U.S. patent application number 10/769071 was filed with the patent office on 2004-10-28 for methods of treating gastrointestinal tract disorders using sodium channel modulators.
This patent application is currently assigned to Dynogen Pharmaceuticals, Inc.. Invention is credited to Burgard, Edward C., Fraser, Matthew Oliver, Landau, Steven B..
Application Number | 20040213842 10/769071 |
Document ID | / |
Family ID | 32831200 |
Filed Date | 2004-10-28 |
United States Patent
Application |
20040213842 |
Kind Code |
A1 |
Burgard, Edward C. ; et
al. |
October 28, 2004 |
Methods of treating gastrointestinal tract disorders using sodium
channel modulators
Abstract
The invention relates to methods of using sodium channel
modulators, particularly TTX-R sodium channel modulators and/or
activity dependent sodium channel modulators to treat
gastrointestinal tract disorders, particularly inflammatory bowel
disorders and irritable bowel syndrome.
Inventors: |
Burgard, Edward C.; (Chapel
Hill, NC) ; Landau, Steven B.; (Wellesley, MA)
; Fraser, Matthew Oliver; (Apex, NC) |
Correspondence
Address: |
ALSTON & BIRD LLP
BANK OF AMERICA PLAZA
101 SOUTH TRYON STREET, SUITE 4000
CHARLOTTE
NC
28280-4000
US
|
Assignee: |
Dynogen Pharmaceuticals,
Inc.
Boston
MA
|
Family ID: |
32831200 |
Appl. No.: |
10/769071 |
Filed: |
January 30, 2004 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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60443731 |
Jan 30, 2003 |
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60443730 |
Jan 30, 2003 |
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60480565 |
Jun 20, 2003 |
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60480598 |
Jun 20, 2003 |
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60495958 |
Aug 18, 2003 |
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Current U.S.
Class: |
424/464 |
Current CPC
Class: |
A61K 31/165 20130101;
A61K 31/165 20130101; A61K 31/506 20130101; A61K 31/53 20130101;
A61P 1/00 20180101; A61K 31/137 20130101; A61K 31/506 20130101;
A61K 45/06 20130101; A61P 1/04 20180101; A61K 31/00 20130101; A61K
31/137 20130101; A61K 2300/00 20130101; A61K 2300/00 20130101; A61K
2300/00 20130101; A61K 2300/00 20130101; A61K 31/53 20130101 |
Class at
Publication: |
424/464 |
International
Class: |
A61K 009/20 |
Claims
What is claimed is:
1. A method for treating a GI tract disorder except for acid peptic
disorders or structural gastroesophageal disorders, which comprises
administering to an individual in need thereof a therapeutically
effective amount of an active agent wherein said agent is a sodium
channel modulator or a pharmaceutically acceptable salt, ester,
amide, prodrug, or active metabolite thereof.
2. The method of claim 1, wherein the active agent is contained
within a pharmaceutical formulation.
3. The method of claim 2, wherein the pharmaceutical formulation is
a unit dosage formulation.
4. The method of claim 1, wherein the active agent is administered
on an as-needed basis.
5. The method of claim 1, wherein the active agent is administered
prior to commencement of an activity wherein suppression of the
symptoms of a GI tract disorder except for acid peptic disorders or
structural gastroesophageal disorders would be desirable.
6. The method of claim 1, wherein the active agent is administered
from about 0 minutes to about 3 hours prior to commencement of an
activity wherein suppression of the symptoms of a GI tract disorder
except for acid peptic disorders or structural gastroesophageal
disorders would be desirable.
7. The method of claim 1, wherein the formulation is a controlled
release dosage formulation.
8. The method of claim 1, wherein the formulation is a delayed
release dosage formulation.
9. The method of claim 7, wherein the formulation is a sustained
release dosage formulation.
10. The method of claim 8, wherein the formulation is a sustained
release dosage formulation.
11. The method of claim 9, wherein the sustained release dosage
form provides drug release over a time period of from about 6 hours
to about 8 hours.
12. The method of claim 1, wherein the active agent is administered
orally.
13. The method of claim 2, wherein the active agent is administered
orally.
14. The method of claim 13, wherein the pharmaceutical formulation
is selected from the group consisting of tablets, capsules,
caplets, solutions, suspensions, syrups, granules, beads, powders
and pellets.
15. The method of claim 1, wherein the active agent is administered
transmucosally.
16. The method of claim 15, wherein the active agent is
administered sublingually.
17. The method of claim 15, wherein the active agent is
administered buccally.
18. The method of claim 15, wherein the active agent is
administered intranasally.
19. The method of claim 15, wherein the active agent is
administered transurethrally.
20. The method of claim 15, wherein the active agent is
administered rectally.
21. The method of claim 15, wherein the active agent is
administered by inhalation.
22. The method of claim 1, wherein the active agent is administered
topically.
23. The method of claim 1, wherein the active agent is administered
transdermally.
24. The method of claim 1, wherein the active agent is administered
parenterally.
25. The method of claim 1, wherein the active agent is administered
intrathecally.
26. The method of claim 1, wherein the GI tract disorder is
selected from the group consisting of inflammatory bowel disorders
and irritable bowel syndrome.
27. The method of claim 26, wherein the inflammatory bowel disorder
is selected from the group consisting of Crohn's disease,
ulcerative colitis, collagenous colitis, lymphocytic colitis, and
proctitis.
28. The method of claim 1, wherein said sodium channel modulator
is: a. a TTX-R sodium channel modulator, or a salt, enantiomer,
analog, ester, amide, prodrug, active metabolite, and derivative
thereof; or b. an activity-dependent sodium channel modulator, or a
salt, enantiomer, analog, ester, amide, prodrug, active metabolite,
and derivative thereof.
29. The method of claim 26, wherein said TTX-R sodium channel
modulator is: a. a compound that interacts with Na.sub.v1.8
channels, or a salt, enantiomer, analog, ester, amide, prodrug,
active metabolite, and derivative thereof; or b. a compound that
interacts with Na.sub.v1.9 channels, or a salt, enantiomer, analog,
ester, amide, prodrug, active metabolite, and derivative
thereof.
30. The method of claim 1, wherein said sodium channel modulator is
Ralfinamide or a salt, enantiomer, analog, ester, amide, prodrug,
active metabolite, and derivative thereof.
32. The method of claim 1, wherein said sodium channel modulator is
Ambroxol or a salt, enantiomer, analog, ester, amide, prodrug,
active metabolite, and derivative thereof.
33. The method of claim 1, wherein said sodium channel modulator is
Sipatrigine or a salt, enantiomer, analog, ester, amide, prodrug,
active metabolite, and derivative thereof.
34. The method of claim 1, wherein said sodium channel modulator is
Lamotrigine or a salt, enantiomer, analog, ester, amide, prodrug,
active metabolite, and derivative thereof.
35. The method of claim 2, wherein the pharmaceutical formulation
further comprises an additional active agent.
36. The method of claim 35, wherein the additional active agent is
selected from the group consisting of: an antispasmodic, a
tricyclic antidepressant, duloxetine, venlafaxine, a monoamine
reuptake inhibitor, a spasmolytic, an anticholinergic, gabapentin,
pregabalin, a substituted aminomethyl-phenyl-cyclohexane
derivative, a 5-HT.sub.3 antagonist, a 5-HT.sub.4 antagonist, a
.beta.3 adrenergic agonist, a neurokinin receptor antagonist, a
bradykinin receptor antagonist, a nitric oxide donor, and
derivatives thereof.
37. A pharmaceutical formulation for treating a GI tract disorder
except for acid peptic disorders or structural gastroesophageal
disorders adapted for transmucosal drug administration, comprising
a therapeutically effective amount of a sodium channel modulator,
or a pharmaceutically acceptable salt, ester, amide, prodrug, or
active metabolite thereof, and a carrier suitable for transmucosal
drug delivery buccally, sublingually, intranasally, rectally, or by
inhalation.
38. A packaged kit for a patient to use in the treatment of a GI
tract disorder except for acid peptic disorders or structural
gastroesophageal disorders, comprising: a pharmaceutical
formulation of a sodium channel modulator; a container housing the
pharmaceutical formulation during storage and prior to
administration; and instructions for carrying out drug
administration in a manner effective to treat a GI tract disorder
except for acid peptic disorders or structural gastroesophageal
disorders.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] This application claims the benefit of U.S. Provisional
Application No. 60/443,731, filed Jan. 30, 2003; U.S. Provisional
Application No. 60/443,730, filed Jan. 30, 2003; U.S. Provisional
Application No. 60/480,565, filed Jun. 20, 2003; U.S. Provisional
Application No. 60/480,598, filed Jun. 20, 2003; and U.S.
Provisional Application No. 60/495,958, filed Aug. 18, 2003; all of
which are hereby incorporated by reference.
FIELD OF THE INVENTION
[0002] The invention relates to methods of using sodium channel
modulators, particularly TTX-R sodium channel modulators and/or
activity dependent sodium channel modulators, to treat
gastrointestinal tract disorders, particularly inflammatory bowel
disorders and irritable bowel syndrome.
BACKGROUND OF THE INVENTION
[0003] Gastrointestinal (GI) tract disorders affect the quality of
life of millions of men and women in the United States every year.
GI tract disorders may involve disturbances of the GI smooth
muscle, epithelium, sensory afferent neurons, or central nervous
system pathways. In spite of the uncertainty regarding whether
central or peripheral mechanisms, or both, are involved in GI tract
disorders, many proposed mechanisms implicate neurons and pathways
that mediate visceral sensation. Viscerosensory information from
the GI tract is relayed by sensory fibers that enter the spinal
cord via the dorsal root ganglion (DRG) or project to the nodose
ganglion via vagal afferents (Physiology, ed. R. M Berne and M. N.
Levy, 1983, CV Mosby Co. St. Louis). A number of different subtypes
of sensory afferent neurons may be involved in neurotransmission
from the GI tract. These may be classified as, but not limited to,
small diameter, medium diameter, large diameter, myelinated,
unmyelinated, sacral, lumbar, DRG, vagal, nodose, peptidergic,
non-peptidergic, IB4 positive, IB4 negative, C fiber, A.delta.
fiber, A.beta. fiber, high threshold or low threshold neurons.
[0004] GI tract disorders have been characterized as structural (or
mucosal) GI tract disorders and non-structural (or non-mucosal) GI
tract disorders. Structural disorders include inflammatory bowel
disorders and non-inflammatory structural GI tract disorders.
Non-structural disorders include a variety of disorders classified
as functional GI tract disorders.
[0005] Inflammatory bowel disorders include a group of disorders
that can cause inflammation or ulceration of the GI tract.
Ulcerative colitis and Crohn's disease are the most common types of
inflammatory bowel disorders, although collagenous colitis,
lymphocytic (microscopic) colitis, and other disorders have also
been described.
[0006] Ulcerative colitis is a chronic inflammatory disorder of
unknown etiology afflicting the large intestine and, except when
very severe, is limited to the bowel mucosa. The course of this
disorder may be continuous or relapsing and may be mild or severe.
Medical treatment primarily includes the use of salicylate
derivatives, glucocorticosteroids such as prednisone or prednisone
acetate and anti-metabolites dependent on the clinical state of the
patient. Salicylate derivatives, such as sulphazine or mesalamine,
are efficacious in patients with mild cases of the disorder.
Glucocorticosteroids and anti-metabolites are efficacious in
patients with moderate or severe disease but are associated with a
number of side effects. Patients who need chronic doses of
glucocorticosteroids or anti-metabolites for control of their
disorder eventually undergo removal of the colon surgically to
eliminate the disease.
[0007] Like ulcerative colitis, Crohn's disease (also known as
regional enteritis, ileitis, or granulomatous ileocolitis) is a
chronic inflammatory disorder of unknown etiology; however the
location and pathology of the disease differ. Crohn's disease
typically presents in either the small intestine, large intestine
or the combination of the two locationsand can cause inflammation
deeper into the muscle and serosa located within the intestinal
wall. The course of the disorder may be continuous or relapsing and
may be mild or severe. Medical treatment includes the continuous
use of salicylate derivatives,
glucocorticosteroids,anti-metabolites, and administration of an
anti-TNF antibody. Many Crohn's disease patients require intestinal
surgery for a problem related to the disease, but unlike ulcerative
colitis subsequent relapse is common.
[0008] Collagenous colitis and lymphocytic colitis are idiopathic
inflammatory disorders of the colon that cause watery diarrhea
typically in middle-aged or older individuals. Lymphocytic colitis
is distinguished from collagenous colitis by the absence of a
thickened subepithelial collagenous layer. Bismuth in the form of
Pepto-Bismol may be an effective treatment in some patients,
although more severe cases may require the use of salicylate
derivatives, antibiotics such as metronidazole, and
glucocorticosteroids.
[0009] Functional GI tract disorders are characterized by
presentation of abdominal-type symptoms without evidence of changes
in metabolism or structural abnormalities. Disorders that are
typically considered under functional disorders include dysphagia,
non-ulcer dyspepsia, irritable bowel syndrome, slow-transit
constipation, and evacuation disorders (Camilleri (2002)
Gastrointestinal Motility Disorders, In WebMD Scientific American
Medicine, edited by David C. Dale and Daniel D. Federman, New York,
N.Y., WebMD). A prominent example of a functional GI tract disorder
is irritable bowel syndrome (IBS), also known by a variety of
synonyms, including functional bowel, pylorospasm, nervous
indigestion, spastic colon, spastic colitis, spastic bowel,
intestinal neurosis, functional colitis, irritable colon, mucous
colitis, laxative colitis, and functional dyspepsia. IBS generally
leads to abdominal pain and/or discomfort and an alteration in
bowel habit with no clear etiology. Diagnosis relies on Rome
criteria taking into account all symptoms related to patient
presentation. (See, e.g., Drossman et al. (1997) Gastroenterology,
112: 2120). Patients typically present with symptoms consistent
with hyperalgesia and allodynia.
[0010] At present, treatments for IBS have been largely
ineffective, and have included stress management, diet, and drugs.
Psychoactive drugs, such as anxiolytics and antidepressants, have
been utilized but have limited utility because of the side effect
profile. Antispasmodics and various antidiarrheal preparations have
also been used but these remain as unsatisfactory remedies to
patients with IBS.
[0011] Non-ulcer dyspepsia (NUD) is another prominent example of a
functional GI tract disorder with no established etiology. Symptoms
related to NUD include nausea, vomiting, pain, early satiety,
bloating and loss of appetite. Altered gastric emptying and
increased gastric sensitivity and distress may contribute to NUD
but do not completely explain its presentation. Treatments include
behavioral therapy, psychotherapy, or administration of
antidepressants, motility regulatory agents, antacids, H.sub.2
-receptor antagonists, and, prokinetics. However, many of these
treatments have shown limited efficacy in many patients.
[0012] In addition to the structural/non-structural classification
described above, GI tract disorders may also be sub-classified
based upon anatomical, physiological, and other characteristics of
different portions of the GI tract as described in Sleisenger and
Fordtran's Gastrointestinal and Liver Disease, 6.sup.th Ed. (W. B.
Saunders Co. 1998); K. M. Sanders (1996) Gastroenterology, 111:
492-515; P. Holzer (1998) Gastroenterology, 114: 823-839; and R. K.
Montgomery et al. (1999) Gastroenterology, 116: 702-731. For
example, acid peptic disorders are generally thought to arise from
damage due to acidic and/or peptic activity of gastric secretions
and may affect the esophagus, stomach, and duodenum. Acid peptic
disorders include gastroesophageal reflux disease, peptic ulcers
(both gastric and duodenal), erosive esophagitis and esophageal
stricture. Zollinger-Ellison Syndrome may be considered an acid
peptic disorder since it typically presents with multiple ulcers
due to excessive acid secretion caused by a endocrine tumor.
Treatments typically include gastric acid suppressive therapies,
antibiotics, and surgery. In some patients, however, these
therapies have proven ineffective.
[0013] Another sub-classification for GI tract disorders may be
drawn between gastroesophageal and intestinal disorders based upon
characteristics between different portions of the GI tract as
disclosed in Sleisenger and Fordtran's Gastrointestinal and Liver
Disease, 6.sup.th Ed. (W. B. Saunders Co. 1998); K. M. Sanders
(1996) Gastroenterology, 111: 492-515; P. Holzer (1998)
Gastroenterology, 114: 823-839; and R. K. Montgomery et al. (1999)
Gastroenterology, 116: 702-731. Structural gastroesophageal
disorders include disorders of the stomach and/or esophagus where
there is no evidence of structural perturbations (including those
observed in the mucosa) distal to the pylorus. Dyspepsia (chronic
pain or discomfort centered in the upper abdomen) is a prominent
feature of most structural gastroesophageal disorders but can also
be observed in non-structural perturbations, and has been estimated
to account for 2 to 5 percent of all general practice
consultations. Structural gastroesophageal disorders include
gastritis and gastric cancer. By contrast, Structural intestinal
tract disorders occur in both the small intestine (the duodenum,
jejunum, and ileum) and in the large intestine. Structural
intestinal tract disorders are characterized by structural changes
in the mucosa or in the muscle layers of the intestine, and include
non-peptic ulcers of the small intestine, malignancies, and
diverticulosis. Non-peptic ulcers in the small intestine are
typically related to administration of non-steroidal
anti-inflammatory drugs. Diverticulosis is a disorder that rarely
occurs in the small intestine and most commonly appears in the
colon.
[0014] Because existing therapies and treatments for GI tract
disorders are associated with limitations as described above, new
therapies and treatments are therefore desirable.
SUMMARY OF THE INVENTION
[0015] Compositions and methods for treating GI tract disorders,
particularly inflammatory bowel disorders and irritable bowel
syndrome, are provided. Compositions of the invention comprise
sodium channel modulators, particularly tetrodotoxin-resistant
(TTX-R) sodium channel modulators and/or activity-dependent sodium
channel modulators as well as pharmaceutically acceptable,
pharmacologically active salts, esters, amides, prodrugs, active
metabolites, and other derivatives thereof. TTX-R sodium channel
modulators for use in the present invention include but are not
limited to compounds that modulate or interact with Nav1.8 and/or
Na.sub.v1.9 channels.
[0016] The compositions are administered in therapeutically
effective amounts to a patient in need thereof for treating GI
tract disorders, particularly inflammatory bowel disorders and
irritable bowel syndrome, in mammals, particularly humans. It is
recognized that the compositions may be administered by any means
of administration as long as an effective amount for the treatment
of GI tract disorders is delivered. The compositions may be
formulated, for example, for sustained, continuous, or as-needed
administration.
BRIEF DESCRIPTION OF THE DRAWINGS
[0017] FIG. 1. FIG. 1A depicts a typical response of a GI tract
afferent neuron to lamotrigine under both slow and fast stimulation
protocols. FIG. 1B shows summary data obtained from three neurons
under control conditions and during application of 100 .mu.M
lamotrigine. Response amplitudes were normalized and mean.+-.SEM
are displayed.
[0018] FIG. 2. FIG. 2A depicts a typical inward TTX-R sodium
current recorded from a labeled GI tract afferent neuron before and
during bath application of Ambroxol. FIG. 2B depicts a summary bar
chart showing the combined effects of Ambroxol on GI tract afferent
neurons. Peak inward current amplitudes were measured when the
responses had reached a steady-state in the presence of drug.
Response amplitudes were normalized and mean.+-.SEM are
displayed.
DETAILED DESCRIPTION OF THE INVENTION
Overview and Definitions
[0019] The present invention provides compositions and methods for
treating GI tract disorders, including structural disorders
(including inflammatory bowel disorders and structural intestinal
disorders), and non-structural disorders (including functional GI
tract disorders), but not acid-peptic disorders or gastroesophageal
disorders. The compositions comprise a therapeutically effective
dose of sodium channel modulators, particularly
tetrodotoxin-resistant (TTX-R) sodium channel modulators and/or
activity-dependent sodium channel modulators. The methods are
accomplished by administering, for example, various compositions
and formulations that contain quantities of a sodium channel
modulator, particularly a tetrodotoxin-resistant (TTX-R) sodium
channel modulator and/or activity-dependent sodium channel
modulator.
[0020] Many modifications and other embodiments of the inventions
set forth herein will come to mind to one skilled in the art to
which these inventions pertain having the benefit of the teachings
presented in the foregoing descriptions and the associated
drawings. Therefore, it is to be understood that the inventions are
not to be limited to the specific embodiments disclosed and that
modifications and other embodiments are intended to be included
within the scope of the appended claims. Although specific terms
are employed herein, they are used in a generic and descriptive
sense only and not for purposes of limitation.
[0021] It must be noted that as used in this specification and the
appended embodiments, the singular forms "a," an" and "the" include
plural referents unless the context clearly dictates otherwise.
Thus, for example, reference to "an active agent" or "a
pharmacologically active agent" includes a single active agent as
well a two or more different active agents in combination,
reference to "a carrier" includes mixtures of two or more carriers
as well as a single carrier, and the like.
[0022] The term "structural GI tract disorder" or "mucosal GI tract
disorder" refers to any GI tract disorder related to structural or
mucosal abnormalities of the GI tract or where there is evidence of
a related metabolic disturbance, including but not limited to
inflammatory bowel disorders, structural gastroesophageal
disorders, and structural intestinal disorders.
[0023] By "inflammatory bowel disorder" is intended any disorder
primarily associated with inflammation of the small and/or large
intestine, including but not limited to ulcerative colitis, Crohn's
disease, ileitis, proctitis, celiac disease (or non-tropical
sprue), enteropathy associated with seronegative arthropathies,
microscopic or collagenous colitis, eosinophilic gastroenteritis,
or pouchitis resulting after proctocolectomy, and post ileoanal
anastomosis.
[0024] "Crohn's disease" is used in its conventional sense to refer
to gastrointestinal inflammation primarily of the small and large
intestine, including disorders with fistulas or with
extraintestinal manifestations, and encompasses all synonyms
including regional enteritis, ileitis, and granulomatous
ileocolitis.
[0025] "Proctitis" is used in its conventional sense to refer to
inflammation of the rectal lining.
[0026] "Celiac disease" is used in its conventional sense to refer
to any disorder primarily associated with altered sensititivity to
gluten or gluten byproducts, with or without alterations in small
bowel morphology (typically villus blunting) and encompasses all
synonyms including celiac sprue and non-tropical sprue. Patients
diagnosed with celiac disease may have symptomatic gluten
intolerance with prominent diarrhea and abdominal pain or with
minimal symptoms such as abdominal discomfort and associated
dermatitis herpetiformis.
[0027] "Colitis" is used in its conventional sense to refer to
inflammation of the large intestine.
[0028] "Ulcerative colitis" is used in its conventional sense to
refer to inflammation and ulcers in the top layers of the lining of
the large intestine and can be of any extent, including proctitis,
proctosigmoiditis, left-sided colitis, or pan-colitis.
[0029] "Collagenous colitis" or "microscopic colitis" is used in
its conventional sense to refer to an inflammatory disorder of
unknown etiology with watery diarrhea as the leading symptom. A
biopsy of the intestine typically demonstrates a
thicker-than-normal layer of collagen (connective tissue) just
beneath the inner surface of the colon (the epithelium) and/or
inflammation of the epithelium and of the layer of connective
tissue that lies beneath the epithelium. There is an association of
arthritis with this disorder.
[0030] "Eosinophilic gastroenteritis" is used in its conventional
sense to refer to a condition where a biopsy of the GI tract
demonstrates infiltration with a type of white blood cell called
eosinophils. There is no single cause of eosinophilic
gastroenteritis and in many cases there is no known cause. Symptoms
may include feeling full before finishing a meal, diarrhea,
abdominal cramping or pain, nausea and vomiting. Asthma and
allergies are sometimes related to the disorder.
[0031] "Pouchitis" is used in its conventional sense to refer to
inflammation in a distal location of the intestine after a surgery
on the intestine.
[0032] "Lymphocytic colitis" is used in its conventional sense to
refer to inflammation of the large intestine without ulceration,
and encompasses all synonyms including microscopic colitis.
[0033] The term "non-structural GI tract disorder" or "non-mucosal
GI tract disorder" refers to any GI tract disorder not related to
structural or mucosal abnormalities of the GI tract, nor where
there is evidence of a related metabolic disturbance, including but
not limited to functional GI tract disorders.
[0034] By "functional GI tract disorder" is intended any GI tract
disorder associated with a disturbance of motor or sensory function
in the absence of mucosal or structural damage or in the absence of
a metabolic disorder. Functional GI tract disorders include
functional dysphagia, non-ulcer dyspepsia, irritable bowel syndrome
(IBS), slow-transit constipation and evacuation disorders.
[0035] By "non-ulcer dyspepsia" is intended any disorder associated
with any abdominal symptom after eating including nausea, vomiting,
pain, early satiety, bloating and loss of appetite where no
ulceration in present in the esophagus, stomach or duodenum.
Altered gastric emptying, increased gastric sensitivity and
distress are considered as factors in the development of non-ulcer
dyspepsia.
[0036] By "irritable bowel syndrome" or "IBS" is intended any
disorder associated with abdominal pain and/or abdominal discomfort
and an alteration in bowel habit, and encompasses all synonyms
including functional bowel, pylorospasm, nervous indigestion,
spastic colon, spastic colitis, spastic bowel, intestinal neurosis,
functional colitis, irritable colon, mucous colitis, laxative
colitis, and functional dyspepsia.
[0037] By "slow-transit constipation" is intended as a disorder
with slowing of motility in the large intestine with a prolonged
transit time through the organ.
[0038] By "evacuation disorders" is intended as any disorder where
defecation occurs poorly and the patient is unable to expel
stool.
[0039] By "acid peptic disorder" is intended any disorder
associated with damage due to acidic and/or peptic activity of
gastric secretions that affect the esophagus, stomach, and/or
duodenum. Acid peptic disorders include gastroesophageal reflux
disease, peptic ulcers (both gastric and duodenal), erosive
esophagitis, esophageal strictures, and Zollinger-Ellison
Syndrome.
[0040] GI tract disorders may divided between gastroesophageal and
intestinal disorders based upon anatomical, physiological, and
other characteristics of different portions of the GI tract as
disclosed in Sleisenger and Fordtran's Gastrointestinal and Liver
Disease, 6.sup.th Ed. (W. B. Saunders Co. 1998); K. M. Sanders
(1996) Gastroenterology, 111: 492-515; P. Holzer (1998)
Gastroenterology, 114: 823-839; and R. K. Montgomery et al. (1999)
Gastroenterology, 116: 702-731.
[0041] By "gastroesophageal" is intended all parts of the esophagus
and stomach. By "gastroesophageal disorders" is intended any
disorder involving the esophagus and/or duodenum. By "structural
gastroesophageal disorder" is intended any disorder of the stomach
and/or esophagus where there is no evidence of structural
perturbations (including those observed in the mucosa) distal to
the pylorus. Structural gastroesophageal disorders include gastric
cancer and gastritis.
[0042] By "intestinal tract" is intended all parts of the duodenum,
jejeunum, ileum and large intestine (or colon). By "intestinal
tract disorder" is intended any disorder involving the duodenum,
jejeunum, ileum, and large intestine (or colon). By "structural
intestinal tract disorder" is intended any disorder involving the
duodenum, jejeunum, ileum, and/or large intestine (or colon) where
important mucosal and structural abnormalities are present or there
is evidence of a related metabolic disturbance that is not an
inflammatory bowel disorder or an acid peptic disorder. Structural
intestinal disorders include ulcers typically related to
medications such as non-steroidal anti-inflammatory drugs,
malignancies, and diverticulosis.
[0043] By "small intestine" is intended all parts of the duodenum,
jejunum, and ileum.
[0044] The term "duodenum" is used in its conventional sense to
refer to that portion of the GI tract beginning at the pylorus and
ending at the ligament of Treitz. The duodenum is divided into four
parts. (See, e.g., Yamada (1999) Textbook of Gastroenterology 3d
Ed., Lippincott Williams & Wilkins). The first part of the
duodenum is also known as the superior portion of the duodenum, and
begins at the pylorus, is about 5 cm long, and passes backward and
upward beneath the liver to the neck of the gall bladder (the first
2-3 cm of which is the duodenal bulb). The second part of the
duodenum is also known as the descending portion of the duodenum,
and extends along the right margin of the head of the pancreas, and
is approximately 7 to 10 cm in length. The third part of the
duodenum is also known as the horizontal portion of the duodenum,
and is where the duodenum passes from right to left across the
spine, inclining upwards for about 5 to 8 cm. The fourth part of
the duodenum is also known as the ascending portion of the duodenum
and begins at the left of the vertebral column, ascends to the left
of the aorta for 2 to 3 cm and ends at the ligament of Treitz.
[0045] The terms "active agent" and "pharmacologically active
agent" are used interchangeably herein to refer to a chemical
compound that induces a desired effect, i.e., in this case,
treatment of GI tract disorders except for acid peptic disorders or
structural gastroesophageal disorders. The primary active agents
herein are compounds that interact with TTX-R sodium channels,
including but not limited to sodium channel modulators,
particularly tetrodotoxin-resistant (TTX-R) sodium channel
modulators and/or activity-dependent sodium channel modulators,
including compounds that modulate or interact with Nav1.8 and/or
Nav1.9 channels. In addition, a combination therapy wherein a
sodium channel modulator, particularly a tetrodotoxin-resistant
(TTX-R) sodium channel modulator and/or activity-dependent sodium
channel modulator compound that interacts with TTX-R sodium
channels is administered with one or more additional active agents
is also within the scope of the present invention. Such combination
therapy may be carried out by administration of the different
active agents in a single composition, by concurrent administration
of the different active agents in different compositions, or by
sequential administration of the different active agents. Included
are and salts, enantiomers, analogs, esters, amides, prodrugs,
active metabolites, and derivatives of those compounds or classes
of compounds specifically mentioned that also induce the desired
effect.
[0046] The term "sodium channel modulator" as used herein is
intended to include agents that interact with the channel pore
itself (e.g., a binding event), or that may act as an allosteric
modulator of the channel by interacting with a site on the channel
complex (e.g., a binding event), as well as salts, esters, amides,
prodrugs, active metabolites, and other derivatives thereof.
Further, it is understood that any salts, enantiomers, analogs,
esters, amides, prodrugs, metabolites, or derivatives are
pharmaceutically acceptable as well as pharmacologically
active.
[0047] The term TTX-R sodium channel modulator as used herein is
intended to include agents that interact with TTX-R sodium channels
and/or any protein associated with a TTX-R sodium channels (e.g., a
binding event) to produce a physiological effect, such as opening,
closing, blocking, up-regulating expression, or down-regulating
expression of the channel, but not antisense or knockout
technologies. "Agents that interact with TTX-R sodium channels
and/or any protein associated with a TTX-R sodium channel" include
but are not limited to, amino acid compounds, peptide, nonpeptide,
peptidomimetic, small molecular weight organic compounds, and other
compounds that modulate or interact with TTX-R sodium channels
(e.g., a binding event) or proteins associates with TTX-R sodium
channels (e.g., a binding event) such as anchor proteins, as well
as salts, esters, amides, prodrugs, active metabolites, and other
derivatives thereof. "Agents that interact with TTX-R sodium
channels and/or any protein associated with a TTX-R sodium channel"
also include but are not limited to, amino acid compounds, peptide,
nonpeptide, peptidomimetic, small molecular weight organic
compounds, and other compounds that modulate or interact with
Nav1.8 and/or Nav1.9 channels (e.g., a binding event) or proteins
associated with Nav1.8 and/or Nav1.9 channels (e.g., a binding
event), such as anchor proteins, as well as salts, esters, amides,
prodrugs, active metabolites, and other derivatives thereof.
Further, it is understood that any salts, enantiomers, analogs,
esters, amides, prodrugs, metabolites, or derivatives are
pharmaceutically acceptable as well as pharmacologically
active.
[0048] The term "activity-dependent sodium channel modulator" or
"use-dependent sodium channel modulator" as used herein is intended
an agent that preferentially modulates the activity of a sodium
channel that has been activated or opened, and exhibits its effect
either by modifying the activity of the open channel, or by
modifying the activity of the inactivated state of the channel as
described in Hille B. (1992) Ionic Channels in Excitable Membranes.
2nd ed. Sinauer Associates, Sunderland, Mass., pp. 390-422. Unless
otherwise indicated, the term "activity-dependent sodium channel
modulator" is intended to include agents that interact with the
channel pore itself (e.g., a binding event), or that may act as an
allosteric modulator of the channel by interacting with a site on
the channel complex (e.g., a binding event), as well as salts,
esters, amides, prodrugs, active metabolites, and other derivatives
thereof. Further, it is understood that any salts, enantiomers,
analogs, esters, amides, prodrugs, metabolites, or derivatives are
pharmaceutically acceptable as well as pharmacologically
active.
[0049] The term "peptidomimetic" is used in its conventional sense
to refer to a molecule that mimics the biological activity of a
peptide but is no longer peptidic in chemical nature, including
molecules that lack amide bonds between amino acids, as well as
pseudo-peptides, semi-peptides and peptoids. Peptidomimetics
according to this invention provide a spatial arrangement of
reactive chemical moieties that closely resembles the
three-dimensional arrangement of active groups in the peptide on
which the peptidomimetic is based. As a result of this similar
active-site geometry, the peptidomimetic has effects on biological
systems that are similar to the biological activity of the
peptide.
[0050] The term "anticholinergic agent" as used herein refers to
any acetylcholine receptor antagonist, including antagonists of
nicotinic and/or muscarinic acetylcholine receptors. The term
"antinicotinic agent" as used herein is intended any nicotinic
acytylcholine receptor antagonist. The term "antimuscarinic agent"
as used herein is intended any muscarinic acetylcholine receptor
antagonist. Unless otherwise indicated, the terms "anticholinergic
agent," "antinicotinic agent," and "antimuscarinic agent" are
intended to include anticholinergic, antinicotinic, and
antimuscarinic agents as disclosed further herein, as well as
salts, esters, amides, prodrugs, active metabolites, and other
derivatives thereof. Further, it is understood that any salts,
enantiomers, analogs, esters, amides, prodrugs, metabolites, or
derivatives are pharmaceutically acceptable as well as
pharmacologically active.
[0051] The term ".beta.3 adrenergic agonist" is used in its
conventional sense to refer to a compound that agonizes .beta.3
adrenergic receptors. Unless otherwise indicated, the term ".beta.3
adrenergic agonist" is intended to include .beta.3 adrenergic
agonist agents as disclosed further herein, as well as salts,
esters, amides, prodrugs, active metabolites, and other derivatives
thereof. Further, it is understood that any salts, enantiomers,
analogs, esters, amides, prodrugs, metabolites, or derivatives are
pharmaceutically acceptable as well as pharmacologically
active.
[0052] The term "spasmolytic" (also known as "antispasmodic") is
used in its conventional sense to refer to a compound that relieves
or prevents muscle spasms, especially of smooth muscle. Unless
otherwise indicated, the term "spasmolytic" is intended to include
spasmolytic agents as disclosed further herein, as well as salts,
esters, amides, prodrugs, active metabolites, and other derivatives
thereof. Further, it is understood that any salts, enantiomers,
analogs, esters, amides, prodrugs, metabolites, or derivatives are
pharmaceutically acceptable as well as pharmacologically
active.
[0053] The term "neurokinin receptor antagonist" is used in its
conventional sense to refer to a compound that antagonizes
neurokinin receptors. Unless otherwise indicated, the term
"neurokinin receptor antagonist" is intended to include neurokinin
receptor antagonist agents as disclosed further herein, as well as
salts, esters, amides, prodrugs, active metabolites, and other
derivatives thereof. Further, it is understood that any salts,
enantiomers, analogs, esters, amides, prodrugs, metabolites, or
derivatives are pharmaceutically acceptable as well as
pharmacologically active.
[0054] The term "bradykinin receptor antagonist" is used in its
conventional sense to refer to a compound that antagonizes
bradykinin receptors. Unless otherwise indicated, the term
"bradykinin receptor antagonist" is intended to include bradykinin
receptor antagonist agents as disclosed further herein, as well as
salts, esters, amides, prodrugs, active metabolites, and other
derivatives thereof. Further, it is understood that any salts,
enantiomers, analogs, esters, amides, prodrugs, metabolites, or
derivatives are pharmaceutically acceptable as well as
pharmacologically active.
[0055] The term "nitric oxide donor" is used in its conventional
sense to refer to a compound that releases free nitric oxide when
administered to a patient. Unless otherwise indicated, the term
"nitric oxide donor" is intended to include nitric oxide donor
agents as disclosed further herein, as well as salts, esters,
amides, prodrugs, active metabolites, and other derivatives
thereof. Further, it is understood that any salts, enantiomers,
analogs, esters, amides, prodrugs, metabolites, or derivatives are
pharmaceutically acceptable as well as pharmacologically
active.
[0056] The terms "treating" and "treatment" as used herein refer to
relieving the symptoms or lessening the discomfort associated with
GI tract disorders except for acid peptic disorders or structural
gastroesophageal disorders.
[0057] By an "effective" amount or a "therapeutically effective
amount" of a drug or pharmacologically active agent is meant a
nontoxic but sufficient amount of the drug or agent to provide the
desired effect, i.e., relieving the symptoms or lessening the
discomfort associated with GI tract disorders except for acid
peptic disorders or structural gastroesophageal disorders.
[0058] By "pharmaceutically acceptable," such as in the recitation
of a "pharmaceutically acceptable carrier," or a "pharmaceutically
acceptable acid addition salt," is meant a material that is not
biologically or otherwise undesirable, i.e., the material may be
incorporated into a pharmaceutical composition administered to a
patient without causing any undesirable biological effects or
interacting in a deleterious manner with any of the other
components of the composition in which it is contained.
"Pharmacologically active" (or simply "active") as in a
"pharmacologically active" derivative or metabolite, refers to a
derivative or metabolite having the same type of pharmacological
activity as the parent compound. When the term "pharmaceutically
acceptable" is used to refer to a derivative (e.g., a salt or an
analog) of an active agent, it is to be understood that the
compound is pharmacologically active as well, i.e., therapeutically
effective for treating GI tract disorders except for acid peptic
disorders or structural gastroesophageal disorders, in mammals,
particularly humans.
[0059] By "continuous" dosing is meant the chronic administration
of a selected active agent. By "as-needed" dosing, also known as
"pro re nata" "prn" dosing, and "on demand" dosing or
administration is meant the administration of a single dose of the
active agent at some time prior to commencement of an activity
wherein suppression of the symptoms of a GI tract disorder except
for acid peptic disorders or structural gastroesophageal disorders,
would be desirable. Administration can be immediately prior to such
an activity, including about 0 minutes, about 10 minutes, about 20
minutes, about 30 minutes, about 1 hour, about 2 hours, about 3
hours, about 4 hours, about 5 hours, about 6 hours, about 7 hours,
about 8 hours, about 9 hours, or about 10 hours prior to such an
activity, depending on the formulation.
[0060] By "short-term" is intended any period of time up to and
including about 8 hours, about 7 hours, about 6 hours, about 5
hours, about 4 hours, about 3 hours, about 2 hours, about 1 hour,
about 40 minutes, about 20 minutes, or about 10 minutes after drug
administration.
[0061] By "rapid-offset" is intended any period of time up to and
including about 8 hours, about 7 hours, about 6 hours, about 5
hours, about 4 hours, about 3 hours, about 2 hours, about 1 hour,
about 40 minutes, about 20 minutes, or about 10 minutes after drug
administration.
[0062] The term "controlled release" is intended to refer to any
drug-containing formulation in which release of the drug is not
immediate, i.e., with a "controlled release" formulation, oral
administration does not result in immediate release of the drug
into an absorption pool. The term is used interchangeably with
"non-immediate release" as defined in Remington: The Science and
Practice of Pharmacy, Twentieth Ed. (Philadelphia, Pa.: Lippincott
Williams & Wilkins, 2000).
[0063] The "absorption pool" represents a solution of the drug
administered at a particular absorption site, and k.sub.r, k.sub.a,
and k.sub.e are first-order rate constants for: 1) release of the
drug from the formulation; 2) absorption; and 3) elimination,
respectively. For immediate release dosage forms, the rate constant
for drug release k.sub.r is far greater than the absorption rate
constant k.sub.a. For controlled release formulations, the opposite
is true, i.e., k.sub.r<<<k.sub.a, such that the rate of
release of drug from the dosage form is the rate-limiting step in
the delivery of the drug to the target area. The term "controlled
release" as used herein includes any nonimmediate release
formulation, including but not limited to sustained release,
delayed release and pulsatile release formulations.
[0064] The term "sustained release" is used in its conventional
sense to refer to a drug formulation that provides for gradual
release of a drug over an extended period of time, and that
preferably, although not necessarily, results in substantially
constant blood levels of a drug over an extended time period such
as up to about 72 hours, about 66 hours, about 60 hours, about 54
hours, about 48 hours, about 42 hours, about 36 hours, about 30
hours, about 24 hours, about 18 hours, about 12 hours, about 10
hours, about 8 hours, about 7 hours, about 6 hours, about 5 hours,
about 4 hours, about 3 hours, about 2 hours, or about 1 hour after
drug administration.
[0065] The term "delayed release" is used in its conventional sense
to refer to a drug formulation that provides for an initial release
of the drug after some delay following drug administration and that
preferably, although not necessarily, includes a delay of up to
about 10 minutes, about 20 minutes, about 30 minutes, about 1 hour,
about 2 hours, about 3 hours, about 4 hours, about 5 hours, about 6
hours, about 7 hours, about 8 hours, about 9 hours, about 10 hours,
about 11 hours, or about 12 hours.
[0066] The term "pulsatile release" is used in its conventional
sense to refer to a drug formulation that provides release of the
drug in such a way as to produce pulsed plasma profiles of the drug
after drug administration. The term "immediate release" is used in
its conventional sense to refer to a drug formulation that provides
for release of the drug immediately after drug administration.
[0067] The term "immediate release" is used in its conventional
sense to refer to a drug formulation that provides for release of
the drug immediately after drug administration.
[0068] By the term "transdermal" drug delivery is meant delivery by
passage of a drug through the skin or mucosal tissue and into the
bloodstream.
[0069] The term "topical administration" is used in its
conventional sense to mean delivery of a topical drug or
pharmacologically active agent to the skin or mucosa.
[0070] The term "oral administration" is used in its conventional
sense to mean delivery of a drug through the mouth and ingestion
through the stomach and digestive tract.
[0071] The term "inhalation administration" is used in its
conventional sense to mean delivery of an aerosolized form of the
drug by passage through the nose or mouth during inhalation and
passage of the drug through the walls of the lungs.
[0072] By the term "parenteral" drug delivery is meant delivery by
passage of a drug into the blood stream without first having to
pass through the alimentary canal, or digestive tract. Parenteral
drug delivery may be "subcutaneous," referring to delivery of a
drug by administration under the skin. Another form of parenteral
drug delivery is "intramuscular," referring to delivery of a drug
by administration into muscle tissue. Another form of parenteral
drug delivery is "intradermal," referring to delivery of a drug by
administration into the skin. An additional form of parenteral drug
delivery is "intravenous," referring to delivery of a drug by
administration into a vein. An additional form of parenteral drug
delivery is "intra-arterial," referring to delivery of a drug by
administration into an artery. Another form of parenteral drug
delivery is "transdermal," referring to delivery of a drug by
passage of the drug through the skin and into the bloodstream.
[0073] Still another form of parenteral drug delivery is
"transmucosal," referring to administration of a drug to the
mucosal surface of an individual so that the drug passes through
the mucosal tissue and into the individual's blood stream.
Transmucosal drug delivery may be "buccal" or "transbuccal,"
referring to delivery of a drug by passage through an individual's
buccal mucosa and into the bloodstream. Another form of
transmucosal drug delivery herein is "lingual" drug delivery, which
refers to delivery of a drug by passage of a drug through an
individual's lingual mucosa and into the bloodstream. Another form
of transmucosal drug delivery herein is "sublingual" drug delivery,
which refers to delivery of a drug by passage of a drug through an
individual's sublingual mucosa and into the bloodstream. Another
form of transmucosal drug delivery is "nasal" or "intranasal" drug
delivery, referring to delivery of a drug through an individual's
nasal mucosa and into the bloodstream. An additional form of
transmucosal drug delivery herein is "rectal" or "transrectal" drug
delivery, referring to delivery of a drug by passage of a drug
through an individual's rectal mucosa and into the bloodstream.
Another form of transmucosal drug delivery is "urethral" or
"transurethral" delivery, referring to delivery of the drug into
the urethra such that the drug contacts and passes through the wall
of the urethra. An additional form of transmucosal drug delivery is
"vaginal" or "transvaginal" delivery, referring to delivery of a
drug by passage of a drug through an individual's vaginal mucosa
and into the bloodstream. An additional form of transmucosal drug
delivery is "perivaginal" delivery, referring to delivery of a drug
through the vaginolabial tissue into the bloodstream.
[0074] In order to carry out the method of the invention, a
selected active agent is administered to a patient suffering from a
GI tract disorder except for acid peptic disorders or structural
gastroesophageal disorders. A therapeutically effective amount of
the active agent may be administered orally, intravenously,
subcutaneously, transmucosally (including buccally, sublingually,
transurethrally, and rectally), topically, transdermally, by
inhalation, or using any other route of administration.
GI Tract Disorders
[0075] GI tract disorders affect the quality of life of millions of
men and women in the United States every year. GI tract disorders
may involve disturbances of the GI smooth muscle, epithelium,
sensory afferent neurons, or central nervous system pathways. In
spite of the uncertainty regarding whether central or peripheral
mechanisms, or both, are involved in GI tract disorders, many
proposed mechanisms implicate neurons and pathways that mediate
visceral sensation. Viscerosensory information from the GI tract is
relayed by sensory fibers that enter the spinal cord via the dorsal
root ganglion (DRG) or project to the nodose ganglion via vagal
afferents (Physiology, ed. R. M Berne and M. N. Levy, 1983, CV
Mosby Co. St. Louis). A number of different subtypes of sensory
afferent neurons may be involved in neurotransmission from the GI
tract. These may be classified as, but not limited to, small
diameter, medium diameter, large diameter, myelinated,
unmyelinated, sacral, lumbar, DRG, vagal, nodose, peptidergic,
non-peptidergic, IB4 positive, IB4 negative, C fiber, A.delta.
fiber, A.beta. fiber, high threshold or low threshold neurons.
Structural and Non-Structural GI Tract Disorders
[0076] GI tract disorders have been characterized as structural (or
mucosal) GI tract disorders and non-structural (or non-mucosal) GI
tract disorders. Structural disorders include inflammatory bowel
disorders and non-inflammatory structural GI tract disorders.
Non-structural disorders include a variety of disorders classified
as functional GI tract disorders.
[0077] Inflammatory bowel disorders include a group of disorders
that can cause inflammation or ulceration of the GI tract.
Ulcerative colitis and Crohn's disease are the most common types of
inflammatory bowel disorders, although collagenous colitis,
lymphocytic (microscopic) colitis, and other disorders have also
been described.
[0078] The compounds of the present invention are useful in the
treatment of ulcerative colitis. Ulcerative colitis is a chronic
inflammatory disorder of unknown etiology afflicting the large
intestine and, except when very severe, is limited to the bowel
mucosa. The course of this disorder may be continuous or relapsing
and may be mild or severe. Medical treatment primarily includes the
use of salicylate derivatives, glucocorticosteroids such as
prednisone or prednisone acetate and anti-metabolites dependent on
the clinical state of the patient. Salicylate derivatives, such as
sulphazine or mesalamine, are efficacious in patients with mild
cases of the disorder. Glucocorticosteroids and anti-metabolites
are efficacious in patients with moderate or severe disease but are
associated with a number of side effects. Patients who need chronic
doses of glucocorticosteroids or anti-metabolites for control of
their disorder eventually undergo removal of the colon surgically
to eliminate the disease. Therefore, the compounds of the present
invention meet an existing need for new treatments for ulcerative
colitis.
[0079] The compounds of the present invention are also useful for
in the treatment of Chron's disease. Like ulcerative colitis,
Crohn's disease (also known as regional enteritis, ileitis, or
granulomatous ileocolitis) is a chronic inflammatory disorder of
unknown etiology; however the location and pathology of the disease
differ. Crohn's disease typically presents in either the small
intestine, large intestine or the combination of the two locations
and can cause inflammation deeper into the muscle and serosa
located within the intestinal wall. The course of the disorder may
be continuous or relapsing and may be mild or severe. Medical
treatment includes the continuous use of salicylate derivatives,
glucocorticosteroids, anti-metabolites, and administration of an
anti-TNF antibody. Many Crohn's disease patients require intestinal
surgery for a problem related to the disease, but unlike ulcerative
colitis subsequent relapse is common. Therefore, the compounds of
the present invention meet an existing need for new treatments for
Chron's disease.
[0080] Compounds of the present invention are also useful in the
treatment of collagenous colitis and lymphocytic colitis.
Collagenous colitis and lymphocytic colitis are idiopathic
inflammatory disorders of the colon that cause watery diarrhea
typically in middle-aged or older individuals. Lymphocytic colitis
is distinguished from collagenous colitis by the absence of a
thickened subepithelial collagenous layer. Bismuth in the form of
Pepto-Bismol may be an effective treatment in some patients,
although more severe cases may require the use of salicylate
derivatives, antibiotics such as metronidazole, and
glucocorticosteroids. Therefore, the compounds of the present
invention meet an existing need for new treatments for collagenous
colitis and lymphocytic colitis.
[0081] Compounds of the present invention are also useful in the
treatment of functional GI tract disorders. Functional GI tract
disorders are characterized by presentation of abdominal-type
symptoms without evidence of changes in metabolism or structural
abnormalities. Disorders that are typically considered under
functional disorders include dysphagia, non-ulcer dyspepsia,
irritable bowel syndrome, slow-transit constipation, and evacuation
disorders (Camilleri (2002) Gastrointestinal Motility Disorders, In
WebMD Scientific American Medicine, edited by David C. Dale and
Daniel D. Federman, New York, N.Y., WebMD). A prominent example of
a functional GI tract disorder is irritable bowel syndrome (IBS),
also known by a variety of synonyms, including functional bowel,
pylorospasm, nervous indigestion, spastic colon, spastic colitis,
spastic bowel, intestinal neurosis, functional colitis, irritable
colon, mucous colitis, laxative colitis, and functional dyspepsia.
IBS generally leads to abdominal pain and/or discomfort and an
alteration in bowel habit with no clear etiology. Diagnosis relies
on Rome criteria taking into account all symptoms related to
patient presentation. (See, e.g., Drossman et al. (1997)
Gastroenterology, 112: 2120). Patients typically present with
symptoms consistent with hyperalgesia and allodynia.
[0082] Compounds of the present invention are also useful in the
treatment of IBS. At present, treatments for IBS have been largely
ineffective, and have included stress management, diet, and drugs.
Psychoactive drugs, such as anxiolytics and antidepressants, have
been utilized but have limited utility because of the side effect
profile. Antispasmodics and various antidiarrheal preparations have
also been used but these remain as unsatisfactory remedies to
patients with IBS. Therefore, the compounds of the present
invention meet an existing need for new treatments for IBS.
[0083] Compounds of the present invention are also useful in the
treatment of non-ulcer dyspepsia. Non-ulcer dyspepsia (NUD) is
another prominent example of a functional GI tract disorder with no
established etiology. Symptoms related to NUD include nausea,
vomiting, pain, early satiety, bloating and loss of appetite.
Altered gastric emptying and increased gastric sensitivity and
distress may contribute to NUD but do not completely explain its
presentation. Treatments include behavioral therapy, psychotherapy,
or administration of antidepressants, motility regulatory agents,
antacids, H.sub.2-receptor antagonists, and prokinetics. However,
many of these treatments have shown limited efficacy in many
patients. Therefore, the compounds of the present invention meet an
existing need for new treatments for NUD.
Anatomical and Physiological Distinctions
[0084] In addition to the structural/non-structural classification
described above, GI tract disorders may also be sub-classified
based upon anatomical, physiological, and other characteristics of
different portions of the GI tract as described in Sleisenger and
Fordtran's Gastrointestinal and Liver Disease, 6.sup.th Ed. (W. B.
Saunders Co. 1998); K. M. Sanders (1996) Gastroenterology, 111:
492-515; P. Holzer (1998) Gastroenterology,114: 823-839; and R. K.
Montgomery et al. (1999) Gastroenterology,116: 702-731. For
example, acid peptic disorders are generally thought to arise from
damage due to acidic and/or peptic activity of gastric secretions
and may affect the esophagus, stomach, and duodenum. Acid peptic
disorders include gastroesophageal reflux disease, peptic ulcers
(both gastric and duodenal), erosive esophagitis and esophageal
stricture. Zollinger-Ellison Syndrome may be considered an acid
peptic disorder since it typically presents with multiple ulcers
due to excessive acid secretion caused by a endocrine tumor.
Treatments typically include gastric acid suppressive therapies,
antibiotics, and surgery. In some patients, however, these
therapies have proven ineffective. Therefore, the compounds of the
present invention meet an existing need for new treatments for acid
peptic disorders.
[0085] Another sub-classification for GI tract disorders may be
drawn between gastroesophageal and intestinal disorders based upon
characteristics between different portions of the GI tract as
disclosed in Sleisenger and Fordtran's Gastrointestinal and Liver
Disease, 6.sup.th Ed. (W. B. Saunders Co. 1998); K. M. Sanders
(1996) Gastroenterology, 111: 492-515; P. Holzer (1998)
Gastroenterology,114: 823-839; and R. K. Montgomery et al. (1999)
Gastroenterology, 116: 702-731. Structural gastroesophageal
disorders include disorders of the stomach and/or esophagus where
there is no evidence of structural perturbations (including those
observed in the mucosa) distal to the pylorus. Dyspepsia (chronic
pain or discomfort centered in the upper abdomen) is a prominent
feature of most structural gastroesophageal disorders but can also
be observed in non-structural perturbations, and has been estimated
to account for 2 to 5 percent of all general practice
consultations. Structural gastroesophageal disorders include
gastritis and gastric cancer. By contrast, structural intestinal
tract disorders occur in both the small intestine (the duodenum,
jejunum, and ileum) and in the large intestine. Structural
intestinal tract disorders are characterized by structural changes
in the mucosa or in the muscle layers of the intestine, and include
non-peptic ulcers of the small intestine, malignancies, and
diverticulosis. Non-peptic ulcers in the small intestine are
typically related to administration of non-steroidal
anti-inflammatory drugs. Diverticulosis is a disorder that rarely
occurs in the small intestine and most commonly appears in the
colon.
[0086] The compounds of the present invention are useful in the
treatment of both gastroesophageal and intestinal disorders.
Non-Inflammatory GI Tract Disorders
[0087] The compounds of the present invention are useful in the
treatment of non-inflammatory GI disorders. Non-inflammatory GI
tract disorders include non-inflammatory structural GI tract
disorders and non-structural GI tract disorders. Non-inflammatory
structural GI tract disorders include, but are not limited to,
hiatal hernias, strictures, esophageal webs, Schatzki's ring,
esophageal diverticula, and esophageal scleroderma. Non-structural
GI tract disorders include motor disorders of the esophagus such as
achalasia and diffuse esophageal spasm, and functional GI tract
disorders such as irritable bowel syndrome.
[0088] Hiatal (also called hiatus) hernias may be divided into two
types: sliding and paraesophageal. (First Principles of
Gastroenterology, The basis of disease and an approach to
management (2000), 4.sup.th edition, Thompson A B R and Shaffer E
A, eds., Canadian Association of Gastroenterology and AstraZeneca).
A sliding hiatal hernia is relatively common and occurs where a
circumferential cuff of cardia and proximal stomach migrates into
the thorax through the diaphragmatic hiatus. (See, e.g., Thompson
and Shaffer, First Principles of Gastroenterology, supra). The
etiology of sliding hiatal hernias is unclear, and they often
reduce and reform spontaneously, although surgical correction may
be performed in extreme cases. (See, e.g., Thompson and Shaffer,
First Principles of Gastroenterology, supra). By contrast,
paraesophageal hiatal hernias are relatively uncommon and occur
where the fundus of the stomach migrates through the hiatus
alongside the esophagus without any displacement of the
gastroesophageal junction. (See, e.g., Thompson and Shaffer, First
Principles of Gastroenterology, supra). The etiology of
paraesophageal hiatal hernias is also unclear. Paraesophageal
hiatal hernias are often asymptomatic, but many are treated
surgically because the herniated portion may become strangulated
and infarcted. (See, e.g., Thompson and Shaffer, First Principles
of Gastroenterology, supra). The compounds of the present invention
are useful in the treatment of hiatal hernias.
[0089] The compounds of the present invention are useful in the
treatment of strictures. A stricture is a narrowing of the GI
tract. An esophageal stricture is a narrowing of the esophagus.
[0090] The compounds of the present invention are also useful in
the treatment of esophageal webs. Esophageal webs are thin,
membrane-like structures that project into the esophageal lumen,
are covered on both sides with squamous epithelium, and are most
commonly found in the cervical esophagus. (See, e.g., Thompson and
Shaffer, First Principles of Gastroenterology, supra). Esophageal
webs rarely occlude enough of the esophageal lumen to cause
dysphagia and are usually detected incidentally during barium
x-rays. (See, e.g., Thompson and Shaffer, First Principles of
Gastroenterology, supra). Although some esophageal webs may be
congenital in origin, others may form after esophageal injury.
(See, e.g., Thompson and Shaffer, First Principles of
Gastroenterology, supra). The precise etiology of esophageal webs
is unclear. (See, e.g., Thompson and Shaffer, First Principles of
Gastroenterology, supra).
[0091] The compounds of the present invention are also useful in
the treatment of Schatzki's ring. Like esophageal webs, Schatzki's
ring is also a membrane-like structure. (See, e.g., Thompson and
Shaffer, First Principles of Gastroenterology, supra). Unlike webs,
however, Schatzki's ring is lined by squamous epithelium on its
superior aspect and columnar epithelium inferiorly. (See, e.g.,
Thompson and Shaffer, First Principles of Gastroenterology, supra).
Schatzki's ring rarely occludes enough of the esophageal lumen to
cause dysphagia, but are detected incidentally in up to 10% of all
upper GI barium x-rays. (See, e.g., Thompson and Shaffer, First
Principles of Gastroenterology, supra). Where dysphagia occurs,
however, Schatzki's ring is a common cause. (See, e.g., Thompson
and Shaffer, First Principles of Gastroenterology, supra).
Treatment of symptomatic Schatzki's ring involves shattering the
ring with a large-diameter bougie or a balloon dilator. (See, e.g.,
Thompson and Shaffer, First Principles of Gastroenterology, supra).
Therefore, the compounds of the present invention meet an existing
need for new treatments for Schatzki's ring.
[0092] The compounds of the present invention are useful in the
treatment of esophageal diverticula. Esophageal diverticula are
outpouchings of one or more layers of the esophageal wall, and
include midesophageal and lower esophageal diverticula.
[0093] Midesophageal diverticula (also called "traction"
diverticula) were once thought to arise secondary to old
mediastinal inflammation, such as tuberculosis, that caused
adherence of mediastinal structures to the outer esophageal wall.
(See, e.g., Thompson and Shaffer, First Principles of
Gastroenterology, supra). Recent evidence suggests that very few
midesophageal diverticula arise this way, but are instead
associated with a motility disorder. (See, e.g., Thompson and
Shaffer, First Principles of Gastroenterology, supra). In fact, it
is likely that midesophageal diverticula are actually "pulsion"
diverticula formed when a peristaltic wave deteriorates into a
simultaneous or spastic contraction in the smooth-muscle esophagus.
(See, e.g., Thompson and Shaffer, First Principles of
Gastroenterology, supra). Midesophageal diverticula rarely require
specific therapy, although the associated motor disorder may
require treatment if symptomatic. (See, e.g., Thompson and Shaffer,
First Principles of Gastroenterology, supra). Therefore, the
compounds of the present invention meet an existing need for new
treatments for midesophageal diverticula.
[0094] Lower esophageal diverticula are also "pulsion" diverticula,
and form just above the lower esophageal sphincter. (See, e.g.,
Thompson and Shaffer, First Principles of Gastroenterology, supra).
Lower esophageal diverticula are invariably associated with an
esophageal motor disorder, and patients usually present with
dysphagia and/or angina-like chest pain. (See, e.g., Thompson and
Shaffer, First Principles of Gastroenterology, supra). Patients may
also complain of nocturnal regurgitation of large quantities of
stagnant fluid. (See, e.g., Thompson and Shaffer, First Principles
of Gastroenterology, supra). Current treatment options include the
use of nitrates and some calcium channel blockers, although
esophageal myotomy may be an option for patients with severe
disease unresponsive to medical measures. (See, e.g., Thompson and
Shaffer, First Principles of Gastroenterology, supra). Therefore,
the compounds of the present invention meet an existing need for
new treatments for lower esophageal diverticula.
[0095] The compounds of the present invention are also useful in
the treatment of esophageal scleroderma. Esophageal scleroderma
often occurs in patients with general scleroderma, and may be
present even in the absence of obvious skin and joint involvement.
(See, e.g., Thompson and Shaffer, First Principles of
Gastroenterology, supra). Initial damage involves small blood
vessels, which leads to intramural neuronal dysfunction and
ultimately to actual muscle damage and fibrosis. (See, e.g.,
Thompson and Shaffer, First Principles of Gastroenterology, supra).
These effects produce a very hypotensive lower esophageal sphincter
and weak non-propulsive esophageal contractions. (See, e.g.,
Thompson and Shaffer, First Principles of Gastroenterology, supra).
Scleroderma may also involve the stomach and cause delayed gastric
emptying as well as gastroesophageal reflux. (See, e.g., Thompson
and Shaffer, First Principles of Gastroenterology, supra). Patients
may report dysphagia, which can be due to poor esophageal
propulsion and/or reflux-induced stricture. (See, e.g., Thompson
and Shaffer, First Principles of Gastroenterology, supra). Such
patients need very aggressive treatment for gastroesophageal
reflux, but because of very poor peristaltic function, anti-reflux
surgery may markedly worsen the dysphagia by increasing the barrier
at the lower esophageal sphincter. (See, e.g., Thompson and
Shaffer, First Principles of Gastroenterology, supra). Therefore,
the compounds of the present invention meet an existing need for
new treatments for esophageal scleroderma.
[0096] The compounds of the present invention are also useful in
the treatment of motor disorders of the esophagus. Motor disorders
of the esophagus may be classified as primary or secondary. Primary
motor disorders of the esophagus usually affect the esophagus alone
and have no known etiology. (See, e.g., Thompson and Shaffer, First
Principles of Gastroenterology, supra). By contrast, secondary
motor disorders of the esophagus are motility disturbances caused
by some other systemic or local condition, including
acid-reflux-induced dysmotility and dysmotility related to diabetic
neuropathy. (See, e.g., Thompson and Shaffer, First Principles of
Gastroenterology, supra).
[0097] Primary motor disorders of the esophagus include diffuse
esophageal spasm (DES) and achalasia. (See, e.g., Thompson and
Shaffer, First Principles of Gastroenterology, supra). DES is
characterized by normal peristalsis interrupted by frequent
high-pressure non-propagated (or "tertiary") waves as well as
multi-peaked waves, with patients often presenting with dysphagia
and chest pain. (See, e.g., Thompson and Shaffer, First Principles
of Gastroenterology, supra). In advanced DES, an x-ray examination
shows a corkscrew pattern due to different portions of the
esophagus vigorously and simultaneously contracting. (See, e.g.,
Thompson and Shaffer, First Principles of Gastroenterology, supra).
Although unknown, the etiology of DES may relate to degenerative
changes in the intrinsic and extrinsic esophageal nerves. (See,
e.g., Thompson and Shaffer, First Principles of Gastroenterology,
supra). Current treatment options include the use of nitrates and
some calcium channel blockers, although long esophageal myotomy may
be an option for patients with severe disease unresponsive to
medical measures. (See, e.g., Thompson and Shaffer, First
Principles of Gastroenterology, supra). Therefore, the compounds of
the present invention meet an existing need for new treatments for
DES.
[0098] Achalasia is a relatively uncommon primary motility disorder
characterized by aperistalsis in the body of the esophagus, an
elevated lower esophageal sphincter pressure, and absent or
incomplete lower esophageal sphincter relaxation in response to
swallowing. (See, e.g., Thompson and Shaffer, First Principles of
Gastroenterology, supra). The absence of lower esophageal sphincter
relaxation produces progressive proximal dilation of the esophagus
and elevated resting intraesophageal pressure. (See, e.g., Thompson
and Shaffer, First Principles of Gastroenterology, supra). The
esophagus is dilated on x-ray examination and the distal esophagus
narrows in a beak-like fashion. Achalasia is caused by degeneration
of inhibitory neurons within the esophageal and lower esophageal
sphincter myenteric plexus, as well as nerve damage in the vagal
nerve trunks and the dorsal motor nuclei. (See, e.g., Thompson and
Shaffer, First Principles of Gastroenterology, supra). The parasite
Trypanosoma cruzi can cause achalasia by destroying myenteric
neurons (Chagas' disease). (See, e.g., Thompson and Shaffer, First
Principles of Gastroenterology, supra). Neoplastic disease can also
cause "secondary" achalasia by interfering with esophageal and
lower esophageal sphincter nerve function. (See, e.g., Thompson and
Shaffer, First Principles of Gastroenterology, supra).
[0099] Patients with achalasia often present with dysphagia, and
some patients may complain of chest pain and/or regurgitation of
esophageal contents. (See, e.g., Thompson and Shaffer, First
Principles of Gastroenterology, supra). Heartburn may also occur,
although it is caused by lactic acid formed by fermentation of
stagnant esophageal contents and not from gastroesophageal reflux.
(See, e.g., Thompson and Shaffer, First Principles of
Gastroenterology, supra). Current treatment options include the use
of nitrates and some calcium channel blockers. (See, e.g., Thompson
and Shaffer, First Principles of Gastroenterology, supra).
Pneumatic balloon dilation of the lower esophageal sphincter may
also be used, which consists of passing a balloon across the
sphincter and inflating it rapidly so that the sphincter is
forcefully dilated. (See, e.g., Thompson and Shaffer, First
Principles of Gastroenterology, supra). For patients who do not
respond to pneumatic dilation, a Heller myotomy may be used in
which a longitudinal incision is made through the muscle of the
lower esophageal sphincter. (See, e.g., Thompson and Shaffer, First
Principles of Gastroenterology, supra). Some recent studies have
also found that injection of botulinum toxin into the muscle of the
lower esophageal sphincter can alleviate dysphagia in approximately
two-thirds of patients with achalasia, but the average duration of
relief is only one year. (See, e.g., Thompson and Shaffer, First
Principles of Gastroenterology, supra). Therefore, the compounds of
the present invention meet an existing need for new treatments for
achalasia.
Peripheral vs. Central Effects
[0100] The mammalian nervous system comprises a central nervous
system (CNS, comprising the brain and spinal cord) and a peripheral
nervous system (PNS, comprising sympathetic, parasympathetic,
sensory, motor, and enteric neurons outside of the brain and spinal
cord). Where an active agent according to the present invention is
intended to act centrally (i.e., exert its effects via action on
neurons in the CNS), the active agent must either be administered
directly into the CNS or be capable of bypassing or crossing the
blood-brain barrier. The blood-brain barrier is a capillary wall
structure that effectively screens out all but selected categories
of substances present in the blood, preventing their passage into
the CNS. The unique morphologic characteristics of the brain
capillaries that make up the blood-brain barrier are: 1)
epithelial-like high resistance tight junctions which literally
cement all endothelia of brain capillaries together within the
blood-brain barrier regions of the CNS; and 2) scanty pinocytosis
or transendothelial channels, which are abundant in endothelia of
peripheral organs. Due to the unique characteristics of the
blood-brain barrier, many hydrophilic drugs and peptides that
readily gain access to other tissues in the body are barred from
entry into the brain or their rates of entry are very low.
[0101] The blood-brain barrier can be bypassed effectively by
direct infusion of the active agent into the brain, or by
intranasal administration or inhalation of formulations suitable
for uptake and retrograde transport of the active agent by
olfactory neurons. The most common procedure for administration
directly into the CNS is the implantation of a catheter into the
ventricular system or intrathecal space. Alternatively, the active
agent can be modified to enhance its transport across the
blood-brain barrier. This generally requires some solubility of the
drug in lipids, or other appropriate modification known to one of
skill in the art. For example, the active agent may be truncated,
derivatized, latentiated (converted from a hydrophilic drug into a
lipid-soluble drug), conjugated to a lipophilic moiety or to a
substance that is actively transported across the blood-brain
barrier, or modified using standard means known to those skilled in
the art. See, for example, Pardridge, Endocrine Reviews 7: 314-330
(1986) and U.S. Pat. No. 4,801,575.
[0102] Where an active agent according to the present invention is
intended to act exclusively peripherally (i.e., exert its effects
via action either on neurons in the PNS or directly on target
tissues), it may be desirable to modify the compounds of the
present invention such that they will not pass the blood-brain
barrier. The principle of blood-brain barrier permeability can
therefore be used to design active agents with selective potency
for peripheral targets. Generally, a lipid-insoluble drug will not
cross the blood-brain barrier, and will not produce effects on the
CNS. A basic drug that acts on the nervous system may be altered to
produce a selective peripheral effect by quaternization of the
drug, which decreases its lipid solubility and makes it virtually
unavailable for transfer to the CNS. For example, the charged
antimuscarinic drug methscopalamine bromide has peripheral effects
while the uncharged antimuscarinic drug scopolamine acts centrally.
One of skill in the art can select and modify active agents of the
present invention using well-known standard chemical synthetic
techniques to add a lipid impermeable functional group such a
quaternary amine, sulfate, carboxylate, phosphate, or sulfonium to
prevent transport across the blood-brain barrier. Such
modifications are by no means the only way in which active agents
of the present invention may be modified to be impermeable to the
blood-brain barrier; other well known pharmaceutical techniques
exist and would be considered to fall within the scope of the
present invention.
Agents
[0103] Compounds useful in the present invention include any active
agent as defined elsewhere herein. Such active agents include, for
example, sodium channel modulators, including TTX-R sodium channel
modulators and/or activity dependent sodium channel modulators.
TTX-R sodium channel modulators for use in the present invention
include but are not limited to compounds that modulate or interact
with Nav1.8 and/or Na.sub.v1.9 channels.
[0104] Voltage gated sodium channels, also known as voltage
dependent sodium channels, are membrane-spanning proteins which
permit controlled sodium influx from an extracellular environment
into the interior of a cell. Opening and closing (gating) of
voltage gated sodium channels is controlled by a voltage sensitive
region of the protein containing charged amino acids that move
within an electric field. The movement of these charged groups
leads to conformational changes in the structure of the channel
resulting in conducting (open/activated) or non-conducting
(closed/inactivated) states.
[0105] Voltage gated sodium channels are present in a variety of
tissues and are implicated in several vital processes in animals.
Changes in sodium influx into cells mediated through voltage
dependent sodium channels have been implicated in various human
disorders such as epilepsy, pain, anaesthesia, neuroprotection,
arrhythmia, and migraine (See, e.g., U.S. Pat. No. 6,479,498).
[0106] At least nine distinct voltage gated sodium channels have
been identified in mammals (A.I. Goldin (2001) Annu. Rev. Physiol.,
63: 871-94). Although most voltage gated sodium channels are
tetrodotoxin-sensitive (TTX-S), tetrodotoxin-resistant (TTX-R)
sodium channels have also been identified. Two of these TTX-R
sodium channels, Na.sub.v1.8 and Na.sub.v1.9, are thought to be
specific to sensory neurons, including neurons of the dorsal root
ganglia (DRG). Antisense and knockout technologies have suggested a
possible role for TTX-R sodium channels in painful bladder
disorders (See e.g., N. Yoshimura et al. (2001) J Neurosci. 21:
8690-6; N. Yoshimura et al. (2001) Urology 57: 116-7).
[0107] Compounds have been described that modulate sodium channels
in an activity-dependent manner, meaning that these compounds
preferentially modulate the activity of a sodium channel that has
been activated or opened, and exhibit their effect either by
modifying the activity of the open channel, or by modifying the
activity of the inactivated state of the channel as described in
Hille B. (1992) Ionic Channels in Excitable Membranes. 2nd ed.
Sinauer Associates, Sunderland, Mass., pp. 390-422. Generally, this
activity-dependent sodium channel modulation will alter the release
of neurotransmitters under conditions that would normally cause
sustained depolarization of neurons and/or repetitive firing of
action potentials. Compounds that modulate sodium channels in an
activity-dependent manner may include agents that interact with the
sodium channel pore itself, as well as those that act as allosteric
modulators of the channel by interacting with to a site on the
channel complex.
[0108] Some sodium channel modulators may selectively modulate
TTX-R sodium channels, while others may act non-selectively on
sodium channels. Likewise, some activity dependent sodium channel
modulators may selectively modulate TTX-R sodium channels, while
others may act non-selectively on sodium channels, or on non-TTX-R
sodium channels.
[0109] Agents useful in the practice of the invention include, but
are not limited to propionamides such as Ralfinamide (NW-1029) (as
disclosed in U.S. Pat. No. 5,236,957 and U.S. Pat. No. 5,391,577),
which is also known as
(+)-2(S)-[4-(2-Fluorobenzyloxy)benzylamino]propionamide and is
represented by the following structure: 1
[0110] It is understood that the present invention also encompasses
any salts, enantiomers, analogs, esters, amides, and derivatives of
Ralfinamide, including:
[0111] a. Safinamide (as disclosed in U.S. Pat. No. 5,236,957 and
U.S. Pat. No. 5,391,577), which is also known as
2(S)-[4-(3-Fluorobenzyloxy)be- nzylamino]propionamide
methanesulfonate and is represented by the following structure:
2
[0112] b. Other N-phenylalkyl substituted .alpha.-amino carboxamide
derivatives in addition to Ralfinamide and Salfinamide as disclosed
in U.S. Pat. No. 5,236,957;
[0113] c. Other N-phenylalkyl substituted .alpha.-amino carboxamide
derivatives in addition to Ralfinamide and Salfinamide as disclosed
in U.S. Pat. No. 5,391,577;
[0114] d. Substituted 2-benzylamino-2-phenyl-acetamide compounds as
disclosed in U.S. Pat. No. 6,303,819, including agents with the
following structural structure: 3
[0115] wherein:
[0116] n is zero, 1, 2, or 3;
[0117] X is --O--, --S--, --CH.sub.2--, or --NH--;
[0118] each of R, R.sub.1, R.sub.2, and R.sub.3, independently, is
hydrogen, C.sub.1-C.sub.6 alkyl, halogen, hydroxyl, C.sub.1-C.sub.6
alkyl, halogen, hydroxyl, C.sub.1-C.sub.6 alkoxy, or
trifluoromethyl;
[0119] each of R.sub.4 and R.sub.5, independently, is hydrogen,
C.sub.1-C.sub.6 alkyl or C.sub.3-C.sub.7 cycloalkyl; or a
pharmaceutically acceptable salt thereof; and
[0120] e. 2-(4-Substituted)-benzylamino-2-methyl-propanamide
derivatives as disclosed in U.S. Pat. No. 5,945,454, including
agents with the following structural structure: 4
[0121] wherein:
[0122] n is zero, 1, 2, or 3;
[0123] X is --O--, --S--, --CH.sub.2--, or --NH--;
[0124] each or R and R.sub.1 independently is hydrogen,
C.sub.1-C.sub.6 alkyl, halogen, hydroxyl, C.sub.1-C.sub.4 alkoxy,
or trifluoromethyl;
[0125] each of R.sub.2, R.sub.3, and R.sub.4 independently is
hydrogen, C.sub.1-C.sub.6 alkyl, or C.sub.3-C.sub.7 cycloalkyl;
or
[0126] a pharmaceutically acceptable salt thereof with a proviso
that when X is --S-- and R, R.sub.1, R.sub.2, R.sub.3, and R.sub.4
are hydrogen, n is not zero.
[0127] It is further understood that the present invention also
encompasses any salts, enantiomers, analogs, esters, amides, and
derivatives of any of the aforementioned compounds.
[0128] Additional agents useful in the practice of the invention
include, but are not limited to, aryldiazines and aryltriazines
such as:
[0129] a. Sipatrigine (BW-619C; as disclosed in U.S. Pat. No.
5,684,005), which is also known as
4-Amino-2-(4-methylpiperazin-1-yl)-5-(2,3,5-trichl-
orophenyl)pyrimidine;
2-(4-Methylpiperazin-1-yl)-5-(2,3,5-trichlorophenyl)-
pyrimidine-4-amine and is represented by the following structure:
5
[0130] b. Lamotrigine (as disclosed in U.S. Pat. No. 4,602,017),
which is also known as
6-(2,3-Dichlorophenyl)-1,2,4-triazine-3,5-diamine and is
represented by the following structure: 6
[0131] c. GW-273293 (as disclosed in U.S. Pat. No. 6,599,905),
which is also known as
3-(2,3,5-Trichlorophenyl)pyrazine-2,6-diamine and is represented by
the following structure: 7
[0132] d. 4030W92 (as disclosed in U.S. Pat. No. 6,124,308), which
is also known as
5-(2,3-Dichlorophenyl)-6-(fluoromethyl)pyrimidine-2,4-diamine and
is represented by the following structure: 8
[0133] It is understood that the present invention also encompasses
any salts, enantiomers, analogs, esters, amides, and derivatives of
the aforementioned agents.
[0134] Additional agents useful in the practice of the invention
include, but are not limited to, dibenzazepines such as:
[0135] a. Carbamazepine (as disclosed in U.S. Pat. No. 2,948,718),
which is also known as 5H-Dibenz[d,f]azepine-5-carboxamide and is
represented by the following structure: 9
[0136] b. Oxcarbazepine (as disclosed in U.S. Pat. No. 3,642,775),
which is also known as
10-Oxo-10,11-dihydro-5H-dibenz[b,f]azepine-5-carboxamide and is
represented by the following structure: 10
[0137] c. Licarbazepine (as disclosed in DE 2011045), which is also
known as (.+-.)-10-Hydroxy-10,11
-dihydro-5H-dibenz[b,f]azepine-5-carboxamide and is represented by
the following structure: 11
[0138] d. BIA-2-093 (as disclosed in U.S. Pat. No. 5,753,646),
which is also known as Acetic acid
5-carbamoyl-10,11-dihydro-5H-dibenzo[b,f]azepin- -10(S)-yl ester
and is represented by the following structure: 12
[0139] and
[0140] e. ADCI (as disclosed in U.S. Pat. No. 5,196,415), which is
also known as
(.+-.)-5,10-Imino-10,11-dihydro-5H-dibenzo[a,d]cycloheptene-5-ca-
rboxamide and is represented by the following structure: 13
[0141] It is understood that the present invention also encompasses
any salts, enantiomers, analogs, esters, amides, and derivatives of
the aforementioned agents.
[0142] Additional agents useful in the practice of the invention
include, but are not limited to, hydantoins such as:
[0143] a. Phenytoin sodium (as disclosed in U.S. Pat. No.
2,409,754) and OROS.RTM.-Phenytoin (as disclosed in U.S. Pat. No.
4,260,769), which are also known as 5,5-Diphenylhydantoin sodium
salt and 5,5-Diphenyl-2,4-imidazolidinedione salt, respectively,
and represented by the following structure: 14
[0144] and
[0145] b. Fosphenytoin sodium (as disclosed in U.S. Pat. No.
4,260,769) and phosphenytoin sodium, which are also known as
3-(Hydroxymethyl)-5,5-d- iphenylhydantoin phosphate ester disodium
salt and 5,5-Diphenyl-3-[(phosph-
onooxy)methyl]-2,4-imidazolidinedione disodium salt and are
represented by the following structure: 15
[0146] It is understood that the present invention also encompasses
any salts, enantiomers, analogs, esters, amides, and derivatives of
the aforementioned agents.
[0147] Additional agents useful in the practice of the invention
include, but are not limited to, 3 and 4 atom spaced phenyl amines
such as:
[0148] a. Pilsicainide hydrochloride (as disclosed in U.S. Pat. No.
4,564,624), which is also known as
N-(2,6-Dimethylphenyl)-8-pyrrolizidine- acetamide hydrochloride;
N-(2,6-Dimethylphenyl)-1-azabicyclo[3.3.0]octane-- 5-acetamide
hydrochloride and is represented by the following structure: 16
[0149] b. Tocainide (as disclosed in DE 2235745), which is also
known as 2-Amino-N-(2,6-dimethylphenyl)propanamide hydrochloride
and is represented by the following structure: 17
[0150] c. Flecainide (as disclosed in U.S. Pat. No. 3,900,481),
which is also known as
N-(2-Piperidylmethyl)-2,5-bis(2,2,2-trifluoroethoxy)benzami- de
monoacetate and is represented by the following structure: 18
[0151] d. Mexiletine hydrochloride (as disclosed in U.S. Pat. No.
3,954,872), which is also known as
1-(2,6-Dimethylphenoxy)-2-propanamine hydrochloride and is
represented by the following structure: 19
[0152] e. Ropivacaine hydrochloride (as disclosed in PCT
Publication No. WO 85/00599), which is also known as
(-)-(S)-N-(n-Propyl)piperidine-2-car- boxylic acid 2,6-xylidide
hydrochloride monohydrate;
(-)-(S)-N-(2,6-Dimethylphenyl)-1-propylpiperidine-2-carboxamide
hydrochloride monohydrate; (-)-(S)-1-Propyl-2',6'-pipecoloxylidide
hydrochloride monohydrate and is represented by the following
structure: 20
[0153] f. Lidocaine (as disclosed in U.S. Pat. No. 2,441,498),
which is also known as
2-(diethylamino)-N-(2,6-dimethylphenyl)acetamide and is represented
by the following structure: 21
[0154] g. Mepivacaine (as disclosed in U.S. Pat. No. 2,799,679),
which is also known as
N-(2,6-dimethylphenyl)-1-methyl-2-piperidinecarboxamide and is
represented by the following structure: 22
[0155] h. Bupivacaine (as disclosed in U.S. Pat. No. 2,955,111),
which is also known as
1-butyl-N-(2,6-dimethylphenyl)-2-piperidinecarboxamide and is
represented by the following structure: 23
[0156] i. Prilocaine (as disclosed in U.S. Pat. No. 3,160,662),
also known as N-(2-methylphenyl)-2-(propylamino)propanamide and is
represented by the following structure: 24
[0157] j. Etidocaine (as disclosed in U.S. Pat. No. 3,812,147),
which is also known as
N-(2,6-dimethylphenyl)-1-methyl-2-piperidinecarboxamide and is
represented by the following structure: 25
[0158] k. Tetracaine (as disclosed in U.S. Pat. No. 1,889,645),
which is also known as 4-(butylamino)benzoic acid
2-(diethylamino)ethyl ester and is represented by the following
structure: 26
[0159] l. Dibucaine (as disclosed in U.S. Pat. No. 1,825,623),
which is also known as
2-butoxy-N-[2-(diethylamino)-ethyl]-4-quinolinecarboxamide and is
represented by the following structure: 27
[0160] m. Soretolide, which is also known as
2,6-Dimethyl-N-(5-methylisoza- xol-3-yl)benzamide and is
represented by the following structure: 28
[0161] n. RS-132943 (as disclosed in U.S. Pat. No. 6,110,937),
which is also known as
3(S)-(4-Bromo-2,6-dimethylphenoxymethyl)-1-methylpiperidine
hydrochloride and is represented by the following structure: 29
[0162] o. Tolperisone (as disclosed in HU 144997), which is also
known as 2-Methyl-1-(4-methylphenyl)-3-(1 -piperidinyl)propan-1-one
and is represented by the following structure: 30
[0163] It is understood that the present invention also encompasses
any salts, enantiomers, analogs, esters, amides, and derivatives of
the aforementioned agents.
[0164] Additional agents useful in the practice of the invention
include, but are not limited to, anticonvulsants such as:
[0165] a. Losigamone (as disclosed in U.S. Pat. No. 3,855,320),
which is also known as
(5R*)-5-[(alphaS*)-o-Chloro-alpha-hydroxybenzyl]-4-methoxy--
2(5H)-furanone and is represented by the following structure:
31
[0166] b. Zonisamide (as disclosed in U.S. Pat. No. 4,172,896),
which is also known as 3-(Sulfamoylmethyl)-1,2-benzisoxazole;
1,2-Benzisoxazole-3-methanesulfonamide and is represented by the
following structure: 32
[0167] c. Topiramate (as disclosed in U.S. Pat. No. 4,513,006),
which is also known as
2,3:4,5-Bis-O-(1-methylethylidene)-1-O-sulfamoyl-beta-D-fru-
ctopyranose;
2,3:4,5-Bis-O-(1-methylethylidene)-beta-D-fructopyranose sulfamate
and is represented by the following structure: 33
[0168] d. Rufinamide (as disclosed in U.S. Pat. No. 4,789,680),
which is also known as
1-(2,6-Difluorobenzyl)-1H-1,2,3-triazole-4-carboxamide and is
represented by the following structure: 34
[0169] e. BW-534U87 (as disclosed in U.S. Pat. No. 5,166,209),
which is also known as
4-Amino-1-(2,6-difluorobenzyl)-1H-1,2,3-triazolo[4,5-c]pyri- dine
hydrochloride and is represented by the following structure: 35
[0170] f. AWD-140-190 (as disclosed in U.S. Pat. No. 5,502,051),
which is also known as
4-(4-Bromophenyl)-3-(morpholin-4-yl)pyrrole-2-carboxylic acid
methyl ester and is represented by the following structure: 36
[0171] g. Harkoseride (as disclosed in U.S. Pat. No. 5,773,475),
which is also known as erlosamide and
2(R)-Acetamido-N-benzyl-3-methoxypropionamid- e and is represented
by the following structure: 37
[0172] h. Memantine hydrochloride (as disclosed in U.S. Pat. No.
3,391,142) which is also known as 3,5-Dimethyl-1-adamantanamine
hydrochloride and is represented by the following structure: 38
[0173] i. Felbamate (as disclosed in U.S. Pat. No. 2,884,444),
which is also known as 2-Phenyl-1,3-propanediol dicarbamate and is
represented by the following structure: 39
[0174] and
[0175] j. Valproate, which is also known as 2-Propylpentanoic acid
sodium salt and is represented by the following structure: 40
[0176] It is understood that the present invention also encompasses
any salts, enantiomers, analogs, esters, amides, and derivatives of
the aforementioned agents.
[0177] Additional agents useful in the practice of the invention
include, but are not limited to, peptide toxins and/or insecticides
such as:
[0178] a. .mu.-conotoxin SmIIIA from Conus stercusmuscarum as
disclosed in West et al. (2002) Biochemistry 41:15388-15393;
[0179] b. Toxins as disclosed in Tan et al. (2001)
Neuropharmacology 40:352-357;
[0180] c. Tarantula venom toxins ProTx-I and ProTx-II as disclosed
in Middleton et al. (2002) Biochemistry 41:14734-14747;
[0181] d. Scorpion neurotoxin BmK IT2;
[0182] e. Pacific Ciguatoxin-1 (P-CTX-1);
[0183] f. Indoxacarb (as disclosed in WO 9211249), which is also
known as methyl
(S)-N-[7-chloro-2,3,4a,5-tetrahydro-4a-(methoxycarbonyl)indeno[1,2-
-e][1,3,4]oxadiazin-2-ylcarbonyl-4'-(trifluoromethoxy)carbanilate
and is represented by the following structure: 41
[0184] g. The DCJW metabolite of indoxacarb;
[0185] h. RH-3421 (as disclosed in Tsurubuchi et al.,
Neurotoxicology 22:443-453, 2001), which is also known as methyl
3-(4-chlorophenyl)-1-[N--
(4-trifluoromethyl-phenyl)carbamoyl]-4-methyl-2-pyrazole-4-carboxylate
and is represented by the following structure: 42
[0186] i. Deltamethrin (as disclosed in DE 2439177), which is also
known as (S)-.alpha.-cyano-3-phenoxybenzyl
(1R,3R)-3-(2,2-dibromovinyl)-2,2-dim- ethylcyclopropanecarboxylate
and is represented by the following structure: 43
[0187] j. Tetramethrin (as disclosed in U.S. Pat. No. 3,268,398),
which is also known as cyclonex-1-ene-1,2-dicarboximidomethyl
(1RS,3RS;
1RS,3SR)-2,2-dimethyl-3-(2-methylprop-1-enyl)cyclopropanecarboxylate
and is represented by the following structure: 44
[0188] It is understood that the present invention also encompasses
any salts, enantiomers, analogs, esters, amides, and derivatives of
the aforementioned agents.
[0189] Additional agents useful in the practice of the invention
include, but are not limited to:
[0190] a. Tetrodotoxin, which is also known as
(4R,4aR,5R,7S,9S,10S,10aR,1-
1S,12S)-Octahydro-12-(hydroxymethyl)-2-imino-5,9:7,10a-dimethano-10aH-[1,3-
]dioxocino[6,5-d]pyrimidine-4,7,10,11,12-pentol and is represented
by the following structure: 45
[0191] b. Ambroxol (as disclosed in U.S. Pat. No. 3,536,713), which
is also known as
4-[[2-amino-3,5-dibromophenyl)methyl]amino]cyclohexanol and is
represented by the following structure: 46
[0192] c. Enecadin hydrochloride (as disclosed in U.S. Pat. No.
6,191,149), which is also known as
4-(4-Fluorophenyl)-2-methyl-6-[5-(1-pi-
peridinyl)pentyloxy]pyrimidine hydrochloride and is represented by
the following structure: 47
[0193] d. Fluphenazine hydrochloride (as disclosed in U.S. Pat. No.
3,058,979), which is also known as
4-[3-[2-(Trifluoromethyl)phenothiazin--
10-yl]propyl]-1-piperazineethanol dihydrochloride and is
represented by the following structure: 48
[0194] e. Trimebutine maleate (as disclosed in FR 1344455), which
is also known as 3,4,5-Trimethoxybenzoic acid
2-(dimethylamino)-2-phenylbutyl ester maleate and is represented by
the following structure: 49
[0195] f. Riluzole (as disclosed in EP 0050551), which is also
known as 2-Amino-6-(trifluoromethoxy)benzothiazole;
6-(Trifluoromethoxy)benzothiaz- ol-2-amine and is represented by
the following structure: 50
[0196] g. Silperisone hydrochloride and analogs thereof (as
disclosed in U.S. Pat. No. 5,198,446), which is also known as
1-(4-Fluorophenyl)-2,2-d- imethyl-3-piperidino-2-silapropane
hydrochloride; 1-[(4-Fluorobenzyl)dimet- hylsilylmethyl]piperidine
hydrochloride and is represented by the following structure: 51
[0197] h. RSD-921 and analogs thereof (as disclosed in U.S. Pat.
No. 5,506,257), which is also known as
(+)-(1R,2R)-N-Methyl-N-[2-(1-pyrrolidi-
nyl)cyclohexyl]benzo[b]thiophene-4-acetamide and is represented by
the following structure: 52
[0198] i. Crobenetine hydrochloride and analogs thereof (as
disclosed in U.S. Pat. No. 6,455,538), which is also known as
(2R,6S)-3-[2(S)-Benzylox- ypropyl]-6,11,11
-trimethyl-1,2,3,4,5,6-hexahydro-2,6-methano-3-benzazocin- -10-ol
hydrochloride and is represented by the following structure: 53
[0199] j. DL-017 and analogs thereof (as disclosed in U.S. Pat. No.
5,340,814), which is also known as
3-[4-(2-Methoxyphenyl)piperazin-1-ylme-
thyl]-5-(methylsulfanyl)-2,3-dihydroimidazo[1,2-c]quinazoline and
is represented by the following structure: 54
[0200] k. SUN-N8075 and analogs thereof (as disclosed in U.S. Pat.
No. 6,407,099), which is also known as
1-(4-Amino-2,3,5-trimethylphenoxy)-3-[-
4-[4-(4-fluorobenzyl)phenyl]piperazin-1-yl]propan-2(S)-ol
dimethanesulfonate and is represented by the following structure:
55
[0201] l. Amitriptyline (as disclosed in U.S. Pat. No. 3,205,264),
which is also known as
3-(10,11-dihydro-5H-dibenzo[a,d]-cyclohepten-5-ylidene)--
N,N-dimethyl-1-propanamine and is represented by the following
structure: 56
[0202] m. Compounds as disclosed in Oda et al. (2000) Anesth.
Analg. 91:1213-1220;
[0203] n. Benzocaine, which is also known as 4-aminobenzoic acid
ethyl ester, and is represented by the following structure: 57
[0204] o. Compounds that inhibit the binding of Annexin II light
chain or FHF1B to TTX-R sodium channels as disclosed in Liu et al.,
(2001) J. Biol. Chem. 276:18925-18933;
[0205] p. Thimerosal (as disclosed in U.S. Pat. No. 1,672,615),
which is also known as
ethyl[2-mercaptobenzoato(2-)-O,S]mercurate(1-) sodium and is
represented by the following structure: 58
[0206] q. Vinpocetine, which is also known as
(3alpha,16alpha)-Eburnamenin- e-14-carboxylic acid ethyl ester and
represented by the following structure: 59
[0207] r. Vincamine, which is also known as
(3.alpha.,14.beta.,16.alpha.)--
14,15-dihydro-14-hydroxyeburnamenine-14-carboxylic acid methyl
ester and represented by the following structure: 60
[0208] s. Quinidine, which is also known as
1(R)-(6-Methoxy-4-quinolinyl)--
1-[(2R,4S,5R)-5-vinyl-1-azabicyclo[2.2.2]oct-2-yl]methanol and is
represented by the following structure: 61
[0209] t. Co-102862 (as disclosed in U.S. Pat. No. 6,613,803),
which is also known as 4-[4-fluorophenoxy]benzaldehyde
semicarbazone and represented by the following structure: 62
[0210] It is understood that the present invention also encompasses
any salts, enantiomers, analogs, esters, amides, and derivatives of
the aforementioned agents.
[0211] Other agents useful in the present invention include, but
are not limited to, other compounds that interact with or modulate
sodium channels, including synthetic peptides, peptidomimetics, or
members of the same series or toxins from the same or related
species as those compounds specifically listed above.
[0212] The identification of other agents that have affinity for
TTX-R sodium channels or proteins associated with TTX-R sodium
channels and would be useful in the present invention can be
determined by methods that measure functional TTX-R channel
activity such as sodium flux as disclosed in Stallcup, WB (1979) J.
Physiol. 286: 525-40 or electrophysiological approaches as
disclosed in Weiser and Wilson (2002) Mol. Pharmacol. 62: 433-438.
The identification of other agents that exhibit activity-dependent
modulation of sodium channels and would be useful in the present
invention can be determined by methods as disclosed in Li et al.,
(1999) Molecular Pharmacology 55:134-141.
[0213] One or more additional active agents can be administered
with a sodium channel modulator, particularly a
tetrodotoxin-resistant (TTX-R) sodium channel modulator and/or
activity-dependent sodium channel modulator, either simultaneously
or sequentially. The additional active agent will generally,
although not necessarily, be one that is effective in treating GI
tract disorders except for acid peptic disorders or structural
gastroesophageal disorders, and/or an agent that augments the
effect of the sodium channel modulator, particularly a
tetrodotoxin-resistant (TTX-R) sodium channel modulator and/or
activity-dependent sodium channel modulator. Suitable secondary
agents include but are not limited to, for example, antispasmodics,
tricyclic antidepressants, duloxetine, venlafaxine, monoamine
reuptake inhibitors (including selective serotonin reuptake
inhibitors (SSRI's) and serotonin/norepinephrine reuptake
inhibitors (SNRI's)), spasmolytics, anticholinergics (particularly
antimuscarinics), gabapentin, pregabalin, substituted
aminomethyl-phenyl-cyclohexane derivatives including tramadol,
5-HT.sub.3 antagonists, 5-HT.sub.4 antagonists, .beta.3 adrenergic
agonists, neurokinin receptor antagonists, bradykinin receptor
antagonists, nitric oxide donors and/or any agent that does not
inhibit the action of the sodium channel modulator, particularly a
tetrodotoxin-resistant (TTX-R) sodium channel modulator and/or
activity-dependent sodium channel modulator.
[0214] Antispasmodic drugs that may be employed as additional
active agents may include, for example, Alibendol, Ambucetamide,
Aminopromazine, Apoatropine, Bevonium Methyl Sulfate,
Bietamiverine, Butaverine, Butropium Bromide, N-Butylscopolammonium
Bromide, Caroverine, Cimetropium Bromide, Cinnamedrine, Clebopride,
Coniine Hydrobromide, Coniine Hydrochloride, Cyclonium Iodide,
Difemerine, Diisopromine, Dioxaphetyl Butyrate, Diponium Bromide,
Drofenine, Emepronium Bromide, Ethaverine, Feclemine, Fenalamide,
Fenoverine, Fenpiprane, Fenpiverinium Bromide, Fentonium Bromide,
Flavoxate, Flopropione, Gluconic Acid, Guaiactamine,
Hydramitrazine, Hymecromone, Leiopyrrole, Mebeverine, Moxaverine,
Nafiverine, Octamylamine, Octaverine, Pentapiperide, Phenamacide
Hydrochloride, Phloroglucinol, Pinaverium Bromide, Piperilate,
PipoxolanHydrochloride, Pramiverin, Prifinium Bromide, Properidine,
Propivane, Propyromazine, Prozapine, Racefemine, Rociverine,
Spasmolytol, Stilonium Iodide, Sultroponium, Tiemonium Iodide,
Tiquizium Bromide, Tiropramide, Trepibutone, Tricromyl, Trifolium,
Trimebutine, N,N-1Trimethyl-3,3-diphenyl-propylamine, Tropenzile,
Trospium Chloride, and Xenytropium Bromide.
[0215] Spasmolytics are compounds that relieve, prevent, or lessen
muscle spasms, especially of smooth muscle. In general,
spasmolytics have been implicated as having efficacy in the
treatment of visceral disorders (See. e.g., Takeda et al. (2000) J.
Pharmacol. Exp. Ther. 293: 939-45).
[0216] Any spasmolytic agent is also useful as an additional active
agent in the present invention. Compounds that have been identified
as spasmolytic agents and are useful as an additional active agent
in the present invention include, but are not limited to:
[0217] a. .alpha.-.alpha.-diphenylacetic
acid-4-(N-methyl-piperidyl) esters as disclosed in U.S. Pat. No.
5,897,875;
[0218] b. Human and porcine spasmolytic polypeptides in
glycosylated form and variants thereof as disclosed in U.S. Pat.
No. 5,783,416;
[0219] c. Dioxazocine derivatives as disclosed in U.S. Pat. No.
4,965,259;
[0220] d. Quaternary
6,11-dihydro-dibenzo-[b,e]-thiepine-11-N-alkylnorscop- ine ethers
as disclosed in U.S. Pat. No. 4,608,377;
[0221] e. Quaternary salts of dibenzo[1,4]diazepinones,
pyrido-[1,4]benzodiazepinones, pyrido[1,5]benzodiazepinones as
disclosed in U.S. Pat. No. 4,594,190;
[0222] f. Endo-8,8-dialkyl-8-azoniabicyclo (3.2.1)
octane-6,7-exo-epoxy-3-- alkyl-carboxylate salts as disclosed in
U.S. Pat. No. 4,558,054;
[0223] g. Pancreatic spasmolytic polypeptides as disclosed in U.S.
Pat. No. 4,370,317;
[0224] h. Triazinones as disclosed in U.S. Pat. No. 4,203,983;
[0225] i. 2-(4-Biphenylyl)-N-(2-diethylamino alkyl)propionamide as
disclosed in U.S. Pat. No. 4,185,124;
[0226] j. Piperazino-pyrimidines as disclosed in U.S. Pat. No.
4,166,852;
[0227] k. Aralkylamino carboxylic acids as disclosed in U.S. Pat.
No. 4,163,060;
[0228] i. Aralkylamino sulfones as disclosed in U.S. Pat. No.
4,034,103;
[0229] m. Smooth muscle spasmolytic agents as disclosed in U.S.
Pat. No. 6,207,852; and
[0230] n. papaverine.
[0231] The identification of further compounds that have
spasmolytic activity and would therefore be useful as an additional
active agent in the present invention can be determined by
performing bladder strip contractility studies as described in U.S.
Pat. No. 6,207,852; Noronha-Blob et al. (1991) J. Pharmacol. Exp.
Ther.256: 562-567; and/or Kachur et al. (1988) J. Pharmacol. Exp.
Ther.247: 867-872.
[0232] Acetylcholine is a chemical neurotransmitter in the nervous
systems of all animals. "Cholinergic neurotransmission" refers to
neurotransmission that involves acetylcholine, and has been
implicated in the control of functions as diverse as locomotion,
digestion, cardiac rate, "fight or flight" responses, and learning
and memory (Salvaterra (Feb. 2000) Acetylcholine. In Encyclopedia
of Life Sciences. London: Nature Publishing Group,
http:/www.els.net). Receptors for acetylcholine are classified into
two general categories based on the plant alkaloids that
preferentially bind to them: 1) nicotinic (nicotine binding); or 2)
antimuscarinic (muscarine binding) (See, e.g., Salvaterra,
Acetylcholine, supra).
[0233] The two general categories of acetylcholine receptors may be
further divided into subclasses based upon differences in their
pharmacological and electrophysiological properties. Nicotinic
receptors are ligand gated ion channels composed of a variety of
subunits that are used to identify the following subclasses: 1)
muscle nicotinic acetylcholine receptors; 2) neuronal nicotinic
acetylcholine receptors that do not bind the snake venom
.alpha.-bungarotoxin; and 3) neuronal nicotinic acetylcholine
receptors that do bind the snake venom .alpha.-bungarotoxin (Dani
et al. (July 1999) Nicotinic Acetylcholine Receptors in Neurons. In
Encyclopedia of Life Sciences. London: Nature Publishing Group,
http:/www.els.net; Lindstrom (October 2001) Nicotinic Acetylcholine
Receptors. In Encyclopedia of Life Sciences. London: Nature
Publishing Group, http:/www.els.net). By contrast, muscarinic
receptors may be divided into five subclasses, labeled
M.sub.1-M.sub.5, and preferentially couple with specific G-proteins
(M.sub.1, M.sub.3, and M.sub.5 with G.sub.q; M.sub.2 and M.sub.4
with G.sub.i/G.sub.o) (Nathanson (July 1999) Muscarinic
Acetylcholine Receptors. In Encyclopedia of Life Sciences. London:
Nature Publishing Group, http:/www.els.net). In general, muscarinic
receptors have been implicated in smooth muscle function (See,
e.g., Appell (2002) Cleve. Clin. J. Med. 69: 761-9; Diouf et al.
(2002) Bioorg. Med. Chem. Lett. 12: 2535-9; Crandall (2001) J.
Womens Health Gend. Based Med. 10: 735-43; Chapple (2000) Urology
55: 33-46).
[0234] Any anticholinergic agent, specifically, any antimuscarinic
agent, is useful as an additional active agent in the present
invention. Compounds that have been identified as antimuscarinic
agents and are useful as an additional active agent in the present
invention include, but are not limited to:
[0235] a. Darifenacin (Daryon.RTM.);
[0236] b. YM-905 (solifenacin succinate);
[0237] c. Oxybutynin (Ditropan.RTM.);
[0238] d. S-Oxybutynin;
[0239] e. N-desethyl-oxybutynin;
[0240] f. Tolterodine (Detrol.RTM.);
[0241] g. Trospium (Uraplex.RTM., Spasmex.RTM.);
[0242] h. Propiverine (Detrunorm.RTM.);
[0243] i. Propantheline bromide (Pro-Banthine.RTM.);
[0244] j. Hyoscyamine sulfate (Levsin.RTM., Cystospaz.RTM.);
[0245] k. Dicyclomine hydrochloride (Bentyl.RTM.);
[0246] l. Flavoxate hydrochloride (Urispas.RTM.);
[0247] m. d,1 (racemic) 4-diethylamino-2-butynyl
phenylcyclohexylglycolate- ;
[0248] n.
(R)-N,N-diisopropyl-3-(2-hydroxy-5-methylphenyl)-3-phenylpropana-
mine L-hydrogen tartrate;
[0249] o. (+)-(1S,3'R)-quinuclidin-3'-yl
1-phenyl-1,2,3,4-tetrahydroisoqui- noline-2-carboxylate
monosuccinate;
[0250] p.
alpha(+)-4-(Dimethylamino)-3-methyl-1,2-diphenyl-2-butanol
proprionate;
[0251] q. 1-methyl-4-piperidyl diphenylpropoxyacetate;
[0252] r. 3"-hydroxyspiro[1"H,5"H-nortropane-8,1'-pyrrolidinium
benzilate;
[0253] s. 4 amino-piperidine containing compounds as disclosed in
Diouf et al. (2002) Bioorg. Med. Chem. Lett. 12: 2535-9;
[0254] t. pirenzipine;
[0255] u. methoctramine;
[0256] v. 4-diphenylacetoxy-N-methyl piperidine methiodide;
[0257] w. tropicamide;
[0258] x.
(2R)-N-[1-(6-aminopyridin-2-ylmethyl)piperidin-4-yl]-2-[(1R)-3,3
-difluorocyclopentyl]-2-hydroxy-2-phenylacetamide;
[0259] y. PNU-200577 ((R)-N,
N-diisopropyl-3-(2-hydroxy-5-hydroxymethylphe-
nyl)-3-phenylpropanamine); and
[0260] z. NS-21.
[0261] The identification of further compounds that have
antimuscarinic activity and would therefore be useful as an
additional active agent in the present invention can be determined
by performing muscarinic receptor binding specificity studies as
described by Nilvebrant (2002) Pharmacol. Toxicol. 90: 260-7 or
cystometry studies as described by Modiri et al. (2002) Urology 59:
963-8.
[0262] Adrenergic receptors are cell-surface receptors for two
major catecholamine hormones and neurotransmitters: noradrenaline
and adrenaline. (Malbon et al. (Feb. 2000) Adrenergic Receptors. In
Encyclopedia of Life Sciences. London: Nature Publishing Group,
http:/www.els.net). Adrenergic receptors have been implicated in
critical physiological processes, including blood pressure control,
myocardial and smooth muscle contractility, pulmonary function,
metabolism, and central nervous system activity (See, e.g., Malbon
et al., Adrenergic Receptors, supra). Two classes of adrenergic
receptors have been identified, .alpha. and .beta., that may be
further subdivided into three major families (.alpha.1, .alpha.2,
and .beta.), each with at least three subtypes (.alpha.A, B, and,
D; .alpha.2A, B, and C; and .beta.1, .beta.2, and .beta.3) based
upon their binding characteristics to different agonists and
molecular cloning techniques. (See, e.g., Malbon et al., Adrenergic
Receptors, supra). It has been shown that .beta.3 adrenergic
receptors are expressed in the detrusor muscle, and that the
detrusor muscle relaxes with a .beta.3-agonist (Takeda, M. et al.
(1999) J.Pharmacol.Exp.Ther. 288: 1367-1373), and in general,
.beta.3 adrenergic receptors have been implicated in bladder
function (See, e.g., Takeda et al. (2002) Neurol. Urodyn. 21:
558-65; Takeda et al. (2000) J. Pharmacol. Exp. Ther. 293:
939-45.
[0263] Other agents useful in the present invention include any
.beta.3 adrenergic agonist agent. Compounds that have been
identified as .beta.3 adrenergic agonist agents and are useful in
the present invention include, but are not limited to:
[0264] a. TT-138 and phenylethanolamine compounds as disclosed in
U.S. Pat. No. 6,069,176, PCT Publication No. WO 97/15549 and
available from Mitsubishi Pharma Corp.;
[0265] b. FR-149174 and propanolamine derivatives as disclosed in
U.S. Pat. Nos. 6,495,546 and 6,391,915 and available from Fujisawa
Pharmaceutical Co.;
[0266] c. KUC-7483, available from Kissei Pharmaceutical Co.,
[0267] d. 4'-hydroxynorephedrine derivatives such as
2-2-chloro-4-(2-((1S,2R)-2-hydroxy-2-(4-hydroxyphenyl)-1-methylethylamino-
)ethyl)phenoxy acetic acid as disclosed in Tanaka et al. (2003) J.
Med. Chem. 46: 105-12;
[0268] e. 2-amino-1-phenylethanol compounds, such as BRL35135
((R*R*)-(.+-.)-[4-[2-[2-(3-chlorophenyl)-2-ydroxyethylamino]propyl]phenox
y]acetic acid methyl ester hydrobromide salt as disclosed in
Japanese Patent Publication No. 26744 of 1988 and European Patent
Publication No. 23385), and SR58611 A
((RS)-N-(7-ethoxycarbonylmethoxy-1,2,3,4-tetrahydro-
naphth-2-yl)-2-(3-chlor ophenyl)-2-hydroxyethanamine hydrochloride
as disclosed in Japanese Laid-open Patent Publication No. 66152 of
1989 and European Laid-open Patent Publication No. 255415);
[0269] f. GS 332 (Sodium (2R)-[3-[3-[2-(3
Chlorophenyl)-2-hydroxyethylamin- o]cyclohexyl]phenoxy]acetate) as
disclosed in lizuka et al. (1998) J. Smooth Muscle Res. 34:
139-49;
[0270] g. BRL-37,344 (4-[-[(2-hydroxy-(3-chlorophenyl)
ethyl)-amino]propyl]phenoxyacetate) as disclosed in Tsujii et al.
(1998) Physiol. Behav. 63: 723-8 and available from
Glaxosmithkline;
[0271] h. BRL-26830A as disclosed in Takahashi et al. (1992) Jpn
Circ. J. 56: 936-42 and available from Glaxosmithkline;
[0272] i. CGP 12177
(4-[3-t-butylamino-2-hydroxypropoxy]benzimidazol-2-one- ) (a
.beta.1/.beta.2 adrenergic antagonist reported to act as an agonist
for the .beta.3 adrenergic receptor) as described in Tavernier et
al. (1992) J. Pharmacol. Exp. Ther. 263: 1083-90 and available from
Ciba-Geigy;
[0273] j . CL 316243
(R,R-5-[2-[[2-(3-chlorophenyl)-2-hydroxyethyl]amino]p- ropyl]-1,3-
benzodioxole-2,2-dicarboxylate) as disclosed in Berlan et al.
(1994) J. Pharmacol. Exp. Ther. 268: 1444-51;
[0274] k. Compounds having .beta.3 adrenergic agonist activity as
disclosed in U.S. Pat. Application 20030018061;
[0275] l. ICI 215,001 HCl
((S)-4-[2-Hydroxy-3-phenoxypropylaminoethoxy]phe- noxyacetic acid
hydrochloride) as disclosed in Howe (1993) Drugs Future 18: 529 and
available from AstraZeneca/ICI Labs;
[0276] m. ZD 7114 HCl (ICI D7114;
(S)-4-[2-Hydroxy-3-phenoxypropylaminoeth-
oxy]-N-(2-methoxyethyl)phenoxyacetamide HCl) as disclosed in Howe
(1993) Drugs Future 18: 529 and available from AstraZeneca/ICI
Labs;
[0277] n. Pindolol
(1-(1H-Indol-4-yloxy)-3-[(1-methylethyl)amino]-2-propan- ol) as
disclosed in Blin et al (1994) Mol.Pharmacol. 44: 1094;
[0278] o. (S)-(-)-Pindolol
((S)-1-(1H-indol-4-yloxy)-3-[(1-methylethyl)ami- no]-2-propanol) as
disclosed in Walter et al (1984) Naunyn-Schmied.Arch.Pharmacol.
327: 159 and Kalkman (1989) Eur.J.Pharmacol. 173:121;
[0279] p. SR 59230A HCl
(1-(2-Ethylphenoxy)-3-[[(1S)-1,2,3,4-tetrahydro-1--
naphthalenyl]amino]-(2S)-2-propanol hydrochloride) as disclosed in
Manara et al. (1995) Pharmacol. Comm. 6: 253 and Manara et al.
(1996) Br. J. Pharmacol. 117: 435 and available from Sanofi-Midy;
and
[0280] q. SR 58611
(N[2s)7-carb-ethoxymethoxy-1,2,3,4-tetra-hydronaphth]-(-
2r)-2-hydroxy-2(3-chlorophenyl) ethamine hydrochloride) as
disclosed in Gauthier et al. (1999) J. Pharmacol. Exp. Ther. 290:
687-693 and available from Sanofi Research.
[0281] The identification of further compounds that have .beta.3
adrenergic agonist activity and would therefore be useful in the
present invention can be determined by performing radioligand
binding assays and/or contractility studies as described by
Zilberfarb et al. (1997) J. Cell Sci. 110: 801-807; Takeda et al.
(1999) J. Pharmacol. Exp. Ther. 288: 1367-1373; and Gauthier et al.
(1999) J. Pharmacol. Exp. Ther. 290: 687-693.
[0282] Tachykinins (TKs) are a family of structurally related
peptides that include substance P, neurokinin A (NKA) and
neurokinin B (NKB). Neurons are the major source of TKs in the
periphery. An important general effect of TKs is neuronal
stimulation, but other effects include endothelium-dependent
vasodilation, plasma protein extravasation, mast cell recruitment
and degranulation and stimulation of inflammatory cells (See Maggi,
C. A. (1991) Gen. Pharmacol., 22: 1-24). In general, tachykinin
receptors have been implicated in bladder function (See, e.g., Kamo
et al. (2000) Eur. J. Pharmacol. 401: 235-40 and Omhura et al.
(1997) Urol. Int. 59: 221-5).
[0283] Substance P activates the neurokinin receptor subtype
referred to as NK.sub.1. Substance P is an undecapeptide that is
present in sensory nerve terminals. Substance P is known to have
multiple actions that produce inflammation and pain in the
periphery after C-fiber activation, including vasodilation, plasma
extravasation and degranulation of mast cells (Levine, J. D. et.
al. (1993) J. Neurosci. 13: 2273).
[0284] Neurokinin A is a peptide which is colocalized in sensory
neurons with substance P and which also promotes inflammation and
pain. Neurokinin A activates the specific neurokinin receptor
referred to as NK.sub.2 (Edmonds-Alt, S., et. al. (1992) Life Sci.
50: PL101). In the urinary tract, TKs are powerful spasmogens
acting through only the NK.sub.2 receptor in the human bladder, as
well as the human urethra and ureter (Maggi, C. A. (1991) Gen.
Pharmacol., 22: 1-24).
[0285] Other agents useful in the present invention include any
neurokinin receptor antagonist agent. Suitable neurokinin receptor
antagonists for use in the present invention that act on the
NK.sub.1 receptor include, but are not limited to:
1-imino-2-(2-methoxy-phenyl)-ethyl)-7,7-diphenyl--
4-perhydroisoindolone(3aR,7aR) ("RP 67580");
2S,3S-cis-3-(2-methoxybenzyla- mino)-2-benzhydrylquinuclidine ("CP
96,345"); and (aR,9R)-7-[3,5-bis(trifl- uoromethyl)benzyl]-8,9,10,
11-tetrahydro-9-methyl-5-(4-methylphenyl)-7H-[1-
,4]diazocino[2,1-g] [1,7]naphthyridine-6,13-dione)("TAK-637").
Suitable neurokinin receptor antagonists for use in the present
invention that act on the NK.sub.2 receptor include but are not
limited to:
((S)-N-methyl-N-4-(4-acetylamino-4-phenylpiperidino)-2-(3,4-dichloropheny
l)butylbenzamide ("SR 48968"); Met-Asp-Trp-Phe-Dap-Leu ("MEN
10,627"); and cyc(Gln-Trp-Phe-Gly-Leu-Met) ("L 659,877"). The
identification of further compounds that have neurokinin receptor
antagonist activity and would therefore be useful in the present
invention can be determined by performing binding assay studies as
described in Hopkins et al. (1991) Biochem. Biophys. Res. Comm.
180: 1110-1117; and Aharony et al. (1994) Mol. Pharmacol. 45:
9-19.
[0286] Bradykinin receptors generally are divided into
bradykinin.sub.1 (B.sub.1) and bradykinin.sub.2 (B.sub.2) subtypes.
Studies have shown that acute peripheral pain and inflammation
produced by bradykinin are mediated by the B.sub.2 subtype whereas
bradykinin-induced pain in the setting of chronic inflammation is
mediated via the B.sub.1 subtype (Perkins, M. N., et. al. (1993)
Pain 53: 191-97); Dray, A., et. al. (1993) Trends Neurosci. 16:
99-104). In general, bradykinin receptors have been implicated in
bladder function (See, e.g., Meini et al. (2000) Eur. J. Pharmacol.
388: 177-82 and Belichard et al. (1999) Br. J. Pharmacol. 128:
213-9).
[0287] Other agents useful in the present invention include any
bradykinin receptor antagonist agent. Suitable bradykinin receptor
antagonists for use in the present invention that act on the
B.sub.1 receptor include but are not limited to: des-arg.sup.10HOE
140 (available from Hoechst Pharmaceuticals) and
des-Arg.sup.9bradykinin (DABK). Suitable bradykinin receptor
antagonists for use in the present invention that act on the
B.sub.2 receptor include but are not limited to: D-Phe.sup.7-BK;
D-Arg-(Hyp.sup.3-Thi.sup.5,8-D-Phe.sup.7)-BK ("NPC 349");
D-Arg-(Hyp.sup.3-D-Phe.sup.7)-BK ("NPC 567");
D-Arg-(Hyp.sup.3-Thi.sup.5-- D-Tic.sup.7-Oic.sup.8)-BK ("HOE 140");
H-DArg-Arg-Pro-Hyp-Gly-Thi-c(Dab-DT-
ic-Oic-Arg)c(7gamma-10alpha)("MEN 11270");
H-DArg-Arg-Pro-Hyp-Gly-Thi-Ser-- DTic-Oic-Arg-OH("Icatibant");
(E)-3-(6-acetamido-3-pyridyl)-N-[N-[2,
4-dichloro-3-[(2-methyl-8-quinolinyl) oxymethyl]
phenyl]-N-methylaminocar- bonylmethyl]acrylamide ("FR173567"); and
WIN 64338. These compounds are more fully described in Perkins, M.
N., et. al., Pain, supra; Dray, A., et. al., Trends Neurosci.,
supra; and Meini et al. (2000) Eur. J. Pharmacol. 388: 177-82. The
identification of further compounds that have bradykinin receptor
antagonist activity and would therefore be useful in the present
invention can be determined by performing binding assay studies as
described in Manning et al. (1986) J. Pharmacol. Exp. Ther. 237:
504 and U.S. Pat. No. 5,686,565.
[0288] Nitric oxide donors may be included in the present invention
particularly for their anti-spasm activity. Nitric oxide (NO) plays
a critical role as a molecular mediator of many physiological
processes, including vasodilation and regulation of normal vascular
tone. The action of NO is implicated in intrinsic local
vasodilation mechanisms. NO is the smallest biologically active
molecule known and is the mediator of an extraordinary range of
physiological processes (Nathan (1994) Cell 78: 915-918; Thomas
(1997) Neurosurg. Focus 3: Article 3). NO is also a known
physiologic antagonist of endothelin-1, which is the most potent
known mammalian vasoconstrictor, having at least ten times the
vasoconstrictor potency of angiotensin II (Yanagisawa et al. (1988)
Nature 332: 411-415; Kasuya et al. (1993) J. Neurosurg. 79:
892-898; Kobayashi et al., (1991) Neurosurgery 28: 673-679). The
biological half-life of NO is extremely short (Morris et al. (1994)
Am. J. Physiol. 266: E829-E839; Nathan (1994) Cell 78: 915-918). NO
accounts entirely for the biological effects of endothelium-derived
relaxing factor (EDRF) and is an extremely potent vasodilator that
is believed to work through the action of cGMP-dependent protein
kinases to effect vasodilation (Henry et al. (1993) FASEB J. 7:
1124-1134; Nathan (1992) FASEB J. 6: 3051-3064; Palmer et al.,
(1987) Nature 327: 524-526; Snyder et al. (1992) Scientific
American 266: 68-77).
[0289] Within endothelial cells, an enzyme known as NO synthase
(NOS) catalyzes the conversion of L-arginine to NO which acts as a
diffusible second messenger and mediates responses in adjacent
smooth muscle cells. NO is continuously formed and released by the
vascular endothelium under basal conditions which inhibits
contractions and controls basal coronary tone and is produced in
the endothelium in response to various agonists (such as
acetylcholine) and other endothelium dependent vasodilators. Thus,
regulation of NOS activity and the resultant levels of NO are key
molecular targets controlling vascular tone (Muramatsu et. al.
(1994) Coron. Artery Dis. 5: 815-820).
[0290] Other agents useful in the present invention include any
nitric oxide donor agent. Suitable nitric oxide donors for the
practice of the present invention include but are not limited
to:
[0291] a. Nitroglycerin;
[0292] b. Sodium nitroprusside;
[0293] c. FK 409 (NOR-3);
[0294] d. FR 144420 (NOR-4);
[0295] e. 3-morpholinosydnonimine;
[0296] f. Linsidomine chlorohydrate ("SIN-1");
[0297] g. S-nitroso-N-acetylpenicillamine ("SNAP");
[0298] h. AZD3582 (CINOD lead compound, available from NicOx
S.A.);
[0299] i. NCX 4016 (available from NicOx S.A.);
[0300] j. NCX 701 (available from NicOx S.A.);
[0301] k. NCX 1022 (available from NicOx S.A.);
[0302] l. HCT 1026 (available from NicOx S.A.);
[0303] m. NCX 1015 (available from NicOx S.A.);
[0304] n. NCX 950 (available from NicOx S.A.);
[0305] o. NCX 1000 (available from NicOx S.A.);
[0306] p. NCX 1020 (available from NicOx S.A.);
[0307] q. AZD 4717 (available from NicOx S.A.);
[0308] r. NCX 1510/NCX 1512 (available from NicOx S.A.);
[0309] s. NCX 2216 (available from NicOx S.A.);
[0310] t. NCX 4040 (available from NicOx S.A.);
[0311] u. Nitric oxide donors as disclosed in U.S. Pat. No.
5,155,137;
[0312] v. Nitric oxide donors as disclosed in U.S. Pat. No.
5,366,997;
[0313] w. Nitric oxide donors as disclosed in U.S. Pat. No.
5,405,919;
[0314] x. Nitric oxide donors as disclosed in U.S. Pat. No.
5,650,442;
[0315] y. Nitric oxide donors as disclosed in U.S. Pat. No.
5,700,830;
[0316] z. Nitric oxide donors as disclosed in U.S. Pat. No.
5,632,981;
[0317] aa. Nitric oxide donors as disclosed in U.S. Pat. No.
6,290,981;
[0318] bb. Nitric oxide donors as disclosed in U.S. Pat. No.
5,691,423;
[0319] cc. Nitric oxide donors as disclosed in U.S. Pat. No.
5,721,365;
[0320] dd. Nitric oxide donors as disclosed in U.S. Pat.
No.5,714,511;
[0321] ee. Nitric oxide donors as disclosed in U.S. Pat. No.
6,511,911; and
[0322] ff. Nitric oxide donors as disclosed in U.S. Pat. No.
5,814,666.
[0323] The identification of further compounds that have nitric
oxide donor activity and would therefore be useful in the present
invention can be determined by release profile and/or induced
vasospasm studies as described in U.S. Pat. Nos. 6,451,337 and
6,358,536, as well as Moon (2002) IBJU Int. 89: 942-9 and
Fathian-Sabet et al. (2001) J. Urol. 165: 1724-9.
[0324] Gabapentin (Neurontin, or 1-(aminomethyl) cyclohexaneacetic
acid) is an anticonvulsant drug with a high binding affinity for
some calcium channel subunits, and is represented by the following
structure: 63
[0325] Gabapentin is one of a series of compounds of formula:
64
[0326] in which R.sub.1 is hydrogen or a lower alkyl radical and n
is 4, 5, or 6. Although gabapentin was originally developed as a
GABA-mimetic compound to treat spasticity, gabapentin has no direct
GABAergic action and does not block GABA uptake or metabolism. (For
review, see Rose et al. (2002) Analgesia 57:451-462). Gabapentin
has been found, however, to be an effective treatment for the
prevention of partial seizures in patients who are refractory to
other anticonvulsant agents (Chadwick (1991) Gabapentin, In Pedley
T A, Meldrum B S (eds.), Recent Advances in Epilepsy, Churchill
Livingstone, New York, pp. 211-222). Gabapentin and the related
drug pregabalin interact with the .alpha..sub.2.delta. subunit of
calcium channels (Gee et al. (1996) J. Biol. Chem. 271:
5768-5776).
[0327] In addition to its known anticonvulsant effects, gabapentin
has been shown to block the tonic phase of nociception induced by
formalin and carrageenan, and exerts an inhibitory effect in
neuropathic pain models of mechanical hyperalgesia and
mechanicauthermal allodynia (Rose et al. (2002) Analgesia 57:
451-462). Double-blind, placebo-controlled trials have indicated
that gabapentin is an effective treatment for painful symptoms
associated with diabetic peripheral neuropathy, post-herpetic
neuralgia, and neuropathic pain (see, e.g., Backonja et al. (1998)
JAMA 280:1831-1836; Mellegers et al. (2001) Clin. J. Pain
17:284-95).
[0328] Pregabalin, (S)-(3-aminomethyl)-5-methylhexanoic acid or
(S)-isobutyl GABA, is another GABA analog whose use as an
anticonvulsant has been explored (Bryans et al. (1998) J. Med.
Chem. 41:1838-1845). Pregabalin has been shown to possess even
higher binding affinity for the .alpha..sub.2.delta. subunit of
calcium channels than gabapentin (Bryans et al. (1999) Med. Res.
Rev. 19:149-177).
[0329] The substituted aminomethyl-phenyl-cyclohexane derivatives
suitable for use in the invention are represented by structural
Formula I: 65
[0330] and enantiomers and mixtures thereof wherein:
[0331] R.sub.1 and R.sub.1' are independently hydrogen, an
aliphatic group, an aryl group, an arylalkyl group, a halogen,
--CN, --OR.sub.6, --SR.sub.6, --NR.sub.6R.sub.6, --OC(O)R.sub.6,
--C(O)OR.sub.6, --C(O)R.sub.6 or --C(O)NR.sub.6R.sub.6;
[0332] R.sub.2 is hydrogen, halogen, --OR.sub.7 or
--OC(O)R.sub.7;
[0333] R.sub.3 is hydrogen or an aliphatic group;
[0334] or R.sub.2 and R.sub.3 together form a double bond;
[0335] R.sub.4 and R.sub.5 are independently hydrogen, an aliphatic
group, an aryl group, or an arylalkyl group;
[0336] R.sub.6 is hydrogen, an aliphatic group, an aryl group or an
arylalkyl group; R.sub.7is hydrogen, an aliphatic group, an aryl
group or an arylalkyl group;
[0337] or pharmaceutically acceptable salts, solvates or hydrates
thereof.
[0338] In a particular embodiment of Formula I, R.sub.2 is --OH.
When R.sub.2 is --OH, it is preferred that R.sub.1' is hydrogen and
R.sub.1 is OCH.sub.3, preferably substituted at the meta position
of the phenyl ring.
[0339] In a further embodiment of Formula I, R.sub.2 is --OH,
R.sub.1' is hydrogen and R.sub.1 is --OR.sub.6, substituted at the
meta position of the phenyl ring and R.sub.6 is an aliphatic group,
for example, and alkyl group. In a particular embodiment, wherein
R.sub.2 is --OH, R.sub.1' is hydrogen and R.sub.1 is --OR.sub.6,
substituted at the meta position of the phenyl ring and R.sub.6 is
an alkyl group, R.sub.3, R.sub.4 and R.sub.5 can be hydrogen or an
alkyl group.
[0340] In one embodiment, the substituted
aminomethyl-phenyl-cyclohexane derivative suitable for use in the
invention is represented by structural Formula II: 66
[0341] and enantiomers and mixtures thereof or pharmaceutically
acceptable salts, solvates or hydrates thereof.
[0342] In a particular embodiment, the compound of Formula II is a
mixture of the (+)cis and (-)cis enantiomers, wherein the C-1 and
C-2 carbons of the cyclohexyl ring are (1R,2R) and (1S,2S),
respectively, and the substituents on C-1 and C-2 are in the cis
orientation.
[0343] In a specific embodiment, the mixture of the (+)cis and
(-)cis enantiomers is a racemic mixture. That is, the compound of
Formula II is a 50:50 mixture of (+)cis and (-)cis enantiomers as
shown below: 67
[0344] In other words, the compound of Formula II is the 50:50
mixture of (+/-)cis-2-[(dimethylamino)methyl]-1-(3-methoxyphenyl)
cyclohexanol, commonly referred to as tramadol. The compound can be
in the form of a pharmaceutically acceptable salt. Typically,
tramadol is administered in the form of the hydrochloride salt. The
tramadol hydrochloride is also known, for example, by the tradename
ULTRAM.RTM..
[0345] Tramadol in the form of the hydrochloride salt, is widely
used as an analgesic. Tramadol is a centrally acting analgesic with
a low affinity for opioid receptors. In contrast to other opioids,
the analgesic action of tramadol is only partially inhibited by the
opioid antagonist naloxone, which suggests the existence of an
additional non-opioid mechanism of action. It has been found that
monoaminergic activity, wherein noradrenaline and serotonin (5-HT)
reuptake are inhibited, contributes significantly to the analgesic
action of tramadol by blocking nociceptive impulses at the spinal
level.
[0346] In a further embodiment, the administered compound is the
(+)cis enantiomer of tramadol, set forth above.
[0347] In another embodiment, the substituted
aminomethyl-phenyl-cyclohexa- ne derivative is represented by the
following structural Formula III in which the nitrogen of the
aminomethyl group is in the form of the N-oxide: 68
[0348] and enantiomers and mixtures thereof or pharmaceutically
acceptable salts, solvates and hydrates thereof.
[0349] In a particular embodiment, the compound of Formula III is a
mixture of the (+)cis and (-)cis enantiomers, wherein the C-1 and
C-2 carbons of the cyclohexyl ring are (1R,2R) and (1S,2S),
respectively, and the substituents on C-1 and C-2 are in the cis
orientation.
[0350] In a specific embodiment, the mixture of the (+)cis and
(-)cis enantiomers is a racemic mixture. That is, the compound of
Formula III is a 50:50 mixture of (+)cis and (-)cis enantiomers as
shown below: 69
[0351] In other words, the compound of Formula III is the 50:50
mixture of the N-oxide of
(+/-)cis-2-[(dimethylamino)methyl]-1-(3-methoxyphenyl)
cyclohexanol.
[0352] In a further embodiment, the N-oxide is predominantly the
(+)cis enantiomer, as set forth above.
[0353] In one embodiment, the substituted
aminomethyl-phenyl-cyclohexane derivative suitable for use in the
invention is represented by structural Formula IV: 70
[0354] and enantiomers and mixtures thereof wherein:
[0355] R.sub.8, R.sub.9 and R.sub.10 are independently hydrogen or
an alkyl group;
[0356] or pharmaceutically acceptable salts, solvates or hydrates
thereof.
[0357] In a particular embodiment, the compound of Formula IV is a
mixture of the (+)cis and (-)cis enantiomers, wherein the C-1 and
C-2 carbons of the cyclohexyl ring are (1R,2R) and (1S,2S),
respectively, and the substituents on C-1 and C-2 are in the cis
orientation.
[0358] In a specific embodiment, the mixture of the (+)cis and
(-)cis enantiomers is a racemic mixture. That is, the compound of
Formula IV is a 50:50 mixture of (+)cis and (-)cis enantiomers as
shown below: 71
[0359] In a further embodiment, the compounds of Formula IV are
predominantly the (+)cis enantiomer, as set forth above.
[0360] In a particular embodiment R.sub.10 is hydrogen. In a
further embodiment wherein R.sub.10 is hydrogen, R.sub.8 and
R.sub.9 are independently hydrogen or an alkyl group, for example,
a methyl group. When R.sub.10 is hydrogen and R.sub.8 and R.sub.9
are methyl groups, and Formula IV is the racemic mixture of the
(+)cis and (-)cis enantiomers, the compound can be referred to as
O-desmethyltramadol. The specific (+) and (-) enantiomers set forth
above, can be referred to as (+)O-desmethyltramadol and
(-)O-desmethyltramadol.
[0361] In yet another embodiment, R.sub.10 is hydrogen, R.sub.8 is
hydrogen and R.sub.9 is a methyl group. When R.sub.10 is hydrogen,
R.sub.8, is hydrogen and R.sub.9 is a methyl group, and Formula IV
is the racemic mixture of the (+)cis and (-)cis enantiomers, the
compound can be referred to as
O-desmethyl-N-mono-desmethyl-tramadol. The specific (+)cis and
(-)cis enantiomers as set forth above can be referred to as
(+)O-desmethyl-N-mono-desmethyl-tramadol and
(-)O-desmethyl-N-mono-desmet- hyl-tramadol.
[0362] In yet another embodiment, the substituted
aminomethyl-phenyl-cyclo- hexane derivative is represented by
structural Formula V: 72
[0363] and enantiomers and mixtures thereof wherein:
[0364] R.sub.11 is --OH;
[0365] R.sub.12 is hydrogen or R.sub.11 and R.sub.12 together form
a double bond;
[0366] R.sub.13 is an aryl group selected from the group consisting
of: 73
[0367] wherein:
[0368] R.sub.14 is hydrogen or an alkyl group;
[0369] R.sub.15 is hydrogen, --NH.sub.2, --NHR.sub.20 or
--OR.sub.20;
[0370] R.sub.16 is hydrogen, --COR.sub.20, --OR.sub.20 or
halogen;
[0371] R.sub.17 is hydrogen, an alkyl group, --O-alkenyl, a phenyl
group or R.sub.16 and R.sub.17 are
--CH.dbd.CR.sub.21--CR.sub.22+CH--, forming an aromatic ring;
[0372] R.sub.18 is hydrogen, --COR.sub.23, --OR.sub.24 or a
halogen;
[0373] R.sub.19 is hydrogen, halogen, an alkyl group, --O-alkyl,
--NO.sub.2 or an aryl group;
[0374] R.sub.20 is a phenyl group optionally substituted by one or
more of the following: halogen, --NO.sub.2, an alkyl group, an
alkenyl group, --OH or --NH.sub.2;
[0375] R.sub.21 and R.sub.22 are independently hydrogen or
--O-alkyl;
[0376] R.sub.23 is a phenyl group optionally substituted by one or
more of the following: halogen, --NO.sub.2, an alkyl group, and
alkenyl group, --OH or --NH.sub.2;
[0377] R.sub.24 is hydrogen, --CO-alkyl (preferably methyl) or a
phenyl group optionally substituted by one or more of the
following: halogen, --NO.sub.2, an alkyl group, and alkenyl group,
--OH or --NH.sub.2;
[0378] R.sub.25 and R.sub.26 are independently hydrogen, an alkyl
group or form a --CH.sub.2--CH.sub.2-- group;
[0379] R.sub.27 is a phenyl group optionally substituted by one or
more of the following: halogen, --NO.sub.2, an alkyl group, an
alkenyl group, --OH or --NH.sub.2;
[0380] or pharmaceutically acceptable salts, solvates or hydrates
thereof.
[0381] In a particular embodiment of Formula V, R.sub.11 is --OH,
R.sub.12 is H and R.sub.13 is: 74
[0382] wherein:
[0383] R.sub.24 is hydrogen or --COCH.sub.3;
[0384] R.sub.19 is halogen, an alkyl group, --O-alkyl or
--NO.sub.2.
[0385] It is preferred that when R.sub.19 is --O-alkyl, the alkyl
group is a methyl group.
[0386] It is preferred that when R.sub.19 is an alkyl group, the
alkyl group is substituted with one or more halogens. For example
the substituted alkyl group is --CF.sub.3.
[0387] Substituted aminomethyl-phenyl-cyclohexane derivatives in
accordance with Formula V are further described in U.S. Pat. No.
6,455,585 and published PCT Application WO01/49650, which are
incorporated herein by reference.
[0388] 5-HT.sub.3 antagonists that may be employed as additional
active agents in the present invention include, but are not limited
to:
[0389] a. Ondansetron
[1,2,3,9-tetrahydro-9-methyl-3-[(2-methyl-1H-imidazo-
l-1-yl]methyl]-4H-carb azol-4-one (cf. Merck Index, twelfth
edition, item 6979);
[0390] b. Granisetron [endo-1-methyl-N-(9-methyl-9-aza-bicyclo[3.3.
1]non-3-yl)-1H-imidazole-3-carboxamide: (cf. Merck Index, twelfth
edition, item 4557);
[0391] c. Dolasetron [1H-indole-3-carboxylic acid (2.alpha.,
6.alpha., 8.alpha.,
9.alpha..beta.)-octahydro-3-oxo-2,6methano-2H-quinolizin-8-yl
ester] (cf. Merck Index, twelfth edition, item 3471);
[0392] d. Indol-3-yl-carboxylic acid-endo-8-methyl-8-aza-bicyclo[3
,2,1]-oct-3-yl-ester, also known as tropisetron. (cf. Merck Index,
twelfth edition, item 9914);
[0393] e.
4,5,6,7-tetrahydro-5-[(1-methyl-indol-3yl)carbonyl]benzimidazole
(see also ramosetron, U.S. Pat. No. 5,344,927);
[0394] f.
(+)-10-methyl-7-(5-methyl-1H-imidazol-4-ylmethyl)-6,7,8,9-tetrah-
ydropyrido [1,2-a]indol-6-one (see also fabesetron, European Patent
No. 0 361 317);
[0395] g.
[N-(1-ethyl-2-imidazolin-2-yl-methyl)-2-methoxy-4-amino-5-chloro-
benzamide (see also lintopride-Chem.-Abstr.-No. 107429-63-0);
and
[0396] h.
2,3,4,5-tetrahydro-5-methyl-2-[(5-methyl-1H-imidazol-4-yl)methyl-
]-1H-pyrid o[4,3-b]indol-1-one (see also alosetron, European Patent
No. 0 306 323).
[0397] 5-HT.sub.4 agonists that may be employed as additional
active agents in the present invention include, but are not limited
to 2-piperazinylbenzothiazole and 2-piperazinylbenzoxazole
derivatives as disclosed in Monge et al. (1994) J. Med. Chem. 37:
1320-1325.
Formulations
[0398] Formulations of the present invention may include, but are
not limited to, continuous, as needed, short-term, rapid-offset,
controlled release, sustained release, delayed release, and
pulsatile release formulations.
[0399] Compositions of the invention comprise sodium channel
modulators, particularly tetrodotoxin-resistant (TTX-R) sodium
channel modulators and/or activity-dependent sodium channel
modulators. TTX-R sodium channel modulators for use in the present
invention include but are not limited to compounds that interact
with Nav1.8 and/or Nav1.9 channels. The compositions are
administered in therapeutically effective amounts to a patient in
need thereof for treating a GI tract disorder except for acid
peptic disorders or structural gastroesophageal disorders. It is
recognized that the compositions may be administered by any means
of administration as long as an effective amount for treating a GI
tract disorder except for acid peptic disorders or structural
gastroesophageal disorders is delivered.
[0400] Any of the active agents may be administered in the form of
a salt, ester, amide, prodrug, active metabolite, derivative, or
the like, provided that the salt, ester, amide, prodrug or
derivative is suitable pharmacologically, i.e., effective in the
present method. Salts, esters, amides, prodrugs and other
derivatives of the active agents may be prepared using standard
procedures known to those skilled in the art of synthetic organic
chemistry and described, for example, by J. March, Advanced Organic
Chemistry: Reactions, Mechanisms and Structure, 4th Ed. (New York:
Wiley-Interscience, 1992). For example, acid addition salts are
prepared from the free base using conventional methodology, and
involves reaction with a suitable acid. Suitable acids for
preparing acid addition salts include both organic acids, e.g.,
acetic acid, propionic acid, glycolic acid, pyruvic acid, oxalic
acid, malic acid, malonic acid, succinic acid, maleic acid, fumaric
acid, tartaric acid, citric acid, benzoic acid, cinnamic acid,
mandelic acid, methanesulfonic acid, ethanesulfonic acid,
p-toluenesulfonic acid, salicylic acid, and the like, as well as
inorganic acids, e.g., hydrochloric acid, hydrobromic acid,
sulfuric acid, nitric acid, phosphoric acid, and the like. An acid
addition salt may be reconverted to the free base by treatment with
a suitable base. Particularly preferred acid addition salts of the
active agents herein are salts prepared with organic acids.
Conversely, preparation of basic salts of acid moieties which may
be present on an active agent are prepared in a similar manner
using a pharmaceutically acceptable base such as sodium hydroxide,
potassium hydroxide, ammonium hydroxide, calcium hydroxide,
trimethylamine, or the like.
[0401] Preparation of esters involves functionalization of hydroxyl
and/or carboxyl groups that may be present within the molecular
structure of the drug. The esters are typically acyl-substituted
derivatives of free alcohol groups, i.e., moieties that are derived
from carboxylic acids of the formula RCOOH where R is alkyl, and
preferably is lower alkyl. Esters can be reconverted to the free
acids, if desired, by using conventional hydrogenolysis or
hydrolysis procedures. Amides and prodrugs may also be prepared
using techniques known to those skilled in the art or described in
the pertinent literature. For example, amides may be prepared from
esters, using suitable amine reactants, or they may be prepared
from an anhydride or an acid chloride by reaction with ammonia or a
lower alkyl amine. Prodrugs are typically prepared by covalent
attachment of a moiety, which results in a compound that is
therapeutically inactive until modified by an individual's
metabolic system.
[0402] Other salts, enantiomers, analogs, esters, amides, prodrugs,
active metabolites, and derivatives of the active agents may be
prepared using standard techniques known to those skilled in the
art of synthetic organic chemistry, or may be deduced by reference
to the pertinent literature. In addition, chiral active agents may
be in isomerically pure form, or they may be administered as a
racemic mixture of isomers.
Pharmaceutical Compositions and Dosage Forms
[0403] Suitable compositions and dosage forms include tablets,
capsules, caplets, pills, gel caps, troches, dispersions,
suspensions, solutions, syrups, transdermal patches, gels, powders,
magmas, lozenges, creams, pastes, plasters, lotions, discs,
suppositories, liquid sprays for nasal or oral administration, dry
powder or aerosolized formulations for inhalation, compositions and
formulations for intravesical administration and the like. Further,
those of ordinary skill in the art can readily deduce that suitable
formulations involving these compositions and dosage forms,
including those formulations as described elsewhere herein.
[0404] Oral Dosage Forms
[0405] Oral dosage forms include tablets, capsules, caplets,
solutions, suspensions and/or syrups, and may also comprise a
plurality of granules, beads, powders or pellets that may or may
not be encapsulated. Such dosage forms are prepared using
conventional methods known to those in the field of pharmaceutical
formulation and described in the pertinent texts, e.g., in
Remington: The Science and Practice of Pharmacy, supra). Tablets
and capsules represent the most convenient oral dosage forms, in
which case solid pharmaceutical carriers are employed.
[0406] Tablets may be manufactured using standard tablet processing
procedures and equipment. One method for forming tablets is by
direct compression of a powdered, crystalline or granular
composition containing the active agent(s), alone or in combination
with one or more carriers, additives, or the like. As an
alternative to direct compression, tablets can be prepared using
wet-granulation or dry-granulation processes. Tablets may also be
molded rather than compressed, starting with a moist or otherwise
tractable material; however, compression and granulation techniques
are preferred.
[0407] In addition to the active agent(s), then, tablets prepared
for oral administration using the method of the invention will
generally contain other materials such as binders, diluents,
lubricants, disintegrants, fillers, stabilizers, surfactants,
preservatives, coloring agents, flavoring agents and the like.
Binders are used to impart cohesive qualities to a tablet, and thus
ensure that the tablet remains intact after compression. Suitable
binder materials include, but are not limited to, starch (including
corn starch and pregelatinized starch), gelatin, sugars (including
sucrose, glucose, dextrose and lactose), polyethylene glycol,
propylene glycol, waxes, and natural and synthetic gums, e.g.,
acacia sodium alginate, polyvinylpyrrolidone, cellulosic polymers
(including hydroxypropyl cellulose, hydroxypropyl methylcellulose,
methyl cellulose, ethyl cellulose, hydroxyethyl cellulose, and the
like), and Veegum. Diluents are typically necessary to increase
bulk so that a practical size tablet is ultimately provided.
Suitable diluents include dicalcium phosphate, calcium sulfate,
lactose, cellulose, kaolin, mannitol, sodium chloride, dry starch
and powdered sugar. Lubricants are used to facilitate tablet
manufacture; examples of suitable lubricants include, for example,
vegetable oils such as peanut oil, cottonseed oil, sesame oil,
olive oil, corn oil, and oil of theobroma, glycerin, magnesium
stearate, calcium stearate, and stearic acid. Stearates, if
present, preferably represent at no more than approximately 2 wt. %
of the drug-containing core. Disintegrants are used to facilitate
disintegration of the tablet, and are generally starches, clays,
celluloses, algins, gums or crosslinked polymers. Fillers include,
for example, materials such as silicon dioxide, titanium dioxide,
alumina, talc, kaolin, powdered cellulose and microcrystalline
cellulose, as well as soluble materials such as mannitol, urea,
sucrose, lactose, dextrose, sodium chloride and sorbitol.
Stabilizers are used to inhibit or retard drug decomposition
reactions that include, by way of example, oxidative reactions.
Surfactants may be anionic, cationic, amphoteric or nonionic
surface active agents.
[0408] The dosage form may also be a capsule, in which case the
active agent-containing composition may be encapsulated in the form
of a liquid or solid (including particulates such as granules,
beads, powders or pellets). Suitable capsules may be either hard or
soft, and are generally made of gelatin, starch, or a cellulosic
material, with gelatin capsules preferred. Two-piece hard gelatin
capsules are preferably sealed, such as with gelatin bands or the
like. (See, for e.g., Remington: The Science and Practice of
Pharmacy, supra), which describes materials and methods for
preparing encapsulated pharmaceuticals. If the active
agent-containing composition is present within the capsule in
liquid form, a liquid carrier is necessary to dissolve the active
agent(s). The carrier must be compatible with the capsule material
and all components of the pharmaceutical composition, and must be
suitable for ingestion.
[0409] Solid dosage forms, whether tablets, capsules, caplets, or
particulates, may, if desired, be coated so as to provide for
delayed release. Dosage forms with delayed release coatings may be
manufactured using standard coating procedures and equipment. Such
procedures are known to those skilled in the art and described in
the pertinent texts (See, for e.g., Remington: The Science and
Practice of Pharmacy, supra). Generally, after preparation of the
solid dosage form, a delayed release coating composition is applied
using a coating pan, an airless spray technique, fluidized bed
coating equipment, or the like. Delayed release coating
compositions comprise a polymeric material, e.g., cellulose
butyrate phthalate, cellulose hydrogen phthalate, cellulose
proprionate phthalate, polyvinyl acetate phthalate, cellulose
acetate phthalate, cellulose acetate trimellitate, hydroxypropyl
methylcellulose phthalate, hydroxypropyl methylcellulose acetate,
dioxypropyl methylcellulose succinate, carboxymethyl
ethylcellulose, hydroxypropyl methylcellulose acetate succinate,
polymers and copolymers formed from acrylic acid, methacrylic acid,
and/or esters thereof.
[0410] Sustained release dosage forms provide for drug release over
an extended time period, and may or may not be delayed release.
Generally, as will be appreciated by those of ordinary skill in the
art, sustained release dosage forms are formulated by dispersing a
drug within a matrix of a gradually bioerodible (hydrolyzable)
material such as an insoluble plastic, a hydrophilic polymer, or a
fatty compound, or by coating a solid, drug-containing dosage form
with such a material. Insoluble plastic matrices may be comprised
of, for example, polyvinyl chloride or polyethylene. Hydrophilic
polymers useful for providing a sustained release coating or matrix
cellulosic polymers include, without limitation: cellulosic
polymers such as hydroxypropyl cellulose, hydroxyethyl cellulose,
hydroxypropyl methyl cellulose, methyl cellulose, ethyl cellulose,
cellulose acetate, cellulose acetate phthalate, cellulose acetate
trimellitate, hydroxypropylmethyl cellulose phthalate,
hydroxypropylcellulose phthalate, cellulose hexahydrophthalate,
cellulose acetate hexahydrophthalate, and carboxymethylcellulose
sodium; acrylic acid polymers and copolymers, preferably formed
from acrylic acid, methacrylic acid, acrylic acid alkyl esters,
methacrylic acid alkyl esters, and the like, e.g. copolymers of
acrylic acid, methacrylic acid, methyl acrylate, ethyl acrylate,
methyl methacrylate and/or ethyl methacrylate, with a terpolymer of
ethyl acrylate, methyl methacrylate and trimethylammonioethyl
methacrylate chloride (sold under the tradename Eudragit RS)
preferred; vinyl polymers and copolymers such as polyvinyl
pyrrolidone, polyvinyl acetate, polyvinylacetate phthalate,
vinylacetate crotonic acid copolymer, and ethylene-vinyl acetate
copolymers; zein; and shellac, ammoniated shellac, shellac-acetyl
alcohol, and shellac n-butyl stearate. Fatty compounds for use as a
sustained release matrix material include, but are not limited to,
waxes generally (e.g., carnauba wax) and glyccryl tristearate.
[0411] Transmucosal Compositions and Dosage Forms
[0412] Although the present compositions may be administered
orally, other modes of administration are suitable as well. For
example, transmucosal administration may be advantageously
employed. Transmucosal administration is carried out using any type
of formulation or dosage unit suitable for application to mucosal
tissue. For example, the selected active agent may be administered
to the buccal mucosa in an adhesive tablet or patch, sublingually
administered by placing a solid dosage form under the tongue,
lingually administered by placing a solid dosage form on the
tongue, administered nasally as droplets or a nasal spray,
administered by inhalation of an aerosol formulation, a non-aerosol
liquid formulation, or a dry powder, placed within or near the
rectum ("transrectal" formulations), or administered to the urethra
as a suppository, ointment, or the like.
[0413] Preferred buccal dosage forms will typically comprise a
therapeutically effective amount of an active agent and a
bioerodible (hydrolyzable) polymeric carrier that may also serve to
adhere the dosage form to the buccal mucosa. The buccal dosage unit
is fabricated so as to erode over a predetermined time period,
wherein drug delivery is provided essentially throughout. The time
period is typically in the range of from about 1 hour to about 72
hours. Preferred buccal delivery preferably occurs over a time
period of from about 2 hours to about 24 hours. Buccal drug
delivery for short term use should preferably occur over a time
period of from about 2 hours to about 8 hours, more preferably over
a time period of from about 3 hours to about 4 hours. As needed
buccal drug delivery preferably will occur over a time period of
from about 1 hour to about 12 hours, more preferably from about 2
hours to about 8 hours, most preferably from about 3 hours to about
6 hours. Sustained buccal drug delivery will preferably occur over
a time period of from about 6 hours to about 72 hours, more
preferably from about 12 hours to about 48 hours, most preferably
from about 24 hours to about 48 hours. Buccal drug delivery, as
will be appreciated by those skilled in the art, avoids the
disadvantages encountered with oral drug administration, e.g., slow
absorption, degradation of the active agent by fluids present in
the gastrointestinal tract and/or first-pass inactivation in the
liver.
[0414] The "therapeutically effective amount" of the active agent
in the buccal dosage unit will of course depend on the potency of
the agent and the intended dosage, which, in turn, is dependent on
the particular individual undergoing treatment, the specific
indication, and the like. The buccal dosage unit will generally
contain from about 1.0 wt. % to about 60 wt. % active agent,
preferably on the order of from about 1 wt. % to about 30 wt. %
active agent. With regard to the bioerodible (hydrolyzable)
polymeric carrier, it will be appreciated that virtually any such
carrier can be used, so long as the desired drug release profile is
not compromised, and the carrier is compatible with the sodium
channel modulator, particularly tetrodotoxin-resistant (TTX-R)
sodium channel modulator and/or activity-dependent sodium channel
modulator, to be administered and any other components of the
buccal dosage unit. Generally, the polymeric carrier comprises a
hydrophilic (water-soluble and water-swellable) polymer that
adheres to the wet surface of the buccal mucosa. Examples of
polymeric carriers useful herein include acrylic acid polymers and
co, e.g., those known as "carbomers" (Carbopol.RTM., which may be
obtained from B. F. Goodrich, is one such polymer). Other suitable
polymers include, but are not limited to: hydrolyzed
polyvinylalcohol; polyethylene oxides (e.g., Sentry Polyox.RTM.
water soluble resins, available from Union Carbide); polyacrylates
(e.g., Gantrez.RTM., which may be obtained from GAF); vinyl
polymers and copolymers; polyvinylpyrrolidone; dextran; guar gum;
pectins; starches; and cellulosic polymers such as hydroxypropyl
methylcellulose, (e.g., Methocel.RTM., which may be obtained from
the Dow Chemical Company), hydroxypropyl cellulose (e.g.,
Klucel.RTM., which may also be obtained from Dow), hydroxypropyl
cellulose ethers (see, e.g., U.S. Pat. No. 4,704,285 to Alderman),
hydroxyethyl cellulose, carboxymethyl cellulose, sodium
carboxymethyl cellulose, methyl cellulose, ethyl cellulose,
cellulose acetate phthalate, cellulose acetate butyrate, and the
like.
[0415] Other components may also be incorporated into the buccal
dosage forms described herein. The additional components include,
but are not limited to, disintegrants, diluents, binders,
lubricants, flavoring, colorants, preservatives, and the like.
Examples of disintegrants that may be used include, but are not
limited to, cross-linked polyvinylpyrrolidones, such as
crospovidone (e.g., Polyplasdone.RTM. XL, which may be obtained
from GAF), cross-linked carboxylic methylcelluloses, such as
croscarmelose (e.g., Ac-di-sol.RTM., which may be obtained from
FMC), alginic acid, and sodium carboxymethyl starches (e.g.,
Explotab.RTM., which may be obtained from Edward Medell Co., Inc.),
methylcellulose, agar bentonite and alginic acid. Suitable diluents
are those which are generally useful in pharmaceutical formulations
prepared using compression techniques, e.g., dicalcium phosphate
dihydrate (e.g., Di-Tab.RTM., which may be obtained from Stauffer),
sugars that have been processed by cocrystallization with dextrin
(e.g., co-crystallized sucrose and dextrin such as Di-Pak.RTM.,
which may be obtained from Amstar), calcium phosphate, cellulose,
kaolin, mannitol, sodium chloride, dry starch, powdered sugar and
the like. Binders, if used, are those that enhance adhesion.
Examples of such binders include, but are not limited to, starch,
gelatin and sugars such as sucrose, dextrose, molasses, and
lactose. Particularly preferred lubricants are stearates and
stearic acid, and an optimal lubricant is magnesium stearate.
[0416] Sublingual and lingual dosage forms include tablets, creams,
ointments, lozenges, pastes, and any other solid dosage form where
the active ingredient is admixed into a disintegrable matrix. The
tablet, cream, ointment or paste for sublingual or lingual delivery
comprises a therapeutically effective amount of the selected active
agent and one or more conventional nontoxic carriers suitable for
sublingual or lingual drug administration. The sublingual and
lingual dosage forms of the present invention can be manufactured
using conventional processes. The sublingual and lingual dosage
units are fabricated to disintegrate rapidly. The time period for
complete disintegration of the dosage unit is typically in the
range of from about 10 seconds to about 30 minutes, and optimally
is less than 5 minutes.
[0417] Other components may also be incorporated into the
sublingual and lingual dosage forms described herein. The
additional components include, but are not limited to binders,
disintegrants, wetting agents, lubricants, and the like. Examples
of binders that may be used include water, ethanol,
polyvinylpyrrolidone; starch solution gelatin solution, and the
like. Suitable disintegrants include dry starch, calcium carbonate,
polyoxyethylene sorbitan fatty acid esters, sodium lauryl sulfate,
stearic monoglyceride, lactose, and the like. Wetting agents, if
used, include glycerin, starches, and the like. Particularly
preferred lubricants are stearates and polyethylene glycol.
Additional components that may be incorporated into sublingual and
lingual dosage forms are known, or will be apparent, to those
skilled in this art (See, e.g., Remington: The Science and Practice
of Pharmacy, supra).
[0418] For transurethral administration, the formulation comprises
a urethral dosage form containing the active agent and one or more
selected carriers or excipients, such as water, silicone, waxes,
petroleum jelly, polyethylene glycol ("PEG"), propylene glycol
("PG"), liposomes, sugars such as mannitol and lactose, and/or a
variety of other materials, with polyethylene glycol and
derivatives thereof particularly preferred.
[0419] Depending on the particular active agent administered, it
may be desirable to incorporate a transurethral permeation enhancer
in the urethral dosage form. Examples of suitable transurethral
permeation enhancers include dimethylsulfoxide ("DMSO"), dimethyl
formamide ("DMF"), N, N-dimethylacetamide ("DMA"),
decylmethylsulfoxide ("C.sub.10 MSO"), polyethylene glycol
monolaurate ("PEGML"), glycerol monolaurate, lecithin, the
1-substituted azacycloheptan-2-ones, particularly
1-n-dodecylcyclazacycloheptan-2-one (available under the trademark
Azone.RTM. from Nelson Research & Development Co., Irvine,
Calif.), SEPA.RTM. (available from Macrochem Co., Lexington,
Mass.), surfactants as discussed above, including, for example,
Tergitol.RTM., Nonoxynol-9.RTM. and TWEEN-80.RTM., and lower
alkanols such as ethanol.
[0420] Transurethral drug administration, as explained in U.S. Pat.
Nos. 5,242,391, 5,474,535, 5,686,093 and 5,773,020, can be carried
out in a number of different ways using a variety of urethral
dosage forms. For example, the drug can be introduced into the
urethra from a flexible tube, squeeze bottle, pump or aerosol
spray. The drug may also be contained in coatings, pellets or
suppositories that are absorbed, melted or bioeroded in the
urethra. In certain embodiments, the drug is included in a coating
on the exterior surface of a penile insert. It is preferred,
although not essential, that the drug be delivered from at least
about 3 cm into the urethra, and preferably from at least about 7
cm into the urethra. Generally, delivery from at least about 3 cm
to about 8 cm into the urethra will provide effective results in
conjunction with the present method.
[0421] Urethral suppository formulations containing PEG or a PEG
derivative may be conveniently formulated using conventional
techniques, e.g., compression molding, heat molding or the like, as
will be appreciated by those skilled in the art and as described in
the pertinent literature and pharmaceutical texts. (See, e.g.,
Remington: The Science and Practice of Pharmacy, supra), which
discloses typical methods of preparing pharmaceutical compositions
in the form of urethral suppositories. The PEG or PEG derivative
preferably has a molecular weight in the range of from about 200 to
about 2,500 g/mol, more preferably in the range of from about 1,000
to about 2,000 g/mol. Suitable polyethylene glycol derivatives
include polyethylene glycol fatty acid esters, for example,
polyethylene glycol monostearate, polyethylene glycol sorbitan
esters, e.g., polysorbates, and the like. Depending on the
particular active agent, it may also be preferred that urethral
suppositories contain one or more solubilizing agents effective to
increase the solubility of the active agent in the PEG or other
transurethral vehicle.
[0422] It may be desirable to deliver the active agent in a
urethral dosage form that provides for controlled or sustained
release of the agent. In such a case, the dosage form comprises a
biocompatible, biodegradable material, typically a biodegradable
polymer. Examples of such polymers include polyesters,
polyalkylcyanoacrylates, polyorthoesters, polyanhydrides, albumin,
gelatin and starch. As explained, for example, in PCT Publication
No. WO 96/40054, these and other polymers can be used to provide
biodegradable microparticles that enable controlled and sustained
drug release, in turn minimizing the required dosing frequency.
[0423] The urethral dosage form will preferably comprise a
suppository that is on the order of from about 2 to about 20 mm in
length, preferably from about 5 to about 10 mm in length, and less
than about 5 mm in width, preferably less than about 2 mm in width.
The weight of the suppository will typically be in the range of
from about 1 mg to about 100 mg, preferably in the range of from
about 1 mg to about 50 mg. However, it will be appreciated by those
skilled in the art that the size of the suppository can and will
vary, depending on the potency of the drug, the nature of the
formulation, and other factors.
[0424] Transurethral drug delivery may involve an "active" delivery
mechanism such as iontophoresis, electroporation or phonophoresis.
Devices and methods for delivering drugs in this way are well known
in the art. Iontophoretically assisted drug delivery is, for
example, described in PCT Publication No. WO 96/40054, cited above.
Briefly, the active agent is driven through the urethral wall by
means of an electric current passed from an external electrode to a
second electrode contained within or affixed to a urethral
probe.
[0425] Preferred transrectal dosage forms include rectal
suppositories, creams, ointments, and liquid formulations (enemas).
The suppository, cream, ointment or liquid formulation for
transrectal delivery comprises a therapeutically effective amount
of the selected phosphodiesterase inhibitor and one or more
conventional nontoxic carriers suitable for transrectal drug
administration. The transrectal dosage forms of the present
invention can be manufactured using conventional processes. The
transrectal dosage unit can be fabricated to disintegrate rapidly
or over a period of several hours. The time period for complete
disintegration is preferably in the range of from about 10 minutes
to about 6 hours, and optimally is less than about 3 hours.
[0426] Other components may also be incorporated into the
transrectal dosage forms described herein. The additional
components include, but are not limited to, stiffening agents,
antioxidants, preservatives, and the like. Examples of stiffening
agents that may be used include, for example, paraffin, white wax
and yellow wax. Preferred antioxidants, if used, include sodium
bisulfite and sodium metabisulfite.
[0427] Preferred vaginal or perivaginal dosage forms include
vaginal suppositories, creams, ointments, liquid formulations,
pessaries, tampons, gels, pastes, foams or sprays. The suppository,
cream, ointment, liquid formulation, pessary, tampon, gel, paste,
foam or spray for vaginal or perivaginal delivery comprises a
therapeutically effective amount of the selected active agent and
one or more conventional nontoxic carriers suitable for vaginal or
perivaginal drug administration. The vaginal or perivaginal forms
of the present invention can be manufactured using conventional
processes as disclosed in Remington: The Science and Practice of
Pharmacy, supra (see also drug formulations as adapted in U.S. Pat.
Nos. 6,515,198; 6,500,822; 6,417,186; 6,416,779; 6,376,500;
6,355,641; 6,258,819; 6,172,062; and 6,086,909). The vaginal or
perivaginal dosage unit can be fabricated to disintegrate rapidly
or over a period of several hours. The time period for complete
disintegration is preferably in the range of from about 10 minutes
to about 6 hours, and optimally is less than about 3 hours.
[0428] Other components may also be incorporated into the vaginal
or perivaginal dosage forms described herein. The additional
components include, but are not limited to, stiffening agents,
antioxidants, preservatives, and the like. Examples of stiffening
agents that may be used include, for example, paraffin, white wax
and yellow wax. Preferred antioxidants, if used, include sodium
bisulfite and sodium metabisulfite.
[0429] The active agents may also be administered intranasally or
by inhalation. Compositions for intranasal administration are
generally liquid formulations for administration as a spray or in
the form of drops, although powder formulations for intranasal
administration, e.g., insufflations, are also known, as are nasal
gels, creams, pastes or ointments. For liquid formulations, the
active agent can be formulated into a solution, e.g., water or
isotonic saline, buffered or unbuffered, or as a suspension.
Preferably, such solutions or suspensions are isotonic relative to
nasal secretions and of about the same pH, ranging e.g., from about
pH 4.0 to about pH 7.4 or, from about pH 6.0 to about pH 7.0.
Buffers should be physiologically compatible and include, simply by
way of example, phosphate buffers. Furthermore, various devices are
available in the art for the generation of drops, droplets and
sprays, including droppers, squeeze bottles, and manually and
electrically powered intranasal pump dispensers. Active agent
containing intranasal carriers may also include nasal gels, creams,
pastes or ointments with a viscosity of, e.g., from about 10 to
about 6500 cps, or greater, depending on the desired sustained
contact with the nasal mucosal surfaces. Such carrier viscous
formulations may be based upon, simply by way of example,
alkylcelluloses and/or other biocompatible carriers of high
viscosity well known to the art (see e.g., Remington: The Science
and Practice of Pharmacy, supra). Other ingredients, such as art
known preservatives, colorants, lubricating or viscous mineral or
vegetable oils, perfumes, natural or synthetic plant extracts such
as aromatic oils, and humectants and viscosity enhancers such as,
e.g., glycerol, can also be included to provide additional
viscosity, moisture retention and a pleasant texture and odor for
the formulation.
[0430] Formulations for inhalation may be prepared as an aerosol,
either a solution aerosol in which the active agent is solubilized
in a carrier (e.g., propellant) or a dispersion aerosol in which
the active agent is suspended or dispersed throughout a carrier and
an optional solvent. Non-aerosol formulations for inhalation may
take the form of a liquid, typically an aqueous suspension,
although aqueous solutions may be used as well. In such a case, the
carrier is typically a sodium chloride solution having a
concentration such that the formulation is isotonic relative to
normal body fluid. In addition to the carrier, the liquid
formulations may contain water and/or excipients including an
antimicrobial preservative (e.g., benzalkonium chloride,
benzethonium chloride, chlorobutanol, phenylethyl alcohol,
thimerosal and combinations thereof), a buffering agent (e.g.,
citric acid, potassium metaphosphate, potassium phosphate, sodium
acetate, sodium citrate, and combinations thereof), a surfactant
(e.g., polysorbate 80, sodium lauryl sulfate, sorbitan
monopalmitate and combinations thereof), and/or a suspending agent
(e.g., agar, bentonite, microcrystalline cellulose, sodium
carboxymethylcellulose, hydroxypropyl methylcellulose, tragacanth,
veegum and combinations thereof). Non-aerosol formulations for
inhalation may also comprise dry powder formulations, particularly
insufflations in which the powder has an average particle size of
from about 0.1 .mu.m to about 50 .mu.m, preferably from about 1
.mu.m to about 25 .mu.m.
[0431] Topical Formulations
[0432] Topical formulations may be in any form suitable for
application to the body surface, and may comprise, for example, an
ointment, cream, gel, lotion, solution, paste or the like, and/or
may be prepared so as to contain liposomes, micelles, and/or
microspheres. Preferred topical formulations herein are ointments,
creams and gels.
[0433] Ointments, as is well known in the art of pharmaceutical
formulation, are semisolid preparations that are typically based on
petrolatum or other petroleum derivatives. The specific ointment
base to be used, as will be appreciated by those skilled in the
art, is one that will provide for optimum drug delivery, and,
preferably, will provide for other desired characteristics as well,
e.g., emolliency or the like. As with other carriers or vehicles,
an ointment base should be inert, stable, nonirritating and
nonsensitizing. As explained in Remington: The Science and Practice
of Pharmacy, supra, ointment bases may be grouped in four classes:
oleaginous bases; emulsifiable bases; emulsion bases; and
water-soluble bases. Oleaginous ointment bases include, for
example, vegetable oils, fats obtained from animals, and semisolid
hydrocarbons obtained from petroleum. Emulsifiable ointment bases,
also known as absorbent ointment bases, contain little or no water
and include, for example, hydroxystearin sulfate, anhydrous lanolin
and hydrophilic petrolatum. Emulsion ointment bases are either
water-in-oil (W/O) emulsions or oil-in-water (O/W) emulsions, and
include, for example, cetyl alcohol, glyceryl monostearate, lanolin
and stearic acid. Preferred water-soluble ointment bases are
prepared from polyethylene glycols of varying molecular weight
(See, e.g., Remington: The Science and Practice of Pharmacy,
supra).
[0434] Creams, as also well known in the art, are viscous liquids
or semisolid emulsions, either oil-in-water or water-in-oil. Cream
bases are water-washable, and contain an oil phase, an emulsifier
and an aqueous phase. The oil phase, also called the "internal"
phase, is generally comprised of petrolatum and a fatty alcohol
such as cetyl or stearyl alcohol. The aqueous phase usually,
although not necessarily, exceeds the oil phase in volume, and
generally contains a humectant. The emulsifier in a cream
formulation is generally a nonionic, anionic, cationic or
amphoteric surfactant.
[0435] As will be appreciated by those working in the field of
pharmaceutical formulation, gels-are semisolid, suspension-type
systems. Single-phase gels contain organic macromolecules
distributed substantially uniformly throughout the carrier liquid,
which is typically aqueous, but also, preferably, contain an
alcohol and, optionally, an oil. Preferred "organic
macromolecules," i.e., gelling agents, are crosslinked acrylic acid
polymers such as the "carbomer" family of polymers, e.g.,
carboxypolyalkylenes that may be obtained commercially under the
Carbopol.RTM. trademark. Also preferred are hydrophilic polymers
such as polyethylene oxides, polyoxyethylene-polyoxypropylene
copolymers and polyvinylalcohol; cellulosic polymers such as
hydroxypropyl cellulose, hydroxyethyl cellulose, hydroxypropyl
methylcellulose, hydroxypropyl methylcellulose phthalate, and
methylcellulose; gums such as tragacanth and xanthan gum; sodium
alginate; and gelatin. In order to prepare a uniform gel,
dispersing agents such as alcohol or glycerin can be added, or the
gelling agent can be dispersed by trituration, mechanical mixing,
and/or stirring.
[0436] Various additives, known to those skilled in the art, may be
included in the topical formulations. For example, solubilizers may
be used to solubilize certain active agents. For those drugs having
an unusually low rate of permeation through the skin or mucosal
tissue, it may be desirable to include a permeation enhancer in the
formulation; suitable enhancers are as described elsewhere
herein.
[0437] Transdermal Administration
[0438] The compounds of the invention may also be administered
through the skin or mucosal tissue using conventional transdermal
drug delivery systems, wherein the agent is contained within a
laminated structure (typically referred to as a transdermal
"patch") that serves as a drug delivery device to be affixed to the
skin. Transdermal drug delivery may involve passive diffusion or it
may be facilitated using electrotransport, e.g., iontophoresis. In
a typical transdermal "patch," the drug composition is contained in
a layer, or "reservoir," underlying an upper backing layer. The
laminated structure may contain a single reservoir, or it may
contain multiple reservoirs. In one type of patch, referred to as a
"monolithic" system, the reservoir is comprised of a polymeric
matrix of a pharmaceutically acceptable contact adhesive material
that serves to affix the system to the skin during drug delivery.
Examples of suitable skin contact adhesive materials include, but
are not limited to, polyethylenes, polysiloxanes, polyisobutylenes,
polyacrylates, polyurethanes, and the like. Alternatively, the
drug-containing reservoir and skin contact adhesive are separate
and distinct layers, with the adhesive underlying the reservoir
which, in this case, may be either a polymeric matrix as described
above, or it may be a liquid or hydrogel reservoir, or may take
some other form.
[0439] The backing layer in these laminates, which serves as the
upper surface of the device, functions as the primary structural
element of the laminated structure and provides the device with
much of its flexibility. The material selected for the backing
material should be selected so that it is substantially impermeable
to the active agent and any other materials that are present, the
backing is preferably made of a sheet or film of a flexible
elastomeric material. Examples of polymers that are suitable for
the backing layer include polyethylene, polypropylene, polyesters,
and the like.
[0440] During storage and prior to use, the laminated structure
includes a release liner. Immediately prior to use, this layer is
removed from the device to expose the basal surface thereof, either
the drug reservoir or a separate contact adhesive layer, so that
the system may be affixed to the skin. The release liner should be
made from a drug/vehicle impermeable material.
[0441] Transdermal drug delivery systems may in addition contain a
skin permeation enhancer. That is, because the inherent
permeability of the skin to some drugs may be too low to allow
therapeutic levels of the drug to pass through a reasonably sized
area of unbroken skin, it is necessary to coadminister a skin
permeation enhancer with such drugs. Suitable enhancers are well
known in the art and include, for example, those enhancers listed
above in transmucosal compositions.
[0442] Parenteral Administration
[0443] Parenteral administration, if used, is generally
characterized by injection, including intramuscular,
intraperitoneal, intravenous (IV) and subcutaneous injection.
Injectable formulations can be prepared in conventional forms,
either as liquid solutions or suspensions; solid forms suitable for
solution or suspension in liquid prior to injection, or as
emulsions. Preferably, sterile injectable suspensions are
formulated according to techniques known in the art using suitable
dispersing or wetting agents and suspending agents. The sterile
injectable formulation may also be a sterile injectable solution or
a suspension in a nontoxic parenterally acceptable diluent or
solvent. Among the acceptable vehicles and solvents that may be
employed are water, Ringer's solution and isotonic sodium chloride
solution. In addition, sterile, fixed oils are conventionally
employed as a solvent or suspending medium. A more recently revised
approach for parenteral administration involves use of a slow
release or sustained release system (See, e.g., U.S. Pat. No.
3,710,795).
[0444] Intrathecal Administration
[0445] Intrathecal administration, if used, is generally
characterized by administration directly into the intrathecal space
(where fluid flows around the spinal cord).
[0446] One common system utilized for intrathecal administration is
the APT Intrathecal treatment system available from Medtronic, Inc.
APT Intrathecal uses a small pump that is surgically placed under
the skin of the abdomen to deliver medication directly into the
intrathecal space. The medication is delivered through a small tube
called a catheter that is also surgically placed. The medication
can then be administered directly to cells in the spinal cord
involved in conveying sensory and motor signals associated with GI
tract disorders.
[0447] Another system available from Medtronic that is commonly
utilized for intrathecal administration is the is the fully
implantable, programmable SynchroMed.RTM. Infusion System. The
SynchroMed.RTM. Infusion System has two parts that are both placed
in the body during a surgical procedure: the catheter and the pump.
The catheter is a small, soft tube. One end is connected to the
catheter port of the pump, and the other end is placed in the
intrathecal space. The pump is a round metal device about one inch
(2.5 cm) thick, three inches (8.5 cm) in diameter, and weighs about
six ounces (205 g) that stores and releases prescribed amounts of
medication directly into the intrathecal space. It is made of
titanium, a lightweight, medical-grade metal. The reservoir is the
space inside the pump that holds the medication. The fill port is a
raised center portion of the pump through which the pump is
refilled. The doctor or a nurse inserts a needle through the
patient's skin and through the fill port to fill the pump. Some
pumps have a side catheter access port that allows the doctor to
inject other medications or sterile solutions directly into the
catheter, bypassing the pump.
[0448] The SynchroMed.RTM. pump automatically delivers a controlled
amount of medication through the catheter to the intrathecal space
around the spinal cord, where it is most effective. The exact
dosage, rate and timing prescribed by the doctor are entered in the
pump using a programmer, an external computer-like device that
controls the pump's memory. Information about the patient's
prescription is stored in the pump's memory. The doctor can easily
review this information by using the programmer. The programmer
communicates with the pump by radio signals that allow the doctor
to tell how the pump is operating at any given time. The doctor
also can use the programmer to change your medication dosage.
[0449] Methods of intrathecal administration may include those
described above available from Medtronic, as well as other methods
that are known to one of skill in the art.
[0450] Additional Dosage Formulations and Drug Delivery Systems
[0451] As compared with traditional drug delivery approaches, some
controlled release technologies rely upon the modification of both
macromolecules and synthetic small molecules to allow them to be
actively instead of passively absorbed into the body. For example,
XenoPort Inc. utilizes technology that takes existing molecules and
re-engineers them to create new chemical entities (unique
molecules) that have improved pharmacologic properties to either:
1) lengthen the short half-life of a drug; 2) overcome poor
absorption; and/or 3) deal with poor drug distribution to target
tissues. Techniques to lengthen the short half-life of a drug
include the use of prodrugs with slow cleavage rates to release
drugs over time or that engage transporters in small and large
intestines to allow the use of oral sustained delivery systems, as
well as drugs that engage active transport systems. Examples of
such controlled release formulations, tablets, dosage forms, and
drug delivery systems, and that are suitable for use with the
present invention, are described in the following published US and
PCT patent applications assigned to Xenoport Inc.: US20030158254;
US20030158089; US20030017964; US2003130246; WO02100172; WO02100392;
WO02100347; WO02100344; WO0242414; WO0228881; WO0228882; WO0244324;
WO0232376; WO0228883; and WO0228411. Some other controlled release
technologies rely upon methods that promote or enhance gastric
retention, such as those developed by Depomed Inc. Because many
drugs are best absorbed in the stomach and upper portions of the
small intestine, Depomed has developed tablets that swell in the
stomach during the postprandial or fed mode so that they are
treated like undigested food. These tablets therefore sit safely
and neutrally in the stomach for 6, 8, or more hours and deliver
drug at a desired rate and time to upper gastrointestinal sites.
Specific technologies in this area include: 1) tablets that slowly
erode in gastric fluids to deliver drugs at almost a constant rate
(particularly useful for highly insoluble drugs); 2) bi-layer
tablets that combine drugs with different characteristics into a
single table (such as a highly insoluble drug in an erosion layer
and a soluble drug in a diffusion layer for sustained release of
both); and 3) combination tablets that can either deliver drugs
simultaneously or in sequence over a desired period of time
(including an initial burst of a fast acting drug followed by slow
and sustained delivery of another drug). Examples of such
controlled release formulations that are suitable for use with the
present invention and that rely upon gastric retention during the
postprandial or fed mode, include tablets, dosage forms, and drug
delivery systems in the following US patents assigned to Depomed
Inc.: U.S. Pat. No. 6,488,962; U.S. Pat. No. 6,451,808; U.S. Pat.
No. 6,340,475; U.S. Pat. No. 5,972,389; U.S. Pat. No. 5,582,837;
and U.S. Pat. No. 5,007,790. Examples of such controlled release
formulations that are suitable for use with the present invention
and that rely upon gastric retention during the postprandial or fed
mode, include tablets, dosage forms, and drug delivery systems in
the following published US and PCT patent applications assigned to
Depomed Inc.: US20030147952; US20030104062; US20030104053;
US20030104052; US20030091630; US20030044466; US20030039688;
US20020051820; WO0335040; WO0335039; WO0156544; WO0132217;
WO9855107; WO9747285; and WO9318755.
[0452] Other controlled release systems include those developed by
ALZA Corporation based upon: 1) osmotic technology for oral
delivery; 2) transdermal delivery via patches; 3) liposomal
delivery via intravenous injection; 4) osmotic technology for
long-term delivery via implants; and 5) depot technology designed
to deliver agents for periods of days to a month. ALZA oral
delivery systems include those that employ osmosis to provide
precise, controlled drug delivery for up to 24 hours for both
poorly soluble and highly soluble drugs, as well as those that
deliver high drug doses meeting high drug loading requirements.
ALZA controlled transdermal delivery systems provide drug delivery
through intact skin for as long as one week with a single
application to improve drug absorption and deliver constant amounts
of drug into the bloodstream over time. ALZA liposomal delivery
systems involve lipid nanoparticles that evade recognition by the
immune system because of their unique polyethylene glycol (PEG)
coating, allowing the precise delivery of drugs to disease-specific
areas of the body. ALZA also has developed osmotically driven
systems to enable the continuous delivery of small drugs, peptides,
proteins, DNA and other bioactive macromolecules for up to one year
for systemic or tissue-specific therapy. Finally, ALZA depot
injection therapy is designed to deliver biopharmaceutical agents
and small molecules for periods of days to a month using a
nonaqueous polymer solution for the stabilization of macromolecules
and a unique delivery profile.
[0453] Examples of controlled release formulations, tablets, dosage
forms, and drug delivery systems that are suitable for use with the
present invention are described in the following US patents
assigned to ALZA Corporation: U.S. Pat. No. 4,367,741; U.S. Pat.
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5,932,547; U.S. Pat. No. 5,938,654; U.S. Pat. No. 5,941,844; U.S.
Pat. No. 5,955,103; U.S. Pat. No. 5,972,369; U.S. Pat. No.
5,972,370; U.S. Pat. No. 5,972,379; U.S. Pat. No. 5,980,943; U.S.
Pat. No. 5,981,489; U.S. Pat. No. 5,983,130; U.S. Pat. No.
5,989,590; U.S. Pat. No. 5,995,869; U.S. Pat. No. 5,997,902; U.S.
Pat. No. 6,001,390; U.S. Pat. No. 6,004,309; U.S. Pat. No.
6,004,578; U.S. Pat. No. 6,008,187; U.S. Pat. No. 6,020,000; U.S.
Pat. No. 6,034,101; U.S. Pat. No. 6,036,973; U.S. Pat. No.
6,039,977; U.S. Pat. No. 6,057,374; U.S. Pat. No. 6,066,619; U.S.
Pat. No. 6,068,850; U.S. Pat. No. 6,077,538; U.S. Pat. No.
6,083,190; U.S. Pat. No. 6,096,339; U.S. Pat. No. 6,106,845; U.S.
Pat. No. 6,110,499; U.S. Pat. No. 6,120,798; U.S. Pat. No.
6,120,803; U.S. Pat. No. 6,124,261; U.S. Pat. No. 6,130,200; U.S.
Pat. No. 6,146,662; U.S. Pat. No. 6,153,678; U.S. Pat. No.
6,174,547; U.S. Pat. No. 6,183,466; U.S. Pat. No. 6,203,817; U.S.
Pat. No. 6,210,712; U.S. Pat. No. 6,210,713; U.S. Pat. No.
6,224,907; U.S. Pat. No. 6,235,712; U.S. Pat. No. 6,245,357; U.S.
Pat. No. 6,262,115; U.S. Pat. No. 6,264,990; U.S. Pat. No.
6,267,984; U.S. Pat. No. 6,287,598; U.S. Pat. No. 6,289,241; U.S.
Pat. No. 6,331,311; U.S. Pat. No. 6,333,050; U.S. Pat. No.
6,342,249; U.S. Pat. No. 6,346,270; U.S. Pat. No. 6365183; U.S.
Pat. No. 6,368,626; U.S. Pat. No. 6,387,403; U.S. Pat. No.
6,419,952; U.S. Pat. No. 6,440,457; U.S. Pat. No. 6,468,961; U.S.
Pat. No. 6,491,683; U.S. Pat. No. 6,512,010; U.S. Pat. No.
6,514,530; U.S. Pat. No. 6534089; U.S. Pat. No. 6,544,252; U.S.
Pat. No. 6,548,083; U.S. Pat. No. 6,551,613; U.S. Pat. No.
6,572,879; and U.S. Pat. No. 6,596,314.
[0454] Other examples of controlled release formulations, tablets,
dosage forms, and drug delivery systems that are suitable for use
with the present invention are described in the following published
US patent application and PCT applications assigned to ALZA
Corporation: US20010051183; WO0004886; WO0013663; WO0013674;
WO0025753; WO0025790; WO0035419; WO0038650; WO0040218; WO0045790;
WO0066126; WO0074650; WO119337; WO119352; WO0121211; WO0137815;
WO0141742; WO0143721; WO0156543; WO3041684; WO03041685; WO03041757;
WO03045352; WO03051341; WO03053400; WO03053401; WO9000416;
WO9004965; WO9113613; WO9116884; WO9204011; WO9211843; WO9212692;
WO9213521; WO9217239; WO9218102; WO9300071; WO9305843; WO9306819;
WO9314813; WO9319739; WO9320127; WO9320134; WO9407562; WO9408572;
WO9416699; WO9421262; WO9427587; WO9427589; WO9503823; WO9519174;
WO9529665; WO9600065; WO9613248; WO9625922; WO9637202; WO9640049;
WO9640050; WO9640139; WO9640364; WO9640365; WO9703634; WO9800158;
WO9802169; WO9814168; WO9816250; WO9817315; WO9827962; WO9827963;
WO9843611; WO9907342; WO9912526; WO9912527; WO9918159; WO9929297;
WO9929348; WO9932096; WO9932153; WO9948494; WO9956730; WO9958115;
and WO9962496.
[0455] Andrx Corporation has also developed drug delivery
technology suitable for use in the present invention that includes:
1) a pelletized pulsatile delivery system ("PPDS"); 2) a single
composition osmotic tablet system ("SCOT"); 3) a solubility
modulating hydrogel system ("SMHS"); 4) a delayed pulsatile
hydrogel system ("DPHS"); 5) a stabilized pellet delivery system
("SPDS"); 6) a granulated modulating hydrogel system ("GMHS"); 7) a
pelletized tablet system ("PELTAB"); 8) a porous tablet system
("PORTAB"); and 9) a stabilized tablet delivery system ("STDS").
PPDS uses pellets that are coated with specific polymers and agents
to control the release rate of the microencapsulated drug and is
designed for use with drugs that require a pulsed release. SCOT
utilizes various osmotic modulating agents as well as polymer
coatings to provide a zero-order drug release. SMHS utilizes a
hydrogel-based dosage system that avoids the "initial burst effect"
commonly observed with other sustained-release hydrogel
formulations and that provides for sustained release without the
need to use special coatings or structures that add to the cost of
manufacturing. DPHS is designed for use with hydrogel matrix
products characterized by an initial zero-order drug release
followed by a rapid release that is achieved by the blending of
selected hydrogel polymers to achieve a delayed pulse. SPDS
incorporates a pellet core of drug and protective polymer outer
layer, and is designed specifically for unstable drugs, while GMHS
incorporates hydrogel and binding polymers with the drug and forms
granules that are pressed into tablet form. PELTAB provides
controlled release by using a water insoluble polymer to coat
discrete drug crystals or pellets to enable them to resist the
action of fluids in the gastrointestinal tract, and these coated
pellets are then compressed into tablets. PORTAB provides
controlled release by incorporating an osmotic core with a
continuous polymer coating and a water soluble component that
expands the core and creates microporous channels through which
drug is released. Finally, STDS includes a dual layer coating
technique that avoids the need to use a coating layer to separate
the enteric coating layer from the omeprazole core.
[0456] Examples of controlled release formulations, tablets, dosage
forms, and drug delivery systems that are suitable for use with the
present invention are described in the following U.S. Pat. No.
patents assigned to Andrx Corporation: U.S. Pat. No. 5,397,574;
U.S. Pat. No. 5,419,917; U.S. Pat. No. 5,458,887; U.S. Pat. No.
5,458,888; U.S. Pat. No. 5,472,708; U.S. Pat. No. 5,508,040; U.S.
Pat. No. 5,558,879; U.S. Pat. No. 5,567,441; U.S. Pat. No.
5,654,005; U.S. Pat. No. 5,728,402; U.S. Pat. No. 5,736,159; U.S.
Pat. No. 5,830,503; U.S. Pat. No. 5,834,023; U.S. Pat. No.
5,837,379; U.S. Pat. No. 5,916,595; U.S. Pat. No. 5,922,352; U.S.
Pat. No. 6,099,859; U.S. Pat. No. 6,099,862; U.S. Pat. No.
6,103,263; U.S. Pat. No. 6,106,862; U.S. Pat. No. 6,156,342; U.S.
Pat. No. 6,177,102; U.S. Pat. No. 6,197,347; U.S. Pat. No.
6,210,716; U.S. Pat. No. 6,238,703; U.S. Pat. No. 6,270,805; U.S.
Pat. No. 6,284,275; U.S. Pat. No. 6,485,748; U.S. Pat. No.
6,495,162; U.S. Pat. No. 6,524,620; U.S. Pat. No. 6,544,556; U.S.
Pat. No. 6,589,553; U.S. Pat. No. 6,602,522; and U.S. Pat. No.
6,610,326.
[0457] Examples of controlled release formulations, tablets, dosage
forms, and drug delivery systems that are suitable for use with the
present invention are described in the following published US and
PCT patent applications assigned to Andrx Corporation:
US20010024659; US20020115718; US20020156066; WO0004883; WO0009091;
WO0012097; WO0027370; WO0050010; WO0132161; WO0134123; WO0236077;
WO0236100; WO02062299; WO02062824; WO02065991; WO02069888;
WO02074285; WO03000177; WO9521607; WO9629992; WO9633700; WO9640080;
WO9748386; WO9833488; WO9833489; WO9930692; WO9947125; and
WO9961005.
[0458] Some other examples of drug delivery approaches focus on
non-oral drug delivery, providing parenteral, transmucosal, and
topical delivery of proteins, peptides, and small molecules. For
example, the Atrigel.RTM. drug delivery system marketed by Atrix
Laboratories Inc. comprises biodegradable polymers, similar to
those used in biodegradable sutures, dissolved in biocompatible
carriers. These pharmaceuticals may be blended into a liquid
delivery system at the time of manufacturing or, depending upon the
product, may be added later by a physician at the time of use.
Injection of the liquid product subcutaneously or intramuscularly
through a small gauge needle, or placement into accessible tissue
sites through a cannula, causes displacement of the carrier with
water in the tissue fluids, and a subsequent precipitate to form
from the polymer into a solid film or implant. The drug
encapsulated within the implant is then released in a controlled
manner as the polymer matrix biodegrades over a period ranging from
days to months. Examples of such drug delivery systems include
Atrix's Eligard.RTM., Atridox.RTM./Doxirobe.RTM., Atrisorb.RTM.
FreeFlow.TM./Atrisorb.RTM.-D FreeFlow, bone growth products, and
others as described in the following published US and PCT patent
applications assigned to Atrix Laboratories Inc.: US RE37950; U.S.
Pat. No. 6,630,155; U.S. Pat. No. 6,566,144; U.S. Pat. No.
6,610,252; U.S. Pat. No. 6,565,874; U.S. Pat. No. 6,528,080; U.S.
Pat. No. 6,461,631; U.S. Pat. No. 6,395,293; U.S. Pat. No.
6,261,583; U.S. Pat. No. 6,143,314; U.S. Pat. No. 6,120,789; U.S.
Pat. No. 6,071,530; U.S. Pat. No. 5,990,194; U.S. Pat. No.
5,945,115; U.S. Pat. No. 5,888,533; U.S. Pat. No. 5,792,469; U.S.
Pat. No. 5,780,044; U.S. Pat. No. 5,759,563; U.S. Pat. No.
5,744,153; U.S. Pat. No. 5,739,176; U.S. Pat. No. 5,736,152; U.S.
Pat. No. 5,733,950; U.S. Pat. No. 5,702,716; U.S. Pat. No.
5,681,873; U.S. Pat. No. 5,660,849; U.S. Pat. No. 5,599,552; U.S.
Pat. No. 5,487,897; U.S. Pat. No. 5,368,859; U.S. Pat. No.
5,340,849; U.S. Pat. No. 5,324,519; U.S. Pat. No. 5,278,202; U.S.
Pat. No. 5,278,201; US20020114737, US20030195489; US20030133964;US
20010042317; US20020090398; US20020001608; and US2001042317.
[0459] Atrix Laboratories Inc. also markets technology for the
non-oral transmucosal delivery of drugs over a time period from
minutes to hours. For example, Atrix's BEMA.TM. (Bioerodible
Muco-Adhesive Disc) drug delivery system comprises pre-formed
bioerodible discs for local or systemic delivery. Examples of such
drug delivery systems include those as described in U.S. Pat. No.
6,245,345.
[0460] Other drug delivery systems marketed by Atrix Laboratories
Inc. focus on topical drug delivery. For example, SMP (Solvent
Particle System) allows the topical delivery of highly
water-insoluble drugs. This product allows for a controlled amount
of a dissolved drug to permeate the epidermal layer of the skin by
combining the dissolved drug with a microparticle suspension of the
drug. The SMP.TM. system works in stages whereby: 1) the product is
applied to the skin surface; 2) the product near follicles
concentrates at the skin pore; 3) the drug readily partitions into
skin oils; and 4) the drug diffuses throughout the area. By
contrast, MCA.RTM. (Mucocutaneous Absorption System) is a
water-resistant topical gel providing sustained drug delivery.
MCA.RTM. forms a tenacious film for either wet or dry surfaces
where: 1) the product is applied to the skin or mucosal surface; 2)
the product forms a tenacious moisture-resistant film; and 3) the
adhered film provides sustained release of drug for a period from
hours to days. Yet another product, BCP.TM. (Biocompatible Polymer
System) provides a non-cytotoxic gel or liquid that is applied as a
protective film for wound healing. Examples of these systems
include Orajel.RTM.-Ultra Mouth Sore Medicine as well as those as
described in the following published US patents and applications
assigned to Atrix Laboratories Inc.: U.S. Pat. No. 6,537,565; U.S.
Pat. No. 6,432,415; U.S. Pat. No. 6,355,657; U.S. Pat. No.
5,962,006; U.S. Pat. No. 5,725,491; U.S. Pat. No. 5,722,950; U.S.
Pat. No. 5,717,030; U.S. Pat. No. 5,707,647; U.S. Pat. No.
5,632,727; and US20010033853.
Dosage and Administration
[0461] The concentration of the active agent in any of the
aforementioned dosage forms and compositions can vary a great deal,
and will depend on a variety of factors, including the type of
composition or dosage form, the corresponding mode of
administration, the nature and activity of the specific active
agent, and the intended drug release profile. Preferred dosage
forms contain a unit dose of active agent, i.e., a single
therapeutically effective dose. For creams, ointments, etc., a
"unit dose" requires an active agent concentration that provides a
unit dose in a specified quantity of the formulation to be applied.
The unit dose of any particular active agent will depend, of
course, on the active agent and on the mode of administration. For
a sodium channel modulator, particularly a TTX-R sodium channel
modulator and/or activity-dependent sodium channel modulator, the
unit dose for oral administration will be in the range of from
about 1 mg to about 10,000 mg, typically in the range of from about
100 mg to about 5,000 mg; for local administration, suitable unit
doses may be lower. Alternatively, for a sodium channel modulator,
particularly a TTX-R sodium channel modulator and/or
activity-dependent sodium channel modulator, the unit dose for oral
administration will be greater than about 1 mg, about 5 mg, about
10 mg, about 20 mg, about 30 mg, about 40 mg, about 50 mg, about
100 mg, about 200 mg, about 300 mg, about 400 mg, about 500 mg,
about 1,000 mg, about 1,500 mg, about 2,000 mg, about 2,500 mg,
about 3,000 mg, about 3,500 mg, about 4,000 mg, about 4,500 mg,
about 5,000 mg, about 5,500 mg, about 6,000 mg, about 6,500 mg,
about 7,000 mg, about 7,500 mg, about 8,000 mg, about 8,500 mg,
about 9,000 mg, or about 9,500 mg. Those of ordinary skill in the
art of pharmaceutical formulation can readily deduce suitable unit
doses for sodium channel modulators, particularly TTX-R sodium
channel modulators and/or activity-dependent sodium channel
modulators, as well as suitable unit doses for other types of
agents that may be incorporated into a dosage form of the
invention.
[0462] For sodium channel modulators, particularly TTX-R sodium
channel modulators and/or activity-dependent sodium channel
modulators, the unit dose for transmucosal, topical, transdermal,
intravesical, and parenteral administration will be in the range of
from about 1 ng to about 10,000 mg, typically in the range of from
about 100 ng to about 5,000 mg. Alternatively, for sodium channel
modulators, particularly TTX-R sodium channel modulators and/or
activity-dependent sodium channel modulators, the unit dose for
transmucosal, topical, transdermal, intravesical, and parenteral
administration will be greater than about 1 ng, about 5 ng, about
10 ng, about 20 ng, about 30 ng, about 40 ng, about 50 ng, about
100 ng, about 200 ng, about 300 ng, about 400 ng, about 500 ng,
about 1 .mu.g, about 5 .mu.g, about 10 .mu.g, about 20 .mu.g, about
30 .mu.g, about 40 .mu.g, about 50 .mu.g, fabout 100 .mu.g, about
200 .mu.g, about 300 .mu.g, about 400 .mu.g, about 500 .mu.g, about
1 mg, about 5 mg, about 10 mg, about 20 mg, about 30 mg, about 40
mg, about 50 mg, about 100 mg, about 200 mg, about 300 mg, about
400 mg, about 500 mg, about 1,000 mg, about 1,500 mg, about 2,000
mg, about 2,500 mg, about 3,000 mg, about 3,500 mg, about 4,000 mg,
about 4,500 mg, about 5,000 mg, about 5,500 mg, about 6,000 mg,
about 6,500 mg, about 7,000 mg, about 7,500 mg, about 8,000 mg,
about 8,500 mg, about 9,000 mg, or about 9,500 mg. Those of
ordinary skill in the art of pharmaceutical formulation can readily
deduce suitable unit doses for sodium channel modulators,
particularly TTX-R sodium channel modulators and/or
activity-dependent sodium channel modulator, as well as suitable
unit doses for other types of agents that may be incorporated into
a dosage form of the invention.
[0463] For sodium channel modulators, particularly TTX-R sodium
channel modulators and/or activity-dependent sodium channel
modulators, the unit dose for intrathecal administration will be in
the range of from about 1 fg to about 1 mg, typically in the range
of from about 100 fg to about 1 ng. Alternatively, for sodium
channel modulators, particularly TTX-R sodium channel modulators
and/or activity-dependent sodium channel modulators, the unit dose
for intrathecal administration will be greater than about 1 fg,
about 5 fg, about 10 fg, about 20 fg, about 30 fg, about 40 fg,
about 50 fg, about 100 fg, about 200 fg, about 300 fg, about 400
fg, about 500 fg, about 1 pg, about 5 pg, about 10 pg, about 20 pg,
about 30 pg, about 40 pg, about 50 pg, about 100 pg, about 200 pg,
about 300 pg, about 400 pg, about 500 pg, about 1 ng, about 5 ng,
about 10 ng, about 20 ng, about 30 ng, about 40 ng, about 50 ng,
about 100 ng, about 200 ng, about 300 ng, about 400 ng, about 500
ng, about 1 .mu.g, about 5 .mu.g, about 10 .mu.g, about 20 .mu.g,
about 30 .mu.g, about 40 .mu.g, about 50 .mu.g, about 100 .mu.g,
about 200 .mu.g, about 300 .mu.g, about 400 .mu.g, or about 500
.mu.g. Those of ordinary skill in the art of pharmaceutical
formulation can readily deduce suitable unit doses for sodium
channel modulators, particularly TTX-R sodium channel modulators
and/or activity-dependent sodium channel modulators, as well as
suitable unit doses for other types of agents that may be
incorporated into a dosage form of the invention.
[0464] A therapeutically effective amount of a particular active
agent administered to a given individual will, of course, be
dependent on a number of factors, including the concentration of
the specific active agent, composition or dosage form, the selected
mode of administration, the age and general condition of the
individual being treated, the severity of the individual's
condition, and other factors known to the prescribing
physician.
[0465] In a preferred embodiment, drug administration is on an
as-needed basis, and does not involve chronic drug administration.
With an immediate release dosage form, as-needed administration may
involve drug administration immediately prior to commencement of an
activity wherein suppression of the symptoms of a GI tract disorder
except for acid peptic disorders or structural gastroesophageal
disorders would be desirable, but will generally be in the range of
from about 0 minutes to about 10 hours prior to such an activity,
preferably in the range of from about 0 minutes to about 5 hours
prior to such an activity, most preferably in the range of from
about 0 minutes to about 3 hours prior to such an activity. With a
sustained release dosage form, a single dose can provide
therapeutic efficacy over an extended time period in the range of
from about 1 hour to about 72 hours, typically in the range of from
about 8 hours to about 48 hours, depending on the formulation. That
is, the release period may be varied by the selection and relative
quantity of particular sustained release polymers. If necessary,
however, drug administration may be carried out within the context
of an ongoing dosage regimen, i.e., on a weekly basis, twice
weekly, daily, etc.
Packaged Kits
[0466] In another embodiment, a packaged kit is provided that
contains the pharmaceutical formulation to be administered, i.e., a
pharmaceutical formulation containing a therapeutically effective
amount of a selected active agent for the treatment of a GI tract
disorder except for acid peptic disorders or structural
gastroesophageal disorders, a container, preferably sealed, for
housing the formulation during storage and prior to use, and
instructions for carrying out drug administration in a manner
effective to treat a GI tract disorder except for acid peptic
disorders or structural gastroesophageal disorders. The
instructions will typically be written instructions on a package
insert and/or on a label. Depending on the type of formulation and
the intended mode of administration, the kit may also include a
device for administering the formulation. The formulation may be
any suitable formulation as described herein. For example, the
formulation may be an oral dosage form containing a unit dosage of
a selected active agent. The kit may contain multiple formulations
of different dosages of the same agent. The kit may also contain
multiple formulations of different active agents.
Insurance Claims
[0467] In general, the processing of an insurance claim for the
coverage of a given medical treatment or drug therapy involves
notification of the insurance company, or any other entity, that
has issued the insurance policy against which the claim is being
filed, that the medical treatment or drug therapy will be
performed. A determination is then made as to whether the medical
treatment or drug therapy that will be performed is covered under
the terms of the policy. If covered, the claim is then processed,
which can include payment, reimbursement, or application against a
deductable.
[0468] The present invention encompasses a method for processing an
insurance claim under an insurance policy for a sodium channel
modulator, particularly a TTX-R sodium channel modulator and/or
activity-dependent sodium channel modulator, or pharmaceutically
acceptable salts, esters, amides, prodrugs, or active metabolites
thereof used in the treatment of GI tract disorders except for acid
peptic disorders or structural gastroesophageal disorders. This
method comprises: 1) receiving notification that treatment of GI
tract disorders except for acid peptic disorders or structural
gastroesophageal disorders using said sodium channel modulator,
particularly a TTX-R sodium channel modulator and/or
activity-dependent sodium channel modulator, or pharmaceutically
acceptable salts, esters, amides, prodrugs or active metabolites
thereof will be performed or receiving notification of a
prescription for said sodium channel modulator to treat GI tract
disorders except for acid peptic disorders or structural
gastroesophageal disorders; 2) determining whether said treatment
using said sodium channel modulator, particularly a TTX-R sodium
channel modulator and/or activity-dependent sodium channel
modulator, or pharmaceutically acceptable salts, esters, amides,
prodrugs or active metabolites is covered under said insurance
policy; and 3) processing said claim for treatment using said
sodium channel modulator, particularly a TTX-R sodium channel
modulator and/or activity-dependent sodium channel modulator or
pharmaceutically acceptable salts, esters, amides, prodrugs, or
active metabolites thereof, including payment, reimbursement, or
application against a deductable.
[0469] The present invention also encompasses the method for
processing an insurance claim described above, wherein a sodium
channel modulator, particularly a TTX-R sodium channel modulator
and/or activity-dependent sodium channel modulator and a secondary
agent are used in the treatment of GI tract disorders except for
acid peptic disorders or structural gastroesophageal disorders.
Secondary agents can include an antispasmodic, a tricyclic
antidepressant, duloxetine, venlafaxine, a monoamine reuptake
inhibitor, a spasmolytic, an anticholinergic, gabapentin,
pregabalin, a substituted aminomethyl-phenyl-cyclohexane
derivative, a 5-HT.sub.3 antagonist, a 5-HT.sub.4 antagonist, a
.beta.3 adrenergic agonist, a neurokinin receptor antagonist, a
bradykinin receptor antagonist, a nitric oxide donor, or
pharmaceutically acceptable salts, esters, amides, prodrugs, or
active metabolites thereof. Futhermore, the method for processing
an insurance claim according to the present invention encompasses
wherein said sodium channel modulator, particularly a TTX-R sodium
channel modulator and/or activity-dependent sodium channel
modulator and said secondary agent, or pharmaceutically acceptable
salts, esters, amides, prodrugs, or active metabolites thereof, are
administered sequentially, concurrently in the same composition, or
concurrently in different compositions. The method for processing
an insurance claim according to the present invention also
encompasses the processing of claims for a sodium channel
modulator, particularly a TTX-R sodium channel modulator and/or
activity-dependent sodium channel modulator and one of the
secondary agents described above, or pharmaceutically acceptable
salts, esters, amides, prodrugs, or active metabolites thereof,
when either has been prescribed separately or concurrently for the
treatment of GI tract disorders except for acid peptic disorders or
structural gastroesophageal disorders.
[0470] Many modifications and other embodiments of the inventions
set forth herein will come to mind to one skilled in the art to
which these inventions pertain having the benefit of the teachings
presented in the foregoing descriptions and the associated
drawings. Therefore, it is to be understood that the inventions are
not to be limited to the specific embodiments disclosed and that
modifications and other embodiments are intended to be included
within the scope of the appended embodiments. Although specific
terms are employed herein, they are used in a generic and
descriptive sense only and not for purposes of limitation.
[0471] All patents, patent applications, and publications mentioned
herein are hereby incorporated by reference in their
entireties.
EXAMPLE
Methods for Treating Gastrointestinal Tract Disorders By
Administering Sodium Channel Modulators
[0472] The invention will be further described in the following
examples, which do not limit the scope of the invention described
in the claims. The following examples illustrate the effects of
administration of sodium channel modulators on well-accepted models
for gastrointestinal tract disorders. It is expected that these
results will demonstrate the efficacy of sodium channel modulators
for treatment of gastrointestinal tract disorders, except for acid
peptic disorders or structural gastroesophageal disorders.
Objective and Rationale
[0473] The objective of the current study was to determine the
effect of TTX-R sodium channel modulators or use dependent sodium
channel modulators on the ability to modulate sodium currents in GI
tract primary afferent neurons, a commonly used model of GI tract
disorders.
Methods
[0474] Labeline of GI tract afferent neurons: Adult female
Sprague-Dawley rats (150-300 g) were deeply anesthetized with
pentobarbital anesthesia and placed on isoflurane maintenance
anesthesia. A ventral midline incision was made through the
abdominal skin and musculature, exposing the GI tract. Five
injections of the fluorescent dyes Di-I (5 .mu.l each of 25mg/ml
Di-I in DMSO) or Fast Blue (4% w/v) were made into the wall of the
colon to label primary afferent fibers innervating the GI tract.
The areas were rinsed with sterile saline to eliminate nonspecific
spread of dye, and the incision was closed. Rats recovered for 5-12
days to allow for transport of fluorescent dye from distal
terminals to the cell somata of dorsal root ganglion (DRG) neurons.
Labeled neurons were identified in vitro using fluorescence
optics
[0475] Neuronal cultures: Fluorescent dye-injected rats were
euthanized with pentobarbital anesthesia. For GI tract neurons,
sacral (S.sub.1) DRG were dissected from the vertebral column.
Ganglia were placed separately in Dulbecco's modified Eagles medium
(DMEM) containing 0.3% collagenase B for 60 min at 37.degree. C.
The cell solution was exchanged for a 0.25% trypsin in
calcium/magnesium-free Dulbecco's phosphate-buffered saline
solution, and further digested for 30 min at 37.degree. C.
Following a wash in fresh DMEM, ganglia were dissociated by a
series of triturations using fire-polished Pasteur pipettes. DRG
cells were plated on polylysine-treated glass coverslips. Cells
were plated at a density of 0.5 ganglion per coverslip in 1 ml DMEM
supplemented with 10% FBS, NGF, and 100 U/ml
penicillin/streptomycin. All experimental procedures involving rats
were conducted under a protocol approved by an Institutional Animal
Care and Use Committee. Small variations in the concentrations of
reagents, incubation times, etc. may occur and are expected to give
similar results.
[0476] In most experiments, neurons were incubated in culture
medium containing the FITC-labeled lectin BSI-B4 (IB4, 10 mg/ml) at
37.degree. C. for 5 min before recording. The coverslip was washed
with extracellular recording solution for 1 min before being placed
in a recording chamber mounted on the stage of an inverted
microscope equipped with fluorescence optics. Neuronal images were
captured using a digital camera system.
[0477] Electrophysiology: Electrophysiologic evaluation of neurons
occured within 4-48 h of plating. Whole cell patch-clamp recordings
were obtained from fluorescent dye-labeled DRG neurons. Recordings
were obtained in an extracellular recording solution (pH 7.4,
295-320 mosM) consisting of (in mM) 140 NaCl, 3 KCl, 1 CaCl2, 1
MgCl2, 0.1 CdCl2, 10 HEPES, and 10 glucose. Patch-clamp electrodes
were pulled from borosilicate glass and fire polished to 2-6 MOhm
tip resistance. The internal pipette recording solution (pH 7.3,
290-300 mosM) consisted of (in mM) 140 CsCl, 10 NaCl, 1 EGTA, and
10 HEPES. Tetrodotoxin (TTX, 0.3uM) was included in the
extracellular solution to block TTX-sensitive sodium currents.
Variations in the concentrations and types of reagents used for
solutions may occur and are expected to give similar results.
[0478] Sodium currents were recorded from DRG neurons using
standard electrophysiologic protocols. Neurons were typically
voltage-clamped at -50 mV. Currents were recorded using a
patch-clamp amplifier and digitized at 3-10 kHz for acquisition.
Neuronal input resistance and membrane capacitance were determined
from the amplitude and kinetics of the current response to a
voltage pulse from a holding potential of -50 mV. Series resistance
was compensated 75-95% for all recordings. Leak currents were
cancelled online using a standard P/4 protocol. A series of 50 msec
voltage steps from -60 to +40 mV in 5 mV increments were delivered
every 5 sec for sodium current-voltage relationships. To study
tonic modulation of sodium currents by drugs, depolarizing test
pulses from either -50 mV or -90 mV to 0 mV were delivered every 5
sec during drug application. To study activity-dependent modulation
of sodium currents by drugs (Li et al., (1999) Molecular
Pharmacology 55:134-141), a high-frequency stimulus train (40
depolarizing pulses at 17 Hz) was delivered immediately prior to
the depolarizing test pulse. For all cell types, baseline responses
were recorded for a period of time to ensure that the response was
stable. A wash out or recovery period usually followed the drug
application period. All data acquisition and analysis was performed
using standard cell electrophysiology software. Variations in the
details of electrophysiologic protocols may occur and are expected
to give similar results.
[0479] For the condition involving Lamotrigine, cells were
constantly perfused with extracellular solution at a rate of
approximately 1 ml/min in the recording chamber. Lamotrigine was
applied through the bath to individual cells until a steady-state
drug effect was achieved.
[0480] For the condition involving Ambroxol, cells were constantly
perfused with extracellular solution at a rate of 0.5-2 ml/min in
the recording chamber and Ambroxol was applied through the bath to
individual cells. These agents were typically applied for 2-10
minutes, or until a steady-state drug effect was achieved.
Cumulative concentration-response curves were obtained from
consecutive increases in drug concentration to each cell.
[0481] All data are expressed as mean.+-.SEM.
Results and Conclusions
[0482] GI tract afferent neurons were identified as fluorescent-dye
positive neurons in in vitro DRG cultures.
[0483] FIG. 1 demonstrates the use-dependent effects of lamotrigine
(100 .mu.M) on peak activity dependent sodium currents recorded in
colon DRG neurons. Slow activation of sodium currents consisted of
step depolarizations from -50 to 0 mV delivered at a frequency of
0.2 Hz. Slow activation of sodium currents consisted of step
depolarizations from -50 to 0 mV delivered at a frequency of 0.2
Hz. Fast activation consisted of the same step depolarizations
delivered at a frequency of 17 Hz. FIG. 1A shows a typical response
to lamotrigine under both slow and fast stimulation protocols. Peak
current amplitude was decreased to a greater extent under fast
stimulation conditions, consistent with use-dependent modulation of
colon DRG sodium currents. FIG. 1B shows summary data obtained from
three neurons. Data were obtained under control conditions and
during application of 100 .mu.M lamotrigine. The mean peak sodium
current amplitude (expressed as mean % control amplitude.+-.SEM) is
decreased to a greater extent under fast stimulation conditions,
consistent with modulation of colon DRG sodium currents in a
use-dependent manner. Asterisk indicates significant difference vs
slow stimulation (P<0.05, t-test).
[0484] FIG. 2A shows a typical inward TTX-R sodium current recorded
before (control) and during (100 .mu.M) bath application of
Ambroxol. The kinetics of this and other responses recorded in
similar GI tract afferent neurons resembled the Nav1.8 subtype of
current. This is the "slow (Nav1.8)" as opposed to the "persistent
(Nav1.9)" sodium current as described in Renganathan et al. (2002)
J. Neurophysiol., 87:761-775.
[0485] FIG. 2B shows that Ambroxol produced a
concentration-dependent reversible block of TTX-R sodium currents
in four GI tract afferent neurons. The block occurred at an
estimated IC50 concentration between 10 and 100 .mu.M, consistent
with selective block of TTX-R current by Ambroxol (Weiser and
Wilson (2002) Mol. Pharmacol. 62:433-438).
[0486] This example demonstrates the efficacy of sodium channel
modulators in mammalian forms of GI tract disorders.
* * * * *
References