U.S. patent application number 13/332239 was filed with the patent office on 2012-04-19 for treatment of autoimmune disorders with a neurotoxin.
This patent application is currently assigned to ALLERGAN, INC.. Invention is credited to Kenneth L. Tong, Pamela D. Van Schaack.
Application Number | 20120093827 13/332239 |
Document ID | / |
Family ID | 37441984 |
Filed Date | 2012-04-19 |
United States Patent
Application |
20120093827 |
Kind Code |
A1 |
Van Schaack; Pamela D. ; et
al. |
April 19, 2012 |
TREATMENT OF AUTOIMMUNE DISORDERS WITH A NEUROTOXIN
Abstract
Methods of treating one or more autoimmune disorders include a
step of administering a Clostridial neurotoxin, such as a botulinum
toxin, to a patient that has an autoimmune disorder. In one aspect,
a method includes a step of administering the neurotoxin to the
thymus gland or near the thymus gland of the patient. In another
aspect, a method includes a step of administering the neurotoxin in
combination with administering a cytokine inhibitor to the patient.
Compositions are also described.
Inventors: |
Van Schaack; Pamela D.;
(Costa Mesa, CA) ; Tong; Kenneth L.; (Carlsbad,
CA) |
Assignee: |
ALLERGAN, INC.
Irvine
CA
|
Family ID: |
37441984 |
Appl. No.: |
13/332239 |
Filed: |
December 20, 2011 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
|
11156502 |
Jun 17, 2005 |
8105611 |
|
|
13332239 |
|
|
|
|
Current U.S.
Class: |
424/145.1 ;
424/239.1 |
Current CPC
Class: |
A61P 37/00 20180101;
A61P 37/06 20180101; A61P 21/04 20180101; A61K 9/0019 20130101;
A61K 38/4893 20130101; A61P 25/00 20180101; A61P 29/00 20180101;
A61P 35/00 20180101; A61K 9/0024 20130101; A61P 37/02 20180101;
A61K 38/4893 20130101; A61K 2300/00 20130101 |
Class at
Publication: |
424/145.1 ;
424/239.1 |
International
Class: |
A61K 39/08 20060101
A61K039/08; A61P 37/00 20060101 A61P037/00; A61K 39/395 20060101
A61K039/395 |
Claims
1. A pharmaceutical composition comprising a Clostridial neurotoxin
and at least one cytokine inhibitor present in amounts effective to
treat an autoimmune disorder
2. The composition of claim 1, wherein the Clostridial neurotoxin
is selected from the group consisting of botulinum toxins types A,
B, C.sub.1, D, E, F, and G.
3. The composition of claim 1, wherein the Clostridial neurotoxin
is botulinum toxin type A.
Description
CROSS REFERENCE
[0001] This application is a continuation of application Ser. No.
11/156,502 filed Jun. 17, 2005, the entire contents of which
application is incorporated herein by reference.
BACKGROUND
[0002] The present invention relates to treatment of autoimmune
disorders using a neurotoxin, and more particularly to methods and
compositions for treating autoimmune disorders using a Clostridial
neurotoxin.
Immune System
[0003] The immune system is the body's first line of defense
involving a complex of organs, glands, highly specialized cells,
and a circulatory system working together to clear infection from
the body. The immune system includes two major parts. One part may
be referred to as the humoral immune system and is involved in the
production of antibodies. The second part may be referred to as the
cellular immune system and is the component that includes thymic
lymphocytes (T lymphocytes or T cells).
[0004] Activated T cells are formed from white blood cells passing
through the thymus gland located in the chest of a human patient.
The thymus consists of two lobes connected by areolar tissue. The
lobes are enclosed in a fibrous capsule which divides the lobes
into lobules that consist of an irregular branching framework of
epithelial cells and lymphocytes. The thymus contains three major
cell populations: (1) epithelial cells, (2) hemopoietic cells, and
(3) accessory cells.
[0005] Epithelial cells seem to be mainly responsible for the
creation of the necessary microenvironments and their factors.
Epithelial cells promote different steps of intrathymic T-cell
differentiation and maturation. There appears to be at least six
different types of epithelial cells: type
1--subcapsular-perivascular cells; type 2--pale epithelial cells,
which predominate in the outer cortex; type 3--thymic nurse cells
that have the unique feature of emperipolesis; type 4--dark cells
that are typical in the medulla; type 5--undifferentiated cells
that are typical in the medulla; type 6--large medullary cells that
are found around and in the Hassall corpuscles.
[0006] The hemopoietic cells include three different types of
lymphoid cells: (1) subcapsular cells; (2) cortical cells; and (3)
medullary cells.
[0007] Thymic accessory cells include macrophages that secrete a
thymocyte-differentiating factor that is mitogenic and induces
functional maturation of the thymocyte; interdigitating cells,
which have a role in determining which T-cell precursors are
activated (helper or killer) during an immunological challenge; and
myoid cells which appear to express acetylcholine receptors and
have a possible role in myasthenia gravis, and may have a role in
expelling thymocytes from the thymus gland.
[0008] Cells of the thymus appear to express acetylcholine
receptors. For example, cholinergic receptors have bound found on
the epithelial cells of the thymus. The thymus appears to also
receive neuronal innervation from the hypothalamus, which may
influence thymic hormones and the immune system in general.
[0009] Lymphocytes originate from haemocytoblasts (stem cells) in
red bone marrow. The lymphocytes appear to be attracted to the
thymus by chemotactic factors produced by epithelial cells. Those
lymphocytes that enter the thymus mature and develop into activated
T-lymphocytes or activated T-cells. The activated T-cells are able
to respond to antigens encountered elsewhere in the body. The
T-cells can divide into two groups: (1) a group that enters the
blood, some of which remain in circulation and some lodge in other
lymphoid tissue; and (2) a group that remains in the thymus gland
and are the source of future generations of T-cells.
[0010] T cells are believed to carry out three defensive functions:
(1) they stimulate the production and growth of antibodies by other
lymphocytes; (2) they stimulate the growth and action of
phagocytes, which surround and engulf invading viruses and
microbes, and (3) they recognize and destroy foreign and abnormal
tissue. Thus, the thymus gland plays a critically important role in
the body's response to disease invasion. The thymus gland and T
cell function play such a pivotal and important role in generating
and regulating immune response that a deficiency or imbalance in
their function will cause immune system dysfunction.
[0011] Autoimmune disorders are diseases caused by an immune
response against the body's own cells or tissues. Autoimmune
disorders result in destruction of one or more types of body
tissues, abnormal growth of an organ or organs, or changes in organ
function or functions. The disorders may affect only one organ or
tissue type or may affect multiple organs and tissue types. In
addition, a person may experience one or more autoimmune disorders
at the same time. Organs and tissues commonly affected by
autoimmune disorders include blood components such as red blood
cells, blood vessels, connective tissues, endocrine glands such as
the thyroid or pancreas, muscles, joints, and skin.
[0012] Autoimmune disorders can be categorized into two general
types: (1) systemic autoimmune diseases (i.e., disorders that
damage many organs or tissues), and (2) localized autoimmune
diseases (i.e., disorders that damage only a single organ or
tissue). However, the effect of localized autoimmune diseases, can
be systemic by indirectly affecting other body organs and
systems.
[0013] Systemic autoimmune diseases include without limitation:
rheumatoid arthritis which can affect joints, and possibly lung and
skin; lupus, including systemic lupus erythematosus (SLE), which
can affect skin, joints, kidneys, heart, brain, red blood cells, as
well as other tissues and organs; scleroderma, which can affect
skin, intestine, and lungs; Sjogren's syndrome, which can affect
salivary glands, tear glands, and joints; Goodpasture's syndrome,
which can affect lungs and kidneys; Wegener's granulomatosis, which
can affect sinuses, lungs, and kidneys; polymyalgia rheumatica,
which can affect large muscle groups, and temporal arteritis/giant
cell arteritis, which can affect arteries of the head and neck.
[0014] Localized autoimmune diseases include without limitation:
Type 1 Diabetes Mellitus, which affects pancreas islets;
Hashimoto's thyroiditis and Graves' disease, which affect the
thyroid; celiac disease, Crohn's diseases, and ulcerative colitis,
which affect the gastrointestinal tract; multiple sclerosis (MS)
and Guillain-Barre syndrome, which affect the central nervous
system; Addison's disease, which affects the adrenal glands;
primary biliary sclerosis, sclerosing cholangitis, and autoimmune
hepatitis, which affect the liver; and Raynaud's phenomenon, which
can affect the fingers, toes, nose, ears.
[0015] The following are additional examples of autoimmune
disorders: pernicious anemia; Addison's disease; dermatomyositis;
myasthenia gravis (MG); Reiter's syndrome; Pemphigus vulgaris;
scleroderma or CREST syndrome; autoimmune hemolytic anemia;
autoimmune thrombocytopenic purpura; ankylosing spondylitis;
vasculitis; and amyotrophic lateral schlerosis (Lou Gehrig's
disease).
[0016] Symptoms of autoimmune disorders can vary widely depending
on the type of disease. Commonly observed symptoms include fatigue,
dizziness, malaise, and fever. Other symptoms that may be observed
in one or more autoimmune disorders include chills, weight loss,
skin rashes, vasculitis, polyarthralgia, patchy hair loss, oral and
nasal sores, lymph-node enlargement, gastric problems, generalized
pain, which may be located in the joints in the case of arthritis,
enlarged glands, such as the thyroid in the case of Grave's
disease, heart palpitations, dermal blisters and lesions, muscle
weakness.
[0017] Treatment of autoimmune diseases is specific to the disease,
and usually concentrates on alleviating or preventing symptoms
rather than correcting the underlying cause.
[0018] One treatment used in certain autoimmune disorders is
administration of cholinesterase inhibitors, which decrease
hydrolysis of the neurotransmitter acetylcholine, and thereby
increase the amount of acetylcholine available in the synaptic
cleft and providing symptomatic relief by increasing stimulation of
cholinergic receptors throughout the central and peripheral nervous
systems.
[0019] Another treatment of autoimmune disorders involves the use
of steroids, including corticosteroids, to control or reduce
inflammation. Corticosteroids usually are reserved for patients who
fail to respond to or do not tolerate anticholinesterase
therapy.
[0020] A third approach is the administration of immunosuppressive
agent, such as azothioprine, to control or reduce the proliferative
nature of the immune response. These drugs work by inhibiting the
replication of cells and, therefore, also suppress non-immune cells
leading to side effects such as anemia.
[0021] A fourth approach involves the surgical removal of the
thymus gland (i.e., thymectomy).
[0022] Another treatment of autoimmune diseases includes the
administration of cytokine inhibitors.
[0023] Human cytokine overexpression and/or underexpression can
result in diseases such as inflammatory bowel disease, arthritis,
and systemic lupus erythematosus (Mackay et al., N. Engl J Med,
345(5):340-350, 2001). Arthritis is a common chronic inflammatory
and destructive arthropathy due to the overexpression of tumor
necrosis factor alpha (TNF-alpha) and/or underexpression of
Interleukin-1 (IL-1) receptor antagonist resulting in a
cell-mediated immune response causing inflammation and joint damage
(Mackay et al., supra; Choy et al., N. Engl. J. Med,
344(12):907-916, 2001).
[0024] Cytokine inhibitors include soluble human cytokine receptor
proteins (e.g., etanercept), monoclonal antibodies (e.g.,
rituxamab, infliximab, D2E7, and nerelimomab), and cytokine
receptor blockers (e.g., interleukin 1 receptor antagonist). Such
inhibitors have been reported to be effective in treating arthritis
(Choy et al., supra), asthma (Xolair package insert, Genentech,
2003), and type 1 diabetes mellitus (Herold et al., N. Engl. J.
Med., 346(22):1692-1698, 2002). Cytokine inhibitors, specifically
monoclonal antibodies, are unique as these agents target specific
antigens that grow on the surface of cells (e.g., cancer cells).
Radioimmunotherapy consists of a radioactive substance linked to an
antibody. This combination provides a targeted delivery (monoclonal
antibody) and treatment (radioactive substance) for a specific
disease.
Botulinum Toxin
[0025] The genus Clostridium has more than one hundred and twenty
seven species, grouped according to their morphology and functions.
The anaerobic, gram positive bacterium Clostridium botulinum
produces a potent polypeptide neurotoxin, botulinum toxin, which
causes a neuroparalytic illness in humans and animals referred to
as botulism. The spores of Clostridium botulinum are found in soil
and can grow in improperly sterilized and sealed food containers of
home based canneries, which are the cause of many of the cases of
botulism. The effects of botulism typically appear 18 to 36 hours
after eating the foodstuffs infected with a Clostridium botulinum
culture or spores. The botulinum toxin can apparently pass
unattenuated through the lining of the gut and attack peripheral
motor neurons. Symptoms of botulinum toxin intoxication can
progress from difficulty walking, swallowing, and speaking to
paralysis of the respiratory muscles and death.
[0026] Botulinum toxin type A is the most lethal natural biological
agent known to man. About 50 picograms of a commercially available
botulinum toxin type A (purified neurotoxin complex).sup.1 is a
LD50 in mice (i.e. 1 unit). One unit of BOTOX..RTM.. contains about
50 picograms (about 56 attomoles) of botulinum toxin type A
complex. Interestingly, on a molar basis, botulinum toxin type A is
about 1.8 billion times more lethal than diphtheria, about 600
million times more lethal than sodium cyanide, about 30 million
times more lethal than cobra toxin and about 12 million times more
lethal than cholera. Singh, Critical Aspects of Bacterial Protein
Toxins, pages 63-84 (chapter 4) of Natural Toxins II, edited by B.
R. Singh et al., Plenum Press, New York (1976) (where the stated
LD50 of botulinum toxin type A of 0.3 ng equals 1 U is corrected
for the fact that about 0.05 ng of BOTOX..RTM.. equals 1 unit). One
unit (U) of botulinum toxin is defined as the LD50 upon
intraperitoneal injection into female Swiss Webster mice weighing
18 to 20 grams each. Available from Allergan, Inc., of Irvine,
Calif. under the tradename BOTOX..RTM.. in 100 unit vials)
[0027] Seven generally immunologically distinct botulinum
neurotoxins have been characterized, these being respectively
botulinum neurotoxin serotypes A, B, C1, D, E, F and G each of
which is distinguished by neutralization with type-specific
antibodies. The different serotypes of botulinum toxin vary in the
animal species that they affect and in the severity and duration of
the paralysis they evoke. For example, it has been determined that
botulinum toxin type A is 500 times more potent, as measured by the
rate of paralysis produced in the rat, than is botulinum toxin type
B. Additionally, botulinum toxin type B has been determined to be
non-toxic in primates at a dose of 480 U/kg which is about 12 times
the primate LD50 for botulinum toxin type A. Moyer E et al.,
Botulinum Toxin Type B: Experimental and Clinical Experience, being
chapter 6, pages 71-85 of "Therapy With Botulinum Toxin", edited by
Jankovic, J. et al. (1994), Marcel Dekker, Inc. Botulinum toxin
apparently binds with high affinity to cholinergic motor neurons,
is translocated into the neuron and blocks the release of
acetylcholine. Additional uptake can take place through low
affinity receptors, as well as by phagocytosis and pinocytosis.
[0028] Regardless of serotype, the molecular mechanism of toxin
intoxication appears to be similar and to involve at least three
steps or stages. In the first step of the process, the toxin binds
to the presynaptic membrane of the target neuron through a specific
interaction between the heavy chain, H chain, and a cell surface
receptor; the receptor is thought to be different for each type of
botulinum toxin and for tetanus toxin. The carboxyl end segment of
the H chain, HC, appears to be important for targeting of the toxin
to the cell surface.
[0029] In the second step, the toxin crosses the plasma membrane of
the poisoned cell. The toxin is first engulfed by the cell through
receptor-mediated endocytosis, and an endosome containing the toxin
is formed. The toxin then escapes the endosome into the cytoplasm
of the cell. This step is thought to be mediated by the amino end
segment of the H chain, HN, which triggers a conformational change
of the toxin in response to a pH of about 5.5 or lower. Endosomes
are known to possess a proton pump which decreases intra-endosomal
pH. The conformational shift exposes hydrophobic residues in the
toxin, which permits the toxin to embed itself in the endosomal
membrane. The toxin (or at a minimum the light chain) then
translocates through the endosomal membrane into the cytoplasm.
[0030] The last step of the mechanism of botulinum toxin activity
appears to involve reduction of the disulfide bond joining the
heavy chain, H chain, and the light chain, L chain. The entire
toxic activity of botulinum and tetanus toxins is contained in the
L chain of the holotoxin; the L chain is a zinc (Zn++)
endopeptidase which selectively cleaves proteins essential for
recognition and docking of neurotransmitter-containing vesicles
with the cytoplasmic surface of the plasma membrane, and fusion of
the vesicles with the plasma membrane. Tetanus neurotoxin,
botulinum toxin types B, D, F, and G cause degradation of
synaptobrevin (also called vesicle-associated membrane protein
(VAMP)), a synaptosomal membrane protein. Most of the VAMP present
at the cytoplasmic surface of the synaptic vesicle is removed as a
result of any one of these cleavage events. Botulinum toxin
serotype A and E cleave SNAP-25. Botulinum toxin serotype C1 was
originally thought to cleave syntaxin, but was found to cleave
syntaxin and SNAP-25. Each of the botulinum toxins specifically
cleaves a different bond, except botulinum toxin type B (and
tetanus toxin) which cleave the same bond. Each of these cleavages
block the process of vesicle-membrane docking, thereby preventing
exocytosis of vesicle content.
[0031] Botulinum toxins have been used in clinical settings for the
treatment of neuromuscular disorders characterized by hyperactive
skeletal muscles (i.e. motor disorders). In 1989 a botulinum toxin
type A complex has been approved by the U.S. Food and Drug
Administration for the treatment of blepharospasm, strabismus and
hemifacial spasm. Subsequently, a botulinum toxin type A was also
approved by the FDA for the treatment of cervical dystonia and for
the treatment of glabellar lines, and a botulinum toxin type B was
approved for the treatment of cervical dystonia. Non-type A
botulinum toxin serotypes apparently have a lower potency and/or a
shorter duration of activity as compared to botulinum toxin type A.
Clinical effects of peripheral intramuscular botulinum toxin type A
are usually seen within one week of injection. The typical duration
of symptomatic relief from a single intramuscular injection of
botulinum toxin type A averages about three months, although
significantly longer periods of therapeutic activity have been
reported.
[0032] Although all the botulinum toxins serotypes apparently
inhibit release of the neurotransmitter acetylcholine at the
neuromuscular junction, they do so by affecting different
neurosecretory proteins and/or cleaving these proteins at different
sites. For example, botulinum types A and E both cleave the 25
kiloDalton (kD) synaptosomal associated protein (SNAP-25), but they
target different amino acid sequences within this protein.
Botulinum toxin types B, D, F and G act on vesicle-associated
protein (VAMP, also called synaptobrevin), with each serotype
cleaving the protein at a different site. Finally, botulinum toxin
type C1 has been shown to cleave both syntaxin and SNAP-25. These
differences in mechanism of action may affect the relative potency
and/or duration of action of the various botulinum toxin serotypes.
Apparently, a substrate for a botulinum toxin can be found in a
variety of different cell types. See e.g. Biochem J 1; 339 (pt
1):159-65:1999, and Mov Disord, 10(3):376:1995 (pancreatic islet B
cells contains at least SNAP-25 and synaptobrevin).
[0033] The molecular weight of the botulinum toxin protein
molecule, for all seven of the known botulinum toxin serotypes, is
about 150 kD. Interestingly, the botulinum toxins are released by
Clostridial bacterium as complexes comprising the 150 kD botulinum
toxin protein molecule along with associated non-toxin proteins.
Thus, the botulinum toxin type A complex can be produced by
Clostridial bacterium as 900 kD, 500 kD and 300 kD forms. Botulinum
toxin types B and C1 is apparently produced as only a 700 kD or 500
kD complex. Botulinum toxin type D is produced as both 300 kD and
500 kD complexes. Finally, botulinum toxin types E and F are
produced as only approximately 300 kD complexes. The complexes
(i.e. molecular weight greater than about 150 kD) are believed to
contain a non-toxin hemaglutinin protein and a non-toxin and
non-toxic nonhemaglutinin protein. These two non-toxin proteins
(which along with the botulinum toxin molecule comprise the
relevant neurotoxin complex) may act to provide stability against
denaturation to the botulinum toxin molecule and protection against
digestive acids when toxin is ingested. Additionally, it is
possible that the larger (greater than about 150 kD molecular
weight) botulinum toxin complexes may result in a slower rate of
diffusion of the botulinum toxin away from a site of intramuscular
injection of a botulinum toxin complex.
[0034] In vitro studies have indicated that botulinum toxin
inhibits potassium cation induced release of both acetylcholine and
norepinephrine from primary cell cultures of brainstem tissue.
Additionally, it has been reported that botulinum toxin inhibits
the evoked release of both glycine and glutamate in primary
cultures of spinal cord neurons and that in brain synaptosome
preparations botulinum toxin inhibits the release of each of the
neurotransmitters acetylcholine, dopamine, norepinephrine
(Habermann E., et al., Tetanus Toxin and Botulinum A and C
Neurotoxins Inhibit Noradrenaline Release From Cultured Mouse
Brain, J Neurochem 51(2); 522-527:1988) CGRP, substance P and
glutamate (Sanchez-Prieto, J., et al., Botulinum Toxin A Blocks
Glutamate Exocytosis From Guinea Pig Cerebral Cortical
Synaptosomes, Eur J. Biochem 165; 675-681:1897. Thus, when adequate
concentrations are used, stimulus-evoked release of most
neurotransmitters is blocked by botulinum toxin. See e.g. Pearce,
L. B., Pharmacologic Characterization of Botulinum Toxin For Basic
Science and Medicine, Toxicon 35(9); 1373-1412 at 1393; Bigalke H.,
et al., Botulinum A Neurotoxin Inhibits Non-Cholinergic Synaptic
Transmission in Mouse Spinal Cord Neurons in Culture, Brain
Research 360; 318-324:1985; Habermann E., Inhibition by Tetanus and
Botulinum A Toxin of the release of [3H]Noradrenaline and [3H]GABA
From Rat Brain Homogenate, Experientia 44; 224-226:1988, Bigalke
H., et al., Tetanus Toxin and Botulinum A Toxin Inhibit Release and
Uptake of Various Transmitters, as Studied with Particulate
Preparations From Rat Brain and Spinal Cord, Naunyn-Schmiedeberg's
Arch Pharmacol 316; 244-251:1981, and; Jankovic J. et al., Therapy
With Botulinum Toxin, Marcel Dekker, Inc., (1994), page 5.
[0035] Botulinum toxin type A can be obtained by establishing and
growing cultures of Clostridium botulinum in a fermenter and then
harvesting and purifying the fermented mixture in accordance with
known procedures. All the botulinum toxin serotypes are initially
synthesized as inactive single chain proteins which must be cleaved
or nicked by proteases to become neuroactive. The bacterial strains
that make botulinum toxin serotypes A and G possess endogenous
proteases and serotypes A and G can therefore be recovered from
bacterial cultures in predominantly their active form. In contrast,
botulinum toxin serotypes C1, D and E are synthesized by
nonproteolytic strains and are therefore typically unactivated when
recovered from culture. Serotypes B and F are produced by both
proteolytic and nonproteolytic strains and therefore can be
recovered in either the active or inactive form. However, even the
proteolytic strains that produce, for example, the botulinum toxin
type B serotype only cleave a portion of the toxin produced. The
exact proportion of nicked to unnicked molecules depends on the
length of incubation and the temperature of the culture. Therefore,
a certain percentage of any preparation of, for example, the
botulinum toxin type B toxin is likely to be inactive, possibly
accounting for the known significantly lower potency of botulinum
toxin type B as compared to botulinum toxin type A. The presence of
inactive botulinum toxin molecules in a clinical preparation will
contribute to the overall protein load of the preparation, which
has been linked to increased antigenicity, without contributing to
its clinical efficacy. Additionally, it is known that botulinum
toxin type B has, upon intramuscular injection, a shorter duration
of activity and is also less potent than botulinum toxin type A at
the same dose level.
[0036] High quality crystalline botulinum toxin type A can be
produced from the Hall A strain of Clostridium botulinum with
characteristics of .gtoreq.3.times.10.sup.7 U/mg, an
A.sub.260/A.sub.278 of less than 0.60 and a distinct pattern of
banding on gel electrophoresis. The known Shantz process can be
used to obtain crystalline botulinum toxin type A, as set forth in
Shantz, E. J., et al, Properties and use of Botulinum toxin and
Other Microbial Neurotoxins in Medicine, Microbiol Rev. 56;
80-99:1992. Generally, the botulinum toxin type A complex can be
isolated and purified from an anaerobic fermentation by cultivating
Clostridium botulinum type A in a suitable medium. The known
process can also be used, upon separation out of the non-toxin
proteins, to obtain pure botulinum toxins, such as for example:
purified botulinum toxin type A with an approximately 150 kD
molecular weight with a specific potency of 1-2.times.10.sup.8 LD50
U/mg or greater; purified botulinum toxin type B with an
approximately 156 kD molecular weight with a specific potency of
1-2.times.10.sup.8 LD50 U/mg or greater, and; purified botulinum
toxin type F with an approximately 155 kD molecular weight with a
specific potency of 1-2.times.10.sup.7 LD50 U/mg or greater.
[0037] Botulinum toxins and/or botulinum toxin complexes can be
obtained from List Biological Laboratories, Inc., Campbell, Calif.;
the Centre for Applied Microbiology and Research, Porton Down,
U.K.; Wako (Osaka, Japan), Metabiologics (Madison, Wis.) as well as
from Sigma Chemicals of St Louis, Mo. Pure botulinum toxin can also
be used to prepare a pharmaceutical composition.
[0038] As with enzymes generally, the biological activities of the
botulinum toxins (which are intracellular peptidases) is dependant,
at least in part, upon their three dimensional conformation. Thus,
botulinum toxin type A is detoxified by heat, various chemicals
surface stretching and surface drying. Additionally, it is known
that dilution of the toxin complex obtained by the known culturing,
fermentation and purification to the much, much lower toxin
concentrations used for pharmaceutical composition formulation
results in rapid detoxification of the toxin unless a suitable
stabilizing agent is present. Dilution of the toxin from milligram
quantities to a solution containing nanograms per milliliter
presents significant difficulties because of the rapid loss of
specific toxicity upon such great dilution. Since the toxin may be
used months or years after the toxin containing pharmaceutical
composition is formulated, the toxin can stabilized with a
stabilizing agent such as albumin and gelatin.
[0039] A commercially available botulinum toxin containing
pharmaceutical composition is sold under the trademark BOTOX.RTM.
(available from Allergan, Inc., of Irvine, Calif.). BOTOX.RTM.
consists of a purified botulinum toxin type A complex, albumin and
sodium chloride packaged in sterile, vacuum-dried form. The
botulinum toxin type A is made from a culture of the Hall strain of
Clostridium botulinum grown in a medium containing N-Z amine and
yeast extract. The botulinum toxin type A complex is purified from
the culture solution by a series of acid precipitations to a
crystalline complex consisting of the active high molecular weight
toxin protein and an associated hemagglutinin protein. The
crystalline complex is re-dissolved in a solution containing saline
and albumin and sterile filtered (0.2 microns) prior to
vacuum-drying. The vacuum-dried product is stored in a freezer at
or below -5.degree. C. BOTOX.RTM. can be reconstituted with
sterile, non-preserved saline prior to intramuscular injection.
Each vial of BOTOX.RTM. contains about 100 units (U) of Clostridium
botulinum toxin type A purified neurotoxin complex, 0.5 milligrams
of human serum albumin and 0.9 milligrams of sodium chloride in a
sterile, vacuum-dried form without a preservative.
[0040] To reconstitute vacuum-dried BOTOX.RTM., sterile normal
saline without a preservative; (0.9% Sodium Chloride Injection) is
used by drawing up the proper amount of diluent in the appropriate
size syringe. Since BOTOX.RTM. may be denatured by bubbling or
similar violent agitation, the diluent is gently injected into the
vial. For sterility reasons BOTOX.RTM. is preferably administered
within four hours after the vial is removed from the freezer and
reconstituted. During these four hours, reconstituted BOTOX.RTM.
can be stored in a refrigerator at about 2.degree. C. to about
8.degree. C. Reconstituted, refrigerated BOTOX.RTM. has been
reported to retain its potency for at least about two weeks.
Neurology, 48:249-53:1997.
[0041] It has been reported that botulinum toxin type A has been
used in clinical settings as follows:
[0042] (1) about 75-125 units of BOTOX.RTM. per intramuscular
injection (multiple muscles) to treat cervical dystonia;
[0043] (2) 5-10 units of BOTOX.RTM. per intramuscular injection to
treat glabellar lines (brow furrows) (5 units injected
intramuscularly into the procerus muscle and 10 units injected
intramuscularly into each corrugator supercihii muscle);
[0044] (3) about 30-80 units of BOTOX.RTM. to treat constipation by
intrasphincter injection of the puborectalis muscle;
[0045] (4) about 1-5 units per muscle of intramuscularly injected
BOTOX.RTM. to treat blepharospasm by injecting the lateral
pre-tarsal orbicularis oculi muscle of the upper lid and the
lateral pre-tarsal orbicularis oculi of the lower lid.
[0046] (5) to treat strabismus, extraocular muscles have been
injected intramuscularly with between about 1-5 units of
BOTOX.RTM., the amount injected varying based upon both the size of
the muscle to be injected and the extent of muscle paralysis
desired (i.e. amount of diopter correction desired).
[0047] (6) to treat upper limb spasticity following stroke by
intramuscular injections of BOTOX.RTM. into five different upper
limb flexor muscles, as follows:
[0048] (a) flexor digitorum profundus: 7.5 U to 30 U
[0049] (b) flexor digitorum sublimus: 7.5 U to 30 U
[0050] (c) flexor carpi ulnaris: 10 U to 40 U
[0051] (d) flexor carpi radialis: 15 U to 60 U
[0052] (e) biceps brachii: 50 U to 200 U. Each of the five
indicated muscles has been injected at the same treatment session,
so that the patient receives from 90 U to 360 U of upper limb
flexor muscle BOTOX.RTM. by intramuscular injection at each
treatment session.
[0053] (7) to treat migraine, pericranial injected (injected
symmetrically into glabellar, frontalis and temporalis muscles)
injection of 25 U of BOTOX..RTM.. has showed significant benefit as
a prophylactic treatment of migraine compared to vehicle as
measured by decreased measures of migraine frequency, maximal
severity, associated vomiting and acute medication use over the
three month period following the 25 U injection.
[0054] Recent studies have demonstrated that botulinum neurotoxin
can inhibit insulin secretion, and thus may have a role in the
control of insulin exocytosis and metabolic control (Huang et al.,
Mol. Endocrinol. 12(7):1060-70, 1998).
[0055] It is known that botulinum toxin type A can have an efficacy
for up to 12 months (European J. Neurology 6 (Supp 4):
S111-S1150:1999), and in some circumstances for as long as 27
months, when used to treat glands, such as in the treatment of
hyperhydrosis. See e.g. Bushara K., Botulinum toxin and rhinorrhea,
Otolaryngol Head Neck Surg 1996; 114(3):507, and The Lalyngoscope
109:1344-1346:1999. However, the usual duration of an intramuscular
injection of Botox..RTM.. is typically about 3 to 4 months.
[0056] The success of botulinum toxin type A to treat a variety of
clinical conditions has led to interest in other botulinum toxin
serotypes. Two commercially available botulinum type A preparations
for use in humans are BOTOX.RTM. available from Allergan, Inc., of
Irvine, Calif., and DYSPORT.RTM. available from Beaufour Ipsen,
Porton Down, England. A Botulinum toxin type B preparation
(MYOBLOC.RTM.) is available from Elan Pharmaceuticals of San
Francisco, Calif.
[0057] In addition to having pharmacologic actions at the
peripheral location, botulinum toxins may also have inhibitory
effects in the central nervous system. Work by Weigand et al,
Nauny-Schmiedeberg's Arch. Pharmacol. 1976; 292, 161-165, and
Habermann, Nauny-Schmiedeberg's Arch. Pharmacol. 1974; 281, 47-56
showed that botulinum toxin is able to ascend to the spinal area by
retrograde transport. As such, a botulinum toxin injected at a
peripheral location, for example intramuscularly, may be retrograde
transported to the spinal cord.
[0058] U.S. Pat. No. 5,989,545 discloses that a modified
clostridial neurotoxin or fragment thereof, preferably a botulinum
toxin, chemically conjugated or recombinantly fused to a particular
targeting moiety can be used to treat pain by administration of the
agent to the spinal cord.
[0059] A botulinum toxin has also been proposed for or has been
used to treat otitis media of the ear (U.S. Pat. No. 5,766,605),
inner ear disorders (U.S. Pat. Nos. 6,265,379; 6,358,926), tension
headache, (U.S. Pat. No. 6,458,365), migraine headache pain (U.S.
Pat. No. 5,714,468), post-operative pain and visceral pain (U.S.
Pat. No. 6,464,986), hair growth and hair retention (U.S. Pat. No.
6,299,893), psoriasis and dermatitis (U.S. Pat. No. 5,670,484),
injured muscles (U.S. Pat. No. 6,423,319) various cancers (U.S.
Pat. No. 6,139,845), smooth muscle disorders (U.S. Pat. No.
5,437,291), and neurogenic inflammation (U.S. Pat. No. 6,063,768).
Controlled release toxin implants are known (see e.g. U.S. Pat.
Nos. 6,306,423 and 6,312,708) as is transdermal botulinum toxin
administration (U.S. patent application Ser. No. 10/194,805).
[0060] Additionally, a botulinum toxin may have an effect to reduce
induced inflammatory pain in a rat formalin model. Aoki K., et al,
Mechanisms of the antinociceptive effect of subcutaneous Botox:
Inhibition of peripheral and central nociceptive processing,
Cephalalgia 2003 September; 23(7):649. Furthermore, it has been
reported that botulinum toxin nerve blockage can cause a reduction
of epidermal thickness. Li Y, et al., Sensory and motor denervation
influences epidermal thickness in rat foot glabrous skin, Exp
Neurol 1997; 147:452-462 (see page 459). Finally, it is known to
administer a botulinum toxin to the foot to treat excessive foot
sweating (Katsambas A., et al., Cutaneous diseases of the foot:
Unapproved treatments, Clin Dermatol 2002 November-December;
20(6):689-699; Sevim, S., et al., Botulinum toxin-A therapy for
palmar and plantar hyperhidrosis, Acta Neurol Belg 2002 December;
102(4):167-70), spastic toes (Suputtitada, A., Local botulinum
toxin type A injections in the treatment of spastic toes, Am J Phys
Med Rehabil 2002 October; 81(10):770-5), idiopathic toe walking
(Tacks, L., et al., Idiopathic toe walking: Treatment with
botulinum toxin A injection, Dev Med Child Neurol 2002; 44(Suppl
91):6), and foot dystonia (Rogers J., et al., Injections of
botulinum toxin A in foot dystonia, Neurology 1993 April; 43(4
Suppl 2)).
[0061] Tetanus toxin, as wells as derivatives (i.e. with a
non-native targeting moiety), fragments, hybrids and chimeras
thereof can also have therapeutic utility. The tetanus toxin bears
many similarities to the botulinum toxins. Thus, both the tetanus
toxin and the botulinum toxins are polypeptides made by closely
related species of Clostridium (Clostridium tetani and Clostridium
botulinum, respectively). Additionally, both the tetanus toxin and
the botulinum toxins are dichain proteins composed of a light chain
(molecular weight about 50 kD) covalently bound by a single
disulfide bond to a heavy chain (molecular weight about 100 kD).
Hence, the molecular weight of tetanus toxin and of each of the
seven botulinum toxins (non-complexed) is about 150 kD.
Furthermore, for both the tetanus toxin and the botulinum toxins,
the light chain bears the domain which exhibits intracellular
biological (protease) activity, while the heavy chain comprises the
receptor binding (immunogenic) and cell membrane translocational
domains.
[0062] Further, both the tetanus toxin and the botulinum toxins
exhibit a high, specific affinity for gangliocide receptors on the
surface of presynaptic cholinergic neurons. Receptor mediated
endocytosis of tetanus toxin by peripheral cholinergic neurons
results in retrograde axonal transport, blocking of the release of
inhibitory neurotransmitters from central synapses and a spastic
paralysis. Contrarily, receptor mediated endocytosis of botulinum
toxin by peripheral cholinergic neurons results in little if any
retrograde transport, inhibition of acetylcholine exocytosis from
the intoxicated peripheral motor neurons and a flaccid
paralysis.
[0063] Finally, the tetanus toxin and the botulinum toxins resemble
each other in both biosynthesis and molecular architecture. Thus,
there is an overall 34% identity between the protein sequences of
tetanus toxin and botulinum toxin type A, and a sequence identity
as high as 62% for some functional domains. Binz T. et al., The
Complete Sequence of Botulinum Neurotoxin Type A and Comparison
with Other Clostridial Neurotoxins, J Biological Chemistry 265(16);
9153-9158:1990.
Acetylcholine
[0064] Typically only a single type of small molecule
neurotransmitter is released by each type of neuron in the
mammalian nervous system, although there is evidence which suggests
that several neuromodulators can be released by the same neuron.
The neurotransmitter acetylcholine is secreted by neurons in many
areas of the brain, but specifically by the large pyramidal cells
of the motor cortex, by several different neurons in the basal
ganglia, by the motor neurons that innervate the skeletal muscles,
by the preganglionic neurons of the autonomic nervous system (both
sympathetic and parasympathetic), by the bag 1 fibers of the muscle
spindle fiber, by the postganglionic neurons of the parasympathetic
nervous system, and by some of the postganglionic neurons of the
sympathetic nervous system. Essentially, only the postganglionic
sympathetic nerve fibers to the sweat glands, the piloerector
muscles and a few blood vessels are cholinergic as most of the
postganglionic neurons of the sympathetic nervous system secret the
neurotransmitter norepinephine. In most instances acetylcholine has
an excitatory effect. However, acetylcholine is known to have
inhibitory effects at some of the peripheral parasympathetic nerve
endings, such as inhibition of heart rate by the vagal nerve.
[0065] The efferent signals of the autonomic nervous system are
transmitted to the body through either the sympathetic nervous
system or the parasympathetic nervous system. The preganglionic
neurons of the sympathetic nervous system extend from preganglionic
sympathetic neuron cell bodies located in the intermediolateral
horn of the spinal cord. The preganglionic sympathetic nerve
fibers, extending from the cell body, synapse with postganglionic
neurons located in either a paravertebral sympathetic ganglion or
in a prevertebral ganglion. Since, the preganglionic neurons of
both the sympathetic and parasympathetic nervous system are
cholinergic, application of acetylcholine to the ganglia will
excite both sympathetic and parasympathetic postganglionic
neurons.
[0066] Acetylcholine activates two types of receptors, muscarinic
and nicotinic receptors. The muscarinic receptors are found in all
effector cells stimulated by the postganglionic, neurons of the
parasympathetic nervous system as well as in those stimulated by
the postganglionic cholinergic neurons of the sympathetic nervous
system. The nicotinic receptors are found in the adrenal medulla,
as well as within the autonomic ganglia, that is on the cell
surface of the postganglionic neuron at the synapse between the
preganglionic and postganglionic neurons of both the sympathetic
and parasympathetic systems. Nicotinic receptors are also found in
many nonautonomic nerve endings, for example in the membranes of
skeletal muscle fibers at the neuromuscular junction.
[0067] Acetylcholine is released from cholinergic neurons when
small, clear, intracellular vesicles fuse with the presynaptic
neuronal cell membrane. A wide variety of non-neuronal secretory
cells, such as, adrenal medulla (as well as the PC12 cell line) and
pancreatic islet cells release catecholamines and parathyroid
hormone, respectively, from large dense-core vesicles. The PC12
cell line is a clone of rat pheochromocytoma cells extensively used
as a tissue culture model for studies of sympathoadrenal
development. Botulinum toxin inhibits the release of both types of
compounds from both types of cells in vitro, permeabilized (as by
electroporation) or by direct injection of the toxin into the
denervated cell. Botulinum toxin is also known to block release of
the neurotransmitter glutamate from cortical synaptosomes cell
cultures.
[0068] A neuromuscular junction is formed in skeletal muscle by the
proximity of axons to muscle cells. A signal transmitted through
the nervous system results in an action potential at the terminal
axon, with activation of ion channels and resulting release of the
neurotransmitter acetylcholine from intraneuronal synaptic
vesicles, for example at the motor endplate of the neuromuscular
junction. The acetylcholine crosses the extracellular space to bind
with acetylcholine receptor proteins on the surface of the muscle
end plate. Once sufficient binding has occurred, an action
potential of the muscle cell causes specific membrane ion channel
changes, resulting in muscle cell contraction. The acetylcholine is
then released from the muscle cells and metabolized by
cholinesterases in the extracellular space. The metabolites are
recycled back into the terminal axon for reprocessing into further
acetylcholine.
[0069] U.S. Pat. No. 6,585,993 discloses a controlled release
neurotoxin system. U.S. Pat. No. 6,506,399 discloses a
biodegradable botulinum toxin implant. U.S. Pat. No. 6,383,509
discloses a biodegradable neurotoxin implant. U.S. Pat. No.
6,312,708 discloses a botulinum toxin implant. U.S. Pat. No.
6,306,423 discloses a neurotoxin implant
[0070] Thus, there remains a need for new compositions and methods
which may be used to treat autoimmune disorders.
SUMMARY
[0071] The present invention addresses this need and provides new
compositions and methods that provide effective relief of one or
more autoimmune disorders.
[0072] In one embodiment, a method for treating an autoimmune
disorder comprises a step of administering a Clostridial
neurotoxin, such as a botulinum toxin, to a location in proximity
to the thymus gland of a patient that has an autoimmune disorder.
In certain embodiments, the Clostridial neurotoxin is a botulinum
toxin type A which is injected directly into the thymus gland. In
this embodiment, the method can also comprise a step of
administering a cytokine inhibitor to the patient.
[0073] In another embodiment, a method for treating an autoimmune
disorder comprises administering a therapeutically effective amount
of a Clostridial neurotoxin, such as a botulinum toxin, and a
therapeutically effective amount of a cytokine inhibitor to a
patient that has an autoimmune disorder. The combined
administration provides synergistic effects not observed by the
administration of either agent alone. In this embodiment, the
method can also comprise a step of administering the neurotoxin to
the thymus gland of the patient.
[0074] Compositions for treating an autoimmune disorder are also
disclosed. Such compositions may be suitable for administration to
or near the thymus gland of a patient with an autoimmune disorder.
The compositions may comprise a combination of one or more
Clostridial neurotoxins and one or more cytokine inhibitors.
[0075] Each and every feature described herein, and each and every
combination of two or more of such features, is included within the
scope of the present invention provided that the features included
in such a combination are not mutually inconsistent. In addition,
any feature or combination of features may be specifically excluded
from any embodiment of the present invention.
[0076] Additional aspects and advantages of the present invention
are set forth in the following description and claims, particularly
when considered in conjunction with the accompanying examples.
DEFINITIONS
[0077] The following definitions apply herein.
[0078] "About" means plus or minus ten percent of the value so
qualified.
[0079] "Biocompatible" means that there is no significant
inflammatory or antigenic response from administration of the
composition.
[0080] "Biologically active compound" means a compound which can
effect a beneficial change in the subject to which it is
administered. For example, "biologically active compounds" include
neurotoxins.
[0081] "Effective amount" as applied to the biologically active
compound means that amount of the compound which is generally
sufficient to effect a desired change in the subject. For example,
where the desired effect is a reduction in an autoimmune disorder
symptom, an effective amount of the compound is that amount which
causes at least a substantial reduction of the autoimmune disorder
symptom, and without resulting in significant toxicity.
[0082] "Effective amount" as applied to a non-active ingredient
constituent of an injectable composition (such as a carrier used
for mixing with a botulinum toxin) refers to that amount of the
non-active ingredient constituent which is sufficient to positively
influence the release and/or activity of the active ingredient when
administered to an individual. This "effective amount" can be
determined based on the teaching in this specification and the
general knowledge in the art.
[0083] "Neurotoxin" means an agent which can interrupt nerve
impulse transmission across a neuromuscular or neuroglandular
junction, block or reduce neuronal exocytosis of a neurotransmitter
or alter the action potential at a sodium channel voltage gate of a
neuron. Examples of neurotoxins include botulinum toxins, tetanus
toxins, saxitoxins, and tetrodotoxin.
[0084] "Treatment" means any treatment of a disease in a mammal,
and includes: (i) preventing the disease from occurring or; (ii)
inhibiting the disease, i.e., arresting its development; (iii)
relieving the disease, i.e., reducing the incidence of symptoms of
or causing regression of the disease.
[0085] "Implants" refer to substantially non-liquid drug delivery
devices. Implants may include a polymeric component, such as a
biodegradable or non-biodegradable polymer, associated with a
neurotoxin. The implants may be solid, semi-solid, or
visco-elastic. Implants are generally larger than microspheres.
[0086] "Microspheres" refers to a polymer or combinations of
polymers made into bodies or elements of various sizes. The
microspheres can be in any shape, although they are often in
substantially spherical shape.
[0087] "Biodegradable" microspheres refer to microspheres that are
capable of being absorbed by the body, chemically, physiologically,
or by other biological means, over a period of time.
[0088] "Therapeutic agent" as used herein refers to any substance
that provides therapeutic effects to the process of autoimmune
disorder treatment or biological or physiological responses to the
autoimmune disorder treatment. An example of therapeutic agent is a
neurotoxin which is effective in relaxing muscles. One example of a
suitable neurotoxin is a neurotoxin produced by Clostridial
bacteria, such as Clostridium beratti, Clostridium butyricum,
Clostridium tetani, and Clostridium botulinum. As described herein,
preferred compositions comprise a botulinum toxin component. A
botulinum toxin component is a portion of the composition which
includes one or more botulinum toxin types selected from the group
consisting of botulinum toxin types A, B, C, D, E, F, and G. The
botulinum toxin component may comprise a botulinum toxin produced
by a Clostridial bacteria, or produced by recombinant technology.
The botulinum toxin can be a recombinantly made or a hybrid
botulinum toxin. In preferred compositions, the botulinum toxin
component comprises a botulinum toxin type A, such as the
commercially available botulinum toxin sold under the tradename,
BOTOX.RTM. (Allergan, Inc., CA).
DESCRIPTION
[0089] New methods of treating autoimmune disorders have been
invented, as well as compositions for treating autoimmune
disorders. The present methods and compositions include a
Clostridial neurotoxin that is administered to a patient, such as a
human or animal patient, suffering from an autoimmune disorder. As
used herein, an autoimmune disorder refers to diseases caused by an
immune response against the body's own cells or tissues. The
present methods and compositions provide novel ways of treating an
autoimmune disorder that can provide reduced side effects and
enhanced durations of relief compared to existing therapeutic
approaches.
[0090] In one embodiment, a method for treating an autoimmune
disorder, comprises administering an effective amount of a
Clostridial neurotoxin to a location in proximity to a thymus gland
of a patient to alleviate at least one symptom of an autoimmune
disorder. In certain situations, the administration of the
Clostridial neurotoxin is effective in completely treating the
autoimmune disorder. By administering the Clostridial neurotoxin to
a location in proximity to the thymus gland, it is believed that
the neurotoxin can effectively reduce the activity of thymus
epithelial cells, and thereby interfere with T cell maturation,
immune function, and immune dysfunction.
[0091] The Clostridial neurotoxin is administered to a region near
the thymus gland. For example, the neurotoxin can be administered
to a region spaced away from the thymus gland tissue but close
enough to cause the desired alleviation of at least one autoimmune
disorder symptom associated with thymus gland activity. While not
wishing to be bound by any particular theory or mechanism of
action, administration of the Clostridial neurotoxin to a location
near the thymus gland can result in the neurotoxin inhibiting
acetylcholine release from cholinergic neurons innervating the
thymus gland. The inhibition of the acetylcholine release can thus
interfere with T cell maturation, as described above. Thus, in one
embodiment, the Clostridial neurotoxin is administered to a
location near the thymus gland and containing cholinergic neurons
innervating the thymus gland. In another embodiment, the
Clostridial neurotoxin is administered directly to the thymus
gland. For example, as discussed herein the Clostridial neurotoxin,
such as a botulinum toxin, can be directly injected into the thymus
gland by inserting a needle into the patient so that the needle tip
contacts tissue of the thymus gland. When the neurotoxin is not
administered directly into the thymus gland, the neurotoxin can be
administered at a location spaced away from the thymus gland by a
distance ranging from about 5 millimeters to about 50 millimeters
from a surface of the thymus gland. In certain embodiments, it may
be desirable to administer the neurotoxin to a non-systemic,
non-muscular region in the body near the thymus gland.
[0092] Locally administering the Clostridial neurotoxin to a
location near the thymus gland can provide effective therapy of the
autoimmune disorder with reduced side effects associated with
conventional therapies. For example, as discussed herein, therapies
using cholinesterase inhibitors may be associated with increased
muscular hypertension and peripheral and central nervous system
activity due to increased amounts of acetylcholine residing in
synaptic clefts. Long term steroid and immunosuppressive agent use
can result in undesirable side effects since such agents are
administered systemically. Thus, this embodiment can provide an
effective autoimmune disorder treatment by providing local
inhibition of neurotransmitter or peptide release near the thymus
gland.
[0093] In certain embodiments, the method comprises one or more
steps to facilitate location of the thymus gland by the physician
performing the administration. For example, an incision may be made
in the chest region overlying the thymus gland to provide direct
physical access to the thymus gland by a neurotoxin delivery
device, such as a needle or cannula configured to pass a neurotoxin
containing composition therethrough. Another method may comprise
using a thymus visualization device, which may not require making
an incision in a chest region of the patient. In certain methods,
the neurotoxin is administered without using an electrode, such as
electrodes that are used to administer BOTOX.RTM. to treat
neuromuscular conditions. Other methods of identifying an
appropriate administration site or target site can be practiced
using routine methods known by persons of ordinary skill in the
art.
[0094] In another embodiment of the present invention, a method for
treating an autoimmune disorder comprises administering an
effective amount of a Clostridial neurotoxin and an effective
amount of a cytokine inhibitor to a patient suffering from an
autoimmune disorder. This combined therapeutic treatment can
alleviate one or more symptoms of the autoimmune disorder or
completely treat the autoimmune disorder.
[0095] In practicing the foregoing method, the Clostridial
neurotoxin and the cytokine inhibitor can be administered in
amounts that provide a greater relief of the symptom or symptoms
compared to the administration of either the Clostridial neurotoxin
or the cytokine inhibitor, but not both. Thus, the present
combination therapy provides an unexpected therapeutic result not
realized by the administration of the Clostridial neurotoxin and
cytokine inhibitor separately. In certain embodiments, the
Clostridial neurotoxin is administered to the thymus gland of the
patient, as discussed herein. In other embodiments, the Clostridial
neurotoxin is administered to a region effective in inhibiting
neuropeptide release, such as the release of calcitonin gene
related peptide (CGRP), glutamate, and substance P, or in
inhibiting inflammatory pain. In further embodiments, the
Clostridial neurotoxin is administered to a patient in an amount
effective in inhibiting neuropeptide mediated inflammation, and the
cytokine inhibitor is administered in an amount effective in
inhibiting cytokine mediated inflammation.
[0096] The cytokine inhibitor that can be administered to the
patients include, without limitation, cytokine neutralizers,
cytokine receptor blockers, and anti-inflammatory cytokines, or
combinations thereof.
[0097] Cytokine neutralizers that block or reduce the activity of
inflammatory cytokines by preventing the inflammatory cytokine from
interacting or binding to its cell-surface receptor. Thus, a
cytokine neutralizer in accordance with the disclosure herein
includes, without limitation, a soluble receptor fusion protein
that can be administered to bind with the inflammatory cytokine, a
natural cytokine antagonist, or an antibody, such as monoclonal
antibody, or fragment thereof, that recognizes and binds the
inflammatory cytokine. Examples of cytokine receptor blockers
include cytokine receptor antagonists and antibodies, such as
monoclonal antibodies, or fragments thereof, that recognize and
bind the cytokine receptor. Anti-inflammatory cytokines can be
administered to inhibit the expression of inflammatory cytokines
from cytokine expressing cells.
[0098] Some specific examples of cytokine inhibitors include
pyridinyl imidazoles, bicyclic imidazoles, oxpentifylline,
thalidomide, and gabexate mesilate. Additional cytokine inhibitors
can be obtained or identified using routine methods known to
persons of ordinary skill in the art. For example, potential
cytokine inhibitors can be identified using screening assays and
comparing the activity of the potential cytokine inhibitor to
existing cytokine inhibitors.
[0099] For autoimmune disorders that are associated with an
inflammatory response, such as asthma, the combination of the
Clostridial neurotoxin and monoclonal antibodies for cytokines or
cytokine receptors can provide a synergistic reduction in the
inflammation associated with the autoimmune disorder. Similar
synergistic effects can be observed in the treatment of diabetes.
In addition, in situations in which the cytokine inhibitor, such as
an antibody, is linked or attached to the neurotoxin, targeted
delivery of the neurotoxin can be achieved to provide enhanced
synergistic effects to treat the autoimmune disorder.
[0100] In the disclosed combination therapies, the site of
administration of the neurotoxin and the cytokine inhibitor can
vary. For example, both the neurotoxin and cytokine inhibitor can
be administered at the same site, or at a different site. In
addition, the modes of administration can be the same or different.
In certain embodiments, the neurotoxin can be administered to a
site in which the patient is experiencing inflammation pain. For
example, the neurotoxin can be injected near or in a joint. Or, the
neurotoxin can be administered in a site effective in controlling
insulin release. The neurotoxin can be administered topically,
transdermally, intradermally, subcutaneously, intraglandularly, or
intramuscularly. The cytokine inhibitor, when administered
separately from the neurotoxin, can be administered in a manner
effective to provide systemic delivery of the inhibitor. It may be
desirable to administer the cytokine inhibitor intramuscularly or
intraperitoneally, however, oral and subcutaneous administration
may also be effective.
[0101] In practicing the foregoing methods, the Clostridial
neurotoxin can be any neurotoxin produced by a Clostridial bacteria
or any neurotoxin have an amino acid sequence substantially
identical or exactly identical to a neurotoxin produced by a
Clostridial bacteria. In certain embodiments, the Clostridial
neurotoxin administered to the patient is selected from the group
consisting of botulinum toxin types A, B, C, D, E, F, and G. In
certain preferred methods, the Clostridial neurotoxin is botulinum
toxin type A. Botulinum toxin type A is desirable due to its high
potency in humans, ready availability, and known use for inhibiting
neurotransmitter release.
[0102] Although the present methods and compositions are described
with particular reference to botulinum toxins, other neurotoxins
may be effective in the present compositions with or without the
botulinum toxins, and such other neurotoxins are included within
the scope of the present invention. Examples of other Clostridial
neurotoxins within the scope of the present invention include
neurotoxins made by Clostridium butyricum and Clostridium beratti
species. The present invention also includes the use of (a)
Clostridial neurotoxins obtained or processed by bacterial
culturing, toxin extraction, concentration, preservation, freeze
drying, and/or reconstitution; and/or (b) modified or recombinant
neurotoxins, that is neurotoxins that have had one or more amino
acids or amino acid sequences deliberately deleted, modified or
replaced by known chemical/biochemical amino acid modification
procedures or by use of known host cell/recombinant vector
recombinant technologies, as well as derivatives or fragments of
neurotoxins so made. These neurotoxin variants retain the ability
to inhibit neurotransmission between or among neurons, and some of
these variants may provide increased durations of inhibitory
effects as compared to native neurotoxins, or may provide enhanced
binding specificity to the neurons exposed to the neurotoxins.
These neurotoxin variants may be selected by screening the variants
using conventional assays to identify neurotoxins that have the
desired physiological effects of inhibiting neurotransmission.
[0103] The neurotoxins used in the present methods can be
administered to the patient in a variety of forms. For example, in
certain embodiments, the neurotoxins is administered in a
composition, such as a solution, that comprises a carrier
component, such as saline, and the like. In other embodiments, the
neurotoxins may be administered by an implant device. The implant
device is a non-liquid device that typically comprises a polymeric
component. The neurotoxin-containing implants may be biodegradable
or non-biodegradable. In other words, the implant may comprise a
biodegradable polymer, a non-biodegradable polymer, and
combinations thereof. In certain embodiments, the neurotoxin is
administered in the form of polymeric microspheres, such as
biodegradable microspheres. Implants may also include a pumping
mechanism to provide controlled release of the neurotoxin, or the
implants may provide a controlled release based on the
physiochemical properties of the implants. Examples of potential
neurotoxin containing implants, include those implants disclosed
the patents identified hereinabove.
[0104] The present methods can thus comprise a step of injecting a
composition comprising a botulinum toxin component and a carrier
component into the patient, placing an implant device comprising a
botulinum toxin into the patient, or a combination thereof. In
certain embodiments, the Clostridial neurotoxin is administered in
a single composition with the cytokine inhibitor. For example, a
liquid or polymeric composition containing a therapeutically
effective amount of a botulinum neurotoxin and a cytokine inhibitor
can be administered to a patient in a single step. In other
embodiments, the neurotoxin and cytokine inhibitor are administered
in separate compositions, which may be administered to the patient
at the same time or at different times. Thus, the present invention
also encompasses pharmaceutical compositions comprising a
Clostridial neurotoxin and one or more cytokine inhibitors present
in a single composition.
[0105] Botulinum toxins for use according to the present invention
can be stored in lyophilized, vacuum dried form in containers under
vacuum pressure or as stable liquids. Prior to lyophilization the
botulinum toxin can be combined with pharmaceutically acceptable
excipients, stabilizers and/or carriers, such as albumin. The
lyophilized material can be reconstituted with saline or water to
create a solution or composition containing the botulinum toxin to
be administered to the patient.
[0106] The amount of the Clostridial neurotoxin in the compositions
or administered according to the present methods can vary according
to the particular characteristics of the disorder being treated,
including its severity and other various patient variables
including size, weight, age, and responsiveness to therapy. To
guide the practitioner, typically, no less than about 1 unit and no
more than about 50 units of a botulinum toxin type A (such as
BOTOX.RTM.) is administered per injection site (i.e. to the thymus
gland or other inflammation site), per patient treatment session.
For a botulinum toxin type A such as DYSPORT.RTM., no less than
about 2 units and no more about 200 units of the botulinum toxin
type A are administered per administration or injection site, per
patient treatment session. For a botulinum toxin type B such as
MYOBLOC.RTM., no less than about 40 units and no more about 2500
units of the botulinum toxin type B are administered per injection
site, per patient treatment session. Less than about 1, 2 or 40
units (of BOTOX.RTM., DYSPORT.RTM. and MYOBLOC.RTM. respectively)
can fail to achieve a desired therapeutic effect, while more than
about 50, 200 or 2500 units (of BOTOX.RTM., DYSPORT.RTM. and
MYOBLOC.RTM. respectively) can result in clinically observable and
undesired muscle hypotonicity, weakness and/or paralysis.
[0107] More preferably: for BOTOX.RTM. no less than about 2 units
and no more about 20 units of a botulinum toxin type A; for
DYSPORT.RTM. no less than about 4 units and no more than about 100
units, and; for MYOBLOC.RTM., no less than about 80 units and no
more than about 1000 units are, respectively, administered per
injection site, per patient treatment session.
[0108] Most preferably: for BOTOX.RTM. no less than about 5 units
and no more about 15 units of a botulinum toxin type A; for
DYSPORT.RTM. no less than about 20 units and no more than about 75
units, and; for MYOBLOC.RTM., no less than about 200 units and no
more than about 750 units are, respectively, administered per
injection site, per patient treatment session. It is important to
note that there can be multiple injection sites (i.e. a pattern of
injections) for each patient treatment session.
[0109] Thus, the present methods may comprise administering an
amount of a botulinum toxin in a range from about 1 unit to about
50,000 units. The amount of botulinum toxin will vary depending on
the type of botulinum toxin, such as the serotype or strain of
botulinum toxin, and the amount of the composition to be
administered to a patient. In certain methods, botulinum toxin A is
administered in an amount ranging from about 10 units to about
2,000 units. In other methods, botulinum toxin type B is
administered in an amount ranging from about 100 units to about
30,000 units. Preferably, the present methods comprise
administering biologically active botulinum toxins as a therapeutic
agent. For example, the present methods do not include
administering a botulinum toxoid to the patient.
[0110] The present methods can be practiced to treat one or more
autoimmune disorders. The autoimmune disorders treatable by the
present methods include either or both of system autoimmune
diseases or localized autoimmune diseases. Examples of autoimmune
disorders treated by the present methods include one or more of any
of the following rheumatoid arthritis which can affect joints, and
possibly lung and skin; lupus, including systemic lupus
erythematosus (SLE), which can affect skin, joints, kidneys, heart,
brain, red blood cells, as well as other tissues and organs;
scleroderma, which can affect skin, intestine, and lungs; Sjogren's
syndrome, which can affect salivary glands, tear glands, and
joints; Goodpasture's syndrome, which can affect lungs and kidneys;
Wegener's granulomatosis, which can affect sinuses, lungs, and
kidneys; polymyalgia rheumatica, which can affect large muscle
groups; temporal arteritis/giant cell arteritis, which can affect
arteries of the head and neck; Type 1 Diabetes Mellitus, which
affects pancreas islets; Hashimoto's thyroiditis and Graves'
disease, which affect the thyroid; celiac disease, Crohn's
diseases, and ulcerative colitis, which affect the gastrointestinal
tract; multiple sclerosis (MS) and Guillain-Barre syndrome, which
affect the central nervous system; Addison's disease, which affects
the adrenal glands; primary biliary sclerosis, sclerosing
cholangitis, and autoimmune hepatitis, which affect the liver;
Raynaud's phenomenon, which can affect the fingers, toes, nose,
ears; pernicious anemia; Addison's disease; dermatomyositis;
myasthenia gravis (MG); Reiter's syndrome; Pemphigus vulgaris;
scleroderma or CREST syndrome; autoimmune hemolytic anemia;
autoimmune thrombocytopenic purpura; ankylosing spondylitis;
vasculitis; and amyotrophic lateral schlerosis (Lou Gehrig's
disease).
[0111] In certain embodiments, the methods are practiced by
administering a Clostridial neurotoxin in proximity to the thymus
gland to treat multiple sclerosis, myasthenia gravis, or systemic
lupus erythematosus.
[0112] The present methods are effective in treating at least one
symptom of an autoimmune disorder, including at least one symptom
selected from the group consisting of fatigue, dizziness, malaise,
fever, chills, weight loss, skin rashes, vasculitis,
polyarthralgia, patchy hair loss, oral and nasal sores, lymph-node
enlargement, gastric problems, generalized pain, which may be
located in the joints in the case of arthritis, enlarged glands,
such as the thyroid in the case of Grave's disease, heart
palpitations, dermal blisters and lesions, muscle weakness, and
combinations thereof.
[0113] In addition, the present methods may be effective in
treating the cause of the autoimmune disorder by controlling or
regulating T cell maturation based on thymus gland activity.
[0114] Although examples of routes of administration and dosages
are provided, the appropriate route of administration and dosage
are generally determined on a case by case basis by the attending
physician. Such determinations are routine to one of ordinary skill
in the art (see for example, Harrison's Principles of Internal
Medicine (1998), edited by Anthony Fauci et al., 14th edition,
published by McGraw Hill). For example, the route and dosage for
administration of a Clostridial neurotoxin according to the present
disclosed invention can be selected based upon criteria such as the
solubility characteristics of the neurotoxin chosen as well as the
intensity and scope of the autoimmune disorder being treated.
[0115] Injection of the compositions can be carried out by syringe,
catheters, needles and other means for injecting or infusing
compositions containing the neurotoxin and/or cytokine inhibitor.
As discussed herein, the injection can be practiced with one or
more steps of identifying a target site for the injection.
[0116] The frequency and the amount injected is determined based on
the nature and location of the particular autoimmune disorder being
treated. Generally, because of the stable and long lasting
character of the neurotoxin injectable composition, multiple
injections are not necessary. In certain cases, however, repeated
injection may be desired to achieve optimal results. The frequency
and the amount of the injection for each particular case is
determined by the person of ordinary skill in the art.
[0117] Administration of the neurotoxin to the thymus gland, or
administration of the neurotoxin in combination with the cytokine
inhibitor, provides an initial relief or alleviation of at least
one symptom of an autoimmune disorder within about seven days after
the administration to the patient. Relief can be obtained for
several months or years depending on the mode of administration.
For example, a liquid composition containing botulinum toxin type
A, such as BOTOX.RTM., can provide relief for about four to about 6
months after administration. An implant that delivers a botulinum
toxin type A can provide a therapeutic relief for at least six
months, and even for more than a year, such as for three or five
years. The synergistic effects provided by the combination therapy
of the neurotoxin and cytokine inhibitors can be observed for
several months, for example between about one and about 12 months.
In certain situations, the neurotoxin effects persist beyond the
effects mediated by the cytokine inhibitors.
[0118] Thus, in one specific embodiment of the present invention, a
method for treating an autoimmune disorder, such as systemic lupus
erythematosus, myasthenia gravis, or multiple sclerosis, comprises
a step of injecting a therapeutically effective amount of a
botulinum toxin type A, such as the compositions available under
the tradenames BOTOX.RTM. or DYSPORT.RTM., into the thymus gland of
a patient that has an autoimmune disorder. The injection of the
botulinum toxin into the thymus gland is effective in reducing the
activity of the thymus epithelial cells, reducing T cell
maturation, immune function, and immune dysfunction.
[0119] In another specific embodiment of the present invention, a
method for treating an autoimmune disorder, such as systemic lupus
erythematosus, arthritis, asthma, and diabetes, comprises a step of
administering a therapeutically effective amount of a botulinum
toxin type A, such as the compositions available under the
tradenames BOTOX.RTM. or DYSPORT.RTM., and a therapeutically
effective amount of a cytokine inhibitor to a patient that has an
autoimmune disorder. The administration of the botulinum toxin and
the cytokine inhibitor provides enhanced or synergistic effects for
the treatment of the autoimmune disorder.
EXAMPLES
[0120] The following non-limiting examples provide those of
ordinary skill in the art with specific preferred methods to treat
conditions within the scope of the present invention and are not
intended to limit the scope of the invention. In the following
examples various modes of non-systemic administration of a
Clostridial neurotoxin can be carried out.
Example 1
[0121] Treatment of Systemic Lupus Erythematosus with a Botulinum
Neurotoxin
[0122] A 42 year old man diagnosed with systemic lupus
erythematosus is treated by injecting 10 units of BOTOX.RTM. into
the thymus gland (5 units are injected into each lobe of the
thymus). After about 1 week, the patient shows a reduced fever,
headache, joint pain, and skin rash. Overall, the patient generally
feels less fatigued and has a positive outlook. The relief persists
for about 4 months.
[0123] Six months after his initial treatment, the patient
undergoes surgery to receive a biodegradable implant containing
botulinum toxin type A. A 1 mg implant is placed 5 mm from the
thymus. The implant contains about 200 units of botulinum toxin
type A and poly (lactide-co-glycolide) polymer (PLGA). The implant
releases the botulinum toxin at a rate of about 2 units per day.
The patient reports an improvement similar to the thymus injection
of BOTOX.RTM. after about 10 days. However, relief from the
symptoms persist for 18 months after the surgical procedure.
Example 2
[0124] Treatment of Myasthenia Gravis with a Botulinum
Neurotoxin
[0125] The procedures of Example 1 are followed to treat a female
patient diagnosed with Myasthenia Gravis. The patient presents with
ptosis, blurred vision, and overall ocular immotility. The
treatments successfully prevent the further development of the
disorder and the associated muscle weakening of arms, hands, and
respiratory system.
Example 3
[0126] Treatment of Multiple Sclerosis with a Botulinum
Neurotoxin
[0127] The procedures of Example 1 are followed to treat a female
patient diagnosed with Multiple Sclerosis. The patient presents
with blurred vision and ocular pain, as well as limb spasticity.
After administering the botulinum toxin type A to the thymus,
without administering the botulinum toxin to a muscle, the symptoms
are alleviated within about 14 days. The alleviation of the
symptoms persists for several months.
Example 4 to 6
[0128] The procedures of Examples 1-3 are repeated for different
patients suffering from the same conditions, but by administering a
four fold greater amount of DYSPORT.RTM. available from Ipsen
Pharmaceuticals, Paris, France.
Example 7 to 9
[0129] The procedures of Examples 1-3 are repeated for different
patients suffering from the same conditions, but by administering
an equal amount of purified botulinum toxin type A (e.g., a
botulinum toxin type A protein preparation without complexing
proteins) available under the name NT 201 from Merz Pharmaceuticals
(Frankfurt, Germany).
Examples 10 to 12
[0130] The procedures of Examples 1-3 are repeated for different
patients suffering from the same conditions, but by administering a
fifty fold greater amount of botulinum toxin type B (i.e.,
MYOBLOC.RTM. available from Solstice Neurosciences, San Diego,
Calif.).
Example 13 to 15
[0131] The procedures of Example 1-3 are repeated for different
patients suffering from the same condition but by administering
therapeutically effective amounts of botulinum toxin type C instead
of botulinum toxin type A.
Example 16 to 18
[0132] The procedures of Example 1-3 are repeated for different
patients suffering from the same condition but by administering
therapeutically effective amounts of botulinum toxin type C instead
of botulinum toxin type A.
Example 19 to 21
[0133] The procedures of Example 1-3 are repeated for different
patients suffering from the same condition but by administering
therapeutically effective amounts of botulinum toxin type D instead
of botulinum toxin type A.
Example 22 to 24
[0134] The procedures of Example 1-3 are repeated for different
patients suffering from the same condition but by administering
therapeutically effective amounts of botulinum toxin type E instead
of botulinum toxin type A.
Example 25 to 27
[0135] The procedures of Example 1-3 are repeated for different
patients suffering from the same condition but by administering
therapeutically effective amounts of botulinum toxin type F instead
of botulinum toxin type A.
Example 28 to 30
[0136] The procedures of Example 1-3 are repeated for different
patients suffering from the same condition but by administering
therapeutically effective amounts of botulinum toxin type G instead
of botulinum toxin type A.
Example 31
[0137] Treatment of Asthma with a Botulinum Neurotoxin and a
Humanized Monoclonal Antibody
[0138] A 38 year old man suffering from asthma is treated by a
combination therapy based on administration of BOTOX.RTM. and the
monoclonal antibody, omalizumab (XOLAIR.RTM.). The man is treated
by injecting 5 units of BOTOX.RTM. into nerve fibers responsible
for bronchoconstriction, and by injecting 150 mg of XOLAIR.RTM. in
a single subcutaneous bolus injection. Immediate relief is provided
by the patient's inhaler. The patient reports a reduced number of
asthmatic episodes over the following six months.
Example 32
[0139] Treatment of Diabetes with a Botulinum Neurotoxin and a
Humanized Monoclonal Antibody
[0140] A 22 year old male with type 1 diabetes mellitus is treated
by a combination therapy of administration of a botulinum
neurotoxin and the anti-CD3 humanized monoclonal antibody
hOKT3gamma1 (Ala-Ala). The patient is administered about 20 units
of BOTOX.RTM. and antibody injections once a week for six weeks.
After about 3 weeks, the symptoms of the diabetes are reduced. The
relief persists for about 6 months after initial treatment.
Example 33
[0141] Treatment of Arthritis with a Botulinum Neurotoxin and a
Cytokine Receptor Blocker
[0142] A 62 year old male suffering from rheumatoid arthritis is
treated by a combination therapy of a botulinum neurotoxin and an
interleukin 1 receptor antagonist. The patient is administered 2
units of BOTOX.RTM. into each of the joints of his left hand and
receives a subcutaneous injection of the antagonist. The patient
experiences an overall reduction in joint pain. The reduction of
pain in his left hand persists for about 4 months whereas the
reduction in joint pain in other regions of his body lasts less
than 4 months.
Example 34 to 36
[0143] The procedures of Examples 31-33 are repeated for different
patients suffering from the same conditions, but by administering a
four fold greater amount of DYSPORT.RTM. available from Ipsen
Pharmaceuticals, Paris, France.
Example 37 to 39
[0144] The procedures of Examples 31-33 are repeated for different
patients suffering from the same conditions, but by administering
an equal amount of purified botulinum toxin (e.g., a botulinum
toxin protein preparation without complexing proteins) available
under the name NT 201 from Merz Pharmaceuticals (Frankfurt,
Germany).
Examples 40 to 42
[0145] The procedures of Examples 31-33 are repeated for different
patients suffering from the same conditions, but by administering a
fifty fold greater amount of botulinum toxin type B (i.e.,
MYOBLOC.RTM. available from Solstice Neurosciences, San Diego,
Calif.).
Example 43 to 45
[0146] The procedures of Example 31-33 are repeated for different
patients suffering from the same condition but by administering
therapeutically effective amounts of botulinum toxin type C instead
of botulinum toxin type A.
Example 46 to 48
[0147] The procedures of Example 31-33 are repeated for different
patients suffering from the same condition but by administering
therapeutically effective amounts of botulinum toxin type C instead
of botulinum toxin type A.
Example 49 to 51
[0148] The procedures of Example 31-33 are repeated for different
patients suffering from the same condition but by administering
therapeutically effective amounts of botulinum toxin type D instead
of botulinum toxin type A.
Example 52 to 54
[0149] The procedures of Example 31-33 are repeated for different
patients suffering from the same condition but by administering
therapeutically effective amounts of botulinum toxin type E instead
of botulinum toxin type A.
Example 55 to 57
[0150] The procedures of Example 31-33 are repeated for different
patients suffering from the same condition but by administering
therapeutically effective amounts of botulinum toxin type F instead
of botulinum toxin type A.
Example 58 to 60
[0151] The procedures of Example 31-33 are repeated for different
patients suffering from the same condition but by administering
therapeutically effective amounts of botulinum toxin type G instead
of botulinum toxin type A.
[0152] Although the present invention has been described in detail
with regard to certain preferred compositions and methods, other
embodiments, versions, and modifications within the scope of the
present invention are possible. For example, a wide variety of
neurotoxins can be effectively used in the methods of the present
invention. Additionally, the present invention includes local
administration methods to alleviate one or more symptoms of an
autoimmune disorder wherein two or more neurotoxins, such as two or
more botulinum toxins, are administered concurrently or
consecutively. For example, botulinum toxin type A can be
administered until a loss of clinical response or neutralizing
antibodies develop, followed by administration of botulinum toxin
type B. Alternately, a combination of any two or more of the
botulinum serotypes A-G can be locally administered to control the
onset and duration of the desired result. Furthermore,
non-neurotoxin compounds can be administered prior to, concurrently
with or subsequent to administration of the neurotoxin to proved
adjunct effect such as enhanced or a more rapid onset of
denervation before the neurotoxin, such as a botulinum toxin,
begins to exert its therapeutic effect.
[0153] Our invention also includes within its scope the use of a
neurotoxin, such as a botulinum toxin, in the preparation of a
medicament for the treatment of an autoimmune disorder.
[0154] All references, articles, patents, applications and
publications set forth above are incorporated herein by reference
in their entireties.
[0155] Accordingly, the spirit and scope of the following claims
should not be limited to the descriptions of the preferred
embodiments set forth above.
* * * * *