U.S. patent application number 09/953021 was filed with the patent office on 2002-10-10 for metabolic intervention with glp-1 to improve the function of ischemic and reperfused skeletal muscle tissue.
Invention is credited to Coolidge, Thomas R., Ehlers, Mario R.W..
Application Number | 20020147131 09/953021 |
Document ID | / |
Family ID | 23168436 |
Filed Date | 2002-10-10 |
United States Patent
Application |
20020147131 |
Kind Code |
A1 |
Coolidge, Thomas R. ; et
al. |
October 10, 2002 |
Metabolic intervention with GLP-1 to improve the function of
ischemic and reperfused skeletal muscle tissue
Abstract
Individuals in need of treatment of ischemia-related reperfusion
are treated, preferably intravenously, with a composition which
includes a compound which binds to a receptor for the glucagon-like
peptide-1. The invention relates to both the method and
compositions for such treatment.
Inventors: |
Coolidge, Thomas R.; (Falls
Village, CT) ; Ehlers, Mario R.W.; (Lincoln,
NE) |
Correspondence
Address: |
MCKEE, VOORHEES & SEASE, P.L.C.
ATTN: BIONEBRASKA
801 GRAND AVENUE, SUITE 3200
DES MOINES
IA
50309-2721
US
|
Family ID: |
23168436 |
Appl. No.: |
09/953021 |
Filed: |
September 11, 2001 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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09953021 |
Sep 11, 2001 |
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09851738 |
May 9, 2001 |
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09851738 |
May 9, 2001 |
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09302596 |
Apr 30, 1999 |
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6284725 |
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60103498 |
Oct 8, 1998 |
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Current U.S.
Class: |
514/11.7 ;
530/308 |
Current CPC
Class: |
A61P 39/06 20180101;
A61K 38/26 20130101; A61P 9/10 20180101; A61K 2300/00 20130101;
A61K 38/26 20130101 |
Class at
Publication: |
514/2 ;
530/308 |
International
Class: |
A61K 038/28; A61K
038/26; C07K 017/00; C07K 016/00; C07K 007/00; C07K 005/00; A61K
038/00; A01N 037/18 |
Claims
What is claimed is:
1. A method for amelioration of organ tissue injury caused by
reperfusion of blood flow following a period of ischemia, which
comprises: administering to an individual in need of such treatment
an effective amount of a composition which includes a compound
which binds to a receptor for glucagon-like peptide-1, in a
pharmaceutical carrier.
2. The method of claim 1 wherein the glucagon-like peptide-1 is
GLP-1 or a biologically active analogue thereof.
3. The method of claim 1 wherein the pharmaceutical carrier is
selected from the group consisting of saline, buffered saline,
dextrose, water, glycerol, ethanol, lactose, phosphate, mannitol,
arginine, treholose, and combinations thereof.
4. The method of claim 1 wherein the administering to an individual
in need of treatment is at a dose level of 0.1 pmol/kg/min. up to
10 pmol/kg/min.
5. The method of claim 4 wherein there is concurrent administration
of glucose.
6. The method of claim 5 wherein there is concurrent administration
of potassium.
7. The method of claim 4 wherein there is concurrent administration
of a free radical scavenger.
8. The method of claim 1 wherein administration commences within 4
hours of an ischemic event.
9. The method of claim 8 wherein administration occurs within 4
hours of an ischemic event and continues thereafter.
10. The method of claim 1 wherein administration is
intravenously.
11. The method of claim 1 wherein administration is by subcutaneous
or micropressure injection, deep lung insufflation, external or
implant pump, depot injection, and other sustained release
mechanisms, oral delivery and patch, buccal and other cross skin
and membrane mechanisms.
12. The method of claim 1 wherein the organ tissue is the
myocardium.
13. The method of claim 8 wherein administration occurs as soon as
possible after the event.
14. The method of metabolic intervention with GLP-1 to improve the
function of ischemic and reperfused tissue, said method comprising:
administering to an individual in need of such treatment an
effective amount of a composition comprising GLP-1 in a
pharmaceutical carrier.
15. The method of claim 14 wherein the glucagon-like peptide-1 is
GLP-1 or a biologically active analog thereof.
16. The method of claim 14 wherein the pharmaceutical carrier is
selected from the group consisting of saline, buffered saline,
dextrose, water, glycerol, ethanol, lactose, phosphate, mannitol,
arginine, treholose, and combinations thereof.
17. The method of claim 14 wherein the administering to an
individual in need of treatment is at a dose level of 0.1
pmol/kg/min to 10 pmol/kg/min.
18. The method of claim 17 wherein there is concurrent
administration of glucose.
19. The method of claim 14 wherein administration commences within
4 hours of an ischemic event.
20. The method of claim 19 wherein administration occurs within 4
hours of an ischemic event and continues thereafter.
21. The method of claim 14 wherein the need for amelioration of
tissue damage by metabolic intervention arises from a medical
procedure that is a surgical event selected from the group
consisting of cardiac surgical procedures, organ transplants,
traumatic limb amputation and reattachment.
22. The method of claim 14 wherein the medical procedure involves
an ischemic reperfusion event, said event being concurrent with gut
infarct and myocardial infarct.
23. A composition for use in metabolic intervention with GLP-1 to
improve the function of ischemic and reperfused tissue, comprising:
an effective amount of GLP-1 in combination with a pharmaceutically
effective carrier.
Description
CROSS REFERENCE TO A RELATED APPLICATION
[0001] This application is a continuation of application 09/851,738
filed May 9, 2001.
FIELD OF THE INVENTION
[0002] This invention relates to metabolic intervention with GLP-1
to therapeutically improve the function of ischemic and reperfused
tissue.
BACKGROUND OF THE INVENTION
[0003] Cellular damage to aerobic organ tissues is well recognized
as a consequence of ischemia, whether endogenous as in the case of
a spontaneous coronary artery occlusion, or iatrogenic such as with
open heart, coronary bypass surgery, or transplant procedures with
the heart or other organs such as the lung, liver, kidney, pancreas
and gastrointestinal tract. The degree and duration of the ischemia
causing events are relevant to the amount of cell death and/or
reversible cellular dysfunction. It is also known that much of the
tissue damage in fact occurs upon reperfusion (i.e., resumption of
blood flow) and re-oxygenation of the previously anoxic tissue.
Reperfusion injury has been the subject of considerable recent
study prompted by medical advances particularly in the treatment of
reperfusion injury after myocardial infarction and other myocardial
remedial procedures such as coronary bypass, other open heart
surgeries, as well as organ transplants.
[0004] As a side product of normal aerobic respiration, electrons
are routinely lost from the mitochondrial electron transport chain.
Such electrons can react with molecular oxygen to generate the
reactive free radical superoxide which through other reaction steps
in the presence of hydrogen peroxide and iron produces the
extraordinarily reactive and toxic hydroxyl radical. Metabolically
active aerobic tissues possess defense mechanisms dedicated to
degrading toxic free radicals before these reactive oxygen species
can interact with cellular organelles, enzymes, or DNA, the
consequences of which could, without such protective mechanisms, be
cell death. These defense mechanisms include the enzymes superoxide
dismutase (SOD) which disproportionates superoxide, catalase which
degrades hydrogen peroxide, and the peptide glutathione which is a
non-specific free radical scavenger.
[0005] While not fully understood, it is believed that with
ischemia of metabolic tissues and subsequent reperfusion, a complex
group of events occurs. Initially during the ischemic period,
intracellular anti-oxidant enzyme activity appears to decrease,
including that of SOD, catalase, and glutathione. There is also an
indication that the level of xanthine oxidase activity
concomitantly increases in vascular endothelial tissue during the
ischemic event. The combination of enhanced ability to produce
oxygen free radicals (via enhanced xanthine oxidase activity) and
reduced ability to scavenge the same oxygen radicals (via reduced
SOD, catalase and glutathione activity) greatly sensitizes the
ischemic cell to an oxidative burst, and hence damage, should these
cells be subsequently reperfused with blood and therefore oxygen.
This oxidative burst occurring within seconds to minutes of
reperfusion could result in reversible and irreversible damage to
endothelial cells and other cells constituting the
ischemic-reperfused organ matrix. If, for example, the heart is the
organ under consideration, reversible oxidative damage can
contribute to myocardial stunning, whereas irreversible damage
presents itself as a myocardial infarction. Attendant with this
initial oxidative burst is oxidation damage to cell membranes.
Lipid oxidation in cell membranes appears to play a role in
neutrophil chemotaxis to post-ischemic areas. Such activated
neutrophils adhere to vascular endothelium, induce the conversion
of xanthine dehydrogenase to xanthine oxidase within said
endothelial cells, and further aggravate loss of endothelial
integrity. Activated neutrophils also migrate out of the
vasculature into myocardial interstitial spaces where the
inflammatory cells can directly kill myocytes. Additionally,
perturbations in normal calcium mobilization from sarcoplasmic
reticulum as a consequence of ischemia-reperfusion contribute to
reversible myocardial dysfunction referred to as myocardial
stunning.
[0006] The consequences of ischemia-reperfusion events are
reversible and irreversible cell damage, cell death, and decreased
organ functional efficiency. More specifically, in the case of
myocardial reperfusion injury, the consequences include myocardial
stunning, arrhythmias, and infarction, and as a result, cariogenic
shock and potentially congestive heart failure.
[0007] The paradox of cellular damage associated with a limited
period of ischemic anoxia followed by reperfusion is that cell
damage and death appear not only likely to directly result from the
period of oxygen deprivation but, additionally, as a consequence of
re-oxygenation of tissues rendered highly sensitive to oxidative
damage during the ischemic period. Reperfusion damage begins with
the initial oxidative burst immediately upon reflow and continues
to worsen over a number of hours as inflammatory processes develop
in the same post-ischemic tissues. Efforts dedicated to decreasing
sensitivity of post-anoxic cells to oxidative damage and,
additionally, efforts to reduce inflammatory responses in these
same tissues have been shown to reduce the reversible and
irreversible damage to post-anoxic reperfused organs. A combination
of methods to reduce both the initial oxidative burst and
subsequent inflammation associated damage could provide synergistic
protection against reperfusion injury.
[0008] With respect to the treatment of ischemia coincident with MI
patients, common therapies now used are to employ thrombolytics
such as streptokinase and t-PA and angioplasty. U.S. Pat. No.
4,976,959 discloses the administration of t-PA and SOD to inhibit
tissue damage during reperfusion and/or percutaneous transluminal
coronary angioplasty coincident with ischemia to restore regional
blood flow. Thus, an increasing number of patients are being
exposed to the likelihood of reperfusion injury and its effects,
particularly cardiac patients.
[0009] Reperfusion injury to organs other than the heart will
generally manifest itself in substantially reduced efficiency of
function, a consequence of which may be premature degeneration of
the organ, or simply shutdown. Additionally, transplanted organs
experience enhanced rejection rates if there is significant
underlying reperfusion injury.
[0010] As discussed briefly above, while the precise mechanism of
reperfusion injury has not been clearly defined, mounting data,
most of which has been gathered in various cardiac model studies,
indicate that the generation of oxygen-derived free radicals,
including superoxide anion (O.sub.2).sup.-, the hydroxyl free
radical (.OH) and H.sub.2O.sub.2, results as a consequence of the
reintroduction of molecular oxygen with reperfusion and plays an
important role in tissue necrosis. Agents which either decrease the
production of these oxygen derived free radicals (including
allopurinol and deferroxamine) or increase the degradation of these
materials such as superoxide dismutase, catalase, glutathione, and
copper complexes, appear to limit infarct size and also may enhance
recovery of left ventricular function from cardiac stunning.
[0011] The use of metabolic intervention as a therapy specifically
during acute myocardial infarction is well established, although
not without controversy. There is abundant experimental and
clinical evidence to support the use of a glucose-insulin-potassium
(GIK) infusion--the primary form of metabolic intervention--after
acute MI, particularly following the success of the Swedish DIGAMI
study (Malmberg, K, and DIGAMI Study Group (1997) Prospective
randomized study of intensive insulin treatment on long term
survival after acute myocardial infarction in patients with
diabetes mellitus. Brit. Med. J. 314, 1512-1515). The DIGAMI study
emphasized the efficacy of a glucose-insulin infusion for acute MI
in diabetic patients, but this type of therapy has never been
suggested or used for reperfusion.
[0012] It therefore can be seen that there is a need for a safe
effective composition having broad applicability to prevent or
ameliorate the harmful effects of ischemia and reperfusion for
tissues in general, especially organ tissue and, including but not
limited to myocardium. It is primary object of the present
invention to fulfill this need.
[0013] Another object of the present invention is to provide a
method for treating ischemia and reperfusion without the side
effects normally attendant with therapies presently available.
[0014] Still another object of the present invention is to provide
a pharmaceutically acceptable carrier composition which can be used
for intravenous administration of the compositions of the present
invention without any significant undesirable side effects and
without adversely affecting antigenic or immune stimulating
properties.
[0015] These and other objects and benefits of the present
invention will be apparent to those skilled in the art from the
further description and the accompanying claims.
SUMMARY OF THE INVENTION
[0016] Individuals in need of treatment of ischemia and/or
reperfusion are treated, preferably intravenously, with a
composition which includes a compound which binds to a receptor for
the glucagon-like peptide-1. The invention relates to both the
method and compositions for such treatment.
DETAILED DESCRIPTION OF THE INVENTION
[0017] GLP-1 is a glucose-dependent insulinotropic hormone that
effectively enhances peripheral glucose uptake without inducing
dangerous hypoglycemia. Further, GLP-1 strongly suppresses glucagon
secretion, independent of its insuliniotropic action, and thereby
powerfully reduces plasma free fatty acid (FFA) levels
substantially more than can be accomplished with insulin. High FFA
levels have been implicated as a major toxic mechanism during
myocardial ischemia.
[0018] We have now developed the concept of GLP-1 as a metabolic
therapy for ischemia-reperfusion injury. This development was based
on the realization that there are two clinical situations in which
ischemia-reperfusion is a routine, and potentially dangerous,
event: thrombolytic procedures for acute MI, and cardiac
reperfusion following ischemic cardioplegia during heart surgery.
Moreover, recent experimental and clinical data have established
that the phenomenon of ischemia-reperfusion is particularly
responsive to metabolic therapy with GIK infusion, even more so
than isolated ischemia without reperfusion (Apstein, CS (1998)
Glucose-insulin-potassium for acute myocardial infarction.
Remarkable results from a new prospective, randomized trial.
Circulation 98, 2223-2226).
[0019] The two most important therapeutic advances in the treatment
of acute ischemia coincident with MI in the past decade have been
the introduction of thrombolysis and .beta.-blockade. However,
despite this overall success, some studies of thrombolysis have
revealed an early excess mortality, which has been attributed to
reperfusion-induced injury and myocardial stunning. The mechanisms
underlying stunning are complex, but an emerging consensus is that
this is likely related to intracellular acidosis leading to
dysfunctional sarcolemmal Ca.sup.2+ pumps and cytosolic Ca.sup.2+
overload. The net result is impaired myocardial contractile
function leading to decreased mechanical efficiency, as well as
reperfusion ventricular arrhythmias. Moreover, recent research has
established that the intracellular acidosis, in turn, is due to an
imbalance between glycolysis and complete glucose oxidation, in the
sense that the rate of glycolysis is uncoupled from the oxidation
of pyruvate (the end product of glycolysis) in the TCA cycle. This
uncoupling results in net H.sup.+ production due to conversion of
pyruvate to lactate. The most likely cause for this imbalance is
the presence of high plasma free fatty acid (FFA) levels, which
preferentially enter the mitochondria and inhibit pyruvate
oxidation, a mechanism that elegantly accounts for the well
established observation that hearts perfused with FFA are less able
to recover in the reperfusion phase than hearts perfused with
glucose. It has here been discovered, and is one of the bases of
this therapeutic invention that GLP-1 suppresses FFA beyond what is
expected with insulin which is at the 50% level of suppression, and
GLP-1 can be as high as 90% suppression of FFA.
[0020] These considerations have strengthened our conviction to
treat ischemia-reperfusion with glucagon-like peptides. It is well
established that during normal perfusion and adequate oxygenation,
the heart depends on aerobic metabolism and uses FFAs as its
preferred fuel. In contrast, during ischemia (reduced blood flow)
or hypoxica (reduced O.sub.2 tension), .beta.-oxidation of fatty
acids is impaired (because it is strictly aerobic) and continued
provision of ATP is dependent increasingly on anaerobic glycolysis.
During the ischemic period, glucose-insulin is of benefit because
it enhances glucose uptake and stimulates glycolysis, thereby
providing ATP for maintenance of essential membrane functions,
especially ion transport. Moreover, glucose-insulin suppresses
adipose tissue lipolysis, thereby reducing plasma FFA levels and
uptake of FFAs into the myocardium. High levels of FFAs are toxic
to the ischemic myocardium, both by direct detergent effects on
membranes and increases in cAMP, and by accumulation of
acylcamitine, which inhibits Ca.sup.2+ pumps. The net effect is
disturbance of ion exchange, cytosolic Ca.sup.2+ overload, and
resultant contractile dysfunction and arrhythmias.
[0021] During the reperfusion period, glucose-insulin is of benefit
because, as explained above, this therapy can alleviate the
metabolic imbalance that produces stunning. This is achieved by
direct stimulation of PDH and hence pyruvate oxidation, and
indirectly by reduced FFA uptake and hence improved ratio of
pyruvate to FFA oxidation.
[0022] From the above discussion it is evident that the dual action
of glucose-insulin--enhanced glucose uptake and metabolism, and
reduced FFA levels--has substantial therapeutic potential in
reperfusion. Some have expressed a concern that during profound,
essentially zero-flow ischemia, glycolytic end products, namely
lactate, will accumulate due to inadequate "wash-out". Lactate
accumulation, in turn, leads to high intracellular proton
concentrations, and failure to reoxidize NADH; high [H.sup.+] and
NADH/NAD.sup.+ ratios inhibit productive glycolysis. Under these
circumstances, glucose can be toxic to cells, because ATP is
actually consumed in the production of fructose-1,6-bisphosphate,
and high [H.sup.+] can aggravate myocyte necrosis (Neely, JR, and
Morgan, HE (1974) Relationship between carbohydrate and lipid
metabolism and the energy balance of heart muscle. Ann. Rev.
Physiol. 36, 413-459). However, these concerns have not been borne
out by the weight of experimental and clinical data, which indicate
that glucose-insulin produces beneficial results. While not wishing
to be bound by theory, the likely explanation for this is that in
humans, acute spontaneous ischemia is not a condition of zero-flow
ischemia, but instead represents a region of low-flow ischemia in
which residual perfusion is adequate for substrate delivery and
lactate washout. This realization has now provided a powerful
physiological logic for the use of metabolic therapy in
ischemia-reperfusion.
[0023] Modern cardiac surgery, whether involving cardiac valve
replacement or coronary artery bypass grafting (CABG), routinely
requires hypothermic cardioplegic arrest, aortic crossclamping, and
cardiopulmonary bypass during surgery. Effectively, therefore,
routine cardiac surgery induces a state of elective global ischemia
followed by reperfusion, which potentially exposes the heart to all
the attendant risks and injuries peculiar to myocardial
ischemia-reperfusion. Hence, prevention of myocardial damage during
and after cardiac operations remains a major concern. Elective
cardioplegic ischemia followed by reperfusion has obvious parallels
with ischemia-reperfusion encountered during acute MI followed by
revascularization, and thus many of the pathophysiological
principles considered in previous sections also apply during
cardiac surgery. However, there are some notable differences
between surgical cardioplegic ischemia-reperfusion and
MI-associated ischemia-reperfusion. During surgery, the heart is
arrested (cardioplegia) and infused with a cold (hypothermic)
solution designed to optimize myocardial preservation. After
completion of the surgery, the heart is reactivated and reperfused
with oxygenated blood at body temperature. This produces a sequence
of hypothermic ischemia and normothermic reperfusion, which may
prevent the accumulation of high tissue levels of H.sup.+ and
lactate. Moreover, unlike acute MI, hypothermic cardioplegia
represents a state of global, zero-flow ischemia, followed by
global reperfusion.
[0024] In our previous application (Ser. No. 60/103,498), of which
this is a continuation-in-part, we reviewed the disadvantages of
glucose-insulin infusions and the advantages of substituting these
with a GLP-1 infusion, which is safer than insulin. In summary, GIK
infusions carry significant risks of both hypoglycemia and
hyperglycemia, and are technically demanding and staff-intensive.
The dangers of hypoglycemia are obvious.
[0025] In contrast, these risks do not exist with a GLP-1 infusion.
Glucagon-like peptide (7-36) amide (GLP-1) is a natural,
gut-derived, insulinotropic peptide that constitutes a major
component of the so-called incretin effect. GLP-1 exerts its major
effect at the pancreatic endocrine cells, where it (1) regulates
insulin expression and secretion from the .beta.-cells in a
glucose-dependent fashion; (2) stimulates the secretion of
somatostatin; and (3) suppresses the secretion of glucagon from the
.alpha. cells. Although not formally resolved, the strong
glucagonostatic effect is presumed to result from one or all of the
following: (1) direct suppression by stimulation of GLP-1 receptors
on .alpha. cells, although this is unlikely; (2) paracrine
suppression of glucagon secretion by intra-islet release of
somatostatin; or (3) paracrine suppression by intra-islet release
of insulin. Whatever the cellular mechanism, GLP-1 is unique in its
capacity to simultaneously stimulate insulin secretion and inhibit
glucagon release. Although a therapeutic insulin infusion also
inhibits glucagon release, this effect is not as potent as that of
GLP-1, which exerts a direct, intra-islet paracrine inhibition of
glucagon secretion.
[0026] The dual capacity of GLP-1 to powerfully stimulate insulin
release and inhibit glucagon secretion, together with the strict
glucose-dependence of its insulinotropic action, endow this
molecule with a unique therapeutic potential in the management of
ischemia-reperfusion. First, GLP-1 strongly stimulates the
secretion of endogenous insulin and therefore can be used to
achieve all of the beneficial actions attributed to an insulin
infusion in the metabolic treatment of ischemia-reperfusion.
Although high-dose GIK infusions typically contain 25-33% glucose
and 50-100 U insulin/L, the requirement for introduction of
hyperglycemia per se to achieve therapeutic efficacy, versus only
providing a metabolic milieu for the safe administration of high
doses of insulin, is unclear. It is likely that adequate blood
glucose levels are required to enable substrate delivery, but this
does not necessarily imply a need for hyperglycemia and should not
detract from the fact that insulin exerts important effects other
than glucose uptake. Therefore, a therapeutic GLP-1 infusion will
likely only require a modest (e.g., 5%) glucose coinfusion in order
to maintain blood glucose at slightly above physiological levels in
order to trigger insulin release. Glucose is not required as a
safety measure, since blood levels of .ltoreq.3.5 mM abrogate the
insulin-stimulating activity of GLP-1, thereby completely
protecting against the dangers of hypoglycemia.
[0027] Second, GLP-1 exerts a powerful glucagonostatic effect,
which together with its insulinotropic action will lead to a strong
suppression of FFAs. One of the major benefits of glucose-insulin
infusions is the reduction in circulating FFA levels and the
suppression of FFA uptake. FFAs and their metabolites have direct
toxic effects on the ischemic myocardium as well as during the
reperfusion period, when they contribute to stunning, and hence
reduction of FFA levels is a major therapeutic goal of metabolic
intervention in ischemia-reperfusion, goal of metabolic
intervention in ischemia-reperfusion. As glucagon is a powerful
stimulus for adipose tissue lipolysis and FFA production, GLP-1
mediated glucagon suppression further augments the insulin-induced
reduction in circulating FFAs. Thus, GLP-1 therapy is superior to a
glucose-insulin infusion in this regard. Indeed, preliminary data
in healthy volunteers indicate that an intravenous GLP-1 infusion
will reduce fasting plasma FFA levels to <10% of control
values.
[0028] GLP-1 should be effective in the majority of patients
without requiring concurrent glucose administration. However, a
small proportion of subjects may require glucose/GLP-1 to elicit an
adequate insulin response. In addition, it also may be necessary to
administer potassium to correct excess shifts of potassium in the
intracellular compartment when glucose is co-administered with
GLP-1.
[0029] In addition to GLP-1 or its biological analogues, the
therapy can include use of free radical scavengers such as
glutathione, melatonin, Vitamin E, and superoxide dismutase (SOD).
In such combinations reperfusion damage risk is lessened even
further.
[0030] The term "GLP-1", or glucagon-like peptide, includes
mimetics, and as used in the context of the present invention can
be comprised of glucagon-like peptides and related peptides and
analogs of glucagon-like peptide-1 that bind to a glucagon-like
peptide-1 (GLP-1) receptor protein such as the GLP-1 (7-36) amide
receptor protein and has a corresponding biological effect on
insulin secretion as GLP-1 (7-36) amide, which is a native,
biologically active form of GLP-1. See Goke, B and Byrne, M,
Diabetic Medicine, 1996, 13:854-860. The GLP-1 receptors are
cell-surface proteins found, for example, on insulin-producing
pancreatic .beta.-cells. Glucagon-like peptides and analogs will
include species having insulinotropic activity and that are
agonists of, i.e. activate, the GLP-1 receptor molecule and its
second messenger activity on, inter alia, insulin producing
.beta.-cells. Agonists of glucagon-like peptide that exhibit
activity through this receptor have been described: EP 0708179A2;
Hjorth, S. A. et al., J. Biol. Chem. 269 (48):30121-30124 (1994);
Siegel, E. G. et al. Amer. Diabetes Assoc. 57th Scientific
Sessions, Boston (1997); Hareter, A. et al. Amer. Diabetes Assoc.
57th Scientific Sessions, Boston (1997); Adelhorst, K. et al. J.
Biol. Chem. 269(9):6275-6278 (1994); Deacon C. F. et al. 16th
International Diabetes Federation Congress Abstracts, Diabetologia
Supplement (1997); Irwin, D. M. et al., Proc. Natl. Acad. Sci. USA.
94:7915-7920 (1997); Mosjov, S., Int. J. Peptide Protein Res.
40:333-343 (1992). Glucagon-like molecules include polynucleotides
that express agonists of GLP-1, i.e. activators of the GLP-1
receptor molecule and its secondary messenger activity found on,
inter alia, insulin-producing .beta.-cells. GLP-1 mimetics that
also are agonists include, for example, chemical compounds
specifically designed to activate the GLP-1 receptor. Glucagon-like
peptide-1 antagonists are also known, for example see e.g.
Watanabe, Y et al., J. Endocrinol. 140(1):45-52 (1994), and include
exendin (9-39) amine, an exendin analog, which is a potent
antagonist of GLP-1 receptors (see, e.g. WO97/46584). Recent
publications disclose Black Widow GLP-1 and Ser.sup.2 GLP-1, see G.
G. Holz, J. F. Hakner/Comparative Biochemistry and Physiology, Part
B 121(1998)177-184 and Ritzel, et al., A synthetic glucagon-like
peptide-1 analog with improved plasma stability, J. Endocrinol 1998
Oct. 159(1):93-102.
[0031] Further embodiments include chemically synthesized
glucagon-like polypeptides as well as any polypeptides or fragments
thereof which are substantially homologous. "Substantially
homologous," which can refer both to nucleic acid and amino acid
sequences, means that a particular subject sequence, for example, a
mutant sequence, varies from a reference sequence by one or more
substitutions, deletions, or additions, the net effect of which
does not result in an adverse functional dissimilarity between
reference and subject sequences. For purposes of the present
invention, sequences having greater than 50 percent homology, and
preferably greater than 90 percent homology, equivalent biological
activity in enhancing .beta.-cell responses to plasma glucose
levels, and equivalent expression characteristics are considered
substantially homologous. For purposes of determining homology,
truncation of the mature sequence should be disregarded. Sequences
having lesser degrees of homology, comparable bioactivity, and
equivalent expression characteristics are considered
equivalents.
[0032] Mammalian GLP peptides and glucagon are encoded by the same
gene. In the ileum the phenotype is processed into two major
classes of GLP peptide hormones, namely GLP-1 and GLP-2. There are
four GLP-1 related peptides known which are processed from the
phenotypic peptides. GLP-1 (1-37) has the sequence His Asp Glu Phe
Glu Arg His Ala Glu Gly Thr Phe Thr Ser Asp Val Ser Ser Tyr Leu Glu
Gly Gln Ala Ala Lys Glu Phe Ile Ala Trp Leu Val Lys Gly Arg Gly
(SEQ. ID NO:1). GLP-1 (1-37) is amidated by post-translational
processing to yield GLP-1 (1-36) NH.sub.2 which has the sequence
His Asp Glu Phe Glu Arg His Ala Glu Gly Thr Phe Thr Ser Asp Val Ser
Ser Tyr Leu Glu Gly Gin Ala Ala Lys Glu Phe Ile Ala Trp Leu Val Lys
Gly Arg (NH.sub.2) (SEQ. ID NO:2); or is enzymatically processed to
yield GLP-1 (7-37) which has the sequence His Ala Glu Gly Thr Phe
Thr Ser Asp Val Ser Ser Tyr Leu Glu Gly Gln Ala Ala Lys Glu Phe Ile
Ala Trp Leu Val Lys Gly Arg Gly (SEQ. ID NO:3). GLP-1 (7-37) can
also be amidated to yield GLP-1 (7-36) amide which is the natural
form of the GLP-1 molecule, and which has the sequence His Ala Glu
Gly Thr Phe Thr Ser Asp Val Ser Ser Tyr Leu Glu Gly Gin Ala Ala Lys
Glu Phe Ile Ala Trp Leu Val Lys Gly Arg (NH.sub.2) (SEQ. ID NO:4)
and in the natural form of the GLP-1 molecule.
[0033] Intestinal L cells secrete GLP-1 (7-37) (SEQ. ID NO:3) and
GLP-1 (7-36) NH.sub.2 (SEQ. ID NO:4) in a ratio of 1 to 5,
respectively. These truncated forms of GLP-1 have short half-lives
in situ, i.e., less than 10 minutes, and are inactivated by an
aminodipeptidase IV to yield Glu Gly Thr Phe Thr Ser Asp Val Ser
Ser Tyr Leu Glu Gly Gln Ala Ala Lys Glu Phe Ile Ala Trp Leu Val Lys
Gly Arg Gly (SEQ. ID NO:5); and Glu Gly Thr Phe Thr Ser Asp Val Ser
Ser Tyr Leu Glu Gly Gln Ala Ala Lys Glu Phe Ile Ala Trp Leu Val Lys
Gly Arg (NH.sub.2) (SEQ. ID NO:6), respectively. The peptides Glu
Gly Thr Phe Thr Ser Asp Val Ser Ser Tyr Leu Glu Gly Gln Ala Ala Lys
Glu Phe Ile Ala Trp Leu Val Lys Gly Arg Gly (SEQ. ID NO:5) and Glu
Gly Thr Phe Thr Ser Asp Val Ser Ser Tyr Leu Glu Gly Gln Ala Ala Lys
Glu Phe Ile Ala Trp Leu Val Lys Gly Arg (NH.sub.2) (SEQ. ID NO:6),
have been speculated to affect hepatic glucose production, but do
not stimulate the production or release of insulin from the
pancreas.
[0034] There are six peptides in Gila monster venoms that are
homologous to GLP-1. Their sequences are compared to the sequence
of GLP-1 in Table 1.
1TABLE 1 a. H A E G T F T S D V S S Y L E G Q A A K E F I A W L V K
G R NH.sub.2 b. H S D G T F T S D L S K Q M E E E A V R L F I E W L
K N G G P S S G A P P P S NH.sub.2 c. D L S K Q M E E E A V R L F I
E W L K N G G P S S G A P P P S NH.sub.2 d. H G E G T F T S D L S K
Q M E E E A V R L F I E W L K N G G P S S G A P P P S NH.sub.2 e. H
S D A T F T A E Y S K L L A K L A L Q K Y L E S I L G S S T S P R P
P S S f. H S D A T F T A E Y S K L L A K L A L Q K Y L E S I L G S
S T S P R P P S g. H S D A I F T E E Y S K L L A K L A L Q K Y L A
S I L G S R T S P P P NH.sub.2 h. H S D A I F T Q Q Y S K L L A K L
A L Q K Y L A S I L G S R T S P P P NH.sub.2 a = GLP-1(SEQ. ID
NO:4). b = Exendin 3(SEQ. ID NO:7). c = Exendin
4(9-39(NH.sub.2(SEQ. ID NO:8). d = Exendin 4(SEQ. ID NO:9). e =
Helospectin I (SEQ. ID NO:10). f = Helospectin II (SEQ. ID NO:11).
g = Helodermin (SEQ. ID NO:12). h = Q.sup.8, Q.sup.9 Helodermin
(SEQ. ID NO:13).
[0035] The major homologies as indicated by the outlined areas in
Table 1 are: peptides c and h are derived from b and g,
respectively. All 6 naturally occurring peptides (a, b, d, e, f and
g) are homologous in positions 1, 7, 11 and 18. GLP-1 and exendins
3 and 4 (a, b and d) are further homologous in positions 4, 5, 6,
8, 9, 15, 22, 23, 25, 26 and 29. In position 2, A, S and G are
structurally similar. In position 3, residues D and E (Asp and Glu)
are structurally similar. In positions 22 and 23 F (Phe) and I
(Ile) are structurally similar to Y (Tyr) and L (Leu),
respectively. Likewise, in position 26 L and I are structurally
equivalent.
[0036] Thus, of the 30 residues of GLP-1, exendins 3 and 4 are
identical in 15 positions and equivalent in 5 additional positions.
The only positions where radical structural changes are evident are
at residues 16, 17, 19, 21, 24, 27, 28 and 30. Exendins also have 9
extra residues at the carboxyl terminus.
[0037] The GLP-1 like peptides can be made by solid state chemical
peptide synthesis. GLP-1 can also be made by conventional
recombinant techniques using standard procedures described in, for
example, Sambrook and Maniaitis. "Recombinant," as used herein,
means that a protein is derived from recombinant (e.g., microbial
or mammalian) expression systems which can be genetically modified
to contain an expression gene for GLP-1 or its biologically active
analogues.
[0038] The GLP-1 like peptides can be recovered and purified from
recombinant cell cultures by methods including, but not limited to,
ammonium sulfate or ethanol) precipitation, acid extraction, anion
or cation exchange chromatography, phosphocellulose chromatography,
hydrophobic interaction chromatography, affinity chromatography,
hydroxylapatite chromatography and lectin chromatography. High
performance liquid chromatography (HPLC) can be employed for final
purification steps.
[0039] The polypeptides of the present invention may be a naturally
purified product, or a product of chemical synthetic procedures, or
produced by recombinant techniques from prokaryotic or eukaryotic
hosts (for example by bacteria, yeast, higher plant, insect and
mammalian cells in culture or in vivo). Depending on the host
employed in a recombinant production procedure, the polypeptides of
the present invention are generally non-glycosylated, but may be
glycosylated.
[0040] GLP-1 activity can be determined by standard methods, in
general, by receptor-binding activity screening procedures which
involve providing appropriate cells that express the GLP-1 receptor
on their surface, for example, insulinoma cell lines such as RINmSF
cells or INS-1 cells. See also Mosjov, S.(1992) and EP0708170A2. In
addition to measuring specific binding of tracer to membrane using
radioimmunoassay methods, cAMP activity or glucose dependent
insulin production can also be measured. In one method, a
polynucleotide encoding the receptor of the present invention is
employed to transfect cells to thereby express the GLP-1 receptor
protein. Thus, for example, these methods may be employed for
screening for a receptor agonist by contacting such cells with
compounds to be screened and determining whether such compounds
generate a signal, i.e. activate the receptor.
[0041] Polyclonal and monoclonal antibodies can be utilized to
detect, purify and identify GLP-1 like peptides for use in the
methods described herein. Antibodies such as ABGA1178 detect intact
unspliced GLP-1 (1-37) or N-terminally-truncated GLP-1 (7-37) or
(7-36) amide. Other antibodies detect on the very end of the
C-terminus of the precursor molecule, a procedure which allows by
subtraction to calculate the amount of biologically active
truncated peptide, i.e. GLP-1 (7-37) or (7-36) amide (Orskov et al.
Diabetes, 1993, 42:658-661; Orskov et al. J. Clin. Invest. 1991,
87:415-423).
[0042] Other screening techniques include the use of cells which
express the GLP-1 receptor, for example, transfected CHO cells, in
a system which measures extracellular pH or ionic changes caused by
receptor activation. For example, potential agonists may be
contacted with a cell which expresses the GLP-1 protein receptor
and a second messenger response, e.g. signal transduction or ionic
or pH changes, may be measured to determine whether the potential
agonist is effective.
[0043] The glucagon-like peptide-1 receptor binding proteins of the
present invention may be used in combination with a suitable
pharmaceutical carrier. Such compositions comprise a
therapeutically effective amount of the polypeptide, and a
pharmaceutically acceptable carrier or excipient. Such a carrier
includes, but is not limited to, saline, buffered saline, dextrose,
water, glycerol, ethanol, lactose, phosphate, mannitol, arginine,
trehalose and combinations thereof. The formulations should suit
the mode of administration and are readily ascertained by those of
skill in the art. The GLP-1 peptide may also be used in combination
with agents known in the art that enhance the half-life in vivo of
the peptide in order to enhance or prolong the biological activity
of the peptide. For example, a molecule or chemical moiety may be
covalently linked to the composition of the present invention
before administration thereof. Alternatively, the enhancing agent
may be administered concurrently with the composition. Still
further, the agent may comprise a molecule that is known to inhibit
the enzymatic degradation of GLP-1 like peptides may be
administered concurrently with or after administration of the GLP-1
peptide composition. Such a molecule may be administered, for
example, orally or by injection.
[0044] Patients administered GLP-1 or its analogues in combination
with the carrier systems here enumerated, especially those treated
before a planned event or within the first 4 hours after an
ischemic event, are observed to have less arrhythmia, less tissue
damage, and less discomfort without side effects.
[0045] From these considerations it is evident that an infusion of
GLP-1 can be expected to exert a major therapeutic effect in
myocardial reperfusion. It is expected that GLP-1 can be
administered either by I.V. or subcutaneous administration for
continuous infusion by intravenous (I.V.)0.1 pmol/kg/min to 10
pmol/kg/min and by subcutaneous (S.C.) 0.1 pmol/kg/min to 75
pmol/kg/min, and for single injection (bolus) by I.V. 0.005 nmol/kg
to 20 nmol/kg and S.C. 0.1 nmol/kg to 100 nmol/kg are suitable
levels of administration. The GLP-1 infusion can be coadministered
with glucose (5%) if required to maintain blood glucose levels
.gtoreq.5 mM (to maintain efficient insulin secretion). Similarly,
coadministration of potassium (K.sup.+) will also be considered,
depending on the extent to which activation of the membrane
Na.sup.+/K.sup.+ ATPase leads to a shift of K.sup.+ into the
intracellular space. The GLP-1 treatment will be commenced as early
in the post-ischemic period as possible after, for example, acute
spontaneous ischemia in the home or ambulance context and before
reperfusion therapies, and continued thereafter. In the case of
cardiac surgery, the GLP-1 infusion should commence 12-24 hours
prior to surgery, during surgery from the onset of anesthesia until
aortic crossclamping, and immediately after unclamping for a period
of at least 72 hours postoperatively. As earlier explained,
co-administration of a free radical scavenger will further aid
reperfusion recovery.
[0046] From the above it can be seen that the invention
accomplishes all of its stated objectives.
Sequence CWU 1
1
13 1 37 PRT mammalian 1 His Asp Glu Phe Glu Arg His Ala Glu Gly Thr
Phe Thr Ser Asp Val 1 5 10 15 Ser Ser Tyr Leu Glu Gly Gln Ala Ala
Lys Glu Phe Ile Ala Trp Leu 20 25 30 Val Lys Gly Arg Gly 35 2 36
PRT mammalian 2 His Asp Glu Phe Glu Arg His Ala Glu Gly Thr Phe Thr
Ser Asp Val 1 5 10 15 Ser Ser Tyr Leu Glu Gly Gln Ala Ala Lys Glu
Phe Ile Ala Trp Leu 20 25 30 Val Lys Gly Arg 35 3 31 PRT mammalian
3 His Ala Glu Gly Thr Phe Thr Ser Asp Val Ser Ser Tyr Leu Glu Gly 1
5 10 15 Gln Ala Ala Lys Glu Phe Ile Ala Trp Leu Val Lys Gly Arg Gly
20 25 30 4 30 PRT mammalian 4 His Ala Glu Gly Thr Phe Thr Ser Asp
Val Ser Ser Tyr Leu Glu Gly 1 5 10 15 Gln Ala Ala Lys Glu Phe Ile
Ala Trp Leu Val Lys Gly Arg 20 25 30 5 29 PRT mammalian 5 Glu Gly
Thr Phe Thr Ser Asp Val Ser Ser Tyr Leu Glu Gly Gln Ala 1 5 10 15
Ala Lys Glu Phe Ile Ala Trp Leu Val Lys Gly Arg Gly 20 25 6 28 PRT
mammalian 6 Glu Gly Thr Phe Thr Ser Asp Val Ser Ser Tyr Leu Glu Gly
Gln Ala 1 5 10 15 Ala Lys Glu Phe Ile Ala Trp Leu Val Lys Gly Arg
20 25 7 39 PRT Gila Monster venom 7 His Ser Asp Gly Thr Phe Thr Ser
Asp Leu Ser Lys Gln Met Glu Glu 1 5 10 15 Glu Ala Val Arg Leu Phe
Ile Glu Trp Leu Lys Asn Gly Gly Pro Ser 20 25 30 Ser Gly Ala Pro
Pro Pro Ser 35 8 31 PRT Gila Monster venom 8 Asp Leu Ser Lys Gln
Met Glu Glu Glu Ala Val Arg Leu Phe Ile Glu 1 5 10 15 Trp Leu Lys
Asn Gly Gly Pro Ser Ser Gly Ala Pro Pro Pro Ser 20 25 30 9 39 PRT
Gila Monster venom 9 His Gly Glu Gly Thr Phe Thr Ser Asp Leu Ser
Lys Gln Met Glu Glu 1 5 10 15 Glu Ala Val Arg Leu Phe Ile Glu Trp
Leu Lys Asn Gly Gly Pro Ser 20 25 30 Ser Gly Ala Pro Pro Pro Ser 35
10 38 PRT Gila Monster venom 10 His Ser Asp Ala Thr Phe Thr Ala Glu
Tyr Ser Lys Leu Leu Ala Lys 1 5 10 15 Leu Ala Leu Gln Lys Tyr Leu
Glu Ser Ile Leu Gly Ser Ser Thr Ser 20 25 30 Pro Arg Pro Pro Ser
Ser 35 11 37 PRT Gila Monster venom 11 His Ser Asp Ala Thr Phe Thr
Ala Glu Tyr Ser Lys Leu Leu Ala Lys 1 5 10 15 Leu Ala Leu Gln Lys
Tyr Leu Glu Ser Ile Leu Gly Ser Ser Thr Ser 20 25 30 Pro Arg Pro
Pro Ser 35 12 35 PRT Gila Monster venom 12 His Ser Asp Ala Ile Phe
Thr Glu Glu Tyr Ser Lys Leu Leu Ala Lys 1 5 10 15 Leu Ala Leu Gln
Lys Tyr Leu Ala Ser Ile Leu Gly Ser Arg Thr Ser 20 25 30 Pro Pro
Pro 35 13 35 PRT Gila Monster venom 13 His Ser Asp Ala Ile Phe Thr
Gln Gln Tyr Ser Lys Leu Leu Ala Lys 1 5 10 15 Leu Ala Leu Gln Lys
Tyr Leu Ala Ser Ile Leu Gly Ser Arg Thr Ser 20 25 30 Pro Pro Pro
35
* * * * *