CYANOCOBALAMIN (VITAMIN B 12) TREATMENT IN ALLERGIC DISEASE

Description

Technical Field

[0001] The invention relates to the use of nutritional supplements to treat disease. It relates particularly to treatment of IgE-type allergies, such as allergic rhinitis (hayfever) and allergic asthma, by the repeated administration over a period of time of vitamin B₁₂, preferably cyanocobalamin, to reduce the symptoms associated with such allergic diseases.

Background Art

[0002] The symptoms of allergic diseases, such as allergic rhinitis (hay fever) and allergic asthma, can be caused by a variety of atopic allergens, such as grasses, trees, weeds, animal dander, insects, molds, drugs and chemicals. These allergic diseases are mediated by an antibody known as immunoglobulin E, or simply IgE. Anti-IgE medicines that reduce IgE levels are attractive treatments for allergy patients.

[0003] IgE bonds to mast cells and basophils. Upon combination of a specific allergen with IgE bound to mast cells or basophils, the IgE may be crosslinked on the cell surface, resulting in the physiological effects of IgE-antigen interaction. This may result in the release of histamine, serotonin, heparin, a chemotactic factor for eosinoplylic leukocytes and/or the leukotrienes, C4, D4 and E4, which cause prolonged constriction of bronchial smooth muscle cells. These released substances are the mediators which result in allergic symptoms.

[0004] Vitamin B₁₂ is essential to cell growth, cell reproduction, hematopoiesis, DNA synthesis and nucleoprotein synthesis. Deficiencies in Vitamin B₁₂ or folic acid can lead to the inhibition of normal cell division and abnormal maturation and functioning of cells produced. These changes are most apparent in cells that undergo rapid mitosis (cell division), but all dividing cells are affected to some degree. In patients with Vitamin B₁₂ or folic acid deficiency, pancytopenia (diminished production of red blood cells, white blood cells and platelets) may occur. The U.S. Food and Drug Administration (FDA) recognized the description of this problem on the molecular level in its approval of B₁₂ for anemia.

[0005] The mechanism of action for Vitamin B₁₂ in IgE-mediated allergic diseases, such as allergic rhinitis and asthma, may involve the maturation of certain immune system cells including polynucleated cells, natural killer (NK) cells, and CD8+ cells. The CD8+ cell is an immune system T lymphocyte believed to "put the brakes on" the immune system, making the allergy patient less sensitive to allergens such as pollen, cats, and mold. Typically, allergic individuals have numbers of the CD8+ suppressor cells that are low relative to CD4 aggressor cells. These immune system cells may require a sustained and elevated serum Vitamin B₁₂ concentration to develop from an immature state to a mature state in which they can exert their down-regulatory function on the immune system. Polynucleated cells are known to have memories that last many years, a concept consistent with controlled studies demonstrating reductions in symptoms and in specific IgE levels persisting many months after parenteral Vitamin B₁₂ treatment.

[0006] When Vitamin B₁₂ is delivered parenterally, it passes into the circulation for distribution throughout the body before arriving at the liver. It is during this first pass in its native form that it is believed to exert its therapeutic effect.

[0007] Studies indicate that ingested oral cyanocobalamin is ineffective in the treatment of allergic disease, perhaps because once ingested, it goes directly to the liver where it metabolized. The ineffectiveness may also be caused by poor absorption. Gastrointestinal absorption of Vitamin B₁₂ depends on the presence of sufficient intrinsic factor and calcium ions. Its absorption may be hindered by the presence of large amounts of Vitamin C. Tens of millions of people have diets rich in Vitamin B₁₂ (from animal products or supplements) and continue to suffer from allergic rhinitis and/or asthma.

[0008] Cyanocobalamin is the most widely sold analogue of Vitamin B₁₂, with other similar molecules also available. Cyanocobalamin is found in injectable and oral modes of delivery, and has the advantage over other types of B₁₂ of having a stable shelf life at standard temperature and pressure (STP).

[0009] The analogues of Vitamin B₁₂ are the only molecules used by the human body that contain cobalt. The empirical formula of cyanocobalamin is: C₆₃H₈₈CON₁₄O₁₄P.

[0010] US 4 432 975 refers to a process for introducing vitamin B₁₂ into the blood stream by using amino lozenge

[0011] U.S. Patent No. 5,135,918, which is owned by the applicant, Allergy Limited LLC, discloses a highly effective method of achieving long term relief from the symptoms of atopic allergy by repeated subcutaneous and/or intramuscular injections of B₁₂ over a short period of time. In practice, the treatment has comprised thirty injections of B₁₂, preferably cyanocobalamin, administered twice daily over a period of fifteen days. This series of 30-injections has been successful from a point of view of efficacy in treating allergic disease, but has resulted in subjects reporting bruising and/or soreness at the local injection site. The difficulties involved in having the patient go

[0012] into a medical clinic 30 times over a fifteen-day period for injections are numerous. However, providing patients with syringes for self-injection also poses problems. Once a syringe has been used it is contaminated and must be disposed of in a biohazard container or there is risk of transmitting diseases such as hepatitis or the HIV virus. Concerns have been raised about the possibility of cross-contamination of vials by lay allergy patients with minimal medical knowledge who self-inject. Both the manufacture and disposal of syringes are environmentally hazardous.

Disclosure of the Invention

[0013] It is the primary object of the present invention to provide patient-friendly modes of delivery to patients of effective allergy-opposing amounts of Vitamin B₁₂ without the inconvenience and discomfort of subcutaneous and intramuscular injections as claimed in claim 1 and dependent claims.

[0014] It is in particular an object of the invention to provide for enhanced delivery of effective amounts of B₁₂ via the mucosal membranes of the patient, i.e., the mouth.

[0015] By repetitive administration over a period of time via transmucosal delivery Vitamin B₁₂ is effective to maintain an elevated and sustained level of B₁₂ in the system sufficient for the reproduction and maturation of polynucleated cells and CD8+ suppressor cells so they can exert their down-regulatory function on the immune system.

[0016] In accordance with the invention, vitamin B₁₂ is instilled in a carrier matrix, such as controlled release lozenges, for patient-friendly, self-administration of effective allergy-opposing amounts of vitamin B₁₂. The invention thereby minimizes inconvenience and discomfort for the patient and alleviates the burden and time demands imposed on medical staff.

[0017] These and other objects and advantages of the invention will become apparent to those of reasonable skill in the art from the following detailed description.

Best Mode for Carrying out the Invention

[0018] The following is a detailed description of certain embodiments of the invention which are presently deemed by the inventors to be the best mode of carrying out the invention. Unless otherwise stated, the following terms used in the specification and claims have the meanings given below:

[0019] "Delivery" refers to the passage of a substance across or through a mucosal membrane (i.e.) sublingual, and buccal, membranes), where the substance can contact, and be absorbed into, the capillaries. In certain instances, the delivery and/or transport of the substance across other membranes will be effected.

[0020] "Buccal delivery" refers to any or lozenge system or device for the oral administration of a drug to a patient that is held in the mouth and is used to deliver a drug through the buccal mucosa and into the patient's body. "Sublingual delivery" refers to administration under the tongue.

[0021] "Enhanced delivery" refers both to the facilitation of the delivery of a pharmaceutical agent and an absolute increase in the molar volume of the pharmaceutical agent transported per unit time through a constant surface area utilizing an equimolar pool of transported material as compared to unenhanced delivery.

[0022] "Penetration enhancer" refers to a substance which is used to increase the transmembrane flux of a compound. A penetration enhancer is typically applied to the mucous membrane in combination with the compound. Enhancers are believed to function by disrupting the mucous membrane barrier or changing the partitioning behavior of the drug in the mucous membrane.

[0023] "Allergy-opposing, pharmaceutically or therapeutically effective dose or amount" refers to a dosage level sufficient to induce a desired biological result. That result may be the delivery of a pharmaceutical agent, alleviation of the signs, symptoms or causes of a disease or any other desired alteration of a biological system.

[0024] The present invention provides several embodiments of transmucosal delivery systems containing any of the analogues of Vitamin B₁₂ (cobalamin). The analogues include cyanocobalamin, hydroxycobalamin, adenosylcobalamin, deoxyadenosylcobalamin and methylcobalamin as well as their respective metabolites. The preferred Vitamin B₁₂ is cyanocobalamin. The invention comprises the use of the Vitamin B₁₂-containing delivery systems in the treatment of IgE-related allergic disease.

[0025] The delivery systems comprise a B₁₂ containing matrix material compatible with the mucosal membrane into which the vitamin B₁₂ is to be absorbed, e.g., a lozenge for buccal ingestion. The matrix material also preferably includes a time controlled or slow release mechanism or agent and a penetration enhancer for stimulating the respective mucosal membrane to enhance absorption of the B₁₂ into the patient's system. Several such matrix materials are described in the literature.

[0026] A presently preferred oral matrix material is the lozenge developed by TheraTech of Salt Lake City, Utah, (a subsidiary of Watson Labs) which is described in U.S. patent 5,346,701. The lozenge is formulated to provide maximum absorption of macromolecules. For convenience of administration and testing of oral delivery of the B₁₂, from about 1,000 to about 5,000 micrograms (mcg) of cyanocobalamin may be instilled in each TheraTech lozenge. The dosage can be more or less, as desired. According to a preferred embodiment, the lozenge is round with a diameter of approximately 1.8 cm (a little smaller than a U.S. dime) and is flavored.

[0027] A presently preferred use for treating allergic disease with the B₁₂ infused TheraTech lozenges comprises administration of from 1,000 to 3,000 mcg of B₁₂ twice daily over a period of twenty-one days. The duration of treatment may be increased or decreased depending upon each patient's response to the treatment.

[0028] To facilitate self-practice of the method, a preferred embodiment of a product comprises a kit containing forty-two of the B₁₂ lozenges and forty-two multivitamin supplements, preferably capsules or tablets each containing:

B1	thiamine mononitrate	25 mg
B2	riboflavin	25 mg
B6	pyridoxine HCL	25 mg
B3	niacin	20 mg
	manganese	6 mg
C	ascorbic acid	500 mg

[0029] Optionally, folic acid (folate) may be included. Folic acid is chemically unrelated to Vitamin B₁₂ but the two are integral to the same pathway that produces nucleotides needed for DNA synthesis. Folic acid is readily absorbed from oral supplementation. Manganese is a mineral that aids in converting cyanocobalamin into its active form (the metabolite). The vitamin C may be included with the other oral vitamins or separate.

[0030] Optionally, each capsule or tablet may also contain the herb Stinging Nettle (from Urtica dioica). In a preferred formula, each capsule contains about 50 mg from the leaf of the Stinging Nettle plant, and is present as standardized 1-2 % plant silica. In another formulation, each capsule contains about 10-100 mg of extract of the root of the plant. The manganese and the other oral supplements can each be provided as part of the treatment for allergic disease in either the oral capsule or tablet, or made part of the lozenge.

[0031] The lozenge is formulated to dissolve completely in the mouth for B₁₂ absorption by the buccal membrane.

[0032] The invention thus provides a simple and convenient mode of administration of an effective amount of B₁₂ to provide allergy sufferers with an elevated and sustained level of Vitamin B₁₂ to alleviate their allergy symptoms.

[0033] Because of the obvious improvements in patient compliance and acceptability of a series of lozenges over a series.of injections, the applicant sponsored a study to compare the absorption of the above-described B₁₂ infused TheraTech lozenges to the absorption of a 15 mcg injectable administered as described in U.S. Patent 5,135,918.

[0034] Baseline Subjects EA (38, M, 81 kg (175 lbs), HW (42, M, 150 kg (330 lbs), AG (36, F, 59 kg (130 lbs)) and JS (50, M. 75kg (165 lbs) had blood drawn at Quest Laboratories in San Diego, CA. Samples sat for 30 min, and had sera removed. Sera were chilled in a refrigerator.

[0035] Baseline Subject EA then received a 15 mcg cyanocobalamin injection via intramuscular injection in the left deltoid.

[0036] Subject HW received one TheraTech lozenge with 1000 mcg cyanocobalamin. He let it dissove completely in his mouth (under and above the tongue) for 30 minutes.

[0037] Subject AG received two TheraTech lozenges with 1000 mcg cyanocobalamin each. She let them dissolve completely in her mouth. She scraped the lozenges with her teeth to expedite dissolving.

[0038] Subject JS received three TheraTech lozenges with 1000 mcg cyanocobalamin each. He let them dissolve completely in his mouth. He sucked on the lozenge for a few minutes, chewed the lozenge and then let the little pieces dissolve in his mouth.

[0039] Approximately one hour after receiving treatment (post-dose), subjects EA, HW, AG and JS had blood drawn.

[0040] Approximately four and a half hours after receiving treatment, subjects AG and JS had blood drawn.

[0041] Approximately six hours after receiving treatment, subjects EA and HW had blood drawn.

[0042] Samples were assayed in different runs using the competitive automated Chemiluminescence System VB12 from Chiron Diagnostics for the quantitative determination of B₁₂ in serum.
Results: (Serum B₁₂ values are in pg/mL, with a reference range of 200-1100.)

EA	HW	AG	JS
15 mcg Injected	1000 mcg Lozenge	2000 mcg Lozenge	3000 mcg Lozenge
% Increase	% Increase	% Increase	% Increase
BASELINE 709	333	399	371
1 HR 1021 44%	386 16%	458 15%	394 6%
4.4 hrs.		576/26%	531 35%
6 hrs. 915 33%	387 16%

[0043] It appears that a lozenge containing 3000 mcg cyanocobalamin provides a similar but somewhat more sustained release than a 15 mcg injection, which provides a spiked release less than an hour after injection. If the mechanism involves CD8+ suppressor cells and/or polynucleated cells in need of an elevated B₁₂ level sustained over the course of 15 days or more to mature, then the lozenge is preferable.

[0044] Cyanocobalamin has been reviewed for safety and approved by the FDA to be injected in high doses (1000 to 5000 mcg). A twice-daily 3000 mcg lozenge with the TheraTech absorption profile provides less of an increase in serum cyanocobalamin than a 50 or 100 mcg injection.

[0045] In view of the above results, a multi-site clinical trial was undertaken (1) to determine whether cyanocobalamin delivered orally via a TheraTech lozenge, and taken concomitantly with oral vitamins can decrease symptoms in patients with seasonal allergic rhinitis, and (2) to determine and monitor the effects of the treatment in regard to certain selected safety issues.

[0046] This was a double blind, placebo controlled, randomized, parallel group, premarketing study comparing active Vitamin B₁₂ therapy and placebo in patient volunteers who had moderate to moderately sever seasonal allergic rhinitis (hay fever). The results showed an active-group reduction in sneezing, runny nose and antihistamine use which persisted for weeks after the end of the treatment.

[0047] The subjects self-administered cyanocobalamin lozenges or placebo at approximately twelve-hour intervals in the morning and the evening daily for twenty-one consecutive days. All subjects received oral multivitamin supplements taken each morning and evening. Patients were not permitted to have had a systemic corticosteriod treatment for one month prior to beginning the treatment or to use other allergy medications during the treatment, but were permitted to continue immunotherapy (allergy shots) if they were on maintenance doses. For compassion reasons, patients were permitted to take up to 16 mgs of an HI antihistamine per day, provided to them as a rescue medication. This was 4 mg chlorpheniramine (CPM).

[0048] The study took place at four medical clinics in San Diego, California during the spring and summer of 1998. The San Diego area pollen counts in 1998 were high relative to most years, possibly because of strong El Nino weather patterns.

[0049] Each patient recorded the severity of runny nose, sneezing, nasal congestion, itchy eyes and nasal itch in the AM and PM daily during an initial one-week baseline period, during the three week treatment period, and for an additional five weeks. Severity was recorded on a scale of 0 to 3, with 0 meaning symptom free and 3 meaning severe discomfort.

[0050] The study was completed with 24 valid male and female patient volunteers, ages 12 to 80; 15 on the active lozenge and 9 on the placebo.

[0051] The medications administered were dietary supplements, in a kit comprising 42 TheraTech lozenges each containing 3000 mcg cyanocobalamin or like appearing placebos. Natural Alternatives International, Inc., San Marcos, CA manufactured the lozenges and capsules. Each active and placebo subject also received 42 capsules, each containing:

B1	thiamine mononitrate	25 mg
B2	riboflavin	25 mg
B3	niacin	50 mg
B6	pyridoxine HCL	25 mg
	manganese	6 mg

Each active and placebo subject also received 42 capsules, each containing:

C

ascorbic acid

500 mg

Each active and placebo subject also received a bottle of chorpheniramine (CPM) 4 mg antihistamine as rescue medication.

[0052] The results of the study yielded reductions in total weekly symptom/rescue medication for the active group compared to the placebo for weeks 2, 6, 8 and 9. In results which tend to replicate those of the injectable cyanocobalamin, symptoms in the active and placebo groups dropped during the treatment, followed by a resumption of symptoms during the post-treatment period in the placebo group but not in the active group. This persistence of effect in the active group was greater for sneezing, runny nose and antihistamine use than for nasal congestion, nasal itch and itchy eye.

[0053] The twenty-four subjects who completed the diary as valid subjects (active = 15; placebo = 9) reported the following scores. Total symptons scores are the weekly means for the active and placebo groups for each patient-reported symptom on a scale of 0 to 3. Rescue medication is the weekly mean of CPM use, with each 4 mg tablet consumed given a value of 1.

Frequency of Increase or Decrease in Total Symptom/Rescue Medication Use

[0054] 

Week 1 (Baseline) Compared to Week 2 Week 1 Compared to Week 3
		Increase	Decrease			Increase	Decrease
Active				Active
	No. Subjects:	3	12		No. Subjects:	3	12
	Percentage:	20%	80%		Percentage:	20%	80%

Placebo				Placebo
	No. Subjects:	5	4		No. Subjects:	3	6
	Percentage:	56%	44%		Percentage:	33 %	67%
Chi-Square		Probability	0.074	Chi-Square		Probability	0.465

Week 1 Compared to Week 4				Week 1 Compared to Week 5
		Increase	Decrease			Increase	Decrease
Active				Active
	No. Subjects:	2	13		No. of Subjects:	2	13
	Percentage:	13 %	87%		Percentage:	13%	87%

Placebo				Placebo
	No. Subjects:	3	6		No. of Subjects:	2	7
	Percentage:	33 %	67%		Percentage:	22%	78 %
Chi-Square		Probability	0.243	Chi-Square	Probability	0.572

Week 1 Compared to Week 6				Week 1 Compared to Week 7
		Increase	Decrease			Increase	Decrease
Active				Active
	No Subjects:	1	14		No. Subjects:	4	11
	Percentage:	7 %	73 %		Percentage:	27 %	73 %

Placebo Placebo
	No. Subjects:	4	5		No. Subjects:	4	5
	Percentage:	44%	56%		Percentage:	44%	56%
Chi-Square		Probability	0.027	Chi-Square	Probability	0.371

Week 1 Compared to Week 8				Week 1 Compared to Week 9
		Increase	Decrease			Increase	Decrease
Active				Active
	No. Subjects:	1	14		No. Subjects:	3	12
	Percentage:	7 %	93 %		Percentage:	20 %	80 %

Placebo				Placebo
	No. Subjects	4	5		No. Subjects:	5	4
	Percentage:	44%	56%		Percentage:	56%	44%
Chi-Square		Probability	0.027	Chi-Square	Probability	0.074

There were no reports of adverse events with the exception of an equal number of active and placebo subjects reporting a red rash minutes after taking the treatment. This flushing went away in all cases in approximately an hour. The investigative physicians concurred that this could be attributed to the large amount of niacin (50mg) in the capsule and the quick release nature of the capsule.

[0055] The patient's total weekly symptom/antihistamine use score was calculated by adding all symptom scores and 4mg antihistamine tablets for any given week. The total weekly symptom/rescue medication score is the mean for all subjects in the group, active or placebo.

[0056] The results yielded reductions (0.1 > p > 0.01) in total weekly symptom/antihistamine use scores for the active group compared to the placebo group for weeks 2, 6, 8 and 9. The greatest differences appeared in the last two weeks of the study. These reductions in the active group were greatest for sneezing, runny nose and antihistamine use.

[0057] In general, approximately one-third of subjects in allergic rhinitis studies report a reduction in symptoms when given a placebo. It can be speculated that the largest differences in symptom/antihistamine use scores reported in the current study were in the last two weeks because the placebo group was reporting a placebo effect during and shortly after the treatment.

[0058] The antihistamine used, CPM, is known to reduce the symptoms associated with allergic rhinitis. Adding antihistamine use to the symptom score simplifies the reporting of results but introduces an element with uncertain impact on the results. Knowing what weight to give the antihistamine is problematic and a search of the literature yielded no accepted way to treat the data. Nevertheless, it is important to observe that both antihistamine use and symptoms were reduced in the active group.

[0059] The invention thus provides a transmucosal B₁₂ delivery system using lozenges, capable of delivering B₁₂ to mucosal membranes to be absorbed in the system for therapeutically effective distribution of B₁₂ throughout the body before arriving at the liver.

[0060] Consequently, elevated and sustained levels of B₁₂ can be maintained in the patient's system to alleviate the symptoms of allergic rhinitis and asthma.

[0061] The objects and advantages of the invention have therefore been shown to be attained in a convenient, practical, effective and facile manner.

Claims

1. Use of a pharmaceutical composition comprising vitamin B₁₂ in combination with a pharmaceutically-acceptable carrier for the manufacture of a medicament for the treatment of atopic allergy in a human host in the pharmaceutical form of a lozenge compatible with the buccal membrane and soluble in the mouth of a human and containing an effective allergy-opposing amount of vitamin B₁₂ absorbable and transferable through the buccal membrane.

2. Use as set forth in claim 1, wherein said lozenge is formulated to dissolve completely in the human mouth for vitamin B₁₂ absorption by the buccal membrane.

3. Use as set forth in claim 1, containing a time-controlled vitamin B₁₂ release agent.

4. Use as set forth in claim 1, containing a penetration enhancer for enhancing the transfer of the vitamin B₁₂ into and through the buccal membrane.

5. Use as set forth in claim 1, containing from about 1,000 to about 5,000 micrograms of vitamin B₁₂ analogue cyanocobalamin, methylcobalamin and/or hydroxycobalamin.

Ansprüche

1. Verwendung einer pharmazeutischen Zusammensetzung, die Vitamin B12 in Kombination mit einem pharmazeutisch verträglichen Träger enthält, zur Herstellung eines Arzneimittels zur Behandlung atopischer Allergie im humanen Wirt in Form einer Pastille, die mit der buccalen Membrane kompatibel und im menschlichen Mund löslich ist und einen gegen Allergie wirksamen Gehalt an Vitamin B12 enthält, das durch die buccale Membrane absorbier- und übertragbar ist.

2. Verwendung nach Anspruch 1, wobei die Pastille so formuliert ist, dass sie vollständig im menschlichen Mund für die Absorption des Vitamins B12 durch die buccale Membrane löslich ist.

3. Verwendung nach Anspruch 1, enthaltend ein Agens zur kontrolierbaren zeitverzögernden Freigabe von Vitamin B12.

4. Verwendung nach Anspruch 1, enthaltend ein Eindringungsverstärker zur Verstärkung der Übertragung des Vitamins B12 in die und durch die buccale Membrane.

5. Verwendung nach Anspruch 1, enthaltend von ungefähr 1,000 bis ungefähr 5,000 Mikrogram des Vitamin B12 Analogs Cyanocobalamin, Methylcobalamin und/oder Hydroxycobalamin.

Revendications

1. Utilisation d'une composition pharmaceutique comprenant la vitamine B₁₂ en combinaison avec un véhicule pharmaceutiquement acceptable pour la fabrication d'un médicament pour le traitement de l'allergie atopique chez un hôte humain sous la forme pharmaceutique d'une tablette compatible avec la membrane buccale et soluble dans la bouche d'un humain et contenant une quantité efficace contre l'allergie de vitamine B₁₂ absorbable et transférable à travers la membrane buccale.

2. Utilisation selon la revendication 1, dans laquelle ladite tablette est formulée pour se dissoudre complètement dans la bouche humaine pour l'absorption de la vitamine B₁₂ par la membrane buccale.

3. Utilisation selon la revendication 1, contenant un agent de libération de vitamine B₁₂ à contrôle temporel.

4. Utilisation selon la revendication 1, contenant un amplificateur de pénétration pour augmenter le transfert de la vitamine B₁₂ dans et à travers la membrane buccale.

5. Utilisation selon la revendication 1, contenant d'environ 1000 à environ 5000 microgrammes d'analogue cyanocobalamine, méthylcobalamine et/ou hydroxycobalamine de la vitamine B₁₂.