PREPARATIONS

FIELD OF THE INVENTION

[0001] The present invention relates generally to methods of treatment of type 1 diabetes mellitus. More particularly, the present invention relates to the use of helminthic parasite ova in pharmaceutical formulations to prevent onset and ameliorate symptoms of type 1 diabetes mellitus. This application claims priority to U.S. Provisional Application No. 61/786,078, filed March 14, 2013, which is incorporated herein by reference in its entirety.

BACKGROUND OF THE INVENTION

[0002] Diabetes is a serious, chronic disease affecting 246 million people worldwide. Current estimates show that 23.6 million people in the United States, or 7.8% of the population, have the disease, including 5.7 million in whom it is undiagnosed. Diabetes affects every organ system of the body. Both major types of diabetes, type 1 and type 2, can lead to serious complications and premature death.

[0003] While type 1 diabetes (T1DM0 is most often diagnosed in children and young adults, onset can occur at any age. Type 1 diabetes comprises 5% to 10% of all diagnosed cases of diabetes in adults. It is caused by autoimmune destruction of the affected individual's pancreatic islet beta cells. Several clinical observations since the 1980s have suggested that the decline in beta cell function characteristic of type 1 diabetes can be abrogated by intensive insulin-based therapies and by various immunosuppressive therapies including cyclosporine, azathioprine plus prednisone, anti-CD3 antibodies, and still others.

[0004] Although promising, these immunosuppressive therapies are limited by (i) adverse effects that may be unacceptable for a disease (type 1 diabetes) for which a treatment (insulin) is available, although imperfect, and (ii) no or only temporary slowing of the progressive loss of pancreatic islet beta cell function and insulin production.

[0005] There remains, therefore, a need for alternative treatments for pediatric, neonatal, and adult TIDM patients, particularly treatments that may be effective in slowing progressive loss of native pancreatic islet beta cell function.

SUMMARY OF THE INVENTION

[0006] The present invention relates to novel therapeutic methods for the treatment of TIDM based on an improved understanding of the autoimmune causes of TIDM.

[0007] In particular, one aspect of the present invention provides a method of treating type 1 diabetes mellitus in a human patient comprising administering to a human patient in need thereof a therapeutically effective amount of a pharmaceutical formulation comprising a helminthic parasite or a biologically active portion thereof and a pharmaceutically acceptable carrier, wherein the helminthic parasite or portion thereof is selected from the group consisting of 7 ^* . suis, S. mansoni, H. polygyrus, T. spiralis, T. trichiura and N. americ mus.

[0008) In some embodiments, the patient may be a neonatal patient or a pediatric patient. In further embodiments, biologically active portion of the helminthic parasite may be selected from the group consisting of parasite extract, parasite eggs, parasite egg extract, parasite larvae, parasite larvae extract, parasite cercariae and parasite cercariae extract. In further embodiments, the pharmaceutical formulation comprises embryonated parasite eggs or embyronated parasite egg extract of T. suis. In still further embodiments, the treatment may act to prevent lymphocyte infiltration and accompanying insulitis and beta cell apoptosis, or, in other embodiments, may prevent an expansion of autoreactive CD4+ and CD8+ T helper cells, autoantibody-producing B cells and/or activation of the innate immune system.

[0009] The effective amount may, in some embodiments, be between about 500 and about 20,000 eggs, between about 2,000 and about 10,000 eggs, be about 2,500 eggs, or be about 7,500 eggs. In further embodiments, the effective amount may be administered between about 1 and about 4 times per month for a duration of three months or greater, six months or greater, or one year or greater. The pharmaceutical formulation may be administered enterally, preferably orally. In further embodiments, the frequency of administration of the pharmaceutical formulation may be greater for a first period of time taking place at the outset of treatment, than the frequency of administration during a second period of time taking place after the first period of time. In yet further embodiments, the frequency of administration of the pharmaceutical formulation may be increased for a period of time when acute symptoms of T1DM appear or are expected to appear, followed by a return to the frequency of administration after the acute symptoms have subsided.

[0010] As used herein, "about" will be understood by persons of ordinary skill in the art and will vary to some extent depending upon the context in which it is used. If there are uses of the term which are not clear to persons of ordinary skill in the art given the context in which it is used, "about" will mean up to plus or minus 10% of the particular term.

[0011] As used herein, the term "active agent" is used to refer to a chemical material or compound that induces a desired beneficial effect when administered topically or orally, and includes agents that are therapeutically and/or prophylactically effective as pharmaceuticals ("pharmacologically active agents"). By an "effective" amount of an active agent is meant a nontoxic but sufficient amount of an active agent to provide the desired beneficial effect.

[0012) As used herein, the term "egg" refers to either embryonated or nonembryonated, viable helminth ova.

[0013] Additional features, advantages, and embodiments of the present disclosure may be set forth from consideration of the following detailed description, drawings, and claims. Moreover, it is to be understood that both the foregoing summary of the present disclosure and the following detailed description are exemplary and intended to provide further explanation without further limiting the scope of the present disclosure claimed.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0014] T1DM progression is usually clinically measured by the assessment of pancreatic beta cell function measured by the area under the curve (AUC) for the plasma C-peptide response over time to a mixed meal tolerance test (MMTT). Assessments may also be measured by assessing blood glucose control as measured by hemoglobin Ale (HbAlc), daily insulin use calculated as insulin units/kg body weight/ day, or as insulin dose-adjusted HbAlc calculated as HbAlc(%) = [4x insulin dose (U/kg per 24h)]. Other assessments used to determine efficacy of the presently claimed treatment may comprise an assessment of targeted mechanistic outcomes with a focus on immune biomarkers (e.g., serum cytokines, peripheral blood mononuclear cell subsets); measures of specific immunoglobulins to TSO to gauge the immune response; or measurement of levels of T1DM autoantibodies such as insulin, GAD, IA-2, or ZnT8. Further, secondary objectives include assessment of the effects on quality of life and/or safety outcomes.

[0015] Other tests may be conducted throughout the course of treatment to determine safety or efficacy of the treatment. As used herein, "clinical chemistry" comprises one or more of the tests selected from the group consisting of total protein, albumin, serum creatinine, blood urea nitrogen (BUN), uric acid, bilirubin (total & direct), alkaline phosphatase, alanine aminotransferase (ALT, SGPT), aspartate aminotransferase (AST, SGOT), creatine phosphokinase (CPK), glucose, calcium, phosphorus, sodium, potassium, chloride, and bicarbonate.

[0016] As used herein, "hematology" refers to the following tests: white blood cell (WBC) count, differential white cell count (lymphocytes, monocytes, basophils, eosinophils, neutrophils), red blood cell (RBC) count, hematocrit, hemoglobin and platelet count. As used herein, "urinalysis" refers to a group of tests comprising color, specific gravity, pH, glucose, ketones, blood, protein, nitrates, leukocyte esterase, RBC, WBC.

Helminthic Preparations

[0017] Embryonated eggs of certain helminths, such as, for example, porcine whipworm Trichuris suis (Trichuris suis ova, TSO), have been shown to colonize the human intestine without invading or infecting. Safety of TSO has been demonstrated in clinical studies with patients suffering from IBD, Multiple Sclerosis, allergies and other autoimmune diseases, as shown in Table 1.

Table 1 : Number (%) of Patients Experiencing Treatment-Emergent Adverse Events by MedDRA Preferred Term - Sorted by Descending Incidence in the Total TSO Column (Study CNDO 201-002)

[0018] Any immunomodulatory non-infective helminth species may be used in the methods described herein, such as, for example, T. suis, S. mansoni, H. polygyrus, T. spiralis, T. trichiura and N. americanus. The entire adult helminth may be used, or any therapeutically effective portion thereof, such as, lor example, parasite extract, parasite eggs, parasite egg extract, parasite larvae, parasite larvae extract, parasite cercariae and parasite cercariae extract. In a preferred embodiment, parasite ova are used.

[0019] Therapeutically effective amounts of the helminth or biologically active portion thereof can be empirically determined and will vary with the pathology being treated, the severity of the symptoms, and the subject being treated. The effective amount may be determined during preclinical trials and clinical trials by methods familiar to physicians and clinicians. An effective amount of a helminthic parasite preparation useful in the methods may be administered to a mammal in need thereof by any of a number of well-known methods for administering pharmaceutical compounds. The peptide may be administered systemically or locally or, in the case of a neonatal patient, may be administered to the mother. In a preferred embodiment, the administration is oral.

[0020] Oral compositions may also include an inert diluent or an edible carrier. For the purpose of oral therapeutic administration, the active compound can be incorporated with excipients and used in the form of tablets, troches, or capsules, e.g., gelatin capsules. Oral compositions can also be prepared using a fluid carrier for use as a mouthwash. Pharmaceutically compatible binding agents, and/or adjuvant materials can be included as part of the composition. The tablets, pills, capsules, troches and the like can contain any of the following ingredients, or compounds of a similar nature: 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.

[0021] Additionally, the helminthic parasite preparation may also comprise a second active agent for the treatment of T1DM. Such an active agent may be selected from the group consisting of ACE inhibitors, ARBs, or cholesterol-lowering drugs.

[0022] The skilled artisan will appreciate that certain factors may influence the dosage and timing required to effectively treat a subject, including but not limited to, the severity of the disease or disorder, previous treatments, the general health and/or age of the subject, and other diseases present. Moreover, treatment of a subject with a therapeutically effective amount of the therapeutic compositions described herein can include a single treatment or a series of treatments. [0023| In preferred embodiments, each dose may comprise from about 500 to about 20,000 eggs, or from about 2,000 eggs to about 10,000 eggs. In further embodiments, each dose may comprise about 1 ,000 eggs, about 1 ,500 eggs, about 2,000 eggs, about 2,500 eggs, about 3,000 eggs, about 3,500 eggs, about 4,000 eggs, about 4,500 eggs, about 5,000 eggs, about 5,500 eggs, about 6,000 eggs, about 6,500 egg, about 7,000 eggs, about 7,500 eggs, about 8,000 eggs, about 8,500 eggs, about 9,000 eggs, about 9,500 eggs, about 10,000 eggs, about 10,500 eggs, about 11,000 eggs, about 1 1 ,500 eggs, about 12,000 eggs, about 12,500 eggs, about 13,000 eggs, about 13,500 eggs, about 14,000 eggs, about 14,500 eggs, about 15,000 eggs, about 15,500 eggs, about 16,000 eggs, about 16,500 eggs, about 17,000 eggs, about 17,500 eggs, about 18,000 eggs, about 18,500 eggs, about 19,000 eggs, or about 19,500 eggs.

[0024] Administration may take place as often or as rarely as necessary to be therapeutically effective. The amount administered may be between about 1 and about 4 times per month for a duration of six months or greater, depending on the pathology of the patient and the presence of acute symptoms. In preferred embodiments, the frequency of administration of the pharmaceutical formulation may be greater for a first period of time taking place at the outset of treatment, than the frequency of administration during a second period of time taking place after the first period of time. Alternatively or additionally, the frequency of administration of the pharmaceutical formulation may be increased for a period of time when acute symptoms of T1DM appear or are expected to appear, followed by a return to the frequency of administration after the acute symptoms have subsided.

[0025] The present invention is further illustrated by the following examples, which should not be construed as limiting in any way.

Examples

Example 1 : Treatment of T1DM in Patients Using Helminthic Parasite Preparations

[0026] In order to demonstrate the efficacy of helminthic preparations in treatment of TIDM, 100 subjects with a confirmed TIDM diagnosis are recruited, having the following inclusion criteria: males or females, 8-35 years old (inclusive), with a diagnosis of type 1 diabetes, based on American Diabetes Association criteria, and either (1) recently diagnosed, (2) confirmed by the presence of at least one diabetes-related autoantibody (either GAD, IA-2, ZnT8, or insulin, the latter measured within ten days after starting insulin therapy); or (3) receiving insulin treatment. The subject must have a fasting plasma C-peptide greater than or equal to 0.3 ng/ml, be willing to comply with "intensive diabetes management" with the goal of maintaining blood glucose as close to American Diabetes Association recommendations as possible. If female, before entry she must be (1) surgically sterile; (2) if hetero sexually active, practicing a highly effective method of birth control, including hormonal prescription oral contraceptives, contraceptive injections, contraceptive patch, intrauterine device, double-barrier method, or male partner sterilization, consistent with local regulations regarding the use of birth control methods for subjects participating in clinical trials, for the duration of their participation in the study and for 2 months after receiving the last administration of any study agent, or (3) not heterosexually active. The subjects must be using a glucose meter that can be downloaded to a computer at the investigative site, must be willing to comply with the schedule of study visits and protocol requirements, and have the ability to provide informed consent.

[0027] In addition, subjects may not have the following exclusion criteria: patients having received any of the following medications in the two weeks before screening: antibiotic, antifungal, antiparasitic, immunosuppressive, or diabetic medication other than insulin; patients with positive stool culture for ova, parasites, or any enteric pathogens at screening; patients with history of drug or alcohol abuse within 6 months prior to screening; patients with evidence of poor compliance with medical advice and instructions including diet or medication; patients with significant medical conditions putting the patient at risk for study participation or put at risk by study procedures; patients having active hepatitis B virus, hepatitis C virus, cytomegalovirus, Epstein Barr Virus, or herpes simplex virus or is known to be HIV positive; patients who have participated in another clinical trial within 30 days of Screening for this trial and/or any experimental treatment for this population; females of childbearing potential who are unwilling or unable to use an acceptable method to avoid pregnancy for the entire study period; females who are pregnant or breastfeeding at the time of enrollment; patients with a white blood cell count < 3,000/mm3 (< 3.0 x 109/L) or > 14,000/mm3 (>14 x 109/L); platelet count < 100,000/μΙ. (<100 x 109/L); serum creatinine >2 x upper limit of normal (ULN); AST (SGOT) or ALT (SGPT) > 2 x ULN; total bilirubin >2 mg/dL (34 μιηοΙ/L); hemoglobin < 9 g/dL. [0028] The active drug product, Trichuris suis ova 7500 is a non-sterile, aqueous suspension of the viable, embryonated eggs of the whipworm Trichuris suis for oral use. Active TSO is administered in 15 mL of the suspension medium supplied in either one or two 30 mL glass containers. The suspension medium is an aqueous solution containing phosphate buffer, pH 5 and 0.05% potassium sorbate as antimicrobial preservative. Each unit dose is supplied in a 30 mL amber glass container with black outer lacquer and is sealed with a white polypropylene screw cap and a blue tamper evident ring.

[0029] The TSO is prepared as delineated in Table 2. The formulation is at a temperature between 2°C (36 °F) and 8°C (46 °F) and are protected from any risk of freezing (i.e., not be placed directly on freezer packs or in ice that could be below 0°C or 32 °F) or temperature greater than 25° C (77 °F). TSO is agitated gently before use to disperse the ova. Following dosing, tap water is to be added to the glass container, agitated, and ingested to ensure administration of the full dose of TSO.

Table 2: TSO Product

[0030] Following informed consent, the 100 subjects are screened on the basis of clinical laboratories and TIDM severity. Informed consent, inclusion and exclusion criteria, vital signs. clinical laboratories (including hematology, serum chemistry, C-reactive protein, and LFTs), urinalysis, stool culture, pregnancy serum test in female patients, 12-lead ECG, concomitant medications, insulin requirements, HbAlc, autoantibodies, fasting plasma C-peptide and blood glucose, ensure that patient has blood glucose meter, review of symptoms of hypoglycemia, medical history and a physical examination will be conducted. Treatment then proceeds according to the Schedule of Events shown in Table 3.

Table 3:

[0031] Eligible subjects are randomized to treatment with TSO 7500, or placebo (in a ratio of 2:1). The randomization is stratified by age cohort (age < 18 years and age > 18 years) During the treatment phase, study drug will be provided in a liquid form and will be administered every 2 weeks, starting with the Baseline visit, through Month 6. The primary time point for assessment of efficacy is at 6 months. Patients return to the clinic every three months during the treatment period of 6 months and every 3 months during the follow-up period of 6 months for assessment of efficacy and safety indices as per the Schedule of Events.

[0032] At the screening assessments, the following evaluations are performed: informed consent, inclusion and exclusion criteria, vital signs, clinical laboratories (including hematology, serum chemistry, C-reactive protein, and LFTs), urinalysis, stool culture, pregnancy serum test in female patients, 12-lead ECG, concomitant medications, insulin requirements, HbAlc, autoantibodies, fasting plasma C-peptide and blood glucose, ensure that patient has blood glucose meter, review of symptoms of hypoglycemia, medical history and a physical examination.

[0033] Subjects who satisfy eligibility requirements from screening will return to the clinic for their baseline (pre-treatment) assessments. The baseline visit may occur anytime between screening to five weeks provided all eligibility criteria have been met. If subjects are still deemed to be eligible, the subject will be randomized and treated with their first dose of study medication. Baseline assessments will include: inclusion and exclusion criteria to ensure subject still meets requirements, medical history to assess any changes since screening, physical examination to assess any changes since screening, clinical laboratories (including hematology, serum chemistry, C-reactive protein, LFTs), urinalysis, pregnancy urine test (female patients only), vital signs, prior medications and on-going medications, insulin requirements, glucose monitoring data (download), HbAlc, HLA, immunoglobulins specific to TSO, immune biomarkers (PBMC, cytokines), and MMTT. For patients who still meet eligibility criteria, the subject will be randomized and receive their first dose of medication.

[0034] Two weeks after baseline visit, patients are contacted by telephone to verify that patient has taken 2 week study drug as directed, and to assess for any adverse events or serious adverse events, or any changes in concomitant medications.

[0035] At month 1, subjects return to the clinic for the following assessments: study medication accountability, adverse events, pregnancy urine test (female patients only), dosing with study medication, and dispensing study medication and study drug dosing instructions.

(0036] At month 3. subjects return to the clinic for the following assessments: study medication accountability, adverse events, concomitant medications, vital signs, clinical laboratories (including hematology, serum chemistry, C-reactive protein, LFTs), urinalysis, prior and ongoing medications, insulin requirements, pregnancy laboratory (female subjects only), glucose monitoring data (download), HbAlc, immunoglobulins specific to TSO, dosing with study medication, an dispensing study medication and study drug dosing instructions.

[0037] At month 6, subjects return to the clinic for the following end-of-treatment-period assessments: study medication accountability, adverse events, concomitant medications, vital signs, clinical laboratories (including hematology, serum chemistry, C-reactive protein, LFTs), urinalysis, stool culture, pregnancy laboratory (female subjects only), physical examination, insulin requirements, glucose monitoring data (download), HbAlc, T1 DM autoantibodies, MMTT, immunoglobulins specific to TSO, immune biomarkers.

[0038] At month 9, patients return to the clinic for the following post-treatment follow-up assessments: adverse events, clinical laboratories, urinalysis, pregnancy urine test (female patients only), vital signs, concomitant medications, insulin requirements, glucose monitoring data (download), and HbAlc.

[0039] At month 12, patients return to the clinic for the following end of post-treatment follow- up assessments: adverse events, physical examination, clinical laboratories, urinalysis, pregnancy urine test (female patients only), stool culture, vital signs, concomitant medications, insulin requirements, glucose monitoring data (download), HbAlc, T1DM autoantibodies, and MMTT. [0040] Data analysis will be tabulated by treatment group and presented using both descriptive and inferential statistics. Efficacy outcomes will be evaluated using the Intent-to-Treat population (all patients randomized and treated with at least one dose of study medication). All inferential tests are two-sided and pairwise between each active TSO arm and the placebo arm. Assessment of outcomes at each protocol-scheduled time point will be performed for each endpoint.

[00411 Generally, categorical endpoints will be assessed using a 2-sided chi-square test. Changes and percent changes from pre-treatment to on-treatment time points will be calculated for continuous efficacy endpoints. Continuous data will be assessed via a mixed model; adjusted (LSMeans) estimates and standard errors will be presented for these values with their associated pairwise p-values. The primary comparisons will be pairwise between the individual TSO treatment arms and placebo. Assessment of dose response will be performed where warranted. Longitudinal assessment of changes over time may be performed for select endpoints, utilizing longitudinal mixed effects model with effects for treatment, center, and time. Graphical displays of changes over time will be presented for select outcomes. All data captured on the case report form (and in the clinical laboratory and other electronic databases) will be presented in by-domain data listings.

[0042] For the purpose of analysis, two populations will be identified. The safety population will comprise all patients treated with the study treatment (i.e., TSO 7500 or placebo). The modified intent-to-treat population (mITT) will include all patients treated with at least one dose of study medication and who have at least one post-baseline assessment.

[0043] The following are assessed as the primary efficacy hypothesis in this study.

Ho: There is no_ difference between treatment with TSO and treatment with placebo with respect to changes in disease severity, as measured by the baseline-standardized percent change in C-peptide AUC from MMTT from pre-treatment to end of treatment (Month 6).

Ha: There is a difference between treatment with TSO and treatment with placebo with respect to changes in disease severity, as measured by the baseline-standardized percent change in C- peptide AUC from MMTT from pre-treatment to end of treatment (Month 6). [0044] The primary endpoint is the total area under the insulin secretory response curve (AUC), i.e., the measure of total C-peptide secretion in response to a mixed meal tolerance test (MMTT). AUC will be expressed as a fraction of the baseline value in order to allow comparison among patients.

[0045] The AUC is calculated within each patient at each protocol-specified time point. Changes and percent changes from pretreatment to each on-treatment time point will then be derived. The primary endpoint analysis of treatment comparability will be based on mixed model with fixed effects for pre-treatment AUC and center; all protocol-specified time points will be included in the model, with the primary p-value the pairwise comparison of TSO to placebo at Month 6. The primary analysis will be performed with no imputation for missing values. Secondary (supportive) assessments of the primary endpoint will be performed using a last value carried forward imputation for missing values.

[0046| Such secondary efficacy endpoints include: Hemoglobin Ale (HbAlc); Daily insulin requirement; and insulin dose-adjusted HbAlc (IDAAlc). Secondary endpoints are assessed according to the scale of the outcome variable of interest. HbAlc and insulin will be expressed as a fraction of the baseline (pre-treatment) value and assessed. Insulin dose-adjusted HbAlc (IDAAlc) will be calculated as HbAlc (%) + [4x insulin dose (U/kg per 24h)]. Absolute change and percent change will also be assessed where appropriate. Assessment of outcomes at each protocol-scheduled time will be performed for each endpoint.

[0047] The foregoing description of illustrative embodiments has been presented for purposes of illustration and of description. It is not intended to be exhaustive or limiting with respect to the precise form disclosed, and modifications and variations are possible in light of the above teachings or may be acquired from practice of the disclosed embodiments. It is intended that the scope of the invention be defined by the claims appended hereto and their equivalents.