Abstract:
The present invention relates to pharmaceutical preparations comprising Factor VIII, a sulfated glycosaminoglycan and a hyaluronidase for the non-intravenous administration in the therapy and prophylactic treatment of bleeding disorders. The invention further relates to the combined use of a Factor VIII, a sulfated glycosaminoglycan and a hyaluronidase for the treatment and prevention of bleeding disorders, and to a method for increasing the bioavailability after non-intravenous administration of Factor VIII by co-adminstration of a sulfated glycosaminoglycan and a hyaluronidase.

Description:
[0001]    The present invention relates to pharmaceutical preparations comprising at least one Factor VIII, at least one sulfated glycosaminoglycan and at least one hyaluronidase for the non-intravenous administration in the therapy and prophylactic treatment of bleeding disorders. The invention further relates to the combined use of Factor VIII, a sulfated glycosaminoglycan and a hyaluronidase for the treatment and prevention of bleeding disorders, and to a method for increasing the bioavailability after non-intravenous administration of Factor VIII by co-administration of a sulfated glycosaminoglycan and a hyaluronidase. 
       BACKGROUND OF THE INVENTION 
       [0002]    Factor VIII (FVIII) 
         [0003]    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. 
         [0004]    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). 
         [0005]    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. 
         [0006]    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 procoagulatory activity. 
         [0007]    Von Willebrand Factor (VWF) 
         [0008]    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. 
         [0009]    The most frequent inherited bleeding disorder in humans is von Willebrand&#39;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. 
         [0010]    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. 
         [0011]    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. 
         [0012]    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. 
         [0013]    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. 
         [0014]    Thus there is a great medical need to obviate the need to infuse Factor VIII intravenously. 
         [0015]    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. 
         [0016]    Another approach to improve the bioavailability upon non-intravenous administration has been to use albumin-fused Factor VIII (WO 2011/020866 A2). 
         [0017]    WO 2010/077297 A1 and WO 2010/077297 A1 teach the use of hyaluronidase as a spreading or dispersing agent to promote, enhance or increase the dispersion and delivery of a vast number of agents, drugs and proteins to improve the pharmacokinetic and pharmacodynamic profile of the co-administered agent, drug or protein. 
         [0018]    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 in combination with a sulfated glycosaminoglycan and a hyaluronidase. 
       SUMMARY OF THE INVENTION 
       [0019]    In a first aspect, the present invention therefore relates to a pharmaceutical preparation comprising at least one Factor VIII, at least one sulfated glycosaminoglycan, and at least one hyaluronidase. 
         [0020]    In a preferred embodiment of the first aspect of the invention, the pharmaceutical preparation comprises Factor VIII, at least one sulfated glycosaminoglycan (e.g. heparin), and at least one hyaluronidase. More preferably, the pharmaceutical preparation comprises human Factor VIII, unfractionated heparin and human hyaluronidase. The Factor VIII may or may not be complexed with VWF. 
         [0021]    In a second aspect, the invention relates to a Factor VIII for use in the treatment or prophylaxis of a bleeding disorder, wherein said treatment or prophylaxis comprises administration of at least one sulfated glycosaminoglycan and at least one hyaluronidase. In a variation of the second aspect, the invention pertains to Factor VIII, a sulfated glycosaminoglycan, and a hyaluronidase for use in the treatment or prophylaxis of a bleeding disorder. 
         [0022]    A preferred embodiment of the second aspect of the invention is Factor VIII for use in the treatment or prophylaxis of a bleeding disorder, wherein said treatment or prophylaxis comprises administration of at least one sulfated glycosaminoglycan and at least one hyaluronidase. More preferably, the treatment or prophylaxis comprises administration of Factor VIII, heparin (e.g. unfractionated heparin) and human hyaluronidase. The Factor VIII may or may not be complexed with VWF. 
         [0023]    It is further preferred that the bleeding disorder is hemophilia A, and that the therapy or prophylaxis comprises non-intravenous administration of the medicament, most preferably by subcutaneous, intramuscular or intradermal injection. 
         [0024]    A third aspect of the invention is the combined use of at least one sulfated glycosaminoglycan and at least one hyaluronidase for improving the bioavailability of one or more Factor VIII. The preferred embodiments of the third aspect correspond to those of the first and second aspect mutatis mutandis. 
         [0025]    A fourth aspect of the invention is a method of treating a bleeding disorder by administering to a subject in need thereof a therapeutically effective amount of at least one Factor VIII, at least one sulfated glycosaminoglycan and at least one hyaluronidase. Factor VIII, the sulfated glycosaminoglycan and the hyaluronidase may be administered simultaneously, e.g. mixed in a single composition. 
         [0026]    Alternatively, one component may be administered separately, while the other two components are administered jointly. In another embodiment, all three components are administered separately, e.g. in a timely staggered manner. 
         [0027]    In yet another aspect, the present invention relates to a pharmaceutical kit comprising at least one Factor VIII, at least one sulfated glycosaminoglycan, and at least one hyaluronidase. 
         [0028]    In all aspects of the invention, the Factor VIII is preferably human Factor VIII. A preferred sulfated glycosaminoglycan is heparin, most preferably unfractionated heparin. 
     
    
     
       DESCRIPTION OF THE FIGUES 
         [0029]      FIG. 1  depicts the results of Example 1. The bioavailability of FVIII is increased if a sulfated glycosaminoglycan and hyaluronidase are co-administered. The effect of the combined administration on the bioavailability of the Factor VIII is synergistic. 
       
    
    
     DETAILED DESCRIPTION 
       [0030]    The present invention concerns the treatment and prophylaxis of bleeding disorders. 
         [0031]    As used herein, the term “bleeding disorders” includes familial and acquired hemophilia A. 
         [0032]    According to the first aspect of the invention a pharmaceutical preparation is provided which comprises at least one Factor VIII, at least one sulfated glycosaminoglycan, and at least one hyaluronidase. 
         [0033]    Factor VIII may be wild-type Factor VIII or 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. 
         [0034]    The terms “blood coagulation Factor VIII”, “Factor VIII” and FVIII″ are used interchangeably herein. “Factor VIII” includes wild type Facto 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. 
         [0035]    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. 
         [0036]    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. 
         [0037]    All of these Factor VIII mutants and variants are incorporated herein by reference in their entirety. 
         [0038]    The amino acid sequence of the mature wild type form of human 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:1 is shown in SEQ ID NO:1. 
         [0039]    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 a heparin, most preferably, the sulfated glycosaminoglycan is selected from the group consisting of unfractionated heparin, low molecular weight heparin and chondroitin sulfate. 
         [0040]    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). 
         [0041]    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. 
         [0042]    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). 
         [0043]    Dermatan sulfate (previously also called Chondroitin sulfate B) is another sulfated glycosaminoglycan which is commercially available. 
         [0044]    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. 
         [0045]    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 lozzo, 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) 
         [0046]    The term “hyaluronidase” refers to any polypeptide having hyaluronoglucuronidase activity, hyaluronoglucosaminidase activity or hyaluronate lyase activity. Preferably, the hyaluronidase is capable of at least partially degrading hyaluronan (hyaluronic acid). 
         [0047]    There are three classes of hyaluronidases:
       (1) Mammalian hyaluronidases (EC 3.2.1.35) which are endo-beta-N-acetylhexosaminidases with tetrasaccharides and hexasaccharides as the major end products. They have both hydrolytic and transglycosidase activities, and can degrade hyaluronan and chondroitin sulfates (CS), specifically C4-S and C6-S.   (2) Bacterial hyaluronidases (EC 4.2.2.1) are endo-beta-N-acetylhexosaminidases that operate by a beta-elimination reaction that yields primarily disaccharide end products.   (3) Hyaluronidases (EC 3.2.1.36) from leeches, other parasites, and crustaceans are endo-beta-glucuronidases that generate tetrasaccharide and hexasaccharide end products through hydrolysis of the beta 1-3 linkage.       
 
         [0051]    Mammalian hyaluronidases are preferred according to the invention and can be further divided into two groups: neutral active and acid active enzymes. Neutral active hyaluronidases are preferred. The hyaluronidase of the present invention may be derived from any species. More preferably, however, the hyaluronidase is a human hyaluronidase. Still more preferably, the hyaluronidases encoded by the human genes HYAL1 (Uniprot/Swissprot Acc. No. Q12794), HYAL2 (Uniprot/Swissprot Acc. No. Q12891), HYAL4 (Uniprot/Swissprot Acc. No. Q2M3T9) and PH20/SPAM1 (Uniprot/Swissprot Acc. No. P38567), respectively, are used as the hyaluronidase in the present invention. Most preferably, the hyaluronidase is human PH20 (Uniprot/Swissprot Acc. No. P38567). Particularly preferred are further the soluble PH20 polypeptides and the extended soluble PH20 polypeptides described in WO 2010/077294 A1 (see in particular, the amino acid sequence of human PH20 depicted in  FIG. 1  of WO 2010/077294 A1). These polypeptides are incorporated herein by reference. 
         [0052]    Further included are any variants and mutants of the above-described hyaluronidases, as long as they still have at least some hyaluronidase activity. 
         [0053]    As used herein, hyaluronidase activity refers to the ability to enzymatically catalyze the cleavage of hyaluronic acid. The United States Pharmacopeia (USP) XXII assay for hyaluronidase determines hyaluronidase activity indirectly by measuring the amount of higher molecular weight hyaluronic acid, or hyaluronan, (HA) substrate remaining after the enzyme is allowed to react with the HA for 30 min at 37° C. (USP XXII-NF XVII (1990) 644-645 United States Pharmacopeia Convention, Inc, Rockville, Md.). A Reference Standard solution can be used in an assay to ascertain the relative activity, in units, of any hyaluronidase. In vitro assays to determine the hyaluronidase activity of hyaluronidases are known in the art. Exemplary assays include the microturbidity assay that measures cleavage of hyaluronic acid by hyaluronidase indirectly by detecting the insoluble precipitate formed when the uncleaved hyaluronic acid binds with serum albumin (see e.g. Hynes, W. L., J. J. Ferretti (1994). Assays for hyaluronidase activity. Meth Enzymol 235: 606-616). Reference Standards can be used, for example, to generate a standard curve to determine the activity in Units of the hyaluronidase being tested. In another example, hyaluronidase activity is measured using a microtiter assay in which residual biotinylated hyaluronic acid is measured following incubation with hyaluronidase (see e.g. Frost and Stern (1997) Anal. Biochem. 251:263-269, U.S. Patent Publication No. 2005/0260186). Other assays to measure hyaluronidase activity also are known in the art and can be used (see e.g. Deipech et al., (1995) Anal. Biochem. 229:35-41; Takahashi et al., (2003) Anal. Biochem. 322:257-263). 
         [0054]    In one embodiment, the Factor VIII, the sulfated glycosaminoglycan, and the hyaluronidase are contained in the same composition. This composition comprising the three components may be administered to the patient by a single injection or the like. 
         [0055]    In another embodiment, the Factor VIII, the sulfated glycosaminoglycan, and the hyaluronidase are not present in the same composition. For example, each of the three components may be provided in a separate dosage form in said pharmaceutical preparation. Alternatively, two of the three components may be present in the same composition, while the third component is provided in a separate dosage form. In yet another variation, each of the three components is provided in a separate dosage form in said pharmaceutical preparation. In summary, the present invention encompasses the following embodiments. 
         [0000]    
       
         
               
               
             
           
               
                 TABLE 1 
               
               
                   
               
               
                 Embodiment 
                 The pharmaceutical preparation or the kit comprises: 
               
               
                   
               
             
             
               
                 1 
                 a composition comprising the Factor VIII, the sulfated 
               
               
                   
                 glycosaminoglycan, and the hyaluronidase (in admixture) 
               
               
                 2 
                 a first composition comprising the Factor VIII and the 
               
               
                   
                 sulfated glycosaminoglycan, and a second composition 
               
               
                   
                 comprising the hyaluronidase. 
               
               
                 3 
                 a first composition comprising the Factor VIII and the 
               
               
                   
                 hyaluronidase, and a second composition comprising the 
               
               
                   
                 sulfated glycosaminoglycan. 
               
               
                 4 
                 a first composition comprising the Factor VIII, and a 
               
               
                   
                 second composition comprising the sulfated glycosamino- 
               
               
                   
                 glycan and the hyaluronidase. 
               
               
                 5 
                 a first composition comprising the Factor VIII, a second 
               
               
                   
                 composition comprising the sulfated glycosaminoglycan, 
               
               
                   
                 and a third composition comprising the hyaluronidase. 
               
               
                   
               
             
          
         
       
     
         [0056]    If the three components are not present in the same composition, as in embodiments (1) to (4) of table 1, the separate compositions may either be administered separately, or they may be mixed shortly before administration so that all three components will be administered simultaneously. If there is separate administration, the administration may be done sequentially, e.g. in a time-staggered manner. When the administration is done separately, the order of the administration may be such that the Factor VIII is administered first, followed by the administration of sulfated glycosaminoglycan and the hyaluronidase. Alternatively, the sulfated glycosaminoglycan may be administered as first component, followed by administration of the Factor VIII and the hyaluronidase. In yet another embodiment, the hyaluronidase is administered first, followed by administration of the Factor VIII and the sulfated glycosaminoglycan. The time between the administration of the three components may vary, e.g. from about 1 second to about 24 hours, or from about 10 seconds to about 1 hour, or from about 20 seconds to about 10 minutes. Typically, the three components are administered within 24 or less, preferably within 1 hour or less, most preferably within 10 minutes or less. In general, it is preferred that the three 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. 
         [0057]    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. 
         [0058]    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 &amp; Francis (2000) or “Handbook of Pharmaceutical Excipients”, 3 rd  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&#39; Desk Reference®, Thomson Healthcare: Montvale, NJ, 2004; Remington: The Science and Practice of Pharmacy, 20th ed., Gennaro et al., Eds. Lippincott Williams &amp; 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. 
         [0059]    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 administration. More preferably, the composition(s) of the invention are formulated for subcutaneous, intramuscular, intraperitoneal, intracerebral, intrapulmonar, intranasal or transdermal adminstration, 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 encompass slow release systems. 
         [0060]    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. 
         [0061]    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 subcutaneous injection to 8 hours after subcutaneous 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. 
         [0062]    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 subcutaneous injection to 16 hours after subcutaneous 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. 
         [0063]    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 subcutaneous injection to 24 hours after subcutaneous 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. 
         [0064]    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 subcutaneous injection to 32 hours after subcutaneous 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. 
         [0065]    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. 
         [0066]    The dose of Factor VIII for one administration is typically 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 FVIII can be administered on its own, or as a complex with VWF. 
         [0067]    The amount of sulfated glycosaminoglycans administered typically ranges from about 0.01 to about 100 mg/kg body weight, from about 0.05 to about 10 mg/kg body weight, from about 0.1 to about 5 mg/kg body weight, from about 0.25 to about 2 mg/kg body weight, or from about 0.5 to about 1 mg/kg body weight. The amount of sulfated glycosaminoglycan may range 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. 
         [0068]    Typically, a therapeutically effective dose of the hyaluronidase is from about 1 to about 10,000 U/kg body weight, from about 3 to about 5,000 U/kg body weight, from about 5 to about 1,000 U/kg body weight, from about 8 to about 500 U/kg body weight, or from about 10 to about 250 U/kg body weight, in a stabilized solution or suspension or a lyophilized from. The formulations can be provided in unit-dose forms such as, but not limited to, ampoules, syringes and individually packaged tablets or capsules. For example, a hyaluronidase can be administered subcutaneously at about 10 U, 25 U, 50 U, 100 U, 250 U, 500 U, 1000 U, 5,000 U or more. The hyaluronidase can be administered separately (from the Factor VIII and the sulfated glycosaminoglycan), or simultaneously with the Factor VIII and the sulfated glycosaminoglycan, optionally with other pharmacologically effective agent or therapeutic agent in a total volume of 0.1-50 ml, 0.5-20 ml, or 1-10 ml, typically 1-10 ml. Typically, volumes of injections or infusions of a hyaluronidase contemplated herein are from at or about 0.01 mL, 0.05 mL, 0.1 mL, 0.2 mL, 0.3 mL, 0.4 mL, 0.5 mL, 1 mL, 2 mL, 3 mL, 5 mL, 10 ml, 25 ml, 50 ml or more. In some examples, dosages can be provided as a ratio of amount of hyaluronidase to Factor VIII administered. The ratio of Units hyaluronidase to U Factor VIII may range from about 50:1to about 1:50, or from about 10:1 to about 1:10, or from about 5:1 to about 1:5. The hyaluronidase can be provided as a stock solution at or about 100 U/ml, 150 U/ml, 200 U/ml, 300 U/ml, 400 U/ml, 500 U/mL, 600 U/mL, 800 U/mL or 1000 U/mL, or can be provided in a more concentrated form, for example at or about 2000 U/ml, 3000 U/ml, 4000 U/ml, 5000 U/ml, 8000 U/ml, 10,000 U/mL or 20,000 U/mL for use directly or for dilution to the effective concentration prior to use. The hyaluronidase can be provided as a liquid or lyophilized formulation. 
         [0069]    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. at 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 herein below. Relative bioavailability of a test preparation refers to the ratio between the AUC of the test preparation and that of the reference preparation which is administered in the same dose and way (e.g. intravenous, subcutaneous or intradermal) as the test preparation. 
         [0070]    According to the present invention, the bioavailability of the Factor VIII (when co-administered with the sulfated glycosaminoglycan and the hyaluronidase) is higher than that of the Factor VIII when administered alone. Preferably, the bioavailability is increased by at least 100%, more preferably by at least 200%, more preferably by at least 300%, most preferably by at least 400%. 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 Factor VIII can be administered on its own, or as a complex with VWF. 
         [0071]    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 
       [0072]    Materials and Animal Model 
         [0073]    The Factor VIII used in the experiments was a B-domain truncated, single-chain recombinant factor VIII (hereinafter referred to as “rFVIII”). It has a deletion of most of the B domain and part of the acidic a3 region of the wild type Factor VIII sequence. This Factor VIII is a “single chain” Factor VIII generated by fusing Asn764 with Thr1653. It has been expressed in cell culture cells and purified from the cell culture medium. 
         [0074]    The further agents used are summarized in Table 2. 
         [0000]    
       
         
               
               
               
             
           
               
                   
                 TABLE 2 
               
               
                   
                   
               
               
                   
                 Compound class 
                 Type of compound and/or source 
               
               
                   
                   
               
             
             
               
                   
                 Heparin 
                 Unfractionated heparin 
               
               
                   
                   
                 (Heparin-Natrium-25000-ratiopharm) 
               
               
                   
                 Hyaluronidase 
                 Bovine Hyaluronidase 
               
               
                   
                   
               
             
          
         
       
     
         [0075]    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. 
         [0076]    Methods 
         [0077]    To assess whether extravascular injections might be an option for an improved therapy with FVIII (human) a typical representative for an extravascular therapy, subcutaneous injection was chosen. The design of the non-clinical pharmacokinetic study performed is detailed in table 3 below. Plasma levels of Factor VIII activity were determined following a single intravenous or subcutaneous injection of FVIII together with various additives (detailed treatment groups in table 3) into a hemophilia A model. 
         [0078]    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 pL (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 3. 
         [0079]    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 4. 
         [0080]    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. 
         [0000]    
       
         
               
             
               
               
               
               
               
               
               
             
           
               
                 TABLE 3 
               
             
             
               
                   
               
               
                 Treatment groups 
               
             
          
           
               
                   
                   
                 FVIII (CS 
                   
                   
                   
                   
               
               
                   
                 Treat- 
                 activity assay)/ 
                 volume 
               
               
                 No. 
                 ment 
                 Additive Dose 
                 [mL/kg] 
                 schedule 
                 route 
                 N 
               
               
                   
               
               
                 1 
                 FVIII 
                 400 IU/kg 
                 8 
                 single 
                 s.c. 
                 25 
               
               
                   
                   
                   
                   
                 injection 
               
               
                   
                   
                   
                   
                 (t = 0) 
               
               
                 2 
                 FVIII/ 
                 400 IU/kg/ 
                 8 
                 single 
                 s.c. 
                 25 
               
               
                   
                 Heparin 
                 40 U/kg 
                   
                 injection 
               
               
                   
                   
                 (5 U/mL product 
               
               
                   
                   
                 applied) 
               
               
                 3 
                 FVIII/ 
                 400 IU/kg/ 
                 8 
                 single 
                 s.c. 
                 20 
               
               
                   
                 Hyaluron- 
                 200 U/kg 
                   
                 injection 
               
               
                   
                 idase 
               
               
                 4 
                 FVIII/ 
                 400 IU/kg/ 
                 8 
                 single 
                 s.c. 
                 20 
               
               
                   
                 Heparin/ 
                 40 U/kg 
                   
                 injection 
               
               
                   
                 Hyaluron- 
                 (5 U/mL product 
               
               
                   
                 idase 
                 applied)/ 
               
               
                   
                   
                 200 U/kg 
               
               
                   
               
             
          
         
       
     
         [0081]    Results 
         [0082]    The results are summarized in Table 4 and  FIG. 1 . Subcutaneous injection of 400 IU/kg FVIII in presence of heparin or hyaluronidase to FVIII ko mice resulted in a significant increase of FVIII activity in plasma level as compared to administration of FVIII alone. When heparin and hyaluronidase were co-administered with FVIII, there was even a synergistic increase in bioavailability. 
         [0000]    
       
         
               
             
               
               
               
               
               
             
           
               
                 TABLE 4 
               
             
             
               
                   
               
               
                 FVIII activity in % of the FVIII activity in normal human plasma 
               
             
          
           
               
                   
                   
                 FVIII 400 IU/kg/ 
                 FVIII/ 
                 FVIII/ 
               
               
                 Time- 
                 FVIII 
                 Heparin 
                 Hyalu- 
                 Heparin/ 
               
               
                 point 
                 400 IU/kg 
                 40 U/kg 
                 ronidase 
                 Hyalu- 
               
               
                 (h) 
                 s.c. 
                 s.c. 
                 s.c 
                 ronidase s.c. 
               
               
                   
               
               
                  0.5 
                 1.02 ± 0.8  
                 52.90 ± 2.70 
                  4.90 ± 2.61 
                 8.23 ± 3.39 
               
               
                  2 
                 13.04 ± 3.90  
                 15.16 ± 4.12 
                 12.70 ± 9.23 
                 41.75 ± 27.45 
               
               
                  5 
                 1.15 ± 1.28 
                 
                   
                             
                     
                         
                         
                     
                   
                 
                 
                   
                             
                     
                         
                         
                     
                   
                 
                 37.57 ± 12.24 
               
               
                  8 
                 2.32 ± 2.27 
                 15.56 ± 4.22 
                 10.08 ± 5.40 
                 
                   
                             
                     
                         
                         
                     
                   
                 
               
               
                 16 
                 4.82 ± 2.35 
                 12.08 ± 2.35 
                 10.34 ± 4.25 
                 16.45 ± 3.73  
               
               
                 24 
                 
                   
                             
                     
                         
                         
                     
                   
                 
                 14.10 ± 3.76 
                  6.46 ± 2.91 
                 16.57 ± 7.66  
               
               
                 32 
                 2.48 ± 2.20 
                 10.84 ± 5.31 
                  7.08 ± 2.14 
                 12.39 ± 6.41  
               
               
                 48 
                 1.15 ± 1.72 
                  7.02 ± 1.24 
                  3.32 ± 2.09 
                 10.01 ± 4.74  
               
               
                 AUC 
                 202.0 
                 598.4 
                 399.3 
                 1034.0 
               
               
                 0-48 
                   
                   
                   
                   
               
               
                 h (h × 
                   
                   
                   
                   
               
               
                 % of 
                   
                   
                   
                   
               
               
                 the 
                   
                   
                   
                   
               
               
                 norm 
                   
                   
                   
                   
               
               
                 SHP) 
               
               
                   
               
               
                 The peak values are shaded in grey. 
               
             
          
         
       
     
       Example 2 
     Assessment of Bioavailability of s.c. Applied Factor VIII and Human Hyaluronidase PH20 in a Hemophilia A Model 
       [0083]    The soluble form of human Hyaluronidase PH20 may be purchased from Halozyme. Alternatively, it may be prepared as described in WO 2010/077297 A1. 
         [0084]    The other agents to be used are identical to those used in Example 1. 
         [0085]    The experiment can be carried out as described above in Example 1. A possible outline of the treatment groups is as follows: 
         [0000]    
       
         
               
             
               
               
               
               
               
               
               
             
           
               
                 TABLE 4 
               
             
             
               
                   
               
               
                 Treatment groups 
               
             
          
           
               
                   
                 Treat- 
                 FVIII: chromogen/ 
                 volume 
                   
                   
                   
               
               
                 No. 
                 ment 
                 Additive Dose 
                 [mL/kg] 
                 schedule 
                 route 
                 N 
               
               
                   
               
               
                 1 
                 FVIII 
                 400 IU/kg 
                 8 
                 single 
                 s.c. 
                 25 
               
               
                   
                   
                   
                   
                 injection 
               
               
                   
                   
                   
                   
                 (t = 0) 
               
               
                 2 
                 FVIII/ 
                 400 IU/kg/ 
                 8 
                 single 
                 s.c. 
                 25 
               
               
                   
                 Heparin 
                 40 U/kg 
                   
                 injection 
               
               
                   
                   
                 (5 U/mL) 
               
               
                 3 
                 FVIII/ 
                 400 IU/kg/ 
                 8 
                 single 
                 s.c. 
                 20 
               
               
                   
                 Hyaluron- 
                 200 U/kg 
                   
                 injection 
               
               
                   
                 idase 
               
               
                   
                 PH20 
               
               
                 4 
                 FVIII/ 
                 400 IU/kg/ 
                 8 
                 single 
                 s.c. 
                 20 
               
               
                   
                 Heparin/ 
                 40 U/kg 
                   
                 injection 
               
               
                   
                 Hyaluron- 
                 (5 U/mL)/ 
               
               
                   
                 idase 
                 200 U/kg 
               
               
                   
                 PH20 
               
               
                   
               
             
          
         
       
     
         [0086]    The results can be displayed in the same manner as for Example 1 above.