9 European Patent office
`
`Office européen des brevets
`
`® Publication number:
`
`0
`
`®
`
`EUROPEAN PATENT APPLICATION
`
`@ Application number: 93114762.3
`@ Date of f'l'ng 14 09 93
`I
`I
`I
`.
`.
`
`@ Int. Cl.5: A51K 31/58, //(A61K31/68,
`31505’31:44)
`
`Priority: 14.09.92 ZA 926990
`
`Date of publication of application:
`04.05.94 Bulletin 94/18
`
`@ Applicant: VESTA MEDICINES (PROPRIETARY)
`LIMITED
`
`Holpro House
`1 Snell Street
`Micor, Johannesburg 2092(ZA)
`
`Designated Contracting States:
`AT BE CH DE DK ES FR GB GR IT LI LU NL SE @ Inventor: Serfontein, Willem Jacob
`47 Selikats Village,
`Selikats Causeway
`Faerie Glen, Pretoria 0043(ZA)
`
`Representative: VOSSIUS & PARTNER
`Postfach 86 07 67
`D-81634 Mtinchen (DE)
`
`(SD Pharmaceutical preparations for lowering homocysteine levels, containing vitamin B6, folic acid
`and vitamin B12.
`
`@ Pharmaceutical preparations for lowering blood and tissue levels of homocysteine are disclosed, comprising:
`a) vitamin B6;
`b) folate or a suitable active metabolite of folate or a substance which releases folate in vivo;
`c) vitamin B12, with or without intrinsic factor
`and optionally antoxidants, choline and/or betaine. a) and b) are provided in slow release form (2-8 hours) and
`c) is to be released immediately (within 20 minutes).
`
`EP0595005A1
`
`Rank Xerox (UK) Business Services
`l3.l0/3.09/3.3.4)
`
`Teva — Fresenius
`
`Exhibit 1010-00001
`
`Teva – Fresenius
`Exhibit 1010-00001
`
`

`
`EP 0 595 005 A1
`
`10
`
`15
`
`25
`
`30
`
`35
`
`40
`
`45
`
`The present invention relates to pharmaceutical preparations for lowering levels of homocysteine or for
`the prophylaxis or treatment of elevated levels of homocysteine in patients and for counteracting the
`harmful effects associated with homocysteine.
`Elevated homocysteine levels can be correlated with some of the principle causes of morbidity and
`5 mortality in the Western world, the so-called "Western" diseases, including such conditions as myocardial
`and cerebral infarction. Precocious vascular disease is the main single cause of death accounting for the
`majority of these deaths (New Eng J Med 1986, 314 : 488). It is generally agreed that nutritional factors
`play an important role in the etiology of this and the other Western diseases. The precise nature of the
`nutritional factors responsible for these diseases, is difficult to define but it can be stated with certainty that
`these are multi-factorial. Briefly, in the affluent Western societies, there is an overconsumption on the one
`hand of macro nutrients such as proteins, fats and refined carbohydrates, which are normally undercon(cid:173)
`sumed in the Third World countries. Due to food refinement and all the other facets of food processing
`necessitated by increased urbanisation in the West, much of the micro-nutrients (vitamins, minerals) are
`lost. This results in a metabolic imbalance between macro-nutrients (especially proteins and fats) on the one
`hand and the essential micro-nutrients on the other hand which are necessary for the normal metabolism of
`the former. Under these conditions, abnormal metabolic pathways may be activated leading to the
`production of toxic and harmful intermediary products which in many cases are the cause of disease and
`which normally are not produced at all or only in very small quantities. The metabolism of the amino acid
`methionine is a good example, in which case excessive quantities of the toxic and unnatural amino acid
`20 homocysteine are produced.
`Elevated homocysteine levels also occur in certain patients due to genetic causes and may also be
`caused by certain drugs, including certain vitamin B6 antagonistic drugs.
`Normally, methionine is metabolised by the transmethylation and transsulfuration pathways to produce
`cysteine.
`Three pathways exist by means of which blood and tissue levels of homocysteine are controlled to
`ensure homocysteine homeostasis:
`1. Conversion into cysteine by means of the vitamin B6 dependent enzyme cystathionine .a-synthase
`(CBS)
`2. Remethylation to methionine which requires folate (as substrate) and vitamin B12 as co-factor.
`3. Remethylation to methionine in which other methyl donors such as betaine participate.
`Elaborate provision therefore exists in the healthy body to keep homocysteine levels in check. The
`reason for this is that homocysteine is a very toxic compound which in the chronic situation may affect a
`variety of systems and tissues in the body.
`A pathological condition due to one or more of several hereditary enzyme defects wherein homo-
`cysteine levels are abnormally high, is known as homocysteinuria. This condition is often associated with
`high blood levels of homocysteine (often 200 ll mole/I or higher) and the associated clinical defects include
`the following:-
`1. Disintegration of the vascular elastic interna due to binding of homocysteine to allysine residues of
`tropoelastin.
`2. Inhibition of the process of polymerisation and cross linking in the formation of elastin and collagen.
`3. Hyperplasia of arterial smooth muscle cells and synthesis of extracellular collective tissue.
`4. Degradation of vascular glycocalyx and synthesis of extracellular connective tissue.
`5. Pro-thrombotic effects (activation of Hagemann factor and stimulation of thromboxane 2 production by
`platelets).
`6. Progressive premature artherosclerosis.
`7. Accelerated osteoporosis (Metabolism 1985, 34 : 1073).
`8. Precocious occlusive vascular disease frequently manifested clinically as myocardial infarction, stroke,
`pulmonary embolism (Am.J.Med.Sc. 1977, 273: 120) and peripheral vascular occlusion.
`9. Abnormalities in eyes, skeletal system, central nervous and vascular systems.
`10. Occlusive disease of cerebral, carotid and aorto-iliac vessels.
`11. Occlusion or stenosis of renal arteries which often results in renovascular hypertension. (See for
`example: Metabolism 1985, 34 : 1073, Am J. Med. Sc. 1977, 273 : 120, Stroke 1984, 15 : 1014,
`Atherosclerosis 1988, 71 : 227.
`12. The sex and age related variations in plasma homocysteine parallel well-established age and sex-
`related risk factors in atherosclerotic disease.
`It has also been shown in many studies, that whereas lipid levels are not markedly different in coronary
`patients and controls, homocysteine levels are significantly different. (See for example J Am. Coll. Cardiol.
`1990, ~:1114)
`
`50
`
`55
`
`2
`
`Teva – Fresenius
`Exhibit 1010-00002
`
`

`
`10
`
`15
`
`20
`
`25
`
`EP 0 595 005 A1
`
`3
`
`It is therefore now widely accepted that elevated plasma homocysteine is a risk factor independent of
`established risk factors such as cigarette smoking, hypertension and diabetes for generalised ar(cid:173)
`teriosclerotic disease (Circulation 1989, 79 : 1180).
`On the other hand, evidence exists which suggests that B6 deficiency independently of homocysteine
`5 may be associated with vascular disease stressing the prime importance of an adequate intracellular B6
`status to prevent these diseases.
`the art that elevated blood levels of homocysteine are highly
`in
`It is therefore now accepted
`undesirable. Normalisation of such elevated levels of homocysteine therefore constitutes a therapeutic goal
`as such without reference to any specific disease entity, possibly causally related to such elevated levels.
`Evidence is mounting that high cholesterol levels alone are not the risk factor in astherosclerotic
`diseases as was previously believed. Before cholesterol contributes to vascular occlusion another form of
`damage occurs which is correlated with high homocysteine levels. Once that damage has occurred the
`beneficial effects of cholesterol-lowering drugs, in particular so-called statins become highly questionable,
`particularly when viewed in the light of side effects of such drugs (raising LPa, decreasing 010, weakening
`the immune system, cataracts, GI disturbances, myositis, myocarditis). Nevertheless, the prejudice in favour
`of cholesterol depressants has been so strong that these adverse findings have, until now, been given
`inadequate coverage in the review literature.
`The present invention is aimed at counteracting root causes of artherosclerotic disease which damage
`the blood vessels before cholesterol becomes a problem.
`The clinical condition of homocysteinuria, is an inborn error of metabolism which is either caused by an
`enzyme defect in the transsulfuration pathway or a similar defect in the 5-methyl tetrahydrofolate dependent
`remethylation of homocysteine to methionine. Patients with this disease usually have very high fasting blood
`levels of homocysteine (in excess of 200 micromolar in homozygotes) and have a limited life expectancy
`due to early vascular complications. This rare condition must be clearly distinguished from other milder (but
`chronic) forms of homocysteinaemia which may arise from other causes - both external and internal - but
`which are clinically of much greater importance due to the vastly higher prevalence thereof. Accordingly, a
`need exists for reducing or preventing not only the extreme elevated homocysteine levels in cases of
`homocysteinuria, but also the much more moderately elevated homocysteine levels pertaining to homo(cid:173)
`cysteineaemia.
`Inadequate metabolic status individually of vitamin B6, folate and vitamin B12 have been recognised as
`determinants of heart and peripheral occlusive disease. At the same time, deficiencies (individually) of each
`of these vitamins have also been known to be associated with increased homocysteine levels. Thus vitamin
`B6 deficient humans have a 43 % reduction in cystathionine ,8-synthase (CBS) activity and they excrete
`increased quantities of homocysteine in the urine, reflecting the effect of an inadequate B6 status on
`35 homocysteine blood levels. A negative correlation exists between dietary B6 intake and blood levels of
`protein bound homocysteine.
`Similar relationships have been described between B12 and folate levels individually on the one hand
`and blood levels of homocysteine on the other hand. These relationships have been described by several
`authors and have been summarised in the following publications:-
`1. Stroke, 1984, 15: 1012
`2. Metabolism 1984, 34 : 1073
`3. Metabolism 1988, 37 : 175
`4. Scan J Clin Lab Invest 1988, 48 : 215
`5. Atherosclerosis 1988, 71 : 227
`6. Circulation 1990, 81 : 2004
`The present state of the art knowledge on homocysteine and its involvement in disease is well summarised
`and presented in a recent review article (J.Lab.Clin Med. 1989, ~ : 473). In the course of own
`investigations into the relationship between B6, B12 and folate metabolic status, homocysteine metabolism
`and occlusive vascular disease, applicant has established that in addition to the known and published
`information on these relationships, certain other aspects - heretofore unknown or not appreciated or not
`correctly interpreted - are of prime importance in connection with treatment and prevention of homocysteine
`related occlusive vascular disease. In addition, by the judicious application of these findings, treatment of
`hyperhomocysteineaemia may be appreciably facilitated.
`Regarding the treatment and prophylaxis of hyperhomocysteineaemia, it is known that vitamin B6,
`vitamin B12 and folate play a role in regulating the methionine - homocysteine pathway and controlling
`levels of homocysteine (David E L Wilken, Nicholas P P Dudman, Haemostasis 1989; 19 (supplement 1) :
`14 - 23; Per Magne Ueland and Helga Refsum, J.Lab.Clin.Med. November 1989, 473 - 501. However, it was
`previously not recognised, that many patients develop hyperhomocysteineaemia not primarily because of a
`
`30
`
`40
`
`45
`
`50
`
`55
`
`Teva – Fresenius
`Exhibit 1010-00003
`
`

`
`EP 0 595 005 A1
`
`4
`
`40
`
`45
`
`50
`
`55
`
`5
`
`20
`
`30
`
`35
`
`15
`
`lack of the relevant vitamins, but often because of absorption problems, especially in the case of vitamin
`812.
`Accordingly there is a need for improvement in pharmaceutical compositions for lowering elevated
`homocysteine levels in plasma and counteracting adverse clinical conditions associated therewith, espe-
`cially with respect to those patients in whom elevated plasma homocysteine levels are primarily related to
`absorption problems such as occur in many elderly patients. It is precisely in such patients that the problem
`of hyperhomocysteineaemia with accompanying vascular pathology is often a serious one.
`In particular, there is a need to provide pharmaceutical compositions and dosage regimens which
`achieve adequate lowering of plasma homocysteine levels and counteracting adverse clinical conditions
`10 associated therewith in the greatest number of patients suffering from elevated plasma homocysteine levels
`covering substantially all age groups and preferably with relatively low dosages of active ingredients.
`More particularly, there is a need for pharmaceutical compositions and dosage regimens which attain
`the aforegoing with surprisingly low dosage rates of folate as compared with the prior art.
`In the present invention, special provision is made to overcome such problems. These preferably
`include the following galenical and biochemical variations:-
`a) the use of pyridoxal instead of pyridoxine as a source of 86 activity;
`b) the galenical presentation of the vitamins concerned in such a form that the rate of release of each
`vitamin is compatible with maximum absorption and utilisation;
`c) the use of transdermal vitamin formulations which allows direct absorption through the skin of small
`quantities over prolonged periods. This is accomplished either through the use of appropriately formu(cid:173)
`lated vitamin plasters or through the use of sub-lingual tablets.
`Reference is made to applicant's copending patent application entitled "Compositions for the Treatment
`and Prophylaxis of Metabolic Disturbances in Infants", claiming priority of ZA-PA 92/6989.
`Here pharmaceutical and dietary preparations are disclosed for the treatment or prophylaxis of elevated
`25 homocysteine and/or methionine levels in the blood of human infants and pathological disturbances
`connected therewith, said preparation comprising in combination:-
`a) vitamin 8 6 as such or in the form of a pharmaceutically acceptable acid salt, at least in part in the
`form of pyridoxal (PL) or a compound which in vivo readily releases PL without the intervention of
`oxidase enzyme or oxygen.
`b) folate or a precursor of folate which releases folate in vivo, and
`c) vitamin 812, with or without intrinsic factor, in the following ratios:(cid:173)
`a) . b) from 1 :25 to 1 O 000 : 1
`b): c) from 1:1to50 000: 1
`The preparations are to be incorporated in infant bone feed mixes. That disclosure, by cross-reference,
`forms part of the present disclosure. The same applies to the contents of a study performed on behalf of
`the applicant and published after the priority date hereof in Am.J.Clinical Nutrition (1993), 57, pp 47-53.
`In accordance with the invention there is provided the use in the manufacture of a pharmaceutical
`preparation for lowering levels of homocysteine or for the prophylaxis or treatment of elevated levels of
`homocysteine in a patient of a combination which comprises
`a) vitamin 86;
`b) folate or a suitable active metabolite of folate or a substance which releases folate in vivo;
`c) vitamin 812, with or without intrinsic factor.
`The invention is applicable to the lowering of total homocysteine blood levels if elevated by any known
`cause, including genetic causes (e.g. enzyme polymorphism) diets, drugs or depressed activity levels of
`folate, vitamin 86, vitamin 812 or any combination of these due to whatever cause, pregnancy, chronic
`renal failure, psoriasis, occlusive vascular disease, chronic liver disease, homocysteine-associated psychiat(cid:173)
`ric problems. Drugs which induce elevated homocysteine levels include anticonvulsant drugs, xanthine
`bronchodilators (e.g. theophylline), methotrexate, nitrous oxide, and many others.
`Preferably, in the preparation, the ingredients a) - c) are present in the following ratios by weight
`calculated on the basis of pure unphosphorylated pyridoxal (PL), pure vitamin 812 and pure folic acid:
`a):b) from 100:1 to 1:10 and
`b):c) from 100:1 to 1 :50
`The preferred ratios are:
`a):b) from 50:1 to 1 :1,5
`b):c) from 15:1 to 1 :2
`more preferred ratios are:(cid:173)
`a):b) from 20:1 to 2,5:1
`b):c) from 4:1 to 1 :1
`
`Teva – Fresenius
`Exhibit 1010-00004
`
`

`
`EP 0 595 005 A1
`
`10
`
`15
`
`and in particular:-
`a):b) from 20:1 to 5:1
`b):c) from 2:1 to 1 :2
`The scope of the invention is intended to include a pharmaceutical preparation as such as aforesaid,
`5 wherein if the preparation is for oral use and any of the vitamin B6 is represented by pyridoxine (PN), such
`PN is formulated in slow-release form. This is particularly advantageous in the context of PN, because of
`the limited capacity of the liver to convert PN into PLP and the resultant risks of excess PN in plasma
`leading to poor utilisation and undesirable entrance of PN into peripheral cells and erythrocytes.
`Pharmaceutical preparations containing the aforesaid active ingredients have been described, albeit for
`totally different purposes and mostly in ratios differing from the aforesaid ratios or at least from the
`preferred or more preferred ratios. In GB-PS 1201 014 (examples 6 and 7) the ratio of a):b)
`3:1 and that
`of b):c) = 1000:5. No indication is disclosed for these dragees. GB-PS 2254 556, published after the
`priority date of the present disclosure, also discloses compositions, only some of which contain in
`combination folic acid, vitamin B12, vitamin B6. No distinction is drawn between pyridoxine, pyridoxal and
`pyridoxamine. These compositions are intended for adolescent girls. GB-PS 149 3993 discloses composi(cid:173)
`tions for treating obesity. Pyridoxal is not disclosed. GB-PS 2145 331 discloses all these ingredients but in
`quite different ratios and in dosages which are partly too high and partly too low for the purposes of the
`present invention. GB-PS 2197 587 describes a "blood conditioning tonic" for race horses. Pyridoxal is not
`disclosed. GB-PS 1431 841 discloses preparations for cataract treatment. The ratios are different from those
`20 according to the invention and pyridoxal is not disclosed. GB 101 3939 discloses compositions for
`paediatric purposes in ratios which overlap the broadest ratio according to the invention, but the important
`feature that the vitamin B6 must be in the form of pyridoxal or suitable precursor thereof is not disclosed.
`This also applies to EP-0144051, EP 0121 036 or PCT WO 83/00085.
`Not one of the aforesaid references discloses such combinations for the treatment or prophylaxis of
`25 elevated homocysteine levels in plasma, or the crucial role of pyridoxal in that context, which is the only
`useful form which when it enters peripheral cells or erythrocytes is directly converted there into active
`pyridoxal phosphate (PLP).
`It is now realised that such intracellular PLP is the sole form in which vitamin B6 controls homocysteine
`levels in plasma.
`The preparations in accordance with the invention are formulated to provide approximate daily dosages
`as follows (llg/d/kg body weight).
`
`30
`
`35
`
`40
`
`a) Vitamin B6
`
`b) Folic Acid
`
`c) Vitamin B12
`
`Broadest range
`
`preferred range
`
`more preferred range
`
`typical example
`
`15-750
`
`30-400
`
`75-250
`
`150
`
`1,5-150
`
`1,5-75
`
`7,5-50
`
`10-30
`
`15
`
`3-15
`
`7-10
`
`7,5
`
`45
`
`These dosages may be exceeded somewhat for short durations, e.g. at the beginning of the treatment.
`Also, where the daily dosages are divided into several dosage units to be administered at different times of
`the day, the compositions may differ to provide optimum effect in accordance with circadien variations in
`homocysteine production. The latter may fluctuate in a manner depending on time, on meal intake, its
`quantity and composition. The dosage regimen may be programmed to be optionally adapted to a
`predetermined daily dietary programme.
`Preferably the preparation is formulated to make available to the patient the vitamin B6 and preferably
`also the folate over a period of more than 1 hour and to make available an effective dosage of the vitamin
`50 B12 in less than 1 hour after administration. This feature is considered to contribute materially to the
`efficacy of the invention and is considered to be novel and inventive per se.
`The preparation may be galenically formulated for parenteral administration, preferably by infusion or
`by intramuscular injection. The latter form inherently provides for a retarded availability of the ingredients,
`which effect may be further enhanced by depot forms of formulation.
`Preferably the preparation combines all three essential ingredients in a single dosage form, which
`except for very drastic cases of elevated homocysteine levels is preferably designed for oral administration.
`However, it is possible within the scope of the invention, to provide separate ingredients of the
`preparation in separate distinctive dosage forms, e.g. capsules, tablets or coated tablets, preferably
`
`55
`
`5
`
`Teva – Fresenius
`Exhibit 1010-00005
`
`

`
`EP 0 595 005 A1
`
`5
`
`10
`
`15
`
`combined in a single package e.g. a blister pack or similarly ordered package, designed to facilitate or
`prescribe to the user the combined administration of the dosage units according to a specific dosage
`regimen. Such dosage regimen may optionally be time programmed, providing for different dosage rates
`during different periods of a course of treatment. Packages designed for that purpose are known per se and
`require no description.
`Preferably at least the vitamin 86 should be galenically formulated for slow release of the compound
`over a period of not less than 2 hours. Likewise the folate or precursor thereof is preferably so formulated.
`On the other hand, it is preferred for the vitamin 812 (with or without intrinsic factor) to be galenically
`formulated for the preparation to release an effective dosage, preferably at least 90% of the vitamin 812
`(with or without intrinsic factor) to the patient, more particularly the stomach in less than 1 hour after
`administration.
`The vitamin 86 as such or in the form of pharmaceutically acceptable acid addition salt may be in the
`form of pyridoxine (PN) or its phosphate (PNP). However, for the reasons already stated above, it is
`preferred for the vitamin 86 to be represented at least in part by pyridoxal (PL) or a compound which
`readily releases PL in vivo without the intervention of oxidase or oxygen, because this avoids situations
`where the normal PN - PL metabolic pathway may be compromised, as may happen e.g. due to genetic or
`pathological or drug-induced conditions.
`Nevertheless, because most patients, in particular non-infants have a reasonable capacity for utilising
`PN it can be advantageous to employ a mixture of PN and PL in the following ratio:-
`PL:PN =
`from 1:10 to 10:1
`from 1 :6 to 4:1
`preferably
`from 1 :6 to 1 :1
`more preferably
`e.g. 1 :4
`Likewise it is preferred for PL or its precursor to be provided in a non-phosphorylated form, to avoid
`situations where the dephosphorylation step may be compromised. It is pointed out that only PL is capable
`of passing from the plasma through the cellular membranes into most cells where it is subsequently
`converted into pyridoxal phosphate (PLP), the active intracellular form of PLP. Also as will be explained
`elsewhere herein, PL itself plays a very active role in certain physiologically important reactions relevant to
`the present invention. For these reasons PL itself is a preferred form of vitamin 86 in the context of the
`30 present invention.
`Vitamin 8 12 may be used in the form of cyanocobalamin or hydroxycabalamin or both.
`"Intrinsic factor" in this art, in the context of vitamin 812 denotes substances (which are for example in
`nature released by the gastric mucosa of the stomach when functioning normally) with which vitamin 812
`forms complexes to facilitate absorption.
`Advantageously the vitamin 86 is galenically formulated to be released over a period of 2 to 8 hours,
`whereas the vitamin 812 (with or without intrinsic factor) is formulated to be released in less than t hour.
`More particularly the vitamin 86 is galenically formulated to be released over a period of 2 to 8 hours,
`preferably 3 to 6 hours, more preferably 4 to 6 hours and the 812 over a period of 5 - 30 minutes.
`Preferably, the folate as well is galenically formulated to be released by the composition in not less than
`40 2 hours, preferably 2 to 8 hours, more preferably 3 to 6 hours, e.g. 4 to 6 hours.
`The preferred compositions contain vitamin 86 and, preferably folate in a part of the composition
`adapted as a slow, timed release composition and containing the vitamin 812 (with or without intrinsic
`factor) in another part adapted for fast release. Examples of such compositions include the following:
`a) a bi-layered tablet,
`b) a coated tablet, containing the vitamin 812 in a rapidly dissolving coating; or
`c) a pharmaceutical composition in granular form, loose or in a capsule.
`Novelty and inventiveness is claimed to reside in the feature as such of combining folate and vitamin
`812 in a combination, wherein the former is galenically formulated or adapted to be administered in a slow,
`timed release manner and the latter is formulated or adapted for fast release. This feature is considered as
`50 a further aspect of the present invention, to be applied as such or in combination with the remaining
`features of the invention herein disclosed.
`The manner of putting that aspect of the invention into effect is as disclosed herein in conjunction with
`the preceding aspects of the invention.
`Furthermore, apart from the proven toxicity of homocysteine, it has in addition now been found that
`55 elevated homocysteine levels in plasma are also indicative of free radical activity and of a general vitamin
`deficiency, and notably a deficiency of those vitamins which control free radicals in plasma. Free radicals in
`plasma as such, are a risk factory, which can be associated with serious diseases, notably vascular
`diseases. Accordingly, the
`invention preferably provides for the co-administration with the aforesaid
`
`35
`
`20
`
`25
`
`45
`
`6
`
`Teva – Fresenius
`Exhibit 1010-00006
`
`

`
`EP 0 595 005 A1
`
`7
`
`40
`
`45
`
`55
`
`5
`
`10
`
`15
`
`25
`
`substances a) or b) or c) of an antioxidant, more particularly d) vitamin C (ascorbic acid or salt thereof)
`and/or e) vitamin E (more particularly in the form of d-a-tocopherol acetate), and/or g) selenium, preferably
`as selenised yeast, and/or h) coenzyme Q10, preferably two or more of these together.
`Components d), e), g) and h) are preferably incorporated in the same pharmaceutical preparation as a)
`and/or b) and preferably likewise in a slow-release form.
`The use of antioxidant vitamins in combination with folate, more particularly in slow-release form (and
`preferably in combination with vitamin B6 and vitamin B12) for the purpose of counteracting the adverse
`clinical effects associated with elevated homocystein levels, notably vascular disease is considered novel
`and inventive per se.
`The daily dosage rate in the context of the invention for vitamin C is preferably from 100 to 1200, more
`preferably 200 to 700, in particular about 500 mg/70kg, and that for vitamin E is preferably 80 to 1000, more
`preferably 150 to 600 in particular about 400 mg/70kg. Another antioxidant which can be used, preferably in
`addition to either or both of d) and e), is f) ,8-carotene, at daily dosage rates of 1 to 20, preferably 5-15, e.g.
`about 7,0 mg/70kg. Selenium is used at a dosage rate of 20-400 1.1.g, preferably 100-300 1.1.g, e.g. about 200
`1.1.g/70kg and coenzyme Q at a dosage rate of 10-100 mg, preferably 25-30 mg, say 20 mg/70 kg.
`The ratios of the antioxidants to other ingredients may be:
`b) to:d)
`1 :2000 -1 :50, preferably 1:1000 - 1:100, e.g. 1 :500
`b) to:e) = 1 :1800 - 1 :40, preferably 1 :900 - 1 :90 e.g. 1 :400
`b) to:f) = 1 :0,5 - 1 :30, preferably 1 :2 - 1 :15, e.g. 1 :7,5
`20 b) to:g) = 1 :0,4 - 1 :0,02 preferably 1 :50 - 1 :15 e.g. 1 :20
`b) to:h) = 1:100 - 1 :5 preferably 1 :50 - 1 :15 e.g. 1 :20.
`The scope of the invention also extends to compositions or preparations as aforesaid compnsmg
`optionally choline or betaine or both, and these are preferably formulated in slow release form. Choline is a
`precursor of betaine. These substances are incorporated to provide a daily dosage rate of 0,007 - 0, 1,
`preferably O,Q1 - 0,05, more preferably O,Q14 - 0,03 g/d/kg body weight, e.g. a daily adult dosage rate of 2,0
`g betaine. HG/ combined with 10 mg PN.HC/. The use and advantages of betaine and choline in slow(cid:173)
`release form are inventive per se.
`By employing betaine or choline in slow release form it is possible to reduce the dose substantially for
`a given homocysteine-reducing effect. In this manner excessive levels of methionine are also counteracted.
`30 At the same time the co-administration of vitamin B6, preferably PL counteracts excessive fluctuations of
`blood amino acid levels. The release characteristics may be similar to those disclosed above for vitamin B6
`and folate, preferably such that 90% are released in 4-6 hrs.
`Betaine and/or choline can even substantially replace either or both of vitamin B12 and folate, because
`betaine, like vitamin B12 and folate, promotes the methylation of homocysteine.
`According to another aspect of the invention, provision is made for the application of the active
`ingredients (vitamins) concerned (one or more) by the use of appropriately formulated:-
`1) sub-lingual tablets (especially in the case of coenzyme Q),
`2) plasters designed for skin absorption,
`3) rectal pesaries,
`4) suitably formulated gels or ointments, or
`5) suitably formulated and concentrated solutions (aqueous, non-aqueous) of vitamins applied to the skin
`and/or other suitable tissues.
`Generally, such preparations are prepared for the direct absorption of one or more of these vitamins
`through various tissues and membranes including the skin, nasal membranes, sub-lingual membranes,
`rectal membranes.
`Preferably also such preparations may contain one or more permeation enhancers such as the mono(cid:173)
`esters of glycerol which are known for that purpose in the art.
`The principle advantage of such parenteral formulations (applying the term "parenteral" in a broad
`sense) is the fact that the inconvenient, unpleasant and often costly application by means of injections can
`50 be avoided. This is of special significance in the case of vitamin B12 and coenzyme Q10.
`It has also been found necessary to use suitable vehicles which are adapted to facilitate and/or control
`the release of the vitamins for absorption through the tissues concerned. Such preparations may include the
`use of certain gels or suitably formulated tablets. Since the three vitamins concerned are normally not
`absorbed at the same rate, in the various systems concerned, it has been found necessary to vary the
`relative concentrations of the vitamins in such preparations to allow for even, parallel and protracted
`absorption of the vitamins. Alternatively, and preferably, a composite plaster containing 3 zones, each
`loaded with one of the relevant vitamins and each containing its own permeation enhancers may be
`prepared. Because in the case of folate and B6, absorption problems are not so serious as those of B12
`
`35
`
`Teva – Fresenius
`Exhibit 1010-00007
`
`

`
`EP 0 595 005 A1
`
`(especially in the aged), this form of parenteral administration is frequently resorted to only in the case of
`812 and coenzyme Q10.
`According to yet another aspect of the invention, absorption problems (especially with respect to 812
`in
`the elderly) are overcome by using the three vitamins in substantially differing
`absorption, e.g.
`concentration ratios in such a manner that the folate and 812 components are presented in higher quantities
`relative to the 86 component (e.g. pyridoxal). The principle is illustrated in the following table. The dosage
`forms in accordance with the invention are to be formulated accordingly:-
`
`Concentration ranges of nyridoxal. folate and vitamin B12 in pharmaceutical
`
`formulations
`
`The following quantities refer to one daily dose for an adult patient of
`approximately 70kg body weight. (PL=pyridoxal; Fol=folate; B12=Vitamin
`B12) Quantities are given in milligrams per day.
`
`PL
`
`Folate
`
`B12
`
`Formulation Range Preferred
`type
`mg
`mg
`
`Range Preferred
`mg mg
`
`Range Preferred
`mg mg
`
`5
`
`0,2-15 1,0
`
`0.1-2 0.5
`
`Normal (no 2-5
`absorption
`problem)
`
`2-50 5
`
`2-15 5
`
`0.2-5 1,0
`
`Spe