Adjunctive Therapy With 25-Hydroxyvitamin D and Articles Therefor

Abstract

Methods, compositions, and kits for adjunctive therapy using 25-hydroxyvitamin D are disclosed. The 25-hydroxyvitamin D may be administered with an agent that increases the risk of hypocalcemia, such as cinacalcet or a salt thereof, and/or an anticancer agent. The adjunctive therapy is effective to treat and prevent iatrogenic hypocalcemia and/or secondary hyperparathyroidism, as well as delay cancer progression and the time to a post-treatment skeletal related event.

Claims

1. A pharmaceutical formulation for oral administration comprising (a) a 25-hydroxyvitamin D compound (b) an agent that increases the risk of hypocalcemia, optionally cinacalcet or a salt thereof, and (c) an anticancer agent.

2. The pharmaceutical formulation of claim 1, comprising a first region comprising the 25-hydroxyvitamin D compound and a second region comprising the agent that increases the risk of hypocalcemia.

3. The pharmaceutical formulation of claim 2, wherein the first region comprising the 25-hydroxyvitamin D compound further comprises a pharmaceutically acceptable excipient, or the second region that comprises the agent that increases the risk of hypocalcemia further comprises a pharmaceutically acceptable excipient, or both the first and second regions each further comprises a pharmaceutically acceptable excipient.

4. The pharmaceutical formulation of claim 1, comprising a matrix that releasably binds and controllably releases the 25-hydroxyvitamin D compound.

5. The pharmaceutical formulation of claim 1, comprising a wax matrix comprising the 25-hydroxyvitamin D compound, a controlled release agent, an emulsifier, an absorption enhancer, and a stabilizing agent.

6. The pharmaceutical formulation of claim 1, comprising a matrix comprising the 25-hydroxyvitamin D compound, about 20 wt % paraffin, about 20 wt % to about 25 wt % glycerol monostearate, about 10 wt % a mixture of lauroyl macrogolglycerides and lauroyl polyoxylglycerides, about 30 wt % to about 35 wt % mineral oil, and about 10 wt % to about 15 wt % hydroxyl propyl methylcellulose.

7. The pharmaceutical formulation of claim 1, wherein formulation or region comprising the 25-hydroxyvitamin D compound comprises a coating comprising a mixture of neutral swellable methacrylic acids esters with trimethylammonioethyl methacrylate chlorides.

8. The pharmaceutical formulation of claim 1, wherein formulation or region comprising the 25-hydroxyvitamin D compound comprises a coating comprising a one or more polyvinyl esters, polyvinyl acetals, polyacrylic acid esters, butadiene sytrene copolymers, or mixtures thereof.

9. The pharmaceutical formulation of claim 1, characterized by an in vitro dissolution profile providing release of the 25-hydroxyvitamin D compound of about 20% to about 40% at 2 hours, at least 35% at 6 hours, and at least 70% at 12 hours.

10. The pharmaceutical formulation of claim 1, characterized by an in vitro dissolution profile providing release of the agent that increases the risk of hypocalcemia of at least 50% at 30 minutes.

11. The pharmaceutical formulation of claim 1, wherein the formulation comprises a capsule having a hard shell.

12. The pharmaceutical formulation of claim 1, wherein the formulation comprises a soft capsule.

13. The pharmaceutical formulation of claim 1, comprising the agent that increases the risk of hypocalcemia disposed in a first capsule shell and the 25-hydroxyvitamin D compound disposed in second capsule shell, the second capsule shell being disposed within the first capsule shell.

14. The pharmaceutical formulation of claim 1, comprising the agent that increases the risk of hypocalcemia in granular form.

15. The pharmaceutical formulation of claim 1, comprising a core region comprising the 25-hydroxyvitamin D compound and an outer region comprising the agent that increases the risk of hypocalcemia.

16. The pharmaceutical formulation of claim 1, wherein the agent that increases the risk of hypocalcemia is disposed within a coating.

17. The pharmaceutical formulation of claim 16, wherein the coating is disposed on at least one nonpareil.

18. The pharmaceutical formulation of claim 17, wherein one or more coated nonpareils are blended with the 25-hydroxyvitamin D compound in a non-aqueous solution, the blend being disposed in a capsule shell.

19. The pharmaceutical formulation of claim 17, wherein the 25-hydroxyvitamin D compound is disposed in a first chamber of a two-chamber capsule, and one or more coated nonpareils are disposed in a second chamber of the two-chamber capsule.

20. The pharmaceutical formulation of claim 1, wherein the agent that increases the risk of hypocalcemia is formulated for rapid release.

21. The pharmaceutical formulation of claim 1, wherein the 25-hydroxyvitamin D compound is 25-hydroxyvitamin D.sub.2, 25-hydroxyvitamin D.sub.3, or a combination thereof.

22. The pharmaceutical formulation of claim 21, wherein the 25-hydroxyvitamin D compound is 25-hydroxyvitamin D.sub.3.

23. The pharmaceutical formulation of claim 1, comprising the 25-hydroxyvitamin D compound in an amount between about 1 mcg and about 1000 mcg.

24. The pharmaceutical formulation of claim 1, comprising the 25-hydroxyvitamin D compound in an amount between about 1 mcg and about 100 mcg.

25. The pharmaceutical formulation of claim 1, comprising the agent that increases the risk of hypocalcemia in an amount between about 1 mg and about 100 mg.

26. The pharmaceutical formulation of claim 1, wherein the agent that increases the risk of hypocalcemia comprises cinacalcet or a salt thereof.

27. The pharmaceutical formulation of claim 26, wherein the cinacalcet or salt thereof comprises cinacalcet HCl.

28. The pharmaceutical formulation of claim 1, further comprising a disintegrant, optionally in an amount of about 1 wt % to 10 wt %.

29. The pharmaceutical formulation of claim 2, wherein the region comprising the agent that increases the risk of hypocalcemia comprises from about 10% to about 40% by weight of cinacalcet or a salt thereof, from about 45% to about 85% by weight of at least one diluent, and from about 1% to about 10% by weight of at least one disintegrant, optionally further comprising from about 1% to about 5% by weight of at least one binder, wherein the percentage by weight is relative to the total weight of the region.

30. The pharmaceutical formulation of claim 2, wherein the region comprising the agent that increases the risk of hypocalcemia comprises: (a) from about 10% to about 40% by weight of cinacalcet or salt thereof; (b) from about 40% to about 75% by weight of microcrystalline cellulose; (c) from about 5% to about 35% by weight of starch; (d) from about 1% to about 10% by weight of crospovidone; (e) from about 0.05% to about 1.5% by weight of colloidal silicon dioxide; and (f) from about 0.05% to about 1.5% by weight of magnesium stearate; wherein the percentage by weight is relative to the total weight of the region.

31. The pharmaceutical formulation of claim 2, wherein the region comprising the agent that increases the risk of hypocalcemia comprises: (a) from about 10% to about 40% by weight of cinacalcet or salt thereof; (b) from about 40% to about 75% by weight of microcrystalline cellulose; (c) from about 1% to about 5% by weight of povidone; (d) from about 5% to about 35% by weight of starch; (e) from about 0.05% to about 1.5% by weight of colloidal silicon dioxide; and (f) from about 0.05% to about 1.5% by weight of magnesium stearate; wherein the percentage by weight is relative to the total weight of the region.

32. The pharmaceutical formulation of claim 2, wherein the region comprising the agent that increases the risk of hypocalcemia comprises: (a) from about 10% to about 40% by weight of cinacalcet or salt thereof; (b) from about 40% to about 75% by weight of microcrystalline cellulose; (c) from about 15% to about 50% by weight of starch; (d) from about 0.05% to about 1.5% by weight of colloidal silicon dioxide; and (e) from about 0.05% to about 1.5% by weight of magnesium stearate; wherein the percentage by weight is relative to the total weight of the region.

33. The pharmaceutical formulation of claim 2, wherein the region comprising the agent that increases the risk of hypocalcemia comprises: (a) from about 10% to about 40% by weight of cinacalcet or salt thereof; (b) from about 40% to about 75% by weight of microcrystalline cellulose; (c) from about 1% to about 5% by weight of povidone; (d) from about 1% to about 10% by weight of a disintegrant selected from the group consisting of croscarmellose, sodium starch glycolate, crosslinked cellulose, crosslinked polymers, crosslinked starches, and combinations thereof; (e) from about 0.05% to about 1.5% by weight of colloidal silicon dioxide; and (f) from about 0.05% to about 1.5% by weight of magnesium stearate; wherein the percentage by weight is relative to the total weight of the region.

34. The pharmaceutical formulation of claim 2, wherein the region comprising the agent that increases the risk of hypocalcemia comprises: (a) from about 10% to about 40% by weight of cinacalcet or salt thereof; (b) from about 40% to about 75% by weight of microcrystalline cellulose; (c) from about 1% to about 5% by weight of a binder selected from the group consisting of gelatin, acacia, tragacanth, alginic acid, cellulose, methyl cellulose, ethyl cellulose, HPMC, HPC, sodium carboxy methyl cellulose, PEG, PVA, polymethacrylate, polyvinylcaprolactam, and combinations thereof; (d) from about 5% to about 35% by weight of starch; (e) from about 1% to about 10% by weight of crospovidone; (f) from about 0.05% to about 1.5% by weight of colloidal silicon dioxide; and (g) from about 0.05% to about 1.5% by weight of magnesium stearate; wherein the percentage by weight is relative to the total weight of the region.

35. A method of managing iatrogenic hypocalcemia and secondary hyperparathyroidism in a patient receiving therapy with cinacalcet or a salt thereof, comprising administering to said patient a pharmaceutical formulation of claim 1.

36. The method of claim 35, wherein the patient has impaired renal function, optionally associated with Chronic Kidney Disease Stage 1, 2, 3, 4, or 5.

37. The method of claim 35, wherein the patient is receiving dialysis.

38. The method of claim 35, wherein the patient is not on dialysis.

39. The method of claim 35, wherein the amount of 25-hydroxyvitamin D is effective to restore or maintain the patient's serum calcium level to at least about 8.0 mg/dL, optionally in a range of about 8.3 mg/dL to about 11.6 mg/dL.

40. The method of claim 35, wherein the amount of 25-hydroxyvitamin D is effective to safely increase the patient's serum level of 25-hydroxyvitamin D to at least 30 ng/mL, optionally in a range of about 30 ng/mL to about 100 ng/mL.

41. The method of claim 35, wherein the amount of 25-hydroxyvitamin D is effective to decrease the patient's serum parathyroid hormone level, optionally by 30% or more.

42. The method of claim 35, wherein the amount of 25-hydroxyvitamin D is administered in an oral modified release formulation, optionally a sustained release formulation.

43. The method of claim 35, wherein the 25-hydroxyvitamin D is co-administered with an oral formulation comprising cinacalcet or a salt thereof.

44. The method of claim 35, wherein the 25-hydroxyvitamin D comprises 25-hydroxyvitamin D.sub.3, 25-hydroxyvitamin D.sub.2, or a combination thereof.

45. The method of claim 44, wherein the 25-hydroxyvitamin D comprises 25-hydroxyvitamin D.sub.3.

46. The method of claim 35, wherein the 25-hydroxyvitamin D is administered in a dosage of 1 mcg to 1000 mcg per day.

47. The method of claim 35, wherein the cinacalcet or salt thereof comprises cinacalcet HCl.

48. The method of claim 35, wherein the patient is receiving cinacalcet administered in a dosage of 1 mg to 400 mg per day.

49. A method of treating hypercalcemia in a patient with parathyroid carcinoma, comprising administering to said patient an effective amount of a 25-hydroxyvitamin D compound by modified release and an effective dose of cinacalcet or a salt thereof in an amount of less than 360 mg daily, wherein said effective amount of cinacalcet or a salt thereof is a reduced dose compared to the effective dose of cinacalcet in the absence of said 25-hydroxyvitamin D administration, and an anticancer agent.

51. The method of claim 49, comprising an initial dose of cinacalcet in a rage of about 20 mg to about 25 mg once daily.

52. The method of claim 49, wherein the amount of 25-hydroxyvitamin D is in a range of about 100 mcg to about 300 mcg.

53. The pharmaceutical formulation of claim 1, wherein the anticancer agent comprises one or more agents in the groups including aromatase inhibitors; anti-estrogens; anti-androgens; gonadorelin agonists; topoisomerase I inhibitors; topoisomerase II inhibitors; microtubule active agents; alkylating agents; retinoids, carotenoids, tocopherols; cyclooxygenase inhibitors; MMP inhibitors; mTOR inhibitors; antimetabolites; platin compounds; methionine aminopeptidase inhibitors; bisphosphonates; antiproliferative antibodies; heparanase inhibitors; inhibitors of Ras oncogenic isoforms; telomerase inhibitors; proteasome inhibitors; Flt-3 inhibitors; Hsp90 inhibitors; kinesin spindle protein inhibitors; MEK inhibitors; antitumor antibiotics; nitrosoureas, compounds targeting/decreasing protein or lipid kinase activity, compounds targeting/decreasing protein or lipid phosphatase activity, antiangiogenic compounds, azacitidine, axathioprine, bevacizumab, bleomycin, capecitabine, carboplatin, chlorabucil, cisplatin, cyclophosphamide, cytarabine, daunorubicin, docetaxel, doxifluridine, doxorubicin, epirubicin, etoposide, fluorouracil, gemcitabine, herceptin, idarubicin, mechlorethamine, melphalan, mercaptopurine, methotrexate, mitoxantrone, oxaliplatin, paclitaxel, tafluposide, teniposide, tioguanine, retinoic acid, valrubicin, vinblastine, vincristine, vindesine, vinorelbine, and receptor tyrosine kinase inhibitors.

54. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more aromatase inhibitors.

55. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more anti-estrogens.

56. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more anti-androgens.

57. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more gonadorelin agonists.

58. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or moretopoisomerase I inhibitors.

59. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more topoisomerase II inhibitors.

60. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more microtubule active agents.

61. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more alkylating agents.

62. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more retinoids.

63. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more carotenoids.

64. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more tocopherols.

65. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more cyclooxygenase inhibitors.

66. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more MMP inhibitors.

67. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more mTOR inhibitors.

68. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more antimetabolites.

69. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more platin compounds.

70. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more methionine aminopeptidase inhibitors.

71. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more bisphosphonates.

72. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more antiproliferative antibodies.

73. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more heparanase inhibitors.

74. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more inhibitors of Ras oncogenic isoforms.

75. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more telomerase inhibitors.

76. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more proteasome inhibitors.

77. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more Flt-3 inhibitors.

78. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more Hsp90 inhibitors.

79. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more kinesin spindle protein inhibitors.

80. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more MEK inhibitors.

81. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more antitumor antibiotics.

82. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more nitrosoureas.

83. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more compounds targeting/decreasing protein or lipid kinase activity.

84. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more compounds targeting/decreasing protein or lipid phosphatase activity.

85. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more antiangiogenic compounds.

86. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises azacitidine.

87. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises axathioprine.

88. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises bevacizumab.

89. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises bleomycin.

90. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises capecitabine.

91. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises carboplatin.

92. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises chlorabucil.

93. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises cisplatin.

94. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises cyclophosphamide.

95. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises cytarabine.

96. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises daunorubicin.

97. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises docetaxel.

98. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises doxifluridine.

99. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises doxorubicin.

100. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises epirubicin.

101. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises etoposide.

102. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises fluorouracil.

103. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises gemcitabine.

104. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises herceptin.

105. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises idarubicin.

106. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises mechlorethamine.

107. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises melphalan.

108. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises mercaptopurine.

109. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises methotrexate.

110. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises mitoxantrone.

111. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises oxaliplatin.

112. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises paclitaxel.

113. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises tafluposide.

114. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises teniposide.

115. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises tioguanine.

116. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises retinoic acid.

117. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises valrubicin.

118. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises vinblastine.

119. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises vincristine.

120. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises vindesine.

121. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises vinorelbine.

122. The pharmaceutical formulation of claim 53, wherein the anticancer agent comprises one or more receptor tyrosine kinase inhibitors.

Description

EXAMPLE 1

One Embodiment of a Modified Release Formulation for Oral Administration

[0118] Purified yellow beeswax and fractionated coconut oil are combined in a ratio of 1:1 and heated with continuous mixing to 75 degrees Celsius until a uniform mixture is obtained. The wax mixture is continuously homogenized while cooled to approximately 45 degrees Celsius. The active compounds, 25-hydroxyvitamin D.sub.2 and 25-hydroxyvitamin D.sub.3, in a ratio of 1:1, are dissolved in absolute ethanol and the ethanolic solution is added, with continuous homogenization, to the molten wax mixture. The amount of ethanol added is in the range of 1 to 2 v/v%. Mixing is continued until the mixture is uniform. The uniform mixture is loaded into soft gelatin capsules. The capsules are immediately rinsed to remove any processing lubricant(s) and briefly immersed in an aqueous solution of acetaldehyde in order to crosslink the gelatin shell. The concentration of the acetaldehyde solution and the immersion time is selected to achieve crosslinking to the desired degree, as determined by near-infrared spectrophotometry. The finished capsules are washed, dried and packaged.

EXAMPLE 2

One Embodiment of a Formulation for Intravenous Administration

[0119] TWEEN Polysorbate 20 is warmed to approximately 50 to 60 degrees Fahrenheit, and 25-hydroxyvitamin D.sub.3, dissolved in a minimal volume of absolute ethanol, is added with continuous stirring. The resulting uniform solution of 25-hydroxyvitamin D.sub.3, absolute ethanol and TWEEN Polysorbate 20 is transferred to a suitable volume of water for injection, which has been thoroughly sparged with nitrogen to remove all dissolved oxygen. Sodium chloride, sodium ascorbate, sodium phosphate (dibasic and monobasic), and disodium edetate are added, followed by sufficient stirring under a protective nitrogen atmosphere, to produce an isotonic homogeneous mixture containing, per 2 mL unit volume: 20 mcg of 25-hydroxyvitamin D.sub.3; less than 0.01% absolute ethanol; 0.40% (w/v) TWEEN Polysorbate 20; 0.15% (w/v) sodium chloride; 1.00% (w/v) sodium ascorbate; 0.75% (w/v) sodium phosphate dibasic anhydrous; 0.18% (w/v) sodium phosphate monobasic monohydrate; and, 0.11% (w/v) disodium edetate. The mixture is sterilized by filtration and filled, with suitable protection from oxygen contamination, into amber glass ampules having an oxygen headspace of less than 1%.

EXAMPLE 3

Pharmacokinetics Testing in Dogs

[0120] Twenty male beagle dogs are divided randomly into two comparable groups and receive no supplemental Vitamin D for the next 30 days. At the end of this time, each dog in Group #1 receives a single softgel capsule containing 25 mcg of 25-hydroxyvitamin D.sub.2 prepared in a controlled release formulation similar to the one disclosed in Example 1. Each dog in the other group (Group #2) receives a single immediate-release softgel capsule containing 25 mcg of 25-hydroxyvitamin D.sub.2 dissolved in medium chain triglyceride oil. All dogs have received no food for at least 8 hours prior to dosing. Blood is drawn from each dog at 0, 0.5, 1, 1.5, 2, 3, 4, 6, 9, 15, 24, 36, and 72 hours after dose administration. The collected blood is analyzed for the contained levels of 25-hydroxyvitamin D, and the data are analyzed by treatment group. Dogs in Group #1 show a slower rise and a lower maximum (C.sub.max) in mean blood levels of 25-hydroxyvitamin D than dogs in Group #2. However, dogs in Group #1 show a more prolonged elevation of mean blood levels of 25-hydroxyvitamin D.sub.2 relative to dogs in Group #2, despite the fact that the C.sub.max recorded in Group #1 is lower. The mean area under the curve (AUC), corrected for predose background levels (recorded at t=0), is substantially greater for Group #1 for 25-hydroxyvitamin D. These procedures demonstrate that administration of 25-hydroxyvitamin D.sub.2 in the formulation described in this invention to dogs results in blood levels of 25-hydroxyvitamin D which rise much more gradually and remain more stable than after dosing with the same amount of 25-hydroxyvitamin D.sub.2 formulated for immediate release (in medium chain triglyceride oil). The greater AUC calculated for blood levels of 25-hydroxyvitamin D in Group #1 demonstrates that the bioavailability of 25-hydroxyvitamin D.sub.2 formulated as described herein is markedly improved.

EXAMPLE 4

Pharmacokinetics Testing in Healthy Normal Volunteers

[0121] Sixteen healthy non-obese adults, aged 18 to 24 years, participate in an 11-week pharmacokinetic study in which they receive successively, and in a double-blinded fashion, two formulations of 25-hydroxyvitamin D.sub.2. One of the formulations (Formulation #1) is a softgel capsule containing 100 mcg of 25-hydroxyvitamin D.sub.2 prepared in a controlled release formulation similar to the one disclosed in Example 1. The other formulation (Formulation #2) is an immediate-release softgel capsule of identical appearance containing 100 mcg of 25-hydroxyvitamin D.sub.2 dissolved in medium chain triglyceride oil. For 60 days prior to study start and continuing through study termination, the subjects abstain from taking other Vitamin D supplements. On Days 1, 3 and 5 of the study, all subjects provide fasting morning blood samples to establish pre-treatment baseline values. On the morning of Day 8, the subjects provide an additional fasting blood sample (t=0), and are randomly assigned to one of two treatment groups. Both groups are dosed with a single test capsule prior to eating breakfast: One group receives a capsule of Formulation #1 and the other group receives a capsule of Formulation #2. Blood is drawn from each subject at 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10, 12, 15, 24, 36, 48, 72 and 108 hours after dose administration. On the morning of Day 70, the subjects provide additional fasting morning blood samples (t=0) and are dosed with a single capsule of the other test formulation prior to eating breakfast. Blood is again drawn from each subject at 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10, 12, 15, 24, 36, 48, 72 and 108 hours after dose administration. All collected blood is analyzed for the contained levels of 25-hydroxyvitamin D, and the data are analyzed by treatment formulation after correction for baseline content. Formulation #1 is found to produce a slower rise and a lower C.sub.max in mean blood levels of 25-hydroxyvitamin D than Formulation #2. However, Formulation #1 also produces a more prolonged elevation of mean blood levels of 25-hydroxyvitamin D.sub.2 relative to Formulation #2, despite the fact that the recorded C.sub.max is lower. The mean AUC for 25-hydroxyvitamin D.sub.2 is substantially greater after administration of Formulation #1. These procedures demonstrate that administration of 25-hydroxyvitamin D.sub.2 in the formulation described in this invention to healthy human adults results in blood levels of 25-hydroxyvitamin D.sub.2 which rise much more gradually and remain more stable than after dosing with the same amount of 25-hydroxyvitamin D.sub.2 formulated for immediate release (in medium chain triglyceride oil). The greater AUC calculated for blood levels of 25-hydroxyvitamin D.sub.2 after dosing with Formulation #1 demonstrates that the bioavailability of 25-hydroxyvitamin D.sub.2 formulated as described herein is better.

EXAMPLE 5

Efficacy Study in Healthy Adult Male Volunteers With Vitamin D Insufficiency

[0122] The effectiveness of three different formulations of Vitamin D in restoring serum total 25-hydroxyvitamin D to optimal levels (>30 ng/mL) is examined in a 23-day study of healthy non-obese men diagnosed with Vitamin D insufficiency. One of the formulations (Formulation #1) is a sustained release softgel capsule containing 30 mcg of 25-hydroxyvitamin D.sub.3 prepared as illustrated in this disclosure. The second formulation (Formulation #2) is an immediate-release softgel capsule of identical appearance containing 50,000 IU of ergocalciferol dissolved in medium chain triglyceride oil. The third formulation (Formulation #3) is an immediate-release softgel capsule, also of identical appearance, containing 50,000 IU of cholecalciferol dissolved in medium chain triglyceride oil. A total of 100 healthy Caucasian and African-American men participate in this study, all of whom are aged 30 to 45 years and have serum 25-hydoxyvitamin D levels between 15 and 29 ng/mL (inclusive). All subjects abstain from taking other Vitamin D supplements for 60 days before study start and continuing through study termination, and from significant sun exposure. On Day 1 and 2 of the study, all subjects provide fasting morning blood samples to establish pre-treatment baseline values of serum total 25-hydroxyvitamin D. On the morning of Day 3, the subjects provide an additional fasting blood sample (t=0), are randomly assigned to one of four treatment groups, and are dosed with a single test capsule prior to eating breakfast: The subjects in Group #1 each receive a single capsule of Formulation #1, and the subjects in Groups #2 and #3 each receive a single capsule of Formulation #2 or Formulation #3, respectively. Subjects in Group #4 receive a matching placebo capsule. Subjects in Group #1 each receive an additional capsule of Formulation #1 on the mornings of Days 4 through 22 before breakfast, but subjects in Groups #2, #3 and #4 receive no additional capsules. A fasting morning blood sample is drawn from each subject, irrespective of treatment group, on Days 4, 5, 6, 10, 17 and 23 (or 1, 2, 3, 7, 14 and 20 days after the start of dosing). All collected blood is analyzed for the contained levels of 25-hydroxyvitamin D, and the data are analyzed by treatment group after correction for baseline values. Subjects in all four treatment groups exhibit mean baseline serum 25-hydoxyvitamin D levels of approximately 16 to 18 ng/mL, based on analysis of fasting blood samples drawn on Days 1 through 3. Subjects in Group #4 (control group) show no significant changes in mean serum total 25-hydroxyvitamin D over the course of the study. Subjects in Group #1 show a steadily increasing mean serum total 25-hydroxyvitamin D reaching at least 30 ng/mL by Day 23. In marked contrast, subjects in Group #2 exhibit marked increases in mean serum 25-hydroxyvitamin D for the first few days post-dosing, reaching a maximum of just above 25 ng/mL, and then rapidly declining thereafter. By study end, serum total 25-hydroxyvitamin D is significantly lower than baseline in Group #2. Subjects in Group #3 exhibit continuing increases in mean serum total 25-hydroxyvitamin D through the first 2 weeks after dosing with gradual, but progressive, decreases occurring thereafter. By study end, mean serum total 25-hydroxyvitamin D is below 30 ng/mL. The data from this study demonstrate that administration of 600 mcg of 25-hydroxyvitamin D.sub.3, formulated as described herein and administered at a dose of 30 mcg per day for 20 days, is substantially more effective in restoring low serum levels of 25-hydroxyvitamin D to optimal levels than immediate-release formulations of 50,000 IU of either ergocalciferol or cholecalciferol administered in single doses, as currently recommended by the NKF and other leading experts on oral Vitamin D replacement therapy.

EXAMPLE 6

Efficacy Study in Osteoporosis Patients Treated with an Antiresorptive Agent

[0123] The effectiveness of oral modified release 25-hydroxyvitamin D.sub.3 in restoring serum total 25-hydroxyvitamin D to optimal levels (>30 ng/mL), and thereby optimizing the effectiveness of an antiresorptive agent at increasing bone mineral density, is examined in a 24-month study of adult male and female patients with osteoporosis. In a randomized, double-blind controlled study, patients are treated with denosumab (60 mg at the start of treatment and again every six months). All denosumab-treated patients are randomized to receive daily oral treatment with one softgel capsule containing either 30 mcg of 25-hydroxyvitamin D.sub.3 in a modified release formulation or 400 IU of Vitamin D.sub.3 (cholecalciferol) in an immediate release formulation. A total of 500 subjects participate in this study, 250 male and 250 female, all of whom are aged 60 to 85 years (inclusive), have bone mineral density T-scores between 2.0 and 4.0, and have serum total 25-hydroxyvitamin D levels less than 30 ng/mL at the time of enrollment. All subjects receive calcium supplements (500 mg/day) and abstain from taking other Vitamin D supplements for 60 days before study start and continuing through study termination, and from significant sun exposure. All subjects begin daily dosing with softgel capsules at the start of denosumab treatment. Serum total 25-hydroxyvitamin D, PTH, calcium, phosphorus, N- and C-telopeptides, and P1NP, and urinary calcium, phosphorus and creatinine, are measured monthly. Bone mineral density at four sites (total hip, femoral neck, radius and lumbar spine) is determined at quarterly intervals.

[0124] After 3 months, the daily softgel capsule dosage is maintained unchanged in patients whose serum total 25-hydroxyvitamin D is between 50 and 90 ng/mL, and increased by one capsule in patients whose serum total 25-hydroxyvitamin D is below 50 ng/mL. The dosage is immediately lowered by one capsule per day in patients whose serum total 25-hydroxyvitamin D rises above 100 ng/mL or whose serum calcium is confirmed above 10.3 mg/dL. After 6 to 9 months, all subjects exhibit serum total 25-hydroxyvitamin D levels that remain essentially stable with continuing dosing and rise to approximately 50 to 100 ng/mL with 25-hydroxyvitamin D.sub.3 treatment or to approximately 25 to 35 ng/mL with Vitamin D.sub.3 treatment. In patients treated with 25-hydroxyvitamin D.sub.3, the incidence of hypocalcemia and severity of secondary hyperparathyroidism is markedly reduced once stable dosing has been achieved. However, in patients treated with Vitamin D.sub.3, hypocalcemia and secondary hyperparathyroidism occur more frequently. After 24 months of treatment, the patients treated with denosumab and 25-hydroxyvitamin D.sub.3 are found to have higher and more consistent serum levels of 25-hydroxyvitamin D.sub.3 and lower serum PTH levels than patients treated with denosumab and Vitamin D.sub.3. Patients treated with denosumab and 25-hydroxyvitamin D.sub.3 are also found to have larger increases in bone mineral density than patients treated with denosumab and Vitamin D.sub.3. Data from this study demonstrate that the modified release formulation of 25-hydroxyvitamin D.sub.3 is effective at increasing serum total 25-hydroxyvitamin D without causing unacceptable side effects related to calcium and PTH metabolism and at augmenting the increases in bone mineral density produced by denosumab.

EXAMPLE 7

Efficacy Study in Prostate Cancer Patients

[0125] The effectiveness of oral modified release 25-hydroxyvitamin D.sub.3 in restoring serum total 25-hydroxyvitamin D to optimal levels (greater than 30 ng/mL), thereby mitigating iatrogenic hypocalcemia and secondary hyperparathyroidism, and optimizing the effectiveness of an antiresorptive agent at mitigating skeletal-related events in prostate cancer patients, is examined in a 24-month study of adult male patients with bone-metastasized castration-resistant prostate cancer. In a randomized, double-blind controlled study, patients are treated with denosumab (120 mg every four weeks). All denosumab-treated patients are randomized to receive daily oral treatment with one softgel capsule containing either 30 mcg of 25-hydroxyvitamin D.sub.3 in a modified release formulation or 400 IU of Vitamin D.sub.3 in an immediate release formulation. A total of 500 subjects participate in this study, all of whom are aged 18 years or older with histologically confirmed prostate cancer. Prior to study admission, patients had to have received treatment for prostate cancer (e.g., bilateral orchiectomy or androgen-deprivation therapy for at least 6 months), have total serum testosterone lower than 50 ng/dL, and have three consecutive increasing PSA tests separated by at least 2 weeks with the last two PSA measurements greater than or equal to 1.0 mcg/L. All patients have serum total 25-hydroxyvitamin D levels less than 30 ng/mL at the time of enrollment. All patients receive a radioisotope bone scan during screening with subsequent imaging by CT, MRI, or plain radiograph if needed to confirm bone metastases. All subjects receive calcium supplements (500 mg/day) and abstain from taking other Vitamin D supplements for 60 days before study start and continuing through study termination, and from significant sun exposure.

[0126] All subjects begin daily dosing with softgel capsules at the start of denosumab treatment. Serum total 25-hydroxyvitamin D, PTH, calcium, phosphorus, N- and C-telopeptides, and P1NP, and urinary calcium, phosphorus and creatinine, are measured monthly. Radiographic bone scans are conducted every 6 months to detect skeletal metastases, with a second imaging modality (CT, MRI, or plain radiograph) used to confirm diagnosis of any metastases detected. Bone mineral density at four sites (total hip, femoral neck, radius and lumbar spine) is determined at the start of the study and thereafter at yearly intervals. After 3 months, the daily dosage of 25-hydroxyvitamin D.sub.3 capsules is maintained unchanged in patients whose serum total 25-hydroxyvitamin D is between 50 and 90 ng/mL, and increased by one 30 mcg capsule in patients whose serum total 25-hydroxyvitamin D is below 50 ng/mL. The dosage is immediately lowered by one 30 mcg capsule per day in patients whose serum total 25-hydroxyvitamin D rises above 100 ng/mL or whose serum calcium is confirmed above 10.3 mg/dL.

[0127] After 6 months to 9 months, all subjects exhibit serum total 25-hydroxyvitamin D levels essentially stable in a range of 50 ng/mL to 90 ng/mL with 25-hydroxyvitamin D.sub.3 treatment or between approximately 25 ng/mL to 35 ng/mL with Vitamin D.sub.3 treatment. In patients treated with 25-hydroxyvitamin D.sub.3, the incidence of hypocalcemia and severity of SHPT and hypercalcemia is markedly reduced once stable dosing has been achieved. In contrast, patients treated with Vitamin D.sub.3 exhibit hypercalcemia and SHPT more frequently. After 24 months of treatment, the patients treated with denosumab and 25-hydroxyvitamin D.sub.3 are found to have higher and more consistent serum levels of 25-hydroxyvitamin D.sub.3 and lower serum PTH levels than patients treated with denosumab and vitamin D.sub.3. Patients treated with denosumab and 25-hydroxyvitamin D.sub.3 are found to have a significantly lower incidence of hypocalcemia, reduced plasma PTH levels and larger increases in bone mineral density and to have a significantly delayed time to first post-treatment SRE, compared to patients treated with denosumab and Vitamin D.sub.3. Data from this study demonstrate that the modified release formulation of 25-hydroxyvitamin D.sub.3 is effective at increasing serum 25-hydroxyvitamin D without causing unacceptable side effects related to calcium and PTH metabolism, and at mitigating hypocalcemia and augmenting the increases in bone mineral density and delayed time to first bone metastasis produced by denosumab.

EXAMPLE 8

Efficacy Study in Breast Cancer Patients

[0128] The effectiveness of oral modified-release 25-hydroxyvitamin D.sub.3 in restoring serum total 25-hydroxyvitamin D to optimal levels (greater than 30 ng/mL), thereby mitigating hypocalcemia and SHPT and optimizing the effectiveness of denosumab at mitigating SRE in breast cancer patients, is examined in a 24-month study of adult female patients with breast cancer. In a randomized, double-blind controlled study, patients are treated with denosumab (120 mg every four weeks). All denosumab-treated patients are randomized to receive daily oral treatment with one softgel capsule containing either 30 mcg of 25-hydroxyvitamin D.sub.3 in a modified release formulation or 400 IU of cholecalciferol in an immediate release formulation. All subjects participating in this study are aged 18 years or older with histologically or cytologically confirmed breast adenocarcinoma and current or prior radiographic (x-ray, CT or MRI) evidence of at least one bone metastasis. All subjects receive calcium supplements (500 mg/day) and abstain from taking other Vitamin D supplements for 60 days before study start and continuing through study termination, and from significant sun exposure. All subjects begin daily dosing with softgel capsules at the start of denosumab treatment. Serum total 25-hydroxyvitamin D, PTH, calcium, phosphorus, N- and C-telopeptides, and P1NP, and urinary calcium, phosphorus and creatinine, are measured monthly. Radiographic bone scans are conducted every 6 months to monitor skeletal metastases, with a second imaging modality (CT, MRI, or plain radiograph) used to confirm any metastases detected. Bone mineral density at four sites (total hip, femoral neck, radius and lumbar spine) is determined at the start of the study and thereafter at yearly intervals. After 3 months, the daily softgel capsule dosage is maintained unchanged in patients whose serum total 25-hydroxyvitamin D is between 50 and 90 ng/mL and increased by one mcg capsule in patients whose serum total 25-hydroxyvitamin D is below 50 ng/mL. The dosage is immediately lowered by one capsule per day in patients whose serum total 25-hydroxyvitamin D rises above 100 ng/mL or whose serum calcium is confirmed above 10.3 mg/dL. After 6 to 9 months, the subjects' serum total 25-hydroxyvitamin D levels remain essentially stable with continued dosing, and rise to a level between about 50 ng/mL and about 90 ng/mL with 25-hydroxyvitamin D.sub.3 treatment or to approximately 25 to 35 ng/mL with cholecalciferol treatment.

[0129] In patients treated with 25-hydroxyvitamin D.sub.3, the incidence of hypocalcemia and severity of secondary hyperparathyroidism are markedly reduced once stable dosing has been achieved. However, in patients treated with vitamin D.sub.3, hypocalcemia and secondary hyperparathyroidism occur more frequently. After 24 months of treatment, the patients treated with denosumab and 25-hydroxyvitamin D.sub.3 are found to have higher and more consistent serum levels of 25-hydroxyvitamin D.sub.3 and lower serum PTH levels than are patients treated with denosumab and vitamin D.sub.3. Patients treated with denosumab and 25-hydroxyvitamin D.sub.3 are found to have a significantly lower incidence of hypocalcemia and larger increases in bone mineral density and to have a significantly delayed time to additional bone metastasis, compared to patients treated with denosumab and Vitamin D.sub.3. Data from this study demonstrate that the modified release formulation of 25-hydroxyvitamin D.sub.3 is effective at increasing serum total 25-hydroxyvitamin D without causing unacceptable side effects related to calcium and PTH metabolism, and at mitigating hypocalcemia and augmenting the increases in bone mineral density and delayed time to bone metastasis produced by denosumab.

EXAMPLE 9

Safety Study in Patients with Metastatic Bone Disease Receiving Treatment with an Antiresorptive Agent

[0130] The safety and tolerability of oral modified release 25-hydroxyvitamin D.sub.3 is examined in an open label, repeat-dose study of adult patients diagnosed with metastases in bone originating from breast or prostate cancer who are receiving ongoing treatment with denosumab or zoledronic acid for at least 3 months. At the start of the study, all patients have plasma PTH greater than 70 pg/mL as evidence of SHPT, serum calcium less than 9.8 mg/dL, spot urine Ca:Cr ratio0.25 (250 mg/g creatinine) and an estimated glomerular filtration rate greater than 15 mL/min/1.73 m.sup.2. Twenty-four (24) patients diagnosed with bone metastases subsequent to breast or pancreatic carcinoma are treated for up to 52 weeks with one or more capsules containing 30 mcg of 25-hydroxyvitamin D.sub.3 in a modified release formulation. Denosumab or zoledronic acid are administered according to the typical standard of care for each patient's condition. Patients whose typical standard of care requires calcium and/or vitamin D supplementation receive less than 1000 mg/day of elemental calcium and/or 2000 IU/day or less of vitamin D (ergocalciferol and/or cholecalciferol). Patients do not receive any other vitamin D analogs (e.g., calcitriol, paricalcitol, doxercalciferol, etc.).

[0131] The 52-week study consists of a 40 week dose escalation phase followed by a 12-week maintenance phase. At the end of the maintenance phase, there is a two-week follow up phase. At the start of the study, all patients receive an initial daily dose of 30 mcg 25-hydroxyvitamin D.sub.3, which is increased at four-week intervals over the course of the dose escalation phase up to a maximum daily dose of 300 mcg. The daily dose achieved by the end of the dose escalation study is the daily dose administered during the maintenance phase. Patients exhibiting a serum calcium level 10.3 mg/dL of the course of the study thus receive a daily dose of: 30 mcg 25-hydroxyvitamin D.sub.3 at the start of the study; 60 mcg 25-hydroxyvitamin D.sub.3 after 4 weeks; 90 mcg 25-hydroxyvitamin D.sub.3 at 8 weeks; 120 mcg 25-hydroxyvitamin D.sub.3 at 12 weeks; 150 mcg 25-hydroxyvitamin D.sub.3 at 16 weeks; 180 mcg 25-hydroxyvitamin D.sub.3 at 20 weeks; 210 mcg 25-hydroxyvitamin D.sub.3 at 24 weeks; 240 mcg 25-hydroxyvitamin D.sub.3 at 28 weeks; 270 mcg 25-hydroxyvitamin D.sub.3 at 32 weeks; and 300 mcg 25-hydroxyvitamin D.sub.3 at 36 weeks and through the maintenance phase. Patients exhibiting a serum calcium level exceeding 10.3 mg/dL for two consecutive visits will suspend dosing until serum calcium returns to 10.0 mg/dL, and then resume treatment at a reduced daily dose and enter a 12-week maintenance phase, followed by a 2-week follow-up period.

[0132] Blood samples are collected at 2-week intervals for monitoring serum levels of calcium and phosphorus. Samples are collected at 4-week intervals for monitoring plasma levels of PTH and PTHrP and serum total 25-hydroxyvitamin D, 24,25-dihydroxyvitamin D.sub.3, calcitriol, and free and total calcifediol. Serum vitamin D metabolites and markers of bone metabolism, immune function, and tumor burden are measured at the beginning of the dose escalation phase and at the beginning and end of the maintenance phase. Urine samples are collected at 4-week intervals for monitoring the Ca/Cr ratio and urine chemistry. The genotype of vitamin D binding protein is determined for each subject at the beginning of the dose escalation phase.

[0133] Serum calcium gradually rises in the dose escalation phase while plasma PTH decreases. When plasma PTH is overly suppressed, serum calcium rises more quickly with continued dose escalation, increasing the risk of hypercalcemia. Patients exhibit significant increases in serum total 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, and 24,25-dihydroxyvitamin D, and decreases in plasma PTH. Patients receiving the starting dose level of 30 mcg of 25-hydroxyvitamin D.sub.3 exhibit mean serum 25-hydroxyvitamin D levels of about 50 ng/mL. Patients receiving the dose level of 90 mcg of 25-hydroxyvitamin D.sub.3 exhibit mean serum 25-hydroxyvitamin D levels of about 100 mg/mL. Patients receiving the highest dose level of 300 mcg of 25-hydroxyvitamin D.sub.3 exhibit mean serum 25-hydroxyvitamin D levels of about 200 to about 300 ng/mL, for example, about 230 ng/mL. Data from this study demonstrate that a modified release formulation of 25-hydroxyvitamin D.sub.3 is effective at increasing serum total 25-hydroxyvitamin D without causing unacceptable side effects related to calcium and PTH metabolism.

EXAMPLE 10

Efficacy Study in Patients with Metastatic Bone Disease Receiving Treatment With an Antiresorptive Agent

[0134] The effectiveness of oral modified-release 25-hydroxyvitamin D.sub.3 in raising serum 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D and delaying cancer progression is examined in a 6-month randomized, double-blind placebo-controlled study of adult patients diagnosed with metastases in bone originating from breast or prostate cancer who are receiving ongoing treatment with denosumab or zoledronic acid for at least 3 months. Patients are treated with one or more capsules containing 30 mcg of 25-hydroxyvitamin D.sub.3 in a modified release formulation or placebo. Denosumab or zoledronic acid are administered according to the typical standard of care for each patient's condition. Patients whose typical standard of care requires calcium and/or vitamin D supplementation receive less than 1000 mg/day of elemental calcium and/or 2000 IU/day or less of vitamin D (ergocalciferol and/or cholecalciferol). Samples are collected at monthly intervals for monitoring serum and urine levels of calcium, plasma levels of PTH and serum total 25-hydroxyvitamin D. Serum markers of tumor burden and bone metabolism, as well as cancer progression are assessed at 3-month intervals.

[0135] Patients treated with 25-hydroxyvitamin D.sub.3 are found to have a greater increase in serum calcium and decrease in plasma PTH, leading to reduced risk of hypocalcemia compared to patients receiving the placebo. Patients treated with denosumab or zoledronic acid and 25-hydroxyvitamin D exhibit an increased delay in time to additional bone metastasis, compared to patients receiving denosumab or zoledronic acid in combination with a placebo. Data from this study demonstrate that the modified release formulation of 25-hydroxyvitamin D.sub.3 is effective at increasing serum total 25-hydroxyvitamin D 1,25-dihydroxyvitamin D and delaying cancer progression, without causing unacceptable side effects related to calcium and PTH metabolism.

EXAMPLE 11

Efficacy Study in Patients with Metastatic Bone Disease Receiving Treatment with an Antiresorptive Agent for Prevention of SREs

[0136] The effectiveness of oral modified release 25-hydroxyvitamin D.sub.3 in delaying the time to the first post-treatment SRE is examined in 24-month randomized, double-blind placebo-controlled studies of adult males with castration-resistant prostate cancer metastatic to bone or adult females with estrogen-independent breast cancer metastatic to bone, who are receiving ongoing treatment with denosumab or zoledronic acid for at least 3 months. Patients are treated with one or more capsules containing 30 mcg of 25-hydroxyvitamin D.sub.3 in a modified release formulation or placebo. Denosumab or zoledronic acid are administered according to the typical standard of care for each patient's condition. Patients are monitored for SREs, including by appropriate non-invasive imaging techniques, and serum markers of tumor burden and bone metabolism at 3-month intervals, and at monthly intervals for serum and urine calcium levels and plasma PTH. Cancer progression is monitored at quarterly intervals.

[0137] Patients treated with 25-hydroxyvitamin D.sub.3 are found to have a greater increase in serum calcium and decrease in plasma PTH, leading to reduced risk of hypocalcemia compared to patients receiving the placebo. Patients treated with denosumab or zoledronic acid and 25-hydroxyvitamin D exhibit an increased delay in time to additional bone metastasis or SRE, compared to patients receiving denosumab or zoledronic acid in combination with a placebo. Data from this study demonstrate that 25-hydroxyvitamin D.sub.3 is effective at significantly increasing the observed time to a post-treatment SRE and inhibiting tumor progression compared to placebo.

EXAMPLE 12

Efficacy Study of Combination Therapy Comprising 25-Hydroxyvitamin D and Cinacalcet in Patients with CKD

[0138] The effectiveness of a composition comprising modified release 25-hydroxyvitamin D.sub.3 and immediate release cinacalcet in preventing and treating hypocalcemia and treating secondary hyperparathyroidism is examined in a randomized, double-blind study of adult patients having CKD. Patients having CKD on dialysis (i.e., having CKD Stage 5), and not on dialysis (i.e., having CKD Stage 1, 2, 3, or 4) are treated daily with combination therapy comprising at least one capsule comprising both 30 mcg to 100 mcg 25-hydroxyvitamin D and 1 mg to 100 mg cinacalcet HCl and are compared to patients receiving placebo or 25-hydroxyvitamin D or cinacalcet alone. All patients have serum total 25-hydroxyvitamin D levels less than 30 ng/mL at the time of enrollment. Serum total 25-hydroxyvitamin D, parathyroid hormone, calcium, and phosphorus, are measured before treatment and then monthly.

[0139] After one to three months, all patients receiving the combination therapy exhibit serum total 25-hydroxyvitamin D levels essentially stable in a range of 50 ng/mL to 90 ng/mL and the incidence of hypocalcemia and severity of secondary hyperparathyroidism is markedly reduced. Patients having CKD on dialysis exhibit improvements in serum 25-hydroxyvitamin D, calcium, and parathyroid hormone levels following treatment with the combination therapy, despite having very severely reduced or no kidney function. Patients having CKD not on dialysis receiving the combination therapy have an incidence of hypocalcemia comparable to patients having CKD not on dialysis, in contrast to previous reports indicating that cinacalcet-treated patients with CKD not on dialysis had an increased risk for hypocalcemia compared to cinacalcet-treat patient with CKD on dialysis.

[0140] The foregoing description has outlined, in general, the featured aspects of the invention. In reference to such, there is to be a clear understanding that the present invention is not limited to the method or detail of manufacture, chemical composition, or application of use described herein. Any other variation of manufacture, chemical composition, use, or application should be considered apparent as an alternative embodiment of the present invention. Other advantages and a fuller appreciation of the specific adaptations, compositional variations and chemical and physical attributes of this invention will be gained upon examination of the detailed description.

[0141] Also, it is understood that the phraseology and terminology used herein are for the purpose of description and should not be regarded as limiting. Throughout the specification and the claims which follow, unless the context requires otherwise, the use of including, having, and comprising and variations thereof herein is meant to encompass the stated integers and steps and equivalents thereof as well as additional items and equivalents thereof.

[0142] Throughout the specification, where compositions are described as including components or materials, it is contemplated that the compositions can also consist essentially of, or consist of, any combination of the recited components or materials, unless described otherwise. Likewise, where methods are described as including particular steps, it is contemplated that the methods can also consist essentially of, or consist of, any combination of the recited steps, unless described otherwise. The invention illustratively disclosed herein suitably may be practiced in the absence of any element or step which is not specifically disclosed herein.

[0143] The foregoing description is given for clearness of understanding only, and no unnecessary limitations should be understood therefrom, as modifications within the scope of the invention may be apparent to those having ordinary skill in the art. All patents, publications and references cited herein are hereby fully incorporated by reference. In case of conflict between the present disclosure and incorporated patents, publications and references, the present disclosure should control.