U.S. patent application number 13/928830 was filed with the patent office on 2013-10-17 for agonists of guanylate cyclase useful for the treatment of gastrointestinal disorders, inflammation, cancer and other disorders.
The applicant listed for this patent is Synergy Pharmaceuticals Inc.. Invention is credited to Gary S. Jacob, Kunwar Shailubhai.
Application Number | 20130274204 13/928830 |
Document ID | / |
Family ID | 41026379 |
Filed Date | 2013-10-17 |
United States Patent
Application |
20130274204 |
Kind Code |
A1 |
Shailubhai; Kunwar ; et
al. |
October 17, 2013 |
Agonists of Guanylate Cyclase Useful for the Treatment of
Gastrointestinal Disorders, Inflammation, Cancer and Other
Disorders
Abstract
The invention provides novel guanylate cyclase-C agonist
peptides and their use in the treatment of human diseases including
gastrointestinal disorders, inflammation or cancer (e.g., a
gastrointestinal cancer). The peptides can be administered either
alone or in combination with an inhibitor of cGMP-dependent
phosphodiesterase. The gastrointestinal disorder may be classified
as either irritable bowel syndrome, constipation, or excessive
acidity etc. The gastrointestinal disease may be classified as
either inflammatory bowel disease or other GI condition including
Crohn's disease and ulcerative colitis, and cancer.
Inventors: |
Shailubhai; Kunwar;
(Audubon, PA) ; Jacob; Gary S.; (New York,
NY) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Synergy Pharmaceuticals Inc. |
New York |
NY |
US |
|
|
Family ID: |
41026379 |
Appl. No.: |
13/928830 |
Filed: |
June 27, 2013 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
|
13716874 |
Dec 17, 2012 |
8497348 |
|
|
13928830 |
|
|
|
|
12478505 |
Jun 4, 2009 |
8207295 |
|
|
13716874 |
|
|
|
|
61058888 |
Jun 4, 2008 |
|
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Current U.S.
Class: |
514/20.9 ;
530/326 |
Current CPC
Class: |
A61P 13/10 20180101;
A61P 1/00 20180101; A61P 11/00 20180101; A61P 35/00 20180101; A61K
38/04 20130101; C07K 7/08 20130101; A61P 1/14 20180101; A61P 9/12
20180101; A61P 1/10 20180101; A61P 1/04 20180101; A61P 9/04
20180101; C07K 7/64 20130101; A61P 13/08 20180101; A61K 45/06
20130101; A61P 17/00 20180101; A61P 1/16 20180101; A61P 29/00
20180101; A61P 11/06 20180101; A61K 38/04 20130101; A61K 2300/00
20130101 |
Class at
Publication: |
514/20.9 ;
530/326 |
International
Class: |
C07K 7/08 20060101
C07K007/08 |
Claims
1. A peptide consisting essentially of the amino acid sequence of
dAsn.sup.1-Asp.sup.2-Glu.sup.3-Cys.sup.4-Glu.sup.5-Leu.sup.6-Cys.sup.7-Va-
l.sup.8-Asn.sup.9-Val.sup.10-Ala.sup.11-Cys.sup.12-Thr.sup.13-Gly.sup.14-C-
ys.sup.15-dLeu-AMIDE.sup.16(SEQ ID NO: 3), wherein said peptide is
a [4,12;7,15] bicyclic peptide.
2. A pharmaceutical composition in unit dose comprising a guanylate
cyclase receptor agonist peptide having the sequence of SEQ ID NO:
3 present in a therapeutically effective amount and a
pharmaceutical carrier, excipient or diluent.
3. The pharmaceutical composition of claim 2, wherein the unit dose
form is selected from the group consisting of a tablet, a capsule,
a solution or inhalation formulation.
Description
RELATED APPLICATIONS
[0001] This application is a divisional application of the U.S.
patent application Ser. No. 13/716,874 filed Dec. 17, 2012, which
is a divisional application of the U.S. patent application Ser. No.
13/467,703 filed May 9, 2012, now U.S. Pat. No. 8,357,775, which is
a divisional application of the U.S. patent application Ser. No.
12/478,505 filed Jun. 4, 2009, now U.S. Pat. No. 8,207,295, which
claims the benefit of U.S. Provisional Application No. 61/058,888,
filed Jun. 4, 2008, the contents of each of which are incorporated
herein by reference in their entireties.
INCORPORATION-BY-REFERENCE OF SEQUENCE LISTING
[0002] The contents of the text file named
"40737-504D03US_ST25.txt", which was created on Jun. 25, 2013 and
is 9.78 KB in size, are hearby incorporated by reference in their
entireties.
FIELD OF THE INVENTION
[0003] The present invention relates to the therapeutic use of
guanylate cyclase C (GC-C) agonists as a means for enhancing the
intracellular production of cGMP. The agonists may be used either
alone or in combination with inhibitors of cGMP-specific
phosphodiesterase to prevent or treat inflammation, cancer and
other disorders, particularly of the gastrointestinal tract and the
lung.
BACKGROUND OF THE INVENTION
[0004] Uroguanylin, guanylin and bacterial ST peptides are
structurally related peptides that bind to a guanylate cyclase
receptor and stimulate intracellular production of cyclic guanosine
monophosphate (cGMP) (1-6). This results in the activation of the
cystic fibrosis transmembrane conductance regulator (CFTR), an
apical membrane channel for efflux of chloride from enterocytes
lining the intestinal tract (1-6). Activation of CFTR and the
subsequent enhancement of transepithelial secretion of chloride
lead to stimulation of sodium and water secretion into the
intestinal lumen. Therefore, by serving as paracrine regulators of
CFTR activity, cGMP receptor agonists regulate fluid and
electrolyte transport in the GI tract (1-6; U.S. Pat. No.
5,489,670). Thus, the cGMP-mediated activation of CFTR and the
downstream signaling plays an important role in normal functioning
of gut physiology. Therefore, any abnormality in this process could
potentially lead to gastrointestinal disorders such as irritable
bowel syndrome, inflammatory bowel disease, excessive acidity and
cancer (25, 26).
[0005] The process of epithelial renewal involves the
proliferation, migration, differentiation, senescence, and eventual
loss of GI cells in the lumen (7, 8). The GI mucosa can be divided
into three distinct zones based on the proliferation index of
epithelial cells. One of these zones, the proliferative zone,
consists of undifferentiated stem cells responsible for providing a
constant source of new cells. The stem cells migrate upward toward
the lumen to which they are extruded. As they migrate, the cells
lose their capacity to divide and become differentiated for
carrying out specialized functions of the GI mucosa (9). Renewal of
GI mucosa is very rapid with complete turnover occurring within a
24-48 hour period (9). During this process mutated and unwanted
cells are replenished with new cells. Hence, homeostasis of the GI
mucosa is regulated by continual maintenance of the balance between
proliferation and apoptotic rates (8).
[0006] The rates of cell proliferation and apoptosis in the gut
epithelium can be increased or decreased in a wide variety of
different circumstances, e.g., in response to physiological stimuli
such as aging, inflammatory signals, hormones, peptides, growth
factors, chemicals and dietary habits. In addition, an enhanced
proliferation rate is frequently associated with a reduction in
turnover time and an expansion of the proliferative zone (10). The
proliferation index has been observed to be much higher in
pathological cases of ulcerative colitis and other GI disorders
(11). Thus, intestinal hyperplasia is the major promoter of
gastrointestinal inflammation and carcinogenesis.
[0007] In addition to a role for uroguanylin and guanylin as
modulators of intestinal fluid and ion secretion, these peptides
may also be involved in the continual renewal of GI mucosa by
maintaining the balance between proliferation and apoptosis in
cells lining GI mucosa. Therefore, any disruption in this renewal
process, due to reduced production of uroguanylin and/or guanylin
can lead to GI inflammation and cancer (25, 26). This is consistent
with previously published data in WO 01/25266, which suggest a
peptide with the active domain of uroguanylin may function as an
inhibitor of polyp development in the colon and may constitute a
treatment of colon cancer. However, recent data also suggest that
uroguanylin also binds to a currently unknown receptor, which is
distinct from GC-C receptor (3,4). Knockout mice lacking this
guanylate cyclase receptor show resistance to ST peptides in the
intestine, but effects of uroguanylin and ST peptides are not
disturbed in the kidney in vivo (3). These results were further
supported by the fact that membrane depolarization induced by
guanylin was blocked by genistein, a tyrosine kinase inhibitor,
whereas hyperpolarization induced by uroguanylin was not effected
(12, 13). Thus, it is not clear if the anti-colon cancer and
anti-inflammatory activities of uroguanylin and its analogs are
mediated through binding to one or both of these receptors.
[0008] Inflammatory bowel disease is a general name given to a
group of disorders that cause intestines to become inflamed,
characterized by red and swollen tissue. Gastrointestinal (GI)
inflammation can be a chronic condition and often leads to GI
cancer (14). Examples of such inflammatory bowel diseases (IBD)
include Crohn's disease and ulcerative colitis (UC). It is
estimated that as many as 1,000,000 Americans are afflicted with
IBD, with male and female patients appearing to be equally
affected. Most cases are diagnosed before age 30, but the disease
can occur in the sixth, seventh, and later decades of life.
[0009] Crohn's disease is a serious inflammatory disease that
predominantly effects ileum and colon, but can also occur in other
sections of the GI tract, whereas UC is exclusively an inflammatory
disease of the colon, the large intestine (15). Unlike Crohn's
disease, in which all layers of the intestine are involved, and in
which there can be normal healthy bowel in between patches of
diseased bowel, UC affects only the innermost lining (mucosa) of
the colon in a continuous manner (16). Depending on which portion
of the GI tract is involved, Crohn's disease may be referred to as
ileitis, regional enteritis, colitis, etc. Crohn's disease and UC
differ from spastic colon or irritable bowel syndrome, which are
motility disorders of the GI tract.
[0010] While the precise cause of IBD is not known, it is believed
that the disruption of the process of continual renewal of GI
mucosa may be involved in disease (17,18). The renewal process of
the GI lining is an efficient and dynamic process involving the
continual proliferation and replenishment of unwanted damaged
cells. Proliferation rates of cells lining the GI mucosa are very
high, second only to the hematopoietic system. Thus, the balance
between proliferation and apoptosis is important to the maintenance
of the homeostasis of the GI mucosa (19,20).
[0011] Necrotizing enterocolitis (NEC) is a devastating
inflammatory condition of the gastrointestinal tract that afflicts
10% of premature infants born weighing less than 1500 grams.
Despite modern medical advances, the etiology remains elusive, and
morbidity and mortality is unacceptably high, with as many as
10-30% of affected infants succumbing to the disease. Although the
pathophysiology is incompletely understood, it is known that
prematurity, formula feeding, intestinal ischemia, and bacterial
colonization are important risk factors. It has been suggested that
these risk factors initiate the activation of the pro-inflammatory
response that ultimately leads to bowel necrosis, and in some cases
multi-organ dysfunction syndrome, and death. Multiple inflammatory
mediators have been identified that might contribute to this final
common pathway. Several of the pro- and anti-inflammatory molecules
have been studied in detail in animal models, in humans, and in
vitro, including IL-6, IL-8, and IL-10 as well as nitric oxide,
oxygen free radicals, and numerous others. Previously, we reported
that SP-304 ameliorates GI inflammation in experimental models of
murine colitis, possibly through downregulation of pro-inflammatory
cytokines such as IL-4, IL-5, IL-17, IL-23 and TNF-a. (Shailubhai
et al, 2007 and 2008). Therefore, GC-C agonists such as
uroguanylin, guanylin, E. coli enterotoxin ST peptides and their
analogs might be used to prevent, control and treat NEC. GC-C
agonists may be given either in drinking water or in mother's milk
to treat NEC in newborn babies.
[0012] GI homeostasis depends on both proliferation and programmed
cellular death (apoptosis) of epithelial cells lining the gut
mucosa. Hence, cells are continually lost from the villus into the
lumen of the gut and are replenished at a substantially equal rate
by the proliferation of cells in the crypts, followed by their
upward movement to the villus. It has become increasingly apparent
that the control of cell death is an equally, if not more,
important regulator of cell number and proliferation index (19,20).
Reduced rates of apoptosis are often associated with abnormal
growth, inflammation, and neoplastic transformation. Thus, both
decreased proliferation and/or increased cell death may reduce cell
number, whereas increased proliferation and/or reduced cell death
may increase the proliferation index of intestinal tissue (20),
which may lead to GI inflammatory diseases and cancer.
[0013] Uroguanylin and guanylin peptides also appear to promote
apoptosis by controlling cellular ion flux. Alterations in
apoptosis have been associated with tumor progression to the
metastatic phenotype. While a primary gastrointestinal (GI) cancer
is limited to the small intestine, colon, and rectum, it may
metastasize and spread to such localities as bone, lymph nodes,
liver, lung, peritoneum, ovaries, and brain. By enhancing the
efflux of K+ and influx of Ca++, uroguanylin and related peptides
may promote the death of transformed cells and thereby inhibit
metastasis
[0014] Irritable bowel syndrome (IBS) and chronic idiopathic
constipation are pathological conditions that can cause a great
deal of intestinal discomfort and distress but unlike the IBD
diseases such as ulcerative colitis and Crohn's disease, IBS does
not cause the serious inflammation or changes in bowel tissue and
it is not thought to increase the risk of colorectal cancer. In the
past, inflammatory bowel disease (IBD), celiac disease and
irritable bowel syndrome (IBS) were regarded as completely separate
disorders. Now, with the description of inflammation, albeit
low-grade, in IBS, and of symptom overlap between IBS and celiac
disease, this contention has come under question. Acute bacterial
gastroenteritis is the strongest risk factor identified to date for
the subsequent development of postinfective irritable bowel
syndrome. Clinical risk factors include prolonged acute illness and
the absence of vomiting. A genetically determined susceptibility to
inflammatory stimuli may also be a risk factor for irritable bowel
syndrome. The underlying pathophysiology indicates increased
intestinal permeability and low-grade inflammation, as well as
altered motility and visceral sensitivity (27). Serotonin
(5-hydroxytryptamine [5-HT]) is a key modulator of gut function and
is known to play a major role in pathophysiology of IBS. It has
been shown that the activity of 5-HT is regulated by cGMP (28).
Therefore, based on this observation as well as other effects of
cGMP, we believe that GC-C agonists will be useful in the treatment
of IBS.
[0015] Given the prevalence of inflammatory conditions in Western
societies and the attendant risk of developing cancerous lesions
from inflamed tissue, particularly intestinal tissue, a need exists
to improve the treatment options for inflammatory conditions,
particularly of the gastrointestinal tract.
SUMMARY OF THE INVENTION
[0016] The present invention is based upon the development of
agonists of guanylate cyclase receptor. The agonists are analogs of
uroguanylin and bacterial ST peptides and have superior properties
such as for example high resistance to degradation at the
N-terminus and C-terminus from carboxypeptidases and/or by other
proteolytic enzymes present in the stimulated human intestinal
juices and human gastric juices.
[0017] The peptides of the invention may be used to treat any
condition that responds to enhanced intracellular levels of cGMP.
Intracellular levels of cGMP can be increased by enhancing
intracellular production of cGMP and/or by inhibition of its
degradation by cGMP-specific phosphodiesterases. Among the specific
conditions that can be treated or prevented are gastrointestinal
disorders, inflammatory disorders, lung disorders, cancer, cardiac
disorders, eye disorders, oral disorders, blood disorders, liver
disorders, skin disorders, prostate disorders, endocrine disorders,
increasing gastrointestinal motility and obesity. Gastointestinal
disorders include for example, irritable bowel syndrome (IBS),
necrotizing enterocolitis (NEC), non-ulcer dyspepsia, chronic
intestinal pseudo-obstruction, functional dyspepsia, colonic
pseudo-obstruction, duodenogastric reflux, gastroesophageal reflux
disease (GERD), ileus inflammation (e.g., post-operative ileus),
gastroparesis, heartburn (high acidity in the GI tract),
constipation (e.g., constipation associated with use of medications
such as opioids, osteoarthritis drugs, osteoporosis drugs; post
surigical constipation, constipation associated with neuropathic
disorders. Inflammatory disorders include tissue and organ
inflammation such as kidney inflammation (e.g., nephritis),
gastrointestinal system inflammation (e.g., Crohn's disease and
ulcerative colitis); pancreatic inflammation (e.g., pancreatis),
lung inflammation (e.g., bronchitis or asthma) or skin inflammation
(e.g., psoriasis, eczema). Lung Disorders include for example
chronic obstructive pulmonary disease (COPD), and fibrosis. Cancer
includes tissue and organ carcinogenesis including metatases such
as for example gastrointestinal cancer, (e.g., gastric cancer,
esophageal cancer, pancreatic cancer colorectal cancer, intestinal
cancer, anal cancer, liver cancer, gallbladder cancer, or colon
cancer; lung cancer; thyroid cancer; skin cancer (e.g., melanoma);
oral cancer; urinary tract cancer (e.g. bladder cancer or kidney
cancer); blood cancer (e.g. myeloma or leukemia) or prostate
cancer. Cardiac disorders include for example, congestive heart
failure, trachea cardia hypertension, high cholesterol, or high
tryglycerides. Liver disorders include for example cirrhosis and
fibrosis. In addition, GC-C agonist may also be useful to
facilitate liver regeneration in liver transplant patients. Eye
disorders include for example increased intra-ocular pressure,
glaucoma, dry eyes retinal degeneration, disorders of tear glands
or eye inflammation. Skin disorders include for example xerosis.
Oral disorders include for example dry mouth (xerostomia),
Sjogren's syndrome, gum diseases (e.g., periodontal disease), or
salivary gland duct blockage or malfunction. Prostate disorders
include for example benign prostatic hyperplasia (BPH). Endocrine
disorders include for example diabetes mellitus, hyperthyroidism,
hypothyroidism, and cystic fibrosis.
[0018] In one aspect, the present invention is directed to a
peptide consisting essentially of the amino acid sequence of, SEQ
ID NOs: 2-8 and to therapeutic compositions which contain these
peptides. The term "consisting essentially of" includes peptides
that are identical to a recited sequence identification number and
other sequences that do not differ substantially in terms of either
structure or function. For the purpose of the present application,
a peptide differs substantially if its structure varies by more
than three amino acids from a peptide of SEQ ID NOs: 2-8 or if its
activation of cellular cGMP production is reduced by more than 50%
compared to a control peptide such as SEQ ID NO:1. Preferably,
substantially similar peptides should differ by no more than two
amino acids and not differ by more than about 25% with respect to
activating cGMP production. The instant peptide sequences comprise
at least 12 amino acid residues, preferably between 12 and 26 amino
acids in length.
[0019] The peptides may be in a pharmaceutical composition in unit
dose form, together with one or more pharmaceutically acceptable
carrier, excipients or diluents. The term "unit dose form" refers
to a single drug delivery entity, e.g., a tablet, capsule, solution
or inhalation formulation. The amount of peptide present should be
sufficient to have a positive therapeutic effect when administered
to a patient (typically, between 100 .mu.g and 3 g). What
constitutes a "positive therapeutic effect" will depend upon the
particular condition being treated and will include any significant
improvement in a condition readily recognized by one of skill in
the art. For example, it may constitute a reduction in
inflammation, shrinkage of polyps or tumors, a reduction in
metastatic lesions, etc.
[0020] In yet another aspect, an invention provides administering
to said patient an effective dose of an inhibitor of cGMP-specific
phosphodiesterase (cGMP-PDE) either concurrently or sequentially
with said guanylate cyclase receptor agonist. The cGMP-PDE
inhibitor includes for example suldinac sulfone, zaprinast, and
motapizone, vardenifil, and sildenafil. In addition, GC-C agonist
peptides may be used in combination with inhibitors of cyclic
nucleotide transporters.
[0021] Optionally, anti-inflammatory agents are also administered.
Anti-inflammatory agents include for example steroids and
non-steroidal anti-inflammatory drugs (NSAIDS).
[0022] Other features and advantages of the invention will be
apparent from and are encompassed by the following detailed
description and claims.
DETAILED DESCRIPTION
[0023] The present invention is based upon the development of
agonists of guanylate cyclase-C (GC-C). The agonists are analogs of
uroguanylin and have superior properties such as for example high
resistance to degradation at the N-terminus and C-terminus from
carboxypeptidases and/or by other proteolytic enzymes such as those
present in the stimulated human intestinal fluid (SIF) and
simulated human gastric fluid (SGF). Specifically, these peptides
contain a d-amino acid at the amino-terminus and the carboxyl
terminus. Additionally these peptides are modified as to mask the
carboxyl-terminal carboxylic acid with an amide. Thus, the peptide
is protected on both termini from degradation by proteases present
in SIF and SGF. Examples of such a peptide include SP-363, SP-365,
SP-367 and SP-373 shown in Table I.
[0024] The GC-C is expressed on various cells including on
gastrointestinal epithelial cells, and on extra-intestinal tissues
including kidney, lung, pancreas, pituitary, adrenal, developing
liver, heart and male and female reproductive tissues (reviewed in
Vaandrager 2002 Mol Cell Biochem 230:73-83). The GC-C is a key
regulator of fluid and electrolyte balance in the intestine and
kidney. In the intestine, when stimulated, the GC-C causes an
increase in intestinal epithelial cGMP. This increase in cGMP
causes a decrease in water and sodium absorption and an increase in
chloride and potassium ion secretion, leading to changes in
intestinal fluid and electrolyte transport and increased intestinal
motility.
[0025] The gualylate cyclase-C agonists according to the invention
include SEQ ID NO:2-8 and are summarized below in Table I. The
gualylate cyclase-C agonists according to the invention are
collectively referred to herein as "GCRA peptides".
TABLE-US-00001 TABLE I GCRA Peptides SEQ ID Name Structure NO:
SP304
Asn.sup.1-Asp.sup.2-Glu.sup.3-Cys.sup.4-Glu.sup.5-Leu.sup.6-Cys.sup.-
7-Val.sup.8-Asn.sup.9-Val.sup.10-Ala.sup.11-Cys.sup.12-Thr.sup.13-Gly.sup.-
14-Cys.sup.15-Leu.sup.16 1 SP-333
dAsn.sup.1-Asp.sup.2-Glu.sup.3-Cys.sup.4-Glu.sup.5-Leu.sup.6-Cys.su-
p.7-Val.sup.8-Asn.sup.9-Val.sup.10-Ala.sup.11-Cys.sup.12-Thr.sup.13-Gly.su-
p.14-Cys.sup.15-dLeu.sup.16 2 SP-363
dAsn.sup.1-Asp.sup.2-Glu.sup.3-Cys.sup.4-Glu.sup.5-Leu.sup.6-Cys.su-
p.7-Val.sup.8-Asn.sup.9-Val.sup.10-Ala.sup.11-Cys.sup.12-Thr.sup.13-Gly.su-
p.14-Cys.sup.15-dLeu-AMIDE.sup.16 3 SP-364
dAsn.sup.1-Asp.sup.2-Glu.sup.3-Cys.sup.4-Glu.sup.5-Leu.sup.6-Cys.su-
p.7-Val.sup.8-Asn.sup.9-Val.sup.10-Ala.sup.11-Cys.sup.12-Thr.sup.13-Gly.su-
p.14-Cys.sup.15-dSer.sup.16 4 SP-365
dAsn.sup.1-Asp.sup.2-Glu.sup.3-Cys.sup.4-Glu.sup.5-Leu.sup.6-Cys.su-
p.7-Val.sup.8-Asn.sup.9-Val.sup.10-Ala.sup.11-Cys.sup.12-Thr.sup.13-Gly.su-
p.14-Cys.sup.15-dSer-AMIDE.sup.16 5 SP-366
dAsn.sup.1-Asp.sup.2-Glu.sup.3-Cys.sup.4-Glu.sup.5-Leu.sup.6-Cys.su-
p.7-Val.sup.8-Asn.sup.9-Val.sup.10-Ala.sup.11-Cys.sup.12-Thr.sup.13-Gly.su-
p.14-Cys.sup.15-dTyr.sup.16 6 SP-367
dAsn.sup.1-Asp.sup.2-Glu.sup.3-Cys.sup.4-Glu.sup.5-Leu.sup.6-Cys.su-
p.7-Val.sup.8-Asn.sup.9-Val.sup.10-Ala.sup.11-Cys.sup.12-Thr.sup.13-Gly.su-
p.14-Cys.sup.15-dTyr-AMIDE.sup.16 7 SP-373
Pyglu.sup.1-Asp.sup.2-Glu.sup.3-Cys.sup.4-Glu.sup.5-Leu.sup.6-Cys.s-
up.7-Val.sup.8-Asn.sup.9-Val.sup.10-Ala.sup.11-Cys.sup.12-Thr.sup.13-Gly.s-
up.14-Cys.sup.15-dLeu-AMIDE.sup.16 8
[0026] The GCRA peptides described herein bind the guanylate
cyclase C (GC-C) and stimulate intracellular production of cyclic
guanosine monophosphate (cGMP). Optionally, the GCRA peptides
induce apoptosis. In some aspects, the GCRA peptides stimulate
intracellular cGMP production at higher levels than naturally
occurring GC-C agonists (e.g., uroguanylin, guanylin, and ST
peptides) and/or SP-304. For example, the GCRA peptides of the
invention stimulate 5, 10%, 20%, 30%, 40%, 50%, 75%, 90% or more
intracellular cGMP compared to naturally occurring GC-C angonists
and/or SP-304. The terms induced and stimulated are used
interchangeably throughout the specification. The GCRA peptides
described herein are more stable than naturally occurring GC-C
agonists and/or SP-304. By more stable it is meant that the peptide
degrade less and/or more slowly in simulated gastrointestinal fluid
and/or simulated intestinal fluid compared to naturally occurring
GC-C angonists and/or SP-304. For example, the GCRA peptide of the
invention degrade 2%, 3%, 5%, 10%, 15%, 20%, 30%, 40%, 50%, 75%,
90% or less compared to naturally occurring GC-C angonists and/or
SP-304.
[0027] The GCRA peptides described herein have therapeutic value in
the treatment of a wide variety of disorders and conditions
including for example gastrointestinal disorders, inflammatory
disorders, lung disorders, cancer, cardiac disorders, eye
disorders, oral disorders, blood disorders, liver disorders, skin
disorders, prostate disorders, endocrine disorders, increasing
gastrointestinal motility and obesity. Gastointestinal disorders
include for example, irritable bowel syndrome (IBS), necrotizing
enterocolitis (NEC), non-ulcer dyspepsia, chronic intestinal
pseudo-obstruction, functional dyspepsia, colonic
pseudo-obstruction, duodenogastric reflux, gastroesophageal reflux
disease (GERD) ileus (e.g., post-operative ileus), gastroparesis,
heartburn (high acidity in the GI tract), constipation (e.g.,
constipation associated with use of medications such as opioids,
osteoarthritis drugs, osteoporosis drugs; post surigical
constipation, constipation associated with neuropathic disorders.
Inflammatory disorders include tissue and organ inflammation such
as kidney inflammation (e.g., nephritis), gastrointestinal system
inflammation (e.g., Crohn's disease and ulcerative colitis);
pancreatic inflammation (e.g., pancreatis), lung inflammation
(e.g., bronchitis or asthma) or skin inflammation (e.g., psoriasis,
eczema). Lung Disorders include for example chronic obstructive
pulmonary disease (COPD), and fibrosis. Cancer includes tissue and
organ carcinogenesis including metatases such as for example
gastrointestinal cancer, (e.g., gastric cancer, esophageal cancer,
pancreatic cancer colorectal cancer, intestinal cancer, anal
cancer, liver cancer, gallbladder cancer, or colon cancer; lung
cancer; thyroid cancer; skin cancer (e.g., melanoma); oral cancer;
urinary tract cancer (e.g. bladder cancer or kidney cancer); blood
cancer (e.g. myeloma or leukemia) or prostate cancer. Cardiac
disorders include for example, congestive heart failure, trachea
cardia hypertension, high cholesterol, or high tryglycerides. Liver
disorders include for example cirrhosis and fibrosis. Eye disorders
include for example increased intra-ocular pressure, glaucoma, dry
eyes retinal degeneration, disorders of tear glands or eye
inflammation. Skin disorders include for example xerosis. Oral
disorders include for example dry mouth (xerostomia), Sjogren's
syndrome, gum diseases (e.g., periodontal disease), or salivary
gland duct blockage or malfunction. Prostate disorders include for
example Benign prostatic hyperplasia (BPH). Endocrine disorders
include for example diabetes mellitus, hyperthyroidism,
hypothyroidism, and cystic fibrosis.
[0028] As used herein, the term "guanylate cyclase C (GC-C)" refers
to the class of guanylate cyclase C receptor on any cell type to
which the inventive agonist peptides or natural agonists described
herein bind. As used herein, "intestinal guanylate cyclase
receptor" is found exclusively on epithelial cells lining the GI
mucosa. Uroguanylin, guanylin, and ST peptides are expected to bind
to these receptors and may induce apoptosis. The possibility that
there may be different receptors for each agonist peptide is not
excluded. Hence, the term refers to the class of guanylate cyclase
receptors on epithelial cells lining the GI mucosa.
[0029] As used herein, the term "GCR agonist" is meant to refer to
peptides and/or other compounds that bind to an intestinal
guanylate cyclase C and stimulate fluid and electrolyte transport.
This term also covers fragments and pro-peptides that bind to GC-C
and stimulate fluid and water secretion.
[0030] As used herein, the term "substantially equivalent" is meant
to refer to a peptide that has an amino acid sequence equivalent to
that of the binding domain where certain residues may be deleted or
replaced with other amino acids without impairing the peptide's
ability to bind to an intestinal guanylate cyclase receptor and
stimulate fluid and electrolyte transport.
[0031] Addition of carriers (e.g., phosphate-buffered saline or
PBS) and other components to the composition of the present
invention is well within the level of skill in this art. In
addition to the compound, such compositions may contain
pharmaceutically acceptable carriers and other ingredients known to
facilitate administration and/or enhance uptake. Other
formulations, such as microspheres, nanoparticles, liposomes, and
immunologically-based systems may also be used in accordance with
the present invention. Other examples include formulations with
polymers (e.g., 20% w/v polyethylene glycol) or cellulose, or
enteric formulations.
[0032] The present invention is based upon several concepts. The
first is that there is a cGMP-dependent mechanism which regulates
the balance between cellular proliferation and apoptosis and that a
reduction in cGMP levels, due to a deficiency of
uroguanylin/guanylin and/or due to the activation of cGMP-specific
phosphodiesterases, is an early and critical step in neoplastic
transformation. A second concept is that the release of arachidonic
acid from membrane phospholipids, which leads to the activation of
cytoplasmic phospholipase A2 (cPLA2), cyclooxygenase-2 (COX-2) and
possibly 5-lipoxygenase (5-LO) during the process of inflammation,
is down-regulated by a cGMP-dependent mechanism, leading to reduced
levels of prostaglandins and leukotrienes, and that increasing
intracellular levels of cGMP may therefore produce an
anti-inflammatory response. In addition, a cGMP-dependent
mechanism, is thought to be involved in the control of
proinflammatory processes. Therefore, elevating intracellular
levels of cGMP may be used as a means of treating and controlling
gastrointestinal disorders, inflammatory disorders, lung disorders,
cancer, cardiac disorders, eye disorders, oral disorders, blood
disorders, liver disorders, skin disorders, prostate disorders,
endocrine disorders, increasing gastrointestinal motility and
obesity. Gastointestinal disorders include for example, irritable
bowel syndrome (IBS), necrotizing enterocolitis (NEC), non-ulcer
dyspepsia, chronic intestinal pseudo-obstruction, functional
dyspepsia, colonic pseudo-obstruction, duodenogastric reflux,
gastroesophageal reflux disease (GERD) ileus (e.g., post-operative
ileus), gastroparesis, heartburn (high acidity in the GI tract),
constipation (e.g., constipation associated with use of medications
such as opioids, osteoarthritis drugs, osteoporosis drugs; post
surigical constipation, constipation associated with neuropathic
disorders. Inflammatory disorders include tissue and organ
inflammation such as kidney inflammation (e.g., nephritis),
gastrointestinal system inflammation (e.g., Crohn's disease and
ulcerative colitis); pancreatic inflammation (e.g., pancreatis),
lung inflammation (e.g., bronchitis or asthma) or skin inflammation
(e.g., psoriasis, eczema). Lung Disorders include for example COPD
and fibrosis. Cancer includes tissue and organ carcinogenesis
including metatases such as for example gastrointestinal cancer,
(e.g., gastric cancer, esophageal cancer, pancreatic cancer
colorectal cancer, intestinal cancer, anal cancer, liver cancer,
gallbladder cancer, or colon cancer; lung cancer; thyroid cancer;
skin cancer (e.g., melanoma); oral cancer; urinary tract cancer
(e.g. bladder cancer or kidney cancer); blood cancer (e.g. myeloma
or leukemia) or prostate cancer. Cardiac disorders include for
example, congestive heart failure, trachea cardia hypertension,
high cholesterol, or high tryglycerides. Liver disorders include
for example cirrhosis and fibrosis. Eye disorders include for
example increased intra-ocular pressure, glaucoma, dry eyes retinal
degeneration, disorders of tear glands or eye inflammation. Skin
disorders include for example xerosis. Oral disorders include for
example dry mouth (xerostomia), Sjogren's syndrome, gum diseases
(e.g., periodontal disease), or salivary gland duct blockage or
malfunction. Prostate disorders include for example Benign
prostatic hyperplasia (BPH). Endocrine disorders include for
example diabetes mellitus, hyperthyroidism, hypothyroidism, and
cystic fibrosis.
[0033] Without intending to be bound by any theory, it is
envisioned that ion transport across the plasma membrane may prove
to be an important regulator of the balance between cell
proliferation and apoptosis that will be affected by agents
altering cGMP concentrations. Uroguanylin has been shown to
stimulate K+ efflux, Ca++ influx and water transport in the
gastrointestinal tract (3). Moreover, atrial natriuretic peptide
(ANP), a peptide that also binds to a specific guanylate cyclase
receptor, has also been shown to induce apoptosis in rat mesangial
cells, and to induce apoptosis in cardiac myocytes by a cGMP
mechanism (21-24).
[0034] Binding of the present agonists to a guanylate cyclase
receptor stimulates production of cGMP. This ligand-receptor
interaction, via activation of a cascade of cGMP-dependent protein
kinases and CFTR, induces apoptosis in target cells. Therefore,
administration of the novel peptides defined by SEQ ID NO:2-8, as
shown in Table I are useful in eliminating or, at least retarding,
the onset of gastrointestinal disorders, inflammatory disorders,
lung disorders, cancer, cardiac disorders, eye disorders, oral
disorders, blood disorders, liver disorders, skin disorders,
prostate disorders, endocrine disorders, increasing
gastrointestinal motility and obesity. Gastointestinal disorders
include for example, irritable bowel syndrome (IBS), necrotizing
enterocolitis (NEC), non-ulcer dyspepsia, chronic intestinal
pseudo-obstruction, functional dyspepsia, colonic
pseudo-obstruction, duodenogastric reflux, gastroesophageal reflux
disease (GERD), ileus inflammation (e.g., post-operative ileus),
gastroparesis, heartburn (high acidity in the GI tract),
constipation (e.g., constipation associated with use of medications
such as opioids, osteoarthritis drugs, osteoporosis drugs; post
surigical constipation, constipation associated with neuropathic
disorders. Inflammatory disorders include tissue and organ
inflammation such as kidney inflammation (e.g., nephritis),
gastrointestinal system inflammation (e.g., Crohn's disease and
ulcerative colitis); pancreatic inflammation (e.g., pancreatis),
lung inflammation (e.g., bronchitis or asthma) or skin inflammation
(e.g., psoriasis, eczema). Lung Disorders include for example
chronic obstructive pulmonary disease (COPD), and fibrosis. Cancer
includes tissue and organ carcinogenesis including metatases such
as for example gastrointestinal cancer, (e.g., gastric cancer,
esophageal cancer, pancreatic cancer colorectal cancer, intestinal
cancer, anal cancer, liver cancer, gallbladder cancer, or colon
cancer; lung cancer; thyroid cancer; skin cancer (e.g., melanoma);
oral cancer; urinary tract cancer (e.g. bladder cancer or kidney
cancer); blood cancer (e.g. myeloma or leukemia) or prostate
cancer. Cardiac disorders include for example, congestive heart
failure, trachea cardia hypertension, high cholesterol, or high
tryglycerides. Liver disorders include for example cirrhosis and
fibrosis. Eye disorders include for example increased intra-ocular
pressure, glaucoma, dry eyes retinal degeneration, disorders of
tear glands or eye inflammation. Skin disorders include for example
xerosis. Oral disorders include for example dry mouth (xerostomia),
Sjogren's syndrome, gum diseases (e.g., periodontal disease), or
salivary gland duct blockage or malfunction. Prostate disorders
include for example Benign prostatic hyperplasia (BPH). Endocrine
disorders include for example diabetes mellitus, hyperthyroidism,
hypothyroidism, and cystic fibrosis.
[0035] Uroguanylin is a circulating peptide hormone with
natriuretic activity and has been found to stimulate fluid and
electrolyte transport in a manner similar to another family of heat
stable enterotoxins (ST peptides) secreted by pathogenic strains of
E. coli and other enteric bacteria that activate guanylate cyclase
receptor and cause secretory diarrhea. Unlike bacterial ST
peptides, the binding of uroguanylin to guanylate cyclase receptor
is dependent on the physiological pH of the gut. Therefore,
uroguanylin is expected to regulate fluid and electrolyte transport
in a pH dependent manner and without causing severe diarrhea.
[0036] GCRA Peptides
[0037] In one aspect, the invention provides a GCRA peptide. The
GCRA peptides are analogues uroguanylin and bacterial ST peptide.
No particular length is implied by the term "peptide". In some
embodiments, the GCRA peptide is less than 25 amino acids in
length, e.g., less than or equal to 20, 15, 14, 13, 12, 11, 10, or
5 amino acid in length.
[0038] The GCRA peptides can be polymers of L-amino acids, D-amino
acids, or a combination of both. For example, in various
embodiments, the peptides are D retro-inverso peptides. The term
"retro-inverso isomer" refers to an isomer of a linear peptide in
which the direction of the sequence is reversed and the chirality
of each amino acid residue is inverted. See, e.g., Jameson et al.,
Nature, 368, 744-746 (1994); Brady et al., Nature, 368, 692-693
(1994). The net result of combining D-enantiomers and reverse
synthesis is that the positions of carbonyl and amino groups in
each amide bond are exchanged, while the position of the side-chain
groups at each alpha carbon is preserved. Unless specifically
stated otherwise, it is presumed that any given L-amino acid
sequence of the invention may be made into an D retro-inverso
peptide by synthesizing a reverse of the sequence for the
corresponding native L-amino acid sequence. For example a GCRA
peptide includes the sequence of SEQ ID NO: SEQ ID NO:2-8.
[0039] By inducing cGMP production is meant that the GCRA peptide
induces the production of intracellular cGMP. Intracellular cGMP is
measured by methods known in the art. For example, the GCRA peptide
of the invention stimulate 5%, 10%, 20%, 30%, 40%, 50%, 75%, 90% or
more intracellular cGMP compared to naturally occurring GC-C
angonists. Optionally, the GCRA peptides of the invention of the
invention stimulate 5%, 10%, 20%, 30%, 40%, 50%, 75%, 90% or more
intracellular cGMP compared SP-304 (SEQ ID NO:1). In further
embodiments, the GCRA peptide stimulates apoptosis, e.g.,
programmed cell death or activate the cystic fibrosis transmembrane
conductance regulator (CFTR). In some embodiments the GCRA peptides
described herein are more stable than naturally occurring GC-C
agonists and/or SP-304 (SEQ ID NO:1). By more stable it is meant
that the peptide degrade less and/or more slowly in simulated
gastric fluid and/or simulated intestinal fluid compared to
naturally occurring GC-C angonists and/or SP-304. For example, the
GCRA peptide of the invention degrade 2%, 3%, 5%, 10%, 15%, 20%,
30%, 40%, 50%, 75%, 90% or less compared to naturally occurring
GC-C angonists and/or SP-304.
[0040] As used herein, the term "AMIDE" is meant to denote that the
terminal carboxylic acid is replaced with an amide group, i.e., the
terminal COOH is replaced with CONH.sub.2.
[0041] In certain embodiments, one or more amino acids of the GCRA
peptides can be replaced by a non-naturally occurring amino acid or
a naturally or non-naturally occurring amino acid analog. There are
many amino acids beyond the standard 20 (Ala, Arg, Asn, Asp, Cys,
Gln, Glu, Gly, His, Ile, Leu, Lys, Met, Phe, Pro, Ser, Thr, Trp,
Tyr, and VaI). Some are naturally-occurring others are not. (See,
for example, Hunt, The Non-Protein Amino Acids: In Chemistry and
Biochemistry of the Amino Acids, Barrett, Chapman and Hall, 1985).
For example, an aromatic amino acid can be replaced by
3,4-dihydroxy-L-phenylalanine, 3-iodo-L-tyrosine, triiodothyronine,
L-thyroxine, phenylglycine (Phg) or nor-tyrosine (norTyr). Phg and
norTyr and other amino acids including Phe and Tyr can be
substituted by, e.g., a halogen, --CH3, --OH, --CH2NH3, --C(O)H,
--CH2CH3, --CN, --CH2CH2CH3, --SH, or another group. Any amino acid
can be substituted by the D-form of the amino acid.
[0042] With regard to non-naturally occurring amino acids or
naturally and non-naturally occurring amino acid analogs, a number
of substitutions in the polypeptide and agonists described herein
are possible alone or in combination.
[0043] For example, glutamine residues can be substituted with
gamma-Hydroxy-Glu or gamma-Carboxy-Glu. Tyrosine residues can be
substituted with an alpha substituted amino acid such as
L-alpha-methylphenylalanine or by analogues such as: 3-Amino-Tyr;
Tyr(CH3); Tyr(PO3(CH3)2); Tyr(SO.sub.3H); beta-Cyclohexyl-Ala;
beta-(1-Cyclopentenyl)-Ala; beta-Cyclopentyl-Ala;
beta-Cyclopropyl-Ala; beta-Quinolyl-Ala; beta-(2-Thiazolyl)-Ala;
beta-(Triazole-1-yl)-Ala; beta-(2-Pyridyl)-Ala;
beta-(3-Pyridyl)-Ala; Amino-Phe; Fluoro-Phe; Cyclohexyl-Gly;
tBu-Gly; beta-(3-benzothienyl)-Ala; beta-(2-thienyl)-Ala;
5-Methyl-Trp; and A-Methyl-Trp. Proline residues can be substituted
with homopro (L-pipecolic acid); hydroxy-Pro; 3,4-Dehydro-Pro;
4-fluoro-Pro; or alpha-methyl-Pro or an N(alpha)-C(alpha) cyclized
amino acid analogues with the structure: n=0, 1, 2, 3 Alanine
residues can be substituted with alpha-substituted or N-methylated
amino acid such as alpha-amino isobutyric acid (aib),
L/D-alpha-ethylalanine (L/D-isovaline), L/D-methylvaline, or
L/D-alpha-methylleucine or a non-natural amino acid such as
beta-fluoro-Ala. Alanine can also be substituted with: n=0, 1, 2, 3
Glycine residues can be substituted with alpha-amino isobutyric
acid (aib) or L/D-alpha-ethylalanine (L/D-isovaline).
[0044] Further examples of unnatural amino acids include: an
unnatural analog of tyrosine; an unnatural analogue of glutamine;
an unnatural analogue of phenylalanine; an unnatural analogue of
serine; an unnatural analogue of threonine; an alkyl, aryl, acyl,
azido, cyano, halo, hydrazine, hydrazide, hydroxyl, alkenyl,
alkynl, ether, thiol, sulfonyl, seleno, ester, thioacid, borate,
boronate, phospho, phosphono, phosphine, heterocyclic, enone,
imine, aldehyde, hydroxylamine, keto, or amino substituted amino
acid, or any combination thereof; an amino acid with a
photoactivatable cross-linker; a spin-labeled amino acid; a
fluorescent amino acid; an amino acid with a novel functional
group; an amino acid that covalently or noncovalently interacts
with another molecule; a metal binding amino acid; an amino acid
that is amidated at a site that is not naturally amidated, a
metal-containing amino acid; a radioactive amino acid; a photocaged
and/or photoisomerizable amino acid; a biotin or biotin-analogue
containing amino acid; a glycosylated or carbohydrate modified
amino acid; a keto containing amino acid; amino acids comprising
polyethylene glycol or polyether; a heavy atom substituted amino
acid (e.g., an amino acid containing deuterium, tritium, .sup.13C,
.sup.15N, or .sup.18O); a chemically cleavable or photocleavable
amino acid; an amino acid with an elongated side chain; an amino
acid containing a toxic group; a sugar substituted amino acid,
e.g., a sugar substituted serine or the like; a carbon-linked
sugar-containing amino acid; a redox-active amino acid; an
.alpha.-hydroxy containing acid; an amino thio acid containing
amino acid; an .alpha.,.alpha. disubstituted amino acid; a
.beta.-amino acid; a cyclic amino acid other than proline; an
O-methyl-L-tyrosine; an L-3-(2-naphthyl)alanine; a
3-methyl-phenylalanine; a .rho.-acetyl-L-phenylalanine; an
O-4-allyl-L-tyrosine; a 4-propyl-L-tyrosine; a tri-O-acetyl-GlcNAc
.beta.-serine; an L-Dopa; a fluorinated phenylalanine; an
isopropyl-L-phenylalanine; a p-azido-L-phenylalanine; a
p-acyl-L-phenylalanine; a p-benzoyl-L-phenylalanine; an
L-phosphoserine; a phosphonoserine; a phosphonotyrosine; a
p-iodo-phenylalanine; a 4-fluorophenylglycine; a
p-bromophenylalanine; a p-amino-L-phenylalanine; an
isopropyl-L-phenylalanine; L-3-(2-naphthyl)alanine;
D-3-(2-naphthyl)alanine (dNal); an amino-, isopropyl-, or
O-allyl-containing phenylalanine analogue; a dopa,
O-methyl-L-tyrosine; a glycosylated amino acid; a
p-(propargyloxy)phenylalanine; dimethyl-Lysine; hydroxy-proline;
mercaptopropionic acid; methyl-lysine; 3-nitro-tyrosine;
norleucine; pyro-glutamic acid; Z (Carbobenzoxyl);
.epsilon.-Acetyl-Lysine; .beta.-alanine; aminobenzoyl derivative;
aminobutyric acid (Abu); citrulline; aminohexanoic acid;
aminoisobutyric acid (AIB); cyclohexylalanine; d-cyclohexylalanine;
hydroxyproline; nitro-arginine; nitro-phenylalanine;
nitro-tyrosine; norvaline; octahydroindole carboxylate; ornithine
(Orn); penicillamine (PEN); tetrahydroisoquinoline; acetamidomethyl
protected amino acids and pegylated amino acids. Further examples
of unnatural amino acids and amino acid analogs can be found in
U.S. 20030108885, U.S. 20030082575, US20060019347 (paragraphs
410-418) and the references cited therein. The polypeptides of the
invention can include further modifications including those
described in US20060019347, paragraph 589. Exemplary GCRA peptides
which include a non-naturally occurring amino acid include for
example SP-368 and SP-369.
[0045] In some embodiments, an amino acid can be replaced by a
naturally-occurring, non-essential amino acid, e.g., taurine.
[0046] Alternatively, the GCRA peptides are cyclic peptides. GCRA
cyclic peptide are prepared by methods known in the art. For
example, macrocyclization is often accomplished by forming an amide
bond between the peptide N- and C-termini, between a side chain and
the N- or C-terminus [e.g., with K.sub.3Fe(CN).sub.6 at pH 8.5]
(Samson et al., Endocrinology, 137: 5182-5185 (1996)), or between
two amino acid side chains, such as cysteine. See, e.g., DeGrado,
Adv Protein Chem, 39: 51-124 (1988). In various aspects the GCRA
peptides are [4,12; 7,15] bicycles.
[0047] In some GCRA peptides one or both members of one or both
pairs of Cys residues which normally form a disulfide bond can be
replaced by homocysteine, penicillamine, 3-mercaptoproline
(Kolodziej et al. 1996 Int J Pept Protein Res 48:274);
.beta.,.beta. dimethylcysteine (Hunt et al. 1993 Int J Pept Protein
Res 42:249) or diaminopropionic acid (Smith et al. 1978 J Med Chem
2 1:117) to form alternative internal cross-links at the positions
of the normal disulfide bonds.
[0048] In addition, one or more disulfide bonds can be replaced by
alternative covalent cross-links, e.g., an amide linkage
(--CH2CH(O)NHCH 2- or --CH2NHCH(O)CH 2-), an ester linkage, a
thioester linkage, a lactam bridge, a carbamoyl linkage, a urea
linkage, a thiourea linkage, a phosphonate ester linkage, an alkyl
linkage (--CH2CH2CH2CH2-), an alkenyl linkage (--CH
2CH.dbd.CHCH2-), an ether linkage (--CH2CH2OCH2- or --CH2OCH2CH2-),
a thioether linkage (--CH2CH2SCH2- or --CH2SCH2CH2-), an amine
linkage (--CH2CH2NHCH2- or --CH2NHCH 2CH2-) or a thioamide linkage
(--CH2CH(S)HNHCH 2- or --CH2NHCH(S)CH 2-). For example, Ledu et al.
(Proc Nat'l Acad. Sci. 100:11263-78, 2003) describe methods for
preparing lactam and amide cross-links. Exemplary GCRA peptides
which include a lactam bridge include for example SP-370.
[0049] The GCRA peptides can have one or more conventional
polypeptide bonds replaced by an alternative bond. Such
replacements can increase the stability of the polypeptide. For
example, replacement of the polypeptide bond between a residue
amino terminal to an aromatic residue (e.g. Tyr, Phe, Trp) with an
alternative bond can reduce cleavage by carboxy peptidases and may
increase half-life in the digestive tract. Bonds that can replace
polypeptide bonds include: a retro-inverso bond (C(O)--NH instead
of NH--C(O); a reduced amide bond (NH--CH2); a thiomethylene bond
(S--CH2 or CH2-S); an oxomethylene bond (O--CH 2 or CH2-O); an
ethylene bond (CH2-CH2); a thioamide bond (C(S)--NH); a
trans-olefine bond (CH.dbd.CH); a fluoro substituted trans-olefine
bond (CF.dbd.CH); a ketomethylene bond (C(O)--CHR or CHR--C(O)
wherein R is H or CH3; and a fluoro-ketomethylene bond (C(O)--CFR
or CFR--C(O) wherein R is H or F or CH3.
[0050] The GCRA peptides can be modified using standard
modifications. Modifications may occur at the amino (N-), carboxy
(C-) terminus, internally or a combination of any of the
preceeding. In one aspect described herein, there may be more than
one type of modification on the polypeptide. Modifications include
but are not limited to: acetylation, amidation, biotinylation,
cinnamoylation, farnesylation, formylation, myristoylation,
palmitoylation, phosphorylation (Ser, Tyr or Thr), stearoylation,
succinylation, sulfurylation and cyclisation (via disulfide bridges
or amide cyclisation), and modification by Cys3 or Cys5. The GCRA
peptides described herein may also be modified by 2,4-dinitrophenyl
(DNP), DNP-lysine, modification by 7-Amino-4-methyl-coumarin (AMC),
flourescein, NBD (7-Nitrobenz-2-Oxa-1,3-Diazole), p-nitro-anilide,
rhodamine B, EDANS (5-((2-aminoethyl)amino)naphthalene-1-sulfonic
acid), dabcyl, dabsyl, dansyl, texas red, FMOC, and Tamra
(Tetramethylrhodamine). The GCRA peptides described herein may also
be conjugated to, for example, polyethylene glycol (PEG); alkyl
groups (e.g., C1-C20 straight or branched alkyl groups); fatty acid
radicals; combinations of PEG, alkyl groups and fatty acid radicals
(See, U.S. Pat. No. 6,309,633; Soltero et al., 2001 Innovations in
Pharmaceutical Technology 106-110); BSA and KLH (Keyhole Limpet
Hemocyanin). The addition of PEG and other polymers which can be
used to modify polypeptides of the invention is described in
US20060 19347 section IX.
[0051] Also included in the invention are peptides that
biologically or functional equivalent to the peptides described
herein. The term "biologically equivalent" or functional
equivalent" is intended to mean that the compositions of the
present invention are capable of demonstrating some or all of the
cGMP production modulatory effects.
[0052] GCRA peptides can also include derivatives of GCRA peptides
which are intended to include hybrid and modified forms of GCRA
peptides in which certain amino acids have been deleted or replaced
and modifications such as where one or more amino acids have been
changed to a modified amino acid or unusual amino acid and
modifications such as glycosylation so long the modified form
retains the biological activity of GCRA peptides. By retaining the
biological activity, it is meant that cGMP and or apoptosis is
induced by the GCRA peptide, although not necessarily at the same
level of potency as that of a naturally-occurring GCRA peptide
identified.
[0053] Preferred variants are those that have conservative amino
acid substitutions made at one or more predicted non-essential
amino acid residues. A "conservative amino acid substitution" is
one in which the amino acid residue is replaced with an amino acid
residue having a similar side chain. Families of amino acid
residues having similar side chains have been defined in the art.
These families include amino acids with basic side chains (e.g.,
lysine, arginine, histidine), acidic side chains (e.g., aspartic
acid, glutamic acid), uncharged polar side chains (e.g., glycine,
asparagine, glutamine, serine, threonine, tyrosine, cysteine),
nonpolar side chains (e.g., alanine, valine, leucine, isoleucine,
proline, phenylalanine, methionine, tryptophan), beta-branched side
chains (e.g., threonine, valine, isoleucine) and aromatic side
chains (e.g., tyrosine, phenylalanine, tryptophan, histidine).
Thus, a predicted nonessential amino acid residue in a GCRA
polypeptide is replaced with another amino acid residue from the
same side chain family. Alternatively, in another embodiment,
mutations can be introduced randomly along all or part of a GCRA
coding sequence, such as by saturation mutagenesis, and the
resultant mutants can be screened to identify mutants that retain
activity.
[0054] Also included within the meaning of substantially homologous
is any GCRA peptide which may be isolated by virtue of
cross-reactivity with antibodies to the GCRA peptide.
[0055] Preparation of GCRA Peptides
[0056] GCRA peptides are easily prepared using modern cloning
techniques, or may be synthesized by solid state methods or by
site-directed mutagenesis. A GCRA peptide may include dominant
negative forms of a polypeptide.
[0057] Chemical synthesis may generally be performed using standard
solution phase or solid phase peptide synthesis techniques, in
which a peptide linkage occurs through the direct condensation of
the amino group of one amino acid with the carboxy group of the
other amino acid with the elimination of a water molecule. Peptide
bond synthesis by direct condensation, as formulated above,
requires suppression of the reactive character of the amino group
of the first and of the carboxyl group of the second amino acid.
The masking substituents must permit their ready removal, without
inducing breakdown of the labile peptide molecule.
[0058] In solution phase synthesis, a wide variety of coupling
methods and protecting groups may be used (See, Gross and
Meienhofer, eds., "The Peptides: Analysis, Synthesis, Biology,"
Vol. 1-4 (Academic Press, 1979); Bodansky and Bodansky, "The
Practice of Peptide Synthesis," 2d ed. (Springer Verlag, 1994)). In
addition, intermediate purification and linear scale up are
possible. Those of ordinary skill in the art will appreciate that
solution synthesis requires consideration of main chain and side
chain protecting groups and activation method. In addition, careful
segment selection is necessary to minimize racemization during
segment condensation. Solubility considerations are also a factor.
Solid phase peptide synthesis uses an insoluble polymer for support
during organic synthesis. The polymer-supported peptide chain
permits the use of simple washing and filtration steps instead of
laborious purifications at intermediate steps. Solid-phase peptide
synthesis may generally be performed according to the method of
Merrifield et al., J. Am. Chem. Soc., 1963, 85:2149, which involves
assembling a linear peptide chain on a resin support using
protected amino acids. Solid phase peptide synthesis typically
utilizes either the Boc or Fmoc strategy, which are well known in
the art.
[0059] Those of ordinary skill in the art will recognize that, in
solid phase synthesis, deprotection and coupling reactions must go
to completion and the side-chain blocking groups must be stable
throughout the synthesis. In addition, solid phase synthesis is
generally most suitable when peptides are to be made on a small
scale.
[0060] Acetylation of the N-terminal can be accomplished by
reacting the final peptide with acetic anhydride before cleavage
from the resin. C-amidation is accomplished using an appropriate
resin such as methylbenzhydrylamine resin using the Boc
technology.
[0061] Alternatively the GCRA peptides are produced by modern
cloning techniques. For example, the GCRA peptides are produced
either in bacteria including, without limitation, E. coli, or in
other existing systems for polypeptide or protein production (e.g.,
Bacillus subtilis, baculovirus expression systems using Drosophila
Sf9 cells, yeast or filamentous fungal expression systems,
mammalian cell expression systems), or they can be chemically
synthesized. If the GCRA peptide or variant peptide is to be
produced in bacteria, e.g., E. coli, the nucleic acid molecule
encoding the polypeptide may also encode a leader sequence that
permits the secretion of the mature polypeptide from the cell.
Thus, the sequence encoding the polypeptide can include the pre
sequence and the pro sequence of, for example, a
naturally-occurring bacterial ST polypeptide. The secreted, mature
polypeptide can be purified from the culture medium.
[0062] The sequence encoding a GCRA peptide described herein can be
inserted into a vector capable of delivering and maintaining the
nucleic acid molecule in a bacterial cell. The DNA molecule may be
inserted into an autonomously replicating vector (suitable vectors
include, for example, pGEM3Z and pcDNA3, and derivatives thereof).
The vector nucleic acid may be a bacterial or bacteriophage DNA
such as bacteriophage lambda or M13 and derivatives thereof.
Construction of a vector containing a nucleic acid described herein
can be followed by transformation of a host cell such as a
bacterium. Suitable bacterial hosts include but are not limited to,
E. coli, B. subtilis, Pseudomonas, Salmonella. The genetic
construct also includes, in addition to the encoding nucleic acid
molecule, elements that allow expression, such as a promoter and
regulatory sequences. The expression vectors may contain
transcriptional control sequences that control transcriptional
initiation, such as promoter, enhancer, operator, and repressor
sequences.
[0063] A variety of transcriptional control sequences are well
known to those in the art. The expression vector can also include a
translation regulatory sequence (e.g., an untranslated 5' sequence,
an untranslated 3' sequence, or an internal ribosome entry site).
The vector can be capable of autonomous replication or it can
integrate into host DNA to ensure stability during polypeptide
production.
[0064] The protein coding sequence that includes a GCRA peptide
described herein can also be fused to a nucleic acid encoding a
polypeptide affinity tag, e.g., glutathione S-transferase (GST),
maltose E binding protein, protein A, FLAG tag, hexa-histidine, myc
tag or the influenza HA tag, in order to facilitate purification.
The affinity tag or reporter fusion joins the reading frame of the
polypeptide of interest to the reading frame of the gene encoding
the affinity tag such that a translational fusion is generated.
Expression of the fusion gene results in translation of a single
polypeptide that includes both the polypeptide of interest and the
affinity tag. In some instances where affinity tags are utilized,
DNA sequence encoding a protease recognition site will be fused
between the reading frames for the affinity tag and the polypeptide
of interest.
[0065] Genetic constructs and methods suitable for production of
immature and mature forms of the GCRA peptides and variants
described herein in protein expression systems other than bacteria,
and well known to those skilled in the art, can also be used to
produce polypeptides in a biological system.
[0066] The peptides disclosed herein may be modified by attachment
of a second molecule that confers a desired property upon the
peptide, such as increased half-life in the body, for example,
pegylation. Such modifications also fall within the scope of the
term "variant" as used herein.
[0067] Therapeutic Methods
[0068] The present invention provides for both prophylactic and
therapeutic methods of treating a subject at risk of (or
susceptible to) a disorder or having a disorder associated that is
mediated by guanylate cyclase receptor agonists. Disorders mediated
by the guanylate cyclase receptor agonists include gastrointestinal
disorders, inflammatory disorders, lung disorders, cancer, cardiac
disorders, eye disorders, oral disorders, blood disorders, liver
disorders, skin disorders, prostate disorders, endocrine disorders,
increasing gastrointestinal motility and obesity. Gastointestinal
disorders include for example, irritable bowel syndrome (IBS),
necrotizing enterocolitis (NEC), non-ulcer dyspepsia, chronic
intestinal pseudo-obstruction, functional dyspepsia, colonic
pseudo-obstruction, duodenogastric reflux, gastroesophageal reflux
disease (GERD) ileus (e.g., post-operative ileus), gastroparesis,
heartburn (high acidity in the GI tract), constipation (e.g.,
constipation associated with use of medications such as opioids,
osteoarthritis drugs, osteoporosis drugs; post surigical
constipation, constipation associated with neuropathic disorders.
Inflammatory disorders include tissue and organ inflammation such
as kidney inflammation (e.g., nephritis), gastrointestinal system
inflammation (e.g., Crohn's disease and ulcerative colitis);
pancreatic inflammation (e.g., pancreatis), lung inflammation
(e.g., bronchitis or asthma) or skin inflammation (e.g., psoriasis,
eczema). Lung Disorders include for example chronic obstructive
pulmonary disease (COPD), and fibrosis. Cancer includes tissue and
organ carcinogenesis including metatases such as for example
gastrointestinal cancer, (e.g., gastric cancer, esophageal cancer,
pancreatic cancer colorectal cancer, intestinal cancer, anal
cancer, liver cancer, gallbladder cancer, or colon cancer; lung
cancer; thyroid cancer; skin cancer (e.g., melanoma); oral cancer;
urinary tract cancer (e.g. bladder cancer or kidney cancer); blood
cancer (e.g. myeloma or leukemia) or prostate cancer. Cardiac
disorders include for example, congestive heart failure, trachea
cardia hypertension, high cholesterol, or high tryglycerides. Liver
disorders include for example cirrhosis and fibrosis. Eye disorders
include for example increased intra-ocular pressure, glaucoma, dry
eyes retinal degeneration, disorders of tear glands or eye
inflammation. Skin disorders include for example xerosis. Oral
disorders include for example dry mouth (xerostomia), Sjogren's
syndrome, gum diseases (e.g., periodontal disease), or salivary
gland duct blockage or malfunction. Prostate disorders include for
example benign prostatic hyperplasia (BPH). Endocrine disorders
include for example diabetes mellitus, hyperthyroidism,
hypothyroidism, and cystic fibrosis.
[0069] The term "treatment" refers to reducing or alleviating
symptoms in a subject, preventing symptoms from worsening or
progressing, and/or preventing disease in a subject who is free
therefrom. For a given subject, improvement in a symptom, its
worsening, regression, or progression may be determined by any
objective or subjective measure. Efficacy of the treatment may be
measured as an improvement in morbidity or mortality (e.g.,
lengthening of survival curve for a selected population). Thus,
effective treatment would include therapy of existing disease,
control of disease by slowing or stopping its progression,
prevention of disease occurrence, reduction in the number or
severity of symptoms, or a combination thereof. The effect may be
shown in a controlled study using one or more statistically
significant criteria.
[0070] Intracellular cGMP induced by exposing, e.g., contacting a
tissue (e.g., gastrointestinal tissue) or cell with GCRA agonists.
GC-C receptors are expressed throughout the GI tract starting from
esophagus, duodenum, jejunum, ilium, caecum and colon. Human colon
cancer cell lines (T81, CaCo-2 and HT-29) also express GC-C
receptors. By inducing is meant an increase in cGMP production
compared to a tissue or cell that has not been in contact with GCRA
peptide or variant. Tissues or cells are directly contacted with a
GCRA peptide or variant. Alternatively, the GCRA peptide or variant
is administered systemically. GCRA peptide or variant are
administered in an amount sufficient to increase intracellular cGMP
concentration. cGMP production is measured by a cell-based assay
known in the art (25).
[0071] Disorders are treated, prevented or alleviated by
administering to a subject, e.g., a mammal such as a human in need
thereof, a therapeutically effective dose of a GCRA peptide. The
GCRA peptides may be in a pharmaceutical composition in unit dose
form, together with one or more pharmaceutically acceptable
excipients. The term "unit dose form" refers to a single drug
delivery entity, e.g., a tablet, capsule, solution or inhalation
formulation. The amount of peptide present should be sufficient to
have a positive therapeutic effect when administered to a patient
(typically, between 10 .mu.g and 3 g). What constitutes a "positive
therapeutic effect" will depend upon the particular condition being
treated and will include any significant improvement in a condition
readily recognized by one of skill in the art.
[0072] The GCRA peptides can be administered alone or in
combination with other agents. For example the GCRA peptides can be
administered in combination with inhibitors of cGMP dependent
phosphodiesterase, such as, for example, suldinac sulfone,
zaprinast, motapizone, vardenafil or sildenifil; one or more other
chemotherapeutic agents; or anti-inflammatory drugs such as, for
example, steroids or non-steroidal anti-inflammatory drugs
(NSAIDS), such as aspirin.
[0073] Combination therapy can be achieved by administering two or
more agents, e.g., a GCRA peptide described herein and another
compound, each of which is formulated and administered separately,
or by administering two or more agents in a single formulation.
Other combinations are also encompassed by combination therapy. For
example, two agents can be formulated together and administered in
conjunction with a separate formulation containing a third agent.
While the two or more agents in the combination therapy can be
administered simultaneously, they need not be. For example,
administration of a first agent (or combination of agents) can
precede administration of a second agent (or combination of agents)
by minutes, hours, days, or weeks. Thus, the two or more agents can
be administered within minutes of each other or within 1, 2, 3, 6,
9, 12, 15, 18, or 24 hours of each other or within 1, 2, 3, 4, 5,
6, 7, 8, 9, 10, 12, 14 days of each other or within 2, 3, 4, 5, 6,
7, 8, 9, or 10 weeks of each other. In some cases even longer
intervals are possible. While in many cases it is desirable that
the two or more agents used in a combination therapy be present in
within the patient's body at the same time, this need not be
so.
[0074] The GCRA peptides described herein may be combined with
phosphodiesterase inhibitors, e.g., sulindae sulfone, Zaprinast,
sildenafil, vardenafil or tadalafil to further enhance levels of
cGMP in the target tissues or organs.
[0075] Combination therapy can also include two or more
administrations of one or more of the agents used in the
combination. For example, if agent X and agent Y are used in a
combination, one could administer them sequentially in any
combination one or more times, e.g., in the order X-Y-X, X-X-Y,
Y-X-Y, Y-Y-X, X-X-Y-Y, etc.
[0076] Combination therapy can also include the administration of
one of the GC-C agonist with azothioprine and/or other
immunomodulating agents. The immunomodulating agents may include
small molecule drugs and biologics such as Remicade, Humaira,
Cimzia etc.
[0077] Combination therapy can also include the administration of
two or more agents via different routes or locations. For example,
(a) one agent is administered orally and another agents is
administered intravenously or (b) one agent is administered orally
and another is administered locally. In each case, the agents can
either simultaneously or sequentially. Approximated dosages for
some of the combination therapy agents described herein are found
in the "BNF Recommended Dose" column of tables on pages 11-17 of
WO01/76632 (the data in the tables being attributed to the March
2000 British National Formulary) and can also be found in other
standard formularies and other drug prescribing directories. For
some drugs, the customary prescribed dose for an indication will
vary somewhat from country to country.
[0078] The GCRA peptides, alone or in combination, can be combined
with any pharmaceutically acceptable carrier or medium. Thus, they
can be combined with materials that do not produce an adverse,
allergic or otherwise unwanted reaction when administered to a
patient. The carriers or mediums used can include solvents,
dispersants, coatings, absorption promoting agents, controlled
release agents, and one or more inert excipients (which include
starches, polyols, granulating agents, microcrystalline cellulose
(e.g. celphere, Celphere Beads.RTM.), diluents, lubricants,
binders, disintegrating agents, and the like), etc. If desired,
tablet dosages of the disclosed compositions may be coated by
standard aqueous or nonaqueous techniques.
[0079] A pharmaceutical composition of the invention is formulated
to be compatible with its intended route of administration.
Examples of routes of administration include parenteral, e.g.,
intravenous, intradermal, subcutaneous, oral (e.g., inhalation),
transdermal (topical), transmucosal, and rectal administration.
Solutions or suspensions used for parenteral, intradermal, or
subcutaneous application can include the following components: a
sterile diluent such as water for injection, saline solution, fixed
oils, polyethylene glycols, glycerine, propylene glycol or other
synthetic solvents; antibacterial agents such as benzyl alcohol or
methyl parabens; antioxidants such as ascorbic acid or sodium
bisulfite; chelating agents such as ethylenediaminetetraacetic
acid; buffers such as acetates, citrates or phosphates, and agents
for the adjustment of tonicity such as sodium chloride or dextrose.
The pH can be adjusted with acids or bases, such as hydrochloric
acid or sodium hydroxide. The parenteral preparation can be
enclosed in ampoules, disposable syringes or multiple dose vials
made of glass or plastic.
[0080] Pharmaceutical compositions suitable for injectable use
include sterile aqueous solutions (where water soluble) or
dispersions and sterile powders for the extemporaneous preparation
of sterile injectable solutions or dispersion. For intravenous
administration, suitable carriers include physiological saline,
bacteriostatic water, Cremophor EL.TM. (BASF, Parsippany, N.J.) or
phosphate buffered saline (PBS). In all cases, the composition must
be sterile and should be fluid to the extent that easy
syringeability exists. It must be stable under the conditions of
manufacture and storage and must be preserved against the
contaminating action of microorganisms such as bacteria and fungi.
The carrier can be a solvent or dispersion medium containing, for
example, water, ethanol, polyol (for example, glycerol, propylene
glycol, and liquid polyethylene glycol, and the like), and suitable
mixtures thereof. The proper fluidity can be maintained, for
example, by the use of a coating such as lecithin, by the
maintenance of the required particle size in the case of dispersion
and by the use of surfactants. Prevention of the action of
microorganisms can be achieved by various antibacterial and
antifungal agents, for example, parabens, chlorobutanol, phenol,
ascorbic acid, thimerosal, and the like. In many cases, it will be
preferable to include isotonic agents, for example, sugars,
polyalcohols such as manitol, sorbitol, sodium chloride in the
composition. Prolonged absorption of the injectable compositions
can be brought about by including in the composition an agent which
delays absorption, for example, aluminum monostearate and
gelatin.
[0081] Sterile injectable solutions can be prepared by
incorporating the active compound (e.g., a GCRA agonist) in the
required amount in an appropriate solvent with one or a combination
of ingredients enumerated above, as required, followed by filtered
sterilization. Generally, dispersions are prepared by incorporating
the active compound into a sterile vehicle that contains a basic
dispersion medium and the required other ingredients from those
enumerated above. In the case of sterile powders for the
preparation of sterile injectable solutions, methods of preparation
are vacuum drying and freeze-drying that yields a powder of the
active ingredient plus any additional desired ingredient from a
previously sterile-filtered solution thereof.
[0082] Oral compositions generally include an inert diluent or an
edible carrier. Such as mannitol, fructooligosaccharides,
polyethylene glycol and other excepients. They can be enclosed in
gelatin capsules or compressed into tablets. For the purpose of
oral therapeutic administration, the active compound can be
incorporated with excipients and used in the form of tablets,
troches, or capsules. Oral compositions can also be prepared using
a fluid carrier for use as a mouthwash, wherein the compound in the
fluid carrier is applied orally and swished and expectorated or
swallowed. Pharmaceutically compatible binding agents, and/or
adjuvant materials can be included as part of the composition. The
tablets, pills, capsules, troches and the like can contain any of
the following ingredients, or compounds of a similar nature: a
binder such as microcrystalline cellulose, gum tragacanth or
gelatin; an excipient such as starch or lactose, a disintegrating
agent such as alginic acid, Primogel, or corn starch; a lubricant
such as magnesium stearate or Sterotes; a glidant such as colloidal
silicon dioxide; a sweetening agent such as sucrose or saccharin;
or a flavoring agent such as peppermint, methyl salicylate, or
orange flavoring.
[0083] For administration by inhalation, the compounds are
delivered in the form of an aerosol spray from pressured container
or dispenser which contains a suitable propellant, e.g., a gas such
as carbon dioxide, or a nebulizer.
[0084] Systemic administration can also be by transmucosal or
transdermal means. For transmucosal or transdermal administration,
penetrants appropriate to the barrier to be permeated are used in
the formulation. Such penetrants are generally known in the art,
and include, for example, for transmucosal administration,
detergents, bile salts, and fusidic acid derivatives. Transmucosal
administration can be accomplished through the use of nasal sprays
or suppositories. For transdermal administration, the active
compounds are formulated into ointments, salves, gels, or creams as
generally known in the art.
[0085] The compounds can also be prepared in the form of
suppositories (e.g., with conventional suppository bases such as
cocoa butter and other glycerides) or retention enemas for rectal
delivery.
[0086] In one embodiment, the active compounds are prepared with
carriers that will protect the compound against rapid elimination
from the body, such as a controlled release formulation, including
implants and microencapsulated delivery systems. Biodegradable,
biocompatible polymers can be used, such as ethylene vinyl acetate,
polyanhydrides, polyglycolic acid, collagen, polyorthoesters, and
polylactic acid. Methods for preparation of such formulations will
be apparent to those skilled in the art. The materials can also be
obtained commercially from Alza Corporation and Nova
Pharmaceuticals, Inc. Liposomal suspensions (including liposomes
targeted to infected cells with monoclonal antibodies to viral
antigens) can also be used as pharmaceutically acceptable carriers.
These can be prepared according to methods known to those skilled
in the art, for example, as described in U.S. Pat. No. 4,522,811,
incorporated fully herein by reference.
[0087] It is especially advantageous to formulate oral or
parenteral compositions in dosage unit form for ease of
administration and uniformity of dosage. Dosage unit form as used
herein refers to physically discrete units suited as unitary
dosages for the subject to be treated; each unit containing a
predetermined quantity of active compound calculated to produce the
desired therapeutic effect in association with the required
pharmaceutical carrier. The specification for the dosage unit forms
of the invention are dictated by and directly dependent on the
unique characteristics of the active compound and the particular
therapeutic effect to be achieved.
[0088] The pharmaceutical compositions can be included in a
container, pack, or dispenser together with instructions for
administration.
[0089] Compositions of the present invention may also optionally
include other therapeutic ingredients, anti-caking agents,
preservatives, sweetening agents, colorants, flavors, desiccants,
plasticizers, dyes, glidants, anti-adherents, anti-static agents,
surfactants (wetting agents), anti-oxidants, film-coating agents,
and the like. Any such optional ingredient must be compatible with
the compound described herein to insure the stability of the
formulation.
[0090] The composition may contain other additives as needed,
including for example lactose, glucose, fructose, galactose,
trehalose, sucrose, maltose, raffnose, maltitol, melezitose,
stachyose, lactitol, palatinite, starch, xylitol, mannitol,
myoinositol, and the like, and hydrates thereof, and amino acids,
for example alanine, glycine and betaine, and polypeptides and
proteins, for example albumen.
[0091] Examples of excipients for use as the pharmaceutically
acceptable carriers and the pharmaceutically acceptable inert
carriers and the aforementioned additional ingredients include, but
are not limited to binders, fillers, disintegrants, lubricants,
anti-microbial agents, and coating agents such as: BINDERS: corn
starch, potato starch, other starches, gelatin, natural and
synthetic gums such as acacia, xanthan, sodium alginate, alginic
acid, other alginates, powdered tragacanth, guar gum, cellulose and
its derivatives (e.g., ethyl cellulose, cellulose acetate,
carboxymethyl cellulose calcium, sodium carboxymethyl cellulose),
polyvinyl pyrrolidone (e.g., povidone, crospovidone, copovidone,
etc), methyl cellulose, Methocel, pre-gelatinized starch (e.g.,
STARCH 1500.RTM. and STARCH 1500 LM.RTM., sold by Colorcon, Ltd.),
hydroxypropyl methyl cellulose, microcrystalline cellulose (FMC
Corporation, Marcus Hook, Pa., USA), or mixtures thereof, FILLERS:
talc, calcium carbonate (e.g., granules or powder), dibasic calcium
phosphate, tribasic calcium phosphate, calcium sulfate (e.g.,
granules or powder), microcrystalline cellulose, powdered
cellulose, dextrates, kaolin, mannitol, silicic acid, sorbitol,
starch, pre-gelatinized starch, dextrose, fructose, honey, lactose
anhydrate, lactose monohydrate, lactose and aspartame, lactose and
cellulose, lactose and microcrystalline cellulose, maltodextrin,
maltose, mannitol, microcrystalline cellulose & guar gum,
molasses, sucrose, or mixtures thereof, DISINTEGRANTS: agar-agar,
alginic acid, calcium carbonate, microcrystalline cellulose,
croscarmellose sodium, crospovidone, polacrilin potassium, sodium
starch glycolate, potato or tapioca starch, other starches,
pre-gelatinized starch, clays, other algins, other celluloses, gums
(like gellan), low-substituted hydroxypropyl cellulose, or mixtures
thereof, LUBRICANTS: calcium stearate, magnesium stearate, mineral
oil, light mineral oil, glycerin, sorbitol, mannitol, polyethylene
glycol, other glycols, stearic acid, sodium lauryl sulfate, sodium
stearyl fumarate, vegetable based fatty acids lubricant, talc,
hydrogenated vegetable oil (e.g., peanut oil, cottonseed oil,
sunflower oil, sesame oil, olive oil, corn oil and soybean oil),
zinc stearate, ethyl oleate, ethyl laurate, agar, syloid silica gel
(AEROSIL 200, W.R. Grace Co., Baltimore, Md. USA), a coagulated
aerosol of synthetic silica (Deaussa Co., Piano, Tex. USA), a
pyrogenic silicon dioxide (CAB-O-SIL, Cabot Co., Boston, Mass.
USA), or mixtures thereof, ANTI-CAKING AGENTS: calcium silicate,
magnesium silicate, silicon dioxide, colloidal silicon dioxide,
talc, or mixtures thereof, ANTIMICROBIAL AGENTS: benzalkonium
chloride, benzethonium chloride, benzoic acid, benzyl alcohol,
butyl paraben, cetylpyridinium chloride, cresol, chlorobutanol,
dehydroacetic acid, ethylparaben, methylparaben, phenol,
phenylethyl alcohol, phenoxyethanol, phenylmercuric acetate,
phenylmercuric nitrate, potassium sorbate, propylparaben, sodium
benzoate, sodium dehydroacetate, sodium propionate, sorbic acid,
thimersol, thymo, or mixtures thereof, and COATING AGENTS: sodium
carboxymethyl cellulose, cellulose acetate phthalate,
ethylcellulose, gelatin, pharmaceutical glaze, hydroxypropyl
cellulose, hydroxypropyl methylcellulose (hypromellose),
hydroxypropyl methyl cellulose phthalate, methylcellulose,
polyethylene glycol, polyvinyl acetate phthalate, shellac, sucrose,
titanium dioxide, carnauba wax, microcrystalline wax, gellan gum,
maltodextrin, methacrylates, microcrystalline cellulose and
carrageenan or mixtures thereof.
[0092] The formulation can also include other excipients and
categories thereof including but not limited to L-histidine,
Pluronic.RTM., Poloxamers (such as Lutrol.RTM. and Poloxamer 188),
ascorbic acid, glutathione, permeability enhancers (e.g. lipids,
sodium cholate, acylcarnitine, salicylates, mixed bile salts, fatty
acid micelles, chelators, fatty acid, surfactants, medium chain
glycerides), protease inhibitors (e.g. soybean trypsin inhibitor,
organic acids), pH lowering agents and absorption enhancers
effective to promote bioavailability (including but not limited to
those described in U.S. Pat. No. 6,086,918 and U.S. Pat. No.
5,912,014), creams and lotions (like maltodextrin and
carrageenans); materials for chewable tablets (like dextrose,
fructose, lactose monohydrate, lactose and aspartame, lactose and
cellulose, maltodextrin, maltose, mannitol, microcrystalline
cellulose and guar gum, sorbitol crystalline); parenterals (like
mannitol and povidone); plasticizers (like dibutyl sebacate,
plasticizers for coatings, polyvinylacetate phthalate); powder
lubricants (like glyceryl behenate); soft gelatin capsules (like
sorbitol special solution); spheres for coating (like sugar
spheres); spheronization agents (like glyceryl behenate and
microcrystalline cellulose); suspending/gelling agents (like
carrageenan, gellan gum, mannitol, microcrystalline cellulose,
povidone, sodium starch glycolate, xanthan gum); sweeteners (like
aspartame, aspartame and lactose, dextrose, fructose, honey,
maltodextrin, maltose, mannitol, molasses, sorbitol crystalline,
sorbitol special solution, sucrose); wet granulation agents (like
calcium carbonate, lactose anhydrous, lactose monohydrate,
maltodextrin, mannitol, microcrystalline cellulose, povidone,
starch), caramel, carboxymethylcellulose sodium, cherry cream
flavor and cherry flavor, citric acid anhydrous, citric acid,
confectioner's sugar, D&C Red No. 33, D&C Yellow #10
Aluminum Lake, disodium edetate, ethyl alcohol 15%, FD&C Yellow
No. 6 aluminum lake, FD&C Blue #1 Aluminum Lake, FD&C Blue
No. 1, FD&C blue no. 2 aluminum lake, FD&C Green No. 3,
FD&C Red No. 40, FD&C Yellow No. 6 Aluminum Lake, FD&C
Yellow No. 6, FD&C Yellow No. 10, glycerol palmitostearate,
glyceryl monostearate, indigo carmine, lecithin, manitol, methyl
and propyl parabens, mono ammonium glycyrrhizinate, natural and
artificial orange flavor, pharmaceutical glaze, poloxamer 188,
Polydextrose, polysorbate 20, polysorbate 80, polyvidone,
pregelatinized corn starch, pregelatinized starch, red iron oxide,
saccharin sodium, sodium carboxymethyl ether, sodium chloride,
sodium citrate, sodium phosphate, strawberry flavor, synthetic
black iron oxide, synthetic red iron oxide, titanium dioxide, and
white wax.
[0093] Solid oral dosage forms may optionally be treated with
coating systems (e.g. Opadry.RTM. fx film coating system, for
example Opadry.RTM. blue (OY-LS-20921), Opadry.RTM. white
(YS-2-7063), Opadry.RTM. white (YS-1-7040), and black ink (S-1-8
106).
[0094] The agents either in their free form or as a salt can be
combined with a polymer such as polylactic-glycoloic acid (PLGA),
poly-(I)-lactic-glycolic-tartaric acid (P(I)LGT) (WO 01/12233),
polyglycolic acid (U.S. Pat. No. 3,773,919), polylactic acid (U.S.
Pat. No. 4,767,628), poly(.epsilon.-caprolactone) and poly(alkylene
oxide) (U.S. 20030068384) to create a sustained release
formulation. Such formulations can be used to implants that release
a polypeptide or another agent over a period of a few days, a few
weeks or several months depending on the polymer, the particle size
of the polymer, and the size of the implant (See, e.g., U.S. Pat.
No. 6,620,422). Other sustained release formulations and polymers
for use in are described in EP 0 467 389 A2, WO 93/24150, U.S. Pat.
No. 5,612,052, WO 97/40085, WO 03/075887, WO 01/01964A2, U.S. Pat.
No. 5,922,356, WO 94/155587, WO 02/074247A2, WO 98/25642, U.S. Pat.
No. 5,968,895, U.S. Pat. No. 6,180,608, U.S. 20030171296. U.S.
20020176841, U.S. Pat. No. 5,672,659, U.S. Pat. No. 5,893,985, U.S.
Pat. No. 5,134,122, U.S. Pat. No. 5,192,741, U.S. Pat. No.
5,192,741, U.S. Pat. No. 4,668,506, U.S. Pat. No. 4,713,244, U.S.
Pat. No. 5,445,832 U.S. Pat. No. 4,931,279, U.S. Pat. No.
5,980,945, WO 02/058672, WO 9726015, WO 97/04744, and US200200
19446. In such sustained release formulations microparticles (Delie
and Blanco-Prieto 2005 Molecule 10:65-80) of polypeptide are
combined with microparticles of polymer. One or more sustained
release implants can be placed in the large intestine, the small
intestine or both. U.S. Pat. No. 6,011,011 and WO 94/06452 describe
a sustained release formulation providing either polyethylene
glycols (i.e. PEG 300 and PEG 400) or triacetin. WO 03/053401
describes a formulation which may both enhance bioavailability and
provide controlled release of the agent within the GI tract.
Additional controlled release formulations are described in WO
02/38129, EP 326151, U.S. Pat. No. 5,236,704, WO 02/30398, WO
98/13029; U.S. 20030064105, U.S. 20030138488A1, U.S. 20030216307A1,
U.S. Pat. No. 6,667,060, WO 01/49249, WO 01/49311, WO 01/49249, WO
01/49311, and U.S. Pat. No. 5,877,224 materials which may include
those described in WO04041195 (including the seal and enteric
coating described therein) and pH-sensitive coatings that achieve
delivery in the colon including those described in U.S. Pat. No.
4,910,021 and WO9001329. U.S. Pat. No. 4,910,021 describes using a
pH-sensitive material to coat a capsule. WO9001329 describes using
pH-sensitive coatings on beads containing acid, where the acid in
the bead core prolongs dissolution of the pH-sensitive coating.
U.S. Pat. No. 5,175,003 discloses a dual mechanism polymer mixture
composed of pH-sensitive enteric materials and film-forming
plasticizers capable of conferring permeability to the enteric
material, for use in drug-delivery systems; a matrix pellet
composed of a dual mechanism polymer mixture permeated with a drug
and sometimes covering a pharmaceutically neutral nucleus; a
membrane-coated pellet comprising a matrix pellet coated with a
dual mechanism polymer mixture envelope of the same or different
composition; and a pharmaceutical dosage form containing matrix
pellets. The matrix pellet releases acid-soluble drugs by diffusion
in acid pH and by disintegration at pH levels of nominally about
5.0 or higher.
[0095] The GCRA peptides described herein may be formulated in the
pH triggered targeted control release systems described in
WO04052339. The agents described herein may be formulated according
to the methodology described in any of WO03105812 (extruded
hyrdratable polymers); WO0243767 (enzyme cleavable membrane
translocators); WO03007913 and WO03086297 (mucoadhesive systems);
WO02072075 (bilayer laminated formulation comprising pH lowering
agent and absorption enhancer); WO04064769 (amidated polypeptides);
WO05063156 (solid lipid suspension with pseudotropic and/or
thixotropic properties upon melting); WO03035029 and WO03035041
(erodible, gastric retentive dosage forms); U.S. Pat. No. 5,007,790
and U.S. Pat. No. 5,972,389 (sustained release dosage forms); WO041
1271 1 (oral extended release compositions); WO05027878,
WO02072033, and WO02072034 (delayed release compositions with
natural or synthetic gum); WO05030182 (controlled release
formulations with an ascending rate of release); WO05048998
(microencapsulation system); U.S. Pat. No. 5,952,314 (biopolymer);
U.S. Pat. No. 5,108,758 (glassy amylose matrix delivery); U.S. Pat.
No. 5,840,860 (modified starch based delivery). JP10324642
(delivery system comprising chitosan and gastric resistant material
such as wheat gliadin or zein); U.S. Pat. No. 5,866,619 and U.S.
Pat. No. 6,368,629 (saccharide containing polymer); U.S. Pat. No.
6,531,152 (describes a drug delivery system containing a water
soluble core (Ca pectinate or other water-insoluble polymers) and
outer coat which bursts (e.g. hydrophobic polymer-Eudragrit)); U.S.
Pat. No. 6,234,464; U.S. Pat. No. 6,403,130 (coating with polymer
containing casein and high methoxy pectin; WO0174 175 (Maillard
reaction product); WO05063206 (solubility increasing formulation);
WO040 19872 (transferring fusion proteins).
[0096] The GCRA peptides described herein may be formulated using
gastrointestinal retention system technology (GIRES; Merrion
Pharmaceuticals). GIRES comprises a controlled-release dosage form
inside an inflatable pouch, which is placed in a drug capsule for
oral administration. Upon dissolution of the capsule, a
gas-generating system inflates the pouch in the stomach where it is
retained for 16-24 hours, all the time releasing agents described
herein.
[0097] The GCRA peptides described herein can be formulated in an
osmotic device including the ones disclosed in U.S. Pat. No.
4,503,030, U.S. Pat. No. 5,609,590 and U.S. Pat. No. 5,358,502.
U.S. Pat. No. 4,503,030 discloses an osmotic device for dispensing
a drug to certain pH regions of the gastrointestinal tract. More
particularly, the invention relates to an osmotic device comprising
a wall formed of a semi-permeable pH sensitive composition that
surrounds a compartment containing a drug, with a passageway
through the wall connecting the exterior of the device with the
compartment. The device delivers the drug at a controlled rate in
the region of the gastrointestinal tract having a pH of less than
3.5, and the device self-destructs and releases all its drug in the
region of the gastrointestinal tract having a pH greater than 3.5,
thereby providing total availability for drug absorption. U.S. Pat.
Nos. 5,609,590 and 5,358,502 disclose an osmotic bursting device
for dispensing a beneficial agent to an aqueous environment. The
device comprises a beneficial agent and osmagent surrounded at
least in part by a semi-permeable membrane. The beneficial agent
may also function as the osmagent. The semi-permeable membrane is
permeable to water and substantially impermeable to the beneficial
agent and osmagent. A trigger means is attached to the
semi-permeable membrane (e.g., joins two capsule halves). The
trigger means is activated by a pH of from 3 to 9 and triggers the
eventual, but sudden, delivery of the beneficial agent. These
devices enable the pH-triggered release of the beneficial agent
core as a bolus by osmotic bursting.
[0098] Exemplary Agents for Combination Therapy
Analgesic Agents
[0099] The GCRA peptides described herein can be used in
combination therapy with an analgesic agent, e.g., an analgesic
compound or an analgesic polypeptide. These polypeptides and
compounds can be administered with the GCRA peptides described
herein (simultaneously or sequentially). They can also be
optionally covalently linked or attached to an agent described
herein to create therapeutic conjugates. Among the useful analgesic
agents are: Ca channel blockers, 5HT receptor antagonists (for
example 5HT3, 5HT4 and 5HT1 receptor antagonists), opioid receptor
agonists (loperamide, fedotozine, and fentanyl), NK1 receptor
antagonists, CCK receptor agonists (e.g., loxiglumide), NK1
receptor antagonists, NK3 receptor antagonists,
norepinephrine-serotonin reuptake inhibitors (NSRI), vanilloid and
cannabanoid receptor agonists, and sialorphin. Analgesics agents in
the various classes are described in the literature.
[0100] Among the useful analgesic polypeptides are
sialorphin-related polypeptides, including those comprising the
amino acid sequence QHNPR (SEQ ID NO: 9), including: VQHNPR (SEQ ID
NO: 10); VRQHNPR (SEQ ID NO: 11); VRGQHNPR (SEQ ID NO: 12);
VRGPQHNPR (SEQ ID NO: 13); VRGPRQHNPR (SEQ ID NO: 14); VRGPRRQHNPR
(SEQ ID NO: 15); and RQHNPR (SEQ ID NO: 16). Sialorphin-related
polypeptides bind to neprilysin and inhibit neprilysin-mediated
breakdown of substance P and Met-enkephalin. Thus, compounds or
polypeptides that are inhibitors of neprilysin are useful analgesic
agents which can be administered with the polypeptides described
herein in a co-therapy or linked to the polypeptides described
herein, e.g., by a covalent bond. Sialophin and related
polypeptides are described in U.S. Pat. No. 6,589,750; U.S.
20030078200 A1; and WO 02/051435 A2.
[0101] Opioid receptor antagonists and agonists can be administered
with the GCRA peptides described herein in co-therapy or linked to
the agent described herein, e.g., by a covalent bond. For example,
opioid receptor antagonists such as naloxone, naltrexone, methyl
nalozone, nalmefene, cypridime, beta funaltrexamine, naloxonazine,
naltrindole, and nor-binaltorphimine are thought to be useful in
the treatment of IBS. It can be useful to formulate opioid
antagonists of this type is a delayed and sustained release
formulation such that initial release of the antagonist is in the
mid to distal small intestine and/or ascending colon. Such
antagonists are described in WO 01/32180 A2. Enkephalin
pentapeptide (HOE825; Tyr-D-Lys-Gly-Phe-L-homoserine (SEQ ID NO:
17)) is an agonist of the mu and delta opioid receptors and is
thought to be useful for increasing intestinal motility {Eur. J.
Pharm. 219:445, 1992), and this polypeptide can be used in
conjunction with the polypeptides described herein. Also useful is
trimebutine which is thought to bind to mu/delta/kappa opioid
receptors and activate release of motilin and modulate the release
of gastrin, vasoactive intestinal polypeptide, gastrin and
glucagons. Kappa opioid receptor agonists such as fedotozine,
asimadoline, and ketocyclazocine, and compounds described in
WO03/097051 and WO05/007626 can be used with or linked to the
polypeptides described herein. In addition, mu opioid receptor
agonists such as morphine, diphenyloxylate, frakefamide
(H-Tyr-D-Ala-Phe(F)-Phe-NH 2 (SEQ ID NO: 18); WO 01/019849 A1) and
loperamide can be used.
[0102] Tyr-Arg (kyotorphin) is a dipeptide that acts by stimulating
the release of met-enkephalins to elicit an analgesic effect (J.
Biol. Chem 262:8165, 1987). Kyotorphin can be used with or linked
to the GCRA peptides described herein.
[0103] Chromogranin-derived polypeptide (CgA 47-66; See, e.g., Ghia
et al. 2004 Regulatory polypeptides 119:199) can be used with or
linked to the GCRA peptides described herein.
[0104] CCK receptor agonists such as caerulein from amphibians and
other species are useful analgesic agents that can be used with or
linked to the GCRA peptides described herein.
[0105] Conotoxin polypeptides represent a large class of analgesic
polypeptides that act at voltage gated calcium channels, NMDA
receptors or nicotinic receptors. These polypeptides can be used
with or linked to the polypeptides described herein. Peptide
analogs of thymulin (FR Application 2830451) can have analgesic
activity and can be used with or linked to the polypeptides
described herein.
[0106] CCK (CCKa or CCKb) receptor antagonists, including
loxiglumide and dexloxiglumide (the R-isomer of loxiglumide) (WO
88/05774) can have analgesic activity and can be used with or
linked to the polypeptides described herein.
[0107] Other useful analgesic agents include 5-HT4 agonists such as
tegaserod (Zelnorm.RTM.), mosapride, metoclopramide, zacopride,
cisapride, renzapride, benzimidazolone derivatives such as BIMU 1
and BIMU 8, and lirexapride. Such agonists are described in: EP1321
142 A1, WO 03/053432A1, EP 505322 A1, EP 505322 B1, U.S. Pat. No.
5,510,353, EP 507672 A1, EP 507672 B1, and U.S. Pat. No.
5,273,983.
[0108] Calcium channel blockers such as ziconotide and related
compounds described in, for example, EP625162B1, U.S. Pat. No.
5,364,842, U.S. Pat. No. 5,587,454, U.S. Pat. No. 5,824,645, U.S.
Pat. No. 5,859,186, U.S. Pat. No. 5,994,305, U.S. Pat. No.
6,087,091, U.S. Pat. No. 6,136,786, WO 93/13128 A1, EP 1336409 A1,
EP 835126 A1, EP 835126 B1, U.S. Pat. No. 5,795,864, U.S. Pat. No.
5,891,849, U.S. Pat. No. 6,054,429, WO 97/01351 A1, can be used
with or linked to the polypeptides described herein.
[0109] Various antagonists of the NK-I, NK-2, and NK-3 receptors
(for a review see Giardina et al. 2003. Drugs 6:758) can be can be
used with or linked to the polypeptides described herein.
[0110] NK1 receptor antagonists such as: aprepitant (Merck & Co
Inc), vofopitant, ezlopitant (Pfizer, Inc.), R-673 (Hoffmann-La
Roche Ltd), SR-48968 (Sanofi Synthelabo), CP-122,721 (Pfizer,
Inc.), GW679769 (Glaxo Smith Kline), TAK-637 (Takeda/Abbot),
SR-14033, and related compounds described in, for example, EP
873753 A1, US 20010006972 A1, US 20030109417 A1, WO 01/52844 A1,
can be used with or linked to the polypeptides described
herein.
[0111] NK-2 receptor antagonists such as nepadutant (Menarini
Ricerche SpA), saredutant (Sanofi-Synthelabo), GW597599 (Glaxo
Smith Kline), SR-144190 (Sanofi-Synthelabo) and UK-290795 (Pfizer
Inc) can be used with or linked to the polypeptides described
herein.
[0112] NK3 receptor antagonists such as osanetant (SR-142801;
Sanoft-Synthelabo), SSR-241586, talnetant and related compounds
described in, for example, WO 02/094187 A2, EP 876347 A1, WO
97/21680 A1, U.S. Pat. No. 6,277,862, WO 98/1 1090, WO 95/28418, WO
97/19927, and Boden et al. (J Med Chem. 39:1664-75, 1996) can be
used with or linked to the polypeptides described herein.
[0113] Norepinephrine-serotonin reuptake inhibitors (NSRI) such as
milnacipran and related compounds described in WO 03/077897 A1 can
be used with or linked to the polypeptides described herein.
[0114] Vanilloid receptor antagonists such as arvanil and related
compounds described in WO 01/64212 A1 can be used with or linked to
the polypeptides described herein.
[0115] The analgesic polypeptides and compounds can be administered
with the polypeptides and agonists described herein (simultaneously
or sequentially). The analgesic agents can also be covalently
linked to the polypeptides and agonists described herein to create
therapeutic conjugates. Where the analgesic is a polypeptide and is
covalently linked to an agent described herein the resulting
polypeptide may also include at least one trypsin cleavage site.
When present within the polypeptide, the analgesic polypeptide may
be preceded by (if it is at the carboxy terminus) or followed by
(if it is at the amino terminus) a trypsin cleavage site that
allows release of the analgesic polypeptide.
[0116] In addition to sialorphin-related polypeptides, analgesic
polypeptides include: AspPhe, endomorphin-1, endomorphin-2,
nocistatin, dalargin, lupron, ziconotide, and substance P.
Agents to Treat Gastrointestinal Disorders
[0117] Examples of additional therapeutic agents to treat
gastrointestinal and other disorders include agents to treat
constipation (e.g., a chloride channel activator such as the
bicylic fatty acid, Lubiprostone (formerly known as SPI-0211;
Sucampo Pharmaceuticals, Inc.; Bethesda, Md.), a laxative (e.g. a
bulk-forming laxative (e.g. nonstarch polysaccharides, Colonel
Tablet (polycarbophil calcium), Plantago Ovata.RTM.,
Equalactin.RTM. (Calcium Polycarbophil)), fiber (e.g. FIBERCON.RTM.
(Calcium Polycarbophil), an osmotic laxative, a stimulant laxative
(such as diphenylmethanes (e.g. bisacodyl), anthraquinones (e.g.
cascara, senna), and surfactant laxatives (e.g. castor oil,
docusates), an emollient/lubricating agent (such as mineral oil,
glycerine, and docusates), MiraLax (Braintree Laboratories,
Braintree Mass.), dexloxiglumide (Forest Laboratories, also known
as CR 2017 Rottapharm (Rotta Research Laboratorium SpA)), saline
laxatives, enemas, suppositories, and CR 3700 (Rottapharm (Rotta
Research Laboratorium SpA); acid reducing agents such as proton
pump inhibitors (e.g., omeprazole (Prilosec.RTM.), esomeprazole
(Nexium.RTM.), lansoprazole (Prevacid.RTM.), pantoprazole
(Protonix.RTM.) and rabeprazole (Aciphex.RTM.)) and Histamine
H2-receptor antagonist (also known as H2 receptor blockers
including cimetidine, ranitidine, famotidine and nizatidine);
prokinetic agents including itopride, octreotide, bethanechol,
metoclopramide (Reglan.RTM.), domperidone (Motilium.RTM.),
erythromycin (and derivatives thereof) or cisapride
(Propulsid.RTM.); Prokineticin polypeptides homologs, variants and
chimeras thereof including those described in U.S. Pat. No.
7,052,674 which can be used with or linked to the polypeptides
described herein; pro-motility agents such as the
vasostatin-derived polypeptide, chromogranin A (4-16) (See, e.g.,
Ghia et al. 2004 Regulatory polypeptides 121:31) or motilin
agonists (e.g., GM-611 or mitemcinal fumarate) or
nociceptin/Orphanin FQ receptor modulators (US20050169917); other
peptides which can bind to and/or activate GC-C including those
described in US20050287067; complete or partial 5HT (e.g. 5HT1,
5HT2, 5HT3, 5HT4) receptor agonists or antagonists (including 5HT1A
antagonists (e.g. AGI-OO1 (AGI therapeutics), 5HT2B antagonists
(e.g. PGN 1091 and PGN1 164 (Pharmagene Laboratories Limited), and
5HT4 receptor agonists (such as tegaserod (ZELNORM.RTM.),
prucalopride, mosapride, metoclopramide, zacopride, cisapride,
renzapride, benzimidazolone derivatives such as BIMU 1 and BIMU 8,
and lirexapride). Such agonists/modulators are described in:
EP1321142 A1, WO 03/053432A1, EP 505322 A1, EP 505322 B1, U.S. Pat.
No. 5,510,353, EP 507672 A1, EP 507672 B1, U.S. Pat. No. 5,273,983,
and U.S. Pat. No. 6,951,867); 5HT3 receptor agonists such as
MKC-733; and 5HT3 receptor antagonists such as DDP-225 (MCI-225;
Dynogen Pharmaceuticals, Inc.), cilansetron (Calmactin.RTM.),
alosetron (Lotronex.RTM.), Ondansetron HCl (Zofran.RTM.),
Dolasetron (ANZEMET.RTM.), palonosetron (Aloxi.RTM.), Granisetron
(Kytril.RTM.), YM060(ramosetron; Astellas Pharma Inc.; ramosetron
may be given as a daily dose of 0.002 to 0.02 mg as described in
EP01588707) and ATI-7000 (Aryx Therapeutics, Santa Clara Calif.);
muscarinic receptor agonists; anti-inflammatory agents;
antispasmodics including but not limited to anticholinergic drugs
(like dicyclomine (e.g. Colimex.RTM., Formulex.RTM., Lomine.RTM.,
Protylol.RTM., Visceral.RTM., Spasmoban.RTM., Bentyl.RTM.,
Bentylol.RTM.), hyoscyamine (e.g. IB-Stat.RTM., Nulev.RTM.,
Levsin.RTM., Levbid.RTM., Levsinex Timecaps.RTM., Levsin/SL.RTM.,
Anaspaz.RTM., A-Spas S/L.RTM., Cystospaz.RTM., Cystospaz-M.RTM.,
Donnamar.RTM., Colidrops Liquid Pediatric.RTM., Gastrosed.RTM.,
Hyco Elixir.RTM., Hyosol.RTM., Hyospaz.RTM., Hyosyne.RTM.,
Losamine.RTM., Medispaz.RTM., Neosol.RTM., Spacol.RTM.,
Spasdel.RTM., Symax.RTM., Symax SL.RTM.), Donnatal (e.g. Donnatal
Extentabs.RTM.), clidinium (e.g. Quarzan, in combination with
Librium=Librax), methantheline (e.g. Banthine), Mepenzolate (e.g.
Cantil), homatropine (e.g. hycodan, Homapin), Propantheline bromide
(e.g. Pro-Banthine), Glycopyrrolate (e.g. Robinul.RTM., Robinul
Forte.RTM.), scopolamine (e.g. Transderm-Scop.RTM.,
Transderm-V.RTM.), hyosine-N-butylbromide (e.g. Buscopan.RTM.),
Pirenzepine (e.g. Gastrozepin.RTM.) Propantheline Bromide (e.g.
Propanthel.RTM.), dicycloverine (e.g. Merbentyl.RTM.),
glycopyrronium bromide (e.g. Glycopyrrolate.RTM.), hyoscine
hydrobromide, hyoscine methobromide, methanthelinium, and
octatropine); peppermint oil; and direct smooth muscle relaxants
like cimetropium bromide, mebeverine (DUSPATAL.RTM.,
DUSPATALIN.RTM., COLOFAC MR.RTM., COLOTAL.RTM.), otilonium bromide
(octilonium), pinaverium (e.g. Dicetel.RTM. (pinaverium bromide;
Solvay S. A.)), Spasfon.RTM. (hydrated phloroglucinol and
trimethylphloroglucinol) and trimebutine (including trimebutine
maleate (Modulon.RTM.); antidepressants, including but not limited
to those listed herein, as well as tricyclic antidepressants like
amitriptyline (Elavil.RTM.), desipramine (Norpramin.RTM.),
imipramine (Tofranil.RTM.), amoxapine (Asendin.RTM.),
nortriptyline; the selective serotonin reuptake inhibitors (SSRTs)
like paroxetine (Paxil.RTM.), fluoxetine (Prozac.RTM.), sertraline
(Zoloft.RTM.), and citralopram (Celexa.RTM.); and others like
doxepin (Sinequan.RTM.) and trazodone (Desyrel.RTM.);
centrally-acting analgesic agents such as opioid receptor agonists,
opioid receptor antagonists (e.g., naltrexone); agents for the
treatment of Inflammatory bowel disease; agents for the treatment
of Crohn's disease and/or ulcerative colitis (e.g., alequel (Enzo
Biochem, Inc.; Farmingsale, N.Y.), the anti-inflammatory
polypeptide RDP58 (Genzyme, Inc.; Cambridge, Mass.), and
TRAFICET-EN.TM. (ChemoCentryx, Inc.; San Carlos, Calif.); agents
that treat gastrointestinal or visceral pain; agents that increase
cGMP levels (as described in US20040121994) like adrenergic
receptor antagonists, dopamine receptor agonists and PDE
(phosphodiesterase) inhibitors including but not limited to those
disclosed herein; purgatives that draw fluids to the intestine
(e.g., VISICOL.RTM., a combination of sodium phosphate monobasic
monohydrate and sodium phosphate dibasic anhydrate); Corticotropin
Releasing Factor (CRF) receptor antagonists (including NBI-34041
(Neurocrine Biosciences, San Diego, Calif.), CRH9-41, astressin,
R121919 (Janssen Pharmaceutica), CP154,526, NBI-27914, Antalarmin,
DMP696 (Bristol-Myers Squibb) CP-316,311 (Pfizer, Inc.), SB723620
(GSK), GW876008 (Neurocrine/Glaxo Smith Kline), ONO-2333Ms (Ono
Pharmaceuticals), TS-041 (Janssen), AAG561 (Novartis) and those
disclosed in U.S. Pat. No. 5,063,245, U.S. Pat. No. 5,861,398,
US20040224964, US20040198726, US20040176400, US20040171607,
US20040110815, US20040006066, and US20050209253); glucagon-like
polypeptides (glp-1) and analogues thereof (including exendin-4 and
GTP-010 (Gastrotech Pharma A)) and inhibitors of DPP-IV (DPP-IV
mediates the inactivation of glp-1); tofisopam,
enantiomerically-pure R-tofisopam, and pharmaceutically-acceptable
salts thereof (US 20040229867); tricyclic anti-depressants of the
dibenzothiazepine type including but not limited to
Dextofisopam.RTM. (Vela Pharmaceuticals), tianeptine (Stablon.RTM.)
and other agents described in U.S. Pat. No. 6,683,072; (E)-4
(1,3bis(cyclohexylmethyl)-1,2,3,4-tetrahydro-2,6-diono-9H-purin-8-yl)cinn-
amic acid nonaethylene glycol methyl ether ester and related
compounds described in WO 02/067942; the probiotic PROBACTRIX.RTM.
(The BioBalance Corporation; New York, N.Y.) which contains
microorganisms useful in the treatment of gastrointestinal
disorders; antidiarrheal drugs including but not limited to
loperamide (Imodium, Pepto Diarrhea), diphenoxylate with atropine
(Lomotil, Lomocot), cholestyramine (Questran, Cholybar), atropine
(Co-Phenotrope, Diarsed, Diphenoxylate, Lofene, Logen, Lonox,
Vi-Atro, atropine sulfate injection) and Xifaxan.RTM. (rifaximin;
Salix Pharmaceuticals Ltd), TZP-201(Tranzyme Pharma Inc.), the
neuronal acetylcholine receptor (nAChR) blocker AGI-004 (AGI
therapeutics), and bismuth subsalicylate (Pepto-bismol); anxiolytic
drugs including but not limited to Ativan (lorazepam), alprazolam
(Xanax.RTM.), chlordiazepoxide/clidinium (Librium.RTM.,
Librax.RTM.), clonazepam (Klonopin.RTM.), clorazepate
(Tranxene.RTM.), diazepam (Valium.RTM.), estazolam (ProSom.RTM.),
flurazepam (Dalmane.RTM.), oxazepam (Serax.RTM.), prazepam
(Centrax.RTM.), temazepam (Restoril.RTM.), triazolam (Halcion.RTM.;
Bedelix.RTM. (Montmorillonite beidellitic; Ipsen Ltd), Solvay
SLV332 (ArQuIe Inc), YKP (SK Pharma), Asimadoline (Tioga
Pharmaceuticals/Merck), AGI-003 (AGI Therapeutics); neurokinin
antagonists including those described in US20060040950; potassium
channel modulators including those described in U.S. Pat. No.
7,002,015; the serotonin modulator AZD7371 (AstraZeneca PIc); M3
muscarinic receptor antagonists such as darifenacin (Enablex;
Novartis AG and zamifenacin (Pfizer); herbal and natural therapies
including but not limited to acidophilus, chamomile tea, evening
primrose oil, fennel seeds, wormwood, comfrey, and compounds of
Bao-Ji-Wan (magnolol, honokiol, imperatorin, and isoimperatorin) as
in U.S. Pat. No. 6,923,992; and compositions comprising lysine and
an anti-stress agent for the treatment of irritable bowel syndrome
as described in EPO 1550443.
Insulin and Insulin Modulating Agents
[0118] The GCRA peptides described herein can be used in
combination therapy with insulin and related compounds including
primate, rodent, or rabbit insulin including biologically active
variants thereof including allelic variants, more preferably human
insulin available in recombinant form. Sources of human insulin
include pharmaceutically acceptable and sterile formulations such
as those available from Eli Lilly (Indianapolis, Ind. 46285) as
Humulin.TM. (human insulin rDNA origin). See, THE PHYSICIAN'S DESK
REFERENCE, 55.sup.th Ed. (2001) Medical Economics, Thomson
Healthcare (disclosing other suitable human insulins).
[0119] The GCRA peptides described herein can also be used in
combination therapy with agents that can boost insulin effects or
levels of a subject upon administration, e.g. glipizide and/or
rosiglitazone. The polypeptides and agonists described herein can
be used in combitherapy with SYMLIN.RTM. (pramlintide acetate) and
Exenatide.RTM. (synthetic exendin-4; a 39 aa polypeptide).
Agents for the Treatment of Postoperative Ileus
[0120] The GCRA peptides described herein can also be used in
combination therapy with agents (e.g., Entereg.TM. (alvimopan;
formerly called ado lor/ADL 8-2698), conivaptan and related agents
describe in U.S. Pat. No. 6,645,959) used for the treatment of
postoperative ileus and other disorders.
Anti-Hypertensive Agents
[0121] The GCRA peptides described herein can be used in
combination therapy with an anti-hypertensive agent including but
not limited to: (1) diuretics, such as thiazides, including
chlorthalidone, chlorthiazide, dichlorophenamide,
hydroflumethiazide, indapamide, polythiazide, and
hydrochlorothiazide; loop diuretics, such as bumetanide, ethacrynic
acid, furosemide, and torsemide; potassium sparing agents, such as
amiloride, and triamterene; carbonic anhydrase inhibitors, osmotics
(such as glycerin) and aldosterone antagonists, such as
spironolactone, epirenone, and the like; (2) beta-adrenergic
blockers such as acebutolol, atenolol, betaxolol, bevantolol,
bisoprolol, bopindolol, carteolol, carvedilol, celiprolol, esmolol,
indenolol, metaprolol, nadolol, nebivolol, penbutolol, pindolol,
propanolol, sotalol, tertatolol, tilisolol, and timolol, and the
like; (3) calcium channel blockers such as amlodipine, aranidipine,
azelnidipine, barnidipine, benidipine, bepridil, cinaldipine,
clevidipine, diltiazem, efonidipine, felodipine, gallopamil,
isradipine, lacidipine, lemildipine, lercanidipine, nicardipine,
nifedipine, nilvadipine, nimodepine, nisoldipine, nitrendipine,
manidipine, pranidipine, and verapamil, and the like; (4)
angiotensin converting enzyme (ACE) inhibitors such as benazepril;
captopril; ceranapril; cilazapril; delapril; enalapril; enalopril;
fosinopril; imidapril; lisinopril; losinopril; moexipril;
quinapril; quinaprilat; ramipril; perindopril; perindropril;
quanipril; spirapril; tenocapril; trandolapril, and zofenopril, and
the like; (5) neutral endopeptidase inhibitors such as omapatrilat,
cadoxatril and ecadotril, fosidotril, sampatrilat, AVE7688, ER4030,
and the like; (6) endothelin antagonists such as tezosentan,
A308165, and YM62899, and the like; (7) vasodilators such as
hydralazine, clonidine, minoxidil, and nicotinyl alcohol, and the
like; (8) angiotensin II receptor antagonists such as aprosartan,
candesartan, eprosartan, irbesartan, losartan, olmesartan,
pratosartan, tasosartan, telmisartan, valsartan, and EXP-3137,
FI6828K, and RNH6270, and the like; (9) .alpha./.beta. adrenergic
blockers such as nipradilol, arotinolol and amosulalol, and the
like; (10) alpha 1 blockers, such as terazosin, urapidil, prazosin,
tamsulosin, bunazosin, trimazosin, doxazosin, naftopidil,
indoramin, WHP 164, and XENO1O, and the like; (11) alpha 2 agonists
such as lofexidine, tiamenidine, moxonidine, rilmenidine and
guanobenz, and the like; (12) aldosterone inhibitors, and the like;
and (13) angiopoietin-2-binding agents such as those disclosed in
WO03/030833. Specific anti-hypertensive agents that can be used in
combination with polypeptides and agonists described herein
include, but are not limited to: diuretics, such as thiazides
(e.g., chlorthalidone, cyclothiazide (CAS RN 2259-96-3),
chlorothiazide (CAS RN 72956-09-3, which may be prepared as
disclosed in U.S. Pat. No. 2,809,194), dichlorophenamide,
hydroflumethiazide, indapamide, polythiazide, bendroflumethazide,
methyclothazide, polythiazide, trichlormethazide, chlorthalidone,
indapamide, metolazone, quinethazone, althiazide (CAS RN 5588-16-9,
which may be prepared as disclosed in British Patent No. 902,658),
benzthiazide (CAS RN 91-33-8, which may be prepared as disclosed in
U.S. Pat. No. 3,108,097), buthiazide (which may be prepared as
disclosed in British Patent Nos. 861,367), and
hydrochlorothiazide), loop diuretics (e.g. bumetanide, ethacrynic
acid, furosemide, and torasemide), potassium sparing agents (e.g.
amiloride, and triamterene (CAS Number 396-01-O)), and aldosterone
antagonists (e.g. spironolactone (CAS Number 52-01-7), epirenone,
and the like); .beta.-adrenergic blockers such as Amiodarone
(Cordarone, Pacerone), bunolol hydrochloride (CAS RN 31969-05-8,
Parke-Davis), acebutolol (.+-.N-[3-Acetyl-4-[2-hydroxy-3-[(1
methylethyl)amino]propoxy]phenyl]-butanamide, or
(.+-.)-3'-Acetyl-4'-[2-hydroxy-3-(isopropylamino)
propoxy]butyranilide), acebutolol hydrochloride (e.g. Sectral.RTM.,
Wyeth-Ayerst), alprenolol hydrochloride (CAS RN 13707-88-5 see
Netherlands Patent Application No. 6,605,692), atenolol (e.g.
Tenormin.RTM., AstraZeneca), carteolol hydrochloride (e.g.
Cartrol.RTM. Filmtab.RTM., Abbott), Celiprolol hydrochloride (CAS
RN 57470-78-7, also see in U.S. Pat. No. 4,034,009), cetamolol
hydrochloride (CAS RN 77590-95-5, see also U.S. Pat. No.
4,059,622), labetalol hydrochloride (e.g. Normodyne.RTM.,
Schering), esmolol hydrochloride (e.g. Brevibloc.RTM., Baxter),
levobetaxolol hydrochloride (e.g. Betaxon.TM. Ophthalmic
Suspension, Alcon), levobunolol hydrochloride (e.g. Betagan.RTM.
Liquifilm.RTM. with C CAP.RTM. Compliance Cap, Allergan), nadolol
(e.g. Nadolol, Mylan), practolol (CAS RN 6673-35-4, see also U.S.
Pat. No. 3,408,387), propranolol hydrochloride (CAS RN 318-98-9),
sotalol hydrochloride (e.g. Betapace AF.TM., Berlex), timolol
(2-Propanol,1-[(1,1-dimethylethyl)amino]-3-[[4-4(4-morpholinyl)-1,2,5-thi-
adiazol-3-yl]oxy]-, hemihydrate, (S)--, CAS RN 91524-16-2), timolol
maleate
(S)-I-[(1,1-dimethylethyl)amino]-3-[[4-(4-morpholinyl)-1,2,5-thia-
diazol-3-yl]oxy]-2-propanol (Z)-2-butenedioate (1:1) salt, CAS RN
26921-17-5), bisoprolol (2-Propanol,
1-[4-[[2-(1-methylethoxy)ethoxy]-methyl]phenoxyl]-3-[(1-meth-ylethyl)amin-
o]-, (.+-.), CAS RN 66722-44-9), bisoprolol fumarate (such as
(.+-.)-1-[4-[[2-(1-Methylethoxy)ethoxy]methyl]phenoxy]-3-[(1-methylethyl)-
amino]-2-propanol (E)-2-butenedioate (2:1) (salt), e.g.,
Zebeta.TM., Lederle Consumer), nebivalol
(2H-1-Benzopyran-2-methanol,
.alpha..alpha.'-[iminobis(methylene)]bis[6-fluoro-3,4-dihydro-, CAS
RN 99200-09-6 see also U.S. Pat. No. 4,654,362), cicloprolol
hydrochloride, such 2-Propanol,
1-[4-[2-(cyclopropylmethoxy)ethoxy]phenoxy]-3-[1-methylethyl)amino]-,
hydrochloride, A.A.S. RN 63686-79-3), dexpropranolol hydrochloride
(2-Propanol,1-[1-methylethy)-amino]-3-(1-naphthalenyloxy)-hydrochloride
(CAS RN 13071-11-9), diacetolol hydrochloride (Acetamide,
N-[3-acetyl-4-[2-hydroxy-3-[(1-methyl-ethyl)amino]propoxy][phenyl]-,
monohydrochloride CAS RN 69796-04-9), dilevalol hydrochloride
(Benzamide,
2-hydroxy-5-[1-hydroxy-2-[1-methyl-3-phenylpropyl)amino]ethyl]-,
monohydrochloride, CAS RN 75659-08-4), exaprolol hydrochloride
(2-Propanol, 1-(2-cyclohexylphenoxy)-3-[(1-methylethyl)amino]-,
hydrochloride CAS RN 59333-90-3), flestolol sulfate (Benzoic acid,
2-fluoro-,3-[[2-[aminocarbonyl)amino]-1-dimethylethyl]amino]-2-hydroxypro-
pyl ester, (+)-sulfate (1:1) (salt), CAS RN 88844-73-9; metalol
hydrochloride (Methanesulfonamide,
N-[4-[1-hydroxy-2-(methylamino)propyl]phenyl]-, monohydrochloride
CAS RN 7701-65-7), metoprolol 2-Propanol,
1-[4-(2-methoxyethyl)phenoxy]-3-[1-methylethyl)amino]-; CAS RN
37350-58-6), metoprolol tartrate (such as
2-Propanol,1-[4-(2-methoxyethyl)phenoxy]-3-[(1-methylethyl)amino]-,
e.g., Lopressor.RTM., Novartis), pamatolol sulfate (Carbamic acid,
[2-[4-[2-hydroxy-3-[(1-methylethyl)amino]propoxyl]phenyl]-ethyl]-,
methyl ester, (.+-.) sulfate (salt) (2:1), CAS RN 59954-01-7),
penbutolol sulfate
(2-Propanol,1-(2-cyclopentylphenoxy)-3-[1,1-dimethyle-thyl)amino]-
1, (S)--, sulfate (2:1) (salt), CAS RN 38363-32-5), practolol
(Acetamide,
N-[4-[2-hydroxy-3-[(1-methylethyl)amino]-propoxy]phenyl]-, CAS RN
6673-35-4) tiprenolol hydrochloride
(Propanol,1-[(1-methylethyl)amino]-3-[2-(methylthio)-phenoxy]-,
hydrochloride, (.+-.), CAS RN 39832-43-4), tolamolol (Benzamide,
4-[2-[[2-hydroxy-3-(2-methylphenoxy)-propyl]amino]ethoxyl]-, CAS RN
38103-61-6), bopindolol, indenolol, pindolol, propanolol,
tertatolol, and tilisolol, and the like; calcium channel blockers
such as besylate salt of amlodipine (such as
3-ethyl-5-methyl-2-(2-aminoethoxymethyl)-4-(2-chlorophenyl)-1,4-dihydro-6-
-methyl-3,5-pyridinedicarboxylate benzenesulphonate, e.g.,
Norvasc.RTM., Pfizer), clentiazem maleate
(1,5-Benzothiazepin-4(5H)-one,
3-(acetyloxy)-8-chloro-5-[2-(dimethylamino)ethyl]-2,3-dihydro-2-(4-methox-
yphenyl)-(2S-cis)-, (Z)-2-butenedioate (1:1), see also U.S. Pat.
No. 4,567,195), isradipine (3,5-Pyridinedicarboxylic acid,
4-(4-benzofurazanyl)-1,4-dihydro-2,6-dimethyl-, methyl
1-methylethyl ester,
(.+-.)-4(4-benzofurazanyl)-1,4-dihydro-2,6-dimethyl-3,5-pyridinedi-
carboxylate, see also U.S. Pat. No. 4,466,972); nimodipine (such as
is isopropyl (2-methoxyethyl)
1,4-dihydro-2,6-dimethyl-4-(3-nitrophenyl)-3,5-pyridine-dicarboxylate,
e.g. Nimotop.RTM., Bayer), felodipine (such as ethyl methyl
4-(2,3-dichlorophenyl)-1,4-dihydro-2,6-dimethyl-3,5-pyridinedicarboxylate-
-, e.g. Plendil.RTM. Extended-Release, AstraZeneca LP), nilvadipine
(3,5-Pyridinedicarboxylic acid,
2-cyano-1,4-dihydro-6-methyl-4-(3-nitrophenyl)-,3-methyl
5-(1-methylethyl) ester, also see U.S. Pat. No. 3,799,934),
nifedipine (such as 3,5-pyridinedicarboxylic
acid,1,4-dihydro-2,6-dimethyl-4-(2-nitrophenyl)-, dimethyl ester,
e.g., Procardia XL.RTM. Extended Release Tablets, Pfizer),
diltiazem hydrochloride (such as
1,5-Benzothiazepin-4(5H)-one,3-(acetyloxy)-5[2-(dimethylamino)ethyl]-2,-3-
-dihydro-2(4-methoxyphenyl)-, monohydrochloride, (+)-cis., e.g.,
Tiazac.RTM., Forest), verapamil hydrochloride (such as
benzeneacetronitrile,
(alpha)-[[3-[[2-(3,4-dimethoxyphenyl)ethyl]methylamino]propyl]-3,4-dimeth-
oxy-(alpha)-(1-methylethyl) hydrochloride, e.g., Isoptin.RTM. SR,
Knoll Labs), teludipine hydrochloride (3,5-Pyridinedicarboxylic
acid,
2-[(dimethylamino)methyl]4-[2-[(1E)-3-(1,1-dimethylethoxy)-3-oxo-1-propen-
yl]phenyl]-1,4-dihydro-6-methyl-, diethyl ester, monohydrochloride)
CAS RN 108700-03-4), belfosdil (Phosphonic acid, [2-(2-phenoxy
ethyl)-1,3-propane-diyl]bis-, tetrabutyl ester CAS RN 103486-79-9),
fostedil (Phosphonic acid, [[4-(2-benzothiazolyl)phenyl]methyl]-,
diethyl ester CAS RN 75889-62-2), aranidipine, azelnidipine,
barnidipine, benidipine, bepridil, cinaldipine, clevidipine,
efonidipine, gallopamil, lacidipine, lemildipine, lercanidipine,
monatepil maleate (1-piperazinebutanamide,
N-(6,11-dihydrodibenzo(b,e)thiepin-11-yl).sub.4-(4-fluorophenyl)-,
(+)-, (Z)-2-butenedioate (1:1)
(.+-.)--N-(6,11-Dihydrodibenzo(b,e)thiep-in-11-yl)-4-(p-fluorophenyl)-1-p-
iperazinebutyramide maleate (1:1) CAS RN 132046-06-1), nicardipine,
nisoldipine, nitrendipine, manidipine, pranidipine, and the like;
T-channel calcium antagonists such as mibefradil; angiotensin
converting enzyme (ACE) inhibitors such as benazepril, benazepril
hydrochloride (such as
3-[[1-(ethoxycarbonyl)-3-phenyl-(1S)-propyl]amino]-2,3,4,5-tetra-
hydro-2-oxo-1H-1-(3S)-benzazepine-1-acetic acid monohydrochloride,
e.g., Lotrel.RTM., Novartis), captopril (such as
1-[(2S)-3-mercapto-2-methylpropionyl]-L-proline, e.g., Captopril,
Mylan, CAS RN 62571-86-2 and others disclosed in U.S. Pat. No.
4,046,889), ceranapril (and others disclosed in U.S. Pat. No.
4,452,790), cetapril (alacepril, Dainippon disclosed in Eur.
Therap. Res. 39:671 (1986); 40:543 (1986)), cilazapril
(Hoffman-LaRoche) disclosed in J. Cardiovasc. Pharmacol. 9:39
(1987), indalapril (delapril hydrochloride
(2H-1,2,4-Benzothiadiazine-7-sulfonamide,
3-bicyclo[2.2.1]hept-5-en-2-yl-6-chloro-3,4-dihydro-, 1,1-dioxide
CAS RN 2259-96-3); disclosed in U.S. Pat. No. 4,385,051), enalapril
(and others disclosed in U.S. Pat. No. 4,374,829), enalopril,
enaloprilat, fosinopril, ((such as L-proline,
4-cyclohexyl-1-[[[2-methyl-1-(1-oxopropoxy)
propoxy](4-phenylbutyl)phosphinyl]acetyl]-, sodium salt, e.g.,
Monopril, Bristol-Myers Squibb and others disclosed in U.S. Pat.
No. 4,168,267), fosinopril sodium (L-Proline,
4-cyclohexyl-1-[[(R)-[(1S)-2-methyl-1-(1-ox-opropoxy)propox),
imidapril, indolapril (Schering, disclosed in J. Cardiovasc.
Pharmacol. 5:643, 655 (1983)), lisinopril (Merck), losinopril,
moexipril, moexipril hydrochloride (3-Isoquinolinecarboxylic acid,
2-[(2S)-2-[[(1S)-1-(ethoxycarbonyl)-3-phenylpropyl]amino]-1-oxopropyl]-1,-
-2,3,4-tetrahydro-6,7-dimethoxy-, monohydrochloride, (3S)-CAS RN
82586-52-5), quinapril, quinaprilat, ramipril (Hoechsst) disclosed
in EP 79022 and Curr. Ther. Res. 40:74 (1986), perindopril erbumine
(such as 2S,3aS,7aS-1-[(S)--N--[(S)-1-Carboxybutyljalanyljhexahydro
-indolinecarboxylic acid, 1-ethyl ester, compound with
tert-butylamine (1:1), e.g., Aceon.RTM., Solvay), perindopril
(Servier, disclosed in Eur. J. clin. Pharmacol. 31:519 (1987)),
quanipril (disclosed in U.S. Pat. No. 4,344,949), spirapril
(Schering, disclosed in Acta. Pharmacol. Toxicol. 59 (Supp. 5): 173
(1986)), tenocapril, trandolapril, zofenopril (and others disclosed
in U.S. Pat. No. 4,316,906), rentiapril (fentiapril, disclosed in
Clin. Exp. Pharmacol. Physiol. 10:131 (1983)), pivopril, YS980,
teprotide (Bradykinin potentiator BPP9a CAS RN 35115-60-7), BRL
36,378 (Smith Kline Beecham, see EP80822 and EP60668), MC-838
(Chugai, see CA. 102:72588v and Jap. J. Pharmacol. 40:373 (1986),
CGS 14824 (Ciba-Geigy,
3-([1-ethoxycarbonyl-3-phenyl-(1S)-propyl]amino)-2,3,4,5-tetrahydro-2-ox--
o-1-(3S)-benzazepine-1 acetic acid HCl, see U.K. Patent No.
2103614), CGS 16,617 (Ciba-Geigy,
3(S)-[[(1S)-5-amino-1-carboxypentyl]amino]-2,3,4,-5-tetrahydro-2-oxo-1H-1-
-benzazepine-1-ethanoic acid, see U.S. Pat. No. 4,473,575), Ru
44570 (Hoechst, see Arzneimittelforschung 34:1254 (1985)), R
31-2201 (Hoffman-LaRoche see FEBS Lett. 165:201 (1984)), CI925
(Pharmacologist 26:243, 266 (1984)), WY-44221 (Wyeth, see J. Med.
Chem. 26:394 (1983)), and those disclosed in US2003006922
(paragraph 28), U.S. Pat. No. 4,337,201, U.S. Pat. No. 4,432,971
(phosphonamidates); neutral endopeptidase inhibitors such as
omapatrilat (Vanlev.RTM.), CGS 30440, cadoxatril and ecadotril,
fasidotril (also known as aladotril or alatriopril), sampatrilat,
mixanpril, and gemopatrilat, AVE7688, ER4030, and those disclosed
in U.S. Pat. No. 5,362,727, U.S. Pat. No. 5,366,973, U.S. Pat. No.
5,225,401, U.S. Pat. No. 4,722,810, U.S. Pat. No. 5,223,516, U.S.
Pat. No. 4,749,688, U.S. Pat. No. 5,552,397, U.S. Pat. No.
5,504,080, U.S. Pat. No. 5,612,359, U.S. Pat. No. 5,525,723,
EP0599444, EP0481522, EP0599444, EP0595610, EP0534363, EP534396,
EP534492, EP0629627; endothelin antagonists such as tezosentan,
A308165, and YM62899, and the like; vasodilators such as
hydralazine (apresoline), clonidine (clonidine hydrochloride
(1H-Imidazol-2-amine, N-(2,6-dichlorophenyl)4,5-dihydro-,
monohydrochloride CAS RN 4205-91-8), catapres, minoxidil (loniten),
nicotinyl alcohol (roniacol), diltiazem hydrochloride (such as
1,5-Benzothiazepin-4(5H)-one,3-(acetyloxy)-5[2-(dimethylamino)ethyl]-2,-3-
-dihydro-2(4-methoxyphenyl)-, monohydrochloride, (+)-cis, e.g.,
Tiazac.RTM., Forest), isosorbide dinitrate (such as
1,4:3,6-dianhydro-D-glucitol 2,5-dinitrate e.g., Isordil.RTM.
Titradose.RTM., Wyeth-Ayerst), sosorbide mononitrate (such as
1,4:3,6-dianhydro-D-glucito-1,5-nitrate, an organic nitrate, e.g.,
Ismo.RTM., Wyeth-Ayerst), nitroglycerin (such as 2,3 propanetriol
trinitrate, e.g., Nitrostat.RTM. Parke-Davis), verapamil
hydrochloride (such as benzeneacetonitrile,
(.+-.)-(alpha)[3-[[2-(3,4
dimethoxyphenyl)ethyl]methylamino]propyl]-3,4-dimethoxy-(alpha)-(1-methyl-
ethyl)hydrochloride, e.g., Covera HS.RTM. Extended-Release,
Searle), chromonar (which may be prepared as disclosed in U.S. Pat.
No. 3,282,938), clonitate (Annalen 1870 155), droprenilamine (which
may be prepared as disclosed in DE2521113), lidoflazine (which may
be prepared as disclosed in U.S. Pat. No. 3,267,104); prenylamine
(which may be prepared as disclosed in U.S. Pat. No. 3,152,173),
propatyl nitrate (which may be prepared as disclosed in French
Patent No. 1,103,113), mioflazine hydrochloride
(1-piperazineacetamide,
3-(aminocarbonyl)-4-[4,4-bis(4-fluorophenyl)butyl]-N-(2,6-dichlorophenyl)-
-, dihydrochloride CAS RN 83898-67-3), mixidine (Benzeneethanamine,
3,4-dimethoxy-N-(1-methyl-2-pyrrolidinylidene)-Pyrrolidine,
2-[(3,4-dimethoxyphenethyl)imino]-1-methyl-1-Methyl-2-[(3,
4-dimethoxyphenethyl)imino]pyrrolidine CAS RN 27737-38-8),
molsidomine (1,2,3-Oxadiazolium,
5-[(ethoxycarbonyl)amino]-3-(4-morpholinyl)-, inner salt CAS RN
25717-80-0), isosorbide mononitrate
(D-Glucito-1,1,4:3,6-dianhydro-, 5-nitrate CAS RN 16051-77-7),
erythrityl tetranitrate (1,2,3,4-Butanetetrol, tetranitrate,
(2R,3S)-rel-CAS RN 7297-25-8), clonitrate(1,2-Propanediol,
3-chloro-, dinitrate (7CI, 8CI, 9CI) CAS RN 2612-33-1),
dipyridamole Ethanol,
2,2',2'',2'''-[(4,8-di-1-piperidinylpyrimido[5,4-d]pyrimidine-2,6-diyl)di-
nitrilo]tetrakis-CAS RN 58-32-2), nicorandil (CAS RN 65141-46-0
3-), pyridinecarboxamide
(N-[2-(nitrooxy)ethyl]-Nisoldipine-3,5-Pyridinedicarboxylic acid,
1,4-dihydro-2,6-dimethyl-4-(2-nitrophenyl)-, methyl 2-methylpropyl
ester CAS RN 63675-72-9), nifedipine-3,5-Pyridinedicarboxylic acid,
1,4-dihydro-2,6-dimethyl-4-(2-nitrophenyl)-, dimethyl ester CAS RN
21829-25-4), perhexyline maleate (Piperidine,
2-(2,2-dicyclohexylethyl)-, (2Z)-2-butenedioate (1:1) CAS RN
6724-53-4), oxprenolol hydrochloride (2-Propanol,
1-[(1-methylethyl)amino]-3-[2-(2-propenyloxy)phenoxy]-,
hydrochloride CAS RN 6452-73-9), pentrinitrol (1,3-Propanediol,
2,2-bis[(nitrooxy)methyl]-, mononitrate (ester) CAS RN 1607-17-6),
verapamil (Benzeneacetonitrile,
.alpha.-[3-[[2-(3,4-dimethoxyphenyl)ethyl]-methylamino]propyl]-3,4-dimeth-
oxy-.alpha.-(1-methylethyl)-CAS RN 52-53-9) and the like;
angiotensin II receptor antagonists such as, aprosartan,
zolasartan, olmesartan, pratosartan, FI6828K, RNH6270, candesartan
(1H-Benzimidazole-7-carboxylic acid,
2-ethoxy-1-[[2'-(1H-tetrazol-5-yl)[1,1'-biphenyl]4-yl]methyl]-CAS
RN 139481-59-7), candesartan cilexetil
((+/-)-1-(cyclohexylcarbonyloxy)ethyl-2-ethoxy-1-[[2'-(1H-tetrazol-5-yl)b-
iphenyl-4-yl]-1H-benzimidazole carboxylate, CAS RN 145040-37-5,
U.S. Pat. No. 5,703,110 and U.S. Pat. No. 5,196,444), eprosartan
(3-[1-4-carboxyphenylmethyl)-2-n-butyl-imidazol-5-yl]-(2-thienylmethyl)
propenoic acid, U.S. Pat. No. 5,185,351 and U.S. Pat. No.
5,650,650), irbesartan
(2-n-butyl-3-[[2'-(1h-tetrazol-5-yl)biphenyl-4-yl]methyl]1,3-diazazspiro[-
4,4]non-1-en-4-one, U.S. Pat. No. 5,270,317 and U.S. Pat. No.
5,352,788), losartan
(2-N-butyl-4-chloro-5-hydroxymethyl-1-[(2'-(1H-tetrazol-5-yl)bip-
henyl-4-yl)-methyl]imidazole, potassium salt, U.S. Pat. No.
5,138,069, U.S. Pat. No. 5,153,197 and U.S. Pat. No. 5,128,355),
tasosartan
(5,8-dihydro-2,4-dimethyl-8-[(2'-(1H-tetrazol-5-yl)[1,r-biphenyl]4-yl)met-
hyl]-pyrido[2,3-d]pyrimidin-7(6H)-one, U.S. Pat. No. 5,149,699),
telmisartan
(4'-[(1,4-dimethyl-2'-propyl-(2,6'-bi-1H-benzimidazol)-r-yl)]-[1,1'-biphe-
nyl]-2-carboxylic acid, CAS RN 144701-48-4, U.S. Pat. No.
5,591,762), milfasartan, abitesartan, valsartan (Diovan.RTM.
(Novartis),
(S)--N-valeryl-N--[[2'-(1H-tetrazol-5-yl)biphenyl-4-yl)methyl]valine,
U.S. Pat. No. 5,399,578), EXP-3137
(2-N-butyl-4-chloro-1-[(2'-(1H-tetrazol-5-yl)biphenyl-4-yl)-methyl]imidaz-
ole-5-carboxylic acid, U.S. Pat. No. 5,138,069, U.S. Pat. No.
5,153,197 and U.S. Pat. No. 5,128,355),
3-(2'-(tetrazol-5-yl)-1,r-biphen-4-yl)methyl-5,7-dimethyl-2-ethyl-3H-imid-
azo[4,5-b]pyridine,
4'[2-ethyl-4-methyl-6-(5,6,7,8-tetrahydroimidazo[1,2-a]pyridin-2-yl]-benz-
imidazol-1-yl]-methyl]-1,r-biphenyl]-2-carboxylic acid,
2-butyl-6-(1-methoxy-1-methylethyl)-2-[2'-)1H-tetrazol-5-yl)biphenyl-4-yl-
methyl]quinazolin-4(3H)-one,
3-[2'-carboxybiphenyl-4-yl)methyl]-2-cyclopropyl-7-methyl-3H-imidazo[4,5--
b]pyridine,
2-butyl-4-chloro-1-[(2'-tetrazol-5-yl)biphenyl-4-yl)methyl]imidazole-carb-
oxylic acid, 2-butyl-4-chloro-1-[[2'-(1H-tetrazol-5-yl)
[1,1'-biphenyl]-4-yl]methyl]-1H-imidazole-5-carboxylic
acid-1-(ethoxycarbonyl-oxy)ethyl ester potassium salt, dipotassium
2-butyl-4-(methylthio)-1-[[2-[[[(propylamino)carbonyl]amino]-sulfonyl](1,-
1'-biphenyl)-4-yl]methyl]-1H-imidazole-5-carboxylate,
methyl-2-[[4-butyl-2-methyl-6-oxo-5-[[2'-(1H-tetrazol-5-yl)-[1,1'-bipheny-
l]-4-yl]methyl]-1-(6H)-pyrimidinyl]methyl]-3-thiophencarboxylate,
5-[(3,5-dibutyl-1H-1,2,4-triazol-1-yl)methyl]-2-[2-(1H-tetrazol-5-ylpheny-
l)]pyridine, 6-butyl-2-(2-phenylethyl)-5
[[2'-(1H-tetrazol-5-yl)[1,1'-biphenyl]-4-methyl]pyrimidin-4-(3H)-one
D,L lysine salt,
5-methyl-7-n-propyl-8-[[2'-(1H-tetrazol-5-yl)biphenyl-4-yl]methyl]-[1,2,4-
]-triazolo[1,5-c]pyrimidin-2(3H)-one,
2,7-diethyl-5-[[2'-(5-tetrazoly)biphenyl-4-yl]methyl]-5H-pyrazolo[1,5-b][-
1,2,4]triazole potassium salt,
2-[2-butyl-4,5-dihydro-4-oxo-3-[2'-(1H-tetrazol-5-yl)-4-biphenylmethyl]-3-
H-imidazol[4,5-c]pyridine-5-ylmethyl]benzoic acid, ethyl ester,
potassium salt,
3-methoxy-2,6-dimethyl-4-[[2'(1H-tetrazol-5-yl)-1,1'-biphenyl-4-yl]-
methoxy]pyridine,
2-ethoxy-1-[[2'-(5-oxo-2,5-dihydro-1,2,4-oxadiazol-3-yl)biphenyl-4-yl]met-
hyl]-1H-benzimidazole-7-carboxylic acid, 1-[N-(2
`-(1H-tetrazol-5-yl)biphenyl-4-yl-methyl)-N-valerolylaminomethyl)cyclopen-
tane-1-carboxylic acid, 7-methyl-2n-propyl-3-[[2`
1H-tetrazol-5-yl)biphenyl-4-yl]methyl]-3H-imidazo[4,5-6]pyridine,
2-[5-[(2-ethyl-5,7-dimethyl-3H-imidazo[4,5-b]pyridine-3-yl)methyl]-2-quin-
olinylisodium benzoate,
2-butyl-6-chloro-4-hydroxymethyl-5-methyl-3-[[2'-(1H-tetrazol-5-yl)biphen-
yl-4-yl]methyl]pyridine,
2-[[[2-butyl-1-[(4-carboxyphenyl)methyl]-1H-imidazol-5-yl]methyl]amino]be-
nzoic acid tetrazol-5-yl)biphenyl-4-yl]methyl]pyrimidin-6-one,
4(S)-[4-(carboxymethyl)phenoxy]-N-[2(R)-[4-(2-sulfobenzamido)imidazol-1-y-
l]octanoyl]-L-proline,
1-(2,6-dimethylphenyl)-4-butyl-1,3-dihydro-3-[[6-[2-(1H-tetrazol-5-yl)phe-
nyl]-3-pyridinyl]methyl]-2H-imidazol-2-one,
5,8-ethano-5,8-dimethyl-2-n-propyl-5,6,7,8-tetrahydro-1-[[2'(1H-tetrazol--
5-yl)biphenyl-4-yl]methyl]-1H,4H-1,3,4a,8a-tetrazacyclopentanaphthalene-9--
one,
4-[1-[2'-(1,2,3,4-tetrazol-5-yl)biphen-4-yl)methylamino]-5,6,7,8-tetr-
ahydro-2-trifylquinazoline,
2-(2-chlorobenzoyl)imino-5-ethyl-3-[2'-(1H-tetrazole-5-yl)biphenyl-4-yl)m-
ethyl-1,3,4-thiadiazoline,
2-[5-ethyl-3-[2-(1H-tetrazole-5-yl)biphenyl-4-yl]methyl-1,3,4-thiazoline--
2-ylidene]aminocarbonyl-1-cyclopentencarboxylic acid dipotassium
salt, and
2-butyl-4-[N-methyl-N-(3-methylcrotonoyl)amino]-1-[[2'-(1H-tetrazol-5-yl)-
biphenyl-4-yl]methyl]-1H-imidzole-5-carboxylic acid
1-ethoxycarbonyloxyethyl ester, those disclosed in patent
publications EP475206, EP497150, EP539086, EP539713, EP535463,
EP535465, EP542059, EP497121, EP535420, EP407342, EP415886,
EP424317, EP435827, EP433983, EP475898, EP490820, EP528762,
EP324377, EP323841, EP420237, EP500297, EP426021, EP480204,
EP429257, EP430709, EP434249, EP446062, EP505954, EP524217,
EP514197, EP514198, EP514193, EP514192, EP450566, EP468372,
EP485929, EP503162, EP533058, EP467207 EP399731, EP399732,
EP412848, EP453210, EP456442, EP470794, EP470795, EP495626,
EP495627, EP499414, EP499416, EP499415, EP511791, EP516392,
EP520723, EP520724, EP539066, EP438869, EP505893, EP530702,
EP400835, EP400974, EP401030, EP407102, EP411766, EP409332,
EP412594, EP419048, EP480659, EP481614, EP490587, EP467715,
EP479479, EP502725, EP503838, EP505098, EP505111 EP513,979
EP507594, EP510812, EP511767, EP512675, EP512676, EP512870,
EP517357, EP537937, EP534706, EP527534, EP540356, EP461040,
EP540039, EP465368, EP498723, EP498722, EP498721, EP515265,
EP503785, EP501892, EP519831, EP532410, EP498361, EP432737,
EP504888, EP508393, EP508445, EP403159, EP403158, EP425211,
EP427463, EP437103, EP481448, EP488532, EP501269, EP500409,
EP540400, EP005528, EP028834, EP028833, EP411507, EP425921,
EP430300, EP434038, EP442473, EP443568, EP445811, EP459136,
EP483683, EP518033, EP520423, EP531876, EP531874, EP392317,
EP468470, EP470543, EP502314, EP529253, EP543263, EP540209,
EP449699, EP465323, EP521768, EP415594, WO92/14468, WO93/08171,
WO93/08169, WO91/00277, WO91/00281, WO91/14367, WO92/00067,
WO92/00977, WO92/20342, WO93/04045, WO93/04046, WO91/15206,
WO92/14714, WO92/09600, WO92/16552, WO93/05025, WO93/03018,
WO91/07404, WO92/02508, WO92/13853, WO91/19697, WO91/11909,
WO91/12001, WO91/11999, WO91/15209, WO91/15479, WO92/20687,
WO92/20662, WO92/20661, WO93/01177, WO91/14679, WO91/13063,
WO92/13564, WO91/17148, WO91/18888, WO91/19715, WO92/02257,
WO92/04335, WO92/05161, WO92/07852, WO92/15577, WO93/03033,
WO91/16313, WO92/00068, WO92/02510, WO92/09278, WO9210179,
WO92/10180, WO92/10186, WO92/10181, WO92/10097, WO92/10183,
WO92/10182, WO92/10187, WO92/10184, WO92/10188, WO92/10180,
WO92/10185, WO92/20651, WO93/03722, WO93/06828, WO93/03040,
WO92/19211, WO92/22533, WO92/06081, WO92/05784, WO93/00341,
WO92/04343, WO92/04059, U.S. Pat. No. 5,104,877, U.S. Pat. No.
5,187,168, U.S. Pat. No. 5,149,699, U.S. Pat. No. 5,185,340, U.S.
Pat. No. 4,880,804, U.S. Pat. No. 5,138,069, U.S. Pat. No.
4,916,129, U.S. Pat. No. 5,153,197, U.S. Pat. No. 5,173,494, U.S.
Pat. No. 5,137,906, U.S. Pat. No. 5,155,126, U.S. Pat. No.
5,140,037, U.S. Pat. No. 5,137,902, U.S. Pat. No. 5,157,026, U.S.
Pat. No. 5,053,329, U.S. Pat. No. 5,132,216, U.S. Pat. No.
5,057,522, U.S. Pat. No. 5,066,586, U.S. Pat. No. 5,089,626, U.S.
Pat. No. 5,049,565, U.S. Pat. No. 5,087,702, U.S. Pat. No.
5,124,335, U.S. Pat. No. 5,102,880, U.S. Pat. No. 5,128,327, U.S.
Pat. No. 5,151,435, U.S. Pat. No. 5,202,322, U.S. Pat. No.
5,187,159, U.S. Pat. No. 5,198,438, U.S. Pat. No. 5,182,288, U.S.
Pat. No. 5,036,048, U.S. Pat. No. 5,140,036, U.S. Pat. No.
5,087,634, U.S. Pat. No. 5,196,537, U.S. Pat. No. 5,153,347, U.S.
Pat. No. 5,191,086, U.S. Pat. No. 5,190,942, U.S. Pat. No.
5,177,097, U.S. Pat. No. 5,212,177, U.S. Pat. No. 5,208,234, U.S.
Pat. No. 5,208,235, U.S. Pat. No. 5,212,195, U.S. Pat. No.
5,130,439, U.S. Pat. No. 5,045,540, U.S. Pat. No. 5,041,152, and
U.S. Pat. No. 5,210,204, and pharmaceutically acceptable salts and
esters thereof; .alpha./.beta. adrenergic blockers such as
nipradilol, arotinolol, amosulalol, bretylium tosylate (CAS RN:
61-75-6), dihydroergtamine mesylate (such as
ergotaman-3',6',18-trione,9,-10-dihydro-12'-hydroxy-2'-methyl-5'-(phenylm-
ethyl)-,(5'(a))-, monomethanesulfonate, e.g., DHE 45.RTM.
Injection, Novartis), carvedilol (such as
(.+-.)-1-(Carbazol-4-yloxy)-3-[[2-(o-methoxyphenoxy)ethyl]amino]-2-propan-
ol, e.g., Coreg.RTM., SmithKline Beecham), labetalol (such as
5-[1-hydroxy-2-[(1-methyl-3-phenylpropyl)amino]ethyljsalicylamide
monohydrochloride, e.g., Normodyne.RTM., Schering), bretylium
tosylate (Benzenemethanaminium, 2-bromo-N-ethyl-N,N-dimethyl-, salt
with 4-methylbenzenesulfonic acid (1:1) CAS RN 61-75-6),
phentolamine mesylate (Phenol,
3-[[(4,5-dihydro-1H-imidazol-2-yl)methyl](4-methylphenyl)amino]-- ,
monomethanesulfonate (salt) CAS RN 65-28-1), solypertine tartrate
(5H-1,3-Dioxolo[4,5-f]indole,
7-[2-[4-(2-methoxyphenyl)-1-piperazinyl]ethyl]-,
(2R,3R)-2,3-dihydroxybutanedioate (1:1) CAS RN 5591-43-5),
zolertine hydrochloride (piperazine,
1-phenyl-4-[2-(1H-tetrazol-5-yl)ethyl]-, monohydrochloride (8Cl,
9Cl) CAS RN 7241-94-3) and the like; a adrenergic receptor
blockers, such as alfuzosin (CAS RN: 81403-68-1), terazosin,
urapidil, prazosin (Minipress.RTM.), tamsulosin, bunazosin,
trimazosin, doxazosin, naftopidil, indoramin, WHP 164, XENO1O,
fenspiride hydrochloride (which may be prepared as disclosed in
U.S. Pat. No. 3,399,192), proroxan (CAS RN 33743-96-3), and
labetalol hydrochloride and combinations thereof; a 2 agonists such
as methyldopa, methyldopa HCL, lofexidine, tiamenidine, moxonidine,
rilmenidine, guanobenz, and the like; aldosterone inhibitors, and
the like; renin inhibitors including Aliskiren (SPP1OO;
Novartis/Speede1); angiopoietin-2-binding agents such as those
disclosed in WO03/030833; anti-angina agents such as ranolazine
(hydrochloride 1-piperazineacetamide,
N-(2,6-dimethylphenyl)-4-[2-hydroxy-3-(2-methoxyphenoxy)propyl]-,
dihydrochloride CAS RN 95635-56-6), betaxolol hydrochloride
(2-Propanol,1-[4-[2
(cyclopropylmethoxy)ethyl]phenoxy]-3-[(1-methylethyl)amino]-,
hydrochloride CAS RN 63659-19-8), butoprozine hydrochloride
(Methanone,
[4-[3(dibutylamino)propoxy]phenyl](2-ethyl-3-indolizinyl)-,
monohydrochloride CAS RN 62134-34-3), cinepazet
maleatel-piperazineacetic acid,
4-[1-oxo-3-(3,4,5-trimethoxyphenyl)-2-propenyl]-, ethyl ester,
(2Z)-2-butenedioate (1:1) CAS RN 50679-07-7), tosifen
(Benzenesulfonamide,
4-methyl-N-[[[(1S)-1-methyl-2-phenylethyl]amino]carbonyl]-CAS RN
32295-184), verapamilhydrochloride (Benzeneacetonitrile,
.alpha.-[3-[[2-(3,4-dimethoxyphenyl)ethyl]methylamino]propyl]-3,4-dimetho-
xy-.alpha.-(1-methylethyl)-, monohydrochloride CAS RN 152-114),
molsidomine (1,2,3-Oxadiazolium,
5-[(ethoxycarbonyl)amino]-3-(4-morpholinyl)-, inner salt CAS RN
25717-80-0), and ranolazine hydrochloride (1-piperazineacetamide,
N-(2,6-dimethylphenyl)-4-[2-hydroxy-3-(2-meth-oxyphenoxy)propyl]-,
dihydrochloride CAS RN 95635-56-6); tosifen (Benzenesulfonamide,
4-methyl-N-[[[(1S)-1-methyl-2-phenylethyl]amino]carbonyl]-CAS RN
32295-184); adrenergic stimulants such as guanfacine hydrochloride
(such as N-amidino-2-(2,6-dichlorophenyl) acetamide hydrochloride,
e.g., Tenex.RTM. Tablets available from Robins);
methyldopa-hydrochlorothiazide (such as
levo-3-(3,4-dihydroxyphenyl)-2-methylalanine) combined with
Hydrochlorothiazide (such as
6-chloro-3,4-dihydro-2H-1,2,4-benzothiadiazine-7-sulfonamide
1,1-dioxide, e.g., the combination as, e.g., Aldoril.RTM. Tablets
available from Merck), methyldopa-chlorothiazide (such as
6-chloro-2H-1,2,4-benzothiadiazine-7-sulfonamide 1,1-dioxide and
methyldopa as described above, e.g., Aldoclor.RTM., Merck),
clonidine hydrochloride (such as
2-(2,6-dichlorophenylamino)-2-imidazoline hydrochloride and
chlorthalidone (such as
2-chloro-5-(1-hydroxy-3-oxo-1-isoindolinyl)benzenesulfonamide),
e.g., Combipres.RTM., Boehringer Ingelheim), clonidine
hydrochloride (such as 2-(2,6-dichlorophenylamino)-2-imidazoline
hydrochloride, e.g., Catapres.RTM., Boehringer Ingelheim),
clonidine (1H-Imidazol-2-amine,
N-(2,6-dichlorophenyl)4,5-dihydro-CAS RN 4205-90-7), Hyzaar (Merck;
a combination of losartan and hydrochlorothiazide), Co-Diovan
(Novartis; a combination of valsartan and hydrochlorothiazide,
Lotrel (Novartis; a combination of benazepril and amlodipine) and
Caduet (Pfizer; a combination of amlodipine and atorvastatin), and
those agents disclosed in US20030069221.
Agents for the Treatment of Respiratory Disorders
[0122] The GCRA peptides described herein can be used in
combination therapy with one or more of the following agents useful
in the treatment of respiratory and other disorders including but
not limited to: (1) .beta.-agonists including but not limited to:
albuterol (PRO VENTIL.RTM., S ALBUT AMO1.RTM., VENTOLIN.RTM.),
bambuterol, bitoterol, clenbuterol, fenoterol, formoterol,
isoetharine (BRONKOSOL.RTM., BRONKOMETER.RTM.), metaproterenol
(ALUPENT.RTM., METAPREL.RTM.), pirbuterol (MAXAIR.RTM.),
reproterol, rimiterol, salmeterol, terbutaline (BRETHAIRE.RTM.,
BRETHINE.RTM., BRICANYL.RTM.), adrenalin, isoproterenol
(ISUPREL.RTM.), epinephrine bitartrate (PRIMATENE.RTM.), ephedrine,
orciprenline, fenoterol and isoetharine; (2) steroids, including
but not limited to beclomethasone, beclomethasone dipropionate,
betamethasone, budesonide, bunedoside, butixocort, dexamethasone,
flunisolide, fluocortin, fluticasone, hydrocortisone, methyl
prednisone, mometasone, predonisolone, predonisone, tipredane,
tixocortal, triamcinolone, and triamcinolone acetonide; (3)
.beta.2-agonist-corticosteroid combinations [e.g.,
salmeterol-fluticasone (AD V AIR.RTM.), formoterol-budesonid
(SYMBICORT.RTM.)]; (4) leukotriene D4 receptor
antagonists/leukotriene antagonists/LTD4 antagonists (i.e., any
compound that is capable of blocking, inhibiting, reducing or
otherwise interrupting the interaction between leukotrienes and the
Cys LTI receptor) including but not limited to: zafhiukast,
montelukast, montelukast sodium (SINGULAIR.RTM.), pranlukast,
iralukast, pobilukast, SKB-106,203 and compounds described as
having LTD4 antagonizing activity described in U.S. Pat. No.
5,565,473; (5) 5-lipoxygenase inhibitors and/or leukotriene
biosynthesis inhibitors [e.g., zileuton and BAY1005 (CA registry
128253-31-6)]; (6) histamine H1 receptor antagonists/antihistamines
(i.e., any compound that is capable of blocking, inhibiting,
reducing or otherwise interrupting the interaction between
histamine and its receptor) including but not limited to:
astemizole, acrivastine, antazoline, azatadine, azelastine,
astamizole, bromopheniramine, bromopheniramine maleate,
carbinoxamine, carebastine, cetirizine, chlorpheniramine,
chloropheniramine maleate, cimetidine clemastine, cyclizine,
cyproheptadine, descarboethoxyloratadine, dexchlorpheniramine,
dimethindene, diphenhydramine, diphenylpyraline, doxylamine
succinate, doxylamine, ebastine, efletirizine, epinastine,
famotidine, fexofenadine, hydroxyzine, hydroxyzine, ketotifen,
levocabastine, levocetirizine, levocetirizine, loratadine,
meclizine, mepyramine, mequitazine, methdilazine, mianserin,
mizolastine, noberastine, norasternizole, noraztemizole,
phenindamine, pheniramine, picumast, promethazine, pynlamine,
pyrilamine, ranitidine, temelastine, terfenadine, trimeprazine,
tripelenamine, and triprolidine; (7) an anticholinergic including
but not limited to: atropine, benztropine, biperiden, flutropium,
hyoscyamine (e.g. Levsin.RTM.; Levbid.RTM.; Levsin/SL.RTM.,
Anaspaz.RTM., Levsinex Timecaps.RTM., NuLev.RTM.), ilutropium,
ipratropium, ipratropium bromide, methscopolamine, oxybutinin,
rispenzepine, scopolamine, and tiotropium; (8) an anti-tussive
including but not limited to: dextromethorphan, codeine, and
hydromorphone; (9) a decongestant including but not limited to:
pseudoephedrine and phenylpropanolamine; (10) an expectorant
including but not limited to: guafenesin, guaicolsulfate, terpin,
ammonium chloride, glycerol guaicolate, and iodinated glycerol;
(11) a bronchodilator including but not limited to: theophylline
and aminophylline; (12) an anti-inflammatory including but not
limited to: fluribiprofen, diclophenac, indomethacin, ketoprofen,
S-ketroprophen, tenoxicam; (13) a PDE (phosphodiesterase) inhibitor
including but not limited to those disclosed herein; (14) a
recombinant humanized monoclonal antibody [e.g. xolair (also called
omalizumab), rhuMab, and talizumab]; (15) a humanized lung
surfactant including recombinant forms of surfactant proteins SP-B,
SP-C or SP-D [e.g. SURFAXIN.RTM., formerly known as dsc-104
(Discovery Laboratories)], (16) agents that inhibit epithelial
sodium channels (ENaC) such as amiloride and related compounds;
(17) antimicrobial agents used to treat pulmonary infections such
as acyclovir, amikacin, amoxicillin, doxycycline, trimethoprin
sulfamethoxazole, amphotericin B, azithromycin, clarithromycin,
roxithromycin, clarithromycin, cephalosporins (ceffoxitin,
cefinetazole etc), ciprofloxacin, ethambutol, gentimycin,
ganciclovir, imipenem, isoniazid, itraconazole, penicillin,
ribavirin, rifampin, rifabutin, amantadine, rimantidine,
streptomycin, tobramycin, and vancomycin; (18) agents that activate
chloride secretion through Ca++ dependent chloride channels (such
as purinergic receptor (P2Y(2) agonists); (19) agents that decrease
sputum viscosity, such as human recombinant DNase 1,
(Pulmozyme.RTM.); (20) nonsteroidal anti-inflammatory agents
(acemetacin, acetaminophen, acetyl salicylic acid, alclofenac,
alminoprofen, apazone, aspirin, benoxaprofen, bezpiperylon,
bucloxic acid, carprofen, clidanac, diclofenac, diclofenac,
diflunisal, diflusinal, etodolac, fenbufen, fenbufen, fenclofenac,
fenclozic acid, fenoprofen, fentiazac, feprazone, flufenamic acid,
flufenisal, flufenisal, fluprofen, flurbiprofen, flurbiprofen,
furofenac, ibufenac, ibuprofen, indomethacin, indomethacin,
indoprofen, isoxepac, isoxicam, ketoprofen, ketoprofen, ketorolac,
meclofenamic acid, meclofenamic acid, mefenamic acid, mefenamic
acid, miroprofen, mofebutazone, nabumetone oxaprozin, naproxen,
naproxen, niflumic acid, oxaprozin, oxpinac, oxyphenbutazone,
phenacetin, phenylbutazone, phenylbutazone, piroxicam, piroxicam,
pirprofen, pranoprofen, sudoxicam, tenoxican, sulfasalazine,
sulindac, sulindac, suprofen, tiaprofenic acid, tiopinac,
tioxaprofen, tolfenamic acid, tolmetin, tolmetin, zidometacin,
zomepirac, and zomepirac); and (21) aerosolized antioxidant
therapeutics such as S-Nitrosoglutathione.
Anti-Obesity Agents
[0123] The GCRA peptides described herein can be used in
combination therapy with an anti-obesity agent. Suitable such
agents include, but are not limited to: 1 1.beta. HSD-I (11-beta
hydroxy steroid dehydrogenase type 1) inhibitors, such as BVT 3498,
BVT 2733, 3-(1-adamantyl)-4-ethyl-5-(ethylthio)-4H-1,2,4-triazole,
3-(1-adamantyl)-5-(3,4,5-trimethoxyphenyl)-4-methyl-4H-1,2,4-triazole,
3-adamantanyl-4,5,6,7,8,9,10,11,12,3a-decahydro-1,2,4-triazolo[4,3-a][11]-
annulene, and those compounds disclosed in WO01/90091, WO01/90090,
WO01/90092 and WO02/072084; 5HT antagonists such as those in
WO03/037871, WO03/037887, and the like; 5HTIa modulators such as
carbidopa, benserazide and those disclosed in U.S. Pat. No.
6,207,699, WO03/031439, and the like; 5HT2c (serotonin receptor 2c)
agonists, such as BVT933, DPCA37215, IK264, PNU 22394, WAY161503,
R-1065, SB 243213 (Glaxo Smith Kline) and YM 348 and those
disclosed in U.S. Pat. No. 3,914,250, WO00/77010, WO02/36596,
WO02/48124, WO02/10169, WO01/66548, WO02/44152, WO02/51844,
WO02/40456, and WO02/40457; 5HT6 receptor modulators, such as those
in WO03/030901, WO03/035061, WO03/039547, and the like;
acyl-estrogens, such as oleoyl-estrone, disclosed in del Mar-Grasa,
M. et al, Obesity Research, 9:202-9 (2001) and Japanese Patent
Application No. JP 2000256190; anorectic bicyclic compounds such as
1426 (Aventis) and 1954 (Aventis), and the compounds disclosed in
WO00/18749, WO01/32638, WO01/62746, WO01/62747, and WO03/015769; CB
1 (cannabinoid-1 receptor) antagonist/inverse agonists such as
rimonabant (Acomplia; Sanofi), SR-147778 (Sanofi), SR-141716
(Sanofi), BAY 65-2520 (Bayer), and SLV 319 (Solvay), and those
disclosed in patent publications U.S. Pat. No. 4,973,587, U.S. Pat.
No. 5,013,837, U.S. Pat. No. 5,081,122, U.S. Pat. No. 5,112,820,
U.S. Pat. No. 5,292,736, U.S. Pat. No. 5,532,237, U.S. Pat. No.
5,624,941, U.S. Pat. No. 6,028,084, U.S. Pat. No. 6,509,367, U.S.
Pat. No. 6,509,367, WO96/33159, WO97/29079, WO98/31227, WO98/33765,
WO98/37061, WO98/41519, WO98/43635, WO98/43636, WO99/02499,
WO00/10967, WO00/10968, WO01/09120, WO01/58869, WO01/64632,
WO01/64633, WO01/64634, WO01/70700, WO01/96330, WO02/076949,
WO03/006007, WO03/007887, WO03/020217, WO03/026647, WO03/026648,
WO03/027069, WO03/027076, WO03/027114, WO03/037332, WO03/040107,
WO03/086940, WO03/084943 and EP658546; CCK-A (cholecystokinin-A)
agonists, such as AR-R 15849, GI 181771 (GSK), JMV-180, A-71378,
A-71623 and SR146131 (Sanofi), and those described in U.S. Pat. No.
5,739,106; CNTF (Ciliary neurotrophic factors), such as GI-181771
(Glaxo-SmithKline), SR146131 (Sanofi Synthelabo), butabindide, PD
170,292, and PD 149164 (Pfizer); CNTF derivatives, such as
Axokine.RTM. (Regeneron), and those disclosed in WO94/09134,
WO98/22128, and WO99/43813; dipeptidyl peptidase IV (DP-IV)
inhibitors, such as isoleucine thiazolidide, valine pyrrolidide,
NVP-DPP728, LAF237, P93/01, P 3298, TSL 225
(tryptophyl-1,2,3,4-tetrahydroisoquinoline-3-carboxylic acid;
disclosed by Yamada et al, Bioorg. & Med. Chem. Lett. 8 (1998)
1537-1540), TMC-2A/2B/2C, CD26 inhibtors, FE 999011, P9310/K364,
VIP 0177, SDZ 274-444, 2-cyanopyrrolidides and 4-cyanopyrrolidides
as disclosed by Ashworth et al, Bioorg. & Med. Chem. Lett.,
Vol. 6, No. 22, pp 1163-1166 and 2745-2748 (1996) and the compounds
disclosed patent publications. WO99/38501, WO99/46272, WO99/67279
(Probiodrug), WO99/67278 (Probiodrug), WO99/61431 (Probiodrug),
WO02/083128, WO02/062764, WO03/000180, WO03/000181, WO03/000250,
WO03/002530, WO03/002531, WO03/002553, WO03/002593, WO03/004498,
WO03/004496, WO03/017936, WO03/024942, WO03/024965, WO03/033524,
WO03/037327 and EP1258476; growth hormone secretagogue receptor
agonists/antagonists, such as NN703, hexarelin, MK-0677 (Merck),
SM-130686, CP-424391 (Pfizer), LY 444,711 (Eli Lilly), L-692,429
and L-163,255, and such as those disclosed in U.S. Ser. No.
09/662,448, U.S. provisional application 60/203,335, U.S. Pat. No.
6,358,951, US2002049196, US2002/022637, WO01/56592 and WO02/32888;
H3 (histamine H3) antagonist/inverse agonists, such as
thioperamide, 3-(1H-imidazol-4-yl)propyl N-(4-pentenyl)carbamate),
clobenpropit, iodophenpropit, imoproxifan, GT2394 (Gliatech), and
A331440, O-[3-(1H-imidazol-4-yl)propanol]carbamates
(Kiec-Kononowicz, K. et al., Pharmazie, 55:349-55 (2000)),
piperidine-containing histamine H3-receptor antagonists (Lazewska,
D. et al., Pharmazie, 56:927-32 (2001), benzophenone derivatives
and related compounds (Sasse, A. et al., Arch. Pharm.(Weinheim)
334:45-52 (2001)), substituted N-phenylcarbamates (Reidemeister, S.
et al., Pharmazie, 55:83-6 (2000)), and proxifan derivatives
(Sasse, A. et al., J. Med. Chem. 43:3335-43 (2000)) and histamine
H3 receptor modulators such as those disclosed in WO02/15905,
WO03/024928 and WO03/024929; leptin derivatives, such as those
disclosed in U.S. Pat. No. 5,552,524, U.S. Pat. No. 5,552,523, U.S.
Pat. No. 5,552,522, U.S. Pat. No. 5,521,283, WO96/23513,
WO96/23514, WO96/23515, WO96/23516, WO96/23517, WO96/23518,
WO96/23519, and WO96/23520; leptin, including recombinant human
leptin (PEG-OB, Hoffman La Roche) and recombinant methionyl human
leptin (Amgen); lipase inhibitors, such as tetrahydrolipstatin
(orlistat/Xenical.RTM.), Triton WR1 339, RHC80267, lipstatin,
teasaponin, diethylumbelliferyl phosphate, FL-386, WAY-121898,
Bay-N-3176, valilactone, esteracin, ebelactone A, ebelactone B, and
RHC 80267, and those disclosed in patent publications WO01/77094,
U.S. Pat. No. 4,598,089, U.S. Pat. No. 4,452,813, U.S. Pat. No.
5,512,565, U.S. Pat. No. 5,391,571, U.S. Pat. No. 5,602,151, U.S.
Pat. No. 4,405,644, U.S. Pat. No. 4,189,438, and U.S. Pat. No.
4,242,453; lipid metabolism modulators such as maslinic acid,
erythrodiol, ursolic acid uvaol, betulinic acid, betulin, and the
like and compounds disclosed in WO03/011267; Mc4r (melanocortin 4
receptor) agonists, such as CHIR86036 (Chiron), ME-10142, ME-10145,
and HS-131 (Melacure), and those disclosed in PCT publication Nos.
WO99/64002, WO00/74679, WO01/991752, WO01/25192, WO01/52880,
WO01/74844, WO01/70708, WO01/70337, WO01/91752, WO02/059095,
WO02/059107, WO02/059108, WO02/059117, WO02/06276, WO02/12166,
WO02/11715, WO02/12178, WO02/15909, WO02/38544, WO02/068387,
WO02/068388, WO02/067869, WO02/081430, WO03/06604, WO03/007949,
WO03/009847, WO03/009850, WO03/013509, and WO03/031410; Mc5r
(melanocortin 5 receptor) modulators, such as those disclosed in
WO97/19952, WO00/15826, WO00/15790, US20030092041;
melanin-concentrating hormone 1 receptor (MCHR) antagonists, such
as T-226296 (Takeda), SB 568849, SNP-7941 (Synaptic), and those
disclosed in patent publications WO01/21169, WO01/82925,
WO01/87834, WO02/051809, WO02/06245, WO02/076929, WO02/076947,
WO02/04433, WO02/51809, WO02/083134, WO02/094799, WO03/004027,
WO03/13574, WO03/15769, WO03/028641, WO03/035624, WO03/033476,
WO03/033480, JP13226269, and JP1437059; mGluR5 modulators such as
those disclosed in WO03/029210, WO03/047581, WO03/048137,
WO03/051315, WO03/051833, WO03/053922, WO03/059904, and the like;
serotoninergic agents, such as fenfluramine (such as Pondimin.RTM.
(Benzeneethanamine, N-ethyl-alpha-methyl-3-(trifluoromethyl)-,
hydrochloride), Robbins), dexfenfluramine (such as Redux.RTM.
(Benzeneethanamine, N-ethyl-alpha-methyl-3-(trifluoromethyl)-,
hydrochloride), Interneuron) and sibutramine ((Meridia.RTM.,
Knoll/Reductil.TM.) including racemic mixtures, as optically pure
isomers (+) and (-), and pharmaceutically acceptable salts,
solvents, hydrates, clathrates and prodrugs thereof including
sibutramine hydrochloride monohydrate salts thereof, and those
compounds disclosed in U.S. Pat. No. 4,746,680, U.S. Pat. No.
4,806,570, and U.S. Pat. No. 5,436,272, US20020006964, WO01/27068,
and WO01/62341; NE (norepinephrine) transport inhibitors, such as
GW 320659, despiramine, talsupram, and nomifensine; NPY 1
antagonists, such as BIBP3226, J-115814, BIBO 3304, LY-357897,
CP-671906, GI-264879A, and those disclosed in U.S. Pat. No.
6,001,836, WO96/14307, WO01/23387, WO99/51600, WO01/85690,
WO01/85098, WO01/85173, and WO01/89528; NPY5 (neuropeptide Y Y5)
antagonists, such as 152,804, GW-569180A, GW-594884A,
GW-587081.times., GW-548118.times., FR235208, FR226928, FR240662,
FR252384, 1229U91, GI-264879A, CGP71683A, LY-377897, LY-366377,
PD-160170, SR-120562A, SR-120819A, JCF-104, and H409/22 and those
compounds disclosed in patent publications U.S. Pat. No. 6,140,354,
U.S. Pat. No. 6,191,160, U.S. Pat. No. 6,218,408, U.S. Pat. No.
6,258,837, U.S. Pat. No. 6,313,298, U.S. Pat. No. 6,326,375, U.S.
Pat. No. 6,329,395, U.S. Pat. No. 6,335,345, U.S. Pat. No.
6,337,332, U.S. Pat. No. 6,329,395, U.S. Pat. No. 6,340,683,
EP01010691, EP-01044970, WO97/19682, WO97/20820, WO97/20821,
WO97/20822, WO97/20823, WO98/27063, WO00/107409, WO00/185714,
WO00/185730, WO00/64880, WO00/68197, WO00/69849, WO/0113917,
WO01/09120, WO01/14376, WO01/85714, WO01/85730, WO01/07409,
WO01/02379, WO01/23388, WO01/23389, WO01/44201, WO01/62737,
WO01/62738, WO01/09120, WO02/20488, WO02/22592, WO02/48152,
WO02/49648, WO02/051806, WO02/094789, WO03/009845, WO03/014083,
WO03/022849, WO03/028726 and Norman et al, J. Med. Chem.
43:4288-4312 (2000); opioid antagonists, such as nalmefene
(REVEX.RTM.), 3-methoxynaltrexone, methylnaltrexone, naloxone, and
naltrexone (e.g. PT901; Pain Therapeutics, Inc.) and those
disclosed in US20050004155 and WO00/21509; orexin antagonists, such
as SB-334867-A and those disclosed in patent publications
WO01/96302, WO01/68609, WO02/44172, WO02/51232, WO02/51838,
WO02/089800, WO02/090355, WO03/023561, WO03/032991, and
WO03/037847; PDE inhibitors (e.g. compounds which slow the
degradation of cyclic AMP (cAMP) and/or cyclic GMP (cGMP) by
inhibition of the phosphodiesterases, which can lead to a relative
increase in the intracellular concentration of cAMP and cGMP;
possible PDE inhibitors are primarily those substances which are to
be numbered among the class consisting of the PDE3 inhibitors, the
class consisting of the PDE4 inhibitors and/or the class consisting
of the PDE5 inhibitors, in particular those substances which can be
designated as mixed types of PDE3/4 inhibitors or as mixed types of
PDE3/4/5 inhibitors) such as those disclosed in patent publications
DE1470341, DE2108438, DE2123328, DE2305339, DE2305575, DE2315801,
DE2402908, DE2413935, DE2451417, DE2459090, DE2646469, DE2727481,
DE2825048, DE2837161, DE2845220, DE2847621, DE2934747, DE3021792,
DE3038166, DE3044568, EP000718, EP0008408, EP0010759, EP0059948,
EP0075436, EP0096517, EPO1 12987, EPO1 16948, EP0150937, EP0158380,
EP0161632, EP0161918, EP0167121, EP0199127, EP0220044, EP0247725,
EP0258191, EP0272910, EP0272914, EP0294647, EP0300726, EP0335386,
EP0357788, EP0389282, EP0406958, EP0426180, EP0428302, EP0435811,
EP0470805, EP0482208, EP0490823, EP0506194, EP0511865, EP0527117,
EP0626939, EP0664289, EP0671389, EP0685474, EP0685475, EP0685479,
JP92234389, JP94329652, JP95010875, U.S. Pat. No. 4,963,561, U.S.
Pat. No. 5,141,931, WO9117991, WO9200968, WO9212961, WO9307146,
WO9315044, WO9315045, WO9318024, WO9319068, WO9319720, WO9319747,
WO9319749, WO9319751, WO9325517, WO9402465, WO9406423, WO9412461,
WO9420455, WO9422852, WO9425437, WO9427947, WO9500516, WO9501980,
WO9503794, WO9504045, WO9504046, WO9505386, WO9508534, WO9509623,
WO9509624, WO9509627, WO9509836, WO9514667, WO9514680, WO9514681,
WO9517392, WO9517399, WO9519362, WO9522520, WO9524381, WO9527692,
WO9528926, WO9535281, WO9535282, WO9600218, WO9601825, WO9602541,
WO9611917, DE3142982, DE1 116676, DE2162096, EP0293063, EP0463756,
EP0482208, EP0579496, EP0667345 U.S. Pat. No. 6,331,543,
US20050004222 (including those disclosed in formulas I-XIII and
paragraphs 37-39, 85-0545 and 557-577), WO9307124, EP0163965,
EP0393500, EP0510562, EP0553174, WO9501338 and WO9603399, as well
as PDE5 inhibitors (such as RX-RA-69, SCH-51866, KT-734,
vesnarinone, zaprinast, SKF-96231, ER-21355, BF/GP-385, NM-702 and
sildenafil (Viagra.TM.)), PDE4 inhibitors (such as etazolate,
ICI63197, RP73401, imazolidinone (RO-20-1724), MEM 1414
(R1533/R1500; Pharmacia Roche), denbufylline, rolipram, oxagrelate,
nitraquazone, Y-590, DH-6471, SKF-94120, motapizone, lixazinone,
indolidan, olprinone, atizoram, KS-506-G, dipamfylline, BMY-43351,
atizoram, arofylline, filaminast, PDB-093, UCB-29646, CDP-840,
SKF-107806, piclamilast, RS-17597, RS-25344-000, SB-207499,
TIBENELAST, SB-210667, SB-211572, SB-211600, SB-212066, SB-212179,
GW-3600, CDP-840, mopidamol, anagrelide, ibudilast, aminone,
pimobendan, cilostazol, quazinone and
N-(3,5-dichloropyrid-4-yl)-3-cyclopropylmethoxy-4-difluoromethoxybenzamid-
e, PDE3 inhibitors (such as ICI153, 100, bemorandane (RWJ 22867),
MCI-154, UD-CG 212, sulmazole, ampizone, cilostamide, carbazeran,
piroximone, imazodan, CI-930, siguazodan, adibendan, saterinone,
SKF-95654, SDZ-MKS-492, 349-U-85, emoradan, EMD-53998, EMD-57033,
NSP-306, NSP-307, revizinone, NM-702, WIN-62582 and WIN-63291,
enoximone and milrinone, PDE3/4 inhibitors (such as benafentrine,
trequinsin, ORG-30029, zardaverine, L-686398, SDZ-ISQ-844,
ORG-20241, EMD-54622, and tolafentrine) and other PDE inhibitors
(such as vinpocetin, papaverine, enprofylline, cilomilast,
fenoximone, pentoxifylline, roflumilast, tadalafil(Cialis.RTM.),
theophylline, and vardenafil(Levitra.RTM.); Neuropeptide Y2 (NPY2)
agonists include but are not limited to: polypeptide YY and
fragments and variants thereof (e.g. YY3-36 (PYY3-36) (N. Engl. J.
Med. 349:941, 2003; IKPEAPGE DASPEELNRY YASLRHYLNL VTRQRY (SEQ ID
NO:19)) and PYY agonists such as those disclosed in WO02/47712,
WO03/026591, WO03/057235, and WO03/027637; serotonin reuptake
inhibitors, such as, paroxetine, fluoxetine (Prozac.TM.),
fluvoxamine, sertraline, citalopram, and imipramine, and those
disclosed in U.S. Pat. No. 6,162,805, U.S. Pat. No. 6,365,633,
WO03/00663, WO01/27060, and WO01/162341; thyroid hormone .beta.
agonists, such as KB-2611 (KaroBioBMS), and those disclosed in
WO02/15845, WO97/21993, WO99/00353, GB98/284425, U.S. Provisional
Application No. 60/183,223, and Japanese Patent Application No. JP
2000256190; UCP-I (uncoupling protein-1), 2, or 3 activators, such
as phytanic acid,
4-[(E)-2-(5,6,7,8-tetrahydro-5,5,8,8-tetramethyl-2-napthalenyl)-1-propeny-
l]benzoic acid (TTNPB), retinoic acid, and those disclosed in
WO99/00123; .beta.3 (beta adrenergic receptor 3) agonists, such as
AJ9677/TAK677 (Dainippon/Takeda), L750355 (Merck), CP331648
(Pfizer), CL-316,243, SB 418790, BRL-37344, L-796568, BMS-196085,
BRL-35135A, CGP12177A, BTA-243, GW 427353, Trecadrine, Zeneca
D7114, N-5984 (Nisshin Kyorin), LY-377604 (Lilly), SR 59119A, and
those disclosed in U.S. Pat. No. 5,541,204, U.S. Pat. No.
5,770,615, U.S. Pat. No. 5,491,134, U.S. Pat. No. 5,776,983, U.S.
Pat. No. 5,705,515, U.S. Pat. No. 5,451,677, WO94/18161,
WO95/29159, WO97/46556, WO98/04526 and WO98/32753, WO01/74782,
WO02/32897, WO03/014113, WO03/016276, WO03/016307, WO03/024948,
WO03/024953 and WO03/037881; noradrenergic agents including, but
not limited to, diethylpropion (such as Tenuate
.RTM. (1-propanone, 2-(diethylamino)-1-phenyl-, hydrochloride),
Merrell), dextroamphetamine (also known as dextroamphetamine
sulfate, dexamphetamine, dexedrine, Dexampex, Ferndex, Oxydess II,
Robese, Spancap #1), mazindol ((or
5-(p-chlorophenyl)-2,5-dihydro-3H-imidazo[2,1-a]isoindol-5-ol) such
as Sanorex.RTM., Novartis or Mazanor.RTM., Wyeth Ayerst),
phenylpropanolamine (or Benzenemethanol, alpha-(1-aminoethyl)-,
hydrochloride), phentermine ((or Phenol,
3-[[4,5-duhydro-1H-imidazol-2-yl)ethyl](4-methylpheny-1)amino],
monohydrochloride) such as Adipex-P.RTM., Lemmon, FASTIN.RTM.,
Smith-Kline Beecham and Ionamin.RTM., Medeva), phendimetrazine ((or
(2S,3S)-3,4-Dimethyl-2-phenylmorpholine L-(+)-tartrate (1:1)) such
as Metra.RTM. (Forest), Plegine.RTM. (Wyeth-Ay erst), Prelu-2.RTM.
(Boehringer Ingelheim), and Statobex.RTM. (Lemmon), phendamine
tartrate (such as Thephorin.RTM.
(2,3,4,9-Tetrahydro-2-methyl-9-phenyl-1H-indenol[2,1-c]pyridine
L-(+)-tartrate (1:1)), Hoffmann-LaRoche), methamphetamine (such as
Desoxyn.RTM., Abbot ((S)--N, (alpha)-dimethylbenzeneethanamine
hydrochloride)), and phendimetrazine tartrate (such as Bontril.RTM.
Slow-Release Capsules, Amarin (-3,4-Dimethyl-2-phenylmorpholine
Tartrate); fatty acid oxidation upregulator/inducers such as
Famoxin.RTM. (Genset); monamine oxidase inhibitors including but
not limited to befloxatone, moclobemide, brofaromine, phenoxathine,
esuprone, befol, toloxatone, pirlindol, amiflamine, sercloremine,
bazinaprine, lazabemide, milacemide, caroxazone and other certain
compounds as disclosed by WO01/12176; and other anti-obesity agents
such as 5HT-2 agonists, ACC (acetyl-CoA carboxylase) inhibitors
such as those described in WO03/072197, alpha-lipoic acid
(alpha-LA), AOD9604, appetite suppressants such as those in
WO03/40107, ATL-962 (Alizyme PLC), benzocaine, benzphetamine
hydrochloride (Didrex), bladderwrack (focus vesiculosus), BRS3
(bombesin receptor subtype 3) agonists, bupropion, caffeine, CCK
agonists, chitosan, chromium, conjugated linoleic acid,
corticotropin-releasing hormone agonists, dehydroepiandrosterone,
DGAT1 (diacylglycerol acyltransferase 1) inhibitors, DGAT2
(diacylglycerol acyltransferase 2) inhibitors, dicarboxylate
transporter inhibitors, ephedra, exendin-4 (an inhibitor of glp-1)
FAS (fatty acid synthase) inhibitors (such as Cerulenin and C75),
fat resorption inhibitors (such as those in WO03/053451, and the
like), fatty acid transporter inhibitors, natural water soluble
fibers (such as psyllium, plantago, guar, oat, pectin), galanin
antagonists, galega (Goat's Rue, French Lilac), garcinia cambogia,
germander (teucrium chamaedrys), ghrelin antibodies and ghrelin
antagonists (such as those disclosed in WO01/87335, and
WO02/08250), polypeptide hormones and variants thereof which affect
the islet cell secretion, such as the hormones of the
secretin/gastric inhibitory polypeptide (GIP)/vasoactive intestinal
polypeptide (VIP)/pituitary adenylate cyclase activating
polypeptide (PACAP)/glucagon-like polypeptide II
(GLP-II)/glicentin/glucagon gene family and/or those of the
adrenomedullin/amylin/calcitonin gene related polypeptide (CGRP)
gene family including GLP-1 (glucagon-like polypeptide 1) agonists
(e.g. (1) exendin-4, (2) those GLP-1 molecules described in
US20050130891 including GLP-1(7-34), GLP-1(7-35), GLP-1(7-36) or
GLP-1(7-37) in its C-terminally carboxylated or amidated form or as
modified GLP-I polypeptides and modifications thereof including
those described in paragraphs 17-44 of US20050130891, and
derivatives derived from GLP-1-(7-34)COOH and the corresponding
acid amide are employed which have the following general formula:
R--NH-HAEGTFTSDVSYLEGQAAKEFIAWLVK-CONH.sub.2 (SEQ ID NO: 20)
wherein R.dbd.H or an organic compound having from 1 to 10 carbon
atoms. Preferably, R is the residue of a carboxylic acid.
Particularly preferred are the following carboxylic acid residues:
formyl, acetyl, propionyl, isopropionyl, methyl, ethyl, propyl,
isopropyl, n-butyl, sec-butyl, tert-butyl) and glp-1 (glucagon-like
polypeptide-1), glucocorticoid antagonists, glucose transporter
inhibitors, growth hormone secretagogues (such as those disclosed
and specifically described in U.S. Pat. No. 5,536,716),
interleukin-6 (IL-6) and modulators thereof (as in WO03/057237, and
the like), L-carnitine, Mc3r (melanocortin 3 receptor) agonists,
MCH2R (melanin concentrating hormone 2R) agonist/antagonists,
melanin concentrating hormone antagonists, melanocortin agonists
(such as Melanotan II or those described in WO 99/64002 and WO
00/74679), nomame herba, phosphate transporter inhibitors,
phytopharm compound 57 (CP 644,673), pyruvate, SCD-I (stearoyl-CoA
desaturase-1) inhibitors, T71 (Tularik, Inc., Boulder Colo.),
Topiramate (Topimax.RTM., indicated as an anti-convulsant which has
been shown to increase weight loss), transcription factor
modulators (such as those disclosed in WO03/026576), .beta.-hydroxy
steroid dehydrogenase-1 inhibitors (.beta.-HSD-I),
.beta.-hydroxy-.beta.-methylbutyrate, p57 (Pfizer), Zonisamide
(Zonegran.TM., indicated as an anti-epileptic which has been shown
to lead to weight loss), and the agents disclosed in US20030119428
paragraphs 20-26.
Anti-Diabetic Agents
[0124] The GCRA peptides described herein can be used in
therapeutic combination with one or more anti-diabetic agents,
including but not limited to: PPAR.gamma. agonists such as
glitazones (e.g., WAY-120,744, AD 5075, balaglitazone, ciglitazone,
darglitazone (CP-86325, Pfizer), englitazone (CP-68722, Pfizer),
isaglitazone (MIT/J&J), MCC-555 (Mitsibishi disclosed in U.S.
Pat. No. 5,594,016), pioglitazone (such as such as Actos.TM.
pioglitazone; Takeda), rosiglitazone (Avandia.TM.; Smith Kline
Beecham), rosiglitazone maleate, troglitazone (Rezulin.RTM.,
disclosed in U.S. Pat. No. 4,572,912), rivoglitazone (CS-O1 1,
Sankyo), GL-262570 (Glaxo Welcome), BRL49653 (disclosed in
WO98/05331), CLX-0921, 5-BTZD, GW-0207, LG-100641, JJT-501
(JPNT/P&U), L-895645 (Merck), R-119702 (Sankyo/Pfizer), NN-2344
(Dr. Reddy/NN), YM-440 (Yamanouchi), LY-300512, LY-519818, R483
(Roche), T131 (Tularik), and the like and compounds disclosed in
U.S. Pat. No. 4,687,777, U.S. Pat. No. 5,002,953, U.S. Pat. No.
5,741,803, U.S. Pat. No. 5,965,584, U.S. Pat. No. 6,150,383, U.S.
Pat. No. 6,150,384, U.S. Pat. No. 6,166,042, U.S. Pat. No.
6,166,043, U.S. Pat. No. 6,172,090, U.S. Pat. No. 6,211,205, U.S.
Pat. No. 6,271,243, U.S. Pat. No. 6,288,095, U.S. Pat. No.
6,303,640, U.S. Pat. No. 6,329,404, U.S. Pat. No. 5,994,554,
WO97/10813, WO97/27857, WO97/28115, WO97/28137, WO97/27847,
WO00/76488, WO03/000685, WO03/027112, WO03/035602, WO03/048130,
WO03/055867, and pharmaceutically acceptable salts thereof;
biguanides such as metformin hydrochloride
(N,N-dimethylimidodicarbonimidic diamide hydrochloride, such as
Glucophage.TM., Bristol-Myers Squibb); metformin hydrochloride with
glyburide, such as Glucovance.TM., Bristol-Myers Squibb); buformin
(Imidodicarbonimidic diamide, N-butyl-); etoformine
(1-Butyl-2-ethylbiguanide, Schering A. G.); other metformin salt
forms (including where the salt is chosen from the group of,
acetate, benzoate, citrate, ftimarate, embonate,
chlorophenoxyacetate, glycolate, palmoate, aspartate,
methanesulphonate, maleate, parachlorophenoxyisobutyrate, formate,
lactate, succinate, sulphate, tartrate, cyclohexanecarboxylate,
hexanoate, octanoate, decanoate, hexadecanoate, octodecanoate,
benzenesulphonate, trimethoxybenzoate, paratoluenesulphonate,
adamantanecarboxylate, glycoxylate, glutamate,
pyrrolidonecarboxylate, naphthalenesulphonate, 1-glucosephosphate,
nitrate, sulphite, dithionate and phosphate), and phenformin;
protein tyrosine phosphatase-IB (PTP-IB) inhibitors, such as
A-401,674, KR 61639, OC-060062, OC-83839, OC-297962, MC52445,
MC52453, ISIS 113715, and those disclosed in WO99/585521,
WO99/58518, WO99/58522, WO99/61435, WO03/032916, WO03/032982,
WO03/041729, WO03/055883, WO02/26707, WO02/26743, JP2002114768, and
pharmaceutically acceptable salts and esters thereof; sulfonylureas
such as acetohexamide (e.g. Dymelor, Eli Lilly), carbutamide,
chlorpropamide (e.g. Diabinese.RTM., Pfizer), gliamilide (Pfizer),
gliclazide (e.g. Diamcron, Servier Canada Inc), glimepiride (e.g.
disclosed in U.S. Pat. No. 4,379,785, such as Amaryl, Aventis),
glipentide, glipizide (e.g. Glucotrol or Glucotrol XL Extended
Release, Pfizer), gliquidone, glisolamide, glyburide/glibenclamide
(e.g. Micronase or Glynase Prestab, Pharmacia & Upjohn and
Diabeta, Aventis), tolazamide (e.g. Tolinase), and tolbutamide
(e.g. Orinase), and pharmaceutically acceptable salts and esters
thereof; meglitinides such as repaglinide (e.g. Pranidin.RTM., Novo
Nordisk), KAD1229 (PF/Kissei), and nateglinide (e.g. Starlix.RTM.,
Novartis), and pharmaceutically acceptable salts and esters
thereof; a glucoside hydrolase inhibitors (or glucoside inhibitors)
such as acarbose (e.g. Precose.TM., Bayer disclosed in U.S. Pat.
No. 4,904,769), miglitol (such as GLYSET.TM., Pharmacia &
Upjohn disclosed in U.S. Pat. No. 4,639,436), camiglibose (Methyl
6-deoxy-6-[(2R,3R,4R,5S)-3,4,5-trihydroxy-2-(hydroxymethyl)piperidino]-al-
pha-D-glucopyranoside, Marion Merrell Dow), voglibose (Takeda),
adiposine, emiglitate, pradimicin-Q, salbostatin, CKD-711,
MDL-25,637, MDL-73,945, and MOR 14, and the compounds disclosed in
U.S. Pat. No. 4,062,950, U.S. Pat. No. 4,174,439, U.S. Pat. No.
4,254,256, U.S. Pat. No. 4,701,559, U.S. Pat. No. 4,639,436, U.S.
Pat. No. 5,192,772, U.S. Pat. No. 4,634,765, U.S. Pat. No.
5,157,116, U.S. Pat. No. 5,504,078, U.S. Pat. No. 5,091,418, U.S.
Pat. No. 5,217,877, and WO01/47528 (polyamines); .alpha.-amylase
inhibitors such as tendamistat, trestatin, and A1-3688, and the
compounds disclosed in U.S. Pat. No. 4,451,455, U.S. Pat. No.
4,623,714, and U.S. Pat. No. 4,273,765; SGLT2 inhibitors including
those disclosed in U.S. Pat. No. 6,414,126 and U.S. Pat. No.
6,515,117; an aP2 inhibitor such as disclosed in U.S. Pat. No.
6,548,529; insulin secreatagogues such as linogliride, A-4166,
forskilin, dibutyrl cAMP, isobutylmethylxanthine (IBMX), and
pharmaceutically acceptable salts and esters thereof; fatty acid
oxidation inhibitors, such as clomoxir, and etomoxir, and
pharmaceutically acceptable salts and esters thereof; A2
antagonists, such as midaglizole, isaglidole, deriglidole,
idazoxan, earoxan, and fluparoxan, and pharmaceutically acceptable
salts and esters thereof; insulin and related compounds (e.g.
insulin mimetics) such as biota, LP-100, novarapid, insulin
detemir, insulin lispro, insulin glargine, insulin zinc suspension
(lente and ultralente), Lys-Pro insulin, GLP-I (1-36) amide, GLP-I
(73-7) (insulintropin, disclosed in U.S. Pat. No. 5,614,492),
LY-315902 (Lilly), GLP-I (7-36)-NH2), AL-401 (Autoimmune), certain
compositions as disclosed in U.S. Pat. No. 4,579,730, U.S. Pat. No.
4,849,405, U.S. Pat. No. 4,963,526, U.S. Pat. No. 5,642,868, U.S.
Pat. No. 5,763,396, U.S. Pat. No. 5,824,638, U.S. Pat. No.
5,843,866, U.S. Pat. No. 6,153,632, U.S. Pat. No. 6,191,105, and WO
85/05029, and primate, rodent, or rabbit insulin including
biologically active variants thereof including allelic variants,
more preferably human insulin available in recombinant form
(sources of human insulin include pharmaceutically acceptable and
sterile formulations such as those available from Eli Lilly
(Indianapolis, Ind. 46285) as Humulin.TM. (human insulin rDNA
origin), also see THE PHYSICIAN'S DESK REFERENCE, 55.sup.th Ed.
(2001) Medical Economics, Thomson Healthcare (disclosing other
suitable human insulins); non-thiazolidinediones such as JT-501 and
farglitazar (GW-2570/GI-262579), and pharmaceutically acceptable
salts and esters thereof; PPAR.alpha./.gamma. dual agonists such as
AR-H039242 (Aztrazeneca), GW-409544 (Glaxo-Wellcome), BVT-142,
CLX-0940, GW-1536, GW-1929, GW-2433, KRP-297 (Kyorin Merck;
5-[(2,4-Dioxo
thiazolidinyl)methyl]methoxy-N-[[4-(trifluoromethyl)phenyl]methyl]benzami-
de), L-796449, LR-90, MK-0767 (Merck/Kyorin/Banyu), SB 219994,
muraglitazar (BMS), tesaglitzar (Astrazeneca), reglitazar (JTT-501)
and those disclosed in WO99/16758, WO99/19313, WO99/20614,
WO99/38850, WO00/23415, WO00/23417, WO00/23445, WO00/50414,
WO01/00579, WO01/79150, WO02/062799, WO03/004458, WO03/016265,
WO03/018010, WO03/033481, WO03/033450, WO03/033453, WO03/043985, WO
031053976, U.S. application Ser. No. 09/664,598, filed Sep. 18,
2000, Murakami et al. Diabetes 47, 1841-1847 (1998), and
pharmaceutically acceptable salts and esters thereof; other insulin
sensitizing drugs; VPAC2 receptor agonists; GLK modulators, such as
those disclosed in WO03/015774; retinoid modulators such as those
disclosed in WO03/000249; GSK 313/GSK 3 inhibitors such as
4-[2-(2-bromophenyl)-4-(4-fluorophenyl-1H-imidazol-5-yl]pyridine
and those compounds disclosed in WO03/024447, WO03/037869,
WO03/037877, WO03/037891, WO03/068773, EP1295884, EP1295885, and
the like; glycogen phosphorylase (HGLPa) inhibitors such as
CP-368,296, CP-316,819, BAYR3401, and compounds disclosed in
WO01/94300, WO02/20530, WO03/037864, and pharmaceutically
acceptable salts or esters thereof; ATP consumption promotors such
as those disclosed in WO03/007990; TRB3 inhibitors; vanilloid
receptor ligands such as those disclosed in WO03/049702;
hypoglycemic agents such as those disclosed in WO03/015781 and
WO03/040114; glycogen synthase kinase 3 inhibitors such as those
disclosed in WO03/035663 agents such as those disclosed in
WO99/51225, US20030134890, WO01/24786, and WO03/059870;
insulin-responsive DNA binding protein-1 (IRDBP-I) as disclosed in
WO03/057827, and the like; adenosine A2 antagonists such as those
disclosed in WO03/035639, WO03/035640, and the like; PPAR.delta.
agonists such as GW 501516, GW 590735, and compounds disclosed in
JP10237049 and WO02/14291; dipeptidyl peptidase IV (DP-IV)
inhibitors, such as isoleucine thiazolidide, NVP-DPP728A
(1-[[[2-[(5-cyanopyridin-2-yl)amino]ethyl]amino]acetyl]-2-cyano-(S)-pyrro-
lidine, disclosed by Hughes et al, Biochemistry, 38(36),
11597-11603, 1999), P32/98, NVP-LAF-237, P3298, TSL225
(tryptophyl-1,2,3,4-tetrahydro-isoquinoline-3-carboxylic acid,
disclosed by Yamada et al, Bioorg. & Med. Chem. Lett. 8 (1998)
1537-1540), valine pyrrolidide, TMC-2A/2B/2C, CD-26 inhibitors,
FE999011, P9310/K364, VIP 0177, DPP4, SDZ 274-444,
2-cyanopyrrolidides and 4-cyanopyrrolidides as disclosed by
Ashworth et al, Bioorg. & Med. Chem. Lett., Vol. 6, No. 22, pp
1163-1166 and 2745-2748 (1996), and the compounds disclosed in U.S.
Pat. No. 6,395,767, U.S. Pat. No. 6,573,287, U.S. Pat. No.
6,395,767 (compounds disclosed include BMS-477118, BMS-471211 and
BMS 538,305), WO99/38501, WO99/46272, WO99/67279, WO99/67278,
WO99/61431WO03/004498, WO03/004496, EP1258476, WO02/083128,
WO02/062764, WO03/000250, WO03/002530, WO03/002531, WO03/002553,
WO03/002593, WO03/000180, and WO03/000181; GLP-I agonists such as
exendin-3 and exendin-4 (including the 39 aa polypeptide synthetic
exendin-4 called Exenatide.RTM.), and compounds disclosed in
US2003087821 and NZ 504256, and pharmaceutically acceptable salts
and esters thereof; peptides including amlintide and Symlin.RTM.
(pramlintide acetate); and glycokinase activators such as those
disclosed in US2002103199 (fused heteroaromatic compounds) and
WO02/48106 (isoindolin-1-one-substituted propionamide
compounds).
[0125] Phosphodiesterase Inhibitors
[0126] The GCRA peptides described herein can be used in
combination therapy with a phosphodiesterase inhibitor. PDE
inhibitors are those compounds which slow the degradation of cyclic
AMP (cAMP) and/or cyclic GMP (cGMP) by inhibition of the
phosphodiesterases, which can lead to a relative increase in the
intracellular concentration of c AMP and/or cGMP. Possible PDE
inhibitors are primarily those substances which are to be numbered
among the class consisting of the PDE3 inhibitors, the class
consisting of the PDE4 inhibitors and/or the class consisting of
the PDE5 inhibitors, in particular those substances which can be
designated as mixed types of PDE3/4 inhibitors or as mixed types of
PDE3/4/5 inhibitors. By way of example, those PDE inhibitors may be
mentioned such as are described and/or claimed in the following
patent applications and patents: DE1470341, DE2108438, DE2123328,
DE2305339, DE2305575, DE2315801, DE2402908, DE2413935, DE2451417,
DE2459090, DE2646469, DE2727481, DE2825048, DE2837161, DE2845220,
DE2847621, DE2934747, DE3021792, DE3038166, DE3044568, EP000718,
EP0008408, EP0010759, EP0059948, EP0075436, EP0096517, EPO1 12987,
EPO1 16948, EP0150937, EP0158380, EP0161632, EP0161918, EP0167121,
EP0199127, EP0220044, EP0247725, EP0258191, EP0272910, EP0272914,
EP0294647, EP0300726, EP0335386, EP0357788, EP0389282, EP0406958,
EP0426180, EP0428302, EP0435811, EP0470805, EP0482208, EP0490823,
EP0506194, EP0511865, EP0527117, EP0626939, EP0664289, EP0671389,
EP0685474, EP0685475, EP0685479, JP92234389, JP94329652,
JP95010875, U.S. Pat. Nos. 4,963,561, 5,141,931, WO9117991,
WO9200968, WO9212961, WO9307146, WO9315044, WO9315045, WO9318024,
WO9319068, WO9319720, WO9319747, WO9319749, WO9319751, WO9325517,
WO9402465, WO9406423, WO9412461, WO9420455, WO9422852, WO9425437,
WO9427947, WO9500516, WO9501980, WO9503794, WO9504045, WO9504046,
WO9505386, WO9508534, WO9509623, WO9509624, WO9509627, WO9509836,
WO9514667, WO9514680, WO9514681, WO9517392, WO9517399, WO9519362,
WO9522520, WO9524381, WO9527692, WO9528926, WO9535281, WO9535282,
WO9600218, WO9601825, WO9602541, WO9611917, DE3142982, DE1 116676,
DE2162096, EP0293063, EP0463756, EP0482208, EP0579496, EP0667345
U.S. Pat. No. 6,331,543, US20050004222 (including those disclosed
in formulas I-XIII and paragraphs 37-39, 85-0545 and 557-577) and
WO9307124, EP0163965, EP0393500, EP0510562, EP0553174, WO9501338
and WO9603399. PDE5 inhibitors which may be mentioned by way of
example are RX-RA-69, SCH-51866, KT-734, vesnarinone, zaprinast,
SKF-96231, ER-21355, BF/GP-385, NM-702 and sildenafil
(Viagra.RTM.). PDE4 inhibitors which may be mentioned by way of
example are RO-20-1724, MEM 1414 (R1533/R1500; Pharmacia Roche),
DENBUFYLLINE, ROLIPRAM, OXAGRELATE, NITRAQUAZONE, Y-590, DH-6471,
SKF-94120, MOTAPIZONE, LIXAZINONE, INDOLIDAN, OLPRINONE, ATIZORAM,
KS-506-G, DIPAMFYLLINE, BMY-43351, ATIZORAM, AROFYLLINE,
FILAMINAST, PDB-093, UCB-29646, CDP-840, SKF-107806, PICLAMILAST,
RS-17597, RS-25344-000, SB-207499, TIBENELAST, SB-210667,
SB-211572, SB-211600, SB-212066, SB-212179, GW-3600, CDP-840,
MOPIDAMOL, ANAGRELIDE, IBUDILAST, AMRINONE, PIMOBENDAN, CILOSTAZOL,
QUAZINONE and
N-(3,5-dichloropyrid-4-yl)-3-cyclopropylmethoxy-4-difluoromethoxybenzamid-
e. PDE3 inhibitors which may be mentioned by way of example are
SULMAZOLE, AMPIZONE, CILOSTAMIDE, CARBAZERAN, PIROXIMONE, IMAZODAN,
CI-930, SIGUAZODAN, ADIBENDAN, SATERINONE, SKF-95654, SDZ-MKS-492,
349-U-85, EMORADAN, EMD-53998, EMD-57033, NSP-306, NSP-307,
REVIZINONE, NM-702, WIN-62582 and WIN-63291, ENOXIMONE and
MILRINONE. PDE3/4 inhibitors which may be mentioned by way of
example are BENAFENTRINE, TREQUINSIN, ORG-30029, ZARDAVERINE,
L-686398, SDZ-ISQ-844, ORG-20241, EMD-54622, and TOLAFENTRINE.
Other PDE inhibitors include: cilomilast, pentoxifylline,
roflumilast, tadalafil(Cialis.RTM.), theophylline, and
vardenafil(Levitra.RTM.), zaprinast (PDE5 specific).
Anti-Uterine Contractions Agents
[0127] The GCRA peptides described herein can be used in
combination therapy (for example, in order to decrease or inhibit
uterine contractions) with a tocolytic agent including but not
limited to beta-adrenergic agents, magnesium sulfate, prostaglandin
inhibitors, and calcium channel blockers.
Anti-Neoplastic Agents
[0128] The GCRA peptides described herein can be used in
combination therapy with an antineoplastic agents including but not
limited to alkylating agents, epipodophyllotoxins, nitrosoureas,
antimetabolites, vinca alkaloids, anthracycline antibiotics,
nitrogen mustard agents, and the like. Particular anti-neoplastic
agents may include tamoxifen, taxol, etoposide and
5-fluorouracil.
[0129] The GCRA peptides described herein can be used in
combination therapy (for example as in a chemotherapeutic
composition) with an antiviral and monoclonal antibody
therapies.
Agents to Treat Congestive Heart Failure
[0130] The GCRA peptides described herein can be used in
combination therapy (for example, in prevention/treatment of
congestive heart failure or another method described herein) with
the partial agonist of the nociceptin receptor ORL1 described by
Dooley et al. (The Journal of Pharmacology and Experimental
Therapeutics, 283 (2): 735-741, 1997). The agonist is a hexapeptide
having the amino acid sequence Ac-RYY (RK) (WI) (RK)-NH2 (SEQ ID
NO: 21) ("the Dooley polypeptide"), where the brackets show
allowable variation of amino acid residue. Thus Dooley polypeptide
can include but are not limited to KYYRWR (SEQ ID NO: 22), RYYRWR
(SEQ ID NO: 23), KWRYYR (SEQ ID NO: 24), RYYRWK (SEQ ID NO: 25),
RYYRWK (all-D amin acids) (SEQ ID NO: 26), RYYRIK (SEQ ID NO: 27),
RYYRIR (SEQ ID NO: 28), RYYKIK (SEQ ID NO: 29), RYYKIR (SEQ ID NO:
30), RYYKWR (SEQ ID NO: 31), RYYKWK (SEQ ID NO: 32), RYYRWR (SEQ ID
NO: 33), RYYRWK (SEQ ID NO: 25), RYYRIK (SEQ ID NO: 27), RYYKWR
(SEQ ID NO: 31), RYYKWK (SEQ ID NO: 32), RYYRWK (SEQ ID NO: 25) and
KYYRWK (SEQ ID NO: 34), wherein the amino acid residues are in the
L-form unless otherwise specified. The GCRA peptides described
herein can also be used in combination therapy with polypeptide
conjugate modifications of the Dooley polypeptide described in
WO0198324.
[0131] Dosage
[0132] Dosage levels of active ingredients in a pharmaceutical
composition can also be varied so as to achieve a transient or
sustained concentration of the compound in a subject, especially in
and around the site of inflammation or disease area, and to result
in the desired response. It is well within the skill of the art to
start doses of the compound at levels lower than required to
achieve the desired effect and to gradually increase the dosage
until the desired effect is achieved. It will be understood that
the specific dose level for any particular subject will depend on a
variety of factors, including body weight, general health, diet,
natural history of disease, route and scheduling of administration,
combination with one or more other drugs, and severity of
disease.
[0133] An effective dosage of the composition will typically be
between about 1 .mu.g and about 10 mg per kilogram body weight,
preferably between about 10 .mu.g to 5 mg of the compound per
kilogram body weight. Adjustments in dosage will be made using
methods that are routine in the art and will be based upon the
particular composition being used and clinical considerations.
[0134] The guanylate cyclase receptor agonists used in the methods
described above may be administered orally, systemically or
locally. Dosage forms include preparations for inhalation or
injection, solutions, suspensions, emulsions, tablets, capsules,
topical salves and lotions, transdermal compositions, other known
peptide formulations and pegylated peptide analogs. Agonists may be
administered as either the sole active agent or in combination with
other drugs, e.g., an inhibitor of cGMP-dependent phosphodiesterase
and anti-inflammatory agent. In all cases, additional drugs should
be administered at a dosage that is therapeutically effective using
the existing art as a guide. Drugs may be administered in a single
composition or sequentially.
[0135] Dosage levels of the GCR agonist for use in methods of this
invention typically are from about 0.001 mg to about 10,000 mg
daily, preferably from about 0.005 mg to about 1,000 mg daily. On
the basis of mg/kg daily dose, either given in single or divided
doses, dosages typically range from about 0.001/75 mg/kg to about
10,000/75 mg/kg, preferably from about 0.005/75 mg/kg to about
1,000/75 mg/kg.
[0136] The total daily dose of each inhibitor can be administered
to the patient in a single dose, or in multiple subdoses.
Typically, subdoses can be administered two to six times per day,
preferably two to four times per day, and even more preferably two
to three times per day. Doses can be in immediate release form or
sustained release form sufficiently effective to obtain the desired
control over the medical condition.
[0137] The dosage regimen to prevent, treat, give relief from, or
ameliorate a medical condition or disorder, or to otherwise protect
against or treat a medical condition with the combinations and
compositions of the present invention is selected in accordance
with a variety of factors. These factors include, but are not
limited to, the type, age, weight, sex, diet, and medical condition
of the subject, the severity of the disease, the route of
administration, pharmacological considerations such as the
activity, efficacy, pharmacokinetics and toxicology profiles of the
particular inhibitors employed, whether a drug delivery system is
utilized, and whether the inhibitors are administered with other
active ingredients. Thus, the dosage regimen actually employed may
vary widely and therefore deviate from the preferred dosage regimen
set forth above.
EXAMPLES
Example 1
Synthesis and Purification of GCRA Peptides
[0138] The GCRA peptides were synthesized using standard methods
for solid-phase peptide synthesis. Either a Boc/Bzl or Fmoc/tBu
protecting group strategy was selected depending upon the scale of
the peptide to be produced. In the case of smaller quantities, it
is possible to get the desired product using an Fmoc/tBu protocol,
but for larger quantities (1 g or more), Boc/Bzl is superior.
[0139] In each case the GCRA peptide was started by either using a
pre-loaded Wang (Fmoc) or Merrifield (Boc) or Pam (Boc) resin. For
products with C-terminal Leu, Fmoc-Leu-Wang (D-1115) or Boc-Leu-Pam
resin (D-1230) or Boc-Leu-Merrifield (D-1030) Thus, for peptides
containing the C-terminal d-Leu, the resin was Fmoc-dLeu-Wang Resin
(D-2535) and Boc-dLeu-Merrifield, Boc-dLeu-Pam-Resin (Bachem
Product D-1230 and D-1590, respectively) (SP-332 and related
analogs). For peptides produced as C-terminal amides, a resin with
Ramage linker (Bachem Product D-2200) (Fmoc) or mBHA (Boc) (Bachem
Product D-1210 was used and loaded with the C-terminal residue as
the first synthetic step.
[0140] Fmoc-tBu Overview
[0141] Each synthetic cycle consisted deprotection with 20%
piperidine in DMF. Resin washes were accomplished with alternating
DMF and IpOH to swell and shrink the resin, respectively. Peptide
synthesis elongated the chain from the C-terminus to the
N-terminus. Activation chemistry for each amino acid was with
HBTU/DIEA in a 4 fold excess for 45 minutes. In automated
chemistries, each amino acid was double coupled to maximize the
coupling efficiency. To insure the correct position of disulfide
bonds, the Cys residues were introduced as Cys(Acm) at positions 15
and 7. Cys(Trt) was positioned at Cys4 and Cys12. This protecting
group strategy yields the correct topoisomer as the dominant
product (75:25). (For enterotoxin analogs, a third disulfide bond
protecting group (Mob) was utilized).
[0142] For peptides containing C-terminal Aeea
(aminoethyloxyethyloxyacetyl) groups, these were coupled to a
Ramage amide linker using the same activation chemistry above by
using an Fmoc-protected Aeea derivative. The Cys numbering in these
cases remains the same and the positioning of the protecting groups
as well. For the peptides containing the N-terminal extension of
Aeea, the Cys residue numbering will be increased by three Cys4
becomes Cys7, Cys12 becomes Cys15; Cys7 becomes Cys10 and Cys 15
becomes Cys18. The latter pair is protected with Acm and the former
pair keeps the Trt groups.
[0143] For analogs containing D-amino acid substitutions, these
were introduced directly by incorporating the correctly protected
derivative at the desired position using the same activation
chemistry described in this document. For Fmoc strategies,
Fmoc-dAsn(Trt)-OH, Fmoc-dAsn(Xan)-OH, Fmoc-dAsp(tBu)-OH,
Fmoc-dGlu(tBu)-OH and for Boc strategies, Boc-dAsn(Xan)-OH,
Boc-dAsn(Trt)-OH, Boc-dAsp(Chx), Boc-dAsp(Bzl)-OH, Boc-dGlu(Chx)-OH
and Boc-dGlu(Bzl)-OH would be utilized.
[0144] Each peptide is cleaved from the solid-phase support using a
cleavage cocktail of TFA:H2O:Trisisopropylsilane (8.5:0.75:0.75)
ml/g of resin for 2 hr at RT. The crude deprotected peptide is
filtered to remove the spent resin beads and precipitated into
ice-cold diethylether.
[0145] Each disulfide bonds was introduced orthogonally. Briefly,
the crude synthetic product was dissolved in water containing
NH.sub.4OH to increase the pH to 9. Following complete
solubilization of the product, the disulfide bond was made between
the Trt deprotected Cys residues by titration with H.sub.2O.sub.2.
The monocyclic product was purified by RP-HPLC. The purified
mono-cyclic product was subsequently treated with a solution of
iodine to simultaneously remove the Acm protecting groups and
introduce the second disulfide bond.
[0146] For enterotoxin analogs, the Mob group was removed via
treatment of the dicyclic product with TFA 85% containing 10% DMSO
and 5% thioanisole for 2 hr at RT.
[0147] Each product was then purified by RP-HPLC using a
combination buffer system of TEAP in H2O versus MeCN, followed by
TFA in H2O versus MeCN. Highly pure fractions were combined and
lyophilized. The final product was converted to an Acetate salt
using either ion exchange with Acetate loaded Dow-Ex resin or using
RP-HPLC using a base-wash step with NH.sub.4OAc followed by 1% AcOH
in water versus MeCN.
[0148] It is also possible to prepare enterotoxin analogs using a
random oxidation methodology using Cys(Trt) in Fmoc or Cys(MeB) in
Boc. Following cleavage, the disulfide bonds can be formed using
disulfide interchange redox pairs such as glutathione (red/ox)
and/or cysteine/cystine. This process will yield a folded product
that the disulfide pairs must be determined as there would be no
way of knowing their position directly.
Boc-Bzl Process
[0149] Peptide synthesis is initiated on a Merrifield or Pam
pre-loaded resin or with mBHA for peptides produced as C-terminal
amides. Each synthetic cycle consists of a deprotection step with
50% TFA in MeCL2. The resin is washed repetitively with MeCl2 and
MeOH. The TFA salt formed is neutralized with a base wash of 10%
TEA in MeCl2. The resin is washed with MeCl2 and MeOH and lastly
with DMF prior to coupling steps. A colorimetric test is conducted
to ensure deprotection. Each coupling is mediated with diisopropyl
carbodiimide with HOBT to form the active ester. Each coupling is
allowed to continue for 2 hr at RT or overnight on difficult
couplings. Recouplings are conducted with either Uronium or
Phosphonium reagents until a negative colorimetric test is obtained
for free primary amines. The resin is then washed with DMF, MeCl2
and MeOH and prepared for the next solid-phase step. Cys protection
utilizes Cys(Acm) at positions 7 and 15, and Cys(MeB) at Cys 4 and
Cys12.
[0150] Cleavage and simultaneous deprotection is accomplished by
treatment with HF using anisole as a scavenger (9:1:1) ml:ml:g
(resin) at 0.degree. C. for 60 min. The peptide is subsequently
extracted from the resin and precipitated in ice cold ether. The
introduction of disulfide bonds and purification follows the exact
same protocol described above for the Fmoc-produced product.
Example 2
In Vitro Proteolytic Stability Using Simulated Gastric Fluid (SGF)
Digestion
[0151] The stability of the GRCA peptide according to the invention
is determined in the presence of simulated gastric fluid (SGF).
GRCA peptide (final concentration of 8.5 mg/ml) is incubated in SGF
(Proteose peptone (8.3 g/liter; Difco), D-Glucose (3.5 g/liter;
Sigma), NaCl (2.05 g/liter; Sigma), KH.sub.2PO.sub.4 (0.6 g/liter;
Sigma), CaCl.sub.2 (0.11 g/liter), KCl (0.37 g/liter; Sigma),
Porcine bile (final 1.times. concentration 0.05 g/liter; Sigma) in
PBS, Lysozyme (final 1.times. concentration 0.10 g/liter; Sigma) in
PBS, Pepsin (final 1.times. concentration 0.0133 g/liter; Sigma) in
PBS). SGF is made on the day of the experiment and the pH is
adjusted to 2.0.+-.0.1 using HCl or NaOH as necessary. After the pH
adjustment, SGF is sterilized filtered with 0.22 .mu.m membrane
filters. SP-304 (final concentration of 8.5 mg/ml) is incubated in
SGF at 37.degree. C. for 0, 15, 30, 45, 60 and 120 min in
triplicate aliquots. Following incubations, samples are snap frozen
in dry ice then are stored in a -80.degree. C. freezer until they
are assayed in duplicate.
Example 3
In Vitro Proteolytic Stability Using Simulated Intestinal Fluid
(SIF) Digestion
[0152] The stability of the GRCA peptide is also evaluated against
digestion with simulated intestinal fluid (SIF). SIF solution was
prepared by the method as described in the United States
Pharmacopoeia, 24th edition, p2236. The recipe to prepare SIF
solution is as described below. The SIF solution contains NaCl
(2.05 g/liter; Sigma), KH.sub.2PO.sub.4 (0.6 g/liter; Sigma),
CaCl.sub.2 (0.11 g/liter), KCl (0.37 g/liter; Sigma), and Pacreatin
10 mg/ml. The pH is adjusted to 6 and the solution is filter
sterilized. A solution of SP-304 (8.5 mg/ml) is incubated in SGF at
37.degree. C. for 0, 30, 60, 90, 120, 150 and 300 min in triplicate
aliquots. Following incubations, samples are removed and snap
frozen with dry ice and stored in a -80.degree. C. freezer until
they are assayed in duplicate. F
[0153] The integrity of GRCA peptide is evaluated by HPLC by
essentially using the method described for SGF digestion.
Example 4
Cyclic GMP Stimulation Assays
[0154] The ability of the GCRA peptide to bind to and activate the
intestinal GC-C receptor is tested by using T 84 human colon
carcinoma cell line. Human T84 colon carcinoma cells are obtained
from the American Type Culture Collection. Cells are grown in a 1:1
mixture of Ham's F-12 medium and Dulbecco's modified Eagle's medium
(DMEM) supplemented with 10% fetal bovine serum, 100 U
penicillin/ml, and 100 .mu.g/ml streptomycin. The cells are fed
fresh medium every third day and split at a confluence of
approximately 80%.
[0155] Biological activity of the GCRA peptides is assayed as
previously reported (15). Briefly, the confluent monolayers of T-84
cells in 24-well plates are washed twice with 250 .mu.l of DMEM
containing 50 mM HEPES (pH 7.4), pre-incubated at 37.degree. C. for
10 min with 250 .mu.l of DMEM containing 50 mM HEPES (pH 7.4) and 1
mM isobutylmethylxanthine (IBMX), followed by incubation with GCRA
peptides (0.1 nM to 10.mu.M) for 30 min. The medium is aspirated,
and the reaction is terminated by the addition of 3% perchloric
acid. Following centrifugation, and neutralization with 0.1 N NaOH,
the supernatant is used directly for measurements of cGMP using an
ELISA kit (Caymen Chemical, Ann Arbor, Mich.).
Example 5
Peggylated Peptides
[0156] The other strategy to render peptides more resistant towards
digestions against digestive proteases is to peggylate them at the
N- and C-terminal. The peptide GCRA peptide is peggylated with the
aminoethyloxy-ethyloxy-acetic acid (Aeea) group at the C-terminal
(or at the N-terminal or at both termini. Cyclic GMP synthesis in
T84 cells is measured by the method as described above.
Example 6
Combination of Guanylate Cyclase Receptor Agonists with
Phosphodiesterase Inhibitors
[0157] Regulation of intracellular concentrations of cyclic
nucleotides (i.e., cAMP and cGMP) and thus, signaling via these
second messengers, is generally considered to be governed by their
rates of production versus their rates of destruction within cells.
Thus, levels of cGMP in tissues and organs can also be regulated by
the levels of expression of cGMP-specific phosphodiesterases
(cGMP-PDE), which are generally overexpressed in cancer and
inflammatory diseases. Therefore, a combination consisting of an
agonist of GC-C with an inhibitor of cGMP-PDE might produce
synergistic effect on levels of cGMP in the target tissues and
organs.
[0158] Sulindac Sulfone (SS) and Zaprinast (ZAP) are two of the
known inhibitors of cGMP-PDE and has shown to induce apoptosis in
cancer cells via a cGMP-dependent mechanism. SS and ZAP in
combination with GCRA peptide is evaluated to see if these PDE
inhibitors have any synergistic effect on intracellular
accumulation of cGMP
Example 7
An Oral Range-Finding Toxicity Study in Cynomolgus Monkeys
[0159] The objective of the study is to determine the toxicity of
the GRCA peptides according to the invention following a single
oral gavage administration to the cynomolgus monkey and to allow
assessment of reversibility of any changes following a minimum
7-day observation/washout period. Each GRCA peptide according to
the invention will be given at two different dose levels.
[0160] Experimental Design
[0161] The test (e.g., the GRCA peptides according to the
invention) and control/vehicle article will be administered in
three phases separated by a minimum 7-day observation period. Each
phase will consist of a single oral gavage administration to female
cynomolgus monkeys as indicated in the tables below:
Phase 1:
[0162] Eight non-naive female cynomolgus monkeys will be
transferred from the ITR Spare Monkey colony and assigned to four
dose groups as follows:
TABLE-US-00002 Group Dose Dose Dose Number of Group Desig- Study
Level Concentration Volume Animals Number nation Day (mg/kg)
(mg/mL) (mL/kg) (Females) 1 Control/ 1 0 0 10 2 Vehicle 4 2 Test 1
1 0.1 10 2 Peptides 4 4
[0163] Following completion of the Phase 1 dosing, all monkeys will
be observed for 33 days. Upon completion of the observation period,
all monkeys will be transferred back to the ITR Spare Monkey
Colony.
Phase 2:
[0164] The same eight non-naive female cynomolgus monkeys as
previously used in Phase 1 will be transferred from the ITR Spare
Monkey colony and assigned to four dose groups as follows:
TABLE-US-00003 Group Dose Dose Dose Number of Group Desig- Study
Level Concentration Volume Animals Number nation Day (mg/kg)
(mg/mL) (mL/kg) (Females) 1 Control/ 1 10 1 10 2 Vehicle 2 Test 1
10 1 10 2 Peptides
[0165] Following completion of the Phase 2 dosing, all monkeys will
be observed for a minimum of 7 days.
[0166] Route of Administration
[0167] The oral route of administration has been chosen because it
is a preferred human therapeutic route.
[0168] Preparation of Test and Control/Vehicle Articles
[0169] The test and control/vehicle articles will be prepared fresh
on the day of dosing in cold distilled water (maintained in an ice
water bath). A sufficient amount of test article powder will be
added to the appropriate amount of distilled water in order to
achieve the desired concentration. The dose formulations will be
mixed by simple inversion.
[0170] Analysis of Test Article Concentration and Stability in the
Dose Formulations
[0171] For possible confirmation of the concentration and stability
of the test article in the formulations, representative samples
will be taken from the middle of each concentration, including the
control/vehicle article on the first day of dosing of each group,
as indicated below. Samples will be collected immediately after
preparation on Day 1 and again after dosing is completed on that
day and will be stored frozen (approximately 80.degree. C. nominal)
in 20 mL screw cap vials. Therefore, the remaining dose formulation
vials will be returned to the Pharmacy Department as soon as
possible after completion of dosing.
[0172] Group 1: 1.5 mL in duplicate from the middle on Day 1
(pre-dose and post-dose).
[0173] Group 2: 1.5 mL in duplicate from the middle on Day 1
(pre-dose and post-dose).
[0174] Group 3: 1.5 mL in duplicate from the middle on Day 1
(pre-dose and post-dose).
[0175] Group 4: 1.5 mL in duplicate from the middle on Day 1
(pre-dose and post-dose).
[0176] The formulations will be maintained cold in an ice water
bath during all sampling procedures.
[0177] The formulations will be stirred continuously with a stir
bar for a minimum of 15 minutes prior to sampling.
[0178] The samples will be retained frozen (approximately
-80.degree. C. nominal) at ITR until requested by the Sponsor to be
shipped to a laboratory designated by the Sponsor for analysis. The
samples can be discarded once it is determined by the analyst and
Study Director that they are no longer needed. These samples'
disposition will be recorded in the raw data.
[0179] If analyzed, a Dose Formulation report will be prepared by
the Principal Investigator (Formulation analysis) and will be
provided to ITR for inclusion in the final report.
[0180] Test System
TABLE-US-00004 Species/Strain: Cynomolgus Monkey (Macaca
Fasicularis) Source: orldwide Primates Inc., P.O. Box 971279 Miami,
Florida, 33187, USA and Covance Research Products Inc. P.O. Box 549
Alice, Texas, 78333, USA Total No. of monkeys 8 non-naive females
on study: Body Weight Range: 2-4 kg at onset of treatment Age Range
at Start: Young adult at onset of treatment Acclimation Period: The
animals will be transferred from ITR's spare monkey colony. They
are therefore, considered to be fully acclimated to the laboratory
environment.
[0181] The actual age and body weight ranges will be noted in the
final report.
[0182] Administration of the Test and Control/Vehicle Articles
[0183] The test and control/vehicle articles will be administered
by oral gavage administration using a gavage tube attached to a
syringe in three Phases separated by a minimum 7-day
observation/washout period. Each dosing session will consist of a
single oral gavage administration. The gavage tube will be flushed
with 3 mL of reverse osmosis water immediately following
administration of the dose formulation in order to ensure that the
entire dose volume has been delivered to the animal. The dose
volume will be 10 mL/kg for all animals, including controls. The
actual volume administered to each monkey on Day 1 of each Phase
will be calculated using the Day -1 body weights of each Phase.
[0184] Dosing formulations will be maintained cold during dose
administration by placing them in an ice water bath.
[0185] The dosing formulations must be placed on a stir plate for a
minimum of 15 minutes prior to the start of dosing and maintained
on the stir plate throughout the dosing procedure.
[0186] The dosing formulations must be used within 2 hours of
preparation.
[0187] Clinical Observations
[0188] Cage-side clinical signs (ill health, behavioral changes
etc.) will be recorded as indicated below except on detailed
clinical examination days, where the morning cage-side clinical
signs will be replaced by a detailed clinical examination (DCE).
During regular cage side clinical signs and detailed examinations,
particular attention will be paid to stools with respect to amount
of stools produced, description of stools, etc.
[0189] Cage side clinical signs will be performed as follows:
[0190] During the pretreatment period and during the 7-day
(minimum) observation periods:
[0191] Three times per day with a minimum of 3 hours between each
occasion.
[0192] On the dosing day of Phase 1: pre-dose, 2, 4, 6, 8 and 24
hours post-dosing
[0193] On the dosing day of Phase 2: pre-dose, continuously for the
first 4 hours post-dose and at 6, 8 and 24 hours post-dosing
[0194] On the dosing day of Phase 3: pre-dose, continuously for the
first 4 hours post-dose and at 6, 8 and 24 hours post-dosing
[0195] A detailed clinical examination of each monkey will be
performed once at the time of animal transfer and once weekly
thereafter.
[0196] Animals whose health status is judged to warrant additional
evaluation will be examined by a Clinical Veterinarian, or a
technician working under the supervision of the Clinical
Veterinarian. Any veterinarian-recommended treatments will only be
performed once agreement has been obtained from the Study Director.
Where possible, the Sponsor will be consulted prior to
administration of therapeutic drugs.
[0197] Body weights will be recorded for all animals once daily
from the day of transfer through to the end of the study.
[0198] Food consumption will be recorded for all animals once daily
from the day of transfer through to the end of the study.
[0199] Cages will be cleaned prior to the start of the daily food
consumption to ensure no food cookies remain in the cage. Monkeys
will be fed 7 cookies before 12 pm and 7 cookies after 12 pm. The
sum of the total number of cookies given for the day will be
recorded.
[0200] The next morning, a visual check will be performed to see
how many cookies are left in the cage. The number of whole cookies
remaining in the food hopper or on the tray will be recorded. The
number of whole cookies left will be subtracted from the total
number of cookies given in order to calculate the number of cookies
eaten.
Example 8
Suckling Mouse Model of Intestinal Secretion (SuMi Assay)
[0201] The GCRA peptides described herein can be tested for their
ability to increase intestinal secretion using a suckling mouse
model of intestinal secretion. In this model a GCRA peptide is
administered to suckling mice that are between seven and nine days
old. After the mice are sacrificed, the gastrointestinal tract from
the stomach to the cecum is dissected ("guts"). The remains
("carcass") as well as the guts are weighed and the ratio of guts
to carcass weight is calculated. If the ratio is above 0.09, one
can conclude that the test compound increases intestinal secretion.
Controls for this assay may include wild-type SP-304, ST
polypeptide and Zelnorm.RTM.. Phenylbenzoquinone-induced writhing
model
[0202] The PBQ-induced writhing model can be used to assess pain
control activity of the GCRA peptide described herein. This model
is described by Siegmund et al. (1957 Proc. Soc. Exp. Bio. Med.
95:729-731). Briefly, one hour after oral dosing with a test
compound, e.g., a GCRA peptide, morphine or vehicle, 0.02%
phenylbenzoquinone (PBQ) solution (12.5 mL/kg) is injected by
intraperitoneal route into the mouse. The number of stretches and
writhings are recorded from the 5.sup.th to the 10.sup.th minute
after PBQ injection, and can also be counted between the 35.sup.th
and 40.sup.th minute and between the 60.sup.th and 65.sup.th minute
to provide a kinetic assessment. The results are expressed as the
number of stretches and writhings (mean.+-.SEM) and the percentage
of variation of the nociceptive threshold calculated from the mean
value of the vehicle-treated group. The statistical significance of
any differences between the treated groups and the control group is
determined by a Dunnett's test using the residual variance after a
one-way analysis of variance (P<0.05) using SigmaStat
Software.
Example 9
Pharmacokinetic Property Determination of GCRA Peptides
[0203] Serum samples are extracted from the whole blood of exposed
(mice dosed orally or intravenously with GCRA peptides (s)
described herein) and control mice, then injected directly (10 mL)
onto an in-line solid phase extraction (SPE) column (Waters Oasis
HLB 25 .mu.m column, 2.0.times.15 mm direct connect) without
further processing. The sample on the SPE column is washed with a
5% methanol, 95% dH.sub.2O solution (2.1 mL/min, 1.0 minute), then
loaded onto an 0 analytical column using a valve switch that places
the SPE column in an inverted flow path onto the analytical column
(Waters Xterra MS C8 5 .mu.m IS column, 2.1.times.20 mm). The
sample is eluted from the analytical column with a reverse phase
gradient (Mobile Phase A: 10 mM ammonium hydroxide in dH.sub.2O,
Mobile Phase B: 10 mM ammonium hydroxide in 80% acetonitrile and
20% methanol; 20% B for the first 3 minutes then ramping to 95% B
over 4 min. and holding for 2 5 min., all at a flow rate of 0.4
mL/min.). At 9.1 minutes, the gradient returns to the initial
conditions of 20% B for 1 min. polypeptide is eluted from the
analytical column and is detected by triple-quadrapole mass
spectrometry (MRM, 764 (+2 charge state)>182 (+1 charge state)
Da; cone voltage=30V; collision=20 eV; parent resolution=2 Da at
base peak; daughter resolution=2 Da at base peak). Instrument
response is converted into concentration units by comparison with a
standard curve using known amounts of chemically synthesized
polypeptide(s) prepared and injected in mouse plasma using the same
procedure.
[0204] Similarly, pharmacokinetic properties are determined in rats
using LCMS methodology. Rat plasma samples containing the GCRA
peptide are extracted using a Waters Oasis MAX 96 well solid phase
extraction (SPE) plate. A 200 .mu.L volume of rat plasma is mixed
with 200 .mu.L of .sup.13Cg, .sup.15N-labeled polypeptide in the
well of a prepared SPE plate. The samples are drawn through the
stationary phase with 15 mm Hg vacuum. All samples are rinsed with
200 .mu.L of 2% ammonium hydroxide in water followed by 200 .mu.L
of 20% methanol in water. The samples are eluted with consecutive
100 .mu.L volumes of May 20, 1975 formic acid/water/methanol and
100 .mu.L May 15, 1980 formic acid/water/methanol. The samples are
dried under nitrogen and resuspended in 100 .mu.L of 20% methanol
in water. Samples are analyzed by a Waters Quattro Micro mass
spectrometer coupled to a Waters 1525 binary pump with a Waters
2777 autosampler. A 40 .mu.L volume of each sample is injected onto
a Thermo Hypersil GOLD C18 column (2.1.times.50 mm, 5 um).
polypeptide is eluted by a gradient over 3 minutes with
acetonitrile and water containing 0.05% trifluoroacetic acid. The
Quattro Micro mass spectrometer is run in multiple reaction
monitoring (MRM) mode using the mass transitions of, for example
764>182 or 682>136. Using this methodology, polypeptide is
dosed orally and by IV to rats at 10 mg/kg. Pharmacokinetic
properties including area under the curve and bioavailability are
determined.
Example 10
Diuresis Related Experiments Effect on Diuresis and Natriuresis
[0205] The effect of GCRA peptides described herein on diuresis and
natriuresis can be determined using methodology similar to that
described in WO06/001931 (examples 6 (p. 42) and 8 (p. 45)).
Briefly, the polypeptide/agonist described herein (180-pmol) is
infused for 60 min into a group of 5 anesthetized mice or primates.
Given an estimated rat plasma volume of 10 mL, the infusion rate is
approximately 3 pmol/mL/min. Blood pressure, urine production, and
sodium excretion are monitored for approximately 40 minutes prior
to the infusion, during the infusion, and for approximately 50
minutes after the infusion to measure the effect of the GCRA
peptides on diuresis and natriuresis. For comparison, a control
group of five rats is infused with regular saline. Urine and sodium
excretion can be assessed. Dose response can also be determined.
polypeptide/GC-C agonist described herein is infused intravenously
into mice or primates over 60 minutes. Urine is collected at 30
minute intervals up to 180 minutes after termination of
polypeptide/GC-C agonist infusion, and urine volume, sodium
excretion, and potassium excretion are determined for each
collection interval. Blood pressure is monitored continuously. For
each dose a dose-response relationship for urine volume, sodium and
potassium excretion can be determined. Plasma concentration of the
polypeptide/GC-agonist is also determined before and after iv
infusion.
[0206] Mouse or Primate Diuresis Experiment: Once an appropriate
level of anesthesia has been achieved, a sterile polyurethane
catheter is inserted into the urethra and secured using 1-2 drops
of veterinary bond adhesive applied to urethra/catheter junction.
Animals are then dosed with either vehicle or test article via the
intravenous or intraperitoneal route. Animals are allowed to regain
consciousness, and the volume of urine excreted over a 1-5 hour
duration is recorded periodically for each rat.
Sequence CWU 1
1
34116PRTArtificial SequenceChemically synthesized GCRA peptide 1Asn
Asp Glu Cys Glu Leu Cys Val Asn Val Ala Cys Thr Gly Cys Leu 1 5 10
15 216PRTArtificial SequenceChemically syntheiszed GCRA peptide
2Xaa Asp Glu Cys Glu Leu Cys Val Asn Val Ala Cys Thr Gly Cys Xaa 1
5 10 15 316PRTArtificial SequenceChemically synthesized GCRA
Peptide 3Xaa Asp Glu Cys Glu Leu Cys Val Asn Val Ala Cys Thr Gly
Cys Xaa 1 5 10 15 416PRTArtificial SequenceChemically synthesized
GCRA peptide 4Xaa Asp Glu Cys Glu Leu Cys Val Asn Val Ala Cys Thr
Gly Cys Xaa 1 5 10 15 516PRTArtificial SequenceChemically
synthesized GCRA peptide 5Xaa Asp Glu Cys Glu Leu Cys Val Asn Val
Ala Cys Thr Gly Cys Xaa 1 5 10 15 616PRTArtificial
SequenceChemically synthesized GCRA peptide 6Xaa Asp Glu Cys Glu
Leu Cys Val Asn Val Ala Cys Thr Gly Cys Xaa 1 5 10 15
716PRTArtificial SequenceChemically synthesized GCRA peptide 7Xaa
Asp Glu Cys Glu Leu Cys Val Asn Val Ala Cys Thr Gly Cys Xaa 1 5 10
15 816PRTArtificial SequenceChemically synthesized GCRA peptide
8Xaa Asp Glu Cys Glu Leu Cys Val Asn Val Ala Cys Thr Gly Cys Xaa 1
5 10 15 95PRTArtificial SequenceChemically synthesized peptide 9Gln
His Asn Pro Arg 1 5 106PRTArtificial SequenceChemically synthesized
peptide 10Val Gln His Asn Pro Arg 1 5 117PRTArtificial
SequenceChemically synthesized peptide 11Val Arg Gln His Asn Pro
Arg 1 5 128PRTArtificial SequenceChemically synthesized peptide
12Val Arg Gly Gln His Asn Pro Arg 1 5 139PRTArtificial
SequenceChemically synthesized peptide 13Val Arg Gly Pro Gln His
Asn Pro Arg 1 5 1410PRTArtificial SequenceChemically synthesized
peptide 14Val Arg Gly Pro Arg Gln His Asn Pro Arg 1 5 10
1511PRTArtificial SequenceChemically synthesized peptide 15Val Arg
Gly Pro Arg Arg Gln His Asn Pro Arg 1 5 10 166PRTArtificial
SequenceChemically synthesized peptide 16Arg Gln His Asn Pro Arg 1
5 175PRTArtificial SequenceChemically synthesized Enkephalin
pentapeptide 17Tyr Xaa Gly Phe Xaa 1 5 184PRTArtificial
SequenceChemically synthesized frakefamide peptide 18Tyr Xaa Phe
Phe 1 1934PRTArtificial SequenceChemically synthesized peptide
19Ile Lys Pro Glu Ala Pro Gly Glu Asp Ala Ser Pro Glu Glu Leu Asn 1
5 10 15 Arg Tyr Tyr Ala Ser Leu Arg His Tyr Leu Asn Leu Val Thr Arg
Gln 20 25 30 Arg Tyr 2027PRTArtificial SequenceChemically
synthesized peptide 20His Ala Glu Gly Thr Phe Thr Ser Asp Val Ser
Tyr Leu Glu Gly Gln 1 5 10 15 Ala Ala Lys Glu Phe Ile Ala Trp Leu
Val Lys 20 25 216PRTArtificial SequenceChemically synthesized
Dooley polypeptide 21Arg Tyr Tyr Xaa Xaa Xaa 1 5 226PRTArtificial
SequenceChemically synthesized peptide 22Lys Tyr Tyr Arg Trp Arg 1
5 236PRTArtificial SequenceChemically synthesized peptide 23Arg Tyr
Tyr Arg Trp Arg 1 5 246PRTArtificial SequenceChemically synthesized
peptide 24Lys Trp Arg Tyr Tyr Arg 1 5 256PRTArtificial
SequenceChemically synthesized peptide 25Arg Tyr Tyr Arg Trp Lys 1
5 266PRTArtificial SequenceChemically synthesized peptide 26Arg Tyr
Tyr Arg Trp Lys 1 5 276PRTArtificial SequenceChemically synthesized
peptide 27Arg Tyr Tyr Arg Ile Lys 1 5 286PRTArtificial
SequenceChemically synthesized peptide 28Arg Tyr Tyr Arg Ile Arg 1
5 296PRTArtificial SequenceChemically synthesized peptide 29Arg Tyr
Tyr Lys Ile Lys 1 5 306PRTArtificial SequenceChemically synthesized
peptide 30Arg Tyr Tyr Lys Ile Arg 1 5 316PRTArtificial
SequenceChemically synthesized peptide 31Arg Tyr Tyr Lys Trp Arg 1
5 326PRTArtificial SequenceChemically synthesized peptide 32Arg Tyr
Tyr Lys Trp Lys 1 5 336PRTArtificial SequenceChemically synthesized
peptide 33Arg Tyr Tyr Arg Trp Arg 1 5 346PRTArtificial
SequenceChemically synthesized peptide 34Lys Tyr Tyr Arg Trp Lys 1
5
* * * * *