TECHNICAL FIELD

The present invention relates to a composition for oral administration suitable for use in reducing and/or preventing the complications of iron overload in a subject. It also provides combinations of said composition with one or more iron-chelating agents.

BACKGROUND OF THE INVENTION

Iron overload results from excess absorption of iron, repeated blood transfusions, or excess oral intake, typically in patients with disorders of erythropoiesis. The most common cause of iron overload is chronic transfusion therapy for inherited anemias and acquired refractory anemias.

Patients with hemoglobinopathies (eg, sickle cell disease, b-thalassemia, sideroblastic anemias), congenital hemolytic anemias (eg, hemoglobinopathies, hereditary spherocytosis) and myelodysplasia undergo regular transfusions. Repeated blood transfusions result in excessive free iron concentration in the blood, causing increased oxidative stress and generation of free radicals. The latter have been implicated in the development of the serious complications of transfusion-related iron overload such as cell damage and subsequent tissue damage. Transfusional iron overload can lead to hepatic fibrosis, arrhythmias and congestive heart failure and a number of endocrinopathies. Iron overload can also result in arthropathy, neurodegenerative disorders, hyperpigmentation, pulmonary hypertension and carcinogenesis.

In order to prevent iron overload, three iron chelators — deferoxamine (DFO), deferiprone (DFP), and deferasirox (DFX) — have been used to remove excess iron in these patients. Each of these chelators has their own advantages and disadvantages, various target diseases, levels of deposited iron and clinical symptoms of the afflicted patients which may affect their selection as the best modality.

Various studies have also evaluated and supported the use of natural ingredients as alternatives to iron chelation therapy for the prevention of the complications cause by iron overload and by the subsequent oxidative stress. The inventors have developed a formulation with natural active ingredients which, according to published studies, have the ability to act as chelating agents and effective antioxidants in order to prevent the aforementioned side effects of iron overload. The ingredients used in the formulation have been separately and individually studied in the various publications. The product disclosed herein contains in a single dose (one tablet per day for adults), the most effective natural active ingredients studied as chelating agents and antioxidants for use in the reduction and/or prevention of the complications of iron overload in a subject, in particular of the complications caused by repeated blood transfusions in patients suffering from thalassemia major, sickle cell disease, aplastic anemia or myelodysplasia. SUMMARY OF THE INVENTION

The invention described herein addresses a need to provide a composition comprising natural ingredients for the reduction and/or prevention of the complications of iron overload in a subject.

One aspect of this invention pertains to compositions for oral administration comprising curcumin within the range from 20 to 600 mg, N-acetyl-L-cysteine within the range from 150 to 250 mg, and one or more vitamins selected from the group consisting of vitamin D, folic acid and vitamin E. Said compositions may optionally comprise Coenzyme Q10 within the range from 50 to 150 mg, one or more minerals selected from the group consisting of zinc, magnesium and selenium, silicon dioxide within the range from 0.5 wt% to 5.0 wt%, one or more disintegrants, fillers and/or lubricants.

A further aspect provides pharmaceutical combinations comprising the compositions of the present invention combined with one or more iron-chelating agents such as deferoxamine, deferiprone, deferasirox, dexrazoxane and ciclopirox.

Yet another aspect provides compositions according to the present invention for use in reducing and/or preventing the complications of iron overload in a subject. Said compositions are particularly useful in the reduction and/or prevention of transfusion- related iron overload in patients suffering from inherited anemias and acquired refractory anemias such as thalassemia major, sickle cell disease, aplastic anemia or myelodysplasia.

Other aspects and further scope of applicability of the present invention will become apparent from the detailed description to follow. DETAILED DESCRIPTION OF THE INVENTION

Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by those of ordinary skill in the art considering the present disclosure and context. All amounts specified herein are based on milligrams unless otherwise indicated. The term "meg" means micrograms, "mg" means milligrams, and "g" means grams. Further, it should be understood that the amounts of components disclosed herein are for a daily dosage and that a daily dosage may comprise one dosage unit or a plurality of dosage units.

The invention provides compositions for administration to humans, comprising curcumin, N- acetyl-L-cysteine and one or more vitamins selected from the group consisting of vitamin D, folic acid and vitamin E. In one embodiment, the compositions comprise curcumin within the range from 20 to 600 mg, N-acetyl-L-cysteine within the range from 150 to 250 mg, and one or more vitamins selected from the group consisting of vitamin D, folic acid and vitamin E. In a preferred embodiment, the compositions comprise curcumin within the range from 20 to 600 mg, N-acetyl-L-cysteine within the range from 150 to 250 mg, and an effective amount of vitamin D, folic acid and vitamin E.

When administered to a human on a regular basis, for example, on a daily basis, the composition of the invention facilitates adequate intake of curcumin, N-acetyl-L-cysteine and vitamins to promote good health. Epidemiological and intervention trials have demonstrated that curcuminoids possess several pharmacological properties including antioxidant, iron-chelating, and anti-inflammatory activities. According to Hatairaktham S. et al., (Ann Hematol. 2021 Jan 3. doi: 10.1007/s00277-020-04379~7) a 24-week curcuminoids supplementation significantly lowered the levels of oxidative stress, hypercoagulability, and inflammatory markers in non- transfused b-thalassemia/Hb E patients. In addition, a double-blind randomized controlled clinical trial conducted on 68 b-thalassemia major patients showed that curcumin administration alleviated iron burden and liver dysfunction by significantly reducing serum levels of nontransferrin bound iron at the end of the study (Mohammadi E et al., Phytother Res. 2018 Sep;32(9):1828-1835). Curcumin is a hydrophobic polyphenol derived from the rhizome of the herb Curcuma longa. The extract of Curcuma longa (turmeric) contains curcuminoids in an amount of 95 wt%. Curcuminoids consist of 65-80 wt% curcumin, 15-20 wt% dimethoxycurcumin and 2-5 wt% bis-demethoxycurcumin. In certain embodiments of the invention, the compositions comprise curcumin in the form of the extract. Curcumin itself is not soluble in water and has low bioavailability.

Thus, in other embodiments, the compositions comprise curcumin in a highly bioavailable form. Any highly-bioavailable form of curcumin may be used, such as, for instance, curcumin complexed with gamma-cyclodextrin (commercially available by Wacker under the trade name Cavacurmin ^® ), curcumin enclosed in a lipophilic matrix (such as phytosomes, or mixtures of Curcumi Soy Lecithi Microcrystalline Cellulose in a ratio of 1:2:2 CSL), or curcumin enclosed in liposomes, to name a few. Cavacurmin ^® is an inclusion complex of natural curcumin with CAVAMAX ^® W8 gamma-cyclodextrin. It is a highly bioavailable curcumin complex that is around 40 times more efficiently absorbed than standard turmeric extract, also having high dispersibility, making it suitable for pharmaceutical formulations. Thus, in the embodiments where curcumin is present in the composition in a complexed, highly bioavailable form, the amount of curcumin included in the compositions of the invention may be substantially reduced. In preferred embodiments, the compositions comprise curcumin in the composition in a complexed, highly bioavailable form, the concentration of curcumin in the composition being within the range from 20 mg to 50 mg. In most preferred embodiments, the compositions comprise curcumin complexed with gamma-cyclodextrin, the concentration of curcumin in the composition being within the range from 20 mg to 50 mg.

N-acetyl L-cysteine (NAC) has also shown efficacy as an antioxidant on iron overload. In a randomized controlled trial, NAC was effective in reduce the oxidative status and increase the pre-transfusion hemoglobin levels in children with thalassemia major. Furthermore, NAC could reduce iron overload in these patients (Yasmen A Mohamed Y.A. et al. (Clin Exp Pediatr. 2020 Nov 3. doi: 10.3345/cep.2020.00227). NAC also restored heart rate variability and prevented serious adverse events in transfusion-dependent thalassemia patients in a double-blind single center randomized controlled trial (Pattanakuhar S. et al., Int J Med Sci. 2020 May 18;17(9):1147-1155. The role of vitamins as anti-oxidants is well documented. Vitamin D deficiency is common in thalassemia major patients and strongly associated with cardiac iron uptake and ventricular dysfunction. It has been hypothesized that the increased oxidative damage observed in thalassaemia major may be due to the depletion of lipid soluble antioxidants such as vitamin D and vitamin E. Folate - the naturally occurring form of folic acid - is a vitamin essential for the maturation of erythrocytes, therefore it is essential for the uptake of iron in red blood cells.

An "effective amount" of a vitamin typically quantifies an amount at least about 10% of the Nutrient Reference Values ("NRV") according to Regulation (EU) No 1169/2011 for that particular vitamin. It is contemplated, however, that amounts of certain vitamins exceeding the NRV may be beneficial for certain subjects. For example, the amount of a given vitamin may exceed the applicable NRV by 100%, 200%, 300% or more. The form of the vitamin may include salts of the vitamin, derivatives of the vitamin, compounds having the same or similar activity of a vitamin, and metabolites of a vitamin. According to the invention, Vitamin D may be in the form of ergocalciferol (D2), cholecalciferol (D3), calcidiol (25 hydroxyvitamin D), or calcitriol (1, 25 dihydroxyvitamin D). Preferably, vitamin D is in the form of cholecalciferol.

Vitamin E may be in the form of any suitable salt, such as in the form of d-alpha tocopheryl acetate or d-alpha tocopheryl succinate. Vitamin E may also be in the form of any vitamin E isomer, such as alpha (a-), beta (b-), gamma (y-), or delta (d-) tocopherol or alpha (a-), beta (b-), gamma (y-), or delta (d-) tocotrienol, preferably in the form of alpha tocopherol.

By providing a combination of these agents in one composition, this invention provides for a natural, convenient and relatively inexpensive way to facilitate the amelioration of the symptoms and complications of iron overload and oxidative stress that follows it. The compositions of the invention may further comprise Coenzyme Q10. The levels of coenzyme Q10 are very low in thalassemia patients. Clinical trials have shown that the administration of Coenzyme Q10 led to significant improvement of biochemical parameters of antioxidant enzymes in beta-thalassemia/Hb E patients (Kalpravidh R.W. et a I., Biofactors. 2005;25(l-4):225-34). The compositions of the present invention may additionally comprise one or more minerals selected from the group consisting of zinc, magnesium and selenium. In a preferred embodiment, the compositions further comprise zinc, magnesium and selenium. The compositions may include one or more forms of an effective amount of any of the minerals described herein or otherwise known in the art. An "effective amount" of a mineral typically quantifies an amount at least about 10% of the Nutrient Reference Values ("NRV") according to Regulation (EU) No 1169/2011 for that particular mineral for a subject. It is contemplated, however, that amounts of certain minerals exceeding the NRV may be beneficial for certain subjects. For example, the amount of a given mineral may exceed the applicable NRV by 50%, 100% or more.

The minerals may be supplied in any suitable form, either organic or inorganic. Suitable forms of minerals include soluble mineral salts, slightly soluble mineral salts, insoluble mineral salts, chelated minerals, mineral complexes, non-reactive minerals such as carbonyl minerals, and reduced minerals, and combinations thereof. Zinc is characterized as an anti-oxidant due to its ability to protect the cell from the effects of oxidative damage, possibly through its interaction with cellular thiols, preventing their oxidative inactivation, and by competing with metal ions that produce reactive oxygen species. In addition, Zinc deficiency may occur during treatment with iron chelators and particularly with deferiprone, thus requiring supplementation. Magnesium is an essential mineral element. Magnesium deficiency is rather common, occurring approximately in 2.5-15% of the general population. It is believed that magnesium deficiency affects iron metabolism, possibly by evoking inefficient iron utilization and iron deposition in tissues that is reinforced by oral iron overload.

Selenium functions as cofactor for reduction of antioxidant enzymes, such as glutathione peroxidases. Selenium deficiency increases iron levels in serum and various tissues because of iron liberated by promoted hemolysis. Selenium has been shown to synergize with vitamin E to provide an antioxidant defense in iron-overloaded tissues and especially in the myocardium. Any suitable form of selenium, either organic or inorganic may be used. A preferred form of selenium suitable for the present invention is selenium combined with a rice protein hydrolyzate (obtained through a controlled enzymatic hydrolysis of rice proteins), supplied by Pileje Laboratoires under the trade name Hypro-ri ^® Se.

The compositions disclosed herein are intended for oral administration. In certain embodiments, the compositions of the invention are formulated in liquid form, such as in the form of aqueous solutions, syrups and the like.

In other embodiments, the compositions of the invention are formulated in solid form. The solid compositions may, in some embodiments, contain liquid or semi-solid components. Suitable solid dosage forms of the present invention include, but are not limited to, tablets, caplets, capsules including soft gel capsules, chewable dosage forms of and sachets and the like. In a preferred embodiment, the compositions disclosed herein are in the form of a tablet. In another preferred embodiment, the compositions of the present invention are in the form of a capsule, such as a soft gelatin capsule or a hard capsule. Preferably, the compositions of the invention are formulated in solid form.

Depending on the dosage form different auxiliary substances and carrier materials are used. Therefore, in addition to the active materials, the compositions may further comprise excipients and processing aides such as: absorbents, diluents, flavorants, colorants, stabilizers, fillers, binders, disintegrants, lubricants, wetting agents, glidants, antiadherents, sugar or film coating agents, preservatives, pH buffering agents, artificial sweeteners, natural sweeteners, dispersants, carriers, phospholipids, thickening agents, solvents, salts for varying the osmotic pressure, thickeners, solubilizing agents and the like or some combination thereof.

In preferred embodiments, the solid compositions of the invention, apart from the active substances, also comprise one or more disintegrants, one or more fillers and/or one or more lubricants. In one embodiment, the excipient may be a disintegrant. Suitable disintegrants are, for example, sodium starch glycolate, cross-linked povidone, cross-linked sodium carboxymethyl cellulose. Preferably, the disintegrant is cross-linked sodium carboxymethyl cellulose.

In another embodiment, the excipient may be a filler. Suitable fillers include carbohydrates, inorganic compounds, and polyvinylpirrolydone. By way of non-limiting example, the filler may be calcium sulfate, both di- and tri-basic, starch, calcium carbonate, magnesium carbonate, microcrystalline cellulose, dibasic calcium phosphate, magnesium carbonate, magnesium oxide, calcium silicate, talc, modified starches, lactose, sucrose, mannitol, and sorbitol, or a combination of the above. Preferably, the filler is microcrystalline cellulose and/or calcium phosphate.

In yet another embodiment, the excipient may be a lubricant. Suitable non-limiting examples of lubricants include a magnesium salt of fatty acid such as magnesium stearate, calcium stearate, zinc stearate, hydrogenated vegetable oils, sterotex, polyoxyethylene monostearate, talc, polyethyleneglycol, sodium benzoate, sodium lauryl sulfate, magnesium lauryl sulfate or a combination thereof. Preferably, the lubricant is magnesium stearate.

Tablets according to the invention may be uncoated or may be coated by known techniques. Capsules containing the intended ingredients can be produced, for example, by mixing the intended ingredients with an inert carrier such as cellulose, microcrystalline cellulose, hydroxypropylmethyl cellulose, lactose or sorbitol and encapsulating them in gelatin capsules.

Tableting compositions containing N-acetyl L-cysteine and (where included in the composition) Coenzyme Q10 present challenges. The presence of these ingredients made the mixture sticky which causes problems during the tableting process. These properties, which include, but are not limited to picking and sticking of materials to tooling, materials sticking to the pistons of the tableting machine during compression and poor tablet weight control. Due to the increase in heat in the tabletop machine during production, these ingredients melted, resulting in the mixture becoming sticky. Turmeric extract (like many extracts) is in itself difficult to handle, especially in combination with other active ingredients that present such difficulties. In order to address this problem, the inventors conducted extensive laboratory tests to identify additional excipients that may be added to the composition to facilitate the tableting step. The efforts also focused on finding a solution that would obviate the need to split the daily dose into 2 tablets (or capsules) per day by increasing the amount of excipients or reducing the amount of problematic active ingredients. The inventors have unexpectedly found that the addition of colloidal silica (silicon dioxide) within the range from 0.5 wt% to 5.0 wt% greatly facilitated the tableting process. Thus, in one embodiment, the solid compositions of the invention further comprise silicon dioxide within the range from 0.5 wt% to 5.0 wt%. Preferably, the compositions comprise silicon dioxide within the range from 0.5 wt% to 2.0 wt%. Most preferably, the compositions comprise silicon dioxide at a concentration of 1 wt%. 5 A preferred tablet or capsule composition of the present invention comprises curcumin within the range from 300 mg to 600 mg, wherein curcumin is in the form of an extract;

N-acetyl-L-cysteine within the range from 150 mg to 250 mg;

Coenzyme Q.10 within the range from 50 mg to 150 mg;

10 vitamin E within the range from 8 mg to 16 mg; vitamin D within the range from 3 meg to 7 meg; folic acid within the range from 300 meg to 700 meg; magnesium within the range from 30 mg to 80 mg, dosed in the form of a pharmaceutically acceptable magnesium compound;

15 zinc within the range from 5 mg to 15 mg, dosed in the form of a pharmaceutically acceptable zinc compound; selenium within the range from 0.03 mg to 0.13 mg, dosed in the form of a pharmaceutically acceptable selenium compound; silicon dioxide within the range from 0.5 wt% to 2.0 wt%; and

20 one or more disintegrants, fillers and/or lubricants.

In another preferred embodiment, the tablet or capsule compositions comprise: curcumin within the range from 20 to 50 mg, wherein curcumin is in a form complexed with gamma-cyclodextrin;

N-acetyl-L-cysteine within the range from 150 mg to 250 mg;

25 Coenzyme Q10 within the range from 50 mg to 150 mg; vitamin E within the range from 8 mg to 16 mg; vitamin D within the range from 3 meg to 7 meg; folic acid within the range from 300 meg to 700 meg; magnesium within the range from 30 mg to 80 mg, dosed in the form of a pharmaceutically acceptable magnesium compound; zinc within the range from 5 mg to 15 mg, dosed in the form of a pharmaceutically acceptable zinc compound; selenium within the range from 0.03 mg to 0.13 mg, dosed in the form of a pharmaceutically acceptable selenium compound; silicon dioxide within the range from 0.5 wt% to 2.0 wt%; and one or more disintegrants, fillers and/or lubricants. In yet another preferred embodiment, the tablet or capsule compositions comprise: curcumin within the range from 20 to 50 mg, wherein curcumin is in a form complexed with gamma-cyclodextrin;

N-acetyl-L-cysteine within the range from 180 mg to 220 mg;

Coenzyme Q10 within the range from 80 mg to 120 mg; vitamin E within the range from 10 mg to 14 mg; vitamin D within the range from 4 meg to 6 meg; folic acid within the range from 400 meg to 600 meg; magnesium within the range from 40 mg to 70 mg, dosed in the form of a pharmaceutically acceptable magnesium compound; zinc within the range from 8 mg to 12 mg, dosed in the form of a pharmaceutically acceptable zinc compound; selenium within the range from 0.03 mg to 0.13 mg, dosed in the form of a pharmaceutically acceptable selenium compound; silicon dioxide within the range from 0.5 wt% to 2.0 wt% microcrystalline cellulose within the range from 20 wt% to 30 wt%; cross-linked sodium carboxymethyl cellulose within the range from 0.5 wt% to 5 wt%; calcium phosphate within the range from 8 wt% to 18 wt%; and magnesium stearate within the range from 0.5 wt% to 2.5 wt%.

The compositions of the invention in a tablet or capsule form may be prepared using ay suitable method known in the art. For instance, tablets may be prepared by combining the components by blending, mixing, stirring, shaking, tumbling, rolling or by any other methods of combining the formulation components to achieve a homogeneous blend. After blending the ingredients, the composition may be formed into tablets using compression methods, for example. Optionally the tablets may be coated using tablet coating materials and methods such as those known to those skilled in the art.

The amounts of the active ingredients disclosed herein are for a daily dose and that dose may be delivered in a single delivery unit. The compositions were designed so that the daily dose can be administered in a single delivery unit (one tablet/capsule per day) in order to achieve better patient compliance. However, it should be understood that the daily dose may administered in multiple delivery units and consumption of these units may occur at the same time or different times during the day. In some embodiments packaging design may be used to facilitate identification of the proper daily dosage to the consumer. For example, a blister pack with labeling to indicate a daily dosage may be used.

It will be appreciated that for administration to children, lower doses may be required. In children the dose may be approximately half the dose used for an adult.

In certain embodiments, the compositions of the present invention are administered in combination with one or more additional active substances. In preferred embodiments, the one or more additional active substances are iron-chelating agents. The one or more iron chelating agents include, but are not limited to, deferoxamine, deferiprone, deferasirox, dexrazoxane and ciclopirox. When taken in combination with a chelating agent, the composition should be taken 2 to 4 hours before the administration of the chelating agent, preferably 2 hours before the administration of the chelating agent.

According to certain embodiments, the compositions are suitable for use in the reduction of one or more symptoms and/or complications of iron overload in a subject. Such symptoms include, but are not limited to, fatigue, irregular heartbeat, joint pain, abdominal pain generalised darkening of skin colour, weight loss, to name a few. Complications of iron overload in a subject include, but are not limited to, liver damage, liver cirrhosis, pancreatic islet cell damage, diabetes, hypothyroidism and hypogonadism.

In preferred embodiments, the iron overload is transfusion-related. Most preferably, the compositions are suitable for use in the reduction of one or more symptoms and/or complications of transfusion-related iron overload in a subject suffering from thalassemia major, sickle cell disease, aplastic anemia or myelodysplasia.

According to other embodiments, the compositions are suitable for use in the prevention of one or more symptoms and/or complications of iron overload in a subject. Such symptoms include, but are not limited to, fatigue, irregular heartbeat, joint pain, abdominal pain generalised darkening of skin colour, weight loss, to name a few. Complications of iron overload in a subject include, but are not limited to, liver damage, liver cirrhosis, pancreatic islet cell damage, diabetes, hypothyroidism and hypogonadism.

In preferred embodiments, the iron overload is transfusion-related. Most preferably, the compositions are suitable for use in the prevention of one or more symptoms and/or complications of transfusion-related iron overload in a subject suffering from thalassemia major, sickle cell disease, aplastic anemia or myelodysplasia.