Note: Descriptions are shown in the official language in which they were submitted.
5971/~72
129Z9~3
1 MONOSACCHARIDE CONTAINING
WOUND HEALING PREPARATION
The present invention relates to methods and
compositions for beneficiating wound healing. More
specifically, it relates to the use of monosaccharides,
especially fructose, to beneficiate wound healing processes.
During the period following development or
infliction of serious physical damage to the skin, by way of
for example, severe burns, wounds, pressure ulcers, and the
like, the injured area is extremely unstable physiologically;
following such injury or trauma, the normal physiological
processes of the area in question may be severely
compromised. Disruption in the normal pattern of skin
growth, blood flow, and immunity may all be impaired to some
extent by the trauma to the region. The physician treating
such damaged tissue must therefore be able to control and
eventually reverse these undesirable effects, while at the
same time stimulating the processes that are necessary to
achieve healing of the area,
Because of the variety of different systems which
may be adversely affected by such injury/ it is difficult to
find a single agent which will be effective in controlling
the various sources of the problems. For example, one of the
most severe difficulties encountered is the immediate
colonization of the wound by a variety of different types of
microbial species. Common invaders of a wound site are such
known pathogens as Staphylococcus aureus, as well as a number
of opportunistic pathogens, such as Escherichia coli or
-2~
l Pseudomonas aeruginosa. Various yeasts, particularly Candida
_lbicans, may also be found at the wound. Although a number
of antimicrobial agents for topical application are known,
none has proven to be without some serious disadvantage. For
exampler silver sulfadiazine, the current antibacterial agent
of choice is effective against gram-positive bacteria and
gram-negative but many resistant strains have developed in
the course of its use, particularly in the genus Pseudomonas.
Similarly, the commonly used Betadine (povidone-iodine),
although effective against both gram-positive and
gram-negative bacteria, can be quite painful to the patient
upon application, kills white cells in the wound,
specifically polymorphonuclear cells, lymphocytes, monocytes,
and macrophages, and may cause sensitization of an area
already severely traumatized. Other known antibacterial
agents may be hampered in their use by low diffusibility of
the composition, or a range of activity that covers
relatively few types of microbes; expense, as with substances
such as the various silver salts, is also a factor to be
considered.
Related to the invasion by microbes of the wound
site is the generally decreased circulation which is also
observed in many cases. For example, in decubitus or stasis
ulcers, a cessation of blood flow may develop gradually,
whereas an acute cessation of flow may occur in
thermo-radiation and chemical burns. In either case the
decrease in the rate of blood flow means a corresponding
decrease in the provision to the cells of nutrients and
oxygen. Thus deprivation in turn leads to necrosis of tissue
in the poorly supplied region, which will be followed by the
invasion of the unwanted bacteria and fungi. In order for
healing to proceed, the damaged area must not only be rid of
~3~ 129Z9~3
l any lingering microbial infection, but also must have a
restored blood flow, which will provide sufficient nutrient
and oxygen supply to support a regeneration of the wounded
region. In the ideal situation, the increased blood flow
should also be accompanied by the formation of healthy
~ granulation tissue. The latter is a layer of highly
vascularized tissue, containing numerous fibroblasts and
collagen and ground substance, which supports the normal
wound healing processes of recollagenation and
reepithelialization~
Another very critical aspect of the wound healing
process is the initiation of wound closure. This is
generally a two-stage process, comprising contraction and
epidermal migration. Contraction is the process of bulk skin
movement from the edges of the wound, while migration is the
separation and movement of activated epidermal cells over the
surface of the wound. Because contraction itself may lead to
some scarring it is preferable to be able to speed healing in
a manner which will increase the process of epidermal
migration. The process of migration is characterized by a
stimulation of mitosis in the epidermal cells, accompanied by
movement across the wound site. The extent to which
epidermal migration, and thus wound closure, can be promoted
will also in some cases determine whether or not additional
skin grafting is required to complete the healing of the
wound.
It is thus evident that a large number of different
factors must be controlled and/or stimulated in order to
achieve thorough regeneration of the damaged tissue. Since
the processes involved, and the mechanisms controlling them,
are so diverse, it has proven difficult to pinpoint a single
treatment composition or method which is capable of aiding
and promoting most or all of the required processes
- 129Z9~3
l simultaneously. As noted above with respect to the various
antibacterial agents available, the majority of wound healing
compositions available suffer from one or another
deficiencies, whether it be in complexity of application,
insufficient ability to control infection, irritation caused
to the patient, limited range of protective activity, or
expense (See for example D. Wise (ed.) Burn Wound Coverings,
Vol. I Chap, I, p. 11-22, CRC Press, 1984).
It has now been surprisingly discovered that
certain monosaccharides, when used either alone or in
combination with many known wound treating compositions, may
have the effect of providing added protection against
microbial infection, enhancing the growth of granulation
tissue, promoting the vascularization of the wound site,
and/or stimulating the process of epidermal migration and
wound closure. When the monosaccharides are used in
combination with known compositions, the effects observed on
wound healing are significantly and unexpectedly improved
with respect to the above features. When used alone, the
monosaccharides show a remarkable and unpredicted effect on
control of bacterial infection on damaged skin. The
monosaccharide fructose has proven to be most useful and
successful in this regard.
Various monosaccharides have previously been known
to be used for therapeutic purposes. For example, it is
known to administer fructose intravenously to inhibit
erythrocyte fragility during surgical extracorporeal
circulation procedures (U.S. Pat. No. 4,448,771). Sorbose is
also known (U.S. Pat. No. 4,390,523) to be used as a sugar
substitute to inhibit acid formation by bacteria in the
mouth, but it does not itself have an effect on bacterial
growth. Oral administration of pure fructose is also known
~5~ 129Z9'~3
l to control human stress response (U.S. Pat. No. 4,024,250).
Bacteriostatic effects have also been attributed to
irradiated glucose and fructose, but this effect is the
apparent result of the peroxide compounds produced by the
irradiation ~Namike et al. Agr. Biol.Chem. 37(5): 989-998,
1973). The latter reference, in fact, shows normal bacterial
growth in the presence of glucose and fructose. Various
natural substances, such as honey or sugar (i.e., sucrose)
have also been traditionally used as a type of folk-medicine
for preventing infection. Thus, there has been no previous
indication that monosaccharides would have any antibacterial
effect either alone or in combination with other products for
a topical wound healing preparation, and in fact, the
monosaccharides show a more marked protective effect than
disaccharides such as sucrose and lactose. As employed
herein, the term wound is intended to apply to any skin or
connective tissue trauma, such as thermal burns, pressure
ulcers, ischemic ulcers, chemical and radiation burns,
abcesses, fistulae, bone defects, malunion of fractures,
vasculitis, tropical parasitic ulcers, leprosy ulcers, and
acne or psoriasis lesions.
The present invention relates to a composition
comprising an effective amount of at least one
pharmaceutically acceptable monosaccharide containing from
about 3 to 7 carbon atoms and a pharmaceutically acceptable
film forming agent. In its preferred embodiment, the present
invention relates to a composition comprising an effective
amount of fructose and a starch hydrolysate, and preferably
to a composition comprising fructose and a starch hydrolysate
having a dextrose equivalent of between 13 and 17. These
compositions are useful both in the treatment and healing of
wounds, as well as for use as carriers for other
dermatological treatment agents to be used in salve form.
6--
~29Z9 ~3
1 The present invention also relates to the use of
monosaccharides, particularly fructose, to control microbial
growth in a mammalian wound.
As used in the present specification and claims,
tne phrase "controlling microbial growth", refers to the
ability of the monosaccharide to either prevent microbial
growth on an as yet uninfected wound, to prevent further
srowth in an already infected wound or to actually kill the
microbes pxesent in a wound. "Microbial" refers to bacterial
or fungal infection.
The monosaccharides as described herein provide an
unex?ectedly bene icial e_rect when used as an addition to
traditional wound healing compositions, as well as being
useful alone as an antibacterial pre~reatment for wounds.
Particularly good effects have been observed when a
monosaccharide is added in a therapeutically effective amount
to various film forming agents which are routinely used as
protective coverings for various types of wounds, especially
burns. These agents in themselves form a simultanecus
barrier to both water and microbes, and as used herein,
comprise various types of dry (non-gel~ films, as well as
biological gels (gelatin and gelatintpectin materials),
synthetic hydrogels, ionic gels and adhesives. Although
monosaccharides may be effectively combined and used with any
of the above materials, unusually favorable results are
achieved by combining a monosaccharide, especially fructose,
with a film-forming starch hydrolysate.
The therapeutic use of starch hydrolysate has been
described in depth in U.S. Patent Nos. 3,812,252 and 4,414,
202. In brief, this material itself has been shown to be an
exceptionally effective treatment for burns, ulcers, lesions,
etc. The starch hydrolysate forms a film which
lZ9Z943
1 ultimately adheres to underlying tissue and which is
semipermeable to gas and fluid. It thus provides a covering
which reduces plasma and fluid loss, while also preventing
invasion by pathogenic microbes. The effects observed with
use of starch hydrolysate are far superior to results seen
with use of traditional wound coverings. When used in
combination with a monosaccharide the effects on wound
healing are tremendously enhanced, producing results which
heretofore have not even been possible with the use of starch
hydrolysate alone.
For example, application of a mixture of a starch
hydrolysate with a monosaccharide, particularly glucose or
fructose, has a remarkable effect on the process of
revascularization of the wound. Within 15 minutes - 6 hours
of such application, the treatment wound takes an intensely
bright red color, visual evidence of the fact that new blood
vessels are being formed in the region, and that normal
circulation i5 returning to the site Although it is part of
the normal healing process that revascularization will
eventually occur, the speed with which new blood vessels
return to the damaged tissue when treated with starch
hydrolysate and fructose is unexpectedly faster than that
observed with starch hydrolysate alone. The presence of the
added monosaccharide thus has a synergistic effect when
combined with the starch hydrolysate, the end results being
unattainable with either of the two substances used alone.
Similar surprising effects are seen in the
development of granulation tissue. As noted above, the
noticeable appearance of healthy granulation tissue signifies
the start of the process of healing, to a large extent by
virtue of a reconstruction of the connective tissue in the
injured region by the numerous fibroblasts associated with
granulation tissue. The use of starch hydrolysate alone
does, to some degree, have a beneficial effect on promoting
-8- i~92943
1 formation of granulation tissue; such tissue, where starch
hydrolysate alone is used, has a relatively smooth
appearance. On the other hand, when starch hydrolysate is
used in combination with a monosaccharide, the granulation
tissue takes on a significantly different appearance, being
very intensely granular, with a rough surface, indicating a
greater level of activity in the tissue thus leading to a
more rapid rate of healing.
Particularly remarkable, however, is the effect the
added monosaccharide has on the process of wound closure.
This process is extremely important in the progression of
healing, since if it proceeds to completion, the necessity
for skin grafts will be minimized or avoided completely. One
of the major problems with many of the known film forming
1~ agents is that they rarely are capable of enhancing the wound
closing process, so that, in a wound of any substantial size,
a skin graft will always be required. Starch hydrolysate
alone has been shown to have a dramatic effect on the
process, and does significantly reduce the necessity for skin
grafting, However, when combined with a monosaccharide, the
results observed with respect to wound closure are truly
outstanding, with much larger wounds showing complete closure
in a relatively shorter period of time than has previously
been known to be possible. The effect of the added
monosaccharide shows itself particularly in the stimulation
of epidermal mitosis and migration; this can be demonstrated
both macroscopically and microscopically. Thus, the use of a
composition containing both starch hydrolysate and a
monosaccharide, preferably fructose, can effectively reduce
or eliminate the need for a skin graft to a far greater
extent than is possible with any known wound coverings.
Finally, of course, the added monosaccharide has an
antibacterial effect in conjunction with the starch
hydrolysate. Whereas the starch hydrolysate alone is known
to have a significant ability to control the level of
g ~ z9~943
l bacterial infection in a wound, when combined with a
monosaccharide~ this ability is so enhanced as to virtually
completely inhibit microbial growth at the site of
application. Thus, with all the superior effects observed
with the application of the film-forming agent
- -monosaccharide combination, the present compositions provide
an exceptional method of treatment for damaged or injured
tissue.
The monosaccharides are also particularly useful
alone as antimicrobial agents. They have been shown to be
extremely effective in controlling microbial infections at
the wound site, and in preventing the development of
infection. These results have been observed clinically in
wounds wherein bacterial and yeast growth is stopped in far
less time than is normal with some of the most popular wound
treatments; this has also been verified under controlled
conditions in vitro. (See Example 3). These compounds are
particularly desirable because they are effective in
controlling growth of colonies of both gram-positive and
gram-negative bacteria, as well as opportunistic yeast
infections which may arise. The monosaccharides are not only
microbiostatic, but also, to some extent, microbicidal. For
example, exposure of bacteria commonly found in wounds to an
effective amount of fructose has been shown to cause visible
disruption of large numbers of bacterial cells. As noted
above, the application may be made to a wound in which
infection already exists, as well as to an injured area of
skin which may be prone to developing infection.
The antimicrobial effects of the monosaccharides
are particularly useful when utilized as a pretreatment of a
wound prior to the application of proven additional methods
of treatment, such as dressings, gels, films, etc., or as a
postreatment therapy when other methods have failed to
produced the desired results. This treatment may be
-lo- ~Z~Z943
1 accomplished in a number of ways. For example, for
pretreatment of a burn patient, the area of damaged tissue
may be immersed in a bath comprising a monosaccharide-
containing solution, for a period of time sufficient to
inhibit potential bacterial growth. The bathing solution may
- contain concentrations of monosaccharides from about 20 to up
to about 95~ but preferably the concentration will be in the
range of about 20-60~.
The length of treatment by immersion will depend on
the extent of the wound. For a small, fairly localized
wound, the period of exposure may be up to 24 hours,
depending upon the concentration of the monosaccharide in
solution. It will be recognized by one skilled in the art
that higher amounts of monosaccharide in the solution will
exert a proportionately greater osmotic effect on the wound,
and will therefore have a tendency to draw out fluids. While
not a tremendous problem with smaller wounds, this effect is
magnified in a patient with, for example, extensive burns
requiring treatment. In such a case, it is desirable to
limit the concentration of monosaccharide, or to keep the
treatment period short. For example, when using high
fructose ~orn syrup as the immersion medium or a very large
wound (very convenient because of the ready availability of
these products), the immersion period should be no more than
about 1 or 2 hours, since the concentration of monosaccharide
in the syrup is so high, approximately 95~. On the other
hand, the syrup may be diluted, up to about 4 times, and the
immersion time increased proportionately.
Similarly, for pretreatment of a less extensive
wound, the injured area may be irrigated with the same
monosaccharide solution, in the same manner as would be
employed with a typical saline solution; this may also be
done by an I-V drip over the damage tissue. Again, length of
1 1- lZ9Z943
1 treatment of the wound with the method depends upon the size
of the wound and the concentration of the monosaccharide.
For a large wound, 1-2 hours is the maximum period
recommended at one time. With a smaller wound, up to 6
hours, several times a day for a period of up to 24 hours may
be permitted.
It is also possible to use the monosaccharides in
dry powder form directly on the wound or burn. The powder
may be simply sprinkled onto the wound, and left for a period
of time consistent with the size of the wound. For example,
with a smaller wound, the powder may remain for a period of
up to 24 hours, with application possible being repeated 4-6
times within that period. With an extensive wound the
application should generally not be prolonged beyond 1-2
hours.
In the practice of the present invention in using
monosaccharide alone, the treatment solution should contain a
concentration of monosaccharides of between about 20 to about
95~ weight/volume and the preferred concentration is between
about 20 to about 60~. To prepare the solution, the
monosaccharide in dry form may be mixed with any
pharmaceutically acceptable liquid vehicle suitable for the
topical treatment of wounds. The preferred diluents are
distilled water, any balanced salt solution, normal saline or
Ringer's solution. These and other pharmaceutically
acceptable solutions will be well known to the skilled
artisan; particularly preferred are balanced salt solutions
which have themselves been shown to have a beneficial effec
on wound healing processes (U.S. Patent No. 4,414,202). The
pH of the solution should be maintained between about 5 to
about 7.4; preferably about 6-7. Alternat,elY, the solution
used may be any of the currently available high fructose corn
12~Z9,~3
1 syrups, either diluted or undiluted. For use in dry form,
the monosaccharide may be any chemically pure powder.
Particularly useful is dried high fructose corn syrup powder,
such as is produced by American Maize Company (Indiana).
This product comprises a mixture of about 95% glucose and
fructose, the remainder being sugars of higher molecular
weight.
The film-forming composition of the present
invention comprises an effective amount of at least one
pharmaceutically acceptable monosaccharide containing from
about 3 to 7 carbon atoms and a pharmaceutically acceptable
film-forming agent.
In a preferred embodiment, the pharmaceutically
acceptable monosaccharide of the present invention is a
pharmaceutically acceptable aldose sugar or a
pharmaceutically acceptable ketose sugar. Among the
pharmaceutically acceptable aldose sugars within the
contemplation of the present invention are erythrose,
threose, ribose, arabinose, xylose, lyxose, allose, altrose,
glucose, mannose, gulose, idose, galactose and talose. Among
the pharmaceutically acceptable ketose sugars preferred for
use in the composition of the present invention are
erythrulose, ribulose, xylulose, psicose, fructose, sorbose,
tagatose, and sedoheptulose. Although either (D) or (L)
isomers may be employed, the (D) form is generally
preferable. Although all of the above aldose and ketose
sugars may be employed as the monosaccharide component of the
composition of the present invention, glucose of the aldose
sugars and fructose and sorbose among the ketose sugars are
particularly preferred. Overall, the ketose sugars are most
particularly preferred, and of these, fructose is the most
preferred monosaccharide for use in the composition of the
-13- ~z~Z943
1 present invention, since the proportions necessary to achieve
the desired effect are smaller when fructose is used. The
monosaccharide is preferably present, in an amount of between
about .01 to about 50~ by weight of the composition. Most
preferably, the monosaccharide is present in an amount of
between about 5 to about 30% of the weight of the
composition. The monosaccharide component may also be a
mixture of two or more monosaccharides. For example, high
fructose corn syrups are available in powder form; these
generally contain about a 95% combination of glucose and
fructose, in approximately equal amounts. Such powders may
be also combined with the starch hydrolysate, preferably in
an amount of up to about 30%, in lieu of addition of a single
monosacchride.
In another preferred embodiment of this invention
the pharmaceutically acceptable film-forming agents include,
but are not limited to, any of starch hydrolysate, polyvinyl
pyrollidone, polyvinyl alcohol, ethylene glycol, albumin,
cellulose, gelatin, solubilized keratin, hydrocolloids such
as alginate, karaya gum, gum arabic, gum tragacanth, agar,
and locust bean gum. Of these film-forming agents, starch
hydrolysate is most preferred.
Those skilled in the art are aware that starch
hydrolysate is a generic term of a mixture of carbohydrates
most commonly classified according to its dextrose
equivalent. The starch hydrolysate of the present invention
is one which has a dextrose equivalent of no more than 85,
but preferably no more than 40. More preferably, the
dextrose equivalent of the starch hydrolysate of the present
invention is between about 5 and 40. Still more preferably,
the dextrose equivalent of the starch hydrolysate is between
about 7.5 and 30. Yet still more preferred is a starch
l;Z9Z943
l hvdrolysate having a dextrose equivalent in the range of
between about 10 and 20. Most preferably, the starch
hydrolysate of the present invention has a dextrose
equivalent in the range of between about 13 and 17. Those
skilled in the art are aware that starch hydrolysates having
a dextrose equivalent in this latter most preferred range are
more specifically maltodextrins. It will also be understood
that "pharmaceutically acceptable" means purified and
sterilized. Any of the known methods, including dry heat,
filtration, or irradiation may be used for the sterilization,
although for the monosaccharide, irradiation is not
particularly recommended because of the possible effect on
- the molecular structure.
The action of the film-forming agent combined with
monosaccharide may be further enhanced by the incorporation
of small amounts of optional ingredients. The optional
components generally do not constitute more than 5% of the
total weight of the composition.
In another preferred embodiment, a principal
additional component of the composition of the present
invention is one which includes ascorbic acid or a
pharmaceutically acceptable salt thereof. Those skilled in
the art are aware that ascorbic acid or a pharmaceutically
acceptable salt thereof promotes the formation and growth of
healthy granulation tissue. Among the pharmaceutically
acceptable ascorbate salts contemplated for use in this
invention are sodium ascorbate, potassium ascorbate and
calcium ascorbate. However, it is emphasized that the acid,
ascorbic acid itself, is most preferred. When employed, the
ascorbate component is preferably used in an amount of from
about 0.1-5% of the total weight of the composition, and most
preferably comprises about 1-3.5% of the composition.
lZ~2943
1 In another preferred embodiment, the composition of
the present invention includes one or more pharmaceutically
acceptable metal salts selected from the group consisting of
iron, calcium, copper, magnesium, selenium, silver,
manganese, zinc and mixtures thereof. The incorporation of
one or more of these salts in the composition of the present
invention beneficiates the process of its healing. Among the
preferred salts, a ferrous ~ion II) containing salt is most
preferred. For example, the utilization of one of ferrous
sulfate, ferrous chloride or ferrous gluconate is preferred.
Of these, the use of ferrous sulfate is particularly
preferred. It is emphasized that more than one of these
salts may be included in the composition of the present
invention. Thus, a ferrous salt may be used with one or more
of the above recited class of metal salts. Of these, ferrous
sulfate is particularly preferred. Among the other salts
contemplated for use here are calcium ascorbate, calcium
chloride, calcium iodate, calcium permanganate, calcium
phosphate (mono-, di, and tribasic), calcium gluconate, zinc
acetate, zinc carbonate, zinc chloride, zinc citrate, zinc
iodate, zinc oxide, zinc permanganate, zinc proxide, zinc
salicylate, zinc stearate, zinc sulfate, magnesium chloride,
magnesium citrate, magnesium chloride, magnesium sulfate,
manganese chloride and copper sulfate. Preferred silver
salts are silver nitrate, silver citrate, silver iodide and
silver lactate. Iodine, in elemental form, and complexed
with starch hydrolysate through heating and as iodine
tincuture, iodine saIts, such as lugol solution, may also be
added. Sodium and potassium iodide, sodium potassium iodate,
30 ~calcium iodate and calcium iodide are particularly preferred.
Dilute PVP-iodine solutions in water, normal saline on
" ~ ~ ~
balanced salts solution may also be effectively employed in
conjunction with the present treatment.
,
-16- ~Z9z943
l A further additional ingredient may be one or more
of the adenosine phosphates, i.e., ATP, ADP or AMP.
In still yet another preferred embodiment of
the composition of the present invention the
composition includes a compound selected from the group
consisting of alpha-ketoglutaric acid and pharmaceutically
acceptable salts of alphaketoglutaric acid.
Alpha-ketoglutaric acid and its salts accelerate collagen
formation thus increasing the rate of healing of the wound to
which the composition of the present invention is applied.
This component is generally presnet in an amount of no more
than 1-2~.
Finally, yet another component may be included in
the composition of the present invention. This component is
one or more amino acids which also improve healing. In a
preferred embodiment one or more, up to all, of the following
amino acids may be provided in the composition of the present
invention: isoleucine, leucine, lysine, methionine,
phenylalanine, threonine, tryptophane, valine, tyrosine,
alanine, arginine, glycine, proline, histidine, serine,
asparagine, aspartic acid, cysteine, cystine, glutamine and
glutamic acid. Of these, glycine, proline and lysine are
particularly preferred.
It will be understood that, as used herein, the
term "amino acid" refers to both the pure form and the
hydrochloric acid salts of the amino acids. Thus, in
preferred embodiments of the present invention wherein amino
acid is employed, one, two or all three of the above
preferred amino acids are included in the composition of this
invention. In general, the amount of amino acid in the
composition should not exceed 1~.
-17- lZ9Z9 ~3
l In a particularly preferred embodiment, the
composition of the instant invention includes starch
hydrolysate and a monosaccharide selected from the
group consisting of d-fructose, d-glucose, and d-sorbose.
More preferably, the composition of the present invention
- comprises a starch hydrolysate having a dextrose equivalent
of not more than 40, and d-fructose. Preferably, the
frutose comprises up to about 30~ of the total weight of t~e
composition.
In other preferred embodiments, the composition
comprising d-fructose and a starch hydrolysate having a
dextrose equivalent of no more than 40 is supplemented with
one or more of the following additives: an amino acid which
is preferably one or more of the amino acids recited above;
alpha-ketoglutaric acid or a pharmaceutically acceptable salt
thereof; a ferrous salt, preferably ferrous sulfate; another
pharmaceutically acceptable salt of a metal selected from the
group consi&ting of calcium, zinc, manganese, magnesium,
copper, selenium and silver.
In a particularly preferred embodiment of the
present invention all of the above components are
included in the composition. That is, a particularly
preferred embodiment of the present invention is provided in
a composition incorporating a principal amount of starch
hydrolysate, having a dextrose equivalent between 13 and 17;
d-fructose, present in a concentration of from 5 to 30
percent; ascorbic acid, present in the concentration of 1 to
5 percent; ferrous sulfate, present in a concentration of 0.1
to 1 percent; a zinc salt, present in a concentration of up
to 1 percent; alphaketoglutarate present in a concentration
of about 1-2~ and at least one amino acid present in a
concentration of 0.1 to 1 percent, all said percentages being
by weight, based on the total weight of the composition.
-18- 1Z9Z943
l In a wound which is only moderately infected or not
yet infected, the inclusion of the monosaccharide is
sufficient to control infection to acceptable levels. In the
cases of particularly heavy infections, however, it may be
desirable to also include, in small amounts one of the known
antibiotics or antifungal agents commonly used in wound
treatment. Among the useful antibiotics are streptomycin,
penicillin, tetracycline, silver sulfadiazine, sulfanilamide,
methylated sulfanilamide (sulfamylonR), cephalosporins, and
amino-glycosides. Useful antifungal agents are nystatin,
mycostatinR, or gramicidin. It must be noted that only small
amounts of the antibiotic need be added.
The compositions of the present invention may be
effectively employed in a regular program of wound treatment.
~or example, in the preferred method of wound treatment, a
starch hydrolysate monosaccharide powder preparation is
applied directly to the wound once or twice a day.
Typically, the wound is first surgically debrided to remove
all necrotic tissue. It is also possible to use water
pulsating instruments to facilitate debridement; enzymatic
debridement may prove useful as well, employing proteolytic
enzymes such as TravaseR, BiozymeR, collagenase or elase.
In accordance with the teachings of U.S. Patent No.
4,414,202, the wound is preferably irrigated, prior to
application of the film forming composition, with a buffered
salt solution having a pH between 6-7.8. It has also been
found that irrigation and/or soaking the wound with dilute
(0.05-1~) PVP-iodine solutions for 5 to 30 minutes before the
addition of the composition aids in enhancing the effect of
the dry material on wound healing. The wound is then covered
with the starch hydrolysate/monosaccharide composition in an
amount sufficient to allow formation of a film over the
wound. The wound may then optionally be covered with a
-19- 12~2943
1 preferred non-adhesive dressing, which may be removed for the
daily repeat of the treatment. This method of treatment is
particularly applicable to mammalian skin wounds, and is most
suitable for treatment of human wounds.
~hen the monosaccharides are usedas an active agent
in a pretreatment solution, it is often desirable to include
small amounts of pharmaceutically acceptable zinc, calcium,
ferrous, copper, manganese, magnesium salts and silver.
These optional components are generally only used in an
amount of between about .001~ to about 5%, preferably about
.01 to about .1% of the total solution. These salts are
known to have a beneficiating effect in the process of wound
healing. Among the salts contemplated for use here are
calcium ascorbate, calcium chloride, calcium iodate, calcium
permanganate, calcium phosphate lmono-, di, and tribasic),
calcium gluconate, zinc acetate, zinc carbonate, zinc
chloride, zinc citrate, zinc iodate, zinc oxide, zinc
permanganate, zinc peroxide, zinc salicylate, zinc stearate,
zinc sulfate, magnesium chloride, magnesium citrate, silver
nitrate, silver iodide, silver lactage, magnesium chloride,
magnesium sulfate, manganese chloride, copper sulfate,
ferrous sulfate, ferrous chloride or ferrous gluconate. Also
useful are iodine salts, such as potassium, sodium, or
calcium iodide or iodate, as well as elemental iodine or
PVP-iodine. These may be used alone or in combination with
the solution or dry powder, but in general it is preferred
that the total amount of these additional components not
exceed 5~ overall. Other possible additives are very small
amounts of antibiotics such as sulfonilamide (SulfamylonR)
sulfadiazine, silver-sulfadiazine, zinc-sulfadiazine,
penicillin, tetracycline, cephalosporins, aminoglycosides,
clindamycin and antifungal agents such as mycostatinR,
nystatin, or gramicidin.
-20- lZ~Z~43
1 It will be recognized by one skilled in the art
that, with respect to the components in the solution and the
dry powder, since these are to be used to prevent microbial
infection, the material should be sterilized prior to
application. Although the method of sterilization is not
particularly restricted, it is recommended that irradiation
not be the method of choice, because of the possible effect
of radiation on the molecular structure of the
monosaccharide, particularly in solution. Dry heat
sterilization has proven particularly suitable for the
purposes of the present invention.
This method of controlling microbial growth is
suitable for use on any mammalian skin wound. However, the
present method is particularly well suited for the treatment
of human skin.
The process of the present invention will be better
unde~stood by references to the following non-limiting
examples:
3
-21-
129Z943
1 Example 1
The following illustrate Examples of wound healing
compositions of the present invention. In each case,
fructose was a chemically pure fructose made by Pfanstiehl
Laboratories, Inc. (Waukegan, Ill.) M-150 refers to a starch
hydrolysate having a dextrose equivalent of 13-17 (Maltrin ,
Grain Processing Corporation, Muscatine, Ia.~. The starch
hydrolysate was sterilized by radiation prior to use.
I. M-150 95g
fructose 5g
II. M-150 70g
fructose 30g
III. M-150 88g
fruetose lOg
ascorbic acid 2g
IV. M-150 72g
fruetose 15g
sodium aseorbate 3g
V. M-150 81g
fruetose l5g
ascorbie aeid 3g
amino aeids
(20 amino aeids in
equal proportions) lg
~::
-22-~Z~2~43
l VI. M-150 77g
fructose 20g
potassium ascorbate 2g
glycine .33g
lysine .33g
proline .34g
VII M-150 80g
fructose 18g
-ketoglutarate lg
ferrous sulfate .lg
amino acid
(20 amino acids in
equal proportions) .9g
:
: 3O
;
-23-
Example 2
A. An 84-year-old white female was affected with
progressive brain syndrome, Alzheimer's disease,
malnutr'tion, cachexia and a non-healing decubitus ulcer of
the left ischiatic region. The ulcer measured, at time of
admission, 5.5 x 6 x 1.8 cms. There were large amounts of
foul-smelling, necrotic, gangrenous tissue. Cultures taken
from the wound indicated the presence of the following
bacteria: Proteus mirabilis, Escherichia coli, Staphylococcus
aureus, and Pseudomonas aeruginosa.
Initially thorough debridement of necrotic tissue
was carried out, followed by intensive irrigation with
TIS-U-SOLR, a balanced salts solution. The ulcerated area
was then filled with M-150, a D-glucose polysaccharide
~starch hydrolysate) with a dextrose equivalent of 13-17.
Treatment thereafter consisted of twice daily irrigation with
the salt solution, and application of the starGh hydrolysate.
The ulcer was covered each time with a non-adhesive dressing.
After 3 weeks of treatment, the infection decreased and the
ulcer decreased in size, but healing was progressing very
slowly,
At this point, treatment was continued in the same
fashion, but instead of the starch hydrolysate alone, a
mixture of starch hydrolysate and fructose, in a ratio of
80:20, was used. An immediate clinical response was
manifested by more highly vascularized granulation tissue
formation, a faster filling in of the crater, a rapid
decrease in the surface area of the ulcer, and a faster
growth of the epithelium. Further the exudate normally
- present in the ulcer decreased significantly, and the
presence of a more sturdy, better organized, more clinging
film over the granulation tissue was noticed. Multiple
-24-
lZ9Z943
l strands of this film could be seen clinging to and binding
several areas of the ulcer granulation tissue platform. By
the end of 3 weeks (a total of six weeks) the ischiatic ulcer
was completely healed.
B. A 67-year-old woman afflicted with multiple
sclerosis of 12 years duration was completely paralyzed, and
had developed severe, deep infected Stage IV pressure ulcers
of both hips, the sacral area, and both ischiatic regions.
She was admitted to the wound healing unit and
underwent the following treatment; twice daily irrigation
with a balanced, buffered salt solution, and sprinkling of
M-150 starch hydrolysate powder. Healing and infection
control began on the first day of treatment; by the end of
the third week, the ulcerated areas had healed about 20% of
the initial size. At that point, the lesions on the right
side were treated with a mixture of starch hydrolysate ~73
parts), fructose (24 parts), ascorbic acid t2 parts) and a
mixture of 20 amino acids in equal proportions (1 part). The
left side lesions received the same treatment as before, and
acted as controls. By the end of 8 weeks, the ulcers treated
with the complex formulation were 90~ healed, whereas the
control areas were only 35~ healed.
-25-
1 ExAMpLE 3
The following example demonstrates one of the
a~tibacterial effects of monosaccharide sugars ln vitro.
Tissue samples of infected lesions were excised by
dermal punch from the center of each wound; each sample had
an average weight of about 0.7g. Tissue samples were dipped
in 95% ethanol and flamed dry to remove surface
contamintaion; the tissue was then ground on a sterile mortar
and pestle, with l.Oml of saline until finaly macerated.
Serial ten-fold dilutions were performed in saline and
smaples plated by pour plate technique. Quantitation was
then performed at 24 hours for facultative anaerobic bacteria
and 48 hours for anaerobically incubated plates, and results
recorded as microorganisms per gram of tissue. Following
identification and quantification, all microorganisms were
transferred to ETHA slants (ETHA was prepared by addition of
1.5~ agar (DIFC0 Labs) to enriched Todd-Hewitt broth, ~ETHB)
containind Todd-Hewitt Broth (Baltimore Biological
Laboratories), 0.5% yeast extract (BBL), 0.05~ hemin (Eastman
Kodak Co.) and 0.005~ menadione (Sigma Chemical Co.). All
microorganisms were grown for 24 hours in ETHB before
inoculation to sugars.
The following sugars were used for comparative
testing of their bacteriostatic effects: glucose, and
fructose, (monosaccharides) and sucrose and lactose
(disaccharides). Each sugar solution is prepared in lOml
tubes of ETHB to concentrations of 10, 20, 30, 50 or 70%
(W/V) and then autoclaved. The pH was adjusted to about 7.4.
A O.lml inoculation containing approximately 1 X 108
organisms was then placed on all tubes, giving a final
concentration of 1 X 10 organism/ml. Tubes were incubated
aerobically for falcultatives, and anaerobically in Gas Pak
-26-
129;2943
l jars (BBL) for obligate anaerobes. It designated time
periods, tubes were removed from incubation and optical
density measured on a Column Hitachi 124.
Results for two trials are shown in Tables l and 2.
Observation of these tests results show that, overall, the
monosaccharides have an unexpectedly much more potent effect
on the prevention of bacterial growth than do the
disaccharides, requiring a much lower percentage of sugar to
achieve bacteriostasis.
:
-27-
43
1 Table 1. Percent sugar necessaryl to reduce growth
of bacteria by 50~ after 24 h of incubation2
Microorganism Glucose Sucrose Fructose Lactose
-
Enterococcus 21.5 29 11.5 N.D.3
Staphylococcus 13.6 26 8.3 15.6
aureus
Proteus mirabilis 13.6 18.6 9.3 14.3
Peptostreptococcus 11 28 6 8.3
Values are the average of results obtained from at least two
clinical ioslates of each microorganism.
Bacteria were incubated under appropriate conditions as
described in Material and Methods.
3N.D. = not do~e
3o
-28-
lZ92~43
l Table 2. Percent sugar necessaryl to reduce growth
of bacteria by 90~ after 24 h of incubation2
Microorganism Glucose Sucrose Fructose Lactose
Enterococcus 28.3 64 21.2 N.D.
-
Staphylococcus 20 74.3 19.6 47
aureus
Proteus mirabilis 28.3 46 34.3 40
Pe~tostreptococcus 80 62 33.3 26.3
Values are the average results obtained from at least two
clinical isolates of each microorganism.
Bacteria were incubated under appropriate conditions as
described in Materials and Methods.
N.D. = not ~one
~0
: 25
3
:
-29-
~Z9Z943
l ExAMpLE 4
The following Example shows the effective treatment
of wounds using a monosaccharide containing pretreatment
solution:
A. The subject was a 90 year old woman affected
with progressive organic brain disease, paralysis,
contractures of the upper and lower extremities and a large,
deep pressure ulcer (bed-sore) on the right trochanteric area
measuring 12cms X 8cms X 2cms. Her pressure ulcer was filled
with large amounts of necrotic tissue and abundant purulent,
foul smelling exudate. X-rays of the hip showed the presence
of a metallic hip replacement prosthesis and osteomyelitis of
the femoral bone.
The pressure ulcer was treated twice daily with
irrigation with balanced salts solution and sprinkled with a
starch hydrolysate powder with a ~extrose Equivalent (D.E.)
of 17 The ulcer was debrided of necrotic tissue daily as
needed. Even though the attendant foul odor decreased with
the u~e of starch hydrolysate alone, the production of
purulent exudate continued as the patient developed fevers of
102-103P. The femoral head prosthesis was removed
surgically and the remaining cavity was thoroughly irrigated
with the balanced salts solution. Portions of the femur and
acetabulum were curetted.
The remaining wound was then treated twice daily by
irrigation with balanced salts solution and sprinkled with
chemically pure fructose powder (Pfanstiehl Laboratories,
Muscatine, I.A.). The remaining infection subsided almost
completely. The foul odor characteristic of this infection
subsided within 24-28 hours and healthy, highly vascularized
granulation tissue began to fill the wound cavity. The
-3~-
~Z9Z943
l epidermis as well began to grow in a centripetal manner. By
the end of the 4th post-operative week the original ulcer
site had healed 80~ and the patient was discharged to an
e~tended care facility.
B. A 72 year-old female suffered a subdural
hematoma on the left occipital region; following a
craniotomy, the subdural hematoma was removed. During the
recovery period throughout which she was laid on her back,
without being turned for several days, she developed a deep,
severely infected, foul-smelling sacral pressure ulcer, State
IV, which extended down to the sacral bone. She was treated
initially with povidone-iodine soaks, which only had the
effect of causing deterioration and enlargement of the ulcer.
At this point, treatment was initiated with a high
fructose corn syrup powder (DE 42-55). The powder was
sprinkled on the wound twice daily, following irrigation with
a balanced salt solution. The infection came under control
almost immediately by the second post-treatment day; this was
~lso a~companied b~ formation of a highly vascularized fast
growing granulation tissue.
Once the healing was initiated in this manner, a
follow-up treatment was begun, approximately, 2 weeks after
the HFGS treatment was started. Because the HFCS alone
cannot form an adequate film to provide a barrier over the
wound, a mixture of starch hydrolysate powder (DE-13-17) and
HFCS powder (70:30) was prepared. The healing progressed
rapidly until complete closure of the original ulcer was
accomplished by the end of the 8th week.
