Patent Application
20210002328
The instant application contains a Sequence Listing which has been filed electronically in ASCII format and is hereby incorporated by reference in its entirety. Said ASCII copy, created on Aug. 16, 2018, is named ALLEG-003G_SL.txt and is 4,887 bytes in size.
The present invention relates generally to the fields of chemistry and medicine and more particularly to integrin receptor antagonists and their methods of use.
The RGD tripeptide sequence is found in a number of proteins, where it plays a role in cell adhesion. Examples of proteins in which the RGD tripeptide sequence is present include collagens, fibronectin, vitronectin, von Willebrand factor (VWF), certain disintegrins, and certain discoidins.
Integrins are heterodimeric cell surface receptors which mediate adhesion between cells and the extracellular matrix (ECM) by binding to ligands having an exposed RGD sequence. Normal integrin-RGD binding is believed to play a role in gene expression involved in cell growth, migration, and survival. Faulty regulation of such cell growth, migration, and survival can result in a number of disease states including thrombosis, inflammation, and cancer. Thus, RGD peptides have been investigated as potential mimics of cell adhesion proteins and for their ability to bind to integrins for therapeutic purposes such as inhibiting cell adhesion, cell migration, cell proliferation, cell differentiation, apoptosis, angiogenesis, tumorigenesis, for inhibiting entry of microbes into cells, for the use in their multimeric form as internal radiotherapeutic agents as well as cancer imaging agents and for their anti-cancer drug carrying abilities.
In the eye, integrins affect a number of processes including ocular development, cell migration, healing and some pathologic processes. Integrins may also modulate inflammation and thrombosis in ocular tissue. Intravitreally injected RGD peptide has also been reported to cause posterior vitreoretinal detachment in an animal model and, thus, may be useful in the treatment of certain retinal disorders and/or to facilitate removal of the vitreous body in a vitrectomy procedure. See Olivera, L. B., et al., RGD Peptide-Assisted Vitrectomy to Facilitate Induction of a Posterior Vitreous Detachment: a New Principle in Pharmacological Vitreolysis; Current Eye Research (8):333-40 (Dec. 25, 2002).
Integrins are also known to be used by various enveloped and non-enveloped viruses and bacteria in infecting host cells. Schornberg, Kathryn L.; α5β1-Integrin Controls Ebolavirus Entry by Regulating Endosomal Cathespins; Proc. Nat. Acad. Sci. USA; Vol. 106, No. 19, pp. 8003-8008 (2009)
The present invention provides novel compounds comprising R-G-Cysteic Acid (i.e., R-G-NH—CH(CH2—SO3H)COOH or Arg-Gly-NH—CH(CH2—SO3H)COOH) and derivatives thereof (including pharmaceutically acceptable salts, hydrates, stereoisomers, multimers, cyclic forms, linear forms, drug-conjugates, pro-drugs and their derivatives).
The present invention also provides compositions and methods for therapeutic or prophylactic inhibition of integrin receptors in human or animal subjects. Such integrin receptor inhibition may be used for treatment or prevention of neovascularization or blood vessel formation in tumors or other tissues (e.g., the retina of the eye), to treat or prevent viral diseases, deter various disorders including diabetic retinopathy and other conditions involving unwanted neovascularization to prevent or treat inhibiting cellular adhesion to RGD binding sites or delivering other diagnostic or therapeutic agents to RGD binding sites in human or animal subjects by administering to the subject an effective amount of a composition comprising an R-G-Cysteic Acid peptide or a derivative thereof (including pharmaceutically acceptable salts, hydrates, stereoisomers, multimers, cyclic forms, linear forms, drug-conjugates, pro-drugs and their derivatives). Specific examples of R-G-Cysteic Acid peptide of this invention include a linear form of Arg-Gly-NH—CH(CH2—SO3H)COOH (example referred to herein as Compound 1) and a cyclic form of Arg-Gly-NH—CH(CH2—SO3H)COOH) (example referred to herein as Compound 2).
General formulas for R-G-Cysteic Acid derivatives of the present invention include but are not limited to compounds having General Formulas I-VII as follows:
where X is selected from: H, C1-C6 alkyl, Ph or SO3H and Y═OH or NH2.
where X is selected from: H, C1-C6 alkyl, Ph or SO3H.
where X is selected from: H, C1-C6 alkyl, Ph or SO3H and wherein Z is selected from: H or SO3H
where X is selected from: H, C1-C6 alkyl, Ph or SO3H; Y is selected from OH or NH2.
where X is selected from: H, C1-C6 alkyl, Ph or SO3H.
where X is selected from: H, C1-C6 alkyl, Ph or SO3H.
X1—R-G-Cysteic Acid-X
where X and X1 are selected from: cyclic or linear -Phe-Val-Ala, -Phe-Leu-Ala, -Phe-Val-Gly, -Phe-Leu-Gly, -Phe-Pro-Gly, -Phe-Pro-Ala, -Phe-Val, or any salt of any combination of the D-isomer or L-isomer of: Arg, Gly, Cysteic, Phe, Val, Ala, Leu, Pro, Thr.
Examples of cyclic forms of General Formula VII include but are not necessarily limited to (SEQ ID NO 1):
Sulfonic acids are stronger acids than corresponding carboxylic acids. This higher polarity of the sulfonic acid group leads to stronger intermolecular bonding. For example, R-G-Cysteic acid, which has a more polarized O—H bond, may form stronger hydrogen bonds than R-G-Aspartic acid (RGD peptide), which has a relatively less polarized O—H bond, with the amide groups of the proteins in the integrin binding site and/or have stronger interactions with metal ions complexed in the integrin binding site.
As described in more detail elsewhere herein, one specific example of General Formula VII, Glycinyl-Arginyl-Glycinyl-Cysteic-Threonyl-Proline-COOH (GRG Cysteic Acid TP; referred to below as Compound 1) (SEQ ID NO 2) was synthesized and tested in animals and found to be effective in inducing posterior vitreous detachment (PVD) from retina surface by inhibiting integrin-extracellular matrix (ECM) interactions. As described also in more detail elsewhere herein, Compound 1 was tested in a model of wound healing using human umbilical vein endothelial cells (HUVEC) and was shown to inhibit cell adhesion by 74% in 12 hours compared to an inhibition of 40% by a cyclic-RGD peptide. These studies suggest and corroborate the rationale that Glycinyl-Arginyl-Glycinyl-Cysteic-Threonyl-Proline-COOH (SEQ ID NO 2) may bind to integrin even more strongly than RGD peptides themselves.
The RG Cysteic Acid peptide sequence, which can be in either L-form or D-form, is a competitive inhibitor of integrin-ECM interactions. The RG Cysteic Acid peptide sequence can be of protease-resistant derivatives or of cyclic derivatives or of pro-drug derivatives or associated with drug delivery systems or of monoclonal antibodies.
The compositions of the present invention are useable to inhibit angiogenesis, which can be useful for treating inflammation, wound-healing, thrombosis, cancer metastases and tumors. Further useful application can be found in ophthalmology including the treatment of, proliferative or non-proliferative diabetic retinopathy, liquefaction of the vitreous, induction of posterior vitreo-retinal detachment (PVD), pathogenesis of vitreoretinal diseases, such as idiopathic macular hole, macular edema, floaters, vitreomacular traction, age related macular degeneration, wet macular degeneration, choroidal neovascularization, vitreoretinal surgery, vein occlusion, and prevention of scar formation in glaucoma surgery. Still further, multimeric and/or radiolabeled compositions of the present invention are useable as diagnostic/imaging agents for the detection of tumors and radiotherapeutic agents for the treatment of tumors and as anti-cancer drug carriers due to their tumor directing properties.
Biomaterials incorporating an RG CYSTEIC ACID peptide can also provide a synthetic adhesive microenvironment for the long term survival and growth of cells and for the engineering of living tissues for applications in tissue engineering and regenerative medicine. Through their property of binding integrin adhesion receptors, RG CYSTEIC ACID peptides can provide an adhesion-promoting signal when it is tethered onto a biomaterial or scaffold. RG CYSTEIC ACID-based materials mediate cell adhesion, spreading, and migration of cells. In addition, integrin-mediated cell adhesion promotes cell proliferation and survival and plays a key role in assembly and organization of multicellular structures and tissues.
Drugs for the treatment of macular degeneration like Lucentis and Avastin are based on inhibiting VEGF, which otherwise causes the growth of new vessels, angiogenesis, and consequently contributes macular edema. It has been known that a small peptide RGD can induce apoptosis by inhibiting cell attachment to extracellular matrix1 by competitive binding as shown in U.S. Pat. No. 6,500, 924 to Brooks et al.
The RGD peptide binding or recognition motif can be found in the proteins of extracellular matrix and integrins which link the intracellular cytoskeleton of cells with the ECM by recognizing the RGD adhesion epitopes. See, for example, Foos, R Y., Invest. Opthalmol. Vis. Sci. (1972) 11, 801-808. Cells, without the attachment to the ECM, normally undergo apoptosis.
In general, interactions between fibroblasts and glycoprotein components of extracellular matrix cause a major scar formation mediated primarily by the RGD containing amino acid sequence interacting on the cell surface integrins. It has also been known that the RGD sequence is involved in cell-ECM interactions during inflammatory and homeostatic reactions (see Hershkoviz, S. M., et al., Invest. Ophthalmol. Vis. Sci., (1994), 35, 2585-2591) and the integrins play an important role in cell migration in wound healing or pathologic processes and modulating inflammation and thrombosis. Thus, potent integrin antagonists, like RGD peptides, might be very useful as pharmacologic agent as anti-inflammatory, anti-metastatic or anti-thrombotic agents (see Elner, S. G. and Elner, V. M., IOVS (1996) 37:696-701. It is also reported in literature that CD44 receptor for hyaluronic acid mediates cell-cell and cell-matrix interactions through its affinity for hyaluronic acid, and possibly also through its affinity for other ligands such as osteopontin, collagens, and matrix metalloproteases (MMPs).
Adhesion with hyaluronan plays an important role in cell migration, tumor growth and progression and also involved in lymphocyte activation, recirculation and homing, and hematopoiesis. Altered expression or dysfunction causes numerous pathogenic phenotypes (see for example, Jiang D., Annu. Rev. Cell. Dev. Biol. (2007) 23: 435-461; and Knudson, W. et al, Matrix Bio. (2002), 21: 15-23).
Recently, it has been shown that the interaction of CD44 and cell-matrix components (e.g., HA) plays a significant role in the development of various inflammatory diseases and interruption of hyaluronan-CD44 interactions would lead to amelioration of choroidal neovascularization (see Hiroshi Mochimaru et al., Invest. Ophthalmol. Vis. Sci. (2009) 50: 4410-4415).
These evidences demonstrate that an adhesion molecule like RGD peptide or CD44 in cell-cell and cell-ECM interactions plays an important role in the development of numerous pathogenic diseases and the inhibition of the interactions can be a novel therapeutic target in treating and curing the diseases.
Synthetic peptides have also been shown to bind to integrins and growth factors. Cyclized pentapeptides containing RGD sequences have been found to inhibit binding of vitronectin to αvβ3 integrin (see Michael A. Dechantsreiter, et al., J. Med. Chem. (1999) 42:3033-3040) and both vitronectin and fibronectin to αvβ3 and αllbβ3 integrins (see Roland Haubner et al., J. Am. Chem. Soc., (1996)118:7461-7472). This inhibition has been shown to be useful in the treatment of multiple, unrelated diseases. In hamster studies, the cyclic pentapeptides delayed growth and metathesis of tumors in comparison with control animals (see M. A. Buerkle et al., British J. Cancer (2002) 86: 788-795). The pentapeptides have also been shown to reduce binding of sickle red blood cells to vascular endothelium and improved hemodynamic behavior (see Eileen M. Finnegan et al., Am. J. Physiol. Heart Circ. Physiol., (2007) 293: H1038-H1045). Another cyclic peptide containing the RGD sequence has shown strong binding to α4β1, an integrin known to play a role in leucocyte binding in inflammatory and immune responses (see Pina M. Cardarelli et al., J. Biol. Chem. (1994) 269:18668-18673). A synthetic, sulfated tetrapeptide has been shown to strongly bind to VEGF (see Maynard, J. A. Hubbell, Acta Biomaterialia (2005) 1: 451-459).
In addition, in an important and useful application, a dimeric RGD peptide-drug conjugate has been shown to be useful for integrin-targeted drug delivery for tumor targeting (see Chen et al., J. Med. Chem., (2005) 48(4): 1098-1106). In another equally important and useful application, multimeric radiolabeled RGD peptides have been shown to be useful as diagnostic/imaging agents for tumor detection and, as radiotherapeutic agents for tumor specific targeting and treatment by targeting the integrin αvβ3 (see Zi-Bo Li et al., J. Nucl. Medicine, (2007) 48: 1162-1171).
In ophthalmology, scar formation in wound healing by fibroblast is one of the major problems, particularly in glaucoma. This arises from interactions between fibroblast and glycoprotein components of ECM. Recognition of ECM glycoproteins occurs via cell surface integrins that are specific for adhesion epitopes, such as the Arg-Gly-Asp (or RGD) sequence. The RGD sequence, which is present in several matrices of plasma proteins, including fibronectin (FN) and vitronectin (VN), is involved in cell-ECM interactions that occur during inflammatory and homeostatic reactions. Inhibition of the interactions between fibroblast and glycoproteins of ECM alleviated the scar formation (see Rami Hershkoviz et al., Invest. Ophthalmol. Vis. Sci. (1994) 35: 2585-2591).
The collagen fibrils of the posterior vitreous cortex adhere to the vitreoretinal interface, specifically to the inner limiting lamina of the retina surface (see Sebag J., Eye (1992), 6: 541-552). The adherence at the vitreous base, the optic disc, along the major retinal vessels and in a facial manner to the entire posterior pole plays an important role in the pathogenesis of vitreoretinal diseases, such as idiopathic macular hole, vitreomacular traction, proliferative diabetic retinopathy, etc. (Akiba J. Quiroz M. A., et al., Ophthalmol. (1990) 97, 1619-1655).
Angiogenesis inhibition is showing early promise with diabetic retinopathy and macular degeneration, which both result from an overgrowth of ocular blood vessels. In these disorders, the vessels interfere with normal structures in the eye, or they block light from reaching the back of the eye. The new blood vessels are themselves the primary pathology, and stopping blood vessel growth could prevent blindness. Thus, angioinhibition could result in not just a treatment of these disorders; it could be a cure. Furthermore, it has been postulated that separation of the vitreous from the retina can alleviate macular traction, reducing the risk of macular hole formation. Accordingly, the posterior vitreous detachment by the inhibition of fibronectin and laminin binding to the integrins on the vitreoretinal interface, may prevent retinal neovascularization in eyes with diabetic retinopathy and retinal vein occlusion (see Akiba J. Quiroz M A, Ophthalmol. (1990) 97, 1619-1655; Kelly N. E., et al., Arch. Ophthalmol. (1991) 109, 654-659; and Kado M, et al., Am. J. Ophthalmol. (1988) 105: 20-24).
In recent years, vitreous surgical procedures have been greatly improved to relieve vitreoretinal tractions and to reduce retinal edema. Despite continued improvement in surgical techniques and instrumentation, it still remains difficult to achieve an atraumatic removal of the vitreous cortex in some patients particularly in diabetic retinophathy and pediatric patients due to complications such as retinal breaks, retinal detachment and retinal nerve fiber damage (see Sebag J., Arch. Clin. Exp. Ophthalmol. (1987) 225: 89-93; and Han D. P., et al., Arch. Ophthalmol. (1998) 106: 998-1000) etc. Thus, a less traumatic approach to selectively cleave the vitreous interface without damaging the retina is highly desirable. In recent years, reports concerning a number of pharmacologic agents for the separation of the vitreoretinal interface have appeared in literature (see Trese M. T., Eye. (2002) 16: 365-368; Gandorfer A., et al., Am. J. Ophthalmol. (2002) 133: 156-159; and Hesse L., et al., Eye Res. (2000) 70: 31-39). The pharmacologic vitreolysis using enzymes such as hyaluronidase (see U.S. Pat. No. 6,863,886 to Karageozian et al.) and autologous plasmin (Sakuma T, et al., Nippon Ganka Gakkai Zassi (2003) 107: 709-718) have been explored to promote the digestion of extracellular matrix and to induce posterior vitreous detachment in the past. Yet, a non-specific destruction of adjacent tissues by the enzymes employed impedes success of their therapeutic application. In the last few years, a novel approach using non-enzymatic pharmacologic agents like urea (see Nickerson, C., et al., in J. Biomechanics, (2008) 41: 1840-1846, and in Macromol. Symp. (2005): 183-189) and RGD peptide (see Leonardo B. Oliviera, et al., Curr. Eye Res. (2002) 25: 333-340) has been investigated by concentrating on the separation of vitreoretinal interface. It has been shown that a synthetic analog of RGD peptide competes for the RGD motif of ECM proteins to disrupt integrin—ECM interactions and to loosen the attachments in-vitro (Williams J. A., Pathol. Bio. (1992) 40: 813-821; Gehlsen K. R., et al., J. Cell. Biol. (1988) 106: 925-930; Pierschbacher, M. D., et al., J. Biol. CHem., (1987) 262: 17294-17298; and Zhon L. L., et al., IOVS. (1996) 37: 104-113) and in-vivo. Thus, the intravitreal injection of soluble RGD peptides led to a release of RGD-epitopes from the insoluble ECM proteins of the retinal surface, consequently facilitating the non-enzymatic PVD in rabbit models. Clearly, these results indicate that the vitreoretinal interface involves integrin connection to RGD motif of ECM as well as adhesion of vitreous cortical collagens to the inner limiting lamella (ILL). RGD peptides and their derivatives promote migration of epithelial cells in a wound (see P. M. Mertz et al., J. Burn Care Res. (1996) 17: 199-206) and maintain their bioactivity when incorporated into synthetic biomaterials such as hydrogels (see M P Lutolf, et al., Proc. Nat. Acad. Sci. (2003) 100: 5413-5418; and M P Lutolf, et al., Nature Biotechnol. (2003) 21: 513-518), other polymer matrices (see Horng-Ban Lin et al., J. Biomed. Material. Res. (2004) 28: 329-342) or as surface films on hard substrates (D. M. Ferris et al., Biomaterials (1999) 20: 2323-2331). RGD peptides also promote increased adhesion of epithelial or endothelial cells to vascular prostheses (see K. Walluscheck et al., Eur. J. Vascular and Endovascular Surgery (1996) 12: 321-330) and other artificial organs (see Jeschke, Brigette, Biomaterials (2002) 23: 3455-3463) coated with the peptide sequence and have been shown to support nerve regrowth (see M. Rafiuddin Ahmed et al., Brain Res. (2003) 993:208-216). The prostheses's biologically active surface can contain synthetic resin fibers or polymers.
The present invention provides novel compounds, including those of General Formulas I through VII above. Specific examples include linear form of Arg-Gly-NH—CH(CH2—SO3H)COOH (example referred to herein as Compound 1) and cyclic form of Arg-Gly-NH—CH(CH2—SO3H)COOH) (example referred to herein as Compound 2) as well as derivatives thereof, including pharmaceutically acceptable salts, hydrates, stereoisomers, mutimers, cyclic forms, linear forms, multimeric forms, drug conjugates, pro-drugs and their derivatives.
Synthesis of Compounds 1 and 2
Conventional solid-phase peptide synthesis (SPPS; see R. B. Merrifield, J. Am. Chem. Soc. (1963) 85 (14): 2149-2154) known to a person of ordinary skill in the art maybe carried out. The SPPS is a preferred method of synthesis because of the high yields. In general, the first stage of the solid phase peptide synthesis technique consists of peptide chain assembly with protected amino acid derivatives on a polymeric support. The second stage of the technique is the cleavage of the peptide from the resin support with the concurrent cleavage of all side chain protecting groups to give the crude free peptide. The general principle of SPPS is one of repeated cycles of coupling-deprotection. The free N-terminal amine of a solid-phase attached peptide is coupled to a single N-protected amino acid unit. This unit is then deprotected, revealing a new N-terminal amine to which a further amino acid may be attached. See Asymmetric Synthesis by Von G. M. Coppola and H. F. Schuster; John Wiley & Sons, New York 1987 for synthesis, protection and deprotection strategies and Greene's Protective Groups in Organic Synthesis by Peter G. M. Wuts and Theodora W. Greene, (2nd edition) J. Wiley & Sons, 1991. for protection and deprotection strategies.
Of the two major used forms of solid phase peptide synthesis—Fmoc (9-fluorenylmethyloxycarbonyl; base labile alpha-amino protecting group) and t-Boc (t-butyloxycarbonyl; acid labile protecting group), Fmoc may be used preferably in the synthesis of the present peptides. Each method involves different resins and amino acid side-chain protection and consequent cleavage/deprotection steps. After cleavage from the resin, peptides are usually purified by reverse phase HPLC using columns such as C-18, C-8, and C-4.
The following is an outline of the synthetic steps for peptide synthesis on Wang resin as the solid support, using the base labile 9-fluorenylmethyloxycarbonyl (Fmoc) protecting group.
Load 0.08 mmol of Fmoc-Pro-Wang resin into a fritted column equipped with a plastic cap. Wash the resin with 2×3-ml portions of DMF (dimethylformamide) for 1 minute each. Next, add about 3 ml of 20% piperidine in DMF and allow the Fmoc deprotection to continue for 15 minutes. During this time, gently swirl or agitate the column to assure a complete mixing. After the reaction is complete (about 15 min.), drain the reaction column and wash the resin again with DMF (4×3 ml).
The desired Fmoc-protected amino acid, Fmoc-Thr-tBu, (3 eq.; relative to resin loading indicated by supplier) and DIEA (6 eq.) in DCM (0.5 M with respect to the amino acid) are then added to the resin. The mixture is cooled at −20° C. for 20 minutes. Next, benzotriazol-1-yl-oxytripyrrolidinophosphoniurn hexafluorophosphate (PyBOP), a peptide coupling reagent used in solid phase peptide synthesis (3 eq.) is added to the reaction. After shaking at −20° C. for 8 hours, the reaction mixture is drained and the resin is washed with DCM (3×).
After the Fmoc deprotection using 20% piperdine in DMF (15 min) and the wash with DMF (3×), the next Fmoc protected amino acid (3 eq.; relative to resin loading), PyBop (is coupled in the same manner as above.
In order obtain the peptide in the free acid form, the ester linkage is cleaved using strongly acidic conditions such as TFA (trifluoroacetic acid). Treat the resin with 2-3 ml of a solution of trifluoroacetic acid and water 95:5. Gently agitate the resin over a period of 25 minutes. Next, drain the column and carefully collect the filtrate into a glass collection vessel.
Synthesis of Compound 1 (GRG Cysteic Acid TP) (SEQ ID NO 2):
a. Fmoc-Thr-tBu (Fmoc threonine-t-butyl ester)
b. Fmoc-cysteic acid-Pfp (Fmoc cysteic acid-pentafluorophenyl ester)
c. Fmoc-Gly (Fmoc glycine)
d. Fmoc-Arg-Pbf (Nα-Fmoc-Nω-(2,2,4,6,7 pentamethyldihydrobenzofuran-5-sulfonyl)-L-arginine)
e. Fmoc-Gly (Fmoc glycine)
A quantity of Compound 1, prepared as described above, was analyzed by High Performance Liquid Chromatography to be >98% area/area in purity [HPLC conditions: Buffer A: 0.1% trifluoroacetic acid (TFA) in water, Buffer B:0.1% TFA in acetonitrile, Mobile Phase(MP) A: 97% Buffer A and 3% Buffer B, Mobile Phase B: 79% Buffer A and 21% Buffer B, Mobile Phase C: 50% Buffer A and 50% Buffer B; for gradient see Table 1 below; flow rate: 1.0 mL/minute; column: Waters Symmetry® C18, 5μ, 4.6×250 mm; column temperature: 30° C.; detector: UV@220 nm; sample injection volume: 20.0 μL; sample preparation: 20 μL sample diluted with 1.0 mL Mobile Phase A (approximately 0.5 mg/mL)]. The corresponding HPLC chromatogram is shown in
Synthesis of Compound 2 (Cyclo-RG CYSTEIC ACIDysteic Acid fN(CH3)V):
a. Fmoc-Phe (Fmoc-phenyl alanine)
b. Fmoc-cysteic acid-PfP (Fmoc-cysteic acid pentafluorophenyl ester)
c. Fmoc-Gly (Fmoc-glycine)
d. Fmoc-Arg-Pbf (Nα-Fmoc-Nω-(2,2,4,6,7 pentamethyldihydrobenzofuran-5-sulfonyl)-L-arginine)
A quantity of Compound 2, prepared as described above, was analyzed by High Performance Liquid Chromatography to be >99% area/area in purity (HPLC conditions: Mobile Phase A: 0.1% trifluoroacetic acid in water, B: 0.1% TFA in (80% acetonitrile plus 20% water); gradient 26% to 36% B in 20 minutes; flow rate: 1.0 mL/minute; column:Phenomenex C18(2) 4.6×150 mm, 5μ, 100A; detector: UV@220 nm; sample injection volume: 100.0 μL). The corresponding HPLC chromatogram is shown in
The present invention also provides methods for inhibiting cellular adhesion to RGD binding sites in a human or animal subject by administering to the subject an effective amount of R-G-Cysteic Acid (i.e., linear form of R-G-NH—CH(CH2—SO3H)COOH or cyclic form of R-G-NH—CH(CH2—SO3H)COOH) or a derivative thereof (including pharmaceutically acceptable salts, hydrates, stereoisomers, multimers, cyclic forms, linear forms, drug-conjugates, pro-drugs and their derivatives).
Applicant has discovered that synthetic RG CYSTEIC ACID peptides of the present invention induce apoptosis by competitively inhibiting the cell attachment to the ECM components. Therefore, the present synthetic RG CYSTEIC ACID peptides and their derivatives can be used as potent integrin antagonists as therapeutic agent against angiogenesis, inflammation, cancer metastasis, thrombosis, prevention and treatment of scar formation as well as a pharmacological vitreolysis agents. In addition, in an important aspect of the present invention, an improved targeting of the α, β integrins using multimerized and radiolabeled RG CYSTEIC ACID peptides, for use as internal radiotherapeutic agents for tumor detection (diagnostic or imaging agent) and tumor treatment is envisaged. In another important aspect, improved RG CYSTEIC ACID peptide conjugates or multimeric RG CYSTEIC ACID peptide conjugates function as drug carriers, for example, as anti-cancer drug carriers for efficient tumor targeting.
As described elsewhere herein, the sulfonic acids in the RG CYSTEIC ACID peptides are stronger acids than corresponding carboxylic acids in RDG-peptides. This higher polarity of the sulfonic acid group leads to stronger intermolecular bonding. For example, R-G-Cysteic acid, which has a more polarized O—H bond, may form stronger hydrogen bonds than R-G-Aspartic acid, which has a relatively less polarized O—H bond, with the amide groups and/or side chains of the amino acids of the proteins in the integrin binding site and/or have stronger interactions with metal ions complexed in the integrin binding site. Therefore, the novel RG CYSTEIC ACID peptides and their derivatives of the present invention present improved compounds and compositions over the corresponding RGD peptides in integrin receptor recognition and binding.
Additionally, in diabetic patients with chronic hyperglycemia associated with elevated IOP, open angle glaucoma particularly is reported to be related to the accumulation of fibronectin in the trabecular meshwork tissue and the excess of fibronectin is believed to inhibit the aqueous outflow (see Oshitari, T, et al., Am. J. Ophthalmol. (2007) 143:363-365). Involvement of fibronectin in the cell-ECM interaction in the trabecular meshwork was indicated in primary open angle glaucoma (see Mark S. Filla, et al., Invest. Ophthalmol. Vis. Sci. (2002) 43:151-161; and Cheryl R. Hann, et al., Ophthalmic Res. (2001) 33: 314-324). It has also been reported that the endothelial cells of Schlemm's canal interact with extracellular matrix in influencing outflow facility (see Cindy K. Bahler et al., Invest. Ophthalmol. Vis. Sci. (2004) 45: 2246-2254). In light of the inhibition of the aqueous outflow by the presence of an excess of extracellular matrix components such as fibronectin, application of RG CYSTEIC ACID peptides and their derivatives to treat the elevated IOP of diabetic patients would be highly beneficial to diabetic patients.
The preferred RG CYSTEIC ACID peptides can be a fusion polypeptide, a cyclic or linear polypeptide, a derivatized polypeptide, including RG CYSTEIC ACID peptide derivatized or associated or coupled with drug delivery systems or other drugs, such as, for example, anti-cancer drugs, a multimerized RG CYSTEIC ACID peptide, a monoclonal antibody containing RG CYSTEIC ACID sequence that immunoreacts with integrins' binding site or functional fragment thereof.
RG CYSTEIC ACID containing polypeptides can have a sequence corresponding to the amino acid residue sequence of natural integrin adhesive binding region, such as those present in fibrinogen, fibronectin, vitronectin, von Willebrand factor, laminin, thrombospondin, and the like ligands.
The present peptide sequence consists of three amino acids having terminal guanidino, sulphonic and carboxylic groups and its derivatives coupled and/or associated with drug delivery systems, including peptide fragments, glycoproteins, and polymer groups such as PEG, Pluronic, and other polymer groups, and, liposomes and nanoparticles. Pharmaceutical compositions comprising them for treatment of various pathological disorders include injectable, gel, suspension, ointment, solid and liquid dosage forms.
Integrin receptors associated with a cell adhesion motif such as fibronectin, vitronectin, laminin, fibrinogen, thrombospondin, and von Willebrand factor, are the target epitope of RG CYSTEIC ACID peptide and its derivatives. The tripeptide, RG CYSTEIC ACID, has been discovered as a recognizable minimal amino acid sequence by cell binding domains. This sequence can also interfere with immune functions unrelated to integrins. Thus, it has been discovered that the synthetic RG CYSTEIC ACID sequence is to mimic the RGD cell binding domain, and a substitution on the a-carbon of aspartic acid gives a stronger binding affinity to the target integrins. The sulfonic acids in the RG CYSTEIC ACID-peptides are stronger acids than corresponding carboxylic acids in RDG-peptides. This higher polarity of the sulfonic acid group leads to stronger intermolecular bonding. For example, R-G-Cysteic acid, which has a more polarized O—H bond, may form stronger hydrogen bonds than R-G-Aspartic acid, which has a relatively less polarized O—H bond, with the amide groups and/or side chains of the amino acids in the integrin binding site and/or have stronger interactions with metal ions complexed in the integrin binding site.
The most general formulas for the RG CYSTEIC ACID sequences of the present invention are as follows:
Where X═—CH(R1)—S(═O)2—Y;
Where X═—CH(R1)—S(═O)2—Y;
where X′ is selected from: H, C1-C6 alkyl, Ph, SO3H; Y═OH, NH2 and Z═H, CH3.
Cyclic forms also include penta and hepta peptides, such as for example a specific compound of General Formula C, namely, Compound 2 (Cyclo-RG CYSTEIC ACID fN(CH3)V), (SEQ ID NO 1) is shown below:
Formula A encompasses General Formulas I-VI described elsewhere herein. Formula B encompasses general formula VII described elsewhere herein.
A1-Arg-Gly-NH—CH(X)—CO-A2
Where X═—CH(R1)—S(═O)2—Y;
The substituted RG CYSTEIC ACID sequences includes cyclic RG CYSTEIC ACID analogues.
The application of the RG CYSTEIC ACID and its derivatives can be made subcutaneously, dermatologically, ophthamically and systemically, by employing a drug delivery system or any pharmaceutically acceptable dosage forms of injection or solid or ointment formulation.
The compounds of the present invention may be administered by any route that is suitable to bring about the intended therapeutic effect including but not limited to: oral, rectal, intravenous, intraarterial, intradermal, subcutaneous, intramuscular, intrathecal, sublingual, buccal, intranasal, transmucosal, transdermal, topical, intraocular, intravitreal, other enteral, other parenteral and/or other possible route(s) of administration.
The compounds of the present invention may be administered at any dosage that provides the intended therapeutic effect while avoiding untoward or toxic effects. Typical dosages at which the compounds of the present invention may be administered to human subjects are in the range of about 1 ng/kg to about 1.0 g/kg.
Where possible and appropriate, compounds of the present invention may optionally be prepared in the form of liposomes or nanoparticles (e.g., nanocapsules). The formation and use of liposomes is generally known to those of skill in the art. Liposomes are formed from phospholipids dispersed in an aqueous medium such that they spontaneously form multilamellar concentric bilayer vesicles sometimes referred to as multilamellar vesicles (MLVs). MLVs are typically from 25 nm to 4 μm in diameter. When sonicated, MLVs form small unilamellar vesicles (SUVs) of about 200 to 500 angstroms in diameters having cores which contain the aqueous solution. In general, when dispersed in an aqueous medium, phospholipids can form various structures other than liposomes, depending on the molar ratio of lipid to water. At low molar lipid to water ratios, liposomes will form. The physical characteristics of liposomes depend on pH, tonicity and the presence or non-presence of divalent cations. Liposomes can interact with cells by different mechanisms, including 1) endocytosis (e.g., phagocytosis of the liposome by cells such as macrophages and neutrophils), adsorption to the cell surface, 2) interaction with cell-surface components, 3) fusion with the plasma cell membrane by insertion of the lipid bilayer of the liposome into the plasma membrane or 4) transfer of liposomal lipids to cellular or subcellular membranes, or vice versa. Varying the liposome formulation can alter which mechanism(s) by which the liposomes will interact with cells in the paranasal sinus, nasal mucosa, etc.
A nanocapsule is any nanoparticle that consists of a shell and a space, in which desired substances may be placed. Techniques for forming nanocapsules are known in the art. Polymeric nanocapsules can be made in specific sizes and shapes. They can be produced as monodisperse particles which have precisely defined physical and chemical properties and, thus, can be tailored to facilitate release of the therapeutic or diagnostic substance in response to particular bimolecular triggering mechanisms, such as pH, mucous flow or other conditions present within the paranasal sinus or other area in the ear, nose or throat where the device is implanted. Nanocapsules can be used in the present invention as “smart drugs” which have specific chemical receptors or binding sites that will bind to specific target cells (e.g., cancer cells or cells associated with inflammatory conditions.
The following are non-limiting examples of formulations for pharmaceutical preparations containing compounds of the present invention. Also included are examples of the safety and/or efficacy demonstrated using exemplary RG CYSTEIC ACID peptides or derivatives in inhibiting cell adhesion. As may be used herein, the terms “RG CYSTEIC ACID Peptide,” “RGCysteic Acid peptide”, “RGC” and “RGCys-peptide” and “compounds of the present invention” shall synonymously mean compositions containing the sequence R-G-Cysteic Acid and their derivatives, including but not limited to those defined by General Formulas I-VII and Compounds 1, and 3-5 as described herein.
Included among the numerous potential therapeutic uses of the compositions of the present invention is the treatment of certain disorders of the eye characterized by excessive vascularization of the retina (herein generally referred to as “neovascular eye disease.” The following non-limiting examples discuss uses of the compositions of the present invention alone, and in combination with other agents, to treat such neovascular eye disorders.
If and when used in this patent application, the following acromyms and abbreviations shall have the following meanings:
Age-related macular degeneration (AMD) is the leading cause of blindness in the Western world, and patients with this condition suffer irreversible damage to the macula, or central part of the retina. Dry AMD causes slowly progressive visual loss, while Wet AMD can lead to rapid deterioration of central vision. Wet AMD causes the vast majority of severe vision loss in affected patients, but both forms represent a major public health concern for the 21st century. Approximately 1.5 million Americans have choroidal neovascularization (CNV) secondary to AMD, and each year 200,000 new cases develop. It has been documented that the prevalence, incidence, and rates of progression of AMD all increase with age. In the United States, people over the age of 65 make up one of the largest segments of the population, and this demographic category is projected to increase substantially over the coming decades. The population over the age of 85 in the United States is expected to double by 2020. Thus, AMD represents a significant public health problem for the United States. In particular, Wet AMD is the most significant factor causing poor vision in patients with AMD. Wet AMD is characterized by choroidal angiogenesis, i.e., the development of abnormal blood vessels under the retina. These vessels leak fluid, bleed, and transform into fibrovascular scar tissue. This process disrupts the overlying photoreceptors and causes severe visual loss. There is good evidence that diminished choroidal perfusion leads to retinal pigment epithelial (RPE) dysfunction and photoreceptor loss in AMD. Diabetic macular edema (DME) is the result of thickening of the center part of the retina due to damage of retinal capillaries from diabetes. DME is the leading cause of blindness in the working age population, also causing mild to moderate vision impairment in this population as well as people who no longer may be working. Application of laser to damaged capillaries within thickened retina has been the mainstay of treatment for over 25 years. Recent results from the Diabetic Retinopathy Clinical Research Network demonstrated that in eyes with reduced visual acuity from DME involving the center of the macula, anti-VEGF therapy with Lucentis in combination with focal/grid laser, provides superior vision outcomes and an acceptable safety profile compared with the previous standard treatment of laser alone. The molecular events involved in the development of pre-retinal and choroidal neovascularization have not been fully elucidated; however, vascular endothelial growth factor (VEGF) has been shown to play a major role in the process. Integrins α5β1, αvβ3 and αvβ5 are also implicated in the angiogenic process, and are known to be expressed in neovascular ocular tissue from patients with Wet AMD and PDR. There are also a number of other molecules that play important roles: bFGF, IL-8, PDGF, various proteases including plasminogen activator and matrix metalloproteinases, chemokines and other inflammatory mediators. Endothelial cell proliferation, increased vascular permeability, inflammation, and excessive production of VEGF are some of the major pathological developments in Wet AMD and DME.
The present invention provides a new class of therapeutic drugs for retinal vascular diseases, including Wet AMD, DR and DME. The compounds of the present invention have multiple mechanisms of action against retinal vascular diseases including a) causing anti-angiogenesis by inhibiting VEGF production directly, b) causing inhibition of the VEGF-2 receptor, c) causing down regulation or inhibition of tyrosine kinase and d) causing liquefaction of the vitreous body and posterior vitreous detachment thereby allowing VEGF diffusion out of the eye. The mechanisms of action may be employed alone (e.g., by therapy using only compound(s) of the present invention) or may be additive or complementary inhibition of existing VEGF (e.g., by combination therapy using compound(s) of the present invention in combination with a composition that binds, traps, scavenges or otherwise deters the effect of VEGF that has already been produced, examples of which include but are not necessarily limited to: Avastin, Lucentis and/or Eylea). Avastin (bevacizumab) is an anti-VEGF monoclonal antibody. Lucentis (ranibizumab) is a recombinant humanized IgG1 kappa isotype monoclonal antibody fragment. Eylea (aflibercept) is a recombinant fusion protein consisting of portions of human. Vascular endothelial growth (VEGF) receptors 1 and 2.
By down-regulating VEGF production rather than sequestering pre-existing VEGF supply, the compounds of the present invention have unique mechanisms of action that allow intervention much earlier in the angiogenic cascade as compared to the current standard of care. This is illustrated schematically in
Examples of neovascular eye diseases that can potentially be treated with compounds of the present invention include Diabetic Retinopathy (DR), Diabetic Macular Edema (DME) and Age-Related Macular Degeneration (AMD). The currently available pharmaceutical treatments for these disorders include certain drugs that bind, trap, scavenge or otherwise deter the effect of VEGF that has already been produced (referred to generally herein as VEGF Traps). Commercially available examples of such “VEGF traps” include bevacizumab (Avastin), ranibizumab (Lucentis) and aflibercept (Eylea). Bevacizumab is described as an anti-VEGF monoclonal antibody. Ranibizumab is described as a recombinant humanized IgG1 kappa isotype monoclonal antibody fragment. Aflibercept is described as a recombinant fusion protein consisting of portions of human vascular endothelial growth (VEGF) receptors 1 and 2. These anti-VEGF antibody-based treatments are typically administered by repeated intravitreal injections, at 4 to 6 week intervals, potentially indefinitely, and at substantial inconvenience, cost and cumulative risk of infection.
Unlike the existing VEGF Traps, the compositions of the present invention have multiple mechanisms of action against neovascular eye diseases, specifically: anti-angiogenesis by directly inhibiting VEGF production, inhibition of the VEGF-2 receptor, down regulation of tyrosine kinase, and inducement of vitreal liquefaction and posterior vitreous detachment (which facilitates diffusion of VEGF or other deleterious entities away from the retina and out of the eye). Some of the examples set forth below describe uses of Compound 1 alone and in combination with other agents (VEGF Traps) in the treatment of neovascular eye diseases.
It is to be appreciated that, in addition to the treatment of neovascular eye diseases, the compositions of the present invention are also useable to treat various other eye disorders which do or do not cause retinal neovascularization. Examples of eye disorders which may be treated by compositions of the present invention include but are not necessarily limited to wet age-related macular degeneration, diabetic macular edema, proliferative or non-proliferative diabetic retinopathy, liquefaction of the vitreous humor, induction of posterior vitreo-retinal detachment (PVD), pathogenesis of vitreoretinal diseases, such as idiopathic macular hole, vitreomacular traction, age related macular degeneration, choroidal neovascularization, vitreoretinal surgery, vein occlusion, corneal neovascularization, ischemic optic nerve, rubiosis iridis and prevention of scar formation in glaucoma surgery.
The following are examples of pharmaceutical formulations I-X, which contain R-G-Cysteic Acid Peptides of the present invention, such as any of those defined by General Formulas I-VII or any of Compounds 1-5 as described herein.
In this example, the PVD-Inducing Effects of RGD Peptides and Glycyl-Arginyl-Glycyl-Cysteic-Threonyl-Proline-COOH (RG Cysteic Acid Peptide; GRG Cysteic Acid TP; Compound 1) (SEQ ID NO 2) were compared in rabbits. The protocol for this study was as follows:
Protocol:
Animal Model
Active Chemicals
Both the RG Cysteic Acid, RGD, RG Cysteic Acid+Sodium EDTA, RGD+Sodium EDTA, and the BSS solutions were injected into the vitreous cavity 24 hours prior to surgery. The rabbits (10 mg/kg body weight) were anesthetized with an intramuscular injection of 2.0 ml of 1:1 combination of xylazine (100 mg/ml) and Ketamine hydrochloride (100 mg/ml). Pupils are dilated with topical cyclopentolate hydrochloride 1% and Phenylephrine hydrochloride 10%.
All animals were initially examined with slit lamp biomicroscopy and indirect ophthalmoscopy to exclude any animals with pre-existing vitreoretinal abnormalities. The intravitreal injection of 0.10 cc was administered 2 mm posterior to the limbus in the supranasal quadrant using a 30-gauge needle attached to a 1.0 cc syringe. Care must be taken to avoid damage to the lens or retina.
Twenty four hours following injection and immediately before initiation of a mechanical vitrectomy, a B-scan ultrasonography was performed to determine the status of the posterior vitreous and also the liquefaction of the vitreous. A two-port pars plana vitrectomy was performed using an infusion fiberoptic and a vitreous cutter attached to a vitrectomy unit. Following a 30 second core vitrectomy, the vitreous cutter was directed to the peripapillary retinal surface where, using low aspiration (<30 mmHg) a separation of the posterior cortical vitreous from the retinal surface was attempted in 4 quadrants. The sclerotomies were sutured and a postoperative B-Scan ultrasonography was carried out to determine the presence and extent of any PVD present in each quadrant. The animals were euthanized with intracardiac sodium pentobarbital injections, and the eyes were immediately enucleated.
Classification of Liquefaction of the Vitreous and PVD was graded following this grading system to evaluate the extent of PVD based on the postoperative B-Scan ultrasound examination;
All eyes underwent a sharp razor penetration at the superior pole sub-adjacent to the pars plana immediately after enucleating to insure rapid penetration of fixative. Care was taken to avoid damage to the adjacent retina and lens. The eyes were immersed in 2% paraformaldehyde plus 2.5% glutaraldehyde for a minimum of 24 hours at 4 degrees Celsius. A unique posterior calotte was removed, dehydrated in methanol, and dried in carbon dioxide to the critical point, sputter-coated in gold and photographed using the scanning electron microscope.
Results:
The results of this study show that RGD and RG Cysteic Acid (GRG Cysteic Acid TP; Compound 1) (SEQ ID NO 2) have similar properties and injection of 2.5% RG Cysteic Acid intravitreally causes complete separation of the vitreous from the retina in 24 hours, and in addition the vitreous of both the RGD and the RG Cysteic Acid rabbits are completely liquefied.
Over all, the activity of RG Cysteic Acid is equal or slightly better than that of RGD in inducing complete PVD in the rabbits and liquefying the vitreous. This is possibly due to its stronger competitive binding ability to the binding sites of integrin-extracellular matrix interactions than RGD. As described elsewhere herein, sulfonic acids are stronger acids than corresponding carboxylic acids. This higher polarity of the sulfonic acid group leads to stronger intermolecular bonding. For example, R-G-Cysteic acid, which has a more polarized O—H bond, may form stronger hydrogen bonds than R-G-Aspartic acid, which has a relatively less polarized O—H bond, with the amide groups and/or side chains of the amino acids in the integrin binding site and/or have stronger interactions with metal ions complexed in the integrin binding site.
The results also indicate that when these compounds are administered with 0.02% Sodium Edetate, the activity of both RGD as well as RG Cysteic Acid are not altered.
The results also show that there were no adverse effects or adverse safety effects from the intravitreal injection of the RG Cysteic Acid compound Compound 1 or the RGD compound.
In this example, multiple injections of RGCysteic Acid Peptide Compound 1 were administered to the eyes of 5 Male and 4 Female New Zealand Rabbits weighing approximately 1.5-2.5 kg. and the eyes were examined as described in the following paragraphs.
The study then protocol was as follows:
The dosing proceeded as follows:
The remaining 6 Rabbits, numbers 902, 903, 905, 906, 907 and 908 were injected a second time 7 days post first injection.
The remaining group of 3 Rabbits, numbers 905, 906, and 908, were then injected a third time, 14 days after the first injection, as follows:
3) Active Chemicals
The active chemicals used in this study were as follows:
a. Disodium EDTA—99.0-100.5% from Spectrum Chemical Corp.
b. RGCysteic Acid Peptide (Compound 1)
c. USP sterile isotonic saline solution.
4) Study Formulations
a) RGCysteic Acid Solution: 2.5 mg/100 μl solution of RGCysteic Acid containing 0.02 mg of disodium EDTA+0.80 mg of sodium chloride and USP sterile water for injection adjusted to a pH=6.5. Sterile filter through a 0.22μ filter into a 2.0 mL vial.
b) Saline (Control): USP Isotonic sterile saline solution pH adjusted 6.5. Sterile filtered through a 0.22μ filter into a sterile vial.
5) Anesthesia for Injection Preparation
a) Intramuscular injection of 2.0 mL of a 1:1 combination of xylazine (100 mg/ml) and Ketamine hydrochloride (100 mg/ml)
b) Pupils were dilated with topical cyclopentolate hydrochloride 1% and Phenylephrine hydrochloride 10%
6) Intravitreal Injection Preparation:
A sterile vial containing the RGCysteic Acid solution containing 2.5 mg/100 μl and isotonic sterile saline solution, pH adjusted to 6.5 was provided.
Prior to the injection, the investigator confirmed that there was 0.10 cc (100 micro liters) of solution in the 1.0 cc syringe.
7) Injection Procedure:
Since the intravitreal injections do not result in a level of visual disability sufficient to disrupt the normal daily activity of the rabbits, this is not considered a major survival procedure according to the animal resolution of the Association for Research in Vision and Ophthalmology guidelines.
Both the RGCysteic Acid solution as well as the sterile saline solutions was injected into the vitreous cavity after the baseline examination of slit lamp Biomicroscopy, Ophthalmoscopy and ERG was completed on the Rabbits. The Rabbits (10 mg/kg body weight) were anesthetized with an intramuscular injection of 2.0 ml of 1:1 combination of xylazine (100 mg/ml) and Ketamine hydrochloride (100 mg/ml). Pupils were dilated with topical cyclopentolate hydrochloride 1% and Phenylephrine hydrochloride 10%.
All animals were initially examined with slit lamp biomicroscopy and indirect opthalmoscopy to exclude any animals with pre-existing vitreoretinal abnormalities. The intravitreal injection of 0.10 cc was administered 2 mm posterior to the limbus in the supronasal quadrent using a 30-gauge needle attached to a 1.0 cc syringe. Care was taken to avoid damage to the lens or retina.
Seven (7) days following injection a mechanical Vitrectomy was performed on the animals. A two-port pars plana vitrectomy was performed using an infusion fiberoptic and a vitreous cutter attached to a vitrectomy unit. Following a 30 second core vitrectomy, the vitreous cutter was directed to the peripapillary retinal surface where, using low aspiration (<30 mmHg) a separation of the posterior cortical vitreous from the retinal surface was attempted in 4 quadrants. The animals were euthanized with intracardiac sodium pentobarbital injections, and the eyes were immediately enucleated.
All eyes underwent a sharp razor penetration at the superior pole sub-adjacent to the pars plana immediately after enucleation to insure rapid penetration of fixative. Care was taken to avoid damage to the adjacent retina and lens. The eyes were immersed in 2% paraformaldehyde plus 2.5% gluteraldehyde for a minimum of 24 hours at 4 degrees Celsius. A unique posterior calotte was removed, dehydrated in methanol, and dried in carbon dioxide to the critical point, sputter-coated in gold and photographed using the scanning electron microscope.
Analysis of Results
The data on the Safety between eyes treated with RGCysteic Acid solution and sterile saline solution was analyzed for safety using the following techniques:
i) Slit lamp biomicroscopy;
ii) Ophthalmoscopy;
iii) ERG;
iv) Histopathology; and
v) Electron microscopy.
First Intravitreal administration of 100 μl of 2.5% RGCysteic Acid solution to the group of nine Rabbits numbers 901, 902, 903, 904, 905, 906, 907, 908, 909, was not associated with any significant toxicity at all time points. There was no significant difference in reported adverse effects between the 2.5% RGCysteic Acid group and the isotonic saline solution group. This lack of toxicity was determined by clinical examination, indirect ophthalmoscopy and ultrasound β-scan and mechanical vitrectomy.
Slit lamp biomicroscopy was performed at all study visits and focused on the lids, conjunctiva and sclera, cornea, endothelial changes, anterior chamber reaction, iris, lens and capsule, as well as the anterior vitreous for signs for inflammation demonstrate a near complete lack of inflammatory reaction to intravitreal injections of 100 μl of 2.5% RGCysteic Acid solution and the isotonic saline solution group. At all study points and in all study groups there did not appear to be any signs of significant toxicity induced by the test articles.
Clinical evaluation of the posterior segment was also followed throughout the study to ensure that there was no significant retinal toxicity present. Indirect ophthalmoscopy as well as slit lamp fundus evaluations were carried out at each evaluation time point with specific attention to any signs of retinal toxicity. The posterior segment was evaluated for any changes in vitreous density, vitreous liquefaction, vitreous attachment, and possible hemorrhage. The retina was evaluated for any signs of RPE toxicity, retinal vascular compromise retinal hemorrhage, exudates, retinal tears, breaks, or detachments. There were no RPE changes at baseline prior to treatment, at all study points and in all study groups there did not appear to be any signs of significant posterior segment changes induced by the test articles. It is important to note that ERG scans performed on the nine animals prior to the intravitreal injections, as well as ERG scans performed on all the animals 1 day and 7 days post injection did not appear to cause any signs of significant change or toxicity induced by the test articles.
The second Intravitreal administration of 100 μl of 2.5% RGCysteic Acid solution to the group of six Rabbits numbers 902, 903, 905, 906, 907, 908, was not associated with any significant toxicity at all time points. There was no significant difference in reported adverse effects between the 2.5% RGCysteic Acid group and the isotonic saline solution group. This lack of toxicity was determined by clinical examination, indirect ophthalmoscopy and ultrasound β-scan and mechanical vitrectomy.
Slit lamp biomicroscopy was performed at all study visits and focused on the lids, conjunctiva and sclera, cornea, endothelial changes, anterior chamber reaction, iris, lens and capsule, as well as the anterior vitreous for signs for inflammation demonstrate a near complete lack of inflammatory reaction to intravitreal injections of 100 μl of 2.5% RGCysteic Acid solution and the isotonic saline solution group. At all study points and in all study groups there did not appear to be any signs of significant toxicity induced by the test articles.
Clinical evaluation of the posterior segment was also followed throughout the study to ensure that there was no significant retinal toxicity present. Indirect ophthalmoscopy as well as slit lamp fundus evaluations were carried out at each evaluation time point with specific attention to any signs of retinal toxicity. The posterior segment was evaluated for any changes in vitreous density, vitreous liquefaction, vitreous attachment, and possible hemorrhage. The retina was evaluated for any signs of RPE toxicity, retinal vascular compromise retinal hemorrhage, exudates, retinal tears, breaks, or detachments. There were no RPE changes at baseline 7 days prior to the second treatment, at all study points and in all study groups there did not appear to be any signs of significant posterior segment changes induced by the test articles. It is important to note that ERG scans performed on the six animals for a second time post the intravitreal injections, as well as ERG scans performed on all the animals 8 days and 14 days post injection did not appear to cause any signs of significant change or toxicity induced by the test articles.
The third Intravitreal administration of 100 μl of 2.5% RGCysteic Acid solution to the group of six Rabbits numbers 905, 906, 908, was not associated with any significant toxicity at all time points. There was no significant difference in reported adverse effects between the 2.5% RGCysteic Acid group and the isotonic saline solution group. This lack of toxicity was determined by clinical examination, indirect ophthalmoscopy and ultrasound β-scan and mechanical vitrectomy.
Slit lamp biomicroscopy was performed at all study visits and focused on the lids, conjunctiva and sclera, cornea, endothelial changes, anterior chamber reaction, iris, lens and capsule, as well as the anterior vitreous for signs for inflammation demonstrate a near complete lack of inflammatory reaction to intravitreal injections of 100 μl of 2.5% RGCysteic Acid solution and the isotonic saline solution group. At all study points and in all study groups there did not appear to be any signs of significant toxicity induced by the test articles.
Clinical evaluation of the posterior segment was also followed throughout the study to ensure that there was no significant retinal toxicity present. Indirect ophthalmoscopy as well as slit lamp fundus evaluations were carried out at each evaluation time point with specific attention to any signs of retinal toxicity. The posterior segment was evaluated for any changes in vitreous density, vitreous liquefaction, vitreous attachment, and possible hemorrhage. The retina was evaluated for any signs of RPE toxicity, retinal vascular compromise retinal hemorrhage, exudates, retinal tears, breaks, or detachments. There were no RPE changes at baseline 14 days prior to the third treatment, at all study points and in all study groups there did not appear to be any signs of significant posterior segment changes induced by the test articles. It is important to note that ERG scans performed on the three animals for a third time post the intravitreal injections, as well as ERG scans performed on all the animal 15 days and 21 days post injection did not appear to cause any signs of significant change or toxicity induced by the test articles.
In this example, in a model of wound healing, it has been demonstrated that RGCysteic Acid peptides have anti-adhesive properties and therefore can prevent development of many pathological vitreoretinal diseases and can inhibit metastases in human melanoma and colon cancer cells.
To test the anti-adhesive properties of RGCysteic Acid peptides in vitro, a wound-healing assay was performed with human umbilical vein endothelial cells (HUVEC). HUVEC were seeded and allowed to grow to a confluent monolayer on a fibronectin coated surface. A wound (a scratch rift) was created by dragging a small pipette tip across the HUVEC monolayer. The cells were then incubated in fresh growth medium containing the RGCysteic Acid peptide (Compound 1; 10 mM), and the wound area was imaged in five different fields at various time points (0, 4, 8, 12, 16, 20, 24 hours) to determine the kinetics of wound closure. The level of wound closure was quantified by determining the fraction of the original wound area that was re-occupied by HUVEC through cellular adhesion, migration and proliferation.
In control studies, the following peptides were used in place of RGCysteic Acid (Compound 1): cyclic-RGD peptide (1 mM), positive control) and RGE peptide (1 mM, negative control).
The effect of the peptides on the kinetics of wound healing is presented in
Cell interaction with the ECM through focal adhesion is a crucial element of cell migration that dictates the rate of wound closure. In two-dimensional cell migration, the anterior end of the cell with growing lamellipodia forms new adhesions with the substrate while the adhesions on the posterior end detach after cytoskeletal contraction,
As described elsewhere herein, the strong adhesion between the vitreous and the retina could account for eventual development of many pathological vitreoretinal diseases such as vitreomacular traction, proliferative diabetic retinopathy, macular hole, age related macular degeneration and floaters. Thus, an atraumatic non-invasive approach to achieve a Posterior Vitreous Detachment, other than the mechanical separation of the vitreous from the inner retinal surface, is highly desirable (see Tezel, T. H. et al, Retina (1998) 18: 7-15; and Verstraeten, T. C, et al., Arch. Ophthalmol. (1993)111: 849-854).
As described elsewhere herein, it is believed that the ECM components, particularly collagen fibrils of the cortical vitreous, are anchored to the inner surface of the retina through integrin binding sites (see Foos, R. Y., Invest. Ophthalmol. Vis. Sci. (1972) 11:801-808) in the inner limiting lamella (ILL). It is also known that major adhesive glycoproteins of the ILL in the eye such as fibronectin and laminin, are heavily linked to integrins (see Curtis, T. M. et al., Am. J. Physiol., (1995) 269: L248-L260; Elner, S. G.,et al., IOVS (1996) 37:696-701; and Horman, S. M, et al., Am. J. Physiol. (1995) 269: L248-L260) through the RGD (Arg-Gly-Asp) sequences and several integrins bind through RGD motif present in ECM proteins. Further, it is known that fibronectin binds to several other integrins besides αvβ3, whereas vitronectin is αvβ3-specific.
The primary connection of the integrins to the ECM involves the Arg-Gly-Asp(RGD) sequence and the RGD sequence binds to a shallow crevice located between the α- and β-subunits of the integrin head (see Xiong, et al., Science (2002) 296: 151-155). Such binding helps modulate various cellular signaling pathways, including cell adhesion, migration, differentiation, angiogenesis and wound healing (see Ruoslahti, E., et al., Science (1987) 238: 491-497; and J. Clin. Invest. (1991) 87: 1-5).
Since the vitreous extracellular matrix; e.g., collagen fibrils are connected to the cellular retina by the integrin binding sites, intravitreal injection of RGCysteic Acid peptides (oligopeptides) could release the RGD motif of the vitreous extracellular matrix from the cellular retina by a competitive binding to the same integrin receptor sites.
Several investigators (see Ruoslahti, E. et al., Science (1987) 238: 491-497; Hynes, R. A., et al., Cell (1992) 68: 303-322; and Humphries, M. J., J. Cell Sci., (1990) 97: 585-592) demonstrated that many integrins (αvβ3, α5β1, α11β3, etc.) can be inhibited by small peptides that possess the RGD sequence motif. It is also well documented that that αvβ3 and α5β1 integrins, as well as vitronectin and fibronectin, were upregulated in tumors such as human melanoma cells (see Nip, J., J. Clin. Invest., (1992) 90: 1406-1413), human breast cancer cells (see Rong, L. et al., Invest. Ophthalmol. Vis. Sci. (2009) 50: 5988-5996), and human retinal pigment epithelial cells (Peter C. Brooks, et al., J. Clin. Invest., (1995) 96: 1815-1822). Thus it has been demonstrated that there is good correlation between metastatic potentials of human melanoma cells and adhesion of melanoma cells to lymph node vitronectin via the αvβ3 integrin receptor and that the adhesion was inhibited by an RGD containing peptide (Nip, J., J. Clin. Invest., (1992) 90: 1406-1413). This demonstrates that RGDpeptides can be an important anti-angiogenic agents.
Further, it has been demonstrated in a human colon cancer cell line that when there is significant increase in cell adhesion, then there is increased metastatic activity (Lehmann, M., Cancer Res., (1994), 54: 2102-2107). Therefore agents that inhibit cell adhesion effectively inhibit colon cancer and melanoma from metastasizing.
Based on the results of the wound healing study where RGCysteic Acid has been shown to inhibit cell adhesion, and upon extrapolation of the metastatic potential of RGD in the Melanoma and Colon cancer models, RGCysteic Acid peptides and their derivatives can effectively inhibit tumor metastases, for example, in melanoma and colon cancer.
In this example, a dimeric RGCysteic Acid Peptide-Paclitaxel conjugate (Compound 3), shown below, is provided. This composition is useful as an antitumor agent. The dimeric RGCysteic Acid Peptide selectively binds to integrin receptors that are highly expressed in certain cancer cells and is useful to treat certain metastatic cancers such as, for example, metastatic breast cancer, by inhibiting cell adhesion.
The synthesis and mechanisms of action, biodistribution and tumor selectivity of the corresponding RGD analogue of Compound 3 are as described in Chen, X., et al.; Synthesis and Biological Evaluation of Dimeric RGD Peptide-Paclitaxel Conjugate as a Model for Integrin-Targeted Drug Delivery; J. Med. Chem., (2005) 48 (4):.1098-1106).
Although Compound 3 comprises a particular anti-tumor agent, Paclitaxel, bound to dimeric RGCysteic Acid peptide, it is to be appreciated that this aspect of the invention includes all monomeric or multimeric forms of RGCysteic Acid peptides bound to any feasible diagnostic or therapeutic agents that may be useful in diagnosing, imaging or treating a tumor or other integrin-containing tissue or structure. Examples of antitumor substances that may be bound to monomeric or multimeric RGCysteic Acid peptides in accordance with this invention may include antitumor agents (e.g., cancer chemotherapeutic agents, biological response modifiers, vascularization inhibitors, hormone receptor blockers, cryotherapeutic agents or other agents that destroy or inhibit neoplasia or tumorigenesis) such as; alkylating agents or other agents which directly kill cancer cells by attacking their DNA (e.g., cyclophosphamide, isophosphamide), nitrosoureas or other agents which kill cancer cells by inhibiting changes necessary for cellular DNA repair (e.g., carmustine (BCNU) and lomustine (CCNU)), antimetabolites and other agents that block cancer cell growth by interfering with certain cell functions, usually DNA synthesis (e.g., 6 mercaptopurine and 5-fluorouracil (5FU), antitumor antibiotics and other compounds that act by binding or intercalating DNA and preventing RNA synthesis (e.g., doxorubicin, daunorubicin, epirubicin, idarubicin, mitomycin-C and bleomycin) plant (vinca) alkaloids and other anti-tumor agents derived from plants (e.g., vincristine and vinblastine), steroid hormones, hormone inhibitors, hormone receptor antagonists and other agents which affect the growth of hormone-responsive cancers (e.g., tamoxifen, herceptin, aromatase ingibitors such as aminoglutethamide and formestane, trriazole inhibitors such as letrozole and anastrazole, steroidal inhibitors such as exemestane), anti-angiogenic proteins, small molecules, gene therapies and/or other agents that inhibit angiogenesis or vascularization of tumors (e.g., meth-1, meth-2, thalidomide), bevacizumab (Avastin), squalamine, endostatin, angiostatin, Angiozyme, AE-941 (Neovastat), CC-5013 (Revimid), medi-522 (Vitaxin), 2-methoxyestradiol (2ME2, Panzem), carboxyamidotriazole (CAI), combretastatin A4 prodrug (CA4P), SU6668, SU11248, BMS-275291, COL-3, EMD 121974, IMC-1C11, IM862, TNP-470, celecoxib (Celebrex), rofecoxib (Vioxx), interferon alpha, interleukin-12 (IL-12) or any of the compounds identified in Science Vol. 289, Pages 1197-1201 (Aug. 17, 2000) which is expressly incorporated herein by reference, biological response modifiers (e.g., interferon, bacillus calmette-guerin (BCG), monoclonal antibodies, interluken 2, granulocyte colony stimulating factor (GCSF), etc.), PGDF receptor antagonists, herceptin, asparaginase, busulphan, carboplatin, cisplatin, carmustine, cchlorambucil, cytarabine, dacarbazine, etoposide, flucarbazine, flurouracil, gemcitabine, hydroxyurea, ifosphamide, irinotecan, lomustine, melphalan, mercaptopurine, methotrexate, thioguanine, thiotepa, tomudex, topotecan, treosulfan, vinblastine, vincristine, mitoazitrone, oxaliplatin, procarbazine, streptocin, taxol, taxotere, analogs/congeners and derivatives of such compounds as well as other antitumor agents not listed here.
In this example, 64CU-Labeled tetrameric and octameric RGCysteic Acid peptides of the present invention (Compounds 4 and 5 respectively), shown below, are useful as radiotherapeutic agents for imaging and diagnostic purposes (e.g., radiolabeling of tumors for PET scanning) as well as for directing or delivering therapeutic agents to tumors or other cells which express integrins, such as tumors which express αvβ3 integrins.
The synthesis and mechanisms of action, biodistribution, tumor selectivity and PET related use of the corresponding RGD analogues of Compounds 4 and 5 are as described in Li, Z. et al., 64CU-Labeled Tetrameric and Octameric RGD Peptides for Small-Animal PET of Tumor αvβ3 Integrin Expression; J. Nucl. Med. 48 (7) pp. 1162-1171 (2007).
In this example, Compound 1 was tested to determine whether it CNV in a published mouse model. See, Umeda N, Kachi S, Akiyama H, Zahn G, Vossmeyer D, Stragies R, Campochiaro P., Suppression and Regression of Choroidal Neovascularization by Systemic Administration of an α5β1 Integrin Antagonist: Molecular Pharmacology:2006, 69,1820-1828.
The study mice had laser-induced rupture of Bruch's membrane followed by an intravitreal injection of a single dose of COMPOUND 1 at the concentration of 1.0 μg/1 μL, 25 μg/1 μL and at 50 μg/1 μL, as well as a vehicle immediately after laser treatment. Fourteen days after laser treatment, the area of CNV was measured by image analysis. The size of CNV lesions appeared somewhat smaller in the eyes treated with 1.0 μg/1 μL and the 50 μg/1 μL concentrations of COMPOUND 1.
The 25 μg/1 μL concentration of Compound 1 exhibited a statistically significant 43% reduction in CNV compared to vehicle treated eyes. This suggests that a single intravitreal injection of Compound 1 at 25 μg/1 μL is sufficient to significantly inhibit CNV.
In this Example, Compound 1 was tested in an ischemic retinopathy mouse model to explore the feasibility of suppressing pre-retinal neovascularization.
Mice that had ischemic retinopathy were injected intravitreously with a single dose of Compound 1 at the concentration of 0.125 μg/1 μL, 12.5 μg/1 μL, 25.0 μg/1 μL and at 50.0 μg/1 μL (Groups B, D, F and H, respectively), as well as a vehicle (BSS) (Controls 1, 2, 3 and 4) on post-natal day 12. On post-natal day 17, 5 days after intravitreal injection, the area of neovascularization was measured by image analysis.
The results of this study suggest that a single intravitreal injection of Compound 1 at 12.5 μg/1 μL, 25.0 μg/1 μL and at 50.0 μg/1 μL is sufficient to significantly inhibit pre-retinal neovascularization.
The following Tables A through E summarize animal toxicity data obtained from the following studies:
Fifteen human patients with late stage DME received three monthly intravitreal injections of Compound 1 as part of a multiple-injection Phase 1 Human Safety Study. There were no Serious Adverse Events and no Significant Adverse Events. While this study was firstly a safety study, efficacy was also assessed. Eight of the patients patients improved three or more lines in BCVA (representing 53% of the treated patients) and four of the patients improved from nearly legally blind to functional vision in the 20/40 to 20/60 range. Additionally, significant improvement in macular anatomy on OCT was observed in eight patients, ranging from 30% to 80%. These improvements in BCVA and OCT central macular thickness persisted for 90 days of follow up off treatment. These results have been achieved despite the fact that these human patients suffered from late stage DME and many had been deemed refractory to current treatment options of both Avastin as well as photocoagulation laser. The following Table F shows a summary of those study patients who had received prior treatment with Avastin or photogoagulation laser therapy:
Further details and results of this study are shown the following Table F, in the graphs and diagrams of
The objective of the Phase 1 study was to evaluate the safety and initial efficacy of the ophthalmic intravitreal injection of COMPOUND 1 in human subjects with end stage diabetic macular edema (DME). The primary endpoint of this study was the observation of dose limiting toxicity. A secondary endpoint of this study was observation of a clinical benefit in reducing the diabetic macular edema in BCVA (ETDRS lines) and OCT central macular thickness.
Fifteen human subjects with chronic end-stage DME completed this open label study. Subjects at enrollment had BCVA of 20/100 or worse primarily due to DME and had not undergone anti-VEGF treatment or focal laser within 90 days prior to enrollment. Many study subjects were refractory to previous Avastin treatments. Study subjects received three monthly intravitreal injections of 2.5 mg COMPOUND 1 and were followed monthly for an additional 3 months. Safety measurements were followed by BCVA, slit lamp evaluation, dilated fundus exam, IOP measurements, OCT, FA, Fundus Photos, B-scan ultrasound, and ERG.
A total of 15 subjects were enrolled in this study. Overall, all study subjects tolerated the study drug COMPOUND 1 extremely well. There were no reports of inflammatory reactions either in the anterior chamber or vitreous cavity. No sustained elevations in IOP were noted. No corneal decompensation or cataract progression was noted during this study. No retinal tears or retinal detachments were noted during this study, however a high incidence (55%) of posterior vitreous detachment was observed by B-scan ultrasound as seen in previous rabbit studies. Furthermore, no vascular occlusions were observed throughout the course of these studies. Of the 15 subjects, there were no Serious Adverse Events or significant Adverse Events reported.
53% (8 out of 15) of the subjects reported a 3 line or more increase in BCVA by study day 90 after receiving 3 intravitreal injections. No study subject lost BCVA from baseline. Interestingly, the same proportion of subjects (53% or 8 out of 15) were noted to have a significant reduction in OCT central macular thickness of at least 30%. The maximum reduction in macular edema was 505 microns (608 to 103), a nearly 80% reduction in macular edema. Improvements in BCVA typically tracked improvements in reduction of macular edema by OCT. One study subject demonstrated progression from their baseline diabetic macular edema, initially improving during their treatment course but later progressing past their baseline OCT macular thickness at study day 150, 3 months off of intravitreal therapy. This study subject's BCVA initially improved 5 lines but later regressed to baseline by study day 150.
In this study, as shown graphically in
Interestingly, despite the end stage nature of the study subjects and the small study size, there appears to be a clear clinical indicator of efficacy with improvements in BCVA tracking anatomic improvements in OCT central macular thickness. Furthermore, the clinical improvements appear to endure at least 90 days past the last intravitreal treatment with COMPOUND 1 in nearly all study subjects that demonstrate improvements. The authors feel that a larger study is required to further evaluate and confirm the safety and efficacy of this new class of anti-angiogenic drugs and better understand the characteristics of its novel mechanism of action.
Transgenic mice in which the rhodopsin promoter drives expression of human VEGF in photoreceptors (rhoNEGF mice) were randomized into separate treatment groups and studies were performed to provide the following comparisons:
Pretreatment measurements of the area of subretinal neovascularization were made on each animal using image analysis by a masked observer. Each animal received its designated treatment in a single intraocular injection. Seven days post-dose, measurements of the area of subretinal neovascularization were again made and compared to the pre-dose measurements to determine the change in subretinal neovascularization area. Also, the animals were sacrificed and the retinas were dissected, immunostained with GSA lectin and examined by fluorescence microscopy.
In summary, at the doses tested in these comparison studies, ranibizumab and Compound 1 each caused a statistically significant reduction in subretinal neovascularization area when administered alone. However, the combination combination of ranibizumab and Compound 1 caused significantly greater reduction in subretinal neovascularization area than either ranibizumab alone or Compound 1 alone. Based on these data, combination therapy using Compound 1 (or another integrin inhibiting compound of the present invention) in combination with a VEGF Trap (such as ranibizumab) has potential clinical benefit in patients suffering from neovascular eye diseases,
As used herein, any reference to treating or treatment of a disease or disorder shall, unless otherwise noted, be construed to include preventing or prevention of the disease or disorder before it has occurred or been detected as well as treating the disease or disorder after it has occurred or has been detected.
It is to be appreciated that the invention has been described here above with reference to certain examples or embodiments of the invention but that various additions, deletions, alterations and modifications may be made to those examples and embodiments without departing from the intended spirit and scope of the invention. For example, any element or attribute of one embodiment or example may be incorporated into or used with another embodiment or example, unless otherwise specified of if to do so would render the embodiment or example unsuitable for its intended use. Also, where the steps of a method or process have been described or listed in a particular order, the order of such steps may be changed unless otherwise specified or unless doing so would render the method or process unworkable for its intended purpose. All reasonable additions, deletions, modifications and alterations are to be considered equivalents of the described examples and embodiments and are to be included within the scope of the following claims. All publications and patent documents cited herein are hereby incorporated by reference in their entirety for all purposes to the same extent as if each were so individually denoted.
This application is a division of copending U.S. patent application Ser. No. 13/467,995 filed May 9, 2012 which a) claims priority to each of U.S. Provisional Patent Applications Ser. No. 61/484,194 filed May 9, 2011, 61/486,195 filed May 13, 2011 and 61/643,118 filed May 4, 2012 and b) is a continuation in part of i) PCT International Patent Application No. PCT/US2010/056277 filed Nov. 10, 2010 and i) U.S. patent application Ser. No. 12/943,900 filed Nov. 10, 2010 and issued on Apr. 28, 2015 as U.S. Pat. No. 9,018,352, both of which claim priority to U.S. Provisional Patent Application Ser. No. 61/259,748 filed Nov. 10, 2009. The entire disclosure of each of the foregoing patents and applications is expressly incorporated herein by reference.
| Number | Date | Country | |
|---|---|---|---|
| 61484194 | May 2011 | US | |
| 61486195 | May 2011 | US | |
| 61643118 | May 2012 | US | |
| 61259748 | Nov 2009 | US | |
| 61259748 | Nov 2009 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 13467995 | May 2012 | US |
| Child | 15867139 | US |
| Number | Date | Country | |
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| Parent | 15867139 | Jan 2018 | US |
| Child | 16750742 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | PCT/US2010/056277 | Nov 2010 | US |
| Child | 13467995 | US | |
| Parent | 12943900 | Nov 2010 | US |
| Child | PCT/US2010/056277 | US |
