Note: Descriptions are shown in the official language in which they were submitted.
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Mixtures of at least two reverse transcriptase
inhibitor's and hydroxycarbamide, in particular for
inhibiting retroviral spread
FIELD OF TH'.E INVENTION
The present invention relates to a combination or an
association of at least two reverse transcriptase
inhibitors and hydroxycarbamide wherein the
l0 combination or association is useful in inhibiting
retroviral :spread.
BACKGROUND OF THE INVENTION
The expresscion "Acquired Immuno-Deficiency Syndrome"
(AIDS) was first used in 1981 to describe a state of
cellular immune deficiency in homosexuals,
characterized by the appearance of opportunistic
infections and Kaposi's Sarcoma evolving very
aggressivel~l (CDC (Center for Disease Control), MMWR,
30 . 305-30~8.DC (1981)). In 1983 a retrovirus since
called HIV (Human Immunodeficiency Virus type 1) was
isolated among AIDS patients (Barre-Sinoussi F. et al
Science, 220 : 868-870 (1983)).
Over the past several years, researchers and
clinicians have gained considerable experience in
studying and caring for individuals infected with HIV
throughout the often prolonged course of HIV disease
and AIDS. On the basis of this experience, it has
become clear that the pathogenic mechanisms underlying
HIV infection and disease are not unidimensional, but
rather are extremely complex (Fauci AS., Science, 239,
617 (1988)). Any attempt to design a comprehensive
therapeutic strategy for HIV disease must take this
fact into ~~ccount. (Fauci, 1993, Science, 262:1011
1018 ) .
After entry of the HIV virus into cells and
CONFIRMATION COPY
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uncoating of the HIV particle, reverse transcription
of the viral RNA genome into DNA replicas occurs.
Among several forms of unintegrated viral DNA (now
containing the long repeats [LTRs], at both the 5' and
the 3' ends) only the two-LTR linear forms can
integrate into the host genome. Such a process appears
strictly dependent upon cell activation/replication of
T lymphocytes, although "resting" T cells are clearly
susceptible to HIV infection. (lack J.A. et al, Cell;
61, 213-222, (1990)). Furthermore, part of the reverse
transcription process also can occur in unactivated T
cells, a process that results in the accumulation of
incomplete DNA molecules, which may persist for
several hours and remain capable of being integrated
into the host genome if the cell undergoes sufficient
activation (Zack J.A. et al, Cell ; 61, 213-222,
(1990)). Therefore, infected "resting" CD4+T
lymphocytes can be considered a transient viral
reservoir in infected individuals (Bokrinsky M.I. et
al; Science, 254, 423-427, (1991)). These observations
are of particular importance in anatomic compartments
such as the peripheral blood and lymphoid organs,
where the CD4+ T cell subset represents the
predominant infected cell type (Schmittman S M. et al,
science, 245, 305-308, (1989)); (Fox CH. et al J.
Infect. Dis., 164, 1051-1057, (1991)).
The above discussion provides a sound scientific
basis for blocking the initial burst of virus
replication and dissemination as well as the
persistent replication throughout the course of
disease by treating HIV-infected individuals with
anti-retroviral agents from the earliest time that HIV
infection is recognized through the entire course of
infection. Unfortunately, currently available agents
used alone are only partially effective in suppressing
virus replication and spread, and this effect is
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transient I;Hirsch MS, et al, New Engl. J. Med. 328
1686, (1993)).
A number of reverse transcriptase inhibitors have
been fount, to be useful for the treatment or
prophylaxis of retroviral infections and especially
HIV and AIDS. Examples of such materials include: 3'-
azido-2',3'-dideoxythymidine or azidothymidine (AZT) ;
2',3'-dideo:xycytosine (ddC) ; 2',3'-dideoxy-adenosine
(ddA); 2',3'-dideoxy-guanosine {ddG) ; and 2',3'-
dideoxy-ino;sine (ddI) ; 2',3'-dideoxy-thymidine (ddT);
2',3'-dideh:Ydro-3'-deoxythymidine (d4T) ; 2'-deoxy-3'-
thiocytidin~~ (3TC). See European patent application
0206497 and published PCT application number WO
87/01284.
Non nucleoside reverse transcriptase inhibitors
(in abreviation NNRTI) have been also proposed, such
as nevira~>ine (Boeringher Ingelheim), pyridinone
(Merck), piperazine or atevidine, imidazo
benzodiazep:ine (Tibo), delavirdine (Upjohn),
loviridine.
Hydroxyc~arbamide (HC) was initially synthesized
over 120 years ago and has been found to demonstrate
activity against a broad spectrum of tumors.
(Donehower, Seminars in Oncology, Vol. 19, No. 3,
Suppl. 9 (June) 1992: pp 11-19). Additionally,
hydroxycarb<~mide has been used as a virucide. In
published PCT application number WO 93/09718,
hydroxycarbamide is taught to be useful in a hydrogel
polymer coating of a blood bag in order to inhibit
viral and HIV infectivity.
Gao et al (PNAS, USA, Vol. 900 pp. 8925-8928,
October 1993) disclose that hydroxyurea
(hydroxycarbamide) treatment of peripheral blood
lymphocytes (PBLs) decreases dNTP levels and the DNA
synthesis rate to levels comparable to quiescent PBLs.
The article alleges a possible use of hydroxyurea
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in AIDS therapy.
However, there still remains a need for more
effective treatments for the suppression of
retroviruses and, in particular, the prevention and/or
inhibition of HIV and viral spread. By viral spread,
it is intended to include the inhibition of viral
replication, and also may include the ability of
inhibiting the virus to infect a further host cells.
Objectives of the present invention in the search
l0 for new antiretroviral agents include:
1) the identification of treatments with less
toxicity and antiviral activity greater than a
combination of two reverse-transcriptase inhibitors
alone,
2) the development of drug combinations or
associations which potentiate the synergistic (if any)
activity of at least two reverse-transcriptase
inhibitors co-administered in a same treatment.
BRIEF SUMMARY OF THE INVENTION
The present invention relates to a combination or
association of at least two different reverse
transcriptase inhibitors and hydroxycarbamide wherein
the combination or association is capable of
preventing and/or inhibiting the spread of
retroviruses including HIV. More specifically, the
present invention relates to a method of preventing
and/or inhibiting the spread of retroviruses,
including HIV (HIV-1 and HIV-2), HTLV-1, HTLV-2, SIV,
by exposing a cell population, including cells
infected by a retrovirus such as, for example, HIV, to
a combination or association of at least two reverse
transcriptase inhibitors and hydroxycarbamide.
Additionally, the present invention encompasses the
treatment of HIV-infected and AIDS patients with a
combination or association of at least two different
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reverse transcriptase inhibitors and hydroxycarbamide
in order to prevent and/or inhibit the spread of HIV
in these patients.
In a preferred embodiment of the present
5 invention, each reverse transcriptase inhibitor is a
dideoxynucleoside, in particular at least one of AZT,
ddC, ddI, ddA, ddG, ddT, and for example ddI.
In another preferred embodiment of the invention,
each reverse transcriptase inhibitor is a
i0 didehydrodeoxynucleoside, in particular d4T.
In another preferred embodiment of the invention,
each reverse transcriptase inhibitor is a non
nucleoside reverse transcriptase inhibitor, in
particular at least one of hevirapine, pyridinone or
atevidine, imidazo-benzodiazepine, delavirdine and
loviridine.
In particular and in the preferred combination or
association of the present invention, it has been
found that the co-administration of hydroxycarbamide
(HC), 2',3'-dideoxy-inosine (ddI), and didehydrodeoxy-
thymidine (d4T) is especially effective in preventing
and/or inhibiting HIV spread. The preferred embodiment
of the invention encompasses a composition including a
pharmaceuti~~al composition comprising a combination of
ddI, d4T and HC. The pharmaceutical composition can
optionally contain a pharmaceutically acceptable
carrier and,/or excipient and/or vehicle. The preferred
method of t:he instant invention comprises preventing
and/or inhilbiting retroviral or HIV spread by treating
a cell population, including cells infected with HIV,
with a combination or association of ddI, d4T and HC.
Additionall~l, the preferred method comprises treating
an HIV infected or AIDS patient with an association or
combination of ddI, d4T and HC so as to prevent and/or
inhibit HIV spread in the patient.
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DETAILED DESCRIPTION OF THE INVENTION
The following example of a specific embodiment of
the present invention is offered for illustrative
purposes only and is not limiting with respect to the
scope of the disclosure or claim coverage.
Clinical evaluation of the use of
hydroxycarbamide, ddI and d4T in HIV infection
We evaluated 6 months' treatment of HIV-infected
l0 patients with the combination therapy hydroxycarbamide
(hydroxyurea), didanosine (ddI) and didehydrodeoxy
thymidine (d4T). The combination or association was
evaluated in asymptomatic patients. The objective was
to evaluate the tolerance and the anti-viral response.
A significant decline in viral load was observed after
6 months' treatment with this combination therapy.
27 volunteers, ddI- and d4T-naive individuals
classified by CDC at entry as A1 or A2 (without
symptoms and CD4 cell count >200 cells/~,1),
seropositive for HIV-1 confirmed by ELISA and Western
Blot, were treated for 6 months. ddI was given at the
dose of 200 mg twice daily, hydroxycarbamide at the
dose of 15 mg/kg per day in two divided doses and d4T
at the dose of 40 mg twice daily. Plasma viral load
was evaluated for HIV-RNA by PCR using the
ultrasensitive PCR Amplicor HIV Monitor (Roche
Diagnostic Systems, Branchburg, NJ, USA).
Treatment was well tolerated; no patient
interrupted treatment due to side-effects. A few minor
transient symptoms such as digestive disorders were
noted in some patients, thrombopenia in one patient,
neuropathy in one patient and an increase in mean
corpuscular volume was seen in all patients. After 180
days, leucopenia was observed in three patients. No
changes is haemaglobin, amylases, lipases, or
transaminases were recorded.
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Average plasma HIV-RNA at baseline was 172 113
copies/ml (see fable). All patients showed a very
significant drop in plasma viral load and in 23 out of
27 patients evaluated at 6 months, viraemia became
undetectable. 4 out of 27 patients showed an average
reduction in plasma viremia of 3.17 log (from 464 312
to 318 copies/mlj. After 180 days of therapy, average
CD4+ lymphocytes relative to total lymphocytes
remained unchanged (28%).
The subject of the present invention is also a new
composition or association for the treatment of a cell
population in the presence of a retrovirus.
Additionall~~, the invention includes a pharmaceutical
composition intended, in particular, for the treatment
and prevention of retroviral infections, especially
those linked to HIV and AIDS wherein the composition
contains hydroxycarbamide (HC) and at least two
different reverse transcriptase inhibitors, in
particular at least two different dideoxynucleosides
and hydroxycarbamide, most preferably a combination of
dideoxyinos:ine, didehydrodeoxy-thymidine, and
hydroxycarbamide as active principle, in a
pharmaceutically acceptable vehicle. The composition
of the invention can also contain inert or
pharmacodynamically active additives, carriers and/or
excipients.
The pharmaceutical composition of the invention
can take the form of a lyophilized powder of the
active combination, to be dissolved immediately before
use in a ~~hysiological solution for the purpose of
injection. The medicament can then be administered
parentera115r, for example intravenously,
intraperitoneally, in the cerebrospinal fluid, and the
like. For injection, the active principle is dissolved
in a phy;~iological solution until the desired
concentration for administration is obtained.
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TABLE
Vlrologicel data at baseline and after 6 months of treatment
o; H) V-i~feated Indlvlduats with $ combtnatlon of
hydroxycarbetrtllna, dtdanosine and d4T.
PCR RNA
RNA CCpI9S/ITi1
plasma
Pat[ent Day 0 Day 180
y non det non det
2 935751 non det
non det
4ggg0 ion det
1820 non det
t 01411 - non det
88528 <200
non det
g 160806 non det
1 p 517 non det
11 1645946 625
1 2 98539 non det
1 g 33384 nan det
1 4 216542 non det
1 5 11754a non det
1 6 1560 non det
1 ~ 76395 non det
~ 8 1 g87 non det
52407 non det
20 2309a 256
21 1382 non det
2 2 T 21 2 non det
2 3 1 189BC nan det
2 4 822913 non det
2 5 99682 218
2 6 non det nOn det
241862 non det
non det: non detectable (sensttivity threshold = 200 RNA coplES/mty
SUBSTITUTE SHEET (RULE 26)
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The pharmaceutical composition according to the
invention can also take a form which is suitable for
oral administration. For example, suitable forms are
tablets, hard gelatin capsules, dragees, powders and
granules. The formation of such oral forms is well-
known to those skilled in the art. Any of the known
formulations are useful in preparing the instant oral
pharmaceutical compositions.
As regards the dosage of the medicament according
to the invention, it will be clear to the artisan that
the doses to be administered are variable according to
the treatment period, and frequency of administration,
the host and the nature and severity of the disease
and that the dosages can be easily determined without
any undue amount of experimentation.
The com~~ositions of the invention are administered
in substantially non-toxic dosage concentrations
sufficient to ensure the release of a sufficient
dosage unit of the present combination or association
into the patient to provide the desired inhibition of
the spread of the retrovirus. The actual dosage
administered will be determined by physical and
physiologic<~1 factors such as age, body weight,
severity of condition, and/or clinical history of the
patient. With these considerations in mind, the dosage
of the instant combination or association for a
particular subject can be readily determined by the
physician. It might be noted that in extreme cases a
dosage approaching the toxic level may be the
acceptable i:reatment protocol.
For example, in the treatment of HIV-infected and
AIDS patieni~s, the composition can comprise from about
1 to 66 mg/Kg/day of ddI, from 0.1 to 2 mg/Kg/day of
d4T, and from abaut greater than 1 mg/Kg/day to about
20 mg/Kg/day of HC.
The invention also covers the use of
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hydroxycarbamide (HC), didehydrodeoxythymidine and
dideoxyinosine in combination with other medicinal
compositions intended for the treatment of retroviral
infections and tumors, in particular HIV protease
5 inhibitors, such as for example indinavir, ritonavir,
saquinavir, nelfinavir, palinavir, VX-478 (Vertex),
and AG1343 (Agouron), immunostimulants and
immunomodulators such as for example cytokines,
including IL-2, IL-12 and interferon molecules can be
ZO used in combination with the present invention.
By association of compounds is meant a co-
administration of these compounds, whether they are
administered in a same composition comprising said
compounds, or they are separately administered, so as
to be available in the blood plasma almost at a same
time.
All of the ref erences cited here i nabwP a,-P
expressly incorporated herein, in toto, by reference
thereto.
The invention has been described with reference to
specific and preferred embodiments. It will be
recognized by those skilled in the art that numerous
changes and substitutions may be made without
departing from the spirit and scope of the invention.
