US20150320861A1 - Egfr targeted therapy of neurological disorders and pain - Google Patents

Egfr targeted therapy of neurological disorders and pain Download PDF

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US20150320861A1
US20150320861A1 US14/654,180 US201314654180A US2015320861A1 US 20150320861 A1 US20150320861 A1 US 20150320861A1 US 201314654180 A US201314654180 A US 201314654180A US 2015320861 A1 US2015320861 A1 US 2015320861A1
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pain
neuropathic pain
egfr
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antibody
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Christian Kersten
Marte Grønlie Cameron
Svein Mjåland
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Sykehuset Sorlandet hf
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    • C07K16/28—Immunoglobulins [IGs], e.g. monoclonal or polyclonal antibodies against material from animals or humans against receptors, cell surface antigens or cell surface determinants
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    • A61K31/505—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim
    • A61K31/517—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim ortho- or peri-condensed with carbocyclic ring systems, e.g. quinazoline, perimidine
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    • A61K31/5375—1,4-Oxazines, e.g. morpholine
    • A61K31/5377—1,4-Oxazines, e.g. morpholine not condensed and containing further heterocyclic rings, e.g. timolol
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    • A61K39/3955—Antibodies; Immunoglobulins; Immune serum, e.g. antilymphocytic serum against materials from animals against proteinaceous materials, e.g. enzymes, hormones, lymphokines
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    • 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
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    • A61K9/0019—Injectable compositions; Intramuscular, intravenous, arterial, subcutaneous administration; Compositions to be administered through the skin in an invasive manner
    • A—HUMAN NECESSITIES
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    • A—HUMAN NECESSITIES
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    • A61P25/28—Drugs for disorders of the nervous system for treating neurodegenerative disorders of the central nervous system, e.g. nootropic agents, cognition enhancers, drugs for treating Alzheimer's disease or other forms of dementia
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    • C07—ORGANIC CHEMISTRY
    • C07K—PEPTIDES
    • C07K2317/00—Immunoglobulins specific features
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    • C—CHEMISTRY; METALLURGY
    • C07—ORGANIC CHEMISTRY
    • C07K—PEPTIDES
    • C07K2317/00—Immunoglobulins specific features
    • C07K2317/20—Immunoglobulins specific features characterized by taxonomic origin
    • C07K2317/24—Immunoglobulins specific features characterized by taxonomic origin containing regions, domains or residues from different species, e.g. chimeric, humanized or veneered
    • C—CHEMISTRY; METALLURGY
    • C07—ORGANIC CHEMISTRY
    • C07K—PEPTIDES
    • C07K2317/00—Immunoglobulins specific features
    • C07K2317/70—Immunoglobulins specific features characterized by effect upon binding to a cell or to an antigen
    • C07K2317/76—Antagonist effect on antigen, e.g. neutralization or inhibition of binding

Definitions

  • the present invention relates to compositions and methods for treatment of neurological disorders.
  • the present invention relates to the epidermal growth factor receptor (EGFR) as a clinical target for treatment of neurological disorders, preferably in conjunction with neuropathic pain.
  • EGFR epidermal growth factor receptor
  • the invention relates in more detail to compositions comprising inhibitors of EGFR.
  • NP Neuropathic pain
  • Pain 2011; 152:2204-5 Not uncommonly, its severity, chronicity and the poor side-effect to benefit ratio of current pharmacotherapy for NP (Dworkin R H. An overview of neuropathic pain: syndromes, symptoms, signs, and several mechanisms. Clin J Pain 2002; 18:343-9; Finnerup N B, Sindrup S H, Jensen T S. The evidence for pharmacological treatment of neuropathic pain.
  • the incidence of NP is estimated to be 1% (Dieleman J P, Kerklaan J, Huygen F J, Bouma P A, Sturkenboom M C. Incidence rates and treatment of neuropathic pain conditions in the general population. Pain 2008; 137:681-88) and rising (Dworkin, supra).
  • Neuropathic pain is a complex, chronic pain state that usually is accompanied by tissue injury. With neuropathic pain, the nerve fibers themselves may be damaged, dysfunctional or injured. These damaged nerve fibers send incorrect signals to other pain centers. The impact of nerve fiber injury includes a change in nerve function both at the site of injury and areas around the injury. Some neuropathic pain studies suggest the use of non-steroidal anti-inflammatory drugs, such as Aleve or Motrin, may ease pain. Some people may require a stronger painkiller, such as those containing morphine. Anticonvulsant and antidepressant drugs seem to work in some cases. If another condition, such as diabetes, is involved, better management of that disorder may alleviate the pain.
  • a pain specialist may use invasive or implantable device therapies to manage the pain. Electrical stimulation of the nerves involved in neuropathic pain generation may also control the pain symptoms.
  • neuropathic pain often responds poorly to standard pain treatments and occasionally may get worse instead of better over time. For some people, it can lead to serious disability. Current treatments are characterized by an unsatisfactory side effect to benefit-ratio.
  • the present invention relates to compositions and methods for treatment of neurological disorders.
  • the present invention relates to EGFR as a clinical target for treatment of neurological disorders, preferably accompanied by neuropathic pain.
  • EGFR is widely expressed on nerve fibers (Andres et al., Quantitative automated microscopy (QuAM) elucidates growth factor specific signalling in pain sensitization, Molceular Pain 2010, 6:98).
  • Quantitative automated microscopy Quantitative automated microscopy (QuAM) elucidates growth factor specific signalling in pain sensitization, Molecular Pain 2010, 6:98.
  • Ciardiello et al. Interaction between the epidermal growth factor receptor (EGFR) and the vascular endothelial growth factor (VEGF) pathways: a rational approach for multi-target anticancer therapy.
  • EGFR inhibitors cause pain
  • antigen binding protein EGFR inhibitors such as anti-EGFR antibodies like cetuximab (Erbitux®) and panitumumab (Vectibix®) or small molecule EGFR inhibitors such as gefitinib (Iressa®) and erlotinib (Tarceva®) alleviate symptoms across a range of various categories of neuropathic pain (e.g., toxic, metabolic, trauma, compressive, autoimmune, infectious and hereditary/congenital neuropathic pain) involving different types of nerve fibers.
  • neuropathic pain e.g., toxic, metabolic, trauma, compressive, autoimmune, infectious and hereditary/congenital neuropathic pain
  • the present invention provides for the use of EGFR inhibitors to treat pain symptoms in a subject.
  • the present invention provides for the use of EGFR inhibitors to alleviate one or more symptoms of neuropathic pain in a subject.
  • the present invention is not limited to alleviation of any particular symptoms of neuropathic pains and includes, but is not limited to alleviation of shooting and burning pain and well as tingling and numbness and combinations thereof.
  • the present invention provides methods of treating a subject with pain, preferably neuropathic pain, more preferably severe neuropathic pain comprising administering to said subject an agent that inhibits at least one biological function of EGFR.
  • the invention further provides compositions comprising at least an agent that inhibits at least one biological function of EGFR for use for the treatment of neurological disorders, preferably neurological disorders accompanied by pain, preferably severe neuropathic pain.
  • the neuropathic pain is non-compressive neuropathic pain.
  • the neuropathic pain is compressive neuropathic pain. In some embodiments, the compressive neuropathic pain is non-cancer related. In some embodiments, the compressive neuropathic pain is cancer related. In some embodiments, the compressive neuropathic pain is pain associated with a syndrome selected from the group consisting of failed back surgery syndrome, carpal tunnel syndrome, compartment syndrome and sciatica.
  • the neuropathic pain is toxic neuropathic pain.
  • the toxic neuropathic pain is chemotherapy-induced peripheral neuropathy.
  • the toxic neuropathic pain is selected from pain associated with exposure to an agent selected from the group consisting of lead, arsenic, asbestos, isoniazid and thallium.
  • the neuropathic pain is metabolic neuropathic pain.
  • the metabolic neuropathic pain is selected from pain associated with painful diabetic neuropathy, nutritional deficiency, alcohol induced neuropathy and thiamine deficient axonal sensorimotor burning neuropathy.
  • the neuropathic pain is traumatic neuropathic pain.
  • the traumatic neuropathic pain is associated with a syndrome selected from the group consisting of phantom limb syndrome and complex regional pain syndrome.
  • the neuropathic pain is autoimmune neuropathic pain.
  • the autoimmune neuropathic pain is selected from the group consisting of chronic inflammatory demyelinating polyneuropathy and vasculitic neuropathy.
  • the neuropathic pain is infectious neuropathic pain.
  • the infectious neuropathic pain is selected from the group consisting of postherpetic neuralgia and painful HIV-distal sensory polyneuropathy.
  • the neuropathic pain is congential or hereditary neuropathic pain.
  • the pain is associated with pain nerve fiber type A. In some embodiments, the pain is associated with pain nerve fiber type B. In some embodiments, the pain is associated with pain nerve fiber type C. In some embodiments, the pain is associated with demyelinated nerve fibers.
  • the agent reduces or modulates symptoms of said pain, wherein said symptom is selected from the group consisting of shooting pain, burning pain, tingling, numbness and combinations thereof.
  • the method provides for the long term palliative care of a subject.
  • the long term palliative care is for a period selected from the group consisting of longer than six months, longer than 12 months, longer than 24 months, longer than 36 months, longer than 48 months and longer than 60 months.
  • the method provides for reduction of the dosage of opioid agents for a subject.
  • the dosage of said agent is reduced following initial administration of said agent.
  • the agent is an antigen binding protein that inhibits at least one biological function of EGFR, such as an anti EGFR antibody or a biologically effective fragment thereof.
  • the antigen binding protein is an anti EGFR antibody, selected from the group consisting of cetuximab, matuzumab, necitumumab, nimotuzumab, panitumumab, and zalutumumab.
  • the antigen binding protein is selected from the group consisting of cetuximab or panitumumab.
  • the antigen binding protein is cetuximab and the administration is every 5 to 14 days. In some embodiments, the cetuximb is administered at an initial dose of about 300 to 500 mg per square meter, followed by weekly infusion of about 100 to 500 mg per square meter. In some embodiments, the antigen binding protein is panitumumab and the administration is every 10 to 20 days.
  • the panitumumab is administered at an initial dose of 6 mg/kg, followed by biweekly infusions of about 6 mg/kg. In some embodiments, administration comprises infusion of an antigen binding protein inhibitor of EGFR.
  • the agent is a small molecule drug that inhibits at least one biological function of EGFR, and said administration is oral.
  • the small molecule drug is selected from the group consisting of afatinib, erlotinib, gefitinib, lapatinib, and neratinib.
  • the small molecule drug is selected from the group consisting of gefitinib and erlotinib. In some embodiments, the small molecule drug is gefitinib and the administration is 10 to 250 mg daily. In some embodiments, the small molecule drug is erlotinib and the administration is 10 to 300 mg daily. In some embodiments, the administration comprises oral administration of a small molecule inhibitor of EGFR.
  • administration comprises administration of an antigen binding protein inhibitor of EGFR followed by administration of a small molecule inhibitor of EGFR.
  • the subject is a human.
  • the present invention provides methods of treating a subject with a neurological disorder, preferably accompanied by neuropathic pain, comprising administering to said subject an agent that inhibits at least one biological function of an EGFR polypeptide.
  • the present invention provides pharmaceutical compositions comprising at least an agent that inhibits at least one biological function of an EGFR polypeptide for use for said treatment methods.
  • the subject exhibits symptoms of a neurological disorder and said administering said agent reduces or modulates symptoms of said neurological disorder, preferably reduces or eliminates neuropathic pain
  • the subject does not have cancer or has not been previously treated for cancer.
  • the neurological disorder is neuropathic pain, or is accompanied by neuropathic pain.
  • the neurological disorder is selected from the group consisting of pain, sciatica, multiple sclerosis, depression, dementia, Parkinson's disease, stroke, axotomia, and ischemia or reperfusion injury, Down's syndrome and autism.
  • the agent that inhibits at least one biological function of an EGFR polypeptide is co-administered with at least additional therapeutic agent, preferably a therapeutic agent that palliates or prevents pain
  • at least additional therapeutic agent is selected from the group consisting of non-steroidal anti-inflammatory drugs, steroidal anti-inflammatory drugs, opioid-based drugs, antidepressants, anticonvulsants, antiepileptics, anti-anxiety drugs, and cannibinoids and combinations thereof.
  • the known agents according to the invention that inhibit at least one biological function of an EGFR polypeptide are currently used and approved as anti-cancer agents usually in a combination treatment with chemotherapeutic agents, such has irinotecan, FOLFIRI,
  • FOLFOX FOLFOX, paclitaxel and others.
  • the anti-cancer effect of these agents above all when anti-EGFR antibodies are applied, is present only in conjunction with a chemotherapeutic and/or radiotherapeutic treatment setting.
  • the agents and compositions according to the present invention elicit their pain-palliating efficacy independent on any anti-cancer efficacy, and independent on the presence of a cancer disease.
  • the EGFR inhibiting agents and compositions according to the invention can be successfully used as monotherapy in cancer therapy accompanied by neuropathic pain which is usually caused there by tumor growth and/or by the side effects of the applied chemotherapeutic agents. They are also effective in patients suffering from cancer and, in addition, from neurological diseases which are not caused or influenced by the primary or secondary cancer disease.
  • the EGFR inhibiting agents and compositions according to the invention are effective in neuropathic pain reduction much faster than the same agents applied in a very similar dose setting in cancer therapy. If applied by intravenous administration by a one-time or initial dose of 250-500 mg/m 2 a pain reduction of at least 50% compared to the untreated condition can be obtained after less than 24 h, preferably less than 12 h, and most preferably less than 6 h.
  • EGFR inhibiting agents that reduce neuropathic pain in a patient suffering from a neurological disease and/or a cancer disease by intravenous administration of an initial or single dose of preferably 250-500 mg/m 2 of an antibody or polypeptide, such as cetuximab or panitumumab, and of 10-300 mg of a small molecule drug, such as erlotinib or gefitinib, by more than 50% of the individual pain score compared to untreated condition within 4 h-6 h after administration, and by more than 90% within 12 h-24 h after administration dependent on the nature and severity of the neuropathic pain.
  • cetuximab a pain reduction of about 90% can be obtained already after 4-6 h after administration.
  • the intravenous administration may be repeated in this case every 5-14 days, preferably every 10-20 days, dependent on the nature of the drug.
  • the additional administration of analgesic drugs can be reduced or omitted. Therefore, in another embodiment of the treatment, the simultaneous administration of other analgesic drugs, or pain killers, such as opioids, can be reduced by at least 50%, 60%, 70%, 80%, 90% or 100%.
  • the oral administration may be repeated in this case every 1-3 days, preferably every day, dependent on the nature of the drug.
  • the additional administration of analgesic drugs can be reduced or omitted. Therefore, in another embodiment of the treatment, the simultaneous administration of other analgesic drugs, or pain killers, such as opioids, can be reduced by at least 50%, 60%, 70%, 80%, 90% or 100%.
  • the treatment comprises a first initial intravenous administration of an anti-EGFR antibody, such as cetuximab and panitumumab, or a biologically active fragment thereof, followed after 5-20 days by oral administration of a small molecule drug, such as erlotinib or gefitinib, every 1-3 days, and optionally reducing or omitting other analgesic drugs such as opioids.
  • an anti-EGFR antibody such as cetuximab and panitumumab
  • a biologically active fragment thereof followed after 5-20 days by oral administration of a small molecule drug, such as erlotinib or gefitinib, every 1-3 days, and optionally reducing or omitting other analgesic drugs such as opioids.
  • the EGFR inhibiting agents of the invention may reduce pathologic symptoms accompanying the neuropathic pain, for example, edema and skin rash in autoimmune neuropathic related disorders, like vasculitis neuropathy.
  • FIGS. 1 a - d describe graphically the clinical course of case 1 over period of 69 months. Progression of the pelvic tumor in case 1 during this period is shown in the magnetic resonance image (MRI) in FIG. 2 a - c.
  • MRI magnetic resonance image
  • FIGS. 2 a - c Recurrent and progressive rectal cancer. Arrows indicate tumor changes affecting the left sacral plexus and left sciatic nerve.
  • 2 a MRI taken three months prior to starting capecitabine, oxaliplatin and cetuximab (corresponds to MRI 2 in FIG. 1 a ). There is a presacral recurrence that extends along the left sciatic nerve.
  • 2 b MRI taken 4 months after starting capecitabine, oxaliplatin and cetuximab (corresponds to MRI 3 in FIG. 1 b ). Both the presacral recurrence and its extension along the sciatic nerve have increased in size.
  • MRI taken eight months after starting cetuximab monotherapy for analgesia corresponds to MRI 4 in FIG. 1 d ). There is further progression of the recurrence in the presacral area and along the left sciatic nerve.
  • FIG. 3 provides graphs of BPI-measurements before and after introduction of EGFR-inhibition for cases 2-5.
  • FIGS. 4 a - d provide graphic depictions of patients treated according to the present invention.
  • Case 2. Photographs depicting the persistence of abnormalities typical of CRPS1, in the patient's right hand. Treatment with the EGRF inhibitor cetuximab relieved her NP but did not influence the vasomotor pathology of the underlying condition.
  • Case 3. MRI taken six weeks postoperatively, due to recurrence of NP back pain, after initial relief. The image demonstrates pathological scar tissue formation around the patient's fifth lumbar spinal nerve root.
  • Case 4. Computed tomography scan of the patient's pelvis before c) and after d) EGFR-inhibition. In the interval between the scans, the patient was completely relieved of his NP despite a growing pelvic tumor which increasingly invaded sacral nerves.
  • FIG. 5 Selected domains of the Brief Pain Inventory after starting intravenous EGFR-inhibition with panitumumab for progressive CIPN. Days since first treatment are shown on the X-axis (infusion repeated every 14 days).
  • FIG. 6 Alleviation of CIPN by EGFR-I exemplified by selected questions from the EORTC QLQ-CIPN20. Five of the twenty questionnaire items are shown. None of the responses deteriorated after start of treatment (data not shown).
  • FIG. 7 Oral EGFR-I effective against NP according to BPI scores.
  • the upper panel shows patient 3, who experienced recurrent severe NP after wash-out of the intravenous drug cetuximab. The pain was completely alleviated after two to three weeks of treatment with the oral EGFR-I gefitinib.
  • the lower panel shows a previously EGFR-I na ⁇ ve patient, who responded to upfront treatment with the oral EGFR-I erlotinib, yellow arrow.
  • the epidermal growth factor receptor EGFR (synonyms: ErbB-1; HER1) is a member of the ErbB family of receptors, a subfamily of four closely related receptor tyrosine kinases: EGFR (ErbB-1), HER2/c-neu (ErbB-2), Her3 (ErbB-3) and Her4 (ErbB-4).
  • the EGF receptor is a transmembrane glycoprotein which has a molecular weight of 170.000, and is found on many epithelial cell types. It is activated by at least three ligands, EGF, TGF- ⁇ (transforming growth factor alpha) and amphiregulin. Both epidermal growth factor (EGF) and transforming growth factor-alpha (TGF-a) have been demonstrated to bind to EGF receptor and to lead to cellular proliferation and tumor growth.
  • EGF epidermal growth factor
  • TGF-a transforming growth factor-alpha
  • ErbB inhibitor Two important types of ErbB inhibitor are in clinical use: chimeric, humanized or fully human antibodies directed against the extracellular domain of EGFR or ErbB2, and small-molecule tyrosine-kinase inhibitors (TKIs) that compete with the ATP in the tyrosine-kinase domain of the receptor.
  • TKIs small-molecule tyrosine-kinase inhibitors
  • Humanized monoclonal antibody 425 (hMAb 425, U.S. Pat. No. 5,558,864; EP 0531 472) and chimeric monoclonal antibody 225 (cMAb 225), both directed to the EGF receptor, have shown their efficacy in clinical trials.
  • the C225 antibody (Cetuximab) was demonstrated to inhibit EGF-mediated tumor cell growth in vitro and to inhibit human tumor formation in vivo in nude mice.
  • the antibody as well as in general all anti-EGFR antibodies act mostly in synergy with certain chemotherapeutic agents (i.e., doxorubicin, adriamycin, taxol, and cisplatin) to eradicate human tumors in vivo in xenograft mouse models (see, for example,
  • tyrosine kinase antagonist/inhibitor or “ErbB-inhibitor” refers according to this invention to natural or synthetic agents that are enabled to inhibit or block tyrosine kinases, receptor tyrosine kinases included.
  • the term includes per se ErbB receptor antagonists/inhibitors, and specifically EGFR inhibitors.
  • tyrosine kinase antagonist agents are chemical compounds which have shown efficacy in mono-drug therapy for breast and prostate cancer.
  • Suitable indolocarbazole-type tyrosine kinase inhibitors can be obtained using information found in documents such as U.S. Pat. Nos. 5,516,771; 5,654,427; 5,461,146; 5,650,407.
  • U.S. Pat. Nos. 5,475,110; 5,591,855; 5,594,009 and WO 96/11933 disclose pyrrolocarbazole-type tyrosine kinase inhibitors and prostate cancer.
  • gefitinib gefitinib
  • Astra Zeneca gefitinib
  • NSCLC non-small cell lung cancer
  • Antibody fragments comprise a portion of an intact antibody, preferably comprising the antigen-binding or variable region thereof.
  • antibody fragments include Fab, Fab′, F(ab′)2, Fv and Fc fragments, diabodies, linear antibodies, single-chain antibody molecules; and multispecific antibodies formed from antibody fragment(s).
  • An “intact” antibody is one which comprises an antigen-binding variable region as well as a light chain constant domain (CL) and heavy chain constant domains, CH1, CH2 and CH3.
  • the term “inhibits at least one biological activity of EGFR” refers to any agent that decreases any activity of EGFR, including EGFR tyrosine kinase (e.g., including, but not limited to, the activities described herein), via directly contacting EGFR protein, contacting EGFR mRNA or genomic DNA, causing conformational changes of EGFR polypeptides, decreasing EGFR protein levels, or interfering with EGFR interactions with different receptors or ligands such as but not limited to EGF, TGF-alpha, Neuregulin, Amphiregulin, Epiregulin, NGF, HER2, HER3 and HER4.
  • Inhibitors also include molecules that indirectly regulate EGFR biological activity by intercepting upstream signaling molecules.
  • the invention is related to EGFR inhibitors that bind to the the extracellaur binding site of the tyrosine kinase receptor molecule, thus blocking binding of the natural ligands, such as EGF.
  • Antibodies, antibody portions, and peptides comprising epitopes that target this extracellular EGF receptor binding domain, are included by the invention.
  • the invention is further related to EGFR inhibitors which can bind or interact with the intracellular phosphorylation site or domain of the tyrosine kinase receptor molecule, such preventing or decreasing phosphorylation by tyrosine kinase. This can be achieved by small (chemical) molecule drugs.
  • neuropathic pain refers to a complex, chronic pain state that usually is accompanied by tissue injury.
  • Neuropathic pain includes, but is not limited to, the following syndromes and disease states: nerve impingement, complex regional pain syndrome types I and II, trigeminal neuralgia, phantom pain, diabetic neuropathy, spinal cord injury, and nerve damage due to i.e. cancer, burns and trauma.
  • Different categories of neuropathic pain include, but are not limited to, toxic, metabolic, trauma, compressive, autoimmune, infectious and hereditary/congenital neuropathic pain.
  • epitopope refers to that portion of an antigen that makes contact with a particular antibody.
  • an antigenic determinant may compete with the intact antigen (i.e., the “immunogen” used to elicit the immune response) for binding to an antibody.
  • telomere binding when used in reference to the interaction of an antibody and a protein or peptide means that the interaction is dependent upon the presence of a particular structure (i.e., the antigenic determinant or epitope) on the protein; in other words the antibody is recognizing and binding to a specific protein structure rather than to proteins in general. For example, if an antibody is specific for epitope “A,” the presence of a protein containing epitope A (or free, unlabelled A) in a reaction containing labeled “A” and the antibody will reduce the amount of labeled A bound to the antibody.
  • non-specific binding and “background binding” when used in reference to the interaction of an antibody and a protein or peptide refer to an interaction that is not dependent on the presence of a particular structure (i.e., the antibody is binding to proteins in general rather that a particular structure such as an epitope).
  • the term “subject” or “patient” refers to any animal (e.g., a mammal), including, but not limited to, humans, non-human primates, rodents, and the like, which is to be the recipient of a particular treatment.
  • the terms “subject” and “patient” are used interchangeably herein in reference to a human subject.
  • non-human animals refers to all non-human animals including, but are not limited to, vertebrates such as rodents, non-human primates, ovines, bovines, ruminants, lagomorphs, porcines, caprines, equines, canines, felines, ayes, etc.
  • amino acid sequence and terms such as “polypeptide” or “protein” are not meant to limit the amino acid sequence to the complete, native amino acid sequence associated with the recited protein molecule.
  • native protein as used herein to indicate that a protein does not contain amino acid residues encoded by vector sequences; that is, the native protein contains only those amino acids found in the protein as it occurs in nature.
  • a native protein may be produced by recombinant means or may be isolated from a naturally occurring source.
  • portion when in reference to a protein (as in “a portion of a given protein”) refers to fragments of that protein.
  • the fragments may range in size from four amino acid residues to the entire amino acid sequence minus one amino acid.
  • in vitro refers to an artificial environment and to processes or reactions that occur within an artificial environment.
  • In vitro environments can consist of, but are not limited to, test tubes and cell culture.
  • in vivo refers to the natural environment (e.g., an animal or a cell) and to processes or reaction that occur within a natural environment.
  • Pain interference (total) score means a score for pain as a result of the disease occurring during administration of the effective drug. Pain interference is assessed using the Brief Pain Inventory (BPI). BPI is used to evaluate pain interference with the following: (a) general activity, (b) mood, (c) walking ability, (d) normal work, (e) relations with other people, (f) sleep, and (g) enjoyment of life. Total score for pain interference is calculated as: (Mean score of non-missing questions) ⁇ (7/number of non-missing questions). If four or more questions are missing, the pain interference total score is set to missing.
  • BPI Brief Pain Inventory
  • chemotherapeutic agent or “anti-neoplastic agent” is regarded according to the understanding of this invention as a member of the class of “cytotoxic agents”, as specified above, and includes chemical agents that exert anti-neoplastic effects, i.e., prevent the development, maturation, or spread of neoplastic cells, directly on the tumor cell, and not indirectly through mechanisms such as biological response modification.
  • Suitable chemotherapeutic agents according to the invention are preferably natural or synthetic chemical compounds, but biological molecules, such as proteins, polypeptides etc. are not expressively excluded.
  • chemotherapeutic agents can be administered optionally together with above-said antibody drug.
  • chemotherapeutic or agents include alkylating agents, for example, nitrogen mustards, ethyleneimine compounds, alkyl sulphonates and other compounds with an alkylating action such as nitrosoureas, cisplatin and dacarbazine; antimetabolites, for example, folic acid, purine or pyrimidine antagonists; mitotic inhibitors, for example, vinca alkaloids and derivatives of podophyllotoxin; cytotoxic antibiotics and camptothecin derivatives.
  • alkylating agents for example, nitrogen mustards, ethyleneimine compounds, alkyl sulphonates and other compounds with an alkylating action such as nitrosoureas, cisplatin and dacarbazine
  • antimetabolites for example, folic acid, purine or pyrimidine antagonists
  • mitotic inhibitors for example, vinca alkaloids and derivatives of podophyllotoxin
  • cytotoxic antibiotics and camptothecin derivatives include
  • Preferred chemotherapeutic agents or chemotherapy include amifostine (ethyol), cabazitaxel, cisplatin, dacarbazine (DTIC), dactinomycin, docetaxel, mechlorethamine, streptozocin, cyclophosphamide, carrnustine (BCNU), lomustine (CCNU), doxorubicin (adriamycin), doxorubicin lipo (doxil), gemcitabine (gemzar), daunorubicin, daunorubicin lipo (daunoxome), procarbazine, ketokonazole, mitomycin, cytarabine, etoposide, methotrexate, 5-fluorouracil (5-FU), vinblastine, vincristine, bleomycin, paclitaxel (taxol), docetaxel (taxotere), aldesleukin, asparaginase, busulfan, carboplatin, cladrib
  • chemotherapeutic agents according to the invention in combination with DI17E6 are cabazitaxel, cisplatin, docetaxel, gemcitabine, doxorubicin, paclitaxel (taxol), irinotecan and bleomycin.
  • the present invention relates to compositions and methods for treatment of neurological disorders.
  • the present invention relates to EGFR as a clinical target for treatment of neurological disorders.
  • Pain is transmitted via different nerve fibers, designated A ⁇ nerve fibers, B nerve fibers and C nerve fibers.
  • pain signals travel from the periphery to the spinal cord along an A-delta or C fiber.
  • A-delta fiber is thicker than the C fiber, and is thinly sheathed in an electrically insulating material (myelin), it carries its signal faster (5-30 m/s) than the unmyelinated C fiber (0.5-2 m/s). Pain evoked by the (faster) A-delta fibers is described as sharp and is felt first. This is followed by a duller pain, often described as burning, carried by the C fibers.
  • Neuropathic pain is caused by damage or disease affecting any part of the nervous system involved in bodily feelings (the somatosensory system). Neuropathic pain is a complex, chronic pain state. With neuropathic pain, the nerve fibers themselves may be damaged, dysfunctional, or injured. These damaged nerve fibers send incorrect signals to other pain centers. The impact of nerve fiber injury includes a change in nerve function both at the site of injury and areas around the injury. Some common causes of neuropathic pain include: Alcoholism; Amputation; Back, leg, and hip problems; Chemotherapy; Diabetes; Facial nerve problems; HIV infection or AIDS; Multiple sclerosis; Shingles and Spine surgery. Symptoms of neuropathic pain include shooting and burning pain and well as tingling and numbness.
  • EGF-MAPK-signaling is activated in neurons and glial cells in response to injury or dysfunction. Inhibition of the EGFR may interrupt a negative feedback loop, thereby alleviating symptoms from neurological disorders, like pain, neuropathic pain, MS, depression, dementia, Parkinson's disease, stroke, axotomia, etc. Especially in neuropathic pain, the pathological sensitization of nerve fibers for pain is inhibited.
  • Pain due to nerve injury is thought to be generated and sustained by MAPK signalling via the three pathways ERK, p38 and JNK in central, spinal and peripheral nerves, as well as in peripheral and central glia such as astrocytes and Schwann cells (Ji R R, Gereau R Wt, Malcangio M, Strichartz G R. MAP kinase and pain. Brain Res Rev 2009; 60(1):135-48). Furthermore, communication between neuronal cells, glial cells and immune cells is an established pathogenic factor in neuropathic pain (Scholz J, Woolf C J. The neuropathic pain triad: neurons, immune cells and glia. Nat. Neurosci. 2007; 10(11):1361-8).
  • Embodiments of the present invention provide methods of treating neurological disorders by inhibiting EGFR.
  • the present invention is not limited to a particular neurological disorder.
  • the present invention provides methods of inhibiting the EGF receptor to treat pain, neuropathic pain, MS, depression, dementia, Parkinson's disease, stroke, ischemia and reperfusion injury, ischemic brain injury, and axotomia. See e.g., Oyagi et al., Neuroscience.
  • administering is useful for ameliorating symptoms associated with genetics disorders such as Down's syndrome and autism.
  • the present invention provides methods of utilizing a reagent that inhibits at least one biological function of an EGFR polypeptide to reduce, ameliorate or modulate, or provide prophylaxis, for one or more symptoms associated with the following diseases or disorders: pain, neuropathic pain, sciatica, MS, depression, dementia, Parkinson's disease, stroke, ischemia and reperfusion injury, ischemic brain injury, axotomia, Amyotrophic lateral sclerosis, Huntington's disease, Chorea, Down's syndrome and autism.
  • diseases or disorders pain, neuropathic pain, sciatica, MS, depression, dementia, Parkinson's disease, stroke, ischemia and reperfusion injury, ischemic brain injury, axotomia, Amyotrophic lateral sclerosis, Huntington's disease, Chorea, Down's syndrome and autism.
  • the present invention provides novel treatment for neuropathic pain.
  • the present invention is not limited to treatment of any particular type of neuropathic pain, and includes, but is not limited to treatment of the following types of neuropathic pain.
  • Ischemic NP This category includes neuropathic pain associated with stroke, gangrene, and other peripheral thrombotic events.
  • Toxic NP The most common toxic condition causing neuropathic pain is a result of chemotherapy and/or radiation in the treatment of cancer. Isoniazid and thallium are also known to cause neuropathic pain conditions. Exposure to chemicals like lead and arsenic also result in nerve damage. Toxic exposure generally results in abnormalities in genetic/protein processing.
  • Metabolic NP Diabetes is clearly the major cause of neuropathic pain (e.g., painful diabetic neuropathy) caused by metabolic dysfunction. Nutritional deficiencies like Beriberi (vitamin B1) also produce neuropathic pain. In the case of diabetes, glycosylation end products inhibit axonal transport and Na+/K+ ATPase producing axonal degeneration. Alcohol induced neuropathy is often a result of thiamine (B1) deficiency although it can produce its own small fiber pain pathology as opposed to a thiamine-deficient axonal sensorimotor burning neuropathy.
  • Trauma NP typically trauma is due to fractures, direct nerve damages and burns. Trauma can also result in phantom limb syndromes and/or complex regional pain syndromes (CRPS). Phantom limb pain is thought to be a result of abrupt loss of sensory input from the peripheral limb to the brain and discharges from the nerve endings at the sight of the amputation that continue to send pain signals to the brain, making the brain think the limb is still there. There is no known mechanism that causes CRPS but many hypotheses have been suggested, including dysfunctional processing throughout the entire nervous system involving peripheral, central and autonomic neurons.
  • Compressive NP Bottom nerve entrapment and excessive external pressure on nerve axons can cause ischemic or distortional (stretching) changes. Prolonged injury results in Wallerian degeneration of the axon with resultant muscle atrophy. Carpal tunnel syndrome and compartment syndromes are common entrapment injuries.
  • the present invention also encompasses treatment of sciatica and trigeminal neuropathic pain.
  • Autoimmune NP This class of neuropathic pain can be quite diverse. They may have autoimmune antibodies involved in their pathophysiology and are usually amenable to immune therapy. Some examples of autoimmune neuropathic pain include chronic inflammatory demyelinating polyneuropathy (CIDP), paraneoplastic syndromes and vasculitic neuropathy.
  • CIDP chronic inflammatory demyelinating polyneuropathy
  • paraneoplastic syndromes and vasculitic neuropathy.
  • Infectious NP Viral conditions are known to result in long-standing neuropathic pain.
  • the classical condition is post-herpetic neuralgia caused by reactivation of the Varicella Zoster Virus. Lyme Disease (spirochetes), Chagas' Disease (trypanosomes), leprosy (mycobacterium), HIV, and Guillain-Barré Syndrome (post-infectious) can all cause neuropathic pain.
  • the present invention specially encompasses treatment of postherpetic neuralgia and painful HIV-distal sensory polyneuropathy as well as neuropathic pain caused by the agents described above.
  • Congenital/Hereditary NP Fabry's Disease and Charcot-Marie-Tooth Disease (burning pain in extremities) are examples of peripheral neuropathic pain associated with congenital abnormalities.
  • Other hereditary conditions like amyloidosis also produce painful conditions.
  • the present invention provides methods of treating a subject with pain comprising administering to said subject an agent that inhibits at least one biological function of EGFR.
  • the pain is neuropathic pain.
  • administration of an EGFR inhibitor causes alleviation of pain symptoms or a reduction in pain symptoms.
  • the present invention is not limited to alleviation of any particular symptoms of neuropathic pain and includes, but is not limited to alleviation or reduction of shooting and burning pain and well as tingling and numbness and combinations thereof.
  • the neuropathic pain may be non-compressive neuropathic pain or compressive neuropathic pain.
  • the compressive neuropathic pain can be cancer related or non-cancer related.
  • the compressive neuropathic pain is pain associated with a syndrome selected from the group consisting of failed back surgery syndrome, failed back surgery syndrome, carpal tunnel syndrome, compartment syndrome and sciatica, although treatment of other syndromes associated with compressive neuropathic pain are encompassed by the invention.
  • the neuropathic pain may be toxic neuropathic pain.
  • the toxic neuropathic pain is chemotherapy-induced peripheral neuropathy.
  • the neuropathic pain is selected from pain associated with exposure to an agent selected from the group consisting of lead, arsenic, asbestos, isoniazid and thallium. Other types of toxic neuropathic pain are also encompassed by the invention.
  • the neuropathic pain may be metabolic neuropathic pain.
  • the metabolic neuropathic pain is selected from pain associated with painful diabetic neuropathy, nutritional deficiency, alcohol induced neuropathy and thiamine deficient axonal sensorimotor burning neuropathy.
  • Other types of metabolic neuropathic pain are also encompassed by the invention.
  • the neuropathic pain may be trauma neuropathic pain.
  • the trauma neuropathic pain is associated with a syndrome selected from the group consisting of phantom limb syndrome and complex regional pain syndrome.
  • Other types of trauma neuropathic pain are also encompassed by the invention.
  • the neuropathic pain may be autoimmune neuropathic pain.
  • the autoimmune neuropathic pain is selected from the group consisting of chronic inflammatory demyelinating polyneuropathy and vasculitic neuropathy. Other types of autoimmune neuropathic pain are also encompassed by the invention.
  • the neuropathic pain may be infectious neuropathic pain.
  • the infectious neuropathic pain is selected from the group consisting of postherpetic neuralgia and painful HIV-distal sensory polyneuropathy. Other types of infectious neuropathic pain are also encompassed by the invention.
  • the neuropathic pain may be or hereditary neuropathic pain.
  • the neuropathic pain is associated with Fabry's Disease and Charcot-Marie-Tooth Disease.
  • Other types of hereditary/congenital neuropathic pain are also encompassed by the invention.
  • the present invention likewise applies to treatment of pain associated with different types of nerve fibers.
  • the pain is associated with pain nerve fiber type A, nerve fiber type B, nerve fiber type C, demyelinated nerve fibers or combinations thereof.
  • the present invention provides for the long term palliative care of a subject.
  • the long term palliative care is for a period selected from the group consisting of longer than six months, longer than 12 months, longer than 24 months, longer than 36 months, longer than 48 months and longer than 60 months and up to about 10 years or longer.
  • the present invention provides for reduction of the dosage of opioid agents or addictive pain relievers for a subject, or indeed, the need to administer opioid or other addictive pain relievers to a subject.
  • the dosage of the EGFR inhibitor is reduced following initial administration of said agent.
  • the present invention utilizes antibodies that target EGFR.
  • Any suitable antibody e.g., monoclonal, polyclonal, or synthetic
  • Any suitable antibody may be utilized in the therapeutic methods disclosed herein.
  • neurological disorders such as neuropathic pain are treated with an antigen binding protein.
  • Suitable antigen binding proteins include, but are not limited to, cetuximab, matuzumab, necitumumab, nimotuzumab, panitumumab, and zalutumumab.
  • the monoclonal antibody cetuximab (commercialized by Eli Lilly, USA, and Merck KGaA, Germany) is used.
  • Cetuximab is a recombinant chimeric IgG1 antibody that binds to the extra-cellular domain of epidermal growth factor receptor with a higher affinity than either endogenous ligand. This binding inhibits receptor phosphorylation and activation and it leads to receptor internalization and degradation. (The biological properties of cetuximab. Vincenzi B, Schiavon G, Silletta M, Santini D, Tonini G. Crit Rev Oncol Hematol. 2008 November; 68(2):93- 106. Epub 2008 Aug. 3. Review). Cetuximab is licensed to treat cancer, and is approved in colorectal cancer without K-RAS mutation in the EGF-signalling pathway.
  • Cetuximab was developed to inhibit EGFR-activation, leading to the further inhibition of several pathways, among others, MAPK-signalling.
  • This IgG1 antibody is used in colorectal cancer to inhibit the activation by the ligand EGF, but since it blocks the EGFR it inhibits binding of other EGF-binding ligands as well.
  • Erbitux is currently approved for the treatment of patients with epidermal-growth-factor-receptor (EGFR)-expressing, KRAS wild-type metastatic colorectal cancer:
  • Cetuximab (Erbitux®) is administered according to the invention by infusion into the subject or patient.
  • cetuximab is administered every 5 to 14 days, most preferably about every 7 days.
  • cetuximab is administered at an initial dose of about 300 to 500 mg per square meter, most preferably about 400 mg per square meter, followed by weekly infusions of about 100 to 500 mg per square meter, preferably about 250 mg per square meter.
  • the dose and the dose regimen of cetuximab according to the invention is similar to the treatment of cancer. Currently, there is a tendency that the doses can be slightly reduced by 10-30% compared to the cancer therapy, without affecting the anti-pain efficacy. Ongoing trials have to verify these results.
  • the monoclonal antibody panitumumab is utilized (Amgen, Thousand Oaks, Calif.).
  • Panitumumab is a fully human monoclonal antibody specific to the epidermal growth factor receptor (also known as EGF receptor, EGFR, ErbB-1 and HER1 in humans). Panitumumab was approved by the European Medicines Agency (EMEA) in 2007, and by Health Canada in 2008 for “the treatment of refractory EGFR-expressing metastatic colorectal cancer in patients with non-mutated (wild-type) KRAS.
  • EMEA European Medicines Agency
  • panitumumab (Vectibix®) is 6 mg per kilogram body weight given once every two weeks as an infusion.
  • the recommended infusion time is around 60 minutes, but larger doses may need 90 minutes.
  • the dose may need to be modified if severe skin reactions occur.
  • panitumumab is administered every 10 to 20 days, most preferably about every 14 days.
  • panitumumab is administered at an initial dose of 6 mg/kg mg per square meter, followed by bi-weekly infusions of 6 mg/kg
  • infusion therapy with antigen binding proteins is combined with administration of small molecule EGFR inhibitors, which are described in more detail below.
  • the subjects are first treated with the antigen binding protein for a period of from about 1 to about 2, 3, 4, 5, 6, 7, 8, 9, or 10 weeks and then switched to treatment with the small molecule EGFR inhibitor which may preferably be administered orally.
  • antibody based therapeutics are formulated as pharmaceutical compositions as described below.
  • administration of an antibody composition of the present invention results in a measurable decrease in symptoms of a neurological disorder.
  • Some embodiments of the present invention utilize small molecules that inhibit one or more biological activities of EGFR.
  • Small molecule therapeutics are identified, for example, using the drug screening methods described herein.
  • the small molecule therapeutics useful in the present invention include, but are not limited to, afatinib, erlotinib, gefitinib, lapatinib, neratinib and vandetanib.
  • the small molecule is gefitinib or erlotinib, tradenamed Iressa (AstraZeneca, London, UK) and Tarceva (Genentech, South San Fransisco, Calif.), respectively (Activation of epidermal growth factor receptors in astrocytes: from development to neural injury. Liu B, Neufeld A H. J Neurosci Res. 2007 December; 85(16):3523-9. Review).
  • the present invention provides for the oral administration of a small molecule EGFR inhibitor to reduce or alleviate one or more symptoms of neuropathic pain.
  • the present invention provides therapeutic regimes where a small molecule EGFR inhibitor is administered either before, or more preferably after, administration of antigen binding protein EGFR inhibitor.
  • the small molecule EGFR inhibitor is administered beginning from about 7 to 14 days following infusion of an antigen binding protein EGFR inhibitor.
  • the small molecule drug is gefitinib and said administration is 10 to 250 mg daily. In other preferred embodiments, the small molecule drug is erlotinib and said administration is 10 to 300 mg daily.
  • the present invention further provides pharmaceutical compositions (e.g., to comprising pharmaceutical agents that modulate the expression or activity of EGFR) for use in the methods described above.
  • the pharmaceutical compositions of the present invention may be administered in a number of ways depending upon whether local or systemic treatment is desired and upon the area to be treated. Administration may be topical (including ophthalmic and to mucous membranes including vaginal and rectal delivery), pulmonary (e.g., by inhalation or insufflation of powders or aerosols, including by nebulizer; intratracheal, intranasal, epidermal and transdermal), oral or parenteral. Parenteral administration includes intravenous, intraarterial, subcutaneous, intraperitoneal or intramuscular injection or infusion; or intracranial, e.g., intrathecal or intraventricular, administration.
  • compositions and formulations for topical administration may include transdermal patches, ointments, lotions, creams, gels, drops, suppositories, sprays, liquids and powders.
  • Conventional pharmaceutical carriers, aqueous, powder or oily bases, thickeners and the like may be necessary or desirable.
  • compositions and formulations for oral administration include powders or granules, suspensions or solutions in water or non-aqueous media, capsules, sachets or tablets. Thickeners, flavoring agents, diluents, emulsifiers, dispersing aids or binders may be desirable.
  • compositions and formulations for parenteral, intrathecal or intraventricular administration may include sterile aqueous solutions that may also contain buffers, diluents and other suitable additives such as, but not limited to, penetration enhancers, carrier compounds and other pharmaceutically acceptable carriers or excipients.
  • compositions of the present invention also include, but are not limited to, solutions, emulsions, and liposome-containing formulations. These compositions may be generated from a variety of components that include, but are not limited to, preformed liquids, self-emulsifying solids and self-emulsifying semisolids. Pharmaceutical compositions of the present invention further include nanoparticle compositions such as inorganic nanoparticles, polymeric nanoparticles, solid lipid nanoparticles, liposomes, nanocrystals, nanotubes and dendrimeric particles.
  • the pharmaceutical formulations of the present invention may be prepared according to conventional techniques well known in the pharmaceutical industry. Such techniques include the step of bringing into association the active pharmaceutical agent with the pharmaceutical carrier(s) or excipient(s). In general the formulations are prepared by uniformly and intimately bringing into association the active ingredients with liquid carriers or finely divided solid carriers or both, and then, if necessary, shaping the product.
  • compositions of the present invention may be formulated into any of many possible dosage forms such as, but not limited to, tablets, capsules, liquid syrups, soft gels, suppositories, and enemas.
  • the compositions of the present invention may also be formulated as suspensions in aqueous, non-aqueous or mixed media.
  • Aqueous suspensions may further contain substances that increase the viscosity of the suspension including, for example, sodium carboxymethylcellulose, sorbitol and/or dextran.
  • the suspension may also contain stabilizers.
  • compositions of the present invention may additionally contain other adjunct components conventionally found in pharmaceutical compositions.
  • the compositions may contain additional, compatible, pharmaceutically-active materials such as, for example, antipruritics, astringents, local anesthetics or anti-inflammatory agents, or may contain additional materials useful in physically formulating various dosage forms of the compositions of the present invention, such as dyes, flavoring agents, preservatives, antioxidants, opacifiers, thickening agents and stabilizers.
  • additional materials useful in physically formulating various dosage forms of the compositions of the present invention such as dyes, flavoring agents, preservatives, antioxidants, opacifiers, thickening agents and stabilizers.
  • such materials when added, should not unduly interfere with the biological activities of the components of the compositions of the present invention.
  • the formulations can be sterilized and, if desired, mixed with auxiliary agents, e.g., lubricants, preservatives, stabilizers, wetting agents, emulsifiers, salts for influencing osmotic pressure, buffers, colorings, flavorings and/or aromatic substances and the like which do not deleteriously interact with the nucleic acid(s) of the formulation.
  • auxiliary agents e.g., lubricants, preservatives, stabilizers, wetting agents, emulsifiers, salts for influencing osmotic pressure, buffers, colorings, flavorings and/or aromatic substances and the like which do not deleteriously interact with the nucleic acid(s) of the formulation.
  • Dosing is dependent on severity and responsiveness of the disease state to be treated, with the course of treatment lasting from several days to several months, or until a cure is effected or a diminution of the disease state is achieved.
  • Optimal dosing schedules can be calculated from measurements of drug accumulation in the body of the patient. The administering physician can easily determine optimum dosages, dosing methodologies and repetition rates.
  • Optimum dosages may vary depending on the relative potency of individual agents, and can generally be estimated based on EC 50 s found to be effective in in vitro and in vivo animal models or based on the examples described herein. In general, dosage is from 0.01 ⁇ g to 100 g per kg of body weight, and may be given once or more daily, weekly, monthly or yearly.
  • the treating physician can estimate repetition rates for dosing based on measured residence times and concentrations of the drug in bodily fluids or tissues. Following successful treatment, it may be desirable to have the subject undergo maintenance therapy to prevent the recurrence of the disease state, wherein the agent is administered in maintenance doses, ranging from 0.01 ⁇ g to 100 g per kg of body weight, once or more daily, to once every 20 years.
  • the EGFR inhibitors of the invention may be combined with other therapeutic drugs which may support the therapy of the subject's neurological disorder and neuropathic pain with the EGFR inhibitors of the invention, optionally by allowing a lower dose of the EGFR-inhibitor of the invention. Therefore, in some embodiments, the present invention provides therapeutic methods comprising one or more compositions described herein (e.g., EGFR inhibitors) in combination with an additional agent (e.g., an agent for treating neurological disorders or neuropathic pain).
  • an additional agent e.g., an agent for treating neurological disorders or neuropathic pain
  • the present invention is not limited to a particular agent.
  • anti-inflammatory agents such as NSAIDs and steroids
  • opioid pain killers such as tricyclics and serotonin-norepinephrine reuptake inhibitors (SNRIs); anticonvulsants such as gabapentin; antiepileptics; benzodiazapines; anti-anxiety drugs such as selective serotonin reuptake inhibitors (SSRIs); dietary supplements such as alpha lipoic acid and benfotiamine; cannabinoids; and the like.
  • anti-inflammatory agents such as NSAIDs and steroids
  • opioid pain killers such as tricyclics and serotonin-norepinephrine reuptake inhibitors (SNRIs); anticonvulsants such as gabapentin; antiepileptics; benzodiazapines; anti-anxiety drugs such as selective serotonin reuptake inhibitors (SSRIs); dietary supplements such as alpha lipoic acid and benfotiamine; cann
  • Classes of useful agents for combination therapy include, for example, non-steroidal anti-inflammatory drugs (NSAIDS) such as Aspirin (Anacin, Ascriptin, Bayer, Bufferin, Ecotrin, Excedrin), Choline and magnesium salicylates (CMT, Tricosal, Trilisate), Choline salicylate (Arthropan), Celecoxib (Celebrex), Diclofenac potassium (Cataflam), Diclofenac sodium (Voltaren, Voltaren XR), Diclofenac sodium with misoprostol (Arthrotec), Diflunisal (Dolobid), Etodolac (Lodine, Lodine XL), Fenoprofen calcium (Nalfon), Flurbiprofen (Ansaid), Ibuprofen (Advil, Motrin, Motrin IB, Nuprin), Indomethacin (Indocin, Indocin SR), Ketoprofen (Actron, Orudis, Orudis
  • Meclofenamate sodium Meclomen
  • Mefenamic acid Mefenamic acid
  • Meloxicam Meloxicam
  • Mobic Nabumetone
  • Naproxen Naprosyn, Naprelan
  • Naproxen sodium Aleve, Anaprox
  • Oxaprozin Daypro
  • Piroxicam Piroxicam
  • Rofecoxib Rofecoxib
  • Salsalate Amigesic, Anaflex 750, Disalcid, Marthritic, Mono-Gesic, Salflex, Salsitab
  • Sodium salicylate variant generics
  • Sulindac Clinoril
  • Tolmetin sodium Tolectin
  • Valdecoxib Bosoidal anti-inflammatory drugs including hydrocortisone, prednisone, methylprednisolone, beclomethasone, beclomethasone, beclomethasone, budesonide, flunisolide, fluticasone propionate, triamcinolone and the like; and opiate-
  • the drugs and pharmaceutical compositions according to the inventions may be further co-administered or combined in conjunction with other drugs than analgesics as described above.
  • the therapy may include co-administration with anti-cancer drugs or with drugs that reduce the side effect of said anti-cancer drugs or of chemotherapy or radiotherapy. So, it is possible to treat a cancer patient with an anti-cancer drugs and in concurrently or subsequently with the EGFR inhibitors according to the invention in order to treat the neuropathic pain or the neuropathic disorder.
  • FIGS. 2 a ) and b A pelvic MRI, taken four months later, showed no change in the pelvic tumor size although the neuropathic pelvic pain was completely gone at that point, see FIGS. 2 a ) and b ).
  • EGFR-inhibitors have been widely tested in clinical trials and are approved oncologic drugs with primarily transient and manageable side-effects (Holt K. Common side effects and interactions of colorectal cancer therapeutic agents. J Pract Nurs 2011; 61:7-20; Petrelli F, Borgonovo K, Cabiddu M, Barni S. Efficacy of EGFR Tyrosine Kinase Inhibitors in Patients With EGFR-Mutated Non-Small-Cell Lung Cancer: A Meta-Analysis of 13 Randomized Trials. Clin Lung Cancer 2012; 13:107-14; Brown T, Boland A, Bagust A, et al. Gefitinib for the first-line treatment of locally advanced or metastatic non-small cell lung cancer. Health Technol Assess 2010; 14:71-9).
  • the patients were asked to complete a BPI short form daily, just before and during the EGFR inhibition, in order to document their neuropathic pain and thus, help us to judge their responses and guide treatment decisions.
  • the patients' scores, when available, are summarized in FIG. 3 .
  • Case 2 is a 53 year old female with an eight-month history of complex regional pain syndrome type 1 (CRPS1) of the right hand, see Table 1 and FIG. 4 a . She had a Pain Detect score of 31/38 and was totally disabled due to excruciating pain despite of extensive treatments, including nerve blocks, see table 1. The patient was given a total of six weekly infusions of cetuximab, ( FIG. 3 upper panel, red arrows).
  • CRPS1 complex regional pain syndrome type 1
  • Gefitinib was started seven days after the last cetuximab infusion and the patient did not experience pain recurrence after conversion to tablets, see FIG. 3 upper panel, green arrows.
  • the patient developed elevated liver transaminases, although her NP continued to be completely relieved.
  • Gefitinib was discontinued and within 48 hours, the excruciating pain recurred.
  • Intravenous panitumumab was again attempted, see FIG. 3 upper panel, blue arrow. This time she had not been given cetuximab shortly beforehand.
  • erlotinib an oral formulation
  • the patient was pain-free upon conversion from panitumumab to erlotinib (see FIG. 3 upper panel, yellow arrow).Her pain has not recurred since, despite the fact that the dose of erlotinib was reduced tod 100 mg daily.
  • the patient's NP continues to be completely resolved.
  • Her daily dose of erlotinib has been reduced to 100 mg per day.
  • EGFR inhibition has had no effect on the vasomotor symptoms that accompany CRPS1.
  • the pain relief has enabled the patient to comply with physiotherapy, which was previously hampered by extreme levels of pain. As a consequence, there is an indirect improvement in the edema that otherwise complicates her condition and that can lead to permanent disability.
  • Case 3 a 63 year old male with an eight-month history of radiculopathy due to failed back surgery syndrome (FBSS) with scar tissue formation at the L4/L5 level (see Table 1 and FIG. 4 b ) was given two weekly infusions of cetuximab ( FIG. 3 , second panel, red arrows). Within hours after the first infusion, the patient's severe and persistent pain was reduced significantly and in the following days, the NP disappeared completely. After his second dose of cetuximab, the patient waited for pain recurrence to start a new treatment. After an eleven-day cetuximab wash-out, his NP began to relapse.
  • FBSS failed back surgery syndrome
  • the patient converted to gefitinib tablets ( FIG. 3 , green arrow). His pain continued to increase for the first two days of oral treatment. However, from the third dose of gefitinib, the pain gradually improved to levels as good as those he had experienced with cetuximab.
  • the patient's NP was so well-controlled by both cetuximab and gefitinib that he could resume his physically active outdoorsman-lifestyle. However, he developed pneumonia one month after starting gefitinib. Dyspnoea persisted after treatment of the pneumonia and interstitial lung disease (ILD) could not be excluded. Gefitinib was therefore discontinued (see FIG. 3 ) and NP recurred after three days. A dose of panitumumab was subsequently given and NP diminished on the very same evening and he was again free from pain.
  • ILD interstitial lung disease
  • Case 4 is a 57 year old male with a twenty-month history of a bladder cancer recurrence invading pelvic organs, muscles and sacral nerve roots ( FIGS. 4 c ) and d ), leading to excruciating NP for the preceding six months, despite extensive treatments, see Table 1.
  • the patient was given cetuximab after treatment with the combination of gabapentin, amitriptyline, paracetamol, steroids, and titration to a 24-hour morphine-equivalent dose of 1800 mg failed to control his NP.
  • the patient experienced complete relief of his NP for the first time in over six months, see FIG. 3 third panel, red arrow.
  • his opioid and gabapentin doses were reduced by 50%, limited by the fear of abstinence symptoms and rebound effects that can be associated with abrupt discontinuation of these substances.
  • Cetuximab was converted to oral gefitinib at the time of the next planned treatment ( FIG. 3 , green arrow).
  • Case 5 was a 72 year old female, suffering from pancreatic cancer with liver metastases. However, her major complaint was an eleven-month history of phantom-limb pain after a below-the-knee amputation due to non-healing ulcers from peripheral vascular disease, see Table 1.
  • Erlotinib is approved for treatment of pancreatic cancer. Panitumumab was therefore replaced by erlotinib in this patient, after the analgesic response was observed. Again, the patient reported phantom-limb pain improvement with erlotinib, but this was not as clearly conveyed in her BPI scores. However, her opioid requirement diminished and she was able to use her prosthesis for the first time since her amputation. Continued swelling and contractures around her knee joint made use of the prosthesis painful, but for the first time, it was possible, because she no longer had phantom limb pain. BPI scores therefore reflect both prosthesis and stump pain and variations in abdominal pain from pancreatic cancer. Her phantom-limb pain did not increase to previous levels during the 91 days of follow up during which she was treated with EGFR-inhibitors.
  • panitumumab treatment she no longer required analgesics and there were no concurrent interventions or other changes in her medications.
  • the patient was treated with panitumumab for a total of 98 days, during which time she did not experienced recurrence of her sciatica.
  • Case 7 had been treated with adjuvant chemotherapy including the cytotoxic platinum compound, oxaliplatin, two years prior to being referred for neuropathic pain.
  • adjuvant chemotherapy including the cytotoxic platinum compound, oxaliplatin
  • CIPN chemotherapy-induced peripheral neuropathy
  • the patient was given a trial of intravenous panitumumab. Two weeks after the first treatment, he reported a lower frequency of the painful bursts and their duration was reduced from several minutes to five to ten seconds. The intensity of the pain still reached a maximum of ten out of ten although it only lasted for a few seconds, representing a clinically meaningful improvement for the patient. However, due to the temporal nature of his painful episodes, the degree of pain relief, as documented in the Brief Pain Inventory (BPI), is graphically under-represented, see FIG. 5 .
  • BPI Brief Pain Inventory
  • panitumumab After four to six weeks (2-3 doses) of treatment with panitumumab, the patient reported that his pain was reduced by 60-70%. In addition, after six to eight weeks of treatment he reported that he was beginning to regain sensibility in his fingers, see FIG. 6 . The patient is an artist/musician and after two years of disabling CIPN he was once again able to play the guitar after having been treated with an EGFR-inhibitor.
  • Case 8 (see Table 1) developed shingles while she was being treated with panitumumab monotherapy for stage IV colon cancer. After five months of EGFR-inhibitor treatment, she developed a pruritic blistering rash along her fifth thoracic dermatome between two treatments (gradual onset between days zero and seven, Table 3).
  • Panitumumab relieved herpetic neuralgia. After five months of treatment with panitumumab, the patient developed a reactivation of varicella-zoster viral infection in her fifth thoracic dermatome between two treatments (day zero and seven). On day 16, she reported severe pain. A new infusion of panitumumab on day 20 led to dramatic pain relief approximately 10 minutes into the infusion. Panitumumab- Herpes Zoster Other relevant Date infusion Related symptoms medications Day 0 Reduced performance status Day 7 + Itching and vesicles in Start valacyclovir 1000 mg ⁇ dermatoma Th5 without signs 3 for 7 days of superinfection. ca.
  • Case 9 is a previously healthy 52 year-old woman with a seven month history of severe NP due to sacral nerve root (S1) impingement from scar tissue formation (visualized on MRI) after surgery for a benign cyst at the S1 level . Nerve block had been effective for only 1-2 days. Subsequently, she was treated with gabapentin 3600 mg/daily. Her PAIN Detect score was 28/38 (indicating a >90% probability of neuropathic pain). The patient's numeric rating scale (NRS) score for worst pain was 10/10, and 7/10 for average pain for the four weeks prior to treatment with EGFR-inhibitor. The severe pain caused her to become increasingly physically disabled and socially isolated and she was unable to work. Inhibition of the EGF-receptor was started with 150 mg Erlotinib tablets on the Oct. 19, 2012, see FIG. 7 , lower panel, yellow arrow.
  • Case 10 was a 25 year old female with advanced, therapy-resistant renal cancer, diagnosed in 2011. Widespread skeletal and pelvic metastases lead to progressive invasion of thoracic and lumbar nerve roots, as well as her sacral plexus, causing neuropathic pain (NP). This pain had persisted for approximately three to four months before an attempt at EGFR-inhibition was made in December, 2012. The patient's PainDetect-score prior to EGFR-inhibition was 25/38. She experienced constant NP radiating down her left leg with an intensity of 7 on a zero to ten numeric rating scale (NRS). In addition, she experienced more intense painful bursts, lasting 1-3 hours, with a severity of 10 out of 10 on the NRS.
  • NRS numeric rating scale
  • the patient remained free of unbearable neuropathic pain for the remainder of her life, although progressive cancer led to increasing pain from skeletal metastases and decubital ulcers.
  • the patient died 9 months after the initial EGFR-I, due to her progressive cancer. She experienced no grade 3 or 4 side effects of the EGFR-Is.
  • Case 11 is a 60 year old male with rectal cancer, metastatic to lymph nodes, liver, lungs, and bone. He was initially treated with effective first line palliative chemotherapy but upon disease progression, developed bone pain and eventually a severe neuropathic component. In addition to pain in the affected skeletal areas (primarily vertebra and pelvis), the pain increasingly radiated down his right leg as the disease progressed. CT scan demonstrated widespread tumor manifestations both in the pelvic soft-tissues and in his vertebra and bony pelvis although there was not any one clear lesion that explained the neuropathic pain. He was treated with palliative radiotherapy, to NSAIDS, paracetamol, opiates, steroids and gabapentin without effect. He had recently (on Aug.
  • panitumumab every 2 weeks and his NP has not recurred. He experienced transient acne when he did not comply with prophylactic antibiotics (tetracycline) as prescribed, but has otherwise not experienced any side effects.
  • Case 12 (see Table 1) is a 41 year old, previously healthy male that had experienced mild lumbar back pain for a year prior to acute onset of increased pain in the same region. A one week period without pain was then followed by sudden onset of more dramatic increase in burning pain radiating down his left leg, along dermatomes L4 and L5. MRI revealed a rupture of the annulus fibrosis of the lumbar disc between L4 and L5 and increased tissue around the dorsal L4 and L5 roots.
  • the radiological findings were interpreted as being the result of a spontaneous enucleation of a lumbar prolapse with resultant inflammation of the nerve root. Neurological examination confirmed L4/5 root affection.
  • the patient's PainDetect-score prior to EGFR-inhibition was 16/38. He described an average pain intensity of 5-6 and worst pain reaching 6-8 in the 10 months prior EGFR-I. His social life was severely disturbed and he was only able to work a 20% job. In attempts to alleviate his NP, the patient received paracetamol, NSAID's, steroids, opiates, and epidural and peripheral nerve blocks with little effect.
  • panitumumab i.v. Ten months after the sudden worsening of NP, 6 mg/kg panitumumab i.v. was given in an attempt at pain relief. Twenty four hours after the infusion, his worst pain was reduced to two on a zero to 10 NRS. However, he increased his level of physical activity and his worst pain levels rose to five. The analgesic effect lasted only one week. After two weeks, a second infusion of panitumumab was given, followed by pain reduction again, albeit to a lesser degree. His new worst pain level was around three, despite a reduction of pregabalin from 375 mg to 225 mg. As a result, after nearly one year of 80% sick leave, he was able to return, full-time, to his previous job, eight weeks after the first infusion of panitumumab.
  • Case 13 is a 63 year old male who was treated with adjuvant chemotherapy including oxaliplatin for a Dukes C colon cancer in 2010. This led to progressive chemotherapy induced peripheral neuropathy (CIPN) for a period of 2.5 years.
  • CIPN peripheral neuropathy
  • the patient was given 6 mg/kg panitumumab i.v. on Oct. 22, 2013, in attempt to alleviate his NP. After two days, he reported a 20-30% reduction in pain intensity. In addition, the distribution of the pain had been reduced, whereby the pain in the legs had completely disappeared and was only located distally in his feet. Two weeks after the panitumumab-infusion, the patient's pain was further reduced by 30-40% of baseline levels and treatment was converted to 150 mg oral erlotinib.
  • four weeks after starting erlotinib he has experienced a week with slightly worsening pain (only 60% pain reduction). This could be ascribed to a) increased physical activity, b) chance, c) colder weather or d) the fact that he uses omeprazole, which can interfere with the absorption of erlotinib.
  • Case 14 (see Table 1) is a 77 year old female who developed post-herpetic neuralgia after an episode of thoracic herpes zoster in August, 2011. Once the rash resolved, there was initial improvement in the pain that she experienced during the acute phase of the disease. However, pain in the affected dermatome persisted and has not improved for well over a year, despite conventional treatments. Paracetamol, codeine, gabapentin, capsacin, benzodiazepines and amitryptiline have been unable to influence the pain although she was able to sleep better with the use of the tricyclic antidepressant in combination with benzodiazepine. Her PainDetect score was 19/38.
  • the patient was given an intravenous infusion of 6 mg/kg panitumumab on Nov. 12, 2013. She experienced gradual improvement in the pain, noticeable from the first day after the infusion. In the first two weeks after the infusion, her worst pain was registered at 6-7 out of 10 despite reducing her amitryptiline dose from 40 mg to 20 mg.
  • her pain continues to improve and she describes her average pain as 4 out of 10. She no longer feels that she has acute exacerbations since her maximum pain has been reduced from 10 to 6 on the 0-10 pain scale. She describes her situation as dramatically improved as she can now carry out tasks that were impossible for her during the previous two years. The pain relief has resulted in improved social functioning and quality of life and she has not experienced any side effects to date.
  • Case 15 is a 42 year old female with metastatic, recurrent cervical cancer, who has been treated with palliative chemotherapy for the past two years. Since the spring of 2013 she has had rapidly progressive disease. Her principle morbidity has been related to the pelvic manifestations of her recurrence which have invaded pelvic nerves, leading to excrutiating NP radiating into her lower extremity. She has been treated with radiotherapy and conventional medications including paracetamol, steroids, opiates, and pregabalin, without significant effect. The pain had become so severe that she required continuous intrathecal anesthesia (marcain, fentanyl, adrenalin) in the intensive care setting. Despite this, she described the pain as unbearable and EGFR-I was therefore given.
  • Intravenous panitumumab 6 mg/kg was given on Nov. 28, 2013.
  • the neuropathic pain was significantly better within hours of the infusion and for the first time in months, she could take a shower rather than a sponge-bath in bed.
  • the neuropathic pain was completely gone as her opiates were being titrated down.
  • She was discharged from the intensive care unit to her home on the day after treatment. She has remained free from NP since the infusion, two weeks ago. Despite progressive cancer, she feels better today (2 weeks after treatment) than she has in the previous 6 months.
  • Case 3 experienced complete washout of the iv antibody (cetuximab), with recurrence of the pain, prior to starting the oral agent gefitinib. See FIG. 3 , second panel, green arrow and FIG. 7 upper panel. Although the analgesic response took longer with gefitinib (one week), it was also complete (pain score 0/10) after three weeks. In other words, the analgesic effect was as pronounced but not as rapid as with the iv agent. In Case 9 we observed the effect of treating NP with oral EGFR-inhibitor up front. The fact that these patients' pain responded more slowly to the oral drug than to intravenous administration of both cetuximab and panitumumab, supports the hypothesized causal and direct effect of EGFR inhibition.
  • Case 2 reported a dramatic increase in pain just hours after infusion of the anti-EGFR antibody panitumumab.
  • cetuximab and panitumumab hinder each other's EGFR binding (Alvarenga M L, Kikhney J, Hannewald J, et al. In-depth biophysical analysis of interactions between therapeutic antibodies and the extracellular domain of the epidermal growth factor receptor. Anal Biochem 2012; 421:138-51). This may possibly have led to the displacement of cetuximab by panitumumab and thereby caused the rapid pain recurrence observed in case 2.

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