Note: Descriptions are shown in the official language in which they were submitted.
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N-Acetylcysteine Compositions And Methods For Treating Acute Exacerbations Of
Inflammatory Lung Disease
[0001] _ _
FIELD OF THE INVENTION
[0002] The present invention relates to N-acetylcysteine compositions and
methods for
treating inflammation and redox imbalance in acute exacerbations of
inflammatory lung disease.
BACKGROUND OF THE INVENTION
Oxidative Stress Associated With GSH Depletion
[0003] A free radical is a highly reactive and usually short-lived
molecular fragment with
one or more unpaired electrons. Free radicals are highly chemically reactive
molecules.
Because a free radical needs to extract a second electron from a neighboring
molecule to pair its
single electron, it often reacts with other molecules, which initiates the
formation of many more
free radical species in a self-propagating chain reaction. This ability to be
self-propagating
makes free radicals highly toxic to living organisms.
100041 Living systems under normal conditions produce the vast majority
of free radicals
and free radical intermediates. They handle free radicals formed by the
breakdown of
compounds through the process of metabolism. Most reactive oxygen species come
from
1 -
CA 02662636 2009-04-15
endogenous sources as by-products of normal and essential metabolic reactions,
such as energy
generation from mitochondria or detoxification reactions involving the
cytochrome P-450
enzyme system. The major sources of free radicals, such as Oland 11N01, are
modest leakages
from the electron transport chains of mitochondria, chloroplasts, and
endoplasmic reticulum.
100051 Reactive oxygen species ("ROS"), such as free radicals and
peroxides, represent a
class of molecules that are derived from the metabolism of oxygen and exist
inherently in all
aerobic organisms. The term "oxygen radicals" as used herein refers to any
oxygen species that
carries an unpaired electron (except free oxygen). The transfer of electrons
to oxygen also may
lead to the production of toxic free radical species. The best documented of
these is the
superoxide radical. Oxygen radicals, such as the hydroxyl radical (01-1-) and
the superoxide ion
(02) are very powerful oxidizing agents that cause structural damage to
proteins, lipids and
nucleic acids. The free radical superoxide anion, a product of normal cellular
metabolism, is
produced mainly in mitochondria because of incomplete reduction of oxygen. The
superoxide
radical, although unreactive compared with many other radicals, may be
converted by biological
systems into other more reactive species, such as peroxyl (ROO), alkoxyl (RO)
and hydroxyl
(01-1) radicals.
[0006] The major cellular sources of free radicals under normal
physiological conditions
are the mitochondria and inflammatory cells, such as granulocytes,
macrophages, and some T-
lymphocytes, which produce active species of oxygen via the nicotinamide
adenine nucleotide
oxidase (NADPH oxidase) system, as part of the body's defense against
bacterial, fungal or viral
infections.
100071 Oxidative injury may lead to widespread biochemical damage within
the cell.
The molecular mechanisms responsible for this damage are complex. For example,
free radicals
2
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=
may damage intracellular macromolecules, such as nucleic acids (e.g., DNA and
RNA), proteins,
and lipids. Free radical damage to cellular proteins may lead to loss of
enzymatic function and
cell death. Free radical damage to DNA may cause problems in replication or
transcription,
leading to cell death or uncontrolled cell growth. Free radical damage to cell
membrane lipids
may cause the damaged membranes to lose their ability to transport oxygen,
nutrients or water to
cells.
100081 Biological systems protect themselves against the damaging
effects of activated
species by several means. These include free radical scavengers and chain
reaction terminators;
"solid-state" defenses, and enzymes, such as superoxide dismutase, catalase,
and the glutathione
peroxidase system.
[0009] Free radical scavengers/chemical antioxidants, such as
vitamin C and vitamin E,
counteract and minimize free radical damage by donating or providing unpaired
electrons to a
free radical and converting it to a nonradical form. Such reducing compounds
may terminate
radical chain reactions and reduce hydroperoxides and epoxides to less
reactive derivatives.
[0010] The term "solid state defense" as used herein refers to the
mechanism whereby a
macromolecule binds a radical-generating compound, de-excites an excited state
species, or
quenches a free radical. The most important solid-state defense in the body is
the black pigment
melanin, which scavenges odd electrons to form stable radical species, thus
terminating radical
chain reactions.
[0011] Enzymatic defenses against active free radical species
include superoxide
dismutase, catalases, and the glutathione reductase/peroxidase system.
Superoxide dismutase
(SOD) is an enzyme that destroys superoxide radicals. Catalase, a heme-based
enzyme that
catalyses the breakdown of hydrogen peroxide into oxygen and water, is found
in all living cells,
3
CA 02662636 2009-04-15
especially in the peroxisomes, which, in animal cells, are involved in the
oxidation of fatty acids
and the synthesis of cholesterol and bile acids. Hydrogen peroxide is a
byproduct of fatty acid
oxidation and is produced by white blood cells to kill bacteria.
[0012] Glutathione, a tripeptide composed of glycine, glutamic acid, and
cysteine that
contains a nucleophilic thiol (SH) group, is widely distributed in animal and
plant tissues. It
exists in both the reduced thiol form (GSH) and the oxidized disulfide form
(GSSG). In its
reduced GSH form, glutathione acts as a substrate for the enzymes GSH-S-
transferases and GSH
peroxidases, both of which catalyze reactions for the detoxification of
xenobiotic compounds,
and for the reduction of reactive oxygen species and other free radicals. The
term "xenobiotic"
is used herein to refer to a chemical which is not a natural component of the
organism exposed to
it.
[0013] Examples of xenobiotics include, but are not limited to,
carcinogens, toxins and
drugs. The metabolism of xenobiotics usually involves two distinct stages.
Phase I metabolism
involves an initial oxidation, reduction or dealkylation of the xenobiotic by
microsomal
cytochrome P-450 monooxygenases (Guengerich, F.P. Chem. Res. Toxicol. 4: 391-
407 (1991);
this step is often needed to provide hydroxyl- or amino groups, which are
essential for phase II
reactions. Glutathione detoxifies many highly reactive intermediates produced
by cytochrome
P450 enzymes in phase I metabolism. Without adequate GSH, the reactive toxic
metabolites
produced by cytochrome P-450 enzymes may accumulate causing organ damage.
[0014] Phase II metabolism generally adds hydrophilic moieties, thereby
making a toxin
more water soluble and less biologically active. Frequently involved phase II
conjugation
reactions are catalyzed by glutathione S-transferases (Beckett, G.J. & Hayes,
J.D., Adv. Clin.
Chem. 30: 281-380 (1993), sulfotransferases (Falany, CN, Trends Pharmacol.
Sci. 12: 255-59
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(1991), and UDP-glucuronyl-transferases (Bock, KW, Crit. Rev. Biochem. Mol.
Biol. 26: 129-
50 (1991). Glutathione S-transferases catalyze the addition of aliphatic,
aromatic, or
heterocyclic radicals as well as epoxides and arene oxides to glutathione.
These glutathione
conjugates then are cleaved to cysteine derivatives primarily by renal enzymes
and then
acetylated, thus forming N-acetylcysteine derivatives. Examples of compounds
transformed to
reactive intermediates and then bound to GSH include, but are not limited to,
bromobenzene,
chloroform, and acetaminophen. Such toxicants may deplete GSH.
[0015] Depletion of GSH may diminish the body's ability to defend against
lipid
peroxidation. Glutathione is a cofactor for Glutathione peroxidase (GPx), an
enzyme of the
oxidoreductase class, which catalyzes the detoxifying reduction of hydrogen
peroxide and
organic peroxides via oxidation of glutathione. GSH is oxidized to the
disulfide linked dimer
(GSSG), which is actively pumped out of cells and becomes largely unavailable
for reconversion
to reduced glutathione. Loss of large amounts of GSH results in cell death,
while loss of smaller
amounts can change cell function.
[0016] The generation of cytokine-induced neutrophil chemoattractants that
affect
neutrophil migration is induced in part by the nuclear factor KB (NF-1(13)
family of proteins, a set
of transcription factors that lie at the heart of most inflammatory responses.
Two vertebrate
cytokines are especially important in inducing inflammatory responses-- tumor
necrosis factor a
(TNF-a) and interleukin-1 (IL-1). Both of these proinflammatory cytokines,
which are made by
cells of the innate immune system, bind to cell surface receptors and activate
NF-x13, which
normally is sequestered in an inactive form in the cytoplasm of almost all
cells. Once activated,
NF-KB turns on the transcription of more than 60 known genes that participate
in inflammatory
CA 02662636 2009-04-15
4
responses, including the canonical neutrophil chemoattractant interluelcin-8
(IL-8). NIL-KB is
responsive to the oxidative stress associated with GSH depletion.
[0017] Thus, unless glutathione is resynthesized through other
pathways, utilization of
oxidized glutathione is associated with a decrease in the amount of
glutathione available.
[0018] Glutathione reductase, a flavoprotein enzyme of the
oxidoreductase class, is
essential for the maintenance of cellular glutathione in its reduced form
(Carlberg & Mannervick,
J. Biol. Chem. 250: 5475-80 (1975)). It catalyzes the reduction of oxidized
glutathione (GSSG)
to reduced glutathione (GSH) in the presence of NADPH and maintains a high
intracellular
GSH/GSSG ratio of about 500 in red blood cells.
[0019] Synthesis of GSH requires cysteine, a conditionally
essential amino acid that must
be obtained from dietary sources or by conversion of dietary methionine via
the cystathionase
pathway. If the supply of cysteine is adequate, normal GSH levels are
maintained. But GSH
depletion occurs if supplies of cysteine are inadequate to maintain GSH
homeostasis in the face
of increased GSH consumption. Acute GSH depletion causes severe -- sometimes
fatal--
oxidative and/or alkylation injury, and chronic or slow arising GSH deficiency
due to
administration of GSH-depleting drugs, such as acetaminophen, or to diseases
and conditions
that deplete GSH, may be similarly debilitating.
[0020] Cysteine is necessary to replenish GSH. Although various
forms of cysteine and
its precursors have been used as nutritional and therapeutic sources of
cysteine, N-acetylcysteine
(NAC) is the most widely used and extensively studied. NAC is about 10 times
more stable than
cysteine and much more soluble than the stable cysteine disulfide, cystine.
Glutathionc,
glutathione monoethyl ester, and L-2-oxothiazolidine-4-carboxylate
(procysteine/OTC) also have
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been used effectively in some studies. In addition, dietary methionine and S-
adenosylmethionine
are an effective source of cysteine.
100211 It is well known that NAC, as a cysteine prodrug, promotes
cellular glutathione
production, and thus decreases, or even prevents, oxidant-mediated damage. In
addition, NAC
may act as a direct scavenger for oxidants. Treatment with NAC provides
beneficial effects in a
number of respiratory, cardiovascular, endocrine, infectious, and other
disease settings as
described in W005/017094. For
example, rapid administration of NAC is the standard of care for preventing
hepatic injury in
acetaminophen overdose. NAC administered intravenously in dogs has been shown
to protect
against pulmonary oxygen toxicity and against ischemic and reperfiision damage
[Gillissen, A.,
and Nowak, A., Respir. Med. 92: 609-23, 613 (1998)1 NAC treatment also has
been shown to
decrease 1\1F-KB activation, which in turn decreases neutrophilic inflammation
in the lung.
Antioxidant Therapy In Chronic Pulmonary Diseases
[0022] The lung exists in a high-oxygen environment, and together with
its large surface
area and blood supply, is highly susceptible to injury mediated by oxidative
stress. Since
reactive oxygen species are constantly formed in the lung, and since oxygen
metabolites are
believed to play a predominant role in the pathogenesis of various pulmonary
inflammatory
disorders, antioxidant therapy would seem to be a rational approach to take in
pulmonary
diseases. Patients with acute respiratory distress syndrome (ARDS), idiopathic
pulmonary
fibrosis (IPF), or chronic obstructive pulmonary disorder (COPD) have been the
primary targets
for clinical studies evaluating the efficacy of NAC in antioxidant therapy.
The results have been,
for the most part, inconclusive.
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[0023] COPD, a syndrome of chronic airway inflammation, initiated in most
cases by
chronic tobacco smoke exposure, which damages the airways and lung parenchyma
over many
years, has been extensively studied in this regard. An accelerated functional
deterioration is
accompanied by the development of cough, sputum production, dyspnea, and
abnormal gas
exchange, and leads to an increasing risk of acute flares of disease referred
to as exacerbations.
Exacerbation frequency increases as the disease progresses, further
accelerating lung function
decline.
[0024] The presence of oxidative stress in the airways of smokers and
patients with
COPD has been shown by increased products of lipid peroxidation and altered
antioxidant status.
Patients with COPD are known to have increased numbers of activated
neutrophils in their
airways that are believed to be attracted to the airways by the cytokines IL-8
and TNF-a, which
are present in increased levels in the lungs of patients with stable COPD.
Drost, E.M., Skwarski,
K.N., Sauleda, J., Soler, N., Roca, J., Agusti, A., MacNee, W. "Oxidative
Stress and Airway
Inflammation in Severe Exacerbations of COPD," Thorax 60: 293-300 (2005)
disclose that
exacerbations of COPD are considered to reflect worsening of the underlying
chronic
inflammation in the airways. They reported that increased oxidative stress in
the airways of
patients with COPD is increased further in severe and very severe
exacerbations of the disease
and is associated with increased neutrophil influx and levels of IL-8, an
inflammatory cytokine
associated with airway inflammation in COPD. The study acknowledged that in
COPD, the
interpretation of differences between exacerbations and the stable state may
actually be a
reflection of differences in disease severity, because exacerbations were
studied in patients with
severe and very severe underlying COPD and compared with stable patients with
moderate
disease.
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[0025] While there is some evidence that oral NAC offsets chronic redox
stress when
administered in the long term for chronic respiratory conditions, some studies
have demonstrated
a beneficial effect, but others have not. For example, NAC has been used for
over 20 years to
treat COPD, a disease not characterized by glutathione deficiency. Gillissen
and Nowak,
Respir. Med. 92: 609-23, 615 (1998), for example, reported that improvements
in glutathione
levels were seen in patients with ARDS and IPF, but not COPD, who received 600-
1800 mg
NAC given daily by mouth. Oral NAC at high doses (generally 1.2 to 1.8 g/day)
has been
proposed for the treatment (preventive or symptomatic) of exacerbations in a
subset of patients
with COPD who are not receiving inhaled corticosteroids (Sutherland, E.R., et
al., COPD
Chronic Obstructive Pulmonary Disease 3: 195-202 (2006)). Although treatment
with 600 mg
oral NAC per day was ineffective at preventing deterioration in lung function
and exacerbations
in patients with COPD who had frequent exacerbations (i.e., at least two per
year for 2 years),
these investigators suggested that higher doses of NAC, such as 1200 mg or
1800 mg per day,
could be assessed in future trials (Decramer, M., Lancet 365: 1552-60 (2005)).
Oral NAC at
high doses (generally 1.2 to 1.8 g/day) also has been proposed for the
treatment (preventive or
symptomatic) of exacerbations in chronic bronchitis, an inflammation, or
irritation, of the
airways in the lungs characterized by a chronic cough and chronic mucus
production without
another known cause (see Grandjean, E.M. et al., Clinical Therapeutics 22(2):
209-21 (2000),
and Stey, C., et al., Eur. Resp. J. 16: 253-62 (2000)).
Cystic Fibrosis
[0026] Cystic fibrosis (CF) is an inherited autosomal recessive disorder.
It is one of the
most common fatal genetic disorders in the United States, affecting about
30,000 individuals,
and is most prevalent in the Caucasian population, occurring in one of every
3,300 live births.
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The gene involved in cystic fibrosis, which was identified in 1989, codes for
a protein called the
cystic fibrosis transmembrane conductance regulator (CFTR). CFTR is normally
expressed by
exocrine epithelia throughout the body and regulates the movement of chloride
ions, bicarbonate
ions and glutathione into and out of cells. In cystic fibrosis patients,
mutations in the CFTR gene
lead to alterations or total loss of CFTR protein function, resulting in
defects in osmolarity, pH
and redox properties of exocrine secretions. In the lungs, CF manifests itself
by the presence of a
thick mucus secretion which clogs the airways. In other exocrine organs, such
as the sweat
glands, CF may not manifest itself by an obstructive phenotype, but rather by
abnormal salt
composition of the secretions (hence the clinical sweat osmolarity test to
detect CF patients).
100271 The predominant cause of illness and death in cystic fibrosis
patients is
progressive lung disease. The thickness of CF mucus, which blocks the airway
passages, is
believed to stem from abnormalities in osmolarity of secretions, as well as
from the presence of
massive amounts of DNA, actin, proteases and prooxidative enzymes originating
from a subset
of inflammatory cells, called neutrophils. Indeed, CF lung disease is
characterized by early,
hyperactive neutrophil-mediated inflammatory reactions to both viral and
bacterial pathogens.
[0028] The hyperinflammatory syndrome of CF lungs has several
underpinnings, among
which an imbalance between pro-inflammatory chemokines, chiefly IL-8, and anti-
inflammatory
cytokines, chiefly IL-10, seems to play a major role. See Chmiel et al. Clin
Rev Allergy
Immunol. 3(1):5-27 (2002). Chronic oxidative stress in CF patients may
severely affect the
deformability of blood neutrophils circulating in CF lung capillaries, thereby
increasing their
recruitment to the lungs. See Hogg. Physiol Rev. 67(4):1249-95 (1987). Chronic
oxidative
stress in CF is linked to the overwhelming release of oxidants by inflammatory
lung neutrophils
and to abnormal antioxidant defenses caused by malabsorption of dietary
antioxidants through
CA 02662636 2009-04-15
the gut and a possible defect in GSH efflux. See Wood et al. J. Am. Coll.
Nutr. 20(2
Suppl):157-165 (2001).
[0029] The hyperinflammatory syndrome at play in CF lungs may predispose
such
patients to chronic infections with opportunistic bacterial pathogens. The
most common
bacterium to infect the CF lung is Pseudomonas aeruginosa, a gram-negative
microorganism.
The lungs of most children with CF become colonized by P. aeruginosa before
their third
birthday. By their tenth birthday, P. aeruginosa becomes dominant over other
opportunistic
pathogens. See Gibson et al., Am. J. Respir. Crit Care Med., 168(8): 918-951
(2003). P.
aeruginosa infections further exacerbate neutrophilic inflammation, which
causes repeated
episodes of intense breathing problems in CF patients. Although antibiotics
may decrease the
frequency and duration of these attacks, the bacterium progressively
establishes a permanent
residence in CF lungs by switching to a so-called "mucoid", biofilm form of
high resistance and
low virulence, which never may be eliminated completely from the lungs. The
continuous
presence in CF lungs of inflammatory by-products, such as extracellular DNA
and elastase,
could play a major role in selecting for mucoid P. aeruginosa forms. See
Walker et al. Infect
Immun. 73(6): 3693-3701 (2005).
[00301 Treatments for CF lung disease typically involve antibiotics, anti-
inflammatory
drugs, bronchodilators, and chest physiotherapy to help fight infection,
neutrophilic
inflammation and obstruction and clear the airways. Nevertheless, the
persistent, viscous and
toxic nature of airway secretions in cystic fibrosis lung disease still leads
to progressive
deterioration of lung function. See Rancourt et al., Am. J. Physiol. Lung Cell
Mol. Physiol.
286(5): L931-38 (2004).
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100311 Although it is characterized by heavy inflammation, CF historically
was thought
to be a mucus disease. N-acetylcysteine (NAC) is a widely used mucolytic drug
in patients with
a variety of disorders, including cystic fibrosis. See Rochat, et al., J. Cell
Physiol. 201(1): 106-
16(2004). It has been hypothesized that NAC works as a mucolytic by rupturing
the disulfide
bridges of the high molecular weight glycoproteins present in the mucus,
resulting in smaller
subunits of the glycoproteins and reduced mucous viscosity. Id. To this end,
researchers and
clinicians have administered NAC to CF patients generally by nebulization, as
well as orally.
Two placebo-controlled studies have reported beneficial effects of oral NAC
treatment on lung
function in cystic fibrosis. See G. Stafanger, et al., Eur. Respir. J. 1(2):
161-67 (1988). Active
treatment consisted of NAC administered as a 200 mg oral dose three times
daily (for patients
weighing less than 30 kg) or as a 400 mg oral dose two times daily (for
patients weighing more
than 30 kg). Ratjen, F., et al., Eur. J. Pediatr. 144(4): 374-78 (1985)
reported improvement in
some measures of lung function but saw no significant clinical differences
between patients
treated with oral NAC (200 mg 3 times a day), the secretolytic drug ambroxol
(30 mg, three
times daily), and placebo. A very short fourth study (2 weeks) failed to find
any significant
difference between the trial arms. See Gotz eta!, Eur. J. Resp. Dis. 61
(Suppl) 111: 122-26
(1980).
100321 Duijvestijn, Y.C. and Brand, P.L. Ada Paediatr. 88(1): 38-41 (1999)
observed,
however, that despite the fact that NAC commonly is used in CF, there is
remarkably little
published data on its effects. They tested their hypothesis that NAC's
antioxidant properties
could be useful in preventing decline of lung function (defmed as forced
expiratory volume in
one second, or FEV1) in cystic fibrosis by performing a systematic review of
the literature to
evaluate whether published evidence supports the use of NAC administered
orally or by
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nebulization to improve lung function in patients with cystic fibrosis. They
identified 23 papers,
the majority of which were uncontrolled clinical observations, of which only
three randomized
controlled trials on nebulized NAC were found. None of these studies showed a
statistically
significant or clinically relevant beneficial effect of NAC aerosol. They
found a small beneficial
effect of doubtful clinical relevance of oral NAC on FEV1 in CF. Although they
suggested that
the effects of long-term treatment with oral NAC on lung function in CF should
be investigated,
they concluded that there is no evidence supporting the use ofN-acetylcysteine
in cystic fibrosis.
[0033] Despite these findings, redox-based therapy is an attractive idea
for CF, since
redox imbalance is a well-recognized aspect of the disease, yet seldom
considered as a
therapeutic target. See Cantin, Curr Opin Pulm Med. 10(6):531-6 (2004).
Systemic oxidative
stress may affect blood neutrophils by lowering their intracellular GSH
levels, which in turn
renders them more prone to lung trapping and dysfunction. See Hogg. Physiol
Rev. 67(4):1249-
95 (1987). Besides, systemic oxidative stress may alter the chemokine/cytokine
balance,
favoring inflammation, which systemic NAC treatment may help alleviate. See
Zafarullah et al.
_
Cell Mol Life Sci. 60(1):6-20 (2003).
[0034] U.S Published Application No..2007/0049641 Al
describes an investigation into whether NAC in high doses
could counter systemic oxidative stress/redox imbalance and inhibit
inflammation when
administered orally to CF patients. Blood neutrophils were targeted before
they reach the lung, a
strategy that had not been tested in CF. The inflammatory and redox aspects of
CF lung disease,
which are major contributors to the progression of the disease, were the focus
of that study.
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Acute Exacerbations Of Pulmonary Disease
100351 A systematic review of randomized controlled trials for established
acute
oxidative/inflammatory syndromes, such as Acute Respiratory Distress Syndrome
(ARDS),
which is characterized by diffuse inflammation of the lung's alveolar-
capillary membrane in
response to various pulmonary and extrapulmonary insults, and Acute Lung
Injury (ALI), a
milder form of lung injury, showed that NAC had no effect on early mortality
in these diseases
(Adhikari, N., Burns, KEA, Meade, MO, The Cochrane Library 1: 1-43, John Wiley
& Sons,
Ltd., 2008).
100361 Acute exacerbations of CF are characterized by increased oxidative
stress and
sputum concentrations of bioactive lipid mediators. Reid, D.W., et al.,
Respirology 12 (1): 63-
69 (2007). McGrath, L.T. et al, "Oxidative stress during acute respiratory
exacerbations in cystic
fibrosis," Thorax 54: 518-523 (1999) have reported that during acute
respiratory exacerbations,
patients with CF are subject to acute oxidative attack in addition to the
chronic systemic
oxidative stress found in this condition. Such acute respiratory exacerbations
in CF are
characterized by increased respiratory symptoms, reduction in forced
expiratory volume in one
second ("FEV1") of more than 10%, and a decision to treat with intravenous
antibiotics. As
reported, although almost all of the antioxidant scavengers developed to cope
with the acute
attack were partially depleted during infection, antibiotic treatment of the
acute infection tended
to reduce measures of free radical damage by moderating the infection and
hence the immune
response.
100371 Like in CF, it is known that chronic phase and acute pathological
flares of such
chronic pulmonary diseases as Acute Respiratory Distress Syndrome (ARDS),
Acute Lung
Injury (ALI), Chronic Bronchitis (CB), and Chronic Obstructive Pulmonary
Disease (COPD)
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share a common feature, i.e., their chronic phase and acute pathological
flares are associated with
redox and inflammatory dysfunctions and an increased proteolysis of lung
tissue.
[0038] Unlike CF, ARDS, AL!, CB, and COPD, both Idiopathic Pulmonary
Fibrosis
(IPF) and Asthma are characterized by considerable matrix
thickening/deposition in the
mucosa/lumen of the airways. The effect of high-dose oral NAC has not been
tested against
acute exacerbations in either IPF or asthma.
[0039] Idiopathic Pulmonary Fibrosis (IPF), a syndrome regrouping several
diseases with
progressive fibrosis of the alveoli, is a chronic, progressive, incurable lung
disease characterized
by deposition of fibers in the lung through the hyperproliferation of
myofibroblasts. Causative
factors remain unknown. In some individuals, it develops quickly, while others
have cryptic
disease. An oxidant-antioxidant imbalance that depletes glutathione levels has
been described in
IPF.
[0040] A clinical study reported by Demedts, Maurits, et al., New England
J. Med. 353
(21): 2229-42 (2005) has suggested that NAC may be beneficial when combined
with standard
therapies for chronic IPF, but the study was not powered to show the impact of
NAC on survival,
did not address use of NAC as a primary therapy in IPF patients, and did not
address the effect of
high-dose oral NAC on acute exacerbations of IPF. The double-blind,
randomized, placebo-
controlled multicenter study assessed the effectiveness over one year of 600
mg NAC
administered three times daily added to standard therapy with prednisone plus
azothioprine to
test whether this regimen would slow the functional deterioration in patients
with IPF has been
reported. The primary endpoints were changes between baseline and month 12 in
vital capacity
(meaning the total amount of air that may be exhaled after a maximum
inspiration) and in single-
breath carbon monoxide diffusing capacity ("DLco"). The results of the study
showed that NAC
CA 02662636 2009-04-15
plus standard therapy ( prednisone plus azothioprine) slows the deterioration
of the primary
endpoints vital capacity and DLco in patients with IPF better than does the
standard therapy
(prednisone plus azothioprine) alone.
100411 Episodes of idiopathic acute respiratory deterioration have been
termed acute
exacerbations of IPF. Collard, H.R. et al., Am. J. Respir. Crit. Care med.
176(7): 636-43 (2007).
The etiology of acute exacerbations of IPF is unknown. There are several
competing hypotheses,
including, but not limited to, the hypothesis that acute exacerbations of IPF
represents a distinct,
pathobiological manifestation of the primary disease process, characterized by
idiopathic lung
injury; the hypothesis that acute exacerbations of IPF may represent
clinically occult but
biologically distinct conditions that go undiagnosed, such as viral infection,
or aspiration; and the
hypothesis that acute exacerbations of IPF may be the sequelae of an acute
direct stress to the
lung, with a subsequent acceleration of the already abnormal
fibroproliferative process intrinsic
to IPF.
[0042] Asthma is an inflammatory disease of the lungs characterized by
reversible (in
most cases) airway obstruction due to narrowing of the conducting airways,
hyper-
responsiveness/hyper-reactivity, and chronic inflammation characterized by an
influx and
activation of inflammatory cells, generation of inflammatory mediators, and
epithelial cell
shedding. In chronic asthma, there is an increased sequestration within the
lungs of leukocytes
from the peripheral microcirculation. Since many chronic asthma patients have
eosinophilic
infiltrates, eosinophils are thought to play a critical role in the
inflammatory response in chronic
asthma. Indeed, it is believed that much of the lung problems in chronic
asthma relates to the
eosinophil disease. In addition, neutrophils isolated from peripheral blood of
asthmatic patients
generate greater amounts of reactive oxygen species than cells from normal
subjects, may be
16
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involved in acute exacerbations of asthma. (Kirkham, P., Rahman, I.,
Pharamacology &
Therapeutics 111: 476-94 (2006)).
[0043] Oxidative stress is believed to play a key role in the pathogenesis
of clinically
stable (chronic) bronchial asthma. It also has been shown that acute
exacerbations of asthma
[meaning a sudden increase in breathlessness over the preceding 48 hours and
presence of one of
the following signs: tachypnea (meaning a respiratory rate of >18), use of
accessory muscles or
respiration, audible wheezing, prolonged expiration with rhonchi (meaning a
sound occurring
during inspiration or expiration caused by air passing through bronchi that
are narrowed by
inflammation, spasm of smooth muscle, or presence of mucus in the lumen heard
on auscultation
(meaning a diagnostic method of listening to the sounds made) of the chest]
are associated with
increased inflammation in the airways and with increased oxidative stress.
Nadeem, A., et al., J.
Asthma 1:45-50 (2005).
[0044] Asthmatic exacerbations commonly occur in two phases: an immediate
phase,
caused by release of mediators, that often is characterized by
bronchoconstriction resulting in
wheezing and coughing, and an inflammatory or late phase, that includes
increasing airway
inflammation, which leads to hyper-responsiveness.
100451 There are many published guidelines for management of asthma
available, but
there is little if any documented objective data to support their usefulness
in acute care of
asthma.
[0046] Although chronic redox and inflammatory stresses in asthma (Nadeem,
2005;
Kirkham 2006) have been documented, the effect of high-dose oral NAC has not
been tested
against acute exacerbations in asthma.
17
=
CA 02662636 2009-04-15
100471 Tuberculosis (TB), once believed to have been almost eradicated, has
shown a
resurgence and a substantial increase in drug resistance. Human
immunodeficiency virus (HIV)
infection is a major risk factor for the development of TB, and TB seems to
make HIV infection
worse [Sacchetini, J.C., et al. Nat. Rev. Microbiol. 6(1):41-52 (2008)1 Immune
reconstitution
inflammatory syndrome (referred to herein as IRS or IRIS), is an adverse
consequence of the
restoration of pathogen-specific immune responses in HIV infected patients
during the initial
months of highly active anti-retroviral therapy. Symptoms include fever,
lymphadenopathy, and
worsening of respiratory and other TB symptoms Although the pathophysiology of
IRIS is
unknown, preliminary investigations suggest that an acute exacerbation of
mycobacterium-
specific Thl responses against mycobacterial antigens after HIV infection
control by this therapy
may cause IRIS in HIV/TB patients. See Bougarit, A. et al., AIDS 20: F1-F7
(2006); Shankar,
E.M., AIDS Research & Therapy 4: 29 (2007).
100481 The present invention describes use of NAC as a primary therapy for
acute
exacerbations of CF, IPF, asthma and TB.
SUMMARY OF THE INVENTION
100491 The present invention describes compositions and methods for
treating acute
exacerbations of an inflammatory lung disease. In one aspect, the present
invention provides a
method of treating the symptoms of an acute exacerbation of an inflammatory
lung disease other
than COPD in a patient in need thereof, the method comprising the step of: (a)
administering to a
patient in need thereof a pharmaceutical composition comprising (1) an acute
exacerbation-
reducing amount of N-acetylcysteine, a pharmaceutically acceptable salt of N-
acetylcysteine, or
a pharmaceutically acceptable derivative of N-acetylcysteine, and (2) a
pharmaceutically
acceptable carrier, and thereby modulating at least one symptom of the acute
exacerbation.
18
CA 02662636 2009-04-15
According to one embodiment of the method, the inflammatory lung disease is
cystic fibrosis.
According to another embodiment, the inflammatory lung disease is an
interstitial lung disease.
According to another embodiment, the interstitial lung disease is idiopathic
pulmonary fibrosis.
According to another embodiment, the inflammatory lung disease is asthma.
According to
another embodiment, the inflammatory lung disease is tuberculosis and the
patient is an HIV
patient. According to another embodiment, ding to claim 1, wherein in step (a)
of the method the
pharmaceutical composition is administered systemically by a route selected
from the group
consisting of orally, buccally, topically, by inhalation, by insufflation,
parenterally and rectally.
According to another embodiment, in step (a) of the method, the pharmaceutical
composition is
administered orally. According to another embodiment, the acute exacerbation-
reducing amount
of N-acetylcysteine, a pharmaceutically acceptable salt of N-acetylcysteine,
or a
pharmaceutically acceptable derivative of N-acetylcysteine in the
pharmaceutical composition
administered orally is about 1.8 grams per day to about 6 grams per day, and
less than or equal to
200 mg per kg per day. According to another embodiment, the acute exacerbation-
reducing
amount of N-acetylcysteine, a pharmaceutically acceptable salt of N-
acetylcysteine, or a
pharmaceutically acceptable derivative of N-acetylcysteine in the
pharmaceutical composition
administered orally is at least about 1800 mg per day and less than or equal
to 200 mg per kg per
day. According to another embodiment, the acute exacerbation-reducing amount
of N-
acetylcysteine, a pharmaceutically acceptable salt of N-acetylcysteine, or a
pharmaceutically
acceptable derivative of N-acetylcysteine in the pharmaceutical composition
administered orally
is at least about 2400 mg per day and less than or equal to 200 mg per kg per
day. According to
another embodiment, the acute exacerbation-reducing amount of N-
acetylcysteine, a
pharmaceutically acceptable salt of N-acetylcysteine, or a pharmaceutically
acceptable derivative
19
CA 02662636 2009-04-15
of N-acetylcysteine in the pharmaceutical composition administered orally is
at least about 3000
mg per day and less than or equal to 200 mg per kg per day. According to
another embodiment,
in step (a) of the method, the pharmaceutical composition is administered
parenterally.
According to another embodiment, the acute exacerbation-reducing amount of N-
acetylcysteine,
a pharmaceutically acceptable salt of N-acetylcysteine, or a pharmaceutically
acceptable
derivative of N-acetylcysteine in the pharmaceutical composition administered
parenterally is
about 200 mg NAC to about 2000 mg NAC per dosage unit. According to another
embodiment,
the method further comprises the step of (b) administering a pharmaceutically
effective amount
of a disease-specific therapeutic agent. According to another embodiment, the
disease specific
therapeutic agent comprises at least one cystic fibrosis therapeutic agent
selected from the group
consisting of an anti-infective agent, a bronchodilating agent, and an anti-
inflammatory agent.
According to another embodiment, the disease-specific therapeutic agent
comprises at least one
idiopathic pulmonary fibrosis therapeutic agent selected from the group
consisting of a
corticosteroid agent, an anticoagulation agent, pirfenidone, and an
antimicrobial agent.
According to another embodiment, the disease-specific therapeutic agent
comprises at least one
asthma therapeutic agent selected from the group consisting of an
antimicrobial agent, a
bronchodilator agent, a corticosteroid; a leukotriene antagonist; and a p-
agonist. According to
another embodiment, the disease specific therapeutic agent comprises at least
one tuberculosis
therapeutic agent. According to another embodiment, the cystic fibrosis
therapeutic agent is at
least one agent selected from the group consisting of an anti-infective agent,
a bronchodilating
agent, and an anti-inflammatory agent. According to another embodiment, the
method further
comprising the step of (b) administering a respiratory therapy to the patient.
According to
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29973-1
another embodiment, the method further comprising the step of (b)
administering a
rehabilitation therapy to the patient.
[0050] In another aspect, the present invention provides a
pharmaceutical kit for
treating an acute exacerbation of an inflammatory lung disease other than COPD
in a subject
in need thereof, the kit comprising a) a first container containing a
pharmaceutically effective
amount of a disease-specific therapeutic agent, and b) a second container
containing a
pharmaceutical composition comprising (i) an acute exacerbation-reducing
amount of N-
acetylcysteine, a pharmaceutically acceptable salt of N-acetylcysteine, or a
pharmaceutically
acceptable derivative of N-acetylcysteine, and (ii) a pharmaceutically
acceptable carrier.
According to one embodiment, the disease specific agent in the first container
comprises at
least one cystic fibrosis agent selected from the group consisting of an anti-
infective agent, a
bronchodilating agent, and an anti-inflammatory agent. According to another
embodiment, the
disease-specific agent in the first container comprises at least one
idiopathic pulmonary
fibrosis therapeutic agent selected from the group consisting of a
corticosteroid agent, an
anticoagulation agent, pirfenidone, and an antimicrobial agent. According to
another
embodiment, the disease-specific agent in the first container comprises at
least one asthma
therapeutic agent selected from the group consisting of an antimicrobial
agent, a
bronchodilator agent, a corticosteroid; a leukotriene antagonist; and a
f3-agonist. According to another embodiment, the disease specific agent
comprises at least one
tuberculosis therapeutic agent.
[0050a] In a use aspect, the invention relates to use of a
pharmaceutical composition for
treating at least one symptom of an acute exacerbation of lung tissue
characterized by
increased oxidative stress and increased sputum concentrations of bioactive
lipid mediators of
an inflammatory lung disease, wherein the inflammatory lung disease is cystic
fibrosis, in a
patient in need thereof, the pharmaceutical composition comprising (1) an
acute exacerbation-
reducing amount of N-acetylcysteine, a pharmaceutically acceptable salt of N-
acetylcysteine,
or a pharmaceutically acceptable derivative of N-acetylcysteine, and (2) a
pharmaceutically
acceptable carrier, wherein the pharmaceutical composition is effective to (a)
modulate the
21
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29973-1
symptoms of the acute exacerbation of lung tissue and (b) decrease plasma
levels of
interleukin-17 (IL-17) in the patient compared to a placebo control.
[005013] A further aspect of the invention relates to a pharmaceutical
kit for treating an
acute exacerbation of lung tissue characterized by increased oxidative stress
and increased
sputum concentrations of bioactive lipid mediators of an inflammatory lung
disease in a
subject in need thereof, the kit comprising a) a first container containing a
pharmaceutically
effective amount of a disease-specific therapeutic agent, and b) a second
container containing
a pharmaceutical composition comprising (i) an acute exacerbation-reducing
amount of
N-acetylcysteine, a pharmaceutically acceptable salt of N-acetylcysteine, or a
pharmaceutically acceptable derivative of N-acetylcysteine, and (ii) a
pharmaceutically
acceptable carrier; and wherein the inflammatory lung disease is cystic
fibrosis.
[0050c1 A still further aspect relates to a use of a pharmaceutical
composition in the
manufacture of a medicament for treating at least one symptom of an acute
exacerbation of
lung tissue characterized by increased oxidative stress and increased sputum
concentrations of
bioactive lipid mediators of an inflammatory lung disease, wherein the
inflammatory lung
disease is cystic fibrosis in a patient in need thereof, the pharmaceutical
composition
comprising (3) an acute exacerbation-reducing amount of N-acetylcysteine, a
pharmaceutically acceptable salt of N-acetylcysteine, or a pharmaceutically
acceptable
derivative of N-acetylcysteine, and (4) a pharmaceutically acceptable carrier,
wherein the
pharmaceutical composition is effective to (c) modulate the symptoms of the
acute
exacerbation of lung tissue and (d) decrease plasma levels of interleukin-17
(IL-17) in the
patient compared to a placebo control.
DETAILED DESCRIPTION OF THE INVENTION
[0051] The present invention describes compositions and methods for
treating acute
exacerbations of an inflammatory lung disease. In some embodiments, the
inflammatory lung
disease is bronchial asthma. In some embodiments, the inflammatory lung
disease is
Idiopathic
21a
CA 02662636 2014-08-12
29973-1
Pulmonary Fibrosis (IPF). In some embodiments, the inflammatory lung disease
is cystic
fibrosis. In some embodiments, the inflammatory lung disease is tuberculosis,
with or without
co-infection with HIV.
[0052] The term "acute" as used herein refers to a rapid onset, brief (not
prolonged), and
severe health-related state.
[0053] The term "chronic" refers to a persistent, long-term, health-related
state of 3
months duration or longer.
100541 The term "condition," as used herein, refers to a variety of health
states and is
meant to include disorders or diseases, and inflammation caused by any
underlying mechanism
or disorder.
[0055] The term "disease" or "disorder," as used herein, refers to an
impairment of health
or a condition of abnormal functioning.
[0056] The term "exacerbations" as used herein refers to an increase in the
severity of a
disease or any of its signs or symptoms.
[0057] The term "idiopathic" refers to a disease of unknown cause.
[00581 The term interstitial lung disease ("ILD") includes a variety of
chronic lung
disorders in which lung tissue is damaged in some known or unknown way, the
walls of the air
'sacs in the lung become inflamed; and scarring (or fibrosis) begins in the
interstitium (or tissue
between the air sacs) and the lung becomes stiff. When all known causes of
interstitial lung
disease have been ruled out, the condition is called idiopathic pulmonary
fibrosis.
[0059] The term "inflammation" as used herein refers to the physiologic
process by
which vascularized tissues respond to injury. See, e.g., FUNDAMENTAL
IMMUNOLOGY,
4th Ed., William E. Paul, ed. Lippincott-Raven Publishers, Philadelphia (1999)
at 1051-1053.
22
CA 02662636 2014-08-12
29973-1
During the inflammatory process, cells involved in
detoxification and repair are mobilized to the compromised site by
inflammatory mediators.
Inflammation is often characterized by a strong infiltration of leukocytes at
the site of
inflammation, particularly neutrophils (polymorphonuclear cells). These cells
promote tissue
damage by releasing toxic substances at the vascular wall or in uninjured
tissue. Traditionally,
inflammation has been divided into acute and chronic responses.
[0060] The term "acute inflammation" as used herein refers to the rapid,
short-lived
(minutes to days), relatively uniform response to acute injury characterized
by accumulations of
fluid, plasma proteins, and neutrophilie leukocytes. Examples of injurious
agents that cause
acute inflammation include, but are not limited to, pathogens (e.g., bacteria,
viruses, parasites),
foreign bodies from exogenous (e.g. asbestos) or endogenous (e.g., urate
crystals, immune
complexes), sources, and physical (e.g., bums) or chemical (e.g., caustics)
agents.
[0061] The term "chronic inflammation" as used herein refers to
inflammation that is of
longer duration and which has a vague and indefinite termination. Chronic
inflammation takes
over when acute inflammation persists, either through incomplete clearance of
the initial
inflammatory agent or as a result of multiple acute events occurring in the
same location.
Chronic inflammation, which includes the influx of lymphocytes and macrophages
and fibroblast
growth, may result in tissue scarring at sites of prolonged or repeated
inflammatory activity.
100621 As used herein, the term "modulate" or "modulating" refers to
adjusting,
changing, or manipulating the function or status of at least one of redox
balance or inflammation
in cystic fibrosis. Such modulation may be any change, including an
undetectable change. In one
embodiment of the present invention, a method of treating an inflammation in
cystic fibrosis
patients comprises the steps of administering to a patient in need thereof a
composition
23
CA 02662636 2009-04-15
comprising an inflammation-reducing amount of NAC, a pharmaceutically
acceptable salt of
NAC, or a pharmaceutically acceptable derivative of NAC, and a
pharmaceutically acceptable
carrier and a pharmaceutically acceptable carrier, thereby modulating the
inflammation.
[0063] Intracellular redox status plays a critical role in cell function.
The term "oxidative
stress" as used herein refers to a condition caused by an imbalance between
reactive oxygen
species and the antioxidant defense mechanisms of a cell, leading to an excess
production of
oxygen metabolites. Skaper, et al., Free Radical Biol. & Med. 22(4): 669-678
(1997).
[0064] The term "redox imbalance" as used herein refers to the imbalance
between
reactive oxygen species and the antioxidant defense mechanisms of a cell.
[0065] The term "syndrome," as used herein, refers to a pattern of symptoms
indicative
of some disease or condition.
[0066] As used herein the term "treating" includes abrogating,
substantially inhibiting,
slowing or reversing the progression of a condition, substantially
ameliorating clinical or
symptoms of a condition, and substantially preventing the appearance of
clinical or symptoms of
a condition.
[0067] In one embodiment of the present invention, the composition of the
present
invention comprises an inflammation-reducing amount of NAC and a
pharmaceutically
acceptable carrier. In another embodiment of the present invention, the
composition of the
present invention comprises a redox imbalance adjusting amount of NAC and a
pharmaceutically
acceptable carrier. In another embodiment of the present invention, the
composition of the
present invention comprises an acute exacerbation-reducing amount of NAC and a
pharmaceutically acceptable carrier.
24
CA 02662636 2009-04-15
100681 As used herein the terms "inflammation-reducing amount," "redox
imbalance
adjusting amount", "acute exacerbation-reducing amount," or "pharmaceutically
effective
amount" refer to the amount of the compositions of the invention that result
in a therapeutic or
beneficial effect following its administration to a subject. The inflammation-
reducing, redox
imbalance adjusting, acute exacerbation-reducing, or pharmaceutically
effective amount may be
curing, minimizing, preventing or ameliorating a disease or disorder, or may
have any other anti-
inflammatory, redox balancing or pharmaceutical beneficial effect. Without
being limited by
theory, it is believed that an acute exacerbation reducing amount of NAC may
be an amount that
may increase a threshold for acute pathways of inflammation; that may act on a
new pathway
that acts on a T-cell subset that controls neutrophil infiltration in the
lung; and/or that may act on
signaling pathways inside other cells and inhibit ability of neutrophils to
enter the lung. The
concentration of the substance is selected so as to exert its inflammation-
reducing, redox
balancing, or pharmaceutical effect, but low enough to avoid significant side
effects within the
scope and sound judgment of the skilled artisan. The effective amount of the
composition may
vary with the age and physical condition of the biological subject being
treated, the severity of
the condition, the duration of the treatment, the nature of concurrent
therapy, the specific
compound, composition or other active ingredient employed, the particular
carrier utilized, and
like factors.
100691 A skilled artisan may determine a pharmaceutically effective amount
of the
inventive compositions by determining the unit dose. As used herein, a "unit
dose" refers to the
amount of inventive composition required to produce a response of 50% of
maximal effect (i.e.
ED50). The unit dose may be assessed by extrapolating from dose-response
curves derived from
in vitro or animal model test systems. The amount of compounds in the
compositions of the
CA 02662636 2009-04-15
present invention which will be effective in the treatment of a particular
disorder or condition
will depend on the nature of the disorder or condition, and may be determined
by standard
clinical techniques. (See, for example, Goodman and Gilman's THE
PHARMACOLOGICAL
BASIS OF THERAPEUTICS, Joel G. Harman, Lee E. Limbird, Eds.; McGraw Hill, New
York,
2001; THE PHYSICIAN'S DESK REFERENCE, Medical Economics Company, Inc.,
Oradell,
N.J., 1995; and DRUG FACTS AND COMPARISONS, FACTS AND COMPARISONS, INC.,
St. Louis, Mo., 1993). The precise dose to be employed in the formulation will
also depend on
the route of administration, and the seriousness of the disease or disorder,
and should be decided
according to the judgment of the practitioner and each patient's
circumstances.
100701 The term "pharmaceutical composition," as used herein, refers to a
composition
that has under gone federal regulatory review, which prevents, reduces in
intensity, cures,
ameliorates, or otherwise treats a target disorder or disease. It is preferred
that the pharmaceutical
compositions according to the present invention contain from about at least
200 to about 2000
mg NAC per dosage unit for oral administration and about at least 200 to about
2000 mg NAC
per dosage unit for parenteral administration at the physician's discretion.
Usual dosage should
be between 1.8 to 6.0 g/d, not to exceed 200 mg/kg/d.
10071] The unit dose of NAC, will usually comprise at least about 200 mg
(for pediatric
doses), usually at least about 600 mg (for adult doses); and usually not more
than about 2000 mg
at the physician's discretion, from a minimum of one to a maximum of six daily
intakes.
Patients on therapy known to deplete cysteine/glutathione or produce oxidative
stress may
benefit from higher amounts of NAC.
10072] The terms "drug carrier", "carrier", or "vehicle" as used herein
refers to a
pharmaceutically acceptable inert agent or vehicle for delivering one or more
active agents to a
26
CA 02662636 2009-04-15
mammal, and often is referred to as "excipient." As used herein the term "a
pharmaceutically
acceptable carrier" refers to any substantially non-toxic carrier
conventionally useable for NAC
administration in which NAC will remain stable and bioavailable. The carrier
suitable for NAC
administration must be of sufficiently high purity and of sufficiently low
toxicity to render it
suitable for administration to the mammal being treated. Carriers and vehicles
useful herein
include any such materials known in the art which are nontoxic and do not
interact with other
components. The (pharmaceutical) carrier may be, without limitation, a binding
agent (e.g.,
pregelatinized maize starch, polyvinylpyrrolidone or hydroxypropyl
methylcellulose, etc.), a
filler (e.g., lactose and other sugars, microcrystalline cellulose, pectin,
gelatin, calcium sulfate,
ethyl cellulose, polyacrylates, calcium hydrogen phosphate, etc.), a lubricant
(e.g., magnesium
stearate, talc, silica, colloidal silicon dioxide, stearic acid, metallic
stearates, hydrogenated
vegetable oils, corn starch, polyethylene glycols, sodium benzoate, sodium
acetate, etc.), a
disintegrant (e.g., starch, sodium starch glycolate, etc.), or a wetting agent
(e.g., sodium lauryl
sulphate, etc.). Other suitable (pharmaceutical) carriers for the compositions
of the present
invention include, but are not limited to, water, salt solutions, alcohols,
polyethylene glycols,
gelatins, amyloses, magnesium stearates, talcs, silicic acids, viscous
paraffins,
hydroxymethylcelluloses, polyvinylpyrrolidones and the like.
100731 In some embodiments, the carrier of the composition of the present
invention
includes a release agent such as sustained release or delayed release carrier.
In such
embodiments, the carrier may be any material capable of sustained or delayed
release to provide
a more efficient administration, e.g., resulting in less frequent and/or
decreased dosage, improve
ease of handling, and extend or delay effects on diseases, disorders,
conditions, syndromes, and
the like, being treated. Non-limiting examples of such carriers include
liposomes, microsponges,
27
CA 02662636 2009-04-15
microspheres, or microcapsules of natural and synthetic polymers and the like.
Liposomes may
be formed from a variety of phospholipids such as cholesterol, stearylamines
or
phosphatidylcholines.
[0074] It is preferred that the NAC be substantially free of sulfones or
other chemicals
that interfere with the metabolism of any co-administered drug in its
bioactive form. It is also
preferred that the NAC be substantially free of its oxidized form, di-N-
acetylcysteine and that the
composition should be prepared in a manner that substantially prevents
oxidation of the NAC
during preparation or storage.
[0075] It may be noted that the effectiveness of NAC depends on the
presence of the
reduced form, which may, for example, liberate the reduced form of glutathione
from homo- and
hetero-disulfide derivatives in thiol-disulfide exchange reactions. A typical
unit dosage may be a
solution suitable for oral or intravenous administration; an effervescent
tablet suitable for
dissolving in water, fruit juice, or carbonated beverage and administered
orally; a tablet taken
from two to six times daily, or one time-release capsule or tablet taken
several times a day and
containing a proportionally higher content of active ingredient, etc. The time-
release effect may
be obtained by capsule materials that dissolve at different pH values, by
capsules that release
slowly by osmotic pressure, or by any other known means of controlled release.
Unit dosage
forms may be provided wherein each dosage unit, for example, teaspoonful,
tablespoonful, gel
capsule, tablet or suppository, contains a predetermined amount of the
compositions of the
present invention. Similarly, unit dosage forms for injection or intravenous
administration may
comprise the compound of the present invention in a composition as a solution
in sterile water,
normal saline or another pharmaceutically acceptable carrier. The
specifications for the unit
dosage forms of the present invention depend on the effect to be achieved and
the intended
28
CA 02662636 2009-04-15
recipient. Thus, in some embodiments, NAC is formulated at high doses as an
effervescent
tablet or in granular form in a single dose packet to be dissolved in water to
prevent untoward
stomach effects.
[0076] Over-the-counter NAC may be variably produced and packaged. Because
the
production and packaging methods generally do not guard against oxidation, the
NAC may be
significantly contaminated with bioactive oxidation products. These may be
particularly
important in view of data indicating that the oxidized form of NAC has effects
counter to those
reported for NAC and is bioactive at doses roughly 10-100 fold less than NAC.
See Sarnstrand et
al J. Pharmacol. Exp. Ther. 288:1174-84 (1999).
100771 The distribution of the oxidation states of NAC as a thiol and
disulfide depends on
the oxidation/reduction (redox) potential. The half-cell potential obtained
for the NAC
thiol/disulfide pair is about +63 mV, indicative of its strong reducing
activity among natural
compounds [see Noszal etal. J. Med. Chem. 43:2176-2182 (2000)]. In a preferred
embodiment
of the invention, the preparation and storage of the formulation is performed
in such a way that
the reduced form of NAC is the primary form administered to the patient.
Maintaining NAC
containing formulations in solid form is preferable for this purpose. When in
solution, NAC
containing formulations are preferably stored in a brown bottle that is vacuum
sealed. Storage in
cool dark environments is also preferred.
[0078] The determination of reduced and oxidized species present in a
sample may be
determined by various methods known in the art, including, but not limited to,
for example,
capillary electrophoresis, and high performance liquid chromatography as
described by
Chassaing etal. J. Chromatogr. B. Biomed. Sci. App!. 735(2):219-27 (1999)..
29
CA 02662636 2009-04-15
[0079] The compositions of the present invention may be administered
systemically
either orally, parenterally, or rectally in dosage unit formulations
containing conventional
nontoxic pharmaceutically acceptable carriers, adjuvants, and vehicles as
desired.
[0080] The compositions of the present invention may be in a form suitable
for oral use,
for example, as tablets, troches, lozenges, aqueous or oily suspensions,
dispersible powders or
granules, emulsions, hard or soft capsules or syrups or elixirs. Compositions
intended for oral
use may be prepared according to any known method, and such compositions may
contain one or
more agents selected from the group consisting of sweetening agents, flavoring
agents, coloring
agents, and preserving agents in order to provide pharmaceutically elegant and
palatable
preparations. Tablets may contain the active ingredient(s) in admixture with
non-toxic
pharmaceutically-acceptable excipients which are suitable for the manufacture
of tablets. These
excipients may be, for example, inert diluents, such as calcium carbonate,
sodium carbonate,
lactose, calcium phosphate or sodium phosphate; granulating and disintegrating
agents, for
example, corn starch or alginic acid; binding agents, for example, starch,
gelatin or acacia; and
lubricating agents, for example, magnesium stearate, stearic acid or talc. The
tablets may be
uncoated or they may be coated by known techniques to delay disintegration and
absorption in
the gastrointestinal tract and thereby provide a sustained action over a
longer period. For
example, a time delay material such as glyceryl monostearate or glyceryl
distearate may be
employed. They also may be coated for controlled release.
[0081] Compositions of the present invention also may be formulated for
oral use as hard
gelatin capsules, where the active ingredient(s) is(are) mixed with an inert
solid diluent, for
example, calcium carbonate, calcium phosphate or kaolin, or soft gelatin
capsules wherein the
-
CA 02662636 2009-04-15
active ingredient(s) is (are) mixed with water or an oil medium, for example,
peanut oil, liquid
paraffin, or olive oil.
[00821 The compositions of the present invention may be formulated as
aqueous
suspensions wherein the active ingredient(s) is (are) in admixture with
excipients suitable for the
manufacture of aqueous suspensions. Such excipients are suspending agents, for
example,
sodium carboxymethylcellulose, methylcellulose, hydroxy-propylmethylcellulose,
sodium
alginate, polyvinylpyrrolidone, gum tragacanth, and gum acacia; dispersing or
wetting agents
may be a naturally-occurring phosphatide such as lecithin, or condensation
products of an
alkylene oxide with fatty acids, for example, polyoxyethylene stearate, or
condensation products
of ethylene oxide with long chain aliphatic alcohols, for example,
heptadecaethyl-eneoxycetanol,
or condensation products of ethylene oxide with partial esters derived from
fatty acids and a
hexitol such as polyoxyethylene sorbitol monooleate, or condensation products
of ethylene oxide
with partial esters derived from fatty acids and hexitol anhydrides, for
example polyethylene
sorbitan monooleate. The aqueous suspensions also may contain one or more
coloring agents,
one or more flavoring agents, and one or more sweetening agents, such as
sucrose or saccharin.
[0083] Compositions of the present invention may be formulated as oily
suspensions by
suspending the active ingredient in a vegetable oil, for example arachis oil,
olive oil, sesame oil
or coconut oil, or in a mineral oil, such as liquid paraffin. The oily
suspensions may contain a
thickening agent, for example, beeswax, hard paraffin or cetyl alcohol.
Sweetening agents, such
as those set forth above, and flavoring agents may be added to provide a
palatable oral
preparation. These compositions may be preserved by the addition of an
antioxidant such as
ascorbic acid.
31
CA 02662636 2009-04-15
100841 Compositions of the present invention may be formulated in the form
of
dispersible powders and granules suitable for preparation of an aqueous
suspension by the
addition of water. The active ingredient in such powders and granules is
provided in admixture
with a dispersing or wetting agent, suspending agent, and one or more
preservatives. Suitable
dispersing or wetting agents and suspending agents are exemplified by those
already mentioned
above. Additional excipients, for example, sweetening, flavoring and coloring
agents also may
be present.
[0085] Compositions of the invention also may be formulated as a beverage
or as an
additive to a beverage, where the term "beverage" refers to any non-alcoholic
flavored
carbonated drink, soda water, non-alcoholic still drinks, diluted fruit or
vegetable juices whether
sweetened or unsweetened, seasoned or unseasoned with salt or spice, or still
or carbonated
mineral waters used as a drink. The term "additive" as used herein refers to
any substance the
intended use of which results, or may reasonably be expected to result,
directly or indirectly, in
its becoming a component or otherwise affecting the characteristics of any
beverage. In some
embodiments, the beverage is a flavored carbonated beverage. In some
embodiments, the
beverage is a flavored non-carbonated beverage. In some embodiments, the
beverage is a natural
fruit beverage. The beverage also may contain one or more coloring agents, one
or more
flavoring agents, one or more sweetening agents, one or more antioxidant
agents, and one or
more preservatives.
[0086] Compositions of the invention also may be in the form of oil-in-
water emulsions.
The oily phase may be a vegetable oil, for example, olive oil or arachis oil,
or a mineral oil, for
example a liquid paraffin, or a mixture thereof. Suitable emulsifying agents
may be naturally-
occurring gums, for example, gum acacia or gum tragacanth, naturally-occurring
phosphatides,
32
CA 02662636 2009-04-15
for example soy bean, lecithin, and esters or partial esters derived from
fatty acids and hexitol
anhydrides, for example sorbitan monooleate, and condensation products of the
partial esters
with ethylene oxide, for example, polyoxyethylene sorbitan monooleate. The
emulsions also
may contain sweetening and flavoring agents.
[0087] Compositions of the invention also may be formulated as syrups and
elixirs.
Syrups and elixirs may be formulated with sweetening agents, for example,
glycerol, propylene
glycol, sorbitol or sucrose. Such formulations also may contain a demulcent, a
preservative, and
flavoring and coloring agents. Demulcents are protective agents employed
primarily to alleviate
irritation, particularly mucous membranes or abraded tissues. A number of
chemical substances
possess demulcent properties. These substances include the alginates,
mucilages, gums, dextrins,
starches, certain sugars, and polymeric polyhydric glycols. Others include
acacia, agar, benzoin,
carbomer, gelatin, glycerin, hydroxyethyl cellulose, hydroxypropyl cellulose,
hydroxypropyl
methylcellulose, propylene glycol, sodium alginate, tragacanth, hydrogels and
the like.
[0088] The compositions of the present invention may be in the form of a
sterile
injectable aqueous or oleaginous suspension. The term "parenteral" as used
herein includes
subcutaneous injections, intravenous, intramuscular, intrasternal injection,
or infusion
techniques. Injectable preparations, such as sterile injectable aqueous or
oleaginous suspensions,
may be formulated according to the known art using suitable dispersing or
wetting agents and
suspending agents. The sterile injectable preparation may also be a sterile
injectable solution or
suspension in a nontoxic parenterally acceptable diluent or solvent, for
example, as a solution in
1, 3-butanediol. Among the acceptable vehicles and solvents that may be
employed are water,
Ringer's solution, and isotonic sodium chloride solution. In addition,
sterile, fixed oils are
conventionally employed as a solvent or suspending medium. For parenteral
application,
33
CA 02662636 2009-04-15
particularly suitable vehicles consist of solutions, preferably oily or
aqueous solutions, as well as
suspensions, emulsions, or implants. Aqueous suspensions may contain
substances which
increase the viscosity of the suspension and include, for example, sodium
carboxymethyl
cellulose, sorbitol and/or dextran. Optionally, the suspension may also
contain stabilizers.
[0089] The term "topical" refers to administration of an inventive
composition at, or
immediately beneath, the point of application. The phrase "topically applying"
describes
application onto one or more surfaces(s) including epithelial surfaces.
Although topical
administration, in contrast to transdermal administration, generally provides
a local rather than a
systemic effect, as used herein, unless otherwise stated or implied, the terms
topical
administration and transdermal administration are used interchangeably. For
the purpose of this
application, topical applications shall include mouthwashes and gargles.
[0090] Topical administration may also involve the use of transdermal
administration
such as transdermal patches or iontophoresis devices which are prepared
according to techniques
and procedures well known in the art. The terms "transdermal delivery system",
transdermal
patch" or "patch" refer to an adhesive system placed on the skin to deliver a
time released dose
of a drug(s) by passage from the dosage form through the skin to be available
for distribution via
the systemic circulation. Transdermal patches are a well-accepted technology
used to deliver a
wide variety of pharmaceuticals, including, but not limited to, scopolamine
for motion sickness,
nitroglycerin for treatment of angina pectoris, clonidine for hypertension,
estradiol for post-
menopausal indications, and nicotine for smoking cessation.
[0091] Patches suitable for use in the present invention include, but are
not limited to, (1)
the matrix patch; (2) the reservoir patch; (3) the multi-laminate drug-in-
adhesive patch; and (4)
the monolithic drug-in-adhesive patch; TRANSDERMAL AND TOPICAL DRUG DELIVERY
34
CA 02662636 2014-08-12
29973-1
SYSTEMS, pp. 249-297 (Tapash K. Ghosh et al. eds., 1997)
These patches are well known in the art and generally available commercially.
100921 The compositions of the present invention may be in the form of a
dispersible dry
powder for pulmonary delivery. Dry powder compositions may be prepared by
processes known
in the art, such as lyophilization and jet milling, as disclosed in
International Patent Publication
No. WO 91/16038 and as disclosed in U.S. Pat. No. 6,921,527.
The composition of the present invention is placed within a suitable
dosage receptacle in an amount sufficient to provide a subject with a unit
dosage treatment. The
dosage receptacle is one that fits within a suitable inhalation device to
allow for the
aerosolization of the dry powder composition by dispersion into a gas stream
to form an aerosol
and then capturing the aerosol so produced in a chamber having a mouthpiece
attached for
subsequent inhalation by a subject in need of treatment. Such a dosage
receptacle includes any
container enclosing the composition known in the art such as gelatin or
plastic capsules with a
removable portion that allows a stream of gas (e.g., air) to be directed into
the container to
disperse the dry powder composition. Such containers are exemplified by those
shown in U.S.
Pat. Nos. 4,227,522; U.S. Pat. No. 4,192,309; and U.S. Pat. No. 4,105,027.
Suitable containers
also include those used in conjunction with Glaxo's Ventolin Rotohaler brand
powder inhaler
or Fison's Spinhaler brand powder inhaler. Another suitable unit-dose
container which provides
a superior moisture barrier is formed from an aluminum foil plastic laminate.
The
pharmaceutical-based powder is filled by weight or by volume into the
depression in the
formable foil and hermetically sealed with a covering foil-plastic laminate.
Such a container for
use with a powder inhalation device is described in U.S. Pat. No. 4,778,054
and is used with
=
CA 02662636 2014-08-12
29973-1
Glaxo's Diskhaler (U.S. Pat. Nos. 4,627,432; 4,811,731; and 5,035,237).
[0093] The compositions of the present invention may be in the form of
suppositories for
rectal administration of the composition. These compositions may be prepared
by mixing the
drug with a suitable nonirritating excipient such as cocoa butter and
polyethylene glycols which
are solid at ordinary temperatures but liquid at the rectal temperature and
will therefore melt in
the rectum and release the drug. When formulated as a suppository the
compositions of the
invention may be formulated with traditional binders and carriers, such as
triglycerides.
[0094] The therapeutically active agent of the present invention may be
formulated per se
or in salt form. The term "pharmaceutically acceptable salts" refers to
nontoxic salts of NAC.
Pharmaceutically acceptable salts include, but are not limited to, those
formed with free amino
groups such as those derived from hydrochloric, phosphoric, sulfuric, acetic,
oxalic, tartaric
acids, etc., and those formed with free carboxyl groups such as those derived
from sodium,
potassium, ammonium, calcium, ferric hydroxides, isopropylamine,
triethylamine, 2-ethylamino
ethanol, histidine, procaine, etc.
[0095] Additional compositions of the present invention may be readily
prepared using
technology which is known in the art such as described in Remington's
Pharmaceutical Sciences,
18th or 19th editions, published by the Mack Publishing Company of Easton,
Pennsylvania.
[0096] The present invention further provides a pharmaceutical pack or
kit comprising
one or more containers filled with one or more of the ingredients of the
pharmaceutical
compositions of the invention. Associated with such container(s) may be a
notice in the form
prescribed by a governmental agency regulating the manufacture, use or sale of
pharmaceuticals
36
CA 02662636 2009-04-15
or biological products, which notice reflects approval by the agency of
manufacture, use or sale
for human administration.
[0097] For example, in one embodiment, a pharmaceutical kit for treating
inflammation
in cystic fibrosis patients according to the present invention includes a
first container filled with
a pharmaceutically effective amount of a cystic fibrosis therapeutic agent and
a second container
filled with a composition comprising a redox-balancing amount of N-
acetylcysteine , a
pharmaceutically acceptable salt of N-acetylcysteine, or a pharmaceutically
acceptable derivative
of N-acetylcysteine, and a pharmaceutically acceptable carrier.
100981 In another embodiment, a pharmaceutical kit for treating redox
imbalance in
cystic fibrosis patients according to the present invention includes a first
container filled with a
pharmaceutically effective amount of a cystic fibrosis therapeutic agent and a
second container
filled with a composition comprising a redox-balancing amount of N-
acetylcysteine , a
pharmaceutically acceptable salt of N-acetylcysteine, or a pharmaceutically
acceptable derivative
of N-acetylcysteine, and a pharmaceutically acceptable carrier.
10099] In yet another embodiment, a pharmaceutical kit for treating
inflammation and
redox imbalance in cystic fibrosis patients according to the present invention
includes a first
container filled with a pharmaceutically effective amount of a cystic fibrosis
therapeutic agent
and a second container filled with a composition comprising an inflammation-
reducing and
redox-balancing amount of N-acetylcysteine , a pharmaceutically acceptable
salt of N-
acetylcysteine, or a pharmaceutically acceptable derivative of N-
acetylcysteine, and a
pharmaceutically acceptable carrier.
1001001 In some embodiments known techniques are used to monitor lung
function. Such
known techniques include, but are not limited to spirometry, which provides
information about
37
CA 02662636 2009-04-15
airflow limitation and lung volumes; plethysmography, which provides
information about airway
resistance, total lung size, and trapped gas; transfer factor, which provides
information about
alveolar function; gas washout tests, which provide information about gas
mixing, small airway
function, and heterogeneous changes in compliance; computational tomography,
which provides
information about large and small airway deterioration; and oscillometry,
which may provide
information about small airways.
[00101] In another embodiment of the present invention, compositions and
methods of the
present invention may be used in combination with known therapeutic agents,
provided that they
are compatible with each other. "Compatible" as used herein means that the
compositions and
methods of the present invention are capable of being combined with existing
therapies in a
manner such that there is no interaction that would substantially reduce the
efficacy of either the
compositions or methods of the present invention or the therapies under
ordinary use conditions.
[00102] In some embodiments, existing cystic fibrosis therapeutic agents
that may be
combined with the compositions and methods of the present invention include,
but are not
limited to, anti-infective agents, bronchodilating agents, and anti-
inflammatory agents.
[00103] Lung and airway infections in cystic fibrosis may be treated with
potent anti-
infective agents, including antibiotics, to improve lung function, reduce days
spent in the hospital
and to reduce use of intravenous antibiotics to reduce bacterial levels in the
lungs. Inhaled
antibiotics also are used to prevent lung infections that may lead to
hospitalization.
[00104] To minimize certain side effects, bronchodilating agents often are
used along with
inhaled antibiotics. Bronchodilating agents are used widely for treating a
variety of obstructive
lung diseases, including cystic fibrosis. They relax smooth muscle in the
small airways of the
lungs, which dilates the ainvays and makes breathing easier, particularly when
airways are
38
CA 02662636 2009-04-15
narrowed by inflammation. Inhaled bronchodilator medications used in asthma,
such as
albuterol, have improved breathing in some people with cystic fibrosis. When
used to treat
cystic fibrosis, bronchodilating agents are usually given through a nebulizer
or with a handheld
inhaler. Airway dilatation before physiotherapy helps the cystic fibrosis
patient to clear chest
secretions.
1001051 Nonsteroidal anti-inflammatory agents reduce inflammation and pain.
Cystic
fibrosis patients often have persistent lung inflammation which becomes part
of the cycle of
continued lung damage in these patients. Anti-inflammatory medications, such
as ibuprofen, in
some patients with CF help to reduce this inflammation. In some children, anti-
inflammatory
medications may significantly slow the progression of lung disease and improve
breathing.
1001061 In some embodiments, therapeutic agents, such as corticosteroids,
anticoagulation
agents, and pirfenidone, may be administered to treat the inflammation present
in some patients
with IPF in combination with the compositions and methods of the present
invention.
Antimicrobial agents also may be used to treat bacterial organisms,
opportunistic pathogens, and
common respiratory viruses.
1001071 In some embodiments, standard doses of existing therapeutic agents
for chronic
and acute exacerbations of asthma may be combined with the compositions and
methods of the
present invention. These include, but are not limited to, antimicrobial
agents, bronchodilators
(e.g., epinephrine, terbutaline, ipratropium (Atrovent0)), inhaled
corticosteroids, leukotriene
antagonists, 0-agonists (e.g., albuterol [e.g., Ventolin 0, Proventi101,
levalbuterol,
Metaproterenol Sulfate (Alupent), isoprotenerol, chromolyn sodium;
aminophylline, and
theophylline.
39
CA 02662636 2009-04-15
1001081 In another embodiment of the present invention, compositions and
methods of the
present invention may be used in combination with known therapies, provided
that they are
compatible with each other.
[00109] The term "respiratory therapy" as used herein refers to chest
physiotherapy, which
is used to help clear excess mucus out of the lungs. To perform chest
physiotherapy, a patient is
placed in various positions allowing major segments of the lungs to point
downward and then
clapping firmly over chest and back on part of the lung segment to shake the
mucus loose. Once
loosened, the mucus will fall to the large airways, where it may be coughed
out. Chest
physiotherapy may be time-consuming since 3-5 minutes is spent clapping over
10-12 lung
segments. It is also difficult for patients to perform on themselves and
usually requires a skilled
caregiver.
[00110] The term "rehabilitative therapy" refers to a therapy designed to
help patients use
their energy more efficiently, i.e., in a way that requires less oxygen.
Rehabilitative therapy
improves shortness of breath and overall survival, especially in those with
advanced disease.
1001111 Where a range of values is provided, it is understood that each
intervening value,
to the tenth of the unit of the lower limit unless the context clearly
dictates otherwise, between
the upper and lower limit of that range and any other stated or intervening
value in that stated
range is encompassed within the invention. The upper and lower limits of these
smaller ranges
which may independently be included in the smaller ranges is also encompassed
within the
invention, subject to any specifically excluded limit in the stated range.
Where the stated range
includes one or both of the limits, ranges excluding either both of those
included limits are also
included in the invention.
CA 02662636 2014-08-12
29973-1
[00112] Unless defined otherwise, all technical and scientific terms used
herein have the
same meaning as commonly understood by one of ordinary skill in the art to
which this invention
belongs. Although any methods and materials similar or equivalent to those
described herein
may also be used in the practice or testing of the present invention, the
preferred methods and
materials are now described.
[00113] It must be noted that as used herein and in the appended claims,
the singular
forms "a", "and", and "the" include plural referents unless the context
clearly dictates otherwise.
All technical and scientific terms used herein have the same meaning.
[00114] The publications discussed herein are provided solely for their
disclosure prior to
the filing date of the present application. Nothing herein is to be construed
as an admission that
the present invention is not entitled to antedate such publication by virtue
of prior invention.
Further, the dates of publication provided may be different from the actual
publication dates
which may need to be independently confirmed.
[00115] EXAMPLES
[00116] The following examples are put forth so as to provide those of
ordinary skill in
the art with a complete disclosure and description of how to make and use the
present invention,
and are not intended to limit the scope of what the inventors regard as their
invention nor are
they intended to represent that the experiments below are all or thn only
experiments performed.
Efforts have been made to ensure accuracy with respect to numbers used (e.g.
amounts,
temperature, etc.) but some experimental errors and deviations should be
accounted for. Unless
41
CA 02662636 2009-04-15
indicated otherwise, parts are parts by weight, molecular weight is weight
average molecular
weight, temperature is in degrees Centigrade, and pressure is at or near
atmospheric.
[00117] Example 1. Treatment of cystic fibrosis patients with oral N-
acetylcysteine
[00118] A phase I trial of high-dose oral N-acetylcysteine (NAC) in CF has
been
completed. This CF Foundation-sponsored dose-escalation safety pilot study was
designed to
assess the dose of oral NAC that may be used safely in order to replenish
glutathione (GSH)
stores in subjects with CF, with the objectives of restoring a proper redox
balance and limiting
lung inflammation in patients.
[00119] Safety was excellent with all doses tested (1.8, 2.4 and 3.0 g/d,
t.i.d, for 4 weeks,
N=6 in each cohort). No clinical adverse effect was identified based on
physical examination,
CBC, laboratory tests, and the CF patient's quality of life ("QOL"). Very mild
and infrequent
drug-related adverse effects were reported in 6 out of 18 patients (Table 1):
heartburn (N = 4),
nausea (N = 1), bad taste (N = 1). Doses of 2.4 and 3.0 g/d had less reported
adverse effects than
1.8 g/d. Treatment compliance was high (93 1%) and not impacted by drug-
related adverse
effects (P > 0.7) or dose (P> 0.3).
[00120] With regards to efficacy, very significant positive effects of the
treatment were
documented. These positive effects (Table 2) included amelioration of: 1-
Whole blood GSH
(+11%, P=0,03), as measured by HPLC and blood neutrophil GSH (+17%, P=0.03),
as measured
by flow cytometry; 2- Live sputum leukocyte (-21%, P=0.03) and neutrophil (-
25%, P=0.02)
counts, as measured by microscopy and sputum elastase activity (-44%, P=0.02),
as measured by
kinetic spectrophotometry; and 3- Perceived weight gain (P=0.01), as measured
by the CF QOL
[00121] After excluding three patients without basal lung inflammation
(total live
leukocytes in sputum in normal range [<0.9, Logl 0 scale]), treatment effects
were even more
42
CA 02662636 2009-04-15
pronounced: 1- Whole blood GSH (+14%, P=0.02) and blood neutrophil GSH (+25%,
P=0.003);
2- Live sputum leukocyte (-28, P=0.005) and neutrophil (-32%, P=0.003) counts
and sputum
elastase activity (-46%, P=0.02), as well as % neutrophils in sputum (-9%,
P=0.04) and sputum
IL-8 (-25%, P=0.02); 3- Perceived weight gain, on the other hand, was less
significantly altered
(P=0.05) when excluding the three CF patients without basal lung inflammation
[00122] The 3 dose cohorts were not significantly different with regards to
most outcome
measurements, but the second and third dose cohort (2.4 and 3.0 g/d) performed
slightly better
overall than the first (1.8 g/d). As expected with short-term treatment (4
weeks), Pulmonary
Function Testing results ("PFT") were not changed.
1. Data acquisition
[00123] Data acquisition was completed very satisfactorily for clinical
assessment, clinical
laboratory tests and research tests. Only one patient in cohort 1 failed to
give enough blood to
perform both clinical laboratory and research tests so that only the latter
were performed.
2. Safety, adverse effects and compliance
[00124] Safety assessment did not raise any particular concern. Sputum
induction was
well tolerated. No clinical adverse effect of treatment was identified based
on physical
examination, CBC, common laboratory tests and CF QOL (no diarrhea or vomiting
recorded).
High-dose oral NAC thus was very well tolerated, with only very mild drug-
related adverse
effects (Table 1, below). Adverse effects were not correlated with dose,
patient age, gender, P.
aeruginosa status or other parameters. Compliance was excellent, averaging 93
1 % (mean
SE) overall and was not influenced by the advent of reported adverse effects
and did not differ
between the three dose cohorts. Therefore, dose escalation from cohort 1 to 3
proceeded with no
safety concerns.
43
CA 02662636 2009-04-15
Table 1. Safety and compliance
Subject information Adverse effects
Trial Cohort Age Gender Peer Coniplianc Clinical Patient Duration
Probable
ID (yrs) status e monitoring reporting (days)
cause(s)
(%)
. .
001 1 11 F N 88 None Headache 1 Dehydration
002 1 11 F Y 93 None Increased cough, 9 "
Infection
sputum;
decreased peak
flow and
exercise
tolerance
-
003 1 40 F N 96 None Heartburn 8 ' Drug
004 1 18 F , Y 93 None Heartburn 5 Drug
005 1 16 F N , 76 None Nausea 3 Drug
006 1 32 F Y 96 None Heartburn 19 Drug
007 2 14 F Y 87 None None N/A N/A
008 2 14 , F Y 94 None Sore throat 1 , Infection
009 2 12 M Y 96 None Headache, mild 28
Ibuprofen
cough _ withdrawal
_
010 2 28 F Y 100 None Bad taste 28 Drug
011 2 19 F ' Y 93 None Rash ' 3 Contact
dermatitis
-
012 2 44 F Y 92 None None N/A N/A
013 3 27 M Y 94 None Heartburn 10 Drug
014 3 35 F Y 94 None Cold symptoms 1
Infection
015 3 38 M Y 95 None Constipation 2 Ddistal
intestinal
obstruction
syndrome
016 3 23 M N 93 None Mild cough, 10 Lung
chestyain disease
' 017 3 31 M Y 100 None Weight loss, 28
Lung
mild cough disease
- M
018 3 31 Y 94 None Increased 18 N/A
gaitum
,
3. Efficacy
1001251 In addition to ascertaining the safety of high-dose oral NAC
treatment in CF
patients, this pilot phase was also designed to provide preliminary assessment
of treatment
efficacy on numerous outcome measurements, including:
1. Redox balance, as reflected chiefly by (i) whole blood GSH measured by
HPLC, and
(ii) live blood neutrophil GSH, measured by flow cytometry
44
CA 02662636 2009-04-15
2. Lung inflammation, as reflected chiefly by (i) sputum counts in total live
leukocytes
and neutrophils (along with % neutrophils in sputum); (iii) plasma / sputum
levels of elastase and
interleukin-8 (IL-8) measured by spectrophotometry and ELISA
3. Lung function, as measured by spirometry.
[00126] Differences between basal and post-NAC values were studied by
matched pair
analysis, first, without distinguishing dose cohorts, to detect drug effects,
and second, with dose
cohorts as a factor, in order to detect potential dose effects. Results show
that 4 week-treatment
with high-dose oral NAC significantly increased the redox balance and reduced
lung
inflammation.
1001271 In addition, analysis of the CF QOL questionnaire revealed a
significant effect on
perceived weight gain. With regards to lung function, none of the parameters
measured by
spirometry showed any change, even as important redox and inflammatory
parameters were
improved upon treatment. This result was expected, based on the power analysis
included in our
original proposal. Any sizeable change in lung function will likely require
longer treatment and
larger group size, which we look forward to implementing in the placebo-
controlled phase of the
study.
[00128] Patients with more severe lung inflammation responded better to
NAC, notably in
terms of the reduction in live sputum leukocytes. In particular, three
patients (patients 001, 011,
and 016: one in each cohort) were in the normal range of live sputum
leukocytes (<0.9 Log10).
When these three patients were excluded, treatment effects were much more
significant (Table
2). In addition, other drug effects became significant, e.g., decreases in
sputum IL-8 and percent
(%) neutrophils.
CA 02662636 2009-04-15
Table 2. Significant drug effects during the phase I trial
Variable
Live Live Neutrophils TI _8 in Elastase
Perceived
Whole N
Subjects Statistics W eutrophil ood sputum sputum
sputum sputum in weight FeV1
GSH
GSH leukocytes neutrophils (%) sputum gain
Change +110/G +17% -21% -25% -44% Increased
All
(N=18) NS NS NS
P value 0.03 0.03 0.03 0.02 0.02 0.01
3 Change +14% +25% -28% -32% -9% -25% -46% Increased
patients
NS
excluded
(N=15) P value 0.02 0.0003 0.005 0.003 0.04 0.02 0.02
0.05
1001291 Except
for baseline sputum count, the drug effect as measured through all the
above variables was not dependent on any of the baseline parameters and was
not significantly
dependent on dose. However, dose cohort 2 (and to a lesser extent cohort 3)
showed significant
drug effects on additional selected parameters (for example, absolute numbers
of neutrophils in
blood, which was significantly decreased by 27%), which was more likely
related to lower
baseline conditions than to a dose effect per se. Indeed, cohort 2 was more
severely affected
with regards to several surrogate markers of disease prior to treatment (lower
FEY I, all infected
with P. aeruginosa, lower perceived weight gain). Thus, cohort 2 may have been
more
conducive to revealing drug effects than the other two cohorts.
[00130] Systemic redox-based therapy is an attractive idea for CF, since
redox imbalance
is a well-recognized aspect of the disease, yet seldom considered as a bona
fide therapeutic
target. In that context, the safety and efficacy of high-dose oral NAC on
redox parameters,
inflammation and lung function has been assessed in CF patients. The results
of the phase 1 trial
show that NAC in oral doses as high as 3.0 g/d do not cause any safety
concerns when
administered for as long as 4 weeks, thus confirming previous studies in other
diseases. The
46
CA 02662636 2009-04-15
phase 1 trial also provides strong evidence that high-dose oral NAC may
significantly ameliorate
both systemic redox stress and lung inflammation in CF.
1001311 Example 2. Placebo-controlled phase of the CF trial
[00132] Summary. Based on the success of the phase I trial, the trial
proceeded to phase
II. This single-center trial consisted of a 12-week placebo-controlled section
followed by a 12-
week open label section, with oral NAC 0.9 g, taken three times daily. The
statistical plan for
the study was designed to assess the safety and efficacy of NAC versus
placebo, at 0 week and
12-week timepoints (placebo-controlled section). Of the 24 subjects screened
for eligibility, 21
were enrolled and randomized into NAC and placebo groups. One subject asked to
be
withdrawn from the prior to the 6 week time point because the medication
regimen was too
onerous. The subject failed to return for the 6-week time point or for the
final study visit at week
12. Two other subjects also were removed from participation in the study by
the principal
investigator due to poor adherence to the study protocol. These subjects did
not return for either
the 6- or the 12-week study visits. Thus, 18 subjects are included in this
intent-to-treat (ITT)
analysis (9 on NAC and 9 on placebo).
[00133J Both NAC and placebo were very well tolerated and did not cause any
serious
adverse events. Adverse events were all mild and did not affect adherence to
treatment, which
was consistently high, aside from the three subjects mentioned above (>93%).
Of the 18 subjects
included in the ITT analysis, two reported symptoms of daily indigestion
related to drug intake.
One of these subjects completed the 12-week treatment period with 95% of study
drug
compliance, but the other patient was removed from the study due to 26%
compliance rate
discovered by the study coordinators prior to the 6-week follow-up.
47
CA 02662636 2009-04-15
=
=
1001341 In phase 1, NAC treatment decreased sputum neutrophil count
and extracellular
human neutrophil elastase (HNE) activity. In this phase 2 trial, the NAC
group, but not the
placebo group, showed significant decreases in sputum neutrophil count
(primary endpoint),
blood neutrophil GSH and sputum HNE enzymatic activity (secondary endpoints),
as well as
sputum HNE and interleulcin-8 protein levels. No significant effect was
measured for the
functional expiratory volume in 1 second as a percent of predicted for age
(FEV1 %pred.) (a
secondary endpoint in this study). Of note, pulmonary exacerbations (which
were not a primary
outcome measure for this study) were significantly less frequent in the NAC
group (2/9) than in
the placebo group (7/9 subjects).
[00135] Serious adverse events and adverse events. During this phase
2 trial, only one
SAE was reported. Subject #2011, who suffered acute pyelonephritis, had a
previous history of
recurrent urinary tract infections and had had a urinary tract infection the
month prior. This SAE
occurred 5 days after the subject received the first dose of NAC. The subject
was admitted to a
local hospital and was treated for 5 days with IV Levaquin and prednisone and
discharged 5 days
after admission to the hospital. The subject reported that she did not take
the study drug during
hospitalization but resumed ta1cing the study drug right after
hospitalization. The subject did not
report for evaluation at the six week time point and was the removed from the
study. This SAE
was not considered related to the study drug. No other SAEs were reported for
the remainder of
the placebo-controlled section. Only one subject out of 18 reported adverse
events that were
likely to be related to the study drug (or placebo). This subject (#2012)
reported daily abdominal
discomfort /indigestion through the study, which was efficiently treated by
Pepcid AC and did
not lead to decreased adherence to treatment. There was no other consistent
gastrointestinal (01)
complaint related to NAC or placebo. No specific pattern of adverse events
emerged from this
48
CA 02662636 2009-04-15
phase 2 study, confirming the phase 1 safety data. CF QOL questionnaires
showed a significant
reduction in flatulence observed in the NAC group, but not in the placebo
group. This may
represent a potential positive effect on the digestive abnormalities of CF
subjects, especially as
NAC is a known remedy for treatment of DIOS in CF patients. As used herein,
the term
"DIOS", which stands for "Distal Intestinal Obstruction Syndrome" refers to a
condition unique
to CF that occurs due to the accumulation of viscous mucous and fecal material
in the terminal
ileum, caecum and ascending colon, which may cause progressive symptoms of
recurrent colicky
abdominal pain, bloating, nausea and anorexia, and signs of small intestinal
obstruction. No
other changes were seen as per the CF QOL. Complete blood count and chemistry
parameters
were not affected by 12-week NAC/ placebo treatment, except for marginal
changes in red blood
cell distribution width and calcium in the NAC group. None of these changes
led to values
outside of the normal range. No change in liver enzymes was noted. This data
confirms the
lack of toxicity of high-dose oral NAC in CF.
[00136] Intention-to-treat analysis of efficacy endpoints. Besides the
necessary
assessment of the safety of high-dose oral NAC in a placebo-controlled
setting, this phase 2 trial
also was designed to gain a better understanding of treatment efficacy with
regards to improving
inflammation, redox imbalance and lung function in CF, albeit within the
limits inherent to a
small study. In particular, the study looked to confirm the positive effects
of high-dose oral
NAC seen on sputum neutrophil count and FINE activity obtained in phase 1. The
primary
efficacy endpoint in this phase 2 study is sputum neutrophil count (based on
the quantification of
live neutrophils by microscopy, reflecting lung inflammation) and the four
secondary efficacy
endpoints are: (i) FEV1 (% Pred), reflecting lung function; (ii) blood
neutrophil GSH, reflecting
systemic redox imbalance; (iii) sputum FINE activity, reflecting lung
inflammation, the current
49
CA 02662636 2009-04-15
best predictor of CF lung disease; and (iv) whole blood GSH, reflecting
systemic redox
imbalance. Data on all other main efficacy endpoints (along with sputum FINE
and IL-8 protein
levels as additional indicators of inflammation) is presented in Table 3
(below) for all 9 subjects
of the NAC group and 9 subjects in the placebo group included in the ITT
analysis.
Table 3. ITT analysis of main efficacy endpoints (placebo-controlled section).
Endpoint Type Group Value wk 0 Value wk 12 P within
group P between groups
Sputum neutrophil count NAC 1.4110.17 1.2410.18 0.03
Inflammation 0.85
(Log10) Placebo 1.0510.18 0.8110.23 0.22
P between groups 0.15 0.16
Functional expiratory NAC 73.717.6 75.618.2 0.15
Lung function 0.74
volume in is (%Pred) Placebo 69.318.3 69.718.3 0.47
P between groups 0.70 0.62
Sputum HNE enzymatic NAC 3.6110.15 3.161020 0.006
inflammation 0.39
activity (Log10) Placebo 3.0810.19 2.8710.18 0.20
P between groups 0.04 0.30
Blood neutrophil intracellulai
Redox NAC 4.0410.08 4.1010.10 0.02
0.60
GSH Placebo 4.0010.07 4.0410.07 0.22
P between groups 0.71 0.59
04
Sputum HNE protein levels
Inflammation NAC 0.0410.13 -0.2730,12 0. 0.66
(Log10) Placebo -0.5110.15 -0.6910.22 0.21
P between groups 0.01 0.11
Sputum I1-8 protein levels Inflammation NAC 2.0110.12 1.8110.18
0.03 0.70
(Log 10) Placebo 1.6810.10 1.3510.30 0.17
P between groups 0.06 0.21
1001371 Consistent
with the phase 1 results, sputum neutrophil count, sputum FINE
enzymatic activity, sputum HNE levels, and IL-8 levels were significantly
decreased in the NAC
group but not in the placebo group. These various markers of inflammation were
measured
independently with different methodologies (e.g., microscopy, kinetic
spectrophotometry,
enzyme-linked immunosorbent assay), the results of which further strengthen
the significance of
these positive outcomes. Moreover, blood neutrophil GSH was significantly
increased in the
NAC group but not in the placebo group, confirming the possible causative link
between low
CA 02662636 2009-04-15
GSH levels in CF blood neutrophils and their increased propensity to migrate
into and
subsequently damage the patients' lungs. The ITT analysis showed no
significant decline in
pulmonary function tests (PFTs) over the course of the trial, which confirms
the safety of the
treatment regimen. However, the analysis also failed to detect any significant
improvement of
FEV1 (% Pred) or other measures of lung function (data not included) in the
NAC group. PFTs
are notoriously weak endpoints in CF trials due to issues with lack of
sensitivity. The low
number of subjects and the confounding effect of concurrent high-impact
treatments (such as
antibiotics or corticosteroid) on the evaluation of PFTs also contributed to
decrease the
likelihood of measuring significant changes in this first phase 2 trial.
Between-group analysis of
pre- vs. post-treatment data failed to return significant values for any of
the above endpoints.
This also likely is due to the low number of subjects in this first phase 2
trial and to the
confounding effect of concurrent high-impact treatments on endpoint
evaluation.
[00138] Rationale for future studies. Our phase 1 data and phase 2 data
presented here
establish an excellent safety profile for high-dose oral NAC treatment in CF
patients. Both sets
of data also strongly suggest a positive effect of high-dose oral NAC on lung
inflammation and
systemic redox imbalance. Without being limited by theory, by reducing the
amount of blood
neutrophils in CF lungs, high-dose oral NAC may affect positively the local
conditions that
normally lead to progressive lung function decline, notably the amount of
extracellular HNE
enzymatic activity in CF lungs. An upcoming phase 2b trial will assess the
effect of high-dose
oral NAC on CF PFTs.
[00139] Example 3. Use of NAC to treat Acute Exacerbations of CF
[00140] A CF patient showing the symptoms of an acute exacerbation of CF
(including,
but not limited to, increased respiratory symptoms, reduction in forced
expiratory volume in one
51
CA 02662636 2009-04-15
second (FEV1) of more than 10%, and a decision to treat with intravenous
antibiotics) may be
treated with a composition comprising an acute exacerbation-reducing amount of
either the
purified L-enantiomer or the racemate mixture composed of equal proportions of
the D- and L-
isomers of NAC administered either serially or co-administered two, three or
four times a day up
to the highest tolerable dose, given that there will be individual variability
in the ability to
tolerate NAC. This dosage of NAC is sufficient to decrease key aspects of an
acute exacerbation
of CF in such patients.
[00141] The phase 2a data suggest that chronic high-dose oral NAC treatment
may
potentially decrease the number of sinus and lung exacerbations in CF
patients. During week 0
through week12, exacerbations of sinus/lung disease affected 9/18 subjects.
Subjects were less
prone to exacerbations in the NAC than in the placebo group (2/9 vs. 7/9,
respectively, P=0.04,
Fisher's exact test). A key molecular correlate of exacerbations, namely
plasma levels of the
cytokine interleukin-17 (IL-17) also was decreased in the NAC group compared
to the placebo-
group (P=0.02), further confirming the anti-inflammatory effect of NAC in CF
and corroborating
its positive effect on acute atacks. IL-17 recently has been identified as a
potent T-cell derived
modulator of acute neutrophilic lung inflammation [Linden, A., et al.
Neutrophils, interleulcin-
17A and lung disease. Eur. Respir. J. 25:159-172 (2008)]
[00142] Example 3. Use of NAC to treat Acute Exacerbations of IPF
[00143] A patient showing the symptoms of an acute exacerbation of In
(including, but
not limited to, idiopathic acute respiratory deterioration) may be treated
with a composition
comprising an acute exacerbation-reducing amount of either the purified L-
enantiomer or the
racemate mixture composed of equal proportions of the D- and L-isomers of NAC
administered
either serially or co-administered two, three or four times a day up to the
highest tolerable dose,
52
CA 02662636 2009-04-15
given that there will be individual variability in the ability to tolerate
NAC. This dosage of NAC
is sufficient to decrease key aspects of an acute exacerbation of IPF in such
patients.
1001441 Example 4. Use of NAC to treat Acute Exacerbations of Asthma
[00145] A child or adult showing the symptoms of an acute exacerbation of
asthma
(including, but not limited to, a sudeen increase in breathlessness over the
preceding 48 hours
and presence of one of the following signs: tachypnea (respiratory rate of
>18), use of accessory
muscles or respiration, audible wheezing, prolonged expiration with rhonchi on
ausculation or a
silent chest) may be treated with a composition comprising at least one
standard asthma
therapeutic agent and an acute exacerbation-reducing amount of either the
purified L-enantiomer
or the racemate mixture composed of equal proportions of the D- and L-isomers
of NAC
administered either serially or co-administered two, three or four times a day
up to the highest
tolerable dose, given that there will be individual variability in the ability
to tolerate NAC. This
dosage of NAC is sufficient to decrease key aspects of an acute exacerbation
of asthma in such
patients.
[00146] Example 5: Use of NAC to treat acute exacerbations of TB in HIV
patients
1001471 An HIV patient having latent or active TB who is being treated with
a formulation
comprising a therapeutically effective amount of a multi-drug regimen as
normally used to treat
HIV and/or TB may be further treated with a composition comprising an acute
exacerbation
reducing amount of either the purified L-enantiomer or the racemate mixture
composed of equal
proportions of the D- and L-isomers of NAC administered either serially or co-
administered two,
three or four times a day up to the highest tolerable dose, given that there
will be individual
variability in the ability to tolerate NAC. This dosage of NAC is sufficient
to decrease key
aspects of IRIS in such patients.
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CA 02662636 2014-08-12
29973-1
[00148] While the present invention has been described with reference
to the specific
embodiments thereof, it should be understood by those skilled in the art that
various changes
may be made and equivalents may be substituted without departing from the true
scope of the
Invention. In addition, many modifications may be made to adapt a particular
situation,
material, composition of matter, process, process step or steps, to the
objective and scope of
the present invention. All such modifications are intended to be within the
scope of the claims
appended hereto.
54
