NOVEL ANTIFOLATE COMBINATION THERAPIES

Abstract: A method of administering an antifolate to a mammal in need thereof, comprising administering an effective amount of said antifolate in combination with a methylmalonic acid lowering agent.

Description: NOVEL ANTIFOLATE COMBINATION THERAPIES Potentially, J %-threatening toxicity remains a major limitation to the optimal administration of antifolates. (see, generally, Antifolate Drugs in Cancer Therapy, edited by Jackman, Ann L., Humana Press, Totowa, NJ, 1999.) In some cases, a supportive intervention is routinely used to permit safe, maximal dosing. For example, steroids, such as dexamethone, can be used to prevent the formation of skin rashes caused by the antifolate. (Antifolate. pg 197.) Antifolates represent one of the most thoroughly studied classes of antineoplastic agents, with aminopterin initially demonstrating clinical activity approximately 50 years ago. Methotrexate was developed shortly thereafter, and today is a standard component of effective chemotherapeutic regimens for malignancies such as lymphoma, breast cancer, and head and neck cancer. (Bonnadonna G, Zambetti M, Valagussa P. Sequential or alternating doxorubicin and CMF regimens in breast cancer with more than three positive nodes: Ten year results. JAMA 1995;273(7):542-547; Bonnadonna G, Valagussa P, Moliterni A, Zambetti M, Brambilla C. Adjuvant cyclophosphamide, methotrexate, and fluorouracil in node-positive breast cancer: The results of 20 years of follow-up. N Engl J Med 1995;332(14):901-906; and Hong WK, Schaefer S, Issell B, et al. A prospective randomized trial of methotrexate versus cisplatin in the treatment of recurrent squamous cell carcinoma of the head and neck. Cancer 1983;52:206-210.) Antifolates inhibit one or several key folate-requiring enzymes of the thymidine and purine biosynthetic pathways, in particular, thymidylate synthase (TS), dihydrofolate reductase (DHFR), and glycinamide ribonucleotide formyltransferase (GARFT), by competing with reduced folates for binding sites of these enzymes. (Shih C, Habeck LL, Mendelsohn LG, Chen VJ, Schultz RM. Multiple folate enzyme inhibition: Mechanism of a novel pyrrolopyrimidine-based antifolate LY231514 (MTA). Advan Enzyme Regul, 1998; 38:135-152 and Shih C, Chen VJ, Gossett LS, et al. LY231514, apyrrolo[2,3-d]pyrimidine-based antifolate that inhibits multiple folate-requiring enzymes. Cancer Res 1997;57:1116-1123.) Several antifolate drugs are currently in development. Examples of antifolates that have thymidylate synthase inhibiting ("TSI") characteristics include 5-fluorouracil and Tomudex®. An example of an antifolate that has dihydrofolate reductase inhibiting ("DHFRI") characteristic is Methotrexate®. An example of an antifolate that has glycinamide ribonucleotide formyltransferase inhibiting ("GARFTI") characteristics is Lometrexol. Many of these antifolate drugs inhibit more than one bio synthetic pathway. For example Lometrexol is also an inhibitor of dihydrofolate reductase and pemetrexed disodium (Alimta®, Eli Lilly and Company, Indianapolis, IN) has demonstrated thymidylate synthase, dihydrofolate reductase, and glycinamide ribonucleotide formyltransferase inhibition. A limitation to the development of these drugs is that the cyto toxic activity and subsequent effectiveness of antifolates may be associated with substantial toxicity for some patients. Additionally antifolates as a class are associated with sporadic severe mylo suppression with gastrointestinal toxicity which, though infrequent, carries a high risk of mortality. The inability to control these toxicities led to the abandonment of clinical development of some antifolates and has complicated the clinical development of others, such as Lometrexol and raltitrexed. (Jackman AL, Calvert AH Folate-Based Thymidylate Synthase Inhibitors as Anticancer Drugs. Ann Oncol 1995;6(9):871-881; Laohavinij S, Wedge SR, Lind MJ, et al. A phase I clinical study of the antipurine antifolate Lometrexol (DDATHF) given with oral folic acid. Invest New Drugs 1996;14:325-335; and Maughan TS, James RD, Kerr D, et al. , on behalf of the British MRC Colorectal Cancer Working Party. Preliminary results of a multicenter randomized trial comparing 3 chemotherapy regimens (deGramont, Lokich, and raltitrexed) in metastatic colorectal cancer. Proc ASCO 1999;18:Abst 1007.) Initially, folic acid was used as a treatment for toxicities associated with GARFTI see, e.g. U.S. Pat. No. 5,217,974. Folic acid has been shown to lower homocysteine levels (see e.g. Homocysteine Lowering Trialist's Collaboration. Lowering blood homocysteine with folic acid based supplements: meta-analysis of randomized trials. BMJ 1998;316:894-898 and Naurath HJ, Joosten E, Riezler R, Stabler SP, Allen RH, Lindenbaum J. Effects of vitamin B 12, folate and vitamin B6 supplements in elderly people withnormal serum vitamin concentrations. Lancet 1995;346:85-89), and homocysteine levels have been shown to be a predictor of cytotoxic events related to the use of GARFT inhibitors, see e.g. U.S. Pat. No. 5,217,974. However, even with this treatment, cytotoxic activity of GARFT inhibitors and antifolates as a class remains a serious concern in the development of antifolates as pharmaceutical drugs. The ability to lower cytotoxic activity would represent an important advance in the use of these agents. Surprisingly and unexpectedly, we have now discovered that certain toxic effects such as mortality and nonhematologic events, such as skin rashes and fatigue, caused by antifolates, as a class, can be significantly reduced by the presence of a methylmalonic acid lowering agent, without adversely affecting therapeutic efficacy. The present invention thus provides a method for improving the therapeutic utility of antifolate drugs by administering to the host undergoing treatment with a methylmalonic acid lowering agent. We have discovered that increased levels of methylmalonic acid is a predictor of toxic events in patients that receive an antifolate drug and that treatment for the increased methylmalonic acid, such as treatment with vitamin B 12, reduces mortality and nonhematologic events, such as skin rashes and fatigue events previously associated with the antifolate drugs. Additionally, we have discovered that the combination of a methylmalonic acid lowering agent and folic acid synergisticaUy reduces the toxic events associated with the administration of antifolate drugs. Although, the treatment and prevention of cardiovascular disease with folic acid in combination with vitamin B 12 is known, the use of the combination for the treatment of toxicity associated with the administration of antifolate drugs was unknown heretofore. The present invention relates to a method of administering an antifolate to a mammal in need thereof, comprising administering an effective amount of said antifolate in combination with a methylmalonic acid lowering agent. Furthermore, the present invention relates to a method of reducing the toxicity associated with the administration of an antifolate to a mammal comprising administering to said mammal an effective amount of said antifolate in combination with a methylmalonic acid lowering agent. Furthermore, the present invention relates to a method of inhibiting tumor growth in mammals comprising administering to said mammals an effective amount of an antifolate in combination with a methylmalonic acid lowering agent. Furthermore, the present invention relates to a method of administering an antifolate to a mammal in need thereof, comprising administering an effective amount of said antifolate in combination with a methylmalonic acid lowering agent and a FBP binding agent. A preferred FBP binding agent is folic acid. Furthermore, the present invention relates to a method of reducing the toxicity associated with the administration of an antifolate to a mammal comprising administering to said mammal an effective amount of said antifolate in combination with a methylmalonic acid lowering agent and a FBP binding agent. A preferred FBP binding agent is folic acid. Furthermore, the present invention relates to a method of inhibiting tumor growth in mammals comprising administering to said mammals an effective amount of an antifolate in combination with a methylmalonic acid lowering agent and a FBP binding agent. A preferred FBP binding agent is folic acid. Furthermore, the present invention relates to the use of a methylmalonic acid lowering agent, alone or in combination with a FBP binding agent, in the preparation of a medicament useful in lowering the mammalian toxicity of an antifolate. A preferred FBP binding agent is folic acid. Furthermore, the present invention relates to the use of a methylmalonic acid lowering agent in the preparation of a medicament useful in lowering the mammalian toxicity associated with an antifolate, and the medicament is administered in combination with an antifolate. Furthermore, the present invention relates to the use of a methylmalonic acid lowering agent in the preparation of a medicament useful in lowering the mammalian toxicity associated with an antifolate, and the medicament is administered in combination with an antifolate and a FBP binding agent. Furthermore, the present invention relates to the use of a methylmalonic acid lowering agent in the manufacture of a medicament for use in a method of inhibiting tumor growth in mammals, which method comprises administering said methylmalonic acid lowering agent in combination with an antifolate. Furthermore, the present invention relates to a product containing a methylmalonic acid lowering agent, an antifolate and optionally a FBP binding agent as a combined preparation for the simultaneous, separate or sequential use in inhibiting tumour growth. The current invention concerns the discovery that administration of a methylmalonic acid lowering agent in combination with an antifolate drug reduces the toxicity of the said antifolate drug. The term ''inhibit'' as it relates to antifolate drugs refers to prohibiting, alleviating, ameliorating, halting, restraining, slowing or reversing the progression of, or reducing tumor growth. As used herein, the term "effective amount" refers to an amount of a compound or drug, which is capable of performing the intended result. For example, an effective amount of an antifolate drug that is administered in an effort to reduce tumor growth is that amount which is required to reduce tumor growth. As used herein, the term "toxicity" refers to a toxic event associated with the administration on an antifolate. Such events include, but are not limited to, neutropenia, thrombopenia, toxic death, fatigue, anorexia, nausea, skin rash, infection, diarrhea, mucositis, and anemia. For further explanation of the types of toxicity experienced by patients receiving antifolates, see, generally, Antifolate Drugs in Cancer Therapy. Preferably, toxicity refers to toxic death, fatigue, neutropenia, thrombopenia, and mucositis. As used herein, the term "nonhematologic event" refers to the occurrence of skin rash or fatigue due to the administration of an antifolate. As used herein, the term "in combination with" refers to the administration of the methylmalonic acid lowering agent, the antifolate drug, and optionally the folic acid; in any order such that sufficient levels of methylmalonic acid lowering agent and optionally folic acid are present to reduce the toxicity of an antifolate in a mammal. The administration of the compounds maybe simultaneous as a single composition or as two separate compositions or can be adrninistered sequentially as separate compositions such that an effective amount of the agent first administered is in the patient's body when the second and/or third agent is administered. The antifolate drug may be administered to the mammal first, followed by treatment with the methylmalonic acid lowering agent. Alternatively, the mammal may be adrninistered the antifolate drug simultaneously with the methylmalonic acid lowering agent. Preferably, the mammal is pretreated with the methylmalonic acid lowering agent and then treated with the antifolate. If folic acid is to be administered in addition to the methylmalonic acid lowering agent, the folic acid may be administered at any time prior, post, or simultaneously to the administration of either the methylmalonic acid lowering agent or the antifolate. Preferably, the mammal is pretreated with the methylmalonic acid, and then treated with folic acid, followed by treatment with the antifolate compound. The terms "antifolate" and "antifolate drug" refer to a chemical compound which inhibits at least one key folate-requiring enzyme of the thymidine or purine bio synthetic pathways, preferably thymidylate synthase ('TS"), dihydrofolate reductase ("DHFR"), or glycinamide ribonucleotide formyltransferase ("GARFT"), by competing with reduced folates for binding sites of these enzymes. Preferred examples of antifolates include 5- fluorouracil, as manufactured by Glaxo; Tomudex®, as manufactured by Zeneca; Methotrexate®, as manufactured by Lederle; Lometrexol®, as manufactured by Tularik; pyrido[2,3-d]pyrimidine derivatives described by Taylor et al. in U.S. Pat. Nos. 4684653, 4833145, 4902796, 4871743, and 4882,334; derivatives described by Akimoto in U.S. Pat. No. 4997838; thymidylate synthase inhibitors as found in EPO application 239,362; and most preferred, Pemetrexed Sodium (ALLMTA), as manufactured by Eli Lilly & Co. The terms ''methylmalonic acid" and "MMA" refer to a structural isomer of succinic acid present in minute amounts in healthy human urine. The term "methylmalonic acid lowering agent" refers to a substrate, which lowers the concentration of methylmalonic acid in a mammal. A preferred example of such a substrate is vitamin B 12. For methods of deteimining methylmalonic acid and substrates therefore, see, e.g., Matchar DB, Feussner JR, Millington DS, et al. Isotope dilution assay for urinary methylmalonic acid in the diagnosis of vitamin B 12 deficiency. A prospective clinical evaluation. Ann Intern Med 1987; 106: 707-710; Norman EJ, Morrison JA. Screening elderly populations for cobalamin (vitamin B 12) deficiency using the urinary methylmalonic acid assay by gas chromatography mass spectrometry. Am J Med 1993; 94: 589-594; Norman EJ. Gas Chromatography mass spectrometry screening of urinary methylmalonic acid: early detection of vitamin B 12 (cobalamin) deficiency to prevent permanent neurologic disability. GC/MS News 1984; 12:120-129; Martin DC, Francis J, Protetch J, Huff FJ. Time dependency of cognitive recovery with cobalamin replacement: report of a pilot study. JAGS 1992; 40: 168-172; Norman EJ, Cronin C. Cobalamin deficiency. Neurol 1996; 47: 310-311; Rasmussen K, Moelby I, Jensen MK. Studies on methylmalonic acid in humans; Savage DG, Lindenbaum J, Stabler SP, Allen RH. Sensitivity of methylmalonic acid and total homocysteine determination for diagnosing cobalamin and folate deficiency. Am J Med 1994; 96: 239-246. The term ''vitamin B 12" refers to vitamin B 12 and its pharmaceutical derivatives, such as hydroxocobalamin, cyano-10-c orocobalarnin, aquocobalamin perchlorate, aquo- 10-cMorocobalamin perchlorate, azidocobalamin, cMorocobalamin, and cobdamin. Preferably the term refers to vitamin B12, cobalamin, and cMorocobalamin. The dosage generally will be provided in the form of a vitamin supplement, namely as a tablet administered orally, such as a sustained release formulation, as an aqueous solution added to drinking water, or as an aqueous parenteral formulation. Preferably the methylmalonic acid lowering agent is administered as an intramuscular injection formulation. Such formulations are known in the art and are commercially available. The skilled artisan will appreciate that the methylmalonic lowering agents are effective over a wide dosage range. For example, when cobalamin is used as the methylmalonic lowering agent, the dosage of cobalamin may fall within the range of about 0.2 μg to about 3000 μg of cobalamin from once daily for a month to once every nine weeks for a year. Preferably, cobalamin will be dosed as an intramuscular injection of about 500 μg to about 1500 μg administered from about every 24 hours to about every 1680 hours. Preferably, it is an intramuscular injection of about 1000 μg administered initially from about 1 to about 3 weeks prior to administration of the antifolate and repeated from about every 24 hours to about every 1680 hours, regardless of when treatment with the antifolate is started and continued until the administration of the antifolate is discontinued. Most preferred is an intramuscular injection of about 1000 μg administered initially from about 1 to about 3 weeks prior to the first administration of the antifolate and repeated every 6 to 12 weeks, preferably about every 9 weeks, and continued until the discontinuation of the antifolate administrations. However, it will be understood that the amount of the methylmalonic acid lowering agent actually administered will be determined by a physician, in the light of the relevant circumstances, including the condition to be treated, the chosen route of administration, the actual agent administered, the age, weight, and response of the individual patient, and the severity of the patient's symptoms, and therefore the above dosage ranges are not intended to limit the scope of the invention in any way. In some instances dosage levels below the lower limit of the aforesaid range may be more than adequate, while in other cases still larger doses may be employed without causing any harmful side effect. The term "FBP binding agent" as used herein refers to a folic binding protein binding agent wMch includes folic acid, (6R)-5-methyl-5,6,7,8-tetrahydrofolic acid, and (6R)-5-formyl-5,6,7,8-tetrahydrofolic acid, or a physiologically-available salt or ester thereof. This latter compound is the (6R)-isomer of leucovorin as disclosed in J. Am. Chem. Soc, 74, 4215 (1952). Both of the tetrahydrofoHc acid compounds are in the unnatural configuration at the 6-position. They are 10-20 fold more efficient in binding the folate binding protein compared with their respective (6S) — isomer, see Ratnam, et. al., Folate and Antifolate Transport in Mammalian Cells Symposium, Mar. 21-22, 1991, Bethesda, MD. These compounds are usually prepared as a mixture with their natural form (6S) of diastereomers by non-stereoselective reduction from the corresponding dehydro precursors followed by separation through chromatograpMc or enzymatic techniques. See e.g. PCT Patent Application Publication WO 880844 (also Derwent Abstract 88-368464/51) and Canadian Patent 1093554. See, e.g. Dietary Reference Intakes for TMamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B 12, Pantothenic Acid, Biotin, and Choline (2000), 8 Folate, pp. 196-305. 'Physiologically-available salt" refers to potassium, sodium, litMum, magnesium, or preferably a calcium salt of the FBP binding agent. 'Thysiologically-available...ester" refers to esters wMch are easily hydrolyzed upon administration to a mammal to provide the corresponding FBP binding agent free acid, such as C1-C4 alkyl esters, mixed anhydrides, and the like. The FBP binding agent to be utilized according to tMs invention can be in its free acid form, or can be in the form of a physiologically-acceptable salt or ester wMch is converted to the parent acid in a biological syste The dosage generally will be provided in the form of a vitamin supplement, namely as a tablet administered orally, preferably as a sustained release formulation, as an aqueous solution added to drinking water, an aqueous parenteral formulation, e.g., an intravenous formulation, or the like. The FBP binding agent is usually administered to the subject mammal prior to treatment with the antifolate. Pretreatment with the suitable amount of FBP binding agent fro about 1 to about 24 hours is usually sufficient to substantially bind to and block the folate binding protein prior to administration of the antifolate. Although one single dose of the FBP binding agent, preferably an oral administration of folic acid, should be sufficient to load the folate binding protein, multiple dosing of the FBP binding agent can be employed for periods up to weeks before treatment with the active agent to ensure that the folate binding protein is sufficiently bound in order to maximize the benefit derived from such pretreatment. In the especially preferred embodiment of tMs invention, about 0.1 mg to about 30 mg, most preferably about 0.3 mg to about 5 mg, of folic acid is administered orally to a mammal about 1 to 3 weeks post administration of the methylmalonic acid lowering agent and about 1 to about 24 hours prior to the parenteral administration of the amount of an antifolate. However, it will be understood that the amount of the methylmalonic acid lowering agent actually administered will be determined by a physician, in the light of the relevant circumstances, including the condition to be treated, the chosen route of administration, the actual agent administered, the age, weight, and response of the individual patient, and the severity of the patient's symptoms, and therefore the above dosage ranges are not intended to limit the scope of the invention in any way. In some instances dosage levels below the lower limit of the aforesaid range may be more than adequate, while in other cases still larger doses may be employed without causing any harmful side effect. In general, the term "pharmaceutical" when used as an adjective means substantially non-toxic to living organisms. Methods To assess the effect of a methylmalonic acid lowering agent, alone or in combination with folic acid on the antitumor efficacy of an antifolate in a human tumor xenograft model, female nude mice bearing human MX-1 breast carcinoma were treated with ALIMTA alone or along with super-physiologic doses of folic acid or vitamin B 12 (cobalamin). The animals were maintained on sterilized standard lab chow ad libitum and sterilized water ad libitum. The human MX- 1 tumor cells (5 x 10 6 ) obtained from donor tumors were implanted subcutaneously in a tMgh of female nude mice 8- to 10- weeks old. Beginning on day 7 post tumor cell implantation, the animals were treated with ALIMTA (100 mg/kg or 150 mg kg) once daily on days 7 through 11 and 14 through 18 by intraperitoneal injection alone or along with folic acid (6 mg kg or 60 mg/kg) and/or vitamin B 12 (165 mg/kg) by intraperitoneal injection on the same schedule. Tumor response was monitored by tumor volume measurements twice weekly over the course of the experiment. Toxicity was monitored by body weight measurements made at the same time as the tumor volume measurements. Tumor growth delay was the difference in days for the treated and the controls tumors to reach 1000 mm 3 . The human MX-1 breast carcinoma xeno graft was responsive to treatment with ALIMTA with doses of 100 mg/kg and 150 mg kg producing tumor growth delays of 17 days and 21 days, respectively. Folic acid was administered to the animals alone at two doses 6 mg/kg and 60 mg kg on the same schedule as ALIMTA and produced tumor growth delays of 7 days and 12 days, respectively. Vitamin B 12 administered alone at a dose of 165 mg/kg resulted in a tumor growth delay of 12 days. Combinations of ALIMTA at each of the two doses were administered along with each of the vitamins as simultaneous combination regimens. Administration of folic acid (6 mg/kg) along with ALIMTA did not alter the tumor growth delay produced from that obtained with ALIMTA alone. The addition of folic acid at the Mgher dose (60 mg/kg) along with each dose of ALIMTA resulted in small increases in tumor growth delay to 22 days and 23 days at the ALLMTA doses of 100 mg/kg and 150 mg/kg, respectively. The tumor growth delays with ALIMTA and vitamin B 12 (165 mg/kg) treatment were 22 days and 24 days at ALIMTA doses of 100 mg/kg and 150 mg/kg, respectively. Body weight was used as a general measure of toxicity for each of the treatment regimens. The body weight loss pattern reflected the treatment regimens with weight decrease during the treatment times of days 7 through 11 and 14 through 18 with some weight recovery during the intervening two days. The weight loss due to ALITMA was dose dependent but overall minor (3%). Folic acid alone at either 6 mg/kg or 60 mg/kg did not cause weight loss, in fact folic acid treated animals maintained weight and gained weight over the course of the experiment better than the control animals. The animals treated with ALIMTA (100 mg/kg) and folic acid (60 mg/kg) gained weight (about 20%) over the course of the experiment. Administration of vitamin B12 did not prevent weight gain in the animals over the time course of the experiment. The animals treated with ALIMTA (100 mg/kg) along with vitamin B 12 gained weight while those treated with ALIMTA (150 mg/kg) along with vitamin B 12 maintained weight over the course of the experiment. In conclusion, administration of super-physiologic but non-toxic doses of the vitamins, folic acid and vitamin B12, did not alter the antitumor activity of ALIMTA in the human MX-1 breast carcinoma xeno graft tumor in nude mice and did not increase the toxicity of ALIMTA as determined by body weight measurements of the animals. The effect of vitamin B 12, alone or in combination with folic acid, on antifolates can be demonstrated in standard tests commonly utilized to determine the antitumor activity and toxic effects of the antifolates themselves. In one such test, mice are inoculated with the C3H strain of πiammary adenocarcinoma by inserting a 2 mm by 2 mm section of tumor into the axillary region of the mice by trocar. The timing of administering the methylmalonic acid lowering agent, alone or in combination with the folic acid, and the antifolate may be varied. Ten animals are used at each dosage level. Antitumor activity is assessed on day ten (when day one is first dosage of antifolate) by measuring the length and width of the tumor growth using vernier calipers, and the activity is expressed as a percent inMbition of tumor growth. When the antifolate is administered to infected mice wMch are maintained on a diet totally free of vitamin B 12 and optionally folic acid for two weeks prior to and during treatment, it exHbits moderated antitumor activity at very low doses, but also causes severe toxicity at a very low dose (measured as death of mice). A test group of mice are maintained on a vitamin B 12 and optionally folic acid free diet for two weeks before treatment. Vitamin B 12 and optionally folic acid is then administered during the treatment by intramuscular injection of 0.0003% vitamin B12 (weight/volume) and optionally providing the animals drinking water containing 0.0003% folic acid (weight/volume). T s concentration translates to about 1.75 mg of vitamin B 12 and optionally folic acid per square meter of body surface per day. As the foregoing results indicate, addition of the indicated level of vitamin B 12 to the diet of a subject receiving an antifolate results in excellent antitumor activity at low doses, with little or no toxic effects. The foregoing tests establish that for tumor bearing mice maintained on a vitamin B12 and optionally folic acid free diet prior to and during treatment with an antifolate, the toxicity of the antifolate is very large, with 1 mg/kg/day being lethal to the majority of the mice, and lower antitumor activity is observed at non-toxic drug doses. Very low doses of vitamin B 12 partially reverses drug toxicity and improved antitumor activity. Larger doses of vitamin B 12 reduce antifolate toxicity even more significantly. Pretreatment of the mouse with vitamin B 12 and then administering folic acid prior to administering the antifolate demonstrates a striking reduction in toxicity, almost eliminating the antifolate toxicity completely. Thus, the use of vitamin B 12 in combination with an antifolate reduces drug toxicity without adversely affecting antitumor activity, and the use of vitamin B12 in conjunction with folic acid synergistically reduces drug toxicity. In a typical clinical evaluation involving cancer patients, all of whom have MstologicaUy or cytologicaUy confirmed diagnosis of cancer, an antifolate is administered in combination with vitamin B 12. Vitamin B 12 is administered as a 1000 μg intramuscular injection 1-3 weeks prior to treatment with the antifolate, and 1000 μg intramuscular injection of vitamin B 12 is made approximately every 9 weeks until the patient discontinues from therapy. The antifolate is administered in four doses over a two week period by rapid intravenous injection, followed by two weeks of non-therapy. Dosing is made on days 1, 4, 8 and 11 of any two week period. Patients will have an initial course of therapy at a dose of 5 mg/m^/dose, and depending upon the toxic effects observed in the initial course, their subsequent courses may be at the same dose, or may be escalated to 6 mg/rn^, or may be attenuated to 4 mg/m?. In preparation for the foregoing climcal study, pilot studies in humans have established that vitamin B 12 given to patients receiving AJimta has effected reduced side effects due to the Alimta. One to two weeks prior to administration of ALIMTA urine is collected and blood is drawn from a human subject; and vitamin metabolite levels, methylmalonic acid and homocysteine, are determined. Homocysteine levels are determined in blood by a fluorescent polarization immunoassay kit manufactured by Abbot Laboratories. MethylmaloMc acid levels are deteπnined by urine levels using a 24 hour urine collection kit available from Biolab Medical Unit (a United Kingdom company). Additionally urine and blood may be collected one week prior to admiMstration of ALIMTA (after at least 5 days of folic acid supplementation and at least 1 week vitamin B12 supplementation), and up to 4 days prior to every cycle. Method of administration and dosing procedures: 1. Folic Acid: Folic acid will be supplied as one of the following options, with preference in order from option #1 to option #3: 1. 350 - 600 μg folic acid. 2. A multivitamin containing folic acid in the range of 350 μg to 600 μg is acceptable if option #1 is not available. 3. A dose of folic acid between 350 μg and 1000 μg is acceptable if neither option #1 or option # 2 is available. For purposes of tMs study, patients should take oral folic acid daily beginning approximately 1 to 3 weeks before treatment with ALLMTA plus cisplatin or cisplatin alone and continuing daily until discontinuation from study therapy. 2. Vitamin B 12 Vitamin B 12 will be obtained and administered as a 1000 μg intramuscular injection. A vitamin B12 injection must be administered approximately 1 to 3 weeks before treatment with ALIMTA and should be repeated approximately every 9 weeks until the patient discontinues from study therapy. Folic acid supplementation, 350 - 600 μg or equivalent should be taken orally daily beginning approximately 1 to 3 weeks prior to the first dose of MTA plus cisplatin and continue daily until the patient discontinues from study therapy. A vitamin B 12 injection, 1000 μg, must be given intramuscularly approximately 1 to 3 weeks prior to the first dose of ALIMTA and should be repeated approximately every 9 weeks until the patient discontinues from study therapy. Compare presupplementation homocysteine and methylmalomc acid levels to a) the level immediately prior to the initial dose of study drug, and b) to the level immediately prior to the second dose of study drug (i.e., after a full cycle of supplementation), and compare the prevalence of specific toxicities experienced in up to the first seven cycles of therapy in patients who have been supplemented from baseline to the prevalence seen in the earlier patients (n = 246) who were not supplemented (Farber et al.) Toxicity may be compared in specific patients in non- supplemented cycles versus supplemented cycles (cross-over patients). The data to be compared are: 1) Patient numbers and baseline demograpMc data for those supplemented from baseline. 2) Homocysteine and methylmaloMc acid levels, levels at baseline, prior to first dose, prior to second dose, and prior to each therapy cycle depending of the type of cancer under study. 3) Grade 3 and 4 hematologic toxicity in these fully supplemented patients. 4) Grade 3 and 4 nonhematologic toxicity in these fully supplemented patients. The grading of toxicities in chemotherapuetic clinical trials is well known to a person of skill in the art. Examples of fatigue and skin rash grading are provided below. Fatigue Grading ~ Neuromotor Grade 0 none or no change Grade 1 subjective weakness; no objective findings Grade 2 mild objective weakness without significant impairment of function Grade 3 objective weakness with impairment of function Grade 4 paralysis Rash Grading — Skin Grade 0 none or no change Grade 1 scattered macular or papular eruption or erythema that is asymptomatic Grade 2 scattered macular or papular eruption or erythema with pruritus or other associated eruption symptoms Grade 3 generalized symptomatic macular, papular, or vesicular eruption Grade 4 exfoliative dermatitis or ulcerating dermatitis The vitamins (both folic acid and B 12) to be used in the following studies may be obtained fromZeMth Gold Line, Centrum, Folvite, or in Canada Apo-Folic. Cyanocobalamin is used as the methylmaloMc acid lowering agent in these studies. Current and past clinical trials show a 4% drug-related death total, 50% grade 3/4 neutropenia, 7% grade 4 tMombocytopenia, and 10% grade 3/4 diarrheas and mucositis in patients administered ALJ TA and folic acid as described in U.S. Pat. No. 5,217,974. Vitamin B 12 supplementation with ALIMTA has a moderate effect on drug related toxicity, lowering drug related deaths to 3% and severe toxicities by about 25%. The combination of vitamin B 12 and folic acid with ALIMTA has lowered the drug related deaths to <1% in over 480 so treated. The combination of vitamin B 12 and folic acid has lowered the drug related grade 3/4 toxic events, see Table 1. Table 1 Additionally, sixty-two chemonaive patients requiring chemotherapeutic treatment were divided into two groups. Seventeen of these patients received ALIMTA, but did not receive vitamin B 12 or folic acid, as described supra. The remaining patients received treatment with vitamin B 12, folic acid, and ALIMTA, as described supra. Of patients who received the combination treatment, 8 out of 45 responded to the chemotherapy. Of patients who did not receive the combination treatment, but rather, received only treatment with ALIMTA, only 1 out of 17 patients responded.

Claims: We Claim: 1. A method of administering an antifolate to a mammal in need thereof, comprising admiMstering an effective amount of said antifolate in combination with a methylmalomc acid lowering agent. 2. A method of reducing the toxicity associated with the adm stration of an antifolate to a mammal comprising administering to said mammal an effective amount of said antifolate in combination with a methylmaloMc acid lowering agent. 3. A method of inMbiting tumor growth in mammals comprising administering to said .mammals an effective amount of an antifolate in combination with a methylmaloMc acid lowering agent. 4. A method of admiMstering an antifolate to a mammal in need thereof, comprising administering an effective amount of said antifolate in combination with a methylmaloMc acid lowering agent and FBP binding agent. 5. A method of reducing the toxicity associated with the ad iMstration of an antifolate to a mammal comprising admiMstering to said mammal an effective amount of said antifolate in combination with a methylmaloMc acid lowering agent and FBP binding agent. 6. A method of inMbiting tumor growth in mammals comprising admiMstering to said mammals an effective amount of an antifolate in combination with a methylmaloMc acid lowering agent and FBP binding agent. 7. A method of any one of claims 1-6 wherein the methylmaloMc acid lowering agent is selected from the group consistmg of hydroxocobalamin, cyano-10- cMorocobalaiMn, aquocobMamin percMorate, aquo-10-cMorocobalarnin percMorate, azidocobalamin, cMorocobalamin, and cobMarnin. 8. A method of any one of claims 4-6 wherein the FBP binding agent is selected from the group consisting of folic acid, (6R)-5-methyl-5,6,7,8-tetrahydrofolic acid, and (6R)-5-formyl-5,6,7,8-tetrahydrofolic acid, or a physiologically-available salt or ester thereof. 9. A method of any one of claims 1-8 wherein the antifolate is ALIMTA. 10. A method of any one of claims 1-9 wherein the mammal is pretreated with methylmaloMc acid lowering agent. 11. The use of a methylmaloMc acid lowering agent in the preparation of a medicament useful in lowering the mammalian toxicity associated with an antifolate, and the medicament is admiMstered in combination with an antifolate. 12. The use of a methylmaloMc acid lowering agent in the preparation of a medicament useful in lowering the mammalian toxicity associated with an antifolate, and the medicament is admiMstered in combination with an antifolate and a FBP binding agent. 13. The use any one of claims 11-12 wherein the methylmaloMc acid lowering agent is selected from the group consisting of hydroxocobMamin, cyano-10- cMorocobalamin, aquocobalamin percMorate, aquo-10-cMorocobalamin percMorate, azidocobalamin, cMorocobalamin, and cobalamin. 14. The use of any one of claims 11-13 wherein the FBP binding agent is selected from the group consisting of folic acid, (6R)-5-methyl-5,6,7,8-tetrahydrofolic acid, and (6R)-5-formyl-5,6,7,8-tetrahydrofolic acid, or a physiologically-available salt or ester thereof. 15. The use of any one of claims 11-14 wherein the antifolate is ALIMTA. 16. The use of any one of claims 11-15 wherein the mammal is pretreated with methylmaloMc acid lowering agent. 17. Use of a methylmaloMc acid lowering agent in the manufacture of a medicament for lowering the mammalian toxicity associated with admiMstration of an antifolate wherein said methylmaloMc acid lowering agent is admiMstered in combination with said antifolate. 18. Use of a methylmaloMc acid lowering agent in the manufacture of a medicament for use in a method of inMbiting tumor growth in mammals, wMch method comprises admiMstering said methylmaloMc acid lowering agent in combination with an antifolate. 19. Use according to claim 17 or 18 wherein a FBP binding agent is also admiMstered in combination with said methylmaloMc acid lowering agent and antifolate. 20. Use according to any one of claims 17-19 wherein the methylmaloMc acid lowering agent, antifolate and optionally FBP binding agent is admiMstered simultaneously, separately or sequentially of one another. 21. The use any one of claims 17-20 wherein the methylmaloMc acid lowering agent is selected from the group consisting of hydro xocobalamin, cyano-10- cMorocobalamin, aquocobalamin percMorate, aquo-10-cMorocobMamin percMorate, azidocobalamin, cMorocobalamin, and cobalamin. 22. The use of any one of claims 19-21 wherein the FBP binding agent is selected from the group consisting of folic acid, (6R)-5-methyl-5,6,7,8-tetrahydrofolic acid, and (6R)-5-formyl-5,6,7,8-tetrahydrofolic acid, or a physiologically-available salt or ester thereof. 23. The use of any one of claims 17-22 wherein the antifolate is ALIMTA. 24. The use of any one of claims 17-23 wherein the mammal is pretreated with the methylmaloMc acid lowering agent. 25. A product containing a methylmaloMc acid lowering agent, an antifolate and optionally a FBP binding agent as a combined preparation for the simultaneous, separate or sequential use in inMbiting tumour growth. 26. A product according to claim 25 wherein the methylmaloMc acid lowering agent is selected from the group consisting of hydroxocobMamin, cyano-10- cMoiOcobalarnin, aquocobalamin percMorate, aquo-10-cMorocobalamin percMorate, azidocobalamin, cMorocobalamin, and cobMamin. 27. A product according to claim 25 or 26 wherein the antifolate is ALIMTA. 28. A product according to anyone of claims 25-27 wherein the FBP binding agent is selected from the group consisting of folic acid, (6R)-5-methyl-5,6,7,8- tetrahydrofolic acid, and (6R)-5-formyl-5,6,7,8-tetrahydrofolic acid, or a physiologically- available salt or ester thereof.

Inventors: NIYIKIZA CLET, PAOLETTI PAOLO, RUSTHOVEN JAMES JACOB, NIYIKIZA, CLET, PAOLETTI, PAOLO, RUSTHOVEN, JAMES, JACOB
Applicants: LILLY CO ELI, NIYIKIZA CLET, PAOLETTI PAOLO, RUSTHOVEN JAMES JACOB, ELI LILLY AND COMPANY, NIYIKIZA, CLET, PAOLETTI, PAOLO, RUSTHOVEN, JAMES, JACOB
Application year: 2001
Main classification: A61K31
IPC codes: A61K31, A61K45, A61P35