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WO2006032053A2 - Methods of treating symptoms of multiple sclerosis using vitamin d and related compounds - Google Patents

Methods of treating symptoms of multiple sclerosis using vitamin d and related compounds Download PDF

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Publication number
WO2006032053A2
WO2006032053A2 PCT/US2005/033421 US2005033421W WO2006032053A2 WO 2006032053 A2 WO2006032053 A2 WO 2006032053A2 US 2005033421 W US2005033421 W US 2005033421W WO 2006032053 A2 WO2006032053 A2 WO 2006032053A2
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WO
WIPO (PCT)
Prior art keywords
dose
calcitriol
glatiramer acetate
alphacalcidol
vitamin
Prior art date
Legal status (The legal status is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the status listed.)
Ceased
Application number
PCT/US2005/033421
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French (fr)
Other versions
WO2006032053A3 (en
Inventor
Aharon Schwartz
David Ladkani
Zeev Mazor
Anat Achiron
Irit Pinchasi
Dina Kofler
Liat Hayardeny
Current Assignee (The listed assignees may be inaccurate. Google has not performed a legal analysis and makes no representation or warranty as to the accuracy of the list.)
Teva Pharmaceutical Industries Ltd
Teva Pharmaceuticals USA Inc
Original Assignee
Teva Pharmaceutical Industries Ltd
Teva Pharmaceuticals USA Inc
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Publication date
Application filed by Teva Pharmaceutical Industries Ltd, Teva Pharmaceuticals USA Inc filed Critical Teva Pharmaceutical Industries Ltd
Priority to CA002580564A priority Critical patent/CA2580564A1/en
Priority to EP05798310A priority patent/EP1796680A2/en
Publication of WO2006032053A2 publication Critical patent/WO2006032053A2/en
Publication of WO2006032053A3 publication Critical patent/WO2006032053A3/en
Priority to IL181762A priority patent/IL181762A0/en
Anticipated expiration legal-status Critical
Ceased legal-status Critical Current

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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/59—Compounds containing 9, 10- seco- cyclopenta[a]hydrophenanthrene ring systems

Definitions

  • Multiple sclerosis is one of the more common neurologic diseases in human adults. This condition is a chronic, inflammatory CNS disease characterized pathologically by demyelination.
  • CNS disease characterized pathologically by demyelination.
  • Benign multiple sclerosis is characterized by 1-2 exacerbations with complete recovery, no lasting disability and no disease progression for 10-15 years after the initial onset. Benign multiple sclerosis may, however, progress into other forms of multiple sclerosis.
  • RR-MS Patients suffering from RR-MS experience sporadic exacerbations or relapses, as well as periods of remission. Lesions and evidence of axonal loss may or may not be visible on MRI for patients with RR-MS.
  • SP-MS may evolve from RR-MS. Patients afflicted with SP-MS have relapses, a diminishing degree of recovery during remissions, less frequent remissions and more pronounced neurological deficits than RR-MS patients. Enlarged ventricles, which are markers for atrophy of the corpus callosum, midline center and spinal cord, are visible on MRI of patients with SP-MS.
  • PP-MS is characterized by a steady progression of increasing neurological deficits without distinct attacks or remissions.
  • PR-MS Cerebral lesions, diffuse spinal cord damage and evidence of axonal loss are evident on the MRI of patients with PP-MS.
  • PR-MS has periods of acute exacerbations while proceeding along a course of increasing neurological deficits without remissions. Lesions are evident on MRI of patients suffering from PR-MS (Multiple sclerosis: its diagnosis, symptoms, types and stages, 2003 ⁇ http://www.albany.net/ ⁇ tjc/multiple-sclerosis .html>) .
  • multiple sclerosis is an autoimmune disease (Compston; Hafler and Weiner; Olsson) .
  • An autoimmune hypothesis is supported by the experimental allergic encephalomyelitis (EAE) model of multiple sclerosis, where the injection of certain myelin components into genetically susceptible animals leads to T cell-mediated CNS demyelination (Parkman) .
  • EAE allergic encephalomyelitis
  • Parkman T cell-mediated CNS demyelination
  • Another theory regarding the pathogenesis of multiple sclerosis is that a virus, bacteria or other agent, precipitates an inflammatory response in the CNS, which leads to either direct or indirect (“bystander”) myelin destruction, potentially with an induced autoimmune component (Lampert; Martyn) .
  • TMEV Theiler' s murine encephalomyelitis virus
  • Fatigue is a common symptom of multiple sclerosis (MS), occurring in 30%-90% of patients (Bergamaschi et al., 1997; Colosimo et al., 1995; Fisk et al., 1994a; Freal et al., 1984; Krupp et al., 1988; Krupp et al., 1989; Murray, 1985; Sandyk, 1996); for many MS victims, fatigue is the most disabling symptom (Comi et al., 2001; Fisk et al., 1994a) . For example, one survey found that 87% of MS patients reported fatigue; 67% reported being fatigued daily, and 22% stated that fatigue encumbered their daily functioning (Freal et al., 1984) .
  • MS multiple sclerosis
  • Glatiramer acetate also known as Copolymer-1, is one of the known and approved treatments for multiple sclerosis (MS) .
  • MS multiple sclerosis
  • glatiramer acetate (20 mg/injection) reduce relapse rates, progression of disability, appearance of new lesions by magnetic resonance imaging (MRI) , (Johnson, K.P. et al. ) and appearance of "black holes" (Filippi, M. et al.) - COPAXONE® is the brand name for a formulation containing glatiramer acetate as the active ingredient.
  • the recommended dosing schedule of COPAXONE® for relapsing-remitting multiple sclerosis is 20 mg per day injected subcutaneously (Physician's Desk Reference, 2003; see also U.S. Patent Nos . 3,849,550; 5,800,808; 5,858,964, 5,981,589; 6,048,898; 6,054,430; 6,214,791; 6,342,476; and 6,362,161) .
  • l ⁇ ,25- dihydroxycholecalciferol prevents the development of murine experimental autoimmune encephalomyelitis (EAE) , a model of multiple sclerosis (Cantorna, M.T., et al. ; Lemire, J.M and Archer, D.C.) . It has also been suggested that l ⁇ , 25-dihydroxycholecalciferol prevents the progression of murine EAE when administered after the induction of EAE (Cantorna, M.T., et al. ) .
  • the invention provides a method of alleviating a symptom of multiple sclerosis in a human subject comprising administering to the human subject in need thereof a dose of a calciferol compound effective to alleviate the symptom of multiple sclerosis.
  • the invention also provides a method of reducing the frequency of relapses in a human subject who is afflicted with relapsing-remitting multiple sclerosis comprising administering to the human subject a dose of glatiramer acetate and administering to the human subject a dose of alphacalcidol or calcitriol, wherein the dose of glatiramer acetate and the dose of alphacalcidol or calcitriol when taken together are effective to reduce the frequency of relapses in the human subject.
  • the subject invention also provides a method of reducing fatigue in a human subject who is afflicted with relapsing-remitting multiple sclerosis comprising administering to the human subject a dose of glatiramer acetate and administering to the human subject a dose of alphacalcidol or calcitriol, wherein the dose of glatiramer acetate and the dose of alphacalcidol or calcitriol when taken together are effective to reduce fatigue in the human subject.
  • Figure 1 shows the relative changes (%) of Fatigue Impact Scale by treatment group - ITT population. Solid, placebo; white, treatment with alfacalcidol; *, adjusted for age; EDSS at baseline and MS treatment at study entry.
  • Figure 2 shows Fatigue Impact Scale improvement (at least one standard deviation) by treatment group - ITT population. Solid, placebo; white, treatment with alfacalcidol.
  • Figure 3 shows the percent (%) improvement of relapse rate per year in MS patients on MS therapy who received 1 ⁇ g of alphacalcidol per day.
  • the annual relapse rate was calculated based on the number of relapses during a six month period adjusted for one year.
  • the P value indicates the statistically significant different in relapses per year between the two treatment groups (active and placebo) .
  • Figure 4 shows the neurological score (mean + se) at days past immunization by GA alone, calcitriol alone and calcitriol together with glatiramer acetate of the EAE model in CSJL/F1 mice.
  • the invention provides a method of alleviating a symptom of multiple sclerosis in a human subject comprising administering to the human subject in need thereof a dose of a calciferol compound effective to alleviate the symptom of multiple sclerosis.
  • the symptom of multiple sclerosis may be fatigue.
  • the symptom of multiple sclerosis may be frequency of relapses in a human subject afflicted with relapsing-remitting multiple sclerosis.
  • the symptom of multiple sclerosis may be the frequency of clinical exacerbation, the accumulation of physical disability, e.g. as measured on an EDSS scale, or lesions and axonal loss, e.g. as may be detected by MRI .
  • the calciferol compound may be l ⁇ ,25 dihydroxyvitamin D 3 ; l ⁇ - hydroxyvitamin D 3 ; l ⁇ , 25-dihydroxyvitamin D 2 ; l ⁇ - hydroxyvitamin D 2 ; l ⁇ , 25- (OH) 2 -16-ene-D 3 ; l ⁇ ,25- (OH) 2 -24- oxo-16-ene-D 3 ; l ⁇ , 24R(OH) 2 -D 3 , ; l ⁇ , 25 (OH) 2 -22-oxa-D 3 ; 20- epi-22-oxa-24 ⁇ , 24 ⁇ , -dihomo-l ⁇ , 25 (OH) 2 -D 3 ; 20-epi-22-oxa- 24 ⁇ ,26 ⁇ ,27 ⁇ ,-trihomo-l ⁇ ; 25 (OH) 2-D 3 , 20-epi-22-oxa- 24homo-l ⁇ , 25 (OH) 2 -D 3 ; 1,
  • the human subject may have never received another compound for the alleviation of a symptom of multiple sclerosis.
  • the human subject at the time of first administration of the calciferol compound may have been receiving another compound for the alleviation of a symptom of multiple sclerosis.
  • the human subject may have been receiving another compound for the alleviation of a symptom of multiple sclerosis for more than 4 weeks.
  • the other compound may be glatiramer acetate.
  • the dose of each of the calciferol compound when taken alone, and the dose of the other compound when taken alone, may be effective to alleviate the symptom of multiple sclerosis .
  • the dose of the calciferol compound and the dose of the other compound, when administered to the same human subject may be effective to alleviate the symptom of multiple sclerosis.
  • the invention also provides a method of reducing the frequency of relapses in a human subject who is afflicted with relapsing-remitting multiple sclerosis comprising administering to the human subject a dose of glatiramer acetate and administering to the human subject a dose of alphacalcidol or calcitriol, wherein the dose of glatiramer acetate and the dose of alphacalcidol or calcitriol when administered to the same human subject- are effective to reduce the frequency of relapses in the human subject.
  • the human subject may have never received glatiramer acetate treatment.
  • the human subject may have been receiving glatiramer acetate treatment prior to administration of alphacalcidol or calcitriol, and the dose of alphacalcidol or calcitriol is effective to reduce the frequency of relapses experienced by the human subject during ongoing treatment with glatiramer acetate as compared with the frequency of relapses experienced by the human subject during treatment with glatiramer- acetate only.
  • the human subject may have been receiving glatiramer acetate treatment for more than four weeks.
  • the dose of glatiramer acetate may be in the range from 10 to 600 mg/week; 80 to 600 mg/week; 100 to 550 mg/week; 20 to 150 mg/week; 150 to 500 mg/week; 200 to 450 mg/week; 250 to 400 mg/week; 300 to 350 mg/week; or 300 mg/week.
  • the dose of glatiramer acetate may be in the range from 10 to 80 mg/day; e.g. 12 to 70 mg/day; 14 to 60 mg/day; 16 to 50 mg/day; 18 to 40 mg/day; 19 to 30 mg/day; or 20 mg/day.
  • the dose of glatiramer acetate may be in the range from 50 to 150 mg/day; or 60 to 140 mg/day; or 70 to 130 mg/day; or 80 to 120 mg/day; or 90 to 110 mg/day; or 100 mg/day.
  • the dose of alphacalcidol or calcitriol may be in the range of 3 ⁇ g to 80 mg/week; e.g. 4.5 ⁇ g to 40 mg/week; 4.5 ⁇ g to 25 mg/week; 3 ⁇ g to 10 mg/week; 3 ⁇ g to 1 mg/week; 3 ⁇ g to 500 ⁇ g/week; 5 ⁇ g to 100 ⁇ g/week; 5 ⁇ g to 50 ⁇ g/week; 5 ⁇ g to 10 ⁇ g/week; 6 ⁇ g to 8 ⁇ g/week; or 7 ⁇ g/week.
  • the dose is of caclitriol in the range of 5 ⁇ g to 10 ⁇ g/week.
  • the dose of alphacalcidol or calcitriol may be in the range of 0.5 ⁇ g to 10 mg/day; e.g. 0.05 ⁇ g to 5 mg/day; 0.05 ⁇ g to 3 mg/day; 1.0 ⁇ g to 3 mg/day; 1.0 ⁇ g to 1 mg/day; 2.5 ⁇ g to 1 mg/day; 0.5 ⁇ g to 500 ⁇ g/day; 0.5 ⁇ g to 100 ⁇ g/day; 5 ⁇ g to 100 ⁇ g/day; 5 ⁇ g to 50 ⁇ g/day; 0.5 ⁇ g to 3 ⁇ g/day; or 1 ⁇ g/day.
  • the amount of glatiramer acetate may be 10 to 80 mg; or 12 to 70 mg; or 14 to 60 mg; or 16 to 50 mg; or 18 to 40 mg; or 20 to 30 mg; or 20 mg.
  • the amount of alphacalcidol or calcitriol may be 0.1 mg to 10 mg; or 0.25 mg to 7.5 mg; or 0.5 mg to 5 mg; or 0.75 to 2.5 mg; or 1 mg to 1.5 mg; or 1 mg.
  • the amount of alphacalcidol or calcitriol may be 0.01 ⁇ g to 5 ⁇ g; or 0.05 ⁇ g to 4 ⁇ g; or 0.1 ⁇ g to 3 ⁇ g; or 0.2 ⁇ g to 2 ⁇ g; or 0.25 ⁇ g to 1 ⁇ g; or 0.5 ug to 0.75 ⁇ g.
  • the dose administration of glatiramer acetate may be effected 3 to 11 days; or once every 5 to 9 days; or once every 7 days; once every 24 hours; twice daily; or once daily.
  • the dose may be half the amount.
  • the administration of alphacalcidol or calcitriol may be effected once every 20 to 28 hours; once every 22 to 26 hours; once every 24 hours; or once daily.
  • the administration of alphacalcidol or calcitriol is in the morning.
  • the administration of the glatiramer acetate substantially precedes the administration of alphacalcidol or calcitriol.
  • the glatiramer acetate and the alphacalcidol or calcitriol may be administered for a period of time of at least 4 days.
  • the period of time may be 5- days to ' 5 years; or 10 days to 3 years; or 2 weeks to 1 year; or 1 month to 6 months; or 3 months to 4 months.
  • the glatiramer acetate and the alphacalcidol or calcitriol may be administered for the lifetime of the subject.
  • the administration of the glatiramer acetate may be effected subcutaneously, intraperitoneally, intravenously, intramuscularly, intraocularly or orally; and the administration of the alphacalcidol or calcitriol may be effected orally.
  • the administration of the glatiramer acetate may be effected subcutaneously and the administration of the alphacalcidol or calcitriol- may be effected orally.
  • each of the dose of glatiramer acetate when taken alone, and the dose of alphacalcidol or calcitriol when taken alone may be effective to reduce the frequency of relapses in a human subject afflicted with relapsing- remitting multiple sclerosis.
  • the subject invention also provides a method of reducing fatigue in a human subject who is afflicted with relapsing-remitting multiple sclerosis comprising administering to the human subject a dose of glatiramer acetate and administering to the human subject a dose of alphacalcidol or calcitriol, wherein the dose of glatiramer acetate and the dose of alphacalcidol or calcitriol when administered to the same human subject are effective to reduce fatigue in the human subject.
  • the human subject may have never received glatiramer acetate treatment.
  • the human subject may have been receiving glatiramer acetate treatment prior to administration of alphacalcidol or calcitriol, and the dose of alphacalcidol or calcitriol may be effective to reduce the fatigue experienced by the human subject during ongoing treatment with glatiramer acetate as compared with the fatigue experienced by the human subject during treatment with glatiramer acetate only.
  • the human subject has been receiving glatiramer acetate treatment for more than 4 weeks .
  • the dose of glatiramer acetate may be in the range from 10 to 600 mg/week; 80 to 600 mg/week; 100 to 550 ' mg/week; 20 to 150 mg/week; 150 to 500 mg/week; 200 to 450 mg/week; 250 to 400 mg/week; 300 to 350 mg/week; or 300 mg/week.
  • the dose of glatiramer acetate may be in the range from 10 to 8,0 mg/day; e.g. 12 to 70 mg/day; 14 to 60 mg/day; 16 to 50 mg/day; 18 to 40 mg/day; 19 to 30 mg/day; or 20 mg/day.
  • the dose of glatiramer acetate may be in the range from 50 to 150 mg/day; or 60 to 140 mg/day; or 70 to 130 mg/day; or 80 to 120 mg/day; or 90 to 110 mg/day; or 100 mg/day.
  • the dose of alphacalcidol or calcitriol may be in the range from 3 ⁇ g to 80 mg/week; e.g. 4.5 ⁇ g to 40 mg/week; 4.5 ⁇ g to 25 mg/week; 3 ⁇ g to 10 mg/week; 3 ⁇ g to 1 mg/week; 3 ⁇ g to 500 ⁇ g/week; 5 ⁇ g to 100 ⁇ g/week; 5 ⁇ g to 50 ⁇ g/week; 5 ⁇ g to 10 ⁇ g/week; 6 ⁇ g to 8 ⁇ g/week; or 7 ⁇ g/week.
  • the dose is of calcitriol in the range of 5 ⁇ g to 10 ⁇ g/week.
  • the dose of alphacalcidol or calcitriol may be in the range of 0.5 ⁇ g to 10 mg/day; e.g. .05 ⁇ g to 5 mg/day; .05 ⁇ g to 3 mg/day; 1.0 ⁇ g to 3 mg/day; 1.0 ⁇ g to 1 mg/day; 2.5 ⁇ g to 1 mg/day; .5 ⁇ g to 500 ⁇ g/day; .5 ⁇ g to 100 ⁇ g/day; 5 ⁇ g to 100 ⁇ g/day; 5 ⁇ g to 50 ⁇ g/day; .5 ⁇ g to 3 ⁇ g/day; or 1 ⁇ g/day.
  • the amount of glatiramer acetate may be 10 to 80 mg; or 12 to 70 mg; or 14 to 60 mg; or 16 to 50 mg; or 18 to 40 mg; or 20 to 30 mg; or 20 mg.
  • the amount of alphacalcidol or calcitriol may be 0.1 mg to 10 mg; or 0.25 mg to 7.5 mg; or 0.5 mg to 5 mg; or 0.75 to 2.5 mg; or 1 mg to 1.5 mg; or 1 mg.
  • the amount of alphacalcidol or calcitriol may be 0.01 ⁇ g to 5 ⁇ g; or 0.05 ⁇ g to 4 ⁇ g; or 0.1 ⁇ g to 3 ⁇ g; or 0.2 ⁇ g to 2 ⁇ g; or 0.25 ⁇ g to 1 ⁇ g; or 0.5 ug to .75 ⁇ g.
  • the administration of glatiramer acetate is effected daily or, in the alternative, twice daily.
  • the dose may be half the amount.
  • the administration of glatiramer acetate is effected once every 3 to 11 days; or once every 5 to 9 days; or once every 7 days; once every 24 hours; or once every 24 hours.
  • the administration of alphacalcidol or calcitriol is effected once every 20 to 28 hours; once every 22 to 26 hours; once every 24 hours; or once daily. In an embodiment, the administration of alphacalcidol or calcitriol is in the morning. In the alternative, the administration of the glatiramer acetate substantially precedes. the administration of alphacalcidol. Alternatively, the glatiramer acetate and the alphacalcidol or calcitriol may be administered for a period of time of at least 4 days . In a further embodiment, the period of time may be 5 days to 5 years; or 10 days to 3 years; or 2 weeks to 1 year; or 1 month to 6 months; or 3 months to 4 months. In yet another embodiment, the glatiramer acetate and the alphacalcidol or calcitriol may be administered for the lifetime of the subject.
  • the administration of the glatiramer acetate may be effected subcutaneously, intraperitoneally, intravenously, intramuscularly, intraocularly or orally and the administration of the alphacalcidol or calcitriol may be effected orally.
  • the administration of the glatiramer acetate is effected subcutaneously and the administration of the alphacalcidol or calcitriol is effected orally.
  • each of the dose of glatiramer acetate when taken alone, and the dose of alphacalcidol or calcitriol when taken alone may be effective to reduce fatigue in a human subject afflicted with relapsing-remitting multiple sclerosis.
  • either the dose of glatiramer acetate when taken alone, the dose of calcitriol when taken alone or each such dose when taken alone may not be effective to reduce the frequency of relapses in a patient afflicted with relapsing-remitting multiple sclerosis .
  • This invention also provides a product containing glatiramer acetate and at least one of alphacalcidol or calcitriol as a combined preparation for simultaneous, separate, or sequential use for reducing fatigue in a human subject afflicted with relapsing-remitting multiple sclerosis .
  • This invention also provides for the use of glatiramer acetate and at least one of alphacalcidol or calcitriol for the manufacture of a medicament for use in reducing fatigue in a human subject who is afflicted with relapsing-remitting multiple sclerosis but who has never received glatiramer acetate treatment.
  • This invention further provides for the use of alphacalcidol or calcitriol for the manufacture of a medicament for use in reducing fatigue in a human subject afflicted with relapsing-remitting multiple sclerosis and already receiving glatiramer acetate treatment.
  • the human subject may have already receiving glatiramer acetate treatment for more than 4 weeks .
  • This invention also provides a use of alphacalcidol or calcitriol for the manufacture of a medicament for use in reducing fatigue in a human subject afflicted with relapsing-remitting multiple sclerosis and already receiving glatiramer acetate treatment.
  • the human subject may have already been receiving glatiramer acetate treatment for more than 4 weeks.
  • the invention also provides a product containing glatiramer acetate and at least one of alphacalcidol or calcitriol as a combined preparation for simultaneous, separate or sequential use for reducing the frequency of relapses in a human subject afflicted with relapsing- remitting multiple sclerosis.
  • the invention further provides a use of alphacalcidol or calcitriol for the manufacture of a medicament for use in reducing the frequency of relapses in a human subject who is afflicted with relapsing-remitting multiple sclerosis but who has never received glatiramer acetate treatment.
  • the invention also provides a use of glatiramer acetate and at least one of alphacalcidol or calcitriol for the manufacture of a medicament for use in reducing the frequency of relapses in a human subject afflicted with relapsing-remitting multiple sclerosis and already receiving glatiramer acetate treatment.
  • the human subject may have already been receiving glatiramer acetate treatment for more than 4 weeks .
  • the subject invention provides a pharmaceutical composition comprising an amount of glatiramer acetate and an amount of calcitriol, wherein the amounts when taken together are effective to alleviate a symptom of a form of multiple sclerosis in a subject.
  • each of the amount of glatiramer acetate when taken alone and the amount of calcitriol when taken alone is effective to alleviate the symptom of multiple sclerosis.
  • either of the amount of glatiramer acetate when taken alone, or the amount of calcitriol when taken alone or each such amount when taken alone is not effective to alleviate the symptom of multiple sclerosis.
  • the subject invention provides a product containing glatiramer acetate and calcitriol as a combined preparation for simultaneous, separate or sequential use in treating a form of multiple sclerosis.
  • the subject invention further provides a product containing glatiramer acetate and calcitriol as a combined preparation for simultaneous, separate or sequential use in alleviating a symptom of a form of multiple sclerosis.
  • This invention also provides a method of treating fatigue in a subject comprising administering a sufficient amount of at least one biologically active calciferol compound, wherein the administering of the at least one calciferol compound decreases fatigue.
  • the at least one calciferol compound is selected from the group consisting of calciferol, 1,25 dihydroxyvitamin D 3 , alfacalcidol, 1, 25-dihydroxyvitamin D 2 , l ⁇ -hydroxyvitamin D 2 , l ⁇ , 25- (OH) 2 -16-ene-D 3 , l ⁇ ,25- (OH) 2 -24-oxo-16-ene-D 3 , l ⁇ , 24R(OH) 2 -D 3 , l ⁇ , 25 (OH) 2 -22-oxa- D 3 , 20-epi-22-oxa-24 ⁇ ,24 ⁇ ,-dihomo-l ⁇ , 25 (OH) 2 -D 3 , 20-epi- 22-oxa-24 ⁇ ,26 ⁇ ,27 ⁇ ,'-trihomo-l ⁇ , 25 (OH) 2-D 3 , 20-epi-22- oxa-24homo-l ⁇ , 25 (OH) 2 -D 3 , 1, 25
  • the subject also suffers from a chronic condition.
  • the at least one calciferol comopound is administered at a dose equivalent to at least 1 ⁇ g of alphacalcidol per day.
  • the calciferol compound is administered orally, parentally, or transdermally.
  • the calciferol compound is formulated with arachis oil.
  • At least one clinical tool is used to determine the decrease in fatigue.
  • the clinical tool is selected from the group consisting of Fatigue Impact Scale and The Quality of Life RAYS Questionnaire.
  • the clinical tool is presented in Table 1 or Table 2.
  • At least one additional therapeutic compound is co-administered.
  • the at least one additional compound is selected from the group consisting of interferon ⁇ l-a, interferon ⁇ l-b, glatiramer acetate, mitoxantrone and natalizumab.
  • the at least one additional compound is selected from the group consisting of prednisolone, triamcinolone, dexamethasone, naproxen, sulindac, diclofenac, piroxicam, ketoprofen, diflunisal, nabumetone, etodolac, oxaprozin, indomethacin, celecoxib, rofecoxib, hydroxychloroquine sulfate, chloroquine, cyclophosphamide, azathioprine, chlorambucil, piroxicam and steroids.
  • the blood calcium levels are monitored and the administration of the calciferol compound is adjusted to avoid hypercalcemia.
  • This invention provides a method of treating fatigue in a subject comprising administering in a continuous manner a composition comprising a sufficient amount of at least one biologically active calciferol compound, wherein the administering of at least one calciferol compound decreases the fatigue.
  • the calciferol compound comprises at least one compound selected from the group consisting of calciferol, 1,25 dihydroxyvitamin D 3 , alfacalcidol, 1,25- dihydroxyvitamin D 2 , l ⁇ -hydroxyvitamin D 2 , l ⁇ , 25- (OH) 2 -16- ene-D 3 , l ⁇ , 25- (OH) 2 -24-oxo-16-ene-D 3 , l ⁇ , 24R(OH) 2 -D 3 , l ⁇ , 25 (OH) 2 -22-oxa-D 3 , 20-epi-22-oxa-24 ⁇ , 24 ⁇ , -dihomo- l ⁇ , 25 (OH) 2 -D 3 , 20-epi-22-oxa-24 ⁇ ,26 ⁇ ,27 ⁇ ,-trihomo-l ⁇ , 25 (OH) 2-D 3 , 20-epi-22-oxa-24homo-l ⁇ ,25(OH) 2 -D 3 , 1, 25
  • the calciferol compound is alphacalciferol.
  • the subject suffers from a chronic condition.
  • the calciferol compound is administered at a dose equivalent to at least 1 ⁇ g of alphacalcidol per day.
  • the calciferol compound is administered orally, parenterally or transdermally.
  • At least one clinical tool is used to determine the decrease in fatigue.
  • the clinical tool is selected from the group consisting of Fatigue Impact Scale and The Quality of Life RAYS Questionnaire.
  • the clinical tool is that presented in Table 1 or Table 2.
  • the calciferol compound is formulated with arachis oil. In another embodiment, the calciferol compound is a timed-release formulation.
  • At least one additional compound is co ⁇ administered.
  • the at least one additional compound is selected from the group consisting of interferon ⁇ l-a, interferon ⁇ l-b, glatiramer acetate, mitoxantrone and natalizumab.
  • the at least one additional compound is selected from the group consisting of prednisone, prednisolone, triamcinolone, dexamethasone, naproxen, sulindac, diclofenac, piroxicam, ketoprofen, diflunisal, nabumetone, etodolac, oxaprozin, indomethacin, celecoxib, rofecoxib, hydroxychloroquine sulfate, chloroquine, cyclophosphamide, azathioprine, chlorambucil, piroxicam and steroids.
  • calciferol in another embodiment, blood calcium levels are monitored and the administration of the calciferol is adjusted to avoid hyper calcalcemia.
  • This invention further provides a method of treating fatigue in a subject comprising administering a composition comprising a sufficient amount of at least one biologically active calciferol compound, wherein the administering of the composition does not correlate with a spike in blood calcium levels; and wherein the administering of at least one calciferol compound decreases fatigue.
  • the calciferol compound comprises at least one selected - from the group consisting of calciferol, 1,25 dihydroxyvitamin D3, alfacalcidol, 1,25- dihydroxyvitamin D 2 , l ⁇ -hydroxyvitamin D 2 , l ⁇ , 25- (OH) 2 -16- ene-D 3 , l ⁇ , 25- (OH) 2 -24-oxo-16-ene-D 3 , l ⁇ , 24R(OH) 2 -D 3 , l ⁇ , 25 (OH) 2 ⁇ 22-oxa-D 3 , 20-epi-22-oxa-24 ⁇ , 24 ⁇ , -dihomo- l ⁇ , 25 (OH) 2 -D 3 , 20-epi-22-oxa-24 ⁇ , 26 ⁇ , 27 ⁇ , -trihomo-l ⁇ , 25 (OH) 2-D 3 , 20-epi-22-oxa-24homo-l ⁇ , 25 (OH) 2 -D 3 , 1,
  • the calciferol compound comprises alphacalcidol.
  • the subject suffers from a chronic condition.
  • the calciferol compound is administered at a dose equivalent to at least 1 ⁇ g of alphacalcidol per day.
  • the calciferol compound is administered orally, parenterally or transdermally.
  • At least one clinical tool is used ⁇ to determine the decrease in fatigue.
  • the clinical tool is selected from the group consisting of Fatigue Impact Scale and The Quality of Life RAYS Questionnaire.
  • the clinical tool is presented in Table 1 or Table 2.
  • the administration is oral
  • the administration is oral and the calciferol compound is formulated with arachis oil.
  • the administration is oral and the calciferol compound is a timed-release formulation.
  • At least one additional therapeutic compound is co-administered.
  • the at least one additional compound is selected from the group consisting of interferon ⁇ l-a, interferon ⁇ l-b, glatiramer acetate, mitoxantrone and natalizumab.
  • the at least one additional compound is selected from the group consisting of prednisone, prednisolone, triamcinolone, dexamethasone, naproxen, sulindac, diclofenac, piroxicam, ketoprofen, diflunisal, nabumetone, etodolac, oxaprozin, indomethacin, celecoxib, rofecoxib, hydroxychloroquine sulfate, chloroquine, cyclophosphamide, azathioprine, chlorambucil, piroxicam and steroids.
  • blood calcium levels are monitored and the administration of the calciferol is adjusted to avoid hypercalcemia.
  • This invention also provides a method of preventing fatigue in a subject comprising administering a sufficient amount of at least one biologically active calciferol compound, wherein the administering of the at least one calciferol compound prevents or delays the onset of fatigue.
  • At least one calciferol compound is seleceted from the group consisting of calciferol, 1,25 dihydroxyvitamin D 3 , alfacalcidol, 1, 25-dihydroxyvitamin D 2 , l ⁇ -hydroxyvitamin D 2 , l ⁇ , 25- (OH) 2 -16-ene-D 3 , l ⁇ ,25- (OH) 2 -24-oxo-16-ene-D 3 , l ⁇ , 24R(OH) 2 -D 3 , l ⁇ , 25 (OH) 2 -22-oxa- D 3 , 20-epi-22-oxa-24 ⁇ ,24 ⁇ ,-dihomo-l ⁇ ,25 (OH) 2 -D 3 , 20-epi- 22-oxa-24 ⁇ ,26 ⁇ ,27 ⁇ ,-trihomo-l ⁇ , 25 (OH) 2-D 3 , 20-epi-22- oxa-24homo-l ⁇ ,25 (OH) 2 -D 3 ,
  • the at least one calciferol compound is alphacalcidol.
  • the subject also suffers from a chronic condition.
  • the at least one calciferol compound is administered at a dose equivalent to at least 1 ⁇ g of alphacalcidol per day.
  • the calciferol is administered orally, parentally, or transdermally. In an embodiment, at least on clinical tool is used to determine the decrease in fatigue.
  • the clinical tool is selected from the group consisting of Fatigue Impact Scale and The Quality of Life 1 RAYS Questionnaire. In another embodiment, the clinical tool is that presented in Table 1 or Table 2. In an embodiment wherein the administration is oral, the calciferol compound is formulated with arachis oil.
  • the calciferol compound is a timed-release formulation.
  • At least one additional therapeutic compound is co-administered.
  • the at least one additional compound is selected from the group consisting of interferon ⁇ l ⁇ a, interferon ⁇ l-b, glatiramer acetate, mitoxantrone and natalizumab.
  • the at least one additional compound is selected from the group consisting of prednisone, prednisolone, triamcinolone, dexamethasone, naproxen, sulindac, diclofenac, piroxicam, ketoprofen, diflunisal, nabumetone, etodolac, oxaprozin, indomethacin, celecoxib, rofecoxib, hydroxychloroquine sulfate, chloroquine, cyclophosphamide, azathioprine, chlorambucil, piroxicam and steroids.
  • blood calcium levels are monitored and the administration of the calciferol compound is adjusted to avoid hypercalcemia.
  • the at least one biologically active calciferol compound is one selected from the group consisting of calciferol, 1,25 dihydroxyvitamin D 3 , alfacalcidol, 1, 25-dihydroxyvitamin D 2 , l ⁇ -hydroxyvitamin D 2 , l ⁇ ,25- (OH) 2 -16-ene-D 3 , l ⁇ ,25- (OH) 2 -24-oxo-16-ene-D 3 , l ⁇ , 24R(OH) 2 -D 3 , l ⁇ , 25 (OH) 2 -22-oxa-D 3 , 20-epi-22-oxa- 24 ⁇ , 24 ⁇ , -dihoruo-l ⁇ , 25 (OH) 2 -D 3 , 20-epi-22-ox
  • the calciferol compound is alphacalcidol.
  • the calciferol compound is formulated with arachis oil. In yet another embodiment, the calciferol compound is supplied for oral, injection, or transdermal administration.
  • the calciferol compound is supplied as a capsule, a pill, a mouthwash, an injectable composition in a syringe or a patch.
  • a means for monitoring blood calcium levels in another embodiment, a means for monitoring blood calcium levels.
  • a means for monitoring blood calciferol levels in a further embodiment, a means for monitoring blood calciferol levels.
  • This invention also provides for a method of preventing fatigue and treating a chronic condition in a subject comprising: administering a sufficient amount of at least one biologically active calciferol compound, and ' administering a sufficient amount of at least one therapeutic agent; wherein the administering of the calciferol compound decreases the fatigue and the therapeutic agent reduces the symptoms of the chronic condition.
  • the calciferol compound comprises at least one selected from the group consisting of calciferol, 1,25 dihydroxyvitamin D 3 , alfacalcidol, 1,25- dihydroxyvitamin D 2 , l ⁇ -hydroxyvitamin D 2 , l ⁇ , 25- (OH) 2 -16- ene-D 3 , l ⁇ , 25- (OH) 2 -24-oxo-16-ene-D 3 , l ⁇ , 24R(OH) 2 ⁇ D 3 , l ⁇ , 25 (OH) 2 -22-oxa-D 3 , 20-epi-22-oxa-24 ⁇ , 24 ⁇ , -dihomo- l ⁇ , 25 (OH) 2 -D 3 , 20-epi-22-oxa-24 ⁇ , 26 ⁇ , 27 ⁇ , -trihomo-l ⁇ , 25
  • the calciferol compound comprises alphacalcidol .
  • a clinical tool is used to assess fatigue.
  • the clinical tool is selected from the group consisting of Fatigue Impact Scale and the Quality of Life RAYS Questionnaire.
  • the clinical tool is that presented in Table 1 or Table 2.
  • This invention provides for the use of a sufficient amount of at least one biologically active calciferol compound administered to a subject suffering from fatigue, wherein the administering of the at least one calciferol compound decreases fatigue.
  • This invention also provides for the use of a composition comprising a sufficient amount of at least one biologically active calciferol compound that is administered in a continuous manner to a subject suffering from fatigue, wherein the administering of the at least one calciferol compound decreases fatigue.
  • This invention further provides for the use of a sufficient amount of at least one biologically active calciferol compound administered to a subject suffering from fatigue, wherein the administering of the composition does not correlate with a spike in blood calcium levels; and wherein the administering of the at least one calciferol compound decreases fatigue.
  • This invention also provides for the use of a sufficient amount of at least one biologically active calciferol compound to prevent fatigue in a subject, wherein the administering of the at least one calciferol compound prevents or delays the onset of fatigue.
  • This invention further provides for the use of a- sufficient amount of at least one biologically active calciferol compound to prevent fatigue and treat a chronic condition in a subject, comprising: administering a sufficient amount of at least one biologically active calciferol compound, and administering a sufficient amount of at least one therapeutic agent; wherein the administering of the calciferol compound decreases fatigue and the therapeutic agent reduces the symptoms of the chronic condition.
  • the at least one calciferol compound is selected from the group consisting of calciferol, 1,25 dihydroxyvitamin D3, alfacalcidol, 1, 25-dihydroxyvitamin D 2 , l ⁇ -hydroxyvitamin D 2 , l ⁇ ,25- (OH) 2 -16-ene-D 3 , l ⁇ , 25- (OH) 2 -24-oxo-16-ene-D 3 , l ⁇ , 24R(OH) 2 - D 3 , l ⁇ , 25 (OH) 2 -22-oxa-D 3 , 20-epi-22-oxa-24 ⁇ ,24 ⁇ , -dihomo- l ⁇ , 25 (OH) 2 -D 3 , 20-epi-22-oxa-24 ⁇ , 26 ⁇ , 27 ⁇ , -trihomo-l ⁇ , 25 (OH) 2-D 3 , 20-epi-22-oxa-24homo-l ⁇ , 25 (OH) 2 -D 3 , 1,
  • the at least one- calciferol compound is alphacalcidol.
  • the subject also suffers from a chronic- condition.
  • the at least one calciferol compound is administered at a dose equivalent to at least 1 ⁇ g of alphacalcidol per day.
  • the calciferol compound is administered orally, parentally, or transdermally.
  • At least one clinical tool is used to determine the decrease in fatigue.
  • the clinical tool is selected from the group consisting of Fatigue Impact Scale and The Quality of Life RAYS Questionnaire.
  • the clinical tool is that presented ' in Table 1 or Table 2.
  • the calciferol compound is formulated with arachis oil.
  • At least one additional therapeutic compound is co-administered.
  • the at least one additional compound is selected from the group consisting of interferon ⁇ l-a, interferon ⁇ l-b, glatiramer acetate, mitoxantrone and natalizumab.
  • the at least one additional compound is selected from the group consisting of prednisone, prednisolone, triamcinolone, dexamethasone, naproxen, sulindac, diclofenac, piroxicam, ketoprofen, diflunisa ⁇ , nabumetone, etodolac, oxaprozin, indomethacin, celecoxib, rofecoxib, hydroxychloroquine sulfate, chloroquine, cyclophosphamide, azathioprine, chlorambucil, piroxicam and steroids.
  • blood calcium levels are monitored and administration of the calciferol compound is adjusted to avoid hypercalcemia.
  • the methods of the invention provide effective and reproducible therapies for the treatment of fatigue.
  • the methods are especially effective in treating people who suffer from chronic conditions, such as multiple sclerosis .
  • a broad range of dosages for the therapeutic administration of the biologically active calciferol ' compounds are contemplated.
  • a preferred dose of the biologically active calciferol compound is up to the maximum that a patient can tolerate and not develop serious hypercalcemia. If the biologically active calciferol compound is not a l ⁇ -hydroxy compound, a daily dose between 0.1 and 250 ⁇ g (approximately 0.8 to 2000 IU) per day is administered, while a particularly advantageous daily dose is between 5.0 and 100 ⁇ g per day. A particularly preferred dose is 1 ⁇ g per day.
  • a daily dose of between 0.1 and 20 ⁇ g per day is administered, while a preferred dose is between 0.5 and 10 ' ⁇ g per day. In a particularly preferred embodiment, the dose is between 3-10 ⁇ g per day.
  • the dose may be divided between two, three, four or five treatments within a twenty-four-hour period, or may be administered once daily.
  • a preferred dose is equivalent to the effect of 1 ⁇ g of alfacalcidol administered orally and once daily. Patients on a low calcium diet, and/or if the compounds are administered at night, may tolerate more per day, and in fact, will probably require more to maintain overall health (Vieth, 1999) .
  • Alfacalcidol a precursor of calcitriol (1,25 dihydroxycalciferol) , is a biologically active calciferol compound. From calciferol, calcitriol is synthesized in two steps: hepatic 25-hydroxylation and renal 1- ⁇ hydroxylation. Alfacalcidol administration saves the renal step hydroxylation and yields calcitriol in the single step of hepatic hydroxylation. The administration of alfacalcidol results in an improved pharmacokinetic profile of the produced calcitriol as it avoids the dangerous spikes that can result from direct calcitriol administration.
  • the specific dose level and frequency of dosage for any- particular patient may be varied and depends upon a variety of factors, including the activity of the specific compound employed, the metabolic stability and length of action of that compound, the age, body weight, general health, sex, diet, mode and time of administration, rate of excretion, drug combination, the severity of the particular condition, and the host undergoing therapy.
  • calciferol and calcium levels in the circulation can be measured to determine if dosage should be adjusted. For example, if calcium levels are high after the commencement of calciferol therapy, calciferol dosages should be decreased, or the calcium levels treated with other therapies. If calciferol levels are low, even though the dose is high, and calcium levels are low, then the dosage should be raised or administered via another route.
  • the biologically active calciferol compound can be administered in pulses of high doses.
  • calcitriol administered at 0.5 ⁇ g/kg once weekly avoids hypercalcemic effects (Beer et al., 2001) .
  • Biologically active calciferol compounds can be co ⁇ administered with other pharmaceutically active compounds, especially those used to treat Addison Disease, anemia, cancer and AIDS, congestive heart failure, dehydration, depression, fibromyalgia, jet lag, kidney failure, multiple sclerosis, myasthenia gravis, stress, systemic lupus erythematosus and vasculitis.
  • interferon ⁇ l-a AVONEX®, REBIF®
  • interferon ⁇ l- b BETASERON®
  • glatiramer acetate COPOXONE®
  • mitoxantrone NOVANTRONE®
  • prednisone prednisolone
  • triamcinolone ARISTOCORT®, KENACORT®
  • FELDENE® ketoprofen
  • ORUDIS® ketoprofen
  • DOLOBID® diflunisal
  • RELAFEN® • nabumetone
  • LODINE® etodolac
  • ARALEN® cyclophosphamide, azathioprine, chlorambucil, piroxicam (FELDENE®) and other steroids can be administered with biologically active calciferol compounds to treat MS and systemic lupus erythematosus.
  • Fatigue may accompany chronic conditions, such as multiple sclerosis; disorders, such as Chronic Fatigue Syndrome (CFS) ; and infections by Epstein-Barr virus and other agents; or may be accompanied by no other signs of any illness or condition (Table A) .
  • CFS Chronic Fatigue Syndrome
  • Poor nutrition can be the culprit, such as low calcium intake (Alscher et al., 2001; Oudesluys-Murphy and de Vries, 2002) .
  • Fatigue can be categorized by duration.
  • CFS chronic fatigue
  • Chronic fatigue in turn is considered a subset of prolonged fatigue, which is fatigue lasting one or more months (Reeves et al., 2003) .
  • fatigue can be defined as (1) unexplained, persistent or relapsing chronic fatigue (of least 6 months duration) that is of new or definite onset (i.e., has not been lifelong) ; (2) not the result of ongoing exertion; (3) not substantially alleviated by rest; and (4) results in substantial reduction in previous levels of occupational, educational, social, or personal activities (Fukuda efc al., 1994) .
  • Another clinical definition of fatigue is simpler: a subjective lack of physical and/or mental energy that is perceived by the individual (or a caregiver) to interfere with usual and desired activities
  • Fatigue can also be further characterized in that fatigue (1) generally occurs on a daily basis;
  • a determination of whether a subject would benefit from prophylactic treatment of fatigue can be determined by- assessing various risk factors.
  • risk factors may be monitored; such as genetic predisposition to chronic conditions that are often accompanied by fatigue (such as MS), amount of sunlight the subject normally receives, the age of the subject, as well as nationality and ancestry/race.
  • Any diagnostic tools such as those presented in Tables 1 and 2, can also be used to diagnose those subjects who may not yet be classifiable as clinically suffering from fatigue, but show tendencies to the condition if onset is gradual.
  • Subjects at risk are prophylactically administered therapeutic/prophylactic amounts of biologically active calciferol compounds to delay or prevent the onset of symptoms of fatigue.
  • Subjects who suffer from Addison Disease, anemia, cancer and AIDS, congestive heart failure, dehydration, depression, fibromyalgia, jet lag, kidney failure, multiple sclerosis, myasthenia gravis, stress, systemic lupus erythematosus and vasculitis, but who do not yet show any signs of fatigue can be treated with the methods of the invention to prevent fatigue.
  • Hypercalcemia is a risk in the administration of biologically active calciferol compounds (e.g., alfacalcidol) because the major physiological function of calciferol is to maintain extracellular calcium levels within a very limited range for normal cellular and metabolic processes, including neuromuscular function and bone mineralization.
  • calcitriol primarily increases intestinal absorption of dietary calcium and phosphate, and when required, mobilizes bone calcium.
  • calcitriol has a potent calcemic effect (i.e., calcitriol generates a calcemic response in a subject) .
  • the primary concern associated with administering calcitriol or its analogues to subjects is elevated serum calcium (hypercalcemia) and phosphate levels, a condition accompanied by a corresponding increase in urinary calcium excretion (hypercalcuria) .
  • calciferol intoxication can also have serious consequences for neurological functions.
  • severe hypercalcemia the threshold for excitation of nerve and muscles is increased, resulting in clinical manifestations of muscle weakness, lethargy, and even coma.
  • Gastrointestinal manifestations of calciferol intoxication include constipation, anorexia, nausea, and vomiting, with subsequent fluid loss that exacerbates the hypercalcemic crisis.
  • Hypercalcemia can also affect cardiovascular functioning, including hypotension, and arrhythmias . Monitoring the development of hypercalcemia in subjects receiving high doses or potent biologically active calciferol compounds is recommended. Hypercalcemia may be monitored in a patient by measuring the terminal serum calcium levels.
  • a method of minimizing the risks of hypercalcemia involves administering the biologically active calciferol compound using timed drug release methods (e.g., suppositories or transdermal patches) or "slow release" biologically active calciferol derivatives (e.g., (Deluca and Schnoes, 1999) ) .
  • timed drug release methods e.g., suppositories or transdermal patches
  • slow release biologically active calciferol derivatives
  • transdermal patch substantially reduces the risk of hypercalcemia caused by mobilization of calcium across the intestinal wall by preventing a delivery spike of the biologically active calciferol compound.
  • a transdermal patch when properly designed and applied, delivers a continuous, low dosage stream of the- biologically active calciferol compounds such that a spike that could cause a severe increase in the mobilization of calcium across the intestine wall is avoided.
  • Another approach to reduce the "spike” phenomenon is to administer a biologically active calciferol compound that does not cause such a spike.
  • Alfacalcidol is such a compound.
  • Assessment tools include the Fatigue Impact Scale (FIS; Table 1) and the RAYS Questionnaire (Table 2) .
  • the FIS measures both fatigue and treatment effect on fatigue, and measures the patients' awareness of the impact of fatigue on their QoL and the effect of various therapies
  • the FIS is a reliable and validated forty- item questionnaire that can monitor a treatment effect. Containing three sub-scales: physical, cognitive and social, each question is scored from 0-4 (higher scores indicating higher impairment) .
  • the RAYS QoL questionnaire can also be administered to determine changes in QoL (Rotstein et al., 2000), which is impacted by fatigue. Each question is scored from 0-4 (higher scores indicating higher impairment) .
  • the Chalder Fatigue Scale has fourteen items that measures fatigue intensity and separates mental and physical fatigue (Chalder et al., 1993) . This tool has been effectively used in large community samples (Jason et al., 1999) .
  • the Krupp Fatigue Severity Scale is sensitive to different aspects and gradations of the severity of fatigue; most of the nine items, rated on a seven-point scale, relate to behavioral consequences of fatigue (Krupp et al., 1989) .
  • Circulating 25 (OH) D levels closely reflect the amount of sunlight to which the epidermis is exposed and the dietary intake of calciferol.
  • Serum 25 (OH) D level is the best indicator to define calciferol deficiency, insufficiency, hypovitaminosis, sufficiency, and toxicity (McKenna and Freaney, 1998; Zittermann, 2003) .
  • 25(OH)D levels below 12-5 nmol/1 can result in bone diseases such as rickets in infants and osteomalacia in adults (Scharla, 1998) .
  • Levels of 25(OH)D below 25 nmol/1 may lead to rickets and osteomalacia in the if maintained over extended periods (Basha et al., 2000) . Therefore, concentrations of 25(OH)D below 40-50 nmol/1 indicate calciferol insufficiency (Malabanan et al., 1998; Need et al., 2000; Vieth, 1999) . Values below this threshold can also lead to functional alterations such as hyperparathyroidism (Zittermann, 2003) .
  • Serum 25 (OH) D concentrations between 50 nmol/1 and 80-100 nmol/1 indicate hypovitaminosis D, where body stores are already depleted of calciferol (Lamberg-Allardt et al., 2001; McKenna and Freaney, 1998) .
  • Circulating 25 (OH) D levels between 100 and 200 nmol/1 are adequate concentrations, where no disturbances in calciferol- dependent body functions occur (Zittermann, 2003) .
  • Hypercalcemia is a risk in the administration of biologically active calciferol compounds, such as alfacalcidol, because the major physiological function of calciferol is to maintain extracellular calcium levels within a very limited normal range for normal cellular and metabolic processes (including neuromuscular function and bone mineralization) . Therefore, it is important to monitor the development of hypercalcemia in patients receiving high exogenous doses of biologically active calciferol compounds.
  • biologically active calciferol compounds such as alfacalcidol
  • Fatigue in medical terminology, refers to the state of reduced capacity for work or accomplishment following a period of mental or physical activity.
  • “Fatigue is reduced,” “reducing fatigue,” “decreasing fatigue,” and the like refer to any degree of qualitative or quantitative reduction in detectable symptoms of fatigue, a detectable impact on the rate of recovery from fatigue, or an increase in the subjective or objective assessment of the quality of life (QoL) , as measured, for example, by FIS or RAYS or any other fatigue- and/or QoL- monitoring clinical tools .
  • Subject refers to a patient which is administered the therapeutic composition comprising biologically active calciferol compounds. Examples of subjects include humans and other animals such as non-human primates, horses, dogs, and cats. The terms “subject,” “patient,” and “participant” are used interchangeably.
  • a unit "dose equivalent” means the amount of any type of one compound which, when absorbed in a biological system, results in the same biological effect as one unit of absorbed dose delivered in the form of another compound.
  • a “therapeutically effective amount” or a “sufficient amount” of a biologically active calciferol compound is the dosage level required for a patient such that the symptoms of fatigue are reduced.
  • a “therapeutically effective amount” or a “sufficient amount” can be applied to any agent that is used to treat a disease, disorder or condition, wherein the amount of the agent reduces at least one symptom of the disease, disorder or condition.
  • Calciferol compound (or “vitamin D compound”) is a compound which has at least one of the following features: the C-ring, D-ring and 3 ⁇ -hydroxycyclohexane A-ring of calciferol interconnected by the 5,7 diene double bond system of calciferol together with any side chain attached to the D-ring (i.e., compounds with a "calciferol nucleus” and substituted or unsubstituted A- , C-, and D-rings interconnected by a 5,7 diene double bond system typical calciferol together with a side chain attached to the D-ring) .
  • Calciferol and its analogues and other relatives have been used to treat and/or prevent a wide variety of diseases and disorders.
  • calciferol mobilizes calcium has been used to diminish bone loss that occurs during to aging (osteoporosis), and concomitant loss in muscle strength (Bischoff et al., 1999; Heaney, 1999; Lamberg-Allardt et al., 2001; McKenna and Freaney, 1998; Need et al., 2000; S ⁇ rensen et al., 1979; Verhaar et al., 2000) .
  • MS Achiron et al., 1999; Achiron et al.
  • vitamin D calciferol
  • the calciferol compounds are a group of structurally similar chemicals and their metabolites including, inter alia, calcitriol (1, 25-dihydroxycholecalciferol) and alphacalcidol (lhydroxycholecacliferol) .
  • Calcitriol is a metabolite of califediol(25-hydroxycholecalciferol) , a metabolite of cholecalciferol (Vitamin D3) and ergocalciferol (Vitamin D2) .
  • Alphacalcidol is a' synthetic analogue of calcitriol and is rapidly converted to calcitriol in the liver.
  • l ⁇ -hydroxyvitamin D 3 alfacalcidol
  • l ⁇ -hydroxyvitamin D 2 various side chain fluorinated derivatives of l ⁇ , 25-dihydroxyvitamin D 3 , 19- nor-vitamin D compounds
  • side chain-modified analogs l ⁇ -hydroxyvitamin D 3 (alfacalcidol)
  • l ⁇ -hydroxyvitamin D 2 various side chain fluorinated derivatives of l ⁇ , 25-dihydroxyvitamin D 3 , 19- nor-vitamin D compounds
  • side chain-modified analogs side chain-modified analogs.
  • Calciferol can be ingested orally or can be formed endogenously by the skin after exposure to ultraviolet (UV) B light (wavelength 290-315 nm) .
  • Orally ingested and endogenously formed calciferol is transported to the liver and is converted to, 25-hydroxyvitamin D (25(OH)D) .
  • the liver does not store significant amounts of 25 (OH)D; once converted, 25(OH)D is rapidly released into the blood.
  • 25 (OH) D is enzymatically converted to calcitriol. Renal synthesis of calcitriol is homeostatically . controlled by parathyroid hormone (PTH) . Synthesis of PTH is regulated by serum concentrations of calcium (Ca) and phosphorous.
  • 25 (OH) D can also be . converted in the kidney to 24,25-dihydroxyvitamin D (Zittermann, 2003) .
  • Calciferol metabolites are known as regulators of sys ⁇ temic Ca homeostasis with actions in the intestine, the kidneys, and bone. Calcitriol increases both intestinal absorption of orally ingested and tubular re-absorption to maintain physiological serum Ca levels (Zittermann, 2003) .
  • Alphacalcidol is l ⁇ -hydroxycholecaliferol (Paterson; Treatment with active vitamin D (alphacalcidol) in patients with mild primary hyperparathyroidism) . After absorption into the body, alphacalcidol is converted into l ⁇ , 25-dihydroxycholecalciferol (Product Description) . Alphacalcidol is commercially available under the tradename, Alpha D 3 ® (Alpha D 3 ) . Alphacalcidol is indicated for conditions in which calcium and/or phosphate metabolism (DeLuca, H.
  • F.; Product Description is impaired such as renal bone disease, osteoporosis, osteopenia, hypoparathyriodism and hyperparathyroidism with bone disease, rickets, osteomalacia and renal osteodystrophy (Product Description) .
  • the recommended dose for alpacalcidol for all of the afore-mentioned indications except osteoporosis is 1 ⁇ g/day for adults, 0.5 ⁇ g/day for the elderly and 1 ⁇ g/day for children 20 kg and over except for renal osteodystrophy, for which the recommended dose is 0.04 to 0.08 ⁇ g/kg/day.
  • Biologically active calciferol compounds useful in the present invention encompass calciferol compounds that are biologically active in vivo, or are acted upon in a subject (i.e., host) such that the compound becomes active in vivo, for example, calcitriol (1,25- dihydroxycholecalciferol) or its synthetic analogue alphacalcidol (1 hydroxyvitamin D3) .
  • calciferol, 1,25 (OH) 2 D3 and analogs thereof e.g., l ⁇ -hydroxyvitamin D 3 (IaOH-D 3 ), 1, 25-dihydroxyvitamin D 2 (1,25-(OH) 2 D 2 ), l ⁇ -hydroxyvitamin D 2 (Ia-OH-D 2 ), 26,27-hexafluoro-1, 25-dihydroxyvitamin D 2 (F 6 -I, 25- (OH) 2 D 3 ) , 19-nor-l, 25-dihydroxyvitamin D 2 (19-nor- 1,25- (OH) 2 D 2 ) , 1, 25-dihydroxy-24 (E) -dehydro-24-homo- vitamin D 3 (1, 25- (OH) 2 -24-homoD 3 ) , 19-nor-l, 25-dihydroxy- 21-epi-vitamin D 3 (19-nor-l, 25- (OH) 2 -21-epi-D 3 ) , l ⁇ ,
  • calciferol compounds that (1) inhibit autoimmunity, but have calcemic activity equal or less to calcitriol; (2) inhibit transplant rejection and have calcemic activity equal or less to calcitriol; (3) that exert effects in in vitro cell differentiation assays, and (4) calciferol mimics; these activate the nuclear calciferol receptor in in vitro transcriptional assays. Examples of each, as well as other references disclosing other biologically active calciferol compounds, are given in Table B.
  • Non-secosteroidal calciferol mimics means non-secosteroid compounds which are capable of mimicking various activities of the secosteroid calcitriol. Examples of such compounds include LG190090, LG190119, LG190155, LG190176, and LG1900178 (Boehm et al., 1999) .
  • Bioly active calciferol compounds encompass calciferol compounds and non-secosteroidal calciferol mimics that are biologically active in vivo, or metabolized in a subject (i.e., host) such that the compound becomes active in vivo (e.g., pro-drug forms of calciferol) .
  • biologically active calciferol compounds encompass calciferol compounds and non-secosteroidal calciferol mimics that are biologically active in vivo, or metabolized in a subject (i.e., host) such that the compound becomes active in vivo (e.g., pro-drug forms of calciferol) .
  • examples of such compounds include: calciferol, 1,25 dihydroxyvitamin D 3 (1,25(OH) 2 D 3 )
  • compositions Biologically active calciferol compounds can be incorporated into pharmaceutical compositions .
  • Such compositions typically contain at least one biologically active calciferol compound and a pharmaceutically acceptable carrier.
  • a "pharmaceutically acceptable carrier” includes any and all solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents, etc., compatible with pharmaceutical administration (Gennaro, 2000) .
  • examples of such carriers or diluents include water, saline, finger's solutions, dextrose solution, and 5% human serum albumin. Liposomes and non-aqueous vehicles such as fixed oils may also be used. Except when a conventional media or agent is incompatible with the biologically active calciferol compound, use of these compositions is contemplated. Supplementary active compounds can also be incorporated into the compositions .
  • the active ingredient (s) is mixed with one or more pharmaceutically acceptable carriers, such as sodium citrate or dicalcium phosphate, and/or any of the following: fillers or extenders, such as starches, lactose, sucrose, glucose, mannitol, and/or silicic acid; binders, such as, for example, carboxymethylcellulose, alginates, gelatin, polyvinyl pyrrolidone, sucrose and/or acacia; humectants, such as glycerol; disintegrating agents, such as agar-agar, calcium carbonate, calcium phosphate, potato or tapioca starch, alginic acid, certain silicates, and sodium carbonate; solution retarding agents, such as paraffin; absorption accelerators, such as quaternary ammonium compounds; wetting agents, such as, for example, cetyl alcohol and
  • the pharmaceutical compositions may also comprise buffering agents.
  • Solid compositions of a similar type may also be employed as fillers in soft and hard-filled gelatin capsules using such excipients as lactose or milk sugars, 'as well as high molecular weight polyethylene glycols and the like.
  • Liquid dosage forms for oral administration of the active ingredients include pharmaceutically acceptable emulsions, microemulsions, solutions, suspensions, syrups and elixirs.
  • the liquid dosage forms may contain inert dilutents commonly used in the art, such as, for example, water or other solvents, solubilizing agents and emulsifiers, such as ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1,3-butylene glycol, oils (in particular, cottonseed, groundnut, corn, germ, olive, castor and sesame oils), glycerol, tetrahydrofuryl alcohol, polyethylene glycols and fatty acid esters of sorbitan, and mixtures thereof.
  • inert dilutents commonly used in the art, such as, for example, water or other solvents, solubilizing agents and emulsifiers, such as ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzy
  • Suspensions in addition to the active compounds, may contain suspending agents such as ethoxylated isostearyl alcohols, polyoxyethylene sorbitol and sorbitan esters, microcrystalline cellulose, aluminum metahydroxide, bentonite, agar-agar and tragacanth, and mixtures thereof.
  • suspending agents such as ethoxylated isostearyl alcohols, polyoxyethylene sorbitol and sorbitan esters, microcrystalline cellulose, aluminum metahydroxide, bentonite, agar-agar and tragacanth, and mixtures thereof.
  • a pharmaceutical composition is formulated to be compatible with the intended route of administration, including intravenous, intradermal, subcutaneous, oral (e.g., inhalation), transdermal, transmucosal, and rectal administration.
  • Solutions or suspensions used for parenteral, intradermal, or subcutaneous application can include: a sterile diluent such as water for injection, saline solution, fixed oils, polyethylene glycols, glycerine, propylene glycol or other synthetic solvents; antibacterial agents such as benzyl alcohol or methyl parabens; antioxidants such as ascorbic acid or sodium bisulfite; chelating agents such as ethylenediaminetetraacetic acid (EDTA) ; buffers such as acetates, citrates or phosphates, and agents for the adjustment of tonicity such as sodium chloride or dextrose.
  • the pH can be adjusted with acids or bases, such as hydrochloric acid or sodium hydroxide.
  • the parenteral preparation can be
  • compositions suitable for injection include sterile aqueous solutions (where water soluble) or dispersions and sterile powders for the extemporaneous preparation of sterile injectable solutions or dispersion.
  • suitable carriers include physiological saline, bacteriostatic water, CREMOPHOR EL TM (BASF, Parsippany, N.J.) or phosphate buffered saline (PBS) .
  • the composition must be sterile and should be fluid so as to be administered using a syringe. Such compositions should be stable during manufacture and storage, and must be preserved against contamination from microorganisms, such as bacteria and fungi.
  • the carrier can be a solvent or dispersion medium containing, for example, water, ethanol, polyol (such as glycerol, propylene glycol, and liquid polyethylene glycol), and suitable mixtures. Proper fluidity can be maintained, for example, by using a coating such as lecithin, by maintaining the required particle size in the case of dispersion, and by using surfactants.
  • compositions that delay absorption include agents such as aluminum monostearate and gelatin.
  • Sterile injectable solutions can be prepared by incorporating a biologically active calciferol compound in an appropriate solvent with one or a combination of ingredients, followed by sterilization.
  • dispersions are prepared by incorporating the calciferol compound into a sterile vehicle that contains a basic dispersion medium and any other required ingredients.
  • - Sterile powders for the preparation of sterile injectable solutions methods of preparation include vacuum drying and freeze-drying that yield a powder containing the active ingredient and any desired ingredient from a sterile solution.
  • Oral compositions containing a biologically active calciferol compound are preferred.
  • Oral compositions generally include an inert diluent or an edible carrier. They can be enclosed in gelatin capsules or compressed into tablets.
  • the biologically active calciferol compounds can be incorporated with excipients and used in the form of tablets, troches, or capsules.
  • Oral compositions can also be prepared using a fluid carrier for use as a mouthwash, wherein the compound in the fluid carrier is applied orally.
  • Pharmaceutically compatible binding agents, and/or adjuvant materials can be included.
  • Tablets, pills, capsules, troches and the like can contain a binder, such as microcrystalline cellulose, gum tragacanth or gelatin; an excipient, such as starch or lactose; a disintegrating agent, such as alginic acid, PRIMOGEL or corn starch; a lubricant, such as magnesium stearate or STEROTES; a glidant, such as colloidal silicon dioxide; a sweetening agent, such as sucrose or saccharin; or a flavoring agent such as peppermint, methyl salicylate, or orange flavoring.
  • a binder such as microcrystalline cellulose, gum tragacanth or gelatin
  • an excipient such as starch or lactose
  • a disintegrating agent such as alginic acid, PRIMOGEL or corn starch
  • a lubricant such as magnesium stearate or STEROTES
  • a glidant such as colloidal silicon dioxide
  • a sweetening agent such as sucrose
  • Systemic administration can be transmucosal or transdermal.
  • penetrants that can permeate the target barrier (s) are selected.
  • Transmucosal penetrants include detergents, bile salts, and fusidic acid derivatives.
  • Nasal sprays or suppositories can be used for transmucosal administration.
  • the active compounds are formulated into suitable forms, such as ointments, salves, gels, or creams .
  • the compounds can also be prepared in the form of suppositories (e.g., with bases such as cocoa butter and other glycerides) or retention enemas for rectal delivery.
  • suppositories e.g., with bases such as cocoa butter and other glycerides
  • retention enemas for rectal delivery.
  • the therapeutic composition comprising biologically active calciferol compounds is administered via a transdermal patch.
  • Transdermal delivery provides a continuous supply of the calciferol compound, maintaining the calciferol receptor occupancy at a stable, optimal level, to achieve the desired biological effect and thus treat fatigue.
  • Transdermal delivery can be more convenient and advantageous than other modes of delivery, especially for children, or those who have trouble taking oral medications, and can increase patient compliance.
  • transdermal patch for delivering therapeutics employs a polyurethane acrylic copolymer
  • transdermal patches include those using polymers and vitamin E
  • alphacalcidol or glatiramer acetate may each independently be oral, nasal, pulmonary, parenteral, intravenous, intra-articular, transdermal, intradermal, subcutaneous, topical, intramuscular, rectal, intrathecal, intraocular, buccal or by gavage .
  • the preferred route of administration is oral or by gavage.
  • the preferred route of administration for glatiramer acetate is subcutaneous or oral.
  • doses at the higher end of the range may be required for oral administration.
  • the administration of the glatiramer acetate may be subcutaneous, intraperitoneal, intravenous, intramuscular, intraocular or oral and the administration of the alphacalcidol may be oral. In another embodiment, the administration of the glatiramer acetate may be subcutaneous and the administration of the alphacalcidol may be oral.
  • Biodegradable, biocompatible polymers can be used, such as ethylene vinyl acetate, polyanhydrides, polyglycolic acid, collagen, polyorthoesters, and polylactic acid (ALZA Corporation; Mountain View, CA and NOVA Pharmaceuticals, Inc.; Lake Elsinore, CA) .
  • Liposomal suspensions can also be used as pharmaceutically acceptable carriers (Eppstein et al., 1985) .
  • Unit dosage form refers to physically discrete units suited . as single doses for a subject to be treated, containing a therapeutically effective quantity of active compound in association with, the required pharmaceutical carrier.
  • the specification for unit dosage forms are dictated by, and directly depend on, the unique characteristics of the biologically active calciferol compound and the particular desired therapeutic effect, and the inherent limitations of compounding the calciferol compound.
  • compositions containing the biologically active calciferol compounds can further comprise other therapeutically active compounds that are usually applied in the treatment of other diseases, disorders and conditions, such as multiple sclerosis.
  • Kits for pharmaceutical compositions The pharmaceutical compositions can be included in a kit, container, pack, or dispenser together with instructions for administration.
  • the different components of the composition may be packaged in separate containers and admixed immediately before use. Such packaging of the components separately may permit long-term storage without losing the activity of the components .
  • Kits may also include reagents in separate containers that facilitate the execution of a specific test, such as diagnostic tests or tissue-typing. Kits may also contain sub-kits that are used to help the user monitor important parameters, such as ' blood calcium and/or calciferol levels . Containers or vessels
  • the reagents included in the kits can be supplied in containers of any sort such that the life of the different components are preserved and are not adsorbed or altered by the materials of the container.
  • sealed glass ampules may contain lyophilized- luciferase or buffer that have been packaged under a neutral non-reacting gas, such as nitrogen.
  • Ampules may consist of any suitable material, such as glass, organic polymers, such as polycarbonate, polystyrene, etc., ceramic, metal or any other material typically employed to hold reagents .
  • suitable containers include bottles that may be fabricated from similar substances as ampules, and envelopes, that may consist of foil-lined interiors, such as aluminum or an alloy.
  • Containers include test tubes, vials, flasks, bottles, syringes, etc.
  • Containers may have a sterile access port, such as a bottle having a stopper that can be pierced by a hypodermic injection needle.
  • Other containers may have two compartments that are separated. by a readily removable membrane that upon removal permits the components to mix. Removable membranes may be glass, plastic, rubber, etc.
  • Kits may also be supplied with instructional materials .
  • Instructions may be printed on paper or other substrate, and/or may be supplied as an electronic-readable medium, such as a floppy disc, CD-ROM, DVD-ROM, Zip disc, videotape, audio tape, etc.
  • Detailed instructions may not be physically associated with the kit; instead, a user may be directed to an internet web site specified by the manufacturer or distributor of the kit, or supplied as electronic mail.
  • the Fatigue Impact Scale (FIS; Table 1) measures both fatigue and treatment effect on fatigue measures the patients' awareness of the impact of fatigue on their QoL and the effect of various therapies (Cutter et al. , 2000; Fisk et al., 1994b; Mathiowetz et al., 2001) . Containing 3 sub-scales: physical, cognitive and social, each question is scored from 0-4 (higher scores indicating higher impairment) .
  • the RAYS QoL questionnaire was also administered to determine changes in QoL (Table 2) . Each question is scored from 0-4 (higher scores indicating higher impairment) .
  • the RAYS A quality of life scale for multiple sclerosis patients
  • Primary efficacy end point was the change from baseline to termination as measured by the FIS. Secondary- efficacy end points were (1) the categorical change from baseline to termination in the FIS; as well as the changes from baseline to termination, as measured by the FIS, in (2) the physical fatigue score; (3) the cognitive fatigue score; and (4) the social fatigue score.
  • the exploratory efficacy end points were the changes from baseline to termination in (1) each of the sub-scale QoL scores (RAYS QoL; (Rotstein et al. , 2000)) and (2) of the test effort as measured by the modified MS Bruce protocol.
  • Positive Fatigue impact scale A relapse during the last 30 40 points or more. days prior to the study.
  • Soft gelatin capsules of alfacalcidol and its identical placebo were supplied in identical containers .
  • Alfacalcidol was supplied as soft gelatin capsules containing 1 ⁇ g of active substance, see Table 4 for formulation. Placebo was supplied in soft gelatin capsules filled with arachis oil; the capsules were identical m appearance to those containing alfacalcidol. The participants were instructed to take one capsule every evening. TABLE 4
  • Active ingredients alfacalcidol 0.5 ⁇ g active Inactive ingredients Citric acid, anhydrous 0.015 mg synergist propyl gallate 0.020 mg antioxidant ⁇ -tocopherol 0.020 mg antioxidant ethanol, anhydrous 1.1445 mg solvent arachis oil 98.80 mg vehicle Soft gelatin capsule shell Gelatin 48.35 mg shell glycerol 85% 11.81 mg plastisizer ANIDRISORB® 85/70* 7.89 mg moisturizer (Roquette Freres; Lestrem, FRANCE) titanium dioxide 0.65 mg color/dye (E171) red iron oxide (E172) 0.043 mg color/dye edible ink, black Trace printing ink A10379**
  • Participants were scheduled for five visits: (1) screening and baseline; beginning of treatment; (2) 2 months, (3) 4 months, and (4) 6 months (termination) after baseline, and (5) 2 months after termination.
  • the first visit consisted of participants signing the informed consent form, being evaluated based on inclusion and exclusion criteria (Table 3) , providing demographic and general medical history data, and providing history directly related to fatigue. Concomitant therapies were assessed, and vital signs and the results of a physical examination were recorded. Calcium levels were also determined.
  • a regular MS follow-up was conducted, which consisted of completing the FIS, RAYS, and the Bruce treadmill test (although only a subpopulation of participants ( ⁇ 60) complete the treadmill test) .
  • the second visit consisted of registering the participants' vital signs, assessing concomitant therapy, measuring blood calcium levels, and the regular MS follow-up. Compliance assessment was recorded, and medication for the next 2 months was supplied. Based on the reported adverse experiences and lab tests (calcium level) , the investigator decided if patients could continue the treatment, or if any changes in medication were required.
  • the fourth visit consisted of registering the participants' vital signs, assessing concomitant therapy, ' measuring blood calcium levels, and the regular MS follow-up. Compliance and adverse experience assessments were recorded. About 60 participants completed a Bruce treadmill test. A termination form was completed. Based on the reported adverse experiences and lab tests (calcium level) , the investigator decided if patients could continue the treatment, or if any changes in medication were required.
  • Consent given by the participants was witnessed, dated, and retained by the investigator. Each participant was given a copy of the consent form.
  • the objective was to evaluate the efficacy, tolerability and safety of alfacalcidol as compared to placebo on fatigue in patients with MS.
  • the efficacy was measured by the change from baseline to termination in the (FIS) . - U Z -
  • the power calculations were based on the primary endpoint, the change from baseline to termination in the FIS.
  • the t-test was used, comparing active treatment group to placebo with two- sided ⁇ level of 0.05. Results of these calculations showed that eighty patients per group provided 88% power to detect a statistically significant difference between an active treatment group and a placebo group.
  • ITT Intent-to-treat
  • LOCF Last Observation Carried Forward
  • the primary end-point is the change between the baseline and last observed value.
  • the principal statistical analysis of the primary endpoint was an Analysis of Covariance (ANCOVA, SAS ® GLM procedure) incorporating baseline EDSS as a one degree of freedom covariate and MS treatment strata as fixed effect.
  • the change from baseline to each visit in the FIS score was also calculated to explore time trends.
  • a Baseline Adjusted Repeated Measures Analysis of Covariance SAS ® PROC MIXED procedure was used to elucidate the time course of the drug effect.
  • the dependent variable was the change from baseline in the FIS score, and the model included the fixed effects of treatment group, month in trial, treatment-by-month interaction, baseline EDSS score as covariate and MS treatment strata.
  • the individual participant intercept and the week effects were also included in the model as random effects.
  • the test for a significant treatment effect was based on the joint statistical significance of the treatment effect and the treatment-by-week interaction. Joint tests of significance were conducted using the -2 Log Likelihood Ratio test.
  • a structural equation model based on the hypothesized MSQLI structure was specified separately for all subjects at baseline and termination.
  • the equivalence of internal structure for the two groups was tested by freeing model parameters to vary between the alfacalcidol and placebo group, and testing for significant improvement in overall model fit.
  • MS patients participated in the study; 74% were female (41 ⁇ 9.2 years), age at MS diagnosis (34.9 ⁇ 9.5 years), and 92.4% had a relapsing- remitting course complaining on MS fatigue (FIS at baseline 77 ⁇ 26) for a mean of 4 years.
  • IMT immunomodulatory therapies
  • Alfacalcidol therefore improved fatigue in patients with MS at six months. Improvement was especially significant in the cognitive subscale of the FIS.
  • Alphacalcidol also reduced the rate of relapses, especially in patients receiving COPAXONE®
  • Figure 3 shows the percent (%) improvement of relapse rate per year in MS patients on MS therapy who received 1 ⁇ g of alphacalcidol per day.
  • the annual relapse rate was calculated based on the number of relapses during a six month period adjusted for one year.
  • the P value indicates the statistically significant different in relapses per year between the two treatment groups (active and placebo) .
  • EXAMPLE 2 CLINICAL TRIAL OF RELAPSING-REMITTING MULTIPLE SCLEROSIS
  • the purpose of this trial is to compare the treatment of participants with relapsing-remitting multiple sclerosis (RR-MS) with COPAXONE® in combination with alphacalcidol, with treatment with COPAXONE® in combination with placebo.
  • the clinical objective is to evaluate the effect of treatments on MRI variables, clinical evaluations and immunological profile.
  • the design of this trial is a randomized, double-masked, 2-arm study of COPAXONE® in combination with alphacalcidol versus COPAXONE® in combination with placebo for the treatment of relapsing-remitting multiple sclerosis.
  • Twenty patients with RR-MS who meet the inclusion/exclusion criteria are enrolled per arm. Patients are randomized and receive either 20 mg SQ (subcutaneous) of COPAXONE® daily plus an oral dose of placebo daily or 20 mg SQ of COPAXONE® in combination ' with 50 mg alphacalcidol every 12 hours.
  • Participant inclusion criteria are as follows: 1) men or women age 18 to 50 years; 2) RR-MS according to the guidelines from the International Panel on the Diagnosis of MS (McDonald et al. ) ; 3) two separate documented relapses in the last two years; 4) active MRI with at least one gadolinium(Gd) -enhancing lesion in the MRI scan at screening; 5) EDSS (extended disability status scale) score between 1.0 and 5.0; 6) no relapse during screening period; 7) pre-treatment with COPAXONE® for at least three weeks, but no more than four weeks, prior to baseline visit; and 8) ability to understand and provide informed consent.
  • Participant exclusion criteria include the following: 1) normal brain MRI; 2) prior treatment with COPAXONE® other than the scheduled three to four week pretreatment prior to baseline visit; 3) previous treatment with immunomodulating agents such as interferon beta or IVIg for the last 6 months prior to entry; 4) previous use of immunosuppressive agents (including azathioprine) in the ' last 12 months prior study entry; 5) steroid treatment one month prior to entry; 6) women not willing to practice reliable methods of contraception; 7) pregnant or nursing women; 8) life threatening or clinically significant diseases; 9) history of alcohol and drug abuse within 6 months prior enrollment; 10) known history of sensitivity to Gd; 11) uncontrolled and uncontrollable head movements (tremor, tics, etc.), muscle spasms, significant urinary urgency and claustrophobia, which will prevent the subject from lying still during the MRI scan; and 12) participation in other investigational therapy in the last 90 days.
  • MRI scans are performed during the screening visit (for eligibility) and at months 5, 10, 11 and 12. Full physical and neurological examinations are performed at -yu-
  • Primary efficacy endpoints include the following: 1) MRI variables as measured on months 10, 11, and 12; 2) total number and volume of Tl GD-enhanced lesions; 3) total number of new T2 lesions; and 4) total volume of T2 lesions.
  • Secondary efficacy endpoints encompass the following: 1) changes in immunological parameters; and 2) PBMC proliferation in response to GA in vitro.
  • the tertiary efficacy endpoints are as follows: 1) change from baseline in relapse rate and MS Functional Composite Score (MSFC) ; and 2) brain atrophy. Tolerability is evaluated with reference to the following: 1) percentage of subjects who discontinue the study; and 2) percentage of subjects who discontinue the study due to adverse events. Safety is evaluated with reference to 1) adverse event frequency and severity; 2) changes in vital signs and 3) clinical laboratory values.
  • the objective of this study was to test the suppressive activity of Calcitriol and Alfa Calcidol, following intraperitoneal administration every alternate day in the Experimental Autoimmune Encephalomyelitis model in CSJL/F1 mice.
  • the EAE is an animal model for multiple sclerosis.
  • the CSJL/ FI strain of mouse was selected, as it is an established EAE model.
  • MSCH/CFA encephalitogenic emulsion
  • mice of the CSJL/FI strain Healthy, nulliparous, non-pregnant female mice of the CSJL/FI strain were obtained from Harlan Animal Breeding Center, Jerusalem, Israel. The animals weighed about 17- 20 g on arrival, and approximately 7 weeks of age. The body weights of the animals will be recorded on the day of delivery. Overtly healthy animals were assigned to study groups arbitrarily before treatment commenced. The mice were individually identified by ear tags. A color- coded card on each cage gave information including cage number, group number and identification.
  • EAE was induced by injecting the encephalitogenic mixture (emulsion) consisting of MSCH and commercial CFA containing 1 mg/mL Mycobacterium tuberculosis to the hind leg foot-pad of the animals.
  • Pertussis toxin was injected intravenously on the day of induction and 48 hours later.
  • mice 110 mice were allocated to the following treatment groups (10 mice/group) :
  • test formulations were prepared in darkness in amber colored vials. Contents of the vial containing 1.0 mg Calcitriol and Alfa Calcidol were reconstituted with 10 mL vehicle (80% Propylene Glycol in 0.05 M disodium phosphate, ph 7.4) to yield 100 ⁇ g/mL and diluted further with the buffer, 0.05 M disodium phosphate, ph 7.4 to reach working concentrations of the test articles. The test formulations were freshly prepared and used- immediately after preparation.
  • mice of groups #3 to 11 were administered intraperitoneally every alternate day (every Sunday, Tuesday and Thursday) for three weeks with the respective dose levels of Calcitriol and Alfa Calcidol at volume dose level of 100 ⁇ L/mouse.
  • test formulations administered subcutaneously were injected in different places in the flanks and scapular region of the neck.
  • the vehicle - 30% PEG 400, 0.7% Poloxamer 407, 0.01M Citric buffer was administered to Group # 1 subcutaneously in a similar manner.
  • mice having a score of 1 and above were considered sick. When the first clinical sign appears all mice were given food soaked in water for supportive treatment, which was spread on different places on the bedding of the cages .
  • the number of dead or moribund animals in each group was obtained and divided by the total number of mice in the group.
  • the mean duration of disease expressed in days was calculated as
  • MMS mean maximal score
  • the group mean score (GMS) was calculated as
  • Calcitriol was toxic at dose level of 10 ⁇ g/kg. After two administrations the mice in this group were treated with 2 ⁇ g/kg. 1 mouse in this group died due to toxicity of test formulation.
  • Group treated with 0.5 ⁇ g/kg Calcitriol did not suppress EAE.
  • the GMS in this group was 17.8% lower than the vehicle administered control group.
  • mice in this group were treated with 4 ⁇ g/kg Alfa Calcidol. 6/10 mice died in this group.
  • mice in groups treated with 4 and 2 ⁇ g/kg Alfa Calcidol exhibited toxic signs manifested by loss in body weight, partial eye lid closure, piloerection, hunch posture, hypo activity and apathy.
  • ** This group received two administrations of 20 ⁇ g/kg. As there were toxic signs this group was administered 4 ⁇ g/kg from the 3 rd administration onwards
  • the objective of this study was to test the suppressive activity of Calcitriol and Alfa Calcidol, following intraperitoneal administration every alternate day alone and along with Glatiramer acetate administered subcutaneousIy along with encephalitogen, in the Experimental Autoimmune Encephalomyelitis model in CSJL/F1 mice.
  • the EAE is an animal model for multiple sclerosis.
  • the CSJL/ FI strain of mouse has been selected, as it is an established EAE model.
  • MSCH/CFA encephalitogenic emulsion
  • CSJL/FI strain obtained from Harlan Animal Breeding Center, Israel were used in the study. The animals weighed about 17-20 g on arrival, and were approximately
  • mice were individually identified by markings on the body.
  • a color-coded card on each cage gave information including cage number, group number and identification.
  • the rodent diet contained 0.2 % Calcium and no vitamin D was added to the diet.
  • the lot of the batch was # 05030107i. It was prepared by Research diets inc, New Brunswick, USA. The animals were on this diet from two days before initiation of the study until the termination of the study.
  • EAE was induced in groups not treated by GA by injecting 50 ⁇ L of the encephalitogenic mixture (emulsion) consisting of MSCH and commercial CFA containing 1 mg/mL Mycobacterium tuberculosis to the hind leg foot-pad of the animals .
  • the groups treated with GA were injected in the hind leg ' foot-pad of the animals with 50 ⁇ L of encephalitogenic mixture (emulsion) containing appropriate dose level of GA.
  • Emulsion consisting of 1 mg/mL and 2 mg/rriL GA (for dose levels of 1.25 and 2.5 mg/kg respectively) in MSCH diluted 1:2 with CFA containing 1 mg/mL Mycobacterium tuberculosis was injected.
  • Pertussis toxin was injected intravenously to all EAE induced mice on the day of induction and 48 hours later.
  • mice The three blocks of mice (MSCH in PBS, MSCH in 1 mg/mL GA and MSCH in 2 mg/mL GA) were each divided into four groups of mice (total 12 groups) . Each group consisted of . 10 to 11 mice.
  • mice were allocated to the following treatment groups (10-11 mice/group) :
  • the Calcitriol and Alfa Calcidol dilutions were prepared in amber colored bottles in the dark. Contents of the vial containing 1.0 mg Calcitriol or Alfa Calcidol was reconstituted with 10 mL vehicle (80 % Propylene Glycol in 0.05 M disodium phosphate, ph 7.4) to yield 100 ⁇ g/mL and diluted further with the buffer (0.05 M disodium phosphate, ph 7.4) to reach working concentrations of the test articles.
  • mice were administered intraperitoneally every alternate day (every Sunday, Tuesday and Thursday) for three weeks with the respective dose levels of Calcitriol and Alfa Calcidol at volume dose level of 100 ⁇ L/mouse.
  • the test formulations were freshly prepared and used immediately after preparation.
  • the vehicle was administered in a similar manner to groups treated with GA alone and to the control group.
  • the groups treated with GA received the treatment once.
  • the GA was administered in emulsion form during time of induction along with the encephalitogen
  • mice having a score of 1 and above were considered sick. When the first clinical sign appears all mice were given food soaked in water for supportive treatment, which was spread on different places on the bedding of the cages .
  • Percent inhibition l-[incidence in treated group/incidence in control group] X 100 2) Calculation of the mortality/ morbidity rate (mortality ratio) :
  • the number of dead or moribund animals in each group was obtained and divided by the total number of mice in the group.
  • the mean duration of disease expressed in days was calculated as
  • the disease duration period for a mouse that did not develop EAE during the observation period was considered as 0 days.
  • MMS mean maximal score
  • the group mean score (GMS) was calculated as
  • Calcitriol at dose levels of 0.5 ⁇ g/kg and 2.0 ⁇ g/kg exhibited additive effect with GA at dose level of 1.25 mg/kg.
  • the additive effect if any, of 1.0 ⁇ g/kg Alfa Calcidiol with both the dose levels of GA (1.25 and 2.5 mg/kg) could not be observed.
  • Calcitriol (0.5 ⁇ g/kg and 2.0 ⁇ g/kg) could not be observed.
  • a synthetic analogue of vitamin D3, 22-oxa-l alpha, 25-dihydroxyvitamin D3, is a potent modulator of in vivo immunoregulating activity without inducing hypercalcemia in mice. Endocrinology.
  • Patent No. 4,522,811 Serial injection of muramyldipeptides and liposomes enhances the anti-infective activity of muramyldipeptides Serial injection of muramyldipeptides and liposomes enhances the anti-infective activity of muramyldipeptides.
  • Garcion E., L. Sindji, S. Nataf, et al. 2003. Treatment of experimental autoimmune encephalomyelitis in rat by 1,25- dihydroxyvitamin D3 leads to early effects within the central nervous system. Acta Neuropathol (Berl) . 105:438-48. Gennaro, A.R. 2000. Remington: The science and practice of pharmacy. Lippincott, Williams & Wilkins, Philadelphia, PA.
  • Vitamin D amide derivatives Hesse, R., S. Setty, and M. Ramgopal. 1998b. US 5,786,347.
  • Vitamin D amine and amide derivatives Hesse, R., S. Setty, M. Ramgopal, et al. 1999. US 5,872,140.
  • Vitamin D analogues Hesse, R., S. Setty, M. Ramgopal, et al. 2000. US 6,013,814. Vitamin D analogues.
  • Copolymer 1 reduces relapse rate and improves disability in relapsing-remitting multiple sclerosis: results of a phase III multicenter, double-blind placebo- controlled trial.
  • Lamberg-Allardt CJ. , T.A. Outila, M.U. Karkkainen, et al. 2001. Vitamin D deficiency and bone health in healthy adults in
  • Vitamin D compounds and method of preparing these compounds.
  • Vitamin D derivatives with carbo- or heterocyclic substituents at C-25 a process for their production, intermediate products and their use for producing medicaments.
  • Vitamin D derivatives with carbo- or heterocyclic substituents at C-25 process for their production, intermediate products and use for the production of pharmaceutical agents.

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Abstract

This invention discloses a method of alleviating a symptom of multiple sclerosis in a human subject comprising administering to the human subject in need thereof a dose of a calciferol compound effective to alleviate the symptom of multiple sclerosis, alone or with another therapeutic agent.

Description

METHODS OF TREATING SYMPTOMS OF MULTIPLE SCLEROSIS USING VITAMIN D AND RELATED COMPOUNDS
Throughout this application, various references are referenced by the first named author in parenthesis. Full citations for these publications may be found listed in alphabetical order at the end of the specification immediately preceding the claims . The disclosures of these publications in their entireties are hereby incorporated by reference into this application in order to more fully describe the state of the art to which this invention pertains.
Background of the Invention Multiple sclerosis is one of the more common neurologic diseases in human adults. This condition is a chronic, inflammatory CNS disease characterized pathologically by demyelination. There are five main forms of multiple sclerosis: 1) benign multiple sclerosis; 2) relapsing- remitting multiple sclerosis (RR-MS); 3) secondary progressive multiple sclerosis (SP-MS); 4) primary progressive multiple sclerosis (PP-MS); and 5) progressive-relapsing multiple sclerosis (PR-MS) . Benign multiple sclerosis is characterized by 1-2 exacerbations with complete recovery, no lasting disability and no disease progression for 10-15 years after the initial onset. Benign multiple sclerosis may, however, progress into other forms of multiple sclerosis. Patients suffering from RR-MS experience sporadic exacerbations or relapses, as well as periods of remission. Lesions and evidence of axonal loss may or may not be visible on MRI for patients with RR-MS. SP-MS may evolve from RR-MS. Patients afflicted with SP-MS have relapses, a diminishing degree of recovery during remissions, less frequent remissions and more pronounced neurological deficits than RR-MS patients. Enlarged ventricles, which are markers for atrophy of the corpus callosum, midline center and spinal cord, are visible on MRI of patients with SP-MS. PP-MS is characterized by a steady progression of increasing neurological deficits without distinct attacks or remissions. Cerebral lesions, diffuse spinal cord damage and evidence of axonal loss are evident on the MRI of patients with PP-MS. PR-MS has periods of acute exacerbations while proceeding along a course of increasing neurological deficits without remissions. Lesions are evident on MRI of patients suffering from PR-MS (Multiple sclerosis: its diagnosis, symptoms, types and stages, 2003 <http://www.albany.net/~tjc/multiple-sclerosis .html>) .
Researchers have hypothesized that multiple sclerosis is an autoimmune disease (Compston; Hafler and Weiner; Olsson) . An autoimmune hypothesis is supported by the experimental allergic encephalomyelitis (EAE) model of multiple sclerosis, where the injection of certain myelin components into genetically susceptible animals leads to T cell-mediated CNS demyelination (Parkman) . Another theory regarding the pathogenesis of multiple sclerosis is that a virus, bacteria or other agent, precipitates an inflammatory response in the CNS, which leads to either direct or indirect ("bystander") myelin destruction, potentially with an induced autoimmune component (Lampert; Martyn) . Another experimental model of multiple sclerosis, Theiler' s murine encephalomyelitis virus (TMEV) (Dal Canto and Lipton; Rodriguez et al. ) , supports the theory that a foreign agent initiates multiple sclerosis. In the TMEV model, injection of the virus results in spinal cord demyelination.
Fatigue is a common symptom of multiple sclerosis (MS), occurring in 30%-90% of patients (Bergamaschi et al., 1997; Colosimo et al., 1995; Fisk et al., 1994a; Freal et al., 1984; Krupp et al., 1988; Krupp et al., 1989; Murray, 1985; Sandyk, 1996); for many MS victims, fatigue is the most disabling symptom (Comi et al., 2001; Fisk et al., 1994a) . For example, one survey found that 87% of MS patients reported fatigue; 67% reported being fatigued daily, and 22% stated that fatigue encumbered their daily functioning (Freal et al., 1984) . In another survey, 14% of MS patients cited fatigue as their worst symptom, while an additional 55% reported fatigue to be among their worst symptoms (Fisk et al., 1994a) . Fatigue in MS seems to worsen when there is active central nervous system inflammation (Metz et al., 2004) .
Glatiramer acetate (GA) , also known as Copolymer-1, is one of the known and approved treatments for multiple sclerosis (MS) . Daily subcutaneous injections of -A-
glatiramer acetate (20 mg/injection) reduce relapse rates, progression of disability, appearance of new lesions by magnetic resonance imaging (MRI) , (Johnson, K.P. et al. ) and appearance of "black holes" (Filippi, M. et al.) - COPAXONE® is the brand name for a formulation containing glatiramer acetate as the active ingredient. The recommended dosing schedule of COPAXONE® for relapsing-remitting multiple sclerosis is 20 mg per day injected subcutaneously (Physician's Desk Reference, 2003; see also U.S. Patent Nos . 3,849,550; 5,800,808; 5,858,964, 5,981,589; 6,048,898; 6,054,430; 6,214,791; 6,342,476; and 6,362,161) .
Recently, it has been suggested that lα,25- dihydroxycholecalciferol prevents the development of murine experimental autoimmune encephalomyelitis (EAE) , a model of multiple sclerosis (Cantorna, M.T., et al. ; Lemire, J.M and Archer, D.C.) . It has also been suggested that lα, 25-dihydroxycholecalciferol prevents the progression of murine EAE when administered after the induction of EAE (Cantorna, M.T., et al. ) .
However, whether lα,25-dihydroxycholecalciferol would have positive effects in a human subject afflicted with a form of multiple sclerosis, and what such effects may be, have not been investigated. Furthermore, lα,25- dihydroxycholecalciferol is one of the metabolites of calciferol (vitamin D) , which is now recognized as pre- pre-pre-hormone and is not a "true" vitamin. The interactions of therapeutic doses of such compounds with an approved multiple sclerosis treatment in a human subject are also unknown.
Summary of the Invention
The invention provides a method of alleviating a symptom of multiple sclerosis in a human subject comprising administering to the human subject in need thereof a dose of a calciferol compound effective to alleviate the symptom of multiple sclerosis.
The invention also provides a method of reducing the frequency of relapses in a human subject who is afflicted with relapsing-remitting multiple sclerosis comprising administering to the human subject a dose of glatiramer acetate and administering to the human subject a dose of alphacalcidol or calcitriol, wherein the dose of glatiramer acetate and the dose of alphacalcidol or calcitriol when taken together are effective to reduce the frequency of relapses in the human subject.
The subject invention also provides a method of reducing fatigue in a human subject who is afflicted with relapsing-remitting multiple sclerosis comprising administering to the human subject a dose of glatiramer acetate and administering to the human subject a dose of alphacalcidol or calcitriol, wherein the dose of glatiramer acetate and the dose of alphacalcidol or calcitriol when taken together are effective to reduce fatigue in the human subject. Brief Description of the Drawings
Figure 1 shows the relative changes (%) of Fatigue Impact Scale by treatment group - ITT population. Solid, placebo; white, treatment with alfacalcidol; *, adjusted for age; EDSS at baseline and MS treatment at study entry.
Figure 2 shows Fatigue Impact Scale improvement (at least one standard deviation) by treatment group - ITT population. Solid, placebo; white, treatment with alfacalcidol.
Figure 3 shows the percent (%) improvement of relapse rate per year in MS patients on MS therapy who received 1 μg of alphacalcidol per day. The annual relapse rate was calculated based on the number of relapses during a six month period adjusted for one year. The P value indicates the statistically significant different in relapses per year between the two treatment groups (active and placebo) .
Figure 4 shows the neurological score (mean + se) at days past immunization by GA alone, calcitriol alone and calcitriol together with glatiramer acetate of the EAE model in CSJL/F1 mice. Detailed Description of the Invention
The invention provides a method of alleviating a symptom of multiple sclerosis in a human subject comprising administering to the human subject in need thereof a dose of a calciferol compound effective to alleviate the symptom of multiple sclerosis.
In an embodiment, the symptom of multiple sclerosis may be fatigue.
In another embodiment, the symptom of multiple sclerosis may be frequency of relapses in a human subject afflicted with relapsing-remitting multiple sclerosis.
Alternatively, the symptom of multiple sclerosis may be the frequency of clinical exacerbation, the accumulation of physical disability, e.g. as measured on an EDSS scale, or lesions and axonal loss, e.g. as may be detected by MRI .
In any of the disclosed embodiments, the calciferol compound may be lα,25 dihydroxyvitamin D3; lα- hydroxyvitamin D3; lα, 25-dihydroxyvitamin D2; lα- hydroxyvitamin D2; lα, 25- (OH)2-16-ene-D3; lα,25- (OH) 2-24- oxo-16-ene-D3; lα, 24R(OH) 2-D3, ; lα, 25 (OH) 2-22-oxa-D3; 20- epi-22-oxa-24α, 24β, -dihomo-lα, 25 (OH) 2-D3; 20-epi-22-oxa- 24α,26α,27α,-trihomo-lα; 25 (OH) 2-D3, 20-epi-22-oxa- 24homo-lα, 25 (OH)2-D3; 1, 25- (OH) 2-16, 23E-diene-26- trifluoro-19-nor-D3; lα, 25-dihydroxy-16ene-vitamin D3; lα, 25-dihydroxy-24-oxo-16ene-vitamin D3; lα, 24R-dihydroxy- vitamin D3; lα, 25-dihydroxy-22-oxa-vitamin D3; 20-Epi-22- oxa-24a, 27, 27a-trihomo-lo(, 25-dihydroxy-vitamin D3; 19-nor- 1, 25-dihydroxy-vitamin D3; 1, 25-dihydroxy-16ene-vitamin D3; 20-Epi-22-oxa-24a, 27, 27a-trihomo-l, 25-dihydroxy- vitamin D3; 1, 25-dihydroxy-16, 23E-diene-26-trifluoro-19- nor-cholecalciferol; llα-vinyl-lα, 25-dihydroxy-vitamin D3; lα, 25-dihydroxy-16ene-23yne-vitamin D3; 24-homo-22- dehydro-22E-lα, 25-dihydroxy-vitamin D3; 1, 25-dihydroxy- 22ene-24-homo-vitamin D3; 2- (3-hydroxypropoxy) -1, 23- dihydroxy vitamin D3; LG190090; LG190119; LG190155; LG190176; or LG1900178. In an embodiment, the calciferol compound may be alphacalcidol or calcitriol.
In any of the disclosed embodiments, the human subject may have never received another compound for the alleviation of a symptom of multiple sclerosis.
In any of the disclosed embodiments, the human subject at the time of first administration of the calciferol compound may have been receiving another compound for the alleviation of a symptom of multiple sclerosis. In an embodiment, the human subject may have been receiving another compound for the alleviation of a symptom of multiple sclerosis for more than 4 weeks. In another embodiment, the other compound may be glatiramer acetate. In yet another embodiment, the dose of each of the calciferol compound when taken alone, and the dose of the other compound when taken alone, may be effective to alleviate the symptom of multiple sclerosis . In a further embodiment, the dose of the calciferol compound and the dose of the other compound, when administered to the same human subject may be effective to alleviate the symptom of multiple sclerosis.
The invention also provides a method of reducing the frequency of relapses in a human subject who is afflicted with relapsing-remitting multiple sclerosis comprising administering to the human subject a dose of glatiramer acetate and administering to the human subject a dose of alphacalcidol or calcitriol, wherein the dose of glatiramer acetate and the dose of alphacalcidol or calcitriol when administered to the same human subject- are effective to reduce the frequency of relapses in the human subject.
In an embodiment, the human subject may have never received glatiramer acetate treatment.
In another embodiment, the human subject may have been receiving glatiramer acetate treatment prior to administration of alphacalcidol or calcitriol, and the dose of alphacalcidol or calcitriol is effective to reduce the frequency of relapses experienced by the human subject during ongoing treatment with glatiramer acetate as compared with the frequency of relapses experienced by the human subject during treatment with glatiramer- acetate only. In an embodiment, the human subject may have been receiving glatiramer acetate treatment for more than four weeks. In any of the disclosed embodiments for reducing relapses, the dose of glatiramer acetate may be in the range from 10 to 600 mg/week; 80 to 600 mg/week; 100 to 550 mg/week; 20 to 150 mg/week; 150 to 500 mg/week; 200 to 450 mg/week; 250 to 400 mg/week; 300 to 350 mg/week; or 300 mg/week.
In any of the disclosed embodiments for reducing relapses, the dose of glatiramer acetate may be in the range from 10 to 80 mg/day; e.g. 12 to 70 mg/day; 14 to 60 mg/day; 16 to 50 mg/day; 18 to 40 mg/day; 19 to 30 mg/day; or 20 mg/day. In the alternative, the dose of glatiramer acetate may be in the range from 50 to 150 mg/day; or 60 to 140 mg/day; or 70 to 130 mg/day; or 80 to 120 mg/day; or 90 to 110 mg/day; or 100 mg/day.
In any of the disclosed embodiments for reducing relapses, the dose of alphacalcidol or calcitriol may be in the range of 3 μg to 80 mg/week; e.g. 4.5 μg to 40 mg/week; 4.5 μg to 25 mg/week; 3 μg to 10 mg/week; 3 μg to 1 mg/week; 3 μg to 500 μg/week; 5 μg to 100 μg/week; 5 μg to 50 μg/week; 5 μg to 10 μg/week; 6 μg to 8 μg/week; or 7 μg/week. In an embodiment, the dose is of caclitriol in the range of 5 μg to 10 μg/week.
In any of the disclosed embodiments for reducing relapses, the dose of alphacalcidol or calcitriol may be in the range of 0.5 μg to 10 mg/day; e.g. 0.05 μg to 5 mg/day; 0.05 μg to 3 mg/day; 1.0 μg to 3 mg/day; 1.0 μg to 1 mg/day; 2.5 μg to 1 mg/day; 0.5 μg to 500 μg/day; 0.5 μg to 100 μg/day; 5 μg to 100 μg/day; 5 μg to 50 μg/day; 0.5 μg to 3 μg/day; or 1 μg/day.
In any of the disclosed embodiments for reducing relapses, the amount of glatiramer acetate may be 10 to 80 mg; or 12 to 70 mg; or 14 to 60 mg; or 16 to 50 mg; or 18 to 40 mg; or 20 to 30 mg; or 20 mg.
In any of the disclosed embodiments for reducing relapses, for each amount of glatiramer acetate, the amount of alphacalcidol or calcitriol may be 0.1 mg to 10 mg; or 0.25 mg to 7.5 mg; or 0.5 mg to 5 mg; or 0.75 to 2.5 mg; or 1 mg to 1.5 mg; or 1 mg. Alternatively, for each amount of glatiramer acetate, the amount of alphacalcidol or calcitriol may be 0.01 μg to 5 μg; or 0.05 μg to 4 μg; or 0.1 μg to 3 μg; or 0.2 μg to 2 μg; or 0.25 μg to 1 μg; or 0.5 ug to 0.75 μg.
In any of the disclosed embodiments for reducing relapses, the dose administration of glatiramer acetate may be effected 3 to 11 days; or once every 5 to 9 days; or once every 7 days; once every 24 hours; twice daily; or once daily. When the administration is effected twice daily, the dose may be half the amount.
In any of the disclosed embodiments for reducing relapses, the administration of alphacalcidol or calcitriol may be effected once every 20 to 28 hours; once every 22 to 26 hours; once every 24 hours; or once daily. In an embodiment, the administration of alphacalcidol or calcitriol is in the morning. In the alternative, the administration of the glatiramer acetate substantially precedes the administration of alphacalcidol or calcitriol.
The glatiramer acetate and the alphacalcidol or calcitriol may be administered for a period of time of at least 4 days. For example, the period of time may be 5- days to' 5 years; or 10 days to 3 years; or 2 weeks to 1 year; or 1 month to 6 months; or 3 months to 4 months. Alternatively, the glatiramer acetate and the alphacalcidol or calcitriol may be administered for the lifetime of the subject.
In any of the disclosed embodiments for reducing relapses, the administration of the glatiramer acetate may be effected subcutaneously, intraperitoneally, intravenously, intramuscularly, intraocularly or orally; and the administration of the alphacalcidol or calcitriol may be effected orally. For example, the administration of the glatiramer acetate may be effected subcutaneously and the administration of the alphacalcidol or calcitriol- may be effected orally.
In any of the disclosed embodiments for reducing relapses, each of the dose of glatiramer acetate when taken alone, and the dose of alphacalcidol or calcitriol when taken alone may be effective to reduce the frequency of relapses in a human subject afflicted with relapsing- remitting multiple sclerosis. The subject invention also provides a method of reducing fatigue in a human subject who is afflicted with relapsing-remitting multiple sclerosis comprising administering to the human subject a dose of glatiramer acetate and administering to the human subject a dose of alphacalcidol or calcitriol, wherein the dose of glatiramer acetate and the dose of alphacalcidol or calcitriol when administered to the same human subject are effective to reduce fatigue in the human subject.
In an embodiment, the human subject may have never received glatiramer acetate treatment.
In any of the disclosed embodiments for treating fatigue, the human subject may have been receiving glatiramer acetate treatment prior to administration of alphacalcidol or calcitriol, and the dose of alphacalcidol or calcitriol may be effective to reduce the fatigue experienced by the human subject during ongoing treatment with glatiramer acetate as compared with the fatigue experienced by the human subject during treatment with glatiramer acetate only. In an embodiment, the human subject has been receiving glatiramer acetate treatment for more than 4 weeks .
Alternatively, the dose of glatiramer acetate may be in the range from 10 to 600 mg/week; 80 to 600 mg/week; 100 to 550 'mg/week; 20 to 150 mg/week; 150 to 500 mg/week; 200 to 450 mg/week; 250 to 400 mg/week; 300 to 350 mg/week; or 300 mg/week. Alternatively, the dose of glatiramer acetate may be in the range from 10 to 8,0 mg/day; e.g. 12 to 70 mg/day; 14 to 60 mg/day; 16 to 50 mg/day; 18 to 40 mg/day; 19 to 30 mg/day; or 20 mg/day. In the alternative, the dose of glatiramer acetate may be in the range from 50 to 150 mg/day; or 60 to 140 mg/day; or 70 to 130 mg/day; or 80 to 120 mg/day; or 90 to 110 mg/day; or 100 mg/day.
In any of the disclosed embodiments to treat fatigue, the dose of alphacalcidol or calcitriol may be in the range from 3 μg to 80 mg/week; e.g. 4.5 μg to 40 mg/week; 4.5 μg to 25 mg/week; 3 μg to 10 mg/week; 3 μg to 1 mg/week; 3 μg to 500 μg/week; 5 μg to 100 μg/week; 5 μg to 50 μg/week; 5 μg to 10 μg/week; 6 μg to 8 μg/week; or 7 μg/week. In an embodiment, the dose is of calcitriol in the range of 5 μg to 10 μg/week.
In any of the disclosed embodiments to treat fatigue, the dose of alphacalcidol or calcitriol may be in the range of 0.5 μg to 10 mg/day; e.g. .05 μg to 5 mg/day; .05 μg to 3 mg/day; 1.0 μg to 3 mg/day; 1.0 μg to 1 mg/day; 2.5 μg to 1 mg/day; .5 μg to 500 μg/day; .5 μg to 100 μg/day; 5 μg to 100 μg/day; 5 μg to 50 μg/day; .5 μg to 3 μg/day; or 1 μg/day.
In any of the disclosed embodiments to treat fatigue, the amount of glatiramer acetate may be 10 to 80 mg; or 12 to 70 mg; or 14 to 60 mg; or 16 to 50 mg; or 18 to 40 mg; or 20 to 30 mg; or 20 mg. In any of the disclosed embodiments to treat fatigue, for each amount of glatiramer acetate, the amount of alphacalcidol or calcitriol may be 0.1 mg to 10 mg; or 0.25 mg to 7.5 mg; or 0.5 mg to 5 mg; or 0.75 to 2.5 mg; or 1 mg to 1.5 mg; or 1 mg. Alternatively, for each amount of glatiramer acetate, the amount of alphacalcidol or calcitriol may be 0.01 μg to 5 μg; or 0.05 μg to 4 μg; or 0.1 μg to 3 μg; or 0.2 μg to 2 μg; or 0.25 μg to 1 μg; or 0.5 ug to .75 μg.
In one embodiment, the administration of glatiramer acetate is effected daily or, in the alternative, twice daily. When the administration is effected twice daily, the dose may be half the amount.
In an additional embodiment, the administration of glatiramer acetate is effected once every 3 to 11 days; or once every 5 to 9 days; or once every 7 days; once every 24 hours; or once every 24 hours.
In a further embodiment, the administration of alphacalcidol or calcitriol is effected once every 20 to 28 hours; once every 22 to 26 hours; once every 24 hours; or once daily. In an embodiment, the administration of alphacalcidol or calcitriol is in the morning. In the alternative, the administration of the glatiramer acetate substantially precedes. the administration of alphacalcidol. Alternatively, the glatiramer acetate and the alphacalcidol or calcitriol may be administered for a period of time of at least 4 days . In a further embodiment, the period of time may be 5 days to 5 years; or 10 days to 3 years; or 2 weeks to 1 year; or 1 month to 6 months; or 3 months to 4 months. In yet another embodiment, the glatiramer acetate and the alphacalcidol or calcitriol may be administered for the lifetime of the subject.
In any disclosed embodiment to treat fatigue, the administration of the glatiramer acetate may be effected subcutaneously, intraperitoneally, intravenously, intramuscularly, intraocularly or orally and the administration of the alphacalcidol or calcitriol may be effected orally. For example, the administration of the glatiramer acetate is effected subcutaneously and the administration of the alphacalcidol or calcitriol is effected orally.
In any disclosed embodiment to treat fatigue, each of the dose of glatiramer acetate when taken alone, and the dose of alphacalcidol or calcitriol when taken alone may be effective to reduce fatigue in a human subject afflicted with relapsing-remitting multiple sclerosis.
In the alternative, either the dose of glatiramer acetate when taken alone, the dose of calcitriol when taken alone or each such dose when taken alone may not be effective to reduce the frequency of relapses in a patient afflicted with relapsing-remitting multiple sclerosis .
This invention also provides a product containing glatiramer acetate and at least one of alphacalcidol or calcitriol as a combined preparation for simultaneous, separate, or sequential use for reducing fatigue in a human subject afflicted with relapsing-remitting multiple sclerosis .
This invention also provides for the use of glatiramer acetate and at least one of alphacalcidol or calcitriol for the manufacture of a medicament for use in reducing fatigue in a human subject who is afflicted with relapsing-remitting multiple sclerosis but who has never received glatiramer acetate treatment.
This invention further provides for the use of alphacalcidol or calcitriol for the manufacture of a medicament for use in reducing fatigue in a human subject afflicted with relapsing-remitting multiple sclerosis and already receiving glatiramer acetate treatment. In an embodiment, the human subject may have already receiving glatiramer acetate treatment for more than 4 weeks .
This invention also provides a use of alphacalcidol or calcitriol for the manufacture of a medicament for use in reducing fatigue in a human subject afflicted with relapsing-remitting multiple sclerosis and already receiving glatiramer acetate treatment. In an embodiment, the human subject may have already been receiving glatiramer acetate treatment for more than 4 weeks.
The invention also provides a product containing glatiramer acetate and at least one of alphacalcidol or calcitriol as a combined preparation for simultaneous, separate or sequential use for reducing the frequency of relapses in a human subject afflicted with relapsing- remitting multiple sclerosis.
The invention further provides a use of alphacalcidol or calcitriol for the manufacture of a medicament for use in reducing the frequency of relapses in a human subject who is afflicted with relapsing-remitting multiple sclerosis but who has never received glatiramer acetate treatment.
The invention also provides a use of glatiramer acetate and at least one of alphacalcidol or calcitriol for the manufacture of a medicament for use in reducing the frequency of relapses in a human subject afflicted with relapsing-remitting multiple sclerosis and already receiving glatiramer acetate treatment. In an embodiment, the human subject may have already been receiving glatiramer acetate treatment for more than 4 weeks .
The subject invention provides a pharmaceutical composition comprising an amount of glatiramer acetate and an amount of calcitriol, wherein the amounts when taken together are effective to alleviate a symptom of a form of multiple sclerosis in a subject. In an embodiment, each of the amount of glatiramer acetate when taken alone and the amount of calcitriol when taken alone is effective to alleviate the symptom of multiple sclerosis. In another embodiment, either of the amount of glatiramer acetate when taken alone, or the amount of calcitriol when taken alone or each such amount when taken alone is not effective to alleviate the symptom of multiple sclerosis.
The subject invention provides a product containing glatiramer acetate and calcitriol as a combined preparation for simultaneous, separate or sequential use in treating a form of multiple sclerosis.
The subject invention further provides a product containing glatiramer acetate and calcitriol as a combined preparation for simultaneous, separate or sequential use in alleviating a symptom of a form of multiple sclerosis.
This invention also provides a method of treating fatigue in a subject comprising administering a sufficient amount of at least one biologically active calciferol compound, wherein the administering of the at least one calciferol compound decreases fatigue.
In an embodiment, the at least one calciferol compound is selected from the group consisting of calciferol, 1,25 dihydroxyvitamin D3, alfacalcidol, 1, 25-dihydroxyvitamin D2, lα-hydroxyvitamin D2, lα, 25- (OH) 2-16-ene-D3, lα,25- (OH)2-24-oxo-16-ene-D3, lα, 24R(OH) 2-D3, lα, 25 (OH) 2-22-oxa- D3, 20-epi-22-oxa-24α,24β,-dihomo-lα, 25 (OH)2-D3, 20-epi- 22-oxa-24α,26α,27α,'-trihomo-lα, 25 (OH) 2-D3, 20-epi-22- oxa-24homo-lα, 25 (OH)2-D3, 1, 25- (OH) 2-16, 23E-diene-26- trifluoro-19-nor-D3, analogs thereof and non-secosteroidal calciferol mimics. In another embodiment, the at least one calciferol compound is alphacalcidol.
In a further embodiment, the subject also suffers from a chronic condition.
In yet another embodiment, the at least one calciferol comopound is administered at a dose equivalent to at least 1 μg of alphacalcidol per day.
In an embodiment, the calciferol compound is administered orally, parentally, or transdermally.
In an embodiment wherein the administration is oral, in another embodiment, the calciferol compound is formulated with arachis oil.
In another embodiment, at least one clinical tool is used to determine the decrease in fatigue. In an embodiment, the clinical tool is selected from the group consisting of Fatigue Impact Scale and The Quality of Life RAYS Questionnaire. In another embodiment, the clinical tool is presented in Table 1 or Table 2.
In an embodiment, at least one additional therapeutic compound is co-administered. In an embodiment, the at least one additional compound is selected from the group consisting of interferon βl-a, interferon βl-b, glatiramer acetate, mitoxantrone and natalizumab. In another embodiment, the at least one additional compound is selected from the group consisting of prednisolone, triamcinolone, dexamethasone, naproxen, sulindac, diclofenac, piroxicam, ketoprofen, diflunisal, nabumetone, etodolac, oxaprozin, indomethacin, celecoxib, rofecoxib, hydroxychloroquine sulfate, chloroquine, cyclophosphamide, azathioprine, chlorambucil, piroxicam and steroids.
In another embodiment, the blood calcium levels are monitored and the administration of the calciferol compound is adjusted to avoid hypercalcemia.
This invention provides a method of treating fatigue in a subject comprising administering in a continuous manner a composition comprising a sufficient amount of at least one biologically active calciferol compound, wherein the administering of at least one calciferol compound decreases the fatigue.
In an embodiment, the calciferol compound comprises at least one compound selected from the group consisting of calciferol, 1,25 dihydroxyvitamin D3, alfacalcidol, 1,25- dihydroxyvitamin D2, lα-hydroxyvitamin D2, lα, 25- (OH) 2-16- ene-D3, lα, 25- (OH) 2-24-oxo-16-ene-D3, lα, 24R(OH) 2-D3, lα, 25 (OH) 2-22-oxa-D3, 20-epi-22-oxa-24α, 24β, -dihomo- lα, 25 (OH)2-D3, 20-epi-22-oxa-24α,26α,27α,-trihomo-lα, 25 (OH) 2-D3, 20-epi-22-oxa-24homo-lα,25(OH)2-D3, 1, 25- (OH)2- 16,23E-diene-26-trifluoro-19-nor-D3, lα, 25-dihydroxy- 16ene-vitamin D3; lα,25-dihydroxy-24-oxo-16ene-vitamin D3; lα, 24R-dihydroxy-vitamin D3; lα, 25-dihydroxy-22-oxa- vitamin D3; 20-Epi-22-oxa-24a, 27, 27a-trihomo-lα, 25- dihydroxy-vitamin D3; 19-nor-l, 25-dihydroxy-vitamin D3 ; 1, 25-dihydroxy-16ene-vitamin D3; 20-Epi-22-oxa-24a, 27, 27a- trihomo-1, 25-dihydroxy-vitamin D3; 1, 25-dihydroxy-16, 23E- diene-26-trifluoro-19-nor-cholecalciferol; 1lex-vinyl- lex, 25-dihydroxy-vitamin D3; lex, 25-dihydroxy-16ene-23yne- vitamin D3; 24-homo-22-dehydro-22E-lα, 25-dihydroxy-vitamin D3; 1, 25-dihydroxy-22ene-24-homo-vitamin D3; 2- (3- hydroxypropoxy) -1, 23-dihydroxy vitamin D3; LG190090, LG190119, LG190155, LG190176 and LG1900178, analogs thereof and non-secosteroidal calciferol mimics.
In another embodiment, the calciferol compound is alphacalciferol.
In a further embodiment, the subject suffers from a chronic condition. In yet another embodiment, the calciferol compound is administered at a dose equivalent to at least 1 μg of alphacalcidol per day. , In an embodiment the calciferol compound is administered orally, parenterally or transdermally.
In another embodiment, at least one clinical tool is used to determine the decrease in fatigue. In an embodiment, the clinical tool is selected from the group consisting of Fatigue Impact Scale and The Quality of Life RAYS Questionnaire. In another embodiment, the clinical tool is that presented in Table 1 or Table 2.
In the embodiment wherein the administration is oral, in another embodiment, the calciferol compound is formulated with arachis oil. In another embodiment, the calciferol compound is a timed-release formulation.
In an embodiment, at least one additional compound is co¬ administered. In an embodiment, the at least one additional compound is selected from the group consisting of interferon βl-a, interferon βl-b, glatiramer acetate, mitoxantrone and natalizumab. In another embodiment, the at least one additional compound is selected from the group consisting of prednisone, prednisolone, triamcinolone, dexamethasone, naproxen, sulindac, diclofenac, piroxicam, ketoprofen, diflunisal, nabumetone, etodolac, oxaprozin, indomethacin, celecoxib, rofecoxib, hydroxychloroquine sulfate, chloroquine, cyclophosphamide, azathioprine, chlorambucil, piroxicam and steroids.
In the embodiment wherein the administration of calciferol is oral, in another embodiment, blood calcium levels are monitored and the administration of the calciferol is adjusted to avoid hyper calcalcemia.
This invention further provides a method of treating fatigue in a subject comprising administering a composition comprising a sufficient amount of at least one biologically active calciferol compound, wherein the administering of the composition does not correlate with a spike in blood calcium levels; and wherein the administering of at least one calciferol compound decreases fatigue. In one embodiment, the calciferol compound comprises at least one selected - from the group consisting of calciferol, 1,25 dihydroxyvitamin D3, alfacalcidol, 1,25- dihydroxyvitamin D2, lα-hydroxyvitamin D2, lα, 25- (OH) 2-16- ene-D3, lα, 25- (OH) 2-24-oxo-16-ene-D3, lα, 24R(OH) 2-D3, lα, 25 (OH) 2~22-oxa-D3, 20-epi-22-oxa-24α, 24β, -dihomo- lα, 25 (OH)2-D3, 20-epi-22-oxa-24α, 26α, 27α, -trihomo-lα, 25 (OH) 2-D3, 20-epi-22-oxa-24homo-lα, 25 (OH)2-D3, 1, 25- (OH)2- 16, 23E-diene-26-trifluoro-19-nor-D3, lα, 25-dihydroxy- 16ene-vitamin D3; lα, 25-dihydroxy-24-oxo-16ene-vitamin D3; lα, 24R-dihydroxy-vitamin D3; lα, 25-dihydroxy-22-oxa- vitamin D3; 20-Epi-22-oxa-24a, 27, 27a-trihomo-lo:, 25- dihydroxy-vitamin D3; 19-nor-l, 25-dihydroxy-vitamin D3 ; 1, 25-dihydroxy-16ene-vitamin D3; 20-Epi-22-oxa-24a, 27, 27a- trihomo-1, 25-dihydroxy-vitamin D3; 1,25-dihydroxy-16,23E- diene-26-trifluoro-19-nor-cholecalciferol; 1lα-vinyl- lα, 25-dihydroxy-vitamin D3; lα, 25-dihydroxy-lβene-23yne- vitamin D3; 24-homo-22-dehydro-22E-lα, 25-dihydroxy-vitamin D3; 1, 25-dihydroxy-22ene-24-homo-vitamin D3; 2-(3- hydroxypropoxy) -1, 23-dihydroxy vitamin D3; LG190090, LG190119, LG190155, LG190176 and LG1900178, analogs thereof and non-secosteroidal calciferol mimics .
In another embodiment, the calciferol compound comprises alphacalcidol.
In a further embodiment, the subject suffers from a chronic condition. In an embodiment, the calciferol compound is administered at a dose equivalent to at least 1 μg of alphacalcidol per day.
In a further embodiment, the calciferol compound is administered orally, parenterally or transdermally.
In another embodiment, at least one clinical tool is used ■ to determine the decrease in fatigue.
In the embodiment that comprises using a clinical too to determine the decrease in fatigue, another embodiment wherein, the clinical tool is selected from the group consisting of Fatigue Impact Scale and The Quality of Life RAYS Questionnaire. In another embodiment, the clinical tool is presented in Table 1 or Table 2.
In the embodiment wherein the administration is oral, another embodiment wherein, the administration is oral and the calciferol compound is formulated with arachis oil. In another embodiment, the administration is oral and the calciferol compound is a timed-release formulation.
In an embodiment, at least one additional therapeutic compound is co-administered. In an embodiment, the at least one additional compound is selected from the group consisting of interferon βl-a, interferon βl-b, glatiramer acetate, mitoxantrone and natalizumab. In another embodiment, the at least one additional compound is selected from the group consisting of prednisone, prednisolone, triamcinolone, dexamethasone, naproxen, sulindac, diclofenac, piroxicam, ketoprofen, diflunisal, nabumetone, etodolac, oxaprozin, indomethacin, celecoxib, rofecoxib, hydroxychloroquine sulfate, chloroquine, cyclophosphamide, azathioprine, chlorambucil, piroxicam and steroids.
In another embodiment, blood calcium levels are monitored and the administration of the calciferol is adjusted to avoid hypercalcemia.
This invention also provides a method of preventing fatigue in a subject comprising administering a sufficient amount of at least one biologically active calciferol compound, wherein the administering of the at least one calciferol compound prevents or delays the onset of fatigue.
In an embodiment, at least one calciferol compound is seleceted from the group consisting of calciferol, 1,25 dihydroxyvitamin D3, alfacalcidol, 1, 25-dihydroxyvitamin D2, lα-hydroxyvitamin D2, lα, 25- (OH)2-16-ene-D3, lα,25- (OH)2-24-oxo-16-ene-D3, lα, 24R(OH) 2-D3, lα, 25 (OH) 2-22-oxa- D3, 20-epi-22-oxa-24α,24β,-dihomo-lα,25 (OH)2-D3, 20-epi- 22-oxa-24α,26α,27α,-trihomo-lα, 25 (OH) 2-D3, 20-epi-22- oxa-24homo-lα,25 (OH)2-D3, 1,25- (OH) 2-16, 23E-diene-26- trifluoro-19-nor-D3, lα, 25-dihydroxy-16ene-vitamin D3; lα, 25-dihydroxy-24-oxo-16ene-vitamin D3; lα, 24R-dihydroxy- vitamin D3; lα, 25-dihydroxy-22-oxa-vitamin D3; 20-Epi-22- oxa-24a, 27, 27a-trihomo-lα, 25-dihydroxy-vitamin D3; 19-nor- 1, 25-dihydroxy-vitamin D3 ; 1, 25-dihydroxy-16ene-vitamin D3; 20-Epi-22-oxa-24a, 27, 27a-trihomo-l, 25-dihydroxy- vitamin D3; l,25~dihydroxy-16,23E-diene-26-trifluo'ro-19- nor-cholecalciferol; llα-vinyl-lα, 25-dihydroxy-vitamin D3; lα, 25-dihydroxy-16ene-23yne-vitamin D3; 24-homo-22- dehydro-22E-lα, 25-dihydroxy-vitamin D3; 1, 25-dihydroxy- 22ene-24-homo-vitamin D3; 2- (3-hydroxypropoxy) -1, 23- dihydroxy vitamin D3; LG190090, LG190119, LG190155, LG190176 and LG1900178, analogs thereof and non- secosteroidal calciferol mimics.
In another embodiment, the at least one calciferol compound is alphacalcidol.
In a further embodiment, the subject also suffers from a chronic condition.
In yet another embodiment, the at least one calciferol compound is administered at a dose equivalent to at least 1 μg of alphacalcidol per day.
In an embodiment, the calciferol is administered orally, parentally, or transdermally. In an embodiment, at least on clinical tool is used to determine the decrease in fatigue.
In an embodiment, the clinical tool is selected from the group consisting of Fatigue Impact Scale and The Quality of Life 1RAYS Questionnaire. In another embodiment, the clinical tool is that presented in Table 1 or Table 2. In an embodiment wherein the administration is oral, the calciferol compound is formulated with arachis oil.
In another embodiment wherein the administration is oral, the calciferol compound is a timed-release formulation.
In an embodiment, at least one additional therapeutic compound is co-administered. In an embodiment, the at least one additional compound is selected from the group consisting of interferon βl~a, interferon βl-b, glatiramer acetate, mitoxantrone and natalizumab. In another embodiment, the at least one additional compound is selected from the group consisting of prednisone, prednisolone, triamcinolone, dexamethasone, naproxen, sulindac, diclofenac, piroxicam, ketoprofen, diflunisal, nabumetone, etodolac, oxaprozin, indomethacin, celecoxib, rofecoxib, hydroxychloroquine sulfate, chloroquine, cyclophosphamide, azathioprine, chlorambucil, piroxicam and steroids.
In a further embodiment, blood calcium levels are monitored and the administration of the calciferol compound is adjusted to avoid hypercalcemia.
This invention further provides for a kit comprising at least one biologically active calciferol compound and instructions for administering the calciferol compound to treat fatigue, wherein the calciferol compound decreases fatigue . In an embodiment, the at least one biologically active calciferol compound is one selected from the group consisting of calciferol, 1,25 dihydroxyvitamin D3, alfacalcidol, 1, 25-dihydroxyvitamin D2, lα-hydroxyvitamin D2, lα,25- (OH)2-16-ene-D3, lα,25- (OH)2-24-oxo-16-ene-D3, lα, 24R(OH)2-D3, lα, 25 (OH) 2-22-oxa-D3, 20-epi-22-oxa- 24α, 24β, -dihoruo-lα, 25 (OH) 2-D3, 20-epi-22-oxa-24α, 26α, 27α, - trihomo-lα, 25 (OH) 2-D3, 20-epi-22-oxa-24homo-lα, 25 (OH) 2- D3, 1,25- (OH) 2-16,23E-diene-26-trifluoro-19-nor-D3, lα,25- dihydroxy-16ene-vitamin D3; lα,25-dihydroxy-24-oxo-16ene- vitamin D3; lα, 24R-dihydroxy-vitamin D3; lα, 25-dihydroxy- 22-oxa-vitamin D3; 20-Epi-22-oxa-24a, 27,27a-trihomo-lα, 25- dihydroxy-vitamin D3; 19-nor-l, 25-dihydroxy-vitamin D3 ; l,25-dihydroxy-16ene-vitamin D3; 20-Epi-22-oxa-24a, 27, 27a- trihomo-1, 25-dihydroxy-vitamin D3; 1, 25-dihydroxy-16, 23E- diene-26-trifluoro-19-nor-cholecalciferol; llα-vinyl- lα, 25-dihydroxy-vitamin D3; lα, 25-dihydroxy-16ene-23yne- vitamin D3; 24-homo-22-dehydro-22E-lα, 25-dihydroxy-vitamin D3; 1, 25-dihydroxy-22ene~24-homo-vitamin D3; 2-(3- hydroxypropoxy) -1, 23-dihydroxy vitamin D3; LG190090, LG190119, LG190155, LG190176 and LG1900178, analogs thereof and non-secosteroidal calciferol mimics.
In another embodiment, the calciferol compound is alphacalcidol.
In a further embodiment, the calciferol compound is formulated with arachis oil. In yet another embodiment, the calciferol compound is supplied for oral, injection, or transdermal administration.
In an embodiment, the calciferol compound is supplied as a capsule, a pill, a mouthwash, an injectable composition in a syringe or a patch.
In another embodiment, a means for monitoring blood calcium levels.
In a further embodiment, a means for monitoring blood calciferol levels.
This invention also provides for a method of preventing fatigue and treating a chronic condition in a subject comprising: administering a sufficient amount of at least one biologically active calciferol compound, and' administering a sufficient amount of at least one therapeutic agent; wherein the administering of the calciferol compound decreases the fatigue and the therapeutic agent reduces the symptoms of the chronic condition.
In an embodiment, the calciferol compound comprises at least one selected from the group consisting of calciferol, 1,25 dihydroxyvitamin D3, alfacalcidol, 1,25- dihydroxyvitamin D2, lα-hydroxyvitamin D2, lα, 25- (OH) 2-16- ene-D3, lα, 25- (OH) 2-24-oxo-16-ene-D3, lα, 24R(OH) 2~D3, lα, 25 (OH) 2-22-oxa-D3, 20-epi-22-oxa-24α, 24β, -dihomo- lα, 25 (OH)2-D3, 20-epi-22-oxa-24α, 26α, 27α, -trihomo-lα, 25
(OH) 2-D3, 20-epi-22-oxa-24homo-lα, 25 (OH)2-D3, 1, 25- (OH)2-
16, 23E-diene-26-triflubro-19-nor-D3, lα, 25-dihydroxy-
16ene-vitamin D3; lα, 25-dihydroxy-24-oxo-16ene-vitamin D3; lα, 24R-dihydroxy-vitamin D3; lα, 25-dihydroxy-22~oxa- vitamin D3; 20-Epi-22-oxa-24a, 27, 27a-trihomo-lα, 25- dihydroxy-vitamin D3; 19-nor-l, 25-dihydroxy-vitamin D3 ; l,25-dihydroxy-16ene-vitamin D3; 20-Epi-22-oxa-24a, 27, 27a- trihomo-1, 25-dihydroxy-vitamin D3; 1, 25-dihydroxy-16, 23E- diene-26-trifluoro-19-nor-cholecalciferol; llα-vinyl- lα, 25-dihydroxy-vitamin D3; lα, 25-dihydroxy-16ene-23yne- vitamin D3; 24-homo-22-dehydro-22E-lα,25-dihydroxy-vitamin D3; 1, 25-dihydroxy-22ene-24-homo-vitamin D3; 2-(3- hydroxypropoxy) -1, 23-dihydroxy vitamin D3; LG190090, LG190119, LG190155, LG190176 and LG1900178, analogs thereof and non-secosteroidal calciferol mimics.
In another embodiment, the calciferol compound comprises alphacalcidol .
In a further embodiment, a clinical tool is used to assess fatigue. In an embodiment, the clinical tool is selected from the group consisting of Fatigue Impact Scale and the Quality of Life RAYS Questionnaire. In another embodiment, the clinical tool is that presented in Table 1 or Table 2.
This invention provides for the use of a sufficient amount of at least one biologically active calciferol compound administered to a subject suffering from fatigue, wherein the administering of the at least one calciferol compound decreases fatigue.
This invention also provides for the use of a composition comprising a sufficient amount of at least one biologically active calciferol compound that is administered in a continuous manner to a subject suffering from fatigue, wherein the administering of the at least one calciferol compound decreases fatigue.
This invention further provides for the use of a sufficient amount of at least one biologically active calciferol compound administered to a subject suffering from fatigue, wherein the administering of the composition does not correlate with a spike in blood calcium levels; and wherein the administering of the at least one calciferol compound decreases fatigue.
This invention also provides for the use of a sufficient amount of at least one biologically active calciferol compound to prevent fatigue in a subject, wherein the administering of the at least one calciferol compound prevents or delays the onset of fatigue.
This invention further provides for the use of a- sufficient amount of at least one biologically active calciferol compound to prevent fatigue and treat a chronic condition in a subject, comprising: administering a sufficient amount of at least one biologically active calciferol compound, and administering a sufficient amount of at least one therapeutic agent; wherein the administering of the calciferol compound decreases fatigue and the therapeutic agent reduces the symptoms of the chronic condition.
In one embodiment of these uses, the at least one calciferol compound is selected from the group consisting of calciferol, 1,25 dihydroxyvitamin D3, alfacalcidol, 1, 25-dihydroxyvitamin D2, lα-hydroxyvitamin D2, lα,25- (OH)2-16-ene-D3, lα, 25- (OH) 2-24-oxo-16-ene-D3, lα, 24R(OH)2- D3, lα, 25 (OH) 2-22-oxa-D3, 20-epi-22-oxa-24α,24β, -dihomo- lα, 25 (OH)2-D3, 20-epi-22-oxa-24α, 26α, 27α, -trihomo-lα, 25 (OH) 2-D3, 20-epi-22-oxa-24homo-lα, 25 (OH)2-D3, 1, 25- (OH)2- 16, 23E-diene-26-trifluoro-19-nor-D3, lα,25-dihydroxy- 16ene-vitamin D3; lα, 25-dihydroxy-24-oxo-16ene-vitamin D3;' lα, 24R-dihydroxy-vitamin D3; lα, 25-dihydroxy-22-oxa- vitamin D3; 20-Epi-22-oxa-24a, 27,27a-trihomo-lα, 25- dihydroxy-vitamin D3; 19-nor-l, 25-dihydroxy-vitamin D3 ; l,25-dihydroxy-16ene-vitamin D3; 20-Epi-22-oxa-24a, 27, 27a- trihomo-1, 25~dihydroxy-vitamin D3; 1,25-dihydroxy-16, 23E- diene-26-trifluoro-19-nor-cholecalciferol; 1lα-vinyl- lα, 25-dihydroxy-vitamin D3; lα, 25-dihydroxy-16ene-23yne- vitamin D3; 24-homo-22-dehydro-22E-lα, 25-dihydroxy-vitamin D3; 1, 25-dihydroxy-22ene-24-homo-vitamin D3; 2-(3- hydroxypropoxy) -1, 23-dihydroxy vitamin D3; LG190090, LG190119, LG190155, LG190176 and LG1900178, analogs thereof and non-secosteroidal calciferol mimics.
In another embodiment of these uses, the at least one- calciferol compound is alphacalcidol. In a further embodiment of these uses, the subject also suffers from a chronic- condition.
In another embodiment of these uses, the at least one calciferol compound is administered at a dose equivalent to at least 1 μg of alphacalcidol per day.
In a further embodiment of these uses, the calciferol compound is administered orally, parentally, or transdermally.
In another embodiment of these uses, at least one clinical tool is used to determine the decrease in fatigue. In one embodiment, the clinical tool is selected from the group consisting of Fatigue Impact Scale and The Quality of Life RAYS Questionnaire. In another embodiment, the clinical tool is that presented' in Table 1 or Table 2.
In the embodiment wherein the administration is oral, in another embodiment, the calciferol compound is formulated with arachis oil.
In another embodiment of these uses, at least one additional therapeutic compound is co-administered. In an embodiment, the at least one additional compound is selected from the group consisting of interferon βl-a, interferon βl-b, glatiramer acetate, mitoxantrone and natalizumab. In another embodiment, the at least one additional compound is selected from the group consisting of prednisone, prednisolone, triamcinolone, dexamethasone, naproxen, sulindac, diclofenac, piroxicam, ketoprofen, diflunisaϊ, nabumetone, etodolac, oxaprozin, indomethacin, celecoxib, rofecoxib, hydroxychloroquine sulfate, chloroquine, cyclophosphamide, azathioprine, chlorambucil, piroxicam and steroids.
In a further embodiment of these uses, blood calcium levels are monitored and administration of the calciferol compound is adjusted to avoid hypercalcemia.
The methods of the invention provide effective and reproducible therapies for the treatment of fatigue. The methods are especially effective in treating people who suffer from chronic conditions, such as multiple sclerosis .
Treatment and dosage
A broad range of dosages for the therapeutic administration of the biologically active calciferol' compounds are contemplated. A preferred dose of the biologically active calciferol compound is up to the maximum that a patient can tolerate and not develop serious hypercalcemia. If the biologically active calciferol compound is not a lα-hydroxy compound, a daily dose between 0.1 and 250 μg (approximately 0.8 to 2000 IU) per day is administered, while a particularly advantageous daily dose is between 5.0 and 100 μg per day. A particularly preferred dose is 1 μg per day. If the biologically active calciferol compound is a lα- hydroxy compound, a daily dose of between 0.1 and 20 μg per day is administered, while a preferred dose is between 0.5 and 10 'μg per day. In a particularly preferred embodiment, the dose is between 3-10 μg per day. The dose may be divided between two, three, four or five treatments within a twenty-four-hour period, or may be administered once daily. A preferred dose is equivalent to the effect of 1 μg of alfacalcidol administered orally and once daily. Patients on a low calcium diet, and/or if the compounds are administered at night, may tolerate more per day, and in fact, will probably require more to maintain overall health (Vieth, 1999) .
Alfacalcidol, a precursor of calcitriol (1,25 dihydroxycalciferol) , is a biologically active calciferol compound. From calciferol, calcitriol is synthesized in two steps: hepatic 25-hydroxylation and renal 1-α hydroxylation. Alfacalcidol administration saves the renal step hydroxylation and yields calcitriol in the single step of hepatic hydroxylation. The administration of alfacalcidol results in an improved pharmacokinetic profile of the produced calcitriol as it avoids the dangerous spikes that can result from direct calcitriol administration.
The specific dose level and frequency of dosage for any- particular patient may be varied and depends upon a variety of factors, including the activity of the specific compound employed, the metabolic stability and length of action of that compound, the age, body weight, general health, sex, diet, mode and time of administration, rate of excretion, drug combination, the severity of the particular condition, and the host undergoing therapy. In any case, calciferol and calcium levels in the circulation can be measured to determine if dosage should be adjusted. For example, if calcium levels are high after the commencement of calciferol therapy, calciferol dosages should be decreased, or the calcium levels treated with other therapies. If calciferol levels are low, even though the dose is high, and calcium levels are low, then the dosage should be raised or administered via another route.
Alternatively, the biologically active calciferol compound can be administered in pulses of high doses. For example, calcitriol administered at 0.5 μg/kg once weekly avoids hypercalcemic effects (Beer et al., 2001) .
Biologically active calciferol compounds can be co¬ administered with other pharmaceutically active compounds, especially those used to treat Addison Disease, anemia, cancer and AIDS, congestive heart failure, dehydration, depression, fibromyalgia, jet lag, kidney failure, multiple sclerosis, myasthenia gravis, stress, systemic lupus erythematosus and vasculitis. For example, interferon βl-a (AVONEX®, REBIF®) interferon βl- b (BETASERON®) glatiramer acetate (COPAXONE®) , mitoxantrone (NOVANTRONE®) , prednisone, prednisolone, triamcinolone (ARISTOCORT®, KENACORT®) , dexamethasone
(DECADRON®) , ibuprofen (MOTRIN®, ADVIL®), naproxen
(NAPROSYN®, ALEVE®) , sulindac (CLINORIL®) , diclofenac (VOLTAREN®) , natalizumab (ANTEGREN®) , piroxicam
(FELDENE®), ketoprofen (ORUDIS®), diflunisal (DOLOBID®) , • nabumetone (RELAFEN®) , etodolac (LODINE®) , oxaprozin
(DAYPRO®) , indomethacin (INDOCIN®) , celecoxib (CELEBREX®) , aspirin, rofecoxib (VIOXX®) , hydroxychloroquine sulfate (PLAQUENIL®) , chloroquine
(ARALEN®) , cyclophosphamide, azathioprine, chlorambucil, piroxicam (FELDENE®) and other steroids can be administered with biologically active calciferol compounds to treat MS and systemic lupus erythematosus.
Preventing fatigue
Many people suffer from fatigue, and many of these victims suffer silently, sleepily and unproductively as their symptoms go undiagnosed or ineffectively treated. Fatigue may accompany chronic conditions, such as multiple sclerosis; disorders, such as Chronic Fatigue Syndrome (CFS) ; and infections by Epstein-Barr virus and other agents; or may be accompanied by no other signs of any illness or condition (Table A) . In some cases, poor nutrition can be the culprit, such as low calcium intake (Alscher et al., 2001; Oudesluys-Murphy and de Vries, 2002) . Unable to function at their fullest, the afflicted experience serious detriments at work, with family and in social activities. The cost of fatigue, due to just CFS alone, is astounding: Reynolds et al. (Reynolds et al., 2004) estimated a 37% decline in household productivity, and a 54% reduction in labor force productivity. The annual total cost of lost productivity in the United States due to CFS was $9.1 billion, which the authors suggested represents about $20,000 per person with CFS.
TABLE A
Examples of conditions that are often accompanied by fatigue
Addison Disease Jet Lag
Anemia Kidney Failure
Cancer and AIDS Multiple Sclerosis
Congestive Heart Failure Myasthenia Gravis
Dehydration Stress
Depression Systemic Lupus
Fibromyalgia Erythematosus
Vasculitis
Fatigue can be categorized by duration. For example, CFS is a subset of chronic fatigue, a broader category defined as unexplained fatigue of greater than, or equal to, six months. Chronic fatigue in turn is considered a subset of prolonged fatigue, which is fatigue lasting one or more months (Reeves et al., 2003) . Clinically, fatigue can be defined as (1) unexplained, persistent or relapsing chronic fatigue (of least 6 months duration) that is of new or definite onset (i.e., has not been lifelong) ; (2) not the result of ongoing exertion; (3) not substantially alleviated by rest; and (4) results in substantial reduction in previous levels of occupational, educational, social, or personal activities (Fukuda efc al., 1994) . Another clinical definition of fatigue is simpler: a subjective lack of physical and/or mental energy that is perceived by the individual (or a caregiver) to interfere with usual and desired activities
(Krupp, 2003) . Fatigue can also be further characterized in that fatigue (1) generally occurs on a daily basis;
(2) tends to worsen as the day progresses; (3) tends to be aggravated by heat and humidity; (4) is not directly- correlated with either depression or the degree of physical impairment; and (5) may occur first thing in the morning even after a restful night's sleep.
Even if properly diagnosed, fatigue sufferers have few choices for effective therapy. No reliable treatment is available to alleviate severe and debilitating fatigue.
The unpredictability in successfully of treating fatigue is illustrated by the results of several clinical studies . The conflicting results from studies of currently used medications, such as amantadine hydrochloride and pemoline, illustrate this point. For example, in one trial, subjects found that taking 100 mg amantadine twice daily significantly improved fatigue (1987) . Pemoline in another trial failed to show significant effect and was poorly tolerated by 25% of the subjects (Vercoulen et al., 1996) . Comparing pemoline and amantadine in yet another trial showed only a positive trend for pemoline (contradicting the Vercoulen, et al. 1996 results), while amantadine had a benefit over placebo in only some fatigue measures (Krupp efc al., 1995); however, there was also a marked placebo effect. A determination of whether a subject would benefit from prophylactic treatment of fatigue can be determined by- assessing various risk factors. A variety of risk factors may be monitored; such as genetic predisposition to chronic conditions that are often accompanied by fatigue (such as MS), amount of sunlight the subject normally receives, the age of the subject, as well as nationality and ancestry/race. Any diagnostic tools, such as those presented in Tables 1 and 2, can also be used to diagnose those subjects who may not yet be classifiable as clinically suffering from fatigue, but show tendencies to the condition if onset is gradual. Subjects at risk are prophylactically administered therapeutic/prophylactic amounts of biologically active calciferol compounds to delay or prevent the onset of symptoms of fatigue.
Subjects who suffer from Addison Disease, anemia, cancer and AIDS, congestive heart failure, dehydration, depression, fibromyalgia, jet lag, kidney failure, multiple sclerosis, myasthenia gravis, stress, systemic lupus erythematosus and vasculitis, but who do not yet show any signs of fatigue can be treated with the methods of the invention to prevent fatigue.
Hypercalcemia
Hypercalcemia is a risk in the administration of biologically active calciferol compounds (e.g., alfacalcidol) because the major physiological function of calciferol is to maintain extracellular calcium levels within a very limited range for normal cellular and metabolic processes, including neuromuscular function and bone mineralization. To maintain serum calcium levels, calcitriol primarily increases intestinal absorption of dietary calcium and phosphate, and when required, mobilizes bone calcium. Thus, calcitriol has a potent calcemic effect (i.e., calcitriol generates a calcemic response in a subject) . The primary concern associated with administering calcitriol or its analogues to subjects (e.g., humans or other mammals) is elevated serum calcium (hypercalcemia) and phosphate levels, a condition accompanied by a corresponding increase in urinary calcium excretion (hypercalcuria) .
The toxicity of calciferol compounds can have serious consequences for renal function; prolonged hypercalcemia can result in calcium deposition in the kidneys (nephrocalcinosis) , kidney stones (nephrolithiasis), and ultimately in renal dysfunction leading to uremia. Calciferol intoxication can also have serious consequences for neurological functions. In severe hypercalcemia, the threshold for excitation of nerve and muscles is increased, resulting in clinical manifestations of muscle weakness, lethargy, and even coma. Gastrointestinal manifestations of calciferol intoxication include constipation, anorexia, nausea, and vomiting, with subsequent fluid loss that exacerbates the hypercalcemic crisis. Hypercalcemia can also affect cardiovascular functioning, including hypotension, and arrhythmias . Monitoring the development of hypercalcemia in subjects receiving high doses or potent biologically active calciferol compounds is recommended. Hypercalcemia may be monitored in a patient by measuring the terminal serum calcium levels.
A method of minimizing the risks of hypercalcemia involves administering the biologically active calciferol compound using timed drug release methods (e.g., suppositories or transdermal patches) or "slow release" biologically active calciferol derivatives (e.g., (Deluca and Schnoes, 1999) ) .
The use of a transdermal patch substantially reduces the risk of hypercalcemia caused by mobilization of calcium across the intestinal wall by preventing a delivery spike of the biologically active calciferol compound. A transdermal patch, when properly designed and applied, delivers a continuous, low dosage stream of the- biologically active calciferol compounds such that a spike that could cause a severe increase in the mobilization of calcium across the intestine wall is avoided.
Another approach to reduce the "spike" phenomenon is to administer a biologically active calciferol compound that does not cause such a spike. Alfacalcidol is such a compound.
Monitoring Fatigue and Calciferol Status
Fatigue
To determine if a subject suffers from fatigue, or is benefiting from treatment (i.e., wherein symptoms are reduced) , the qualitative and quantitative symptoms of fatigue can be monitored using art-accepted tools . Assessment tools include the Fatigue Impact Scale (FIS; Table 1) and the RAYS Questionnaire (Table 2) . The FIS measures both fatigue and treatment effect on fatigue, and measures the patients' awareness of the impact of fatigue on their QoL and the effect of various therapies
(Cutter et al., 2000; Fisk et al. , 1994b; Mathiowetz et al., 2001) . The FIS is a reliable and validated forty- item questionnaire that can monitor a treatment effect. Containing three sub-scales: physical, cognitive and social, each question is scored from 0-4 (higher scores indicating higher impairment) . The RAYS QoL questionnaire can also be administered to determine changes in QoL (Rotstein et al., 2000), which is impacted by fatigue. Each question is scored from 0-4 (higher scores indicating higher impairment) .
Other tools that measure fatigue can be used. For example, the Chalder Fatigue Scale has fourteen items that measures fatigue intensity and separates mental and physical fatigue (Chalder et al., 1993) . This tool has been effectively used in large community samples (Jason et al., 1999) . The Krupp Fatigue Severity Scale is sensitive to different aspects and gradations of the severity of fatigue; most of the nine items, rated on a seven-point scale, relate to behavioral consequences of fatigue (Krupp et al., 1989) .
Assessment of calciferol status
Monitoring and assessing calciferol status can provide important information, including levels of calciferol in circulation, the effectiveness of administered calciferol in increasing circulating levels, and calciferol toxicity. Circulating 25 (OH) D levels closely reflect the amount of sunlight to which the epidermis is exposed and the dietary intake of calciferol. Serum 25 (OH) D level is the best indicator to define calciferol deficiency, insufficiency, hypovitaminosis, sufficiency, and toxicity (McKenna and Freaney, 1998; Zittermann, 2003) . In general, 25(OH)D levels below 12-5 nmol/1 can result in bone diseases such as rickets in infants and osteomalacia in adults (Scharla, 1998) . Levels of 25(OH)D below 25 nmol/1 may lead to rickets and osteomalacia in the if maintained over extended periods (Basha et al., 2000) . Therefore, concentrations of 25(OH)D below 40-50 nmol/1 indicate calciferol insufficiency (Malabanan et al., 1998; Need et al., 2000; Vieth, 1999) . Values below this threshold can also lead to functional alterations such as hyperparathyroidism (Zittermann, 2003) . Serum 25 (OH) D concentrations between 50 nmol/1 and 80-100 nmol/1 indicate hypovitaminosis D, where body stores are already depleted of calciferol (Lamberg-Allardt et al., 2001; McKenna and Freaney, 1998) . Circulating 25 (OH) D levels between 100 and 200 nmol/1 are adequate concentrations, where no disturbances in calciferol- dependent body functions occur (Zittermann, 2003) .
Any clinically accepted method of measuring calciferol levels, especially those that measure serum 25 (OH)D concentrations, can be used.
Calcium levels
Hypercalcemia is a risk in the administration of biologically active calciferol compounds, such as alfacalcidol, because the major physiological function of calciferol is to maintain extracellular calcium levels within a very limited normal range for normal cellular and metabolic processes (including neuromuscular function and bone mineralization) . Therefore, it is important to monitor the development of hypercalcemia in patients receiving high exogenous doses of biologically active calciferol compounds.
Any clinically accepted method of monitoring blood calcium levels can be used. Definitions
"Fatigue," in medical terminology, refers to the state of reduced capacity for work or accomplishment following a period of mental or physical activity.
"Fatigue is reduced," "reducing fatigue," "decreasing fatigue," and the like refer to any degree of qualitative or quantitative reduction in detectable symptoms of fatigue, a detectable impact on the rate of recovery from fatigue, or an increase in the subjective or objective assessment of the quality of life (QoL) , as measured, for example, by FIS or RAYS or any other fatigue- and/or QoL- monitoring clinical tools .
"Subject" refers to a patient which is administered the therapeutic composition comprising biologically active calciferol compounds. Examples of subjects include humans and other animals such as non-human primates, horses, dogs, and cats. The terms "subject," "patient," and "participant" are used interchangeably.
A unit "dose equivalent" means the amount of any type of one compound which, when absorbed in a biological system, results in the same biological effect as one unit of absorbed dose delivered in the form of another compound.
A "therapeutically effective amount" or a "sufficient amount" of a biologically active calciferol compound is the dosage level required for a patient such that the symptoms of fatigue are reduced. Likewise, a "therapeutically effective amount" or a "sufficient amount" can be applied to any agent that is used to treat a disease, disorder or condition, wherein the amount of the agent reduces at least one symptom of the disease, disorder or condition.
"Calciferol compound" (or "vitamin D compound") is a compound which has at least one of the following features: the C-ring, D-ring and 3β-hydroxycyclohexane A-ring of calciferol interconnected by the 5,7 diene double bond system of calciferol together with any side chain attached to the D-ring (i.e., compounds with a "calciferol nucleus" and substituted or unsubstituted A- , C-, and D-rings interconnected by a 5,7 diene double bond system typical calciferol together with a side chain attached to the D-ring) .
Calciferol and its analogues and other relatives have been used to treat and/or prevent a wide variety of diseases and disorders. Classically, calciferol supplementation, through the administration of cod liver oil, was used to prevent rickets and osteomalacia (adult rickets) (Basha et al., 2000; Heaney, 1999; Vieth, 1999) . Because calciferol mobilizes calcium, it has been used to diminish bone loss that occurs during to aging (osteoporosis), and concomitant loss in muscle strength (Bischoff et al., 1999; Heaney, 1999; Lamberg-Allardt et al., 2001; McKenna and Freaney, 1998; Need et al., 2000; Sørensen et al., 1979; Verhaar et al., 2000) . The consequences of some auto-immune diseases, such as MS (Achiron et al., 1999; Achiron et al. , 2003; Deluca and Cantorna, 2001; Deluca et al., 2002; Deluca et al., 1998; Garcion et al., 2003; Vieth, 1999) and inflammatory bowel disease (Cantorna et al., 2000; Deluca and Cantorna, 2001; Hayes and Nashold, 2002b) , can also respond to calciferol treatment. Using calciferol as a preventative measure to thwart cancer has shown promise in prostate, breast, colon, cheek, liver, skin and head and neck cancers (Lin and White, 2004) .
Although traditionally classified as a vitamin, calciferol (vitamin D) is now recognized as a pre-pre- pre-hormone and is not a "true" vitamin. However, throughout this specification, calciferol and "vitamin D" are used interchangeably to indicate this pre-pre-pre- hormone for simplicity, with the caveat that this substance is not a true vitamin.
The calciferol compounds are a group of structurally similar chemicals and their metabolites including, inter alia, calcitriol (1, 25-dihydroxycholecalciferol) and alphacalcidol (lhydroxycholecacliferol) . Calcitriol is a metabolite of califediol(25-hydroxycholecalciferol) , a metabolite of cholecalciferol (Vitamin D3) and ergocalciferol (Vitamin D2) . Alphacalcidol is a' synthetic analogue of calcitriol and is rapidly converted to calcitriol in the liver. (RxMed, Vitamin D: General Monograph, available at http:// www.rxmed.com/b.main/b2.pharmaceutical/b2.prescribe.html) The lα-hydroxylated metabolites of calciferol, most importantly lα, 25-dihydroxyvitamin D3 (calcitriol, which is the active form of vitamin D within the body) and lα, 25-dihydroxyvitamin Do, are highly potent hormonal-like regulators of calcium cation homeostasis in animals and humans. Biologically active vitamin D compounds, including many analogs, have been identified. Important examples of such analogs are lα-hydroxyvitamin D3 (alfacalcidol) , lα-hydroxyvitamin D2, various side chain fluorinated derivatives of lα, 25-dihydroxyvitamin D3, 19- nor-vitamin D compounds, and side chain-modified analogs. These compounds are in use, or have been proposed for use, in the treatment of a variety of diseases, such as renal osteodystrophy, vitamin D-resistant rickets, psoriasis, and some malignancies (Deluca and Schnoes, 1999) .
Calciferol can be ingested orally or can be formed endogenously by the skin after exposure to ultraviolet (UV) B light (wavelength 290-315 nm) . Orally ingested and endogenously formed calciferol is transported to the liver and is converted to, 25-hydroxyvitamin D (25(OH)D) . The liver does not store significant amounts of 25 (OH)D; once converted, 25(OH)D is rapidly released into the blood. In the kidney, 25 (OH) D is enzymatically converted to calcitriol. Renal synthesis of calcitriol is homeostatically . controlled by parathyroid hormone (PTH) . Synthesis of PTH is regulated by serum concentrations of calcium (Ca) and phosphorous. 25 (OH) D can also be . converted in the kidney to 24,25-dihydroxyvitamin D (Zittermann, 2003) .
Calciferol metabolites are known as regulators of sys¬ temic Ca homeostasis with actions in the intestine, the kidneys, and bone. Calcitriol increases both intestinal absorption of orally ingested and tubular re-absorption to maintain physiological serum Ca levels (Zittermann, 2003) .
Alphacalcidol is lα-hydroxycholecaliferol (Paterson; Treatment with active vitamin D (alphacalcidol) in patients with mild primary hyperparathyroidism) . After absorption into the body, alphacalcidol is converted into lα, 25-dihydroxycholecalciferol (Product Description) . Alphacalcidol is commercially available under the tradename, Alpha D3® (Alpha D3) . Alphacalcidol is indicated for conditions in which calcium and/or phosphate metabolism (DeLuca, H. F.; Product Description) is impaired such as renal bone disease, osteoporosis, osteopenia, hypoparathyriodism and hyperparathyroidism with bone disease, rickets, osteomalacia and renal osteodystrophy (Product Description) . The recommended dose for alpacalcidol for all of the afore-mentioned indications except osteoporosis is 1 μg/day for adults, 0.5 μg/day for the elderly and 1 μg/day for children 20 kg and over except for renal osteodystrophy, for which the recommended dose is 0.04 to 0.08 μg/kg/day. The dose for osteoporosis has not been established, but clinical trials have used 0.5 - 1.0 μg/day. It is recommended that the dose be adjusted according to the biochemical response in order to avoid hypercalcemia (Product Description) . Some have suggested that alphacalcidol be taken in the morning (Commonly Taken Drugs (for Kidney Failure)) . In this application, the terms "alphacalcidol" and "alfa calcidol" are used synonymously.
Biologically active calciferol compounds useful in the present invention encompass calciferol compounds that are biologically active in vivo, or are acted upon in a subject (i.e., host) such that the compound becomes active in vivo, for example, calcitriol (1,25- dihydroxycholecalciferol) or its synthetic analogue alphacalcidol (1 hydroxyvitamin D3) .
Further examples include: calciferol, 1,25 (OH) 2D3 and analogs thereof (e.g., lα-hydroxyvitamin D3 (IaOH-D3), 1, 25-dihydroxyvitamin D2 (1,25-(OH)2D2), lα-hydroxyvitamin D2 (Ia-OH-D2), 26,27-hexafluoro-1, 25-dihydroxyvitamin D2 (F6-I, 25- (OH)2D3) , 19-nor-l, 25-dihydroxyvitamin D2 (19-nor- 1,25- (OH) 2D2) , 1, 25-dihydroxy-24 (E) -dehydro-24-homo- vitamin D3 (1, 25- (OH) 2-24-homoD3) , 19-nor-l, 25-dihydroxy- 21-epi-vitamin D3 (19-nor-l, 25- (OH) 2-21-epi-D3) , lα,25 dihydroxyvitamin D3 triacetate and 25-acetyl-lα, 25 dihydroxyvitamin D3, 1,25-dihydroxy-24-homo-22-dehydro- 22E-vitamin D3, 19-nor-l, 25-dihydroxy-24-homo-22-dehydro- 22E-vitamin D3, lα, 25- (OH)2 -24-epi-D2, lα, 25- (OH)2 -24a- Homo-D3,lα,25-(OH)2-24a-Dihomo-D3, lα, 25- (OH) 2-19-nor-D3, and 20-epi-24-homo-lα,25- (OH) 2 -D3) . (Bouillon et al. , 1995; Deluca et al., 1999; Munro, 2001) . Other examples include I. Calcipotriol-diavonex, which is about a hundred-fold times less calcemic than calcitriol (I) ; paricalcitol 1, 25-dihydroxy- nor-19 D2 (Abbot Laboratories; Chicago, IL), which is about ten to a hundred-fold less calcemic than calcitriol; and RO 237553 (Roche, (II)) , which has no observed hypercalcemia.
Figure imgf000055_0001
Figure imgf000055_0002
Other biologically active calciferol compounds, represented by various functional classes, are also useful in practicing the invention. They are calciferol compounds that (1) inhibit autoimmunity, but have calcemic activity equal or less to calcitriol; (2) inhibit transplant rejection and have calcemic activity equal or less to calcitriol; (3) that exert effects in in vitro cell differentiation assays, and (4) calciferol mimics; these activate the nuclear calciferol receptor in in vitro transcriptional assays. Examples of each, as well as other references disclosing other biologically active calciferol compounds, are given in Table B.
TABLE B
Classes of useful calciferol compounds, examples, and references
Class Examples References
(1) auto¬ lα, 25-dihydroxy-16ene- (Abe et al., immunity vitamin D3 and lα,25- 1989; Deluca dihydroxy-24-oxo-16ene- et al., 1998; vitamin D3; lα,24R- Koizumi et dihydroxy-vitamin D3; al., 1985; lα, 25-dihydroxy-22-oxa- Lemire et al. , vitamin D3; 20-Epi-22- 1994; oxa-24a, 27, 27a-trihomo- Lillevang et lα, 25-dihydroxy-vitamin al., 1992) D3; and 19-nor-l, 25- dihydroxy-vitamin D3
(2) transplant 1, 25-dihydroxy-16ene- (Lemire et rejection vitamin D3; and 20-Epi- al., 1992; 22-oxa-24a,27,27a- Veyron et al . , trihomo-1,25-dihydroxy- 1993) vitamin D3
;3) cell 1, 25-dihydroxy-l6,23E- (Asou et al. , differentiation diene-26-trifluoro-19- 1998; Bouillon nor-cholecalciferol; et al., 1992; llα-vinyl-lα, 25- Norman et al . , dihydroxy-vitamin D3; 1990; Perlman lα, 25-dihydroxy-16ene- et al., 1990) 23yne-vitamin D3; 24- homo-22-dehydro-22E- TABLE B
Classes of useful calciferol compounds, examples, and references
Class Examples References lα, 25-dihydroxy-vitamin D3 and 1, 25-dihydroxy- 22ene-24-homo-vitamin D3
A) mimics LG190090, LG190119, (Boehm et al. , LG190155, LG190176, 1999) LG1900178
[5) other (Calverley and Pedersen, 1998; Daniewski et al., 2001; DeLuca and Schnoes, 1999; DeLuca et al., 1981; Grue-Sørensen, 1998; Grue-Sørensen, 1999; Gure- Sorensen, 1998; Hayes and Nashold, 2002a; Hesse and Setty, 1998; Hesse et al., 1998a; Hesse et al., 1998b; Hesse et al., 1999; Ikeda et al., 1999; Miyamoto and Kubodera, 1999; Mourino et al., 1999; Ono, 1999; Paaren, 1999; Schneider, 1999) (Bernardon, 2004; Bishop and Mazess, 2003; Bouillon et al., 2000; Bretting, 2001; Bretting, 2003; Carswell et al., 2001; DeLuca and Cai, 2001; DeLuca and Sicinski, 2000a; DeLuca and Sicinski, 2000b; DeLuca and Sicinski, 2001; DeLuca and Sicinski, 2002a; DeLuca and Sicinski, 2002b; DeLuca and Sicinski, 2003; Deluca and Sicinski, 2003; Deluca et al., 2003; TABLE B
Classes of useful calciferol compounds, examples, and references
Class Examples References
Halkes et al., 2001; Hansen, 2003a; Hansen, 2003b; Hesse et al., 2002; Hesse et al., 2000; Kawase, 2001; Kawase, 2003; Kirsch et al., 2002; Knutson et al., 2000; Miyamoto and Kubodera, 2000; Norman and Okamura, 2000; Ogasawara and Takahaski, 2002; Pascal et al., 2001; Serbinova, 2001; Steinmeyer et al., 2003a; Steinmeyer et al., 2003b; Steinmeyer et al., 2003c; Steinmeyer et al., 2003d; Valles et al., 2000; Watanabe, 2002; Wynberg et al., 2002)
"Non-secosteroidal calciferol mimics" (or "non- secosteroidal calciferol mimics") means non-secosteroid compounds which are capable of mimicking various activities of the secosteroid calcitriol. Examples of such compounds include LG190090, LG190119, LG190155, LG190176, and LG1900178 (Boehm et al., 1999) .
"Biologically active calciferol compounds" (or "biologically active vitamin D compounds) encompass calciferol compounds and non-secosteroidal calciferol mimics that are biologically active in vivo, or metabolized in a subject (i.e., host) such that the compound becomes active in vivo (e.g., pro-drug forms of calciferol) . Examples of such compounds include: calciferol, 1,25 dihydroxyvitamin D3 (1,25(OH)2D3)
(calcitriol) , 5 and analogs thereof [e.g., lα- hydroxyvitamin D3 (Ia-OH-D3), 1, 25-dihydroxyvitamin D2 (1,25-(OH)2D2), lα-hydroxyvitamin D2 (Ia-OH-D2), lα,25-
(OH)2-16-ene-D3, lα, 25- (OH) 2-24-oxo-16-ene-D3, lα, 24R(OH)2-
D3, lα,25(OH)2-22-oxa-D3, 20-epi-22-oxa-24α, 24β, -dihomo- lα, 25 (OH)2-D3, 20-epi-22-oxa-24α, 26α, 27α, -trihomo-lα, 25
(OH) 2-D3, 20-epi-22-oxa-24homo-lα, 25 (OH)2-D3, 1,25-(OH)2-. 16, 23E-diene-26-trifluoro-19-nor-D3, 2- (3-hydroxypropoxy) -
1, 23-dihydroxy vitamin D3 and non-secosteroidal calciferol mimics . Table B lists some of these and other compounds .
Therapeutic Preparations and Combinations Pharmaceutical compositions Biologically active calciferol compounds can be incorporated into pharmaceutical compositions . Such compositions typically contain at least one biologically active calciferol compound and a pharmaceutically acceptable carrier. A "pharmaceutically acceptable carrier" includes any and all solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents, etc., compatible with pharmaceutical administration (Gennaro, 2000) . Examples of such carriers or diluents include water, saline, finger's solutions, dextrose solution, and 5% human serum albumin. Liposomes and non-aqueous vehicles such as fixed oils may also be used. Except when a conventional media or agent is incompatible with the biologically active calciferol compound, use of these compositions is contemplated. Supplementary active compounds can also be incorporated into the compositions .
In solid dosage forms of the invention for oral administration (capsules, tablets, pills, dragees, powders, granules and the like), the active ingredient (s) is mixed with one or more pharmaceutically acceptable carriers, such as sodium citrate or dicalcium phosphate, and/or any of the following: fillers or extenders, such as starches, lactose, sucrose, glucose, mannitol, and/or silicic acid; binders, such as, for example, carboxymethylcellulose, alginates, gelatin, polyvinyl pyrrolidone, sucrose and/or acacia; humectants, such as glycerol; disintegrating agents, such as agar-agar, calcium carbonate, calcium phosphate, potato or tapioca starch, alginic acid, certain silicates, and sodium carbonate; solution retarding agents, such as paraffin; absorption accelerators, such as quaternary ammonium compounds; wetting agents, such as, for example, cetyl alcohol and glycerol monostearate; absorbents, such as kaolin and bentonite clay; lubricants, such a talc, calcium stearate, magnesium stearate, solid polyethylene glycols, sodium lauryl sulfate, and mixtures thereof; and coloring agents. In the case of capsules, tablets and pills, the pharmaceutical compositions may also comprise buffering agents. Solid compositions of a similar type may also be employed as fillers in soft and hard-filled gelatin capsules using such excipients as lactose or milk sugars, 'as well as high molecular weight polyethylene glycols and the like. Liquid dosage forms for oral administration of the active ingredients include pharmaceutically acceptable emulsions, microemulsions, solutions, suspensions, syrups and elixirs. In addition to the active ingredient (s) , the liquid dosage forms may contain inert dilutents commonly used in the art, such as, for example, water or other solvents, solubilizing agents and emulsifiers, such as ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1,3-butylene glycol, oils (in particular, cottonseed, groundnut, corn, germ, olive, castor and sesame oils), glycerol, tetrahydrofuryl alcohol, polyethylene glycols and fatty acid esters of sorbitan, and mixtures thereof. Suspensions, in addition to the active compounds, may contain suspending agents such as ethoxylated isostearyl alcohols, polyoxyethylene sorbitol and sorbitan esters, microcrystalline cellulose, aluminum metahydroxide, bentonite, agar-agar and tragacanth, and mixtures thereof.
General considerations
A pharmaceutical composition is formulated to be compatible with the intended route of administration, including intravenous, intradermal, subcutaneous, oral (e.g., inhalation), transdermal, transmucosal, and rectal administration. Solutions or suspensions used for parenteral, intradermal, or subcutaneous application can include: a sterile diluent such as water for injection, saline solution, fixed oils, polyethylene glycols, glycerine, propylene glycol or other synthetic solvents; antibacterial agents such as benzyl alcohol or methyl parabens; antioxidants such as ascorbic acid or sodium bisulfite; chelating agents such as ethylenediaminetetraacetic acid (EDTA) ; buffers such as acetates, citrates or phosphates, and agents for the adjustment of tonicity such as sodium chloride or dextrose. The pH can be adjusted with acids or bases, such as hydrochloric acid or sodium hydroxide. The parenteral preparation can be enclosed in ampules, disposable syringes or multiple dose vials made of glass or plastic.
Injectable formulations
Injection provides a direct and facile route of administration, although depending on the choice of biologically active calciferol compound, injection may not be desired if sudden introduction of the compound would lead to a spike in blood calcium levels . Pharmaceutical compositions suitable for injection include sterile aqueous solutions (where water soluble) or dispersions and sterile powders for the extemporaneous preparation of sterile injectable solutions or dispersion. For intravenous administration, suitable carriers include physiological saline, bacteriostatic water, CREMOPHOR EL™ (BASF, Parsippany, N.J.) or phosphate buffered saline (PBS) . In all cases, the composition must be sterile and should be fluid so as to be administered using a syringe. Such compositions should be stable during manufacture and storage, and must be preserved against contamination from microorganisms, such as bacteria and fungi. The carrier can be a solvent or dispersion medium containing, for example, water, ethanol, polyol (such as glycerol, propylene glycol, and liquid polyethylene glycol), and suitable mixtures. Proper fluidity can be maintained, for example, by using a coating such as lecithin, by maintaining the required particle size in the case of dispersion, and by using surfactants. Various antibacterial and antifungal agents, such as parabens, chlorobutanol, phenol, ascorbic acid and thimerosal can control microorganism contamination. Isotonic agents, such as sugars, polyalcohols such as manitol, sorbitol, and sodium chloride can be included in the composition. Compositions that delay absorption include agents such as aluminum monostearate and gelatin.
Sterile injectable solutions can be prepared by incorporating a biologically active calciferol compound in an appropriate solvent with one or a combination of ingredients, followed by sterilization. Generally, dispersions are prepared by incorporating the calciferol compound into a sterile vehicle that contains a basic dispersion medium and any other required ingredients.- Sterile powders for the preparation of sterile injectable solutions methods of preparation include vacuum drying and freeze-drying that yield a powder containing the active ingredient and any desired ingredient from a sterile solution. Ora1 compositions
Oral compositions containing a biologically active calciferol compound are preferred. Oral compositions generally include an inert diluent or an edible carrier. They can be enclosed in gelatin capsules or compressed into tablets. The biologically active calciferol compounds can be incorporated with excipients and used in the form of tablets, troches, or capsules. Oral compositions can also be prepared using a fluid carrier for use as a mouthwash, wherein the compound in the fluid carrier is applied orally. Pharmaceutically compatible binding agents, and/or adjuvant materials can be included. Tablets, pills, capsules, troches and the like can contain a binder, such as microcrystalline cellulose, gum tragacanth or gelatin; an excipient, such as starch or lactose; a disintegrating agent, such as alginic acid, PRIMOGEL or corn starch; a lubricant, such as magnesium stearate or STEROTES; a glidant, such as colloidal silicon dioxide; a sweetening agent, such as sucrose or saccharin; or a flavoring agent such as peppermint, methyl salicylate, or orange flavoring.
Systemic administration
Systemic administration can be transmucosal or transdermal. For transmucosal or transdermal administration, penetrants that can permeate the target barrier (s) are selected. Transmucosal penetrants include detergents, bile salts, and fusidic acid derivatives. Nasal sprays or suppositories can be used for transmucosal administration. For transdermal administration, the active compounds are formulated into suitable forms, such as ointments, salves, gels, or creams .
The compounds can also be prepared in the form of suppositories (e.g., with bases such as cocoa butter and other glycerides) or retention enemas for rectal delivery.
In some preferred embodiments, the therapeutic composition comprising biologically active calciferol compounds is administered via a transdermal patch. Transdermal delivery provides a continuous supply of the calciferol compound, maintaining the calciferol receptor occupancy at a stable, optimal level, to achieve the desired biological effect and thus treat fatigue. Transdermal delivery can be more convenient and advantageous than other modes of delivery, especially for children, or those who have trouble taking oral medications, and can increase patient compliance.
One example of a transdermal patch for delivering therapeutics employs a polyurethane acrylic copolymer
(Szycher et al . , 1987) . Other examples transdermal patches include those using polymers and vitamin E
(Fischer and Klokkers, 1998), adhesive matrices of silicone or polyisobutylene (or both; (Jona et al., 1999) ) .
The administration of alphacalcidol or glatiramer acetate may each independently be oral, nasal, pulmonary, parenteral, intravenous, intra-articular, transdermal, intradermal, subcutaneous, topical, intramuscular, rectal, intrathecal, intraocular, buccal or by gavage . For alphacalcidol, the preferred route of administration is oral or by gavage. The preferred route of administration for glatiramer acetate is subcutaneous or oral. One of skill in the art would recognize that doses at the higher end of the range may be required for oral administration.
In one embodiment, the administration of the glatiramer acetate may be subcutaneous, intraperitoneal, intravenous, intramuscular, intraocular or oral and the administration of the alphacalcidol may be oral. In another embodiment, the administration of the glatiramer acetate may be subcutaneous and the administration of the alphacalcidol may be oral. Carriers
Biologically active calciferol compounds can be prepared with carriers that protect the compound against rapid elimination from the body, such as controlled release formulations, including implants and microencapsulated delivery systems. Biodegradable, biocompatible polymers can be used, such as ethylene vinyl acetate, polyanhydrides, polyglycolic acid, collagen, polyorthoesters, and polylactic acid (ALZA Corporation; Mountain View, CA and NOVA Pharmaceuticals, Inc.; Lake Elsinore, CA) . Liposomal suspensions can also be used as pharmaceutically acceptable carriers (Eppstein et al., 1985) . Unit dosage
Oral formulations or parenteral compositions in unit dosage form can be created to facilitate administration and dosage uniformity. Unit dosage form refers to physically discrete units suited . as single doses for a subject to be treated, containing a therapeutically effective quantity of active compound in association with, the required pharmaceutical carrier. The specification for unit dosage forms are dictated by, and directly depend on, the unique characteristics of the biologically active calciferol compound and the particular desired therapeutic effect, and the inherent limitations of compounding the calciferol compound.
The pharmaceutical compositions containing the biologically active calciferol compounds can further comprise other therapeutically active compounds that are usually applied in the treatment of other diseases, disorders and conditions, such as multiple sclerosis.
Kits for pharmaceutical compositions The pharmaceutical compositions can be included in a kit, container, pack, or dispenser together with instructions for administration. When the invention is supplied as a kit, the different components of the composition may be packaged in separate containers and admixed immediately before use. Such packaging of the components separately may permit long-term storage without losing the activity of the components .
Kits may also include reagents in separate containers that facilitate the execution of a specific test, such as diagnostic tests or tissue-typing. Kits may also contain sub-kits that are used to help the user monitor important parameters, such as ' blood calcium and/or calciferol levels . Containers or vessels
The reagents included in the kits can be supplied in containers of any sort such that the life of the different components are preserved and are not adsorbed or altered by the materials of the container. For example, sealed glass ampules may contain lyophilized- luciferase or buffer that have been packaged under a neutral non-reacting gas, such as nitrogen. Ampules may consist of any suitable material, such as glass, organic polymers, such as polycarbonate, polystyrene, etc., ceramic, metal or any other material typically employed to hold reagents . Other examples of suitable containers include bottles that may be fabricated from similar substances as ampules, and envelopes, that may consist of foil-lined interiors, such as aluminum or an alloy. Other containers include test tubes, vials, flasks, bottles, syringes, etc. Containers may have a sterile access port, such as a bottle having a stopper that can be pierced by a hypodermic injection needle. Other containers may have two compartments that are separated. by a readily removable membrane that upon removal permits the components to mix. Removable membranes may be glass, plastic, rubber, etc. Instructional materials
Kits may also be supplied with instructional materials .
Instructions may be printed on paper or other substrate, and/or may be supplied as an electronic-readable medium, such as a floppy disc, CD-ROM, DVD-ROM, Zip disc, videotape, audio tape, etc. Detailed instructions may not be physically associated with the kit; instead, a user may be directed to an internet web site specified by the manufacturer or distributor of the kit, or supplied as electronic mail.
Experimental Details
EXAMPLE 1 - Randomized, parallel, double-blind, placebo- controlled study to evaluate the effect of alfacalcidol on fatigue and QoL in patients with Multiple Sclerosis (MS) --Methods, materials and participant criteria
I. Introduction
The study was a clinical phase II trial. The objectives were to evaluate the effect of alfacalcidol on fatigue and quality of life (QoL) in patients with MS, and to assess alfacalcidol' s safety and tolerability in this patient population. The study was conducted at the Multiple Sclerosis Center, the Chaim Sheba Medical Center, Tel-HaShomer, Israel. Alfacalcidol (1-hydroxy calciferols) was administered as soft gelatin capsules containing 1 μg 1-hydroxy calciferol3 in arachis oil.
One hundred fifty MS patients who met all eligibility criteria were randomized and treated for six months in two groups, alfacalcidol-treated and placebo-treated. Fatigue was assessed by the FIS scale for the whole study population. An exploratory use of the modified MS Buce treadmill device was completed at random on 60 patients of the study assess the feasibility of using this device, as an objective measure for fatigue. The QoL was evaluated in all patients using the RAYS questionnaire.
II. Assessment tools and endpoint criteria A. Fatigue Impact Scale (FIS)
The Fatigue Impact Scale (FIS; Table 1) measures both fatigue and treatment effect on fatigue measures the patients' awareness of the impact of fatigue on their QoL and the effect of various therapies (Cutter et al. , 2000; Fisk et al., 1994b; Mathiowetz et al., 2001) . Containing 3 sub-scales: physical, cognitive and social, each question is scored from 0-4 (higher scores indicating higher impairment) .
TABLE 1 Fatigue impact scale
Rate the following statements from 0 to 4: 0, none; 1, mild; 2, moderate; 3, severe and 4, extreme. Give only one answer per question.
Figure imgf000071_0001
Figure imgf000072_0001
Figure imgf000073_0001
Figure imgf000074_0001
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B. RAYS QoL (Rotstein et al., 2000)
The RAYS QoL questionnaire was also administered to determine changes in QoL (Table 2) . Each question is scored from 0-4 (higher scores indicating higher impairment) .
TABLE 2
The RAYS: A quality of life scale for multiple sclerosis patients
The following questions 8. I could not complete tasks focus on the past week. We are started. interested in obtaining information about any problem or 9. I found it difficult to solve difficulty you have had during problems, make decisions, plan or learn new information. this period. Even if some of the questions seem redundant, 10. I had difficulties falling they are in fact different so asleep and/or woke up in the please answer all questions. middle of the night and/or awoke However, if any question is un-refreshed. impossible for you to answer please move to the next one. 11. I did not enjoy activities that once brought me pleasure.
We would like to emphasize that all questions refer to the 12. I devoted time and effort to effects of multiple sclerosis. grooming and personal appearance. If you feel that another factor 13. I felt sad or depressed. has influenced your response please note that next to the 14. Physical problems occupied or specific item. bothered me.
All questions relate to the 15. I felt changes in my last 7 days. appearance make me unattractive.
Rate the following statements from 0 to 4: 0, Social-familial domain none; 1, mild; 2, moderate; 3, severe and 4, extreme. Give 1. I worked/was employed. only one answer per question. 2. I took part in household
Physical domain chores.
1. My driving is limited. 3. I took part in leisure time activities or hobbies.
2. I have stayed in bed during the day. 4. I went out socially.
3. I found it difficult to lift 5. I used public transportation. objects, bend, walk up stairs. 6. I participated in social
4. My walking is limited. gatherings.
5. difficulty in bladder 7. I took part in managing family - I b-
control limited my activites. and parental duties.
6. I suffered pains or was 8. My sexual activities declined. uncomfortable.
9. I engaged in family and social
I needed help to get up from a conversations. chair, get into a car, get out
10. I was demanding, irritable of bed. and short-tempered to those around
8. I was unstable when walking. me.
9. I had difficulties with find 11. I felt lonely. co-ordination of my hands (e.g.,
12. I was satisfied with my writing, buttoning, lacing my achievements. shoes) .
13. I listened to the news, read
10. I suffered blurred or a newspaper, watched television. double vision.
11. I felt tired. 14. I received emotional support from my family, friends,
12. I had ^accidents' such as: caretakers. dropping objects, falls, bumping
15. I was coping with my illness. into things.
13. Warm weather exacerbated my condition. Additional concerns
14. I suffered from muscle 1. I suffered/was bothered by cramps or rigidity. side-effects of my treatment/medications.
15. Due to speech or voice difficulties others found it 2. My treating physician was hard to understand me. available to answer my needs.
3. Generally I was satisfied with
Psychological domain my quality of life.
4. I felt my illness makes me
1. I am a burden to others. disabled.
2. I laughed or cried suddenly for no reason. 5. I spoke with my family/friends about my illness.
3. I blamed or cursed myself.
4. I spoke hopelessly of the future.
5. I was afraid/frightened of what the near future holds for me.
6. I had difficulties remembering details.
7. I reacted slowly to things said or done around me. C. Alfacalcidol
The safety and tolerability of alfacalcidol was assessed by (1) vital signs, (2) blood calcium levels, (3) adverse events reports and (4) neurological examination. D. End points
Primary efficacy end point was the change from baseline to termination as measured by the FIS. Secondary- efficacy end points were (1) the categorical change from baseline to termination in the FIS; as well as the changes from baseline to termination, as measured by the FIS, in (2) the physical fatigue score; (3) the cognitive fatigue score; and (4) the social fatigue score.
The exploratory efficacy end points were the changes from baseline to termination in (1) each of the sub-scale QoL scores (RAYS QoL; (Rotstein et al. , 2000)) and (2) of the test effort as measured by the modified MS Bruce protocol.
III. Inclusion and exclusion criteria
Prior to initiating the therapy all patients signed the Ethic Committee's approved consent form, completed a medical history form and had various tests completed. The results of the tests and forms were reviewed to ensure that the inclusion criteria are met (Table 3) .
TABLE 3
Inclusion and exclusion criteria for enrolled patients
Inclusion criteria Exclusion criteria
1. The patients were diagnosed 1. Life threatening and/or with clinically definite MS unstable clinical condition which (using Posner criteria) . in the opinion of the
EDSS at screening: 0 to 5.5, investigator might compromise inclusive. trial completion
2. Positive Fatigue impact scale 2. A relapse during the last 30 40 points or more. days prior to the study.
3. Age 18-55 years. 3. Blood calcium levels higher
4. Co-operating patient, capable than 10.5 mg/dl. of complying with all of trial 4. Known hypersensitivity or procedures [i.e., FIS, QoL, intolerance, to alfacalcidol or etc ) . related substances or to any
5. Patient who signed written component of the formulation. informed consent. 5. Alcohol abuse or drugs abuse
6. Women of childbearing 6. Participation in experimental potential must use effective drug trials during the last 30 birth control method during days prior to the trial. study.
IV. Materials
Soft gelatin capsules of alfacalcidol and its identical placebo were supplied in identical containers .
Alfacalcidol was supplied as soft gelatin capsules containing 1 μg of active substance, see Table 4 for formulation. Placebo was supplied in soft gelatin capsules filled with arachis oil; the capsules were identical m appearance to those containing alfacalcidol. The participants were instructed to take one capsule every evening. TABLE 4
Formulation for alfacalcidol in capsule form
Constituent Quantity/Capsule 5 Function μg
Active ingredients alfacalcidol 0.5 μg active Inactive ingredients Citric acid, anhydrous 0.015 mg synergist propyl gallate 0.020 mg antioxidant α-tocopherol 0.020 mg antioxidant ethanol, anhydrous 1.1445 mg solvent arachis oil 98.80 mg vehicle Soft gelatin capsule shell Gelatin 48.35 mg shell glycerol 85% 11.81 mg plastisizer ANIDRISORB® 85/70* 7.89 mg moisturizer (Roquette Freres; Lestrem, FRANCE) titanium dioxide 0.65 mg color/dye (E171) red iron oxide (E172) 0.043 mg color/dye edible ink, black Trace printing ink A10379**
Net weight of capsule 68.74 mg shell
Total weight 168.74 mg
*consists of 25-40% sorbitol, 20-30% sorbitan anhydrides, 0-6% marinitol, 12.5-19% superior polyols and 15-17% water **contains shellac, iron oxide black (E172), denaturated ethanol, isopropyl alcohol, 1-butanol and ethyl acetate V. Schedule of activitiesr evaluations
Participants were scheduled for five visits: (1) screening and baseline; beginning of treatment; (2) 2 months, (3) 4 months, and (4) 6 months (termination) after baseline, and (5) 2 months after termination.
Between the regular visits, "phone visits" were performed to insure that there were no complains related to safety or tolerability. Phone visits were instigated by the investigators and/or by patient initiative.
A. Visit 1: screening and baseline
The first visit consisted of participants signing the informed consent form, being evaluated based on inclusion and exclusion criteria (Table 3) , providing demographic and general medical history data, and providing history directly related to fatigue. Concomitant therapies were assessed, and vital signs and the results of a physical examination were recorded. Calcium levels were also determined. In addition, a regular MS follow-up was conducted, which consisted of completing the FIS, RAYS, and the Bruce treadmill test (although only a subpopulation of participants (∞60) complete the treadmill test) .
Participants who met all of the criteria were randomized into a treatment group according to the appropriate strata; the participants were then supplied with sufficient medication for 2 months. B. Visits 2 and 3: two and four months after baseline
The second visit consisted of registering the participants' vital signs, assessing concomitant therapy, measuring blood calcium levels, and the regular MS follow-up. Compliance assessment was recorded, and medication for the next 2 months was supplied. Based on the reported adverse experiences and lab tests (calcium level) , the investigator decided if patients could continue the treatment, or if any changes in medication were required.
C. Visit 4: six months from baseline (termination)
The fourth visit consisted of registering the participants' vital signs, assessing concomitant therapy, ' measuring blood calcium levels, and the regular MS follow-up. Compliance and adverse experience assessments were recorded. About 60 participants completed a Bruce treadmill test. A termination form was completed. Based on the reported adverse experiences and lab tests (calcium level) , the investigator decided if patients could continue the treatment, or if any changes in medication were required.
D. Visit 5: two months after termination (follow-up)
Participants who completed the entire treatment as well as participants who interrupted the treatment, were observed. The visit consisted of registering the participants' vital signs, assessing concomitant therapy, and the regular MS follow-up. Compliance and adverse experience assessments were recorded. Calcium levels were measured at the discretion of the investigators. Based on the reported adverse experiences and laboratory tests (calcium levels), the investigators decided if patients could continue the treatment or if any changes in medication were required.
VI. Treatment discontinuation criteria Patients were withdrawn from the study if they (1) interrupted therapy for more than four weeks; (2) experienced intolerable adverse effects; (3) refused to continue treatment for whatever reason; (4) had serum calcium levels above 11 mg/dl; or (5) were not having, in an investigator's judgment, their best interests being served by continuing treatment.
A. Adverse experiences
Special attention was given to detecting known adverse effects, such as reporting hypercalcemia. Investigators recorded a description of any adverse experiences, as well as the duration, severity, actions taken, relationship to the study drug and outcome of the events .
B. Informed consent
Consent given by the participants was witnessed, dated, and retained by the investigator. Each participant was given a copy of the consent form.
VII. Statistical methods
The objective was to evaluate the efficacy, tolerability and safety of alfacalcidol as compared to placebo on fatigue in patients with MS. The efficacy was measured by the change from baseline to termination in the (FIS) . - U Z -
A. Sample size rationale
The power calculations were based on the primary endpoint, the change from baseline to termination in the FIS. The power was estimated under the assumptions that the baseline FIS mean (SD) was 60 (SD=40) and the expected treatment effect was 20 (SD=40) , as estimated by Fisk et al. (Fisk et al., 1994b) . The t-test was used, comparing active treatment group to placebo with two- sided α level of 0.05. Results of these calculations showed that eighty patients per group provided 88% power to detect a statistically significant difference between an active treatment group and a placebo group.
B. Subject cohorts (ITT and CO) Intent-to-treat (ITT) cohort consisted of all subjects randomized. In accordance with the ITT principle, all subjects randomized and who took at least one dose of the study drug were kept in their originally assigned treatment group. This cohort served as the principal cohort for statistical inference. Only in this cohort was the Last Observation Carried Forward (LOCF) approach applied to account for missing data during study or at study termination. Safety assessment was performed only this cohort. Completers (CO) cohort consisted of all subjects who completed the six months of the double-blind treatment.
C. Significance level
The significance level for this study was 5% two-tailed. D. Safety assessment
Safety assessment included the incidence and the frequency of adverse experiences. These were summarized and presented according to regulatory-accepted dictionary definitions. Serious adverse events were listed and discussed individually.
E. Calcium level tests
Frequency counts and data listings of laboratory tests outside the normal range were presented at each visit by treatment group. Descriptive statistics as well as changes from baseline were also presented by study group at each scheduled visit. Listings of measurements of potentially clinical significant laboratory test abnormalities were also presented by study group. F. Vital signs
Frequency counts and data listings of potential clinical significance vital signs (blood pressure, and heart rate) measurements were presented at each visit by treatment group. Descriptive statistics as well as changes from baseline of vital signs were also presented by study group at each scheduled visit.
G. Neuro exam
The changes from baseline in EDSS score and frequency of relapses were summarized by treatment groups and randomization strata.
VIII. Efficacy assessment
Efficacy assessment was performed on the ITT and CO subject cohorts. A. Primary efficacy endpoints
These were the changes from baseline to termination as measured by the FIS. The primary end-point is the change between the baseline and last observed value. The principal statistical analysis of the primary endpoint was an Analysis of Covariance (ANCOVA, SAS® GLM procedure) incorporating baseline EDSS as a one degree of freedom covariate and MS treatment strata as fixed effect. The change from baseline to each visit in the FIS score was also calculated to explore time trends. A Baseline Adjusted Repeated Measures Analysis of Covariance (SAS® PROC MIXED procedure) was used to elucidate the time course of the drug effect. The dependent variable was the change from baseline in the FIS score, and the model included the fixed effects of treatment group, month in trial, treatment-by-month interaction, baseline EDSS score as covariate and MS treatment strata. The individual participant intercept and the week effects were also included in the model as random effects. The test for a significant treatment effect was based on the joint statistical significance of the treatment effect and the treatment-by-week interaction. Joint tests of significance were conducted using the -2 Log Likelihood Ratio test.
B. Secondary efficacy endpoints
These were the categorical change from baseline to termination in the FIS. The change from baseline to termination in the (FIS) was dichotomized according to the cut-off point of an improvement from baseline to last observed value of 30% or more. This binary endpoint was summarized in a 2 x 2 table by study group. The. statistical analysis of this endpoint was a Baseline Adjusted Logistic Regression (SAS® GENMOD) procedure incorporating baseline EDSS as a one degree of freedom covariate and MS treatment strata as fixed effect. The Odds Ratio and the corresponding CI were presented.
The change as measured by the FIS, from baseline to termination in the Physical Fatigue Score, in the Cognitive Fatigue Score, in the Social Fatigue Score were all analyzed similarly to the primary analysis.
C. Exploratory efficacy endpoints
These were the changes from baseline to termination in each of the Sub-Scale QoL Scores (RAYS questionnaire) . The change from baseline to each visit in each of the sub-scale QoL scores (RAYS questionnaire) was calculated. A Baseline Adjusted Repeated Measures Analysis of Covariance (SAS® PROC MIXED) procedure was used to examine the time course of the drug effect. The model incorporated the baseline EDSS score and the RAYS questionnaire overall score at baseline as covariates, and the MS treatment strata as fixed effect. The change from baseline to termination of the test effort as measured by the modified MS Bruce protocol was a descriptive evaluation. D. Secondary analyses
1. Relationship between RAYS scores to EDSS and fatigue scores
For each time-point, RAYS sub-scale differences from baseline were correlated to the EDSS and FIS scores.
2. Main and differential effects of treatment on QoL dimensions
For each patient, a standardized change score from baseline was computed for each of the RAYS sub-scales at each time. A Repeated Measure ANOVA tested the overall treatment effect at each time point. The Sub-scale by Drug Interaction was also examined to detect whether the magnitude of treatment differed between the scales in the two groups . 3. Effect of treatment on the internal structure of the MSQLI
A structural equation model based on the hypothesized MSQLI structure was specified separately for all subjects at baseline and termination. The equivalence of internal structure for the two groups was tested by freeing model parameters to vary between the alfacalcidol and placebo group, and testing for significant improvement in overall model fit.
E. Statistical software SAS® software (SAS Institute Inc.; Cary, NC) was used for statistical analysis and data presentation of the information collected in this study. RESULTS (Figures 1, 2, and 3)
One-hundred fifty-eight MS patients participated in the study; 74% were female (41 ± 9.2 years), age at MS diagnosis (34.9 ± 9.5 years), and 92.4% had a relapsing- remitting course complaining on MS fatigue (FIS at baseline 77 ± 26) for a mean of 4 years. The majority- were treated with immunomodulatory therapies (IMT) to treat their MS conditions: Copaxone (13%), intravenous immune globulin (IVIg; 26%) and interferon-β preparations (29%) . Thirty-two percent received no IMT. The relative improvements (%) measured from baseline to last observed value in the total FIS, and in all subscales (physical, cognitive and psychological) were statistically significant within each of the treatment groups (p<0.001) . Differences in the relative FIS between treatment groups showed a trend in favor of alfacalcidol (p=0.069) and reached statistical significance in the cognitive subscale (p=0.023) . Similarly, a trend was shown for more patients to improve by 30% on alfacalcidol than placebo on the total FIS (Relative Risk (RR)=1.45, Confidence Intervals (CI) =0.75 - 2.78, p=0.26), which again reached significance on cognitive subscale (RR=2.63, CI=I.33 - 5.20, p=0.005)
Alfacalcidol therefore improved fatigue in patients with MS at six months. Improvement was especially significant in the cognitive subscale of the FIS.
Alphacalcidol also reduced the rate of relapses, especially in patients receiving COPAXONE® Figure 3 shows the percent (%) improvement of relapse rate per year in MS patients on MS therapy who received 1 μg of alphacalcidol per day. The annual relapse rate was calculated based on the number of relapses during a six month period adjusted for one year. The P value indicates the statistically significant different in relapses per year between the two treatment groups (active and placebo) .
EXAMPLE 2 - CLINICAL TRIAL OF RELAPSING-REMITTING MULTIPLE SCLEROSIS The purpose of this trial is to compare the treatment of participants with relapsing-remitting multiple sclerosis (RR-MS) with COPAXONE® in combination with alphacalcidol, with treatment with COPAXONE® in combination with placebo. The clinical objective is to evaluate the effect of treatments on MRI variables, clinical evaluations and immunological profile.
The design of this trial is a randomized, double-masked, 2-arm study of COPAXONE® in combination with alphacalcidol versus COPAXONE® in combination with placebo for the treatment of relapsing-remitting multiple sclerosis. Twenty patients with RR-MS who meet the inclusion/exclusion criteria are enrolled per arm. Patients are randomized and receive either 20 mg SQ (subcutaneous) of COPAXONE® daily plus an oral dose of placebo daily or 20 mg SQ of COPAXONE® in combination' with 50 mg alphacalcidol every 12 hours.
Participant inclusion criteria are as follows: 1) men or women age 18 to 50 years; 2) RR-MS according to the guidelines from the International Panel on the Diagnosis of MS (McDonald et al. ) ; 3) two separate documented relapses in the last two years; 4) active MRI with at least one gadolinium(Gd) -enhancing lesion in the MRI scan at screening; 5) EDSS (extended disability status scale) score between 1.0 and 5.0; 6) no relapse during screening period; 7) pre-treatment with COPAXONE® for at least three weeks, but no more than four weeks, prior to baseline visit; and 8) ability to understand and provide informed consent.
Participant exclusion criteria include the following: 1) normal brain MRI; 2) prior treatment with COPAXONE® other than the scheduled three to four week pretreatment prior to baseline visit; 3) previous treatment with immunomodulating agents such as interferon beta or IVIg for the last 6 months prior to entry; 4) previous use of immunosuppressive agents (including azathioprine) in the' last 12 months prior study entry; 5) steroid treatment one month prior to entry; 6) women not willing to practice reliable methods of contraception; 7) pregnant or nursing women; 8) life threatening or clinically significant diseases; 9) history of alcohol and drug abuse within 6 months prior enrollment; 10) known history of sensitivity to Gd; 11) uncontrolled and uncontrollable head movements (tremor, tics, etc.), muscle spasms, significant urinary urgency and claustrophobia, which will prevent the subject from lying still during the MRI scan; and 12) participation in other investigational therapy in the last 90 days.
MRI scans are performed during the screening visit (for eligibility) and at months 5, 10, 11 and 12. Full physical and neurological examinations are performed at -yu-
screening, baseline and at months 2, 5, 9 and 12. Safety laboratory is performed at screening baseline and at months 1, 2, 5, 9 and 12. In addition, blood Ca+ levels are monitored on the first and second months after baseline visit. The immunological profile is monitored at baseline and at months 1, 2, 4, and 5.
Primary efficacy endpoints include the following: 1) MRI variables as measured on months 10, 11, and 12; 2) total number and volume of Tl GD-enhanced lesions; 3) total number of new T2 lesions; and 4) total volume of T2 lesions. Secondary efficacy endpoints encompass the following: 1) changes in immunological parameters; and 2) PBMC proliferation in response to GA in vitro. The tertiary efficacy endpoints are as follows: 1) change from baseline in relapse rate and MS Functional Composite Score (MSFC) ; and 2) brain atrophy. Tolerability is evaluated with reference to the following: 1) percentage of subjects who discontinue the study; and 2) percentage of subjects who discontinue the study due to adverse events. Safety is evaluated with reference to 1) adverse event frequency and severity; 2) changes in vital signs and 3) clinical laboratory values.
Patients treated with the COPAXONE® and alphacalcidol combination exhibit a comparable or greater reduction in Tl and T2 Gd-enhancing lesions and other lesions, as compared to the group receiving COPAXONE® and placebo. Additionally, the group receiving the COPAXONE® and alphacalcidol combination demonstrate a comparable or greater reduction in the number of relapses per year as compared with the group receiving COPAXONE® and placebo. EXAMPLE 3 - SUPPRESSIVE ACTIVITY OF CALCITRIOL AND ALFA CALCIDOL ADMINISTERED INTRAPERITONEALLY IN THE EAE MODEL IN CSJL/F1 MICE
INTRODUCTION
The objective of this study was to test the suppressive activity of Calcitriol and Alfa Calcidol, following intraperitoneal administration every alternate day in the Experimental Autoimmune Encephalomyelitis model in CSJL/F1 mice.
Background
The EAE is an animal model for multiple sclerosis.
The CSJL/ FI strain of mouse was selected, as it is an established EAE model.
General Design
Disease was induced in all mice by the injection of the encephalitogenic emulsion (MSCH/CFA) . The test articles and the vehicle were administered until the termination of the study 23 days after initiation.
MATERIALS
1) Polyethylene glycol 400 (PEG 400), RLB # 044T0299, Exp. Datel4.6.2009.
2) Calcitriol, CN 413700304
3) Alfa Calcidol, CN 412700104
4) 0.05M Di sodium Phosphate Buffer for dissolving of Calcitriol and Alfa Calcidol
5) Purified water
6) Tri sodium citrate dihydrate, Lot # A188648
7) Citric acid anhydrous, RLB 034T0025
8) Lutrol F127 (Poloxamer 407) , Lot 180026
9) Pertusis toxin, "Sigma", Code # 2980, Lot # 044K1449, Exp. Date 7.7.2005.
10) Lyophilized mouse spinal cord homogenate (MSCH), batch # 27BG.
11) Complete Freund' s Adjuvant (CFA) "Sigma", code: F-5881, Lot # 093K8932.
12) PBS "Sigma" code 3813, batch # 260, Exp. Date 14.6.2005.
EXPERIMENTAL ANIMALS
Healthy, nulliparous, non-pregnant female mice of the CSJL/FI strain were obtained from Harlan Animal Breeding Center, Jerusalem, Israel. The animals weighed about 17- 20 g on arrival, and approximately 7 weeks of age. The body weights of the animals will be recorded on the day of delivery. Overtly healthy animals were assigned to study groups arbitrarily before treatment commenced. The mice were individually identified by ear tags. A color- coded card on each cage gave information including cage number, group number and identification.
Appropriate animals housing and care conditions were maintained. TEST PROCEDURES
EAE was induced by injecting the encephalitogenic mixture (emulsion) consisting of MSCH and commercial CFA containing 1 mg/mL Mycobacterium tuberculosis to the hind leg foot-pad of the animals. Pertussis toxin was injected intravenously on the day of induction and 48 hours later.
110 mice were allocated to the following treatment groups (10 mice/group) :
Figure imgf000094_0001
Figure imgf000095_0001
The test formulations were prepared in darkness in amber colored vials. Contents of the vial containing 1.0 mg Calcitriol and Alfa Calcidol were reconstituted with 10 mL vehicle (80% Propylene Glycol in 0.05 M disodium phosphate, ph 7.4) to yield 100 μg/mL and diluted further with the buffer, 0.05 M disodium phosphate, ph 7.4 to reach working concentrations of the test articles. The test formulations were freshly prepared and used- immediately after preparation.
The mice of groups #3 to 11 were administered intraperitoneally every alternate day (every Sunday, Tuesday and Thursday) for three weeks with the respective dose levels of Calcitriol and Alfa Calcidol at volume dose level of 100 μL/mouse.
The test formulations administered subcutaneously were injected in different places in the flanks and scapular region of the neck.
The vehicle - 30% PEG 400, 0.7% Poloxamer 407, 0.01M Citric buffer was administered to Group # 1 subcutaneously in a similar manner.
EXPERIMENTAL OBSERVATIONS
All animals were examined once daily to detect if any is dead or moribund.
Scoring of EAE clinical signs was initiated from Day 10 post-EAE induction and was continued daily until Day 22. The clinical signs were recorded on observation cards according to the grading system described in the table below.
Evaluation of the EAE clinical signs.
Figure imgf000097_0001
All mice having a score of 1 and above were considered sick. When the first clinical sign appears all mice were given food soaked in water for supportive treatment, which was spread on different places on the bedding of the cages .
Moribund animals were sacrificed on humane grounds . Animals with score 4 for three days were given score 5 and sacrificed on humane grounds. For calculation purposes, the score of animals that were sacrificed or died (5) was carried forward. Interpretation of Results
1) Calculation of the incidence of disease (Disease ratio) :
- The number of sick animals in each group was obtained.
- The incidence of disease was calculated as
number of sick mice in group total number of mice in group
The percent inhibition according to incidence was calculated as
Percent inhibition =l-[incidence in treated group/ incidence in control group] X 100
2) Calculation of the mortality/ morbidity rate (mortality ratio:
The number of dead or moribund animals in each group was obtained and divided by the total number of mice in the group.
3) Calculation of disease duration:
The mean duration of disease expressed in days was calculated as
∑ disease duration of each mouse / number of mice in the group. For calculation purposes, the disease duration period for a mouse that did not develop EAE during the observation period was considered as 0 days.
4) Calculation of the mean maximal score and percent inhibition:
The mean maximal score (MMS) of each group was calculated as
∑ maximal score of each mouse / number of mice in the group.
The percent inhibition according to MMS was calculated as
Percent inhibition =1- MMS of treated group/ MMS of control group X 100
5) Calculation of the group mean score and percent inhibition:
The daily scores of each mouse in the test group were summed and the individual mean daily score (IMS) was calculated as
∑ daily score of mouse / observation period (days) .
The group mean score (GMS) was calculated as
∑ IMS of each mouse / number of mice in the group. The percent inhibition was calculated as
Percent inhibition =!-[ GMS of treated group 1 X 100
•GMS of control group
RESULTS
The individual daily scores of each mouse, mean maximal scores (MMS) , incidence, mortality, group mean score (GMS), onset of disease, duration of disease and a figure of the clinical profile were recorded.
A summary of the incidence, mortality, MMS and GMS and the activity of each group according to incidence, MMS and GMS is shown in the Summary Table 5.
Calcitriol was toxic at dose level of 10 μg/kg. After two administrations the mice in this group were treated with 2 μg/kg. 1 mouse in this group died due to toxicity of test formulation.
Mice in groups treated with 2 and 5 μg/kg Calcitriol exhibited slight toxic signs manifested by piloerection, hunch posture, hypo activity and apathy.
Calcitriol exhibited inhibition of EAE at dose levels of 1.0, 2.0 and 5.0 μg/kg with between 75.5 and 81.4% (p= between 0.003 and 0.008) activity according to GMS compared to the control group where the vehicle was administered intra peritoneally. Group treated with 0.5 μg/kg Calcitriol did not suppress EAE. The GMS in this group was 17.8% lower than the vehicle administered control group.
The groups treated with high dose levels of Alfa Calcidol exhibited severe toxic signs. All 10 mice died in group treated with 10 μg/kg.
Because of toxic signs in group treated with 20 μg/kg, after two administrations of 20 μg/kg, the mice in this group were treated with 4 μg/kg Alfa Calcidol. 6/10 mice died in this group.
Mice in groups treated with 4 and 2 μg/kg Alfa Calcidol exhibited toxic signs manifested by loss in body weight, partial eye lid closure, piloerection, hunch posture, hypo activity and apathy.
Group treated with 1.0 μg/kg Alfa Calcidol did not suppress EAE. The GMS in this group was 18.1% lower than the vehicle administered control group.
Summary Table 5: Mortality, incidence, MMS, GMS and duration of EAE of various test rou s and their activity compared to respective vehicle
Figure imgf000102_0001
Figure imgf000103_0001
* = This group received two administrations of 10 μg/kg. As there were toxic signs this group was administered 2 μg/kg from the 3rd administration onwards
** = This group received two administrations of 20 μg/kg. As there were toxic signs this group was administered 4μg/kg from the 3rd administration onwards
Example 4 - SUPPRESSIVE ACTIVITY OF CALCITRIOL AND ALFA CALCIDOL ADMINISTERED INTRAPERITONEALLY ALONE AND TOGETHER WITH GLATIRAMER ACETATE ADMINISTERED SUBCUTANEOUSLY ALONG WITH THE ENCEPHALITOGEN IN THE EAE MODEL IN CSJL/F1 MICE
INTRODUCTION
The objective of this study was to test the suppressive activity of Calcitriol and Alfa Calcidol, following intraperitoneal administration every alternate day alone and along with Glatiramer acetate administered subcutaneousIy along with encephalitogen, in the Experimental Autoimmune Encephalomyelitis model in CSJL/F1 mice.
The EAE is an animal model for multiple sclerosis. The CSJL/ FI strain of mouse has been selected, as it is an established EAE model.
Disease was induced in all mice by the injection of the encephalitogenic emulsion (MSCH/CFA) . The test articles and the vehicle was administered until the termination of the study 23 days after initiation.
MATERIALS
1) Propylene Glycol, 1,2-Propanediol, "Sigma", Code # P-1009,Lot # 102K0172
2) Calcitriol, CN 413700304
3) Alfa Calcidol, CN 412700104
4) Buffer for dissolving of Calcitriol and Alfa Calcidol, 0.05 M disodium phosphate, ph 7^4
5) Purified water
6) Pertusis toxin, "Sigma", Code # 2980.
7) Lyophilized mouse spinal cord homogenate (MSCH) , batch # 27BG.
8') Complete Freund' s Adjuvant (CFA) "Sigma", code: F-5881, 093K8932. 9) PBS "Sigma" code 3813, batch # 260, Exp.
Date 14.6.2005. EXPERIMENTAL ANIMALS
Healthy, nulliparous, non-pregnant female mice of the
CSJL/FI strain obtained from Harlan Animal Breeding Center, Israel were used in the study. The animals weighed about 17-20 g on arrival, and were approximately
7 weeks of age. The body weights of the animals were recorded on the day of delivery. Overtly healthy animals were assigned to study groups arbitrarily before treatment commenced.
The mice were individually identified by markings on the body. A color-coded card on each cage gave information including cage number, group number and identification.
Appropriate animals housing and care conditions were maintained.
Animals were fed a low calcium diet. The rodent diet contained 0.2 % Calcium and no vitamin D was added to the diet. The lot of the batch was # 05030107i. It was prepared by Research diets inc, New Brunswick, USA. The animals were on this diet from two days before initiation of the study until the termination of the study.
TEST PROCEDURES
EAE was induced in groups not treated by GA by injecting 50 μL of the encephalitogenic mixture (emulsion) consisting of MSCH and commercial CFA containing 1 mg/mL Mycobacterium tuberculosis to the hind leg foot-pad of the animals . The groups treated with GA were injected in the hind leg' foot-pad of the animals with 50 μL of encephalitogenic mixture (emulsion) containing appropriate dose level of GA.
Emulsion consisting of 1 mg/mL and 2 mg/rriL GA (for dose levels of 1.25 and 2.5 mg/kg respectively) in MSCH diluted 1:2 with CFA containing 1 mg/mL Mycobacterium tuberculosis was injected.
Pertussis toxin was injected intravenously to all EAE induced mice on the day of induction and 48 hours later.
The three blocks of mice (MSCH in PBS, MSCH in 1 mg/mL GA and MSCH in 2 mg/mL GA) were each divided into four groups of mice (total 12 groups) . Each group consisted of . 10 to 11 mice.
The mice were allocated to the following treatment groups (10-11 mice/group) :
Figure imgf000106_0001
Figure imgf000107_0001
The Calcitriol and Alfa Calcidol dilutions were prepared in amber colored bottles in the dark. Contents of the vial containing 1.0 mg Calcitriol or Alfa Calcidol was reconstituted with 10 mL vehicle (80 % Propylene Glycol in 0.05 M disodium phosphate, ph 7.4) to yield 100 μg/mL and diluted further with the buffer (0.05 M disodium phosphate, ph 7.4) to reach working concentrations of the test articles.
The mice were administered intraperitoneally every alternate day (every Sunday, Tuesday and Thursday) for three weeks with the respective dose levels of Calcitriol and Alfa Calcidol at volume dose level of 100 μL/mouse. The test formulations were freshly prepared and used immediately after preparation.
The vehicle was administered in a similar manner to groups treated with GA alone and to the control group.
The groups treated with GA received the treatment once. The GA was administered in emulsion form during time of induction along with the encephalitogen
EXPERIMENTAL OBSERVATIONS
All animals were examined once daily to detect if any is dead or moribund. Scoring of EAE clinical signs was initiated from Day 10 post-EAE induction and was continued daily until Day 22. The clinical signs were recorded on observation cards according to the grading system described in the table below.
Evaluation of the EAE clinical signs.
Figure imgf000108_0001
AlI mice having a score of 1 and above were considered sick. When the first clinical sign appears all mice were given food soaked in water for supportive treatment, which was spread on different places on the bedding of the cages .
Moribund animals were sacrificed on humane grounds . Animals with score 4 for three days were given score 5 and sacrificed on humane grounds .
For calculation purposes, the score of animals that were sacrificed or died (5) was carried forward.
Interpretation of Results
1) Calculation of the incidence of disease (Disease ratio) :
- The number of sick animals in each group was obtained.
- The incidence of disease was calculated as
number of sick mice in group/ total number of mice in group
The percent inhibition according to incidence was calculated as
Percent inhibition =l-[incidence in treated group/incidence in control group] X 100 2) Calculation of the mortality/ morbidity rate (mortality ratio) :
The number of dead or moribund animals in each group was obtained and divided by the total number of mice in the group.
3) Calculation of disease duration:
The mean duration of disease expressed in days was calculated as
∑ disease duration of each mouse / number of mice in the group.
For calculation purposes, the disease duration period for a mouse that did not develop EAE during the observation period was considered as 0 days.
4) Calculation of the mean maximal score and percent inhibition:
The mean maximal score (MMS) of each group was calculated as
∑ maximal score of each mouse / number of mice in the group
The percent inhibition according to MMS was calculated as
Percent inhibition =1- MMS of treated group/ MMS of control group X 100 5) Calculation of the group mean score and percent inhibition:
The daily scores of each mouse in the test group were summed and the individual mean daily score (IMS) was calculated as
∑ daily score of mouse / observation period (days)
The group mean score (GMS) was calculated as
∑ IMS of each mouse / number of mice in the group
The percent inhibition was calculated as
Percent inhibition=l-f 6MS of treated group ] X 100
GMS of control group
RESULTS
The individual daily scores of each mouse, mean maximal scores (MMS), incidence, mortality, group mean score (GMS), onset of disease, duration of disease and a figure of the clinical profile were recorded.
A summary of the incidence, mortality, MMS and GMS and the activity of each group according to incidence, MMS and GMS is shown in the Summary Table 6.
Calcitriol at dose levels of 0.5 μg/kg and 2.0 μg/kg exhibited additive effect with GA at dose level of 1.25 mg/kg. The group mean score of groups treated with 1.25 mg/kg GA along with 0.5 μg/kg and 2.0 μg/kg Calcitriol were 95.8 % (p = 0.00000001) and 75.0 % (p = 0.0001) less than the vehicle administered control group.
In each of the three groups treated alone with Calcitriol at dose level of 0.5 μg/kg and 2.0 μg/kg, and GA at dose level of 1.25 mg/kg, the group mean scores were 33.3 % (p = 0.1) less than the vehicle administered control group.
Alfa Calcidiol at dose level of 1.0 μg/kg exhibited 83.3 % inhibition (p = 0.000004) of EAE compared to the vehicle treated control group. Thus the additive effect if any, of 1.0 μg/kg Alfa Calcidiol with both the dose levels of GA (1.25 and 2.5 mg/kg) could not be observed.
GA at dose level of 2.5 mg/kg exhibited 87.5 % inhibition (p = 0.000001) of EAE compared to control group. Thus the additive effect of 2.5 mg/kg GA with both the dose levels of
Calcitriol (0.5 μg/kg and 2.0 μg/kg) could not be observed.
Summary Table 6: Mortality, incidence, MMS, GMS and duration of EAE of various test rou s and their activity
Figure imgf000113_0001
Figure imgf000114_0001
Summary table 7 (neurological score at days past immunization is shown in Fig.4)
Figure imgf000114_0002
* The value in parentheses is number of mice died not from the disease
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Claims

What is claimed is:
1. A method of alleviating a symptom of multiple sclerosis in a human subject comprising administering to the human subject in need thereof a dose of a calciferol compound effective to alleviate the symptom of multiple sclerosis.
2. The method of claim 1, wherein the symptom of multiple sclerosis is fatigue.
3. The method of claim 1, wherein the symptom of multiple sclerosis is frequency of relapses in a human subject afflicted with relapsing-remitting multiple sclerosis.
4. The method of any of claims 1-3, wherein the calciferol compound is lα,25 dihydroxyvitamin D3; lα-hydroxyvitamin D3; lα,25-dihydroxyvitamin D2; lα-hydroxyvitamin D2; lα, 25- (OH) 2-16-ene-D3; lα,25- (OH)2-24-oxo-16-ene-D3; lα, 24R(OH) 2-D3, ; lα, 25 (OH)2- 22-oxa-D3; 20-epi-22-oxa-24α, 24β, -dihomo- lα, 25 (OH) 2-D3; 20-epi-22-oxa-24α, 26α, 27α, -trihomo- lα; 25 (OH) 2-D3, 20-epi-22-oxa-24homo-lα, 25 (OH) 2- D3; 1, 25- (OH) 2-16, 23E-diene-26-trifluoro-19-nor-D3; lα, 25-dihydroxy-16ene-vitamin D3; lα, 25-dihydroxy- 24-oxo-16ene-vitamin D3; lα, 24R-dihydroxy-vitamin D3; lα,25-dihydroxy-22-oxa-vitamin D3; 20-Epi-22- oxa-24a, 27, 27a-trihomo-lα, 25-dihydroxy-vitamin D3; 19-nor-l, 25-dihydroxy-vitamin D3; 1, 25-dihydroxy- lβene-vitamin D3; 20-Epi-22-oxa-24a, 27, 27a- trihomo-1, 25-dihydroxy-vitamin D3; 1, 25-dihydroxy- 16, 23E-diene-26-trifluoro-19-nor-cholecalciferol; llα-vinyl-lα, 25-dihydroxy-vitamin D3; lα,25- dihydroxy-16ene-23yne-vitamin D3; 24-homo-22- dehydro-22E-lα, 25-dihydroxy-vitamin D3; 1,25- dihydroxy-22ene-24-homo-vitamin D3; 2- (3- hydroxypropoxy) -1, 23-dihydroxy vitamin D3; LG190090; LG190119; LG190155; LG190176; or LG1900178.
5. The method of claim 4, wherein the calciferol compound is alphacalcidol or calcitriol.
6. The method of any of claims 1-5, wherein the human subject has never received another compound for the alleviation of a symptom of multiple sclerosis .
7. The method of any of claims 1-5, wherein the human subject at the time of first administration of the calciferol compound has been receiving another compound for the alleviation of a symptom of multiple sclerosis.
8. The method of claim 7, wherein the human subject' has been receiving another compound for the alleviation of a symptom of multiple sclerosis for more than 4 weeks .
9. The method of claim 7 or 8, wherein the other compound is glatiramer acetate.
10. The method of any of claims 7-9, wherein each of the dose of the calciferol compound when taken alone, and the dose of the other compound when taken alone, is effective to alleviate the symptom of multiple sclerosis.
11. The method of any of claims 7-9, wherein the dose of the calciferol compound and the dose of the other compound, when administered to the same human subject are effective to alleviate the symptom of multiple sclerosis. ■
12. A method of reducing the frequency of relapses in a human subject who is afflicted with relapsing- remitting multiple sclerosis comprising administering to the human subject a dose of glatiramer acetate and administering to the human subject a dose of alphacalcidol or calcitriol, wherein the dose of glatiramer acetate and the dose of alphacalcidol or calcitriol when administered to the same human subject are effective to reduce the frequency of relapses in the human subject.
13. The method of claim 12, wherein the human subject has never received glatiramer acetate treatment.
14. The method of claim 12, wherein the human subject has been receiving glatiramer acetate treatment prior to administration of alphacalcidol or calcitriol, and the dose of alphacalcidol or' calcitriol is effective to reduce the frequency of relapses experienced by the human subject during ongoing treatment with glatiramer acetate as compared with the frequency of relapses experienced by the human subject during treatment with glatiramer acetate only.
15. The method of any of claims 12-14, wherein the dose of glatiramer acetate is in the range from 80 to 600 mg/week.
16. The method of claim 15, wherein the dose of glatiramer acetate is 300 mg/week.
17. The method of any of claims 12-14, wherein the dose of glatiramer acetate is in the range from 10 to 80 mg/day.
18. The method of claim 17, wherein the dose of glatiramer acetate is 20 mg/day.
19. The method of any of claims 12-18, wherein the dose of alphacalcidol or calcitriol is in the range of 3 μg to 80 mg/week.
20. The method of claim 19, wherein calcitriol only is administered at a dose of 5 μg to 10 μg once per week.
21. The method of any of claims 12-18, wherein the dose of alphacalcidol or calcitriol is in the range of 0.5 μg to 10 mg/day.
22. The method of claim 21, wherein the dose of alphacalcidol or calcitriol is 1 μg/day.
23. The method of any of claims 12-22, wherein the dose administration of glatiramer acetate is effected daily.
24. The method of any of claims 12-22, wherein the administration of glatiramer acetate is effected once every 5 to 9 days .
25. The method of any of claims 12-22, wherein the administration of alphacalcidol or calcitriol is. effected once every 20 to 28 hours.
26. The method of any of claims 12-25, wherein the administration of alphacalcidol or calcitriol is effected once daily.
27. The method of any of claims 12-26, wherein the administration of the glatiramer acetate is effected subcutaneously, intraperitoneally, intravenously, intramuscularly, intraocularly or orally; and the administration of the alphacalcidol or calcitriol is effected orally.
28. The method of claim 27, wherein the administration of the glatiramer acetate is effected subcutaneously and the administration of the alphacalcidol or calcitriol is effected orally.
29. The method of any of claims 12-28, wherein each of the dose of glatiramer acetate when taken alone, and the dose of alphacalcidol or calcitriol when taken alone is effective to reduce the frequency of relapses in a human subject afflicted with relapsing-remitting multiple sclerosis.
30. A method of reducing fatigue in a human subject who is afflicted with relapsing-remitting multiple sclerosis comprising administering to the human subject a dose of glatiramer acetate and administering to the human subject a dose of alphacalcidol or calcitriol, wherein the dose of glatiramer acetate and the dose of alphacalcidol or calcitriol when administered to the same human subject are effective to reduce fatigue in the human subject.
31. The method of claim 30, wherein the human subject has never received glatiramer acetate treatment.
32. The method of claim 30, wherein the human subject has been receiving glatiramer acetate treatment for more than 4 weeks prior to administration of alphacalcidol or calcitriol, and the dose of alphacalcidol or calcitriol is effective to reduce the fatigue experienced by the human subject during ongoing treatment with glatiramer acetate as compared with the fatigue experienced by the human subject during treatment with glatiramer acetate only.
33. The method of any of claims 30-32, wherein the dose of glatiramer acetate is in the range from 80 to 600 mg/week.
34. The method of claim 33, wherein the dose of glatiramer acetate is 300 mg/week.
35. The method of any of claims 30-32, wherein the dose of glatiramer acetate is in the range from 10 to 80 mg/day.
36. The method of claim 35, wherein the dose of glatiramer acetate is 20 mg/day.
37. The method of any of claims 30-36, wherein the dose of alphacalcidol or calcitriol is in the range of 3.0 μg to 80 mg/week.
38. The method of claim 36, wherein calcitriol only is administered at" a dose of 5 μg to 10 μg once per week.
39. The method of any of claims 30-36, wherein the dose of alphacalcidol or calcitriol is in the range of .5 μg to 10 mg/day.
40. The method of claim 39, wherein the dose of alphacalcidol or calcitriol is 1 μg/day.
41. The method of any of claims 30-40, wherein the administration of glatiramer acetate is effected daily.
42. The method of any of claims 30-40, wherein the administration of glatiramer acetate is effected once every 5 to 9 days.
43. The method of any of claims 30-40, wherein the administration of alphacalcidol or calcitriol is effected once every 20 to 28 hours.
44. The method of any of claims 30-43, wherein the administration of alphacalcidol or calcitriol is effected once daily.
45. The method of any of claims 30-44, wherein the administration of the glatiramer acetate is effected subcutaneously, intraperitoneally, intravenously, intramuscularly, intraocularly or orally; and ' the administration of the alphacalcidol or calcitriol is effected orally.
46. The method of claim 45, wherein the administration 5 of the glatiramer acetate is effected subcutaneously and the administration of the alphacalcidol calcitriol is effected orally.
47. The method of any of claims 30-46, wherein each of the dose of glatiramer acetate when taken alone,
10 and the dose of alphacalcidol or calcitriol when taken alone is effective to reduce fatigue in a human subject afflicted with relapsing-remitting multiple sclerosis.
48. A product containing glatiramer acetate and at 15 least one of alphacalcidol or calcitriol as a combined preparation for simultaneous, separate or sequential use for reducing fatigue in a human subject afflicted with relapsing-remitting- multiple sclerosis .
20 49. Use of glatiramer acetate and at least one of alphacalcidol or calcitriol for the manufacture of a medicament for use in reducing fatigue in a human subject who is afflicted with relapsing- remitting multiple sclerosis but who has never
2.5 received glatiramer acetate treatment.
50. Use of alphacalcidol or calcitriol for the manufacture of a medicament for use in reducing fatigue in a human subject afflicted with relapsing-remitting multiple sclerosis and already receiving glatiramer acetate treatment.
51. A product containing glatiramer acetate and at least one of alphacalcidol or calcitriol as a combined preparation for simultaneous, separate or sequential use for reducing the frequency of relapses in a human subject afflicted with relapsing-remitting multiple sclerosis.
52. Use of alphacalcidol or calcitriol for the manufacture of a medicament for use in reducing the frequency of relapses in a human subject who is afflicted with relapsing-remitting multiple sclerosis but who has never received glatiramer acetate treatment.
53. Use of glatiramer acetate and at least one of alphacalcidol or calcitriol for the manufacture of a medicament for use in reducing the frequency of relapses in a human subject afflicted with- relapsing-remitting multiple sclerosis and already receiving glatiramer acetate treatment.
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Cited By (2)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
WO2007036802A3 (en) * 2005-07-07 2007-08-30 Teva Pharma Sublingual dosage form comrising vitamin d analogue, in particular calcitriol
WO2009097614A1 (en) * 2008-02-01 2009-08-06 Wisconsin Alumni Research Foundation Methods of treating multiple sclerosis by administering pulse dose calcitrol

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US5716946A (en) * 1996-02-13 1998-02-10 Wisconsin Alumni Research Foundation Multiple sclerosis treatment
US6214791B1 (en) * 1997-01-10 2001-04-10 Yeda Research And Development Co. Ltd. Treatment of multiple sclerosis through ingestion or inhalation of copolymer-1
US6114317A (en) * 1998-05-21 2000-09-05 Wisconsin Alumni Research Foundation Method of locking 1α-OH of vitamin D compounds in axial orientation

Cited By (2)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
WO2007036802A3 (en) * 2005-07-07 2007-08-30 Teva Pharma Sublingual dosage form comrising vitamin d analogue, in particular calcitriol
WO2009097614A1 (en) * 2008-02-01 2009-08-06 Wisconsin Alumni Research Foundation Methods of treating multiple sclerosis by administering pulse dose calcitrol

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