U.S. patent application number 14/441111 was filed with the patent office on 2015-09-24 for compositions and methods for lowering triglycerides without raising ldl-c levels in a subject on concomitant statin therapy.
The applicant listed for this patent is AMARIN PHARMACEUTICALS IRELAND LIMITED. Invention is credited to Rene Braeckman, Mehar Manku, Ian Osterloh, Paresh Soni, Pierre Wicker.
Application Number | 20150265566 14/441111 |
Document ID | / |
Family ID | 50685306 |
Filed Date | 2015-09-24 |
United States Patent
Application |
20150265566 |
Kind Code |
A1 |
Osterloh; Ian ; et
al. |
September 24, 2015 |
Compositions and Methods for Lowering Triglycerides without Raising
LDL-C Levels in a Subject on Concomitant Statin Therapy
Abstract
In various embodiments, the present invention provides
compositions and methods for treating and/or preventing
cardiovascular-related diseases in subject in need thereof.
Inventors: |
Osterloh; Ian; (Kent,
GB) ; Wicker; Pierre; (Mystic, CT) ;
Braeckman; Rene; (Richboro, PA) ; Soni; Paresh;
(Mystic, CT) ; Manku; Mehar; (Birmingham,
GB) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
AMARIN PHARMACEUTICALS IRELAND LIMITED |
Dublin |
|
IE |
|
|
Family ID: |
50685306 |
Appl. No.: |
14/441111 |
Filed: |
November 6, 2013 |
PCT Filed: |
November 6, 2013 |
PCT NO: |
PCT/US13/68647 |
371 Date: |
May 6, 2015 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
|
61723108 |
Nov 6, 2012 |
|
|
|
61747689 |
Dec 31, 2012 |
|
|
|
61761398 |
Feb 6, 2013 |
|
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|
61830463 |
Jun 3, 2013 |
|
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Current U.S.
Class: |
514/560 |
Current CPC
Class: |
A61K 31/202
20130101 |
International
Class: |
A61K 31/202 20060101
A61K031/202 |
Claims
1-23. (canceled)
24. A method of increasing a ratio of omega-3 fatty acids to
omega-6 fatty acids (.omega.-3/.omega.-6) in plasma or RBCs of a
subject having baseline fasting triglycerides of about 200 mg/dl to
about 500 mg/dl and on stable statin therapy, the method comprising
administering to the subject a pharmaceutical composition
comprising about 1 g to about 4 g of EPA per day, wherein upon
administering the composition to the subject daily for a period of
12 weeks, the subject exhibits an increase in .omega.-3/.omega.-6
in plasma and/or RBCs of at least 50% compared to a control subject
on stable statin therapy without EPA, wherein the control subject
also has baseline fasting triglycerides of about 200 mg/dl to about
500 mg/dl.
25. (canceled)
26. The method of claim 24, wherein the increase decrease in
.omega.-3/.omega.-6 in plasma and/or RBCs is at least 60%.
27. (canceled)
28. The method of claim 24, wherein the increase includes an
increase in .omega.-3/.omega.-6 in plasma of at least 60%.
29. (canceled)
30. (canceled)
31. The method of claim 24, wherein the increase includes an
increase in .omega.-3/.omega.-6 in RBCs of at least 60%.
32. (canceled)
33. (canceled)
34. The method of claim 24, wherein the omega-3 fatty acids include
one or more of: .alpha.-linolenic acid, stearidonic acid,
eicosatrienoic acid, .omega.-3 arachidonic acid, eicosapentaenoic
acid, .omega.-3 docosapentaenoic acid and docosahecaenoic acid.
35. The method of claim 24, wherein the omega-6 fatty acids include
one or more of: linoleic acid, .gamma.-linolenic acid,
eicosadienoic acid, dihomo-.gamma.-linolenic acid, .omega.-6
arachidonic acid, adrenic acid, and .omega.-6 docosapentaenoic
acid.
36. The method of claim 24, wherein the subject is administered
about 2 g/day of EPA.
37. The method of claim 24, wherein the subject is administered
about 4 g/day of EPA.
38. The method of claim 24, wherein the subject further exhibits no
increase, no substantial increase, or a reduction in plasma and/or
RBC levels of DHA compared to the control subject.
39. A method of increasing a ratio of omega-3 fatty acids to total
fatty acids in plasma or RBCs of a subject having baseline fasting
triglycerides of about 200 mg/dl to about 500 mg/dl and on stable
statin therapy, the method comprising administering to the subject
a pharmaceutical composition comprising about 1 g to about 4 g of
EPA per day, wherein upon administering the composition to the
subject daily for a period of 12 weeks, the subject exhibits an
increase in the ratio of omega-3 fatty acids to total fatty acids
in plasma and/or RBCs of at least 50% compared to a control subject
on stable statin therapy without EPA, wherein the control subject
also has baseline fasting triglycerides of about 200 mg/dl to about
500 mg/dl.
40. (canceled)
41. The method of claim 39, wherein the increase is at least about
60%.
42. (canceled)
43. (canceled)
44. The method of claim 39, wherein the increase includes an
increase in the ratio in plasma of at least 60%.
45. (canceled)
46. The method of claim 39, wherein the increase includes an
increase in the ratio in RBCs of at least 50%.
47. (canceled)
48. The method of claim 39, wherein the omega-3 fatty acids include
one or more of: .alpha.-linolenic acid, stearidonic acid,
eicosatrienoic acid, .omega.-3 arachidonic acid, eicosapentaenoic
acid, .omega.-3 docosapentaenoic acid and docosahecaenoic acid.
49. The method of claim 39, wherein the total fatty acids include
one or more of: .alpha.-linolenic acid, stearidonic acid,
eicosatrienoic acid, .omega.-3 arachidonic acid, eicosapentaenoic
acid, .omega.-3 docosapentaenoic acid, docosahecaenoic acid,
linoleic acid, .gamma.-linolenic acid, eicosadienoic acid,
dihomo-.gamma.-linolenic acid, .omega.-6 arachidonic acid, adrenic
acid, .omega.-6 docosapentaenoic acid, myristoleic acid,
palmitoleic acid, cis-vaccenic acid, oleic acid, gondoic/gadoleic
acid, erucic acid, nervonic acid, myristic acid, palmitic acid,
stearic acid, arachidic acid, behenic acid and lignoceric acid.
50. The method of claim 39, wherein the subject is administered
about 2 g/day of EPA.
51. The method of claim 39, wherein the subject is administered
about 4 g/day of EPA.
52. The method of claim 39, wherein the subject further exhibits no
increase, no substantial increase, or a reduction in plasma and/or
RBC levels of DHA compared to the control subject.
53. A method of decreasing a ratio of omega-6 fatty acids to total
fatty acids in plasma or RBCs of a subject having baseline fasting
triglycerides of about 200 mg/dl to about 500 mg/dl and on stable
statin therapy, the method comprising administering to the subject
a pharmaceutical composition comprising about 1 g to about 4 g of
EPA per day, wherein upon administering the composition to the
subject daily for a period of 12 weeks, the subject exhibits a
decrease in the ratio of omega-6 fatty acids to total fatty acids
in plasma and/or RBCs of at least 4% compared to a control subject
on stable statin therapy without EPA, wherein the control subject
also has baseline fasting triglycerides of about 200 mg/dl to about
500 mg/dl.
54. (canceled)
55. The method of claim 53, wherein the decrease is at least about
7%.
56. (canceled)
57. (canceled)
58. The method of claim 53, wherein the decrease includes a
decrease in the ratio in plasma of at least 4%.
59. (canceled)
60. The method of claim 53, wherein the decrease includes a
decrease in the ratio in RBCs of at least 11%.
61. (canceled)
62. The method of claim 53, wherein the omega-6 fatty acids include
one or more of: linoleic acid, .gamma.-linolenic acid,
eicosadienoic acid, dihomo-.gamma.-linolenic acid, .omega.-6
arachidonic acid, adrenic acid, and .omega.-6 docosapentaenoic
acid.
63. The method of claim 53, wherein the total fatty acids include
one or more of: .alpha.-linolenic acid, stearidonic acid,
eicosatrienoic acid, .omega.-3 arachidonic acid, eicosapentaenoic
acid, .omega.-3 docosapentaenoic acid, docosahecaenoic acid,
linoleic acid, .gamma.-linolenic acid, eicosadienoic acid,
dihomo-.gamma.-linolenic acid, .omega.-6 arachidonic acid, adrenic
acid, .omega.-6 docosapentaenoic acid, myristoleic acid,
palmitoleic acid, cis-vaccenic acid, oleic acid, gondoic/gadoleic
acid, erucic acid, nervonic acid, myristic acid, palmitic acid,
stearic acid, arachidic acid, behenic acid and lignoceric acid.
64. The method of claim 53, wherein the subject is administered
about 2 g/day of EPA.
65. The method of claim 53, wherein the subject is administered
about 4 g/day of EPA.
66. The method of claim 53, wherein the subject further exhibits no
increase, no substantial increase, or a reduction in plasma and/or
RBC levels of DHA compared to the control subject.
67-87. (canceled)
Description
PRIORITY CLAIM
[0001] The present application is a 371 national stage application
of PCT/US2013/068647 filed Nov. 6, 2013, which claims priority to
U.S. Provisional Patent Application Ser. Nos. 61/723,108, filed on
Nov. 6, 2012, 61/747,689, filed on Dec. 31, 2012, 61/761,398, filed
on Feb. 6, 2013, and 61/830,463, filed on Jun. 3, 2013, the entire
contents of each of which are hereby relied upon and incorporated
herein by reference.
BACKGROUND
[0002] Cardiovascular disease is one of the leading causes of death
in the United States and most European countries. It is estimated
that over 70 million people in the United States alone suffer from
a cardiovascular disease or disorder including but not limited to
high blood pressure, coronary heart disease, dyslipidemia,
congestive heart failure and stroke.
SUMMARY
[0003] In various embodiments, the present invention provides
pharmaceutical compositions and methods of using such compositions
to treat and/or prevent cardiovascular-related diseases. In one
embodiment, the subject is on concomitant statin therapy. In
another embodiment, the subject on statin therapy has a baseline
fasting serum triglyceride level of about 200 mg/dL to about 500
mg/dL.
[0004] In one embodiment, the invention provides a method of
lowering triglycerides in a subject on stable statin therapy having
baseline fasting triglycerides of about 200 mg/dl to about 500
mg/dl, the method comprising administering to the subject a
pharmaceutical composition comprising polyunsaturated fatty acids,
for example about 1 g to about 4 g of EPA per day, wherein upon
administering the composition to the subject daily for a period of
12 weeks the subject exhibits at least 5% lower fasting
triglycerides than a control subject maintained on stable statin
therapy (optionally with placebo matching the EPA) without
concomitant EPA for a period of 12 weeks wherein the control
subject also has baseline fasting triglycerides of about 200 mg/dl
to about 500 mg/dl. In another embodiment, upon administering the
composition to the subject daily for a period of 12 weeks the
subject exhibits no serum LDL-C increase, no statistically
significant serum LDL-C increase, a serum LDL-C decrease, or the
subject is statistically non-inferior to the control subjects
(statin plus optional placebo) in regard to serum LDL-C
elevation).
[0005] In various embodiments, the present invention provides
pharmaceutical compositions and methods of using such compositions
to increase plasma, serum and/or red blood cell (RBC) EPA levels
and/or to treat or prevent cardiovascular-related diseases.
[0006] In one embodiment, a pharmaceutical composition according to
the present disclosure comprises about 1 g of ethyl
eicosapentaenoate and provides a mean plasma C.sub.max of about
154.9+/-49.4 .mu.g/mL, a mean plasma AUC.sub.0-24h of about
2907+/-1160 .mu.gh/mL, a median plasma T.sub.max of about 5 hours,
and a mean plasma T.sub.1/2 of about 75.1+/-46.5 hours of ethyl
eicosapentaenoate when administered orally twice per day to a human
subject.
[0007] In another embodiment, a pharmaceutical composition
comprises about 2 g of ethyl eicosapentaenoate and provides a mean
plasma C.sub.max of about 347.2+/-112.5 .mu.g/mL, a mean plasma
AUC.sub.0-24h of about 6519+/-1963 .mu.gh/mL, a median plasma
T.sub.max of about 5 hours, and a mean plasma T.sub.1/2 of about
89.3+/-42.0 hours of ethyl eicosapentaenoate when administered
orally twice per day to a human subject.
[0008] These and other embodiments of the present invention will be
disclosed in further detail herein below.
BRIEF DESCRIPTION OF THE DRAWINGS
[0009] FIG. 1 depicts the mean placebo-adjusted changes from
baseline in plasma and RBC concentrations of EPA after 12 weeks of
treatment with 2 g/day or 4 g/day of ultra-pure EPA in subjects on
statin therapy and having baseline triglycerides of about 200 mg/dL
to less than 500 mg/dL.
[0010] FIG. 2 depicts placebo-adjusted least square mean changes
from baseline in plasma and RBC concentrations and ratios of
selected fatty acids and fatty acid groups in subjects on statin
therapy and having baseline triglycerides of about 200 mg/dL to
less than 500 mg/dL.
[0011] FIG. 3 depicts the dose dependence of EPA concentrations in
plasma and RBCs in subjects on statin therapy and having baseline
triglycerides of about 200 mg/dL to less than 500 mg/dL.
[0012] FIG. 4A depicts the relationship between plasma
triglyceride-lowering and EPA concentrations in plasma (a
pharmacokinetic/pharmacodynamic relationship) in subjects on statin
therapy and having baseline triglycerides of about 200 mg/dL to
less than 500 mg/dL.
[0013] FIG. 4B depicts the relationship between plasma
triglyceride-lowering and EPA concentrations in RBCs (a
pharmacokinetic/pharmacodynamic relationship) in subjects on statin
therapy and having baseline triglycerides of about 200 mg/dL to
less than 500 mg/dL.
[0014] FIG. 5 depicts the mean placebo-adjusted changes from
baseline in in plasma and red blood cell concentrations of EPA
after 12 weeks of treatment with 2 g/day or 4 g/day of ultra-pure
EPA in subjects having baseline triglycerides of at least about 500
mg/dL.
[0015] FIGS. 6A-6B depicts placebo-adjusted least square mean
changed from baseline in plasma and red blood cell concentrations
and ratios of selected fatty acids and fatty acid groups for 4
g/day (FIG. 6A) and 2 g/day (FIG. 6B) doses of ultra-pure EPA in
subjects having baseline triglycerides of at least about 500
mg/dL.
[0016] FIG. 7 depicts the dose dependence of EPA concentrations in
plasma and red blood cells in subjects having baseline
triglycerides of at least about 500 mg/dL.
[0017] FIG. 8A depicts the relationship between plasma
triglyceride-lowering and EPA concentrations in plasma (a
pharmacokinetic/pharmacodynamic relationship) in subjects having
baseline triglycerides of at least about 500 mg/dL.
[0018] FIG. 8B depicts the relationship between plasma
triglyceride-lowering and EPA concentrations in red blood cells (a
pharmacokinetic/pharmacodynamic relationship) in subjects having
baseline triglycerides of at least about 500 mg/dL.
[0019] FIG. 9 depicts the distribution and disposition of subjects
among four dosing groups, referred to herein as Groups 1 to 4.
[0020] FIG. 10 depicts the mean total plasma eicosapentaenoic acid
concentration over time for dosing Groups 1 to 4. Bars indicate one
standard deviation at each point.
[0021] FIG. 11 depicts the mean total plasma eicosapentaenoic acid
trough concentration (C.sub.min) over time for dosing Groups 1 to
4. Bars indicate one standard deviation at each point.
[0022] FIG. 12A depicts the mean total eicosapentaenoic acid plasma
AUC.sub.0-24h measured 28 days after onset of dosing for dosing
Groups 1 to 4. FIG. 12B depicts the mean unesterified
eicosapentaenoic acid plasma AUC.sub.0-24h measured 28 days after
onset of dosing for dosing Groups 1 to 4. FIG. 12C depicts the mean
total eicosapentaenoic acid red blood cell (RBC) AUC.sub.0-24h
measured 28 days after onset of dosing for dosing Groups 1 to 4.
Bars in FIGS. 12A to 12C indicate one standard deviation.
[0023] FIG. 13A depicts the mean total eicosapentaenoic acid plasma
C.sub.max measured 28 days after onset of dosing for dosing Groups
1 to 4. FIG. 13B depicts the mean unesterified eicosapentaenoic
acid plasma C.sub.max measured 28 days after onset of dosing for
dosing Groups 1 to 4. FIG. 13C depicts the mean total
eicosapentaenoic acid red blood cell (RBC) C.sub.max measured 28
days after onset of dosing for dosing Groups 1 to 4. Bars in FIGS.
13A to 13C indicate one standard deviation.
[0024] FIG. 14 depicts median triglyceride percent change from
baseline (y-axis) vs. mean plasma EPA concentration percent change
from baseline (x-axis) for subjects administered placebo, EPA 2 g
per day and EPA 4 grams per day. Bars in FIG. 14 indicate 95%
confidence intervals for both axes.
[0025] FIG. 15 depicts mean trough total EPA plasma concentrations
at baseline and end-of-treatment for various clinical studies.
[0026] FIG. 16 shows IPE Dose Dependence of RBC EPA Concentrations
in the Phase 1 Pharmacokinetic ("PK"), MARINE, and ANCHOR
studies.
[0027] FIG. 17 shows IPE Dose Dependence of Plasma EPA
Concentrations in the Phase 1 PK, MARINE, and ANCHOR studies.
[0028] FIGS. 18A-18B show median percent changes from baseline for
plasma triglycerides as a function of mean changes in EPA
concentration in plasma (FIG. 18A) and red blood cells (FIG. 18B)
for subjects in the MARINE study.
[0029] FIGS. 19A-19B show median percent changes from baseline for
plasma triglycerides as a function of mean changes in EPA
concentration in plasma (FIG. 19A) and red blood cells (FIG. 19B)
for subjects in the ANCHOR study.
DETAILED DESCRIPTION
[0030] While the present invention is capable of being embodied in
various forms, the description below of several embodiments is made
with the understanding that the present disclosure is to be
considered as an exemplification of the invention, and is not
intended to limit the invention to the specific embodiments
illustrated. Headings are provided for convenience only and are not
to be construed to limit the invention in any manner. Embodiments
illustrated under any heading may be combined with embodiments
illustrated under any other heading.
[0031] The use of numerical values in the various quantitative
values specified in this application, unless expressly indicated
otherwise, are stated as approximations as though the minimum and
maximum values within the stated ranges were both preceded by the
word "about." Also, the disclosure of ranges is intended as a
continuous range including every value between the minimum and
maximum values recited as well as any ranges that can be formed by
such values. Also disclosed herein are any and all ratios (and
ranges of any such ratios) that can be formed by dividing a
disclosed numeric value into any other disclosed numeric value.
Accordingly, the skilled person will appreciate that many such
ratios, ranges, and ranges of ratios can be unambiguously derived
from the numerical values presented herein and in all instances
such ratios, ranges, and ranges of ratios represent various
embodiments of the present invention.
[0032] In one embodiment, the invention provides a method for
treatment and/or prevention of cardiovascular-related diseases. The
term "cardiovascular-related disease" herein refers to any disease
or disorder of the heart or blood vessels (i.e. arteries and veins)
or any symptom thereof. Non-limiting examples of
cardiovascular-related disease and disorders include
hypertriglyceridemia, hypercholesterolemia, mixed dyslipidemia,
coronary heart disease, vascular disease, stroke, atherosclerosis,
arrhythmia, hypertension, myocardial infarction, and other
cardiovascular events.
[0033] The term "treatment" in relation a given disease or
disorder, includes, but is not limited to, inhibiting the disease
or disorder, for example, arresting the development of the disease
or disorder; relieving the disease or disorder, for example,
causing regression of the disease or disorder; or relieving a
condition caused by or resulting from the disease or disorder, for
example, relieving, preventing or treating symptoms of the disease
or disorder. The term "prevention" in relation to a given disease
or disorder means: preventing the onset of disease development if
none had occurred, preventing the disease or disorder from
occurring in a subject that may be predisposed to the disorder or
disease but has not yet been diagnosed as having the disorder or
disease, and/or preventing further disease/disorder development if
already present.
[0034] In one embodiment, the present invention provides a method
of blood lipid therapy comprising administering to a subject or
subject group in need thereof a pharmaceutical composition as
described herein. In another embodiment, the subject or subject
group has hypertriglyceridemia, hypercholesterolemia, mixed
dyslipidemia, borderline high/high triglycerides (e.g., about 200
to about 499 mg/dl), and/or very high triglycerides (e.g., at least
about 500 mg/dl).
[0035] In another embodiment, the subject or subject group being
treated has a baseline triglyceride level (or mean or median
baseline triglyceride level in the case of a subject group), fed or
fasting, of about 200 mg/dl to about 500 mg/dl. In another
embodiment, the subject or subject group has a baseline LDL-C level
(or mean or median baseline LDL-C level), despite stable statin
therapy, of about 40 mg/dl to about 115 or about 40 to about 100
mg/dl. In another embodiment, the subject or subject group being
treated has a baseline triglyceride level (or median baseline
triglyceride level in the case of a subject group), fed or fasting,
of at least about 200 mg/dl, at least about 300 mg/dl, at least
about 400 mg/dl, at least about 500 mg/dl, at least about 600
mg/dl, at least about 700 mg/dl, at least about 800 mg/dl, at least
about 900 mg/dl, at least about 1000 mg/dl, at least about 1100
mg/dl, at least about 1200 mg/dl, at least about 1300 mg/dl, at
least about 1400 mg/dl, or at least about 1500 mg/dl, for example
about 200 mg/dl to about 499 mg/dl, about 400 mg/dl to about 2500
mg/dl, about 450 mg/dl to about 2000 mg/dl or about 500 mg/dl to
about 1500 mg/dl.
[0036] In another embodiment, the subject or subject group being
treated has a baseline triglyceride level (or mean or median
baseline triglyceride level in the case of a subject group), fed or
fasting, of about 200 mg/dl to about 499 mg/dl. In another
embodiment, the subject or subject group has a baseline LDL-C level
(or mean or median baseline LDL-C level), despite stable statin
therapy, of about 40 mg/dl to about 115 or about 40 to about 100
mg/dl.
[0037] In one embodiment, the subject or subject group being
treated in accordance with methods of the invention is on
concomitant statin therapy, for example atorvastatin, rosuvastatin
or simvastatin therapy (with or without ezetimibe). In another
embodiment, the subject is on concomitant stable statin therapy at
time of initiation of ultra-pure EPA therapy.
[0038] In one embodiment, the subject or subject group being
treated in accordance with methods of the invention has previously
been treated with Lovaza.RTM. and has experienced an increase in,
or no decrease in, LDL-C levels and/or non-HDL-C levels. In one
such embodiment, Lovaza.RTM. therapy is discontinued and replaced
by a method of the present invention
[0039] In another embodiment, the subject or subject group being
treated in accordance with methods of the invention has a body mass
index (BMI or mean BMI) of not more than about 45 kg/m.sup.2.
[0040] In one embodiment, the invention provides a method of
lowering triglycerides in a subject on stable statin therapy having
baseline fasting triglycerides of about 200 mg/dl to about 500
mg/dl, the method comprising administering to the subject a
pharmaceutical composition comprising about 1 g to about 4 g of
EPA, about 2 g to about 4 g of EPA, or about 3.5 g to about 4 g of
EPA, wherein upon administering the composition to the subject
daily for a period of about 12 weeks the subject exhibits at least
10%, at least 15%, at least 20%, at least 25%, at least 30%, at
least 35%, at least 40%, at least 45%, at least 50%, at least 55%,
at least 60%, at least 65%, at least 70%, or at least 75% lower
fasting triglycerides than a control subject maintained on stable
statin therapy (and optionally placebo matching the EPA) without
concomitant EPA for a period of about 12 weeks, wherein the control
subject also has baseline fasting triglycerides of about 200 mg/dl
to about 500 mg/dl. The term "stable statin therapy" herein means
that the subject, subject group, control subject or control subject
group in question has been taking a stable daily dose of a statin
(e.g. atorvastatin, rosuvastatin or simvastatin) for at least 4
weeks prior to the baseline fasting triglyceride measurement (the
"qualifying period"). For example, a subject or control subject on
stable statin therapy would receive a constant daily (i.e. the same
dose each day) statin dose for at least 4 weeks immediately prior
to baseline fasting triglyceride measurement. In one embodiment,
the subject's and control subject's LDL-C is maintained between
about 40 mg/dl and about 115 mg/dl or about 40 mg/dl to about 100
mg/dl during the qualifying period. The subject and control subject
are then continued on their stable statin dose for the 12 week
period post baseline.
[0041] In one embodiment, the statin is administered to the subject
and the control subject in an amount of about 1 mg to about 500 mg,
about 5 mg to about 200 mg, or about 10 mg to about 100 mg, for
example about 1 mg, about 2 mg, about 3 mg, about 4 mg, about 5 mg,
about 6 mg, about 7 mg, about 8 mg, about 9 mg, or about 10 mg;
about 15 mg, about 20 mg, about 25 mg, about 30 mg, about 35 mg,
about 40 mg, about 45 mg, about 50 mg, about 55 mg, about 60 mg,
about 65 mg, about 70 mg, about 75 mg, about 80 mg, about 90 mg,
about 100 mg, about 125 mg, about 150 mg, about 175 mg, about 200
mg, about 225 mg, about 250 mg, about 275 mg, about 300 mg, about
325 mg, about 350 mg, about 375 mg, about 400 mg, about 425 mg,
about 450 mg, about 475 mg, or about 500 mg. In another embodiment,
the subject (and optionally the control subject) has a baseline
LDL-C level, despite stable statin therapy, of about 40 mg/dl to
about 115 mg/dl or about 40 mg/dl to about 100 mg/dl. In another
embodiment, the subject and/or control subject has a body mass
index (BMI; or mean BMI) of not more than about 45 kg/m.sup.2.
[0042] In another embodiment, the invention provides a method of
lowering triglycerides in a subject group on stable statin therapy
having mean baseline fasting triglycerides of about 200 mg/dl to
about 499 mg/dl, the method comprising administering daily to
members of the subject group a pharmaceutical composition
comprising about 1 g to about 4 g of EPA per day, wherein upon
administering the composition to the members of the subject group
daily for a period of about 12 weeks the subject group exhibits at
least 10%, at least 15%, at least 20%, at least 25%, at least 30%,
at least 35%, at least 40%, at least 45%, at least 50%, at least
55%, at least 60%, at least 65%, at least 70%, at least 75% lower
mean fasting triglycerides than a control subject group maintained
on stable statin therapy without concomitant EPA (optionally with
matching placebo) for a period of about 12 weeks, wherein the
control subject group also has mean baseline fasting triglycerides
of about 200 mg/dl to about 499 mg/dl. In a related embodiment, the
stable statin therapy will be sufficient such that the subject
group has a mean LDL-C level about at least about 40 mg/dl and not
more than about 100 mg/dl or about 40 mg/dl to about 100 mg/dl for
the 4 weeks immediately prior to the baseline fasting triglyceride
measurement.
[0043] In another embodiment, the invention provides a method of
lowering triglycerides in subject group on stable statin therapy
and having a mean baseline fasting triglyceride level of about 200
mg/dl to about 499 mg/dl, the method comprising administering daily
to members of the subject group a pharmaceutical composition
comprising about 1 g to about 4 g of EPA, wherein upon
administering the composition to members of the subject group daily
for a period of about 12 weeks the subject group exhibits: (a) at
least 10%, at least 15%, at least 20%, at least 25%, at least 30%,
at least 35%, at least 40%, at least 45%, at least 50%, at least
55%, at least 60%, at least 65%, at least 70%, at least 75% lower
mean fasting triglycerides by comparison with a control subject
group maintained on stable statin therapy without concomitant
ultra-pure EPA (optionally with matching placebo) for a period of
about 12 weeks, and (b) no serum LDL-C increase, no statistically
significant serum LDL-C increase, a serum LDL-C decrease, or the
subject is statistically non-inferior to the control subjects
(statin plus optional placebo) in regard to serum LDL-C elevation)
no increase in mean serum LDL-C levels compared to baseline,
wherein the control subject also has mean baseline fasting
triglycerides of about 200 mg/dl to about 499 mg/dl.
[0044] In another embodiment, the invention provides a method of
lowering triglycerides in subject on stable statin therapy and
having mean baseline fasting triglyceride level of about 200 mg/dl
to about 499 mg/dl, the method comprising administering daily to
the subject a pharmaceutical composition comprising about 1 g to
about 4 g of EPA, wherein upon administering the composition to the
subject daily for a period of about 12 weeks the subject exhibits
(a) at least 10%, at least 15%, at least 20%, at least 25%, at
least 30%, at least 35%, at least 40%, at least 45%, at least 50%,
at least 55%, at least 60%, at least 65%, at least 70%, or at least
75% lower fasting triglycerides by comparison with a control
subject maintained on stable statin therapy without concomitant EPA
for a period of about 12 weeks and (b) no increase in serum LDL-C
levels compared to baseline, wherein the control subject also has
baseline fasting triglycerides of about 200 mg/dl to about 499
mg/dl.
[0045] In another embodiment, the invention provides a method of
lowering triglycerides in subject group on stable statin therapy
and having mean baseline fasting triglyceride level of about 200
mg/dl to about 499 mg/dl, the method comprising administering daily
to members of the subject group a pharmaceutical composition
comprising about 1 g to about 4 g of EPA, wherein upon
administering the composition to the members of the subject group
daily for a period of about 12 weeks the subject group exhibits:
(a) at least 10%, at least 15%, at least 20%, at least 25%, at
least 30%, at least 35%, at least 40%, at least 45%, at least 50%,
at least 55%, at least 60%, at least 65%, at least 70%, at least
75% lower mean fasting triglycerides and (b) at least 5%, at least
10%, at least 15%, at least 20%, at least 25%, at least 30%, at
least 35%, at least 40%, at least 45% or at least 50% lower mean
serum LDL-C levels by comparison with a control subject group
maintained on stable statin therapy without concomitant EPA
(optionally with matching placebo) for a period of about 12 weeks,
no serum LDL-C increase, no statistically significant serum LDL-C
increase, no statistically significant serum LDL-C increase, a
serum LDL-C decrease, or the subject group is statistically
non-inferior to the control subject group (statin plus optional
placebo) in regard to serum LDL-C elevation), wherein the control
subject group also has mean baseline fasting triglycerides of about
200 mg/dl to about 499 mg/dl.
[0046] In another embodiment, the invention provides a method of
lowering triglycerides in subject group on stable statin therapy
and having mean baseline fasting triglyceride level of about 200
mg/dl to about 499 mg/dl, the method comprising administering daily
to members of the subject group a pharmaceutical composition
comprising about 1 g to about 4 g of EPA, wherein upon
administering the composition to the members of the subject group
daily for a period of about 12 weeks the subject group exhibits (a)
at least 10%, at least 15%, at least 20%, at least 25%, at least
30%, at least 35%, at least 40%, at least 45%, at least 50%, at
least 55%, at least 60%, at least 65%, at least 70%, at least 75%
lower mean fasting triglycerides and (b) at least 5%, at least 10%,
at least 15%, at least 20%, at least 25%, at least 30%, at least
35%, at least 40%, at least 45% or at least 50% lower mean serum
LDL-C levels by comparison with a control subject group maintained
on stable statin therapy without concomitant EPA (optionally with
matching placebo) for a period of about 12 weeks, no serum LDL-C
increase, no statistically significant serum LDL-C increase, no
statistically significant serum LDL-C increase, a serum LDL-C
decrease, or the subject group is statistically non-inferior to the
control subject group (statin plus optional placebo) in regard to
serum LDL-C elevation), wherein the control subject group also has
mean baseline fasting triglycerides of about 200 mg/dl to about 499
mg/dl.
[0047] In another embodiment, the subject or subject group being
treated has a baseline triglyceride level (or median baseline
triglyceride level in the case of a subject group), fed or fasting,
of at least about 300 mg/dl, at least about 400 mg/dl, at least
about 500 mg/dl, at least about 600 mg/dl, at least about 700
mg/dl, at least about 800 mg/dl, at least about 900 mg/dl, at least
about 1000 mg/dl, at least about 1100 mg/dl, at least about 1200
mg/dl, at least about 1300 mg/dl, at least about 1400 mg/dl, or at
least about 1500 mg/dl, for example about 400 mg/dl to about 2500
mg/dl, about 450 mg/dl to about 2000 mg/dl or about 500 mg/dl to
about 1500 mg/dl.
[0048] In another embodiment, the invention provides a method of
lowering triglycerides in a subject group having mean baseline
fasting triglycerides of at least about 500 mg/dl, the method
comprising administering daily to members of the subject group a
pharmaceutical composition comprising about 1 g to about 4 g of EPA
per day, wherein upon administering the composition to the members
of the subject group daily for a period of about 12 weeks the
subject group exhibits at least 10%, at least 15%, at least 20%, at
least 25%, at least 30%, at least 35%, at least 40%, at least 45%,
at least 50%, at least 55%, at least 60%, at least 65%, at least
70%, at least 75% lower mean fasting triglycerides than a control
subject group not receiving EPA (optionally with matching placebo)
for a period of about 12 weeks, wherein the control subject group
also has mean baseline fasting triglycerides of at least about 500
mg/dl. In a related embodiment, the members of the subject group
and/or the control subject group also receive statin therapy, such
as stable statin therapy.
[0049] In another embodiment, the invention provides a method of
lowering triglycerides in a subject or subject group having mean
baseline fasting triglycerides of at least about 500 mg/dl, the
method comprising administering daily to the subject or the members
of the subject group a pharmaceutical composition comprising about
1 g to about 4 g of EPA, wherein upon administering the composition
to members of the subject group daily for a period of about 12
weeks the subject group exhibits: (a) at least 10%, at least 15%,
at least 20%, at least 25%, at least 30%, at least 35%, at least
40%, at least 45%, at least 50%, at least 55%, at least 60%, at
least 65%, at least 70%, at least 75% lower mean fasting
triglycerides by comparison with a control subject group not
receiving EPA (optionally with matching placebo) for a period of
about 12 weeks, and (b) no serum LDL-C increase, no statistically
significant serum LDL-C increase, a serum LDL-C decrease, or the
subject is statistically non-inferior to the control subjects
(statin plus optional placebo) in regard to serum LDL-C elevation)
no increase in mean serum LDL-C levels compared to baseline,
wherein the control subject also has mean baseline fasting
triglycerides of at least about 500 mg/dl.
[0050] In another embodiment, the invention provides a method of
lowering triglycerides in a subject or a subject group having mean
baseline fasting triglycerides of at least about 500 mg/dl, the
method comprising administering daily to the subject or subject
group a pharmaceutical composition comprising about 1 g to about 4
g of EPA, wherein upon administering the composition to the subject
daily for a period of about 12 weeks the subject exhibits (a) at
least 10%, at least 15%, at least 20%, at least 25%, at least 30%,
at least 35%, at least 40%, at least 45%, at least 50%, at least
55%, at least 60%, at least 65%, at least 70%, or at least 75%
lower fasting triglycerides by comparison with a control subject
not receiving EPA for a period of about 12 weeks and (b) no
increase in serum LDL-C levels compared to baseline, wherein the
control subject also has baseline fasting triglycerides of at least
about 500 mg/dl.
[0051] In another embodiment, the invention provides a method of
lowering triglycerides in a subject or subject group having mean
baseline fasting triglycerides of at least about 500 mg/dl, the
method comprising administering daily to the subject or members of
the subject group a pharmaceutical composition comprising about 1 g
to about 4 g of EPA, wherein upon administering the composition to
the members of the subject group daily for a period of about 12
weeks the subject group exhibits: (a) at least 10%, at least 15%,
at least 20%, at least 25%, at least 30%, at least 35%, at least
40%, at least 45%, at least 50%, at least 55%, at least 60%, at
least 65%, at least 70%, at least 75% lower mean fasting
triglycerides and (b) at least 5%, at least 10%, at least 15%, at
least 20%, at least 25%, at least 30%, at least 35%, at least 40%,
at least 45% or at least 50% lower mean serum LDL-C levels by
comparison with a control subject group not receiving EPA
(optionally with matching placebo) for a period of about 12 weeks,
no serum LDL-C increase, no statistically significant serum LDL-C
increase, no statistically significant serum LDL-C increase, a
serum LDL-C decrease, or the subject group is statistically
non-inferior to the control subject group (statin plus optional
placebo) in regard to serum LDL-C elevation), wherein the control
subject group also has mean baseline fasting triglycerides of at
least about 500 mg/dl.
[0052] In another embodiment, the invention provides a method of
lowering triglycerides in a subject or subject group having mean
baseline fasting triglycerides of at least about 500 mg/dl, the
method comprising administering daily to members of the subject
group a pharmaceutical composition comprising about 1 g to about 4
g of EPA, wherein upon administering the composition to the members
of the subject group daily for a period of about 12 weeks the
subject group exhibits (a) at least 10%, at least 15%, at least
20%, at least 25%, at least 30%, at least 35%, at least 40%, at
least 45%, at least 50%, at least 55%, at least 60%, at least 65%,
at least 70%, at least 75% lower mean fasting triglycerides and (b)
at least 5%, at least 10%, at least 15%, at least 20%, at least
25%, at least 30%, at least 35%, at least 40%, at least 45% or at
least 50% lower mean serum LDL-C levels by comparison with a
control subject group not receiving EPA (optionally with matching
placebo) for a period of about 12 weeks, no serum LDL-C increase,
no statistically significant serum LDL-C increase, no statistically
significant serum LDL-C increase, a serum LDL-C decrease, or the
subject group is statistically non-inferior to the control subject
group (statin plus optional placebo) in regard to serum LDL-C
elevation), wherein the control subject group also has mean
baseline fasting triglycerides of at least about 500 mg/dl.
[0053] In another embodiment, the subject or subject group being
treated in accordance with methods of the invention exhibits a
fasting baseline absolute plasma level of free total fatty acid (or
mean thereof) not greater than about 300 nmol/ml, not greater than
about 250 nmol/ml, not greater than about 200 nmol/ml, not greater
than about 150 nmol/ml, not greater than about 100 nmol/ml, or not
greater than about 50 nmol/ml.
[0054] In another embodiment, the subject or subject group being
treated in accordance with methods of the invention exhibits a
fasting baseline absolute plasma level of free EPA (or mean thereof
in the case of a subject group) not greater than about 0.70
nmol/ml, not greater than about 0.65 nmol/ml, not greater than
about 0.60 nmol/ml, not greater than about 0.55 nmol/ml, not
greater than about 0.50 nmol/ml, not greater than about 0.45
nmol/ml, or not greater than about 0.40 nmol/ml. In another
embodiment, the subject or subject group being treated in
accordance with methods of the invention exhibits a baseline
fasting plasma level (or mean thereof) of free EPA, expressed as a
percentage of total free fatty acid, of not more than about 3%, not
more than about 2.5%, not more than about 2%, not more than about
1.5%, not more than about 1%, not more than about 0.75%, not more
than about 0.5%, not more than about 0.25%, not more than about
0.2% or not more than about 0.15%. In one such embodiment, free
plasma EPA and/or total fatty acid levels are determined prior to
initiating therapy.
[0055] In another embodiment, the subject or subject group being
treated in accordance with methods of the invention exhibits a
fasting baseline absolute plasma level of free EPA (or mean
thereof) not greater than about 1 nmol/ml, not greater than about
0.75 nmol/ml, not greater than about 0.50 nmol/ml, not greater than
about 0.4 nmol/ml, not greater than about 0.35 nmol/ml, or not
greater than about 0.30 nmol/ml.
[0056] In another embodiment, the subject or subject group being
treated in accordance with methods of the invention exhibits a
fasting baseline plasma, serum or red blood cell membrane EPA level
not greater than about 150 .mu.g/ml, not greater than about 125
.mu.g/ml, not greater than about 100 .mu.g/ml, not greater than
about 95 .mu.g/ml, not greater than about 75 .mu.g/ml, not greater
than about 60 .mu.g/ml, not greater than about 50 .mu.g/ml, not
greater than about 40 .mu.g/ml, not greater than about 30 .mu.g/ml,
or not greater than about 25 .mu.g/ml.
[0057] In another embodiment, methods of the present invention
comprise a step of measuring the subject's (or subject group's
mean) baseline lipid profile prior to initiating therapy. In
another embodiment, methods of the invention comprise the step of
identifying a subject or subject group having one or more of the
following: baseline non-HDL-C value (or mean) of about 200 mg/dl to
about 400 mg/dl, for example at least about 210 mg/dl, at least
about 220 mg/dl, at least about 230 mg/dl, at least about 240
mg/dl, at least about 250 mg/dl, at least about 260 mg/dl, at least
about 270 mg/dl, at least about 280 mg/dl, at least about 290
mg/dl, or at least about 300 mg/dl; baseline total cholesterol
value (or mean) of about 250 mg/dl to about 400 mg/dl, for example
at least about 260 mg/dl, at least about 270 mg/dl, at least about
280 mg/dl or at least about 290 mg/dl; baseline VLDL-C value (or
mean) of about 140 mg/dl to about 200 mg/dl, for example at least
about 150 mg/dl, at least about 160 mg/dl, at least about 170
mg/dl, at least about 180 mg/dl or at least about 190 mg/dl;
baseline HDL-C value (or mean) of about 10 to about 100 mg/dl, for
example not more than about 90 mg/dl not, not more than about 80
mg/dl, not more than about 70 mg/dl, not more than about 60 mg/dl,
not more than about 60 mg/dl, not more than about 50 mg/dl, not
more than about 40 mg/dl, not more than about 35 mg/dl, not more
than about 30 mg/dl, not more than about 25 mg/dl, not more than
about 20 mg/dl, or not more than about 15 mg/dl; and/or baseline
LDL-C value (or mean) of about 30 to about 300 mg/dl, for example
not less than about 30 mg/dl, not less than about 40 mg/dl, not
less than about 50 mg/dl, not less than about 60 mg/dl, not less
than about 70 mg/dl, not less than about 90 mg/dl, not less than
about 100 mg/dl, not less than about 110 mg/dl, not less than about
120 mg/dl, not less than about 130 mg/dl, not less than about 140
mg/dl, not less than about 150 mg/dl, not less than about 160
mg/dl, not less than about 170 mg/dl, not less than about 180
mg/dl, not less than about 190 mg/dl, not less than about 200
mg/dl, not less than about 210 mg/dl, not less than about 220
mg/dl, not less than about 230 mg/dl, not less than about 240
mg/dl, not less than about 250 mg/dl, not less than about 260
mg/dl, not less than about 270 mg/dl, not less than about 280
mg/dl, not less than about 290 mg/dl, or not less than about 300
mg/dl.
[0058] In a related embodiment, upon treatment in accordance with
the present invention, for example over a period of about 1 to
about 200 weeks, about 1 to about 100 weeks, about 1 to about 80
weeks, about 1 to about 50 weeks, about 1 to about 40 weeks, about
1 to about 20 weeks, about 1 to about 15 weeks, about 1 to about 12
weeks, about 1 to about 10 weeks, about 1 to about 5 weeks, about 1
to about 2 weeks or about 1 week, the subject or subject group
exhibits one or more of the following outcomes:
[0059] (a) reduced triglyceride levels compared to baseline or
placebo control (e.g. a subject on stable statin plus placebo
matching the EPA treatment group);
[0060] (b) reduced Apo B levels compared to baseline or placebo
control;
[0061] (c) increased HDL-C levels compared to baseline or placebo
control;
[0062] (d) no increase in LDL-C levels compared to baseline or
placebo control;
[0063] (e) a reduction in LDL-C levels compared to baseline or
placebo control;
[0064] (f) a reduction in non-HDL-C levels compared to baseline or
placebo control;
[0065] (g) a reduction in VLDL levels compared to baseline or
placebo control;
[0066] (h) an increase in apo A-I levels compared to baseline or
placebo control;
[0067] (i) an increase in apo A-I/apo B ratio compared to baseline
or placebo control;
[0068] (j) a reduction in lipoprotein A levels compared to baseline
or placebo control;
[0069] (k) a reduction in LDL particle number compared to baseline
or placebo control;
[0070] (l) an increase in LDL size compared to baseline or placebo
control;
[0071] (m) a reduction in remnant-like particle cholesterol
compared to baseline or placebo control;
[0072] (n) a reduction in oxidized LDL compared to baseline or
placebo control;
[0073] (o) no change or a reduction in fasting plasma glucose (FPG)
compared to baseline or placebo control;
[0074] (p) a reduction in hemoglobin A.sub.1c (HbA.sub.1c) compared
to baseline or placebo control;
[0075] (q) a reduction in homeostasis model insulin resistance
compared to baseline or placebo control;
[0076] (r) a reduction in lipoprotein associated phospholipase A2
compared to baseline or placebo control;
[0077] (s) a reduction in intracellular adhesion molecule-1
compared to baseline or placebo control;
[0078] (t) a reduction in interleukin-6 compared to baseline or
placebo control;
[0079] (u) a reduction in plasminogen activator inhibitor-1
compared to baseline or placebo control;
[0080] (v) a reduction in high sensitivity C-reactive protein
(hsCRP) compared to baseline or placebo control;
[0081] (w) an increase in serum or plasma EPA compared to baseline
or placebo control;
[0082] (x) an increase in red blood cell membrane EPA compared to
baseline or placebo control;
[0083] (y) a reduction or increase in one or more of serum and/or
red blood cell content of docosahexaenoic acid (DHA),
docosapentaenoic acid (DPA), arachidonic acid (AA), palmitic acid
(PA), stearidonic acid (SA) or oleic acid (OA) compared to baseline
or placebo control;
[0084] (z) a reduction in the ratio of arachidonic acid to EPA
("AA/EPA") in serum, plasma and/or RBCs compared to baseline or
placebo control;
[0085] (aa) an increase in the ratio of omega-3 fatty acids to
omega-6 fatty acids in serum, plasma, and/or RBCs compared to
baseline or placebo control;
[0086] (bb) a decrease in the ratio of omega-6 fatty acids to total
fatty acids in serum, plasma, and/or RBCs compared to baseline or
placebo control; and/or
[0087] (cc) an increase in the ratio of omega-3 fatty acids to
total fatty acids in serum, plasma, and/or RBCs compared to
baseline or placebo control.
[0088] In one embodiment, methods of the present invention comprise
measuring baseline levels of one or more markers set forth in
(a)-(cc) above prior to dosing the subject or subject group. In
another embodiment, the methods comprise administering a
composition as disclosed herein to the subject after baseline
levels of one or more markers set forth in (a)-(cc) are determined,
and subsequently taking an additional measurement of said one or
more markers.
[0089] In another embodiment, upon treatment with a composition of
the present invention, for example over a period of about 1 to
about 200 weeks, about 1 to about 100 weeks, about 1 to about 80
weeks, about 1 to about 50 weeks, about 1 to about 40 weeks, about
1 to about 20 weeks, about 1 to about 15 weeks, about 1 to about 12
weeks, about 1 to about 10 weeks, about 1 to about 5 weeks, about 1
to about 2 weeks or about 1 week, the subject or subject group
exhibits any 2 or more of, any 3 or more of, any 4 or more of, any
5 or more of, any 6 or more of, any 7 or more of, any 8 or more of,
any 9 or more of, any 10 or more of, any 11 or more of, any 12 or
more of, any 13 or more of, any 14 or more of, any 15 or more of,
any 16 or more of, any 17 or more of, any 18 or more of, any 19 or
more of, any 20 or more of, any 21 or more of, any 22 or more of,
any 23 or more of, any 24 or more of, any 25 or more of, any 26 or
more of, any 27 or more of, any 28 or more of, or all 29 of
outcomes (a)-(cc) described immediately above.
[0090] In another embodiment, upon treatment with a composition of
the present invention, the subject or subject group exhibits one or
more of the following outcomes:
[0091] (a) a reduction in triglyceride level of at least about 5%,
at least about 10%, at least about 15%, at least about 20%, at
least about 25%, at least about 30%, at least about 35%, at least
about 40%, at least about 45%, at least about 50%, at least about
55% or at least about 75% (actual % change or median % change) as
compared to baseline or placebo control (e.g. a subject on statin
and placebo matching the EPA treatment group);
[0092] (b) a less than 30% increase, less than 20% increase, less
than 10% increase, less than 5% increase or no increase in
non-HDL-C levels or a reduction in non-HDL-C levels of at least
about 1%, at least about 3%, at least about 5%, at least about 10%,
at least about 15%, at least about 20%, at least about 25%, at
least about 30%, at least about 35%, at least about 40%, at least
about 45%, at least about 50%, at least about 55% or at least about
75% (actual % change or median % change) as compared to baseline or
placebo control;
[0093] (c) substantially no change in HDL-C levels, no change in
HDL-C levels, or an increase in HDL-C levels of at least about 5%,
at least about 10%, at least about 15%, at least about 20%, at
least about 25%, at least about 30%, at least about 35%, at least
about 40%, at least about 45%, at least about 50%, at least about
55% or at least about 75% (actual % change or median % change) as
compared to baseline or placebo control;
[0094] (d) a less than 60% increase, less than 50% increase, less
than 40% increase, less than 30% increase, less than 20% increase,
less than 10% increase, less than 5% increase or no increase in
LDL-C levels, or a reduction in LDL-C levels of at least about 5%,
at least about 10%, at least about 15%, at least about 20%, at
least about 25%, at least about 30%, at least about 35%, at least
about 40%, at least about 45%, at least about 50%, at least about
55%, at least about 55% or at least about 75% (actual % change or
median % change) as compared to baseline or placebo control;
[0095] (e) a decrease in Apo B levels of at least about 5%, at
least about 10%, at least about 15%, at least about 20%, at least
about 25%, at least about 30%, at least about 35%, at least about
40%, at least about 45%, at least about 50%, at least about 55% or
at least about 75% (actual % change or median % change) as compared
to baseline or placebo control;
[0096] (f) a reduction in VLDL levels of at least about 5%, at
least about 10%, at least about 15%, at least about 20%, at least
about 25%, at least about 30%, at least about 35%, at least about
40%, at least about 45%, at least about 50%, or at least about 100%
(actual % change or median % change) compared to baseline or
placebo control;
[0097] (g) an increase in apo A-I levels of at least about 5%, at
least about 10%, at least about 15%, at least about 20%, at least
about 25%, at least about 30%, at least about 35%, at least about
40%, at least about 45%, at least about 50%, or at least about 100%
(actual % change or median % change) compared to baseline or
placebo control;
[0098] (h) an increase in apo A-I/apo B ratio of at least about 5%,
at least about 10%, at least about 15%, at least about 20%, at
least about 25%, at least about 30%, at least about 35%, at least
about 40%, at least about 45%, at least about 50%, or at least
about 100% (actual % change or median % change) compared to
baseline or placebo control;
[0099] (i) a reduction in lipoprotein (a) levels of at least about
5%, at least about 10%, at least about 15%, at least about 20%, at
least about 25%, at least about 30%, at least about 35%, at least
about 40%, at least about 45%, at least about 50%, or at least
about 100% (actual % change or median % change) compared to
baseline or placebo control;
[0100] (j) a reduction in mean LDL particle number of at least
about 5%, at least about 10%, at least about 15%, at least about
20%, at least about 25%, at least about 30%, at least about 35%, at
least about 40%, at least about 45%, at least about 50%, or at
least about 100% (actual % change or median % change) compared to
baseline or placebo control;
[0101] (k) an increase in mean LDL particle size of at least about
5%, at least about 10%, at least about 15%, at least about 20%, at
least about 25%, at least about 30%, at least about 35%, at least
about 40%, at least about 45%, at least about 50%, or at least
about 100% (actual % change or median % change) compared to
baseline or placebo control;
[0102] (l) a reduction in remnant-like particle cholesterol of at
least about 5%, at least about 10%, at least about 15%, at least
about 20%, at least about 25%, at least about 30%, at least about
35%, at least about 40%, at least about 45%, at least about 50%, or
at least about 100% (actual % change or median % change) compared
to baseline or placebo control;
[0103] (m) a reduction in oxidized LDL of at least about 5%, at
least about 10%, at least about 15%, at least about 20%, at least
about 25%, at least about 30%, at least about 35%, at least about
40%, at least about 45%, at least about 50%, or at least about 100%
(actual % change or median % change) compared to baseline or
placebo control;
[0104] (n) substantially no change, no statistically significant
change, or a reduction in fasting plasma glucose (FPG) of at least
about 5%, at least about 10%, at least about 15%, at least about
20%, at least about 25%, at least about 30%, at least about 35%, at
least about 40%, at least about 45%, at least about 50%, or at
least about 100% (actual % change or median % change) compared to
baseline or placebo control;
[0105] (o) substantially no change, no statistically significant
change, a reduction in hemoglobin A.sub.1c (HbA.sub.1c) of at least
about 5%, at least about 10%, at least about 15%, at least about
20%, at least about 25%, at least about 30%, at least about 35%, at
least about 40%, at least about 45%, or at least about 50% (actual
% change or median % change) compared to baseline or placebo
control;
[0106] (p) a reduction in homeostasis model index insulin
resistance of at least about 5%, at least about 10%, at least about
15%, at least about 20%, at least about 25%, at least about 30%, at
least about 35%, at least about 40%, at least about 45%, at least
about 50%, or at least about 100% (actual % change or median %
change) compared to baseline or placebo control;
[0107] (q) a reduction in lipoprotein associated phospholipase A2
of at least about 5%, at least about 10%, at least about 15%, at
least about 20%, at least about 25%, at least about 30%, at least
about 35%, at least about 40%, at least about 45%, at least about
50%, or at least about 100% (actual % change or median % change)
compared to baseline or placebo control;
[0108] (r) a reduction in intracellular adhesion molecule-1 of at
least about 5%, at least about 10%, at least about 15%, at least
about 20%, at least about 25%, at least about 30%, at least about
35%, at least about 40%, at least about 45%, at least about 50%, or
at least about 100% (actual % change or median % change) compared
to baseline or placebo control;
[0109] (s) a reduction in interleukin-6 of at least about 5%, at
least about 10%, at least about 15%, at least about 20%, at least
about 25%, at least about 30%, at least about 35%, at least about
40%, at least about 45%, at least about 50%, or at least about 100%
(actual % change or median % change) compared to baseline or
placebo control;
[0110] (t) a reduction in plasminogen activator inhibitor-1 of at
least about 5%, at least about 10%, at least about 15%, at least
about 20%, at least about 25%, at least about 30%, at least about
35%, at least about 40%, at least about 45%, at least about 50%, or
at least about 100% (actual % change or median % change) compared
to baseline or placebo control;
[0111] (u) a reduction in high sensitivity C-reactive protein
(hsCRP) of at least about 5%, at least about 10%, at least about
15%, at least about 20%, at least about 25%, at least about 30%, at
least about 35%, at least about 40%, at least about 45%, at least
about 50%, or at least about 100% (actual % change or median %
change) compared to baseline or placebo control;
[0112] (v) an increase in serum, plasma and/or RBC EPA of at least
about 5%, at least about 10%, at least about 15%, at least about
20%, at least about 25%, at least about 30%, at least about 35%, at
least about 40%, at least about 45%, at least about 50%, at least
about 100%, at least about 200%, at least about 220%, at least
about 223%, about 223.6%, 223.6%, at least about 230%, about
230.7%, 230.7%, at least about 250%, at least about 257%, about
257.3%, 257.3%, about 268%, 268.2% about 290%, 290.4%, 297.7%,
about 298%, at least about 300%, at least about 345%, about 345.6%,
345.6%, at least about 400%, about 402%, 402.3%, at least about
450%, at least about 460%, at least about 462%, about 462.3%,
462.3%, at least about 480%, about 489.6%, 489.6%, about 490%, at
least about 500%, at least about 600%, about 619%, 619.2%, at least
about 645%, about 645.9%, about 646%, at least about 649%, about
649.7%, 649.7%, about 650%, at least about 698%, about 698.9%,
about 699%, at least about 700%, about 790%, 792%, or at least
about 800% (actual % change or median % change) compared to
baseline or placebo control;
[0113] (w) an increase in serum phospholipid and/or red blood cell
membrane EPA of at least about 5%, at least about 10%, at least
about 15%, at least about 20%, at least about 25%, at least about
30%, at least about 35%, at least about 40%, at least about 45%, r
at least about 50%, at least about 100%, at least about 200%, or at
least about 400% (actual % change or median % change) compared to
baseline or placebo control;
[0114] (x) a reduction or increase in one or more of serum
phospholipid and/or red blood cell DHA, DPA, AA, PA and/or OA of at
least about 5%, at least about 10%, at least about 15%, at least
about 20%, at least about 25%, at least about 30%, at least about
35%, at least about 40%, at least about 45%, at least about 50%, at
least about 55% or at least about 75% (actual % change or median %
change) compared to baseline or placebo control;
[0115] (y) a reduction in total cholesterol of at least about 5%,
at least about 10%, at least about 15%, at least about 20%, at
least about 25%, at least about 30%, at least about 35%, at least
about 40%, at least about 45%, at least about 50%, at least about
55% or at least about 75% (actual % change or median % change)
compared to baseline or placebo control;
[0116] (z) a reduction in the ratio of arachidonic acid to EPA
("AA/EPA") in serum, plasma and/or RBCs of at least about 50%, at
least about 55%, at least about 60%, at least about 65%, at least
about 70%, at least about 75%, about 75.4%, at least about 80%, at
least about 83%, about 83.7%, 83.7%, about 83.9%, 83.9%, about 84%,
at least about 84%, about 84.2%, 84.2%, about 84.8%, 84.8%, about
85%, at least about 85%, at least about 86%, about 86.5%, about
87%, about 87.1%, about 87.8%, 87.8%, about 88%, 88.4%, at least
about 90%, about 90.3%, at least about 95%, about 98.5%, about 91%,
91.1%, about 99%, 99.4%, at least about 100%, about 102%, 102%, at
least about 105%, at least about 110%, at least about 115%, at
least about 120%, at least about 125%, at least about 130%, at
least about 135%, at least about 140%, at least about 145%, or at
least about 150% (actual % or median % change) compared to baseline
or placebo control;
[0117] (aa) no significant change in the ratio of omega-3 fatty
acids to omega-6 fatty acids in serum, plasma, and/or RBCs, or an
increase in the ratio of omega-3 fatty acids to omega-6 fatty acids
in serum, plasma, and/or RBCs of at least about 50%, at least about
54%, about 54.5%, 54.5%, about 55%, at least about 55%, at least
about 60%, about 60.4%, about 64.3%, at least about 65%, about 65%,
65.5%, about 66%, at least about 70%, at least about 75%, 76.8%,
about 77%, at least about 80%, at least about 85%, at least about
90%, about 90.9%, 90.9%, about 91%, at least about 95%, at least
about 100%, at least about 105%, 106.9%, about 107%, at least about
110%, at least about 115%, at least about 120%, about 123.0%, at
least about 125%, at least about 130%, at least about 135%, at
least about 140%, at least about 145%, 145.8%, about 146%, at least
about 150%, at least about 155%, at least about 160%, at least
about 165%, about 165.9%, at least about 170%, at least about 175%,
at least about 180%, at least about 185%, at least about 190%, at
least about 195%, or at least about 200% (actual % or median %
change) compared to baseline or placebo control;
[0118] (bb) a decrease in the ratio of omega-6 fatty acids to total
fatty acids in serum, plasma, and/or RBCs of at least about 4%,
about 4.6%, at least about 5%, at least about 6%, at least about
7%, about 7.4%, at least about 8%, at least about 9%, at least
about 10%, at least about 11%, about 11.3%, at least about 12%, at
least about 13%, about 13%, 13.2%, at least about 14%, at least
about 15%, at least about 16%, at least about 17%, about 17%,
17.3%, at least about 18%, at least about 19%, about 19.7%, at
least about 20%, at least about 21%, at least about 22%, at least
about 23%, at least about 24%, at least about 25% (actual % or
median % change) compared to baseline or placebo control;
and/or
[0119] (cc) an increase in the ratio of omega-3 fatty acids to
total fatty acids in serum, plasma, and/or RBCs of at least about
40%, at least about 45%, at least about 50%, about 50.0%, about
53%, 53.4%, at least about 55%, at least about 60%, about 60.3%, at
least about 65%, about 68%, 68.4%, at least about 70%, at least
about 75%, at least about 80%, at least about 85%, about 89.1%, at
least about 90%, at least about 95%, at least about 100%, at least
about 105%, at least about 110%, at least about 115%, at least
about 120%, at least about 125%, at least about 130%, 132.7%, about
133%, at least about 135%, at least about 140%, about 142.2%, at
least about 145%, at least about 150%, at least about 155%, at
least about 160%, at least about %, at least about 165%, at least
about 170%, at least about 175%, at least about 180%, at least
about 185%, at least about 190%, at least about 195%, at least
about 200% (actual % or median % change) compared to baseline or
placebo control.
[0120] In one embodiment, methods of the present invention comprise
measuring baseline levels of one or more markers set forth in
(a)-(cc) prior to dosing the subject or subject group. In another
embodiment, the methods comprise administering a composition as
disclosed herein to the subject after baseline levels of one or
more markers set forth in (a)-(cc) are determined, and subsequently
taking a second measurement of the one or more markers as measured
at baseline for comparison thereto.
[0121] In another embodiment, upon treatment with a composition of
the present invention, for example over a period of about 1 to
about 200 weeks, about 1 to about 100 weeks, about 1 to about 80
weeks, about 1 to about 50 weeks, about 1 to about 40 weeks, about
1 to about 20 weeks, about 1 to about 15 weeks, about 1 to about 12
weeks, about 1 to about 10 weeks, about 1 to about 5 weeks, about 1
to about 2 weeks or about 1 week, the subject or subject group
exhibits any 2 or more of, any 3 or more of, any 4 or more of, any
5 or more of, any 6 or more of, any 7 or more of, any 8 or more of,
any 9 or more of, any 10 or more of, any 11 or more of, any 12 or
more of, any 13 or more of, any 14 or more of, any 15 or more of,
any 16 or more of, any 17 or more of, any 18 or more of, any 19 or
more of, any 20 or more of, any 21 or more of, any 22 or more of,
any 23 or more of, any 24 or more of, any 25 or more of, any 26 or
more of, any 27 or more of, any 28 or more of, or all 29 of
outcomes (a)-(cc) described immediately above.
[0122] Parameters (a)-(cc) can be measured in accordance with any
clinically acceptable methodology. For example, triglycerides,
total cholesterol, HDL-C and fasting blood sugar can be sample from
serum and analyzed using standard photometry techniques. VLDL-TG,
LDL-C and VLDL-C can be calculated or determined using serum
lipoprotein fractionation by preparative ultracentrifugation and
subsequent quantitative analysis by refractometry or by analytic
ultracentrifugal methodology. Apo A1, Apo B and hsCRP can be
determined from serum using standard nephelometry techniques.
Lipoprotein (a) can be determined from serum using standard
turbidimetric immunoassay techniques. LDL particle number and
particle size can be determined using nuclear magnetic resonance
(NMR) spectrometry. Remnants lipoproteins and LDL-phospholipase A2
can be determined from EDTA plasma or serum and serum,
respectively, using enzymatic immunoseparation techniques. Oxidized
LDL, intercellular adhesion molecule-1 and interleukin-2 levels can
be determined from serum using standard enzyme immunoassay
techniques. These techniques are described in detail in standard
textbooks, for example Tietz Fundamentals of Clinical Chemistry,
6.sup.th Ed. (Burtis, Ashwood and Borter Eds.), WB Saunders
Company.
[0123] In one embodiment, subjects fast for up to 12 hours prior to
blood sample collection, for example about 10 hours.
[0124] In another embodiment, the subject being treated is in the
highest risk category of Adult Treatment Panel (ATP) III
Classification of LDL, Total, and HDL Cholesterol (mg/dL) (e.g. CHD
or CHD Risk Equivalents (10-year risk >20%)). In another
embodiment, the subject is in the ATP III Multiple (2+) risk factor
category.
[0125] In one embodiment, the invention provides a method of
lowering triglycerides in a subject in the highest risk category of
Adult Treatment Panel (ATP) III Classification of LDL, Total, and
HDL Cholesterol (mg/dL) (e.g. CHD or CHD Risk Equivalents (10-year
risk >20%)). In another embodiment, the subject is in the ATP
III Multiple (2+) risk factor category. In another embodiment, the
method includes a step of identifying a subject in the ATP III
Multiple (2+) risk factor category prior to administering
ultra-pure E-EPA to the subject.
[0126] In another embodiment, the present invention provides a
method of treating or preventing primary hypercholesterolemia
and/or mixed dyslipidemia (Fredrickson Types IIa and IIb) in a
patient in need thereof, comprising administering to the patient
one or more compositions as disclosed herein. In a related
embodiment, the present invention provides a method of reducing
triglyceride levels in a subject or subjects when treatment with a
statin or niacin extended-release monotherapy is considered
inadequate (Frederickson type IV hyperlipidemia).
[0127] In another embodiment, the present invention provides a
method of treating or preventing risk of recurrent nonfatal
myocardial infarction in a patient with a history of myocardial
infarction, comprising administering to the patient one or more
compositions as disclosed herein.
[0128] In another embodiment, the present invention provides a
method of slowing progression of or promoting regression of
atherosclerotic disease in a patient in need thereof, comprising
administering to a subject in need thereof one or more compositions
as disclosed herein.
[0129] In another embodiment, the present invention provides a
method of treating or preventing very high serum triglyceride
levels (e.g. Types IV and V hyperlipidemia) in a patient in need
thereof, comprising administering to the patient one or more
compositions as disclosed herein.
[0130] In another embodiment, the present invention provides a
method of treating subjects having very high serum triglyceride
levels (e.g. greater than 1000 mg/dl or greater than 2000 mg/dl)
and that are at risk of developing pancreatitis, comprising
administering to the patient one or more compositions as disclosed
herein.
[0131] In one embodiment, a composition of the invention is
administered to a subject in an amount sufficient to provide a
daily dose of EPA of about 1 mg to about 10,000 mg, 25 about 5000
mg, about 50 to about 3000 mg, about 75 mg to about 2500 mg, or
about 100 mg to about 1000 mg, for example about 1 mg, about 2 mg,
about 3 mg, about 4 mg, about 5 mg, about 6 mg, about 7 mg, about 8
mg, about 9 mg, about 10 mg, about 15 mg, about 20 mg, about 25 mg,
about 30 mg, about 35 mg, about 40 mg, about 45 mg, about 50 mg,
about 55 mg, about 60 mg, about 65 mg, about 70 mg, about 75 mg,
about 100 mg, about 125 mg, about 150 mg, about 175 mg, about 200
mg, about 225 mg, about 250 mg, about 275 mg, about 300 mg, about
325 mg, about 350 mg, about 375 mg, about 400 mg, about 425 mg,
about 450 mg, about 475 mg, about 500 mg, about 525 mg, about 550
mg, about 575 mg, about 600 mg, about 625 mg, about 650 mg, about
675 mg, about 700 mg, about 725 mg, about 750 mg, about 775 mg,
about 800 mg, about 825 mg, about 850 mg, about 875 mg, about 900
mg, about 925 mg, about 950 mg, about 975 mg, about 1000 mg, about
1025 mg, about 1050 mg, about 1075 mg, about 1100 mg, about 1025
mg, about 1050 mg, about 1075 mg, about 1200 mg, about 1225 mg,
about 1250 mg, about 1275 mg, about 1300 mg, about 1325 mg, about
1350 mg, about 1375 mg, about 1400 mg, about 1425 mg, about 1450
mg, about 1475 mg, about 1500 mg, about 1525 mg, about 1550 mg,
about 1575 mg, about 1600 mg, about 1625 mg, about 1650 mg, about
1675 mg, about 1700 mg, about 1725 mg, about 1750 mg, about 1775
mg, about 1800 mg, about 1825 mg, about 1850 mg, about 1875 mg,
about 1900 mg, about 1925 mg, about 1950 mg, about 1975 mg, about
2000 mg, about 2025 mg, about 2050 mg, about 2075 mg, about 2100
mg, about 2125 mg, about 2150 mg, about 2175 mg, about 2200 mg,
about 2225 mg, about 2250 mg, about 2275 mg, about 2300 mg, about
2325 mg, about 2350 mg, about 2375 mg, about 2400 mg, about 2425
mg, about 2450 mg, about 2475 mg, about 2500 mg, about 2525 mg,
about 2550 mg, about 2575 mg, about 2600 mg, about 2625 mg, about
2650 mg, about 2675 mg, about 2700 mg, about 2725 mg, about 2750
mg, about 2775 mg, about 2800 mg, about 2825 mg, about 2850 mg,
about 2875 mg, about 2900 mg, about 2925 mg, about 2950 mg, about
2975 mg, about 3000 mg, about 3025 mg, about 3050 mg, about 3075
mg, about 3100 mg, about 3125 mg, about 3150 mg, about 3175 mg,
about 3200 mg, about 3225 mg, about 3250 mg, about 3275 mg, about
3300 mg, about 3325 mg, about 3350 mg, about 3375 mg, about 3400
mg, about 3425 mg, about 3450 mg, about 3475 mg, about 3500 mg,
about 3525 mg, about 3550 mg, about 3575 mg, about 3600 mg, about
3625 mg, about 3650 mg, about 3675 mg, about 3700 mg, about 3725
mg, about 3750 mg, about 3775 mg, about 3800 mg, about 3825 mg,
about 3850 mg, about 3875 mg, about 3900 mg, about 3925 mg, about
3950 mg, about 3975 mg, about 4000 mg, about 4025 mg, about 4050
mg, about 4075 mg, about 4100 mg, about 4125 mg, about 4150 mg,
about 4175 mg, about 4200 mg, about 4225 mg, about 4250 mg, about
4275 mg, about 4300 mg, about 4325 mg, about 4350 mg, about 4375
mg, about 4400 mg, about 4425 mg, about 4450 mg, about 4475 mg,
about 4500 mg, about 4525 mg, about 4550 mg, about 4575 mg, about
4600 mg, about 4625 mg, about 4650 mg, about 4675 mg, about 4700
mg, about 4725 mg, about 4750 mg, about 4775 mg, about 4800 mg,
about 4825 mg, about 4850 mg, about 4875 mg, about 4900 mg, about
4925 mg, about 4950 mg, about 4975 mg, about 5000 mg, about 5050
mg, about 5100 mg, about 5150 mg, about 5200 mg, about 5250 mg,
about 5300 mg, about 5350 mg, about 5400 mg, about 5450 mg, about
5500 mg, about 5550 mg, about 5600 mg, about 5650 mg, about 5700
mg, about 5750 mg, about 5800 mg, about 5850 mg, about 5900 mg,
about 5950 mg, about 6000 mg, about 6050 mg, about 6100 mg, about
6150 mg, about 6200 mg, about 6250 mg, about 6300 mg, about 6350
mg, about 6400 mg, about 6450 mg, about 6500 mg, about 6550 mg,
about 6600 mg, about 6650 mg, about 6700 mg, about 6750 mg, about
6800 mg, about 6850 mg, about 6900 mg, about 6950 mg, about 7000
mg, about 7050 mg, about 7100 mg, about 7150 mg, about 7200 mg,
about 7250 mg, about 7300 mg, about 7350 mg, about 7400 mg, about
7450 mg, about 7500 mg, about 7550 mg, about 7600 mg, about 7650
mg, about 7700 mg, about 7750 mg, about 7800 mg, about 7850 mg,
about 7900 mg, about 7950 mg, about 8000 mg, about 8050 mg, about
8100 mg, about 8150 mg, about 8200 mg, about 8250 mg, about 8300
mg, about 8350 mg, about 8400 mg, about 8450 mg, about 8500 mg,
about 8550 mg, about 8600 mg, about 8650 mg, about 8700 mg, about
8750 mg, about 8800 mg, about 8850 mg, about 8900 mg, about 8950
mg, about 9000 mg, about 9050 mg, about 9100 mg, about 9150 mg,
about 9200 mg, about 9250 mg, about 9300 mg, about 9350 mg, about
9400 mg, about 9450 mg, about 9500 mg, about 9550 mg, about 9600
mg, about 9650 mg, about 9700 mg, about 9750 mg, about 9800 mg,
about 9850 mg, about 9900 mg, about 9950 mg, or about 10,000
mg.
[0132] In another embodiment, any of the methods disclosed herein
are used in treatment of a subject or subjects that consume a
traditional Western diet. In one embodiment, the methods of the
invention include a step of identifying a subject as a Western diet
consumer or prudent diet consumer and then treating the subject if
the subject is deemed a Western diet consumer. The term "Western
diet" herein refers generally to a typical diet consisting of, by
percentage of total calories, about 45% to about 50% carbohydrate,
about 35% to about 40% fat, and about 10% to about 15% protein. A
Western diet may alternately or additionally be characterized by
relatively high intakes of red and processed meats, sweets, refined
grains, and desserts, for example more than 50%, more than 60% or
more or 70% of total calories come from these sources.
[0133] In another embodiment, any of the methods disclosed herein
are used in treatment of a subject or subjects that consume less
than (actual or average) about 150 g, less than about 125 g, less
than about 100 g, less than about 75 g, less than about 50 g, less
than about 45 g, less than about 40 g, less than about 35 g, less
than about 30 g, less than about 25 g, less than about 20 g or less
than about 15 g of fish per day.
[0134] In another embodiment, any of the methods disclosed herein
are used in treatment of a subject or subjects that consume less
than (actual or average) about 10 g, less than about 9 g, less than
about 8 g, less than about 7 g, less than about 6 g, less than
about 5 g, less than about 4 g, less than about 3 g, less than
about 2 g per day of omega-3 fatty acids from dietary sources.
[0135] In another embodiment, any of the methods disclosed herein
are used in treatment of a subject or subjects that consume less
than (actual or average) about 2.5 g, less than about 2 g, less
than about 1.5 g, less than about 1 g, less than about 0.5 g, less
than about 0.25 g, or less than about 0.2 g per day of EPA and DHA
(combined) from dietary sources.
[0136] In one embodiment, compositions useful in various
embodiments of the invention comprise a polyunsaturated fatty acid
as an active ingredient. In another embodiment, such compositions
comprise EPA as an active ingredient. The term "EPA" as used herein
refers to eicosapentaenoic acid (e.g.
eicosa-5,8,11,14,17-pentaenoic acid) and/or a pharmaceutically
acceptable ester, derivative, conjugate or salt thereof, or
mixtures of any of the foregoing.
[0137] In one embodiment, the EPA comprises all-cis
eicosa-5,8,11,14,17-pentaenoic acid. In another embodiment, the EPA
is in the form of an eicosapentaenoic acid ester. In another
embodiment, the EPA comprises a C.sub.1-C.sub.5 alkyl ester of EPA.
In another embodiment, the EPA comprises eicosapentaenoic acid
ethyl ester, eicosapentaenoic acid methyl ester, eicosapentaenoic
acid propyl ester, or eicosapentaenoic acid butyl ester. In still
another embodiment, the EPA comprises all-cis
eicosa-5,8,11,14,17-pentaenoic acid ethyl ester.
[0138] In still other embodiments, the EPA comprises ethyl-EPA,
lithium EPA, mono, di- or triglyceride EPA or any other ester or
salt of EPA, or the free acid form of EPA. The EPA may also be in
the form of a 2-substituted derivative or other derivative which
slows down its rate of oxidation but does not otherwise change its
biological action to any substantial degree.
[0139] The term "pharmaceutically acceptable" in the present
context means that the substance in question does not produce
unacceptable toxicity to the subject or interaction with other
components of the composition.
[0140] In one embodiment, EPA present in a composition suitable for
use according to the invention comprises ultra-pure EPA. The term
"ultra-pure" as used herein with respect to EPA refers to a
composition comprising at least 96% by weight EPA (as the term
"EPA" is defined and exemplified herein). Ultra-pure EPA can
comprise even higher purity EPA, for example at least 97% by weight
EPA, at least 98% by weight EPA or at least 99% by weight EPA,
wherein the EPA is any form of EPA as set forth herein. Ultra-pure
EPA can further be defined (e.g. impurity profile) by any of the
description of EPA provided herein.
[0141] In some embodiments, EPA is present in a composition in an
amount of about 50 mg to about 5000 mg, about 75 mg to about 2500
mg, or about 100 mg to about 1000 mg, for example about 75 mg,
about 100 mg, about 125 mg, about 150 mg, about 175 mg, about 200
mg, about 225 mg, about 250 mg, about 275 mg, about 300 mg, about
325 mg, about 350 mg, about 375 mg, about 400 mg, about 425 mg,
about 450 mg, about 475 mg, about 500 mg, about 525 mg, about 550
mg, about 575 mg, about 600 mg, about 625 mg, about 650 mg, about
675 mg, about 700 mg, about 725 mg, about 750 mg, about 775 mg,
about 800 mg, about 825 mg, about 850 mg, about 875 mg, about 900
mg, about 925 mg, about 950 mg, about 975 mg, about 1000 mg, about
1025 mg, about 1050 mg, about 1075 mg, about 1100 mg, about 1025
mg, about 1050 mg, about 1075 mg, about 1200 mg, about 1225 mg,
about 1250 mg, about 1275 mg, about 1300 mg, about 1325 mg, about
1350 mg, about 1375 mg, about 1400 mg, about 1425 mg, about 1450
mg, about 1475 mg, about 1500 mg, about 1525 mg, about 1550 mg,
about 1575 mg, about 1600 mg, about 1625 mg, about 1650 mg, about
1675 mg, about 1700 mg, about 1725 mg, about 1750 mg, about 1775
mg, about 1800 mg, about 1825 mg, about 1850 mg, about 1875 mg,
about 1900 mg, about 1925 mg, about 1950 mg, about 1975 mg, about
2000 mg, about 2025 mg, about 2050 mg, about 2075 mg, about 2100
mg, about 2125 mg, about 2150 mg, about 2175 mg, about 2200 mg,
about 2225 mg, about 2250 mg, about 2275 mg, about 2300 mg, about
2325 mg, about 2350 mg, about 2375 mg, about 2400 mg, about 2425
mg, about 2450 mg, about 2475 mg, or about 2500 mg, about 2525 mg,
about 2550 mg, about 2575 mg, about 2600 mg, about 2625 mg, about
2650 mg, about 2675 mg, about 2700 mg, about 2725 mg, about 2750
mg, about 2775 mg, about 2800 mg, about 2825 mg, about 2850 mg,
about 2875 mg, about 2900 mg, about 2925 mg, about 2950 mg, about
2975 mg, about 3000 mg, about 3025 mg, about 3050 mg, about 3075
mg, about 3100 mg, about 3125 mg, about 3150 mg, about 3175 mg,
about 3200 mg, about 3225 mg, about 3250 mg, about 3275 mg, about
3300 mg, about 3325 mg, about 3350 mg, about 3375 mg, about 3400
mg, about 3425 mg, about 3450 mg, about 3475 mg, about 3500 mg,
about 3525 mg, about 3550 mg, about 3575 mg, about 3600 mg, about
3625 mg, about 3650 mg, about 3675 mg, about 3700 mg, about 3725
mg, about 3750 mg, about 3775 mg, about 3800 mg, about 3825 mg,
about 3850 mg, about 3875 mg, about 3900 mg, about 3925 mg, about
3950 mg, about 3975 mg, about 4000 mg, about 4025 mg, about 4050
mg, about 4075 mg, about 4100 mg, about 4125 mg, about 4150 mg,
about 4175 mg, about 4200 mg, about 4225 mg, about 4250 mg, about
4275 mg, about 4300 mg, about 4325 mg, about 4350 mg, about 4375
mg, about 4400 mg, about 4425 mg, about 4450 mg, about 4475 mg,
about 4500 mg, about 4525 mg, about 4550 mg, about 4575 mg, about
4600 mg, about 4625 mg, about 4650 mg, about 4675 mg, about 4700
mg, about 4725 mg, about 4750 mg, about 4775 mg, about 4800 mg,
about 4825 mg, about 4850 mg, about 4875 mg, about 4900 mg, about
4925 mg, about 4950 mg, about 4975 mg, or about 5000 mg.
[0142] In various embodiments, one or more antioxidants can be
present in the EPA (e.g. E-EPA or ultra pure E-EPA). Non-limiting
examples of suitable antioxidants include tocopherol, lecithin,
citric acid and/or ascorbic acid. One or more antioxidants, if
desired, are typically present in the EPA in an amount of about
0.01% to about 0.1%, by weight, or about 0.025% to about 0.05%, by
weight.
[0143] In one embodiment, a composition of the invention contains
not more than about 10%, not more than about 9%, not more than
about 8%, not more than about 7%, not more than about 6%, not more
than about 5%, not more than about 4%, not more than about 3%, not
more than about 2%, not more than about 1%, or not more than about
0.5%, by weight of total fatty acids, docosahexaenoic acid ("DHA")
or derivative thereof such as E-DHA, if any. In another embodiment,
a composition of the invention contains substantially no
docosahexaenoic acid or derivative thereof such as E-DHA. In still
another embodiment, a composition of the invention contains no
docosahexaenoic acid or E-DHA.
[0144] In another embodiment, EPA represents at least about 60%, at
least about 70%, at least about 80%, at least about 90%, at least
about 95%, at least about 97%, at least about 98%, at least about
99%, or 100%, by weight, of all fatty acids present in a
composition useful in accordance with the invention.
[0145] In another embodiment, a composition of the invention
contains less than 30%, less than 20%, less than 10%, less than 9%,
less than 8%, less than 7%, less than 6%, less than 5%, less than
4%, less than 3%, less than 2%, less than 1%, less than 0.5% or
less than 0.25%, by weight of the total composition or by weight of
the total fatty acid content, of any fatty acid other than EPA, or
derivative thereof. Illustrative examples of a "fatty acid other
than EPA" include linolenic acid (LA) or derivative thereof such as
ethyl-linolenic acid, arachidonic acid (AA) or derivative thereof
such as ethyl-AA, docosahexaenoic acid (DHA) or derivative thereof
such as ethyl-DHA, alpha-linolenic acid (ALA) or derivative thereof
such as ethyl-ALA, stearadonic acid (STA) or derivative thereof
such as ethyl-SA, eicosatrienoic acid (ETA) or derivative thereof
such as ethyl-ETA and/or docosapentaenoic acid (DPA) or derivative
thereof such as ethyl-DPA.
[0146] In another embodiment, a composition of the invention has
one or more of the following features: (a) eicosapentaenoic acid
ethyl ester represents at least 96%, at least 97%, or at least 98%,
by weight, of all fatty acids present in the composition; (b) the
composition contains not more than 4%, not more than 3%, or not
more than 2%, by weight, of total fatty acids other than
eicosapentaenoic acid ethyl ester; (c) the composition contains not
more than 0.6%, 0.5%, 0.4% or 0.3% of any individual fatty acid
other than eicosapentaenoic acid ethyl ester; (d) the composition
has a refractive index (20.degree. C.) of about 1 to about 2, about
1.2 to about 1.8 or about 1.4 to about 1.5; (e) the composition has
a specific gravity (20.degree. C.) of about 0.8 to about 1.0, about
0.85 to about 0.95 or about 0.9 to about 0.92; (f) the composition
contains not more than 20 ppm, 15 ppm or 10 ppm heavy metals, (g)
the composition contains not more than 5 ppm, 4 ppm, 3 ppm, or 2
ppm arsenic, and/or (h) the composition has a peroxide value not
more than 5, 4, 3, or 2 meq/kg.
[0147] In another embodiment, a composition useful in accordance
with the invention comprises, consists essentially of or consists
of at least 95% by weight ethyl eicosapentaenoate (EPA-E), about
0.2% to about 0.5% by weight ethyl octadecatetraenoate (ODTA-E),
about 0.05% to about 0.25% by weight ethyl nonaecapentaenoate
(NDPA-E), about 0.2% to about 0.45% by weight ethyl arachidonate
(AA-E), about 0.3% to about 0.5% by weight ethyl eicosatetraenoate
(ETA-E), and about 0.05% to about 0.32% ethyl heneicosapentaenoate
(HPA-E). In another embodiment, the composition is present in a
capsule shell. In still another embodiment, the capsule shell
contains no chemically modified gelatin.
[0148] In another embodiment, compositions useful in accordance
with the invention comprise, consist essentially of, or consist of
at least 95%, 96% or 97%, by weight, ethyl eicosapentaenoate, about
0.2% to about 0.5% by weight ethyl octadecatetraenoate, about 0.05%
to about 0.25% by weight ethyl nonaecapentaenoate, about 0.2% to
about 0.45% by weight ethyl arachidonate, about 0.3% to about 0.5%
by weight ethyl eicosatetraenoate, and about 0.05% to about 0.32%
by weight ethyl heneicosapentaenoate. Optionally, the composition
contains not more than about 0.06%, about 0.05%, or about 0.04%, by
weight, DHA or derivative thereof such as ethyl-DHA. In one
embodiment the composition contains substantially no or no amount
of DHA or derivative thereof such as ethyl-DHA. The composition
further optionally comprises one or more antioxidants (e.g.
tocopherol) in an amount of not more than about 0.5% or not more
than 0.05%. In another embodiment, the composition comprises about
0.05% to about 0.4%, for example about 0.2% by weight tocopherol.
In another embodiment, about 500 mg to about 1 g of the composition
is provided in a capsule shell. In another embodiment, the capsule
shell contains no chemically modified gelatin.
[0149] In another embodiment, compositions useful in accordance
with the invention comprise, consist essentially of, or consist of
at least 96% by weight ethyl eicosapentaenoate, about 0.22% to
about 0.4% by weight ethyl octadecatetraenoate, about 0.075% to
about 0.20% by weight ethyl nonaecapentaenoate, about 0.25% to
about 0.40% by weight ethyl arachidonate, about 0.3% to about 0.4%
by weight ethyl eicosatetraenoate and about 0.075% to about 0.25%
by weight ethyl heneicosapentaenoate. Optionally, the composition
contains not more than about 0.06%, about 0.05%, or about 0.04%, by
weight, DHA or derivative thereof such as ethyl-DHA. In one
embodiment the composition contains substantially no or no amount
of DHA or derivative thereof such as ethyl-DHA. The composition
further optionally comprises one or more antioxidants (e.g.
tocopherol) in an amount of not more than about 0.5% or not more
than 0.05%. In another embodiment, the composition comprises about
0.05% to about 0.4%, for example about 0.2% by weight tocopherol.
In another embodiment, the invention provides a dosage form
comprising about 500 mg to about 1 g of the foregoing composition
in a capsule shell. In one embodiment, the dosage form is a gel- or
liquid-containing capsule and is packaged in blister packages of
about 1 to about 20 capsules per sheet.
[0150] In another embodiment, compositions useful in accordance
with the invention comprise, consist essentially of or consist of
at least 96%, 97% or 98%, by weight, ethyl eicosapentaenoate, about
0.25% to about 0.38% by weight ethyl octadecatetraenoate, about
0.10% to about 0.15% by weight ethyl nonaecapentaenoate, about
0.25% to about 0.35% by weight ethyl arachidonate, about 0.31% to
about 0.38% by weight ethyl eicosatetraenoate, and about 0.08% to
about 0.20% by weight ethyl heneicosapentaenoate. Optionally, the
composition contains not more than about 0.06%, about 0.05%, or
about 0.04%, by weight, DHA or derivative thereof such as
ethyl-DHA. In one embodiment the composition contains substantially
no or no amount of DHA or derivative thereof such as ethyl-DHA. The
composition further optionally comprises one or more antioxidants
(e.g. tocopherol) in an amount of not more than about 0.5% or not
more than 0.05%. In another embodiment, the composition comprises
about 0.05% to about 0.4%, for example about 0.2% by weight
tocopherol. In another embodiment, the invention provides a dosage
form comprising about 500 mg to about 1 g of the foregoing
composition in a capsule shell. In another embodiment, the capsule
shell contains no chemically modified gelatin.
[0151] In another embodiment, the invention provides a method of
increasing serum, plasma and/or red blood cell (RBC) EPA levels
comprising administering a composition as described herein to a
subject in need of such treatment. In one embodiment, upon orally
administering a composition as set forth herein to a subject for a
period of at least about 5, about 10, about 15, about 20, about 25,
about 30, about 35, about 40, about 42, about 45 or about 50 days,
the subject exhibits at least about a 2-fold, at least about a
3-fold, at least about a 3.5-fold, at least about a 3.75-fold or at
least about a 4-fold increase or change (final absolute EPA level
divided by baseline EPA level) in serum, plasma and/or RBC EPA. In
one embodiment, the method comprises a step of identifying a
patient in need of an increase in serum, plasma and/or red blood
cell (RBC) EPA prior to said administration step. In a related
embodiment, the subject has a baseline EPA plasma, serum and/or RBC
level not greater than about 50 .mu.g/g. In another embodiment, the
subject is provided with about 2 g to about 4 g per day of a
composition as described herein. In another embodiment, upon
administering the composition to the subject as per above, the
subject exhibits a decrease in DHA, AA and/or DGLA plasma, serum
and/or RBC levels. In another embodiment, upon administering the
composition to the subject as per above, the subject exhibits an
increase in DPA plasma, serum and/or RBC levels. In still another
embodiment, upon administering the composition to the subject as
per above, DHA plasma, serum and/or RBC levels decrease by at least
15%, DGLA plasma, serum and/or RBC levels decrease by at least 30%,
AA plasma, serum and/or RBC levels decrease by at least 20%, and/or
DPA plasma, serum and/or RBC levels increase by greater than
130%.
[0152] In another embodiment, the invention provides a method of
increasing serum, plasma and/or red blood cell (RBC) EPA levels
comprising administering a composition as described herein to a
subject in need of increased serum, plasma and/or RBC EPA levels.
In a related embodiment, upon administering the composition to the
subject for a period of at least about 5, about 10, about 15, about
20, about 25, about 30, about 35, about 40, about 42, about 45, or
about 50 days, the subject exhibits at least about a 100%, at least
about a 150%, at least about a 200%, at least about a 250%, at
least about a 300%, at least about a 350% or at least about a 400%
increase (change in EPA level from baseline divided by baseline EPA
level) in plasma, serum and/or RBC EPA levels compared to baseline.
In a related embodiment, the subject has a baseline EPA plasma,
serum and/or RBC level not greater than about 50 .mu.g/g. In
another embodiment, the subject is provided with about 2 g to about
4 g per day of a composition as described herein. In another
embodiment, upon administering the composition to the subject as
per above, the subject exhibits a decrease in DHA, AA and/or DGLA
plasma, serum and/or RBC levels. In another embodiment, upon
administering the composition to the subject as per above, the
subject exhibits an increase in DPA plasma, serum and/or RBC
levels. In still another embodiment, upon administering the
composition to the subject as per above, DHA plasma, serum and/or
RBC levels decrease by at least 15%, DGLA plasma, serum and/or RBC
levels decrease by at least 30%, AA plasma, serum and/or RBC levels
decrease by at least 20%, and/or DPA plasma, serum and/or RBC
levels increase by greater than 130%.
[0153] In a related embodiment, upon orally administering about 2
to about 4 g per day of a composition as described herein to a
subject for a period of at least about 5, about 10, about 15, about
20, about 25, about 30, about 35, about 40, about 45 or about 50
days, the subject exhibits at least about a 10 .mu.g/g increase, at
least about a 15 .mu.g/g increase, at least about a 20 .mu.g/g
increase, at least about a 25 .mu.g/g increase, at least about a 30
.mu.g/g increase, at least about a 35 .mu.g/g increase, at least
about a 40 .mu.g/g increase, at least about a 45 .mu.g/g increase,
at least about a 50 .mu.g/g increase, at least about a 75 .mu.g/g
increase, at least about a 100 .mu.g/g increase, or at least about
a 150 .mu.g/g increase in serum, plasma and/or RBC EPA compared to
baseline. In another embodiment, upon administering the composition
to the subject as per above, the subject exhibits a decrease in
DHA, AA and/or DGLA plasma, serum and/or RBC levels. In another
embodiment, upon administering the composition to the subject as
per above, the subject exhibits an increase in DPA plasma, serum
and/or RBC levels. In still another embodiment, upon administering
the composition to the subject as per above, DHA plasma, serum
and/or RBC levels decrease by at least 15%, DGLA plasma, serum
and/or RBC levels decrease by at least 30%, AA plasma, serum and/or
RBC levels decrease by at least 20%, and/or DPA plasma, serum
and/or RBC levels increase by greater than 130%.
[0154] In another embodiment, the subject has not been on an
omega-3 fatty acid therapy or supplement for at least 2 weeks, 3
weeks, 4 weeks, 6 weeks or 12 weeks prior to initiating therapy as
described herein.
[0155] In another embodiment, a composition as described herein is
administered to a subject once or twice per day. In another
embodiment, 1, 2, 3 or 4 capsules, each containing about 1 g (e.g.,
about 900 mg to about 1.1 g) of a composition as described herein
are administered to a subject daily. In another embodiment, 1 or 2
capsules, each containing about 1 g of a composition as described
herein, are administered to the subject in the morning, for example
between about 5 am and about 11 am, and 1 or 2 capsules, each
containing about 1 g of a composition as described herein, are
administered to the subject in the evening, for example between
about 5 pm and about 11 pm.
[0156] In one embodiment, a subject being treated in accordance
with methods of the invention is not on fibrate or nitrate
therapy.
[0157] In one embodiment, a subject being treated in accordance
with methods of the invention is not otherwise on lipid-altering
therapy, for example statin, fibrate, niacin and/or ezetimibe
therapy.
[0158] In another embodiment, compositions useful in accordance
with methods of the invention are orally deliverable. The terms
"orally deliverable" or "oral administration" herein include any
form of delivery of a therapeutic agent or a composition thereof to
a subject wherein the agent or composition is placed in the mouth
of the subject, whether or not the agent or composition is
swallowed. Thus "oral administration" includes buccal and
sublingual as well as esophageal administration. In one embodiment,
the composition is present in a capsule, for example a soft gelatin
capsule.
[0159] A composition for use in accordance with the invention can
be formulated as one or more dosage units. The terms "dose unit"
and "dosage unit" herein refer to a portion of a pharmaceutical
composition that contains an amount of a therapeutic agent suitable
for a single administration to provide a therapeutic effect. Such
dosage units may be administered one to a plurality (i.e. 1 to
about 10, 1 to 8, 1 to 6, 1 to 4 or 1 to 2) of times per day, or as
many times as needed to elicit a therapeutic response.
[0160] In another embodiment, the invention provides use of any
composition described herein for treating moderate to severe
hypertriglyceridemia in a subject in need thereof, comprising:
providing a subject having a fasting baseline triglyceride level of
about 500 mg/dl to about 1500 mg/dl and administering to the
subject a pharmaceutical composition as described herein. In one
embodiment, the composition comprises about 1 g to about 4 g of
eicosapentaenoic acid ethyl ester, wherein the composition contains
substantially no docosahexaenoic acid.
[0161] In one embodiment, compositions of the invention, upon
storage in a closed container maintained at room temperature,
refrigerated (e.g. about 5 to about 5-10.degree. C.) temperature,
or frozen for a period of about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,
or 12 months, exhibit at least about 90%, at least about 95%, at
least about 97.5%, or at least about 99% of the active
ingredient(s) originally present therein.
[0162] In one embodiment, the invention provides use of a
composition as described herein in manufacture of a medicament for
treatment of any of a cardiovascular-related disease. In another
embodiment, the subject is diabetic.
[0163] In one embodiment, a composition as set forth herein is
packaged together with instructions for using the composition to
treat a cardiovascular disorder.
[0164] It will be appreciated that the pharmacological activity of
the compositions of the invention can be demonstrated using
standard pharmacological models that are known in the art.
Furthermore, it will be appreciated that the disclosed compositions
can be incorporated or encapsulated in a suitable polymer matrix or
membrane for site-specific delivery, or can be functionalized with
specific targeting agents capable of effecting site specific
delivery. These techniques, as well as other drug delivery
techniques, are well known in the art.
[0165] In one embodiment, a pharmaceutical composition of the
present disclosure provides a mean total eicosapentaenoic acid,
unesterified plasma eicosapentaenoic acid, or total
eicosapentaenoic acid red blood cell C.sub.max of about 0.5
.mu.g/mL to about 500 .mu.g/mL, for example about 105 .mu.g/mL to
about 204 .mu.g/mL, about 235 .mu.g/mL to about 460 .mu.g/mL, about
0.5 .mu.g/mL, about 0.6 .mu.g/mL, about 0.7 .mu.g/mL (e.g, about
0.66 .mu.g/mL), about 1 .mu.g/mL, about 1.4 .mu.g/mL, about 5
.mu.g/mL, about 10 .mu.g/mL, about 15 .mu.g/mL, about 20 .mu.g/mL,
about 25 .mu.g/mL, about 30 .mu.g/mL, about 31 .mu.g/mL, about 35
.mu.g/mL, about 38 .mu.g/mL (e.g, about 37.6 .mu.g/mL), about 40
.mu.g/mL, about 42 .mu.g/mL (e.g, about 42.3 .mu.g/mL), about 45
.mu.g/mL, about 50 .mu.g/mL, about 55 .mu.g/mL, about 60 .mu.g/mL,
about 65 .mu.g/mL, about 70 .mu.g/mL, about 75 .mu.g/mL, about 77
.mu.g/mL (e.g, about 76.7 .mu.g/mL), about 80 .mu.g/mL, about 85
.mu.g/mL, about 90 .mu.g/mL, about 95 .mu.g/mL, about about 100
.mu.g/mL, about 105 .mu.g/mL, about 110 .mu.g/mL, about 115
.mu.g/mL, about 120 .mu.g/mL, about 125 .mu.g/mL, about 130
.mu.g/mL, about 135 .mu.g/mL, about 140 .mu.g/mL, about 145
.mu.g/mL, about 150 .mu.g/mL, about 155 .mu.g/mL (e.g, about 154.9
.mu.g/mL), about 160 .mu.g/mL, about 165 .mu.g/mL, about 170
.mu.g/mL, about 175 .mu.g/mL, about 180 .mu.g/mL, about 185
.mu.g/mL, about 190 .mu.g/mL, about 195 .mu.g/mL, about 200
.mu.g/mL, about 205 .mu.g/mL, about 210 .mu.g/mL (e.g, about 210.5
.mu.g/mL), about 215 .mu.g/mL, about 220 .mu.g/mL, about 225
.mu.g/mL, about 230 .mu.g/mL, about 233 .mu.g/mL (e.g, about 232.8
.mu.g/mL), about 235 .mu.g/mL, about 240 .mu.g/mL, about 245
.mu.g/mL, about 250 .mu.g/mL, about 255 .mu.g/mL, about 260
.mu.g/mL, about 265 .mu.g/mL, about 270 .mu.g/mL, about 275
.mu.g/mL, about 280 .mu.g/mL, about 285 .mu.g/mL, about 290
.mu.g/mL, about 295 .mu.g/mL, about 300 .mu.g/mL, about 305
.mu.g/mL, about 310 .mu.g/mL, about 315 .mu.g/mL, about 320
.mu.g/mL, about 325 .mu.g/mL, about 330 .mu.g/mL, about 335
.mu.g/mL, about 340 .mu.g/mL, about 345 .mu.g/mL, about 347
.mu.g/mL (e.g., about 347.2 .mu.g/mL), about 350 .mu.g/mL, about
355 .mu.g/mL, about 360 .mu.g/mL, about 365 .mu.g/mL, about 370
.mu.g/mL, about 375 .mu.g/mL, about 380 .mu.g/mL, about 385
.mu.g/mL, about 390 .mu.g/mL, about 395 .mu.g/mL, about 400
.mu.g/mL, about 405 .mu.g/mL, about 410 .mu.g/mL, about 415
.mu.g/mL, about 420 .mu.g/mL, about 425 .mu.g/mL, about 430
.mu.g/mL, about 435 .mu.g/mL, about 440 .mu.g/mL, about 445
.mu.g/mL, about 450 .mu.g/mL, about 455 .mu.g/mL, about 460
.mu.g/mL, about 465 .mu.g/mL, about 470 .mu.g/mL, about 475
.mu.g/mL, about 480 .mu.g/mL, about 485 .mu.g/mL, about 490
.mu.g/mL, about 495 .mu.g/mL, or about 500 .mu.g/mL.
[0166] In one embodiment, a pharmaceutical composition of the
present disclosure provides a mean total eicosapentaenoic acid,
unesterified plasma eicosapentaenoic acid, or total
eicosapentaenoic acid red blood cell AUC.sub.0-24h of about 1
.mu.gh/mL to about 7000 .mu.gh/mL, for example about 1 .mu.gh/mL to
about 20 .mu.gh/mL, about 500 .mu.gh/mL to about 1500 .mu.gh/mL,
about 2500 .mu.gh/mL to about 7000 .mu.gh/mL, about 1 .mu.gh/mL,
about 2 .mu.gh/mL, about 3 .mu.gh/mL, about 4 .mu.gh/mL, about 5
.mu.gh/mL, about 6 .mu.gh/mL, about 7 .mu.gh/mL, about 8 .mu.gh/mL,
about 9 .mu.gh/mL, about 10 .mu.gh/mL, about 11 .mu.gh/mL, about 12
.mu.gh/mL, about 13 .mu.gh/mL, about 14 .mu.gh/mL, about 15
.mu.gh/mL, about 16 .mu.gh/mL, about 17 .mu.gh/mL, about 18
.mu.gh/mL, about 19 .mu.gh/mL, about 20 .mu.gh/mL, about 500
.mu.gh/mL, about 550 .mu.gh/mL, about 600 .mu.gh/mL, about 650
.mu.gh/mL, about 700 .mu.gh/mL, about 750 .mu.gh/mL, about 800
.mu.gh/mL, about 850 .mu.gh/mL, about 900 .mu.gh/mL, about 950
.mu.gh/mL, about 1000 .mu.gh/mL, about 1050 .mu.gh/mL, about 1100
.mu.gh/mL, about 1150 .mu.gh/mL, about 1200 .mu.gh/mL, about 1250
.mu.gh/mL, about 1300 .mu.gh/mL, about 1350 .mu.gh/mL, about 1400
.mu.gh/mL, about 1450 .mu.gh/mL, about 1500 .mu.gh/mL, about 2500
.mu.gh/mL, about 2550 .mu.gh/mL, about 2600 .mu.gh/mL, about 2650
.mu.gh/mL, about 2700 .mu.gh/mL, about 2750 .mu.gh/mL, about 2800
.mu.gh/mL, about 2850 .mu.gh/mL, about 2900 .mu.gh/mL, about 2950
.mu.gh/mL, about 3000 .mu.gh/mL, about 3050 .mu.gh/mL, about 3100
.mu.gh/mL, about 3150 .mu.gh/mL, about 3200 .mu.gh/mL, about 3250
.mu.gh/mL, about 3300 .mu.gh/mL, about 3350 .mu.gh/mL, about 3400
.mu.gh/mL, about 3450 .mu.gh/mL, about 3500 .mu.gh/mL, about 3550
.mu.gh/mL, about 3600 .mu.gh/mL, about 3650 .mu.gh/mL, about 3700
.mu.gh/mL, about 3750 .mu.gh/mL, about 3800 .mu.gh/mL, about 3850
.mu.gh/mL, about 3900 .mu.gh/mL, about 3950 .mu.gh/mL, about 4000
.mu.gh/mL, about 4050 .mu.gh/mL, about 4100 .mu.gh/mL, about 4150
.mu.gh/mL, about 4200 .mu.gh/mL, about 4250 .mu.gh/mL, about 4300
.mu.gh/mL, about 4350 .mu.gh/mL, about 4400 .mu.gh/mL, about 4450
.mu.gh/mL, about 4500 .mu.gh/mL, about 4550 .mu.gh/mL, about 4600
.mu.gh/mL, about 4650 .mu.gh/mL, about 4700 .mu.gh/mL, about 4750
.mu.gh/mL, about 4800 .mu.gh/mL, about 4850 .mu.gh/mL, about 4900
.mu.gh/mL, about 4950 .mu.gh/mL, about 5000 .mu.gh/mL, about 5050
.mu.gh/mL, about 5100 .mu.gh/mL, about 5150 .mu.gh/mL, about 5200
.mu.gh/mL, about 5250 .mu.gh/mL, about 5300 .mu.gh/mL, about 5350
.mu.gh/mL, about 5400 .mu.gh/mL, about 5450 .mu.gh/mL, about 5500
.mu.gh/mL, about 5550 .mu.gh/mL, about 5600 .mu.gh/mL, about 5650
.mu.gh/mL, about 5700 .mu.gh/mL, about 5750 .mu.gh/mL, about 5800
.mu.gh/mL, about 5850 .mu.gh/mL, about 5900 .mu.gh/mL, about 5950
.mu.gh/mL, about 6000 .mu.gh/mL, about 6050 .mu.gh/mL, about 6100
.mu.gh/mL, about 6150 .mu.gh/mL, about 6200 .mu.gh/mL, about 6250
.mu.gh/mL, about 6300 .mu.gh/mL, about 6350 .mu.gh/mL, about 6400
.mu.gh/mL, about 6450 .mu.gh/mL, about 6500 .mu.gh/mL, about 6550
.mu.gh/mL, about 6600 .mu.gh/mL, about 6650 .mu.gh/mL, about 6700
.mu.gh/mL, about 6750 .mu.gh/mL, about 6800 .mu.gh/mL, about 6850
.mu.gh/mL, about 6900 .mu.gh/mL, about 6950 .mu.gh/mL, or about
7000 .mu.gh/mL.
[0167] In one embodiment, a pharmaceutical composition of the
present disclosure provides a mean total eicosapentaenoic acid,
unesterified plasma eicosapentaenoic acid, or total
eicosapentaenoic acid red blood cell C.sub.min of about 0.2
.mu.g/mL to about 250 .mu.g/mL, for example about 0.2 .mu.g/mL to
about 2 .mu.g/mL, about 20 .mu.g/mL to about 70 .mu.g/mL, about 70
.mu.g/mL to about 215 .mu.g/mL, about 0.2 .mu.g/mL, about 0.3
.mu.g/mL, about 0.4 .mu.g/mL (e.g., about 0.36 .mu.g/mL, about 0.41
.mu.g/mL or about 0.44 .mu.g/mL), about 0.5 .mu.g/mL, about 0.6
.mu.g/mL, about 0.7 .mu.g/mL, about 0.8 .mu.g/mL, about 0.9
.mu.g/mL, about 1 .mu.g/mL (e.g., about 1.06 .mu.g/mL), about 1.1
.mu.g/mL, about 1.2 .mu.g/mL, about 1.3 .mu.g/mL, about 1.4
.mu.g/mL, about 1.5 .mu.g/mL, about 1.6 .mu.g/mL, about 1.7
.mu.g/mL, about 1.8 .mu.g/mL, about 1.9 .mu.g/mL, about 2 .mu.g/mL,
about 5 .mu.g/mL, about 10 .mu.g/mL, about 15 .mu.g/mL, about 18
.mu.g/mL, about 20 .mu.g/mL, about 21 .mu.g/mL (e.g., about 20.7
.mu.g/mL), about 25 .mu.g/mL, about 26 .mu.g/mL (e.g., about 26.3
.mu.g/mL), about 30 .mu.g/mL, about 31 .mu.g/mL (e.g., about 31.2
.mu.g/mL), about 35 .mu.g/mL, about 40 .mu.g/mL, about 45 .mu.g/mL,
about 50 .mu.g/mL, about 55 .mu.g/mL, about 60 .mu.g/mL, about 64
.mu.g/mL (e.g., about 64.1 .mu.g/mL), about 65 .mu.g/mL, about 70
.mu.g/mL (e.g., about 69.7 .mu.g/mL), about 75 .mu.g/mL (e.g.,
about 75.1 .mu.g/mL), about 80 .mu.g/mL, about 84 .mu.g/mL (e.g.,
about 83.5 .mu.g/mL), about 85 .mu.g/mL, about 89 .mu.g/mL (e.g.,
about 89.3 .mu.g/mL), about 90 .mu.g/mL, about 95 .mu.g/mL, about
100 .mu.g/mL, about 101 .mu.g/mL, about 104 .mu.g/mL, about 105
.mu.g/mL, about 110 .mu.g/mL, about 115 .mu.g/mL, about 120
.mu.g/mL, about 125 .mu.g/mL, about 130 .mu.g/mL, about 135
.mu.g/mL, about 140 .mu.g/mL, about 145 .mu.g/mL, about 150
.mu.g/mL, about 155 .mu.g/mL, about 160 .mu.g/mL, about 165
.mu.g/mL, about 170 .mu.g/mL, about 175 .mu.g/mL, about 180
.mu.g/mL, about 185 .mu.g/mL, about 190 .mu.g/mL, about 195
.mu.g/mL, about 200 .mu.g/mL, about 205 .mu.g/mL, about 210
.mu.g/mL, about 215 .mu.g/mL, about 220 .mu.g/mL, about 225
.mu.g/mL, about 230 .mu.g/mL, about 235 .mu.g/mL, about 240
.mu.g/mL, about 245 .mu.g/mL, or about 250 .mu.g/mL.
[0168] In one embodiment, a pharmaceutical composition of the
present disclosure provides a mean total eicosapentaenoic acid,
unesterified plasma eicosapentaenoic acid, or total
eicosapentaenoic acid red blood cell T.sub.max of about 1 hour to
about 36 hours, for example about 1 hour, about 2 hours, about 3
hours, about 4 hours, about 5 hours, about 6 hours, about 7 hours,
about 8 hours, about 9 hours, about 10 hours, about 11 hours, about
12 hours, about 13 hours, about 14 hours, about 15 hours, about 16
hours, about 17 hours, about 18 hours, about 19 hours, about 20
hours, about 21 hours, about 22 hours, about 23 hours, about 24
hours, about 25 hours, about 26 hours, about 27 hours, about 28
hours, about 29 hours, about 30 hours, about 31 hours, about 32
hours, about 33 hours, about 34 hours, about 35 hours, about 36
hours.
[0169] In one embodiment, a pharmaceutical composition of the
present disclosure provides a mean total eicosapentaenoic acid,
unesterified plasma eicosapentaenoic acid, or total
eicosapentaenoic acid red blood cell T.sub.1/2 of about 50 hours to
about 700 hours, for example about 50 hours, about 55 hours, about
60 hours, about 65 hours, about 70 hours, about 75 hours, about 80
hours, about 85 hours, about 90 hours, about 95 hours, about 100
hours, about 105 hours, about 110 hours, about 115 hours, about 120
hours, about 125 hours, about 130 hours, about 135 hours, about 140
hours, about 145 hours, about 150 hours, about 155 hours, about 160
hours, about 165 hours, about 170 hours, about 175 hours, about 180
hours, about 185 hours, about 190 hours, about 195 hours, about 200
hours, about 205 hours, about 210 hours, about 215 hours, about 220
hours, about 225 hours, about 230 hours, about 235 hours, about 240
hours, about 245 hours, about 250 hours, about 255 hours, about 260
hours, about 265 hours, about 270 hours, about 275 hours, about 280
hours, about 285 hours, about 290 hours, about 295 hours, about 300
hours, about 305 hours, about 310 hours, about 315 hours, about 320
hours, about 325 hours, about 330 hours, about 335 hours, about 340
hours, about 345 hours, about 350 hours, about 355 hours, about 360
hours, about 365 hours, about 370 hours, about 375 hours, about 380
hours, about 385 hours, about 390 hours, about 395 hours, about 400
hours, about 405 hours, about 410 hours, about 415 hours, about 420
hours, about 425 hours, about 430 hours, about 435 hours, about 440
hours, about 445 hours, about 450 hours, about 455 hours, about 460
hours, about 465 hours, about 470 hours, about 475 hours, about 480
hours, about 485 hours, about 490 hours, about 495 hours, about 500
hours, about 505 hours, about 510 hours, about 515 hours, about 520
hours, about 525 hours, about 530 hours, about 535 hours, about 540
hours, about 545 hours, about 550 hours, about 555 hours, about 560
hours, about 565 hours, about 570 hours, about 575 hours, about 580
hours, about 585 hours, about 590 hours, about 595 hours, about 600
hours, about 605 hours, about 610 hours, about 615 hours, about 620
hours, about 625 hours, about 630 hours, about 635 hours, about 640
hours, about 645 hours, about 650 hours, about 655 hours, about 660
hours, about 665 hours, about 670 hours, about 675 hours, about 680
hours, about 685 hours, about 690 hours, about 695 hours, or about
700 hours.
[0170] In one embodiment, a pharmaceutical composition of the
present disclosure provides a mean total eicosapentaenoic acid,
unesterified plasma eicosapentaenoic acid, or total
eicosapentaenoic acid red blood cell CL/F of about 500 mL/hr to
about 400,000 mL/hr, for example about 500 mL/hr, about 525 mL/hr,
about 550 mL/hr, about 575 mL/hr, about 600 mL/hr, about 625 mL/hr,
about 650 mL/hr, about 675 mL/hr, about 684 mL/hr (e.g., about
683.7 mL/hr), about 658 mL/hr (e.g., about 684.5 mL/hr), about 700
mL/hr, about 725 mL/hr, about 750 mL/hr, about 775 mL/hr, about 776
mL/hr (e.g., about 776.4 mL/hr), about 800 mL/hr, about 825 mL/hr,
about 850 mL/hr, about 868 mL/hr (e.g., about 867.7 mL/hr), about
875 mL/hr, about 900 mL/hr, about 925 mL/hr, about 950 mL/hr, about
975 mL/hr, about 1,000 mL/hr, about 200,000 mL/hr, about 210,000
mL/hr, about 220,000 mL/hr, about 230,000 mL/hr, about 240,000
mL/hr, about 250,000 mL/hr, about 260,000 mL/hr, about 270,000
mL/hr, about 280,000 mL/hr, about 290,000 mL/hr, about 300,000
mL/hr, about 310,000 mL/hr, about 320,000 mL/hr, about 330,000
mL/hr, about 340,000 mL/hr, about 350,000 mL/hr, about 360,000
mL/hr, about 370,000 mL/hr, about 380,000 mL/hr, about 390,000
mL/hr, or about 400,000 mL/hr.
[0171] In one embodiment, a pharmaceutical composition of the
present disclosure provides a mean total eicosapentaenoic acid,
unesterified plasma eicosapentaenoic acid, or total
eicosapentaenoic acid red blood cell V.sub.z/F of about 50 L to
about 50,000 L, for example about 75 L to about 90 L, about 28,000
L to about 41,000 L, about 50 L, about 55 L, about 60 L, about 65
L, about 70 L, about 75 L, about 79 L (e.g., about 79.3 L), about
80 L (e.g., about 79.8 L), about 85 L, about 88 L (e.g., about 88.4
L), about 90 L, about 95 L, about 100 L, about 28,000 L, about
28,200 L, about 29,000 L, about 30,000 L, about 31,000 L, about
32,000 L, about 33,000 L, about 33,160 L (e.g., about 33,164 L),
about 34,000 L, about 35,000 L, about 36,000 L, about 37,000 L,
about 38,000 L, about 39,000 L, about 40,000 L, about 40,870 L
(e.g., about 40,873 L), about 41,000 L, about 42,000 L, about
43,000 L, about 44,000 L, about 45,000 L, about 46,000 L, about
47,000 L, about 48,000 L, about 49,000 L, or about 50,000 L.
[0172] In one embodiment, a pharmaceutical composition of the
present disclosure comprising about 1 g of ethyl eicosapentaenoate
(e.g., about 800 mg to about 1200 mg, about 850 mg to about 1150
mg, about 900 mg to about 1100 mg, about 950 mg to about 1050 mg,
or about 975 mg to about 1025 mg) provides a mean plasma C.sub.max
of about 154.9+/-49.4 .mu.g/mL, a mean plasma AUC.sub.0-24h of
about 2907+/-1160 .mu.gh/mL, a median plasma T.sub.max of about 5
hours, and a mean plasma T.sub.1/2 of about 75.1+/-46.5 hours of
ethyl eicosapentaenoate when administered orally twice per day to a
human subject. In some embodiments, the pharmaceutical composition
further provides a mean plasma C.sub.min of about 101.0+/-50.4
.mu.g/mL of ethyl eicosapentaenoate. In some embodiments, the
preceding claims, wherein the pharmaceutical composition further
provides a mean plasma CL/F of about 776.4+/-256.9 mL/h of ethyl
eicosapentaenoate. In some embodiments, the pharmaceutical
composition further provides a mean plasma VZ/F of about
79.8+/-62.6 L of ethyl eicosapentaenoate. In some embodiments, the
pharmaceutical composition provides a mean RBC C.sub.max of about
42.3+/-14.0 .mu.g/mL, a mean RBC AUC.sub.0-24h of about
801.5+/-268.5 .mu.gh/mL, a median RBC T.sub.max of about 12 hours,
and a mean RBC T.sub.1/2 of about 683.8 hours of ethyl
eicosapentaenoate. In some embodiments, the pharmaceutical
composition further provides a mean RBC C.sub.min of about
31.2+/-12.2 .mu.g/mL of ethyl eicosapentaenoate. In some
embodiments, the pharmaceutical composition further provides a mean
plasma C.sub.max of about 0.66+/-0.34 .mu.g/mL, a mean plasma
AUC.sub.0-24h of about 6.9+/-3.1 .mu.gh/mL, a median plasma
T.sub.max of about 5 hours, and a mean plasma T.sub.1/2 of about
80.8+/-37.5 hours of unesterified eicosapentaenoic acid when
administered orally twice per day to a human subject. In some
embodiments, the pharmaceutical composition further provides a mean
plasma C.sub.min of about 0.41+/-0.28 .mu.g/mL of unesterified
eicosapentaenoic acid. In some embodiments, the pharmaceutical
composition further provides a mean plasma CL/F of about
364,513+/-214,003 mL/h of unesterified eicosapentaenoic acid. In
some embodiments, the pharmaceutical composition further provides a
mean plasma V.sub.z/F of about 33,164+/-8,068 L of unesterified
eicosapentaenoic acid.
[0173] In some embodiments, a pharmaceutical composition comprising
about 2 g of ethyl eicosapentaenoate (e.g., about 1600 mg to about
2400 mg, about 1650 mg to about 2350 mg, about 1700 mg to about
2300 mg, about 1750 mg to about 2250 mg, about 1800 mg to about
2200 mg, about 1850 mg to about 2150 mg, about 1900 mg to about
2100 mg, or about 1950 mg to about 2050 mg) provides a mean plasma
C.sub.max of about 347.2+/-112.5 .mu.g/mL, a mean plasma
AUC.sub.0-24h of about 6519+/-1963 .mu.gh/mL, a median plasma
T.sub.max of about 5 hours, and a mean plasma T.sub.1/2 of about
89.3+/-42.0 hours of ethyl eicosapentaenoate when administered
orally twice per day to a human subject. In some embodiments, the
pharmaceutical composition further provides a mean plasma C.sub.min
of about 101.0+/-50.4 .mu.g/mL of ethyl eicosapentaenoate. In some
embodiments, the pharmaceutical composition further provides a mean
plasma CL/F of about 683.7+/-280.6 mL/h of ethyl eicosapentaenoate.
In some embodiments, the pharmaceutical composition further
provides a mean plasma VZ/F of about 88.4+/-55.2 L of ethyl
eicosapentaenoate. In some embodiments, the pharmaceutical
composition further provides a mean RBC C.sub.max of about
76.7+/-25.2 .mu.g/mL, a mean RBC AUC.sub.0-24h of about
1472+/-469.5 .mu.gh/mL, a median RBC T.sub.max of about 8 hours,
and a mean RBC T.sub.1/2 of about 371.4+/-311.5 hours of ethyl
eicosapentaenoate. In some embodiments, the pharmaceutical
composition further provides a mean RBC C.sub.min of about
64.1+/-21.8 .mu.g/mL of ethyl eicosapentaenoate.
[0174] In some embodiments, the pharmaceutical composition provides
a mean plasma C.sub.max of about 1.4+/-0.41 .mu.g/mL, a mean plasma
AUC.sub.0-24h of about 18.4+/-4.6 gh/mL, a median plasma T.sub.max
of about 5 hours, and a mean plasma T.sub.1/2 of about 97.2+/-36.5
hours of unesterified eicosapentaenoic acid. In some embodiments,
the pharmaceutical composition further provides a mean plasma
C.sub.min of about 1.06+/-0.56 .mu.g/mL of unesterified
eicosapentaenoic acid. In some embodiments, the pharmaceutical
composition further provides a mean plasma CL/F of about
234,329+/-81,639 mL/h of unesterified eicosapentaenoic acid. In
some embodiments, the pharmaceutical composition further provides a
mean plasma VZ/F of about 28,200+/-10,929 L of unesterified
eicosapentaenoic acid.
[0175] In some embodiments, the pharmaceutical composition is
administered in unit dose form, wherein each unit dose includes
about 500 mg or about 1000 mg of ethyl eicosapentaenoate. In some
embodiments, unit dose forms are administered about 1 to about 4
times per day, for example about 1 time per day, about 2 times per
day, about 3 times per day, or about 4 times per day.
EXAMPLES
Example 1
Ethyl Eicosapentaenoic Acid in Subjects Having Fasting
Triglycerides of about 200 mg/dL to Less than 500 mg/dL
[0176] A multi-center, placebo-controlled, randomized,
double-blind, 12-week study was performed to evaluate the efficacy
and safety of >96% E-EPA in patients with fasting triglyceride
levels .gtoreq.200 mg/dl and <500 mg/dl despite statin therapy
(the mean of two qualifying entry values needed to be .gtoreq.185
mg/dl and at least one of the values needed to be .gtoreq.200
mg/dl). The primary objective of the study was to determine the
efficacy of >96% E-EPA 2 g daily and 4 g daily, compared to
placebo, in lowering fasting TG levels in patients with high risk
for cardiovascular disease and with fasting TG levels .gtoreq.200
mg/dL and <500 mg/dL, despite treatment to LDL-C goal on statin
therapy.
[0177] The secondary objectives of this study were the following:
[0178] 1. To determine the safety and tolerability of >96% E-EPA
2 g daily and 4 g daily; [0179] 2. To determine the effect of
>96% E-EPA on lipid and apolipoprotein profiles including total
cholesterol (TC), non-high-density lipoprotein cholesterol
(non-HDL-C), low density lipoprotein cholesterol (LDL-C), high
density lipoprotein cholesterol (HDL-C), and very high density
lipoprotein cholesterol (VHDL-C); [0180] 3. To determine the effect
of >96% E-EPA (on lipoprotein associated phospholipase A.sub.2
(Lp-PLA.sub.2) from baseline to week 12; [0181] 4. To determine the
effect of >96% E-EPA on low-density lipoprotein (LDL) particle
number and size; [0182] 5. To determine the effect of >96% E-EPA
on oxidized LDL; [0183] 6. To determine the effect of >96% E-EPA
on fasting plasma glucose (FPG) and hemoglobin A.sub.1c
(HbA.sub.1c); [0184] 7. To determine the effect of >96% E-EPA on
insulin resistance; [0185] 8. To determine the effect of >96%
E-EPA on high-sensitivity C-reactive protein (hsCRP); [0186] 9. To
determine the effects of >96% E-EPA 2 g daily and 4 g daily on
the incorporation of fatty acids into red blood cell membranes and
into plasma phospholipids; [0187] 10. To explore the relationship
between baseline fasting TG levels and the reduction in fasting TG
levels; and [0188] 11. To explore the relationship between changes
of fatty acid concentrations in plasma and red blood cell
membranes, and the reduction in fasting TG levels.
[0189] The population for this study was men and women >18 years
of age with a body mass index .ltoreq.45 kg/m.sup.2 with fasting TG
levels greater than or equal to 200 mg/dl and less than 500 mg/dl
and on a stable does of statin therapy (with or without ezetimibe).
The statin was atorvostatin, rosuvastatin or simvastatin. The dose
of statin must have been stable for .gtoreq.4 weeks prior to the
LDL-C/TG baseline qualifying measurement for randomization. The
statin dose was optimized such that the patients are at their LDL-C
goal at the LDL-C/TG baseline qualifying measurements. The same
statin at the same dose was continued until the study ended.
[0190] Patients taking any additional non-statin, lipid-altering
medications (niacin >200 mg/day, fibrates, fish oil, other
products containing omega-3 fatty acids, or other herbal products
or dietary supplements with potential lipid-altering effects),
either alone or in combination with statin therapy (with or without
ezetimibe), must have been able to safely discontinue non-statin,
lipid-altering therapy at screening.
[0191] Patients at high risk for CVD, i.e., patients with clinical
coronary heart disease (CHD) or clinical CHD risk equivalents
(10-year risk >20%) as defined in the National Cholesterol
Education Program (NCEP) Adult Treatment Panel III (ATP III)
Guidelines were eligible to participate in this study. Those
included patients with any of the following criteria: (1) Known
CVD, either clinical coronary heart disease (CHD), symptomatic
carotid artery disease (CAD), peripheral artery disease (PAD) or
abdominal aortic aneurism; or (2) Diabetes Mellitus (Type 1 or
2).
[0192] Approximately 702 patients were randomized at approximately
80 centers in the U.S. The study was a 18- to 20-week, Phase 3,
multi-center study consisting of 2 study periods: (1) A 6- to
8-week screening period that included a diet and lifestyle
stabilization, a non-statin lipid-altering treatment washout, and
an LDL-C and TG qualifying period and (2) A 12-week, double-blind,
randomized, placebo-controlled treatment period.
[0193] During the screening period and double-blind treatment
period, all visits were within .+-.3 days of the scheduled time.
All patients continued to take the statin product (with or without
ezetimibe) at the same dose they were taking at screening
throughout their participation in the study.
[0194] The 6- to 8-week screening period included a diet and
lifestyle stabilization, a non-statin lipid-altering treatment
washout, and an LDL-C and TG qualifying period. The screening visit
(Visit 1) occurred for all patients at either 6 weeks (for patients
on stable statin therapy [with or without ezetimibe] at screening)
or 8 weeks (for patients who will require washout of their current
non-statin lipid-altering therapy at screening) before
randomization, as follows: [0195] Patients who did not require a
washout: The screening visit occurred at Visit 1 (Week -6).
Eligible patients entered a 4-week diet and lifestyle stabilization
period. At the screening visit, all patients received counseling
regarding the importance of the National Cholesterol Education
Program (NCEP) Therapeutic Lifestyle Changes (TLC) diet and
received basic instructions on how to follow this diet. [0196]
Patients who required a washout: The screening visit occurred at
Visit 1 (Week -8). Eligible patients began a 6-week washout period
at the screening visit (i.e. 6 weeks washout before the first
LDL-C/TG qualifying visit). Patients received counseling regarding
the NCEP TLC diet and received basic instructions on how to follow
this diet. Site personnel contacted patients who did not qualify
for participation based on screening laboratory test results to
instruct them to resume their prior lipid-altering medications.
[0197] At the end of the 4-week diet and lifestyle stabilization
period or the 6-week diet and stabilization and washout period,
eligible patients entered the 2-week LDL-C and TG qualifying period
and had their fasting LDL-C and TG levels measured at Visit 2 (Week
-2) and Visit 3 (Week -1). Eligible patients must have had an
average fasting LDL-C level >40 mg/dL and <100 mg/dL and an
average fasting TG level 200 mg/dL and <500 mg/dL to enter the
12-week double-blind treatment period. The LDL-C and TG levels for
qualification were based on the average (arithmetic mean) of the
Visit 2 (Week -2) and Visit 3 (Week -1) values. If a patient's
average LDL-C and/or TG levels from Visit 2 and Visit 3 fell
outside the required range for entry into the study, an additional
fasting lipid profile was collected 1 week later at Visit 3.1. If a
third sample was collected at Visit 3.1, entry into the study was
based on the average (arithmetic mean) of the values from Visit 3
and Visit 3.1.
[0198] After confirmation of qualifying fasting LDL-C and TG
values, eligible patients entered a 12-week, randomized,
double-blind treatment period. At Visit 4 (Week 0), patients were
randomly assigned to 1 of the following treatment groups: [0199]
>96% E-EPA 2 g daily, [0200] >96% E-EPA 4 g daily, or [0201]
Placebo.
[0202] Approximately 216 patients per treatment group were
randomized in this study. Stratification was by type of statin
(atorvastatin, rosuvastatin or simvastatin), the presence of
diabetes, and gender. Baseline parameters for randomized subjects
in this study are shown in Table 1 below. The lower-efficacy statin
regimen included administration of 5-10 mg of simvastatin per day;
the medium-efficacy statin regimens included administration of 5-10
mg rosuvastatin per day, 10-20 mg of atorvastatin per day, 20-40 mg
of simvastatin per day, or 10-20 mg of simvastatin and 5-10 mg of
ezetimibe per day; and the higher-efficacy statin regimens included
administration of 20-40 mg of rosuvastatin per day, 40-80 mg of
atorvastatin per day, 80 mg of simvastatin per day, or 40-80 mg of
simvastatin and 5-10 mg of ezetimibe per day.
TABLE-US-00001 TABLE 1 Patient Characteristics (Randomized
Population) AMR101 AMR101 4 g/day 2 g/day Placebo (n = 233) (n =
236) (n = 233) Age, y, mean (SD) 61.1 (10.03) 61.8 (9.42) 61.2
(10.05) Male, n (%) 142 (60.9) 144 (61.0) 145 (62.2) White, n (%)
226 (97.0) 226 (95.8) 224 (96.1) Weight, kg, 94.5 (18.30) 95.5
(18.29) 97.0 (19.14) mean (SD) BMI, kg/m.sup.2, 32.7 (4.99) 32.9
(4.98) 33.0 (5.04) mean (SD) Diabetes, n (%) 171 (73.4) 172 (72.9)
171 (73.4) Baseline TG >750 NA NA NA mg/dL, n (%) Statin use, n
(%): Any 233 (100) 236 (100) 233 (100) Atorvastatin 44 (18.9) 43
(18.2) 45 (19.3) Simvastatin 134 (57.5) 136 (57.6) 133 (57.1)
Rosuvastatin 55 (23.6) 57 (24.2) 55 (23.6) Statin efficacy
regimens, n (%) Lower 16 (6.9) 17 (7.2) 15 (6.4) Medium 148 (63.5)
148 (62.7) 144 (61.8) Higher 69 (29.6) 71 (30.1) 74 (31.8)
[0203] Baseline lipid parameters for subjects in the
intent-to-treat ("ITT") population of this study are shown in Table
2 below. Data are presented as median (interquartile range)
values.
TABLE-US-00002 TABLE 2 Baseline Lipid Parameters (ITT Population)
AMR101 AMR101 4 g/day 2 g/day Placebo Lipid Parameter (IQR) (IQR)
(IQR) (mg/dL) (n = 233) (n = 236) (n = 233) TG 264.8 (93.0) 254.0
(92.5) 259.0 (81.0) (n = 226) (n = 234) (n = 227) LDL-C 82.0 (25.0)
82.0 (24.0) 84.0 (27.0) (n = 225) (n = 233) (n = 226) Non-HDL-C
128.0 (32.0) 128.0 (33.0) 128.0 (34.0) (n = 226) (n = 234) (n =
227) TC 167.0 (38.0) 169.0 (34.0) 168.0 (38.0) (n = 226) (n = 234)
(n = 227) HDL-C 37.0 (12.0) 38.0 (13.0) 39.0 (12.0) (n = 226) (n =
234) (n = 227)
[0204] During the double-blind treatment period, patients returned
to the site at Visit 5 (Week 4), Visit 6 (Week 11), and Visit 7
(Week 12) for efficacy and safety evaluations.
[0205] Eligible patients were randomly assigned at Visit 4 (Week 0)
to receive orally >96% E-EPA 2 g daily, >96% E-EPA 4 g daily,
or placebo.
[0206] >96% E-EPA was provided in 1 g liquid-filled, oblong,
gelatin capsules. The matching placebo capsule was filled with
light liquid paraffin and contained 0 g of >96% E-EPA. >96%
E-EPA capsules were to be taken with food (i.e. with or at the end
of a meal).
[0207] During the double-blind treatment period, patients were to
take 2 capsules (>96% E-EPA or matching placebo) in the morning
and 2 capsules in the evening for a total of 4 capsules per day.
[0208] Patients in the >96% E-EPA 2 g/day treatment group
received 1>96% E-EPA 1 g capsule and 1 matching placebo capsule
in the morning and in the evening. [0209] Patients in the >96%
E-EPA 4 g/day treatment group received 2>96% E-EPA 1 g capsules
in the morning and evening. [0210] Patients in the placebo group
received 2 matching placebo capsules in the morning and
evening.
[0211] The primary efficacy variable for the double-blind treatment
period was percent change in TG from baseline to Week 12 endpoint.
The secondary efficacy variables for the double-blind treatment
period included the following: [0212] Percent changes in total
cholesterol (TC), high-density lipoprotein cholesterol (HDL-C),
LDL-C, calculated non-HDL-C, and very low-density lipoprotein
cholesterol (VLDL-C) from baseline to Week 12 endpoint; [0213]
Percent change in very low-density lipoprotein TG from baseline to
Week 12; [0214] Percent changes in apolipoprotein A-I (apo A-I),
apolipoprotein B (apo B), and apo A-I/apo B ratio from baseline to
Week 12; [0215] Percent changes in lipoprotein(a) from baseline to
Week 12; [0216] Percent changes in LDL particle number and size,
measured by nuclear magnetic resonance, from baseline to Week 12;
[0217] Percent change in remnant-like particle cholesterol from
baseline to Week 12; [0218] Percent change in oxidized LDL from
baseline to Week 12; [0219] Changes in FPG and HbA.sub.1c from
baseline to Week 12; [0220] Change in insulin resistance, as
assessed by the homeostasis model index insulin resistance, from
baseline to Week 12; [0221] Percent change in lipoprotein
associated phospholipase A.sub.2 (Lp-PLA.sub.2) from baseline to
Week 12; [0222] Change in intracellular adhesion molecule-1 from
baseline to Week 12; [0223] Change in interleukin-2 from baseline
to Week 12; [0224] Change in plasminogen activator inhibitor-1 from
baseline to Week 12. Note: this parameter will only be collected at
sites with proper storage conditions; [0225] Change in hsCRP from
baseline to Week 12; and [0226] Change in plasma concentration and
red blood cell membrane content of fatty acid from baseline to Week
12 including EPA, docosapentaenoic acid (DPA), docosahexaenoic acid
(DHA), arachidonic acid (AA), dihomo-.gamma.-linolenic acid (DGLA),
the ratio of EPA/AA, ratio of oleic acid/stearic acid (OA/SA), and
the ratio of total omega-3 acids over total omega-6 acids.
[0227] Safety assessments included adverse events, clinical
laboratory measurements (chemistry, hematology, and urinalysis),
12-lead electrocardiograms (ECGs), vital signs, and physical
examinations.
[0228] For TG, TC, HDL-C, LDL-C, calculated non-HDL-C, and VLDL-C,
baseline was defined as the average of Visit 4 (Week 0) and the
preceding lipid qualifying visit (either Visit 3 [Week -1] or if it
occurs, Visit 3.1) measurements. Baseline for all other efficacy
parameters was the Visit 4 (Week 0) measurement.
[0229] For TG, TC, HDL-C, LDL-C, calculated non-HDL-C, and VLDL-C,
Week 12 endpoint was defined as the average of Visit 6 (Week 11)
and Visit 7 (Week 12) measurements.
[0230] Week 12 endpoint for all other efficacy parameters were the
Visit 7 (Week 12) measurement.
[0231] The primary efficacy analysis was performed using a 2-way
analysis of covariance (ANCOVA) model with treatment as a factor
and baseline TG value as a covariate. The least-squares mean,
standard error, and 2-tailed 95% confidence interval for each
treatment group and for each comparison were estimated. The same
2-way ANCOVA model was used for the analysis of secondary efficacy
variables.
[0232] The primary analysis was repeated for the per-protocol
population to confirm the robustness of the results for the
intent-to-treat population.
[0233] Non-inferiority tests for percent change from baseline in
LDL-C were performed between >96% E-EPA doses and placebo using
a non-inferiority margin of 6% and a significant level at 0.05.
[0234] For the following key secondary efficacy parameters,
treatment groups were compared using Dunnett's test to control the
Type 1 error rate: TC, LDL-C, HDL-C, non-HDL-C, VLDL-C,
Lp-PLA.sub.2, and apo B. For the remaining secondary efficacy
parameters, Dunnett's test was be used and the ANCOVA output were
considered descriptive.
[0235] The evaluation of safety was based primarily on the
frequency of adverse events, clinical laboratory assessments, vital
signs, and 12-lead ECGs. The primary efficacy variable is the
percent change in fasting TG levels from baseline to Week 12. A
sample size of 194 completed patients per treatment group provided
90.6% power to detect a difference of 15% between >96% E-EPA and
placebo in percent change from baseline in fasting TG levels,
assuming a standard deviation of 45% in TG measurements and a
significance level of p<0.05.
[0236] Previous data on fasting LDL-C show a difference in percent
change from baseline of 2.2%, with a standard deviation of 15%,
between study drug and placebo. A sample size of 194 completed
patients per treatment group provided 80% power to demonstrate
non-inferiority (p<0.05, one-sided) of the LDL-C response
between >96% E-EPA 4 g daily and placebo, within a 6% margin. To
accommodate a 10% drop-out rate from randomization to completion of
the double-blind treatment period, a total of 648 randomized
patients was planned (216 patients per treatment group); 702
subjects were randomized, as further described below.
[0237] A summary of baseline values, end-of-treatment values, and
median placebo-adjusted percent change from baseline to study end
of inflammation-associated end points in each of the three ITT
sub-populations is shown in Table 3.
TABLE-US-00003 TABLE 3 Median Placebo-adjusted Percent Change From
Baseline to Study End in Inflammation-associated End Points (ITT
Populations). Median Placebo- adjusted % AMR101 4 g/day AMR101 2
g/day Placebo Change From Baseline Base- End-of- Change Base-
End-of- Change Base- End-of- Change AMR101 AMR101 line treatment
from line treatment from line treatment from 4 g/day 2 g/day value
value baseline, value value baseline, value value baseline, vs pla-
vs pla- (IQR) (IQR) % (IQR) (IQR) (IQR) % (IQR) (IQR) (IQR) % (IQR)
cebo, P cebo, P MARINE n = 76 n = 73 n = 75 ICAM-1 (ng/mL) 250.0
253.0 -0.9 255.5 257.5 -0.4 247.5 246.0 2.6 -2.5 -2.3 (n = 75, 70,
72) (85.00) (89.00) (10.69) (86.00) (102.00) (12.29) (101.00)
(89.50) (13.43) 0.1188 0.2201 Ox-LDL (U/L) 78.8 74.8 -3.0 76.2 75.2
0.4 74.3 74.8 3.3 -6.4 -3.0 (n = 74, 70, 71) (26.51) (26.52) (2.35)
(24.00) (23.52) (2.41) (24.86) (23.32) (2.39) 0.0599 0.3818
Lp-PLA.sub.2 (ng/mL) 246.0 201.0 -17.1 235.0 220.5 -5.1 253.0 256.0
-2.4 -13.6 -5.1 (n = 73, 70, 70) (116.00) (100.00) (24.43) (106.00)
(101.00) (24.14) (126.00) (146.00) (29.35) 0.0003 0.1529 IL-6
(pg/mL) 2.3 2.4 0.3 3.0 3.0 3.4 2.5 2.3 5.3 11.0 4.7 (n = 60, 62,
61) (3.34) (3.32) (93.07) (2.78) (5.39) (76.70) (4.12) (1.85)
(79.27) 0.3629 0.6654 hsCRP (mg/L) 2.2 2.2 -2.5 2.0 2.4 25.1 1.8
2.5 33.3 -36.0 -10.1 (n = 75, 70, 72) (3.10) (2.90) (81.19) (2.70)
(3.20) (96.43) (3.05) (3.95) (80.49) 0.0012 0.4028 ANCHOR n = 226 n
= 234 n = 227 ICAM-1 (ng/mL) 273.0 270.0 0.8 267.0 268.5 0.5 269.0
257.0 3.6 -2.4 -2.2 (n = 78, 74, 83) (96.00) (110.00) (13.27)
(97.00) (89.00) (12.41) (122.00) (131.00) (12.07) 0.1888 0.1944
Ox-LDL (U/L) 54.0 51.4 -4.8 54.0 55.8 2.6 51.8 59.7 11.6 -13.3 -5.8
(n = 78, 75, 84) (14.60) (17.50) (19.63) (17.80) (22.80) (18.28)
(16.80) (18.10) (28.09) 0.0001 0.0946 Lp-PLA.sub.2 (ng/mL) 180.0
160.0 -12.8 190.0 183.5 -1.8 185.0 200.0 6.7 -19.0 -8.0 (n = 217,
224, (56.00) (57.00) (18.52) (55.50) (57.50) (23.11) (58.00)
(71.00) (24.03) <0.0001 <0.0001 213) IL-6 (pg/mL) 2.7 2.6 3.1
2.4 2.7 6.9 3.2 2.9 3.3 -1.0 7.0 (n = 78, 74, 83) (2.61) (2.08)
(56.47) (2.01) (2.28) (51.85) (3.23) (2.95) (59.37) 0.9031 0.3643
hsCRP (mg/L) 2.2 2.0 -2.4 1.9 2.5 10.3 2.2 2.6 17.1 -22.0 -6.8 (n =
217, 227, (2.70) (3.00) (62.75) (2.90) (3.40) (88.61) (4.00) (4.70)
(107.99) 0.0005 0.2889 219)
[0238] Only subsets with non-missing baseline and week 12 values
are included in the data of Table 3. Data are presented as median
(interquartile range) for end point values. End Point
Abbreviations: hsCRP, high-sensitivity C-reactive protein; ICAM-1,
intracellular adhesion molecule-1; IL-6, interleukin-6; IQR,
interquartile range; Lp-PLA2, lipoprotein-associated phospholipase
A2; Ox-LDL, oxidized low-density lipoprotein.
Results
[0239] Of the 702 randomized subjects, 687 were in the
intent-to-treat ("ITT") population as follows: [0240] Ultra-pure
EPA, 4 g/day: 226 subjects [0241] Ultra-pure EPA, 2 g/day: 234
subjects [0242] Placebo: 227 subjects
[0243] Lipids were extracted from plasma and red blood cell ("RBC")
suspensions and converted into fatty acid methyl esters for
analysis using a standard validated gas chromatography/flame
ionization detection method. Fatty acid parameters were compared
between EPA treatment groups and placebo using an ANCOVA model with
treatment, gender, type of statin therapy, and presence of diabetes
as factors, and the baseline parameter value as a covariate. LSMs,
SEs, and 2-tailed 95% confidence intervals for each treatment group
and for each comparison were determined.
[0244] Baseline characteristics of the three ITT groups were
comparable, with 61.4% of the ITT subjects being male, 96.3% being
white, having a mean age of 61.4 years, a weight of 95.7 kg and a
BMI of 32.9 kg/m.sup.2. ITT subjects with incomplete fatty acid
data at baseline and/or at 12 weeks were excluded from the analyses
described below (as reflected in the n numbers shown in Tables
4-6).
[0245] As shown in Table 4, ultra-pure EPA at 2 g/day and 4 g/day
both significantly increased mean placebo-adjusted plasma
concentrations of EPA, DPAn-3, and the ratio of total omega-3 to
omega-6 fatty acids ("total .omega.-3/total .omega.-6"). In
addition, both 2 g/day and 4 g/day doses of ultra-pure EPA
significantly decreased mean placebo-adjusted plasma concentrations
of arachidonic acid, palmitic acid, stearic acid, oleic acid,
linoleic acid, and the plasma ratio of arachidonic acid to EPA.
Neither dose of ultra-pure EPA produced a significant change in
mean placebo-adjusted plasma concentration of DHA.
TABLE-US-00004 TABLE 4 Change from Baseline to Week 12 in Plasma
Fatty Acid Concentrations and Ratios. Placebo-adjusted percent IPE
4 g/day (n = 226) IPE 2 g/day (n = 234) Placebo (n = 227) chanage
from baseline Change Change Change IPE 4 g/ IPE 2 g/ Base- End-of-
from Base- End-of- from Base- End-of- from day vs day vs line
treatment baseline line treatment baseline line treatment baseline
placebo, placebo, (SD) (SD) (SE) (SD) (SD) (SE) (SD) (SD) (SE) %, P
%, P EPA 19.7 147.7 137.7 26.6 89.3 71.3 24.3 24.6 10.3 649.7 268.2
n = 41, 50, 51 (6.1) (53.8) (5.9) (13.1) (39.7) (5.3) (29.0) (25.0)
(6.3) <0.0001 <0.0001 DHA 51.6 53.6 2.3 58.9 62.7 5.0 58.6
62.6 6.1 -2.9 -0.7 n = 47, 51, 52 (15.5) (13.7) (2.0) (18.9) (18.6)
(1.8) (34.3) (33.5) (1.8) 0.4925 0.8711 DPAn-3 19.9 50.2 31.8 23.3
44.3 22.4 21.6 24.0 3.9 143.6 88.9 n = 48, 51, 51 (5.2) (14.3)
(1.8) (6.6) (13.5) (1.7) (7.9) (9.4) (1.7) <0.0001 <0.0001 AA
281.4 222.8 -60.1 301.2 266.7 -31.1 307.6 328.4 26.0 -30.7 -19.1 n
= 49, 51, 51 (71.0) (66.1) (6.4) (73.5) (61.2) (6.0) (75.1) (67.8)
(6.2) <0.0001 <0.0001 Palmitic 984.7 843.8 -161 1066 1004
-50.1 1045 1109 59.9 -23.3 -12.1 n = 47, 49, 50 (215.5) (215.6)
(45.4) (291.6) (321.2) (43.7) (298.3) (351.0) (43.2) <0.0001
0.0139 Stearic 277.3 253.4 -31.2 302.5 276.2 -19.6 293.7 306.3 14.2
-15.5 -12.6 n = 49, 46, 49 (55.1) (48.5) (8.2) (61.8) (52.8) (8.2)
(61.2) (61.8) (8.1) <0.0001 0.0003 Oleic 970.0 782.6 -219 1029
972.1 -61.7 1018 1102 71.3 -30.1 -14.3 n = 46, 49, 50 (256.8)
(210.9) (49.6) (271.3) (328.9) (46.9) (296.3) (400.2) (47.1)
<0.0001 0.0089 Linoleic 1066 921.8 -152 1125 1082 35.0 1099 1229
128.6 -24.8 -14.5 n = 49, 49, 51 (253.6) (202.4) (82.6) (253.0)
(285.0) (37.2) (257.3) (350.8) (36.8) <0.0001 0.0003 Ratio of
16.3 1.6 -14.1 13.2 3.4 -11.2 16.8 16.4 0.5 -90.3 -75.4 AA/EPA
(6.7) (0.8) (0.6) (4.2) (1.7) (0.5) (6.8) (6.5) (0.5) <0.0001
<0.00001 n = 46, 50, 49 Ratio of total 0.1 0.2 0.2 0.1 0.2 0.1
0.1 0.1 0.0 165.9 64.3 .omega.-3/total .omega.-6 (0.01) (0.06)
(0.01) (0.02) (0.04) (0.01) (0.04) (0.04) (0.01) <0.0001
<0.0001 n = 46, 51, 50 Mean and SD are reported for baseline and
end-of-treatment values; LS mean and SE are reported for changes
from baseline and placebo-adjusted changes from baseline.
[0246] As shown in Table 5, ultra-pure EPA at 2 g/day and 4 g/day
both significantly increased mean placebo-adjusted concentrations
of EPA, DPAn-3, and the ratio of total omega-3 to omega-6 fatty
acids ("total .omega.-3/total .omega.-6") in RBCs. In addition,
both 2 g/day and 4 g/day doses of ultra-pure EPA significantly
decreased mean placebo-adjusted RBC concentrations of arachidonic
acid and the RBC ratio of arachidonic acid to EPA. The RBC
concentration of linoleic acid significantly decreased over placebo
for subjects in the 4 g/day EPA group. Both doses of ultra-pure EPA
produced a significant change in mean placebo-adjusted RBC
concentration of DHA.
TABLE-US-00005 TABLE 5 Change from Baseline to Week 12 in RBC Fatty
Acid Concentrations and Ratios. Placebo-adjusted percent IPE 4
g/day (n = 226) IPE 2 g/day (n = 234) Placebo (n = 227) change from
baseline Change Change Change IPE 4 g/ IPE 2 g/ Base- End-of- from
Base- End-of- from Base- End-of- from day vs day vs line treatment
baseline line treatment baseline line treatment baseline placebo,
placebo, (SD) (SD) (SE) (SD) (SD) (SE) (SD) (SD) (SE) %, P %, P EPA
6.1 43.2 39.4 8.2 29.4 21.1 7.2 6.5 0.8 619.2 290.4 n = 48, 49, 47
(2.3) (18.2) (1.8) (2.7) (8.5) (1.8) (3.3) (3.3) (1.8) <0.0001
<0.0001 DHA 44.0 39.0 -6.4 50.5 44.7 -5.5 47.5 45.4 -2.5 6.6
-5.4 n = 43, 48, 46 (11.8) (8.4) (1.0) (13.2) (11.4) (0.9) (11.8)
(11.8) (0.9) 0.0107 0.0310 DPAn-3 28.3 61.9 33.6 31.6 52.2 21.2
29.9 28.9 -0.8 122.4 74.9 n = 46, 50, 46 (5.6) (12.6) (1.4) (5.0)
(8.9) (1.3) (5.3) (4.7) (1.4) <0.0001 <0.0001 AA 184.7 153.1
-87.5 190.9 173.0 -20.0 190.3 195.1 1.9 -20.3 -11.6 n = 43, 48, 46
(37.2) (28.8) (3.6) (28.8) (25.7) (3.3) (25.4) (25.9) (3.4)
<0.0001 <0.0001 Palmitic 304.0 301.2 -6.3 317.3 321.1 4.9
314.8 315.4 0.9 -2.7 0.5 n = 45, 49, 49 (37.8) (37.0) (4.4) (37.2)
(41.4) (4.1) (39.1) (30.2) (4.1) 0.1091 0.7706 Stearic 170.6 170.5
1.4 174.9 178.7 3.9 174.5 176.0 1.4 -1.3 1.8 n = 44, 50, 45 (19.0)
(18.9) (2.5) (22.4) (22.9) (2.3) (14.6) (16.5) (2.4) 0.4773 0.3753
Oleic 194.4 188.8 -6.0 201.7 204.7 3.1 200.0 200.2 -0.4 -3.7 1.6 n
= 44, 50, 44 (27.6) (24.1) (3.1) (30.0) (31.6) (2.8) (23.3) (21.9)
(3.0) 0.0498 0.3599 Linoleic 147.1 132.7 -15.1 154.3 153.1 -1.3
152.3 154.8 1.9 -11.1 -2.1 n = 47, 49, 47 (32.2) (26.2) (3.8)
(33.4) (37.6) (3.5) (23.7) (31.6) (3.6) 0.0003 0.4709 Ratio of 32.0
3.6 -26.8 26.1 6.4 -21.9 31.0 32.8 3.0 -98.5 -87.1 AA/EPA (10.5)
(1.7) (0.8) (8.2) (2.0) (0.8) (11.2) (9.6) (0.8) <0.0001
<0.0001 n = 45, 50, 49 Ratio of total 0.2 0.4 0.2 0.2 0.3 0.1
0.2 0.2 -0.0 123.0 60.4 .omega.-3/total .omega.-6 (0.03) (0.11)
(0.01) (0.05) (0.06) (0.01) (0.04) (0.04) (0.01) <0.0001
<0.0001 n = 47, 52, 49 Mean and SD are reported for baseline and
end-of-treatment values; LS mean and SE are reported for changes
from baseline and placebo-adjusted changes from baseline.
[0247] Table 6 shows changes from baseline and placebo-adjusted
percent changes from baseline in the proportion (mol %) of fatty
acid classes to total fatty acids in both plasma and in RBCs. The
monounsaturated fatty acid group included myristoleic, palmitoleic,
cis-vaccenic, oleic, gondoic/gadoleic, erucic and nervonic acids.
The saturated fatty acid group included myristic, palmitic,
stearic, arachidic, behenic and lignoceric acids. The "total
.omega.-3" group included .alpha.-linolenic, stearidonic,
eicosatrienoic, .omega.-3 arachidonic, eicosapentaenoic, .omega.-3
docosapentaenoic and docosahecaenoic acids. The "total .omega.-6"
group included linoleic, .gamma.-linolenic, eicosadienoic,
dihomo-.gamma.-linolenic, .omega.-6 arachidonic, adrenic, and
.omega.-6 docosapentaenoic acids. The "total fatty acid" group
represented the sum of the monounsaturated, saturated, total
.omega.-3 and total .omega.-6 groups. Treatment with 2 g/day or 4
g/day ultra-pure EPA resulted in an increased proportion of
.omega.-3 fatty acids in plasma and in RBCs compared to placebo,
and a decreased proportion of .omega.-6 fatty acids in plasma and
in RBCs compared to placebo. Treatment with 4 g/day ultra-pure EPA
also resulted in a decreased proportion of monounsaturated fatty
acids in plasma and RBCs compared to placebo.
TABLE-US-00006 TABLE 6 Placebo-adjusted Percent Change in the
Proportion of Fatty Acid Classes to Total Fatty Acids.
Placebo-adjusted percent IPE 4 g/day (n = 226) IPE 2 g/day (n =
234) Placebo (n = 227) chanage from baseline Change Change Change
IPE 4 g/ IPE 2 g/ Base- End-of- from Base- End-of- from Base-
End-of- from day vs day vs line treatment baseline line treatment
baseline line treatment baseline placebo, placebo, (SD) (SD) (SE)
(SD) (SD) (SE) (SD) (SD) (SE) %, P %, P Plasma Saturated 33.7 33.6
-0.5 34.3 33.6 -0.7 34.2 33.6 -0.7 0.4 <0.2 n = 49, 52, 52 (2.5)
(2.4) (0.3) (2.2) (2.2) (0.3) (2.5) (2.4) (0.3) 0.6923 0.8387
Monounsaturated 28.6 26.7 -2.0 28.5 28.0 -0.7 28.7 28.6 -0.3 -5.8
-1.4 n = 49, 52, 52 (2.8) (3.0) (0.4) (2.2) (2.6) (0.4) (2.6) (3.3)
(0.4) 0.0026 0.4631 Total .omega.-6 34.7 32.6 -1.8 34.0 33.3 -0.8
34.0 34.7 0.7 -7.4 -4.6 n = 49, 52, 52 (3.9) (3.5) (0.5) (2.7)
(3.4) (0.5) (8.4) (3.8) (0.5) 0.0002 0.0171 Total .omega.-3 2.9 7.1
4.4 3.2 5.1 2.1 3.1 3.1 0.3 142.2 60.3 n = 49, 52, 52 (0.5) (2.0)
(0.2) (0.7) (1.2) (0.2) (1.3) (1.2) (0.2) <0.0001 <0.0001
RBCs Saturated 43.4 44.2 0.6 43.7 43.5 -0.3 43.8 42.9 -0.9 3.2 1.3
n = 49, 52, 52 (2.2) (3.0) (0.3) (3.0) (2.1) (0.3) (2.6) (1.7)
(0.3) 0.0009 0.1589 Monounsaturated 20.5 19.8 -0.5 19.9 19.9 -0.1
19.9 20.1 0.0 -2.7 -0.7 n = 49, 52, 52 (2.2) (1.7) (0.2) (1.2)
(1.1) (0.2) (1.6) (1.9) (0.2) 0.0419 0.5771 Total .omega.-6 30.8
25.8 -4.9 30.3 28.1 -2.4 30.6 31.5 0.8 -19.7 -11.3 n = 49, 52, 52
(2.0) (3.2) (0.4) (3.1) (2.1) (0.4) (3.1) (2.2) (0.4) <0.0001
<0.0001 Total .omega.-3 5.4 10.2 4.9 6.1 8.5 2.8 5.7 5.5 -0.0
89.1 60.0 n = 49, 52, 52 (1.1) (2.5) (0.2) (1.3) (1.5) (0.2) (1.2)
(1.1) (0.2) <0.0001 <0.0001 Mean and SD are reported for
baseline and end-of-treatment values; LS mean and SE are reported
for changes from baseline and placebo-adjusted changes from
baseline. Total = sum of .omega.-3, .omega.-6, monounsaturated, and
saturated fatty acids. .omega.-3 fatty acids = sum of
.alpha.-linolenic, stearidonic, eicosatrienoic, .omega.-3
arachidonic, eicosapentaenoic, .omega.-3 docosapentaenoic, and
docosahexaenoic acids. .omega.-6 fatty acids = sum of linoleic,
.gamma.-linolenic, eicosadienoic, dihomo-.gamma.-linolenic,
.omega.-6 arachidonic, adrenic, and .omega.-6 docosapentaenoic
acids. Monounsaturated fatty acids = myristoleic, palmitoleic,
cis-vaccenic, oleic, gondoic/gadoleic, erucic, and nervonic acids.
Saturated fatty acids = sum of myristic, palmitic, stearic,
arachidic, behenic, and lignoceric acids.
[0248] FIG. 1 shows the placebo-adjusted least squares mean changes
(P<0.0001) in EPA concentration from baseline to week 12 in
plasma and RBCs. The error bars represent 95% confidence intervals.
Treatment with 4 g/day ultra-pure EPA (referred to as "IPE" in the
Figures) resulted in a 649.7% placebo-adjusted LS mean increase in
plasma EPA over baseline, and a 619.2% placebo-adjusted LS mean
increase in RBC EPA over baseline. Treatment with 2 g/day
ultra-pure EPA resulted in a 268.2% placebo-adjusted LS mean
increase in plasma EPA over baseline, and a 290.4% placebo-adjusted
LS mean increase in RBC EPA over baseline.
[0249] FIG. 2 shows plasma (dark diamonds) and RBC (light diamonds)
placebo-adjusted least square mean changes from baseline to week 12
for select individual fatty acids and ratios of arachidonic acid to
EPA ("AA/EPA") and total .omega.-3 fatty acids to total .omega.-6
fatty acids ("n-3/n-6") upon treatment with 4 g/day ultra-pure EPA
(left) or 2 g/day ultra-pure EPA (right). The values for each data
point and corresponding P values are reported in Tables 4 and 5.
Error bars represent 95% confidence intervals.
[0250] FIG. 3 depicts the EPA dose dependence of changes in EPA
plasma and RBC concentration from baseline. Increased doses of
ultra-pure EPA resulted in increased EPA concentration in both
plasma and RBCs. EPA concentration in plasma (dark circles,
.gamma.-axis on left) increased 10.3 .mu.g/g for the placebo group,
71.3 .mu.g/g for the 2 g/day ultra-pure EPA group, and 137.7
.mu.g/g for the 4 g/day ultra-pure EPA group. EPA concentration in
RBCs (light circles, y-axis on right) increased 0.8 .mu.g/g for the
placebo group, 21.1 .mu.g/g for the 2 g/day ultra-pure EPA group,
and 39.4 .mu.g/g for the 4 g/day ultra-pure EPA group. Error bars
represent 95% confidence intervals for each data point.
[0251] FIG. 4 shows the relationship between plasma triglyceride
lowering and changes in EPA plasma and RBC concentrations (a
pharmacokinetic/pharmacodynamic relationship). Increased EPA
concentrations in plasma (FIG. 4A) and RBCs (FIG. 4B) were
accompanied by greater reductions in plasma triglyceride levels.
Triglyceride concentrations are presented in FIG. 4 as median
percent changes from baseline. Vertical error bars represent the
first and third quartile of the IQR. EPA concentrations are
presented in FIG. 4 as mean percent changes from baseline.
Horizontal error bars represent 95% confidence intervals.
[0252] As shown in FIG. 14, a linear concentration-response
pharmacodynamics relationship between EPA plasma levels and
triglyceride reduction was also observed. Error bars represent 95%
confidence intervals for both median triglyceride percent change
from baseline (y-axis; vertical error bars) and mean EPA plasma
concentration percent change from baseline (x-axis; horizontal
error bars). This data is consistent with the observation in all
studies to-date that a greater increase in EPA concentrations in
both plasma and RBCs was observed for subjects administered about 4
g per day of EPA compared to those administered about 2 g per day.
In addition, median percent reductions in triglycerides (compared
to baseline) were higher for subjects administered about 4 grams of
EPA per day than for those administered about 2 g of EPA per day in
both the ANCHOR study (described herein and also in U.S. Pat. No.
8,410,486, incorporated herein by reference) and also in the MARINE
study (see, e.g., U.S. Pat. No. 8,357,677, incorporated herein by
reference).
[0253] These data indicate that ultra-pure EPA at either 2 g/day or
4 g/day significantly increased the concentrations of EPA and its
metabolite, DPA n-3, in plasma and RBCs; significantly reduced the
arachidonic acid/EPA ratio in plasma and RBCs (suggested by others
to be a useful biomarker for arteriosclerotic disease); decreased
the concentrations of key fatty acids including arachidonic,
palmitic, stearic, oleic and linoleic acids in plasma and
arachidonic acid (both doses) and linoleic acid (4 g/day only) in
RBCs; increased the proportion of omega-3 fatty acids and decreased
the proportion of omega-6 fatty acids in plasma and RBCs; and did
not significantly increase the concentration of DHA in plasma or
RBCs, indicating that its metabolic effects (including triglyceride
lowering) are not due to increases in DHA levels.
[0254] Overall, administration of 2 g/day or 4 g/day ultra-pure EPA
significantly increased EPA concentrations in a linear,
dose-dependent fashion consistent with its triglyceride-lowering
effect, caused beneficial shifts in the fatty acid profile, and
significantly decreased the arachidonic acid/EPA ratio in plasma
and RBCs.
Example 2
Improvement of Cognitive Performance in Subjects with
Age-Associated Memory Impairment
[0255] A single-center, 6-week, double-blind, randomizes,
parallel-group, placebo-controlled, dose-ranging pilot study was
performed to evaluate the efficacy, tolerability, and safety of
>96% ethyl-EPA in subjects with subjective and objective memory
impairment according to generally accepted criteria for
Age-Associated Memory Impairment ("AAMI"). The primary objective of
the study was to determine the effect of >96% ethyl-EPA 1 g, 2
g, and 4 g daily, compared to placebo, on cognitive performance in
subjects with AAMI.
[0256] The secondary objectives of this study were the
following:
1. To determine the effect of >96% E-EPA on the following tests
in the computerized cognitive battery: [0257] Continuity of
attention tasks; [0258] Quality of working memory tasks; [0259]
Quality of episodic memory tasks; and [0260] Speed of attention
tasks; 2. To determine the safety and tolerability of >96% E-EPA
from routine clinical laboratory tests, adverse events ("AE")
monitoring, and vital signs; and 3. To determine the potential
dose-effect relationship of >96% E-EPA on the cognitive
endpoints by measurement of essential fatty acids in plasma and red
blood cell membranes.
[0261] The population for this study was men and women between ages
50 and 70 with self-reported complaints of memory loss, subjective
and objective cognitive impairment with a score of at least one
standard deviation below that of the mean for age-matched elderly
population as determined by the total score of between 13 and 20
from the Paired Associated Learning ("PAL") subset of the Wechsler
Memory Scale, evidence of adequate intellectual function as
determined by a scaled score of at least 9 (raw score of at least
32) on the Vocabulary subtest of the Wechsler Adult Intelligence
Scale and absence of dementia as determined by a score of 24 or
higher on the Mini-Mental State Examination ("MMSE").
[0262] Potential subjects were excluded based on the following
exclusion criteria: [0263] Unlikely or unable to comply with
investigational medication dosing requirements; [0264] Diagnosis of
major depressive disorder, Alzheimer's or vascular dementia as
defined according to the Mini International Neuropsychiatric
Interview ("MINI")/Diagnostic and Statistical Manual of Mental
Disorders (4th edition) Text Revision ("TR") criteria; [0265] Past
or current history of: [0266] a neurological or psychiatric
disorder that could have affected cognitive function; [0267]
inflammatory gastrointestinal disease such as Crohn's Disease or
ulcerative colitis; [0268] cancer other than basal cell carcinoma;
[0269] clinically significant cardiac abnormality as measured by
12-lead ECG; [0270] Any other medical condition or intercurrent
illness not adequately controlled, which, in the opinion of the
study investigator, may have put the subject at risk when
participating in the study or may have influenced the results of
the study or affected the subject's ability to take part in the
study; [0271] Clinically significant abnormal screening results
(e.g., haematology, biochemistry) on screening or vital signs that
fell outside the normal range for this population, which in the
opinion of the study investigator affected the subject's
suitability for the study; [0272] Changes to prescribed medication
for a medical condition within 4 weeks of the baseline visit;
[0273] Omega-3 supplementation within 4 weeks of the baseline visit
or during the study treatment period; [0274] Currently taking
anticoagulants or daily dose of aspirin greater than 325 mg. [0275]
Cough or flu remedies containing opiates or antihistamines within 2
weeks of the baseline visit or during the 6-week treatment period;
and [0276] Known allergy to any ingredients of the study drug or
placebo.
[0277] Ninety-four subjects were randomized into one of six groups:
1 g E-EPA daily (n=23), 2 g E-EPA daily (n=24), 4 g E-EPA daily
(n=24), 1 g placebo daily (n=7), 2 g placebo daily (n=8), and 4 g
placebo daily (n=8). E-EPA was provided as 500 mg soft gel capsules
containing >96% E-EPA and 0.2% dl-.alpha.-tocopherol as an
antioxidant. Placebo capsules contained 467 mg of liquid paraffin
and 0.2% dl-.alpha.-tocopherol. Ninety-one subjects completed the
study. Two subjects in the 2 g E-EPA group and one subject in the 2
g placebo group discontinued the study.
[0278] The study consisted of a screening visit, a training visit,
and four study visits. At the screening visit, subjects'
eligibility was determined through cognitive tests (verbal paired
associated learning [PAL] subscale, vocabulary subtest, Memory
Assessment Clinics Questionnaire [MAC-Q], mini mental state
evaluation [MMSE] and MINI [mini international neuropsychiatric
interview; sections 1 and 2 of Diagnostic and Statistical Manual of
Mental Disorders, 4th Edition (DSM-IV) plus dysthymia]),
haematology, clinical chemistry and 12-lead electrocardiogram
(ECG). At the training visit, subjects were shown how to use the
CDR computerized system. Subjects took study drug for 6 weeks and
on Days 0, 14, 28 and 42, subjects underwent the CDR cognitive test
battery.
[0279] At screening cognitive testing and suitability for the study
were assessed using the Verbal Paired Associates 1 (Wechsler Memory
Scale), Vocabulary Subtest of the WAIS, MAC-Q, MMSE and MINI
(DSM-IV Sections 1 and 2 plus Dysthymia).
[0280] A selection of tasks from the CDR computerized cognitive
assessment system were administered at Visit 2 (training visit),
Visit 3 (baseline), Visit 4 (Day 14), Visit 5 (Day 28) and Visit 6
(Day 42). Parallel forms of the tests were presented at each
testing session. All tasks were computer-controlled, the
information presented on high resolution monitors, and the
responses recorded via a response model containing two buttons: one
marked `no` and the other `yes`. Five CDR composite scores were
used as the primary/secondary outcome variables. The task titles
were: [0281] Word Presentation [0282] Immediate Word Recall [0283]
Picture Presentation [0284] Simple Reaction Time [0285] Digit
Vigilance [0286] Choice Reaction Time [0287] Spatial Working Memory
[0288] Numeric Working Memory [0289] Delayed Word Recall [0290]
Word Recognition [0291] Picture Recognition [0292] Bond-Lader
Visual Analogue Scales of Mood and Alertness [0293] Screen, Using
the Computer Mouse
[0294] To ensure consistency of approach, full training on the
cognitive tests and CDR test battery was provided to study site
staff and study subjects. The results of each variable were
automatically recorded using the machine interface developed by
CDR.
[0295] Blood samples (10 mL) were collected at Visit 1 (screening)
and at Visits 4, 5 and 6. Analysis was performed by MSR Lipid
Analysis, Scottish Crop Research Institute, Dundee, UK. The
screening sample acted as baseline for the EFA measurements. Lipid
was extracted from plasma, serum and RBC suspensions and converted
into fatty acid methyl esters which were analyzed by gas
chromatography to give fatty acid profiles as micrograms fatty acid
per gram of sample (mFA/g) and normalized area percent.
[0296] All randomized subjects with at least 1 visit post-baseline
were included in the Intent to Treat ("ITT") population, regardless
of treatment actually received.
[0297] All randomized subjects that completed the study, excluding
significant protocol deviators, were defined as the Safety Per
Protocol population. An Efficacy Per Protocol population was based
on the Efficacy completers. The intercept of the Safety and
Efficacy Per Protocol populations defined the Study Per Protocol
Population.
[0298] All randomized subjects that received at least 1 dose of
study medication were included in the Safety Population.
[0299] Summary statistics were provided for the ITT and Study Per
Protocol Populations separately for all composite scores, major and
supportive variables. Summary statistics were performed for both
the unadjusted and difference from baseline data (i.e. the
difference from the time matched predose assessments on Day 0).
Summary statistics were calculated by treatment, day and
time-point. The summary statistics comprised n, mean, median, SD,
standard error of mean ("SEM"), minimum and maximum values.
[0300] Difference from baseline data for each major variable was
evaluated by an Analysis of Covariance ("ANCOVA") using SAS.RTM.
PROC MIXED Version 8.2. Fixed effects for treatment, day, time
point, treatment by day, treatment by time point, treatment by day
by time-point were fitted. Subject within treatment was fitted as a
repeated effect using the repeated statement. The compound symmetry
covariance structure was used. Subjects' time-matched predose
assessments on Day 0 were used as a covariate in the analysis.
[0301] Least squares means (LS means) were calculated for treatment
by day, treatment by time-point and treatment by day by time-point
interaction. This formal analysis was conducted for the ITT and
Study PP Populations separately.
[0302] Safety evaluations were based on the safety population.
Safety and tolerability were assessed in terms of AEs, vital signs,
12-lead ECG, clinical laboratory data, medical history, and study
drug compliance. Safety and tolerability data were presented by
treatment group.
[0303] RBC and plasma EFA data were collected at baseline, Day 14,
28 and 42 and summarized by visit for each treatment group. Change
from baseline and percent change from baseline were also
summarized. ANCOVA comparison of ethyl-EPA dose groups and
ethyl-EPA versus placebo was performed.
[0304] Efficacy Results.
[0305] All CDR cognitive test battery analyses were completed for
the ITT and Study PP analysis populations.
[0306] For the Intent-to-Treat Analysis for Power of Attention,
there was no statistically significant effect of treatment, nor any
treatment by day, treatment by time-point or treatment by day by
time-point interactions. There was no LS mean difference between
active treatment and placebo at any time-point.
[0307] For the contributing subtasks Simple Reaction Time and Digit
Vigilance Speed, there were no statistically significant effects of
treatment, nor any treatment by day, treatment by time-point or
treatment by day by time-point interactions. For the subtask
measure Choice Reaction Time, there was a statistically significant
treatment by day interaction (p=0.011).
[0308] For the Study Per-Protocol Power of Attention, there was no
statistically significant effect of treatment, nor any treatment by
day, treatment by time-point or treatment by day by time-point
interactions. There was no difference between active treatment and
placebo at any time-point.
[0309] For the subtasks Simple Reaction Time and Digit Vigilance
Speed, there were no statistically significant effects of
treatment, nor any treatment by day, treatment by time-point or
treatment by day by time-point interactions. For the subtask
measure, Choice Reaction Time, there was a statistically
significant treatment by day interaction (p=0.013).
[0310] The Intent-to-Treat Continuity of Attention and the
contributing subtask Digit Vigilance Targets Detected tests showed
no statistically significant effect of treatment, nor any treatment
by day, treatment by time-point or treatment by day by time-point
interactions.
[0311] For the Study Per Protocol Continuity of Attention test,
there was no statistically significant effect of treatment, nor any
treatment by day, treatment by time-point or treatment by day by
time-point interactions.
[0312] For the subtask Digit Vigilance Targets Detected, there was
a statistically significant treatment by time-point interaction
(p=0.040).
[0313] For the Intent-to-Treat Quality of Working Memory test,
there was a statistically significant treatment by day interaction
(p=0.019).
[0314] For the contributing subtask Spatial Working Memory
Sensitivity Index, there was a statistically significant treatment
by day interaction (p=0.015).
[0315] For Numeric Working Memory Sensitivity Index, there was a
statistical trend for a treatment by day interaction (p=0.089).
[0316] For the Study Per-Protocol Quality of Working Memory test,
there was a statistically significant treatment by day interaction
(p=0.021).
[0317] For the contributing subtask Spatial Working Memory
Sensitivity Index, there was a statistically significant treatment
by day interaction (p=0.014).
[0318] For the Intent-to-Treat Quality of Episodic Secondary Memory
test, there was no statistically significant effect of treatment,
nor any treatment by day, treatment by time-point or treatment by
day by time-point interactions. The LS mean differences showed
overall statistically significant decreases versus placebo for
ethyl-EPA 1 g and 2 g (p=0.040 and p=0.035, respectively).
[0319] For the contributing subtasks Immediate and Delayed Word
Recall Accuracies and for Word and Picture Recognition Sensitivity
Indices, there were no statistically significant effects of
treatment or treatment by day, treatment by time-point or treatment
by day by time-point interactions. For Immediate Word Recall
Accuracy, the LS mean differences showed statistically significant
decreases for 1 g on Day 14 (p=0.028) and for 2 g on Day 28
(p=0.017). There were statistically significant decreases versus
placebo for 1 g and 2 g at AM 1 (p=0.040 and p=0.028,
respectively). There were statistically significant decreases for
ethyl-EPA 1 g versus placebo on Day 14 at PM 2 (p=0.020) and for 2
g on Day 28 at AM 1 (p=0.006). For Word Recognition Sensitivity
Index, the LS mean differences showed statistically significant
decreases for ethyl-EPA 1 g on Day 28 (p=0.024) and for 4 g on Day
42 (p=0.038) versus placebo. There was a statistically significant
decrease for 4 g at PM 2 (p=0.045) and a statistically significant
decrease for 4 g versus placebo on Day 28 at PM 2 (p=0.030). For
Picture Recognition Sensitivity Index, the LS mean differences
showed statistically significant decrease for 1 g versus placebo on
Day 28 at AM 2 (p=0.017) and at PM 2 (p=0.040). For the Study
Per-Protocol Quality of Episodic Secondary Memory test, there were
no statistically significant effects of treatment, nor treatment by
day, treatment by time-point or treatment by day by time-point
interactions. The LS mean differences showed overall statistically
significant decreases versus placebo for 1 g and 2 g (p=0.043 and
p=0.036, respectively).
[0320] For the contributing subtasks Immediate and Delayed Word
Recall Accuracies and for Word and Picture Recognition Sensitivity
Indices, there were no statistically significant effects of
treatment or treatment by day, treatment by time-point or treatment
by day by time-point interactions. For Immediate Word Recall
Accuracy, the LS mean differences to placebo showed statistically
significant decreases for ethyl-EPA 1 g on Day 14 (p=0.024) and for
2 g on Day 28 (p=0.017). There were statistically significant
decreases for 1 g and 2 g at AM 1 (p=0.038 and p=0.029,
respectively) and for 1 g at AM 2 (p=0.048). There were
statistically significant decreases for 1 g versus placebo on Day
14 at PM 2 (p=0.019) and for 2 g on Day 28 at AM 1 (p=0.006).
[0321] For Word Recognition Sensitivity Index, the LS mean
differences to placebo showed statistically significant decreases
for 4 g on Day 42 (p=0.038) and for 1 g on Day 28 (p=0.027).
[0322] For Picture Recognition Sensitivity Index, the LS mean
differences showed statistically significant decreases versus
placebo for 1 g on Day 28 at AM 2 (p=0.020) and PM 2 (p=0.026).
[0323] For Intent-to-Treat Speed of Memory and the contributing
subtasks Spatial and Numeric Working Memory Speeds and Word, and
Picture Recognition Speeds, there were no statistically significant
effects of treatment, nor treatment by day, treatment by time-point
or treatment by day by time-point interactions. For Spatial Working
Memory Speed, the LS mean differences showed a statistically
significant benefit versus placebo for ethyl-EPA 4 g on Day 14 at
PM 1 (p=0.048) and a trend for a benefit for 4 g on Day 42 at AM 1
(p=0.061). For Picture Recognition Speed, there were trends for
benefits versus placebo for 1 g on Day 14 at AM 2 (p=0.084) and on
Day 28 at AM 1 (p=0.085).
[0324] For Study Per-Protocol Speed of Memory and the contributing
subtasks Spatial and Numeric Working Memory Speed and Word, and
Picture Recognition Speed, there were no statistical significant
effects of treatment, nor any treatment by day, treatment by
time-point or treatment by day by time-point interactions.
[0325] For Intent-to-Treat Self-Rated Alertness, there was no
statistically significant effect of treatment, nor any treatment by
day, treatment by time-point or treatment by day by time-point
interactions. The LS mean differences showed a statistically
significant decrease in ratings for ethyl-EPA 2 g on Day 28
(p=0.047) versus placebo. There was a statistically significant
decrease in ratings versus placebo for 2 g on Day 28 at AM 2
(p=0.041). For Study Per-Protocol Self-Rated Alertness, there was
no statistically significant effect of treatment, nor any treatment
by day, treatment by time-point or treatment by day by time-point
interactions. The LS mean differences showed a statistically
significant decrease in ratings for ethyl-EPA 2 g on Day 28
(p=0.035) versus placebo. There was a statistically significant
decrease in ratings versus placebo for 2 g on Day 28 at AM 2
(p=0.033).
[0326] For Intent-to-Treat Self-Rated Contentment, there was a
statistically significant treatment by day interaction
(p<0.001). The LS mean difference to placebo showed no
statistically significant effects. For Study Per-Protocol
Self-Rated Contentment, there was a statistically significant
treatment by day interaction (p<0.001). The LS mean difference
to placebo showed no statistically significant effects.
[0327] For Intent-to-Treat Self-Rated Calmness, there was no
statistically significant effect of treatment, nor any treatment by
day, treatment by time-point or treatment by day by time-point
interactions. For Study Per-Protocol Self-Rated Calmness, there was
no statistically significant effect of treatment, nor any treatment
by day, treatment by time-point or treatment by day by time-point
interactions. The LS mean differences showed a statistical trend
for an increase in ratings versus placebo for ethyl-EPA 4 g on Day
42 at PM 1 (p=0.071).
[0328] A post-hoc analysis compared the individual placebo groups
(1 g, 2 g and 4 g paraffin oil) with the corresponding ethyl-EPA
doses.
[0329] The pattern of data provided evidence that ethyl-EPA 4 g
might improve speed in the attention based measures. For Power of
Attention, there was an overall benefit versus the corresponding
placebo for 4 g on Day 42. The subtask Simple Reaction Time showed
improvements in performance for 4 g at PM 2 collapsed across days
and at several time-points on Days 14 and 42. The improvements for
4 g were most pronounced in the Choice Reaction Time task, where
there was an overall benefit versus corresponding placebo for 4 g,
reflecting a benefit for 4 g over placebo on all study days. The
pattern of improvement in performance throughout the assessment
days was quite convincing as the improvements began on Day 14 with
improvements seen at 2 time points, whereas on Day 42 ethyl-EPA 4 g
was superior to placebo at every time point.
[0330] For Continuity of Attention, there were isolated declines or
improvements in performance, but there was no general pattern of
effects and it was considered unlikely these differences were due
to the study compound. For Quality of Working Memory and in the
subtask measure Numeric Working Memory Sensitivity Index, there
were, as in the original analyses, only isolated improvements and
declines in performance that were most likely not
treatment-related. However, for Spatial Working Memory Sensitivity
Index, there was an overall benefit for ethyl-EPA 4 g over placebo
on Day 42 in the Study PP Population, which corresponds to the
improvements seen for the attention based measures.
[0331] For Quality of Episodic Secondary Memory and contributing
subtasks, there were a number of decreases for ethyl-EPA that could
be explained by the pre-existing differences in performance between
the placebo and active treatment groups which was seen in the
original analyses. In contrast to the original analysis, the
subtask measures of Speed of Memory showed some signs of
improvement in performance for active treatment, mostly for 1 g
versus placebo. For Self-rated Alertness and Self-rated
Contentment, the 1 g dose showed decreases in ratings on Days 14
and 28. However, these decreases were not correlated with a decline
in performance in the CDR attention tasks. As with the original
planned analysis, there were no differences between active
treatment and placebo in Self-Rated Calmness.
[0332] Safety Results.
[0333] Subjects who used less than 80% of the prescribed dose were
to be considered non-compliant; other than those subjects who
withdrew for other reasons only 1 subject fell into this category
and was withdrawn.
[0334] Overall, 139 treatment emergent AEs ("TEAEs") were reported
by 62 (66.0%) of subjects during the study. Most TEAEs were
considered mild in severity and unrelated to study drug. More TEAEs
were reported for the ethyl-EPA treatment groups (105 events)
compared to the placebo treatment groups (34 events). One SAE was
reported for the ethyl EPA 2 g treatment group and 3 subjects
discontinued due to TEAEs: 2 subjects from the ethyl-EPA 2 g
treatment group (the primary reason for discontinuation for 1 of
these subjects was non-compliance), and 1 subject from the placebo
2 g treatment group.
[0335] There were no deaths during the study. No TEAEs were
Definitely Related to the study drug. One subject receiving 1 g
ethyl-EPA experienced nausea that was Probably Related to the study
drug. Another subject receiving 4 g ethyl-EPA experienced diarrhea
that was Probably Related to the study drug; another subject
receiving 2 g placebo also experienced diarrhea that was Probably
Related to the study drug. Five subjects experienced nausea that
was Possibly Related to the study drug; two were in the 1 g
ethyl-EPA cohort; one was in the 2 g ethyl-EPA cohort; two were in
the 4 g ethyl-EPA cohort. One subject receiving 2 g placebo
experienced headache that was Possibly Related to the study drug.
All other TEAEs were Not Related or Unlikely Related to the study
drug, and included nasopharyngitis (n=3), cystitis (n=2), cough
(n=7), toothache (n=2), pharyngolaryngeal pain (n=2), back pain
(n=2), pollakiuria (n=2), influenza-like illness (n=2), headache
(n=15), diarrhea (n=2), and nausea (n=1).
[0336] One subject with a history of transient ischaemic attack,
hypertension and osteoarthritis of the hand and osteopaenia
receiving 2 g ethyl-EPA experienced worsening epigastric chest pain
17 days after the start of the study and 9 days after the last dose
of the study drug. A planned endoscopy revealed oesophagitis and a
small hiatus hernia. The subject was treated with omeprazole, which
settled her symptoms. The subject had taken felodipine,
rosuvastatin, aspirin, glucosamine, and quinine within 14 days of
the onset of her symptoms. The study investigator determined that
her symptoms were unrelated to the study drug and withdrew the
subject from the study. No other Serious Adverse Events occurred
during the study.
[0337] Essential fatty acid parameters in plasma and RBCs was
measured at baseline and on Day 14, 28 and 48 (shown in Tables
7-12).
TABLE-US-00007 TABLE 7 EFA Parameter EPA (Plasma and RBC) Mean
change from Baseline to Days 14, 28 and 42. EFA Ethyl-EPA Placebo
Parameter 1 g 2 g 4 g 1 g 2 g 4 g (.mu.g/g) (N = 23) (N = 24) (N =
24) (N = 7) (N = 8) (N = 8) Plasma Baseline: n 23 24 24 7 8 8 Mean
(SD) 48.3 (31.03) 44.9 (25.01) 49.1 (17.23) 47.5 (26.41) 42.1
(16.18) 42.5 (11.86) Day 14: n 23 22 24 7 7 8 Mean (SD) 61.2
(26.61) 124.6 (42.25) 207.7 (57.05) 1.6 (24.69) -1.2 (19.82) 21.9
(32.91) Day 28: n 22 22 24 7 7 8 Mean (SD) 60.3 (36.03) 142.2
(46.23) 215.2 (58.68) 6.5 (15.46) 1.6 (13.64) 1.3 (14.03) Day 42: n
23 22 24 7 7 8 Mean (SD) 62.0 (39.43) 133.4 (43.34) 204.6 (80.69)
11.9 (26.34) 0.4 (21.18) 4.4 (23.32) 1 or 2 g versus 4 g LS Mean
-111.8 -60.9 -- -- -- -- CI -123.6, -100.sup. -72.7, -49.0 -- -- --
-- p-value <0.001 <0.001 -- -- -- -- RBC Baseline: n 23 24 24
7 7 8 Mean (SD) 19.8 (10.85) 18.9 (8.91) 19.8 (5.28) 20.4 (5.77)
19.3 (6.58) 17.2 (4.94) Day 14: n 23 22 24 7 7 8 Mean (SD) 12.3
(7.39) 26.9 (9.15) 39.5 (13.16) -0.5 (6.32) 0.0 (7.17) 2.6 (6.73)
Day 28: n 22 22 24 7 7 8 Mean (SD) 14.5 (10.47) 32.9 (10.11) 50.2
(15.82) 1.5 (4.16) 0.0 (7.06) 0.6 (4.42) Day 42: n 23 22 24 7 7 8
Mean (SD) 17.6 (11.89) 38.3 (12.46) 52.5 (20.56) -0.2 (5.90) 1.0
(8.01) -0.2 (6.97) 1 or 2 g versus 4 g LS Mean -24.4 -11.8 -- -- --
-- CI -27.6, -21.2 -15.0, -8.6 -- -- -- -- p-value <0.001
<0.001 -- -- -- --
TABLE-US-00008 TABLE 8 EFA Parameter AA (Plasma and RBC) Mean
change from Baseline to Days 14, 28 and 42. EFA Ethyl-EPA Placebo
Parameter 1 g 2 g 4 g 1 g 2 g 4 g (.mu.g/g) (N = 23) (N = 24) (N =
24) (N = 7) (N = 8) (N = 8) Plasma Baseline: n 23 24 24 7 8 8 Mean
(SD) 202.5 (44.40) 227.3 (42.26) 220.9 (42.80) 210.7 (35.68) 191.6
(28.24) 248.0 (53.52) Day 14: n 23 22 24 7 7 8 Mean (SD) -9.7
(22.20) -13.9 (22.13) -27.2 (28.89) 0.8 (40.0) -14.4 (19.45) -5.9
(25.00) Day 28: n 22 22 24 7 7 8 Mean (SD) -11.3 (28.13) 21.6
(28.32) -43.7 (32.24) 3.8 (28.11) -7.4 (23.72) -16.4 (31.42) Day
42: n 23 22 24 7 7 8 Mean (SD) -8.7 (31.35) -27.3 (26.76) -48.3
(22.20) 8.2 (20.30) -11.5 (20.88) -11.0 (25.82) 1 or 2 g versus 4 g
LS Mean 4.2 15.6 -- -- -- -- CI -8.0, 16.4 3.4, 27.8 -- -- -- --
p-value 0.496 0.013 -- -- -- -- RBC Baseline: n 23 24 24 7 8 8 Mean
(SD) 171.2 (19.79) 172.8 (22.79) 171.0 (25.17) 176.4 (17.65) 152.8
(17.36) 180.4 (23.68) Day 14: n 23 22 24 7 7 8 Mean (SD) -8.1
(21.95) -3.1 (25.84) -15.7 (26.76) -8.5 (22.75) 3.0 (18.20) -8.1
(27.53) Day 28: n 22 22 24 7 7 8 Mean (SD) -17.0 (20.69) -14.1
(26.89) -22.8 (29.56) 5.2 (22.95) -2.6 (17.78) -8.2 (26.89) Day 42:
n 23 22 24 7 7 8 Mean (SD) -14.2 (27.69) -18.8 (25.62) -34.4
(31.44) -9.8 (21.59) 9.7 (16.58) -10.6 (33.49) 1 or 2 g versus 4 g
LS Mean 8.4 9.8 -- -- -- -- CI 2.0, 14.9 3.3, 16.2 -- -- -- --
p-value 0.010 0.003 -- -- -- --
TABLE-US-00009 TABLE 9 EFA Parameter DHA (Plasma and RBC) Mean
change from Baseline to Days 14, 28 and 42. EFA Ethyl-EPA Placebo
Parameter 1 g 2 g 4 g 1 g 2 g 4 g (.mu.g/g) (N = 23) (N = 24) (N =
24) (N = 7) (N = 8) (N = 8) Plasma Baseline: n 23 24 24 7 8 8 Mean
(SD) 73.1 (30.43) 75.1 (24.02) 78.8 (19.00) 73.7 (14.21) 73.3
(27.74) 76.7 (15.68) Day 14: n 23 22 24 7 7 8 Mean (SD) -6.4
(13.30) -5.4 (14.29) -10.3 (13.35) 0.4 (18.16) -0.8 (14.28) 13.8
(21.05) Day 28: n 22 22 24 7 7 8 Mean (SD) -6.6 (15.53) -8.1
(15.82) -13.5 (14.10) 4.7 (16.31) -0.6 (8.29) 6.0 (17.36) Day 42: n
23 22 24 7 7 8 Mean (SD) -5.4 (18.17) -6.0 (16.69) -13.8 (15.31)
11.8 (21.27) 0.8 (17.57) 6.2 (13.40) 1 or 2 g versus 4 g LS Mean
-0.8 1.5 -- -- -- -- CI -7.3, 5.7 -5.0, 8.1 -- -- -- -- p-value
0.810 0.644 -- -- -- -- RBC Baseline: n 23 24 24 7 8 8 Mean (SD)
66.5 (18.65) 64.8 (17.65) 68.3 (14.24) 71.1 (7.48) 66.0 (15.90)
66.2 (15.83) Day 14: n 23 22 24 7 7 8 Mean (SD) -4.6 (9.76) -2.0
(9.46) -6.9 (9.13) -5.5 (11.93) -0.2 (12.39) -0.4 (12.50) Day 28: n
22 22 24 7 7 8 Mean (SD) -6.4 (11.57) -6.2 (9.34) -8.7 (11.63) 0.6
(12.86) -0.3 (11.29) 1.1 (12.54) Day 42: n 23 22 24 7 7 8 Mean (SD)
-7.0 (12.20) -6.3 (9.42) -13.8 (13.76) -4.1 (12.02) 4.6 (12.94)
-0.1 (17.63) 1 or 2 g versus 4 g LS Mean 1.0 1.0 -- -- -- -- CI
-3.5, 5.4 -3.5, 5.5 -- -- -- -- p-value 0.674 0.664 -- -- -- --
TABLE-US-00010 TABLE 10 EFA Parameter DPAn-3 (Plasma and RBC) Mean
change from Baseline to Days 14, 28 and 42. EFA Ethyl-EPA Placebo
Parameter 1 g 2 g 4 g 1 g 2 g 4 g (.mu.g/g) (N = 23) (N = 24) (N =
24) (N = 7) (N = 8) (N = 8) Plasma Baseline: n 23 24 24 7 8 8 Mean
(SD) 21.1 (6.62) 19.7 (4.50) 21.7 (4.69) 17.9 (5.18) 18.0 (4.39)
19.0 (2.67) Day 14: n 23 22 24 7 7 8 Mean (SD) 7.5 (5.11) 17.4
(7.49) 24.5 (11.28) -0.2 (3.13) -1.0 (3.59) 2.2 (4.98) Day 28: n 22
22 24 7 7 8 Mean (SD) 8.9 (5.62) 19.4 (8.48) 29.7 (13.23) 1.2
(2.06) 0.6 (3.44) 1.3 (3.40) Day 42: n 23 22 24 7 7 8 Mean (SD)
11.3 (6.61) 19.3 (8.63) 32.0 (16.01) 2.2 (3.29) 0.1 (3.61) 0.8
(6.70) 1 or 2 g versus 4 g LS Mean -15.1 -9.5 -- -- -- -- CI -17.6,
-12.7 -12.0, -7.1 -- -- -- -- p-value <0.001 <0.001 -- -- --
-- RBC Baseline: n 23 24 24 7 8 8 Mean (SD) 34.1 (5.43) 33.2 (4.51)
34.5 (4.34) 34.0 (4.27) 33.0 (1.20) 32.4 (2.41) Day 14: n 23 22 24
7 7 8 Mean (SD) 0.9 (5.03) 5.6 (6.28) 5.4 (5.38) -2.8 (4.86) -0.3
(4.96) -0.9 (4.74) Day 28: n 22 22 24 7 7 8 Mean (SD) 3.3 (5.42)
9.4 (6.74) 12.4 (6.98) 0.1 (4.51) -0.8 (4.03) -0.6 (5.19) Day 42: n
23 22 24 7 7 8 Mean (SD) 6.5 (6.19) 13.2 (7.23) 16.2 (10.07) -1.8
(4.64) 2.2 (4.44) -0.9 (6.03) 1 or 2 g versus 4 g LS Mean -6.2 -2.5
-- -- -- -- CI -7.8, -4.7 -4.1, -1.0 -- -- -- -- p-value <0.001
0.002 -- -- -- --
TABLE-US-00011 TABLE 11 EFA Parameter DGLA (Plasma and RBC) Mean
change from Baseline to Days 14, 28 and 42. EFA Ethyl-EPA Placebo
Parameter 1 g 2 g 4 g 1 g 2 g 4 g (.mu.g/g) (N = 23) (N = 24) (N =
24) (N = 7) (N = 8) (N = 8) Plasma Baseline: n 23 24 24 7 8 7 Mean
(SD) 51.2 (15.01) 53.5 (14.12) 57.1 (14.73) 51.6 (9.20) 41.6
(10.30) 52.6 (7.74) Day 14: n 23 22 24 7 7 8 Mean (SD) -10.4
(10.90) -14.1 (6.88) -22.9 (9.00) -4.1 (8.07) -0.0 (8.63) -1.0
(11.58) Day 28: n 22 22 24 7 7 8 Mean (SD) -10.6 (10.23) -16.2
(9.88) -24.2 (10.73) -4.6 (7.43) -0.6 (5.91) 1.5 (11.78) Day 42: n
23 22 24 7 7 8 Mean (SD) -9.4 (9.41) -17.3 (9.92) -22.5 (10.87)
-3.9 (12.90) 0.9 (9.34) 0.8 (11.04) 1 or 2 g versus 4 g LS Mean 3.7
2.5 -- -- -- -- CI 0.4, 7.0 -0.9, 5.8 -- -- -- -- p-value 0.028
0.143 -- -- -- -- RBC Baseline: n 23 24 24 7 8 7 Mean (SD) 23.0
(5.19) 23.0 (5.76) 24.0 (5.77) 22.4 (5.06) 19.7 (5.87) 22.4 (4.91)
Day 14: n 23 22 24 7 7 8 Mean (SD) -2.7 (3.82) -2.6 (3.54) -5.3
(4.10) -1.5 (2.08) 0.2 (1.76) -1.8 (4.00) Day 28: n 22 22 24 7 7 8
Mean (SD) -3.8 (3.31) -4.5 (3.58) -7.1 (4.63) 0.2 (3.63) -0.7
(4.06) -0.7 (3.81) Day 42: n 23 22 24 7 7 8 Mean (SD) -3.5 (4.51)
-5.3 (3.65) -8.0 (4.98) -1.6 (4.93) 1.9 (3.61) -1.1 (5.31) 1 or 2 g
versus 4 g LS Mean 1.5 1.5 -- -- -- -- CI 0.2, 2.9 0.1, 2.9 -- --
-- -- p-value 0.027 0.032 -- -- -- --
TABLE-US-00012 TABLE 12 EFA Parameter EPA/AA (Plasma and RBC) Mean
change from Baseline to Days 14, 28 and 42. Ethyl-EPA Placebo 1 g 2
g 4 g 1 g 2 g 4 g EFA Parameter (N = 23) (N = 24) (N = 24) (N = 7)
(N = 8) (N = 8) Plasma Baseline: n 23 24 24 7 8 8 Mean (SD) 0.2
(0.14) 0.2 (0.12) 0.2 (0.07) 0.2 (0.11) 0.2 (0.10) 0.2 (0.07) Day
14: n 23 22 24 7 7 8 Mean: (SD) 0.3 (0.4) 0.6 (0.23) 1.1 (0.28) 0.0
(0.09) 0.0 (0.12) 0.1 (0.12) Day 28: n 22 22 24 7 7 8 Mean (SD) 0.3
(0.20) 0.8 (0.35) 1.3 (0.42) 0.0 (0.08) 0.0 (0.09) 0.0 (0.06) Day
42: n 23 22 24 7 7 8 Mean (SD) 0.3 (0.24) 0.7 (0.29) 1.3 (0.45) 0.0
(0.10) 0.0 (0.12) 0.0 (0.08) 1 or 2 g versus 4 g LS Mean -0.66
-0.41 -- -- -- -- CI -0.731, -0597 -0.475, -0.341 -- -- -- --
p-value <0.001 <0.001 -- -- -- -- RBC Baseline: n 23 24 24 7
8 8 Mean (SD) 0.1 (0.07) 0.1 (0.06) 0.1 (0.04) 0.1 (0.04) 0.1
(0.06) 0.1 (0.03) Day 14: n 23 22 24 7 7 8 Mean (SD) 0.1 (0.04) 0.2
(0.04) 0.3 (0.07) 0.0 (0.03) -0.0 (0.05) 0.0 (0.03) Day 28: n 22 22
24 7 7 8 Mean (SD) 0.1 (0.05) 0.02 (0.06) 0.4 (0.11) 0.0 (0.01)
-0.0 (0.04) 0.0 (0.02) Day 42: n 23 22 24 7 7 8 Mean (SD) 0.1
(0.06) 0.3 (0.06) 0.4 (0.14) 0.0 (0.03) -0.0 (0.05) 0.0 (0.03) 1 or
2 g versus 4 g LS Mean -0.18 -0.11 -- -- -- -- CI -0.204, -0.162
-0.126, -0.085 -- -- -- -- p-value <0.001 <0.001 -- -- --
--
[0338] Notable changes for these parameters occurred in the
ethyl-EPA treatment groups at Days 14, 28 and 42 compared to
placebo. EPA, DPAn-3 and EPA/AA ratio values increased
substantially from baseline, in plasma and RBC, to Day 42 for the
ethyl-EPA 1, 2 and 4 g treatment groups, but remained similar to
baseline in the placebo treatment groups. AA, DHA and DGLA values
decreased substantially from baseline, in plasma and RBC, to day 42
for the ethyl EPA 1, 2 and 4 g treatment groups, but remained
similar to baseline in the placebo treatment groups. The difference
in EPA, AA (RBC only), DPAn-3, DGLA (1 g only for plasma) and
EPA/AA ratio levels in the plasma and RBC were significantly (LS
means, p.ltoreq.0.05) different for the ethyl-EPA 4 g treatment
group compared to the ethyl-EPA 1 g and 2 g treatment groups.
Example 3
Ethyl Eicosapentaenoic Acid in Subjects Having Fasting
Triglycerides of at Least 500 mg/dL
[0339] A multi-center, placebo-controlled randomized, double-blind,
12-week study with an open-label extension is performed to evaluate
the efficacy and safety of AMR101 in patients with fasting
triglyceride levels .gtoreq.500 mg/dL. The primary objective of the
study is to determine the efficacy of AMR101 2 g daily and 4 g
daily, compared to placebo, in lowering fasting TG levels in
patients with fasting TG levels .gtoreq.500 mg/dL and .ltoreq.1500
mg/dL (.gtoreq.5.65 mmol/L and 16.94 mmol/L).
[0340] The secondary objectives of this study are the following:
[0341] To determine the safety and tolerability of AMR101 2 g daily
and 4 g daily; [0342] To determine the effect of AMR101 on lipid
and apolipoprotein profiles; [0343] To determine the effect of
AMR101 on low-density lipoprotein (LDL) particle number and size;
[0344] To determine the effect of AMR101 on oxidized LDL; [0345] To
determine the effect of AMR101 on fasting plasma glucose (FPG) and
hemoglobin A.sub.1c (HbA.sub.1c); [0346] To determine the effect of
AMR101 on insulin resistance; [0347] To determine the effect of
AMR101 on high-sensitivity C-reactive protein (hsCRP); [0348] To
determine the effects of AMR101 2 g daily and 4 g daily on the
incorporation of fatty acids into red blood cell membranes and into
plasma phospholipids; [0349] To explore the relationship between
baseline fasting TG levels and the reduction in fasting TG levels;
and [0350] To explore the relationship between an increase in red
blood cell membrane eicosapentaenoic acid (EPA) concentrations and
the reduction in fasting TG levels.
[0351] The population for this study is men and women (women of
childbearing potential will need to be on contraception or practice
abstinence) >18 years of age with a body mass index .ltoreq.45
kg/m.sup.2 who are not on lipid-altering therapy or are currently
on lipid-altering therapy. Patients currently on statin therapy
(with or without ezetimibe) will be evaluated by the investigator
as to whether this therapy can be safely discontinued at screening,
or if it should be continued. If statin therapy (with or without
ezetimibe) is to be continued, dose(s) must be stable for .gtoreq.4
weeks prior to randomization. Patients taking non-statin,
lipid-altering medications (niacin >200 mg/day, fibrates, fish
oil, other products containing omega-3 fatty acids, or other herbal
products or dietary supplements with potential lipid-altering
effects), either alone or in combination with statin therapy (with
or without ezetimibe), must be able to safely discontinue
non-statin, lipid-altering therapy at screening.
[0352] Approximately 240 patients will be randomized at
approximately 50 centers in North America, South America, Central
America, Europe, India, and South Africa. The study will be a 58-
to 60-week, Phase 3, multi-center study consisting of 3 study
periods: (1) A 6- to 8-week screening period that includes a diet
and lifestyle stabilization and washout period and a TG qualifying
period; (2) A 12-week, double-blind, randomized, placebo-controlled
treatment period; and (3) A 40-week, open-label, extension
period.
[0353] During the screening period and double-blind treatment
period, all visits are to be within .+-.3 days of the scheduled
time. During the open-label extension period, all visits are to be
within .+-.7 days of the scheduled time. The screening period
includes a 4- or 6-week diet and lifestyle stabilization period and
washout period followed by a 2-week TG qualifying period. s) must
be stable for weeks prior to randomization.
[0354] The screening visit (Visit 1) will occur for all patients at
either 6 weeks (for patients not on lipid-altering therapy at
screening or for patients who will not need to discontinue their
current lipid-altering therapy) or 8 weeks (for patients who will
require washout of their current lipid-altering therapy at
screening) before randomization, as follows:
[0355] Patients who do not require a washout: The screening visit
will occur at Visit 1 (Week -6). Eligible patients will enter a
4-week diet and lifestyle stabilization period. At the screening
visit, all patients will receive counseling regarding the
importance of the National Cholesterol Education Program (NCEP)
Therapeutic Lifestyle Changes (TLC) diet and will receive
instructions on how to follow this diet. Patients who will require
a washout: The screening visit will occur at Visit 1 (Week -8).
Eligible patients will begin a 6-week washout period at the
screening visit. Patients will receive counseling regarding the
NCEP TLC diet and will receive instructions on how to follow this
diet. Site personnel will contact patients who do not qualify for
participation based on screening laboratory test results to
instruct them to resume their prior lipid-altering medications.
[0356] At the end of the 4-week diet and lifestyle stabilization
period or the 6-week diet and stabilization and washout period,
eligible patients will enter the 2-week TG qualifying period and
will have their fasting TG level measured at Visit 2 (Week -2) and
Visit 3 (Week -1). Eligible patients must have an average fasting
TG level 500 mg/dL and 1500 mg/dL (.gtoreq.5.65 mmol/L and
.ltoreq.16.94 mmol/L) to enter the 12-week double-blind treatment
period. The TG level for qualification will be based on the average
(arithmetic mean) of the Visit 2 (Week -2) and Visit 3 (Week -1)
values. If a patient's average TG level from Visit 2 and Visit 3
falls outside the required range for entry into the study, an
additional sample for fasting TG measurement can be collected 1
week later at Visit 3.1. If a third sample is collected at Visit
3.1, entry into the study will be based on the average (arithmetic
mean) of the values from Visit 3 and Visit 3.1.
[0357] After confirmation of qualifying fasting TG values, eligible
patients will enter a 12-week, randomized, double-blind treatment
period. At Visit 4 (Week 0), patients will be randomly assigned to
1 of the following treatment groups: [0358] AMR101 2 g daily,
[0359] AMR101 4 g daily, or [0360] Placebo.
[0361] During the double-blind treatment period, patients will
return to the site at Visit 5 (Week 4), Visit 6 (Week 11), and
Visit 7 (Week 12) for efficacy and safety evaluations.
[0362] Patients who complete the 12-week double-blind treatment
period will be eligible to enter a 40-week, open-label, extension
period at Visit 7 (Week 12). All patients will receive open-label
AMR101 4 g daily. From Visit 8 (Week 16) until the end of the
study, changes to the lipid-altering regimen are permitted (e.g.,
initiating or raising the dose of statin or adding non-statin,
lipid-altering medications to the regimen), as guided by standard
practice and prescribing information. After Visit 8 (Week 16),
patients will return to the site every 12 weeks until the last
visit at Visit 11 (Week 52).
[0363] Eligible patients will be randomly assigned at Visit 4 (Week
0) to receive orally AMR101 2 g daily, AMR101 4 g daily, or placebo
for the 12-week double-blind treatment period. AMR101 is provided
in 1 g liquid-filled, oblong, gelatin capsules. The matching
placebo capsule is filled with light liquid paraffin and contains 0
g of AMR101. During the double-blind treatment period, patients
will take 2 capsules (AMR101 or matching placebo) in the morning
and 2 in the evening for a total of 4 capsules per day. Patients in
the AMR101 2 g/day treatment group will receive 1 AMR101 1 g
capsule and 1 matching placebo capsule in the morning and in the
evening. Patients in the AMR101 4 g/day treatment group will
receive 2 AMR101 1 g capsules in the morning and evening.
[0364] Patients in the placebo group will receive 2 matching
placebo capsules in the morning and evening. During the extension
period, patients will receive open-label AMR101 4 g daily. Patients
will take 2 AMR101 1 g capsules in the morning and 2 in the
evening.
[0365] The primary efficacy variable for the double-blind treatment
period is percent change in TG from baseline to Week 12 endpoint.
The secondary efficacy variables for the double-blind treatment
period include the following: [0366] Percent changes in total
cholesterol (TC), high-density lipoprotein cholesterol (HDL-C),
calculated low-density lipoprotein cholesterol (LDL-C), calculated
non-high-density lipoprotein cholesterol (non-HDL-C), and very
low-density lipoprotein cholesterol (VLDL-C) from baseline to Week
12 endpoint; [0367] Percent change in very low-density lipoprotein
TG from baseline to Week 12; [0368] Percent changes in
apolipoprotein A-I (apo A-I), apolipoprotein B (apo B), and apo
A-I/apo B ratio from baseline to Week 12; [0369] Percent changes in
lipoprotein(a) from baseline to Week 12 (selected sites only);
[0370] Percent changes in LDL particle number and size, measured by
nuclear magnetic resonance, from baseline to Week 12 (selected
sites only); [0371] Percent change in remnant-like particle
cholesterol from baseline to Week 12 (selected sites only); [0372]
Percent change in oxidized LDL from baseline to Week 12 (selected
sites only); [0373] Changes in FPG and HbA.sub.1c from baseline to
Week 12; [0374] Change in insulin resistance, as assessed by the
homeostasis model index insulin resistance, from baseline to Week
12; [0375] Percent change in lipoprotein associated phospholipase
A2 from baseline to Week 12 (selected sites only); [0376] Change in
intracellular adhesion molecule-1 from baseline to Week 12
(selected sites only); [0377] Change in interleukin-6 from baseline
to Week 12 (selected sites only); [0378] Change in plasminogen
activator inhibitor-1 from baseline to Week 12 (selected sites
only); [0379] Change in hsCRP from baseline to Week 12 (selected
sites only); [0380] Change in serum phospholipid EPA content from
baseline to Week 12; [0381] Change in red blood cell membrane EPA
content from baseline to Week 12; and [0382] Change in serum
phospholipid and red blood cell membrane content in the following
fatty acids from baseline to Week 12: docosapentaenoic acid,
docosahexaenoic acid, arachidonic acid, palmitic acid, stearic
acid, and oleic acid.
[0383] The efficacy variable for the open-label extension period is
percent change in fasting TG from extension baseline to end of
treatment. Safety assessments will include adverse events, clinical
laboratory measurements (chemistry, hematology, and urinalysis),
12-lead electrocardiograms (ECGs), vital signs, and physical
examinations
[0384] For TG, TC, HDL-C, calculated LDL-C, calculated non-HDL-C,
and VLDL-C, baseline will be defined as the average of Visit 4
(Week 0) and the preceding lipid qualifying visit (either Visit 3
[Week -1] or if it occurs, Visit 3.1) measurements. Baseline for
all other efficacy parameters will be the Visit 4 (Week 0)
measurement.
[0385] For TC, HDL-C, calculated LDL-C, calculated non-HDL-C, and
VLDL-C, Week 12 endpoint will be defined as the average of Visit 6
(Week 11) and Visit 7 (Week 12) measurements. Week 12 endpoint for
all other efficacy parameters will be the Visit 7 (Week 12)
measurement.
[0386] The primary efficacy analysis will be performed using a
2-way analysis of covariance (ANCOVA) model with treatment as a
factor and baseline TG value as a covariate. The least-squares
mean, standard error, and 2-tailed 95% confidence interval for each
treatment group and for each comparison will be estimated. The same
2-way ANCOVA model will be used for the analysis of secondary
efficacy variables.
[0387] The primary analysis will be repeated for the per-protocol
population to confirm the robustness of the results for the
intent-to-treat population.
[0388] The primary efficacy variable will be the percent change in
fasting TG levels from baseline to Week 12. A sample size of 69
completed patients per treatment group will provide .gtoreq.90%
power to detect a difference of 30% between AMR101 and placebo in
percent change from baseline in fasting TG levels, assuming a
standard deviation of 45% in TG measurements and a significance
level of p<0.01. To accommodate a 15% drop-out rate from
randomization to completion of the double-blind treatment period, a
total of 240 randomized patients is planned (80 patients per
treatment group).
[0389] Results
[0390] Of the 229 randomized subjects, 224 were in the
intent-to-treat ("ITT") population as follows: [0391] Ultra-pure
EPA, 4 g/day: 76 subjects [0392] Ultra-pure EPA, 2 g/day: 73
subjects [0393] Placebo: 75 subjects
[0394] Lipids were extracted from plasma and RBC suspensions and
converted into fatty acid methyl esters for analysis using a
standard validated gas chromatography/flame ionization detection
method. Fatty acid parameters were compared between EPA treatment
groups and placebo using an ANCOVA model with treatment, gender,
type of statin therapy, and presence of diabetes as factors, and
the baseline parameter value as a covariate. LSMs, SEs, and
2-tailed 95% confidence intervals for each treatment group and for
each comparison were determined.
[0395] Baseline characteristics of the three ITT groups were
comparable, with 76% of the ITT subjects being male, 88% being
white, having a mean age of 52.9 years, a weight of 95.7 kg and a
BMI of 30.8 kg/m.sup.2. The median triglyceride level of the ITT
subjects was 679.5 mg/dl. ITT subjects with incomplete fatty acid
data at baseline and/or at 12 weeks were excluded from the analyses
described below (as reflected in the n numbers shown in Tables
1-3).
[0396] As shown in Table 13, ultra-pure EPA at 2 g/day and 4 g/day
both significantly increased mean placebo-adjusted plasma
concentrations of EPA, docosapentaenoic acid m-3 ("DPAn-3"), and
the ratio of total omega-3 to omega-6 fatty acids ("Ratio of
n-3/n-6 FA"). In addition, both 2 g/day and 4 g/day doses of
ultra-pure EPA significantly decreased mean placebo-adjusted plasma
concentrations of arachidonic acid, palmitic acid, stearic acid,
oleic acid, linoleic acid, and the plasma ratio of arachidonic acid
to EPA. Neither dose of ultra-pure EPA produced a significant
change in mean placebo-adjusted plasma concentration of DHA.
TABLE-US-00013 TABLE 13 Icosapent ethyl (IPE): change from baseline
to week 12 in plasma fatty acid concentrations and ratios. IPE 4
g/day (n = 76) IPE 2 g/day (n = 73) Change Change Base- End-of-
from Base- End-of- from line treatment baseline line treatment
baseline (SD) (SD) (SE) (SD) (SD) (SE) EPA 50.4 279.8 233.0 50.0
157.5 111.8 n = 48, 53, 44 (52.0) (161.3) (15.1) (45.5) (71.0)
(14.4) DHA 125.5 118.1 -4.5 118.2 104.8 -13.1 n = 48, 55, 46 (93.1)
(81.6) (6.6) (67.1) (43.5) (6.2) DPAn-3 37.5 91.1 54.6 38.0 73.4
36.7 n = 46, 56, 47 (20.8) (43.7) (4.3) (19.1) (26.0) (3.9) AA
359.0 280.3 -76.2 368.6 327.3 -36.7 n = 47, 56, 48 (119.6) (93.9)
(11.3) (121.4) (101.4) (10.6) Palmitic 2287 1789 -560 2297 2015
-353 n = 44, 54, 48 (1344.1) (1006.9) (138.1) (1070.9) (661.3)
(126.9) Stearic 599.5 500.3 -101 577.9 541.5 -57.8 n = 47, 55, 47
(317.6) (239.7) (35.4) (229.7) (165.2) (33.3) Oleic 2353 1885 -546
2322 2018 -414 n = 46, 55, 46 (1499.9) (1130.3) (154.0) (1246.1)
(837.7) (142.9) Linoleic 2098 1882 -309 2113 1981 -227 n = 47, 54,
48 (872.3) (910.8) (128.1) (934.8) (775.1) (121.4) Ratio of 12.3
1.2 -10.8 11.4 2.3 -9.6 AA/EPA (7.9) (0.9) (0.5) (6.0) (1.4) (0.5)
n = 45, 53, 41 Ratio of 0.11 0.24 0.4 0.11 0.17 0.07 n-3/n-6 FA
(0.050) (0.090) (0.009) (0.062) (0.071) (0.009) n = 49, 55, 46 Mean
placebo-adjusted percent change from Placebo (n = 75) baseline
Change IPE 4 g/ IPE 2 g/ Base- End-of- from day vs day vs line
treatment baseline placebo, placebo, (SD) (SD) (SE) %, P %, P EPA
41.0 37.4 1.4 792.0 402.3 n = 48, 53, 44 (22.4) (24.3) (15.8)
<0.0001 <0.0001 DHA 112.2 113.4 -0.7 2.4 -2.3 n = 48, 55, 46
(56.5) (63.6) (6.8) 0.7115 0.7217 DPAn-3 36.7 39.4 4.1 150.8 107.2
n = 46, 56, 47 (13.2) (15.6) (4.3) <0.0001 <0.0001 AA 338.7
361.0 17.8 -26.8 -16.4 n = 47, 56, 48 (95.7) (121.4) (11.3)
<0.0001 <0.0001 Palmitic 2418 2687 252.1 -34.4 -23.9 n = 44,
54, 48 (1107.2) (1306.6) (135.4) 0.0001 0.0011 Stearic 646.4 709.9
79.6 -28.4 -20.7 n = 47, 55, 47 (306.5) (359.0) (36.0) 0.0002
0.0040 Oleic 2653 2878 274.9 -31.9 -23.8 n = 46, 55, 46 (1460.3)
(1616.0) (156.7) 0.0001 0.0023 Linoleic 2374 2521 167.3 -23.7 -15.2
n = 47, 54, 48 (1178.7) (1174.6) (129.0) 0.0003 0.0136 Ratio of
11.1 12.2 0.4 -99.4 -88.4 AA/EPA (5.7) (6.0) (0.5) <0.0001
<0.0001 n = 45, 53, 41 Ratio of 0.10 0.10 0.00 145.8 76.8
n-3/n-6 FA (0.036) (0.044) (0.010) <0.0001 <0.0001 n = 49,
55, 46
[0397] Mean and standard deviation are reported in Table 13 for
baseline and end-of-treatment values; least squares mean and
standard error are reported for changes from baseline and
placebo-adjusted changes from baseline. Abbreviations for Table 13:
AA=arachidonic acid; DHA=docosahexaenoic acid;
DPAn-3=docosahexaenoic acid (omega-3); EPA=eicosapentaenoic acid;
n-3/n-6 FA=ratio of total omega-3 fatty acids to total omega-6
fatty acids.
[0398] As shown in Table 14, ultra-pure EPA at 2 g/day and 4 g/day
both significantly increased mean placebo-adjusted concentrations
of EPA, DPAn-3, and the ratio of total omega-3 to omega-6 fatty
acids ("Ratio of n-3/n-6 FA") in RBCs. In addition, both 2 g/day
and 4 g/day doses of ultra-pure EPA significantly decreased mean
placebo-adjusted RBC concentrations of arachidonic acid and the RBC
ratio of arachidonic acid to EPA. The RBC concentration of linoleic
acid significantly decreased over placebo for subjects in the 4
g/day EPA group. Neither dose of ultra-pure EPA produced a
significant change in mean placebo-adjusted RBC concentrations of
DHA.
TABLE-US-00014 TABLE 14 Icosapent ethyl (IPE): change from baseline
to week 12 in red blood cell fatty acid concentrations and ratios.
Mean placebo-adjusted percent change from IPE 4 g/day (n = 76) IPE
2 g/day (n = 73) Placebo (n = 75) baseline Change Change Change IPE
4 g/ IPE 2 g/ Base- End-of- from Base- End-of- from Base- End-of-
from day vs day vs line treatment baseline line treatment baseline
line treatment baseline placebo, placebo, (SD) (SD) (SE) (SD) (SD)
(SE) (SD) (SD) (SE) %, P %,P EPA 11.4 50.2 39.4 10.1 32.8 23.3 10.1
8.2 -1.1 489.6 297.7 n = 50, 56, 45 (6.9) (18.0) (2.0) (5.6) (14.7)
(1.9) (5.7) (5.2) (2.1) <0.0001 <0.0001 DHA 62.1 51.7 -9.7
58.3 51.5 -7.3 60.1 54.4 -5.6 -5.2 -1.8 n = 48, 52, 43 (20.0)
(16.6) (1.6) (17.1) (14.6) (1.5) (21.3) (19.6) (1.7) 0.1216 0.5859
DPAn-3 28.9 56.9 27.7 28.2 49.8 21.6 29.0 27.0 -2.4 105.6 86.4 n =
48, 53, 40 (5.7) (14.3) (1.5) (6.9) (12.3) (1.4) (4.5) (4.8) (1.6)
<0.0001 <0.0001 AA 186.1 148.8 -36.2 179.9 160.3 -20.9 176.0
171.4 -7.6 -15.7 -8.0 n = 47, 53, 44 (34.6) (25.2) (3.4) (34.7)
(33.5) (3.2) (27.2) (25.5) (3.5) <0.0001 0.0008 Palmitic 346.1
340.6 -5.8 344.1 341.7 -2.9 341.5 341.2 -1.4 -0.7 -0.1 n = 48, 53,
44 (44.5) (42.6) (5.7) (45.1) (51.9) (5.4) (37.7) (53.3) (6.0)
0.7427 0.9465 Stearic 186.5 178.1 -8.2 181.1 179.0 -4.7 179.8 176.6
-6.5 -0.7 1.1 n = 50, 55, 46 (30.6) (24.8) (3.1) (25.7) (25.0)
(2.9) (23.9) (21.4) (3.2) 0.7565 0.5886 Oleic 215.5 208.3 -5.6
216.0 213.0 -1.4 210.3 214.7 4.8 -3.7 -2.1 n = 48, 50, 42 (45.0)
(37.1) (4.1) (44.5) (39.5) (4.1) (35.3) (46.3) (4.4) 0.1325 0.3736
Linoleic 188.7 164.7 -25.0 176.3 169.6 -10.7 186.6 187.6 -0.9 -13.0
-4.7 n = 46, 53, 43 (40.6) (40.8) (4.9) (38.5) (42.5) (4.7) (32.4)
(42.3) (5.1) <0.0001 0.1278 Ratio of 22.6 3.1 -19.9 22.2 5.2
-17.7 24.1 25.7 2.4 -102 -91.1 AA/EPA (12.4) (1.6) (1.0) (10.5)
(2.0) (0.9) (15.4) (13.3) (1.0) <0.0001 <0.0001 n = 48, 54,
44 Ratio of 0.22 0.42 0.20 0.22 0.33 0.12 0.22 0.20 -0.01 106.9
65.5 n-3/n-6 FA (0.072) (0.114) (0.011) (0.068) (0.102) (0.010)
(0.076) (0.072) (0.012) <0.0001 <0.0001 n = 50, 56, 43
[0399] Mean and standard deviation are reported in Table 14 for
baseline and end-of-treatment values; least-squares mean and
standard error are reported for changes from baseline and
placebo-adjusted changes from baseline. Abbreviations for Table 14:
AA=arachidonic acid; DHA=docosahexaenoic acid;
DPAn-3=docosahexaenoic acid (omega-3); EPA=eicosapentaenoic acid;
n-3/n-6 FA=ratio of total omega-3 fatty acids to total omega-6
fatty acids.
[0400] Table 15 shows changes from baseline and placebo-adjusted
percent changes from baseline in the proportion (mol %) of fatty
acid classes to total fatty acids in both plasma and in RBCs. The
monounsaturated fatty acid group included myristoleic, palmitoleic,
cis-vaccenic, oleic, gondoic/gadoleic, erucic and nervonic acids.
The saturated fatty acid group included myristic, palmitic,
stearic, arachidic, behenic and lignoceric acids. The "total
omega-3" group included .alpha.-linolenic, stearidonic,
eicosatrienoic, .omega.-3 arachidonic, eicosapentaenoic, .omega.-3
docosapentaenoic and docosahecaenoic acids. The "total omega-6"
group included linoleic, .gamma.-linolenic, eicosadienoic,
dihomo-.gamma.-linolenic, .omega.-6 arachidonic, adrenic, and
.omega.-6 docosapentaenoic acids. The "total fatty acid" group
represented the sum of the monounsaturated, saturated, total
omega-3 and total omega-6 groups. Treatment with 2 g/day or 4 g/day
ultra-pure EPA resulted in an increased proportion of omega-3 fatty
acids in plasma and in RBCs compared to placebo, and a decreased
proportion of omega-6 fatty acids in plasma compared to placebo.
Treatment with 2 g/day or 4 g/day ultra-pure EPA also resulted in a
decreased proportion of monounsaturated fatty acids in plasma and
RBCs compared to placebo. Neither dose induced significant changes
in the proportion of saturated fatty acids in plasma or in
RBCs.
TABLE-US-00015 TABLE 15 Icosapent ethyl: placebo-adjusted percent
change in the proportion of fatty acid classes to total.sup.a fatty
acids. Mean placebo-adjusted percent change from IPE 4 g/day (n =
76) IPE 2 g/day (n = 73) Placebo (n = 75) baseline Change Change
Change IPE 4 g/ IPE 2 g/ Base- End-of- from Base- End-of- from
Base- End-of- from day vs day vs line treatment baseline line
treatment baseline line treatment baseline placebo, placebo, (SD)
(SD) (SE) (SD) (SD) (SE) (SD) (SD) (SE) %, P %, P Plasma Saturated
35.9 34.8 -1.2 36.2 35.8 -0.3 35.6 35.7 -0.2 -2.8 -0.4 n = 49, 56,
49 (3.9) (3.5) (0.5) (3.8) (3.7) (0.5) (3.0) (3.2) (0.5) 0.1049
0.8076 Monounsaturated 30.1 28.7 -1.7 30.7 29.5 -1.4 31.4 32.3 0.9
-7.7 -7.4 n = 49, 56, 49 (5.3) (4.0) (0.5) (5.1) (4.9) (0.5) (4.7)
(5.2) (0.5) 0.0008 0.0009 Total omega-6 30.8 29.8 -0.9 30.0 29.8
-0.2 30.0 29.1 -0.9 0.5 3.2 n = 49, 56, 49 (7.2) (6.2) (0.7) (7.1)
(6.8) (0.7) (5.8) (5.4) (0.7) 0.8846 0.3044 Total omega-3 3.2 6.7
3.8 3.0 4.8 2.0 2.9 3.0 0.2 132.7 68.4 n = 49, 56, 49 (1.2) (1.9)
(0.2) (1.0) (1.3) (0.2) (0.9) (1.1) (0.2) <0.0001 <0.0001
RBCs Saturated 43.5 44.5 0.6 43.8 44.4 0.3 44.2 43.8 -0.3 1.9 1.1 n
= 50, 56, 49 (1.4) (2.5) (0.4) (1.8) (3.0) (0.4) (4.2) (2.6) (0.4)
0.1145 0.3278 Monounsaturated 19.6 19.5 -0.2 20.2 20.0 -0.1 20.4
20.8 0.6 -3.9 -3.1 n = 50, 56, 49 (2.2) (1.9) (0.3) (2.8) (1.9)
(0.3) (3.0) (2.9) (0.3) 0.0154 0.0435 Total omega-6 30.4 25.5 -4.7
29.8 27.0 -2.9 29.1 29.5 -0.1 -17.3 -13.2 n = 50, 56, 49 (2.2)
(2.9) (0.5) (3.2) (3.3) (0.4) (5.1) (3.6) (0.5) <0.0001 0.0014
Total omega-3 6.6 10.4 4.1 6.2 8.7 2.6 6.2 5.9 -0.2 53.4 23.8 n =
50, 56, 49 (1.7) (2.3) (0.3) (1.6) (2.2) (0.3) (2.2) (2.0) (0.3)
0.0008 0.1183
[0401] Mean and standard deviation are reported in Table 15 for
baseline and end-of-treatment values; least-squares mean and
standard error are reported for changes from baseline and
placebo-adjusted changes from baseline.
[0402] .sup.aTotal=sum of omega-3, omega-6, monounsaturated, and
saturated fatty acids.
[0403] The term "Saturated fatty acids" as used in Table 15 refers
to the sum of myristic, palmitic, stearic, arachidic, behenic, and
lignoceric acids.
[0404] The term "Monounsaturated fatty acids" as used in Table 15
refers to myristoleic, palmitoleic, cis-vaccenic, oleic,
gondoic/gadoleic, erucic, and nervonic acids.
[0405] The term "Omega-6 fatty acids" as used in Table 15 refers to
the sum of linoleic, .gamma.-linolenic, eicosadienoic,
dihomo-.gamma.-linolenic, omega-6 arachidonic, adrenic, and omega-6
docosapentaenoic acids.
[0406] The term "Omega-3 fatty acids" as used in Table 15 refers to
the sum of .alpha.-linolenic, stearidonic, eicosatrienoic, omega-3
arachidonic, eicosapentaenoic, omega-3 docosapentaenoic, and
docosahexaenoic acids.
[0407] FIG. 5 shows the placebo-adjusted least squares mean changes
(P<0.0001) in EPA concentration from baseline to week 12 in
plasma and RBCs. The error bars represent 95% confidence intervals.
Treatment with 4 g/day ultra-pure EPA (referred to as "IPE" in the
Figures) resulted in a 792.0% placebo-adjusted LS mean increase in
plasma EPA over baseline, and a 489.6% placebo-adjusted LS mean
increase in RBC EPA over baseline. Treatment with 2 g/day
ultra-pure EPA resulted in a 402.3% placebo-adjusted LS mean
increase in plasma EPA over baseline, and a 297.7% placebo-adjusted
LS mean increase in RBC EPA over baseline.
[0408] FIG. 6A shows plasma (dark diamonds) and RBC (light
diamonds) placebo-adjusted least square mean changes from baseline
to week 12 for select individual fatty acids and ratios of
arachidonic acid to EPA ("AA/EPA") and total omega-3 fatty acids to
total omega-6 fatty acids ("n-3/n-6") upon treatment with 4 g/day
ultra-pure EPA. The values for each data point and corresponding P
values are reported in Tables 4 and 5. Error bars represent 95%
confidence intervals.
[0409] FIG. 6B shows plasma (dark diamonds) and RBC (light
diamonds) placebo-adjusted least square mean changes from baseline
to week 12 for select individual fatty acids and ratios of
arachidonic acid to EPA ("AA/EPA") and total omega-3 fatty acids to
total omega-6 fatty acids ("n-3/n-6") upon treatment with 2 g/day
ultra-pure EPA. The values for each data point and corresponding P
values are reported in Tables 13 and 14. Error bars represent 95%
confidence intervals.
[0410] FIG. 7 depicts the ultra-pure EPA dose dependence of changes
in EPA plasma and RBC concentration from baseline. Increased doses
of ultra-pure EPA resulted in increased EPA concentration in both
plasma (dark squares, y-axis on left) and RBCs (light diamonds,
y-axis on right). Error bars represent 95% confidence intervals for
each data point.
[0411] FIGS. 8A and 8B shows the relationship between plasma
triglyceride lowering and changes in EPA plasma and RBC
concentrations (a pharmacokinetic/pharmacodynamic relationship).
Increased EPA concentrations in plasma (FIG. 8A) and RBCs (FIG. 8B)
were accompanied by greater reductions in plasma triglyceride
levels. Triglyceride concentrations are presented in FIG. 8 as
median percent changes from baseline. Vertical error bars represent
the first and third quartile of the IQR. EPA concentrations are
presented in FIG. 8 as mean percent changes from baseline.
Horizontal error bars represent 95% confidence intervals.
[0412] These data indicate that ultra-pure EPA at either 2 g/day or
4 g/day significantly increased the concentrations of EPA and its
metabolite, DPAn-3, in plasma and RBCs; significantly reduced the
arachidonic acid/EPA ratio in plasma and RBCs (suggested by others
to be a useful biomarker for arteriosclerotic disease); decreased
the concentrations of key fatty acids including arachidonic,
palmitic, stearic, oleic and linoleic acids in plasma and
arachidonic acid (both doses) and linoleic acid (4 g/day only) in
RBCs; increased the proportion of omega-3 fatty acids and decreased
the proportion of omega-6 fatty acids in plasma and RBCs; and did
not significantly increase the concentration of DHA in plasma or
RBCs, indicating that its metabolic effects (including triglyceride
lowering) are not due to increases in DHA levels.
[0413] Overall, administration of 2 g/day or 4 g/day ultra-pure EPA
significantly increased EPA concentrations in a linear,
dose-dependent fashion consistent with its triglyceride-lowering
effect, increased the concentrations of docosapentaenoic acid n-3
(an EPA metabolite), caused beneficial shifts in the fatty acid
profile, and significantly decreased the arachidonic acid/EPA ratio
in plasma and RBCs.
Example 4
Pharmacokinetics of Pharmaceutical Compositions Comprising Ethyl
Eicosapentaenoate
[0414] A study to characterize the pharmacokinetics of ethyl
eicosapentaenoate in plasma and red blood cells after multiple-dose
administration of IPE at 2 g per day and 4 g per day was performed
in healthy adult male and female humans.
[0415] The study was a phase 1, open-label, randomized, multidose
study in healthy, nonsmoking men and women aged >18 and
.ltoreq.55 years with a body mass index (BMI)>18 and .ltoreq.30
kg/m.sup.2. Exclusion criteria included use within 6 weeks prior to
randomization through study end of any lipid-altering medications
or supplements, including statins, niacin at levels of greater than
200 mg/day, fibrates, ezetimibe, bile acid sequestrants, omega-3
fatty acid medications, and supplements or foods enriched with
omega-3 fatty acids (no more than 2 servings of fish per week were
permitted).
[0416] Following a 14-day screening period, subjects entered a
28-day treatment period and were randomized to one of four IPE dose
regimen treatment groups as shown in FIG. 1. Group 1 received IPE 2
g daily (1000-mg capsules; twice-daily [BID] regimen); Group 2
received IPE 4 g daily (1000-mg capsules; BID regimen); Group 3
received IPE 2 g daily (1000-mg capsules; once-daily [QD] regimen);
and Group 4 received IPE 2 g daily (500-mg capsules; BID regimen).
Treatment was administered orally, with or following a meal in the
morning and evening for BID regimens, or in the morning only for
the QD regimen. Subjects then entered an 18-day post-treatment
pharmacokinetic sampling period.
[0417] The safety population was defined as all randomized subjects
who received at least one dose of study drug. The per-protocol
population was defined as all safety population subjects who
completed the 28-day treatment period without any major protocol
deviations, and who provided blood samples for EPA analyses.
[0418] Assessments and Measurements
[0419] Fasting EPA concentrations were measured with a validated
liquid chromatography with tandem mass spectrometry (LC-MS/MS)
method in plasma and RBCs prior to the morning dose (days 1, 14,
26, 28) and at serial time points (1, 3, 5, 6, 8, 10, 12, 24, 48,
72, 120, 192, 312, and 432 hours) after the morning dose on day 28.
After the last dose on day 28, EPA concentrations were followed for
18 days to estimate the expected long half-life of EPA. Total
plasma EPA included all EPA forms (unesterified EPA and that
incorporated in phospholipids, triacylglycerols, and cholesteryl
esters). In RBCs, EPA was measured in the cell membrane, where EPA
is mainly incorporated in phospholipids.
[0420] For total EPA in plasma and RBCs, lipids were isolated by
acid/methanol/chloroform extraction followed by centrifugation and
purified by isohexane and solid-phase extraction after confirmed
complete lipid hydrolysis and transmethylation (acid/methanol,
50.degree. C. overnight). For unesterified EPA in plasma, 25 .mu.L
of an inhibitor solution (0.5 g sodium fluoride, 1.0 g L-ascorbic
acid, and 0.25 g 5-methylisoxazole-3-carboxylic acid per 10 mL
water) was included per 1 mL plasma sample to prevent degradation
and lipids were isolated by centrifugation after
methanol/chloroform extraction (without hydrolysis or methylation)
and further purified by protein precipitation and solid-phase
extraction. Quantitation utilized linolenic acid as an internal
standard and EPA as the standard for the calibration curve; for
total plasma EPA, RBC EPA, and unesterified EPA, the lower limits
of quantitation were 10 .mu.g/mL, 5 .mu.g/mL, and 50 ng/mL,
respectively. EPA concentrations were measured at Charles River
Laboratories Ltd (Elphinstone Research Center, Tranent, Edinburgh,
Scotland, UK).
[0421] Pharmacokinetic parameters were calculated with standard
methods and included area under the plasma concentration versus
time curve from time zero to 24 hours (AUC.sub.0-24h), calculated
using the linear trapezoidal rule; maximum observed concentration
(C.sub.max); minimum observed plasma concentration (C.sub.min,
pre-dose, trough concentration); apparent terminal elimination
half-life (T.sub.1/2) calculated from (log.sub.e2)/.lamda..sub.z,
where .lamda..sub.z is the apparent terminal rate constant obtained
from the slope of the line, fitted by linear least-squares
regression, through the terminal points of the natural log of the
concentration versus time plots of these points; apparent total
plasma clearance (CL/F) after an oral dose, calculated from
Dose/AUC.sub.0-.tau., where F is the oral bioavailability; time of
observed C.sub.max (T.sub.max); and apparent volume of distribution
after an oral dose (V.sub.z/F), calculated from
Dose/AUC.sub.0-.tau..times..lamda..sub.z, where F is the oral
bioavailability. Unless otherwise specified, all reported
parameters are based on baseline-subtracted concentrations
(baseline is due to EPA derived from dietary sources).
[0422] The average daily dose of IPE was calculated based on the
unused capsule counts across all treatment days prior to the last
day of dosing. Percent compliance was calculated as actual daily
dose/planned daily dose.times.100.
[0423] Safety assessments consisted of adverse event (AE)
monitoring, clinical laboratory measurements (chemistry,
hematology, and urinalysis) 12-lead electrocardiographic
measurements, vital signs (systolic and diastolic blood pressure,
heart rate, respiratory rate, and oral body temperature) and
physical examination findings.
[0424] Results--Subjects
[0425] A total of 48 subjects were randomized to the 4 treatment
groups, with 6 male and 6 female subjects in each group. There were
6 subjects who discontinued the study due to withdrawal of consent
(n=5) and an AE (n=1; cholecystitis due to previously undiagnosed,
longstanding cholelithiasis unrelated to study drug); 42 subjects
completed the study (87.5%) (FIG. 1). Mean age (SD) was 38.8 (11.9)
years and subjects were primarily white (n=37; 77.1%). Demographic
and other baseline characteristics for subjects in the safety
population are presented in Table 16:
TABLE-US-00016 TABLE 16 Subject Demographics (Safety Population).
Group 1 Group 2 Group 3 Group 4 Total Characteristic (n = 12) (n =
12) (n = 12) (n = 12) (n = 48) Age, mean (SD), y 36.9 (13.5) 37.9
(12.9) 39.8 (10.7) 40.7 (11.5) 38.8 (11.9) Male, n (%) 6 (50.0) 6
(50.0) 6 (50.0) 6 (50.0) 24 (50.0) Race, n (%) White 8 (66.7) 10
(83.3) 9 (75.0) 10 (83.3) 37 (77.1) Black 4 (33.3) 2 (16.7) 3
(25.0) 2 (16.7) 11 (22.9) Ethnicity Hispanic 9 (75.0) 9 (75.0) 8
(66.7) 8 (66.7) 34 (70.8) Weight, mean (SD), kg 74.5 (14.1) 75.5
(13.4) 72.9 (11.0) 73.1 (12.1) 74.0 (12.4) BMI, mean (SD),
kg/m.sup.2 26.2 (2.6) 27.2 (2.6) 26.1 (2.5) 25.7 (3.0) 26.3
(2.6)
[0426] Baseline total EPA plasma concentrations were variable
between subjects, with a study-wide mean (SD) of 15.3 (15.2)
.mu.g/mL. Fourteen subjects had baseline total EPA values lower
than the lower limit of quantitation (10 .mu.g/mL). The study-wide
mean (SD) baseline unesterified EPA plasma concentration was 0.099
(0.095) .mu.g/mL, which is less than 1% of the total EPA plasma
concentration. In RBCs, the study-wide mean (SD) baseline
unesterified EPA concentration was 8.01.+-.9.89 .mu.g/mL.
[0427] Mean daily IPE dose was 2 g for all groups except Group 2,
which had a mean daily IPE dose of 3.9 g. Compliance rates were
99.4%, 97.1%, 99.1%, and 101.3% for Group 1 through 4,
respectively.
[0428] Pharmacokinetic Results
[0429] Following IPE dosing, maximum concentration of total EPA was
reached in approximately 5 to 6 hours in plasma (Table 17, FIG. 10)
and approximately 8 to 24 hours in RBCs (Table 17). The mean
terminal half-life of total EPA in plasma was long, ranging between
70 and 89 hours for the 4 treatment groups. The mean oral clearance
and volume of distribution of total EPA in plasma ranged between
684 and 868 mL/hr and 79 and 88 L, respectively (Table 17). Steady
state was reached by day 14 in plasma in all treatment groups (FIG.
11). However, RBC concentrations slowly increased over the duration
of treatment, and steady state was not reached by day 28 (data not
shown). Study-wide steady-state means (SD) for half-life (mainly
from plasma lipids), total plasma clearance, and volume of
distribution of total EPA were 79 (47) hours, 757 (283) mL/hr, and
82 (56) L, respectively.
TABLE-US-00017 TABLE 17 Pharmacokinetic parameters by treatment at
day 28 (per-protocol population). Group 1: Group 2: Group 3: Group
4: IPE 2 g/d IPE 4 g/d IPE 2 g/d IPE 2 g/d PK 1 .times. 1000 mg BID
2 .times. 1000 mg BID 2 .times. 1000 mg QD 2 .times. 500 mg BID
Analyte parameter* (n = 10) (n = 9) (n = 12) (n = 12) Total EPA in
Baseline (.mu.g/mL) 7.9 (7.0) 19.3 (16.1) 19.2 (17.5) 14.7 (16.6)
plasma C.sub.max (.mu.g/mL) 154.9 (49.4) 347.2 (112.5) 232.8
(127.6) 210.5 (93.1) AUC.sub.0-24 hr (.mu.g hr/mL) 2907 (1160) 6519
(1963) 2659 (1136) 3233 (1104) C.sub.min (.mu.g/mL) 101.0 (50.4)
211.9 (68.2) 75.1 (40.5) 104.2 (42.4) T.sub.max (hr) 5 (5, 8) 5 (3,
8) 5 (3, 12) 6 (5, 8) T.sub.1/2 (hr) 75.1 (46.5) 89.3 (42.0) 69.7
(60.9) 83.5 (38.8) CL/F (mL/hr) 776.4 (256.9) 683.7 (280.6) 867.7
(328.8) 684.5 (248.3) V.sub.z/F (L) 79.8 (62.6) 88.4 (55.2) 79.3
(71.5) 79.3 (35.3) Total EPA in Baseline (.mu.g/mL) 5.7 (4.3) 12.1
(15.7) 8.2 (7.1) 6.7 (10.4) RBC C.sub.max (.mu.g/mL) 42.3 (14.0)
76.7 (25.2) 31.0 (11.1) 37.6 (15.7) AUC.sub.0-24 hr (.mu.g hr/mL)
801.5 (268.5) 1472 (469.5) 557.6 (239.7) 573.9 (336.4) C.sub.min
(.mu.g/mL) 31.2 (12.2) 64.1 (21.8) 20.7 (8.6) 26.3 (17.7) T.sub.max
(hr) 12 (1, 72) 8 (1, 12) 10 (6, 48) 24 (0, 120) T.sub.1/2 (hr)
683.8 (NC) 371.4 (311.5) 303.2 (NC) 314.4 (194.5) Unesterified
Baseline (.mu.g/mL) 0.13 (0.12) 0.08 (0.05) 0.09 (0.06) 0.10 (0.13)
EPA in plasma C.sub.max (.mu.g/mL) 0.66 (0.34) 1.4 (0.41) 1.4
(0.49) 0.70 (0.24) AUC.sub.0-24 hr (.mu.g hr/mL) 6.9 (3.1) 18.4
(4.6) 9.0 (2.5) 7.5 (2.6) C.sub.min (.mu.g/mL) 0.41 (0.28) 1.06
(0.56) 0.36 (0.22) 0.44 (0.24) T.sub.max (hr) 5 (0, 48) 5 (0, 24) 5
(3, 8) 3 (0, 24) T.sub.1/2 (hr) 80.8 (37.5) 97.2 (36.5) 136.3
(80.8) NC CL/F (mL/hr) 364,513 (214,003) 234,329 (81,639) 241,855
(82,203) 326,622 (207,574) V.sub.z/F (L) 33,164 (8068) 28,200
(10,929) 40,873 (19,580) NC
[0430] A small fraction (.ltoreq.0.5%) of the total EPA was
determined to be unesterified. Based on AUC.sub.0-24hr in plasma,
0.3% of the total EPA was unesterified in Group 1 (2 g/day) and
Group 2 (4 g/day); based on maximum concentration in plasma, 0.5%
and 0.4% of the total EPA was unesterified EPA in group 1 (2 g/day)
and group 2 (4 g/day), respectively.
[0431] Comparisons of exposure (AUC.sub.0-24 hr and C.sub.max)
revealed similarity between QD and BID regimens and between
1.times.1000-mg and 2.times.500-mg formulations (FIGS. 4 and 5;
Group 1 vs. Group 3, AUC.sub.0-24 hr for total plasma, total RBCs,
and unesterified EPA, with observed differences in maximum
concentration expected based on dosing regimen; Group 1 vs. Group
4, AUC.sub.0-24hr and maximum concentration for total plasma and
unesterified EPA). Dose linearity was observed between IPE 2 g/day
and 4 g/day (Group 1 vs. Group 2; dose-normalized comparison of AUC
and maximum concentration for total plasma, total RBCs, and
unesterified EPA). Based on graphical examination of the
AUC.sub.0-24 hr and maximum concentration of total and unesterified
plasma EPA concentrations, no effect of age was observed. Minimum
concentration appeared to be slightly lower for males compared with
females in some treatment groups, but overall, no consistent gender
effect was observed based on all remaining exposure parameters.
[0432] Safety and Tolerability
[0433] Fourteen (29.2%) subjects reported at least one adverse
event ("AE") during the study (3 [25.0%] in Group 1, 4 [33.3%] in
Group 2, 3 [25.0%] in Group 3, and 4 [33.3%] in Group 4). All AEs
were treatment emergent and mild or moderate in intensity. The most
common AEs were upper respiratory tract infection (two subjects in
Group 2) and headache (two subjects in Group 3). One subject in
Group 2 discontinued study treatment as noted earlier due to
cholecystitis, which was considered unrelated to study drug. There
were no clinically meaningful changes in laboratory,
electrocardiographic, or physical examination findings.
Discussion
[0434] The present study describes the plasma and RBC
pharmacokinetics of IPE, a high-purity prescription form of EPA
ethyl ester. Once-daily versus twice-daily regimens, 500-mg versus
1000-mg formulations, and 2 g/day versus 4 g/day doses were
compared, and the effects of age and gender were also
evaluated.
[0435] Following oral dosing with IPE 4 g/day and 2 g/day, the
study-wide mean (SD) elimination half-life of total EPA at steady
state was 79 (47) hours. The study-wide mean apparent total plasma
clearance of total EPA at steady state was 757 (283) mL/hr and the
apparent volume of distribution of total EPA at steady state was 82
(56) L. Maximum concentrations of total EPA were attained
approximately 5 to 6 hours in plasma after dosing. Maximum EPA
concentrations occurred later in RBCs compared with plasma
(.about.8-24 hours after dosing). Steady-state concentrations of
total plasma EPA were observed 14 days after continuous dosing,
whereas steady state was not reached by day 28 in RBCs.
[0436] The slow increase in RBC concentrations observed over the
duration of treatment in the present study was consistent with the
slow washout of EPA after cessation of dosing (long elimination
half-life) in RBCs and likely due to the known slower process of
incorporation of EPA into RBC membranes. The maximum plasma
concentration of 5 to 6 hours post dosing observed in this study
are in agreement with that of a prescription formulation of ethyl
EPA available in Japan. The study-wide mean elimination half-life
of total plasma EPA of 79 hours was consistent with previously
reported mean elimination half-lives ranging from approximately 1
to 3 days for plasma EPA in phospholipids, cholesteryl esters, and
triacylglycerol.
[0437] Based on dose-normalized maximum observed concentration and
AUC of total and unesterified EPA in plasma and total EPA in RBCs,
the mean exposure to EPA appears to be dose-proportional between
IPE 2 and 4 g/day. This pharmacokinetic dose-linearity was
supported by the statistical comparisons of dose-normalized
pharmacokinetic values, indicating that IPE has predictable
pharmacokinetics. Administration of prescription omega-3-acid ethyl
esters (EPA plus DHA) has also been shown to result in
dose-dependent increases in serum EPA, but increases in serum DHA
were found to be less pronounced and not dose-dependent.
[0438] In general, the once-daily and twice-daily dosing regimens
for the same daily dose of IPE resulted in similar total AUC for
total EPA in plasma. As expected, the maximum observed
concentration was higher and the trough concentration was lower in
the once-daily regimen compared with the twice-daily regimen. As is
typical for drugs with long half-lives, the major determinant of
steady-state exposure to EPA in plasma, and even more so in RBCs,
was the total daily dose of IPE, irrespective of how the dose was
divided over the course of the day. The relatively long half-life
of EPA in plasma permits a dosing schedule with intervals of >12
hours, and day-to-day variability in the dosing interval is not
expected to influence the average plasma or tissue exposure to EPA.
In comparing the 500-mg and 1000-mg formulations of IPE at the same
daily dose, similar total plasma EPA maximum observed
concentrations and AUCs were observed, indicating that, as
expected, the 500-mg and 1000-mg formulations provide comparable
exposures at comparable doses.
Example 5
Pharmacokinetic and TG-Lowering Pharmacodynamic Effects of Ethyl
Eicosapentaenoate Across Clinical Studies
[0439] The objective of this Example is to examine the effects of
high-purity ethyl eicosapentaenoate ("IPE") on EPA concentrations
in plasma and RBCs in response to dose and the relationship to
triglyceride ("TG") lowering across 3 clinical studies.
[0440] MARINE and ANCHOR were 12-week, phase 3, double-blind
studies that randomized patients to IPE 4 g/day, 2 g/day, or
placebo. MARINE randomized 229 patients with TG.gtoreq.500 and
.ltoreq.2000 mg/dL while ANCHOR randomized 702 high-risk patients
with TG.gtoreq.200 and <500 mg/dL despite LDL-C control while on
statin therapy. IPE 4 g/day and 2 g/day were also investigated in
48 healthy subjects for 4 weeks in a phase 1 pharmacokinetic ("PK")
study.
[0441] In all studies, a greater increase in EPA concentrations in
both plasma and RBCs was observed with IPE 4 g/day than with 2
g/day, indicating a dose-dependent increase in EPA exposure. EPA
concentration data from healthy volunteers and in patients with
hypertriglyceridemia indicate that the PK of EPA are linear with
dose. In MARINE and ANCHOR, median percent reductions in TG from
baseline were higher with IPE 4 g/day than with 2 g/day and
demonstrated a dose-proportional relationship. In plasma and RBCs,
a linear PD relationship between EPA levels and TG reduction was
also observed, demonstrating a linear concentration-response
relationship.
[0442] Taken together, the linear-dose-PK and
dose-concentration-response PD relationships indicate that the
PK/PD of IPE are predictable, as the results demonstrate a trend of
increasing TG-lowering efficacy with respect to both the IPE dose
and EPA concentration in plasma and RBCs.
[0443] A phase 1 PK study conducted in healthy volunteers
demonstrated that the PK profile of IPE was that of a slowly
cleared and extensively distributed molecule with
dose-linearity.
[0444] The MARINE and ANCHOR pivotal studies demonstrated
collectively that IPE significantly reduced TG levels in patients
with very high (MARINE) or high (ANCHOR) TG levels and on statin
therapy without raising LDL-C.
[0445] The present analysis evaluated data from 2 studies conducted
in patients with elevated TG levels and 1 study conducted in
healthy volunteers for a PK/PD dose-response relationship with
respect to IPE dose, EPA concentration in plasma and RBCs, and
reduction in TG levels. [0446] Study Designs: [0447] Phase 1 PK
study [0448] Open-label, randomized, multidose study with a 14-day
screening period followed by a 4-week treatment period [0449]
Healthy, nonsmoking volunteers aged >18 and .ltoreq.55 years not
receiving any lipid-altering medications or supplements within 6
weeks before the study were randomized to 4 IPE dose regimens
(groups 1 and 2 are included in this analysis): [0450] Group 1: IPE
2 g/day (one 1000-mg capsule BID) [0451] Group 2: IPE 4 g/day (two
1000-mg capsules BID) [0452] Group 3: IPE 2 g/day (two 1000-mg
capsules QD) [0453] Group 4: 2 g/day (two 500-mg capsules BID)
[0454] After dosing, subjects entered an 18-day post-treatment PK
sampling period [0455] MARINE and ANCHOR1,2 [0456] Phase 3,
placebo-controlled, randomized, double-blind, multicenter studies
with a 4- to 6-week lead-in period of diet, lifestyle, and
medication stabilization with washout of prohibited lipid-altering
medications [0457] In both studies, patients aged >18 years with
qualifying lipid levels (MARINE: TG.gtoreq.500 mg/dL and
.ltoreq.2000 mg/dL; ANCHOR: TG.gtoreq.200 and <500 mg/dL and
LDL-C.gtoreq.40 and .ltoreq.115 mg/dL) entered a 12-week,
double-blind treatment period and were randomized to receive either
IPE 4 g/day, IPE 2 g/day, or matched placebo [0458] In the MARINE
study, stable statin therapy with or without ezetimibe was
permitted but not required [0459] In the ANCHOR study, patients
were required to be at high risk for cardiovascular disease as
defined by the NCEP ATP III guidelines 3 and on stable statin dose
(atorvastatin, rosuvastatin, or simvastatin with or without
ezetimibe)
[0460] Assessments and Measurements
[0461] In the MARINE and ANCHOR studies, the trough EPA
concentrations were measured after 12 weeks of dosing with placebo,
2 g/day or 4 g/day IPE
[0462] In the Phase 1 PK study, the trough EPA concentrations were
measured after 28 days of dosing with 2 or 4 g/day IPE (there was
no placebo group; a value of zero is used in plots as a point of
reference)
[0463] EPA concentrations were measured with a validated LC-MS/MS
method in plasma and in RBCs in all 3 studies
[0464] Total plasma EPA included all EPA forms (unesterified EPA
and that incorporated in phospholipids, triacylglycerols, and
cholesteryl esters); in RBCs, EPA was from cell membranes, where it
is mainly incorporated in phospholipids
[0465] Total EPA in plasma and RBCs: lipids were isolated by
acid/methanol/chloroform extraction followed by centrifugation and
purified by isohexane and solid-phase extraction after confirmed
complete lipid hydrolysis and transmethylation (acid/methanol,
50.degree. C. overnight)
[0466] Quantitation utilized linolenic acid as an internal standard
and EPA as the standard for the calibration curve; for total plasma
EPA and total RBC EPA, the lower limits of quantitation were 10
.mu.g/mL and 5 .mu.g/mL, respectively
[0467] TG levels were evaluated as in the MARINE and ANCHOR studies
as previously reported.
[0468] Serum TG levels were measured with enzymatic colorimetric
tests with calibration directly traceable to US CDC reference
procedures
[0469] RESULTS
[0470] Subjects
[0471] Baseline characteristics are summarized in Table 18 and were
comparable among treatment groups within each study.
TABLE-US-00018 TABLE 18 Demographics and Baseline Characteristics.
Phase 1 PK Study MARINE ANCHOR IPE IPE IPE IPE IPE IPE 4 g/day 2
g/day 4 g/day 2 g/day Placebo 4 g/day 2 g/day Placebo
Characteristic (n = 12) (n = 12) (n = 77) (n = 76) (n = 76) (n =
233) (n = 236) (n = 233) Age, mean (SD), y 37.9 36.9 51.9 53.4 53.4
61.1 61.8 61.2 (12.9) (13.5) (10.3) (9.3) (8.3) (10.0) (9.4) (10.1)
Male, n (%) 6 6 59 58 58 142 144 145 (50.0) (50.0) (76.6) (76.3)
(76.3) (60.9) (61.0) (62.2) Weight, mean (SD), kg 75.5 74.5 93.2
92.1 93.0 94.5 95.5 97.0 (13.4) (14.1) (18.3) (15.6) (16.9) (18.3)
(18.3) (19.1) BMI, mean (SD), 27.2 26.2 30.4 30.8 31.0 32.7 32.9
33.0 kg/m.sup.2 (2.6) (2.6) (4.3) (4.2) (4.3) (5.0) (5.0) (5.0)
Diabetes, n (%) NA NA 22 20 21 171 172 171 (28.6) (26.3) (27.6)
(73.4) (72.9) (73.4) TG, median (IQR), NA NA 679.5 656.5 703.0
264.8 254.0 259.0 mg/dL (265.3) (303.5) (426.5) (93.0) (92.5)
(81.0) n = 76 n = 73 n = 75 n = 226 n = 234 n = 227 Total plasma
EPA, 19.3 7.9 61.2 63.6 57.7 28.1 28.1 28.1 mean (SD), ug/mL (16.1)
(7.0) (67.4) (51.4) (42.7) (18.8) (13.7) (28.0) n = 9 n = 10 n = 69
n = 62 n = 61 n = 71 n = 73 n = 81 RBC EPA, mean 12.1 5.7 16.0 15.7
14.7 11.6 10.9 11.2 (SD), ug/mL (15.7) (4.3) (9.2) (9.9) (9.3)
(5.6) (5.2) (6.6) n = 9 n = 10 n = 66 n = 61 n = 64 n = 69 n = 71 n
= 79
[0472] EPA Dose Response
[0473] Both healthy subjects and patients with hypertriglyceridemia
experienced dose-dependent increases in plasma EPA concentrations
following treatment with IPE (FIG. 15).
[0474] Increasing doses of IPE led to greater increases in EPA
concentrations in both plasma and RBCs in all three studies, as
shown in FIGS. 16 and 17. Mean concentrations shown in FIGS. 16-17
are based on baseline-subtracted trough concentrations of total EPA
(change from baseline) at steady state.
[0475] As shown in FIGS. 18 and 19, subjects in the MARINE and
ANCHOR studies treated with IPE experienced dose-dependent
reduction in triglyceride levels that also was linearly associated
with an increase in EPA levels as measured in both plasma (FIGS.
18A, 19A) and red blood cells (FIGS. 18B, 19B).
[0476] Data from both the MARINE and ANCHOR studies demonstrate
that gender, age, baseline TG levels, body weight, and BMI have no
effect on EPA concentrations in plasma and RBCs.
[0477] Treatment with concomitant medications including statins,
antihypertensive medications, and antiplatelet medications did not
affect increases in plasma EPA concentrations in both the MARINE
and ANCHOR studies.
[0478] Analysis of patients in ANCHOR indicated that patients with
and without diabetes mellitus had on average the same plasma and
RBC EPA increases.
[0479] IPE was administered with or following a meal (or snack) and
therefore exposure measurements of EPA were studied in the fed
state.
[0480] Plasma and RBC EPA levels were increased compared with
baseline in both the 2 and 4 g/day groups in all 3 studies, and
were linear with dose, indicating that IPE has predictable
pharmacokinetics.
[0481] The relationships between IPE dose and TG-lowering response
and between EPA concentration and TG-lowering response were similar
and linear, indicating that IPE has predictable PD and PK/PD
characteristics.
[0482] Demographic factors (age, gender, body weight, BMI, and
presence of diabetes mellitus), baseline TG levels, and concomitant
medications (statins, antihypertensives, and antiplatelets) did not
affect the increase in EPA concentrations in plasma and RBCs after
treatment with IPE.
[0483] The PK results were similar among all three studies; the
PK/PD results were similar between the MARINE and ANCHOR
studies.
* * * * *