Development of a low-dose monthly injectable contraceptive system: I. Choice of compounds, dose and administration route

CONTRACE

VELOP SYSTEM: J.

NT OF A L -D O S E NTHLY I . Choice of compounds, dose

Garza-Fiores

i,2

, V.

Diaz-Sanchez

and H . W .

].

ECTABLE C T CE IVE and inist ti r te '

D e p ar t m e n t

i

Fertility

of B i o them i st ry, and

Sterility

S.

Jimenez-Thomas

2

National

Institute

Sch o o I of M e d i c i ne,

Research

ABST

2

del3

D e p a r t m e n t of R e p r o d u c t i v e Biology, of N u t r i t on, S a l v a d o r Zubir~n

t

ION

Centre,

Mexico

City

CT

A l o w - d o s e comb i n e d e s t r o g e n - p r o g e s t o g e n su s t si :ned re Iea s e system has been develop The controI of crystal ~ ze of t h e s t e r o i d s p r o d u c e d s u s t i n e d d i s s o l u t on in v i t r o and in v i v o . A d o s e ~ r e s p o n s e experiment carried a thy worn in nd cared that 10 mg o f n o e t h i s t e r o n e (NET) w i t h 1 of e t h i n y l e s r a d ol (EE when given by intr s u c u l a r injec ion mantained NET s e Um l e v e l s above ! ng/m for at least 25 d a y s ) T.... h e s y s t e m ~s considered su table for one m o n t h con r a c e p t i v e p r o t e c t on.

S u b m i t t e d for p u b l i c a t i o n August Accepted for publication October

14, 1 9 8 4 2, 1 9 8 4

Rep ri n t sis to J. Ga r z a- F ! o r e s , r t Reproductive B i o l o g y , Na i o n a l I n s t i t u t e of N u t r t i o n , $ ] v a d o r Z u b i r ~ n V a s c o de Q u i r o g a No. i5, 1 4 0 0 0 , M e x i c o , D F.

ER 1984

30

4

371

C

,,,

T ......

tON

. . . . . . . .

INTRODU

I ON

R e c e n t l y , a t t e n t i o n has b e e n d i r e c t e d t o w a r d s the use of n e w de l i v e r y s y s t e m s for p r o l o n g i n g the re lease of ho nat contraceptives, with special is pa n ral c ira pti (1,2). I n i t i a l s t u d i e s w i t h s i 0 w l y d i s s o l v i n g p e l l e t s h a v e indicated that this approach provides a longer duration of e f l e e s w h e n c o m p a r e d w i t h s i m i l a r d o s e s ....o£ . steroids given as m i c r o c r y s tal iine i n t r a m u s c u l a r inje i (3,4). In...additi . biocompatible m e r i a l s s u c h as p _ l y m e t h y I s i l e h aiso b e e n u s e d to c o n t r o l the r e l e a s e of s t e r o i d s for e x t e n d e d p e r i o d s of t i m e (5,6 7) ; m o r e o v e r , the c s dell of c o n t r a c e p t i v e s t e r o i d s has b e e n e f f e c t i v e l y achieved with bi o d e g r a d a b ie po rs such polyiactic acid .....d polycaprola .... (8 9 ) . However ~ h e s e d e l i v e r y s y s t e m s s t i l l include fo ign materiais in their formuiations. T h e s e o b s e r v a t ons p r o m p t e d to sess a s rained le e s y s t e m w i t h the ~fo li o w i n g c h a r a c t e r i s t i c s ) U s a g e of t h e p r o g e s t o g e n an d e s t r o g e n c o m p o n e n t s of the oral c t cepti s at a b o u t the s a ~ e m o n t h l y dose or less; 2) N o a d d i t i v e s or chemical modi c a t i o n s are i n c i u d e d in the s y s t e m to d e l a y the re le as e o f t he act ive ~ n g r e di ent s ; an d 3) T h e s te r oi ds are f o r m u l a t e d as a m i c r o c r y s t a l l i n e a q u e o u s s u s p e n s i o n to be in ected through a 19-gauge needle. E RIALS

D

THODS

C r y s t a i l i n e n o r e t h i n d r o n e (NET) ( i 7 0 ( e t h i n y 1 ~ 7 - h y d r o x y - 4 es r e n - 3 - o n e ) a n d e h i n les radiol (EEl) ...(...7 ethinyi 1,3, 5{10)-es ratrien-3,17-diol) w e r e k i n d l # ...p. r o v i d e d by S y n t e x ( x i c o City) . T h e p u r i t y of t11e s t e r o i d s w a s a s s e s s e d b y I.R., U.V. , G L C a n d TLC. A wide _ange of partlcle sizes of N E T and E~ we re ob a i n e d by s i e v l n g ....T h e p ticle s i z e s w e r e f u r t h e r ~ s s e s s e d by l i g h t m i c r o s c o p i c asu nt .... T h e sized particles were stored in sealed c .... t a i n e r s f o r i n vitro and in v i v o s t u d i e s ..... In v i t r o

studies

It b e c a m e a p p a r e n t f r o m scopic ex nati qu titati s i e v i n g y i e d e d a material h a v i n g an i r r e g u l r ....d i s t r i b u t i o n of p a r t i c l e size; t h e r e f o r e an n v i t r o s y s t e m u s i n g pol o r g a n i c s o l v e n t s h a d to be d e v e l o p e a r a p i d eval i o f d i s s o l u t i o n r a t e s as a ~ e t h o d £ o r 5 a r c h s t a n d a r i z a t i o n . The method consisted of the addition of a weighed amount (S rag) of the v a r i o u s c r y s t a l s i z e r a n g e s into 100 ml f a s k s in an a q u e o u s m e d i u m c 50% e oi dissolution

372

R 1984 VOL. 3 0 NO. 4

CONTRACE

I

of NET and 55% v/v ethanol r EE 2. After incubation :in a w a t e r b a t h at 3 7 ° C w i t h c o n s t a n t shli..aking, s a m p l e s (0,S ml) w e r e r e m o v e d at v a r i o u s t i m e i n t e r v a i s u p t o 90 rain. The NET EE2 t t dete i in a V i Spect o ter, using a w a v e len0,'thg o f 240 a n d 279 n m , s ti R e s u ! t s w e r e e x p r e s s e d as .... l o g l 0 o f t h e p e r c e n t a g e of st id dissolved a g a i n s t Io I0 o f t i ~ e . T h e ::formulation of N E T - E E 2 :for :injection to h u m a n i ee w a s p r e p a r ed u n d e r s t a n d a r d co n d i t i on s of p h a r ~ a c e u t ic a i practice T h e s t e r o i d s w e r d s i e v e d to y i e i d fracti s in t h e 177 t o 2 5 0 u m r a n g e o f N E T a n d t h e 250 to 5 0 0 u m r a n g e of Aiiquots o f t h e s e f r a c t i o n s w e r e a c c u r a t e l y w e i g h e d , deposited in p l a s t i c d i s p ? s a b l e syringes and sterilized by the ethylene oxfde method Bacteriological tests were perfo ed for each batch. One milliliter of s o d f u m ch'lor de 0.9% solution containing 0.1% e e n 20 w a s u s e d ...as . icle. The suspens on was vigorously m i x e d p r i o r to i n j e c t i o n .

In v i v o

studies

Human

s t u d i e s . A gr.oup o f s e v e n h e a l t h y w o ~ e n a g e d b e t w e e n rs w i t h a p r e v i o u s h i s t o r y o f re 2ar nst el cycles, who had not used any form of steroid I c o n t r a c e p ..... tion n the preceding three ths lu ee d to partic ate in t h e study;, w r i t t e n i n f o r m e d c o n s e n t w a s o b t a i n e d f r o m ali p a r t i c i p a n t s ....A l l o m e n w e r e a d v i s e d to u s e a barrier m e t h od o £ c o nt r a c e p t ion .... C I in i c a I re c o rd s and approp r ia te f o r m s w e r e c o m p l e t e d ~ at t h e t i m e o f a d m i s s i o n ...... L o c a l and s y s t e m i c t o I e r a n c e w e re a i s o document e d t h ro u g h o u t th e study. Ddsign of the rio were a

study. Graded doses istered o women on

cycle

wo~en

Three

recex

ed

o f N E T - E E 2 in a I 0 : I r a flay 5 o f t h e i r m ~ n s t r u a l

a ....s i n g i e

subcutaneous

( s ......c . )

i n j e c t i o n w h e r e a s t h e o t h e r f o u r w o m e n w e re g y e n t h e s a m e formuiation intramuscularly (i.m. in t h e g l u t e a ! re i o n ...... Peripherai venbus blood s p l e s w e re t a k e n three times a week for the first week a~d twice a week for the flowing three weeks B l o o d s a m p l e s w e r e o b t a i n e d b y ...v. e n e p u n c t u r e centri£uged and the serum separated and stored at 20°C0 until a n a l y s e d .... T h e s e r u m c o n c e n t r a t i o n s of NET for each sample was determined by a specific ioimmuno ssay as previousiy described (i0). T h e t i m e (in d a y s ) at NET in serum was still above I ng/ml (3 3 nmo!/l) versus the administered d o s e to e a c h s u b j e c t w a s c a i c u l a t e d ....

BER 1984 VOL. 30 NO, 4

¸3¸¸73

NTRACE

ION ,SU

S

! n v i t ro di s s o lu t i o n p r o f i le s o f N E T an d EE at d i f fe re t tryst 1 size ran s are s h o w n in d22. As e x p e c e d , an i n v e r s e reiationship between the percentage dissoived and size range of crystals for both ste oids was observed. It c a n b e s e e n f r o m the data of I that c lete d i s s o l u t i o n o f t h e m i c r o n i z e d ....s t e r o i d ( < S0 u m f r a c t i o n ) was achieved at 60 m i n u t e s .

NET ,=s ' t p m t77--2

o

250

, , ,'" ,,

~m

~Jm

...= ,,,,, ,,,,,,,,,,,;,,, ,,,,, ) 5

~:

20. ,i

i !)!!))!! ii!! i iii!)i

!! i i)

10 i¸

0

' '0

0

,)og t i m e (m i n) F i g . ]. N o r e t h i s t e r o n e d i s s o l u t i o n r es in vitro, e sol nt s y s t e ~ c o n s i s t e d o f e t h a n o i : w er S0 50 Experiments w e re c a r r i e d o u t o n t h r e e d i f f e r e n t o c a s s i o n s ....) According to the solubiiity of the steroids, a pa icle size range of um NET selected for in vi The in vitro dissoluti o £ EE .... a s .....o,p t i , m i z e . . . . justing the ion o£ the microni~ed fraction to be compieted wi bin one hour. Fig. 2 shows the dissolution pattern of EE Z when various sieved fractions w e re t e s t e d .... e fra i o f 2 5 0 ....5. 0 0 u m w a s c h o s e n f o r f u r t h e r in v i v o assessment When the co ined I i of N E T an 2 w~ administered

374

R

19

VOL

3 0 NO. 4

TRACE

to v o l u n t e e r s either by subcutaneous or the t o t a l a m o u n t r e t a i n e d in the s y r i n g e (22 9 + 6 . 3 ) o f t h e t o t a l d o s e

i r s did not

ION

far ed

tes ZS%

E E2 <

g,'

eo

0

......................... -

............

time (min)

i

Fig 2. !n v i t r o d i . s s o l u t i o n o f e t h i n y l e s t r a d i o l y asta! s i z e r a n g e . [The s o l v e n t a n cti rained ethanol: w ter 3 5 " 6 5 V/v.)

{EE2) as media con-

No s i g n s o f l o c a l i r r i t a t i o n w e r e r e p o r t e d by any of the women after the administration of the for !ation; r, s y s t e m i c ...s . i d e e f f e c t s s u c h as n a u s e a and yore r i n g w e r e experienced 5 y ali v o i u n t e e r s . The details are presented in T a b l e I. It c a n b e s e e n f r o m t h e d a t a t h a t the onset of n a u s e a w a s d e l a y e d in w o m e n w h o r e c e i v e d the formulation b y sub cut aneou s inj ec t i on The anal ys i s o f mens t aI pan all t e r n s i n d i c a ~~ed that b r e a k t h r o u g h b l e e d i n g o c c u r r e d sub e c t s . Table I also shows e time after n j e c t i o n at which breakthrough bleeding st r ed Ii cycle i e n g t h a f t e r i n j e c t o n .... t

e n t h e adm n i s t e r e d e at w h i c h N E T se

BER ! 9

doses o f NET w e r e c o r r e l a I e s w e r e st 1,I a b o v e

V O L . 3 0 NO. 4

ed I ng/mi,

a

3 75

CONTRACE

ION

direct reiationship was observed. F r o m the d a t a of Fig. 3 the r e q u i r e d N E T d o s e to c o v e r o n e mont was estimated a r o u n d jO m g w h e n a inistered by intramuscular route, w h e r e a s a b o u t 7 m g o f N E T w o u l d be a d e q u a t e f o r the same duration of effect by subcutaneous a ministration. Table

I.

Clinicgl parameters a f t e r the a d m i n i s t r a t i o n of N E T - E H 2 to s e v e n h e a l t h y w o m e n ( m e a n va s • S.D.)

E

,(: )

NI z

+7.4 Z. 2

...S.3 .02

+S. 2 i. 3

-'0..09 ..

ION E

ins tr n

CNS OF N EA

n

3

CYCLE LEN

(d

1 + 9.7 4. . . . . 0 5 eno

+0.56

BRE ROU(]~ BLEEDING 6.6 +- 0.S

18.7

I 0.0

+- ~ 7

+- 0.8

+-

36.0 7.8 37.0

+- 1.2

:25 ¸

20 ¸

0

<

!

>

Z

3

4

S.... 6

R E TH STE RONE

7 I) O S E

8

9

iO

|rag}

Fig. 3 A dose-response exper nt after a single o f N T ( 7 7 ...2.5 0 urn) a n d E E 2 (2S0 ....500 . u~) t o se on d a y S o f t h e i r m e n s t r u a l cycle. 376

nistrati n no I w

BER 1984 VOL. 3 0 NO. 4

n

CONTRACE

i

DISCUSS i There is great interest in the de I nt d i r nt o f injectable contraceptives by means of modifying t h e ...d .osage of currently available compounds, the design of new st u~s, and i rovement o f d r u g de I i v e s y s terns (Z, 4 ~ ], I 2). Th a c c u m u I a t e d e x p e r i e n ce w i th the f or m u i a t i on s c u r r e n t iy available indicates h a t the d es well ab t effe i pharmacologic range suggesting that they be subst ti ly reduced without losing their anovulatory potency (~.5). The experience with the oral formulation o f 0 .... 4 mg of NET combined with 0.03S mg of 2 (14) , h a s es fished a baseline of elf cacy and safety, w h i c h s e r v e d in t h e lop ..... me n t o f t h e p r e s e n t s y s t e m ..... T h e r e s u l t s o f the in v i t r o experiments presented here confirm the established re,at i o n s h ip b e t w e e n t h e s u r f a c e a r e a an d d i s s o u t on ~....:~ ....t e s (15 These observations l e d us to s e l e c t the s i z e .... ~.. .~s .. o f b o t h ....s ..t e r o i d s u s e d in t h e h u m a n s t u d i e s The side effects (nausea, vomiting d b aktllr gh } ~........o ~0:. ~...... observed after the injection were interpre e d as a~ o.~ roge induced effect suggesting tha EE was rapidly ~ibso~ .....~ d d therefore, the use a less soluble estrogen s u c h , .0 .. tranol could be empioyed instead of EE to improve :.I~cpcl...... formance of the present system In sp ~e o f t h e a d v a n t a g e s O f the s.c. route (i.e. iess dose required for abe same d u r a t i o n ) , t h e i.m. a d m i n i s t r a t i o n was considered a more practical approach for a monthly system. The overall data suggest that the present system nstitutes a novel approach of delivery of hormones for fertil ty ulation w th d o s e s s i m i l a r to those employed in the ' low dose" oral contraceptives. Clinical s t u d i e s ai d t o a s s e s s t h e p h a r m a c o k i n e t i cs a n d p h a r m a c o d y n ami cs o f 0 of NET w i th ] m g o f e i t h e r E E o r ~ e s t r a n o i as a m o n th iy injectable are current ly unde r wa .

ACKN

L E DGE,%~NT S

T h e p re s e n t i n v e s t i g at i o n re ce i v e d p a rt i a i s u p p o r t f r o m the World Heaith Organization's Special Progra e in Human p r o d u c t i o n .... W e w o u l d ....a.l s o I k e o acknowledge the skiilful assistance of Mrs. Guadaiupe Alarcon.

BER 1 9 8 4 VOL. 3 0

.4

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CONTRACE

ION NCES

B e n an g i an o, G ....L o n g - a ct i n g s y s te mi c c on t r a c e p t i y e s ....I n: WHO Symposium on A d v a n c e s in r t i l ty g u l a t i o n (Dicz .... falusy, E ...,. Ed. Scriptor, Copenhagen, 3 2 3 ....3 6 0 ( i 9 7 6 ) H a i l , P . E .....a n d Y r a s e r , I Monthly injectable contraceptives. In: A d v a n c e s in H u m an F e r t i l i t y and Reproductive E n d o c r i n o I o g y ....L o n - A c t i n g S t e r o i d C on t r a c e p t i o n (Mishe II D ....R. . , ) . R a v e n P r e s s , ...N . e w Y o r k , 2 °65 .....88 . (1983 O

Rivera. R ..... G a i t a n , J . R , Ortega, M . , =I o r e s , C. and H e r n a n d e z . A . The use o f b i o d e g r a d a b l e no rethisterone implants as 6-month contraceptive system. F. Steri =e r t i l 4Z-ZZS 232 (i984

4.

N a s h , }!.A. a n d S e d e r h o l t D ....A s s e s s m e n t of the toxicity of delivery systems for injectable contraceptives. J. S te r oi d B io c h e m . 6 : £ 09 - 9 S ( 9 75)

S.

Nash, son, rods

H.A. , Robertson, D.N. , Moo Young, A ......J and AtkinL ...... E ..... S eroid release f r o m ...s. i l a s i c c a p s u l e s and Contraception i8:367-394 (i978)

Croxatto, H.B., Diaz, S and Miranda, P. P l a s m a Of levonor estrel ....i n w o m e n d u r n g l o n g - t e r m use p l a n t s .... C o n t r a c e p t i o n 22:585 593 (i980) t

t

O

levels of nor-

Diaz, S., Pavez, M., Miranda, P., R o b e r t s o n , D . N . , Sivin, I. and Croxatto, H B . A f i v e ....y e a r clinical tria21, of len o r g e s t re !...s. i i a s t i c i m p i an t s ( No r p i a n t) C o n t r aception 2 5 : 4 4 7 ...4.5 6 ( 1 9 8 Z )

Beck, L R .... a n d T i c e , T . R .... ( P o l y i a c t i c acid) and (poly!a~ tic ac d-co-glycolic a c d) c o n r a c e p t i v e d e l i v e r y syste in" A d v a n c e s in ...H. u m a n ...F .ertility and Reproductive ndocrinology. Long-Acting Steroid Contraception ( M i s h e i l D. R. , E d ....) R a v e n P r e s s , N e w Y o r k , 2 i 75 ....i 99 ( i 9 83) Ory S.J., Ha ond, C B. , Yancy, S.G., [{endren, R.W. d P it, C.G. The feet o£ a biodegradable traceptive capsule (Capronor) containining ievonorgestre! on gonadotropin, estrogen, and progesterone l e v e l s ......... J. O b s Gynecol. 1 4 S : 6 0 0 .....6..0 5 ( 98

10.

Garza-Flores, J., Diaz-SAnchez, V. B e d o l l a - T o v a r , N .... d L o z a n o ....R u y , S . A ....A r a p i d a n d s e n s i t i v e radioimmunoassay for Norethisterone Steroids 4-693-701 (1983)

11.

Toppozada, traceptive

M The clinical use of monthly injectable preparations. Obstet Gynecol Surv 32:33S ....347 ..

( 9 7 7)

378

BER

1984 VOL. 30

.4

CONTRACE

12.

~i ~..............

" ~

"' ~ ~' } ~ ~i¸

~

15 : . . 7 5 - 3 g 4 13.

.... ( : . , Wise, D . L ..... a n d ~ { o w e s , J . F . ~e~lsc fertility controi .s. y s . t e r n

Am C

inje tra

..

!

able pti

[ i :9 7 6 )

Bassoi, S. , Garza-Flores, J. Cravioto, V. , Votlle rby, K. , L i c h t e n b e rg, R ...... a n d

M.C. , Diaz S Pe re z Pal acios,

chez G.

O v a r i a n f u n c t i o n f o l i o w i n g a single adm n i s t r a t i o n of d p o m e d r o x y p r o g e s t e r o n e acetate (DNPA) at diffe nt doses. Fertil

14.

5

..... S t e r

1.

42"2i6

......2 2 2

Rude i, W. , N a q u e o N. , J Safe y and effectiveness tracept ve" A three ear N e d ..... 2 i : 7 0 ....8 8 ( 1 9 7 8

Ca lde r on e, J. d r tinezou, o f a n e w l o w - d o s e ....o r a l con study of 1 000 omen J. R e p r o d ....

|lelm 1oh, N.I, and ltuseby, ab s orpt ion o f reed roxyproges ment II, 79-95 (1965)

BER

19

L. 3 0 N O . 4

1984)

R.A te rone

Factors acet at.

influencing Steroids

S

the l e ....

379