U.S. patent application number 12/486971 was filed with the patent office on 2010-09-16 for systemic administration of nac for vaccination prophylaxis.
Invention is credited to F. Timothy Guilford, Brooke Schumm, III.
Application Number | 20100233193 12/486971 |
Document ID | / |
Family ID | 31192030 |
Filed Date | 2010-09-16 |
United States Patent
Application |
20100233193 |
Kind Code |
A1 |
Guilford; F. Timothy ; et
al. |
September 16, 2010 |
SYSTEMIC ADMINISTRATION OF NAC FOR VACCINATION PROPHYLAXIS
Abstract
The invention is for the combination and related methods of
N-acetyl-cysteine oral, inhaled, or intravenous, or glutathione
inhaled or intravenous, generally in combination with antibiotic
and /or antiviral therapy to ameliorate the toxic effects of
infection with materials used in Bioterror incidents such as
Bacillus anthracis and smallpox virus, and alternatively, upon
exposure to radiation, during testing, and vaccination, as
treatment prior to treatment with antibiotic or antiviral therapy
to ameliorate the toxic effects of infection and exposure with
these organisms.
Inventors: |
Guilford; F. Timothy; (Palo
Alto, CA) ; Schumm, III; Brooke; (Ellicott City,
MD) |
Correspondence
Address: |
BROOKE SCHUMM III;Daneker, McIntire, Schumm, Prince, Goldstein et al
ONE NORTH CHARLES STREET, SUITE 2450
BALTIMORE
MD
21201
US
|
Family ID: |
31192030 |
Appl. No.: |
12/486971 |
Filed: |
June 18, 2009 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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10289934 |
Nov 7, 2002 |
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12486971 |
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60338267 |
Nov 9, 2001 |
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60371590 |
Apr 11, 2002 |
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Current U.S.
Class: |
424/184.1 |
Current CPC
Class: |
A61K 33/04 20130101;
A61P 17/16 20180101; A61P 43/00 20180101; A61K 45/06 20130101; A61P
31/12 20180101; A61P 31/16 20180101; A61K 31/221 20130101; A61K
38/063 20130101; A61K 38/063 20130101; A61P 31/20 20180101; A61K
2300/00 20130101; A61K 2300/00 20130101; A61K 2300/00 20130101;
A61K 33/04 20130101; A61K 31/221 20130101 |
Class at
Publication: |
424/184.1 |
International
Class: |
A61K 39/00 20060101
A61K039/00; A61P 43/00 20060101 A61P043/00 |
Claims
1. A combination for ameliorating the side effects of a vaccine
against a bioterror weapon or disease more generally, comprising:
in a pharmaceutically acceptable carrier, said vaccine, and a
therapeutic dose of NAC.
2. The combination according to claim 2, further comprising: said
therapeutic dose of NAC being selected from the group of water
soluble NAC compounds.
3. The claim according to claim 3, further comprising: a
therapeutic dose of Selenium.
4. The claim according to claim 4, further comprising: a
therapeutic dose of DHEA.
5. A method of ameliorating the side effects of a vaccine against a
bioterror weapon or disease more generally, comprising the
following steps: administering in a pharmaceutically acceptable
carrier a course of therapeutic doses of NAC prior to
administration of said vaccine; administering said vaccine;
continuing said administration of a course of therapeutic doses of
NAC subsequent to administration of said vaccine at least until any
potential side effects of said vaccine are attenuated.
6. The method according to claim 5, further comprising the
additional step: administering a therapeutic dose of selenium.
7. The method according to claim 6, further comprising the
additional step: administering a therapeutic dose of DHEA.
8. A method of ameliorating the side effects of a vaccine against a
bioterror weapon or disease more generally, comprising the
following steps: administering said vaccine; administering in a
pharmaceutically acceptable carrier a therapeutic dose of NAC
contemporaneously to administration of said vaccine.
9. The method according to claim 8, further comprising the
additional step: continuing said administration of a course of
therapeutic doses of NAC subsequent to administration of said
vaccine at least until any potential side effects of said vaccine
are attenuated.
10. The method according to claim 9, further comprising: said
therapeutic dose of NAC being selected from the group of water
soluble NAC compounds.
11. The method according to claim 10, further comprising the
additional step: administering a therapeutic dose of selenium.
12. The method according to claim 11, further comprising the
additional step: administering a therapeutic dose of DHEA.
Description
[0001] This application is a divisional application of pending U.S.
application Ser. No. 10/289,934 entitled "Systemic Administration
Of NAC As An Adjunct In The Treatment Of Bioterror Exposures Such
As Anthrax, Smallpox Or Radiation And For Vaccination Prophylaxis,
And Use In Combination With DHEA For The Treatment Of Smallpox And
Other Viruses" which in turn claims benefit of provisional
application 60/338,267 filed on Nov. 9, 2001 entitled "Systemic
Administration Of Glutathione Or Precursor Such As NAC As An
Adjunct In The Treatment Of Bacillus Anthracis Exposure Or
Infection, and of provisional application 60/371,590 filed on Apr.
11, 2002 entitled Use Of Glutathione Precursor In The Treatment Of
Smallpox And The Use Of Glutathione Precursor In The Treatment Of
Radiation Exposure, The Use Of The Combination Of Glutathione
Precursor And DHEA For The Treatment Of Smallpox And Other
Viruses," all of which are incorporated by reference herein.
SUMMARY
[0002] The invention is for the combination of N-acetyl-cysteine
oral, inhaled, or intravenous, or glutathione inhaled or
intravenous, and antibiotic and/or antiviral therapy to ameliorate
the toxic effects of infection with materials used in Bioterror
incidents such as Bacillus anthracis and smallpox virus, and
alternatively, upon radiation exposure, during testing or
vaccination, as treatment prior to treatment with antibiotic or
antiviral therapy to ameliorate the toxic effects of infection and
exposure with these organisms.
TECHNICAL FIELD
[0003] The present invention relates to the treatment of infection
with Bacillus anthracis or smallpox virus using systemic
antioxidant support in forms including intravenous NAC and inhaled
glutathione individually and in combination and as an adjunct
therapy with antibiotic and/or antiviral agents. Systemic
antioxidant support using intravenous NAC and inhaled glutathione
individually and in combination is also used as therapy for
ameliorating the effects of radiation induced depletion of
antioxidant defense. Prophylactic protection against complications
after smallpox vaccination and radiation exposure is discussed.
Combination with DHEA for the same purposes is presented.
BACKGROUND OF THE INVENTION
[0004] Bioterror exposures include the possibility of exposure to
either individual or combinations of biologic and radiation agents.
After a documented or suspected Bioterror exposure, there is a
variable period of time during which it is not clear what agent was
used or what therapy would be most specific. In this situation it
may not be known what specific therapy may be most effective, such
as an antiviral or antibiotic. During this period and regardless of
what specific agent is chosen, antioxidant support in the form
described in this invention may be useful to support the immune
system and improve the likelihood of survival of the affected
individual.
[0005] The biology with the bacteria Bacillus anthracis and
smallpox Smallpox virus, variola are reviewed as background for the
invention.
[0006] In the early stage of exposure to anthrax the bacteria is
usually in the spore form. The body uses the macrophage to
phagocytize the spore and it is carried to regional lymph nodes.
The formation of vegetative organisms thus occurs in the lymphatic
system and spreads to the bloodstream. In a small number of cases,
systemic anthrax can lead to meningeal involvement by means of
lymphatic or hematogenous spread. At autopsy a classic finding of
anthrax infection is the finding of extensive hemorrhage of the
leptomeninges, which gives them a dark red appearance described as
"cardinal's cap."
[0007] In cases of pulmonary anthrax, peribronchial hemorrhagic
lymphadenitis blocks pulmonary lymphatic drainage, leading to
pulmonary edema. Death results from septicemia, toxemia, or
pulmonary complications and can occur one to seven days after
exposure.
[0008] Illness and death related to infection with the bacteria
Bacillus anthracis is mediated by the interaction of three toxins
formed by anthrax. The first is an antiphagocytic capsule
(poly-n-glutamic acid), edema toxin and lethal toxin. The
antiphagocytic factor inhibits phagocytosis and locks onto the
scavenging cell called macrophage. This is followed by the
insertion of the two other toxins, lethal factor toxin and edema
toxin. The lethal factor appears to mediate the rapid onset of
shock and death associated with systemic anthrax. While edema toxin
causes swelling in all cells, lethal toxin exerts its effect
selectively on the macrophage, even though the lethal toxin is
injected into all cells (Hanna P et al, "On the Role of Macrophages
in Anthrax," Proc Natl Acad Sci (PNAS) USA: Vol. 90;10198-10201,
1993).
[0009] The presence of low levels of toxin in macrophages
stimulates the production of cell signaling hormones called
cytokines such as IL-1 and TNF. At low levels these cytokines
stimulate the immune response of the host, but at higher levels
they mediate damage to the host, even extending to fatal shock
(Hanna P et al, "On the Role of Macrophages in Anthrax," PNAS USA:
Vol. 90;10198-10201, 1993). It is postulated that the macrophage
accumulates the IL-1 until a critical level of toxin is reached
which causes lysis of the cell and uncontrolled release of the
accumulated IL-1 in a large amount that can lead to shock and
death. The accumulation of IL-1 in many macrophages coupled with
the contemporaneous release from many cells can result in death
being the presenting symptom of anthrax infection (Hanna P et al,
PNAS USA: Vol. 90;10198-10201, 1993).
[0010] Thus the macrophage plays a contradictory rote. With most
infections the macrophage plays a protective role ingesting and
incapacitating invading organisms. With anthrax the normal
protective mechanism has been mal-appropriated to facilitate the
lethality of the anthrax toxin. The macrophage becomes the mediator
of the lethality related to the toxin.
[0011] Macrophage disruption is mediated by an increase in the
formation of Reactive Oxygen Species also known as Free Radicals.
At high levels the toxins cause destruction of the macrophages. At
lower levels the toxin-mediated free radicals stimulates these
cells to produce cytokines (interleukin-1 beta and tumor necrosis
factor-alpha), which induce systemic shock and death. Antioxidants
have been shown to moderately inhibit anthrax toxin-induced
cytokine production in vitro. NAC also blocked the production of
TNF-alpha in rat peritoneal macrophages activated with endotoxin
(Pahan K, "N-acetyl cysteine inhibits induction of NO production by
endotoxin or cytokine stimulated rat peritoneal macrophages C6
glial cells and astrocytes," Free Radic Biol Med, 24(0:39-48 1998
Jan. 1). Mice pretreated with N-acetyl-L-cysteine showed partial
protection against anthrax toxin exposure (Hanna P et al, "Role of
macrophage oxidative burst in the action of anthrax lethal toxin,"
Molecular Medicine (Mol Med) 1994 November; 1(1):7-18).
[0012] Increasing the level of cysteine, a precursor of glutathione
reduces the production of the cytokines and TNF-.alpha. that caused
the body more harm than benefit. The increase in glutathione
precursor also increases the potential for surviving toxin exposure
in animals (Hanna P et al, "Role of macrophage oxidative burst in
the action of anthrax lethal toxin," Mol Med 1994 November;
1(1):7-18). Other studies have also demonstrated that reactive
oxygen species are involved in the deterioration of cardiac
function seen in endotoxin shock and their effect can be diminished
by the use of antioxidants (Pattanaik U et al, "Reactive oxygen
species and endotoxic shock: effect of dimethylthiourea," J
Cardiovasc Pharmacol Ther 2001 July;6(3):273-85). The use of NAC
prior to exposure to anthrax or its toxins have already been
demonstrated to help reduce the negative effects of ROS and the
release of cytokines in cell studies. NAC prior to exposure reduces
the lethality of anthrax in animal studies.
[0013] While Hanna et at suggest positive effect in mice by NAC on
exposure to toxins and on survivability of macrophages in culture,"
(Hanna P et al, "Role of macrophage oxidative burst in the action
of anthrax lethal toxin," Mol Med 1994 November;1(1):7-18), no
reference cites a method or combination of NAC with antibiotics to
treat anthrax in humans or mammals. Dixon, Meselson, Guillemin and
Hanna, "Anthrax," N. Engl. J. Med. 341(11): 815-26, Sep. 9, 1999
specifically note "Unfortunately, anti-toxin preparations are not
currently available in the United States. Based on the findings of
the animal and cell studies, glutathione and glutathione precursors
containing cysteine or its physiologic form cystine represent a
potent strategy for ameliorating the effects of inhalation
anthrax.
[0014] Viruses are strands of information, either RNA or DNA, that
depend on living cells to provide either the additional components
or an environment which allow the virus to reproduce. Since they
neither breathe nor reproduce on their own they are not considered
living. After using the host cell machinery and enzymes to make new
copies of itself, viruses program the production of a new covering
which allow it to be released out of the cell and accepted by the
next cell. To accomplish replication most viruses need to use the
information contained in the DNA of the cell. Smallpox viruses are
unusual in that they contain all of the information that they need
to replicate, however it still needs the interior of the cell to
replicate. Scientists who study the evolution of viruses conjecture
that the information in the smallpox virus may have belonged to
another organism that has now become incorporated in the DNA
replication machinery of our cells (Takemura M, "Poxviruses and the
origin of the eukaryotic nucleus," J Mol Evol. Vol. 52(5):419-25,
May 2001.). Viruses cause problems by changing the machinery of the
cell that it has commandeered and by creating so many copies of
itself that the cell cannot maintain its normal function, ceases
functioning normally and may even rupture, releasing large amounts
of virus.
[0015] Smallpox virus, called variola, is a DNA virus containing
all the information that is necessary to reproduce; however it must
be incorporated into a cell for reproduction to occur. This allows
for the virus to replicate in the cytoplasm of a cell and to
utilize the cell wall machinery to form a capsule and be released
rapidly. The virus, after replicating in various tissue cells and
creating a large number of copies, is released into the bloodstream
before invading the skin and, in most cases, developing the skin
lesions, or pocks that give rise to the common name for the disease
state triggered by the virus: smallpox. While this is happening,
the patient may not feel ill. Usually 12 days after exposure a
feverish illness appears. Two to three days later the
characteristic skin rash may appear. The rash appears as small pink
spots called macules and progresses to enlarged, slightly raised
papules. The papules progress to blisters. Eventually the blisters
become turbid, looking like pustules, which were previously called
pocks and are the characteristic feature for which the virus is
named. The pustules then dry up and shrink, leaving a hard crust
that eventually flakes off leaving a sunken scar. The distribution
of the rash is characteristic of smallpox with the head and
extremities affected more than the trunk.
[0016] Usually the severity of the disease follows the severity of
the rash, but severe illness may precede the rash with the patient
becoming prostrate before the outbreak of a rash. It is also
possible to spread the virus without developing the rash, which
means that outbreaks can be precipitated by individuals without
rash or even severe illness.
[0017] Mortality: There is no treatment recognized once the illness
has started. There are reports of mortality of 30% or more in
unvaccinated populations (Henderson D A et al, "Consensus statement
regarding Smallpox," J. Am. Med. Assoc. Vol. 281(22):2127-37, Jun.
9, 1999).
[0018] Poxviruses have caused infections in man documented as far
back as the Egyptian pharaohs. The Pharaoh Ramses V was apparently
inflicted with the virus at the time of his death in 1157 B.C.
Smallpox inflicted Europe in 710 A.D. Cortez carried smallpox to
the America's in 1520 and precipitated the death of 2 million
Aztecs in the following 2 years. In the cities of 18.sup.th century
Europe, smallpox reached plague proportions as the highly
infectious disease affected rich and poor alike, with five reigning
monarchs dieing with the disease
(http://www.tulane.edu/.about.dmsander/WWW/335/Poxviruses.html).
The last outbreak of small pox occurred in modern times in Somalia
in 1977.
[0019] While most pox diseases, such as chickenpox, occur in man as
well as animals, only smallpox uses humans as its reservoir. The
selectivity of smallpox has allowed the success of an aggressive
immunization campaign by the World Health Organization to eradicate
the disease. The structure of the poxviruses are similar, which
allows the use of a similar, but less virulent virus to effect a
cross reacting immunization. In addition, smallpox causes only
acute disease and does not set up dormant disease such as the
Herpes virus does. The result is that individuals who survive a
smallpox infection have immunity that lasts for life.
[0020] The fact that the animal poxviruses share similar
biochemical characteristics on their covers that are recognized by
the immune system allowed Edward Jenner to demonstrate the concept
of vaccination in 1796 (Id). It had been observed that the
milkmaids, while frequently affected with cowpox, rarely if ever
became infected with smallpox. Jenner used cowpox, obtained from a
milkmaid to inoculate an 8-year-old boy. Later, Jenner challenged
the boy with an inoculation of smallpox and demonstrated that the
immunization led to protection from the infection.
[0021] Vaccination became common around the world beginning around
1800, but smallpox was not eradicated until the World Health
Organization made a major commitment to eradicate the virus with a
worldwide vaccination campaign. Vaccination is done with a less
virulent virus called vaccinia. The vaccinia virus used in modern
vaccinations may have developed through the serial passage from arm
to arm since the time of Jenner.
[0022] Smallpox causes serious infections with skin lesions and it
is spread easily through respiratory contact with cough droplets.
As a biological weapon, smallpox represents a serious threat as it
has been reported to carry a case-fatality rate of 30% or more in
unvaccinated populations. In addition there is no antiviral therapy
specific for smallpox (Henderson D A et al , "Consensus statement
regarding Smallpox," Jour Amer Med Assoc. Vol. 281(22):2127-37,
Jun. 9, 1999). The ability of an unvaccinated individual thus
becomes dependent on the capacity of the individuals immune system
to respond to the virus.
[0023] While smallpox is unique in its ability to replicate in the
cytoplasm of a cell, it has common features with other viruses that
make it identifiable by the immune system. Apparently the viral
covering is different from self-tissue to the extent that an immune
response is created to the viral cover. This is the foundation for
the use of the vaccinia virus as a vaccine to stimulate antibodies
to smallpox. It is the ability of the immune system to process the
viral information, produce antibodies and coordinate the immune
cell response for removal of virus that makes the immune system an
effective protector against viruses.
[0024] Enhancing immune cell function with nutrient materials such
as N-Acetyl-cysteine, which increase glutathione in the body and
inside cells, will increase the immune surveillance and response
mechanism and increase the likelihood of surviving a smallpox
infection. Further, even for weakened virus, or cross-reacting
immunization, N-Acetyl cysteine, which increases glutathione in the
body and inside cells, increases and favorably influences immune
response and lessens the likelihood of complications from
vaccination.
[0025] Exposure of cells to virus decreases the intracellular
glutathione, starting immediately after virus challenge. In a study
with the herpes simplex virus type 1 (HSV-1) the addition of
glutathione to the culture was not only able to restore the
intracellular glutathione levels to near normal levels, but was
also able to inhibit over 99% of the replication of HSV-1 (Palamara
A T et al., "Evidence for antiviral activity of glutathione: in
vitro inhibition of herpes simplex virus type 1 replication,"
Antiviral Res, Vol. 27(3):237-53 1995). Additionally, it was
observed that the inhibition was concentration dependent and was
maintained even if the glutathione was added as late as 24 hours
after virus challenge, when the virus was fully established.
Studies of the HSV-1 infected cells showed that glutathione
dramatically reduced the number of extracellular and
intracytoplasmic virus particles. Nucleocapsids were still detected
within the nuclei of glutathione treated cells. The decrease in
virus replication was related to a decrease in glycoprotein B,
which is crucial for the release and infectivity of the virus. This
suggests that glutathione inhibits the replication of HSV-1 by
interfering with very late stages of the virus life cycle and not
by interfering with cellular metabolism Id.
[0026] Viral pathogenesis and mutation is increased by free radical
mediated oxidation (Akaike T, "Role of free radicals in viral
pathogenesis and mutation Review Medical Virology," Vol.
11(2):87-101 March.-April. 2001). The mechanism may be related to
the depletion of antioxidant with resulting increase in oxidation.
The increase in oxidation decreases the available glutathione. The
oxidation stress status of the individual has been demonstrated to
affect the pathogenicity of virus in animal studies (Beck M A et
al, "Host nutritional status and its effect on a viral pathogen," J
Infect Disease Vol. 182 Suppl 1:S93-96, September 2000).
[0027] It is well documented that cellular immune function, termed
T helper cell type 1 (TH1) function, is affected by the level of
glutathione. Antigen presenting cells deficient in glutathione
predispose to the formation of a TH2 response with a decrease in
TH1 or cell mediated immune response (Peterson J D et al,
"Glutathione levels in antigen-presenting cells modulate TH1 versus
TH2 response pattern," Proc Natl. Acad Sci USA, Vol.95(6):3071-6,
Mar. 17, 1998). Cytotoxic T cell function, which is important in
the management of viral infection, is decreased by 30% in animals
deficient in glutathione (Lawrence B P et al,
"Gamma-glutamyltranspeptidase knockout mice as a model for
understanding the consequences of diminished glutathione on T
cell-dependent immune responses," European Journal Immunology Vol.
30(7):1902-10, July 2000). Thus, maintaining the glutathione level
will help maintain a more favorable balance in the immune responses
and an increase in survival. NAC has been demonstrated to increase
and maintain the intracellular level of glutathione and protect
against intracellular oxidative damage (Afaq F et al, "N-acetyl
L-cysteine attenuates oxidant-mediated toxicity induced by
chrysotile fibers," Toxicology Letters Vol. 117(1-2):53-60, Sep.
30, 2000).
[0028] Intravenous NAC will improve survival of individuals
infected with the smallpox virus by either of two methods. [0029]
1. NAC may contribute to a direct reduction in viral replication
[0030] 2. NAC improves the immune surveillance and responsiveness
of the immune system.
[0031] In addition, regardless of exposure, whether it is bacterial
or viral, NAC has been shown to be of benefit in the reducing the
ventilator time in individuals with sepsis who require respiratory
support. Intravenous NAC has been shown in humans with adult
respiratory distress syndrome in patients with septic shock to be
effective in reducing length of stay in the intensive care unit
from 32 days to 13 days (Spapen H et al, "Does N-acetyl-L-cysteine
influence cytokine response during early human septic shock?,"
Chest, Vol. 113(6):1616-24 June, 1998. One of the beneficial
mechanisms of NAC demonstrated in the study was the reduction in
the production of the interleukin IL-8, a potential mediator of
lung injury. Intravenous NAC infusion to lab rats after exposure to
endotoxin reduced the features associated with septic shock
(Schmidt W et al, Intensive Care Med, Vol. 24(9):967-72 September.
1998.
[0032] Studies have also demonstrated that reactive oxygen species
are involved in the deterioration of cardiac function seen in
endotoxin shock and their effect can be diminished by the use of
antioxidants (Pattanaik U et al, J "Reactive oxygen species and
endotoxic shock: effect of dimethylthiourea". Cardiovascular
Pharmacology Therapy., Vol.6(3):273-85 July 2001.
[0033] Thus, Intravenous NAC becomes an important adjunct in the
management of bacterial and viral diseases as well as complications
related to such infections such as septic shock, adult respiratory
distress and deterioration of cardiac function during endotoxin
shock.
[0034] The effects of NAC are mediated directly and through the
production of increased amounts of intracellular glutathione (Afaq
F et al, "N-acetyl L-cysteine attenuates oxidant-mediated toxicity
induced by chrysotile fibers," Toxicology Letters Vol.
117(1-2):53-60, Sep. 30, 2000). Many of the benefits seen in
management of viral disease with NAC are mediated through free
radical scavenging, particularly of the .sup.-OH radical.
[0035] Removal of this radical performed by glutathione peroxidase,
an enzyme that is mediated by the mineral selenium. The importance
of selenium in supporting this reaction is demonstrated in a study
that demonstrates that a non-lethal virus, Coxsackie virus, becomes
lethal in animals deficient in selenium. It was determined that not
only was the immune function of the animal altered, the viral
genome was altered in such a way that the virus became more
pathogenic (Beck M A, "Antioxidants and viral infections: host
immune response and viral pathogenicity," Journal American College
Nutrition 20(5 Suppl):384S-388S; discussion 396S-397S, October.
2001). Selenium 100 mcg to 200 mcg should be given in addition to
NAC to maintain and restore Selenium levels. Selenium may
administered as organic forms of selenium, such as selenomethionine
and selenocysteine, as well as the inorganic forms of the mineral,
like sodium selenite and selenate.
[0036] Cell studies have demonstrated that a decreased level of
glutathione increases sensitivity to radiation (Meister A et al,
"Intracellular cysteine and glutathione delivery systems" Journal
American College Nutrition 5(2):137-51, 1986). The ability of
glutathione and its precursors to moderate the effect of the
.sup.-OH radical makes NAC an ideal candidate for use in the
treatment of radiation exposure. Scavengers of the .sup.-OH radical
have been demonstrated to protect mammalian animal cells against
the damaging effects of radiation (Ewing D et al, "Radiation
protection of in vitro mammalian cells: effects of hydroxyl radical
scavengers on the slopes and shoulders of survival curves,"
Radiation Res, Vol.126(2):187-97, May 1991). The mechanism is
related to the scavenging of the .sup.-OH radical as well as other
intracellular mechanisms. An evaluation of 35 people with "post
radiation syndrome" after exposure to substantial amounts of
ionizing radiation (0.01-0.5 Gy) while participating in recovery
work in Chernoblyl demonstrated that they had a significant
decrease in antioxidant defense with a decrease in the activity of
glutathione peroxidase and deficiency of selenium (Kumerova A O et
al, "Antioxidant defense and trace element imbalance in patients
with postradiation syndrome: first report on phase I studies,"
Biology Trace Element Research Vol. 77(1):1-12, October 2000).
[0037] The "post radiation syndrome" produces headache; dizziness,
poor memory, and local pains Id.. These symptoms are not
necessarily specific of any disease and may be easily confused with
the early symptoms of illness such as viral influenza or even viral
infection such as smallpox. The early symptoms of anthrax also
mimic the early symptoms of viral influenza. Thus, it may be
difficult to identify the etiologic cause of the early stage
symptoms of biological weapons or radiation. The use of antioxidant
support therapy with NAC is an inexpensive way to support an
affected individual's antioxidant system while the specific
etiology is identified and as an adjunct to antibiotic or antiviral
therapy. The NAC antioxidant therapy may be initiated as either
oral and/or intravenous therapy. Selenium should also be
administered orally at 200 mg per day.
[0038] Additional factors also play a role in limiting the
individual's ability to combat infection. The stress of infection
with either microbial or viral agents will cause a shift in hormone
production. This is manifest as a shift in the
hypothalamo-pituitary-adrenal axis (HPA) with the resulting
production of excess cortisol, the major glucocorticoid. Elevation
in cortisol is accompanied by a decrease in cellular immunity in
humans undergoing significant stress such as surgery (Tashiro T et
al, "Changes in immune function following surgery for esophageal
carcinoma," Nutrition, Vol. 15(10):760-6, October 1999). Stress
will also lower the response to vaccination and decrease protection
to subsequent infection challenge in pigs immunized with a viral
vaccine. Excess of the glucocorticoid is associated with
suppression of antiviral immunity (Padgett D A et al, "Steroid
hormone regulation of antiviral immunity," Ann N Y Acad Sci,
Vol.917:935-43, 2000). Counter regulation of immunosuppression due
to glucocorticoid elevation would improve immune response and limit
virus-mediated damage. Dehydroepiandrosterone (DHEA) and its
metabolite Androstenediol (5-androstene-3 beta, 17 beta-diol, AED)
have been demonstrated to be protective against lethal infection
from influenza A virus in animals Id.. The effect is apparently due
to a counterbalance of the immunosuppressive effect of
glucorticoids. AED prevents the glucocorticoid-mediated suppression
of IL-1, TNF-alpha and IL-2 secretion. An ocular infection model in
mice exposed to herpes simplex virus1 (HSV-1) was favorably
modified by the subcutaneous administration of AED (Carr D J, J
"Increased levels of IFN-gamma in the trigeminal ganglion correlate
with protection against HSV-1-induced encephalitis following
subcutaneous administration with androstenediol," Neuroimmunol Vol.
89(1-2):160-7, Aug. 14, 1998). The dose of AED used in this study
was 320 mg/kg. The AED administration results in the increase of
chemokines IP-10, MCP-1, the cytokine interleukin-6 (IL-6) and
interferon-gamma (IFN-g) and IL-2 and natural killer cell activity,
an important component of the removal of cells infected with virus.
Thus, DHEA or AED becomes on an important component of antiviral
therapy. Samuel et al, U.S. Pat. No. 6,168,804 refer to the use of
DHEA as a component of a slow release vehicle to induce TH1 immune
response to an immunizing antigen. Daynes et al, U.S. Pat. No.
5,919,465 , claim the use of DHEA to augment the immune response
due to stress including the stress of viral infection. No patent,
however, has claimed the use of a combination of NAC and DHEA or
its metabolite AED as an immune enhancing combination for the
treatment of viral diseases such as smallpox.
[0039] Vaccination after exposure to smallpox has been proposed as
part of the management of the disease. Vaccination administered
within 4 days of first exposure has been shown to offer some
protection against acquiring infection and significant protection
against a fatal outcome. (Henderson D A et al , "Consensus
statement regarding Smallpox," Journal American Med Association
June 9;281(22):2127-37, 1999). As the presence of viral infection
will decrease the level of glutathione it is likely that the
immunization response may be compromised in individuals who are
already carrying smallpox. It has been demonstrated that decreased
immunologic function in individuals with cysteine or glutathione
deficiency can be enhanced by cysteine supplementation (Droge W et
al, "Glutathione and immune function," Proc Nutrition Soc, Vol.
59(4):595-600, November 2000). Maintaining glutathione levels with
glutathione precursors will improve the immune response to
vaccination during vaccination for smallpox exposure. It is
anticipated that inoculation for smallpox would be under taken at a
time of concern about the appearance of smallpox used as a
bioterror weapon. In this situation stress will be increased, and
the use of the combination of NAC and DHEA is useful to maximize
efficient immune response to immunization. The preferred method of
use of the invention utilizes the combination of NAC and DHEA prior
to or at the time of immunization.
OBJECTIVES OF THE INVENTION
[0040] The object of the invention is to generally deal with
weapons of mass destruction exposure, particularly biological
bioterror and radiation release (nuclear) weapons. Another object
is to utilize systemic glutathione therapy with oral and
intravenous NAC as well as intravenous and inhaled glutathione as a
prophylactic, adjunct and frontline therapy in the treatment and
support of individuals exposed to anthrax, small pox and
radiation.
[0041] Another object is to utilize DHEA and systemic glutathione
therapy as an adjunct and frontline therapy in the treatment and
support of individuals exposed to small pox, viral disease and
radiation.
[0042] Another object is to enable immediate treatment without fear
of toxicity of individuals exposed to bioterror or radiation
without fear of compromising later desired treatments, particularly
in instances of delayed diagnosis.
[0043] Another object is to enable treatment of multiple vector
exposure without fear of toxicity of individuals and without fear
of compromising later desired treatments, particularly useful where
a number of threats may be combined.
[0044] Another object is that in the event of mass attack, not
everyone will be exposed or present with symptoms, and this
invention, utilizing NAC, enables some treatment by purchasing
economically in relatively vast quantities enabling more optimal
use of more limited and considerably more expensive antibiotic,
anti-viral and vaccination resources.
[0045] For patients who present with ambiguous symptoms for whom
antibiotic treatment may be premature or have severe side effects,
or patients with risk of exposure to anthrax but demonstrating no
symptoms, the invention proposes an immediate method to blunt any
toxin effects while awaiting testing.
[0046] For patients who present with symptoms suggesting the need
for antibiotic therapy, the invention enables the individual to
begin immediate toxin management. The antibiotic is designed to
slow and eliminate the reproduction of anthrax spores, but the
antibiotic is ineffective for toxin detoxification.
[0047] For patients with compromised immune systems, either from
anthrax or other cause such as HIV or other disease, the invention
accomplishes immune system enhancement, and detoxification of
anthrax toxin while the antibiotic takes effect.
[0048] For patients with inhalation anthrax, for whom the prognosis
is very poor, the addition of IV NAC offers one of the few
non-toxic detoxification regimes to interrupt the dramatic and
life-threatening effect of toxin release and apoptotic effect
triggered by Bacillus anthracis.
[0049] The invention also can give partial protection against
changes by bioterrorists to the anthrax activity because the
invention combats through natural metabolic pathways the toxin
effect whatever the strain of anthrax that is the source. Such
sources may change because of the emergence of antibiotic resistant
strains either through natural selection or the introduction of
antibiotic resistance through genetic manipulation by manufacturers
of bioterror weapons.
DESCRIPTION OF INVENTION
[0050] Pharmacologic Compounds
[0051] NAC will be the collective reference for glutathione pathway
enhancing compounds in this description. Those compounds include
N-acetyl-cysteine which is normally referred to as NAC, but in this
invention, the term NAC, and the term glutathione precursor, also
includes the following:
[0052] Cystine is (3,3'-dithiobis [2-aminopropanoic acid]). Cystine
is readily reduced to cysteine. Cystine is present in most
mammalian hair and keratin.
[0053] Cysteine is 2-amino-3-mercapto propanoic acid. It is readily
converted by oxidoreduction to cystine. It is a constituent of
glutathione and abundantly present in the metallothioneines.
[0054] Cystine in the body-useful form as L-cystine is available
from Spectrum Chemical Mfg. Corp. 14422 S. San Pedro St, Gardena,
Calif. 90248.
[0055] Cystine, cysteine, and N-Acetyl cysteine and
pharmaceutically acceptable salts, including the pharmaceutically
active forms described in Kozhemyakin et al, published by WIPO as
WO 00/031120, PCT/RU99/00453, filed internationally on 19 Nov.
1999, "Hexapeptide with the Stabilized Disulfide Bond and
Derivatives Thereof Regulating Metabolism, Proliferation,
Differentiation and Apoptosis," will all collectively be referred
to as NAC in this invention. Other glutathione pathway enhancing
compounds understandable to one of ordinary skill in the art which
are encompassed in the term NAC are stable forms of compounds that
enhance the glutathione pathway, the substituents of which are
suggested in Kozhemyakin et al, Hexapeptide with the Stabilized
Disulfide Bond and Derivatives thereof Regulating Metabolism,
Proliferation, Differentiation and Apoptosis published as WO
00/31120, Jun. 2, 2000. Included in the term NAC is also any
therapeutically beneficial sulfur-donating compound, such as lipoic
acid and including ebselen and s-acetyl-glutathione, which
interacts with the glutathione pathway and the monoethyl ester of
glutathione (in which the glycine carboxyl group is esterified)
(Puri R N, Meister A. "Transport of glutathione, as
gamma-glutamylcysteinyiglycyl ester, into liver and kidney", Proc
National Academy Science USA, Vol. 80(17):5258-60, September 1983).
The invention contemplates in the term NAC undenatured whey protein
products designed to have enhanced cystine concentration as well as
protein products that contain cysteine and cystine. They can be in
the form of food products.
[0056] The addition of cystine, cysteine, N-acetyl cysteine, or the
pharmaceutically acceptable salt of those substances yields another
effect in this invention not facially evident from the independent
properties of the basic components of the invention (hereafter each
substance or a pharmaceutically acceptable salt is referred to as a
"cystine"). Administration of a cystine family member, preferably
cystine, which has the best and most rapid upload into the
glutathione pathway and better storage capability by the body, or
N-acetyl cysteine, enhances the immune system competency of the
patient.
[0057] In individuals on prophylactic therapy including antiviral
agents for presumed exposure to smallpox or potassium iodide for
radiation the NAC can be continued for extended periods with oral
ingestion of NAC or a cystine source such as undenatured whey
protein such as Immunocal (a Registered Trademark of a product
manufactured by lmmunotec, Montreal Canada). Immunocal.RTM.
undenatured whey protein has the added advantage of providing the
cysteine in the disulfide form, called cystine 80% of the
circulating cysteine in the body is in the form of cystine. Cystine
is readily absorbed into cells and has been demonstrated to be
preferred by certain cells such as astrocytes (Kranich O et al,
"Utilization of cysteine and cysteine precursors for the synthesis
of glutathione in astroglial cultures: preference for cystine,"
Glia. Vol. 22(1):11-8 January 1998.).
[0058] The NAC may be used in combination with anthrax vaccine to
minimize side effects, or as an alternative for those intolerant of
anthrax vaccine pending presentment with symptoms.
[0059] The reference to anthrax antibiotic or "antibiotic" is to
antibiotics for combating anthrax or other bacterial diseases that
are effective bioterror agents which are listed below.
[0060] Antibiotics that have been accepted for use in the treatment
of anthrax include Penicillin, Doxyclycline and Ciprofloxacin.
[0061] The present invention may be combined with other antibiotics
as well.
[0062] These antibiotics would include, but not be limited to
[0063] 1. Aminoglycoside==Gentamicin, Tobramycin, Netilmicin,
Amikacin, Streptomycin. [0064] 2. Cephalosporins=Cefazolin,
Cefuroxime, Cefotetan, Ceftriaxone, Ceftazidine. [0065] 3.
Clindamycin [0066] 4. Macrolides=Erythromycin, Clarithromycin,
Azithromycin. [0067] 5. Metronidazole [0068] 6.
Penicillins=Penicillin, Ampicillin, Nafcillin, Piperacillin. With
or without Aztreonam, Imipenem, or with Beta-lactamase
inhibitor=Ampicillin/sulbactam (Augmentum) or
Pipercillin/tazobactam and Beta-lactam=Ceftriaxone, Cefuroxime
[0069] 7. Quinolones=Ciprofloxacin, Ofloxacin, Gatifloxacin or
Trovafloxacin [0070] 8. Tetracyclines=Tetracycline, Doxycycline, or
Minocycline [0071] 9. Trimethoprim-Sulfamethoxazole [0072] 10.
Vancomycin [0073] 11. Chloramphenicol [0074] 12. Erythromycin
[0075] Antibiotic dosing schedule per Hanna P, "Medical Review of
anthrax," The New England Journal of Medicine Volume
341(10;815-825, 1999 PHARMACOLOGIC THERAPY FOR BACILLUS ANTHRACIS
INFECTION AND ITS SEQUELAE.
TABLE-US-00001 Treatment of infection Therapy Dosage for Adults
Dosage for children Penicillin V 200-500 mg orally 4 2550 mg/kg of
body times/day weight/day orally in divided doses 2 or 4 times/day
Penicillin G 8 million-12 million U total, 100,000-150,000 U/kg/day
intravenously in divided in divided doses doses every 46 hr
Streptomycin 30 mg/kg intramuscularly or intravenously per day -
gentamicin can also be used (in conjunction with penicillin)
Tetracycline 250-500 mg orally or Tetracycline is not intravenously
4 approved for children times/day Doxycycline 200 mg orally or
Doxycycline is not intravenously as a loading approved for children
< 9 yr dose, then 50100 mg every old 12 hr For children 45 kg:
2.5 mg/kg every 12 hr For children > 45 kg: use adult dosage
Erythromycin 250 mg orally every 6 hr 40/mg/kg/day orally in
divided doses every 6 hr Erythromycin lactobionate 1520 mg/kg
(maximum, 4 20-40 mg/kg/day g) intravenously per day intravenously
in divided doses every 6 hr (1- to 2-hr infusion) Chloramphenicol
50-100 mg/kg/day orally or 50-75 mg/kg/day in divided intravenously
in divided doses every 6 hr doses every 6 hr Ciprofloxacin 250-750
mg orally 20-30 mg/kg/day in divided twice/day 200- doses every 12
hr 400 mg intravenously every Oral or intravenous dosing 12 hr is
not approved for patients < 18 yr old
TABLE-US-00002 Prophylaxis Antibiotic Adult dosage Child Dosage
Doxycycline 100 mg orally twice/day for 4 wk Ciprofloxacin 500 mg
orally twice/day for 4 wk
TABLE-US-00003 Corticosteroid therapy for severe edema
Dexamethasone 0.750.90 mg/kg/day 0.25-0.5 mg/kg every 6 hr orally,
intravenously, or intramuscularly in divided doses every 6 hr
Prednisone 12 mg/kg or 560 mg 0.52 mg/kg/day orally/day
[0076] Most B. anthracis strains are resistant to cefuroxime in
vitro.
[0077] For inhalational, gastrointestinal, or meningeal anthrax
infection in adults, the intravenous regimen is used with
penicillin G, streptomycin, tetracycline, doxycycline, erythromycin
lactobionate, chloramphenicol, and ciprofloxacin; for these
infections in children, the intravenous regimen is used with
penicillin G, doxycycline, erythromycin lactobionate, and
chloramphenicol.
[0078] Selenium will be the collective reference for selenium
enhancing compounds in this description. Those compounds include
Selenium which is normally referred to as Selenium, but in this
invention, the term selenium, also includes the following: Selenium
may administered as organic forms of selenium, such as
selenomethionine and selenocysteine, as well as the inorganic forms
of the mineral, like sodium selenite and selenate.
[0079] If patient is unvaccinated, initial doses of vaccine may be
begun.
Further Information on the Invention:
[0080] While infection with Bacillus anthracis in the past has been
generally treated with only antibiotic therapy there are other
compelling reasons to consider adjunctive therapy of NAC. The
reasons include the emergence of antibiotic resistant strains
either through natural selection or the introduction of antibiotic
resistance through genetic manipulation by manufacturers of
bioterror weapons. Another factor is the observation that even with
antibiotic therapy the bacteria may have the opportunity to
manufacture sufficient quantity of toxin to compromise the
individual. Antibiotic therapy does not address the effect of the
toxin on the immune system. (Hanna P et al, "Role of macrophage
oxidative burst in the action of anthrax lethal toxin," Mol Med
1994 November;1(1):7-18.
[0081] The present invention discloses the use of specific
antioxidants delivered as systemic infusions or via inhalation
therapies. The effectiveness of the therapy can be enhanced using
blood sample monitoring of glutathione levels. Glutathione can be
measured in the serum, white blood cell or red blood cell. There is
no risk to elevating the level of the precursors of glutathione
such as NAC as gamma-glutamylcysteine the direct precursor of
glutathione is regulated by the enzyme glutamyl synthase. The
feedback regulator of glutathione production in the cell is the
level of glutathione. If glutathione is low and glutathione
precursors are available, the cell mechanisms will form
glutathione. If adequate glutathione is present, additional
glutathione is not produced. Cysteine or cystine has been shown to
be the rate limiting factor in the production of glutathione
(Meister, "New aspects of glutathione biochemistry and
transport-selective alteration of glutathione metabolism," Nutrit
Rev 1984; 42:397-410). Monitoring the level of glutathione will
maximize the dosing schedule for the glutathione precursor being
used.
[0082] Intravenous NAC is normally not recommended as a stand-alone
therapy, but as a preliminary non-toxic therapy in patients
presenting with no symptoms or ambiguous symptoms, or for
particularly sensitive individuals such as pregnant women or
children for whom premature and ultimately unnecessary treatment
for symptoms determined to be unrelated to anthrax could have
undesired side effects. The preferred mode is envisioned to be used
in combination with appropriate antibiotics. Antibiotics that have
been accepted for use in the treatment of anthrax include
Penicillin, Doxyclycline and Ciprofloxacin. The addition of an
adjunctive therapy to delay the effect of the anthrax toxin is
useful even with early and vigorous treatment, the prognosis of
inhalation, gastrointestinal or meningeal anthrax remains poor
(Hanna P, "Medical Review of anthrax," The New England Journal of
Medicine Volume 341(11);815-825, 1999).
[0083] In defense against Biological Terror weapons, the invention
would also be useful for use as an initial therapeutic for
individuals who may have been exposed to a presumed toxin, and
while confirmation and identification of exposure is pending. In
other words, IV antioxidant such as NAC or glutathione will
attenuate the impact of the anthrax toxin, reducing the likelihood
of severe impact from the toxin and act as an attenuator of the
toxin while confirmation of exposure is pending. The effect of NAC
on the immune system would be beneficial even if the biological
turned out to be something other than anthrax as the improved
immune function would be useful in defending the individual against
viruses (De Flora S, et al, "Attenuation of influenza-like
symptomatology and improvement of cell-mediated immunity with
long-term N-acetylcysteine treatment," Eur Respir J 1997
July;10(7):1535-41).
[0084] This is a reasonably priced therapy with fewer side effects
for persons presenting with modest or ambiguous symptoms and who
are awaiting anthrax culture results.
[0085] Positive anthrax culture results justify aggressive
intervention with both antibiotic and antioxidant therapy because
of the severity of the infection and the lack of side effects from
the systemic antioxidant therapy. That aggressive intervention
requires both interference with toxin effects achieved by NAC or
its pharmaceutical equivalent referenced in this invention, and
antibiotic treatment.
[0086] The NAC may be used in combination with smallpox vaccine to
minimize side effects, or as an alternative for those in tolerant
of smallpox vaccine pending presentment with symptoms or as an
adjunct in patients undergoing prophylactic smallpox immunization.
It may also be used as a prophylactic for individuals concerned
about possible exposure to radiation.
[0087] At the present time no antiviral drug has been demonstrated
to be effective against smallpox. Due to the communicability of
smallpox, animal studies have not been performed using available
antiviral medications. However, there are suggestions that at least
one of the currently available antiviral drugs may be useful (Haney
D, Associated press Nov. 21, 2001
http://ap.tbo.com/ap/breaking/MGAVLPA2AUC.html). The most promising
drug is cidofovir, an intravenous medication used in the treatment
of cytomeglaovirus. While oral or intravenous NAC therapy may be
initiated prior to considering antiviral medications, the preferred
mode is envisioned to be used in combination with appropriate
antiviral medications. These may include, in addition to cidofivar,
Broad spectrum antivirals such as the Triazole carboxamine
Ribavirin, protease inhibitors such as Saquinavir, Ritonavir,
Indinavir, and Nelfinavir. Compatible antivirals also include the
tricyclic amines such as Amantadine and Rimantadine as well as the
Meuraminic acid mimetics such as Relenza and Tamiflu, and the small
cyclics such as Pleconaril. Additional antiviral medications
include Nucleoside analogues such as Vidarabine, Acyclovir,
Gancyclovir, valganciclovir, Nucleoside Reverse transcriptase
inhibitors such as Zidovudine (AZT), Didanosine (ddl), Zaocaitabine
(ddC), Stravudine (d4T), Lamivudine (3TC) and Non-Nucleoside
Reverse transcriptase inhibitors such as Nevirapine, and
Delaviridine.
[0088] The present invention discloses the use of specific
antioxidants delivered as oral therapies, systemic infusions or via
inhalation therapies. The effectiveness of the therapy can be
enhanced using blood sample monitoring of glutathione levels.
Glutathione can be measured in the serum, white blood cell or red
blood cell. There is no risk to elevating the level of the
precursors of glutathione such as NAC as gamma-glutamylcysteine the
direct precursor of glutathione is regulated by the enzyme
gamma-glutamyl synthase. The feedback regulator of glutathione
production in the cell is the level of glutathione. If glutathione
is low and glutathione precursors are available, the cell
mechanisms will form glutathione. If adequate glutathione is
present, additional glutathione is not produced. Cysteine or
cystine has been shown to be the rate-limiting factor in the
production of glutathione (Meister A, "New aspects of glutathione
biochemistry and transport-selective alteration of glutathione
metabolism," Nutrit Rev 1984; 42:397-410). Monitoring the level of
glutathione will maximize the dosing schedule for the glutathione
precursor being used.
[0089] Oral or intravenous NAC is normally not recommended as a
stand-alone therapy, but as a preliminary non-toxic therapy in
patients presenting with no symptoms or ambiguous symptoms, or for
particularly sensitive individuals such as pregnant women or
children for whom premature and ultimately unnecessary treatment
for symptoms determined to be unrelated to smallpox could have
undesired side effects. While the preferred mode is in combination
with a specific antiviral therapy there is no current consensus
that antiviral therapy would be effective. For individuals
intending to be immunized against smallpox it is useful to begin
oral NAC prior to the immunization. In the preferred mode the
individual would begin oral NAC at least two days prior to the
immunization. The use of NAC to maximize the effectiveness of
immunization may begin 2 weeks prior to immunization in situations
in which the vaccination is elective. The earlier use of NAC will
also help diminish side effects from the administration of the
vaccination.
[0090] In defense against Biological Terror weapons one of the
greatest problems is the anxiety created when presumed exposures
occur. It may be difficult to determine if the exposure has been
bacterial, viral, radiation or a combination of these materials.
The invention would also be useful for use as an initial
therapeutic for individuals who may have been exposed smallpox or
other toxin, and while confirmation and identification of exposure
is pending. In other words, antioxidant such as NAC, oral or IV, or
IV glutathione will attenuate the impact of the smallpox virus or
the severity of the infection, reducing the likelihood of severe
impact from the exposure and act as an attenuator of the virus
while confirmation of exposure is pending. The effect of NAC on the
immune system would be beneficial even if the biological weapon
turned out to be something other than smallpox or radiation as the
improved immune function would be useful in defending the
individual against viruses in general and enhances the antioxidant
capacity of the body (De Flora S, et al, Attenuation of
influenza-like symptomatology and improvement of cell-mediated
immunity with long-term N-acetylcysteine treatment, Eur Respir Jour
Vol. 10(7):1535-41 July 1997. The reduction in anxiety facilitated
by being able to initiate a therapy with minimal side effects that
enhances immune function as well as well reduces the impact of
toxins and radiation may be very beneficial to the health of
individuals as well as the general population. This is a reasonably
priced therapy with few if any side effects for persons presenting
with modest or ambiguous symptoms and who are awaiting confirmation
of exposure or definitive culture.
[0091] Positive identification of infection with smallpox justifies
aggressive intervention with antioxidant therapy because of the
severity of the infection and the lack of side effects from the
systemic antioxidant therapy. In the treatment of small pox
additional therapy with antiviral medication and antibiotic for
specific complications is warranted and will be enhanced by the use
of systemic antioxidant therapy achieved by oral or intravenous NAC
or its pharmaceutical equivalent referenced in this invention.
[0092] The invention may be packaged in the form of powdered NAC
either by itself or in combination with Selenium and/or DHEA for
convenience of use. This would be particularly advantageous to
individuals engaged in activities that require them to pack their
supplies such as soldiers in the field. The example of soldiers
typifies the situation in which availability of the invention for
prophylaxis, early treatment or aggressive treatment of exposure to
bioterror weapons is important. The invention may be prepackaged
with antibiotic and/or antiviral therapy to facilitate rapid, easy
use. Like wise the invention may be incorporated into a food
product using cold mixing techniques.
[0093] The use of laboratory assessment of the glutathione levels
and antioxidant capacity is useful in order to maximize the
therapy.
[0094] Assessment of the glutathione levels and antioxidant
capacity also defines a second population at risk for greater
susceptibility to infection as well as complications from smallpox
infection. Smallpox infection in unvaccinated populations has a
reported mortality rate of 30%. Large-scale studies have not been
done, but it is likely that populations deficient in glutathione
and overall antioxidant capacity are at greater risk due to their
inability to mount an adequate TH1 and NK cell response. The use of
baseline assessment of glutathione level and antioxidant capacity
early after concern of exposure will identify individuals who may
be at greater risk of progressing with smallpox after exposure or
of greater risk of complication. The use of NAC immediately prior
to at the time of immunization for smallpox will also lessen the
likelihood of developing a complication of the vaccination. As the
vaccine is composed of a live, less virulent form of "pox" virus
there is a risk estimated to be as high as 1:100,000 of developing
serious side-effects including encephalitis. The CDC estimates the
fatality rate of smallpox vaccination encephalitis to be as high as
50%
(http://www.bt.cdc.gov/agent/smallpox/vaccination/facts.asp).
Dosing
[0095] Selenium should also be administered 200 mg per day.
[0096] NAC IV infusion, 150 mg/Kg in 250 ml of D5W over 15
minutes
[0097] Followed by continuous infusion of 50 mg/kg in 500 ml over 4
hr
[0098] Has been demonstrated to be safe and effective in a small
study (Spapen H et al, "Does N-acetyl-L-cysteine influence cytokine
response during early human septic shock?," Chest, 113(6):1616-24
1998 June). The intravenous infusion could be continued to for as
long as needed depending on the individual's response to the
therapy.
[0099] Intravenous NAC is not normally recommended as a stand-alone
therapy, but is envisioned to be used in combination with
antibiotics when necessary. It would also be useful for use as an
initial therapeutic for individuals who may have been exposed, and
while confirmation of exposure is pending. In other words, an oral
or short IV dose will potentially attenuate the impact of the
anthrax, smallpox virus or radiation, reducing the likelihood of
severe infection from the biologic agent and acts as a preventative
while confirmation of exposure is pending. The effect of NAC on the
immune system would be beneficial even if the biological turned out
to be something other than smallpox as the improved immune function
would be useful in defending the individual against viruses (De
Flora S, et al, Eur Respir J Vol. 10(7):1535-41 July 1997.
[0100] Intravenous NAC is manufactured using pharmaceutical grade
NAC obtained from any major supplier of USP grade NAC, such as
Spectrum Chemical Mfg. Corp. 14422 S. San Pedro St., Gardena,
Calif. 90248. 8 grams of NAC are diluted in 100 ml sterile water or
saline for injection. The process is performed using a layer of
nitrogen gas to expel the excess oxygen overlying the liquid. This
step is done to maintain an oxygen free environment that will limit
the amount of oxidation that may occur during storage.
[0101] Oral dosage of NAC for prophylaxis is 500 mg. two or three
times a day.
[0102] Oral dosage for use prior to immunization is 500 mg. two to
three a day beginning two days prior to immunization. If it is not
possible to initiate NAC prior to immunization initiation of NAC at
the time of immunization is acceptable.
[0103] Intravenous glutathione is prepared in a similar fashion
using reduced L-glutathione obtained from any major supplier of USP
grade NAC, such as Spectrum Chemical, Gardena, Calif. The
glutathione is diluted in sterile water or saline using 200 mg
glutathione per ml of diluent. Doses range is 400-1200 mg per
day.
[0104] Glutathione may also be administered by inhalation with the
use of a nebulizer. The reduced form of L-glutathione can be mixed
in sterile saline in concentrations of 60 mg/ml, or 100 mg/ml and
administered as 2 ml to 4 times per day. The frequency of
administration will depend on the severity of the patient's
condition.
[0105] Inhaled glutathione 60 mg/ml may be mixed with NAC at a dose
of 125 mg/ml, and administered at a dose of 2 ml 2 to 4 times a
day.
[0106] DHEA in a dose sufficient to obtain the desired clinical
effect. Dosing may range from 50 mg per day for 5 days to 300 mg/kg
per day for 5 days.
[0107] Dosage for use for prophylaxis in adults if smallpox
exposure possible in the future and for use after routine
preventative vaccination with vaccinia: NAC 1000 mg per day in two
divided doses. This should be used on a continuous basis. Children
should use a dose of NAC equivalent to 14 mg/Kg of body weight
daily in divided doses. If using a whey protein concentrate such
asimmunocal the dose for Adults is 10 grams of whey protein a day
for children 1/2 pack per day.
[0108] Dosage for use after small pox exposure with or without
vaccination: Adults--NAC 2000 mg per day in two or four divided
doses. Children--14-20 mg/Kg body weight daily in divided
doses.
[0109] Doses for use for prophylaxis of exposure to radiation:
Adults--NAC 1000 mg per day in two divided doses. This should be
used on a continuous basis. Children--should use a dose of NAC
equivalent to 14 mg/Kg of body weight daily in divided doses. If
using a whey protein concentrate such as Immunocal the dose for
Adults is 20 grams of whey protein a day for children 1/2 to 1 pack
per day. These doses should be continued for the duration of the
exposure and for 2 to 4 weeks after the exposure. If the exposure
is high dose radiation, the dosage should be continued for 6
months.
[0110] Dosage for use if anthrax or smallpox infection is likely or
effects of infection are suspected: Use the doses recommended for
exposure to smallpox combined with the use of intravenous NAC:
loading is 150 mg/kg in 250 ml of D5W, over 15 minutes. This was
followed by continuous infusion of 50 mg/kg in 500 ml over 4 hrs.
In a 70 kg man this translates to 10.5 grams (10,500 mg) over 15
minutes. This dose is then followed by 3500 mg (3.5 gms) over 4
hours. The total is 14 gms in 4 hours. The patient may be continued
on oral NAC using the dosage for post exposure. This dose may be
supplemented with inhaled glutathione 60 mg/ml, 2 ml 2 to 4 times a
day. Additionally intravenous glutathione may be used particularly
if there are signs of central nervous system involvement using a
dose of 600 mg twice a day. The addition of DHEA with Dosing ranges
from 50 mg per day for 5 days to 300 mg/kg per day for 5 days is
recommended.
[0111] Doses for use for prophylaxis of exposure to radiation: NAC
1000 mg per day in two divided doses. This should be used on a
continuous basis. Children should use a dose of NAC equivalent to
14 mg/Kg of body weight daily in divided doses. If using a whey
protein concentrate such as Immunocal the dose for Adults is 20
grams of whey protein a day for children 1/2 to 1 pack per day.
[0112] Dosage for use after radiation exposure: Adults--NAC 2000 to
4000 mg per day in two or four divided doses. Children--14-20 mg/Kg
body weight daily in divided doses. If using a whey protein
concentrate such as Immunocal the dose for Adults is 20-30 grams of
whey protein a day for children 1/2 to 1 pack per day. The addition
of DHEA with Dosing ranges from 50 mg per day for 5 days to 300
mg/kg per day for 5 days is recommended.
[0113] If symptoms of radiation toxicity are developing Use the
doses recommended for exposure to radiation combined with the use
of intravenous NAC: loading is 150 mg/kg in 250 ml of D5W, over 15
minutes. This was followed by continuous infusion of 50 mg/kg in
500 ml over 4 hrs. In a 70 kg man this translates to 10.5 grams
(10,500 mg) over 15 minutes. This dose is then followed by 3500 mg
(3.5 gms) over 4 hours. The total is 14 gms in 4 hours. The patient
may be continued on oral NAC using the dosage for post
exposure.
[0114] This dose may be supplemented with inhaled glutathione 60
mg/ml, 2 ml to 4 times a day. Additionally Intravenous glutathione
may be used particularly if there are signs of central nervous
system involvement using a dose of 600 mg twice a day. The addition
of DHEA with Dosing ranges from 50 mg per day for 5 days to 300
mg/kg per day for 5 days is recommended.
[0115] Dosage for use if effects of infection related to Biological
terror weapon other than anthrax or smallpox, such as another virus
are suspected: Use the doses recommended for exposure to smallpox
combined with the use of intravenous NAC: loading is 150 mg/kg in
250 ml of D5W, over 15 minutes. This was followed by continuous
infusion of 50 mg/kg in 500 ml over 4 hrs. In a 70 kg man this
translates to 10.5 grams (10,500 mg) over 15 minutes. This dose is
then followed by 3500 mg (3.5 gms) over 4 hours. The total is 14
gms in 4 hours. The patient may be continued on oral NAC using the
dosage for post exposure.
[0116] This dose may be supplemented with inhaled glutathione 60
mg/ml, 2 ml 2 to 4 times a day. Additionally Intravenous
glutathione may be used particularly if there are signs of central
nervous system involvement using a dose of 600 mg twice a day. The
addition of DHEA with Dosing ranges from 50 mg per day for 5 days
to 300 mg/kg per day for 5 days is recommended.
Management Information:
[0117] Intravenous NAC has a small risk as noted in a small group
of patients given IV NAC. Rare episodes of "anaphylactoid" reaction
manageable with benedryl have been reported (Bailey B et al Ann
Emerg Med, 31(6):710-5 1998). It has been observed that NAC
infusion may be restarted shortly after initiating benedryl without
risk. "Non-life-threatening anaphylactoid reactions to intravenous
NAC are treated easily and the infusion may be continued or
restarted safely after the administration of diphenhydramine"
(Bailey B et al, Ann Emerg Med, 31(6):710-5 1998). Intravenous
glutathione will have no greater incidence of reaction than
intravenous NAC. While administering intravenous glutathione in
numerous cases, no episodes of reactions have been observed by the
inventors.
[0118] An excess of glutathione (GSH) does not appear practically
possible with the use of NAC. The formation of GSH inside of cells
is regulated by a feedback mechanism that prevents excess formation
as the level of glutathione regulates the formation of additional
glutathione. Thus, there is no concern that an excess of
glutathione will be formed. As the glutathione is depleted,
additional glutathione is formed. In deficient states, the
availability of the amino acid cysteine becomes the rate-limiting
factor in the synthesis of GSH (Meister A, "New aspects of
glutathione biochemistry and transport-selective alteration of
glutathione metabolism," Nutrit Rev Vol. 42:397-410, 1984.). Oral
glutathione has not been demonstrated to increase the level of
glutathione in the White Blood Cells (Meister A, "New aspects of
glutathione biochemistry and transport-selective alteration of
glutathione metabolism," Nutrit Rev Vol. 42:397-410, 1984.). Thus,
it was initially conjectured that intravenous glutathione would
have little beneficial effect. The observation of reduction in the
severity of tremor in patients with Parkinson's disease strongly
suggests that IV glutathione transits the blood brain barrier and
is absorbed into cells (Such G, "Reduced glutathione in the
treatment of early Parkinson's disease" Neuropsychopharmacology
Biology Psychology October, 1996). This feature of the invention
will help reduce the incidence of meningitis associated with viral
infection such as small pox.
[0119] The invention also refers to not only combinations, but also
methods of treatment, including serial or combined doses of the
substances suggested above, and methods of manufacturing them in
tandem. The intent is to administer therapeutic doses of the
substances referred to herein. The term "therapeutic dose" is
intended to mean that amount of a drug or pharmaceutical agent that
will elicit the biological or medical response of a tissue, a
system, animal or human that is being sought by a researcher,
veterinarian, medical doctor or other clinician. The term
"prophylactically effective amount" is intended to mean that amount
of a pharmaceutical drug that will prevent or reduce the risk of
occurrence of the biological or medical event that is sought to be
prevented in a tissue, a system, animal or human by a researcher,
veterinarian, medical doctor or other clinician. A consideration of
these factors is well within the purview of the ordinarily skilled
clinician for the purpose of determining the therapeutically
effective or prophylactically effective amount. "Therapeutic
window" is the therapeutic dose between the minimum amount of and
the maximum amount of a pharmaceutical drug that will prevent or
reduce the risk of occurrence of the biological or medical event
that is sought to be prevented in a tissue, a system, animal or
human by a researcher, veterinarian, medical doctor or other
clinician. A "prophylactic dose" dose contemplates a dose that may
be slightly less than the normal minimum amount of a pharmaceutical
drug that will treat a biological or medical event that is sought
to be overcome in a tissue, a system, animal or human by a
researcher, veterinarian, medical doctor or other clinician, and
addresses the problem of minimizing the toxicity of many drugs
while having at least some of the drug present in the mammalian
system to reduce the time before effective treatment by a drug
begins.
[0120] The invention is not meant to be limited to the disclosures,
including best mode of invention herein, and contemplates all
equivalents to the invention and similar embodiments to the
invention for humans and mammals and veterinary science.
Equivalents include all pharmacologically active racemic mixtures,
diastereomers and enantiomers of the listed compounds and their
pharmacologically acceptable salts in any pharmaceutically
acceptable carrier.
* * * * *
References