Note: Descriptions are shown in the official language in which they were submitted.
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TITLE OF THE INVENTION
METHOD OF STIMULATING THE MOTILITY OF THE GASTROINTESTINAL
SYSTEM USING IPAMORELIN
RELATED APPLICATIONS
This application claims the benefit of U.S. Provisional Application
61/008,828, filed
December 21, 2007, the entire contents of which are hereby incorporated by
reference herein.
INCORPORATION BY REFERENCE
All references cited herein, including patents, patent applications, and
published patent
applications, are hereby incorporated by reference in their entireties,
whether or not each is
further individually incorporated by reference.
BACKGROUND OF THE INVENTION
Gastrointestinal (GI) motility is a coordinated neuromuscular process that
transports
nutrients through the digestive system. C. Scarpignato, "Pharmacological
Stimulation of
Gastrointestinal Motility: Where We Are And Where Are We Going?" Dig. Dis.,
15: 112 (1997).
Impaired (i.e., slowed) motility of the gastrointestinal system, which can be
involved in
gastroesophageal reflux disease, gastroparesis (e.g., diabetic and
postsurgical), irritable bowel
syndrome, ileus, and constipation (e.g., diet or opioid-induced), is one of
the largest health care
burdens of industrialized nations. S. D. Feighner et al., "Receptor for
Motilin Identified in the
Human Gastrointestinal System," Science, 284: 2184-2188 (Jun. 25, 1999).
Growth hormone secretagogues (GHS), such as ghrelin and mimetics thereof, have
been
reported to stimulate gastrointestinal motility. However, the specific GHS
compounds that have
been studied have pharmacokinetic properties that will not allow them to be
used clinically for
the treatment of gastrointestinal motility. Specifically, ghrelin is a 28-
amino acid peptide that is
produced in the stomach. The biologically active form of ghrelin, i.e., the
acylated form, has a
serum half-life of only 9-13 minutes (Akamizu et al. (2004) European Journal
of Endocrinology
150.447-55). Additionally, synthetic GHS compounds such as GHRP-6 have been
evaluated for
the ability to treat GI motility. Similar to ghrelin, GHRP-6 has a short serum
half life that
prohibits the use of this compound from being used to treat GI motility
disorders. Bowers et al.
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demonstrated that the serum half life of GHRP-6 is only 20 minutes ((1992)
Journal of Clinical
Endocrinology and Metabolism 74:292-8).
In view of the above, an effective, physiological way to effectively stimulate
motility of
the gastrointestinal system is highly desirable and would be an advance in the
art.
SUMMARY OF THE INVENTION
The present invention relates to a method of stimulating the motility of the
gastrointestinal system in a subject in need thereof, wherein the subject
suffers from maladies
(i.e., disorders, diseases, conditions, or drug- or surgery-induced
dysfunction) of the
gastrointestinal system. The method comprises administering to a subject in
need thereof a
therapeutically effective amount of a ghrelin mimetic compound or a
pharmaceutically
acceptable salt, hydrate or solvate thereof. In a preferred embodiment, the
ghrelin mimetic is
ipamorelin as represented by Formula I (see below), or a pharmaceutically
acceptable salt,
hydrate or solvate thereof.
As described above, ghrelin and ghrelin mimetic compounds have been shown to
have
limited serum half lives, and are therefore not suitable for use in treating
GI motility disorders.
In contrast to ghrelin and GHRP-6, the serum half life of ipamorelin in humans
has been
demonstrated to be between 3 and 6.5 hours. Accordingly, the instant invention
provides
methods and therapeutically effective compositions for stimulating the
motility of the
gastrointestinal system.
Stimulation of gastrointestinal motility is used in a method of treating
opioid-induced
gastrointestinal dysfunction, e.g., morphine-induced bowel dysfunction or
constipation, in a
subject in need thereof comprising administering a therapeutically effective
amount of a ghrelin
mimetic compound or a pharmaceutically acceptable salt, hydrate or solvate
thereof. The subject
may be using opiates or opioids for post-surgical pain management or for
chronic pain
management. Exemplary opiates and opioids include morphine, codeine,
oxycodone,
hydromorphone, hydrocodone, methadone, fentanyl, and combinations with anti-
inflammatory
agents such as acetaminophen or aspirin. A preferred ghrelin mimetic is
ipamorelin as
represented by Formula I, or a pharmaceutically acceptable salt, hydrate or
solvate thereof.
Stimulation of gastrointestinal motility can be used to treat gastroparesis in
a subject in
need thereof by administering a therapeutically effective amount of a ghrelin
mimetic compound.
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A preferred ghrelin mimetic is ipamorelin as represented by Formula I, or a
pharmaceutically
acceptable salt, hydrate, derivative, acid amide, or solvate thereof.
In a further embodiment, stimulation of gastrointestinal motility is used in a
method of
treating gastroesophageal reflux disease (GERD) in a subject in need thereof
comprising
administering a therapeutically effective amount of a ghrelin mimetic
compound. In a particular
embodiment, the ghrelin mimetic is ipamorelin as represented by Formula I, or
a
pharmaceutically acceptable salt, hydrate or solvate thereof. In a particular
embodiment, the
gastroesophageal reflux disease is nocturnal gastroesophageal reflux disease.
The invention also provides methods for stimulating gastrointestinal motility
for the
treatment of irritable bowel syndrome (IBS) in a subject in need thereof by
administering a
therapeutically effective amount of a ghrelin mimetic compound. A preferred
ghrelin mimetic is
ipamorelin as represented by Formula I, or a pharmaceutically acceptable salt,
hydrate or solvate
thereof. The irritable bowel syndrome can be constipation-predominant
irritable bowel
syndrome or alternating constipation/diarrhea irritable bowel syndrome.
The invention also provides methods for stimulating gastrointestinal motility
to treat
constipation in a subject in need thereof by administering a therapeutically
effective amount of a
ghrelin mimetic compound. A preferred ghrelin mimetic is ipamorelin as
represented by
Formula I, or a pharmaceutically acceptable salt, hydrate or solvate thereof.
In one embodiment, stimulation of gastrointestinal motility is used in a
method of treating
surgery-induced or related gastrointestinal dysfunction, e.g. post-operative
ileus, in a subject in
need thereof comprising administering a therapeutically effective amount of a
ghrelin mimetic
compound. In a particular embodiment, the ghrelin mimetic is ipamorelin as
represented by
Formula I, or a pharmaceutically acceptable salt, hydrate or solvate thereof.
A preferred ghrelin mimetic is ipamorelin as represented by Formula I (a-
Methylalanine-
L-histidine-D-(3-(2-naphthyl)-alanine-D-phenylalanine-L-lysinamide or H-Aib-
His-B-(2-
naphthyl)-D-Ala-D-Phe-Lys-NH2):
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N 5:11
O NH O O
Me\ NH H
Me- `H NNH2
NH2 O O
NH2
or a pharmaceutically acceptable salt, hydrate or solvate thereof.
It is noted that in this disclosure and particularly in the claims and/or
paragraphs, terms
such as "comprises", "comprised", "comprising" and the like can have the
meaning attributed to
it in U.S. Patent law; e.g., they can mean "includes", "included",
"including", and the like; and
that terms such as "consisting essentially of' and "consists essentially of
have the meaning
ascribed to them in U.S. Patent law, e.g., they allow for elements not
explicitly recited, but
exclude elements that are found in the prior art or that affect a basic or
novel characteristic of the
invention.
These and other embodiments are disclosed or are obvious from and encompassed
by, the
following Detailed Description.
BRIEF DESCRIPTION OF THE DRAWINGS
The following Detailed Description, given by way of example, but not intended
to limit
the invention solely to the specific embodiments described, may best be
understood in
conjunction with the accompanying drawings, in which:
FIG. I shows the gastrokinetic efficacy of oral administration of ipamorelin
at 10 and 100
mg/kg in a rat model for post-operative ileus.
FIG. 2 shows the efficacy of J. v. administered ipamorelin at 0.1, 0.25 or 1.0
mg/kg on a
rat model of post-operative ileus.
FIG. 3 shows the efficacy of i.v. administered ipamorelin at 0.01, 0.03 and
0.1 mg/kg in a
rat model for post-operative ileus.
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FIG. 4 demonstrates that ghrelin did not accelerate gastric emptying in the
rats
administered 4 mg/kg of morphine and that rats administered saline or ghrelin
displayed the
same group mean absorbance of phenol red.
FIG. 5 shows the gastrokinetic efficacy of intravenous administration of
ipamorelin
(referred to as 26-0161 in the figure) at 0.25, 1.0, 2.5 mg/kg as compared to
10 mg/kg RC-1139
to treat post-operative ileus in a rat model.
FIG. 6 shows the reversal of morphine-induced slowing of gastrointestinal
motility in
humans by the intravenous administration of a single dose of ipamorelin at
doses of 0.01, 0.03
and 0.06 mg/kg.
FIG. 7 shows a bar graph comparing the effect of various ghrelin mimetics on
stomach
emptying.
FIG. 8 shows a bar graph comparing the effect of various ghrelin mimetics on
gastrointestinal motility through the small intestine.
FIG. 9 shows a bar graph comparing the effect of various ghrelin mimetics on
stomach
emptying.
FIG. 10 shows a bar graph comparing the effect of various ghrelin mimetics on
gastrointestinal motility through the small intestine (distal distance from
pyloric sphincter).
FIG. 11 shows a bar graph comparing the effect of various ghrelin mimetics on
gastrointestinal motility through the small intestine (proximal distance from
pyloric sphincter).
FIG. 12A-D show the effect of abdominal surgery on colonic transit time, fecal
pellet
output, food intake, and body weight gain in rat model of post-operative
ileus.
FIG 13 shows colonic transit time in rats after abdominal surgery after single
dose
administration of ipamorelin at 0.1 and 1 mg/kg relative to vehicle and a
control (GHRP-6).
FIG. 14 shows cumulative fecal pellet output at 12h, 24h or 48h in rats after
abdominal
surgery after single dose administration of ipamorelin at 0.1 and 1 mg/kg
relative to vehicle and
a standard control (GHRP-6).
FIG. 15 shows cumulative food intake at different time points between 3-48 h
in rats after
abdominal surgery after single dose administration of ipamorelin at 0.1 and 1
mg/kg relative to
vehicle and a standard control (GHRP-6).
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FIG. 16 shows the effect on body weight at 24h and 48h in rats after abdominal
surgery
after single dose administration of ipamorelin at 0.1 and 1 mg/kg relative to
vehicle and a
standard control (GHRP-6).
FIG. 17 shows colonic transit time in rats after abdominal surgery after
multiple doses of
0.01, 0.1 and 1.0 mg/kg ipamorelin relative to vehicle.
FIG 18 shows the effect of fecal pellet output over a 48h period in rats after
abdominal
surgery after multiple doses of ipamorelin at 0.01, 0.1 and 1.0 mg/kg
ipamorelin relative to
vehicle.
FIG 19 shows the effect on cumulative food intake over a 48h period in rats
after
abdominal surgery after multiple doses of ipamorelin at 0.01, 0.1 and 1.0
mg/kg ipamorelin
relative to vehicle.
FIG 20 shows the effect on body weight gain over a 48h period in rats after
abdominal
surgery after multiple doses of ipamorelin at 0.01, 0.1 and 1.0 mg/kg
ipamorelin relative to
vehicle.
DETAILED DESCRIPTION
The present invention relates to a method of stimulating the motility of the
gastrointestinal system in a subject in need thereof, wherein the subject
suffers from maladies
(i.e., disorders or diseases or drug- or surgery-induced dysfunction) of the
gastrointestinal
system. In certain embodiments, the maladies include opioid-induced
gastrointestinal
dysfunction, e.g., morphine-induced gastrointestinal dysfunction,
constipation, diabetes-related
gastroparesis, gastroesophageal reflux disease (GERD), irritable bowel
syndrome (IBS), or drug-
or surgery-induced gastrointestinal dysfunction, e.g., post-operative ileus.
The method
comprises administering to a subject in need thereof a therapeutically
effective amount of a
ghrelin mimetic compound or a pharmaceutically acceptable salt, hydrate or
solvate thereof. The
ghrelin mimetic is preferably ipamorelin as represented by Formula I, or a
pharmaceutically
acceptable salt, hydrate or solvate thereof.
Ghrelin mimetics
As used herein, the terms "ghrelin mimetic" or "ghrelin mimetic compound" or
"ghrelin
agonist" are synonymous with the historical terms "growth hormone
secretagogue," or "growth
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hormone secretagogue compound". A ghrelin mimetic or ghrelin agonist refers to
a substance
(e.g., a molecule, a compound) which promotes (induces or enhances) at least
one function that
is characteristic of binding to the ghrelin receptor (GRLN). The GRLN receptor
has been
previously reported in the literature as the GHSIa receptor which reflected
its first known
attribute - secretion of growth hormone. The ghrelin receptor is primarily
expressed in the
hypothalamus and pituitary. Activation of these receptors in the pituitary
induces the secretion
of growth hormone. In addition to inducing the secretion of growth hormone,
recent studies
have shown the ghrelin mimetics can increase appetite and body weight. In a
particular
embodiment, the ghrelin mimetics are those described in U.S. Patent Nos.
5,767,085, 6,303,620,
6,576,648, 5,977,178, 6,566,337, 6,083,908, 6,274,584 and 6,919,315, the
entire content of all of
which are incorporated herein by reference.
Subsequently the GRLN receptor was identified in locations in the body other
than the
pituitary and hypothalamus, such as the gastrointestinal tract and the
vasculature. The binding of
ghrelin or ghrelin mimetics to these receptors resulted in pharmacological
activity other than, or
in addition to, growth hormone release. Specifically, this other pharmacologic
activity was an
increase in gastrointestinal prokinetic activity as well as changes in cardiac
function. Thus, the
growth hormone secretagogue compounds as they were previously named are now
more
generally called ghrelin mimetics or agonists to represent the wider spectrum
of physiological
actions resulting from binding to its receptor (GRLN).
Most identified ghrelin mimetics have a core peptide backbone with differing
lengths of
the backbone (tri-, tetra-, penta-, and hexapeptides, as well as macrocyclic).
It is also expected
that the different molecular structures will result in differing affinities
for the ghrelin receptor
and, therefore, could produce differing pharmacological outcomes. A priori one
cannot
determine which molecule might produce unusual activity or potency relative to
others in a
general class. It generally emerges from scientific investigation with an
unusual result or finding.
A compound having GRLN receptor agonist activity can be identified and
activity
assessed by any suitable method. For example, the binding affinity of a GRLN
receptor agonist
to the GRLN receptor can be determined employing receptor binding assays and
growth
hormone stimulation can be assessed as described in United States Patent No.:
6,919,315, which
is incorporated herein by reference. The ghrelin mimetics can be obtained from
any source,
including any commercial source.
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In the case of this invention the preferred ghrelin mimetic is ipamorelin as
represented by
the structural Formula I (a-Methylalanine-L-histidine-D-(3-(2-naphthyl)-
alanine-D-
phenylalanine-L-lysinamide or H-Aib-His-B-(2-naphthyl)-D-Ala-D-Phe-Lys-NH2):
NH 0
O O
MMe H NH H N NH2
- ~AN NHZ O O
NHz
or a pharmaceutically acceptable salt, hydrate, acid, amide, crystal or
solvate thereof
The present invention is based in part on the surprising discovery made by the
present
inventors that certain particular ghrelin mimetics, in particular, ipamorelin,
have a surprisingly
efficacious and potent stimulatory effect on gastrointestinal motility.
Although ipamorelin is a
potent growth hormone secretagogue, its binding affinity with the GRLN
receptor is about 2-3
logs weaker than many other reported ghrelin mimetics.
Co-administered substances
Another aspect of the present invention relates to the co-administration of
one or more
substances and a ghrelin mimetic, e.g., ipamorelin, to treat a
gastrointestinal disorder, disease, or
condition. Co-administered can mean the administration of two or more
substances together as a
single pharmaceutical composition, or the administration of two or more
substances in a short
period of time, e.g., within seconds of each other to within a day of each
other.
Peripherally acting opioid antagonists
It is possible to administer peripherally acting opioid receptor antagonists,
such as, for
example, methylnaltrexone, naloxone, naltrexone, nalmefene and alvimopan
(ENTEREG),
which do not-cross the blood-brain barrier, to treat opioid-induced side
effects without provoking
opioid withdrawal symptoms or reverse analgesia. (Holzer P., "Opioids and
Opioid Receptors in
the Enteric Nervous System: From a Problem in Opioid Analgesia to a Possible
New Prokinetic
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Therapy in Humans," Neurosci Lett., 361(1-3):192-5 (2004), incorporated herein
by reference).
As used herein, peripherally acting opioid antagonists refer to opioid
antagonists that act
peripherally (i.e., not centrally, for example, do not act on the central
nervous system).
Proton pump inhibitors
In another aspect, the present invention provides for co-administration of a
ghrelin
mimetic, e.g., ipamorelin, and a proton pump inhibitor for the treatment of
gastrointestinal
conditions or maladies. Proton pump inhibitors suppress gastric acid
secretion, the final step of
acid production, by specific inhibition of the H + K + -ATPase enzyme system
at the secretory
surface of gastric parietal cells. Proton pump inhibitors include
benzimidazole compounds, for
example, esomeprazole (NEXIUM ), omeprazole (PRILOSECTM), lansoprazole
(PREVACIDTM), rabeprazole (ACIPHEXTM). and pantoprazole (ProtonixTM). These
proton
pump inhibitors contain a sulfinyl group situated between substituted
benzimidazole and
pyridine rings. At neutral pH, esomeprazole, omeprazole, lansoprazole, and
pantoprazole are
chemically stable, lipid soluble, weak bases that are devoid of inhibitory
activity. These
uncharged weak bases reach parietal cells from the blood and diffuse into the
secretory
canaliculi, where the drugs become protonated and thereby trapped. The
protonated species
rearranges to form a sulfenic acid and a sulfenamide, the latter species
capable of interacting
with sulfhydryl groups of H + K + -ATPase. Full inhibition occurs with two
molecules of
inhibitor per molecule of enzyme. The specificity of the effects of proton
pump inhibitors is
believed to derive from: a) the selective distribution of H + K + -ATPase; b)
the requirement for
acidic conditions to catalyze generation of the reactive inhibitor; and c) the
trapping of the
protonated drug and the cationic sulfenamide within the acidic canaliculi and
adjacent to the
target enzyme. Goodman & Gilman's The Pharmacological Basis of Therapeutics,
9th Edition,
pp. 901-915 (1996), incorporated herein by reference.
H2 receptor antagonists
In yet another aspect, the present invention provides for the co-
administration of a ghrelin
mimetic, e.g., ipamorelin, and an H2 receptor antagonist for the treatment of
gastrointestinal
conditions or maladies. H2 receptor antagonists competitively inhibit the
interaction of histamine
with H2 receptors. They are highly selective and have little or no effect on
H1 receptors.
Although H2 receptors are present in numerous tissues, including vascular and
bronchial smooth
muscle, H2 receptor antagonists interfere remarkably little with physiological
functions other
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than gastric acid secretion. H2 receptor antagonists include, but are not
limited to, nizatidine
(AXIDTM), ranitidine (ZANTACTM and TRITECTM), famotidine (PEPCID ACTM), and
cimetidine (TAGAMETTM.Goodman & Gilman's The Pharmacological Basis of
Therapeutics,
9th Edition, pp. 901-915 (1996), incorporated herein by reference. H2 receptor
antagonists
inhibit gastric acid secretion elicited by histamine, other H2 agonists,
gastrin, and, to a lesser
extent, muscarinic agonists. H2 receptor antagonists also inhibit basal and
nocturnal acid
secretion.
Antacids
Another aspect of the present invention provides a method for the co-
administration of a
ghrelin mimetic, e.g., ipamorelin, and an antacid for treating a
gastrointestinal condition or
malady. For example, compounds of the invention can be co-administered with
antacids to
neutralize gastric acid. For instance, aluminum and magnesium hydroxide
(MAALOXTM 'and
MYLANTATM) neutralize gastric acidity, resulting in an increase in pH in the
stomach and
duodenal bulb.
Laxatives
The present invention further provides a method for the co-administration of a
ghrelin
mimetic, e.g., ipamorelin, and a laxative for treating _a gastrointestinal
condition or malady.
Laxatives come in various forms, including, for example, liquids, tablets,
suppositories, powders,
granules, capsules, chewing gum, chocolate-flavored wafers, and caramels. The
basic types of
laxatives are bulk-forming laxatives, lubricant laxatives, stool softeners
(also called emollient
laxatives), and stimulant laxatives.
Bulk-forming laxatives contain materials, such as cellulose and psyllium, that
pass
through the digestive tract without being digested. In the intestines, these
materials absorb liquid
and swell, making the stool soft, bulky, and easier to pass. The bulky stool
then stimulates the
bowel to move. Laxatives in this group include such brands as FIBERCON ,
FIBERALL ,
and METAMUCIL .
Lubricant laxatives include, for example, mineral oil. Mineral oil is the most
widely used
lubricant laxative. Taken by mouth, the oil coats the stool. This keeps the
stool moist and soft
and makes it easier to pass. Lubricant laxatives are often used for patients
who need to avoid
straining (e.g., after abdominal surgery).
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Stool softeners (emollient laxatives) make stools softer and easier to pass by
increasing
their moisture content. This type of laxative does not really stimulate bowel
movements, but it
makes it possible to have bowel movements without straining. Stool softeners
are best used to
prevent constipation in people who need to avoid straining, because of recent
surgery, for
example. Stool-softening agents include, for example, docusate sodium (COLACE
,
REGUTOL , and others), docusate calcium (SURFAK , DC SOFTGELS ) and docusate
potassium (DIALOSE , DIOCTO-K ).
Serotonin receptor (5-HT) agonists (pure or mixed)
The present invention also provides a method for the co-administration of a
ghrelin
mimetic, e.g., ipamorelin, and a serotonin receptor agonist, such as a 5-HT4
agonist, for treating a
gastrointestinal condition or malady. The serotonin agonists can either be a
pure or mixed 5-HT
receptor subtype(s), or mixed with other central nervous system receptors such
as dopamine.
The 5-HT4 agonists speed up movement of bowel contents through the colon and
reduce
sensitivity to intestinal nerve stimulation. Suitable serotonin agonists which
can be used in
combination with the compounds of the invention include, but not restricted
to, rauwolscine,
yohimbine, metoclopramide, prucalopride and tegaserod (ZELNORM ). Spiller R.,
"Serotonergic Modulating Drugs for Functional Gastrointestinal Diseases," Br J
Clin Pharmacol.
54:11-20 (2002) and U.S. Patent No. 6,413,988, incorporated herein by
reference.
Motilin receptor agonists
The present invention further provides a method for the co-administration of a
ghrelin
mimetic, e.g., ipamorelin, and a motilin receptor agonist for treating a
gastrointestinal condition
or malady. Motilin is a peptide of 22 amino acids which is produced in the
gastrointestinal
system of a number of species. Motilin induces smooth muscle contractions in
the stomach
tissue of dogs, rabbits, and humans as well as in the colon of rabbits. Apart
from local
gastrointestinal intestinal tissues, motilin and its receptors have been found
in other tissues.
In addition to motilin, there are other substances which are agonists of the
motilin
receptor and which elicit gastrointestinal emptying. One of those agents is
the antibiotic
erythromycin. Studies have shown that erythromycin elicits biological
responses that are
comparable to motilin itself and therefore can be useful in the treatment of
diseases such as
chronic idiopathic intestinal pseudo-obstruction and gastroparesis. Weber, F.
et al., The
American Journal of Gastroenterology, 88:4, 485-90 (1993), incorporated herein
by reference.
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Dopamine antagonists
Another aspect of the present invention provides a method for the co-
administration of a
ghrelin mimetic, e.g., ipamorelin, and a dopamine antagonist for treating a
gastrointestinal
condition or malady.
Dopamine antagonists are drugs that bind to, but do not activate, dopamine
receptors
thereby blocking the actions of dopamine or exogenous agonists. This class of
drugs includes,
but is not limited to, metoclopramide, domperidone, amisulpride, clebopride,
mosapramine,
nemonapride, remoxipride, risperidone, sulpiride, sultopride and ziprasidone.
Cholinesterase inhibitors
The present invention also provides a method for the co-administration of a
ghrelin
mimetic, e.g., ipamorelin, and a cholinesterase inhibitor for treating a
gastrointestinal condition
or malady. The term "cholinesterase inhibitor" refers to one or more agents
that prolong the
action of acetylcholine by inhibiting its destruction or hydrolysis by
cholinesterase.
Cholinesterase inhibitors are also known as acetylcholinesterase inhibitors.
Examples of
cholinesterase inhibitors include, but are not limited to, edrophonium,
neostigmine, neostigmine
methylsulfate, pyridostigmine, tacrine and physostigmine, ambenonium chloride
(MYTELASE ), edrophonium chloride (TENSILON ), neostigmine (PROSTIGMINE ),
piridogstimina (MESTINON ), distigmine bromide, eptastigmine, galanthamine,
axeclidine,
acetylcholine bromine, acetylcholine chloride, aclatonium napadisilate,
benzpyrinium bromide,
carbachol, carponium chloride, cemecarium bromide, dexpanthenol, diisopropyl
paraoxon,
echothiophate chloride, eseridine, furtrethonium, methacholine chloride,
muscarine,
oxapropanium idoide, and xanomeline.
Stereochemistry
Many of the compounds described herein can have one or more chiral centers and
therefore can exist in different enantiomeric forms. If desired, a chiral
carbon can be designated
with an asterisk (*). When bonds to the chiral carbon are depicted as straight
lines in the
formulas of the invention, it is understood that both the (R) and (S)
configurations of the chiral
carbon, and hence both enantiomers and mixtures thereof are embraced within
the formula. As
is used in the art, when it is desired to specify the absolute configuration
about a chiral carbon,
one of the bonds to the chiral carbon can be depicted as a wedge (bonds to
atoms above the
plane) and the other can be depicted as a series or wedge of short parallel
lines is (bonds to atoms
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below the plane). The Cahn-Inglod-Prelog system can be used to assign the (R)
or (S)
configuration to a chiral carbon.
When a compound of the present invention has two or more chiral carbons, it
can have
more than two optical isomers and can exist in diastereoisomeric forms. For
example, when
there are two chiral carbons, the compound can have up to 4 optical isomers
and 2 pairs of
enantiomers ((S,S)/(R,R) and (R,S)/(S,R)). The pairs of enantiomers (e.g.,
(S,S)/(R,R)) are
mirror image stereoisomers of one another. The stereoisomers which are not
mirror-images
(e.g., (S,S) and (R,S)) are diastereomers. The diastereoisomeric pairs may be
separated by
methods known to those skilled in the art, for example chromatography or
crystallization and the
individual enantiomers within each pair may be separated as described above.
The present
invention includes each diastereoisomer of such compounds and mixtures
thereof.
Screening
It is understood that ghrelin mimetic compounds can be identified, for
example, by
screening libraries or collections of molecules using suitable methods.
Another source for the
compounds of interest are combinatorial libraries which can comprise many
structurally distinct
molecular species. Combinatorial libraries can be used to identify lead
compounds or to optimize
a previously identified-lead. Such libraries can be manufactured by well-known
methods of
combinatorial chemistry and screened by suitable methods.
Methods of treating gastrointestinal maladies
The present invention provides a method of stimulating the motility of the
gastrointestinal
system in a subject in need thereof, wherein the subject suffers from maladies
(i.e., disorders,
diseases, conditions, or drug- or surgery-induced dysfunction) of the
gastrointestinal system.
The method comprises administering to a subject in need thereof a
therapeutically effective
amount of a ghrelin mimetic compound or a pharmaceutically acceptable salt,
hydrate or solvate
thereof. The ghrelin mimetic is ipamorelin as represented by Formula I, or a
pharmaceutically
acceptable salt, hydrate or solvate thereof.
As used herein, the term "gastrointestinal maladies" refers to any disease,
disorder,
condition, or dysfunction resulting in impaired gastrointestinal function. For
example, the
gastrointestinal malady can be opioid-induced gastrointestinal dysfunction,
e.g., morphine-
induced constipation, post-operative ileus, or gastroparesis.
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Constipation
In another aspect, the invention provides a method of treating constipation by
administering a therapeutically effective amount of a ghrelin mimetic, e.g.,
ipamorelin.
Constipation is a condition in which a person has uncomfortable or infrequent
bowel movements.
A person with constipation produces hard stools that can be difficult to pass.
The person also
can feel as though the rectum has not been completely emptied. Acute
constipation begins
suddenly and noticeably. Chronic constipation, on the other hand, can begin
insidiously and
persist for months or years.
The method of treating constipation of the invention can further comprise co-
administering a ghrelin mimetic, e.g., ipamorelin, with a therapeutically
effective amount of a
laxative. Suitable laxatives include, but are not limited to, bulk forming
laxatives, lubricant
laxatives, stool softeners, or any combination thereof.
Opioid-induced constipation
The invention provides a method of treating opioid-induced constipation by
administering a therapeutically effective amount of a ghrelin mimetic, e.g.,
ipamorelin. Use of
opioid analgesics to relieve chronic pain can cause effects on organs outside
the targets in the
central nervous system. For example, opioid action can slow stomach emptying
and inhibit
bowel movement. The increased time of fecal contents in the intestines results
in excessive
absorption of water and sodium from fecal contents, resulting in harder, drier
stools and
constipation. This effect afflicts approximately 90% of individuals on
analgesic pain killers. For
chronic pain patients on opioid medications, the resulting constipation can be
a dose limiting
side-effect. In addition, analgesics used for post-surgical pain management
can cause opioid-
induced constipation. Suitable opioids include, but are not limited to,
morphine, codeine,
oxycodone, hydromorphone, hydrocodone, methadone, fentanyl, and combinations
with anti-
inflammatory agents such as acetaminophen or aspirin or any combination
thereof.
The method of treating opioid-induced constipation can further comprise co-
administering a ghrelin mimetic compound, e.g., ipamorelin, with a
therapeutically effective
amount of a peripherally acting opioid antagonist, a laxative, or any
combination thereof.
Suitable peripherally acting opioid antagonists include, but are not limited
to, methylnaltrexone,
naltrexone, nalmefene, naloxone and alvimopan or any combination thereof.
Suitable laxatives
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include, but are not limited to bulk forming laxatives, lubricant laxatives,
stool softeners, or any
combination thereof.
Post-operative ileus
The present invention provides a method of treating post-operative ileus by
administering
a therapeutically effective amount of a ghrelin mimetic, e.g., ipamorelin. It
is well established
that the motility of the gastrointestinal (GI) tract is temporarily impaired
after surgery. The
effect that an abdominal operation has on gastrointestinal motility is
generally referred to as
"post-operative ileus," a term denoting disruption of the normal coordinated
movements of the
gut, resulting in failure of the propulsion of intestinal contents. Ileus has
also been defined as a
functional, non-mechanical obstruction of the bowel. The term "post-operative
ileus" refers to
delay in normal gastric and colonic emptying.
The method of treating post-operative ileus can further comprise co-
administering a
ghrelin mimetic, e.g., ipamorelin, with a therapeutically effective amount of
a dopamine
antagonist. Suitable dopamine antagonists include, but are not limited to,
metoclopramide,
domperidone, amisulpride, clebopride, mosapramine, nemonapride, remoxipride,
risperidone,
sulpiride, sultopride and ziprasidone, or any combination thereof.
Irritable bowel syndrome
The present invention provides a method of treating irritable bowel syndrome
by
administering a therapeutically effective amount of a ghrelin mimetic, e.g.,
ipamorelin. Irritable
bowel syndrome (IBS) is a functional disorder effecting motility of the entire
gastrointestinal
tract that can produce abdominal pain, constipation, and/or diarrhea. The
impaired movement of
the digestive tract in IBS is not accompanied by a change in physical
structure, such as
inflammation or tumors. The symptoms of IBS are thought to be related to
abnormal muscle
contractions in any part of the intestines.
In this syndrome, the gastrointestinal tract is especially sensitive to
gastrointestinal
stimuli. Stress, diet, drugs, hormones, or minor irritants can cause the
gastrointestinal tract to
contract abnormally. There are different types of IBS: constipation-
predominant, diarrhea -
predominant and alternating constipation-predominant/diarrhea-predominant lBS.
The method of treating IBS may comprise co-administering a ghrelin mimetic
compound,
e.g., ipamorelin, with a therapeutically effective amount of H2 receptor
antagonist; a serotonin 5-
HT agonist; a laxative; or any combination thereof.
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Suitable H2 receptor antagonists include, but are not limited to, nizatidine,
ranitidine,
famotidine, and cimetidine, or any combination thereof. Suitable central
nervous system
receptor agonists include, but are not limited to, rauwolscine, yohimbine,
metoclopramide,
tegaserod, or any combination thereof. Suitable laxatives include, but are not
limited to, bulk
forming laxatives, lubricant laxatives, stool softeners, or any combination
thereof.
Gastroesophageal reflux disorder.
The invention further provides a method of treating gastroesophageal reflux
disorder by
administering a therapeutically effective amount of a ghrelin mimetic, e.g.,
ipamorelin.
Gastroesophageal reflux disease (GERD) is a condition in which gastric stomach
contents (e.g.,
bile salts) back up into the food pipe (esophagus), causing chronic
regurgitation of gastric
contents from the stomach into the lower esophagus. Commonly known as
heartburn, GERD
causes esophageal irritation and inflammation.
For people with GERD, the esophageal sphincter (a ring-shaped muscle located
at the
lower end of the esophagus to prevent stomach contents from going backwards
into the
esophagus) can fail to carry out its protective duties. Instead of opening
only when a person is
eating or swallowing, it relaxes and allows digestive juices to reflux into
the esophagus and
irritate the esophageal lining.
Two types of GERD have been identified, upright or daytime GERD and supine or
nocturnal GERD. Nocturnal reflux episodes occur less frequently, but acid
clearance is more
prolonged. Nocturnal reflux can be associated with the complications of GERD,
such as
esophageal erosions, ulceration, and respiratory symptoms. An estimated 17
million Americans
currently suffer from heartburn and other symptoms of GERD.
The method of treating GERD comprises co-administering a ghrelin mimetic
compound,
e.g., ipamorelin, with a therapeutically effective amount of H2 receptor
antagonist; an antacid; a
proton pump inhibitor; or any combination thereof
Suitable H2 receptor antagonist include, but are not limited to, nizatidine,
ranitidine,
famotidine, and cimetidine, or any combination thereof Suitable antacids
include, but are not
limited to, aluminum and magnesium hydroxide and combinations thereof Suitable
proton
pump inhibitors include, but are not limited to, esomeprazole (NEXIUM ),
omeprazole,
lansoprazole, pantoprazole, or a combination thereof
Gastroparesis
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The present invention provides a method of treating gastroparesis, e.g.
diabetic or
idiopathic, by administering a therapeutically effective amount of a ghrelin
mimetic, e.g.,
ipamorelin. Gastroparesis, also referred to as delayed gastric emptying, is a
disorder in which
the stomach takes too long to empty its contents. It often occurs in people
with type 1 diabetes
mellitus or type 2 diabetes mellitus. Gastroparesis can occur when nerves to
the stomach are
damaged or stop working. The vagus nerve controls the movement of food through
the digestive
tract. If the vagus nerve is damaged, the muscles of the stomach and
intestines do not work
normally, and the movement of food is slowed or stopped. Diabetes can damage
the vagus nerve
if blood glucose levels remain high over a long period of time. High blood
glucose causes
chemical changes in nerves and damages the blood vessels that carry oxygen and
nutrients to the
nerves.
The method of treating gastroparesis can comprise co-administering a ghrelin
mimetic
compound, e.g., ipamorelin, with a therapeutically effective amount of
dopamine antagonist.
Suitable dopamine antagonists include, but are not limited to, metoclopramide,
domperidone,
amisulpride, clebopride, mosapramine, nemonapride, remoxipride, risperidone,
sulpiride,
sultopride and ziprasidone, or any combination thereof.
The invention further relates to pharmaceutical compositions useful for
stimulating (i.e.,
inducing) motility of the gastrointestinal system. The pharmaceutical
composition comprises a
ghrelin mimetic and optionally a pharmaceutically acceptable carrier. The
pharmaceutical
composition can comprise a second amount of a suitable therapeutic agent. A
suitable
therapeutic agent can be determined based on the condition being treated in
the subject.
For example, the pharmaceutical composition can comprise a first amount of a
ghrelin
mimetic, e.g., ipamorelin, and a second amount of a laxative when treating
constipation. The
pharmaceutical composition of the present invention can optionally contain a
pharmaceutically
acceptable carrier. The ghrelin mimetic and laxative can each be present in
the pharmaceutical
composition in a therapeutically effective amount. In another aspect, said
first and second
amount can together comprise a therapeutically effective amount.
The pharmaceutical composition can comprise a first amount of a ghrelin
mimetic and a
second amount of a H2 receptor antagonist. The pharmaceutical composition of
the present
invention can optionally contain a pharmaceutically acceptable carrier. The
ghrelin mimetic and
H2 receptor antagonist can each be present in the pharmaceutical composition
in a therapeutically
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effective amount. In another aspect, said first and second amount can together
comprise a
therapeutically effective amount.
The pharmaceutical composition can comprise a first amount of a ghrelin
mimetic and a
second amount of a serotonin receptor agonist. The pharmaceutical composition
can optionally
contain a pharmaceutically acceptable carrier. The ghrelin mimetic and
serotonin receptor
agonist can each be present in the pharmaceutical composition in a
therapeutically effective
amount. The first and second amount can together comprise a therapeutically
effective amount.
The pharmaceutical composition can comprise a first amount of a ghrelin
mimetic, e.g.,
ipamorelin, and a second amount of an antacid. The pharmaceutical composition
can optionally
contain a pharmaceutically acceptable carrier. The ghrelin mimetic and antacid
can each be
present in the pharmaceutical composition in a therapeutically effective
amount. In another
aspect, said first and second amount can together comprise a therapeutically
effective amount.
The pharmaceutical composition can comprise a first amount of a ghrelin
mimetic and a
second amount of an opioid antagonist. The pharmaceutical composition can
optionally contain a
pharmaceutically acceptable carrier. The ghrelin mimetic and opioid antagonist
can each be
present in the pharmaceutical composition in a therapeutically effective
amount. The first and
second amount can together comprise a therapeutically effective amount.
The pharmaceutical composition can comprise a first amount of a ghrelin
mimetic and a
second amount of a proton pump inhibitor. The pharmaceutical composition can
optionally
contain a pharmaceutically acceptable carrier. The ghrelin mimetic and proton
pump inhibitor
can each be present in the pharmaceutical composition in a therapeutically
effective amount.
The first and second amount can together comprise a therapeutically effective
amount.
The pharmaceutical composition can comprise a first amount of a ghrelin
mimetic and a
second amount of a motilin receptor agonist. The pharmaceutical composition
can optionally
contain a pharmaceutically acceptable carrier. The ghrelin mimetic and motilin
receptor agonist
can each be present in the pharmaceutical composition in a therapeutically
effective amount.
The first and second amount can together comprise a therapeutically effective
amount.
The pharmaceutical composition can comprise a first amount of a ghrelin
mimetic and a
second amount of a dopamine antagonist. The pharmaceutical can optionally
contain a
pharmaceutically acceptable carrier. The ghrelin mimetic and dopamine
antagonist can each be
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present in the pharmaceutical composition in a therapeutically effective
amount. The first and
second amount can together comprise a therapeutically effective amount.
The pharmaceutical composition can comprise a first amount of a ghrelin
mimetic and a
second amount of a cholinesterase inhibitor. The pharmaceutical composition
can optionally
contain a pharmaceutically acceptable carrier. The ghrelin mimetic and
cholinesterase inhibitor
can each be present in the pharmaceutical composition in a therapeutically
effective amount.
The first and second amount can together comprise a therapeutically effective
amount.
The pharmaceutical composition can comprise a first amount of a ghrelin
mimetic and a
second amount of somatostatin. The pharmaceutical composition can optionally
contain a
pharmaceutically acceptable carrier. The ghrelin mimetic and somatostatin can
each be present
in the pharmaceutical composition in a therapeutically effective amount. The
first and second
amount can together comprise a therapeutically effective amount.
The invention further relates to use of a ghrelin mimetic compound for the
manufacture
of a medicament for stimulating (i.e., inducing) the motility of the
gastrointestinal system.
Subject, as used herein, refers to animals such as mammals, including, but not
limited to,
primates (e.g., humans), cows, sheep, goats, horses, pigs, dogs, cats,
rabbits, guinea pigs, rats,
mice or other bovine, ovine, equine, canine, feline, rodent or murine species.
In a preferred
embodiment, the mammal is a human.
As used herein, treating and treatment refer to stimulating (e.g., inducing)
motility of the
gastrointestinal system.
As used herein, therapeutically effective amount refers to an amount
sufficient to elicit
the desired biological response. The desired biological response is
stimulating (e.g., inducing)
motility of the gastrointestinal system. The desired biological response is
stimulating (e.g.,
inducing) motility of the gastrointestinal system to treat opioid induced
constipation in a subject
in need thereof. The subject may be using opioids for post-surgical pain
management or for
chronic pain management.
The desired biological response is stimulating (e.g., inducing) motility of
the
gastrointestinal system to treat gastroparesis in a subject in need thereof.
The desired biological response is stimulating (e.g., inducing) motility of
the
gastrointestinal system to treat gastroesophageal reflux disease in a subject
in need thereof. The
gastroesophageal reflux disease is nocturnal gastroesophageal reflux disease.
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The desired biological response is stimulating (e.g., inducing) motility of
the
gastrointestinal system to treat irritable bowel syndrome in a subject in need
thereof The
irritable bowel syndrome is constipation-predominant irritable bowel syndrome.
In yet another
embodiment, the irritable bowel syndrome is constipation/diarrhea irritable
bowel syndrome.
The desired biological response is stimulating (e.g., inducing) motility of
the
gastrointestinal system to treat constipation in a subject in need thereof
The desired biological response is stimulating (e.g., inducing) motility of
the
gastrointestinal system to treat post-operative ileus in a subject in need
thereof.
Pharmaceutical compositions
Pharmaceutical compositions suitable for use in the present invention include
compositions wherein the active ingredients are contained in a therapeutically
effective amount
to achieve its intended purpose. It will be appreciated that the unit content
of active ingredient or
ingredients contained in an individual dose of each dosage form need not in
itself constitute an
effective amount since the necessary effective amount can be reached by
administration of a
plurality of dosage units (such as capsules or tablets or vials or
combinations thereof). In
addition, it is understood that at some dosage levels, an effective amount may
not show any
measurable effect until after a week, a month, three months, or six months of
usage.
Determination of the effective amounts is well within the capability of those
skilled in the art,
especially in light of the detailed disclosure provided herein. The specific
dose level for any
particular user will depend upon a variety of factors including the age, the
physical activity level,
general health, and the severity of the gastrointestinal malady.
A therapeutically effective dose also refers to that amount necessary to
achieve the
desired effect without unwanted or intolerable side effects. Toxicity and
therapeutic efficacy of a
ghrelin mimetic, e.g., ipamorelin, of the invention can be determined by
standard pharmaceutical
procedures in cell cultures or experimental animals. Using standard methods,
the dosage that
shows effectiveness in about 50% of the test population, the ED50, may be
determined.
Similarly, the dosage that produces an undesirable side effect to 50% of the
population, the SD50,
can be determined. The dose ratio between side effect and therapeutic effects
can be expressed
as the therapeutic index and it can be expressed as a ratio between SD50/ED50.
Ghrelin mimetics
with high therapeutic indexes are preferred, e.g., ipamorelin, i.e., those
which are effective at low
dosage and which do not have undesirable side effects, if any, until very high
doses. A preferred
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therapeutic index is greater than about 3, more preferably, the therapeutic
index is greater than
10, most preferably the therapeutic index is greater than 25, such as, for
example, greater than
50. Furthermore, ghrelin mimetics that do not have side effects at any dosage
levels are more
preferred. Finally, ghrelin mimetics that are effective at low dosages and do
not have side effects
at any dosage levels are most preferred. The exact formulation, route of
administration and
dosage can be chosen depending on the desired effect and can be made by those
of skill in the
art.
In certain embodiments, the ghrelin mimetics are formulated as
pharmaceutically
acceptable salts. As used herein, the term pharmaceutically acceptable salt
refers to a salt of a
compound to be administered prepared from pharmaceutically acceptable non-
toxic acids
including inorganic acids, organic acids, solvates, hydrates, or clathrates
thereof. Examples of
such inorganic acids are hydrochloric, hydrobromic, hydroiodic, nitric,
sulfuric, and phosphoric.
Appropriate organic acids may be selected, for example, from aliphatic,
aromatic, carboxylic and
sulfonic classes of organic acids, examples of which are formic, acetic,
propionic, succinic,
camphorsulfonic, citric, fumaric, gluconic, isethionic, lactic, malic, mucic,
tartaric, para-
toluenesulfonic, glycolic, glucuronic, maleic, furoic, glutamic, benzoic,
anthranilic, salicylic,
phenylacetic, mandelic, embonic (pamoic), methanesulfonic, ethanesulfonic,
pantothenic,
benzenesulfonic (besylate), stearic, sulfanilic, alginic, galacturonic, and
the like.
The ghrelin mimetics of the invention can be prepared in the form of their
hydrates, such
as hemihydrate, monohydrate, dihydrate, trihydrate, tetrahydrate and the like
and as solvates.
The ghrelin mimetics, e.g., ipamorelin, and derivatives thereof and any co-
administered
agents can be incorporated into any suitable pharmaceutical compositions which
may be
appropriate or suitable for administration. Such compositions typically
comprise an active agent
(e.g., a ghrelin mimetic of the invention) and a pharmaceutically acceptable
carrier.
As-used herein, "pharmaceutically acceptable carrier" is intended to include
any and all
solvents, dispersion media, coatings, antibacterial and antifungal agents,
isotonic and absorption
delaying agents, and the like, compatible with pharmaceutical administration.
The use of such
media and agents for pharmaceutically active substances is well known in the
art. Except insofar
as any conventional media or agent is incompatible with the active compound,
use thereof in the
compositions is contemplated. Supplementary active compounds can also be
incorporated into
the pharmaceutical compositions of the invention. Modifications can be made to
any of the
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pharmaceutical composition components to affect solubility or clearance of the
factors of the
invention. Peptidic molecules may also be synthesized with D-amino acids to
increase resistance
to enzymatic degradation. In some cases, the composition can be co-
administered with one or
more solubilizing agents, preservatives, and permeation enhancing agents.
Administration of ghrelin mimetics
The therapeutically effective amount or dose will depend on the age, sex and
weight of
the patient, and the current medical condition of the patient. The skilled
artisan will be able to
determine appropriate dosages depending on these and other factors to achieve
the desired
biological response.
A suitable dose per day for a ghrelin mimetic of the invention can be in the
range of from
about 1 ng to about 10,000 mg, about 5 ng to about 9,500 mg, about 10 ng to
about 9,000 mg,
about 20 ng to about 8,500 mg, about 30 ng to about 7,500 mg, about 40 ng to
about 7,000 mg,
about 50 ng to about 6,500 mg, about 100 ng to about 6,000 mg, about 200 ng to
about 5,500 mg,
about 300 ng to about 5,000 mg, about 400 ng to about 4,500 mg, about 500 ng
to about 4,000
mg, about 1 g to about 3,500 mg, about 5 g to about 3,000 mg, about 10 g to
about 2,600 mg,
about 20 g to about 2,575 mg, about 30 g to about 2,550 mg, about 40 g to
about 2,500 mg,
about 50 g to about 2,475 mg, about 100 g to about 2,450 mg, about 200 g to
about 2,425
mg, about 300 g to about 2,000, about 400 g to about 1,175 mg, about 500 g
to about 1,150
mg, about .5 mg to about 1,125 mg, about 1 mg to about 1,100 mg, about 1.25 mg
to about 1,075
mg, about 1.5 mg to about 1,050 mg, about 2.0 mg to about 1,025 mg, about 2.5
mg to about
1,000 mg, about 3.0 mg to about 975 mg, about 3.5 mg to about 950 mg, about
4.0 mg to about
925 mg, about 4.5 mg to about 900 mg, about 5 mg to about 875 mg, about 10 mg
to about 850
mg, about 20 mg to about 825 mg, about 30 mg to about 800 mg, about 40 mg to
about 775 mg,
about 50 mg to about 750 mg, about 100 mg to about 725 mg, about 200 mg to
about 700 mg,
about 300 mg to about 675 mg, about 400 mg to about 650 mg, about 500 mg, or
about 525 mg
to about 625 mg.
Other suitable doses per day for a ghrelin mimetic of the invention include
doses of about
or greater than 1 ng, about 5 ng, about 10 ng, about 20 ng, about 30 ng, about
40 ng, about 50 ng,
about 100 ng, about 200 ng, about 300 ng, about 400 ng, about 500 ng, about 1
g, about 5 g,
about 10 g, about 20 g, about 30 g, about 40 g, about 50 g, about 100 g,
about 200 g,
about 300 g, about 400 g, about 500 g (0.5 mg), about 1 mg, about 1.25 mg,
about 1.5 mg,
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about 2.0 mg, about 2.5 mg, about 3.0 mg, about 3.5 mg, about 4.0 mg, about
4.5 mg, about 5
mg, about 10 mg, about 20 mg, about 30 mg, about 40 mg, about 50 mg, about 100
mg, about
200 mg, about 300 mg, about 400 mg, about 500 mg, about 600 mg, about 625 mg,
about 650
mg, about 675 mg, about 700 mg, about 725 mg, about 750 mg, about 775 mg,
about 800 mg,
about 825 mg, about 850 mg, about 875 mg, about 900 mg, about 925 mg, about
950 mg, about
975 mg, about 1000 mg, about 1025 mg, about 1050 mg, about 1075 mg, about 1100
mg, about
1125 mg, about 1150 mg, about 1175 mg, about 1200 mg, about 1225 mg, about
1250 mg, about
1275 mg, about 1300 mg, about 1325 mg, about 1350 mg, about 1375 mg, about
1400 mg, about
1425 mg, about 1450 mg, about 1475 mg, about 1500 mg, about 1525 mg, about
1550 mg, about
1575 mg, about 1600 mg, about 1625 mg, about 1650 mg, about 1675 mg, about
1700 mg, about
1725 mg, about 1750 mg, about 1775 mg, about 1800 mg, about 1825 mg, about
1850 mg, about
1875 mg, about 1900 mg, about 1925 mg, about 1950 mg, about 1975 mg, about
2000 mg, about
2025 mg, about 2050 mg, about 2075 mg, about 2100 mg, about 2125 mg, about
2150 mg, about
2175 mg, about 2200 mg, about 2225 mg, about 2250 mg, about 2275 mg, about
2300 mg, about
2325 mg, about 2350 mg, about 2375 mg, about 2400 mg, about 2425 mg, about
2450 mg, about
2475 mg, about 2500 mg, about 2525 mg, about 2550 mg, about 2575 mg, about
2600 mg, about
3,000 mg, about 3,500 mg, about 4,000 mg, about 4,500 mg, about 5,000 mg,
about 5,500 mg,
about 6,000 mg, about 6,500 mg, about 7,000 mg, about 7,500 mg, about 8,000
mg, about 8,500
mg, about 9,000 mg, or about 9,500 mg.
A suitable dose of the ghrelin mimetic can be in the range of from about 0.20
mg to about
4000 mg per day, such as from about 1 mg to about 4000 mg, for example, from
about 5 mg to
about 3000 mg, such as about 10 mg to about 2400 mg per day. The dose can be
administered in
a single dosage or in multiple dosages, for example from 1 to 4 or more times
per day. When
multiple dosages are used, the amount of each dosage can be the same or
different.
A suitable dose for an additional therapeutic agent, such as, for example, a
laxative, can
be in same range as described above for the ghrelin mimetic. The dose of
ghrelin mimetic and
additional agent can be the same or different. Suitable doses for the
additional agents can be
found in the literature.
The compounds for use in the method of the invention can be formulated for
administration by any suitable route, such as for oral or parenteral, for
example, transdermal,
transmucosal (e.g., sublingual, lingual, (trans)buccal), vaginal (e.g., trans-
and perivaginally),
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(intra)nasal and (trans)rectal), subcutaneous, intramuscular, intradermal,
intra-arterial,
intravenous, inhalation, and topical administration.
In a preferred embodiment, the compounds of the invention are formulated for
intravenous delivery. In another preferred embodiment, the compounds of the
invention are
formulated for oral delivery. Suitable compositions and dosage forms include
tablets, capsules,
caplets, pills, gel caps, troches, dispersions, suspensions, solutions,
syrups, granules, beads,
transdermal patches, gels, powders, pellets, magmas, lozenges, creams, pastes,
plasters, lotions,
discs, suppositories, liquid sprays, dry powders or aerosolized formulations.
It is preferred that the compounds are orally administered. Suitable oral
dosage forms
include, for example, tablets, capsules or caplets prepared by conventional
means with
pharmaceutically acceptable excipients such as binding agents (e.g.,
polyvinylpyrrolidone or
hydroxypropylmethylcellulose); fillers (e.g., lactose, microcrystalline
cellulose or calcium
phosphate); lubricants (e.g., magnesium stearate, talc or silica);
disintegrates (e.g., sodium starch
glycolate); or wetting agents (e.g., sodium lauryl sulphate). If desired, the
tablets can be coated,
e.g., to provide for ease of swallowing or to provide a delayed release of
active, using suitable
methods. Liquid preparation for oral administration can be in the form of
solutions, syrups or
suspensions. Liquid preparations (e.g., solutions, suspensions and syrups) are
also suitable for
oral administration and can be prepared by conventional means with
pharmaceutically acceptable
additives such as suspending agents (e.g., sorbitol syrup, methyl cellulose or
hydrogenated edible
fats); emulsifying agent (e.g., lecithin or acacia); non-aqueous vehicles
(e.g., almond oil, oily
esters or ethyl alcohol); and preservatives (e.g., methyl or propyl p-hydroxy
benzoates or sorbic
acid).
Preferably, a pharmaceutical composition comprising a ghrelin mimetic of the
invention
is used to treat a gastrointestinal malady (e.g., a disorder, disease,
condition or injury of the
gastrointestinal tract which impairs gastrointestinal kinetics) by stimulating
gastrointestinal
kinetics or motility. The exact formulation, route of administration and
dosage can be chosen
depending on the desired effect and can be made by those of skill in the art.
Dosage intervals can be determined by experimental testing. One or more
ghrelin
mimetics of the invention could be administered using a regimen which
maintains
gastrointestinal motility at about 10% above or below normal, about 20% above
or below
normal, above 50% above or below normal.
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Another suitable administration method is to provide a ghrelin mimetic of the
invention
through an implant or a cell line capable of expressing a ghrelin mimetic so
that the implant or
cell line can provide the ghrelin mimetic to a cell of the gastrointestinal
system.
A pharmaceutical composition of the invention can be formulated to be
compatible with
its intended route of administration.
Oral administration refers to the administration of a pharmaceutical
composition of the
invention via the mouth through ingestion, or via any other part of the
gastrointestinal system
including the esophagus or through suppository administration. Parenteral
administration refers
to the delivery of a composition, such as a composition comprising a ghrelin
mimetic by a route
other than through the gastrointestinal tract (e.g., oral delivery). In
particular, parenteral
administration may be via intravenous, subcutaneous, intramuscular or
intramedullary (i.e.,
intrathecal) injection. The parenteral preparation can be enclosed in
ampoules, disposable
syringes or multiple dose vials made of glass or plastic. Topical
administration refers to the
application of a pharmaceutical agent to the external surface of the skin or
the mucous
membranes (including the surface membranes of the nose, lungs and mouth (in
which case it
may also be a form of oral administration, such that the agent crosses the
external surface of the
skin or mucous membrane and enters the underlying tissues. Topical
administration of a
pharmaceutical agent can result in a limited distribution of the agent to the
skin and surrounding
tissues or, when the agent is removed from the treatment area by the
bloodstream, can result in
systemic distribution of the agent.
In one form of topical administration contemplated by the invention, the
ghrelin mimetic
is delivered by transdermal delivery. Transdermal delivery refers to the
diffusion of an agent
across the barrier of the skin. Absorption through intact skin can be enhanced
by placing the
active agent in an oily vehicle before application to the skin (a process
known as inuection) and
the use of microneedles. Passive topical administration may consist of
applying the active agent
directly to the treatment site in combination with emollients or penetration
enhancers. Another
method of enhancing delivery through the skin is to increase the dosage of the
pharmaceutical
agent. The dosage for topical administration may be increased up to ten, a
hundred or a thousand
folds more than dosages administered by other routes.
Penetrants for transdermal delivery are generally known in the art, and
include, for
example, for transmucosal administration, detergents, bile salts, and fusidic
acid derivatives.
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Transmucosal administration can be accomplished through the use of nasal
sprays or
suppositories. For administration by inhalation, the ghrelin mimetics of the
invention can be
delivered in the form of an aerosol spray from pressured container or
dispenser that contains a
suitable propellant, e.g., a gas such as carbon dioxide, or a nebulizer. For
transdermal
administration, the ghrelin mimetics of the invention can be formulated into
ointments, salves,
gels, or creams as generally known in the art.
In addition, the ghrelin mimetics of the invention may be delivered by nasal
or
pulmonary methods. The respiratory delivery of aerosolized medicaments is
described in a
number of references, beginning with Gansslen (1925) Klin. Wochenschr. 4:71
and including
Laube et al. (1993) JAMA 269:2106-21-9; Elliott et al. (1987) Aust. Paediatr.
J. 23:293-297;
Wigley et al. (1971) Diabetes 20:552-556. Corthorpe et al. (1992) Pharm Res
9:764-768;
Govinda (1959) Indian J. Physiol. Pharmacol. 3:161-167; Hastings et al. (1992)
J. Appl. Physiol.
73:1310-1316; Liu et al. (1993) JAMA 269:2106-2109; Nagano et al. (1985)
Jikeikai Med. J.
32:503-506; Sakr (1992) Int. J. Phar. 86:1-7; and Yoshida et al. (1987) Clin.
Res. 35:160-166,
each of which are incorporated herein by reference. Pulmonary delivery of dry
powder
medicaments is described in U.S. Pat. No. 5,254,330. A metered dose inhaler is
described in Lee
and Sciara (1976) J. Pharm. Sci. 65:567-572. The intrabronchial administration
of recombinant
insulin is briefly described in Schlutiter et al. (Abstract) (1984) Diabetes
33:75A and Kohler et
al. (1987) Atemw. Lungenkrkh. 13:230-232. Intranasal and respiratory delivery
of a variety of
polypeptides are described in U.S. Pat. No. 5,011,678 and Nagai et al. (1984)
J. Contr. Rel. 1:15-
22.
Pharmaceutical compositions suitable for injectable use are known in the art
and include,
for example, sterile aqueous solutions (where water soluble) or dispersions
and sterile powders
for the extemporaneous preparation of sterile injectable solutions or
dispersion. For intravenous
administration of the ghrelin mimetics of the invention, physiologically
acceptable, suitable
carriers include, for example, physiological saline, bacteriostatic water,
Cremophor EL TM
(BASF, Parsippany, N.J.) or phosphate buffered saline (PBS).
Physiologically acceptable carriers maybe any carrier known in the field as
suitable for
pharmaceutical (i.e., topical, oral, and parenteral) application. Suitable
pharmaceutical carriers
and formulations are described, for example, in Remington's Pharmaceutical
Sciences (19th ed.)
(Genarro, ed. (1995) Mack Publishing Co., Easton, Pa.).
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Oral compositions generally include a physiologically acceptable, inert
diluent or an
edible carrier. They can be enclosed in gelatin capsules or compressed into
tablets. For the
purpose of oral therapeutic administration, the ghrelin mimetics of the
invention can be
incorporated with physiological excipients and used in the form of tablets,
troches, or capsules.
A number of systems that alter the delivery of injectable drugs can be used to
change the
pharmacodynamic and pharmacokinetic properties of therapeutic agents (see,
e.g., K. Reddy,
2000, Annals of Pharmacotherapy 34:915-923). Drug delivery can be modified
through a
change in formulation (e.g., continuous-release products, liposomes) or an
addition to the drug
molecule (e.g., pegylation). Potential advantages of these drug delivery
mechanisms include an
increased or prolonged duration of pharmacologic activity, a decrease in
adverse effects, and
increased patient compliance and quality of life. Injectable continuous-
release systems deliver
drugs in a controlled, predetermined fashion and are particularly appropriate
when it is important
to avoid large fluctuations in plasma drug concentrations. Encapsulating a
drug within a
liposome can produce a prolonged half-life and an increased distribution to
tissues with
increased capillary permeability (e.g., tumors). Pegylation provides a method
for modification of
therapeutic peptides or proteins to minimize possible limitations (e.g.,
stability, half-life,
immunogenicity) associated with the ghrelin mimetics of the invention.
In accordance with the invention, one or more ghrelin mimetics can be
formulated with
lipids or lipid vehicles (e.g., micelles, liposomes, microspheres, protocells,
protobionts,
liposomes, coacervates, and the like) to allow formation of multimers.
Similarly, ghrelin
mimetics can be multimerized using pegylation, cross-linking, disulfide bond
formation,
formation of covalent cross-links, glycosylphosphatidylinositol (GPI) anchor
formation, or other
established methods. The multimerized ghrelin mimetics can be formulated into
a
pharmaceutical composition, and used to increase or enhance their effects.
The ghrelin mimetics can also be prepared in the form of suppositories (e.g.,
with
conventional suppository bases such as cocoa butter and other glycerides) or
retention enemas
for rectal delivery.
The skilled artisan will appreciate that a variety of techniques are known
that can be used
to deliver the ghrelin mimetics of the invention more specifically to local
gastrointestinal tissues,
such as, but not limited to, the stomach, esophagus, small intestine, or
colon. The delivery
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method will depend on factors such as the tissue of interest, the nature of
the compound to be
delivered, and the duration of the treatment.
In one aspect, the ghrelin mimetics of the invention are prepared with
carriers that will
protect the ghrelin mimetics against rapid elimination from the body, such as
a controlled release
formulation, including implants and microencapsulated delivery systems. These
can be prepared
according to methods known to those skilled in the art, for example, as
described in U.S. Pat. No.
4,522,811.
Having thus described in detail preferred embodiments of the present
invention, it is to be
understood that the invention defined by the above paragraphs is not to be
limited to particular
details set forth in the above description as many apparent variations thereof
are possible without
departing from the spirit or scope of the present invention.
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EXAMPLES
The invention will now be further described by way of the following non-
limiting
examples.
The gastrokinetic efficacy of ipamorelin was evaluated in a rat model of post-
operative
ileus. In these studies ipamorelin was administered either orally (10 mg/kg
and 100 mg/kg) or via
a single intravenous injection was administered to male rats following
abdominal surgery over a
dose range of 0.01 mg/kg to 1.0 mg/kg. The effect of ipamorelin on gastric
emptying relative to
control animals was determined by administration of a dose of phenol red via
oral gavage
followed immediately with the dose of ipamorelin.
EXAMPLE 1. Gastrokinetic efficacy of ipamorelin (10 or 100 mg/kg) in a rat
model of post-
operative ileus
This study evaluated the potential gastrokinetic efficacy of ipamorelin
following a single
oral administration in a rat model of post-operative ileus at a dose of 10 or
100 mg/kg.
Treatment Group Dose level Dose Dose volume No. of males
(mg/kg) concentration (mL/kg)
(mg/mL)
1 Vehicle/control 0 0 5 8
2 Ipamorelin 10 2 5 8
3 Ipamorelin 100 20 5 8
* Animals in this group underwent all surgical procedures but with no cecum
manipulation.
Methods and experimental design
Male Sprague-Dawley CD (Cr1: CD (SD)) rats (Rattus norvegicus) were received
from
Charles River Canada Inc. St. Constant, Quebec, Canada,.
Nine days were allowed between receipt of the animals and the start of
treatment to accustom the
animals to the laboratory environment. At the start of treatment, animals were
approximately 7
weeks of age and were in the weight range of 230 g to 254 g.
Animals were housed individually in stainless steel wire mesh-bottomed cages
equipped
with an automatic watering valve. Each cage was clearly labeled with a color-
coded cage card
indicating project, group, animal numbers and sex. Each animal was uniquely
identified. The
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targeted conditions for animal room environment and photoperiod were as
follows: Temperature
22 3 C; Humidity 50 20%; Light Cycle 12 hours light and 12 hours dark.
All animals were given free access (except during designated procedures) to a
standard
certified pelleted commercial laboratory diet (PMI Certified Rodent Chow 5002:
PMI Nutrition
International Inc.). The diet was controlled and routinely analyzed by the
manufacturer for
maximum allowable concentrations of contaminants (eg, heavy metals,
aflatoxins,
organophosphates, chlorinated hydrocarbons and PCBs). Municipal tap water
which had been
softened, purified by reverse osmosis and exposed to ultraviolet light was
provided ad libitum
(except during designated procedures). It is considered that there were no
known contaminants in
the dietary materials that could have influenced the outcome of the study.
The ipamorelin obtained and used in this study was obtained from Bachem AG
(Bubendorf, Switzerland). The vehicle used was 0.9% sodium chloride for
injection (Baxter).
The gastrointestinal marker used to evaluate level stomach emptying was phenol
red (Sigma
Aldrich).
Appropriate amounts of test article were dissolved in 0.9% Sodium Chloride for
Injection
USP. The test article formulations were adjusted between pH 7.4 to 7.5 with
0.1N/1N
hydrochloric acid or 0.1N sodium hydroxide, as required. All dosing
formulations were kept at
room temperature, protected from light. The phenol red was prepared on the day
of dosing as a 5
mg/mL solution in deionized water and was stored at room temperature,
protected from light.
Catheterization surgery
Each animal received an antibiotic injection of Benzathine penicillin G and
Procaine
penicillin G (0.1 mL) intramuscularly on the day of surgery and again 2 days
following surgery.
The animals were anesthetized with isoflurane gas prior to surgery
preparation, which included
shaving of the femoral and dorsal exteriorization sites. The shaved areas were
washed with
Chlorhexidine gluconate 4% followed by a liberal application of Povidone
iodine 10%. Prior to
surgery and at the end of the surgical procedure, while under anesthesia, a
bland lubricating
ophthalmic agent (Tears Naturale PM) was administered to each eye. Animals
were maintained
under isoflurane gas anesthesia throughout the surgical procedure.
A small incision was made in the right groin region and the femoral vein was
isolated. A
small phlebotomy was made in the vein and a medical grade silicone-based
catheter was inserted
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and the tip of the catheter was placed in the vena cava at approximately the
level of the kidneys.
The catheter was secured in place with an appropriate suture material and then
brought
subcutaneously to the exteriorization point at the nape of the neck. The
femoral site was
irrigated with warm (approximately 37 C) 0.9% Sodium Chloride Injection, USP.
The femoral
site was closed with interrupted mattress sutures and the exteriorization site
with a purse stitch,
which was removed in 5-10 days or depending upon healing results. A topical
antibiotic
(Polymyxin B, Bacitracin, Neomycin) was administered to the catheter
exteriorization site, daily
until termination, and the femoral site until considered unnecessary.
A jacket was placed on the animal to hold the tether system. The catheter,
prefilled with
0.9% Sodium Chloride Injection, U.S.P., was fed through the tether system and
attached to a
swivel secured to the outside of the cage. The upper portion of the swivel was
connected to the
infusion pump and all animals were continuously infused with 0.9% Sodium
Chloride Injection,
U.S.P. at a rate of 0.4 mL/h until initiation of treatment.
Surgery to induce post-operative ileus
All treatment procedures were replicated over two consecutive days with
approximately
equal numbers of animals from each group treated on each day. Food was
withdrawn from
animals overnight prior to surgery. On the day of surgery animals were
anesthetized with
isoflurane gas and a bland ophthalmic lubricant (Tears Naturale PM) was
applied to each eye.
The animals were prepared for surgery by shaving of the entire abdominal
region. The shaved
area was cleaned and disinfected appropriately prior to incision. Using a
scalpel blade, the
abdomen was opened and the cecum localized. The cecum was exteriorized and
manipulated for
approximately one minute (i.e. gently patted between hands in saline-soaked
gauze). Thereafter,
the cecum was repositioned and the surgical site closed using absorbable
suture material
(interrupted sutures) and staples. Animals were then returned to their home
cage to permit
recovery from the anesthesia.
Animals assigned to the sham control group (Group 1) underwent the same
treatment
procedures, with the exception that the cecum was exteriorized and
repositioned without
manipulation.
Dose administration
Dosing commenced on consecutive days with approximately equal numbers of
animals
from each group being dosed on each day. Prior to dosing, the animals were
water deprived. The
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test/control articles were administered by oral gavage using a syringe and
flexible gavage tube.
The animals were dosed immediately following the oral gavage dose of phenol
red. The dose
volume was 5 mL/kg (for both ipamorelin and phenol red administration) and the
actual dose
administered was based on the most recent body weight of each animal.
Gastrointestinal assessment
Approximately 30 minutes following the morphine injection, all animals
received 0.4 mL
of phenol red by oral gavage. Approximately 30 minutes following
administration of control or
test article, the rats were euthanized. The stomach was then exposed by
laparotomy, quickly
ligated at the pylorus and the cardia and removed. The stomach was cut open
and its contents
extracted with 100 mL of 0.1N NaOH. The phenol red content of this extract was
assayed
colorimetrically at 558 nm in a spectrophotometer. Following collection,
samples were stored on
wet ice pending transfer for analysis.
Results
Orally administered following post-operative ileus, ipamorelin accelerated
stomach
emptying by approximately 12.4% and 41.6% at 10 and 100 mg/kg, respectively,
when
compared to the control animals, without, however, attaining statistical
significance. See FIG. 1.
Conclusion
Ipamorelin administered orally at doses of 10 or 100 mg/kg accelerated
emptying in a dose dependent relationship, in a rat model of post-operative
ileus.
EXAMPLE 2. Gastrokinetic efficacy of intravenous-administered ipamorelin (0.1,
0.25 or 1.0
mg/kg) in a rat model of post-operative ileus
In this study ipamorelin was administered as a slow bolus intravenous
injection via an
indwelling catheter (over a period of ca. 100 seconds).
Treatment Group Dose level Dose Dose volume No. of males
(mg/kg) concentration (mL/kg)
(mg/mL)
1 Sham* / 0 0 5 8
Vehicle
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2 Surgery / 0 0 5 .8
Vehicle
3 Surgery / 0.1 0.02 5 8
ipamorelin
4 Surgery / 0.25 0.05 5 8
ipamorelin
Sugery / 1.0 0.2 5 8
ipamorelin
* Animals in this group underwent all surgical procedures but with no cecum
manipulation.
Methods and experimental design
Male Sprague-Dawley CD (Crl: CD (SD)) rats (Rattus norvegicus) were received
from Charles River Canada Inc. St. Constant, Quebec, Canada. Eight days were
allowed
between receipt of the animals and the surgical implantation of the
catheters to allow the animals to become acclimated to the physical and
environmental
conditions. Dosing of the animals was initiated approximately one week
following surgical
implantation of the catheters to allow appropriate recovery of the animals
prior to treatment. At
the start of treatment, animals were approximately between 10 to 12 weeks of
age and were in
the weight range of 327 g to 397 g.
Animals were housed individually in stainless steel wire mesh-bottomed cages
equipped
with an automatic watering valve. Each cage was clearly labeled with a color-
coded cage card
indicating project, group, animal numbers and sex. Each animal was uniquely
identified. The
targeted conditions for animal room environment and photoperiod were as
follows: Temperature
22 3 C; Humidity 50 20%; Light Cycle 12 hours light and 12 hours dark.
All animals were given free access (except during designated procedures) to a
standard
certified pelleted commercial laboratory diet (PMI Certified Rodent Chow 5002:
PMI Nutrition
International Inc.). The diet was controlled and routinely analyzed by the
manufacturer for
maximum allowable concentrations of contaminants (eg, heavy metals,
aflatoxins,
organophosphates, chlorinated hydrocarbons and PCBs). Municipal tap water
which had been
softened, purified by reverse osmosis and exposed to ultraviolet light was
provided ad libitum
(except during designated procedures).
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It is considered that there were no known contaminants in the dietary
materials that could have
influenced the outcome of the study.
The ipamorelin obtained and used in this study was obtained from Bachem AG.
The
vehicle used was 0.9% sodium chloride for injection (Baxter). The
gastrointestinal marker used
to evaluate level stomach emptying was phenol red (Sigma Aldrich).
Catheterization surgery
Each animal received an antibiotic injection of Benzathine penicillin G and
Procaine
penicillin G (0.1 mL) intramuscularly on the day of surgery and again 2 days
following surgery.
The animals were anesthetized with isofluran( gas prior to surgery
preparation, which included
shaving of the femoral and dorsal exteriorization sites. The shaved areas were
washed with
Chlorhexidine gluconate 4% followed by a liberal application of Povidone
iodine 10%. Prior to
surgery and at the end of the surgical procedure, while under anesthesia, a
bland lubricating
ophthalmic agent (Tears Naturale PM) was administered to each eye. Animals
were maintained
under isoflurane gas anesthesia throughout the surgical procedure.
A small incision was made in the right groin region and the femoral vein was
isolated. A
small phlebotomy was made in the vein and a medical grade silicone-based
catheter was inserted
and the tip of the catheter was placed in the vena cava at approximately the
level of the kidneys.
The catheter was secured in place with an appropriate suture material and then
brought
subcutaneously to the exteriorization point at the nape of the neck. The
femoral site was
irrigated with warm (approximately 37 C) 0.9% Sodium Chloride Injection, USP.
The femoral
site was closed with interrupted mattress sutures and the exteriorization site
with a purse stitch,
which was removed in 5-10 days or depending upon healing results. A topical
antibiotic
(Polymyxin B, Bacitracin, Neomycin) was administered to the catheter
exteriorization site, daily
until termination, and the femoral site until considered unnecessary.
A jacket was placed on the animal to hold the tether system. The catheter,
prefilled with
0.9% Sodium Chloride Injection, U.S.P., was fed through the tether system and
attached to a
swivel secured to the outside of the cage. The upper portion of the swivel was
connected to the
infusion pump and all animals were continuously infused with 0.9% Sodium
Chloride Injection,
U.S.P. at a rate of 0.4 mL/h until initiation of treatment.
Surgery to induce post-operative ileus
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All treatment procedures were replicated over two consecutive days with
approximately
equal numbers of animals from each group treated on each day. Food was
withdrawn from
animals overnight prior to surgery. On the day of surgery animals were
anesthetized with
isoflurane gas and a bland ophthalmic lubricant (Tears Naturale PM) was
applied to each eye.
The animals were prepared for surgery by shaving of the entire abdominal
region. The shaved
area was cleaned and disinfected appropriately prior to incision. Using a
scalpel blade, the
abdomen was opened and the cecum localized. The cecum was exteriorized and
manipulated for
approximately one minute (i.e. gently patted between hands in saline-soaked
gauze). Thereafter,
the cecum was repositioned and the surgical site closed using absorbable
suture material
(interrupted sutures) and staples. Animals were then returned to their home
cage to permit
recovery from the anesthesia.
Animals assigned to the sham control group (Group 1) underwent the same
treatment
procedures, with the exception that the cecum was exteriorized and
repositioned without
manipulation. Note that due to technical oversight, the cecums of animal Nos.
2001, 2009, 3001
and 4001 were manipulated with sterile water for injection USP instead of
saline soaker gauze.
This minor deviation was considered to have had no impact on the study outcome
or upon the
interpretation of the results.
Dose administration
Dosing commenced on consecutive days with approximately equal numbers of
animals
from each group being dosed on each day. The test/control articles were
administered as a slow
bolus intravenous injection via an indwelling catheter (over a period of ca.
100 seconds). The
animals were dosed immediately following the oral gavage dose of phenol red.
The dose volume
was 5 mLlkg (for both ipamorelin and phenol red administration) and the actual
dose
administered was based on the most recent body weight of each animal.
Gastrointestinal assessment
Prior to dosing of the phenol red, the animals were water deprived. At
approximately 30
minutes post-surgery (ileus), animals received 0.4 mL of phenol red by oral
gavage. Animals
were then dosed and approximately 30 minutes later, were euthanized. Upon
euthanasia, the
stomach was exposed by laparotomy, quickly ligated at the pylorus and the
cardia removed. The
stomach was cut open and its contents extracted with 100 mL of 0.1N NaOH. The
phenol red
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content of this extract was assayed colorimetrically at 558 urn in a
spectrophotometer. Following
collection, samples were stored on wet ice pending transfer for analysis.
Results
Intravenously administered ipamorelin at doses of 0.1, 0.25 and 1.0 mg/kg
following
surgery accelerated stomach emptying in the male albino rats when compared to
the vehicle
control and sham control animals, although a dose relationship was not
observed.
Animals treated with an intravenous dose (0.1, 0.25 or 1.0 mg/kg) of
ipamorelin displayed
a reduction in stomach phenol red content relative to the vehicle control
group (85.7%, 95.6%
and 92.2%, respectively). These reductions reached statistical significance at
the 0.25 and
1.0 mg/kg dose levels (p < 0.001 and p <0.01, respectively). See FIG. 2.
The average stomach phenol red content of the vehicle control group was
similar and not
statistically different from that of the sham control group and may reflect
(unexpected) ileus in
the sham control group or an inability to induce detectable ileus in the
surgery control group.
Consequently, when expressed relative to the sham control group, animals
treated with
intravenous doses (0.1, 0.25 or 1.0 mg/kg) of ipamorelin displayed reductions
in stomach phenol
red content (87.1%, 96.0% and 93.1 %, respectively) that were statistically
significant at all
dose levels. See FIG. 2.
Conclusion
Ipamorelin administered intravenously to male albino rats at a dose of 0.1,
0.25 and 1.0
mg/kg following surgery significantly accelerated stomach emptying when
compared to the
sham and vehicle control animals.
EXAMPLE 3. Gastrokinetic efficacy of intravenous-administered ipamorelin
(0.01, 0.03 or 0.1
mg/kg) in a rat model of post-operative ileus
In this study ipamorelin was administered as a slow bolus intravenous
injection via an
indwelling catheter (over a period of ca. 100 seconds) at a dose of 0.01, 0.03
or 0.1 mg/kg.
Treatment Group Dose level Dose Dose volume No. of males
(mg/kg) concentration (mL/kg)
(mg/mL)
1 Non-operated 0 0 5 8
control
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2 Surgery / 0 0 5 8
Vehicle
3 Surgery/ 0.01 0.02 0.5 8
ipamorelin
4 Surgery / 0.03 0.02 1.5 8
ipamorelin
Sugery / 0.1 0.02 5 8
ipamorelin
* Animals in this group did not undergo surgery for ileus induction.
Male Sprague-Dawley CD (Crl: CD (SD)) rats (Rattus norvegicus) were used.
Seven days were allowed between receipt of the animals and the surgical
implantation of
the catheters to allow the animals to become acclimated to the physical and
environmental
conditions. Dosing of the animals was initiated approximately one week
following surgical
implantation of the catheters to allow appropriate recovery of the animals
prior to treatment.
At the start of treatment, animals were approximately 10 weeks of age and were
in the
weight range of 334 g to 385 g.
Animals were housed individually in stainless steel wire mesh-bottomed cages
equipped with
an automatic watering valve. The targeted conditions for animal room
environment and
photoperiod were as follows:
Temperature: 22 3 C; Humidity: 50 20%; Light cycle: 12 hours light and 12
hours dark.
All animals were examined twice daily for mortality and signs of ill health or
reaction to
treatment (except on the day of arrival and necropsy when the animals were
examined once).
Individual body weights were measured at randomization and on the day prior to
dosing (for
dose calculation purposes only).
Catheterization surgery
A small incision was made in the right groin region and the femoral vein was
isolated. A
small phlebotomy was made in the vein and a medical grade silicone-based
catheter was inserted
and the tip of the catheter was placed in the vena cava at approximately the
level of the kidneys.
The catheter was secured in place with an appropriate suture material and then
brought
subcutaneously to the exteriorization point at the nape of the neck. The
femoral site was
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irrigated with warm (approximately 37 C) 0.9% Sodium Chloride Injection, USP.
The femoral
site was closed with interrupted mattress sutures and the exteriorization site
with a purse stitch,
which was removed in 5-10 days or depending upon healing results. A topical
antibiotic
(Polymyxin B, Bacitracin, Neomycin) was administered to the catheter
exteriorization site, daily
until termination, and the femoral site until considered unnecessary.
A jacket was placed on the animal to hold the tether system. The catheter,
prefilled with
0.9% Sodium Chloride Injection, U.S.P., was fed through the tether system and
attached to a
swivel secured to the outside of the cage. The upper portion of the swivel was
connected to the
infusion pump and all animals were continuously infused with 0.9% Sodium
Chloride Injection,
U.S.P. at a rate of 0.4 mL/h until initiation of treatment.
Surgery to induce post-operative ileus
All treatment procedures were replicated over two consecutive days with
approximately
equal numbers of animals from each group treated on each day. Food was
withdrawn from
animals overnight prior to surgery. On the day of surgery animals were
anesthetized with
isoflurane gas and a bland ophthalmic lubricant (Tears Naturale PM) was
applied to each eye.
The animals were prepared for surgery by shaving of the entire abdominal
region. The shaved
area was cleaned and disinfected appropriately prior to incision. Using a
scalpel blade, the
abdomen was opened and the cecum localized. The cecum was exteriorized and
manipulated for
approximately one minute (i.e. gently patted between hands in saline-soaked
gauze). Thereafter,
the cecum was repositioned and the surgical site closed using absorbable
suture material
(interrupted sutures) and staples. Animals were then returned to their home
cage to permit
recovery from the anesthesia.
Animals assigned to the non-operated control group (Group 1) did not undergo
surgery to
induce post-operative ileus.
Dose administration
Dosing commenced on consecutive days with approximately equal numbers of
animals
from each group being dosed on each day. The test/control articles were
administered as a slow
bolus intravenous injection via an indwelling catheter. The animals were dosed
immediately
following the oral gavage dose of phenol red. The dose volume was 5 mL/kg for
Groups 1, 2
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and 5; 0.5 mL/kg for Group 3 and 1.5 mL/kg for Group 4. The actual dose
administered was
based on the most recent body weight of each animal.
Gastrointestinal assessment
Prior to dosing of the phenol red, the animals were water deprived. At
approximately 30
minutes post-surgery (ileus), animals received 0.4 mL of phenol red by oral
gavage. Animals
were then dosed and approximately 30 minutes later, were euthanized. Upon
euthanasia, the
stomach was exposed by laparotomy, quickly ligated at the pylorus and the
cardia removed. The
stomach was cut open and its contents extracted with 100 mL of 0.1N NaOH. The
phenol red
content of this extract was assayed colorimetrically at 558 nm in a
spectrophotometer. Following
collection, samples were stored on wet ice pending transfer for analysis.
Results
Intravenously administered ipamorelin at doses of 0.01, 0.03 and 0.1 mg/kg
following
surgery accelerated stomach emptying in the male albino rats when compared to
the vehicle
control and non-operated control animals, although a dose relationship was not
observed.
Animals treated with intravenous doses (0.01, 0.03 or 0.1 mg/kg) of ipamorelin
displayed
reductions in stomach phenol red content relative to the vehicle control
group. These reductions
reached statistical significance at all dose levels (p<0.05 at 0.01 and 0.1
mg/kg and p<0.0 at 0.03
mg/kg). See FIG. 3.
The average stomach phenol red content of the vehicle control group was
similar and not
statistically different from that of the non-operated control group and may
reflect an inability to
induce detectable ileus in the surgery control group. Consequently, when
expressed relative to
the non-operated control group, animals treated with intravenous doses (0.01,
0.03 or 0.1 mg/kg)
of ipamorelin displayed reductions in stomach phenol red content that were
statistically
significant at all dose levels.
EXAMPLE 4. Efficacy of morphine to induce gastric ileus in rats
The purpose of this study was to evaluate the potential efficacy of morphine
to induce
gastric ileus in rats. Treatment groups were set up as follows.
Treatment Morphine Ghrelin Ghrelin Dose volume No. of males
Group Dose level Dose level . concentration (mL/kg)
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(mg/kg) (ug/kg) (ug/mL)
1 Saline control 0 0 0 1.5 8
2 Morphine + 1* 0 0 1.5 8
saline -
3 Morphine + 1 * 50 33.33 1.5 8
ghrelin
4 Morphine + 4** 0 0 1.5 8
saline
Morphine + 4** 50 33.33 1.5 8
ghrelin
* Morphine was administered at a dose volume of 0.1 mL/kg for groups 2-3
** Morphine was administered at a dose volume of 0.4 mL/kg for groups 4-5
Methods and experimental design
Male Sprague-Dawley CD (Crl: CD(O(SD)) rats (Rattus norvegicus) were received
from Charles River Canada Inc. St. Constant, Quebec, Canada. Subsequent to
arrival, all animals
were subjected to a general physical examination by a
qualified member of the veterinary staff to ensure normal health status. All
animals were
considered acceptable for use. Nine days were allowed between receipt of the
animals and the
start of treatment to accustom the animals to the laboratory environment. At
the start of
treatment, animals were approximately between 7 weeks of age and were in the
weight range of
231 g to 267g. Please note that the animals body weights were slightly outside
the protocol stated
range. This deviation was considered to have had no impact on the outcome of
the study or upon
interpretation of the results.
Animals were housed individually in stainless steel wire mesh-bottomed cages
equipped
with an automatic watering valve. The targeted conditions for animal room
environment and
photoperiod were as follows: Temperature 22 3 C; Humidity 50 20%; Light
Cycle 12 hours
light and 12 hours dark.
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All animals were given free access (except during designated procedures) to a
standard
certified pelleted commercial laboratory diet (PMI Certified Rodent Chow 5002:
PMI Nutrition
International Inc.). The diet was controlled and routinely analyzed by the
manufacturer for
maximum allowable concentrations of contaminants (eg, heavy metals,
aflatoxins,
organophosphates, chlorinated hydrocarbons and PCBs). The results of these
analyses are
retained in the scientific archives of PCS-MTL. Municipal tap water which had
been softened,
purified by reverse osmosis and exposed to ultraviolet light was provided ad
libitum (except
during designated procedures). Periodic analysis of the water was
subcontracted to management
authorized analytical laboratories which were audited by the Quality Assurance
department of
PCS-MTL. The results of these analyses are retained in the scientific archives
of PCS-MTL.
It is considered that there were no known contaminants in the dietary
materials that could have
influenced the outcome of the study.
The dose formulations were prepared on the day of dosing. The appropriate
control was
dissolved in the vehicle to achieve the desired concentration. The morphine
sulfate solution was
used as supplied. The phenol red was prepared on the day of dosing as a 5
mg/mL solution
and stored at room temperature, protected from light pending use.
Dose administration
Morphine (4 mg/kg or 1 mg/kg) was administered once to the upper dorsum
(scapular
region) by subcutaneous injection using a hypodermic needle attached to a
syringe. Morphine
was administered approximately 30 minutes prior to the administration of the
control/positive
control articles. The dose volume was 0.1 mL/kg for Groups 2 and 3 and 0.4
mL/kg for Groups 4
and 5. The actual dose administered was based on the most recent practical
body weight of each
animal.
Gastrointestinal assessment
Approximately 30 minutes following the morphine injection, all animals
received 0.4 mL
of phenol red by oral gavage. Approximately 30 minutes following
administration of control or
test article, the rats were euthanized. The stomach was then exposed by
laparotomy, quickly
ligated at the pylorus and the cardia and removed. The stomach was cut open
and its contents
extracted with 100 mL of 0.1N NaOH. The phenol red content of this extract was
assayed
colorimetrically at 558 nm in a spectrophotometer. Following collection,
samples were stored on
wet ice pending transfer for analysis.
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Results
Subcutaneously administered at a dose of 1 or 4 mg/kg, morphine significantly
reduced
the stomach emptying by approximately 42% when compared to the control
animals, without
however attaining statistical significance. Ghrelin, a potent prokinetic
peptide known to reverse
gastric ileus, administered intravenously at a dose of 50 g/kg following
exposure with 1 mg/kg
of morphine, accelerated stomach emptying by approximately 37% when compared
to the
animals treated with 1 mg/kg and saline, and reversed the ileus induced by
approximately 11 %.
However, ghrelin did not accelerate gastric emptying in the rats administered
4 mg/kg of
morphine and both groups (saline vs ghrelin) displayed the same group mean
absorbance of
phenol red (2.99 and 3.01, respectively). See FIG. 4.
Conclusion
Morphine administered subcutaneously to male albino rats at doses of 1 or
4 mg/kg induced similar level of gastric ileus, in a non dose-dependent
manner. Ghrelin
accelerated stomach emptying and reversed the gastric ileus induced following
exposure with
1 mg/kg of morphine but had no effects on the stomach emptying of the rats
administered doses
of 4 mg/kg of morphine.
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EXAMPLE 5. Gastrokinetic efficacy of intravenous injection of ipamorelin (1.0,
2.5, 10
mg/kg) as compared to RC-1139 to treat post-operative ileus in a rat model
Ipamorelin was evaluated in a rat model of post-operative ileus in comparison
to RC-
1139, a ghrelin mimetic with known gastrokinetic efficacy. In this study each
drug was
administered as a single intravenous injection as shown in the table below.
Treatment groups
were as follows.
Treatment Dose level Dose Dose volume No. of males
Group (mg/kg) concentration (mL/kg)
(mg/mL)
1 Vehicle/ 0 0 5 8
Control
2 Ipamorelin 1 0.2 5 8
3 Ipamorelin 2.5 0.5 5 8
4Ipamorelin 10/0.25 2.5/0.05 5 8*
RC-1139 10 2 5 8
(reference
article)
*Lethality was observed immediately following administration of a 10 mg/kg
dose (n=2) and consequently the dose level was
reduced to 0.25 mg/kg for all remaining animals in Group 4
All animals were examined twice daily for mortality and signs of ill health or
reaction to
treatment (except on the day of arrival and necropsy when the animals were
examined once).
Individual body weights were measured at randomization and on the day prior to
dosing (for
dose calculation purposes only). Two animals died immediately following
administration of
ipamorelin at a dose of 10 mg/kg and consequently all remaining animals from
Group 4 were
dosed at 0.25 mg/kg.
Methods and experimental design
Male Sprague-Dawley CD (Crl: CD (SD)) rats (Rattus norvegicus) were
randomized to
treatment groups At least 5 days was allowed between receipt of the animals
and the start of
treatment to accustom the animals to the laboratory environment. At the start
of treatment,
animals were approximately 7 weeks of age and were in the weight range of 205
g to 272 g.
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Prior to the first dose formulation preparation, a trial preparation was
conducted at 2
mg/mL (test article solution) and at 2 mg/mL (reference article solution) to
confirm the
suitability of the proposed formulation method.
For dosing, formulations were prepared by dissolving the appropriate quantity
of test or
reference article in 0.9% Sodium Chloride for Injection USP. The dosing
formulations were
then pH adjusted from 7.4 to 7.5 with 0.1N/1N hydrochloric acid or 0.1N sodium
hydroxide, as
required. All dosing formulations were filtered via 0.2 m PVDF filters prior
to use and were
kept at room temperature, protected from light.
The phenol red was prepared on the day of dosing as a 5 mg/mL solution in
deionized
water and was stored at room temperature, protected from light.
Surgery to induce post-operative ileus
All treatment procedures were replicated over two consecutive days with
approximately
equal numbers of animals from each group treated on each day. Food was
withdrawn from
animals overnight prior to surgery. On the day of surgery animals were
anesthetized with
isoflurane gas and a bland ophthalmic lubricant was applied to each eye. The
animals were
prepared for surgery by shaving of the entire abdominal region. The shaved
area was cleaned and
disinfected appropriately prior to incision. Using a scalpel blade, the
abdomen was opened and
the cecum localized. The cecum was exteriorized and manipulated for
approximately one minute
(i.e. gently patted between hands in saline-soaked gauze). Thereafter, the
cecum was
repositioned and the surgical site closed using absorbable suture material
(interrupted sutures)
and staples. Animals were then returned to their home cage to permit recovery
from the
anesthesia.
Dose administration
Animals were dosed immediately following the oral gavage dose of phenol red.
The
test/control articles and reference article were administered by intravenous
injection (given as a
slow bolus injection over a period of ca. 100 seconds) into the tail vein
using a syringe and
appropriate gauge needle. The dose volume was 5 mL/kg and the actual dose
administered was
based on the most recent body weight of each animal.
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Gastrointestinal assessment
Prior to dosing of the phenol red, the animals were water deprived. At
approximately 30
minutes post-surgery, animals received 0.4 mL of phenol red by oral gavage,
then dosed with the
test article, and then, approximately 30 minutes later, were euthanized. Upon
euthanasia, the
stomach was exposed by laparotomy, quickly ligated at the pylorus and the
cardia and removed.
The stomach was cut open and its contents extracted with 100 mL of 0.1N NaOH.
The phenol
red content of this extract was assayed colorimetrically at 558 nm in a
spectrophotometer.
Following collection, samples were stored on wet ice pending transfer for
analysis.
Results
Ipamorelin administered intravenously at doses of 0.25, 1 and 2.5 mg/kg
following
induction of a post-operative ileus accelerated stomach emptying in the male
albino rats, when
compared to the control and RC-1 139 treated animals, although a monotonic
dose relationship
was not observed. See FIG. 5.
Intravenous doses of 0.25 and 2.5 mg/kg each displayed a similar level of
efficacy with
approximately 50 and 60% reductions in phenol red content, respectively, while
approximately
21 % emptying was observed following the 1 mg/kg dose. The stomach content of
the phenol red
marker following administration of the 10 mg/kg RC-1139 dose was approximately
16% lower
than that of the control group.
Conclusion
Ipamorelin administered intravenously at doses of 0.25, 1 and 2.5 mg/kg to
male albino
rats with post-operative ileus accelerated stomach emptying, when compared to
the control and
reference animals.
EXAMPLE 6. Administration of ipamorelin in healthy volunteers to reverse a
morphine-
induced slowing of gastric emptying
Introduction
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Delay in gastric emptying plays an etiologic role in several important target
indications
including post-operative ileus, opiate-induced bowel dysfunction, and
gastroparesis.
In addition, delays in gastric emptying may promote or exacerbate nausea.
Consequently, an
agent such as ipamorelin, with demonstrated ability to promote gastric
emptying in animal
models (see above Examples), may serve an important therapeutic role in a
variety of GI
disorders categorized by reduced motility.
Ipamorelin is a ghrelin mimetic. Ghrelin, a 28-amino acid peptide hormone, is
primarily
synthesized in the oxyntic gland in the stomach and to a lesser degree in
other organs of the body
such as the kidney and hypothalamus. Among the important physiologic effects
exerted by
ghrelin is its ability to modulate gastric motility and it has demonstrated a
strong prokinetic
effect (both upper and lower GI) in a variety of animal species as well as
humans. See Masuda
2000, Asakawa 2001, Tack 2006. Additionally, in a rat model ghrelin has been
shown to resolve
gastric postoperative ileus. See Trudel 2002.
The prokinetic activity of ghrelin is likely mediated either by direct effect
on the gut or
indirectly by the vagal-cholinergic-muscarinic pathway. It acts locally in the
stomach to
stimulate the firing of vagal afferent neurons and stimulate gastric motility.
See Peeters 2003.
Efforts have been underway for many years to exploit the positive effects of
ghrelin in a
variety of disorders via the identification and development of pharmaceutical
agents that
mimic ghrelin. Ghrelin has an exceptionally short half-life (approximately 10
minutes) in
humans and consequently has a limited therapeutic potential. Ipamorelin is a
ghrelin mimetic
with a half-life of approximately six hours in humans, available as an
intravenous treatment and
thus, is suitable for therapeutic use.
The present study was designed to employ a well-validated, clinical
pharmacology model
(acetaminophen AUC) for assessment of the effect of ipamorelin on gastric
emptying.
Ipamorelin was demonstrated in the examples described above to have potent,
stimulating effects
on gastric emptying in a rat model. This study was intended to extend these
findings into
humans.
Dosages
The dose of ipamorelin selected for this study (0.06 mg/kg IV infused over 15
minutes),
was a dose that' has been demonstrated to be safe and well-tolerated in prior
Phase 1 studies.
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Ipamorelin was formulated as a 0.5 mg/mL sterile solution with 2 equivalents
of acetic acid in
normal saline. The sterile solution was further diluted with normal saline to
an appropriate
volume for administration prior to use.
The dose of morphine selected for this study (0.05 mg/kg IV bolus) was a dose
that is
both clinically relevant as an analgesic dose and has been demonstrated
previously to
significantly delay gastric emptying in normal volunteers [Yuan 1998].
The acetaminophen dose selected for this study (1000 mg oral suspension) is a
standard
Over-the-Counter dose of acetaminophen. This dose has been employed
successfully in prior
gastric emptying studies and produces plasma concentrations which are readily
measured
(>0.2 g/mL).
The study design was a standard, three-period, randomized, single-dose
crossover study.
This study was carried out with single-dose administrations, which is
appropriate and
well-studied in the acetaminophen AUC model of gastric emptying. All of the
three drugs
employed in the present study have terminal half-lives of six hours or less,
consequently a
washout interval of 5-8 days will ensure complete elimination of the drugs
from the body.
This study's objectives included assessing the ability of intravenous
ipamorelin to reverse
opiate-induced delay in gastric emptying as well as assessing the ability of
intravenous
ipamorelin to reverse opiate-induced nausea. The inventors predicted that
ipamorelin will
reverse opiate-induced delay in gastric emptying as assessed by plasma
acetaminophen
absorption: the plasma acetaminophen AUCO_60 following ipamorelin
administration will be 50%
greater than that following placebo.
Study design
The study was conducted as a single-center, double-blind, randomized, single-
dose,
three-way crossover investigation. The study compared the following
treatments:
1. Morphine + Ipamorelin;
2. Morphine Control; and
3. Normal Control
Plasma samples were obtained over the three hours following acetaminophen
administration for determination of acetaminophen AUC as a measure of gastric
emptying.
It was anticipated that morphine would significantly delay gastric emptying
[Yuan 1998]; it was
further anticipated that ipamorelin would reverse the observed delay in
emptying. The primary
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parameter of interest is the early absorption of acetaminophen as reflected in
the plasma AUC
over the first hour following acetaminophen administration (AUCO_60).
Parameters of
additional interest include AUCO-i80, CMAx, and TMAX.
The study drug was administered via a well-calibrated infusion pump (e.g.,
Harvard pump or similar) over a 15 minute period. Each subject's dose was
calculated based on body weight to a maximum of 100 kg (6 mg). The dosing
volume was
then diluted to a total volume of 15 mL using normal saline for injection as
the diluent.
The syringe was drawn up with an air bubble (to facilitate agitation) and the
syringe
was mixed by gently inverting six times.
Morphine administration
Morphine (1.0 mg/mL)/placebo was administered by slow bolus (over 30-60
seconds).
The infusion catheter was then flushed immediately with 3-5 mL normal saline.
Acetaminophen administration
An acetaminophen suspension (32 mg/mL) was shaken well prior to
administration. The
dose to be administered was 31 mL (992 mg). The subject was then given an
additional 150 mL
water to drink.
Results
Treatment with ipamorelin was well-tolerated and the results showed a reverse
in
morphine-induced slowing of gastrointestinal motility in humans. See FIG. 6.
EXAMPLE 7. Examination of Lower Doses of Ipamorelin in the Morphine-Induced
Delay
in Gastric Emptying in Healthy Male Volunteers
This study was the same design as that of Example 6a but evaluated lower doses
of IV
ipamorelin to reverse opiate-induced delay in gastric emptying. Data are
presented for the twenty
three subjects who completed all treatments. The study treatments were: (1)
untreated (saline)
control; (2) morphine 0.05 mg/kg IV; and (3) morphine 0.05 mg/kg + ipamorelin
0.01 mg/kg IV
and (4) morphine 0.05 mg/kg + ipamorelin 0.03 mg/kg IV. Acetaminophen elixir
was
administered orally in each treatment cycle to permit assessment of gastric
emptying. The
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treatments were administered in a single-blind, placebo-controlled, 3-way
crossover study with a
washout of 5-8 days between treatments.
The results show that administration of morphine delayed gastric emptying as
determined
by reduced plasma acetaminophen levels. This effect was reversed by both doses
of ipamorelin
and was comparable to that presented in Example 6. Data are shown in Figure 6.
EXAMPLE 8. Comparison of the effects of various ghrelin mimetics, including
ipamorelin,
on gastrointestinal motility in rats
The objective of this study was to evaluate the pharmacological effects of a
series of
ghrelin mimetics on gastrointestinal motility in rats, as measured by charcoal
transit, relative to a
commonly used prokinetic agent, metoclopramide, and control, following a
single intravenous
infusion of the experimental agent.
Treatment groups were as follows:
Group/ Dose Level Dose Dose Volume Number of
Identification (mg/kg) Concentration (mIJkg) Males
(mg/nL)
1/Saline control 0 0 5 8
2lMetoclopran ide 10 1 10 8
3/GHRP-6 0.25 0.05 5 8
4/Ghrelin 025 0:05 5 8
5/Ipamorelin 0. .25 0.05 5 8
6/RC-1139 acetate 0.25a 0.05 5 8
7/RC-1089 fiunarate 0.25a 0.05 5 8
8/RC-1 187 acetate 0.251 0.05 5 8
9/RC-1141 acetate 0.25a 0.05 5 8
a Doses were corrected for the test articles saltlbase ratio
Treatment Procedure:
Each dosing formulation was prepared on the day of dosing. For the ghrelin
mimetics an
aliquot of a 4 mg/mL stock solution was diluted with an appropriate volume of
vehicle to achieve
the final desired concentration. The reference article formulations were also
prepared on the day
of dosing by mixing the appropriate amount of reference article with the
appropriate volume of
vehicle to achieve the desired final concentration. The saline and
metoclopramide (1 mg/mL)
were used as supplied.
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Dosing was performed on consecutive days with approximately equal numbers of
animals being dosed on each day. The animals were deprived of food overnight
prior to
treatment. Each formulation was administered by intravenous injection into the
tail vein using a
syringe and appropriate gauge needle. The dose volume was 5 mL/kg or 10 mL/kg
(in the case of
metoclopramide only).
Approximately 30 minutes following dosing with the test article, all animals
received 3
mL of activated charcoal by oral gavage, followed by a 20-minute period in
which the animals
were food and water deprived.
Following the observation period the rats were euthanized, the abdominal
cavity opened,
and the stomach and intestines removed. The presence or absence of charcoal
was documented.
The stomachs were weighed (with or without contents) to give an indication of
gastric emptying.
The intestines were opened and extended to their full length. The charcoal was
located and the
distances from the pyloric sphincter to the most proximal and distal traces of
charcoal were
measured as was the total distance from the pyloric sphincter to the cecum.
Also, the distance
traveled by the charcoal as a percentage of the total length of the small
intestine was measured.
Results
Metoclopramide significantly increased intestinal motility, increasing the
distal distance
traveled by the charcoal meal from 67.3% for the control group to 86.9% for
the
metoclopramide-treated group, a 29% increase. In contrast, the stomach
charcoal content of the
group of animals administered metoclopramide was not significantly different
from that of the
control group.
Ipamorelin significantly increased stomach emptying relative to the control
group,
reducing the amount of charcoal remaining in the stomach by 66%. Ghrelin and
GHRP-6 also
significantly reduced the amount of charcoal remaining in the stomach, by 57%
and 64%,
respectively, relative to the control group, but their effects did not differ
significantly from that
of ipamorelin.
Ipamorelin clearly produced a highly significant (P < 0.00 1) increase in
stomach
emptying and a tendency towards an increase in intestinal motility compared to
saline-treated
control group animals, supporting the view that ipamorelin is a potent
gastroprokinetic agent.
The results of these experiments are set forth in Figures 7 and 8.
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EXAMPLE 9. Comparison of the effects of various'ghrelin mimetics, including
ipamorelin,
on gastrointestinal motility in rats
The objective of this study was to evaluate the pharmacological effects of a
series of
ghrelin mimetics on gastrointestinal motility in rats, as measured by charcoal
transit, relative to
control, following a single intravenous infusion of the experimental agent.
Treatment groups were as follows:
Number
Group/ Dose Level Dose Level' Concentration Concentration Dose Volume
of
Identification (kunoles/kg) (mom) ( moles/mL) (1119/ML) (MDkg) Males
I/ Saline control 0 0 0 0 5 14
2/ Ghrelin 75 0.2486 15 0.0497 5 14
3/ GHRP-6 75 0.0655 15 0.0131 5 14
4/ Ipamorelin 75 0.0562 15 0.0113 5 14
5/ RC-1139 acetate 75 0.0523 15 0.0105 5 14
a Doses of Ipa norel rr .aid RC-1139 were corrected for their respective
purity
b Both compounds were co-administered via a single formulation containing the
appropriate amount of each
compound and dosed as a single injection.
Treatment Procedure:
Dosing commenced on consecutive days with approximately equal numbers of
animals
from each group being dosed on each day. The animals were food deprived
overnight prior to
treatment. Prior to dosing, the animals were water deprived. The
test/reference/positive control
articles were administered by intravenous injection into the tail vein using a
syringe and
appropriate gauge needle. The dose volume was 5 mL/kg and the actual dose
administered was
based on the most recent practical body weight of each animal.
Approximately 30 minutes following dosing with the test/reference or positive
control
article, all animals received 3 mL of activated charcoal by oral gavage,
followed by a 20-minute
period during which the animals were food and water deprived.
At the end of the observation period, the rats were euthanized and the
abdominal cavity
was opened and the stomach and intestines were removed. The presence or
absence of charcoal
in the stomach was documented. The stomachs were weighed (with and without
contents) and
this was recorded to give an indication of gastric emptying. The intestines
were opened and
extended to their full length. The charcoal was located and the distances from
the pyloric
sphincter to the most proximal and distal traces of charcoal were measured and
recorded, as well
as the total distance from the pyloric sphincter to the cecum (all distances
were measured in
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mm). In addition to the stomachs weights (with and without contents) the
distance traveled by
the charcoal as a percentage of the total length of the small intestine was
recorded to give an
indication of the gastric emptying. Any abnormal or unusual clinical signs
noted during the 20-
minute observation period were recorded.
Results
At a single intravenous dose of 75 moles/kg, ghrelin and the three ghrelin
mimetics
tested in this study (ipamorelin, GHRP-6, and RC-1 139 acetate) displayed
disparate effects on
gastric emptying and intestinal transit in the male albino rat when
administered independently.
Only ipamorelin displayed similar prokinetic effects to ghrelin on gastric
emptying and both
measurements of intestinal transit (proximal and distal distances traveled by
the charcoal from
the pyloric sphincter). Ghrelin, GHRP-6, and ipamorelin resulted in gastric
emptying by one of
the two measures (proximal distance traveled by the charcoal from the pyloric
sphincter) of
intestinal transit. See Figures 9, 10 and 11.
EXAMPLE 10. Efficacy of ipamorelin for the treatment of postoperative ileus in
rats
The objective of this study was to investigate whether ipamorelin would
accelerate
colonic transit in a rat model of POI. To perform this assessment both single
dose and multiple
dose efficacy were evaluated.
Materials and Methods
Animals: Adult male Sprague-Dawley rats with indwelling catheters implanted in
the
right jugular vein were obtained from Charles River (Wilmington, MA). The
initial body weight
of the animals was 250-270 g. The catheters were maintained patent during the
acclimation and
were used for the dosing of ipamorelin or vehicle. An additional group of
control rats, not
subjected to surgery and drug or vehicle treatment, were purchased with an
indwelling catheter
implanted into the proximal colon (1-2 cm from the cecum) used for infusion of
a dye marker
measuring colonic transit. All rats were single-housed under controlled
conditions (25 C, 12 h
light/dark cycle) with free access to food and water. An acclimation period of
at least one week
was allowed prior to the experiments.
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Induction ofpost-operative ileus (POI): POI was induced by a surgical
procedure described as
"running of the bowel" (Kaffet al., 1998). Specifically, rats were
anesthetized with isoflurane
(2-3%) inhalation, the abdomen was shaved, disinfected and a midline incision
was made to
expose the viscera. The small intestine and the cecum were exteriorized and
inspected for 5 min
using cotton applicators soaked in sterile saline. After completing the
inspection, the intestine
was covered with gauze soaked in saline and the abdomen remained open for
additional 10 min.
To study colonic transit, 200 l of a non-absorbable dye marker (trypan blue
in saline) was
injected into the proximal colon (1 cm distal to the cecum). The incision was
then closed with
silk sutures. The whole procedure lasted 25-30 min. Surgeries were always
performed at 6:00-
8:00 AM and the animals received ipamorelin or vehicle treatment during the
light phase of the
light/dark cycle.
Measurement of colonic transit time: Prior to the experiments, the rats were
fasted for 20-22 h
with free access to water. At the end of the surgical procedure the rats
received intracolonic
injection of the dye marker. Following the surgery the rats were placed in
clean home cages
supplied with pre-weighed food (Purina rat chow) and water. Colonic transit
time was evaluated
as the period between the end of surgery and the appearance of dye in the
fecal pellet. A naive rat
not subjected to surgery and drug or vehicle treatment was studied on each
experimental day
together with the rats with POI. The naive rats were equipped with colonic
catheters used to
infuse the dye marker into the colon following a 20-22 h fasting. The data
collected from these
animals served as a reference to healthy controls. In previous studies rats
with POI showed a
significant delay in colonic transit times compared to naive animals (Zittel
et al., 1998;
Greenwood-Van Meerveld, unpublished data).
Cumulative fecal output, food intake and body weight: Fecal pellets were
counted and weighed
at 3-h intervals and 12-h intervals during the first 48 post-surgery (see
experimental design). The
cumulative fecal output was evaluated by adding the number of pellets
throughout a 48-h post-
surgical period. Food intake was recorded at 3-h interval or 12-h intervals
according to the
experimental design and was normalized as g/IOOg body weight. The cumulative
food intake was
calculated for 48 h post-surgery in both series of experiments. Body weight
was measured daily
at 8:00-9:00 AM before fasting the animals, on the day of experiment before
the surgery and at
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24 h and 48 h post-surgery. Changes in body weight are expressed as body
weight gain
compared to the weight of the fasted animal taken before the surgery.
Test and control articles: The test compound ipamorelin (free base) was
converted to the
diacetate salt by mixing with 2 molar equivalents of glacial acetic acid.
Stock solutions of 0.5
mg/ml were prepared daily in sterile saline plus glacial acetic acid (0.1 l
per ml) to bring
ipamorelin into solution (pH 3-4). Then the solution was titrated with NaOH to
pH 7.0-7.2.
Additional dilutions were made in saline. Sterile saline was used in the
vehicle control
experiments. The positive control [D-Lys3]-GHRP-6 was purchased from Sigma-
Aldrich (St.
Louis, MO) and dissolved in sterile saline. Both the test and control articles
were administered as
a bolus i.v. infusion via the jugular catheter at a volume of 0.2 ml /100g
body weight.
Data and Statistical Analysis: The data expressed as the mean SEM for each
group.
Differences between groups were assessed for statistical significance by
Student's T test, as well
as by one-way or two-way ANOVA followed by Dunnett's or Bonferroni's test for
multiple
comparison where appropriate. A level of p < 0.05 was considered significant.
Additionally, the
data for the effects of multiple dosing were evaluated using linear regression
analysis to
determine significant differences between the slopes of the lines between
treatments.
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Experimental Design:
Experimental Series 1: Determine the acute effects induced by a single dose of
ipamorelin in a
rat model of POI.
= rats acclimated to the facility for 7 days; patency of catheters maintained
= day 0: rats weighed and fasted at 8:00-9:00 AM
= day 1: at 6:00-8:00 AM "running of the bowel" surgery under isoflurane
anesthesia
dye infused in to the proximal colon at end of surgery
single-dose treatment with ipamorelin or vehicle
observation in home cage (time to first fecal pellet; fecal output and food
intake. at 3, 6, 9, and 12 h post-surgery)
= day 2: 7:00-8:00 AM body weight, fecal output, food intake at 24-h post-
surgery
= day 3: 7:00-8:00 AM body weight, fecal output, food intake at 48-h post-
surgery
. euthanized with overdose of isoflurane
Naive rats were fasted but not subjected to surgery. Body weight, colonic
transit, fecal
pellet output and food intake were measured at the same time points as in rats
with POI.
Groups (single dose treatment):
POI + vehicle i.v.) n = 12
POI + ipamorelin 0.1 mg/kg (i.v.) n= 9
POI + ipamorelin 1 mg/kg (i.v.) n=10
POI + GHRP-6 20 g/kg (i.v.) n= 8
Naive (no surgery, no drug) n= 14
Experimental Series 2: Determine the efficacy of multiple doses of ipamorelin
in a rat model of
POI.
= rats acclimated to the facility for 7 days; patency of catheters maintained
= day 0: rats weighed and fasted at 8:00-9:00 AM
= day 1: at 6:00-8:00 AM "running of the bowel" surgery under isoflurane
anesthesia
dye infused in to the proximal colon at end of surgery
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multiple dosing of ipamorelin or vehicle (1St dose at end of surgery, 2 d, 3rd
and 4th dose at 3-h intervals)
observation in home cage (time to first fecal pellet, fecal output, food
intake at 3, 6, 9 and 12 h post-surgery)
= day 2: 7:00-8:00 AM body weight at 24-h post surgery
multiple dosing of ipamorelin or vehicle (1St dose after measuring body
weight, 2"d, 3rd and 4th dose at 3-h intervals)
observation in home cage (fecal output, food intake at 24, 27, 30, 33 and
36 h post-surgery)
= day 3: 7:00-8:00 AM body weight, fecal output, food intake at 48-h post
surgery
euthanasia with isoflurane overdose
Naive rats were fasted but not subjected to surgery. Body weight, colonic
transit, fecal
pellet output and food intake were measured at the same time points as in rats
with POI. Note
that the naive animals remained in their home cage and were not handled in
contrast to the rats
with POI, which were handled multiple times during the dosing of ipamorelin or
vehicle.
Groups (multiple dosing):
POI + vehicle (i.v.) n = 8
POI + ipamorelin 0.01 mg/kg (i.v.) n = 8
POI + ipamorelin 0.1 mg/kg (i.v.) n = 8
POI + ipamorelin 1 mg/kg (i.v.) n=7
Naive (no surgery, no drug) n= 8
Results
POI in the rat: Effect of abdominal surgery on colonic transit time, fecal
pellet output, food
intake and body weight.
A comparison between rats subjected to "running of the bowel "surgery and
naive rats
demonstrated that surgery results in the development of POI characterized as a
delay in colonic
transit (Fig. 12A), a decrease in fecal pellet output (Fig. 12 B), decreased
food intake (Fig. 12 C)
and body weight gain (Fig. 12 D).
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The rat model of POI. (A) Colonic transit time, measured as the time to the
first marked
fecal pellet, is significantly delayed following surgery compared to naive
rats. (B) The
cumulative fecal pellet output at 24 h and 48 h post-surgery is reduced
compared to naive rats
(C) Cumulative food intake is significantly decreased at 24 h and 48 h post
surgery compared to
naive rats. (D) Body weight gain is reduced following surgery compared to
naive rats. Data are
mean SEM from 12 rats with POI and 14 naive rats. Significance of the
differences between
rats subjected to surgery and naive rats was tested using Student t- test: *
p<0.05, ** p<0.01,
p<0.001.
Experimental series 1: Determine the acute effects induced by a single dose
treatment
with ipamorelin in a rat model of POI.
Experiments were performed in rats with POI to investigate the efficacy of a
single-dose
treatment with 0.1 mg/kg or 1 mg/kg ipamorelin. Ipamorelin or the vehicle was
administered via
i.v. infusion following the end of the surgery. The time to the first fecal
pellet (Fig. 13), as well
as cumulative fecal pellet output (Fig. 14), food intake (Fig. 15) and body
weight gain (Fig. 16)
were measured during the first 48 h post-surgery and the efficacy of
ipamorelin was evaluated by
comparing the effects of ipamorelin to the effect of the vehicle. In addition,
the effect of 20 g
GHPR-6, an agonist of GRLN, i.e., GHS-R,,, was used as a positive control
(Davenport et al.,
2005). The results presented in Fig. 13 demonstrate that a single post-
surgical dose of 1 mg/kg
ipamorelin or 20 gg GHRP-6 significantly decreased the colonic transit time.
However, neither ipamorelin nor GHRP-6 had a significant effect on fecal
pellet output
(Fig. 14) food intake (Fig. 15) or body weight gain (Fig. 16) during the first
48 h post-surgery.
In summary, the results obtained in Experimental series 1 demonstrate that a
single-dose
treatment with 1 mg/kg ipamorelin given at the end of surgery decreased the
time to the first
bowel movement, but did not induce effects on fecal output and food intake
during the 48-h
course of recovery in rats with POI. However, these results are consistent
with those expected
based on the reported half-life of ipamorelin in the rat of 30-60 minutes.
(Johansen et. al., 1998).
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Experimental series 2: Determine the efficacy of multiple doses of ipamorelin
in a rat
model of POI.
The dose-response effect of multiple doses of ipamorelin (0.01, 0.1 or 1 mg/kg
i.v.) was
investigated in rats with POI. The results showed that the multiple dosing of
0.1 mg/kg or 1
mg/kg ipamorelin caused a significant acceleration of colonic transit compared
to the effect of
the vehicle (Fig. 17).
The effects of multiple doses of ipamorelin on fecal pellet output are
presented in Fig. 18.
Multiple doses of ipamorelin induced an increase in cumulative fecal pellet
output compared to
the vehicle. The effect reached significance at doses of 0.1 mg/kg or 1 mg/kg
(Fig. 18). Fecal
output increased at a higher rate (lower 1/slope values) in the rats receiving
ipamorelin at doses
of 0.1 or 1mg/kg i.v. compared to rats treated with vehicle. At a dose of 0.01
mg/kg, ipamorelin
showed no significant effect. In addition, ipamorelin induced an increase food
intake (Figs. 19).
The increase in food intake induced by the higher doses of ipamorelin was
associated with an
increase in body weight. As illustrated in Fig. 20, the rats receiving the
highest dose of 1 mg/kg
ipamorelin, administered according to the multiple dosing paradigm, gained
significantly more
body weight during the first 48 h after surgery compared to the rats treated
with the vehicle.
Conclusion
Overall, the results demonstrate that multiple i.v. dosing of ipamorelin in
rats during the
first 48-h after surgery improves colonic transit and food intake and
increases body weight gain
suggesting that post-surgical i.v. infusions of ipamorelin may ameliorate the
symptoms in
patients with POI.
Having now fully provided the instant disclosure, it will be appreciated by
those skilled
in the art that the same can be performed within a wide range of equivalent
parameters,
concentrations, and conditions without departing from the spirit and scope of
the disclosure and
without undue experimentation. Further, while the disclosure has been
described in connection
with specific embodiments thereof, it will be understood that it is capable of
further
modifications. This application is intended to cover any variations, uses, or
adaptations of the
disclosure following, in general, the disclosed principles and including such
departures from the
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disclosure as come within known or customary practice within the art to which
the disclosure
pertains and as may be applied to the essential features hereinbefore set
forth.
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REFERENCES
Asakawa A, Inui A, Kaga T, Yuzuriha H, Nagata T, Ueno N, et al. Ghrelin is an
appetitestimulatory signal from stomach with structural resemblance to
motilin.
Gastroenterology, 2001 Feb;120(2):337-45.
Masuda Y, Tanaka T, Inomata N, Ohnuma N, Tanaka S, Itoh Z, et al. Ghrelin
stimulates
gastric acid secretion and motility in rats. Biochem Biophys Res Commun 2000
Oct
5;276(3):905-8.
Murphy DB, Sutton JA, Prescott L, Murphy MB, Opioid-induced Delay in Gastric
Emptying: A Peripheral Mechanism in Humans. Anesthesiology 1997 Oct; (4)765-
70.
Peeters TL. Central and peripheral mechanisms by which ghrelin regulates gut
motility. J
Physiol Pharmacol 2003 Dec;54 Suppl 4:95-103.
Poitras P, Polvino WJ, Rocheleau B. Gastrokinetic effect of ghrelin analog RC-
1139 in
the rat. Effect on post-operative and on morphine induced ileus. Peptides.
2005 Sep;26(9):1598-
601.
Tack J, Depoortere I, Bisschops R, Delporte C, Coulie B, Meulemans A, et al.
Influence
of ghrelin on interdigestive gastrointestinal motility in humans. Gut 2006
Mar;55(3):327-33.
Trudel L, Tomasetto C, Rio MC, Bouin M, Plourde V, Eberling P, et al.
Ghrelin/motilinrelated peptide is a potent prokinetic to reverse gastric
postoperative ileus in rat.
AmJ
Physiol Gastrointest Liver Physiol 2002 Jun;282(6):G948-G952.
Yuan CS, Foss JF, O'Connor M, Roizen MF, Moss J. Effects of low-dose morphine
on
gastric emptying in healthy volunteers. J Clin Pharmacol. 1998 Nov;38(11):1017-
20.
