WO2013135737A1

WO2013135737A1 - Compositions for dysphagia assessment

Info

Publication number: WO2013135737A1
Application number: PCT/EP2013/055064
Authority: WO
Inventors: Chrispulo GALLEGOS-MONTES; Edmundo BRITO-DE LA FUENTE; José M. MAINOU-SIERRA; Lida-Andrea QUINCHIA-BUSTAMANTE; Mirta Viviana JOZAMI; Conceptión VALENCIA BARRAGÁN; Josè Maria FRANCO-GÓMEZ
Original assignee: Fresenius Kabi Deutschland Gmbh
Priority date: 2012-03-15
Filing date: 2013-03-13
Publication date: 2013-09-19
Also published as: EP2825064A1

Abstract

Dysphagia, or abnormal swallowing of foods and/ or liquids, affects people of all ages from the newborn to the elderly. Management of dysphagia is commonly done by the prescription of texture-controlled diets. Ideally, the most appropriate modification of food consistencies should follow from a clear assessment of the swallowing problem. Rheology and swallowing are connected at the diagnosis level. The "gold standard" technique is a videofluoroscopic swallowing study (VFSS). The swallowing process can be visualized using videoradiography by employing either ready-to-use commercial contrast medium or by mixing food with barium sulphate (BaSO₄), making it radiopaque. Unfortunately, there is no standardization to perform VFSS. This lack of standardization leads to variability of results as well as their interpretation. In practice, lack of standardization often requires that individual speech pathologist, dieticians and dysphagia food manufacturers determine their own dietary consistencies. Another possibility is the use of encapsulated MRI superparamagnetic contrast agents for oral administration. The main goal of this invention has been to develop new and improved formulations of carriers/vehicles for radio-opaque (barium sulphate) or magnetic contrast agents (superparamagnetic iron oxide) that can be used as ready-to-use/ powder commercial formulations as contrast media for imaging diagnosis (VFSS or MRI) of dysphagia.

Description

Compositions for dysphagia assessment

Background

Dysphagia, or abnormal swallowing of foods and/ or liquids, affects people all ages from the newborn to the elderly. Management of dysphagia is commonly done by the prescription of texture-controlled diets. Ideally, tiie most appropriate modification of food consistencies should follow from a clear assessment o the swallowing problem. Rhcology and swallowing are connected at the diagnosis level. The "gold standard" technique is a videoffuoioscopic swallowing study (VFSS). The swallowing process can be visualized using vidcoradiography by employing either ready-to-use commercial contrast medium or by mixing food with barium sulphate (BaSO^, making it radiopaque. Unfortunately, there is no standardization to perform VFSS. This lack of standardization leads to variabilit of results as well as their interpretation. In practice, lack of standardization often requires that individual speech pathologist, dieticians and dysphagia food manufacturers determine their own dietary consistencies. Another possibility is the use of encapsulated MRI superparamagnetic contrast agents for oral administration. The main goal of this invention has been to develop new and improved formulations f carriers/vehicles for radio-opaque (barium sulphate) or magnetic contrast agents (superparamagnetic iron oxide) that can be used as ready-to-use/ powder commercial formulations as contrast media for imaging diagnosis (VFSS or R!) f dysphagia.

Summary.

The invention is directed to a composition suitable for dysphagia assessment by image diagnosis comprising an oral contrast agent, a carminative, a piokinetic agent, an antacid, and a hydrocolloid. The carminative is simethicone. Hie pi okinetic agent can be domperidone, benzamide, cisapride, erythromycin, itopi ide, mosapn^'de, metoclopramide, prucalopiide, renzapride, tegaserod, and mitemcinal. The antacid can be pantopraz le, omeprazole, lansoprazole, dexlansoprazole, esomeprazole, rabeprazole, cimetidine, and burimamide. The oral contrast agent can be selected from the group of radio opaque and contrast agents suitable for magnetic resonance imaging. The oral contrast agent can be a radio-opaque agent selected from the group consisting of barium sulphate and iodine. The oral contrast agent can be a contrast agent suitable for magnetic resonance imaging and can be selected from the group consisting of superparamagnetic iron oxide (SPIO), gadolinium chelates, manganese chelates, iron salts, barium sulphate, clay, perflubron, and natural products with high manganese concentration. The oral contrast agent can have a pharmaceutical acceptable coating. The hydrocolloid can be selected from the group of starch, cellulose, methylated cellulose, pectin, gum acacia, galactomannan, carubin, agar, carrageen, alginate, gelatin caseinate, xanthan, dextran, scleroglucan, guar, tara or combinations thereof. The composition can further comprise a polyalcohol wherein die polyalcohol is selected from the group of glycerol, glycol, erythritol, threitol, arabitol, xylitol, ribiiol, mannitol, sorbitol, dulcitol, fucitol, iditol, isomalt, maltitol, lactitol, and polyglycitol or combinations thereof. The composition c n comprise one or more compounds selected from the group consisting o flavoring agents, dextrines, stabilisers, non-saccharide sweeteners, and preservatives or combinations thereof.

The invention also relates t o a composition suitable for the preparation of a composition for dysphagia assessment by image diagnosis comprising a guar gum in an amount of 0-0.5%, xanthan gum in an amount of 0.1%-1.5%, tara gum in an amount of 0.0-0.1%, carboxy- methyl cellulose in an amount of 0.0-1.0%, maltodextrin in an amount of 0.5-1.0%, optionally containing n oral contrast agent, a carminative, a piokinetic agent, an antacid, a flavoring agents, dextrine, stabilisers, non-saccharide sweeteners, and/or preservatives.

A powdered preparation comprising any of the above described compositions can be prepared. Alternatively, a liquid preparation comprising the composition of any of the above claims can be prepared. The invention also relates to a method for producing the compositions o the invention as a powder comprising providing any of the above described compounds and mixing said compounds, (hereby producing the composition of the invention.

An embodiment relates to a method for producing the liquid preparation of the invention comprising the steps for making a powder above further comprising adding water to the compounds, thereby dispersing the compounds in said water wherein the water is either provided before the compounds are added or the water is added after the entire powdery compositio has been prepared. 'Hie method can be performed at room temperature. The method can comprise the sterilization of the obtained mixt tire or dispersion.

Particularly preferred is a method for imaging the swallowing of a liquid by a subject by an x- ray or MRI imaging system comprising recording the x-ray or MR I signals emitted from a subject swallowing the liquid preparation of the invention and imaging the x-ra or MRI signals. In a preferred embodiment, the liquid preparation can comprise SPIO and an MRI imaging system is used in the practice the imaging method.

Brief description of the figutes

Fig. 1 Liquid compositions of the. invention compared to commercial nectar-like contrast fluid.

Fig, 2 Liquid compositions of the invention compared to commercial nectat-like contrast fluid.

Fig. 3 Liquid compositions of die invention compared to commercial pudding-like contrast fluid.

Fig. 4 Liquid compositions of the invention compared to commercial pudding- like contrast fluid.

Qefitiitions

A carminative is a preparation that either prevents formation of gas in the gastrointestinal tract or facilitates the expulsion of said gas, thereby combating flatulence. Carminatives have been shown to decrease lower esophageal pressure, which on the other hand increases the risk of Gastroesophageal Reflux Disease (GERD) or 'heartburn.¹ An example of a carminative is simethicone.

An antiemetic is a drug that is effective against vomiting and nausea. Antiemetics are typically used to treat motion sickness and the side effects of opioid analgesics, general ana es lietics, and chemotherapy directed against cancer. Antiemetics in the sense of the invention can comprise prokinetic agents.

A gaslroprokinetic agent, gastrokinctic, or prokinetic agent are all different names for the same type of drug. It is a type of drug which enhances gastrointestinal motility by increasing the frequency of contractions in the small intestine or making them stronger, but without disrupting their rhythm. They are used to relieve gastrointestinal symptoms such as abdominal discomfort, bloating, constipation, heart burn, nausea, and vomiting (insofar the)' can overlap with antiemetic agents). Prokinetic drugs can be M_¾ receptor antagonists (tliereby inhibiting acetylcholine release) and 5-HT, antagonists. Prokinetic drugs can be beiv/amide, cisapride, domperidone, erythromycin, itopride, mosapride, metoclopramide, prucalopride, renzapride, tegaserod, or mitemcinal. Prokinetic agents can have antiemetic effects.

Antiemetics include, but are not limited to, 5-HT₃ receptor antagonists (these block serotonin receptors in the central nervous system and gastrointestinal tract), dopamine antagonists, N 1 receptor antaganists, antihistamines (11, histamine receptor antagonists), cannabinoids, benzodiazepines, anticholinergics, steroids (e.g. dexmethasone).

5-HT₃ receptor antagonists can be. (respective trademarks are provided in brackets) dolasetron (Anzemet), granisetron (Kytiil, Sancuso), ondansetron (Zofran), tropisctron (Navoban), palonosetron (Aloxi), mirtazapine (Remeron), an antidepressant that also has antiemetic effects.

Dopamine antagonists can be (respective trademarks are provided in brackets) domperidone, olanzapine, dropcridol, haloperidol, chlorpromazine, promethazine, prochlorperazine, or metoclopramide (Rcglan).

NK1 receptor antagonist can be aprepitant and casopitant.

Antiliistamines (I i, histamine receptor antagonists) can be (respective trademarks are provided in brackets) cyc!izine, diphenhydramine (Benadryl), dimenhydrinate (Gravol, Diamamine),meclozine (Bonine, Antivert), promethazine (Pentazine, Phenergan, Promaeot), hydroxyzine.

Cannabinoids can be cannabis, dronabinol (Marinol), or nabilone (Cesairiet).

Benzodiazepines can be midazolam or lorazepam.

Anticholinergics can be hyoscine (also known as scopolamine).

An example of a steroid is dexaniethasone.

Antacids ate agents that reduce acidity in the gastiOintestinac tract. Basically two classes of agents are available: agents that neutralize the produced acid (curing of symptoms) or agents that prevent the production of acid at the source (H₂-receptor antagonists, proton pump inhibitors). Antacids in the sense of the invention are H_?-receptor antagonists and proton pump inhibitors. Thus, the invention is directed to antacids that prevent the production of acid.

Proton-pump inhibitors (PPIs) are a group of drugs whose main action is a pronounced and long-lasting reduction of gastric acid production. Proton pump inhibitors act by irreversibly blocking the hydrogen / otassium adenosine triphosphatase enzyme system (the H+/ + ATPase, or more commonly gastric proton pump) of the gastric parietal cells. The proton pump is the terminal stage in gastric acid secretion, being directly responsible for secreting H+ ions into the gastric lumen, making it an ideal target for inhibiting acid secretion. PPIs are omeprazole (brand names: Losec, Prilosec, Zegerid, ocid, Lomac, Omepral, Omcz), lansoprazole (brand names: Prevacid, Zoton, Monolitum, Inhibitol, Levant, Luptzo!e), dexlansoprazole (brand name: Kapidex, Dexilant), esomeprazole (brand names: Nexium, Esot ex), pantoprazole (brand names: Protonix, Somac, Pantoloc, Pantozo!, Zutcal, Zentro, Pan, Controloc), rabeprazole (brand names: Zcchin, Rabecid, N'/ole- 1), AcipHex, Pariet, Rabeloc, and Revaprazan).

The H₂ receptor antagonists e a class of drugs used to block the action histamine on parietal cells in the stomach, decreasing the production f acid by these, cells. I I₂ receptor antagonists arc citnetidine, burimamide, and ranitidine,

A hydiocolloid is defined as colloidal system wherein the colloid particles are dispersed in water. A hydiocolloid has colloid particles spread throughout water, and depending on the quantity of water available can take different states, e.g., gel or sol (liquid). A hydiocolloid can be selected from the group of starch, cellulose, methylated cellulose, pectin, gum acacia, galactomannan, carubin, agar, carrageen, aliginate, gelatin caseinate, xanthan, dextran, scleroglucan, guar, tara, taracanth, karaya gum, locust bean gum or mixtures thereof. A dextrine is a hydroiysed form of starch wherein the hydroiysed forms have Ό glucose units connected in chains of variable length, in particular, in a range from three to nineteen glucose units and have a DE (dextrose equivalent) of between 3 lo 20. The glucose units are linked by a(l→4) glycosidic bonds. A preferred dextrine is maltodextrin.

Dextrose equivalent (DE) is a measure of the amount of reducing sugars present in a sugar product, relative to glucose, expressed as a percentage on a dry basis. The DE corresponds to the amount of glucose that, based on lOOg of the sugar product on a dry basis, has the same reducing power.

A polyalcohol is a hydrogenated form of carbohydrate, whose carbonyl group (aldehyde or ketone, reducin sugar) has been reduced to a primary or secondary hydroxy! group. Sugar alcohols have (he general formula H(HCHO)_{Il+ 1}H. Examples of pharmaceutical acceptable polyalcohols are glycerol, crythritol, threitol, tabito!, xylitol, ribitol, mannitol, sorbitol, dulcitol, fucito!, iditol, isomalt, maltitol, lactitol, polyglycitol.

Flavoring agents ate agents that contribute a flavor to a composition and exist in a wide variety of forms and flavours. For example, citric acid can render a composition sour.

Stabilisers are agents that enhance dispersion stability, by slowing down suspension phase separation. An example is polysorbate 80.

Preservatives prevent decomposition a nutritional product or a product containing organic material by microbial growth or by undesirable chemical changes. Examples are potassium sorbate, calcium propionate, sodium nitrate, sodium nitrite, and (sodium) benzoate.

Non-saechafide sweeteners imitate or even multipl the effect of sugar in taste, usually with less food energy. Examples are aspartame, cyclamate, (sodium) saccharin, stevia, and sucralosc.

A pre-encapsulated compound is compound that is prepared to be entrapped inside a fluid matrix or to have a solid coating. Thus, pre- encapsulation provides a firs encapsulation to the compound. Subsequent to that pre-encapsulation the compound may be mixed with other pre-encapsulated or non-encapsulated compounds or remain unmixed. Th pre- encapsulated compound or the mixture of pre-encapsulated and other compounds may undergo a further encapsulation procedure. Detailed description of the invention

The section headings serve to clarify the subject matter and should not be interpreted to limit the subject matter. If ranges of values are disclosed each individual value Is considered to be covered by d e range, in particular, each integer number. If not noted otherwise, values in % relate to weight/weight (w/w) values.

Pharmaceutical active ingredient

The compositions can comprise a pharmaceutical active ingredient comprising compounds selected from the group consisting of a carminative and an antacid. The composition can comprise 0.05% to 0.3%, 0.10% to 0.20%, 0.125% to 0.175%, or 0. 15% of the pharmaceutical active ingredient. The amount of the carminative in the pharmaceutical ingredient can be 10-90% while the amount o the antacid can be 90-10%. Their combined amounts can make 100% of the pharmaceutical active ingredient. The skilled person based on the nature of the compound can determine any suitable amount for the composition.

The pharmaceutical active ingredient can further comprise a prokinetic agent without altering the total amount of the pharmaceutical active ingredient in die composition. In other words, if a prokinetic agent is comprised in the pharmaceutical active ingredient, the combined amounts of the carminative and the antacid make up for (100% - the amount in % of the prokinetic agent comprised) of the pharmaceutical active ingredient. According to one embodiment, the amount f the carminative in the pharmaceutical ingredient can be 10 80% while the amount of the antacid can be 80-10% and the amount the prokinetic agent can be 80 10. Their combined amounts can make 100% of the pharmaceutical active ingredient. The skilled person based on the nature of the compound can determine any suitable amount f r the composition.

The carminative can be simethicone.

The antacid can be selected from the group of H₂-receptor antagonists and proton pump inhibitors. In particular, the antacid can be selected from the group consisting o omeprazole, lansoprazole, dcxlansoprazole, esomeprazole, pantoprazole, rabeprazole, cimetidine, burimamidc, and ranitidine. Particularl preferred is pantoprazole.

The prokinetic agent can be selected from the group consisting of Μ_Λ receptor antagonists and 5-1 1T₄ antagonists. Preferred prokinetic drugs can be benzamide, cisapride, domperidonc, erythromycin, itopride, mosapride, metoclopramide, prucalopride, renzapride, tcgaserod, or mitemcina!. Particularly preferred is domperidone. Domperidone can also have antiemetic properties. Thus, the composition can comprise agents with antiemetic properties (antiemetic agents).

Oral contiast agent

Oral contrast agents are agents that can be visualized during dysphagia assessment by image diagnosis such as X-ray or magnetic resonance imaging (Mill). Suitable contrast agents are, depending on the used imaging technique, radio opaque (and therefore suitable for X-ray analysis) and/or can be made visible by magnetic resonance imaging (MRI contrast agents). Radio-opaque contrast agents are salts of iodine or barium. A preferred radio-opaque contrast agent is barium sulphate.

MRI contrast agents are selected from the group consisting of gadolinium chelates, manganese chelates, iron salts, superparamagnetic iron oxide (SPIO), barium sulphate, clay, perflubron, and natural products with high manganese concentration (e.g. blueberry and green tea). Particularly preferred is SPIO.

The compositions can comprise 20· 40%, 25-35%, or 30% of a radio-opaque contrast agent, in particular, barium sulphate. In a preferred embodiment, the radio-opaque contrast agent is pre- encapsula ted.

The compositions can comprise 0.01-0.20, 0.04 -0.1 %, 0.05 0.10% of an MRI contrast agent, in particular, SPIO. In a preferred embodiment, the MRI contrast agent is pre-encapsulated.

Encapsulation

The contrast agents can be pre-encapsulated . The encapsulating agent c n be a gum or a dextrine, in particular, a maltodextrine. Preferable, the barium sulphate is provided in a pre- encapsulated form. Preferably barium sulphate is pre-encapsulated with a gum. MRI contrast agents can be pre-encapsulated with dextrin.

Hydrocolloids

The hydrocolloid or the combination of hydrocolloids can define the iheological properties of the composition.

The hyd ocolloid can be selected from the group of starch, cellulose, methylated cellulose, carboxy-methylated cellulose (CMC), pectin, gum acacia, galactomannan, cambin, aga , carrageen, alginate, gelatin caseinate, xanthan, dextran, scle oglucan, guar, rata, taracanth, karaya gum, locust bean gum or mixtures thereof. The composition can comprise hydrocolloids in an amount of 0.75 -1.75%, 1.0-1.5%, 1.1 -1.4%, 1.2-1.35%, or 1.3%. Particularly preferred is guar gum. Particularly preferred is guar gum in a range from 0-1.5%, 0.14.5%, 0.2-1.4%, 0.3-1.3%, 0.4-1.2%, 0.5-1.1%, 0.6-1.0%, 0.7- 0.9%, 0.1-0.5%, 0.1-0.4%, 0.1- 0.3%, 0.2-0.35%, 0.3-0.75%, or 0.4-0.6%. An amount of 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.75, or 0,8% of gu r gum is also disclosed.

Also particularly preferred is xanthan gum. Particularly preferred is xanthan gum in a range from 0-1,5%, 0.1-1.5% 0.2-1.4%, 0.3-1.3%, 0.4-1.2%, 0.5-1.1%, 0.6 1.0%, 0.7-0.9%, 0.7-1.3%, 0.8-1.2%, 0.9-1.1%, 0.05-0.4%, 0.1-0.3%, 0.1-0.2%. An amount of 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.75, 0.8%, 0.9%, or 1.0% of xanthan gum is also disclosed.

Furthermore, particularly preferred is methylated cellulose. Particularly preferred is methylated cellulose in a range from 0-1.5%, 0.1-1.5% 0.2-1.4%, 0.3-1.3%, 0.4-1.2%, 0.5- 1.1%, 0.6 1.0%, or 0.7-0.9%. An amount of 0.0, 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0,75, 0.8% of methylated cellulose is also disclosed.

The preferred methylated cellulose is carboxymcthylat cellulose (CMC).

The composition can also comprise t a gum. The composition can compris tara gum in an amount of 0.0, 0.0 -0.2%, 0.05-0.15%, or 0.1 %.

It is contemplated that every range defined for one radi ocolloid can be combined with every range defined for a second or more hydrocolloids.

Dextrine

The composition can comprise dextrines. The composition can comprise dextrines in an amount of 0.25-1.5%, 0.5-1.25%, 0.75- 1.0%, 0.5, 0.8, or 1.0%. The preferred dextrine is maltodex trin.

Stabilize

Stabilizers can be present in an amount of 0.3-0.5% or 0.4 %. The stabilizer can be selected from the group consisting of polysorbate 80, ceteaiyl alcohol, polysorbate 20, and cetcareth 20. The preferred stabiliser is polysorbate 80.

Flavouring agents can be present in an amount of 0.1-5.0%, 0.1-1.0%, 0.2-0.5%, 0.25-0.35%, or 0.3%. Preferred flavouring agents are cit ic acid, glutamic acid salts, glycine salts, guanylic acid salts, inosinic acid salts, 5'-ribonucleotide salts, acetic acid, ascorbic acid, fumaric acid, lactic acid, malic acid, phosphoric acid, and tartaric acid, or combinations thereof. The preferred flavouring agent is citric acid providing a sour taste. Suitable flavouring agents ate also those that have the taste of vanilla, strawberry, chocolate, cappuccino, mango, orange, peach, etc., wherein each of them can belong to the group of synthetic, natural- or natural identical flavours.

Polyalcohol

The compositions can comprise pharmaceutical acceptable polyalcohols. The polyalcohols can be present in an amount of 0.5-4.0%, 1 -3.5%, 1.5-3.0%, 1.25-2.5% or 2.0%.

Polyalcohols have the general formula H(HCHO)_n+1H. Pharmaceutical acceptable polyalcohols can be selected from the group consisting of glycerol (glycerin), erythrifol, threitol, arabitol, xylitol, ribitol, mannitol, sorbitol, dulcitol, fucitol, iditol, isomalt, maltitol, lactitol, polyglycitol. Polyalcohols comprisin 3 or 4 carbon atoms, in particular, comprising 3 carbon atoms are preferred. Particularly preferred is glycerol.

l'le eiy m es

Preservatives can be present in an amount of 0.0-0.4%, 0.1 - 0.3%, or 0,2%. The preservative can be selected from the group consisting of potassium sorbate, calcium propionate, sodium nitrate, sodium nitrite, and (sodium) benzoatc, or mixtures thereof. Preferred preservatives are potassium sorbate and sodium benzoatc. Preferably, potassium sorbate is present in an amount of 0.1 % and sodium benzoate in an amount of 0.1%

Non-saccharide sweeteners

Non-saccha ide sweeteners can be present in an amount of 0.1-0.3% or 0.2%. The sweeteners ate selected from the group consisting of aspartame, cyclamate, (sodium) saccharin, stcvia, and sucralose. Preferably, the composition contains sodium saccharin.

Nectar and Pudding formulations

A further preferred embodiment relates to formulations having nectar- or pudding like characteristics. These formulations are already disclosed by die combination,? of compounds and ranges described above and are here merely presented for further clarification of the invention.

In particular, the inventions relates to compositions comprising hydrocoUoids that show the same viscosity behavior like nectar and pudding formulations of die prior art (e.g., Varibar Nectar barium Sulfate Suspension and Varibar Pudding Barium Sulfate Esophageal Paste). The claimed formulations show a steady state shear viscosity (η in IVs) in a shear range of

0.001 t 100 (1/s) or 0.01 to 10 (1/s) that is essentially identical to those of nectar and pudding formulations of the prior art. The respective steady state shear viscosity only deviates from the reference formulations by maximally ±10%, ± 1%, ±0.1%, or ±0.01%. Viscous flow measurements can be carried out in a MARS controlled-stress rheometcr (Thermo -Haakc, Germany) using coaxial- cylinders and plate-and-platc geometries. They can have serrated surfaces, to avoid wall- slip phenomena.

A pudding formulation can comprise 0.0-0.5% or 0.4-0.6% guar gum, 0.8 -1.2% or 1.0% xanthan gum, and 25-35% or 30% barium sulphate, 0.4-0.6% or 0.5% maltodextrin,. A further pudding formulation can comprise 0.0-1.0% guar guam, 1.0-1.5% or 1.25% xanthan gum, 0.5-1.0% CMC, 0.4-0.6% or 0.5% maltodextrin, and 0.05- 0.10% pre-encapsulated

SPIO.

Both pudding formulations can comprise 0.3% citric acid, 2.0% glycerol, 0.4% polysorbate 80, 0.1% potassium sorbate, 0.2% sodium saccharin, 0,1% sodium benzoate, 0.3% sodium citrate, and 0.15% of a pharmaceutical active ingredient comprising a carminative, a prokinetic agent, and an antacid (e.g. simethicone, domperidone, pantobrazole).

nectar formulation can comprise 0.0-0.3% or 0.1-0.2 guar guam, 0.1 0.4% or 0.25% xanthan gum, 0.0-0.1 lata gum and 25-35% or30% barium sulphate, 0.9-1.1%. or 1.0% maltodextrin,. A further nectar formulation can comprise 0.1 -0.5% guar guam, 0.1-0.5% or 0.30% xanthan gum, 0.1 0.5 tara gum, 0.9-1.1 % or 1.0% maltodextrin, and 0.05 0.10% pre- encapsulated SPIO.

Both nectar formulations can comprise 0.3% citric acid, 2.0% glycerol, 0.4% polysorbate 80, 0.1% potassium sorbate, 0.04% sodium saccharin, 0.1% sodium benzoate, 0.3% sodium citrate, nd 0.15% of pharmaceutical active ingredient comprising a carminative, a prokinetic agent, and n antacid (e.g. simethicone, domperidone, pantobrazole).

Met hod of producing liquid compositions

Furthermore, a method for producing liquid compositions of the inventions is provided. The method comprises the steps of providing any f the compounds or a subgroup of the compounds described above, mixing said compounds and thereby producing the composition of the invention. In one embodiment the compounds can be the carminative, the antacid, the oral contrast agent, and the hydrocolloid. The oral contrast agent may be provided in a pre-encapsulated form. Optionally, a further compound may be a prokinetic agent . Optionally, a further compound may be a polyalcohol.

In a further embodiment the water is provided and the compounds are added to the water. Alternatively or in addition, water can be added to the prepared mixture or solution. The obtained solution may be a true solution wherein all compounds are dissolved or alternatively a suspension or dispersion. In a further embodiment the oral contrast agent is pie encapsulated with a compound (gum, maltodextiin or others) in a watery dispersion (made from purified water) by mixing the encapsulating agent and the oral contrast agent under stirring. Preferentially, barium sulfate is pie-encapsulated with a gum and SPIO is pre-encapsu!ated with a dextrin (e.g. maltodextiin). The stilling speed can be 100 to 500 rpm, 200 to 400 rpm, or 300 tpm. The stirring/incubation time can be 1 to 6 Min, 2 to 4 Min, and preferentially 3 Min yielding a first dispersion. The remaining compounds can be mixed separately by combining water, hydrocolloids (e.g. gums), and other compounds. The mixing occurs under stirring. The stirring speed can be 100 to 500 rpm, 200 to 400 rpm, or 300 rpm. The stirring/incubation time can be 1 to 20 Min, 5 to 15 Min, and preferentially 10 Min yielding a second dispersion. First and second dispersions can be mixed under stirring. The stirring speed can be 500 to 2000 rpm, 750 to 1500 rpm, or 1000 rpm. The stirring/incubation time can be 1 to 60 Min, 15 to 45 Min, and preferentially 30 Min yielding a third dispersion.

In a preferred embodiment the above steps re performed at room temperature. Room temperature can be any value between 20°C-25°C, or 20°C, or 21 °C, or 22° C, or 23°C, 24°C, or 25°C.

In a final step the obtained solution or mixture can be sterilized. The sterilization can be any suitable form of sterilization method suitable for a liquid dispersion like thermal sterilization or sterilization by irradiation. Preferably, the liquid dispersion is thermally sterilized. Conditions for thermally sterilizing a composition are provided in this description.

Method of producing powder compositions

Particularl preferred is to obtain a powder from a liquid dispersion containing pre- encapsulated barium sulphate or SPIO. Moreover, a method for producing a powdered composition of tills invention is provided Phe method comprises the steps of providing any of the compounds or a subgroup of the compounds described above, dry mixing said compounds, then encapsulating the compounds. The compounds of the composition that is prepared by mixing can be one or more hydrocolloids and an oral contrast agent. The composition ca also comprise a compound selected from the group consisting of a carminative, a prokinetic agent an antacid, r mixtures thereof. The composition ca also comprise flavours or polya!cholhols (e.g. glycerol). The mixing can be achieved with the use of a fluidizecl bed and thereby producing the powdered composition of the invention. In one embodiment the compounds can be a carminative, an antacid, a prokinetic agent, an oral contrast agent, and/ or a hydrocolloid. The oral contrast agent may be provided in a pre- encapsulated fomi. Th oral contrast agent can be pre-encapsulated with a compound (g m, maltodextrin or others) in a watery dispersion (made from purified water) by mixing the pre- encapsulating agent and the oral contrast agent under stirring. Preferentially, barium sul ate is pre-encapsulated with a gum and SPIO is pre-encapsulated with a dextrin (e.g. maltodextrin). The stirring speed can be 100 to 500 rpm, 200 to 400 rpm, or 300 rpm. The stirring/incubation time can be 1 to 6 Min, 2 to 4 Min, and preferentially 3 Min yielding a dispersion. Then the obtained dispersion is dried to yield a powdered form of the pre-encapsulated contrast agent and is ready for use in the above described dry mixing method.

The powder composition obtainable by the above method contains all non-liquid compounds that are required for preparing a composition for dysphagia assessment. Only water needs to be added to reconstitute a dispersion.

Imaging Method

A method for imaging the swallowing of a liquid by a subject by an x-ray or MRI imaging system is provided. The method comprises recording the x-ra or Mill signals emitted from a subject swallowing a liquid preparation of the compositions provided in this description and imaging the x-ray or MRI signals. In the case o x- ray imaging the subject can be exposed to x-rays when the x-ray images ate recorded. Methods for recording x-ray or MRI signals are known in the art. However, the liquid compositions disclosed in this description are different from the liquid compositions of the prior art.

In addition, a method for diagnosing dysphagia is disclosed. Hie method comprises the imagin steps defined above followed by a diagnostic phase where it is analysed whether the subject exhibits signs of dysphagia. The analysis can be performed by visual inspection by a skilled practitioner or by an automated method, for example, assisted by a computer program.

The i f value o the solution can be between 3 and 6, between 4 and 5, between 4.3 and 4.6, or can be 4.4 or 4.5.

Sterilization

The compositions of the invention can be thermally sterilized (at a temperature that is above room temperature, i.e. above 25 C). Preferably, the sterilization is performed above 100°C, more preferably 105 und 150°C, in particular, between 110 und 130°C, or at 121°C. The length of the period at elevated temperature can be from 2 seconds up to 30 min., up to 25 min., in particular, between 10 min. and 20 min., or be 15 min. The sterilization can be performed at regular atmospheric pressure (1.0 bar) or at elevated pressure (1.8 to 2.0 bar).

Administration /dosage

The liquid compositions can be provided as ready-to-use compositions in containers of 150 ml, 200 ml, 250 ml, or 300 ml size or as powders to be reconstituted by adding the necessary amount of water to produce, for instance, nectar-like or pudding like compositions compositions in containers of 50 ml, 200 ml, 250 ml, or 300 ml size. The patient is positioned laterally before a suitable x-ray or Mill device and asked to swallow one of the compositions. A suitable recording equipment is then used to visualize and record the passage of the composition through the mouth and throat down to the esophagus during swallowing.

Advantages

The invention has several advantages over the swallow test feeds f the prior art. In particular, the unique combination o hydro colloids allows to better simulate the theological behavior of nectar and pudding like compositions.

The claimed compositions contain in some embodiments a carminative, a prokinetic agent, and an antacid (for example, simethicone, domperidone, and pantoprazole), a combination that has not been used before fo dysphagia assessment. This mixture has been used aiming to avoid/prevent the negative effects of oral contrast media, in particular, barium sulphate on the patient. Barium sulphate causes nausea, vomiting, diarrhea, constipation, abdominal pain, etc. These active ingredients do not modify the performance of these contrast media but do improve patient's quality of life after dysphagia diagnosis tests. The chosen combination has been found to be particularly beneficial for the patients' well-being fter swallowing a composition containing an oral contrast agent.

The flavouring of the formulations allows a better compliance. Thus, the formulations provided by the invention are more likely to be accepted by the patient.

The use of glycerol can enhance the suspension stability and favours hydrocolloid dispersion, thereby avoiding the formation of aggregates and preventing phase separation.

In particular embodiments, the radio opaque, contrast agent (e.g. barium sulphate) is pre- encapsulated . It has been surprisingly found that the barium sulphate pre-cncapsulation contributes to a decrease, in barium sulphate adhesion to the stomach and intestinal walls. Further more, it has been found that with respect to barium sulphat the pre-encapsulation improves suspension stability, improves organoleptic properties, improves particle size distribution, decreases barium sulphate adhesion to the stomach and intestinal walls. In addition, it has been found that the pie-encapsulation of SPIO improves iron particle stability, avoids agglomeration, and favors diagnosis by MRI.

A powder can be prepared from a composition having the radio opaque contrast agent in p e-encapsulated form which allows easier handling, storage and shelf life of the composition. The powder may comprise any of the powdery compounds described in the detailed description.

All manufacturing steps can be performed at room temperature thereby simplifying the production method and associated costs.

Furthermore, this liquid formulation can be submitted to thermal sterilization in a final preparative step- Finally, this is the first time SPIO is used for dysphagia assessment. Presently, there are no contrast media for dysphagia assessment available containing superparamagnetic iron oxide in the market. Barium sulphate is the "standard" contrast agent for dysphagia assessment. However, barium sulphate cannot be metabolised by the human body. Thus, it has been reported that barium sulphate can adhere to the gastrointestinal tract which can have a negative effect on the patient. On the. contrary, iron diffuses to the blood stream, being its excess metabolised and eliminated by macrophages, spleen, liver and faeces. Thus, the use of Mill contrast agents has advantages.

Examples

Example 1: Exemplary compositions comprising supetpaiamagnetic iron oxide

Table 1

Table 2

CARMINATIVES, PROKINET1C 0.15

AGENTS, ANTACIDS

(SIMETHICONE, DOMPERIDONE,

PANTOPRAZOLE)

FLAVOURS (vanilla, strawberry) 0-5.0

PURIFIED WATER Up to 100%

Example 2: Exemplary compositions comprising barium sulphate The formulations were produced according to following scheme:

Dispersions A and B were prepared separately and then mixed. The obtained mixture was treated with an agitator (IKA T50 basic) as indicated above yielding a dispersion C. Finally the dispersion was subjected to sterilization.

Table 3

BARIUM SULPHATE 30.0

CITRIC ACID 0.3

GLYCERIN 2.0

MALTODEXTRIN 0.5

POLYSORBATE 80 0.4

POTASSIUM SORBATE 0.1

SODIUM SACCHARIN 0.2

SODIUM ΒΕΝΖΟΑΊΈ 0.1

SODIUM CITRATE 0.3

ANTIEMETICS AND 0.15

ANTIACIDS

(SIMETHICONE,

D OMPERID ONE,

ANTO PR AZO L E)

FLAVOURS (vanilla, 0-5.0

strawberry)

PURIFIED WATER Up to 100%

Tabic 4

The following three compositions A-C were prepared.

Table 5

Nectar formulation

Ingredient Composition

A B C XANTHAN GUM 0.3 0.35 0.4

OTHER INGREDIENTS Up to 100% Up to 100% Up to 100%

The viscosities of these fluids (η in IVs) were measured in relation to t e shear rate (γ in s^"1) using a rheometer equipped with, a serrated plate-plate geometry at 25°C. The control nectar was Varibar Nectar Barium Sulfate Suspension (Ezcm, Canada). As can be observed in Fig. 1 the formulations show the flow behavior o control nectar.

The following four compositions I IV were prepared.

Table 6

The viscosities of these fluids (n in IVs) were measured in relation to the shear rate (γ in s ') as above at 25°C. The control nectar was Varibar Nectar Barium Sulfate Suspension (Ezem, Canada). As can be observed in Fig. 2, the viscous behavior of these 4 compositions matches the flow behavior of die control nectar.

The following diree compositions A-C were prepared.

Table 7

The viscosities of these fluids (η in Pa's) were measured in relation to the shear rate ( in s^"1) as above at 25°C. The control pudding was V atibat Pudding Barium Sulfate Esophageal Paste (Ezem, Canada). As can be observed in Fig. 3, only composition A matches die flow behavior of the control pudding.

The following compositions 1-lV were prepared. Table 8 Pudding formulation

The viscosities of these fluids (η in IVs) were measured in relation to the sheaf rate (γ in s^"1) as above at 25°C. The control pudding was Vaiibar Pudding Barium Sulfate Esophageal Paste (Ezem, Canada). As can be observed Fig. 4, only the composition II does not match the flow behavior of the control pudding.

Claims

1. Composition suitable, for dysphagia assessment by image diagnosis comprising an oral contrast agent, a carminative, a prokinetic agent, an antacid, and a hydrocol!oid.

2. Composition according to claim 1 wherein the carminative is simethicone.

3. Composition according to any of the above claims wherein the prokinetic agent is selected from the group of domperidone, benzamide, cisapride, erythromycin, itopridc, niosapiide, metocloptamide, p) ucalopiide, renzapride, tegaserod, and mitemcinal.

4. Composition according to any of the above claims wherein the antacid is selected from the group of patitoprazole, omeprazole, lansoprazole, dexlansoprazole, esomeprazole, labeprazole, cimetidine, and burimamide.

5. Composition according to any of the above claims wherein the oral contrast agent is selected from the group of radio-opaque and contrast agents suitable for magnetic resonance imaging.

6. Composition according to any o the above claims wherein the oral contrast agent is a radio- opaque agent selected from the group consisting of barium sulphate and iodine.

7. Composition accordin to any of the above claims wherein the oral contrast agent is contrast agent suitable for magnetic resonance imaging and is selected from the group consisting of superparamagnetic iron oxide (SPIO), gadolinium chelates, manganese chelates, iron salts, barium sulphate, clay, perflubron, and natural products with high manganese concentration.

8. Composition according to the above claims wherein the oral cont ast agent has a pharmaceutical acceptable encapsulating agent.

9. Composition according to any of the above claims wherein the hydrocolloid is selected from the group of starch, cellulose, methylated cellulose, pectin, gum acacia, galactomannan, carubin, agar, carrageen, alginate, gelatin caseinate, xanthan, de.xti.an, scleroglucan, guar, tara or combinations thereof.

10. Composition according to any the above claims further comprising a polyalcohol wherein the polyalcohol is selected from the group of glycerol, glycol, erythritol, threitol, tabito!, xylttol, ribitol, mannitol, sorbitol, dulcitol, fucitol, iditol, isomalt, maldtol, lactifol, and polyglycitoi or combinations thereof.

11. Composition according to any of the above claims further comprising one or more compounds selected from the group consisting of flavoring agents, dextrines, stabilisers, non-saccharide sweeteners, and preservatives or combinations thereof.

12. Composition suitable for the preparation o a composition for dysphagia assessment b image diagnosis comprising a guar gum in an amount of 0-0.5%, xanthan gum in an amount of 0.1% 1.5%, tara gum in an amount of 0.0-0.1%, carboxy-methyl cellulose in an amount of 0.0 1.0%, maltodextrin in an amount of 0.5-1.0%, optionally containing an oral contrast agent, a carminative, a prokinetic agent, an antacid, a flavorin agents, dextrine, stabilisers, non-saccharide sweeteners, and/or preservatives.

13. A powdered preparat ion comprising the composition of any of die above claims.

14. A liquid preparation comprising the composition of any of the above claims.

15. A method for producing a composition of claims 1-12 comprising

a. Providing the compounds of claims 1 -12

b. Mixing said compounds

thereby producing die composition of any of claims 1 12.

16. A method for producing the liquid preparation of claim 14, comprising the steps of claim 15, further comprising adding water to the compounds of claims 1-12, thereby dispersing the compounds in said water

wherein said water is added in a step prior to step a, pre- a., or in a step following step b., step c.

17. The method of claims 15 or 16 wherein the method is performed at room temperature.

18. The method of claim 17 further comprising the sterilization of the obtained mixture or dispersion

1 . A method for imaging the swallowing of a liquid by a subject by an x- ray or MRI imaging system comprising

a. recording the x-ra or MRI signals emitted from a subject swallowing the liquid preparation of claim 14

b. imaging the x-ray or MRI signals.

20. The method of claim 19 wherein the liquid preparation comprises SPIO and an MRI imaging system is used.