CH702779B1 - Use of pentosan polysulfate sodium in the preparation of a medicament for the treatment of diabetic nephropathy. - Google Patents

Abstract

The invention relates to the use of sodium pentosan polysulfate for the preparation of a medicament for the treatment of diabetic nephropathy.

Description

Description

Field of the invention

This invention relates to the use of sodium pentosan polysulfate in the preparation of a medicament for the treatment of diabetic nephropathy.

Context of the invention

[0002] Diabetic nephropathy and intercapillary glomerulonephritis is a progressive renal disease caused by angiopathy of the capillaries in the glomeruli of the kidney following so-called diabetes mellitus. Diabetes Mellitus is a disease where the body is unable to properly metabolize carbohydrates. This disease is characterized by excessive amounts of sugar in the blood (hyperglycemia) and in the urine due to inadequate production and / or use of insulin in the body. This disease causes damage to many organs including the eyes, nerves, blood vessels, heart and kidneys. Diabetes Mellitus is the most common cause of kidney failure and accounts for more than one-third of all patients undergoing dialysis. Some ethnic groups, particularly African-Americans, Hispanics and Native Americans, are particularly susceptible to kidney damage following a complication of diabetes.

The syndrome can be found in patients with chronic diabetes (15 years or more from the first appearance), so that patients are usually of a certain age (between 50 and 70 years). The disease is progressive and can be fatal two to three years after the initial lesions, and is more common in men. People with both type 1 and type 2 diabetes are at risk. The risk is higher if blood glucose levels are poorly controlled. In addition, when nephropathy develops, more rapid progression is detected in patients who have poor control of their blood pressure. People with high cholesterol levels in the blood are also at greater risk than others. In some cases, genetics or heredity may also play a role. Strict control of blood glucose and blood pressure can reduce the risk of developing nephropathy, but these goals are not always easy to achieve because of the limitations of current drug therapies and lifestyle. The kidneys are formed of many filtration units called nephrons. Each nephron has a cluster of tiny blood vessels called a glomerulus. Together, these structures help eliminate waste from the body. Too high blood sugar levels can damage these structures and cause them to thicken and heal. Slowly, over time, more blood vessels are destroyed. Renal structures begin to leak and proteins (albumin) begin to pass into the urine. At an early stage, diabetic nephropathy has no symptoms. These develop at later stages and may be the result of excretion of large amounts of protein in the urine or due to kidney failure.

[0004] Hypertension or high blood pressure is a negative factor in all progressive nephropathies and in particular in diabetic nephropathies. Hypertension is a complication of diabetes that is thought to contribute most directly to diabetic nephropathy. Hypertension is considered both the cause of diabetic nephropathy and the result of the damage caused by the disease. During the evolution of kidney disease, physical changes in the kidneys often result in higher blood pressure. Uncontrolled hypertension may cause progression to the final phase of diabetic nephropathy faster.

[0005] Diabetic nephropathy is described as evolving through five phases. Phase 1 (very early diabetes) - increased requirements placed on the kidneys indicated by a glomerular filtration rate (GFR) above normal. Phase 2 (development of diabetes) - glomerular filtration rate remains high or returned to normal, but glomerular damage has progressed to significant microalbuminuria (slightly higher protein albumin level in the urine). Patients in phase 2 excrete more than 30 mg of albumin in the urine over a 24-hour period. Significant microalbuminuria will progress to end-stage renal failure (ESRI). Therefore, all patients with diabetes should be screened for microalbuminuria on a regular basis (every year). Phase 3 (diabetes manifested or detected by the test strip) - glomerular damage progressed to clinical albuminuria. Urine has a positive test strip test and contains more than 300 mg of albumin over a 24-hour period. High blood pressure typically develops during phase 3. Phase 4 (advanced diabetes) - continuous glomerular damage, with increased amounts of protein albumin in the urine. The filtration capacity of the kidneys begins to decrease steadily and blood urea nitrogen (BRIOCHE) and creatinine (Cr) start to increase. The glomerular filtration rate decreases by 30% per year. Almost all patients have stage 4 hypertension. Stage 5 (end stage renal failure, ESRI) - GFR glomerular filtration rate has dropped to approximately 10 mL / min (10 mL / min) and replacement therapy kidney (ie hemodialysis, peritoneal dialysis or renal transplantation) is required.

[0006] The control of blood pressure is the keystone in the prevention and treatment of diabetic nephropathy. Controlling blood pressure is critical to slowing the natural course of diabetic nephropathy in patients with type 1 and type 2 diabetes. Parving et al. studied 12 type 1 diabetics and treated hypertension before angiotensin inhibitors were available. By the use of metoprolol, hydralazine and diuretics, patients with macroalbuminuria and a declining glomerular filtration rate

2 have been treated to reduce average blood pressure from 120 to less than 105 mmHg. Diuretics have been shown to be extremely beneficial supplements for the control of blood pressure. Diuretics are first-line agents for many subjects with hypertension and are used as second-line supplements after complete inhibition of angiotensin in diabetics (Parving H, Mauer M, Ritz E. Diabetic Nephropathy. Brenner BM, Brenner and Rector's The Kidney, Philadelphia 8th ed., Pa: Saunders Elsevier, 2007: Ch.36).

[0007] Drugs such as angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor antagonists (ARBs) help reduce the amount of protein in the urine. Many studies have suggested that a combination of these two types of drugs would be ideal. It is also very important to control lipid levels, maintain a healthy weight, and practice regular physical activity for a healthy lifestyle. Urinary tract infections and other infections are common and can be treated with appropriate antibiotics. Dialysis may be required during the terminal phase of nephropathy. At this stage, a kidney transplant should be considered. Another option for patients with type 1 diabetes is a combined kidney and pancreas transplant.

[0008] Angiotensin Converting Enzyme Inhibitors (ACEIs) are a group of pharmaceuticals that are used primarily in the treatment of hypertension and congestive heart failure (CHF); ACE inhibitors block the conversion of angiotensin I to angiotensin II. Clinical trials have shown that ACE inhibitors slow the progression of diabetic nephropathy regardless of their effect of reducing blood pressure. This action of ACE inhibitors is used in the prevention of renal failure due to diabetes. All angiotensin converting enzyme inhibitors except fosinopril are excreted primarily by the kidneys. They have similar actions and side effects, including severe hypotension, acute renal failure (especially in cases of bilateral renal artery stenosis), hyperkalemia, dry cough (sometimes accompanied by wheezing of the breath), and angioedema. Cough and angioedema are considered to be controlled by bradykinin. IECA inhibitors include captopril (Capoten brand); zofenopril; Enalapril (trademark Vasotec / Renitec); Ramipril (trademark Altace, Tritace, Ramace, Ramiwin); Ouinapril (Accupril brand); Perindopril (Coversyl brand, Aceon); Lisinopril (Lisodur brand, Lopril, Novatec, Prinivil, Zestril); Benazepril (Lotensin brand) and Fosinopril (Monopril brand).

[0009] Angiotensin receptor antagonists (ARBs) are specific and selective antagonists of the angiotensin 1 1 receptor. In comparison with ACE inhibitors, ARBs are associated with a lower incidence of cough, rash. and / or alterations in taste of medicinal origin. Losartan (brand Cozaar) and Valsartan (brand Diovan) are used in patients who are not able to tolerate ACE inhibitors. They can induce a more complete inhibition of the renin-angiotensin system than the ACE inhibitors. They do not alter the reaction to bradykinin and are less likely to be associated with cough and angioedema. Irbesartan (brand Avapro) and Valsartan lower albumin, excretion and prevent the development of diabetic nephropathy, even when changes in blood pressure are controlled. These drugs only reduce the rate of progression of the disease but not stop it. The average patient experienced a delay in progression to end-stage renal failure (ESRI) of about 2 years. The most common side effects of ARBs are coughing, high potassium levels, low blood pressure, dizziness, headache, drowsiness, diarrhea, feeling of abnormal taste (metallic or salty), and rashes. In comparison with ACE inhibitors, coughing appears less often with ARAs. The most serious side effects are kidney failure, liver failure, allergic reactions, decreased white blood cells and tissue swelling (angioedema). ARAs are not usually prescribed during pregnancy as they may cause birth defects (Finnegan PM, Gleason BL, Combination ACE inhibitors and angiotensin II receptor blockers for hypertension, Ann Pharmacother 2003, 37 (6): 886- 9. PMID 12773079 and Krum H, Carson P, Farsang C, et al., Effect of valsartan ACE inhibitor therapy in patients with heart failure: results from Val-HeFT Eur J Heart Fail 2004; 6 (7): 937 PMID 15556056).

Brief description of figures [0010]

Fig. 1 illustrates the effects of PPS on podocyte production of chemotactic factors for monocytes (MCP-1) stimulated by lipopolysaccharides (LPS).

Fig. Figure 2 illustrates the effects of PPS on macrophage production of chemotactic factors for monocytes (MCP-1) and nitric oxide stimulated by lipopolysaccharides (LPS).

Fig. 3 illustrates the effects of PPS on glomerular collagen type 4.

Fig. 4 illustrates the effects of PPS on glomerular and tubulointerstitial lesions caused by diabetic nephropathy.

Fig. 5 and 6 illustrate the effects of PPS on albuminuria.

3 Detailed description of the invention

[0011] There is therefore a need for new drugs and treatments that are effective against diabetic nephropathy and intercapillary glomerulonephritis and that can be administered orally and that effectively and safely treat the conditions designated by causing a regression of established lesions.

According to the invention, it is proposed the use of sodium pentosan polysulfate in the preparation of a medicament for the treatment of diabetic nephropathy. Preferably, the drug comprises sodium pentosan polysulfate in a dosage of 300 to 3000 mg per day and the dose comprises dosage units of 50-300 mg.

Sodium pentosan polysulfate (PPS) is a polysaccharide, esterified with sulfuric acid. It has a molecular weight ranging from about 1500 Daltons to about 6000 Daltons. Regarding its chemical and physical properties, sodium pentosan polysulfate belongs to polyanions having a high electrical charge density. The basic structure of this macromolecule consists of pentoses, that is, connected (1 → 4) beta-D-xylopyranose units containing glucuronic acid groups statistically every tenth unit. Pentosan polysulfate has a higher degree of sulfation than heparin and 1/15 the anticoagulant activity of heparin. It is represented by the following general structure, where n represents the number of recurring units: o

S-O <'> Na *

[0014] PPS is chemically and structurally similar to heparin and glycosaminoglycan. It produces an effect similar to heparin. The main difference between heparin and heparinoids lies in the method of production. Pentosan polysulfate is obtained from plant material derived from beech. This explains its homogeneous molecular weight distribution. In contrast, heparins or heparinoids come from animal or bacterial sources. The compound has been approved by the FDA for use as an oral capsule for the treatment of interstitial cystitis in humans (Bouchelouche et al., 2001, Jepsen et al., 1998, "Use as an oral capsule of Pentosan polysulfate for the treatment of interstitial cystitis in humans "). Pentosan polysulfate is administered orally, subcutaneously, intramuscularly, intravenously, intra-articularly or topically. Its use over the last 30 years has shown that pentosan polysulfate is a very safe medicine with few side effects and low toxicity. Pentosan polysulfate sodium has been available for more than 30 years as an anti-thrombotic / anti-lipemic agent (Ghosh et al., Sodium pentosan polysulfate has been available for over 30 years as an anti-thrombotic / anti-lipaemic agent (1992)). By virtue of its multiple efficacy, sodium pentosan polysulfate has been used for therapeutic purposes for the treatment of interstitial cystitis and as an anti-thrombotic / anti-lipemic agent. Millions of patients have been treated with various dosage forms and regimens of sodium pentosan polysulfate, a population sample that provides experimental data for its high efficacy and safety. Various forms of pentosan polysulfate sodium have been approved and marketed for the above-mentioned conditions in countries with excellent medical standards.

According to one advantage of the invention, a patient suffering from diabetic nephropathy is administered an effective amount of sodium pentosan polysulfate. The phrase "an effective amount" as used herein means an amount of PPS incorporated into a pharmaceutical preparation that is effective when administered one or more times daily for a prescribed period of time; for the prevention or substantial reduction of inflammations, the decrease of albumin levels in the urine and the reduction of mesangial matrix expansion. In patients, a total daily dosage of PPS from about 300 mg to about 3000 mg daily administered in one to four divided doses is effective to achieve the therapeutic purpose of preventing and reducing inflammation, decreasing albumin levels. in the urine and reducing the expansion of the mesangial matrix.

The advantage of a preferred embodiment of the invention is the administration to the patient comprising an effective amount of PPS and at least one pharmaceutically acceptable inert ingredient. As a pharmaceutically acceptable inert ingredient, fillers, binders or solvents are contemplated which do not compromise the desired activity of the PPS. Fillers such as clays or diatomite may be used if it is desired to adjust the size of the dosage form. Other ingredients such as excipients and vehicles may be necessary to impart the desired physical properties to the dosage form. Such physical properties are, for example, clearance rate, texture and size. Examples of excipients and carriers that are useful for oral dosage forms are waxes such as beeswax, castor wax, glucose wax or carnauba wax, cellulose compounds such as methylcellulose, ethylcellulose, and the like. , carboxymethylcellulose, cellulose acetate phthalate, hydroxypropylcellulose and hydroxypropylmethylcellulose, polyvinyl chloride, polyvinylpyrrolidone / polyvidone, stearyl alcohol, glycerin monostearate, methacrylate compounds such as polymethacrylate, methyl methacrylate and ethylene glycol / ethyl glycol dimethacrylate, polyethylene glycol or hydrophilic gums . The composition can be

4 in any dosage form commonly used in the pharmaceutical field but is preferably an orally administered dosage form. Dosage forms for oral administration may include conventional tablets, dermal tablets, capsules or caplets, sustained release tablets, capsules or caplets, lozenges, liquids, elixirs or any other form of oral dosage known in the art. pharmaceuticals. In the compositions of the invention, the active ingredient PPS is desirably present in an amount between about 50 mg and about 300 mg per dosage unit.

The exact dose administered to each patient will be based on the physical characteristics of the patient such as his age and body weight. Although oral administration is preferred, the method of treatment also includes administration of parenteral PPS and any other route of administration commonly used in the medical and pharmaceutical arts. Also, the compositions of the invention may include PPS in a parenteral vehicle or parenteral dosage form or other conventional pharmaceutically acceptable carrier or dosage form with suitable inert solvents, excipients and inert additives. Regardless of the route of administration or the type of pharmaceutical dosage form used, the daily dosage for the active ingredient PPS is between about 300 mg to about 3000 mg, although the dosage amounts down this scale would probably be used for parenteral administration.

The preferred embodiment of the invention is a formulation of PPS constant or slow release or prolonged in the form of an orally administered tablet, as follows: sodium pentosan polysulfate 300 mg hydroxypropyl methylcellulose (HPMC) 420 mg polyvinyl pyrrolidone (PVP) / polyvinylate 38.67 mg

Microcrystalline cellulose powder (MCCP) 67.83 mg isopropyl alcohol (IPA) q.s. magnesium stearate 4.5 mg purified talcum 9.0 mg

On the basis of its anti-inflammatory properties, PPS is an ideal product for use in diabetic nephropathy. There is no mention or suggestion available in the literature regarding the use of PPS in diabetic nephropathy. Excessive accumulation of extracellular matrix plays a major role in the evolution of diabetic nephropathy. Mesangial cells contribute to the renewal of the extracellular glomerular matrix. It has also been discovered that PPS decreases the production of type I and type IV collagen by mesangial cells. Chronic inflammation in the glomeruli and tubulointerstice is an essential component in the evolution of diabetic nephropathy. Our tests with PPS have established that PPS decreases the production by macrophages, mesangial cells and podocytes monocytes chemo-attracting protein 1 (MCP-1). There is no mention or suggestion in the prior art that pentosan sodium polysulfate decreases the production of type I and type IV collagen by mesangial cells. Our tests with PPS also established that the treatment of ROP / Os + diabetic mice with PPS decreases the expansion of the mesangial matrix.

The following experimental examples illustrate the invention without, however, limiting its extent:

Examples

To examine the effects of PPS on the production of MCP-1, podocytes or mesangial cells were cultured at a normal (6 nM) or high (30 nM) glucose level in the presence or absence of PPS (200 μg / ml) for two weeks. The effect of PPS on macrophage production of chemotactic factor for monocytes (MCP-1) stimulated by the final product lipopolysaccharide (LPS) and aminoglycans (AGE) from the peritoneum of C57B6 mice was also studied. examinations. The cell types used were: a. inflammatory cells (macrophages) b. parietal cells (podocytes - a glomerular cell of the kidneys)

The first efforts were to characterize sodium pentosan polysulfate a. For two purposes: i. Characterize the in vitro system ii. Determine if the product has a reproducible effect on the cell culture system in question

Applied general experimental methodology:

Hyperglycemia is introduced into female mice ROP / Os + aged 3 months by streptozootoxin (50 μg / g). After reaching stable hyperglycemia (> 250 mg / dL), the mice are randomly grouped into PPS group

5 (25 mg / kg / day in their drinking water) or control group (no active ingredient / placebo) and are followed for 3 months. Excretion of albumin in urine, histology, and levels of type IV collagen in glomeruli are measured. The effect of PPS on monocyte chemotactic factor production (MCP-1) is examined in podocytes or mesangial cells cultured for two weeks at a high level (30 μM) of glucose in the presence / absence of PPS (200 μg / ml).

For measurement of nitric oxide

The production of nitric oxide is determined by measuring the total concentration of nitrites / nitrates representing the final product of the metabolism of nitric oxide. In order to determine the local production of NO, the NOx total of culture supernatants are tested using the Griess reaction. 100 μl of supernatant are incubated for 30 minutes at 370 ° C. in the presence of 0.2 U / ml of Aspergillus nitrate reductase, 5 μΜ FAD and 0.1 mM NADPH in 50 mM of HEPES buffer (total volume 500 μΙ) for nitrate conversion. in nitrite. Following incubation, 5 μl of lactate dehydrogenase (1500 U / ml) and 50 μl of 100 mM pyruvic acid are added to each tube to oxidize all unreacted NADPH (pyridine nucleotides). greatly reduce the Griess reaction). Samples are then incubated for an additional 10 minutes at 37 ° C. Finally, 1 ml of pre-mixed Griess reagent is added to each tube. After an incubation time of 10 minutes at room temperature, the absorption of each sample is determined at 543 nm with a Hitachi U-2000 spectrophotometer.

For the measurement of MCP-1

The secretion of MCP-1 is measured in the culture supernatant by ELISA test.

Example 1

According to the general methodology, podocytes are cultured at high glucose (30mM9 x2) for two weeks in the presence / absence of PPS (200 μg / ml). MCP-1 production is measured at two weeks and compared to the control group. As shown in fig. 1, the results demonstrate that PPS treatment decreases the production of MCP1 stimulated by high glucose levels by podocytes and mesangial cells.

Example 2

According to the general methodology, macrophages are stimulated with LPS (0.5 μg / ml) +/- PPS (200 μg / ml). As shown in fig. 2, the results show that PPS almost completely blocks macrophage production of MCP-1 and LPS-stimulated nitric oxide.

Example 3

Diabetes is induced in female mice ROP / Os + aged 3 months by streptozootoxin injections (50 μg / g) to obtain glycemic levels of 200-400 mg / dL. It takes 2 weeks to obtain stable hyperglycemia in ROP / Os + mice. After establishment of stable hyperglycemia (> 250 mg / dL), mice are given PPS (25 mg / kg / day in their drinking water since PPS is soluble in water). The water consumption by each animal is recorded every two days. The drug concentration in the water is adjusted on the basis of the water consumption. The mice are controlled for 3 months. The excretion of albumin in the urine is monitored weekly during the first month following the onset of diabetes. A renal biopsy is performed in mice one month after the onset of diabetes.

[0029] Immunohistochemistry: Frozen tissues or tissues incorporated in low-melting paraffin wax are used for immunohistochemistry. Paraffin sections are rehydrated in a series of graduated alcohols to phosphate buffered saline (PBS). The infiltration of macrophages, polymorphonuclear cells and T cells is identified by means of commercial antibodies. Cell proliferation is identified by Ki67 positive staining. Extracellular matrix staining (collagen type 1, type III and type IV), growth factor (TGF-βΙ), chemokines and adhesion molecules (MCP-1, RANTES, VCAM-1), cell cycle regulatory molecules (cyclin D, cyclin E, p27) and aminoglycans / AGEs (CML, MG-AGE, RAGE, AGER1) are carried out using commercial antibodies or antibodies from our laboratory. The TUNEL (Terminal deoxynucleotidyl transferase dUTP Nick End Labeling) method is used to detect apoptotic cells. The results as illustrated in FIG. 3 clearly show that ROP / Os + diabetic mice after treatment with PPS show a decrease in glomerular collagen type 4.

Example 4

[0030] Renal Histology: The kidneys are fixed in situ by perfusion with freshly prepared 10% paraformaldehyde at mean arterial pressure and the tissue is incorporated into methacrylate to test morphology and glomerular volume and mesangial fractional area. . Tubulointerstitial lesions are evaluated semi-quantitatively. For electron microscopy, the tissue fragments are post-fixed for 1 hour in 1.0% osmium tetroxide (in 0.2 mol / L sodium cacodylate), pre-stained in 1.25% uranyl acetate for 1 hour. hour, dehydrated by means of

6

Claims (7)

graduated alcohol solutions, and incorporated in EPON epoxy resin. Glomerular and tubulointerstitial lesions are quantified by morphometry. FIG. Figure 4 shows the presence of several glomerular and tubulointerstitial lesions in the control mice whereas the glomeruli and tubulointerstices of PPS-treated mice were essentially normal. Thus, PPS treatment decreases the severity of diabetic nephropathy and improves tubulointerstitial inflammatory lesions. Example 5 [0032] STZ-Induced Sweet Diabetes Mellitus: mice are injected intraperitoneally with 40 μg / g STZ every day or every other day until stable hyperglycemia is established (> 200 mg / dL). . Renal biopsies are performed. The excretion of albumin in the urine is examined twice a week by ELISA. Figs. 5 and 6 clearly illustrate that PPS reduces albuminuria. P <0.05 vs. mouse from the control group. SPP treatment reduces albuminuria and the severity of nephropathy in ROP / Os + diabetic mice. Thus, the above results clearly show that sodium pentosan polysulfate reduces inflammatory lesions in the kidneys of mice with type I diabetes induced by streptozootoxin. SPP treatment is associated with decreased albuminuria and reduced kidney fibrosis. PPS inhibits pro-inflammatory reactions of glomerular mesangial cells, podocytes and macrophages. In addition, PPS decreases inflammatory reactions in both traditional inflammatory cells and organs. This means that PPS has a plethora of effects on chronic diseases affecting tissue and inflammation. It is evident from the experimental examples that the composition of the invention shows anti-inflammatory properties in the kidneys. It reduces albuminuria, kidney fibrosis, mesangial expansion and glomerular lesions in the kidneys, and is ideal for the treatment of diabetic nephropathy. claims 1. Use of pentosan polysulfate sodium for the preparation of a medicament for the treatment of diabetic nephropathy. The use of sodium pentosan polysulfate for the preparation of a medicament according to claim 1, wherein the sodium pentosan polysulfate is at a dosage of from 300 to 3000 mg per day. 3. Use of sodium pentosan polysulfate for the preparation of a medicament according to claim 2, wherein the assay comprises dosage units of between 50-300 mg. The use of sodium pentosan polysulfate for the preparation of a medicament according to claims 1 to 3, wherein the medicament comprises 300 mg of sodium pentosan polysulfate, 420 mg of hydroxypropyl methylcellulose, 38.67 mg of polyvinylpyrrolidone, 67.83 mg of powder. micro crystalline cellulose, qs of isopropyl alcohol, 4.5 mg of magnesium stearate and 9.0 mg of purified talc. 5. Use of sodium pentosan polysulfate for the preparation of a medicament according to one of claims 1 to 4, wherein the medicament is for oral administration. The use of sodium pentosan polysulfate for the preparation of a medicament according to claim 5, wherein the medicament is in the form of tablets, capsules, caplets or lozenges or liquids, syrups or elixirs. 7. Use of sodium pentosan polysulfate for the preparation of a medicament according to claim 6, wherein the tablets, capsules, caplets or lozenges or liquids, syrups or elixirs are in the form of immediate release or in a form of continuous release or extended. 7