WO2020120519A1

WO2020120519A1 - Combinatorial oral treatment of metabolic disorders through orchestrated release of enterokines

Info

Publication number: WO2020120519A1
Application number: PCT/EP2019/084531
Authority: WO
Inventors: Kai Deusch; Steffen-Sebastian Bolz
Original assignee: Aphaia Pharma Ag
Priority date: 2018-12-10
Filing date: 2019-12-10
Publication date: 2020-06-18

Abstract

The present invention relates to pharmaceutical packages comprising at least two different pharmaceutical oral dosage forms each containing a core and an enteric coating, the cores each containing at least one compound stimulating enteroendocrine cells to release at least one enterokine and a disintegrant leading to a burst release of the core when the respective enteric coating is substantially dissolved and/or degraded, wherein each of the pharmaceutical oral dosage forms exhibit a burst release of the respective core in different parts of the small intestine of a subject and/or the dosage forms exhibit different travelling times through the small intestine of the subject. The active compounds of such combination of oral dosage forms can be the same or different in each of the dosage forms. The present combination of pharmaceutical oral dosage form are used for prevention and/or treatment of disorders and conditions relating to the energy household of and metabolism in the, preferably human, body, but also conditions or disorders being the consequence of or relating to, respectively, malfunction of energy household and metabolism.

Description

COMBINATORIAL ORAL TREATMENT OF METABOLIC DISORDERS THROUGH ORCHESTRATED RELEASE OF ENTEROKINES

The present invention relates to pharmaceutical packages comprising at least two different pharmaceutical oral dosage forms each containing a core and an enteric coating, the cores each containing at least one compound stimulating enteroendocrine cells to release at least one enterokine and a disintegrant leading to a burst release of the core when the respective enteric coating is substantially dissolved and/or degraded, wherein each of the

pharmaceutical oral dosage forms exhibit a burst release of the respective core in different parts of the small intestine of a subject and/or the dosage forms exhibit different travelling times through the small intestine of the subject. The active compounds of such combination of oral dosage forms can be the same or different in each of the dosage forms. The present combination of pharmaceutical oral dosage form are used for prevention and/or treatment of disorders and conditions relating to the energy household of and metabolism in the, preferably human, body, but also conditions or disorders being the consequence of or relating to, respectively, malfunction of energy household and metabolism.

It has early been recognised that delivery of a nutritional substance to the ileum through use of an enteric dosage form of the nutritional substance leads to satiety of a mammalian subject (US 5753253 A). More recently, specific delivery of a nutritional substance, in particular glucose, to the ileum of a subject, in particular dosage forms of a nutritional substance like glucose, which dosage forms release at least 50 % of the administered substance in the ileum of the subject, was suggested for treatment of metabolic diseases like type 2 diabetes mellitus, metabolic syndrome, insulin resistance, obesity, non-alcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatosis (NASH) and other conditions (WO 2010/027498 A2, WO 2012/118712 A2).

The technical problem underlying the present invention is to provide improved preventive and therapeutic measures against metabolic and cardiovascular disorders as well as other conditions relating thereto.

The solution to the above technical problem is provided by the embodiments of the present invention as disclosed in the claims, the present description and the accompanying figures. In particular, the present invention relates to a combination of at least two pharmaceutical oral dosage forms for use in the prevention and/or treatment of a condition, disorder or disease selected from the group consisting of insulin resistance, type 2 diabetes, non alcoholic fatty liver disease, non-alcoholic steatohepatosis, microvascular dysfunction, metabolic syndrome, obesity, osteoporosis, neurodegenerative diseases, cardiovascular diseases, malabsorption conditions and conditions of impaired gastro-intestinal function in a subject wherein the combination comprises at least a first and a second dosage form each comprising a core and a pH-sensitive enteric coating, wherein each core comprises at least one compound stimulating enteroendocrine cells to release at least one enterokine, and at least one disintegrant providing a burst release of the ingredients of the core when the coating is substantially degraded and/or dissolved, and wherein each coating comprises a pH sensitive polymer being selected such that the coating substantially dissolves and/or is substantially degraded in a selected part of the small intestine of a subject, wherein said first and second dosage form are formulated such that said first dosage form releases the at least one compound stimulating enteroendocrine cells to release at least one enterokine in a different part of the small intestine of the subject than the second dosage form and/or the first and second dosage form are formulated such that said first dosage form show a travelling time through the small intestine of the subject being different from the travelling time of the second dosage form through the small intestine of the subject;

wherein the at least one compound stimulating enteroendocrine cells to release at least one enterokine of said first and second dosage form can be the same or different.

The rationale of the present invention is to address a large as possible population of enteroendocrine cells in the small intestine of a subject, preferably a human subject, in particular a subject suffering or being danger of or being suspected to develop one ore more of the above conditions, diseases or disorders, to release one or more enterokines, in particular to release a substantial amount of said one or more enterokines over its/their baseline level(s) in that subject so as to improve or normalize the energy household and/or metabolism in said subject leading in return in improvement, at best cure, and/or prevention of the conditions, diseases or disorders stated above and further below.

A“pharmaceutical oral dosage from” according to the invention is a pharmaceutical composition typically formulated such that it is suitable for oral administration to a subject, preferably a human patient. Preferred oral dosage forms for use in the invention include tablets, capsules, pellets and granules. An“enteroendocrine cell” (EEC) as used in the present invention, is a cell present in a subject’s, preferably, human subject’s, intestine, in particular in the small intestine’s mucosa, and secretes one or more enterokines upon receiving an appropriate trigger by a nutritional component. There are several types of enteroendocrine cells which can be addressed by the active compound or compounds released by the pharmaceutical dosage form of the invention (for a review of enteroendorine cells of the lower gastrointestinal tract, see, for example, Gunawardene et al. (2011) Int. J. Exp. Pathol. 92, 219-231 , and Latorre et al.

(2017) Neurogastrol. Motil 28 (5), 620-630). In particular, preferred enteroendocrine cells in the context of the invention are I cells, K cells and L cells with L cells being most preferred.

According to the invention, an“enterokine”^' is a hormone secreted by EECs in the gastro intestinal system. Preferred enterokines are the incretins, i.e. hormones regulating the blood sugar level upon intake of nutrition, preferably GLP-1 , GLP-2 GIP and PYY, more preferably GLP-1 and PYY. Other preferred enterokines secreted by the EEC(s) through release of the active compound(s) in the pharmaceutical dosage form are CCK and neurotensin.

I cells are predominantly present in the proximal small intestine, in particular in the lower duodenum and in the jejunum, and secrete cholecystokinin (CCK) upon sensing of nutrients such as amino acids and fatty acids. CCK effects the release of bile acids from the gall bladder into the small intestine, but also promotes the release of digestive secrete from the pancreas.

K cells are found in the complete small intestine and release GIP (glucose-dependent insulinotropic peptide; also known as gastric inhibitory peptide) leading to inhibition of gastric motility and enhancement of insulin production and secretion.

L cells are present throughout the small intestine, i.e. duodenum, jejunum, and ileum, and release GLP-1 (glucagon-like peptide 1), GLP-2 (glucagon-like peptide 2) and PYY (peptide YY) in response to various nutrients. The concentration of L cells raises from duodenum to jejunum to ileum, and the GLP-1 release from L cells shows a gradient sloping from proximal to distal small intestine with highest GLP-1 release capacity in the terminal ileum. The gradient is not only a function of increasing number of L cells, but also a function of their maturation state and production rate of GLP-1 , which also increase from proximal to distal ileum. In particular, GLP-1 is released from L cells in the crypts and on the villi of the mucosa. L cells mature from crypt to villi, and GLP-1 release capacity is highest when the L cells reach the top of the villi. L cells further secrete PYY (peptide YY) which is predominantly released in the terminal ileum. The time dependency of GLP-1 and PYY release by L cells in the jejunum and ileum in response to glucose uptake by a human subject is schematically depicted in Fig. 1. The maturation dependency of GLP-1 and PYY secretion capacity of L cells is shown schematically in Fig. 2. GLP-1 enhances nutrient-stimulated insulin secretion and inhibits glucagon secretion, gastric emptying and feeding. GLP-1 also has proliferative, neogenic and antiapoptotic effects on pancreatic b-cells. As an intestinal trophic peptide, GLP-2 stimulates cell proliferation and inhibits apoptosis in the intestinal crypt compartment,

It also regulates intestinal glucose transport, food intake and gastric acid secretion and emptying. Furthermore, GLP-2 improves intestinal barrier function. PYY inhibits gastric motility and increases water and electrolyte absorption in the colon. PYY also suppresses pancreatic secretion and has been shown to reduce appetite. PYY slows gastric emptying; whereby it increases efficiency of digestion and nutrient absorption after a meal.

EECs, in particular L cells, are triggered to release enterokines such as GLP-1 and PYY through a variety of mechanisms being effected by the one or more active compound(s) in the pharmaceutical dosage form of the invention.

L cells release GLP-1 and PYY (and also GLP-2; note that GLP-1 and GLP-2 are derived from a common mRNA so that these hormones are essentially co-released; cf. , for example, the review of Baggio and Drucker (2004) Best Practice & Research Clinical Endocrinology & Metabolism 18 (4), 531-554) in response to various mechanisms triggered by compounds such as nutrients. One mechanism includes intake of a carbohydrate such as glucose through glucose transporters GLUT2 and/or SGLT1. Other mechanisms rely on the binding to specialized G protein-coupled receptors such as taste receptors, fatty acid receptors, bile acid receptors, peptide receptors and amino acid receptors.

These signals, glucose transport and binding to G protein-coupled receptor, are typically transmitted in the cells by one or more of three mechanisms and lead ultimately to the release of the enterokine, in the case of L cells GLP-1 and PYY: transmembrane calcium influx, intracellular calcium release and/or intracellular cAMP increase. The various cellular mechanisms leading to release of enterokines such as GLP-1 and PYY by EECs (in that case L cells) are schematically depicted in Fig. 3.

Accordingly, the active compound(s) triggering the release of an enterokine through an EEC are preferably selected from nutrients, and more preferred active compounds include carbohydrates, fatty acids, bile acids, peptides (including oligopeptides, polypeptides and proteins), amino acids, alcohol amides and anthocyanins. Preferred fatty acids are fatty acids having 2 to 6 carbon atoms. Ethanolamides such as oleoylethanolamide, anandamide (N- arachidonoylethenolamide, AEA), palmitoylethanolamide, steaorylethanolamide, and derivatives of anandaminde such as prostamides, can also preferably be used as alcohol amide compounds in the inventive oral dosage forms. A particularly preferred ethanolamide is oleoylethanolamide (OEA). A preferred example of a peptidic active compound is the protein bovine serum albumin (BSA). Carbohydrates are preferably selected from glucose and sucralose, with glucose being most preferred. In a particular preferred embodiment of the invention, at least one of the first and second pharmaceutical dosage forms contains about 1 % (w/w) to about 80 % (w/w), more preferably 60 to 70 % (w/w) of active compound triggering the EECs, preferably a carbohydrate, most preferred glucose.

In a preferred embodiment, at least one of the first and second pharmaceutical oral dosage forms contains as an active compound an anthocyanin, more preferably one or more anthocyanins from Vaccinium myrtilloides Michx. A particularly preferred anthocyanin to be included in the core of one or both of the at least first and second pharmaceutical oral dosage forms of the invention is delphinidin 3-rutinoside.

In preferred embodiments of the invention, one or more of the above active compounds triggering enterokine release by EECs are combined in preferably synergistic combinations.

It is to be understood that each of the at least first and second pharmaceutical oral dosage forms can comprise one or more active compounds. In further preferred embodiments, active compounds are combined wherein one of the at least first and second pharmaceutical oral dosage forms contains an active compound as disclosed herein that is different from the active compound contained in the other (or others) of the at least first and second pharmaceutical oral dosage forms.

In a preferred embodiment one of said first and second oral dosage forms contains a carbohydrate and the other one of said first and second oral dosage forms contains at least one compound selected from fatty acids having 2 to 6 carbon atoms, oleic acid, bile acids, alcohol amides, peptides, amino acids and anthocyanins.

According to another preferred embodiment, one of said first and second oral dosage forms contains a fatty acid having 2 to 6 carbon atoms and the other one of said first and second oral dosage forms contains at least one compound selected from carbohydrates, oleic acid, bile acids, alcohol amides, peptides, amino acids and anthocyanins.

In a further preferred combination of active compounds, one of said first and second oral dosage forms contains oleic acid and the other one of said first and second oral dosage forms contains at least one compound selected from carbohydrates, fatty acids having 2 to 6 carbon atoms, bile acids, alcohol amides, peptides, amino acids and anthocyanins.

Still a further preferred combination is provided wherein one of said first and second oral dosage forms contains a fatty acid having 2 to 6 carbon atoms and the other one of said first and second oral dosage forms contains at least one compound selected from carbohydrates, fatty acids having 2 to 6 carbon atoms, oleic acid, bile acids, alcohol amides, peptides, amino acids and anthocyanins.

Another preferred embodiment is a combination of active compounds wherein one of said first and second oral dosage forms contains a peptide and the other one of said first and second oral dosage forms contains at least one compound selected from carbohydrates, fatty acids having 2 to 6 carbon atoms, oleic acid, bile acids, amino acids and anthocyanins.

A further preferred type of combination is provided wherein one of said first and second oral dosage forms contains an amino acid and the other one of said first and second oral dosage forms contains at least one compound selected from carbohydrates, fatty acids having 2 to 6 carbon atoms, oleic acid, bile acids, alcohol amides, peptides, and anthocyanins.

Yet in other preferred embodiments of the invention one of said first and second oral dosage forms contains an anthocyanin and the other one of said first and second oral dosage forms contains at least one compound selected from carbohydrates, fatty acids having 2 to 6 carbon atoms, oleic acid, bile acids, alcohol amides, peptides and amino acids.

Preferred examples of active compounds for use as combinations according to the present invention have already elaborated above.

The combinatorial approach using two or more pharmaceutical oral dosage forms as described herein with respect to different active compounds is illustrated in Fig. 6.

The differential targeting of EECs through the inventive combination of pharmaceutical oral dosage forms can be effected in various ways.

According to one preferred embodiment, the differential targeting of EECs is effected by different sizes of the at least first and second pharmaceutical dosage forms which lead to different travelling times through the small intestine. In a preferred embodiment of the invention, one of said first and second pharmaceutical oral dosage forms has a size of 3 mm or more, based on the largest dimension of said oral dosage form, and wherein the other of said first and second pharmaceutical dosage forms has a size of less than 3 mm, based on the largest dimension of said other oral dosage form.

This embodiment is illustrated in Fig. 4 and Fig. 5.

As shown in Fig 4, larger oral dosage forms (e.g. tablets, capsules) having a largest dimension of 3 mm or more (upper encircled area in the middle diagram) behave like solid food as regards the rate of gastric emptying. Such larger oral dosage forms show a lag phase after ingestion, slow gastric emptying, they travel slow through the small intestine, and are fractionated into separate boli (in the case of multiple tablets or capsules and the like, fractionation of the overall orally administered dose) through periodic pyloric sphincter opening. On the contrary, small oral dosage forms of less than 3 mm in their largest dimension behave like fluids (lower encircled area in the middle diagram). They show no lag phase in gastric emptying which follows instantaneously after ingestion. Consequently, such small oral dosage forms travel much faster through the small intestine as compared to dosage forms having 3 mm or more in their largest dimension, and exhibit only a limited fractionation of the overall dose administered.

As shown in Fig. 5, the consequence of the differential behaviour of small (less than 3 mm in their largest dimension) and larger pharmaceutical oral dosage form (3 or more mm in their largest dimension) is that the larger oral dosage form can be targeted to the, preferably distal (= terminal), jejunum of the subject, particular embodiments through selection of the enteric coating providing a substantial dissolution and/or degradation of the pH sensitive polymer, preferably in the range of pH about 5.5 to about 7.8, more preferably about pH 5.5 to about 7.5, even more preferred about pH 7.2 to about pH 7.3. Due to its much faster travelling of the smaller dosage form it will be targeted to the more distal part of the small intestine, in particular to the ileum, more preferably the distal (= terminal) ileum, thus releasing its core contents in that area of the small intestine.

A typical range for larger pharmaceutical oral dosage forms for use in the invention are dosage forms having a largest dimension of about 3 to about 10 mm. It is to be understood that this range includes all integers of mm, namely, 3, 4, 5, 6, 7, 8, 9 and 10 mm as well as any sub-proportions thereof. Preferred small pharmaceutical oral dosage forms for use in the invention are dosage forms having a largest dimension of about 0.6 mm to about 1.7 mm in the largest dimension.

In other preferred embodiments of the invention said at least first pharmaceutical oral dosage form and said second pharmaceutical oral dosage form both have an enteric coating of a pH sensitive polymer dissolving at a pH value of from about 5.5 to 7.8, preferably about 5.5 to 7.5, more preferably about 7.2 to about 7.3, and wherein the thickness of the enteric coating of the first and the second dosage form is selected such that the coating of one of said first and second dosage forms is substantially degraded and/or dissolved in the jejunum, preferably terminal (=distal) jejunum, and preferably the proximal ileum of the subject, and such that the coating of the other of said first and second dosage forms is substantially degraded and/or dissolved in the ileum, preferably the terminal (= distal) ileum of the subject.

According to a further preferred embodiment of the invention, the differential targeting of the at least first and second pharmaceutical oral dosage forms is attained by providing one of the at least first and second dosage forms with an enteric coating comprising a pH sensitive polymer being selected such that the coating substantially dissolves and/or is substantially degraded in the jejunum, preferably the terminal jejunum, of a subject, and wherein the other of said first and second dosage forms has an enteric coating comprising a pH sensitive polymer being selected such that the coating substantially dissolves and/or is substantially degraded in the ileum, preferably the terminal ileum, of a subject. In preferred embodiments of this aspect, the pH-sensitive polymer for the oral dosage targeted to the jejunum, preferably the terminal jejunum, substantially dissolves and/or degrades at a pH of from about 6.8 to about 7.4, preferably at a pH of from about 7.0 to about 7.3, more preferred at a pH of from about 7.2 to 7.3, whereas the pH sensitive polymer for the oral dosage form targeted to the ileum substantially dissolves at a pH of about 7.5 or above, preferably at a pH of from about 7.5 to 7.8.

Such pH sensitive polymers are preferably selected from hydroxypropylmethyl celluloses (also called hereinafter“hypromelloses”) and anionic copolymers of methacrylic acid and methacrylmethacrylate. Most preferably, the pH sensitive enteric coating containing or being made of hydroxypropylmethyl cellulose is hydroxypropylmethyl cellulose acetate succinate. A highly preferred commercially available product of this kind is AQOAT®, particularly preferred AQOAT®-HF (Shin-Etsu Chemical Co., Chiyoda, Japan). In other preferred embodiments of the type of anionic copolymers of methacrylic acid and methcrylmethacrylate various forms of Eudragit® polymers may also be used. Eudragit® is commercially available from Evonik Healthcare & Nutrition GmbH, Essen, Germany. In a preferred embodiment, Eudragit® FS30D is used as the pH sensitive polymer of the coating, or at least a part thereof.

In further preferred embodiments of the invention, different coatings can be applied in combination. According to one embodiment, the coating comprises or is made of a combination of a hydroxypropylmethyl cellulose and an anionic copolymer of methacrylic acid and methacrylmethacrylate. Preferably, a combination of coatings is applied such that typically a sub-coating of one pH sensitive polymer is applied as a first layer and a coating of a second pH sensitive polymer is applied on the sub-coating as a second layer. For example, the pH sensitive coating can comprise a sub-coating of or comprising, respectively, a hydroxypropylmethyl cellulose as a first layer, and a second coating comprising or being made of an anionic copolymer of methacrylic acid and methacrylmethacrylate provided as a second layer on the sub-coating. In a further preferred embodiment, the coating of the pharmaceutical oral dosage form of the invention comprises a coating comprising a first layer (sub-coating) comprising or being made of an anionic polymer of methacrylic acid and methacrylmethacrylate such as an Eudragit®, more preferably Eudragit® FS30D, and a second layer comprising or being made of a hydroxypropylmethyl cellulose such as

AQOAT®, more preferably AQOAT®-HF. More preferably, the anionic copolymer of methacrylic acid and methacrylmethacrylate, e.g. an Eudragit®, preferably Eurdragit®

FS30D, is present in less amount than the hydroxypropylmethyl cellulose such as AQOAT®, more preferably AQOAT®^HF. In other words, the thickness of the first layer of this type of combination is lower then the thickness of the second layer in this combination. More specifically, the ratio of amount or thickness, respectively, between first layer and second layer typically ranges from about 1 :10 to about 1 :50, particularly preferred from about 1 :20 to about 1 :30.

The active compound(s) in the core part of the pharmaceutical oral dosage forms (at least in one of the at least first and second pharmaceutical oral dosage forms) are preferably further combined with active ingredients having various functions.

Preferred examples of additional active ingredients are EEC maturation agents. As exemplified before with L cells such maturation agents typically enhance the release capacity of the EECs, such as L cells, for the relevant enterokine, in the case of L cells GLP-1 and/or PYY and/or GLP-2. Preferred EEC maturation agents, in particular L cell maturation agents, include human milk oligosaccharides (HMO) and inhibitors of NOTCH signalling such as y- secretase inhibitors, preferably dibenzazepine. Various HMOs are commercially available (Jennewein Biotechnologie GmbH, Rheinbreitbach, Germany) and preferred HMOs in the context of the invention include, but are not limited t, e.g. 2’-fucosyllactose, 3-fucosyllactose, 6’-sialyllactose and lacto-N-neotetraose as well as mixtures thereof.

The pharmaceutical oral dosage forms for use in the invention are designed to burst release the active ingredient(s) at the targeted area of the small intestine of a subject, preferably the duodenum, jejunum and/or ileum, more preferably the jejunum (particularly preferred the terminal jejunum) and/or the ileum (more preferably the terminal ileum), of the, preferably human, subject. For effecting burst release of the core ingredients of the pharmaceutical dosage forms, the core contains a disintegrant. Disintegrants for use in the present invention are generally known in the art as rapidly expanding and dissolving when coming into contact with the targeted environment, typically, an aqueous environment as in the present invention, namely, the small intestine of a subject, preferably a human. Disintegrants lead to rapid breakdown of the core of the pharmaceutical oral dosage forms for use in the invention when the core comes into contact of the aqueous medium present in the subject’s small intestine. Preferably, the disintegrant in the pharmaceutical dosage forms for use in the the invention is selected such that more than 70 % of the core is released within two minutes or less or more than 85 % of the core is released within 5 minutes or less, following contact with water or an aqueous medium like the small intestine of a human subject. A typical time line of a burst release of a pharmaceutical dosage form of the invention is depicted in Fig. 7. Preferred disintegrants in the context of the invention are crosslinked polyvinylpyrrolidones, crosslinked carboxymethyl celluloses and modified starchs. Particularly preferred crosslinked

polyvinylpyrrolidones for use in the invention include Polyplasdones, in particular

Polyplasdone XL, Polyplasdone XL-10 and Polyplasdone INF-10 (commercially available from Ashland Inc., Covington, KY, USA). Other useful disintegrants include, but are not limited to, polyvinylpolypyrrolidone, croscarmellose and carboxymethylcellulose (preferably, the sodium salt thereof).

The burst release of the core’s ingredients, in particular the active compound(s) such as glucose, establishes a steep gradient between intracellular and extracellular levels of the respective active compound(s), preferably glucose, sucralose, ethanolamides, BSA and/or an anthocyanine such as delphinidin 3-rutinoside, in the targeted EEC, preferably L cells, at the site of release of the core ingredients.

Compared to previous technologies, in particular WO 2010/027498 A2 and WO 2012/118712 A2, the burst release of the active ingredient(s) from the pharmaceutical oral dosage forms of the invention in the different targeted areas of the small intestine a subject provides an improved triggering of EECs, in particular L cells, since the compound(s) sensed by the EECs can access the target cells, preferably L cells, over the whole small intestine such that more enterokines, in particular GLP-1 and PYY, are produced and released by the EECs (see also Fig. 2 and its further description herein below). In turn, far less amount of active ingredient(s) such as glucose is needed to be administered to the subject with the aid of the invention as compared to prior art formulations (e.g., 10 g of glucose must be administered to a patient according to WO 2012/118712 A2; cf. Example 1 on page 43 of WO 2012/118712 A2).

For controlling and monitoring the appropriate release and also the spreading of the ingredients of the cores of the pharmaceutical oral dosage forms for use in the invention in the intestinal tract of the subject, preferably a human, it is convenient to include a tracer substance in the core part of at least one of the pharmaceutical dosage forms. A preferred tracer substance is caffeine. One example of a preferred combination of active compound and tracer substance is glucose and caffeine, preferably, about 60 to about 70 % (w/w) glucose and about 2 to about 4 % (w/w) caffeine, most preferred about 67 % (w/w) glucose and about 3.2 % (w/w) caffeine, based on the total weight of the core. The release of the tracer substance from the pharmaceutical oral dosage form in the small intestine can be conveniently monitored by analytical methods generally known in the art. In the case of caffeine, blood samples are taken from the subject before and at suitable time intervals after oral administration of the oral dosage form. After centrifugation of the blood sample, the caffeine content in the serum fraction of the sample is measured by ELISA testing using commercially available test kits (e.g. Caffeine ELISA Kit, BioVision Inc., Milpitas, CA, USA) according to the manufacturer’s instructions.

In addition to the above components the pharmaceutical oral dosage forms for use in the invention may contain further ingredients typically present in oral dosage forms such as tablets, capsules, granules and pellets, for providing and/or improving various parameters. Typical additional ingredients for use in the present invention include excipients, carriers, fillers, glidants, dispersants, plasticizers, wetting agents, anti-tacking agents, neutralization agents and the like. The person skilled in the art of formulating pharmaceutical oral dosage forms is readily able to identify specific compounds and substances of the above and other types as well as their combinations and amounts to be used. Further guidance can be found in Remington's Pharmaceutical Sciences, 18th Ed. Mack Printing Company, 1990, in particular pages 1289-1329. The present invention further relates to a pharmaceutical package comprising at least a first pharmaceutical oral dosage form and a second oral dosage form wherein said first and second oral dosage forms are as defined as described above-

A further embodiment of the invention is a method for the prevention and/or treatment of a condition or disease selected from the group consisting of insulin resistance, type 2 diabetes, non-alcoholic fatty liver disease, non-alcoholic steatohepatosis, microvascular dysfunction, metabolic syndrome, obesity, osteoporosis, neurodegenerative diseases, cardiovascular diseases, malabsorption conditions and conditions of impaired gastro-intestinal function in a subject comprising the step of orally administering an effective amount of at least a first and a second pharmaceutical oral dosage form to the subject in need thereof wherein said at least first and second pharmaceutical oral dosage forms are as defined and described above.

The therapeutic and preventive, respectively aspect of the invention relating to impaired gastro-intestinal function is based on the known proliferative and antiapoptotic effect of enterokines as described herein, specifically GLP-1 and GLP-2, on cells of the gastro intestinal tract, especially of the gastro-intestinal mucosa (see, for example, Sigalet (2012) J. Anim. Sci. 90, 1224-1232; Aw et al. (2017) Asia-Pac. J. Clin. Oncol. 14, 23-31 ; and Kissow et al. (2012) Cancer Chemother. Pharmacol. 70, 39-48). By administration of the

pharmaceutical oral dosage forms of the invention it is possible not only to prevent and/treat malabsorption disorders in affected subjects, but also to treat subjects, in particular human subjects, suffering from disorders, diseases and/or conditions of impaired gastro-intestinal function due to irregular gastro-intestinal growth (including reduced intestinal length and impaired/reduced formation of intestinal mucosa and villi, especially, and preferably, in neonatal and infant children, and/or due to disorders of the intestinal mucosa such as mucositis, preferably resulting from chemotherapy, radiotherapy and/or infections, especially in tumour and/or cancer patients. This treatment aspect of the invention also comprises the prevention of the above gastro-intestinal disorders and diseases.

In general, the at least first and second oral dosage forms can be administered sequentially or simultaneously. Simultaneous administration is preferred.

In general, the combined administration of the pharmaceutical oral dosage forms as described and defined herein leads to a substantial increase of the addressed at least one enterokine, preferably GLP-1 , GLP-2, GIP, PYY, CCK and/or neurotensin, particularly preferred GLP-1 and/or GLP-2 and/or PYY, above the respective base-line level of the enterokine, in particular the level of the enterokine in the blood serum/plasma of the subject being treated. In preferred embodiments of the invention, the level of the respective enterokine in the subject’s blood serum/plasma increases by at least about 50 % or more, preferably about 50 % to about 200 % or even more such as about 300 %, as compared to the level in the blood plasma/serum of the subject before administration of the

pharmaceutical oral dosage form of the invention. The increase in enterokine concentration in the subject’s blood plasma/serum typically occurs within about 3 to about 6 hours post administration, preferably simultaneous administration, of the combination of pharmaceutical oral dosage forms as described herein.

According to the invention, the term“effective amount of the pharmaceutical oral dosage form(s)” depends on various factors such as the specific condition, disorder or disease to be treated and/or prevented, the age and sex of the subject as well as the general condition of the subject. Furthermore, the“effective amount of the pharmaceutical oral dosage form(s)” depends on the type of active compound(s) used. Typically, however, pharmaceutical oral dosage forms used in the invention are preferably administered once daily in one or more unit dosages, more preferably in the fasted state of the subject, particularly preferred at least about 30 min, more preferred at least about 45 min, even more preferred at least 1 hour before the first meal of the day. With glucose as a preferred active compound, the effective amount is preferably a daily dose of about 0.5 to about 6 g glucose orally administered in one or more unit dosages in the fasted state of the subject as outlined before. A dose of about 1 to about 5.5 g once daily is more preferred, and about 5 g glucose once daily may be given as a particularly preferred regimen. A typical unit dosage of glucose within a pharmaceutical oral dosage form as described herein is about 0.5 g to about 2 g, more preferably about 0.75 to about 1.5 g glucose such as ca. 1 g glucose per unit dosage.

As regards the pharmaceutical oral dosage form, its use and treatment method of the invention as described above, it is of particular benefit when the dosage form is formulated such that the at least one compound stimulating enteroendocrine cells to release an enterokine stimulates said cells present in the intestine of the subject from the jejunum to the ileo-cecal valve of the, preferably human, subject.

The figures show:

Fig. 1 : illustrates GLP-1 and PYY release by L cells along the small intestine. The left panel is a schematic representation of the gastro-intestinal tract of a human. The human’s small intestine comprises, from gastric side to colon side, the three parts duodenum, jejunum and ileum. L cells are present in the human small intestine from duodenum to ileum with the concentration and maturation of L cells increasing from proximal to distal small intestine. The highest concentration of L cells is found in the terminal (i.e. distal) ileum. Panels on the right show the time dependency of GLP-1 and PYY, respectively, output of L cells in the jejunum (upper right panel) and in the ileum (lower right panel). Upon stimulation by nutrients, here exemplified by glucose, L cells release the enterokines GLP-1 and PYY, whereby GLP-1 is released from L cells throughout the small intestine (i.e. duodenum, jejunum and ileum), however, substantial release of GLP-1 starts in the jejunum and increases from proximal to distal small intestine with peak release in the terminal ileum. On the contrary, PYY release is much lower in the jejunum and increases strongly only in the ileum where GLP-1 and PYY are co-released to substantially equal extend.

Fig. 2: shows a schematic representation of a cross-section of a villus in the mucosa of the small intestine of a human subject. GLP-1 is released from L cells in the crypts and on the villi. However, the GLP-1 release capacity per L cells increases with the maturation state of the L cell, i.e. it is highest when the L cells reach the top of the villi. Contrary to GLP-1 , L cells start to synthesize PYY only at a higher maturation state. The maturation of L cells can be accelerated by substances such as human milk oligosaccharides (HMO) and a variety of pathway inhibitors (e.g. NOTCH signalling inhibitors). Thus, combining L cell maturation enhancing substances with a nutrient like glucose or other active compound (such as anthocyanin) in the at least one of the combined oral dosage forms leads to a synergistic increase of GLP-1 and PYY by L cells.

Fig. 3: is a schematic representation showing the various molecular mechanisms by which a stimulus to an L cell is translated in the cell to a release of enterokines GLP-1 and PYY.

Thus, GLP-1 and PYY are released in response to stimuli that activate glucose transporters (GLUT2, SGLT1) and G protein-coupled receptors such as taste receptors, fatty acid receptors, amino acid receptors and bile acid receptors. The signals generated by the glucose transporters or G-protein-coupled receptors are transmitted by three main mechanisms: transmembrane calcium influx, intracellular calcium release and intracellular cAMP release. Hence, signalling events in L cells can be separated into three segments: (i) glucose transporter (GLUT2 and SGTL1) levels and levels of G protein-coupled receptors; (ii) the intracellular signalling pathway level (calcium and cAMP-dependent pathways); and (iii) the amount of fusion events of vesicles with the plasma membrane to release their content (release level). Through these mechanisms the nature of the released enterokine does not depend on the stimulus or signalling pathways involved but exclusively on (a) the location of the L cell in the small intestine (duodenum, jejunum or ileum) and (b) on the maturation state of the L cell (corresponding to its position in the crypts or on the villi of the mucosa).

Fig. 4: illustrates the impact of the dimensions of pharmaceutical dosage forms on their behaviour in the gastrointestinal tract: larger oral dosage forms (e.g. tablets, capsules) having a largest dimension of 3 mm or more (upper encircled area in the middle diagram) behave like solid food as regards the rate of gastric emptying. Such larger oral dosage forms show a lag phase after ingestion, slow gastric emptying, they travel slow through the small intestine, and are fractionated into separate boli (in the case of multiple tablets or capsules and the like, fractionation of the overall orally administered dose) through periodic pyloric sphincter opening. On the contrary, small oral dosage forms of less than 3 mm in their largest dimension behave like fluids (lower encircled area in the middle diagram). They show no lag phase in gastric emptying which follows instantaneously after ingestion.

Consequently, such small oral dosage forms travel much faster through the small intestine as compared to dosage forms having 3 mm or more in their largest dimension, and exhibit only a limited fractionation of the overall dose administered.

Fig. 5: illustrates the consequence of the differential behaviour of small (less than 3 mm in their largest dimension) and larger pharmaceutical oral dosage form (3 or more mm in their largest dimension): the larger oral dosage form can be targeted to the, preferably distal (= terminal), jejunum of the subject, particular embodiments through selection of the enteric coating providing a substantial dissolution and/or degradation of the pH sensitive polymer, preferably in the range of pH about 5.5. to about 7.5, more preferably about pH 7.2 to about pH 7.3. Due to its much faster travelling of the smaller dosage form it will be targeted to the more distal part of the small intestine, in particular to the ileum, more preferably the distal (= terminal) ileum, thus releasing its core contents in that area of the small intestine. The differential targeting of the combination of small and larger oral dosage forms leads to an optimisation of the release of entorkines by the targeted EECs, in the present example GLP- 1 and PYY released by L cells.

Fig. 6: illustrates the combinatorial approach of the invention using different pharmaceutical oral dosage forms with different active compounds (here three oral dosage forms with three different active compounds A, B and C).

Fig. 7: shows a graphic representation depicting the data of online UV/VIS

spectrophotometric measurement of caffeine released from the core of a pharmaceutical oral dosage form of the invention in an aqueous buffer as indicated over time. The data show a burst release of the core components: almost 70 % of the core contents are released into the buffer solution within less than 2 min, and more than 85 % are released within 5 min.

Fig. 8: shows graphical representations of experimental data obtained from GLUTag cells (as a cell culture model of human L cells, especially in terms of their stimulation properties to secrete enterokines; cf; Kuhre et al. (2016) J. Mol. Endocrinol. 56 (3), 201-21 1 ) stimulated by the indicated active compounds at the indicated concentrations (depolarization and the mixture of Forskolin (3R,4aR,5S,6S,6aS, 10S,10aR, 10bS)-dodecahydro-5,6,10,10b- tetrahydroxy-3,4a,7,7, 10a-pentamethyl-1 -oxo-3-vinyl-1 H-naphtho[2, 1 -b]pyran-5-yl acetat)/BMK (the venom of scorpion Buthus martensii Karsch) were used as positive controls). GLP-1 release was measured in the stimulation medium supernatant. (A) Data of GLP-1 release are expressed as fold increase in comparison to negative control (stimulation medium supernatant of cells without treatment by any stimulus) (B) Data of GLP-1 release are expressed as GLP-1 concentration in the stimulation medium supernatant with signal of negative control (stimulation medium supernatant of cells without treatment by any stimulus) subtracted. Numbers in brackets above the columns indicate the number of independent experiment for each stimulant or control, respectively.

Fig. 9: shows graphical representations of dose response data of GLUTag cells stimulated with glucose (Fig. 9A), ethanolamide (Fig. 9B) or delphinidin 3-rutinoside (Fig. 9C) at the indicated concentrations.

Fig. 10 shows a graphical representation of experimental data obtained from GLUTag cells (as a cell culture model of L cells) stimulated by BSA at 0.5 % (w/v). GLP-1 concentration was measured in the stimulation medium supernatant. The phosphodiesterase inhibitor 3- isobutyl-1 -methylxanthine (IBMX) was used as positive control. Negative control was stimulation medium supernatant only.

The following non-limiting examples further illustrate the present invention.

EXAMPLES

Example 1 : Burst release tablet core

A core for a pharmaceutical oral dosage form for use in the invention has been developed to provide a burst release kinetic of disintegration in tap water or aqueous buffer of less than 2 min. Glucose has been selected as an example of the active compound. A glucose gentle direct compression process was used employing specific functional excipients to enable a good followability as well as processability and tablet properties on the one hand side and a fast disintegration and dissolution behaviour of glucose on the other hand. More specifically, the following excipients were selected:

- Silicified microcrystalline cellulose (Prosolv SMCC 90) has been selected and

utilized as a binder..

- Crossinked povidone - Crospovidone (Polyplasdone XL-10) has been

selected as super-disintegrant to provide a burst release kinetic.

- Magnesium stearate and colloidal silicon dioxide (Aerosil 200) have been

selected as lubricant and glidant agents, respectively.

The final composition of the tablet core is given in Table 1

Tab. 1. Composition of the glucose tablet core

The prepared oral dosage form showed the following general characteristics:

Weight: 1.67 +/- 1.2 %

Height: 8.3 mm +/- 0.4 %

Breaking strength: 245 N +/- 7 %

Disintegration: < 30 s

The burst release of the tablet core in aqueous buffer (500 ml 0.05 M phosphate buffer, pH 7.3 at 37 °C) was measured by online UV/VIS spectrophotometry of the caffeine as internal standard. The results of two independent experiments are shown in Fig. 7. The results show a fast dissolution of about > 85 % release of the internal standard within 5 min. Example 2: Hypromellose acetate succinate-coated tablet

The tablet core of Example 1 was coated with AQOAT®-HF to provide an enteric coating and drug please at a specific pH value of >6.8, specifically at pH 7.3. In more detail, the tablet core of Example 1 was spray-coated using the following coating composition:

Tab. 2:AQOAT® coating composition

The above coating was applied on the tablet core of Example 1 by using a LCH 25 Lodige lab-coater (Gebruder Lodige Maschinenbau GmbH, Paderborn, Germany).

Example 3: Eudragit®-coated tablet

In an alternative embodiment, the tablet core of Example 1 was coated with Eudragit® FS30D to provide an enteric coating and drug release at a pH value of >7.0, specifically at pH 7.3. In more detail, the tablet core of Example 1 was spray-coated using the following coating composition:

Tab. 3: Eudragit® coating composition

Example 4: GLP-1 release of GLUTag cells in response to different active compounds Murine GLUTag cells (ATCC, Manassas, VA, USA) of 80 % confluency were split from a T25 into 6 wells of a 12-well plate. On day 1 , the resulting cells were 40-50% confluent and on day 2 the cells were 50-60% confluent. The cells were mostly single cells or very small aggregates; with no large aggregates observable.

Cells were gently washed 2 times with warm PBS (supplemented with calcium; D8662).

Then, 300 pi of stimulation medium, either non-supplemented PBS as negative control or PBS supplemented with 10mM FSK/IBMX (positive control), 10 mM glucose, 50 mM sucralose, 10 mM delphinidin 3-rutinoside or 100 mM oleoylethanolamide, were added to the cells. The cells were then incubated for 2 hours at 37°C.

The 300 mI of stimulation medium were removed from the well and centrifuged for 5 minutes. 200 mI of the supernatant were transferred to a fresh test tube and the samples were stored at -80°C until subjected to GLP-1 measurement. The cells were discarded.

GLP-1 in the supernatant was measured using a commercially available ELISA (Mouse GLP- 1 Elisa Kit, Chrystal Chem (Europe), Zaandam, The Netherlands) according to the manufacturer’s instructions.

The results of this experiment are shown in Fig. 8 (A: data expressed as fold increase of measured GLP-1 concentration in the sample over negative control; B: data expressed as GLP-1 concentration in the supernatant after subtraction of signal measured in negative control).

In a further experiment, dose-response data of the stimulants glucose (at concentrations of 0,01 mM, 0,1 mM, 1 mM and 10 mM), oleoylethanolamide (at concentrations of 1 mM, 10 mM and 100 mM) and delphinidin 3-rutinoside (at concentrations of 10 mM, 50 mM, 100 mM and 500 mM) were measured as described above. The results are shown in Fig. 9A (glucose), 9B (ethanolamide) and 9C (delphinidin 3-rutinoside), respectively.

In another experiment, BSA (at a concentration of 0.5 % (w/v)) was used as a peptidic stimulant of GLP-1 release by GLUTag cells. Again, stimulation medium alone (PBS) was used as negative control, and IBMX served as the positive control. The results are shown in Fig. 10.

Claims

1. A combination of at least two pharmaceutical oral dosage forms for use in the

prevention and/or treatment of a condition or disease selected from the group consisting of insulin resistance, type 2 diabetes, non-alcoholic fatty liver disease, non alcoholic steatohepatosis, microvascular dysfunction, metabolic syndrome, obesity, osteoporosis, neurodegenerative diseases, cardiovascular diseases, malabsorption conditions and conditions of impaired gastro-intestinal function in a subject wherein the combination comprises at least a first and a second dosage form each comprising a core and a pH-sensitive enteric coating, wherein each core comprises at least one compound stimulating enteroendocrine cells to release at least one enterokine, and at least one disintegrant providing a burst release of the ingredients of the core when the coating is substantially degraded and/or dissolved, and wherein each coating comprises a pH sensitive polymer being selected such that the coating substantially dissolves and/or is substantially degraded in a selected part of the small intestine of a subject, wherein said first and second dosage form are formulated such that said first dosage form releases the at least one compound stimulating enteroendocrine cells to release at least one enterokine in a different part of the small intestine of the subject than the second dosage form and/or the first and second dosage form are formulated such that said first dosage form show a travelling time through the small intestine of the subject being different from the travelling time of the second dosage form through the small intestine of the subject;

2. The combination for use of claim 1 wherein one of said first oral dosage form has a size of 3 mm or more, based on the largest dimension of said dosage form, and wherein the other of said first and second oral dosage forms has a size of less than 3 mm, based on the largest dimension of said other oral dosage form.

3 The combination for use of claim 1 or 2 wherein said first dosage form and said

second dosage form both have an enteric coating of a pH sensitive polymer dissolving at a pH value of from about 5.5 to 7.8 preferably about 7.2 to about 7.3, and wherein the thickness of the enteric coating of one of said first and second dosage form is selected such that the coating of said dosage form is substantially degraded and/or dissolved in the jejunum, preferably the terminal jejunum, and proximal ileum of the subject, and such that the coating of the other of said first and second oral dosage forms is substantially degraded and/or dissolved in the terminal ileum of the subject.

4. The combination for use of claim 1 or 2 wherein one of said first and second oral dosage forms has an enteric coating comprising a pH sensitive polymer being selected such that the coating substantially dissolves and/or is substantially degraded in the jejunum, preferably the terminal jejunum, of a subject, and wherein the other of said first and second oral dosage forms has an enteric coating comprising a pH sensitive polymer being selected such that the coating substantially dissolves and/or is substantially degraded in the ileum, preferably the terminal ileum, of a subject.

5. The combination for use according to any one of the preceding claims wherein said first and second dosage form contain different compound(s) stimulating

enteroendocrine cells to release at least one enterokine.

6. The combination for use according to any one of the preceding claims wherein said compound(s) stimulating enteroendocrine cells to release at least one enterokine are selected from the group consisting of carbohydrates, fatty acids, bile acids, peptides, amino acids, alcohol amides, and anthocyanins.

7. The combination for use of claim 5 or 6 wherein one of said first and second oral dosage forms contains a carbohydrate and the other one of said first and second oral dosage forms contains at least one compound selected from fatty acids having 2 to 6 carbon atoms, oleic acid, bile acids, alcohol amides, peptides, amino acids and anthocyanins.

8. The combination for use of claim 5 or 6 wherein one of said first and second oral dosage forms contains a fatty acid having 2 to 6 carbon atoms and the other one of said first and second oral dosage forms contains at least one compound selected from carbohydrates, oleic acid, bile acids, alcohol amides, peptides, amino acids and anthocyanins.

9 The combination for use of claim 5 or 6 wherein one of said first and second oral dosage forms contains oleic acid and the other one of said first and second oral dosage forms contains at least one compound selected from carbohydrates, fatty acids having 2 to 6 carbon atoms, bile acids, alcohol amides, peptides, amino acids and anthocyanins.

10. The combination for use of claim 5 or 6 wherein one of said first and second oral dosage forms contains a fatty acid having 2 to 6 carbon atoms and the other one of said first and second oral dosage forms contains at least one compound selected from carbohydrates, fatty acids having 2 to 6 carbon atoms, oleic acid, bile acids, alcohol amides, peptides, amino acids and anthocyanins.

11. The combination for use of claim 5 or 6 wherein one of said first and second oral dosage forms contains a peptide and the other one of said first and second oral dosage forms contains at least one compound selected from carbohydrates, fatty acids having 2 to 6 carbon atoms, oleic acid, bile acids, amino acids and

anthocyanins.

12. The combination for use of claim 5 or 6 wherein one of said first and second oral dosage forms contains an amino acid and the other one of said first and second oral dosage forms contains at least one compound selected from carbohydrates, fatty acids having 2 to 6 carbon atoms, oleic acid, bile acids, alcohol amides, peptides, and anthocyanins.

13. The combination for use of claim 5 or 6 wherein one of said first and second oral dosage forms contains an anthocyanin and the other one of said first and second oral dosage forms contains at least one compound selected from carbohydrates, fatty acids having 2 to 6 carbon atoms, oleic acid, bile acids, alcohol amides, peptides and amino acids.

14. The combination for use according to any one of claims 6 to 13 wherein the

carbohydrate is selected from the group consisting of glucose and sucralose.

15. The combination for use according to any one of claims 6 to 14 wherein the peptide is selected from the group consisting of oligopeptides, polypeptides and proteins.

16. The combination for use of claim 15 wherein the protein is BSA.

17. The combination for use according to any one of claims 6 to 16 wherein the alcohol amide is an ethanolamide.

18. The combination for use of claim 17 wherein the ethanolamide is oleoylethanolamide.

19. The combination for use according to any one of claims 6 to 18 wherein the

anthocyanin is selected from anthocyanins of Vaccinium myrtilloides Michx.

20. The combination for use of claim 19 wherein the anthocyanine is delphinidin 3- rutinoside.

21. The combination for use according to any one of the preceding claims wherein the combination comprises more than two pharmaceutical oral dosage forms.

22. The combination for use according to any one of the preceding claims wherein the enteroendocrine cells are selected from the group consisting of I cells, K cells and L cells.

23. The combination for use according to any one of the preceding claims wherein the core of at least one of said at least fist and second pharmaceutical oral dosage forms further contains an enteroendocrine cell maturation agent.

24. The combination for use of claim 23 wherein the maturation agent is a human milk oligosaccharide (HMO).

25 The combination for use according to any one of the preceding claims wherein at least one, preferably both, of the pH sensitive polymers of the at least first and second pharmaceutical oral dosage forms substantially degrades and/or dissolves at a pH value of about 5.5 to about 7.8, preferably about 5.5 to about 7.5, more preferably about 7.2 to about 7.3.

26. The combination for use according to any one of the preceding claims wherein at least one, preferably both, of the pH sensitive polymers of the at least first and second pharmaceutical oral dosage is selected from the group consisting of hydroxypropylmethyl celluloses and anionic copolymers of methacrylic acid and methacrylmethacrylate.

27. The combination for use of claim 26 wherein the hydroxypropyl methyl cellulose is hydroxypropylmethyl cellulose acetate succinate.

28. The combination for use of claim 26 wherein the anionic copolymer of methacrylic acid and methacrylmethacrylate is an Eudragit® polymer.

29. The combination for use according to any one of claims 26 to 28 wherein the coating of at least one, preferably both, of said first and second pharmaceutical oral dosage forms comprises a first and a second layer of a pH sensitive polymer, the second layer being coated onto the first layer.

30. The combination for use of claim 28 wherein the first layer contains or is made of an anionic copolymer of methacrylic acid and methacrylmethacrylate.

31. The combination for use of claim 29 or 30 wherein the second layer contains or is made of hydroxypropylmethyl cellulose.

32. The combination for use according to any one of claims 29 to 31 wherein the ratio of thickness between the first and the second layer is from about 1 :10 to about 1 :50.

33. The combination for use according to any one of the preceding claims wherein the disintegrant of at least one, preferably both, of said first and said second

pharmaceutical oral dosage forms is selected from the group consisting of a crosslinked polyvinylpyrrolidone, a crosslinked carboxymethyl cellulose and a modified starch.

34. The combination for use of claim 33 wherein the crosslinked polyvinylpyrrolidone is Polyplasdone.

35. The combination for use according to any one of the preceding claims wherein the enterokine is selected from the group consisting of GLP-1 , PYY, GLP-2, CCK, GIP and neurotensin, preferably GLP-1 and PYY.

36. The combination for use according to any one of the preceding claims wherein the core of at least one of said first and second pharmaceutical oral dosage forms comprises a tracer substance.

37. The combination for use of claim 37 wherein the tracer substance is caffeine.

38. The combination for use of claim 37 wherein the core of at least one of said first and said second pharmaceutical oral dosage forms contains 60 to 70 % (w/w) glucose and 2 to 4 % (w/w) caffeine, based on the total weight of the core.

39. The combination for use of of claim 38 wherein the core contains 67 % (w/w) glucose and 3.2 % (w/w) caffeine, based on the total weight of the core.

40. The combination for use according to any one of the preceding claims wherein said at least first and second pharmaceutical oral dosage are in the form of a tablet, capsule, pellet or granule.

41. A pharmaceutical package comprising at least a first pharmaceutical oral dosage form and a second pharmaceutical oral dosage form wherein said first and second pharmaceutical oral dosage forms are as defined in any one of the preceding claims.

42. A method for the prevention and/or treatment of a condition or disease selected from the group consisting of insulin resistance, type 2 diabetes, non-alcoholic fatty liver disease, non-alcoholic steatohepatosis, microvascular dysfunction, metabolic syndrome, obesity, osteoporosis, neurodegenerative diseases, cardiovascular diseases, malabsorption conditions and impaired gastro-intestinal function in a subject comprising the step of orally administering an effective amount of at least a first and a second pharmaceutical oral dosage form to the subject in need thereof wherein said at least first and second pharmaceutical oral dosage forms are as defined in any one of claims 1 to 40.