WO2017085642A1

WO2017085642A1 - Pharmaceutical composition

Info

Publication number: WO2017085642A1
Application number: PCT/IB2016/056901
Authority: WO
Inventors: Мыкола Ивановыч ГУМЕНЮК
Original assignee: Товарыство З Обмэжэною Видповидальнистю Мэдычный Центр "Мтк"
Priority date: 2015-11-17
Filing date: 2016-11-16
Publication date: 2017-05-26
Also published as: MD20180049A2; MD4763C1; MD4763B1

Abstract

The invention relates to a pharmaceutical composition containing arginine hydrochloride, levocarnitine and water for injections.

Description

PHARMACEUTICAL COMPOSITION

Technical field

The technical solution relates to the field of medicine, namely to means for the treatment of coronary heart disease and its consequences.

State of the art

The term coronary heart disease (IHD for short) is used to denote a group of cardiovascular diseases, which are based on myocardial damage, which is caused by disorders of the coronary circulation and arises as a result of an imbalance between the delivery and metabolic oxygen demand of the heart muscle.

Myocardial oxygen demand is determined primarily by heart rate, myocardial contractile function, heart size and blood pressure. An increase in any of these indicators increases myocardial oxygen demand. Under normal conditions, there is a sufficient reserve for dilatation of the coronary arteries, providing, if necessary, a five-fold increase in coronary blood flow. The limitation of myocardial blood supply occurs due to a decrease in the lumen of the coronary artery by more than 50%. Inconsistency of coronary blood flow with the metabolic needs of the heart muscle is always accompanied by myocardial ischemia, it is clinically manifested by an attack of angina pectoris, severe heart rhythm and conduction disorders, in some cases the occurrence of myocardial infarction, sometimes sudden death occurs.

According to Order N ° 54 of the Ministry of Health of Ukraine in 2001, the allocation of such forms of coronary heart disease is provided:

1. Sudden coronary death:

- sudden clinical coronary death with successful resuscitation;

- sudden coronary death (death).

2. Angina pectoris:

- stable angina with an indication of the functional class (FC);

- stable angina, angiographically intact vessels (coronary syndrome X);

- vasospastic angina pectoris (angiospastic, spontaneous, variant, Prinzmetal).

3. Unstable angina pectoris:

- primary angina pectoris;

- progressive angina pectoris;

- early post-infarction angina (from 3 to 28 days of myocardial infarction).

4. Acute myocardial infarction:

- acute myocardial infarction with the presence of a pathological Q wave;

- acute myocardial infarction without a pathological Q wave;

- acute myocardial infarction (indefinite);

- recurrent myocardial infarction (from 3 to 28 days);

- repeated myocardial infarction (after the 28th day);

- acute coronary insufficiency; 5. Complications of myocardial infarction (indicating the time of occurrence):

- acute heart failure (classes according to T. Killip I-IV);

- violation of heart rhythm and conduction;

- cardiac rupture, external (with hemopericardium, without hemopericardium) and internal (interventricular septal defect, atrial septal defect, tendon chord rupture, papillary muscle rupture);

- thromboembolism of various localization;

- acute aneurysm of the heart;

- Dressler's syndrome;

- post-infarction angina (after 3 to 28 days).

6. Cardiosclerosis.

- Focal cardiosclerosis:

- post-infarction cardiosclerosis (indicating the history of myocardial infarction, its location and time of development);

- chronic heart aneurysm;

- focal cardiosclerosis (without indicating myocardial infarction).

- Diffuse cardiosclerosis.

7. A painless form of coronary heart disease.

The main etiological factor of coronary heart disease is coronary artery atherosclerosis. Important factors contributing to its development are: hyperlipidemia, arterial hypertension, high-calorie diet, obesity, diabetes, smoking, physical inactivity, genetic predisposition, age, male gender. Myocardial ischemia, which is associated with damage to coronary arteries of a different origin (rheumatism, septic endocarditis, etc.), as well as hemodynamic disorders of non-coronary origin (aortic heart defects), does not belong to IHD and is considered as a secondary syndrome in the framework of nosological forms.

Coronary atherosclerosis occurs in 95% of patients with coronary artery disease. An increasing atherosclerotic plaque, hemorrhage at the base of the plaque with its decay, and the formation of a blood clot lead to a narrowing of the lumen or a complete violation of patency, resulting in an organic obstruction of the coronary artery.

Myocardial endothelium also produces vasodilators: prostaglandin, prostacyclin, and endothelial relaxing factor (abbreviated ERF), nitric oxide (NO), which are also antiplatelet agents. In patients with coronary artery disease, the dynamic balance between endothelial vasodilating and antiplatelet factors, on the one hand, and vasoconstrictive and proaggregate, on the other, is disturbed. The latter begins to prevail, which leads to the development of coronary spasm and increased platelet aggregation. In the progression of coronary heart disease, an important role is given to disorders in the hemostatic system: changes in platelet function, increased blood viscosity, inhibition of fibrinolysis, which can cause the development of intravascular thrombosis. The underdeveloped network of collateral coronary blood supply matters. It is proved that the overproduction of catecholamines, which happens in case of stressful situations, can cause myocardial damage. Attention should be paid to the consequences of functional physical overload of the heart. One of the main medicines for the treatment of IHD patients is arginine. Arginine (δ-guanidine-a-aminovalerianic acid) is the main a-amino acid, the L-form of which is a semi-essential amino acid.

In vascular smooth muscle cells, including coronary arteries, arginine interacts with SH groups (nitrate receptors) to form nitric oxide (NO), which is similar in structure and action to ERF. Arginine, due to its properties, expands arterioles and peripheral veins, reduces total peripheral vascular resistance, reduces venous outflow, and also dilates pulmonary vessels, helps reduce resistance in the pulmonary circulation and leads to regression of symptoms in pulmonary edema, reduces final diastolic pressure and ventricular volume due to which the need for myocardium in oxygen decreases. Arginine also dilates coronary arteries and prevents their spasm, reduces diastolic stress of the ventricular wall, resulting in improved coronary blood flow in the ischemic zone.

The prior art method for the complex treatment of coronary heart disease - the drug Tivortin (web page at http://mozdocs.kiev. Ua / likiview.php? Id = 23530), which contains arginine in the form of arginine hydrochloride and water for injection .

It is known from open sources that in cardiometabolic therapy, substances of the so-called class of metabolic correctors are widely used - inhibitors of the oxidation of free fatty acids, which affect the activity of enzymes involved in biochemical reactions.

A well-known representative of these inhibitors is levocarnitine (also known as L-carnitine). Levocarnitine facilitates the entry of long-chain fatty acids into the mitochondria of cells, thus providing a substrate for oxidation and energy production, which significantly improves the recovery of heart muscle cells in myocardial infarction. Levocarnitine inhibits the formation of atherosclerotic plaques in blood vessels and promotes the resorption of plaques that have already formed.

Thus, due to its properties, levocarnitine reduces the contribution to the development of coronary heart disease such factors as hyperlipidemia, high-calorie diet, obesity, diabetes mellitus, smoking, lack of exercise, age.

The prior art does not disclose pharmaceutical compositions for the treatment of coronary artery disease containing both arginine and levocarnitine. The publications indicate the use of a drug containing arginine and a drug containing levocarnitine in the treatment of coronary heart disease - but these drugs are not used together, the administration is carried out with an interval of time.

Disclosure of invention

The objective of the technical solution is to increase the effectiveness of complex treatment of coronary heart disease, improve approaches to the prevention and treatment of the consequences of coronary heart disease, improve the quality of life of patients by reducing the frequency of angina attacks, and improve survival rates of patients.

The problem is solved using a pharmaceutical composition that contains arginine hydrochloride, levocarnitine and water for injection, in the following ratio, in mg / ml: arginine hydrochloride 10-100

levocarnitine 5-50

water for injection up to 1 ml

Advantageously, the pharmaceutical composition according to the technical solution may have the following composition, in mg / ml:

arginine hydrochloride 37-47

levocarnitine 16-24

water for injection up to 1 ml

arginine hydrochloride 42

levocarnitine 20

water for injection up to 1 ml

Advantageously, the pharmaceutical composition according to the technical solution can be used for the treatment of coronary heart disease, in particular, for the treatment of such forms of coronary heart disease as angina pectoris, angina pectoris, spontaneous angina pectoris, myocardial infarction, post-infarction cardiosclerosis, heart rhythm disturbance, heart failure.

Arginine is used in pharmaceuticals in the form of a salt such as arginine hydrochloride, hereinafter in the text under the term “arginine” we will mean precisely such a form of arginine as arginine hydrochloride.

Option (s) for carrying out the invention

The claimed pharmaceutical composition is a clear solution, the dosage form for use is a solution for infusion. A method of manufacturing the claimed pharmaceutical composition is shown further in examples 1-16.

Example 1

90 liters of water for injection are poured into a stainless steel reactor. Water is saturated with nitrogen to a residual amount of oxygen in water of not more than 300 ppm. Then, 1 kg of arginine hydrochloride is loaded into the reactor and stirred for a certain time until a clear solution is obtained. Then, 0.5 kg of levocarnitine is loaded into the reactor and stirred for a certain time until a clear solution is obtained. Then, water for injection is added to the reactor, bringing the solution volume to 100 liters. The resulting solution is saturated with nitrogen to a residual amount of oxygen of not more than 300 ppm, after which the solution is filtered through two successive membrane filters. After filtration, the solution is poured into glass or plastic containers (bottles).

Example 2

The claimed pharmaceutical composition is prepared analogously to the method described in example 1, while loading arginine hydrochloride in an amount of 1 kg and levocarnitine in an amount of 1, 5 kg.

Example 3

The claimed pharmaceutical composition is prepared analogously to the method described in example 1, while loading arginine hydrochloride in an amount of 1 kg and levocarnitine in an amount of 3 kg.

Example 4 The claimed pharmaceutical composition is prepared analogously to the method described in example 1, while loading arginine hydrochloride in an amount of 1 kg and levocarnitine in an amount of 5 kg

Example 5

The claimed pharmaceutical composition is prepared analogously to the method described in example 1, while loading arginine hydrochloride in an amount of 3 kg and levocarnitine in an amount of 0.5 kg.

Example 6

The claimed pharmaceutical composition is prepared analogously to the method described in example 1, while loading arginine hydrochloride in an amount of 3 kg and levocarnitine in an amount of 1, 5 kg.

Example 7

The claimed pharmaceutical composition is prepared analogously to the method described in example 1, while loading arginine hydrochloride in an amount of 3 kg and levocarnitine in an amount of 3 kg

Example 8

The claimed pharmaceutical composition is prepared analogously to the method described in example 1, while loading arginine hydrochloride in an amount of 3 kg and levocarnitine in an amount of 5 kg

Example 9

The claimed pharmaceutical composition is prepared analogously to the method described in example 1, while loading arginine hydrochloride in an amount of 6 kg and levocarnitine in an amount of 0.5 kg.

Example 10

The claimed pharmaceutical composition is prepared analogously to the method described in example 1, while loading arginine hydrochloride in an amount of 6 kg and levocarnitine in an amount of 1, 5 kg.

Example 11

The claimed pharmaceutical composition is prepared analogously to the method described in example 1, while loading arginine hydrochloride in an amount of 6 kg and levocarnitine in an amount of 3 kg.

Example 12

The claimed pharmaceutical composition is prepared analogously to the method described in example 1, while loading arginine hydrochloride in an amount of 6 kg and levocarnitine in an amount of 5 kg

Example 13

The claimed pharmaceutical composition is prepared analogously to the method described in example 1, while loading arginine hydrochloride in an amount of 10 kg and levocarnitine in an amount of 0.5 kg.

Example 14

The claimed pharmaceutical composition is prepared analogously to the method described in example 1, while loading arginine hydrochloride in an amount of 10 kg and levocarnitine in an amount of 1, 5 kg.

Example 15 The claimed pharmaceutical composition is prepared analogously to the method described in example 1, while loading arginine hydrochloride in an amount of 10 kg and levocarnitine in an amount of 3 kg

Example 16

The claimed pharmaceutical composition is prepared analogously to the method described in example 1, while loading arginine hydrochloride in an amount of 10 kg and levocarnitine in an amount of 5 kg

The manufacture of the claimed pharmaceutical composition is also possible in other ways.

To study the pharmaceutical effect of the use of the claimed pharmaceutical composition, a number of studies have been conducted.

At the first stage, preclinical studies were conducted to study the specific activity of the claimed pharmaceutical composition.

Preclinical studies were performed on rats with a model of pituitrin-isadrine myocardial infarction (abbreviated as MI), which were administered the claimed pharmaceutical composition, as well as other drugs - comparison drugs.

In the process of preclinical studies, the following indicators of the state of the animal organism were determined:

creatine phosphokinase level (abbreviated as CPK);

the level of myocardial isoenzyme of creatine phosphokinase (abbreviated as MV-KFK);

level of adenosine triphosphoric acid (abbreviated ATP);

malate level;

lactate level;

catalase level;

- the level of glutathione peroxidase (abbreviated GPO);

the level of aldehyde phenylhydrazones (abbreviated as AFH);

the level of carboxylphenylhydrazones (abbreviated CFG);

- morphological and functional characteristics of animal cardiomyocytes.

As morphological and functional characteristics of cardiomyocytes of animals, such indicators as:

area of the nuclei of cardiomyocytes;

density of nuclei per 1 mm ^{2 of} the myocardium area;

- the concentration of RNA in the cytoplasm of cardiomyocytes;

- the density of the nuclei of apoptotic and destructively altered cardiomyocytes per 1 mm ^{2 of} the myocardium.

To determine the effect of the content of arginine and levocarnitine components in the claimed pharmaceutical composition on the pharmaceutical effect, studies were conducted at various concentrations of arginine and levocarnitine in the claimed pharmaceutical composition. The concentrations of arginine and levocarnitine in the claimed pharmaceutical composition were varied from 10 to 100 mg / ml for arginine and from 5 to 50 mg / ml for levocarnitine. The research results are shown in table 1.

According to the results of the studies it is clear that the introduction of the claimed pharmaceutical composition with different contents of arginine and levocarnitine led to a decrease in the activity of CPK and MV-CPK in the blood. Significant decrease CPK and MV-CPK in the blood is seen with an increase in the concentration of arginine / levocarnitine to 42/20 mg / ml, respectively - a further increase in the concentration of arginine and levocarnitine in the claimed pharmaceutical composition does not significantly increase the pharmaceutical effect.

Studies have been conducted to determine indicators of energy metabolism in the myocardium of animals with MI. As a result, an increase in ATP level and a decrease in lactate level were observed.

Studies have also been conducted that show a decrease in oxidative stress markers of aldehyde phenylhydrazones and carboxylphenylhydrazones, and an increase in the activity of antioxidant enzymes - catalase and glutathione peroxidase. The most pronounced pharmaceutical effect according to the above indicators is seen with an increase in the concentration of arginine / levocarnitine to the level of 42/20 mg / ml - a further increase in the concentration of arginine and levocarnitine in the claimed pharmaceutical composition does not lead to a significant increase in the pharmaceutical effect.

The results of histological studies showed a decrease in changes in morphological and functional indicators of cardiomyocytes under the influence of ischemia. A significant increase in the density of cardiomyocyte nuclei was recorded in the animal myocardium of the experimental group, which indicated a decrease in cell death and the preservation of a healthy myocardial structure. The most significant results are visible with an increase in the concentration of arginine / levocarnitine to the level of 42/20 mg / ml - a further increase in the concentration of arginine and levocarnitine in the claimed pharmaceutical composition does not significantly increase the pharmaceutical effect.

Table 1

The effect of concentrations of arginine and levocarnitine in the claimed pharmaceutical composition on indicators of the state of the animal

Core area

07.8+ 08.3+ 08.5+ 09.3+ 12.7+ 12.75+ 12.78+ 12.81+ 12.82+ cardiomyocytes,

0.2 0.21 0.23 0.3 0.30 0.3 0.4 0.3 0.35 μm ²

The density of cores on

6650 + 1 6876 + 1 7000 + 1 7076.4 7851.0 7851.5 7851.7 7852 + 1 7852.2 1 mm ² area

77 82 83 +176 +220.0 +150.5 +180.1 65 +172 myocardium

Concentration

RNA in the cytoplasm 0.050+ 0.055+ 0.057+ 0.060+ 0.077+ 0.078+ 0.079+ 0.081+ 0.083+ cardiomyocytes, 0.002 0.002 0.002 0.002 0.002 0.002 0.001 0.001 0.002 EOP

Core density

apoptotic and

destructively

889.5+ 700.1+ 726.5+ 735.3+ 600.0+ 559.8+ 559.5+ 559.1+ 559.0+ modified

11.0 12.1 11.3 12.6 13.0 12.5 12.0 11.0 12.3 cardiomyocytes

on 1 mm ² square

myocardium

To compare the pharmaceutical effects of the action of separate arginine, separately levocarnitine, and arginine and levocarnitine together, a preclinical study was conducted on rats with a model of pituitrin-isadrine myocardial infarction (MI).

To conduct these studies were used:

- a drug that is a claimed pharmaceutical composition containing 42 mg / ml arginine and 20 mg / ml levocarnitine;

- the first reference drug containing arginine in an amount of 42 mg / ml;

- the second reference drug containing levocarnitine in an amount of 20 mg / ml. Animals were divided into the following groups:

- intact animals (healthy animals);

- IM (control), these are animals with a model of pituitrin-isadrine myocardial infarction;

- IM + arginine, these are animals with a model of pituitrin-isadrine myocardial infarction, which were injected with the first comparison drug;

- IM + levocarnitine, these are animals with a model of pituitrin-isadrine myocardial infarction, which were injected with a second comparison drug;

- IM + Technical solution, these are animals with a model of pituitrin-isadrine myocardial infarction, which were administered the claimed pharmaceutical composition.

As is known, an increase in the activity of creatine phosphokinase (CPK) and the myocardial isoenzyme KFK (MV-KFK) indicate ischemic damage to the myocardium.

According to biochemical studies, it was found that the introduction of animals with MI arginine, levocarnitine and the claimed pharmaceutical composition led to a decrease in the activity of CPK and MV-CPK in the blood, and a group of animals that received the claimed pharmaceutical composition, marked less pronounced hyperfermentemia - the research results are shown in table 2.

This indicates a pronounced cardioprotective effect of the claimed pharmaceutical composition, which exceeds the effect of arginine and levocarnitine.

table 2

The content of biochemical markers of ischemic myocardial damage in blood serum

- changes are significant in relation to the animals of the control group (p <0.05).

Also, the claimed pharmaceutical composition more pronouncedly improves energy metabolism in the myocardium of animals with MI. In animals receiving the claimed pharmaceutical composition, a significant increase in ATP level was observed against an increase in malate, which indicated the normalization of the Krebs cycle and a decrease in the level of lactate, which demonstrated inhibition of glycolysis - the research results are shown in table 3.

Table 3

Indicators of energy metabolism in the cytosolic fraction of the heart of animals

According to the strength of the effect on the ΝΟ / reduced thiols, the claimed pharmaceutical composition also turned out to be the leader.

The analysis of the data obtained, shown in table 4, demonstrates the antioxidant effect of arginine, levocarnitine and the claimed pharmaceutical composition - a decrease in the markers of oxidative stress AFG and CPG is seen. Also in the myocardium of animals treated with the claimed pharmaceutical composition, a significant increase in the activity of antioxidant enzymes - catalase and GPO was revealed, which gave the antioxidant effect of the claimed pharmaceutical composition a more pronounced character compared to the similar effect of the comparison drugs.

Table 4

Indicators of the pro and antioxidant system

in the cytosolic fraction of the heart of animals IM +

Intact IM IM + IM +

Indicators Technical animals (Control) arginine levocarnitine

decision

Catalase, mkat / mg 17.2 + 1.5 8.70 + 0.77 10.5 + 0.71 10.9 + 0.75 14.3 + 1.12 * GPO. 154.2 + 11.2 73.7 + 6.83 80.4 + 7.55 81.8 + 7.80 93.7 + 8.81 * μmol / mg / min.

AFG, c.u./g 10.2 + 1.21 35.7 + 2.11 29.7 + 2.16 * 32.1 + 2.00 * 18.1 + 1.17 *

KFG, at. E. / g 6.52 + 0.71 19.7 + 1.71 17.0 + 1.12 * 18.6 + 1.10 * 14.31 + 0.87 *

The powerful cardioprotective effect of the technical solution is also evidenced by histological data. It was found that the administration to animals with MI of the claimed pharmaceutical composition leads to a decrease in the morphological and functional parameters of cardiomyocytes under the action of ischemia. A significant increase in the density of cardiomyocyte nuclei was recorded in the animal myocardium of the experimental group, which indicated a decrease in cell death and the preservation of a healthy myocardial structure - the results of the studies are shown in table 5.

Table 5

Morphofunctional characteristics of animal cardiomyocytes

From the data of table 5 it is seen that the claimed pharmaceutical composition has the greatest cardioprotective effect, since it simultaneously with a decrease in the death of cardiomyocytes increases the RNA content in the cytoplasm cardiomyocytes, which indicates increased translation in the cell and activation of reparative processes.

From the foregoing, we can conclude that the claimed pharmaceutical composition based on arginine and levocarnitine has a pronounced cardioprotective effect by activating the antioxidant system and optimizing the energy balance of cells. The pronounced cardioprotective effect of the claimed pharmaceutical composition is manifested in a decrease in the biochemical parameters of acute myocardial ischemia and the preservation of a healthy histostructure of animal heart tissues with the MI model.

The analysis of the data in table 2-5 shows that the claimed pharmaceutical composition, in comparison with preparations containing only arginine and levocarnitine separately, has a more pronounced protective effect and has an unexpected technical result - as a result of the analysis of the data obtained during the studies, we can speak about the manifestation of the claimed pharmaceutical composition of unexpected synergistic effect.

In pharmacology, a special case of synergism, in which the effect of the simultaneous use of two or more active substances exceeds the total effect of the use of each of these substances separately, is called potentiation. As will be shown later by calculations, the use of such components as arginine and levocarnitine together in the claimed pharmaceutical composition gives a potentiation effect, respectively, according to the technical solution, the pharmaceutical composition exhibits an unpredictable synergistic effect.

The calculation of the pharmaceutical effect for each of the three drugs and the determination of whether the potentiation effect is present was carried out according to the following procedure. First, the maximum possible pharmaceutical effect was calculated, which is the difference between the values of one of the indicators of the state of the organism in animals of the "intact animals" group and the corresponding indicator of animals of the "IM (control)" group. The pharmaceutical effect for the first comparison drug was defined as the difference between the values of one of the indicators of the state of the body in animals of the IM (control) group and the corresponding indicator of the animals of the IM + arginine group, and was expressed as a percentage relative to the maximum possible pharmaceutical effect. The pharmaceutical effect for the second comparison drug was defined as the difference between the values of one of the indicators of the state of the body in animals of the IM (control) group and the corresponding indicator of the animals of the IM group (levocarnitine), and was expressed as a percentage relative to the value of the maximum possible pharmaceutical effect. The pharmaceutical effect for the drug, which is the claimed pharmaceutical composition, was determined as the difference between the values of one of the indicators of the state of the body in animals of the IM (control) group and the corresponding indicator of the animals of the IM + Technical solution group, and was expressed as a percentage relative to the maximum possible value pharmaceutical effect. After that, the expected total pharmaceutical effect of using the first comparison drug and the second comparison drug together was calculated by summing the pharmaceutical effects of the first comparison drug and the second drug. Then the difference between the pharmaceutical effect of the drug, which is the claimed pharmaceutical composition, and the estimated expected total pharmaceutical effect of the use of the first comparative drug and the second comparison drug together - if the pharmaceutical effect for the drug, which is the claimed pharmaceutical composition, exceeds the calculated expected total pharmaceutical effect of the application together the first comparison drug and the second comparison drug, one can judge the presence of potentiation of action Wii arginine and levocarnitine.

For example, according to biochemical studies, the use of all three drugs led to a decrease in the rate of CPK activity in the blood. The maximum possible pharmaceutical effect is 423.2. The pharmaceutical effect for arginine is 136.1, which is 32.16% of 423.2, the pharmaceutical effect for levocarnitine is 23.8, which is 5.6% of 423.2. Accordingly, the expected total pharmaceutical effect from the use of two comparison drugs is 32.16% + 5.6% = 37.76%. The pharmaceutical effect for the drug, which is the claimed pharmaceutical composition, is 172.2, which is 40.69% of 423.2. The value of the pharmaceutical effect for the drug, which is the claimed pharmaceutical composition, exceeds the value of the expected total pharmaceutical effect from the use of two comparison drugs: 40.69% - 37.76% = 2.93%.

Calculations of the pharmaceutical effect of all three drugs were carried out for each specific indicator of the state of the animal organism.

With the use of each drug, a decrease in the activity index of MV-CPK in the blood was observed. The pharmaceutical effect expressed as a percentage for the arginine preparation is 31.42%, the pharmaceutical effect expressed as a percentage for the levocarnitine preparation is 12.26%. The expected total pharmaceutical effect from the use of two comparison drugs is 31.42% + 12.26% = 43.68%. The pharmaceutical effect for the drug, which is the claimed pharmaceutical composition, is 48.66%, which exceeds the expected total pharmaceutical effect from the use of two comparison drugs to reduce the activity of MV-CPK in the blood by: 48.66% - 43.68% = 4, 98%

With the use of each drug, an increase in the level of ATP in the blood was observed. The pharmaceutical effect expressed as a percentage for the arginine preparation is 6.98%, the pharmaceutical effect expressed as a percentage for the levocarnitine preparation is 10.08%. The expected total pharmaceutical effect from the use of the two comparison products is 6.98% + 10.08% = 17.0 5%. The pharmaceutical effect for the drug, which is the claimed pharmaceutical composition, is 37.21%, which exceeds the expected total pharmaceutical effect from the use. two comparison drugs to increase ATP indices by: 37.21% - 17.05% = 20.16%.

With the use of each drug, an increase in the level of malate in the blood was observed. The pharmaceutical effect expressed as a percentage for arginine is 4.17%, the pharmaceutical effect expressed as a percentage for levocarnitine is 41.67%. The expected total pharmaceutical effect of the use of two comparison drugs is 4.17% + 41.67% = 45.83%. The pharmaceutical effect for the drug, which is the claimed pharmaceutical composition, is approximately 100%, which exceeds the expected total pharmaceutical effect of the use of two comparison drugs to increase malate by 100% - 45.83% = 54.17%.

With each drug, a decrease in blood lactate levels was observed. The pharmaceutical effect expressed as a percentage for the arginine preparation is 14.10%, the pharmaceutical effect expressed as a percentage for the levocarnitine preparation is 18.68%. The expected total pharmaceutical effect from the use of two comparison drugs is 14.10% + 18.68% = 32.78%. The pharmaceutical effect for the drug, which is the claimed pharmaceutical composition, is 44.32%, which exceeds the expected total pharmaceutical effect from the use of two comparative drugs to reduce lactate indices by: 44.32% - 32.78% = 11.54%.

With the use of each drug, an increase in the activity of catalase in the blood was observed. The pharmaceutical effect expressed as a percentage for an arginine preparation is 21.18%, the pharmaceutical effect expressed as a percentage for a levocarnitine preparation is 25.88%. The expected total pharmaceutical effect from the use of two comparison drugs is 21.18% + 25.88% = 47.06 The pharmaceutical effect for the drug, which is the claimed pharmaceutical composition, is 65.88%, which exceeds the expected total pharmaceutical effect from the use of two drugs comparisons to increase the activity of catalase in the blood by: 65.88% - 47.06% = 18.82%.

With the use of each drug, an increase in the activity of GPO in the blood was observed. The pharmaceutical effect expressed as a percentage for arginine is 8.32%, the pharmaceutical effect expressed as a percentage for levocarnitine is 10.06%. The expected total pharmaceutical effect from the use of two comparison drugs is 8.32% + 10.06% = 18.39%. The pharmaceutical effect for the drug, which is the claimed pharmaceutical composition, is 24.84%, which exceeds the expected total pharmaceutical effect from the use of two comparison drugs to increase blood glucose activity indicators: 24.84% - 18.39% = 6, 46 %

With the use of each drug, a decrease in the level of AFH in the blood was observed. The pharmaceutical effect is expressed as a percentage for the arginine preparation is 23.53%, the pharmaceutical effect is expressed as a percentage for the drug levocarnitine is 14.12%. The expected total pharmaceutical effect from the use of two comparison drugs is 23.53% + 14.12% = 37.65%. The pharmaceutical effect for the drug is the claimed pharmaceutical composition, is 69.02%, which exceeds the expected total pharmaceutical effect of the use of two comparison drugs to reduce the levels of APH in the blood by: 69.02% - 37.65% = 31 37%.

With the use of each drug, a decrease in the level of CFG in the blood was observed. The pharmaceutical effect expressed as a percentage for the arginine preparation is 20.49%, the pharmaceutical effect expressed as a percentage for the drug levocarnitine is 8.35%. The expected total pharmaceutical effect of the use of two comparison drugs is 20.49% + 8.35% = 28.83%. The pharmaceutical effect for the drug, which is the claimed pharmaceutical composition, is 40.90%, which exceeds the expected total pharmaceutical effect from the use of two comparison drugs to reduce blood KFG values: 40.90% - 28.83% = 12.06%.

With the use of each drug, an increase in the density of the nuclei of cardiomyocytes was observed. The pharmaceutical effect expressed as a percentage for the arginine preparation is 12.82%, the pharmaceutical effect expressed as a percentage for the levocarnitine preparation is 15.38%. The expected total pharmaceutical effect from the use of two comparison drugs is 12.82% + 15.38% = 28.21%. The pharmaceutical effect for the drug, which is the claimed pharmaceutical composition, is 48.66%, which exceeds the expected total pharmaceutical effect from the use of two comparison drugs to increase the area of the nuclei of cardiomyocytes by: 38.46% - 28.21% = 10.26% .

When using each drug, an increase in the density of nuclei per 1 mm of the myocardial area was observed. The pharmaceutical effect expressed as a percentage for the arginine preparation is 14.07%, the pharmaceutical effect expressed as a percentage for the levocarnitine preparation is 22.19%. The expected total pharmaceutical effect from the use of two comparison drugs is 14.07% + 22.19% = 36.26%. The pharmaceutical effect for the drug, which is a pharmaceutical composition according to the technical solution, is 51.05%, which exceeds the expected total pharmaceutical effect from the use of two drugs comparing the increase in core density per 1 mm2 of the myocardium by: 51.05% - 36.26% = 14.79%.

With the use of each drug, an increase in the RNA content in the cytoplasm of cardiomyocytes was observed. The pharmaceutical effect expressed as a percentage for arginine is 10.53%, the pharmaceutical effect expressed as a percentage for levocarnitine is 21.05%. The expected total pharmaceutical effect from the use of two comparison drugs is 10.53% + 21.05% = 31.58%. The pharmaceutical effect for the drug, which is the claimed pharmaceutical composition, is 78.95%, which exceeds the expected total pharmaceutical effect from the use of two comparison drugs to increase the RNA content in the cytoplasm of cardiomyocytes by: 78.95% - 31.58% = 47, 37%

With the use of each drug, a decrease in the density of the nuclei of apoptotic and destructively altered cardiomyocytes was observed. The pharmaceutical effect expressed as a percentage for the arginine preparation is 14.24%, the pharmaceutical effect expressed as a percentage for the levocarnitine preparation is 6.97%. The expected total pharmaceutical effect from the use of two comparison drugs is 14.24% + 6.97% = 21.22%. The pharmaceutical effect for the drug, which is the claimed pharmaceutical composition, is 30.71%, which exceeds the expected total pharmaceutical effect from the use of two comparison drugs in reducing the core density of apoptotic and destructively altered cardiomyocytes by: 30.71% - 21.22% = 9.50%. Thus, the calculations for each indicator of the state of the animal organism show the effect of potentiation of the simultaneous action of arginine and levocarnitine in the claimed pharmaceutical composition.

At the second stage, to study the effectiveness of the claimed pharmaceutical composition in the complex therapy of coronary heart disease, a randomized, open, comparative, parallel in three groups clinical trial was conducted on patients with acute coronary syndrome (abbreviated ACS) without persistent ST segment elevations and unstable angina pectoris.

The study was conducted on 90 patients (30 in each group) of both sexes aged 25 to 75 years, in whom a clear picture of unstable angina was recorded, or less than 24 hours after the onset of symptoms of myocardial infarction.

Patients of the main group, in addition to basic therapy, received the claimed pharmaceutical intravenous drip 1 time per day for 10 days. Patients in the first control group were prescribed basic therapy, which included nitroglycerin, aspirin and beta-blockers and arginine (in individually prescribed doses). Patients in the second control group were prescribed basic therapy, which included nitroglycerin, aspirin and beta-blockers, and levocarnitine (in individually prescribed doses).

Assessment of the effectiveness of treatment was carried out on the basis of the following criteria:

• lack of clinical and ECG parameters for signs of myocardial ischemia;

• stabilization of the state (absence of myocardial infarction, sudden death).

Additional criteria for the effectiveness of treatment for ACS were elevated levels of troponins T, KFK or MV-KFK; hemodynamic instability during the observation period from the moment of admission to the hospital; decreased contractile function of the left ventricle (less than 40%).

According to the results, during the period of inpatient treatment in patients of all three groups, positive clinical dynamics were noted: the disappearance of angina attacks, a decrease in blood pressure, an increase in exercise tolerance. On the third day after the administration of the claimed pharmaceutical composition, relapses of anginal pain were less likely to occur (20.8% of cases in the main group and 32.0% in the control groups). At the same time, there was a decrease in the need to use narcotic analgesics for the treatment of recurrent pain syndrome (22.1% in the main group, and 36.2% and 37%, respectively, in the second and third control groups). In addition, on the 3rd day of acute myocardial infarction in patients of the main group, a decrease in the number of cases of atrioventricular blockade was recorded (4.2% in the main group and 12.6% and 11.8% in the second and third control groups, respectively). When analyzing the entire hospital period, it was found that in patients receiving the claimed pharmaceutical composition, almost 3 times less than in the control, all cases of atrioventricular blockade were observed. The frequency of registration of ventricular extrasystole decreased on the 7th (by 36.2%) and 10th day (by 44.6%) of the disease.

To detect necrosis in the myocardium, the level of cardiac troponins was determined, as well as the determination of the mass of the MB fraction of CPK. The peak CPK in patients of the main group (the claimed pharmaceutical composition) was 3.16 + 0.09 μkat / l, in patients control groups - 3.21 + 0.12 μkat / l and 3.33 + 0.10 μkat / l; MV-KFK - 0.24 + 0.02, in patients of the control groups 0.25 + 0.01 μkat / L and 0.27 + 0.02 μkat / L, which indicates insignificant differences in the volume of the initially necrotic myocardium. The introduction of the claimed pharmaceutical composition in the first hours on the background of traditional therapy reduced the time to reach a peak in CPK activity in patients of the main group and amounted to 13.5 + 0.6 hours, in patients in the control groups this indicator reached 17.1 + 0.8 hours and 17, 5 + 0.5 h, respectively; MV-KFK - 9.9 + 0.4 and 13.9 + 0.6 μkat / l, respectively. Moreover, the necrotic lesion zone (calculated by the change in the activity of MV-CPK in the blood serum) was 26.4% less in the patients of the main group compared with the control ones - 45.4 + 2.1 g / equiv. and 61.6 + 2.9 g / equiv and 61.3 + 2.0 g / equiv, respectively. This was due to a decrease in the time to normalize the activity of KFK and MV-KFK in serum by an average of 8.1 hours (main group), and 9.4 hours and 9.2 hours (control groups), respectively. In comparison, the early onset of the peak of enzymes (CPK, MV-CPK) indicates a more rapid formation of the necrosis zone, and a reduction in the time for their washing out indicates the prevention of further damage to healthy cardiomyocytes in patients of the main group (see table 6).

Table 6

Comparison results using paired student t-test of biomarkers for each group of patients

* Conclusion made at significance level

gcritic = 2.012 at f = 46

gcritic = 2.011 at f = 47

In the course of the study, a number of positive general clinical changes were also noted: in the main observation group, the reverse development of the pain syndrome was faster than in the control ones. So, in the first 12 hours after the development of intense pain, there was no significant difference in its severity between the groups. On the third day of treatment, compared with the 1st day in three groups, the intensity of the pain syndrome significantly decreased. From the 7th day of therapy, the degree of pain decreased more pronounced in the main group compared with the control. Until the end of the observation period, this trend continued. Decrease the intensity and frequency of anginal pain was accompanied by a decrease in the need for patients of the main group in nitrates.

Surveys of patients during the study showed that the introduction of the claimed pharmaceutical composition, starting from the first days of the development of ACS, positively affects the subjective complaints of patients. Compared with the control groups in patients of the main group, up to 10 days there was a significant decrease in subjective sensations such as a feeling of fear, inner anxiety, weakness, pain in the heart or in other parts of the chest, a feeling of lack of air. Thus, the use of the claimed pharmaceutical composition against the background of traditional therapy of ACS without raising the ST segment had a positive effect on the main clinical indicators.

As for the indicators of echocardiography, they were recorded before and after 10 days from the moment of admission to the hospital. According to the echocardiogram (abbreviated Echocardiography), all three groups were statistically the same at the beginning of the study.

The dynamics of observation revealed no significant changes in the size of the cavity of the left ventricle (the final diastolic volume (abbreviated BWW) of the left ventricle) in three groups. At the same time, in the main group, in contrast to the control group, there was a significant increase in the ejection fraction (abbreviated as EF) of the LV after 7 days of treatment. When evaluating the results of a dynamic study of echocardiography in the main group against the background of standard therapy, it was found that early administration of the claimed pharmaceutical composition positively affects cardiodynamics, reducing dilatation of the LV cavity, resulting in a decrease in LV systolic volume (abbreviated as CSR) by 10 days observations. At the same time, in the control groups there was a tendency to increase the final diastolic index on the 7th and 10th day of acute myocardial infarction. The LV ejection fraction increased in patients of all groups, but its increase on the tenth day of acute myocardial infarction was more significant in the main group: 9.3%, and 6.1% and 5.7% in the control groups, respectively. The data obtained by echocardiography allow us to conclude that the use of the claimed pharmaceutical composition as part of the basic standard therapy reliably and effectively affects LV remodeling in ACS without raising the ST segment.

Assessing the overall effectiveness of the drugs was carried out using an integral variable, which included stabilization of the patient's condition, the presence of complications, cases of recurrent myocardial infarction and sudden death. In patients of the main group, one Q-forming MI and one MI without Q wave were recorded in the control groups. The reasons for the development of myocardial infarction were not directly dependent on the treatment and were caused by the duration and intensity of the pain syndrome before the start of therapy and patients' non-compliance with the prescribed motor regimen restrictions. In both cases, MI proceeded without complications and developed in the first 12 hours from the moment of admission to the hospital. In the total number of observations (85), two cases of MI were 6.67%, 6.67% in relation to 30 patients of the main group, and 6.6% in up to 30 patients of the control groups. In one of the groups, deaths from ACS were not observed. The results of the analysis of this variable by the methods of descriptive statistics (frequency and percentage in%) are shown in table 7.

Based on the results, it was concluded that the treatment efficacy groups were statistically significantly different. Thus, the use of the claimed pharmaceutical composition in the main group of patients, in addition to significantly earlier stabilization of the symptoms of ACS, allowed us to achieve a significant reduction in early post-infarction angina pectoris and ventricular tachyarrhythmia (ventricular fibrillation / ventricular tachycardia), which is life-threatening.

The conclusion about increasing the effectiveness of treatment using the claimed pharmaceutical composition was made taking into account confidence intervals. The calculation results are shown in table 8.

Thus, due to the fact that the lower limit of the 95% confidence interval for the difference in fractions is greater than the limits of the excess of the efficiency zone (0%), it can be concluded that complex therapy using the claimed pharmaceutical composition is more effective than basic therapy in control groups.

Table 7

Evaluation of the effectiveness of treatment with investigational and reference drugs

Table 8

Treatment Efficiency Analysis Results

Standard Error 8.37

Lower bound 95% CI 4.1

High limit 95% CI 36.9

Summarizing the data of preclinical and clinical studies, we can conclude that the claimed pharmaceutical composition based on 2 active substances of arginine and levocarnitine increases the effectiveness of complex therapy of coronary heart disease, improves the prevention and treatment of the consequences of coronary heart disease, improves the quality of life of patients by reducing the frequency of angina attacks and improved survival rates.

The above research results show that:

1) The pharmaceutical composition according to the claimed technical solution has a significantly greater cardioprotective effect in MI when compared with preparations containing arginine and levocarnitine separately, and is ahead of the comparison preparations in terms of activity and shows an unexpected effect of potentiation of the action of arginine and levocarnitine.

2) The pharmaceutical composition according to the claimed technical solution has a greater anti-ischemic effect when compared with preparations containing separately arginine and levocarnitine, and is ahead of the comparison preparations in terms of activity and shows an unexpected effect of potentiation of the action of arginine and levocarnitine.

3) The pharmaceutical composition according to the claimed technical solution has a greater antioxidant effect when compared with preparations containing arginine and levocarnitine separately, and is ahead of the comparison preparations in terms of activity and shows an unexpected effect of potentiation of the action of arginine and levocarnitine.

The above indicates that the claimed pharmaceutical composition according to the technical solution is highly effective and promising for implementation in medical practice as a means for the treatment of coronary heart disease and its consequences.

The examples of the implementation of the technical solution only illustrate it and do not limit it.

Claims

FORMULA

1. A pharmaceutical composition that contains arginine hydrochloride and water for injection, characterized in that it further contains levocarnitine in the following ratio, in mg / ml:

arginine hydrochloride 10-100

levocarnitine 5-50

water for injection up to 1 ml

2. The pharmaceutical composition according to paragraph 1, characterized in that it contains arginine hydrochloride, levocarnitine and water for injection in the following ratio, in mg / ml:

arginine hydrochloride 37-47

levocarnitine 16-24

water for injection up to 1 ml

3. The pharmaceutical composition according to paragraph 2, characterized in that it contains arginine hydrochloride, levocarnitine and water for injection in the following ratio, in mg / ml:

arginine hydrochloride 42

levocarnitine 20

water for injection up to 1 ml

4. The pharmaceutical composition according to paragraph 1, characterized in that it is used to treat coronary heart disease.

5. The pharmaceutical composition according to paragraph 4, characterized in that to coronary heart disease include angina pectoris, angina pectoris, spontaneous angina pectoris, myocardial infarction, post-infarction cardiosclerosis, heart rhythm disturbance, heart failure.