WO2009087116A1 - Use of spp100 for the treatment of acute mi - Google Patents

Use of spp100 for the treatment of acute mi Download PDF

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Publication number
WO2009087116A1
WO2009087116A1 PCT/EP2009/000122 EP2009000122W WO2009087116A1 WO 2009087116 A1 WO2009087116 A1 WO 2009087116A1 EP 2009000122 W EP2009000122 W EP 2009000122W WO 2009087116 A1 WO2009087116 A1 WO 2009087116A1
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salts
salt
active ingredient
treatment
group
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PCT/EP2009/000122
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French (fr)
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Michele D'amico
Clara Di Filippo
Enrico Lampa
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Novartis Ag
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    • 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
    • A61K31/16—Amides, e.g. hydroxamic acids
    • A61K31/165—Amides, e.g. hydroxamic acids having aromatic rings, e.g. colchicine, atenolol, progabide
    • 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
    • A61P9/10—Drugs for disorders of the cardiovascular system for treating ischaemic or atherosclerotic diseases, e.g. antianginal drugs, coronary vasodilators, drugs for myocardial infarction, retinopathy, cerebrovascula insufficiency, renal arteriosclerosis

Definitions

  • the enzyme cascade of the renin-angiotensin system comprises a series of biochemical events and, as it is well known, there are a variety of approaches for using regulatory intervention to open up treatment possibilities, for example treatment of hypertension.
  • Pharmacological suppression of the RAS through angiotensin converting enzyme (ACE) inhibition and/or angiotensin receptor blockade, is a proven effective therapeutic approach for the treatment of a wide range of cardiovascular diseases (CVDs).
  • Inhibitors of the enzymatic activity of renin bring about a reduction in the formation of angiotensin I. As a result a smaller amount of angiotensin Il is produced.
  • renin inhibitors or salts thereof, may be employed, e.g., as antihypertensives or for treating congestive heart failure. Further evaluations may reveal that renin inhibitors may also be employed for a much broader range of therapeutic indications.
  • myocardial infarction is a medical condition that reflects death of cardiac myocytes caused by prolonged ischemia and can be defined from a number of different perspectives related to clinical, electrocardiographic (ECG), biochemical and pathologic characteristics.
  • ECG electrocardiographic
  • the clinical presentation and outcome depends on the severity and duration of myocardial ischemia.
  • Myocardial damage may occur in different clinical settings, for example, spontaneous or during coronary artery intervention (e.g. coronary angioplasty or implantation of coronary artery stents).
  • the presence or lack and the amount of myocardial damage resulting from prolonged ischemia can be evaluated by a number of different means, including pathologic examination, measurement of myocardial proteins in the blood, ECG recordings (ST-T segment wave changes, Q waves), imaging modalities such as myocardial perfusion imaging, echocardiography and contrast ventriculography.
  • Ischemia in a clinical setting can be identified from symptoms such as chest, epigastric, arm, wrist or jaw discomfort with exertion or at rest.
  • the discomfort associated with acute myocardial infarction usually lasts at least 20 min, but may be shorter in duration.
  • Other ischemic symptoms can be unexplained nausea and vomiting, persistent shortness of breath secondary to left ventricular failure and unexplained weakness, dizziness, lightheadedness or syncope, or a combination of these. These symptoms may be noted together with chest discomfort or they may occur in the absence of chest symptoms.
  • Myocardial necrosis may also occur without symptoms and thus it may be detected only by the ECG, cardiac imaging or other.
  • Ml myocardial infarction
  • the aim of the present invention is to provide a therapeutic approach for the treatment of acute myocardial infarction.
  • the present invention relates to the simultaneous, separate or sequential use of a renin inhibitor or a pharmaceutically acceptable salt thereof in combination with one or more active ingredient for the manufacture of a medicament for the treatment of acute myocardial infarction.
  • Preferred other active ingredients are selected from the group consisting of ACEIs, beta blockers, angiotensin Il receptor antagonists, aspirin and salts thereof.
  • Suitable ACEIs which may be employed according to the present invention include ACEIs having differing structural features, for example a member of the group consisting of alacepril, benazepril, benazeprilat, captopril, ceronapril, cilazapril, delapril, enalapril, enaprilat, fosinopril, imidapril, lisinopril, moveltopril, perindopril, quinapril, ramipril, spirapril, temocapril, trandolapril and salts thereof.
  • the ACE inhibitor is selected from the group consisting of benazepril, benazeprilat, captopril, enalapril, enaprilat and salts thereof; most preferably the ACE inhibitor is benazepril, benazeprilat or salts thereof.
  • the present invention relates to the simultaneous, separate or sequential use of aliskiren, or a salt thereof, in combination with an ACEI, or salt thereof, such as alacepril, benazepril, benazeprilat, captopril, ceronapril, cilazapril, delapril, enalapril, enaprilat, fosinopril, imidapril, lisinopril, moveltopril, perindopril, quinapril, ramipril, spirapril, temocapril, trandolapril or salts thereof, more preferably benazepril, benazeprilat, captopril, enalapril, enaprilat or salts thereof, most preferably benazepril, benazeprilat or salts thereof.
  • an ACEI or salt thereof
  • the present invention relates to the simultaneous, separate or sequential use of a renin inhibitor or a pharmaceutically acceptable salt thereof in combination with an angiotensin Il receptor antagonist for the manufacture of a medicament for the treatment of acute myocardial infarction.
  • angiotensin Il receptor antagonists selected from the group consisting of valsartan, losartan, eprosartan, irbesartan, telmisartan, candesartan, saprisartan and salts thereof; most preferably the angiotensin Il receptor antagonists is valsartan or salt thereof.
  • the present invention relates to the simultaneous, separate or sequential use of aliskiren, or a salt thereof, in combination with an angiotensin Il receptor antagonist, or a salt thereof, such as valsartan, losartan, eprosartan, irbesartan, telmisartan, candesartan, saprisartan or salts thereof; most preferably valsartan or salt thereof.
  • ⁇ -blockers suitable for use in the present invention include ⁇ -adrenergic blocking agents ( ⁇ -blockers) which compete with epinephrine for ⁇ -adrenergic receptors and interfere with the action of epinephrine.
  • ⁇ -blockers ⁇ -adrenergic blocking agents
  • the ⁇ -blockers are selective for the ⁇ - adrenergic receptor as compared to the alpha ( ⁇ )-adrenergic receptors, and so do not have a significant ⁇ -blocking effect.
  • Suitable ⁇ -blockers include compounds selected from acebutolol, atenolol, betaxolol, bisoprolol, carteolol, carvedilol, esmolol, labetalol, metoprolol, nadolol, oxprenolol, penbutolol, pindolol, propranolol, sotalol, timolol and salts thereof; more preferably atenolol, metoprolol, propranolol and salts thereof.
  • Especially preferred ⁇ -blockers for use in the present invention are atenolol, metoprolol, propranolol and salts thereof.
  • the present invention relates to a method for treatment of acute myocardial infarction, which method comprises administering to a warm-blooded animal, including man, in need thereof, a therapeutically effective amount of a pharmaceutical composition comprising a renin inhibitor, preferably aliskiren, or a pharmaceutically acceptable salt thereof, in combination with an ACEI, or salt thereof.
  • a pharmaceutical composition comprising a renin inhibitor, preferably aliskiren, or a pharmaceutically acceptable salt thereof, in combination with an ACEI, or salt thereof.
  • Particularly preferred ACEIs of this embodiment are selected, for example, from the group of preferred ACEIs above mentioned; more preferably the ACEI is benazepril or salt thereof.
  • the present invention relates to a method for treatment of acute myocardial infarction, which method comprises administering to a warm-blooded animal, including man, in need thereof, a therapeutically effective amount of a pharmaceutical composition comprising a renin inhibitor, preferably aliskiren, or a pharmaceutically acceptable salt thereof, in combination with a ⁇ -blocker, or salt thereof.
  • a pharmaceutical composition comprising a renin inhibitor, preferably aliskiren, or a pharmaceutically acceptable salt thereof, in combination with a ⁇ -blocker, or salt thereof.
  • Particularly preferred ⁇ -blockers of this embodiment are selected, for example, from the group of preferred ⁇ -blockers above mentioned.
  • Acute or evolving myocardial infarction in accordance with the present invention, is defined by either one of the following criteria:
  • An increased CK-MB (preferably CK-MB mass) value can be defined as one that exceeds the 99th percentile of CK-MB values in a reference control group on two successive samples, or maximal value exceeding twice the upper limit of normal for the specific institution on one occasion during the first hours after the index clinical event.
  • aliskiren if not defined specifically, is to be understood both as the free base and as a salt thereof, especially the hemi-fumarate, nitrate, hydrogen sulfate and orotate salt thereof, most preferably the hemi-fumarate salt thereof.
  • Valsartan or a pharmaceutically acceptable salt thereof, can, e.g., be prepared in a manner known per se.
  • Preferred salts forms include acid addition salts.
  • the compounds having at least one acid group e.g., COOH or 5-tetrazolyl
  • Suitable salts with bases are, e.g., metal salts, such as alkali metal or alkaline earth metal salts, e.g., sodium, potassium, calcium or magnesium salts, or salts with ammonia or an organic amine, such as morpholine, thiomorpholine, piperidine, pyrrolidine, a mono-, di- or tri-lower alkylamine, e.g., ethyl-, tert-butyl-, diethyl-, diisopropyl-, triethyl-, tributyl- or dimethylpropylamine, or a mono-, di- or trihydroxy lower alkylamine, e.g., mono-, di- or tri-ethanolamine.
  • metal salts such as alkali metal or alkaline earth metal salts, e.g., sodium, potassium, calcium or magnesium salts, or salts with ammonia or an organic amine, such as morpholine, thiomorpho
  • Corresponding internal salts may furthermore be formed. Salts which are unsuitable for pharmaceutical uses but which can be employed, e.g., for the isolation or purification of free compounds I or their pharmaceutically acceptable salts, are also included. Even more preferred salts are, e.g., selected from the mono-sodium salt in amorphous form; di-sodium salt of Valsartan in amorphous or crystalline form, especially in hydrate form, thereof. Mono-potassium salt of Valsartan in amorphous form; di-potassium salt of Valsartan in amorphous or crystalline form, especially in hydrate form, thereof.
  • Valsartan is used as the free acid.
  • ⁇ -blocker is an acid or base or otherwise capable of forming pharmaceutically acceptable salts or prodrugs
  • these forms are considered to be encompassed herein, and it is understood that the compounds may be administered in free form or in the form of a pharmaceutically acceptable salt or a prodrug, such as a physiologically hydrolizable and acceptable ester.
  • a pharmaceutically acceptable salt or a prodrug such as a physiologically hydrolizable and acceptable ester.
  • metoprolol is suitably administered as its tartrate salt
  • propranolol is suitably administered as the hydrochloride salt, and so forth.
  • Salts are especially the pharmaceutically acceptable salts. They can be formed where salt forming groups, such as basic or acidic groups, are present that can exist in dissociated form at least partially, e.g. in a pH range from 4 to 10 in aqueous solutions, or can be isolated especially in solid, especially crystalline, form. Such salts are formed, for example, as acid addition salts, preferably with organic or inorganic acids, from compounds with a basic nitrogen atom (e.g. imino or amino), especially the pharmaceutically acceptable salts. Suitable inorganic acids are, for example, halogen acids, such as hydrochloric acid, sulfuric acid, or phosphoric acid.
  • Suitable organic acids are, for example, carboxylic, phosphonic, sulfonic or sulfamic acids, for example acetic acid, propionic acid, lactic acid, fumaric acid, succinic acid, citric acid, amino acids, such as glutamic acid or aspartic acid, maleic acid, hydroxymaleic acid, methylmaleic acid, benzoic acid, methane- or ethane-sulfonic acid, ethane-1 ,2-disulfonic acid, benzene- sulfonic acid, 2-naphthalenesulfonic acid, 1 ,5-naphthalene-disulfonic acid, N-cyclohexyl- sulfamic acid, N-methyl-, N-ethyl- or N-propyl-sulfamic acid, or other organic protonic acids, such as ascorbic acid.
  • carboxylic, phosphonic, sulfonic or sulfamic acids for example ace
  • salts may also be formed with bases, e.g. metal or ammonium salts, such as alkali metal or alkaline earth metal salts, for example sodium, potassium, magnesium or calcium salts, or ammonium salts with ammonia or suitable organic amines, such as tertiary monoamines, for example triethylamine or tri(2- hydroxyethyl)amine, or heterocyclic bases, for example N-ethyl-piperidine or N,N'-di- methylpiperazine.
  • bases e.g. metal or ammonium salts, such as alkali metal or alkaline earth metal salts, for example sodium, potassium, magnesium or calcium salts, or ammonium salts with ammonia or suitable organic amines, such as tertiary monoamines, for example triethylamine or tri(2- hydroxyethyl)amine, or heterocyclic bases, for example N-ethyl-piperidine or N,N'-di- methylpiperaz
  • the active agents may be present in prodrug form.
  • the invention includes prodrugs for the active pharmaceutical species of the invention, for example in which one or more functional groups are protected or derivatised but can be converted in vivo to the functional group, as in the case of esters of carboxylic acids convertible in vivo to the free acid, or in the case of protected amines, to the free amino group.
  • prodrug represents in particular compounds which are rapidly transformed in vivo to the parent compound, for example, by hydrolysis in blood.
  • Carboxylic acid Esters including e.g. acyloxyalkyl esters, amides
  • Alcohol Esters including e.g. sulfates and phosphates as well as carboxylic acid esters
  • Amine Amides carbamates, imines, enamines,
  • Prodrugs also include compounds convertible to the active drug by an oxidative or reductive reaction. As examples may be mentioned:
  • metabolic activations of prodrugs are nucleotide activation, phosphorylation activation and decarboxylation activation.
  • protected derivatives of compounds of the invention may not possess pharmacological activity as such, they may be administered, for example parenterally or orally, and thereafter metabolised in the body to form compounds of the invention which are pharmacologically active. Such derivatives are therefore examples of "prodrugs". All prodrugs of the described compounds are included within the scope of the invention.
  • the use of protecting groups is fully described in ' Protective Groups in Organic Chemistry ' , edited by J W F McOmie, Plenum Press (1973), and ' Protective Groups in Organic Synthesis ' , 2nd edition, T W Greene & P G M Wutz, Wiley-lnterscience (1991).
  • effective amount refers to the amount of the active ingredient or agent which halts or reduces the progress of the condition being treated or which otherwise completely or partly cures or acts palliatively on the condition.
  • drug active substance
  • active ingredient active agent
  • treatment means the management and care of a patient for the purpose of preventing, combating or delaying the disease, condition or disorder, preferably forthe purpose of combating the disease, condition or disorder.
  • treatment refers to "pretreatment”, which relates to the administration of an active agent, preferably a renin inhibitor such as aliskiren, before the onset of the disease for the purpose of preventing, combating or delaying progression of the disease, condition or disorder.
  • pretreatment relates to the administration of an active agent, preferably a renin inhibitor such as aliskiren, before the onset of the disease for the purpose of preventing, combating or delaying progression of the disease, condition or disorder.
  • an active agent preferably a renin inhibitor such as aliskiren
  • this means at the stage where the patient's blood levels of the above-mentioned specific biomarkers and/or ECG changes are not yet indicative of an acute myocardial infarction as defined herein.
  • the present invention relates to the use of a renin inhibitor, such as aliskiren, or a pharmaceutically acceptable salt thereof for the manufacture of a medicament for the pretreatment of acute myocardial infarction.
  • a renin inhibitor such as aliskiren
  • a pharmaceutically acceptable salt thereof for the manufacture of a medicament for the pretreatment of acute myocardial infarction.
  • the structure of the active agents identified by generic or tradenames or code numbers may be taken from the actual edition of the standard compendium "The Merck Index" or from databases, e.g., Life Cycle Patents International (e.g. IMS World Publications). Any person skilled in the art is fully enabled to identify the active agents and, based on these references, likewise enabled to manufacture and test the pharmaceutical indications and properties in standard test models, both in vitro and in vivo.
  • compositions according to the invention are those suitable for enteral, such as oral or rectal, transdermal and parenteral administration to mammals, including man, with the compositions comprising the pharmacological active compound either alone or together with customary pharmaceutical auxiliary substances.
  • the pharmaceutical compositions consist of from about 0.1 % to 100 %, preferably of from about 1 % to about 80 %, of the active compound.
  • Pharmaceutical compositions for enteral or parenteral administration are, for example, in unit dose forms, such as coated tablets, tablets, capsules or suppositories and also ampoules. These are prepared in a manner which is known per se, for example using conventional mixing, granulation, coating, solubulizing or lyophilizing processes.
  • compositions for oral use can be obtained by combining the active compound with solid excipients, if desired granulating a mixture which has been obtained, and, if required or necessary, processing the mixture or granulate into tablets or coated tablet cores after having added suitable auxiliary substances.
  • the pharmaceutical composition comprising a renin inhibitor, in particular, aliskiren, preferably in the form of the hemi-fumarate salt thereof; and optionally at least one therapeutic agent selected from the group consisting of an ACE inhibitor, an angiotensin Il receptor antagonist, a beta-blocker, aspirin and pharmaceutically acceptable salts thereof, can take the form, for example, of solutions, suspensions, tablets, pills, capsules, powders, microemulsions and unit dose packets. .
  • tablets and gelatin capsules comprising the active ingredient together with: a) diluents, e.g., lactose, dextrose, sucrose, mannitol, sorbitol, cellulose and/or glycine; b) lubricants, e.g., silica, talcum, stearic acid, its magnesium or calcium salt and/or polyethyleneglycol; for tablets also c) binders, e.g., magnesium aluminum silicate, starch paste, gelatin, tragacanth, methylcellulose, sodium carboxymethylcellulose and or polyvinylpyrrolidone; if desired d) disintegrants, e.g., starches, agar, alginic acid or its sodium salt, or effervescent mixtures; and/or e) absorbants, colorants, flavors and sweeteners.
  • Injectable compositions are preferably aqueous isotonic solutions or suspensions, and suppositories are advantageous
  • the dosage of the active compound can depend on a variety of factors, such as mode of administration, homeothermic species, age and/or individual condition.
  • Preferred dosages for pharmaceutical combinations are therapeutically effective dosages, especially those which are commerically available. Especially preferred are low dose combinations.
  • an approximate daily dose of from 1 mg to about 360 mg is to be estimated, e.g., for a patient of approximately 75 kg in weight.
  • the doses of renin inhibitor, for example aliskiren, to be administered to warm-blooded animals, for example human beings, of, for example, approximately 70 kg body weight, especially the doses effective for the inhibition of the enzyme renin, e.g. in lowering blood pressure, may be of from 3 mg to 3 g, preferably of from 10 mg to 1 g, for example of from 20 mg to 600 mg (e.g. 150 mg to 300 mg), per person per day; divided preferably into 1 to 4 single doses which may, e.g., be of the same size.
  • Single doses, of for example aliskiren comprise, for example, 75, 100, 150, 200, 250, 300 or 600 mg per adult patient.
  • Preferred dosage unit forms of angiotensin Il receptor antagonist may be, for example, tablets or capsules comprising e.g. a therapeutically effective amount, e.g. of from 10 to about 360 mg of, for example, valsartan, preferably 40 mg, 80 mg, 160 mg or 320 mg.
  • the application of the active ingredient may occur up to three times a day, starting e.g. with a daily dose of 20 mg or 40 mg of, for example, valsartan, increasing via 80 mg daily and further to 160 mg daily up to 320 mg daily.
  • valsartan is applied twice a day with a dose of 80 mg or 160 mg, respectively, each.
  • Corresponding doses may be taken, for example, in the morning, at mid-day or in the evening.
  • Preferred is b.i.d. administration.
  • Preferred dosage unit forms of ACE inhibitors are, for example, tablets or capsules comprising e.g. of from 5 mg to 20 mg, preferably 5 mg, 10 mg or 20 mg of, for example, benazepril; of from 6.5 mg to 100 mg, preferably 6.25 mg, 12.5 mg, 25 mg, 50 mg, 75 mg or 100 mg of, for example, captopril; of from 2.5 mg to 20 mg, preferably 2.5 mg, 5 mg, 10 mg or 20 mg of, for example, enalapril; of from 10 mg to 20 mg, preferably 10 mg or 20 mg of, for example, fosinopril; of from 2.5 mg to 4 mg, preferably 2 mg or 4 mg of, for example, perindopril; of from 5 mg to 20 mg, preferably 5 mg, 10 mg or 20 mg of, for example, quinapril; or of from 1.25 mg to 5 mg, preferably 1.25 mg, 2.5 mg, or 5 mg of, for example, ramipril. Preferred is t.i.d.
  • Suitable daily dosages of ⁇ -blockers (for adults) for oral administration are, for example: of from 200 to 1200 mg of, for example, acebutolol; of from 25 to 100 mg of, for example, atenolol; of from 10 to 20 mg of, for example, betaxolol; of from 5 to 10 mg of, for example, bisoprolol; of from 2.5 to 10 mg of, for example, carteolol; of from 100 to 1 ,800 mg of, for example, labetalol; of from 50 to 450 mg of, for example, metoprolol; of from 40 to 240 mg of, for example, nadolol; of from 60 to 480 mg of, for example, oxprenolol; of from 20 to 80 mg of, for example, penbutolol; of from 10 to 60 mg of, for example pindolol; of from 40 to 320 mg or of from 60 to 320 mg (for long-acting formulation) of, for example
  • the exact dose of the active agent and the particular formulation to be administered depend on a number of factors, e.g., the rate of release of the active agent.
  • the amount of the active agent required and the release rate thereof may be determined on the basis of known in vitro or in vivo techniques, determining how long a particular active agent concentration in the blood plasma remains at an acceptable level for a therapeutic effect.
  • kits may comprise, e.g., two or three separate pharmaceutical compositions: (1) a composition comprising a renin inhibitor, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier or diluent and (2) at least one therapeutic agent selected from the group consisting of an ACE inhibitor, or a pharmaceutically acceptable salt thereof, an angiotensin Il receptor antagonist, e.g., valsartan, or a pharmaceutically acceptable salt thereof, a beta blocker, or a pharmaceutically acceptable salt thereof, aspirin, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier or diluent.
  • the amounts of (1) and (2) are such that, when coadministered separately a beneficial therapeutic effect(s) is achieved.
  • the kit comprises a container for containing the separate compositions such as a divided bottle or a divided foil packet, wherein each compartment contains a plurality of dosage forms (e.g., tablets) comprising, e.g., (1) or (2).
  • the kit may contain separate compartments each of which contains a whole dosage which in turn comprises separate dosage forms.
  • An example of this type of kit is a blister pack wherein each individual blister contains two or three (or more) tablets, one (or more) tablet(s) comprising a pharmaceutical composition (1), and the second (or more) tablet(s) comprising a pharmaceutical composition (2).
  • kits comprises directions for the administration of the separate components.
  • the kit form is particularly advantageous when the separate components are preferably administered in different dosage forms (e.g., oral and parenteral), are administered at different dosage intervals, or when titration of the individual components of the combination is desired by the prescribing physician.
  • a kit may, e.g., comprise:
  • At least one therapeutic agent selected from the group consisting of an ACE inhibitor, or a pharmaceutically acceptable salt thereof, an angiotensin Il receptor antagonist, e.g., valsartan, or a pharmaceutically acceptable salt thereof, a beta blocker, or a pharmaceutically acceptable salt thereof, aspirin, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier or diluent, in a second dosage form, and
  • renin inhibitors may be used for the treatment of acute myocardial infarction.
  • the beneficial cardio-protective effect of renin inhibitors can be demonstrated, for example, by carrying out a study in a hypertensive rat model of acute myocardial infarct. The results of this study demonstrate the cardioprotective effect of renin inhibitors, either alone or in combination with a further active ingredient as described herein.
  • renin inhibitors such as aliskiren, can have a beneficial cardio-protective effect.
  • LADCA left anterior descending coronary artery
  • AR area at risk
  • PBS phospate buffered saline
  • MABP mean arterial blood pressure
  • MPO myeloperoxidase
  • KC pro-inflammatory chemokine
  • IL-1 B pro-inflammatory cytokine
  • TNF- ⁇ pro-inflammatory cytokine
  • CXCL8 interleukin 8 s.c: subcutaneous bid. (administration): bis in a day t.i.d. (administration): tris in a day
  • a combination according to the present invention comprising a renin inhibitor, or a pharmaceutically acceptable salt thereof, can be administered by various routes of administration.
  • Each agent can be tested over a wide-range of dosages to determine the optimal drug level for each therapeutic agent in the specific combination to elicit the maximal response.
  • treatment groups consisting of at least 6 animals per group. Each study is best performed in a way wherein the effects of the combination treatment group are determined at the same time as the individual components are evaluated.
  • AR area at risk
  • IS Infarct size
  • LADCA is re- occluded and Evans blue dye is injected into the carotid artery catheter.
  • the heart is removed and the LV is excised and weighed.
  • the heart is then sectioned transversely into five sections with one section made at the site of ligature, and each section is weighed. Sections of the ventricle from the level of the ligature to the apex, which are unstained, define the AR.
  • Such sections are then used to define the infarcted area by TCC staining (1.5% w/v triphenyltetrazolium chloride in PBS).
  • the area of infarction for each slice is determined by computerized planimetry using an image analysis software program (NIH Image Software, NIH, Bethesda, MD).
  • the size of infarction (IS) is determined by the following equation:
  • A percent area of infarction by planimetry from different sections
  • WT weight of the corresponding sections
  • the LV is excised without performing any staining procedure, and tissue is frozen at -80 0 C for the following analysis:
  • MCP-1 leukocyte adhesion molecule
  • Pressure rate index (PRI, mmHg/min/10 3 )
  • a relative indicator of myocardial oxygen consumption is calculated as the product of MABP and HR.
  • a renin inhibitor for example aliskiren, is administered to mREN-2 rats for 7 days at a dose of, for example, 100 mg/kg/day through subcutaneous osmotic minipumps, alone or in combination with a dose of, for examplel O mg/kg/day, of, for example, an ACEI, like benazepril.
  • the experimental procedure (25 min ischemia followed by 120 min reperfusion) is performed in the following setting:
  • the rats are treated with a renin inhibitor, for example aliskiren, at a dose of, for example, 100 mg/kg/day, together with a dose of, for example 10 mg/kg/day, of, for example an ACEI (benazepril):
  • Basal MABP levels (180 ⁇ 3.3 mmHg) are significantly affected by the I/R procedure, with a maximal hypotensive effect at 25 min (151 ⁇ 2.5 mmHg).
  • Treatment with aliskiren, benazepril or their combination significantly reduces basal MABP, by 27%, 29% and 39% (p ⁇ 0.01 vs vehicle and vs each monotherapy), respectively.
  • HR significantly increases compared to vehicle after treatment with aliskiren, benazepril or their combination (p ⁇ 0.05), and remains significantly higher compared to vehicle during the I/R procedure (p ⁇ 0.05).
  • Benazepril treatment significantly reduces (p ⁇ 0.01) all biochemical parameters to a similar extent.
  • Combination therapy produces an additive effect on cardiac levels of MPO, TNF- ⁇ and CXCL8 (p ⁇ 0,01 vs vehicle and vs each monotherapy), and a possible synergistic effect on caspase-3 (p ⁇ 0.0001 for interaction) which should be further investigated.

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Abstract

The invention relates to the use of a renin inhibitor, or a pharmaceutically acceptable salt thereof, alone or in combination with one or more active ingredient, for the manufacture of a medicament for the treatment of acute myocardial infarction.

Description

USE OF SPPlOO FOR THE TREATMENT OF ACUTE MI
The enzyme cascade of the renin-angiotensin system (RAS) comprises a series of biochemical events and, as it is well known, there are a variety of approaches for using regulatory intervention to open up treatment possibilities, for example treatment of hypertension. Pharmacological suppression of the RAS, through angiotensin converting enzyme (ACE) inhibition and/or angiotensin receptor blockade, is a proven effective therapeutic approach for the treatment of a wide range of cardiovascular diseases (CVDs). Inhibitors of the enzymatic activity of renin bring about a reduction in the formation of angiotensin I. As a result a smaller amount of angiotensin Il is produced. The reduced concentration of that active peptide hormone is the direct cause of, e.g., the antihypertensive effect of renin inhibitors. Accordingly, renin inhibitors, or salts thereof, may be employed, e.g., as antihypertensives or for treating congestive heart failure. Further evaluations may reveal that renin inhibitors may also be employed for a much broader range of therapeutic indications.
A described in European Heart Journal (2000), 21 , 1502-1513, myocardial infarction is a medical condition that reflects death of cardiac myocytes caused by prolonged ischemia and can be defined from a number of different perspectives related to clinical, electrocardiographic (ECG), biochemical and pathologic characteristics. The clinical presentation and outcome depends on the severity and duration of myocardial ischemia. Myocardial damage may occur in different clinical settings, for example, spontaneous or during coronary artery intervention (e.g. coronary angioplasty or implantation of coronary artery stents). The presence or lack and the amount of myocardial damage resulting from prolonged ischemia can be evaluated by a number of different means, including pathologic examination, measurement of myocardial proteins in the blood, ECG recordings (ST-T segment wave changes, Q waves), imaging modalities such as myocardial perfusion imaging, echocardiography and contrast ventriculography.
Ischemia in a clinical setting can be identified from symptoms such as chest, epigastric, arm, wrist or jaw discomfort with exertion or at rest. The discomfort associated with acute myocardial infarction usually lasts at least 20 min, but may be shorter in duration. Other ischemic symptoms can be unexplained nausea and vomiting, persistent shortness of breath secondary to left ventricular failure and unexplained weakness, dizziness, lightheadedness or syncope, or a combination of these. These symptoms may be noted together with chest discomfort or they may occur in the absence of chest symptoms. Myocardial necrosis may also occur without symptoms and thus it may be detected only by the ECG, cardiac imaging or other.
The term "myocardial infarction" (Ml) has been used rather indiscriminately when dealing with acute coronary syndromes. In general, Ml has been used to describe the whole history of the event from the initial ischaemia with chest pain, through the acute necrotic phase and into the post-myocardial phase where scarring of the heart muscle and long- term cardiac remodeling takes place. However, the European Society of Cardiology and the American College of Cardiology stress the importance to distinguish between the different phases of myocardial infarction. According to the European Heart Journal, 21 , 2000, 1502-1513 and Journal of the American College of Cardiology, 36, 2000, 959-969, the term myocardial infarction should be used with further qualifications, whether in clinical practice, in the description of patient cohorts or in population studies. Such qualifications should refer to the amount of myocardial cell loss (infarct size), to the circumstances leading to the infarct (spontaneous or in the setting of a coronary artery diagnostic or therapeutic procedure) and to the timing of the myocardial necrosis relative to the time of the observation (acute or evolving, healing and healed myocardial infarction). Thus, in order to categorize the different symptoms and in order to define the (very) different objects and means of treating patients over the time course of myocardial infarction the cited literature distinguishes between three clear stages of Ml,
• acute or evolving Ml: 6h to 7 days
• healing Ml : 7 to 28 days
• healed Ml: 29 days or more
These different stages of Ml are characterized by very different measurable events, for example during the acute phase biochemical markers of myocardial necrosis are transiently increased (for a few hours, usually 6 h but less than 12 h) and ischemic symptoms are present. An acute or evolving infarction is characterized by the presence of polymorphonuclear leukocytes. If the interval between the onset of infarction and death is brief (e.g., 6 h), minimal or no polymorphonuclear leukocytes may be seen. The presence of mononuclear cells and fibroblasts and the absence of polymorphonuclear leukocytes characterize a healing infarction. A healed infarction is manifested as scar tissue without cellular infiltration. The entire process leading to a healed infarction usually requires five to six weeks or more.
Myocardial infarction can be recognized when blood levels of specific biomarkers are increased in the clinical setting of acute myocardial ischemia. Myocardial necrosis' biomarkers include, for example, myoglobin, cardiac troponins (troponin T or troponin I), creatine kinase or lactate dehydrogenase. The preferred biomarker for myocardial damage is cardiac troponin (I or T) which has nearly absolute myocardial tissue specificity, as well as high sensitivity. Another biomarker for myocardial damage is the MB (muscle brain) fraction of creatine kinase (CK-MB).
The aim of the present invention is to provide a therapeutic approach for the treatment of acute myocardial infarction.
Summary of the Invention
In one aspect, the present invention relates to the use of a renin inhibitor, or a pharmaceutically acceptable salt thereof, either alone or in combination with one or more active ingredient, such as, for instance, ACEIs, beta blockers, aspirin or salts thereof, for the treatment of acute myocardial infarction. The present invention also relates to the use of an ACE inhibitor, or a pharmaceutically acceptable salt thereof, either alone or in combination with one or more active ingredient, for the treatment of acute myocardial infarction.
In another aspect, the present invention relates to a pharmaceutical composition for the treatment of acute myocardial infarction, which comprises a renin inhibitor, or a pharmaceutically acceptable salt thereof, either alone or in combination with one or more active ingredient, such as, for example, ACEIs1 angiotensin Il receptor antagonists, beta blockers aspirin or salts thereof.
In a further embodiment, the present invention relates to a pharmaceutical composition for simultaneous, separate or sequential use for the treatment of acute myocardial infarction comprising a renin inhibitor, or a pharmaceutically acceptable salt thereof, in combination with one or more active ingredient e.g. selected from the group consisting of ACE inhibitors, angiotensin Il receptor antagonists, beta-blockers, aspirin and salts thereof, in each case in a unit dosage form, in admixture with a pharmaceutically acceptable carrier.
The invention furthermore relates to a method for the treatment of acute myocardial infarction which comprises administering to a warm-blooded animal, including human, a therapeutically effective amount of a renin inhibitor, or a pharmaceutically acceptable salt thereof, either alone or in combination with one or more active ingredient, such as, for example, ACEIs, beta blockers, angiotensin Il receptor antagonists, aspirin or salts thereof.
Preferred embodiments according to the invention
The renin inhibitors to which the present invention applies are any of those having renin inhibitory activity in vivo and, therefore, pharmaceutical utility, e.g., as therapeutic agents for the prevention of, delay the onset of and/or treatment of e.g., hypertension (whether for malignant, essential, reno-vascular, diabetic, isolated systolic, or other secondary type of hypertension). Further indications for which renin inhibitors can be useful are described e.g. in WO2004/002549, WO2005/089731 , WO2006/041763, WO2006/041974, WO2006/116435, WO2002/40007 and in PCT application No. 2007/065564.
For example, the present invention relates to renin inhibitors disclosed in: U.S. Patents No. 5559111 , 6197959, 6376672, 6051712, 6197959, 6268499 and 6274735; in US patent applications 2004/0204455, 2002/087002; in WO2003/099767, WO2005/054177, WO2005/051895, WO2005/051911 , WO2006/066896, WO2006/069788, WO2006/074924, WO2006/094763, WO2006/100036, WO2006/0117183, WO2006/125621 , WO2006/128659, WO2007/006534, WO2007/077005; in WO2003/093267, WO2004/002957, WO2004/096116, WO2004/096799, WO2004/096803, WO2004/096804, WO2005/040120, WO2005/040165, WO2005/040173, WO2005/054243, WO2005/054244, WO2006/021399, WO2006/021401 , WO2006/021402, WO2006/021403, WO2006/058546, WO2006/059304, WO2006/061791 , WO2006/063610, WO2006/064484, WO2006/079988, WO2006/092268, WO2006/129237, WO2006/131884, WO2007/034406, WO2007/034445, WO2007/049224, WO2003/103652, WO2003/103652, WO2007/045551 , WO2004/089915, WO2000/63173, WO2000/64873, WO2000/64887, WO1997/09311 , WO2005/037803, WO2005/061457, WO2005/070870, WO2005/070871 , WO2005/070877, WO2005/090304, WO2005/090305, WO2006/005741 , WO2006/061426, WO2006/061427, WO2006/095020, WO2006/103273, WO2006/103275, WO2006/103277, WO2007/031557 and WO2007/031558; in PCT applications 2007/005130 and 2007/005131 ; in European patent application 0711 1290.8 and in European patent No. 0863875; in particular in the compound claims and the final products of the working examples.
Preferred renin inhibitors are selected from the group consisting of ditekiren, terlakiren, zankiren, aliskiren and salts thereof. A preferred renin inhibitor is aliskiren or a salt thereof, especially the hemi-fumarate, nitrate, hydrogen sulfate and orotate, more preferably the hemi-fumarate salt thereof. Aliskiren in form of the free base is chemically defined as 2(S),4(S),5(S),7(S)-Λ/-(3-amino-2,2-dimethyl-3-oxopropyl)-2,7-di(1- methylethyl)-4-hydroxy-5-amino-8-[4-methoxy-3-(3-methoxy-propoxy)phenyl]- octanamide and is specifically disclosed in EP 678503 A as Example 83.
In a preferred embodiment, the present invention relates to the simultaneous, separate or sequential use of a renin inhibitor or a pharmaceutically acceptable salt thereof in combination with one or more active ingredient for the manufacture of a medicament for the treatment of acute myocardial infarction.
Preferred other active ingredients are selected from the group consisting of ACEIs, beta blockers, angiotensin Il receptor antagonists, aspirin and salts thereof.
In one embodiment, preferred other active ingredients to be used in a combination with renin inhibitors, or salts thereof, are ACE inhibitors, or salts thereof.
Suitable ACEIs which may be employed according to the present invention include ACEIs having differing structural features, for example a member of the group consisting of alacepril, benazepril, benazeprilat, captopril, ceronapril, cilazapril, delapril, enalapril, enaprilat, fosinopril, imidapril, lisinopril, moveltopril, perindopril, quinapril, ramipril, spirapril, temocapril, trandolapril and salts thereof. More preferably, the ACE inhibitor is selected from the group consisting of benazepril, benazeprilat, captopril, enalapril, enaprilat and salts thereof; most preferably the ACE inhibitor is benazepril, benazeprilat or salts thereof.
In a particularly preferred embodiment, the present invention relates to the simultaneous, separate or sequential use of aliskiren, or a salt thereof, in combination with an ACEI, or salt thereof, such as alacepril, benazepril, benazeprilat, captopril, ceronapril, cilazapril, delapril, enalapril, enaprilat, fosinopril, imidapril, lisinopril, moveltopril, perindopril, quinapril, ramipril, spirapril, temocapril, trandolapril or salts thereof, more preferably benazepril, benazeprilat, captopril, enalapril, enaprilat or salts thereof, most preferably benazepril, benazeprilat or salts thereof.
In a still further preferred embodiment, the present invention relates to the simultaneous, separate or sequential use of a renin inhibitor or a pharmaceutically acceptable salt thereof in combination with an angiotensin Il receptor antagonist for the manufacture of a medicament for the treatment of acute myocardial infarction.
Suitable angiotensin Il receptor antagonists which may be employed according to the present invention include angiotensin Il receptor antagonists having differing structural features. For example, mention may be made of the compounds which are listed in the European Patent Application having the No. 443983 and in the European Patent No. 1146872B1 ; in particular in the compound claims and the final products of the working examples. Preference is given to (S)-N-(I -carboxy-2-methylprop-1-yl)-N-pentanoyl-N- [2'(1 H-tetrazol-5-yl) biphenyl-4-ylmethyl]amine [Valsartan] and its pharmaceutically acceptable salts. Furthermore, reference is made to the compounds which are listed in: European Patent Application having the publication No. 253310, European Patent Application having the publication No. 403159, PCT Patent Application having the publication No. WO 91/14679, European Patent Application having the publication No. 420237, European Patent Application having the publication No. 502314, European Patent Application having the publication No. 459136 , European Patent Application having the publication No. 504888, European Patent Application having the publication No. 514198, European Patent Application having the publication No. 475206, PCT Patent Application having the publication No. WO 1993/20816; in particular in the compound claims and the final products of the working examples therein. Preference is given to the angiotensin Il receptor antagonists selected from the group consisting of valsartan, losartan, eprosartan, irbesartan, telmisartan, candesartan, saprisartan and salts thereof; most preferably the angiotensin Il receptor antagonists is valsartan or salt thereof.
In a particularly preferred embodiment, the present invention relates to the simultaneous, separate or sequential use of aliskiren, or a salt thereof, in combination with an angiotensin Il receptor antagonist, or a salt thereof, such as valsartan, losartan, eprosartan, irbesartan, telmisartan, candesartan, saprisartan or salts thereof; most preferably valsartan or salt thereof.
In a yet further preferred embodiment, the present invention relates to the simultaneous, separate or sequential use of a renin inhibitor or a pharmaceutically acceptable salt thereof in combination with a β-blocker for the manufacture of a medicament for the treatment of acute myocardial infarction.
β-blockers suitable for use in the present invention include β-adrenergic blocking agents (β-blockers) which compete with epinephrine for β-adrenergic receptors and interfere with the action of epinephrine. Preferably, the β-blockers are selective for the β- adrenergic receptor as compared to the alpha (α)-adrenergic receptors, and so do not have a significant α-blocking effect. Suitable β-blockers include compounds selected from acebutolol, atenolol, betaxolol, bisoprolol, carteolol, carvedilol, esmolol, labetalol, metoprolol, nadolol, oxprenolol, penbutolol, pindolol, propranolol, sotalol, timolol and salts thereof; more preferably atenolol, metoprolol, propranolol and salts thereof. Especially preferred β-blockers for use in the present invention are atenolol, metoprolol, propranolol and salts thereof.
In a further embodiment, the present invention relates to a pharmaceutical composition for the treatment of acute myocardial infarction comprising a renin inhibitor, such as aliskiren, or a pharmaceutically acceptable salt thereof, in combination with an ACE inhibitor or salt thereof. Particularly preferred ACEIs of this embodiment are selected, for example, from the group of preferred ACEIs above mentioned; more preferably the ACEI is benazepril or salt thereof. In a still further embodiment, the present invention relates to a pharmaceutical composition for the treatment of acute myocardial infarction comprising a renin inhibitor, such as aliskiren, or a pharmaceutically acceptable salt thereof, in combination with an angiotensin Il receptor antagonist or salt thereof. Particularly preferred angiotensin Il receptor antagonists of this embodiment are selected, for example, from the group of preferred angiotensin Il receptor antagonists above mentioned; more preferably the angiotensin Il receptor antagonist is valsartan or salt thereof.
In a yet further embodiment, the present invention relates to a pharmaceutical composition for the treatment of acute myocardial infarction comprising a renin inhibitor, such as aliskiren, or a pharmaceutically acceptable salt thereof, in combination with a β- blocker or salt thereof. Particularly preferred β-blockers of this embodiment are selected, for example, from the group of preferred β-blockers above mentioned.
In yet another preferred embodiment, the present invention relates to a method for treatment of acute myocardial infarction, which method comprises administering to a warm-blooded animal, including man, in need thereof, a therapeutically effective amount of a pharmaceutical composition comprising a renin inhibitor, preferably aliskiren, or a pharmaceutically acceptable salt thereof, in combination with an ACEI, or salt thereof. Particularly preferred ACEIs of this embodiment are selected, for example, from the group of preferred ACEIs above mentioned; more preferably the ACEI is benazepril or salt thereof.
In another particularly preferred embodiment, the present invention relates to a method for treatment of acute myocardial infarction, which method comprises administering to a warm-blooded animal, including man, in need thereof, a therapeutically effective amount of a pharmaceutical composition comprising a renin inhibitor, preferably aliskiren, or a pharmaceutically acceptable salt thereof, in combination with an angiotensin Il receptor antagonist, or a salt thereof. Particularly preferred angiotensin Il receptor antagonists of this embodiment are selected, for example, from the group of preferred angiotensin Il receptor antagonists above mentioned; more preferably the angiotensin Il receptor antagonist is valsartan or salt thereof.
In still another particularly preferred embodiment, the present invention relates to a method for treatment of acute myocardial infarction, which method comprises administering to a warm-blooded animal, including man, in need thereof, a therapeutically effective amount of a pharmaceutical composition comprising a renin inhibitor, preferably aliskiren, or a pharmaceutically acceptable salt thereof, in combination with a β-blocker, or salt thereof. Particularly preferred β-blockers of this embodiment are selected, for example, from the group of preferred β-blockers above mentioned.
Listed below are definitions of various terms used throughout the specification:
Acute or evolving myocardial infarction, in accordance with the present invention, is defined by either one of the following criteria:
1) increased value of myocardial necrosis' biomarkers and one of the following: a) ischemic symptoms b) development of pathologic Q waves on the ECG c) ECG changes indicative of (myocardial) ischemia or d) coronary artery intervention.
2) Pathologic finding of an acute Ml
An increased value of cardiac troponin or CK-MB can be defined as one that exceeds the 99th percentile of the values for a reference control group (on at least one occasion during the first 24 h after the index clinical event).
An increased CK-MB (preferably CK-MB mass) value can be defined as one that exceeds the 99th percentile of CK-MB values in a reference control group on two successive samples, or maximal value exceeding twice the upper limit of normal for the specific institution on one occasion during the first hours after the index clinical event.
In the absence of availability of a troponin or CK-MB assay, total creatine kinase (CK) (greater than two times the upper reference limit for CK) or the B fraction of creatine kinase may be employed.
ECG changes indicative of (myocardial) ischemia are defined as: (1) in patients with ST-segment elevation: -new or presumed new ST-segment elevation at the J point in two or more contiguous leads with the cut-off points ≥0-2 mV in leads V1 , V2, or V3 and >0-1 mV in other leads, or (2) in patients without ST-segment elevation:
-ST-segment depression or T wave abnormalities, wherein new or presumed new ST-segment depression or T wave abnormalities, or both, should be observed in two or more contiguous leads on two consecutive ECGs at least several (6-24) hours apart, and wherein new or presumed new symmetric inversion of T waves ≥1 mm should be present in at least two contiguous leads.
The term "aliskiren", if not defined specifically, is to be understood both as the free base and as a salt thereof, especially the hemi-fumarate, nitrate, hydrogen sulfate and orotate salt thereof, most preferably the hemi-fumarate salt thereof.
The term "valsartan", if not defined specifically, is to be understood both as the free base and as a salt thereof, especially a pharmaceutically acceptable salt thereof, as described below.
Valsartan , or a pharmaceutically acceptable salt thereof, can, e.g., be prepared in a manner known per se. Preferred salts forms include acid addition salts. The compounds having at least one acid group (e.g., COOH or 5-tetrazolyl) can also form salts with bases. Suitable salts with bases are, e.g., metal salts, such as alkali metal or alkaline earth metal salts, e.g., sodium, potassium, calcium or magnesium salts, or salts with ammonia or an organic amine, such as morpholine, thiomorpholine, piperidine, pyrrolidine, a mono-, di- or tri-lower alkylamine, e.g., ethyl-, tert-butyl-, diethyl-, diisopropyl-, triethyl-, tributyl- or dimethylpropylamine, or a mono-, di- or trihydroxy lower alkylamine, e.g., mono-, di- or tri-ethanolamine. Corresponding internal salts may furthermore be formed. Salts which are unsuitable for pharmaceutical uses but which can be employed, e.g., for the isolation or purification of free compounds I or their pharmaceutically acceptable salts, are also included. Even more preferred salts are, e.g., selected from the mono-sodium salt in amorphous form; di-sodium salt of Valsartan in amorphous or crystalline form, especially in hydrate form, thereof. Mono-potassium salt of Valsartan in amorphous form; di-potassium salt of Valsartan in amorphous or crystalline form, especially in hydrate form, thereof. Calcium salt of Valsartan in crystalline form, especially in hydrate form, primarily the tetrahydrate thereof; magnesium salt of Valsartan in crystalline form, especially in hydrate form, primarily the hexahydrate thereof; calcium/magnesium mixed salt of Valsartan in crystalline form, especially in hydrate form; ύ/s-diethylammonium salt of Valsartan in crystalline form, especially in hydrate form; Jb/s-dipropylammonium salt of Valsartan in crystalline form, especially in hydrate form; ύ/s-dibutylammonium salt of Valsartan in crystalline form, especially in hydrate form, primarily the hemihydrate thereof; mono-L-arginine salt of Valsartan in amorphous form; ύ/s-L-arginine salt of Valsartan in amorphous form; mono-L-lysine salt of Valsartan in amorphous form; bis-L- lysine salt of Valsartan in amorphous form.
Most preferably, Valsartan is used as the free acid.
Where the β-blocker is an acid or base or otherwise capable of forming pharmaceutically acceptable salts or prodrugs, these forms are considered to be encompassed herein, and it is understood that the compounds may be administered in free form or in the form of a pharmaceutically acceptable salt or a prodrug, such as a physiologically hydrolizable and acceptable ester. For example, metoprolol is suitably administered as its tartrate salt, propranolol is suitably administered as the hydrochloride salt, and so forth.
Salts are especially the pharmaceutically acceptable salts. They can be formed where salt forming groups, such as basic or acidic groups, are present that can exist in dissociated form at least partially, e.g. in a pH range from 4 to 10 in aqueous solutions, or can be isolated especially in solid, especially crystalline, form. Such salts are formed, for example, as acid addition salts, preferably with organic or inorganic acids, from compounds with a basic nitrogen atom (e.g. imino or amino), especially the pharmaceutically acceptable salts. Suitable inorganic acids are, for example, halogen acids, such as hydrochloric acid, sulfuric acid, or phosphoric acid. Suitable organic acids are, for example, carboxylic, phosphonic, sulfonic or sulfamic acids, for example acetic acid, propionic acid, lactic acid, fumaric acid, succinic acid, citric acid, amino acids, such as glutamic acid or aspartic acid, maleic acid, hydroxymaleic acid, methylmaleic acid, benzoic acid, methane- or ethane-sulfonic acid, ethane-1 ,2-disulfonic acid, benzene- sulfonic acid, 2-naphthalenesulfonic acid, 1 ,5-naphthalene-disulfonic acid, N-cyclohexyl- sulfamic acid, N-methyl-, N-ethyl- or N-propyl-sulfamic acid, or other organic protonic acids, such as ascorbic acid. In the presence of negatively charged radicals, such as carboxy or sulfonyl, salts may also be formed with bases, e.g. metal or ammonium salts, such as alkali metal or alkaline earth metal salts, for example sodium, potassium, magnesium or calcium salts, or ammonium salts with ammonia or suitable organic amines, such as tertiary monoamines, for example triethylamine or tri(2- hydroxyethyl)amine, or heterocyclic bases, for example N-ethyl-piperidine or N,N'-di- methylpiperazine. When a basic group and an acid group are present in the same molecule, a compound may also form internal salts.
The active agents may be present in prodrug form. The invention includes prodrugs for the active pharmaceutical species of the invention, for example in which one or more functional groups are protected or derivatised but can be converted in vivo to the functional group, as in the case of esters of carboxylic acids convertible in vivo to the free acid, or in the case of protected amines, to the free amino group. The term "prodrug," as used herein, represents in particular compounds which are rapidly transformed in vivo to the parent compound, for example, by hydrolysis in blood. A thorough discussion is provided in T. Higuchi and V. Stella, Pro-drugs as Novel Delivery Systems, Vol. 14 of the A.C.S. Symposium Series, Edward B. Roche, ed., Bioreversible Carriers in Drug Design, American Pharmaceutical Association and Pergamon Press, 1987; H Bundgaard, ed, Design of Prodrugs, Elsevier, 1985; and Judkins, et al. Synthetic Communications, 26(23), 4351-4367 (1996), each of which is incorporated herein by reference.
Prodrugs therefore include drugs having a functional group which has been transformed into a reversible derivative thereof. Typically, such prodrugs are transformed to the active drug by hydrolysis. As examples may be mentioned the following:
Functional Group Reversible derivative
Carboxylic acid Esters, including e.g. acyloxyalkyl esters, amides
Alcohol Esters, including e.g. sulfates and phosphates as well as carboxylic acid esters
Amine Amides, carbamates, imines, enamines,
Carbonyl (aldehyde, Imines, oximes, acetals/ketals, enol esters, ketone) oxazolidines and thiazoxolidines
Prodrugs also include compounds convertible to the active drug by an oxidative or reductive reaction. As examples may be mentioned:
Oxidative activation
• N- and O- dealkylation
• Oxidative deamination
• N-oxidation
• Epoxidation
Reductive activation
• Azo reduction
• Sulfoxide reduction
• Disulfide reduction
• Bioreductive alkylation
• Nitro reduction.
Also to be mentioned as metabolic activations of prodrugs are nucleotide activation, phosphorylation activation and decarboxylation activation. For additional information, see "The Organic Chemistry of Drug Design and Drug Action", R B Silverman (particularly Chapter 8, pages 497 to 546).
Although protected derivatives of compounds of the invention may not possess pharmacological activity as such, they may be administered, for example parenterally or orally, and thereafter metabolised in the body to form compounds of the invention which are pharmacologically active. Such derivatives are therefore examples of "prodrugs". All prodrugs of the described compounds are included within the scope of the invention. The use of protecting groups is fully described in 'Protective Groups in Organic Chemistry', edited by J W F McOmie, Plenum Press (1973), and 'Protective Groups in Organic Synthesis', 2nd edition, T W Greene & P G M Wutz, Wiley-lnterscience (1991). Where the plural form is used for compounds, salts, pharmaceutical compositions, diseases, disorders and the like, this is intended to mean one (preferred) or more single compound(s), salt(s), pharmaceutical composition(s), disease(s), disorder(s) or the like, where the singular or the indefinite article ("a", "an") is used, this is intended to include the plural (for example also different configuration isomers of the same compound, e.g. enantiomers in racemates or the like) or preferably the singular ("one").
The terms "effective amount" or "therapeutically effective amount" refers to the amount of the active ingredient or agent which halts or reduces the progress of the condition being treated or which otherwise completely or partly cures or acts palliatively on the condition.
The terms "drug", "active substance", "active ingredient", "active agent" are to be understood as meaning a compound in free form or in the form of a pharmaceutically acceptable salt, in particular compounds of the type specified herein.
The term "warm-blooded animal or patient" are used interchangeably herein and include, but are not limited to, humans, dogs, cats, horses, pigs, cows, monkeys, rabbits, mice and laboratory animals. The preferred mammals are humans.
The term "treatment" means the management and care of a patient for the purpose of preventing, combating or delaying the disease, condition or disorder, preferably forthe purpose of combating the disease, condition or disorder. In one preferred embodiment, the term "treatment" refers to "pretreatment", which relates to the administration of an active agent, preferably a renin inhibitor such as aliskiren, before the onset of the disease for the purpose of preventing, combating or delaying progression of the disease, condition or disorder. Typically this means at the stage where the patient's blood levels of the above-mentioned specific biomarkers and/or ECG changes are not yet indicative of an acute myocardial infarction as defined herein. Thus, in one embodiment, the present invention relates to the use of a renin inhibitor, such as aliskiren, or a pharmaceutically acceptable salt thereof for the manufacture of a medicament for the pretreatment of acute myocardial infarction. The structure of the active agents identified by generic or tradenames or code numbers may be taken from the actual edition of the standard compendium "The Merck Index" or from databases, e.g., Life Cycle Patents International (e.g. IMS World Publications). Any person skilled in the art is fully enabled to identify the active agents and, based on these references, likewise enabled to manufacture and test the pharmaceutical indications and properties in standard test models, both in vitro and in vivo.
The pharmaceutical compositions according to the invention are those suitable for enteral, such as oral or rectal, transdermal and parenteral administration to mammals, including man, with the compositions comprising the pharmacological active compound either alone or together with customary pharmaceutical auxiliary substances. For example, the pharmaceutical compositions consist of from about 0.1 % to 100 %, preferably of from about 1 % to about 80 %, of the active compound. Pharmaceutical compositions for enteral or parenteral administration are, for example, in unit dose forms, such as coated tablets, tablets, capsules or suppositories and also ampoules. These are prepared in a manner which is known per se, for example using conventional mixing, granulation, coating, solubulizing or lyophilizing processes. Thus, pharmaceutical compositions for oral use can be obtained by combining the active compound with solid excipients, if desired granulating a mixture which has been obtained, and, if required or necessary, processing the mixture or granulate into tablets or coated tablet cores after having added suitable auxiliary substances. For oral administration, the pharmaceutical composition comprising a renin inhibitor, in particular, aliskiren, preferably in the form of the hemi-fumarate salt thereof; and optionally at least one therapeutic agent selected from the group consisting of an ACE inhibitor, an angiotensin Il receptor antagonist, a beta-blocker, aspirin and pharmaceutically acceptable salts thereof, can take the form, for example, of solutions, suspensions, tablets, pills, capsules, powders, microemulsions and unit dose packets. . Preferred are tablets and gelatin capsules comprising the active ingredient together with: a) diluents, e.g., lactose, dextrose, sucrose, mannitol, sorbitol, cellulose and/or glycine; b) lubricants, e.g., silica, talcum, stearic acid, its magnesium or calcium salt and/or polyethyleneglycol; for tablets also c) binders, e.g., magnesium aluminum silicate, starch paste, gelatin, tragacanth, methylcellulose, sodium carboxymethylcellulose and or polyvinylpyrrolidone; if desired d) disintegrants, e.g., starches, agar, alginic acid or its sodium salt, or effervescent mixtures; and/or e) absorbants, colorants, flavors and sweeteners. Injectable compositions are preferably aqueous isotonic solutions or suspensions, and suppositories are advantageously prepared from fatty emulsions or suspensions.
Said compositions may be sterilized and/or contain adjuvants, such as preserving, stabilizing, wetting or emulsifying agents, solution promoters, salts for regulating the osmotic pressure and/or buffers.
The dosage of the active compound can depend on a variety of factors, such as mode of administration, homeothermic species, age and/or individual condition. Preferred dosages for pharmaceutical combinations are therapeutically effective dosages, especially those which are commerically available. Especially preferred are low dose combinations.
Normally, in the case of oral administration, an approximate daily dose of from 1 mg to about 360 mg is to be estimated, e.g., for a patient of approximately 75 kg in weight.
Usually, children receive about half of the adult dose or they can receive the same dose as adults. The dose necessary for each individual can be monitored, e.g., by measuring the serum concentration of the active ingredient, and adjusted to an optimum level. All doses are based on the active agent, i.e. for aliskiren, the doses are based on the free base.
The doses of renin inhibitor, for example aliskiren, to be administered to warm-blooded animals, for example human beings, of, for example, approximately 70 kg body weight, especially the doses effective for the inhibition of the enzyme renin, e.g. in lowering blood pressure, may be of from 3 mg to 3 g, preferably of from 10 mg to 1 g, for example of from 20 mg to 600 mg (e.g. 150 mg to 300 mg), per person per day; divided preferably into 1 to 4 single doses which may, e.g., be of the same size. Single doses, of for example aliskiren, comprise, for example, 75, 100, 150, 200, 250, 300 or 600 mg per adult patient.
Preferred dosage unit forms of angiotensin Il receptor antagonist may be, for example, tablets or capsules comprising e.g. a therapeutically effective amount, e.g. of from 10 to about 360 mg of, for example, valsartan, preferably 40 mg, 80 mg, 160 mg or 320 mg. The application of the active ingredient may occur up to three times a day, starting e.g. with a daily dose of 20 mg or 40 mg of, for example, valsartan, increasing via 80 mg daily and further to 160 mg daily up to 320 mg daily. Preferably, valsartan is applied twice a day with a dose of 80 mg or 160 mg, respectively, each. Corresponding doses may be taken, for example, in the morning, at mid-day or in the evening. Preferred is b.i.d. administration.
Preferred dosage unit forms of ACE inhibitors are, for example, tablets or capsules comprising e.g. of from 5 mg to 20 mg, preferably 5 mg, 10 mg or 20 mg of, for example, benazepril; of from 6.5 mg to 100 mg, preferably 6.25 mg, 12.5 mg, 25 mg, 50 mg, 75 mg or 100 mg of, for example, captopril; of from 2.5 mg to 20 mg, preferably 2.5 mg, 5 mg, 10 mg or 20 mg of, for example, enalapril; of from 10 mg to 20 mg, preferably 10 mg or 20 mg of, for example, fosinopril; of from 2.5 mg to 4 mg, preferably 2 mg or 4 mg of, for example, perindopril; of from 5 mg to 20 mg, preferably 5 mg, 10 mg or 20 mg of, for example, quinapril; or of from 1.25 mg to 5 mg, preferably 1.25 mg, 2.5 mg, or 5 mg of, for example, ramipril. Preferred is t.i.d. administration.
Suitable daily dosages of β-blockers (for adults) for oral administration are, for example: of from 200 to 1200 mg of, for example, acebutolol; of from 25 to 100 mg of, for example, atenolol; of from 10 to 20 mg of, for example, betaxolol; of from 5 to 10 mg of, for example, bisoprolol; of from 2.5 to 10 mg of, for example, carteolol; of from 100 to 1 ,800 mg of, for example, labetalol; of from 50 to 450 mg of, for example, metoprolol; of from 40 to 240 mg of, for example, nadolol; of from 60 to 480 mg of, for example, oxprenolol; of from 20 to 80 mg of, for example, penbutolol; of from 10 to 60 mg of, for example pindolol; of from 40 to 320 mg or of from 60 to 320 mg (for long-acting formulation) of, for example, propranolol; of from 160 to 320 mg of, for example, sotalol; of from 20 to 60 mg of, for example, timolol.
Ultimately, the exact dose of the active agent and the particular formulation to be administered depend on a number of factors, e.g., the rate of release of the active agent. For example, the amount of the active agent required and the release rate thereof may be determined on the basis of known in vitro or in vivo techniques, determining how long a particular active agent concentration in the blood plasma remains at an acceptable level for a therapeutic effect.
Since the present invention has an aspect that relates to methods for treatment with a combination of compounds which may be administered separately, the invention also relates to combining separate pharmaceutical compositions in a kit form. The kit may comprise, e.g., two or three separate pharmaceutical compositions: (1) a composition comprising a renin inhibitor, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier or diluent and (2) at least one therapeutic agent selected from the group consisting of an ACE inhibitor, or a pharmaceutically acceptable salt thereof, an angiotensin Il receptor antagonist, e.g., valsartan, or a pharmaceutically acceptable salt thereof, a beta blocker, or a pharmaceutically acceptable salt thereof, aspirin, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier or diluent. The amounts of (1) and (2) are such that, when coadministered separately a beneficial therapeutic effect(s) is achieved. The kit comprises a container for containing the separate compositions such as a divided bottle or a divided foil packet, wherein each compartment contains a plurality of dosage forms (e.g., tablets) comprising, e.g., (1) or (2). Alternatively, rather than separating the active ingredient-containing dosage forms, the kit may contain separate compartments each of which contains a whole dosage which in turn comprises separate dosage forms. An example of this type of kit is a blister pack wherein each individual blister contains two or three (or more) tablets, one (or more) tablet(s) comprising a pharmaceutical composition (1), and the second (or more) tablet(s) comprising a pharmaceutical composition (2). Typically the kit comprises directions for the administration of the separate components. The kit form is particularly advantageous when the separate components are preferably administered in different dosage forms (e.g., oral and parenteral), are administered at different dosage intervals, or when titration of the individual components of the combination is desired by the prescribing physician. In the case of the instant invention a kit may, e.g., comprise:
(1) a therapeutically effective amount of a composition comprising a renin inhibitor, in particular, aliskiren, preferably in the form of the hemi-fumarate salt thereof, and a pharmaceutically acceptable carrier or diluent, in a first dosage form, and
(2) at least one therapeutic agent selected from the group consisting of an ACE inhibitor, or a pharmaceutically acceptable salt thereof, an angiotensin Il receptor antagonist, e.g., valsartan, or a pharmaceutically acceptable salt thereof, a beta blocker, or a pharmaceutically acceptable salt thereof, aspirin, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier or diluent, in a second dosage form, and
(3) a container for containing said first and second and dosage forms. It has surprisingly been found that renin inhibitors may be used for the treatment of acute myocardial infarction. The beneficial cardio-protective effect of renin inhibitors can be demonstrated, for example, by carrying out a study in a hypertensive rat model of acute myocardial infarct. The results of this study demonstrate the cardioprotective effect of renin inhibitors, either alone or in combination with a further active ingredient as described herein. Specifically, the present inventors have found that renin inhibitors, such as aliskiren, can have a beneficial cardio-protective effect. Moreover, it has been found that the cardio-protective effect of the renin inhibitor can be improved by combining it with a further active ingredient, such as an ACEI. For example, it has surprisingly been found that, a combination of a renin inhibitor, such as aliskiren, and an ACEI, such as benazepril, can achieve greater therapeutic effect than the administration of a renin inhibitor or an ACEI alone. Further benefits are that lower doses of the individual drugs to be combined according to the present invention can be used to reduce the dosage, e.g., that the dosages need not only often be smaller but are also applied less frequently, or can be used to diminish the incidence of side effects. This is in accordance with the desires and requirements of the patients to be treated.
Methods
Abbreviations
LADCA: left anterior descending coronary artery
AR: area at risk
IS: infarct size
LV: left ventricle
TCC (staining): triphenyltetrazolium chloride
PBS: phospate buffered saline
MABP: mean arterial blood pressure
HR: heart rate
PRI: pressure rate index
SHR (rats): spontaneous hypertensive rats
MBP: mean blood pressure
MPO: myeloperoxidase
KC: pro-inflammatory chemokine
IL-1 B: pro-inflammatory cytokine TNF-α: pro-inflammatory cytokine
MCP-1 : leukocyte adhesion molecule
CXCL8: interleukin 8 s.c: subcutaneous bid. (administration): bis in a day t.i.d. (administration): tris in a day
ELISA: Enzyme-Linked Immunosorbent Assay
The pharmaceutical activities as effected by administration of a renin inhibitor or by administration of a combination of therapeutic agents used according to the present invention may be demonstrated, e.g., by using corresponding pharmacological models well-known in the pertinent art. A person skilled in the art is fully enabled to select a relevant test model to prove the hereinbefore and hereinafter indicated therapeutic indications and beneficial effects.
A combination according to the present invention comprising a renin inhibitor, or a pharmaceutically acceptable salt thereof, can be administered by various routes of administration. Each agent can be tested over a wide-range of dosages to determine the optimal drug level for each therapeutic agent in the specific combination to elicit the maximal response. For these studies, it is preferred to use treatment groups consisting of at least 6 animals per group. Each study is best performed in a way wherein the effects of the combination treatment group are determined at the same time as the individual components are evaluated. The cardio-protective effect of a renin inhibitor, either alone or in combination with a further active ingredient as described herein, may be demonstrated experimentally by means of an animal model of ischemia/reperfusion in hypertensive transgenic rats over-expressing the mouse renin gene (mREN-2 rats).
Inter alia the following study prodedures may be used: Acute Ml study procedure:
Surgical Procedure Acute myocardial infarction is induced in anesthetized rats by ligation of the left anterior descending coronary artery (LADCA). After a 25 minutes period of ischemia, the ligature is released and reperfusion is allowed for 2 h.
Measurement of area at risk (AR) and Infarct size (IS)
Myocardial tissue damage is quantified by tissue staining of flat sections and assessment of the following parameters:
• extension of the Infarct Size (IS) within the area at risk (AR);
• extension of the IS within the left ventricle (LV);
• extension of the AR on the LV.
To delineate the AR, at the end of the ischemia-reperfusion procedure, LADCA is re- occluded and Evans blue dye is injected into the carotid artery catheter. The heart is removed and the LV is excised and weighed. The heart is then sectioned transversely into five sections with one section made at the site of ligature, and each section is weighed. Sections of the ventricle from the level of the ligature to the apex, which are unstained, define the AR. Such sections are then used to define the infarcted area by TCC staining (1.5% w/v triphenyltetrazolium chloride in PBS). The area of infarction for each slice is determined by computerized planimetry using an image analysis software program (NIH Image Software, NIH, Bethesda, MD). The size of infarction (IS) is determined by the following equation:
IS = (A1 - WT1)+(A2 - WT2)+(A3 - WT3)+(A4 - WT4)
wherein A is percent area of infarction by planimetry from different sections, and WT is weight of the corresponding sections.
Biochemical Determinations
Following the ischemia-reperfusion injury procedure, the LV is excised without performing any staining procedure, and tissue is frozen at -80 0C for the following analysis:
• measurement of myeloperoxidase (marker of neutrophil infiltration), by colorimetric reaction;
• measurement of CX-CL8 (pro-inflammatory chemokine), by ELISA; • measurement of IL-1 β (pro-inflammatory cytokine), by ELISA;
• measurement of TNF-α (pro-inflammatory cytokine), by ELISA;
• measurement of MCP-1 (leukocyte adhesion molecule), by ELISA;
• measurement of caspase-3 (marker of apoptosis), by ELISA.
Hemodynamic parameters
The following haemodynamic parameters are monitored throughout the study:
• mean arterial blood pressure (MABP, mmHg);
• heart rate (HR, beats min 1).
Pressure rate index (PRI, mmHg/min/103), a relative indicator of myocardial oxygen consumption is calculated as the product of MABP and HR.
Drug Treatment
A renin inhibitor, for example aliskiren, is administered to mREN-2 rats for 7 days at a dose of, for example, 100 mg/kg/day through subcutaneous osmotic minipumps, alone or in combination with a dose of, for examplel O mg/kg/day, of, for example, an ACEI, like benazepril.
General Experimental Outline
The experimental procedure (25 min ischemia followed by 120 min reperfusion) is performed in the following setting:
a) mREN-2 rats are treated for 7 days with either a renin inhibitor, for example, aliskiren (dose of, for example, 100 mg/kg/day s.c, n=6), or vehicle alone (n=6), or sham (negative control, no LADCA ligation, n=6) for heart staining purposes (assessment of Area at Risk and Infarct Size), along with monitoring of hemodynamic parameters (MBP, HR, PRI); b) mREN-2 rats are treated for 7 days with a renin inhibitor, for example aliskiren (dose of, for example, 100 mg/kg/day s.c, n=6), or vehicle alone (n=6), or sham (negative control, no LADCA ligation, n=6) for heart biochemical determinations (MPO, CX-CL8, IL-1 β, TNF-α, MCP-1 , caspase-3), along with monitoring of hemodynamic parameters (MBP, HR, PRI). c) mREN-2 rats are treated for 7 days with either a dose of, for example 10 mg/kg/day, of, for example an ACEI (benazepril) (n=6), or vehicle alone (n=6), or sham (negative control, no LADCA ligation, n=6) for heart staining purposes (assessment of Area at Risk and Infarct Size), along with monitoring of hemodynamic parameters (MBP, HR, PRI); d) mREN-2 rats are treated for 7 days with either a dose of, for example 10mg/kg/day, of, for example an ACEI (benazepril) (n=6), or vehicle alone (n=6), or sham (negative control, no LADCA ligation, n=6) for heart biochemical determinations (MPO, CX-CL8, IL-1 β, TNF-α, MCP-1 , caspase-3), along with monitoring of hemodynamic parameters (MBP, HR, PRI).
To assess whether the additional effect of the renin inhibitor, for example aliskiren, is beyond that achievable by simply increasing the dose of, for example, an ACEI, in a separate set of experiments the rats are treated with a renin inhibitor, for example aliskiren, at a dose of, for example, 100 mg/kg/day, together with a dose of, for example 10 mg/kg/day, of, for example an ACEI (benazepril):
e) mREN-2 rats are treated for 7 days with either a renin inhibitor, for example aliskiren (dose of, for example, 100 mg/kg/day s.c) together with a dose of, for example 10 mg/kg/day, of, for example, an ACEI (benazepril) (n=6), or vehicle alone (n=6), or sham (no LADCA ligation, n=6) for heart staining purposes (assessment of Area at Risk and Infarct Size), along with monitoring of hemodynamic parameters (MBP, HR, PRI); f) mREN-2 rats are treated for 7 days with either a renin inhibitor, for example aliskiren (dose of, for example, 100 mg/kg/day s.c) together with a dose of, for example 10 mg/kg/day, of, for example, an ACEI (benazepril) (n=6), or vehicle alone (n=6), or sham (negative control, no LADCA ligation, n=6) for heart biochemical determinations (MPO, CX-CL8, IL-1 β, TNF-α, MCP-1 , caspase-3), along with monitoring of hemodynamic parameters (MBP, HR, PRI).
The above description fully discloses the invention including preferred embodiments thereof. Modifications and improvements of the embodiments specifically disclosed herein are within the scope of the following claims. Without further elaboration, it is believed that one skilled in the art can, using the preceding description, utilize the present invention to its fullest extent. Therefore, the Examples herein are to be construed as merely illustrative of certain aspects of the present invention and are not a limitation of the scope of the present invention in any way.
The following examples illustrate the above-described invention:
Example:
Following the above experimental outline (a) to (f), the following results were obtained: In mREN-2 rats, the myocardial ischemia/reperfusion (I/R) procedure produces IS=51% AR and 29% LV. Treatment with aliskiren exerts a significant protective effect on myocardial damage compared with vehicle, with IS=33% AR and 22% LV (P<0,01 vs vehicle). Similarly, treatment with benazepril produces IS=34% of the AR and 23% of LV (p<0,01 vs vehicle). The combination aliskiren and benazepril exerts an additive protective effect, with IS=22% of AR and 18% of LV (p<0,01 vs vehicle and vs each monotherapy). Basal MABP levels (180 ± 3.3 mmHg) are significantly affected by the I/R procedure, with a maximal hypotensive effect at 25 min (151 ± 2.5 mmHg). Treatment with aliskiren, benazepril or their combination significantly reduces basal MABP, by 27%, 29% and 39% (p<0.01 vs vehicle and vs each monotherapy), respectively. HR significantly increases compared to vehicle after treatment with aliskiren, benazepril or their combination (p<0.05), and remains significantly higher compared to vehicle during the I/R procedure (p<0.05). PRI is significantly reduced by treatment with aliskiren or benazepril alone (p<0.01 vs vehicle) or in combination (p<0.01 vs vehicle and vs each monotherapy) The I/R procedure is associated with a significant increase of myocardial levels of MPO, IL-1 β, TNF-α, CXCL8, MCP-1 , and caspase-3. Aliskiren treatment significantly reduces compared to vehicle (p<0,01) myocardial levels of MPO (by 33%) TNF-α (by 30%), IL-1 β (by 20%), MCP-1 (by 25%), CXCL8 (by 44%) and caspase-3 (by 25%). Benazepril treatment significantly reduces (p<0.01) all biochemical parameters to a similar extent. Combination therapy produces an additive effect on cardiac levels of MPO, TNF-α and CXCL8 (p<0,01 vs vehicle and vs each monotherapy), and a possible synergistic effect on caspase-3 (p<0.0001 for interaction) which should be further investigated.
The above results demonstrate that renin inhibitors, such as aliskiren, either alone or in combination with other active agents can be useful in the treatment of acute myocardial infarction.

Claims

CLAIMS:
1. Use of a renin inhibitor or a pharmaceutically acceptable salt thereof for the manufacture of a medicament for the treatment of acute myocardial infarction.
2. Use of a renin inhibitor or a pharmaceutically acceptable salt thereof in combination with one or more active ingredient for the manufacture of a medicament for the treatment of acute myocardial infarction.
3. Use according to claim 1 or 2 for wherein the other active ingredient is selected from the group consisting of ACEIs, beta blockers, angiotensin Il receptor antagonists or aspirin.
4. Use according to claims 2 or 3 wherein the other active ingredient is an ACEI selected from the group consisting of alacepril, benazepril, benazeprilat, captopril, ceronapril, cilazapril, delapril, enalapril, enaprilat, fosinopril, imidapril, lisinopril, moveltopril, perindopril, quinapril, ramipril, spirapril, temocapril, trandolapril and salts thereof.
5. Use according to claims 2 or 3 wherein the other active ingredient is an angiotensin Il receptor antagonist selected from the group consisting of valsartan, losartan, eprosartan, irbesartan, telmisartan, candesartan, saprisartan and salts thereof.
6. Use according to either one of claims 1 to 5 wherein the renin inhibitor is aliskiren or a salt thereof.
7. Use according to any one of claims 1 to 6 for simultaneous, separate or sequential use.
8. A pharmaceutical composition for the treatment of acute myocardial infarction comprising a renin inhibitor.
9. A pharmaceutical composition according to claim 8 comprising further (one or more) active ingredient.
10. A pharmaceutical composition according to claim 9 wherein the further active ingredient is selected from the group consisting of ACE inhibitors, angiotensin Il receptor antagonists, beta-blockers and aspirin.
11. A pharmaceutical composition according to claims 9 or 10 wherein the further active ingredient is selected from the group consisting of alacepril, benazepril, benazeprilat, captopril, ceronapril, cilazapril, delapril, enalapril, enaprilat, fosinopril, imidapril, lisinopril, moveltopril, perindopril, quinapril, ramipril, spirapril, temocapril, trandolapril and salts thereof.
12. A pharmaceutical composition according to any one of claims 8 to 10 wherein the further active ingredient is selected from the group consisting of valsartan, losartan, eprosartan, irbesartan, telmisartan, candesartan, saprisartan and salts thereof.
13. A pharmaceutical composition according to any one of claims 8 to 11 wherein the renin inhibitor is aliskiren or a salt thereof.
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Citations (5)

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