I lllll llllllll Ill lllll lllll lllll lllll lllll 111111111111111111111111111111111
`US009060992B2
`
`c12) United States Patent
`Sanguinetti et al.
`
`(IO) Patent No.:
`(45) Date of Patent:
`
`US 9,060,992 B2
`*Jun. 23, 2015
`
`(54) TREATMENT OF SHORT BOWEL
`SYNDROME PATIENTS WITH
`COLON-IN-CONTINUITY
`
`(75)
`
`Inventors: Elizabeth Lemaire Sanguinetti, Salt
`Lake City, UT (US); Thomas B.
`Marriott, Sandy, UT (US); Jennifer
`Lopansri, Salt Lake City, UT (US);
`Consuelo Maria Blosch, Mercer Island,
`WA (US)
`
`(73) Assignee: NPS Pharmaceuticals, Inc.,
`Bedminster, NJ (US)
`
`( *) Notice:
`
`Subject to any disclaimer, the term ofthis
`patent is extended or adjusted under 35
`U.S.C. 154(b) by 1032 days.
`
`This patent is subject to a terminal dis(cid:173)
`claimer.
`
`(21) Appl. No.: 12/938,117
`
`(22) Filed:
`
`Nov. 2, 2010
`
`(65)
`
`Prior Publication Data
`
`US 2011/0172152Al
`
`Jul. 14, 2011
`
`Related U.S. Application Data
`
`(62) Division of application No. 11/262,980, filed on Nov.
`1, 2005, now Pat. No. 7,847,061.
`
`(60) Provisional application No. 60/623,233, filed on Nov.
`1, 2004.
`
`(51)
`
`(52)
`
`(58)
`
`(2006.01)
`(2006.01)
`(2006.01)
`
`Int. Cl.
`A61K 35138
`C07K 141575
`A61K 38126
`U.S. Cl.
`CPC ...................................... A61K 38126 (2013.01)
`Field of Classification Search
`None
`See application file for complete search history.
`
`(56)
`
`References Cited
`
`U.S. PATENT DOCUMENTS
`
`5,789,379 A
`6,077,949 A
`6,184,201 Bl*
`7,411,039 B2
`7,847,061 B2 *
`
`8/ 1998 Drucker et al.
`612000 Munrose et al.
`212001 Drucker et al.
`8/2008 Thim et al.
`12/2010 Sanguinetti et al.
`
`514/11.7
`
`530/308
`
`OTHER PUBLICATIONS
`Jeppesen, et al., JPEN, 1999, 23, Sl01-Sl05.*
`Jeppesen, et al., J. Nutr., 2003, 133, 3721-3724.*
`Buchman, 2004, MedGenMed, 6(2), 10 pages.*
`Sigalet, 2001, Current Opinion in Investigational Drugs, 2(4), 505-
`509.*
`Burrin, Domestic Animal Endocrinology 24 (2003) 103-122.*
`Retrieved from website:
`'http://www.yourdictionary.com/negli(cid:173)
`gible' 1 page, retrieved on Jun. 9, 2014.*
`Ferrone, et al., "Teduglutide for the treatment of short bowel syn(cid:173)
`drome", The Annals ofPharmacotherapy, 2006, vol. 40, No. 6, 1105-
`1109.
`International Preliminary Report on Patentability and Written Opin(cid:173)
`ion issued in International Application No. PCT/US2005/039222
`dated May 1, 2007.
`International Search Report issued in International Application No.
`PCT/US2005/039222 dated Jul. 17, 2006.
`Jeejeebhoy, "Short bowel syndrome: a nutritional and medical
`approach", CMAJ, 2002, 166(10) 1297-1302.
`Jeppesen, et al., "Impaired meal stimulated glucagon-like peptide 2
`response in Heal resected short bowel patients with intestinal failure",
`Gut, 45:559-563, 1999.
`Jeppesen, et al., "Elavated plasma glucagon-like peptide 1 and 2
`concentrations in Ileum resected short bowel patients with a pre(cid:173)
`served colon", Gut, 47:370-376, 2000.
`Jeppesen, et al., "Glucagon-like peptide 2 improves nutrient absorp(cid:173)
`tion and nutritional status in short bowel-patients with no colon",
`Gastroenterology, vol. 120, No. 4, 2001, 806-815.
`Jeppesen, et al., "ALX-600, a dipeptidyl peptidase-IV resistant
`glucagon-like peptide-2 (GLP-2) analog, improves intestinal func(cid:173)
`tion in short bowel syndrome (SBS) patients with a jejunostomy",
`Database Bio sis (Online) Biosciences Information Service, Philadel(cid:173)
`phia, PA, Apr. 2002, Database accession No. PREV200200518922.
`Jeppesen, et al., "Teduglutide (ALX-0600), adipeptidylpeptidaseIV
`resistant glucagon-like peptide 2 analogue, improves intestinal func(cid:173)
`tion in short bowel syndrome patients", Gut, vol. 54, No. 9, 2005,
`1224-1231.
`Office Action issued in U.S. Appl. No. 111262,980 dated Nov. 1,
`2006.
`Office Action issued in U.S. Appl. No. 111262,980 dated May 15,
`2007.
`Office Action (final) issued in U.S. Appl. No. 111262,980 dated Feb.
`4, 2008.
`Office Action issued in U.S. Appl. No. 111262,980 dated Oct. 29,
`2008.
`Office Action issued in U.S. Appl. No. 111262,980 dated Aug. 4,
`2009.
`Request for Continued Examination filed in U.S. Appl. No.
`111262,980 filed Aug. 4, 2008.
`Response to Office Action filed in U.S. Appl. No. 111262,980 filed
`Mar. 1, 2007.
`Response to Office Action filed in U.S. Appl. No. 111262,980 filed
`Nov. 15, 2007.
`Response to Office Action filed in U.S. Appl. No. 111262,980 filed
`Apr. 29, 2009.
`Response to Office Action filed in U.S. Appl. No. 111262,980 filed
`Jan. 4, 2010.
`
`(Continued)
`
`FOREIGN PATENT DOCUMENTS
`
`Primary Examiner - Satyanarayana R Gudibande
`(74) Attorney, Agent, or Firm - Stoel Rives LLP
`
`EP
`WO
`WO
`WO
`WO
`WO
`WO
`WO
`
`1231219
`WO 9639031
`WO 9739091
`WO 9943361
`WO 0149314
`WO 02066511
`WO 2004035624
`WO 2004085471
`
`8/2002
`12/1996
`10/1997
`9/1999
`7/2001
`8/2002
`412004
`10/2004
`
`ABSTRACT
`(57)
`Intestinal absorption is enhanced in short bowel syndrome
`patients presenting with colon-in-continuity by treatment
`with a GLP-2 receptor agonist, such as teduglutide.
`
`26 Claims, 2 Drawing Sheets
`
`CFAD Exhibit 1078
`CFAD v. NSP
`IPR2015-01093
`
`1
`
`

`
`US 9,060,992 B2
`Page 2
`
`(56)
`
`References Cited
`OTHER PUBLICATIONS
`Response to Restriction Requirement filed in U.S. Appl. No.
`111262,980 filed Oct. 11, 2006.
`Restriction Requirement issued in U.S. Appl. No. 111262,980 issued
`Sep. 11, 2006.
`Scott, et al., "GLP-2 Augments the adaptive response to massive
`intestinal resection in rat", Am. J. Physiol. (Gastrointestinal Liver
`Physiology 38): G91 l-G921, 1988.
`
`Yang, et al., "Novel Agents in the treatment of intestinal failure:
`humoral factors", Gastroenterology, vol. 130, No. 2, 2006, Sl l 7-
`Sl21.
`Teduglutide, (online), NPS Pharmaceuticals, Oct. 3, 2003, accessed
`May 16, 2011, http://replay.web.archive.org/2003 l 003111216/
`http://www.npsp.com/drug_development/dd_alx0600.php.
`
`* cited by examiner
`
`2
`
`

`
`U.S. Patent
`
`Jun.23,2015
`
`Sheet 1of2
`
`US 9,060,992 B2
`
`Figure 1.
`
`Fecal
`output
`
`Intestinal
`Absorption
`
`0.6 1.3*** 0.3
`
`Urine
`output
`
`6
`
`2.8 2.1 ** 3.1
`
`1.4 2.0*** 1.4
`
`5
`
`4
`
`3
`
`2 -~ cu
`.:.:: --
`
`3:! 1
`C>
`
`"§,0.---------------_.,..~ ...... ---------------
`·-
`~
`Q;-1
`~
`
`-2
`
`-3
`
`B
`A
`s
`E
`L
`I
`N
`E
`
`F
`T
`R
`0
`E
`L
`A
`L
`T
`0
`M w
`E
`N
`T
`
`B
`A
`s
`E
`L
`I
`N
`
`T
`R
`E
`A
`T
`M
`E
`
`F
`0
`L
`L
`0
`w
`
`B
`A
`s
`E
`L
`I
`N
`
`T
`F
`0
`R
`E
`L
`A
`L
`T
`0
`M w
`E
`
`3
`
`

`
`U.S. Patent
`
`Jun.23,2015
`
`Sheet 2of2
`
`US 9,060,992 B2
`
`Figure 2.
`
`16
`
`14
`
`12
`
`10
`
`4
`
`2
`
`0
`
`Fecal
`output
`5.5 4.6· 5.7
`
`Intestinal
`Absorption
`6.2 7.0 5.9
`
`F
`0
`L
`L
`0
`w
`
`B
`A
`s
`E
`L
`I
`N
`E
`
`T
`R
`E
`A
`T
`M
`E
`N
`T
`
`8
`A
`s
`E
`L
`I
`N
`
`T
`R
`E
`A
`T
`M
`E
`
`F
`0
`L
`L
`0 w
`
`4
`
`

`
`1
`TREATMENT OF SHORT BOWEL
`SYNDROME PATIENTS WITH
`COLON-IN-CONTINUITY
`
`FIELD OF THE INVENTION
`
`US 9,060,992 B2
`
`2
`benefit of pharmacologic doses ofGLP-2 receptor agonists in
`these patients is not obvious and has not been studied.
`
`SUMMARY OF THE INVENTION
`
`This invention relates to products and methods useful
`medically to treat patients presenting with short bowel syn(cid:173)
`drome. More particularly, the invention relates to glucagon(cid:173)
`like peptide 2 (GLP-2) and other GLP-2 receptor agonists 10
`effective to improve intestinal function particularly in
`patients presenting with short bowel syndrome with colon(cid:173)
`in-continuity.
`
`BACKGROUND TO THE INVENTION
`
`It has now been determined that intestinal absorption is
`enhanced in SBS patients presenting with colon-in-continu(cid:173)
`ity when those patients are treated with a GLP-2 receptor
`agonist.
`Thus, in one aspect, the present invention provides a
`method for enhancing intestinal absorption in a patient with
`short bowel syndrome, comprising the steps of selecting
`for
`treatment a short, bowel syndrome patient presenting with at
`15 least about 25% colon in continuity with renmant small intes(cid:173)
`tine, and treating said patient with a GLP-2
`receptor
`agonist to enhance intestinal absorption by said patient.
`In a related aspect, the present invention provides for the
`20 use ofa GLP-2 receptor agonist in the preparation ofa medi(cid:173)
`cament for enhancing intestinal absorption in short bowel
`syndrome patients presenting with at least about 25% colon in
`continuity with renmant small intestine.
`In a preferred embodiment, the GLP-2 receptor agonist is
`25 [Gly2]hGLP-2, known as teduglutide.
`
`The estimated prevalence of short bowel syndrome (SBS)
`patients with non-malignant disease
`requiring home
`parenteral nutrition (HPN) is at least 40 per million of the U.S.
`population. SBS usually results from surgical resection of
`some or most of the small intestine for conditions such as
`Crohn's disease, mesenteric infarction, volvulus, trauma,
`congenital anomalies, and multiple strictures due to adhe(cid:173)
`sions or radiation. Surgical resection may also include resec(cid:173)
`tion of all or part of the colon. SBS patients suffer from
`malabsorption that may lead to malnutrition, dehydration and
`weight loss. Some patients can maintain their protein and
`energy balance through hyperphagia; more rarely they can
`sustain fluid and electrolyte requirements to become indepen(cid:173)
`dent from parenteral fluid.
`Although long-term parenteral nutrition (PN) is life saving
`in patients with intestinal failure, it is expensive, impairs
`quality of life and is associated with serious complications
`such as catheter sepsis, venous occlusions and liver failure.
`Treatments that amplify absolute intestinal absorption, and
`eliminate or minimize the need for PN have great potential
`significance to SBS patients.
`The endogenous meal-stimulated hormone, glucagon-like 40
`peptide-2 (GLP-2), raises considerable interest for SBS
`patients. GLP-2 functions to slow gastric emptying, reduce
`gastric secretions, increase intestinal blood-flow and stimu(cid:173)
`late growth of the small and large intestine. In animal studies,
`GLP-2 administration induces mucosa! epithelial prolifera- 45
`tion in the stomach and small and large intestine by stimula(cid:173)
`tion of crypt cell proliferation and inhibition of enterocyte
`apoptosis.
`SBS patients with end-jejunostomy and no colon have low
`basal GLP-2 levels andlimitedmeal-stimulated GLP-2 secre- 50
`tion due to removal of GLP-2 secreting L-cells, which are
`located primarily in the terminal ileum and colon. This GLP-2
`deficiency results in a minimal adaptive response following
`resection and could explain the gastric hypersecretion, rapid
`intestinal transit and lack of intestinal adaptation observed in 55
`these SBS patients.
`Jeppesen et al. (Gastroenterology 2001; 120:806-815)
`have described positive benefit in an open-label study using
`pharmacologic doses of native GLP-2 in SBS jejunostomy
`patients. There was significant improvement in intestinal wet
`weight absorption and a more modest improvement in energy
`absorption that led to an increase in body weight, lean body
`mass and a rise in urinary creatinine excretion.
`In contrast, SBS patients with colon-in-continuity have
`elevated basal endogenous GLP-2 levels resulting in an adap(cid:173)
`tive response to resection characterized by improved wet
`weight gain and energy absorption. The potential for added
`
`BRIEF REFERENCE TO THE DRAWINGS
`
`Embodiments of the invention are now described with
`30 reference to the accompanying drawings in which:
`FIG. 1 illustrates results measured in terms of fecal wet
`weight, intestinal wet weight absorption and urine weight in
`the individual patients at Baseline (Days-3 to 0), during
`treatment (Days 18 to 21), and at follow-up (Days 39 to 42).
`FIG. 2 illustrates results measured in terms of fecal energy
`excretion and intestinal absorption in the individual patients
`at Baseline (Days-3 to 0), during treatment (Days 18 to 21 ),
`and at follow-up (Days 39 to 42).
`
`35
`
`DETAILED DESCRIPTION
`
`The positive effect ofGLP-2 receptor agonists on intestinal
`absorption in SBS patients that retain at least some, e.g.,
`>25%, of their colon is particularly surprising. These patients
`have essentially retained GLP-2 producing tissue and,
`indeed, show elevated basal levels of the endogenous GLP-2
`that can be as high as meal stimulated levels in normal,
`healthy individuals and that, in normal individual, is respon(cid:173)
`sible for maintenance of the intestinal lining required for
`intestinal absorption. There is nevertheless significant clini(cid:173)
`cal benefit for these patients, manifest principally as
`enhanced intestinal absorption as indicated by increased
`absolute wet weight absorption, when they are treated in
`accordance with the present method.
`More particularly, patient candidates for the present treat-
`ment are those presenting with SBS resulting from small
`intestine resection which may be secondary to Crohn's dis(cid:173)
`ease, vascular ischemic disease, malrotation or volvulus,
`trauma, congenital anomalies, or multiple strictures due to
`60 adhesions or radiation and who require parenteral nutrition to
`meet their needs. As patients presenting with short bowel
`syndrome, such patients typically retain, following resection,
`a length of small intestine that is within the range from at least
`about 25 cm and at most about 200 cm., e.g., from about
`65 50-150 cm. Such SBS patients include those patients present(cid:173)
`ing withjejunostomy, in which part of the jejunum is resected
`and generally all of the ileum, and/or ileostomy in which part
`
`5
`
`

`
`US 9,060,992 B2
`
`3
`of the ileum is resected and the jejunum may or may not be
`present. SBS patients with jejunostomy or ileostomy gener(cid:173)
`ally do not have any remaining colon, but if they do, it is not
`in continuity with the remnant small intestine.
`SBS patients selected for treatment by the present method
`are those who retain, in continuity with remnant small intes(cid:173)
`tine, at least some length of their colon, such as at least about
`25%, and desirably 30%, 35%, 40%, 45% and preferably at
`least 50%, 60%, 70%, 80%, 90% or more. The remaining
`length of colon typically will be determined from the surgical 10
`records of a patient candidate. Expressed in other terms,
`preferred candidates for the present treatment are short bowel
`syndrome patients who retain colon sufficient to produce
`endogenous GLP-2 at levels that are at least greater than the
`negligible levels produced by patients with no colon, and 15
`ideally are similar to those GLP-2 levels produced by healthy
`volunteers. Endogenous GLP-2 levels for normal, healthy
`individuals are 15±2 pmol/L fasted, and 61±19 pmol/L fed.
`Candidates for the present treatment thus are SBS patients
`that retain sufficient functional colon to produce at least about 20
`10%, 20%, 30%, 40%, 50% or more of such levels in the fed
`state, e.g., at least about 5 pmol/L fed, and desirably 10, 15,
`20, 25, 30, 35, 40, 45, 50, 55, 60, 65 and 70 pmol/L endog(cid:173)
`enous GLP-2 in the fed state.
`In a preferred embodiment, treatment candidates are those
`short bowel syndrome patients who retain at least 50% or
`more of colon length in continuity with remnant small intes(cid:173)
`tine. Such a treatment candidate is identified herein as a
`patient with ;;:50% colon-in-continuity. In other preferred
`embodiments, the SBS patient with colon in continuity has a
`remnant small intestine at least about 50 cm in length which,
`desirably but not essentially, incorporates at least a portion of
`the ileum.
`The patients can be selected for treatment by the present
`method at any time following the surgical resection. That is,
`patients that are undergoing adaptation, as well as those who
`have had sufficient time to adapt following the surgery, are
`acceptable treatment candidates.
`Treatment of short bowel syndrome patients presenting
`with colon-in-continuity, in accordance with the present
`method, is effective to enhance intestinal absorption, particu(cid:173)
`larly of fluid including water and salts, but including nutrients
`as well. This effect is revealed particularly as a treatment(cid:173)
`mediated, statistically significant increase in absolute wet
`weight absorption, which is determined by subtracting fecal
`wet weight from diet wet weight using a vigorous nutrient
`absorption test. The effect of treatment is also generally seen
`as a reduction in fecal wet weight, an increase in urine wet
`weight, a reduction in energy excretion (measured as herein
`described), and in other respects noted in the examples herein.
`The present treatment method entails dosing the selected
`patient with a GLP-2 receptor agonist using a treatment regi(cid:173)
`men effective to enhance intestinal absorption. Such GLP-2
`receptor agonists are characterized as molecules that bind
`with, preferably selectively, and stimulate the human GLP-2
`receptor, as reported by Monroe et al. in U.S. Pat. No. 6,077,
`949 issued Jun. 20, 2000, incorporated herein by reference.
`Briefly, GLP-2 receptor agonists are revealed as agents that
`trigger production of, or trigger an elevation in the level of, a
`second messenger coupled to the human GLP-2 receptor,
`when exposed to a host cell that produces that receptor natu(cid:173)
`rally or is transfected with DNA encoding that receptor.
`In one embodiment of the invention, the GLP-2 receptor
`agonist is human GLP-2. In other embodiments, the GLP-2
`receptor agonist is a vertebrate, e.g., manmialian, homo log of
`human GLP-2. Thus, GLP-2 receptor agonists useful in
`embodiments of the present invention include GLP-2 having
`
`4
`the sequence found in GLP-2 endogenous to human, cow, pig,
`primate, sheep, rodents including mouse, rat, degu and the
`like, and other vertebrate species.
`In other embodiments, the GLP-2 receptor agonist is an
`analog ofhuman GLP-2, which incorporates at least one, and
`usually not more than 5, e.g., 1, 2 or 3, amino acid substitu(cid:173)
`tions or additions, and may also have a C-terminal truncation
`of from 1 to 5 or more amino acids.
`In a preferred embodiment, the GLP-2 receptor agonist is a
`GLP-2 peptide analog that is altered to prolong serum half(cid:173)
`life. In a particularly preferred embodiment, the GLP-2 pep(cid:173)
`tide incorporates an amino acid substitution that renders the
`peptide resistant to the endogenous enzyme dipeptidyl pep-
`tidase IV (DPP-IV). Such analogs incorporate an appropriate
`substitution of the Ala2 residue desirably, but not essentially,
`by a genetically encoded amino acid, to permit recombinant
`production of the desired protein. Amino acids that can use(cid:173)
`fully substitute at Ala2 to provide GLP-2 analogs that retain
`GLP-2 receptor agonist activity and are less susceptible to
`DPP-IV include GLy, D-Ala, Val, Glu, Lys, Arg, Leu and Ile.
`Still other GLP-2 analogs include those substituted at MetlO
`by an amino acid that is less sensitive to oxidation.
`In alternative embodiments, the GLP-2 peptide, or GLP-2
`25 peptide analog is derivatized, for instance at an internal or
`substituted lysine, to prolong serum half-life by conjugation
`with lipophilic groups, with polyethylene glycol groups, with
`albumin or with any other functional group having the desired
`effect of reducing the rate at which the peptide is degraded
`30 endogenously following its administration. Such derivatized
`forms may be derivatized analogs of GLP-2, which carry
`substitutions, such as conserved or non-conserved lysine sub(cid:173)
`stitutions, having no appreciable negative effect on GLP-2
`receptor activation but allowing for conjugation of the desired
`35 functional group. It will be appreciated that these derivatized
`forms of GLP-2 or of GLP-2 analogs are considered to be
`GLP-2 receptor agonists if they exert their endogenous effect
`through the GLP-2 receptor after administration, even if this
`GLP-2 receptor agonist property is not displayed while in the
`40 pro-drug, pre-administration form.
`A wide variety of useful active GLP-2 analogs and deriva(cid:173)
`tives have been described in the literature, as revealed in U.S.
`Pat. No. 5,789,379 issued Jun. 20, 2000 and related W097/
`39031 published Oct. 23, 1997 which teach site-specific
`45 GLP-2 analogs; in W002/066511 published Aug. 27, 2003
`which teaches albumin-derivatized forms of GLP-2 and ana(cid:173)
`logs, and in W099/43361 published Oct. 14, 1999, W004/
`035624 published Apr. 29, 2004 and W004/085471 pub(cid:173)
`lished Oct. 7, 2004 which describe lipophilic-derivatized
`50 forms ofGLP-2 and analogs.
`In a particularly preferred embodiment of the present
`invention, the GLP-2 receptor agonist is [Gly2]hGLP-2,
`known as teduglutide.
`The dosing regimen effective to treat the SBS patients with
`55 colon-in-continuity entails delivering the selected GLP-2
`receptor agonist to the patient for a time and at a dose suffi(cid:173)
`cient to enhance intestinal absorption. As noted in the
`examples herein, and according to a preferred embodiment of
`the present invention, one suitable treatment regimen entails
`60 once daily administration of teduglutide, by subcutaneous
`injection in the abdomen, thigh or arm, at a dose in the range
`from 30 to 150 ug/kg/day for a period of about 21 days. It is
`anticipated that effective daily doses ofteduglutide, as well as
`human GLP-2 per se and other GLP-2 receptor agonist with
`65 comparable properties, will lie generally in the broader range
`from about 5 to 500 ug/kg/day e.g., from 10 to 400 ug/kg/day,
`such as 20 to 300 ug/kg/day.
`
`6
`
`

`
`US 9,060,992 B2
`
`5
`It will be appreciated from these results that a similarly
`beneficial effect can be expected when using either tedug(cid:173)
`lutide, or when using a related GLP-2 receptor agonist, in an
`alternative dosing schedule. With respect to teduglutide per
`se, administration twice daily or still more frequently can be
`beneficial. Twice daily (every 12 hours) dosing usefully deliv-
`ers about 5 to 250 ug/kg/dose. Benefits can also accrue to
`schedules that entail shorter or, more desirably, longer term
`dosing, such as from about 14 days to many months or even
`years. Maintenance dosing also is desirable, in which patients
`receive either continued or follow up dosing. Follow-up dos(cid:173)
`ing usefully occurs at regular frequencies such as weekly,
`biweekly, every month, every three months, etc. Continued
`dosing usefully provides to the patient a dose efficient to
`maintain the benefits of increased absorptive surface area
`with increased intestinal absorption that arise from initial
`treatment, and can be effected by dosing the patient at least
`once within every 1-28 days, e.g., every other day, 2-3 times
`per week, once per week, etc. Continued or follow-up dosing
`can be important to preserve the medical benefits mediated by 20
`the GLP-2 receptor agonist; as noted in the examples,
`improvements in intestinal absorption following treatment
`with teduglutide for instance, can be lost rapidly, for example
`within four weeks following cessation of dosing.
`The teduglutide dosing regimen herein described is useful 25
`to determine effective dosing schedules for other GLP-2
`receptor agonists for which pharmacokinetics properties are
`either already known or can be determined, by relating phar(cid:173)
`macologic, pharmacokinetic and pharmacodynamic proper(cid:173)
`ties, in accordance with standard practise in drug develop- 30
`ment.
`It will be appreciated that the route of administration, and
`the particular dosage form of the GLP-2 receptor agonist, will
`be chosen to preserve and desirably optimize the effect of the
`drug. Administration by injection, such as subcutaneous,
`intramuscular, intravenous, etc., is suitable. Alternatively, the
`drug may be administered by infusion or by any other route
`that delivers the drug to the target site on the serosal side of the
`intestinal tissue, such as by depot injection. If delivered by
`injection, the drug can be formulated as a lyophilized powder
`for reconstitution by the user, and as either unit or multiple
`doses. One formulation of teduglutide, for instance, is
`described in WOOl/49314 published Jul. 12, 2001, and pro(cid:173)
`vides a powder for reconstitution in which teduglutide is
`present with L-histidine, mannitol and sodium phosphate.
`This is usefully provided as a 3 mL glass vial containing 10
`mg teduglutide, for reconstitution with 1 mL water for injec(cid:173)
`tion and self-administration. An alternative formulation pro(cid:173)
`vides 10 mg of teduglutide in a smaller volume of aqueous
`vehicle, such as 0.5 mL water for injection.
`Most suitably, the chosen treatment parameters, including
`choice of GLP-2 receptor agonist, and dosing schedule, are
`selected to provide optimal enhancement of intestinal absorp(cid:173)
`tion, e.g. to provide for an increase in the volume of fluid and
`the nutrients absorbed by the patient, which is revealed for
`instance as a decrease of at least about 5%, 10%, 15%, 20% or
`more in fecal wet weight, and/or an increase of at least about
`5%, 10% or more in urine weight.
`Embodiments of the invention are exemplified below:
`Patients
`Study subjects were recruited from centers in the U.S. and
`Denmark that care for patients receiving PN. All patients had
`undergone extensive resection of the small intestine without
`any surgical resection of the stomach, duodenum or pancreas.
`Study inclusion criteria were: Over 18 years of age; diag(cid:173)
`nosis of SBS that could be secondary to Crohn's disease,
`volvulus, injury or vascular ischemia, remnant small intestine
`
`6
`of 150 cm or less; no clinical evidence of active inflammatory
`bowel disease (IBD) or fistulas; no history ofradiation enteri(cid:173)
`tis, or sprue; no alcohol or drug abuse; no significant renal,
`hepatic or cardiac diseases; no glutamine for at least four
`weeks prior to screening; no growth factors or participation in
`any clinical trial within three months of screening (except use
`of teduglutide in patients in the rechallenge group). SBS
`patients with ;;:50% colon-in-continuity had a demonstrated
`fecal weight exceeding 1 kg/day and fecal energy loss
`10 exceeding 2 MJ/day [478 Kcal/day].
`Women of childbearing age had to have a negative blood
`~-human chorionic gonadotropin test before inclusion in the
`study and used effective contraceptives during the study.
`Usual medications such as proton pump inhibitors, codeine,
`15 loperamide, and oral and parenteral supplements were kept
`constant. Local Ethics Committees or Institutional Review
`Boards approved the protocol. Procedures were in accor(cid:173)
`dance with ethical standards of the Helsinki Declaration of
`1964 as modified by the 48'h World Medical Association in
`1996. Each eligible patient signed an informed consent form
`prior to study.
`Study Protocol
`This was an open-label, pilot study to determine the safety
`and effect of teduglutide in patients with short bowel syn(cid:173)
`drome (SBS). The patient's history was reviewed and a physi(cid:173)
`cal examination performed to determine eligibility before
`inclusion in the study. Estimated residual small intestine and
`colon lengths were determined by reviewing operative
`reports and available radiographic studies. Eligible patients
`were admitted as inpatients to hospital wards or General
`Clinic Research Centers (GCRC) on three separate occa-
`sions, 18 days apart, for the last four days and three nights of
`the baseline period and at the end of the treatment and follow(cid:173)
`up periods. Treatment consisted of recombinant teduglutide
`35 (supplied by NPS Allelix, Mississauga, ON, Canada) formu(cid:173)
`lated as a lyophilized powder with L-histidine, mannitol, and
`monobasic and dibasic sodium phosphate (Lot 8502901).
`Water was added to reconstitute the drug for administration
`by subcutaneous ( s.c.) injections in the abdomen or thigh. Ten
`40 SBS patients withjejunostomy received 0.03 mg/kg/d, 0.10
`mg/kg/d or 0.15 mg/kg/d once daily for 21 days. Five SBS
`patients with ;;:50% colon-in-continuity received teduglutide
`0.10 mg/kg/d once daily for 21 days. During each inpatient
`period, patients underwent 72-hour nutrient balance and
`45 D-Xylose absorption studies, and a proximal or distal endo(cid:173)
`scopy to ascertain the condition of the intestinal mucosa and
`obtain biopsy samples. In jejunostomy patients, biopsies
`were obtained through the jejunostomy stoma or by upper
`gastrointestinal endoscopy. In patients with colon-in-conti-
`50 nuity, colo-rectal biopsies were obtained. Teduglutide treat(cid:173)
`ment began on Day 1 (immediately after the baseline period)
`and continued once-daily for 21 days. On the first and last day
`of dosing, all patients had blood collections for plasma levels
`and pharmacokinetic parameters and to test for any antibod-
`55 ies to teduglutide or E. coli protein. Patients were monitored
`for safety (adverse events, physical exams, vital signs, ECGs,
`laboratory results, and injection site examinations) during the
`inpatient periods and during outpatient visits on days 7 and
`14.
`The 72-hour nutrient balance studies were completed with
`each patient eating their usual diet, calculated from a seven(cid:173)
`day food diary completed by the patient during the screening
`period. It was intended that patients eat the same quantity and
`quality of food and beverages during each admission. During
`65 the 72-hour balance periods, all oral intake (duplicate meals
`and beverages and declined food), fecal/stomal output, and
`urine were collected and weighed. All stool samples were
`
`60
`
`7
`
`

`
`US 9,060,992 B2
`
`8
`
`7
`refrigerated during the collection period. Stools and diets
`were separately homogenized and analyzed for energy con(cid:173)
`tent (by bomb calorimetry), nitrogen (by the macro(cid:173)
`Kjeldahl's method), fat (by the gravimetric technique), and
`sodium and potassium (by atomic absorption).
`D-Xylose was used to test intestinal carbohydrate absorp(cid:173)
`tion. After an overnight fast, patients drank a test solution of
`25 g D-Xylose in 200-mL distilled water over a 2-3 minute
`period. A blood sample was taken at two hours and urine
`collected for 5-hours following ingestion.
`Morphological Analysis
`Endoscopic examinations were performed in each subject
`at the completion of baseline, treatment and follow-up
`phases. All tissue samples for measurement of villus height
`and crypt depth were prepared and analyzed in a blinded
`fashion by the same pathologist. Villus height and crypt depth
`were measured using light microscopy (eyepiece microme(cid:173)
`ter) as the mean of ten well-oriented villi and crypts. The
`number of mitotic figures per 100 crypt epithelial cells was
`calculated.
`Statistics
`Using the SAS (Version 8.2; SAS Institute, Cary, N.C.)
`statistical program, a Student's paired t test was employed
`that compared treatment to baseline values, and follow-up to
`baseline values. No comparisons were made between patients
`on different doses or with different anatomy due to the limited
`number of patients in the study. Data are expressed as
`mean±SD. A value of p<0.05 was considered significant.
`Results
`Patients
`Sixteen SBS patients (nine females, seven males) enrolled
`in this open-label, multicenter, dose-ranging pilot study and
`received teduglutide. Four U.S. sites recruited 6 patients and
`one Danish site recruited 10 patients. The baseline character(cid:173)
`istics of these 16 patients treated are given in Table 1. These
`patients were subdivided into an end-jejunostomy group of 10
`(Group 2) and ;;,;50% colon-in-continuity group of 5 (Group
`3 ). There were originally 11 jejunostomy patients, but patient
`03 was found on biopsy to have a renmant segment of colon,
`later estimated to be 30%. This individual was not included in
`any subgroup analysis. As judged from analysis of duplicate
`meals adjusted for declined food, some patients had better
`dietary consistency than others. Patients who had an oral food
`intake where the dietary wet weight and energy content at
`treatment did not differ more than 10% from baseline values
`were termed "high dietary compliance". Ten patients had a
`high dietary compliance ( <l 0% variability from baseline
`value), 5 with end jejunostomy and 5 with ;;,;50% colon-in(cid:173)
`continuity (Group 4).
`The demographics of the two groups ofSBS patients, those
`with end jejunostomy and those with colon-in-continuity,
`were similar with ages ranging from 27-74 years, weights
`ranging from 38.9-79 .2 kg, heights ranging from 158-180 cm,
`BMI ranging from 15.0-26.9 kg/m2
`, years since last intestinal
`resection ranging from 2.4-20 years (except one patient 0.9
`years post-resection, whose results were similar to others who
`received0.15 mg/kg/day), andrenmantjejunum lengths rang(cid:173)
`ing from 25-150 cm. The causes for intesti