Note: Descriptions are shown in the official language in which they were submitted.
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DRUG DELIVERY DEVICES AND METHODS FOR TREATMENT OF VIRAL
AND MICROBIAL INFECTIONS AND WASTING SYNDROMES
1. FIELD OF THE INVENTION
The present invention is directed to methods of
treating an animal affected by a viral or microbial
infection, particularly an infection with a retrovirus,
such as HIV, or by a wasting syndrome, especially a wasting
syndrome associated with HIV infection or malignancy, by
administering a polar compound such as N,N'-
dimethylformamide (DMF) or dimethylsulfoxide (DMSO). The
invention also provides pharmaceutical preparations and
drug delivery devices comprising a polar compound such as
DMF or DMSO for treatment of an animal affected by a viral
or other microbial infection or a wasting syndrome.
2. BACKGROUND OF THE INVENTION
2.1 THE HUMAN IMMUNODEFICIENCY VIRUS
Human immunodeficiency virus (HIV) induces a
persistent and progressive infection leading, in the vast
majority of cases, to the development of the acquired
immunodeficiency syndrome (AIDS) (Barre-Sinoussi et al.,
1983, Science 220: 868-870; Gallo et al., 1984, Science
224:500-503). There are at least two distinct types of
HIV: HIV-1 (Barre-Sinoussi et al., 1983, Science 220:868-
870; Gallo et al., 1984, Science 224:500-503) and HIV-2
" (Clavel et al., 1986, Science 223:343-346; Guyader et al.,
1987, Nature 326:662-669). In humans, HIV replication
occurs prominently in CD4+ T lymphocyte populations, and
HIV infection leads to depletion of this cell type and
eventually to immune incompetence, opportunistic
SUBSTITUTE SHEET (RULE 26)
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infections, neurological dysfunctions, neoplastic growth,
and ultimately death.
HIV is a member of the lentivirus family of
retroviruses (Teich et al., 1984, RNA Tumor Viruses, Weiss
et al., eds., CSH-press, pp. 949-956). Retroviruses are
small enveloped viruses that contain a single-stranded RNA
genome, and replicate via a DNA intermediate produced by a
virally-encoded reverse transcriptase, an RNA-dependent DNA
polymerase (Varmus, H., 1988, Science 240:1427-1439).
Other retroviruses include, for example, oncogenic viruses
such as human T-cell leukemia viruses (HTLV-1, -II, -III),
and feline leukemia virus.
The HIV viral particle consists of a viral core,
composed in part of capsid proteins designated p24 and p18,
together with the viral RNA genome and those enzymes
required for early replicative events. Myristylated gag
protein forms an outer viral shell around the viral core,
which is, in turn, surrounded by a lipid membrane envelope
derived from the infected cell membrane. The HIV envelope
surface glycoproteins are synthesized as a single 160
kilodalton precursor protein which is cleaved by a cellular
protease during viral budding into two glycoproteins, gp41
and gp120. gp41 is a transmembrane glycoprotein and gp120
is an extracellular glycoprotein which remains non-
covalently associated with gp4l, possibly in a trimeric or
multimeric form (Hammerskjold, M. and Rekosh, D., 1989,
Biochem. Biophys. Acta 989:269-280).
HIV, like other enveloped viruses, introduces viral
genetic material into the host cell through a viral
envelope mediated fusion of viral and target membranes.
HIV is targeted to CD4+ cells because a CD4 cell surface
protein (CD4) acts as the cellular receptor for the HIV-1
virus (Dalgleish et al., 1984, Nature 312:763-767;
Klatzmann et al., 1984, Nature 312:767-768, Maddon et al.,
1986, Cell 47:333-348). Viral entry into cells is
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dependent upon gp120 binding the cellular CD4 receptor
molecules (Pal et al., 1993, Virology 194:833-837; McDougal
et al., 1986, Science 231:382-385, Maddon et al., 1986,
Cell 47:333-348), explaining HIV's tropism for CD4~ cells,
while gp41 anchors the envelope glycoprotein complex in the
viral membrane. The binding of gp120 to CD4 induces
conformational changes in the viral glycoproteins, but this
binding alone is insufficient to lead to infection
(reviewed by Sattentau and Moore, 1993, Philos. Trans. R.
Soc. London (Biol.) 342:59-66).
Studies of HIV-1 isolates have revealed a
heterogeneity in their ability to infect different human
cell types (reviewed by Miedema et al., 1994, Immunol. Rev.
140:35-72). The majority of extensively passaged
laboratory strains of HIV-1 readily infect cultured T cells
lines and primary T lymphocytes, but not primary monocytes
or macrophages. These strains are termed T-tropic. T-
tropic HIV-1 strains are more likely to be found in HIV-1
infected individuals during the late stages of aids (Weiss
et al., 1996, Science 272:1885-1886). The majority of
primary HIV-1 isolates (i.e., viruses not extensively
passaged in culture) replicate efficiently in primary
lymphocytes, monocytes and macrophages, but grow poorly in
established T cell lines. These isolates have been termed
M-tropic. The viral determinant of T- and M- tropism maps
to alterations in the third variable region of gp120 (the
V3 loop) (Choe et al., 1996, Cell 85:1135-1148; Cheng-Mayer
et al., 1991, J. Virol. 65:6931-6941; Hwang et al., 1991,
Science 253:71-74; Kim et al., 1995, J. Virol., 69:1755-
1761; and 0' Brien et al., 1990, Nature 348:69-73). The
characterization of HIV isolates with distinct tropisms
taken together with the observation that binding to CD4
cell surface protein alone is insufficient to lead to
infection, suggest that cell-type specific cofactors might
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be required in addition to CD4 for HIV-1 entry into the
host cell.
2.2 TREATMENT FOR HIV INFECTION
HIV infection is pandemic and HIV-associated diseases
represent a major world health problem. Although
considerable effort is being put into the design of
effective Therapeutics, currently no curative anti
retroviral drugs against AIDS exist. In attempts to
develop such drugs, several stages of the HIV life cycle
have been considered as targets for therapeutic
intervention (Mitsuya, H., et al., 1991, FASEB J. 5:2369-
2381). Many viral targets for intervention with HIV life
cycle have been suggested, as the prevailing view is that
interference with a host cell protein would have
deleterious side effects. For example, virally encoded
reverse transcriptase has been one focus of drug
development. A number of reverse-transcriptase-targeted
> >
drugs, including 2 , 3 -dideoxynucleoside analogs such as
AZT, ddI, ddC, and d4T have been developed which have been
shown to been active against HIV (Mitsuya, H., et al.,
1991, Science 249:1533-1544).
The new treatment regimes for HIV-1 show that a
combination of anti-HIV compounds, which target reverse
transcriptase (RT), such as azidothymidine (AZT),
lamivudine (3TC), dideoxyinosine (ddI), dideoxycytidine
(ddC) used in combination with an HIV-1 protease inhibitor
have a far greater effect (2 to 3 logs reduction) on viral
load compared to AZT alone (about 1 log reduction). For
example, impressive results have recently been obtained
with a combination of AZT, ddI, 3TC and ritonavir
(Perelson, A.S., et al., 1996, Science 15:1582-1586).
However, it is likely that long-term use of combinations of
these chemicals will lead to toxicity, especially to the
bone marrow. Long-term cytotoxic therapy may also lead to
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suppression of CD8+ T cells, which are essential to the
control of HIV, via killer cell activity (Blazevic, V., et
al., 1995, AIDS Res. Hum.Retroviruses 11:1335-1342) and by
the release of suppressive factors, notably the chemokines
5 Rantes, MIP-1« and MIP-li3 (Cocchi, F., et al., 1995,
Science 270:1811-1815). Another major concern in long-term
chemical anti-retroviral therapy is the development of HIV
mutations with partial or complete resistance (Lange, J.M.,
1995, AIDS Res. Hum Retroviruses 10:577-82). It is thought
that such mutations may be an inevitable consequence of
anti-viral therapy. The pattern of disappearance of wild-
type virus and appearnace of mutant virus due to treatment,
combined with coincidental decline in CD4+ T cell numbers
strongly suggests that, at least with some compounds, the
appearance of viral mutants is a major underlying factor in
the failure of AIDS therapy.
Attempts are also being made to develop drugs which
can inhibit viral entry into the cell, the earliest stage
of HIV infection. Here, the focus has thus far been on
CD4, the cell surface receptor for HIV. Recombinant
soluble CD4, for example, has been shown to inhibit
infection of CD4+ T cells by some HIV-1 strains (Smith,
D.H., et al., 1987, Science 238:1704-1707). Certain
primary HIV-1 isolates, however, are relatively less
sensitive to inhibition by recombinant CD4 (Daar, E., et
al., 1990, Proc. Natl. Acad. Sci. USA 87:6574-6579). In
addition, recombinant soluble CD4 clinical trials have
produced inconclusive results (Schooley, R., et al., 1990,
Ann. Int. Med. 112:247-253; Kahn, J.O., et al., 1990, Ann.
Int. Med. 112:254-261; Yarchoan, R., et al., 1989, Proc.
Vth Int. Conf. on AIDS, p. 564, MCP 137).
The late stages of HIV replication, which involve
crucial virus-specific processing of certain viral encoded
proteins, have also been suggested as possible anti-HIV
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drug targets. Late stage processing is dependent on the
activity of a viral protease, and drugs are being developed
which inhibit this protease (Erickson, J., 1990 Science
249:527-533).
Recently, chemokines produced by CD8+ T cells have
been implicated in suppression of HIV infection (Paul,
W.E., 1994, Cell 82:177; Bolognesi, D.P., 1993, Semin.
Immunol. 5:203).
The chemokines RANTES, MIP-la and MIP-1i3, which are
secreted by CD8+ T cells, were shown to suppress HIV-1 p24
antigen production in cells infected with HIV-1 or HIV-2
isolates in vitro (Cocchi, F, et al., 1995, Science
270:1811-1815).
Thus, these and other chemokines may prove useful in
therapies for HIV infection. The clinical outcome,
however, of all these and other candidate drugs is still in
question.
Attention is also being given to the development of
vaccines for the treatment of HIV infection. The HIV-1
envelope proteins (gp160, gp120, gp41) have been shown to
be the major antigens for anti-HIV antibodies present in
AIDS patients (Barin et al., 1985, Science 228:1094-1096).
Thus far, therefore, these proteins seem to be the most
promising candidates to act as antigens for anti-HIV
vaccine development. Several groups have begun to use
various portions of gp160, gp120, and/or gp41 as
immunogenic targets for the host immune system. See for
example, Ivanoff, L., et al., U.S. Pat. No. 5,141,867;
Saith, G., et al., W092/22,654; Shafferman, A.,
W091/09,872; Formoso, C., et al., W090/07,119. To this
end, vaccines direct against HIV proteins are problematic
in that the virus mutates rapidly rendering many of these
vaccines ineffective. Clinical results concerning these
candidate vaccines, however, still remain far in the
future.
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Thus although a great deal of effort is being directed
to the design and testing of anti-retroviral drugs,
effective, non-toxic treatments are still needed.
2. WASTING SYDROMES
Wasting syndrome is a serious clinical problem
characterized by a decrease in body mass of more than 10%
from baseline body weight and a disproportionate loss of
body mass with respect to body fat (Weinroth et al., 1995,
Infectious Agents and Disease 4:76-94; Kotler and Grunfeld,
1995, AIDS Clin. Rev. 96:229-275). Thus, wasting is
distinguished from starvation in which higher levels of
body fat than body cell mass are depleted (Kotler et al.,
1985, Am J. Clin. Nutr. 42:1255-1265; Cahill, 1970, N.
Engl. J. Med. 282:668-675). Wasting is associated with a
variety of conditions, including HIV infection, other
infectious diseases, sepsis, cancer, chronic cardiovascular
disease and diarrhea (Kotler et al., 1989, Am. J. Clin.
Nutr. 50:444-447; Heymsfield et al., 1982, Am. J. Clin.
Nutr. 36:680-690). Importantly, wasting is a significant
factor in the mortality of patients suffering from
infections or cancer. In fact, body cell mass depletion
has a linear relationship to time of survival in AIDS
patients (Kotler et al., 1989, Am. J. Clin. Nutr. 50:444
447) .
The cause of wasting syndrome in AIDS and other
conditions is unclear and is most likely multifactorial.
Metabolic abnormalities, irregular levels of hormones and
cytokines, and malabsorption have all been implicated in
wasting syndrome. Not all AIDS patients suffer from
wasting, suggesting that the cause of the wasting is not
HIV itself. Most cases of HIV associated wasting syndrome
are apparently caused by complications of AIDS, such as
secondary infections and gastrointestinal disease (Kotler
and Grunfeld, 1995, AIDS Clin. Rev. 96:229-275).
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Current and potential therapies for wasting syndromes
include nutritional support, appetite enhancers such as
dronabinol and megestrol acetate, anabolic therapies, such
as growth hormone, and cytokine inhibitors. However, mixed
results have been obtained with nutritional support and
appetite enhancers in that patients tended to gain only fat
and not overall body mass. Administration of growth
hormone, and cytokine inhibitors are still being tested and
may pose a risk of side effects (Kotler and Grunfeld, 1995,
AIDS Clin. Rev. 96:229-275; Weinroth et al., 1995
Infectious Agents and Disease 4:76-94).
Thus, treatment of wasting is critical to the survival
and well-being of patients suffering from serious diseases
such as cancer and AIDS; thus, there is a need for safe and
effective therapies for wasting syndrome associated with
cancer, AIDS and other infectious diseases.
2.4 PROPERTIES OF DIMETHYLFORMAMIDE AND OTHER POLAR
COMPOUNDS
N,N'-Dimethylformamide(DMF)(molecularformula:C3H~ON)
is a colourless, polar, hygroscopic liquid with low
volatility and a boiling point of 152.5-153.5°C. It is
freely miscible with water, alcohols and some hydrocarbons.
DMF is generally used as a polar solvent and is readily
absorbed through the skin, by inhalation, and upon oral
ingestion. DMF is rapidly metabolized, mainly in the
liver, and excretion occurs principally in the urine. In
rat, mouse, hamster and man the main metabolites of DMF are
N-hydroxymethyl-N-methylformamide(HMMF),N-methylformamide
(NMF), and N-acetyl-S-(N-methylcarbamoyl) cysteine (AMCC),
as well as dihydroxymethylformamide (DHMF) and N-
hydroxymethylformamide (HMF) . Unchanged DMF is excreted in
the urine as a small fraction of an administered dose of
DMF.
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DMF has low acute dermal, oral and inhalation
toxicity. It is considered to be a mild to moderate skin
and eye irritant and readily permeates the skin. There is
no indication of skin sensitizing properties. The
principal toxic effect of DMF and its metabolites is on the
liver; DMF is well known to cause reversible hepatic damage
associated with typical clinical complaints, classical
biochemical changes in the blood, and the appearance of
hepatocyte necrosis in liver biopsies. DMF is teratogenic,
but is not thought to be a mutagen or a carcinogen.
Viza et al. have reported that DMF and DMSO inhibit in
vitro replication of HIV and Human Herpes Virus 6 (HHV-6)
in certain cultured cell lines. (See Viza et al., 1990
AIDS Res. Hum. Retroviruses 6:131-132; Viza et al., 1989,
AIDS-FORSCHUNG 4:349-352; Viza et al., 1992, Antiviral Res.
18:27-38 and erratum at 19:179).
DMF has been described as an in vitro differentiating
agent for certain transformed cells in culture (See
Koeffler, 1983, Blood 62:709-721; Calabresi et al., 1979,
Biochem. Pharmacol. 28:1933-1941). When added to certain
malignant cells in vitro, DMF has been reported to reduce
their tumorigenicity upon subsequent inoculation into nude
mice (See Dexter, 1977, Cancer Res. 37:3136-3140; Dexter et
al., 1979, Cancer Res. 39:1020-1025). Upon intraperitoneal
injection into nude mince, DMF and NMF have been reported
to slow the growth of certain human cancer xenografts (See
Van Dongen et al., 1989, Int. J. Cancer 43:285-292;
Braakhuis et al., 1989, Head & Neck 11:511-515; Van Dongen
et al., 1988, Acta Otolaryngol. 105:488-493, Dexter et al.,
1982, Cancer Res. 42:5018-5022). However, the toxic side
effects of formamide and its N-methyl derivatives in a
mouse sarcoma allograft model led investigators to conclude
that these agents were unlikely to prove therapeutically
useful (See Clarke et al., 1953, Proc. Sec. Exp. Biol. Med.
84:203-207).
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Attempts at treating human cancer patients with DMSO
led to the conclusion that no objective response had been
shown (See Spremulli & Dexter, 1984, J. Clin. Oncol. 2:227-
241). Oral administration of NMF to human patients with
5 cancer of the head and neck was reported as resulting in
hepatotoxicity with no beneficial response (see Vogel et
al., 1987, Invest. New Drugs 5:203-206), or with only
minimal activity (See Planting et al., 1987, Cancer Treat
Rep. 71:1293-1294).
10 U.S. Patent No. 3,551,154 discloses the use of DMF as
a penetration enhancer to promote transdermal absorption of
topically applied medications. U.S. Patent No. 4,855,294
discloses the use of glycerin to mitigate the skin
irritation arising from the use of DMSO and DMF as
penetration enhancers to promote transdermal absorption of
topically applied medications. The use of DMSO as a
penetration enhancer to promote transdermal absorption of
antiviral agents is discussed in Woodford & Barry, 1986, J.
Toxicol. Cut. & Ocular Toxicol. 5:167-177.
Citation or identification of any reference in Section
2 (or any other section) of this application shall not be
construed as an admission that such reference is available
as prior art to the present invention.
3. SUMMARY OF THE INVENTION
The present invention is directed to methods,
compositions and drug delivery devices for treating an
animal of fected by a viral or other microbial infection,
especially an infection with a retrovirus such as HIV. The
invention also provides methods, compositions and drug
delivery devices for treating an animal affected by a
wasting syndrome, such as wasting associated with HIv
infection or malignancy.
According to the present invention, there is
administered to an animal in need of treatment a
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composition comprising N,N'dimethylformamide
(dimethylformamide, DMF); N-hydroxymethyl N-methylformamide
(HMMF); N-hydroxymethylformamide (HMF);
dihydroxymethylformamide (DHMF); N-acetyl, S-(N-
methylcarbamoyl)cysteine (AMCC); N-methylformamide (NMF);
dimethylsufoxide (DMSO); formamide; acetamide;
methylacetamide, dimethylacetamide; diethylacetamide;
isopropylacetamide; diisopropylacetamide; N-
acetylpiperidine; N-(~i-hydroxyethyl)acetamide; N,N'-di(b-
hydroxyethyl)acetamide; N-acetylmorpholine, acrylamide;
propionamide; N-fluoromethyl-N-methyl-formamide; pyridine-
N-oxide; or any agent selected from the group consisting of
amides of the general formula R3-CO-NR1R2, in which R1 and
R2 are independently selected from the group consisting of
H, methyl, halomethyl, saturated and unsaturated C2-C3 alkyl
groups, and hydroxylated alkyl groups; or
Rl and R2 are together selected from the group
consisting of (CH2) 4, (CH2) 5, and (CH2) 20 (CH2) 2; and
R3 is selected from the group consisting of H, methyl,
and saturated and unsaturated C2-C3 alkyl groups. The
therapeutic composition may comprise a mixture of any two
or more of the aforementioned compounds.
In a patient infected with HIV, the therapeutic
regimen may optionally combine a composition of the present
invention with one or more additional agents effective for
treating HIV infection, including but not limited to agents
selected from the group consisting of nucleoside analog
reverse transcriptase inhibitors, non-nucleoside reverse
transcriptase inhibitors, and protease inhibitors, in any
desired combination.
The invention also extends to a vaccine prepared from
antibodies that are obtained from the body of an animal
after treatment with a composition of the invention for a
viral infection.
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4. BRIEF DESCRIPTION OF THE FIGURES
The present invention may be more fully understood by
reference to the following detailed description of the
invention, examples of specific embodiments of the
invention and the appended figures in which:
FIGURE 1 illustrates plasma concentrations of DMF as
a function of time in 4 patients treated with 2 DMF dermal
patches for 8 hours.
FIGURE 2 illustrates plasma concentrations of DMF as
a function of time in 3 patients treated with 2 DMF dermal
patches for 6 hours.
FIGURE 3 illustrates HIV-1 viral load as measured by
quantitative PCR in a patient treated with transdermal DMF.
Two DMF patches were placed against the skin of the forearm
for 12 hours on days 0, 8, and 13 (indicated by arrows).
FIGURE 4 illustrates the general condition of HiV
infected patients before and after treatment with
transdermal DMF, as assessed according to the Karnofsky
performance scale. See text, Section 7, for details.
5. DETAILED DESCRIPTION OF THE INVENTION
The present invention provides methods, compositions
and drug delivery devices for treating viral and microbial
infections. In one embodiment, the infection to be treated
is an infection with a retrovirus such as HIV, including an
asymptomatic infection, a latent infection, an infection
accompanied by one or more symptoms of the AIDS-related
complex, and an infection accompanied by clinical AIDS.
Alternatively, the infection to be treated is any other
viral or microbial infection, including infection with
rubella, a herpesvirus such as Human Herpes Virus 6, the
Epstein-Barr virus or cytomegalovirus, infection with any
virus having a capsid protective coating, and any
opportunistic infection associated with disease of the
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immune system, such as an opportunistic infection in a
patient infected with HIV.
The present invention also provides methods,
compositions and drug delivery devices for treatment or
prevention of any disease or disorder characterized by a
loss of body mass. Particular conditions that can be
treated by the methods and compositions of the invention
include, but are not limited to, wasting associated with
viral (e.g. HIV), bacterial, or any other types of
infection or sepsis, cachexia associated with malignancy,
chemotherapy or radiation therapy, wasting associated with
chronic cardiovascular disease, wasting caused by exposure
to toxic or radioactive substances, and wasting associated
with diarrhea and other gastrointestinal disorders.
The subject to be treated may be any animal, including
but not limited to a monkey, cow, sheep, ox, pig, horse,
cat, dog chicken and the like, and is preferably a mammal,
more preferably a primate, and most preferably a human
adult or child, for instance a human child weighing at
least 3 kg. As used herein, the term "patient" refers to
any animal in need of treatment according to the methods or
compositions of the present invention.
According to the present invention, there is
administered a therapeutic composition comprising DMF;
HMMF; HMF; DHMF; AMCC; NMF; DMSO; formamide; acetamide;
methylacetamide; dimethylacetamide; diethylacetamide;
isopropylacetamide; diisopropylacetamide; N-
acetylpiperidine, N- (i3-hydroxyethyl) acetamide; N, N' -di (f~-
hydroxyethyl)acetamide; N-acetylmorpholine; acrylamide;
propionamide;N-fluoromethyl-N-methyl-formamide;pyridine-N-
oxide; any agent selected from the group consisting of
amides of the general formula R3-CO-NRIR2, in which
Rl and R2 are independently selected from the group
consisting of H, methyl, halomethyl, saturated and
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unsaturated C2-C3 alkyl groups, and hydroxylated alkyl
groups; and
R3 is selected from the group consisting of H, methyl,
and saturated and unsaturated C2-C3 alkyl groups; or any
agent selected from the group consisting of amides of the
general formula R3-CO-NR1R2, in which
Rl and R2 are independently selected from the group
consisting of H, methyl, halomethyl, saturated and
unsaturated C2-C3 alkyl groups, and hydroxylated alkyl
groups; or
Rl and R2 are together selected from the group
consisting of (CH2) 4, (CH2) 5, and (CH2) 20 (CH2) 2; and
R3 is selected from the group consisting of H, methyl,
and saturated and unsaturated C2 -C3 alkyl groups.
In one specific embodiment, at least one of Rl and R2 is a
methyl group. In another specific embodiment, at least one
of Rl and R2 is a fluorinated Cl - C3 alkyl group. The
therapeutic composition may comprise a mixture of any two
or more of the aforementioned compounds. Especially
preferred is a composition comprising DMF.
For treatment of an animal infected with HIV, the
therapeutic regimen may optionally include, in addition to
a composition of the present invention, one or more other
agents effective for treating HIV infection, for instance
one or more nucleoside analog reverse transcriptase
inhibitors such as zidovudine (AZT, ZDV), zalcitabine
(ddC), didanosine (ddI), lamivudine (3TC), stavudine (d4T);
one or more non-nucleoside reverse transcriptase inhibitors
such as nevirapine, delavirdine, loviride, atevirdine,
pyridinone; one or more protease inhibitors such as
saquinavir, indinavir, ritonavir, nelfinavir; or any
combination of the aforesaid or other anti-HIV therapeutic
agents. The composition of the present invention and the
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additional anti-HIV therapeutic agent or agents may be
administered simultaneously, sequentially, or in cycles of
treatment according to any desired therapeutic protocol.
The compositions of the present invention may be
5 administered by any desired enteral or parenteral route,
including but not limited to transdermal, intradermal,
subcutaneous, intramuscular, intraperitoneal, intravenous,
intranasal, epidural, intralymphatic and oral routes. The
compounds may be administered by any convenient method, for
10 example by infusion or bolus injection, by absorption
through epithelial or mucocutaneous linings (e. g., oral,
gastric, intestinal or rectal mucosa, etc.) and may be
administered together with other biologically active
agents.
15 Administration can be systemic or local. In addition, it
may be desirable to introduce the pharmaceutical
compositions of the invention into the central nervous
system by any suitable route, including intraventricular
and intrathecal injection; intraventricular injection may
be facilitated by an intraventricular catheter, for
example, attached to a reservoir, such as an Ommaya
reservoir. Pulmonary administration can also be employed,
e.g., by use of an inhaler or nebulizer, and the
formulation may include an aerosolizing agent. If desired,
any two or more routes of administration may be employed
simultaneously, sequentially, or in cycles of treatment
according to any therapeutic protocol.
In a specific embodiment, it may be desirable to
administer a composition of the invention locally to the
area in need of treatment; this may be achieved, for
example and not by way of limitation, by topical
application, by injection, by means of a catheter, by
means of a suppository, or by means of an implant, said
implant being of a porous, non-porous, or gelatinous
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material, including membranes, such as sialastic membranes,
or fibres.
In another embodiment, a composition of the invention
can be delivered in a vesicle, in particular a liposome
(see Langer, Science 249:1527-1533 (1990); treat et al., in
Liposomes in the Therapy of Infectious Disease and Cancer,
Lopez-Berestein and Fidler (eds.), Liss, New York, pp. 353-
365 (1989); Lopez-Berestein, ibid., pp. 317-327; see
generally ibid.)
In yet another embodiment, a composition of the
invention can be delivered in a controlled release system.
In one embodiment, a pump may be used (see Langer,
supra; Sefton, CRC Crit. Ref. Biomed. Eng. 14:201 (1987) ;
Buchwald et al., Surgery 88:507 (1980); Saudek et al, N.
Engl. J. Med. 321:547 (1989) ). In another embodiment,
polymeric materials can be used (see Medical Applications
of Controlled Release, Langer and Wise (eds.), CRC Pres.,
Boca Raton, Florida (1974); Controlled Drug
Bioavailability, Drug Product Design and Performance,
Smolen and Ball (eds.) Wiley, New York (1984); Ranger and
Peppas, J. Macromol. Sci. Rev. Macromol. Chem. 23:61
(1983): see also Levy et al., Science 228:190 (1985);
During et al., Ann. Neurol. 25:351 (1989); Howard et al.,
J. Neurosurg. 71:105 (1989)). In yet another embodiment,
a controlled release system can be placed in proximity of
the therapeutic target, thus requiring only a fraction of
the systemic dose (see, e.g., Goodson, in Medical
Applications of Controlled Release, supra, vol. 2, pp. 115-
138 (1984) ) .
Other controlled release systems are discussed in the
review by Langer (Science 249:1527-1533 (1990)).
The present invention also provides pharmaceutical
preparations. Such preparations comprise a therapeutically
effective amount of a composition of the invention and a
pharmaceutically acceptable carrier. In a specific
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17
embodiment, the term "pharmaceutically acceptable" means
approved by a regulatory agency of the Federal or a state
or other government or listed in the U.S. Pharmacopoeia or
other generally recognized pharmacopoeia for use in
animals, and more particularly in humans. The term
"carrier" refers to a diluent, adjuvant, excipient, or
vehicle with which the composition of the present invention
is administered. Such pharmaceutical carriers can be
sterile liquids, such as water and oils, including those of
petroleum, animal, vegetable or synthetic origin, such as
peanut oil, soybean oil, mineral oil, sesame oil and the
like . Water is a preferred carrier when the pharmaceutical
preparation is administered intravenously. Saline
solutions and aqueous dextrose and glycerol solutions can
also be employed as liquid carriers, particularly for
injectable solutions. Suitable pharmaceutical excipients
include starch, glucose, lactose, sucrose, gelatin, malt,
rice, flour, chalk, silica gel, sodium stearate, glycerol
monostearate, talc, sodium chloride, dried skim milk,
glycerol, propylene glycol, water, ethanol and the like.
The pharmaceutical preparation, if desired, can also
contain minor amounts of wetting or emulsifying agents, or
pH buffering agents. These preparations can take the form
of solutions, suspensions, emulsion, tablets, pills,
capsules, powders, sustained-release formulations and the
like. The preparation can be formulated as a suppository,
with traditional binders and carriers such as
triglycerides. Oral formulation can include standard
carriers such as pharmaceutical grades of mannitol,
lactose, starch, magnesium stearate, sodium saccharine,
cellulose, magnesium carbonate, etc. Examples of suitable
pharmaceutical carriers are described in "Reminton's
Pharmaceutical Sciences" by E.W. Martin. Such preparations
will contain a therapeutically effective amount of the
therapeutic, preferably in purified form, together with a
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suitable amount of carrier so as to provide the form for
proper administration to the patient. The formulation
should suit the mode of administration.
The compositions of the present invention may be
administered transdermally. In one embodiment, a
composition of the invention is directly applied to the
skin. In another embodiment, a composition of the
invention is applied to a reservoir (e. g. a cotton wool
pad, a synthetic polymer such as TeflonTM, or any suitable
adsorbant) that is applied to the skin, preferably under an
occlusive dressing. In a specific embodiment, a
composition of the present invention is applied to the skin
by means of a dermal patch. The concentration of the active
therapeutic agent in the composition that is applied to the
skin, contained in or adsorbed onto the reservoir, or
contained in the dermal patch may be about 10-1000,
preferably at least 500, more preferably at least 900.
In a preferred embodiment, a polar compound such as
DMF is administered transdermally using any suitable drug
delivery device, for example by applying one or more dermal
patches. The dermal patch may optionally comprise a
backing, a reservoir such as an adsorbant impregnated with
a polar compound of the invention, and a permeable membrane
that is placed in contact with the skin. The backing may
be of any material, such as a natural or synthetic polymer,
that resists chemical attack by the polar compound.
Especially preferred is a backing of high density
polyethylene. The adsorbant may be a colloidal substance,
for instance diatomaceous earth or colloidal silicon
dioxide. The permeable membrane may be of any material
that chemically resists the polar compound and may
optionally be provided with pores. In a preferred
embodiment, the permeable membrane is a TeflonTM membrane
having pores with a diameter of about 0.1 ~,m, a diameter of
about 0.5 ~.m, or a diameter within the range of from about
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0.1 ~cm to about 0.5 ~.m. The patch may be self-adhesive or
may be held in contact with the skin by an applicator, such
as a wrapping or bandage, including without limitation an
elastic bandage or an adhesive bandage; an Elastoplast TM
bandage is suitable for this purpose. Preferably, the
patch contains a greater quantity of polar compound than is
intended to be delivered through the skin of the patient to
be treated; for instance, the patch may contain about 500
more of the polar compound than is intended to be
delivered. The patch may be of any desired size and shape,
and may for instance take the form of a disk approximately
9cm in diameter.
In one embodiment, the patch comprises a polar
compound, such as DMF, and at least one other
pharmacologically active agent, for instance an local anti
irritant such as glycerine. In another embodiment, the
patch comprises a polar compound, such as DMF, and has no
other pharmacologically active agent present. In a further
embodiment, the patch comprises a polar compound, such as
DMF, and has present no other pharmacologically active
agent that is capable of being systemically absorbed
through the skin, or has present no other pharmacologically
active agent in an mount that is systemically effective
after transdermal absorption. In yet another embodiment,
the patch comprises a polar compound, such as DMF, and has
present no other systemically active pharmacological agent.
In yet a further embodiment, the patch comprises a polar
compound, such as DMF, and has present no other antiviral
agent, for instance acyclovir or arildone.
The present invention thus provides a dermal patch
comprising a polar compound, such as DMF, in an amount that
is effective for treating a viral or microbial infection
(for example an infection with HIV) in a human adult or a
human child. The present invention further provides a
dermal patch comprising a polar compound, such as DMF, in
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an mount that is effective for treating a wasting syndrome
in a human adult or a human child. In one embodiment, the
patch contains at least 0.258 of a polar compound such as
DMF, preferably at least 0.5g, more preferably at least 1g,
5 and still more preferably at least 5g, for instance 5-15g
of a polar compound such as DMF.
To minimize evaporative loss of the polar compound,
the patch may optionally be stored in a sealed container,
such as a sealed polymer bag. If desired, each patch may
10 be individually sealed for convenience of use. Optionally,
the patches may be refrigerated prior to use, for instance
at about 4°C, so as to reduce evaporative loss of the polar
compound. Preferably, the patches are prepared within 24
hours of use and are stored in a sealed container at 4°C;
15 however, patches are stable for one or more weeks when
stored in a sealed container at 4°C. Prior to applying a
patch, an area of skin is preferably washed with a mild
soap and water, rinsed to remove soap residue, thoroughly
dried, and then hydrated with a suitable skin lubricant and
20 moistening agent, such as KYTM jelly. The patch is then
removed from the packing material and applied so that the
permeable membrane contacts the prepared skin surface. The
patch may be held in place with an applicator . After a
desired dosage period, the patch is removed. After removal
of the patch, the treated area may be thoroughly washed
with a mild soap and water to remove any residue of the
polar compound.
The compositions of the present invention may be
administered at any desired interval, for instance once
3o every two or three weeks; once, twice or three times per
week; every second day; or daily. Preferably, a
composition of the invention is administered in a dose that
results in a peak plasma level of about 2-200 mg/l, more
preferably about 100-200 mg/1, still more preferably about
150 mg/1 of the active ingredient of the composition, such
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as DMF. Especially preferred is a peak plasma level of
100-150 mg/1 or 150-200 mg/1 of DMF. As used herein, the
term "ppm" refers to parts per million by weight, and is in
practice equivalent to mg/1.
For transdermal administration of a polar compound,
the rate of absorption is determined by the skin of the
subject. Upon exposure to the human skin, liquid DMF is
absorbed at a steady-state rate of approximately 9.4
mg/cm2/hour (see Mraz and Nohova, 1992, Occup. Env. Health
64:85-92). Accordingly, the desired rate of absorption may
be achieved by controlling the surface area of the skin
exposed to the drug, as by determining the area of each
patch and the number of patches applied to the skin. For
example, two patches of diameter 9 cm will expose a total
skin surface area of 127 cm2 to the polar compound; for
DMF, this will result in an absorption rate of about 1.2 g
of DMF per hour. An initial dose of about 15 mg/kg of DMT
is especially preferred.
In one embodiment, a patient weighing about 72 kg is
initially treated with DMF by administering two 9 cm
diameter dermal patches for one hour, resulting in an
initial adsorbed dose of about 1.2 g of DMF, equivalent to
about 16.7 mg/kg. The number of patches may be scaled up
or down, and a longer or shorter initial period of exposure
used, according to the body weight of the patient being
treated. This starting dose may be repeated at any desired
interval, as described above, and preferably is given at
weekly intervals . Preferably, the patient is monitored for
at least 72 hours after administration of DMF for signs of
toxicity, such as liver toxicity, for example by monitoring
the serum or plasma levels of enzymes such as aspartate
aminotransferase (AST), alanine aminotransferase (ALT), y-
glutamyl transferase (~yGT) and alkaline phosphatase,
proteins such as albumin, or substances such as conjugated
or unconjugated bilirubin. Preferably, serum or plasma
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levels of AST and ALT do not exceed five times the upper
limit of normal as determined by the reference range of the
laboratory and population in question; more preferably
serum or plasma levels of AST and ALT do not exceed three
times the upper limit of normal, most preferably AST and
ALT are not elevated above normal levels or above pre-
treatment levels. The dose of DMF may be escalated by
applying the patches for successively longer periods; in
one embodiment the patches are applied for two hours, then
four hours, then six hours, and so on; in another
embodiment, the period of exposure is successively doubled.
Preferably, the patient is monitored prior to any dose
escalation, in order to detect any signs of toxicity. If
desired, the dose may be escalated at weekly intervals.
The dose may be escalated in this manner until the dose is
calculated to be about 150 mg/kg/dose; or until a desired
peak plasma level, for instance 100-150 or 150-200 mg/1 is
achieved; or until the period of exposure is about 6 hours
or about 8 hours. One should be cautious before increasing
the dose above 240 mg/kg/dose.
6. EkAMPLE: TREATMENT OF HIV INFECTION BY TRANSDERMAL
ADMINISTRATION OF N,N'-DIMETHYLFORMAMIDE (DMF)
Patients infected with HIV-1 were treated with
dimethylformamide (DMF) by the application of skin patches
impregnated with a dimethylformamide gel to the patient's
body. N-acetyl-cysteine-glutathione and/or essential
phospholipids were administered (orally or intravenously)
to the patients at a dosage of 250 mg to 300 mg daily as a
liver booster. Instead or in addition, glutamine may also
be administered to the patient as a liver booster.
Two skin patches were applied to different parts of
the patient's body, for example to the forearm. Each skin
patch contained about 7,068 of gel comprising DMF (92,5
m/m) and colloidal silicone dioxide (7,5 o m/m). The gel
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served to prevent leakage of liquid DMF from the patches.
The patches were manufactured at most 12 hours prior to use
as DMF evaporates rapidly. The intended level of DMF in
the patient's blood was 100 ppm. For a patient weighing
about 60 kg, an amount of about 14g over a period of 12
hours is required to produce a level of 100ppm. Based on
studies by Marz and Nohova the surface area required to
absorb this amount in about 127,2 cm2. To obtain a blood
level of 100 ppm about 1,272 g of DMF must be absorbed per
hour, thus each sticker requires about 7,064 g DMF to
deliver the required amount, having a surface area of 6,36
cm2 (each sticker). DMF absorption rate is 9,4 mg/cm2/hour.
In theory this treatment will deliver 125 - 135 ppm, but
due to evaporation of the DMF, 100 ppm was obtained.
Absorption capability varies from patient to patient
depending on factors such as skin-type and skin thickness.
To obtain the desired levels of DMF in the patients, plasma
DMF concentrations were monitored for each patient and
treatment adjusted accordingly depending on the DMF level
of each patient. Figure 1 shows the plasma DMF levels of
4 patients treated with 2 dermal DMF patches for 8 hours.
Figure 2 shows the plasma DMF levels of 3 patients treated
with 2 dermal DMF patches for 6 hours.
The stickers were thus each loaded with about 7,064 g
of the gel of DMF and silicone dioxide. Each patch was
applied for a period of 12 hours, either once per week over
a period of 12 weeks, or twice per week over a period of 6
weeks.
Blood tests in certain patients indicate an increase
in CD4 T-cell counts from 350 to 1000, and a rapid
reduction of PCR (Polymerase chain reaction) (viral load)
of 120,000 to 500/ml within three weeks with as little as
three treatments. Figure 3 shows serial quantitative PCR
measurements of HIV-1 viral load in a patient prior to
treatment and following three treatments with 2 dermal DMF
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24
patches for 12 hours. The PCR test conducted was the Roche
amplicor HIV monitor. A viral load of < 500/ml plasma is
considered to be undetectable.
Some patients undergoing treatment had severe acne or
displayed German measles symptoms before treatment. When
treated with DMF so that the DMF level in the natient'~
blood was 50 - 100 ppm, the German measles symptoms and the
severe acne cleared up or disappeared within 7 days.
Prior to the treatment with dimethylformamide, a
comprehensive base-line clinical and psychological
evaluation of the patient was conducted. The evaluation
provided baseline biochemical and hematological data on the
patient. Detailed virological serology (HIV-1) tests were
also conducted to determine the patient's total body virus
count, and these tests were conducted on a weekly basis, or
as per treatment.
The concentration of DMF in the patient's blood was
determined hourly during the period of treatment. An
intravenous line was introduced each morning to take blood
samples and was kept open with an infusion of Normal Saline
at a rate of 20m1/hour and daily monitoring of the active
metabolite AMCC (eg by 4-hourly urine sampling) derived
from the DMF was also conducted. Subsequent applications
of DMF were adjusted in accordance with measured changes in
blood level DMF concentration resulting from changes in
absorption variables and daily full haematological and
biochemical profiles were conducted to detect any changes
in liver function. Daily full clinical and psychological
evaluations were also conducted.
A daily virological serology workout to establish
total body virus count and to monitor improvements in the
immune status of the patient (CD4- T-helper cells) and
prognostic factors were also conducted. The serology
workout was based on p24 antigen and quantitative PCR or,
optionally, by other methods. A weekly determination of
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CD4 counts and Beta-2-macroglobulin was also conducted
specifically to monitor improvements in the patient's
immune status and prognosis. All clinical and laboratory
data were fed into a centralized data system to facilitate
5 rapid response to any detrimental change so as to curtail
treatment to maximize clinical effect and minimize
potential side effects.
The tests included
a) Serum: Na, K, C1, C02, Urea, Urate, Creatinine,
10 Ca, Mg, Phosphate, Total and Conjugated
Bilirubin;
b) Hematology: Hemoglobin, Red cell count,
Hematocrit, MCV, MCH, MCHC, RDW;
c) Serum Protein Electrophoresis: Total Proteins,
15 Albumin, Total Globulin, Alphal Globulin, Alpha2
Globulin, Beta Globulin, Gamma Globulin;
d) White cell analysis: Differential white cell
count, Absolute Neutrophil, Lymphocyte, Monocyte,
Eosinophil and Basophil counts;
20 e) Liver Enzymes: Alk. Phos, Gamma GT, ALT (SGPT),
AST (SGOT), LDH;
f) Other: Cell markers, PCR, Beta2-Mocroglobulin,
p24 Antigen, C-Reactive protein, CK-MB
concentration;
25 g) Blood analysis for DMF levels;
h) Urine analysis for AMCC levels
It appears as if DMF acts as at least one of a reverse
transcriptase inhibitor and a protease inhibitor. In vitro
tests were conducted and it appears that the solvent
properties of DMF dissolve the virus particles, e.g. the
capsid.
7. EXAMPLE: TREATMENT OF HIV INFECTION BY TRANSDERMAL
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ADMINISTRATION OF N,N'-DIMETHYLFORMAMIDE (DMF)
A pilot study was conducted to evaluate the efficacy
of transdermal DMF in the treatment of patients infected
with HIV. Informed consent was obtained from each patient.
Seropositive status was verified by Western blot using a
commercial kit for detecting antibodies to p24 (Abbott
Diagnostics) and the presence of HIV-1 was documented by
quantitative PCR using a commercial kit (Roche Amplicor).
DMF as obtained commercially (Sigma-Aldrich) and in
plasma samples was analysed by mass spectroscopy/ gas
chromatography (GC/MS), using a Varian 9600 gas
chromatograph, OV 351 column, carbowax-PEG capillary
column, and Finnegan Mat ITS40 ion trap detector.
Operational parameters were as follows: GC temperature
program: 60°C for 1 min. followed by a temperature gradient
of 9.4°C/min. for 20 min. MS ionization method: electron
impact; mass range: 40-80 mass units; 1 scan/sec; peak
threshold: 3 counts/sec; background mass: 69 mass units.
A stock solution of dimethylacetamide was used as an
internal standard. All samples were extracted with an
organic solvent containing the internal standard, allowed
to precipitate for 30 min. in a refrigerator, and
centrifuged at 30008 for 5 min. before transfer to GC vials
for injection. Retention time of the DMF peak relative to
the internal standard was 3.26 minutes; the calibration
curve showed a correlation of 0.98. Quantitation of DMF
appeared linear up to 100 mg/1 and the lower limit of
detection was estimate at 0.5 mg/1 based on a signal-to-
background ratio of 3:1.
Dermal patches 9 cm in diameter were used within 12
hours of manufacture. Each patch had a backing of high
density polyethylene (0.245 g), a permeable membrane of
TeflonTM (pore size 0.2 ~,m; 0.268 g) for placement against
the skin, and containing 0.573 g of colloidal silicon
dioxide impregnated with 7.067 g DMF between the backing
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and the permeable membrane. The patches were visually
inspected to verify the absence of leakage and were weighed
on an analytical balance to verify less than 10% deviation
from a total mass of 8.153 g. The patches were applied to
the skin of the forearm and secured with ElastoplastTM
bandages. Either one or two patches were used for the
initial dose, as determined from the predicted skin
transfer rate of 9.4 mg/cm2/hr and the patient's body
weight.
A s taged dose of DMF was used, with two-hourly blood
and urine sampling
to determine
peak plasma
DMF levels.
Patients were clinically monitored for any toxic side-
effects and were kept under comprehensive biochemical
surveill ance while the dosage was increased as necessary
to
achieve a peak plasma DMF level of 100-120 ppm. Once the
correct dosage was established, transdermal DMF was given
once a week. Initial evaluation included daily
determination
of:
a) vital signs and body weight;
b) clinical checklist and Karnofsky score;
a) full blood count and erythrocyte sedimentation
rate;
b) serum urea, creatinine, glucose, sodium,
potassium, ALT, AST, alkyline phosphatase and
total bilirubin;
c) Coulter analysis of CD4+ and CD8+ counts and
CD4/CD8 ratio;
d) Quantitative estimates of HIV-1 load by PCR
(Roche Amplicor) and analysis of antibody to p24
(Abbott);
e) Urinalysis (Dipstix).
At each weekly
visit, the
patients were
evaluated for
adverse effects, virtually all these tests were repeated,
and blood and
urine were
collected for
measurement
of DMF
and its metabolites.
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Patient 1 [ADF] began the protocol in relatively good
health, complaining principally of pains in the arms and
legs and inability to sleep. Two DMF patches were
administered once a week, for an average exposure period of
8 hours. The average weekly dose of DMF was 6.11 g and the
resulting peak plasma DMF level average 75 mg/1. After 9
weeks, the patient's CD4+ T cell count had increased from
140 to 640 cells/~,l and the PCR-measured viral load had
decreased from 250,000 to 50,000 copies/ml. After 10 weeks
the patient's weight had increased from 81.9 to 96.0 kg,
the patient was clinically well and no longer complained of
pain in the limbs.
Patient 2 [AM] began the protocol complaining of loss
of strength, inability to sleep, pains in the arms and
legs, and had herpes sores in the mouth. One DMF patch was
administered per week, for an average exposure period of 8
hours. The average weekly dose of DMF was 7.12 g and the
resulting peak plasma DMF level averaged 125 m/P. After 9
weeks, the patient's CD4+ T cell count has increased from
460 to 720 cells/~CP, the PCR-measured viral load had
decreased from 29,000 to 13,000 copies/m2, and the
patient's weight had increased from 58.4 to 63.0 kg. The
patient's herpetic sores had resolved, the limb pains had
disappeared and the patient appeared clinically well.
Patient 3 [SM] began the protocol with overt clinical
AIDS, and complained of respiratory difficulty. Two DMF
patches were administered once a week, for an average
exposure period of 8 hours. The average weekly dose of DMF
was 8.97 g and the resulting peak plasma DMF level averaged
121 mg/P. After 7 weeks, the patient's CD4+ T cell count
had increased from 39 to 138 cells/~CQ, the PCR-measured
viral load had decreased from 222, 000 to 160, 000 copies/m$,
and the patient' s weight had increased from 74 .2 to 100 kg.
The patient's appetite had improved, the respiratory
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difficulties had resolved, the patient appeared clinically
well and started exercising again.
Patient 4 [EM] began the protocol with secondary
infections (including herpes), anemia, diarrhea and acne.
Two DMF patches were administered once weekly, for an
average exposure period of 8 hours. The average weekly
dose of DMF was 7.33 g and the resulting peak plasma DMF
level averaged 90 mg/P. After 18 weeks, the patient's CD4+
T cell count had increased from 249 to 450 cells/~,P, the
PCR-measured viral load had decreased from 13,000 to
4,000 copies/m~, and the patient's weight had increased
from 81.5 to 90.4 kg. The patient appeared clinically well
and had no active medical complaints.
Patient 5 [SV] began the protocol complaining of poor
appetite, forgetfulness, abdominal pain, and severe fatigue
that prompted him to consider selling his interest in his
business. Two DMF patches were administered once weekly,
for an average exposure period of 6 hours. The average
weekly dose of DMF was 3.75 g and the resulting peak plasma
DMF level average 67 mg/P. After 5 weeks, the patient's
CD4+ T cell count had increased from 354 to 396 cells/~CP,
the PCR-measured viral load had decreased from 156,000 to
13,000 copies/m~, and the patient's weight had increased
from 56.0 to 58.0 kg. The patient was clinically well, had
acquired his business partner's share, and was running the
business himself.
Patent 6 [W] began the protocol complaining of
secondary infections (including herpes), ataxia, and
numbness of the left arm and left side of the face. Two
DMF patches were administered weekly, for an average
exposure period of 8 hours. The average weekly dose of DMF
was 8.25 g and the resulting peak plasma DMF level averaged
110 mg/$. After 19 weeks, the patient's CD4+ cell count
had increased from 260 to 450 cells/~Ce, the PCR-measured
viral load had decreased from 120,000 to 24,000 copies/m$,
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and the patient's weight had increased from 75.4 to 84.6
kg. The secondary infections had resolved and the patient
appeared clinically well.
Patient 7 [AJF] began the protocol severely ill. The
5 patient's initial CD4+ T cell count was 29 cell/~,P, and the
initial PCR-measured viral load was 1,156,000 copies/mP.
Treatment was with 1 patch, for an average exposure period
of 4 hours. The average weekly dose of DMF was 4.60 g and
the resulting peak plasma DMF level averaged 100 mg/P.
10 After the first treatment, the patient's CD4+ T cell count
decreased to 14 cells/~ce. Treatment was given daily for
five days and then continued at weekly intervals. After 9
treatments, the patient's CD4+ T cell count had increased
to 35 cells/~.P, the PCR-measured viral load had decreased
15 to 9,000 copies/mP, and the patient's weight had increased
from 46.5 kg (at commencement of DMF therapy) to 49.0 kg.
The patient felt well and had returned to full-time
employment.
Patient 8 [MS] began the protocol with severe herpetic
20 lesions in the lower back and genitalia. Two DMF patches
were given once weekly, for an average exposure period of
8 hours. The average weekly dose of DMF was 6.24 g and the
resulting peak plasma DMF level averaged 130 mg/e. After 8
weeks, the patient's CD4+ T cell count had increased from
25 200 to 240 cells/~.$, the PCR-measured viral load had
decreased from 1,200,000 to 250,000 copies/m~. The
patient's weight had increased from 48.1 to 52.2 kg, and
the Herpes lesions had entirely resolved.
Two patients were excluded from the trial, one due to
30 alcohol abuse and one due to viral hepatitis B.
Most patients experienced mild local skin irritation
at the area of application after removal of the patches;
the skin at the application site had a maculopapular
appearance, probably due to intense hydration under the
patch. In one case, there was slight blistering that
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resolved within 24 hours and that did not cause the patient
significant discomfort. Most patients experienced mild
transient nausea, usually on day three after treatment,
which gradually decreased during the treatment protocol;
one patient reported moderate transient nausea. Four
patients showed transient elevation of liver enzymes, which
never exceeded three times the upper limit of normal and
which in most cases returned to pre-treatment levels prior
to the next dose of DMF. Most instances of elevated liver
enzymes were associated with at least one factor unrelated
to the treatment protocol (alcohol consumption, hepatitis,
and previous anti-HIV therapy with other agents).
Virtually all patients showed clinical improvement
after 2-3 weeks of treatment. As shown by Figure 4, every
patient showed improved general condition after treatment
with DMF when assessed according to the Karnofsky
performance scale, in which a patient's general status is
assigned a numerical value as follows: 100 - normal, no
complaints; 90 = able to carry on normal activities, minor
signs or symptoms of disease; 80 - normal activity with
effort; 70 - cares for self, unable to carry on normal
activity or to do active work; 60 - requires occasional
assistance, but is able to care for most needs; 50 -
requires considerable assistance and frequent medical care;
40 - disabled, requires special care; 30 - severely
disabled, hospitalization indicated although death not
imminent; 20 - very sick, hospitalization and active
supportive treatment necessary; 10 - moribund, fatal
process progressing rapidly; 0 - dead. (See Kanofsky et
al., 1984, Cancer 1:634-655). Improvement in neurological
symptoms and Herpes viral infections was remarkable.
Additional anti-microbial therapy for secondary infections
was rarely needed. Within the first 14 days of DMF
treatment, there was marked improvement in general fatigue
and in appetite. All the patients gained weight. Clinical
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improvement correlated well with disease status as assessed
by viral load and CD4+ T cell count. For five out of eight
patients, the relative PCR-measured viral load could be
fitted to Gompertz curves; this analysis revealed an 88.8a
decline in PCR-measured viral load after 42 days of DMF
treatment. For seven out of eight patients, the relative
CD4+ T cell count could be fitted to Gompertz curves; this
analysis showed a 73.40 increase in CD4+ T cell counts
after 42 days of DMF treatment.
The present invention is not to be limited in scope by
the exemplified embodiments, which are intended as
illustrations of single aspects of the invention. Indeed,
various modifications of the invention in addition to those
shown and described herein will become apparent to those
skilled in the art from the foregoing description and
accompanying drawings. Such modifications are intended to
fall within the scope of the appended claims.
All publications cited herein are incorporated by
reference in their entirety.
