CA2166873A1 - Combination of a progestational agent and a nitric oxide synthase substrate and/or donor for the treatment of preeclampsia and preterm labor - Google Patents
Combination of a progestational agent and a nitric oxide synthase substrate and/or donor for the treatment of preeclampsia and preterm laborInfo
- Publication number
- CA2166873A1 CA2166873A1 CA002166873A CA2166873A CA2166873A1 CA 2166873 A1 CA2166873 A1 CA 2166873A1 CA 002166873 A CA002166873 A CA 002166873A CA 2166873 A CA2166873 A CA 2166873A CA 2166873 A1 CA2166873 A1 CA 2166873A1
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- Prior art keywords
- nitric oxide
- txa2
- donor
- pgi2
- inhibitor
- Prior art date
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K31/00—Medicinal preparations containing organic active ingredients
- A61K31/56—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids
- A61K31/565—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids not substituted in position 17 beta by a carbon atom, e.g. estrane, estradiol
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K31/00—Medicinal preparations containing organic active ingredients
- A61K31/04—Nitro compounds
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K31/00—Medicinal preparations containing organic active ingredients
- A61K31/185—Acids; Anhydrides, halides or salts thereof, e.g. sulfur acids, imidic, hydrazonic or hydroximic acids
- A61K31/19—Carboxylic acids, e.g. valproic acid
- A61K31/195—Carboxylic acids, e.g. valproic acid having an amino group
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K31/00—Medicinal preparations containing organic active ingredients
- A61K31/185—Acids; Anhydrides, halides or salts thereof, e.g. sulfur acids, imidic, hydrazonic or hydroximic acids
- A61K31/19—Carboxylic acids, e.g. valproic acid
- A61K31/195—Carboxylic acids, e.g. valproic acid having an amino group
- A61K31/197—Carboxylic acids, e.g. valproic acid having an amino group the amino and the carboxyl groups being attached to the same acyclic carbon chain, e.g. gamma-aminobutyric acid [GABA], beta-alanine, epsilon-aminocaproic acid, pantothenic acid
- A61K31/198—Alpha-aminoacids, e.g. alanine, edetic acids [EDTA]
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K31/00—Medicinal preparations containing organic active ingredients
- A61K31/28—Compounds containing heavy metals
- A61K31/295—Iron group metal compounds
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K31/00—Medicinal preparations containing organic active ingredients
- A61K31/33—Heterocyclic compounds
- A61K31/335—Heterocyclic compounds having oxygen as the only ring hetero atom, e.g. fungichromin
- A61K31/34—Heterocyclic compounds having oxygen as the only ring hetero atom, e.g. fungichromin having five-membered rings with one oxygen as the only ring hetero atom, e.g. isosorbide
- A61K31/341—Heterocyclic compounds having oxygen as the only ring hetero atom, e.g. fungichromin having five-membered rings with one oxygen as the only ring hetero atom, e.g. isosorbide not condensed with another ring, e.g. ranitidine, furosemide, bufetolol, muscarine
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K31/00—Medicinal preparations containing organic active ingredients
- A61K31/56—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids
- A61K31/57—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids substituted in position 17 beta by a chain of two carbon atoms, e.g. pregnane or progesterone
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K31/00—Medicinal preparations containing organic active ingredients
- A61K31/60—Salicylic acid; Derivatives thereof
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
- A61P13/00—Drugs for disorders of the urinary system
- A61P13/02—Drugs for disorders of the urinary system of urine or of the urinary tract, e.g. urine acidifiers
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
- A61P15/00—Drugs for genital or sexual disorders; Contraceptives
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
- A61P15/00—Drugs for genital or sexual disorders; Contraceptives
- A61P15/06—Antiabortive agents; Labour repressants
Abstract
preeclampsia and preterm labor in a pregnant female mammal are treated by administering thereto a combination of a progestin and a nitric oxide syntbase substrate, a nitric oxide donor or both, optionally in further combination with olle or more of a cyclooxygenase inhibitor, a PGI2-mimetic, a tromboxane (TXA2) inhibitor, a compound possessing TXA2-agonistic and TX2-inhibiting properties, a compound possessing TXA2-antagonistic and PGI2-memetic activities, and a TXA2 antagonist.
Description
W095/0~8 21~ ~ 8 7 3 PCT~4/02368 Comb~nat~on of a progestat~onal agent and a n~tr~c oxlde synthase substrate and/or donor for ~he treatment of preeclamps~a and preterm labor.
Backqround of the Invention This invention relates to a method for the treatment of preeclampsia and of preterm labor with the combination of a progestational agent and a nitric oxide synthase substrate, a nitric oxide donor or both, alone or in further combination with one or more of a cyclooxygenase inhibitor, a PGI2-mimetic, a thromboxane (TXA2) inhibitor, A compound possessing TXA2-agonistic and TXA2-inhibiting properties, a compound possessing TXA2 antagonistic and PGI2-memetic activities, and a TXA2 antagonist, and to pharmaceutical compositions comprising such a combination.
Preeclampsia, toxemia or eclampsia of pregnancy can be a significant health problem during pregnancy and they are the leading causes of fetal growth retardation, fetal mortality and morbidity, premature birth and maternal mortality. The etiology of the disease is largely unknown and effective therapy is not available.
Preeclampsia of pregnancy is characterized by a triad of hypertension, pathological edema and proteinuria. This disease affects 6 to 10% of all pregnancies.
Recently, nitric oxide has been shown to be endo-thelium derived relaxing factor (EDRF) from the endothel-ium of blood vessels. Nitric oxide is considered to be a major mediator in the control of vascular reactivity.
Nitric oxide is synthesized from L-arginine by nitric oxide synthase located in endothelial cells. Nitric Oxide can also be generated by application of various nitric oxide donors such as sodium nitroprusside, nitro-glycerin, glyceryl trinitrite, SIN-1, isosorbid mono-nitrite, isosorbid dinitrite, etc.
Treatment of pregnant rats with nitric oxide syn-thase inhibitors, which are analogues of L-arginine (such as L-NAME, N- nitro-L-arginine methyl ester) results in SUBSTITUT~ SHEET(RULE 26) W095/0~8 PCT~ ~4/02368 2~6873 elevated blood pressure, fetal retarded growth and pro-teinuria. Thus, inhibition of nitric oxide synthesis produces conditions and symptoms identical to preeclampsia of pregnancy and establishes that preeclampsia is the direct result of the decrease in nitric oxide synthesis and/or a change in the regulation of vascular tone. These conditions give rise to in-creased blood pressure, decreased blood flow to the fetus, retarded fetal development and proteinuria.
Agents which raise nitric oxide levels therefore are useful in the treatment of preeclampsia of pregnancy.
Since nitric oxide donors also reduce contractility of the uterus during pregnancy, nitric oxide donors are also useful for use in preterm labor.
The nitric oxide effects on smooth muscle depend upon the activation of guanylate cyclase and generation of cGMP to produce relaxation and this step is progesterone dependent. Thus, combinations of nitric oxide donors with progesterone are particularly efficacious for the treatment of preeclampsia and of preterm labor.
EP O 441 119 A2 discloses the use of L-arginine in the treatment of hypertension and other vascular dis-orders. It suggests that the me~h~n; ~m by which L-arginine is effective for this purpose is because it may be the physiological precursor of "the most powerful endothelial-derived releasing factor, nitric oxide." The use of L-arginine in combination with other pharmaceu-tically active agents is not discussed in this publica-tion.
Objects of the Invention It is an object of the invention to provide a method for the prevention and treatment of preeclampsia with a combination of a progestational agent and a nitric oxide substrate and/or donor.
It is another object to provide such a method in which a progestational agent is used in combination with SU8STiTU T E ~HEET (RULE 26~
216~873 W095/0~8 PCT~4/02368 .
.. .
~, : , . !
a nitric oxide substrate and/or donor for the prevention and treatment of preeclampsia.
It is a further object to provide a method for the prevention and treatment of preterm labor using a pro-gestational agent in combination with a nitric oxide substrate and/or donor.
A further object is the provision of pharmaceutical compositions useful in practicing the methods of this invention.
Other objects will be apparent to those skilled in the art to which this invention pertains.
Summary of the Invention In a method aspect, this invention relates to a method of treating at least one of preeclampsia and pre-term labor in a pregnant female which comprises admini-stering to a pregnant female manifesting the symptoms thereof, (a) a progestational agent and (b) one or both of a nitric oxide synthase substrate and a nitric oxide donor, alone or in further combination with one or more of a cyclooxygenase inhibitor, a PGI2-mimetic, a throm-boxane (TXA2) inhibitor, a compound possessing TXA2-agonistic and TXAz-inhibiting properties, a compound pos-sessing TXA2-antagonistic and PGl2-memetic activities, and a TXA2 antagonist, in amounts effective to ameliorate the symptoms thereof, the amount of the progesta~ional agent administered being bioequivalent to 50-300 mg. of in-jected progesterone and the amount of the nitric oxide synthase substrate, nitric oxide donor or both being effective to, respectively, either raise the blood level of circulating L-arginine in a pregnant female to whom the composition is administered to at least about 1 mmole above the normally 2 to 3 mmolar circulating levels or raise nitric oxide donor levels to about 1 to 100 nmolar (nanamolar).
In another method aspect, this invention relates to a method of treating preterm labor in a pregnant female which comprises administering to a pregnant female SllBSTIT~TE SHEET (~ULE 26) W095/0~8 PCT~ ~4/0~68 21~6~73 manifesting the symptoms thereof, amounts of (a) a pro-gestational agent and (b) at least one of a nitric oxide synthase substrate and a nitric oxide donor effective to terminate the preterm labor, alo-ne or in further combina-tion with one or more of a cyclooxygenase inhibitor, a PGI2-mimetic, a thromboxane (TXA2) inhibitor, a compound possessing TXA2-agonistic and TXA2-inhibiting properties, a compound possessing TXA2-antagonistic and PG12-memetic activities, and a TXA2 antagonist, the amount of the pro-gestational agent administered being bioequiva-lent to 50-300 mg. of injected progesterone and the amount of the nitric oxide synthase substrate, nitric oxide donor or both being effective to, respectively, either raise the blood level of circulating L-arginine in a pregnant fe-male to whom the composition is administered to at least about 1 mmole above the normally 2 to 3 mmolar circulat-ing levels, or raise nitric oxide donor levels to about 1 to 100 nmolar.
In a product aspect, this invention relates to a pharmaceutical composition comprising (a) a progesta-tional agent and (b) at least one of a nitric oxide synthase substrate and a nitric oxide donor, alone or in further combination with one or more of a cyclooxygenase inhibitor, a PGI2-mimetic, a thromboxane (TXA2) inhibitor, a compound possessing TXA2-agonistic and TXA2-inhibiting properties, a compound possessing TXA2-antagonistic and PGl2-memetic activities, and a TXA2 antagonist, with the amount of the progestational agent per unit dosage being bioequivalent to 50-300 mg. of injected progesterone and the amount of the nitric oxide synthase substrate, a nitric oxide donor or both per unit dosage being effective to, repsectively, either raise the blood level of circulating L-arginine to at~least about 1 mmole above the normally 2 to 3 mmolar circulating levels or raise the nitric oxide donor levels to about 1 to 1000 nmolar.
SU~STITl)TE SHEET ~RULE 26) 2166~3 In another aspec~ ~his invention relales to the use of (a) a proges~in and (b) a nitric oxide synthase substrate, a nitric oxide donor or bo~h, optionally, in further combination with one or more of a cycloo.cygenase inhibi~or, a PGI2-mimetic, a thromboxane (TX~) inhihitor, a compound possessing TXA -agonistic and TXAz-inhibiting proper~ies, a compound possessing TXA-~-antagonistic and PGIz mimetic activities, and a TXA~
an~agonis~, for manufacture of a medicament lor treating a~ least one ot` preeclampsia and preterm labor in a pre~nant female mammal.
In a preferred embodiment~ (a) is used in an amount which is bioequivalentto 50-30~ mg of in jected pro~esterone and (b) in an amount which is efrec~ive to raise the blood level of circulating L-arginine to at least about I mmole ahove the normally 2 lo ~ mmolar circulating levels.
In a further embodiment of the invenlion the female mammal is a human suffering from preeclampsia.
In slill a further embodiment ofthe invention the ~emale mammal is a human who has exhibited or is a candidate for pre~erm lahor.
Accordingto a further aspect the female mammal is a human and (b) is a nitric oxide synthase substrate.
In a pre~erred embodimentthe subs~rate is L-arginine.
According to another embodiment the temalc mammal is a human and (b) is a nitric oxide donor.
In a prel~rrc~l embodiment thc nitric oxidc ~lonor is sodium nitroprusside, nitroglycerin, gl! ccr! Itrinitritc. SI~\I-I. isosorbidmononitrile or isosorbiddinitri~e.
In a lurlhcr cmbodimenl Ihe nilric oxide donor can bc l`or oral administraLion.
In anolher embodimenl the female mammal is a human and the nitric oxide substrate or donor is lor administration in combination with a cyclooxygenase inhibitor.
SUBSTITUTE SHEET (RULE 26) 21~68~3 The us~ ol' aspirin as an inhibi~or is prel'errcd.
In slill anolh~r embodimen~ t)l' the inv~n~ion ~h~ malt: mammal is a human and ~he ni~ric oxid~ sul stra~ or donor is t'or administra~ion in combination wi~h a PGI ,-mim~ic.
The PGI~-mime~ic is prel'erra~ly iloprost or cicaprosl.
In ano~her pr~lerred ~mbodimen~ the l'emale mammal is a human and lhC pro~estin is pn)gcstcronc.
SU8~E S~ U~E 2~
W095l0~8 21 ~ ~ ~ 7 3 PCT~4/0~68 Detailed Di~closure The methods of this invention treat one or more of preeclampsia and preterm labor in a pregnant female mam-mal, preferably a human, who is manifesting the symptoms thereof or who is a high risk candidate for doing so, e.g., as determined by the progress of a present or pre-VlOUS pregnancy.
Because these abnormal conditions of pregnancy are produced by or aggravated by subnormal nitric oxide syn-thesis, both nitric oxide synthase substrates, e.g., L-arginine, and nitric oxide donors, e.g., sodium nitro-prusside, nitroglycerin, glyceryl trinitrate, SIN-l, isosobid mononitrate and isosorbid dinitrate, are useful for ameliorating the symptoms thereof and, in one aspect of the method of this invention, a combination of both are employed.
A synergistic effect is achieved when a progesta-tional agent is administered concurrently with the nitric oxide substrate and/or nitric acid donor.
Thus, the method aspect of this invention and the pharmaceutical composition aspect of this invention em-ploys a combination of (a) a progestational agent, e.g., progesterone, and (b) either or both of a nitric oxide donor and a nitric oxide synthase substrate and, op-tionally, (c) one or more of a cyclooxygenase inhibitor, e.g., aspirin; a PGI2-mimetic, e.g., iloprost and cica-prost; a thromboxane (TXA2) inhibitor, e.g., dazoxiben hydrochloride (benzoic acid, 4-[2-(lH-imadazoll-yl)-ethoxy]-, monohydrochloride; UK 37248), dazmegrel (lH-indole-l-propanoic acid, 3-(lH-imidazol-l-ylmethyl)-2-methyl-; UK 3885), ozagrel (2-propenoic acid, 3-t4-(1-H-imidazol-l-ylmethyl)phenyl]-; OKY-046) and pirmagrel (imidazo[1,5-a]pryidine-5-hexanoic acid; CGS-13080); a compound possessing TXA2-agonistic and TXA2-inhibiting properties, e.g., ridogrel (pentanoic acid, 5-[[[3-pyri-dinyl[3-(trifluoromethyl)phenyl]methylene]-amino]oxy]-;
R-68070) and labogrel (6-heptenoic acid, 7-phenyl-7-(3-~UBSTmJTE SIIEET (Rl ~LE 2B~
7' W095/0~W8 :- PCT~ ~4/02368 216~873 pydridinyl)-; a compound possessing TXA2-antagonis~ic and PGl2-memetic activities, e.g., 5-heptenoic acid, 7-[3-[[(diphenylmethoxy)-imino]-bicyclo,t2.2.1]hept-2-~1]-; EP
035-rac) and 5-heptenoic acid, 7-[3-[[(diphenylmethoxy)-imino]methyl]biclo[2.2.2]-oct-5-en-2-yl]- (EP 157); and a TXA2 antagonist, e.g., 5-heptenoic acid, 7-[3-[[2-(phenyl-amino)carbonyl]-hydrazino]methyl]7-oxabicyclo[2.2.1]hept-2-yl]-, lS[l.alpha.,2.alpha.(Z),3.alpha.,4.alpha.]]- (SQ
29548); benzenepropanoic acid, 2-[[3-4[(pentylamino)car-bonyl]-2-oxazolyl]-7-oxabicyclo[2.2.1]hept-2-ylmethyl}-(BMS 180291); acetic acid, [4-[2-[(phenylsulfonyl)amino]-ethyl]penoxy]- (sultroban, BM-13177); benzeneacetic acid, 4-[2-[[[4-chlorophenyl)sulfonyl]amino]ethyl]- (daltroban, BM-13505); (S-145 rac); 5-hexenoic acid, 6-[3-[[[(4-bromophenyl)sulfonyl]amino]methyl]bicyclo[2.2.1]hep-2-yl]-, decyl ester, [IS[l.alpha.2.alpha.2.alpha.(Z),-3.beta.,4.alpha.]]- (ONO 8809); 9H-carbazole-9-propanoic acid, 3-[[(4-fluorophenyl)su fonyl]amino]-1,2,3,4-tetra-hydro-, (~)- (bay-u-3405); and (4Z)-6-[(5S)-5-(4-chlor-phenylsulfonyl(aminomethyl)-cycloent-1-enyl]4-hexenoic acid (ZU 154343).
Examples of combinations of active agents which can be administered concurrently with a nitric oxide sub-strate and/or a nitric oxide donor and a progesterone (or other progestational agent) are low dose (e.g.,10-100 mg) of aspirin (or other cyclooxygenase inhibitor; PGI2-mimetics (e.g., iloprost, cicaprost); combinations of a PGI2-mimetic and low dose aspirin.
Examples of dosage ranges of typical N0-substrates and N0-donors (per os) are:
total dose:
L-Arginine S00 mg - 10 g p.o.
Sodium Nitroprusside range 500-2000 ug/kg/day Nitroglycerin 0.5-10 mg Isosorbid mononitrate 10-100 mg Isosorbid dinitrate 10-100 mg SU8STITUTE SHEET (~ULE 26) wo gs/o~ 21 6 ~ 8 7 3 PCT~4/02368 The following are typical oral dosage ranges active agents of the progestin and the optional other active agents concurrently administered with the nitric oxide su~strate or donor:
Progestins: A daily dose bioequivalent to 50-300 mg cf progesterone/day, e.g., an injectable suspension of medroxyprogersterone acetate to provide a weekly dose of thereof of 100-1000 mg or tablets or dragees providing an oral dose thereof of 5-10 mg/day; an injectable solution of hydroxyprogesterone caproate which provides a weekly dose of 250-500 mg; tablets, capsules or dragees of northindrone acetate which provide a daily dose of 5-20 mg.
Cicaprost: 5-100 ug/kg/day p.o.
Aspirin: 10-100 mg/kg/day p.o.
The pharmacologically active agents employed in this invention can be administered in admixture with conven-tional excipients, i.e., pharmaceutically acceptable liquid, semi-liquid or solid organic or inorganic car-riers suitable, e.g., for parental or enteral appli-cation and which do not deleteriously react with the active compound in admixture therewith. Suitable pharma-ceutically acceptable carriers include but are not limited to water, salt solutions, alcohols, vegetable oils, polyethylene glycols, gelatin, lactose, amylose, magnesium stearate, talc, silicic acid, viscous paraffin, perfume oil, fatty acid monoglycerides and diglycerides, pentaerythritol fatty acid esters, hydroxy methylcellu-lose, polyvinyl pyrrolidone, etc. The pharmaceutical preparations can be sterilized and if desired mixed with auxiliary agents, e.g., lubricants, preservatives, stabi-lizers, wetting agents, emulsifiers, salts for influenc-ing osmotic pressure, buffers, coloring, flavoring and/or aromatic substances and the like which do not delete-riously react with the active compounds.
For parental application, particularly suitable are solutions, preferably oily or aqueous solutions, as well as suspensions, emulsions, or implants, including suppos-itories. Ampoules are convenient unit dosages.
SUBSTITUT~ SHEET (~ULE 26) W095/0~8 PCT~ ~4/02368 21~873 In a preferred aspect, the composition of this invention is adapted for ingestion.
For enteral application, particularly suitab~e are unit dosage forms, e.g., tablets, dragees or capsules hav-ing talc and/or a carbohydrate carrier or binder or the like, the carrier preferably being lactose and/or corn starch and/or potato starch; particulate solids, e.g., granules; and liquids and semi-liquids, e.g., syrups and elixirs or the like, wherein a sweetened vehicle is em-ployed. Sustained release compositions can be formulated including those wherein the active compound is protected with differentially degradable coatings, e.g., by micro-encapsulation, multiple coatings, etc.
Suitable for oral administration are, inter alia, tablets, dragees, capsules, pills, granules, suspensions and solutions. Each unit dose, e.g., each tablespoon of liquid or each tablet, or dragee contains, for example, 5-5000 mg of each active agent.
Solutions for parenteral administration contain, for example, 0.01 - 1~ of each active agent in an aqueous or alcoholic solution.
The nitric oxide substrate and/or donor can be admin-istered as an admixture with the progestational agent and any other optional active agent or as a separate unit dosage form, either simultaneously there-with or at dif-ferent times during the day from each other.
The combination of active agents is preferably ad-ministered at least once daily (unless administered in a dosage form which delivers the active agents continu-ously) and more preferably several times daily, e.g., in 2 to 6 divided doses. The typical dose is about 0.5 to 1000 mg of each active agent, although some less active agents, e.g., L-Arginine, require much higher oral dos-ages, e.g., 500 to 10,000 mg, and others, e.g., sodium nitroprusside, require lower doses, e.g., 500-2,000 ug/kg/day. Doses for nitroglycerine typically are orally 2.5 mg 2 x daily; sublingually, 0.8 mg 1-4 x dialy; and SU~STIJl IJ ~ SHEcT (RULE 26) W095/0~8 216 6 8 7 3 PCT~ ~4/02368 transdermally, 0.2-0.4 mg/hr. Since the LD50 dosages of most of these active agents is known in the prior art, a lower dosage regimen can be initiated and the dosage increased until a positive effect is achieved or a higher dosage regimen can initially be employed, e.g., in a crisis situation, and the dosages regulated downward as relief from the symptoms is achieved.
In humans, both L-arginine and progesterone (or bioequivalent of another progestin) should be given in a ratio which produces blood plasma levels of about 1-5mMol/ml and 300-1,000 ng/ml (0.9-3~Mol/l), respec-tively. The N0-donor, e.g., sodium nitroprusside, should be given with the progesterone (or bioequivalent of another progestin) in a ratio producing blood plasma levels of about l-10 ~Mol/l and 300-1,000 ng/ml (0.9-3~Mol/l), respectively.
Brief DescriPtion of the Drawinqs With reference to the drawings, FIGURE 1 is a series of strip chart recordings showing the effect of L-arginine on spontaneously contracting uterine strips from rat on day 18 of gestation;
FIGURE 2: Dose-dependent relaxation effects of L-arginine (0.1 mM to lO mM) on spontaneously contracting uterine strips from rats at different stages of gestation, during delivery adn post partum. The tissues were obtained on days 17-22 (dl7, dl8, dl9 and d22) of gestation, on day 22 (d22 del) during spontaeous delivery (1-3 pups delivered), or on 1 (dlpp) and 2 (d2pp) days postpartum. The duration of complete inhiition of spontaneous uterine contractiosn are dose-dependent.
Data are analyzed by repeated measures ANOVA on seven groups. The effects of L-arginihe from concentrations of 1 mM are significantly (P<0.01) decreased durign spontaeous delivery at term adn postpartum, compared to all other times. Each data point represent mean ~ S.E.M.
SUBSTITUTE SHEET (RULE 26) W095/0~8 PCT~4/0~68 21~6373 The total number of strips studied at each time period was 8-16 from 4-6 animals per group.
FIGURE 3: Dose response effects of L-argini~e (O.6 mM to 10 mM) on the spontaeous contractility of uterine strips from ovariectomized adult rats. Animals recei~ed s.c. injection of 1 ug estradiol - 17b (OVX + E), 2 mg progesterone (OVX + P), estraodiol and progesterone (OVZ
+ E + P) in sesame oil or oil alone (OVX + Oil) for 3 days prior to contractility measurements. Values are mean + SEM for 4 strips from each animal from 4 rats per group. Data are analyzed by repeated measures ANOVA on four groups. *P<0.05 OVX + P vs OVX + E.
FIGURE 4: 8-bromo-cGMP dose relaxation-response curves for uterine tissues from rats delivering, spontaeously at term (DEL), preterm with ZK299 (PRETERM
DEL) and nondelivering (NONDEL) on day 18 of gestation.
Each point represent means ~ SEM for 4 strips from each animal from 4 rats per group.
FIGURE 5 is a bar chart which shows the effect on blood pressure of test animals of 50 mg of the hyper-tensive agent L-NAME, alone or in combination with one or both of L-arginine and progmesterone (R-5020); and FIGURE 6 is bar chart which shows the effect in the same experiments on pup weights of these compounds.
Discu~sion of the Drawin~s The strip chart recordings of Figure 1 show that the application of L-arginine (1-3 mM) (A, B, E), sodium nitroprusside (5 mM)(C), nitric oxide (0.1 mM) (D) to muscle baths produced substantial relaxations. The effects of L-arginine were reversed by L-NAME (3 mM)(B) and methylene blue (0. mM)(E). These ar etypical recordings of 8-16 strips from 6 animals in each group.
Each upstroke from baseline represents a contraction.
The strip chart recording of Figure lC show that the application of sodium nitroprusside (SNP) caused sustained relaxation in spontaneously contracting uterine strips after a lag period and that tissues in the relax SUBSTITU ï E SHEET (RULE 26) W095/0~8 216 6 8 ~ 3 PCT~4/02368 state were responsive to potassium chloride. Similar recordings of 12 uterine strips from 4 animals were obtained.
The strip chart recording in F gure lD show the re-laxation produced by authentic nitric oxide gas (O~1 mM).
Similar recordings were obtained from 8 strips from 4 animals.
The strip chart recordings of Figure lE show that L-arginine (1 mM) produced relaxation of spontaneously contracting tissues and these effects were repeatable in the same strip (as in Fig. lA) and that the relaxation effect of L-arginine (1 mM) was abolished by methylene blue (0.1 mM) when added before the application of L-arginine (B).
In the experiments whose results are shown by the graph of Figure 2, the tissues were obtained on days 17-22 (dl7, dl8, dl9 and d22) of gestation, on day 22 (d22 del) during spontaneous delivery (1-3 pups delivered), or on 1 (dlpp) and 2 (d2pp~ days postpartum. The duration of complete inhibition of spontaneous uterine contrac-tions are dose-dependent. The effects of L-arginine from concentrations of 1 mM are significantly (P<O.O1) decreased during spontaneous delivery at term and post-partum, compared to all other times. Each data point represent mean ~ S.E.M. The total number of strips studied at each time period was 8-16 from 4-6 animals per group.
In the experiments whose results are shown by the graph of Figure 3, nonpregnant ovariectomized rats received s.c. injection of 1 ug estradiol-17-~ (OVX + E), 2 mg progesterone (OVX + P), estradiol and progesterone (OVX + E + P) in sesame oil or oil alone (OVX + Oil) for 3 days prior to contractility measurements. Values are mean + SEM for 4 strips from each animal from 4 rats per group. *P<0.05 OVX + P vs OVX + E.
The charge of Figure 4 shows 8-bromo-cGMP dose relaxation-response curves for uterine tissues from rats SUBSTITUTE SHEET (~ULE 26~
W095/0~8 PCT~ ~4/0~68 2~ 6~73 delivering, spontaeous~y at term (DEL), preterm with ZK299 (PRETERM DEL) and nondelivering (NONDEL) on day 18 of gestation. Each point represent means i SEM for 4 strips from each animal from 4 rats per group.
The data in Table 1 below show the effects of L-NAME
infusion on blood pressure (mm Hg) in pregnant rats.
Blood Pressure (mm Hg) L-NAME
Gestation CONTROL
daY 25 m~/daY 50 mq/day Day lS 121 + 3 119 + 2a 123 i 3 Day 18 119 + 3~ 144 i 4b 166 i 2c Day 22 120 i 5a 146 i 2b 168 i 3c Means with different superscripts differ significantly (p<0.05) The data in Table 2 below show the delivery and the pups delivered of L-NAME infusion to pregnant rats.
T~BLE 2 CONTROL L-NAME
25 mq/day 50 mq/day Day of Delivery22.3 + 0.2 22.4 + 0.222.7 i 0.2 Total # of pups 59 65 56 # of dead pups 2 5 10 Weight of pups6.32 i 0.05a 5.05 + 0.08b 4.56 i 0.10C
Total # of animals 8 9 10 Means with different superscripts differ significantly (p<0.05)-Another experiment using L-NAME-induced" pre-eclampsia" showed that treatment with L-arginine alone partially reduced blood pressure (Figure 5). Similarly, animals treated with L-NAME and R 5020 (promegestone), a progestational agent with no antimineralocorticoid effect SU~STlTlJTE SHEET ~RULE 26) W095/0~ 216 6 8 7 3 PCT~4102368 ^15-or other antagonistic or agonistic properties, also partinally reduced L-NAME-induced hypertension. As also shown in Figure 5, when the same doses of L-arginine and R 5020 were given simultaneously, their combined effect lowered blood pressure to normal levels.
Additionally, evaluation of fetal weights in the same animals treated as described above, showed intrauterine fetal retardation (decreased weight of pups), typical preeclamptic fetuses (Figure 6).
Treatment of the "preeclamptic" groups of animals with either L-arginine alone or R 5020 alone slightly but statistically significant, elevated fetal weights. As also shown in Figure 6, the combined effect of the two compounds administered together significantly elevated fetal weight above that observed with either compound alone, a highly significant advantage to survival of the fetus under these conditions.
It can be concluded from these studies that the combined treatment of L-arginine with a progestational agent whose activity is "pure", like R 5020 provides results which cannot be achieved with either type o~ drug alone. The studies show that the basis for this effectiveness lies in the ability of the progestional agent to increase the effectiveness of nitric oxide (or L-arg nine, the substrate of nitric oxide) to dilate bood vessels and thereby lower blood pressure as well as increase fetalmaternal profusion, thereby increasing fetal weight.
The combined effect of the combination of these agents is surprisingly dramatic and, more importantly, the significant fetal and maternal effects observed with treatment with the combination. Prior medical evidence does not suggest that the combination would provide these advantages, because the basis for them is not the simple combination of two agonistic compounds but instead is the sensitizing of nitric oxide provided by the progestin.
The studies clearly indicate that progestins increase the SUBS~ITUTE ~I~EET (RULE 26) W095/0~8 ;~ ; PCT~ ~4/02368 2~668~3 ~
effector system for nitric oxide tnot increase nitric oxide synthesis).
The method of treatment employed in this invention can also be employed for the treatment of hypertension (in both females and males), climacteric disorders (hot flushes, mood swings) in menopausal women, thrombotic disorders, menstrual disorders (dysmenorrhea, functional uterine bleeding), and hemorrhage, etc., following the dosage regime described herein.
Without further elaboration, it is believed that one skilled in the art can, using the preceding description, utilize the present invention to its fullest extent. The preferred specific embodiments are, therefore, to be construed as merely illustrative, and not limitative of the disclosure in any way whatsoever.
The entire disclosure of all applications, patents and publications, cited above and below are hereby incorporated by reference.
ExamPles ExamPle 1 - Treatment of Preeclampsia To a pregnant human female (ca 20-40 years; 60-80 kg) usually in her second half of pregnancy and displaying the symptoms of preeclampsia, including hypertension (above 140 mm systolic and above 90 mm diastolic), edema and protein-uria, administer 0.5 to 20 g of L-arginine and 200 mg of micronized progesterone per os daily in three divided doses until the symptoms are ameliorated. Thereafter, administer 0.5 to 5 mg of L-arginine and 60 mg of progesterone per os daily whenever the diastolic pressure rises above 80 mm; with increasing doses of L-argininine to from 5 to 20 mg daily until remission of the symptoms again occurs.
ExamPle 2 - Treatment of preeclampsia To a human female comparable to and displaying the same symptoms as the one described in Example 1, administer daily 2 x 2.5 mg of nitroglycerine and 200 mg SUBSTITUTE SHEET (RUL~ 2~) W095/0~8 21~ 6 8 7 3 PCT~4/02368 ~ . . . .
of progesterone following the same protocol, until the symptoms are ameliorated.
Example 3 - Treatment of Preterm Labor To a human female in her sixth month of pregnancy and displaying symptoms of a threatened spontaneous abortion, including blood spotting and periodic uterine spasms, administer daily 17 g of L-arginine and 50 mg of progesterone per os daily in three divided doses until the symptoms are ameliorated. Thereafter, administer 5 g of L-arginine and 50 mg of progesterone per os daily with increasing doses to 20 g of L-arigine daily until remission of the symptoms again occurs.
ExamPle 5 - Treatment of Preterm Labor To a pregnant human female comparable to and displaying the same symptoms as the one described in Example 3, administer daily 2 x 25 mg of nitroglycerine and up to 180 mg of progesterone, following the same protocol, until the symptoms are ameliorated.
The preceding examples can be repeated with similar success by substituting the generically or specifically described reactants and/or operating conditions of this invention for those used in the preceding examples.
From the foregoing description, one skilled in the art can easily ascertain the essential characteristics of this invention, and without departing from the spirit and scope thereof, can make various changes and modifications of the invention to adapt it to various usages and conditions.
STITUTE SHEET (RULE 26)
Backqround of the Invention This invention relates to a method for the treatment of preeclampsia and of preterm labor with the combination of a progestational agent and a nitric oxide synthase substrate, a nitric oxide donor or both, alone or in further combination with one or more of a cyclooxygenase inhibitor, a PGI2-mimetic, a thromboxane (TXA2) inhibitor, A compound possessing TXA2-agonistic and TXA2-inhibiting properties, a compound possessing TXA2 antagonistic and PGI2-memetic activities, and a TXA2 antagonist, and to pharmaceutical compositions comprising such a combination.
Preeclampsia, toxemia or eclampsia of pregnancy can be a significant health problem during pregnancy and they are the leading causes of fetal growth retardation, fetal mortality and morbidity, premature birth and maternal mortality. The etiology of the disease is largely unknown and effective therapy is not available.
Preeclampsia of pregnancy is characterized by a triad of hypertension, pathological edema and proteinuria. This disease affects 6 to 10% of all pregnancies.
Recently, nitric oxide has been shown to be endo-thelium derived relaxing factor (EDRF) from the endothel-ium of blood vessels. Nitric oxide is considered to be a major mediator in the control of vascular reactivity.
Nitric oxide is synthesized from L-arginine by nitric oxide synthase located in endothelial cells. Nitric Oxide can also be generated by application of various nitric oxide donors such as sodium nitroprusside, nitro-glycerin, glyceryl trinitrite, SIN-1, isosorbid mono-nitrite, isosorbid dinitrite, etc.
Treatment of pregnant rats with nitric oxide syn-thase inhibitors, which are analogues of L-arginine (such as L-NAME, N- nitro-L-arginine methyl ester) results in SUBSTITUT~ SHEET(RULE 26) W095/0~8 PCT~ ~4/02368 2~6873 elevated blood pressure, fetal retarded growth and pro-teinuria. Thus, inhibition of nitric oxide synthesis produces conditions and symptoms identical to preeclampsia of pregnancy and establishes that preeclampsia is the direct result of the decrease in nitric oxide synthesis and/or a change in the regulation of vascular tone. These conditions give rise to in-creased blood pressure, decreased blood flow to the fetus, retarded fetal development and proteinuria.
Agents which raise nitric oxide levels therefore are useful in the treatment of preeclampsia of pregnancy.
Since nitric oxide donors also reduce contractility of the uterus during pregnancy, nitric oxide donors are also useful for use in preterm labor.
The nitric oxide effects on smooth muscle depend upon the activation of guanylate cyclase and generation of cGMP to produce relaxation and this step is progesterone dependent. Thus, combinations of nitric oxide donors with progesterone are particularly efficacious for the treatment of preeclampsia and of preterm labor.
EP O 441 119 A2 discloses the use of L-arginine in the treatment of hypertension and other vascular dis-orders. It suggests that the me~h~n; ~m by which L-arginine is effective for this purpose is because it may be the physiological precursor of "the most powerful endothelial-derived releasing factor, nitric oxide." The use of L-arginine in combination with other pharmaceu-tically active agents is not discussed in this publica-tion.
Objects of the Invention It is an object of the invention to provide a method for the prevention and treatment of preeclampsia with a combination of a progestational agent and a nitric oxide substrate and/or donor.
It is another object to provide such a method in which a progestational agent is used in combination with SU8STiTU T E ~HEET (RULE 26~
216~873 W095/0~8 PCT~4/02368 .
.. .
~, : , . !
a nitric oxide substrate and/or donor for the prevention and treatment of preeclampsia.
It is a further object to provide a method for the prevention and treatment of preterm labor using a pro-gestational agent in combination with a nitric oxide substrate and/or donor.
A further object is the provision of pharmaceutical compositions useful in practicing the methods of this invention.
Other objects will be apparent to those skilled in the art to which this invention pertains.
Summary of the Invention In a method aspect, this invention relates to a method of treating at least one of preeclampsia and pre-term labor in a pregnant female which comprises admini-stering to a pregnant female manifesting the symptoms thereof, (a) a progestational agent and (b) one or both of a nitric oxide synthase substrate and a nitric oxide donor, alone or in further combination with one or more of a cyclooxygenase inhibitor, a PGI2-mimetic, a throm-boxane (TXA2) inhibitor, a compound possessing TXA2-agonistic and TXAz-inhibiting properties, a compound pos-sessing TXA2-antagonistic and PGl2-memetic activities, and a TXA2 antagonist, in amounts effective to ameliorate the symptoms thereof, the amount of the progesta~ional agent administered being bioequivalent to 50-300 mg. of in-jected progesterone and the amount of the nitric oxide synthase substrate, nitric oxide donor or both being effective to, respectively, either raise the blood level of circulating L-arginine in a pregnant female to whom the composition is administered to at least about 1 mmole above the normally 2 to 3 mmolar circulating levels or raise nitric oxide donor levels to about 1 to 100 nmolar (nanamolar).
In another method aspect, this invention relates to a method of treating preterm labor in a pregnant female which comprises administering to a pregnant female SllBSTIT~TE SHEET (~ULE 26) W095/0~8 PCT~ ~4/0~68 21~6~73 manifesting the symptoms thereof, amounts of (a) a pro-gestational agent and (b) at least one of a nitric oxide synthase substrate and a nitric oxide donor effective to terminate the preterm labor, alo-ne or in further combina-tion with one or more of a cyclooxygenase inhibitor, a PGI2-mimetic, a thromboxane (TXA2) inhibitor, a compound possessing TXA2-agonistic and TXA2-inhibiting properties, a compound possessing TXA2-antagonistic and PG12-memetic activities, and a TXA2 antagonist, the amount of the pro-gestational agent administered being bioequiva-lent to 50-300 mg. of injected progesterone and the amount of the nitric oxide synthase substrate, nitric oxide donor or both being effective to, respectively, either raise the blood level of circulating L-arginine in a pregnant fe-male to whom the composition is administered to at least about 1 mmole above the normally 2 to 3 mmolar circulat-ing levels, or raise nitric oxide donor levels to about 1 to 100 nmolar.
In a product aspect, this invention relates to a pharmaceutical composition comprising (a) a progesta-tional agent and (b) at least one of a nitric oxide synthase substrate and a nitric oxide donor, alone or in further combination with one or more of a cyclooxygenase inhibitor, a PGI2-mimetic, a thromboxane (TXA2) inhibitor, a compound possessing TXA2-agonistic and TXA2-inhibiting properties, a compound possessing TXA2-antagonistic and PGl2-memetic activities, and a TXA2 antagonist, with the amount of the progestational agent per unit dosage being bioequivalent to 50-300 mg. of injected progesterone and the amount of the nitric oxide synthase substrate, a nitric oxide donor or both per unit dosage being effective to, repsectively, either raise the blood level of circulating L-arginine to at~least about 1 mmole above the normally 2 to 3 mmolar circulating levels or raise the nitric oxide donor levels to about 1 to 1000 nmolar.
SU~STITl)TE SHEET ~RULE 26) 2166~3 In another aspec~ ~his invention relales to the use of (a) a proges~in and (b) a nitric oxide synthase substrate, a nitric oxide donor or bo~h, optionally, in further combination with one or more of a cycloo.cygenase inhibi~or, a PGI2-mimetic, a thromboxane (TX~) inhihitor, a compound possessing TXA -agonistic and TXAz-inhibiting proper~ies, a compound possessing TXA-~-antagonistic and PGIz mimetic activities, and a TXA~
an~agonis~, for manufacture of a medicament lor treating a~ least one ot` preeclampsia and preterm labor in a pre~nant female mammal.
In a preferred embodiment~ (a) is used in an amount which is bioequivalentto 50-30~ mg of in jected pro~esterone and (b) in an amount which is efrec~ive to raise the blood level of circulating L-arginine to at least about I mmole ahove the normally 2 lo ~ mmolar circulating levels.
In a further embodiment of the invenlion the female mammal is a human suffering from preeclampsia.
In slill a further embodiment ofthe invention the ~emale mammal is a human who has exhibited or is a candidate for pre~erm lahor.
Accordingto a further aspect the female mammal is a human and (b) is a nitric oxide synthase substrate.
In a pre~erred embodimentthe subs~rate is L-arginine.
According to another embodiment the temalc mammal is a human and (b) is a nitric oxide donor.
In a prel~rrc~l embodiment thc nitric oxidc ~lonor is sodium nitroprusside, nitroglycerin, gl! ccr! Itrinitritc. SI~\I-I. isosorbidmononitrile or isosorbiddinitri~e.
In a lurlhcr cmbodimenl Ihe nilric oxide donor can bc l`or oral administraLion.
In anolher embodimenl the female mammal is a human and the nitric oxide substrate or donor is lor administration in combination with a cyclooxygenase inhibitor.
SUBSTITUTE SHEET (RULE 26) 21~68~3 The us~ ol' aspirin as an inhibi~or is prel'errcd.
In slill anolh~r embodimen~ t)l' the inv~n~ion ~h~ malt: mammal is a human and ~he ni~ric oxid~ sul stra~ or donor is t'or administra~ion in combination wi~h a PGI ,-mim~ic.
The PGI~-mime~ic is prel'erra~ly iloprost or cicaprosl.
In ano~her pr~lerred ~mbodimen~ the l'emale mammal is a human and lhC pro~estin is pn)gcstcronc.
SU8~E S~ U~E 2~
W095l0~8 21 ~ ~ ~ 7 3 PCT~4/0~68 Detailed Di~closure The methods of this invention treat one or more of preeclampsia and preterm labor in a pregnant female mam-mal, preferably a human, who is manifesting the symptoms thereof or who is a high risk candidate for doing so, e.g., as determined by the progress of a present or pre-VlOUS pregnancy.
Because these abnormal conditions of pregnancy are produced by or aggravated by subnormal nitric oxide syn-thesis, both nitric oxide synthase substrates, e.g., L-arginine, and nitric oxide donors, e.g., sodium nitro-prusside, nitroglycerin, glyceryl trinitrate, SIN-l, isosobid mononitrate and isosorbid dinitrate, are useful for ameliorating the symptoms thereof and, in one aspect of the method of this invention, a combination of both are employed.
A synergistic effect is achieved when a progesta-tional agent is administered concurrently with the nitric oxide substrate and/or nitric acid donor.
Thus, the method aspect of this invention and the pharmaceutical composition aspect of this invention em-ploys a combination of (a) a progestational agent, e.g., progesterone, and (b) either or both of a nitric oxide donor and a nitric oxide synthase substrate and, op-tionally, (c) one or more of a cyclooxygenase inhibitor, e.g., aspirin; a PGI2-mimetic, e.g., iloprost and cica-prost; a thromboxane (TXA2) inhibitor, e.g., dazoxiben hydrochloride (benzoic acid, 4-[2-(lH-imadazoll-yl)-ethoxy]-, monohydrochloride; UK 37248), dazmegrel (lH-indole-l-propanoic acid, 3-(lH-imidazol-l-ylmethyl)-2-methyl-; UK 3885), ozagrel (2-propenoic acid, 3-t4-(1-H-imidazol-l-ylmethyl)phenyl]-; OKY-046) and pirmagrel (imidazo[1,5-a]pryidine-5-hexanoic acid; CGS-13080); a compound possessing TXA2-agonistic and TXA2-inhibiting properties, e.g., ridogrel (pentanoic acid, 5-[[[3-pyri-dinyl[3-(trifluoromethyl)phenyl]methylene]-amino]oxy]-;
R-68070) and labogrel (6-heptenoic acid, 7-phenyl-7-(3-~UBSTmJTE SIIEET (Rl ~LE 2B~
7' W095/0~W8 :- PCT~ ~4/02368 216~873 pydridinyl)-; a compound possessing TXA2-antagonis~ic and PGl2-memetic activities, e.g., 5-heptenoic acid, 7-[3-[[(diphenylmethoxy)-imino]-bicyclo,t2.2.1]hept-2-~1]-; EP
035-rac) and 5-heptenoic acid, 7-[3-[[(diphenylmethoxy)-imino]methyl]biclo[2.2.2]-oct-5-en-2-yl]- (EP 157); and a TXA2 antagonist, e.g., 5-heptenoic acid, 7-[3-[[2-(phenyl-amino)carbonyl]-hydrazino]methyl]7-oxabicyclo[2.2.1]hept-2-yl]-, lS[l.alpha.,2.alpha.(Z),3.alpha.,4.alpha.]]- (SQ
29548); benzenepropanoic acid, 2-[[3-4[(pentylamino)car-bonyl]-2-oxazolyl]-7-oxabicyclo[2.2.1]hept-2-ylmethyl}-(BMS 180291); acetic acid, [4-[2-[(phenylsulfonyl)amino]-ethyl]penoxy]- (sultroban, BM-13177); benzeneacetic acid, 4-[2-[[[4-chlorophenyl)sulfonyl]amino]ethyl]- (daltroban, BM-13505); (S-145 rac); 5-hexenoic acid, 6-[3-[[[(4-bromophenyl)sulfonyl]amino]methyl]bicyclo[2.2.1]hep-2-yl]-, decyl ester, [IS[l.alpha.2.alpha.2.alpha.(Z),-3.beta.,4.alpha.]]- (ONO 8809); 9H-carbazole-9-propanoic acid, 3-[[(4-fluorophenyl)su fonyl]amino]-1,2,3,4-tetra-hydro-, (~)- (bay-u-3405); and (4Z)-6-[(5S)-5-(4-chlor-phenylsulfonyl(aminomethyl)-cycloent-1-enyl]4-hexenoic acid (ZU 154343).
Examples of combinations of active agents which can be administered concurrently with a nitric oxide sub-strate and/or a nitric oxide donor and a progesterone (or other progestational agent) are low dose (e.g.,10-100 mg) of aspirin (or other cyclooxygenase inhibitor; PGI2-mimetics (e.g., iloprost, cicaprost); combinations of a PGI2-mimetic and low dose aspirin.
Examples of dosage ranges of typical N0-substrates and N0-donors (per os) are:
total dose:
L-Arginine S00 mg - 10 g p.o.
Sodium Nitroprusside range 500-2000 ug/kg/day Nitroglycerin 0.5-10 mg Isosorbid mononitrate 10-100 mg Isosorbid dinitrate 10-100 mg SU8STITUTE SHEET (~ULE 26) wo gs/o~ 21 6 ~ 8 7 3 PCT~4/02368 The following are typical oral dosage ranges active agents of the progestin and the optional other active agents concurrently administered with the nitric oxide su~strate or donor:
Progestins: A daily dose bioequivalent to 50-300 mg cf progesterone/day, e.g., an injectable suspension of medroxyprogersterone acetate to provide a weekly dose of thereof of 100-1000 mg or tablets or dragees providing an oral dose thereof of 5-10 mg/day; an injectable solution of hydroxyprogesterone caproate which provides a weekly dose of 250-500 mg; tablets, capsules or dragees of northindrone acetate which provide a daily dose of 5-20 mg.
Cicaprost: 5-100 ug/kg/day p.o.
Aspirin: 10-100 mg/kg/day p.o.
The pharmacologically active agents employed in this invention can be administered in admixture with conven-tional excipients, i.e., pharmaceutically acceptable liquid, semi-liquid or solid organic or inorganic car-riers suitable, e.g., for parental or enteral appli-cation and which do not deleteriously react with the active compound in admixture therewith. Suitable pharma-ceutically acceptable carriers include but are not limited to water, salt solutions, alcohols, vegetable oils, polyethylene glycols, gelatin, lactose, amylose, magnesium stearate, talc, silicic acid, viscous paraffin, perfume oil, fatty acid monoglycerides and diglycerides, pentaerythritol fatty acid esters, hydroxy methylcellu-lose, polyvinyl pyrrolidone, etc. The pharmaceutical preparations can be sterilized and if desired mixed with auxiliary agents, e.g., lubricants, preservatives, stabi-lizers, wetting agents, emulsifiers, salts for influenc-ing osmotic pressure, buffers, coloring, flavoring and/or aromatic substances and the like which do not delete-riously react with the active compounds.
For parental application, particularly suitable are solutions, preferably oily or aqueous solutions, as well as suspensions, emulsions, or implants, including suppos-itories. Ampoules are convenient unit dosages.
SUBSTITUT~ SHEET (~ULE 26) W095/0~8 PCT~ ~4/02368 21~873 In a preferred aspect, the composition of this invention is adapted for ingestion.
For enteral application, particularly suitab~e are unit dosage forms, e.g., tablets, dragees or capsules hav-ing talc and/or a carbohydrate carrier or binder or the like, the carrier preferably being lactose and/or corn starch and/or potato starch; particulate solids, e.g., granules; and liquids and semi-liquids, e.g., syrups and elixirs or the like, wherein a sweetened vehicle is em-ployed. Sustained release compositions can be formulated including those wherein the active compound is protected with differentially degradable coatings, e.g., by micro-encapsulation, multiple coatings, etc.
Suitable for oral administration are, inter alia, tablets, dragees, capsules, pills, granules, suspensions and solutions. Each unit dose, e.g., each tablespoon of liquid or each tablet, or dragee contains, for example, 5-5000 mg of each active agent.
Solutions for parenteral administration contain, for example, 0.01 - 1~ of each active agent in an aqueous or alcoholic solution.
The nitric oxide substrate and/or donor can be admin-istered as an admixture with the progestational agent and any other optional active agent or as a separate unit dosage form, either simultaneously there-with or at dif-ferent times during the day from each other.
The combination of active agents is preferably ad-ministered at least once daily (unless administered in a dosage form which delivers the active agents continu-ously) and more preferably several times daily, e.g., in 2 to 6 divided doses. The typical dose is about 0.5 to 1000 mg of each active agent, although some less active agents, e.g., L-Arginine, require much higher oral dos-ages, e.g., 500 to 10,000 mg, and others, e.g., sodium nitroprusside, require lower doses, e.g., 500-2,000 ug/kg/day. Doses for nitroglycerine typically are orally 2.5 mg 2 x daily; sublingually, 0.8 mg 1-4 x dialy; and SU~STIJl IJ ~ SHEcT (RULE 26) W095/0~8 216 6 8 7 3 PCT~ ~4/02368 transdermally, 0.2-0.4 mg/hr. Since the LD50 dosages of most of these active agents is known in the prior art, a lower dosage regimen can be initiated and the dosage increased until a positive effect is achieved or a higher dosage regimen can initially be employed, e.g., in a crisis situation, and the dosages regulated downward as relief from the symptoms is achieved.
In humans, both L-arginine and progesterone (or bioequivalent of another progestin) should be given in a ratio which produces blood plasma levels of about 1-5mMol/ml and 300-1,000 ng/ml (0.9-3~Mol/l), respec-tively. The N0-donor, e.g., sodium nitroprusside, should be given with the progesterone (or bioequivalent of another progestin) in a ratio producing blood plasma levels of about l-10 ~Mol/l and 300-1,000 ng/ml (0.9-3~Mol/l), respectively.
Brief DescriPtion of the Drawinqs With reference to the drawings, FIGURE 1 is a series of strip chart recordings showing the effect of L-arginine on spontaneously contracting uterine strips from rat on day 18 of gestation;
FIGURE 2: Dose-dependent relaxation effects of L-arginine (0.1 mM to lO mM) on spontaneously contracting uterine strips from rats at different stages of gestation, during delivery adn post partum. The tissues were obtained on days 17-22 (dl7, dl8, dl9 and d22) of gestation, on day 22 (d22 del) during spontaeous delivery (1-3 pups delivered), or on 1 (dlpp) and 2 (d2pp) days postpartum. The duration of complete inhiition of spontaneous uterine contractiosn are dose-dependent.
Data are analyzed by repeated measures ANOVA on seven groups. The effects of L-arginihe from concentrations of 1 mM are significantly (P<0.01) decreased durign spontaeous delivery at term adn postpartum, compared to all other times. Each data point represent mean ~ S.E.M.
SUBSTITUTE SHEET (RULE 26) W095/0~8 PCT~4/0~68 21~6373 The total number of strips studied at each time period was 8-16 from 4-6 animals per group.
FIGURE 3: Dose response effects of L-argini~e (O.6 mM to 10 mM) on the spontaeous contractility of uterine strips from ovariectomized adult rats. Animals recei~ed s.c. injection of 1 ug estradiol - 17b (OVX + E), 2 mg progesterone (OVX + P), estraodiol and progesterone (OVZ
+ E + P) in sesame oil or oil alone (OVX + Oil) for 3 days prior to contractility measurements. Values are mean + SEM for 4 strips from each animal from 4 rats per group. Data are analyzed by repeated measures ANOVA on four groups. *P<0.05 OVX + P vs OVX + E.
FIGURE 4: 8-bromo-cGMP dose relaxation-response curves for uterine tissues from rats delivering, spontaeously at term (DEL), preterm with ZK299 (PRETERM
DEL) and nondelivering (NONDEL) on day 18 of gestation.
Each point represent means ~ SEM for 4 strips from each animal from 4 rats per group.
FIGURE 5 is a bar chart which shows the effect on blood pressure of test animals of 50 mg of the hyper-tensive agent L-NAME, alone or in combination with one or both of L-arginine and progmesterone (R-5020); and FIGURE 6 is bar chart which shows the effect in the same experiments on pup weights of these compounds.
Discu~sion of the Drawin~s The strip chart recordings of Figure 1 show that the application of L-arginine (1-3 mM) (A, B, E), sodium nitroprusside (5 mM)(C), nitric oxide (0.1 mM) (D) to muscle baths produced substantial relaxations. The effects of L-arginine were reversed by L-NAME (3 mM)(B) and methylene blue (0. mM)(E). These ar etypical recordings of 8-16 strips from 6 animals in each group.
Each upstroke from baseline represents a contraction.
The strip chart recording of Figure lC show that the application of sodium nitroprusside (SNP) caused sustained relaxation in spontaneously contracting uterine strips after a lag period and that tissues in the relax SUBSTITU ï E SHEET (RULE 26) W095/0~8 216 6 8 ~ 3 PCT~4/02368 state were responsive to potassium chloride. Similar recordings of 12 uterine strips from 4 animals were obtained.
The strip chart recording in F gure lD show the re-laxation produced by authentic nitric oxide gas (O~1 mM).
Similar recordings were obtained from 8 strips from 4 animals.
The strip chart recordings of Figure lE show that L-arginine (1 mM) produced relaxation of spontaneously contracting tissues and these effects were repeatable in the same strip (as in Fig. lA) and that the relaxation effect of L-arginine (1 mM) was abolished by methylene blue (0.1 mM) when added before the application of L-arginine (B).
In the experiments whose results are shown by the graph of Figure 2, the tissues were obtained on days 17-22 (dl7, dl8, dl9 and d22) of gestation, on day 22 (d22 del) during spontaneous delivery (1-3 pups delivered), or on 1 (dlpp) and 2 (d2pp~ days postpartum. The duration of complete inhibition of spontaneous uterine contrac-tions are dose-dependent. The effects of L-arginine from concentrations of 1 mM are significantly (P<O.O1) decreased during spontaneous delivery at term and post-partum, compared to all other times. Each data point represent mean ~ S.E.M. The total number of strips studied at each time period was 8-16 from 4-6 animals per group.
In the experiments whose results are shown by the graph of Figure 3, nonpregnant ovariectomized rats received s.c. injection of 1 ug estradiol-17-~ (OVX + E), 2 mg progesterone (OVX + P), estradiol and progesterone (OVX + E + P) in sesame oil or oil alone (OVX + Oil) for 3 days prior to contractility measurements. Values are mean + SEM for 4 strips from each animal from 4 rats per group. *P<0.05 OVX + P vs OVX + E.
The charge of Figure 4 shows 8-bromo-cGMP dose relaxation-response curves for uterine tissues from rats SUBSTITUTE SHEET (~ULE 26~
W095/0~8 PCT~ ~4/0~68 2~ 6~73 delivering, spontaeous~y at term (DEL), preterm with ZK299 (PRETERM DEL) and nondelivering (NONDEL) on day 18 of gestation. Each point represent means i SEM for 4 strips from each animal from 4 rats per group.
The data in Table 1 below show the effects of L-NAME
infusion on blood pressure (mm Hg) in pregnant rats.
Blood Pressure (mm Hg) L-NAME
Gestation CONTROL
daY 25 m~/daY 50 mq/day Day lS 121 + 3 119 + 2a 123 i 3 Day 18 119 + 3~ 144 i 4b 166 i 2c Day 22 120 i 5a 146 i 2b 168 i 3c Means with different superscripts differ significantly (p<0.05) The data in Table 2 below show the delivery and the pups delivered of L-NAME infusion to pregnant rats.
T~BLE 2 CONTROL L-NAME
25 mq/day 50 mq/day Day of Delivery22.3 + 0.2 22.4 + 0.222.7 i 0.2 Total # of pups 59 65 56 # of dead pups 2 5 10 Weight of pups6.32 i 0.05a 5.05 + 0.08b 4.56 i 0.10C
Total # of animals 8 9 10 Means with different superscripts differ significantly (p<0.05)-Another experiment using L-NAME-induced" pre-eclampsia" showed that treatment with L-arginine alone partially reduced blood pressure (Figure 5). Similarly, animals treated with L-NAME and R 5020 (promegestone), a progestational agent with no antimineralocorticoid effect SU~STlTlJTE SHEET ~RULE 26) W095/0~ 216 6 8 7 3 PCT~4102368 ^15-or other antagonistic or agonistic properties, also partinally reduced L-NAME-induced hypertension. As also shown in Figure 5, when the same doses of L-arginine and R 5020 were given simultaneously, their combined effect lowered blood pressure to normal levels.
Additionally, evaluation of fetal weights in the same animals treated as described above, showed intrauterine fetal retardation (decreased weight of pups), typical preeclamptic fetuses (Figure 6).
Treatment of the "preeclamptic" groups of animals with either L-arginine alone or R 5020 alone slightly but statistically significant, elevated fetal weights. As also shown in Figure 6, the combined effect of the two compounds administered together significantly elevated fetal weight above that observed with either compound alone, a highly significant advantage to survival of the fetus under these conditions.
It can be concluded from these studies that the combined treatment of L-arginine with a progestational agent whose activity is "pure", like R 5020 provides results which cannot be achieved with either type o~ drug alone. The studies show that the basis for this effectiveness lies in the ability of the progestional agent to increase the effectiveness of nitric oxide (or L-arg nine, the substrate of nitric oxide) to dilate bood vessels and thereby lower blood pressure as well as increase fetalmaternal profusion, thereby increasing fetal weight.
The combined effect of the combination of these agents is surprisingly dramatic and, more importantly, the significant fetal and maternal effects observed with treatment with the combination. Prior medical evidence does not suggest that the combination would provide these advantages, because the basis for them is not the simple combination of two agonistic compounds but instead is the sensitizing of nitric oxide provided by the progestin.
The studies clearly indicate that progestins increase the SUBS~ITUTE ~I~EET (RULE 26) W095/0~8 ;~ ; PCT~ ~4/02368 2~668~3 ~
effector system for nitric oxide tnot increase nitric oxide synthesis).
The method of treatment employed in this invention can also be employed for the treatment of hypertension (in both females and males), climacteric disorders (hot flushes, mood swings) in menopausal women, thrombotic disorders, menstrual disorders (dysmenorrhea, functional uterine bleeding), and hemorrhage, etc., following the dosage regime described herein.
Without further elaboration, it is believed that one skilled in the art can, using the preceding description, utilize the present invention to its fullest extent. The preferred specific embodiments are, therefore, to be construed as merely illustrative, and not limitative of the disclosure in any way whatsoever.
The entire disclosure of all applications, patents and publications, cited above and below are hereby incorporated by reference.
ExamPles ExamPle 1 - Treatment of Preeclampsia To a pregnant human female (ca 20-40 years; 60-80 kg) usually in her second half of pregnancy and displaying the symptoms of preeclampsia, including hypertension (above 140 mm systolic and above 90 mm diastolic), edema and protein-uria, administer 0.5 to 20 g of L-arginine and 200 mg of micronized progesterone per os daily in three divided doses until the symptoms are ameliorated. Thereafter, administer 0.5 to 5 mg of L-arginine and 60 mg of progesterone per os daily whenever the diastolic pressure rises above 80 mm; with increasing doses of L-argininine to from 5 to 20 mg daily until remission of the symptoms again occurs.
ExamPle 2 - Treatment of preeclampsia To a human female comparable to and displaying the same symptoms as the one described in Example 1, administer daily 2 x 2.5 mg of nitroglycerine and 200 mg SUBSTITUTE SHEET (RUL~ 2~) W095/0~8 21~ 6 8 7 3 PCT~4/02368 ~ . . . .
of progesterone following the same protocol, until the symptoms are ameliorated.
Example 3 - Treatment of Preterm Labor To a human female in her sixth month of pregnancy and displaying symptoms of a threatened spontaneous abortion, including blood spotting and periodic uterine spasms, administer daily 17 g of L-arginine and 50 mg of progesterone per os daily in three divided doses until the symptoms are ameliorated. Thereafter, administer 5 g of L-arginine and 50 mg of progesterone per os daily with increasing doses to 20 g of L-arigine daily until remission of the symptoms again occurs.
ExamPle 5 - Treatment of Preterm Labor To a pregnant human female comparable to and displaying the same symptoms as the one described in Example 3, administer daily 2 x 25 mg of nitroglycerine and up to 180 mg of progesterone, following the same protocol, until the symptoms are ameliorated.
The preceding examples can be repeated with similar success by substituting the generically or specifically described reactants and/or operating conditions of this invention for those used in the preceding examples.
From the foregoing description, one skilled in the art can easily ascertain the essential characteristics of this invention, and without departing from the spirit and scope thereof, can make various changes and modifications of the invention to adapt it to various usages and conditions.
STITUTE SHEET (RULE 26)
Claims (22)
1. Use of (a) a progestin and (b) a nitric oxide synthase subtrate, a nitric oxide donor or both, optionally, in further combination with one or more of a cyclooxygenase inhibitor, a PGI2-mimetic, a thromboxane (TXA2) inhibitor, a compound possessingTXA2-agonistic and TXA2-inhibiting prpperties, a compound possessing TXA2-antagonistic and PGI2 mimetic activities, and a TXA2 antagonist, for manufacture of a medicament for treating at least one of preeclampsia and preterm labor in a pregnant female mammal.
2. Use of claim 1, wherein (a) is used in an amount of which is bioequivalent to 50-300 mg of injected progesterone and (b) in an amount which is effective to raise the blood level of circulating L-arginine to at least about 1 mmole above the normally 2 to 3 mmolar circulating levels.
3. Use of claim 1 or 2, wherein the female mammal is a human suffering from preeclampsia.
4. Use of claim 1 or 2, wherein the female mammal is a human who has exhibited or is a candidate for preterm labor.
5. Use of claim 1 or 2, wherein the female mammal is a human and wherein (b) is a nitric oxide synthase substrate.
6. Use of claim 5, wherein the substrate is L-arginine.
7. Use of claim 1 or 2, wherein the female mammal is a human and wherein (b) is a nitric oxide donor.
8. Use of claim 7, wherein the nitric oxide donor is sodium nitroprusside, nitroglycerin, glycelyltrinitrite, SIN-1, isosorbidmononitrite or isosorbiddinitrite.
9. Use of claim 7, wherein the nitric oxide donor is for oral administration.
10. Use of claim 1 or 2, wherein the female mammal is a human and the nitric oxide substrate or donor is for administration in combination with a cyclooxygenase inhibitor.
11. Use of claim 10, wherein the inhibitor is aspirin.
12. Use of claim 1 or 2, wherein the female mammal is a human and the nitric oxide substrate or donor is for administration in combination with a PGI2-mimetic.
13. Use of claim 12, wherein the PGI2-mimetic is iloprost or cicaprost.
14. Use of claim 1 or 2, wherein the female mammal is a human and the progestin is progesterone
15. A pharmaceutical composition comprising an admixture of (a) a progestin and (b) a nitric oxide synthesis substrate, a nitric oxide donor or both, and optionally, also at least one of a cyclooxygenase inhibitor, a PGI2-mimetic, a thromboxane (TXA2) inhibitor, a PGI2-mimetic, a thromboxane (TXA2) inhibitor, a compound possessing TXA2-agonistic and TXA2-inhibiting properties, a compound possessing TXA2-antagonistic and PGl2-memetic activities, and a TXA2 antagonist, in amounts effective to ameliorate the symptoms of preeclampsia, toxemia or preterm labor in a pregnant female mammal when administered thereto in an amount effective provide an amount of the progestin bioequivalent to 50-300 mg.
of injected progesterone and an amount of the nitric oxide synthase substrate, nitric oxide donor or both effective to raise the blood level of circulating L-arginine to at least about 1 mmole above the normally 2 to 3 mmolar circulating levels or raise the nitric oxide donor levels to about 1 to 1000 nmolar.
of injected progesterone and an amount of the nitric oxide synthase substrate, nitric oxide donor or both effective to raise the blood level of circulating L-arginine to at least about 1 mmole above the normally 2 to 3 mmolar circulating levels or raise the nitric oxide donor levels to about 1 to 1000 nmolar.
16. The composition according to claim 15, wherein (b) is a nitric oxide synthesis substrate.
17. The composition according to claim 16, wherein the nitric oxide synthesis substrate is L-arginine.
18. The composition according to claim 15, wherein (b) is a nitric oxide donor.
19. The composition according to claim 18, wherein the nitric oxide donor is sodium nitroprusside, nitroglycerin, glyceryltrinitrie, SIN-1, isosorbidmononitrite or isosorbiddinitrite.
20. The composition according to claim 18, which comprises a cyclooxygenase inhibitor.
21. The composition according to claim 18, which comprises a PGI2-mimetic.
22. The composition according to claim 18, which comprises a thromboxane inhibitor.
Applications Claiming Priority (2)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| US08/092,426 US5895783A (en) | 1993-07-16 | 1993-07-16 | Treatment of preeclampsia and preterm labor with combination of progestational agent and a nitric oxide synthase substrate and/or donor |
| US08/092,426 | 1993-07-16 |
Publications (1)
| Publication Number | Publication Date |
|---|---|
| CA2166873A1 true CA2166873A1 (en) | 1995-01-26 |
Family
ID=22233157
Family Applications (1)
| Application Number | Title | Priority Date | Filing Date |
|---|---|---|---|
| CA002166873A Abandoned CA2166873A1 (en) | 1993-07-16 | 1994-07-18 | Combination of a progestational agent and a nitric oxide synthase substrate and/or donor for the treatment of preeclampsia and preterm labor |
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| NO (1) | NO312335B1 (en) |
| NZ (1) | NZ271077A (en) |
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| SK (1) | SK282292B6 (en) |
| UA (1) | UA39206C2 (en) |
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| US5811416A (en) * | 1994-06-06 | 1998-09-22 | Board Of Regents The University Of Texas System | Endothelin antagonist and/or endothelin synthase inhibitor in combination with a progestin, an estrogen, a cyclooxygenase inhibitor, or a nitric acid donor or substrate |
| US6613757B1 (en) * | 1994-09-22 | 2003-09-02 | Board Of Regents, The University Of Texas System | Combination of prostacyclin with an estrogen or progestin for the prevention and treatment of atherosclerotic vascular disease including preeclampsia and for the treatment of hypertension, and for hormone replacement therapy |
| GB9424694D0 (en) * | 1994-12-07 | 1995-02-01 | Wellcome Found | Compounds for use in medicine |
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| US5910482A (en) * | 1996-03-19 | 1999-06-08 | Board Of Regents, The University Of Texas System | Treatment or prevention of preeclampsia, eclampsia with calcitonin gene related peptide, CGRP analog, progestational agent, nitric oxide source, and cyclooxygenase inhibitor |
| US5898038A (en) * | 1996-03-19 | 1999-04-27 | Board Of Regents, The University Of Texas System | Treatment of osteoporosis and metabolic bone disorders with nitric oxide substrate and/or donors |
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| US5906987A (en) * | 1997-03-10 | 1999-05-25 | Schering Aktiengesellschaft And Board Of Regents | Treatment of male climacteric disorders with nitric oxide synthase substrates and/or donors, in combination with androgens and/or aromatase inhibitors |
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| US4855142A (en) * | 1987-02-27 | 1989-08-08 | Ciba-Geigy Corporation | Pharmaceutical plaster |
| EP0441119A3 (en) * | 1990-01-09 | 1992-10-14 | Richard D. Levere | The use of l-arginine in the treatment of hypertension and other vascular disorders |
| US5508045A (en) * | 1992-10-09 | 1996-04-16 | The Regents Of The University Of California | Method and agents for control and management of labor during pregnancy |
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- 1993-07-16 US US08/092,426 patent/US5895783A/en not_active Expired - Fee Related
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- 1994-07-18 NZ NZ271077A patent/NZ271077A/en unknown
- 1994-07-18 ES ES94924261T patent/ES2150497T3/en not_active Expired - Lifetime
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- 1994-07-18 UA UA96010200A patent/UA39206C2/en unknown
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- 1994-07-18 AT AT94924261T patent/ATE192652T1/en not_active IP Right Cessation
- 1994-07-18 SK SK65-96A patent/SK282292B6/en unknown
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- 1994-07-18 CA CA002166873A patent/CA2166873A1/en not_active Abandoned
- 1994-07-18 BR BR9407069A patent/BR9407069A/en not_active Application Discontinuation
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