AU602154B2 - Improvements in or relating to organic compounds - Google Patents

Description

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'a- C O M M O N W E A'L T H bF A U-S T R IN I A PATENT ACT 1952 COMPLETE SPECIFICATION6 0 2 15 4 (Original) FOR OFFICE USE I Class Int. Class Application Number: Lodged: Complete Specification Lodged: Accepted: Published: a- ~0 .0 0'1'0 .0 0$ a 0 0 0.0

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0~Tq Priority: Related Art: Name of Applicant:

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0 4 0 Address of Applicant: SANDOZ LTD.

CH-4002 Basle,

SWITZERLAND

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Address for Service: DAVIES COLLISON, Patent Attorneys, 1 Little Collins Street, Melbourne, 3000.

Complete Specification for the invention entitled: "IMPROVEMENTS IN OR RELATING TO ORGANIC COMPOUNDS" The following statement is a full description of this invention, including the best method of performing it known to us t la. CASE 100-6862

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00 0 opC 0 0* 0 o a NEW USE OF BROMOCRIPTINE The present invention relates to novel means of therapy, in particular immunosuppressive therapy, for the treatment of autoimmune disease. More especially the present invention relates to novel means of therapy as aforesaid and comprising administration of Bromocriptine for the treatment of specific auto-immune diseases.

Bromocriptine, also known as 2-bromo-12'-hydroxy-2'-(methylethyl)-5'-(2-methylpropyl)-ergotaman-3',6',18-trione and 2-bromo-a-ergokryptin MERCK INDEX, 10th. Edition (1983), item 1386) is a known compound having valuable pharmaceutical properties, in particular prolactin secretion inhibitory activity. It is commercially available in pharmaceutically acceptable acid addition salt form, i.e. as the methane sulfonate, under Registered Trade Marks PARLODEL) and PRAVIDEL for use in the treatment of e.g. hyperprolactinaemia, Parkinson's disease and acromegaly.

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Signature of declarant(s) (no attestatlon required) l No t e i all de lntera ons) Note: Initial all alterations.

I DAVIES COLLISON, MELBOURNE and CAI~t~ orizedduy ihried t er' a 2 100-6862 In accordance with the present invention it has now surprisingly been found that, of the many various auto-immune diseases known from the literature, effective and advantageous treatment of the specific diseases: a) Myasthenia gravis; b) Endocrine opthalmopathy; c) Graves disease; d) Juvenile diabetes (diabetes mellitus type I); e) Glomerulonephritis (with or without nephrotic syndrome); .0 f) Systemic lupus erythematosus; Autoimmune hematological disorder; o. h) Multiple Sclerosis; and i) Autoimmune inflammatory bowel disease; can be effected employing Bromocriptine as monotherapy. For these specific diseases Bromocriptine alone, administered at appropriate dosage rates in accordance with an appropriate dosage regimen or technique, provides adequate and unexpectedly beneficial medication.

This finding may be seen to be of exceptional benefit in relation to the long-term treatment of subjects exhibiting the particular t c diseases a) to i) li.sted above, or in the treatment of said diseases in subjects "resistant" to cyclosporin therapy or considered "at risk" to potential cyclosporin induced organ damage, e.g. for the treatment of said diseases in infants and children or in patients already exhibiting organ, e.g. kidney or liver, damage or malfunction.

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3 -100-6862 Thus for the specific listed auto-immune diseases a) to use of Bromocriptine monotherapy may be anticipated to be of particular benefit in subjects, e.g. in the "resistant" or "at risk" categories above indicated, subsequent to preliminary cyclosporin monotherapy or cyclosporin/Bromocriptine mixed therapy, e.g. for use in the remission phase of the disease or as maintainance therapy, thus alleviating the need for continued long term cyclosporin therapy.

08 In accordance with the foregoing the present invention provides a 8o°" method of treating a disease selected from the group consisting S* of: 80 0 o0 0 a) Myasthenia gravis; S" b) Endocrine opthalmopathy; c) Graves disease; 'o d) Juvenile diabetes (diabetes mellitus type I); ,0o0. e) Glomerulonephritis (with or without nephrotic syndrome); f) Systemic lupus erythematosus; g) Autoimmune hematological disorder; h) Multiple sclerosis; and i) Autoimmune inflammatory bowel disease; in a subject in need of such treatment, which method comprises administering to said subject an effective amount of Bromocriptine.

Specific disease sub-groups to which the method of the invention is applicable include: 4 4 100-6862 el) Idiopathic nephrotic syndrome or minimal change nephropathy; gl) Heamolytic anaemia; g 2 Aplastic anaemia; g 3 Pure red cell anaemia; g 4 Idiopathic trhombocytopaenia; ii) Chron's disease; and i2) Ulcerative colitis.

As previously indicated Bromocriptine exists in both free and acid addition salt forms. In general the pharmaceutically acceptable acid addition salts of Bromocriptine, e.g. the commercially available Bromocriptine mesylate, have been found to have the same level or order of tolerability and effectiveness as the free compound. References to Bromocriptine throughout the present specification and claims are accordingly to be understood as including both the free compound and its pharmaceutically acceptable acid addition salts unless otherwise specified.

For use in accordance with the present invention Bromocriptine is preferably employed in pharmaceutically acceptable acid addition salt form, most preferably as Bromocriptine mesylate.

The method in accordance with the present invention is especially applicable to subjects undergoing maintainance therapy or in the remission phase of specified diseases a) to i).

Effectiveness of Bromocriptine in accordance with the method of the invention may be demonstrated in standard animal test models as well as in clinical trials, carried out e.g. as follows:

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-Lli i i _i i 100-6862 [For all of the following tests and clinical trials, Bromocriptine is administered in the form of its mesylate (methane sulfonate) salt].

1. JUVENILE DIABETES TYPE I BB/Worcester Rat Model 14 4 4 4 4 1 :1 44n 4 44 41

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41 Ci 4C 1: The trial is based on the general methodology described by Like et al. in Am. J. Pathol. 117, 92 97 (1984). For purposes of the test, groups of BB/W (0 and 6) rats (a strain spontaneously developing auto-immune diabetes comparable with juvenile diabetes type I) aged 60 days are employed.

Test therapy consists of Bromocriptine administered alone at dosages of from 3 to 10 mg/kg/day administered continously throughout the day for 10 days.

Control groups receive olive oil placebo in place of test substance. All test animals are screened regularly for the occurrence of glycosuria.

In groups receiving Bromocriptine, substantial reduction in the number of animals exhibiting diabetes, e.g. exhibiting abnormally elevated blood glucose levels/glycosuria, is observed in comparison with results for control groups receiving placebo.

i- -J 6 100-6862 2. MYASTHENIA GRAVIS Experimental Allergic Myasthenia Gravis (EAMG) Testing is carried out in accordance with the general methodology described by V.A. Lennon et al. in J. Exp. Med.

141, 1365 1375 (1975). EAMG is induced in groups of 8 to 12 Lewis rats weighing ca. 150 200 g by intracutaneous injection of a mixture containing 1 part Freund's complete adjuvant (Gifco, 0638-60) and 1 part of a solution comprising 10 pg purified acetylcholine receptor (obtained from Torpedo california rats). Additional adjuvant (pertussis, e" a 1 x 1010 units) is administered s.c. into the hind paw pad.

,Autoantibody titres are determined at weekly intervals using ELISA technique.

Test therapy consists of Bromocriptine administered alone at S" dosages of from 1 to 10 mg/kg/day 5 days a week.

STherapy commences either: on the day of immunisation, to determine prophylactic effectiveness; or after autoantibodies have already been formed (generally ca. 14 days after i immunisation) to determine therapeutic effectiveness, In groups receiving the above therapy, substantial inhibition of antibody formation employing a prophylactic regime/reduction in auto-antibody titres employing a therapeutic regime is observed in comparison with results for control groups receiving placebo.

i 7 -100-6862 3. MULTIPLE SCLEROSIS Activity in Established Experimental Allergic Encephalomyelitis (EAC) Testing is carried out in accordance with the general methodology described by Borel et al. in Agents and Action, 6, 468 (1976). EAE is induced in groups of 8 to 12 Wistar (0) or Lewis rats each weighing 150 to 200 g, by intradermal injection into each hind foot pad of 0.1 ml of an emulsion ad' comprising 2.5 g bovine spinal cord (lyophylised and reconstituted with 12 ml H20), 1.5 ml Arlacel A, 8.0 ml Nujol Sb" and 0.2 ml saline containing 20 mg killed, dried Mycobacterium phlei.

D o Test therapy consists of Bromocriptine administered alone at dosages of from 1 to 1) mg/kg/day s.c. administered daily or every 2nd day and continuing ca. 14 days.

During the treatment period, test animals are examined daily for the symptoms of the disease (paralysis in the hind limbs and tail) and disease appearance is scored as positive when ,L complete involvement of both hind legs and the tail is observed. The test animals are kept under observation for a total period of 25 days.

In groups receiving the above therapy, substantial reduction in appearance of EAE disease symptoms is observed in comparison with results for control groups receiving placebo.

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-8 100-6862 4. SYSTEMIC LUPUS ERYTHEMATOSUS (NZB/NZW)F1 mouse model: It r f It r a a( ea Trials are based on the (NZB/NZW)F1 mouse strain as described and discussed by Steinberg et al. in Bulletin on the Rheumatic Diseases 28, Nos. 4 5, 940 946 (1977 1978) published by The Arthritis Foundation, Atlanta, Georgia. Females of this strain spontaneously develop characteristica of the SLE syndrome including formation of anti-DNA and anti-erythrocyte autoantibodies as well as proteinurea at age ca. 5 to 7.5 months. The condition ultimately leads to death.

For the purpose of the trial, groups of 6 to 8 mice are employed.

a t I CI It' 4( a It I tttttt A r 4 R i ~-ll c~ 9 100-6862 Test therapy consists of Bromocriptine administered at dosages of from 1 to 10 mg/kg/day 5 x weekly.

Therapy is applied either prior to spontaneous development of auto-antibodies at ca. 5 months age) for determination of prophylactic effectiveness, or subsequent to spontaneous development of auto-antibodies, at ca. 8 9 months age) for determination of therapeutic effectiveness. In both instances therapy is continued for a total of ca. 8 to 10 weeks. Anti-DNA and anti.-erythrocyte antibody o' titres are measured at regular intervals during the trial S* period employing ELISA technique commencing from ca. 1 week prior to the start of therapy. Additional parameters subject to control are development of proteinuria (measured 1 x/ week) and life span.

4* In groups receiving the above therapy, substantial reduction o of proteinuria as well as increase in average life span is observed in both prophylactic and therapeutic treatments compared with results for control groups receiving placebo.

5. AUTOIMMUNE HEMATOLOGICAL DISORDER (HEMOLYTIC ANAEMIA) s 9 Rat Erythrocyte Induced Anti-Mouse Erythrocyte Autoantibody Model Testing is carried out in accordance with the general methodology described by Naysmith et al. in Immunological Rev. 55, 54 86 (1981). Four injections each comprising ca. 108 well-washed rat erythrocytes are administered to groups of young, normal/healthy mice at days 0, 7, 14 and 21 F 10 100-6862 of the test, injection being effected i.p. From day 21 on the animals are bled at fixed 5 to 7 day intervals into citrate saline, and a direct Coomb's test is performed using a broad spectrum sheep anti-mouse immunoglobulin antiserum.

Positive reaction in the Coomb's test is generally observed in control animals receiving no medication from ca. week 3 to 4 of the trial on. The trial is continued for ca. 10 to 12 weeks.

*4 Test therapy consists of Bromocriptine alone administered at dosages of from 1 to 10 mg/kg/day p.o. or. 5 x weekly.

a Swa a ,0 Therapy is applied either commencing on day 0 of the trial for determination of prophylactic effectiveness or commencing after auto-antibodies have been developed (positive reaction in Coomb's test, generally ca. 21 to 28 days after day 0) for determination of therapeutic effectiveness. In a 6 both instances therapy is continued for a total of ca. 4 to 6 weeks.

In groups receiving the above therapy, substantial reduction in the number of animals reacting positively in the Coomb's test following prophylactic treatment/substantial reduction of response in the Coomb's test following therapeutic treatment is observed in comparison with results for control groups receiving placebo.

11 100-6862 6. GLOMERULONEPHRITIS/NEPHROTIC SYNDROME Back-Ground Female NZB/W hybrid mice spontaneously develop renal disease characterised by immunogiobulin (Ig) and complement deposition at 3 to 6 months of age, with histological glomerulonephritis and proteinurea from about 6 months. They thus provide an appropriate animal model for the disease o°0 glomerulonephritis as it occurs in man.

o 04 0 0* 0 Method 0o o a Female NZB/W mice are randomly sorted into control and treatment groups of 10 mice each. Each mouse is ear-marked to permit individual identification. Experiments are started 00 when the mice are aged 12, 24 or 36 weeks old and test o therapy continues for 12 weeks.

Test therapy consists of Bromocriptine administered alone at dosages of from 1 to 10 mg/kg/day 5 x weekly.

The degree of proteinurea is estimated by staining 10 1I urine spots on filter paper with bromophenol blue. A thinlayer-chromatography scanner connected to an intergrating computer is used to quantify the intensity of the stained Surine spots compared to a serial dilution of bovine serum albumin. Levels of protein above 100 mg are considered abnormal and positive.

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12 100-6862 Mice are sacrificed at the end of each experiment and the kidneys vrutinely prepared for histological examination.

Direct immunofluorescent studies are performed using antisera directed against mouse Ig and C3 (Nordic). Glomerulonephritis is classified into mild endothelialmesangial lesions, (ii) more severe segmental proliferative, and (iii) most severe membrano-proliferative type. Scoring is from no lesion progressing to severe lesion. Immunofluorescent 0 scoring ranges from nothing to strong. Results are compared ""with a control group receiving placebo only. If an animal 1 0 0 dies while having proteinurea during the experiment, it is o° o considered positive.

6 o* 00 0 In groups receiving the above therapy, substantial reduction of deposition of immunoreactants and histological evidence of glomerulonephritis is observed in comparison with results for control groups receiving placebo.

Effectiveness of Bromocriptine in accordance with the method of S the invention may also be shown in clinical trials, e.g. performed as follows: CLINICAL TRIAL: JUVENILE DIABETES TYPE I The trial is carried out employing volunteer, insulin-dependent diabetics, diagnosed as exhibiting Juvenile Diabetes Type I.

Diagnosis is made on clinical grounds in non-obese subjects with confirmed hyperlycaemia [National Diabetes Data Group, Diabetes 28, 1039 (1979)].

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Bromocriptine.

13 100-6862 Baseline creatinine clearance, urinalysis, serum creatinine, blood urea nitrogen, serum glutamic-oxaloacetic transaminase (SGOT), and alkaline phosphatase levels are determined to ensure that these are normal.

Trial medication is administered to each subject in accordance with the medication regimen below.

After discharge patients are seen weekly for 2 weeks and monthly thereafter. At each in-clinic visit, blood is drawn for determination of test substance levels, creatinine and electrolyte ,F concentrations and for hematological and liver function tests; basal and glucagon-stimulated plasma C-peptide concentrations are t measured at 1 month and at 3 months intervals thereafter.

During the course of the trial all patients are treated with insulin and are encouraged to effect administration 2 x daily and to monitor blood glucose concentrations using visual matching or reference meter methods with reagent strips. They are instructed in a diabetic diet appropriate for maintainance of normal body weight and activity. Insulin dosage is adjusted as far as possible to achieve a mean blood glucose level of 7.8 m mole/litre before the main meals and evening snack. Insulin dosage is reduced when control of glycaemia is consistant with these targets or in order to avoid hypoglycaemia. Subjects for-which insulin is completely withdrawn for at least 1 week without loss of target control or development or ketonuria and who need not resume insulin treatment during the course of the study are classed as no longer-insulin-requiring (NIR) and are deemed to be "in remission". Where subjects becoming NIR subsequently develop hyperglycaemia exceeding treatment goals, application of insulin or the oral hypoglycemic agent glybenclamide is undertaken.

1~i~ *.1 1- 1. tI I -r 4 4~, 14 100-6862 TRIAL MEDICATION REGIMEN *0 00oo 0 090+ o 03 0 0 09 0 0o Bromocriptine alone administered: i) initially at a dose of ca. 1.25 mg p.o. at sleep for ca. 3 4 days; increasing to ii) 1.25 mg/day p.o. in the morning plus 1.25 mg p.o. at sleep for ca. 3 4 days 2.5 mg/day in toto); increasing to iii) 1.25 mg in the morning and 2.5 mg p.o. at sleep for ca. 3 4 days 3.75 mg/day in toto); with iv) further possible increment in daily dosage of ca. 1.25 mg/day each 3 4 days to a maximum daily dosage of mg/day in toto.

RESGLTS

Results indicate a marked and significant increase of NIR remission in subjects receiving the above medication as compared with remission spontaneous NIR remissions) recorded for groups of juvenile diabetics for whom no therapy is attempted or in comparison with NIR remissions recorded in groups of juvenile diabetics receiving alternative intervention therapy. Results indicate effectiveness of Bromocriptine monotherapy in accordance with the present invention.

Results further indicate that medication is well tolerated, e.g.

as evidenced by measurement of other physiological parameters during the course of the trial.

s00 0 0 000 9 15 100-6862 Equivalent results to the above may be obtained in analogously designed, clinical trials for subjects exhibiting glomerulonephritis (with or without nephrotic syndrome), myasthenia gravis, autoimmune hematological disorder (including aplastic anaemia, pure red cell anaemia, idiopatic thrombocytopaenia and, in particular, hemolytic anaemia), systemic lupus erythematosus, autoimmune inflammatory disease (including ulcerative colitis and, in particular, Chron's disease), endocrine opthalmopathy, Grave's disease or multiple sclerosis, employing Bromocriptine mono-therapy.

Doses of Bromocriptine, e.g. in the form of its mesylate, to be administered in accordance with the present invention will of course vary, e.g. depending on the mode of administration and the particular condition to be treated.

Bromocriptine will preferably be administered at dosage levels, and/or in accordance with a daily administration regimen, and/or in a form permitting round-the-clock, i.e. continuous, reduction of regular serum prolactin levels. In normal subjects, serum prolactin levels e.g. as determined by radioimmunoassay (RIA), exhibit cyclical variation during any 24 hour period, with average levels of the order of from ca. 3 5 ng/ml (RIA) during S the day time rising to ca. 15 20 ng/ml (RIA) towards the evening and at night. Preferably in practicing the method of the present invention, bromocriptine dosaging will be effected in f such a manner as to ensure that serum prolactin levels do not rise above about 5, preferably about 3, more preferably about 2 ng/ml (RIA) at any time during any 24 hour period. Suitably administration will be effected in such a manner as to ensure that average serum prolactin levels in any 24 hour period do not exceed above 3, preferably above 2 or even above 1 ng/ml (RIA).

i i i ii 16 100-6862 In order to achieve continuous reduction of regular serum prolactin levels as described above, .administration may be effected either enterally Gcally) or parenterally in divided doses administered e.g. 2 x or more, preferably 3 x or more,/day, or by use of an appropriate custained release form.

A suitable oral Bromocriptine daily dosage will generally be of the order of from ca. 2.5 (preferably ca. 3.75) to ca. 15 mg (preferably ca. 10 mg) administered in divided doses, e.g. 2 to 4 x/day,preferably 2 x/day, for example with a 1/3 dose at morning and a 2/3 dose in the evening.

Bromocriptine therapy is suitably introduced in a step-wise fashion with incremental increase in daily dosage rate over a f t Cperiod of e.g. 3 to 5 or more weeks, until the final desired Sdosage rate is achieved, for example as hereinbefore described in Both oral and parenteral dosage forms for Bromocriptine suitable for use in practising the method of the invention, are knowi in the art and are commercially available. Thus Bromocriptine

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mesylate is commercially available under the Registered Trade Marks Parlodeln and Pravidel(a in 2.5 mg tablet form (divisible e.g. to provide a 1.25 mg dosage) as well as in 5 mg and 10 mg capsule form.

Claims (1)

100-6862 THE CLAIMS DEFINING THE INVEI\TIION ARE AS FOLLOW~S: 1. A method of treating a disease selected froin the group cunsisting of: a) Myasthenia gravis; b) Endocrine opthalinopathy; c) Grave's disease; d) Juvenile diabetes (diabetes inellitus type 1); e) Gloierulonephritis (with or without nephrotic syndrome); f) Systemic lupus erythe';Htosus; g) Autoimmune hematological disorder; h) Niultiple sclerosis; and i) Autoirmmune inflanmatory bowel disease in a subject in need of such treatment, which method com- prises administering to said sujbject an effective amount of Bromocripti ne. 2. A method according to claim 1, wherein the Bromocriptine is Bromocriptine mesylate. DATED this 16th day of July Sandoz ,Limited By Its Patent Attorneys{ DAVIES COLLISON