# Patent

## Title
Use of sulfated glycosaminoglycans for improving the bioavailability of factor VIII

## Abstract

The present invention relates to pharmaceutical preparations comprising one or more Factor VIII and a sulfated glycosaminoglycan for increasing the bioavailability of Factor VIII upon non-intravenous administration. The invention further relates to the combined use of Factor VIII and a sulfated glycosaminoglycan for the treatment and prevention of bleeding disorders, whereby the bioavailability of Factor VIII is increased, and to a method for increasing the bioavailability after non-intravenous administration of Factor VIII by coadminstration of a sulfated glycosaminoglycan.

## Background
The present invention relates to pharmaceutical preparations comprising at least one Factor VIII and a sulfated glycosaminoglycan for increasing the bioavailability of Factor VIII upon non-intravenous administration. The invention further relates to the combined use of a Factor VIII and a sulfated glycosaminoglycan for the treatment and prevention of bleeding disorders, whereby the bioavailability of the Factor VIII is increased, and to a method for increasing the bioavailability after non-intravenous administration of a Factor VIII by co-administration of a sulfated glycosaminoglycan.
BACKGROUND OF THE INVENTION
Factor VIII (FVIII)
FVIII is a blood plasma glycoprotein of about 280 kDa molecular mass, produced in the liver of mammals. It is a critical component of the cascade of coagulation reactions that lead to blood clotting. Within this cascade is a step in which Factor IXa (FIXa), in conjunction with activated Factor VIII (FVIIIa), converts Factor X (FX) to an activated form, FXa. FVIIIa acts as a cofactor at this step, being required together with calcium ions and phospholipids for maximizing the activity of FIXa. The most common hemophilic disorder is caused by a deficiency of functional FVIII called hemophilia A.
An important advance in the treatment of Hemophilia A has been the isolation of cDNA clones encoding the complete 2,351 amino acid sequence of human FVIII (U.S. Pat. No. 4,757,006) and the provision of the human FVIII gene DNA sequence and recombinant methods for its production).
Analysis of the deduced primary amino acid sequence of human FVIII determined from the cloned cDNA indicates that it is a heterodimer processed from a larger precursor polypeptide. The heterodimer consists of a C-terminal light chain of about 80 kDa in a metal ion-dependent association with an about 200 kDa N-terminal heavy chain. (See review by Kaufman, Transfusion Med. Revs. 6:235 (1992)). Physiological activation of the heterodimer occurs through proteolytic cleavage of the protein chains by thrombin. Thrombin cleaves the heavy chain to a 90 kDa protein, and then to 54 kDa and 44 kDa fragments. Thrombin also cleaves the 80 kDa light chain into a 72 kDa protein. It is the latter protein, and the two heavy chain fragments (54 kDa and 44 kDa above), held together by calcium ions, that constitute active FVIII. Inactivation occurs when the 44 kDa A2 heavy chain fragment dissociates from the molecule or when the 72 kDa and 54 kDa domains are further cleaved by thrombin, activated protein C or FXa. In plasma, FVIII is stabilized by association with a 50-fold molar excess of Von Willebrand Factor protein (“VWF”), which appears to inhibit proteolytic destruction of FVIII as described above.
The amino acid sequence of FVIII is organized into three structural domains: a triplicated A domain of 330 amino acids, a single B domain of 980 amino acids, and a duplicated C domain of 150 amino acids. The B domain has no homology to other proteins and provides 18 of the 25 potential asparagine(N)-linked glycosylation sites of this protein. The B domain has apparently no function in coagulation and can be deleted with the B-domain deleted FVIII molecule still having procoagulant activity.
Von Willebrand Factor (VWF)
VWF is a multimeric adhesive glycoprotein present in the plasma of mammals, which has multiple physiological functions. During primary hemostasis VWF acts as a mediator between specific receptors on the platelet surface and components of the extracellular matrix such as collagen. Moreover, VWF serves as a carrier and stabilizing protein for procoagulant FVIII. VWF is synthesized in endothelial cells and megakaryocytes as a 2813 amino acid precursor molecule. The precursor polypeptide, pre-pro-VWF, consists of a 22-residue signal peptide, a 741-residue pro-peptide and the 2050-residue polypeptide found in mature plasma VWF (Fischer et al., FEBS Lett. 351: 345-348, 1994). Upon secretion into plasma VWF circulates in the form of various species with different molecular sizes. These VWF molecules consist of oligo- and multimers of the mature subunit of 2050 amino acid residues. VWF can be usually found in plasma as one dimer up to multimers consisting of 50-100 dimers (Ruggeri et al. Thromb. Haemost. 82: 576-584, 1999). The in vivo half-life of human VWF in the human circulation is approximately 12 hours.
The most frequent inherited bleeding disorder in humans is von Willebrand's disease (VWD). Depending on the severity of the bleeding symptoms, VWD can be treated by replacement therapy with concentrates containing VWF, in general derived from human plasma but recombinant VWF also is under development. VWF can be prepared from human plasma as for example described in EP 0503991. In patent EP 0784632 a method for isolating recombinant VWF is described.
VWF is known to stabilize FVIII in vivo and, thus, plays a crucial role to regulate plasma levels of FVIII and as a consequence is a central factor to control primary and secondary hemostasis. It is also known that after intravenous administration of pharmaceutical preparations containing VWF in VWD patients an increase in endogenous FVIII:C to 1 to 3 units per ml in 24 hours can be observed demonstrating the in vivo stabilizing effect of VWF on FVIII.
The patients in general benefit from the specific mode of action of the active ingredients but currently all commercially available Factor VIII preparations are administered via intravenous administration which involves a risk for infections at the injection site and is in general a procedure patients would like to avoid especially in the treatment of children with defects in their coagulation system.
Until today the standard treatment of Hemophilia A and VWD involves frequent intravenous infusions of preparations of FVIII and VWF concentrates. The treatment of Hemophilia B requires the biweekly administration of Factor IX and in the treatment of inhibitor patients with FVIIa, multiple administrations of FVIIa per week are used to avoid bleedings.
These replacement therapies are generally effective, however, for example in severe hemophilia A patients undergoing prophylactic treatment Factor VIII has to be administered intravenously (i.v.) about 3 times per week due to the short plasma half life of Factor VIII of about 12 hours. Already by achieving FVIII levels above 1% of normal human plasma corresponding to a raise of FVIII levels by 0.01 U/ml, severe hemophilia A is turned into moderate hemophilia A. In prophylactic therapy the dosing regime is designed such that the trough levels of FVIII activity do not fall below levels of 2-3% of the FVIII activity of non-hemophiliacs.
The administration of a Factor VIII via intravenous administration is cumbersome, associated with pain and entails the risk of an infection especially as this is mostly done in home treatment by the patients themselves or by the parents of children being diagnosed for hemophilia A. In addition, frequent intravenous injections inevitably result in scar formation, interfering with future infusions As prophylactic treatment in severe hemophilia is started early in life, with children often being less than 2 years old, it is even more difficult to inject FVIII 3 times per week into the veins of such small patients. For a limited period of time, implantation of port systems may offer an alternative. However, in these cases repeated infections may occur and ports can cause inconvenience during physical exercise.
Thus there is a great medical need to obviate the need to infuse Factor VIII intravenously.
Subcutaneous administration has been proposed for Factor VIII, e.g. in WO 95/01804 A1 and WO 95/026750. However, very high doses of Factor VIII had to be administered to achieve an acceptable bioavailability.
Another approach to improve the bioavailability upon non-intravenous administration has been to use albumin-fused Factor VIII (WO 2011/020866 A2).
It is highly desirable to improve the bioavailability of Factor VIII upon non-intravenous administration. The inventors of this application surprisingly found that the bioavailability of Factor VIII is substantially increased if it is administered together with sulfated glycosaminoglycans.
SUMMARY OF THE INVENTION
In a first aspect the present invention therefore relates to a Factor VIII for use in the treatment or prevention of a bleeding disorder, said treatment or prevention comprising the non-intravenous injection of said Factor VIII and of a sulfated glycosaminoglycan,
In a further aspect, the present invention therefore relates to a Factor VIII for use in the treatment or prevention of a bleeding disorder, said treatment or prevention comprising the non-intravenous injection of said Factor VIII and of a sulfated glycosaminoglycan, wherein, during a period from 2 hours after injection to 48 hours after injection, the plasma level of the Factor VIII in the treated subject is continuously higher than 2% of the normal plasma level of the Factor VIII in healthy subjects when the Factor VIII is administered subcutaneously at a dose of 50 to 1000 IU/kg body weight.
A preferred embodiment of this aspect is a Factor VIII for use in the treatment or prophylaxis of hemophilia A in a human individual, said treatment or prophylaxis comprising the administration of said Factor VIII and of a sulfated glycosaminoglycan by subcutaneous, intradermal or intramuscular injection, wherein, during a period from 2 hours after injection to 48 hours after injection, the plasma level of the Factor VIII in the human individual is continuously higher than 2% of the normal plasma level of the Factor VIII in healthy human individuals when the Factor VIII is administered subcutaneously at a dose of 50 to 1000 IU/kg body weight.
Another aspect of the invention is a Factor VIII for use in the treatment or prophylaxis of a bleeding disorder in a human individual, said treatment or prophylaxis comprising the administration of said Factor VIII and of a sulfated glycosaminoglycan by subcutaneous, transdermal or intramuscular injection, wherein the relative bioavailability of the Factor VIII in the human individual is at least 20% higher than that of the Factor VIII administered in the same manner without sulfated glycosaminoglycan.
A preferred embodiment of this aspect is a Factor VIII for use in the treatment or prophylaxis of hemophilia A in a human individual, said treatment or prophylaxis comprising the administration of said Factor VIII and of a sulfated glycosaminoglycan by subcutaneous, intradermal or intramuscular injection, wherein the relative bioavailability of the Factor VIII in the human individual is at least 20% higher than that of the Factor VIII administered in the same manner without sulfated glycosaminoglycan.
In a third aspect, the invention relates to a sulfated glycosaminoglycan for improving the bioavailability of a Factor VIII.
In a further aspect, the invention relates to a sulfated glycosaminoglycan for improving the bioavailability of a Factor VIII, wherein said sulfated glycosaminoglycan and said Factor VIII are administered by subcutaneous, transdermal or intramuscular injection.
A further aspect of the invention is a pharmaceutical kit for the therapy or prophylaxis of a bleeding disorder, comprising a Factor VIII and a sulfated glycosaminoglycan.
A further aspect of the invention is a method of treating or preventing a bleeding disorder, comprising administering to a subject in need thereof a therapeutically effective amount of a Factor VIII and a sulfated glycosaminoglycan so as to increase the bioavailability of the Factor VIII, wherein said administration comprises subcutaneous, transdermal or intramuscular injection.
A further aspect of the invention is a method for increasing the bioavailability of a Factor VIII, wherein a sulfated glycosaminoglycan is co-administered with said Factor VIII by subcutaneous, intradermal or intramuscular injection.
In all aspects of the invention, the Factor VIII is preferably human Factor VIII. A preferred sulfated glycosaminoglycan is heparin, most preferably the heparin is unfractionated heparin.



DESCRIPTION OF THE FIGURE
FIG. 1 depicts the results of Example 1. The bioavailability of FVIII is increased if a sulfated glycosaminoglycan is co-administered. As can be seen, dextran sulfate has no positive effect.



DETAILED DESCRIPTION
The present invention concerns the treatment and prophylaxis of bleeding disorders.
As used herein, the term “bleeding disorders” includes familial and acquired hemophilia A.
According to the first aspect of the invention a therapeutic, non-intravenous use of a Factor VIII is provided which comprises co-administration of a sulfated glycosaminoglycan.
Factor VIII may be wild-type Factor VIII polypeptides or Factor VIII polypeptides which may contain mutations. The degree and location of glycosylation or other post-translation modifications may vary depending on the chosen host cells and the nature of the host cellular environment. When referring to specific amino acid sequences, posttranslational modifications of such sequences are encompassed in this application.
The terms “Factor VIII”, and FVIII” are used interchangeably herein. “Factor VIII” includes wild type Factor VIII as well as derivatives of wild type Factor VIII having the procoagulant activity of wild type Factor VIII. Derivatives may have deletions, insertions and/or additions compared with the amino acid sequence of wild type Factor VIII. The term Factor VIII includes proteolytically processed forms of Factor VIII, e.g. the form before activation, comprising heavy chain and light chain.
The term “Factor VIII” includes any Factor VIII variants or mutants having at least 10%, preferably at least 25%, more preferably at least 50%, most preferably at least 75% of the biological activity of wild type Factor VIII. A suitable test to determine the biological activity of Factor VIII is the one stage or the two stage coagulation assay (Rizza et al. 1982. Coagulation assay of FVIII:C and FIXa in Bloom ed. The Hemophilias. NY Churchchill Livingston 1992) or the chromogenic substrate FVIII activity assay (S. Rosen, 1984. Scand J Haematol 33: 139-145, suppl.). The content of these references is incorporated herein by reference.
As non-limiting examples, Factor VIII molecules include Factor VIII mutants preventing or reducing APC cleavage (Amano 1998. Thromb. Haemost. 79:557-563), albumin-fused FVIII molecules (WO 2011/020866 A2), FVIII-Fc fusion molecules (WO 04/101740 A), Factor VIII mutants further stabilizing the A2 domain (WO 97/40145), FVIII mutants resulting in increased expression (Swaroop et al. 1997. JBC 272:24121-24124), Factor VIII mutants with reduced immunogenicity (Lollar 1999. Thromb. Haemost. 82:505-508), FVIII reconstituted from differently expressed heavy and light chains (Oh et al. 1999. Exp. Mol. Med. 31:95-100), FVIII mutants reducing binding to receptors leading to catabolism of FVIII like HSPG (heparan sulfate proteoglycans) and/or LRP (low density lipoprotein receptor related protein) (Ananyeva et al. 2001. TCM, 11:251-257), disulfide bond-stabilized FVIII variants (Gale et al., 2006. J. Thromb. Hemost. 4:1315-1322), FVIII mutants with improved secretion properties (Miao et al., 2004. Blood 103:3412-3419), FVIII mutants with increased cofactor specific activity (Wakabayashi et al., 2005. Biochemistry 44:10298-304), FVIII mutants with improved biosynthesis and secretion, reduced ER chaperone interaction, improved ER-Golgi transport, increased activation or resistance to inactivation and improved half-life (summarized by Pipe 2004. Sem. Thromb. Hemost. 30:227-237), and FVIII mutants having a deletion of all or part of the B-domain (see, e.g., WO 2004/067566 A1, WO 02/102850 A2, WO 00/24759 A1 and U.S. Pat. No. 4,868,112). Particularly preferred are FVIII molecules which are “single chain” FVIII molecules. Single chain FVIII have a deletion of all or part of the B-domain and a deletion of all or a part of the acidic a3 region, so that the cleavage site at Arg1648 (which is usually cleaved during secretion) is deleted. Single chain FVIII molecules are disclosed in, e.g., WO 2004/067566 A1; US 2002/132306 A1; Krishnan et al. (1991) European Journal of Biochemistry vol. 195, no. 3, pages 637-644; Herlitschka et al. (1998) Journal of Biotechnology, vol. 61, no. 3, pages 165-173; Donath et al. (1995) Biochem. J., vol. 312, pages 49-55.
All of these Factor VIII mutants and variants are incorporated herein by reference in their entirety.
The amino acid sequence of the mature wild type form of human Factor VIII is shown in SEQ ID NO:2. The reference to an amino acid position of a specific sequence means the position of said amino acid in the FVIII wild-type protein and does not exclude the presence of mutations, e.g. deletions, insertions and/or substitutions at other positions in the sequence referred to. For example, a mutation in “Glu2004” referring to SEQ ID NO:2 does not exclude that in the modified homologue one or more amino acids at positions 1 through 2332 of SEQ ID NO:2 are missing. A DNA sequence encoding SEQ ID NO:2 is shown in SEQ ID NO:1.
The term “glycosaminoglycan”, as used herein, refers to an oligo- or polysaccharide comprising particularly aminohexose units. Sulfated glycosaminoglycans include, but are not limited to chondroitin sulfate, dermatan sulfate, keratan sulfate, heparin and heparan sulfate. Preferably, the sulfated glycosaminoglycan is heparin, most preferably, the sulfated glycosaminoglycan is unfractionated heparin.
The term “heparin” includes unfractionated heparin and heparins having a lower molecular weight. In one embodiment, the heparin used in accordance with this invention is “unfractionated heparin” which may have an average molecular weight of about 8 kDa to about 30 kDa, preferably of about 10 kDa to about 20 kDa, most preferably of about 12 kDa to about 16 kDa, e.g. about 15 kDa. In another embodiment, the heparin used in accordance with this invention is a low molecular weight heparin (LMWH). LMWHs are heparins or heparin salts having an average molecular weight of less than 8000 Da and for which at least 60% of all chains have a molecular weight less than 8000 Da. Preferably, the molecular weight of the LMWH used in accordance with this invention is about 2 kDa to about 8 kDa, more preferably about 3 kDa to about 6 kDa, most preferably of about 4 kDa to about 5 kDa, e.g. about 4.5 kDa. The LMWHs can be obtained by various methods of fractionation or depolymerisation of polymeric heparin. Examples of LMWHs include, but are not limited to, ardeparin (Normiflo), certoparin (Sandoparin), enoxaparin (Lovenox and Clexane), parnaparin (Fluxum), tinzaparin (Innohep and Logiparin), dalteparin (Fragmin), reviparin (Clivarin) and nadroparin (Fraxiparin).
The term “heparin” includes also small molecular weight fragments of heparin molecules, either derived from naturally occurring heparin by cleavage and isolation or by synthetic routes. A commercially available sulfated pentasaccharide exists for example that is manufactured synthetically and which structure is derived from heparin. It is available as Fondaparinux sodium.
Chondroitin sulfate includes, e.g., chondroitin sulfate A (chondroitin-4-sulfate), chondroitin sulfate C (chondroitin-6-sulfate), chondroitin sulfate D (chondroitin-2,6-sulfate), and chondroitin sulfate E (chondroitin-4,6-sulfate).
Dermatan sulfate (previously also called chondroitin sulfate B) is another sulfated glycosaminoglycan which is commercially available.
Keratan sulfate is another sulfated glycosaminoglycan. The structure of keratan sulfate is described in, e.g., Funderburgh (2000) Glycobiology vol. 10 no. 10 pp. 951-958.
Heparan sulfate is an N-sulfated polysaccharide which is different from Heparin (see, e.g., Gallagher, J. T., Lyon, M. (2000). “Molecular structure of Heparan Sulfate and interactions with growth factors and morphogens”. In Iozzo, M, V. Proteoglycans: structure, biology and molecular interactions. Marcel Dekker Inc. New York, N.Y. pp. 27-59; and Gallagher, J. T. Walker, A. (1985). “Molecular distinctions between Heparan Sulphate and Heparin: Analysis of sulphation patterns indicates Heparan Sulphate and Heparin are separate families of N-sulphated polysaccharides”. Biochem. J. 230 (3): 665-74)
In one embodiment of the invention, the plasma level of the Factor VIII in the treated subject is, during a period from 5 hours after injection to 8 hours after injection, continuously higher than 2%, preferably higher than 5%, more preferably higher than 8%, most preferably higher than 10%, of the normal plasma level of the Factor VIII in healthy subjects. The plasma level is to be determined as shown hereinafter in Example 1.
In one embodiment of the invention, the plasma level of the Factor VIII in the treated subject is, during a period from 4 hours after injection to 16 hours after injection, continuously higher than 2%, preferably higher than 5%, more preferably higher than 8%, most preferably higher than 10%, of the normal plasma level of the Factor VIII in healthy subjects.
In another embodiment of the invention, the plasma level of the Factor VIII in the treated subject is, during a period from 3 hours after injection to 24 hours after injection, continuously higher than 2%, preferably higher than 4%, more preferably higher than 6%, most preferably higher than 8%, of the normal plasma level of the Factor VIII in healthy subjects.
In another embodiment of the invention, the plasma level of the Factor VIII in the treated subject is, during a period from 2 hours after injection to 32 hours after injection, continuously higher than 2%, preferably higher than 3%, more preferably higher than 4%, most preferably higher than 5%, of the normal plasma level of the Factor VIII in healthy subjects.
In yet another embodiment of the invention, the plasma level of the Factor VIII in the treated subject is, during a period from 1 hour after injection to 48 hours after injection, continuously higher than 2%, preferably higher than 3%, more preferably higher than 4%, most preferably higher than 5%, of the normal plasma level of the Factor VIII in healthy subjects.
The above-mentioned plasma levels are preferably obtained when the Factor VIII (e.g. FVIII) is administered by subcutaneous injection at a dose of less than 1,000 IU/kg body weight, or less than 800 IU/kg body weight, or less than 600 IU/kg body weight, or less than 400 IU/kg body weight, e.g. at a dose of from about 10 IU/kg body weight to about 1,000 IU/kg body weight, or from about 20 IU/kg body weight to about 800 IU/kg body weight, or from about 30 IU/kg body weight to about 700 IU/kg body weight, or from about 40 IU/kg body weight to about 600 IU/kg body weight, or from about 50 IU/kg body weight to about 500 IU/kg body weight, or from about 75 IU/kg body weight to about 400 IU/kg body weight, or from about 100 IU/kg body weight to about 300 IU/kg body weight, or from about 50 IU/kg body weight to about 1,000 IU/kg body weight, or from about 50 IU/kg body weight to about 800 IU/kg body weight, or from about 50 IU/kg body weight to about 700 IU/kg body weight, or from about 50 IU/kg body weight to about 600 IU/kg body weight, or from about 50 IU/kg body weight to about 500 IU/kg body weight, or from about 50 IU/kg body weight to about 400 IU/kg body weight, or from about 50 IU/kg body weight to about 300 IU/kg body weight, or about 50 IU/kg body weight to about 200 IU/kg body weight.
In one embodiment, the Factor VIII and the sulfated glycosaminoglycan are contained in the same composition. This composition comprising the two components may be administered to the patient by a single injection or the like.
In another embodiment, the Factor VIII and the sulfated glycosaminoglycan are not present in the same composition. For example, each of the two components may be provided in a separate dosage form in said pharmaceutical preparation.
If the two components are not present in the same composition the separate compositions may either be administered separately, or they may be mixed shortly before administration so that the Factor VIII and the sulfated glycosaminoglycan will be administered simultaneously. If there is separate administration, the administration may be done sequentially, e.g. in a time-staggered manner. In general, it is preferred that the two components are administered simultaneously by a single administration, e.g. injection. Various routes of administration are discussed below. They apply to the above mutatis mutandis.
The components of the pharmaceutical preparation may be dissolved in conventional physiologically compatible aqueous buffer solutions to which there may be added, optionally, pharmaceutical excipients to provide the pharmaceutical preparation. The components of the pharmaceutical preparation may already contain all necessary pharmaceutical, physiologically compatible excipients and may be dissolved in water for injection to provide the pharmaceutical preparation.
Such pharmaceutical carriers and excipients as well as the preparation of suitable pharmaceutical formulations are well known in the art (see for example “Pharmaceutical Formulation Development of Peptides and Proteins”, Frokjaer et al., Taylor & Francis (2000) or “Handbook of Pharmaceutical Excipients”, 3rd edition, Kibbe et al., Pharmaceutical Press (2000)). In certain embodiments, a pharmaceutical composition can comprise at least one additive such as a filler, bulking agent, buffer, stabilizer, or excipient. Standard pharmaceutical formulation techniques are well known to persons skilled in the art (see, e.g., 2005 Physicians' Desk Reference®, Thomson Healthcare: Montvale, N.J., 2004; Remington: The Science and Practice of Pharmacy, 20th ed., Gennaro et al., Eds. Lippincott Williams & Wilkins: Philadelphia, Pa., 2000). Suitable pharmaceutical additives include, e.g., sugars like mannitol, sorbitol, lactose, sucrose, trehalose, or others, amino acids like histidine, arginine, lysine, glycine, alanine, leucine, serine, threonine, glutamic acid, aspartic acid, glutamine, asparagine, phenylalanine, or others, additives to achieve isotonic conditions like sodium chloride or other salts, stabilizers like Polysorbate 80, Polysorbate 20, Polyethylene glycol, propylene glycol, calcium chloride, or others, physiological pH buffering agents like Tris(hydroxymethyl)aminomethan, and the like. In certain embodiments, the pharmaceutical compositions may contain pH buffering reagents and wetting or emulsifying agents. In further embodiments, the compositions may contain preservatives or stabilizers. In particular, the pharmaceutical preparation comprising the Factor VIII may be formulated in lyophilized or stable soluble form. The Factor VIII may be lyophilized by a variety of procedures known in the art. Also if the sulfated glycosaminoglycan and the Factor VIII are contained in the same composition, such composition may also be provided in lyophilized or in stable soluble form. Lyophilized formulations are reconstituted prior to use by the addition of one or more pharmaceutically acceptable diluents such as sterile water for injection or sterile physiological saline solution or a suitable buffer solution.
The composition(s) contained in the pharmaceutical preparation of the invention may be delivered to the individual by any pharmaceutically suitable means. Various delivery systems are known and can be used to administer the composition by any convenient route. Preferably, the composition(s) contained in the pharmaceutical preparation of the invention are delivered to the individual by non-intravenous injection. More preferably, the composition(s) of the invention are formulated for subcutaneous, intramuscular, intraperitoneal, intracerebral, intrapulmonar, intranasal, intradermal or transdermal administration, most preferably for subcutaneous, intramuscular or transdermal administration according to conventional methods. The formulations can be administered continuously by infusion or by bolus injection. Some formulations may encompass slow release systems.
The composition(s) of the pharmaceutical preparation of the present invention is/are administered to patients in a therapeutically effective dose, meaning a dose that is sufficient to produce the desired effects, preventing or lessening the severity or spread of the condition or indication being treated without reaching a dose which produces intolerable adverse side effects. The exact dose depends on many factors as e.g. the indication, formulation, mode of administration and has to be determined in preclinical and clinical trials for each respective indication.
In the case of Factor VIII, the dose of one administration may be selected such that, during a period from 2 hours after injection to 48 hours after injection, the plasma level of the Factor VIII in the treated subject is continuously higher than 2%, preferably higher than 3%, more preferably higher than 4%, most preferably higher than 5%, of the normal plasma level of Factor VIII in healthy subjects.
Preferably, the dose of Factor VIII for one administration is less than 1,000 IU/kg body weight, or less than 800 IU/kg body weight, or less than 600 IU/kg body weight, or less than 400 IU/kg body weight, e.g. at a dose of from about 10 IU/kg body weight to about 1,000 IU/kg body weight, or from about 20 IU/kg body weight to about 800 IU/kg body weight, or from about 30 IU/kg body weight to about 700 IU/kg body weight, or from about 40 IU/kg body weight to about 600 IU/kg body weight, or from about 50 IU/kg body weight to about 500 IU/kg body weight, or from about 75 IU/kg body weight to about 400 IU/kg body weight, or from about 100 IU/kg body weight to about 300 IU/kg body weight, or from about 50 IU/kg body weight to about 1,000 IU/kg body weight, or from about 50 IU/kg body weight to about 800 IU/kg body weight, or from about 50 IU/kg body weight to about 700 IU/kg body weight, or from about 50 IU/kg body weight to about 600 IU/kg body weight, or from about 50 IU/kg body weight to about 500 IU/kg body weight, or from about 50 IU/kg body weight to about 400 IU/kg body weight, or from about 50 IU/kg body weight to about 300 IU/kg body weight, or about 50 IU/kg body weight to about 200 IU/kg body weight.
The Factor VIII can be administered on its own together with the sulfated glycosaminoglycan. Alternatively, the Factor VIII can be administered in association with vWF, i.e. as a FVIII/vWF complex, together with the sulfated glycosaminoglycan.
The amount of sulfated glycosaminoglycan administered typically ranges from about 0.001 to about 100 mg/mL product applied, from about 0.01 to about 10 mg/mL product applied, from about 0.05 to about 1 mg/mL product applied.
The term “bioavailability”, as used herein, refers to the proportion of an administered dose of a Factor VIII (e.g. Factor VIII or a FVIII-related preparation) that can be detected in plasma at predetermined times until a final time point after subcutaneous, intravenous or intradermal administration. Typically, bioavailability is measured in test animals by administering a dose of between 10 IU/kg and 1000 IU/kg of the preparation (e.g. 400 IU/kg body weight); obtaining plasma samples at pre-determined time points after administration; and determining the content of the Factor VIII, e.g. Factor VIII or Factor VIII-related polypeptides in the samples using one or more of a chromogenic or clotting assay (or any bioassay), an immunoassay, or an equivalent thereof. The bioavailability is expressed as the area under the curve (AUC) of the concentration or activity of the Factor VIII in plasma on the y-axis and the time after administration on the x-axis until a predefined final time point after administration. Preferably, this predefined time point is 48 hours after administration. Most preferably, the bioavailability is determined as shown in Example 1 below. Relative bioavailability of a test preparation refers to the ratio between the AUC of the test preparation (e.g. Factor VIII+sulfated glycosaminoglycan) and that of the reference preparation (e.g. Factor VIII alone) which is administered in the same dose and way (e.g. intravenous, subcutaneous or intradermal) as the test preparation.
According to the present invention, the bioavailability of the Factor VIII (when co-administered with the sulfated glycosaminoglycan) is higher than that of the Factor VIII when administered alone. Preferably, the bioavailability is increased by at least 20%, more preferably by at least 50%, more preferably by at least 75%, most preferably by at least 100%. The increase in bioavailability is preferably obtained when the Factor VIII is administered by subcutaneous injection at a dose of less than 1,000 IU/kg body weight, or less than 800 IU/kg body weight, or less than 600 IU/kg body weight, or less than 400 IU/kg body weight, e.g. at a dose of from about 10 IU/kg body weight to about 1,000 IU/kg body weight, or from about 20 IU/kg body weight to about 800 IU/kg body weight, or from about 30 IU/kg body weight to about 700 IU/kg body weight, or from about 40 IU/kg body weight to about 600 IU/kg body weight, or from about 50 IU/kg body weight to about 500 IU/kg body weight, or from about 75 IU/kg body weight to about 400 IU/kg body weight, or from about 100 IU/kg body weight to about 300 IU/kg body weight, or from about 50 IU/kg body weight to about 1,000 IU/kg body weight, or from about 50 IU/kg body weight to about 800 IU/kg body weight, or from about 50 IU/kg body weight to about 700 IU/kg body weight, or from about 50 IU/kg body weight to about 600 IU/kg body weight, or from about 50 IU/kg body weight to about 500 IU/kg body weight, or from about 50 IU/kg body weight to about 400 IU/kg body weight, or from about 50 IU/kg body weight to about 300 IU/kg body weight, or about 50 IU/kg body weight to about 200 IU/kg body weight.
The pharmaceutical composition(s) of the invention may be administered alone or in conjunction with other therapeutic agents. These agents may be incorporated as part of the same pharmaceutical.
EXAMPLES
Example 1
Assessment of Bioavailability of s.c. Applied FVIII and Various Additives in a Hemophilia a Model
Materials and Animal Model
The Factor VIII used in the experiments was a B-domain truncated, single-chain recombinant factor VIII (hereinafter referred to as “rFVIII”). The Factor VIII was obtained by directly fusing Asn764 with Thr1653. It has been expressed in cell culture cells and purified from the cell culture medium.
The further agents used are summarized in Table 1.








TABLE 1





Compound class
Type of compound and/or source







Unfractionated heparin
Heparin-Natrium-25000-ratiopharm


Low molecular weight
Dalteparin (Fragmin ® from Pfizer)


heparin


Dextran sulfate
Ca. 500 kDa


Pentosan sulfate
Fondaparinux sodium (Arixtra ® from SKB)


N-Acetyl de-O-sulfated
N-Acetyl-de-O-sulfated heparin sodium salt


Heparin
from Sigma-Aldrich (Sigma product No.



A6039) CAS Number 133686-69-8


Chondroitin sulfate
Chondroitin sulfate A sodium salt from bovine



trachea, obtained from Sigma-Aldrich (Sigma



product No. C9819)



CAS Number 39455-18-0









Factor VIII knockout mice were used as animal model for hemophilia A. These mice lack exons 16 and 17 and thus do not express FVIII (Bi L. et al, Nature genetics, 1995, Vol 10(1), 119-121; Bi L. et al, Blood, 1996, Vol 88(9), 3446-3450). This allows the analysis of FVIII levels following treatment by quantification of FVIII activity in the plasma of the ko mice.
Methods
To assess whether extravascular injections might be an option for an improved therapy with rFVIII (human), a typical representative for an extravascular therapy, subcutaneous injection, was chosen. The design of the non-clinical pharmacokinetic study performed is detailed in tables 2 and 3 below. Plasma levels of Factor VIII activity were determined following a single intravenous or subcutaneous injection of rFVIII together with various additives (detailed treatment groups in table 2) in a hemophilia A model.
Corresponding groups were treated with the same dose of FVIII (chromogenic substrate (CS) activity assay) in the presence of various different additives. For a single application the various different components for each treatment group were mixed together in a volume of 200 μL (identical volumes for all groups) prior to subcutaneous application to FVIII knockout (ko) mice weighing about 25 g. The treatment groups are summarized in table 2.
Under short term anesthesia, blood samples were drawn, anticoagulated using sodium citrate to 10% citrate blood, processed to plasma and stored at −70° C. for the determination of FVIII activity. The sampling time points are detailed in table 3. Quantification of FVIII activity in plasma was performed by a standard, aPTT based approach (Behring Coagulation Timer). The animals were kept at standard housing conditions.







TABLE 2







Treatment groups















FVIII (CS activity








assay)/Additive
volume


No.
Treatment
Dose
[mL/kg]
schedule
route
N





1
rFVIII
400 IU/kg
8
single
s.c.
25






injection (t = 0)


2
rFVIII/
400 IU/kg/
8
single
s.c.
25



unfractionated
5 U/mL product

injection



Heparin
applied


3
rFVIII/
400 IU/kg/
8
single
s.c.
25



Dextransulfate (ca.
400 μg/mL product

injection



500 kDa)
applied


4
rFVIII/
400 IU/kg/
8
single
s.c.
20



Fragmin
5 U/mL product

injection




applied


5
rFVIII/
400 IU/kg/
8
single
s.c.
20



Fondaparinux
10 μg/mL product

injection




applied


6
rFVIII/
400 IU/kg/
8
single
s.c.
20



N-Acetyl de-O-
10 μg/mL product

injection



sulfated Heparin
applied


7
rFVIII/
400 IU/kg/
8
single
s.c.
20



Chondroitin sulfate
10 μg/mL product

injection




applied









Results

The results are summarized in Table 3 and FIG. 1. Subcutaneous injection of 400 IU/kg rFVIII in presence of various sulfated glycosaminoglycans into FVIII ko mice resulted in a significant increase of FVIII activity in plasma level as compared to administration of FVIII alone or FVIII+dextran sulfate. The increase for co-administration of heparin was particularly strong.







TABLE 3





FVIII activity in % of the FVIII activity in normal human plasma
















The peak values are shaded in grey.



























The peak values are shaded in grey.

## Claims

1. A method of treatment or prophylaxis for a bleeding disorder, the method comprising:
administering to a patient in need thereof a first pharmaceutical composition comprising Factor VIII by a non-intravenous route, wherein the Factor VIII is administered at a dose ranging from about 50 IU/kg body weight to about 800 IU/kg body weight; and
administering a second pharmaceutical composition comprising a sulfated glycosaminoglycan by a non-intravenous route, wherein the sulfated glycosaminoglycan is administered at a dose ranging from about 0.001 to about 100 mg per mL product applied, wherein the administered dosage of the Factor VIII and the sulfated glycosaminoglycan are sufficient to maintain a blood plasma level in the patient of more than 2% of the normal plasma level of Factor VIII in a healthy subject during a period from 1 hour after administration to 48 hours after administration, wherein the non-intravenous route is selected from the group consisting of subcutaneous, intramuscular, intraperitoneal, intradermal or transdermal administration,
thereby providing treatment or prophylaxis for the bleeding disorder.

2. The method of claim 1, wherein the sulfated glycosaminoglycan is heparin.

3. The method of claim 2, wherein the heparin is unfractionated heparin.

4. The method of claim 3, wherein the average molecular weight of the unfractionated heparin ranges from about 8 kDa to about 30 kDa.

5. The method of claim 1, wherein the Factor VIII is in a complex with von Willebrand Factor.

6. The method of claim 1, wherein the method comprises simultaneously administering the first pharmaceutical composition and the second pharmaceutical composition.

7. The method of claim 1, wherein the method comprises sequentially administering the first pharmaceutical composition and the second pharmaceutical composition.

8. The method of claim 1, wherein the non-intravenous administration is subcutaneous.

9. The method of claim 1, wherein the bleeding disorder is hemophilia A.

10. A method for increasing the bioavailability of an administered Factor VIII composition, the method comprising:
administering a first pharmaceutical composition comprising Factor VIII by a non-intravenous route, wherein the Factor VIII is administered at a dose ranging from about 50 IU/kg body weight to about 800 IU/kg body weight; and
administering a second pharmaceutical composition comprising a sulfated glycosaminoglycan by a non-intravenous route, wherein the sulfated glycosaminoglycan is administered at a dose ranging from about 0.001 to about 100 mg per mL product applied,
wherein the first pharmaceutical composition and the second pharmaceutical composition are administered at a dose that results in at least about a 20% increase in the bioavailability of Factor VIII relative to the bioavailability when Factor VIII is administered without the second pharmaceutical composition and wherein the non-intravenous route is selected from the group consisting of subcutaneous, intramuscular, intraperitoneal, intradermal or transdermal administration.

11. The method of claim 10, wherein the sulfated glycosaminoglycan is heparin.

12. The method of claim 11, wherein the heparin is unfractionated heparin.

13. The method of claim 12, wherein the average molecular weight of the unfractionated heparin ranges from about 8 kDa to about 30 kDa.

14. The method of claim 10, wherein the non-intravenous administration is subcutaneous, transdermal or intramuscular administration.

15. The method of claim 1, wherein the sulfated glycosaminoglycan is chosen from heparin and chondroitin.

16. The method of claim 10, wherein the sulfated glycosaminoglycan is chosen from heparin and chondroitin.

17. The method of claim 1, wherein the first and second pharmaceutical compositions are administered subcutaneously.

18. The method of claim 10, wherein the first and second pharmaceutical compositions are administered subcutaneously.