Note : Les descriptions sont présentées dans la langue officielle dans laquelle elles ont été soumises.
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The u~e o~ Medicaments Cont~;n;ng Interferon-~
Description
The present invention relates to the use of inter-
feron-~ for the preparation of medicaments for the ad-
juvant systemic intramuscular or subcutaneous therapy
in low dosage of diseases induced by humanopathogenic
papilloma virus.
Interferons (IFNs) belong to the group of regulatory
proteins of the immunological system, the cytokins, and
have an antiviral, antiproliferative, cell-differen-
tiating and immunomodulating effect. Based on their an-
tigenic properties, we differentiate between 3 IFN
families: IFN-~, IFN-$ and IFN-~. Among the three IFN
families, IFN-y displays a number of peculiarities. For
this reason, it is also called Type II IFN as opposed
to the other two Type I IFNs. While the development of
Type I IFNs is initiated by virus and two-stranded RNA,
mitogens and specific antigens are the inductors for
IFN-X. Accordingly, the main biological activity of the
Type I IFNs is antiviral, whereas IFN-X primarily acts
as an immunoregulatory substance. In addition, there
are a number of other differences between the two IFN
types, e.g. with regard to acid stability, gene local-
isation and receptor binding (Came and Carter, 1984;
Baron et al., 1991; Hundgen and von Eick, 1991).
In addition to IFNs obtained from human cells (natural
IFNs), IFNs produced by genetic engineering with the
aid of host cells (recombinant IFNs) have been used in-
creasingly for the therapy of human diseases since the
beginning of the 1980s. Methods for obt~'nlng natural
and recombinant IFNs are described in various publica-
tions, among those many patent applications (surveys in
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Came and Carter, 1984; Finter and Oldham, 1985; Tabor,
1986).
Due to the fact that recombinant IFNs are produced in
host cells, they must be present in high purity (c99 ~)
when used for human therapy so as to ensure that the
medicaments contain no substances which originate from
other species and may therefore be toxic. Natural IFN
preparations which, as a rule, are not subjected to se-
vere purification usually also contain other cytokins
(Came and Carter, 1984; Finter and Oldham, 198~)
With regard to pharmacokinetics, IFN-~ has special
properties. While intramuscular (i.m.) or subcutaneous
(s.c.) administrations of IFN-a or INF-~ can still be
measured in the serum at a dosage of 1 x 106 interna-
tional units (I.U.), IFN-~ when administered the same
way is not detectable in the serum below a dosage of 3
- 9 x 106 I.U. From this fact, one can conclude a high
tissue affinity of IFN-$ to its application site
(Koyama, 1983; Finter and Oldham, 1985; Hundgen and von
Eick, 1991; Wills, 1990, Fierlbeck (not published)).
Therefore, IFN-$ is highly suitable for local therapy
(Hundgen and von Eick, 1991). Systemic treatment with
IFN-~ is thus often carried out intravenously (i.v )
(instructions for use of Fiblaferon~ of Rentschler,
Laupheim, Germany; instructions for u-se of Feron~ of
Toray, Tokyo, Japan). In case o~ systemic i.m. applica-
tion, natural IFN-~ for therapeutic purposes is gener-
ally used in dosages of 2 2 x 106 I.U (instructions
for use of Frone~ of Serono, Rome, Italy). Treatment
with natural IFN-~ administered by the systemic s.c.
route has so far been carried out in individual cases
only; therefore, no general therapy recommendations can
be given for this type of a~plication.
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In the studies carried out so far with the objective of
determining the dosage to be used, recombinant IFN-
~was administered by the i.v., i.m. and s.c. routes. In
case of multiple sclerosis, the recommended and thera-
peutically effective daily dosage is 8 x 105 I.U. i.m.
or 6 x 106 I.U. s.c., respectively (instructions for
use of Betaseron~ of Berlex, Richmond, CA., information
to the press of Biogen, Cambridge, Mass.). In case o~
the systemic i.m. or s.c. application for treating
various other diseases such as chronic myeloid leukae-
mia (Aulitzky et al., 1993), hepatitis B and C (Irving
Fox, Biogen, Cambridge, Mass., personal information)
and condylomata acuminata (Gerd Gross, Dermatology De-
partment of the Hamburg University, personal informa-
tion; Robert Gerety, Biogen, Cambridge, Mass, personal
in~ormation), the lowest daily dosage was 3 x lo6 I.U.
Accordingly, there have been no therapy recommendations
for either natural or recombinant IFN-~ to use smaller
daily dosages than 2 x 106 I.U. in case of systemic
i.m. or s.c. application.
Humanopathogenic papilloma virus (HPV) represent a he-
terogeneous group of DNA virus which may cause a number
of epithelial tumours (warts and papillomae). At pres-
ent, over 70 HPV types are ~nown. Among the most widely
known clinical appearances are common warts ( verrucae
vulgares), thorn warts (verrucae plantares) and level
juvenile warts (verrucae planae juveniles), the pointed
condylomae ( condylomata acuminata) and HP.V associated
dysplasia of the cervix (cervicale intraepitheliale
neoplasia, condylomata plana) in the genital area
(Kirby and Corey, 1987; Cobb, 1990; Gross et al., 1990;
Lowy et al., 1994. Genital HPV diseases are generally
spread through sexual intercourse. In the U. K., condy-
lomata acuminata (CA) is the most ~requent virus dis-
ease spread by sexual activity (Lancet editorial,
1991). According to statistical surveys of the American
4 2l 99l54
Center for Disease Control (CDC), CA occurs three times
more frequently than genital herpes~ Thus, approx. one
million patients suf~ering ~rom CA sought treatment
with local practitioners in the United States in 1983
(Kirby and Corey, 1987).
Deficiencies in cell-communicated immunity promote HPV
infections and are often found in patients with recur-
ring HPV diseases (Kirby and Corey, 1987; Cobb, 1990;
Lancet editorial, 1991). In otherwise healthy persons,
the spontaneous rate o~ remission o~ HPV diseases dur-
ing the first year after infection is 20 to 50 ~. It is
therefore not surprising that placebo effects play an
important role in the therapy of HPV diseases (Kirby,
1988, Cobb, 1990). Therefore, an unambiguous scientific
proof of effectiveness for a certain method of treat-
ment is only possible by randomised, placebo-controlled
studies.
Therapy o~ HPV diseases mainly comprises surgical meas-
ures such as curettage, electrocauterisation, cryogenic
and laser surgery as well as touching the sites with
keratolytic and caustic substances such as salicylic
acid, podophyllin, trichloroacetic acid and 5-fluoro-
uracil (Kirby and Corey, 1987; Cobb, 1990; Gross et
al., 1990; Cirelli and Tyring, 1994). On the whole,
however, the results of these therapies are not very
satisfactory, since HPV diseases often recur. In case
of primary CA, a recidivation rate of 20 to 40 ~ must
be expected within a period of three months (Jensen,
1985). As a rule, the rate o~ recidivation even exceeds
50 ~ for patients with prolonged and/or recurring CA
(Cirelli and Tyring, 1994).
Based on their antiviral, antiproliferative and immuno-
modulating properties, the IFNs seem to be suitable
substances for the therapy of HPV diseases (Cobb,
_ _ . .. , . . , _ . . . .. . .
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1990). Therefore, it is not surprising that IFNs have
been used for treating such diseases as early as the
1970s. They were administered systemically, topically
on an ointment basis or locally by intralesional injec-
tion. Surveys about the numerous studies conducted
since are given by Kirby and Corey, 1987; Gross et al.,
1990; Cirelli and Tyring, 1994.
Even though the effectiveness of IFNs for the local
therapy of CA is undisputed, it is of little signifi-
cance for practical application, since this form of
treatment does not have any advantages in comparison
with other conventional therapy methods. Untreated
warts either do not respond at all or only marginally.
In addition, intralesional injections are very painful
(Kirby, 1988; Gross et al., 1990). Only small warts re-
spond to topical IFN preparations (Brzoska, 1994). How-
ever, this form of application is not suitable for CA
in the anal area or large-scale lesions of the skin or
mucous membranes.
The investigations conducted so far on the systemic
monotherapy of CA produced inconsistent results. Pla-
cebo-controlled double-blind studies with s.c. applied
recombinant IFN-a in a dosage of 1.5, 3 and 9 x 106
I.U. did not confirm the positive results of open stud-
ies (Condylomata International Collaborative Study
Group 1991, 1993). So far, only a few studies of which
two had a placebo-controlled design were conducted with
natural IFN-$. In both studies, a daily dosage of 2 x
106 I.U. i.m. was used. The side effects of this ther-
apy were negligible. In the verum-groups, a healing of
CA was confirmed in noticeably more patients than in
the placebo groups (Schonfeld et al., 1984; Costa et
al., 1988). When viewing these positive results, how-
ever, it should be noted that only patients who were
suffering from primary CA from three weeks to six
6 2~ 991 54
months were included in the study, but not patients
with recurring older CA who, as experience has shown,
respond less well to the treatment with IFNs (Gross et
al, 1990; Fierlbeck et al. 1991; Cirelli and Tyring,
1994). In an open study on patients with old CA, for
example, complete remission was not achieved in a sin-
gle case (Piccoli et al., 1989). So far, results on re-
combinant IFN-~ are not available. As far as IFN-~ is
concerned, two placebo-controlled studies confirmed ef-
fectiveness against CA ~Gross et al., 1991). One of the
disadvantages of a systemic monotherapy with IFNs, how-
ever, is the sometimes long duration o~ the treatment
and the considerable time lapse until the symptoms on
the skin disappear. In addition, this form of therapy
is successful in only half of the patients. The major-
ity of dermatologists, therefore, consider the systemic
application of IFNs for the treatment of CA unsuitable
(Kirby, 1988).
In our own double-blind, placebo-controlled study we
have adjuvantly used recombinant IFN-$ in the systemic
therapy of CA in order to reduce the rate of recidiva-
tion. Treatment with IFN-$ started within one week of
surgical removal of the CA. As opposed to previous
treatment methods, the daily dosage was only 1 x 106
I . U . ~m; n; stration was carried out s.c. under the ab-
dominal skin on five consecutive days and repeated af-
ter an intermission of three weeks (total dosage 10 x
106 I.U.). Only patients with recurring CA were ac-
cepted. Within three months after surgical removal of
the CA, the rate of recidivation was determlned for
both groups. Even an intermediate evaluation of the
study after the e~m;n~tion of 25 patients suitable for
analysis showed a statistically significant difference
between the two groups, i.e. the recidivation rate of
CA could be reduced noticeably by the ad~uvant therapy
with IFN-$ administered system-ically s.c. On the basis
~ ' 7 2~99154
of the previous assumption that the effect of 1 x 106
I.U. o~ IFN-~ after s.c application is by no means
sufficient, this result could not be expected. It was
particularly surprising that patients with recurring CA
responded to this low dosage.
-
In addition to the therapeutic regimen described above,other treatment schemes may also be used for the adju-
vant systemic therapy of HPV diseases with IFN-~. In
such cases, the details may be as follows:
dosage 0.5 - 1.5 x 106 I.U.,
applied i.m. or s.c.,
application ~requency 1 - 7 times per week, and
duration of therapy 1 day - 3 months.
The formulations for i.m. or s.c. injection are pre-
pared in the form of sterile, aqueous preparations o~
the active ingredient which are preferably isotonic
with the blood of the recipient. The dosage units pre-
pared for injection may be provided in individual small
sterile bottles, e.g. as lyophilisate in a quantity of,
for example, 0.5 x 106, 1.0 x 106 or 1.5 x 106 I.U.
based on the pure active ingredient IFN-$ as individual
dosage, the active ingredient being prepared for appli-
cation immediately before use by solving it in aqua ad
injectabilia. Physiologically compatible buffers are
considered as formulation buffer, e.g. 0.1 M sodium
phosphate with 0.05 M sodium chloride. A suitable car-
rier substance for the lyophilisate, for example, is
0.5 - 30 mg/ml human serum albumin based on the recon-
stituted solution
~ 219915~
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