Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/56—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P17/00—Drugs for dermatological disorders
  • A61P17/06—Antipsoriatics
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P29/00—Non-central analgesic, antipyretic or antiinflammatory agents, e.g. antirheumatic agents; Non-steroidal antiinflammatory drugs [NSAID]
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P31/00—Antiinfectives, i.e. antibiotics, antiseptics, chemotherapeutics
  • A61P31/04—Antibacterial agents
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P37/00—Drugs for immunological or allergic disorders
  • A61P37/02—Immunomodulators
  • A61P37/06—Immunosuppressants, e.g. drugs for graft rejection
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P43/00—Drugs for specific purposes, not provided for in groups A61P1/00-A61P41/00
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P5/00—Drugs for disorders of the endocrine system
  • A61P5/14—Drugs for disorders of the endocrine system of the thyroid hormones, e.g. T3, T4
  • A61P5/16—Drugs for disorders of the endocrine system of the thyroid hormones, e.g. T3, T4 for decreasing, blocking or antagonising the activity of the thyroid hormones

Definitions

• This invention relates generally to steroidal therapies for treating autoimmune diseases, and, more particularly, to administering primary agents being estrogens or estrogen receptor active agents for the treatment of cell mediated diseases.
• primary agents being estrogens or estrogen receptor active agents for the treatment of cell mediated diseases.
• secondary agents which effect the immune and/or nervous system may also be co-administered or tapered onto.
• This therapy may be used in patients, including post-partum patients.
• This invention also relates to steroidal therapies for the treatment of neurodegenerative diseases and disorders, including cell mediated diseases.
• treatment kits are provided containing at least one primary agent and at least one secondary agent for treating a patient presenting with symptomology of an autoimmune disease or a neurodegenerative disease or disorder.
• MS multiple sclerosis
• RA rheumatoid arthritis
• MG myasthenia gravis
• Sjogren's syndrome Sjogren's syndrome
• Hashimoto's thyroiditis For example, MS is a chronic, and often debilitating disease affecting the central nervous system (brain and spinal cord). MS affects more than 1 million people worldwide and is the most common neurological disease among young adults, particularly woman. The exact cause of MS is still unknown. MS attacks the nervous system resulting in myelin sheaths surrounding neuronal axons to be destroyed.
• MS can have different patterns, sometimes leaving patients relatively well after episodes of acute worsening, sometimes leading to progressive disability that persists after episodes of worsening, hi the worst cases the disease can lead to paralysis or blindness.
• Steroid hormones or sex-linked gene inheritance may be responsible for the enhanced susceptibility of women to these autoimmune diseases.
• a role for steroid hormones in susceptibility to autoimmune disease is supported by observations of alternations in disease symptomatology, with alterations in sex hormone levels such as during pregnancy, menopause or exogenous hormone administration (in the form of hormone replacement (HRT) or oral contraceptives (ORC)).
• HRT hormone replacement
• ORC oral contraceptives
• T helper cell secretion of interferon gamma (IFN-.gamma.) and tumor necrosis factor beta (TNF- b).
• humoral immunity is mediated by another group of T helper cells (Th2) secreting interleukin (IL)-IO, IL-4, IL-5 and IL-6.
• Examples of potential candidates which effect may effect MS during pregnancy include: Sex hormones (estrogens, progesterone), Cortisol, vitamin D, alpha-fetoprotein, human chorionic gonadotropin and pregnancy specific glycoproteins.
• E3 autoimmune encephalomyelitis
• ThI cell-mediated autoimmune diseases
• EAE disease severity could be reduced by treatment with estriol, either before or after disease onset.
• Treatment of EAE mice with 90 day release pellets of 5 milligrams or 15 milligrams of estriol (E3) was shown not only to decrease disease severity but also to enhance autoantigen specific humoral-immunity, increase production of the Th2 cytokine IL-IO and reduced inflammation and demyelination in EAE mice.
• these changes in the disease were induced by a dose (5 mg) which was shown to yield estriol levels in serum that were similar to those which occur during late pregnancy (Kim et al., Neurology, 50(4 Supp.
• ER alpha and ER beta nuclear estrogen receptors
• ER alpha and ER beta would each have distinct tissue distributions, thereby providing a means through which use of selective estrogen receptor modifiers.
• the relationship between ER alpha and ER beat became complex, with most tissues expressing some detectable level of each of these receptors.
• the two receptors at times did, and at other times did not, co-localize to the same cells within a given tissue.
• the two receptors were shown to act synergistically, whereas in the other tissues they act antagonistically.
• Estrogen treatment has been shown previously to be neuroprotective in a variety of neurodegenerative disease models including Parkinson's disease, cerebellar ataxia, stroke, and spinal cord injury (Leranth et al., 2000; Dubai et al., 2001; Wise et al., 2001; Jover et al., 2002; Rau et al., 2003; Sierra et al., 2003; Sribnick et al., 2003, 2005).
• Estrogens are lipophilic, readily traversing the blood-brain barrier, with the potential to be directly neuroprotective (Brinton, 2001; Garcia-Segura et al., 2001; Wise et al., 2001).
• Estrogen-mediated protection of neurons has been demonstrated in a variety of in vitro models of neurodegeneration including those induced by excitotoxicity and oxidative stress (Behl et al., 1995; Goodman et al., 1996; Behl et al., 1997; Harms et al., 2001). Estrogens have also been shown to decrease glutamate-induced apoptosis and preserve electrophysiologic function in primary cortical neurons (Sribnick et al., 2003, 2004).
• a general object of the present invention is to provide a method of administering steroid hormones to mammals to treat autoimmune related diseases, more particularly, ThI -mediated (cell-mediated) autoimmune diseases including: multiple sclerosis (MS), rheumatoid arthritis (RA), autoimmune thyroiditis, uveitis and other autoimmune diseases in which clinical symptomology has shown improvement during the third term of pregnancy.
• the method may also include the treatment of post-partum patients having been diagnosed with, or at risk for developing autoimmune diseases, including MS.
• the method may also include the treatment of patients having been diagnosed with, or at risk for developing neurodegenerative diseases, including MS.
• these objectives are accomplished by providing a treatment for autoimmune related diseases with a selected dose and course of a primary agent being an estrogen or estrogen receptor- effective composition.
• the primary agent may include estrogen receptor selective ligands, such as agonists which mimic the effect of estrogens.
• these objectives are accomplished by providing a patient with a therapeutically effective amount of estriol, comprising from about 4 to 16 milligrams per day, or more specifically, about 8 milligrams once daily via oral administration.
• these objectives are accomplished by providing a therapeutically effective amount of a primary agent in combination with a therapeutically effective amount of a secondary active agent, such as progesterone, glucocorticoids and/or known or experimental drugs used to treat autoimmune diseases.
• a secondary active agent such as progesterone, glucocorticoids and/or known or experimental drugs used to treat autoimmune diseases.
• the invention comprises the use of a primary agent comprising an estrogen receptor alpha ligand having anti-inflammatory and/or neuroprotective effects to prevent or ameliorate clinical symptoms of autoimmune and/or neurodegenerative diseases or disorders, including multiple sclerosis.
• the invention comprises the use of a primary agent comprising an estrogen receptor beta ligand having neuroprotective effects to prevent or ameliorate clinical symptoms of neurodegenerative diseases or disorders, including multiple sclerosis.
• FIG. Ia is a schematic depicting the trial design described in Example 1 ;
• FIG. Ib is a bar graph depicting human serum levels during pregnancy, estriol treatment (Tx), and pretreatment (Pre Tx levels).
• FIG. 2a is a bar graph describing the Delayed Type Hypersensitivity (DTH) responses to tetanus and to Candida;
• FIG. 2b is a bar graph depicting levels of IFN.gamma. between treatment groups.
• DTH Delayed Type Hypersensitivity
• FIG. 3a-f are bar graphs depicting each patient's gadolinium enhancing lesion volumes on serial cerebral MRIs which were assessed at each month during the pretreatment, estriol treatment and post treatment periods.
• FIG. 4 is a bar graph depicting mean percent change in PASAT scores during treatment with estriol as compared to pretreatment.
• FIGs. 6A-C are graphs showing the effect of ER alpha selective ligand on clinical scores in wild type (WT), ER beta knock-out (KO), or ER alpha KO in mice treated with a control (vehicle), estrogen receptor alpha ligand (PPT) or estradiol treated animals.
• FIGs. 7A-D are bar graphs showing proinflammatory cytokine production by peripheral immune cells in ovariectomized, wild type (WT) C57BL/6 female mice with EAE.
• FIGs. 8A-E depict various measures of estrogen receptor alpha ligand reduced inflammation and demyelination in spinal cords of mice with EAE.
• FIG. 8A are thoracic spinal cord sections from normal, or treated mice (vehicle, estradiol (E2) or estrogen receptor alpha ligand (PPT));
• FIG. 8B depicts luxol fast-blue stained magnified regions of the dorsal spinal column for the same sections as shown in 8 A (4Ox magnification);
• FIG. 8C depicts anti-BMP immunostained magnified regions of the dorsal spinal column for the same sections as shown in 8A;
• FIG. 8D is a bar graph showing white matter cell density by treatment group; and
• FIG. 8E is a bar graph showing myelin density by treatment group.
• FIGs. 9A-E depict various measures of estrogen receptor alpha ligand reduced inflammation and demyelination in spinal cords of mice with EAE.
• FIGs. 9A-D are split images of thoracic spinal cord sections stained with NeuN 4" (red) in I and Nissl in ii at 4x magnification, derived from mice from each treatment group (normal, vehicle, estradiol (E2) or estrogen receptor alpha ligand (PPT)).
• FIG. 9E is a bar graph showing the number of NeuN 4 immunolabeled neurons in the delineated glfijt ⁇ atteEIGs.
• 10A-D depict various measures of estrogen receptor alpha ligand reduced inflammation and demylination in spinal cords of mice with EAE.
• FIGs. 1OA and B are images of thoracic spinal cord sections shown in FIG. 5 co-immunostained with NF200 (green) and CD45 (red) at 1Ox magnification, derived from mice from each treatment group (normal, vehicle, estradiol (E2) or estrogen receptor alpha ligand (PPT)).
• FIG. 1OC is a bar graph showing the axon number and
• FIG. 1OD is a bar graph showing Mac-3 cell density measurements.
• FIGs. 12A-G are graphs showing the effect on clinical scores of wild type (WT), estrogen receptor alpha ligand (PPT) and estrogen receptor beta ligand (DPN) treated animals.
• FIGs. 13A-C are bar graphs showing the effect of treatment with a estrogen receptor selective ligand (DPN), vehicle or estradiol on proliferation or cytokine production.
• DPN estrogen receptor selective ligand
• FIGs. 14A-F depict various measures of estrogen receptor alpha ligand reduced inflammation and demyelination in spinal cords of mice with EAE.
• FIG. 14A and C are early and late thoracic spinal cord sections from normal, or treated mice (vehicle, estrogen receptor alpha (PPT) or estrogen receptor beta ligand (DPN));
• FIG. 14B depicts early white matter cell density for each treatment group;
• FIG. 14D depicts late white matter cell density for each treatment group;
• 14 E and F depict early and late sections co-immunostained with NF200 (green) and CD45 (red) at 10x magnification, derived from mice from each treatment group.
• FIGs. 15A-H depict various measures of estrogen receptor alpha and beta ligand preservation of MBP and spare axonal pathology in spinal cords of EAE mice.
• FIGs. 15A and C are images of thoracic spinal cord sections stained withNeuN (red) 10x magnification, derived from mice at early and late time points from each treatment group (normal, vehicle, estrogen alpha ligand (PPT) or estrogen receptor beat ligand (DPN)).
• PPT estrogen alpha ligand
• DPN estrogen receptor beat ligand
• FIGS. 15E and G are images of thoracic spinal cord sections co- immunostained with anti-NF200 (green, i) and anti-BMP (red, ii), shown merged in Hi, derived from mice at early and late time points from each treatment group (normal, vehicle, estrogen alpha ligand (PPT) or estrogen receptor beat ligand (DPN));
• FIG. 15 B and D are a bar graphs showing myelin density, early and late, respectively, while FIG. 15 F and H show axon number, early and late, respectively.
• FIGs. 16A-D depict various measures of estrogen receptor alpha and beta ligand preservation of neuronal staining of gray matter in spinal cords of mice with EAE.
• FIG. 9A-D are split images of thoracic spinal cord sections stained withNeuN (red) in I and Nissl in ii at 4x magnification, derived from mice from each treatment group (normal, vehicle, estradiol (E2) or estrogen receptor alpha ligand (PPT)).
• FIG. 9E is a bar graph showing the number of NeUN + immunolabeled neurons in the delineated gray matter.
• the invention involves a method of treating mammal exhibiting clinical symptoms of an autoimmune disease comprising administering a primary agent at a therapeutically effective dosage in an effective dosage form at a selected interval.
• the treatment is aimed at reducing the symptomology and/or progression of the disease.
• human patients clinically diagnosed with MS including both relapsing remitting or secondary progressive type patients
• Amelioration of the autoimmune disease refers to any observable beneficial effect of the treatment.
• the beneficial effect can be evidenced by a delayed onset or 59 progression of disease symptomology, a reduction in the severity of some or all of the clinical symptoms, or an improvement in the overall health.
• patients who have clinical symptoms of an autoimmune disease often suffer from some or all of the following symptoms: worsening of preexisting symptoms (such as joint pain in rheumatoid arthritis), the appearance of new symptoms (new joints affected in rheumatoid arthritis) or increased generalized weakness and fatigue.
• MS patients in particular suffer from the following symptoms: weakness, numbness, tingling, loss of vision, memory difficulty and extreme fatigue.
• an amelioration of disease in MS would include a reduction in the frequency or severity of onset of weakness, numbness, tingling, loss of vision, memory difficulty and extreme fatigue.
• amelioration of disease would be evidenced by a decrease in the number or volume of gadolinium enhancing lesions, a stabilization or slowing of the accumulation of T2 lesions and/or a slowing in the rate of atrophy formation.
• Th2 cytokines such as IL-10
• ThI cytokines such as interferon gamma
• Patients may also express criteria indicating they are at risk for developing autoimmune diseases. These patients may be preventatively treated to delay the onset of clinical symptomology. More specifically, patients who present initially with clinically isolated syndromes (CIS) may be treated using the treatment paradigm outlined in this invention. These patients have had at least one clinical event consistent with MS, but have not met full criteria for MS diagnosis since the definite diagnosis requires more than one clinical event at another time (McDonald et al., 2001). Treatment of the present invention would be advantageous at least in preventing or delaying the development of clinically definite MS.
• CIS clinically isolated syndromes
• the primary agent useful in this invention is a steroid hormone, more particularly a estrogen or a steroidal or non-steroidal estrogen receptor active agent.
• the primary agent is estriol (estra-l,3,5(10)-triene- 3,16,17-triol), E3, such as estriol succinate, estriol dihexanate or estriol sulfmate.
• the primary agent may be precursors or analogs of estriol (such as nyestriol), estrone (El) or precursors or analogs of estrone, 17. beta. -estradiol (E2) or precursors (including aromatizable testosterone) or analogs of 17.beta. -estradiol, or estranges.
• the primary agent may also be a metabolite or derivatives of El, E2 or E3 which are active at the estrogen receptor .alpha, or .beta. Metabolites and derivatives may have a similar core structure to El, E2 or E3 but may have one or more different groups (ex. hydroxyl, ketone, halide, etc.) at one or more ring positions. Synthetic steroids which are effective at estrogen receptor are also useful in this invention, such as those described in WO 97/08188 or U.S. Pat. No. 6,043,236 to Brattsand, which is hereby incorporated by reference herein.
• the primary agent may also be an estrogen receptor .alpha, or .beta., agonists and/or antagonist.
• These agonists or antagonists may be steroidal or nonsteroidal agents which bind to and/or cause a change in activity or binding of at least one of the estrogen receptor .alpha, or .beta, subtypes.
• specific agonists of ER alpha and ER beta may be useful in this invention (Fritzmeier, et al.). Doses of these agonists may be titrated to achieve an effect on disease similar to that which is observed during pregnancy and during treatment with pregnancy doses of estriol by methodologies known to those skilled in the art of steroid pharmacology.
• estriol may be selected over 17.beta.-estradiol, because estriol causes minimal endometrial proliferation and is not associated with increased risk of breast cancer. Minimal endometrial proliferation is observed when the long-acting estriol derivative, nyestriol is used. Indeed, because estriol has partial antagonist action on the binding of 17.beta.-estradiol to the estrogen receptor in vivo, estriol was at one point in the past considered as a therapeutic agent for treatment and prevention of breast cancer.
• a therapeutically effective dose of the primary agent is one sufficient to raise the serum concentration above basal levels, and preferably to pregnancy levels or above pregnancy levels. Most preferably, the therapeutically effective dosage of the primary agent is selected to result in serum levels in a patient equivalent to the steroid hormone level of that agent in women in the second or third trimester of pregnancy.
• estradiol levels are in the range of about 350 pg/ml serum.
• estradiol levels are in the range of about 350 pg/ml serum.
• estradiol levels rise progressively during pregnancy to levels from 3,000 to 30,000 pg/ml (3 to 30 ng/ml) (www.il-st-acad- sci.org/steroidl .html#se3t).
• the preferable dose is from about 4 to 16 milligrams daily, and more specifically, about 8 milligrams daily.
• blood serum levels preferably reach at least about 2 ng/ml, may reach about 10 to about 35 ng/ml, or most preferably about 20-30 ng/ml. (Sicotte et al. Neurology 56:A75).
• estradiol (E2) levels would preferably reach at least about 2 ng/ml and most preferably about to 10-35 ng/ml.
• estrone (El) levels would preferably reach at least about 2 ng/ml and most preferably about 5-18 ng/ml (DeGroot and Jameson, 1994).
• the dosage of the primary agent may be selected for an individual patient depending upon the route of administration, severity of disease, age and weight of the patient, other medications the patient is taking and other factors normally considered by the attending physician, when determining the individual regimen and dosage level as the most appropriate for a particular patient.
• this group of primary agents is advantageous in at least that other known or experimental treatments for cellular mediated autoimmune diseases are chemotherapeutic immunosuppresants which have significant risks and side effects to patients, including decreasing the ability of the patient to fight infections, inducing liver or heart toxicity which are not caused by estrogen treatment.
• Other agents used in MS do not cause these side effect, but are associated with flu-like symptoms or chest tightness.
• these previously used agents are associated with local skin reactions since they entail injections at frequencies ranging from daily to once per week.
• the therapeutically effective dose of the primary agent included in the dosage form is selected at least by considering the type of primary agent selected and the mode of administration.
• the dosage form may include the active primary agent in combination with other inert ingredients, including adjutants and pharmaceutically acceptable carriers for the facilitation of dosage to the patient as known to those skilled in the pharmaceutical arts.
• the dosage form may be any form suitable to cause the primary agent to enter into the tissues of the patient.
• the dosage form of the primary agent is an oral preparation (liquid, tablet, capsule, caplet or the like) which when consumed results in elevated serum estrogen levels.
• the oral preparation may comprise conventional carriers including dilutents, binders, time release agents, lubricants and disinigrants.
• the dosage form may be provided in a topical preparation (lotion, creme ointment or the like) for transdermal application.
• the dosage form may be provided in a suppository or the like for transvaginal or transrectal application.
• That estrogens or estrogen receptor active agents can be delivered via these dosage forms is advantageous in that currently available therapies, for MS for example, are all injectables which are inconvenient for the user and lead to decreased patient compliance with the treatment.
• Non-injectable dosage forms are further advantageous over current injectable treatments which often cause side effects in patients including flu-like symptoms (particularly, .beta, interferon) and injection site , reactions which may lead to lipotrophy (particularly, glatiramer acetate copolymer-1).
• the dosage form may also allow for preparations to be applied subcutaneously, intravenously, intramuscularly or via the respiratory system.
• any one or a combination of secondary active agents may be included in the dosage form with the primary agent.
• any one or a combination of secondary active agents may be administered independently of the primary agent, but concurrent in time such that the patient is exposed to at least two agents for the treatment of their immunological disease.
• the secondary agents are preferably immunotherapeutic agents, which act synergistically with the primary agent to diminish the symptomology of the patient is exposed to at least two agents for the treatment of their immunological disease.
• the secondary agents are preferably immunotherapeutic agents, which act synergistically with the primary agent to diminish the symptomology of the autoimmune disease.
• Secondary active agents may be selected to enhance the effect of the estrogen or estrogen receptor active agent, reduce the effect of the estrogen or estrogen receptor active agent or effect a different system than that effected by the estrogen or estrogen receptor active agent.
• Secondary active agents include immunotherapeutic agents which cause a change in the activity or function of the immune system.
• a secondary agent may be a therapeutically effective amount of progesterone, precursor, analog or progesterone receptor agonist or antagonist. Most preferably, the secondary agent is 100-200 milligrams of progesterone administered daily. Progesterone in combination with estrogen or estrogen receptor active agent treatment is advantageous in at least protecting patients against risks associated with long term estrogen exposure, including, but not limited to endometrial proliferation and breast cancers.
• a secondary agent may be a therapeutically effective amount of glucocorticoid, precursor, analog or glucocorticoid receptor agonist or antagonist.
• prednisone may be administered, most preferably in the dosage range of about 5-60 milligrams per day. Also, methyl prednisone
• Solumedrol may be administered, most preferably in the dosage range of about 1-2 milligrams per day.
• Glucocorticoids are currently used to treat relapse episodes in MS patients, and symptomatic RA within this dosage range.
• a secondary agent may be selected from the group immunotherapeutic compounds.
• a secondary agent may be selected from the group immunotherapeutic compounds.
• .beta.-interferon Asvonex.RTM. (interferon-beta Ia), Rebiff.RTM. (by Serono); Biogen, Betaseron.RTM. (interferon- beta Ib) Berlex, Schering), glatiramer acetate copolymer-1 (Copaxone.RTM.; Teva), antineoplastics (such as mitoxantrone; Novatrone.RTM. Lederle Labs), human monoclonal antibodies (such as natalizumab; Antegren.RTM. Elan Corp.
• Avonex.RTM. interferon-beta Ia
• Rebiff.RTM. by Serono
• Biogen Betaseron.RTM. (interferon- beta Ib) Berlex, Schering)
• immonusuppressants such as mycophenolate mofetil; CellCeptRTM. Hoffman-LaRoche Inc.
• paclitaxel Taxol.RTM.; Bristol-Meyers Oncology
• cyclosporine such as cyclosporin A
• corticosteroids glucocorticoids, such as prednisone and methyl prednisone
• azathioprine cyclophosphamide
• methotrexate cladribine
• 4-aminopyridine and tizanidine and natalizumab (Tysabri) By way of example, which is consistent with the current therapeutic uses for these treatments, Avonex.RTM.
• Betaseron.RTM. in a dosage of about 0 to about 0.25 mg may be injected subcutaneously every other day.
• Copaxone.RTM. in a dosage of about 0 to about 20 mg may be injected subcutaneously every day.
• Rebiff.RTM. may be injected at a therapeutic dose and at an interval to be determined based on clinical trial data.
• any of these secondary agents may be used in increasing, constant or decreasing dose in combination with a primary agent, such as estriol or an ER alpha or beta receptor ligand.
• dosages and method of administration may be altered to maximize the effect of these therapies in conjunction with estrogen treatment.
• Dosages may be altered using criteria that are known to those skilled in the art of diagnosing and treating autoimmune diseases.
• secondary agents would be administered in the dosage ranges currently used to treat patients having autoimmune diseases, including MS patients.
• the secondary agents may be administered at a reduced dose or with reduced frequency due to synergistic or duplicative physiological effects with the primary agent.
• patients exhibiting symptomology of autoimmune diseases are treated with the above agents (estrogen or estrogen receptor active agents with or without secondary agents).
• patients exhibit autoimmune diseases marked by improvement in symptomology at least during a treatment regimen, including but not limited to that reflecting patterns observed during the second or third trimester of pregnancy.
• the invention may include methods of steroidal therapies for preventing or treating female post-partum patients, expressing symptoms of or at risk for autoimmune diseases.
• the invention may include the method of preventing or treating a subject having been diagnosed with at least one symptom of an autoimmune disease to reduce the symptomology of/and or slow the progression of the disease.
• the method according to the invention may comprise administering primary agents being estrogens or estrogen receptor active agents for the treatment of cell mediated diseases.
• the invention may further include the treatment with secondary agents which effect the immune system, which may be co-administered or tapered onto.
• the use of the primary agents, combinations of primary agents with secondary agents, at the doses and in the dosage forms may be administered as described above for auto immune diseases.
• human post-partum patients who are clinically diagnosed with an autoimmune disease may be treated with an oral preparation of 8 milligrams estriol daily, resulting in ameliorated symptomology. Additionally, patients could be administered an estriol or an estrogen following birth, then tapered onto a conventional FDA approved therapy, such as Copaxone.
• Amelioration of the post-partum autoimmune disease refers to any observable beneficial effect of the treatment. The beneficial effect can be evidenced by a delayed onset or progression of disease symptomology, a reduction in the severity of some or all of the clinical symptoms, or an improvement in the overall health.
• patients who have clinical symptoms of an autoimmune disease often suffer from some or all of the following symptoms: worsening of preexisting symptoms (such as joint pain in rheumatoid arthritis), the appearance of new symptoms (new joints affected in rheumatoid arthritis) or increased generalized weakness and fatigue.
• Multiple sclerosis patients in particular suffer from the following symptoms: weakness, numbness, tingling, loss of vision, memory difficulty and extreme fatigue.
• an amelioration of disease in multiple sclerosis would include a reduction in the frequency or severity of onset of weakness, numbness, tingling, loss of vision, memory difficulty and extreme fatigue.
• MRI magnetic resonance imaging
• Th2 cytokines such as IL-10
• ThI cytokines such as interferon gamma
• Patients may also express criteria indicating they are at risk for developing autoimmune diseases. These patients may be preventatively treated to delay the onset of clinical symptomology. More specifically, patients who present initially with clinically isolated syndromes (CIS) may be treated using the treatment paradigm outlined in this invention.
• the invention comprises the use of a primary agent comprising an estrogen receptor alpha ligand, such as an agonist, having an anti-inflammatory and neuroprotective effect to prevent or ameliorate clinical symptoms of auto immune diseases including multiple sclerosis.
• multiple sclerosis is an inflammatory, neurodegenerative disease for which experimental autoimmune encephalomyelitis (EAE) is a model.
• EAE experimental autoimmune encephalomyelitis
• Treatments with estrogens have been shown to decrease the severity of EAE through antiinflammatory and neuropreservation mechanisms.
• ER alpha estrogen receptor alpha
• EAE treatment with a highly selective ER alpha agonist ameliorated clinical disease in both wild-type and ER beta knock-out mice, but not in ER alpha knock-out mice, suggesting that the ER alpha ligand maintained ER alpha selectivity in vivo during disease.
• the invention comprises the treatment of neurodegenerative diseases and disorders, including MS.
• the invention may include the method of preventing or treating a subject having been diagnosed or exhibiting at least one clinical symptom of a neurodegenerative disease or disorder.
• the method according to the invention may comprise administering a primary agent at a therapeutically effective dosage in an effective dosage form at a selected interval to prevent, reduce the frequency or reduce the severity of the symptoms and/or progression of the disease or disorder.
• the method may comprise administration of 8 milligrams estriol daily, such as in an oral preparation and result in ameliorated symptomology.
• the method may comprise treating the patent with a combination of estrogen and progestin or progesterone, as a secondary agent.
• the use of the primary agents, combinations of primary agents with secondary agents, at the doses and in the dosage forms may be administered as described above for auto immune diseases.
• the primary agent may comprise an estrogen receptor beta ligand, such as a estrogen receptor beta agonist.
• Neurodegenerative diseases and disorders for which the invention may be effective include, but are not limited to: Alzheimer's disease, Parkinson's disease, multiple sclerosis, stroke, amyotrophic lateral sclerosis (Lou Gehrig's Disease), frontotemporal dementia (Pick's Disease), prion disease and Huntington's disease.
• Additional disorders that may be treated on the basis of the pharmacological results with estrogens or estrogen receptor active agents, include, but are not limited to cerebral ischemia, idiopathic Morbus Parkinson, topically- or drug-induced Parkinson syndrome, Morbus Alzheimer and cerebral dementia syndromes of different origin, Huntington's chorea, infectious-induced neurodegeneration disorders such as AIDS- encephalopathy, Creutzfeld- Jakob disease, encephalopathies induced by rubiola and herpes viruses and borrelioses, metabolic-toxic neurodegenerative disorders such as hepatic-, alcoholic-, hypoxic-, hypo- or hyperglycemically-induced encephalopathies as well as encephalopathies induced by solvents or pharmaceuticals, degenerative retina disorders of various origin, traumatically-induced brain and bone marrow damage, cerebral hyperexcitability symptoms of varying origin such as after the addition of and/or withdrawal of medicaments, toxins, noxae and drugs, mentally and traumatically-induced cerebral hyperexcitability states, neurode
• kits are provided for use by the treating physician in the clinic or prescribed patient for self-administration of treatment.
• the kits of this invention include at least one primary agent and one secondary agent in the appropriate dosages and dosage form for the treatment of the patient's clinical symptoms.
• the primary agent is estriol in doses of about 4-16 milligrams and the secondary agent is progesterone in doses of about 100 to about 200 milligrams.
• the primary agent is estriol in doses of about 4-16 milligrams and the secondary agent is a glucocorticoid, such as prednisone (about 5-60 milligrams per day) or methyl prednisone (1-2 milligrams per day).
• the primary agent is estriol in doses of about 4-16 milligrams and the secondary agent is .beta.-interferon in doses of about 0.25 milligrams of Betaseron.RTM. or 30 meg of Avonex.RTM.
• the primary agent is estriol in doses of about 4 to about 16 milligrams and the secondary agent is glatiramer acetate copolymer in doses of about 20 milligrams of Copaxone.RTM.
• the kit also preferably contains instructions for use of the kit by the use by the treating physician or patients to treat their autoimmune disease. Such information would include at least the schedule for the administration of the primary agent dose and the secondary agent dose.
• EDSS 0-6.5 who had been off interferon beta and copolymer-1 for at least six months, and had no steroid treatment for at least three months were eligible. At least 5 cm 3 of lesion burden on a screening T2 weighted brain MRI was required. Subjects who were pregnant or nursing, on oral contraceptives or hormone replacement therapy, or who had a history of thrombosis, neoplasm or gynecologic disease, or who had been treated in the past with total lymphoid irradiation, monoclonal antibody, T cell vaccination, cladribine or bone marrow transplantation were excluded. [0096] Patients. Twelve female patients with clinically definite MS were enrolled. Six had RR disease and six had SP disease.
• DTH to tetanus (Tetanus Toxoid, Wyeth Laboratories, Marietta, PA) and Candida (Candin, Allermed Laboratories, San Diego, CA) were tested at two timepoints, once in the pretreatment period at study month 3 and once at the end of the treatment period at study month 12 (FIG. Ia).
• a group of six untreated healthy control women were also tested twice, spanning the same time interval (9 months).
• 0.1 ml of each solution was injected intradermally on the anterior surface of the forearm. Induration at each injection site was read after 48 hours. Each site was measured twice, once vertically and once horizontally with the average recorded.
• the same nurse (RK) administered all injections and read all responses on all subjects at both time points.
• PBMCs Peripheral blood mononuclear cells
• PBMCs peripheral blood mononuclear cells
• PBMCs were thawed in parallel from a given patient during the two pre-treatment timepoints and the two treatment timepoints.
• Total RNA was isolated, DNA was removed and mRNA was reverse transcribed.
• IFN-.gamma. and actin were amplified from the same cDNA, however, the cDNA was diluted 1 :9 prior to amplification for actin. Amplification was done in 1 mM MilligramsCl 2 using IFN. ⁇ and actin primer sequences (Life Technologies, Rockville, Md.).
• Complementary DNA was amplified for 35 cycles: 45" @ 95° C, 60" @ 54° C and 45" @ 72° C. PCR products were separated on a 1.5% agarose gel containing ethidium bromide and densitometry performed.
• MRIs were performed on a 1.5T G.E. scanner.
• the pulse sequences obtained were a Tl-weighted scan with and without gadolinium (Omniscan 0.1 mmol/kg) and a PD/T2 weighted scan.
• Digitized image data was transferred to a SGI workstation (Silicon Graphics, Inc) for further processing.
• the number and volume of new and total gadolinium enhancing lesions was determined using a semiautomated threshold based technique (Display, Montreal Neurological Institute) by a single experienced operator (NS). The operator was blinded as to whether patients had RR or SP disease.
• IFN.gamma is a signature cytokine for ThI responses. Therefore, we assessed IFN.gamma. levels by RT-PCR of unstimulated peripheral blood mononuclear cells (PBMCs) derived ex vivo from patients during the pretreatment and the treatment periods. In the six RR patients, levels of IFN.gamma.
• PBMCs peripheral blood mononuclear cells
• estriol treatment would have an anti-inflammatory effect as manifested by decreases in enhancing lesions on serial brain MRIs.
• the total volume and number of enhancing lesions for all ten MS patients (6RR, 4SP) decreased during the treatment period.
• This improvement in the group as a whole was driven by the beneficial effect of estriol treatment in the RR, not the SP, group (FIGS. 3A and 3B).
• Therapeutic effects of estriol treatment in the RR group were therefore examined in further detail.
• This beneficial effect of estriol treatment on PASAT scores of RR MS patients is consistent with previous reports describing a beneficial effect of estrogen replacement therapy in surgically menopausal women and high dose estrogen treatment in Alzheimer's disease. Sicottte, et al. Treatment of Women with Multiple Sclerosis Using Pregnancy Hormone Estradiol: A Pilot Study.
• EXAMPLE 2 Progesterone in combination with estrogen treatments has been shown to protect against endometrial proliferation and cancer. Indeed, estrogen cannot be given for a lengthy period of time in an "unopposed" fashion in any woman with a uterus. Thus, seven of the 12 patients wanted to remain on estriol after completion of the 18 month study. These patients were then put back on 8 milligrams of estriol and 100 milligrams of progesterone per day. In an extension phase of the study which began after completion of the post treatment phase. This extension phase was 4 months in duration. Each of the seven patients had an MRI every month during the 4 month extension phase. Additionally, each of the seven patients was examined neurologically and had serologic studies done at the end of this phase. No known negative effects 100 milligrams of progesterone in combination therapy with 8 milligrams of estriol treatment were noted. [00109] EXAMPLE 3.
• EXAMPLE 4 A 33 year old white female patient was diagnosed as having relapsing remitting multiple sclerosis. Following the delivery of her first child (now age 7), the patient was treated only with Copaxone and relapsed at 6 weeks. Following the delivery of her second child (now age 3), the patient was again treated with Copaxone alone and again relapsed, this time at 4.5 months.
• EXAMPLE 5 Animals. Female C57BL/6 mice, 8 weeks of age, were purchased from Taconic (Germantown, NY). ERa KO mice backcrossed onto the C57BL/6 background for 16 generations were a generous gift from Dr. Dennis Lubahn (University of Missouri, Columbia, MO) (Lubahn et al, 1993). Wild-type littermates from Fl 6 crosses served as ERa KO matched controls. ER ⁇ KO mice, a generous gift from Dr. Jan Ake Gustafsson (Karolinska Institute, Sweden) (Krege et al., 1998), were backcrossed onto the C576BL/6 background for eight generations.
• PPT was purchased from Tocris Bioscience (Ellisville, MO), and E2 was purchased from Sigma-Aldrich (St. Louis, MO).
• Miglyol 812 N a thin liquid oil, was obtained from Sasol North America (Houston, TX).
• Myelin oligodendrocyte glycoprotein (MOG) peptide amino acids 35-55, was synthesized to > 98% purity by Chiron Mimotopes (San Diego, CA). .
• EAE EAE.
• each mouse was graded using the standard 0-5 scale: 0, unaffected; 1, tail limpness; 2, failure to right on attempt to roll over; 3, partial paralysis; 4, complete paralysis; and 5, moribund.
• the mean of the clinical scores of all mice within a given treatment group were determined, thereby yielding the mean clinical score for that treatment group.
• Some mice were followed clinically for up to 40 d after disease induction, and others were killed earlier for mechanistic studies, 1-2 d after the onset of clinical signs in the vehicle-treated group (day 16-19 after disease induction).
• Treatments Isoflurane-anesthetized female mice were ovariectomized and allowed to recuperate for 10 days.
• estradiol, PPT or vehicle alone were given by daily subcutaneous injections along the midbackline and continued for the entire disease duration (up to 40 days after disease induction).
• interferon- ⁇ (IFN ⁇ ) interleukin-6 (IL6), and IL5 were determined by cytometic bead array (BD Biosciences Pharmingen, San Diego, CA) as described previously (Liu et al., 2003).
• the following primary antibodies were used: anti- ⁇ 3 tubulin and anti-neurofilament-NF200 [monoclonal (Chemicon, Temecula, CA); polyclonal (Sigma Biochemical)], anti-neuronal-specific nuclear protein (NeuN), anti-CD45 (Chemicon), anti-myelin basic proteins (MBP; Chemicon) and anti-Mac 3 (BD Biosciences Pharmingen).
• the second antibody step was performed by labeling with antibodies conjugated to TRITC, FITC, and Cy5 (Vector Laboratories and Chemicon).
• Neuronal cells were quantified by counting the NeuN +/ ⁇ 3-tubulin+ /DAPI + cells per square millimeter in the whole gray matter. Both white and gray matter assessments occurred its the T1-T5 spinal cord sections. Laser-scanning confocal microscopic scans at 4OX were performed on Mac 3 + / ⁇ 3-tubulin+ immunostained spinal cord sections corresponding to levels T1-T5 ventral horn. The results for each experimental condition were averaged from four unilateral levels per mouse (100 ⁇ m apart, three mice in each treatment group, total of 12 sections per treatment group) and were expressed as mean fold change compared with healthy match controls. [00125] Statistical analysis.
• EAE disease severity was compared between groups using the Friedman test, histopathological changes were assessed using 1 x 4 ANOVAs, and uterine weights and cytokine levels were compared between treatment groups using Student's t test, as described previously (Dalai et al., 1997). ⁇ [00126] Results.
• Treatment with an ERa ligand remains highly selective for ERa in vivo during EAE.
• Sensitivity of this technique was shown by the decrease in uterine weight in ovariectomized compared with sham-operated, vehicle- treated mice.
• Treatment with injections of high doses of estradiol (to induce pregnancy levels in serum) served as a positive control, whereas treatment with injections of vehicle alone served as a negative control.
• uterotrophic responses were also examined during PPT treatment of ERa or ER ⁇ knock-out mice. Significant increases in uterine weight were observed in PPT-treated ER ⁇ knock-out mice (FIG. IB) but not in ERa knockout mice (FIG. 1C). Together, these data demonstrated that the method of administration of the ERa ligand PPT induced an expected biological response in vivo on a positive control tissue.
• FIG. 5 depicts results showing results showing treatment with an ERa- selective ligand is highly selective in vivo during EAE.
• Uterine weight was increased with PPT given as daily subcutaneous injections at 10 mg/kg/day.
• the decrease in uterine weight with ovariectomy compared with sham surgery demonstrated the sensitivity of the technique in detecting differences in uterine weights associated with differences in estrogen levels.
• ERa knock-out female mice have high circulating estradiol levels; hence, estrogen unresponsiveness in this mouse could be attributable to the ERa genetic modification or the estrogen history of the mouse before ovariectomy at 4 weeks. Because male ERa knock-out mice do not have high circulating levels of estradiol, similar results in both the female and male ERa knockouts make the ERa genetic modifications, not the estrogen history of the mouse, most likely responsible for effects observed.
• FIG. 6 Treatment with an ER ⁇ -selective ligand is sufficient to reduce the clinical severity of EAE.
• EAE clinical severity was decreased in ovariectomized, wild-type (WT) C57BL/6 female mice treated with PPT.
• Daily treatments of ovariectomized mice with injections of vehicle (negative control), estradiol (positive control), or PPT (10 mg/kg/day) began, and then 7 d later, active EAE was induced with MOG 35-55 peptide.
• Mean clinical scores were significantly reduced in both estradiol-and PPT-treated mice compared with vehicle treated (p ⁇ 0.0001, Friedman test). Data are representative from experiments repeated a total of five times. As shown in FIG.
• InERa knock-out mice mean clinical scores were not significantly different in PPT-treated compared with vehicle-treated.
• PPT-treated wild-type mice served as a positive control for a PPT treatment effect within the experiment.
• Treatment with an ERa ligand reduces autoantigen-specific proinflammatory cytokine production. Because it had been shown previously using ERa knock-out mice that both disease protection and a reduction in proinflammatory cytokines (TNF ⁇ and IFN ⁇ ) were dependent on ERa, we next determined whether treatment with an ERa ligand could reduce proinflammatory cytokine production.
• EAE reduced proinflammatory cytokine production by peripheral immune cells in ovariectomized, wild-type C57BL/6 female mice with EAE.
• EAE was induced as in FIG. 6, and then at day 40 after disease induction, mice were killed, and cytokine production by MOG 35-55 stimulated splenocytes was determined.
• TNF ⁇ , IFN ⁇ , and IL6 levels were each significantly reduced with PPT treatment, whereas IL5 levels were increased with PPT treatment.
• FIG. 8 treatment with an ERa ligand reduced inflammation and demyelination in spinal cords of mice with EAE.
• FIG. 8A representative H&E-stained thoracic spinal cord sections (4X magnification) from normal (healthy control), as well as vehicle-, E2-, and PPT-treated EAE mice are shown.
• Vehicle- treated EAE mouse spinal cord shows multifocal to coalescing areas of inflammation in the leptomeninges and white matter, around blood vessels, and in the parenchyma of the white matter (areas of inflammation shown byarrows). No inflammation was observed in either E2-or PPT-treated EAE spinal cords.
• FIG. 8A representative H&E-stained thoracic spinal cord sections (4X magnification) from normal (healthy control), as well as vehicle-, E2-, and PPT-treated EAE mice are shown.
• Vehicle- treated EAE mouse spinal cord shows multifocal to coalescing areas of inflammation in the leptomeninges and white matter, around blood
• Microglia/monocytes were stained for Mac 3, a lysosomal antigen equivalent to LAMP-2 (lysosomal-associated membrane protein 2)/CD107b, present on the surface of microglia and mature mononuclear phagocytes, and sections were coimmunolabeled with anti-B3-tubulin (FIG. 10B). Striking Mac 3+ reactivity was observed in gray matter of mice at this very early time point in EAE, only 1-2 days after the onset of clinical signs in the vehicle-treated group. Most of the MAC 3+ cells demonstrated a morphology similar to that of activated microglia (FIG. 1OB, inset).
• FIG. 10 treatment with an ERa ligand reduced CD45+ and Mac 3+ cells in white and gray matter of mice with EAE.
• FIG. 1OA thoracic spinal cord sections from mice used in FIG. 9 were coimmunostained with NF200 (green) and CD45 (red) at 1OX magnification. Shown are partial images with white and gray matter from normal control, vehicle-treated EAE, E2-treated EAE, or ERa ligand (PPT)-treated EAE mice.
• LF Lateral funiculus of white matter
• GM gray matter.
• the vehicle-treated EAE cords had large areas of CD45+ cells associated with reduced NF200 axonal staining in white matter compared with the normal control, whereas estradiol and ERa ligand-treated EAE mice had only occasional CD45 positivity, with intact NF200 axonal staining.
• FIG. 1OB consecutive sections from the same mice were also coimmunostained with ⁇ 3- tubulin (green) and Mac 3 (red), with the section of the ventral horn designated by the dotted line square area in FIG. 1OA scanned at 4OX magnification by confocal microscopy.
• FIG. 10D Mac 3X cells were analyzed by density measurements and represented as percentage of vehicle-treated groups. Compared with vehicle-treated EAE mice, both the E2-treated and PPT-treated had significantly lower Mac 3+ immunoreactivity in gray matter. Number of mice, three per treatment group; number of T1-T5 sections per mouse, four; total number of sections per treatment group, 12. ** Statistically significant compared with normal (p ⁇ 0.001); 1 x 4 ANOVAs. Data are representative of experiments repeated in their entirety on another set of EAE mice with each of the treatments. [00144] EXAMPLE 6. The neuroprotective effects of estrogen receptor (ER) Beta. Methods. Animals.
• ER estrogen receptor
• mice Female wild type C57BL/6 mice, as well as female ERJ3 1(0 mice on the C57BL16 background, age 8 weeks, were obtained from 'laconic (Germantown, NY). Wild type SIlL female mice, age S weeks, were obtained from Harlan laboratories (Indianapolis, IN). Animals were maintained in accordance with guidelines set by the National Institutes of Health and as mandated by the University of California Los Angeles Office for the Protection of Research Subjects and the Chancellor's Animal Research Committee.
• Uterine weights to assess dosing Uterine weight was used as a positive control to assess dosing of estrogen agonists.
• Hormone manipulations during EAE are examples of EAE.
• Isotlurane-anesthetized female mice were ovariectomized and allowed to recuperate for 7-10 days.
• Daily subcutaneous injections of vehicle, estradiol, PPT, or DPN began seven days prior to EAE immunization, and continued throughout the entire disease duration.
• Estradiol was delivered at a concentration of 0.04 mg/kg/day, DPN at 8 mg/kg/day and ITT at 10mg/kg/day.
• Vehicle alone treatments consisted of 10% Ethanol and 90% Migylol.
• Active EkE was induced by immunizing with 300 gg of myelin oligodenrocyte glycoprotein (MOO) peptide, amino acids 35-55, and 500 pg of Mycobacterium tuberculosis in complete Freund's adjuvant as described. Active EAE was induced in SiT, mice with 100 jig of proteolipid protein (PLP) peptide, amino acids 139-15 1, and 100 jig of Mycobacterium tuberculosis in complete Freund's adjuvant as described.
• MOO myelin oligodenrocyte glycoprotein
• mice were monitored and scored daily for clinical disease severity according to the standard 0-5 EAE grading scale: 0, unaffected; 1, tail limpness; 2, failure to right upon attempt to roll over; 3, partial paralysis; 4, complete paralysis; and 5, moribund.
• the mean of the clinical scores of all mice within a given treatment group were determined, thereby yielding the mean clinical score for that treatment group.
• Some mice were followed clinically for up to 50 days after disease induction, while others were sacrificed earlier for mechanistic studies at day 19 after disease induction, corresponding to day 4-6 after the onset of clinical signs in the vehicle treated group.
• Rotarod Testing Motor behavior was tested up to two times per week for each mouse using a rotarod apparatus (Med Associates me, St. Albans, VT). Briefly, animals were placed on a rotating horizontal cylinder for a maximum of 200 seconds. The amount of time the mouse remained walking on the cylinder, without falling, was recorded. Each mouse was tested on a speed of 3-30 rpm and given three trials for any given day. The three trials were averaged to report a single value for an individual mouse, and then averages were calculated for all animals within a given treatment group. The first two trial days, prior to immunization (day 0), served as practice trials.
• Spleens were harvested either after deep anesthesia prior to perfusion or after euthanasia. Splenocytes were stimulated with the indicated autoantigens at 25 pg/ml, and proliferation assessed using standard H3 incorporation assays, as described. Supernatants were collected after 48 and 72 hours, and levels of TNF-i, IFN-y, 11,6, and 1L5 were determined by cytometric bead array (BD Biosciences), as described.
• the following primary antibodies were used: anti- ⁇ 3 tubulin and anti-neurofilament-NF200 (monoclonal, Chemicon; polyclonal Sigma Biochemical), anti-neuronal specific nuclear protein (NeuN), anti-CD4S (Chemicon), and anti-MW (Chemicon).
• the second antibody step was performed by labeling with antibodies conjugated to TRITC, FITC and Cy5 (Vector Labs and Chemicon). IgG-control experiments were performed for all primary antibodies, and no staining was observed under these conditions.
• the ERa ligand propyl pyrazole triol (PPT) was given to ovariectomized C7BL/6 females for 10 days at either an optimal (10 mg/kg/day) or suboptimal (3.3 mg/kg/day) dose, and a significant increase in uterine weight as compared to vehicle treated was observed (FIG. 11).
• PPT ERa ligand propyl pyrazole triol
• a dose was selected which was shown to be neuroprotective in an animal model of global ischemia. When this DPN dose (8 mg/kg/day) was given in combination with PPT treatment, the increase in uterine weight mediated by PPT treatment was significantly reduced.
• Doses of the ERa and ER ⁇ ligands induce known biological responses on a positive control tissue.
• C57BLI6 mice were ovariectomized, then treated for 10 days with indicated doses of ERa or ER ⁇ ligands as daily subcutaneous injections to determine the effect of this dosing regimen on uterine weight.
• uterine weight was increased with PPT treatments at both 10 mg/kg/day and 3.3 mg/kg/day, as compared to vehicle treated controls.
• Treatment with DPN alone at 8mg/kg/day had no effect on uterine weight, while this DPN dose antagonized the PPT 3.3 mg/kg/day mediated increase in uterine weight.
• Each treatment group, n 4. * indicates p ⁇ 0.05, student t- test.
• ERa ligand treatment significantly reduced levels of proinflammatory cytokines (TNF ⁇ , IFN ⁇ , and IL6), while increasing the anti- inflammatory cytokine IL5, during both early (FIG. 12D) and later (FIG. 12F) stages of EAE.
• ER ⁇ ligand treatment was not statistically different from vehicle treatment in all measured cytokines (TNF ⁇ , IFN ⁇ , and IL6, and IL5) at either the early (FIG. 12E) or later (FIG. 12G) time points.
• Treatment with ERa versus ER ⁇ selective ligands has differential effects on chronic EAE and autoantigen specific immune responses in C57BL/6 mice.
• FIG. 12B DPN treated mice, as compared to vehicle treated mice, were not significantly different early in disease (up to day 20 after disease induction), but then became significantly improved later during EAE, (following day 30 after disease induction) p ⁇ 0.001, Friedman test.
• mice were sacrificed and cytokine production by MOO 35-55 stintulated splenocytes was determined. ITT treatment significantly reduced TNF ⁇ , LFN ⁇ , and LL6, and increased LU during early
• EAE EAE
• FIG. 12D EAE
• FIG. 12E late EAE
• Data are representative of two to five experiments for each time point.
• FIG. D-G No differences were observed with either ERa or ER ⁇ ligand treatment, as compared to vehicle, for ILlO production, while 11,4 and 1L12 levels were too low to detect (not shown).
• PLP 139-151 peptide in ovariectomized SJL female mice treated with either vehicle, DPN or estradiol.
• mice were sacrificed and splenic immune responses to the disease initiating antigen (PLP 139-151), as well as to possible epitope speading antigens (PLP 178-191 and MBP 83-102) were assessed.
• the only detectable response in all three treatment groups was to the disease initiating antigen (PLP 139-151), while responses to possible epitope speading antigens were undetectable. No significant differences were observed in proliferation or cytokine 2006/037259
• TNF ⁇ or LEN ⁇ production during the PLP 139-151 specific response in the DPN treated group as compared to the vehicle treated group.
• Estradiol treatment served as the positive control for a treatment effect on immune responses, demonstrating decreases in the proliferative response, as well as in TNF ⁇ and IFN ⁇ cytokine production, when compared to vehicle treated, consistent with previous reports.
• Double immunohistochemistry using anti-CD4S and anti-NIF200 antibodies was then used to stain inflammatory cells and axons, respectively.
• ERa ligand treated EAE mice as compared to vehicle treated EAE, had less C045 staining in white matter. This reduction in C045 staining was most marked at the early time point in EAE (FIG. 14E), while at the later time point, some C045 staining was detectable in the ERa ligand treated, albeit still less than in vehicle treated (FIG. 14F).
• ER ⁇ ligand treated EAE mice did not have reduced CD45 staining in white matter, at either the early or the later time points.
• Staining with anti-NF200 antibody revealed axonal loss in white matter of vehicle treated mice at both early and later time points of disease as compared to normal controls, while both ERa ligand and ER ⁇ ligand treatment resulted in less axonal loss, as compared to that in vehicle treated EAE mice (FIG. 15 E, G).
• Quantification of NF200 staining in anterior fununculus revealed a 49 ⁇ 12% (p ⁇ 0.01) and 40 ⁇ 8% (p O.005) reduction in vehicle treated EAE, at the early and later time points, respectively, as compared to healthy controls (FIG. 15F, H)
• Axon numbers in ERa ligand and ER ⁇ ligand treated EAE mice were not significantly reduced as compared to those in healthy controls.
• FIG. 15 Treatment with an ERa ligand and an ER ⁇ ligand each preserved myelin basic protein immunoreactivity and spared axonal pathology in white matter of spinal cords of mice with EAE. Dorsal columns of thoracic spinal cord sections were imaged at lox magnification from mice in FIG. 14 that were immunostained with antiMBP (red). At day 19 (FIG. 15A) and day 40 (FIG. 15C) after disease induction, vehicle treated mice had reduced MBP immunoreactivity as compared to normal controls, while PPT treated EAE and DPN treated EAE mice showed relatively preserved MBP staining. Upon quantification (FIG.
• MBP immunoreactivity in dorsal column was significantly lower in vehicle treated EAE mice as compared to normal mice, while PPT and DPN treated EAE mice demonstrated no significant decreases.
• Myelin density is presented as percent of normal. Statistically significant compared with normal (*p ⁇ 0.01; p ⁇ 0.005), 1 x 4 ANOVAs.
• FIG. 15 F, H Upon quantification (FIG. 15 F, H), neurofilament stained axon numbers in white matter were significantly lower in vehicle treated EAE mice as compared to normal mice, while PPT and DPN treated EAE mice demonstrated no significant reduction in axon numbers. Axon number is presented as percent of normal. Statistically significant compared with normal (*p ⁇ 0.01; **p ⁇ 0.005), 1 x 4 ANOVAs.
• Example 5 we demonstrated neuronal abnormalities surprisingly early during EAE (day 15), which were prevented by treatment with either estradiol or PPT. Whether ER ⁇ ligand treatment might preserve neuronal integrity at both the early (day 19) and later (day 40) time points of EAE was examined. Using a combination of Nissl stain histology and anti NeuN/ ⁇ 3 -tubulin immunolabeling of neurons in gray matter were identified and quantified, at both the early and later time points in EAE.
• FIG 16. Treatment with an ERa ligand and an ER ⁇ ligand each preserved neuronal staining in gray matter of spinal cords of mice with EAE.
• PPT ERa ligand
• DPN ER ⁇ ligand
• Panel (iii) is a merged confocal scan at 4OX of NeUN + (red) and (33-tubulin+ (green) co-labeled neurons from an area represented by dotted white square area in (i).
• Panel (iv) is a 4OX magnification of Nissl stained area in solid black square in (ii). A decrease in NeuN 1" immunostaining and Nissl staining was observed in the dorsal horn, intermediate zone and ventral horn of vehicle treated EAE mice as compared to normal control. White arrows in panel (iii) denote loss of NeuN 1" staining. In contrast, EAE mice treated with either PPT or DPN had preserved NeuN and Nissl staining.
• NeUN + immuno labeled neurons were significantly decreased, by nearly 41%, in vehicle treated EAE mice at day 19 (FIG. 16B) and nearly 31% at day 40 (FIG. 16D) as compared to normal controls, while PPT and DPN treated EAE mice were not statistically different from normal controls.
• Protection from neuropathology is mediated by ER ⁇ .
• FIG. 17 DPN treatment mediated protection from neuropathology during EAE is dependent upon ER ⁇ .
• FIG. 17A part of the anterior funniculus of thoracic spinal cord sections from ER ⁇ knock out control mice, vehicle treated EE ⁇ knock out with EAE and DPN treated ER ⁇ knock out with EAE at day 40 after disease induction were imaged at 4OX magnification upon co-immunostaining with anti-NF200 (green, i) and anti-MBP (red, ii). Merged images are shown in panel iii.
• ER ⁇ knock out control sections showed robust NF200 and MBP immunostaining similar to wild type normal controls in FIG.
• FIG. 17B shows split images of thoracic spinal cord sections, derived from mice in FIG. 17A, stained with NeuN (red) in (i) and Nissl in (ii) at 4X magnification, showed neuronal losses in gray matter of both the vehicle treated and DPN treated ER ⁇ knock out mice with EAE.
• FIG. 17C-F Quantification of white matter cell density, myelin density, axonal numbers and NeuN 1" cells revealed that DPN treatment does not prevent white and gray matter pathology during EAE in ER ⁇ knock out mice.
• Statistically significant compared with normals (**p ⁇ 0.001), 1 x 4 ANOVAs.
• FIG. 18 Treatment with an ER ⁇ selective ligand results in recovery of motor function late during EAE. Ovariectoniized C57BL/6 female mice with EAE were treated with DPN and assessed for motor performance on a rotarod apparatus. As shown in FIG.

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