U.S. patent application number 11/599814 was filed with the patent office on 2007-03-15 for combinations of immunosupressive agents for the treatment or prevention of graft rejections.
Invention is credited to Paolo Brenner, Emanuele Luigi Cozzi, Peter John Friend, Francoise Richard, Hendrik J. Schuurman, Guy Taccard, John Wallwork, David James Graham White.
Application Number | 20070060511 11/599814 |
Document ID | / |
Family ID | 26315533 |
Filed Date | 2007-03-15 |
United States Patent
Application |
20070060511 |
Kind Code |
A1 |
Schuurman; Hendrik J. ; et
al. |
March 15, 2007 |
Combinations of immunosupressive agents for the treatment or
prevention of graft rejections
Abstract
A pharmaceutical composition useful in the treatment or
prevention of transgenic xenograft rejection comprising
immunosuppressant compounds selected from the group consisting of
an IL-2 transcription inhibitor and immunosuppressant compounds
that immunosuppress for B-cell-mediated or antibody-mediated
rejection of xenografts, and pharmaceutically acceptable diluents
or carriers, and a method of preventing hyperacute rejection,
reducing early graft damage, improving early xenograft function and
promoting long term survival of said transgenic xenografts
comprising the steps of i) contacting the body fluid removed from a
human recipient with a xenoantigenic material which is bound to a
biocompatible solid support, ii) reintroducing the treated body
fluid into the recipient, and iii) treating the recipient with said
pharmaceutical composition.
Inventors: |
Schuurman; Hendrik J.;
(Charlestown, MA) ; Cozzi; Emanuele Luigi;
(Padova, IT) ; Richard; Francoise; (St. Louis,
FR) ; Taccard; Guy; (Hegenheim, FR) ; White;
David James Graham; (Harston, GB) ; Friend; Peter
John; (Oxford, GB) ; Wallwork; John;
(Cambridge, GB) ; Brenner; Paolo; (Munich,
DE) |
Correspondence
Address: |
NOVARTIS;CORPORATE INTELLECTUAL PROPERTY
ONE HEALTH PLAZA 104/3
EAST HANOVER
NJ
07936-1080
US
|
Family ID: |
26315533 |
Appl. No.: |
11/599814 |
Filed: |
November 15, 2006 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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11178573 |
Jul 11, 2005 |
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11599814 |
Nov 15, 2006 |
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10035663 |
Nov 7, 2001 |
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11178573 |
Jul 11, 2005 |
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PCT/EP00/04250 |
May 10, 2000 |
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10035663 |
Nov 7, 2001 |
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Current U.S.
Class: |
424/133.1 ;
424/468; 514/20.5; 514/291; 514/469 |
Current CPC
Class: |
A61K 31/4745 20130101;
A61K 31/00 20130101; A61K 31/365 20130101; A61P 37/06 20180101;
A61K 38/13 20130101; A61K 31/00 20130101; A61K 31/4745 20130101;
A61P 43/00 20180101; A61K 2300/00 20130101; A61K 2300/00 20130101;
A61K 2300/00 20130101; A61K 2300/00 20130101; A61K 38/13 20130101;
A61K 31/365 20130101 |
Class at
Publication: |
514/011 ;
514/291; 514/469; 424/468 |
International
Class: |
A61K 38/13 20060101
A61K038/13; A61K 31/4745 20060101 A61K031/4745; A61K 31/365
20060101 A61K031/365; A61K 9/22 20060101 A61K009/22 |
Foreign Application Data
Date |
Code |
Application Number |
May 10, 1999 |
GB |
9910835.9 |
Oct 27, 1999 |
GB |
9925443.5 |
Claims
1. A pharmaceutical composition useful in the treatment or
prevention of xenograft rejection comprising (a) cyclosporin; (b)
an immunosuppressant compound selected from the group consisting of
mycophenolic acid, a pharmaceutically acceptable salt of
mycophenolic acid, and combinations thereof; and (c) rapamycin
and/or derivatives thereof.
2. A pharmaceutical composition comprising (a) cyclosporin; (b) an
immunosuppressant compound selected from the group consisting of
mycophenolic acid, a pharmaceutically acceptable salt of
mycophenolic acid, and combinations thereof; and (c) rapamycin
and/or derivatives thereof as a combined preparation for
simultaneous, separate or sequential use in the treatment or
prevention of xenograft rejection.
3. A kit of parts comprising a pharmaceutical composition according
to claim 1 together with instructions for use in the treatment or
prevention of xenograft rejection.
4. Use of a pharmaceutical composition according to claim 1 or 2 in
the manufacture of a medicament for the treatment or prevention of
xenograft rejection.
5. A pharmaceutical composition according to claim 1 or 2 wherein
the pharmaceutically acceptable salt of mycophenolic acid is MPA
sodium salt formulated as an enteric-coated solid oral dosage
form.
6. A method for the treatment or prevention of xenograft rejection
comprising administering a pharmaceutical composition according to
claim 1 or 2.
7. A method for reducing early graft damage, improving early
xenograft function or promoting long term survival of xenografts of
transgenic organ in human recipients comprising: (i) exposing body
fluid removed from a human with a xenoantigenic material or
anti-human mono- or polyclonal antibodies or another antibody
adsorbent, which is bound to a biocompatible solid support; (ii)
reintroducing the treated body fluid into the human, and (iii)
treating the human with a composition comprising at least two
immunosuppressant compounds selected from the group consisting of
(a) IL-2 transcription inhibitors and (b) immunosuppressant
compounds that immunosuppress for B-cell-mediated or
antibody-mediated rejection of xenografts.
8. A method for reducing early graft damage, improving early
xenograft function or promoting long term survival of xenografts of
an organ transgenic for hDAF in human recipients comprising: (i)
exposing body fluid removed from a human with a xenoantigenic
material or anti-human mono- or polyclonal antibodies or another
antibody adsorbent, which is bound to a biocompatible solid
support; (ii) reintroducing the treated body fluid into the human,
and (iii) treating the human with a composition comprising at least
two immunosuppressant compounds selected from the group consisting
of (a) IL-2 transcription inhibitors and (b) immunosuppressant
compounds that immunosuppress for B-cell-mediated or
antibody-mediated rejection of xenografts.
9. The method according to claim 7 wherein the steps (i) and (ii)
are conducted postoperatively and in parallel with treatment with
the composition.
Description
[0001] This is a continuation of International Application No.
PCT/EP00/04250, filed May 10, 2000, the contents of which are
incorporated herein by reference.
[0002] This invention is concerned with certain novel
pharmaceutical compositions comprising combinations of
immunosuppressive agents, the use of such compositions for the
treatment or prevention of xenograft rejection, and novel therapies
for facilitating transplantation of xenogenic tissues or organs
into humans and to promote long term survival of said tissues or
organs.
[0003] In order for xenotransplantation to present a clinically
viable treatment for organ disease, it is necessary to effectively
treat or prevent acute rejection and chronic rejection of donor
organs. Effective treatments need to inhibit T-cells, and also
B-cell-mediated or antibody-mediated rejection.
[0004] However, a problem associated with combining compounds that
suppress T-cells as well as compounds that act against
B-cell-mediated rejection or antibody-mediated rejection is the
potential and unpredictable pharmacokinetic interaction of the
compounds which may influence the toxicity or the immunosuppression
of the combination.
[0005] Surprisingly, the applicant has found that pharmaceutical
compositions comprising a certain combination of immunosuppressant
compounds display good tolerability whilst at the same time display
prolonged xenograft survival of donor organs, few rejection
episodes and good graft function.
[0006] The invention provides in one aspect a method of treatment
or prevention of xenograft rejection which comprises administering
of at least two immunosuppressant compounds indepentally selected
from the group consisting of (a) IL-2 transcription inhibitors and
(b) immunosuppressant compounds that immunosuppress for
B-cell-mediated or antibody-mediated rejection of xenografts.
[0007] Pharmaceutical compositions useful in the treatment or
prevention of xenograft rejection comprise at least two
immunosuppressant compounds selected from the group consisting of
(a) IL-2 transcription inhibitors and (b) immunosuppressant
compounds that immuno-suppress for B-cell-mediated or
antibody-mediated rejection of xenografts.
[0008] Therefore, the invention provides in another aspect a
pharmaceutical composition useful in the prevention or treatment of
xenograft rejection comprising combinations of immuno-suppressant
compounds selected from the group consisting of (a) IL-2
transcription inhibitors and (b) immunosuppressant compounds that
immunosuppress for B-cell-mediated or antibody-mediated rejection
of xenografts.
[0009] In another aspect, the group of immunosuppressant compounds
consists of (a) an IL-2 transcription inhibitor and (b)
immunosuppressant compounds that immunosuppress for B-cell-mediated
or antibody-mediated rejection of xenografts.
[0010] As used herein, including the claims, the combinations of
immunosuppressant agents cover the administration of the agents for
simultaneous, separate or sequential use. Thus e.g. they may be in
a package or in a blister.
[0011] The term "IL-2 transcription inhibitor" refers to
immunosuppressive compounds whose immunosuppressive activity
derives principally or in significant part from their direct or
indirect inhibition of IL-2 gene transcription, e.g.
corticosteroids, ascomycins and cyclosporines, FK506 and their
various derivatives and analogues.
[0012] Cyclosporine, (also known as cyclosporin A or cyclosporin)
is an immunosuppressive cyclic undecapeptide. Its structure is
disclosed, e.g. in the Merck Index, 11th edition; Merck & Co.
Inc., Rahway, N.J., USA (1989) under listing 2759. Formulations of
cyclosporine are commercially available under the trademark
SANDIMMUN or SANDIMMUNE and a microemulsion preconcentrate
formulation of cyclosporine is sold under the trademark NEORAL or
OPTORAL.
[0013] Immunosuppressant compounds that immunosuppress for
B-cell-mediated or antibody-mediated rejection of xenografts
include rapamycin and/or derivatives thereof including
40-O-(2-hydroxyethyl)-rapamycin, or myriocin analogues such as
2-amino-2-[2-(4-octylphenyl)-ethyl]-1,3-propanediol, or
mycophenolic acid (MPA) or pharmaceutically acceptable salts
thereof, or cyclophosphamide.
[0014] A preferred rapamycin derivative is
40-O-(2-hydroxyethyl)-rapamycin. 40-O-(2-hydroxyethyl)-rapamycin is
a rapamycin derivative the structure of which is disclosed in WO
94/09010, example 8, and is a semi-synthetic derivative of
rapamycin. The structure of rapamycin is given in Kesseler, H., et
al.; 1993; Helv. Chim. Acta; 76; 117, and numerous
immunosuppressive derivatives and analogues of rapamycin are
known.
[0015] MPA sodium salt is known and is disclosed in published
patent application No. WO 97/38689. Even more preferred is a MPA
sodium salt in form of a formulation as described in U.S. Pat. No.
6,025,391 which is incorporated herein by reference.
[0016] More preferred pharmaceutical compositions according to the
invention comprise combinations of a pharmaceutically acceptable
salt of mycophenolic acid (MPA), for example the sodium salt of
MPA, rapamycin and/or derivatives thereof including
40-O-(2-hydroxy-ethyl)-rapamycin, and IL-2 transcription
inhibitors.
[0017] Most preferred pharmaceutical compositions according to the
invention comprise double combinations of MPA sodium salt and
cyclosporine or 40-O-(2-hydroxyethyl)-rapamycin, the double
combination of cyclosporine and 40-O-(2-hydroxyethyl)-rapamycin, or
a triple combination of MPA sodium salt, cyclosporine and
40-O-(2-hydroxyethyl)-rapamycin.
[0018] Pharmaceutical compositions according to the invention act
synergistically, i.e. the immuno-suppressive effect of the
combination of compounds is greater than additive. This has the
advantage that relatively low doses of each compound may be used in
the pharmaceutical compositions. Synergy may be calculated
according to a method described in Berenbaum, Clin. Exp. Immunol.
(1977) 28:1.
[0019] The indications for which the pharmaceutical compositions
are useful are conditions associated with, or causal to, transplant
rejection, for example treatment (including amelioration,
reduction, elimination or cure of etiology or symptoms) or
prevention (including substantial or complete restriction,
prophylaxis or avoidance) of xenograft rejection, including acute
and chronic rejection of an organ when the organ donor is of a
different species from the recipient, most especially rejection
mediated by B-cells or antibody-mediated rejection.
[0020] Preferably, in one group of embodiments there is no IL-2
transcription inhibitor present. In another group of embodiments,
one IL-2 transcription inhibitor is present, and yet in another
group of embodiments, two or more IL-2 transcription inhibitors are
present.
[0021] More particularly the method comprises the administration of
a pharmaceutical composition comprising a combination of a
pharmaceutically acceptable salt of MPA, for example the sodium
salt of MPA, rapamycin and/or derivatives thereof including
40-O-(2-hydroxyethyl)-rapamycin, and IL-2 transcription
inhibitors.
[0022] Preferably the method comprises the administration of a
pharmaceutical composition comprising a combination of MPA sodium
salt and one or more immunosuppressant compounds selected from the
group consisting of (a) an IL-2 transcription inhibitor, especially
cyclosporine, and (b) rapamycin and/or derivatives thereof,
especially 40-O-(2-hydroxyethyl)-rapamycin.
[0023] In a further aspect of the invention there is provided the
use of a pharmaceutical composition comprising compounds selected
from the group consisting of (a) an IL-2 transcription inhibitor
and (b) immunosuppressant compounds that immunosuppress for
B-cell-mediated or antibody-mediated rejection of xenografts, in
the treatment of a condition as hereinabove described.
[0024] More particularly the invention provides the use of a
pharmaceutical composition comprising a combination of a
pharmaceutically acceptable salt of MPA, for example the sodium
salt of MPA, rapamycin and/or derivatives thereof including
40-O-(2-hydroxyethyl)-rapamycin, and IL-2 transcription inhibitors,
in the treatment of a condition as hereinabove described.
[0025] Preferably the invention provides the use of pharmaceutical
compositions comprising combinations of MPA sodium salt and one or
more immunosuppressant compounds selected from the group consisting
of (a) an IL-2 transcription inhibitor, especially cyclo-sporine,
and (b) rapamycin and/or derivatives thereof, especially
40-O-(2-hydroxyethyl)-rapamycin, in the treatment of a condition as
hereinabove described.
[0026] In yet another aspect of the invention there is provided a
kit-of-parts comprising any of the pharmaceutical compositions
hereinabove described, especially a pharmaceutical composition
comprising MPA sodium salt and one or more immunosuppressant
compounds selected from the group consisting of (a) an IL-2
transcription inhibitor, especially cyclosporine, and (b) rapamycin
and/or derivatives thereof, especially
40-O-(2-hydroxyethyl)-rapamycin, together with instructions for use
in the treatment or prevention of a condition as hereinabove
described.
[0027] The dosages of the compounds will vary depending on the
individual to be treated, the route of administration and the
nature and severity of the condition to be treated. For example, in
the prevention or treatment of xenograft rejection, an initial dose
of about 2 to 3 times the maintenance dose may suitably be
administered about 4 to 12 hours before transplantation, followed
by a daily dosage of 2 to 3 times the maintenance dosage for one to
two weeks, before gradually tapering down the dose at a rate of
about 5% per week to reach the maintenance dose.
[0028] The exact dosage of each compound may be determined having
regard to the particular therapeutic blood levels required for each
compound. Thus, through judicious selection of the dosage of each
compound, surprisingly it has been found that pharmaceutical
compositions may be formed that are tolerated and which display
synergistic action in immune suppression.
[0029] Accordingly, in another aspect of the invention there is
provided a pharmaceutical composition comprising (a) an IL-2
transcription inhibitor, in particular cyclosporine, that may be
delivered to a patient at a dosage such that the 16 hour blood
trough level is e.g. up to 1500 ng per ml, e.g. 50 to 1500, e.g. 50
to 1000 ng per ml, e.g. up to 500 ng per ml, , e.g. 50 to 500 ng
per ml, more particularly 100 to 500 ng per ml, e.g. 300 to 500 ng
per ml, and (b) an immunosuppressant compound that immunosuppresses
for B-cell-mediated or antibody-mediated rejection of xenografts
that may be delivered to a patient at a dosage such that the 16
hour blood trough level is e.g. 0.1 to 20, e.g. 0.1 to 10, e.g. 1
to 10, preferably 3 to 6 .mu.g per ml of the active substance, or
is e.g. 1 to 90, e.g. 5 to 50, e.g. 10 to 35 ng per ml, more
particularly 10 to 20 ng per ml.
[0030] In particularly preferred pharmaceutical compositions, a
pharmaceutically acceptable salt of MPA, for example the sodium
salt of MPA, may be delivered to a patient at a dosage such that
the 16 hour blood trough level is e.g. 0.1 to 20, e.g. 0.1 to 10,
e.g. 1 to 10, preferably 3 to 6 .mu.g per ml of MPA. IL-2
transcription inhibitors, e.g. cyclosporine may be delivered to a
patient at a dosage such that the 16 hour blood trough level of,
e.g. cyclosporine is e.g. up to 1500 ng per ml, e.g. 50 to 1500,
e.g. 50 to 1000 ng per ml, e.g. up to 500 ng per ml, for example 50
to 500 ng per ml, more particularly 100 to 500 ng per ml, e.g. 300
to 500 ng per ml. Rapamycin and/or derivatives thereof, e.g.
40-O-(2-hydroxyethyl)-rapamycin may be delivered to a patient at a
dosage such that the 16 hour blood trough level of, e.g.
40-O-(2-hydroxyethyl)-rapamycin is e.g. 1 to 90, e.g. 5 to 50, e.g.
10 to 35 ng per ml, more particularly 10 to 20 ng per ml.
[0031] The blood concentrations hereinabove described may be
determined according to any convenient method known in the art. For
example, blood may be collected in EDTA-coated containers, and
detection of blood levels may be carried out by, e.g.
radioimmunoassay or by ELISA. Detection of MPA is suitably carried
out after protein precipitation using acetonitrile using an HPLC
method with UV detection at 305 nm. From the data collected in this
way, the blood trough levels may be calculated by methods known in
the art.
[0032] Having regard to the blood trough levels stated hereinabove,
the skilled person may determine those dosages that provide a
therapeutic amount of compound at a level that is tolerated and
which exhibits synergistic action in immune suppression.
[0033] The weight ratio of component compounds of the
pharmaceutical compositions may vary having regard to the desired
blood trough levels stated hereinabove.
[0034] Pharmaceutical compositions may comprise combinations of (a)
an IL-2 transcription inhibitor and (b) an immunosuppressant
compound or compounds that immunosuppress for B-cell-mediated or
antibody-mediated rejection of xenografts in a weight ratio of e.g.
about 1:50 to 1000:1, e.g. about 1:50 to 500:1, e.g. about 1:50 to
200:1, more particularly 1:2 to 50:1, e.g. 10:1. When more than one
compound that immunosuppresses for B-cell-mediated or
antibody-mediated rejection of xenografts is employed, for example
in the case of a triple combination, the combined weight of said
immunosuppressant compounds is reflected in the aforementioned
weight ratio.
[0035] In a preferred embodiment a pharmaceutical composition
comprises MPA sodium salt and cyclosporine in a weight ratio of
e.g. about 1:0.03 to about 1:2, e.g. about 1:0.03 to about
1:0.5.
[0036] In another preferred embodiment a pharmaceutical composition
comprises MPA sodium salt and 40-O-(2-hydroxyethyl)-rapamycin in a
weight ratio of about 1:0.0005 to 0.015, to 1:0.001 to 0.0075, in
particular, 1:0.0025.
[0037] In a particularly preferred pharmaceutical composition
comprising the double combination of MPA sodium salt and
cyclosporine, MPA sodium salt may be applied at a dosage of e.g. 10
to 200, e.g. 10 to 100 mg/kg/day, preferably 20 to 60 mg/kg/day, in
particular 40 to 60 mg/kg/day; whereas cyclosporine may be applied
at a dosage of e.g. 10 to 100, e.g. 10 to 50 mg/kg/day, preferably
10 to 15 mg/kg/day, in particular 3 to 6 mg/kg/day. Most preferably
MPA sodium salt may be applied at a dosage of 20 mg/kg/day and
cyclosporine may be applied at a dosage of 10 mg/kg/day.
[0038] In another particularly preferred pharmaceutical composition
comprising a double combination of MPA sodium salt and
40-O-(2-hydroxyethyl)-rapamycin, MPA may be applied at dosages
referred to in the preceding paragraph, whereas 40-O-(2-
hydroxyethyl)-rapamycin may be applied at a dosage of from 0.05 to
1.5 mg/kg/day, e.g. 0.1 to 0.75 mg/kg/day, e.g. 0.25 to 0.5
mg/kg/day. Most preferably MPA sodium salt may be applied at a
dosage of 20 mg/kg/day and 40-O-(2-hydroxyethyl)-rapamycin may be
applied at a dosage of 1.5 mg/kg/day.
[0039] In yet another particularly preferred pharmaceutical
composition comprising a double combination of cyclosporine and
40-O-(2-hydroxyethyl)-rapamycin, cyclosporine may be applied at a
dosage of e.g. 10 to 100, e.g. 10 to 50 mg/kg/day, preferably 10 to
15 mg/kg/day, in particular 3 to 6 mg/kg/day; whereas
40-O-(2-hydroxyethyl)-rapamycin may be applied at a dosage of 0.05
to 1.5 mg/kg/day, e.g. 0.1 to 0.75 mg/kg/day, e.g. 0.25 to 0.5
mg/kg/day.
[0040] In yet another particularly preferred pharmaceutical
composition comprising the triple combination aforementioned, MPA
sodium salt may be applied at a dosage of e.g. 10 to 200, e.g. 10
to 100 mg/kg/day, preferably 20 to 60 mg/kg/day, in particular 40
to 60 mg/kg/day; cyclosporine may be applied at a dosage of e.g. 10
to 100, e.g. 10 to 50 mg/kg/day, preferably 10 to 15 mg/kg/day, in
particular 3 to 6 mg/kg/day. 40-O-(2-hydroxyethyl)-rapamycin may be
applied at a dosage of from 0.05 to 1.5 mg/kg/day, e.g. 0.1 to 0.75
mg/kg/day, e.g. 0.25 to 0.5 mg/kg/day. Most preferably MPA sodium
salt may be applied at a dosage of 20 mg/kg/day, and
40-O-(2-hydroxyethyl)-rapamycin may be applied at a dosage of 1.5
mg/kg/day. Cyclosporine may be applied at a dosage of 10
mg/kg/day.
[0041] The dosages referred to hereinabove may be administered to a
patient in any convenient way, for example individual dosages
referred to hereinabove may be administered daily in 2 divided
doses. Any regimen may be used, provided that therapeutic amounts
of the individual compounds are delivered to the patient.
[0042] In larger mammals, for example humans, an indicated daily
dosage for MPA sodium salt is in the range of 0.5 to 2.0 g/day,
e.g. about 1.5 g/day, cyclosporine is in the range of from about 25
mg to about 1000 mg per day, preferably 50 mg to 500 mg per day,
and 40-O-(2-hydroxyethyl)-rapamycin is in the range from about 0.25
mg to about 15 mg per day.
[0043] The application of the pharmaceutical composition may be
preceded by the administration of a suitable induction therapy,
chosen from any suitable induction therapy known in the art, for
example a short course of cyclophosphamide, e.g. up to 40 mg/kg,
e.g. 20 to 40 mg/kg i.v. per day for 4 days. Furthermore, a
tapering course of steroids, e.g. methylprednisolone at a
concentration of 1 mg/kg at day one tapering to a baseline of 0.2
mg/kg/day may be administered.
[0044] The compounds hereinabove described may be used in
pharmaceutical compositions according to the invention in free or
fixed combination, preferably in free combination. By `free` is
meant that each compound is formulated separately in a discrete
dosage form. By `fixed` is meant that the compounds are formulated
together in one carrier. As a further embodiment, the
pharmaceutical compositions may be both free and fixed whereby two
or more compounds may be formulated in a single carrier whereas a
further compound of the pharmaceutical composition may be
formulated as a discrete dosage form.
[0045] Where one or more of the compounds are formulated
separately, the individual dosage forms may be taken together or
substantially at the same time (e.g. within fifteen minutes or
less) so that, in the case of oral administration for example, said
compounds are present simultaneously in the stomach.
[0046] The pharmaceutical composition according to the invention
may be formulated in any convenient dosage form, the component
compounds being either in a single carrier or formulated as
discrete dosage forms as in a free combination, for example oral
dosage forms, e.g. solid oral dosage forms or solutions or
dispersions, or in forms suitable for intravenous
administration.
[0047] Pharmaceutical compositions for oral administration of, e.g.
cyclosporine and/or 40-O-(2-hydroxyethyl)-rapamycin, are suitably
emulsions, microemulsions, preconcentrates of either, or solid
dispersions, especially water-in-oil microemulsion preconcentrates
or oil-in-water microemulsions.
[0048] Cyclosporine may be formulated in any of the ways known in
the art, in particular the known microemulsion preconcentrate
formulations of cyclosporine are particularly suitable for use in
the present invention.
[0049] 40-O-(2-hydroxyethyl)-rapamycin may be formulated in any of
the ways known in the art, for example as a microemulsion (see WO
96/13273), as a fat emulsion for use in intravenous administration
(see WO 97/25977), as a suspension (see WO 96/13239) or as a solid
oral dosage form, for example, as a co-precipitate with a suitable
carrier medium (a so-called solid dispersion) as more fully
described in WO 97/03654 all of which documents are incorporated
herein by reference.
[0050] MPA sodium salt may be formulated in any of the ways
described in WO 97/38689 which is incorporated herein by reference,
in particular as a solid oral dosage form, e.g. an enteric-coated
tablet.
[0051] Pharmaceutical compositions according to the invention are
useful as therapies in the treatment or prevention of xenograft
rejection, including acute or chronic rejection of an organ from a
discordant species, e.g. heart, lung, combined heart-lung, liver,
kidney, islet cells, most especially when the rejection is mediated
by B-cells or antibodies.
[0052] Whereas the pharmaceutical compositions are useful in the
treatments as set forth in the preceding paragraph, nevertheless a
significant obstacle in the successful treatment of patients with
the afore-mentioned pharmaceutical compositions is the prevention
or amelioration of hyperacute rejection.
[0053] Hyperacute rejection is the first immunological barrier to
the transplantation of a donor organ from discordant species into
humans. It occurs when the recipient's own immune system attacks
and destroys the transplanted organ, usually within minutes or
within a number of hours. Hyperacute rejection occurs in a
xenograft because humans have pre-formed xenoreactive antibodies
which bind to the animal tissue,activating the human complement
cascade and leading to graft damage. Accordingly, organ transplants
from animal species, such as a pig, into humans may not be viable
unless treatments are available that prevent hyperacute
rejection.
[0054] Means for ameliorating hyperacute rejection are known in the
art. For example, organs from pigs transgenic for human
decay-accelerating factor (hDAF) may not be hyperacutely rejected
upon transplantation into non-human primates. Similarly,
extracorporeal removal of xenoantibodies from a recipient's blood
is also known in the treatment of hyperacute rejection, see for
example U.S. Pat. No. 5,817,528 or U.S. Pat. No. 5,651,968.
[0055] However, whereas hyperacute rejection may be prevented in
this manner, antibodies may nevertheless trigger damage to the
donor organ and thereby compromise the organ leading to poor early
graft function or premature organ failure notwithstanding the
administration of immunosuppressive therapies.
[0056] The applicant has now found that long term survival of a
transgenic donor organ may be enhanced if a recipient receives
treatment to remove xenoantibodies extracorporeally as well as
receiving appropriate immunosuppressive drug therapy.
[0057] Accordingly, the invention provides in another aspect a
method of treating a patient in need of such therapy comprising i)
exposing the body fluid removed from a human recipient with a
xenoantigenic material or anti human mono- or polyclonal antibodies
or an other antibody adsorbent, which is bound to a biocompatible
solid support, ii) reintroducing the treated body fluid into the
recipient, and iii) treating the recipient with immunosuppressive
drug therapy comprising a combination of immunosuppressant
compounds selected from the group consisting of (a) IL-2
transcription inhibitor and (b) immunosuppressant compounds that
immunosuppress for B-cell-mediated or antibody-mediated rejection
of xenografts.
[0058] In another aspect, the group of immunosuppressant compounds
consists of (a) an IL-2 transcription inhibitor and (b)
immunosuppressant compounds that immunosuppress for B-cell-mediated
or antibody-mediated rejection of xenografts.
[0059] Methods and materials for carrying out the steps i) and ii)
referred to above are known in the art and suitable examples are
described in U.S. Pat. No. 5,817,528 or U.S. Pat. No. 5,651,968, or
published international application PCT EP98/02227 each of which
are incorporated herein by reference.
[0060] In a particularly preferred aspect of the invention, the
step i) may be carried out using an Ig-Therasorb.RTM. column
thereby selectively immunoadsorbing IgM, IgG and IgA.
[0061] The step i) is usually carried out pre-operatively. However,
alternatively or additionally it may be used perioperatively or
post-operatively in parallel with the immunosuppressive drug
therapy. Such post-operative use may be used if during treatment a
build up of xenospecific antibodies is detected. Judicious use of
the step i) and ii) pre-operatively, perioperatively and/or
post-operatively in parallel with the immunosuppressive drug
therapy may contribute significantly to the long term survival of
donor organs.
[0062] In addition to the improvement of the early graft function,
effective treatments need to inhibit T-cells and also
B-cell-mediated or antibody-mediated rejection. Accordingly,
preferred immunosuppressive drug therapies for use in step iii)
comprise any of the pharmaceutical compositions, dosages and other
aspects as hereinabove described.
[0063] There now follows a series of examples which are
illustrative of the invention.
EXAMPLE 1
Organ Xenograft Studies: Porcine Kidney to Cynomolgus Monkey
[0064] Cynomolgus monkeys undergo heterotopic renal transplants
using porcine kidneys transgenic for hDAF.
[0065] Immunosuppression consists of induction therapy consisting
of cyclophosphamide, Neoral.RTM. and a tapering course of steroids
followed by maintenance therapy with a free combination of
cyclosporine and MPA sodium salt as set forth in Table 1.
[0066] Induction therapy consists of four non-consecutive daily
intravenous injections of cyclo-phosphamide (40 mg/kg), Neoral.RTM.
and methylprednisolone low dose treatment (1 mg/kg) day one and
thereafter reducing the dose each day by 0.05 mg/kg, and
subsequently to a baseline dose of 0.02 mg/kg/day as part of the
maintenance therapy.
[0067] Maintenance therapy, subsequent to the induction therapy,
consists of cyclosporine. (Neoral.RTM.) and MPA sodium salt (MPA Na
in Table 1) in the form of a powder in a 1% methylcellulose
(Courtauld's Chemicals) solution.
[0068] Dosing occurs twice daily at 8 am and 4 pm and the doses set
forth in Table 1 are equally divided for that purpose. Dosing is
carried out by gastric gavage under slight ketamine anaesthesia (10
mg/kg) in a volume of 2 ml/kg of body weight followed by flushing
with at least 10 ml/kg physiological saline. TABLE-US-00001 TABLE 1
Tolerability of a combination of MPA Sodium and Cyclosporine in
Cynomolgus Monkeys. (Dosages in mg/kg). MPA Na Cyclosporine.sup.2
Outcome 50 bid 25 bid Tolerated 100 bid 25 bid Tolerated 40 +
60.sup.1 30 bid Tolerated .sup.1First dose at 7 am, second at 3 pm
.sup.2Neoral .RTM. bid = Twice per day
[0069] Significant prolongation of the xenografts treated with the
foregoing combinations were observed compared with monotherapy of
the individual compounds of the combinations.
EXAMPLE 2
Organ Xenograft Studies: Hamster-to-Rat
[0070] Donor male Chinese hamsters are obtained from Tongji Medical
University.
[0071] Recipient male SD rats are obtained from Tongji Medical
University.
[0072] Maintenance therapy consists of MPA sodium in the form of a
powder in a 1% methylcellulose (Courtauld's Chemicals) solution,
cyclosporine (Neoral.RTM.), and/or 40-O-(2-hydroxyethyl)-rapamycin
in the form of a solid dispersion at 9.09% by weight, together with
HPMC (81.82% by weight) and lactose (9.09% by weight).
[0073] All compounds are freshly prepared before administration and
dissolved in distilled water. The compounds are administered daily
per oral by gavage (<2 ml/kg body weight).
[0074] Anaesthesia is carried out using Hypnorm and Hypnovel i.v.
anaesthesia. TABLE-US-00002 TABLE 2 Table 2 illustrates significant
prolongation of xenografts using compositions according to the
invention. Treatment Schedule (mg/kg/day) Graft survival (days) n
MPA Sodium salt (20) 5, 5, 6, 6, 6, 14 6 Cyclosporine A (10) MPA
Sodium salt (20) 6, 7, 7, 11, 16, 17 6
40-O-(2-hydroxyethyl)-rapamycin (1.5) MPA Sodium salt (20) 6, 7,
10, 10, 12 5 40-O-(2-hydroxyethyl)-rapamycin (1.5) Cyclosporine A
(10) n: number of patients
EXAMPLE 3
Use of Immunoadsorntion in Heterotopic Xenotransplantation of hDAF
Pig Hearts to Baboons
[0075] Baboons undergo heterotopic heart transplants using porcine
hearts transgenic for hDAF.
[0076] Materials for Immunosuppression are:-
[0077] Cyclosporin A (CyA): (Sandimmun.RTM.) given via
intramuscular injection at a concentration of 100 mg/ml; and
Optoral.RTM. given by oral gavage at 100 mg/ml.
[0078] Cyclophosphamide (CyP): Endoxan.RTM. for injection at 200
mg/ml
[0079] Mycophenolate sodium: In a form describe in Example 2
above.
[0080] Methylprednisolon (MPS): Urbason.RTM. in a 40 mg vial.
[0081] Prednisolon (PDN): Prednesol.RTM. as a 5 mg tablet.
[0082] Post-operative anesthesia is carried out using buprenorphine
hydrochloride. Nausea and vomiting are treated using
metoclopramide.
[0083] Animals are dosed twice a day with a 12 hour interval.
Animals receive the following regimen: CyA is applied initially as
i.m. injection at a dose of 25 mg/kg/day after surgery. On the
first post-operative day 20 mg/kg is applied i.m. In the afternoon
Optoral is given by oral gavage at a dose of 100 mg/kg. Thereafter
doses are modified according to CyA trough levels aiming at
>1500 ng/ml.
[0084] CyP is given i.v. on the day before surgery at 40 mg/kg, on
the day of surgery at 20 mg/kg and on the second post-operative day
at 20-30 mg/kg. An additional dose may be given up to 20 mg/kg on
day 4. The last dose may be modified according to WBC and platelet
count. Thereafter, CyP is administered only for rejection
treatment.
[0085] Mycophenolic acid sodium is given orally twice a day to
ensure trough levels of 3-6 .mu.g/ml.
[0086] MPS is given at the time of surgery at a dose of 1 mg/kg
i.v. On the following two days the same dose will be applied orally
and thereafter the dose is reduced to 0.05 mg/kg/day until a
baseline of 0.2 mg/kg is reached.
[0087] Body weight of the animals is taken during morning dosing .
Food is provided one hour after morning dosing and water is freely
available.
[0088] For Xenotransplantation of transgenic organs
immunoadsorption is carried out pre-operatively using an
Ig-Therasorb.RTM. column. According to the xenoreactive natural
antibody titre, between 6 and 14 cycles are carried out withdrawing
blood from a central venous catheter.
[0089] The treatment was well tolerated and the xenografts
exhibited good long term survival.
* * * * *