COMPOSITION FOR TREATMENT OF CONSTIPATION AND IRRITABLE BOWEL SYNDROME

Abstract: Constipation and Irritable Bowel Syndrome are treated by a delayed and sustained release composition of an opioid antagonist which commences release of the opioid antagonist in the mid to distal small intestine or ascending colon and provides sustained release along any remaining part of the small intestine and along the colon. Preferred opioid antagonists are naloxone and naltrexone.

Description: Composition for Treatment of Constipation and Irritable Bowel Syndrome The present invention relates to the use of an opioid antagonist, especially naloxone and naltrexone, for the treatment of opioid induced or idiopathic constipation or of Irritable Bowel Syndrome (IBS) by delayed and sustained release . Opioids, including codeine phosphate and morphine, are widely used as analgesics and are known to cause constipation as a troublesome and often serious complication. The effect is particularly troublesome amongst in-patients requiring prolonged opioid therapy in high doses such as terminally ill patients with a malignant disease. Treatment of the constipation is usually by use of conventional laxatives, but it is often poorly controlled. IBS is a functional bowel disorder consisting of abdominal pain and altered bowel habit. Pain is characteristically relieved by defecation and may be associated with increase or decrease in stool frequency, alterations in stool consistency, straining or urgency, a sensation of incomplete evacuation, passage of mucus or abdominal distention. The pathophysiology is poorly understood despite the fact that about a quarter of the population in the UK may exhibit the symptoms. There has been no convincing evidence that any current drug regime is of proven benefit in the treatment of IBS. Primary treatment involves counselling and dietary modification. Drug therapy is considered to be beneficial if directed at individual symptoms. For diarrhoea predominant cases, anti-diarrhoeal drugs are used, particularly loperamide. For constipation predominant cases, ispaghula is often used to increase dietary fibre. Where patients have pain and distension as predominant symptoms, antispasmolytics are commonly used. Mebeverine and peppermint oil are often used in such cases. Other agents that have been tried, in treating IBS, include beta- blockers, naloxone, ondansetron, calcium channel blockers, simethicone, leuprorelin, octreotide and cholecystokinin antagonists, with variable results (Martindale The Extra Pharmacopoeia, 31st Edition (1996) p 1197) . Naloxone (17-allyl-6-deoxy-7, 8-dihydro-14-hydroxy-6- oxonormorphine) is known to be a specific opioid antagonist and is given intravenously for the treatment of opioid overdosage and to reverse therapeutic effects of opioids (for example postoperatively when opioids are used during surgery) . It has a short plasma half-life of about lh after parenteral administration. It is absorbed from the gastrointestinal tract and subject to considerable first- pass metabolism. Naltrexone (17- (cyclopropylmethyl) -4 , 5α-epoxy-3 , 14- dihydroxymorphinan-6-one) is known to have opioid-blocking activity. It is given orally in the treatment of opioid dependence as an aid to maintaining abstinence following opioid withdrawal . Naltrexone is more potent than naloxone and has a longer duration of action. Naltrexone is also used as an adjunct in the management of alcohol withdrawal. Strong opioids delay gastrointestinal transit and patients treated with them experience marked constipation. The delay is partly mediated by opioid receptors in the gut. Naloxone has been shown to produce a laxative effect in patients with advanced cancer that are being treated with an opioid analgesic, although there were a number of instances of withdrawal observed. It appeared that the dose regime of naloxone was dependant on the dose of the constipation-causing opioid administered, however it was observed that any clinical use of naloxone should not > OJ M t H H LΠ o in o Ul O LΠ cn tl TJ I- 1 tl TJ P. ^ 0i ?r , "<5 " O 0 Φ tl rr 01 TJ Φ O cn LQ n φ to H H- Φ rt 3 P H - O Ω ► tr Oi P- rt tl Oi φ T φ rt Ω 0 tr 0 Φ 0 O tl 0i rt ^ t-i tι cn H α 3 Ω rt (- ■ - Φ P. • Φ tr tr Oi 0i φ rt tl φ Φ rt rt TJ H Ω rt Φ M- 3 φ Φ O P. tι <! Φ tl Oi tl 0 ) O Φ P P. rt cn rt CO cn rt Φ 3 H- H- φ 0 § P Φ P. 0 LQ r O rr tl Φ tl tr LQ a tl rt ri • φ φ M- P. 0i 01 H- cn o TJ O rt P rr !-•- CO T Hi μ- LQ Φ & tr Φ O tl P. Φ o OJ 0 tl P. φ t-i TJ • φ CO ^ - ^ H- φ r 3 H 3 rt O P. H- LO O O H- TJ - 3 L TJ O H P. Oi 01 . cn Φ tr CD rr rt rt - φ 1 - tr Φ cn ^ J Φ φ P. * H H- 3 a tl x o rt O P. rt P. tr φ - tr H CD O Oi to p. Φ 0i tn cn » H H H rt Φ Φ LO 01 cn φ tr P- Tj LΠ Φ Oi O Oi ^-^ O tl r rt Hi O 1~J • h- 1 cn tr tl H- p: tr rt - cn rr O 0i tr Oi Oi rt 1 H- <! Φ < 3 φ 3 h*. T Φ o 0 Φ • rt n tr TJ Oi Φ O rt Φ Φ H- cn 3 O Φ 0 0 to tl H- P. Φ ^ - ^ 0 P- • z P Oi TJ n coatings such as polyacrylates or cellulose acetate phthalates . US-A-4, 987,136 (Kreek et al) relates to the treatment of a range of gastrointestinal dysmotility conditions including constipation and IBS by administering opioid antagonists such as naloxone or naltrexone. Preferably, the opioid antagonist will be in an oral sustained release form allowing sustained release along the gastrointestinal tract, in a pH independent manner. The sustained release formulation may be administered in a hard gelatin capsule. There is a need to provide a therapeutic treatment that will relieve (opioid induced) constipation and treat IBS . The desired therapy would relieve opioid induced constipation without reversing the analgesic effect for which the opioid was intended. The inventors have now found that an opioid antagonist specifically released, initially, in the mid to distal small intestine, especially the distal ileum, and/or ascending colon is effective in treating IBS and both opioid induced and idiopathic constipation. Accordingly, in a first aspect of the invention, there is provided an opioid antagonist for use in the manufacture of a medicament for the treatment of a condition selected from constipation and Irritable Bowel Syndrome by targeting initial release of said antagonist to the mid to distal small intestine and/or ascending colon and providing subsequent sustained release of said antagonist along any remaining part of the small intestine and along the colon. Preferably, initial release of the antagonist is targeted to the distal ileum and/or ascending colon and subsequent sustained release occurs along the colon. The invention has particular application to the treatment of idiopathic constipation and especially opioid induced constipation. Preferred opioid antagonists for use in the invention are naloxone and naltrexone and pharmacologically acceptable salts, derivatives and metabolites thereof. Other opioid antagonists include methyl naloxone, nalmefene, cypridime, beta funaltrexamine, naloxonazine, naltrindole, nor-binaltorphimine and any pharmacologically acceptable salts, derivatives and metabolites thereof. References herein to pharmacologically acceptable derivative, include any derivative which has the same type of pharmacological activity as the relevant opioid antagonist . In a second aspect of the invention, there is provided a composition comprising an opioid antagonist in an oral delayed and sustained release form which targets initial release of the opioid antagonist to the mid to distal small intestine and/or ascending colon and provides sustained release along any remaining part of the small intestine and along the colon. Preferably, initial release of the antagonist is targeted to the distal ileum and/or ascending colon and subsequent sustained release occurs along the colon. The presently preferred opioid antagonist is naloxone. This substance is particularly suited to administration by the oral route since it is known to be efficiently metabolised by the liver, which minimises its absorption into the blood circulatory system thus limiting the risk of systemic side effects, such as negation of systemic pain relief for which certain opioids are administered. 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LO LO to to H H LΠ o LΠ o in o LΠ n ø μ- rt O tr -- Φ Φ tl rt Φ hj μ- Ω Ω 0 01 rt μ- tι LQ 3 O rt Φ hf μ- 0i CD Hi O hi ø tn Φ μ- tι rr tr φ LO LO t t in o in O LΠ o LΠ 1 • CD TJ tl μ- CO rt 01 Λ *• Ω rt hi 0i • -' rr in μ- rt 1 Oi O 0 * < 0i ft C tr Φ rt 0 tr Ω 0 rt Ω P. 0 P. P. 01 O rt Oi 3 φ Hi hi * rt Hi P. μ- ^ P. LQ .. μ- Ω 0> tl tr ft O to O rt o rt Ω p. (_: rt O O φ , tr O rt — < Pi ft φ O Ω μ- 01 Oi Φ o tr Φ which will dissolve in the small intestine can be used. A suitable unit dose for the treatment of constipation by opioid antagonists is in the range of 0.5 to 30 mg naloxone or the equivalent thereof . The invention will now be illustrated by the following non-limiting Examples. Example 1 A delayed, sustained release oral formulation was prepared as follows. Naloxone hydrochloride (10 mg) was suspended in 400 to 450 mg of a matrix of Gelucire™ 50/13 and Gelucire™ 42/12 (a polyglycolised glyceride supplied by Gattefosse, France) in the ratio 82.5:17.5 and the resulting suspension filled into a size No. 2 hard gelatin capsule. Formulations were also prepared with naloxone suspended in the following polyglycolised glycerides : a) Gelucire™ 42/12, b) Gelucire™ 44/14, c) Gelucire™ 46/07, d) Gelucire™ 48/09, e) Gelucire™ 50/13, f) Gelucire™ 53/10, g) Gelucire™ 54/02, h) Gelucire™ 62/05, i) Gelucire™ 64/02, j) Gelucire™ 54/02 & Gelucire™ 46/07 50:50, k) Gelucire™ 62/05 S Gelucire™ 46/07 50:50, 1) Gelucire™ 64/02 & Gelucire™ 46/07 50:50, m) Gelucire™ 54/02 & Gelucire™ 46/07 75:25, n) Gelucire™ 64/07 & Gelucire™ 46/07 75:25, o) Gelucire™ 54/02 & Gelucire™ 46/07 30:70, p) Gelucire™ 64/02 & Gelucire™ 46/07 30:70, q) Gelucire™ 53/10 & Gelucire™ 42/12 92.5:7.5, r) Gelucire™ 50/13 & Gelucire™ 42/12 95:5, s) Gelucire™ 42/12, Gelucire™ 54/02 S. Gelucire™ 46/07 5:45:50, t) Gelucire™ 42/12, Gelucire™ 64/02 & Gelucire™ 46/07 7.5:42.5:50 and u) Gelucire™ 53/10 & Gelucire™ 42/12 90:10. The capsules were then enteric coated using a 3% w/w acrylic resin (Eudragit™ S) dissolved in an organic solvent mixture (methanol 10% v/v in acetone 90% v/v) . Diethyl phthalate was included as the plasticiser and dimethicone 20 as a lubricant. 75 cm 3 of this mixture was used to coat 100 capsules. 12 healthy, non-smoking volunteers were enrolled in a study to assess the effect of oral naloxone when taking oral codeine. The study consisted of four 10-day study periods, with at least two weeks between each, which were in a randomised order and the capsules being administered daily in a double blind manner. The capsules in each case were A (codeine phosphate 30 mg or placebo) and B (naloxone 10 mg or placebo) and the study conducted such that all four combinations of treatments were given, that is to say placebo only, codeine with placebo, placebo with naloxone and codeine with naloxone. The capsules were administered twice a day ("bd") . The naloxone formulation used was that in a matrix of Gelucire™ 50/13 and Gelucire™ 42/12 in the ratio 82.5:17.5. The study protocol was as follows: On day 0, subjects were given capsule B and on days 1 to 9, were given capsules A and B. On days 3 to 6, the subjects took transit markers; packaged in distinctly coloured capsules, each containing 20 different shaped radio opaque marker pellets (Dunn Clinical Nutrition) . From day 7, the subjects' next two bowel motions were collected. A normal diet was adhered to throughout the study period and recorded on days 3 to 6. The results of the study are presented in tables of gut transit times. Table 1 shows the gut transit time of all 12 patients in the study for the control period and for the periods of treatment with codeine, naloxone and the combined treatment. Table 2 shows gut transit times for only those patients whose gut transit time was increased when taking codeine. Table 1: Gut transit times of all patients (n=12) SEM = Standard Error of the Mean; bd = twice a day Table 2 : Gut transit times of 8 patients whose transit time was increased by codeine (n=8) * SEM = Standard Error of the Mean; b bd = twice a day Statistical analysis of the above results was carried out and the results of this analysis are expressed as P values in Table 3. The results appear to be a good approximation to a normal distribution. For the sake of clarity both parametric and non-parametric statistics have been performed. Table 3 : Significance of difference between groups of paired data The experiment showed that naloxone alone and naloxone with codeine both produced reduced gut transit time. This indicates that the naloxone preparation accelerates gut transit by blocking opioid receptors and hence is effective in both opioid induced constipation and idiopathic constipation. Example 2 In a further study, the procedure of Example 1 was substantially followed using Gelucire™ 53/10 & Gelucire™ 42/12 95:5 as the polyglycolised glyceride matrix. The capsule was enterically coated with a mixture of acrylic resin materials (Eudragit™ LS) which caused the capsule to remain intact until the mid small intestine. The glyceride provided a harder melt than Gelucire™ 50/13 & Gelucire™ 42/12 82.5:17.5 and released the naloxone over a 12 hour period. 12 male volunteers throughout each of four 10-14 day study periods were given a fixed dose of naloxone (5mg bd, lOmg bd, 20mg bd or identical placebo) . The gut transit time was measured at the end of the first week. During the second week, each volunteer was also given 30mg bd codeine and gut transit times measured again at the end of the second week. The outcome of the study was that naloxone in all three doses was shown to accelerate gut transit time by " blocking the opioid effect, with the 10 and 20 mg bd doses being more reliable. Example 3 A 38 year old female patient with Irritable Bowel Syndrome having been subject to abdominal distension, pain and constipation for approximately ten years was treated with a naloxone hydrochloride formulation as used in Example 1, administered twice daily for one year. The treatment kept the patient almost symptom free for the duration of the treatment. Example 4 A 66 year old female patient demonstrating the symptoms of Irritable Bowel Syndrome was administered, intermittently, with a similar dosage form of naloxone hydrochloride to that of Example 3 and showed substantial clinical benefit.

Claims: Claims 1. The use of an opioid antagonist in the manufacture of a medicament for the treatment of a condition selected from constipation and Irritable Bowel Syndrome by targeting initial release of said antagonist to the mid to distal small intestine and/or ascending colon and providing subsequent sustained release of said antagonist along any remaining part of the small intestine and along the colon. 2. A use as claimed in Claim 1, wherein the condition is constipation. 3. A use as claimed in Claim 1, wherein the condition is Irritable Bowel Syndrome. 4. A use as claimed in any one of Claims 1 to 3 , wherein said opioid antagonist is naloxone or a pharmaceutically acceptable salt thereof. 5. A use as claimed in any one of Claims 1 to 3 , wherein said opioid antagonist is naltrexone or a pharmaceutically acceptable salt thereof . 6. A use as claimed in any one of the preceding claims, wherein the constipation is opioid induced. 7. A use as claimed in any one of the preceding claims, wherein the initial release of the opioid antagonist is targeted to the ascending colon. 8. A use as claimed in any one of Claims 1 to 6, wherein the initial release of the opioid antagonist is targeted to the distal ileum. 9. A composition comprising an opioid antagonist in an oral delayed and sustained release form which targets initial release of the opioid antagonist to the mid to distal small intestine and/or ascending colon and provides sustained release along any remaining part of the small intestine and along the colon. 10. A composition as claimed in Claim 9, wherein said opioid antagonist is naloxone or pharmaceutically acceptable salt thereof . 11. A composition as claimed in Claim 9, wherein said opioid antagonist is naltrexone or pharmaceutically acceptable salt thereof . 12. A composition as claimed in any one of Claims 9 to 11, wherein the opioid antagonist is dispersed in a matrix enclosed in a capsule which capsule disintegrates upon reaching the mid to distal small intestine and/or ascending colon to allow subsequent sustained release of the opioid antagonist from the matrix. 13. A composition as claimed in Claim 12, wherein said matrix is a thermolabile matrix. 14. A composition as claimed in Claim 13, wherein said matrix comprises a saturated polyglycolised glyceride excipient including mono-, di- and triglycerides and mono- and dicarboxylic fatty acid ester of polyethylene glycol. 15. A composition as claimed in Claim 14, wherein said matrix comprises a polyglycolised excipient having melting point/HLB value of 53/10. 16. A composition as claimed in Claim 14, wherein said matrix comprises a mixture of polyglycolised excipients having melting point/HLB values of 50/13 and 42/12. 17. A composition as claimed in Claim 16, wherein said mixture of 50/13 and 42/12 excipients are present in a ratio in the range 80:20 to 95:5. 18. A composition as claimed in any one of Claims 12 to 17, which capsule is an enteric coated gelatin capsule. " 19. A composition as claimed in Claim 18, wherein the enteric coating comprises a copolymer of methacrylic acid and methyl methacrylate having a ratio of free hydroxyl groups to ester groups of 1:1 to 1:2. 20. A composition as claimed in Claim 19, wherein the enteric coating comprises a copolymer of methacrylic acid and methyl methacrylate having a ratio of free hydroxyl groups to ester groups of 1:2. 21. A composition as claimed in any one of Claims 9 to 20, containing the opioid antagonist in an amount of 0.5 to 30 mg naloxone or the equivalent thereof per unit dose. 22. A method of treating a condition selected from constipation and Irritable Bowel Syndrome comprising administering to a patient an effective amount of an oral delayed and sustained release composition which targets initial release of the opioid antagonist to the mid to distal small intestine and/or ascending colon and provides sustained release along any remaining part of the small intestine and along the colon.

Inventors: EVANS BRIAN KENNETH, RHODES JOHN, EVANS, BRIAN, KENNETH, RHODES, JOHN
Applicants: EVANS BRIAN KENNETH, RHODES JOHN, RODEVA LTD, EVANS, BRIAN, KENNETH, RHODES, JOHN, RODEVA LIMITED
Application year: 2000
Main classification: A61K31
IPC codes: A61K9, A61K31, A61K45, A61K47, A61P1