Composition and method for the treatment of disorders of calcium metabolism

The water-soluble calcitonins and the water-soluble pharmaceutically-acceptable compounds of acidic nature which are effective against Paget's disease and which contain at least two acidic groups separated by not more than two carbon atoms act synergistically in inhibiting a pathological increased calcium metabolism rate (including the solubilization of bone calcium which occurs in Paget's disease). The components in combination, when administered in respectively preferred amounts, inhibit or arrest loss of calcium by the bones of the body with less severe side effects than those caused by equivalent therapeutic doses of the calcitonin alone or by equivalent therapeutic doses of the compounds of acidic nature alone.

FIELD OF THE INVENTION 
The present invention relates to compositions for inhibiting a pathological 
increased calcium metabolism rate as shown during Paget's disease (morbus 
Paget, osteodystrophia deformans), hypercalcemia and osteoporosis. The 
invention includes the compositions themselves in dry and dissolved bulk 
and unit dose state, methods for the preparation of the compositions, and 
the treatment of the above-mentioned diseases with those materials 
administered together or separately. The invention further includes a 
sterile package containing the components in forms suitable for dosing. 
BACKGROUND OF THE INVENTION 
Paget's disease causes a change in the composition and structure of the 
affected bones and results in their deformation. The disease appears in 
circumscribed areas and can affect one or a number of bones. It affects 
particularly frequently the bones of the sacrum, pelvis, femur, tibia, and 
the vault of the cranium. 
In Paget's disease the dimensions of the affected bone or bones increase 
about 10-fold and newly formed bone possesses a faulty structure and is 
undermineralized (i.e., it contains an insufficient proportion of calcium 
and similar elements). The increased volume of the bone can destroy 
adjacent nerves and blood vessels, and the low mineral content of the bone 
frequently leads to their undergoing spontaneous fracture (i.e., a 
fracturing which has no evident cause). Osteosarcomas frequently have 
their site in a locus which is affected by Paget's disease. 
In hypercalcemia, increased solubilization of calcium in bones frequently 
occurs in combination with a reduction in the amount of calcium secreted 
by the kidneys, and both these events lead to an increase of the calcium 
level in the blood serum of the mammal affected. The causes of this 
disease (hypercalcemia) have been ascribed to an increased sensitivity to 
vitamin D or to substances like vitamin-D which are produced in tumors 
(paraneoplastic syndrome). The symptoms of hypercalcemia have also been 
found in primary or secondary hyperparathyreoidism or in tumors (in many 
instances carcinomas) which secrete parathormone-like substances. 
Plasmacytomas or an estrogeninduced hypercalcemia are also possible. 
Osteoporosis is one of the most frequent disorders resulting from faulty 
bone metabolism (i.e., catabolism), and is characterized by a loss of bone 
substance, the bone otherwise remaining unchanged in composition. The 
disease is observed in mammals in general. In men, loss of bone substance 
generally starts at the ages of 40 to 50, and in women it occurs 
particularly frequently after menopause. Disorders in the hormone balance 
are frequently assumed to be the cause. But non-hormal factors, e.g. the 
immobility of extremities and food or medicine-related factors cannot be 
excluded from the genesis of osteoporosis. 
The loss of bone substance, measured as a percentage of the total calcium 
of the body before onset of the disease, can amount to 30%. Thinning of 
the cortical bones, as well as conversion of the bone to a spongy porous 
structure leads more frequently with increasing age to spontaneous 
fractures. 
Up to the present, treatments of the above-mentioned bone diseases have 
been unsatisfactory. Attempts were made to slow down degradation or 
alteration of the bones by administration of corticoids and salicylates, 
but it was found that effective doses of these medicaments led rapidly to 
undesired side effects. Indomethacin, phenylbutazone and substances which 
stimulate the circulation provided temporary relief to the patient, but 
they had no effect on the progress of the disease. Treatments with sodium 
fluoride produced visible results only in a few cases. 
In the last few years two new therapies were found which provided better 
results, particularly in Paget's disease. The hormone calcitonin, (also 
termed "thyrocalcitonin") which is responsible in the organism of mammals 
(including humans), together with Parathormone (i.e., the parathyroid 
hormone) for calcium homeostasis and which is formed in the parafollicular 
cells of the thyroid gland was found to have a definite efficacy. 
Calcitonin itself is a polypeptide hormone composed of 32 amino acid 
units. This material, as well as several animal analogs (of salmon, pig 
and cattle), and their synthetic analogs (hereinafter termed 
"calcitonins") possess the property of decreasing the level of ionic 
calcium (Ca.sup.2+) in the blood serum rapidly; they also possess the 
property of causing dissolved calcium to be absorbed or to be reabsorbed 
by the bone. Prolonged treatment with human calcitonin, and particularly 
with its synthetic and animal produced analogs, presents the danger of 
causing undesirable formation of antibodies and a resulting 
incompatibility. In addition, therapy with calcitonin does not result in a 
complete regression of the principal symptoms of Paget's disease, e.g. the 
increase in the alkaline phosphatase level in the blood serum and the 
increase in the secretion of hydroxyproline in the urine. 
Another therapy of the above-described disorders of bone metabolism in man 
and other mammals is based on the administration of certain water-soluble 
diphosphonic compounds and other acidic compounds. These substances act 
primarily on the mineral phase of the bone and decrease the 
crystallization of apatite and the solubility of the bone materials. In 
addition, they appear to provide sites for absorption of the soluble 
calcium ions in the blood. The latter effect is based on a strong 
chemisorption of these compounds on the surface of calciferous minerals 
like apatite. These compounds contain at least two acidic substituents 
(e.g. phosphono, carboxy and sulfo) separated by not more than two carbon 
atoms, and come from the group consisting of the water-soluble 
aminophosphonic acids, the water-soluble amidophosphonic acids, the 
water-soluble carboxyphosphonic acids, cyclohexanehexacarboxylic acid, and 
the water-soluble salts thereof. 
The increased rate of degenerative bone metabolism can be decreased by oral 
administration of these acidic inhibitors. Good results are obtained 
particularly in controlling Paget's disease. Hypercalcemia is also 
decreased, and osteoporosis of the bones undergoes reversal. 
Though these compounds are more effective than calcitonin, prolonged 
therapy therewith has been found to provide undesired side effects. Not 
only is the rate of dissolution of the bone minerals decreased, but 
mineralization of the bones is inhibited, the number of unmineralized 
osteoplasts increases, and an increase in the number of osteo disorders 
occurs when large doses are administered. 
DESCRIPTION OF THE INVENTION 
The discovery has now been made that a combination of the therapy of 
administration of the calcitonins and certain pharmaceutically-acceptable 
aminophosphonic acids, amidophosphonic acids, carboxyphosphonates and 
cyclohexanehexacarboxylic acids (and their pharmaceutically-acceptable 
water-soluble salts), as more particularly stated above, when employed 
together as treating agents against the diseases mentioned, provide very 
satisfactory therapeutic results; i.e., the combination arrests the 
diseases or decreases their severity, while causing less severe side 
reactions, with substantially decreased dosages. The components therefore 
appear to interact synergistically. The invention appears to be generally 
applicable to combinations of the calcitonins with water-soluble 
pharmaceutically acceptable compounds containing at least two acidic 
substituents separated by not more than two carbon atoms. 
The invention thus combines the advantages of the two individual therapies 
without incorporating their disadvantages. The decrease of the calcitonin 
dose greatly decreases the danger of the formation of antibodies. The 
decrease of the dose of the acid component (the aminophosphonic acids, 
amidophosphonic acids, cyclohexane hexacarboxylic acids, and the 
pharmacologically harmless watersoluble salts of these acids) leads in 
Paget's disease to a clear decrease in the content of alkaline 
phosphatases in blood serum and in the content of hydroxyproline in the 
urine, without the formation of visible osteoid borders. The general 
tolerability of the therapeutically effective doses of the combination of 
agents (even when they are administered separately, by different routes) 
is much better than that of each of the agents administered singly in 
therapeutically effective amounts. The treatment can thus be continued 
over a longer period of time, and undesired side effects are at a low 
level. 
The compositions of the present invention thus comprise (A) a water-soluble 
calcitonin and (B) a water-soluble pharmaceutically acceptable adjuvant 
organic compound which is effective against Paget's disease which contains 
at least two acidic groups separated by not more than two carbon atoms and 
which is selected from the group consisting of the water-soluble 
aminophosphonic acids, the amidophosphonic acids, the carboxyphosphonic 
acids, cyclohexane-hexacarboxylic acid, and the water-soluble salts 
thereof, the ratio of (A) to (B) being from 1:10 to 10:1, if the amount of 
(A) is expressed in MRC units and (B) in mg. Two or more of the organic 
acidic compounds can be present. 
The composition can be present in a single injectible solution in a 
pharmaceutically acceptable injectable liquid, which, if desired, can be 
present in emulsified state in a pharmaceutically acceptable oil to retard 
the absorption time. If desired, the composition can be present in unit 
dose form. 
The adjuvant can be prepared for unit dose administration as a compressed 
tablet or dragee, or can be prepared as an encapsulated loose powder. 
In numerous instances no need will be found to administer the calcitonin 
more than once a day, but it will often be found desirable to administer 
the adjuvant as many as four times a day. Accordingly, the invention 
includes a hermetically sealed, sterile daily dose package for dosing a 
mammal suffering from pathological increased calcium metabolism, which 
comprises at least one sterile ampoule containing calcitonin in an amount 
sufficient to supply from 0.01 to 20 international medical research 
council units per kilogram of body weight and at least one tablet 
containing between 25 mg. and 400 mg. of a water-soluble adjuvant compound 
as is described above. With this package it becomes convenient to 
administer by injection the single daily dose of calcitonin and to 
administer the adjuvant in uniformally spaced doses orally. 
The invention further provides an emulsion in oil of an aqueous solution of 
the calcitonin and the adjuvant, permitting both to be injected in slowly 
absorbable form. 
The invention further provides a method of inhibiting the pathological 
increased calcium metabolism in mammals, which comprises administering 
daily thereto (A) a water-soluble calcitonin and (B) a water-soluble 
pharmaceutically acceptable organic adjuvant compound, said adjuvant 
compound containing at least two acidic groups separated by not more than 
two carbon atoms and being selected from the group consisting of the 
water-soluble aminophosphonic acids, the water-soluble amidophosphonic 
acids, the carboxyphosphonic acids, cyclohexanehexacarboxylic acid, and 
the water-soluble salts thereof, the amount of said calcitonin being 
sufficient to supply between about 0.01 and 20 Medical Research Council 
units thereof per kilogram of body weight per day, and the amount of said 
adjuvant being 1:10 to 10:1 times the amount of said calcitonin, if the 
amount of calcitonin is expressed in MRC units and the amount of adjuvant 
in mg. 
The new pharmaceutical preparations for the treatment of the 
above-described disorders of calcium metabolism (i.e., for decreasing the 
solubilization of bone calcium in mammals) are characterized in that they 
contain as one active substances a calcitonin and as the other active 
airstance at least one other active component which acts as adjuvant 
selected from the aforementioned groups. More particularly, the groups are 
as follows. (a) Aminophosphonic and amidophosphonic acids of the general 
formula: 
##STR1## 
wherein R is a hydrogen atom or C.sub.1-6 alkyl, and n is 1 to 3; 
##STR2## 
wherein R is H or C.sub.1-4 ; alkyl, and n is 1 to 3; 
##STR3## 
wherein R is H or C.sub.1-6 alkyl; 
##STR4## 
wherein R is H or C.sub.1-6 alkyl; 
##STR5## 
wherein R is H or C.sub.1-4 alkyl, and n is 3 to 6; 
##STR6## 
wherein R.sub.1 and R.sub.2 represent H or C.sub.1-3 alkyl; (b) 
carboxyphosphonic acids of the general formula: 
##STR7## 
wherein R represents H or a C.sub.1-3 alkyl, R.sub.1 represents --PO.sub.3 
H.sub.2, 
##STR8## 
wherein R.sub.2 represents H, C.sub.1-3 alkyl, 
##STR9## 
and (c) cyclohexane-1,2,3,4,5,6-hexacarboxylic acid; and 
(d) the pharmacologically harmless salts of the above compounds. 
When the calcitonin is administered by injection, the dose of calcitonin is 
in an amount sufficient to provide from 0.01 to 20 International Medical 
Research Council units per kilogram of body weight. 
When both the components are administered by injection, the ratio of 
calcitonin to adjuvant is generally between 1:1 and 10:1, if the amount of 
calcitonin is expressed in MRC units and the amount of adjuvant in mg. 
When the calcitonin is administered by injection and the adjuvant is 
aministered orally, the ratio of calcitonin to adjuvant is generally 
between 1:10 and 1:1, if the amount of calcitonin is expressed in MRC 
units and the amount of adjuvant in mg. 
The calcitonins which are suitable for use in the invention comprise 
synthetic and natural human calcitonin and the natural calcitonin of pigs, 
cattle and salmon and synthetic calcitonins of those latter types. Natural 
calcitonins, the biological effectiveness of which has been modified by 
replacement of individual amino acid groups in their peptide chain (which 
consists of 32 amino acid units) can be used equally well. Certain of 
these modified calcitonins are commercially available. 
Aminophosphonic acids of formula (I) can be prepared by reacting 
shorter-chained substituted or unsubstituted dicarboxylic amides, 
.alpha.,.omega.-dinitriles, or an appropriate imide (for example 
succinimide) with phosphonylating agents, like phosphorus trihalides for 
example PCl.sub.3 or H.sub.3 PO.sub.3, followed by acid hydrolysis. 
Diaminoalkane-tetraphosphonic acids of formula (II) can be prepared by 
reacting the longer chain, substituted or unsubstituted dicarboxylic 
diamides or .alpha.,.omega.-dinitriles with phosphonylating agents, like 
phosphorus trihalides or H.sub.3 BO.sub.3, followed by acid hydrolysis. 
Pyrrolidone-5,5-diphosphonic acids of formula (III) are preferably prepared 
by highly alkaline hydrolysis of amino-phosphonic acids of formula I 
wherein n is 3. 
Piperidone-6,6-diphosphonic acids of formula (IV) are preferably prepared 
by highly alkaline hydrolysis of aminophosphonic acids of formula I 
wherein n is 3. 
Azacycloalkane-2,2-diphosphonic acids of formula (V) can be prepared by 
reacting lactams with phosphonylating agents like phosphorus trihalides or 
H.sub.3 PO.sub.3. 
3-Amino-1-hydroxypropane-1,1-diphosphonic acids of formula (VI) can be 
prepared by phosphonylating .beta.-alanine or .beta.-alanine alkylated on 
the nitrogen atom with phosphorus trihalides or H.sub.3 PO.sub.3. 
The above-mentioned phosphonic acids can be converted to partial or 
complete salt form by neutralization in aqueous solution with an 
appropriate amount of the indicated base. 
The pharmacologically harmless salts of the above compounds of acidic 
character (e.g., sodium, potassium, magnesium, zinc, ammonium and 
substituted ammonium salts like the mono, di, or triethanol ammonium 
salts) are suitable for use in the compositions of the present invention 
instead of or in combination with the above-mentioned aminophosphonic 
acids. Both the partial salts (i.e. salts in which only a part of the acid 
protons is substituted by other cations), and the complete salts can be 
used, but the partial salts which provide a substantially neutral or 
mildly alkaline pH in aqueous solution (i.e., a pH in the range of 5 to 9) 
are preferred. Mixtures of the above-mentioned salts can likewise be used. 
The required amount of the adjuvant of the present invention to be 
administered depends on the disease to be treated, the severity of the 
disease, and the duration of the treatment. Single doses can be tolerated 
between 0.1 mg. and 200 mg. per kilogram of body weight. Doses between 0.5 
mg. and 30 mg/kg. are preferable and up to 4 doses within this range can 
be administered per day. The higher doses are administered orally because 
absorption of the agent by the body is incomplete when they are 
administered in this way. Repeated administrations of more than 100 mg/kg 
of the adjuvant can cause toxic symptoms and should be avoided, even when 
the compound is administered per os. 
The following table shows suggested oral doses of the adjuvants for 
different diseases: 
______________________________________ 
Oral Dose Up to 
Disease 4 Times Daily 
______________________________________ 
Paget's disease 
1 to 20 mg./kg. of 
body weight 
Osteoporosis 0.5 to 10 
Hypercalcemia 0.5 to 20 
______________________________________ 
A higher initial dose may be necessary, for example, up to twice the amount 
of the normal or maintenance dose shown above. 
The adjuvants can also be administered parenterally in aqueous solution by 
subcutaneous, intradermal, intermuscular, intraperitoneal and intravenous 
injection, preferably in the form of their neutral or mildly alkaline 
salts. The following doses are prepared when the adjuvant is administered 
by injection. 
______________________________________ 
Parentertal Dose Up 
Method to 4 Times Daily 
______________________________________ 
Subcutaneous 0.1 to 10 mg/kg of 
body weight 
Intradermal 0.1 to 10 
Intramuscular 0.05 to 5 
Intravenous 0.05 to 5 
Intraperitoneal 
0.05 to 5 
______________________________________ 
Oral administration is preferred, however. The adjuvants can be present in 
the form of solutions (which preferably have a mildly alkaline pH), in 
which event the compounds are present in the form of their partial salts. 
For oral administration the compounds are provided in convenient dose 
units, e.g. in the form of capsules, dragees, tablets, or pills alone or 
in admixture with diluents, carriers, flavors, colorants, etc. 
Calcitonin is preferably administered in aqueous solution by subcutaneous, 
intradermal, intramuscular, intraperitoneal or intravenous injection. 
The following doses are preferred when the calcitonin is administered by 
injection: 
______________________________________ 
Dose (units per 
Method of Injection 
kilogram of body weight per day) 
______________________________________ 
Subcutaneous 0.02 to 20 MRC 
Intradermal 0.02 to 20 
Intramuscular 0.01 to 10 
Intraperitoneal 
0.01 to 10 
Intravenous 0.01 to 10 
______________________________________ 
The international MRC (Medical Research Council) unit for calcitonin is 
defined as 1/10 of the amount of calcitonin which causes the concentrates 
of calcium in the blood plasma of a rat weighing 150 g. to decrease by 10% 
in the first hour after injection intravenously. 
Synthetic human calcitonin and pig calcitonin have activities of about 100 
MRC units per mg. The activity of natural salmon calcitonin is about 3,000 
to 4,000 MRC units per mg. 
Phosphonoalkane-polycarboxylic acids suitable for use in the present 
invention are listed in the following table. 
TABLE 1 
Phosphono-ethane-1,2-dicarboxylic acid 
1-Phosphono-propane-1,2-dicarboxylic acid 
1-Phosphono-pentane-1,2-dicarboxylic acid 
2-Phosphono-propane-2,3-dicarboxylic acid 
2-Phosphono-pentane-1,2-dicarboxylic acid 
2-Phosphono-butane-2,3-dicarboxylic acid 
2-Phosphono-pentane-2,3-dicarboxylic acid 
4-Phosphono-octane-4,5-dicarboxylic acid 
2-Phosphono-butane-1,2,4-tricarboxylic acid 
2-Phosphono-pentane-1,2,4-tricarboxylic acid 
2-Phosphono-hexane-1,2,4-tricarboxylic acid 
2-Phosphono-heptane-1,2,4-tricarboxylic acid 
3-Phosphono-pentane-2,3,5-tricarboxylic acid 
3-Phosphono-heptane-1,3,4-tricarboxylic acid 
3-Phosphono-hexane-2,3,5-tricarboxylic acid 
4-Phosphono-octane-3,4,6-tricarboxylic acid 
5-Phosphono-nonane-4,5,7-tricarboxylic acid 
3-Phosphono-octane-2,3,5-tricarboxylic acid 
1,3-Diphosphono-butane-3,4-dicarboxylic acid 
2,4-Diphosphonopentane-4,5-dicarboxylic acid 
3,5-Diphosphonohexane-5,6-dicarboxylic acid 
2,4-Diphosphonoheptane-1,2-dicarboxylic acid 
1,3-Diphosphonopentane-3,4-dicarboxylic acid 
1,3-Diphosphonohexane-3,4-dicarboxylic acid 
2,4-Diphosphonohexane-4,5-dicarboxylic acid 
3,5-Diphosphonooctane-5,6-dicarboxylic acid 
3,5-Diphosphonononane-5,6-dicarboxylic acid 
3,5-Diphosphonooctane-2,3-dicarboxylic acid 
1,3-Diphosphonobutane-2,3,4-tricarboxylic acid 
1,3-Diphosphono-pentane-2,3,4-tricarboxylic acid 
1,3-Diphosphono-heptane-2,3,4-tricarboxylic acid 
1-Phosphono-propane-1,2,3-tricarboxylic acid 
2-Phosphono-butane-2,3,4-tricarboxylic acid 
3-Phosphono-pentane-1,2,3-tricarboxylic acid 
3-Phosphono-hexane-1,2,3-tricarboxylic acid 
4-Phosphono-heptane-2,3,4-tricarboxylic acid 
2-Phosphono-hexane-2,3,4-tricarboxylic acid 
4-Phosphono-nonane-4,5,6-tricarboxylic acid 
2-Phosphono-pentane-2,3,4-tricarboxylic acid 
3-Phosphono-heptane-3,4,5-tricarboxylic acid 
1-Phosphono-2-methyl-propane-1,2,3-tricarboxylic acid 
2-Phosphono-3-ethyl-butane-2,3,4-tricarboxylic acid 
3-Phosphono-4-methyl-pentane-3,4,5-tricarboxylic acid 
4-Phosphono-5-propyl-hexane-4,5,6-tricarboxylic acid 
2-Phosphono-3-methyl-hexane-2,3,4-tricarboxylic acid 
4-Phosphono-5-methyl-nonane-4,5,6-tricarboxylic acid 
1-Phosphono-2-methyl-pentane-1,2,3-tricarboxylic acid 
2-Phosphono-3-methyl-pentane-2,3,4-tricarboxylic acid 
3-Phosphono-4-ethyl-heptane-3,4,5-tricarboxylic acid 
1,1-Diphosphono-propane-2,3-dicarboxylic acid 
2,2-Diphosphono-butane-3,4-dicarboxylic acid 
3,3-Diphosphono-pentane-4,5-dicarboxylic acid 
3,3-Diphosphono-hexane-1,2-dicarboxylic acid 
2,2-Diphosphono-pentane-3,4-dicarboxylic acid 
4,4-Diphosphono-heptane-2,3-dicarboxylic acid 
1,1-Diphosphono-pentane-2,3-dicarboxylic acid 
3,3-Diphosphono-heptane-4,5-dicarboxylic acid 
1,1-Diphosphono-2-methyl-propane-2,3-dicarboxylic acid 
2,2-Diphosphono-3-methyl-butane-3,4-dicarboxylic acid 
2,2-Diphosphono-3-methyl-pentane-3,4-dicarboxylic acid 
3,3-Diphosphono-4-ethyl-heptane-4,5-dicarboxylic acid 
2,2-Diphosphono-3-propyl-heptane-3,4-dicarboxylic acid 
1-Phosphono-butane-2,3,4-tricarboxylic acid 
1-Phosphono-pentane-2,3,4-tricarboxylic acid 
1-Phosphono-3-methyl-pentane-2,3,4-tricarboxylic acid 
1-Phosphono-3-methyl-heptane-2,3,4-tricarboxylic acid 
1-Phosphono-3-propyl-hexane-2,3,4-tricarboxylic acid 
1-Phosphono-3-methyl-butane-2,3,4-tricarboxylic acid 
1-Phosphono-3-propyl butane-2,3,4-tricarboxylic acid 
The above-mentioned acids can also be employed in the form of their full or 
partial salts with water-soluble physiologically harmless cations. 
Suitable cations include the sodium, potassium, magnesium, and ammonium, 
as well as ammonium substituted by alkanol groups in the form of mono-, 
di-, and triethanolammonium cations. Both the partial salts, in which only 
a part of the acid protons is substituted by other cations, and the 
complete salts can be used, but partial salts which provide a 
substantially neutral to slightly alkaline pH (i.e., pH in the range of 5 
to 9) when dissolved in water are preferred. Mixtures of the 
above-mentioned salts can likewise be used. 
Particularly good results are obtained when calcitonin is administered 
together with the sodium partial salts of the following 
carboxyphosphonates: 
1. 1,2-Phosphono-ethane-dicarboxylic acid (2:1 by weight mixture of the 
disodium and trisodium salts). 
2. 2-Phosphono-2,3-propane-dicarboxylic acid (2:1 by weight mixture of the 
disodium and trisodium salts). 
3. 2-Phosphono-1,2,4-butane-tricarboxylic acid (trisodium salt). 
The phosphonealkane polycarboxylic acids used are prepared according to 
known methods. 
1-Phosphono-1,2-ethane-dicarboxylic acid can be prepared by reaction of 
maleic ester (diethyl maleate) with diethyl phosphite in the presence of 
sodium alcoholate followed by acid saponification of the ester. 
2-Phosphono-2,3-propane dicarboxylic acid can be obtained in the same 
manner with addition of the step of reacting the mixture with methyl 
chloride before the saponification step. 
1-Phosphono-1,2,3-propane-tricarboxylic acid can be prepared by reacting 
maleic ester with phosphonoacetic ester (ethyl phosphonoacetate) in the 
presence of sodium alcoholate and subsequent saponification of the ester 
obtained. 1-Phosphono-2,3,4-butane tricarboxylic-acid can also be obtained 
by reacting dimethyl phosphite with 1-butane-2,3,4-tricarboxylic acid in 
the presence of sodium alcoholate followed by saponification of the ester 
thus obtained to the acid. 
By reacting a lower alkyl methane-diphosphonate with a lower alkyl maleate 
in the presence of sodium alcoholate an ester is obtained which is 
converted by acid hydrolysis into 1,1-diphosphono-2,3-propane dicarboxylic 
acid. 
2-Phosphono-2,3,4-butane-tricarboxylic acid can be obtained by reacting the 
methyl ester of .alpha.-diethyl phosphonopropionic acid with diethyl 
maleate in the presence of sodium alcoholate followed by saponification of 
the ester obtained. 
The production of 2,2-diphosphono-3,4-butane-dicarboxylic acid is effected 
by reacting diethyl maleate with ethyl ethane-1,1-diphosphonate in the 
presence of sodium alcoholate followed by acid saponification of the 
product obtained. 
The other phosphonalkane polycarboxylic acids are obtained by an analogous 
method where particularly ethyl citraconate is used instead of diethyl 
maleate. 
The production of the corresponding water-soluble salts can be effected by 
complete or partial neutralization of the acids with water-soluble 
inorganic bases e.g. NaOH, KOH, and NH.sub.4 OH or with alkanolamines, as 
well as with alkali metal carbonates. 
Cyclohexane-1,2,3,4,5,6-hexacarboxylic acid can be prepared by partially 
hydrogenating phthalic acid to form 3,5-cyclohexadiene-1,2-dicarboxylic 
acid, reacting the product with maleic anhydride to form bicyclo-2,2,2, 
7-octane-2,3,5,6-tetracarboxylic acid, and catalytically oxidizing this 
intermediate. 
Such a method is described as French Pat. No. 1,563,486. The acid can be 
converted in known manner by complete or partial neutralization into the 
desired salts. 
For pharmaceutical applications, instead of the free acids the 
pharmacologically harmless salts thereof can be used, e.g., the sodium, 
potassium, magnesium, zinc, ammonium and substituted ammonium salts (e.g., 
the mono, di, or triethanol ammonium salts). Both the partial salts (in 
which only a part of the acid protons present in the acid substituent is 
substituted by other cations) and the complete salts can be used, but 
partial salts which provide a substantially neutral or slightly alkaline 
pH in aqueous solution (pH 5-9) are preferred. Mixtures of the 
above-mentioned salts can likewise be used. 
Cyclohexanehexacarboxylic acid in the form of its neutral salts can also be 
administered parenterally in aqueous solution by subcutaneous, 
intradermal, intramuscular, intrapertioneal or intravenous injection. 
The invention is illustrated by the examples which follows. These examples 
provide illustrations of the invention and are not to be construed in 
limitation thereof.

EXAMPLE 1 
The following illustrates the treatment of a case of Paget's disease by 
subcutaneous injection of calcitonin and oral administration of a 
substantially neutral salt of an aminophosphonate adjuvant in weight ratio 
of 1:20, the material being administered twice daily, the materials being 
administered respectively at the rate of 0.5 mg. and 5 mg. per kilogram of 
body weight per day. 
A patient weighing about 70 kg. who suffered from Paget's disease, and 
whose blood serum showed greatly increased alkaline phosphatases and whose 
urine showed greatly increased hydroxyproline values, was treated twice 
daily with 0.5 mg. of synthetic human calcitonin (administered by 
subcutaneous injection) at rate of 1.4 MRC units/kg. of body weight per 
day and 350 mg. of disodium 3-amino-1-hydroxypropane-1,1-diphosphonate 
(administered orally). The amino-diphosphonate was administered as a dry 
powder contained in an ordinary capsule with additional components as 
follows: 
______________________________________ 
Mg. per 
Component Capsule 
______________________________________ 
Disodium 3-amino-hydroxy- 
350.0 
propane-1,1-diphosphonate 
Starch 47.5 
Sodium lauryl sulfate 2.5 
______________________________________ 
After 4 weeks of the therapy, the biochemical control values had dropped 
considerably. After four months of the therapy the blood serum alkaline 
phosphatase and the urine hydroxyproline values were normal. The 
histological condition of the bones was likewise normal, and in particular 
there was no unmineralized osteoid tissue. 
Similar results are obtained when the disodium salt of 
2,7-dioxo-2-hydroxy-3-amino-3-phosphono-1,2-azaphosphacycloheptane or the 
disodium salt of azacycloheptane-2,2-diphosphonic acid is used. Similar 
results are also obtained if the synthetic human calcitonin is replaced by 
equivalent amounts of other calcitonins. 
EXAMPLE 2 
The following illustrates the treatment of a case of Paget's disease by 
subcutaneous administration of calcitonin and intravenous administration 
of a substantially neutral salt of an aminophosphonic acid, the materials 
being administered twice daily. 
A patient weighing about 55 kg. who suffered from Paget's disease and 
showed greatly increased blood serum phosphates and urine hydroxyproline 
values was treated twice daily with 0.2 mg. of synthetic human calcitonin 
(administered subcutaneously (equivalent to 0.7 MRC units per kilogram of 
body weight per day) and 25 mg. of the disodium salt of 
2,7-dioxo-2-hydroxy-3-amino-3-phosphono-1,2-azaphosphacycloheptane 
(administered intravenously.) After a few weeks of treatment the 
biochemical values had dropped considerably and the bone aches 
disappeared. After a few months of the treatment the condition of the 
patient was almost normal. In particular, histological examination 
revealed no unmineralized osteoid tissue. 
Similar results are obtained when the disodium salts of 
3-amino-1-hydroxypropane-1,1-diphosphonic acid or of 
azacycloheptane-2,2-diphosphonic acid are used. Instead of the synthetic 
human calcitonin, equivalent amounts of other calcitonins can be used. 
EXAMPLE 3 
The following illustrates the preparation of tablets of the adjuvant 
component in unit dose form suitable for oral administration, and the use 
thereof in the treatment of a patient suffering from osteoporosis. 
Tablets are produced in conventional manner by compacting the following 
mixture. 
______________________________________ 
Mg. per 
Components Tablet 
______________________________________ 
Disodium azacycloheptane- 
250.0 
2,2-diphosphonate 
Lactone 80.0 
Starch 19.0 
Magnesium stearate 1.0 
______________________________________ 
With oral administration of one tablet twice daily and daily injection of 
0.02 mg. of synthetic salmon calcitonin (80 MRC units/kg. of body weight) 
administered intramuscularly, loss of bone substance is considerably 
reduced in osteoporosis patients of about 50-70 kg. of body weight. During 
the period running from the start of the therapy for one year no 
spontaneous fractures were observed. 
Similar results were obtained with the administration of tablets which were 
formulated in a similar manner, but which respectively contained, instead 
of the disodium salt of the azacycloheptane-2,2-diphosphonic acid, (a) the 
disodium salt of 3-amino-1-hydroxypropane-1,1-diphosphonic acid and (b) 
2,7-dioxo-2-hydroxy-3-amino-3-phosphono-1,2-azaphosphacycloheptane. Other 
pharmaceutically acceptable tabletting aids than lactose, starch and 
magnesium stearate can be present without impairing the effectiveness of 
the phosphonic acid. 
Similar results are also obtained when the synthetic salmon calcitonin is 
replaced by equivalent amounts of other calcitonins. 
EXAMPLE 4 
The following illustrates the preparation of a dragee containing an 
adjuvant of the present invention and the treatment therewith in 
conjunction with calcitonin of a patient suffering from hypocalcemia. 
Dragees are produced in conventional manner with a core which consists of 
the following components. 
______________________________________ 
Mg. per 
Components Dragee 
______________________________________ 
Disodium 3-amino-1-hydroxy- 
propane 1,1-diphosphonate 
250.0 
Lactose 60.0 
Starch 12.0 
Carboxymethyl cellulose 18.0 
Talcum 8.0 
Calcium stearate 2 
______________________________________ 
With oral administration of one dragee twice daily and with daily injection 
of 0.75 mg. of synthetic pig calcitonin (75 MRC units subcutaneously) a 
drop in the calcium ion content of the blood serum is observed after a few 
hours in a hypercalcemia patient weighing 70 kg. In the course of a few 
days the serum calcium value again attains the normal value in most 
patients. 
Similar results are obtained when the disodium salts of 
2,7-dioxo-2-hydroxy-3-amino-3-phosphono-1,2-azaphosphacycloheptane and of 
azacycloheptane-2,2-diphosphonic acid are respectively used. 
Similar results are also obtained when the pig calcitonin is replaced with 
equivalent amounts of other calcitonins. 
EXAMPLE 5 
The following illustrates the treatment of a patient suffering from Paget's 
disease by subcutaneous administration of calcitonin and by administration 
of an adjuvant in powdered encapsulated form. 
A patient weighing about 70 kg. who suffered from Paget's disease and who 
showed greatly increased phosphatase and urine hydroxyproline values, was 
treated twice daily with 0.5 mg. of synthetic human calcitonin 
administered subcutaneously (equivalent of 1.4 MRC units per kilogram of 
body weight per day) and 350 mg. of 2-phosphonopropane-2,3 dicarboxylic 
acid (2:1 mixture of the disodium and trisodium salts) administered 
orally. The carboxyphosphonate is administered in admixture with carrier 
material in capsules of the following composition. 
______________________________________ 
Mg. per 
Components Capsule 
______________________________________ 
2-Phosphono-propane-2,3 
dicarboxylic acid 
(2:1 mixture of 
disodium: trisodium 
salts) 350.0 
Starch 47.5 
Sodium lauryl sulfate 2.5 
______________________________________ 
After 4 weeks of therapy the biochemical control values have dropped 
considerably. The bone aches have completely disappeared. After four 
months the alkaline phosphatase and the urine-hydroxyproline values are 
normal. The histological finding is also normal, in particular there is no 
unmineralized osteoid tissue. 
Similar results are obtained when (a) a 2:1 mixture of the disodium and 
trisodium salts of phosphonoethane-1,2-dicarboxylic acid and (b) trisodium 
2-phosphono-propane-2,3-dicarboxylate are used. Instead of synthetic human 
calcitonin can also be used equivalent amounts of other calcitonins. 
EXAMPLE 6 
A patient weighing about 55 kg. who suffered from Paget's disease and who 
showed greatly increased blood serum alkaline phosphatase and urine 
hydroxyproline values was treated twice daily with 0.2 mg. of synthetic 
human calcitonin (equivalent to 0.7 MRC units per kilogram of body weight 
per day) administered subcutaneously and 25 mg. of trisodium 
2-phosphonobutane-1,2,4-tricarboxylate (administered intravenously). After 
a few weeks the biochemical control values of the patient dropped 
considerably and bone aches disappeared. After a few months the condition 
of the patient was almost normal. In particular, the histological findings 
show no unmineralized osteoid tissue. 
Similar results are obtained when 2:1 mixtures of the disodium and 
trisodium salts of phosphonoethane-1,2-dicarboxylic acid and 
2-phosphono-propane-2,3-dicarboxylic acid are used. Instead of the 
synthetic human calcitonin can also be used equivalent amounts of other 
calcitonins. 
EXAMPLE 7 
The following illustrates the treatment of a case of Paget's disease by 
subcutaneous administration of calcitonin and oral administration of the 
adjuvant. 
Unit dose tablets of the following composition are produced by tabletting a 
homogenous mixture of the following materials. 
______________________________________ 
Mg. per 
Components Tablet 
______________________________________ 
Trisodium 2-phosphono-butane 
250.0 
1,2,4-tricarboxylate 
Lactose 80.0 
Starch 19.0 
Magnesium stearate 1.0 
______________________________________ 
With oral administration twice daily and daily subcutaneous injection of 
0.02 mg. of synthetic salmon calcitonin (80 MCR units per kilogram of body 
weight per day administered intramuscularly), loss of bone matter is 
considerably reduced in patients of about 50 - 70 kg. body weight. In a 
period of one year after the start of the therapy no spontaneous fractures 
are observed. 
Similar results are obtained with the administration of tablets similarly 
made but which respectively contain instead of trisodium salt of 
2-phosphono-butane-1,2,4 tricarboxylic acid (a) a mixture of the disodium 
and trisodium salts in 2:1 ratio of phosphono-ethane-1,2-dicarboxylic acid 
and (b) 2-phosphono-propane-2,3-carboxylic acid. 
Similar results are also obtained when the synthetic salmon calcitonin is 
replaced by corresponding doses of other calcitonins. 
EXAMPLE 8 
In a known manner are produced dragees the core of which consists of a 
tablet of the following materials. 
______________________________________ 
Mg. per 
Components Dragee 
______________________________________ 
Phosphonoethane-1,2- 
dicarboxylic acid 
(2:1 mixture of 
disodium and trisodium 
salts) 250.0 
Lactose 60.0 
Starch 12.0 
Carboxymethyl cellulose 
18.0 
Talcum 8.0 
Calcium stearate 2.0 
______________________________________ 
With oral administration of one dragee twice daily and daily injection of 
0.75 mg. of synthetic pig calcitonin (75 units per kilogram of body 
weight, administrated subcutaneously) a drop of the calcium level is 
observed after a few hours in a hypercalcemia patient weighing 70 kg. 
In the course of a few days the serum calcium value again attains in most 
patients the normal value. 
Similar results are obtained when trisodium 
2-phosphono-butane,1,2,4-tricarboxylate or a mixture of the disodium and 
trisodium salts (ratio 2:1) of 2-phosphonopropane-2,3-dicarboxylic acid is 
used. 
Similar results are also obtained with equivalent amounts of other 
calcitonins. 
EXAMPLE 9 
A patient of about 70 kg. who suffered from Paget's disease and showed 
greatly increased alkaline phosphatase and urine hydroxyproline values, 
was treated twice daily with 0.5 mg. of synthetic human calcitonin 
(equivalent to 1.4 MRC units per kilogram of body weight per day) and 350 
mg. of trisodium cyclohexane-1,2,3,4,5,6-hexacarboxylate (administered 
orally) in the form of capsules of the following composition: 
______________________________________ 
Mg. per 
Components Capsule 
______________________________________ 
Trisodium cyclohexane- 
1,2,3,4,5,6-hexa- 
carboxylate 350.0 
Starch 47.5 
Sodium lauryl sulfate 2.5 
______________________________________ 
After 4 weeks of therapy, the biochemical control values were considerably 
lower than at the start, and the bone aches had completely disappeared. 
After 4 months the blood serum alkaline phosphatase and the urine 
hydroxyproline values are normal. The histological finding is also normal. 
In particular there is no unmineralized osteoid tissue. 
Similar results are obtained when the synthetic human calcitonin is 
replaced by corresponding doses of other calcitonins. 
EXAMPLE 10 
A patient of about 55 kg. who suffered from Paget's disease and who showed 
greatly increased blood serum, alkaline phosphatase and urine 
hydroxyproline values was treated twice daily by administration of 0.2 mg. 
of synthetic human calcitonin (equivalent to 0.7 MRC units per kilogram of 
body weight per day) and 25 mg. of trisodium cyclohexane 
1,2,3,4,5,6-hexacarboxyate administered intravenously. After a few weeks 
the biochemical control values were considerably lower and the bone aches 
had disappeared. After a few months the condition of the patient was 
greatly normalized, in particular the histological findings show no 
unmineralized osteoid tissue. 
Similar results are obtained when the synthetic human calcitonin is 
replaced by corresponding doses of other calcitonins. 
EXAMPLE 11 
Unit doses of an equivalent according to the present invention are produced 
by tabletting the following mixture. 
______________________________________ 
Mg. per 
Component Tablet 
______________________________________ 
Trisodium cyclohexane- 
1,2,3,4,5,6-hexa- 
carboxylate 250.0 
Lactose 80.0 
Starch 19.0 
Magnesium stearate 1.0 
______________________________________ 
With oral administration of one tablet of the adjuvant twice daily (total 
500 mg.) and daily injection of 0.02 mg. of synthetic salmon calcitonin 
(80 MRC units per kilogram of body weight per day, administered 
intramuscularly), loss of bone is considerably reduced in osteoporosis 
patients of about 50 - 70 kg. body weight. In a period of one year from 
the start of the therapy no spontaneous fractures were observed. 
Similar results are also obtained when the synthetic salmon calcitonin is 
replaced by therapeutically equivalent amounts of other calcitonins. 
EXAMPLE 12 
Dragees containing an acid adjuvant suitable for use in the present 
invention are produced in conventional manner, the core of which is a 
tablet of the following composition. 
______________________________________ 
Mg. per 
Components Dragee 
______________________________________ 
Cyclohexane-1,2,3,4,5,6- 
hexacarboxylic acid 250.0 
Lactose 60.0 
Starch 12.0 
Carboxymethyl cellulose 
18.0 
Talcum 8.0 
Calcium stearate 2 
______________________________________ 
With oral administration of two tablets of the adjuvant twice daily (total 
500 mg.) and daily injection of 0.75 mg. of synthetic pig calcitonin (75 
MRC units per kilogram of body weight per day, administered 
subcutaneously) a drop in the calcium level of the blood serum is observed 
after a few hours in a hypercalcemic patient of 70 kg. of body weight. In 
the course of a few days the serum calcium value becomes normal value in 
most patients. 
Similar results are also obtained when the pig calcitonin is replaced by 
therapeutically equivalent amounts of other calcitonins. 
EXAMPLE 13 
The following illustrates the preparation of a pharmaceutical preparation 
of a calcitonin and a phosphonate as a single injectable solution and 
treatment of Paget's disease therewith. 
For the production of pharmaceutical preparations in form of injectable 
solutions, the known methods of preparation were followed to produce a 
solution having an effective dosage as follows. 
______________________________________ 
Dosage 
Component Unit 
______________________________________ 
Disodium-3-amino-1- 30 mg./ml. 
hydroxy-propane-1,1-diphos- 
phonate 
Salmon calcitonin 0.01 mg./ml. 
(spec. activity 3000 MRC U/mg.) 
______________________________________ 
The resulting solution has a pH value of 7.4 and is adjusted with sodium 
chloride to plasma ionic strength. A patient suffering from morbus paget, 
weighing 60 kg, is treated with intramuscular injections of one ml./day of 
this pharmaceutical solution for several months. After 6 weeks a 
noticeable decrease in the biochemical parameters "serum alkaline 
phosphatase" and "urine hydroxyproline" is observed. Simultaneously, bone 
pain disappears. After four months of treatment, the state of the patient 
has normalized. Bone biopsies show no sign of unmineralized bone tissue. 
Similar results are obtained using solutions containing combinations of 
salmon, human or bovine calcitonin and either of two diphosphonates 
(disodium-azacycloheptane-2,2-diphosphonate or the disodium salt and of 
2,7-dioxo-2-hydroxy-3-amino-3-phosphono-1,2-azaphosphacycloheptane). 
EXAMPLE 14 
The following illustrates the preparation of a similar pharmaceutically 
acceptable preparation wherein the calcitonin is human calcitonin. 
For the production of pharmaceutical preparations in form of injectable 
aqueous solutions, the known methods of preparation were followed to 
produce a solution having an effective dosage unit as follows. 
______________________________________ 
Dosage 
Component Unit 
______________________________________ 
Trisodium-2-phosphono- 50 mg./ml. 
butane-1,2,4-tricarboxy- 
late 
Human calcitonin 0.25 mg./ml. 
(Spec. activity 100 MRC U/mg.) 
______________________________________ 
The resulting solution has a pH value of 7.4 and is adjusted with sodium 
chloride to plasma ionic strength. A patient suffering from osteoporosis, 
weighing approximately 50 kg., is treated with intravenous injections of 
one ml./day of this pharmaceutical preparation for one year. The rate of 
bone loss in the patient is greatly reduced, and within the period of 
treatment no further spontaneous bone fractures were observed. 
Similar results are obtained using solutions containing combinations of 
salmon, human or bovine calcitonin and either of two 
phosphono-carboxylates(phosphonoethane-1,2-dicarboxylate and 
phosphonopropane-2,3-dicarboxylate) as 2:1 mixtures of the di- and 
trisodium salts respectively. 
EXAMPLE 15 
The following illustrates the preparation of a similar pharmaceutically 
acceptable preparation wherein the calcitonin is bovine calcitonin. 
For the production of pharmaceutical preparations in the form of injectable 
aqueous solutions, the known methods of preparation were followed to 
produce a solution having an effective dosage unit as follows. 
______________________________________ 
Dosage 
Component Unit 
______________________________________ 
Cyclohexane-1,2,3,4,5,6- 
70 mg./ml. 
hexacarboxylic-acid, 
trisodium salt 
Bovine calcitonin 0.5 mg./ml. 
(spec. activity 140 MRC U/mg.) 
______________________________________ 
The resulting solution has a pH value of 7.4 and is adjusted with sodium 
chloride to plasma ionic strength. 
In a group of three patients suffering from hypercalcemia weighing 72, 60 
and 58 kg. respectively, each patient is treated by daily subcutaneous 
injections of one ml. of this pharmaceutical preparation. After a few 
hours a reduction in the plasma calcium level is observed, and within a 
few days, plasma calcium levels have returned to normal. 
Similar results are obtained using solutions containing combinations of 
either salmon or synthetic human calcitonin with trisodium 
cyclohexanehexacarboxylate.