US20230146264A1 - Treatment of Ascites - Google Patents
Treatment of Ascites Download PDFInfo
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- US20230146264A1 US20230146264A1 US17/831,556 US202217831556A US2023146264A1 US 20230146264 A1 US20230146264 A1 US 20230146264A1 US 202217831556 A US202217831556 A US 202217831556A US 2023146264 A1 US2023146264 A1 US 2023146264A1
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- terlipressin
- ascites
- continuous infusion
- patients
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- 206010003445 Ascites Diseases 0.000 title claims abstract description 48
- 238000011282 treatment Methods 0.000 title claims description 20
- 108010010056 Terlipressin Proteins 0.000 claims abstract description 46
- BENFXAYNYRLAIU-QSVFAHTRSA-N terlipressin Chemical compound NCCCC[C@@H](C(=O)NCC(N)=O)NC(=O)[C@@H]1CCCN1C(=O)[C@H]1NC(=O)[C@H](CC(N)=O)NC(=O)[C@H](CCC(N)=O)NC(=O)[C@H](CC=2C=CC=CC=2)NC(=O)[C@H](CC=2C=CC(O)=CC=2)NC(=O)[C@@H](NC(=O)CNC(=O)CNC(=O)CN)CSSC1 BENFXAYNYRLAIU-QSVFAHTRSA-N 0.000 claims abstract description 46
- 229960003813 terlipressin Drugs 0.000 claims abstract description 46
- 238000000034 method Methods 0.000 claims abstract description 42
- 238000001802 infusion Methods 0.000 claims abstract description 35
- 201000011200 hepatorenal syndrome Diseases 0.000 claims abstract description 24
- 239000011734 sodium Substances 0.000 claims description 14
- DGAQECJNVWCQMB-PUAWFVPOSA-M Ilexoside XXIX Chemical compound C[C@@H]1CC[C@@]2(CC[C@@]3(C(=CC[C@H]4[C@]3(CC[C@@H]5[C@@]4(CC[C@@H](C5(C)C)OS(=O)(=O)[O-])C)C)[C@@H]2[C@]1(C)O)C)C(=O)O[C@H]6[C@@H]([C@H]([C@@H]([C@H](O6)CO)O)O)O.[Na+] DGAQECJNVWCQMB-PUAWFVPOSA-M 0.000 claims description 12
- 229910052708 sodium Inorganic materials 0.000 claims description 12
- 208000019425 cirrhosis of liver Diseases 0.000 claims description 11
- 239000002934 diuretic Substances 0.000 claims description 10
- 150000003839 salts Chemical class 0.000 claims description 10
- 229940030606 diuretics Drugs 0.000 claims description 9
- 230000009467 reduction Effects 0.000 claims description 9
- 230000002485 urinary effect Effects 0.000 claims description 8
- 230000029142 excretion Effects 0.000 claims description 7
- 206010021036 Hyponatraemia Diseases 0.000 claims description 5
- 210000003567 ascitic fluid Anatomy 0.000 claims description 5
- 229940079593 drug Drugs 0.000 abstract description 5
- 239000003814 drug Substances 0.000 abstract description 5
- 108090000765 processed proteins & peptides Proteins 0.000 abstract description 2
- DDRJAANPRJIHGJ-UHFFFAOYSA-N creatinine Chemical compound CN1CC(=O)NC1=N DDRJAANPRJIHGJ-UHFFFAOYSA-N 0.000 description 16
- 210000002966 serum Anatomy 0.000 description 16
- 238000002560 therapeutic procedure Methods 0.000 description 16
- XSQUKJJJFZCRTK-UHFFFAOYSA-N Urea Chemical compound NC(N)=O XSQUKJJJFZCRTK-UHFFFAOYSA-N 0.000 description 9
- 239000004202 carbamide Substances 0.000 description 9
- 230000006872 improvement Effects 0.000 description 9
- 230000008859 change Effects 0.000 description 8
- 229940109239 creatinine Drugs 0.000 description 8
- 230000000694 effects Effects 0.000 description 8
- 239000012530 fluid Substances 0.000 description 7
- 238000001990 intravenous administration Methods 0.000 description 7
- 230000003907 kidney function Effects 0.000 description 7
- 238000002347 injection Methods 0.000 description 5
- 239000007924 injection Substances 0.000 description 5
- 208000005176 Hepatitis C Diseases 0.000 description 4
- 208000037265 diseases, disorders, signs and symptoms Diseases 0.000 description 4
- 206010016654 Fibrosis Diseases 0.000 description 3
- 230000037396 body weight Effects 0.000 description 3
- 230000007882 cirrhosis Effects 0.000 description 3
- 230000003247 decreasing effect Effects 0.000 description 3
- 201000010099 disease Diseases 0.000 description 3
- 230000003862 health status Effects 0.000 description 3
- 230000036514 plasma sodium concentration Effects 0.000 description 3
- 206010057573 Chronic hepatic failure Diseases 0.000 description 2
- 208000010334 End Stage Liver Disease Diseases 0.000 description 2
- 206010062070 Peritonitis bacterial Diseases 0.000 description 2
- 238000009825 accumulation Methods 0.000 description 2
- 229940124977 antiviral medication Drugs 0.000 description 2
- 206010003119 arrhythmia Diseases 0.000 description 2
- 208000011444 chronic liver failure Diseases 0.000 description 2
- 201000001320 Atherosclerosis Diseases 0.000 description 1
- 206010052895 Coronary artery insufficiency Diseases 0.000 description 1
- 206010020772 Hypertension Diseases 0.000 description 1
- 206010022657 Intestinal infarction Diseases 0.000 description 1
- 206010030172 Oesophageal haemorrhage Diseases 0.000 description 1
- 208000001647 Renal Insufficiency Diseases 0.000 description 1
- 210000000683 abdominal cavity Anatomy 0.000 description 1
- KBZOIRJILGZLEJ-LGYYRGKSSA-N argipressin Chemical compound C([C@H]1C(=O)N[C@@H](CCC(N)=O)C(=O)N[C@@H](CC(N)=O)C(=O)N[C@@H](CSSC[C@@H](C(N[C@@H](CC=2C=CC(O)=CC=2)C(=O)N1)=O)N)C(=O)N1[C@@H](CCC1)C(=O)N[C@@H](CCCN=C(N)N)C(=O)NCC(N)=O)C1=CC=CC=C1 KBZOIRJILGZLEJ-LGYYRGKSSA-N 0.000 description 1
- 230000006793 arrhythmia Effects 0.000 description 1
- 208000006673 asthma Diseases 0.000 description 1
- 230000008901 benefit Effects 0.000 description 1
- 210000004369 blood Anatomy 0.000 description 1
- 239000008280 blood Substances 0.000 description 1
- 230000005794 circulatory dysfunction Effects 0.000 description 1
- 238000003745 diagnosis Methods 0.000 description 1
- 230000001882 diuretic effect Effects 0.000 description 1
- 238000002651 drug therapy Methods 0.000 description 1
- 230000001747 exhibiting effect Effects 0.000 description 1
- ZZUFCTLCJUWOSV-UHFFFAOYSA-N furosemide Chemical compound C1=C(Cl)C(S(=O)(=O)N)=CC(C(O)=O)=C1NCC1=CC=CO1 ZZUFCTLCJUWOSV-UHFFFAOYSA-N 0.000 description 1
- 229960003883 furosemide Drugs 0.000 description 1
- 230000036541 health Effects 0.000 description 1
- 208000007386 hepatic encephalopathy Diseases 0.000 description 1
- 230000000977 initiatory effect Effects 0.000 description 1
- 201000006370 kidney failure Diseases 0.000 description 1
- 230000002045 lasting effect Effects 0.000 description 1
- 230000002503 metabolic effect Effects 0.000 description 1
- 238000012986 modification Methods 0.000 description 1
- 230000004048 modification Effects 0.000 description 1
- 208000010125 myocardial infarction Diseases 0.000 description 1
- 239000000047 product Substances 0.000 description 1
- 239000000243 solution Substances 0.000 description 1
- 231100000419 toxicity Toxicity 0.000 description 1
- 230000001988 toxicity Effects 0.000 description 1
- 238000011269 treatment regimen Methods 0.000 description 1
- 210000002700 urine Anatomy 0.000 description 1
- 239000005526 vasoconstrictor agent Substances 0.000 description 1
- 229960003726 vasopressin Drugs 0.000 description 1
- 239000002699 waste material Substances 0.000 description 1
Classifications
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K38/00—Medicinal preparations containing peptides
- A61K38/04—Peptides having up to 20 amino acids in a fully defined sequence; Derivatives thereof
- A61K38/08—Peptides having 5 to 11 amino acids
- A61K38/095—Oxytocins; Vasopressins; Related peptides
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
- A61P1/00—Drugs for disorders of the alimentary tract or the digestive system
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
- A61P1/00—Drugs for disorders of the alimentary tract or the digestive system
- A61P1/16—Drugs for disorders of the alimentary tract or the digestive system for liver or gallbladder disorders, e.g. hepatoprotective agents, cholagogues, litholytics
Definitions
- the disclosure is directed to a method for treating ascites patients by administering the peptide drug terlipressin.
- the inventors have identified a need in the art for a method to treat ascites patients on an outpatient basis and potentially avoid or delay the need for hospitalization due to HRS or other life-threatening complications.
- the disclosure is directed to a method for treating a patient diagnosed with ascites due to liver cirrhosis.
- the method including administering terlipressin or salt thereof as a continuous infusion.
- the condition of the patient may not have progressed to HRS.
- the disclosure is directed to a method for reducing the volume of ascitic fluid during a paracentesis procedure in an ascites patient.
- the method includes administering terlipressin or salt thereof as a continuous infusion.
- the disclosure is directed to a method for reducing the number of monthly paracentesis procedures in an ascites patient.
- the method includes administering terlipressin or salt thereof as a continuous infusion.
- the disclosure is directed to a method for improving renal function in an ascites patient.
- the method includes administering terlipressin or salt thereof as a continuous infusion.
- the improvement in renal function includes one or more of the following: a reduction in serum creatinine concentration, an increase in plasma sodium concentration, an increase in urinary sodium excretion, and a decrease in urea concentration in serum.
- the disclosure is also directed to a method for correcting hyponatremia in an ascites patient.
- the method includes administering to the patient terlipressin or salt thereof as a continuous infusion.
- the disclosure is directed to a method for improving the health status of the ascites patient with liver cirrhosis due to hepatitis C.
- the method includes method comprising administering a hepatitis C antiviral medication in combination with administering terlipressin or salt thereof as a continuous infusion.
- the disclosure is directed to a method of improving the Model for End-Stage Liver Disease (MELD) score of an ascites patient.
- the method includes administering terlipressin or salt thereof with a continuous infusion.
- the condition of the patient may not have progressed to HRS.
- the terlipressin dose may range from about 1.0 mg to about 12.0 mg per day, and the terlipressin dose may be escalated over the course of the therapy.
- the terlipressin may be administered for a time period of about 1 day to about 12 months. Further, the continuous terlipressin may be administered with an ambulatory infusion pump.
- Terlipressin is a synthetic vasopressin that is approved in many countries outside of the United States to treat the life-threatening complications of cirrhosis, including hepatorenal syndrome (HRS) and esophageal bleeding (EVB). Its use is limited to the hospital setting due to its short half-life (26 minutes) (Nilsson, et al., 1990), necessitating its administration as an intravenous bolus usually every 4 to 6 hours. Additionally, terlipressin can cause side effects in up to 40% of patients. Severe side effects — including myocardial infarction, arrhythmia and intestinal infarction — can require discontinuation of treatment in up to 10% of the patients (Angeli, 2011). Indeed, due to the rapid vasoconstrictor properties, IV bolus dosed terlipressin must be used with caution in patients with severe asthma, severe hypertension, advanced atherosclerosis, cardiac dysrhythmias, and coronary insufficiency.
- the disclosure is directed to the administering terlipressin or a salt thereof for the treatment of patients suffering from ascites due to, for example, advanced liver cirrhosis.
- patients are typically non-hospitalized (or ambulatory) and may include patients whose condition has not progressed to type 2 HRS (ambulatory HRS patients) or type 1 HRS (requiring hospitalization).
- Treatment includes a continuous infusion of terlipressin by means of a pump device, typically a portable ambulatory pump, for a period of several hours, lasting up to days, weeks, or months.
- the treatment is effective at reducing or resolving ascites disease on, for most patients, an outpatient basis.
- Ambulatory pumps are commonly used to infuse parenteral drugs directly into the bloodstream via catheters to increase efficacy and/or decrease toxicity. This has been found to be safer than some approved terlipressin drug therapy that require the administration of terlipressin to hospitalized hepatorenal syndrome (HRS) patients and esophageal bleed (EVB) patients using slow bolus IV injections.
- HRS hospitalized hepatorenal syndrome
- EVB esophageal bleed
- terlipressin is administered continuously by a pump at a dosage rate of about 0.5 mg to about 20 mg every 24 hours, more particularly for example, about 1 mg to about 12 mg every 24 hours, more particularly for example, about 5 to about 15 mg every 24 hours, or for instance, about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, or 20 mg every 24 hours.
- Administration can continue for, typically, at least about one day and may continue for about 12 months or longer as necessary to bridge a patient until a transplant is available.
- the administration can continue for about 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, one week, two weeks, three weeks, one month, two months, three months, six months, 9 months or twelve months.
- the dose of terlipressin escalates over the course of the therapy.
- patients may begin therapy at 2 mg/day, and be increased to 3 mg/day or up to 12 mg/day over the course of treatment.
- the disclosure is directed to a method for treating a patient diagnosed with ascites due to liver cirrhosis.
- the method can improve renal function in an ascites patient and reduce the volume of ascitic fluid during paracentesis procedure in the patient.
- the method can be used for reducing the risk of spontaneous bacterial peritonitis, improving the Model for End-Stage Liver Disease (MELD) score of an ascites patient and/or correcting hyponatremia in an ascites patient.
- the method disclosed herein can be used in combination with hepatitis C antiviral medications to improve the health status of the ascites patient with liver cirrhosis due to hepatitis C.
- terlipressin or salt thereof is administered with a continuous infusion pump.
- the patient's ascites condition may not have progressed to hepatorenal syndrome.
- the determination of the presence, progression, or improvement of disease can be determined by measuring one or more of the following: serum creatinine concentration, plasma sodium concentration, urinary sodium excretion, and urea concentration in serum.
- an improvement in renal function that indicates an improvement in disease condition includes one or more of the following: a reduction in serum creatinine concentration, an increase in plasma sodium concentration, an increase in urinary sodium excretion, a decrease in urea concentration in serum of disease.
- continuous infusion pump (CIP) terlipressin represents a potentially life-saving solution for these seriously ill patients who are still ambulatory (have not yet been administered to the hospital for treatment) and have not developed type 1 or type 2 HRS.
- FIRS patients treated with continuous infusion terlipressin were evaluated for improvement in acsites. All six patients had diuretic intractable or refractory ascites (5 of 6 with hyponatremia). The patients were evaluated for the following parameters before, during and after treatment: number of paracentesis procedures per month, volume of ascites removed, weight, serum sodium, urinary sodium excretion, serum creatinine, serum urea, and whether diuretics were included in the treatment regimen. None of the six patients had a complete set of data for all parameters. The effect of continuous infusion terlipressin on each parameter is presented in Tables 1-7.
- the average number of monthly paracentesis procedures decreased from three prior to initiation of continuous infusion therapy to two during therapy, and the average monthly ascites fluid volume removed was reduced by 55%.
- Average body weight per patient a proxy for ascitic fluid accumulation in the abdominal cavity, decreased by 11% or 9 kg ( ⁇ 19.8 lbs).
- Plasma Na increased by 15% in patient #4 and by 19% in patient #6. Importantly, after the cessation of therapy, plasma sodium remained normal in patient #6 (data “after therapy” available for one of the two patients).
- the concentration of urea in patients' blood serum decreased in all patients by an overall average of 45%. This increase in urea clearance is indicative of improved renal function.
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- Health & Medical Sciences (AREA)
- Life Sciences & Earth Sciences (AREA)
- General Health & Medical Sciences (AREA)
- Pharmacology & Pharmacy (AREA)
- Animal Behavior & Ethology (AREA)
- Public Health (AREA)
- Medicinal Chemistry (AREA)
- Veterinary Medicine (AREA)
- Chemical & Material Sciences (AREA)
- Bioinformatics & Cheminformatics (AREA)
- Engineering & Computer Science (AREA)
- Gastroenterology & Hepatology (AREA)
- Organic Chemistry (AREA)
- Nuclear Medicine, Radiotherapy & Molecular Imaging (AREA)
- Chemical Kinetics & Catalysis (AREA)
- General Chemical & Material Sciences (AREA)
- Epidemiology (AREA)
- Proteomics, Peptides & Aminoacids (AREA)
- Immunology (AREA)
- Medicines That Contain Protein Lipid Enzymes And Other Medicines (AREA)
- Medicinal Preparation (AREA)
- Infusion, Injection, And Reservoir Apparatuses (AREA)
- Dermatology (AREA)
- Pharmaceuticals Containing Other Organic And Inorganic Compounds (AREA)
- Acyclic And Carbocyclic Compounds In Medicinal Compositions (AREA)
Abstract
Description
- This application is a continuation of U.S. patent application Ser. No. 15/198,050, filed Jun. 30, 2016, which claims the benefit of U.S. provisional patent application 62/321,558, filed Apr. 12, 2016, U.S. provisional patent application 62/267,510, filed Dec. 15, 2015, and U.S. provisional patent application 62/186,638, filed Jun. 30, 2015, each of which is incorporated by reference herein their entirety
- The disclosure is directed to a method for treating ascites patients by administering the peptide drug terlipressin.
- Ascites is a frequent and life-threatening complication of advanced liver cirrhosis with an expected 40% mortality rate within two years of diagnosis. To date the US FDA has not approved any therapies specifically to treat ascites, although a few drugs (e.g., diuretics) are being used off-label with limited and temporary efficacy. Studies have shown that intravenous (IV) injections of terlipressin every 4 to 6 hours in hospitalized patients with type 1 hepatorenal syndrome (HRS) can save their lives. FIRS is the beginning of renal failure and frequently occurs in patients with ascites that has become refractory to treatment with diuretics. Additionally, investigational studies have shown that IV injections of terlipressin every 4 to 6 hours in combination with diuretics may resolve refractory ascites in hospitalized patients and decrease the need for large volume paracentesis (ascites fluid withdrawal by needle). However these intermittent high-dose IV injections (typically 1 or 2 mg in a single dose) carry a high risk of side-effects. More recent studies with hospitalized HRS patients indicate that a continuous infusion of terlipressin can achieve similar efficacy to intermittent injections with a much better safety profile. However to date there have been no published studies of using a continuous low-dose infusion terlipressin to manage ascites in non-hospitalized patients with cirrhosis.
- Accordingly, the inventors have identified a need in the art for a method to treat ascites patients on an outpatient basis and potentially avoid or delay the need for hospitalization due to HRS or other life-threatening complications.
- In one aspect, the disclosure is directed to a method for treating a patient diagnosed with ascites due to liver cirrhosis. The method including administering terlipressin or salt thereof as a continuous infusion. The condition of the patient may not have progressed to HRS.
- In another aspect, the disclosure is directed to a method for reducing the volume of ascitic fluid during a paracentesis procedure in an ascites patient. The method includes administering terlipressin or salt thereof as a continuous infusion.
- In yet another aspect, the disclosure is directed to a method for reducing the number of monthly paracentesis procedures in an ascites patient. The method includes administering terlipressin or salt thereof as a continuous infusion.
- Still further, the disclosure is directed to a method for improving renal function in an ascites patient. The method includes administering terlipressin or salt thereof as a continuous infusion. In various aspects, the improvement in renal function includes one or more of the following: a reduction in serum creatinine concentration, an increase in plasma sodium concentration, an increase in urinary sodium excretion, and a decrease in urea concentration in serum.
- The disclosure is also directed to a method for correcting hyponatremia in an ascites patient. The method includes administering to the patient terlipressin or salt thereof as a continuous infusion.
- In a further aspect, the disclosure is directed to a method for improving the health status of the ascites patient with liver cirrhosis due to hepatitis C. The method includes method comprising administering a hepatitis C antiviral medication in combination with administering terlipressin or salt thereof as a continuous infusion.
- In another aspect, the disclosure is directed to a method of improving the Model for End-Stage Liver Disease (MELD) score of an ascites patient. The method includes administering terlipressin or salt thereof with a continuous infusion.
- In each of the aspects of the invention, the condition of the patient may not have progressed to HRS. Also, the terlipressin dose may range from about 1.0 mg to about 12.0 mg per day, and the terlipressin dose may be escalated over the course of the therapy. In addition, the terlipressin may be administered for a time period of about 1 day to about 12 months. Further, the continuous terlipressin may be administered with an ambulatory infusion pump.
- Terlipressin is a synthetic vasopressin that is approved in many countries outside of the United States to treat the life-threatening complications of cirrhosis, including hepatorenal syndrome (HRS) and esophageal bleeding (EVB). Its use is limited to the hospital setting due to its short half-life (26 minutes) (Nilsson, et al., 1990), necessitating its administration as an intravenous bolus usually every 4 to 6 hours. Additionally, terlipressin can cause side effects in up to 40% of patients. Severe side effects — including myocardial infarction, arrhythmia and intestinal infarction — can require discontinuation of treatment in up to 10% of the patients (Angeli, 2011). Indeed, due to the rapid vasoconstrictor properties, IV bolus dosed terlipressin must be used with caution in patients with severe asthma, severe hypertension, advanced atherosclerosis, cardiac dysrhythmias, and coronary insufficiency.
- In one aspect, the disclosure is directed to the administering terlipressin or a salt thereof for the treatment of patients suffering from ascites due to, for example, advanced liver cirrhosis. These patients are typically non-hospitalized (or ambulatory) and may include patients whose condition has not progressed to type 2 HRS (ambulatory HRS patients) or type 1 HRS (requiring hospitalization). Treatment includes a continuous infusion of terlipressin by means of a pump device, typically a portable ambulatory pump, for a period of several hours, lasting up to days, weeks, or months. The treatment is effective at reducing or resolving ascites disease on, for most patients, an outpatient basis.
- Patients with cirrhosis exhibiting type 1 hepatorenal syndrome (HRS-1) have been safely treated with terlipressin administered continuously. Dosage ranged from 2.0-12.0 mg per 24 hours (Angeli, et al., 2009: 2 -12 mg/24h; Gerbes, 2009: starting dose 3mg/day; Robertson, et al., 2014: 3mg/day; Ding, 2013: 4 mg/day; Cavallin 2015: 3 — 12 mg/day). However, none of these studies have either evaluated or reported an effect of terlipressin infusion on ascites burden or the effect of continuous infusion terlipressin on patients whose condition have not progressed to HRS.
- Ambulatory pumps are commonly used to infuse parenteral drugs directly into the bloodstream via catheters to increase efficacy and/or decrease toxicity. This has been found to be safer than some approved terlipressin drug therapy that require the administration of terlipressin to hospitalized hepatorenal syndrome (HRS) patients and esophageal bleed (EVB) patients using slow bolus IV injections. Accordingly, in one aspect of the disclosure, terlipressin is administered continuously by a pump at a dosage rate of about 0.5 mg to about 20 mg every 24 hours, more particularly for example, about 1 mg to about 12 mg every 24 hours, more particularly for example, about 5 to about 15 mg every 24 hours, or for instance, about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, or 20 mg every 24 hours. Administration can continue for, typically, at least about one day and may continue for about 12 months or longer as necessary to bridge a patient until a transplant is available. For example, the administration can continue for about 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, one week, two weeks, three weeks, one month, two months, three months, six months, 9 months or twelve months. In some instances, the dose of terlipressin escalates over the course of the therapy. For example, patients may begin therapy at 2 mg/day, and be increased to 3 mg/day or up to 12 mg/day over the course of treatment.
- Accordingly, in various aspects, the disclosure is directed to a method for treating a patient diagnosed with ascites due to liver cirrhosis. The method can improve renal function in an ascites patient and reduce the volume of ascitic fluid during paracentesis procedure in the patient. Still further, the method can be used for reducing the risk of spontaneous bacterial peritonitis, improving the Model for End-Stage Liver Disease (MELD) score of an ascites patient and/or correcting hyponatremia in an ascites patient. In another aspect, the method disclosed herein can be used in combination with hepatitis C antiviral medications to improve the health status of the ascites patient with liver cirrhosis due to hepatitis C. In each case terlipressin or salt thereof is administered with a continuous infusion pump. In each of these aspects, the patient's ascites condition may not have progressed to hepatorenal syndrome.
- In addition, the determination of the presence, progression, or improvement of disease can be determined by measuring one or more of the following: serum creatinine concentration, plasma sodium concentration, urinary sodium excretion, and urea concentration in serum. For example, an improvement in renal function that indicates an improvement in disease condition includes one or more of the following: a reduction in serum creatinine concentration, an increase in plasma sodium concentration, an increase in urinary sodium excretion, a decrease in urea concentration in serum of disease.
- The use of ambulatory pump delivery of continuous infusion of terlipressin would avoid the need for patient hospitalization and make such therapy available to the vast majority of ascites patients who have not yet been hospitalized for severe complications that often follow advanced ascites, such as post-paracentesis circulatory dysfunction, HRS, EVB, hepatic encephalopathy, spontaneous bacterial peritonitis and other life-threatening conditions.
- The following are provided for exemplification purposes only and are not intended to limit the scope of the disclosure described in broad terms above.
- 15 subjects that are to be confirmed to have ascites, but not type 1 or type 2 HRS, due to liver cirrhosis will be administered continuous low dose (escalating from 2.0 to 3.0 mg per 24 hours) terlipressin via ambulatory infusion pump. These patients are expected to experience a decrease the severity of ascites and the accumulation of ascites fluid over the course of treatment ranging from 1 day to 28 days. This method is also expected to reduce the number of paracentesis procedures required to remove ascitic fluid over a 28-day period, compared to the 28-day period prior to treatment inception, and some patients should avoid paracentesis altogether. Additionally the average amount of fluid withdrawn after beginning continuous infusion pump terlipressin therapy should be significantly less than prior to the start of treatment. Furthermore the improvement in patient health status can be achieved safely with no serious side effects. Accordingly, continuous infusion pump (CIP) terlipressin represents a potentially life-saving solution for these seriously ill patients who are still ambulatory (have not yet been administered to the hospital for treatment) and have not developed type 1 or type 2 HRS.
- Six FIRS patients treated with continuous infusion terlipressin were evaluated for improvement in acsites. All six patients had diuretic intractable or refractory ascites (5 of 6 with hyponatremia). The patients were evaluated for the following parameters before, during and after treatment: number of paracentesis procedures per month, volume of ascites removed, weight, serum sodium, urinary sodium excretion, serum creatinine, serum urea, and whether diuretics were included in the treatment regimen. None of the six patients had a complete set of data for all parameters. The effect of continuous infusion terlipressin on each parameter is presented in Tables 1-7.
- Reduction in frequency of paracentesis and fluid volume during therapy
- The average number of monthly paracentesis procedures decreased from three prior to initiation of continuous infusion therapy to two during therapy, and the average monthly ascites fluid volume removed was reduced by 55%.
-
TABLE 1 Volume Fluid Max. Paracenteses/Month Removed/Month (L) Patient Dose Duration % % # M/F (mg/day) (days) Before During Change Before During Change 1 M 12 63 1 0 −100% — — — 2 F 12 195 8 6 −25% 80 42 −48% 3 M 3 10 4 2 −50% 40 14 −65% 4 M 10 11 2 3 50% 14 9 −36% 5 F 3 22 3 2 −33% 21 6 −71% 6 F 2 12 1 0 −100% 2 0 −100% Average (excludes patient #1): 3 2 −32% 31 14 −55% “—” indicates missing data - Reduction in body weight during therapy
- Average body weight per patient, a proxy for ascitic fluid accumulation in the abdominal cavity, decreased by 11% or 9 kg (˜19.8 lbs).
-
TABLE 2 Max. Terli. Body Weight (kg) Patient Dose % # M/F (mg/day) Duration (days) Before During Change After 1 M 12 63 83 74 −11% 74 2 F 12 195 64 71 11% — 3 M 3 10 128 99 −23% 128 4 M 10 11 60 — — — 5 F 3 22 71 64 −10% 77 6 F 2 12 64 55 −14% 68 Average (excludes Patient #4): 82 73 −11% 87 “—” indicates missing data - Requirement for diuretics for effect on ascites
- During treatment, improvement of ascites was seen without diuretics in four of six patients.
-
TABLE 3 Treatment % Change Max. Terli. Volume Patient Dose Diuretics Diuretics Paracentesis Fluid Body # M/F (mg/day) Before During per Month Removed Weight 1 M 12 A A −100% — −11% 2 F 12 A None −25% −48% 11% 3 M 3 F + A None −50% −65% −23% 4 M 10 F + A None 50% −36% — 5 F 3 A None −33% −71% −10% 6 F 2 F + A F + A −100% −100% −14% Average: −32% −55% −11% F = furosemide; A = anti-aldosteronic drug. “—” indicates missing data. - Increase in urinary sodium excretion during therapy
- The observed improvement in ascites and renal function was further supported by a substantial increase in excretion of sodium into the urine. The average urinary sodium increased from 7 to 127 mEq/24h in three of sis patients with data recorded before and after starting continuous infusion terlipressin therapy.
-
TABLE 4 Max. Terli. Urinary Na over 24 hours (mEq/ Patient Dose Duration 24 hr) # M/F (mg/day) (days) Before During % Change 1 M 12 63 5 46 820% 2 F 12 195 — 301 — 3 M 3 10 — — — 4 M 10 11 1 20 1900% 5 F 3 22 — 33/140 — 6 F 2 12 16 315 1869% Average (excludes patients #2, #3, #5): 7 127 1632% “—” indicates missing data - Improvement in plasma sodium
- Treatment with continuous infusion terlipressin corrected severe hyponatremia in two patients: Plasma Na increased by 15% in patient #4 and by 19% in patient #6. Importantly, after the cessation of therapy, plasma sodium remained normal in patient #6 (data “after therapy” available for one of the two patients).
-
TABLE 5 Plasma Max. Terli. Sodium Patient Dose Duration (mEq/L) % # M/F (mg/day) (days) Before During Change After 1 M 12 63 140 137 −2% — 2 F 12 195 125 128 2% — 3 M 3 10 133 136 2% 140 4 M 10 11 123 141 15% — 5 F 3 22 131 128 −2% — 6 F 2 12 118 140 19% 131 Average: 128 135 5% 136 “—” indicates missing data - Reduction in blood urea during treatment
- The concentration of urea in patients' blood serum decreased in all patients by an overall average of 45%. This increase in urea clearance is indicative of improved renal function.
-
TABLE 6 Max. Terli. Serum Urea (mmol/L) Patient Dose Duration % # M/F (mg/day) (days) Before During Change After 1 M 12 63 31.1 8.8 −72% — 2 F 12 195 36.6 23.2 −37% — 3 M 3 10 17.0 9.1 −46% 10.8 4 M 10 11 51.8 37.3 −28% — 5 F 3 22 6.4 5.3 −17% 10.5 6 F 2 12 20.4 6.6 −68% 10.0 Average: 27.2 15.1 −45% 10.4 “—” indicates missing data - Reduction in serum creatinine
- Levels of the metabolic waste product serum creatinine are indicative of renal health. An average decrease of 47% was seen in serum creatinine levels for the treated group of patients. This was consistent with the decrease in serum urea and indicates improved renal function, contributing to a decrease in ascites severity.
-
TABLE 7 Max. Terli. Serum Creatinine (mmol/L) Patient Dose Duration % # M/F (mg/day) (days) Before During Change After 1 M 12 63 248 189 −24% — 2 F 12 195 383 208 −46% — 3 M 3 10 233 116 −50% 122 4 M 10 11 319 104 −67% — 5 F 3 22 68 55 −19% 55 6 F 2 12 195 90 −54% 137 Average: 241 127 −47% 105 “—” indicates missing data - All references cited in this disclosure are incorporated herein by reference.
- Nilsson, G. et al., 1990. Nilsson G, Lindblom P, OhlPharmacokinetics of Terlipressin After Single i.v. Doses to Healthy Volunteers. Drugs Under Experimental and Clinical Research, Volume 16, pp. 307-314.
- Angeli, P., 2011. Terlipressin for Hepatorenal Syndrome: Novel Strategies and Future Perspectives. Frontiers of Gastrointestinal Research, Volume 28, pp. 189-197.
- Angeli, P. et al., 2009. Terlipressin Given as Continous Intravenous Infusion Versus Terlipressin Given as Intravenous Boluses in the Treatment of Type 1 Hepatorenal Syndrome (HRS) in Patients with Cirrhosis. Journal of Hepatology, 50(Supplement 1), p. S73.
- Gerbes AL, Huber E, Gillberg V. 2009 Terlipressin for hepatorenal syndrome: continuous infusion as an alternative to i.v. bolus administration. 2009 Gastroenterology. 137(3):1179; author reply 1179-81
- Ding, C. et al., 2013. Hemodynamic effects of continuous versus bolus infusion of terlipressin for portal hypertension: A randomized comparison. Journal of Gastroenterology and Hepatology, 28(7), pp. 1242-1246.
- Robertson, M. et al., 2014. Continuous outpatient terlipressin infusion for hepatorenal syndrome as a bridge to successful liver transplantation. Hepatology Mar 2014. Hepatology, Volume March, pp. 1-2.
- Cavallin M, et. al., 2015 Terlipressin Plus Albumin Versus Midodrine and Octreotide Plus Albumin in the Treatment of Hepatorenal Syndrome: A Randomized Trial. Hepatology, 2015 (in press)
- Fimiani, B. et al., 2011. The Use of Terlipressin in Cirrhotic Patients with Refractory Ascites and Normal Renal Function: A Multicentric Study. European Journal of Internal Medicine, Volume 22, pp. 587-590.
- Krag, A. et al., 2007. Telipressin Improves Renal Function in Patients with Cirrhosis and Ascites Without Hepatorenal Syndrome. Hepatology, 46(6), pp. 1863-1871.
- Although various specific embodiments of the present disclosure have been described herein, it is to be understood that the disclosure is not limited to those precise embodiments and that various changes or modifications can be affected therein by one skilled in the art without departing from the scope and spirit of the disclosure.
Claims (11)
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Fimiani et al., 2011, The use of terlipressin in cirrhotic patients with refractory ascites and normal renal function: A multicentric study, European Journal of Internal Medicine, 22: 587-590. * |
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