U.S. patent application number 15/890108 was filed with the patent office on 2018-06-07 for treatment of conditions related to shock.
The applicant listed for this patent is The Regents of the University of California. Invention is credited to Frank A. DeLano, Geert W. Schmid-Schoenbein.
Application Number | 20180153834 15/890108 |
Document ID | / |
Family ID | 40526587 |
Filed Date | 2018-06-07 |
United States Patent
Application |
20180153834 |
Kind Code |
A1 |
Schmid-Schoenbein; Geert W. ;
et al. |
June 7, 2018 |
TREATMENT OF CONDITIONS RELATED TO SHOCK
Abstract
Techniques are disclosed for prevention or treatment of
physiological shock by administering a specific therapeutic agent,
which is able to use smaller volumes of reagent to achieve complete
inhibition, than other previously described techniques.
Inventors: |
Schmid-Schoenbein; Geert W.;
(Del Mar, CA) ; DeLano; Frank A.; (San Diego,
CA) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
The Regents of the University of California |
Oakland |
CA |
US |
|
|
Family ID: |
40526587 |
Appl. No.: |
15/890108 |
Filed: |
February 6, 2018 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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15404002 |
Jan 11, 2017 |
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15890108 |
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15010058 |
Jan 29, 2016 |
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15404002 |
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12681510 |
Aug 9, 2010 |
9272034 |
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PCT/US2008/011529 |
Oct 6, 2008 |
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15010058 |
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60977587 |
Oct 4, 2007 |
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60980430 |
Oct 16, 2007 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A61K 31/195 20130101;
A61K 31/4164 20130101; A61P 31/00 20180101; A61K 31/24 20130101;
A61K 31/201 20130101; A61K 31/197 20130101; A61K 31/546 20130101;
A61K 31/431 20130101; A61K 31/407 20130101; A61K 38/57 20130101;
A61P 5/50 20180101; A61P 43/00 20180101; A61K 31/65 20130101; A61K
31/496 20130101; A61K 31/424 20130101; A61K 31/65 20130101; A61K
2300/00 20130101; A61K 45/06 20130101; A61K 38/38 20130101; A61K
31/337 20130101 |
International
Class: |
A61K 31/195 20060101
A61K031/195; A61K 31/65 20060101 A61K031/65; A61K 45/06 20060101
A61K045/06 |
Goverment Interests
GRANT INFORMATION
[0002] This invention was made with government support under Grant
Nos. HL-10881, HL-067825 and HL-43026 awarded by National
Institutes of Health. The United States government has certain
rights in the invention.
Claims
1. A method for treating or preventing septic shock in an
individual in need thereof, the method comprising administering to
a peritoneum of the individual a therapeutic dose of: (i) a
pancreatic digestive enzyme inhibitor, (ii) a cytotoxic mediator
inhibitor, (iii) an antibacterial agent, or (iv) a combination of
two or more thereof.
2. The method of claim 1, further comprising administering to the
individual a therapeutic dose of an MMP inhibitor.
3. The method of claim 1, wherein the MMP inhibitor is
doxycycline.
4. The method of claim 1, further comprising administering to an
intestine of the individual a therapeutic dose of: (i) a serine
protease inhibitor, (ii) a lipase inhibitor, or (iii) a combination
thereof.
5. The method of claim 1, comprising administering the pancreatic
digestive enzyme inhibitor.
6. The method of claim 5, wherein the pancreatic digestive enzyme
inhibitor is nafamostat mesilate, aprotinin, tranexamic acid,
orlistat, or a combination of two or more thereof
7. The method of claim 6, wherein the pancreatic digestive enzyme
inhibitor is tranexamic acid.
8. A method for treating or preventing septic shock in an
individual in need thereof, the method comprising administering
into a lumen of an intestine of the individual a therapeutic dose
of a serine protease inhibitor.
9. The method of claim 8, wherein the serine protease inhibitor is
nafamostat mesilate, aprotinin, tranexamic acid, or
6-amidino-2-naphthyl p-guanidobenzoate dimethane-sulfate.
10. The method of claim 9, wherein the serine protease inhibitor is
tranexamic acid.
11. The method of claim 8, wherein administering into a lumen of an
intestine comprises oral administration, introduction via an
esophageal catheter, or direct injection into the lumen of the
intestine.
12. The method of claim 8, further comprising administering to the
peritoneal cavity of the individual a therapeutic dose of a
pancreatic digestive enzyme inhibitor.
13. The method of claim 12, wherein the pancreatic digestive enzyme
inhibitor is nafamostat mesilate, aprotinin, tranexamic acid,
orlistat, or a combination of two or more thereof.
14. The method of claim 12, wherein the pancreatic digestive enzyme
inhibitor is a serine protease inhibitor.
15. The method of claim 14, wherein the serine protease inhibitor
is nafamostat mesilate, aprotinin, tranexamic acid, or
6-amidino-2-naphthyl p-guanidobenzoate dimethane-sulfate.
16. The method of claim 15, wherein the serine protease inhibitor
is tranexamic acid.
17. A method for treating or preventing septic shock in an
individual in need thereof, the method comprising administering to
the peritoneum of the individual a therapeutic dose of a serine
protease inhibitor.
18. The method of claim 17, wherein the serine protease inhibitor
is nafamostat mesilate, aprotinin, tranexamic acid, or
6-amidino-2-naphthyl p-guanidobenzoate dimethane-sulfate.
19. The method of claim 18, wherein the serine protease inhibitor
is tranexamic acid.
Description
CROSS REFERENCE TO RELATED APPLICATION(S)
[0001] This application is a continuation of U.S. Ser. No.
15/404,002, filed Jan. 11, 2017, now pending, which is a
continuation of U.S. Ser. No. 15/010,058, filed Jan. 29, 2016, now
abandoned, which is a divisional of U.S. Ser. No. 12/681,510, filed
Aug. 9, 2010, now issued as U.S. Pat. No. 9,272,034, which is a US
national stage application under 35 U.S.C. 371 of International
application No. PCT/US2008/011529, filed Oct. 6, 2008, which claims
priority to U.S. Provisional Patent Application Ser. No.
60/977,587, filed Oct. 4, 2007, and to U.S. Provisional Patent
Application Ser. No. 60/980,430, filed Oct. 16, 2007, the contents
of all of which are hereby incorporated by reference in their
entirety into this disclosure.
BACKGROUND OF THE INVENTION
Field of the Invention
[0003] The present invention relates to treatment of shock. In
particular, the present invention relates to treatment of
conditions related to shock.
Background Information
[0004] Shock is a life-threatening complication in situations
associated with trauma including burns, surgery, ischemia, sepsis,
and other critical care applications. Shock is a broad term that
describes a group of circulatory syndromes, all of which result in
general cellular hypoxia. This leads to a depletion of the
adenosine triphosphate (ATP), the failure of the sodium-potassium
pump, mitochondrial dysfunction, and ultimately the release of a
variety of toxic substances, including superoxides. Superoxides are
toxic to essentially all tissues. They react with proteins and
cause unfolding and are able to induce DNA damage. Additionally,
cellular activation in the circulation can be detected by
leukocytes or endothelial cells resulting in superoxide production,
pseudopod projections, enzyme release, cytokine release, and
expression of membrane adhesion molecules. Cell activation
fundamentally alters the biomechanics of microvascular blood flow
by a shift in rheological, adhesive, and cytotoxic cell properties.
Eventually these stress responses give rise to irreversible
cardiovascular collapse because of their combined effects on the
microcirculation.
[0005] There are few satisfactory drugs, treatment methods, or
interventions available for the prevention of conditions related to
shock. Most currently available methods for the treatment of such
conditions related to shock deal with the symptoms, rather than the
cause. For this reason, current clinical approaches are limited in
their efficacy and can only prevent further damage from
occurring.
[0006] Thus, there is a need in the art for a more effective
treatment of conditions related to shock. The treatment should be
simple to administer, effective and capable of aiding in emergency
situations.
SUMMARY OF THE INVENTION
[0007] The present invention is a technique for treatment of
conditions related to physiological shock by administering a more
specific combination of therapeutic agents, which is able to use
smaller volumes of reagent to achieve complete inhibition, than
other previously described methods, for example, that in U.S. Pat.
No. 6,534,283, which is incorporated by reference herein in its
entirety. The present invention is based upon a new hypothesis for
the cause of shock and multi-organ failure: self-digestion through
gut ischemic complications rather than bacterial/endotoxin
invasion.
[0008] The present invention dramatically reduces symptoms of
multi-organ failure and mortality in septic shock associated with
leakage of cecal material into the peritoneum (e.g., cecal ligation
shock). Furthermore, the present invention reduces symptoms of
insulin resistance in shock (e.g., septic, hemorrhagic and cecal
ligation shock). The methods were tested and verified in various
animal studies as discussed below.
[0009] In experimental models, it was demonstrated that blockade of
pancreatic enzymes in the lumen of the intestine in combination
with treatment against cytotoxicity in the peritoneum (blockade of
digestive enzymes, binding of cytotoxic mediators and
anti-bacterial treatment in the peritoneum) leads to a dramatic
enhancement of survival rate in a model of septic shock (cecal
ligation model).
[0010] In experimental models, it has further been demonstrated
that plasma of animals (such as rats) in shock produced by cecal
ligation have plasma that exhibits protease activity. The activity
is sufficient to cleave the binding domain of insulin on the
insulin receptor alpha. Introduction of Futhane and Doxycycline
attenuates the insulin receptor cleavage. It is expected that other
symptoms of cell and organ dysfunction (such as arterial vasospasm,
immune suppression, enhanced permeability, apoptosis, etc.)
characteristic for shock will also be attenuated by this
treatment.
[0011] Such findings lead to the present invention resulting in
treatment techniques for prevention of multi-organ failure and
mortality in septic shock associated with leaks from intestine
during surgery, punctured intestine, ruptured intestinal legions or
appendix, or other any other situation associated with leakage of
intestinal material (e.g., cecal or fecal matter). Further, such
treatments would lead to prevention of the metabolic syndromes in
trauma patients and patients in the ICU.
[0012] In certain exemplary embodiments, the present invention is a
method for prevention or treatment of physiological shock. The
method includes administering to a peritoneum of an individual a
therapeutic dose of any combination of one or more of: pancreatic
digestive enzyme inhibitor, cytotoxic mediator inhibitor, and
antibacterial agent.
[0013] A method according to the present invention blocks formation
of inflammatory mediators by pancreatic digestive enzymes in the
intestine in septic shock and thereby reduces symptoms of
multi-organ failure and significantly reduces mortality rate. It
also serves to reduce morbidity and reduce post-operative
complications, enhance recovery rate, and shorten hospital
stays.
[0014] The treatment is administered into the lumen of the
intestine to block fully activated digestive enzymes and
auto-digestion of the intestine. The treatment is highly effective
to attenuate prolonged formation of inflammation in septic shock,
destruction of the intestinal epithelial lining, and reduces
mortality. There is currently no comparable treatment for septic
shock.
DETAILED DESCRIPTION OF THE INVENTION
[0015] This invention describes techniques for treatment of
conditions related to shock. Various exemplary embodiments are
presented to provide a broad spectrum of treatment available and
application to such conditions.
[0016] As discussed above, the strategy for inhibiting gut enteral
function has been described in U.S. Pat. No. 6,534,283, which is
incorporated by reference herein in its entirety. This patent
describes the use of protease inhibition in the lumen of the gut in
principle and more specifically using specific commercially
available protease inhibitors. The current strategy proposes
numerous applications related to pancreatic protease
inhibitors.
[0017] In the present invention, treatment is administered into the
lumen of the intestine in combination with a treatment of the
peritoneal cavity that can be administered after onset of
shock.
[0018] In one series of experiments, the inventors discovered that
delayed inhibition of digestive enzymes in the lumen of the
intestine reduces inflammatory markers after shock. As a clinically
relevant situation, the inventors examined the effectiveness of a
delayed intestinal protease inhibition during reperfusion after
SMAO. Male Wistar rats were exposed to superior mesenteric artery
occlusion (SMAO) for 100 min and treated by delayed intestinal
lavage beginning 40 min after reperfusion with either buffer or a
reversible digestive protease inhibitor (FOY, 0.37 mM). Arterial
pressure during reperfusion was significantly lower in shock
animals compared with sham shock animals. SMAO and reperfusion
without protease blockade caused the formation of leukocyte
activation factors in intestinal homogenates and in plasma, as well
as intestinal injury and also caused a significant increase in
activated leukocytes in venules of cremaster muscle. In contrast,
with digestive protease inhibition in the intestine, delayed lavage
at 40 min after reperfusion led to a highly significant restoration
of the initial blood pressure before shock, decreased formation of
intestine-derived leukocyte activation factors and intestinal
injury. Delayed digestive enzyme blockade also caused lower
leukocytes adhesion in post-capillary venules and reduced cell
death in the cremaster muscle microcirculation. Intestinal
ischemia-induced endotoxemia was prevented by digestive enzyme
inhibition.
[0019] In summary, delayed intestinal protease inhibition serves to
improve experimental SMAO-induced shock by reducing intestinal
injury, the level of cell activation in plasma and in the
microcirculation, and by restoring the blood pressure.
[0020] Another series of experiments were performed to show that
inhibition of pancreatic digestive enzymes in the lumen of the
intestine reduces the need for resuscitation in hemorrhagic shock.
The inventors examined the utility of intestinal lavage in a
porcine model of hemorrhagic shock. An objective of this study was
to determine the effect of digestive protease blockade in the lumen
of the intestine during hemorrhagic shock. The animals (16 pigs)
were subjected to a shock that mimics clinical events. Pigs were
bled 30 ml/kg over 30 minutes and maintained at a mean arterial
pressure of 30 mmHg for 60 minutes and shed blood was then used to
maintain a pressure of 45 mmHg for three hours. Both treated pigs
(6-amidino-2-naphthyl p-guanidobenzoate dimethane-sulfate (ANGD),
100 ml/kg of 0.37 mM in GOLYTELY, PEG-3350 and electrolytes for
oral solution, via a duodenal catheter at 1 liter/hr directly into
the lumen of the intestine) and controls (GOLYTELY, PEG-3350 and
electrolytes for oral solution, only) had significant reductions in
protein and protease levels in the duodenum during enteroclysis,
however only ANGD treated animals had persistent suppression of
protease activity in the intestinal lumen and in plasma throughout
the experiment. Pigs with blockade of digestive enzymes had a major
reduction of transfusion requirement of shed blood (18.1.+-.4.5
ml/kg versus 30.+-.0.43 ml/kg; p=0.002), a significantly lower
level of neutrophil activation than controls after resuscitation
(31.1.+-.3.3% versus 46.9.+-.4.5% in controls, p=0.0002). Leukocyte
infiltration into the lung was lower in treated than control
animals (p=0.04) and the liver and small intestine showed less
injury in treated animals. In summary, a digestive enzyme inhibitor
given via enteroclysis significantly reduces leukocyte activation
and transfusion requirements during resuscitation from hemorrhagic
shock.
[0021] In another series of studies, the inventors show that
blockage of digestive enzymes in the lumen of the intestine
attenuates microvascular inflammation in peripheral organs. These
experiments were designed to examine whether inflammatory mediators
generated in the intestine by digestive enzymes are released early
into the circulation and may contribute to the severe systemic
inflammatory response syndrome during shock, a condition that
involves the microcirculation in peripheral organs. Intestinal
ischemia and reperfusion-induced hypotension upon reperfusion was
accompanied by a significant increase in the level of neutrophil
activating factors in the intestine and plasma. During reperfusion
a significant increase in leukocyte-endothelium interactions in
post-capillary venules and parenchymal cell death are observed in
the cremaster muscle in controls after SMAO. In contrast,
intra-intestinal pancreatic protease inhibition (gabexate mesilate,
0.37 mM) results in a stable blood pressure throughout the
experiment. Cell activation and leukocyte-endothelial interactions,
both in term of rolling and firm adhesion to the endothelium and
cell death (as measured by propidium iodine labeling) in the
cremaster muscle, were almost completely abolished after blockade
with gabexate mesilate. In addition, ischemia-induced intestinal
mucosal injury is attenuated with intestinal pancreatic protease
inhibition. In conclusion, intestinal pancreatic protease
inhibition significantly attenuates intestinal ischemia-induced
shock by reducing the systemic inflammatory response syndrome.
[0022] In another series of experiments, the inventors show that
digestive enzyme blockade is protective against inflammation in
shock if placed inside the lumen of the intestine and less by
intravenous administration. From a mechanistic point of view, an
important feature is the fact that the significant protection
rendered by the inhibition of pancreatic digestive enzymes is only
provided if the enzymes are blocked inside the lumen of the
intestine. If the enzyme inhibitors are administered directly into
the circulation (i.v., i.a., i.m.), less, and in some cases no
protection is achieved, a feature that has been confirmed using
different protease inhibitors (ANGD and aprotinin). This
observation supports the hypothesis that digestive enzymes in the
lumen of the intestine--where they are fully activated and in high
concentrations--are the major enzymes in acute intestinal ischemia.
They produce inflammatory mediators that are carried towards the
central circulation via the portal venous system, but also via the
intestinal lymphatics. Besides the portal venous circulation and
the intestinal lymphatics, the inventors showed that inflammatory
mediators can also be carried directly across the intestinal wall
into the peritoneal cavity, along a third major pathway.
[0023] In another study, the inventors show that digestive enzymes
mediate microvascular inflammation in septic shock. Sepsis is
accompanied by severe inflammation whose mechanism remains
uncertain. The inventors examined the possibility that pancreatic
digestive enzymes may also be involved in inflammation in an
experimental form of septic shock with a lethal dose of endotoxin
in the rat. Immediately after intravenous endotoxin administration,
the small intestine was subjected to intra-luminal lavage with and
without an inhibitor of pancreatic digestive proteases (FOY,
gabexate mesilate). After endotoxin administration (4 mg/kg,
gram-negative), control rats developed hypotension, tachycardia,
hyperventilation and leukopenia. The intestine and plasma contained
mediators that activated leukocytes. The leukocyte-endothelial
interaction within the cremaster muscle microcirculation was
enhanced. Endotoxin administration resulted in elevated IL-6 plasma
levels and histological evidence indicates liver and intestinal
injury. In contrast, blockade of pancreatic proteases in the
intestinal lumen significantly improved hemodynamic parameters and
reduces all indices of inflammation in plasma as well as cell
injury in peripheral skeletal muscle microcirculation. These
experiments indicate that inflammatory mediators derived from the
intestine by digestive proteases may be involved in the prolonged
inflammatory response and may sustain symptoms of sepsis after an
endotoxin challenge. A bolus administration of endotoxin causes a
transient inflammation response and elevated intestinal
permeability. But the sustained inflammation that leads to
multi-organ failure in this situation is caused by auto-digestion
due to escape of pancreatic digestive enzymes from the lumen of the
intestine due to the elevated mucosal permeability.
[0024] A study of the long term survival after blockade of
digestive enzymes provided further support to the findings. In
preparation for this application the inventors carried out pilot
studies in the rat with (a) hemorrhagic, (b) endotoxic and (c)
cecal ligation shock, followed by an observation period for two
weeks until normal cage activities were recorded in survivors.
Without food restriction, in hemorrhagic shock the mean blood
pressure was reduced for two hours to 35 mmHg followed by return of
all blood volume but no further resuscitation. The digestive
enzymes were blocked at 1 hour after hypotension by direct infusion
of ANGD (0.37 mM, 15 ml) into the intestinal lumen after a
temporary exposure via a midline incision. In endotoxic shock, the
rats received gram-negative endotoxin (5 mg/kg, i.v.); the
digestive enzymes were blocked in the same way at 1 hour after
endotoxin administration. No other agent was administered. In cecal
ligation shock both the digestive enzymes in the lumen of the
intestine as well as inside the peritoneum were blocked with ANGD.
Untreated controls in each model of shock had high mortality
(within less than 8 hours), while blockade of the digestive enzymes
ANGD in each shock model lead to a significantly enhanced survival
rate (Table I). In contrast to untreated controls, all treated
survivors returned after anesthesia within hours to normal activity
(walking, climbing, grooming, drinking, eating, bowel movements)
and within 3 days to normal weight gain. Furthermore, treatment
with alternative serine protease inhibitors (CYCLOKAPRON,
tranexamic acid; TRASYLOL, aprotinin) in cecal ligation shock gave
significant survival rates (5/5 rats, P<0.0079; 4/5 rats,
P<0.02, respectively).
TABLE-US-00001 TABLE I Long-Term Survival Following Shock With and
Without Intra-Intestinal Enzyme Blockade* (A) Hemorrhagic
Shock.sup.1 (B) Endotoxic Shock.sup.2 (C) Cecal Lig. Shock.sup.3
Non- Non- Non- Survivor Survivor Survivor Survivor Survivor
Survivor Untreated 9 3 Untreated 9 4 Untreated 9 1 ANGD 2 10 ANGD 1
10 ANGD 1 9 Treated Treated Treated *number of rats .sup.1P <
0.01 .sup.2P < 0.04 .sup.3P < 0.001 by Fisher's Exact
Test
[0025] It was further shown that plasma of shock rats has protease
activity and causes cleavage of the extracellular domain of the
insulin receptor, E-cadherin, and CAT-1. In all forms of shock
there is consistently proteolytic activity in plasma. Therefore the
inventors investigated the ability of central venous plasma of rats
in hemorrhagic shock (collected at 4 hours) to cleave the
extracellular domain of the insulin receptor a by using an antibody
against the extracellular binding domain of insulin combined with
membrane receptor density measurements. Exposure of normal donor
cells to plasma from shock rats, but not to plasma of control rats,
causes extensive cleavage of the insulin binding domain.
Furthermore, this cleavage causes also a reduction of the glucose
transport into the cell cytoplasm. These results show that the
plasma enzymatic activity may be responsible for the development of
insulin resistance typical for patients in shock. The activity can
be significantly blocked with ANGD (by more than 50%, results not
shown), suggesting that proteases are a major component of this
enzyme activity. There is also a significant cleavage of the
extracellular domain of the tight junction protein E-cadherin in
intestinal epithelium and CAT-1 in leukocytes.
[0026] Another recent study by the inventors, listed as item (9)
below, and which is incorporated by reference herein in its
entirety, showed that pancreatic enzymes generate cytotoxic
mediators in the intestine. And, thus, there exists a link between
the permeability increase in the intestinal wall and the early
stages of shock with formation of inflammatory and cytotoxic
factors. These factors may either be already present in form of
digested food or may be created by action of digestive enzymes on
interstitial structures after entry into the intestinal wall and
may cause the intestinal necrosis observed in shock. We have shown
that both individual serine proteases and fluid from the lumen of
the intestine with endogenous proteases have the ability to
generate cytotoxicity from intestinal wall homogenates and that
luminal fluid may also generate cytotoxicity from homogenized food.
These findings further support the hypothesis that lavage of the
content of the small intestine with broad-spectrum inhibitors may
be protective in shock, in line with experimental evidence. There
is a need to identify the actual biochemical structure of the
cytotoxic factors and determine their mechanism of action.
[0027] In another follow up study, listed as item (10) below and
incorporated by reference herein in its entirety, the inventors
sought to show that the intestine is a source of cytotoxic
mediators in shock, and the role of free fatty acids and
degradation of lipid-binding proteins. In this study, the inventors
showed that using chloroform/methanol separation of rat small
intestine homogenates into lipid fractions and aqueous and
sedimented protein fractions and measuring cell death caused by
those fractions, it was found that the cytotoxic factors are lipid
in nature. Recombining the lipid fraction with protein fractions
prevented cell death, except when homogenates were protease
digested. Using a fluorescent substrate, the inventors found high
levels of lipase activity in intestinal homogenates and cytotoxic
levels of free fatty acids. Addition of albumin, a lipid binding
protein, prevented cell death, unless the albumin was previously
digested with protease. Homogenization of intestinal wall in the
presence of the lipase inhibitor orlistat prevented cell death
after protease digestion. In vivo, orlistat plus the protease
inhibitor aprotinin, administered to the intestinal lumen,
significantly improved survival time compared with saline in a
splanchnic arterial occlusion model of shock. These results
indicate that major cytotoxic mediators derived from an intestine
under in vitro conditions are free fatty acids (FFAs). Breakdown of
free fatty acid binding proteins by proteases causes release of
free fatty acids to act as powerful cytotoxic mediators.
[0028] The discovery further includes clarification of the
mechanism that leads to insulin resistance. It is shown that one of
the ways that the present invention works is due to enzymatic
cleavage of the insulin binding-domain, and introduction of
proteases attenuates the process.
[0029] There is currently no generally accepted treatment algorithm
or protocol for treatment of insulin resistance in shock. Limited
options include insulin administration.
[0030] In another recent study, listed as item (11) below and
incorporated by reference herein in its entirety, the inventors
showed that there is a relationship between proteinase activity and
receptor cleavage and that there appears to be a mechanism for
insulin resistance in the spontaneously hypertensive rat. The
inventors hypothesized that enhanced proteolytic activity in the
microcirculation of spontaneously hypertensive rats (SHRs) may be a
pathophysiological mechanism causing cell membrane receptor
cleavage and examined this for 2 different receptors.
Immunohistochemistry of matrix-degrading metalloproteinases (matrix
metalloproteinase (MMP)-9) protein showed enhanced levels in SHR
microvessels, mast cells, and leukocytes compared with normotensive
Wistar-Kyoto rats. In vivo microzymography shows cleavage by MMP-1
and -9 in SHRs that colocalizes with MMP-9 and is blocked by metal
chelation. SHR plasma also has enhanced protease activity. The
inventors demonstrated with an antibody against the extracellular
domain that the insulin receptor-a density is reduced in SHRs, in
line with elevated blood glucose levels and glycohemoglobin. There
is also cleavage of the binding domain of the leukocyte integrin
receptor CD18 in line with previously reported reduced leukocyte
adhesion. Blockade of MMPs with a broad-acting inhibitor
(doxycycline, 5.4 mg/kg per day) reduces protease activity in
plasma and microvessels; blocks the proteolytic cleavage of the
insulin receptor, the reduced glucose transport; normalizes blood
glucose levels and glycohemoglobin levels; and reduces blood
pressure and enhanced microvascular oxidative stress of SHRs. The
results suggest that elevated MMP activity leads to proteolytic
cleavage of membrane receptors in the SHR, e.g., cleavage of the
insulin receptor-binding domain associated with insulin
resistance.
[0031] Further, there is currently no generally accepted treatment
algorithm or protocol for septic shock. There is an FDA approved
treatment with activated protein C (XIGRIS, drotrecogin alfa
(activated), Eli Lilly), which gives a minor but confirmed survival
benefit. However, even such treatment has been called into question
as more recent trials could not confirm the effectiveness of
activated protein C.
[0032] Treatment of septic shock is based on supportive care by
treating the underlying infection (appropriate antibiotics within
the first 4-8 hours of presentation) and on restoring tissue
perfusion with a combination of fluid resuscitation (e.g., albumin,
lactated or hypertonic saline) and vasopressor administration
(e.g., noreinephrine).
[0033] In an exemplary embodiment, the present invention involves
several components, which may be performed independently or in
combination. One component of a treatment according to the present
invention includes administration of a pancreatic enzyme inhibitor
directly into the lumen of the intestine (by oral administration,
introduction via an esophageal catheter, direct injection into the
lumen of the intestine during surgery, etc.). The agents to be used
individually or in combination include but are not limited to:
FUTHAN, nafamostat mesilate (0.37 mM); TRASYLOL, aprotinin
(Aprotinin, Bayer) (1.4 mg/ml), serine protease inhibitor;
CYKLOKAPRON, tranexamic acid (Pfizer) (1.4 mg/ml), serine protease
inhibitor; broad based MMP inhibitors (e.g., doxycycline); orlistat
(5 to 50 mg/ml), lipase inhibitor; plus any other pancreatic enzyme
inhibitor. The amount administered may be adjusted according to
intestine size and enzyme levels to achieve complete blockade of
digestive enzyme activity.
[0034] A second component of a treatment according to the present
invention includes treatment of the peritoneum by a combination of
three protective interventions: blockade of pancreatic digestive
enzymes (serine proteases, lipases, as outlined in the first
component described above); blockade of cytotoxic lipid derived
mediators (e.g., free fatty acids) with free fatty acid binding
proteins (e.g., albumin, and others); antibacterial treatment
against gram-positive and gram-negative bacteria that have entered
into the peritoneal space (with antibiotic treatment, e.g.,
ciprofloxacin, metronidazole, imipenem and cilastatin, ticarcillin
and clavulanate, cefuroxime). Further effectiveness of the
treatment is achieved by peritoneal/intraintestinal lavage in
combination with the treatments listed above.
[0035] The administration of the serine proteases and MMPs with
broad spectrum blockers, as outlined in the first component
described above, may be alternatively or additionally performed
through an intravenous (i.v.) route.
[0036] The present invention may be used in numerous medical
treatments, including but not limited to, treatment for prevention
of multi-organ failure and mortality in septic shock. Any lipase
inhibitor in combination with a pancreatic or leukocyte derived
protease inhibitor may have utility to prevent inflammation in
septic shock.
[0037] In one exemplary embodiment, which may be used for treatment
for prevention of post-operational complications, including
multi-organ failure, sepsis, morbidity, and mortality, pancreatic
protease inhibition is initiated to reduce complications and
hospital stay after trauma/surgery. Here, it has been shown that
pancreatic enzymes in the intestine have the ability to generate
powerful inflammatory mediators and that blockade of pancreatic
enzymes in the lumen of the intestine attenuates inflammatory
symptoms after different shock models.
[0038] In this embodiment, the present invention allows a reduction
in inflammatory symptoms and complications (swelling, embolism
formation, selected organ dysfunction, pulmonary embolism,
incidence of stroke, patient mobility, morbidity, multi-organ
failure, mortality) in any form of elective surgery/general
anesthesia associated with elevated risks (such as prolonged
surgery procedures, surgery with bypass requirements, surgery on
patients with preconditions and risk factors, surgery involving the
intestine and pancreas). This results in a reduction in
post-surgical complications, enhance wound healing, reduce total
recovery period, and reduce hospitalization requirements and
time.
[0039] In elective surgery, pre-administration of a pancreatic
enzyme inhibitor may be conducted directly into the lumen of the
intestine (by oral administration, introduction via an esophageal
catheter, direct injection into the lumen of the intestine during
surgery). The agents to be used are individually or in combination:
Futhane (0.1 mM); Trasylol (Aprotinin, Bayer) (1.4 mg/ml), serine
protease inhibitor; cyclokapron (Pfizer) (1.4 mg/ml), serine
protease inhibitor; Orlestat (5 to 50 mg/ml), lipase inhibitor plus
any other pancreatic enzyme inhibitor. The amount administered is
adjusted according to intestine size to achieve complete blockade
of digestive enzyme activity. The inhibitor is administered prior
to general anesthesia/surgery as pretreatment.
[0040] This is the first intervention against a major source of
inflammation in multi-organ failure associated with surgery/general
anesthesia. Blockade of digestive enzymes prior to general
anesthesia may serve to preserve barrier properties of the
intestinal mucosa, reduce inflammation in the central circulation,
and consequently reduce recovery and wound healing periods,
post-surgical complications, hospital stays, etc.
[0041] A potentially useful application of the digestive enzyme
inhibition as pre-treatment is for patients subjected to radiation
or chemotherapeutic treatment. It could also work for radiation
treatment under other circumstances to reduce symptoms of
multi-organ failure.
[0042] In another exemplary embodiment, the present invention
provides a method for pancreatic protease inhibition in septic
shock. There are many uses for this embodiment, including but not
limited to, treatment for prevention of multi-organ failure and
mortality in septic shock. Such treatment works by blocking
formation of inflammatory mediators by pancreatic digestive enzymes
in the intestine in septic shock and thereby reducing symptoms of
multi-organ failure and mortality.
[0043] The treatment is administered into the lumen of the
intestine to block fully activated digestive enzymes and
auto-digestion of the intestine. The treatment is highly effective
to attenuate prolonged formation of inflammation in septic shock,
destruction of the intestinal epithelial lining, and reduces
mortality.
[0044] It is demonstrated that blockade of pancreatic enzymes in
the lumen of the intestine attenuates inflammatory symptoms after
administration of a lethal dose of endotoxin (6 mg/kg). Experiments
demonstrate reduced long-term mortality in the same sepsis
model.
[0045] Administration of a pancreatic enzyme inhibitor may be
conducted directly into the lumen of the intestine (by oral
administration, introduction via an esophageal catheter, direct
injection into the lumen of the intestine during surgery). The
agents to be used are individually or in combination: FUTHAN,
nafamostat mesilate (0.1 mM); TRASYLOL, aprotinin (1.4 mg/ml),
serine protease inhibitor; orlistat (5 to 50 mg/ml), lipase
inhibitor; plus any other pancreatic enzyme inhibitor. The amount
administered is adjusted according to intestine size to achieve
complete blockade of digestive enzyme activity.
[0046] In another exemplary embodiment, the present invention is
used for pancreatic lipase inhibition to reduce mortality after
shock. This embodiment is very useful for developing treatment for
prevention of multi-organ failure and mortality in hemorrhagic
shock, preventive treatment to reduce the probability for
development of multi-organ failure in elective surgery, long-term
treatment to reduce production of lipid derived inflammatory
mediators associated in chronic diseases. It is also particularly
useful because there does not appear to be any treatment proposed
to attenuate inflammation by blockade of lipase activity in the
intestine in either acute or chronic inflammatory conditions.
[0047] This embodiment is designed as an intervention to block the
lipase activity in the lumen of the intestine and also in the
general circulation in those cases in which lipase enters from the
lumen of the intestine into the circulation. This prevents
formation of lipid derived inflammatory or cytotoxic mediators in
shock and other inflammatory diseases and attenuate multi-organ
failure in shock and chronic inflammation in diseases like
hypertension, diabetes, the metabolic syndrome, cancers and in
chronic degenerative diseases.
[0048] Recent evidence resulting in this invention suggests that a
major component of inflammatory mediators from the intestine in
shock causing multi-organ failure and mortality (e.g., after
surgery/general anesthesia, trauma, chronic diseases and any other
condition leading multi-organ failure) is derived from the action
of pancreatic lipases (lipid splitting enzymes). Blockade of
pancreatic lipase serves to reduce mortality during shock and
reduce inflammation that leads to multi-organ failure. Blockade of
pancreatic lipase prior to general anesthesia may serve to preserve
barrier properties of the intestinal mucosa, reduce inflammation in
the central circulation, and consequently reduce recovery and wound
healing periods, post-surgical complications, hospital stays,
etc.
[0049] The inventors have shown that the ischemic intestine
produces a powerful set of lipid derived cytotoxic mediators and
that the blockade of lipase in the intestine under in-vitro
conditions blocks the production of lipid-derived cytotoxic
mediators.
[0050] In elective surgery, pre-administration of a pancreatic
enzyme inhibitor directly into the lumen of the intestine (by oral
administration, introduction via an esophageal catheter, direct
injection into the lumen of the intestine during surgery) may have
a positive effect on recovery. The agents to be used are
individually or in combination: orlistat (5 to 50 mg/ml), lipase
inhibitor; plus any other pancreatic enzyme inhibitor. The amount
administered is adjusted according to intestine size and content to
achieve complete blockade of digestive enzyme activity. As
treatment the inhibitor is administered after trauma or sepsis
associated with risk for shock and multi-organ failure. As
pretreatment the inhibitor is administered prior to general
anesthesia/surgery.
[0051] The above exemplary embodiments have shown various uses and
techniques for decreasing certain conditions related to shock.
Thus, as a whole, the present invention is based on data from
animal studies that show dramatic reduction in life-threatening
shock by inhibiting a body's own aggressive digestive enzymes. This
novel approach targets trigger mechanisms in auto-digestion before
it launches lethal inflammatory cascade.
[0052] Death from heart, lung and kidney failure during shock due
to inadequate blood flow can be prevented by an unusual
experimental treatment that inhibits the aggressive enzymes that
are produced in body to digest food.
[0053] The invention provides evidence from recent animal studies
that for the first time, studies showed that blockade of the
digestive enzymes during shock leads to long-term survival. The
results show a dramatic reduction of mortality in hemorrhagic shock
induced multi-organ failure. This treatment holds great promise for
future clinical application, particularly in emergency rooms and
before high-risk surgeries. When a person is in shock, his or her
life is on the line. The patient's survival may be in jeopardy not
just that day, but within an hour because healthy organs can fail
and die in rapid succession.
[0054] An estimated 1 million cases of various types of shock are
treated annually in U.S. hospital emergency rooms. Shock is a
serious medical condition with a fatality rate of approximately
29%. While the optimal management of shock patients can improve
survival rates, overall shock remains a condition with a high death
rate.
[0055] Administering a drug to inhibit the body's digestive enzymes
is a relatively new approach that was begun in the past decade. In
1998 a finding was made in laboratory studies on the body's
inflammatory cascade and the factors that turn this normal
tissue-healing biological process into a virulent, out of control
firestorm against the body's normal tissue.
[0056] The researchers then began animal studies. The present
invention is based on the latest research using rodent models of
human hemorrhagic shock. Here it has been discovered that the
sudden lowering of blood pressure that occurs in people suffering
from stroke can provoke the body's digestive enzymes to break down
the body's own intestinal tissue as if it were food. Such enzymes'
abnormal actions may be defined as "auto-digestion." Auto-digestion
is dangerous because not only does it injure healthy tissue but
also contributes to multi-organ failure, which can be fatal.
[0057] The healthy cells of the animals' intestinal tissue react to
auto-digestion by releasing a slew of substances that can be toxic
to the heart and other body organs. These substances, termed
cytotoxic mediators, can reach these body organs via the blood
stream. In their latest studies, shock was induced in 19 lab
rodents, all of which were then treated with therapies that mirror
the emergency room care given to many human patients who suffer
shock, which typically occurs when blood flow to the heart, lungs
and other body organs is slowed as a result of trauma, dehydration,
heart attack or stroke.
[0058] A total of 10 of the 19 lab rodents in shock were also
treated with the experimental digestive enzyme inhibitor called
ANGD. Eight of the ten survived. However, only one of the nine
"untreated" animals in shock survived. The other eight animals died
from organ failure within 12 hours. Although these "untreated"
animals did not receive ANGD, the inhibitor, they were given basic
shock care. The enzyme inhibitor ANGD dramatically improved the
survival rate among the lab animals in which shock had been
induced.
[0059] In the pig studies, the scientists also are conducting
experiments to identify the time period when the experimental
treatment will be the most effective in saving lives. The findings
will be relevant to the emergency care of human patients in shock.
Data indicate that the earlier the treatment occurs, the better the
chances for survival. Current research indicates that the window of
opportunity for the treatment to be effective does not seem to be
very narrow.
[0060] The discovery of the "auto-digestion" process and their
positive findings from the experimental treatment ANGD are based on
National Institutes of Health funded basic research to determine
the origin of the inflammatory cascade that causes organ failure
and death. Basically, inflammatory is the body's mechanism to
repair, to heal tissue. But in shock, the inflammation never stops.
It is out of control. Normally the body senses when the
inflammatory process has completed its job and brings it to a
halt.
[0061] There is little surprise that tissue can be severely damaged
by the actions the body's digestive enzymes, which are secreted by
the pancreas but do not become activated until they arrive into the
intestines. Digestive enzymes have to be very aggressive, and there
has to be lots of them, for the body to efficiently digest, to
break down, the food that we eat. Normally the intestinal tissue is
protected from these enzymes by a layer of secreted mucus and by
the tight packing of the cells in the intestinal wall. The enzymes
are too big to defuse between these cells under normal
conditions.
[0062] The following references, some as cited above, are hereby
incorporated by reference herein in their entirety into this
disclosure:
[0063] 1. Schmid-Schonbein G W, Hugli T E. A New Hypothesis for
Microvascular Inflammation in Shock and Multiorgan Failure:
Self-Digestion by Pancreatic Enzymes. Microcirculation. 2005;
12:71-82.
[0064] 2. Doucet J J, Hoyt D B, Coimbra R, et al. Inhibition of
enteral enzymes by enteroclysis with nafamostat mesilate reduces
neutrophil activation and transfusion requirements after
hemorrhagic shock. J Trauma. 2004; 56:501-511.
[0065] 3. Fitzal F, DeLano F A, Young C, Schmid-Schonbein G W.
Improvement in early symptoms of shock by delayed intestinal
protease inhibition. Arch Surg. 2004; 139:1008-1016.
[0066] 4. Deitch E A, Shi H P, Lu Q, et al. Serine proteases are
involved in the pathogenesis of trauma-hemorrhagic shock-induced
gut and lung injury. Shock. 2003; 19:452-456.
[0067] 5. Shi H P, Liu Z J, Wen Y. Pancreatic enzymes in the gut
contributing to lung injury after trauma/hemorrhagic shock. Chin J
Traumatol. 2004; 7:36-41.
[0068] 6. Muhs B E, Patel S, Yee H, et al. Inhibition of matrix
metalloproteinases reduces local and distant organ injury following
experimental acute pancreatitis. J Surg Res. 2003; 109 :110-7.
[0069] 7. Rosario H S, Waldo S W, Becker S A, et al. Pancreatic
trypsin increases matrix metalloproteinase-9 accumulation and
activation during acute intestinal ischemia-reperfusion in the rat.
Am J Pathol. 2004; 164:1707-16.
[0070] 8. Fitzal F, DeLano F A, Young C, Rosario H S, Junger W G,
Schmid-Schonbein G W. Pancreatic enzymes sustain systemic
inflammation after an initial endotoxin challenge. Surgery,
134:446-456, 2003.
[0071] 9. Penn, A H, Hugli, T E, Schmid-Schonbein, G W. Pancreatic
enzymes generate cytotoxic mediators in the intestine. Shock, Vol.
27, No. 3, pp. 296-304, 2007.
[0072] 10. Penn, A H, Schmid-Schonbein, G W. The intestine as
source of cytotoxic mediators in shock: free fatty acids and
degradation of lipid binding proteins. Am J Physiol Heart Circ
Physiol 294: H1779-H1792, 2008.
[0073] 11. DeLano, F A, Schmid-Schonbein, G W. Proteinase activity
and receptor cleavage: mechanism for insulin resistance in the
spontaneously hypertensive rat. Hypertension. 2008; 52:415-423.
[0074] The foregoing disclosure of the preferred embodiments of the
present invention has been presented for purposes of illustration
and description. It is not intended to be exhaustive or to limit
the invention to the precise forms disclosed. Many variations and
modifications of the embodiments described herein will be apparent
to one of ordinary skill in the art in light of the above
disclosure. The scope of the invention is to be defined only by the
claims appended hereto, and by their equivalents.
[0075] Further, in describing representative embodiments of the
present invention, the specification may have presented the method
and/or process of the present invention as a particular sequence of
steps. However, to the extent that the method or process does not
rely on the particular order of steps set forth herein, the method
or process should not be limited to the particular sequence of
steps described. As one of ordinary skill in the art would
appreciate, other sequences of steps may be possible. Therefore,
the particular order of the steps set forth in the specification
should not be construed as limitations on the claims. In addition,
the claims directed to the method and/or process of the present
invention should not be limited to the performance of their steps
in the order written, and one skilled in the art can readily
appreciate that the sequences may be varied and still remain within
the spirit and scope of the present invention.
* * * * *