U.S. patent application number 17/059932 was filed with the patent office on 2021-07-15 for parenteral nutrition formulation.
The applicant listed for this patent is BAXTER HEALTHCARE SA, BAXTER INTERNATIONAL INC.. Invention is credited to Julie FAHIER, Julien HECQ, Mary HISE BROWN, Laurent JEANNIN, Jean-Luc TROUILLY.
Application Number | 20210212936 17/059932 |
Document ID | / |
Family ID | 1000005506502 |
Filed Date | 2021-07-15 |
United States Patent
Application |
20210212936 |
Kind Code |
A1 |
TROUILLY; Jean-Luc ; et
al. |
July 15, 2021 |
PARENTERAL NUTRITION FORMULATION
Abstract
Parenteral nutrition formulations for pediatric patients are
disclosed. The nutritional formulations include a lipid formulation
that comprises an aqueous phase and an oil phase, wherein the lipid
formulation is in the form of an oil-in-water emulsion.
Multi-chamber containers for parenteral nutrition administration
comprising a carbohydrate formulation present in a first chamber,
an amino acid formulation present in a second chamber, and the
lipid formulation present in a third chamber also are
disclosed.
Inventors: |
TROUILLY; Jean-Luc; (Braine
L'Alleud, BE) ; HISE BROWN; Mary; (Vernon Hills,
IL) ; JEANNIN; Laurent; (Uccle, BE) ; HECQ;
Julien; (Glattpark (Opfikon), CH) ; FAHIER;
Julie; (Braine L'Alleud, BE) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
BAXTER INTERNATIONAL INC.
BAXTER HEALTHCARE SA |
Deerfield
Glattpark (Opfikon) |
IL |
US
CH |
|
|
Family ID: |
1000005506502 |
Appl. No.: |
17/059932 |
Filed: |
June 1, 2018 |
PCT Filed: |
June 1, 2018 |
PCT NO: |
PCT/US2019/034388 |
371 Date: |
November 30, 2020 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
|
62679352 |
Jun 1, 2018 |
|
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|
Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A61K 31/14 20130101;
A61K 31/685 20130101; A61K 36/05 20130101; A61K 47/10 20130101;
A23L 33/125 20160801; A61K 31/232 20130101; A23D 7/0053 20130101;
A23D 7/011 20130101; A23L 33/40 20160801; A23L 33/12 20160801; A23L
33/11 20160801; A61J 1/10 20130101; A61K 9/107 20130101; A23L
33/175 20160801; A23V 2002/00 20130101; A23D 7/06 20130101; A61K
31/202 20130101; A61K 9/0029 20130101 |
International
Class: |
A61K 9/00 20060101
A61K009/00; A61K 9/107 20060101 A61K009/107; A61K 31/232 20060101
A61K031/232; A61K 31/14 20060101 A61K031/14; A61K 31/202 20060101
A61K031/202; A61K 31/685 20060101 A61K031/685; A61K 47/10 20060101
A61K047/10; A61K 36/05 20060101 A61K036/05; A61J 1/10 20060101
A61J001/10; A23L 33/125 20060101 A23L033/125; A23L 33/175 20060101
A23L033/175; A23L 33/12 20060101 A23L033/12; A23L 33/11 20060101
A23L033/11; A23L 33/00 20060101 A23L033/00; A23D 7/005 20060101
A23D007/005; A23D 7/06 20060101 A23D007/06; A23D 7/01 20060101
A23D007/01 |
Claims
1-76. (canceled)
77. A multi-chamber container for parenteral administration
comprising: (i) a carbohydrate formulation present in a first
chamber; (ii) an amino acid formulation present in a second
chamber; and (iii) a lipid formulation present in a third chamber;
wherein: the lipid formulation comprises an aqueous phase and about
5% to about 35% by weight of an oil phase based on the total weight
of the lipid formulation; the lipid formulation is present in the
form of an oil-in-water emulsion; the oil phase comprises
docosahexaenoic acid (DHA) obtained from a single cell source,
wherein the single cell source is an extract of microalgae and
wherein DHA is present in a concentration of from 0.1 g to 5.0 g
per 100 g of oil phase; the lipid formulation includes about 70 mg
phytosterols or less per 100 g of oil phase; and the lipid
formulation is essentially free of water soluble forms of choline,
wherein the carbohydrate formulation and/or the amino acid
formulation comprises at least one water-soluble form of choline
selected from the group consisting of choline chloride, choline
bitartrate, choline citrate, choline gluconate, choline malate,
choline cytidine diphosphate choline (CDP) salt and
glycerophosphocholine, preferably glycerophosphocholine.
78. The multi-chamber container of claim 77, wherein DHA is present
in a concentration of from 0.25 g to 3.0 g per 100 g of oil
phase.
79. The multi-chamber container of claim 77, wherein DHA is present
in a concentration of from 1.5 g to 2.5 g per 100 g of oil
phase.
80. The multi-chamber container of claim 77, wherein DHA is present
in triglyceride form or ethyl ester form, preferably triglyceride
form.
81. The multi-chamber container of claim 77, wherein the lipid
formulation comprises eicosapentaenoic acid (EPA) and the ratio of
DHA to EPA in the lipid formulation is 10:1 to 1000:1 (w/w).
82. The multi-chamber container of claim 77, wherein the lipid
formulation comprises EPA and the ratio of DHA to EPA in the lipid
formulation is 10:1 to 200:1.
83. The multi-chamber container of claim 77, wherein the lipid
formulation comprises EPA and the ratio of DHA to EPA in the lipid
formulation is 20:1 to 150:1.
84. The multi-chamber container of claim 81, wherein DHA and/or EPA
are present in triglyceride form or ethyl ester form, preferably
triglyceride form.
85. The multi-chamber container of claim 77, wherein the lipid
formulation is essentially free of EPA.
86. The multi-chamber container of claim 77, wherein the microalgae
is Crypthecodinium cohnii or Schizochytrium sp, preferably
Schizochytrium sp.
87. The multi-chamber container of claim 77, wherein the lipid
formulation includes about 15 mg to about 35 mg phytosterols per
100 g of oil phase, preferably about 25 mg phytosterols or less per
100 g of oil phase.
88. The multi-chamber container of claim 77, wherein the lipid
formulation comprises one or more pharmaceutically acceptable
surfactants selected from the group consisting of phospholipids,
oleate salts, and combinations thereof.
89. The multi-chamber container of claim 88, wherein the
phospholipid is selected from the group consisting of egg
phosphatide and soy lecithin.
90. The multi-chamber container of claim 77, wherein the lipid
formulation comprises one or more pharmaceutically acceptable
isotonic agents.
91. The multi-chamber container of claim 90, wherein the
pharmaceutically acceptable isotonic agent is glycerol.
92. The multi-chamber container of claim 77, wherein the lipid
formulation comprises one or more pharmaceutically acceptable
antioxidants selected from the group consisting of tocopherols,
ascorbyl palmitate, and combinations thereof.
93. The multi-chamber container of claim 77, wherein the lipid
formulation has a pH in the range of about 6 to about 9, preferably
about 7 to about 8.
94. The multi-chamber container of claim 77, wherein the at least
one water-soluble form of choline is present in a concentration of
from 20 mg to 2000 mg choline equivalent per liter of a
reconstituted multi-chamber container, such as 30 mg to 1000 mg
choline equivalent per liter of a reconstituted multi-chamber
container.
95. A method of treating patients who require parenteral nutrition
when oral and enteral nutrition is not possible, insufficient or
contraindicated by using a multi-chamber container of claim 77.
96. The method of claim 95, wherein the patients are pediatric
patients.
97. A multi-chamber container for parenteral administration
comprising: (i) a carbohydrate formulation present in a first
chamber; (ii) an amino acid formulation present in a second
chamber; and (iii) a lipid formulation present in a third chamber;
wherein: the lipid formulation comprises an aqueous phase and about
5% to about 35% by weight of an oil phase based on the total weight
of the lipid formulation; the lipid formulation is present in the
form of an oil-in-water emulsion; the oil phase comprises
docosahexaenoic acid (DHA) obtained from a single cell source,
wherein the single cell source is an extract of microalgae and
wherein DHA is present in a concentration of from 0.1 g to 5.0 g
per 100 g of oil phase; the lipid formulation includes about 70 mg
phytosterols or less per 100 g of oil phase; and the lipid
formulation is essentially free of water soluble forms of choline,
wherein the carbohydrate formulation and/or the amino acid
formulation comprises at least one water-soluble form of choline
selected from the group consisting of choline chloride, choline
bitartrate, choline citrate, choline gluconate, choline malate,
choline cytidine diphosphate choline (CDP) salt and
glycerophosphocholine, preferably glycerophosphocholine, wherein
the multi-chamber container comprises openable seals among the
first chamber, the second chamber and the third chamber, and
wherein the carbohydrate formulation, the amino acid formulation
and the lipid formulation are admixed into a whole liquid solution
after the openable seals are open for the parenteral
administration.
98. The multi-chamber container of claim 97, wherein the lipid
formulation is essentially free of water soluble forms of choline
and arachidonic acid (ARA).
Description
BACKGROUND
Field
[0001] The disclosure is directed to parenteral nutrition
formulations, including ready-to-use ternary parenteral nutrition
formulations. More particularly, the present disclosure is directed
to lipid formulations and to multi-chamber containers containing
lipid formulations, carbohydrate formulations, and amino acid
formulations, particularly for use with pediatric patients.
Description of the Related Art
[0002] Medical solutions for pediatric nutrition need to be
formulated with the needs of preterm babies, neonates, infants,
children, and adolescents in mind. Preterm babies lack substantial
energy and fat reserves, for example, making it important to
provide proper lipid intake via parenteral nutrition. Lipids,
particularly long-chain polyunsaturated fatty acids, have been
found to be involved in growth, visual development, neural
development, and long-term health, among other functions.
[0003] Docosahexaenoic acid (DHA) (C22:6 n-3) is a long-chain
polyunsaturated fatty acid synthetized from .alpha.-linolenic acid
(ALA). DHA is a major structural lipid for cellular membranes in
the brain and the retina of the eyes, and is a key component of the
heart. While the use of parenteral nutrition is associated with
liver disease (e.g., liver failure, hepatic steatosis, cirrhosis),
DHA was found to have a beneficial impact on liver steatosis.
[0004] Arachidonic acid (ARA) (C20:4 n-6) is a long-chain
polyunsaturated fatty acid formed by biosynthesis from linoleic
acid (LA). ARA is the most abundant fatty acid in the brain where
it plays an important role in cell division, signaling and many
basic cellular functions.
[0005] An improved parenteral nutrition product for pediatric
patients, including preterm babies, neonates, infants, children,
and adolescents, who require parenteral nutrition when oral and
enteral nutrition is not possible, insufficient or contraindicated,
is needed accordingly.
SUMMARY
[0006] In light of the disclosure herein, and without limiting the
scope of the invention in any way, in a first aspect of the present
disclosure, which may be combined with any other aspect listed
herein unless specified otherwise, a multi-chamber container for
parenteral administration includes a carbohydrate formulation
present in a first chamber, an amino acid formulation present in a
second chamber, and a lipid formulation present in a third chamber.
The lipid formulation has an aqueous phase and an oil phase,
includes about 5% to about 35% by weight of the oil phase based on
the total weight of the lipid formulation, and is present in the
form of an oil-in-water emulsion. Furthermore, the oil phase
comprises docosahexaenoic acid (DHA) obtained from a single cell
source, the single cell source being an extract of microalgae. In
the oil phase, DHA is present in a concentration of from 0.1 g to
5.0 g per 100 g of oil phase. The lipid formulation includes about
70 mg phytosterols or less per 100 g of oil phase, and is
essentially free of water soluble forms of choline and/or
arachidonic acid (ARA).
[0007] In a second aspect of the present disclosure, which may be
combined with any other aspect listed herein unless specified
otherwise, DHA is present in a concentration of from 0.25 g to 3.0
g per 100 g of oil phase.
[0008] In a third aspect of the present disclosure, which may be
combined with any other aspect listed herein unless specified
otherwise, DHA is present in a concentration of from 1.5 g to 2.5 g
per 100 g of oil phase.
[0009] In a fourth aspect of the present disclosure, which may be
combined with any other aspect listed herein unless specified
otherwise, DHA is present in triglyceride form or ethyl ester form,
preferably triglyceride form.
[0010] In a fifth aspect of the present disclosure, which may be
combined with any other aspect listed herein unless specified
otherwise, the lipid formulation includes eicosapentaenoic acid
(EPA) and the ratio of DHA to EPA in the lipid formulation is 10:1
to 1000:1 (w/w).
[0011] In a sixth aspect of the present disclosure, which may be
combined with any other aspect listed herein unless specified
otherwise, the lipid formulation includes EPA and the ratio of DHA
to EPA in the lipid formulation is 10:1 to 200:1.
[0012] In a seventh aspect of the present disclosure, which may be
combined with any other aspect listed herein unless specified
otherwise, the lipid formulation includes EPA and the ratio of DHA
to EPA in the lipid formulation is 20:1 to 150:1.
[0013] In an eighth aspect of the present disclosure, which may be
combined with any other aspect listed herein unless specified
otherwise, DHA and/or EPA are present in triglyceride form or ethyl
ester form, preferably triglyceride form.
[0014] In a ninth aspect of the present disclosure, which may be
combined with any other aspect listed herein unless specified
otherwise, the lipid formulation is essentially free of EPA.
[0015] In an tenth aspect of the present disclosure, which may be
combined with any other aspect listed herein unless specified
otherwise, the microalgae is Crypthecodinium cohnii or
Schizochytrium sp, preferably Schizochytrium sp.
[0016] In an eleventh aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, the lipid formulation includes about 15 mg to about 35
mg phytosterols per 100 g of oil phase, and in one preferred
embodiment, about 25 mg phytosterols or less per 100 g of oil
phase.
[0017] In a twelfth aspect of the present disclosure, which may be
combined with any other aspect listed herein unless specified
otherwise, the lipid formulation includes one or more
pharmaceutically acceptable surfactants selected from the group
consisting of phospholipids, oleate salts, and combinations
thereof.
[0018] In a thirteenth aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, the phospholipid is selected from the group consisting
of egg phosphatide and soy lecithin.
[0019] In a fourteenth aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, the lipid formulation includes one or more
pharmaceutically acceptable isotonic agents.
[0020] In a fifteenth aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, the pharmaceutically acceptable isotonic agent is
glycerol.
[0021] In a sixteenth aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, the lipid formulation includes one or more
pharmaceutically acceptable antioxidants selected from the group
consisting of tocopherols, ascorbyl palmitate, and combinations
thereof.
[0022] In a seventeenth aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, the lipid formulation has a pH in the range of about 6
to about 9, and in one preferred embodiment, about 7 to about
8.
[0023] In a eighteenth aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, the carbohydrate formulation and/or the amino acid
formulation includes at least one water-soluble form of choline
selected from the group consisting of choline chloride, choline
bitartrate, choline citrate, choline gluconate, choline malate,
choline cytidine diphosphate choline (CDP) salt and
glycerophosphocholine, preferably glycerophosphocholine.
[0024] In a nineteenth aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, the at least one choline is present in a concentration
of from 20 mg to 2000 mg choline equivalent per liter of a
reconstituted multi-chamber container, such as 30 mg to 1000 mg
choline equivalent per liter of a reconstituted multi-chamber
container.
[0025] In a twentieth aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, a method of treating patients who require parenteral
nutrition when oral and enteral nutrition is not possible,
insufficient or contraindicated includes parenterally administering
the contents of a multi-chamber container that includes a lipid
formulation. The lipid formulation has an aqueous phase and an oil
phase, includes about 5% to about 35% by weight of the oil phase
based on the total weight of the lipid formulation, and is present
in the form of an oil-in-water emulsion. Furthermore, the oil phase
comprises docosahexaenoic acid (DHA) obtained from a single cell
source, the single cell source being an extract of microalgae. In
the oil phase, DHA is present in a concentration of from 0.1 g to
5.0 g per 100 g of oil phase. The lipid formulation includes about
70 mg phytosterols or less per 100 g of oil phase, and is
essentially free of water soluble forms of choline and/or
arachidonic acid (ARA).
[0026] In a twenty-first aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the patients are pediatric patients.
[0027] In a twenty-second aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, a lipid formulation for parenteral
administration includes an aqueous phase and an oil phase. The
lipid formulation includes about 5% to about 35% by weight of the
oil phase based on the total weight of the lipid formulation, and
is present in the form of an oil-in-water emulsion. Furthermore,
the aqueous phase includes at least one pharmaceutically acceptable
water soluble form of choline. The oil phase includes
docosahexaenoic acid (DHA). The lipid formulation includes about 70
mg phytosterols or less per 100 g of oil phase, and is essentially
free of arachidonic acid (ARA).
[0028] In a twenty-third aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the DHA is obtained from a single cell source,
the single cell source being an extract of microalgae.
[0029] In a twenty-fourth aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the microalgae is Crypthecodinium cohnii or
Schizochytrium sp, preferably Schizochytrium sp.
[0030] In a twenty-fifth aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, DHA is present in a concentration of from 0.25
g to 3.0 g per 100 g of oil phase.
[0031] In a twenty-sixth aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, DHA is present in a concentration of from 1.5
g to 2.5 g per 100 g of oil phase.
[0032] In a twenty-seventh aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, DHA is present in triglyceride form or ethyl
ester form, preferably triglyceride form.
[0033] In a twenty-eighth aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the lipid formulation includes
eicosapentaenoic acid (EPA) and the ratio of DHA to EPA in the
lipid formulation is 10:1 to 1000:1 (w/w).
[0034] In a twenty-ninth aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the lipid formulation includes EPA and the
ratio of DHA to EPA in the lipid formulation is 10:1 to 200:1
(w/w).
[0035] In a thirtieth aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, the lipid formulation includes EPA and the ratio of DHA
to EPA in the lipid formulation is 20:1 to 150:1 (w/w).
[0036] In a thirty-first aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, DHA and/or EPA are present in triglyceride
form or ethyl ester form, preferably triglyceride form.
[0037] In a thirty-second aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the lipid formulation is essentially free of
EPA.
[0038] In a thirty-third aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the lipid formulation includes 15 mg to 35 mg
phytosterols per 100 g of oil phase, and in one preferred
embodiment, about 25 mg phytosterols or less per 100 g oil
phase.
[0039] In a thirty-fourth aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the lipid formulation includes one or more
pharmaceutically acceptable surfactants selected from the group
consisting of phospholipids, oleate salts, and combinations
thereof.
[0040] In a thirty-fifth aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the phospholipid is selected from the group
consisting of egg phosphatide and soy lecithin.
[0041] In a thirty-sixth aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the lipid formulation includes one or more
pharmaceutically acceptable isotonic agents.
[0042] In a thirty-seventh aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the pharmaceutically acceptable isotonic agent
is glycerol.
[0043] In a thirty-eighth aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the lipid formulation includes one or more
pharmaceutically acceptable antioxidants selected from the group
consisting of tocopherols, ascorbyl palmitate, and combinations
thereof.
[0044] In a thirty-ninth aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the lipid formulation has a pH in the range of
about 6 to about 9, and in one preferred embodiment, about 7 to
about 8.
[0045] In a fortieth aspect of the present disclosure, which may be
combined with any other aspect listed herein unless specified
otherwise, the at least one choline is selected from the group
consisting of choline chloride, choline bitartrate, choline
citrate, choline gluconate, choline malate, choline cytidine
diphosphate choline (CDP) salt and glycerophosphocholine,
preferably glycerophosphocholine.
[0046] In a forty-first aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, the at least one choline is present in a concentration
of from 0.1 g to 12 g of choline equivalent per liter of lipid
emulsion, for example, from 0.2 g to 10 g of choline equivalent per
liter of lipid emulsion, from 3 g to 6 g of choline equivalent per
liter of lipid emulsion, from 0.5 to 4 g of choline equivalent per
liter of lipid emulsion, from 0.1 g to 0.5 g of choline equivalent
per liter of lipid emulsion, from 0.5 g to 1 g of choline
equivalent per liter of lipid emulsion, from 1 g to 2 g of choline
equivalent per liter of lipid emulsion, from 2 g to 3 g of choline
equivalent per liter of lipid emulsion, from 3 g to 4 g of choline
equivalent per liter of lipid emulsion, from 4 g to 5 g of choline
equivalent per liter of lipid emulsion, from 5 g to 6 g of choline
equivalent per liter of lipid emulsion, from 6 g to 7 g of choline
equivalent per liter of lipid emulsion, from 7 g to 8 g of choline
equivalent per liter of lipid emulsion, from 8 g to 9 g of choline
equivalent per liter of lipid emulsion, from 9 g to 10 g of choline
equivalent per liter of lipid emulsion, from 10 g to 11 g of
choline equivalent per liter of lipid emulsion, and/or from 11 g to
12 g of choline equivalent per liter of lipid emulsion.
[0047] In a forty-second aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the at least one choline is present in a
concentration of from 0.2 g to 10 g of choline equivalent per liter
of lipid emulsion.
[0048] In a forty-third aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, the at least one choline is present in a concentration
of from 3 g to 6 g of choline equivalent per liter of lipid
emulsion.
[0049] In a forty-fourth aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, a method of treating patients who require
parenteral nutrition when oral and enteral nutrition is not
possible, insufficient or contraindicated includes parenterally
administering a lipid formulation. The lipid formulation includes
an aqueous phase and an oil phase, about 5% to about 35% by weight
of an oil phase based on the total weight of the lipid formulation,
and is present in the form of an oil-in-water emulsion.
Furthermore, the aqueous phase includes at least one
pharmaceutically acceptable water soluble form of choline. The oil
phase includes docosahexaenoic acid (DHA). The lipid formulation
includes about 70 mg phytosterols or less per 100 g of oil phase,
and is essentially free of arachidonic acid (ARA).
[0050] In a forty-fifth aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, the patients are pediatric patients.
[0051] In a forty-sixth aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, a multi-chamber container for parenteral administration
includes a carbohydrate formulation present in a first chamber, an
amino acid formulation present in a second chamber, and a lipid
formulation present in a third chamber. The lipid formulation
includes an aqueous phase and an oil phase, about 5% to about 35%
by weight of an oil phase based on the total weight of the lipid
formulation, and is present in the form of an oil-in-water
emulsion. Furthermore, the aqueous phase includes at least one
pharmaceutically acceptable water soluble form of choline. The oil
phase includes docosahexaenoic acid (DHA). The lipid formulation
includes about 70 mg phytosterols or less per 100 g of oil phase,
and is essentially free of arachidonic acid (ARA).
[0052] In a forty-seventh aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, a lipid formulation for parenteral
administration includes an aqueous phase and an oil phase. The
lipid formulation includes about 5% to about 35% by weight of the
oil phase based on the total weight of the lipid formulation, and
is present in the form of an oil-in-water emulsion. Furthermore,
the aqueous phase includes at least one pharmaceutically acceptable
water soluble form of choline. The oil phase includes
docosahexaenoic acid (DHA) and arachidonic acid (ARA), and the
ratio of DHA to ARA in the lipid formulation is from 10:1 to 1:5
(w/w). The lipid formulation includes about 70 mg phytosterols or
less per 100 g of oil phase.
[0053] In a forty-eighth aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the ratio of DHA to ARA in the lipid
formulation is 1:1 to 1:3 (w/w).
[0054] In a forty-ninth aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, DHA is obtained from a single cell source, wherein the
single source is an extract of microalgae.
[0055] In a fiftieth aspect of the present disclosure, which may be
combined with any other aspect listed herein unless specified
otherwise, the microalgae is Crypthecodinium cohnii or
Schizochytrium sp, preferably Schizochytrium sp.
[0056] In a fifty-first aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, ARA is obtained from a single cell source, wherein the
cell source is fungi.
[0057] In a fifty-second aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the fungus is Mortierella alpina.
[0058] In a fifty-third aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, DHA and/or ARA are present in triglyceride form or ethyl
ester form, preferably triglyceride form.
[0059] In a fifty-fourth aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, ARA is present in a concentration range of
from 0.1 g to 15 g per 100 g of oil phase.
[0060] In a fifty-fifth aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, ARA is present in a concentration range of from 1.5 g to
7.5 g per 100 g of oil phase.
[0061] In a fifty-sixth aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, DHA is present in a concentration of from 0.25 g to 3.0
g per 100 g of oil phase.
[0062] In a fifty-seventh aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, DHA is present in a concentration of from 1.5
g to 2.5 g per 100 g of oil phase.
[0063] In a fifty-eighth aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the lipid formulation comprises EPA and
wherein the ratio of DHA to EPA in the lipid formulation is 10:1 to
1000:1 (w/w).
[0064] In a fifty-ninth aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, the lipid formulation comprises EPA and the ratio of DHA
to EPA in the lipid formulation is 10:1 to 200:1 (w/w).
[0065] In a sixtieth aspect of the present disclosure, which may be
combined with any other aspect listed herein unless specified
otherwise, the lipid formulation comprises EPA and the ratio of DHA
to EPA in the lipid formulation is 20:1 to 150:1 (w/w).
[0066] In a sixty-first aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, DHA and/or EPA are present in triglyceride form or ethyl
ester form, preferably triglyceride form.
[0067] In a sixty-second aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the lipid formulation is essentially free of
EPA.
[0068] In a sixty-third aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, the lipid formulation includes 15 mg to 35 mg
phytosterols per 100 g of oil phase, and in one preferred
embodiment, about 25 mg phytosterols or less per 100 g oil
phase.
[0069] In a sixty-fourth aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the lipid formulation comprises one or more
pharmaceutically acceptable surfactants selected from the group
consisting of phospholipids, oleate salts, and combinations
thereof.
[0070] In a sixty-fifth aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, the phospholipid is selected from the group consisting
of egg phosphatide and soy lecithin.
[0071] In a sixty-sixth aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, the lipid formulation comprises one or more
pharmaceutically acceptable isotonic agents.
[0072] In a sixty-seventh aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the pharmaceutically acceptable isotonic agent
is glycerol.
[0073] In a sixty-eighth aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the lipid formulation includes one or more
pharmaceutically acceptable antioxidants selected from the group
consisting of tocopherols, ascorbyl palmitate, and combinations
thereof.
[0074] In a sixty-ninth aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, the lipid formulation has a pH in the range of about 6
to about 9, and in one preferred embodiment, about 7 to about
8.
[0075] In a seventieth aspect of the present disclosure, which may
be combined with any other aspect listed herein unless specified
otherwise, the at least one water soluble form of choline is
selected from the group consisting of choline chloride, choline
bitartrate, choline citrate, choline gluconate, choline malate,
choline cytidine diphosphate choline (CDP) salt and
glycerophosphocholine.
[0076] In a seventy-first aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the at least one choline is present in a
concentration of from 0.1 g to 12 g of choline equivalent per liter
of lipid emulsion, for example, from 0.2 g to 10 g of choline
equivalent per liter of lipid emulsion, from 3 g to 6 g of choline
equivalent per liter of lipid emulsion, from 0.5 to 4 g of choline
equivalent per liter of lipid emulsion, from 0.1 g to 0.5 g of
choline equivalent per liter of lipid emulsion, from 0.5 g to 1 g
of choline equivalent per liter of lipid emulsion, from 1 g to 2 g
of choline equivalent per liter of lipid emulsion, from 2 g to 3 g
of choline equivalent per liter of lipid emulsion, from 3 g to 4 g
of choline equivalent per liter of lipid emulsion, from 4 g to 5 g
of choline equivalent per liter of lipid emulsion, from 5 g to 6 g
of choline equivalent per liter of lipid emulsion, from 6 g to 7 g
of choline equivalent per liter of lipid emulsion, from 7 g to 8 g
of choline equivalent per liter of lipid emulsion, from 8 g to 9 g
of choline equivalent per liter of lipid emulsion, from 9 g to 10 g
of choline equivalent per liter of lipid emulsion, from 10 g to 11
g of choline equivalent per liter of lipid emulsion, and/or from 11
g to 12 g of choline equivalent per liter of lipid emulsion.
[0077] In a seventy-second aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the at least one choline is present in a
concentration of from 0.2 g to 10 g of choline equivalent per liter
of lipid emulsion.
[0078] In a seventy-third aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the at least one choline is present in a
concentration of from 3 g to 6 g of choline equivalent per liter of
lipid emulsion.
[0079] In a seventy-fourth aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, the choline is present in a concentration of
from 0.5 to 4 g of choline equivalent per liter of lipid
emulsion.
[0080] In a seventy-fifth aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, a method of treating pediatric patients who
require parenteral nutrition when oral and enteral nutrition is not
possible, insufficient or contraindicated includes parenterally
administering a lipid formulation. The lipid formulation includes
an aqueous phase and an oil phase, about 5% to about 35% by weight
of the oil phase based on the total weight of the lipid
formulation, and is present in the form of an oil-in-water
emulsion. Furthermore, the aqueous phase includes at least one
pharmaceutically acceptable water soluble form of choline. The oil
phase includes docosahexaenoic acid (DHA) and arachidonic acid
(ARA), and the ratio of DHA to ARA in the lipid formulation is from
10:1 to 1:5 (w/w). The lipid formulation includes about 70 mg
phytosterols or less per 100 g of oil phase.
[0081] In a seventy-sixth aspect of the present disclosure, which
may be combined with any other aspect listed herein unless
specified otherwise, a multi-chamber container for parenteral
administration includes a carbohydrate formulation present in a
first chamber, an amino acid formulation present in a second
chamber, and a lipid formulation present in a third chamber. The
lipid formulation includes an aqueous phase and an oil phase, about
5% to about 35% by weight of the oil phase based on the total
weight of the lipid formulation, and is present in the form of an
oil-in-water emulsion. Furthermore, the aqueous phase includes at
least one pharmaceutically acceptable water soluble form of
choline. The oil phase includes docosahexaenoic acid (DHA) and
arachidonic acid (ARA), and the ratio of DHA to ARA in the lipid
formulation is from 10:1 to 1:5 (w/w). The lipid formulation
includes about 70 mg phytosterols or less per 100 g of oil
phase
[0082] In light of the disclosure and aspects set forth herein, it
is accordingly an advantage of the present disclosure to provide a
parenteral nutrition formulation that better meets the requirements
of pediatric patients.
[0083] It is another advantage of the present disclosure to provide
a beneficial impact on visual, somatic, and/or neural
development.
[0084] It is a further advantage of the present disclosure to
reduce parenteral nutrition-associated liver disease (PNALD), which
is associated with liver failure, hepatic steatosis, and
cirrhosis.
[0085] It is yet another advantage of the present disclosure to
reduce non-alcoholic fatty liver disease (NAFLD).
[0086] It is yet a further advantage of the present disclosure to
reduce chronic liver disease.
[0087] It is still a further advantage of the present disclosure to
deplete phytosterols.
[0088] Additional features and advantages of the disclosed
formulations are described in, and will be apparent from, the
following Detailed Description and the Figures. The features and
advantages described herein are not all-inclusive and, in
particular, many additional features and advantages will be
apparent to one of ordinary skill in the art in view of the figures
and description. Also, any particular embodiment does not
necessarily have to have all of the advantages listed herein.
Moreover, it should be noted that the language used in the
specification has been principally selected for readability and
instructional purposes, and not to limit the scope of the inventive
subject matter.
BRIEF DESCRIPTION OF THE FIGURES
[0089] Understanding that figures depict only typical embodiments
of the invention and are not to be considered to be limiting the
scope of the present disclosure, the present disclosure is
described and explained with additional specificity and detail
through the use of the accompanying figures.
[0090] FIG. 1 is a plan view of one embodiment of a 300 ml
container of the present invention.
[0091] FIG. 2 depicts the development of the alanine
aminotransferase (ALT) function in the animal study described in
Example 1. Control groups received saline solution (NaCl) or lipid
emulsion LE 10% only, whereas further groups received the same LE
10% lipid emulsion, however with three different choline sources,
choline chloride, CDP-choline and GPC contained in the lipid
emulsion. The expression "high" denotes a concentration of the
choline derivative of 31 mmol/L in the LE 10% lipid emulsion. The
graph shows that the drop of ALT activity from day 5 to day 17,
demonstrating an improvement of the liver condition, is most
pronounced when GPC is present in the lipid emulsion.
[0092] FIG. 3 shows the development of the alanine aminotransferase
activity in percent of the normal value for plasma in an animal
study as described in Example 1 (Step #3). The animals tested
received either saline solution or LE 10% lipid emulsion ("LE 10%")
only, wherein the lipid emulsion contained normal amounts of
phytosterol ("Phyto") but no GPC. Another lipid emulsion,
containing also LE 10% and comparable amounts of phytosterol,
further contained GPC in a concentration of 40 mmol/L ("LE 10%+GPC
Step #2"). A third composition was again consisting of a lipid
emulsion (LE 13%) with GPC added at a concentration of 40 mmol/L
and a reduced phytosterol content (phytosterol doses are given in
FIG. 3).
[0093] FIG. 4A and FIG. 4B represent the results of the animal
study as described in Example 1 and the histopathological
evaluation of the livers of animals that had been subjected to
parenteral nutrition with saline solution, LE 10% lipid emulsion,
and LE 10% lipid emulsions supplemented with choline chloride,
CDP-choline and GPC, respectively (FIG. 4A). FIG. 4A shows that the
administration of a lipid emulsion comprising GPC has the most
significant impact on the development of vacuolation in comparison
with all choline derivatives tested. FIG. 4B provides for the
results of administering again saline solution alone, a lipid
emulsions (LE 13%) which has been supplemented with DHA and ARA
(triangles) and a lipid emulsion (LE 13%) which has been
supplemented with DHA, ARA and GPC (squares). FIG. 4B shows that
the presence of DHA and ARA already has a significant positive
effect on liver vacuolation. The expression "low" refers to a
concentration of the respective choline derivative of 15 mmol/L.
The expression "high" refers to a choline derivative concentration
of 31 mmol/L. Grades are defined as provided for in Example
3.3.
[0094] FIG. 5 represents the results of the animal study as
described in Example 1, wherein the influence of the parenteral
administration of various lipid emulsions was determined based on
the ratio of liver weight and body weight in percent. The study
animals were treated with either saline solution, LE 10% lipid
emulsion ("Lipid emulsion 10%") without any choline derivative, and
the same LE 10% lipid emulsion further containing 31 mmol/L of a
choline derivative as shown. The expression "high" refers to a
choline derivative concentration in the lipid emulsion of 31
mmol/L.
[0095] FIG. 6 shows exemplary photographs of Grade 1 to 5
vacuolation determined in the histopathological analysis of the
liver of study animals (see Examples 1 and 3). The histological
slides shown were stained with hematoxylin-eosin. Grades were
assigned according to the following scheme: FIG. 6A: GRADE
1=Minimal/very few/very small vacuoles, scattered. FIG. 6B: GRADE
2=Slight/few/small vacuoles, centrilobular to midzonal. FIG. 6C:
GRADE 3=Moderate/moderate number/moderate size vacuoles,
centrilobular to midzonal. FIG. 6D: GRADE 4=Marked/many/large
vacuoles, centrilobular to periportal. FIG. 6E: GRADE
5=Severe/many/large vacuoles, diffuse, all liver regions
affected.
DETAILED DESCRIPTION
[0096] Certain embodiments described herein relate generally to the
field of parenteral nutrition. More particularly, some embodiments
described herein relate to lipid formulations for parenteral
administration, wherein the lipid formulation comprises an aqueous
phase and an oil phase and the lipid formulation is present in the
form of an oil-in-water emulsion. Related embodiments described
herein relate to multi-chamber containers for parenteral
administration, wherein the containers comprise a carbohydrate
formulation in a first chamber, an amino acid formulation in a
second chamber, and a lipid formulation in a third chamber.
[0097] As used herein, the term "pediatric" may refer to neonates,
including premature, full term, and post-mature neonates of up to
one month of age; infants of between one month and one year of age;
children of between one and up to 12 years of age, and adolescents
of between 13 and up to 21 years of age.
[0098] As used herein, the term "long-chain polyunsaturated fatty
acid" may refer to a polyunsaturated fatty acid having at least 18
carbon atoms in the fatty acid portion of the molecule (i.e., the
portion of the molecule that excludes any carbon atoms that form an
ester moiety), for example, at least 20 carbon atoms, at least 22
carbon atoms, or at least 24 carbon atoms in the fatty acid portion
of the molecule.
[0099] As used herein, the term "essentially free" may refer to a
composition that contains no more than 5% of the specified
component, for example, no more than 3%, no more than 2%, no more
than 1%, no more than 0.5%, no more than 0.1%, no more than 0.05%,
no more than 0.02%, no more than 0.01%, no more than 0.005%, no
more than 0.002%, and/or no more than 0.001% of the specified
component. For example, a composition that is "essentially free of
EPA" may refer to a composition that contains no more than 5% EPA,
such as no more than 3%, no more than 2%, no more than 1%, no more
than 0.5%, no more than 0.1%, no more than 0.05%, no more than
0.02%, no more than 0.01%, no more than 0.005%, no more than
0.002%, and/or no more than 0.001% EPA.
[0100] The expressions "liver disease", "liver injury" and "liver
damage" are interchangeably used herein. The expression refers to a
condition of the liver which is defined by an increased alanine
aminotransferase (ALT) activity, histologically determined
vacuolation, as well as increase in the ratio of liver weight per
body weight. Specifically, the expressions refer to hepatic
steatosis which can be diagnosed by means of the above markers.
More specifically, they refer to NAFLD. Even more specifically,
they refer to NAFLD caused by choline deficiency, especially
choline deficiency caused by long-term total parenteral
nutrition.
Lipid Formulations
[0101] The disclosure provides lipid formulations for parenteral
administration. The lipid formulations disclosed herein include an
aqueous phase and an oil phase and are present in the form of an
oil-in-water emulsion. Typically, the lipid formulation includes an
aqueous phase and about 5% to about 35% by weight of an oil phase
based on the total weight of the lipid formulation. For example,
oil phase of the lipid formulation is present in an amount about
10% to about 20%, about 10% to about 15%, about 15% to about 20%,
about 12% to about 17%, about 11%, about 12%, about 13%, about 14%,
about 15%, about 16%, about 17%, about 18%, and/or about 19% by
weight based on the total weight of the lipid formulation.
[0102] The aqueous phase of the lipid formulation includes water.
In some cases, the aqueous phase of the lipid formulation includes
at least one water soluble form of choline. As used herein, "water
soluble form of choline" refers to (1) water soluble salts
containing the N,N,N-trimethylethanolammonium cation and (2) water
soluble compounds containing a choline moiety, such as cytidine
diphosphate choline or glycerophosphocholine. The water soluble
form of choline may be selected from the group consisting of
choline chloride, choline bitartrate, choline citrate, choline
gluconate, choline malate, choline cytidine diphosphate choline
(CDP) salt (e.g., sodium salt, potassium salt, or inner salt), and
glycerophosphocholine. In a preferred embodiment, the water-soluble
form of choline is present in a concentration of from 0.1 g to 12 g
of choline equivalent per liter of lipid emulsion, for example,
from 0.2 g to 10 g of choline equivalent per liter of lipid
emulsion, from 3 g to 6 g of choline equivalent per liter of lipid
emulsion, from 0.5 to 4 g of choline equivalent per liter of lipid
emulsion, from 0.1 g to 0.5 g of choline equivalent per liter of
lipid emulsion, from 0.5 g to 1 g of choline equivalent per liter
of lipid emulsion, from 1 g to 2 g of choline equivalent per liter
of lipid emulsion, from 2 g to 3 g of choline equivalent per liter
of lipid emulsion, from 3 g to 4 g of choline equivalent per liter
of lipid emulsion, from 4 g to 5 g of choline equivalent per liter
of lipid emulsion, from 5 g to 6 g of choline equivalent per liter
of lipid emulsion, from 6 g to 7 g of choline equivalent per liter
of lipid emulsion, from 7 g to 8 g of choline equivalent per liter
of lipid emulsion, from 8 g to 9 g of choline equivalent per liter
of lipid emulsion, from 9 g to 10 g of choline equivalent per liter
of lipid emulsion, from 10 g to 11 g of choline equivalent per
liter of lipid emulsion, and/or from 11 g to 12 g of choline
equivalent per liter of lipid emulsion. In a further preferred
embodiment, the water soluble form of choline is
glycerophosphocholine in a concentration of from 0.1 g to 15.0 g
per liter of lipid emulsion, for example, from 0.1 g to 6.0 g per
liter of lipid emulsion, from 0.1 g to 2.0 g per liter of lipid
emulsion, from 0.2 g to 0.9 g per liter of lipid emulsion, from 0.5
to 6.0 g per liter of lipid emulsion, from 0.5 g to 5.0 g per liter
of lipid emulsion, from 0.5 g to 4.0 g per liter of lipid emulsion,
from 0.5 g to 3.0 g per liter of lipid emulsion, from 1.0 g to 12.0
g per liter of lipid emulsion, from 1.0 g to 10.0 g per liter of
lipid emulsion, from 1.0 g to 5.0 g per liter of lipid emulsion,
from 2.0 g to 12.0 g per liter of lipid emulsion, from 2.0 g to 9.0
g per liter lipid emulsion, from 2.0 g to 4.0 g per liter of lipid
emulsion, from 4.0 g to 11.0 g per liter of lipid emulsion, from
4.0 g to 10.0 g per liter of lipid emulsion, or from 5.0 g to 12.0
g per liter of lipid emulsion.
[0103] The oil phase of the lipid formulation includes
polyunsaturated fatty acids, such as long-chain polyunsaturated
fatty acids, which may be present as the free acid, as an ionized
or salt form of the free acid, and/or in ester form. Suitable
esters of the polyunsaturated fatty acids/long-chain
polyunsaturated fatty acids include, but are not limited to, alkyl
esters (e.g., methyl esters, ethyl esters, propyl esters, or
combinations thereof) and triglyceride esters. In some cases, the
long-chain polyunsaturated fatty acid has a structure
R(C.dbd.O)OR', wherein R is an alkenyl group having at least 17
carbon atoms, at least 19 carbon atoms, at least 21 carbon atoms,
or at least 23 carbon atoms, and R' is absent, H, a counter ion, an
alkyl group (e.g., methyl, ethyl, or propyl), or a glyceryl group
(e.g., R(C.dbd.O)OR' is a monoglyceride, a diglyceride, or a
triglyceride). Polyunsaturated fatty acids for use in the lipid
formulations disclosed herein include, but are not limited to,
linoleic acid (LA), arachidonic acid (ARA), .alpha.-linolenic acid
(ALA), eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA),
stearidonic acid (SDA), .gamma.-linolenic acid (GLA),
dihomo-.gamma.-linolenic acid (DPA), and docosapentaenoic acid
(DPA), particularly, DHA, ARA, and EPA, each of which may be
present in free acid form, ionized or salt form, alkyl ester form,
and/or triglyceride form. In some cases, the polyunsaturated fatty
acids and/or long-chain fatty acids are present in triglyceride
form.
[0104] In some cases, the polyunsaturated fatty acids for the lipid
formulations (e.g., the long-chain polyunsaturated fatty acids),
are obtained from a single source. In some cases, the single source
is an extract of microalgae. Suitable micro-algal sources include,
but are not limited to, Crypthecodinium cohnii and Schizochytrium
sp. In some cases, Crypthecodinium cohnii or Schizochytrium sp. is
the single source of the long-chain polyunsaturated fatty acid DHA.
In some cases, the amount of DHA in an oil isolated from
Schizochytrium sp. will be about 250 to about 700 mg/g of oil, such
as about 300 to about 600 mg/g, about 350 to about 550 mg/g, and/or
about 400 to about 500 mg/g of oil.
[0105] When the lipid formulation includes Schizochytrium sp. as
the single source of polyunsaturated fatty acids, the lipid
formulation includes DHA in relatively greater amount that EPA or
ARA. For example, when Schizochytrium sp. is the single source of
the polyunsaturated fatty acids in the lipid formulation, the ratio
of DHA to EPA in the lipid formulation is typically at least 10:1
(w/w), for example about 10:1 to about 1000:1 (w/w), about 20:1 to
about 1000:1 (w/w), about 50:1 to about 1000:1 (w/w), about 100:1
to about 1000:1 (w/w), about 10:1 to about 200:1 (w/w), about 20:1
to about 150:1 (w/w), at least about 50:1 (w/w), at least about
100:1 (w/w), at least about 500:1 (w/w), and/or at least about
1000:1 (w/w). Further, when Schizochytrium sp. is the single source
of the polyunsaturated fatty acids in the lipid formulation, the
ratio of DHA to ARA in the lipid formulation is typically at least
20:1 (w/w), for example about 20:1 to about 1000:1 (w/w), about
50:1 to about 1000:1 (w/w), about 100:1 to about 1000:1 (w/w), at
least about 50:1 (w/w), at least about 100:1 (w/w), at least about
500:1 (w/w), and/or at least about 1000:1 (w/w).
[0106] In some cases, the oil phase includes DHA obtained from a
single cell source, wherein the single cell source is an extract of
microalgae. In some cases, DHA is present in a concentration of
from 0.1 g to 5.0 g per 100 g of oil phase, for example, 0.25 g to
3.0 g per 100 g of oil phase, and/or 1.5 g to 2.5 g per 100 g of
oil phase. In some cases, the lipid formulation comprises
eicosapentaenoic acid (EPA) and the ratio of DHA to EPA in the
lipid formulation is 10:1 to 1000:1 (w/w), for example, 10:1 to
200:1 (w/w) and/or 20:1 to 150:1 (w/w).
[0107] In some cases, the lipid formulation is essentially free of
EPA.
[0108] In some cases, the lipid formulation is essentially free of
water soluble forms of choline, such as water soluble salts
containing the N,N,N-trimethylethanolammonium cation and/or water
soluble compounds containing a choline moiety.
[0109] In some cases, the lipid formulation is essentially free of
ARA.
[0110] In some cases, the oil phase includes a blend of oils
derived from the microalgae Schizochytrium sp. and the fungi
Mortierella alpina. The oils in such a blend include, but are not
limited to, myristic acid (C14:0), palmitic acid (C16:0),
palmitoleic acid (C16:1), stearic acid (C18:0), oleic acid (C18:1),
linoleic acid (C18:2 n-6), gamma-linolenic acid (C18:3, n-6),
alpha-linolenic acid (C18:3, n-3), arachidic acid (C20:0), ARA
(C20:4, n-6), EPA (C20:5, n-3), behenic acid (C22:0), DPA (C22:5,
n-3), DHA (C22:6, n-3), and lignoceric acid (C24:0). In some cases,
the blend includes ARA, DHA, and EPA.
[0111] In some cases, ARA is included in the lipid formulation.
When ARA is added to the lipid formulation, the formulation
typically contains a greater amount of ARA than when Schizochytrium
sp. is the single source of the polyunsaturated fatty acids in the
lipid formulation. In some cases, the ratio of DHA to ARA in the
lipid formulation is about 10:1 to about 1:5 (w/w), for example,
about 5:1 to about 1:5 (w/w), about 3:1 to 1:3 (w/w), about 1:1 to
about 1:3 (w/w), about 1:1.5 to about 1:2.5 (w/w), such as about
1:2 (w/w). Further, when ARA is added to the lipid formulation, the
ratio of DHA to EPA in the lipid formulation can be at least 10:1
(w/w), for example about 10:1 to about 1000:1 (w/w), about 20:1 to
about 1000:1 (w/w), about 50:1 to about 1000:1 (w/w), about 100:1
to about 1000:1 (w/w), about 10:1 to about 200:1 (w/w), about 20:1
to about 150:1 (w/w), at least about 50:1 (w/w), at least about
100:1 (w/w), at least about 500:1 (w/w), and/or at least about
1000:1 (w/w).
[0112] In some cases, the oil phase includes ARA obtained from a
single cell source, wherein the single cell source is fungi, such
as an extract of fungi. In a preferred embodiment, the fungus is
Mortierella alpina. In some cases, ARA is present in a
concentration of from 0.1 g to 15 g per 100 g of oil phase, for
example, from 1.5 g to 7.5 g per 100 g of oil phase.
[0113] The lipid formulations disclosed herein typically include
reduced levels of phytosterols. In particular, the oils used in the
lipid formulations have been depleted in phytosterols, typically by
an amount of at least 25% of the total amount of phytosterols
initially present in the oil, for example, at least 40%, at least
50%, at least 60%, and/or at least 75% depleted. In some cases, the
lipid formulations include 70 mg phytosterols or less per 100 g of
oil phase, for example, about 15 mg to about 35 mg phytosterols per
100 g of oil phase, and/or about 25 mg phytosterols or less per 100
g of oil phase. Removal or depletion of phytosterols can be carried
out by, for example, short path distillation, active charcoal
treatment following by filtration, supercritical CO.sub.2
chromatography, or chromatographic purification.
[0114] The lipid formulations disclosed herein may further include
saturated, monounsaturated, and polyunsaturated fatty acids. In
some cases, these fatty acids are present in a concentration of
from 95 g to 99.1 g per 100 g of oil phase, for example, 97 g to
99.75 per 100 g of oil phase, and/or 97.5 g to 98.5 g per 100 g of
oil phase. In some cases, these fatty acids may be obtained from
animal and/or plant sources. In some cases, these fatty acids may
be present mainly as triglycerides.
[0115] The lipid formulations disclosed herein may further include
additional components, such as surfactants (also referred to as
emulsifiers), co-surfactants, isotonic agents, pH adjusters, and
antioxidants. Generally, surfactants are added to stabilize
emulsions by reducing the interfacial tension between the oil phase
and the aqueous phase. Surfactants typically include a hydrophobic
part and a hydrophilic part, and the amount of
surfactant/emulsifier included in the formulations is determined
based on the amount that is needed to achieve a desired level of
stabilization of the emulsion. Typically, the amount of surfactant
in the lipid formulation is about 0.01% to about 3% by weight based
on the total weight of the lipid formulation, for example, about
0.01% to about 2.5%, about 0.01% to about 2.3%, about 0.02% to
about 2.2%, about 0.02% to about 2.1%, about 0.02% to about 2%,
about 0.05% to about 1.8%, about 0.1% to about 1.6%, about 0.5% to
about 1.5%, about 0.8% to about 1.4%, about 0.9% to about 1.3%,
about 1% to about 1.2%, and/or about 1.2% by weight. Suitable
surfactants and co-surfactants include surfactants that are
approved for parenteral use, and include, but are not limited to,
phospholipids (e.g., egg phosphatide and soy lecithin), oleate
salts, and combinations thereof. An exemplary surfactant is
lecithin, including both natural and synthetic lecithin, such as
lecithins derived from egg, corn or soybean or mixtures thereof. In
some cases, lecithin is included in an amount of about 1.2% based
on the total weight of the lipid formulation. In some cases, the
lipid emulsion formulation includes a co-surfactant. Typically, the
amount of co-surfactant in the lipid formulation is less than the
amount of surfactant, and typically the amount of co-surfactant in
the formulation is about 0.001% to about 0.6% by weight based on
the total weight of the lipid formulation, for example, about
0.001% to about 0.55%, about 0.001% to about 0.525%, about 0.001%
to about 0.5%, about 0.005% to about 0.5%, about 0.01% to about
0.4%, about 0.02% to about 0.3%, about 0.03% to about 0.2%, about
0.04% to about 0.1%, and/or about 0.05% to about 0.08%. An
exemplary co-surfactant is oleate, such as sodium oleate. In some
cases, the lipid formulation includes lecithin and oleate as
surfactant and co-surfactant, for example, an in amount of 1.2%
lecithin and 0.03% oleate. In some cases, sodium oleate is included
in an amount of about 0.03% by weight based on the total weight of
the lipid formulation.
[0116] Isotonic agent can be added to the lipid formulations to
adjust the osmolarity of the lipid emulsion formulation to a
desired level, such as a physiologically acceptable level. Suitable
isotonic agents include, but are not limited to, glycerol.
Typically, the lipid emulsion formulation has an osmolarity of
about 180 to about 300 milliosmols/liter, such as about 190 to
about 280 milliosmols/liter, and/or about 200 to about 250
milliosmols/liter. In some cases, the lipid emulsion formulation
includes an isotonic agent in an amount of about 1% to about 10% by
weight based on the total weight of the lipid formulation, such as
about 1% to about 5%, about 1% to about 4%, and/or about 2% to
about 3%. In some cases, the lipid emulsion formulation includes
about 2% to about 3% by weight of glycerol.
[0117] pH modifiers can be added to the lipid formulations to
adjust the pH to a desired level, such as a physiologically
acceptable pH for parenteral use. Suitable pH modifiers include,
but are not limited to sodium hydroxide and hydrochloric acid.
Typically, the lipid emulsion formulation has a pH of about 6 to
about 9, such as about 6.1 to about 8.9, about 6.2 to about 8.8,
about 6.3 to about 8.7, about 6.4 to about 8.6, about 6.5 to about
8.5, about 6.6 to about 8.4, about 6.7 to about 8.3, about 6.8 to
about 8.2, about 6.9 to about 8.1, about 7 to about 8, about 7.1 to
about 7.9, about 7.2 to about 7.8, about 7.3 to about 7.7, about
7.4 to about 7.6, about 7, about 7.5, and/or about 8.
[0118] The lipid formulations may further include antioxidants.
Suitable antioxidants may be pharmaceutically acceptable
antioxidants and include, but are not limited to, tocopherols
(e.g., gamma tocopherol, delta tocopherol, alpha tocopherol),
ascorbyl palmitate, or combinations thereof. In some cases, the
lipid emulsion formulation includes an antioxidant in an amount of
about 0 to about 200 mg/L, for example, about 10 to about 200 mg/L,
about 40 to about 150 mg/L, about 50 to about 120 mg/L, about 75 to
about 100 mg/L antioxidant, such as vitamin E.
[0119] The aqueous (or water) phase of all intravenous lipid
emulsions must conform to the pharmacopeial requirements that make
it suitable for injection, that is, the water must be sterile water
for injection.
[0120] Also included in the disclosure are lipid emulsions wherein
the choline source (e.g., GPC), if present, is added, e.g. through
a medical port, to a ready-to-use lipid emulsion or a reconstituted
solution before administration to a patient. The choline source
(e.g., GPC) can be provided in the form of a suitable solution, for
example in a vial or a suitable flexible or rigid container, or can
be provided in lyophilized form, for example in a glass vial,
wherein the lyophilized choline source (e.g., GPC) is dissolved in
a suitable solvent before adding it to the lipid emulsion or
reconstituted solution. The choline source (e.g., GPC) can be
present as the single active component in such solution or
lyophilisate for addition to a lipid emulsion or reconstituted
solution, or can be present in combination with at least one
further active component such as, for example, vitamins, trace
elements, DHA, EPA and/or ARA. Therefore, according to another
embodiment of the invention, a method of providing a choline source
(e.g., GPC) to a patient is provided, wherein the choline source
(e.g., GPC) is added to a ready-to-use lipid emulsion or a
reconstituted solution from a MCB providing for formulations for
parenteral nutrition before administration.
[0121] A first lipid formulation according to the disclosure
includes an oil phase comprising docosahexaenoic acid (DHA)
obtained from a single cell source, wherein the single cell source
is an extract of microalgae and wherein DHA is present in a
concentration of from 0.1 g to 5.0 g per 100 g of oil phase.
Further, the oils provided for the first lipid formulation have
been depleted in phytosterols such that the lipid formulation
includes about 70 mg phytosterols or less per 100 g of oil phase.
Additionally, the first lipid formulation is essentially free of
water soluble forms of choline and/or arachidonic acid (ARA). As
discussed in more detail herein, the first lipid formulation
includes an aqueous phase and about 5% to about 35% by weight of an
oil phase based on the total weight of the lipid formulation and
the lipid formulation is present in the form of an oil-in-water
emulsion.
[0122] A second lipid formulation according to the disclosure
includes at least one pharmaceutically acceptable water soluble
form of choline and an oil phase comprising docosahexaenoic acid
(DHA). Further, the oils provided for the second lipid formulation
have been depleted in phytosterols such that the lipid formulation
includes about 70 mg phytosterols or less per 100 g of oil phase.
Additionally, lipid formulation is essentially free of arachidonic
acid (ARA). As discussed in more detail herein, the second lipid
formulation comprises an aqueous phase and about 5% to about 35% by
weight of an oil phase based on the total weight of the lipid
formulation and the lipid formulation is present in the form of an
oil-in-water emulsion.
[0123] A third lipid formulation according to the disclosure
includes at least one pharmaceutically acceptable water soluble
form of choline, and an oil phase comprising docosahexaenoic acid
(DHA) and arachidonic acid (ARA). The third lipid formulation has a
ratio of DHA to ARA in the lipid formulation is 10:1 to 1:5 (w/w).
Further, the oils provided for the third lipid formulation have
been depleted in phytosterols such that the lipid formulation
includes about 70 mg phytosterols or less per 100 g of oil phase.
As discussed in more detail herein, the third lipid formulation
comprises an aqueous phase and about 5% to about 35% by weight of
an oil phase based on the total weight of the lipid formulation and
the lipid formulation is present in the form of an oil-in-water
emulsion.
[0124] In some cases, an oil phase according to the disclosure
comprises omega-3 fatty acids consisting of DHA and a low amount of
EPA, and omega-6 fatty acids such as ARA.
[0125] The lipid emulsions disclosed herein can be prepared
according to generally known processes (see, for example,
Hippalgaonkar et al, AAPS PharmSciTech 2010, 11(4), 1526-1540).
Generally, water soluble and oil-soluble ingredients are dissolved
in the aqueous phase and oil phase, respectively. Accordingly, the
choline source, if present, is dissolved in the aqueous phase.
Emulsifiers, such as phosphatides, can be dispersed in either oil
or aqueous phase. Both phases are adequately heated and stirred to
disperse or dissolve the ingredients. The lipid phase is then
generally added to the aqueous phase under controlled temperature
and agitation (using high-shear mixers) to form a homogenously
dispersed coarse or pre-emulsion. Pre-emulsions with a droplet size
smaller than 20 .mu.m generally produces unimodal and physically
stable fine emulsions. The pre-emulsion is then homogenized (using
a microfluidizer or a high-pressure homogenizer) at optimized
pressure, temperature, and number of cycles to further reduce the
droplet size and form a fine emulsion. Factors such as type and
concentration of oil phase and surfactants, operating temperature,
pressure, number of cycles, etc. can influence the mean droplet
size during high-pressure homogenization and microfluidization.
Throughout the shelf-life of an emulsion, the mean droplet size and
PFATS (volume-weighted percentage of fat globules.gtoreq.5 .mu.m)
of an injectable fine emulsion should be .ltoreq.500 nm and
.ltoreq.0.05%, respectively. The pH of the resulting fine emulsion
is then adjusted to the desired value and the emulsion is filtered
through 1-5 .mu.m filters. The fine emulsions are then transferred
into suitable containers. Plastic containers which are permeable to
oxygen and/or contain oil-soluble plasticizers and usually avoided.
The entire process (filtration/coarse and fine emulsion
preparation) is usually carried out under nitrogen atmosphere
whenever possible and especially in cases where the excipients and
specific components of the lipid emulsion are sensitive to
oxidation. Sterilization of the lipid formulations can be achieved
by terminal heat sterilization or by aseptic filtration. Terminal
sterilization generally provides greater assurance of sterility of
the final product. However, if the components of the emulsions are
heat labile, sterile filtration can be used. Sterilization by
filtration requires the emulsion droplet size to be below 200 nm.
Alternatively, aseptic processing may be employed. However, this
process is relatively equipment and labor intensive and requires
additional process validation data and justification during
regulatory submissions.
[0126] Accordingly, lipid emulsions according to the invention can
be prepared by the following steps comprising: [0127] a. Separately
heating up the oil phase and the aqueous phase to a temperature of
from about 70.degree. C. to about 80.degree. C. under agitation;
[0128] b. Adding a choline source such as glycerophosphocholine to
the aqueous phase; [0129] c. Preparing the pre-emulsion by
transferring the oil phase to the aqueous phase under agitation;
[0130] d. Homogenizing the pre-emulsion at a temperature of from
about 40.degree. C. to 60.degree. C. under pressure; [0131] e.
Optionally adding water to adjust the required volume and
concentrations; [0132] f. Optionally adjusting the pH to a range of
from about 7.8 to 8.8; and [0133] g. Optionally sterilizing the
lipid emulsion.
[0134] Sterilization can be done by methods known in the art, such
as, for example, by heat. Usually, steps (a) through (d) will be
performed in the presence of an inert gas, such as N.sub.2, for
avoiding any oxidation reactions. The pressure used for
homogenization of the pre-emulsion can vary over a broad range.
Generally, it will be in a range of from 100 to 1300 bar, from 200
to 1000 bar, from 300 to 800 bar, or from 400 to 1100 bar.
Amino Acid Formulations
[0135] The amino acid formulation includes a sterile, aqueous
solution of one or more amino acids and one or more electrolytes.
Typically, the amino acid formulation includes about 2 grams to
about 10 grams of amino acids per 100 mL of amino acid formulation,
such as about 3 grams to about 9 grams, about 4 grams to about 8
grams, and/or about 5 grams to about 7 grams per 100 mL of amino
acid formulation. The amino acid formulation generally includes
isoleucine, leucine, valine, lysine, methionine, phenylalanine,
threonine, tryptophan, arginine, histidine, alanine, aspartic acid,
cysteine, glutamic acid, glycine, proline, serine, tyrosine,
ornithine, and taurine. Further, the content of tyrosine can be
increased by adding, for example, a glycyl-tyrosine dipeptide or
acetyl-tyrosine (Ac-Tyr). Typically, however, the glycyl-tyrosine
dipeptide has improved pharmacokinetics compared to Ac-Tyr, which
is more rapidly eliminated by the kidney, resulting in diminished
release of tyrosine in the blood.
[0136] The amino acid formulation may further include electrolytes
such as sodium, potassium, calcium, magnesium, and/or phosphate
ions. For example, the amino acid formulation can include from
about 0.1 mmol to about 10 mmol of sodium (e.g., about 3.75 mmol to
about 10 mmol of sodium), from about 0.1 mmol to about 10 mmol of
potassium (e.g., about 3.75 mmol to about 6.90 mmol of potassium),
from about 0.05 mmol to about 1.0 mmol of magnesium (e.g., about
0.05 mmol to about 0.11 mmol and/or about 0.38 mmol to about 0.65
mmol of magnesium), from about 0.1 mmol to about 10 mmol of calcium
(e.g., about 1.13 mmol to about 5.10 mmol of calcium), from about
0.1 mmol to about 10 mmol of phosphate (e.g., about 0.94 mmol to
about 5.10 mmol of phosphate) and not more than 10 mmol of chloride
(e.g., not more than 5.6 mmol of chloride) per 100 mL of amino acid
formulation. When calcium and phosphorus are present together in
the same heat-sterilized solution, insoluble calcium phosphate
precipitation can occur. Using an organic salt of phosphorus such
as sodium glycerophosphate 5.H.sub.2O or calcium glycerophosphate,
calcium and phosphate amounts may be increased without solubility
issues and without providing excess sodium or chloride. In the
amino acid formulation, sodium may be provided in the form of
sodium chloride, calcium may be provided in the form of calcium
chloride 2.H.sub.2O or calcium gluconate, magnesium may be provided
in the form of magnesium acetate 4.H.sub.2O or magnesium chloride,
and potassium may be provided in the form of potassium acetate.
[0137] The amino acid formulation may further include a
water-soluble form of choline selected from the group consisting of
choline chloride, choline bitartrate, choline citrate, choline
gluconate, choline malate, choline cytidine diphosphate choline
(CDP) salt and glycerophosphocholine. In a preferred embodiment,
the water-soluble form of choline is present in a concentration of
from 20 mg to 2000 mg choline equivalent per liter of the
reconstituted multi-chamber container, for example, from 30 mg to
1000 mg choline equivalent per liter of the reconstituted
multi-chamber container.
Carbohydrate Formulations
[0138] The carbohydrate formulations provide a supply of calories,
typically in the form of glucose. In particular, the carbohydrate
formulation provides an amount of carbohydrate sufficient to avoid
adverse effects such as hyperglycemia that has been observed in
patients receiving parenteral nutrition. Typically, the
carbohydrate formulation includes about 20 to 50 grams of glucose
per 100 mL of carbohydrate formulation.
[0139] The carbohydrate formulation may further include a
water-soluble form of choline selected from the group consisting of
choline chloride, choline bitartrate, choline citrate, choline
gluconate, choline malate, choline cytidine diphosphate choline
(CDP) salt and glycerophosphocholine. In a preferred embodiment,
the water-soluble form of choline is present in a concentration of
from 20 mg to 2000 mg choline equivalent per liter of the
reconstituted multi-chamber container, for example, from 30 mg to
1000 mg choline equivalent per liter of the reconstituted
multi-chamber container.
Multi-Chamber Containers
[0140] The disclosure provides a multi-chamber container for
parenteral administration of nutritional formulations. For example,
the container may be in the form of a bag having multiple
compartments or chambers. The container, such as a bag, includes at
least two chambers, such as three, four, or five chambers, and in
one preferred embodiment, three chambers. Suitable containers,
including bags, typically are sterile, non-pyrogenic, single-use,
and/or ready-to-use. The multi-chamber containers are particularly
useful for holding a pediatric and/or neonatal parenteral nutrition
product and generally provide a carbohydrate formulation as
disclosed herein in the first chamber, an amino acid formulation as
disclosed herein in a second chamber, and a lipid formulation as
disclosed herein in a third chamber of the container.
[0141] The multi-chamber container, such as a three-chamber bag,
may include vertical chambers. Suitable multi-chamber containers
are disclosed in U.S. Patent Publication No. 2007/0092579, which is
incorporated by reference in its entirety. For example, the
multi-chamber container may be configured as a bag that includes
three adjacent chambers or compartments. If desired, frangible
barriers or openable seals (e.g., peel seals or frangible seals)
are used to separate the chambers of the multi-chamber container.
The openable seals permit formulations to be separately stored and
admixed just prior to administration thereby allowing storage in a
single container of formulations which should not be stored as an
admixture for an extended period of time. Opening of the seals
allows communication between the chambers and mixing of the
contents of the respective chambers. The outside seals of the
multi-chamber container are strong seals that do not open under the
fluid pressure supplied to open the weaker peel seals or frangible
seals between the chambers.
[0142] The multi-chamber container may be provided with
instructions explaining a desired order with which to open the peel
seals, so that constituent fluids are mixed in a desired order. The
unsealing strengths of the two or more peel seals may be varied to
promote the opening of the seals in the desired order. For example,
the unsealing strength of the peel seal to be opened first may be
1/3 to 1/2 of the unsealing strength required to open the peel seal
to be opened second.
[0143] FIG. 1 illustrates one embodiment of a multiple chamber
container of the present invention. Preferably, the container 10
which is configured as a bag includes three adjacent chambers or
chambers 12, 14, and 16. Chamber 12 is located at a lateral or side
end 18 and chamber 16 is located at an opposite lateral or side end
20. The three chambers 12, 14, and 16 are preferably designed to
hold aqueous solutions and/or lipid emulsions. Preferably,
frangible barriers or openable seals 22 and 24 are used to separate
the chambers. Container 10 preferably includes ports 26, 28, and 30
to provide communication with chambers 12, 14, and 16 respectively.
Container 10 also preferably provides a hanger portion 36 which in
the embodiment shown in FIG. 1 is a flap having a centrally located
hole 38 for hanging the container. The flap 36 defines a border 40
of the upper end of all the chambers 12, 14, and 16.
Methods of Use
[0144] The disclosure provides methods of treating patients who
require parenteral nutrition when oral and enteral nutrition is not
possible, insufficient or contraindicated. The methods involve
using the multi-chamber containers and lipid formulations disclosed
herein. In particular, the methods involve parenterally
administering the contents of a multi-chamber container and/or
lipid formulations as disclosed herein to a patient. In a preferred
embodiment, the patients are pediatric patients.
[0145] In some cases, the lipid emulsions and compositions
comprising same disclosed herein are used for avoiding and/or
treating hepatic steatosis. Hepatic steatosis is defined as
intrahepatic fat of at least 5% of liver weight. Simple
accumulation of triacylglycerols in the liver could be
hepatoprotective; however, prolonged hepatic lipid storage may lead
to liver metabolic dysfunction, inflammation, and advanced forms of
nonalcoholic fatty liver disease (NAFLD). NAFLD includes a spectrum
of disease from simple steatosis to nonalcoholic steatohepatitis
(NASH), which can progress to cirrhosis and hepatocellular
carcinoma. Histologically, NASH is defined by the presence of
macrovesicular steatosis, lobular inflammation, and hepatocellular
ballooning (Kneeman, Secondary Causes of nonalcoholic fatty liver
disease, Therap Adv Gastroenterol 2012; 5: 199-207). Long-term
total parenteral nutrition (TPN) can be one of many causes for
NAFLD. TPN may lead to the depletion of carnitine, a compound
necessary for the transfer of free fatty acids from the hepatic
cytoplasm into the mitochondria for beta-oxidation. As mentioned
before, the cytosolic concentration of choline also decreases,
promoting lipid storage in hepatocytes. Such lipid storage is
connected to the fact that predominant histologic findings are
steatosis, intrahepatic cholestasis, and ductular reduplication.
Accordingly, the effect of choline supplementation in TPN can also
be determined by validating the histological features of the liver.
Such histological analysis allows assessment of the degree of
steatosis by analyzing the extent of vacuolation. Example 3
provides for the results of such histopathological investigations
done in an animal study. It is shown there that liver damage due to
methionine and choline deficient diet followed by parenteral
nutrition can be effectively addressed by the presence of
glycerophosphocholine in the PN solution. It also provides for the
evidence that GPC provides for a significantly better effect than
other choline derivatives, specifically choline chloride and
CDP-choline. The additional presence of DHA and ARA seem to have an
additional, synergistic benefit.
[0146] Serum alanine aminotransferase (ALT) assays are the most
common laboratory tests for the detection of liver diseases.
Because the enzyme concentration in a population forms a continuous
distribution, the cut-off concentration that discriminates between
healthy and diseased livers is not clearly defined. However, the
upper normal limit of serum alanine aminotransferase is set on
average at 40 IU/l, ranging from 30-50 IU/l (Kim et al. BMJ 2004,
328:983). Said upper limit is used as a normal serum alanine
aminotransferase (referred herein also as "aminotransferase" or
"ALT") concentration in the context of the present invention. Kim
et al. also describe that the association between the
aminotransferase concentration and mortality from liver disease is
significant. Therefore, serum aminotransferase concentration was
used in the context of the present invention to determine the
efficacy of glycerophosphocholine for the treatment of liver damage
which can be caused, for example, by parenteral nutrition in
comparison to lipid emulsion not containing any choline, but also
in comparison with other choline sources, including choline
chloride and CDP-choline. FIGS. 1 and 2 demonstrate the
significantly better effect of GPC on lowering ALT
concentrations.
[0147] ALT activity is determined by a modification recommended by
the International Federation of Clinical Chemistry (IFCC), see also
Example 2. ALT catalyzes the reaction of alpha-ketoglutarate with
L-alanine to form L-glutamate and pyruvate. Under the action of
LDH, pyruvate converts to lactate, and NADH is converted to NAD.
The decrease in absorbance of NADH, measured at 340 nm (secondary
wavelength is 700 nm), is directly proportional to the serum
activity of ALT. It is a kinetic reaction. In general, serum is
used for analysis. The serum is separated from the cells within 2
hours of collection and stored at -70.degree. C. until assayed.
Monitoring the ALT activity over time in an animal model is used
herein as one straightforward and conclusive way to determine the
efficacy of GPC in treating liver disease, specifically liver
damage caused by a choline-deficient diet (Examples 1 and 2, FIGS.
2 and 3).
[0148] Plasma-free choline concentration can be determined by
high-pressure liquid chromatography (HPLC) and gas
chromatography-mass spectrometry according to protocols known in
the art (Pomfret et al.: Measurement of choline and choline
metabolite concentrations using high pressure liquid chromatography
and gas chromatography-mass spectrometry. Anal Biochem. 1989; 180:
85-90).
[0149] Methods of depleting phytosterol from an oil, specifically
from a plant derived oil, such as olive or soybean oils, are known.
For example, phytosterols can be removed as described in Ostlund et
al., Am J Clin Nutr 2002, 75, 1000-1004, or as described in U.S.
Pat. No. 6,303,803 B1.
EXAMPLES
Example 1: Animal Model
[0150] Animal studies were performed in order to identify and
confirm the most effective choline derivative for use in parenteral
nutrition solutions, specifically in lipid emulsions, for avoiding
and/or treating and ameliorating liver damage, specifically liver
steatosis. The study further served to identify any potential
metabolic interactions between the choline derivate which was found
to be the most effective and polyunsaturated fatty acids,
specifically of DHA and ARA.
[0151] The effects of GPC as well as of the combination of DHA, ARA
and GPC were investigated in a sick animal model, wherein male
Sprague-Dawley rats with steatosis, induced by choline and
methionine deficient (MCD) diet (S SNIFF MCD pelleted
choline/methionine deficient diet (S SNIFF Spezialdiaten GmbH,
Soest, Germany, Product No. E15653-94)) were kept on parenteral
nutrition. Steatosis was confirmed in the respective groups by
histopathology (Example 3).
[0152] Parenteral nutrition started after 14 days under MCD diet.
First measurements were done after 5 days of parenteral nutrition,
followed by measurements after 9 and 17 days. The daily lipid
uptake was 2.31 g/kg/d. The rats were split into several groups as
set forth below in Table I.
[0153] Two groups served as control groups, wherein a first group
was treated with saline solution (0.90% w/v of NaCl in water for
injection). A second group received a lipid emulsion ("LE 10%")
containing refined olive oil (80.0 g/L) and refined soybean oil
(20.0 g/L) in water for injection, pH 6-8; LE 10% further contained
egg lecithin (6.0 g/L), glycerol (11.25 g/L) and sodium oleate
(0.15 g/L). LE 10% contained 100 g/L lipids. In certain experiments
the lipid emulsion "LE" was used in different concentrations, for
example as "LE 13%", or "LE 20%" which indicates that the above
concentrations were accordingly higher.
[0154] Various choline derivatives selected from the group
consisting of choline chloride, glycerophosphocholine (GPC) and
cytidine diphosphate-choline (CDP-choline) were added in two
concentrations (low/high) to LE 10%, respectively, see Table I
(Step #2). "Low" refers to a concentration of 15 mmol/L lipid
emulsion, "high" refers to a concentration of 31 mmol/L of lipid
emulsion. Choline chloride (2-Hydroxyethyl)trimethylammonium
chloride), Pharmaceutical Secondary Standard, was purchased from
Sigma-Aldrich (Merck KGaA, Germany). CDP-choline (prepared by
fermentation) was from TCI Europe N.V. (Antwerp, Belgium).
Glycerophosphocholine, prepared from egg phosphatide by
saponification, was supplied by Lipoid GmbH, Germany. DHA (from
algae, Schizochytrium sp.) and ARA (from fungi, Mortierella alpina)
were purchased from BASF AG, Germany. Vitamin E was purchased from
ADM (IL, U.S.A.)
[0155] The choline derivative supplemented "LE" lipid emulsions
were prepared as follows. In a first step, raw phases are heated
up. In case of the oil phase, soybean and olive oils and egg
phosphatide as well as DHA and ARA oils and vitamin E in case of
Step #3 experiments are heated in an inox beaker to 75.degree. C.
under N.sub.2 protection while continuously agitating using an
Ultra Turrax. The aqueous phase was prepared by mixing glycerol,
sodium oleate and Milli-Q water and constantly heated in an inox
beaker to about 75.degree. C. under N.sub.2 protection. Where
needed, the choline derivative is added under constant agitation.
In a second step, the pre-emulsion is prepared by adding the oily
phase to the aqueous phase using a peristaltic pump under
continuous agitation and then transferred to a high shear inline
disperser (e.g. Dispax Reactor.RTM. DR). The receiving vessel is
closed and flushed with nitrogen. In a third step the pre-emulsion
is homogenized by passing it several times through a high-pressure
homogenizer at 600 bar and a temperature of about 50.degree. C.,
under a N.sub.2 atmosphere.
[0156] The emulsion is then adjusted to the required volume (2L)
with Milli-Q water and cooled down to a temperature of
approximately 18 to 28.degree. C., preferably 20.degree. C. to
25.degree. C. The pH is adjusted to a range of from 7.8 to 8.8,
preferably to about 8.3 to 8.8 with 0.1N NaOH. The emulsion is
filtered with a 4.5 .mu.m filter and transferred in 100 mL bags,
which are then overpouched, making use of an oxygen
absorber/indicator, for later use. The lipid emulsion is then
autoclaved at 121.degree. C. to achieve a FO of at least 15
minutes.
TABLE-US-00001 TABLE I Study Groups and Experimental Setup:
Standard "LE" lipid emulsion was used for the experiments wherein
certain amounts of a choline source were added to the lipid
emulsion. This test setup which is focused on the effect of GPC as
such is otherwise designated as "Step#2") Lipid Dose Emulsion/
Choline Equivalent [mmol/ Group Solution [mmol/L] kg/day] Control 1
Saline -- -- Solution Control 2 LE 10% -- -- Efficacy LE 10%
Choline Chloride [15] 0.38* Choline Chloride [31] 0.77* Efficacy LE
10% Glycerophosphocholine [15] 0.38* Glycerophosphocholine [31]
0.77* Efficacy LE 10% CDP-choline [15] 0.38* CDP-choline [31]
0.77*
TABLE-US-00002 TABLE II Study Groups and Experimental Setup:
Phytosterol depleted "LE" lipid emulsion as described above was
used for experiments, wherein GPC as well as DHA and ARA were added
as indicated. This test setup is otherwise designated as "Step#3").
Choline Source Group Lipid emulsion/Solution [mmol/L] Control
Saline solution -- Control LE 13%, phytosterol depleted, + DHA none
and ARA + vitamin E supplementation (40 .mu.g/mL LE) Efficacy LE
13%, phytosterol depleted, + vitamin Glycerophosphocholine E
supplementation (40 .mu.g/mL LE) [40 mmol/L] Efficacy LE 13%,
phytosterol depleted + DHA Glycerophosphocholine and ARA + vitamin
E [40 mmol/L] supplementation (40 .mu.g/mL LE)
Example 2: Aminotransferase (ALT) Development
[0157] For assessing the effect of GPC on the liver status of the
animals tested as described in Example 1, the aminotransferase
(ALT) activity in the plasma of tested animals was tested after 5
and 17 days of parenteral nutrition both in a Step #2 and Step #3
setup. As described before, liver damage (cholestasis) may be
determined by increased aminotransferase levels. ALT activity was
determined with an ADVIA 1800 blood biochemistry analyzer/IFCC
modified (Siemens) according to standard protocols such as
described before.
[0158] In order to summarize the results of the experiments, FIG. 2
shows the development of ALT activity in the tested rats. As can be
seen there, there is an expected increase in ALT activity upon
parenteral nutrition over 17 days with LE 10%. In comparison, ALT
activity does not increase in study groups where a choline source
is present in the lipid emulsion. However, the effect is most
notable in the presence of GPC, where a clear drop in ALT activity
can be determined. In contrast, choline chloride and CDP-choline
rather provide for a stable situation where ALT activity neither
significantly increases or decreases. Notably, phosphatidylcholine
which is contained in LE lipid emulsion(s) does not seem to have
any effect, confirming that choline cannot make use of the choline
provided in the form of phosphorylcholine in lipid emulsions.
[0159] After having identified GPC as a surprisingly effective
choline derivative for the reduction of ALT activity and thus liver
damage, another experiment focused on the synergy between GPC and
the PUFAs DHA and ARA. Lipid emulsions as described in Example 1
were used as further shown in Table III.
[0160] FIG. 3 summarizes the results for ALT activity in terms of
the change in activity of the normal value. The test includes one
experiment with a composition wherein the phytosterol content of
the lipid emulsion was reduced as indicated in FIG. 3 according to
the Step #3 setup. The results also demonstrate that both the
saline solution and lipid emulsion ("LE") without choline source
and normal phytosterol content lead to an increase in ALT activity,
evidencing a progressive deterioration of the liver. In contrast,
both lipid emulsions with GPC (40 mmol/L), irrespective of the
phytosterol content, result in a significant decrease of ALT
activity. Phytosterol doses are shown in FIG. 3. Phytosterol was
contained in the LE 13% lipid emulsion in a concentration of from
40 .mu.g/mL to 120 .mu.g/L. Notably, phosphatidylcholine which is
contained in the lipid emulsion(s) used here does not seem to have
any effect, confirming that the body cannot make use of the choline
provided in the form of phosphorylcholine in lipid emulsions.
Example 3: Determination of Histopathological Grades
Example 3.1: Preparation of Histological Slides
[0161] A part of the liver was preserved in buffered formalin, the
infusion sites and the sampled macroscopic lesions were trimmed
according to the RITA guidelines, where applicable (Ruehl-Fehlert
et al., Exp Toxic Pathol 2003; 55, 91-106), embedded in paraffin
wax, sectioned at a thickness of approximately four microns and
stained with hematoxylin-eosin. The frozen liver sample was
cryosectioned in slides of approximately five microns and stained
by Oil Red O. Tissue processing was performed at Citoxlab,
France.
Example 3.2: Microscopic Examination
[0162] A microscopic examination was performed on both slides
(hematoxylin eosin and Oil Red O) of the liver, the infusion sites
and the macroscopic lesions from all animals of the study. Peer
review was performed on at least 30% of the animals from the
high-dose group and on an adequate number of slides from identified
target organs to confirm that findings recorded by the Study
Pathologist were consistent and accurate. After completion of the
pathology peer review, all tissue slides were returned to Citoxlab
France for archiving. During microscopic examinations,
representative photographs were made at the discretion of the
pathologist.
Example 3.3: Mean Histology Vacuolation
[0163] Liver samples taken after 8 and 15 days, respectively, were
examined as described above and assigned to five grades of
hepatocellular vacuolation. Vacuolation was generally diffuse and
affected all regions for Grade 5. Periportal areas were lesser
affected and the vacuoles were smaller in size for lower grades.
Grades have been assigned according to the following
definition:
GRADE 1=Minimal/very few/very small vacuoles, scattered. GRADE
2=Slight/few/small vacuoles, centrilobular to midzonal. GRADE
3=Moderate/moderate number/moderate size vacuoles, centrilobular to
midzonal. GRADE 4=Marked/many/large vacuoles, centrilobular to
periportal. GRADE 5=Severe/many/large vacuoles, diffuse, all liver
regions affected.
[0164] Exemplary photographs for each Grade are shown in FIG. 6.
The histological slides shown are stained with hematoxylin-eosin
(HE).
[0165] After 8 days, the administration of saline solution results
in four of four animals showing signs of liver damage in terms of
vacuolation according to Grade 5 (see Table IV). Parenteral
nutrition with LE 13% in the presence of DHA and ARA already
generates a positive effect on liver histopathology. Out of five
animals, two still show Grade 5 vacuolation. However, three of the
five animals' livers can be assigned to Grade 4. In the presence of
GPC additional to DHA and ARA, the vacuolation of the liver is even
more improved. Only one of five animals shows Grade 5 signs of
liver damage, whereas another two rats show Grade 4 symptoms and
two Grade 3 symptoms. Finally, if only GPC is added to the lipid
emulsion, none of the five rats shows Grade 5 damage of the liver.
Three show Grade 4, one shows Grade 3 and one even shows Grade 2
vacuolation.
TABLE-US-00003 TABLE IV Microscopic changes of the liver after 8
days Relevant microscopic changes in the liver on Day 8 Group 1 2 3
4 Treatment LE 13% + LE 13% + Saline DHA + DHA + LE 13% + solution
ARA ARA + GPC GPC No. animals 4 5 5 5 Vacuolation; hepatocellular
Grade 2 -- -- -- 1 Grade 3 -- -- 2 1 Grade 4 -- 3 2 3 Grade 5 4 2 1
--
[0166] After 15 days into parenteral nutrition, the above effect
was even more pronounced. Whereas the liver condition of those
animals receiving saline solution remained as critical as could be
expected, the presence of GPC in the lipid emulsion as well as the
presence of all of DHA, ARA and GPC lead to a clear and significant
improvement of the liver status of the animal. After 15 days, it
becomes evident also that the presence of DHA and ARA within a
certain concentration range in addition to GPC even lead to
synergistically improved results. FIG. 4B summarizes the effects of
DHA, ARA and GPC on the development of liver vacuolation, in terms
of the above defined grades. The graph shows a significant
amelioration of the liver condition in the presence of all DHA, ARA
and GPC, wherein GPC seems to have an additional, surprising impact
in the already beneficial presence of DHA and ARA in the lipid
emulsion.
[0167] Identical histopathological tests were performed for
comparing the effect of choline derivatives alone, i.e. in the
absence of DHA and ARA. FIG. 4A summarizes the result of the
histopathological examination of the livers of the animal study
group. The effects of GPC are significantly better, both in at a
high (31 mmol/L) and low (15 mmol/L) GPC concentration. CDP-choline
(low concentration, 15 mmol/L) also had an effect. No grades could
be assigned to the CDP-choline group with a high concentration (31
mmol/L). The groups which had received choline chloride as part of
the lipid emulsion (high and low concentration) fared better than
those with only saline or lipid emulsion without any choline
derivative. However, the liver damage could not be addressed with
said choline chloride supplemented lipid emulsions to any relevant
extent.
TABLE-US-00004 TABLE V Microscopic changes of the liver after 15
days Relevant microscopic changes in the liver on Day 15 Group 1 2
3 4 Treatment LE 13% + Saline LE 13% + DHA + LE 13% + solution DHA
+ ARA ARA + GPC GPC No. animals 5 5 5 5 Vacuolation; hepatocellular
Grade 2 -- 1 1 2 Grade 3 -- -- 4 2 Grade 4 -- 2 -- 1 Grade 5 5 2 --
--
Example 4: Development of Liver to Body Weight
[0168] The study groups as described in Example 1 were further
evaluated with regard to the development of liver weight versus
body weight. An increase in liver weight which is not proportional
to the increase of body weight is typical for the development of
liver damage, specifically steatosis, as described before. FIG. 5
shows the results for the liver to body weight ratio in percent
again for those groups of animals that received only saline
solution, LE 10%, and the same lipid emulsion with choline
derivatives added in concentration as described before ("high": 31
mmol/L). As can be seen, the administration of a lipid emulsion
alone leads to an increase in said ratio, indicating a gain in
liver weight due to liver damage (steatosis). The addition of
choline chloride or CDP-choline both lead to a reduction of the
ratio and thus an improvement of the liver status. However, the
most pronounced reduction of the ratio is again achieved with GPC.
Again, phosphatidylcholine which is contained in the lipid
emulsion(s) does not seem to have any effect.
Example 5: Stability of Lipid Emulsions in the Presence of Choline
Derivatives
[0169] Besides investigating into the efficacy of choline
derivatives in addressing liver damage, the lipid emulsions
prepared as described in Example 1 were further assessed for their
respective stability after sterilization (see Table VI). It was
found that the stability of the lipid emulsions was improved in the
presence of GPC compared to choline chloride or CDP-choline. In
fact, choline chloride and CDP-choline were found to destabilize
the lipid emulsions during sterilization (heat). Lipid emulsions
containing either choline chloride or CDP-choline resulted in a
phase separation of the lipid emulsions during sterilization. In
the presence of GPC, the lipid emulsions remained stable.
TABLE-US-00005 TABLE VI Stability of lipid emulsions upon
sterilization in the presence of different choline derivatives
Lipid Emulsions Concentration tested: Choline Derivative (mmol/L)
LE (%) Comment Choline Chloride 15 10, 13, 20 Phase separation
during sterilization Glycerophosphocholine 30 10, 20 Stable
emulsion CDP-choline 30 10 Phase separation during
sterilization
* * * * *