WO2015160703A1 - Treatment methods for gut-mediated hiv immune dysfunction - Google Patents

Abstract

Methods are provided for treatment or prophylaxis of gut-mediated immune dysfunction in HIV-infected individuals by the administration of GLP-2 peptide or GLP-2 peptide analogs. In some instances, GLP-2 peptide analogs according to the present disclosure include peptides that conform to the sequence of the general formula presented below as SEQ ID NO:2: R1-(Y1)m-X1-X2-X3-X4-Ser5-Phe6-Ser7-Asp8-(P1)-Leu14-Asp15-Asn16-Leu17-Ala18-X19-X20-Asp21-Phe22-(P2)-Trp25-Leu26-lle27-Gln-28-Thr29-Lys30-(P3)-(Y2)n-R2.

Description

TREATMENT METHODS FOR GUT-MEDIATED HIV IMMUNE DYSFUNCTION

RELATED APPLICATIONS

[0001] This application claims priority to and the benefit of U.S. Provisional Patent Application No. 61/979,269, filed April 14, 2014, which is hereby incorporated by reference herein in its entirety

TECHNICAL FIELD

[0002] The disclosure relates to methods useful for treatment or prophylaxis of gut-mediated immune dysfunction in HIV-infected individuals. More particularly, the disclosure relates to methods of using a GLP-2 peptide, or analogs thereof, for the treatment or prophylaxis of gut-mediated immune dysfunction in HIV-infected individuals.

BACKGROUND

[0003] In the early 1980s, when it first became apparent that a virus was the causative agent in the condition that later came to be known as AIDS, the diagnosis was widely considered a death sentence (Centers for Disease Control. MMWR Morb Mortal Wkly Rep. 1982;31 (37):507-508, 513-514). There were no truly effective treatments for the Kaposi sarcoma, Pneumocystis carinii pneumonia, and other opportunistic infections that resulted in death, often within one to two years of the first manifestation of disease (Kaiser Family Foundation. The HIV/AIDS epidemic in the United States. HIV/AIDS Policy Fact Sheet. March 2013. Publication #3029-14. http://kff.org/hivaids/fact-sheet/the-hivaids-epidemic-in-the-united-states/. Accessed June 20, 2013). Since that time, remarkable progress has been made in the prevention, detection, and treatment of AIDS. The development of highly active antiretroviral therapies (HAART) has transformed the lives of HIV-infected individuals, turning HIV into a chronic disease.

[0004] Today, most treated individuals achieve nearly complete viral suppression, and there has been a dramatic decline in morbidity and mortality among patients with access to therapy (Hunt PW. Curr Opin HIV AIDS. 2010;5(2):189-193; and Palella FJ Jr, Delaney KM, Moorman AC, et al. N Engl J Med. 1998;338:853-860). More people with HIV are living with the infection, as mortality decreases and the incidence of new infections remains stable. In the United States, the age-adjusted HIV death rate has declined by 80% since its peak in 1995 (Kaiser Family Foundation. The HIV/AIDS epidemic in the United States. HIV/AIDS Policy Fact Sheet. March 2013. Publication #3029-14. http://kff rg/hivaids/fact-sheet/the-hivaids-epidemic-in-the- united-states/. Accessed June 20, 2013). Opportunistic infections and malignancies now occur rarely among patients who initiate therapy as currently recommended by international guidelines, before CD4+ T-cell counts fall below 350 cells/mm³ (Hunt PW. Curr Opin HIV AIDS. 2010;5(2):189-193).

[0005] Nevertheless, HAART fails to restore normal health in many individuals (Hunt PW. Curr Opin HIV AIDS. 2010;5(2):189-193; and Deeks SG. Top HIV Med. 2009;17(4):1 18-123). There is a growing body of evidence that gut-mediated immune dysfunction plays a central role in non-AIDS-related morbidity and mortality in HIV infection (Hunt PW. Curr Opin HIV AIDS. 2010;5(2):189-193; and Brenchley JM, Douek DC. Annu Rev Immunol. 2012;30:149-173).

Epidemiology

[0006] There were an estimated 34 million people worldwide living with HIV/AIDS in 201 1 (World Health Organization. Global Health Observatory, HIV/AIDS. http://www.who.int/gho/hiv/en/. Accessed June 20, 2013). In the United States, an estimated 1 ,148,200 people aged 13 and older were living with HIV infection in 2009; this figure includes an estimated 207,600 people (18.1 %) whose infection had not been diagnosed (Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data— United States and 6 U.S. dependent areas— 2010. HIV Surveillance Supplemental Report 2012;17(No. 3, part A).

http://www.cdc.gov/hiv/library/reports/surveillance/2010/surveillance_Report_vol_17_ no_3.html. Accessed June 21 , 2013). Even among patients who are diagnosed with HIV infection and have access to HAART, many have inadequate immune response to treatment.

[0007] Although most patients are able to achieve normal CD4+ T-cell counts, HAART may not fully reverse all the immunologic deficiencies associated with HIV infection. Immunologic failure— that is, failure to achieve an adequate CD4+ response despite virologic suppression— occurs in about 15% to 20% of patients (Robbins GK, Spritzler JG, Chan ES, et al. Clin Infect Dis. 2009;48(3):350-361 ). Suboptimal CD4+ counts are associated with higher morbidity and mortality, with a direct correlation between lower CD4+ cell counts and earlier mortality. At age 20, the number of additional years of life expectancy is approximately 50 years in patients with CD4+ count nadir of >200 cells/mm³, 42 years in patients with CD4+ count nadir of 100 cells/mm³ to 200 cells/mm³, and 32 years in patients with CD4+ count nadir of <100 cells/mm³ (Antiretroviral Therapy Cohort Collaboration. Lancet. 2008;372:293-299). By contrast, data from the SMART and ESPRIT studies indicate that there is no increased mortality risk in HIV-infected individuals with CD4+ counts >500 cells/mm³ compared with age- and sex-matched controls (Rodger A, Lodwick R, Schechter M, et al. AIDS. 2013;27:973-979).

[0008] In addition, high or rising CD8+ T-cell counts after starting combination antiretroviral therapy appear to predict virologic treatment failure (Krantz EM, Hullsiek KH, Okulicz JF, et al. J Acquir Immune Defic Syndr. 201 1 ;57(5):396-403). Data from the AIDS Clinical Trial Group Protocol 384 show that the majority of patients have elevated CD8+ T cells with activated phenotype years into successful antiretroviral therapy (Robbins GK, Spritzler JG, Chan ES, et al. Clin Infect Dis. 2009;48(3):350-361 ). It is worth noting that increased levels of terminally differentiated CD8+ effector memory cells, which appear to be resistant to apoptosis, reduced levels of naive CD8+ cells, and a reversed ratio of CD4+ to CD8+ cells are consistently implicated in immunosenescence, or the "aging" of the immune system (Deeks SG. Top HIV Med. 2009;17(4):1 18-123).

[0009] Even with appropriate treatment, life expectancy is reduced by 10 to 30 years in HIV-infected versus non-infected individuals (Lewden C, Chene G, Morlat P, et al. J Acquir Immune Defic Syndr. 2007;46(1 ):72-77; Lima VD, Hogg RS, Harrigan PR, et al. AIDS. 2007;21 :685-692; Lohse N, Hansen AB, Pedersen G, et al. Ann Intern Med. 2007;146:87-95; Antiretroviral Therapy Cohort Collaboration. Lancet. 2008;372:293-299; Deeks SG. Top HIV Med. 2009;17(4):1 18-123; and Hunt PW. Curr Opin HIV AIDS. 2010;5(2):189-193). Notably, HIV-infected individuals are at increased risk for a variety of non-AIDS-related chronic diseases that are commonly associated with aging compared with the age-matched general population, including premature onset of cardiovascular disease (CVD), liver disease, kidney disease, neurocognitive dysfunction, osteoporosis and osteopenia, and cancer (Deeks SG, Phillips AN. BMJ. 2009;338:a3172).

Etiology

[0010] Much of the increased non-AIDS-related morbidity in HIV-infected individuals is associated with persistent inflammation and immune activation, although a number of factors may contribute to poor health and accelerated aging among patients receiving long-term HAART. One possible contributing factor may be age itself. As treatment has become more effective, the HIV-infected population has gotten older; it is expected that by 2015, more than half of the HIV-infected population will be older than 50 years of age (Effros RB, Fletcher CV, Gebo K, et al. Clin Infect Dis. 2008;47:542-553; and Luther VP, Wilkin AM. Clin Geriatr Med. 2007;23:567-583). Other contributing factors may include direct toxicities of antiretroviral drugs and the high prevalence of traditional modifiable risk factors (i.e., dyslipidemia and smoking) in HIV-infected individuals (DAD Study Group, Friis- M0ller N, Reiss P, Sabin CA, et al. N Engl J Med. 2007;356(17):1723-1735; Kaplan RC, Kingsley LA, Sharrett AR, et al. Clin Infect Dis. 2007 Oct 15;45(8):1074-1081 ). Injection drug use and hepatitis C coinfection are also potential confounding factors (Hunt PW. Curr Opin HIV AIDS. 2010;5(2):189-193).

[0011] Nevertheless, several studies have assessed non-AIDS-related morbidity and mortality while controlling for factors such as aging, adverse effects of therapy, lifestyle risks, and comorbidities (Lohse N, Hansen AB, Pedersen G, et al. Ann Intern Med. 2007;146:87-95; Lewden C, Chene G, Morlat P, et al. J Acquir Immune Defic Syndr. 2007;46(1 ):72-77; Lima VD, Hogg RS, Harrigan PR, et al. AIDS. 2007;21 :685-692; Antiretroviral Therapy Cohort Collaboration. Lancet. 2008;372:293-299; and Bhaskaran K, Hamouda O, Sannes M, et al. JAMA. 2008;300(1 ):51 -59). These assessments confirm an independent association of HIV infection with an increased risk for non-AIDS-related morbidity and mortality.

[0012] Persistent immune activation and inflammation are strong predictors of non-AIDS events in HAART-treated individuals (Hunt PW. Curr Opin HIV AIDS. 2010;5(2):189-193). In 2008, Kuller and colleagues established that inflammatory and coagulation biomarkers predict all-cause mortality and CVD in treated HIV infection (Kuller LH, Tracy R, Belloso W, et al. PLoS Med. 2008;5:e203). Another analysis showed that there were higher levels of inflammatory or coagulation markers (e.g., high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), D- dimer, and cystatin C) in patients with treated HIV disease than in controls (Neuhaus J, Jacobs D, the INSIGHT SMART, MESA and CARDIA Study Groups. [Abstract 740.] 16th Conference on Retroviruses and Opportunistic Infections. February 8-1 1 , 2009; Montreal, Canada). It is worth noting that many of the non-AIDS-related complications seen in HIV-infected individuals also occur with increased frequency in patients with other chronic inflammatory diseases, such as systemic lupus erythematosus and rheumatoid arthritis (Hunt PW. Curr Opin HIV AIDS. 2010;5(2):189-193).

[0013] Persistent immune activation and inflammation appear to be one of the most important factors preventing restoration of optimal heath in patients with HIV, but the underlying pathology and potential interventions to correct these abnormalities are not yet fully characterized. Gut-associated lymphoid tissue (GALT)-mediated abnormalities, including early and massive loss of CD4+ T lymphocytes during acute HIV infection and increased microbial translocation, are thought to play a key role in immune dysfunction (Hunt PW. Curr Opin HIV AIDS. 2010;5(2):189-193). Increased microbial translocation also appears to be associated with increases in mucosal inflammation and alterations in bacterial flora (Brenchley JM, Douek DC. Annu Rev Immunol. 2012;30:149-173).

Gut-Mediated Immune Dysfunction

[0014] Although the gastrointestinal (Gl) tract is commonly thought of as a primarily digestive organ system, it also functions as a lymphoid organ that plays a crucial role in the human immune response. The lumen of the Gl tract is heavily populated with an enormous quantity and variety of bacterial species that thrive, often in symbiosis with the healthy human host. Beneficial effects of the normal microbiota include protecting against pathogenic infection and attenuating negative immune responses, as well as enhancing the integrity of the structural barrier of the Gl mucosal barrier. However, both pathogens and inflammation can alter the structural integrity of the Gl barrier and upset the balance of the Gl immune system (Brenchley JM, Douek DC. Annu Rev Immunol. 2012;30:149-173).

[0015] Failure of the Gl immune system can lead to transfer of pathogenic microbial products into the systemic circulation, with deleterious effects on health. Some of the diseases associated with this microbial translocation include inflammatory bowel disease, hepatitis B and C, fatty liver disease, pancreatitis, graft- versus-host disease, and HIV infection. Chronic alcohol use is also associated with significant microbial translocation (Brenchley JM, Douek DC. Annu Rev Immunol. 2012;30:149-173).

[0016] HIV causes significant damage to the lining of the intestine and the intestinal mucosal barrier in both acute and chronic infection, resulting in a condition of increased intestinal permeability sometimes described as "leaky gut syndrome" (Epple HJ, Zeitz M. Ann NY Acad Sci. 2012;1258:19-24). Acute infection is marked by depletion of CD4+ helper T cells (specifically Th17 cells) in GALT (Hunt PW. Curr Opin HIV AIDS. 2010;5(2):189-193). In chronic infection, mucosal production of inflammatory cytokines results in epithelial permeability, apoptosis, and tight junction changes, and subsequently, microbial translocation (Brenchley JM, Douek DC. Annu Rev Immunol. 2012;30:149-173). Microbial translocation due to enteropathy in turn contributes to chronic immune activation, malabsorption, and subsequent disease progression (Hunt PW. Curr Opin HIV AIDS. 2010;5(2):189-193).

[0017] Epple, et al., have shown that histologic changes in the Gl mucosa associated with HIV enteropathy in untreated HIV-infected individuals include increased epithelial permeability and villous atrophy with increased epithelial apoptosis (Epple HJ, Schneider T, Troger H, et al. Gut. 2009;58:220-227). These abnormalities were absent in duodenal biopsies from HIV-seronegative volunteers and suppressively treated HIV patients. There is also evidence from both in vitro and in vivo studies that the composition and function of the intercellular tight junctions of the intestinal epithelium are disrupted by HIV, suggesting that both cellular (i.e., increased epithelial apoptosis) and paracellular (i.e., altered tight junction composition) changes contribute to the barrier defect seen with HIV infection (Schmitz H, Rokos K, Florian P, et al. AIDS. 2002;16: 983-991 ; Nazli A, Chan O, Dobson-Belaire WN, et al. PLoS Pathog. 2010;6(4): e1000852; Clayton F, Kapetanovic S, Kotler DP. AIDS. 2001 ;15:123-124; Epple HJ, Schneider T, Troger H, et al. Gut. 2009;58:220-227; and Epple HJ, Zeitz M. Ann NY Acad Sci. 2012;1258:19-24).

Characteristics of HIV Immune Dysfunction

[0018] HIV immune dysfunction is defined by residual HIV replication and persistent viral expression in lymph nodes. It is characterized by persistent inflammation and abnormal levels of helper T-cells despite HAART (Deeks SG. Top HIV Med. 2009;17(4):1 18-123). Compared with uninfected control subjects, patients with treated HIV disease exhibit higher levels of inflammatory and coagulation markers including CRP, IL-6, D-dimer, and cystatin C (Neuhaus J, Jacobs D, the INSIGHT SMART, MESA and CARDIA Study Groups. [Abstract 740.] 16th Conference on Retroviruses and Opportunistic Infections. February 8-1 1 , 2009; Montreal, Canada). Additional abnormalities include the loss of immunoregulatory cells, collagen deposition, high pathogen load (e.g., cytomegalovirus, hepatitis B or C virus), and thymic dysfunction (Deeks SG. Top HIV Med. 2009;17(4):1 18-123). [0019] GALT is a major site of HIV replication and CD4+ cell loss. An HIV- induced barrier defect of the intestinal mucosa allows for increased translocation of microbial antigens and promotes an ongoing cycle of immune activation and further CD4+ cell depletion (Epple HJ, Zeitz M. Ann NY Acad Sci. 2012;1258:19-24). It appears that this mucosal barrier defect develops early, during the acute phase of HIV infection, although the cause is not yet known (Epple JH, Allers K, Troger H, et al. Gastroenterology. 2010;139:1289-1300).

[0020] Th17 cells in particular play a key role in the defense against microbial translocation. Among other effects, these cells help stimulate mucosal epithelial cell proliferation to protect against pathogenic invasion. Their loss from GALT during early HIV infection is reflected by decreases in plasma lipopolysaccharide (LPS), soluble CD14, and bacterial 16S ribosomal DNA levels. These markers of microbial translocation remain abnormal even after several years of viral suppression in HIV- infected individuals compared with uninfected individuals. Persistent deletion of Th17 from GALT despite HAART is also likely (Hunt PW. Curr Opin HIV AIDS. 2010;5(2):189-193).

[0021] In addition to CD4+ T-cell depletion, other immunologic changes in the intestinal mucosa include a significant increase in perforin expression by CD8+ T- cells in patients with acute (but not chronic) HIV infection, a finding that suggests a role for cytotoxic T-lymphocyte-induced epithelial apoptosis in the initial induction of the mucosal barrier defect (Epple JH, Allers K, Troger H, et al. Gastroenterology. 2010;139:1289-1300). However, preclinical studies indicate that the later stages of HIV infection are associated with a loss of perforin expression (Epple HJ, Zeitz M. Ann NY Acad Sci. 2012;1258:19-24).

[0022] It appears that while the release of cytotoxic T cells in response to immune activation triggers a defect in the intestinal mucosa during the acute phase of infection, the defect is maintained by mucosal production of inflammatory mucosal cytokines {e.g., tumor necrosis factor-a, IL-2, IL-4, and IL-13) during the chronic phase. In addition to promoting further epithelial apoptosis, these cytokines also alter the composition of tight junction protein membranes. Mucosal HIV replication also contributes to the barrier defect via receptor-mediated tubulin disruption at epithelial tight junctions (Epple HJ, Zeitz M. Ann NY Acad Sci. 2012;1258:19-24).

[0023] Recent research provides further support for the role of persistent inflammation as a cause of the early onset of chronic disease in HIV patients. Investigators from the University of California, San Francisco report evidence that changes in intestinal bacteria may perpetuate persistent inflammation triggered by the initial immune response to HIV, thus worsening HIV disease. The investigators identified a dysbiotic mucosal-adherent community enriched in Proteobacteria and depleted of Bacteroidia members that was associated with markers of mucosal immune disruption, T-cell activation, and chronic inflammation in HIV-infected subjects (Vujkovic-Cvijin I, Dunham RM, Iwai S, et al. Sci Transl Med. 2013;5(193):193ra91 . doi: 10.1 126/scitranslmed.3006438).

[0024] The gut microbiome was very different in HIV-infected individuals, who had harbored more bacteria associated with harmful inflammation, such as Pseudomonas, Salmonella, Escherichia coli, and Staphylococcus. Furthermore, this dysbiosis was evident among HIV-infected subjects undergoing HAART, including patients in whom serum HIV levels had been reduced to undetectable levels. The extent of dysbiosis correlated with activity of the kynurenine pathway of tryptophan catabolism and plasma concentrations of the inflammatory cytokine IL-6, two established markers of disease progression (Vujkovic-Cvijin I, Dunham RM, Iwai S, et al. Sci Transl Med. 2013;5(193):193ra91 . doi: 10.1 126/scitranslmed.3006438).

HIV Enteropathy

[0025] The term "HIV enteropathy" has been used to describe changes in mucosal structure and function associated with gut-mediated immune dysfunction, as well as to denote the clinical syndrome of chronic diarrhea without an identified infectious cause. In addition to chronic diarrhea, HIV enteropathy is often characterized by increased Gl inflammation, increased intestinal permeability, and malabsorption of bile acids and vitamin B₁₂— abnormalities that are thought to be due to direct or indirect effects of HIV on the enteric mucosa (Brenchley JM, Douek DC. Mucosal Immunol 2008;1 :23-30). Clinical consequences include decreased fat and carbohydrate absorption, a trend toward decreased small-bowel transit time, and jejunal atrophy.

[0026] The early initiation of HAART has been shown to improve manifestations of HIV enteropathy, but no therapies have a U.S. Food and Drug Administration (FDA) approved indication for this condition (Epple HJ, Schneider T, Troger H, et al. Gut. 2009;58:220-227). Nonetheless, the diarrhea and malabsorption associated with HIV enteropathy can be addressed by various available and investigational treatments, as well as by modification of the HAART regimen and use of nutritional supplementation.

[0027] Antimotility agents {e.g., loperamide and diphenoxylate with atropine) are often used for symptomatic relief in HIV enteropathy. Bulking agents {e.g., cholestyramine) may be used to reduce bowel movements and reverse weight loss, particularly if the diarrhea is associated with bile acid malabsorption. Crofelemer, which is an antisecretory agent, may be used for relief of noninfectious diarrhea in adult HIV patients on HAART. Acetorphan/racecadotril, an enkephalinase inhibitor available outside the U.S., has an antisecretory effect in reducing secretion of water and electrolytes into the intestine; some studies show efficacy in reducing stool number.

[0028] Investigational treatments aimed at the symptomatic effects of HIV enteropathy include octreotide, nitazoxanide, and immunolin. None of these available or investigational approaches, however, address the underlying defects of the Gl mucosal barrier associated with the clinical manifestations of HIV enteropathy.

Proposed Interventions in HIV Immune Dysfunction

[0029] A variety of interventions have been proposed to decrease microbial translocation and/or T-cell depletion in HIV infection. For example, interventions that could decrease inflammation in the GALT might restore the number or function of Th17 cells and thus interrupt the cycle of microbial translocation and Th17 depletion (Hunt PW. Curr Opin HIV AIDS. 2010;5(2):189-193). Another approach, which is the subject of considerable current research attention, is the development of interventions that might block microbial translocation and its consequences (Hunt PW. Curr Opin HIV AIDS. 2010;5(2):189-193; and Brenchley JM, Douek DC. Annu Rev Immunol. 2012;30:149-173).

[0030] Brenchley and Douek have divided therapeutic interventions to block microbial translocation into four general classes: reduction of local inflammation, alteration of the composition of the Gl microbiota {e.g., antibiotics, probiotics), enhanced clearance of products of microbial translocation from the circulation {e.g., anti-LPS monoclonal antibodies), and repair of the enterocyte barrier (Brenchley JM, Douek DC. Annu Rev Immunol. 2012;30:149-173). For example, the administration of cytokines such as IL-22 can improve enterocyte homeostasis in animal models of intestinal tissue damage and inflammation. However, a recently completed clinical study of recombinant IL-2 showed increased CD4+ counts (mean 160 cells/ L) but no improvement in clinical outcomes in HIV-infected individuals (INSIGHT-ESPRIT Study Group, SILCAAT Scientific Committee, Abrams D, Levy Y, Losso MH, et al. N Engl J Med. 2009;361 :1548-1559). It was hypothesized that the negative findings might have resulted from an atypical phenotype of CD4+ cells produced under IL-2 treatment. Phase II studies of recombinant IL-7 (CYT 107), which led to rapid increases in CD4+ counts in phase I trials, are ongoing (Levy Y, Sereti I, Tambussi G, et al. Clin Infect Dis. 2012;55:291 -300).

[0031] Agents currently under investigation for treatment of HIV immune dysfunction include chloroquine to reduce CD8+ T-cell activation associated with chronic, untreated, and treated HIV-1 infection in chronically infected subjects on or off antiretroviral therapy (placebo-controlled study, A5258 [NCT00819390]); atorvastatin to reduce biomarkers of inflammation, coagulopathy, angiogenesis, and T-lymphocyte (CD8+ T-cell) activation in HIV-1 infected individuals with suppressed HIV-1 RNA and low-density lipoprotein cholesterol less than 130 mg/dL (pilot study, A5275 [NCT01351025]); rifaximin to modulate gut microbial translocation and systemic immune activation in HIV-infected individuals with incomplete CD4+ T-cell recovery on antiretroviral therapy (pilot study, A5286 [NCT01466595]); and sevelamer to reduce endotoxemia and endotoxin-associated monocyte and T cell activation in HIV-1 -infected subjects (proof of concept study, A5296 [NCT01543958]).

[0032] Priorities in current HIV/AIDS research may include determining the clinical relevance of gut mucosal immunopathogenesis, including Gl T-cell depletion and gut-mediated microbial translocation. One of the major objectives for the AIDS Clinical Trials Group's (ACTG) research in this priority area includes determining whether treatment that decreases or eliminates inflammation or microbial translocation at this anatomic site might impact HIV-1 disease pathogenesis, particularly during early events after HIV transmission and acute infection.

DETAILED DESCRIPTION

[0033] The present disclosure provides methods for treating gut-mediated immune dysfunction in HIV-infected individuals. The methods disclosed comprise the step of administering to an HIV-infected individual a GLP-2 peptide or a GLP-2 peptide analog in an amount effective to treat gut-mediated immune dysfunction.

[0034] This disclosure also provides methods for prophylaxis against gut- mediated immune dysfunction in HIV-infected individuals. The methods disclosed comprise administering to an HIV-infected individual a GLP-2 peptide, or a GLP-2 peptide analog in an amount effective for prophylaxis of gut-mediated immune dysfunction.

[0035] It will be readily understood that the embodiments, as generally described herein, are exemplary. The following more detailed description of various embodiments is not intended to limit the scope of the present disclosure, but is merely representative of various embodiments. Moreover, the order of the steps or actions of the methods disclosed herein may be changed by those skilled in the art without departing from the scope of the present disclosure. In other words, unless a specific order of steps or actions is required for proper operation of the embodiment, the order or use of specific steps or actions may be modified.

[0036] Each and every patent, report, and other reference recited herein is incorporated by reference in its entirety.

Definitions

[0037] Unless specifically defined otherwise, the technical terms, as used herein, have their normal meaning as understood in the art. The following terms are specifically defined with examples for the sake of clarity.

[0038] The term "GLP-2 peptide" and the term "GLP-2" refer herein to the various naturally produced forms of GLP-2, particularly the mammalian forms, e.g., rat GLP- 2, ox GLP-2, porcine GLP-2, bovine GLP-2, guinea pig GLP-2, hamster GLP-2, and human GLP-2, the sequences of which have been reported by many authors including Buhl, et al., in J. Biol. Chem., 263:8621 , 1988, which is hereby incorporated by reference in its entirety.

[0039] GLP-2 peptides include peptides that conform to the general formula represented below as SEQ ID NO:1 :

R1 -[Y]m-His-Ala-Asp-Gly-Ser-Phe-Ser-Asp-Glu-Met-Asn-Thr-aa1 -Leu-Ala- aa2-Leu -Ala-aa3-Arg-Asp-Phe-lle-Asn-Trp-Leu-aa4-aa5-Thr-Lys-lle-Thr-Asp-[X]-n- R2

wherein aa refers to an amino acid residue that is synthetic or genetically encoded, and;

aa1 is a neutral/polar/large/nonaromatic residue such as lie or Val; aa2 is a neutral/polar residue such as Asn or Ser;

aa3 is a neutral residue such as Ala or Thr;

aa4 is a neutral/polar/large/nonaromatic residue such as lie or Leu; aa5 is a neutral or basic residue such as Gin or His;

X is Arg, Lys, Arg-Lys or Lys-Lys;

Y is Arg or Arg-Arg;

m is 0 or 1 ;

n is 0 or 1 ;

R1 is H or an N-terminal blocking group; and

R2 is OH or a C-terminal blocking group SEQ ID NO:1 .

[0040] The "blocking groups" represented by R1 and R2 are chemical groups that are routinely used to confer biochemical stability and resistance to digestion by exopeptidase. Suitable N-terminal protecting groups include, for example, Ci_-5 alkanoyl groups such as acetyl. Also suitable as N-terminal protecting groups are amino acid analogs lacking the amino function. Suitable C-terminal protecting groups include groups which form ketones or amides at the carbon atom of the C-terminal carboxyl, or groups which form esters at the oxygen atom of the carboxyl. Ketone and ester-forming groups include alkyl groups, particularly branched or unbranched Ci-5 alkyl groups, e.g., methyl, ethyl, and propyl groups, while amide-forming groups include amino functions such as primary amine, or alkylamino functions, e.g., mono- Ci-5-alkylamino and di-Ci_-5 alkylamino groups such as methylamino, ethylamino, dimethylamino, diethylamino, methylethylamino and the like. Amino acid analogs are also suitable for protecting the C-terminal end of the present compounds, for example, decarboxylated amino acid analogs such as agmatine.

[0041] GLP-2 peptides are known in the art, and are further disclosed in U.S. Patent No. 5,990,077, which is hereby incorporated by reference in its entirety.

[0042] The term "GLP-2 peptide analog" and the term "GLP-2 analog" refer herein to a peptide that incorporates an amino acid substitution at one or more sites within a GLP-2 peptide "background", which is either a mammalian GLP-2 species per se, or is a variant of a mammalian GLP-2 species in which the C-terminus and/or the N- terminus has been altered by addition of one or two basic residues, or has been modified to incorporate a blocking group of the type used conventionally in the art of peptide chemistry to protect peptide termini from undesired biochemical attack and degradation in vivo. Thus, GLP-2 peptide analogs incorporate an amino acid substitution in the context of any mammalian GLP-2 species, including but not limited to human GLP-2, bovine GLP-2, rat GLP-2, degu GLP-2, ox GLP-2, porcine GLP-2, guinea pig GLP-2, and hamster GLP-2, the sequences of which have been reported by many authors, including Buhl T, Thim L, Kofod H, et al., in J Biol Chem. 1988;263(18):8621 -8624, which is hereby incorporated by reference. The GLP-2 analogs disclosed herein only include peptides that when administered in a therapeutically effective dose to HIV-infected individuals, demonstrate at least one of the following properties: prophylaxis of gut-mediated immune dysfunction or treatment of gut-mediated immune dysfunction. The disclosure provided herein, and the knowledge available in the art would allow a person skilled in the art to determine which of GLP-2 peptides or GLP-2 analogs would retain at least one of the said properties. For example, the disclosure provided herein provides guidance regarding the design of GLP-2 peptides and GLP-2 peptide analogs. Furthermore, the guidance provided herein demonstrate how to determine whether a GLP-2 peptide or a GLP-2 analog have one of the properties of prophylaxis of gut-mediated immune dysfunction or treatment of gut-mediated immune dysfunction. In this light, the following examples of GLP-2 analogs are provided.

[0043] In some instances, GLP-2 peptide analogs according to the present disclosure include peptides that conform to the sequence of the general formula presented below as SEQ ID NO:2:

R1 -(Y1 )m-X1 -X2-X3-X4-Ser5-Phe6-Ser7-Asp8-(P1 )-Leu14-Asp15-Asn16- Leu17-Ala18-X19-X20-Asp21 -Phe22-(P2)-Trp25-Leu26-lle27-Gln-28-Thr29-Lys30- (P3)-(Y2)n-R 2,

wherein

X1 is His or Tyr

X2 is Ala or any other amino acid conferring on said analog resistance to dipeptidyl peptidase IV enzyme (DPP-IV);

X3 is Asp or Glu;

X4 is Gly or Ala;

P1 is Glu-X10-Asn-Thr-lle or Tyr-Ser-Lys-Tyr (SEQ ID NO:3);

X10 is Met or an oxidatively stable amino acid;

X19 is Ala or Thr;

X20 is Arg, Lys, His or Ala;

P2 is lle-Asn, lie-Ala or Val-Gln;

P3 is a covalent bond, or is lie, lle-Thr or lle-Thr-Asp;

R1 is H or an N-terminal blocking group;

R2 is OH or a C-terminal blocking group; Y1 is one or two basic amino acids selected from the group Arg, Lys, and

His;

Y2 is one or two basic amino acids selected from the group Arg, Lys, and

His; and

m and n, independently, are 0 or 1 ;

wherein at least one of X1 , X2, X3, X4, P1 , X10, X19, X20, P2 and P3 is other than a wild-type, mammalian GLP-2 residue; and

wherein when the peptide is administered in a therapeutically effective dose to HIV-infected individuals the GLP-2 analog has at least one of the following properties: prophylaxis of gut-mediated immune dysfunction or treatment of gut- mediated immune dysfunction.

[0044] GLP-2 peptide analogs may be analogs of full-length GLP-2, i.e., GLP-2(1 - 33), and P3 is accordingly the sequence lle-Thr-Asn. Alternatively, the GLP-2 analogs may be C-terminally truncated, to yield GLP-2(1 -32) forms in which P3 is lle- Thr, or GLP-2(1 -31 ) forms in which P3 is lie, or GLP-2(1 -30) forms in which P3 is a covalent bond.

[0045] Furthermore, in certain embodiments, GLP-2 analogs may incorporate desired amino acid substitutions into a "background" which is an N-terminally or C- terminally modified form of a mammalian GLP-2 peptide. Such analogs are represented according to SEQ ID NO:2 as those in which R1 constitutes an N- terminal blocking group, and/or when m is 1 then Y1 is one or two basic amino acids such as Arg or Lys; and/or R2 is a C-terminal blocking group; and/or when n is 1 then Y2 is independently, one or two basic amino acids such as Arg or Lys.

[0046] The "blocking groups" represented by R1 and R2 are chemical groups that are routinely used in the art of peptide chemistry to confer biochemical stability and resistance to digestion by exopeptidase. Suitable N-terminal protecting groups include, for example, Ci_-5 alkanoyl groups such as acetyl. Also suitable as N-terminal protecting groups are amino acid analogs lacking the amino function. Suitable C- terminal protecting groups include groups which form ketones or amides at the carbon atom of the C-terminal carboxyl, or groups which form esters at the oxygen atom of the carboxyl. Ketone and ester-forming groups include alkyl groups, particularly branched or unbranched Ci_-5 alkyl groups, e.g., methyl, ethyl, and propyl groups, while amide-forming groups include amino functions such as primary amine, or alkylamino functions, e.g., mono-Ci_-5 alkylamino and di-Ci_-5 alkylamino groups such as methylamino, ethylamino, dimethylamino, diethylamino, methylethylamino and the like. Amino acid analogs are also suitable for protecting the C-terminal end of the present compounds, for example, decarboxylated amino acid analogs such as agmatine.

[0047] GLP-2 analogs can alternately be generated using standard techniques of peptide chemistry according to the guidance provided herein. Particularly preferred analogs for use in the disclosure are those based upon the sequence of human GLP-2 (SEQ ID NO:4) wherein one or more amino acid residues are conservatively substituted for another amino acid residue, and wherein when the peptide is administered in a therapeutically effective dose to HIV-infected individuals the GLP-2 analog has at least one of the following properties: prophylaxis of gut-mediated immune dysfunction or treatment of gut-mediated immune dysfunction.

[0048] Conservative substitutions in any naturally occurring GLP-2, preferably the human GLP-2 sequence, are defined as exchanges of any member of the following five groups for another member of the same group:

I. Ala, Ser, Thr, Pro, Gly

II. Asn, Asp, Glu, Gin

III. His, Arg, Lys

IV. Met, Leu, lie, Val, Cys

V. Phe, Tyr, Trp.

[0049] In certain embodiments, GLP-2 analogs may be created by changing an amino acid residue in one mammalian GLP-2 to the corresponding amino acid in another mammalian GLP-2 peptide. Wild-type mammalian GLP-2 residues which occur at a specific position are determined by aligning the sequences of GLP-2's isolated from different mammalian species and comparing the sequence to the human sequence, reproduced below, for convenience (SEQ ID NO:3):

His-Ala-Asp-Gly-Ser-Phe-Ser-Asp-Glu-Met-Asn-Thr-lle-Leu-Asp-Asn-Leu- Ala-Ala-Arg-Asp-Phe-lle-Asn-Trp-Leu-lle-Gln-Thr-Lys-lle-Thr-Asp

[0050] The amino acid residues which, for purposes of this application, are known to vary at specific positions in wild-type mammalian GLP-2s are the following (according to the notation of SEQ ID NO:2): position X13, which may be lie or Val; position X16, which may be Asn or Ser; position X19, which may be Ala (Alanine) or Thr (Threonine); position X20, which may be Arg or Lys; position X27, which may be lie or Leu; and position X28, which may be Gin or His. [0051] GLP-2 analogs also include peptides with non-conservative substitutions of amino acids in any vertebrate GLP-2 sequence, provided that the non- conservative substitutions occur at amino acid positions known to vary in GLP-2 isolated from different species. Such non-conserved residue positions are readily determined by aligning all known vertebrate GLP-2 sequences. For example, Buhl T, Thim L, Kofod H, et a/., in J Biol Chem. 1988;263(18):8621 -8624, compared the sequences of human, porcine, rat, hamster, guinea pig, and bovine GLP-2's, and found that positions 13, 16, 19, 27, and 28 according to SEQ ID NO:3 were non- conserved (position numbers refer to the analogous position in the human GLP-2 sequence). Nishi M and Steiner DF, in Mol Endocrinol. 1990;4:1 192-1 198, found that an additional position corresponding to residue 20 of SEQ ID NO:3 also varied in degu, a rodent species indigenous to South America. Thus, under this standard, the amino acid positions which vary in mammals and which preferably may be substituted with non-conservative residues are, according to the positions of SEQ ID NO:3, positions 13, 16, 19, 20, 27, and 28. The additional amino acid residues which vary in vertebrates and which also may be substituted with non-conserved residues occur at positions 2, 5, 7, 8, 9, 10, 12, 17, 21 , 22, 23, 24, 26, 29, 30, 31 , 32, and 33 in SEQ ID NO:3.

[0052] Alternatively, non-conservative substitutions may be made at any position by alanine-scanning provided that when the resulting peptide is administered in a therapeutically effective dose to HIV-infected individuals, the GLP-2 analog has at least one of the following properties: prophylaxis of gut-mediated immune dysfunction or treatment of gut-mediated immune dysfunction. The technique of alanine scanning mutagenesis is described by Cunningham BC and Wells JA, in Science. 1989;244:1081 -1085, and incorporated herein by reference in its entirety. Since most GLP-2 sequences consist of only approximately 33 amino acids (and in human GLP-2 alanine already occurs at four positions), one of skill in the art could easily test an alanine analog at each remaining position for one or more of the effects of prophylaxis of gut-mediated immune dysfunction or treatment of gut- mediated immune dysfunction.

[0053] One particular GLP-2 analog, teduglutide, is particularly useful because it is a DPP-IV resistant GLP-2 analog with the peptide sequence:

His-Gly-Asp-Gly-Ser-Phe-Ser-Asp-Glu-Met-Asn-Thr-lle-Leu-Asp-Asn-Leu- Ala-Ala-Arg-Asp-Phe-lle-Asn-Trp-Leu-lle-Gln-Thr-Lys-lle-Thr-Asp (SEQ ID NO:4) [0054] GLP-2 analogs are known in the art, and are further disclosed in U.S. Patent No. 5,789,379, U.S. Patent No. 5,834,428, U.S. Patent No. 6,184,201 , U.S. Patent Application Pub. No. 2003/0162703, and U.S. Patent Application Pub. No. 2006/0105954, all of which are hereby incorporated by reference in their entirety.

Methods

[0055] Glucagon-like peptide 2 (GLP-2) protein is involved in the rehabilitation of the intestinal lining and may be used in the repair of the enterocyte barrier. This 33- amino-acid member of the proglucagon superfamily of peptides is one of several proglucagon-derived proteins secreted by the intestinal mucosa after food is ingested and whose actions are largely restricted to the intestinal mucosa via GLP-2 receptors (Munroe DG, Gupta AK, Kooshesh F, et al. Proc Natl Acad Sci U S A. 1999;96(4):1569-1573). GLP-2 has been shown in animal models to promote intestinal growth, enhance intestinal barrier function, and promote nutrient transporter activity (Cheeseman CI, Tsang R. Am J Physiol. 1996;271 (3 Pt 1 ):G477- 482; Drucker DJ, Erlich P, Asa SL, Brubaker PL. Proc Natl Acad Sci U S A. 1996;93(15):791 1 -7916; Scott RB, Kirk D, MacNaughton WK, Meddings JB. Am J Physiol. 1998;275(5 Pt 1 ):G91 1 -921 ; Munroe DG, Gupta AK, Kooshesh F, et al. Proc Natl Acad Sci U S A. 1999;96(4):1569-1573; Benjamin MA, McKay DM, Yang PC, Cameron H, Perdue MH. Gut. 2000;47(1 ):1 12-1 19; Schonhoff SE, Giel-Moloney M, Leiter AB. Endocrinology. 2004;145(6):2639-2644. doi: 10.1210/en.2004-0051 ; and Dube PE, Brubaker PL. Am J Physiol Endocrinol Metab. 2007;293(2):E460-465).

[0056] Teduglutide, as described above, is a recombinant analog of human GLP- 2 that differs from the native 33-amino-acid peptide only by the substitution of a glycine for the alanine at the n-amino terminal. This change renders teduglutide resistant, or substantially resistant, to degradation by the DPP-IV enzyme, which inactivates native GLP-2 within minutes after administration, resulting in a viable therapeutic agent with a half-life of more than 1 .5 hours that is otherwise functionally identical to endogenous GLP-2 (GATTEX^® (teduglutide [rDNA origin]) for injection. NPS Pharmaceuticals, Inc. Briefing Document for the Gastrointestinal Drug Advisory Committee Meeting. NPS Pharmaceuticals, Inc., Bedminster, NJ. October 16, 2012).

[0057] Teduglutide has been demonstrated to improve the structural integrity of the Gl tract and enhance enterocyte function in both preclinical and clinical trials in patients with short bowel syndrome (SBS) (Jeppesen PB, Sanguinetti EL, Buchman A, et al. Gut. 2005;54(9):1224-1231 ; Buchman AL, Katz S, Fang JC, et al. Inflamm Bowel Dis. 2010;16(6):962-973; Jeppesen PB, Gilroy R, Pertkiewicz M, et al. Gut. 201 1 ;60(7):902-914; Jeppesen PB, Pertkiewicz M, Messing B, et al. Gastroenterology. 2012;143(6):1473-1481 , e1473; and O'Keefe SJ, Jeppesen PB, Gilroy R, et al. Clin Gastroenterol Hepatol. 2013;1 1 (7):815-823). Targeted pharmacodynamic effects of teduglutide in SBS include increased nutrient absorption, improved fluid absorption, and decreased gastrointestinal fluid losses, with evidence of structural adaptation through an increase in villus height and crypt depth (Jeppesen PB, Sanguinetti EL, Buchman A, et al. Gut. 2005;54(9):1224-1231 ). Teduglutide has also been shown to increase levels of plasma citrulline, a biomarker of enterocyte mass and functionality in HIV enteropathy (Jeppesen PB, Gilroy R, Pertkiewicz M, et al. Gut. 201 1 ;60(7):902-914; and Crenn P, De Truchis P, Neveux N, et al. Am J Clin Nutr. 2009;90:587-594).

[0058] Although there may be clinical and symptomatic overlap among HIV enteropathy and gut-mediated immune dysfunction, gut-mediated immune dysfunction may represent a significant unmet need in HIV/AIDS treatment. A variety of interventions can be used to manage HIV enteropathy. However, even in the absence of overt Gl symptoms, a substantial proportion of HIV-infected individuals fail to achieve the full expected benefits of HAART, presumably because of gut- mediated immune dysfunction. In addition, inadequate absorption of antiretroviral agents may contribute to viral persistence and immune dysfunction.

[0059] A GLP-2 peptide or a GLP-2 peptide analog (e.g., human GLP-2 or teduglutide) may act as an adjunctive agent in HIV/AIDS. The GLP-2 peptide or the GLP-2 peptide analog may rehabilitate HIV-damaged intestinal mucosa and improve enterocyte function, thus addressing critical pathogenic factors in gut-mediated immune dysfunction. Administration of GLP-2 peptides or GLP-2 peptide analogs may advantageously affect immune activation and inflammation in HIV/AIDS patients with incomplete response to HAART. Further, administration of GLP-2 peptides or GLP-2 peptide analogs may diminish non-AIDS-related morbidity and mortality due to, but not limited to, metabolic inflammation, CVD, and/or liver disease by specifically decreasing chronic antigen presentation through impaired Gl integrity.

[0060] A GLP-2 peptide or a GLP-2 peptide analog may enhance bioavailability of antiretroviral and other oral agents. Better absorption of nutrients and fluids can also contribute to improved clinical status. GLP-2 peptides and/or GLP-2 peptide analogs can improve intestinal absorptive capacity in SBS. Data from both placebo-controlled and long-term clinical trials in patients with SBS indicate that the GLP-2 peptide analog teduglutide is well tolerated and leads to durable and continued intestinal rehabilitation in this vulnerable population (Jeppesen PB, Gilroy R, Pertkiewicz M, et al. Gut. 201 1 ;60(7):902-914; Jeppesen PB, Pertkiewicz M, Messing B, et al. Gastroenterology. 2012;143(6):1473-1481 , e1473; and O'Keefe SJ, Jeppesen PB, Gilroy R, et al. Clin Gastroenterol Hepatol. 2013;1 1 (7):815-823). Treatment with a GLP-2 peptide or a GLP-2 peptide analog (e.g., human GLP-2 or teduglutide) may help ameliorate the Gl damage that is often a hallmark of HIV infection and pathogenesis.

[0061] A GLP-2 peptide or a GLP-2 peptide analog may promote regeneration and apoptosis of healthy mucosal tissue and may prevent microbial translocations associated with inflammation and immune dysfunction in HIV infection. In addition, a GLP-2 peptide or a GLP-2 peptide analog may facilitate enhanced absorption and bioavailability of antiretroviral agents. Improved pharmacokinetics and bioavailability of HAART should allow patients to achieve more of the benefits, or the full benefits, of HAART.

[0062] HIV can cause significant damage to the lining of the intestine and the intestinal mucosal barrier in acute and chronic infection. Acute infection is marked by depletion of CD4+ cells (particularly Th17) in GALT. In chronic infection, mucosal production of inflammatory cytokines results in epithelial permeability, apoptosis and tight junction changes, and subsequently, microbial translocation. Microbial translocation due to enteropathy contributes to chronic immune activation, malabsorption, and subsequent disease progression. These pathogenic mechanisms appear to at least partially underlie the non-AIDS-related morbidity and mortality that remain a major cause of suboptimal outcomes despite recommended treatment with HAART.

[0063] GLP-2 peptides or GLP-2 peptide analogs including, but not limited to, human GLP-2 and teduglutide may be of clinical benefit in management of HIV patients by helping to repair HIV-associated Gl damage; GLP-2 peptides or GLP-2 peptide analogs can also help improve outcomes by enhancing the bioavailability of HAART.

[0064] The methods described herein are methods for treatment or prophylaxis of gut-mediated immune dysfunction in HIV-infected individuals. In these methods, GLP-2 or GLP-2 peptide analogs are administered to HIV-infected individuals. A researcher may determine whether a particular GLP-2 or GLP-2 peptide analog has a prophylactic effect against gut-mediated immune dysfunction by administering the peptide or analog to HIV-infected individuals in danger of developing gut-mediated immune dysfunction. The researcher would then determine whether the individuals thus treated are less likely to develop gut-mediated immune dysfunction. Methods for measuring change and/or improvement in Gl tract function can include, but are not limited to: endoscopy for direct examination of epithelium and mucosa; histological evaluation and/or tissue procurement for direct evaluation of structural changes and/or immune biomarkers; urine tests for assessment of permeability with non-absorbable sugars and LPS levels; stool tests for assessment of inflammation and/or microbiota changes; and/or blood tests for assessment of specific markers, including CD4+ cell counts, Th17 cell counts, and/or LPS levels.

[0065] Likewise, a researcher can determine whether a particular GLP-2 peptide or analog may be used to treat gut-mediated immune dysfunction by administering the peptide or analog to HIV-infected individuals who have gut-mediated immune dysfunction. The researcher would then determine whether the individuals thus treated show improvement in Gl tract function.

[0066] The specific therapeutic regimens used to assess whether a molecule has a desired effect are well known in the art. A researcher faced with the task of determining whether a particular GLP-2 peptide or analog may be used for treatment or prophylaxis of gut-mediated immune dysfunction would choose the appropriate regimen to make this determination.

[0067] Delivery methods and formulations useful for administering peptides to individuals are well known in the art, and a skilled person would be able to determine the suitability of any particular method of delivery of a peptide to an individual for particular circumstances. For the purposes of illustration only, the following examples of methods and formulations for administering peptides to individuals are provided.

[0068] Peptides may be administered to individuals orally; however, actions of the digestive system will generally greatly reduce the bioavailability of the peptide. In order to increase peptide oral bioavailability, peptides may be administered in formulations containing enzyme inhibitors, or the peptides may be administered as part of a micelle, nanoparticle, or emulsion in order to protect the peptide from digestive activity. [0069] Peptides may also be administered by means of an injection. The peptides may be injected subcutaneously, intramuscularly, or intravenously. Further disclosure regarding methods of administering peptides through injection is found in U.S. Patent No. 5,952,301 , which is hereby incorporated by reference in its entirety.

[0070] Peptides may further be administered by pulmonary delivery. A dry powder inhalation system may be used, wherein peptides are absorbed through the tissue of the lungs, allowing delivery without injection, while bypassing the potential reduction in bioavailability seen with oral administration (Onoue S, Hashimoto N, Yamada S. Expert Opin Ther Pat. 2008;18(4):429-442, which is hereby incorporated by reference).

[0071] A typical human dose of a GLP-2 peptide would be from about 10 pg/kg body weight/day to about 10 mg/kg/day, from about 50 g/kg/day to about 5 mg/kg/day, or from about 100 g/kg/day to about 1 mg/kg/day. As the GLP-2 analogs can be from about 10 to even about 100 times more potent than GLP-2, a typical dose of such a GLP-2 analog may be lower, for example, from about 100 ng/kg body weight/day to about 1 mg/kg/day, from about 1 g/kg/day to about 500 g/kg/day, or from about 1 g/kg/day to about 100 g/kg/day.

[0072] In one aspect of the disclosure, a GLP-2 peptide, or a GLP-2 peptide analog may be used in a method to treat gut-mediated immune dysfunction in HIV- infected individuals. In one embodiment of a method to treat gut-mediated immune dysfunction in HIV-infected individuals, one or more of a GLP-2 peptide or a GLP-2 peptide analog are administered to an individual having impaired Gl tract function in an amount sufficient to cause improvement of Gl tract function, wherein the HIV- infected individual is experiencing gut-mediated immune dysfunction.

[0073] In several embodiments of the method to treat gut-mediated immune dysfunction of the disclosure, the GLP-2 peptide analog is teduglutide (SEQ ID NO:4). In another embodiment, teduglutide is administered at a dose in the range of from about 0.001 mg/kg/day to about 10 mg/kg/day, from about 0.01 mg/kg/day to about 1 mg/kg/day, from about 0.05 mg/kg/day to about 0.2 mg/kg/day, from about 0.001 mg/kg/day to about 0.01 mg/kg/day, from about 0.01 mg/kg/day to about 0.1 mg/kg/day, from about 0.1 mg/kg/day to about 1 mg/kg/day, or from about 1 mg/kg/day to about 10 mg/kg/day.

[0074] In some embodiments, improvement in Gl tract function may be observed in a time frame of less than one, one, two, three, four, five, six, seven, eight, nine, ten, eleven, twelve, or more than twelve weeks after the beginning of administration of one or more of GLP-2 peptide or GLP-2 peptide analog to the individual with gut- mediated immune dysfunction.

[0075] In another aspect of the disclosure, GLP-2 peptide, or a GLP-2 peptide analog may be used in a method for prophylaxis against gut-mediated immune dysfunction in HIV-infected individuals. In one embodiment of a method for prophylaxis against gut-mediated immune dysfunction in HIV-infected individuals, one or more of a GLP-2 peptide or a GLP-2 peptide analog are administered to an HIV-infected individual in an amount sufficient for prophylaxis against gut-mediated immune dysfunction, wherein the HIV-infected individual is experiencing gut- mediated immune dysfunction.

[0076] In another embodiment of a method for prophylaxis against gut-mediated immune dysfunction in HIV-infected individuals, the GLP-2 peptide analog is teduglutide (SEQ ID NO:4). In another embodiment, teduglutide is administered at a dose in the range of from about 0.001 mg/kg/day to about 10 mg/kg/day, from about 0.01 mg/kg/day to about 1 mg/kg/day, from about 0.05 mg/kg/day to about 0.2 mg/kg/day, from about 0.001 mg/kg/day to about 0.01 mg/kg/day, from about 0.01 mg/kg/day to about 0.1 mg/kg/day, from about 0.1 mg/kg/day to about 1 mg/kg/day, or from about 1 mg/kg/day to about 10 mg/kg/day.

[0077] In another embodiment, prophylaxis against gut-mediated immune dysfunction in HIV-infected individuals occurs in a time frame of less than one, one, two, three, four, five, six, seven, eight, nine, ten, eleven, twelve, or more than twelve weeks after the beginning of administration of one or more of GLP-2 peptide or GLP- 2 peptide analog to the individual.

EXAMPLES

[0078] To further illustrate these embodiments, the following examples are provided. These examples are not intended to limit the scope of the claimed invention, which should be determined solely on the basis of the attached claims.

Example 1 - Treatment of Gut-Mediated Immune Dysfunction in HIV- infected Individuals

[0079] A randomized, double-blind, placebo-controlled trial can be conducted to assess the effects of GLP-2 peptide or GLP-2 peptide analog treatment in HIV- infected individuals having gut-mediated immune dysfunction. HIV-infected individuals having gut-mediated immune dysfunction can be identified. The identified individuals can be divided into two groups. Individuals in Group 1 can be treated with GLP-2 peptide or GLP-2 peptide analog and individuals in Group 2 can be treated with a placebo. Intestinal absorptive capacity, regeneration of mucosal tissue, apoptosis of mucosal tissue, HIV-associated Gl tract damage, and/or microbial translocation can be measured in individuals from both groups and measurements from the two groups can be compared.

Example 2 - Prophylaxis of Gut-Mediated Immune Dysfunction in HIV- infected Individuals

[0080] Similar to Example 1 , a randomized, double-blind, placebo-controlled trial can be conducted to assess the prophylactic effects of GLP-2 peptide or GLP-2 peptide analog treatment in HIV-infected individuals not having gut-mediated immune dysfunction. HIV-infected individuals not having gut-mediated immune dysfunction can be identified. The identified individuals can be divided into two groups. Individuals in Group 1 can be treated with GLP-2 peptide or GLP-2 peptide analog and individuals in Group 2 can be treated with a placebo. Onset or lack of onset of gut-mediated immune dysfunction in individuals from both groups can be assessed and compared. Additionally, intestinal absorptive capacity, regeneration of mucosal tissue, apoptosis of mucosal tissue, HIV-associated Gl tract damage, and/or microbial translocation can be measured in individuals from both groups and measurements from the two groups can be compared.

Example 3 - GLP-2 Peptide or GLP-2 Peptide Analog in Combination with

HAART

[0081] A randomized, double-blind, placebo-controlled trial can be conducted to assess the effects of GLP-2 peptide or GLP-2 peptide analog treatment in combination with HAART. HIV-infected individuals undergoing HAART can be identified. The identified individuals can be divided into two groups. Individuals in Group 1 can be treated with GLP-2 peptide or GLP-2 peptide analog and individuals in Group 2 can be treated with a placebo. Absorption of antiretroviral agents, immune activation and inflammation, HIV-associated Gl tract damage, and/or intestinal absorption can be measured in individuals from both groups and measurements from the two groups can be compared. Example 4 - Long-Term Clinical Trials Using GLP-2 Peptide or GLP-2

Peptide Analog in HIV-infected Individuals

[0082] Any of the trials disclosed in Examples 1 -3 can be adapted for a long-term clinical trial. In addition to the indications or symptoms assessed or measured in Examples 1 -3, long-term tolerance of administration of GLP-2 peptide or GLP-2 peptide analog in HIV-infected individuals can be measured and assessed. The durability of the effects of long-term administration of GLP-2 peptide or GLP-2 peptide analog on Gl tract function can also be measured and assessed.

[0083] It will be apparent to those having skill in the art that many changes may be made to the details of the above-described embodiments without departing from the underlying principles of the invention. The scope of the present invention should, therefore, be determined only by the following claims.

Claims

Claims:

1 . A method of treating gut-mediated immune dysfunction in an HIV-infected individual, comprising the step of administering to an HIV-infected individual having gut-mediated immune dysfunction one or more of a GLP-2 peptide or a GLP-2 peptide analog in an amount effective to cause improvement in gastrointestinal tract function.

2. The method of claim 1 , wherein the GLP-2 peptide analog is human GLP-2 (SEQ ID NO:3).

3. The method of claim 1 , wherein the GLP-2 peptide or the GLP-2 peptide analog is administered at a dose of between about 0.001 mg/kg/day and about 10 mg/kg/day.

4. The method of claim 2, wherein the human GLP-2 is administered at a dose of between about 0.05 mg/kg/day and about 0.1 mg/kg/day.

5. The method of claim 1 , wherein the improvement in gastrointestinal tract function is observed within about four weeks after the beginning of administering the GLP-2 peptide or GLP-2 peptide analog to the individual.

6. A method for prophylaxis against gut-mediated immune dysfunction in an HIV- infected individual, comprising the step of administering to an HIV-infected individual one or more of a GLP-2 peptide or a GLP-2 peptide analog in an amount effective for prophylaxis against gut-mediated immune dysfunction.

7. The method of claim 6, wherein the GLP-2 peptide analog is human GLP-2 (SEQ ID NO:3).

8. The method of claim 6, wherein the GLP-2 peptide or the GLP-2 peptide analog is administered at a dose of between about 0.001 mg/kg/day and about 10 mg/kg/day.

9. The method of claim 7, wherein human GLP-2 is administered at a dose of between about 0.05 mg/kg/day and about 0.1 mg/kg/day.

10. The method of claim 6, wherein the prophylaxis against gut-mediated immune dysfunction is observed within about four weeks after the beginning of administering the GLP-2 peptide or GLP-2 peptide analog to the individual.

1 1 . A method for prophylaxis against impairment of gastrointestinal tract function in an HIV-infected individual, comprising the step of administering to an HIV-infected individual one or more of a GLP-2 peptide or a GLP-2 peptide analog in an amount effective for prophylaxis against gut-mediated immune dysfunction.

12. The method of claim 1 1 , wherein the GLP-2 peptide analog is human GLP-2 (SEQ ID NO:3).

13. The method of claim 1 1 , wherein the GLP-2 peptide or the GLP-2 peptide analog is administered at a dose of between about 0.001 mg/kg/day and about 10 mg/kg/day.

14. The method of claim 12, wherein human GLP-2 is administered at a dose of between about 0.05 mg/kg/day and about 0.1 mg/kg/day.

15. The method of claim 1 1 , wherein the prophylaxis against impairment of gastrointestinal tract function is observed within about four weeks after the beginning of administering the GLP-2 peptide or GLP-2 peptide analog to the individual.