Patent Application
20150374749
The present invention relates to the combination of a nitroprusside salt or a solvate thereof with a sulfide salt or a solvate thereof for use in the treatment or prevention of a cardiovascular disease/disorder, such as heart failure, heart attack or hypertension.
Sodium nitroprusside (SNP), i.e. Na2[Fe(CN)5NO], is a potent vasodilator, the principal pharmacological action of which is relaxation of vascular smooth muscle and consequent dilatation of peripheral arteries and veins, whereby it is more active on veins than on arteries. Its vasodilatory effects are assigned to the release of nitric oxide NO. (referred to as NO in the following). In the human heart, NO reduces both total peripheral resistance as well as venous return, thus decreasing both preload and afterload. SNP is indicated for the immediate reduction of blood pressure of patients in hypertensive crises as well as for the treatment of acute congestive heart failure (package insert for Nitropress® (sodium nitroprusside injection), Hospira, Inc., 2006). However, when SNP is metabolized, it gives rise to considerable quantities of cyanide ions (CN−) that can reach toxic, potentially lethal levels, which severely restricts the potential to use SNP as a therapeutic agent. Yet, in certain clinical cases, SNP is still a therapeutic of choice in acute hypertensive crisis, despite its toxicity due to cyanide release.
It would be highly desirable to provide an SNP-based therapeutic composition for the treatment of cardiovascular diseases/disorders, which should not suffer from the disadvantage of causing severe side effects due to the release of toxic cyanide ions from SNP. Accordingly, it is an object of the present invention to provide a novel therapeutic for the medical intervention of cardiovascular diseases/disorders, which should overcome the toxic side effects of SNP resulting from the release of cyanide ions when SNP is used alone.
In the context of the present invention, it has surprisingly been found that, when a nitroprusside salt and a sulfide salt (such as SNP and Na2S) are used in combination, all of the toxic cyanide that would otherwise be released from nitroprusside is transformed into harmless thiocyanate (SCN−), which indicates that the combination of a nitroprusside salt and a sulfide salt lacks the toxicity of nitroprusside alone. Consequently, the combination of a nitroprusside salt and a sulfide salt can be administered safely in higher doses than SNP alone, which further expands the therapeutic potential of this combination.
Hydrogen sulfide (H2S) has been increasingly recognized as an important signaling molecule. Evidence accumulated over the past decade shows that H2S plays an important role in regulating vascular contractility and neuronal activity (Li, L. et al., 2009; Li, L. et al., 2011). Experiments using knockout mice lacking cystathionine gamma-lyase, an enzyme involved in H2S biosynthesis, unambiguously demonstrated its essential role in blood pressure regulation (Yang, G. et al, 2008; Mustafa, A. K. et al., 2011). A strong pharmacological potential for both H2S and newly developed H2S donors to minimize the effects of ischemia-reperfusion injuries and atherosclerosis has been documented using numerous disease models (Szabo, C., 2007). Cardioprotective effects of H2S have further been reported in various models (Szabó, G. et al., 2011).
The similarities between the physiological effects of H2S and NO suggest a possible cross-talk between these two gaseous species (Li, L. et al., 2009). The first such proposal came from Ali et al. who showed that H2S inhibits the relaxation of isolated aorta rings induced by sodium nitroprusside (Ali, M. Y. et al., 2006). They proposed the intermediate formation of a stable S-nitrosothiol (RSNO). More recently, Yong et al. suggested that the product of NO and H2S interactions should be a thiol-modifying agent with a positive inotropic effect on the heart (Yong, Q. C. et al., 2011). In a prior study, they had found similarities between this product and nitroxyl (HNO) (Yong, Q. C. et al., 2010).
In all of these studies, SNP was used as the NO donor. However, SNP is not a true NO donor unless it is exposed to light, and its “NO-like” physiological effects are still not well understood (Butler, A. R. et al., 2002). In SNP, i.e. Na2[Fe(CN)5(NO)], NO coordinated to iron has an NO+ character and undergoes chemistry that is best described as direct nitrosation rather than NO biochemistry (Roncaroli, F. et al., 2007). The reactions of SNP with low molecular weight thiols, like cysteine and glutathione, have been investigated (Butler, A. R. et al., 1988; Grossi, L. et al., 2005; Johnson, M. D. et al., 1983; Szaciowski, K. et al., 2002), and the intermediate formation of S-nitrosothiol was postulated based on these biomimetic studies to account for the vasodilatory effects of SNP. Studies on the reaction of SNP with H2S were performed under anaerobic and very alkaline conditions (Butler, A. R. et al., 1988; Rock, P. A. et al., 1965; Quiroga, S. L. et al., 2011), but nothing has definitively been known about the products of this reaction under physiological conditions (Filipovic, M. R. et al., 2012, a). In another study, the reaction between SNP and sodium HS was postulated to result in the formation of an SNP-HS adduct (Kruszyna, H. et al., 1985). Yet, none of these studies provide any suggestion how the cyanide toxicity of SNP could possibly be overcome.
In other studies, SNP was employed as an NO donor together with an H2S donor, and their vasodilatory effects were tested (Hosoki, R. et al., 1997; Wang, Y. F. et al., 2008). However, these studies fail to address the problem of overcoming the toxicity of SNP resulting from the release of cyanide ions and furthermore fail to provide any insights into the molecular interaction of SNP with H2S. The therapeutic use of SNP is also described, e.g., in WO 2010/015260, CH-A-656618, and Yamamoto, H. A., 1990.
Nitroxyl (HNO), the one electron reduced sibling of NO, is even more potent in regulating blood pressure due to the fact that it stimulates the release of calcitonin gene-related peptide (CGRP) which is the strongest known vasodilator (Wink, D. A. et al., 2003). Additionally, HNO has a positive inotropic effect on the heart (Paolocci, N. et al., 2001; Paolocci, N. et al., 2007) and is considered to be important in saving failing heart and to be a very promising therapeutic agent for cardiovascular diseases (Flores-Santana, W. et al., 2011; Irvine, J. C. et al., 2008). A current goal of pharmaceutical companies is the generation of efficient HNO donors that could be used for the regulation of blood pressure and the treatment of heart failure (DuMond, J. F. et al., 2011; Shoman, M. E. et al., 2011; Keefer, L. K., 2011), particularly because, unlike NO donors, HNO does not cause nitrate-tolerance which is a serious drawback of therapy with NO (Bullen, M. L. et al., 2011). Known HNO donors and their use in the treatment of heart failure and other conditions are described, e.g., in US 2004/0039063, US 2005/0192254, US 2007/0299107, US 2009/0163487 and US 2012/0201907.
As explained above, the present invention addresses the problem of providing an SNP-based therapeutic for the medical intervention of cardiovascular diseases/disorders, which should not entail the severe side effects resulting from toxic cyanide ions released from SNP. The invention is based on the finding that, when a nitroprusside salt and a sulfide salt are used in combination, the toxic cyanide that would otherwise be released from the nitroprusside is transformed into harmless thiocyanate (SCN−), which was completely unexpected in view of the prior art.
Accordingly, the present invention provides a nitroprusside salt or a solvate thereof in combination with a sulfide salt or a solvate thereof for use in the treatment or prevention of a cardiovascular disease/disorder.
The invention also relates to a pharmaceutical composition for use in the treatment or prevention of a cardiovascular disease/disorder, the pharmaceutical composition comprising a nitroprusside salt or a solvate thereof in combination with a sulfide salt or a solvate thereof, and optionally a pharmaceutically acceptable excipient. Likewise, the present invention relates to the use of a nitroprusside salt or a solvate thereof in combination with a sulfide salt or a solvate thereof for the preparation of a medicament for the treatment or prevention of a cardiovascular disease/disorder.
The invention further provides a nitroprusside salt or a solvate thereof for use in the treatment or prevention of a cardiovascular disease/disorder, wherein the nitroprusside salt or solvate is to be administered in combination with a sulfide salt or a solvate thereof. The invention also provides a sulfide salt or a solvate thereof for use in the treatment or prevention of a cardiovascular disease/disorder, wherein the sulfide salt or solvate is to be administered in combination with a nitroprusside salt or a solvate thereof.
Moreover, the present invention relates to a method of treating or preventing a cardiovascular disease/disorder, the method comprising the administration of a nitroprusside salt or a solvate thereof in combination with a sulfide salt or a solvate thereof, or a pharmaceutical composition comprising a nitroprusside salt or a solvate thereof, a sulfide salt or a solvate thereof and optionally a pharmaceutically acceptable excipient, to a subject in need thereof. The nitroprusside salt or solvate and the sulfide salt or solvate are preferably administered to the subject in therapeutically effective amounts. The subject is preferably a human or a non-human animal, and is more preferably a human.
The nitroprusside salt or solvate and the sulfide salt or solvate may be administered either simultaneously/concomitantly or sequentially (e.g., the nitroprusside salt or solvate may be administered first, followed by the administration of the sulfide salt or solvate, or vice versa). When administration is simultaneous, the nitroprusside salt or solvate and the sulfide salt or solvate may be administered either in the same pharmaceutical composition or in different/separate pharmaceutical compositions. It is preferred that the nitroprusside salt or solvate and the sulfide salt or solvate are provided as separate powders which can be reconstituted for simultaneous administration, e.g., by dissolving both powders in an infusion solution, such as an aqueous solution containing 0.9 wt-% sodium chloride, or lactated Ringer's solution or Hartmann's solution (as described, e.g., in White S. A. et al., 1997), or any other buffered infusion solution. Accordingly, the invention relates to a nitroprusside salt or a solvate thereof in combination with a sulfide salt or a solvate thereof for use in the treatment or prevention of a cardiovascular disease/disorder, wherein the nitroprusside salt or solvate and the sulfide salt or solvate are provided as separate powders.
The nitroprusside salt to be used in accordance with the present invention may be, e.g., an alkali salt of nitroprusside (e.g., sodium nitroprusside or potassium nitroprusside), and is preferably sodium nitroprusside (SNP). Particularly preferred is disodium nitroprusside dihydrate, i.e. Na2[Fe(CN)5NO].2H2O.
The sulfide salt or solvate is preferably an alkali hydrogensulfide salt (e.g., NaHS or KHS), a dialkali sulfide salt (e.g., Na2S or K2S), an alkaline earth metal sulfide salt (e.g., MgS or CaS), or a solvate thereof. More preferably, the sulfide salt or solvate is an alkali hydrogensulfide salt, a dialkali sulfide salt or a solvate thereof, and even more preferably it is sodium hydrogensulfide (NaHS) or sodium sulfide (Na2S). Most preferably, the sulfide salt is Na2S. It is to be understood that the term “sulfide salt” as used herein encompasses salts of S2− and salts of HS−.
While other compounds capable of releasing/providing H2S under physiological conditions, such as the H2S donors known in the art and described in the pertinent literature (e.g., Wallace J. L., 2007; Caliendo G. et al., 2010; Zhao Y. et al., 2011; Hughes M. N. et al., 2009; Kashfi K. et al., 2012), can also be used in combination with a nitroprusside salt or solvate for the treatment or prevention of a cardiovascular disease/disorder, the use of a sulfide salt or solvate in accordance with the present invention is advantageous over the use of such other H2S donors because the latter release H2S slowly and are therefore less suitable to render harmless the toxic cyanide that would otherwise be released from nitroprusside.
It is thus particularly preferred that SNP and NaHS are to be used in combination, and it is even more preferred that SNP and Na2S are to be used in combination.
The sulfide salt or solvate is preferably used in a molar excess as compared to the nitroprusside salt or solvate. It is particularly preferred that the sulfide salt or solvate (such as, e.g., Na2S or NaHS) is used in an about 2-fold to about 10-fold molar excess, more preferably in an about 3-fold to about 7-fold molar excess, even more preferably in an about 5-fold to about 6-fold molar excess, and yet even more preferably in an about 6-fold molar excess, with respect to the amount of the nitroprusside salt or solvate (e.g., SNP) to be employed.
In the context of the present invention, the reaction of SNP and a sulfide salt has been studied under physiologically relevant conditions using both chemical and physiological/pharmacological tools. It has surprisingly been found that nitroprusside salts such as SNP react directly with H2S released from sulfide salts to generate nitroxyl (HNO), without any intermediate formation of NO, and to convert the toxic cyanide released from nitroprusside into harmless thiocyanate. As shown in Example 2, the intracellular formation of HNO from SNP and Na2S has been confirmed and the subsequent release of calcitonin gene-related peptide (CGRP) from mouse heart has been demonstrated. The present invention thus provides a novel HNO-generating therapeutic having potent vasodilatory and positive inotropic effects for the medical intervention of cardiovascular diseases/disorders, which allows to avoid the toxic side effects of SNP resulting from the release of cyanide from nitroprusside and to avoid the emergence of nitrate-tolerance.
The cardiovascular disease/disorder to be treated or prevented in accordance with the present invention is preferably selected from heart failure (such as, e.g., congestive heart failure (e.g., acute congestive heart failure), acute decompensated heart failure, diastolic heart failure, or cardiac asthma), heart attack or myocardial infarction, hypertension (such as, e.g., hypertensive heart disease, hypertensive nephropathy, essential hypertension, secondary hypertension (e.g., renovascular hypertension), pulmonary hypertension, malignant hypertension, benign hypertension, systolic hypertension, white coat hypertension, or acute hypertension), coronary obstruction, coronary artery disease (CAD), angina pectoris, ischemic cardiomyopathy and/or infarction, pulmonary congestion, pulmonary edema, cardiac fibrosis, valvular heart disease, pericardial disease, circulatory congestive state, peripheral edema, ascites, myocarditis, Chagas disease, ventricular hypertrophy, or heart valve disease.
It is particularly preferred that the cardiovascular disease/disorder to be treated or prevented is selected from heart failure (such as, e.g., congestive heart failure (e.g., acute congestive heart failure), acute decompensated heart failure, diastolic heart failure, or cardiac asthma), heart attack, myocardial infarction, or hypertension (such as, e.g., hypertensive heart disease, hypertensive nephropathy, essential hypertension, secondary hypertension (e.g., renovascular hypertension), pulmonary hypertension, malignant hypertension, benign hypertension, systolic hypertension, white coat hypertension, or acute hypertension).
The combination of a nitroprusside salt or a solvate thereof with a sulfide salt or a solvate thereof according to the invention is also useful as a vasodilator, e.g., to promote wound healing or for treating or preventing trauma or physical injury, such as anal fissure. Accordingly, the present invention relates to a nitroprusside salt or a solvate thereof in combination with a sulfide salt or a solvate thereof for use in promoting wound healing and also for use in treating or preventing trauma or physical injury, such as, e.g., anal fissure.
The nitroprusside salt or solvate as well as the sulfide salt or solvate to be used in accordance with the present invention are commercially available and can also be prepared in accordance with or in analogy to synthetic routes described in the literature (e.g., Hyde, F. S., 1897; Brauer, G., 1963).
It is to be understood that any salts to be used as pharmaceuticals or to be contained in a pharmaceutical composition in the present invention, including in particular the nitroprusside salts and the sulfide salts described herein, are preferably pharmaceutically acceptable salts.
Moreover, the invention relates to the nitroprusside salts and the sulfide salts described herein in any solvated form, including, e.g., solvates with water, for example hydrates, or with organic solvents such as, e.g., methanol, ethanol or acetonitrile, i.e., as a methanolate, ethanolate or acetonitrilate, respectively, or in the form of any polymorph.
The nitroprusside salts and the sulfide salts described herein may be administered as compounds per se or may be formulated as medicaments. The medicaments/pharmaceutical compositions may optionally comprise one or more pharmaceutically acceptable excipients, such as carriers, diluents, fillers, disintegrants, lubricating agents, binders, colorants, pigments, stabilizers, preservatives, antioxidants, or solubility enhancers.
The pharmaceutical compositions can be formulated by techniques known to the person skilled in the art, such as the techniques published in Remington's Pharmaceutical Sciences, 20th Edition. The pharmaceutical compositions can be formulated as dosage forms for parenteral, such as intramuscular, intravenous, subcutaneous, intradermal, intraarterial, intracardial, rectal, nasal, topical, aerosol or vaginal administration. Dosage forms for parenteral administration include solutions, emulsions, suspensions, dispersions and powders and granules for reconstitution. Emulsions are a preferred dosage form for parenteral administration. Dosage forms for rectal and vaginal administration include suppositories and ovula. Dosage forms for nasal administration can be administered via inhalation and insufflation, for example by a metered inhaler. Dosage forms for topical administration include creams, gels, ointments, salves, patches and transdermal delivery systems. Preferably, the pharmaceutical compositions of the invention are formulated as dosage forms for parenteral administration (such as, e.g., for intravenous, intraarterial, intraperitoneal, intrathecal, intraventricular, intraurethral, intrasternal, intracardial, intracranial or intramuscular administration), particularly for intramuscular or intravenous administration, and most preferably for intravenous infusion.
The nitroprusside salt or solvate and the sulfide salt or solvate according to the invention, or the corresponding pharmaceutical compositions described above, may be administered to a subject by any convenient route of administration, whether systemically/peripherally or at the site of desired action, including but not limited to one or more of: topical (e.g., transdermal, intranasal, ocular, buccal, and sublingual), parenteral (e.g., using injection techniques or infusion techniques, and including, for example, by injection, e.g., subcutaneous, intradermal, intramuscular, intravenous, intraarterial, intracardiac, intrathecal, intraspinal, intracapsular, subcapsular, intraorbital, intraperitoneal, intratracheal, subcuticular, intraarticular, subarachnoid, or intrasternal by, e.g., implant of a depot, for example, subcutaneously or intramuscularly), pulmonary (e.g., by inhalation or insufflation therapy using, e.g., an aerosol, e.g., through mouth or nose), gastrointestinal, intrauterine, intraocular, subcutaneous, ophthalmic (including intravitreal or intracameral), rectal, and vaginal. The parenteral route of administration is particularly envisaged, with intramuscular or intravenous administration being preferred, and intravenous infusion being most preferred.
Accordingly, the nitroprusside salt or solvate and the sulfide salt or solvate according to the invention, or corresponding pharmaceutical compositions, are preferably administered parenterally. Examples of such administration include one or more of: intravenously, intraarterially, intraperitoneally, intrathecally, intraventricularly, intraurethrally, intrasternally, intracardially, intracranially or intramuscularly administering the compounds or pharmaceutical compositions, and/or by using infusion techniques. For parenteral administration, the compounds are best used in the form of a sterile aqueous solution which may contain other substances, for example, enough salts or glucose to make the solution isotonic with blood. The aqueous solutions should be suitably buffered (preferably to a pH of from 3 to 9), if necessary. The preparation of suitable parenteral formulations under sterile conditions is readily accomplished by standard pharmaceutical techniques well known to those skilled in the art.
The nitroprusside salt or solvate and the sulfide salt or solvate according to the invention, or corresponding pharmaceutical compositions, may also be administered by the pulmonary route, rectal routes, or the ocular route. For ophthalmic use, they can be formulated as micronized suspensions in isotonic, pH adjusted, sterile saline, or, preferably, as solutions in isotonic, pH adjusted, sterile saline, optionally in combination with a preservative such as a benzylalkonium chloride. Alternatively, they may be formulated in an ointment such as petrolatum.
For topical application to the skin, the nitroprusside salt or solvate and the sulfide salt or solvate according to the invention, or corresponding pharmaceutical compositions, can be formulated as a suitable ointment containing the active compound(s) suspended or dissolved in, for example, a mixture with one or more of the following: mineral oil, liquid petrolatum, white petrolatum, propylene glycol, emulsifying wax and water. Alternatively, they can be formulated as a suitable lotion or cream, suspended or dissolved in, for example, a mixture of one or more of the following: mineral oil, sorbitan monostearate, a polyethylene glycol, liquid paraffin, polysorbate 60, cetyl esters wax, 2-octyldodecanol, benzyl alcohol and water.
It is particularly preferred that the combination of a nitroprusside salt or a solvate thereof with a sulfide salt or a solvate thereof according to the present invention is to be administered parenterally, in particular by intravenous injection or infusion, and most preferably by intravenous infusion.
Typically, a physician will determine the actual dosage which will be most suitable for an individual subject. The specific dose level and frequency of dosage for any particular individual subject may be varied and will depend upon a variety of factors including the activity of the specific compounds/salts employed, the metabolic stability and length of action of these compounds/salts, the age, body weight, general health, sex, diet, mode and time of administration, rate of excretion, drug combination, the severity of the particular condition, and the individual subject undergoing therapy.
A proposed, yet non-limiting dose of the combination of a nitroprusside salt or solvate with a sulfide salt or solvate according to the invention for parenteral (particularly intravenous) administration to an animal (e.g., a human) is in the range of about 1 μg to about 1 mg of the nitroprusside salt or solvate (e.g., SNP) per kg body weight per day in combination with about 1 μg to about 5 mg of the sulfide salt or solvate (e.g., NaHS or Na2S) per kg body weight per day, including in particular a dose in the range of about 10 μg/kg/day to about 1 mg/kg/day of the nitroprusside salt or solvate in combination with about 5 μg/kg/day to about 7 mg/kg/day of the sulfide salt or solvate. The combination of the nitroprusside salt or solvate with the sulfide salt or solvate may be administered, e.g., by continuous intravenous infusion or by 1 to 4 injections per day. If administered continuously, the combination according to the invention may be administered at a dose rate of about 0.5 μg/kg/min to about 100 μg/kg/min. It will be appreciated that it may be necessary to make routine variations to the dosage depending on the age and weight of the patient/subject as well as the severity of the condition to be treated. The precise dose and also the route of administration will ultimately be at the discretion of the attendant physician or veterinarian.
The combination of a nitroprusside salt or a solvate thereof with a sulfide salt or a solvate thereof according to the present invention may be administered in the context of a monotherapy (i.e., using the nitroprusside salt or solvate and the sulfide salt or solvate as the sole pharmaceutically active agents for the treatment or prevention of a cardiovascular disease/disorder) or in combination with one or more further pharmaceutically active agents. When the nitroprusside salt or solvate and the sulfide salt or solvate according to the invention are used in combination with a further pharmaceutically active agent which is active against the same cardiovascular disease/disorder, a lower dose of each agent may be used. The combination of the nitroprusside salt or solvate and the sulfide salt or solvate according to the present invention with one or more further pharmaceutically active agents may comprise the simultaneous/concomitant administration of the further pharmaceutically active agents with the nitroprusside salt or solvate and the sulfide salt or solvate according to the invention. However, sequential/separate administration is also envisaged.
Preferably, the further pharmaceutically active agent to be administered in combination with the nitroprusside salt or solvate and the sulfide salt or solvate according to the present invention is an agent for the treatment or prevention of a cardiovascular disease or disorder, such as, e.g., a vasodilator, a positive inotropic agent, a diuretic, or a beta-adrenergic receptor antagonist.
The vasodilator may, e.g., be selected from glyceryl trinitrate, isosorbide dinitrate, isosorbide mononitrate, linsidomine, molsidomine, pentaerythritol tetranitrate, propatylnitrate, tenitramine, trolnitrate, flosequinan, itramin tosilate, prenylamine, oxyfedrine, benziodarone, carbocromen, hexobendine, etafenone, heptaminol, imolamine, dilazep, trapidil, molsidomine, efloxate, cinepazet, cloridarol, nicorandil, nesiritide, gapicomine, pimobendan, or levosimendan.
The positive inotropic agent may, e.g., be selected from berberine, levosimendan, omecamtiv, dopamine, dobutamine, dopexamine, epinephrine (adrenaline), isoprenaline (isoproterenol), norepinephrine (noradrenaline), digoxin, digitalis, prostaglandins, phosphodiesterase inhibitors (such as, e.g., enoximone, milrinone, amrinone, or theophylline), glucagon, or insulin.
The diuretic may, e.g., be selected from acetazolamide, furosemide, bumetanide, etacrynic acid, etozoline, muzolimine, piretanide, tienilic acid, torasemide, hydrochlorothiazide, bendroflumethiazide, hydroflumethiazide, chlorothiazide, polythiazide, trichlormethiazide, cyclopenthiazide, methyclothiazide, cyclothiazide, mebutizide, quinethazone, clopamide, chlortalidone, mefruside, clofenamide, metolazone, meticrane, xipamide, indapamide, clorexolone, fenquizone, amiloride, triamterene, benzamil, spironolactone, eplerenone, potassium canrenoate, canrenone, mannitol, urea, conivaptan, mozavaptan, satavaptan, tolvaptan, demeclocycline, mersalyl, meralluride, theobromine, or cicletanine.
The beta-adrenergic receptor antagonist (“beta blocker”) may, e.g., be selected from alprenolol, bopindolol, bupranolol, carteolol, cloranolol, mepindolol, nadolol, oxprenolol, penbutolol, pindolol, propranolol, sotalol, tertatolol, timolol, acebutolol, atenolol, betaxolol, bevantolol, bisoprolol, celiprolol, epanolol, esmolol, nebivolol, metoprolol, practolol, S-atenolol, talinolol, carvedilol, labetalol, or butaxamine.
The combinations referred to above may conveniently be presented for use in the form of a pharmaceutical formulation. The individual components of such combinations may be administered either sequentially or simultaneously/concomitantly in separate or combined pharmaceutical formulations by any convenient route. When administration is sequential, either the combination of a nitroprusside salt or a solvate thereof with a sulfide salt or a solvate thereof according to the invention or the further pharmaceutically active agent may be administered first. When administration is simultaneous, the combination including the further pharmaceutically active agent may be administered either in the same or different pharmaceutical compositions. When combined in the same formulation, it will be appreciated that the various compounds must be stable and compatible with each other and the other components of the formulation. When formulated separately, they may be provided in any convenient formulation, conveniently in such manner as is known for such compounds in the art.
Accordingly, the present invention relates to a nitroprusside salt or a solvate thereof for use in the treatment or prevention of a cardiovascular disease/disorder, wherein the nitroprusside salt or solvate is to be administered in combination with a sulfide salt or a solvate thereof and with a further pharmaceutically active agent (such as, e.g., a vasodilator, a positive inotropic agent, a diuretic, or a beta-adrenergic receptor antagonist). The invention also provides a sulfide salt or a solvate thereof for use in the treatment or prevention of a cardiovascular disease/disorder, wherein the sulfide salt or solvate is to be administered in combination with a nitroprusside salt or a solvate thereof and with a further pharmaceutically active agent (such as, e.g., a vasodilator, a positive inotropic agent, a diuretic, or a beta-adrenergic receptor antagonist). The invention furthermore relates to a pharmaceutical composition for use in the treatment or prevention of a cardiovascular disease/disorder, the pharmaceutical composition comprising a nitroprusside salt or a solvate thereof in combination with a sulfide salt or a solvate thereof and optionally a pharmaceutically acceptable excipient, wherein the pharmaceutical composition is to be administered in combination with a further pharmaceutically active agent (such as, e.g., a vasodilator, a positive inotropic agent, a diuretic, or a beta-adrenergic receptor antagonist).
The subject or patient, such as the subject in need of treatment or prevention, may be an animal (e.g., a non-human animal), a vertebrate animal, a mammal, a rodent (e.g., a guinea pig, a hamster, a rat, a mouse), a murine (e.g., a mouse), a canine (e.g., a dog), a feline (e.g., a cat), an equine (e.g., a horse), a primate, a simian (e.g., a monkey or ape), a monkey (e.g., a marmoset, a baboon), an ape (e.g., a gorilla, chimpanzee, orang-utan, gibbon), or a human. The meaning of the terms “animal”, “mammal”, etc. is well known in the art and can, for example, be deduced from Wehner and Gehring (1995; Thieme Verlag). In the context of this invention, it is also envisaged that animals are to be treated which are economically, agronomically or scientifically important. Scientifically important organisms include, but are not limited to, mice, rats, and rabbits. Non-limiting examples of agronomically important animals are sheep, cattle and pigs, while, for example, cats and dogs may be considered as economically important animals. Preferably, the subject/patient is a mammal. More preferably, the subject/patient is a human or a non-human mammal (such as, e.g., a guinea pig, a hamster, a rat, a mouse, a rabbit, a dog, a cat, a horse, a monkey, an ape, a marmoset, a baboon, a gorilla, a chimpanzee, an orang-utan, a gibbon, a sheep, cattle, or a pig). Even more preferably, the subject/patient is a human.
The term “treatment of a disorder or disease” as used herein is well known in the art. “Treatment of a disorder or disease” implies that a disorder or disease is suspected or has been diagnosed in a patient/subject. A patient/subject suspected of suffering from a disorder or disease typically shows specific clinical and/or pathological symptoms which a skilled person can easily attribute to a specific pathological condition (i.e., diagnose a disorder or disease).
“Treatment of a disorder or disease” may, for example, lead to a halt in the progression of the disorder or disease (e.g., no deterioration of symptoms) or a delay in the progression of the disorder or disease (in case the halt in progression is of a transient nature only). “Treatment of a disorder or disease” may also lead to a partial response (e.g., amelioration of symptoms) or complete response (e.g., disappearance of symptoms) of the subject/patient suffering from the disorder or disease. “Amelioration” of a disorder or disease may, for example, lead to a halt in the progression of the disorder or disease or a delay in the progression of the disorder or disease. Such a partial or complete response may be followed by a relapse. It is to be understood that a subject/patient may experience a broad range of responses to a treatment (e.g., the exemplary responses as described herein above).
Treatment of a disorder or disease may, inter alia, comprise curative treatment (preferably leading to a complete response and eventually to healing of the disorder or disease) and palliative treatment (including symptomatic relief).
Also the term “prevention of a disorder or disease” as used herein is well known in the art. For example, a patient/subject suspected of being prone to suffer from a disorder or disease as defined herein may, in particular, benefit from a prevention of the disorder or disease. The subject/patient may have a susceptibility or predisposition for a disorder or disease, including but not limited to hereditary predisposition. Such a predisposition can be determined by standard assays, using, for example, genetic markers or phenotypic indicators. It is to be understood that a disorder or disease to be prevented in accordance with the present invention has not been diagnosed or cannot be diagnosed in the patient/subject (for example, the patient/subject does not show any clinical or pathological symptoms). Thus, the term “prevention” comprises the use of compounds of the present invention before any clinical and/or pathological symptoms are diagnosed or determined or can be diagnosed or determined by the attending physician.
The term “about” refers to ±10% of the indicated numerical value, and in particular to ±5% of the indicated numerical value. Whenever the term “about” is used, a specific reference to the exact numerical value indicated is also included. For example, the expression “about 100” refers to the range of 90 to 110, in particular the range of 95 to 105, and preferably refers to the specific value of 100.
In this specification, a number of documents including patent applications and scientific literature are cited. The disclosure of these documents, while not considered relevant for the patentability of this invention, is herewith incorporated by reference in its entirety. More specifically, all referenced documents are incorporated by reference to the same extent as if each individual document was specifically and individually indicated to be incorporated by reference.
The invention is also illustrated by the following illustrative figures. The appended figures show:
The invention will now be described by reference to the following examples which are merely illustrative and are not to be construed as a limitation of the scope of the present invention.
Unless stated otherwise, all chemicals were purchased from Sigma Aldrich. Na2S was purchased in the anhydrous form and was both opened and stored in a glove box (<1 ppm O2 and <1 ppm H2O). In all experiments described in the following, Na2S was used to provide H2S. The solutions were prepared and handled as in described in Filipovic, M. R. et al., 2012, c.
1) General Notes on the Reaction of SNP with Thiols
As illustrated in Scheme 1 below, the general mechanism for the reactions of SNP with thiols involves the initial formation of a coordinated S-nitrosothiol, which has the characteristic pink color that has long been used as a proof for thiols in Brand's assay (Brand, E. et al., 1930). The S-nitrosothiols (RSNOs) formed account for the “NO-like” physiology of SNP because they can be either homolytically cleaved to give NO (Grossi, L. et al., 2005; Szaciowski, K. et al., 2002), corresponding to pathway a in Scheme 1, or they can be released to further react with the corresponding physiological targets (Butler, A. R. et al., 2002; Roncaroli, F. et al., 2007; Butler, A. R. et al., 1988; Grossi, L. et al., 2005; Johnson, M. D. et al., 1983), as reflected by pathway b in Scheme 1.
A chemical study of the reactions of H2S with SNP has recently appeared (Quiroga, S. L. et al., 2011) and describes the reaction mechanism as initially being similar to that of thiols (although at pH 9-11) with the resulting pink-colored product characteristic of the HSNO/SNO− coordinated adduct of SNP. The end products of this reaction were found to be NH3 (at pH 8.5-11) and N2O (at pH>11), corresponding to pathways c and d in Scheme 1. However, the characterization of some of the intermediates reported in the literature was subsequently questioned (Filipovic, M. R. et al., 2012, a). Notably, both the in vitro and in vivo generation of and reactions with free (non-coordinated) HSNO/SNO−, the smallest S-nitrosothiol, have been recently reported (Filipovic, M. R. et al., 2012, b; Kemsley, J., 2012).
However, it has been shown in the context of the present invention that, under physiologically relevant conditions (aerobic conditions at pH=7.4), the H2S and SNP reaction mixture forms a blue product solution. This result is obviously different from the pink/purple products reported for reactions with cysteine, glutathione or H2S (under anaerobic and alkaline conditions), which implies that a different reaction mechanism occurred.
2) Analysis of the Reaction of SNP with H2S by Amperometric Detection of NO and H2S
In the literature dealing with the physiology and pharmacology of H2S, there is a prevailing opinion (Ali, M. Y. et al., 2006; Whiteman, M. et al., 2006) that H2S and NO react to form a stable S-nitrosothiol that decomposes upon the addition of copper ions to release NO.
To both test the hypothesis of stable S-nitrosothiol formation and determine the actual source of the NO release, the reaction between SNP and H2S was followed using an NO-sensitive electrode both in the total absence of light and under ambient light. The fate of NO was monitored throughout the course of the reaction using ISO-NO probes connected to a Free Radical Analyzer (World Precision Instruments) (Filipovic, M. R. et al., 2012, b).
As expected, there was no release of NO from SNP in the dark, and the addition of H2S had no effect. Minor amounts of NO were released over time when SNP was exposed to ambient light; however, H2S addition completely suppressed further NO release, as also shown in
Next, the effect of SNP on H2S removal from the solution was followed using a 2 mm shielded H2S-sensitive electrode (Filipovic, M. R. et al., 2012, b). As shown in
3) Organ Bath Studies on Isolated Rat Uteri to Detect Potential NO Release from SNP During the Reaction with H2S
The effects of H2S, SNP and their combination on the spontaneous and Ca2+-induced contraction of isolated rat uterus preparations were tested. This particular pharmacological model was chosen because, unlike other models, it is relatively resistant (at high millimolar concentration) to SNP-induced dilatation (Hennan, J. K. et al., 1998) but still sensitive to other, real NO donors (Demirkoprulu, N. et al., 2005), which makes it suitable for testing the potential NO release from the SNP and H2S reaction mixture.
Isolated uteri from virgin Wistar rats (200-250 g) in the oestrus phase of the estrous cycle, as determined by examining a daily vaginal lavage, were used (Appiah, I. et al., 2010). All of the rats were sacrificed by cervical dislocation following a procedure approved by the animal protection authorities (University of Belgrade, Serbia). The uterine horns were rapidly excised and carefully cleaned of any surrounding connective tissue and mounted vertically in a 10 mL volume organ bath containing De Jalon's solution (in g·L−1: NaCl 9.0, KCl 0.42, NaHCO3 0.5, CaCl2 0.06 and glucose 0.5) aerated with 95% oxygen and 5% carbon dioxide at 37° C. The uteri, either acting spontaneously or being contracted with Ca2+ (6 mM), were allowed to equilibrate at 1 g tension before adding the test drugs. Both H2S and SNP were added cumulatively. The myometrial tension was recorded isometrically using a TSZ-04-E isolated organ bath and transducer (Experimetria, Budapest, Hungary). Each concentration of the activating substance studied was allowed to act for 15 min. Overall, 7 to 10 uteri were used per experiment.
It was found that H2S alone caused a concentration-dependent inhibition of both the spontaneous and calcium-induced smooth muscle contraction (
4) Identification of the Products from the Reaction of SNP with H2S
To identify the reaction products from SNP and H2S, the corresponding reaction mixture was first analyzed using ultra-high resolution (UHR) ESI-TOF MS (maXis, Bruker Daltonics) with a low-temperature cryo-spray ionization (+4° C.) to prevent any potential temperature-induced decomposition of the products during ionization. The data analysis, mass convolution and spectral simulations were performed using the Data Analysis software provided by the manufacturer.
A negative mode mass spectrum of SNP revealed a molecular ion peak at m/z 238.9, which was assigned to Na[Fe(CN)5(NO)]−, as also shown in
To gain further insight into the reaction mechanism and products, GC-MS and 14N NMR measurements were performed.
For GC-MS analysis, a 2 mM SNP solution at pH 7.4 was mixed with H2S in a 1:1, 1:2 and 1:5 ratio, and the gas phase of the reaction mixture was analyzed (15 min after the reaction began) by gas chromatography with a triple-quadrupole mass spectrometer detector.
In particular, 2 mM SNP in 50 mM KPi pH 7.4 was degassed with argon and kept in dark glass vials sealed with PTFE septa until Na2S was added to yield the respective final sulfide concentration. GC-MS analyses were performed on a Bruker GC 450 TQ MS 300. The gas chromatograph was equipped with a Varian VF-5m capillary column. Headspace gas samples 50 μL in volume were injected in the splitless mode. The following oven temperature program was used with helium as the carrier gas: ramped from 50 to 155° C. at a rate of 10° C./min and then to 260° C. at a rate of 30° C./min. The positive electron impact ionization mode was used. The detector multiplier voltage was set to 1400 V, and the detection was performed by selected ion monitoring of m/z 44 (corresponding to N2O) and m/z 30 (corresponding to NO) with a dwell time of 50 ms and SIM scan width of 0.7 a.u. The areas under the peaks were determined using software provided by the manufacturer.
The results of the GC-MS analysis, presented in
To further confirm this N2O formation, an 14N NMR study was performed by collecting NMR spectra over 10 h. In particular, a 25 mM solution of SNP both with and without the addition of 25 mM Na2S in 300 mM KPi pH 7.4 was placed in a 10 mm NMR tube, and the spectra were recorded using a Bruker 400 MHz spectrometer using the 15N signal of nitromethane as a reference. AU of the spectra were recorded at 50.67 MHz, and 200 transients were collected with a 35° pulse width and a 5 s relaxation delay.
As shown in
To obtain additional mechanistic insight, the reaction between SNP and H2S was followed in solution amperometrically using a selective H2S electrode and via both time resolved UV/Vis spectroscopy and real-time FTIR spectroscopy.
When injected into a buffered solution, H2S disappears over time due to its slow oxidation in ambient air. The presence of SNP in the buffered solutions (pseudo-first order conditions: 50 μM H2S and 500 μM-10 mM SNP) led to the rapid removal of H2S, which was determined to be concentration dependent, as also shown in
To gain further mechanistic insight and detect possible intermediate species in the reaction pathway, rapid scan UV/Vis stopped-flow measurements were used. Kinetic data were obtained by recording the time-resolved UV/Vis spectra using a modified μSFM-20 Bio-Logic stopped-flow module combined with a Huber CC90 cryostat and equipped with a J&M TIDAS high-speed diode array spectrometer containing both deuterium and tungsten lamps (200-1015 nm wavelength range) as described in Bisset, W. I. K. et al., 1981.
The reaction was performed under pseudo-first order conditions by applying an excess of H2S. Unlike the studies described in the literature (Butler, A. R. et al., 1988; Rock, P. A. et al., 1965; Quiroga, S. L. et al., 2011), these measurements were conducted using a physiologically relevant pH 7.4 and under aerobic conditions.
The time-resolved spectra (
The fate of this adduct was then examined, which proved to be short-lived at pH 7.4, as it rapidly transformed into a final blue species with an absorbance maximum at 575 nm and a broad UV/Vis band (shoulder) at about 390 nm (
Although a species with an absorbance maximum at 575 nm was ascribed to [(CN)5FeN(O)S]4− (deprotonated form of the initial [(CN)5FeN(O)SH]3− adduct) in the recent literature (Quiroga, S. L. et al., 2011), it should be noted that some previous work (Swinehart, J. H., 1967) on light-induced SNP reactions with SCN− reported the exact same spectral features (absorption maximum at ˜575 nm). This finding implies a thiocyanate coordination occurred as a result of the photo-induced NO release (Swinehart, J. H., 1967). In general, the resulting blue-violet color and an absorbance maximum at 575 nm are typical of Fe(II)-thiocyanato species (Roncaroli, F. et al., 2002), especially those with more SCN− ligands (between 4 and 6) that can even be maintained under aerobic conditions (also while starting from the Fe(III) species) (Kratochvil, B. et al., 1970). The same product (
The 720 nm band for the above mentioned transient species is characteristic of a mixed-valent cyano-bridged complex (a Prussian blue type compound) that could be independently obtained either from the reaction of aqua [FeII(CN)5-x(SCN)x(H2O)]3− complexes in the presence of oxygen or upon addition of the corresponding Fe(III) complexes (Roncaroli, F. et al., 2002). The UV/Vis band at approximately 440 nm can be attributed to transient [(CN)5Fe(HNO)]3− (spectra at the bottom of
The transformation of the initial [(CN)5FeN(O)SH]3− adduct into the final thiocyanato species was faster with increasing H2S and oxygen concentrations. However, the concentration dependence proved to be rather complicated because of a) the cross-interaction between H2S (i.e., HSx−/HS(x+1)•2−) and oxygen, b) the involvement of oxygen in the generation of the transient mixed-valent Fe(II)/Fe(III) species and c) the involvement of the HSx−/HS(x+1)•2− species in the transformation of CN− to SCN− (Luthy, R. G. et al., 1979). The detailed quantification of the H2S and O2 concentration-dependent kinetic behavior would require a separate study.
The proposed mechanism is in good agreement with the solution in real-time FTIR measurements, which monitored the characteristic vibrations of SNP in the 1700-2500 cm−1 region. Namely, the IR spectrum of SNP in the solution contained three particularly intense bands at 1924, 2143 and 2258 cm−1 assigned to the NO, radial CN−, and axial CN− stretching frequencies, respectively, as described previously (Swinehart, J. H., 1967). The addition of H2S (in fourfold excess) caused an immediate change that led to the disappearance of the NO (1924 cm−1) and radial CN− (2144 cm−1) stretching bands with a concomitant formation of two new peaks at 2056 and 2091 cm−1 (
To further prove that thiocyanate (SCN−) formation occurs, 1 mM SNP samples treated with a 2, 5 and 10 fold excess of H2S were analyzed by GC-MS via an extractive alkylation, with pentafluorobenzyl bromide (PFB-Br) as the alkylating agent and tetrabutylammonium sulfate (TBA) as the phase-transfer catalyst (Paul, B. D. et al., 2006). 2,5-Dibromotoluene (DBT) was used as an internal standard for the quantitation of SCN−. The products were analyzed by gas chromatography-mass spectrometry on a Bruker GC 450 TQ MS 300.
The results of the GC-MS detection of SCN− are shown in
These results demonstrate that a nitroprusside salt and a sulfide salt, such as SNP and Na2S, react under physiological conditions to provide HNO, without any intermediate formation of NO. Moreover, toxic cyanide is not released from the nitroprusside complex but is rather converted into innocuous thiocyanate.
1) Intracellular Detection of HNO Formed from the SNP/H2S Reaction Mixture
It was further sought to confirm the formation of HNO from the SNP and H2S mixture in a biological milieu. To accomplish this goal, a recently developed Cu2+-based fluorescent sensor, CuBOT1, was used for the intracellular HNO detection (Rosenthal, J. et al., 2009).
Human umbilical vein endothelial cells (HUVEC, passage 2-3) were obtained from PromoCell GmbH (Heidelberg, Germany) and cultured in 35 mm μ-dishes (ibidi, Martinsried, Germany) using a commercially available cell growth medium (PromoCell GmbH) at 37° C. and 5% CO2. For NO detection, the cells were preloaded for 10 min with 10 μM 4-amino-5-methylamino-2′,7′-difluorofluorescein diacetate (DAF-FM-DA). For HNO detection, the HUVECs were incubated for 20 min with 10 μM CuBOT1 (Rosenthal, J. et al., 2009; Filipovic, M. R. et al., 2012, b). For both NO detection and HNO detection, the HUVECs were then washed three times and treated with 100 μM SNP, 100 μM H2S or the mixture of both for 15 min. Fluorescence microscopy was performed using an inverted microscope (Axiovert 40 CLF, Carl Zeiss) equipped with green fluorescent filters and an AxioCam. The images were processed using ImageJ software.
The intracellular formation of the fluorescent Cu+BOT1 was visualized by fluorescence microscopy. Neither H2S alone nor SNP alone caused any detectable change in the fluorescent intensity; however, the combination of these two molecules increased the fluorescence, as shown in
2) Ex-Vivo Release of CGRP from Isolated Hearts Induced by the SNP/H2S Reaction Mixture
The primary proposed biological marker for HNO formation is the increased release of calcitonin gene-related peptide (CGRP), a potent vasodilator (Paolocci, N. et al., 2001). CGRP is a neuropeptide for chemosensory primary afferent nerve fibers located in the epicardial surface of the heart.
The release of CGRP from the isolated heart of C57BL/6 mice was measured as reported in Strecker, T. et al., 2006. Briefly, the mice were suffocated in a pure CO2 atmosphere and the complete heart was excised by cutting the central blood vessels. The procedures were approved by the animal protection authorities (of the “Regierung von Mittelfranken”, Ansbach, Germany). The hearts were passed through a series of synthetic interstitial fluid incubations both with and without the addition of the test compounds (H2S alone, SNP alone, or the combination of H2S and SNP) and spent 5 min in each test tube at 37° C. (details are indicated in
Using this experimental model, it was shown that 1 mM of H2S had no effect on CGRP release, while 500 μM SNP induced a small increase that could have originated from the reaction of SNP with intracellular H2S. The combination of both H2S and SNP, however, significantly increased the CGRP release (p=0.028, n=6, Wilcoxon matched pairs test), as also shown in
These results strongly confirm that HNO is formed from the combination of a nitroprusside salt with a sulfide salt, resulting in the release of the potent vasodilator CGRP from the heart. This indicates that the combination of a nitroprusside salt or solvate with a sulfide salt or solvate according to the present invention, including in particular the combination of SNP with Na2S, is highly effective in the medical intervention of cardiovascular diseases/disorders.
3) Reaction Mechanism of SNP with H2S and its Physiological Consequences
Despite the long interest in the reactions of H2S with SNP since 1850 (Sidgwick, N. V., 1950), the reaction mechanism has eluded researchers due primarily to methodological limitations. The present invention provides the first study to combine chemical tools with pharmacological/physiological experiments at a physiological pH and under aerobic conditions to elucidate the reaction between SNP and H2S. Based on the results presented herein, the overall reaction mechanism can be depicted as shown in Scheme 2 below.
SNP reacts very rapidly with H2S to form the intermediate [(CN)5FeN(O)SH]3−, which is further transformed into the thiocyanate product(s). During the second reaction step, H2S plays a catalytic role. Upon reducing the coordinated HSNO/SNO−, it initially oxidizes to disulfide, which can oxidize to form the polysulfides used in the reaction progress. As a result of this step, a [(CN)5Fe(HNO)]3− intermediate formed, as indicated by the time-resolved UV/Vis spectral analysis (440 nm band, see spectra at the bottom of
The production of both N2O (
Overall, all these data are indicative of the operation of a novel, previously undescribed mechanism (Scheme 2) with physiologically important features: the release of HNO at a physiological pH of 7.4 and the conversion of cyanides into thiocyanates with the latter generally being catalized in vivo by rhodaneses (Mueller, E. G., 2006; Cipollone, R. et al., 2007). Rhodanese is the common name for a thiosulfate:cyanide sulfurtransferase class of enzymes that use thiosulfate to catalyze the detoxification of cyanide (Cipollone, R. et al., 2007). This enzyme is found in mitochondria and the mechanism of its action is similar to what has presently been observed for the reaction of SNP with H2S: persulfides (formed during the reaction of thiosulfate with the free protein thiols in the enzyme) react with cyanide to form thiocyanate (Cipollone, R. et al., 2007).
The formation of HNO is important because it is considered to be a very promising therapeutic agent for the treatment of cardiovascular diseases (Flores-Santana, W. et al., 2011; Irvine, J. C. et al., 2008). As a redox congener of NO, HNO reacts in the cell orthogonally to NO. It stimulates CGRP release (Wink, D. A. et al., 2003), among other things, and accounts for the positive inotropic heart effects observed when an HNO donor was used (Paolocci, N. et al., 2001; Paolocci, N. et al., 2007). It has been shown that, unlike NO donors, HNO donors do not induce a nitrate-tolerance (Bulien, M. L. et al., 2011). Because the intracellular production of HNO is still a matter of debate, with evidence showing its production from NO via NO synthase (Schmidt, H. H. et al., 1996), cytochrome c (Sharpe, M. A. et al., 1998) and manganese superoxide dismutase (MnSOD) (Filipovic, M. R. et al., 2007) or from hydroxylamine by heme-containing proteins (Donzelli, S. et al., 2008), the synthesis of donors that could release HNO under physiological conditions is one of the current pharmacological goals (DuMond, J. F. et al., 2011; Shoman, M. E. et al., 2011; Keefer, L. K., 2011).
SNP is still used in acute hypertensive crises to regulate blood pressure. However, it must be combined with thiosulfate to minimize the toxic effects of cyanide through natural rhodanese activity (Bisset, W. I. K. et al., 1981; Pasch, T. et al., 1983). The results provided herein offer a new perspective on the clinical application of SNP. The combination of SNP with a sulfide salt as an H2S donor, which causes the HNO-induced release of CGRP and transforms toxic cyanide into thiocyanate, provides a new, more effective and less toxic therapeutic alternative to the combination of SNP with thiosulfate. Furthermore, by accounting for the recently revised plasma levels of H2S (in the micromolar range) (Shen, X. et al., 2011), it can be speculated that part of the vasodilatory effects of SNP could be due to reactions with circulatory H2S via a rhodanese-like mechanism.
| Number | Date | Country | Kind |
|---|---|---|---|
| 13154594.9 | Feb 2013 | EP | regional |
| Filing Document | Filing Date | Country | Kind |
|---|---|---|---|
| PCT/EP2014/051911 | 1/31/2014 | WO | 00 |
