# Patent

## Title
Methods and compositions for treating asthma

## Abstract

The present invention relates to use of a composition for symptomatic relief, when needed, comprising, in admixture

    
    
        (a) a first active ingredient which is formoterol, a pharmaceutically acceptable salt or solvate thereof or a solvate of such a salt; and
        (b) a second active ingredient which is budesonide;

for the manufacture of a medicament for use in the prevention or treatment of an acute condition of asthma and/or intermittent asthma and/or episodes in chronic asthma. The invention further relates to a method for prevention or treatment of an acute condition of asthma and/or intermittent asthma and/or episodes in chronic asthma by administering, by inhalation, a composition comprising the first and second active ingredients as defined previously.

## Background
This application is a continuation of application Ser. No. 09/367,950, filed Aug. 18, 1999 now abandoned, which is the National Stage of International Application No. PCT/SE99/01031, filed Jun. 10, 1999, which claims priority from Swedish Application No. 9802073-8, filed Jun. 11, 1998.


FIELD OF THE INVENTION
The present invention relates to use of a composition for symptomatic relief, when needed, comprising, in admixture

    
    
        (a) a first active ingredient which is formoterol, a pharmaceutically acceptable salt or solvate thereof or a solvate of such a salt; and
        (b) a second active ingredient which is budesonide;

for the manufacture of a medicament for use in the prevention or treatment of an acute condition of asthma and/or intermittent asthma and/or episodes in chronic asthma. The invention further relates to a method for prevention or treatment of an acute condition of asthma and/or intermittent asthma and/or episodes in chronic asthma by administering, by inhalation, a composition comprising the first and second active ingredients as defined previously.

    
    


BACKGROUND OF THE INVENTION
Despite recent advances in the awareness of asthma and the introduction of powerful and effective anti-asthma drugs, asthma remains a poorly understood and frequently poorly treated disease. There have been recent advances in the treatment of the disease which result from the recognition that asthma is a chronic inflammatory disease. Therapy is now aimed at both controlling the symptoms and reducing the inflammation. The symptoms may be controlled by β2-adrenoceptor agonists such as terbutaline, salbutamol, formoterol and salmeterol. Prophylactic therapy is typically provided by steroids such asbeclomethasone dipropionate, fluticasone propionate, mometasone furoate and budesonide.
In spite of modern maintenance treatment too many asthmatic patients are undertreated for a number of reasons with a negative impact on their quality of life. Too complicated therapy with different medications and devices may lead to misunderstanding and communication problems between patient and doctor. Poor compliance is a common phenomenon. Improved patient education may partly counteract this, but does not completely solve the problem. A new and more simple approach to asthma treatment could thus be of tremendous help for many patients suffering from respiratory disease, particularly asthma. The combination of budesonide and formoterol in the same device as suggested in PCT applications WO 93/11773 and WO 98/15280 (both to Astra AB of Sweden) offers a favorable pathway to improve today's asthma management with an excellent safety profile. However, although having an adequate regular, e.g. bid, treatment with such a combination, many patients will now and then run into acute situations with a higher frequency and severity of exacerbations, when additional medication is needed. Such an additional medication is often a β2-adrenoceptor agonist with fast onset, normally terbutaline or salbutamol. A second medicament is thus needed, and this can negatively affect the overall compliance of the patient. There is thus need for a neat way of handling maintenance treatment together with the treatment of acute situations which.
SUMMARY OF THE INVENTION
It is an object of the present invention to provide use of a suitable composition for the manufacture of a medicament for the treatment of acute episodes of asthma as a complement to maintenance treatment.
More specifically, according to the invention there is provided use of a composition for symptomatic relief when needed comprising, in admixture

    
    
        (a) a first active ingredient which is formoterol, a pharmaceutically acceptable salt or solvate thereof or a solvate of such a salt; and
        (b) a second active ingredient which is budesonide;

for the manufacture of a medicament for use in the prevention or treatment of an acute condition of asthma and/or intermittent asthma and/or episodes in chronic asthma.

    
    


Use of the present composition, when needed, relates to use of said composition during one or more of the following conditions:
i) an acute condition of asthma, i.e. acute asthma attacks,
ii) intermittent asthma and/or
iii) short periods (episodes) of acute attacks of bronchospasms in chronic asthma.
Acute asthma attacks may occur on an irregular basis when exposed to an agent e.g. during the pollen season, a virus infection, cold air, perfumes or any other agent(s) triggering an asthma attack in the patient.
It lies within the scope of the present invention, to use the compositions comprising active compounds (a) and (b) for treating acute conditions of asthma, intermittent asthma and episodes in chronic asthma, in addition to treating chronic asthma on a regular basis, with the same active compounds (a) and (b) or one or more different active compounds, preferably selected from short-acting β-agonists, long-acting β-agonists and glucocorticosteroids.
We contemplate preventive use when the patient expects to encounter asthma inducing conditions e.g. intends to take exercise or go into smoky conditions.
According to a further aspect of the invention a method of prevention or treatment of an acute condition of asthma and/or intermittent asthma and/or episodes in chronic asthma, when needed, which comprises administering, by inhalation, to a patient an effective amount of a composition comprising, in admixture:
(a) a first active ingredient which is formoterol, a pharmaceutically acceptable salt or solvate thereof or a solvate of such a salt; and
(b) a second active ingredient which is budesonide.
According to the present invention it has surprisingly been found that the medicament can be administered when needed to a patient with an acute attack of asthma.
The recommended dose regimen described in the prior art as disclosed above is twice a day. This dose recommendation was a result of a concern not to have too high an administration of the active compounds. However, in the present invention it has been found that it is possible for the patient to administer this mixture as often as needed.
The combination of formoterol and budesonide can be used as a rescue medication. Worsening of symptoms can be counteracted by incremental use of the combination for symptom relief, e.g. during exacerbations with the additional steroid component coming in as early as possible to suppress the enhanced airway inflammation. The long duration of formoterol will reduce the risk of too frequent dosing. When taking the combination budesonide/formoterol when needed the severity of exacerbations can be reduced. The as needed use (Pro Re Nata, PRN) will also minimize the difficulty of predicting which patients will be controlled on a low dose of inhaled steroid rather than increasing the is steroid dose before adding a long-acting β2-agonist. Under-treatment with inhaled glucocorticosteroids following a too low maintenance dose will be more or less “self-corrected” by the rescue usage according to the present invention. The PRN use of the combination will always give some beneficial anti-inflammatory effects even if it is used by the patient only for rescue purposes. A treatment for patients suffering from respiratory disease, particularly asthma (including allergic conditions, e.g. episodic or intermittent asthma), will therefore be to use the combination formoterol/budesonide for maintenance therapy as well as on an as needed basis (for rescue purposes), e.g. for prevention of exercise and/or allergen induced asthma.
DETAILED DESCRIPTION OF THE INVENTION
Formoterol is a compound which can exist in several stereochemical forms. The present invention includes the individual stereoisomers as well as mixtures thereof. It is intended that the present invention includes geometrical isomers, rotational isomers, racemates, diastereomers and enantiomers, in particular the R,R enantiomer of formoterol.
Suitable physiologically salts of formoterol include acid addition salts derived from inorganic and organic acids such as the hydrochloride, hydrobromide, sulfate, phosphate, maleate, fumarate, tartrate, citrate, benzoate, 4-methoxybenzoate, 2- or 4-hydroxybenzoate, 4-chlorobenzoate, p-toluenesulphonate, methanesulphonate, ascorbate, salicylate, acetate, succinate, lactate, glutarate, gluconate, tricarballylate, hydroxy-naphthalene-carboxylate or oleate. Formoterol is preferably used in the form of its fumarate salt and as a dihydrate of this salt.
The present invention also encompasses compositions comprising the 22R epimer of budesonide as the second active ingredient.
A suitable unit dose of formoterol (as fumarate dihydrate) is in the range of from 1 μg to 48 μg, preferably from 2 μg to 24 μg, and more preferably between 3 μg and 12 μg. The daily dose of formoterol (as fumarate dihydrate), including maintenance therapy, should be in the range of from 1 μg to 100 μg, preferably from 2 μg to 60 μg, and more preferably from 3 μg to of 48 μg.
A suitable unit dose of budesonide is in the range of from 20 μg to 1600 μg, suitably from 30 μg to 800 μg, preferably from 50 μg to 400 μg, and more preferably between 100 μg and 200 μg. The daily dose of budesonide, including maintenance therapy, should be in the range of 20 μg to 4800 μg, preferably from 30 μg to 3200 μg, and more preferably from 40 μg to 1600 μg. The particular dose regimen will depend on the patient (age, sex, weight etc.) and the severity of the disease (mild, moderate, severe asthma etc.).
The molar ratio of the first active ingredient (as formoterol) to the second active ingredient of the invention, suitably lies in the range of from 1:1 to 1:100, preferably from 1:1 to 1:70, and more preferably from 1:1 to 1:50.
Preferably the mixture comprises one or more pharmaceutically acceptable additives, diluents or carriers, more preferably in an amount of from 50 μg to 4000 μg in each dose, most preferably in an amount of from 100 μg to 2000 μg and most preferably from 100 μg to 1000 μG. Examples of suitable additives, diluents or carriers include lactose, dextran, mannitol or glucose. Preferably lactose is used, and more preferably as the monohydrate.
One or more of the ingredients of the mixture may be in the form of dry powder, more preferably a small particle dry powder, most preferably an agglomerated small particle dry powder. Alternatively one or more of the active ingredients (a) or (b) are in the form of an ordered mixture with diluent, additive or carrier. The ingredients used in the invention can be obtained in these preferred forms using methods known to those skilled in the art. The particle size of the active ingredients is preferably less than 10 μm.
Administration may be by inhalation orally or intranasally. The ingredients of the system are preferably adapted to be administered from a dry powder inhaler, a pressurized metered dose inhaler, or a nebulizer.
When the ingredients of the system are adapted to be administered from a pressurized inhaler, they are preferably in a small particle form. They are dissolved, or, preferably, suspended in a liquid propellant mixture. The propellants which can be used include chlorofluorocarbons, hydrocarbons or hydrofluorocarbons. Especially preferred, propellants are P134a (tetrafluoroethane), P152a (difluoroethane) and P227 (heptafluropropane) each of which may be used alone or in combination. They are optionally used in combination with one or more other propellants and/or one or more surfactants and/or one or more other excipients, for example ethanol, a lubricant, an antioxidant and/or a stabilizing agent.
When the ingredients of the system of the invention are adapted to be administered via a nebulizer they may be in the form of a nebulized aqueous suspension or solution, with or without suitable pH or tonicity adjustment, either as a unit dose or multidose formulation.


EXAMPLES
The ingredients can be formulated as illustrated by the following examples which are not intended to limit the scope of the invention.
In the examples micronization is carried out in a conventional manner such that the particle size range for each component is suitable for administration by inhalation. Turbuhaler® is a trademark of Astra AB.
Example 1
4.5 Parts by weight of formoterol fumarate dihydrate were mixed with 915 parts by weight of lactose monohydrate. The blend was micronized using a high pressure air jet mill and then conditioned using the process of EP-A-717 616. 80 Parts by weight of micronized budesonide were added to the conditioned product by mixing and homogenizing with a low pressure jet mill. The mixture was then spheronized using the process of EP-A-721 331 and filled into the storage compartment of Turbuhaler.®
Example 2
9 Parts by weight of formoterol fumarate dihydrate were mixed with 831 parts by weight of lactose monohydrate. The blend was micronized using a high pressure air jet mill and then conditioned using the process of EP-A-717 616. 160 Parts by weight of micronized budesonide were added to the conditioned product by mixing and homogenizing with a low pressure jet mill. The mixture was then spheronized using the process of EP-A-721 331 and filled into the storage compartment of Turbuhaler.®
Example 3
6 Parts by weight of formoterol fumarate dihydrate were mixed with 894 parts by weight of lactose monohydrate. The blend was micronized using a high pressure air jet mill and then conditioned using the process of EP-A-717 616. 100 Parts by weight of micronized budesonide were added to the conditioned product by mixing and homogenizing with a low pressure jet mill. The mixture was then spheronized using the process of EP-A-721 331 and filled into the storage compartment of Turbuhaler.®
Example 4
12 Parts by weight of formoterol fumarate dihydrate were mixed with 788 parts by weight of lactose monohydrate. The blend was micronized using a high pressure air jet mill and then conditioned using the process of EP-A-717 616. 200 Parts by weight of micronized budesonide were added to the conditioned product by mixing and homogenizing with a low pressure jet mill. The mixture was then spheronized using the process of EP-A-721 331 and filled into the storage compartment of Turbuhaler.®
Example 5
A patient on maintenance treatment with the fixed combination formoterol fumarate dihydrate/budesonide in a dose of 4.5/80 μg or 4.5/160 μg bid additionally uses the same combination either for rescue purposes once or twice daily to treat sporadic breakthrough symptoms, or as needed to treat exacerbations during one or two weeks, with a maximum daily dose of 36/640 μg (8 puffs of 4.5/80 μg) and 36/1280 μg (8 puffs of 4.5/160 μg), respectively.
Example 6
A patient with intermittent asthma uses the fixed combination formoterol fumarate dihydrate/budesonide as sole medication to be taken as needed until the asthma resolves. The highest recommended daily dose will be either 36/640 μg (8 puffs of 4.5/80 μg) or 36/1280 μg (8 puffs of 4.5/160 μg) for a period not exceeding 8-120 weeks. If symptoms still persist after that period of time—regular maintenance therapy should be considered.

## Claims

1. A method of treating asthma in a patient, the method comprising administering an effective amount of a composition comprising, in admixture:
(a) a first active ingredient that is formoterol, a pharmaceutically acceptable salt or solvate thereof or a solvate of such a salt; and
(b) a second active ingredient that is budesonide;

characterized in that the patient is administered (i) a maintenance dose of the composition twice per day, on a regular basis, and (ii) one or more additional doses on an irregular basis, wherein the one or more additional doses are administered as-needed, as determined by the patient.

2. The method according to claim 1, wherein the molar ratio of (a) to (b) calculated as formoterol to budesonide is from 1:1 to 1:100.

3. The method according to claim 1, wherein the first active ingredient is formoterol fumarate dihydrate.

4. The method according to claim 1, wherein the first active ingredient is the R,R enantiomer of formoterol or a pharmaceutically acceptable salt or solvate of said enantiomer or a solvate of such a salt.

5. The method according to claim 3, wherein the composition is in the form of unit doses, each of which delivers 1 μg to 48 μg of the first active ingredient, calculated as formoterol fumarate dihydrate.

6. The method according to claim 3, wherein the patient is administered an amount per day of the composition, including for maintenance therapy, that contains a total of 1 μg to 100 μg of the first active ingredient, calculated as formoterol fumarate dihydrate.

7. The method according to claim 1, wherein the second active ingredient is the 22R epimer of budesonide.

8. The method according to claim 1, wherein the composition is in the form of unit doses, each of which delivers 20 μg to 1600 μg of budesonide to the patient.

9. The method according to claim 1, wherein the patient is administered an amount per day of the composition, including for maintenance therapy, that contains a total of 20 μg to 4800 μg of budesonide.

10. The method according to claim 1, wherein the particle size of the active ingredients (a) and (b) is less than 10 μm.

11. The method according to claim 1, wherein the composition additionally comprises one or more pharmaceutically acceptable additives, diluents or carriers.

12. The method according to claim 1, wherein the composition additionally comprises lactose monohydrate.

13. The method according to claim 2, wherein the molar ratio of (a) to (b) calculated as formoterol to budesonide is from 1:1 to 1:70.

14. The method according to claim 5, wherein the composition is in the form of unit doses, each of which delivers 3 μg to 12 μg of the first active ingredient to the patient, calculated as formoterol fumarate dihydrate.

15. The method according to claim 6, wherein the patient is administered an amount per day of the composition, including maintenance therapy, that contains a total of 2 μg to 60 μg of the first active ingredient, calculated as formoterol fumarate dihydrate.

16. The method according to claim 8, wherein the composition is in the form of unit doses, each of which delivers 50 μg to 400 μg of budesonide to the patient.

17. The method according to claim 9, wherein the patient is administered an amount per day of the composition, including maintenance therapy, that contains a total of 30 μg to 3200 μg of budesonide.

18. A method of treating asthma in a patient, the method comprising
administering an effective amount of a composition comprising, in admixture:
(a) a first active ingredient that is formoterol, a pharmaceutically acceptable salt or solvate thereof or a solvate of such a salt; and
(b) a second active ingredient that is budesonide;
characterized in that the patient is administered (i) a maintenance dose of the composition twice per day on a regular basis, and (ii) one or more additional doses on an irregular basis, wherein the one or more additional doses are administered when the patient expects to encounter an asthma inducing condition.

19. The method of claim 18 wherein the asthma inducing condition is selected from the group consisting of exercise, exposure to cold air, exposure to pollen, exposure to perfume, and exposure to a smoky environment.

20. A method of treating asthma in a patient, the method comprising
administering an effective amount of a composition comprising, in admixture:
(a) a first active ingredient that is formoterol, a pharmaceutically acceptable salt or solvate thereof or a solvate of such a salt; and
(b) a second active ingredient that is budesonide;
characterized in that the patient is administered (i) a maintenance dose of the composition twice per day on a regular basis, and (ii) one or more additional doses, wherein the one or more additional doses are administered when the patient experiences an acute asthma attack.

21. The method of claim 1, wherein the first and second active ingredients are both in dry powder form.

22. The method of claim 1, wherein the composition is administered from a pressurized metered dose inhaler.

23. The method of claim 22, wherein the first and second active ingredients are suspended in a liquid propellant.

24. The method of claim 23, wherein the liquid propellant is one or more of tetrafluoroethane, difluoroethane, and heptafluoropropane.

25. The method of claim 23, wherein the liquid propellant is heptafluoropropane.

26. The method of claim 1, wherein the composition is administered by the patient.

27. A method of treating asthma in a patient, the method comprising administering an effective amount of a composition comprising, in admixture:
(a) a first active ingredient that is formoterol, a pharmaceutically acceptable salt or solvate thereof or a solvate of such a salt; and
(b) a second active ingredient that is budesonide;
characterized in that the patient is administered (i) a maintenance dose of the composition twice per day on a regular basis, and (ii) one or more additional doses on an irregular basis, wherein the one or more additional doses are administered when needed for symptom relief.

28. A method of treating asthma in a patient, the method comprising administering an effective amount of a composition comprising, in admixture:
(a) a first active ingredient that is formoterol, a pharmaceutically acceptable salt or solvate thereof or a solvate of such a salt; and
(b) a second active ingredient that is budesonide;
characterized in that the patient is administered (i) a maintenance dose of the composition on a regular basis as determined by the patient's physician, and (ii) one or more additional doses on an irregular basis, wherein the one or more additional doses are administered when the patient determines the additional dose or doses are needed for symptom relief or when the patient expects to encounter an asthma inducing condition.

29. The method of claim 18, wherein the first active ingredient is formoterol fumarate dihydrate.

30. The method of claim 20, wherein the first active ingredient is formoterol fumarate dihydrate.

31. The method of claim 27, wherein the first active ingredient is formoterol fumarate dihydrate.

32. The method of claim 28, wherein the first active ingredient is formoterol fumarate dihydrate.

33. The method of claim 1, wherein the composition is inhaled by the patient from an inhaler, and each puff from the inhaler delivers 4.5 μg formoterol fumarate dihydrate and 80 μg budesonide to the patient.

34. The method of claim 1, wherein the composition is inhaled by the patient from an inhaler, and each puff from the inhaler delivers 4.5 μg formoterol fumarate dihydrate and 160 μg budesonide to the patient.

35. The method of claim 18, wherein the composition is inhaled by the patient from an inhaler, and each puff from the inhaler delivers 4.5 μg formoterol fumarate dihydrate and 80 μg budesonide to the patient.

36. The method of claim 18, wherein the composition is inhaled by the patient from an inhaler, and each puff from the inhaler delivers 4.5 μg formoterol fumarate dihydrate and 160 μg budesonide to the patient.

37. The method of claim 20, wherein the composition is inhaled by the patient from an inhaler, and each puff from the inhaler delivers 4.5 μg formoterol fumarate dihydrate and 80 μg budesonide to the patient.

38. The method of claim 20, wherein the composition is inhaled by the patient from an inhaler, and each puff from the inhaler delivers 4.5 μg formoterol fumarate dihydrate and 160 μg budesonide to the patient.

39. The method of claim 27, wherein the composition is inhaled by the patient from an inhaler, and each puff from the inhaler delivers 4.5 μg formoterol fumarate dihydrate and 80 μg budesonide to the patient.

40. The method of claim 27, wherein the composition is inhaled by the patient from an inhaler, and each puff from the inhaler delivers 4.5 μg formoterol fumarate dihydrate and 160 μg budesonide to the patient.

41. The method of claim 28, wherein the composition is inhaled by the patient from an inhaler, and each puff from the inhaler delivers 4.5 μg formoterol fumarate dihydrate and 80 μg budesonide to the patient.

42. The method of claim 28, wherein the composition is inhaled by the patient from an inhaler, and each puff from the inhaler delivers 4.5 μg formoterol fumarate dihydrate and 160 μg budesonide to the patient.