Adjunctive therapy with 25-hydroxyvitamin d

Abstract

To provide a novel vitamin D supplementation method to patients with cancer and patients treated with an agent that increases the risk of hypocalcemia.SOLUTION: 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 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.SELECTED DRAWING: None

Description

[Technical field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims the benefit under 35 U.S.C. §119(e) of U.S. Provisional Patent Application No. 62 / 034,604, filed August 7, 2014, the disclosure of which is incorporated herein by reference. [Background technology]

[0002] background Vitamin D metabolites known as 25-hydroxyvitamin D2 and 25-hydroxyvitamin D3 (collectively referred to as "25-hydroxyvitamin D") are vitamin D prohormones that contribute to maintaining adequate levels of vitamin D hormones, calcium, and phosphorus in the bloodstream. The prohormones 25-hydroxyvitamin D2 and 25-hydroxyvitamin D3 (calciferol) are produced from vitamin D2 (ergocalciferol) and 25-hydroxyvitamin D3 (calciferediol), respectively, from vitamin D3 (cholecalciferol) by one or more enzymes located primarily in the liver. These two prohormones can also be produced outside the liver from vitamin D2 and vitamin D3 (collectively referred to as "vitamin D") in certain cells, such as intestinal cells, that contain enzymes that are the same or similar to those found in the liver. The vitamin D prohormones are further metabolized in the kidney by the 1α-hydroxylase enzyme CYP27B1 to potent hormones. The prohormone 25-hydroxyvitamin D2 is metabolized to a hormone known as 1α,25-dihydroxyvitamin D2 (elcalcitriol); similarly, 25-hydroxyvitamin D3 is metabolized to 1α,25-dihydroxyvitamin D3 (calcitriol). Production of these hormones from the prohormones can also occur outside the kidney, within cells that contain the required enzymes.

[0003] Vitamin D hormones play essential roles in human health mediated by the intracellular vitamin D receptor (VDR). They are involved in regulating cell differentiation and growth, parathyroid hormone (PTH) secretion by the parathyroid gland, and normal bone formation and metabolism. In particular, vitamin D hormones regulate blood calcium levels by controlling the absorption of dietary calcium and phosphorus by the small intestine and calcium reabsorption by the kidney. Under normal conditions, the effect of vitamin D on stimulating intestinal calcium absorption is predominant, and as a result, dietary calcium is the primary source of serum calcium. However, when dietary calcium or vitamin D is insufficient, the parathyroid gland increases the secretion of PTH to promote calcium mobilization from bone to maintain serum calcium levels. Excessive hormone levels, whether temporary or persistent, can lead to abnormally high urinary calcium (hypercalciuria), blood calcium (hypercalcemia), and blood phosphorus (hyperphosphatemia). Insufficient hormone levels can result in the opposite syndrome of abnormally low blood calcium levels (hypocalcemia). Vitamin D hormones are also required for the normal functioning of the musculoskeletal, immune and renin-angiotensin systems. Based on the demonstrated presence of intracellular VDR in nearly all human tissues, numerous other roles for the vitamin D hormones have been postulated or elucidated.

[0004] If left untreated, inadequate vitamin D supply can cause serious bone disorders, including rickets and osteomalacia, and can contribute to the development of many other disorders, including osteoporosis, non-traumatic fractures of the spine and hip, obesity, diabetes, muscle weakness, immune deficiencies, hypertension, psoriasis, and various cancers. The Institute of Medicine (IOM) of the National Academy of Sciences has concluded that the Adequate Intake (AI) of vitamin D for healthy individuals ranges from 200 to 600 IU per day, depending on the individual's age and sex (Standing Committee on the Scientific Evaluation of Dietary Reference Intakes: Dietary reference intakes: calcium, phosphorus, magnesium, vitamin D, and fluoride. Washington, DC: National Academy Press (1997), the contents of which are incorporated by reference). The AI ​​for vitamin D was defined primarily based on serum 25-hydroxyvitamin D levels sufficient (or ≥11 ng / mL) to prevent vitamin D deficiency rickets or osteomalacia. The IOM also established a Tolerable Upper Intake Level (UL) for vitamin D of 2,000 IU per day, based on evidence that higher doses are associated with increased risk of hypercalciuria, hypercalcemia, and related complications, including cardiac arrhythmias, stroke, and systemic vascular and other soft tissue calcification. Currently available oral vitamin D supplements are far from ideal for achieving and maintaining optimal blood 25-hydroxyvitamin D levels. These preparations typically contain 400 IU to 5,000 IU of vitamin D3 or 50,000 IU of vitamin D2 and are formulated for rapid or immediate release in the gastrointestinal tract. When administered in chronically high doses, as is often required for vitamin D sufficiency, these products are very, sometimes severely, limited.

[0005] Abnormalities in vitamin D signaling and metabolism are present in a wide variety of tumors (Krishnan et al., (2012). Rheum Dis Clin North Am 38, 161-178) and are believed to be due to increased expression of CYP24 (Luo et al., (2013) J Steroid Biochem Mol Biol 136, 252-257). Cancer patients commonly exhibit vitamin D deficiency, so calcium resorption from bone calcium stores plays a major role in normalizing blood calcium levels. Regardless of the type of cancer, low serum levels of 25-hydroxyvitamin D and reduced VDR activation are associated with increased metastasis. Cancer deaths are commonly the result of metastasis. In certain types of cancer, particularly breast and prostate cancer, the majority of the tumor burden at the time of death is in the bone. The impact of metastasis on bone metabolism and resulting morbidity is substantial and is osteolytic (e.g., breast cancer, myeloma) or osteoblastic (e.g., prostate cancer) in nature, depending on the origin of the primary tumor. However, bone formation and bone resorption are coupled, so the "osteolytic" and "osteoblastic" classifications correspond to the net balance of bone metabolism associated with metastasis. Several factors released from tumors can affect the net balance of bone metabolism, including parathyroid hormone-related peptide (PTHrP), transforming growth factor-β (TGF-β), insulin-like growth factors (IGFs), bone morphogenetic proteins (BMPs), and platelet-derived growth factors (PDGFs).

[0006] PTHrP is produced by certain types of cancer cells, such as breast cancer cells, and can induce net bone resorption by stimulating production of the ligand for the receptor activator of NFκB (RANKL) (Rabbani, SA (2000). Int J Oncol 16, 197-206.; Soyfoo et al. (2013). Support Care Cancer 21, 1415-1419). Like PTH, PTHrP can be regulated by activating the vitamin D signaling pathway (Bhatia et al. (2009). Mol Cancer Ther 8, 1787-1798; El Abdaimi et al. (1999). Cancer Res 59, 3325-3328.). As a result, the use of vitamin D and related analogues has been proposed to help control the excessive hypercalcemia caused by overexpression of PTHrP in breast and prostate cancer (Richard et al. (2005) Crit Rev Eukaryot Gene Expr 15, 115-132.). The majority of cases of hypercalcemia in cancer patients are thought to be related to the production of PTHrP (Motellon et al. (2000) Clin Chim Acta 290, 189-197.). In some cases, hypercalcemia of malignancies has been associated with the use of vitamin D or calcifediol, which is related to elevated PTHrP expression. Like PTH, PTHrP expression may increase the expression of CYP27B1, a renal enzyme involved in the activation of calcifediol. Cancer patients who are vitamin D deficient and have higher than normal levels of PTHrP may therefore express high levels of unoccupied CYP27B1; a sudden bolus of calcifediol can cause a spike in 1,25-dihydroxyvitamin D, potentially leading to hypercalcemic episodes (Motellon et al 2000, supra; Sato et al. (1993). Intern Med 32, 886-890.) and further upregulation of CYP24.These hypercalcemic episodes are due to increased intestinal absorption of Ca, in contrast to those caused by PTHrP stimulation of RANKL.

[0007] The relationship between tumor metastasis progression and bone metabolism depends to a large extent on the tumor microenvironment in bone. In certain types of cancer, such as prostate cancer, bone formation can be stimulated by TGF-β, IGF, PDGF, and BMP, and these factors play an important role in establishing the bone microenvironment. These patients may suffer from hypocalcemia, which is a decrease in serum calcium levels in the blood. Severe hypocalcemia may be referred to as the "starved bone" syndrome. Thus, bone health may be an important determinant of the progression of the metastatic process, including tumor cell invasion of bone, angiogenic response, and tumor cell proliferation, as well as differentiation of bone cell precursors into osteoblasts and osteoclasts. There is evidence that vitamin D status may affect each of these parameters, suggesting that vitamin D adequacy may be essential to minimize the progression of bone metastases. Although many clinical studies have attempted to increase vitamin D levels for the treatment of various cancers, currently available therapies do not safely elevate 25-hydroxyvitamin D levels high enough to establish the impact of 25-hydroxyvitamin D on tumor growth and metastasis or related pathologies. Because bone resorption is a common pathophysiology of bone metastases, regardless of primary tumor type, patients are typically treated with antiresorptive drugs that inhibit bone resorption by targeting osteoclasts in bone and reducing their osteolytic activity. Antiresorptive drugs, also known as bone-sparing drugs, reduce the impact of cancer-related increases in bone resorption. Antiresorptive drugs can prevent or delay skeletal-related events (SREs). SREs are defined as pathological fractures, radiation or surgery to bone, and spinal cord compression, and are used to evaluate the clinical efficacy of antiresorptive drugs because SREs are associated with poor prognosis and quality of life. Because antiresorptive drugs can slow bone loss, they are also prescribed to patients with osteoporosis and other bone disorders. Examples of antiresorptive drugs include bisphosphonates, such as zoledronic acid, selective estrogen receptor modulators (SERMs), calcitonin, estrogen, and monoclonal antibodies, such as denosumab. Treatment with antiresorptive drugs also reduces the efficiency of PTH-stimulated bone resorption, so patients must rely on intestinal absorption of calcium to maintain serum calcium levels.

[0008] The most important and immediate side effect of bone antiresorptive drugs is hypocalcemia. Other therapeutic agents that may increase the risk of hypocalcemia include anticonvulsants, corticosteroids, antihypercalcemic drugs, antimicrobials, and combinations thereof. Serum calcium is important for normal nerve and muscle function in the body, and serum calcium levels are tightly regulated within narrow limits in healthy subjects. Hypocalcemia can be a significant cause of morbidity and mortality. Severe hypocalcemia, where serum calcium levels fall below the lower limit of normal, can have fatal consequences, including muscle stiffness and cardiac arrest. Such treatment-induced hypocalcemia, also known as iatrogenic, can be severe and even fatal, and must be controlled. Following administration of the bone resorption inhibitor denosumab, hypocalcemia may be directly attributable to the inhibitory effect of denosumab on the activity and number of bone-resorbing osteoclasts. Clinical studies suggest that blood calcium levels fall as soon as one day after the initiation of denosumab treatment. Similarly, in a recent study of patients with bone metastases treated with the bone resorption inhibitor zoledronic acid, 39% of patients developed hypocalcemia (Zuradelli et al., (2009) Oncologist 14, 548-556). Hypocalcemia is one of the most common adverse reactions leading to the interruption of treatment with zoledronic acid or denosumab.

[0009] Vitamin D supplementation is therefore recommended for patients undergoing antiresorptive drug therapy. Treatment protocols in published multiple-dose clinical studies of denosumab have uniformly required denosumab-treated subjects to receive daily calcium supplements (at least 0.5-1.0 g) and at least 400-800 IU of vitamin D (cholecalciferol and / or ergocalciferol) to prevent hypocalcemia. Recommendations for calcium and vitamin D supplementation in denosumab-treated subjects are included in the FDA-approved labeling for denosumab. However, currently available oral vitamin D supplements are not optimal for raising and maintaining desired serum levels of 25-hydroxyvitamin D or 1,25-dihydroxyvitamin D. The shortcomings of currently available vitamin D supplements in completely alleviating hypocalcemia in denosumab-treated subjects have been highlighted by a recent advisory from Health Canada, which noted that postmarketing cases of severe symptomatic hypocalcemia have occurred in denosumab-treated subjects with an estimated rate of 1-2%, including some cases that have been fatal.

[0010] Another side effect of bone antiresorptive drugs and other medications that increases the risk of hypocalcemia is secondary hyperparathyroidism (SHPT). A decrease in serum calcium can result in increased production of PTH. Elevated PTH levels are common in patients treated with bone antiresorptive drugs and indicate increased vitamin D requirements. Regulation of blood calcium requires adequate production of calcitriol, which stimulates intestinal absorption of dietary calcium and calcium resorption by the kidney. In response to elevated PTH, calcitriol also mobilizes calcium from bone. Adequate calcitriol production requires an adequate supply of the precursor calcifediol, and the first sign of inadequate calcitriol production is an increase in plasma PTH. PTH stimulates the expression of CYP27B1 in the kidney, thereby increasing the conversion of calcifediol to calcitriol. When serum calcitriol levels are restored to adequate levels, PTH secretion decreases. If serum calcitriol levels cannot be corrected, as in the case of insufficient calcifediol supply (i.e., vitamin D deficiency), plasma PTH will remain elevated and continue to mobilize calcium from bone. A recent study (Berruti et al. (2012) Oncologist 17, 645-652) reported that 82%-90% of subjects with prostate cancer metastases to bone and receiving zoledronic acid showed elevated PTH compared with 17% of patients receiving placebo. Elevated PTH is negatively associated with survival. The prevalence and persistence of SHPT despite supplementation with vitamin D and calcium in patients on antiresorptive therapy suggests that appropriate supplementation regimens have yet to be clearly defined for this patient population and that even mild hypocalcemia and / or SHPT may limit the efficacy of antiresorptive drugs. Summary of the Invention [Problem to be solved by the invention]

[0011] Clearly, cancer patients and those treated with drugs that increase the risk of hypocalcemia need alternative approaches to currently available vitamin D supplementation. [Means for solving the problem]

[0012] overview The present disclosure relates to 25-hydroxyvitamin D therapy as an adjunctive therapy and / or treating cancer in a patient. In one aspect, a method of treating or preventing iatrogenic hypocalcemia and / or secondary hyperparathyroidism in a patient treated with an agent that increases the risk of hypocalcemia comprises administering to the patient an effective amount of 25-hydroxyvitamin D. In another aspect, a method of increasing bone mineral density in a patient treated with an agent that increases the risk of hypocalcemia comprises administering to the patient an effective amount of 25-hydroxyvitamin D. In another embodiment, a method of reducing blood levels of a bone resorption marker in a patient treated with an agent that increases the risk of hypocalcemia comprises administering to the patient an effective amount of 25-hydroxyvitamin D. In another embodiment, a method of treating bone pain in a patient treated with an agent that increases the risk of hypocalcemia comprises administering to the patient an effective amount of 25-hydroxyvitamin D. In another embodiment, a method for increasing the time to a first skeletal-related event after treatment in a patient treated with an agent that increases the risk of hypocalcemia comprises administering to the patient an effective amount of 25-hydroxyvitamin D. In another embodiment, a method for treating a patient treated with an agent that increases the risk of hypocalcemia comprises administering to the patient an effective amount of 25-hydroxyvitamin D to effectively and safely restore blood 25-hydroxyvitamin D levels to at least 30 ng / mL and maintain blood 25-hydroxyvitamin D levels at said optimal level.

[0013] In any of the methods disclosed herein, the agent that increases the risk of hypocalcemia is selected from the group consisting of antiresorptive agents, anticonvulsants, corticosteroids, antihypercalcemic agents, antibacterial agents, and combinations thereof. In one aspect, the agent that increases the risk of hypocalcemia is an antiresorptive agent, optionally selected from the group consisting of bisphosphonates (e.g., zoledronic acid, alendronate, risedronate, ibandronate, etidronate, and pamidronate), selective estrogen receptor modulators (e.g., raloxifene), calcitonin, hormones (e.g., estrogen), and monoclonal antibodies (e.g., denosumab). In another embodiment, a method of lowering elevated serum parathyroid hormone levels in a patient having bone metastases and being treated with an antiresorptive drug comprises administering an effective amount of 25-hydroxyvitamin D. In another embodiment, a method of stabilizing serum calcium levels in a patient having bone metastases and being treated with an antiresorptive drug comprises administering an effective amount of 25-hydroxyvitamin D. In yet another embodiment, a method of treating starving bone syndrome comprises administering an effective amount of 25-hydroxyvitamin D to a patient in need of treatment.

[0014] In any of the methods of the disclosure, the patient optionally has osteoporosis and / or cancer. In one embodiment, a method of managing iatrogenic hypocalcemia and secondary hyperparathyroidism in a patient with bone metastases treated with an antiresorptive drug comprises administering an effective amount of 25-hydroxyvitamin D to prevent or reverse iatrogenic hypocalcemia and reduce the patient's serum parathyroid hormone levels. In another embodiment, a method of alleviating cancer progression and / or skeletal-related events in a patient with a bone tumor, optionally bone metastases from a solid tumor, comprises treating the patient with (a) an anticancer drug; (b) an antiresorptive drug; and (c) a 25-hydroxyvitamin D compound, wherein the combination of (a), (b), and (c) is effective to slow tumor growth and / or metastasis and / or increase the time to first skeletal-related event after treatment. In yet another aspect, a method of treating a patient with cancer and bone metastases comprises (a) administering a prophylactic and continuing course of an effective amount of 25-hydroxyvitamin D to stabilize the patient's 25-hydroxyvitamin D and calcium levels without causing or worsening hypercalcemia; followed by (b) treatment with an agent known to increase the risk of iatrogenic hypocalcemia, wherein the treatment in step (a) prevents and / or treats iatrogenic hypocalcemia in the patient.

[0015] In another embodiment, a method of alleviating the progression of cancer in bone in a patient comprises administering an effective amount of 25-hydroxyvitamin D. In another embodiment, a method of inhibiting cancer cell proliferation and migration comprises administering to a patient in need thereof an effective amount of 25-hydroxyvitamin D. In another embodiment, a method of treating cancer in a patient comprises administering to the patient an effective amount of a combination of 25-hydroxyvitamin D and an anti-cancer drug. In any of the foregoing methods, the patient optionally has a cancer selected from the group consisting of bone cancer, bladder cancer, breast cancer, colon cancer, endometrial cancer, kidney cancer, leukemia, lung cancer, lymphoma, pancreatic cancer, prostate cancer, skin cancer, thyroid cancer, and metastatic forms thereof. The present disclosure also relates to the use of 25-hydroxyvitamin D as an adjunctive therapy for treating hypocalcemia in a patient in need thereof, optionally in a modified release formulation. In another aspect, the present disclosure provides a pharmaceutical composition comprising (a) 25-hydroxyvitamin D and (b) an agent that increases the risk of hypocalcemia and / or an anti-cancer agent. In another aspect, the present disclosure provides a kit comprising (a) 25-hydroxyvitamin D; (b) an agent that increases the risk of hypocalcemia and / or an anti-cancer agent; and (c) instructions for co-administration of effective amounts of (a) and (b) to a patient in need thereof.

[0016] In another embodiment, the disclosed method includes administering 25-hydroxyvitamin D in a modified release formulation, optionally an oral modified release formulation. In another embodiment, the 25-hydroxyvitamin D is administered in a sterile intravenous formulation. In various embodiments, the 25-hydroxyvitamin D can be selected from the group consisting of 25-hydroxyvitamin D2, 25-hydroxyvitamin D3, 25-hydroxyvitamin D4, 25-hydroxyvitamin D5, 25-hydroxyvitamin D7, and combinations thereof. In the compositions and methods described herein, optional features, including but not limited to components, compositional ranges thereof, substituents, conditions, and steps, are contemplated to be selected from the various aspects, embodiments, and examples provided herein. Further aspects and advantages will become apparent to those skilled in the art upon consideration of the following detailed description taken in conjunction with the drawings. While the compositions and methods are susceptible to embodiment in various forms, the following description includes specific embodiments with the understanding that the disclosure is illustrative and is not intended to limit the invention to the specific embodiments described herein. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0017] Detailed Description The present disclosure relates to 25-hydroxyvitamin D therapy as adjunctive therapy and in the treatment of cancer. In various embodiments, the present disclosure provides methods of administering an effective amount of 25-hydroxyvitamin D, optionally administered as a modified release oral formulation or in an intravenous form, to a subject undergoing treatment with an agent that increases the risk of hypocalcemia and / or an anti-cancer agent. Administration of 25-hydroxyvitamin D to a patient of the present disclosure effectively accomplishes one or more of the following: (a) treat or prevent hypocalcemia, e.g., iatrogenic hypocalcemia; (2) treat or prevent secondary hyperparathyroidism; (3) increase bone mineral density; (4) reduce blood levels of bone resorption markers; (5) decrease bone pain; (6) increase the time to first skeletal-related event after treatment; (6) safely restore blood 25-hydroxyvitamin D levels to optimal levels (defined as greater than 30 ng / mL in human subjects) without causing hypocalcemia or hypercalcemia, and maintain blood 25-hydroxyvitamin D levels at the optimal levels; (7) reduce elevated serum parathyroid hormone levels; (8) stabilize serum calcium levels; (9) treat starvation bone syndrome. (10) manage iatrogenic hypocalcemia and secondary hyperparathyroidism in patients with bone tumors; (11) ameliorate cancer progression, i.e., by inhibiting proliferation and / or migration of cancer cells; (12) restore or maintain serum calcium levels corrected for serum albumin to at least 8.0 mg / dL, optionally to at least 8.3 mg / dL or 8.5 mg / dL, and optionally up to 11.6 mg / dL, e.g., within the range of 8.3 mg / dL to 11.6 mg / dL; (13) safely increase serum levels of 1,25-dihydroxyvitamin D, optionally to at least 50 pg / mL; (14) achieve or maintain safe serum phosphorus levels and treat or prevent hypophosphatemia; (15) have a positive effect on serum levels of bone formation markers; and / or (16) maintain or reduce tumor burden.

[0018] The present disclosure also relates to the use of 25-hydroxyvitamin D as an adjunctive therapy for treating hypocalcemia, as well as compositions and kits comprising (a) 25-hydroxyvitamin D and (b) an agent that causes hypocalcemia and / or an anti-cancer agent. The disclosed methods, compositions, and kits are contemplated to include embodiments that include any combination of one or more of the additional optional elements, features, and steps, unless otherwise specified. In jurisdictions that prohibit the patenting of methods practiced on the human body, the meaning of "administering" a composition to a human subject shall be limited to prescribing a controlled substance that the human subject will self-administer by any means (e.g., orally, inhalation, topical application, injection, insertion, etc.). The broadest reasonable interpretation consistent with statutes or regulations defining patentable subject matter is intended. In jurisdictions that do not prohibit the patenting of methods practiced on the human body, "administering" a composition includes both methods practiced on the human body and the aforementioned activities. As used herein, the following definitions may be helpful in assisting the skilled practitioner in understanding the present invention. As used herein, the term "comprising" indicates the possible inclusion of other agents, elements, steps or features in addition to those specified.

[0019] As used herein, the term "25-hydroxyvitamin D" refers to one or more of 25-hydroxyvitamin D2, 25-hydroxyvitamin D3, 25-hydroxyvitamin D4, 25-hydroxyvitamin D5, 25-hydroxyvitamin D7, analogs of the foregoing, and combinations thereof. In particular, in any embodiment herein, it is contemplated that 25-hydroxyvitamin D can include 25-hydroxyvitamin D3, 25-hydroxyvitamin D2, or a combination of 25-hydroxyvitamin D3 and 25-hydroxyvitamin D2. For example, in particular, in any embodiment described herein, it is contemplated that 25-hydroxyvitamin D can include 25-hydroxyvitamin D3. Serum total 25-hydroxyvitamin D refers to the sum of all 25-hydroxyvitamin D forms measured by assay, unless a specific 25-hydroxyvitamin D form is referred to. As used herein, the term "1,25-dihydroxyvitamin D" refers to one or more of 1,25-dihydroxyvitamin D2, 1,25-dihydroxyvitamin D3, 1,25-dihydroxyvitamin D4, 1,25-dihydroxyvitamin D5, 1,25-dihydroxyvitamin D7, analogs of the foregoing, and combinations thereof. For example, 1,25-dihydroxyvitamin D can include 1,25-dihydroxyvitamin D2, 1,25-dihydroxyvitamin D3, or a combination of 1,25-dihydroxyvitamin D2 and 1,25-dihydroxyvitamin D3. Serum total 1,25-dihydroxyvitamin D, unless a specific 1,25-dihydroxyvitamin D form is referenced, will of course refer to the sum of all such 1,25-dihydroxyvitamin D forms by assay.

[0020] As used herein, the term "adjunctive therapy" refers to the administration of 25-hydroxyvitamin D to a patient who is (a) currently undergoing, (b) previously undergoing, or (c) about to undergo treatment with a non-25-hydroxyvitamin D therapeutic agent. In one embodiment, adjunctive therapy refers to the administration of 25-hydroxyvitamin D to a patient prior to the administration of a non-25-hydroxyvitamin D therapeutic agent. In another embodiment, adjunctive therapy refers to the administration of 25-hydroxyvitamin D to a patient simultaneously with the administration of a non-25-hydroxyvitamin D therapeutic agent. In another embodiment, adjunctive therapy refers to the administration of 25-hydroxyvitamin D to a patient after the administration of a non-25-hydroxyvitamin D therapeutic agent. The non-25-hydroxyvitamin D therapeutic agent is optionally an agent that increases the risk of hypocalcemia or an anti-cancer agent. As used herein, the term "antiresorptive agent" refers to a compound that inhibits bone resorption, i.e., a "bone sparing" agent. Examples of antiresorptive agents include, but are not limited to, bisphosphonates (e.g., zoledronic acid, alendronate, risedronate, ibandronate, etidronate, and pamidronate), selective estrogen receptor modulators (e.g., raloxifene), calcitonin, hormones (e.g., estrogen), and monoclonal antibodies (e.g., denosumab).

[0021] As used herein, the term "co-administer" refers to administering to a subject in a manner that allows the drug or anti-cancer drug that increases the risk of hypocalcemia and 25-hydroxyvitamin D to exert their respective pharmacological actions during overlapping times and in the form of adjunctive therapy. The co-administered drug and 25-hydroxyvitamin D can be administered by the same or different routes and in the same or different compositions. The co-administered drug and 25-hydroxyvitamin D can be administered simultaneously or at different times (e.g., on alternating days or at different times on the same day) during a course of treatment. For example, it is contemplated that co-administration can include administration of both a bone-resorption inhibitor and a 25-hydroxyvitamin D compound within 6 months of each other, or within 3 months of each other, or within 1 month of each other, or within 2 weeks of each other, or within 1 week of each other, or within 2 days of each other, or on the same day. The course of the drug or anti-cancer drug that increases the risk of hypocalcemia can include a relatively long administration interval, for example, every 6 months, while the 25-hydroxyvitamin D treatment can be at a shorter interval, for example, daily. As used herein, the term "substantially constant" with respect to serum or blood levels of 25-hydroxyvitamin D means that the release profile of any formulation administered as detailed herein should not include a transient increase in total serum or blood levels of 25-hydroxyvitamin D3 or 25-hydroxyvitamin D2 of more than about 3 ng / mL following administration of a unit dose. As used herein, the term "modified release" refers to any modification of release from an immediate release profile and can include controlled or sustained release and / or delayed release characteristics. As used herein, the terms "controlled release" and "sustained release" are used interchangeably and refer to the release of an administered 25-hydroxyvitamin D from a composition over an extended period of time, e.g., 4 to 24 hours or longer.

[0022] As used herein, the term "vitamin D toxicity" means side effects associated with overdosing of 25-hydroxyvitamin D and excessively elevated 25-hydroxyvitamin D blood levels, including, but not limited to, nausea, vomiting, polyuria, hypercalciuria, hypercalcemia, and hyperphosphatemia. As used herein, the term "hypocalcemia" refers to a condition in which a patient has a calcium-corrected serum level of less than about 8.3 mg / dL or less than about 8.5 mg / dL. Severe hypocalcemia refers to a condition in which a patient has a calcium-corrected serum level of less than 7 mg / dL. Normal and safe calcium-corrected serum levels for humans are in the range of about 8.3 to about 11.6 mg / dL. Calcium-corrected serum levels refer to values ​​corrected for serum albumin of less than 4.0 g / dL. The term "iatrogenic hypocalcemia" refers to hypocalcemia that occurs following treatment with a therapeutic agent, i.e., an agent that increases the risk of hypocalcemia. Examples of agents that increase the risk of hypocalcemia include, but are not limited to, bone antiresorptive agents, anticonvulsants, corticosteroids, antihypercalcemic agents, antibacterial agents, and combinations thereof. As used herein, the term "hypercalcemia" refers to the condition in a patient in which the patient has a calcium-corrected serum level greater than about 11.6 mg / dL. As used herein, the term "hypophosphatemia" refers to a condition in which a patient has a serum phosphorus level below about 2.5 mg / dL. Normal and safe values ​​for serum phosphorus in humans are within the range of about 2.5 mg / dL to about 4.5 mg / dL. As used herein, the term "hyperphosphatemia" refers to a condition in a patient in which the patient has a serum phosphorus level greater than about 4.5 mg / dL.

[0023] As used herein, the term "supraphysiological" with respect to intraluminal, intracellular and / or blood concentrations of 25-hydroxyvitamin D means that the total concentration of 25-hydroxyvitamin D forms during the 24-hour post-administration period is greater than 5 ng / mL above the generally stable level observed over the preceding 24 hours by laboratory measurement. The term "supraphysiological" with respect to intraluminal, intracellular and / or blood concentrations of 1,25-dihydroxyvitamin D means that the total concentration of 1,25-dihydroxyvitamin D forms is greater than 5 pg / mL above the generally stable level observed over the preceding 24 hours by laboratory measurement. As used herein, the term "vitamin D insufficiency and deficiency" is generally defined in humans as having serum 25-hydroxyvitamin D levels below 30 ng / mL (National Kidney Foundation guidelines, NKF, Am. J. Kidney Dis. 42:S1-S202 (2003), which are incorporated herein by reference). It is specifically understood that any numerical value recited herein encompasses all values ​​from the lower value to the higher value. That is, all possible combinations of numerical values ​​between the minimum and maximum recited values ​​should be considered as being expressly recited in this application. For example, reciting a concentration range or range of beneficial effect as 1%-50% is intended to expressly recite values ​​such as 2%-40%, 10%-30%, or 1%-3%, etc., in this specification. These are merely examples of what is specifically intended.

[0024] In one aspect, the present disclosure provides a method of adjunctive treatment with 25-hydroxyvitamin D for patients treated with drugs and / or anti-cancer drugs that increase the risk of hypocalcemia. The disclosed method provides the dual unexpected benefit of superior efficacy in restoring blood 25-hydroxyvitamin D to optimal levels with regular administration over an extended period of time, and superior safety compared to currently available formulations of vitamin D or 25-hydroxyvitamin D. The disclosed method includes providing a gradual, sustained and direct release of effective amounts of 25-hydroxyvitamin D preferentially into circulating DBPs (rather than into chylomicrons), thereby mitigating or eliminating blood, intraluminal and intracellular 25-hydroxyvitamin D concentration spikes and associated undesirable catabolic effects. Administration of the disclosed 25-hydroxyvitamin D enhances intestinal absorption of calcium and reduces PTH-mediated bone resorption. This reduces the likelihood of hypocalcemic events and simultaneously reduces the expression of PTH, thereby mitigating metastatic effects on bone resorption. Increasing a patient's 25-hydroxyvitamin levels as described herein can stabilize serum calcium levels and affect the bone microenvironment, cancer progression, and bone-related events.

[0025] Adjunctive therapy comprising 25-hydroxyvitamin D of the present disclosure improves the efficacy of co-administered drugs (e.g., bone antiresorptive drugs) that increase the risk of hypocalcemia by one or more measures. In one embodiment, co-administration of an effective amount of 25-hydroxyvitamin D with a drug that increases the risk of hypocalcemia is effective to treat or prevent iatrogenic hypocalcemia and SHPT. In another embodiment, co-administration of an effective amount of 25-hydroxyvitamin D with a drug that increases the risk of hypocalcemia is effective to increase bone mineral density. In another embodiment, co-administration of an effective amount of 25-hydroxyvitamin D with a drug that increases the risk of hypocalcemia is effective to reduce bone pain. In another embodiment, co-administration of an effective amount of 25-hydroxyvitamin D with a drug that increases the risk of hypocalcemia is effective to treat secondary hyperparathyroidism by reducing elevated plasma PTH levels, optionally by at least 30%. In another embodiment, co-administration of an effective amount of 25-hydroxyvitamin D with a drug that increases the risk of hypocalcemia is effective to reduce the incidence or risk of hypocalcemia. In another embodiment, co-administration of an effective amount of 25-hydroxyvitamin D with an agent that increases the risk of hypocalcemia is effective to stabilize serum calcium levels, optionally at serum albumin-corrected levels, within the range of 8.3 mg / dL to 11.6 mg / dL. In another embodiment, co-administration of an effective amount of 25-hydroxyvitamin D with an agent that increases the risk of hypocalcemia is effective to increase blood levels of bone formation markers. In another embodiment, co-administration of an effective amount of 25-hydroxyvitamin D with an agent that increases the risk of hypocalcemia is effective to decrease blood levels of bone resorption markers. In another embodiment, co-administration of an effective amount of 25-hydroxyvitamin D with an agent that increases the risk of hypocalcemia is effective to delay the time to the first SRE after treatment. In another embodiment, co-administration of an effective amount of 25-hydroxyvitamin D with an agent that increases the risk of hypocalcemia is effective to delay the time to further bone metastases.In another embodiment, co-administration of an effective amount of 25-hydroxyvitamin D with an agent that increases the risk of hypocalcemia is effective to safely raise serum total 25-hydroxyvitamin D levels to at least 30 ng / mL, and optionally to supraphysiological levels. In another embodiment, co-administration of an effective amount of 25-hydroxyvitamin D with an agent that increases the risk of hypocalcemia is effective to raise serum total 1,25-hydroxyvitamin D levels, and optionally to supraphysiological levels. In another embodiment, co-administration of an effective amount of 25-hydroxyvitamin D with an agent that increases the risk of hypocalcemia may be effective to attenuate or halt cancer progression, for example, by inhibiting cancer cell proliferation and migration or maintaining or reducing tumor burden.

[0026] In one embodiment, an effective amount of 25-hydroxyvitamin D is administered to a patient undergoing or who has previously undergone treatment with an agent that increases the risk of hypocalcemia. For example, in one embodiment, 25-hydroxyvitamin D is administered after administration of an agent that increases the risk of hypocalcemia, such as a bone antiresorptive agent or an antihypercalcemic agent. In another embodiment, 25-hydroxyvitamin D is administered prophylactically to a patient prior to treatment with an agent that increases the risk of hypocalcemia. In various embodiments, the agent that increases the risk of hypocalcemia is optionally selected from the group consisting of a bone antiresorptive agent, an anticonvulsant, a corticosteroid, an antihypercalcemic agent, an antibacterial agent, and combinations thereof. For example, in one embodiment, the agent that increases the risk of hypocalcemia is an antihypercalcemic agent, such as cinacalcet (SENSIPAR, Amgen Inc., Thousand Oaks, Calif.). In another embodiment, the agent that increases the risk of hypocalcemia is a bone antiresorptive agent, optionally selected from the group consisting of a bisphosphonate (e.g., zoledronic acid), a RANKL inhibitor (e.g., denosumab), a monoclonal antibody (e.g., denosumab), and combinations thereof.

[0027] Another aspect of the present disclosure is the treatment of cancer in patients. Most cancer patients show vitamin D deficiency (i.e., serum total 25-hydroxyvitamin D less than 30ng / mL). There are several possible causes, including diet and reduced exposure to sunlight, but recent evidence suggests that accelerated vitamin D catabolism may also be a contributing factor. Genomic amplification at the 20q.13 chromosomal locus that codes for CYP24A1 (Albertson et al. (2000) Nat Genet 25, 144-146) has been identified in several tumor types (Krishnan et al., supra). Overexpression of CYP24A1 mRNA has been reported in a wide variety of human cancers, including breast (Friedrich et al. (2003) Recent Results Cancer Res 164, 239-246), lung (Parise et al. (2006) Int J Cancer 119, 1819-1828), and colorectal cancer, and in some cases has been associated with poor prognosis and reduced overall survival (Mimori et al. (2004) Ann Oncol 15, 236-241). Overexpression of CYP24A1 enhances tumor cell proliferation and reduces tumor responsiveness to the anticancer effects of endogenous calcitriol (Anderson et al. (2006) Cancer Chemother Pharmacol 57, 234-240; Friedrich et al., supra). Thus, higher levels of 25-hydroxyvitamin D may be required to obtain sufficient vitamin D for normal cellular and physiological functions and to exert optimal antitumor effects. Administration of 25-hydroxyvitamin D as described herein acts via activation of the vitamin D receptor pathway to maintain normal calcium homeostasis, thereby targeting a variety of tumor types.

[0028] Administration of 25-hydroxyvitamin D to patients with cancer and adjunctive therapy including 25-hydroxyvitamin D and anti-cancer drugs is contemplated to have a therapeutic effect by one or more measures. In one embodiment, administering an effective amount of 25-hydroxyvitamin D to a patient, optionally with an anti-cancer drug and / or a drug that increases the risk of hypocalcemia, is effective to treat cancer, for example, by inhibiting cancer cell proliferation and migration. In another embodiment, administering an effective amount of 25-hydroxyvitamin D, optionally with an anti-cancer drug and / or a drug that increases the risk of hypocalcemia, is effective to maintain or reduce the tumor burden in a patient. In another embodiment, administering an effective amount of 25-hydroxyvitamin D, optionally with an anti-cancer drug and / or a drug that increases the risk of hypocalcemia, is effective to mitigate the progression of cancer in bone. In another embodiment, administration of an effective amount of 25-hydroxyvitamin D, optionally with anti-cancer drugs and / or drugs that increase the risk of hypocalcemia, is effective to slow tumor growth and / or metastasis and increase the time to first SRE after treatment of patients with bone tumors, optionally bone metastases from solid tumors. In another embodiment, administration of a prophylactic and continuous course of an effective amount of 25-hydroxyvitamin D to a patient to stabilize serum 25-hydroxyvitamin D and calcium levels, followed by treatment with drugs known to increase the risk of iatrogenic hypocalcemia, is effective to prevent or treat iatrogenic hypocalcemia.

[0029] In any of the methods disclosed herein, administration of 25-hydroxyvitamin D to a patient, e.g., a patient treated with an agent that increases the risk of hypocalcemia or an anti-cancer agent as described herein, may be characterized by one or more of the measures described below, either individually or in combination. In one embodiment, the amount of 25-hydroxyvitamin D administered is effective to restore or maintain the patient's corrected serum calcium level to at least about 8.0 mg / dL, and optionally within the range of about 8.3 mg / dL to about 11.6 mg / dL. In another aspect, the dosage of 25-hydroxyvitamin D can be effective to restore or maintain a patient's corrected serum calcium level to at least about 8.3 mg / dL, 8.5 mg / dL, at least about 9.0 mg / dL, at least about 9.5 mg / dL, at least about 10 mg / dL, at least about 10.5 mg / dL, or at least about 11.0 mg / dL, optionally within the range of, for example, about 8.5 mg / dL to about 11.0 mg / dL, about 8.3 mg / dL to about 10.2 mg / dL, about 8.3 mg / dL to about 11.0 mg / dL, or about 8.5 mg / dL to about 10.2 mg / dL. In another aspect, the dose of 25-hydroxyvitamin D may be effective to safely raise a patient's 25-hydroxyvitamin D serum level to at least about 30 ng / mL, optionally within the range of about 30 ng / mL to about 100 ng / mL, about 35 ng / mL to about 90 ng / mL, about 40 ng / mL to about 100 ng / mL, or about 50 ng / mL to about 100 ng / mL. In another aspect, the dose of 25-hydroxyvitamin D may be effective to safely raise a patient's 25-hydroxyvitamin D serum level to at least about 35 ng / mL, at least about 40 ng / mL, at least about 50 ng / mL, at least about 60 ng / mL, at least about 70 ng / mL, at least about 80 ng / mL, at least about 90 ng / mL, at least about 100 ng / mL, at least about 150 ng / mL, at least about 200 ng / mL, at least about 250 ng / mL, or at least about 300 ng / mL.

[0030] In another embodiment, the dosage of 25-hydroxyvitamin D may be effective to reduce a patient's serum parathyroid hormone levels, optionally by at least about 10%, at least about 20%, at least about 30%, at least about 40%, or at least about 50%. In another embodiment, the dosage of 25-hydroxyvitamin D may be effective to reduce a patient's serum parathyroid hormone-related peptide (PTHrP) levels, optionally by at least about 10%, at least about 20%, at least about 30%, at least about 40%, or at least about 50%. In another embodiment, the amount of 25-hydroxyvitamin D administered is effective to safely raise the patient's 1,25-dihydroxyvitamin D serum level to, optionally, at least about 50 pg / mL, at least about 60 pg / mL, at least about 70 pg / mL, at least about 80 pg / mL, at least about 90 pg / mL, or at least about 100 pg / mL.

[0031] In another embodiment, the dosage of 25-hydroxyvitamin D can be effective to achieve or maintain a safe serum phosphorus level and prevent hypophosphatemia. In another embodiment, the dosage of 25-hydroxyvitamin D can be effective to achieve or maintain a serum phosphorus level greater than about 2.5 mg / dL, greater than about 3.0 mg / dL, greater than about 3.5 mg / dL, greater than about 4.0 mg / dL, or greater than about 4.5 mg / dL, optionally within the range of about 2.5 mg / dL to about 4.5 mg / dL. In another embodiment, the dosage of 25-hydroxyvitamin D may be effective to positively affect the serum level of bone formation markers in a patient, compared to untreated or treated with bone antiresorptive drugs alone. For example, the dosage of 25-hydroxyvitamin D may be effective to increase the serum level of bone formation markers, such as bone morphogenetic protein or osteocalcin, in a patient by at least about 10%, at least about 20%, at least about 30%, at least about 40%, or at least about 50%, compared to untreated or treated with bone antiresorptive drugs alone. In another embodiment, the dosage of 25-hydroxyvitamin D may be effective to reduce the serum level of bone resorption markers in a patient, optionally by at least 10%, at least 20%, at least about 30%, at least about 40%, or at least about 50%, compared to untreated or treated with bone antiresorptive drugs alone. In another embodiment, the dosage of 25-hydroxyvitamin D may be effective to alleviate the elevation of the serum level of bone resorption markers in a patient, compared to untreated or treated with bone antiresorptive drugs alone. In various embodiments, the bone resorption marker is selected from the group consisting of PTHrP, FGF23, NTX, CTX, TRAC-5b, and combinations thereof.

[0032] In another embodiment, the amount of 25-hydroxyvitamin D administered may be effective to decrease or increase, optionally by at least about 10%, at least about 20%, at least about 30%, at least 40%, or at least about 50%, a patient's serum levels of immune mediating cytokines, such as C-reactive protein (CRP), interleukin 12, or interleukin 10. In another embodiment, the amount of 25-hydroxyvitamin D may be effective to increase the spot calcium / creatinine (Ca / Cr) ratio. In another embodiment, the dosage of 25-hydroxyvitamin D may be effective to maintain or reduce the patient's tumor burden. Tumor burden may be measured using assays known in the art, such as X-rays, computed tomography (CT), or magnetic resonance imaging (MRI). Tumor burden may also be assessed by measuring one or more markers of tumor burden. In another embodiment, the dosage of 25-hydroxyvitamin D may be effective to reduce the patient's serum levels of tumor burden markers, optionally by at least about 10%, at least about 20%, at least about 30%, at least about 40%, or at least about 50%, compared to untreated or treated with anti-cancer drugs and / or drugs that increase the risk of hypocalcemia alone. In another embodiment, the dosage of 25-hydroxyvitamin D may be effective to alleviate the patient's tumor burden or elevated serum levels of tumor burden markers, compared to untreated or treated with anti-cancer drugs and / or drugs that increase the risk of hypocalcemia alone. In embodiments, the tumor burden marker may optionally be selected from the group consisting of CEA, CA 125, CA15-3, CA 27-29, prostate specific antigen (PSA), and combinations thereof.

[0033] In one class of embodiments, an effective amount of 25-hydroxyvitamin D is co-administered with an agent that increases the risk of hypocalcemia and / or an anti-cancer agent. The present disclosure also provides a kit comprising (a) 25-hydroxyvitamin D, (b) an agent that increases the risk of hypocalcemia and / or an anti-cancer agent, and (c) instructions for co-administering effective amounts of (a) and (b) to a patient in need thereof. The efficacy and method of administration of the agent co-administered with 25-hydroxyvitamin D according to the present invention are not particularly limited and may be equivalent to those already taught in the literature. The disclosed method is suitable for treating patients with conditions responsive to administration of 25-hydroxyvitamin D as described above. In one type of embodiment, the patient has osteoporosis. In another type of embodiment, the patient has starving bone syndrome. In another type of embodiment, the patient has renal dysfunction, for example, a patient with chronic kidney disease stage 1, 2, 3, 4, or 5. In another type of embodiment, the patient has cancer, optionally selected from the group consisting of bone cancer, bladder cancer, breast cancer, colon cancer, endometrial cancer, kidney cancer, leukemia, lung cancer, lymphoma, pancreatic cancer, prostate cancer, skin cancer, thyroid cancer, and metastatic forms thereof. In one embodiment, the patient has cancer and a bone tumor, i.e., bone metastasis from a solid tumor. For example, the patient may have metastatic bone cancer, metastatic prostate cancer, metastatic lung cancer, and / or metastatic breast cancer.

[0034] Optionally, the patient has cancer and is undergoing, has previously undergone, or will undergo treatment with an anti-cancer drug. Exemplary classes of anti-cancer drugs include, but are not limited to, aromatase inhibitors; antiestrogens; antiandrogens; gonadorelin agonists; topoisomerase I inhibitors; topoisomerase II inhibitors; microtubule active agents; alkylating agents; retinoids, carotenoids, or tocopherols; cyclooxygenase inhibitors; MMP inhibitors; mTOR inhibitors; antimetabolites; platinum 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 that target / reduce protein or lipid kinase activity, compounds that target / reduce protein or lipid phosphatase activity, antiangiogenic compounds, and combinations thereof. In various types of embodiments, the patient may be treated with an anti-cancer drug selected from the group consisting of azacitidine, axathioprine, bevacizumab, bleomycin, capecitabine, carboplatin, chlorabcil, cisplatin, cyclophosphamide, cytarabine, daunorubicin, docetaxel, doxifluridine, doxorubicin, epirubicin, etoposide, fluorouracil, gemcitabine, herceptin, idarubicin, mechlorethamine, melphalan, mercaptopurine, methotrexate, mitoxantrone, oxaliplatin, paclitaxel, tafluposide, teniposide, thioguanine, retinoic acid, valrubicin, vinblastine, vincristine, vindesine, vinorelbine, receptor tyrosine kinase inhibitors, and combinations thereof.

[0035] Optionally, a patient having the above conditions to be treated with 25-hydroxyvitamin D is currently undergoing, has previously undergone, or will undergo treatment with an agent that increases the risk of hypocalcemia, optionally selected from the group consisting of bone antiresorptives, anticonvulsants, corticosteroids, antihypercalcemic agents, antibacterial agents, and combinations thereof. In one type of embodiment, the agent that increases the risk of hypocalcemia is an antihypercalcemic agent, optionally the antihypercalcemic agent cinacalcet. In another type of embodiment, the agent that increases the risk of hypocalcemia is an antiresorptive agent, optionally selected from the group consisting of bisphosphonates, selective estrogen receptor modulators, calcitonin, hormones, and monoclonal antibodies. In one type of embodiment, the bone antiresorptive agent comprises a RANKL inhibitor, optionally the RANKL inhibitor denosumab. In another type of embodiment, the bone antiresorptive agent comprises a bisphosphonate, optionally the bisphosphonate zoledronic acid. In some cases, a patient with cancer is undergoing, has previously undergone, or will undergo treatment with an anti-cancer drug and an agent that increases the risk of hypocalcemia.

[0036] For each of the above-mentioned measures, adjunctive therapy with 25-hydroxyvitamin D is contemplated to achieve such increase, reduction and / or delay to a greater extent than administration of an agent that increases the risk of hypocalcemia and / or an anti-cancer drug alone. In another embodiment, adjunctive therapy with 25-hydroxyvitamin D is contemplated to achieve such increase, reduction and / or delay to a greater extent than administration of an agent that increases the risk of hypocalcemia with cholecalciferol and, optionally, an anti-cancer drug. Adjunctive therapy with 25-hydroxyvitamin D is contemplated to achieve such increase, reduction and / or delay to a greater extent than administration of an agent that increases the risk of hypocalcemia with ergocalciferol and, optionally, an anti-cancer drug. Adjunctive therapy with 25-hydroxyvitamin D is also contemplated to alleviate, i.e., reduce the severity of, undesirable effects compared to administration of drugs that increase the risk of hypocalcemia and / or anticancer drugs alone or coadministration of an antiresorptive drug with cholecalciferol or ergocalciferol, optionally with an anticancer drug. Examples of undesirable effects include, but are not limited to, increases or decreases in serum calcium or phosphorus to levels outside the normal range, decreases in blood levels of bone formation markers, increases in blood levels of bone resorption markers, and increases in tumor burden (e.g., increases in tumor progression markers).

[0037] The present disclosure also contemplates compositions and related methods of administration, including oral or intravenous formulations of 25-hydroxyvitamin D. The compositions and related methods of administration can be selected to have one or more characteristics, including increasing blood levels of 25-hydroxyvitamin D without the potential first-pass effect of 25-hydroxyvitamin D prohormones in the duodenum; without supraphysiological surges in luminal, intracellular and blood levels of 25-hydroxyvitamin D and their consequences; without causing substantially elevated catabolism of administered 25-hydroxyvitamin D; and without a significant side effect associated with vitamin D supplementation, i.e., vitamin D toxicity. In one type of embodiment, modified release compositions intended for oral administration according to the present invention are designed to contain a concentration of 25-hydroxyvitamin D (e.g., 25-hydroxyvitamin D3, or a combination of 25-hydroxyvitamin D2 and 25-hydroxyvitamin D3) of 1-1000 mcg / unit dose, or 1-500 mcg / unit dose, or 1-100 mcg / dose, or 1-50 mcg / dose, or 10-40 mcg / dose, for example 30 mcg / dose or 60 mcg / dose, or 90 mcg / dose, and are prepared in a manner to provide a controlled or substantially constant release of 25-hydroxyvitamin D to the gastrointestinal tract of a subject over an extended period of time. In one embodiment, the 25-hydroxyvitamin D is 25-hydroxyvitamin D3. In another aspect, the 25-hydroxyvitamin D is a combination of 25-hydroxyvitamin D3 and 25-hydroxyvitamin D2, and is useful for supporting the endocrine system with both vitamin D3 and vitamin D2. Currently available oral vitamin D supplements and previously marketed oral formulations of 25-hydroxyvitamin D3 support only one or the other system. In one type of embodiment, release can be in the ileum or thereafter, for example, in the colon. In another type of aspect, the composition can provide substantially increased absorption of 25-hydroxyvitamin D via DBP-based transport and reduced absorption via transport in chylomicrons. In another type of embodiment, the composition can provide substantially constant serum levels of 25-hydroxyvitamin D for 24 hours after administration. Examples of 25-hydroxyvitamin D modified release compositions are described in U.S. Patent Nos. 8,207,149, 8,361,488, and 8,426,391, and U.S. Patent Application No. 14,213,285, which are incorporated herein by reference.

[0038] The compositions of the present disclosure comprising 25-hydroxyvitamin D optionally further comprise an agent that increases the risk of hypocalcemia or an anti-cancer agent. In one type of embodiment, 25-hydroxyvitamin D is administered orally. For example, 25-hydroxyvitamin D can be administered in an oral modified release formulation. In an alternative embodiment, 25-hydroxyvitamin D can be administered in multiple daily doses in an oral immediate release formulation to produce a pharmacokinetic profile of serum 25-hydroxyvitamin D similar to that achieved by an oral modified or sustained release formulation.

[0039] The preparation of modified release forms of 25-hydroxyvitamin D suitable for oral administration can be accomplished by many different techniques. For example, one or more 25-hydroxyvitamin D compounds can be dispersed within a matrix. That is, a unique mixture of rate-controlling components and excipients in carefully selected ratios can be dispersed within a matrix, optionally surrounded by a coating material. In another alternative embodiment, various coating techniques can be utilized to control the rate and / or location of release of 25-hydroxyvitamin D from pharmaceutical formulations. For example, dissolution of the coating can be triggered by the pH of the surrounding medium, and the resulting gradual dissolution of the coating over time exposes the matrix to the body fluids of the local environment. In one type of embodiment, 25-hydroxyvitamin D diffuses out of the outer surface of the matrix after the coating becomes permeable. As 25-hydroxyvitamin D becomes depleted or exhausted from this surface, the underlying stores begin to be depleted by diffusion through the disintegration of the matrix into the external solution. In another type of embodiment, release of 25-hydroxyvitamin D is due to gradual breakdown or erosion of the matrix, for example, due to solubility and / or loss of physical integrity of one or more components of the matrix.

[0040] In one embodiment, the formulations of the present invention provide one or more 25-hydroxyvitamin D compounds within a matrix that is releasably associated with a sustained release component, for example, upon exposure to the contents of the ileum and / or colon. Optionally, the 25-hydroxyvitamin D-containing matrix can be appropriately coated with a coating that resists disintegration in gastric fluids. The coated modified release formulation of 25-hydroxyvitamin D is then administered to a subject, e.g., an animal or human patient. As the formulation progresses through the proximal small intestine, the enteric coating becomes progressively more permeable, which in suitable embodiments forms a sustained structural framework around the 25-hydroxyvitamin D-containing matrix. The 25-hydroxyvitamin D-containing matrix becomes significantly exposed to intestinal fluids in the ileum via the permeable overcoating, resulting in the gradual release of 25-hydroxyvitamin D by simple diffusion and / or slow disintegration of the matrix.

[0041] Upon release into the lumen of the ileum, 25-hydroxyvitamin D is absorbed into the lymphatic system or portal bloodstream, where it binds to and is transported by DBP. In this embodiment, 25-hydroxyvitamin D is absorbed primarily beyond the duodenum and jejunum. These proximal portions of the small intestine can respond to high intraluminal levels of 25-hydroxyvitamin D, and in the process, can catabolize significant amounts of 25-hydroxyvitamin D. By substantially delaying 25-hydroxyvitamin D release until the ileum and / or colon, the pharmaceutical compositions described herein virtually eliminate these possible first-pass effects in the proximal intestine, reducing undesirable catabolism. Significant catabolism of administered 25-hydroxyvitamin D before it is absorbed into the bloodstream significantly reduces its bioavailability. Elimination of the first-pass effect reduces the risk of vitamin D toxicity. The substantially delayed release of 25-hydroxyvitamin D (i.e., beyond the duodenum and jejunum) significantly reduces the amount of 25-hydroxyvitamin D taken up and absorbed from the small intestine via chylomicrons (since chylomicron formation and absorption occurs primarily in the jejunum) and correspondingly increases the amount of 25-hydroxyvitamin D absorbed across the intestinal wall directly onto DBP circulating in the lymph or portal blood.

[0042] In one embodiment of the present invention, a controlled release oral formulation of 25-hydroxyvitamin D is generally prepared according to the following procedure: A sufficient amount of 25-hydroxyvitamin D is completely dissolved in a minimum volume of USP grade absolute alcohol (or other suitable solvent) and mixed with appropriate amounts and types of pharmaceutical grade excipients to form a matrix that is solid or semi-solid at room temperature and at standard human body temperatures. The matrix is ​​completely or almost entirely resistant to digestion in the stomach and upper small intestine, and it slowly disintegrates in the lower small intestine and / or colon. In suitable formulations, the matrix binds the 25-hydroxyvitamin D compound to allow for a slow, relatively steady, e.g., substantially constant, release of 25-hydroxyvitamin D into the luminal contents of the lower small intestine and / or colon by simple diffusion and / or gradual disintegration over a period of 4 to 8 hours or more. The formulation optionally further comprises an enteric coating that is partially soluble in an aqueous solution having a pH of about 7.0 to 8.0, or that simply dissolves slowly enough to delay significant release of 25-hydroxyvitamin D until after passage of the formulation through the duodenum and jejunum.

[0043] As noted above, means for providing controlled release of 25-hydroxyvitamin D may utilize any suitable controlled release delivery system, including any known controlled release delivery system for active ingredients over a period of about four hours or more, such as wax matrix systems and the EUDRAGIT RS / RL system (Rohm Pharma, GmbH, Weiterstadt, Germany). The wax matrix system provides a lipophilic matrix. The wax matrix system may utilize, for example, beeswax, white wax, cachalot wax, or similar compositions. The active ingredient is dispersed in a wax matrix binder that disintegrates slowly in intestinal fluids to gradually release the active ingredient. The wax binder impregnated with 25-hydroxyvitamin D may be filled into a soft gel capsule. The soft gel capsule may include one or more gel formers, such as gelatin, starch, carrageenan, and / or other pharma- ceutically acceptable polymers. In one embodiment, a partially cross-linked soft gelatin capsule is used. Alternatively, a vegetable-based capsule may be used. The wax matrix system disperses the active ingredient in a wax binder that softens at body temperature and disintegrates slowly in intestinal fluids to gradually release the active ingredient. The system may include a mixture of waxes, optionally with the addition of oils, to achieve a melting point above body temperature but below the melting temperature of the selected formulation used to make the soft or hard capsule shell, or other formulations used to make the shell coat or other coating.

[0044] Specifically, in one suitable embodiment, the wax selected for the matrix is ​​melted and thoroughly mixed. The desired amount of oil is subsequently added, followed by thorough mixing to homogenize. The wax mixture is then gradually cooled to a temperature just above its melting point. The desired amount of 25-hydroxyvitamin D dissolved in ethanol is uniformly dispersed in the molten matrix, and the matrix is ​​filled into a capsule, such as a vegetable-based or gelatin-based capsule. When in use, the filled capsule is optionally treated with a solution containing an aldehyde, such as acetaldehyde, for a suitable period of time to partially crosslink the polymer, such as gelatin, within the capsule shell. Over the course of several weeks, the capsule shell becomes increasingly crosslinked, thereby increasing its resistance to dissolution in the stomach and upper intestinal contents. When properly constructed, the gelatin shell slowly dissolves after oral administration and becomes sufficiently porous (without completely disintegrating) by the time it reaches the ileum to allow the 25-hydroxyvitamin D to slowly diffuse from the wax matrix into the contents of the lower small intestine and / or colon. Other examples of lipid matrices suitable for use in the methods of the present invention include one or more of glycerides, fatty acids and alcohols, and fatty acid esters.

[0045] In one embodiment, the formulation may include an oil vehicle for the 25-hydroxyvitamin D compound. Any pharma- ceutically acceptable oil may be used. Examples include animal (e.g., fish oil), vegetable (e.g., soybean oil), and mineral oils. The oil will preferably dissolve the 25-hydroxyvitamin D used easily. The oil vehicle may include non-digestible oils, such as mineral oils, especially liquid paraffin, and squalene. The ratio between the wax matrix and the oil vehicle may be optimized to achieve the desired release rate of the 25-hydroxyvitamin D compound. Thus, when a heavier oil component is used, relatively less wax matrix may be used, and when a lighter oil component is used, relatively more wax matrix may be used. In one embodiment, the particular selection of the oil vehicle allows for a controlled release such that the absorption of the 25-hydroxyvitamin D is delayed until the formulation reaches the ileum and / or colon.

[0046] Another suitable controlled release oral drug delivery system is the EUDRAGIT RL / RS system in which the active 25-hydroxyvitamin D ingredient is formed into granules having dimensions of 25 / 30 mesh. The granules are then uniformly coated with a thin polymer lacquer that is water soluble but slowly water permeable. The coated granules can be mixed with optional additives, including one or more of antioxidants, stabilizers, binders, lubricants, processing aids, and the like. The mixture can be compressed into tablets. The tablets are hard and dry prior to use and can be further coated or poured into capsules. After the tablet or capsule is swallowed and comes into contact with aqueous intestinal fluids, the thin lacquer begins to swell, allowing for slow penetration by the intestinal fluids. As the intestinal fluids slowly penetrate the lacquer coating, the contained 25-hydroxyvitamin D is slowly released. By the time the tablet or capsule passes through the small intestine, after about 4-8 hours or more, the 25-hydroxyvitamin D will have been slowly but completely released. Thus, an ingested tablet will release not only 25-hydroxyvitamin D but also a steady stream of any other active ingredients.

[0047] The EUDRAGIT system includes a high permeability lacquer (RL) and a low permeability lacquer (RS). RS is a water-insoluble film former based on a neutral swellable methacrylate ester and a small proportion of trimethylammonioethyl methacrylate chloride; the molar ratio of quaternary ammonium groups to neutral ester groups is about 1:40. RL is also a water-insoluble swellable film former based on a neutral methacrylate ester and a small proportion of trimethylammonioethyl methacrylate chloride; the molar ratio of quaternary ammonium groups to neutral ester groups is about 1:20. By varying the ratio of the coating materials RS and RL, the permeability of the coating and therefore the time course of drug release can be titrated. For further details on the Eudragit RL / RS system, see the following technical publications, which are incorporated herein by reference: Rohm Tech, Inc. 195 Canal Street, Maiden, Mass., 02146 and K. Lehmann, D. Dreher "Coating of tablets and small particles with acrylic resins by fluid bed technology," Int. J. Pharm. Tech. & Prod. Mfr. 2(r), 31-43 (1981). Other examples of insoluble polymers include polyvinyl esters, polyvinyl acetals, polyacrylic esters, butadiene styrene copolymers, and the like.

[0048] In one embodiment, once the coated granules are formed into a tablet or injected into a capsule, the tablet or capsule is coated with an enteric coating material that dissolves at a pH of 7.0 to 8.0. One such pH-dependent enteric coating material is EUDRAGIT L / S, which dissolves in intestinal fluids but not in gastric fluids. Other enteric coating materials such as cellulose acetate phthalate (CAP), which is resistant to dissolution by gastric fluids but is readily degraded by the hydrolytic action of intestinal esterases, may also be used. In one embodiment, the particular selection of enteric and controlled release coating materials provides a controlled, substantially constant release over a 4-8 hour period or longer such that substantial release is delayed until the formulation reaches the ileum. In some cases, the controlled release compositions of the present invention, when administered once daily, can advantageously provide substantially constant intraluminal, intracellular and blood levels of 25-hydroxyvitamin D compared to an immediate release composition of an equivalent dose of 25-hydroxyvitamin D administered once daily.

[0049] The dosage form may contain auxiliary agents, such as preservatives or stabilizing agents. For example, a preferred formulation contains 25-hydroxyvitamin D (e.g., about 30mcg, about 60mcg, or about 90mcg of 25-hydroxyvitamin D3), about 2wt% absolute ethanol, about 10wt% lauroyl polyoxyl glyceride, about 20wt% solid paraffin, about 23wt% glycerol monostearate, about 35wt% liquid paraffin or mineral oil, about 10wt% hydroxypropyl methylcellulose, and optionally a small amount of preservative (e.g., butylated hydroxytoluene). The formulation of the present invention may contain other therapeutically useful substances or may contain more than one compound as defined herein and in the claims in admixture.

[0050] As an alternative to oral 25-hydroxyvitamin D, intravenous administration of 25-hydroxyvitamin D is also contemplated. In one embodiment, 25-hydroxyvitamin D is administered as a sterile intravenous bolus, optionally as a bolus injection of a composition that provides a sustained release profile. In another embodiment, 25-hydroxyvitamin D is administered by gradual injection / infusion, for example, over 1-5 hours, to provide a controlled or substantially constant release of 25-hydroxyvitamin D directly into DBP in the patient's blood. For example, the composition may be injected or infused over at least about 1 hour, at least about 2 hours, at least about 3 hours, at least about 4 hours, at least about 5 hours, or at least about 6 hours. In one embodiment, compositions intended for intravenous administration according to the present invention are designed to contain a concentration of 1-100 mcg of 25-hydroxyvitamin D compound per unit dose. A sterile, isotonic formulation can be prepared by dissolving 25-hydroxyvitamin D in absolute ethanol, propylene glycol or another suitable solvent, and combining the resulting solution with one or more surfactants, salts and preservatives in an appropriate amount of water for injection.The formulation can be administered from a syringe, for example, via a heparin lock, or by adding a large volume of sterile solution (e.g., saline) steadily infused over time.In one embodiment, the composition can be co-injected or co-infused with an anti-cancer drug.

[0051] In another aspect, administration of an effective amount of a composition of the present disclosure can be effective to achieve supraphysiological levels of 25-hydroxyvitamin D and / or 1,25-dihydroxyvitamin D safely, i.e., without causing hypercalcemia and / or hyperphosphatemia. Advantageously, the adjunctive therapy comprising 25-hydroxyvitamin D and an agent that increases the risk of hypocalcemia and / or an anti-cancer agent, optionally together with other therapeutic agents, can be administered orally or intravenously in a dosage of 1-100 mcg per day, preferably 5-50 mcg per day, according to the above embodiment. When 25-hydroxyvitamin D and an agent that increases the risk of hypocalcemia and / or an anti-cancer agent are co-administered in combination with other therapeutic agents, the ratio of each compound in the combination administered will depend on the particular disease state being addressed. For example, one may choose to administer 25-hydroxyvitamin D orally together with one or more calcium salts (intended as calcium supplements or dietary phosphate binders), calcimimetics, nicotinic acid, iron, phosphate binders, cholecalciferol, ergocalciferol, active vitamin D sterols, or blood glucose and hypertension control agents. Furthermore, one may choose to administer 25-hydroxyvitamin D intravenously together with cholecalciferol, ergocalciferol, active vitamin D sterols, or blood glucose and hypertension control agents. In practice, higher amounts of the compounds of the present disclosure will be used where therapeutic treatment of a disease state is the desired goal, while lower doses are generally used for prophylactic purposes; it will be understood that the specific dosage administered in any given case will be adjusted depending on the particular compound being administered, the disease being treated, the condition of the subject, and other relevant medical facts which may modify the activity of the drug or the subject's response, as is well known to those of skill in the art. The present invention is further illustrated by the following examples which should not be construed as limiting the scope of the invention. EXAMPLES

[0052] Example 1 One embodiment of a modified release formulation for oral administration Refined yellow beeswax and fractionated coconut oil are combined in a 1:1 ratio and heated to 75°C with continuous mixing until a homogenous mixture is obtained. The wax mixture is allowed to cool to approximately 45°C with continued matrixization. The active compounds, 25-hydroxyvitamin D2 and 25-hydroxyvitamin D3 are dissolved in absolute ethanol in a 1:1 ratio and the ethanol solution is added to the molten wax mixture with continued homogenization. The amount of ethanol added is in the range of 1-2 v / v%. Mixing is continued until the mixture is homogenous. The homogenous mixture is filled into soft gelatin capsules. The capsules are immediately rinsed to remove any processing lubricants and briefly immersed in an aqueous solution of acetaldehyde to crosslink the gelatin shells. The concentration of the acetaldehyde solution and the immersion time are selected to achieve the desired degree of crosslinking as measured by near infrared spectroscopy. The finished capsules are washed, dried and packaged.

[0053] Example 2 One embodiment of the formulation for intravenous administration Warm the TWEEN Polysorbate 20 to approximately 50-60°F (10-16°C) and, with continued stirring, add 25-hydroxyvitamin D3 dissolved in a minimum volume of absolute ethanol. Transfer the resulting homogenous solution of 25-hydroxyvitamin D3, absolute ethanol, and TWEEN Polysorbate 20 to an appropriate amount of water for injection that has been thoroughly flushed with nitrogen to remove all dissolved oxygen. Addition of sodium chloride, sodium ascorbate, sodium phosphate (dibasic and monobasic), and disodium edetate is followed by thorough mixing under a protective nitrogen atmosphere to produce an isotonic homogenous mixture containing the following per 2 mL unit volume: 20 mcg 25-hydroxyvitamin D3; less than 0.01% absolute alcohol; 0.40% (w / v) TWEEN polysorbate 20; 0.15% (w / v) sodium chloride; 1.00% (w / v) sodium ascorbate; 0.75% (w / v) anhydrous sodium phosphate dibasic; 0.18% (w / v) monobasic sodium phosphate monohydrate; and 0.11% (w / v) disodium edetate. The mixture is sterilized by filtration and packaged into amber glass ampoules with less than 1% oxygen headspace, appropriately protected from oxygen contamination.

[0054] Example 3 Pharmacokinetic study in dogs Twelve male beagle dogs are randomly divided into two comparison groups and are not given supplemental vitamin D for the next 30 days. At the end of this period, each dog in group #1 is given a single softgel capsule containing 25 mcg of 25-hydroxyvitamin D2 prepared in a controlled release formulation similar to that disclosed in Example 1. Each dog in the other group (group #2) is given a single immediate release softgel capsule containing 25 mcg of 25-hydroxyvitamin D2 dissolved in medium chain triglyceride oil. All dogs are deprived of 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 blood samples are analyzed for 25-hydroxyvitamin D levels and the data are analyzed by treatment group. Dogs in group #1 have mean blood levels of 25-hydroxyvitamin D that rise more slowly and have lower maximum levels (C max However, dogs in group #1 showed a higher C than those in group #1. max The mean blood level of 25-hydroxyvitamin D2 increases for a longer duration compared to dogs in group #2, despite the fact that the mean blood level of 25-hydroxyvitamin D2 is lower. The mean area under the curve (AUC) corrected for pre-administration background levels (recorded at t=0) for 25-hydroxyvitamin D is substantially greater in group #1. These procedures demonstrate that administration of 25-hydroxyvitamin D2 in the formulation described in the present invention to dogs results in a much more gradual increase and stable blood level of 25-hydroxyvitamin D than after administration of the same amount of 25-hydroxyvitamin D2 formulated for immediate release (in medium chain triglyceride oil). The greater AUC calculated for the blood levels of 25-hydroxyvitamin D in group #1 demonstrates a significant improvement in the bioavailability of 25-hydroxyvitamin D2 formulated as described herein.

[0055] Example 4 Pharmacokinetic studies in healthy volunteers Sixteen healthy non-obese adults aged 18-24 years will participate in an 11-week pharmacokinetic study. They will receive two formulations of 25-hydroxyvitamin D2 sequentially and in a double-blind fashion. One of the formulations (Formulation #1) is a softgel capsule containing 100 mcg of 25-hydroxyvitamin D2 prepared in a controlled release formulation similar to that disclosed in Example 1. The other formulation (Formulation #2) is an identically appearing immediate release softgel capsule containing 100 mcg of 25-hydroxyvitamin D2 dissolved in medium chain triglyceride oil. Subjects will be asked to abstain from other vitamin D supplements for 60 days prior to the start of the study and continuously until the end of the study. On days 1, 3, and 5 of the study, all subjects will provide early morning fasting blood samples to establish pretreatment baseline values. On day 8, subjects will provide an additional fasting blood sample (t=0) and will be randomly assigned to one of two treatment groups. Both groups will receive a single test capsule before breakfast. One group receives capsules of Formulation #1 and the other group receives capsules 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, subjects are asked to provide an additional early morning fasting blood sample (t=0) and receive a single capsule of the other test formulation before 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 blood draws are analyzed for 25-hydroxyvitamin D content levels and data are analyzed by treatment formulation after correction for baseline content. Formulation #1 was associated with a slower rise in mean blood levels of 25-hydroxyvitamin D and a lower C than Formulation #2. max However, formulation #1 was found to result in a recorded C maxIt also results in a longer duration of increase in the mean blood level of 25-hydroxyvitamin D2 compared to formulation #2, despite the fact that the mean AUC for 25-hydroxyvitamin D2 is lower. The mean AUC for 25-hydroxyvitamin D2 is substantially greater after administration of formulation #1. These procedures demonstrate that administration of 25-hydroxyvitamin D2 in the formulations described herein to healthy human adults results in a much more gradual increase and stable blood level of 25-hydroxyvitamin D than after administration of the same amount of 25-hydroxyvitamin D2 formulated for immediate release (in medium chain triglyceride oil). The greater AUC calculated for the blood level of 25-hydroxyvitamin D after administration of formulation #1 demonstrates the better bioavailability of 25-hydroxyvitamin D2 formulated as described herein.

[0056] Example 5 Efficacy study in healthy adult male volunteers with vitamin D deficiency The efficacy 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 in healthy non-obese men diagnosed with vitamin D deficiency. One of the formulations (Formulation #1) is a sustained release softgel capsule containing 30 mcg of 25-hydroxyvitamin D3 prepared as described in this disclosure. The second formulation (Formulation #2) is an identically appearing immediate release softgel capsule containing 50,000 IU of ergocalciferol dissolved in medium chain triglyceride oil. The third formulation (Formulation #3) is again an identically appearing immediate release softgel capsule containing 50,000 IU of cholecalciferol dissolved in medium chain triglyceride oil. A total of 100 healthy Caucasian and African American men participated in the study, all aged 30-45 years, with serum 25-hydroxyvitamin D levels between 15-29 ng / mL (including borderline). All subjects will abstain from other vitamin D supplements and significant sun exposure for 60 days prior to the start of the study and will continue to do so until the end of the study. On days 1 and 2 of the study, all subjects will provide an early morning fasting blood sample to establish a pretreatment baseline value for serum total 25-hydroxyvitamin D. On the morning of day 3, subjects will provide an additional fasting blood sample (t=0) and will be randomly assigned to one of four treatment groups to receive a single test capsule before breakfast. Each subject in group #1 will receive a single capsule of formulation #1, and each subject in groups #2 and #3 will receive a single capsule of formulation #2 or formulation #3, respectively. Subjects in group #4 will receive a matching placebo capsule. Each subject in group #1 will receive an additional capsule of formulation #1 before breakfast on the mornings of days 4-22, while subjects in groups #2, #3, and #4 will not receive an additional capsule. Early morning fasting blood samples will be collected from each subject, regardless of treatment group, on days 4, 5, 6, 10, 17, and 23 (or 1, 2, 3, 7, 14, and 20 after dosing commencement). All blood samples will be analyzed for 25-hydroxyvitamin D levels, and data will be analyzed by treatment formulation after correction for baseline values.Subjects in all four treatment groups demonstrate mean baseline serum 25-hydroxyvitamin D levels of approximately 16-18 ng / mL based on analysis of fasting blood samples taken on days 1-3. Subjects in Group #4 (control group) demonstrate no significant change in mean serum total 25-hydroxyvitamin D levels over the course of the study. Subjects in Group #1 demonstrate a steady rise in mean serum total 25-hydroxyvitamin D reaching at least 30 ng / mL by day 23. In sharp contrast, subjects in Group #2 demonstrate a marked increase in mean serum 25-hydroxyvitamin D during the first few days after dosing that actually reaches a maximum of over 25 ng / mL before rapidly declining thereafter. By the end of the study, serum total 25-hydroxyvitamin D is significantly lower than baseline in Group #2. Subjects in Group #3 demonstrate a continued increase in mean serum total 25-hydroxyvitamin D during the first 2 weeks after dosing, followed by a progressive decline. By the end of the study, 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 D3, 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 ergocalciferol or cholecalciferol administered in a single dose as currently recommended by the NKF and other authorities on oral vitamin D replacement therapy.

[0057] Example 6 Efficacy study in osteoporosis patients treated with antiresorptive drugs The efficacy of oral modified-release 25-hydroxyvitamin D3 in restoring serum total 25-hydroxyvitamin D to optimal levels (>30 ng / mL) in increasing bone mineral density, thereby optimizing the efficacy of bone antiresorptive drugs, is examined in a 24-month study of adult male and female patients with osteoporosis. Patients are treated with denosumab (60 mg at the start of treatment and again every 6 months) in a randomized, double-blind, controlled study. All denosumab-treated patients are randomized to receive daily oral treatment with one softgel capsule containing either 30 mcg of 25-hydroxyvitamin D3 in a modified-release formulation or 400 IU of vitamin D3 (cholecalciferol) in an immediate-release formulation. A total of 500 subjects will participate in the study, 250 men and 250 women, all aged 60-85 years (inclusive), with a bone mineral density T-score of -2.0 to -4.0, and serum total 25-hydroxyvitamin D levels less than 30 ng / mL at enrollment. All subjects will receive calcium supplements (500 mg / day) and will abstain from other vitamin D supplements and significant sun exposure for 60 days prior to and continuing through the end of the study. All subjects will begin daily softgel capsules at the initiation of denosumab treatment. Serum total 25-hydroxyvitamin D, PTH, calcium, phosphorus, N-telopeptide, C-telopeptide, and P1NP, as well as urinary calcium, phosphorus, and creatinine will be measured monthly. Bone mineral density will be measured at four sites (hip, femoral neck, 1 / 3 radius, and lumbar spine) four times a year.

[0058] After three months, patients with serum total 25-hydroxyvitamin D between 50 and 90 ng / mL maintain the daily softgel capsule dosage unchanged, while patients with serum total 25-hydroxyvitamin D below 50 ng / mL increase by one capsule. Patients with serum total 25-hydroxyvitamin D greater than 100 ng / mL or confirmed serum calcium greater than 10.3 mg / dL immediately reduce the dosage by one capsule per day. After six to nine months, all subjects demonstrate serum total 25-hydroxyvitamin D levels that remain essentially stable with continued dosing and rise to approximately 50 to 100 ng / mL with 25-hydroxyvitamin D3 treatment or to approximately 25 to 35 ng / mL with vitamin D3 treatment. In patients treated with 25-hydroxyvitamin D3, once stable dosing is achieved, the incidence of hypocalcemia and the severity of secondary hyperparathyroidism are significantly reduced. However, hypocalcemia and secondary hyperparathyroidism occur more frequently in patients treated with vitamin D3. After 24 months of treatment, patients treated with denosumab and 25-hydroxyvitamin D3 are found to have higher and more consistent serum levels of 25-hydroxyvitamin D3 and lower serum PTH levels than patients treated with denosumab and vitamin D3. Patients treated with denosumab and 25-hydroxyvitamin D3 also experience a greater increase in bone mineral density than patients treated with denosumab and vitamin D3. The data from this study demonstrate that a modified-release formulation of 25-hydroxyvitamin D3 is effective in increasing serum total 25-hydroxyvitamin D and augmenting the bone mineral density increase produced by denosumab without causing unacceptable side effects related to calcium and PTH metabolism.

[0059] Example 7 Efficacy study in prostate cancer patients The efficacy of oral modified-release 25-hydroxyvitamin D3 in restoring serum total 25-hydroxyvitamin D to optimal levels (greater than 30 ng / mL) in alleviating skeletal-related events in patients with prostate cancer, thereby alleviating iatrogenic hypocalcemia and secondary hyperparathyroidism, and optimizing the efficacy of bone-resorbing drugs, is examined in a 24-month study of adult male patients with castration-resistant prostate cancer with bone metastases. Patients are treated with denosumab (120 mg every 4 weeks) in a randomized, double-blind, controlled study. All denosumab-treated patients are randomized to receive daily oral treatment with one softgel capsule containing either 30 mcg of 25-hydroxyvitamin D3 in a modified-release formulation or 400 IU of vitamin D3 in an immediate-release formulation. A total of 500 subjects are enrolled in the study, all of whom are 18 years of age or older with histologically confirmed prostate cancer. Prior to study admission, patients had to have undergone treatment for prostate cancer (e.g., bilateral orchiectomy or at least 6 months of androgen deprivation therapy), had total serum testosterone less than 50 ng / dL, and had three consecutive elevated PSA tests at least 2 weeks apart, with the last two PSA measurements being ≥ 1.0 μg / L. All patients had total serum 25-hydroxyvitamin D levels less than 30 ng / mL at enrollment. All patients underwent radioisotope bone scans during screening, followed by CT, MRI, or plain radiographic imaging if necessary to identify bone metastases. All subjects were given calcium supplements (500 mg / day) and were required to abstain from other vitamin D supplements and significant sun exposure for 60 days prior to and continuing through the end of the study.

[0060] All subjects will begin daily softgel capsules at the initiation of denosumab treatment. Serum total 25-hydroxyvitamin D, PTH, calcium, phosphorus, N-telopeptide, C-telopeptide, and P1NP, and urinary calcium, phosphorus, and creatinine will be measured monthly. Radioactive bone scans will be performed every 6 months to detect skeletal metastases, and the diagnosis of any detected metastases will be confirmed with a secondary imaging modality (CT, MRI, or plain radiographs). Bone mineral density will be measured at 4 sites (hip, femoral neck, 1 / 3 radius, and lumbar spine) at study entry and at 1-year intervals thereafter. After 3 months, the daily dose of 3 capsules of 25-hydroxyvitamin D will be maintained unchanged in patients with serum total 25-hydroxyvitamin D between 50 and 90 ng / mL, and increased to one 30 mcg capsule in patients with serum total 25-hydroxyvitamin D less than 50 ng / mL. In patients with documented serum total 25-hydroxyvitamin D greater than 100 ng / mL or serum calcium greater than 10.3 mg / dL, immediately reduce dosage to one 30 mcg capsule per day.

[0061] After 6-9 months, all subjects show essentially stable serum total 25-hydroxyvitamin D levels within the range of about 50ng / mL-100ng / mL for 25-hydroxyvitamin D3 treatment or about 25ng / mL-35ng / mL for vitamin D3 treatment. In patients treated with 25-hydroxyvitamin D3, once stable dosing is achieved, the incidence of hypocalcemia and the severity of SHPT and hypercalcemia are significantly reduced. In contrast, patients treated with vitamin D3 show hypocalcemia and SHPT more frequently. After 24 months of treatment, patients treated with denosumab and 25-hydroxyvitamin D3 are found to have higher and more consistent serum levels of 25-hydroxyvitamin D3 and lower serum PTH levels than patients treated with denosumab and vitamin D3. Patients treated with denosumab and 25-hydroxyvitamin D3 showed significantly lower incidence of hypocalcemia, greater reductions in plasma PTH levels, and greater increases in bone mineral density, and a significantly delayed time to first SRE after treatment compared to patients treated with denosumab and vitamin D3.The data from this study demonstrate that a modified-release formulation of 25-hydroxyvitamin D3 is effective in increasing serum 25-hydroxyvitamin D and attenuating hypocalcemia, enhancing the bone mineral density increase and delay to first bone metastasis produced by denosumab, without causing unacceptable side effects related to calcium and PTH metabolism.

[0062] Example 8 Efficacy study in breast cancer patients The efficacy of oral modified-release 25-hydroxyvitamin D3 in restoring serum total 25-hydroxyvitamin D to optimal levels (greater than 30 ng / mL) in alleviating SREs in breast cancer patients, thereby alleviating hypocalcemia and SHPT, and optimizing the efficacy of denosumab, is examined in a 24-month study in adult female patients with breast cancer. Patients are treated with denosumab (120 mg every 4 weeks) in a randomized, double-blind, controlled study. All denosumab-treated patients are randomized to receive daily oral treatment with one softgel capsule containing either 30 mcg of 25-hydroxyvitamin D3 in a modified-release formulation or 400 IU of cholecalciferol in an immediate-release formulation. All subjects participating in this study are 18 years of age or older with histologically or cytologically confirmed breast adenocarcinoma and current or previous radiological (X-ray, CT, or MRI) evidence of at least one bone metastasis. All subjects receive calcium supplements (500 mg / day) and abstain from other vitamin D supplements and significant sun exposure for 60 days prior to and continuing through the end of the study. All subjects begin daily softgel capsules at the initiation of denosumab treatment. Serum total 25-hydroxyvitamin D, PTH, calcium, phosphorus, N-telopeptide, C-telopeptide, and P1NP, as well as urinary calcium, phosphorus, and creatinine, are measured monthly. Skeletal metastases are monitored every 6 months with radioactive bone scans, and any detected metastases are confirmed with a secondary imaging modality (CT, MRI, or plain radiographs). Bone mineral density is measured at 4 sites (hip, femoral neck, 1 / 3 radius, and lumbar spine) at the beginning of the study and at 1-year intervals thereafter. After 3 months, maintain the daily softgel capsule dosage unchanged in patients with serum total 25-hydroxyvitamin D between 50-90 ng / mL, increase by 1 mcg capsule in patients with serum total 25-hydroxyvitamin D less than 50 ng / mL, and immediately reduce dosage by 1 capsule per day in patients with confirmed serum total 25-hydroxyvitamin D greater than 100 ng / mL or serum calcium greater than 10.3 mg / dL.After 6 to 9 months, subjects' serum total 25-hydroxyvitamin D levels remain essentially stable with continued dosing and increase to levels of approximately 50 ng / mL to 100 ng / mL with 25-hydroxyvitamin D3 treatment or approximately 25 ng / mL to 35 ng / mL with cholecalciferol treatment.

[0063] In patients treated with 25-hydroxyvitamin D3, once stable dosing is achieved, the incidence of hypocalcemia and the severity of secondary hyperparathyroidism are significantly reduced. However, hypocalcemia and secondary hyperparathyroidism occur more frequently in patients treated with vitamin D3. After 24 months of treatment, patients treated with denosumab and 25-hydroxyvitamin D3 are found to have higher and more consistent serum levels of 25-hydroxyvitamin D3 and lower serum PTH levels than patients treated with denosumab and vitamin D3. Patients treated with denosumab and 25-hydroxyvitamin D3 are found to have a significantly lower incidence of hypocalcemia and a greater increase in bone mineral density, and a significantly delayed time to further bone metastasis, compared to patients treated with denosumab and vitamin D3. The data from this study demonstrate that a modified-release formulation of 25-hydroxyvitamin D3 is effective in increasing serum total 25-hydroxyvitamin D without causing unacceptable side effects related to calcium and PTH metabolism, and in attenuating hypocalcemia and enhancing the bone mineral density increase and lag time to bone metastases produced by denosumab.

[0064] Example 9 Safety study in patients with metastatic bone disease treated with antiresorptive drugs The safety and tolerability of oral modified-release 25-hydroxyvitamin D3 will be examined in an open-label, multiple-dose study in adult patients diagnosed with bone metastases due to breast or prostate cancer receiving ongoing treatment with denosumab or zoledronic acid for at least 3 months. At study entry, all patients were required to have evidence of SHPT as follows: plasma PTH greater than 70 pg / mL, serum calcium less than 9.8 mg / dL, spot urinary Ca:Cr ratio ≤ 0.25 (≤ 250 mg / g creatinine), and 15 mL / min / 1.73 m 2 24 patients diagnosed with bone metastases after breast or prostate cancer are treated for up to 52 weeks with one or more capsules containing 30 mcg of 25-hydroxyvitamin D3 in a modified release formulation. Denosumab or zoledronic acid are administered according to the typical standard of care appropriate 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.).

[0065] 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 2-week follow-up period. At study entry, all patients receive an initial daily dose containing 30 mcg of 25-hydroxyvitamin D3, with doses increasing at 4-week intervals during the dose escalation phase to a maximum daily dose of 300 mcg. The daily dose reached at the end of the dose escalation study is the daily dose administered during the maintenance phase. Therefore, patients demonstrating a serum calcium level of ≦10.3 mg / dL over the course of the study will receive daily doses of 30 mcg of 25-hydroxyvitamin D3 at the start of the study; 60 mcg of 25-hydroxyvitamin D3 after 4 weeks; 90 mcg of 25-hydroxyvitamin D3 at 8 weeks; 120 mcg of 25-hydroxyvitamin D3 at 12 weeks; 150 mcg of 25-hydroxyvitamin D3 at 16 weeks; 180 mcg of 25-hydroxyvitamin D3 at 20 weeks; 210 mcg of 25-hydroxyvitamin D3 at 24 weeks; 240 mcg of 25-hydroxyvitamin D3 at 28 weeks; 270 mcg of 25-hydroxyvitamin D3 at 32 weeks; and 300 mcg of 25-hydroxyvitamin D3 throughout the 36 week and maintenance phase. Patients with serum calcium levels above 10.3 mg / dL on two consecutive visits will discontinue treatment until serum calcium returns to ≤10.0 mg / dL, then resume treatment at a reduced daily dose and enter a 12-week maintenance phase followed by a 2-week follow-up phase.

[0066] Blood samples will be collected at 2-week intervals to monitor serum calcium and phosphorus levels. Blood will be collected at 4-week intervals to monitor plasma levels of PTH and PTHrP and serum total 25-hydroxyvitamin D, 24,25-dihydroxyvitamin D3, calcitriol, and free and total calcifediol. Serum vitamin D metabolites and markers of bone metabolism, immune function, and tumor burden will be measured at the start of dose escalation and at the beginning and end of the maintenance phase. Urine samples will be collected at 4-week intervals to monitor Ca / Cr ratios and urine chemistry. At the start of dose escalation, the vitamin D binding protein genotype will be determined for each subject. During the dose escalation phase, serum calcium gradually increases, while plasma PTH decreases. If plasma PTH is excessively suppressed, serum calcium increases rapidly with continued dose escalation, increasing the risk of hypercalcemia. Patients show significant increases in serum total 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, and 24,25-dihydroxyvitamin D, as well as decreases in plasma PTH. Patients receiving a starting dose level of 30 mcg of 25-hydroxyvitamin D3 show mean serum 25-hydroxyvitamin D levels of about 50 ng / mL. Patients receiving a dose level of 90 mcg of 25-hydroxyvitamin D3 show mean serum 25-hydroxyvitamin D levels of about 100 mg / mL. Patients receiving a maximum dose level of 300 mcg of 25-hydroxyvitamin D3 show mean serum 25-hydroxyvitamin D levels of about 200 to about 300 ng / mL, e.g., about 230 ng / mL. The data from this study demonstrate that a modified release formulation of 25-hydroxyvitamin D3 is effective in increasing serum total 25-hydroxyvitamin D without causing unacceptable side effects related to calcium and PTH metabolism.

[0067] Example 10 Efficacy study in patients with metastatic bone disease treated with antiresorptive drugs The efficacy of oral modified-release 25-hydroxyvitamin D3 in increasing serum 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D and slowing cancer progression is examined in a 6-month randomized, double-blind, placebo-controlled study in adult patients diagnosed with bone metastases due to breast or prostate cancer who have been undergoing 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 D3 in a modified-release formulation or containing placebo. Denosumab or zoledronic acid is administered according to the typical standard of care appropriate for each patient's condition. Patients whose typical standard of care requires calcium and / or vitamin D supplementation are given less than 1000 mg / day of elemental calcium and / or 2000 IU / day or less of vitamin D (ergocalciferol and / or cholecalciferol). Blood is drawn at monthly intervals for monitoring serum and urinary levels of calcium, plasma levels of PTH, and serum total 25-hydroxyvitamin D. Tumor burden and bone metabolism, as well as serum markers of cancer progression, will be assessed at 3-month intervals. Patients treated with 25-hydroxyvitamin D3 show greater increases in serum calcium and decreases in plasma PTH compared to patients receiving placebo, resulting in a reduced risk of hypocalcemia. Patients treated with denosumab or zoledronic acid and 25-hydroxyvitamin D show greater delays in time to further bone metastases compared to patients receiving denosumab or zoledronic acid with placebo. The data from this study demonstrate that a modified release formulation of 25-hydroxyvitamin D3 is effective in 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.

[0068] Example 11 Efficacy study in patients with metastatic bone disease treated with antiresorptive drugs for the prevention of SREs The efficacy of oral modified-release 25-hydroxyvitamin D3 in delaying the time to first SRE after treatment is examined in a 24-month randomized, double-blind, placebo-controlled study in adult men with castration-resistant prostate cancer metastatic to bone or adult women with estrogen-dependent breast cancer metastatic to bone who have been undergoing 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 D3 in a modified-release formulation or placebo. Denosumab or zoledronic acid is administered according to typical standards of care appropriate for each patient's condition. Patients are monitored for SREs, including by appropriate non-invasive imaging techniques, at 3-month intervals for serum markers of tumor burden and bone metabolism, and at monthly intervals for serum and urinary calcium levels and plasma PTH. Cancer progression is monitored quarterly. Patients treated with 25-hydroxyvitamin D3 exhibit greater increases in serum calcium and decreases in plasma PTH compared to patients receiving placebo, leading to a lower risk of hypocalcemia. Patients treated with denosumab or zoledronic acid and 25-hydroxyvitamin D exhibit increased time to further bone metastases or SRE compared to patients receiving denosumab or zoledronic acid with placebo. The data from this study demonstrate that 25-hydroxyvitamin D3 is effective in inhibiting tumor progression by significantly reducing the observed time to SRE after treatment compared to placebo.

[0069] The foregoing description has generally outlined the characteristic aspects of the present invention. In this regard, it should be expressly understood that the present invention is not limited to the methods or details of manufacture, chemical composition, or application of use described herein. Any other variations of manufacture, chemical composition, use, or application should be expressly considered as alternative embodiments of the present invention. Other advantages and a more complete appreciation of the specific applications, compositional versatility, and chemical and physical attributes of the present invention will be obtained upon examination of the detailed description. It is also to be understood that the phraseology and terminology used herein is for the purpose of description and should not be regarded as limiting. Throughout this specification and the claims that follow, unless the context otherwise requires, the words "including," "having," and "comprising" and variations thereof as used herein are meant to encompass not only the specified integers and steps and equivalents thereof but also additional items and equivalents thereof.

[0070] Throughout the specification, where a composition is described as comprising components and materials, it is also contemplated that the composition consists essentially of, or may consist of, any combination of the specified components or materials, unless otherwise specified. Similarly, where a method is described as including particular steps, it is also contemplated that the method consists essentially of, or may consist of, any combination of the specified steps, unless otherwise specified. The inventions illustratively disclosed herein can suitably be practiced in the absence of any element or step not specifically disclosed herein. The foregoing description has been given for clarity of understanding only, and no unnecessary limitations should be implied therefrom, since modifications within the scope of the invention may become apparent to those skilled in the art. All patents, publications, and references cited herein are hereby incorporated by reference in their entirety. In the event of any conflict between this disclosure and the cited patents, publications, and references, this disclosure shall control.

Claims

1. 1. A composition comprising 25-hydroxyvitamin D for use in a method of treating a patient, the method comprising: i. a method for treating or preventing iatrogenic hypocalcemia and secondary hyperparathyroidism in a patient treated with an agent that increases the risk of hypocalcemia, comprising administering to said patient an effective amount of said 25-hydroxyvitamin D; or ii. a method of increasing bone mineral density in a patient treated with an agent that increases the risk of hypocalcemia, comprising administering to said patient an effective amount of said 25-hydroxyvitamin D; or iii. a method for reducing blood levels of a bone resorption marker in a patient treated with an agent that increases the risk of hypocalcemia, comprising administering to said patient an effective amount of said 25-hydroxyvitamin D; or iv. a method for treating bone pain in a patient treated with an agent that increases the risk of hypocalcemia, comprising administering to said patient an effective amount of said 25-hydroxyvitamin D; or v. A method for increasing the time to a first skeletal-related event after treatment in a patient treated with an agent that increases the risk of hypocalcemia, comprising administering to said patient an effective amount of said 25-hydroxyvitamin D; or vi. A method of treating a patient treated with an agent that increases the risk of hypocalcemia, comprising administering to said patient an effective amount of said 25-hydroxyvitamin D to effectively and safely restore blood 25-hydroxyvitamin D levels to at least 30 ng / mL and maintain blood 25-hydroxyvitamin D levels at said optimal level. The composition,

2. 1. A method for treating iatrogenic hypocalcemia and secondary hyperparathyroidism in a patient treated with an agent that increases the risk of hypocalcemia, the method comprising administering to the patient an effective amount of 25-hydroxyvitamin D.

3. 1. A method of increasing bone mineral density in a patient being treated with an agent that increases the risk of hypocalcemia, comprising administering to said patient an effective amount of 25-hydroxyvitamin D.

4. 1. A method for reducing blood levels of a bone resorption marker in a patient being treated with an agent that increases the risk of hypocalcemia, the method comprising administering to the patient an effective amount of 25-hydroxyvitamin D.

5. 1. A method for treating bone pain in a patient being treated with an agent that increases the risk of hypocalcemia, comprising administering to said patient an effective amount of 25-hydroxyvitamin D.

6. 1. A method for increasing the time to a first skeletal-related event after treatment in a patient treated with an agent that increases the risk of hypocalcemia, the method comprising administering to the patient an effective amount of 25-hydroxyvitamin D.

7. 1. A method of treating a patient treated with an agent that increases the risk of hypocalcemia, comprising administering to the patient an effective amount of 25-hydroxyvitamin D to effectively and safely restore blood 25-hydroxyvitamin D levels to at least 30 ng / mL and maintain blood 25-hydroxyvitamin D levels at said optimal level.

8. 8. A composition or method for use according to any one of claims 1 to 7, wherein the patient treated with an agent that increases the risk of hypocalcemia is undergoing or has undergone treatment with an agent that increases the risk of hypocalcemia.

9. 9. The composition or method for use according to any one of claims 1 to 8, wherein the agent that increases the risk of hypocalcemia is selected from the group consisting of bone antiresorptive agents, anticonvulsants, corticosteroids, antihypercalcemic agents, antibacterial agents, and combinations thereof.

10. A composition or method for use according to any one of claims 1 to 9, wherein the agent that increases the risk of hypocalcemia is an antihypercalcemic agent, optionally the antihypercalcemic agent cinacalcet.

11. 11. The composition or method for use according to claim 9 or 10, wherein the 25-hydroxyvitamin D is administered after administration of the antihypercalcemic agent.

12. The composition or method for use according to any one of claims 1 to 9, wherein the drug that increases the risk of hypocalcemia is a bone resorption inhibitor.

13. 1. A composition comprising 25-hydroxyvitamin D for use in a method of treating a patient, the method comprising: i. a method for lowering elevated serum parathyroid hormone levels in a patient with bone metastases and being treated with an antiresorptive drug, comprising administering an effective amount of said 25-hydroxyvitamin D; or ii. Methods for stabilizing serum calcium levels in patients with bone metastases and being treated with antiresorptive drugs The composition,

14. 1. A method for lowering elevated serum parathyroid hormone levels in a patient having bone metastases and being treated with an antiresorptive drug, comprising administering an effective amount of 25-hydroxyvitamin D.

15. A method for stabilizing serum calcium levels in a patient with bone metastases and being treated with an antiresorptive drug.

16. The composition for use according to claim 12 or 13 or the method according to any one of claims 12 or 14-15, wherein the bone antiresorptive drug is selected from the group consisting of bisphosphonates, selective estrogen receptor modulators, calcitonin, hormones, monoclonal antibodies, and combinations thereof.

17. 17. The composition for use according to claim 12 or 13 or 16, or the method according to any one of claims 12 or 14 to 16, wherein the bone anti-resorptive drug comprises a RANKL inhibitor, optionally the RANKL inhibitor denosumab.

18. 17. The composition for use according to claim 12 or 13 or 16, or the method according to any one of claims 12 or 14 to 16, wherein the bone antiresorptive drug comprises a bisphosphonate, optionally the bisphosphonate zoledronic acid.

19. 1. A composition comprising 25-hydroxyvitamin D for use in a method of treating a patient, the method being a method of treating starvation bone syndrome comprising administering to a patient in need of treatment an effective amount of the 25-hydroxyvitamin D.

20. 1. A method for treating starving bone syndrome, comprising administering to a patient in need of treatment an effective amount of 25-hydroxyvitamin D.

21. A composition or method for use according to any one of claims 1 to 20, wherein the patient has osteoporosis.

22. The composition or method for use according to any one of claims 1 to 21, wherein the patient has cancer.

23. 1. A composition comprising 25-hydroxyvitamin D for use in a method of treating a patient, the method comprising: i. a method for managing iatrogenic hypocalcemia and secondary hyperparathyroidism in a patient with bone metastases receiving antiresorptive therapy, comprising administering an effective amount of the 25-hydroxyvitamin D to prevent or reverse iatrogenic hypocalcemia and reduce serum parathyroid hormone levels in the patient; or ii. a method for inhibiting cancer cell proliferation and migration, comprising administering to a patient in need thereof an effective amount of said 25-hydroxyvitamin D; or iii. a method for ameliorating the progression of cancer in bone, comprising administering to a patient an effective amount of said 25-hydroxyvitamin D; or iv. a method of treating a patient with cancer and bone metastases comprising: (a) administering a prophylactic and continuing course of an effective amount of said 25-hydroxyvitamin D to stabilize said patient's serum 25-hydroxyvitamin D and calcium levels without causing or worsening hypercalcemia; followed by (b) treatment with an agent known to increase the risk of iatrogenic hypocalcemia, wherein the treatment in step (a) prevents and / or treats said iatrogenic hypocalcemia in said patient; or v. a method of treating cancer in a patient, comprising administering to the patient an effective amount of the combination of 25-hydroxyvitamin D and an anti-cancer drug; or vi. A method for ameliorating cancer progression and / or skeletal-related events in a patient with bone metastases from a solid tumor, comprising treating said patient with (a) an anti-cancer drug; (b) a bone anti-resorptive drug, and (c) said 25-hydroxyvitamin D compound, wherein the combination of (a), (b), and (c) slows tumor growth and / or metastasis and increases the time to first skeletal-related event after treatment. The composition,

24. 1. A method for managing iatrogenic hypocalcemia and secondary hyperparathyroidism in a patient with bone metastases receiving antiresorptive therapy, comprising administering an effective amount of 25-hydroxyvitamin D to prevent or reverse iatrogenic hypocalcemia and reduce serum parathyroid hormone levels in the patient.

25. 1. A method for inhibiting the proliferation and migration of cancer cells, comprising administering to a patient in need thereof an effective amount of 25-hydroxyvitamin D.

26. 11. A method of alleviating the progression of cancer in bone, comprising administering to a patient an effective amount of 25-hydroxyvitamin D.

27. 1. A method of treating a patient with cancer and bone metastases comprising: (a) administering a prophylactic and continuing course of an effective amount of 25-hydroxyvitamin D to stabilize the patient's serum 25-hydroxyvitamin D and calcium levels without causing or worsening hypercalcemia; followed by (b) treatment with an agent known to increase the risk of iatrogenic hypocalcemia, wherein the treatment in step (a) prevents and / or treats the patient's iatrogenic hypocalcemia.

28. 1. A method of treating cancer in a patient, comprising administering to the patient an effective amount of a combination of 25-hydroxyvitamin D and an anti-cancer drug.

29. A method for alleviating cancer progression and / or skeletal-related events in a patient with bone metastases from a solid tumor, comprising treating the patient with (a) an anticancer drug; (b) a bone antiresorptive drug and (c) a 25-hydroxyvitamin D compound, wherein the combination of (a), (b), and (c) slows tumor growth and / or metastasis and increases the time to first skeletal-related event after treatment.

30. 30. The composition for use according to option v or vi of claim 23, or the method according to claim 28 or 29, wherein the anticancer drug is selected from the group consisting of azacitidine, axathioprine, bevacizumab, bleomycin, capecitabine, carboplatin, clorabcil, cisplatin, cyclophosphamide, cytarabine, daunorubicin, docetaxel, doxifluridine, doxorubicin, epirubicin, etoposide, fluorouracil, gemcitabine, herceptin, idarubicin, mechlorethamine, melphalan, mercaptopurine, methotrexate, mitoxantrone, oxaliplatin, paclitaxel, tafluposide, teniposide, thioguanine, retinoic acid, valrubicin, vinblastine, vincristine, vindesine, vinorelbine, receptor tyrosine kinase inhibitors, and combinations thereof.

31. 31. The composition for use according to claim 22 or 23, or the method according to any one of claims 22 or 24 to 30, wherein the cancer is selected from the group consisting of bone cancer, bladder cancer, breast cancer, colon cancer, endometrial cancer, kidney cancer, leukemia, lung cancer, lymphoma, pancreatic cancer, prostate cancer, skin cancer, thyroid cancer, and metastatic forms thereof.

32. The composition or method for use according to any one of claims 1 to 31, wherein the patient has metastatic bone cancer, metastatic prostate cancer, metastatic lung cancer, and / or metastatic breast cancer.

33. A composition or method for use according to any one of claims 1 to 32, wherein the patient has a bone tumor, optionally bone metastases from a solid tumor.

34. 34. The composition or method for use according to any one of claims 1 to 33, wherein the patient has impaired renal function, optionally with chronic kidney disease stage 1, 2, 3, 4 or 5.

35. 35. The composition or method for use of any one of claims 1 to 34, wherein the effective 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, and optionally within the range of about 8.3 mg / dL to about 11.6 mg / dL.

36. 36. The composition or method for use of any one of claims 1 to 35, wherein the effective amount of 25-hydroxyvitamin D is effective to raise the patient's serum level of 25-hydroxyvitamin D to at least 30 ng / mL, optionally within the range of about 30 ng / mL to about 100 ng / mL.

37. 37. A composition or method for use according to any one of claims 1 to 36, wherein the effective amount of 25-hydroxyvitamin D is effective to reduce serum parathyroid hormone levels in the patient, optionally by 30% or more.

38. 38. A composition or method for use according to any one of claims 1 to 37, wherein the effective amount of 25-hydroxyvitamin D is effective to reduce serum parathyroid hormone related peptide levels in the patient.

39. 39. A composition or method for use according to any one of claims 1 to 38, wherein the effective amount of 25-hydroxyvitamin D is effective to raise the patient's serum levels of 1,25-dihydroxyvitamin D safely above the normal range, optionally to at least 50 pg / mL.

40. 40. The composition or method for use of any one of claims 1 to 39, wherein the effective amount of 25-hydroxyvitamin D is effective to achieve or maintain safe serum phosphorus levels and to treat or prevent hypophosphatemia.

41. 41. The composition or method for use according to any one of claims 1 to 40, wherein the effective amount of 25-hydroxyvitamin D is effective to provide a positive effect on serum levels of bone formation markers in the patient that exceeds the positive effect achieved by treatment with an antiresorptive drug alone.

42. 42. A composition or method for use according to any one of claims 1 to 41, wherein the effective amount of 25-hydroxyvitamin D is effective to reduce serum levels of a bone resorption marker in the patient, optionally by at least 20%.

43. 43. The composition or method for use of claim 42, wherein the bone resorption marker is selected from the group consisting of PTHrP, FGF23, NTX, CTX, TRAC-5b, and combinations thereof.

44. 44. A composition or method for use according to any one of claims 1 to 43, wherein said effective amount of 25-hydroxyvitamin D is effective to maintain or reduce tumor burden in said patient.

45. 45. A composition or method for use according to claim 44, wherein said effective amount of 25-hydroxyvitamin D is effective to maintain or reduce serum levels of a marker of tumor burden in said patient.

46. 46. ​​The composition or method for use of claim 45, wherein said tumor burden marker is selected from the group consisting of CEA, CA 125, CA15-3, CA 27-29, prostate specific antigen (PSA), and combinations thereof.

47. 47. A composition or method for use according to any one of claims 1 to 46, wherein the effective amount of 25-hydroxyvitamin D is effective to inhibit the proliferation and / or migration of cancer cells.

48. 48. A composition or method for use according to any one of claims 1 to 47, wherein the 25-hydroxyvitamin D is administered in a modified release formulation.

49. 49. The composition or method for use of claim 48, wherein the modified release formulation is selected from the group consisting of a sustained release formulation, a delayed release formulation, and a delayed sustained release formulation.

50. 50. The composition or method for use of claim 48 or 49, wherein the modified release formulation comprises a waxy formulation.

51. 51. The composition or method for use of any one of claims 48 to 50, wherein the modified release formulation consists essentially of about 20 wt% paraffin, about 20 wt% to about 25 wt% glycerol monostearate, about 10 wt% of a mixture of lauroyl macrogol glycerides and lauroyl polyoxyl glycerides, about 30 wt% to about 35 wt% mineral oil, and about 10 wt% to about 15 wt% hydroxypropyl methylcellulose.

52. 52. A composition or method for use according to any one of claims 1 to 51, wherein the effective amount of 25-hydroxyvitamin D is administered in an oral sustained release formulation.

53. 53. A composition or method for use according to any one of claims 1 to 52, wherein the 25-hydroxyvitamin D is administered in the form of a capsule.

54. 54. A composition or method for use according to any one of claims 1 to 53, wherein the effective amount of 25-hydroxyvitamin D is absorbed primarily in the ileum and / or colon of the patient.

55. 48. A composition or method for use according to any one of claims 1 to 47, wherein the 25-hydroxyvitamin D is administered in multiple daily doses in an oral immediate release formulation to produce a pharmacokinetic profile of serum 25-hydroxyvitamin D similar to that achieved by an oral modified or sustained release formulation.

56. 50. The composition or method for use according to any one of claims 1 to 49, wherein the 25-hydroxyvitamin D is administered in a sterile intravenous formulation.

57. 57. The composition or method for use of claim 56, wherein the 25-hydroxyvitamin D is administered as an intravenous bolus.

58. 58. The composition or method for use of claim 57, wherein the 25-hydroxyvitamin D is infused for at least 1 hour.

59. The 25-hydroxyvitamin D is 25-hydroxyvitamin D 2 , 25-hydroxyvitamin D 3 , 25-hydroxyvitamin D 4 , 25-hydroxyvitamin D 5 , 25-hydroxyvitamin D 7 59. The composition or method for use according to any one of claims 1 to 58, selected from the group consisting of: and combinations thereof.

60. The 25-hydroxyvitamin D is 25-hydroxyvitamin D 3 and / or 25-hydroxyvitamin D 2 A composition or method for use according to any one of claims 1 to 59, comprising:

61. The 25-hydroxyvitamin D is 25-hydroxyvitamin D 3 A composition or method for use according to any one of claims 1 to 60, comprising:

62. 62. A composition or method for use according to any one of claims 1 to 61, wherein the 25-hydroxyvitamin D is administered in a dose of 30 μg to 300 μg per day.

63. 2. Use of 25-hydroxyvitamin D, optionally in a modified release formulation, as adjunctive therapy for treating or preventing hypocalcemia in a patient in need of such treatment or prevention.

64. 1. A composition comprising 25-hydroxyvitamin D, optionally in a modified release formulation, for use in a method of treatment of a patient, the method being adjunctive therapy for treating or preventing hypocalcemia in a patient in need of such treatment or prevention.

65. A pharmaceutical composition comprising (a) 25-hydroxyvitamin D and (b) an agent that increases the risk of hypocalcemia and / or an anti-cancer agent.

66. A kit comprising: (a) 25-hydroxyvitamin D; (b) an agent that increases the risk of hypocalcemia and / or an anti-cancer agent; and (c) instructions for co-administering effective amounts of (a) and (b) to a patient in need thereof.