Patent Application
20230165822
The present invention relates to novel medicinal and/or pharmaceutical urinary, extended-release alkalizing composition advantageously a tablet for the oral treatment of interstitial cystitis/bladder pain syndrome (IC/BPS) by alkalizing the urine and/or for general alkalization of the human body for long term where according to the subject matter of the invention the composition is potassium free, the composition has a sustained and/or controlled release dosage form and comprises following components advantageously with the following consistence as active ingredients in weight percentage:
Citric acid, advantageously 50 to 100 mg, especially advantageously 68.00 mg or 53.17 mg and
Sodium citrate, advantageously 130 to 250 mg, especially advantageously 183.00 mg or 143.09 mg and
Magnesium citrate, advantageously 190 to 290 mg, especially advantageously 243.00 mg or 190 mg;
and comprises following components advantageously with the following consistence as excipients in weight percentage where the total weight percentage of the above active ingredients in the especially advantageous case is totally 60% and this percentage depends on the advantageous ranges of the excipients:
Aerosil, advantageously 0.5% weight percentage;
Avicel DG, advantageously 15% to 25%, especially advantageously 19% weight percentage;
Benecel hypromellose microcrystalline cellulose (HPMC) as grade, advantageously Benecel K100M PH DC HPMC advantageously 15% to 25%, especially advantageously 20% weight percentage, where the number (K100) indicates the viscosity of the grades, the PH means pharmaceutical quality and DC indicates that the grade can be pressed;
Magnesium stearate, advantageously 0.5% weight percentage.
The subject matter of the present invention relates furthermore to novel medicinal and/or pharmaceutical urinary, extended-release alkalizing composition wherein a single administered dose of the composition achieves a therapeutic alkalizing concentration for providing a neutral pH value of the urine between values of 6.9 to 7.5 advantageously 7.38 in an individual for about 8 to about 14 hours advantageously 12 hours.
The subject matter of the present invention furthermore relates to the process for the formulation of the medicinal and/or pharmaceutical urinary, extended-release alkalizing composition according to the invention comprising the above-described components in the especially advantageous amounts as described above by in a solid form advantageously a tablet by the following steps:
during the homogenization of the above described active ingredients a special formulation process is needed for avoiding liquefaction and the formation of eutectic therefore
According to the definition of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK, the USA) Interstitial Cystitis/Bladder Pain Syndrome (henceforth IC/BPS) is a chronic, or long lasting, condition that causes painful urinary symptoms.1 Its symptoms greatly affect the patients' quality of life.2 As IC/BPS progresses, the pain and the frequent voiding (which may exceed more than 80 occasions per day) can severely impede work, sexual intercourse, social life and night-time resting. Other chronic conditions occur more frequently in IC/BPS patients than in the general population.3
According to our present knowledge, there is no permanent cure for IC/BPS.4 On the other hand, patients can be free from symptoms for years, and their normal quality of life can be preserved, assuming they get the appropriate treatment. Due to the increasing number of diagnosed cases and the length of treatment, IC/BPS shall demand an increasing amount of resources from the healthcare systems in the near future.
IC/BPS: The Known Facts
The causes of IC/BPS are still not known. The possible explanations are the dysfunction of the related nerves, autoimmune problems, allergic reactions, and stress. Hereditary factors may take part, too. Nevertheless, none of these hypotheses have been proven scientifically.
The condition itself, on the other hand, has been well described.5 The symptoms occur because of the inadequate status of the mucosa of the bladder and the upper part of the urethra. The healthy layer of mucosa—which consists of glucose amino glycan or GAG—prevents salts, acids and other urinary products (which are present in the urine naturally) interfering with the deeper layers of this tissue; most importantly with the sub-mucosal pain receptors. In the case of IC/BPS, this GAG-layer is being damaged and enables the compounds described above to reach the tissues. This process results in a sterile inflammation—in which there are no bacteria present. The inflammation can spread to the deeper layers of the bladder wall, too, and leads to an increased amount of mast cells. These cells secrete histamine, which increases the pain. The constant irritation raises the number of pain receptors, which makes the symptoms worse. If the inflammation persists for years, other elements of the connective tissues build up in the edematous tissue, which makes the bladder wall lose its elastic properties. At the end of this process, the bladder turns into a shrunken bladder (a hard bladder with very low capacity), which is an irreversible condition. As a consequence, kidney failure may appear, too.
Since it, the cause of the GAG-layer loss is not known, it is impossible to prevent IC/BPS. Moreover, there is no therapy available which cures the condition for good. The early diagnosis and the proper treatment can stop the progression of IC/BPS; therefore, in sense of the way, its effects are somewhat preventive. Controlling the urine pH is a vital part of the treatment, because not only the concentrated but also the too acidic—or even too alkalic—pH makes the symptoms more severe.
Diagnosis and Prevalence: Double Difficulty
Despite a lot of efforts taken to find any marker, so far nothing has been discovered that can be inarguably associated with IC/BPS.6 There are no alterations either that would refer to IC/BPS, without doubt, so using the most known imaging methods in themselves do not provide an unambiguous diagnosis. The image of the healthy bladder and the disrupted one may be identical. On the other hand, the insufficiency of the GAG-layer can refer to other diseases, too. Excluding malign transformations and infections is a necessary step, but even the presence of any other condition cannot rule out IC/PBS. Therefore, IC/BPS can sometimes only be diagnosed after the successful treatment of the easily identifiable condition.
The usual symptoms of IC/BPS can be divided into two major groups.7
Pain
Voiding
The presence of these symptoms varies by patients and affected by several factors. Namely, consuming certain foods and drinks, the amount of physical and/or mental stress, digestive disorders, urinary infections (UTIs) and (in women) their menstrual cycle (the symptoms are usually worse after ovulation).
Most urologists define a condition as IC/BPS if the characteristic symptoms persist for a certain period (1.5-6 months) given that every disease of similar symptoms can be excluded. Filling out questionnaires can identify the presence of symptoms; the O'Leary-Sant Symptom Index is one of the most frequently used ones8. However, because no lab tests or any other kind of examination can unequivocally confirm IC/BPS, the condition can never be diagnosed with a 100% certainty. Fortunately, not only are there a handful of supplemental examinations which can be used for refining the diagnosis, but also the medical practice has improved significantly in this field in recent years.
The occurrence of disease can usually be described by two kinds of data. Incidence means the newly registered cases during a certain period (usually a year). Prevalence, on the other hand, means the total amount of people affected by the disease at a certain point of time. In the case of IC/BPS, which appears to be a life-long condition, the latter data is relevant.
The international estimations of prevalence are based on the presence of symptoms, filling in questionnaires, and data on patients having diagnosed with IC/BPS. The number of people affected by IC/BPS is usually referred to as 100,000 people.
However, neither the questionnaires nor the way of their evaluation is standardized. Certain studies that used only the data gathered from doctors focusing on the diagnosed IC/BPS cases concluded a prevalence of 45-197/100,000.9 On the other hand, a survey in which households had been contacted by phone estimated 1,900-4,200/100,000 men and 2,750-6350/100,000 women affected by IC/BPS. A mere 10% of the latter group had been diagnosed.10 11 According to another research based on self-reporting via e-mail, IC/BPS can affect 258-13,114/100,000 people, depending on the way of calculations.12
In 2017 Interstitial Cystitis Association (ICA) reported that alone in the USA, there are 3-8 million women and 1-4 million men affected by IC/BPS.13 In recent years, this estimation seems to have been accepted by many relevant papers and organizations.14, 15 Considering the mean of both values, a prevalence of 2,400/100,000 appears to be a reasonable calculation.
Certain reports explain that in case of a percentage of the patients, the symptoms can disappear without any treatment (given that the condition has never been severe). Including this in our calculations, a prevalence of 2,000/100,000 must be close to the reality.
That said, the diagnosis rate of IC/BPS is less than 5-10%, even in the countries with the most advanced healthcare. There is no other disorder of this seriousness, which has a lower diagnostic rate. The disease is unknown to most people and a certain part of the medical society, too.
The healthcare sector needs to be enlightened, especially urologists, gynecologists, and family doctors since these are the groups most probably turned to by patients in the first place. It is also essential to give relevant information to the society about IC/BPS. The existence of a severe, painful disease like this, which can be fatal if remains untreated, must be a well-known fact.
Nevertheless, enlightening seems to be an ongoing trend, regardless of our effort.
As a consequence of the improvement of the diagnostic methods, the number of resources spent on the treatment of IC/BPS shall show an increasing trend worldwide.
The Treatment of IC/BPS and the Role of Alkalization Therein
Most guidelines—including the one of American Urological Association (AUA)—shares the view that the doctor should start with the least invasive method and progress step by step towards the more invasive technics.16
The least invasive therapeutic possibilities describe lifestyle changes. Diet has a major impact on the symptoms. IC/BPS food and drink lists are widely available on the internet17, 18, 19, and scientific papers have been published about this topic, too20, 21. Most of the references agree that certain nourishments irritate the damaged bladder wall. Lists usually mention the following things:—
Not only are there nourishment categories on these lists which are increasing the acidity of urine but also most dietary recommendations are suggesting the alkalization of the urine, too.
If there is no improvement experienced, the next major line of treatment is oral therapy. The most common active ingredients are antihistaminic, non-steroidal or corticosteroid anti-inflammatories, tricyclic antidepressants, gabapentin nerve pain relieve, and pentosan-polysulfate sodium (PPS).
Urine alkalizing agents are regularly administered as well.
The correlation between the urine pH and the symptoms was discovered long ago; it has been described in several papers22; recent guidelines usually mention it as an effective way to mitigate the symptoms.23
If the oral therapy turns out to be ineffective, the next possibility is the local treatment: the GAG-layer replenishment substances are being instilled directly into the bladder. The approved drugs are different depending on the country. The most widespread substances are heparin, hyaluronic acid, chondroitin sulfate, pentosan polysulfate sodium, dimethyl sulfoxide (DMSO) and lidocaine. It is worth pointing out that alkalization is beneficial in this phase of the treatment, too; alkalized lidocaine is often used as an ingredient of the medicines (aka. bladder cocktails).24 All the less invasive methods are usually performed during the local therapy.
Alkalization and dilution of the urine are essential for the proper treatment in all but the most severe cases.
Keeping the urine pH in the optimal range is crucial, regardless of the guideline being used for different other treatments of IC/BPS.
Alkalization overview Alkalization has been a part of the medical practice for a long time. There are several conditions in whose treatment alkalization plays a key role. The most important—and most common—are to mention are gout, kidney, and bladder stones. Due to the relatively high prevalence of these conditions, there are plenty of alkalizing medicines, medicinal compositions, dietary supplements, and other products on the market.
Their popularity can be demonstrated with the fact that Milurit (allopurinol) was the eighth most frequently prescribed medicine in Hungary in 2018 (more than 500,000 cases).25 Its active agent, allopurinol, is used mostly for treating gout, however it is administered in case of other conditions, too, because it inhibits the synthesis of uric acid.26
Regarding urinary alkalization, the most common medical products used in the USA contain sodium bicarbonate or citric acid/citrate salts as active pharmaceutical ingredients.27 These products are available in every country, manufactured by different companies, under different names. Neut and Brioschi, brands from the USA, Sellymin from Canada, in some other countries simply active ingredient “sodium bicarbonate” is named (as a product). Alkurin, Cytra-K, Bicitra, and Virtrate products contain citric acid and different citric salts. Some of these products are for systematic alkalization, too.
Although the market seems to be diverse and overbought, it must be pointed out that none of these products have IC/BPS as their primary indication. There is one single alkalizing dietary supplement which is directly recommended in case of IC/BPS. It is named Prelief, and it works differently. Prelief does not alkalize the urine; it has to be taken with the food or beverage consumed so that it can reduce the acid content of the nourishment. In spite of the difference, Prelief appears to be the closest competitor of the composition according to the subject matter of the invention.
It is worth mentioning, though, that Prelief does not change the urine pH directly, so any factors that affect the acidity of the urine and are independent of nutrition still prevail.
A considerable portion of urinary alkalizing products can and should not be used for treating IC/BPS at all.
Firstly, certain products contain potassium, which is proven to make both the urinary and the pain syndromes worse, given that the GAG-layer of the bladder is already damaged.28, 29, 30 Potassium, on the other hand, causes no problems in case of a healthy GAG-layer. Potassium citrate is generally used for treating gout since it brings the uric acid causing joint problems into a water-soluble form. Too much potassium, nevertheless, can lead to hyperkalemia, whose typical symptoms can be found in many of the leaflets of the alkalizing medicines, as notable side effects.31
Also, the increased potassium intake results in higher concentration of potassium in the bladder, which is seriously irritative.
Secondly, urine pH has a natural fluctuation. It happens due to several factors: food intake, exercise, daily routine, hormonal activities. This fluctuation cannot be felt in case of a healthy GAG-layer but can lead to flare-ups (sudden, short but severe periods of pain) in many of the IC/BPS patients. There are plenty of reports and summaries explaining the correlation between certain foods and flare-ups.32 Not only the acidic urine pH can raise the frequency of these incidents, but also the rapid changes. According to several patients' reports the alkaline urine (pH>7.5) can cause just as severe pain as the highly acidic (pH<6.0) does. Currently available alkalizing tablets have to be taken three or four times a day; typically after a meal and sometimes before bedtime, too—or even more frequently.33, 34 The way the traditional alkalizing tablets are being administered lead inevitably to the sudden changes of the urine pH. After meals—which usually makes the urine more acidic—the pH does rise quickly (in 15 minutes to 1 hour) and may reach the optimal range to compensate the effect of the food intake, but may enter the dangerously alkalic range, too. An even bigger issue is that the effect of these tablets lasts for 1-4 hours, so the daily mean value of the urine pH still remains in the highly acidic range. Therefore, for treating IC/BPS, a urinary alkalizing tablet of a slower, longer effect would be much more efficient.
It is worth mentioning that there are certain medicines on the market which are able to raise the urine pH and have a long-lasting effect or slow-release forms. Diamox is one of these products.35 This, and other medicines, containing acetazolamide as an active pharmaceutical ingredient, are designed for completely different indications. Even if 90% of acetazolamide is said to reach the bladder, these drugs affect several other organs and tissues, and the risk of experiencing side effects is relatively high, too. Therefore, using them at the treating of IC/BPS is not recommended.
Methazolamide is another agent which may have some alkalizing effect, but since only a fraction of the compound reaches the bladder, its efficiency for treating urinary conditions is questionable.36
That said, currently, there is neither alkalizing medicine, medicinal composition nor dietary supplement available on the market which would be able to raise the urine pH with a long-lasting, slow-release effect. Thus, according to the prior art there is no optimal way to alkalize the urine for IC/BPS patients.
Using the traditional urinary alkalizing medicines was proved to be effective for raising the urine pH, but as it was described in the previous chapter, potassium caused the worsening of the symptoms during the process, lowering their efficacy.
According to the literature for the alkalization of the urine the optimal solution is the use of different citric salts like in case of e.g. Magurlit or Blemaren-N but both medicines contain potassium salts.
Using NaHCO3 for urine alkalization is not a good solution because the acid content of the stomach immediately neutralises the effect thereof.
The citric salts are optimal for alkalizing the urine but because of their quick half period the alkalizing effect passes quickly and the therefore to keep the pH value in the appropriate neutral range the dosage of the normal alkalizing tablets comprising citric salts could be 4-6 tablets or more a day which is very high.
Using magnesium and sodium salts of citric acid is also optimal because magnesium and sodium are completely eliminating from the human body within 24-48 hours so a danger of a cumulation is excluded.
Therefore the composition according to the subject matter of the invention
According to several in vitro tests, a duration of 12 hours is also possible concerning the alkalizing effect of the tablet.
During this time, the tablet will release the active ingredients sustained and linearly as a controlled-release tablet a determined, nearly constant quantity of the active ingredient was released.
Based on the above concerning of the preparation of the optimal alkalizing agent for oral treatment of the IC/BPS by controlling the pH of the urine the target of the invention can be solved as follows:
Preparing a sustained, controlled release tablet with the above indication the optimal choice was using Benecel hypromellose microcrystalline cellulose (HPMC), advantageously Benecel K100M PH DC HPMC as grade, because polymers or Carbomer matrix systems cannot be used because of the high Mg2+ and Na+ content thereof.
The osmotic pressure generated by the cations namely would have destroyed the texture of the matrix.
The HPMC is much more resistant against the osmotic pressure generated by cations and has a high viscosity which is optimal for a formulation of a sustained, controlled release tablet.
Finding the exact optimal consistence of the controlled release alkalizing tablet was a very important target and the result was found only by careful and detailed investigation of the dissolution of the active ingredient by using HPLC (High Pressure Thin Layer Chromatography) technique.
There were features of two excipients investigated:
During the investigation of the active ingredient release following parameters were used:
Mathematical Analysis of the Drug Release Profiles in HPLC Investigations.
To compare the individual dissolution data of the two mostly varying 3.3 tablet compositions, similarity or difference factors were calculated, as a model independent approach. Dissolution efficacies were also calculated for the average dissolution data (1).
where n is the sampling number, Rj and Tj are the percent dissolved of the reference and the test products at each time point j.
f2=50×log{[1+(1/n)Σj=1nwj|Rj−Tj|2]−0.5×100}
where wj is an optional weight factor.
where y is the drug percent dissolved at time t.
For the determination of release kinetics of active ingredient, release data was fitted to zero-order, first-order and Korsmeyer-Peppas model equations in MS Excel.
where Q is amount of drug release at time t, Q0 is the initial amount of drug, Qt is the amount of drug remaining at time t, and where Qt/Q∞ is fraction of drug released at time t. k0, k1, and kkp are the kinetic constants for zero order, first order, and Korsmeyer-Peppas models, respectively and n is the release exponent, indicative of the drug release mechanism. For Korsmeyer-Peppas model, only release data points were used in the analysis up to 60% drug release (2).
Results of our investigations:
The kinetics of the active ingredient release is represented in
Based on the test results of the dissolution test, we can state that of 28.33% of the API dissolved in 1 hour. Additionally, 54.64% of the API was released in 3 hours. Finally, 80.83% of the API was released to the dissolution media in 6 hours. The result of the dissolution efficacy calculation was 86.40%. When the data of the two mostly varying samples were compared the result of the difference and similarity factor calculations were found to be 4.03 and 64.87, respectively. First order model was to be the best model describing the release of the API from the hydrophilic matrices, R2=0.9651 and in case of Korsmeyer-Peppas model the value was R2=0.9226.
According to the measured rheological values the investigated granulate shows prime flow features and so the granulate is extremely well usable for formulation of a tablet. As it is shown on
The present invention relates to a novel urinary, sustained and/or controlled-release alkalizing tablet for the oral treatment of interstitial cystitis/bladder pain syndrome (IC/BPS) and/or for general alkalization of the human body for long term where according to the subject matter of the invention the composition is potassium free, and comprises citric acid and citric acid salts as active ingredients.
As the active ingredient components are extremely hygroscopic a special formulation process was needed for formulating the alkalizing tablet using also different excipients with moisture relating capability.
Using the alkalizing tablet according to the invention following indications can be treated.
| Number | Date | Country | Kind |
|---|---|---|---|
| P2000144 | Apr 2020 | HU | national |
| Filing Document | Filing Date | Country | Kind |
|---|---|---|---|
| PCT/HU2021/000004 | 4/29/2021 | WO |
