Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K35/00—Medicinal preparations containing materials or reaction products thereof with undetermined constitution
  • A61K35/12—Materials from mammals; Compositions comprising non-specified tissues or cells; Compositions comprising non-embryonic stem cells; Genetically modified cells
  • A61K35/28—Bone marrow; Haematopoietic stem cells; Mesenchymal stem cells of any origin, e.g. adipose-derived stem cells
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K35/00—Medicinal preparations containing materials or reaction products thereof with undetermined constitution
  • A61K35/12—Materials from mammals; Compositions comprising non-specified tissues or cells; Compositions comprising non-embryonic stem cells; Genetically modified cells
  • A61K35/48—Reproductive organs
  • A61K35/54—Ovaries; Ova; Ovules; Embryos; Foetal cells; Germ cells
  • A61K35/545—Embryonic stem cells; Pluripotent stem cells; Induced pluripotent stem cells; Uncharacterised stem cells
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K38/00—Medicinal preparations containing peptides
  • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
  • A61K38/17—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
  • A61K38/18—Growth factors; Growth regulators
  • A61K38/1825—Fibroblast growth factor [FGF]
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K38/00—Medicinal preparations containing peptides
  • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
  • A61K38/17—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
  • A61K38/18—Growth factors; Growth regulators
  • A61K38/1858—Platelet-derived growth factor [PDGF]
  • A61K38/1866—Vascular endothelial growth factor [VEGF]
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
  • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K48/00—Medicinal preparations containing genetic material which is inserted into cells of the living body to treat genetic diseases; Gene therapy
  • A61K48/005—Medicinal preparations containing genetic material which is inserted into cells of the living body to treat genetic diseases; Gene therapy characterised by an aspect of the 'active' part of the composition delivered, i.e. the nucleic acid delivered
• • C—CHEMISTRY; METALLURGY
  • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
  • C12N—MICROORGANISMS OR ENZYMES; COMPOSITIONS THEREOF; PROPAGATING, PRESERVING, OR MAINTAINING MICROORGANISMS; MUTATION OR GENETIC ENGINEERING; CULTURE MEDIA
  • C12N2710/00—MICROORGANISMS OR ENZYMES; COMPOSITIONS THEREOF; PROPAGATING, PRESERVING, OR MAINTAINING MICROORGANISMS; MUTATION OR GENETIC ENGINEERING; CULTURE MEDIA dsDNA viruses
  • C12N2710/00011—Details
  • C12N2710/10011—Adenoviridae
  • C12N2710/10041—Use of virus, viral particle or viral elements as a vector
  • C12N2710/10043—Use of virus, viral particle or viral elements as a vector viral genome or elements thereof as genetic vector

Definitions

• the present invention relates to a treatment of acute and chronic diseases of the organs of the body, and more particularly to a combination of growth factor therapy and cell therapy for the treatment of acute and chronic diseases of the organs.
• myocardial ischemia is the leading cardiac illness affecting the general population in the Western world. Since the occurrence of angina symptoms or objective physiological manifestations of myocardial ischemia signifies a mismatch between myocardial oxygen demand and the available coronary blood flow, the goal of therapy is to restore this balance. This can be achieved either by attempting to prevent further disease progression through modification of risk factors, or by more aggressive modes of therapy such as reducing the myocardial oxygen demand (i.e.
• Stem cells have the ability to divide indefinitely, and to specialize into specific types of cells. Due to the regenerative properties of stem cells, they have been considered an untapped resource for potential engineering of tissues and organs. It would be a major advancement in science to provide uses of stem cells with respect to addressing acute and chronic diseases of the organs.
• Angiogenesis is a complex process that involves endothelial cell migration and proliferation, extracellular matrix breakdown, attraction of pericytes and macrophages, smooth muscle cell proliferation and migration, formation and "sealing" of new vascular structures, and deposition of new matrix.
• a number of growth factors including the fibroblast growth factors (FGF) and vascular endothelial growth factors (VEGF) are integrally involved in the angiogenic response in ischemic conditions and in certain pathological states. The availability of these factors has led to studies, which have demonstrated a therapeutic benefit in various animal models of the treatment of acute and chronic myocardial ischemia.
• basic fibroblast growth factor is an attractive candidate as an agent for therapeutic angiogenesis.
• these growth factors and stem cells are useful in the treatment of diseases of many other organs of the body.
• the invention provides a method for treating acute and chronic diseases of the organs by pretreating the patient with growth factors and/or gene therapy followed by the administration of adult stem cells or other cell therapy.
• the invention provides a method for the systemic, multi-tiered treatment of acute and chronic diseases of the organs by first selecting a patient displaying symptoms of acute or chronic diseases of the organs.
• the patient is pretreated with a growth factor protein formulation comprising at least one of the following: FGF-I and FGF-2; and at least one of the following: VEGF, VEGFA, VEGFB, PLGF, VEGFl 21, VEGF 145, VEGF 165; VEGFl 89, VEGF206 and mixtures, thereof.
• Gene therapy may also be used for pretreating the diseased organs, wherein the gene therapy is AD5(FGF4) or VEGF 165 plasmid DNA.
• Adult stem cells or other cell therapy are administered to the patient following pretreatment with the growth factor formulation and/or gene therapy formulation. The patient is continuously monitored to determine the progress of the treatment. If it determined that organ function is not improving, the concentration(s) of the growth factors is increased and/or the method of delivery is changed to a more invasive route of delivery. If it is determined that that there is insufficient organ tissue regeneration occurring, the number of stem cells or other cell therapy administered is increased and/or the method of delivery of the stem cells or other cell therapy is changed to a more invasive route of delivery. Treatment is continued until there is a clinical indication of amelioration of the symptoms of acute or chronic diseases of the organs in the patient, or until there is contraindication to continued treatment.
• a method for the systemic, multi-tiered treatment of acute and chronic diseases of the organs of the body by delivering a formulation comprising one or more therapeutic growth factor proteins together with adult stem cells or other cell therapy comprising the steps of: (i) selecting a patient displaying symptoms of acute or chronic disease of one organ; (ii) administrating at least one dose of an effective amount of a first therapeutic growth factor protein formulation selected from the group consisting of: FGF-I, FGF-2, VEGF, VEGFA, VEGFB, PLGF, VEGF121, VEGF145,
• VEGF 165 VEGF 189, VEGF206, and mixtures thereof; (iii) following administration of at least one dose of an effective amount of a first therapeutic growth factor protein formulation, administrating at least one dose of an effective amount of adult stem cells or other cell therapy; (iv) monitoring the effectiveness of administration of adult stem cells or other cell therapy by a monitoring means selected from the group of ultrasound, MRI, CAT scan, cardiac echo, EEG, EKG, EMG or blood tests; (v) determining, based on monitoring the effectiveness of stem cell treatment or other cell treatment by said monitoring means, whether an additional dose of stem cells or other cell therapy is necessary or whether an additional dose of growth factor protein is necessary; and (vi) repeating steps b) through e) until there is a clinical indication of amelioration of the symptoms of acute or chronic disease of an organ in the patient, or until there is contraindication to continued treatment.
• a monitoring means selected from the group of ultrasound, MRI, CAT scan, cardiac echo, EEG, EKG, EMG or blood tests.
• the invention provides a method for the treatment of acute and chronic diseases of the organs of the fetus from conception to birth by delivering a formulation comprising one or more therapeutic growth factor proteins together with adult and/or embryonic stem cells or other cell therapy, comprising the steps of: (i) selecting a fetus displaying acute or chronic disease of one or more organs; (ii) administering at least one dose of an effective amount of a first therapeutic growth factor protein formulation to the fetus in utero or the fetus removed from the womb comprising a growth factor protein selected from the group consisting of: FGFl , FGF2, VEGF, VEGFA, VEGFB, PLGF, VEGF121, VEGF145, VEGF165, VEGF189, and VEGF206; (iii) following administration of at least an effective amount of a first therapeutic growth factor protein formulation, administering at least one dose of an effective amount of adult and/or embryonic stem cells or other cell therapy; (i)
• a method for the repair of a hole thru an organ comprising: (i) sewing both sides of the hole with absorbable sutures; (ii) treating the sutures and/or the space between both sutures with a therapeutic growth factor protein formulation; and (iii) following administration of at least one dose of an effective amount of a first therapeutic growth factor formulation, administering at least one dose of an effective amount of adult and/or embryonic stem cells or other cell therapy into the space between the sutures or into the cavity of the organ as indicated.
• a method for the injection of growth factor proteins and stem cells or other cell therapy is provided.
• the method comprises: (i) providing a catheter having a tiny needle inside; (ii) the catheter being inserted down to the organ; (iii) the tiny needle being advanced to inject a growth factor protein into the organ; (iv) the needle being withdrawn to the outside of the organ; (v) from right after withdrawal of the needle up to 1 month later the stem cells or other cell therapy being injected into the organ by advancing the tiny needle; (vi) the needle being withdrawn to the outside of the organ; and (vii) steps c) to f) being repeated until the treatment is completed.
• of the invention provides for use of creatine kinase to assess the death or pending death of muscle cells in patients with chronic peripheral artery disease, acute peripheral artery disease, unstable claudication, or acute arterial occlusion.
• creatine kinase wherein the creatine kinase is monitored to assess the effects of growth factors and/or gene therapy and/or stem cell therapy or other cell therapy on the treatment of ischemic or other muscle diseases.
• FIG. 1 is an illustration of the lung, indicating a mechanism of delivery of aerosol drug articles through the lung and into the bloodstream;
• FIG. 2 is an illustration of the results of measured regional wall thickening in the LAD (normal) and LCX (collateral-dependent) distribution;
• FIG. 3 is an illustration of, at top, MRI perfusion images of the left ventricle and, at bottom, the ischemic zone extent in all groups of test animals; and
• FIG. 4 is an illustration of histopathological sections from the LCX distribution demonstrating an increased number of capillaries in all treatment groups.
• the invention relates to the treatment of acute and chronic diseases of the organs using at least one of the following: FGF-I and FGF-2; and at least one of the following: VEGF, VEGFA, VEGFB, PLGF, VEGF121, VEGF145, VEGF165; VEGF189, VEGF206 and mixtures, thereof.
• FGF-I and FGF-2 at least one of the following: VEGF, VEGFA, VEGFB, PLGF, VEGF121, VEGF145, VEGF165; VEGF189, VEGF206 and mixtures, thereof.
• FGF-I and FGF-2 at least one of the following: VEGF, VEGFA, VEGFB, PLGF, VEGF121, VEGF145, VEGF165; VEGF189, VEGF206 and mixtures, thereof.
• this combination of FGF and VEGF provides a synergistic effect in the treatment of the diseased organ.
• Gene therapy may also be used for pretreating the
• the cell therapy includes one or more of the following: hematopoetic stem cells, endothelial stem cells, hepatic stem cells, neuronal stem cells, muscle stem cells, cardiac stem cells, adult stem cells, embryonic stem cells, epidermal stem cells, adipose stem cells, mesenchymel stem cells, epithelial stem cells, stem cells obtained from a zygote, stem cells obtained from a blastocys, stem cells from any organ, stem cells from any tissue, neurons, oligodentrocytes, astrocytes, cells from any organ, cells from any tissue and combinations thereof.
• the diseased organ may include but is not limited to the brain, spinal cord, pancreas, liver, kidney, muscle, heart and upper and lower gastrointestinal tracts.
• the invention relates to a multi-tiered approach to the treatment of acute or chronic diseases of the organs.
• the patient is treated with growth factors including at least one of: FGF-I and FGF-2; and at least one of: VEGF, VEGFA, VEGFB, PLGF, VEGF121, VEGF 145, VEGF 165; VEGF 189, VEGF206, and mixtures thereof.
• the factors utilized with gene therapy include AD5(FGF4) and/or VEGF 165 plasmid DNA.
• the growth factors prime the organ that has been damaged by ischemia or other disease. The extent of improvement is monitored by ultrasound, MRI, CAT scan, cardiac echo, EEG, EKG, EMG or blood tests.
• the patient is treated with growth factors including at least one of: FGF-I, FGF-2, VEGF, VEGFA, VEGFB, PLGF, VEGFl 21, VEGF 145, VEGF 165; VEGFl 89, VEGF206, and mixtures thereof.
• the growth factors prime the organ that has been damaged by ischemia or other means.
• following administration of at least one dose of an effective amount of a first therapeutic growth factor protein formulation administrating at least one dose of an effective amount of adult stem cells or other cell therapy is performed. The extent of improvement is monitored by ultrasound, MRI, CAT scan, cardiac echo, EEG, EKG, EMG or blood tests.
• Intravenous administration is among the least invasive, but questions remain as to the ultimate delivery of the proteins to physiological sites at therapeutically effective levels.
• Next most invasive is intracoronary infusion through catheters.
• the insertion and manipulation of catheters has seen increasingly widespread use in the treatment of the symptoms of heart disease and a number of other clinical conditions.
• cardiac patients there is a very low level of toleration of such catheterization procedures, so that the possibility of repeated deliver of growth factor proteins is extremely limited.
• Next on the relative scale of invasiveness is intrapericardial injection of growth factors.
• the most invasive delivery method is direct injection of FGF and related proteins.
• the most non-invasive delivery method includes intrapulmonary inhalation therapy and intranasal delivery, which offers significant advantages over previous delivery strategies.
• Formulation and delivery technology has reached a state where a number of therapeutic macromolecules, including insulin, can now be delivered consistently, and at clinically effective levels via inhalation therapy.
• An added advantage arising from the non-invasive nature of inhalation therapy or intranasal delivery is that they are particularly attractive in the treatment of chronic organ conditions that require repeated dosing over longer time intervals.
• Inhalation treatment with FGF and/or VEGF for the management of acute or chronic heart disease is successful because the lung is one of the least blood or oxygen starved organs.
• the FGF or VEGF travels to the left atrium of the heart and from there travels to the coronary arteries where these growth factors are most useful.
• the inhalation of FGF and/or VEGF into the lungs can be used for the treatment of MI, unstable angina, or an anginal attack.
• This delivery system could also be used before, during, and/or after thrombolytic therapy (such as administration of recombinant tissue plasminogen activator) to help alleviate ischemic or reperfusion injury.
• the growth factors can be administered via inhalation therapy or intranasal delivery.
• the concentration of growth factors is increased or a more invasive procedure for administering the growth factors is utilized.
• the inhalation or intranasal therapy is repeated or the FGF and/or VEGF is given through a catheter into the coronary arteries or by direct injection to the diseased organ, or through the lymphatic system, or through the biliary ducts.
• other available methods of delivery are sublingual or IV utilizing one of the forms of FGF and/or VEGF. If the least invasive approaches are not successful, then alternate delivery systems should be explored. As clinically indicated, the FGF and/or VEGF could be given through a catheter into the coronary arteries or by direct injection into the diseased organ.
• VEGF and/or FGF you could follow the extent of improvement of the diseased organ by monitoring with ultrasound, MRI, CAT scan, cardiac echo, EEG, EKG, EMG or blood tests.
• FGF and/or VEGF could be administered by intrathecal, intra-arterial to the organ, retrograde venous injection to the organ, or through the lymphatic system, or through the biliary ducts. When injected directly into the organ, slow release forms of FGF or VEGF should be considered.
• the least invasive method can be attempted depending on the clinical status of the patient. If the least invasive approaches are not successful in achieving clinical improvement, then alternate delivery systems should be explored. As clinically indicated the
• FGF and/or VEGF could be given by direct injection into the diseased organ. If the treating physician determines that intranasal delivery or oral inhalation would be ineffective, a more invasive delivery method is used initially.
• Pulmonary Routes of Administration Pulmonary delivery of potentially therapeutic agents provides a direct route to the circulatory system, with a minimum amount of discomfort and pain, and is a cost-effective alternative when compared to the more invasive routes of delivery typically utilized for the administration of FGF, VEGF, and related proteins.
• the potentially most significant barrier to the delivery of compounds via the lungs is the tightly packed, single-cell-thick layer known as the pulmonary epithelium.
• the epithelium of the airway is very different from that of the alveolus.
• Thick, ciliated, mucus-covered cells line the surface of the airway, but the epithelial cell layer thins out as it reaches deeper into the lungs, until reaching the tightly packed alveolar epithelium.
• Insulin administered by oral inhalation effectively normalized diabetic patients' plasma glucose levels without adverse effects.
• Numerous patents have issued, directed to methods, formulations and devices for the oral administration of insulin via inhalation therapy. See, for example, U.S. Pat. Nos. 5, 952,008; 5,858,968; and 5,915,378, the disclosures of which are hereby incorporated specifically by reference.
• LHRH analogues used in treating osteoporosis
• interferon- ⁇ composed of 165 amino acids
• Some smaller peptides such as glucagon (29 amino acids) and somatostatin (28 amino acids) reach 1% bioavailability.
• the degree of bioavailability is thought to depend on the peptide or protein susceptibility to certain hydrolytic enzymes in the lung. How a macromolecular drug is formulated also affects its delivery to the deep lung.
• intravenous administration is among the least invasive, but questions remain as to the ultimate delivery of the proteins to physiological sites at therapeutically effective levels.
• Next most invasive is intracoronary infusion through catheters.
• the insertion and manipulation of catheters has seen increasingly widespread use in the treatment of the symptoms of heart disease and a number of other clinical conditions.
• there is a very low level of toleration of such catheterization procedures so that the possibility of repeated deliver of growth factor proteins is extremely limited.
• formulation and delivery technology has reached a state where a number of therapeutic macromolecules, including insulin, can now be delivered consistently, and at clinically effective levels via inhalation therapy.
• An added advantage arising from the non-invasive nature of inhalation therapy or intranasal delivery is that it is particularly attractive in the treatment of chronic organ conditions that require repeated dosing over longer time intervals.
• FGF and/or VEGF can improve the trafficking of the stem cells to the diseased or ischemic or damaged organ.
• the growth factors would increase blood flow optimizing the implantation and differentiation of the stem cells. See, U.S. Patent No. 4,296,100.
• the growth factors may also prevent ischemic damage to the stem cells or other cell therapy. See, U.S. Patent No. 4,296,100.
• Ventricular remodeling is in part determined by neovascularization and increased apoptosis, especially in the border zone of the infarction. Circulating stem cells have regenerative capacity and can repair some of the damaged organ following a disease. Growth factor pretreatment followed by cell therapy enhances organ tissue regeneration and restores organ function.
• Cell therapy follows growth factor treatment.
• the length of time between growth factor treatment and cell therapy depends on several factors. These include the degree of angiogenesis with growth factor pretreatment, the extent of organ damage, and the prognosis for the patient.
• the time period may be as short as 1 minute and as long as 2 months.
• One skilled in the art would be able to determine the length of time between growth factor pretreatment and cell therapy without undue experimentation depending upon the clinical status of the patient.
• PBSC peripheral blood stem cells
• Human bone marrow stem cells have been shown to traffic to nonhematopoietic organs where they can differentiate into cells.
• Human adult mesenchymal stem cells are accessible from the bone marrow and peripheral blood and can differentiate into endothelial cells and cardiomyocytes.
• endothelial cells and cardiomyocytes There is growing evidence that adult bone marrow cells can function to repair disease by repopulating damaged organs.
• PBSC peripheral blood stem cell
• PBSC peripheral blood cells
• the PBSC may be isolated from the peripheral blood through apheresis.
• the PBSC may be further purified by fluorescence- activated cell sorting or density gradient centrifugation.
• the route of delivery that is selected for the stem cells is crucial in that it helps to determine whether or not repair of the damaged organ will occur.
• a high stem cell concentration near the damaged area increases the chances that sufficient stem cell localization and differentiation occurs in order to repair the organ. In many cases this involves the targeted and regional administration of stem cells.
• the route of delivery of the stem cells or other cell therapy is intracoronary administration.
• the stem cells or other cell therapy may also be administered by injection through intrathecal, intra-arterial, retrograde venous injection to the organ, or direct injection into the organ or injection through the lymphatic system or injection through the biliary ducts.
• the stem cells or other cell therapy may also be delivered to the border area of the infarct. As one skilled in the art would be aware, the infarcted area is visible grossly, allowing the specific placement of stem cells or other cell therapy to be possible.
• the route of delivery is by intravenous injection.
• This route of delivery has the advantage of being the easiest to administer.
• the disadvantage of this route of delivery is that many of the stem cells or other cell therapy will spend a considerable time in the circulation system before the stem cells or other cell therapy reach the infarct-related organ.
• Organ regeneration following growth factor treatment and cell therapy is monitored by ultrasound, MRI, CAT scan, cardiac echo, EEG, EKG, EMG or blood tests. If it is determined that insufficient cell differentiation was occurring, then cell therapy is modified to increase delivery of stem cells or other cell therapy to the affected area. Thus, if it is determined by ultrasound, MRI, CAT scan, cardiac echo, EEG, EKG, EMG or blood tests that there is insufficient cell regeneration, then the number of stem cells or other cell therapy is increased or a more invasive route for stem cell delivery is used.
• Patients were excluded from the study if they had any of the following criteria: uncompensated congestive heart failure or an ejection fraction ⁇ 20%; a myocardial infarction within three months; new onset of angina or unstable angina within three weeks; PTCA, CABG, stroke or transient ischemic attack within six months; uncontrolled hemodynamically significant arrhythmias; critical valvular disease; restrictive or hypertrophic cardiomyopathy; arteriovenous malformations; proliferative retinopathy, retinal vein occlusion, or macular edema; renal insufficiency (creatinine clearance ⁇ 80 ml/min by 24-h urine collection); vasculitis or chronic immunosuppressive therapy; or any malignancy within the past 10 years (except for curatively treated nonmelanoma skin cancer).
• Patients with diabetes mellitus were eligible if they had no proliferative retinopathy or severe nonproliferative retinopathy, and no microalbuminuria.
• Patient population Fifty-two patients met all eligibility criteria and received a single IC infusion of rFGF-2. The mean age was 60.8.+-.10.1 years (range 41 to 80) and 2 of 52 patients were women. Six patients (1 1%) had diabetes mellitus and 31 patients (60%) had elevated cholesterol (serum cholesterol>200 mg/dl). Forty-three patients (83%) had a history of at least one prior CABG. The mean ejection fraction (evaluated by MR imaging) was 51.4.+-.12.0% (range 20% to 73%). Sixty-nine percent of patients had NYHA class II or III symptoms of congestive heart failure. Study design. This was an open-label interpatient dose escalation study. The initial dose of
• 0.33 g/kg was escalated over eight sequential groups to 48 g/kg IC. At least four patients were studied at each dose. If no patient experienced dose-limiting toxicity as defined by the protocol within six days, the dose was escalated; if one patient experienced dose-limiting toxicity, an additional four patients were studied at that dose.
• the MTD was defined as the dose tolerated by 9 of 10 patients.
• recombinant FGF-2 (rFGF-2, Chiron Corporation, Emeryville, Calif.) was infused with a Baxter pump through diagnostic catheters into two major conduits of myocardial blood supply over 20 min (10 min in each vessel) with continuous monitoring of systemic blood pressure and right atrial and pulmonary capillary wedge pressures, and cardiac output. In occasional patients the entire dose was infused into a single vessel that was believed to be the major source of blood supply.
• rFGF-2 Prior to initiation of rFGF-2 infusion, normal saline was administered intravenously (i.v.), if required, to ensure mean pulmonary capillary wedge pressure>12 mm Hg. Heparin (40 U/kg) was administered i.v. more than 10 min before rFGF-2.
• the volume of infusion varied with dose and the patient's weight, ranging from 10 ml at lower does to 40 ml at higher doses.
• the right heart (Swan-Ganz) catheter was left in place for 7 h following drug infusion to monitor filling pressures and cardiac output.
• Patients were monitored with full- disclosure telemetry for 24 h following rFGF-2 administration.
• Patients were discharged 24 h after study drug infusion and clinical follow-up visits were performed at days 6, 15, 29, 57, 180 and 360.
• Quality of life was assessed using the Seattle Angina Questionnaire at baseline and days 57 and 180.
• ETT's were obtained at days 29, 57 and 180.
• Exercise stressed nuclear perfusion scans rest thallium/stress .sup.99m Tc-sestamibi
• resting cardiac magnetic resonance scans were performed at days 29, 57 and 180.
• a fundamental question pertaining to IC delivery is how a drug with a relatively short plasma half-life can promote a relatively long-term process such as new collateral formation.
• One possible explanation is that first-pass extraction at the desired site of action is the primary determinant of FGF-2 biological effect. Although such extraction certainly occurs, animal studies demonstrated that ⁇ 1% of .sup.125 I-FGF-2 administered using the intracoronary route is deposited in the myocardium at 1 h and much less remains at 24 h.
• rFGF-2 intracoronary rFGF-2 was assessed through clinical observations, electrocardiography, hemodynamic monitoring, hematologic and serum chemistry profiles, development of anti-rFGF-2 antibodies, detailed ophthalmological exams with fundus photography and assessment of renal function by determination of creatinine clearance and proteinuria using 24-h urine collection.
• Dose-limiting toxicity was predefined as a persistent (>10 min) drop in systolic blood pressure by >50 mm Hg, change in heart rate to >120/min or to ⁇ 50/min, new clinically significant arrhythmia, new ischemic symptoms or ECG changes, new congestive heart failure, deterioration in renal function or any other serious adverse events.
• Clinical follow-up and safety assessment Clinical follow-up of at least six months was obtained on all patients. A total of 30 serious adverse events were reported in 22 patients. There was no apparent relationship between increasing dose of rFGF-2 and serious adverse events.
• rFGF-2 may have exacerbated the lymphoma course.
• One patient (2 g/kg) died 72 days after rFGF-2 infusion from complications of cardiac transplantation after sustaining several myocardial infarctions beginning four days after drug infusion.
• One patient with preexisting lymphadenopathy (6 g/kg) died at 62 days from septic complications of large-cell lymphoma, which was diagnosed at 10 days after dosing. In retrospect, the lymphoma most likely predated rFGF-2 infusion.
• Efficacy variables were analyzed using a linear mixed effects model with an unstructured covariance assumption for the repeated measurements, fit using the restricted maximum likelihood method. Model-based estimates of the means.+-.standard errors (SEM) are presented. An overall F-test for equality across all time points was conducted first. If this initial test was statistically significant, pairwise t tests to compare baseline with each on-study time point were performed at the nominal a-level. All reported p-values are two-sided, and a p- value ⁇ 0.05 was considered statistically significant.
• Magnetic resonance (MR) imaging Magnetic resonance (MR) imaging was performed at baseline and days 29, 57 and 180 in the body coil of a 1.5 T whole-body Siemens Vision or Philips NT system.
• Myocardial perfusion assessment Myocardial perfusion was assessed using MR imaging.
• the mean size of the delayed contrast arrival zone was 15.4.+-.0.8% of the left ventricle at baseline and was similar to the global left ventricular extent of ischemia determined by nuclear perfusion imaging (17.3.+-.1.8%).
• the size of the myocardial area demonstrating delayed contrast arrival was significantly reduced from baseline (15.4.+-.0.8%) at day 29 (9.0.+-.0.6%, pO.OOl), day 57 (5.6.+-.0.7%, p ⁇ 0.001) and day 180 (4.9.+-.0.8%, p ⁇ 0.001), overall pO.001.
• the pericardium was closed using 6-0 Prolene suture, (J&J Ethicon, Cincinnati, Ohio) and the chest was closed.
• a single dose of i.v. cefazolin (70 mg/kg) was given, and i.m. narcotic analgesics were administered as needed. Animals then were allowed to recover for 3 weeks (time sufficient for ameroid closure) before growth factor delivery.
• the treatment of animals was based on the National Institutes of Health guidelines, and the protocol was approved by the Institutional Animal Care and Utilization Committee of the Beth Israel Deaconess Medical Center. Growth Factor Delivery.
• Three weeks after ameroid placement animals were anesthetized with i.m. ketamine (10 mg/kg) and isoflurane by inhalation.
• a right femoral cut-down was performed and an 8 French arterial sheath was inserted for blood sampling, pressure monitoring, and left heart catheterization. Coronary angiography was then performed in multiple views using a 7 French JR4 diagnostic catheter (Cordis, Miami, FIa.) to confirm LCX occlusion and to assess the extent of collateral circulation in the LCX distribution ("collateral index"). After LCX occlusion was documented, percutaneous subxyphoid pericardial access was undertaken. With the animals in the supine position, the epigastric area was prepped and draped. An epidural introducer needle (Tuohy-17) was advanced gently under fluoroscopic guidance with a continuous positive pressure of 20 to 30 mm Hg. Entry into the pericardial space was confirmed by the injection of 1 ml of diluted contrast. A soft floppy-tipped guidewire was then advanced into the pericardial space and the needle was exchanged for a 4 French infusion catheter.
• the infusate was diluted to 10 ml with saline and infused over 5 min with continuous electrocardiographic and pressure monitoring.
• the catheter was withdrawn, and a set of colored microspheres (blue) was injected into the left atrium to obtain baseline (pretreatment) myocardial blood flow.
• a magnetic resonance study was carried out to obtain quantitative measures of global and regional left ventricular function [ejection fraction (EF) and radial wall motion] and assessment of perfusion using myocardial contrast density mapping.
• the animals then were allowed to recover for 4 weeks.
• Final Study Four weeks after intrapericardial agent administration, all animals underwent final evaluation.
• Pigs were anesthetized with i.m. ketamine (10 mg/kg) and isoflurane by inhalation. A left femoral cut-down was performed and an 8 French arterial sheath was inserted for blood sampling, pressure monitoring, and left heart catheterization. Coronary angiography was performed again in multiple views. A second magnetic resonance study was carried out for global and regional left ventricular function and myocardial perfusion. Myocardial blood flow was determined using colored microspheres at rest (yellow) and after maximal coronary vasodilation with i.v. adenosine (white). Animals then were euthanized under anesthesia and the heart was obtained for additional analysis. In addition, a detailed macroscopic and histologic postmortem examination was carried out on three animals in each group.
• the remaining 49 animals were randomized to each of five treatment groups with 10 animals in each of the FGF-2 and saline control groups and 9 animals in the heparin group. There were no significant hemodynamic effects of intrapericardial FGF-2 administration at any dose; no changes in blood pressure, heart rate, or left atrial pressure were observed with drug administration.
• Coronary angiography was performed in multiple views (right anterior oblique, anteroposterior, and left anterior oblique views for the left coronary artery; right anterior oblique and left anterior oblique for the right coronary artery). Evaluation of angiographic collateral density was performed by two independent angiographers blinded to treatment assignment. Differences in interpretations were resolved by a third angiographer. The collateral index was assessed for left-to-left and right-to-left collaterals using a 4-point scale (0, no visible collateral vessels; 1 , faint filling of side branches of the main epicardial vessel without filling the main vessel; 2, partial filling of the main epicardial vessel; and 3, complete filling of the main vessel).
• Myocardial Blood Flow Colored microspheres (15.+-.0.1 .mu.m diameter; Triton Technology Inc., San Diego, Calif.) were used to determine coronary blood flow before treatment initiation (blue) and at the time of final study (yellow and white).
• an angiographic JR4 catheter was advanced into the left ventricle and manipulated to engage the left atrium outflow by slow counterclockwise rotation of the catheter; catheter position was verified by contrast injection into the left atrium. In addition, mean left atrial pressure was recorded.
• a set of microspheres (6.times.lO.sup.6) was diluted in 10 ml of saline and injected into the left atrium over 30 s. Reference blood samples were withdrawn by using a syringe pump at a constant rate of 5 ml/min through the femoral artery. At the time of final study, coronary flow was measured at rest and after maximal vasodilation (achieved with the injection of i.v. adenosine, 1.25 mg/kg). After study completion, the heart was excised and regional myocardial blood flow was determined. The heart was excised and a 1-cm midtransverse slice was sectioned and cut into eight segments.
• tissue samples and the reference blood samples were digested in an 8 M KOH/2% Tween 80 solution and microspheres were collected using a vacuum filter. Dyes from microspheres were extracted using dimethyl formamide. Samples were then analyzed in a spectrophotometer (HP 8452 A; Hewlett Packard, Palo Alto, Calif). Regional blood flow was calculated from optical absorbance (AU) measurements corrected by tissue weight as follows:
• MRI Magnetic resonance Imaging
• MRI was available on 44 animals (8 in the control group; 9 in the heparin group; and 9 in each of the 30 .mu.g, 200 .mu.g, and 2 mg FGF-2 groups). In five animals, MRI was not performed due to temporary technical problems with the MRI system at the time of the final study.
• the porcine ameroid occlusion model is associated with the development of small areas of left ventricular myocardial necrosis in most animals.
• FIG. 3 depicts the extent of the ischemic zone of contrast in the five groups.
• FGF-2 induced a dose-dependent reduction in the extent of the ischemic zone, indicating achievement of better myocardial perfusion in the FGF-2 treatment groups [FIG. 3 bottom; ischemic zone (% of left ventricle): controls, 23.54.+-.2.84; heparin, 22.41.
• Sections (5 .mu.m) were obtained from all tissue samples, stained with hematoxylin/eosin, and examined microscopically.
• tissue samples were obtained from pericardium, epicardial coronary artery, and myocardium in the left anterior descending coronary artery (LAD) distribution (normal) and LCX distribution (ischemic).
• LAD left anterior descending coronary artery
• LCX LCX distribution
• FGF-2 was administered in a murine model of myocardial stunning.
• the advantages of this mouse model are well-defined markers of ischemia-reperfusion injury, including ischemic contracture, alteration in calcium homeostasis, and prolonged ventricular dysfunction, occurring within a time window too short to activate the mitogenic properties of FGF-2.
• Transgenic mouse hearts deficient in the expression of the inducible isoform of NOS (NOS2-/-) were used to further investigate the coupling of FGF-2 and NO during acute myocardial ischemia and reperfusion.
• Myocardial stunning is the phenomenon whereby an ischemic insult interferes with normal cardiac function, cellular processes, and ultrastructure for prolonged periods. Numerous mechanisms of myocardial stunning have been proposed, the most probable of which include generation of oxygen-derived free radicals, metabolic impairment, and calcium overload. Recently, a number of pharmacological agents and physiological manipulations have been shown to induce early or late ischemic preconditioning, a state characterized by reduced susceptibility to postischemic decline in myocardial function. In particular, FGF-2 has been demonstrated to improve myocardial function in the setting of acute myocardial ischemia both in vivo and in isolated rat heart studies. The well-known angiogenic effects of FGF-2, however, occur too gradually to be relevant in such settings. The purpose of this study, therefore, was to study the potential role of NO release in FGF-2- mediated cardioprotection and to define the NOS isoform responsible for FGF-2-induced NO release.
• Hearts were excised from adult C57/BL6 mice of either sex that had been anesthetized and heparinized (500 U/100 g body wt).
• the aorta was slipped over a 20-gauge blunt-tipped stainless steel needle through which oxygenated (95% O.sub.2 -5% CO.sub.2) Krebs-Henseleit (KH) buffer (in mM: 118.0 NaCl, 4.7 KCl, 1.2 KH.sub.2 PO.sub.4, 1.5 CaCl.sub.2, 1.2 MgCl.sub.2, 23.0 NaHCO.sub.3, 10.0 dextrose, and 0.3 EDTA, pH 7.4) was pumped at a rate of .sup.- 3 ml/mm.
• An intraventricular balloon catheter system specially designed for the mouse heart was passed through the mitral annulus into the left ventricle, and the distal end of the balloon catheter was connected to a Statham P23b (Gould, Cleveland, Ohio) transducer to record intraventricular pressure, Left ventricular (LV) pressure recordings were analyzed with regard to LV developed pressure (LVP), LV end-diastolic pressure, peak rate of pressure development (dP/dt.sub.max), time to 90% pressure decline, and peak rate of pressure decline (dP/dt.sub.min).
• LVP left ventricular
• LVP left ventricular
• LV end-diastolic pressure peak rate of pressure development
• dP/dt.sub.max peak rate of pressure development
• dP/dt.sub.min peak rate of pressure decline
• Ischemia and reperfusion The hearts were subjected to no-flow ischemia for 15 min. The organ bath was evacuated of its oxygenated solution and refilled with nitrogen-saturated perfusate. Pacing was maintained during ischemia. LV pressure was monitored throughout ischemia and reperfusion. All hearts ceased to contract within 3 min. The time for LVP to fall to 10% of baseline (T.sub.LVPIO) was measured to quantify differences in LV function during early ischemia. Mean ischemic Ca.sub.i.sup.2+ was calculated as the mean Ca.sub.i.sup.2+ recorded from the 2nd through the 14th minute of ischemia. Contracture was defined as an abrupt and sustained rise in intraventricular pressure above 4 mmHg.
• Contracture time was measured as the time from the onset of ischemia to the onset of contracture. At the end of 15 mm of ischemia, the nitrogen-saturated bath was replaced by the original bath maintained at 3O.degree. C. Flow was recommenced. Mean Ca.sub.i.sup.2+ during early reflow was calculated as the mean of the peaks of Ca.sub.i.sup.2+ recorded during the 1st minute of reperfusion. After 20 min of reperfusion, Ca.sub.i.sup.2+ and functional parameters were again measured.
• rFGF-2 Recombinant bovine FGF-2
• Chiron Spin Fluoride
• L-NAME N.sup.G -nitro-L-arginine methyl ester
• L-NIL L-N.sup.6 -(l-iminoethyl)lysine
• St. Louis, Mo. All studies were conducted at 3O.degree. C, and hearts were paced at 6 Hz to minimize consumption of aequorin. After a 15-min equilibrium period, baseline conditions were recorded.
• aequorin was injected into the apex of the heart. Briefly, after the perfusate was modified to contain 0.5 mM CaCl.sub.2, 0.6 mM MgCl.sub.2, and 20 mM dextrose, 1-3 .mu.l of aequorin were injected with a glass micropipette into a localized region of 2 mm.sup.2 at the apex of the heart.
• the heart was positioned in an organ bath such that the aequorin-loaded region was .sup.- 2 mm from the bottom of the bath.
• the Ca.sup.2+ and Mg.sup.2+ concentrations of the perfusate were increased to 2.5 mM Ca.sup.2+ and 1.2 mM Mg.sup.2+ in a stepwise fashion over a period of 40 min.
• the entire isolated heart preparation was positioned in a light-tight box for collection of the aequorin light signal. Aequorin luminescence was detected by a photomultiplier tube and recorded as anodal current.
• Triton X-100 was injected into the coronary perfusate to quickly permeabilize the myocardial cell membranes and expose the remaining active aequorin to saturating Ca.sup.2+. This resulted in a burst of light, the integral of which approximated the maximum light (L.sub.max) against which light signals of interest (L) provided the fractional luminescence (L/L.sub.max). L/L.sub.max was referred to a calibration equation to estimate Ca.sub.i.sup.2+.
• Myocardial Calcium Homeostasis Myocardial Calcium Homeostasis.
• primers were as follows: 5' (sense), 5'-GCCTCGCTCTGG AA AG A-3' (bases 1,425-1,441) (SEQ ID NO: 3); antisense, 5'-TCCATGCAGACAACCTT-S' (bases 1,908-1 ,924) (SEQ ID NO: 4).
• Glyceraldehyde-3 -phosphate dehydrogenase (GAPDH) mRNA was amplified from the same amount of RNA at the same time to correct for variation between different samples. The PCR products, separated on 1% agarose gels, were scanned and quantitated using Image-Quant software (Molecular Dynamics).
• NOS2 isoform
• ischemia in both NOS2 +/+ and NOS2-/- hearts was characterized by an abrupt fall in LV pressure, a gradual onset of ischemic contracture, and prolonged ventricular dysfunction throughout 20 min of reperfusion.
• rFGF-2 pretreatment prolonged T.sub.LVPIO, reduced the onset of contracture, and improved LV recovery throughout reperfusion.
• rFGF-2 failed to provide any protective effects against global ischemia and stunning as measured by changes in LVP, dP/dt.sub.max, and dP/dt.sub.min after 20 min of reperfusion. Release of NO and FGF-2 Effects on NOS Gene Expression
• NO concentration of NO in coronary effluent before and after rFGF-2 administration was measured. NO concentration increased significantly after perfusion with rFGF-2 compared with measurements after perfusion with vehicle (236.+- .24 vs. 190.+-.25 nM/g, P ⁇ 0.05) in wild-type hearts.
• the "knockout" of the NOS2 gene may have affected expression of NOSl or NOS3 genes in these mice.
• Northern analysis of NOS 1 and NOS3 gene expression in hearts from C57/BL6 NOS2+/+ and NOS2-/-mice No significant changes in expression of either gene compared with that in control mice were detected.
• Baseline parameters of cardiac function including myocardial Ca.sub.i.sup.2+ were similar at baseline in all groups and were not affected by administration of L-NAME, L-NIL (not shown), or rFGF-2. Interruption of coronary flow led to an abrupt fall in LV pressure in all hearts. This fall in LV pressure during early ischemia was significantly attenuated in hearts pretreated with rFGF-2 compared with control hearts. Pretreatment with rFGF-2 prolonged T.sub.LVPIO (124.+-.9 vs. 74.+-.5 s, rFGF-2 vs. control, P ⁇ 0.05) and significantly delayed the onset of contracture
• NAME was used to inhibit all isoforms of NOS in the heart. Pretreatment with L-NAME completely blocked the cardioprotective effects of rFGF-2 during ischemia, significantly reducing T.sub.LVPIO (79.+-.2 vs. 124.+-.9 s, L-NAME+rFGF-2 vs. rFGF-2, P ⁇ 0.05) and accelerating the onset of ischemic contracture (674.+-.24 vs. 893.+-.7 s, L-NAME+rFGF-2 vs. rFGF-2, P+0.05).
• L-NIL a NOS2- selective inhibitor, L-NIL was used. Similarly to L-NAME, L-NIL fully inhibited the cardioprotective effects of rFGF-2, significantly reducing T.sub.LVPIO (62.+-.3 vs. 124.+-.9 s, L-NIL+rFGF-2 vs. rFGF-2, P ⁇ 0.05) and accelerating the onset of Ischemic contracture (652.+-.16 vs. 893.+-.7 s, L-NIL+rFGF-2 vs. rFGF-2, P ⁇ 0.05).
• Myocardial Ischemia A porcine ameroid model was chosen for preclinical testing of delivery strategies because of several unique aspects.
• the ameroid occluder results in consistent and gradual occlusion of the LCX, resulting in minimal myocardial necrosis, but reduced regional myocardial function, which is detectable with various noninvasive imaging modalities.
• an effect of estrogen on cardiac angiogenesis cannot be ruled out and synchronization of these studies with the menstrual cycle is logistically impossible, females were excluded from this study.
• daily intracoronary injections of FGF-2 also induced increased vascularity of ischemic myocardium. Although very encouraging, there are little data considering the efficacy of single intravascular administration of angiogenic growth factors.
• a plastic ameroid (inner diameter, 2 to 2.5 mm; Research Instruments, Escondido, Calif.) was placed on the proximal left circumflex artery (LCX) or a major side branch, through a left lateral fourth intercostal thoracotomy. Three weeks (second phase, midstudy) later, right and left coronary catheterization was performed through a standard femoral cut-down after systemic anticoagulation with Heparin 100 U/kg. Intraarterial pressure and electrocardiogram were continuously recorded.
• LCX left circumflex artery
• Heparin 100 U/kg Three weeks (second phase, midstudy) later, right and left coronary catheterization was performed through a standard femoral cut-down after systemic anticoagulation with Heparin 100 U/kg. Intraarterial pressure and electrocardiogram were continuously recorded.
• the intracoronary FGF-2 was equally divided and infused into the right coronary artery (RCA) and the proximal LCX using a 3F Cordis infusion catheter. Intravenous infusions were given through an ear vein. In short proximal LCX stumps, FGF-2 was delivered into the proximal part of the LAD.
• the segment in the LCX territory was further subdivided in an endocardial and epicardial piece.
• Tissue samples and reference blood samples were digested and the microspheres retrieved according to the manufacturers protocol.
• Coronary angiography Seven follow-up angiograms, two in the control group, two in the FGF 2 .mu.g/kg IV, one in the FGF 6 .mu.g/kg IV, and two in the FGF 2 .mu.g/kg IC group, were not available for analysis. Collateral index had improved significantly in the 6 .mu.g/kg IV group and in both 2 and 6 .mu.g/kg IC groups, whereas baseline collateral index was similar (p 0.119, Kruskal Wallis). For all groups pooled, collateral index resulted from left-to-left collaterals
• Arterial pulse-gated MRI was performed on anesthetized (1% to 2% isoflurane) and ventilated animals, in the body coil of a 1.5-Tesla whole-body (Siemens, Munich Germany) Vision prototype.
• Baseline anatomic images were obtained by a turboFLASH technique to identify coordinates for apical four-chamber, two-chamber, and short-axis views.
• 24 sequential image frames were collected over 12 heartbeats during breath-hold using shared-center turboFLASH in each of the three standard views.
• TI optimal inversion time
• Tl gadodiamide
• the series of images was viewed as a movie, to locate the zone with impaired contrast arrival.
• the short axis at the center of that zone (target zone) was prescribed graphically.
• AU measurements were performed by two independent investigators blinded to treatment. Custom-designed software was used to define myocardial borders and measure wall thickness.
• End-systolic and end-diastolic left ventricular volumes were computed from biplane measurement (apical four-chamber and two- chamber views) as previously validated, and used to calculate left ventricular ejection fraction.
• Target wall motion (radial shortening) and target wall thickening were expressed as percentage of the radial length or wall thickness at the end of diastole. Both parameters were also measured at the septum, yielding normal target wall motion and target wall thickening.
• the area of delayed contrast arrival was defined as myocardium demonstrating distinctly slowed time (.gtoreq.l cardiac cycle) to half-maximal signal intensity, using a two-dimensional map of contrast intensity versus time.
• MRI left ventricular function
• EF left ventricular ejection fraction
• indexed target wall motion target wall motion/normal wall motion
• Hematology parameters included hemoglobin, mean corpuscular hemoglobin concentration, hematocrit, erythrocyte count, total leukocyte count, differential, platelet count, mean corpuscular hemoglobin, and mean corpuscular volume.
• Serum chemistry included aspartate aminotransferase, alanine aminotransferase, gamma glutyltransferase, alkaline phosphatase, lactate dehydrogenase, total bilirubin, total cholesterol, triglycerides, blood urea nitrogen, creatinine, creatine phosphokinase, albumin, globulin, total protein, electrolytes (Na, K, and Cl), calcium, phosphorus, and glucose.
• tissue samples were taken from major organs and processed for histology. Histopathological findings were graded on a scale of 1 to 4 (minimal ⁇ mild ⁇ moderate ⁇ marked), by a veterinary pathologist blinded to treatment. There were no macroscopic or microscopic lesions related to intravenous or intracoronary administration of FGF-2. Furthermore, no changes in hematological or biochemical parameters were observed in any of the treatment groups.
• FGF-2 intracoronary injection of 120 to 150 .mu.g FGF-2 improves regional blood flow as well as regional and global cardiac function.
• the ineffectiveness of intravenous FGF-2 might result from less favorable pharmacokinetics.
• Several studies have reported a 3- to 10-fold lower recovery of radiolabeled FGF-2 from the myocardium after intravenous administration than after intracoronary injection, which in turn has a lower recovery and shorter redistribution times than intrapericardially delivered FGF-2.
• FGF-2 might be retained in the myocardium by a high-capacity, low-affinity sink provided by heparin sulfates in the matrix and on the surface of endothelial cells, which are upregulated by ischemia.
• expression of FGF-Rl receptors which are the primary transducers of FGF-2 signaling, is also upregulated by ischemia.
• intravenous FGF-2 and 2 .mu.g/kg intracoronary FGF-2 had no major hemodynamic, hematotogic, or biochemical side effects.
• patients with a viable and ischemic myocardial area that could not be revascularized were randomized to receive heparin-alginate pellets containing 10 or 100 .mu.g of bFGF or placebo that were placed on the epicardial surface during CABG.
• the study population consisted of patients undergoing CABG at Beth Israel Deaconess Medical Center and Albert Einstein College of Medicine in Boston, Mass.
• the inclusion criteria included an area of myocardium supplied by a major coronary artery with advanced disease not amenable to bypass grafting or percutaneous intervention, inducible ischemia, and the ability to understand and sign the informed consent and to comply with planned follow-up.
• Heparin-sepharose beads (Pharmacia LKB) were sterilized under ultraviolet light for 30 minutes and then mixed with filter-sterilized sodium alginate. The mixed slurry was dropped through a needle into a beaker containing a hardened solution of CaCl.sub.2 (1.5% wt/vol). Beads formed instantaneously. Uniformly cross-linked capsule envelopes were obtained by incubating the capsules in the CaCl.sub.2 solution for 5 minutes under gentle mixing and then for 10 minutes without mixing. The beads were washed with sterile water and stored in 0.9% NaCl-I mmol/L CaCl.sub.2 at 4.degree. C.
• bFGF loading was performed by incubating 10 capsules in 0.9% NaCl-I mmol/L CaCl.sub.2 - 0.05% gelatin with 12.5 p (for 10-.mu.g dose) or 125 .mu. (for 100-.mu.g dose) of bFGF (GMP grade human recombinant bFGF provided by Scios, Inc) for 16 hours under gentle agitation at 4.degree. C.
• bFGF GMP grade human recombinant bFGF provided by Scios, Inc
• Previous studies have shown that under these conditions, 80% of bFGF in solution is absorbed into heparin-alginate pellets. The end product was sterilized under ultraviolet light for 30 minutes. With each preparation, several beads were cultured to ensure sterility.
• bFGF Heparin-Alginate Delivery After completion of coronary bypasses to all areas of the heart that could be revascularized and failure to graft the target vessel (which on occasions involved probing of the target vessel), multiple linear incisions were made in the epicardial fat surrounding the target vessel. Heparin-alginate pellets (containing bFGF or placebo) were inserted into the epicardial fat overlying the artery and secured in place by a 6.0 prolene suture to close the subepicardial incision. A total of 10 pellets were used in each patient (2 to 3 pellets were placed in each incision).
• LIMA left internal mammary artery
• LAD left anterior descending artery
• proximal vein-to-aorta anastomoses were constructed. Ventilation was reestablished, and cardiopulmonary bypass was terminated. Routine closure was then performed.
• the extent of CABG surgery was the same in all treatment groups; there were no significant differences with regard to the number of grafts, duration of surgery (average 3.0.+-.0.9 hours), or cross-clamp time (average 56.+-.13 minutes).
• the target vessel was the right coronary artery (RCA) in 15 patients, left circumflex artery in 7, and diagonal branch of the LAD in 2.
• One patient in the control group died 24 hours after surgery secondary to an autopsy-documented occlusion of one of the saphenous vein grafts, with a large myocardial infarction in that territory.
• a second death occurred in a patient in the 100-.mu.g bFGF group who could not be weaned off cardiopulmonary bypass (preoperative ejection fraction of 20%); an autopsy revealed patent grafts with extensive myocardial scarring and a thin rim of epicardial viable myocardium.
• Two other patients (both in the control group) required intra-aortic balloon pump support after surgery (in 1 patient, the intra-aortic balloon pump was inserted before surgery).
• Placement of bFGF-containing heparin-alginate microspheres had no significant short-term effects on blood pressure or heart rate; the mean arterial pressure was 84.8.+-.10.6 mm Hg before bypass, 89.+-.12 mm Hg on day 1, 93.+-.7 mm Hg on day 3, and 83.4.+-.1 1.1 mm Hg on day 5 and was not different among the treatment groups.
• In-Hospital follow-Up The postoperative course was evaluated, including-hemodynamic parameters, duration of ventilatory support, postoperative ECGs, postoperative cardiac isoenzymes, duration of hospitalization, and any evidence of infection.
• Serum bFGF levels were measured (ELISA, R&D Systems) before implantation and on the first, third, and fifth postoperative days. Complete blood count, coagulation parameters, serum chemistries, and urinalysis were performed before treatment and at days 3 and 5 after treatment.
• Clinical follow-up was available in the 22 surviving patients (7 from the placebo group, 8 from the 10 .mu.g-bFGF group, and 7 from the 100 .mu.g-bFGF group) and averaged 16.0.+-.6.8 months.
• all patients were angina-free except for 3 patients in the placebo group (Canadian Cardiovascular Society [CCS] class II in 1 and class HI in 2 patients) and 1 patient in the 10-.mu.g bFGF group (CCS class II).
• CCS Canadian Cardiovascular Society
• Two of the 3 placebo patients with angina underwent successful percutaneous revascularization (1 involved the target vessel and the second involved a vein graft stenosis). After hospital discharge, none of the patients died or sustained a myocardial infarction. There were no delayed wound infections, no clinical evidence of pericarditis, and no other adverse events. Laboratory evaluation at 90 days (available in 21 patients) did not show any adverse effect on complete blood count, coagulation parameters, serum chemistries
• MR perfusion imaging was performed as follows: a series of 4 inversion recovery images (1 every second heartbeat) was obtained as inversion time (TI) and adjusted to minimize the signal intensity from myocardium in the fourth frame. With the best TI determined by these scout images, a series of concurrent parallel images were acquired in diastole during breathhold, 1 every other heartbeat, at baseline and again with contrast injection (0.05 mmol/kg gadodiamide). In addition, complete blood count, coagulation parameters, serum chemistries, urinalysis, and serum bFGF level measurements were repeated at 3 months. Nuclear Perfusion Imaging. Twenty of the surviving 22 patients underwent stress nuclear perfusion imaging 90 days after CABG. In the first 10 patients, baseline studies were performed before CABG.
• the extent of myocardial injury and necrosis resulting from an ischemic insult is determined by the duration of interruption to antegrade flow, the size of the compromised territory, and the extent of collateral circulation to the region.
• these findings provide a rationale for investigation of new strategies that use growth factors such as bFGF to pharmacologically enhance collateral growth and to blunt the effects of impaired antegrade myocardial perfusion.
• bFGF growth factors
• Coronary Occlusion and Reperfusion Twenty-two mongrel dogs of either sex (weight, 17 to 23 kg) were randomly assigned to treatment with bFGF or vehicle.
• intraprocedural anticoagulation was achieved with the use of Hirulog, a synthetic direct thrombin inhibitor; after an intravenous loading dose of 2.5 mg/kg, intravenous infusion was commenced at 5 mg.multidot.kg.sup.- l.multidot.h.sup.-l and the rate adjusted to maintain the activated clotting time at >300 seconds.
• An angioplasty balloon catheter (balloonrartery ratio 1.0) was then inflated at 2 atm in the middle part of the LAD distal to the first diagonal branch, and occlusion was confirmed angiographically. After 4 hours' occlusion, the balloon catheter was deflated and removed, and LAD patency was confirmed angiographically.
• Ten micrograms of human recombinant bFGF in 20 mmol/L sodium citrate, 1 mmol/L EDTA, and 9% sucrose, pH 5; Scios Nova Inc
• 10 mL normal saline or vehicle (10 mL normal saline) was administered directly into the left main coronary artery via the guiding catheter 10 minutes after occlusion and again just before reperfusion.
• Measurement of Activated Clotting Time Activated clotting time was measured with the use of the Hemochron 801 timer (International Technidyne Corp). After 2 mL of whole blood was collected into a Hemochron tube containing 12 mg of Johns-Manville diatomaceous earth, the time taken to complete coagulation at 37.degree. C. was measured. Delivery and Biological Activity of bFGF.
• radiolabeled bFGF was passed through new and used systems.
• 20 .mu.g of cold bFGF was mixed with 25 .mu.Ci of radiolabeled bFGF in 20 mL of normal saline solution.
• a second batch of 20 .mu.g of cold bFGF was mixed with 25 .mu.Ci of radiolabeled bFGF in 20 mL of normal saline solution containing 1 mg/mL of dog albumin (Sigma Chemical Co). The number of counts per minute from both solutions was quantified in a scintillation counter.
• HistoChoice (Ameresco) for 4 hours, after which the left ventricle was cut into 1 -cm-thick slices perpendicular to its long axis, and the slices were weighed. With this technique, areas of viable tissue in the LAD distribution are stained red, necrotic areas remain white, and the circumflex territory is stained blue. For each slice, the area at risk, the area of infarction, and the circumflex territory were determined by computer-assisted planimetry, as previously described.
• tissue samples were taken from areas of infarction and areas at risk of infarction for histological examination to seek evidence of neovascularization. Given the assumptions that (1) neovascularization of ischemic regions would proceed from the circumflex and nonoccluded LAD distributions and (2) the tissue stimulus for neovascularization would be intense in tissue adjacent to the infarct zone, "border-zone" samples were taken from the area at risk midway between the edges of the macroscopically infarcted myocardium and the junction of the LAD and circumflex territories. Staining with hematoxylin and eosin was used to confirm the presence of tissue necrosis in the infarct zones. Immunohistochemical staining of tissue samples was performed with factor VIH-related antigen to detect endothelial cells and PCNA to detect proliferating cells.
• a blocking solution of 1: 10 (vol/vol) normal rabbit serum (Dako Corp) was added for 10 minutes before application of a l-in-50 dilution of murine monoclonal antibodies directed against PCNA (PClO Clone, Dako Corp).
• a blocking solution of 1 : 10 (vol/vol) normal swine serum (Dako Corp) was added for 10 minutes before application of a 1 :300 dilution of rabbit polyclonal antibodies directed against factor Vlll-related antigen (Dako Corp).
• the dilutions of the primary antibodies were prepared with the use of 1 % BSA in PBS and were incubated with the tissue sample at 30.degree. C.
• Left Ventricular Ejection Fraction Left ventricular ejection fractions were determined from single-plane left ventriculograms measured by a trained technician who was blinded to treatment assignment. Ejection fractions were calculated by use of the length-area method with a computer analysis package (Angiographic Ventricular Dynamics 5.1, Siemens).
• the results of the occlusion-reperfusion study demonstrated a reduction in infarct size without histochemical evidence of myocardial neovascularization.
• the acute hemodynamic study was performed to assess the presence of a vasodilator action of bFGF as described in dogs and other species whereby flow to the infarct zone could possibly be auggmented by an increase in the conductance of preexisting collateral channels, independently of neovascularization.
• coronary blood flow and coronary vascular resistance were unchanged after incremental pharmacological doses of intracoronary bFGF despite pronounced vasodilator responses to 10- and 20-second coronary occlusion and intracoronary NTG.
• Example 7 Intracoronary and Intravenous Administration of FGF-2 This study was designed to investigate the myocardial and tissue deposition and retention of bFGF after IC and i.v. administration in normal and chronically ischemic animals.
• i.v. cefazolin 70 mg/kg
• i.m. narcotic analgesics were administered as needed. Animals were then allowed to recover for 3 weeks (time sufficient for ameroid closure) before radiolabeled growth factor delivery.
• the treatment of animals was done according to National Institutes of Health guidelines and the protocol was approved by the Institutional Animal Care and Utilization Committee of the Beth Israel Deaconess Medical Center.
• Ischemic animals three weeks after ameroid placement
• normal noninstrumented animals were anesthetized with i.m. ketamine (10 mg/kg) and halo thane inhalation anesthesia.
• i.m. ketamine 10 mg/kg
• halo thane inhalation anesthesia By sterile technique, an i.v. line was inserted into the ear vein and a right femoral cut down was performed to introduce an 8Fr arterial sheath.
• Coronary angiography was then performed in multiple views using a 7 French JR4 diagnostic catheter (Cordis Laboratories, Inc., Miami, FIa.) to confirm LCX occlusion in ischemic animals and to assess the coronary anatomy, .sup.125 I-Bolton Hunter-labeled bFGF (.sup.125 I-bFGF; 25 .mu.Ci; New England Nuclear) with a specific activity of 110 .mu.Ci/.mu.g (4050 kBq/.mu.g) was combined with 30 .mu.g of cold bFGF and 3 mg of heparin (similar to the dose used in animal studies and in the recent phase I IC and i.v.
• IC IC
• i.v. i.v.
• IC IC
• i.v. i.v.
• i.v. i.v.
• Specific activity for urine was 0.01. +-.0.01% for IC and 0.005.+- .0.01% for i.v. administration at 1 h and increased to 0.02.+-.0.01% for IC and 0.03.+- .0.05% at 24 h for i.v. delivery, however, that increase was not statistically significant.
• LCX deposition for IC and i.v. delivery dropped to 0.0006.+-.0.0008% and 0.0005.+-.0.0002% in normal animals and 0.0006.+-.0.0006% and 0.0004.+-.0.0004% in ischemic animals, respectively.
• RCA myocardial distribution was similar to LAD and LCX distribution for i.v. administration. However, for IC delivery, RCA myocardial deposition was significantly lower than LAD or LCX myocardial deposition, because the radiolabel was infused in the left main coronary artery.
• LCX/LAD territory activity was 79% and 154% for nonischemic and isohemic animals at 1 h and 116% and 75% for nonischemic and ischemic animals at 24 h, respectively.
• Intravenous administration resulted in an LCX/LAD activity of 97% and 100% for nonisohemic and ischemic animals at 1 h and 123% and 98% for nonischemic and ischemic animals at 24 h. respectively.
• Myocardial autoradiography confirmed myocardial deposition for both IC and i.v. delivery with three times enhanced deposition for IC delivery compared with i.v. delivery at I h with near equalization of tissue deposition at 24 h (measured using densitometric analysis).
• IC delivery resulted in increased deposition in LAD and LCX deposition compared with RCA (noninfused territory) deposition
• i.v. delivery resulted in a more uniform distribution in the three myocardial territories by qualitative analysis.
• Light level autoradiography after 72-h exposure showed LAD endothelial deposition for IC delivery after 1 h. Evaluation of other arteries for IC delivery at 24 h and for all coronary arteries at all time points failed to show .sup.125 I-bFGF deposition even after 96 h of exposure.
• Duplicate plasma, urine (spot samples), and tissue samples from the liver, lung, kidney, and quadriceps muscle were obtained. Tissues were washed three times in saline to avoid contribution of radioactivity in blood. The heart, liver, lungs, and kidneys were weighed to determine total organ weight. Duplicate samples were also obtained from the right ventricle and from the proximal portion of the left anterior descending coronary arteries (LADs) and right coronary arteries (RCAs).
• LADs left anterior descending coronary arteries
• RCAs right coronary arteries
• a 1-cm mid left ventricular transverse slice was sectioned and cut into eight segments; each segment was divided into epicardial, mid- myocardial, and endocardial portions, .sup.125 I-bFGF activity was determined in a gamma counter (LKB Instruments, Inc., Gaithersburg, Md.). Background was subtracted and the amount of .sup.125 I-bFGF deposited within a specific sample was calculated as a percentage of the total activity administered. Total solid organ deposition was calculated by multiplying the specific activity per gram of tissue by the weight of the organ. Trichloroacetic acid precipitation was performed to determine specific activity, which averaged 86.3.+-.24.4%.
• a 2-mm transverse left ventricular section was obtained for organ level autoradiography and exposed in a phosphoimager for 24 h.
• tissue samples were obtained from the LAD and the subtended myocardium, formalin-fixed, paraffin- embedded, and 10 .mu.m sections were mounted on a slide, coated by a photographic emulsion for 72 h, developed, and examined using light level microscopy.
• IC delivery resulted in higher deposition in ischemic myocardium, possibly related to the increased expression of fibroblast growth factor receptors associated with myocardial ischemia. This was not seen in i.v. delivery, possibly related to the initial concentrations delivered to the ischemic myocardium.
• IC delivery by providing higher initial concentrations in the coronary circulation, may result in higher deposition in ischemic areas.
• IC delivery resulted in enhanced bFGF deposition compared with i.v. delivery only in myocardial territories subtended by the infused artery. Therefore, for IC delivery to provide an advantage over i.v. delivery, infusion should be carried out in all coronary arteries and bypass grafts if present. Whether infusing a larger dose of bFGF would result in similar myocardial deposition to IC delivery (a more invasive approach) was not investigated. For IC delivery, bFGF was identified on the endothelial cells of the infused arteries, where it might exert its effect. In addition, this study raises an important question of whether more local or sustained delivery is necessary for bFGF effect, particularly with the relatively low cardiac deposition for both delivery modalities.
• dosage levels for administration of FGF, VEGF and/or related growth factor proteins can be initiated at levels substantially the same as those utilized for IC delivery. If ineffective, as measured by CPK-MB levels, then either repeated doses, or higher dose loading can be utilized.
• the preferred method of oral inhalation delivery utilizes a dry powder inhalant formulation due to the relative high stability of proteins in the dried crystal form.
• the delivery parameters for FGF and similar proteins are much less stringent in that the severe, potentially fatal, consequences of administering overdoses of insulin are not of concern. Possible adverse consequences of administration are easily monitored on the clinical level and appropriate adjustments of dose level and dosing frequency can be made.
• compositions comprising FGF, VEGF and/or related proteins suitable for delivery by oral inhalation, preferably in a dry powder form.
• Acceptable levels of dosing and a suitable dosing regimen are summarized below:
• a 45 year old white male has an echocardiogram which shows inferior hypokinesis and a low normal ejection fraction of 45%.
• Patient has no chest pain and cpk/mb level is normal; there is no acute damage.
• Patient has an angiogram which shows the artery to the inferior wall at the heart to be 50% blocked.
• 1 mg of VEGF A is given intra coronary to the artery which feeds the inferior wall.
• a dose of 2 x 10 4 of stem cells is given IV.
• the patient's recovery is followed by echocardiography.
• the stem cell dose is repeated daily for 5 days.
• the echo-cardiogram shows no inferior hypokinesis and a normal ejection fraction at 50%.
• Example 10 A fifty three year old black female has an echocardiogram which shows global hypokinesis and an ejection fraction at 30%. Clinically she appears to be in acute heart failure. Angiogram shows essentially normal coronary arteries. A dose of 2 mg FGF-2 is given intracoronary to each of the 4 main arteries supplying the heart. Simultaneously a does of 20 mg FGF-2 is given by inhalation; 2 inhalations repeated at 5 minutes; twice daily; maintain for 7 days. Simultaneously, a dose at 2 x 10 4 of stem cells is given intracoronary to the left main artery and to the right coronary artery and repeated every four hours for 10 days. The patient is followed by echo cardiogram at 3 weeks shows no global hypokinesis and an ejection fraction of 45% low normal.
• Echocardiography shows an ejection fraction at 30% with global hypokinesis.
• the four main arteries are each treated with gene therapy - 500 micrograms VEGFl 65 plasmid DNA.
• 2 x 10 4 of PBSC are injected into the right coronary artery and 2 x 10 4 of PBSC are injected into the left main coronary artery. This procedure is repeated 4 times per day for 10 days.
• an echo-cardiogram shows the ejection fraction at 45% and normal (wall motion).
• Example 12 A fifty-five year old black female experiences an acute anterior myocardial infarction.
• An echo-cardiogram shows an ejection fraction of 40% with regional acute anterior hypokinesis.
• the patient undergoes emergency bypass surgery. During surgery the patient is injected with 5 doses of 100 ⁇ g FGF-2 around and adjacent to the necrotic myocardium. Ten minutes later 5 doses of 1 x 10 4 of PBSC is administered just outside the FGF.
• Four weeks later echo-cardiography shows almost normal anterior wall with an ejection fraction at 45%.
• Example 13 A 21 year old white male was shot in the heart during a hunting accident. During emergency surgery he is found to have a VA inch hole in his left ventricle. The VA inch hole is sewed over both sides with absorbable sutures. The sutures are infused with 2 mgs of VEGF A on each side. A catheter is placed into the left ventricle during heart catheterization. 2 x 10 4 of stem cells are injected daily through the catheter for 10 days. Four weeks later, an echo-cardiogram shows that the heart is fully healed with an ejection fraction of 60%.
• a fifty-seven year old white male patient has chronic cardiomyopathy.
• the patient has an echocardiogram which shows an ejection fraction of 35% and global hypokinesis.
• the patient has an angiogram which shows 65% blockage of left anterior descending (LAD) and 60 % blockage of the right coronary artery.
• the patient receives gene therapy delivered by an arterial infusion with adenovirus vector Ad5 (FGF4) in both the LAD and right main coronary artery. Each dose was 10 10 viroparticles.
• FGF4 adenovirus vector
• a 61 year old white male is suffering from multi-infarct dementia.
• the patient receives 20 mg of FGFl intranasal for 7 days to prime the brain.
• On day 2 the patient is treated with 2 x 10 4 stems IV daily for 6 days.
• Patient's initial mini-mental status score is
• a 63 year old white female suffers from Alzheimer's disease. She suffers from an acute delirium and a lumbar puncture is performed to rule out a central nervous system infection.
• the catheter remains in the spinal cord as the work up proceeds. The work up is negative for infection and on day 5 the delirium resolves.
• 10 mg of VEGFA is injected intrathecally to prime the brain.
• a dose of 10 5 stem cells is injected intrathecally.
• Baseline mini-mental status prior to the delirium is 22. Repeat mini- mental status 6 months later is 27. Repeat MRI 8 weeks after treatment is essentially normal especially in the area of the hippocampus.
• a 24 year old white female suffers from acute encephalitis.
• a brain biopsy is performed to rule out herpes as the cause.
• a catheter remains in the brain as the work up proceeds.
• 2 mg of FGFl is injected into the brain through the catheter to prime the brain.
• 1 x 10 5 stem cells are injected into the brain.
• 10 mg of FGFl is given intranasally for 3 days.
• day 2
• a 35 year old black male is shot in the brain leaving an approximate 1 A" in circumference area of damage.
• the bullet is removed and after the bleeding stops, 2 mg of FGFl is injected into the area of damage. 5 minutes later 8 x 10 4 nueronal stem cells are injected into the damaged area.
• Repeat MRI in 8 weeks is essentially normal.
• Repeat neurological exam in 6 months is completely normal.
• a 63 year old white male has severe Alzheimer's disease. After an angiogram diagnoses a patent cerebral circulation, the brain is primed with lmg of VEGFA injected arterially. The dose is repeated for 5 days. Four hours later 2 x 10 4 stem cells are injected arterially for 5 days. Initial mini-mental status score is 10. Repeat mini-mental status score 6 months later is 22. MRI 8 weeks later shows an approximate 50% improvement in cortical atrophy and also atrophy of the hippocampus.
• a 49 year old white male has a possible diagnosis of alcoholic hepatitis.
• a liver biopsy is performed and the catheter remains in the liver as the work up proceeds.
• the liver biopsy shows alcoholic hepatitis.
• the patient has a Child-Turcotle-Pugh score of 7-class B.
• 2.0 mg of FGFl is injected into the liver through the catheter.
• 30 minutes later 10 5 stems are injected into the liver through the catheter.
• repeat CAT scan of the liver is normal and bilirubin and AST are normal.
• a 21 year old white female has an acetaminophen overdose.
• the patient has a Child- Turcotle-Pugh score of 10 - class C.
• the patient is injected with 2.0 mg of FGFl into the hepatic artery.
• the dose is repeated daily for 3 days.
• 4 x 10 stem cells are injected into the hepatic artery daily for 3 days.
• Repeat CAT scan of the liver in 6 weeks is normal. Also in 6 weeks the protime is normal, encephalopathy is grade zero, and the blood ph is normal.
• Example 22 A 41 year old black male has a diagnosis of Budd-Chiari Syndrome. After treatment with angioplasty, a repeat hepatic venogram shows a patent hepatic venous outflow. Patient has a Child-Turcotle-Pugh score of 8 - class B. Patient receives 1.0 mg of VEGFl 65 by retro grade venous injection into the liver to prime the liver. Two hours later the patient receives a dose of 10 5 stem cells into the hepatic vein. Repeat CAT scan of the liver in 6 weeks is normal. Also in 6 weeks ascites is absent and protime, albumin, and bilirubin are all normal.
• a 48 year old white female suffers from primary biliary cirrhosis.
• Patient has disabling intractable pruritus.
• Patient has a Child-Turcotle-Pugh score of 7 - class B.
• Patient receives a dose of 10 mg of FGF2 into the hepatic vein to prime the liver.
• Four hours later patient receives a dose of 6 x 10 4 hepatic stem cells IV.
• Six weeks later repeat CAT scan of the liver shows a decrease in pathology.
• the bilirubin is ⁇ 4 and pruritus is only minimal.
• a 30 year old white female has acute viral hepatitis B.
• Patient has hepatic encephalopathy grade III and a protime > 20 seconds. Vitamin k doesn't correct the protime.
• the patient receives 100 mg po of lamivudine.
• the patient receives 2.0 mg of FGFl by injection into the liver by the transjugular route to prime the liver. The catheter is pulled back out of the liver, yet remains in the vein and 2 hours later 10 5 stem cells are injected.
• hepatic encephalopathy is grade I.
• the patient also receives a dose of HBIG during and also after treatment with stem cells:
• a 58 year old white female has Parkinson's disease. After a small craniotomy 2 mg of FGF2 are injected into the dorsal striatum to prime the brain. A catheter goes down to the brain and a tiny needle inside is advanced for the injection and then withdrawn. One hour later 2 x 10 s stem cells are injected into the dorsal striatum.
• PET scan with radioactive raclopide in 8 weeks show that the grafted stem cells release dopamine.
• the patient on neuro exam has an approximate 70% decrease in rest tremor and approximate 70% decrease in rigidity and an approximate 70% improvement in bradykinesia.
• Repeat MRI in 8 weeks shows no change especially in the area of the stem cell graft.
• a 68 year old black female suffers from a cerebellar hemorrhage.
• Patient is demonstrating focal brain stem signs.
• a neurosurgeon performs evacuation of the hematoma.
• 1.0 mg of FGFl is injected to prime the brain.
• 10 minutes later 8 x 10 4 stem cells are injected into the same area.
• Repeat neurological exam at 6 weeks is completely normal.
• Repeat MRI at 8 weeks is essentially normal especially in the area of stem cell injection.
• Example 27 A 34 year old white female is paralyzed from the waist down after a traumatic spinal cord injury during a car accident. During neurosurgery 2.0 mg of FGF is injected in to the area where the spinal cord is severed (1.0 mg above and 1.0 mg below). 30 minutes later 1 x 10 5 stem cells are injected where the spinal cord is severed Vi the amount above and Vi the amount below. At 3 months repeat MRI with contrast of the entire spine is normal. Also at 3 months after extensive physical therapy patient walks independently and completely normal.
• a 28 year old white male suffers a cervical spinal cord injury during a truck accident.
• Patient is suffering from respiratory insufficiency and is intubated.
• MRI of the spine with contrast shows a thin linear upper cervical cord laceration 1 A cm long.
• Patient receives 2 mg of FGFl intrathecal daily for 3 days. Two hours after the FGF treatment patient receives 8 x
• Example 29 A 55 year old white male is suffering from multiple sclerosis and is wheel chair bound. Patient receives 2.0 mg of FGF2 intrathecal daily x 7 days. 90 minutes after the growth factor treatment patient receives 6 x 10 4 stem cells plus 4 x 10 4 oligo dentrocytes intrathecal daily for 7 days. Repeat MRI 4 months later shows a 60% decrease in lesions of the brain, brain stem and spinal cord. 4 months later after extensive physical therapy, patient walks with a walker.
• a 68 year old white male is suffering from lumber spinal cord compression secondary to a herniated disc.
• Patient's symptoms include back pain, progressive difficulty in walking, sensory impairment and urinary retention with overflow incontinence.
• 1.0 mg of FGFl is injected into the area of spinal cord injury.
• 1 x 10 s stem cells are injected into the area of spinal cord injury.
• 3 months later MRI of the spine with contrast is normal. Also at 3 months patient's neurological symptoms have resolved.
• a 55 year old black male suffers from systemic hypotension. As a result spinal cord infarction occurs at the T3-T4 level. Patient experiences bilateral sensory loss and weakness below the level of the lesion. Patient's blood pressure is stabilized. Patient receives 1.0 mg of FGF2 intrathecal x 3 days. 1 hour after the FGF2 treatment, patient receives 6 x 10 4 stem cells intrathecal for 3 days. 3 months later MRI of the spine with contrast is normal. Also 3 months later after extensive physical therapy patient's neurological exam is normal.
• a 49 year old white male suffers from transverse myelitis at the lumbar spinal cord secondary to herpes zoster. Patient experiences back pain, progressive difficulty in walking, sensory impairment and urinary retention with overflow incontinence.
• Patient is treated with acyclovir.
• Patient also receives 2.0 mg of FGFl intrathecal daily x 2 days. Two hours after the FGF treatment, patient receives 6 x 10 4 stems cells intrathecal daily for 2 days. 3 months later MRI at the spine with contrast is normal. Also neurological exam is normal.
• a 38 year old white male is shot in the thoracic spine leaving a 1/2 inch hole through the spine cord.
• the 1/2 inch hole is sewed over both sides with absorbable sutures.
• the sutures are infused with 2.0 mg of FGFl on each side.
• Two minutes after the sutures are infused with FGFl, 4 x 10 4 stem cells are delivered intrathecally for 10 days.
• 3 months later MRI at the spine with contrast is normal. Also neurological testing is normal.
• Example 34 An eighteen year old white male is suffering from Type I diabetes. He is treated with insulin; Hemoglobin AIC is 9. Patient receives 1.0 mg VEGFA through the pancreatic artery and into the pancreas. The dose is repeated daily for 3 days. Two hours later the patient receives 6 x 10 4 stem cells through the pancreatic artery daily for 3 days. Three months later repeat CAT scan at the pancreas is normal. Also at 3 months hemoglobin AIC is 7 - without insulin treatment.
• a 55 year old black male has Type II diabetes mellitus. According to this family he refuses to take insulin. His hemoglobin AIC is 10. Patient receives 2.0 mg FGF2 through the pancreatic artery into the pancreas. Three hours later the patient receives a dose of 10 s stem cells through the pancreatic artery. Three months later repeat CAT scan of the pancreas is normal. Also at 3 months hemoglobin AIC is 7.5 without any insulin.
• a 49 year old white female suffers from severe gall stone pancreatitis.
• Patient is treated with urgent ERCP and biliary sphincterotomy at 48 hours after presentation of her symptoms.
• 2.0 mg of VEGFl 65 is injected through the pancreatic ducts into the area of pancreatic inflammation.
• 1 hour later 4 x 10 4 stem cells are injected into the pancreatic duct near the area of pancreatic inflammation.
• Repeat CAT scan of pancreas at two months is normal.
• Example 37 51 year old white male suffers from necrotizing pancreatitis. Patient undergoes CT guided percutaneous aspiration for gram stain and culture. After aspiration patient receives an injection of 1.0 mg of VEGFA into the pancreas. 30 minutes later patient receives 8 x 10 4 stem cells by injection into the pancreas. Patient is also treated with appropriate antibiotics. At 3 months repeat dynamic dual phase CAT scanning with IV contrast is normal.
• Patient has severe pain and steatorrhea.
• Patient receives 2.0 mg of FGFl through the pancreatic artery into the pancreas daily for 3 days. Two hours later the patient receives 6 x 10 4 stem cells through the pancreatic artery daily for 3 days. Four months later repeat CAT scan of the pancreas is essentially normal. Also at 4 months his pain and steatorrhea are gone.
• VEGF 165 is injected into the area of damage. 10 minutes later 8 x 10 4 stem cells are injected into the damaged area. Repeat CAT scan of the pancreas in 3 months is normal.
• Example 40 During an accident a 37 year old white male falls off a roof and lands on a rake.
• a 28 year old black male is stabbed with a knife into his left kidney during a fight. During emergency surgery he is found to have a 3 A inch in circumference area of damage.
• a 63 year old diabetic female suffers from end stage renal disease.
• Patient is suffering from pericarditis, progressive neuropathy, and encephalopathy.
• Patient receives 1 mg of VEGFl 21 into the left kidney through the renal artery. The dose is repeated daily for 5 days.
• One hour after the VEGFl 21 treatment the patient receives 6 x 10 4 stem cells for 5 days through the renal artery.
• Repeat CAT scan at the left kidney at 4 months is essentially normal. At 4 months creatinine is 1.5 and pericarditis, neuropathy and encephalopathy are gone.
• Example 43 A 52 year old white female suffers from a disease with pulmonary and renal involvement.
• Patient is oliguric, has a creatinine of 7 and is receiving dialysis.
• Patient has a renal biopsy and the catheter is left in place. After the biopsy shows Good-pasture's syndrome 1.0 mg of VEGF 165 is injected into the right kidney. 30 minutes later 1 x 10 5 stem cells are injected into the patient. 4 months later repeat CAT scan at the right kidney is essentially normal. Also at 4 months the creatine is 1.8 the patient is urinating and off dialysis.
• Example 44 A 57 year old white female initially presents with nephrotic syndrome. She has low complement levels. After 5 years she has progressive end stage renal disease. She has a renal biopsy which shows membranoproriferative GN Type I. Her disease is felt to be idiopathic. During the biopsy the catheter is left in the kidney (right). After the biopsy
• Example 46 A 50 year old white female was on doxycycline and aspirin. Patient complains of adynophagia and dysphagia. Endoscopy shows extensive damage. After temporarily increasing the patient's anesthesia and applying topical xylocaine; 1.0 mg of VEGFA is injected into the area of damage. One minute later 8 x 10 4 epithelial stem cells are injected into the area of damage. Three months later repeat endoscopy is essentially normal and her symptoms resolved.
• a 39 year old white female complains of epigastric pain.
• On endoscopy patient is found to have a gastric ulcer with a small perforation.
• 1.0 mg of FGF2 is injected adjacent to the area of perforation.
• 4 x 10 4 stem cells are injected into the stomach daily for 3 days.
• follow up endoscopy at 3 months is normal. Patient's pain has resolved.
• a 51 year old white male has ulcerative colitis.
• On sismoidoscopy after increasing the patient's anesthesia 1.0 mg of VEGF 165 is injected into the area of deep ulcerations.
• Patient receives 6 x 10 4 stem cells daily into the sigmoid in the area of deep ulceration. In 3 months repeat single-contrast barium enema in the area of deep ulcerations is essentially normal.
• Angiography shows a 60% blockage in the artery feeding to the right calf.
• the patient received gene therapy delivered by a single arterial infusion with an adenovirus vector (Ad5-FGF4).
• Ad5-FGF4 adenovirus vector
• the dose was 10 11 viral particles.
• the patient receives a dose of stem cells 2 x 10 4 daily into the artery for 7 days.
• the stem cells will aid in angionesis and also muscle cell generation as needed.
• the patient is claudication free. Also MRI of the right calf muscle at 3 months is essentially normal.
• Example 51 A 55 year old white male suffers from unstable claudication with an increase in severity, duration and frequency of his pain. The pain is especially worse in his left calf.
• Patient has a creatinine kinase of 500 - presumably from muscle cell death or pending death.
• patient is injected with 5 doses of basic FGF - 100 micrograms mixed with 50 micrograms of VEGFA mixed with 2 x 10 4 stem cells around and adjacent to the necrotic and/or ischemic calf muscle. In 3 months patient is claudication free. Repeat MRI of the left calf is essentially normal. Creatinine kinase is 180.
• Creatine kinase should be used to assess death or pending death of muscle cells in patients with chronic peripheral artery disease, unstable claudication, or acute arterial occlusion.
• the creatine kinase can be monitored to assess the effects of growth factor and/or gene therapy and/or stem cell therapy.
• Example 52 A seven year old white male suffers from Duchenne muscular dystrophy. Creatinine kinase is 2000. Patient receives a total of 250 micrograms of VEGF 165 plasmid DNA injected at 5 separate sites in each thigh muscle. Seven days later patient receives 4 x 10 4 stem cells by injection in each area of previous injection. By age 8 he is walking without a brace, repeat MRI of the thigh muscles is essentially normal, and creatine kinase is 200.
• Echocardiogram shows ventricular septal defect that is moderate in size.
• the fetus is removed from the womb.
• the hole in the heart is sewn over both sides with absorbable sutures.
• 0.2 mg FGF2 is injected in the space between both sutures.
• Five minutes later 3 x 10 3 embryonic stem cells are injected into the same space.
• the fetus is replaced into the womb.
• For the remainder of the birth there is no more distress.
• an echocardiogram shows the heart to be completely normal.
• Kinane is 1800. Patient receives a total of 1 mg of VEGF-165 injected at 5 separate sites in each thigh muscle. One hour later patient receives 3 x 10 4 muscle stem cells by injection in each area of previous injection. By age 9 patient is walking without a brace. Repeat MRI of the thigh muscle is essentially normal and Creatinine Kinase is 180.
• a 4 month old fetus has an ultrasound which shows congenital absence of the right kidney. 0.2 mg of VEGFA is injected into the fetus in the area where the right kidney should be. Ten minutes later 3 x 10 3 stem cells obtained from a blastocyst are injected into the same space. For the remainder of the pregnancy the fetus does well. At birth an ultrasound shows the kidneys to be completely normal.

Landscapes

• Health & Medical Sciences (AREA)
• Life Sciences & Earth Sciences (AREA)
• Public Health (AREA)
• Epidemiology (AREA)
• Veterinary Medicine (AREA)
• General Health & Medical Sciences (AREA)
• Medicinal Chemistry (AREA)
• Chemical & Material Sciences (AREA)
• Pharmacology & Pharmacy (AREA)
• Animal Behavior & Ethology (AREA)
• Engineering & Computer Science (AREA)
• Developmental Biology & Embryology (AREA)
• Immunology (AREA)
• Cell Biology (AREA)
• Zoology (AREA)
• Biotechnology (AREA)
• Virology (AREA)
• Bioinformatics & Cheminformatics (AREA)
• Proteomics, Peptides & Aminoacids (AREA)
• Gastroenterology & Hepatology (AREA)
• Reproductive Health (AREA)
• Biomedical Technology (AREA)
• Molecular Biology (AREA)
• Gynecology & Obstetrics (AREA)
• Genetics & Genomics (AREA)
• Hematology (AREA)
• Vascular Medicine (AREA)
• Medicines That Contain Protein Lipid Enzymes And Other Medicines (AREA)

Applications Claiming Priority (4)

Publications (2)

Family

ID=36407758

Family Applications (1)

Country Status (2)

Families Citing this family (2)

Citations (7)

Family Cites Families (2)

• 2005
  • 2005-11-17 WO PCT/US2005/041740 patent/WO2006055743A2/en active Application Filing
  • 2005-11-17 EP EP05823219A patent/EP1827494A4/de not_active Withdrawn

Patent Citations (7)

Non-Patent Citations (3)

Also Published As

Similar Documents

Legal Events