Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
  • A61K31/505—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim
  • A61K31/519—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim ortho- or peri-condensed with heterocyclic rings
  • A61K31/525—Isoalloxazines, e.g. riboflavins, vitamin B2
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P9/00—Drugs for disorders of the cardiovascular system
  • A61P9/12—Antihypertensives

Definitions

• the present invention relates to the use of riboflavin in the treatment of hypertension in a genotype specific population.
• Hypertension commonly referred to as high blood pressure, is a medical condition where the blood pressure is elevated, generally chronically elevated. Hypertension of any aetiology is one of the major risk factors for cardiovascular disease (CVD), which includes heart disease and stroke.
• CVD cardiovascular disease
• MTHFR 10- methylenetetrahydrofolate reductase
• anti-hypertensive drugs e.g. ACE inhibitors, beta blockers and diuretics
• ACE inhibitors beta blockers and diuretics
• these drugs can have undesirable side effects and some subjects may remain hypertensive despite being tried on more than one type of anti-hypertensive drug.
• vitamin B2 riboflavin
• riboflavin in the manufacture of a medicament for the treatment or prophylaxis of elevated blood pressure in a subject homozygous or heterozygous for the MTHFR C677T polymorphism.
• a pharmaceutical product for the treatment or prophylaxis of elevated blood pressure in a subject homozygous or heterozygous for the MTHFR C677T polymorphism comprising a pharmaceutically effective amount of an anti-hypertensive agent and riboflavin, for simultaneous, separate or sequential administration.
• Suitable anti-hypertensive agents include ACE inhibitors such as quinapril, captopril, lisinopril, benazepril, perindopril, enalapril maleate, trandolapril, ramipril and cilazapril; beta blockers such as atenolol, tertatolol, metoprolol tartrate, bisoprolol fumarate, nebbivolol, celiprolol and pindolol; Ca ⁇ antagonists such as nifedipine, diltiazem, amlodipine, verapamil and felopidine; alpha blockers such as methyldopa, doxazosin, clonidine and prazosin; angiotensin II antagonists such as irbesartan, candesartan cilextil, olmesartan medoxomil, valsartan,
• Riboflavin may be used to reduce blood pressure in the absence of any other antihypertensive agents.
• other anti-hypertensive agents are administered with riboflavin, either simultaneously, separately or sequentially, the amount of the other antihypertensive agents necessary to have the required effect may advantageously be reduced, in that lesser amounts of the agents may be required in order to effect the treatment or prophylaxis of elevated blood pressure in a subject, thereby minimising any undesirable side effects of conventional anti-hypertensive agents.
• a method for the treatment or prophylaxis of elevated blood pressure in a subject homozygous or heterozygous for the MTHFR C677T polymorphism comprising administering riboflavin to the subject.
• the medicament or product of the invention is preferably in a form suitable for oral or parenteral administration.
• suitable oral dosage forms include tablets, capsules (including slow release capsules), pills, powders, granules and the like.
• Parenteral administration includes, for example, intravenous, intramuscular, intraarterial, intraperitoneal, intranasal, intravesical (e. g., to the bladder), intradermal, topical or subcutaneous administration.
• Suitable parenteral dosage forms include sterile injectable aqueous solutions or dispersions and sterile powders for the preparation of sterile injectable solutions or dispersions.
• the preferred route of administration is oral.
• Riboflavin may be administered together with a pharmaceutically compatible or acceptable carrier suitable for oral or parenteral administration, selected according to the particular type of administration used.
• riboflavin may be administered with one or more solid inactive ingredients for the preparation of suitable oral dosage forms.
• riboflavin may be administered with at least one excipient such as fillers, binders, humectants, disintegrating agents, solution retarders, absorption accelerators, wetting agents, absorbents or lubricating agents.
• riboflavin may be administered with a suitable carrier or diluent such as water, ethanol, saline solution, aqueous dextrose (glucose) and related sugar solutions, glycerol, or a glycol such as propylene glycol or polyethylene glycol.
• a suitable carrier or diluent such as water, ethanol, saline solution, aqueous dextrose (glucose) and related sugar solutions, glycerol, or a glycol such as propylene glycol or polyethylene glycol.
• the dose of riboflavin will be within dietary reference levels up to and including the maximum level considered to be safe. Although, unlike many other nutrients, no official upper tolerable level has been established for riboflavin, it is generally considered to be safe even at very high doses with evidence showing that levels up to 500mg/day are tolerated with no adverse effects. This compares with recommended dietary levels of riboflavin for adults which range from 1.1 to 1.8mg/day.
• the medicament or product is most preferably formulated for administration of riboflavin to a subject in an amount of approximately 1.6 mg/day. However, the medicament or product may be formulated for administration of riboflavin to a subject in any other suitable dose greater or less than 1.6 mg/day.
• a suitable dose may be from about 0.5 mg/day to 50 mg/day, preferably from about 0.75 mg/day to 20 mg/day, more preferably from about 1 mg/day to 10 mg/day, more preferably from about 1.2 mg/day to 5 mg/day, even more preferably from about 1.4 mg/day to about 5 mg/day.
• the invention has application in the area of personalised nutrition. There is an increasing interest in gene-nutrient interactions, and with the greater accessibility of genetic profiling, the market for personalised nutrition is emerging in recent years. This approach is based on the view that dietary requirements should consider not only general factors such as age and sex, but also genetic factors which are specific to the subject. For example, a subject could check their MTHFR genotype and then proceed to take low-dose riboflavin, specifically if they are found to have the TT or CT genotype.
• the invention also has application in the design of clinical drug trials, e.g. those testing new anti-hypertensive medication drugs. For the successful outcome and correct interpretation of such trials, it will be critical that those with the TT genotype for the MTHFR C677T polymorphism in combination with low riboflavin status are stratified and randomised equally to the different treatment groups.
• Study design The study was a 16-week placebo controlled intervention trial. Patients were stratified on the basis of their initial screening plasma homocysteine within each genotype group and subsequently randomised within each stratum to receive either riboflavin (1.6mg/day) or placebo, as indicated in Figure 1. In an attempt to maximise compliance, patients were provided with riboflavin every 4 weeks in 7-day pill boxes and asked to return any unused pills which were recorded. Non-fasting blood samples were collected at screening and post intervention either at Altnagelvin hospital, their workplace or their own homes.
• Blood pressure measurements were recorded as the mean of two separate measurements taken 15 minutes apart using an Omcron 705CP electronic blood pressure monitor (Medisave, Dorset, UK). Weight (kg) and height in (m), were used to calculate BMI (weight (kg)/height 2 (m)). Waist circumference (cm) was also measured. All measurements were made using Seca approved equipment (Brosch Direct, Ltd, Peterborough, UK).
• One 30ml blood sample was collected from each patient, one 9ml EDTA tube for plasma and washed red cells, one 4ml EDTA tube for the preparation of red blood cell lysates and the measurement of haemoglobin (HB) and packed cell volume (PCV); one 8ml serum separation tube for serum extraction, one 5ml serum separation tube for lipid profile analysis and one 4ml sodium citrate tube for coagulation screening.
• the 9ml EDTA was immediately wrapped in tin foil and placed on ice. Samples were centrifuged within 2 hours of sampling at 3000rpm for 15 minutes. Plasma was removed and stored at -80 0 C for plasma homocysteine and PLP analysis.
• the buffy layer was removed for confirmation of MTHFR genotyping and stored at -20 C.
• the remaining red blood cells were thrice washed with phosphate buffered saline (PBS) with the supernatant and remaining buffy layer being discarded after each wash.
• PBS phosphate buffered saline
• the washed red cells were removed and stored at - 80 0 C for EGRac analysis (a functional indicator of riboflavin status). Serum was removed and stored at -80 0 C for serum folate.
• Plasma homocysteine was measured by immunoassay using the Abbott Imx analyser (Leino A., 1999, “Fully automated measurement of total homocysteine in plasma and serum on the Abbott IMx analyzer.” Clin. Chem, 45, 569-71). Serum folate and red blood cell folate concentrations were determined by microbiological assay using the cryopreserved, microtitre plate method (Molloy et al, 1997, "Microbiological assay for serum, plasma, and red cell folate using cryopreserved, microtiter plate method.” Methods Enzymol, 281, 43-53).
• Plasma PLP was determined by reverse-phase high pressure liquid chromatography (HPLC) with fluorescence detection (Bates et al, 1999, "Plasma pyridoxal phosphate and pyridoxic acid and their relationship to plasma homocysteine in a representative sample of British men and women aged 65 years and over.” British Journal of Nutrition, 1, 191-201). Identification of the MTHFR C677T genotype was carried out using the polymerase chain reaction (PCR) amplification followed by HinFl (Frosst et al, 1995, "A candidate genetic risk factor for vascular disease: A common mutation in methyl enetetrahydrofolate reductase.” Nat Genetc, 10, 111-113).
• PCR polymerase chain reaction
• Riboflavin status was determined on the basis of EGRac, a functional assay whereby the activity of glutathione reductase is measured both with and without added FAD. EGRac is then calculated as a ratio of FAD-stimulated to unstimulated enzyme activity (Powers et al, 1983, "The relative effectiveness of iron and iron with riboflavin in correcting a microcytic anaemia in men and children in rural Gambia.” Hum Nutr Clin Nutr, 37, 413-425), and values >1.3 are generally considered to reflect sub-optimal riboflavin status. Coagulation screening was measured by ACI Instrumentation Laboratories.
• HB and PCV were measured using Sysmex XE-2100 (Sysmex, UK Ltd. Milton Keynes UK) analyser and lipid profiles were measured using Abbott Architect CI 8200 analyser (Abbott Laboratories, USA). For all assays, samples were analysed blind, in duplicate and within 1 year of collection. Quality control was provided by repeated analysis of stored batches of pooled washed red blood cells (for EGRac), plasma for homocysteine and PLP and serum for folate covering a wide range of values.
• Figure 1 shows the flow diagram of study design.
• Figure 2(i) shows homocysteine concentration ( ⁇ mol/1) by MTHFR genotype group among healthy controls;
• Figure 2(ii) shows systolic blood pressure (mmHg) by MTHFR genotype group among healthy controls;
• Figure 2(iii) shows diastolic blood pressure (mmHg) by MTHFR genotype group among healthy controls.
• Values in Figures 2(i), 2(ii) and 2(iii) are mean (standard error bars). Different letters denote statistically significant differences between the MTHFR genotype groups, ANOVA with Tukey post-hoc test, P ⁇ 0.05 significant.
• Figure 3(i) shows homocysteine concentration ( ⁇ mol/1) by MTHFR genotype group among premature CVD patients;
• Figure 3(ii) shows systolic blood pressure (mmHg) by MTHFR genotype group among premature CVD patients;
• Figure 3(iii) shows diastolic blood pressure (mmHg) by MTHFR genotype group among premature CVD patients.
• Values in Figures 3(i), 3(ii) and 3(iii) are mean (standard error bars). Different letters denote statistically significant differences between the MTHFR genotype groups, ANOVA with Tukey post-hoc test, P ⁇ 0.05 significant.
• Patients with premature CVD are generally defined as subjects who develop CVD before the age of 55 for men, or before the age of 65 for women.
• patients with premature CVD and with the TT genotype had elevated blood homocysteine concentration, compared with both CC and CT patients.
• TT patients were also found to have significantly increased systolic and diastolic blood pressure, as shown in Figure 3, compared to CC patients.
• CT individuals were found to have intermediate levels of diastolic blood pressure, compared to CC and TT patients (as shown in Figure 3).
• TT premature CVD patients sorted in accordance with their MTHFR genotype
• CT CT patients
• Table 2 The baseline characteristics of premature CVD patients sorted in accordance with their MTHFR genotype (TT, CT, or CC) are shown in Table 2 below. Referring to Table 2, it was observed that TT patients had significantly elevated systolic and diastolic blood pressure, compared to CC patients. CT patients were found to have intermediate values for diastolic blood pressure. Of note, the elevated blood pressure levels found in TT patients were strongly influenced by riboflavin status; patients with the combination of the TT genotype and low riboflavin status were unexpectedly found to have markedly elevated blood pressure.
• Body mass index (kg/m2) 29.1 (4.6) 29.3 (4.8) 28.7 (4.5) 29.3 (4.5) 0.724
• Plasma homocysteine ( ⁇ mol/1) 10.9 (5.3) 9.8 (3.3) a 10.5 (3.9) ab 12.8 (8.0) b 0.007
• MTHFR methylenetetrahydrofolate reductase
• erythrocyte glutathione reductase activation coefficient riboflavin status, a higher EGRac value indicates lower vitamin status
• Higher' and 'lower' riboflavin status was determined using the median EGRac value within each genotype group as a cut-off.
• Serum folate ( ⁇ g/l) 12.1(8.5) 14.0(9.6) 0.052 10.5(6.5) 12.0(7.5) 0.094
• Red cell folate (nmol/1) 991(388) 991(434) 0.997 1008(400) 1022(460) 0.759
• Diastolic blood pressure (mmHg) 82.0(12.1) 81.9(14.2) 0.962 86.0(10.8) 84.2(9.2) 0.336
• Red cell folate (nmol/1) 808(488) 903(580) 0.164 845(303) 889(306) 0.305
• Diastolic blood pressure (mmHg) 84.5(10.7) 85.4(12.7) 0.739 88.1(14.2) 80.2(14.2) 0.002
• MTHFR methylenetetrahydrofolate reductase
• EGRac erythrocyte glutathione reductase activation coefficient (riboflavin status, higher values indicate lower status).
• Plasma homocysteine 9.3 (1.9)a 8.9 (2.1)a 14.1 (8.0)b ⁇ 0.001
• Vitamin B6 status (PLP; 79.1 (47.4) 79.7 (38.7) 68.3 (35.5) 0.370 nmol/1)
• Riboflavin J ⁇ treatment median 137.0(121.9, 148.4) 143.5(129.8, 156.2) 0.077 150.0(135.5, 153.3) 150.0(137.2, 153.4) 0.797 139.5(129.9, 142.5) 145.0(133.3, 151.1) 0.970
• Riboflavin treatment median 80.5(73.7, 88.3) 86.5(78.7, 91.9) 0.033 87.0(82.7, 94.2) 89.0(83.3, 94.7) 0.767 88.5(81.1, 91.6) 88.5(82.8, 95.1) 0.172
• Values are median (95% confidence interval).

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