WO2014210369A2

WO2014210369A2 - Reversal of cysteine-inactivated neuromuscular blocking drugs with combinations of reversal agents

Info

Publication number: WO2014210369A2
Application number: PCT/US2014/044422
Authority: WO
Inventors: Paul M. Heerdt; John J. Savarese
Original assignee: Cornell University
Priority date: 2013-06-28
Filing date: 2014-06-26
Publication date: 2014-12-31
Also published as: WO2014210369A3

Abstract

We provide methods and kits to reverse neuromuscular block caused by a cysteine-inactivated neuromuscular blocking drug, comprising administering to said subject a combination of a cysteine-like agent and an acetylcholinesterase inhibitor. An antimuscarinic agent may also be administered to said subject.

Description

Reversal of Cysteine-Inactivated Neuromuscular Blocking Drugs with Combinations of Reversal Agents

Cross-Reference to Related Applications

This application claims the priority of U.S. Ser. No. 61/841,211, filed June 28, 2013, the disclosure of which is incorporated herein by reference in its entirety.

Background

We have invented non-depolarizing neuromuscular blocking drugs (NMBDs) of intermediation and short duration, (for example, see US Pat. Nos. 6,187,789 and 8,148,398; US Published Patent Application US2012/0095041; and US provisional patent applications serial numbers 61/666,244, 61/703,991, and 61/817,706 by one of the inventors herein). Subsequent investigations established that their duration was largely due to rapid, non-enzymatic inactivation of the molecule by endogenous L-cysteine. Based upon this novel concept of "molecular inactivation", our group showed that: a) the

neuromuscular blocking effects of these NMBDs could be eliminated by mixing the drug with cysteine-like agents; and b) even complete paralysis induced by the NMBDs can be rapidly and completely reversed by injection of exogenous cysteine-like agents, a process we've come to call "facilitated molecular inactivation." (see: US Published Patent Application US2012/0214873 and PCT Publ. No. WO2005/041960 by the inventor, each incorporated herein by reference in its entirety).

A major advantage of NMBDs that are reversible with cysteine-like agents (referenced herein after as "cysteine-inactivated NMBDs") is that paralysis induced by these agents can be reversed at any time. This is in sharp contrast to the action of most existing NMBDs that require some degree of spontaneous muscle recovery before "conventional reversal" with inhibitors of acetylcholinesterase, such as neostigmine and edrophonium. These drugs amplify the nerve to muscle acetylcholine signal to overcome the receptor antagonism produced by the NMBD.

Summary

In various embodiments, the invention provides methods to reverse neuromuscular block in a subject caused by a cysteine-inactivated neuromuscular blocking drug, comprising administering to said subject a combination of a cysteine- like agent and an acetylcholinesterase inhibitor. An antimuscarinic agent may also be administered to said subject.

The invention also provides kits comprising a cysteine-like agent, an acetylcholinesterase inhibitor, and instructions for using the kit. The kit may further comprise an antimuscarinic agent and may also comprise a cysteine- inactivated neuromuscular blocking drug.

Brief Description of the Drawings

Figure 1. Results of experiments in a 3.9 kg rabbit, in which the NMBD CW002 was administered at 20 mg/kg, followed ten minutes later by L-cysteine alone at 20 mg/kg, neostigmine alone in a dose of 0.05 mg in conjunction with glycopyrrolate at 0.01 mg/kg, saline, or a combination of L-cysteine, neostigmine, and glycopyrrolate, resulted in faster reversal with the combination of reversal agents.

Figure 2. Results of administration of varying reversal agents and doses after administering CW002 to a 10 kg beagle dog at 0.08 mg.kg. Administration of no agent was the slowest route to full recovery, followed by L-cysteine alone at 10 mg/kg, followed by L-cysteine 10 mg/kg in combination with 0.05 mg/kg neostigmine and 0.01 mg/kg glycopyrrolate, followed by L-cysteine alone at 20 mg/kg, and the fastest full recovery caused by L-cysteine at 20 mg/kg in combination with 0.05 mg/kg neostigmine and 0.01 mg/kg glycopyrrolate. Figure 3. We tested methods of recovery from administration of a NMBD with no treatment, administration of a cysteine-like agent, and administration of a cysteine-like agent in combination with an acetylcholinesterase inhibitor and an antimuscarinic agent. The NMBD 1759-50 was administered via continuous infusion to cats. Administration of no agent was the slowest route to full recovery, followed by L-cysteine alone at 30 mg/kg, followed by L-cysteine 30 mg/kg in combination with Neostigmine at 0.05 mg/kg with Atropine at 0.05 mg/kg.

Detailed Description

In the following description, reference is made to the accompanying drawings that form a part hereof, and in which is shown by way of illustration specific embodiments which may be practiced. These embodiments are described in detail to enable those skilled in the art to practice the invention, and it is to be understood that other embodiments may be utilized and that logical changes may be made without departing from the scope of the present invention. The following description of example embodiments is, therefore, not to be taken in a limited sense, and the scope of the present invention is defined by the appended claims.

The Abstract is provided to comply with 37 C.F.R. § 1.72(b) to allow the reader to quickly ascertain the nature and gist of the technical disclosure. The Abstract is submitted with the understanding that it will not be used to interpret or limit the scope or meaning of the claims.

Work from our laboratory has established cysteine dose-reversal relationships for our cysteine-inactivated NMBDs. These studies have not indicated significant side effects within the clinically projected dose range and higher doses as well. Nonetheless, it may be desirable to use as low a cysteine dose as possible for reversal of NMBDs. Additionally, it may be useful to find additional agents useful to have additional means to reverse the neuromuscular block caused by our NMBDs. This invention discloses and claims a method of reversal of neuromuscular blockade with a cysteine-reversible NMBD comprising combining acetylcholinesterase inhibitors (for example, neostigmine or edrophonium) with cysteine in order to enhance reversal of susceptible NMBDs. Additionally, since acetylcholinesterase inhibitors have cholinergic- muscarinic side effects such as bradycardia, they are commonly administered in combination with an antimuscarinic drug such as atropine or glycopyrrolate.

Cysteine-inactivated NMBDs include those described in US Pat. No. 6,187,789, US Pat. No. 8,148,398, and US Pat. No. 8,592,451 ; US Published Patent Application US2012/0095041 ; US provisional patent applications serial numbers 61/666,244, 61/703,991, and 61/817,706, and PCT application serial number PCT/US2013/048771, published as WO2014/005122, all incorporated by reference herein in their entireties.

US Pat. No. 6,187,789 (incorporated herein by reference in its entirety) describes a compound that is a cysteine-inactivated NMBD:

wherein: X is halogen; h is from 1 to 2; Y is hydrogen or methoxy; Z¹ and Z² are methyl; W¹ and W² are carbon; and A is a pharmaceutically acceptable anion.

US Pat. No. 6,187,789 further describes another compound that is a cysteine-inactivated NMBD:

an

wherein: T is hydroxyl or halide; Y is hydrogen or methoxy; Z is methyl; W is carbon; X is halogen; n is 0 or 1 ; h is 1 or 2; and A is a pharmaceutically acceptable anion.

US Pat. No. 6,187,789 further describes another compound that is a cysteine-inactivated NMBD called gantacurium:

US Pat. No. 8,148,398 also describes compounds that are cysteine- inactivated NMBDs, one of which is called AV002, also known as CW002:

US Publ. No. US2012/0095041 describes additional compounds that cysteine-inactivated NMBDs:

wherein a double dashed line indicates that a single bond or a double bond or a triple bond is present at that position; the double bond, when present, is of Z or E configuration and each carbon atom of the double bond is substituted with a single respective hydrogen atom; for the single bond, when present, each carbon atom bears two respective hydrogen atoms; R¹ and R² are each independently (Cl-C4)alkyl, (Cl-C4)alkenyl, or (Cl-C4)alkynyl; R³ and R⁴ are each independently hydrogen or (Cl-C4)alkyl, (Cl-C4)alkenyl, or (Cl-C4)alkynyl; R¹¹, R¹², R¹³, and R¹⁴ are each independently (Cl-C4)alkoxy or (Cl-C4)acyloxy; or any two adjacent R¹¹, R¹², R¹³, or R¹⁴ are methylenedioxy; ml and m3 are each independently 2, 3, or 4; m2 and m4 are each independently 2 or 3; nl and n2 are each independently 1 to about 4; pi and p2 are each independently 0 or 1 ; X is independently at each occurrence a pharmaceutically acceptable anion; including any stereoisomer thereof, or, any solvate, hydrate, metabolite or prodrug thereof.

US provisional patent applications 61/666,244, 61/703,991, and

61/817,706, and PCT application PCT/US2013/048771, published as

WO2014/005122, describe additional compounds that are cysteine-inactivated or cystei -reversible NMBDs:

2 Q©

(I)

wherein each of Ri and R₂ is independently selected from the group consisting of hydrogen and halogen, and Ri and R₂ can be disposed in a cis or a trans configuration on the two double-bonded carbon atoms to which Ri and R₂ are respectively bonded; T is selected from the group consisting of CH₂ and CI¾, wherein if T is CI¾, the phenyl group with the Xi - X5 substituents is not present; B is selected from the group consisting of CH₂, O, NR, and a direct single bond, wherein R is H, (Ci_6)alkyl, or (Ci_6)acyl; nl and n2 are each independently equal to 0, 1, 2, or 3; each of Xi, X₂, X₃, X₄, and X5, is independently at each occurrence hydrogen, hydroxy or methoxy, or any two adjacent Xi, X₂, X₃, X₄, or X5, together form a methylenedioxy or ethylenedioxy group; each of Yi, Y₂, Y₃, Y₄, and Y5, is independently at each occurrence hydrogen, hydroxy or methoxy, or any two adjacent Yi, Y₂, Y₃, Y₄, or Y5, together form a methylenedioxy or ethylenedioxy group; each of Zi, Z₂, Z₃, and Z₄, is independently at each occurrence hydrogen, hydroxy or methoxy, or any two adjacent Zi, Z₂, Z₃, or Z₄, together form a methylenedioxy or ethylenedioxy group; W is selected from the group consisting of methyl and a benzyl group of

wherein each of Ai, A₂ A₃, A4, and A5, is independently at each occurrence hydrogen or methoxy, or any two adjacent Ai, A₂ A₃, A₄, or A¾, together form a methylenedioxy or ethylenedioxy group, and a wavy line indicates a point of bonding; and, wherein each Q^Q is an independently selected pharmaceutically acceptable anion. The NMBD of formula (I) of PCT application

PCT/US2013/048771 possesses in its core structure two chiral centers disposed adjacent to each other in the isoquinolinium quaternary moiety, i.e., the carbon atom bearing group T and the quaternarized ammonium bearing group W. Accordingly, the group T and the group W can be disposed in a cis or a trans configuration with respect to the ring of the isoquinolinium moiety that bears them. For example, the group T and the group W can be disposed in a cis ring configuration, i.e., disposed on the same side of the ring, while the group that links to the unsaturated diester moiety bearing groups Ri and R₂.

The groups Ri and R₂ are each independently selected from hydrogen and halogen, and the disposition of Ri and R₂ around the double bond of the carbon atoms that respectively bear the Ri/R₂ groups can be cis or trans. Accordingly, the invention provides bis-quaternary diesters including maleates, halomaleates, dihalomaleates, fumarates, halofumarates, and dihalofumarates. An example of a halogenated diester is a chlorfumarate bis-quaternary diester.

Each of the two diastereomers of formula (I) of PCT application PCT/US2013/048771 itself possesses two possible enantiomeric forms; for the diastereomer wherein the group T and the group W are in the ring cis configuration (i.e., group T and the linker to the ester group are in the ring trans configuration), these two enantiomers are shown as formulas (IR) and (IS), below. The (R) and the (S) designations are applied based on the absolute configuration of the carbon atom bearing group T. The designated absolute configuration of the ammonium nitrogen atom bearing group W can vary depending upon the identity of group W in the CIP rules discussed above, but in formula (IR), having an (R) absolute configuration at the carbon atom bearing group T, and in formula (IS) having an (S) absolute configuration at the carbon atom bearing group T, the group W is disposed in a ring cis configuration to T, while the linking chain to the central unsaturated diester moiety is ring trans to T.

In PCT application PCT/US2013/048771 , a cysteine-reversible

Qe (IR)

wherein Ri, R₂, nl, n2, X_u X₂, X₃, ¾, Xs, Yi, Y₂, Y , Y₄, Ys, Z_u Z₂, Z₃, Z₄, A_u A₂, A₃, A_t, A_¾, W, B, Q© , and T are as defined above for formula (I).

PCT application PCT/US2013/048771 also describes the enantiomeric form of formula (IR), i.e., a cysteine-reversible neuromuscular blocking agent of formula (IS),

2 Q9 (IS) wherein R R₂, nl, n2, X X₂, X₃, X₄, X₅, Yi, Y₂, Y3, Y₄, Y5, Zi, Z₂, Z₃, Z₄, Ai, A₂, A₃, A4, A5, W, B, Q^Q , and T are as defined above for formula (I).

In all of formulas (I), (IR), and (IS), the two positive electrical charges of the bis-quaternium NMBA are balanced by two anionic charges, which can be comprised by a single multiply-charged anion (e.g., sulfate, phosphate), or by two singly- charged anions (e.g., halide, such as chloride). Each Q ^Q is an independently selected pharmaceutically acceptable anion in the above compositions of matter.

Each of the rings bearing groups X, Y, Z, or (optionally) A, can be a substituted ring as defined above. For example, in various embodiments, the invention provides a neuromuscular blocking agent of the invention wherein at least one of Xi, X₂, X3, X₄, or X5, is non-hydrogen; or at least one of Yi, Y₂, Y₃, Y₄, or Y5, is non-hydrogen; or at least one of Zi, Z₂, Z3, or Z₄, is non- hydrogen; or at least one of Ai, A₂, A3, A₄, or A5, is non-hydrogen; or any combination thereof. As seen in the specific examples, below, rings can be substituted at any available position, and are often substituted on the 4-position or disubstituted on the 3,4-positions of the phenyl groups, and on the 6,7-position of the isoquinolinium group.

In PCT application PCT/US2013/048771 , a cysteine-reversible NMBD is described wherein X₂ and X3 are both methoxy or together form methylenedioxy or ethylenedioxy, or Y₂ and Y₃ are both methoxy or together form

methylenedioxy or ethylenedioxy, or Z₂ and Z3 are both methoxy or together form methylenedioxy or ethylenedioxy, or any combination thereof. More specifically, the invention can provide a neuromuscular blocking agent of the invention wherein T is CH₂ and the phenyl ring bearing Xi - X5 is present. With respect to the quaternary moiety including a morpholinium (B is oxygen), piperidinium (B is CH₂), piperazinium (B is NR), or pyrrolidinium (B is a direct single bond) system that is disposed adjacent to a benzyl group, i.e., comprising group B, a quaternary center is permanently present due to the presence of the quaternarized nitrogen atom in the chain connecting the Y-substituted phenyl ring with the central unsaturated diester group. In various embodiments, B can be an oxygen atom (morpholinium series). In other embodiments, B can be a direct single bond (pyrrolidinium series). The two linking chains bonding each of the two quaternary moieties each contain at least two carbon atoms and an oxygen atom which forms an ester linkage with the central chlorofumarate, maleate, etc. One of the carbon atoms of each linker is bonded directly to the quaternary nitrogen atom, i.e., of the isoquinolinium group in one quaternary moiety and of the ring comprising group B in the other quaternary moiety. For example, when each variable nl and n2 is equal to 1 , the each linker comprises three backbone carbon atoms connecting the respective quaternary nitrogen atom to the respective ester oxygen atom. In other embodiments, two, four, or five backbone atoms are contained by each linker group.

For instance, PCT/US2013/048771 , published as WO2014/005122, provides, in various embodiments, a maleate ester, i.e., when the Ri and R₂ groups are disposed in a cis configuration, and Ri and R₂ are both hydrogen. For example, a NMBD of the invention comprising a maleate ester can be selected from the group consisting of morpholium maleates and pyrrolidinium maleates.

14/210369

PCT/US2014/044422

5

wherein each Q © is an independently selected pharmaceutically acceptable anion, e.g., chloride.

Reversal agents

Cysteine-like agents, as used herein, include L-cysteine, D-cysteine, racemic mixtures thereof, N-acetylcysteine, glutathione, homocysteine, methionine, S-adenosyl-methionine, penicillamine, as well as related cysteine analogs and combinations thereof.

Acetylcholinesterase inhibitors used as NMBD reversal agents are known in the art, and include but are not limited to neostigmine and edrophonium. Antimuscarininic agents used to mitigate side-effects of acetylcholinesterase inhibitors used as NMBD reversal agents are known in the art, and include but are not limited to atropine and glycopyrrolate.

In various embodiments, the invention provides a method to reverse neuromuscular block in a subject caused by a cysteine-inactivated

neuromuscular blocking drug comprising administering to said subject a combination of a cysteine-like agent and an acetylcholinesterase inhibitor. The method can further comprise administering an antimuscarinic agent to said subject. The NMBDs described above as cysteine-reversible are suitable NMBDs for carrying out a method of the present invention.

Pharmaceutical compositions of the compounds

Methods of invention comprise use of compounds in various compositions adapted to induce and reverse neuromuscular blockade in patients as needed in surgical anesthesia.

In various embodiments compounds of the invention are administered by bolus injection or by continuous infusion, such as for example for total intravenous anesthesia or TIVA, as a suitable solution, and produces and then reverses neuromuscular blockade of sufficient completeness to enable the compounds to effectively be used as an adjunct to anesthesia in major surgery. The compounds can be administered in a manner known to the anesthesiologist or surgeon of ordinary skill in the art, using the methods and apparatus well known for this procedure in surgery.

In various embodiments, compositions used in the invention comprise a compound of the invention provided in a powder or solid form. In various embodiments, compositions used in the invention comprise a compound of the invention and an excipient, which may for example be a suitable biocompatible solvent. The compositions can be adapted for parenteral administration to a human patient, comprising an injectable or infusable solution of the compound in a suitable biocompatible solvent. The solution can be administered via syringe, via intravenous drip, or via any of the techniques well known to the practitioner of the art.

In various embodiments, a suitable biocompatible solvent comprises sterile, pyrogen-free water. The solvent can further comprise isotonic NaCl, or other tonicity adjustment substances. In various embodiments, the suitable biocompatible solvent can comprise alcohol, a polyethylene glycol, DMSO, or any mixture thereof, which can be neat or can be in a mixture with water.

A therapeutically effective amount of the NMBD of the present invention is sufficient to provide muscle relaxation during anesthesia and surgery and in emergency medicine in a subject. The dosage of active ingredient(s) may vary, depending on the reason for use and the individual subject. The dosage may be adjusted based on the subject's weight, the age and health of the subject, and tolerance for the compound or composition. A suitable dose of a NMBD to obtain a neuromuscular blockade for adult humans (150 lbs. or 70 kg) is about 0.1 mg to about 500 mg, or in some embodiments about 1 mg to about 500 mg, or in other embodiments about 0.5 mg to about 150 mg, or in further embodiments about 3.5 mg to about 50 mg. Thus a suitable pharmaceutical parenteral preparation for administration of a NMBD to humans will preferably contain 0.1 to 50 mg/ml of one or more of the NMBD in solution οτ multiples thereof for multi-dose vials.

A therapeutically effective amount of antagonists of NMBDs of the present invention is sufficient to antagonize a neuromuscular blockade caused by administration to a mammal of a NMBD of the invention. The dosage of active ingredient(s) may vary, depending on the reason for use and the individual subject. The dosage may be adjusted based on the subject's weight, the age and health of the subject, and tolerance for the compound or composition.

A suitable dose of a cysteine-like agent to antagonize a NMBD in adult humans (with an average weight of about 150 lbs. or 70 kg) is about 5 mg to about 10,000 mg, or about 50 mg to about 2000 mg or about 150 to about 750 mg. Thus a suitable pharmaceutical parenteral preparation for administration to humans will preferably contain 0.1 to 2000 mg/ml of a cysteine-like agent, in solution or multiples thereof for multi-dose vials. Alternatively, in general, therapeutically effective dosages in humans for cysteine-like agents are about 10-100 mg/kg or about 30-50 mg/kg. Thus, the typical dosages and volumes of a cysteine-like agent to be injected will likely be in the range of about 1000-

10000 mg or about 2000-5000 mg of cysteine (based on body weights of 70-100 kg). Thus, compositions and methods have been developed to provide these amounts of a cysteine-like agent in convenient volumes of about 5 ml to about 50 ml or about 10 ml to about 25 ml. Such compositions can be administered quickly, for example, as a single bolus intravenous injection over a period of time of about 2 seconds to about 60 seconds, or about 5 seconds to about 10 seconds. The solutions described herein have concentrations of a cysteine-like agent that are about 100-300 mg/ml or about 180-250 mg/ml cysteine so that appropriate in vivo concentrations of cysteine-like agent are achieved after administration to quickly reverse a neuromuscular blockade.

A suitable dose of an acetylcholinesterase inhibitor to antagonize a NMBD in adult humans (with an average weight of about 150 lbs. or 70 kg) is about 1.75 mg to about 70 mg, or about 30 mg to about 70 mg or about 1.75 to about 3.5 mg. Neostigmine, for example, is typically given in the context of NMBD reversal in doses of 25 to 50 meg (0.025 to 0.050 mg) per kilogram.

Thus a suitable pharmaceutical parenteral preparation for administration to humans will preferably contain 1 to 10 mg/ml of an acetylcholinesterase inhibitor, in solution or multiples thereof for multi-dose vials. Alternatively, in general, therapeutically effective dosages in humans for acetylcholinesterase inhibitors are about 0.025 to 1.0 mg/kg or about 0.025 to 0.5 mg/kg. Thus, the typical dosages and volumes of an acetylcholinesterase inhibitor to be injected will likely be in the range of about 1.75 to 70 mg of the acetylcholinesterase inhibitor (based on body weights of 70-100 kg). Thus, compositions and methods have been developed to provide these amounts of an

acetylcholinesterase inhibitor in convenient volumes of about 1.0 ml to about 10 ml. Such compositions can be administered quickly, for example, as a single bolus intravenous injection over a period of time of about 2 seconds to about 60 seconds, or about 5 seconds to about 10 seconds. The solutions described herein have concentrations of an acetylcholinesterase inhibitor that are about 1 to 10 mg/ml of acetylcholinesterase inhibitor so that appropriate in vivo

concentrations of the acetylcholinesterase inhibitor are achieved after administration to quickly reverse a neuromuscular blockade.

A suitable dose of a antimuscarinic agent to mitigate the effects of an acetylcholinesterase inhibitor in adult humans (with an average weight of about 150 lbs. or 70 kg) is about 0.30 mg to about 2.1 mg, or about 0.30 mg to about 1.05 mg or about 0.35 to about 1.05 mg. Thus a suitable pharmaceutical parenteral preparation for administration to humans will preferably contain 0.1 to 1 mg/ml of an antimuscarinic agent, in solution or multiples thereof for multi- dose vials. Alternatively, in general, therapeutically effective dosages in humans for antimuscarinic agents are about 0.005 to 0.3 mg/kg or about 0.005 to 0.015 mg/kg. Thus, the typical dosages and volumes of an antimuscarinic agent to be injected will likely be in the range of about 0.35 to 21 mg or about 0.35 to 1.05 mg of antimuscarinic agent (based on body weights of 70-100 kg). Thus, compositions and methods have been developed to provide these amounts of an antimuscarinic agent in convenient volumes of about 3 ml to about 21 ml or about 2 ml to about 5 ml. Such compositions can be administered quickly, for example, as a single bolus intravenous injection over a period of time of about 2 seconds to about 60 seconds, or about 5 seconds to about 10 seconds. The solutions described herein have concentrations of an antimuscarinic agent that are about 0.1 to 1.0 mg/ml or about 0.1 to 0.2 mg/ml antimuscarinic agent so that appropriate in vivo concentrations of antimuscarinic agent are achieved after administration to quickly mitigate the effects of an acetylcholinesterase inhibitor. Used in combination, in an embodiment the following doses are used:

embodiment, the following doses are used

All three agents may be administered simultaneously, or in sequence, but the antimuscarinic agent must be administered simultaneously with, or very soon after, the acetylcholinesterase inhibitor is administered. Kits

The invention further provides kits. The elements of said kits may include: (a) at least one cysteine-reversible NMBD in an amount sufficient to relax or block skeletal muscle activity; (b) a cysteine-like agent in an amount effective to reverse the effects of the NMBD on a mammal; (c) an

acetylcholinesterase inhibitor in an amount effective to reverse the effects of the NMBD on a mammal; (d) an antimuscarinic agent in an amount effective to mitigate the side effects of the acetylcholinesterase inhibitor; (e) instructions explaining how to administer the NMBD to a mammal and how to employ the reversal agents to reverse the effects of the NMBD on the mammal to which the NMBD was administered. For example, the cysteine-reversible NMBD can be any of the cysteine-reversible drugs described above. The kit may include all said elements, or may be sold separately from the cysteine-reversible NMBD. The cysteine-like agent, acetylcholinesterase inhibitor, and antimuscarinic agent may be combined in one package. The acetylcholinesterase inhibitor and the antimuscarinic agent may be combined in one package, separate from the cysteine-like agent. All the elements present may be packaged separately. Any of the drugs may be in a powder, soluble solid, or other dry form, and the instructions included with the kit may include directions for mixing the powder or soluble solid, or other dry form with a pharmaceutically acceptable liquid carrier such as, without limitation, water, dextrose or saline solutions.

Examples

The present description is further illustrated by the following examples, which should not be construed as limiting in any way. The contents of all cited references (including literature references, issued patents, and published patent applications as cited throughout this application) are hereby expressly incorporated by reference.

Evaluation of cysteine-like agent and acetylcholinesterase inhibitor combinations in our laboratory has demonstrated marked acceleration of reversal of the NMBD CW002 relative to cysteine alone.

Example 1

As shown in Figure 1, after administering CW002 at 20 mg/kg to a 3.9 kg rabbit, combining L-cysteine at 20 mg/kg with neostigmine in a dose of 0.05 mg in conjunction with glycopyrrolate at 0.01 mg/kg, resulted in faster reversal that L-cysteine alone, neostigmine + glycopyrrolate alone, or saline.

Example 2

As shown in Figure 2, we also tested various doses of a cysteine- like agent in combination with an acetylcholinesterase inhibitor and an

antimuscarinic agent. The NMBD CW002 was administered to a 10 kg beagle dog at 0.08 mg.kg. Administration of no agent was the slowest route to full recovery, followed by L-cysteine alone at 10 mg/kg, followed by L-cysteine 10 mg/kg in combination with 0.05 mg/kg neostigmine and 0.01 mg/kg of glycopyrrolate, followed by L-cysteine alone at 20 mg/kg, and the fastest full recovery caused by L-cysteine at 20 mg/kg in combination with 0.05 mg/kg neostigmine and 0.01 mg/kg glycopyrrolate.

Example 3

As shown in Figure 3, we tested methods of recovery from

administration of a NMBD with no treatment, administration of a cysteine- like agent, and administration of a cysteine-like agent in combination with an acetylcholinesterase inhibitor and an antimuscarinic agent. The NMBD 1759-50 was administered via continuous infusion to cats. The NMBD was infused at a rate of 20mg/kg/min and achieved 99%- 100% nerve block, for between 1 and 2 hours. The infusion was stopped, and they waited one minute. Some were left to recovery spontaneously, while for others, the various interventions (cysteine alone, or cysteine + cholinesterase+antimuscarinic) was administered.

Administration of no agent was the slowest route to full recovery, followed by L-cysteine alone at 30 mg/kg, followed by L-cysteine 30 mg/kg in combination with Neostigmine at 0.05 mg/kg with Atropine at 0.05 mg/kg.

All patents and publications referred to herein are incorporated by reference herein to the same extent as if each individual publication was specifically and individually indicated to be incorporated by reference in its entirety.

The terms and expressions which have been employed are used as terms of description and not of limitation, and there is no intention that in the use of such terms and expressions of excluding any equivalents of the features shown and described or portions thereof, but it is recognized that various modifications are possible within the scope of the invention claimed. Thus, it should be understood that although the present invention has been specifically disclosed by preferred embodiments and optional features, modification and variation of the concepts herein disclosed may be resorted to by those skilled in the art, and that such modifications and variations are considered to be within the scope of this invention as defined by the appended claims.

Claims

1. A method to reverse neuromuscular block in a subject caused by a cysteine- inactivated neuromuscular blocking drug comprising administering to said subject a combination of a cysteine-like agent and an acetylcholinesterase inhibitor.

2) The method of claim 1 , further comprising administering an antimuscarinic agent to said subject.

3) A kit comprising a cysteine-like agent, an acetylcholinesterase inhibitor, and instructions for using the kit.

4) The kit of claim 3 further comprising a cysteine-inactivated neuromuscular blocking drug.

5) The kit of claim 3 further comprising an antimuscarinic agent.