quantitative mobility and leg function performance test based on a timed 25-walk. The patient is directed to one end of a clearly marked 25-foot course and is instructed to walk 25 feet as quickly as possible, but safely. The time is calculated from the initiation of the instruction to start and ends when the patient has reached the 25-foot mark. The task is immediately administered again by having the patient walk back the same distance. Patients may use assistive devices when doing this task. The score for the T25-FW is the average of the two completed trials. This score can be used individually or used as part of the MSFC composite score (National MS Society Website).
One of the central symptoms of multiple sclerosis is fatigue. Fatigue can be measured by several tests including but not limited to decrease of French valid versions of the Fatigue Impact Scale (EMIF-SEP) score, and European Quality of Life (EuroQoL) Questionnaire (EQSD). Other tests, including but not limited to Clinician Global Impression of Change (CGIC) and Subject Global Impression (SGI), as well as EQ-5D, can be used to evaluate the general health status and quality of life of MS patients.
“Ambulation Index” or “AI” is a rating scale developed by Hauser et al. to assess mobility by evaluating the time and degree of assistance required to walk 25 feet. Scores range from 0 (asymptomatic and fully active) to 10 (bedridden). The patient is asked to walk a marked 25-foot course as quickly and safely as possible. The examiner records the time and type of assistance (e.g., cane, walker, crutches) needed. (Hauser, 1983)
“EQ-5D” is a standardized questionnaire instrument for use as a measure of health outcome applicable to a range of health conditions and treatments. It provides a simple descriptive profile and a single index value for health status that can be used in the clinical and economic evaluation of health care as well as population health surveys. EQ-5D was developed by the “EuroQoL” Group which comprises a network of international, multilingual, multidisciplinary researchers, originally from seven centers in England, Finland, the Netherlands, Norway and Sweden. The EQ-5D questionnaire is in the public domain and can be obtained from EuroQoL.
“SF-36” is a multi-purpose, short-form health survey with 36 questions which yields an 8-scale profile of functional health and well-being scores as well as psychometrically-based physical and mental health summary measures and a preference-based health utility index. It is a generic measure, as opposed to one that targets a specific age, disease, or treatment group. The survey is developed by and can be obtained from QualityMetric, Inc. of Providence, R.I.
A “pharmaceutically acceptable carrier” refers to a carrier or excipient that is suitable for use with humans and/or animals without undue adverse side effects (such as toxicity, irritation, and allergic response) commensurate with a reasonable benefit/risk ratio. It can be a pharmaceutically acceptable solvent, suspending agent or vehicle, for delivering the instant compounds to the subject.
It is understood that where a parameter range is provided, all integers within that range, and tenths thereof, are also provided by the invention. For example, “0.1-2.5 mg/day” includes 0.1 mg/day, 0.2 mg/day, 0.3 mg/day, etc. up to 2.5 mg/day.
This invention will be better understood by reference to the Experimental Details which follow, but those skilled in the art will readily appreciate that the specific experiments detailed are only illustrative of the invention as described more fully in the claims which follow thereafter.
Teriflunomide and laquinimod have different mechanisms of action.
Teriflunomide directly targets inflammation. Although its mechanism of action in MS is not fully elucidated, it has been suggested to involve a reduction of the number of proinflammatory activated T-cells infiltrating into the CNS (Zeyda 2005). Teriflunomide has a modest anti-inflammatory and no clear neuroprotective effects in RRMS patients.
Laquinimod mostly targets neurodegeneration with its primary activity in the CNS. It was thought to interfere with microglial and astrocytic activation. In MS, laquinimod showed potential for slowing neurodegeneration and reducing non-relapse-dependent disability progression. Laquinimod has major neuroprotective effects with relatively lower anti-inflammatory effects in RRMS patients.
Laquinimod and teriflunomide administered separately have been shown to reduce clinical and MRI markers of inflammation in large clinical trials (Comi 2012 and O'Connor 2011). Laquinimod has also shown disproportional large decrease in disability progression considering the modest effect on relapses. The effect of laquinimod is on the whole brain and thalamus while the effect of teriflunomide is predominantly on normal-appearing white matter (NAWM) volume (Comi 2012, Nelson 2011).
In this experiment, MOG-induced EAE Mice are treated with two doses of laquinimod (5 and 25 mg/kg) alone or with add-on teriflunomide (3 or 10 mg/kg) to assess the efficacy of laquinimod alone or in combination with teriflunomide. MOG-induced Experimental Autoimmune Encephalomyelitis (EAE) in the C57BL/6 strain of mice is an established EAE model for testing efficacy of candidate molecules for MS treatment.
Disease is induced in all mice by injection of the encephalitogenic emulsion (MOG/CFA) and intraperitoneal injection of pertussis toxin on the first day and 48 hours later.
EAE is induced by subcutaneous injection of encephalitogenic emulsion at a volume of 0.2 ml/mouse in the flanks at two injection sites. On the day of induction, pertussis toxin is injected i.p. at a volume dose of 0.2 ml/mouse.
Day 0: Subcutaneous injection of MOG into right flank, ip injection of Pertussis toxin, beginning of daily laquinimod treatment.
Day 2: ip injection of Pertussis toxin.
Day 10: initiation of scoring of mice for EAE clinical signs.
Day 30: termination of study.
Healthy, nulliparous, non-pregnant female mice of the C57BL/6 strain are used in the study.
The animals weighed 17-20 gr, and are approximately 7 weeks old on receipt.
The body weights of the animals are recorded on the day of delivery.
Overtly healthy animals are assigned to study groups arbitrarily before treatment commenced.
The mice are individually identified by using ear tags. A color-coded card on each cage gives information including cage number, group number and identification.
Active EAE is induced on Day 1 by the subcutaneous injection in the flanks at two injection sites, the encephalitogenic mixture (emulsion) consisting of MOG and commercial CFA containing 5 mg/mL Mycobacterium tuberculosis (MT) at a volume of 0.2 mL/mouse in the right flank of the animals.
Pertussis toxin is injected intraperitoneally on the day of induction and 48 hours later at dose level of 300 ng/0.2 ml/mouse. The dose of the MOG and MT is 150 μg/mouse and 200 μg/mouse respectively.
Study Design:
The mice are allocated randomly into groups according to Table 1 below.
Oil portion: CFA (containing 1 mg/ml MT) enriched with mycobacterium tuberculosis to yield 5 mg/ml MT.
Liquid portion: 60 mg of MOG or equivalent is weighed and dissolved in 20 ml saline to yield 3 mg/ml MOG.
The solution is mixed and incubated for 1 hour (t=37° C.).
Emulsion: The emulsions are made from equal parts of oil (CFA containing 5.0 mg/ml MT) and liquid portions (3 mg MOG/ml) in two syringes connected to each other with Leur lock to yield 0.75 mg/ml MOG.
The emulsion is administered subcutaneous at two injection sites in the flanks of the mice to mice of the respective groups once on Day 1 of the study.
The dose of the MOG in all the groups is 0.30 mg/0.2 ml/mouse.
The dose of the MT in all the groups is 0.5 mg/0.2 ml/mouse.
100 L Pertussis toxin (200 μg/ml) is added to 26.57 ml PBS to yield 750 ng/ml.
0.2 mL of 750 ng/ml is injected intraperitoneally to the mice equivalent to 150 ng/0.2 ml/mouse. Total dose (0.150+0.150 μg/mouse=0.300 μg/mouse).
Laquinimod is diluted in 0.5% CMC/H2O+Tween 80.
For dose level of 5.0 mg/kg Laquinimod, 0.5 mg/ml stock solution is prepared (groups #2, 6 and 7).
For dose level of 25.0 mg/kg Laquinimod, 2.5 mg/ml stock solution is prepared (group #3).
The test formulations are stored at 2 to 8° C. until use in amber colored bottles.
Formulation of Teriflunomide is prepared daily in 0.5% CMC/H2O+Tween 80.
Concentrations of 0.3 mg/mL (groups #4 and 6) and 1.0 mg/ml (groups #5 and 7) is prepared for dose levels of 3 and 10 mg/kg bid and administered to the respective groups in the morning.
Laquinimod, Teriflunomide or the vehicle (0.5% CMC+Tween 80) is administered to mice of the respective groups daily, bolus oral gavage at a volume of 200 ul/mouse according to the experimental design.
All of the treatment groups are administered from Day 1, with the respective test formulations.
Eae Clinical Signs:
The mice are observed daily from the 10th day post-EAE induction (first injection of MOG) and the EAE clinical signs are scored according to the grades described in Table 2 presented below.
All mice with score 1 and above are considered sick. When the first clinical sign appears all mice are given food soaked in water, which is spread on different places on the bedding of the cages.
Percent inhibition of the combination is calculated as the sum of the percent inhibition of each drug alone.
The results of this study suggest that laquinimod and teriflunomide can be used in combination to achieve a better therapeutic result than when each agent is administered alone, and provides evidence that such a combination can be used for therapeutic treatment of human MS and CIS patients.
The objective of this study was to assess any additive or synergistic effect when combining laquinimod (QD) and teriflunomide (QD) treatment in MOG induced EAE.
Disease was induced in all mice by the injection of the encephalitogenic emulsion (MOG/CFA). The test articles and vehicle were dosed daily via gavage from day 1 until Day 30 (termination of study). The treatment groups are presented in table of Experimental design.
Healthy, nulliparous, non-pregnant female mice of the C57BL/6 strain were used in the study. The animals weighed about 17-20 g on arrival, and were approximately 7 weeks of age. The body weights of the animals were recorded on the day of delivery.
Overtly healthy animals were assigned to study groups arbitrarily before treatment commenced. The mice were individually identified by markings on the body. A color-coded card on each cage gave information including cage number, group number and identification.
Active EAE was induced on Day 1 by the subcutaneous injection in the flanks at two injection sites. The encephalitogenic mixture (emulsion) consisting of MOG and commercial CFA containing 5 mg/mL Mycobacterium tuberculosis (MT) at a volume of 0.2 mL/mouse was administered to the right flank of the animals.
Pertussis toxin was injected intraperitoneally on the day of induction and 48 hours later at dose level of 150 ng/0.2 ml/mouse.
The dose of the MOG and MT is 300 μg/mouse and 500 μg/mouse respectively.
Oil portion: CFA (containing 1 mg/ml NT) enriched with mycobacterium tuberculosis to yield 5 mg/ml MT.
90 mg of MOG were weighed and dissolved in 30 ml saline to yield 3 mg/ml MOG.
The solution was mixed and incubated for 1 hour (t=37° C.).
The emulsions were made from equal parts of oil (CPA containing 5.0 mg/ml MT) and liquid portions (3 mg MOG/ml) in two syringes connected to each other with Leur lock to yield 1.5 mg/ml MOG.
The emulsion was administered subcutaneous at two injection sites in the flanks of the mice once on Day 1 of the study.
The dose of the MOG in all the groups was 0.30 mg/0.2 ml/mouse.
The dose of the MT in all the groups was 0.5 mg/0.2 ml/mouse.
100 μL Pertussis toxin (200 μg/ml) was added to 26.57 ml PBS to yield 750 ng/ml.
0.2 mL of 750 ng/ml Pertussis toxin was injected intraperitoneally to the mice equivalent to 150 ng/0.2 ml/mouse.
Total dose (0.150+0.150 μg/mouse=0.300 μg/mouse).
On Day 1 the MOG EAE induced mice were allocated to the following treatment groups (15 mice/group).
Laquinimod was diluted in vehicle (0.06 w/v % CMC/H2O+0.5% Tween 80).
For dose level of 5.0 mg/kg laquinimod, 0.5 mg/ml stock solution was prepared (Groups 2, 6 and 7).
For dose level of 25.0 mg/kg laquinimod, 2.5 mg/ml stock solution was prepared (Group 3).
The test formulations were stored at 2-8° C. until use in amber colored bottles for not more than 8 days.
Formulations of teriflunomide were prepared daily in Vehicle.
0.06 w/v % CMC/HxO+0.5% Tween 80.
In 1000 mL water 600 mg CMC and 5 ml Tween 80 were added.
The mixture was stirred on magnetic stirrer until homogenous solution was formed. The ingredients were mixed by stirring.
Concentration of 0.3 mg/mL (Groups 4 and 6) and 1.0 mg/ml (Groups 5 and 7) teriflunomide were prepared for dose levels of 3 and 10 mg/kg bid and administered to the respective groups in the morning. The mixtures were stirred on magnetic stirrer for 30 minutes before use and mixed on rotor during administration.
Laquinimod, teriflunomide or the vehicle (0.06 w/v % CMC+0.5% Tween 80) were administered to mice of the respective groups daily, bolus oral gavage at a volume of 200 μl/mouse according to the experimental design.
All of the treatment groups were administered from Day 1, with the respective test formulations in accordance with Table 3.
All animals were examined once daily to detect if any is dead or moribund.
Scoring of EAE clinical signs was initiated on the 10th day post-EAE induction and continued daily. The clinical signs were recorded on observation cards according to a grading system described in Table 4 below.
All mice having scores of 1 and above were considered sick.
Animals with score 5 for more than two days was given score 6 and sacrificed for humane reasons. For calculation purposes, the score (5) of animals that are sacrificed or died was carried forward (LOCF).
Acceptance criteria for Negative Control Group:
The control group should have at least 70% incidence.
The MMS should be more than 2.0.
Same as Example 1 above.
A summary of the incidence, mortality, MMS, GMS, duration of the disease, onset of the disease, and the activity of each group compared to the vehicle treated control group is shown in Table
The clinical profile is presented graphically in Error! Reference source not found.
Teriflunomide (10 mg/kg)+laquinimod (5 mg/kg) exhibited 72.2% inhibition (p<0.0001), which is a better effect than each one of teriflunomide and laquinimod tested separately. Laquinimod alone (5 mg/kg) exhibited 58.4% inhibition (p=0.002) and Teriflunomide alone (10 mg/kg) exhibited 42.9% inhibition (p=0.03).
Periodic oral administration of laquinimod (p.o. 0.6 mg/day or 1.2 mg/day) as an add-on therapy for a human patient afflicted with a form of MS who is already receiving teriflunomide (p.o. 14 mg/day) provides a clinically meaningful advantage and is more effective in treating the patient than when teriflunomide is administered alone (at the same dose).
Periodic oral administration teriflunomide (p.o. 14 mg/day) as an add-on therapy for a human patient afflicted with a form of MS who is already receiving of laquinimod (p.o. 0.6 mg/day or 1.2 mg/day) provides a clinically meaningful advantage and is more effective in treating the patient than when laquinimod is administered alone (at the same dose).
The add-on therapies also provides better efficacy in treating the patient without undue adverse side effects or affecting the safety of the treatment. As compared to when each agent is administered alone:
Administration of laquinimod (p.o., 0.6 mg/day and 1.2 mg/day) as an add-on therapy to teriflunomide (p.o. 14 mg/day) provides a clinically meaningful advantage and is more effective) in delaying the conversion to clinically definite MS in patients presenting a CIS suggestive of MS than when teriflunomide is administered alone (at the same dose).
Administration of laquinimod (p.o., 0.6 mg/day and 1.2 mg/day) as an add-on therapy to teriflunomide (p.o. or 14 mg/day) provides a clinically meaningful advantage and is more effective in reducing the rate of development of clinically definite MS, the occurrence of new MRI-detected lesions in the brain, the accumulation of lesion area in the brain and brain atrophy in persons at high risk for developing MS, and is more effective in reducing the occurrence of clinically definite MS and preventing irreversible brain damage in these persons than when teriflunomide is administered alone (at the same dose).
Administration of teriflunomide (p.o. 14 mg/day) as an add-on therapy to laquinimod (p.o., 0.6 mg/day and 1.2 mg/day) provides a clinically meaningful advantage and is more effective in delaying the conversion to clinically definite MS in patients presenting a CIS suggestive of MS than when laquinimod is administered alone (at the same dose).
Administration of teriflunomide (p.o. 14 mg/day) as an add-on therapy to laquinimod (p.o., 0.6 mg/day and 1.2 mg/day) provides a clinically meaningful advantage and is more effective in reducing the rate of development of clinically definite MS, the occurrence of new MRI-detected lesions in the brain, the accumulation of lesion area in the brain and brain atrophy in persons at high risk for developing Ms, and is more effective in reducing the occurrence of clinically definite MS and preventing irreversible brain damage in these persons than when laquinimod is administered alone (at the same dose).
Periodic oral administration of laquinimod (0.6 mg/day or 1.2 mg/day) in combination with teriflunomide (p.o. 14 mg/day) to a human patient afflicted with relapsing form of multiple sclerosis provides increased efficacy in treating the patient than when laquinimod is administered alone or when teriflunomide is administered alone (at the same dose). The combination therapy also provides efficacy in treating the patient without undue adverse side effects or affecting the safety of the treatment.
The combination therapy provides a clinically meaningful advantage and is more effective in treating the patient than when laquinimod or teriflunomide is administered alone (at the same dose) in the following manner:
Administration of laquinimod (p.o., 0.6 mg/day and 1.2 mg/day) in combination with teriflunomide (p.o. 14 mg/day) provides a clinically meaningful advantage and is more effective in delaying the conversion to clinically definite MS in patients presenting a CIS suggestive of MS than when teriflunomide is administered alone (at the same dose).
Administration of laquinimod (p.o., 0.6 mg/day and 1.2 mg/day) in combination with teriflunomide (p.o. 14 mg/day) provides a clinically meaningful advantage and is more effective in reducing the rate of development of clinically definite MS, the occurrence of new MRI-detected lesions in the brain, the accumulation of lesion area in the brain and brain atrophy in persons at high risk for developing MS, and is more effective in reducing the occurrence of clinically definite MS and preventing irreversible brain damage in these persons than when teriflunomide is administered alone (at the same dose).
This application claims priority of U.S. Provisional Application No. 61/920,064, filed Dec. 23, 2013, the entire content of which is hereby incorporated by reference herein. Throughout this application, various publications are referred to by first author and year of publication. Full citations for these publications are presented in a References section immediately before the claims. Disclosures of the documents and publications referred to herein are hereby incorporated in their entireties by reference into this application.
| Filing Document | Filing Date | Country | Kind |
|---|---|---|---|
| PCT/US14/72244 | 12/23/2014 | WO | 00 |
| Number | Date | Country | |
|---|---|---|---|
| 61920064 | Dec 2013 | US |
