CH672987A5 - - Google Patents

Description

DESCRIPTION The present invention relates to new agents for therapy, in particular immunosuppressive therapy for the treatment of autoimmune disease. The present invention particularly relates to novel agents containing bromocriptine for the therapy mentioned above.

Bromocriptine, also known as 2-bromo-12'-hydroxy-2 / - (methyl-ethyl) -5 '- (2-methylpropyl) -ergotaman-3', 6 ', 18-trione and 2-bromo-a- ergocriptin (cf. MERCK INDEX, 10th edition (1983), Pt. 1386) is a known compound with valuable pharmaceutical properties, in particular an inhibition of prolactin secretion. It is commercially available in pharmaceutically acceptable acid addition salt form, i.e. as methanesulfonate under the registered trademarks PARLODEL® and PRAVIDEL®, for use in the treatment of e.g. B. hyperprolactinaemia, Parkinson's disease and acromegaly, available.

In accordance with the present invention, it has now surprisingly been found that, among the numerous different autoimmune diseases known in the literature, an effective and advantageous treatment of the following specific diseases:

a) myasthenia gravis;

b) endocrine ophthalmopathy;

c) Graves' disease;

d) juvenile diabetes (type I diabetes mellitus);

e) glomerulonephritis (with or without nephrotic syndrome);

f) systemic lupus erythematosus;

g) autoimmune haematological disorder;

h) multiple sclerosis; and i) autoimmune inflammatory bowel disease; can be performed using bromocriptine as monotherapy. For the diseases listed above, administration of bromocriptine alone at appropriate dose rates / in accordance with an appropriate dosing technique or regimen enables adequate and unexpectedly useful medication.

This finding can be of extraordinary benefit in connection with the long-term treatment of patients who have one of the diseases listed under a) to i) above, or in the treatment of the diseases mentioned in patients who are "resistant" to cyclosporin therapy or are considered a “risk” for possible organ damage caused by cyclosporin, eg for the treatment of the diseases mentioned in infants and children or in patients who already have an organ (e.g. kidney or liver) damage or malfunction.

Bromocriptine monotherapy can be of particular advantage in patients e.g. of the above-mentioned "resistant" or "risk" categories, after a previous cyclosporin monotherapy or a cyclosporin / bromocriptine mixed therapy, e.g. for use in the remission phase of the disease or as maintenance therapy, so as to ease the need for continued long-term cyclosporin therapy.

In accordance with the foregoing, the present invention provides the use of bromocriptine for the manufacture of a pharmaceutical composition for the treatment of a disease from the group below:

a) myasthenia gravis;

b) endocrine ophthalmopathy;

c) Graves' disease;

d) juvenile diabetes (type I diabetes mellitus);

e) glomerulonephritis (with or without nephrotic syndrome);

f) systemic lupus erythematosus;

g) autoimmune haematological disorder;

h) multiple sclerosis; and i) autoimmune inflammatory bowel disease.

Specific subgroups of the disease for which the

Use of the invention in question includes the following:

e1) Idiopathic nephrotic syndrome or minimal

Alternating nephropathy;

g1) hemolytic anemia;

g2) aplastic anemia;

g3) "Pure red cell anemia";

g4) idiopathic thrombocytopania;

11) Chron's disease; and

12) Ulcerative colitis.

As indicated above, bromocriptine is in both free form and acid addition salt form. In general, it has been found that the pharmaceutically acceptable acid addition salts of bromocriptine, e.g. the commercially available bromocriptine mesylate has the same level or degree of tolerance and potency as the free compound. References to bromocriptine in the present specification are to be understood to include 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 called phar2

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pharmaceutically acceptable acid addition salt form, most preferably used as bromcriptine mesylate.

The present invention is particularly applicable to patients who are undergoing maintenance therapy or to patients in the remission phase of the specified diseases a) to i). The effectiveness of bromocriptine can be demonstrated using standard animal test models as well as in clinical trials, e.g. be carried out as follows:

[In all subsequent tests and clinical trials, bromocriptine is given in the form of its mesylate salt (methanesulfonate)]

1. JUVENILER DIABETES TYPE I

BB / Worcester rat model The experiment is based on the general methodology as described by Like et al. in Am. J. Pathol. 117, 92-97 (1984). Groups of BB / W (Ç and J1) rats aged 60 days are used for the test (a strain of spontaneously developing auto-immune diabetes, comparable to juvenile type I diabetes).

The test therapy consists of the administration of bromocriptine alone in doses of 3 to 10 mg / kg / day, the administration being continuous for 10 days during the day i.m. he follows.

Control groups receive olive oil placebo instead of the test substance. All test animals are regularly checked for the appearance of glucosuria.

In groups receiving bromcriptin, compared to the results of control groups receiving placebo, a significant reduction in the number of animals showing diabetes, e.g. by having abnormally high blood glucose / glucosuria.

2. MYASTHENIA GRAVIS Experimental Allergic Myasthenia Gravis (EAMG) The exam is conducted in accordance with the general methodology as described by V.A. Lennon et al. in J. Exp. Med. 141, 365-1375 (1975). EAMG is induced in groups of 8 to 12 Lewis rats weighing approx. 150-200 g (Ç) by intracutaneous injection of a mixture containing 1 part Freund's complete adjuvant (Difco, 0638-60) and 1 part of a solution containing 10 μg purified acetylcholine receptor (obtained from California torpedo rats). In addition, adjuvant (pertussis, 1 x 1010 units) is placed in the hind paw s.c. administered. The autoantibodies are determined at weekly intervals using the ELISA technique.

The test therapy consists in the sole administration of bromocriptine doses of 1 to 10 mg / kg / day SC for 5 days a week.

Therapy begins either on the day of immunization to determine prophylactic efficacy or to determine therapeutic efficacy after autoantibodies have already been formed (generally approximately 14 days after immunization).

In groups receiving the above therapy, a substantial inhibition of antibody formation was observed when the prophylactic conditions were used, and a reduction in autoantibody titers when the therapeutic conditions were used, in comparison with the results for control groups which received placebo.

3. MULTIPLE Sclerosis Activity in Established Experimental Allergic Ence-

phalomyelitis (EAE)

The experiments are carried out in accordance with the general methodology as described by Borei et al. in Agents and Action, 6,468 (1976). EAE is administered in groups of 8 to 12 Wistar (Q) or Lewis (Ç) rats, each weighing 150 to 200 g, by intradermal injection into each hind paw of 0.1 ml of an emulsion containing 2.5 g of bovine spinal cord strand (lyophyli -sied and restored with 12 ml H ^ O), 1.5 ml Arlacell A, 8.0 ml Nujol and 0.2 ml saline, containing 20 ml killed, dried Mycobacterium phlei.

The test therapy consists of the administration of bromocriptine alone in doses of 1 to 10 mg / kg / day s.c. administered daily or every other day and continued for about 14 days.

During the treatment period, the test animals are checked daily for symptoms of the disease (paralysis of the hind legs and tail). The occurrence of the disease is considered positive if it can be observed

that both hind legs and tail are completely paralyzed. The test animals are kept under observation for a total of 25 days.

In groups receiving the above therapy, a significant decrease in the incidence of EAE was observed during the test period compared to the results of the control groups receiving placebo.

4. SYSTEMIC LUPUS ERYTHEMATOSUS (NZB / NZW) Fl mouse model:

The experiments are based on the (NZB / NZW) Fl mouse strain as described by Steinberg et al. in Bulletin on the Reumatic Diseases 28, Nos. 4 - 5,940-946 (1977-1987), published and discussed by the Arthritis Foundation, Atlanta, Georgia. Female mice of this strain spontaneously develop characteristics of the SLE syndrome including anti-DNA and anti-erythrocyte autoantibodies as well as proteinuria at the age of approximately 5 to 7.5 months. The condition ultimately leads to death.

Groups of 6 to 8 9 mice are used for the experiments.

The test therapy consists in the administration of bromocriptine in doses of 1 to 10 mg / kg / day s.c. 5 times a week.

The therapy is used either before the spontaneous formation of autoantibodies (e.g. at the age of approx. 5 months) to determine the prophylactic effectiveness or after the spontaneous formation of autoantibodies (e.g. at the age of approx. 8 to 9 months) to determine the therapeutic efficacy. In both cases, the therapy is continued for a total of approximately 8 to 10 weeks. Anti-DNA and anti-erythrocyte antibody titers are measured at regular intervals during the trial period using the ELISA technique. This starts about 1 week before the start of therapy. Other parameters that are subject to control are the development of proteinuria (measured once a week) and the lifespan.

In groups receiving the above therapy, a significant reduction in proteinuria as well as an increase in the average lifespan were observed for both prophylactic and therapeutic treatments compared to results for control groups receiving placebo.

5. AUTOIMMUNE HEMATOLOGICAL DISORDER (HEMOLYTIC ANEMIA) induced rat erythrocytes

Anti-mouse erythrocyte autoantibody model

The experiments were carried out in accordance with the general methodology described by Nay-smith et al. in Immunological Rev. 55, 54-86 (1981). Four

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Injections, each containing 108 well-washed rat erythrocytes, were given to groups of young, normal / healthy mice on days 0.7, 14 and 21 of the test. The injections were i.p. From day 21 onwards, the animals are allowed to bleed at fixed 5-7 day intervals in a citrate saline solution and a direct Coomb s test is carried out. A broad spectrum sheep anti-mouse immunoglobulin antiserum is used. A positive reaction in the Coomb s test is generally observed in control animals which received no medication from about the 3rd to 4th week from the test. The trial will continue for approximately 10 to 12 weeks.

The test therapy consists of the administration of bromocriptine alone in doses of 1 to 10 mg / kg / day p. o. or s.c. 5 times a week.

The therapy is used, either starting on day 0 of the attempt to determine the prophylactic effectiveness or starting after autoantibodies have been formed (positive reaction in the Coomb s test, generally approx. 21 to 28 days after day 0) to determine the therapeutic effectiveness . In both cases, therapy is continued for a total of approximately 4 to 6 weeks.

In groups receiving the above therapy, a significant decrease in the number of animals that responded positively to the Coomb s test following prophylactic treatment and a significant decrease in response in the Coomb s test following therapeutic treatment could be observed in the Comparison with results of the control groups who received placebo.

6. GLOMERULONEPHRITIS / NEPHROTIC SYNDROME background

Female NZB / W hybrid mice spontaneously develop kidney disease, which is characterized by immunoglobulin (Ig) and complement (C) precipitation, at the age of 3 to 6 months, with histological glomerulonephritis and proteinuria of about 6 months. They are therefore a suitable animal model for the disease glomerulonephritis, as it occurs in humans.

method

Female NZB / W mice are randomly sorted into control and treatment groups of 10 mice each. Each mouse has an ear tag so that it can be identified. The experiments start when the mice are 12, 24 or 36 weeks old. The test therapy will continue for 12 weeks.

The test therapy consists of the administration of bromocriptine alone! in doses of 1 to 10 mg / kg / day p.o., 5 times a week.

The level of proteinuria is estimated by discoloring 10 | il urine stains on filter paper with bromophenol blue. A thin layer chromatography analyzer (scanner) connected to an "integrating" computer is used to quantify the intensity of the discolored urine stains compared to a serial dilution of bovine serum albumin. Protein levels above 100 mg% are considered abnormal and positive.

At the end of each experiment, the mice are sacrificed and the kidneys routinely prepared for histological examination. Direct immunofluorescence assays are performed using anti-mouse Ig and C3 (Nordic) antisera. Glomerulonephritis is classified into (i) mild endothelial mesangial injuries, (ii) severe, segmental proliferative, and (iii) severe membrane-proliferative type. The rating goes from no injury to severe injury. The immunofluorescence rating goes from zero to strong. The results are compared to a control group that only receives placebo. If an animal dies from having proteinuria during the trial, it is considered positive.

In groups receiving the above therapy, a significant decrease in immunoreactant deposition and histological evidence of glomerulonephritis was observed compared to the results for control groups receiving placebo.

The efficacy of bromocriptine in accordance with the use of the present invention can also be demonstrated in clinical studies, e.g. as shown below:

CLINICAL TRIAL:

JUVENILER DIABETES TYPE I

The trial is conducted using volunteers, insulin-dependent diabetics, who have been diagnosed with Type I juvenile diabetes. The diagnosis was made on the basis of clinical reasons in non-obese patients with confirmed hyperclemia [National Diabetes Data Group, Diabetes 28,1039 (1979)].

Creatinine normal values, urine status, serum creatinine, blood urea, SGOT and alkaline phosphatase levels were measured to ensure that these values were within the normal range.

The trial medication will be administered to each patient in accordance with the medication instructions given below.

After discharge, patients are seen once a week for 2 weeks and then monthly. With each visit to the clinic, blood is taken to determine the test substance levels, creatinine and electrolyte concentrations and for hematological and liver function tests. Basic and glucagon-stimulated plasma C peptide concentrations are measured after one month and then after 3 months intervals.

During the course of the trial, all patients are treated with insulin and are asked to administer them twice daily and to monitor blood sugar concentrations by optical comparison or reference measurement methods using test paper strips. You will be instructed on a diabetes diet that is suitable for maintaining normal body weight and activity. Insulin dosage is adjusted as far as possible to achieve an average blood sugar level of 7.8 m mol / liter before the main meals and the evening snack.

Insulin doses will be reduced if control of hyperglycaemia is compatible with these goals or to avoid hypoglycaemia. Patients in whom insulin has been completely omitted for at least a week without the patient reverting to diabetes and without development of kentonuria and who do not need to resume insulin treatment during the trial are considered "no longer insulin required ”(NIR) and are considered“ in remission ”. If NIR patients subsequently develop hyperglycemia and exceed the treatment goals, insulin or the oral hyperglycaemia agent glybenzamit is administered.

TRIAL MEDICATION

Bromocriptine administered alone:

i) Initially in a dose of approx. 1.25 mg p. o. at

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Going to bed for 3-4 days; increasing up to -

ii) 1.25 mg / day p.o. in the morning plus 1.25 mgp.o. at bedtime for about 3-4 days (= 2.5 mg / day in total); increasing up to -

iii) 1.25 mg p.o. in the morning and 2.5 mg p.o. at bedtime for about 3-4 days (= 3.75 mg / day in total); With -

iv) further possible increase in the daily dosage of approximately 1.25-2.5 mg / day every 3-4 days up to a maximum daily dosage of 10 mg / day in total.

RESULTS

The results show a marked and significant increase in NIR remission in patients who received the medication above compared to a remission (ie spontaneous NIR remission) recorded for groups of young diabetics for whom no therapy was used or in comparison with NIR -Remissions that received alternative intervention therapy. The results demonstrate the effectiveness of bromocriptine monotherapy in accordance with the present invention.

The results also indicate that the medication is well tolerated, e.g. can be shown by measuring further physiological parameters in the course of the experiment.

Equivalent results to the above can be obtained in analogously designed clinical trials for patients suffering from glomerulonephritis (with or without nephrotic syndrome), myasthenia gravis, autoimmune haematological disorder (including aplastic anemia, pure red cell anemia, idiopathic thrombocytopenia and especially hemolytic Anemia), systemic lupus erythematosus, autoimmune inflammatory disease (including ulcerative colitis and especially Chron's disease), endocrine ophthalmophilia, Graves' disease, or multiple sclerosis using bromocriptine monotherapy.

The dose of bromocriptine to be administered in accordance with the present invention, e.g. B. in the form of their mesylate, will of course depend on the mode of administration and the particular condition to be treated.

Bromocriptine is preferably administered in dosage levels and / or in accordance with a daily mode of administration and / or in a form that is available around the clock, i.e. continuously allows a reduction in normal serum prolactin levels. In normal people, serum prolactin levels, e.g. by radio-dioimmunoassay (RIA), cyclic variations during any 24 hour period with average levels of about 3-5 ng / ml (RIA) during the day increasing to about 15-20 ng / ml towards evening and at night. Preferably, in the practice of the present invention, the dosage of bromocriptine is carried out in such a way as to ensure that the serum prolactin levels do not rise above about 5, preferably about 3, and more preferably about 2 ng / ml (RIA) any 24 hour period. Appropriate administration is carried out in such a way as to ensure that the average serum prolactin levels during any 24 hour period do not exceed 3, preferably not exceed 2 or even 1 ng / ml (RIA).

To achieve a continuous decrease in normal serum prolactin levels as described above, administration can be either enterai (e.g. oral) or penteral (e.g. i.m.) in divided doses, e.g. 2 x or more, preferably 3 x or more / day or by using a suitable sustained delivery form.

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

Bromocriptine therapy is suitably gradually introduced by gradually increasing the daily dosage rate, e.g. 3 to 5 or more weeks until the desired final dose rate is reached, for example in relation to the clinical trial method.

Both the oral and parenteral dosage forms for bromocriptine that are useful in the practice of the present invention are known and commercially available. Bromocriptine mesylate is commercially available under the registered trademarks Parlodel® and Pravidel® in tablet form of 2.5 mg (divisible e.g. to enable a 1.25 mg dosage) and in 5 mg and 10 mg capsule form.

The present invention further comprises a pharmaceutical composition containing bromocriptine as an active ingredient for use in a disease from the above group.

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Claims (4)

672,987 PATENT CLAIMS 1. A pharmaceutical composition containing bromocriptine as an active ingredient for use in treating a disease selected from the group consisting of: a) myasthenia gravis; b) endocrine ophthalmopathy; c) Graves' disease; d) juvenile diabetes, type I diabetes mellitus; e) glomerulonephritis, with or without nephrotic syndrome; f) systemic lupus erythematosus; g) autoimmune haematological disorder; h) multiple sclerosis; and i) autoimmune inflammatory bowel disease 2. A pharmaceutical composition according to claim 1, wherein the bromocriptine is in the form of its mesylate. 3. A pharmaceutical composition according to claim 1, containing 2.5 to 10 milligrams of bromocriptine per unit dose. 4. The use of bromocriptine for the manufacture of a pharmaceutical composition according to claim 1 for the treatment of a disease selected from the group consisting of: a) myasthenia gravis; b) endocrine ophthalmopathy; c) Graves' disease; d) juvenile diabetes, type I diabetes mellitus; e) glomerulonephritis, with or without nephrotic syndrome; f) systemic lupus erythematosus; g) autoimmune haematological disorder; h) multiple sclerosis; and i) autoimmune inflammatory bowel disease.