U.S. patent application number 10/387269 was filed with the patent office on 2003-10-16 for methods and compositions for improving sleep.
This patent application is currently assigned to Vaxis Therapeutics Corporation, now CellegyCanada, Inc.. Invention is credited to Ackman, C. Bruce, Adams, Michael A., Heaton, Jeremy P.W., Ratz, Jodan D..
Application Number | 20030195140 10/387269 |
Document ID | / |
Family ID | 26879788 |
Filed Date | 2003-10-16 |
United States Patent
Application |
20030195140 |
Kind Code |
A1 |
Ackman, C. Bruce ; et
al. |
October 16, 2003 |
Methods and compositions for improving sleep
Abstract
Methods and compositions for improving sleep in individuals with
sleep disorders or other conditions which interfere with normal
sleep via administration of a NO-mimetic are provided.
Inventors: |
Ackman, C. Bruce; (Kingston,
CA) ; Adams, Michael A.; (Kingston, CA) ;
Heaton, Jeremy P.W.; (Grananoque, CA) ; Ratz, Jodan
D.; (Kingston, CA) |
Correspondence
Address: |
TOWNSEND AND TOWNSEND AND CREW, LLP
TWO EMBARCADERO CENTER
EIGHTH FLOOR
SAN FRANCISCO
CA
94111-3834
US
|
Assignee: |
Vaxis Therapeutics Corporation, now
CellegyCanada, Inc.
Suite 1606 116 Barrie Street
Kingston
CA
|
Family ID: |
26879788 |
Appl. No.: |
10/387269 |
Filed: |
March 11, 2003 |
Related U.S. Patent Documents
|
|
|
|
|
|
Application
Number |
Filing Date |
Patent Number |
|
|
10387269 |
Mar 11, 2003 |
|
|
|
09791127 |
Feb 22, 2001 |
|
|
|
6586478 |
|
|
|
|
60184087 |
Feb 22, 2000 |
|
|
|
60236727 |
Oct 2, 2000 |
|
|
|
Current U.S.
Class: |
514/1 |
Current CPC
Class: |
A61K 31/34 20130101;
A61K 31/535 20130101; A61K 31/455 20130101; A61K 9/7023 20130101;
A61K 45/06 20130101; A61P 25/20 20180101; A61K 31/21 20130101; Y10S
514/923 20130101 |
Class at
Publication: |
514/1 |
International
Class: |
A61K 031/00 |
Claims
What is claimed is:
1. A method for improving sleep in an individual suffering from a
sleep disorder or a condition wherein normal sleep is interrupted
or interfered with, said method comprising administering to the
individual a NO-mimetic in an amount therapeutically effective to
improve sleep in the individual.
2. The method of claim 1 wherein the amount of NO-mimetic
administered is less than an amount effective to appreciably alter
systemic vascular tone.
3. The method of claim 2 where the amount of NO-mimetic
administered is one half to one fortieth of the amount of
NO-mimetic known to appreciably alter systemic vascular tone in
normal circulation in a human.
4. The method of claim 1, wherein the NO-mimetic is administered by
transdermal patch.
5. The method of claim 1 wherein the NO-mimetic is co-administered
with an established drug for sleep disorders or a condition wherein
normal sleep is interrupted or interfered with.
6. A method for decreasing a therapeutic dosage of an established
drug for sleep disorders or a condition wherein normal sleep is
interrupted or interfered with, said method comprising
co-administering the established drug with a NO-mimetic.
7. A pharmaceutical composition comprising a NO-mimetic and an
established drug for sleep disorders or a condition wherein normal
sleep is interrupted or interfered with.
Description
INTRODUCTION
[0001] This application claims the benefit of priority of U.S.
provisional patent application Serial No. 60/236,727, filed Oct. 2,
2000 and U.S. provisional patent application Serial No. 60/184,087,
filed Feb. 22, 2000.
FIELD OF THE INVENTION
[0002] The present invention relates to methods and compositions
for improving sleep in individuals suffering from sleep disorders
(SDs) and other conditions which interfere with sleep. More
particularly, the present invention relates to methods of improving
sleep in individuals through administration of low doses of nitric
oxide-mimetics (NO-mimetics).
BACKGROUND OF THE INVENTION
[0003] Sleep is a complex process with many parts of the nervous
system being involved in controlling it and influencing its
different stages. Stages or levels of sleep include drowsiness,
light sleep, deep sleep, and dream sleep. It is possible to
identify which stage of sleep a person is in by measuring different
activities of the brain (central nervous system) and body
(peripheral nervous system).
[0004] For most people, falling asleep and staying asleep are parts
of a natural process. Good sleepers are likely to have developed
certain lifestyle and dietary habits that promote sound sleep.
These habits or behaviors, known as sleep hygiene, can have
positive effects on sleep before, during, and after time spent in
bed. For other people, particularly those suffering from a sleep
disorder, problems falling asleep and staying asleep have a large
negative impact on their lives.
[0005] Sleep disorders (SDs) are diagnosed and treated by many
different healthcare providers, including general practitioners and
specialists in neurology, pulmonary medicine, psychiatry,
psychology, pediatrics and other fields. The International
Classification of Sleep Disorders (ICSD) has over seventy sleep
disorders listed, and includes, THE DYSSOMNIAS: Intrinsic Sleep
Disorders (Psychophysiological Insomnia, Sleep State Misperception,
Idiopathic Insomnia, Narcolepsy, Recurrent Hypersomnia (excessive
sleepiness), Idiopathic Hypersomnia, Posttraumatic Hypersomnia,
Obstructive Sleep Apnea Syndrome, Central Sleep Apnea Syndrome,
Central Alveolar Hypoventilation, Periodic Limb Movement Disorder
(PLM), Restless Leg Syndrome (RLS), and Intrinsic Sleep Disorder
Not Otherwise Specified (NOS)), Extrinsic Sleep Disorders
(Inadequate Sleep Hygiene, Environmental Sleep Disorder, Altitude
Insomnia, Adjustment Sleep Disorder, Insufficient Sleep Syndrome,
Limit-Setting Sleep Disorder, Sleep-Onset Association Disorder,
Food Allergy Insomnia, Nocturnal Eating/Drinking Syndrome,
Hypnotic-Dependent Sleep Disorder, Stimulant-Dependent Sleep
Disorder, Alcohol-Dependent Sleep Disorder, Toxin-Induced Sleep
Disorder, and Extrinsic Sleep Disorder Not Otherwise Specified
(NOS)), Circadian Rhythm Sleep Disorders (Time-Zone Change
(Jet-Lag), Syndrome Shift-Work Sleep Disorder, Irregular Sleep/Wake
Pattern, Delayed Sleep-Phase Syndrome, Advanced Sleep-Phase
Syndrome, Non-24-Hour Sleep/Wake Disorder, and Circadian Rhythm
Sleep Disorder Not Otherwise Specified (NOS)); and THE PARASOMNIAS:
Sleep/Wake Transition Disorders (Rhythmic Movement Disorder, Sleep
Starts (Hypnic Jerks), Sleep Talking, and Nocturnal Leg Cramps
(Nocturnal Myoclonus), Arousal Disorders (Confusional Awakenings
(Sleep Drunkenness), Sleepwalking (Somnambulism), and Night Terrors
(Pavor Nocturnus, Incubus Attacks)), Parasomnias Usually Associated
With REM Sleep (Nightmares Sleep Paralysis, Impaired Sleep-Related
Penile Erections, Sleep-Related Painful Erections, REM
Sleep-Related Sinus Arrest, and REM Sleep Behavior Disorder), Other
Parasomnias (Sleep Bruxism (Teeth Grinding), Sleep Enuresis (Bed
Wetting), Sleep-Related Abnormal Swallowing Syndrome, Nocturnal
Paroxysmal Dystonia, Sudden Unexplained Nocturnal Death Syndrome,
Primary Snoring Infant Sleep Apnea, Congenital Central
Hypoventilation Syndrome, Sudden Infant Death Syndrome (SIDS),
Benign Neonatal Sleep Myoclonus, and other Parasomnias Not
Otherwise Specified (NOS)). Sleep disorders (SDs) can lead to
lowered quality of life and reduced personal health. They endanger
public safety by contributing to traffic and industrial accidents.
These disorders can lead to problems falling asleep and staying
asleep, difficulties staying awake or staying with a regular
sleep/wake cycle, sleepwalking, bedwetting, nightmares, and other
problems that interfere with sleep. Some sleep disorders can be
life-threatening.
[0006] There are many limitations to the use of sleeping pills.
While pills may help, for example, to aid sleeping during an
overnight airplane ride or in a crisis situation to prevent an
acute sleeping problem from turning into chronic insomnia, in
general, the long-term use of sleeping pills has more risks than
benefits. Today, most insomnia patients are not given sleeping
pills, and most insomnia patients who do take drugs use them only
briefly. Instead, long-term users usually have either a generalized
anxiety disorder or a chronic physical illness exacerbated by
anxiety, such as arthritis or heart disease.
[0007] The drugs used to induce drowsiness (hypnotics and
sedatives) are often the same as those used to relieve anxiety
(anxiolytics). Today, the most popular anxiety relievers and sleep
inducers are the benzodiazepines, which enhance the effect of the
inhibitory neurotransmitter gamma-aminobutyric acid (GABA). The
benzodiazepines used as sleeping pills include diazepam (VALIUM)
and temazepam (RESTORIL). However, development of tolerance to
their effects often renders these drugs ineffective within a few
weeks. Zolpidem (AMBIEN) is a short-acting drug that is not a
benzodiazepine but has a similar mechanism of action. Preparations
containing antihistamines are sold over the counter under such
names as NYTOL and SOMINEX. They are fairly safe and may be useful,
but tolerance may develop quickly. For depression associated with
disturbed sleep, sedative antidepressant drugs such as
amitriptyline (ELAVIL) and trazodone (DESYREL), are often
prescribed. Antipsychotic drugs (neuroleptics) may provoke sleep in
anxious, hallucinating manic or schizophrenic patients.
Dopaminergic agents such as levadopa/carbidopa, bromocriptine
mesylate (PARLODEL, a D.sub.2 receptor agonist), and pergolide (a
D.sub.1/D.sub.2 receptor agonist) have been suggested for use in
sleep disorders such as restless leg syndrome (RLS). Opioids such
as codeine, propoxyphene, oxycodone, pentazocrine, hydrocodone, and
methadone have also been prescribed for patients with severe and
relentless symptoms of RLS. However, these drugs are also
unfortunately frequently associated with undesirable side effects.
The opioids can be addictive and are generally not prescribed for
people with a history of addictive behavior. Many people on
levodopa therapy may experience what is known as an "augmentation"
effect: symptoms begin to occur and intensify during the afternoon
or early evening, even though relief is felt at night.
[0008] Thus, there is a need for a drug treatment which improves
sleep in individuals suffering from sleep disorders and other
conditions which interfere with normal sleep that does not exhibit
undue side effects.
SUMMARY OF THE INVENTION
[0009] According to a broad aspect, the present invention provides
a method of improving sleep in an individual in need of such
treatment comprising administering to the individual a NO-mimetic
in an amount therapeutically effective to improve sleep. The
NO-mimetic can be administered to an individual to treat a
diagnosed sleep disorder, preferably a dyssomnia. The NO-mimetic
can also be administered to improve sleep in an individual
suffering from a condition such as fibromyalgia or a peripheral
sensory neurogenic syndrome such as restless leg syndrome or
diabetic neuropathy, wherein normal sleep is interrupted or
interfered with. In a preferred embodiment, the NO-mimetic is
administered at an amount therapeutically effective to improve
sleep, but ineffective to appreciably alter systemic vascular tone
in the individual. Thus, in this present invention, preferred
amounts of NO-mimetic therapeutically effective to improve sleep
are less than an amount effective to induce systemic vascular
dilation or used to manage the symptoms associated with angina
pectoris or congestive heart failure. Preferably, a NO-mimetic is
administered in an amount between about one half (1/2) to about one
fortieth ({fraction (1/40)}) the amount effective to appreciably
alter systemic vascular tone in the individual, about one fourth
(1/4) to about one fortieth ({fraction (1/40)}) the amount
effective to appreciably alter systemic vascular tone in the
individual, or one eighth (1/8) to about one fortieth ({fraction
(1/40)}) the amount effective to appreciably alter systemic
vascular tone in the individual.
[0010] The NO-mimetic can be administered by oral, supralingual,
sublingual, transdermal or buccal administration. In a preferred
embodiment, the NO-mimetic is administered by transdermal
patch.
DETAILED DESCRIPTION OF THE INVENTION
[0011] The symptoms in an individual with a sleep disorder or a
condition which leads to interrupted sleep manifest themselves
through an individual's sensory perception and result from what is
believed to be a common underlying neurogenic pathway. It is
believed that the inability to sleep experienced by those
individuals suffering from sleep disorders and/or conditions which
interfere with sleep may be linked to changes in the nitric
oxide-cyclic GMP signaling mechanisms within the peripheral and
central nervous system as well nitric oxide mechanisms which are
independent of cyclic GMP. Further, it is believed that the some
symptoms of sleep disorders or other sleep interfering condition
are brought on when the neuronal environment or functioning is
altered such that cyclic GMP levels are decreased. Nitric oxide is
known to signal cGMP in the peripheral nerves (Aoki E. et al. Brain
Res. 1993; 620:142-145). It has now been found that NO-mimetics
improve sleep via, what is believed to be, action of the NO-mimetic
on cyclic GMP dependent pathway and/or pathways independent of
cyclic GMP.
[0012] The present invention relates to methods for improving sleep
in individuals suffering from a sleep disorder or other condition
which interferes with or interrupts sleep via administration of a
NO-mimetic administered either alone or in combination with
additional NO-mimetics or an established drug for sleep disorders.
When the No-mimetic is administered in combination with an
established drug for sleep disorders, it is expected that lower
doses of the established drug than normally recommended can be used
to improve sleep, thereby eliminating many of the unwanted side
effects which have been reported for these known treatments.
Accordingly, the present invention also provides methods for
decreasing the therapeutic dosage of an established drug for sleep
disorders or a condition wherein normal sleep is interrupted or
interfered with by co-administering the established drug with a
NO-mimetic. By co-administer it is meant that the established drug
is administered at the same time, just prior to, or just after
administration of a NO-mimetic. In one embodiment of the present
invention, a single pharmaceutical composition is provided which
comprises an established drug for sleep disorders and conditions
wherein normal sleep is interrupted or interfered with and a
NO-mimetic. Well known methods for formulation such as those
described herein can be used to prepares these pharmaceutical
compositions. Examples of established drugs for sleep disorders and
conditions wherein normal sleep is interrupted or interfered with
which can be used in the methods and pharmaceutical compositions of
the present invention include, but are not limited to, hypnotics,
sedatives and anxiolytics such as the benzodiazepines diazepam and
temazepam, zoldipem, antihistamines such as NYTOL and SOMINEX,
sedative antidepressants such as amitriptyline and trazodone,
dopaminergic agents such as levodopa/carbidopa, bromocriptine
mesylate and pergolide, and opioids such as codeine, propoxyphene,
oxycodone, pentazocrine, hydrocodone, and methadone.
[0013] The methods and compositions are believed to provide relief
to an individual suffering from a sleep disorder or a condition
which interferes with normal sleep by replacing the deficit in
endogenous NO and/or enhancing endogenous neuronal pathways for
generating NO or cyclic GMP. Unlike agents currently used to induce
sleep such as the sedative hypnotics, the present invention
improves sleep by conditioning the neuronal micro-environment in an
individual such that their ability to get to sleep and maintain a
restful sleep is greatly enhanced. Small, regulatory doses of a
NO-mimetic such as nitroglycerin to a patient with a sleep disorder
or a condition which leads to interrupted sleep have now been
demonstrated to be sufficient to restore the levels of nitric oxide
in the nerves to normal levels and decrease the patient's
perception of his or her sleep disorder symptoms. The net effect of
the NO-mimetic agents which can be used to improve sleep in
individuals with sleep disorders or other conditions which
interfere with sleep is to act as neuronal conditioners which
either directly or indirectly inhibit the action of nerves
responsible for generating the characteristic set of symptoms of
sleeplessness. While experiments described herein involve use of
the NO-mimetic nitroglycerin, it is believed that any NO-mimetic
that can alter the action of these nerves can be used to improve
sleep in individuals suffering from sleep disorders or other
conditions which interfere with sleep. Administration of any
NO-mimetic, either alone or in combination with another NO-mimetic
or an established drug for treatment of sleep disorders, provides
relief of sleeplessness associated with sleep disorders and other
conditions wherein sleep is interrupted by maintaining normalized
physiological functioning in the nerves responsible for the
sleeplessness. As a result, administration of a NO-mimetic prevents
the symptoms of the sleep disorder or other condition which
interferes with sleep, and is useful in treating sleeplessness
associated with sleep disorders and other conditions which
interfere with sleep and preventing individuals suffering from such
disorders or conditions from perceiving sleep disorder symptoms.
Also, unlike agents currently used in the treatment of sleep
disorders, the use of low doses of a NO-mimetic are not habit
forming or addictive and possibly leave the user feeling more alert
upon waking. When the NO-mimetic is used in combination with an
established drug for sleep disorders, it is believed that lower
doses of the established drug than routinely prescribed can be
used, thus alleviating the unwanted habit forming or addictive side
effects as well as the lack of alertness upon waking associated
with many of these established drugs. Accordingly, pharmaceutical
compositions of the present invention which comprise a NO-mimetic
and an established drug for sleep disorders and conditions wherein
normal sleep is interrupted or interfered with may comprise a lower
amount of established drug than routinely prescribed or
administered.
[0014] The contents of all documents cited in this application are
incorporated herein by reference in their entirety.
[0015] Definitions:
[0016] As used herein in the detailed description and in the
claims, the term "sleep disorder (SD)" is intended to mean any
irregularity in sleep and is inclusive of diagnosed sleep disorders
as well as conditions which interrupt or interfere with normal
sleep. Sleep disorders can be acute or chronic. Sleep disorders can
also vary in nature and degree. Sleep disorder is also meant to
include any new or existing sleep disorders in the two major sleep
disorder classes as listed by the International Classification of
Sleep Disorders (ICSD) including dyssomnias (insomnia) and
parasomnias (abnormal behaviors during sleep). As used herein and
in the claims, this term is also meant to be inclusive of
conditions which are known to interfere with sleep such as
fibromyalgia and peripheral sensory neurogenic syndromes such as
restless leg syndrome and diabetic neuropathy. Sleep consists of
two distinct states: REM (rapid eye movement) sleep and NREM
(non-REM) sleep. Dreaming occurs mostly in REM sleep. Sleep is a
cyclic phenomenon, with four or five REM periods during the night,
which accounts for about 25 percent of the total night's sleep. Any
physical or perceived symptoms which interfere with this cyclic
pattern is considered for purposes of the present invention a
"sleep disorder" or "condition wherein normal sleep is interrupted
or interfered with".
[0017] As used herein, the term "insomnia" is intended to mean the
sense of not getting enough sleep to awake refreshed and affects 20
to 40 percent of all adults in the course of any year. This term is
employed ubiquitously to indicate any and all gradations and types
of sleep loss. Although insomnia has myriad causes, it can roughly
be divided into three categories: predisposing, precipitating and
perpetuating.
[0018] Predisposing factors are the built-in characteristics of a
person that make him or her vulnerable. Tense or driven people
whose heads are brimming with plans or worries can easily lose
sleep. Others with severe depression often cannot sleep through the
night. In manic disorders, sleeplessness may be important early
sign of impending mania in bipolar patients. Predisposing factors
also include neurologic conditions such as peripheral sensory
neurogenic syndrome or fibromyalgia has also been associated with
insomnia. In fact, the peripheral sensory neurogenic syndrome,
referred to as restless legs syndrome, is included in the list of
dyssomnias published in the International Classification of Sleep
Disorders and affects individuals mainly at night as does the
involuntary twitching of leg muscles referred to nocturnal
myoclonus.
[0019] The term "peripheral sensory neurogenic syndrome (PSNS)"
refers to the manifestation of a characteristic set of signs and
symptoms which result from a common underlying neurogenic pathway.
The syndrome is characterized by a number of sensory nerve symptoms
including sensations which are described by the patient as pulling,
drawing, crawling, tingling, prickly, and sometimes momentarily
painful. These sensations typically begin in the toes and legs, but
can spread to the hands, arms and trunk. Two of the most commonly
observed conditions involving PSNS are the so-called "restless leg
syndrome" (also sometimes referred to as "Ekbom's Syndrome") and
the sensations in the extremities which accompany diabetic
neuropathy. Fibromyalgia or fibrositis is intended to mean a
condition that is associated with widespread aching, stiffness and
fatigue which originates in the muscles and soft tissues.
Fibromyalgia can also include overlapping conditions such as
rheumatic pain modulation disorder, myofascial pain syndrome,
chronic fatigue syndrome (Buchwald D. Rheum Dis Clin North Am
22(2):219-243, 1996) and sleep-related myoclonus. The cause of
fibromyalgia is unknown, but there is evidence to suggest that
there is a link between fibromyalgia and sleep disorders since most
patients have disrupted sleep patterns (Harding, S. M. Am J Med Sci
315: 367-376. 1998). Methods of the present invention are
particularly useful in improving sleep in individuals suffering
from conditions such as these which interfere with or interrupt
normal sleep.
[0020] Precipitating factors are events in life that trigger a
period of disturbed sleep. Stresses that precipitate insomnia may
include an increase in responsibilities, the loss of a loved one,
hospitalization or acute pain, to name a few. An abrupt alteration
of schedule, resulting from a change of shift at work or jet lag,
can also provoke insomnia.
[0021] Perpetuating factors are behaviors that help to maintain
sleeplessness once it has begun. These include irregular sleep
habits and the use of drugs. Abuse of alcohol may cause or be
secondary to the sleep disturbance. Heavy smoking (more than a pack
a day) causes difficulty in falling asleep. Short-term or transient
insomnia is seen in people who have no history of sleep
disturbances and who have a fairly obvious precipitating
factor.
[0022] As used herein, the term "improve" with respect to sleep, is
meant to reduce, prevent (e.g., prophylaxis), reverse (e.g.,
alleviate), ameliorate, control, or manage the sleeplessness and
other symptoms associated with sleep disorders as well as other
conditions which interfere with normal sleep. As used herein,
"other symptoms" refers to characteristic sensations which result
from a common underlying sensory neurogenic pathway and that are
associated with sleep disorders, including, for example, dyssomnias
(insomnia) and parasomnias (abnormal behaviors during sleep).
Improvement of sleep can be measured both quantitatively and
qualitatively. For example, qualitatively, sleep improvement can be
determined by any number of factors including but not limited to,
an easier time falling asleep at bedtime, a decrease in the
frequency of waking up in the middle of the night, waking up at an
appropriate time (i.e. not too early in the morning), and getting
good quality sleep that enables the individual to feel refreshed
the following day. Factors which can be used to determine
improvement in sleep quantitatively include, but are not limited
to, polysomnographic data demonstrating increased sleep efficiency,
more time spent asleep in deeper stages of sleep such as Stage 2-4
as opposed to Stage 1, and decreased number of periodic limb
movements.
[0023] As used herein, the term "apnea" is intended to mean the
absence of breathing. During sleep, our breathing changes with the
stage or depth of sleep. Some individuals stop breathing for brief
intervals, however, when these episodes of apnea become more
frequent and last longer, they can cause the body's oxygen level to
decrease, which can disrupt sleep. The patient may not fully
awaken, but is aroused from the deep restful stages of sleep, and
thus feels tired the next day. There are two main types of sleep
apnea which may occur together. The most common is obstructive
sleep apnea, during which, breathing is blocked by a temporary
obstruction of the main airway, usually in the back of the throat.
This often occurs because the tongue and throat muscles relax,
causing the main airway to close. The muscles of the chest and
diaphragm continue to make breathing efforts, but the obstruction
prevents any airflow. After a short interval lasting seconds to
minutes, the oxygen level drops, causing breathing efforts to
become more vigorous, which eventually opens the obstruction and
allows airflow to resume. This often occurs with a loud snort and
jerking of the body, causing the patient to arouse from deep sleep.
After a few breaths, the oxygen level returns to normal, the
patient falls back to sleep, the muscles of the main airway relax
and the obstruction occurs again. This cycle is then repeated over
and over during certain stages of sleep. Most people with
obstructive sleep apnea snore suggesting that their main airway is
already partly obstructed during sleep, but not all people who
snore have obstructive sleep apnea. A less common form of sleep
apnea is central sleep apnea, so named because the central control
of breathing is abnormal. This control center lies in the brain,
and its function can be disrupted by a variety of factors. There is
no obstruction to airflow. The patient with sleep apnea stops
breathing because the brain suddenly fails to signal the muscles of
the chest and diaphragm to keep breathing. These patients do not
resume breathing with a snort and body jerk, but merely start and
stop breathing at various intervals. Although the mechanism is
different than obstructive sleep apnea, sleep is still disturbed by
the periodic decreases in oxygen, and the patients suffer from the
same daytime symptoms. Some patients may suffer from a combination
of the two causes of apnea, a disorder which is called mixed-sleep
apnea. Sleep apnea should be suspected in individuals who are noted
to have excessive daytime sleepiness and other symptoms described
above, especially if they are known to snore and have a restless
sleep. Commonly, these patients have exhibited loud snoring for
many years, more often are male, and note that the daytime
sleepiness has become a progressive problem over many months. Less
commonly, they may be bothered by bedwetting or impotence. The
sleep problems are often aggravated by alcohol or sedative
medications. They are also more readily noticed by the patient's
family and friends, especially the bed partner.
[0024] As used herein, by the term "NO" or "nitric oxide" it is
meant to be inclusive of NO in its various redox forms. The
presence of nitric oxide (NO) in biological systems is usually
inferred based on its physiological effect. However, several
different redox forms of NO such as the NO free radical (NO.), the
nitrosonium cation (NO+), the nitroxyl anion (NO-) or other oxides
of nitrogen (NOx) are known to exist under physiological conditions
and there is no clear evidence to suggest that one form is favored
over another (Butler et al. Trends Pharmacol. Sci. 16:18-22 (1995);
Stamler et al. Science 258:1898-1902 (1992)). NO is also know to
react with thiols to form S-nitrosothiols (RS-NO) and may represent
a long-term storage form for NO. Thus, the term "NO" as used herein
refers to any and all forms of nitric oxide which exist under
physiological conditions.
[0025] As used herein, the term "NO-mimetic" is intended to mean NO
(nitric oxide), or a functional equivalent thereof; any compound
which mimics the effects of NO, generates or releases NO through
biotransformation, any compound which generates NO spontaneously,
any compound which spontaneously releases NO, or any compound which
in any other manner generates NO or a NO-like moiety when
administered to a mammal. Such a compound can also be referred to
as a "NO donor", "NO prodrug", "NO producing agent", "NO delivering
compound", "NO generating agent" and "NO provider". Examples of
such compounds include, but are not necessarily limited to:
metabolic precursors for NO such as L-arginine and L-citrulline;
so-called "organonitrates" such as nitroglycerin (GTN), isosorbide
5-mononitrate (ISMN), isosorbide dinitrate (ISDN), pentaerythritol
tetranitrate (PETN), erythrityl tetranitrate (ETN), amino acid
derivatives such as N-hydroxy-L-arginine (NOHA),
N.sup.6-(1-iminoethyl)lysine) (L-NIL),
L-N.sup.5-(1-iminoethyl)ornithine (LN-NIO),
N.sup.-methyl-L-arginine (L-NMMA), and S-nitrosoglutathione (SNOG);
other compounds which generate or release NO under physiologic
conditions such as S,S-dinitrosodithiol (SSDD),
[N-[2-(nitroxyethyl)]-3-p- yridinecarboxamide (nicorandil), sodium
nitroprusside (SNP), S-nitroso-N-acetylpenicillamine (SNAP),
3-morpholino-sydnonimine (SIN-1), molsidomine, DEA-NONOate
(2-(N,N-diethylamino)-diazenolate-2-oxide), spermine NONOate
(N-[4-[1-(3-aminopropyl)-2-hydroxy-2-nitrosohydrazino]bu-
tyl-1,3-propanediamine), and NO gas, or a functional equivalent
thereof. The organic nitrates GTN, ISMN, ISDN, ETN, and PETN, as
well as nicorandil are commercially available in pharmaceutical
dosage forms (see Tables 3 and 4). SIN-1, SNAP, S-thioglutathione,
L-NMMA, L-NIL, L-NIO, spermine NONOate, and DEA-NONOate are
commercially available from Biotium, Inc. 183 Shoreline Court,
Richmond, Calif., USA. The term "NO-mimetic", as used herein, is
also intended to mean any compound that acts as a NO pathway
mimetic, that has NO-like activity, or that mimics the effect of
NO, e.g. CO. Such compounds do not necessarily release, generate,
or provide NO, but they have the same effect as NO on a pathway
that is affected by NO. For example, NO can have both cyclic
GMP-dependent and cyclic GMP-independent effects. NO is known to
activate the soluble form of guanylyl cyclase thereby increasing
intracellular levels of the second messenger cyclic GMP. As such,
any compounds which directly activate guanylyl cyclase such as
3-(5'-hydroxymethyl-2'furyl)-1- -benzyl indazole (YC-1) or which
act as cyclic-GMP analogues such as 8-bromo-cyclic-GMP (8-Br-cGMP)
and 8-(4-chlorophenylthio)guanosine 3',5'-cyclic monophosphate
(8-PCPT-cGMP) are considered NO-mimetics. For purposes of the
present invention, phosphodiesterase inhibitors or any compound
that inhibits enzymatic degradation of a cyclic nucleotide are also
considered NO-mimetics. These NO-mimetics include, for example,
compounds that antagonize or inhibit the biosynthesis or actions of
any enzyme that degrades a cyclic nucleotide. Such degradation may
comprise the cleavage of a phosphodiester such as cGMP or cAMP to
give a phosphomonoester and a free hydroxyl group. Examples of
these NO-mimetics include, but are not limited to, sildenafil;
cilostamide
(N-cyclohexyl-N-methyl-4-(1,2-dihydro-2-oxo-6-quinolyloxy)butyramide;
dipyridamole
(2,6-bis(diethanol-amino)-4,8-dipipendinopyrimido-[5,4-d]pyr-
imidine); erythro-9-(2-hydroxy-3-nonyl)adenine (EHNA); etazolate
(1-ethyl-4-[(1-methylethylidene)hydrazino]-1H-pyrazolo-[3,4-b]-pyridine-5-
-carboxylic acid, ethyl ester);
4-[[3,4-(methylene-dioxy)benzyl]amino]-6-c- hloroquinazoline
(MBCQ); 8-methoxymethyl-1-methyl-3-(2-methylpropyl)xanthi- ne
(MMPX); 1-(3-chlorophenylamino)-4-phenyl-phthalazine (MY-5445);
4-(3-butoxy-4-methoxyphenyl)methyl-2-imidazolidone (Ro 20-1724);
Rolipram (4-(3-(cyclopentyloxy)-4-methoxyphenyl)pyrrolidin-2-one);
vinpocetine (3,16)eburnamenine-14-carboxylic acid ethyl ester);
zaprinast (2-propyloxyphenyl)-8-azapurin-6-one); and zardaverine
(6-[4-(difluoro-methoxy)-3-methoxyphenyl]-3(2H)-pyridazinone. These
NO-mimetics are available from Tocris Cookson Inc., 114 Holloway
Road, Suite 200 Ballwin, Mo. 63011 USA.
[0026] Also contemplated as falling within the scope of the present
invention for use in improving sleep are the pharmaceutically
acceptable salts of any of the foregoing NO-mimetics. As used
herein, the term "pharmaceutically acceptable salt" refers to those
salts which are within the scope of sound medical judgment,
suitable for use in contact with the tissues of humans and lower
animals without undue toxicity, irritation, allergic response and
the like, and are commensurate with a reasonable benefit/risk
ratio. Pharmaceutically acceptable salts are well known in the art.
For example, S. M. Berge, et al. describe pharmaceutically
acceptable salts in detail in J. Pharmaceutical Sciences, 66: 1-19
(1977). The salts can be prepared in situ during the final
isolation and purification of the compounds of the invention, or
separately by reacting the free base function with a suitable
organic acid. Examples of pharmaceutically acceptable, nontoxic
acid addition salts are salts of an amino group formed with
inorganic acids such as hydrochloric acid, hydrobromic acid,
phosphoric acid, sulfuric acid and perchloric acid or with organic
acids such as acetic acid, oxalic acid, maleic acid, tartaric acid,
citric acid, succinic acid or malonic acid or by using other
methods used in the art such as ion exchange. Other
pharmaceutically acceptable salts include adipate, alginate,
ascorbate, aspartate, benzenesulfonate, benzoate, bisulfate,
borate, butyrate, camphorate, camphorsulfonate, citrate,
cyclopentanepropionate, digluconate, dodecylsulfate,
ethanesulfonate, formate, fumarate, glucoheptonate,
glycerophosphate, gluconate, hemisulfate, heptanoate, hexanoate,
hydroiodide, 2-hydroxy-ethanesulfonate, lactobionate, lactate,
laurate, lauryl sulfate, malate, maleate, malonate,
methanesulfonate, 2-naphthalene-sulfonate, nicotinate, nitrate,
oleate, oxalate, palmitate, pamoate, pectinate, persulfate,
3-phenylpropionate, phosphate, picrate, pivalate, propionate,
stearate, succinate, sulfate, tartrate, thiocyanate,
p-toluenesulfonate, undecanoate, valerate salts, and the like.
Representative alkali or alkaline earth metal salts include sodium,
lithium, potassium, calcium, magnesium, and the like. Further
pharmaceutically acceptable salts include, when appropriate,
nontoxic ammonium, quaternary ammonium, and amine cations formed
using counterions such as halide, hydroxide, carboxylate, sulfate,
phosphate, nitrate, lower alkyl sulfonate and aryl sulfonate.
Preferred acid addition salts of compounds contemplated for use in
the method of the present invention are the hydrochloride and
acetate salts.
[0027] The term "prodrug" refers to compounds that are rapidly
transformed in vivo to yield NO, as for example, by hydrolysis in
blood or other biotransformation mechanism. T. Higuchi and V.
Stella provide a thorough discussion of the prodrug concept in
"Prodrugs as Novel Delivery Systems," Vol. 14 of the A.C.S.
Symposium Series, American Chemical Society (1975). Examples of
esters useful as prodrugs for compounds containing carboxyl groups
may be found on pages 14-21 of Bioreversible Carriers in Drug
Design: Theory and Application, edited by E. B. Roche, Pergamon
Press (1987).
[0028] The term "prodrug ester group" refers to any of several
ester-forming groups that are hydrolyzed under physiological
conditions. Examples of prodrug ester groups include
pivoyloxymethyl, acetoxymethyl, phthalidyl, indanyl and
methoxymethyl, as well as other such groups known in the art.
[0029] As used herein, the term "pharmaceutically acceptable ester"
refers to esters which hydrolyze in vivo and include those that
break down readily in the human body to leave the parent compound
or a salt thereof. Suitable ester groups include, for example,
those derived from pharmaceutically acceptable aliphatic carboxylic
acids, particularly alkanoic, alkenoic, cycloalkanoic and
alkanedioic acids, in which each alkyl or alkenyl moiety
advantageously has not more than 6 carbon atoms. Examples of
particular esters includes formates, acetates, propionates,
butyrates, acrylates and ethylsuccinates.
[0030] The phrase "without appreciably altering systemic vascular
tone" as used herein means not affecting mean arterial pressure so
as to produce inappropriate systemic vasodilation with effects such
as hypotension, headache, and flushing.
[0031] Pharmaceutical Formulations:
[0032] Pharmaceutical formulations for the administration of
NO-mimetics to improve sleep in accordance with the method of the
present invention may take the form of ointments, transdermal
patches, transbuccal patches, injectables, nasal inhalant forms,
spray forms for deep lung delivery through the mouth, orally
administered ingestable tablets and capsules, and tablets or
lozenges, or "lollipop" formulations for administration through the
oral mucosal tissue. The latter formulations include tablets,
lozenges and the like which are dissolved while being held on or
under the tongue, or in the buccal pouch. It is preferred that the
pharmaceutical preparations provide the desired dosage over a
sustained period of time selected based upon the individual needs
of a patient suffering from a sleep disorder or other condition
which interferes with or interrupts normal sleep. Thus, for
purposes of the present invention, a "sustained period" may range
from only a few minutes up to about 12 hours and is inclusive of,
but not limited to intermediary ranges such as 0.5-10, 2-8, 2-6 and
3-4 hours.
[0033] The pharmaceutical compositions of the present invention
comprise a therapeutically effective amount of a NO-mimetic
formulated together with one or more pharmaceutically acceptable
carriers. In addition to the NO-mimetic, the pharmaceutical
compositions of the present invention may further comprise an
established durg for sleep disorders and conditions wherein normal
sleep is interrupted or interfered with. Examples of established
drugs for use in these pharmaceutical compositions include, but are
not limited to, hypnotics, sedatives and anxiolytics such as the
benzodiazepines diazepam and temazepam, zoldipem, antihistamines
such as NYTOL and SOMINEX, sedative antidepressants such as
amitriptyline and trazodone, dopaminergic agents such as
levodopa/carbidopa, bromocriptine mesylate and pergolide, and
opioids such as codeine, propoxyphene, oxycodone, pentazocrine,
hydrocodone, and methadone.
[0034] As used herein, the term "pharmaceutically acceptable
carrier" means a non-toxic, inert solid, semi-solid or liquid
filler, diluent, encapsulating material or formulation auxiliary of
any type. Some examples of materials which can serve as
pharmaceutically acceptable carriers are sugars such as lactose,
glucose and sucrose; starches such as corn starch and potato
starch; cellulose and its derivatives such as sodium carboxymethyl
cellulose, ethyl cellulose and cellulose acetate; powdered
tragacanth; malt; gelatin; talc; excipients such as cocoa butter
and suppository waxes; oils such as peanut oil, cottonseed oil,
safflower oil, sesame oil, olive oil, corn oil and soybean oil;
glycols such a propylene glycol; esters such as ethyl oleate and
ethyl laurate; agar; buffering agents such as magnesium hydroxide
and aluminum hydroxide; alginic acid; pyrogen-free water; isotonic
saline; Ringer's solution; ethyl alcohol, and phosphate buffer
solutions, as well as other non-toxic compatible lubricants such as
sodium lauryl sulfate and magnesium stearate, as well as coloring
agents, releasing agents, coating agents, sweetening, flavoring and
perfuming agents, preservatives and antioxidants can also be
present in the composition, according to the judgment of the
formulator. The pharmaceutical compositions of this invention can
be administered to an individual orally, rectally, parenterally,
intracisternally, intravaginally, intraperitoneally, topically (as
by powders, ointments, or drops), supralingually (on the tongue)
sublingually (under the tongue), bucally (held in the buccal
pouch), or as an oral or nasal spray. The oral spray may be in the
form of a powder or mist which is delivered to the deep lungs by
oral inhalation.
[0035] Liquid dosage forms for oral administration include
pharmaceutically acceptable emulsions, microemulsions, solutions,
suspensions, syrups and elixirs. In addition to the active
compounds, the liquid dosage forms may contain inert diluents
commonly used in the art such as, for example, water or other
solvents, solubilizing agents and emulsifiers such as ethyl
alcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzyl
alcohol, benzyl benzoate, propylene glycol, 1,3-butylene glycol,
dimethylformamide, oils (in particular, cottonseed, groundnut,
corn, germ, olive, castor, and sesame oils), glycerol,
tetrahydrofurfuryl alcohol, polyethylene glycols and fatty acid
esters of sorbitan, and mixtures thereof. Besides inert diluents,
the oral compositions can also include adjuvants such as wetting
agents, emulsifying and suspending agents, sweetening, flavoring,
and perfuming agents. Injectable preparations, for example, sterile
injectable aqueous or oleaginous suspensions may be formulated
according to the known art using suitable dispersing or wetting
agents and suspending agents. The sterile injectable preparation
may also be a sterile injectable solution, suspension or emulsion
in a nontoxic parenterally acceptable diluent or solvent, for
example, as a solution in 1,3-butanediol. Among the acceptable
vehicles and solvents that may be employed are water, Ringer's
solution, U.S.P. and isotonic sodium chloride solution. In
addition, sterile, fixed oils are conventionally employed as a
solvent or suspending medium. For this purpose any bland fixed oil
can be employed including synthetic mono- or di-glycerides. In
addition, fatty acids such as oleic acid are used in the
preparation of injectables.
[0036] The injectable formulations can be sterilized, for example,
by filtration through a bacterial-retaining filter, or by
incorporating sterilizing agents in the form of sterile solid
compositions which can be dissolved or dispersed in sterile water
or other sterile injectable medium prior to use.
[0037] In cases where it is desirable to prolong the effect of the
drug, the absorption of the drug from subcutaneous or intramuscular
injection can be slowed. This may be accomplished by the use of a
liquid suspension of crystalline or amorphous material with poor
water solubility. The rate of absorption of the drug then depends
upon its rate of dissolution which, in turn, may depend upon
crystal size and crystalline form. Alternatively, delayed
absorption of a parenterally administered drug form is accomplished
by dissolving or suspending the drug in an oil vehicle. Injectable
depot forms are made by forming microencapsule matrices of the drug
in biodegradable polymers such as polylactide-polyglycolide.
Depending upon the ratio of drug to polymer and the nature of the
particular polymer employed, the rate of drug release can be
controlled. Examples of other biodegradable polymers include
poly(orthoesters) and poly(anhydrides). Depot injectable
formulations are also prepared by entrapping the drug in liposomes
or microemulsions which are compatible with body tissues.
[0038] Compositions for rectal or vaginal administration are
preferably suppositories which can be prepared by mixing the
compounds of this invention with suitable non-irritating excipients
or carriers such as cocoa butter, polyethylene glycol or a
suppository wax which are solid at ambient temperature but liquid
at body temperature and therefore melt in the rectum or vaginal
cavity and release the active compound.
[0039] Solid dosage forms for oral administration include capsules,
tablets, pills, powders, and granules. In such solid dosage forms,
the active compound is mixed with at least one inert,
pharmaceutically acceptable excipient or carrier such as sodium
citrate or dicalcium phosphate and/or a) fillers or extenders such
as starches, lactose, sucrose, glucose, mannitol, and silicic acid,
b) binders such as, for example, carboxymethylcellulose, alginates,
gelatin, polyvinylpyrrolidinone, sucrose, and acacia, c) humectants
such as glycerol, d) disintegrating agents such as agar-agar,
calcium carbonate, potato or tapioca starch, alginic acid, certain
silicates, and sodium carbonate, e) solution retarding agents such
as paraffin, f) absorption accelerators such as quaternary ammonium
compounds, g) wetting agents such as, for example, cetyl alcohol
and glycerol monostearate, h) absorbents such as kaolin and
bentonite clay, and I) lubricants such as talc, calcium stearate,
magnesium stearate, solid polyethylene glycols, sodium lauryl
sulfate, and mixtures thereof. In the case of capsules, tablets and
pills, the dosage form may also comprise buffering agents.
[0040] Solid compositions of a similar type may also be employed as
fillers in soft and hard-filled gelatin capsules using such
excipients as lactose or milk sugar as well as high molecular
weight polyethylene glycols and the like. The solid dosage forms of
tablets, dragees, capsules, pills, and granules can be prepared
with coatings and shells such as enteric coatings and other
coatings well known in the pharmaceutical formulating art. They may
optionally contain opacifying agents and can also be of a
composition that they release the active ingredient(s) only, or
preferentially, in a certain part of the intestinal tract,
optionally, in a delayed manner. Examples of embedding compositions
which can be used include polymeric substances and waxes.
[0041] Solid compositions of a similar type may also be employed as
fillers in soft and hard-filled gelatin capsules using such
excipients as lactose or milk sugar as well as high molecular
weight polyethylene glycols and the like. The active compounds can
also be in micro-encapsulated form with one or more excipients as
noted above. The solid dosage forms of tablets, dragees, capsules,
pills, and granules can be prepared with coatings and shells such
as enteric coatings, release controlling coatings and other
coatings well known in the pharmaceutical formulating art. In such
solid dosage forms the active compound may be admixed with at least
one inert diluent such as sucrose, lactose or starch. Such dosage
forms may also comprise, as is normal practice, additional
substances other than inert diluents, e.g., tableting lubricants
and other tableting aids such a magnesium stearate and
microcrystalline cellulose. In the case of capsules, tablets and
pills, the dosage forms may also comprise buffering agents. They
may optionally contain opacifying agents and can also be of a
composition that they release the active ingredient(s) only, or
preferentially, in a certain part of the intestinal tract,
optionally, in a delayed manner. Examples of embedding compositions
which can be used include polymeric substances and waxes.
[0042] Powders and sprays can contain, in addition to the compounds
of this invention, excipients such as lactose, talc, silicic acid,
aluminum hydroxide, calcium silicates and polyamide powder, or
mixtures of these substances. Sprays can additionally contain
customary propellants such as chlorofluorohydrocarbons.
[0043] Dosage forms for topical or transdermal administration of a
compound of this invention include ointments, pastes, creams,
lotions, gels, powders, solutions, sprays, inhalants or patches.
The active component is admixed under sterile conditions with a
pharmaceutically acceptable carrier and any needed preservatives or
buffers as may be required. Ophthalmic formulation, ear drops, eye
ointments, powders and solutions are also contemplated as being
within the scope of this invention. Transdermal patches have the
added advantage of providing controlled delivery of a compound to
the body. Such dosage forms can be made by dissolving or dispensing
the compound in the proper medium. Absorption enhancers can also be
used to increase the flux of the compound across the skin. The rate
can be controlled by either providing a rate controlling membrane
or by dispersing the compound in a polymer matrix or gel.
[0044] The ointments, pastes, creams and gels may contain, in
addition to an active compound of this invention, excipients such
as animal and vegetable fats, oils, waxes, paraffins, starch,
tragacanth, cellulose derivatives, polyethylene glycols, silicones,
bentonites, silicic acid, talc and zinc oxide, or mixtures
thereof.
[0045] A preferred mode of delivery is one which provides a
reasonably steady-state delivery of therapeutic agent, so as to
maintain steady-state plasma concentrations. Such delivery avoids
any substantial initial spike in plasma concentration of the agent,
as it would be desirable to avoid plasma concentrations that
produce negative side effects. Transdermal patches and pulsed
delivery systems are preferred modes of delivery.
[0046] Nitroglycerin Transdermal Patches:
[0047] A preferred formulation and dose delivery system of the
present invention comprises a patch for transdermal delivery of a
NO-mimetic such as nitroglycerin, isosorbide 5-mononitrate,
isosorbide dinitrate, pentaerythritol tetranitrate, and erythrityl
tetranitrate. A preferred NO-mimetic for transdermal patches in
accordance with the present invention is nitroglycerin.
[0048] Transdermal nitroglycerin patches (MINITRAN, 3M Corporation,
St. Paul, Minn., USA) were prepared in three sizes, both in forms
containing nitroglycerin and drug-free placebo. The patches had a
release liner, uniformly of 1 inch.sup.2 (6.65 cm.sup.2), with a
circular drug-containing (or placebo) patch having areas of 3.33
cm.sup.2, 1.65 cm.sup.2, or 0.825 cm.sup.2. The various-size
drug-containing patches had nitroglycerin loadings of about 2.7 mg
of nitroglycerin/cm.sup.2 and the total loadings shown in Table
1.
[0049] 3M MINITRAN transdermal nitroglycerin patches of 10 cm.sup.2
and 20 cm.sup.2 areas deliver plasma levels of 102 pg/mL and
between 129 pg/mL and 310 pg/mL, respectively. The 3.3 cm.sup.2
patch, with a total loading of 9 mg of nitroglycerin in each patch,
has a mean rate of drug delivery of about 0.81 mg/cm.sup.2/hour.
The two smaller patches (1.65 cm.sup.2 and 0.825 cm.sup.2) used in
the studies described herein had areas of one half and one fourth
the 3.33 cm.sup.2 patch. Based on the ratios of patch surface area
and assuming linearity in the rates of drug delivery, the estimated
rates of delivery and extrapolated values of plasma levels of
nitroglycerin for the three low or microdose patches are given in
Table 1.
1TABLE 1 Calculated Delivery Rates and Plasma Levels of
Nitroglycerin Delivered from Microdose Patches Patch Area Delivery
Rate (cm.sup.2) mg/cm.sup.2/24 hours Plasma Level (pg/mL) 10.0 0.81
102.sup.1 3.33 0.63-0.81.sup.2 34.sup.3 1.65 0.63-0.81.sup.2
17.sup.3 0.825 0.63-0.81.sup.2 9.sup.3 .sup.1Measured;
.sup.2Estimated; .sup.3Extrapolated from larger-size patches
assuming linearity.
[0050] The stability of low or microdose transdermal nitroglycerin
patches for use in accordance with the method of the present
invention is illustrated by the data appearing in Table 2.
2TABLE 2 Nitroglycerin Patch Stability Nitroglycerin content
(mg/patch) After 6 months After 6 months storage at storage at
Patch Size Theoreti- 25.degree. C. and 60% 70.degree. C. and 60%
Lot (cm.sup.2) cal Initial relative humidity relative humidity A
3.33 9.0 9.22 9.24 9.03 B 1.65 4.5 4.63 4.72 4.45 C 0.825 2.25 2.33
2.28 2.17
[0051] Dosing and Administration:
[0052] In doses used for prophylaxis of acute attacks of angina
pectoris and for general vasodilation, compounds which generate or
release NO, such as those listed above, dilate the capacitance
veins and the conductance arteries. Dilation of the capacitance
veins decreases the ventricular filling pressure, while dilation of
the conductance arteries decreases arterial impedance. The former
effect tends to decrease cardiac output, while the latter tends to
increase it with a net increase in cardiac output if serum levels
of NO are maintained.
[0053] These compounds all have a common mechanism of action which
involves in vivo denitration to produce NO which is also an
endothelial-derived relaxing factor (EDRF) endogenously generated
by the oxidation of L-arginine. NO reacts with sulfhydryl compounds
in blood vessels to form adducts which stimulate guanylyl cyclase,
causing smooth muscle relaxation.
[0054] In accordance with the present invention, a NO-mimetic is
administered to an individual in an amount therapeutically
effective to improve sleep. An effective amount can be that which
is provided to induce systemic vasodilation in normal circulation
in an individual. Therapeutically effective amounts of NO-mimetics
that induce systemic vasodilation in normal circulation in a human
are given in Table 3 under the column heading "Commercial Product".
However, administration of such amounts of NO-mimetics is often
associated with negative side effects of the NO-mimetics. It has
been discovered in the present invention that sleep can be improved
in individuals with sleep disorders by the administration of a
NO-mimetic in an amount substantially smaller than that which
appreciably alters systemic tone in a human or is used to manage
the symptoms associated with angina or congestive heart failure,
thereby largely avoiding the negative side effects of NO-mimetics.
Thus, in accordance with a preferred aspect of the invention,
typical "low doses" of NO-mimetics are as described in Table 3
under the column heading "Preferred Dose According to the Present
Invention".
[0055] The terms "low dose" or "microdose" of a NO-mimetic are used
interchangeably throughout this specification and the appended
claims and mean a dose which ranges between about one half (1/2) to
about one fortieth ({fraction (1/40)}) of the dose known to
appreciably alter systemic vascular tone in normal circulation in a
human. This "low" or "microdose" range for the use of NO-mimetics
in the present invention is derived from the observation that doses
of a NO-mimetic which are below the upper end of the range, i.e.
below about 1/2 the normal dose, systemic vasodilation is generally
no longer seen. Doses below the low end of the range, i.e. below
about {fraction (1/40)} the normal dose, do not elicit the desired
improvement in sleep. Accordingly, one of skill in the art can
routinely select and/or determine appropriate doses of an
NO-mimetic to be administered in the present invention to improve
sleep based upon the teachings provided herein and upon doses of
NO-mimetics established in the prior art to appreciably alter
systemic vascular tone. Appropriate doses to be administered to an
individual may be routinely selected based upon the teachings
herein by monitoring the patient for symptoms of inappropriate
systemic vasodilation such as hypotension, headache, and flushing
as well as parameters as set forth herein for determining improved
sleep. Appropriate doses will improve one or more parameters of
sleep as set forth herein. For examples of typical preferred
low-dose or microdose ranges for representative NO-mimetics, see
Table 3.
3TABLE 3 Typical Vasodilatory and Microdoses off Organonitrates
Preferred Dose According to Compound Commercial Product
Vasodilatory Dose the Present Invention Nitroglycerin NITROSTAT
(Parke- Dissolve one tablet Dissolve one tablet containing
(sublingual Davis); 0.3 mg, 0.4 (0.3-0.6 mg) from about 0.02 to
about 0.1 tablets) mg and 0.6 mg sublingually or in mg sublingually
or in the sublingual tablets the buccal pouch at buccal pouch as
needed the first sign of an acute anginal attack Nitroglycerin
NITROLINGUAL Spray One or two metered About 0.02 mg to about 0.1 mg
(lingual (Rhone-Poulenc doses (0.4-0.8 mg) sprayed onto or under
the aerosol) Rorer); metered sprayed onto or tongue as needed
aerosol, 0.4 under the tongue at mg/metered dose the onset of an
anginal attack Nitroglycerin MINITRAN (3M Suggested dose is About
0.0125-0.1 mg/h as (transdermal Corporation); between 0.2-0.8
needed patch) Transdermal patches mg/h for 12-14 h having the
following daily with a characteristics (size minimum nitrate-
(cm.sup.2), delivery rate free interval of (mg/h)); (3.3, 0.1;
10-12 h 6.7, 0.2; 13.3, 0.4; and 20.0, 0.6) Nitroglycerin NITRO-BID
Ointment Doses used in Ointment containing about (ointment)
(Hoechst Marion clinical trials 0.375 mg to about 3.75 mg of
Roussel); lactose and have ranged from 1/2 nitroglycerin applied to
the 2% nitroglycerin in a inch (1.3 cm; 7.5 arms or legs over an
area of base of lanolin and mg), to 2 inches about 36 square inches
(232 white petrolatum. (5.1 cm; 30 mg), cm.sup.2) Each inch (2.5
cm), typically applied as squeezed from the to 36 square inches
tube, contains (232 square cm) of approximately 15 mg skin on the
arms or of nitroglycerin legs Isosorbide 5- IMSO (Wyeth-Ayerst) 20
mg twice daily About 1 to about 2.5 mg twice mononitrate 20 mg
tablets daily Erythrityl CARDILATE Chronic (Adults): Chronic
(Adults): About 0.5 to tetranitrate (Burroughs-Wellcome); 10 mg
orally 4 about 1.25 mg orally 4 times oral/sublingual times daily,
daily, gradually increased to tablets, 5 mg, 10 mg gradually
increased about 0.5 to about 2.5 mg/day, to 20 mg, if if necessary,
not to exceed necessary, not to about 5 to about 12.5 mg/day exceed
100 mg/day. Sodium NIPRIDE (Roche); Slow infusion at a Slow
infusion at a rate of nitroprusside NITROPRESS (Abbott); rate of
0.5 from 0.025 .mu.g/kg/min to about intravenous solution
.mu.g/kg/min of a 0.063 .mu.g/kg/min of a solution solution of 50
mg of 50 mg in 500-1000 mL of 5% in 500-1000 mL of dextrose up to a
limit of 5% dextrose up to a about 0.18 mg/kg to about 0.44 limit
of 3.5 mg/kg mg/kg in brief infusions in brief infusions
Molsidomine CORVATON (Hoechst 2 mg/day up to 36 0.1 mg/day up to
4.5 mg/day Marion Roussel) ; 2 mg/day given in given in separate
doses either mg, 4 mg, and 6 mg separate doses twice or three times
daily tablets either twice or three times daily Nicorandil
NICORANDIL (Chugai For the treatment About 0.5 mg to about 1 mg
Pharmaceuticals, of angina 10-20 mg twice daily Japan), DANCOR
twice daily (Merck) 10 mg, 20 mg tablets
[0056] Using GTN transdermal patches as an example, Table 4
compares the sizes (cm.sup.2) patches typically used in accordance
with the present invention to the size (cm.sup.2) of the smallest
patch currently available from 3M (3M MINITRAN patch). As can be
seen from Table 4, the sizes of patches used in accordance with the
present invention are about 1/2 to {fraction (1/40)} the size of
the smallest commercially available patch. Assuming that dosage
scales linearly with patch size, the patch sizes used in the
present invention provide dosages in the range of about 1/2 to
{fraction (1/40)} those provided by the smallest commercially
available patch.
[0057] For those formulations containing a NO-mimetic which is
commercially available, the low dose or microdose formulations
contemplated for use in the method of the present invention are
formulated according to the same methods as the commercially
available higher dose formulations, but with amounts generally
ranging between about 1/2 and about {fraction (1/40)} of the active
ingredient. Methods of formulation are within the skill of
pharmaceutical formulation chemists and are fully described in such
works as Remington's Pharmaceutical Science, 18.sup.th Edition,
Alfonso R. Gennaro, Ed., Mack Publishing Co., Easton, Pa., USA,
1990.
4TABLE 4 Comparison of 3M and Invention Patch Areas Invention Patch
Areas as a Invention Patch Fraction of 3M 3M Patch Area (cm.sup.2)
Areas (cm.sup.2) Patch Area 3.3 1.65 {fraction (1/2 )} 3.3 0.825 or
0.83 {fraction (1/4 )} 3.3 0.413 {fraction (1/8 )} 3.3 0.206
{fraction (1/16)} 3.3 0.165 {fraction (1/20)} 3.3 0.110 {fraction
(1/30)} 3.3 0.0825 {fraction (1/40)}
[0058] As can be seen from the data in Table 4, patches according
to the invention providing about 1/8 or less of the dose of GTN
known to induce systemic vasodilation are considerably small. When
such small doses of NO-mimetic are desired, it is preferable to
reformulate (i.e., dilute) the NO-mimetic so that a larger patch
size can be used, while maintaining the required low dose. Also,
since the laws of mass action are a key factor in determining
delivery rates, it has also been contemplated that there is a
potential that the rate of drug delivery in the smaller sized
patches would not scale linearly (i.e. a patch area of {fraction
(1/40)} as presented in Tables 1 and 4, may deliver plasma levels
of the drug at less than {fraction (1/40)} the dose of the 3.3
cm.sup.2 patch). As discussed above, methods of such formulation
are within the skill of pharmaceutical formulation chemists and are
fully described in such works as Remington's Pharmaceutical
Science, 18.sup.th Edition, Alfonso R. Gennaro, Ed., Mack
Publishing Co., Easton, Pa., USA, 1990.
[0059] The following nonlimiting examples are provided to further
illustrate the present invention.
EXAMPLES
Example 1
Improving Sleep in 4 Subjects with Sleep Disorders
[0060] Subject 1:
[0061] The subject was a 50 year old male with a history of sleep
disorders including PLMS for at least 4 years. Over this period the
subject had five visits to a sleep laboratory, which confirmed his
diagnosis of PLMS, and through which various treatments were
devised. These included drug therapies with PAXIL/WELLBUTRIN,
CLOMIPRAMINE, IMOVANE, DESIPRAMINE, ZOLOFT, TEMAZEPAM, TRYPTAN, and
FLUVOXAMINE. None of the drug therapies were successful in treating
the symptoms of the sleep disorder, and, through lack of
restorative sleep and inappropriate drug therapy, the subject's
condition gradually deteriorated, leading additionally to
depression and overall poor health, such that his career was in
jeopardy.
[0062] At this point, the subject was administered a 1.65 cm.sup.2
GTN patch as described above in reference to Table 4. The patch was
applied just before retiring at night. This was repeated for three
consecutive nights. The subject reported having a restful night's
sleep with substantially no sleep disorder symptoms, and a minor
headache that resolved within one hour of waking. On the fourth
night, the subject applied a 1.1 cm.sup.2 GTN patch, and on the
fifth night, a 0.825 cm.sup.2 GTN patch. The subject reported that
the 0.825 cm.sup.2 GTN patch ameliorated the sleep disorder
symptoms, and produced no negative side-effects; i.e., no
headache.
[0063] Subject 2:
[0064] The subject was a 43 year old male who has chronically had
difficulties sleeping (at least 10 years). The subject has asthma
treated only with periodic use of VENTOLIN (1-3 times daily). The
subject stated that the major reasons/symptoms for his inability to
sleep or not to have a restful sleep appeared to be: (I) inability
to stop actively thinking about current or the next day's events
(i.e. anxiety, tension, stress, creative thought processes); (ii)
an overall restlessness that occurs following late-in-the-day
exercise; (iii) a leg restlessness that occurs up to three hours
prior to going to bed; and/or (iv) an inability to get to sleep but
with no apparent cause. All of these reasons fall under the three
categorical causes of insomnia: predisposing, precipitating and
perpetuating.
[0065] At the onset of any the above described symptoms, the
subject used a 0.825 cm.sup.2 transdermal GTN patch, initially by
dividing it into quarters (0.206 cm.sup.2) or halves (0.413
cm.sup.2) as described above in reference to Table 4. The
GTN-containing patch material was cut with scissors prior to use
and the remaining portion kept within the original foil package
between uses. During the first week of use, the subject began by
applying a quarter of the 0.825 cm.sup.2 GTN patch (0.206 cm.sup.2)
to his skin, while a second quarter of the GTN patch (0.206
cm.sup.2) was applied next to the first quarter of the GTN patch if
the subject determined that a satisfactory effect had not been
obtained. During the initial assessment, the subject found that he
had to apply two quarter pieces (2.times.0.206 cm.sup.2) of the
0.825 cm.sup.2 GTN patch in about half of the trials meaning that a
total GTN patch area of 0.413 cm.sup.2 was used. Following this
initial assessment, the subject only used half sections (0.413
cm.sup.2) of the 0.833 cm.sup.2 GTN patch.
[0066] In general, in the initial trials, the subject indicated
that the time to "response" (meaning a perceived relief of the
symptoms that caused the insomnia) was between 20-45 minutes. This
was determined by the subject perceiving changes which included: an
increased feeling of relaxation, a withdrawal of tension
(particularly from the upper body), a feeling within the head
similar to the beginning of a very mild headache but without
discomfort, and/or decreased irritability in the lower extremities
(i.e. reduced leg movements).
[0067] In a specific case, the subject had attended a conference in
a different city and indicated that the use of half of a 0.825
cm.sup.2 GTN patch (0.413 cm.sup.2) each evening provided complete
relief of the sleep disturbances that are normally greatly
exaggerated during stays at hotels when away without his family.
This improved sleeping behavior was corroborated by his roommate (a
physician) who had observed the sleeping difficulty at numerous
other conferences prior to this one.
[0068] In another specific case, the subject indicated that during
one evening, use of half of a 0.825 cm.sup.2 GTN patch (0.413
cm.sup.2) had relieved the predisposing symptoms of insomnia and
allowed him to fall asleep within a 10-15 minute period. However,
the subject awoke 1-1.5 hours later with similar signs and symptoms
as had occurred prior to falling asleep. It was at this time that
the subject discovered that the half-patch had fallen off. Upon
re-applying a new half of a 0.825 cm.sup.2 GTN patch (0.413
cm.sup.2) the subject was able to return to sleep.
[0069] The subject has been using half of a 0.825 cm.sup.2 GTN
patch (0.413 cm.sup.2) for over 8 weeks to aid his sleep. No
untoward effects have resulted from the use of half of a 0.825
cm.sup.2 GTN patch (0.413 cm.sup.2). At the time this data was
collected, the subject was using half of a 0.825 cm.sup.2 GTN patch
(0.413 cm.sup.2) 3-4 times each week as required and planned to
continue to do so.
[0070] Subject 3:
[0071] The subject was a 29 year old male who had experienced
problems sleeping on numerous occasions following intense, late
evening physical activity. On four separate occasions following a
two hour session of hockey, as per usual, the subject returned home
around midnight feeling invigorated and unable to go to sleep.
However, at this point, the subject applied to the skin on the
inside of his wrist one-half of a 0.825 cm.sup.2 GTN patch (0.413
cm.sup.2, as described above in reference to Table 4) and went to
bed. Following application of half of a 0.825 cm.sup.2 GTN patch
(0.413 cm.sup.2) the subject reported feeling a calming effect, a
decrease in his muscle tension and an improvement in his ability to
relax. The subject also reported that the last thing that he
remembered before waking up rested and feeling like he had a very
restful sleep was placing the patch on his wrist. The subject
reported a mild headache upon waking, that was gone within 30
minutes of removing the patch. The subject was continuing to use
the GTN patch to facilitate sleeping following late evening
exercise at the time this data was collected.
[0072] Subject 4:
[0073] A thirty-seven year old male, suffering from periodic
restless leg syndrome was administered nitroglycerin by transdermal
patch in a modified blinded study. The subject was administered
either placebo or a nitroglycerin patch having an area of 0.833
cm.sup.2 of the type described above. The patches were coded as to
whether they represented a placebo patch or a patch containing
nitroglycerin. A patch was randomly selected from the lot of
patches containing placebo or active patch by the test
administrator and applied to the inner wrist of the subject
approximately 1 hour to 1.5 hours just prior to retiring at
night.
[0074] Later in the evening, or on the morning following the
application of a transdermal patch, the subject would make an
assessment whether he had received a placebo patch or a patch
containing nitroglycerin, based upon the extent to which the
symptoms had been alleviated. The results are presented in Table 5.
If symptoms were present and alleviated, and the subject correctly
identified the patch as containing nitroglycerin, the entry for the
date in question was scored as "+". Likewise, if symptoms were
present, and not alleviated, and the subject correctly identified
the patch as placebo, the entry for the date in question was scored
as "+". If the subject experienced PSNS symptoms, and incorrectly
identified the patch as placebo when it contained nitroglycerin,
the entry for the date in question was scored as "-". Similarly, if
symptoms were present and not alleviated by a patch containing
nitroglycerin, and the subject identified the patch as placebo, a
score of "-" was entered for the date in question.
5 TABLE 5 Date Score 10/28 + 10/29 + 10/31 .sup. +.sup.1 11/1 -
11/2 .sup. +.sup.1 11/3 .sup. -.sup.2 11/4 + 11/5 +
[0075] .sup.1 On these dates the subject, after correctly
identifying the patch as placebo, requested a patch containing
nitroglycerin; after applying this patch the symptoms disappeared
shortly thereafter. .sup.2 The subject incorrectly identified a
nitroglycerin- containing patch as placebo.
Example 2
Phase II Clinical Study
[0076] A human clinical trial is currently being conducted at the
Toronto Western Hospital, Centre for Sleep and Chronobiology, Sleep
Disorders Clinic. The trial is a prospective, randomized, double
blind, placebo controlled, single center study. Twenty subjects
meeting inclusion and exclusion criteria underwent two identical
in-clinic assessments on consecutive evenings; one night on the
study medication and the other night on placebo. The study measured
standard polysomnographic parameters, blood pressure, and the
subject's assessment of his/her sleep quality and RLS/PLMS
symptoms.
[0077] Inclusion criteria for the study include that the subject
must be adult between the ages of 18 and 65, with diagnosed mild or
moderate primary RLS and PLMS according to the American Sleep
Disorders Association, International Classification of Sleep
Disorders, revised: Diagnostic and Coding Manual, Rochester Minn.,
1997. Subjects included suffered from the presence of RLS symptoms
interfering with sleep onset or the continuity of sleep more than
three nights per week for at least 3 months. Subjects included
suffered from active RLS/PLMS symptoms during the course of the
study.
[0078] Diagnostic criteria for RLS included that the subject has a
complaint of an unpleasant sensation in the legs at night or
difficulty in initiating sleep and disagreeable sensations of
"creeping" inside the calves present and often associated with
general aches and pains in the legs. Further, this discomfort is
relieved by movement of the limbs. Mild RLS is defined as occurring
episodically, with no more than a mild disruption of sleep onset
that does not cause the subject significant distress. Moderate RLS
is defined as occurring less than twice a week, with significant
delay of sleep onset, moderate disruption of sleep, and mild
impairment of daytime function.
[0079] Diagnostic Criteria for PLMS included that the subject has a
complaint of insomnia or excessive sleepiness and that the subject
occasionally will be asymptomatic, and the movements are noticed by
an observer. In addition, repetitive highly stereotyped limb muscle
movements are present; in the leg, these movements are
characterized by extension of the big toe in combination with
partial flexion of the ankle, knee, and sometimes hip. Mild PLMS is
defined as mild insomnia or mild sleepiness typically associated
with a PLM index of 5 or more but less than 25. Moderate PLMS is
defined as moderate insomnia or moderate sleepiness typically
associated with a PLM index of 25 or more but less than 50.
[0080] Subjects excluded from the study included those currently
receiving organic nitrate therapy of any kind; those having
received pharmacological treatment for their RLS symptoms within
the last 2 weeks; those with co-morbid sleep related conditions
such as sleep apnea; those diagnosed neurological conditions such
as Parkinson's, multiple sclerosis or Alzheimer's disease; those
with known hypersensitivity or idiosyncratic reaction to
nitroglycerin or any component of the formulation; those diagnosed
with primary psychiatric disorders such as schizophrenia,
schizo-affective, bipolar or other major depressive disorder; those
diagnosed with diabetic neuropathy, anemia or iron deficiency
(serum ferritin levels below 20 .mu.g/l for men, 10 .mu.g/l for
women), or chronic renal failure; those known to have abused drugs
or alcohol within the past one year; those suffering from open or
closed angle glaucoma; those with (treated or untreated)
hypertension (supine systolic pressure >160 mmHg or 100 mm Hg at
screening); those with hypotension, defined as resting blood
pressure <90/50 mmHg; those suffering from uncorrected
hypovolemia, myocardial infarction within the previous six months,
unstable angina, or any other major active cardiovascular
impairment; those having been treated with any investigational
therapy or device within the previous month; and those with any
clinical condition which in the opinion of the investigator would
not allow safe completion of the protocol and safe administration
of the trial medication.
[0081] Efficacy of treatment was assessed by a reduction in PLMS
index; an increase in total sleep time; an increase in sleep
efficiency; improvement in sleep latency; subjective assessment of
improvement in severity of RLS/PLMS symptoms; and satisfaction with
treatment received.
[0082] Safety was assessed by monitoring for blood pressure
changes, changes in EKG, changes in EOG, EMG, EEG readings, and any
other adverse events in treatment versus control.
[0083] Nitroglycerin for the treatment of RLS, PLMS and sleep
symptoms was provided in single dose transdermal patches packaged
in individual foil pouches. Each single dose transdermal patch has
a surface area of 0.83 cm.sup.2, contains 2.25 mg of nitroglycerin,
and releases the nitroglycerin at a rate of 0.025 mg/hour (0.75
mg/cm.sup.2/24 hours). After 8 hours 85% of the nitroglycerin
remains entrained in the adhesive substrate of the transdermal
patch.
[0084] Placebo patches were identical in all respects except that
they did not contain nitroglycerin.
[0085] Results from one subject in this Phase II study are depicted
in Table 6 below. This subject spent two consecutive nights in a
sleep clinic. The first night no treatment was administered. These
second night a transdermal GTN patch was applied 1 hour before
retiring to bed.
[0086] Blood pressure did not change in this subject following
administration of the GTN patch.
6TABLE 6 Results from ongoing Phase II study No Treatment Treatment
Sleep latency (min) 26.0 16.5 REM latency (min) 116.0 86.5 Sleep
Efficiency (%) 72.4 83.7 Stage 1 (min) 25.0 25.0 Stage 2 (min)
133.0 186.5 Stage 3 (min) 33.5 49.5 Stage 4 (min) 44.5 12.5 REM
(min) 53.5 64.5 Arousal index (/hr) 14.7 16.3 PLMS index (/hr) 15.3
8.5 PLMS arousals (/hr) 3.9 4.8
[0087] While there have been shown and described what are believed
at present to constitute the preferred embodiments of the present
invention, it will be apparent to one of ordinary skill in the art
that various modifications may be made therein without departing
from the scope of the invention as it is defined by the appended
claims.
* * * * *