U.S. patent application number 14/350050 was filed with the patent office on 2014-12-11 for compositions and methods for treating heart failure.
The applicant listed for this patent is ZENSUN (SHANGHAI) SCIENCE & TECHNOLOGY LTD.. Invention is credited to Mingdong Zhou.
Application Number | 20140364366 14/350050 |
Document ID | / |
Family ID | 48081325 |
Filed Date | 2014-12-11 |
United States Patent
Application |
20140364366 |
Kind Code |
A1 |
Zhou; Mingdong |
December 11, 2014 |
COMPOSITIONS AND METHODS FOR TREATING HEART FAILURE
Abstract
The present invention provides methods for treating chronic
heart failure patients using the medication comprising neuregulin.
The methods comprise first performing a companion diagnostic test
of each patient before treatment; and then providing a suitable
treatment to the patient according to the results of the companion
diagnostic test. When the result of the test is within a favorite
treatment zone, the patient is suitable for heart failure treatment
by administering an effective amount of neuregulin.
Inventors: |
Zhou; Mingdong; (Shanghai,
CN) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
ZENSUN (SHANGHAI) SCIENCE & TECHNOLOGY LTD. |
Shanghai |
|
CN |
|
|
Family ID: |
48081325 |
Appl. No.: |
14/350050 |
Filed: |
October 8, 2012 |
PCT Filed: |
October 8, 2012 |
PCT NO: |
PCT/CN12/01354 |
371 Date: |
April 4, 2014 |
Current U.S.
Class: |
514/9.6 ;
435/7.92; 530/395 |
Current CPC
Class: |
A61K 45/06 20130101;
A61P 31/12 20180101; C07K 14/4756 20130101; A61P 29/00 20180101;
A61K 9/0019 20130101; G01N 33/6893 20130101; A61P 39/02 20180101;
G01N 2800/52 20130101; G01N 2800/325 20130101; A61P 9/10 20180101;
A61K 38/1883 20130101; G01N 2333/58 20130101; A61P 9/04 20180101;
G01N 33/74 20130101 |
Class at
Publication: |
514/9.6 ;
530/395; 435/7.92 |
International
Class: |
A61K 38/18 20060101
A61K038/18; G01N 33/68 20060101 G01N033/68 |
Foreign Application Data
Date |
Code |
Application Number |
Oct 10, 2011 |
CN |
PCT/CN2011/001691 |
Nov 2, 2011 |
CN |
PCT/CN2011/081699 |
Claims
1. A method of treating chronic heart failure, comprising: a)
performing a companion diagnostic test of each patient before
treatment; and b) providing a suitable treatment to the patient
according to the results of the companion diagnostic test.
2. The method of claim 1, wherein the companion diagnostic test is
the NYHA heart function classification.
3. The method of claim 1, wherein the companion diagnostic test is
the test of plasma level of NT-proBNP or BNP.
4. The method of claim 1, wherein the suitable treatment comprising
neuregulin treatment.
5. The method of claim 4, wherein the suitable treatment further
comprising treating heart failure using one or more anti-heart
failure drugs selected from a group consisting of: ACE inhibitors,
.beta.-blockers, ARBs, diuretics, and digitalis.
6. The method of claim 2, wherein said suitable treatment is
administered when the heart function is NYHA class II or III.
7. The method of claims 3, wherein said suitable treatment is
administered when plasma level of NT-proBNP is .ltoreq.4000
fmol/ml.
8. The method of claim 4, wherein the neuregulin is
neuregulin-1.
9. The method of claim 4, wherein the neuregulin protein comprises
of EGF-like domain of neuregulin-1.
10. The method of claim 4, wherein the neuregulin comprises of SEQ
ID NO: 1.
11. Use of neuregulin for the preparation of medications for
treating chronic heart failure patients, wherein the patients have
a plasma NT-proBNP level of .ltoreq.4000 fmol/ml before
treatment.
12-17. (canceled)
18. Use of neuregulin for the preparation of medications for
treating chronic heart failure patients, wherein the patients has a
class II or III heart function as classified by NYHA functional
classification.
19-24. (canceled)
25. A method of treating chronic heart failure comprising
administering neuregulin, wherein the administration of neuregulin
improves the clinical indication of the patient.
26-48. (canceled)
49. A method of selecting a heart failure patient for treatment by
neuregulin, comprises performing a companion diagnostic test before
treatment and decide whether the result of the test is indicative
for the treatment by neuregulin.
50. The method of claim 49, wherein the companion diagnostic test
is measuring the plasma level of NT-proBNP in said patient.
51. The method of claim 50, wherein the result of the test is
indicative for the treatment by neuregulin when the plasma level of
NT-proBNP.ltoreq.4000 fmol/ml.
52. The method of claim 50, wherein the result of the test is
indicative for the treatment by neuregulin when the plasma level of
NT-proBNP is between 1600 fmol/ml and 4000 fmol/ml.
53. The method of claim 50, wherein the result of the test is
indicative for the treatment by neuregulin when the plasma level of
NT-proBNP is .ltoreq.1600 fmol/ml.
54. The method of claim 50, wherein the plasma level is measured by
immunoassay.
55. The method of claim 49, wherein the companion diagnostic test
is evaluating heart function by NYHA heart function
classification.
56. The method of claim 50, wherein the result of the test is
indicative for the treatment by neuregulin when the heart function
is NYHA class II or III.
57. The method of claim 49, wherein the neuregulin is
neuregulin-1.
58. The method of claim 49, wherein the neuregulin protein
comprises of EGF-like domain of neuregulin-1.
59. The method of claim 49, wherein the neuregulin comprises of SEQ
ID NO: 1.
60-62. (canceled)
Description
1. FIELD OF THE INVENTION
[0001] The present invention relates to the use of neuregulin
protein for the preparation of medication for preventing, treating
or delaying heart failure in humans and methods for preventing,
treating or delaying heart failure in humans using said medication.
Particularly, the present invention provides methods for
preventing, treating or delaying heart failure using the medication
comprising a neuregulin protein in specific populations of chronic
heart failure patients.
[0002] 2. BACKGROUND OF THE INVENTION
[0003] Heart failure affects approximately five million Americans,
and more than 550,000 new patients are diagnosed with the condition
each year. Current drug therapy for heart failure is primarily
directed to angiotensin-converting enzyme (ACE) inhibitors, which
are vasodilators that cause blood vessels to expand, lowering blood
pressure and reducing the heart's workload. While the percent
reduction in mortality has been significant, the actual reduction
in mortality with ACE inhibitors has averaged only 3%-4%, and there
are several potential side effects. Additional limitations are
associated with other options for preventing or treating heart
failure. For example, heart transplantation is clearly more
expensive and invasive than drug treatment, and it is further
limited by the availability of donor hearts. Uses of mechanical
devices, such as biventricular pacemakers, are similarly invasive
and expensive. Thus, there has been a need for new therapies given
the deficiencies in current therapies.
[0004] One promising new therapy involves administration of
neuregulin (hereinafter referred to as "NRG") to a patient
suffering from or at risk of developing heart failure. NRGs, a
family of EGF-like growth factors, comprises a family of
structurally related growth and differentiation factors that
include NRG1, NRG2, NRG3 and NRG4 and isoforms thereof, are
involved in an array of biological responses: stimulation of breast
cancer cell differentiation and secretion of milk proteins;
induction of neural crest cell differentiation to Schwann cells;
stimulation of skeletal muscle cell synthesis of acetylcholine
receptors; and, promotion of myocardial cell survival and DNA
synthesis. In vivo studies of neuregulin gene-targeted homozygous
mouse embryos with severe defects in ventricular trabecular
formation and dorsal root ganglia development indicate that
neuregulin is essential for heart and neural development.
[0005] NRGs bind to the EGF receptor family, which comprises EGFR,
ErbB2, ErbB3 and ErbB4, each of which plays an important role in
multiple cellular functions, including cell growth, differentiation
and survival. They are protein tyrosine kinase receptors,
consisting of an extracellular ligand-binding domain, transmembrane
kinase domain and cytoplasmic tyrosine kinase domain. After NRG
bind to the extracellular domain of ErbB3 or ErbB4, it induces a
conformational change that leads to heterodimer formation between
ErbB3, ErbB4 and ErbB2 or homodimer formation between ErbB4 itself,
which results in phosphorylation of the receptor's C-terminal
domain inside the cell membrane. The phosphorylated intracellular
domain then binds additional signal proteins inside the cell,
activating the corresponding downstream AKT or ERK signaling
pathway, and inducing a series of cell reactions, such as
stimulation or depression of cell proliferation, cell
differentiation, cell apoptosis, cell migration or cell adhesion.
Among these receptors, mainly ErbB2 and ErbB4 are expressed in the
heart.
[0006] It has been shown that the EGF-like domains of NRG-1,
ranging in size from 50 to 64-amino acids, are sufficient to bind
to and activate these receptors. Previous studies have shown that
neuregulin-1.beta. (NRG-1.beta.) can bind directly to ErbB3 and
ErbB4 with high affinity. The orphan receptor, ErbB2, can form
heterdimer with ErbB3 and ErbB4 with higher affinity than ErbB3 or
ErbB4 homodimers. Research in neural development has indicated that
the formation of the sympathetic nervous system requires an intact
NRG-1.beta.. ErbB2 and ErbB3 signaling system. Targeted disruption
of the NRG-1.beta. or ErbB2 or ErbB4 led to embryonic lethality due
to cardiac development defects. Recent studies also highlighted the
roles of NRG-1.beta., ErbB2 and ErbB4 in the cardiovascular
development as well as in the maintenance of adult normal heart
function. NRG-1.beta. has been shown to enhance sarcomere
organization in adult cardiomyocytes. The administration of a
recombinant NRG-1.beta. EGF-like domain significantly improves or
protects against deterioration in myocardial performance in
distinct animal models of heart failure as well as in clinical
trials. These results make NRG-1 promising as a lead compound for
the treatment of heart failure. However, there is still a need for
more evidences of whether NRG-1 treatment can provide long-term
benefits to the heart failure patients and whether the benefits can
be provided to all chronic heart failure patients or some
subpopulations.
3. SUMMARY OF THE INVENTION
[0007] In human clinical trials of neuregulin for treating heart
failure, applicant discovered that evaluating New York Heart
Association (NYHA) heart function classification or measuring
plasma level of NT-proBNP or BNP in patients allows the selection
of heart failure patients who will receive significant treatment
benefits from neuregulin. Such benefits include significant
reduction in mortality rate.
[0008] It has been discovered by applicant that NRG enhances
cardiac muscle cell differentiation and organization of sarcomeric
and cytoskeleton structure, as well as cell adhesion. It has been
also discovered by applicant that that NRG significantly improves
or protects against deterioration in myocardial performance in
distinct animal models of heart failure and in clinical trials.
Neuregulin, neuregulin polypeptide, neuregulin derivatives, or
compounds which mimic the activities of neuregulins, fall within
the scope of the present invention.
[0009] Thus, in a first aspect of the invention, a pharmaceutical
composition comprise an effective amount of neuregulin is provided
for treating chronic heart failure patients, and the patients
received significant benefits from the pharmaceutical composition.
In some embodiments, the benefit is significant reduction of
mortality rate. In some embodiments, the benefit is significant
reduction of rehospitalization. In some embodiments, the benefit is
the improvement of the biomarkers levels which indicate the
improvement of chronic heart failure. In some embodiments, the
pharmaceutical composition is administered to the patients for an
introduction regimen. In some optimized embodiments, the
introduction regimen includes an administration of the
pharmaceutical composition for at least consecutive 3, 5, 7 or 10
days. In some optimized embodiments, the pharmaceutical composition
is administered to the patients for a maintenance regimen for at
least 3, 6 or 12 months after the introduction regimen. In some
optimized embodiments, the maintenance regimen includes
administration of the pharmaceutical composition every 3, 5, 7 or
10 days.
[0010] In a second aspect, the invention provides a method to
improve survival or reduce mortality of chronic heart failure
patients, comprising administering a pharmaceutical composition
comprising an effective amount of neuregulin to the chronic heart
failure patients. In some embodiments, the pharmaceutical
composition is administered to the patients for an introduction
regimen. In some optimized embodiments, the introduction regimen
includes administration of the pharmaceutical composition for at
least consecutive 3, 5, 7 or 10 days. In some optimized
embodiments, the pharmaceutical composition is administered to the
patients for a maintenance regimen for at least 3, 6 or 12 months
after the introduction regimen. In some optimized embodiments, the
maintenance regimen includes an administration of the
pharmaceutical composition every 3, 5, 7 or 10 days.
[0011] In a third aspect of the invention, a pharmaceutically
effective amount of neuregulin is used for treating chronic heart
failure patients whose plasma level of NT-proBNP is within a
favorite treatment zone prior to neuregulin treatment. In one
embodiment, the favorite treatment zone is no more than 4000
fmol/ml. In another embodiment, the favorite treatment zone is
between 1600 fmol/ml and 4000 fmol/ml. In yet another embodiment,
the favorite treatment zone is no more than 1600 fmol/ml. In
another preferred embodiment, the plasma level is measured by
immunoassay.
[0012] In a fourth aspect of the invention, a pharmaceutically
effective amount of neuregulin is used for treating chronic heart
failure patients who has a specific class of heart function
classified by NYHA heart function classification. In some
embodiments, the specific class of heart function is NYHA class II.
In some embodiments, the specific class of heart function is NYHA
class III.
[0013] In a fifth aspect, the invention features a method of
selecting a heart failure patient for treatment by neuregulin. This
method comprises measuring the plasma level of NT-proBNP in the
patient. In one embodyment, a level of no more than 4000 fmol/ml is
indicative of the patient being suitable for heart failure
treatment by neuregulin. In another embodiment, a level of between
1600 fmol/ml and 4000 fmol/ml is indicative of the patient being
suitable for heart failure treatment by neuregulin. In yet another
embodiment, a level of no more than 1600 fmol/ml is indicative of
the patient being suitable for heart failure treatment by
neuregulin.
[0014] In a sixth aspect, the invention features a method of
selecting a heart failure patient for treatment by neuregulin. This
method comprises evaluating heart function class by NYHA heart
function classification. In one embodiment, NYHA class II is
indicative of the patient being suitable for heart failure
treatment by neuregulin. In another embodiment, NYHA class III is
indicative of the patient being suitable for heart failure
treatment by neuregulin.
[0015] In a seventh aspect, the invention features a diagnostic
kits for selecting a heart failure patient for treatment by
neuregulin. In one embodiment, the diagnostic kits comprises
immunoassay reagents to measure plasma level of NT-proBNP in a
heart failure patient wherein a level of no more than 4000 fmol/ml
is indicative of the patient being suitable for heart failure
treatment by neuregulin. In another embodiment, a level of between
1600 fmol/ml and 4000 fmol/ml is indicative of the patient being
suitable for heart failure treatment by neuregulin. In yet another
embodiment, a level of no more than 1600 fmol/ml is indicative of
the patient being suitable for heart failure treatment by
neuregulin.
[0016] In a eighth aspect of the invention, the use of neuregulin
protein for preparation of a medication was provided. The
medication can be provided to chronic heart failure patients for
long-term benefits. In one embodiment, the long-term benefit is the
improvement of survival. In one embodiment, the long-term benefit
is the reduction of re-hospitalization. In another embodiment, the
long-term benefit is the improvement of biomarkers which indicate
the long-term prognosis of chronic heart failure. In some
embodiments, the medication is administered to the patients for an
introduction regimen. In some optimized embodiments, the
introduction regimen includes administration of medication for at
least consecutive 3, 5, 7 or 10 days. In some optimized
embodiments, the medication is administered to the patients for a
maintenance regimen for at least 3, 6 or 12 months after the
introduction regimen. In some optimized embodiments, the
maintenance regimen includes an administration of the medication
every 3, 5, 7 or 10 days.
[0017] In a ninth aspect of the invention, a companion diagnostic
test was provided for the treatment of chronic heart failure by
neuregulin protein. N-terminal pro-brain natriuretic peptide
(NT-proBNP) is used as a biomarker for the companion diagnostic
test. In one embodiment, a level of no more than 4000 fmol/ml is
indicative of the patient being suitable for heart failure
treatment by neuregulin. In another embodiment, a level of between
1600 fmol/ml and 4000 fmol/ml is indicative of the patient being
suitable for heart failure treatment by neuregulin. In yet another
embodiment, a level of no more than 1600 fmol/ml is indicative of
the patient being suitable for heart failure treatment by
neuregulin.
[0018] In a tenth aspect of the invention, a method of treating
chronic heart failure using neuregulin is provided. The method
comprises an evaluation procedure before treatment and decides
whether each patient is suitable to receive neuregulin treatment
according to the result of the evaluation. In one embodiment, the
evaluation procedure includes NYHA heart function classification of
a chronic heart failure patient. In another embodiment, the
evaluation procedure includes test of plasma NT-proBNP or BNP for
each chronic heart failure patient.
[0019] In a eleventh aspect of the invention, a companion
diagnostic kit for deciding whether a chronic heart failure patient
is suitable for receiving neuregulin protein treatment is provided.
The companion diagnostic kit comprises a test kit for plasma
NT-proBNP or BNP and an instruction of how to use the kit and how
to judge whether the subject is suitable for neuregulin protein
treatment according to the test result.
4. DETAILED DESCRIPTION OF THE INVENTION
[0020] For clarity of disclosure, and not by way of limitation, the
detailed description of the invention hereinafter is divided into
the subsections that follow. All publications mentioned herein are
incorporated by reference to disclose and describe the methods
and/or materials in connection with which the publications are
cited.
A. DEFINITIONS
[0021] Unless defined otherwise, all technical and scientific terms
used herein have the same meaning as is commonly understood by one
of ordinary skill in the art to which this invention belongs. All
patents, applications, published applications and other
publications referred to herein are incorporated by reference in
their entirety. If a definition set forth in this section is
contrary to or otherwise inconsistent with a definition set forth
in the patents, applications, published applications and other
publications that are herein incorporated by reference, the
definition set forth in this section prevails over the definition
that is incorporated herein by reference.
[0022] As used herein, the singular forms "a", "an", and "the" mean
"at least one" or "one or more" unless the context clearly dictates
otherwise.
[0023] As used herein, "neuregulin" or "NRG" used in the present
invention refers to proteins or peptides that can bind and activate
ErbB2, ErbB3, ErbB4 or combinations thereof, including but not
limited to all neuregulin isoforms, neuregulin EGF-like domain
alone, polypeptides comprising neuregulin EGF-like domain,
neuregulin mutants or derivatives, and any kind of neuregulin-like
gene products that also activate the above receptors as described
in detail below. Neuregulin also includes NRG-1, NRG-2, NRG-3 and
NRG-4 proteins, peptides, fragments and compounds that mimic the
activities of neuregulin. Neuregulin used in the present invention
can activate the above ErbB receptors and modulate their biological
reactions, e.g., stimulate acetylcholine receptor synthesis in
skeletal muscle cell; and/or improve cardiocyte differentiation,
survival and DNA synthesis. Neuregulin also includes those variants
with conservative amino acid substitutions that do not
substantially alter their biological activity. Suitable
conservative substitutions of amino acids are known to those of
skill in this art and may be made generally without altering the
biological activity of the resulting molecule. Those of skill in
this art recognize that, in general, single amino acid
substitutions in non-essential regions of a polypeptide do not
substantially alter biological activity (see, e.g., Watson et al.,
Molecular Biology of the Gene, 4.sup.th Edition, 1987, The
Bejacmin/Cummings Pub. co., p. 224). In preferred embodiments,
neuregulin used in the present invention binds to and activates
ErbB2/ErbB4 or ErbB2/ErbB3 heterodimers, for example, but not for
the purpose of restriction, peptides including the 177-237 residues
of NRG-1 .beta.2 isoform containing the amino acid sequence:
SHLVKCAEKEKTFCVNGGECF MVKDLSNPSRYLCKCPNEFTGDRCQNYVMASFYKAEELYQ (SEQ
ID NO:1). The peptides including the 177-237 residues of NRG-1
.beta.2 isoform comprises the EGF-like domain, which has been
proved to be sufficient to bind to and activate the receptors.
[0024] As used herein, "epidermal growth factor-like domain" or
"EGF-like domain" refers to a polypeptide motif encoded by the
neuregulin gene that binds to and activates ErbB2, ErbB3, ErbB4, or
combinations thereof, and bears a structural similarity to the EGF
receptor-binding domain as disclosed in WO 00/64400, Holmes et al.,
Science, 256:1205-1210 (1992); U.S. Pat. Nos.5,530,109 and
5,716,930; Hijazi et al., Int. J. Oncol., 13:1061-1067 (1998);
Chang et al., Nature, 387:509-512 (1997); Carraway et al., Nature,
387:512-516 (1997); Higashiyama et al., J. Biochem., 122:675-680
(1997); and WO 97/09425, the contents of which are all incorporated
herein by reference. In certain embodiments, EGF-like domain binds
to and activates ErbB2/ErbB4 or ErbB2/ErbB3 heterodimers. In
certain embodiments, EGF-like domain comprises the amino acid
sequence of the receptor binding domain of NRG-1. In some
embodiments, EGF-like domain comprises the amino acid sequence
corresponding to amino acid residues 177-226, 177-237, or 177-240
of NRG-1. In certain embodiments, EGF-like domain comprises the
amino acid sequence of the receptor binding domain of NRG-2. In
certain embodiments, EGF-like domain comprises the amino acid
sequence of the receptor binding domain of NRG-3. In certain
embodiments, EGF-like domain comprises the amino acid sequence of
the receptor binding domain of NRG-4. In certain embodiments,
EGF-like domain comprises the amino acid sequence of Ala Glu Lys
Glu Lys Thr Phe Cys Val Asn Gly Gly Glu Cys Phe Met Val Lys Asp Leu
Ser Asn Pro, as described in U.S. Pat. No.5,834,229.
[0025] The formulation, dosage and route of administration of a
neuregulin protein, preferably in the form of pharmaceutical
compositions, can be determined according to the methods known in
the art (see e.g., Remington: The Science and Practice of Pharmacy,
Alfonso R. Gennaro (Editor) Mack Publishing Company, April 1997;
Therapeutic Peptides and Proteins: Formulation, Processing, and
Delivery Systems, Banga, 1999; and Pharmaceutical Formulation
Development of Peptides and Proteins, Hovgaard and Frkjr (Ed.),
Taylor & Francis, Inc., 2000; Medical Applications of
Liposomes, Lasic and Papahadjopoulos (Ed.), Elsevier Science, 1998;
Textbook of Gene Therapy, Jain, Hogrefe & Huber Publishers,
1998; Adenoviruses: Basic Biology to Gene Therapy, Vol. 15, Seth,
Landes Bioscience, 1999; Biopharmaceutical Drug Design and
Development, Wu-Pong and Rojanasakul (Ed.), Humana Press, 1999;
Therapeutic Angiogenesis: From Basic Science to the Clinic, Vol.
28, Dole et al. (Ed.), Springer-Verlag New York, 1999).
[0026] The neuregulin protein, can be formulated for oral, rectal,
topical, inhalational, buccal (e.g., sublingual), parenteral (e.g.,
subcutaneous, intramuscular, intradermal, or intravenous),
transdermal administration or any other suitable route of
administration. The most suitable route in any given case will
depend on the nature and severity of the condition being treated
and on the nature of the particular neuregulin protein, which is
being used. The neuregulin protein can be administered alone.
Alternatively and preferably, the neuregulin protein is
co-administered with a pharmaceutically acceptable carrier or
excipient. Any suitable pharmaceutically acceptable carrier or
excipient can be used in the present method (See e.g., Remington:
The Science and Practice of Pharmacy, Alfonso R. Gennaro (Editor)
Mack Publishing Company, April 1997).
[0027] According to the present invention, the neuregulin protein,
alone or in combination with other agents, carriers or excipients,
may be formulated for any suitable administration route, such as
intracavernous injection, subcutaneous injection, intravenous
injection, intramuscular injection, intradermal injection, oral or
topical administration. The method may employ formulations for
injectable administration in unit dosage form, in ampoules or in
multidose containers, with an added preservative. The formulations
may take such forms as suspensions, solutions or emulsions in oily
or aqueous vehicles, and may contain formulatory agents such as
suspending, stabilizing and/or dispersing agents. Alternatively,
the active ingredient may be in powder form for constitution with a
suitable vehicle, sterile pyrogen-free water or other solvents,
before use. Topical administration in the present invention may
employ the use of a foam, gel, cream, ointment, transdermal patch,
or paste.
[0028] Pharmaceutically acceptable compositions and methods for
their administration that may be employed for use in this invention
include, but are not limited to those described in U.S. Pat. Nos.
5,736,154; 6,197,801 B1; 5,741,511; 5,886,039; 5,941,868; 6,258,374
B1; and 5,686,102.
[0029] The magnitude of a therapeutic dose in the treatment or
prevention will vary with the severity of the condition to be
treated and the route of administration. The dose, and perhaps dose
frequency, will also vary according to age, body weight, condition
and response of the individual patient.
[0030] It should be noted that the attending physician would know
how to and when to terminate, interrupt or adjust therapy to lower
dosage due to toxicity, or adverse effects. Conversely, the
physician would also know how to and when to adjust treatment to
higher levels if the clinical response is not adequate (precluding
toxic side effects).
[0031] Any suitable route of administration may be used. Dosage
forms include tablets, troches, cachet, dispersions, suspensions,
solutions, capsules, patches, and the like. See, Remington's
Pharmaceutical Sciences. In practical use, the neuregulin protein,
alone or in combination with other agents, may be combined as the
active in intimate admixture with a pharmaceutical carrier or
excipient, such as beta-cyclodextrin and
2-hydroxy-propyl-beta-cyclodextrin, according to conventional
pharmaceutical compounding techniques. The carrier may take a wide
form of preparation desired for administration, topical or
parenteral. In preparing compositions for parenteral dosage form,
such as intravenous injection or infusion, similar pharmaceutical
media may be employed, water, glycols, oils, buffers, sugar,
preservatives, liposomes, and the like known to those of skill in
the art. Examples of such parenteral compositions include, but are
not limited to dextrose 5% wlv, normal saline or other solutions.
The total dose of the neuregulin protein, alone or in combination
with other agents to be administered may be administered in a vial
of intravenous fluid, ranging from about 1 ml to 2000 ml. The
volume of dilution fluid will vary according to the total dose
administered.
[0032] The invention also provides for kits for carrying out the
therapeutic regimens of the invention. Such kits comprise in one or
more containers therapeutically effective amounts of the neuregulin
protein, alone or in combination with other agents, in
pharmaceutically acceptable form. Preferred pharmaceutical forms
would be in combination with sterile saline, dextrose solution, or
buffered solution, or other pharmaceutically acceptable sterile
fluid. Alternatively, the composition may be lyophilized or
desiccated; in this instance, the kit optionally further comprises
in a container a pharmaceutically acceptable solution, preferably
sterile, to reconstitute the complex to form a solution for
injection purposes. Exemplary pharmaceutically acceptable solutions
are saline and dextrose solution.
[0033] In another embodiment, a kit of the invention further
comprises a needle or syringe, preferably packaged in sterile form,
for injecting the composition, and/or a packaged alcohol pad.
Instructions are optionally included for administration of
composition by a physician or by the patient.
[0034] As used herein, "treat", "treatment" and "treating" refer to
any manner in which the symptoms of a condition, disorder or
disease are ameliorated or otherwise beneficially altered. The
effect may be prophylactic in terms of completely or partially
preventing a disease or symptom thereof and/or may be therapeutic
in terms of a partial or complete cure for a disease and/or adverse
effect attributable to the disease. Treatment also encompasses any
pharmaceutical use of the compositions herein.
[0035] As used herein, "heart failure" means an abnormality of
cardiac function where the heart does not pump blood at the rate
needed for the requirements of metabolizing tissues. Heart failure
includes a wide range of disease states such as congestive heart
failure, myocardial infarction, tachyarrhythmia, familial
hypertrophic cardiomyopathy, ischemic heart disease, idiopathic
dilated cardiomyopathy, myocarditis and the like. The heart failure
can be caused by any number of factors, including, without
limitation, ischemic, congenital, rheumatic, viral, toxic or
idiopathic forms. Chronic cardiac hypertrophy is a significantly
diseased state which is a precursor to congestive heart failure and
cardiac arrest.
[0036] As used herein, "protein" is synonymous with "polypeptide"
or "peptide" unless the context clearly dictates otherwise.
[0037] As used herein, "plasma" is synonymous with "serum" unless
the context clearly dictates otherwise.
[0038] As used herein, "long-term benefit" means benefit caused by
a treatment or interference which may not be observed in a short
period after the treatment or interference. For chronic heart
failure patients, long-term benefit may be improvement of survival,
reduction of re-hospitalization or improvement of biomarkers which
indicate the long-term prognosis. In some embodiments, the time
period for observation of the benefit is about 6 months. In some
embodiments, the time period for observation of the benefit is
about 1 year. In some embodiments, the time period for observation
of the benefit is about 2 years. And in other embodiments, the time
period for observation of the benefit is about 3 years, 5 years, 10
years or longer.
[0039] As used herein, "survival" means the time or probability one
subject may remain alive or living. It could be expressed by
survival time or survival rate. Survival time is the time period
start from the diagnosis or treatment to the end of the life.
Survival rate means the percentage of people who are alive for a
given period of time after diagnosis or treatment. For each
subject, prolonged survival time caused by a treatment or
interference could be regarded as a benefit. For a group of
subjects or large populations, prolonged mean survival time or
increased survival rate could be regarded as a benefit.
[0040] As used herein, "re-hospitalization" means the times or
frequency of the patient admitted to the hospital in a given period
of time. The admission to the hospital may be caused by all
conditions, or only caused by the same condition which is being
treated. For each subject, a reduction of times of
re-hospitalizations in a given period of time could be regarded as
a benefit. And for a group of subjects or large populations, a
reduction of total times or mean times of re-hospitalizations could
be regarded as a benefit.
[0041] As used herein, "N-terminal brain natriuretic peptide" or
"NT-proBNP" means the inactive remnant N-terminal proBNP, the
latter is the pro hormone of BNP which is a hormonally active
natriuretic peptide that is mainly released from the cardiomyocytes
in the left ventricular wall. In reaction to stretch and tension of
the myocardial wall the pro hormone proBNP splits into BNP and the
hormonally inactive remnant NT-proBNP by proteolytic cleavage.
[0042] BNP and NT-proBNP plasma levels are promising tools in the
daily management of suspected or established heart failure. Most
studies on the use of BNP and NT-proBNP in clinical practice
addressed their diagnostic properties, and an increasingly amount
of evidence is available supporting the prognostic value of BNP and
NT-proBNP. As NT-proBNP has about 6 times longer of half-life in
the blood than BNP, it is more widely used as a diagnostic or
prognostic marker for heart failure. The plasma NT-proBNP level can
be analyzed by commercial kits. For the purpose of example, but not
limitation, the commercial kits from Roche or Biomedica. In the
examples of the present invention, the NT-proBNP level was detected
by kit from Biomedica (Austria).
[0043] Both BNP and NT-proBNP levels in the blood are used for
screening, diagnosis of heart failure and are useful to establish
prognosis in heart failure, as both markers are typically higher in
patients with worse outcome. And, it is discovered in the present
invention that plasma level of BNP or NT-proBNP is indicative of
the patient being suitable for heart failure treatment by
neuregulin. In fact, any diagnostic or prognostic markers for heart
failure can be used to determine whether a patient is suitable for
heart failure treatment by neuregulin. The plasma level of
NT-proBNP identified in this invention shall be used as guidance
rather than a limitation for selection of heart failure patients
who will receive significant treatment benefits from neuregulin.
For example, using a plasma level of 5000 fmol/ml is still able to
select heart failure patients who will receive treatment benefits
from neuregulin, but some of these patients will receive treatment
benefits in a lesser degree.
[0044] As used herein, "New York Heart Association" or "NYHA" heart
function classification is a simple way of classifying the extent
of heart failure. It places patients in one of four categories
based on how much they are limited during physical activity; the
limitations/symptoms are in regards to normal breathing and varying
degrees in shortness of breath and/or angina pain: I, no symptoms
and no limitation in ordinary physical activity, e.g. shortness of
breath when walking, climbing stairs etc.; II, mild symptoms (mild
shortness of breath and/or angina) and slight limitation during
ordinary activity; III, marked limitation in activity due to
symptoms, even during less-than-ordinary activity, e.g. walking
short distances (20-100 m), comfortable only at rest; and IV,
severe limitations, experiences symptoms even while at rest, mostly
bedbound patients.
[0045] As used herein, "activity unit" or "EU" or "U" means the
quantity of standard product that can induce 50% maximal reaction.
In other words, to determine the activity unit for a given active
agent, the EC50 must be measured. For example, if the EC50 for a
batch of product was 0.1 .mu.g, which would be one unit. Further,
if 1 .mu.g of that product is being used, then 10 EU (1/0.1) is
being used. The EC50 can be determined by any method known in the
art, including the method employed by the inventors. This
determination of the activity unit is important for quality control
of genetically engineered products and clinically used drugs,
permits product from different pharmaceuticals and/or different
batch numbers to be quantified with uniform criteria.
[0046] The following is an exemplary, rapid, sensitive, high flux
and quantitative method for determination of biological activity of
NRG-1 through combining NRG with cell surface ErbB3/ErbB4 molecule
and indirect mediation of ErbB2 phosphorylation (See e.g., Michael
D. Sadick et al., 1996, Analytical Biochemistry, 235:207-214 and
WO03/099300).
[0047] Briefly, the assay, termed a kinase receptor activation
enzyme-linked immunosorbant assay (KIRA-ELISA), consists of two
separate microtiter plates, one for cell culture, ligand
stimulation, and cell lysis/receptor solubilization and the other
plate for receptor capture and phosphotyrosine ELISA. The assay was
developed for analysis of NRG-induced ErbB2 activation and utilizes
the stimulation of intact receptor on the adherent breast carcinoma
cell line, MCF-7. Membrane proteins are solubilized via Triton
X-100 lysis and the receptor is captured in ELISA wells coated with
ErbB2-specific antibodies with no cross-reaction to ErbB3 or ErbB4.
The degree of receptor phosphorylation is then quantified by
antiphosphotyrosine ELISA. A reproducible standard curve is
generated with a EC50 of approximately 360 pM for heregulin beta I
(177-244). When identical samples of HRG beta 1 (177-244) are
analyzed by both the KIRA-ELISA and quantitative
antiphosphotyrosine Western Blot analysis, the results correlate
very closely with one another. The assay described in this report
is able to specifically quantify tyrosine phosphorylation of ErbB2
that results from the interaction of HRG with ErbB3 and/or
ErbB4.
[0048] Since most of the genetically engineered medicines are
proteins and polypeptides, their activity can be determined by
their amino acid sequences or the activity center formed by their
spatial structure. Activity titer of protein and polypeptide is not
consistent with their absolute quality, therefore cannot be
determined with weight unit as that of chemical drugs. However,
biological activity of genetically engineered medicines is
generally consistent with their pharmacodynamics and titer
determination system established through given biological activity
can determine its titer unit. Therefore, biological activity
determination can be part of a titration process of the substance
with biological activity and is an important component of quality
control of genetically engineered product. It is important to
determine biological activity criteria for quality control of
genetically engineered product and clinically used drugs.
[0049] Quantity of standard product that can induce 50% maximal
reaction is defined as an activity unit (1 EU). Accordingly,
product from different pharmaceuticals and of different batch
numbers can be quantitated with uniform criteria.
B. EXAMPLES
Example 1
The effect of Neucardin.TM. Administration by Different Routes on
the Survival Rate of Rats with CHF
[0050] Introduction:
[0051] In this study, we used a coronary artery ligation (CAL)
induced CHF model to investigate whether administration of
Neucardin.TM. by IV drip using a micro-injection pump or by
subcutaneous (SC) bolus had any effects on survival rate and
cardiac hemodynamics, 120 days after the initiation of
administration of Neucardin.TM. 4 weeks after CAL. Echocardiography
and cardiac remodeling were also used to determine cardiac function
and recovery from CAL.
[0052] 2. Methods:
[0053] 2.1. Test animals:
[0054] Strain, Origin: Wistar rats, Shanghai SLAC Laboratory Animal
CO. LTD; Weight, 200.+-.10 g, male;
[0055] 2.2 Test article:
[0056] 2.2.1 Neucardin.TM.
[0057] Identification: Recombinant human neuregulin-1 for injection
(rhNRG-1, Neucardin.TM.)
[0058] Lot Number: 200607009
[0059] Manufacturer: Zensun (Shanghai) Sci & Tech Co., Ltd
[0060] Dose form: Lyophilized powder
[0061] Appearance: White or off-white cake
[0062] Labeled Content of rhNRG-1: 250 .mu.g/vial
[0063] Specific activity: 4897 U/vial
[0064] Storage conditions: 2-8.degree. C.
[0065] 2.2.2 Vehicle:
[0066] Identification: Placebo for recombinant human
neuregulin-1
[0067] Dose form: Lyophilized powder
[0068] Appearance: White or off-white cake
[0069] Composition: Human serum albumin, mannitol, phosphate,
NaCl
[0070] Storage conditions: 2-8.degree. C.
[0071] 2.3 Procedure:
[0072] 2.3.1 To establish the rat CHF model:
[0073] The LAD of the rats was ligated. Briefly, the rats were
anesthetized with ketamine hydrochloride (100 mg/kg, IP) and their
chest was shaved and sterilized. The rats were endotracheally
intubated and mechanically ventilated with room air (respiratory
rate 60 breaths/min, tidal volume 20 ml). A left thoracotomy was
then performed at the 4th and 5th intercostal space and then the
skin was incised along the left sternal border. The fourth rib was
then cut proximal to the sternum. The pericardial sac was
perforated and the heart was exposed. The LAD was ligated
approximately 2 mm from its origin using a 6-0 silk suture.
Subsequently, the air within the thorax was removed and the chest
was closed in three layers (ribs, muscles and then skin). The rats
were then allowed to resume spontaneous respiration, recover from
the anesthesia and were then returned to their cages. Rats were
maintained during a period of 4 weeks, then echocardiography
evaluated, included in the formal study if they were shown an EF %
value of 30-45%. Animals from all Groups were housed 5 per cage,
fed ad libitum with standard diet and had free access to pure
water. Room temperature was maintained at 21.+-.1.degree. C. and in
al 2 h light/dark cycle.
[0074] 2.3.2 IV Drip via Microinjection Pump:
[0075] The method of IV drip of vehicle or Neucardin.TM. was
through the tail vein. For this procedure, an appropriate rat
restrainer was used according to the weight of the animal. The rat
was placed near the restrainer and was gently placed into the
apparatus. Normally the rats entered the restrainer without aid.
Subsequently the tail of the rat was swabbed with a gauze dampened
with alcohol to increase blood flow to the tail vein and to the
intenerate skin corneum. The two lateral (on the side) tail veins
were located and with the bevel of the needle facing upward with
the needle almost parallel to the vein, the needle was inserted 2
mm into the tail vein 2-3 cm from the end of the tail. To confirm
that the needle was successfully inserted into the tail vein, blood
was extracted into the hub of the needle. The needle was fixed into
the tail using medical tape. The infusion of drug or vehicle at the
appropriate rate (0.2-0.4 ml/h) by microinjection pump or bolus
injection was initiated.
[0076] 2.3.3 SC Bolus
[0077] The SC bolus of vehicle or Neucardin.TM. was from the back
of the rat. For this procedure, an appropriate rat restrainer was
used according to the weight of the animal. The back of the rat was
swabbed with gauze dampened with alcohol to sterilize the skin.
With the bevel of the needle facing upward with the needle almost
parallel to the skin, the needle was subcutaneously inserted 3-4 cm
into the back of the rat. The needle was fixed onto the back using
medical tape and connected to the perfusion tube. Then, the rat was
placed near the restrainer and was gently placed into the
apparatus. Normally the rats entered the restrainer with no aid.
After fasten the restrainer, the bolus injection was initiated.
[0078] 2.3.4 Experiment Groups and Drug Infusion:
[0079] MI rats were randomized by EF % value into four Groups as
follows:
[0080] Group A (Negative control) for both IV and SC bolus. n=58
rats: IV drip of vehicle for 10-days by micro-injection pump at a
speed of 0.2 ml/h for 8 h each day for the first 10 days, SC bolus
of vehicle (same volume as Neucardin.TM.), every 5days until Day
120;
[0081] Group B (SC bolus Neucardin.TM.), n=58: IV drip of vehicle
by micro-injection pump at a speed of 0.2 ml/h for 8 h each day in
the first 10 days, SC bolus Neucardin.TM. (10.mu.g/day), every 5
days until Day 120;
[0082] Group C (IV drip Neucardin.TM.), n=57: IV drip of
Neucardin.TM. 0.625 m/kg/h) by micro-injection pump at a speed of
0.2 ml/h for 8 h each day for the first 10 days, SC bolus of
vehicle (same volume as Neucardin.TM.), every 5 days until Day
120.
[0083] Group D (IV drip and SC bolus Neucardin.TM.), n=57: IV drip
of Neucardin.TM. (0.625 .mu.g/kg/h) by micro-injection pump at a
rate of 0.2 ml/h for 8 h per day for the first 10 days, SC bolus of
vehicle (same volume as Neucardin.TM.) at 1st, 6th, 11th day, and
then SC bolus Neucardin.TM. (10 .mu.g/kg), every 5 days from 16th
day to the end.
[0084] 2.3.5 Data Acquisition
[0085] Survival rate; Echocardiography parameters; Hemodynamics
parameters;
[0086] 3. Results
[0087] 3.1 Survival rate:
[0088] Table 1 illustrates the survival rates between each Group.
The survival rates were 48.3%, 62.1%, 64.9% and 82.5% in the IV
drip & SC bolus of vehicle Group A, SC bolus of Neucardin.TM.
Group B, IV drip of Neucardin.TM. Group C and IV drip & SC
bolus of Neucardin.TM. Group D, respectively. All the survival rate
or mean survival time of mortalities in Group B, C and D were
improved or prolonged compared to Group A with Group D had best
efficacy.
TABLE-US-00001 TABLE 1 Mortality, Survival rate and Mean survival
time in the four Groups Survival Mean survival tim Start rat rat
Survival mortalities in da Group Treatment number Deaths number
rate (%) S.E. A Vehicle 58 30 28 48.3% 83.8 .+-. 5.9 B SC bolus
Neucardin .TM. 58 22 36 62.1% 91.4 .+-. 5.5 C IV drip Neucardin
.TM. 57 20 37 64.9% 97.5 .+-. 5.1 D SC bolus & IV drip
Neucardin .TM. 57 10 47 82.5% 107.5 .+-. 4.1 indicates data missing
or illegible when filed
[0089] 3.2 Echocardiography Parameters:
[0090] Echocardiography parameters were shown in Table 2.
Four-weeks after coronary artery ligation and before administration
of the test article, the CHF rats were randomized into four Groups
according to their EF% values. As shown in Table 2, there were no
significant differences between the four Groups before treatment
(BT). 120 days after the start of administration, the EF% values
were 30.7.+-.3.1, 32.9.+-.4.1, 33.5.+-.3.4, 36.2.+-.4.8% in the
vehicle, Neucardin.TM. via SC bolus, Neucardin.TM. via IV drip and
Neucardin.TM. via IV drip plus SC bolus Groups, respectively. After
treatment, EF % and FS % of Group B, C and D were all higher than
that of Group A.
TABLE-US-00002 TABLE 2 Echocardiography parameters in the four
Groups BT LVEDd LVEDs EF % FS Group AT N (cm) (cm) (%) (% A.
Negative control BT 58 0.987 .+-. 0.083 0.829 .+-. 0.088 38.0 .+-.
5.5 16.2 .+-. AT 25 1.100 .+-. 0.089 0.961 .+-. 0.090 30.7 .+-. 3.1
12.7 .+-. B. SC bolus Neucardin .TM. BT 58 0.992 .+-. 0.066 0.831
.+-. 0.066 38.2 .+-. 4.0 16.3 .+-. AT 33 1.104 .+-. 0.063 0.952
.+-. 0.070 33.1 .+-. 4.1 13.9 .+-. C. IV drip Neucardin .TM. BT 57
0.985 .+-. 0.061 0.824 .+-. 0.068 38.5 .+-. 4.4 16.3 .+-. AT 36
1.080 .+-. 0.072 0.929 .+-. 0.073 33.4 .+-. 3.4 14.0 .+-. D. SC
bolus & IV drip Neucardin .TM. BT 57 0.979 .+-. 0.065 0.818
.+-. 0.066 38.7 .+-. 4.3 16.5 .+-. AT 44 1.052 .+-. 0.087 0.893
.+-. 0.092 36.2 .+-. 4.8 15.3 .+-. BT: Before treatment; AT: After
treatment; indicates data missing or illegible when filed
[0091] 3.3 Hemodynamic Parameters:
[0092] Table 3 shows the MAP, HR, .+-.dp/dt, LVEDP and LVSP values
as measured in the four Groups of anesthetized animals on day 121.
When Neucardin.TM. was administered by SC bolus or by IV drip alone
(Group B and C), Neucardin.TM. significantly increased dp/dt and
-dp/dt by 19.6% and 27.1%, 22.5% and 29.8% compared to Group A.
When Neucardin.TM. was administered by both IV drip and SC bolus
routes (Group D), significant increases in mean arterial pressure
(MAP, 112.3.+-.5.5 mmHg), left ventricular systolic pressure (LVSP,
139.4+9.8 mmHg), +dp/dt (7012.1.+-.903.0 mmHg/s), -dp/dt
(-4353.2.+-.847.6 mmHg/s) compared to vehicle were obtained.
Interestingly, these values of MAP, LVSP, +dp/dt and -dp/dt were
10.6%, 9.2%, 38.5% and 37.8% higher than vehicle treated rats,
respectively. The results showed that Group B, C and D were all
better than Group A in hemodynamic parameters with Group D had best
efficacy.
TABLE-US-00003 TABLE 3 Hemodynamics parameters in the four Groups
SBP DBP MAP LVSP Group Treatment N (mmHg) (mmHg) (mmHg) (mmHg) A
Vehicle 14 118.7 .+-. 11.5 94.1 .+-. 12.3 102.3 .+-. 11.7 128.5
.+-. 14.7 B SC bolus Neucardin .TM. 27 123.8 .+-. 11.5 95.3 .+-.
8.9 104.9 .+-. 9.5 129.5 .+-. 13.6 C IV drip Neucardin .TM. 25
122.5 .+-. 10.5 95.0 .+-. 7.5 104.4 .+-. 8.2 131.7 .+-. 10.0 D SC
bolus & IV drip Neucardin .TM. 35 132.6 .+-. 7.1 102.1 .+-. 5.3
112.3 .+-. 5.5 139.4 .+-. 9.8 LVEDP dp/dt (-dp/dt) Heart rate Group
Treatment N (mmHg) (mmHg/s) (mmHg/s) (Beat/min) A Vehicle 14 5.8
.+-. 3.5 4995.6 .+-. 532.2 3087.5 .+-. 715.7 297.2 .+-. 16.0 B SC
bolus Neucardin .TM. 27 4.5 .+-. 2.8 6050.9 .+-. 1231.3 4013.8 .+-.
838.3 292.6 .+-. 23.0 C IV drip Neucardin .TM. 25 4.0 .+-. 3.2
6199.9 .+-. 709.5 4098.9 .+-. 823.5 296.3 .+-. 13.5 D SC bolus
& IV drip Neucardin .TM. 35 3.9 .+-. 2.5 7012.1 .+-. 903.0
4353.2 .+-. 847.6 292.5 .+-. 19.1
4. Conclusion
[0093] A combined administration of Neucardin.TM. by IV drip &
SC bolus or administration of the peptide given by each route alone
all increased the survival rate of rats with CHF induced by CAL and
improved cardiac functional parameters compared to rats treated
with vehicle.
Example 2
A Randomized, Double-Blinded, Multi-Center, Placebo Controlled
Study to Evaluate the Efficacy and Safety of Recombinant Human
Neuregulin 1 in Patients with Chronic Heart Failure Based on
Standard Treatment
[0094] To evaluate the efficacy of recombinant human neuregulin-1
for injection on chronic heart failure, a phase II, double-blinded,
multi-center, placebo controlled, standard treatment based study
was carried out in multiple clinical centers in China. A total of
195 patients with NYHA Class II or III stable chronic heart failure
were enrolled and randomized into three groups: placebo, or 0.6
.mu.g/kg and 1.2 .mu.g/kg of rhNRG-1. There were no significant
variations in demographics or background therapies among groups.
According to the schedule, patients were administered the drug for
10 consecutive days in the hospital first, after finishing the day
11 follow up, they were discharged from the hospital. Another two
on site follow up were at day 30 and day 90. A telephone interview
was conducted one year after the last patient enrolled.
[0095] Investigational Product:
[0096] Specification: Neucardin.TM., 61 amino acid polypeptide
comprises the EGF-like domain of Neuregulin-1 .beta.2 isoform, with
the molecular weight of 7054 Dal (1 .mu.g=0.14 nmol). 250 .mu.g
(5000 EU)/vial (1 m=20 EU).
[0097] Preparation: For Injection.
[0098] Mode of administration: Intravenously drip.
[0099] Storage: in safe place, with limited access and protected
from light, at 3-8.degree. C.
[0100] Placebo:
[0101] Specification: Excipient for Neucardin.TM. (250 .mu.g/vial
without active recombinant human neuregulin-1 protein).
[0102] Dosage Groups:
TABLE-US-00004 Dosage 0 .mu.g/kg/day 0.6 .mu.g/kg/day 1.2
.mu.g/kg/day Administration Intravenous infusion Volume 50 ml
Course 10 hours per day, for consecutive 10 days
[0103] Study Procedure
[0104] Criteria for participation in the trial included patients
with CHF (NYHA class II or III) between the ages of 18 and 65 years
old, LVEF .ltoreq.40%, in relatively stable clinical condition
(including clinical signs, symptoms and accepted standard treatment
for CHF at the target dose or maximum tolerance dose for over 1
month). Major exclusion criteria included acute myocardial
infarction, hypertrophic cardiomyopathy, constrictive pericarditis,
significant valve disease or congenital heart disease, severe
pulmonary hypertension, systolic blood pressure <90 mmHg or
>160 mmHg, severe ventricular arrhythmia, cardiac surgery or a
cerebrovascular event within the previous six months,
claustrophobia or pregnant female subjects. All patients provided
witnessed written consent.
[0105] Patients were randomly assigned to three groups, treated
with placebo or rhNRG-1 (0.6 or 1.2 .mu.g/kg/day) for 10
consecutive days, after finishing the day 11 follow up, they were
discharged from the hospital. Another two on site follow up were at
day 30 and day 90. Blood samples of each patient were collected
before treatment and at day 11, 30 and 90. Plasma NT-proBNP was
tested in the core lab with NT-proBNP assays (kit from Biomedica).
One year after the last patient enrolled, the telephone interview
was made for collecting the information of re-hospitalizations, all
telephone interviews were recorded in a special form with
investigators signature.
[0106] Of the 48 patients with available re-hospitalization
information in the placebo group, 12 (25.0%) were rehospitalized
for worsening heart failure at least once. For the 0.6 .mu.g/kg
group, only 4 (8.7%) of the 46 patients readmitted to the hospital
(P=0.05 compared to placebo); Rehopitalization rate of the 1.2
.mu.g/kg group was 22.0% (11/50). The average times of
re-hospitalizations was 0.458 (22/48) per patient in the placebo
group, while they were reduced by 57.4% and 17.0% respectively in
the 0.6 (8/41) and 1.2 .mu.g/kg group (19/50).
[0107] In the placebo group, the NT-proBNP were almost the same
during the study while compare to the baseline. At day 11, the
NT-proBNP was significantly increased in rhNRG-1 treated groups
(from 1853.+-.1512 to 2399.+-.1841 fmol/ml in 0.6 .mu.g/kg group,
P<0.01; from 1562.+-.1275 to 2774.+-.1926 fmol/ml in 1.2
.mu.g/kg group, P<0.01). But his increase was transient and was
not caused by a worsening heart function as the cardiac function
shown to be increased, the NT-proBNP decreased to the baseline
level at Day 30 and Day 90 in the 1.2 .mu.g/kg group. Moreover, in
the 0.6 .mu.g/kg group, the NT-proBNP was significantly reduced at
day 30 (1323.+-.1124 fmol/ml, P=0.01) and day 90 (1518.+-.1403
fmol/ml, P=0.01) while compare to the baseline.
[0108] These results showed that rhNRG-1 treatment can reduce the
re-hospitalizations and the plasma level of NT-proBNP, which may
indicate rhNRG-1 can provide long-term benefits to chronic heart
failure patients.
Example 3
A Randomized, Double-Blinded, Multi-Center, Placebo Controlled
Survival Study of Recombinant Human Neuregulin 1 in Patients with
Chronic Heart Failure Based on Standard Treatment
[0109] To evaluate the efficacy of recombinant human neuregulin-1
for injection on chronic heart failure, a phase II, double-blinded,
multi-center, placebo controlled, standard treatment based study
was carried out in multiple clinical centers in China. A total of
351 patients with NYHA Class III or IV stable chronic heart failure
were enrolled and randomized into placebo group or rhNRG-1 group
(0.6 .mu.g/kg). There were no significant variations in
demographics or background therapies among groups. According to the
schedule, patients were administered with the drug for 10
consecutive days in the hospital, after finishing the day 11 follow
up, they were discharged from the hospital, and were administered
with the drug once weekly from the 3.sup.rd week till the 25.sup.th
week as out-patient. Blood samples of each patient were collected
before treatment (baseline) and at each follow up. Plasma NT-proBNP
level was tested in the core lab with NT-proBNP assays (kit from
Biomedica). The survival information was collected at 52th week of
the study.
[0110] Investigational Product:
[0111] Specification: Neucardin.TM., 61 amino acid polypeptide
comprises the EGF-like domain of Neuregulin-1.beta. isoform, with
the molecular weight of 7054 Dal (1 .mu.g=0.14 nmol). 250 .mu.g
(5000 EU)/vial (1 .mu.g=20 EU).
[0112] Preparation: For Injection.
[0113] Mode of administration: Intravenously drip or infusion.
[0114] Storage: in safe place, with limited access and protected
from light, at 3-8.degree. C.
[0115] Placebo:
[0116] Specification: Excipient for Neucardin.TM.. 250 .mu.g/vial
and without active recombinant human neuregulin-1 protein.
[0117] Dosage and regimens:
TABLE-US-00005 Day 1-10 Week 3-25 Dose 0.6 .mu.g/kg/day rhNRG-1 or
0.8 .mu.g/kg/day rhNRG-1 or placebo placebo Route Intravenous drip
Intravenous infusion regimen 10 hours per day for 10 days 10
minutes infusion weekly
[0118] Criteria for participation in the trial included patients
with CHF (NYHA class III or IV) between the ages of 18 and 80 years
old, LVEF .ltoreq.40%, in relatively stable clinical condition
(including clinical signs, symptoms and accepted standard treatment
for CHF at the target dose or maximum tolerance dose for over 1
month). Major exclusion criteria included acute myocardial
infarction, hypertrophic cardiomyopathy, constrictive pericarditis,
significant valve disease or congenital heart disease, severe
pulmonary hypertension, systolic blood pressure <90 mmHg or
>160 mmHg, severe ventricular arrhythmia, cardiac surgery or a
cerebrovascular event within the previous six months,
claustrophobia or pregnant female subjects. All patients provided
witnessed written consent.
[0119] The all-cause mortality of the placebo group at 52 week is
15.91%, with 28 death in 176 patients, while the number is 9.71% in
rhNRG-1 group, with 16 death in 175 patients completed the trial
(Hazard ratio=0.425, 95% CI 0.222-0.813, p=0.0097). Considering the
mortality caused by cardiovascular events, the number of the
placebo group at 52 week is 14.77%, with 26 death in 176 patients,
and 9.71% in the rhNRG-1 group. So from the results we can find
around 40% decrease of the mortality of rhNRG-1 administration
compared with placebo group, even the placebo group were still
maintain their previous standard treatment for chronic heart
failure.
[0120] We also analyzed the all-cause mortality based on the
stratification of baseline NT-proBNP. When the NT-proBNP level is
stratified into 3 stratums as .ltoreq.1600 fmol/ml, >1600
fmol/ml and .ltoreq.4000 fmol/ml, or >4000fmol/ml, the mortality
of rhNRG-1 group vs placebo group are 1.49% vs 8.49%, 8.96% vs
23.33%, and 26.67% vs 28.00%, respectively. And if the NT-proBNP
level is stratified as .ltoreq.4000 fmol/ml or >4000 fmol/ml,
the mortality of rhNRG-1 group vs placebo group are 5.22% vs 14.89%
(p=0.0092), and 26.67% vs 28.00%, respectively. These results show
statistical significance that rhNRG-1 can effectively improve the
survival of chronic heart failure patients.
[0121] Further, the patients were stratified with their baseline
NYHA heart function class, to be class III or class IV. The
all-cause mortality of class III patients in rhNRG-1 group or
placebo group is 6.06% (8 death in 132 patients) and 15.49% (22
death in 142 patients), respectively, p=0.0189. While the all-cause
mortality of class IV patients in rhNRG-1 group or placebo group is
20.93% (9 death in 43 patients) and 17.65% (6 death in 34
patients), respectively, p=0.7789.
Sequence CWU 1
1
2161PRTHomo sapiens 1Ser His Leu Val Lys Cys Ala Glu Lys Glu Lys
Thr Phe Cys Val Asn 1 5 10 15 Gly Gly Glu Cys Phe Met Val Lys Asp
Leu Ser Asn Pro Ser Arg Tyr 20 25 30 Leu Cys Lys Cys Pro Asn Glu
Phe Thr Gly Asp Arg Cys Gln Asn Tyr 35 40 45 Val Met Ala Ser Phe
Tyr Lys Ala Glu Glu Leu Tyr Gln 50 55 60 223PRTHomo sapiens 2Ala
Glu Lys Glu Lys Thr Phe Cys Val Asn Gly Gly Glu Cys Phe Met 1 5 10
15 Val Lys Asp Leu Ser Asn Pro 20
* * * * *