U.S. patent number 6,472,390 [Application Number 09/986,807] was granted by the patent office on 2002-10-29 for use of therapeutic dosages for nitric oxide donors which do not significantly lower blood pressure or pulmonary artery pressure.
This patent grant is currently assigned to Duke University. Invention is credited to Mark W. Dewhirst, Claude A. Piantadosi, Jonathan S. Stamler.
United States Patent |
6,472,390 |
Stamler , et al. |
October 29, 2002 |
Use of therapeutic dosages for nitric oxide donors which do not
significantly lower blood pressure or pulmonary artery pressure
Abstract
Patients with pathologic conditions involving constriction or
proliferation of smooth muscle or disease associated with cysteine
containing proteins, or who are at risk for such, are administered
a therapeutically effective amount of a nitric oxide (NO) donor
which is insufficient to acutely lower mean arterial blood pressure
or pulmonary artery pressure by more than 10%. In one subgenus, NO
donor is administered to modify red blood cell membrane receptors
to prevent red blood cells from causing vasoconstriction. A related
method which allows increased dosage of NO donor without acutely
lowering mean arterial blood pressure comprises administering the
NO donor into an artery of the patient. In another method, patients
having a cardiovascular syndrome, or who are at risk for such, are
administered a therapeutically effective amount of thiol which does
not acutely affect blood pressure to a significant degree.
Inventors: |
Stamler; Jonathan S. (Chapel
Hill, NC), Piantadosi; Claude A. (Durham, NC), Dewhirst;
Mark W. (Durham, NC) |
Assignee: |
Duke University (Durham,
NC)
|
Family
ID: |
25532762 |
Appl.
No.: |
09/986,807 |
Filed: |
November 13, 2001 |
Current U.S.
Class: |
514/236.5;
514/509; 514/535; 514/561; 514/611; 514/742; 514/16.4; 514/17.6;
514/15.1; 514/1.9; 514/15.7 |
Current CPC
Class: |
A61P
1/00 (20180101); A61K 31/223 (20130101); A61K
31/21 (20130101); A61P 21/00 (20180101); A61P
25/22 (20180101); A61P 11/06 (20180101); A61P
25/24 (20180101); A61P 7/06 (20180101); A61P
7/00 (20180101); A61P 9/00 (20180101); A61P
11/00 (20180101); A61K 31/5377 (20130101); A61P
9/10 (20180101); A61P 25/00 (20180101); A61P
9/12 (20180101); A61P 7/02 (20180101) |
Current International
Class: |
A61K
31/223 (20060101); A61K 31/5377 (20060101); A61K
31/21 (20060101); A61K 31/5375 (20060101); A61K
031/535 () |
Field of
Search: |
;514/6,18,509,236.5,535,611,561,742 |
References Cited
[Referenced By]
U.S. Patent Documents
Other References
Bing et al, Biochemical And Biophysical Research Communications,
vol. 275, pp. 350-352, 2000..
|
Primary Examiner: Reamer; James H.
Claims
What is claimed is:
1. A method for prophylaxis or treatment of a patient with a
disease of the vasculature involving constriction or proliferation
of smooth muscle or other pathologic condition involving
constriction or proliferation of smooth muscle, or at risk for
such, except for acute thrombotic complications of restenosis or
platelet embolism or other thromboembolic events, said method
comprising administering to said patient an NO donor that donates
nitric oxide or a related redox species and provides bioactivity
that is identified with nitric oxide and which is capable of
acutely lowering mean arterial blood pressure or pulmonary artery
pressure by more than 10% in a therapeutically effective amount
which is insufficient to acutely lower mean arterial blood pressure
or pulmonary artery pressure by more than 10%, with the proviso
that when the NO donor is ethyl nitrite, it is administered in a
liquid, orally or by infusion.
2. The method of claim 1 where the disease or condition is selected
from the group consisting of acute coronary spasm, angina, and
pulmonary hypertension.
3. The method of claim 1 where the disease or condition is asthmas
or COPD and the dose for the NO donor is insufficient to raise FEV1
by 10% or more.
4. The method of claim 1 where the disease or condition is rectal
spasm and the dose for the NO donor is insufficient to lower
gastrointestinal muscle tone by more than 10%.
5. The method of claim 1 where the disease or condition is
esophageal spasm and the dose for the NO donor is insufficient to
lower esophageal muscle tone by more than 10%.
6. The method of claim 1 where the disease or condition is pyloric
stenosis and the dose for the NO donor is insufficient to dilate
the pyloris by more than 10%.
7. The method of claim 1 where the disease or condition is
stroke.
8. The method of claim 1 wherein the disease or condition is
systemic hypertension.
9. The method of claim 1 where the administration is given
prophylactically to a patient at risk for pathologic condition
involving constriction or proliferation of smooth muscle.
10. A method for prophylaxis or treatment of a patient with a
disease associated with a receptor having a cysteine residue or
other cysteine containing protein that is modified by NO donor to
inhibit its function, or at risk therefor, comprising administering
to said patient an NO donor that donates nitric oxide or a related
redox species and provides bioactivity that is identified with
nitric oxide and which is capable of acutely lowering mean arterial
blood pressure or pulmonary artery pressure by more than 10% in a
therapeutically effective amount which is insufficient to acutely
lower mean arterial blood pressure or pulmonary artery pressure
more than 10%, with the proviso that when the NO donor is ethyl
nitrite, it is administered in a liquid, orally or by infusion.
11. The method of claim 10 where the receptor is a serotonin
receptor.
12. The method of claim 11 where the disease is depression.
13. The method of claim 11 where the disease is stress and/or
anxiety.
14. The method of claim 11 where the disease is
atherosclerosis.
15. The method of claim 10 where the receptor is an adrenergic
receptor.
16. The method of claim 15 where the disease is systemic or
pulmonary hypertension.
17. The method of claim 15 where the disease is coronary artery
disease.
18. The method of claim 10 where the-receptor is a red blood cell
membrane receptor.
19. The method of claim 18 where the NO donor is administered in an
amount to S-nitrosylate membrane receptors in red blood cells.
20. The method of claim 19 where the NO donor administration is to
prevent red blood cells causing vasoconstriction and decrease the
associated risk of heart attack, stroke, pulmonary hypertension and
systemic hypertension.
21. The method of claim 18 where the NO donor is administered to
prophylax against or treat an ischemic disorder, sickle cell
disease or a thalassemia.
22. A method for treating a patient in need of an NO donor and
increased blood pressure comprising administering a therapeutically
effective amount of NO donor directly into an artery of the
patient.
23. A method for the prophylaxis or treatment of a patient with a
cardiovascular syndrome, or at risk therefor, comprising
administering a therapeutically effective amount of a thiol which
is insufficient to acutely lower mean arterial blood pressure or
pulmonary artery pressure more than 10%.
24. The method of claim 1 where the NO donor is an S-nitroso
compound.
25. The method of claim 1 where the NO donor is ethyl nitrite in a
liquid.
26. The method of claim 10 where the NO donor is selected from the
group consisting of S-nitroso compounds, nitroglycerin and
molsidomine.
27. The method of claim 10 where the NO donor comprises ethyl
nitrite in a liquid.
Description
TECHNICAL FIELD
One invention relates to prophylaxis or treatment of pathologic
conditions involving constriction or proliferation of smooth muscle
or of disease associated with cysteine-containing proteins. A
different invention relates to prophylaxis or treatment of a
patient in need of a nitric oxide donor and increased blood
pressure. Still another invention is directed to prophylaxis or
treatment of cardiovascular syndromes.
BACKGROUND OF THE INVENTION
Nitric oxide (NO) donors are known to be useful for therapeutic
utility, e.g., to prevent restenosis following angioplasty (Groves,
P., et al., Cardiovascular Research 26, 615-619 (1992)), to inhibit
platelets to prevent coagulation and thrombus formation (Groves,
P., et al., Circulation 87, 590-597 (1993)) and to treat angina
(Knight, et al., Circulation 95, 125-132 (1997)). NO donors are
considered to have additional therapeutic utility in cancer,
killing microbes and viruses, relaxing airways and intestinal
smooth muscle (e.g., for treating asthma and esophageal spasms), in
promoting erectile function and in treatment of heart failure and
urinary incontinence. The dosages used and considered to be
necessary have, at the very least, the effect of lowering systemic
blood pressure and pulmonary artery pressure, by relaxing of smooth
muscle, a result which has been viewed as a basis for efficacy. In
many cardiovascular syndromes, e.g., myocardial infarction and
heart failure, standard therapy involves maximal non-harmful
lowering of blood pressure as this lowers stress on the heart.
SUMMARY OF THE INVENTION
It has been discovered herein that NO donors, as defined herein,
can block constriction and thus ameliorate (and prophylax against)
pathological constriction of smooth muscle at doses below those
that relax smooth muscle and can desensitize receptors at doses
that have no effect on vascular tone.
One embodiment of an invention herein, denoted the first
embodiment, is directed at a method for prophylaxis or treatment of
a patient with a pathologic condition involving constriction or
proliferation of smooth muscle, e.g., diseases of the vasculature,
or who is at risk for such, except for a patient having acute
thrombotic complications of restenosis or platelet embolism or
other thromboembolic event (e.g., pulmonary embolism or embolic
stroke secondary to endocarditis), said method comprising
administering an NO donor which is capable of acutely lowering mean
arterial blood pressure or pulmonary artery pressure by more than
10% to said patient in a therapeutically effective amount which is
insufficient to acutely lower mean arterial blood pressure or
pulmonary artery pressure by more than 10%, e.g., by more than 5%
(i.e., by amounts that would be otherwise viewed as
non-therapeutic). The exception for acute thrombotic complications
of restenosis is because Langford, E. J., et al., Lancet 344,
1458-460 (1994) describes low dose administration of NO donor in
the setting of putting in a stent and because Kaposzta, Z., et al.,
Circulation 103, 2371-2375 (2001) shows low dose administration of
NO donor decreases platelet embolism and because
S-nitrosoglutathione has been shown previously to inhibit other
thromboembolic events at doses that do not acutely drop blood
pressure reflecting a more potent effect on platelets than on blood
pressure. However, there has been no disclosure previously of use
of NO donors as defined herein, to treat disorders of blood vessels
without acutely dropping blood pressure or directly affecting tone
in these vessels, e.g., for treatment of vasospasms or long term
antiproliferation or antiatherogenic effect or long term
amelioration of systemic hypertension or pulmonary
hypertension.
Another embodiment of the invention herein, denoted the second
embodiment, is directed to a method for prophylaxis or treatment of
a patient with a disease associated with a receptor having a
cysteine residue or other cysteine containing protein that is
modified by NO donor to alter its function, or at risk therefor,
comprising administering an NO donor which is capable of acutely
lowering mean arterial blood pressure or pulnonary artery pressure
by more than 10% to said patient in a therapeutically effective
amount which is insufficient to acutely lower mean arterial blood
pressure or pulmonary artery pressure more than 10%, e.g., by more
than 5%. The term "disease associated with" is used herein to mean
a disease in which over or under activation of the receptor or
other protein is implicated in the disease.
The term "acutely lower mean arterial blood pressure or pulmonary
artery pressure more than 10%, e.g., by more than 5%," is used
herein to mean lowering of mean arterial blood pressure or
pulmonary artery pressure more than 10%, e.g., by more than 5%, by
a single dose of a drug over the period of the half-life of the
drug.
Pulmonary artery pressures are measured in the pulmonary artery
according to a standard method using a Swan-Ganz catheter.
The first and second embodiments are directed to prophylaxis or
treatment. The treatment can involve patients without symptoms in
an inactive state of disease to prevent or delay reoccurrence in
response to an aggravating stimulus. For example, in the cases of
unstable angina or asthma, a patient may be in an inactive status,
but symptoms will recur rapidly in response to aggravating
stimulus. Thus treatment can be of the disease where symptoms have
already been relieved or reduced but sensitivity to aggravating
stimulus persists.
A different invention herein, denoted the third embodiment, is
directed to treating a patient in need of an NO donor and increased
blood pressure, comprising administering a therapeutically
effective amount of NO donor directly into an artery of the patient
(in distinction to other routes of administration).
Still another invention herein, denoted the fourth embodiment, is
directed to a method for the prophylaxis or treatment of a patient
with a cardiovascular syndrome, or at risk therefor, comprising
administering a therapeutically effective amount of thiol which is
insufficient to acutely lower mean arterial blood pressure or
pulmonary artery pressure by more than 10%, e.g., by more than
5%.
Usefulness of the result of not acutely lowering blood pressure in
some cases is supported by Bing, R. J., et al., Biochem. Biophys.
Res. Com. 275, 350-353 (2000).
BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 1 is a tracing of tension (force) versus time with respect to
in vitro testing on a mouse aorta with concentration of added
compounds shown along the tracing and shows results of Example I of
blocking constriction responses to agonists at concentrations of NO
donor which would not significantly lower blood pressure and do not
directly increase the tone of the vessel.
FIG. 2 depicts bar graphs of increase in constricting effect cause
by phenylephrine (10.sup.-6 M) in an in vitro arterial ring
bioassay for control and following exposure to amounts of NO donors
that have no effect on vascular tone directly but which block the
constriction and shows results of Example II.
FIG. 3 depicts a graph of time versus change in pulmonary artery
pressure in an in vivo isolated-perfused rabbit lung test for
control and following pretreatment with NO donors, showing blocking
of constricting effect (because Ppa is shown not to go down on
pretreatment with NO donor) of serotonin at concentrations of NO
donors which have no effect on, i.e., do not lower, pulmonary
pressures or decrease pulmonary vascular tone, and shows results of
Example III.
FIG. 4A is a graph of time versus relative mean arterial blood
pressure and relative heart rate for intravenous infusion of
S-nitrosothiol (S-nitrosohemoglobin) and shows results of Example
IV. The time t=0 is the time at which infusion is started.
FIG. 4B is a graph of time versus relative mean arterial blood
pressure and relative heart rate for intraarterial infusion of
S-nitrosothiol (S-nitrosohemoglobin) and shows results of Example
IV. Asterisks mean p<0.05 compared to baseline. The time t=0 is
the time at which infusion is initiated.
FIG. 5 depicts bar graphs for control, treatment with
S-nitrosocysteine and treatment with S-nitrosocysteine ethyl ester,
followed by washing free of S-nitrosothiol, showing percent
contraction in a rabbit aortic ring bioassay, and shows results of
Example V.
FIG. 6A depicts the effect of red blood cells previously exposed to
S-nitrosocysteine on infusion into dogs on coronary blood flow
without induction of ischemia and with induction of ischemia, and
shows results of Example VI.
FIG. 6B depicts the effect of infusion into dogs of
S-nitrosocysteine or S-nitrosoalbumin on systemic blood pressure
without and with induction of ischemia and shows results of Example
VI.
DETAILED DESCRIPTION
We turn now to the method of the first embodiment of the invention
herein, that is to the method for prophylaxis or treatment of a
patient with a pathologic condition involving constriction or
proliferation of smooth muscle or who is at risk for such, except
for a patient having acute thrombotic complications of restenosis
or platelet embolism or other thromboembolic event, said method
comprising administering an NO donor which is capable of acutely
lowering mean arterial blood pressure or pulmonary artery pressure
by more than 10% to said patient in a therapeutically effective
amount which is insufficient to acutely lower mean arterial blood
pressure or pulmonary artery pressure by more than 10%, e.g., by
more than 5%.
The treatment is directed to patients with a pathological condition
involving constriction or proliferation of smooth muscle.
The prophylaxis is directed to patients who are at risk for a
pathological condition involving constriction or proliferation of
smooth muscle.
Pathological conditions involving constriction or proliferation of
smooth muscle are, for example, acute coronary spasm (e.g., from
angina, myocardial infarction and all ischemic syndromes),
pulmonary hypertension (e.g., from heart failure, primary pulmonary
hypertension and chronic obstructive pulmonary disease, i.e.,
COPD), systemic hypertension, asthma, rectal spasm, esophageal
spasm, pyloric stenosis, and stroke. Of these, coronary spasm,
pulmonary hypertension, systemic hypertension, and heart failure
are diseases of vascular smooth muscle. Asthma involves airway
smooth muscle. Rectal spasm and esophageal spasm and pyloric
stenosis involve gastrointestinal smooth muscle. All these
pathological conditions involve constriction of smooth muscle
except for heart failure. Pulmonary hypertension, pyloric stenosis
and asthma involve proliferation of smooth muscle. In respect to
systemic hypertension, the invention causes no acute drop in mean
arterial blood pressure but reduction over time (analogous to
treatment of depression), e.g., over 2 weeks; this is an important
effect in the vast majority of cases of hypertension, where the
risk accumulates over many years and acute effects are not
relevant.
We turn now to the NO donor which is administered. An NO donor
donates nitric oxide or a related redox species and more generally
provides nitric oxide bioactivity, that is activity which is
identified with nitric oxide, e.g., vasorelaxation or stimulation
or inhibition of a receptor protein, e.g., ras protein, adrenergic
receptor, NFK.kappa.B. NO donors including S-nitroso, O-nitroso,
C-nitroso and N-nitroso compounds and nitro derivatives thereof and
metal NO complexes, but not excluding other NO bioactivity
generating compounds, useful herein are described in "Methods in
Nitric Oxide Research," edited by Feelisch, M., and Stamler, J. S.,
John Wiley & Sons, New York, 1996, pages 71-115 which is
incorporated herein by reference. NO donors which are C-nitroso
compounds where nitroso is attached to a tertiary carbon which are
useful herein include those described in U.S. patent application
Ser. No. 09/695,934. Examples of S-nitroso compounds including
S-nitrosothiols useful herein include, for example,
S-nitrosoglutathione, S-nitroso-N-acetylpenicillamine,
S-nitroso-cysteine and ethyl ester thereof S-nitroso cysteinyl
glycine, S-nitroso-gamma-methyl-L-homocysteine,
S-nitroso-L-homocysteine, S-nitroso-gamma-thio-L-leucine,
S-nitroso-delta-thio-L-leucine, and S-nitrosoalbumin. Examples of
other NO donors useful herein are sodium nitroprusside (nipride),
ethyl nitrite, nitroglycerin, SIN1 which is molsidomine,
furoxamines, N-hydroxy (N-nitrosamine) and perfluorocarbons that
have been saturated with NO or a hydrophobic NO donor. The NO
donors herein are ones that acutely lower blood pressure or
pulmonary artery pressure if the dose administered is high enough.
A discovery herein is that these same NO donors can still block
constriction and thus ameliorate (and prophylax against)
pathological constriction of smooth muscle and can desensitize
receptors at lower dosages which do not acutely lower blood
pressure or pulmonary artery pressure. The term NO donors capable
of lowering mean arterial blood pressure or pulmonary artery
pressure by more than 10% is used herein to mean NO donor, the
administration of which, will lower mean arterial blood pressure or
pulmonary artery pressure by more than 10% if the dose administered
is high enough, and is used herein to distinguish NO donors, the
administration of which will not cause acute lowering of mean
arterial blood pressure or pulmonary artery pressure by more than
10% regardless of dosage. It appears that an NO donor which will
not acutely lower mean arterial blood pressure by more than 10%
regardless of dosage is described in Bing, R. J., et al., Biochem.
Biophys. Res. Com. 275, 350-353 (2000) and is referred to therein
as 2-hydroxybenzoic acid 3-nitrooxymethylphenyl ester and also as
B-NOD; regardless of whether or not B-NOD will acutely lower mean
arterial blood pressure or pulmonary artery pressure by more than
10% at some dosage, it is meant to exclude B-NOD from the NO donors
herein.
As indicated above, administration is of the NO donor is in a
therapeutically effective amount which is insufficient to acutely
lower mean arterial blood pressure or pulmonary artery pressure
more than 10%, e.g., by more than 5% (and thus previously deemed
ineffective). Additionally, the dosage is insufficient to raise
FEVI by 10% or more (and thus previously viewed as ineffective) for
the treatment or prophylaxis of asthma as measured by standard
medical approaches, e.g., spirometry, insufficient to lower
gastrointestinal muscle tone by more than 10% in the treatment or
prophylaxis of rectal spasm by as measured by standard medical
approaches, e.g., manometry, insufficient to lower esophageal
smooth muscle tone by more than 10% in the treatment or prophylaxis
of esophageal spasm as measured by standard medical approaches,
e.g., manometry, and insufficient to dilate the pyloris by more
than 10% in the treatment or prophylaxis of pyloric stenosis as
measured by standard medical approaches, e.g., manometry.
The therapeutically effective amount is an amount that ameliorates
a symptom or symptoms of the condition being treated or in the case
of prophylaxis an amount that prevents symptom(s) from occurring or
causes the symptom(s) which occur to be less in intensity than
those that would occur without the administration of the invention.
For acute coronary spasm, symptom(s) that are ameliorated include
chest pain, hypoxemia and myocardial infarction or size of
infarction is decreased. For pulmonary hypertension, symptom(s)
that are ameliorated include heart failure, shortness of breath and
cough. For systemic hypertension, symptom(s), signs, that are
ameliorated include headache, but need not be present. For asthma,
symptom(s) which are ameliorated include shortness of breath, cough
and wheezing. For rectal spasm, symptoms that are ameliorated
include pain. For esophageal spasm, symptoms that are ameliorated
include pain. For pyloric stenosis, symptom(s) which are
ameliorated include pain and insufficient food intake. For stroke,
symptoms which are ameliorated include cognitive, sensory, and
motor symptoms. In all these cases, prophylaxis involves
administration to those at risk to prevent the symptoms from
occurring or causes the symptom(s) which do occur to be less in
intensity than those which would otherwise occur and treatment
involves administration to those having the disease or condition
even if asymptomatic.
In general, administering a therapeutically effective amount for
the first embodiment involves administration in an amount to
achieve a concentration of NO donor in the blood of 100 picomolar
to 100 micromolar (depending on the drug administered and the
disease treated or at risk for) which is less than the amount which
acutely lowers mean arterial blood pressure more than 10%, e.g., by
more than 5%, for example, less than amounts causing at least 50%
smooth muscle relaxation, ie., micromolar amounts, or to achieve
concentration less than that which lowers pulmonary artery pressure
more than 10%, e.g., by more than 5%. Amounts of drug will vary
depending on NO donor as well as disease state.
Routes of administration for the first embodiment for NO donor
include, for example, intravenous, nebulized, aerosolized, topical,
sublingual, and subcutaneous but not intraarterial. Ethyl nitrite
may be administered, for example, as a gas or in an infusion.
We turn now to the method of the second embodiment of the invention
herein, that is to the method for prophylaxis or treatment of a
patient with a disease associated with a receptor having a cysteine
residue or other cysteine containing protein that is modified by NO
donor to inhibit or stimulate its function or at risk therefor,
comprising administering an NO donor which is capable of acutely
lowering mean arterial blood pressure or pulmonary artery pressure
by more than 10% to said patient in a therapeutically effective
amount which is insufficient to acutely lower mean arterial blood
pressure or pulmonary artery pressure by more than 10%, e.g., by
more than 5%.
Receptors having cysteine residues include serotonin receptors,
adrenergic receptors, NMDA receptors, ryanodine receptors,
muscarinic receptors, and kinin receptors. In one subgenus of the
second embodiment, the receptors having a cysteine residue also
include membrane receptors. In a different subgenus of the second
embodiment, the receptors having a cysteine residue do not also
include membrane receptors.
Other cysteine containing protein that is modified by NO donor to
inhibit its function includes NF.kappa.B, AP1, ras, Na.sup.+
channels, Ca.sup.2+ channels, K.sup.+ channels, and prion protein.
(See Stamler, J. S., Cell, 2001.)
Diseases associated with serotonin receptors treatable in the
second embodiment herein include, for example, depression, stress,
anxiety and atherosclerosis.
Diseases associated with adrenergic receptors include, for example,
systemic hypertension, pulmonary hypertension and coronary artery
disease.
Diseases associated with NMDA receptors include, for example,
atherosclerosis, neurodegeneration, Alzieimer's disease, dementia,
Parkinson's disease, stress and anxiety.
We turn now to the membrane receptors. In one subgenus of the
second embodiment, the NO donor is administered to modify membrane
receptors, such as those in red blood cells, e.g., AEI protein;
this prevents the causing of vasoconstriction by red blood cells
and decreases the associated risk of heart attack, stroke,
pulmonary hypertension and systemic hypertension and thus mitigates
the cardiovascular toxicity associated with red blood cells. The
method of this subgenus includes infusing NO donor in an amount
which is insufficient to acutely lower mean arterial blood pressure
and pulmonary artery pressure more than 10%, e.g., more than 5%,
but which is a therapeutic amount to load red blood cells to
prevent vasoconstricting effect of red blood cells and prophylax
against or treat ischemic disorders, sickle cell disease, and
thalassemias.
We turn now to the cysteine containing proteins that are not
receptors.
Diseases that are associated with NF.kappa.B, Ca.sup.2+ and K.sup.+
channels include stroke and heart failure.
Diseases that are associated with other cysteine containing protein
that is not receptor include prion related diseases, e.g.,
Creutzfeldt-Jacob disease, kuru and mad cow disease, and malignant
hyperthermia.
We turn now to the method of the second embodiment generally.
The treatment involves administration to those having the
disease.
The prophylaxis involves administration to those at risk for the
disease.
The NO donors administered are the same as in the case of the first
embodiment.
We turn now to the amount of NO donor administered in the second
embodiment. As indicated above, this is a therapeutically effective
amount of NO donor which is insufficient to acutely lower mean
arterial blood pressure or pulmonary artery pressure more than 10%,
e.g., by more than 5%, and which changes blood vessel diameter less
than 10%.
The therapeutically effective amount for the second embodiment is
an amount that ameliorates a symptom or symptoms of the disease
being treated or in the case of prophylaxis an amount that prevents
symptoms from occurring or causes the symptom(s) which occur to be
less in intensity than those which would occur without the
administration of the invention. For treatment or prophylaxis of
depression, the amount is an amount effective to ameliorate the
presence or occurrence of symptoms of depression, e.g., morbid
mood, sleep disorder and inability to experience grief, joy or
pleasure. For treatment or prophylaxis of stress, the amount is an
amount effective to ameliorate the presence or occurrence of fear
and anxiety. For treatment or prophylaxis of anxiety, the amount is
an amount effective to ameliorate the presence or occurrence of
symptoms of restlessness, unusual fatigability, difficulty in
concentration, irritability, muscle tension and disturbed sleep.
For treatment or prophylaxis of atherosclerosis, the amount is an
amount effective to ameliorate the presence or occurrence of
symptoms of vasospasm, ischemia, myocardial infarction, progression
of atherosclerotic lesions and heart failure. For prophylaxis of
systemic hypertension, the amount is an amount effective to control
blood pressure to improve symptoms, e.g., headache, and to prevent
stroke or other complication. In the treatment or prophylaxis of
pulmonary hypertension, the amount is an amount effective to
ameliorate the presence or occurrence of symptoms as described
above. In the treatment or prophylaxis of heart failure, the amount
is an amount effective to ameliorate the presence or occurrence of
symptoms of shortness of breath, fatigue, exercise intolerance, and
swelling of the legs. In the treatment or prophylaxis of asthma or
COPD, the amount is an amount effective to ameliorate the presence
of symptoms as described above. In the treatment or prophylaxis of
neurodegeneration, the amount is an amount effective to ameliorate
the presence or occurrence of symptoms of cognitive, motor,
sensory, and vestibular impairment. In the treatment or prophylaxis
of Alzheimer's disease, the amount is an amount effective to
ameliorate the presence or occurrence of symptoms of memory loss or
other impairments as recited in standard textbooks. In the
treatment or prophylaxis of dementia, the amount is an amount
effective to ameliorate the presence or occurrence of cognitive
symptoms or other related impairments as defined in standard
textbooks. In the treatment or prophylaxis of a prion-related
disease, the amount is an amount effective to ameliorate the
presence or occurrence of cognitive symptoms or psychological
impairment. In the treatment or prophylaxis of coronary artery
disease, the amount is an amount effective to ameliorate the
presence or occurrence of symptoms of pain or myocardial infarction
or to decrease its size. In a treatment or prophylaxis involving
red blood cells, the amount is an amount effective to prevent
vasoconstricting effect of red blood cells.
Benefit is obtained because the doses used herein are sufficient to
desensitize receptors and alter other proteins involved in disease
where hyposensitivity mediates or potentiates the occurrence and
intensity of symptoms. For example, for prophylaxis or treatment of
atherosclerosis, the administration of the second embodiment
negates sensitivity to vasospasm, ischemic and myocardial
infarction. Benefit is obtained because dosages functional to
desensitize receptors and other disease involved proteins include
dosages which have no effect on vascular tone. The goal here is to
mitigate hyposensitivity without affecting vascular tone or blood
pressure. The dosages used for the second embodiment are those that
mitigate hyposensitivity without affecting vascular tone.
In general, administering a therapeutically effective amount for
the second embodiment involves administration to provide in blood a
concentration of NO donor of 100 picomolar to 100 micromolar
(depending on the drug administered and the disease treated or at
risk for) which is less than the amount which acutely lowers the
mean arterial blood pressure or pulmonary artery pressure more than
10%, for example, more than 5%, for example, less than micromolar
amounts, or equivalent amount of NO bioactivity.
Routes of administration for the second embodiment herein, include,
for example, intravenous, oral, subcutaneous, nebulized, bur not
intraarterial.
We turn now to the third embodiment herein, i.e., the method herein
for treating a patient in need of an NO donor and of increased
blood pressure, comprising administering a therapeutically
effective amount of NO donor directly into an artery of the
patient.
The patients for this method include, for example, those having the
disorders of sepsis or orthostatic hypotension or hypotention of
any cause with mean arterial blood pressures less than 90 mm Hg or
systolic blood pressure less than 90 mm Hg.
The NO donors are those described above and include, for example,
S-nitrosohemoglobin and S-nitrosoglutathione.
The therapeutically effective amount is an amount which relieves
symptoms of the disorder being treated and raises mean arterial
blood pressure by at least about 10%, e.g., from 90 to 100 mm Hg.
The amounts depend on the drug being administered but generally
provide nanomolar to micromolar concentrations of drug in the
blood.
This method is related to the first and second embodiments
described above in allowing increased dosage compared to what is
described for the first and second embodiments without acutely
lowering mean arterial blood pressure.
We turn now to the fourth embodiment herein, i.e., the method
herein for the prophylaxis or treatment of a patient with a
cardiovascular syndrome, or at risk therefor, comprising
administering a therapeutically effective amount of a thiol which
is insufficient to acutely lower mean arterial blood pressure or
pulmonary artery pressure by more than 10%, e.g., by more than
5%.
The term "cardiovascular syndrome" is used herein to mean heart
disease, stroke, transient ischemic attack, ischemic coronary
syndrome, peripheral vascular disease, claudication, impotence, and
mesenteric or other organ ischemia.
The treatment is directed to patients with a cardiovascular
syndrome.
The prophylaxis is directed to patients at risk for a
cardiovascular syndrome.
The thiols useful in the fourth embodiment are those that, when
added to blood, promote S-nitrosothiol formation in blood, i.e.,
cause increase in levels of circulating endogenous S-nitrosothiols.
The term "circulating" is used to mean circulating in blood.
Addition of thiol to blood to raise circulating endogenous
S-nitrosothiol levels is described in Lipton, Nature, 2001.
Suitable thiols for use in the fourth embodiment include, for
example, glutathione and N-acetylcysteine.
The therapeutically effective for the fourth embodiment is an
amount that causes increase in level of circulating S-nitrosothiols
and thereby ameliorates a symptom or symptoms of the pathological
condition being treated, or in the case of prophylaxis prevents
symptoms from occurring or causes the symptom(s) which occur to be
less in intensity than those that would occur without the
administration of the invention. For the treatment of angina, for
example, the therapeutically effective amount is an angina
ameliorating amount. Increase in level of circulating
S-nitrosothiols can be measured as described in Feelisch, M. and
Stamler, J. S., "Methods in Nitric Oxide Research," John Wiley
& Sons, New York, 1996.
In general, administering a therapeutically effective amount for
the fourth embodiment involves administration to provide in the
blood a concentration of administered thiol of 1 nanomolar to 10
millimolar (depending on the drug administered and the disease
treated, or at risk for) which is less than the amount which
acutely lowers the mean arterial blood pressure and pulmonary
artery pressure by more than 10%, e.g., by more than 5%.
Routes of administration for the second embodiment, include, for
example, oral and intravenous administration.
Thus, in the fourth embodiment herein, thiol, e.g., glutathione or
N-acetylcysteine, is given to a patient, e.g., by oral or
intravenous administration, at concentrations that do not acutely
change blood pressure or pulmonary artery pressure, in order to
raise the circulating levels of endogenous S-nitrosothiols. Lipton
(Nature, 2001) has shown that thiol added to blood promotes
S-nitrosothiol formation. The fourth embodiment herein differs from
Lipton in administering amounts of thiol that do not acutely
affected mean arterial blood pressure or pulmonary artery pressure
in a significant degree.
The following working examples, show scientific basis for the
invention or are directed to treatment or prophylaxis according to
the inventions herein.
EXAMPLE I
Avascular ring bioassay is carried out on mouse aorta rings as
described in Stamler, J. S., PNAS 89, 8087-8091 (1992). The assay
involves a chamber of solution into which mouse aorta ring attached
to a force transducer is placed where the solution is bubbled with
21% O.sub.2 /5% CO.sub.2 /balance N.sub.2. The force transducer
moves a pen in response to contraction and relaxation effects to
give a tracing of forces (tension) in the Y-direction versus time
in the X-direction on a chart.
Various agents as described later are applied to the aorta rings to
give to give contraction and relaxation effects. Tracings of force
(tension) in the Y-direction versus time in the X-direction are
obtained with upward direction indicating contraction and downward
direction indicating relaxation.
Experimental conditions and results (the tracing) are shown in FIG.
1. As shown in FIG. 1, there is a 1 gram contraction range; this
means 1 gram of tension is applied. The distance in the X-direction
representing 10 minutes is shown on FIG. 1 at the left. On FIG. 1,
"E" means application of phenylephrine, a constricting agent, and
the concentrations thereof at particular times are denoted; "ACh"
means application of acetyIcholine (which causes a relaxation
effect in response to endogenous nitric oxide) and the
concentration thereof at particular times are denoted; and "GSNO"
means application of S-nitrosoglutathione, an NO donor, and the
concentrations thereof at particular times are denoted.
As shown in FIG. 1, phenylepirine is applied starting at time zero
at a concentration of 10.sup.-8 molar increasing to a concentration
of 10.sup.-5.5 molar, and this causes a contracting effect. As
further shown in FIG. 1, acetylcholine is then applied at a
concentration of 10.sup.-9 molar increasing to a concentration of
10.sup.-6.5 and causes a relaxing response as a result of causing
production of endogenous NO. As further shown in FIG. 1, flushing
is then carried out three times then and one more time; the
flushing is carried out (with Krebs-Henseleit solution described
hereinafter in Example III) and removes the acetylcholine. As
further shown in FIG. 1, phenylephrine is then applied starting at
a concentration of 10.sup.-7 molar increasing to a concentration of
10.sup.-5.5 molar. This causes a contracting response despite the
previous application of acetylcholine. As further shown in FIG. 1,
S-nitrosoglutathione is then applied starting at a concentration of
1 nanomolar, increasing to a concentration of 10 micromolar, and
this causes a relaxing (contraction-attenuating) effect. As further
shown in FIG. 1, flushing is then carried out three times (with
Krebs-Henseleit solution); and then one more time with the same
flushing agent; this flushing removes the S-nitrosoglutathione. As
further shown in FIG. 1, phenylephrine is then applied at a
concentration of 10.sup.-7 molar, increasing to 10.sup.-5 molar;
this does not cause a contracting response.
The experiment shows that unlike endogenous NO, the application of
NO donor modifies adrenergic receptor and prevents adrenergic
agonist (phenylephrine) from working and that pretreatment with NO
donor blocks subsequent response to adrenergic agonist.
EXAMPLE II
A vascular ring bioassay was carried out as follows: Artery rings
(3 mm) were harvested from New Zealand white rabbits and mounted in
25 ml tissue baths filled with Krebs-Henseleit buffer and bubbled
with 21% O.sub.2 /5% CO.sub.2 /balance N.sub.2. Isometric tension
was measured. All rings in the study were suspended with similar
baseline levels of tension (.about.2 g). Tissue baths were
thoroughly rinsed with fresh buffer between interventions.
Three runs were carried out. In one run denoted the control, no
additive was added. In a second run, S-nitrosoglutathione (GSNO)
was added to provide a concentration of 1 .mu.M (which has no
effect on resting tone but which as shown later prevents
contraction). In a third run, SIN1 was added to provide a
concentration of 1 .mu.M. The NO donors did not cause a relaxing
effect at the concentrations used.
After flushing with solution as described in Example I,
phenylephrine was then added in each case to provide a
concentration of 1 to 10 .mu.M.
The results are shown in FIG. 2 where percent increase in tone is
indicated on the Y-axis and additive or absence thereof (control)
is indicated on the X-axis.
As shown in FIG. 2, there was over a 100% increase in tone for the
control case and less than 30% increase in tone in the cases of
GSNO and SIN1 indicating the NO donors used at levels that had no
effect on vascular resting tone blocked constriction responses to
adrenergic agonist (phenylephrine). Thus the NO donors at
concentrations not affecting baseline tone mitigated subsequently
imparted constricting impetus but did not relax the blood
vessels.
EXAMPLE III
The experiments of this example were performed in isolated
buffer-perfused lungs (IPL) of rabbits as described in
Nozik-Grayck, E., et al., American Journal of Physiology 273,
C296-C304 (1997). The buffer was Krebs-Henseleit (KH) solution
containing sodium chloride (82.8 mM), potassium chloride (4.7 mM),
monobasic potassium phosphate (2.4 mM), sodium bicarbonate (25 mM),
magnesium sulfate (1.2 mM), calcium chloride (2.7 mM), and dextrose
(11.1 mM) at pH 7.4. New Zealand white rabbits (May's Farm, NC)
weighing 2.5-3.5 kg were anticoagulated with 5,000 U sodium heparin
and anesthetized with 25 mg/kg sodium pentobarbital by ear vein. An
incision was made in the left chest wall, exposing the heart. The
animal was exsanguinated via the left ventricle and the thorax
entered by excising the rib cage. Stainless steel cannulas were
placed in the trachea, main pulmonary artery and left atrium to
measure tracheal (airway) and pulmonary artery pressure. The aorta
also was tied with the pulmonary artery to prevent loss of
perfusate to systemic circulation. The lungs were inflated with 80
ml of air and ventilated with 21% O.sub.2 and 5% CO.sub.2 (balance
N.sub.2) with an animal respirator (Harvard Apparatus Company,
Inc., S Natick, Mass.) at a rate of 30 breaths/minute. The tidal
volume was adjusted to maintain a peak tracheal pressure of 8-10
torr with a positive end expiratory pressure of 2-3 torr. The
perfusion circuit contained a reservoir suspended freely from a
force transducer (Model FT100, Grass Instrument Company, Quincy,
Mass.) and a water heater set at 37.degree. C. Perfusate was
circulated by a roller pump (Sams, Inc., Ann Arbor, Mich.) and
passed through a bubble trap before entering the pulmonary artery.
The perfusate returned to the left atrium and then to the reservoir
which was set at the lowest portion of the lung to provide a left
atrial pressure of zero. Perfusion began slowly and was gradually
increased to 100 ml/min. After rinsing the lungs free of blood with
500 ml buffer, a recirculating system was established. The total
volume in the circuit was approximately 250 ml. Mean pulmonary
artery pressure (Ppa) was measured using pressure transducers
(P231D, Gould Statham Instruments, Inc., Hato Ray, PR).
Three runs were carried out. In one case (control), no additive was
injected into the recirculating system. In a second case,
S-nitrosoglutathione (GSNO), 50 .mu.M, was injected into the
recirculating system to provide a concentration of nanomolar to
micromolar GSNO therein. In a third case, SIN1, 100 .mu.M, was
injected into the recirculating system to provide a concentration
of nanomolar to micromolar SIN1 therein. The injection of the GSNO
(50 .mu.M) and SIN1 (100 .mu.M) did not cause change in Ppa.
Sixty minutes later, the serotoninergic agonist serotonin was
injected into the recirculating system in each of the three cases
to provide a concentration of 1 micromolar.
The results are shown in FIG. 3 where the filled in circles
represent the run with GSNO, the filled in triangles represent the
run with SIN1, and the open squares represent control. The Y-axis
represents change in Ppa from baseline (baseline is before NO
donors were added). As indicated in FIG. 3, both NO donors
prevented constriction by agonist (serotonin) which has been
implicated in pulmonary vasoconstriction and ischemic
syndromes.
In addition, tracheal pressure (airway pressure) measured using
pressure transducers, was not altered by the NO donors.
EXAMPLE IV
Rats (n=4) were infused via femoral vein with 200 nmol/kg of
S-nitrosothiol (S-nitrosohemoglobin). Mean arterial blood pressure
(MAP) and heart rate (HR) were measured. Results are shown in FIG.
4A. As shown in FIG. 4A, the intravenous infusion had no effect on
resting blood pressure or heart rate higher doses of S-nitrosothiol
cause blood pressure to fall.
In another case, rats (n=4) were infused via femoral artery with
200 nmol/kg of S-nitrosothiol (S-nitrosohemoglobin). Mean arterial
blood pressure (MAP) and heart rate (HR) were measured. Results are
shown in FIG. 4B. As shown in FIG. 4B, the intraarterial infusion
increased mean arterial blood pressure and heart rate.
In FIG. 4A and FIG. 4B, the continuous lines represent mean
arterial blood pressure (MAP) and the lines composed of dashes
represent heart rate (HR).
EXAMPLE V
Red blood cells (RBC) are treated for 5 minutes with
S-nitrosocysteine or S-nitrosocysteine ethyl ester (1:10 ratio of
NO to hemoglobin) to load the red blood cells with
S-nitrosocysteine or S-nitrosocysteine ethyl ester to nitrosylate
membrane receptors including AEI proteins (Pawloski, Nature, 2001)
and then washed free of S-nitrosothiol. The nitrosothiol loaded red
blood cells and control red blood cells were incubated in a rabbit
aortic ring bioassay (described in the first paragraph of Example
II). Results are shown in FIG. 5. As shown in FIG. 5, control red
blood cells produce contraction of blood vessels. The amount of
contraction is above that produced by 10.sup.-6 M phenylephrine. As
shown in FIG. 5, where S-nitrosocysteine treated red blood cells
are denoted CysNO-RBC and S-nitrosocysteine ethyl ester treated red
blood cells are denoted CysNOEE-RBC, this contraction is attenuated
by S-nitrosylation of receptors. The S-nitrosothiol treatment does
not produce relaxation of blood vessels. Similar results are seen
if the nitrosothiols are co-incubated in the bioassays with the red
blood cells.
EXAMPLE VI
Red blood cells previously exposed to S-nitrosocysteine (at ratio
of 1:1,000 to 1:10 NO to hemoglobin) to nitrosylate membrane
receptors have no effect on coronary blood flow in dogs (see
"BASELINE" bar graph in FIG. 6A) but improve coronary flow when
ischemia is induced in the dogs (see "ISCHEMIA" bar graph in FIG.
6A). The membrane receptor nitrosylated red blood cells have no
effect on blood pressure.
In another case, S-nitrosocysteine (3 nmol/kg) or S-nitrosoalbumin
(10 nmol/kg) is infused systemically into dogs. Responses are shown
in FIG. 6B. As shown in FIG. 6B, the infision of S-nitrosocysteine
has no effect on systemic blood pressure even when the dogs are
made ischemic. The response to S-nitrosoalbimim infusion is no
different. The infusions of NO donors result in reaction with
membrane receptors in red blood cells. As shown in FIG. 6A, the
reactions with membrane receptors in red blood cells can increase
coronary flow in ischemic but not healthy (normotoxic) animals.
EXAMPLE VII
A 70-year-old male who complains of recurrent episodes of acute
vasospastic angina is treated with S-nitrosoglutathione (GSNO) at
1-1,000 .mu.g orally 4.times./day. Blood pressure is unchanged and
acute symptoms resolve. In addition, the frequency of vasospastic
chest pain decreases over the following three weeks.
EXAMPLE VIII
A 27-year-old white fermale with primary pulmonary hypertension
class II presents complaining of shortness of breath. She is given
10 mM GSNO in 1 cc saline nebulized 3.times./day. Symptoms of
shortness of breath resolve but pulmonary artery pressure and
systemic pressure are unchanged with acute administration. After
four months of therapy, pulmonary artery pressure has dropped by 5
mm of mercury and the patient's symptoms have improved. The patient
is subsequently given oral GSNO at 10 .mu.g TID and doses are
empirically changed to prevent any significant change in blood
pressure.
EXAMPLE IX
A 25-year-old white female with poorly controlled asthma presents
with an exacerbation. She is treated with inhaled S-nitrosocysteine
ethyl ester 1-1,000 .mu.g nebulized in 10 cc which does not
significantly improve airway tone. However, the acute episode of
asthma is brought under control over the following three days and
the patient is subsequently continued on oral GSNO 10 .mu.g Q 6
hours. The frequency of asthma exacerbations decline.
EXAMPLE X
A 60-year-old white male with recurrent rectal spasm is given oral
ethyl nitrite 0.125% in ethanol (1 cc) 3.times./day. Blood pressure
does not change but the symptoms of rectal pain resolve. He then
continued on this therapy with a decrease in incidence of rectal
pain.
EXAMPLE XI
A 65-year-old alcoholic with esophageal spasm is given 2 cc of
0.125% ethyl nitrite in ethanol 3.times./day. Symptoms of
esophageal pain resolve and symptoms do not recur on the same
maintenance dose.
EXAMPLE XII
An infant with pyloric stenosis is given 2 cc of 0.125% ethyl
nitrite in ethanol 3.times./day.
Symptoms of intestinal pain resolve.
EXAMPLE XIII
A 65-year-old male presents with a transient ischemic attack
evidenced by confusion and headache. Carotid dopplers show 98% new
occlusion of the right carotid artery. Systolic blood pressure is
180 mm of mercury. He is given an infusion intravenously of
S-nitrosocysteinyl glycine 10 .mu.g with resolution of the
headache. The systemic blood pressure remains 175 mm of mercury.
Symptoms of headache and confusion resolve. The patient is then
maintained on oral S-nitrosoglutathione 1-10 .mu.g 3.times./day
with no recurrence of transient ischemic symptoms.
EXAMPLE XIV
A 50-year-old black female presents with symptoms of depression.
She is begun on oral molsidomine (SIN-1) 10 .mu.g per kg
dose-adjusted so that blood pressure is unchanged. Over the
following three weeks the symptoms of depression resolve and the
patient is maintained on this dose with no recurrence.
EXAMPLE XV
A 40-year-old white male with risk factors of hypertension,
diabetes, and hypercholestolemia and a strong family history of
atherosclerosis presents with claudication and a leg ulcer. He is
begun on an infusion of (SIN-1) 0.3 .mu.m/kg per hour for a total
of 1 mg with no change in blood pressure. Symptoms of rest pain
resolve. He is then begun on oral S-nitrosoglutathione 1-10 .mu.g
3.times./day with improvement of duration of exercise and no
recurrence of rest pain.
EXAMPLE XVI
A 60-year-old white male with uncontrolled hypertension of 200/90
mm of mercury on a complex medical regimen including angiotension
converting enzyme inhibitor, an alpha blocker, and beta blocker has
a blood pressure of 200/110. He is begun on oral GSNO at 1 to 10
micrograms QID and ethyl nitrite 0.025% (1 cc) 3.times./day. The
blood pressure does not change. However, over the following two
weeks the blood pressure falls to 170/100 consistent with better
management of his disease. He is maintained on these doses with no
further exacerbation.
EXAMPLE XVII
A 56-year-old with hyperhomocystenemia and strong family history of
premature coronary artery disease undergoes cardiac cauterization
which shows severe three vessel disease. He is begun on oral GSNO
titrated so that his resting systolic blood pressure of 100 mm of
mercury does not change. He does well with no symptoms of coronary
disease over the following three years.
EXAMPLE XVIII
A 68-year-old female complains of anxiety and stress and is begun
on nitroglycerin, 1/2 to 1 inch patch 3.times./day titrated to
avoid a change in blood pressure or headache, and symptoms are
alleviated in 4 days.
EXAMPLE XIX
A 70-year-old white male with congestive heart failure develops
hypotension and angina. S-nitrosoglutathione (200 nmol/kg) is
infused via the brachial artery over 3 minutes. The angina
resolves. The systolic blood pressure rises from 85 mm Hg to 100 mm
Hg.
EXAMPLE XX
A 65-year-old white male receiving erythropoietin to raise red
blood count depleted because of treatment for cancer or renal
failure, develops chest pain (caused by increased concentration of
red blood cells). An infusion of S-nitrosocysteine ethyl ester
(1-10 nmolkg/min) is given, alleviating chest pain without a change
in blood pressure.
EXAMPLE XXI
A 65-year-old white male receiving erythropoietin to raise red
blood count depleted by renal failure, develops chest pain (caused
by increased concentration of red blood cells). An infusion of
N-acetylcysteine (50 ng/kg) is begun, alleviating his chest pain
without a change in blood pressure. The patient is then begun on
N-acetylcysteine, 600 ng, PO, TID, and frequency of angina
decreases and blood pressure drops over three weeks.
VARIATIONS
Many variations will be obvious to those skilled in the art.
Therefore, the invention is defined by the claims.
* * * * *