WO2007060440A2

WO2007060440A2 - The use of peptides in anti-ulcer therapy

Info

Publication number: WO2007060440A2
Application number: PCT/GB2006/004390
Authority: WO
Inventors: Rupert Donald Holms; Ravshan Inoyatovich Ataullakhanov
Original assignee: Regent Research L.L.P.
Priority date: 2005-11-23
Filing date: 2006-11-23
Publication date: 2007-05-31
Also published as: WO2007060440A3

Abstract

Ulcers and erosions of the gastro-intestinal tract are treated with ezrin-related peptides either as a monotherapy or in combination with a proton pump inhibitor or H2 antagonist, typically plus antibiotic therapy.

Description

THE USE OF PEPTIDES IN ANTI-ULCER THERAPY

Field of the Invention

The present invention relates to the treatment of ulcers of the mucous membranes of the gut. Background of the Invention

The general phenomenon of ulceration of the mucous membranes of the gut is usually divided into a number of different diseases, including disorders related to ulcers of the stomach such as peptic ulcer disease (PUD) and gastro-oesophageal reflux disease (GORD), duodenal ulcers and ulcers of the small intestine. However, in addition, diseases of the lower gut such as inflammatory bowel disease, also known as irritable bowel syndrome (IBS), ulcerative colitis and Crohn's disease, involve mucous membrane ulceration, although the underlying disease mechanism is poorly understood.

Gastric ulcers are a common problem. In the USA, about four million people have active peptic ulcers, about 350,000 new cases are diagnosed each year, and approximately 3000 deaths per year are due to gastric ulcers. The primary therapeutic approach to gastric ulcer treatment remains the inhibition of gastric acid secretion, to produce symptom relief and to allow natural crater healing. If treatment fails, gastric ulcers can lead to haemorrhage, perforation, obstruction and death. H2 antagonists and, more recently, proton pump inhibitors (PPIs) have been used in therapy. PPIs act by irreversibly blocking the K+/H+-ATPase of the gastric parietal cell, therefore blocking the final process in hydrogen ion transport, and thus reducing gastric acid secretion. The irreversible nature of the inhibition results in a class of drugs that is significantly more effective than H2 antagonists at reducing gastric acid secretion; generally, levels of stomach acid falls by up to 99%. The lack of the acid in the stomach reduces the pain from indigestion and heartburn (which is caused by excess stomach acid), and allows the natural processes of healing of stomach and duodenal ulcers.

Currently, five proton PPIs are in general clinical use, i.e. omeprazole (US4786505 and US4853230), lansoprazole (US4628098), esomeprazole (US4786505 and US4853230), pantoprazole (US4758579 and US5997903) and rabeprazole (US5035899 and US504552). PPIs have been shown to increase healing rates and improve clinical symptoms, but not all ulcers respond to this treatment. Very generally, in any group of peptic ulcer patients, up to 40% will naturally heal their ulcers with placebo alone in under two months, and about 70% will heal their ulcers with PPIs in under two months, but about 30% are treatment failures with PPIs, and ulcers fail to heal after two months. Adverse reactions may develop from the long-term use of PPIs for total acid suppression in the stomach. The long-term effect of PPIs on ulcer relapse rates is not well known.

Helicobacter pylori (H. pylori) has been strongly implicated in the development of PUD and GORD, and to a lesser extent in duodenal ulcers. Most people infected with H. pylori are asymptomatic, and additional factors are necessary for the development of H. py/orA-associated mucosal inflammation which can lead to ulcers in the stomach and duodenum.

H. pylori can usually be eradicated with a combination of antibiotics and PPIs. Current recommendations forthe treatment of H. pylori are that two different antibiotics are used in conjunction with a PPI for two weeks continuously. Eradication rates for H. pylori are generally in the 80-95% range, depending on the geographic area and the level of antibiotic resistance. The relative long-term efficacy of different treatments, particularly the combination of PPIs with antibiotics, and the effect of dose variation on relapse and complications from gastric ulcers, are not well studied. Current ulcer combination treatment consists a PPI plus clarithromycin and amoxicillin or a PPI plus bismuth, metronidazole and tetracycline. Reinfection is less than 2% per year in developed countries. Studies also suggest an interaction between H. pylori infection and peptic ulcers which develop as a result of the use of non-steroidal antiinflammatory drugs (NSAIDs). The development of erosive oesophagitis may be a side-effect of H. pylori eradication.

Non-H. pylori peptic ulcers remain a serious problem, especially in the USA, where one study showed that more than 40% of peptic ulcers were not due to H. pylori infection. Non-H. pylori ulcers are usually more refractory to PPI therapy. There is also a high frequency of non-H. py/oπ-related duodenal ulcers. Recent controlled studies have found that, in the absence of NSAIDs, H. pylori is absent in 30-40% duodenal ulcers. After complete H. pylori eradication, recurrence of duodenal ulcers within 6 months can be as high as 20% of patients treated. The evidence suggests that high acidity and reduced duodenal mucosal resistance remain the primary causes of duodenal ulcers and that H. pylori infection affects the chronicity. Generally, ulcerative disease of the lower gut is considered unrelated to stomach and duodenal ulcers. However, a similar disease process based on common host factors is probably involved in all types for mucous membrane ulceration. Similarities in the epidemiological features of ulcerative colitis and Crohn's disease support the idea of IBS as a general disease state of inflammation of the lower gut leading to ulceration. Ulcerative colitis is a chronic inflammatory disease of the colon with an increasing incidence worldwide. Although specific success in the understanding of the clinical diagnosis of ulcerative colitis has been achieved, therapy is often unsuccessful. Even in the application of antibiotic therapy for the distal form of ulcerative colitis, traditionally considered as the less serious form, resistance to even a continuous course of therapy is common, and observed in 20-25% of cases. This results in persistent pain in the patients, the loss of ability to work and, in rare cases, the transformation into more serious forms of ulcerative colitis.

The medical management of this disease continues to expand as drugs to induce and maintain remission become available, but treatment frequently fails and some conditions result in the need for colectomy. The standard of care for the treatment of mild, moderate and severe ulcerative colitis usually involves the use of 5- aminosalicylates, corticosteroids, azathioprine and cyclosporine, to suppress inflammation and immunity. However, in a number of cases, the use of these preparations is not effective. With distal forms of ulcerative colitis, resistance to treatment is frequently encountered.

Ezrin is a member of the ERM (ezrin-radixin-moesin) family of proteins which play structural and regulatory roles in a wide range of cell types and is found in abundance in the cell membranes of the microvilli of the gut endothelia. There is considerable evidence to indicate that ezrin regulates the structure of the cortical cytoskeleton to control cell surface topography and the organisation of cell surface receptors and associated intracellular kinase cascades. Ezrin adopts two main conformations: an inactive, soluble, folded form which is found in the cytoplasm, and an active, unfolded and elongated form which is found attached to the cytoplasmic surface of the cell membrane, particularly in conjunction with activation, related protein complexes.

Ezrin-related peptides are known. For example, US5773573 describes the immunomodulator HEP1 , a synthetic peptide having the amino acid sequence TEKKRRETEREKE, SEQ ID NO: 1 , identical to amino acids 324-337 of human ezrin. Peptides derived from domains A and B of ezrin are disclosed in US6849596 which give the sequences of these domains which together constitute amino acids 308-373 of human ezrin. The contents of both publications, and all references given herein, are incorporated by reference.

It is generally assumed that peptides are destroyed too rapidly by peptidases and acid hydrolysis in the gut to be an effective therapy for gut disorders. In addition, activation of ezrin would be expected to enhance gastric acid secretion. Summary of the Invention

Surprisingly, it has been found that ezrin-related peptides, and in particular those having an amino acid sequence identical to the central alpha helical region of human ezrin, are useful in the treatment of ulcers of the gut. A first aspect of the present invention is the use of a peptide which comprises at least a part of the sequence of amino acids 308-373 of human ezrin, at least a part of the sequence of amino acids 308-373 of human ezrin, or which comprises a sequence having at least 75% identity to TEKKRRETEREKE or a fragment thereof, for the manufacture of a medicament for the treatment of a subject having an ulcerative condition. This may also be expressed as a method for the treatment of an ulcerative condition, which comprises administering to a subject in need thereof a therapeutically effective amount of a peptide.

A second aspect of the present invention is a product comprising a peptide as defined above, and a second active agent selected from proton pump inhibitors and H2 antagonists, for simultaneous, sequential or separate use in the treatment of an ulcerative condition. Another, related aspect is a combination of the peptide and the second active agent, for the treatment of an ulcerative condition.

Although it is known that peptides are rapidly degraded in the gut, it has been found that HEP1 , when given orally in solution, acts rapidly to induce biological responses in the gut. This can result in the rapid healing of ulcers. Without wishing to be bound by theory, the mechanism of action is related to enhanced immunity, accelerated wound healing and some suppression of gastric acid secretion.

Therapy according to the invention (which may be treatment of an existing condition or prophylaxis) can be of any of the conditions described above. These include disorders related to ulcers of the stomach, duodenal ulcers, ulcers of the small intestine, disorders of the lower gut such as IBS, ulcerative colitis and Crohn's disease.

They also include H. pylori and non-H. py/o/7-related conditions.

Description of Preferred Embodiments

The peptide that is used may be any of those described in US6849596. Typically, the peptide comprises or consists of 5 to 20 consecutive amino acids of domain A and/or domain B of human ezrin, e.g. EREKE (SERQ ID NO: 2). The preferred peptide comprises of consists of TEKKRRETEREKE, hereinafter described as HEPL

The invention further contemplates the use of peptides that are closely related to HEP1. Such peptides may be, for example, variants or fragments of HEP1.

Variants may have, for example, conservative amino acid substitutions or additions that do not materially reduce the relevant biological activity of the peptide as compared to HEP1. Thus, variants would be expected to have a high degree of sequence identity with to the HEP1 sequence. Typically, this sequence identity is at least 75%, more preferably greater than 90% and even more preferably greater than 95% (including 96, 97, 98 and 99%) such that there may be, for example, one to five amino acid substitutions, additions or deletions. "Fragments" refer to peptides that have a small number (from one to five, for example) of amino acids removed from one or both ends of the peptide. Closely related peptides contemplated for use according to the subject invention include, for example, those described at columns 3 and 4 of US5773573 or in US6849596. The amino acid identity of any variant will be highest in critical regions of the peptide that account for biological activity or are involved in the determination of three- dimensional configuration, which is ultimately responsible for the biological activity. In this regard, certain amino acid substitutions are acceptable and can be expected to be tolerated. For example, these substitutions can be in regions of the peptide that are not critical to activity. Analyzing the crystal structure of the peptide, and software- based protein structure modelling, can be used to identify regions of a protein that can be modified (using site-directed mutagenesis, etc).

Variants with conservative amino acid substitutions are contemplated according to the subject invention. Amino acids can be placed in the following classes: non- polar, uncharged polar, basic and acidic. Conservative substitutions whereby an amino acid of one class is replaced with another amino acid of the same type fall within the scope of the subject invention so long as the substitution is not adverse to the biological activity of the compound. Table 1 provides a listing of examples of amino acids belonging to each class.

Table 1

In some instances, non-conservative substitutions can also be made. The critical factor is that these substitutions must not significantly detract from the functional/biological activity of the peptide. Fusion peptides are also contemplated according to the subject invention wherein, for example, HEP1 , or a fragment or variant thereof, is fused to another entity. The other entity could be, for example, a polymer, another peptide or protein, or another biologically active agent. Maintenance of relevant biological activity refers to, for example, the ability to improve the rate of repair of ulcers of the gut either as a monotherapy or as a combination therapy with a PPI as described herein. Biological activity can be readily determined as described herein or as described in US5773573 or US6849596.

Peptides for use in this invention are known or may be synthesised by procedures known to those skilled in the art. These include, for example, using a solid phase method and either Boc or Fmoc chemistry. Similarly, PPIs and H2 antagonists are known or may be synthesized by published methods.

The peptide may be used as a monotherapy or combined in a pharmaceutical formulation, or in a combination therapy, with a proton pump inhibitor (PPI) usually orally administered, for the treatment of disorders of the gut, and specifically for the treatment of ulcers of the gut that have failed to respond to PPI monotherapy. The combination may comprise one of the clinically available PPIs such as esomeprazole, pantoprazole, rabeprazole, lansoprazole or omeprazole.

Alternatively, the peptide may be combined in a pharmaceutical formulation, or in a combination therapy, with a H2 antagonist used in the suppression of stomach acid. An exemplary H2 antagonist is ranitidine.

In some clinical situations, the combination of HEP1 (to which reference is made by way of illustration) with conventional therapy may be superior to HEP1 monotherapy, for example in the treatment of stomach and duodenal ulcers with PPIs. HEP1 may accelerate wound healing by the amplification of repair processes in the mucous membranes, resulting in the formation of granulation tissues and efficient scar formation.

For use in the invention, formulations may be prepared in known manner. For examples, 0.01 to 1000 mg of lyophilised peptide may be dissolved in 1-50 ml distilled water and administered orally. 0.01 to 1000 mg of the peptide may be formulated in to a pill or capsule or suppository with carriers used commonly by those skilled in the art of pill or capsule or suppository manufacture and administered orally or anally. 0.01 to 1000 mg of lyophilised peptide may be dissolved in 1-50 ml distilled water and administered by endoscope catheter direct to the ulcer crater in the stomach or duodenum. A filter-sterilized solution of between 0.01 mg and 1000 mg of peptide in distilled water or physiological saline may be injected intra-rectally as an enema. For treatment of stomach and duodenal ulcers, a suitable oral dose of HEP1 is 2 mg/d in 10 ml to 50 ml water. A suitable daily oral dose of a PPI is generally 30 mg/d for lansoprazole, 20 mg/d for omeprazole, 40 mg/d for pantoprazole and 20 mg/d for rabeprazole. A suitable oral dose of a H2 antagonist such as ranitidine is 150 mg/2x d. A solution of peptide plus a PPI may be mixed immediately prior to administration or the peptide solution may be used as a wash to swallow a PPI in tablet form. A tablet combining a PPI and HEP1 may be formulated and administered orally.

For the treatment of ulcerous inflammatory bowel disease and related phenomena, 0.1 to 10 mg of HEP1 dissolved in 10 ml to 50 ml distilled water may be injected intra-rectally as an enema or formulated as a suppository and administered rectally.

The peptide plus a PPI may be taken about one hour before eating a meal, once a day for the duration of treatment.

Use of a peptide in accordance with the invention may be accompanied by antibiotic treatment. This, and suitable agents, are conventional.

The following Examples serve to illustrate the invention only, and should not be construed as limiting it in any way.

Example 1 demonstrates that HEP1 delivered by catheter to the crater of stomach ulcers and duodenal ulcers, three times over a seven day period, results in rapid healing in one week, and the disappearance of the clinical symptoms of disease over two weeks, even in sick patients who had failed either conventional PPI anti-acid therapy or conventional H2 antagonist anti-acid therapy combined with antibiotics.

Example 2 demonstrates that HEP1 delivered by catheter to the crater of stomach ulcers and duodenal ulcers, three times over a seven day period in combination with two antibiotics plus omeprazole or ranitidine results in rapid healing in one week, the disappearance of the clinical symptoms of disease over two weeks, even in seriously ill patients with bleeding ulcers who had failed either conventional PPl anti-acid therapy or conventional H2 antagonist anti-acid therapy combined with antibiotics. Example 3 demonstrates that HEP1 delivered to elderly patients who had failed conventional anti-ulcer therapy, as an oral solution of 2 mg in 20 ml water, once a day, daily for five days, resulted in the healing of gastrointestinal lesions and stomach ulcers by the third week of treatment in the majority of cases. In addition, it demonstrates that that HEP1 delivered to elderly patients who had failed conventional anti-ulcer therapy as an oral solution of 2 mg in 20 ml water, once a day, daily for five days, in combination with standard therapy comprising of the proton pump inhibitor omeprazol, plus two antibiotics, resulted in the healing of gastrointestinal lesions, duodenal ulcers and stomach ulcers by the third week of treatment in all cases.

Example 4 demonstrates that 2 mg HEP1 as a micro-enema in 10 ml physiological saline or 2 mg HEP1 blended in 1.5 g cocoa butter as a suppository administered intra-rectally to patients suffering from chronic ulcerous colitis with associated bleeding and pain, benefited from a significant reduction in the clinical symptoms of disease and healing of the mucous membrane of the large intestine.

Example 5 provides details of a further study. It demonstrates that HEP1 can prevent ulcer relapse which is a major problem associated with conventional therapy. Example 1

Eight patients between 23 and 45 years old underwent gastroduodenoscopy, general blood cell counting, blood biochemistry and urine tests. Six had duodenal ulcers and two had stomach ulcers. The ulcers ranged in size from 0.5 to 2.5 cm in diameter, and were associated with gastric pain, nausea and vomiting. The patients had been suffering recurrence of ulcers for between 6 months to 5 years and were considered as failures to conventional anti-ulcer therapy.

Pharmaceutical grade "HEP1 0.002 g lyophilized sterile powder" was supplied directly from its manufacturer (Immapharma, Moscow, Russia). The preparation was introduced topically into the crater of the ulcer as an irrigation with 0.04% HEP1 sterile solution (0.002 g HEP1 in 5 ml water) via a gastroendoscope device. Three such topical administrations of HEP1 solution were performed on day 1 , day 4 and day 7.

Neither side-effects nor adverse effects were noticed. Rapid healing of ulcers was recorded in all 8 patients. According to gastroduodenoscopy, erosions were completely epithelized by day 7 of treatment. At the follow-up gastroduodenoscopy on days 10-14, a scar was found instead of the ulcer in all patients and, typically, the scar formed was around half the size of the ulcer. Clinical symptoms of disease also disappeared. Example 2

29 patients between 22 and 65 years old underwent gastroduodenoscopy, general blood cell counting, blood biochemistry and urine tests. 23 had duodenal ulcers and 6 had stomach ulcers. The ulcers ranged in size from 0.5 cm in diameter to 0.9 cm x 3 cm, and were associated with gastric pain, nausea and vomiting. Three patients were bleeding which was immediately stopped by standard haemostasis measures. The patients had been suffering recurrence of ulcers for between 1 and 10 years or more, and were considered as failures to conventional anti-ulcer therapy. The patients were split into two groups and received either of the following two therapeutic protocols. Protocol 1 (22 patients): omeprazole (20 mg once a day); metronidazole (0.5 g x 2 times a day); ampicillin (0.5 g x 3 times a day); pharmaceutical grade "HEP1 0.002 g lyophilized sterile powder". The preparation was introduced topically into the crater of the ulcers as an irrigation with 0.04% HEP1 sterile solution (0.002 g HEP1 in 5 ml water) via a gastroduodenoscope device. Three such topical administrations of HEP1 solution were performed, on day 1 , day 4 and day 7. ^Λ

Protocol 2 (7 patients) was the same as Protocol 1 , but using ranitidine (150 mg x 2 times a day) instead of omeprazole.

Neither side-effects nor adverse effects of HEP1 were noticed. Rapid healing of ulcers was recorded in all patients. Generally, according to gastroduodenoscopy, erosions were completely epithelized by day 7 of treatment. At the follow-up gastroduodenoscopy on days 10-14, a scar was found instead of the ulcer in the majority of patients, with the exception of two patients who had unusually large lesions. In these two cases, scar formation and healing were still underway. Typically, the scar formed was around half the size of the preceding ulcer. Clinical symptoms of disease also disappeared. Example 3

19 patients with erosive-ulcerous damage of the gastroduodenal tract aged from 63 to 75 years old were advised of the study. Polyclinical and instrumental inspection of all patients was carried out. This included EGDS (esophagogastroduodenoscopy) with biopsy and determination of H. pylori presence by cytology and urease and respiratory tests, on day 1 , day 7 and day 21. The state of the immune system was determined, on day 1 and day 7, and before the discharge of the patient from hospital. Stomach ulcers were encountered in 45% of the inspected patients, while duodenal ulcer was noted only in 15% of patients. The duration of ulcerous anamnesis varied in the inspected patients, between those who revealed the disease for the first time and patients with prolonged anamnesis of disease (more than 40 years). Determination of the presence of H. pylori in the inspected patients revealed that, in the majority of the cases, the erosive-ulcerous damage of the stomach was not connected with the presence of the organism.

The immune status of patients with erosive-ulcerous damage of the gastroduodenal showed an active chronic immune process, evidenced by the activation of some populations of T-helper cells, cytotoxic T-cells, hyperplasia and the intensification of the cytolytic properties of Natural Killer cells, as well as activation of monocytes and neutrophils. Furthermore, in the inspected patients, there was a change in the balance of the serum factors of immunity, evidenced by the decreased activities of complement, weakening the production of immunoglobulins M and G. The scarcity of some components of the immune system in the inspected patients was obvious: the exhaustion of naive T-cells, scarcity of "classical" CD16+/56+- natural killer cells, scarcity of ripe (segmento-nuclear) neutrophils, weakening in production of IgM, and reduction in the activity of complement. In order to assess the influence of HEP1 on the healing of the erosive-ulcerous damages of the gastro-duodenal zone, the patients were divided into two groups, and were given different therapies. In Group One (monotherapy), 11 patients (5 stomach ulcers, 6 Gl erosions) were given HEP1 at a dose of 2 mg/20 ml water orally, daily for five days. In Group Two (combination therapy), 8 patients (3 stomach ulcers, 3 duodenal ulcers and 2 Gl erosions) were given HEP1 at a dose of 2 mg/20 ml water orally, plus a standard therapy regime of two antibiotics (amoxycillin, metronidazole) plus omeprazole.

During analysis of the general data for both groups of patients (using EGDS), significant positive changes were already noted by day 7 of therapy. HEP1 in combination with standard PPI therapy led to healing the ulcers in all patients with stomach ulcers and duodenal ulcers by day 21 ; with standard PPI therapy, the average period of treatment required for elderly patients with stomach ulcers not associated with H. pylori was usually between 35 to 45 days. The data also showed that HEP1 in combination with standard PPI therapy was more effective than HEP1 monotherapy, where the healing was slower and not all the patients had fully recovered by day 21.

The morphological study, by biopsy of the gastric mucosa of the patients before the treatment, showed expressed dystrophic changes in the mucous membrane of the stomach, the vacuolization of cytoplasm of the epithelium with stratification of nuclei, the impregnation of stroma by erythrocytes, and the infiltration of the basal membrane of the mucous membrane of the stomach by plasma cells. By day 7 of treatment with HEP1 alone or in combination with PPl, positive changes were noted: the epithelization of the ulcerous defect, and the decrease of cellular infiltration and disturbances of microscirculation of the mucous membrane of the stomach.

Positive changes were also noted in the immune status of all patients receiving HEP1 patients. Against the background of HEP1 therapy, normalization of a quantity of ripe neutrophils and Natural Killer cells was noted. Example 4

36 patients with ulcerative colitis (distal damage, resistant form) who were hospital in-patients (19 men, 17 women, age 22 to 69 years: an average of 45.5 years) were treated. They had failed to respond to standard therapy with anti-inflammatory 5- aminosalicylic acid preparations and local applications of immunosuppressive corticosteroids, and were considered as treatment failures. The degree of gravity of ulcerous colitis was determined by the Schroeder

Index (Mayo Clinic, University of California, DAI). It was mild in 20 patients and median-moderate in 16 patients.

A preparation of HEP1 was delivered either in the form of rectal suppositories or micro-enemas. HEP1 was a sterile lyophilized preparation in vials (0.002 g) produced by "Immapharma" (Moscow). For the micro-enemas, the preparation was dissolved directly before use in sterile physiological solution (0.85% percent NaCI).

The composition of each suppository was HEP1 0.001 g, cocoa butter 1.5 g.

The patients were divided into 3 groups. For the duration of HEP1 treatment, basic treatment with anti-inflammatory 5-aminosalicylic acid preparations and corticosteroids was abolished.

Group-1 (n = 21) comprised patients with the proctitis form of ulcerative colitis;

HEP1 was administered in the form of rectal suppositories; one suppository a day, for

4 days. Group-2 (n = 5) comprised patients with the proctitis form of ulcerous colitis;

HEP1 was administered in the form of rectal suppositories one suppository a day, for 7 days.

Group-3 (n = 10) comprised patients with the proctosigmoiditis form of ulcerous colitis; HEP1 was administered in the form of micro-enemas, 0.002 g daily for 7 days. After the end of treatment with the HEP1 preparations, all patients were transferred back onto anti-inflammatory 5-aminosalicylic acid preparations and local applications of corticosteroids.

In 24 of 26 sick patients, of Group-1 and Group-2, after the application of only the first suppository of HEP1 , there was observed a positive clinical effect, with the disappearance of false urges and a decrease in the admixture of blood in the stools.

This positive result remained during the continuation of the treatment in 17 of the patients. Of these sick patients, 10 achieved clinical remission, and 7 showed total clinico-endoscopic remission of disease.

The other 7 patients responded to HEP1 treatment with only transient improvement. They had clinical improvement after the first suppository, but relapsed into the previous state during the continuation of treatment. Nevertheless, in 4 of 7 patients, it was possible to achieve a clinical remission from ulcerative colitis, after continuing the treatment by the addition of local aminosalicylates immediately after the end of treatment with HEP1 suppositories (the patients were administered with suppositories of Salofalk over one month). A comparison of clinical effect between the different courses of suppositories of HEP1 in Group-1 and Group-2 did not reveal any essential differences between the groups. It is possible to conclude that one suppository of HEP1 a day for 4 or 7 days had the same clinical effectiveness.

In Group-3, in 9 of 10 patients that received HEP1 as micro-enemas, clinico- endoscopic improvement was noted. In 2 of 9 sick patients, the positive effect was short-term, and only observed after the first micro-enema; then the symptoms of disease appeared again. After the end of treatment with HEP1 micro-enemas, hydrocortisone (125 mg/day) and suppositories with prednisolone (20 mg/day) were administered for one month, after which there was a remission of disease. 7 of 9 sick patients achieved a positive clinical effect from the HEP1 micro-enemas which proved to be stable: clinical and endoscopic manifestations of the ulcerative colitis were absent both at 7 days and 1 month after the completion of treatment. Only 1 of the 10 sick patients treated with HEP1 micro-enemas did not show any positive benefit.

The application of HEP1 succeeded in producing clinico-endoscopic improvement, and overcame the resistance to basic anti-inflammatory therapy in 30 of 36 patients. After treatment with HEP1 , there were substantial increases in the number of functional NK cells in the exhausted population of the cytolytic NK-cells containing perforin. At the same time, the content of the pathologically elevated cytolytic CD8+ T-cells was reduced to levels approaching normal values. The preparation of HEP1 showed efficacy for the treatment of the chronic continuous forms of ulcerative colitis with distal damage as part of combination therapy for this disease. Example 5

An experimental group of 19 patients had been treated with HEP1 during a 14 month period. They all showed sustained remission during the following two years, and 16 of 19 after a further 4 months. Three of these 19 patients had one relapse only in the year after remission. In 2 of these 3 cases, the relapse happened 3.5 years after the HEP1 treatment. The period of remission was a minimum of 2 years.

Among the 19 patients (3 gastric and 16 duodenal ulcers), no relapse was recorded in 6 patients after HEP1 monotherapy, while 1 of 8 patients treated using HEP1 + Protocol 1 (omeprazole and metronidazole + ampicillin) and 2 of 5 patients treated using HEP1 + Protocol 2 (ranitidine + metronidazole + ampicillin) suffered one relapse each.

In the control group of 6 patients treated using conventional anti-ulcer Protocol 1 without HEP1 , there was a serious problem with relapses. After conventional treatment, the status of these patients improved, though in all cases there was relapse 6-12 months after the treatment. During the following years, the frequency of relapses was 1 or 2 per year. In one of these control cases, there was a perforation of the relapsed ulcer and the patient had to undergo surgery. In summary, in the control group, 100% of patients suffered one to two relapses per year. In the HEP1 -treated group (monotherapy patients plus combination therapy patients), there were no relapses two years after treatment and only 16% of patients suffered one relapse in the third year after of treatment.

Claims

1. Use of a peptide which comprises at least a part of the sequence of amino acids 308-373 of human ezrin, or which comprises a sequence having at least 75% identity to TEKKRRETEREKE, for the manufacture of a medicament for the treatment of a subject which has an ulcerative condition.

2. Use according to claim 1 , wherein the peptide comprises or consists of 5 to 20 consecutive amino acids of said sequence.

3. Use according to claim 1 , wherein the peptide comprises or consists of TEKKRRETEREKE.

4. Use according to any of claims 1 to 3, wherein the peptide is used as a monotherapy.

5. Use according to any of claims 1 to 3, wherein the subject is also receiving a proton pump inhibitor (PPI).

6. Use according to claim 5, wherein the PPI is lansoprazole.

7. Use according to claim 5, wherein the PPI is esomeprazole.

8. Use according to claim 5, wherein the PPI is pantoprazole.

9. Use according to claim 5, wherein the PPI is rabeprazole.

10. Use according to claim 5, wherein the PPI is omeprazole.

11. Use according to claims 1 to 3, wherein the subject is also receiving a H2 antagonist.

12. Use according to claim 11 , wherein the H2 antagonist is ranitidine.

13. Use according to any of claims 1 to 12, wherein the condition is an ulcer of the gastrointestinal tract.

14. Use according to any of claims 1 to 12, wherein the condition is a duodenal ulcer.

15. Use according to any of claims 1 to 12, wherein the condition is irritable bowel syndrome.

16. Use according to any of claims 1 to 12, wherein the condition is ulcerative colitis.

17. Use according to any of claims 1 to 16, wherein the medicament is a solution.

18. Use according to any of claims 1 to 16, wherein the medicament is a suppository.

19. A product comprising a peptide as defined in any of claims 1 to 3, and a second active agent selected from proton pump inhibitors and H2 antagonists, for simultaneous, sequential or separate use in the treatment of an ulcerative condition.

20. A product according to claim 19, wherein the second active agent is as defined in any of claims 6 to 10 and 12.

21. A product according to claim 19 or claim 20, wherein the condition is as defined in any of claims 13 to 16.

22. A peptide as defined in any of claims 1 to 3, for the treatment of an ulcerative condition.

23. A combination of a peptide as defined in any of claims 1 to 3, and a second active agent as defined in any of claims 5 to 12, for the treatment of an ulcerative condition.

24. A combination according to claim 23, wherein the condition is as defined in any of claims 13 to 16.

25. A method for the treatment of an ulcerative condition, which comprises administering to a subject in need thereof a therapeutically effective amount of a peptide as defined in any of claims 1 to 3.