Related application

This application is related to the Indian Provisional Patent Application No. 201721045728 filed on l9 ^th December 2017 and is incorporated herein in its entirety.

Field of the invention

The present invention is related to the use of vitamin K2 compositions for the treatment of drug- induced neuropathy. More particularly it is related to the use of vitamin K2-7 compositions for the treatment of drug- induced peripheral neuropathy caused by the drugs used for the treatment of multiple myeloma.

Background of the invention

Peripheral neuropathy refers to a broad range of disorders affecting the peripheral nerves. A wide range of factors can lead to peripheral neuropathy such as Type II Diabetes Mellitus, alcohol abuse, paraneoplastic syndromes or toxins, Vitamin B12 deficiency etc. The peripheral nervous system consists of motor, sensory and autonomic nerves. The severity of the condition depends on the factors responsible and the duration of the condition. Sensory symptoms are distal dysesthesias is, pain and numbness which begin with the distal portions of the nerves. There is loss of temperature and vibratory perception in the toes and feet to begin with. Motor symptoms are characterized by weakness. Muscle tone is slowly lost and turns flaccid. Reflexes are also slowly lost. In case of Autonomic neuropathy dysfunction is reflected in orthostatic hypotension.

Drug induced peripheral neuropathy refers to a more specific form of peripheral neuropathy caused by the administration of certain drugs which are reportedly toxic, when administered over extended time periods, can lead to loss of movement and sensation along with the experiences of numbness, tingling, burning in hands and feet, as well as muscle weakness. It can begin after few weeks or months after the treatment is initiated. Drug induced peripheral neuropathy leads to discomfort and pain but is not fatal. It can be treated by discontinuing the drug causing the condition, lowering the dose and / or by administering pain relievers. This can take few weeks or months depending upon the severity of the condition. Also, the damage could be reversible or permanent. The symptoms of drug induced neuropathy are numbness, tingling, or abnormal sensations in the hands and/or feet, muscle weakness, claudication’s, experience of loss in sensation beginning in the hands and feet and then spread towards the body. Constant tingling and numbness may occur in the area surrounding the affected nerves. The magnitude of severity can vary from patient to patient. The loss of sensation could be partially reversible or permanent due to permanent nerve damage.

A wide range of drugs are reported to causedrug induced peripheral neuropathy (DIPN) depending on their toxicity to the body. The classes of drugs and specific examples are listed below. 1) Drugs for the treatment of autoimmune diseases, such as: Etanercept, Infliximab, Leflunomide, Azathioprine, Cyclophosphamide, Cyclosporine, Mycophenolate and

Methotrexate 2) Anti-inf ectives, such as Chloroquine, Isoniazid, Metronidazole,

Nitrofurantoin and Thalidomide 3) Anti HIV drugs such as: Didanosine, Stavudine,

Zalcitabine 4) Anti cancer drugs such as, Cisplatin, Incristine, Paclitaxel. For instance, combination of Vinca alkaloids and Cisplatine is reportedly more toxic. Similarly a combination of Paclitaxel and Cisplatine or Carboplatin is highly toxic 5) Drugs for the treatment of alcohol abuse such as Disulfiram 6) Cardiovascular drugs such as Statins especially Simvastatin, Pravastatin, Fluvastatin and Amiodarone 7) Drugs for the treatment of multiple myeloma e.g. Bortezomib and Thalidomide. Combination of Bortezomib and Thalidomide has been recommended for refractory multiplemyeloma; however, the combination is reportedly more toxic than a single drug. Similarly, Epothilones are used in the treatment of advanced breast cancer. Ixabepilone used to treat refractory breast cancer is known to cause severe peripheral neuropathy. In some cases, Vitamin B12 administration is known to ameliorate the symptoms 8) Biological drugs such as Etanercept, Infliximab or Adalimumab are recommended for the treatment of autoimmune diseases such as rheumatoid arthritis, ankylosing spondylitis or inflammatory bowel disease but are reported to cause peripheral neuropathy. Antifungal drugs such as Itraconazole and Voriconazole reportedly increase the risk of peripheral neuropathy. A combination of Itraconazole and Bortezomide also causes peripheral neuropathy.

The pathophysiology underlying chemotherapy-induced peripheral neuropathy, is complex and drug dependent. Until a clearer understanding of the same emerges, the treatment would continue to be symptomatic. Mohty et al [1] studied pathogenesis of peripheral neuropathy of Bortezomib and Thalidomide but accurate grading of drug induced neuropathy in the two cases was still not possible. The causes and mechanisms of drug-induced peripheral neuropathies of various drugs in animal models have been reviewed by Dieziei al [2]. While studies on various drugs in animal models throw some light on the origins of chemotherapy induced peripheral neuropathy, further validation is needed. The pathophysiology of drugs belonging to family of Taxanes, Vinca alkaloids, Thalidomide, Bortezomib has been reviewed by Addington and Freiner [3]. It was concluded that while anti-neoplastic features of these drugs were well studied, the neurotoxic side effects are possibly unrelated to the anti neoplastic pathway and remain clear.

Difficulty in the treatment of peripheral neuropathy is the quantification of the magnitude of symptoms, since accurate evaluation of signs and symptoms is the first step in the

administration of the treatment. Methods have been developed to distinguish between various clinical components of peripheral neuropathy to separate pain, numbness, and tingling which are measured on a scale of 0 to 10. National Cancer Institute’s Common Toxicity Criteria score is one of the protocols for the evaluation of peripheral neuropathy. Visual Analog Scale (VAS) Score, provides a complete assessment of symptoms, signs, ability aspects, and electrophysiology of the patient. Nerve conduction studies and needle Electromyography help identify the neural structure, axonal degeneration or demyelination, and the severity of axonal damage to confirm the diagnosis of peripheral neuropathy. Similarly, the European

Organisation for Research and Treatment of Cancer developed a questionnaire to assess the severity of neuropathy for self-evaluation by patients [4] .

Chemotherapy induced peripheral neuropathy may develop as a result of nerve injury at various anatomic regions of the nerve depending on the specific drug. Results are sensory peripheral neuropathy , motor peripheral neuropathy, and also autonomic nerve damage. While the causes of peripheral neuropathy are not equivocally established, It has been hypothesized that the myeloma protein produced by the malignant plasma cells, damages the nerve cells, resulting in symptoms of neuropathy. Amyloidosis can also cause peripheral neuropathy. High levels of paraprotein can result in hyperviscosity of the blood causing sluggish blood flow, which could lead to symptoms of peripheral neuropathy. Peripheral nerves, leaving the spinal cord, may be damaged due to a fractured vertebra caused by myeloma bone disease.

While various therapies practiced today provide symptomatic relief from drug induced peripheral neuropathy, they do not treat the underlying causes thereof. It is believed that no single drug is likely to be effective for the treatment of all peripheral neuropathies, which are a result of multiple causes.

In view of the differences in the origin of peripheral neuropathy and symptomatic nature of the treatment, the results often vary. In a critical review by Majithia et al [5] the success of various drugs in the treatment of chemotherapy-induced peripheral neuropathy and recommendations of the American Society of Clinical Oncology was assessed. Herein, Gabapentinoids were concluded to be useful in individual cases but were not found to yield statistically significant results over placebos. Topical Baclofen, Amitriptyline, and Ketamine (BAK) offered limited toxicity but there was insufficient evidence to recommend them.

The symptoms of drug induced neuropathy depend on the drug used, the dosage, and the cumulative dose administered. Damage due to drug may not be manifest for two to three months but may vary in terms of symptoms and duration of appearance. Drug dose adjustment during treatment is often used to ameliorate neuropathic pain. A wide range of drugs such as Gabapentin, Pregabalin, tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors, carbamazepine, and opioid-type analgesics are prescribed depending on the severity of symptoms, but with limited success.

Use of Pregabalin 150-600 mg/d for at least 3 months or Gabapentin 300-2,400 mg/d, Duloxetine (30-60 mg/d) for the treatment of Multiple myeloma induced peripheral neuropathy has been prescribed in the literature [1] Recently, Mount Desert Island (MDI) Biological Laboratory has filed in 2016 a provisional patent, which mentions two new molecules that prevent paclitaxel-induced neurotoxicity by reducing the activity of MMP-13, (matrix-metalloproteinase 13). The two molecules prevented the degeneration of axons and restored the touch response in zebrafish. The molecules therefore have potential to reverse peripheral neuropathy, caused by various types of cancers as well as diabetes.

Researchers at the Catalan Institute of Oncology have reported a new molecule which would prevent the development of drug induced peripheral neuropathy in cancer patients [6].

The 2018 global market for pain-relieving drugs is estimated at $10 billion. Chemotherapy- induced peripheral neuropathy (CIPN), affects 30% to 40% of patients treated is mainly symptomatic. The treatment includes administration of anticonvulsants, antidepressants, and opioids. In view of the limited success and unpredictability of performance of conventional drugs, a number of alternative treatments are being practiced for ameliorating the pain caused by the peripheral neuropathy. Complementary medicine is extensively practiced to the extent of 36% [7]. Capsaicin 0.075% gives a temporary analgesic effect. Lignocaine cream or patches produce a temporary local anaesthetic affect. Use of 1% topical menthol cream also leads to temporary improvement in pain and function.

Use of Transcutaneous electrical nerve stimulation (TENS), low level light therapy (LLLT) or cold laser therapy and infrared light emitting diode (LED) therapy, acupuncture and reflexology are other methods suggested. Massage, Yoga and Energy Therapies have also been suggested.

Several supplements have also been suggested. These include Amino acids: Acetyl 1- camitine; Glutamine, Magnesium and Potassium supplements. Fish and vegetable oils, Omega -3 fatty acids, Flax seed oil, Vitamin B complex that includes Bl ,B6 , B12 and Folic acid, Vitamin E, Alpha-lipoic acid, evening primrose oil etc. It is recommended that these be supported by healthy and regular lifestyle, exercise and relaxation techniques. However, use of supplements has been questioned in some publications [5].

In summary, chemotherapy induced peripheral neuropathy is a problem associated with a wide range of drugs that needs to be addressed with ingenious solutions.

Vitamin K, especially Vitamin K2-7 _, has been shown to be effective in various disease conditions such as cardiovascular disease and osteoporosis.

Vitamin K is a family of structurally similar, fat-soluble, 2-methyl- 1, 4-naphthoquinones, including phylloquinone [Vitamin Kl] andmenaquinones [Vitamin K2]. The structural difference is in the substituent side chain at the gamma position. The other difference is in the activity and efficacy of these two isoforms, precisely of vitamin Kl and of vitamin K2- 7.Vitamin Ki has an elimination half-life of 1.5 hrs whereas Vitamin K2-7 has a half-life of more than 72 hrs thus available to the body for longer period with higher therapeutic activity as shown in number of studies. Vitamin K2-7 occurs in nature, but is commercially produced by a range of bacteria also.

It has been observed that even at high doses, the natural forms of vitaminK2-7have not produced symptoms of toxicity. Consuming more than the body's needs for dietary vitamin K does not cause any toxicity especially related to blood clotting in healthy people. Research in the field of vitamin K has resulted in novel applications. Traditionally, vitamin K has been associated with blood coagulation where it serves as a cofactor for the carboxylation of vitamin K-dependent proteins of coagulation cascade to render them active. It is now known that vitamin K is present in every tissue and by the virtue of its ubiquitous nature, the molecule plays · an important role in bone mineralization, prevention of arterial calcification, apoptosis, phagocytosis, growth control, chemotaxis and signal transduction. US patent 8354129 claims food products to promote human bone health and cardiovascular health. US patent 7605179 claims naphthoquinone-type compounds including vitamin K to modulate aggregation of protein associated with neurodegenerative disease such as Alzheimer's disease. The patent application W02009/063485 discloses treatment of human disease conditions and disorders using vitamin K analogues and derivatives.

Detailed Description of the Invention

Vitamin K2-7 is now a well-established nutraceutical in the industry and its applications are well established. While developing newer applications of Vitamin K2-7, it has now been surprisingly found that it ameliorates the symptoms of peripheral neuropathy caused by the drugs used in the treatment of multiple myeloma.

The present invention is related to the therapeutic uses of vitamin K. It refers to the compositions comprising vitamin K2-7 for the treatment of drug induced neuropathy. More specifically it refers to the compositions comprising vitamin K2-7 for the treatment of drug induced peripheral neuropathy caused during the treatment of multiple myeloma

vitamin K2-7 compositions of the invention is in the form of capsule, tablets, syrups and sachets.

In another embodiment of the invention vitamin K2-7 compositions are used for treatment of peripheral neuropathy caused by drugs for the treatment of autoimmune diseases, such as: Etanercept, Infliximab, Leflunomide, Azathioprine, Cyclophosphamide, Cyclosporine, Mycophenolate and Methotrexate.

In one embodiment, the invention provides a vitamin K2-7 composition and use for treatment of peripheral neuropathy caused by Anti-inf ectives, such as Chloroquine, Isoniazid,

Metronidazole, Nitrofurantoin and Thalidomide.

In addition, the vitamin K2-7 composition is used for treatment of peripheral neuropathy caused by anti cancer drugs such as, Cisplatin, Incristine, Paclitaxel. In another aspect of the invention, the vitamin K2-7 composition is used for treatment of peripheral neuropathy caused by Anti HIV drugs such as: Didanosine, Stavudine, Zalcitabine. The invention also provides vitamin K2-7 composition for use in treatment of peripheral neuropathy caused by administration of drugs during the treatment of alcohol abuse such as Disulfiram.

In another aspect, the invention provides vitamin K2-7 compositions for use in the treatment of peripheral neuropathy caused by cardiovascular drugs such as statins especially

simvastatin, pravastatin, fluvastatin and amiodarone.

The vitamin K2-7 compositions are also used for treatment of peripheral neuropathy caused by drugs for the treatment of multiple myeloma e.g. Bortezomib and Thalidomide. In another aspect, the vitamin K2-7 compositions are also used for treatment of peripheral neuropathy caused by drugs for the treatment of multiple myeloma, wherein the said drugs are selected from the group consisting of proteasome inhibitors (ex: Bortezomib), immune suppressants (ex: Cyclophosphamide), steroids (ex: Prednisolone), corticosteroids (ex: Dexamethasone), immune modulators (ex: Lenalidomide), bisphosphonates (ex: Zolendroic acid), monoclonal antibodies (ex: Rituximab), and vinca alkaloids (ex: vincrystine) or a combination thereof.

In another aspect of the invention the vitamin K2-7 compositions are used for treatment of peripheral neuropathy caused by drugs Lenalidomide and Dexamethasone.

The invention also encompasses vitamin K2-7 compositions composition for use in the treatment of peripheral neuropathy caused by drugs Lenalidomide and Zolendroic acid or Lenalidomide, Dexamethasone and Zolendroic acid

Furthermore, the invention provides vitamin K2-7 compositions for use in the treatment of peripheral neuropathy caused by drugs Bortezomib, Cyclophosphamide and Dexamethasone. In an aspect of the invention the composition comprises preferable 100 pg - 700 pg of vitamin K2-7/day or more preferably 50pg-l lOOpg vitamin K2-7/day.

In an aspect of the invention the composition of the invention is administered once or twice daily. It is envisaged that the vitamin K2-7 administered is released in the intestine.

In an aspect of the invention the vitamin K2-7 composition of the invention is administered to a patient suffering from drug induced peripheral neuropathy not cured by administration of Vitamin B 12 _. In one aspect of the invention the composition of the invention administered to a patient suffering from drug induced peripheral neuropathy minimises or lowers the symptoms of drug induced peripheral neuropathy.

In another aspect of the invention the composition of the invention administered to a patient suffering from drug induced peripheral neuropathy eliminates the symptoms of drug induced peripheral neuropathy.

In yet another aspect of the invention the composition of the invention administered to a patient simultaneously with the drugs which are reported to cause peripheral neuropathy minimises the symptoms of drug induced peripheral neuropathy.

In an aspect of the invention the composition of the invention administered to a patient simultaneously with the drugs which are reported to cause peripheral neuropathy prevents the occurrence of the symptoms of drug induced peripheral neuropathy.

In an aspect of the invention the composition of the invention administered to a patient simultaneously with the drugs which are reported to cause peripheral neuropathy, enables continued administration of the drugs for the treatment of multiple myeloma by minimizing the symptoms of drug induced neuropathy.

In an aspect of the invention the composition of the invention administered to a patient prior to the administration of the drugs which are reported to cause peripheral neuropathy prevents the occurrence of the symptoms of drug induced peripheral neuropathy.

In an aspect of the invention the vitamin K2-7 composition of the invention administered to a patient prior to the administration of the drugs which are reported to cause peripheral neuropathy minimises the symptoms of drug induced peripheral neuropathy.

In an aspect of the invention, the vitamin K2-7 composition of the invention is administered to patient 2-24 weeks prior to the administration of the drugs which are reported to cause the symptoms of drug induced peripheral neuropathy.

The composition comprising vitamin K2-7 of the invention is used for the treatment of peripheral neuropathy wherein upon administration of vitamin K2-7, the patient is relieved of the symptoms of peripheral neuropathy during the next cycle of administration of the drugs for the treatment of multiple myeloma. Hence vitamin K2-7 is used as a preventive nutraceutical to prevent the occurrence of symptoms of drug-induced peripheral neuropathy.

The beneficial effects on administration of vitamin K2-7 to patients suffering from

chemotherapy induced peripheral neuropathy during the treatment of multiple myeloma are now described below with examples which are illustrative and should not be in anyway considered as limiting the scope of the invention.

Example 1

An open labelled study was conducted to evaluate the effect of Vitamin K2-7 on drug induced peripheral neuropathy. Patients who were diagnosed with Multiple myeloma and are on chemotherapy treatment for the same, were assessed for the occurrence of symptoms of peripheral neuropathy and then selected. Patients were given 2 capsules of 100 meg or 350 meg, of Vitamin K2-7 along with the ongoing chemotherapy. The evaluation of symptoms of peripheral neuropathy such as tingling, numbness, burning sensation, muscle cramps etc., were assessed by VAS score (Schematic 1) from 0 to 10 (nil to unbearable). The scale has been used in various studies to measure the intensity and severity of various symptoms of neuropathy [8, 9].

It was observed that before the beginning of Vitamin K2-7 therapy, the VAS score in all the patients was between the range of 8-9 for the symptoms of tingling, numbness and burning sensation. As the patients continue with the therapy, it was observed that VAS score for all the symptoms decreased to‘ 1-2’. This decrease has happened over a period of 2 to 5 months, depending upon the individual cases treated. Further, no adverse events were noted during the Vitamin K2-7 therapy. Hence, it can be concluded that Vitamin K2-7 helps in relieving the symptoms of drug- induced Peripheral Neuropathy significantly and helps patient for better compliance to the chemotherapeutic agents. The examples given in Table 1, summarises the data for 11 patients who were on Vitamin K2-7 therapy for drug- induced Peripheral Neuropathy due to treatment for Multiple myeloma. In Table 1, treatment administered refer to the cyclical chemotherapy provided to the patients of Multiple Myeloma (MM). These cycles are normally of 3 weeks or 21 days period, based on the attending physician’s assessment of the patient’s condition and tolerance.

However, vitamin K2-7 was administered on daily basis as 2 capsules of 100 pg each. If patient did not respond to the 100 pg dose of vitamin K2-7 for a period of 2 cycles then they were administered 350 pg/day of vitamin K2-7.

Thus, out of 11 patients 1 patient remained on 100 pg of vitamin K2-7, two times a day daily, with significant improvement in peripheral neuropathy.

Treatment with vitamin K2-7 of subjects continued even after their having reached VAS score of‘2’. Such continues treatment stabilised the VAS Score. Further, it was noticed that continuation of Vitamin K2-7 during the subsequent cycles prevented the flair up of the symptoms of drug induced peripheral neuropathy. It was also observed that in patients administered with Vitamin K2-7, the compliance rate of the for chemotherapy were improved significantly.

Schematic 1. Visual Analog Scale with gradations

1

The gradation was judged by Physician based on following criteria.

By using Visual analog Scale i.e. 0 - 10 point scale:

20 0 = Absent 1 - 3 = Mild 4 - 6 = Moderate 7 - 10 = Severe

Tablel: Summary of 11 patients receiving Vitamin K2-7 therapy for Drug induced

Peripheral Neuropathy due to treatment for Multiple myeloma

2

*-l- Bortezomib, 2- Cyclophosphamide, 3- Dexamethasone, 4- Fenalidomide, 5- Zolendronic Acid, 6- Rituximab, 7- Doxorubicin, 8- Vincristine, 9- Prednisolone

References:

1. Bilal Mohty, Jean El-Cheikh, Ibrahim Yakoub-Aghaei. al. Peripheral neuropathy and new treatments for multiple myeloma: background and practical recommendations. Haematoiogica February 2010 (95): 311-319.

2. Diezi Manuela, BuclinThierrya andKuntzerThierryc. Toxic and drug-induced peripheral neuropathies: updates on causes, mechanisms and management. CurrOpin Neurol. 2013 Oct;26(5):48l-8.

3. J Addington and M Freimer. Chemotherapy-induced peripheral neuropathy: an update on the current understanding. FlOOOResearch 2016, 5(Fl000 Faculty Rev): 1466.

4. Grammatico S, Cesini F and Petrucci M. Managing treatment-related peripheral neuropathy in patients with multiple myeloma. Blood and Fymphatic Cancer: Targets and Therapy 2016:6 37-47.

5. Majithia N, Foprinzi CF and Smith TJ. New Practical Approaches to Chemotherapy- Induced Neuropathic Pain: Prevention, Assessment, and Treatment. Oncology (Williston Park). 2016 Nov l5;30(l 1): 1020-9.

6. Bruna, J., Videla, S., Argyriou, A. A. el. al. Efficacy of a Novel Sigma- 1 Receptor Antagonist for Oxaliplatin-Induced Neuropathy: A Randomized, Double-Blind, Placebo-Controlled Phase Ila Clinical Trial. Neuro therapeutics (2018) 15: 178.

7. Idan Ben-Horin, Peretz Kahan and Farisa Ryvo. Acupuncture and Reflexology for Chemotherapy-Induced Peripheral Neuropathy in Breast Cancer. Integrative Cancer Therapies. 2017, Vol. 16(3) 258-262.

8. Wewers ME, Fowe NK. A critical review of visual analogue scales in the measurement of clinical phenomena. Res. Nur. Health 1990 Aug;l3(4):227-36.

9. Fakhan SE, Velasco DN and Tepper D. Botulinum Toxin-A for Painful Diabetic Neuropathy: A Meta- Analysis. Pain Med. 2015 Sep; 16(9): 1773-80.