Patent Application
20100016423
The instant invention relates to a use of dronedarone or one of its pharmaceutically acceptable salts for preparing a medicament for the treatment of patients with arrhythmia, wherein said patients have an increase of creatinine level due to dronedarone administration and to a method of managing the risk due to an observation of serum creatinine increase leading to inappropriate management of patients with CHF (Congestive Heart Failure). The instant invention more specifically relates to a method of managing the risk due to an observation of serum creatinine increase in patients treated by dronedarone and by ACE inhibitors or angiotensin II antagonists or potassium sparing diuretics.
RR means relative risk.
2-n-butyl-3-[4-(3-di-n-butylaminopropoxy)benzoyl]-5-methylsulfonamido-benzofuran, or dronedarone, and its pharmaceutically acceptable salts are described in the European patent EP 0 471 609 B1.
Dronedarone is an antiarrhythmic agent effective in the reduction of cardiovascular hospitalization and death in patients with atrial fibrillation or atrial flutter or with a history of atrial fibrillation or atrial flutter. By the oral route, dronedarone is administered at daily doses up to 800 mg, in one or several intakes.
Creatinine is an end-product of muscle metabolism, which is freely filtered at the glomerulus and not metabolized in the kidney. It is secreted by the proximal tubules by both the anionic and the cationic secretory pathways. Usually an increase in creatinine level is considered as a marker of decreased glomerular filtration and as a sign of renal impairment (Journal of Internal medicine, 1999, 246, 247-252).
During clinical trials with dronedarone, it has been observed that administration of this active principle is associated with a slight increase in the serum creatinine levels of the patient. This increase occurred early after treatment initiation (within two days). Creatinine levels remained stable during treatment and returned to baseline within three days after treatment discontinuation.
It has however been demonstrated that such an increase in the creatinine levels is not linked to renal impairment, but is due to decreased secretion of this substance at the kidney tubular level. In fact, in a specific study in healthy subjects, this increase was shown to be related to inhibition of creatinine secretion at the tubular level, with no effect on glomerular filtration or on renal blood flow. Hence dronedarone can not be considered as a nephrotoxic agent. This decrease in the tubular secretion of creatinine is also reported with other drugs such as cimetidine, trimethoprim or even amiodarone (Br. J. Clin. Pharmac., 1993, 36, 125-127).
This effect of dronedarone on the creatinine levels becomes of particular relevance when this agent is co-prescribed to patients receiving another therapy that could interact with kidney function. This is especially the case for the treatment of patients with cardiovascular disease such as patients with heart failure, coronary disease and other cardiovascular risk factors receiving ACE inhibitors and/or angiotensin II receptor antagonists and/or spironolactone or other potassium sparing diuretics. Indeed, such categories of active ingredients are known for their adverse effects on the renal function. In patients treated both by dronedarone and by ACE inhibitors and/or angiotensin II receptor antagonists and/or potassium sparing diuretics, an increase in creatinine levels might be misinterpreted by the physician as a sign of nephrotoxicity of ACE inhibitors or angiotensin II receptor antagonists or potassium sparing diuretics, leading to inappropriate discontinuation of these agents. These treatments have been shown to prevent mortality in patients with heart failure (Pfeffer M A et al., Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. The SAVE Investigators, N. Engl. J. Med. 1992 Sep. 3; 327(10):669-77; Pitt B et al., The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators, N. Engl. J. Med. 1999; 341:709-717; Pitt B et al., Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction., N. Engl. J. Med. 2003; 348:1309-1321) and in patients with coronary disease (Indications for ACE inhibitors in the early treatment of acute myocardial infarction: systematic overview of individual data from 100,000 patients in randomized trials. ACE Inhibitor Myocardial Infarction Collaborative Group. Circulation 1998; 97:2202-2212; Swedberg K et al., Effects of the early administration of enalapril on mortality in patients with acute myocardial infarction. Results of the Cooperative New Scandinavian Enalapril Survival Study II (CONSENSUS II)., N. Engl. J. Med. 1992; 327:678-684; Dickstein K et al., Effects of losartan and captopril on mortality and morbidity in high-risk patients after acute myocardial infarction: the OPTIMAAL randomised trial. Optimal Trial in Myocardial Infarction with Angiotensin II Antagonist Losartan, Lancet 2002; 360:752-760) or to prevent events, including cardiovascular mortality, in patients at cardiovascular risk (Yusuf S et al., Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators, N. Engl. J. Med. 2000 Jan. 20; 342(3):145-53). Inappropriate interruption of the treatment with ACE inhibitors or angiotensin II receptor antagonists or potassium sparing diuretics therefore exposes these patients to an increased cardiovascular morbidity and mortality.
The Applicant has now found a method for managing such a risk. The method according to the invention enables to decrease the risk of an inappropriate interruption of ACE inhibitors, of angiotensin II receptor antagonists treatment or of potassium sparing diuretics, which consequently enables to decrease the risk of morbidity and mortality of the patient.
The instant invention therefore relates to a method of managing the risk of an increased morbidity and mortality rate in patients treated by an association of dronedarone or one of its pharmaceutically acceptable salts and of at least a compound B selected from ACE inhibitors, angiotensin II receptor antagonists and potassium sparing diuretics. Said method is performed by performing the following steps:
The instant invention further relates to a method of managing the risk of an increase in the mortality rate in patients treated by an association of dronedarone or one of its pharmaceutically acceptable salts and of at least a compound B selected from ACE inhibitors, angiotensin II receptor antagonists and potassium sparing diuretics, which method comprises the following steps:
The instant invention further relates to a method of treatment of patients with cardiac arrhythmia comprising the administration of dronedarone or one of its pharmaceutically acceptable salts to patients treated, in addition, by at least a compound B selected from ACE inhibitors, angiotensin II receptor antagonists and potassium sparing diuretics, which method comprises the following steps:
The instant method of treatment can be more specifically directed to the treatment of patients with atrial fibrillation or atrial flutter.
Examples of ACE inhibitors may be captopril, enalapril, perindopril, quinapril, lisinopril, ramipril, etc.
Examples of angiotensin II receptor antagonists may be losartan, valsartan, candesartan, telmisartan, irbesartan, etc.
Examples of potassium sparing diuretics may be spironolactone, eplerenone, etc.
Such compounds are usually prescribed for prevention and treatment of various pathologies of the cardiac function, such as cardiovascular disorders, congestive heart failure, left ventricular dysfunction or hypertension.
As regards to dronedarone, the daily dose by the oral route is up to 800 mg, in one or several intakes.
In specific cases, higher or lower dosages may be appropriate; these dosages are comprised within the scope of the present invention. According to usual practice, the dosage suitable to each patient is determined by the physician according to the administration route, the weight and response of the patient.
The appropriate unitary dosage forms for dronedarone comprise the oral forms, such as tablets, hard or soft gelatin capsules, powders, granules and oral solutions or suspensions, as well as the sublingual, buccal, intratracheal, intraocular, intranasal forms, the forms adapted to inhalation, topical, transdermal, sub-cutaneous, intramuscular or intra-venous delivery, the rectal forms and the implants. For the topical application, dronedarone may be used as creams, gels, ointments or lotions.
Concerning step a) of the methods of the invention, as mentioned before, in most patients with atrial fibrillation or atrial flutter the maximal increase in creatinine levels, compared to the level before administration of dronedarone, was smaller than 30%, with a mean increase ranging from 10 to 15% or more. Then during the treatment with dronedarone, mean creatinine levels remain stable, this corresponds to a plateau.
In step a) of the methods according to the invention, the serum creatinine levels may in particular be measured one week after the start of dronedarone administration to the patient.
By “initially” in step a), one may for instance mean “one week after initiation of treatment with dronedarone”, being understood that a few days less or more are also encompassed within the scope of the step a), so that the reference level for serum creatinine may be measured at 3 to 15 days, more particularly 3 to 11 days, for example, after start of dronedarone administration to the patient.
In step b) of the methods according to the invention, the monitoring of the serum creatinine levels at regular intervals means that the serum creatinine shall be measured over the total duration of the treatment with dronedarone and compound B, based on a schedule depending on the specific pathological state of the patient and on the prescription labelling for the compound B. Such monitoring may for example be performed every 2 months in patients with renal impairment.
Step c) of the methods according to the instant invention targets to identify whether dronedarone or compound B may be the cause of the increase in the creatinine level above the reference level, or if it may be due to another cause, i.e. an outside cause than the active principles administered to the patient. In fact, various pathological states can be responsible for transient or permanent creatinine elevation, for example diabetes or impaired cardiac function, deshydration, hypovolemia, renal impairment, drug toxicity etc. Thus, a deterioration of the pathological state of the patient under the treatment of dronedarone and of compound B may involve serum creatinine elevation.
Step c) may be achieved by temporarily interrupting treatment with dronedarone, while maintaining treatment with compound B. Indeed, compound B should not be primarily interrupted unless there is a specific reason, especially in CHF patients.
The temporary interruption of dronedarone treatment or dronedarone discontinuation may for example range from 1 to 2 weeks. Then the serum creatinine level shall be measured. If it returns to the reference level, then dronedarone treatment shall be reinstated. Indeed, this would mean that the increase in creatinine was due to dronedarone itself, and not related to any other concomitant disease including other drug toxicity.
On the other hand, if the creatinine level does not return to the reference level after the dronedarone treatment interruption, then it would imply that dronedarone is not the cause of the further creatinine increase. In such a case it shall be determined whether the increase is due to compound B, in which case treatment with compound B may be interrupted, or at least closely monitored to avoid renal impairment, or if the increase is due to another cause, as described above, in which case appropriate treatment of such other cause shall be undertaken. Appropriate treatment shall be appreciated by the physician depending on the patient's clinical condition and associated pathologies.
Another subject of the instant invention is the use of dronedarone for preparing a medicament for use in the treatment of arrhythmia, wherein dronedarone or one of its pharmaceutically acceptable salts is used in combination with a compound B selected from ACE inhibitors, angiotensin II receptor antagonists and potassium sparing diuretics and wherein said use involves the following steps:
In an embodiment, the subject of the instant invention is the use of, or an association of dronedarone or one of its pharmaceutically acceptable salts and at least a compound B selected from ACE inhibitors, angiotensin II receptor antagonists and potassium sparing diuretics for preparing a medicament for the treatment of patients with arrhythmia, said patients having an increase of creatinine level due to dronedarone administration, said patients being defined with the following steps:
a) initially measuring serum creatinine levels, which provides a reference level,
b) monitoring serum creatinine levels at regular intervals during treatment of the patient by dronedarone and by the compound B,
c1) if the serum creatinine levels increases above the reference level, temporarily interrupting treatment with dronedarone, while maintaining treatment with compound B,
d1) when the increase is reversible, treatment with said combination is pursued,
e1) repeating steps b), c1) and d1) for the duration of the treatment with said combination.
In an embodiment, the subject of the instant invention is the use of, or an association of dronedarone or one of its pharmaceutically acceptable salts and at least a compound B selected from ACE inhibitors, angiotensin II receptor antagonists and potassium sparing diuretics for preparing a medicament for the treatment of patients with arrhythmia, said patients having an increase of creatinine level due to compound B administration, said patients being defined with the following steps:
a) initially measuring serum creatinine levels, which provides a reference level,
b) monitoring serum creatinine levels at regular intervals during treatment of the patient by dronedarone and by the compound B,
c1) if the serum creatinine levels increases above the reference level, temporarily interrupting treatment with dronedarone, while maintaining treatment with compound B,
d2) when the increase is not reversible, treatment with compound B may be interrupted,
e2) repeating steps b), c1) and d2) for the duration of the treatment with said combination.
In an embodiment, the subject of the instant invention is the use of, or an association of dronedarone or one of its pharmaceutically acceptable salts and at least a compound B selected from ACE inhibitors, angiotensin II receptor antagonists and potassium sparing diuretics for preparing a medicament for the prevention of death of patients with cardiac arrhythmia, said patients having an increase of creatinine level due to dronedarone administration, said patients being defined with the following steps:
a) initially measuring serum creatinine levels, which provides a reference level,
b) monitoring serum creatinine levels at regular intervals during treatment of the patient by dronedarone and by the compound B,
c1) if the serum creatinine levels increases above the reference level, temporarily interrupting treatment with dronedarone, while maintaining treatment with compound B
d1) when the increase is reversible, treatment with said combination is pursued,
e1) repeating steps b), c1) and d1) for the duration of the treatment with said combination.
In an embodiment, the subject of the instant invention is the use of, or an association of dronedarone or one of its pharmaceutically acceptable salts and at least a compound B selected from ACE inhibitors, angiotensin II receptor antagonists and potassium sparing diuretics for preparing a medicament for the prevention of death of patients with cardiac arrhythmia, said patients having an increase of creatinine level due to compound B administration, said patients being defined with the following steps:
a) initially measuring serum creatinine levels, which provides a reference level,
b) monitoring serum creatinine levels at regular intervals during treatment of the patient by dronedarone and by the compound B,
c1) if the serum creatinine levels increases above the reference level, temporarily interrupting treatment with dronedarone, while maintaining treatment with compound B,
d2) when the increase is not reversible, treatment with compound B may be interrupted,
e2) repeating steps b), c1) and d2) for the duration of the treatment with said combination.
In an embodiment, the subject of the instant invention is the use of dronedarone or one of its pharmaceutically acceptable salts for preparing a medicament for the treatment of patients with arrhythmia, said patients having an increase of creatinine level due to dronedarone administration, said creatinine level increasing following dronedarone treatment initiation, said creatinine level increase reaching a plateau and being used as a new baseline, said creatinine level increase being reversible after dronedarone discontinuation.
In an embodiment, the subject of the instant invention is the use of dronedarone or one of its pharmaceutically acceptable salts for preparing a medicament for the treatment of patients with arrhythmia, said patients having an increase of creatinine level due to dronedarone administration, wherein said use involves the following steps:
In an embodiment, the subject of the instant invention is the use of an association of dronedarone or one of its pharmaceutically acceptable salts and compound B as defined above for preparing a medicament for the treatment of patients with arrhythmia, said patients having an increase of creatinine level not due to compound B administration, wherein said use involves the following steps:
In an embodiment, the subject of the instant invention is a method of treatment of patients with arrhythmia comprising
i) initiating administration of dronedarone or a pharmaceutically acceptable salt thereof in said patient;
ii) obtaining a blood sample from the patient following initiation of administration of dronedarone, or a pharmaceutically acceptable salt thereof, to the patient; and
iii) measuring the serum creatinine levels from the blood sample to provide a reference level. In some embodiments, the patient is also being treated with a compound selected from the group consisting of ACE inhibitors, angiotensin II receptor antagonists and potassium sparing diuretics. In some embodiments, the method is for the treatment of patients with atrial fibrillation or atrial flutter. In some embodiments, the serum creatinine level in step iii) is measured within 3 to 15 days, more particularly within 3 to 11 days after initiation of treatment with dronedarone. In some embodiments, the serum creatinine level in step iii) is measured within one week after initiation of treatment with dronedarone.
In an embodiment, the subject of the instant invention is a method of treatment of patients with arrhythmia comprising
i) initiating administration of dronedarone or a pharmaceutically acceptable salt thereof in said patient,
ii) obtaining a blood sample from the patient following initiation of administration to the patient of dronedarone, or a pharmaceutically acceptable salt thereof;
iii) measuring the serum creatinine level from the blood sample to provide a reference level;
iv) discontinuing administration of dronedarone, or a pharmaceutically acceptable salt thereof, temporarily;
v) obtaining a blood sample from the patient following discontinuance of administration of dronedarone or a pharmaceutically acceptable salt thereof to the patient; and
vi) measuring the serum creatinine level in the blood sample from the patient following discontinuance to provide a reference level. In some embodiments, the method is for the treatment of patients with atrial fibrillation or atrial flutter. In some embodiments, the patient is also being treated with a compound selected from the group consisting of ACE inhibitors, angiotensin II receptor antagonists and potassium sparing diuretics. In some embodiments, the serum creatinine level in step iii) is measured within 3 to 15 days, more particularly within 3 to 11 days after initiation of treatment with dronedarone. In some embodiments, the serum creatinine level in step iii) is measured within one week after initiation of treatment with dronedarone.
In an embodiment, the subject of the instant invention is a method of treatment of patients with arrhythmia, wherein dronedarone or one of its pharmaceutically acceptable salts is used in combination with at least a compound B selected from ACE inhibitors, angiotensin II receptor antagonists and potassium sparing diuretics, said method comprising
i) initiating administration of dronedarone, or a pharmaceutically acceptable salt thereof, in said patient;
ii) obtaining a blood sample from the patient following initiation of dronedarone, or a pharmaceutically acceptable salt thereof, administration to the patient,
iii) measuring the serum creatinine level in the blood sample to provide a reference level,
iv) obtaining a blood sample from the patient and measuring serum creatinine level during treatment of the patient by dronedarone, or a pharmaceutically acceptable salt thereof, and by the compound B,
v) determining the cause of an increase serum creatinine level above the reference level,
vi) continuing treatment of dronedarone and compound B when the increase is due to treatment with dronedarone or pharmaceutically acceptable salt thereof; or interrupting treatment with compound B when the increase is caused by treatment with compound B; or undertaking appropriate treatment when the increase is due to a cause other than administration of dronedarone or of compound B, and
vii) repeating steps iv) to vi) at regular intervals for the duration of the treatment with dronedarone and compound B. In some embodiments, the method is for the treatment of patients with atrial fibrillation or atrial flutter. In some embodiments, the serum creatinine level in step iii) is measured within 3 to 15 days, more particularly within 3 to 11 days after initiation of treatment with dronedarone. In some embodiments, the serum creatinine level in step iii) is measured within one week after initiation of treatment with dronedarone, or a pharmaceutically acceptable salt thereof.
In an embodiment, the subject of the instant invention is a method of providing dronedarone, or a pharmaceutically acceptable salt thereof, wherein said dronedarone or pharmaceutically acceptable salt thereof is provided along with information indicating that serum creatinine levels increase following treatment initiation of dronedarone, or a pharmaceutically acceptable salt thereof. In some embodiments the information comprises printed matter that indicates that serum creatinine levels increase following treatment initiation of dronedarone, or a pharmaceutically acceptable salt thereof. In some embodiments, the information comprises written material recommending that if an increase in creatininemia is observed, this value should be used as the new baseline. In some embodiments, the printed matter is a label.
The term “providing” includes selling, distributing, shipping, offering for sell, importing etc.
In an embodiment, the subject of the instant invention is a method of promoting the use of dronedarone or a pharmaceutically acceptable salt thereof, the method comprising the step of conveying to a recipient at least one message selected from the group consisting of:
(1) measure plasma creatinine values within 7 days after treatment initiation of dronedarone or a pharmaceutically acceptable salt thereof;
(2) if an increase in creatininemia is observed, this value should be used as the new baseline;
(3) serum creatinine level increase following treatment initiation of dronedarone or a pharmaceutically acceptable salt thereof;
(4) dronedarone, or a pharmaceutically acceptable salt thereof, causes an increase in serum creatinine;
(5) the elevation of serum creatinine level reaches a plateau; and
(6) an increase in serum creatinine level is reversible after discontinuation of dronedarone or pharmaceutically acceptable salt thereof.
In an embodiment, the subject of the instant invention is an article of manufacture comprising
a) a packaging material;
b) dronedarone or a pharmaceutically acceptable salt thereof; and
c) a label or package insert contained within the packaging material indicating that serum creatinine level may change following treatment initiation of dronedarone, or a pharmaceutically acceptable salt thereof.
In an embodiment, the subject of the instant invention is a package comprising dronedarone or a pharmaceutically acceptable salt thereof and a label, said label comprising a printed statement which informs a prospective user that an increase in serum creatinine has been observed following initiation of treatment with dronedarone or a pharmaceutically acceptable salt thereof.
In an embodiment, the subject of the instant invention is a package comprising dronedarone or a pharmaceutically acceptable salt thereof and a label, said label comprising a printed statement which recommends that if an increase in creatininemia is observed following treatment initiation of dronedarone, or a pharmaceutically acceptable salt thereof, the increased value should be used as a baseline.
In an embodiment, the subject of the instant invention is a method of transforming a patient treated by an association of dronedarone and at least one compound B selected from ACE inhibitors, angiotensin II receptor antagonists and potassium sparing diuretics by managing the risk of an increase in the mortality rate in said patient which method comprises
The instant invention is illustrated by the clinical data below.
As a preliminary comment, it has been observed and later demonstrated in a clinical trial in 627 patients with a recent severe episode of Congestive Heart failure (ANDROMEDA) that among all prognostic factors, the most important risk factor for death in patients receiving the dronedarone concomitantly, was the absence of treatment with ACE inhibitors or angiotensin II receptor antagonists (table 1).
Despite the equal distribution of treatment with ACE inhibitors/AII receptor antagonists at baseline, concomitant treatment with these drugs became unbalanced during the course of the ANDROMEDA study, as more patients in the dronedarone 400 mg BID group discontinued these treatments and fewer started them (table 2).
Among patients who interrupted, or did not start treatment with ACE inhibitors/AII receptor antagonists (hereinafter “ACE/AII”), more patients in the dronedarone 400 mg BID group died, as opposed to patients who never interrupted ACE inhibitors/AII receptor antagonists (3.6% and 4%, respectively in placebo and dronedarone 400 mg BID groups) as shown in table 3.
Table 4 shows how an increase in creatinine level induces the physicians to interrupt the treatment with ACE/AII.
In the dronedarone 400 mg BID group, 14 of 41 patients who discontinued ACE/AII experienced “blood creatinine increased” or “renal impairment” adverse events, versus none among the 18 patients taking placebo in this category. This observation supports the hypothesis that an increase in serum creatinine observed in patients taking dronedarone may have led investigators to discontinue ACE/AII treatment (table 4).
In the ATHENA trial, the above mentioned instructions to appropriately handle plasma creatinine increase and ACE inhibitors/AII receptor antagonists have been shown to be effective for the prevention of cardiovascular mortality and cardiovascular morbidity (hospitalizations for cardiovascular reasons), including in patients with different status of renal function, i.e. different values of creatinine clearance at baseline (chart 1 (
ACE/AII have been largely used in ATHENA clinical study and at the same rate in the dronedarone group and in the placebo group. More than 75% of the patients had received one of these compounds during the study. Table 5 shows the numbers and percentages of patients using various medications at the inclusion in the study, whereas table 6 shows the numbers and percentages of patients who received concomitant medications during the study. Diuretics with potassium sparing properties, and among them spirolonolactone, have also been prescribed in the ATHENA trial.
| Number | Date | Country | Kind |
|---|---|---|---|
| 08290407.9 | Apr 2008 | EP | regional |
| Number | Date | Country | |
|---|---|---|---|
| 61048732 | Apr 2008 | US |
