AN AQUEOUS INTRAVENOUS INFUSION SOLUTION COMPRISING LEVOSIMENDAN OR A SALT THEREOF

Technical field
The present invention relates to levosimendan solutions for pharmaceutical use,
and particularly for intravenous administration The solutions of the invention have enhanced stability and they are particularly useful as infusion or injection solutions or infusion concentrates Levosimendan, or (-)-[[4-(l,4,5,6-tetrahydro-4-methyl-6-oxo-3-
pyridazinyl)phenyl]hydrazono]propanedimtnle, is useful in the treatment of congestive

heart failure.
Background of the invention
Levosimendan, which is the (-)-enantiomer of [[4-(l,4,5,6-tetrahydro-4-methyl-
6-oxo-3-pyridazinyl)phenyl]hydrazono]propanedinitrile, and methods for its preparation
are described in EP 565546 Bl and WO 97/35841 Levosimendan is potent in the
treatment of heart failure and has significant calcium dependent binding to troponin
Levosimendan is represented by the formula

The hemodynamic effects of levosimendan in man are described in Sundberg, S
et al,Am J Cardiol, 1995, 75 1061-1066 Pharmacokinetics of levosimendan in man
after i v and oral dosing is described in Sandell, E -P. et al, J- Cardiovasc Pharmacol,
26(Suppl 1), S57-S62,1995 The use of levosimendan in the treatment of myocardial
ischemia is described in WO 93/21921 Transdermal compositions of levosimendan are
described in WO 98/01111 Clinical studies have confirmed the beneficial effects of
levosimendan in heart failure patients
Administration of a drug by parenteral, e g intravenous, administration provides
a number of advantages including the following

- an almost immediate response may be obtained by administering by
intravenous injection or infusion a solution, usually-aqueous, of the drug,
- the therapeutic response may be more readily controlled by administering the
drug parenterally, and
- a drug can be administered parenterally to a patient when it cannot be
administered orally because of the unconscious state of the patient, or because of
inactivation or lack of absorption in the intestinal tract
The manufacture of levosimendan solutions, and particularly solutions suitable for intravenous use, involves a number of problems which are caused by the sensitivity
of levosimendan against chemical and physical influences In solutions levosimendan is

sensitive to chemical degradation which limits the shelf-life of solutions and may
produce undesirable degradation products. Levosimendan is also poorly soluble in water
and precipitates easily from aqueous solutions. The precipitation of intravenous
solutions is extremely dangerous because particulate material may occlude the blood
vessels. The solubility of levosimendan decreases further strongly when the pH is
lowered from neutral, so that low pH would in principle seem unfavourable Thus, there
is a need for improved aqueAus.formulatipns of levosimendan which are chemically and physically stable under prolonged storage and suitable for intravenous administration
Summary of the invention
It has now been found that the chemical stability of levosimendan solutions can
be significantly improved if the pH the solution is lowered from neutral to lower than
5, preferably to 4 5 or lower, most preferably to 3 - 4 2. Furthermore, it has been found that the precipitation of the active ingredient can be prevented in such chemically stable
solutions.

Thus, in one aspect, the present invention provides a pharmaceutical aqueous
solution with improved stability comprising
(a) levosimendan or a pharmaceutically acceptable salt thereof as an active
ingredient, the pH-value of the solution being lower than 5, preferably about 4 5 or
lower, most preferably from about 3 to-about 4 2, and optionally
(b) a solubility enhancing agent
In another aspect, the invention provides an aqueous intravenous infusion
solution with improved stability comprising

(a) levosimendan or a pharmaceutically acceptable salt thereof as an active
ingredient, the pH-value of the solution being lower than 5, preferably about 4 5 or
lower, most preferably from about 3 to about 4 2, and optionally
(b) a solubility enhancing agent
Still in another aspect the invention provides an intravenous infusion
concentrate, particularly to be diluted with an aqueous vehicle before use, comprising (a) levosimendan or a pharmaceutically acceptable salt thereof as an active
ingredient,
(b) organic solvent comprising ethanol,
(c) a stability enhancing amount of a pharmaceutically acceptable organic acid
having pKa in the range of from 2 to 4, and optionally
(d) a solubility enhancing agent
Detailed description of the invention
Levosimendan is crystalline powder at room temperature and has pKa of 6.26.
At room temperature the solubility of levosimendan in phosphate buffer is 0 4 mg/ml
(pH 7 4), 0 03 mg/ml (pH 6) and 0 02 mg/ml (pH 2) Thus, the water solubility of
levosimendan decreases quite sharply when pH is lowered below neutral However, it
has been found that it is possible to prepare pharmaceutically acceptable aqueous
solutions of levosimendan with pH lower than 5 Such solutions are chemically and
physically stable over an extended period of time and, therefore, they are particularly
suitable for pharmaceutical use
In one aspect, the invention provides a pharmaceutical composition which
comprises levosimendan or a pharmaceutically acceptable salt thereof as an active
ingredient in an aqueous solution with pH lower than 5, preferably about 4 5 or lower,
and most preferably from about 3 to about 4 2. The composition of the invention is
particularly useful in various pharmaceutical applications in which levosimendan must
be stored in the form of an aqueous solution for an extended penpd of time
The therapeutically effective amount of levosimendan included in the
composition of the invention depends e g on the administration route of the
composition, the treatment procedure and the condition to be treated In general, the
amount of levosimendan in the composition is within the range of about 0 001 -5
mg/ml The daily dosage of levosimendan in man is within the range of about 0 1 - 50
mg, preferably about 0 2 - 20 mg, depending on the administration route, age, body

weight and condition of the patient Preferred peak plasma levels of levosimendan in
steady state for the treatment of congestive heart failure are within the range of from
about 1 to about 300 ng/ml, more preferably from about 10 to about 150 ng/ml, and
especially from about 20 to about 60 ng/ml Levosimendan can be administered
intravenously with the infusion rate in the range of about 0 005 - 100 µg/kg/mm,
typically 0 01 to 10 µg/kg/min, more typically about 0 02 to 1 µg/kg/mm For the
treatment of heart failure with continuous infusion the suitable rate is 0.05 — 0 4
µg/kg/mm of levosimendan
Salts of levosimendan may be prepared by known methods Pharmaceutically
acceptable salts fare useful as active medicaments, however, preferred~salts~are*the salts
with alkali or alkaline earth metals
The control of pH of the composition is essential to .maintain the required
stability of the active ingredient Therefore, a suitable pharmaceutically acceptable
acidic compound or buffer system in an amount effective to maintain the pH of the
composition in the desired range, may be used Preferred acidic compounds include
pharmaceutically acceptable organic acids having pKa in the range of from about 2 to
about 4 Such acids include 2-hydroxy alkanoic acids, such as citric acid, lactic acid,
tartaric acid or malic acid If a pharmaceutically acceptable buffer system is used, it is
selected from a group of buffers that are effective to maintain pH below 5, preferably at
4 5 or lower, most preferably in the range of about 3 - 4 2, which buffers are well
known in the art Most preferably the buffer may be selected from citrate, acetate,
phosphate and lactate buffers The preparation of buffer systems is well known for one
skilled in the art. In general, the acidic compound or buffer is used in an amount
necessary to adjust the pH into the desired range However, the amount used must be
pharmaceutically acceptable
The composition of the invention may also comprise a solubility enhancing
agent. The term "solubility enchancing agent" means herein a substance capable of
increasing the amount of levosimendan that can be maintained in a dissolved state in an
aqueous solution, including the prevention of crystallization or crystalline growth of
levosimendan Suitable solubility enhancing agents include co-solvents such as ethanol
or propylene glycol, surfactants and polymeric substances such as polysorbates,
polyalkylene glycols (e g polyethylene glycol), poloxamers or polyvinylpyrrolidone,
and oily fatty acids and their mono- or diglyceryl esters such as linoleic acid or glyceryl
monolaurate In general, the amount of the solubility enhancing agent is within the
range of about 0 001 - 80 %, preferably 0 005 - 10 %, most preferably 0 01-5%, by

weight of the composition For intravenous administration, wherein the choice of
acceptable adjuvants is limited, polyvinylpyrrolidone or ethanol or a mixture thereof is
the preferred solubility enhancing agent polyvinylpyrrolidone being the most preferred
Suitable polyvinyl pyrrohdones are those with a number average weight below 40,000,
more suitably below 5000, and particularly about 2,500 Such a polyvinyl pyrrohdone is
exemplified by Kollidon PF 12 (registered trademark)
It will be understood that vanous additives commonly used in this field of the
art, such as preservatives, can be also included in the composition of the invention
In another aspect, the invention provides an aqueous intravenous solution
comprising levosimendan or a Salt thereof as an active ingredient the pH-value of the
solution being lower than 5, preferably about 4.5 or lower, and most preferably from
about 3 to about 4 2. The aqueous intravenous solution, which can be in a form of e g
an injection or infusion solution, of the invention is chemically and physically stable
under storage conditions over an extended period of time Preferably the aqueous
intravenous solution is a ready to use intravenous solution for infusion or bolus
injection.
The amount of levosimendan included in the aqueous intravenous solution of the
invention depends e g on the treatment procedure and the condition to be treated, but is
generally a therapeutically effective amount The amount may vary e g. within the range
of about 0 001 - 1 0 mg/ml, preferably about 0.005 - 0.5 mg/ml, most preferably about
0 01-0.1 mg/ml.
For maintaining the pH of the aqueous intravenous composition of the invention
in the desired range a suitable pharmaceutically acceptable acidic compound or buffer
system may be used as described above
-The aqueous intravenous composition of the invention maty also comprise a
solubility enhancing agent for increasing the amount of levosimendan that can be
maintained in a dissolved state in an aqueous solution, including the prevention of
crystallization or crystalline growth of levosimendan For intravenous administration,
wherein the choice of acceptable adjuvants is limited, polyvinylpyrrolidone or ethanol
or a mixture thereof is the preferred solubility enhancmg agent polyvinyl pyrrollidone
being the most preferred The amount of the solubility enhancing agent in the aqueous
intravenous composition is generally within the range of about 0 001 - 20 %, preferably
0 005 - 5 %, by weight of the aqueous intravenous composition The preferred amount

of polyvinylpyrrolidone is within the range of about 0 005 - 0 5 % by weight of the
aqueous intravenous composition
The aqueous intravenous composition of the invention may also comprise a
physiologically and pharmaceutically acceptable compound effective to render the
aqueous intravenous composition isotonic, i e to have an osmotic pressure
corresponding to that of a 0 9 % solution of sodium chloride Typical examples of such
compounds are chloride salts such as NaCl and saccharides such as sorbitol, mannitol
and dextrose/glucose The preparation of isotonic solutions is well known for one
skilled in the art.
The aqueous intravenous composition of the invention may be prepared e g by
dissolving levosimendan and other adjuvants into stenle isotonic aqueous vehicles, e g.
0 9 % solution of sodium chloride while stimng. Alternatively a suitable amount of
isotonic rendering compound is dissolved together with levosimendan and other
adjuvants into aqueous vehicle, e g stenle distilled water The solution may be also
prepared by dissolving levosimendan and other adjuvants first in suitable solvent such
as ethanol, and diluting the solution with stenle isotonic aqueous vehicles. The bulk
solution is filtered and filled into infusion bottles or ampules The product is sterilized
preferably using autoclavmg in a manner known in the art.
In yet another aspect the invention provides a pharmaceutical solution,
particularly an intravenous infusion concentrate to be diluted with an aqueous vehicle
before use, compnsing (a) levosimendan or a pharmaceutically acceptable salt thereof
as an active ingredient, (b) pharmaceutically acceptable organic solvent compnsing
ethanol, preferably dehydrated ethanol, and (c) a stability enhancing amount of a
pharmaceutically acceptable organic acid having pKa in the range of from about 2 to
about 4 It has been found that the pharmaceutically acceptable organic acid having pKa
in the range of from about 2 to about 4 improves the stability of levosimendan in the
concentrate solutions of the invention. It has also been found that the concentrate
solutions of the invention can be successfully diluted with an aqueous infusion vehicle
to obtain aqueous intravenous solutions which are chemically and physically stable over
an extended penod of time
The amount of pharmaceutically acceptable organic solvent is generally within
the range of 90 - 99.9 %, preferably 95 - 99 9 %, by weight of the concentrate solution
of the invention Typically at least about 50 % by weight of the solvent is ethanol More
suitably, the solvent consists essentially of ethanol, whereby at least 90 %, preferably at

least 95 %, more preferably at least 99 %, by weight of the solvent is ethanol Most
preferably the solvent consists solely of ethanol, preferably dehydrated ethanol
The amount of said pharmaceutically acceptable organic acid is preferably
within the range of 0 005 - 2 %, preferably 0 01 - 1 %, by weight of the concentrate
solution Said pharmaceutically acceptable organic acid is a preferably a 2-hydroxy
alkanoic acid Such acids include citric acid, lactic acid, tartaric acid and malic acid the
most preferred being citric acid
The amount of levosimendan included in the concentrate solution of the
invention is generally an amount which is therapeutically effective The amount may
vary e g within the range of about 0 1-10 mg/ml, preferably about 0 5-8 mg/ml, most
preferably about 1-5 mg/ml
The concentrate solution of the invention may also comprise a solubility
enhancing agent for increasing the amount of levosimendan that can be maintained in a
dissolved state in an aqueous solution, including the prevention of crystallization ox
crystalline growth of levosimendan. The amount of the solubility enhancing agent in the
concentrate solution of the invention is generally within the range of about 0 01-5%,
by weight of the composition. The solubility enhancing agent can be selected as
described above The most preferred solubility enhancing agent is polyvinylpyrrolidone
The preferred amount of polyvinylpyrrolidone is generally within the range of about
0 5 - 2 %, by weight of the concentrate composition
^ssiSsrA particularly preferred concentrate solution for intravenous infusion comprises
"(a) levosimendan or a pharmaceutically acceptable salt thereof in amount of 0 01 - 1 0
% by weight, "^ *
'(b) dehydrated ethanol in amount of 95 - 99_jL%.by weight, \/$^
(c) citric acid in amount of 0 03 -/0.6 % by weight, and $? , \ IF^LS
1—"~~ , / \ Jt^Z^^
(d) polyvinylpyrrolidone in amount of 0 5-2 %by weight ^r ^s^
The concentrate solution maybe prepared by dissolving stability enhancing
organic acid, levosimendan and the optional solubility enhancing agent and possible
other additives to the solvent in the sterilized preparation vessel under stirring The
resulting bulk solution is filtered through a sterile filter The sterilization method of the
product is preferably a stenle filtration, because ethanol solution cannot be autoclaved
due to the explosion nsk The sterile filtered bulk solution is aseptically filled into
injection vials and closed with rubber closures

J / The concentrate solution for intravenous infusion is diluted with an aqueous
vehicle before use Typically the concentrate solution is diluted with aqueous isotonic
vehicles for intravenous infusion, such as 5 % glucose solution or 0 9 % NaCl solution
The concentrate infusion is diluted such that an aqueous intravenous solution is
obtained, wherein the amount of levosimendan is generally withm the range of about
0 001 - 1 0 mg/ml, preferably about 0 005 - 0 5 mg/ml, most preferably about 0 01-01
mg/ml, depending e g on the treatment procedure and the condition to be treated
The invention is illustrated but in no way limited, by the following examples
Example 1. Concentrate solution for intravenous infusion i (a) levosimendan 2 5 mg/ml ""^ *""~^ (b)Kollidon.PF12 lOmg/mT , "~> \ ' C (
(c) citric acid 2 mg/ml -——1 ^ „ %£ ^
,^---~" (d) dehydrated ethanol , * ad^l 'ml^TSJmg) ^
The concentrate solution was prepared by dissolving citric acid, Kollidon PF121
and levosimendan to dehydrated ethanol in the sterilized preparation vessel under
stirring The resulting bulk solution was filtered through a sterile filter (0.22 fim) The
sterilization method of the product was sterile filtration, because ethanol solution cannot
be autoclaved due to the explosion nsk. The sterile filtered bulk solution was then
aseptically filled into 8 ml and 10 ml injection vials (with 5 ml and 10 ml filling
volumes) and closed with rubber closures The product has a shelf-life of 2 years in 2 -
8°C. y
Example 2.
The effect of citric acid on the chemical stability of levosimendan in ethanohc
infusion concentrate solutions stored in different temperatures was studied. The
solutions were prepared as described in Example 1 The results are shown in Tables 1
and 2. In the Tables "OR-1746/refers to (4-Ethoxy-6-immo-5-{[4-(4-methyl-6-oxo-
l,4,5,6-tetrahydro-pyridazm-3-yl)-phenyl]hydrazono}-5,6-dihydro-l(H)-pyrimidin-2-
ylidene)-[4-(4-methyl-6-oxo-l,4,5,6-tetrahydro-pyridazin-3-yl)-phenylazo]acetonitnle

Table 1 Effect of citric acid on the chemical stability of levosimendan All
solutions contain levosimendan (1 25 mg/ml), KolhdonPF12 (10 mg/ml) and v t .
dehydrated ethanol (ad 1 ml) ' = ~~' -V ^*
<
5
r
Table 2. Effect of citric acid on the chemical stability of levosimendan. All
solutions contain levosimendan (2 50 mg/ml), Kollidon PF12 (10 mg/ml) and
dehydrated ethanol (ad 1 ml) .

nd = not determined/ '/
The results show that citric acid significantly improves the chemical stability of 71
levosimendan in infusion concentrate solutions | J
') /
^ / Example 3 Aqueous solution for infusion, pH 3 9_ /

(a) levosimendan 0 025 mg/ml
psl J>j$>) Kolhdon PF12 0 10 mg/ml ^
(c) citric acid 0 02 mg/ml
co ro/« • (d) ethanol 7 85 mg/ml
(e) sodium chloride 9 0 mg/ml
(e) water__ ad 1 ml
The above aqueous infusion solution was obtained by diluting the infusion
S
concentrate solution of Example 1 with isotonic (0 9 %) sodium chloride solution such
that the resulting aqueous solution contained 0 025 mg/ml of levosimendan. The diluted
solution was clear with no precipitation
The chemical stability of levosimendan in the aqueous solution of Example 3
was studied after 24 hour storage (at room temperature) and after one month storage (at
2 - 8 °C) The results are shown in Table 3 "OR-1420" refers to (E)-2-cyano-2-[[4-
(l,4,5,6-tetrahydro-4-methyl-6-oxo-3-pyridazmyl)phenyl]hydrazono]acetamide
Table 3 The chemical stability of levosimendan in a solution of Example 3 after
the storage of 24 hours (at room temperature 25 °C) and after the storage of one month
(at2-8°C).

For comparison, the chemical stability of levosimendan in Reference solutions
having pH of 7 - 8 was studied after the storage of 2 and 5 days at 8 - 15 °C and room
temperature The results are shown in Table 4
Reference solutions
(a) levosimendan 0 01 - 0.25 mg/ml
(b) sodium chloride 9 mg/ml
(c) sodium carbonate monohydr 0 02 - 0 5 mg/ml

(d) hydrochloric acid 0 1 M to adjust pH to 7 - 8
(e) water ad 1 ml
Table 4 The chemical stability of Ievosimendan in Reference solutions (0 01,
0 1 and 0 25 mg/ml of Ievosimendan) having pH of 7 - 8 after the storage of 2 and 5
days at 8 - 15 °C and room temperature (25 °C)

The results show that degradation of Ievosimendan is significantly retarded in
the solution of Example 3 compared to Reference solutions. In the Reference solutions
significant amounts of degradation products are formed already after the storage of 5
days, whereas the solution of Example 3 is stable even after the storage of one month It
can be also noted that the pH tends to increase in Reference solutions

WE CLAIM:
1 Aqueous intravenous infusion solution comprising levosimendan or a salt thereof
as an active ingredient the pH-value of the solution being lower than 5, preferably 4 5
or lower, and optionally a solubility enhancing agent such as herein described
2 A solution as claimed in claim 1 in which the pH-value of the solution is 4 5 or
lower
3 A solution as claimed in claim 2 the pH-value of the solution being in the range of
from 3 to 4 2
4 A solution as claimed in any one of claims 1 to 3, which comprises a solubility
enhancing agent such as herein described
5 A solution as claimed in any one of claims 1 to 4, wherein the solubility enhancing
agent is polyvinylpyrrolidone or efhanol
6 A pharmaceutical solution comprising

(a) levosimendan or a pharmaceutically acceptable salt thereof as an active ingredient,
(b) pharmaceutically acceptable organic solvent comprising efhanol,
(c) a stability enhancing amount of a pharmaceutically acceptable organic acid having
pKa in the range of from 2 to 4, and optionally
(d) a water-solubility enhancing agent such as herein described

7 A solution as claimed in claim 6 which is an intravenous infusion concentrate
8 A solution as claimed in claim 6 or 7, wherein the amount of said solvent is 90-
99 9%, preferably 95-99 9%, by weight of the solution

9 A solution as claimed in claim 6, 7 or 8, wherein the amount of said organic acid is
0 005-2%, preferably 0 01-1%, by weight of the solution
10 A solution as claimed in any one of claims 6-9, wherein pharmaceutically
acceptable organic acid is a 2-hydroxy alkanoic acid
11 A solution as claimed in claim 10, wherein pharmaceutically acceptable organic
acid is citric acid, lactic acid, tartaric acid or malic acid
12 A solution as claimed in claim 6, wherein the amount of water-solubility
enhancing agent such as herein described is 0 1-5% by weight
13 A solution as claimed in claim 6, wherein the water-solubility enhancing agent is
polyvinylpyrrolidone
14 A solution as claimed in claim 6 comprising
(a) levosimendan or a pharmaceutically acceptable salt thereof in amount of 0 01-
1 0% by weight,
(b) dehydrated ethanohn amount of 95-99 5% by weight,
(c) citric acid in amount of 0 03-0 6% by weight, and
(d) polyvinylpyrrolidone in amount of 0 5-2% by weight

(54) Title: PHARMACEUTICAL SOLUTIONS OF LEVOSIMENDAN
(57) Abstract. The invention relates to levosimendan solutions for pharmaceutical use, and particularly for intravenous administration.
The solutions of the invention have enhanced stability and they are particularly useful as infusion or injection solutions or
infusion concentrates. Levosimendan is useful in the treatment of congestive heart failure.