(12) INTERNATIONAL APPLICATION PUBLISHED UNDER THE PATENT COOPERATION TREATY (PCT)
`
`(19) World Intellectual Property Organization
`International Bureau
`
`(43) International Publication Date
`7 December 2000 (07.12.2000)
`
` AQ AMAA
`
`(10) International Publication Number
`WO 00/73331 A2
`
`(51) International Patent Classification’:
`
`CO07K 14/00
`
`(21) International Application Number:
`
`PCT/US00/14231
`
`(22) International Filing Date:
`
`23 May 2000 (23.05.2000)
`
`(25) Filing Language:
`
`(26) Publication Language:
`
`English
`
`English
`
`(74) Agent: BERKMAN,Charles, S.; Lyon & Lyon LLP, 633
`West Fifth Street, Suite 4700, Los Angeles, CA 90071-
`2066 (US).
`
`(81)
`
`Designated States (national): AE, AG, AL, AM,AT, AU,
`AZ, BA, BB, BG, BR, BY, CA, CH, CN, CR, CU, CZ, DE,
`DK, DM,DZ, EE, ES, FI, GB, GD, GE, GH, GM, HR, HU,
`ID,IL,IN,IS, JP, KE, KG, KP, KR, KZ, LC, LK, LR, LS,
`LT, LU, LV, MA, MD, MG, MK, MN, MW, MX, MZ, NO,
`NZ, PL, PT, RO, RU, SD, SE, SG, SI, SK, SL, TJ, TM, TR,
`TTI, TZ, UA, UG, UZ, VN, YU, ZA, ZW.
`
`(30) Priority Data:
`09/323,867
`
`1 June 1999 (01.06.1999)
`
`US
`
`(84)
`
`(71) Applicant. AMYLIN PHARMACEUTICALS, INC.
`[US/US]; 9373 Towne Centre Drive, San Diego, CA 92121
`(US).
`
`Designated States (regional): ARIPO patent (GH, GM,
`KE, LS, MW, MZ, SD, SL, SZ, TZ, UG, ZW), Eurasian
`patent (AM, AZ, BY, KG, KZ, MD, RU,TJ, TM), European
`patent (AT, BE, CH, CY, DE, DK,ES, FI, FR, GB, GR,IE,
`IT, LU, MC, NL, PT, SE), OAPI patent (BF, BJ, CF, CG,
`CI, CM, GA, GN, GW, ML, MR,NE, SN, TD, TG).
`
`(72) Inventors: HILES, Richard; 13526 Esprit Avenue, San
`Diego, CA 92128 (US). PRICKETT, Kathryn,S.; 7612
`Trailbrush Terrace, San Diego, CA 92126 (US).
`
`Published:
`Without international search report and to be republished
`upon receipt of that report.
`
`[Continued on next page]
`
`==
`
`54) Title: USE OF EXENDINS AND AGONISTS THEREOF FOR THE TREATMENT OF GESTATIONAL DIABETES MEL-
`= LITUs
`
`Oo€aeroeneraSND
`002
`oot
`=
`°
`
`=
`
`Maternal pre-dose
`
`Maternal posraose ee
`
`AN
`—_
`mn
`er)
`mn
`™—
`eS
`eS
`
`.
`Amniotic fiuid
`
`Fetal blood
`
`(57) Abstract: Methods fortreating gestational diabetes which comprise administration of an effective amount of an exendin or an
`exendin agonist, alone or in conjunction with other compounds or compositions that lower blood glucoselevels.
`
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`

`WO 00/7333 A2
`
`—_[TIUIINMNRIIUITIACIITINIE ACMACCC
`
`Fortwo-letter codes and other abbreviations, refer to the "Guid-
`ance Notes on Codes and Abbreviations" appearing at the begin-
`ning of each regularissue of the PCT Gazette.
`
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`WO 00/73331
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`PCT/US00/14231
`
`DESCRIPTION
`
`Use Of Exendins And Agonists Thereof
`
`For The Treatment Of Gestational Diabetes Mellitus
`
`Field Of The Invention
`
`treating
`for
`invention relates to methods
`The present
`gestational diabetes mellitus comprising administration of
`an effective amount of
`an exendin or
`an exendin agonist
`alone or in conjunction with other compounds or compositions
`that affect blood glucose control,
`such as an insulin or an
`amylin agonist. Pharmaceutical compositions for use in the
`methods of the invention are also disclosed.
`
`Background
`information
`summarizes
`description
`following
`The
`It
`is not an admission
`to the present
`invention.
`relevant
`that any of the information provided herein is prior art to
`the presently claimed
`invention,
`nor
`that
`any
`of
`the
`publications specifically or implicitly referenced are prior
`art to that invention.
`
`10
`
`15
`
`Gestational Diabetes Mellitus
`
`20
`
`Gestational diabetes mellitus
`
`(“GDM”)
`
`is
`
`a disorder
`
`25
`
`associated with
`
`elevated
`
`circulating
`
`plasma
`
`glucose.
`
`the
`GDM have been
`Although the diagnostic criteria for
`subject of controversy for decades,
`it was defined by the
`Third Workshop Conference on Gestational Diabetes Mellitus
`as carbohydrate intolerance of varying severity with onset
`or first
`recognition during pregnancy,
`irrespective of
`the
`glycemic status after delivery. Metzger
`(ed.) Proceedings of
`the Third International Workshop Conference on Gestational
`
`Diabetes Mellitus, Diabetes 40(Suppl. 2),
`
`1991.
`
`Despite
`
`30
`
`advances
`
`in clinical management of GDM,
`
`there are problems
`
`associated with GDM which persist,
`including elevated rate
`of perinatal morbidity and elevated rate of malformations in
`
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`

`

`WO 00/73331°
`
`PCT/US00/14231
`
`In
`and Pregnancy,
`Persson et al., Diabetes
`newborns.
`International Textbook of Diabetes Mellitus, Second Edition,
`
`John Wiley & Sons 1997
`
`(Alberti et al. Eds.). For example,
`
`it has been reported that, when the mean blood glucose level
`
`is greater than 105 mg/dl,
`
`there is a greater risk for the
`
`(“LGA”)
`development
`of
`tJlarge-for-gestational
`age
`infants
`Id.
`when compared with a control population.
`Additional
`reported consequences of untreated GDM include an increased
`
`incidence of macrosomia,
`
`respiratory distress syndrome,
`
`and
`
`10
`
`other abnormalities of
`
`fetal metabolism.
`
`Langer, Am.
`
`J.
`
`Obstet
`
`Gynecol.
`
`176:S186,
`
`1997;
`
`American
`
`Diabetes
`
`Association:
`
`Self-Monitoring
`
`of Blood Glucose Consensus
`
`Statement, Diabetes Care
`
`17:81~-82,
`
`1994(“ABA Consensus
`
`Statement”); Coetzee & Jackson, S. Afr. Med. J. 56:467-475,
`
`15
`
`1979.
`
`It has been clearly established by those in the field
`
`that
`
`tight
`
`glycemic
`
`control
`
`can
`
`serve
`
`as
`
`the
`
`primary
`
`prevention of fetal disease relating to GDM. Drexel et al.,
`
`Diabetes Care 11:761~768,
`
`1988; Roversi et al., Diabetes
`
`Care 3:489-494, 1980; Langer
`
`& Mazze, Am. J. Obstet Gynecol.
`
`20
`
`159:1478-1483, 1988; Langer et al., Am.
`
`J. Obstet Gynecol.
`
`161:646-653, 1989). GDM results in a greater
`
`incidence of
`
`intrauterine death or neonatal mortality. Position Statement
`
`American Diabetes Association:
`
`Gestational Diabetes
`
`Mellitus, Diabetes Care
`
`21
`
`(Suppl.
`
`1):S60-61,
`
`1998.
`
`GDM
`
`25
`
`pregnancies are at
`
`an increased risk for fetal macrosomia
`
`and neonatal morbidities
`
`including neural
`
`tube defects,
`
`hypoglycemia, hypocalcemiea, hypomagnsemia, polycythemia and
`
`hyperbilirubinemia and subsequent childhood and adolescent
`
`obesity.
`
`Siccardi,
`
`Gestational
`
`Diabetes.
`
`Other
`
`30
`
`complications
`
`to
`
`the woman
`
`include
`
`increased rates
`
`of
`
`disorders
`hypertensive
`delivery,
`cesarean
`preeclamsia and urinary tract infections.
`
`including
`
`Tt has been
`
`reported that
`
`approximately 4% of all
`
`pregnancies (135,000 cases annually) are complicated by GDM,
`
`35
`
`however, it has been estimated that
`
`the incidence may range
`
`from 13
`
`to 14%
`
`of all pregnancies,
`
`depending
`
`on
`
`the
`
`MYLANINST. EXHIBIT 1083 PAGE 4
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`

`WO 00/73331°
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`
`population and diagnostic tests
`
`employed.
`
`ADA Consensus
`
`Statement, supra.
`
`Normally during pregnancy,
`fasting plasma
`levels of
`insulin gradually increase to reach concentrations that are
`approximately twice as high in the third trimester as they
`were outside of pregnancy. Women with gestational diabetes
`mellitus
`(“GDM”) have fasting insulin levels comparable to
`er higher
`than those of normal pregnant women with the
`highest
`levels
`seen
`in women with GDM who
`are obese.
`Insulin secretion also increases gradually in pregnancy and
`
`also reaches a maximum during the third trimester. However,
`
`the relative increase in secretion is significantly smaller
`
`in women with GDM than in normal glucose tolerant
`
`(“NGT”)
`
`is
`first-phase insulin response in NGT women
`The
`women.
`significantly higher than in GDM women; second phase insulin
`response was similarly increased during pregnancy in both
`groups.
`This
`finding is consistent with the finding that
`GDM women have a
`later time of peak insulin concentration
`
`than do NGT women.
`during an oral glucose tolerance test
`Consistent with this observation,
`the insulin response per
`unit of glycemic stimulus
`is significant:y higher
`in NGT
`women than in GDM women
`(90% and 40%,
`respectively).
`The
`
`that glucose tolerance deteriorates in both normal and
`fact
`GDM pregnancies while at
`the same
`time,
`insulin secretion
`increases
`indicates
`a
`decrease
`in
`insulin sensitivity.
`
`Comparative results from an intravenous glucose tolerance
`test
`and
`a hyperinsulinemic,
`euglycemic
`clamp
`showed
`a
`sensitivity decrease during pregnancy in both groups of 50-
`60%, but GDM women had a slightly lower sensitivity.
`In
`another study using radioactive glucose,
`turnover of glucose
`and amino acids in GDM women was comparable to NGT women
`only when insulin concentrations 3-5 fold higher in the GDM
`group were used.
`Thus,
`it appears
`that GDM is due to a
`combination
`of
`diminished
`insulin
`sensitivity and
`an
`
`10
`
`15
`
`20
`
`25
`
`30
`
`35
`
`impaired ability to increase insulin secretion and has,
`
`in
`
`MYLANINST. EXHIBIT 1083 PAGE 5
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`WO 00/73331
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`
`fact, many features in common with type 2 diabetes.
`
`Normal
`
`or near normal glycemic control returns upon parturition.
`
`Clinical Diagnosis:
`
`It
`
`is common clinical practice to screen women
`
`for
`
`elevated glucose and glucose intolerance between weeks
`
`24
`
`the
`especially women with any one
`and 28 of gestation,
`following four characteristics:
`age >25;
`race/ethnicity of
`Hispanic, Native American, Asian, African-American
`or
`
`Pacific
`
`Islander origin;
`
`obese
`
`or
`
`a
`
`family history of
`
`10
`
`diabetes.
`
`In addition, women with previous pregnancies with
`
`complications
`
`due
`
`to a
`
`large weight
`
`fetus/neonate
`
`are
`
`usually tested.
`
`In some medical centers all pregnant women
`
`are tested.
`
`Indeed, certain investigators have
`
`found that
`
`historical risk factors account for only roughly half of the
`
`15
`
`women
`
`known
`
`to have GDM.
`
`Carr, Diabetes Care 21(Suppl.
`
`2):B14-B1i8,
`
`1998.
`
`| Additionally,
`
`there is
`
`some
`
`reported
`
`evidence
`
`that
`
`advancing maternal
`
`age
`
`is associated with
`
`increased incidence of GDM.
`
`Id.
`
`The clinical diagnosis is generally based on a multi-
`
`20
`
`step process.
`
`The evaluation is most typically performed by
`
`measuring plasma glucose 1 hour after a 50-gram oral glucose
`
`challenge test
`in either the fasted or
`the unfasted state.
`If the value in the glucose challenge test is > 140 mg/dl,
`a
`3-hr 100 g oral glucose tolerance test is done.
`If two or
`
`25
`
`more of
`
`the following criteria are met,
`
`the patient
`
`is
`
`considered in need of glycemic control: fasted venous plasma
`> 105 mg/dl,
`venous plasma > 190 mg/dl at
`1 hr,
`venous
`plasma > 165 mg/dl at 2 hr or venous plasma > 145 mg/dl at
`3
`hr. Williams et al., Diabetes Care 22:
`418
`- 421,
`1999.
`
`30
`
`Variations of this test are also used by some.
`
`See,
`
`e@.g.,
`
`Coustan, Gestational Diabetes In Diabetes in America, 2d ed.
`
`National Institutes of Health Publication No. 95-1468, 1995.
`
`MYLANINST. EXHIBIT 1083 PAGE 6
`
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`

`WO 00/73331
`
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`
`Current Clinical Therapy:
`The current
`therapeutic approach for GDM is to control
`plasma glucose for the remainder of the gestation (i.e.,
`the
`third trimester through parturition).
`GDM has many features
`
`in common with type 2 diabetes.
`
`The endocrine
`
`(impaired
`
`insulin
`
`secretion)
`
`and metabolic
`
`(insulin
`
`resistance)
`
`abnormalities that characterize both forms of diabetes are
`
`by
`characterized
`is
`pregnancy
`general,
`In
`similar.
`increases in both insulin resistance and insulin secretion.
`
`10
`
`Women with GDM fail to respond with increased insulin to the
`
`15
`
`20
`
`decrease in insulin sensitivity.
`
`to exist
`shown
`been
`significant correlation has
`A
`between late-stage gestational maternal glucose levels and
`preeclamsia, macrosomia, Cesarean
`section
`delivery
`and
`phototherapy for hyperbilirubinemia. Sermer et al., Diabetic
`Care
`21
`(Suppl.
`2):B33-B42,
`1998.
`It
`has
`also
`been
`determined that
`the length of hospitalization of
`the new
`mother
`and the length of
`time the neonate spent
`in the
`nursery could be correlated to the degree of elevation of
`plasma glucose in the pregnant woman.
`Id. Tallarigo, et al.
`reported a striking rise in the risk of
`fetal macrosomia
`(9.9 vs. 27.5%)
`and preeclamsia/Cesarean sections (19.9 vs.
`
`40.0%)
`
`in women with
`
`abnormal
`
`glucose
`
`tolerance when
`
`compared to NGT women. Tallarigo et al., N. Engl. J. Med.
`
`25
`
`315:989-992, 1986.
`
`30
`
`the goals for therapy of GDM are to achieve and
`Thus,
`maintain as near normal glycemia as feasible with a special
`emphasis to keep postprandial glucose concentrations within
`the normal
`range.
`Optimal
`therapeutic strategies are safe
`and efficacious in achieving a metabolic balancing without
`creating complications, which may
`include ketosis
`and/or
`hypoglycemia.
`Jovanovic, Diabetes Care 21(Suppl. 2):B131-
`B137,
`1998.
`The
`initial
`therapeutic approach is
`through
`
`diet.
`
`Jovanovic-Peterson & Peterson,
`
`JU. Am. Coll. Nutr.
`
`35
`
`9:320-325, 1990.
`
`MYLANINST. EXHIBIT 1083 PAGE 7
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`

`WO 00/73331
`
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`
`If diet or diet and exercise are not effective (i.e.,
`failure is
`fasting glucose >
`105 mg/dl
`and/or
`a 2-hr
`postprandial plasma glucose of > 120 mg/dl on 2 or more
`occasions within a
`1-
`to 2-week period),
`then insulin
`
`therapy
`
`(preferably,
`
`human
`
`insulin)
`
`is
`
`considered
`
`appropriate. ADA Position Statement, supra.
`recommended during
`Oral glucose-lowering agents are not
`pregnancy.
`Kuhi et al., Diabetic Care 21
`(Suppl. 2): B19-
`B26, 1998. Although sulfonylureas are used in the treatment
`of
`type
`2 diabetes
`due
`to their activity in increasing
`
`insulin sensitivity,
`
`these agents are contraindicated for
`
`use in GDM.
`
`Jovanovic, Diabetes Care 21
`
`(Suppl. 2):B131-
`
`B137,
`
`1998.
`
`See
`
`also Kahn
`
`&
`
`£Shechter,
`
`Insulin, Oral
`
`the Endocrine
`and the Pharmacology of
`Hypoglycemic Agents,
`Pancreas,
`In Goodman & Gilman’s The Pharmacological Basis of
`Therapeutics (gth ed. 1993 Goodman Gilman et al. eds.). Oral
`hypoglycemic drugs
`traverse the placenta,
`and may
`cause
`
`prolonged severe hypoglycemia
`
`in the newborn. Persson et
`
`al., supra.
`
`10
`
`15
`
`20
`
`The
`
`difficulties with,
`
`and
`
`the
`
`highly
`
`variable
`
`approaches to insulin therapy in GDM have been reviewed,
`
`for
`
`example,
`
`by
`
`Langer,
`
`et
`
`al.
`
`Langer, Diabetes
`
`Care
`
`21(Suppl.2):B91-B98, 1998. The problems commonly associated
`
`with insulin therapy in a non-pregnant population remain
`
`25
`
`when used in the treatment of GDM.
`
`They are determination
`
`30
`
`of
`the proper dose, maintenance of
`good glucose control
`through each 24-hr period, possible hypoglycemia and weight
`gain. Hypoglycemia can result when insulin is administered
`to control postprandial
`plasma
`glucose,
`but
`the
`fetus
`demands
`for energy in the presence of excess insulin later
`causes the glucose level
`to drop to a hypoglycemic level.
`
`This physiological state can be dangerous to both the mother
`
`and the fetus.
`
`Excess weight gain is undesirable in any
`
`pregnancy. Another problem with insulin therapy is the day-
`
`35
`
`to-day
`
`and week-to-week variability in
`
`glucose
`
`control
`
`vs.insulin dose.
`
`MYLANINST. EXHIBIT 1083 PAGE 8
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`

`WO00/73331
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`
`Thus,
`
`it can be appreciated that an effective means
`
`to
`
`treat gestational diabetes remains
`a major challenge and a
`superior method of treatment would be of great utility.
`Such
`a method,
`and compounds
`and compositions which are useful
`therefor, have been invented and are described and claimed
`
`herein.
`
`Exendins and Exendin Agonists
`Exendins are peptides that were first isolated form the
`salivary secretions of
`the Gila-monster,
`a lizard found in
`Arizona,
`and
`the Mexican Beaded Lizard.
`Exendin-3
`is
`
`10
`
`in the salivary secretions of Heloderma horridum,
`present
`and
`exendin-4
`is present
`in the
`salivary secretions of
`
`Heloderma
`
`suspectum (Eng,
`
`265:20259-62,
`
`1990; Eng.,
`
`J.,
`
`J.,
`
`et al.,
`
`J. Biol. Chem.,
`
`et al.,
`
`J. Biol. Chem.,
`
`15
`
`267:7402-05,
`
`1992).
`
`The
`
`exendins
`
`have
`
`some
`
`sequence
`
`the glucagon-like peptide
`similarity to several members of
`family, with the highest homology,
`53%, being to GLP-1[7-
`36]NH»
`(Goke, et al.,
`J. Biol. Chem., 268:19650-55, 1993).
`
`GLP-1[7-36]NH2, also known as proglucagon[78-107]
`
`and most
`
`20
`
`effect,
`insulinctropic
`an
`has
`“GLP-1,”
`as
`commonly
`stimulating insulin secretion from pancreatic B-cells; GLP-1
`also inhibits glucagon secretion from pancreatic a-cells
`(Orskov, et al., Diabetes, 42:658-61,
`1993; D’Alessio, et
`
`al., J. Clin.
`
`Invest., 97:133-38, 1996).
`
`GLP-1 is reported
`
`25
`
`J Clin
`8B, et al.,
`(Williams
`to inhibit gastric emptying
`Endocrinol Metab 81
`(1): 327-32, 1996; Wettergren A, et al.,
`
`and gastric
`1993),
`665-73,
`(4):
`38
`Dig Dis Sci
`acid
`(Schjoldager BT, et al., Dig Dis Sci
`34
`secretion.
`(5):
`703-8,
`1989; O'Halloran DJ, et al.,
`J Endocrinol 126
`(1):
`169-73, 1990; Wettergren A, et al., Dig Dis Sci 38
`(4): 665-
`73,
`$1993).
`GLP-1[7-37], which has
`an additional glycine
`
`30
`
`residue at
`
`its carboxy terminus,
`
`also stimulates
`
`insulin
`
`secretion in humans
`
`(Orskov, et al., Diabetes, 42:658-61,
`
`1993).
`A transmembrane G-protein adenylate-cyclase-coupled
`receptor believed to be responsible for
`the insulinotropic
`
`35
`
`MYLANINST. EXHIBIT 1083 PAGE 9
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`

`WO 00/73331°
`
`PCT/US00/14231
`
`effect of GLP-l1 is reported to have been cloned from a B-
`
`cell
`
`line (Thorens, Proc. Natl. Acad. Sci. USA 89:8641-45
`
`(1992)).
`
`Exendin-4 potently binds at GLP-1 receptors on insulin-
`secreting BTCl cells, at dispersed acinar cells from guinea
`
`pig pancreas,
`
`and at parietal cells
`
`from stomach;
`
`the
`
`peptide is also said to stimulate somatostatin release and
`
`inhibit gastrin release in isolated stomachs
`
`(Goke, et al.,
`
`J. Biol. Chem. 268:19650-55, 1993; Schepp, et al., Eur.
`
`J.
`
`10
`
`Pharmacol.,
`
`69:183-91,
`
`1994; Eissele, et al., Life Sci.,
`
`55:629-34, 1994).
`
`Exendin-3 and exendin-4 were reported to
`
`Stimulate
`
`cAMP production in,
`
`and amylase
`
`release from,
`
`(Malhotra, R., et al., Regulatory
`pancreatic acinar cells
`Peptides, 41:149-56,
`1992; Raufman, et al.,
`J. Biol. Chem.
`267:21432-37,
`1992; Singh, et al., Regul. Pept. 53:47-59,
`1994).
`The
`use
`of
`exendin-3
`and
`exendin-4
`as
`
`15
`
`insulinotrophic
`
`agents
`
`for
`
`the
`
`treatment
`
`of
`
`diabetes
`
`mellitus
`
`and
`
`the
`
`prevention
`
`of
`
`hyperglycemia
`
`has
`
`been
`
`proposed (Eng, U.S. Patent No. 5,424,286).
`C-terminally
`truncated
`exendin
`peptides
`
`20
`
`such
`
`as
`
`exendin-4[9-39],
`
`a carboxyamidated molecule,
`
`and fragments
`
`3-39
`
`through 9-39
`
`have been reported to be potent
`
`and
`
`selective antagonists of GLP-1
`
`(Goke,
`
`et al.,
`
`J. Biol.
`
`Chem., 268:19650-55, 1993; Raufman, J.P., et al.,
`
`J. Biol.
`
`25
`
`Chem. 266:2897-902, 1991; Schepp, W., et al., Eur. J. Pharm.
`269:183-91,
`1994; Montrose-Rafizadeh,
`et al., Diabetes,
`
`45(Suppl. 2):152A, 1996).
`
`Exendin-4[9-39]
`
`is said to block
`
`endogenous GLP-1
`
`in vivo,
`
`resulting in reduced insulin
`
`secretion. Wang, et al., J. Clin. Invest., 95:417-21, 1995;
`
`30
`
`D’Alessio, et al., J. Clin.
`
`Invest., 97:133-38, 1996).
`
`The
`
`receptor
`effect
`
`apparently
`of GLP-1
`has
`
`for
`responsible
`reportediy been
`
`insulinotropic
`the
`cloned
`from rat
`
`pancreatic islet cell
`
`(Thorens, B., Proc. Natl. Acad. Sci.
`
`Exendins and exendin-4[9-39] are
`USA 89:8641-8645, 1992).
`said to bind to the cloned GLP-1 receptor (rat pancreatic B-
`
`35
`
`cell GLP-1 receptor
`
`(Fehmann HC, et al., Peptides 15
`
`(3):
`
`MYLANINST. EXHIBIT 1083 PAGE 10
`
`MYLAN INST. EXHIBIT 1083 PAGE 10
`
`MYLAN INST. EXHIBIT 1083 PAGE 10
`
`

`

`WO 00/73331
`
`PCT/US00/14231
`
`453-6,
`
`1994)
`
`and human GLP-1l
`
`receptor
`
`(Thorens B, et al.,
`
`Diabetes
`
`42
`
`(11): 1678-82, 1993).
`
`In cells transfected
`
`with the cloned GLP-1 receptor, exendin-4 is reportedly an
`
`agonist,
`
`i-.e.,
`
`it
`
`increases
`
`cAMP, while exendin[9-39]
`
`is
`
`identified as an antagonist, i.e., it blocks the stimulatory
`
`actions of exendin-4 and GLP-1.
`Exendin-4 [9-39]
`is
`also
`
`Id.
`reported
`
`to
`
`act
`
`as
`
`an
`
`antagonist
`
`of
`
`the
`
`full
`
`length
`
`exendins,
`
`inhibiting
`
`stimulation of pancreatic acinar cells
`
`by
`
`exendin-3 and
`
`10
`
`exendin-4
`
`(Raufman,
`
`et al.,
`
`J. Biol. Chem.
`
`266:2897-902,
`
`1991; Raufman, et al., J. Biol. Chem., 266:21432-37, 1992).
`
`It
`
`is
`
`also
`
`reported
`
`that
`
`exendin[9-39]
`
`inhibits
`
`stimulation of
`
`plasma
`
`insulin levels
`
`by
`
`exendin-4,
`
`the
`
`and
`
`inhibits
`
`the somatostatin release~stimulating and gastrin
`
`15
`
`reiease-inhibiting
`
`activities
`
`of
`
`exendin-4
`
`and
`
`GLP-1
`
`(Kolligs, F., et al., Diabetes, 44:16-19, 1995; Eissele, et
`
`al., Life Sciences, 55:629-34, 1994).
`
`Methods
`
`for
`
`regulating gastrointestinal motility using
`
`exendin agonists are described and claimed in United States
`Application Serial No. 08/908,867,
`filed August
`8,
`1997,
`
`20
`
`entitled,
`
`“Methods
`
`for
`
`Regulating
`
`Gastrointestinal
`
`Motility,” which application is a continuation-in-part of
`
`United States Application Serial No.
`
`08/694,954,
`
`filed
`
`August
`
`8,
`
`1996, which
`
`enjoys
`
`common ownership with the
`
`25
`
`present invention and is hereby incorporated by reference.
`
`Methods of reducing food intake using exendin agonists
`
`are described and
`
`claimed
`
`in United States Application
`
`Serial No. 09/003,869, filed January 7, 1998, entitled, “Use
`
`of Exendin and Agonists Thereof
`
`for
`
`the Reduction of Food
`
`30
`
`Intake,” claiming the benefit of Provisional Application
`
`Nos. 60/034,905,
`
`filed January 7,
`
`1997, 60/055,404,
`
`filed
`
`August
`
`7,
`
`1997,
`
`60/065,442 filed November
`
`14,
`
`1997,
`
`and
`
`60/066,029 filed November 14, 1997.
`
`These applications also
`
`enjoy common ownership with the present
`
`invention and are
`
`35
`
`hereby incorporated by reference.
`
`MYLANINST. EXHIBIT 1083 PAGE 11
`
`MYLAN INST. EXHIBIT 1083 PAGE 11
`
`MYLAN INST. EXHIBIT 1083 PAGE 11
`
`

`

`WO 00/73331°
`
`PCT/US00/14231
`
`10
`
`Exendins have also been found to have
`
`inotropic and
`
`diuretic
`
`effects.
`
`International
`
`Application
`
`No.
`
`1999,
`filed February 5,
`PcT/USS9/02554,
`benefit of Provisional Application No.
`
`claiming the
`1998,
`60/075,122,
`filed
`
`February 13,
`
`1998.
`
`These applications also enjoy common
`
`ownership with
`
`the
`
`present
`
`invention
`
`and
`
`are
`
`hereby
`
`incorporated by reference.
`
`Additionally,
`
`exendins
`
`have
`
`been
`
`found
`
`to suppress
`
`glucagon secretion (United States Provisional Application
`
`10
`
`Glucagon
`for
`“Methods
`entitled,
`60/132,017,
`No.
`242/168,
`1999,
`docket no.
`Suppression,”
`filed April
`30,
`which enjoys common ownership with the present
`invention and
`is hereby incorporated by reference).
`
`Exendin
`
`[9-39]
`
`has
`
`been
`
`used
`
`to
`
`investigate
`
`the
`
`15
`
`physiological relevance of central GLP-1 in control of
`
`food
`
`intake (Turton, M.D. et al. Nature 379:69-72, 1996).
`
`GLP-1
`
`administered by intracerebroventricular
`
`injection inhibits
`
`food intake in rats.
`
`This satiety-inducing effect of GLP-1
`
`delivered ICV is reported to be inhibited by ICV injection
`
`20
`
`of exendin [9-39]
`
`(Turton,
`
`supra).
`
`However,
`
`it has been
`
`food intake in mice
`inhibit
`reported that GLP-1 does not
`when administered by peripheral
`injection (Turton, M.D.,
`
`Nature 379:69-72, 1996; Bhavsar, S.P., Soc. Neurosci. Abstr.
`
`21:460 (188.8), 1995).
`
`25
`
`Summary Of The Invention
`
`The present
`
`invention concerns the surprising discovery
`
`that
`
`exendins
`
`and
`
`exendin
`
`agonists
`
`do
`
`not
`
`cross’
`
`the
`
`placenta,
`
`and yet have a profound and prolonged effect on
`
`blood glucose,
`
`rendering them ideal agents for the treatment
`
`30
`
`of gestational diabetes mellitus.
`The present
`invention is directed to novel methods for
`treating
`gestational
`diabetes mellitus
`comprising
`the
`administration of an exendin,
`for example, exendin-3 [SEQ ID
`
`NO. 1: His Ser Asp Gly Thr Phe Thr Ser Asp Leu Ser Lys Gln
`
`35
`
`Met Glu Glu Glu Ala Val Arg Leu Phe Ile Glu Trp Leu Lys Asn
`
`MYLANINST. EXHIBIT 1083 PAGE 12
`
`MYLAN INST. EXHIBIT 1083 PAGE 12
`
`MYLAN INST. EXHIBIT 1083 PAGE 12
`
`

`

`WO 00/73331°
`
`PCT/US00/14231
`
`11
`
`Gly Gly Pro Ser Ser Gly Ala Pro Pro Pro Ser], or exendin-4
`[SEQ ID NO. 2: His Gly Glu Gly Thr Phe Thr Ser Asp Leu Ser
`Lys Gln Met Glu Glu Glu Ala Val Arg Leu Phe Ile Glu Trp Leu
`Lys Asn Gly Gly Pro Ser Ser Gly Ala Pro Pro Pro Ser], or
`other compounds which effectively bind to the receptor at
`which exendin exerts its actions which are beneficial
`in the
`
`treatment of gestational diabetes mellitus.
`In a first aspect,
`the invention features a method of
`treating gestational
`diabetes mellitus
`in
`a
`subject
`a
`comprising administering to the subject
`therapeutically
`effective amount of an exendin or an exendin agonist.
`By an
`
`10
`
`the
`that mimics
`compound
`a
`is meant
`“exendin agonist”
`effects of exendin in the treatment of gestational diabetes
`
`receptors where
`by binding to the receptor or
`mellitus
`exendin causes one or more of
`these effects. Exendins and
`
`15
`
`exendin agonists should be especially beneficially in the
`treatment of GDM because, due to their actions to inhibit
`gastric emptying,
`administration of
`such compounds
`should
`not
`result
`in increased weight gain.
`Additionally,
`in
`animal
`and
`human
`studies
`to
`date,
`administration
`of
`
`exendins
`
`and
`
`exendin agonists
`
`have not
`
`resulted in an
`
`increased incidence of hypoglycemia.
`for
`Exendin agonist
`compounds
`include exendin acids,
`example
`exendin-3
`acid
`and
`exendin-4
`acid.
`Preferred
`exendin
`agonist
`compounds
`include
`those
`described
`in
`International Application
`No.
`PCT/US98/16387,
`entitled,
`“Novel Exendin Agonist Compounds,”
`filed August
`6,
`1998,
`claiming the benefit of United States Provisional Patent
`Application Serial No. 60/055,404, entitled, filed August 8,
`1997; International Application No. PCT/US98/24220 entitled,
`“Novel Exendin Agonist Compounds,” filed November 13, 1998,
`claiming priority on United States Provisional
`Patent
`Application Serial No. 60/065,442,
`filed November 14, 1997;
`and International Application No. PCT/US98/24273 entitled,
`“Novel Exendin Agonist Compounds,”
`filed November 13, 1998,
`claiming priority on United States United States Provisional
`
`20
`
`25
`
`30
`
`35
`
`MYLANINST. EXHIBIT 1083 PAGE 13
`
`MYLAN INST. EXHIBIT 1083 PAGE 13
`
`MYLAN INST. EXHIBIT 1083 PAGE 13
`
`

`

`WO 00/73331
`
`PCT/US00/14231
`
`12
`
`Patent Application Serial No. 60/066,029, filed November 14,
`1997; all of which enjoy common ownership with the present
`application and all
`of which
`are
`incorporated by
`this
`reference into the present application as though fully set
`forth
`herein.
`Additional
`preferred
`exendin
`agonist
`compounds are those described and claimed in United States
`Provisional Application Serial No.
`60/132,018,
`entitled,
`“Modified Exendins and Exendin Agonists,"
`filed April 30,
`1999, docket no. 242/040, which enjoys common ownership with
`the present application and which is incorporated by this
`reference into the present application as though fully set
`forth herein.
`is meant
`“GDM”
`By “gestational diabetes mellitus” or
`any degree
`of glucose
`intolerance with onset or
`first
`recognition during pregnancy.
`invention
`the present
`Thus,
`in a
`first
`embodiment,
`provides
`a method for
`treating gestational diabetes
`in a
`subject
`comprising
`administering
`to
`said
`subject
`a
`therapeutically effective amount of an exendin or an exendin
`agonist.
`Preferred exendin agonist compounds
`include those
`described in International Application Nos. PCT/US98/16387,
`PCT/US98/24220,
`and
`PCT/US98/24273,
`which
`have
`been
`incorporated
`by
`reference
`in
`the
`present
`application.
`Preferably,
`the subject
`is a vertebrate, more preferably a
`mammal,
`and most preferably a human woman.
`In preferred
`is
`aspects,
`the
`exendin or
`exendin agonist
`administered
`parenterally, more preferably by
`injection.
`In a most
`preferred aspect,
`the injection is a peripheral
`injection.
`Preferably, about
`1 ywg-30 pg to about 1 mg of the exendin or
`exendin agonist
`is administered per day. More preferably,
`about 1-30 pug
`to about 500 yg, OF about 1-30 pg to about 50
`ug of
`the exendin or exendin agonist
`is administered per
`day. Most preferably,
`about
`3 Hg
`to about
`50
`pg of
`the
`exendin or exendin agonist is administered per day.
`In one preferred aspect,
`the exendin or exendin agonist
`used in the methods of
`the present
`invention is exendin-3.
`
`10
`
`15
`
`20
`
`25
`
`30
`
`35
`
`MYLANINST. EXHIBIT 1083 PAGE 14
`
`MYLAN INST. EXHIBIT 1083 PAGE 14
`
`MYLAN INST. EXHIBIT 1083 PAGE 14
`
`

`

`WO 00/73331
`
`PCT/US00/1 4231
`
`13
`
`In another preferred aspect,
`
`said exendin is
`
`exendin-4.
`
`Other preferred exendin agonists
`
`include exendin-4
`
`(1-30)
`
`{SEQ ID NO 6: His Gly Glu Gly Thr Phe Thr Ser Asp Leu Ser
`
`Lys Gln Met Glu Glu Glu Ala Val Arg Leu Phe Ile Glu Trp Leu
`
`Lys Asn Gly Gly], exendin-4 (1-30)
`
`amide
`
`[SEQ ID NO 7: His
`
`Gly Glu Giy Thr Phe Thr Ser Asp Leu Ser Lys Gln Met Glu Glu
`
`Glu Ala Val Arg Leu Phe Ile Glu Trp Leu Lys Asn Gly Gly-NH2],
`
`exendin-4 (1-28)
`
`amide
`
`[SEQ ID NO 40: His Giy Glu Gly Thr
`
`10
`
`Phe Thr Ser Asp Leu Ser Lys Gln Met Glu Glu Glu Ala Val Arg
`Leu Phe Ile Glu Trp Leu Lys Asn-NH2],
`‘“Leu,*°Phe exendin-4
`amide {SEQ ID NO 9: His Gly Glu Gly Thr Phe Thr Ser Asp Leu
`
`Ser Lys Gln Leu Glu Glu Glu Ala Val Arg Leu Phe Ile Glu Phe
`
`Leu Lys Asn Gly Gly Pro Ser Ser Gly Ala Pro Pro Pro Ser-NH2],
`147eu, Phe exendin-4 (1-28) amide [SEQ ID NO 41: His Gly Glu
`
`15
`
`Gly Thr Phe Thr Ser Asp Leu Ser Lys Gln Leu Glu Glu Glu Ala
`
`and
`Lys Asn-NH2],
`Leu
`Phe
`Tle Glu
`Phe
`Leu
`Val Arg
`M41eu,77Ala,*°Phe exendin-4 (1-28) amide [SEQ ID NO 8: His Gly
`Glu Gly Thr Phe Thr Ser Asp Leu Ser Lys Gln Leu Glu Glu Glu
`
`Ala Val Arg Leu Ala Ile Glu Phe Leu Lys Asn-NH2].
`In the methods of
`the present
`invention,
`
`20
`
`the exendins
`
`and
`
`exendin agonists may
`
`be
`
`administered separately or
`
`together with one or more other compounds and compositions
`
`that exhibit a long term or short-term blood glucose control
`
`action,
`
`including, but not
`
`limited to other compounds and
`
`25
`
`compositions that comprise an insulin or an amylin agonist.
`Suitable amylin agonists include,
`for example,
`[7928 29pro-] -
`human
`amylin
`(also
`known
`as
`‘“pramlintide,”
`previously
`referred to as
`‘AC-137,” and ,
`referred to in its acetate
`
`salt form by its trademark SYMLIN™ (pramlintide acetate), as
`described in “Amylin Agonist Peptides and Uses Therefor,”
`
`30
`
`U.S. Patent No. 5,686,511,
`
`issued November 11,
`
`1997,
`
`and
`
`salmon calcitonin.
`
`MYLANINST. EXHIBIT 1083 PAGE 15
`
`MYLAN INST. EXHIBIT 1083 PAGE 15
`
`MYLAN INST. EXHIBIT 1083 PAGE 15
`
`

`

`WO 00/73331°
`
`PCT/US00/14231
`
`14
`
`Brief Description Of The Drawings
`Figure 1 depicts the amino acid sequences for certain
`
`exendin agonist
`
`compounds useful
`
`in the present
`
`invention
`
`[SEQ ID NOS 9-39].
`
`Figure 2 depicts concentrations of exendin-4 (AC2993)
`
`in plasma and amniotic fluid of rats after 2lpg subcutaneous
`
`injection.
`
`Figure 3 depicts concentrations of exendin-4 (AC2993)
`
`in
`
`plasma
`
`and
`
`amniotic
`
`fluid
`
`of
`
`rats
`
`after
`
`210pg
`
`10
`
`subcutaneous injection.
`
`Detailed Description Of The Invention
`
`Exendins and exendin agonists are useful as described
`
`herein
`
`in
`
`view of
`
`their
`
`pharmacological
`
`properties.
`
`Activity as exendin agonists can be indicated by activity in
`
`15
`
`the assays described below. Effects of exendins or exendin
`
`agonists in treating gestational diabetes can be identified,
`
`evaluated, or screened for, using the methods described in
`
`the Examples below, or other methods known in the art
`
`for
`
`determining effects on blood glucose control.
`
`20
`
`Exendin Agonist Compounds
`
`Exendin
`
`agonist
`
`compounds
`
`are
`
`those
`
`described
`
`in
`
`International Application No. PCT/US98/16387,
`
`filed August
`
`6, 1998, entitled,
`
`“Novel Exendin Agonist Compounds,” which
`
`claims the benefit of United States Provisional Application
`
`25
`
`No. 60/055,404, filed August 8, 1997,
`
`including compounds of
`
`the formula (I)
`
`[SEQ ID NO. 3]:
`
`Xaa, Xaazp Xaa3 Gly Thr Xaa, Xaas Xaae Xaaz Xaag
`
`Ser Lys Gln Xaag Glu Glu Glu Ala Val Arg Leu
`
`Xaai9 Xaai1 Xaaino Xaai3 Leu Lys Asn Gly Gly Xaaiq
`
`30
`
`Ser Ser Gly Ala Xaais Xaaig Xaaiz7 Xaaie-Z
`
`wherein Xaa;
`
`is His, Arg or Tyr; Xaaz2
`
`is Ser, Gly, Ala or
`
`Thr; Xaa3 is Asp or Glu; Xaa, is Phe, Tyr or naphthylalanine,;
`
`Xaas is Thr or Ser; Xaag is Ser or Thr; Xaa;
`
`is Asp or Glu;
`
`Xaag
`
`is Leu,
`
`Ile, Val, pentylglycine or Met; Xaag is Leu,
`
`MYLANINST. EXHIBIT 1083 PAGE 16
`
`MYLAN INST. EXHIBIT 1083 PAGE 16
`
`MYLAN INST. EXHIBIT 1083 PAGE 16
`
`

`

`WO 00/73331"
`
`PCT/US00/14231
`
`15
`
`Tle,
`
`pentylglycine, Val
`
`or Met; Xaaio
`
`is
`
`Phe,
`
`Tyr
`
`or
`
`naphthylalanine; Xaa,,; is Tle, Vai, Leu, pentyliglycine, tert-
`
`butylglycine or Met; Xaajz2 is Glu or Asp; Xaaj3 is Trp, Phe,
`
`Tyr,
`
`or naphthylalanine; Xaai4, Xaais, Xaaig
`
`and Xaaiz are
`
`independently Pro, homoproline,
`
`3Hyp,
`
`4Hyp,
`
`thioproline, N-
`
`alkylglycine, N-alkylpentylglycine or N-alkylalanine; Xaaig
`
`is Ser, Thr or Tyr; and Z
`
`is -OH or -NH2; with the proviso
`
`that the compound is not exendin-3 or exendin-4.
`
`Preferred N-alkyl
`
`groups
`
`for N-alkylglycine,
`
`N-
`
`10
`
`alkylpentylglycine and N-alkylalanine include
`
`lower alkyl
`
`groups preferably of
`
`1
`
`to about
`
`6
`
`carbon
`
`atoms, more
`
`preferably of
`
`1
`
`to 4
`
`carbon atoms.
`
`Suitable compounds
`
`include
`
`those
`
`listed in
`
`Figure
`
`10
`
`having
`
`amino
`
`acid
`
`sequences of