Patent Application
20250032410
The present invention relates to pharmaceutical compositions for the treatment of respiratory diseases and of epithelial tissue such as COVID-19 infections, acute respiratory distress syndrome (ARDS), chronic obstructive pulmonary disease (COPD), respiratory viral, bacterial and fungal infections, cystic fibrosis (CF), among others.
Non-steroidal anti-inflammatory drugs (NSAIDs) are a heterogeneous group of drugs that share their therapeutic action (analgesic, anti-inflammatory, and antipyretic effect), but differ in their relative toxicity and efficacy. The ibuprofen molecule with a molecular weight of 206.3 g/mol, as well as other derivatives of 2-arylpropionate, including ketoprofen, flurbiprofen, naproxen, etc., contains a chiral carbon in the alpha position of the propionate.
Ibuprofen is used as an antipyretic and for the symptomatic relief of headache (cluster), dental pain, muscle pain or myalgia, menstrual discomfort, mild neurological pain, and post-surgical pain. It is also used to treat inflammatory conditions such as those present in arthritis, rheumatoid arthritis, and gouty arthritis.
L-arginine is a semi-essential endogenous amino acid that plays an important role in cell division, wound healing, removal of ammonia from the body, immune function, hormone release, and is also the only biological precursor of nitric oxide (NO).
Nitric oxide (NO), which is produced from L-arginine by a family of isoenzymes called nitric oxide synthases (NOSs), plays an essential role in a variety of biological processes in the lung including host defense against pathogens, smooth muscle relaxation, bronchodilation, and inflammation [Ricciardolo, F. L. M. et al. (2004). Nitric Oxide in Health and Disease of the Respiratory System. Physiological Reviews, 84 (3), 731-765. https://doi.org/10.1152/physrev.00034.2003].
In the vascular endothelium, NO has shown antithrombotic and antimicrobial properties. In this regard, NO release from endothelium and platelets plays a crucial role in maintaining fluidity and preventing coagulation. NO-induced vasodilation helps to eliminate “microaggregates” and inhibits platelet adhesion and aggregation, preventing vascular occlusion [Izzo J. L. (2008). Hypertension primer: [the essentials of high blood pressure; basic science population science and clinical management] (4. ed.). Lippincott Williams & Wilkins]. On the other hand, virucidal and bactericidal effects have also been described in the literature. The antibacterial effect of NO has been demonstrated against infection-causing pathogens such as Staphylococcus aureus, Staphylococcus epidermis, Pseudomonas aeruginosa, Escherichia coli, Acinetobacter baumanii, Listeria monocytogenes, and Enterococcus faecalis. The antimicrobial mechanisms of NO include nitrosation of amines and thiols in the extracellular matrix, lipid peroxidation and tyrosine nitration in the cell wall, and DNA cleavage in the cell matrix [Pant, J. et al. (2017). Tunable Nitric Oxide Release from S-Nitroso-N-acetylpenicillamine via Catalytic Copper Nanoparticles for Biomedical Applications. ACS Applied Materials and Interfaces, 9 (18), 15254-15264. https://doi.org/10.1021/acsami.7b01408]. In addition, the ability of NO to suppress the replication of a respiratory coronavirus, which is unique to NO among other vasodilators, has been reported. [De Mel, A. (2020). Potential roles of nitric oxide in COVID-19: A perspective. Integrative Molecular Medicine, 7 (3). https://doi.org/10.15761/imm.1000403].
In the lungs, NO serves diverse purposes. For example, it functions as a selective pulmonary vasodilator to improve oxygenation and reduce pulmonary vascular resistance [Star, R. A. (1993). Southwestern internal medicine conference: Nitric oxide. American Journal of the Medical Sciences, 306(5), 348-358. https://doi.org/10.1097/00000441-199311000-00015.—Tripathi, P. (2007). Nitric oxide and immune response. Indian Journal of Biochemistry & Biophysics, 44 (5), 310-319.—Susswein, A. J., Katzoff, A., Miller, N., & Hurwitz, I. (2004). Nitric Oxide and Memory. The Neuroscientist, 10 (2), 153-162. https://doi.org/10.1177/1073858403261226.—Robbins, R. A., & Grisham, M. B. (1997). Nitric Oxide. Int. J. Biochem. Cell Bid, 29 (6), 857-860. https://doi.org/10.1016/S1357-2725 (96) 00167-7]. As a bronchial/airway dilator, NO promotes oxygen inhalation, increasing blood flow in the capillaries which exchange gas with the alveoli and accelerating the oxygen circulation in the body [Fang, W. et al. (2021). The role of NO in COVID-19 and potential therapeutic strategies. Free Radical Biology and Medicine, 163, 153-162. https://doi org/10.1016/j.freeradbiomed 2020.12.008]. As a regulator of the immune system, it has been recognized that NO performs many functions where there are large numbers of cells in the system that produce and respond to NO [Tripathi, P., Tripathi, P., Kashyap, L., & Singh, V. (2007). The role of nitric oxide in inflammatory reactions. FEMS Immunology and Medical Microbiology, 51 (3), 443-452. https://doi.org/10.1111/j.1574-695X.2007.00329.x]. As a vascular anticoagulant, it inhibits blood coagulation and excessive platelet activation. And as an anti-inflammatory molecule, it prevents excessive inflammation through early non-specific immunity and regulates vascular inflammation and proliferation of immune cells [Fang, W. et al. (2021). The role of NO in COVID-19 and potential therapeutic strategies. Free Radical Biology and Medicine, 163, 153-162. https://doi.org/10.1016/j.freeradbiomed.2020.12.008].
In patients with cystic fibrosis (CF), higher concentrations of exhaled NO are closely related to improvement in lung function [Grasemann, H. et al. (1997). Decreased Concentration of Exhaled Nitric Oxide (NO) in Patients With Cystic Fibrosis. Pediatric Pulmonology, 24 (3), 173-177. https://doi.org/10.1002/(sici)1099-0496(199709)24:3<173::aid-ppul2>3.0.co; 2-o-Ho, L. P. et al. (1998). Exhaled nitric oxide is not elevated in the inflammatory airways diseases of cystic fibrosis and bronchiectasis. European Respiratory Journal, 12 (6), 1290-1294. https://doi.org/10.1183/09031936.98.12061290—Keen, C. et al. (2010). Low levels of exhaled nitric oxide are associated with impaired lung function in cystic fibrosis. Pediatric Pulmonology, 45(3), 241-248. https://doi.org/10.1002/ppul.21137]. Indeed, Ratjen and cols. [Grasemann, H. et al. (2006). Inhaled L-arginine improves exhaled nitric oxide and pulmonary function in patients with cystic fibrosis. American Journal of Respiratory and Critical Care Medicine, 174(2), 208-212. https://doi.org/10.1164/rccm.200509-1439OC] found that the administration of L-arginine inhalation therapy resulted in a transient improvement in the pulmonary function of CF patients. In later studies [Grasemann, H. et al. (2013). A randomized controlled trial of inhaled I-Arginine in patients with cystic fibrosis. Journal of Cystic Fibrosis, 12(5), 468-474. https://doi.org/10.1016/j.jcf.2012.12.008], they found that L-arginine inhalation was well tolerated and resulted in a significant increase in exhaled NO. FEV1 increased by an average of 56 ml compared to −8 ml after saline solution, but this difference did not reach statistical significance. Moreover, there was no change in inflammatory markers in sputum. They concluded that the repeated inhalation of L-arginine alone in patients with CF was safe and well tolerated. Inhaled L-arginine increased NO production but no evidence of changes in airway inflammation was found. It is interesting to note that they opted to use a twice-daily inhalation of 5 mL of a 100 mg/mL solution, resulting in a cumulative daily dose of 1 g L-arginine. They showed that, after 14 days of inhalation treatment with a high concentration of L-arginine, there was a measurable increase in the concentrations of the NOS inhibitor ADMA and the L-arginine/ADMA ratio (NOS substrate over inhibitor), which is decreased in CF patients and correlates with low airway NO. However, the study found that the potential effect of increased L-arginine concentrations is counteracted by an increase in both L-ornithine, which competes with L-arginine for transport into the cell, and ADMA, which acts as a competitive NOS inhibitor.
Another article studied the supplementation of gaseous NO to treat antibiotic-resistant bacterial and fungal lung infections in patients with cystic fibrosis [Deppisch, C. et al. (2016). Gaseous nitric oxide to treat antibiotic resistant bacterial and fungal lung infections in patients with cystic fibrosis: a phase I clinical study. Infection, 44 (4), 513-520. https://doi.org/10.1007/s15010-016-0879-x]. In this article, the authors reported large reductions in bacterial numbers that led to reduced pulmonary inflammation and increases in the lung function parameter FEV1 from baseline to a degree seldom observed after antibiotic therapy courses in CF patients. Nonetheless, the fact that treatment with gaseous NO for long periods of time would unequivocally lead to the formation of toxic NO2 levels, MetHb, and hypoxemia, represents a major disadvantage of this treatment alternative.
On the other hand, it has also been shown that NO can have detrimental effects on the organism of people suffering from pulmonary diseases. For example, asthmatic patients have higher concentrations of exhaled NO than healthy people and it is known that reactive nitrogen species are involved in the pathogenesis of asthma and the development of “nitrosative stress” [Kleniewska, P., & Pawliczak, R. (2017). The participation of oxidative stress in the pathogenesis of bronchial asthma. Biomedicine and Pharmacotherapy, 94, 100-108. https://doi.org/10.1016/j.biopha.2017.07.066]. In patients with pneumonia by COVID-19, high production of reactive species oxygen (ROS) and reactive nitrogen species (RNS, e g., nitric oxide (NO)) can lead to septic shock [Chavarria, A. P. et al. (2021). Antioxidants and pentoxifylline as coadjuvant measures to standard therapy to improve prognosis of patients with pneumonia by COVID-19. Computational and Structural Biotechnology Journal, 19, 1379-1390. https://doi.org/10.1016/j.csbj.2021.02.009]. Moreover, cells that are damaged due to NO production express nitrotyrosine which, in turn, can have a pathogenic effect due to its ability to react with many different molecules [Adebayo, A., Varzideh, F., Wilson, S., Gambardella, J., Eacobacci, M., Jankauskas, S. S., Donkor, K., Kansakar, U., Trimarco, V., Mone, P., Lombardi, A., & Santulli, G. (2021). L-arginine and covid-19: An update. Nutrients, 13(11). https://doi.org/10.3390/nu13113951].
In summary, NO has many beneficial effects that can be useful to treat lung diseases; however, an excess of NO can also lead to cytotoxic effects causing oxidative damage and cell death. Whether or not NO has a toxic or protective effect depends on many factors.
Oxidative stress is caused by an excessive systemic manifestation of reactive oxygen species (ROS) compared to a reduced capacity of a biological system to rapidly neutralize the reactive intermediates or repair the resulting damage. Increased ROS concentrations are capable of reducing the amount of bioactive NO by chemical inactivation to form toxic peroxynitrite. Peroxynitrite, in turn, can “uncouple” endothelial NO synthase and become a dysfunctional superoxide-generating enzyme that further contributes to vascular oxidative stress [Förstermann, U. (2010). Nitric oxide and oxidative stress in vascular disease. Pflugers Archiv European Journal of Physiology, 459(6), 923-939. https://doi.org/10.1007/s00424-010-0808-2]. In this vein, a correlation between the presence of systemic or local oxidative stress and various pulmonary diseases, including all those treated in the examples herein, has been described in the literature [Ornatowski, W. et al. (2020). Complex interplay between autophagy and oxidative stress in the development of pulmonary disease. Redox Biology, 36. https://doi.org/10.1016/j.redox.2020.101679—Zinellu, E. et al. (2021). Oxidative stress biomarkers in chronic obstructive pulmonary disease exacerbations: A systematic review. Antioxidants, 10(5), 710. https://doi.org/10.3390/antiox10050710—Farouk, A. et al. (2016). Role of oxidative stress and outcome of various surgical approaches among patients with bullous lung disease candidate for surgical interference. Journal of Thoracic Disease, 8(10), 2936-2941. https://doi.org/10.21037/jtd.2016.10.41—Bai, Y. et al. (2018). A Chinese herbal formula ameliorates pulmonary fibrosis by inhibiting oxidative stress via Upregulating Nrf2. Frontiers in Pharmacology, 9(JUN). https://doi.org/10.3389/fphar.2018.00628—Horvath, I. et al. (1998). Increased levels of exhaled carbon monoxide in bronchiectasis: A new marker of oxidative stress. Thorax, 53(10), 867-870. https://doi.org/10.1136/thx.53.10.867—Jesenak, M. et al. (2017). Oxidative stress and bronchial asthma in children-causes or consequences? Frontiers in Pediatrics, 5. https://doi.org/10.3389/fped.2017.00162—Nikolova, G. D. et al. (2018). Oxidative stress and related diseases. Part 1: Bronchial asthma. Bulgarian Chemical Communications, 50, 30-35—Fernandes, I. G. et al. (2020). SARS-COV-2 and Other Respiratory Viruses: What Does Oxidative Stress Have to Do with It? Oxidative Medicine and Cellular Longevity, 2020. https://doi.org/10.1155/2020/8844280—Chavarria, A. P. et al. (2021). Antioxidants and pentoxifylline as coadjuvant measures to standard therapy to improve prognosis of patients with pneumonia by COVID-19. Computational and Structural Biotechnology Journal, 19, 1379-1390. https://doi.org/10.1016/j.csbj.2021.02.009], and therefore disease treatments targeting ROS inhibition and restoration of the oxidant/antioxidant imbalance have also been proposed.
In view of the present state of the art, it becomes apparent that there is a need for therapeutic treatments that, using low doses of active pharmaceutical ingredients, control oxidative stress in respiratory diseases. The present invention provides a solution to this problem, achieving its therapeutic effects by decreasing oxidative stress. The present invention surprisingly manages to reduce oxidative stress through the synergistic combination of ibuprofen with arginine in a hypertonic alkaline solution for nebulization. Achieving therapeutic effects never seen before in patients with various lung diseases.
Regarding ibuprofen and arginine combinations, several Ibuprofen-arginine formulations containing ibuprofen arginate salt (molar ratio 1:1) can be found in the market since that combination is characterized by rapid absorption and higher peak plasma concentrations of ibuprofen, as well as by lower tmax values compared to the free acid form and other preparations [Cattaneo, D., & Clementi, E. (2010). Clinical Pharmacokinetics of Ibuprofen Arginine. Current Clinical Pharmacology, 5 (4), 239-245. https://doi.org/10.2174/157488410793352012]. On the other hand, a previous work [Tsikas, D. et al. (2017). GC-MS and GC-MS/MS measurement of ibuprofen in 10-μL aliquots of human plasma and mice serum using [α-methylo-2H3]ibuprofen after ethyl acetate extraction and pentafluorobenzyl bromide derivatization: Discovery of a collision energy-dependent H/D isotope effect and pharmacokinetic application to inhaled ibuprofen-arginine in mice. Journal of Chromatography B: Analytical Technologies in the Biomedical and Life Sciences, 1043, 158-166. https://doi.org/10.1016/j.jchromb.2016.06.014] discloses a method for the determination of ibuprofen in human plasma samples that was used to measure the concentration of ibuprofen in serum samples of mice upon inhalation of an ibuprofen arginate preparation in saline. However, said article does not anticipate or suggest the existence of a range of concentrations for the combination of ibuprofen and arginine that improves lung function in any pathology. In addition, it is worth noting that all these preparations are based on the ibuprofen arginate salt and therefore, the arginine/ibuprofen molar ratio is 1.
In contrast, the present invention provides a pharmaceutical composition comprising an arginine/Ibuprofen molar ratio, preferably lower than 6.5, and also preferably greater than 1, that has a synergistic effect on the inhibition of reactive oxygen species. Said pharmaceutical formulation can be administered by nebulization to treat different lung diseases such as; asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), pulmonary hypertension, bronchopulmonary dysplasia, acute respiratory distress syndrome (ARDS), respiratory syndrome coronavirus 2 (SARS-COV-2), bilateral pneumonia, viral, bacterial and fungal lung infections and bronchiectasis, among others, improving oxygen saturation, respiratory rate, cardiac frequency, and blood pressure.
The pharmaceutical composition of the present invention shows important physiological benefits for treating lung diseases. This composition comprises very simple molecules like an anti-inflammatory (ibuprofen) and a basic amino acid (arginine) that, when combined at specific concentrations, ionic strength, and pH values, exhibits a synergic effect in the synthesis and release of nitric oxide (NO), which also improve the vasodilation. Moreover, the presence of Arginine formulated together with Ibuprofen to be nebulized, not only affects NO levels but also has a marked synergistic effect on the reduction of oxidative stress, as shown in the examples herein. As a consequence, it induces an improvement in the O2 saturation, causing an increase in the pulmonary function (FEV1) in patients. This protective strategy is associated with reduced acute lung injury (ALI). This synergistic effect is achieved at much lower arginine concentrations than those used in other treatments, it is longer lasting, and no inhibiting effects have been observed in sustained treatments over time.
In addition, this composition contains an anti-inflammatory molecule such as Ibuprofen which has also shown bactericidal properties against Gram+ and Gram-bacteria, especially by inhibiting bacteria such as P. aeruginosa, S. aureus, B. cepacia and also having a virucidal effect on those lipid-enveloped viruses [Argañarás, L. A. et al. (2021). Bactericidal and virucidal pharmaceutical composition. DC: U.S. Patent and Trademark Office. U.S. Pat. No. 10,973,787 B2—García, N. H. et al. (2020). Ibuprofen, a traditional drug that may impact the course of COVID-19 new effective formulation in nebulizable solution. Medical Hypotheses, 144. https://doi.org/10.1016/j.mehy.2020.110079]. Furthermore, the pharmaceutical composition of the present invention comprises a dissolved salt in a composition such that the synergistic bactericidal and antiviral effect disclosed in the patent U.S. Pat. No. 10,973,787 B2 is achieved, boosting the overall bactericidal and virucidal effect of said pharmaceutical composition and making it more suitable for the treatment of lung diseases caused by pathogens.
A pharmaceutical composition to be applied on the pulmonary epithelium for the treatment of respiratory or lung diseases, main object of the present invention, comprises ibuprofen, arginine, solubilized in a hypertonic aqueous solution at a pH between 7.5 and 9.5 wherein the arginine/ibuprofen molar ratio is preferably lower than 6.5 and preferably greater than 1. Wherein more preferably the arginine/ibuprofen molar ratio is from 1.5 and 5, wherein preferably is from 2 to 5, more preferably 2. Wherein the ibuprofen is in a concentration from 10 mM to 50 mM, and wherein said ibuprofen is racemic, or is the S enantiomer, or is the R enantiomer. Wherein said ibuprofen comprises, as a counterion, the monovalent cation selected from the group comprising sodium, potassium, lithium, arginate, lysinate, histidinate and combinations thereof. And said arginine comprises a concentration from 10 mM to 250 mM.
In a preferred embodiment of the present invention, said formulation further comprises a pH in aqueous solution of 8.0 to 9.0, preferably of 8.5.
The composition of the present invention is administered by nebulization or inhalation and comprises a state selected from the group comprising liquid, powder and lyophilized state.
In a preferred embodiment, said composition is hypertonic because it comprises a salt in a concentration from 0.3 to 2.0 M, preferably from 0.4 to 1.1 M, more preferably from 0.5 to 1.0 M. Said salt is suitable for human consumption and is selected from the group comprising sodium chloride, potassium chloride, sodium carbonate and combinations thereof. Preferably, said salt is NaCl.
The pharmaceutical composition is useful for the treatment of lung disease such as; asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), pulmonary hypertension, and bronchopulmonary dysplasia, acute respiratory distress syndrome (ARDS), respiratory syndrome coronavirus 2 (SARS-COV-2), viral, bacterial and fungal lung infections, bilateral pneumonia and bronchiectasis.
In another embodiment, the pharmaceutical composition to be applied on the pulmonary epithelium for the improvement of lung function, comprises ibuprofen, arginine, solubilized in a hypertonic aqueous solution at a pH between 7.5 and 9.5 wherein the arginine/ibuprofen molar ratio is greater than 1 and lower than 6.5.
In another embodiment, the pharmaceutical composition to be applied on the pulmonary epithelium for the improvement of lung function, comprises ibuprofen, arginine, solubilized in a hypertonic aqueous solution at a pH between 7.5 and 9.5 wherein the arginine/ibuprofen molar ratio is greater than 1 and lower than 6.5 and wherein the ibuprofen concentration is between 10 mM and 50 mM and the arginine concentration is between 10 mM and 250 mM.
Another object of the present invention is a manufacturing process of a pharmaceutical composition with bactericidal, virucidal and anti-inflammatory properties to be applied on epithelial tissue such as pulmonary tissue, which comprises the following steps:
Optionally, said process comprises the following steps:
Another object of the present invention is a method for treating lung disease comprising administering an effective amount the pharmaceutical composition to the pulmonary epithelium of the subject; wherein the pharmaceutical composition is administered to the subject as a nebulized solution. In one embodiment, between 1 mL and 25 mL of the pharmaceutical composition is administered to the subject; preferably, between 1 mL and 10 mL; more preferably, between 1 mL and 5 mL. More preferably 3 mL of the pharmaceutical composition is administered to the subject.
Said lung disease is selected from the group comprising; asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), pulmonary hypertension, and bronchopulmonary dysplasia, acute respiratory distress syndrome (ARDS), respiratory syndrome coronavirus 2 (SARS-COV-2), viral, bacterial and fungal lung infections, bilateral pneumonia and bronchiectasis.
Wherein the subject is hypoxic, or has a pulse-oximetry blood-oxygen saturation level of less than 92%, or has a respiratory rate of 21-25 breaths/minute, or has a respiratory rate of 25-30 breaths/minute, or has a respiratory rate of 30-40 breaths/minute, or has a respiratory rate over 41 breaths/minute, or has a pulse rate of 91-110 beats/minute, or has a pulse rate of 111-130 beats/minute, or has a pulse rate of over 131 beats/minute, or has a NEWS2 Score of 0-4, or has a NEWS2 Score of 5-6, or has a NEWS2 Score of 7 or greater, is intubated, is pre-intubation, or is non-hypoxic.
A pharmaceutical composition to be applied on the pulmonary epithelium, main object of the present invention, comprises a non-steroidal anti-inflammatory drug (NSAID), a basic amino acid, solubilized in an aqueous solution at alkaline pH between 7.5 and 9.5.
“NSAID” refers to a non-steroidal anti-inflammatory drug which is selected from the group comprising ibuprofen, naproxen, flurbiprofen, ketoprofen, diclofenac, diflunisal, etodolac, fenoprofen, indomethacin, meclofenamate, mefenamic acid, meloxicam, oxaprozin, piroxicam, sulindac, celecoxib, acetylated salicylate, and combinations thereof. Wherein said NSAID, is in a concentration from 5 mM to 500 mM, preferably in a concentration from 5 mM to 180 mM, more preferably in a concentration from 5 mM to 50 mM. Said NSAID is in its deprotonated form, in which the proton is replaced with another cation. Said NSAID comprises as a counterion the monovalent cation selected from the group comprising sodium, potassium, lithium, arginate, lysinate, histidinate, and combinations thereof. In one embodiment, the preferred formulation comprises ibuprofen.
Given that ibuprofen has one chiral center, it has two possible enantiomers R and S. The invention contemplates the use of the R enantiomer, the use of the S enantiomer and mixtures thereof, including racemic mixtures (1:1 mixtures of the R and S enantiomers). The designation of the R enantiomer or the S enantiomer indicates an optical purity of at least 90%, 95%, 98%, or 99% by weight. “Optical purity” refers to the percent of the designated enantiomer relative to the combined weight of both enantiomers.
In the present invention, said ibuprofen to be solubilized in an aqueous solution can be added in its acid form or as a salt comprising as a counterion the monovalent cation selected from the group comprising sodium, potassium, lithium, arginate, lysinate, histidinate and combination thereof.
“Basic amino acids” refers to the amino acids that have basic side chains at neutral pH, such as; arginine, lysine, and histidine. Their side chains contain nitrogen and resemble ammonia, which is a base. In one embodiment, said basic amino acid, is in a concentration from 10 mM to 500 mM, preferably in a concentration from 25 mM to 300 mM, more preferably in a concentration from 50 mM to 250 mM, and even more preferably in a concentration from 80 mM to 150 mM. Where said basic amino acid is preferably arginine.
“Aqueous solution” refers to the solution that uses a polar liquid as a solvent, preferably water, and has the NSAID and the basic amino acid solubilized in it. In another embodiment, said aqueous solution further comprises a salt suitable for human consumption, preferably Na2CO3, KCl, or NaCl, more preferably NaCl. Wherein said aqueous solution is preferably hypertonic comprising a concentration of said salt suitable for human consumption from 0.3 M to 2 M, preferably from 0.4 M to 1.1 M, even more preferably from 0.5 M to 1.0 M. Alternatively, the molar ratio of said ibuprofen to salt (ibuprofen:amino acid) is from 1:0.6 to 1:400.
Furthermore, said pharmaceutical composition comprises a pH in aqueous solution between pH 7.5 and pH 9.5, preferably between pH 8 and pH 9, more preferably the pH of said pharmaceutical composition is 8.5.
The pharmaceutical composition of the invention is administered by inhalation or nebulization. Administering a formulation by “inhalation” refers to administering the formulation directly to the lungs through the mouth or/and nasal cavity, commonly by inhaling the formulation.
Administration of the pharmaceutical composition of the present invention can be accomplished by nebulization, in which a nebulizer changes liquid medicine into fine droplets (in aerosol or mist form) that are inhaled through a mouthpiece or mask. Nebulization can be accomplished by any suitable means, including by 1) jet, which uses compressed gas to make an aerosol (tiny particles of medication in the air or 2) ultrasound, which makes an aerosol through high-frequency vibrations. In one embodiment, the nebulization is carried out with a piston nebulizer. In one embodiment, the nebulized droplets are of a sufficient size to reach the alveoli.
Alternatively, the pharmaceutical composition may be delivered with an inhaler. In one example, the pharmaceutical formulation is administered through a metered dose inhaler (MDI), which “pushes out” a pre-measured spray of the pharmaceutical composition, with, for example, a hydrofluoroalkane aerosol spray. In another example, a soft mist inhaler (SMI) provides a pre-measured amount of the pharmaceutical formulation in a slow-moving mist.
Furthermore, the present invention may be prepared either in a liquid state or as a powder or lyophilized by drying or lyophilization from the final aqueous solution of said pharmaceutical composition. Both the drying process and the lyophilization of pharmaceutical composition are well known in the prior art, therefore providing further details on the subject is not considered necessary.
The present invention is a pharmaceutical composition that is useful for the treatment of lung diseases and viral or no-viral lung infections such as; asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), pulmonary hypertension, bronchopulmonary dysplasia, acute respiratory distress syndrome (ARDS), respiratory syndrome coronavirus 2 (SARS-COV-2), bilateral pneumonia, and bronchiectasis.
Cystic fibrosis is a serious disease that mainly affects children. Is an inherited condition that causes sticky mucus to build up in the lungs and digestive system. This causes lung infections and problems with digesting food. Asthma is a disease of the respiratory system characterized by chronic inflammation of the airway that affects both children and adults. Chronic Obstructive Pulmonary Disease (COPD) is the name for a group of lung conditions that cause breathing difficulties. Is a common condition that mainly affects middle-aged or older adults who smoke. The breathing problems tend to get gradually worse over time. Pulmonary hypertension is high blood pressure in the blood vessels that supply the lungs (pulmonary arteries). It is a serious condition that can damage the right side of the heart. The walls of the pulmonary arteries become thick and stiff, and cannot expand as well to allow blood through.
Bronchopulmonary dysplasia (BPD) is a form of chronic lung disease that affects newborns, most often those who are born prematurely and need oxygen therapy. In BPD the lungs and the airways (bronchi) are damaged, causing tissue destruction (dysplasia) in the tiny air sacs of the lung (alveoli); acute respiratory distress syndrome (ARDS); occurs when fluid builds up in the tiny, elastic air sacs (alveoli) in your lungs. The fluid keeps the lungs from filling with enough air, which means less oxygen reaches the bloodstream. This deprives the organs of the oxygen they need to function.
Respiratory Syndrome Coronavirus 2 (SARS-COV-2) is a recent virus disease where patients show pneumonia. In this case, fever was the most common symptom, followed by coughing. Most patients present lower values of O2 saturation and less capability to breathe. Bilateral lung involvement with ground-glass opacity was the most common finding from computed tomography images of the chest.
The formulation of the present invention achieves the therapeutic effects described in the examples by acting on oxidative stress. Oxidative stress is caused by an excessive systemic manifestation of reactive oxygen species (ROS) compared to a reduced capacity of a biological system to rapidly neutralize the reactive intermediates or repair the resulting damage. In this vein, a relation between the presence of systemic or local oxidative stress and diverse lung diseases, including all the ones treated in the examples, have been described in the literature and, therefore, disease treatments targeting ROS inhibition and restoration of the oxidants/antioxidants imbalance have also been proposed.
For example, Ornatowski et al. [Ornatowski, W. et al. (2020). Complex interplay between autophagy and oxidative stress in the development of pulmonary disease. Redox Biology, 36. https://doi.org/10.1016/j.redox.2020.101679] discussed the interplay of ROS and autophagy in lung diseases including Chronic Obstructive Pulmonary Disease, Acute Lung Injury, Cystic Fibrosis, Idiopathic Pulmonary Fibrosis, Pulmonary Arterial Hypertension, and Asthma, and concluded that ROS-autophagy interaction plays a critical and complex role in the pathogenesis of these lung diseases. In particular, Zinellu et al. [Zinellu, E. et al. (2021). Oxidative stress biomarkers in chronic obstructive pulmonary disease exacerbations: A systematic review. Antioxidants, 10(5), 710. https://doi.org/10.3390/antiox10050710] reviewed articles related to oxidative stress biomarkers in exacerbated COPD patients compared to the stable phase of the disease, identifying reliable oxidative stress biomarkers that could be useful in monitoring disease progression in COPD patients and especially in those more susceptible to exacerbations. Farouk et al. [Farouk, A. et al. (2016). Role of oxidative stress and outcome of various surgical approaches among patients with bullous lung disease candidate for surgical interference. Journal of Thoracic Disease, 8(10), 2936-2941. https://doi.org/10.21037/jtd.2016.10.41] found significantly higher plasma levels of oxidative stress markers and lower antioxidant vitamins levels among the patients suffering from bullous lung disease when compared with the control group and proved that oxidative stress plays an important role in the pathogenesis of the disease.
Oxidative stress also plays important roles in the inflammation, collagen deposition, and fibrosis of pulmonary fibrosis lungs; and free radical activity, lipid products and oxidized proteins have been identified in exhaled air, bronchus alveolar lavage fluid, serum and lung of patients with pulmonary fibrosis [Bai, Y. et al. (2018). A Chinese herbal formula ameliorates pulmonary fibrosis by inhibiting oxidative stress via Upregulating Nrf2. Frontiers in Pharmacology, 9(JUN). https://doi.org/10.3389/fphar.2018.00628]. Likewise, it is known that the pathophysiology of bronchiectasis involves oxidative stress and oxidative stress biomarkers have been found in the breath of patients with bronchiectasis [Horvath, I. et al. (1998). Increased levels of exhaled carbon monoxide in bronchiectasis: A new marker of oxidative stress. Thorax, 53 (10), 867-870. https://doi.org/10.1136/thx.53.10.867].
Regarding bronchial asthma, it is generally accepted that oxidative stress represents an important part of its pathogenesis [Jesenak, M. et al. (2017). Oxidative stress and bronchial asthma in children-causes or consequences? Frontiers in Pediatrics, 5. https://doi.org/10.3389/fped.2017.00162]. Also, it has been confirmed that the development and maintenance of inflammatory processes in the respiratory tract are associated with the oxidative and nitrosative stress present in asthmatic patients [Nikolova, G. D. et al. (2018). Oxidative stress and related diseases. Part 1: Bronchial asthma. Bulgarian Chemical Communications, 50, 30-35].
In addition, respiratory viruses, comprising human respiratory syncytial virus (RSV), influenza (IV), human rhinovirus (HRV), human metapneumovirus (HMPV), parainfluenza, and adenoviruses and coronaviruses (CoVs), induce ROS-generating enzymes, such as nicotinamide adenine dinucleotide phosphate oxidases (NADPH oxidase, Nox) and xanthine oxidase (XO), while creating unbalanced antioxidant levels [Fernandes, I. G. et al. (2020). SARS-COV-2 and Other Respiratory Viruses: What Does Oxidative Stress Have to Do with It? Oxidative Medicine and Cellular Longevity, 2020. https://doi.org/10.1155/2020/8844280].
Finally, patients with moderate and severe pneumonia by COVID-19 may develop sepsis. Sepsis has been the leading cause of mortality in intensive care units worldwide during the last pandemic. Septic shock is a consequence of sepsis, where there is a high production of ROS, and RNS (e g., nitric oxide (NO)) that can cause multiple organ failure (pulmonary, cardiac, neurological, and hepatic) [Chavarría, A. P. et al. (2021). Antioxidants and pentoxifylline as coadjuvant measures to standard therapy to improve prognosis of patients with pneumonia by COVID-19. Computational and Structural Biotechnology Journal, 19, 1379-1390. https://doi.org/10.1016/j.csbj.2021.02.009].
The present invention has advantages that had never been reported before since using very low doses of NSAID and basic amino acid, combined at specific concentrations and specific pH and salt concentration values, exhibits a synergic effect in the synthesis and release of nitric oxide (NO) and in the reduction of oxidative stress, which also improve the vasodilation and as consequence induce the improvement in the O2 saturation and finally an increase of the pulmonary function FEV-1 in patients.
Technically, using very low concentrations of NSAIDs and the basic amino acid arginine, result in a synergic effect on O2 saturation and FEV-1 and produce a decrease in blood pressure with a reduction of the common adverse effects of these anti-inflammatory drugs and on the other hand, the lower doses of arginine in this formulation prevent the increase of asymmetric dimethylarginine (ADMA), an inhibitor of endothelial NOS that appear when high doses of arginine were used.
Moreover, due to the nature of its composition, the present invention achieves the synergistic bactericidal and antiviral effects described in U.S. Pat. No. 10,973,787 B2, boosting the overall bactericidal and virucidal effect of said pharmaceutical composition and making it more suitable for the treatment of lung diseases caused by pathogens.
Another object of the present invention is a process of manufacturing a pharmaceutical composition to be applied to epithelial tissue such as pulmonary tissue, comprising the following steps:
In a preferred embodiment of the present invention, said process further comprises the following steps:
In a more preferred embodiment, the process of manufacturing a pharmaceutical composition to be applied on epithelial tissue such as pulmonary tissue, comprises the following steps:
In an even more preferred embodiment of the present invention, said process further comprises the following steps:
Another object of the present invention is directed to the use of the pharmaceutical composition for the treatment of the lung diseases previously mentioned in a subject.
A “subject” is a mammal, preferably a human, but can also be an animal in need of veterinary treatment, e.g., companion animals (e.g., dogs, cats, and the like), farm animals (e.g., cows, sheep, pigs, horses, and the like) and laboratory animals (e.g., rats, mice, guinea pigs, and the like).
“Treat,” “treating,” or “treatment,” when used in connection with a subject with a lung disease, includes improving the effects or symptoms of the disease or shortening the duration of said disease. In instances where the subject has become hypoxic, “treat,” “treating,” or “treatment,” refers to returning blood oxygenation to normal or near normal more rapidly than in the absence of treatment. In instances where the subject has progressed to severe disease, “treat,” “treating,” or “treatment,” refers to lessening the likelihood of requiring intubation, decreasing the time requiring intubation, decreasing recovery time, and/or reducing the mortality rate.
“Effective amount” means an amount when administered to the subject with a lung disease which results in beneficial or desired results, including improvement of the effects or symptoms of said lung diseases, including normalizing blood oxygenation levels, shortening recovery time, decreasing the likelihood of requiring intubation in severe disease and/or decreasing mortality.
The precise amount of the pharmaceutical solution administered to provide an “effective amount” to the subject will depend on the type, and severity of the lung disease, and on the characteristics of the subject, such as general health, age, sex, body weight, and tolerance to drugs. The skilled artisan will be able to determine appropriate dosages depending on these and other factors. Suitable dosages are known for approved therapeutic agents and can be adjusted by the skilled artisan according to the condition of the subject, the type of lung disease being treated and the amount of pharmaceutical composition being used by following, for example, dosages reported in the literature and recommended in the Physician's Desk Reference (57th ed., 2003). For example, an “effective amount” can be between 1 mL to 50 mL of the pharmaceutical composition used in the disclosed methods. Alternatively, an “effective amount” is between 1 mL to 25 mL of the pharmaceutical composition used in the disclosed methods. In another alternative, “effective amount” is between 1 mL and 10 mL of the pharmaceutical composition used in the disclosed methods. In another alternative, “effective amount” is between 3 mL and 7 mL of the pharmaceutical composition used in the disclosed methods. In yet another alternative, an “effective amount” is 3 mL of the pharmaceutical composition used in the disclosed methods. An effective amount is administered between 1 and 5 times daily, alternatively from 1 to 3 times daily. The time of administration varies between 5 minutes and 1 hour and alternatively between 5 minutes and 30 minutes. In yet another alternative, the time of administration varies between 10 minutes and 20 minutes.
A small but significant percentage of subjects with a respiratory viral infection progress to severe and even life-threatening disease such as pneumonia or acute respiratory distress syndrome (ARDS) (referred to herein as “severe disease”). Pneumonia is an infection that inflames the air sacs (alveoli) in one or both lungs. The air sacs may fill with fluid or pus (purulent material), causing cough with phlegm or sputum, fever, chills, and difficulty breathing. ARDS is also characterized by fluid build-up in the air sacs in the lungs, but it is also accompanied by hyperinflammation, which may induce a condition sometimes referred to as “cytokine storm” or systemic inflammation which can lead to respiratory failure and death. Symptoms of ARDS include severe shortness of breath, labored and unusually rapid breathing, low blood pressure and/or confusion and extreme tiredness.
Low blood oxygenation levels also accompany pneumonia and ARDS and are responsible, at least in part, for the severe symptoms associated with these conditions. Oxygen saturation levels offer an integrated assessment of pulmonary and cardiac function, and its non-invasive measurement with transdermal pulse oximetry has become a routine component of the assessment of disease severity. “Low blood oxygenation levels in a subject refers to a pulse-oximetry oxygen saturation level of less than 95%, the lower limit of normal for healthy subjects (patients with hypercapnic respiratory disease live with lower chronic oxygen saturation levels). Oxygen saturation of <92% is considered an urgent matter, requiring immediate intervention, particularly when this reflects an acute change from baseline normal values as is often observed in patients with viral pneumonitis. A subject with a low blood oxygenation level is also referred to herein as being “hypoxic”. Subjects with respiratory viral infection diseases who have progressed to pneumonia or ARDS, when treated according to the disclosed methods, have shown improved blood oxygenation, including restoration of blood oxygenation levels to normal and with relief of the severe symptoms associated with ARDS.
A second common measure of cardiopulmonary status is the respiratory rate, which in healthy adults is typically less than or equal to 20 breaths/minute. Subjects with respiratory viral infections that have progressed to pneumonia or ARDS frequently present with respiratory rates far above the normal range (up to 21-25 breathes/minute, 25-30 breathes/minute or, in more severe cases, 30 to 40 breaths/minute), and such subjects, when treated according to the disclosed methods, have shown improvement in respiratory rate to the normal range. This is one component of the alleviation of severe symptoms associated with ARDS described above.
A third measure of cardiopulmonary status is the heart rate, which in healthy adults at rest is typically less than 90 beats per minute, but may be markedly elevated in subjects with respiratory viral infections that have progressed to pneumonia or ARDS. Subjects with respiratory viral infections that have progressed to pneumonia or ARDS frequently present with heart rates far above the normal range (from 91-110 beats/minute, in more severe cases from 111-130 beats/minute, to over 131 beats/minute in the most severe cases). Subjects with viral pneumonia or ARDS, when treated according to the disclosed methods, have shown improvement in heart rate to the normal range.
The National Early Warning Score (NEWS2) is an accepted assessment tool for identifying subjects who have or are likely to develop an acute illness. See, for example, Royal College of Physicians, National Early Warning Score (NEWS) 2: Standardizing the Assessment of Acute-Illness Severity in the NHS. Updated Report of the Working Party, London: RCP, 2017. Specifically, a NEWS2 Score of 0-4 indicates a low level of clinical risk for the subject; a NEWS2 Score of 5-6 indicates a moderate level of clinical risk for the subject; and a NEWS2 Score of 7 or more indicates a high level of clinical risk for the subject. The disclosed methods can be used to treat a subject with a NEWS2 Score of 0-4, 5-6 or 7 or more to reduce the likelihood of increasing the scope or to reduce the score to bring the subject to an improved condition with a lower score.
In particularly severe cases, subjects with ARDS require breathing assistance and are put on a mechanical ventilator, i.e., the subject is “intubated”. The disclosed methods can increase blood oxygenation and are useful in reducing the likelihood that a hypoxic subject with severe disease who is not yet intubated will subsequently require intubation. The disclosed methods are also useful in increasing blood oxygenation in intubated patients, thereby increasing the likelihood of recovery and decreasing the amount of time the subject spends on a ventilator.
In some instances, subjects with lung diseases who are experiencing only mild symptoms may nonetheless be hypoxic, i.e., have low blood oxygen levels. The low blood oxygenation levels are an indication that the subject with only mild symptoms is at risk for progressing to severe disease, such as pneumonia or ARDS. The disclosed methods of treatment are effective in reducing the likelihood that hypoxic subjects experiencing only mild symptoms will progress to severe disease such as pneumonia or ARDS. As noted above, the disclosed methods of treatment have also been shown to be effective in treating subjects who are hypoxic and who have already developed more severe disease such as pneumonia or ARDS.
The disclosed methods can also be used to treat non-hypoxic subjects with lung diseases who are experiencing only mild symptoms to reduce the likelihood of these subjects becoming hypoxic and/or progressing to severe disease.
Considering the information previously mentioned and the results shown in the examples (see below), It has been demonstrated that the composition of the present invention shows important improvement for the treatments of various diseases that affect the lungs, such as: asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), pulmonary hypertension, bronchopulmonary dysplasia, acute respiratory distress syndrome (ARDS), respiratory syndrome coronavirus 2 (SARS-CoV-2), bilateral pneumonia, and bronchiectasis, among others. In all these pathologies the nebulization with this composition containing a mix of Ibuprofen-arginine-salt at a pH of 8.5, produces a substantial anti-inflammatory effect and an improvement of oxygen saturation, respiratory rate, heart rate, and blood pressure.
Add to a suitable container, water for injection corresponding to 70% of the final volume of the batch. Then proceed to incorporate and dissolve the amount of sodium carbonate necessary for the preparation of the batch. This process is carried out by mechanical agitation and avoiding contamination and loss of the solution.
Once the sodium carbonate is dissolved, add the ibuprofen with strong agitation. Agitate until complete dissolution.
Add the sodium citrate and, once it has dissolved, add the sodium chloride, maintaining moderate agitation until the solution is homogeneous. Measure the pH of the solution. Adjust the pH of the solution to 8.6±0.1 at 25° C., adding a 10% sodium carbonate solution as needed.
After adjusting the pH, add purified water to reach the final volume of the solution.
The preferred method of preparation of the formulation used for the embodiment of the present invention, which proves to be the best known to the inventors, is described, but is not the only possible one.
In this and the following example, the “RF” values refer to respiratory rate and are given in breaths/minute. The “CFq” values refer to heart rate in beats/minute. The “PO2” values refer to O2 saturation, measured by pulse oximetry and expressed in percentage. The “BP” values refer to systolic/diastolic blood pressure and are expressed in mmHg. The term “HBP” means high blood pressure.
Admission in Hospital: Aug. 20, 2021 (had been with COVID-19 for 8 days). The PO2 was 92-93% at room air, without oxygen supplementation. The RF was 22 and the CFq was 89. The subject receives oxygen supplementation (low flow O2 2 L/h) and support treatment with dexamethasone and heparin. The subject received nebulization treatment with AHI solution every 8 h from Aug. 20, 2021 to Aug. 28, 2021.
At 11 AM on Aug. 28, 2021, the subject received a nebulization treatment with 3 mL of AHI solution containing 6 mM of L-Arginine Hydrochloride. No substantial changes were observed, after 6 hs the PO2 remained at 93%.
At 5 PM on Aug. 28, 2021, the subject received a nebulization treatment with 3 mL of AHI solution containing 12 mM of L-Arginine Hydrochloride. After nebulization RF was 22, the CFq was 86, and PO2 was still at 93%.
At 11 PM on Aug. 28, 2021, the subject received a nebulization treatment with 3 mL of AHI solution containing 25 mM of L-Arginine Hydrochloride. PO2 remained at 93-94%.
At 6 AM of Aug. 29, 2021, the subject received a nebulization treatment with 3 mL of AHI solution containing 50 mM of L-Arginine Hydrochloride. After nebulization, the RF was 22, the CFq was 86, and PO2 rose to 96% and remained at 96% for at least 6 hours.
At 12 AM on Aug. 29, 2021, the subject received a nebulization treatment with 3 mL of AHI solution containing 100 mM of L-Arginine Hydrochloride. After nebulization, the RF was 18-19, the CFq was 75-76, and PO2 increased again, reaching values of 98-99% which were maintained for 8 to 10 h.
The subject continued this treatment and was discharged on Sep. 3, 2021. No adventitious or “added” sounds were observed. The subject reported feeling much better. No adverse effects were observed during the treatment.
Admission in Hospital: Aug. 31, 2021 (had been with COVID-19 for 8 days). The PO2 was 91-93% at room air. The RF was 20 and the CFq was 69. The subject receives oxygen supplementation (low flow O2 2 L/h) and support treatment with dexamethasone and heparin. Adventitious sounds were observed: bibasilar crackles, right predominance. The subject received nebulizations with AHI solution every 6 h from Aug. 24, 2021 to Aug. 31, 2021.
On Aug. 31, 2021 the subject started receiving a nebulization treatment with 3 mL of Ibu-Arg solution every 8 h. At the end of nebulization, PO2 was 97%, without O2 supplementation. Eight hours after nebulization, PO2 was 95%, without O2 supplementation.
The subject continued this treatment and was discharged on Sep. 6, 2021 with PO2=97%, RF=18, and CF=88. No presence of adventitious or “added” sounds were observed at this point.
Admission in Hospital: Aug. 21, 2021. The PO2 was 93%, RF was 21, and CFq was 70. The subject receives oxygen supplementation (intermittent O2, according to the patient's needs) and support treatment with dexamethasone and heparin. Observations: decrease of vesicular murmur, marked dyspnea. The subject received nebulization treatment with AHI solution every 8 h from Aug. 14, 2021 to Aug. 21, 2021.
On Aug. 21, 2021 the subject started receiving a nebulization treatment with 3 mL of Ibu-Arg solution every 8 h and the PO2 reached 98%. 8 h after nebulization, PO2 was 95%.
The subject continued this treatment and was discharged on Sep. 26, 2021 with PO2=97%, RF=20, and CF=68. No presence of adventitious or “added” sounds were observed at this point.
Admission in Hospital: Aug. 31, 2021 (had been with COVID-19 for 8 days). The PO2 was 88-90% at room air. The RF was 22 and the CFq was 88. The subject receives oxygen supplementation (low flow oxygen 2 L/h) and support treatment with dexamethasone and heparin. The subject had a fever, headache, and global hypoventilation; also adventitious sounds were observed: bibasilar crackles. The subject started receiving nebulizations with AHI solution every 6 h on Aug. 26, 2021.
On Aug. 31, 2021 the subject started receiving a nebulization treatment with 3 mL of Ibu-Arg solution every 6 h and the PO2 reached 94%. Six hours after nebulization, PO2 was 91%.
The subject continued this treatment and was discharged on Sep. 6, 2021 with PO2=97%, RF=17, and CF=74. No presence of adventitious or “added” sounds were observed at this point.
The subject started receiving nebulizations with AHI solutions seven months ago. It improved O2 saturation from 84% to 90% and lowered oxygen requirements. The subject could not speak, not even on the phone.
On Sep. 10, 2021, the subject started receiving a nebulization treatment with 3 mL of Ibu-Arg solution every 12 h. The PO2 increased to 96% and CFq decreased to 110.
One hour after nebulization, RF was 24, CFq was 102, and PO2 was 92% (without O2 backpack). The subject did not cough. The subject can speak, subjective improvement and objective clinical improvement were observed.
Two years ago, the subject started receiving nebulizations with 5 mL of AHI solutions every 8 hs (basal state: PO2=94%, RF=20, CFq=72, BP=140/80). Since then, the subject never required hospital admission again. The subject had only one episode of pneumonia that was overcome with antibiotic therapy. The subject manifests having continuous white secretions.
On Sep. 10, 2021, the subject started receiving a nebulization treatment with 5 mL of Ibu-Arg solution every 8 h. During nebulization, the PO2 reaches values of 95-97% and CFq was 71. The nebulization was briefly interrupted to expectorate.
One hour after nebulization the PO2 was 96% and CFq was 71. Clinical improvement is observed.
The subject continued this treatment and was discharged on Sep. 25, 2021.
Eight months ago, the subject started receiving nebulizations with 3 mL of AHI solutions every 12 hs (basal state: PO2=94%, RF=18, CFq=77, BP=125/70). This treatment allowed to reduce the dose of seretide.
On Sep. 10, 2021, the subject received a nebulization treatment with 3 mL of Ibu-Arg solution. During nebulization, the PO2 reached 99% and CFq was 75. The subject had no coughing spells.
One hour after nebulization the PO2 was 98% and CFq was 68. Great clinical improvement was observed.
One year ago, the subject started receiving nebulizations with 3 mL of AHI solutions every 8 hs (basal state: PO2=90-92%, RF=24, CFq=76, BP=150/90). The subject noticed that the treatment made him dizzy, but improved oxygen saturation.
On Sep. 11, 2021, the subject received a nebulization treatment with 3 mL of Ibu-Arg solution. During nebulization the PO2 increased to 96-97%, RF was 23, CFq was 72, and BP was 150/90. The treatment was well tolerated.
One hour after nebulization the PO2 was 98%, RF was 21, CFq was 70, and BP was 130/80. No adverse effects were observed, and the subject was visibly excited.
Nine months ago, the subject started receiving nebulizations with AHI solutions (basal state: PO2=94%, RF=21, CFq=74, BP=120/80). It reduced wheezing, could talk, reduced dyspnea on exertion, and coughing. Improves sleep quality, (she could not sleep on her back). The treatment allowed to decrease the dose of neumoterol. The subject still presented bronchospasms, wheezing, and cough.
On Sep. 11, 2021 the subject received a nebulization treatment with 3 mL of Ibu-Arg solution. During nebulization the PO2 reached 99%, RF was 12, and CFq was 71. The treatment improved expiration and reduced itching.
One hour after nebulization the PO2 was still at 99%, RF was 13, CFq was 71, and BP was 100/60. Subjective improvement and objective clinical improvement.
Walking test: PO2 at rest was 96%-2 min: bronchospasm with basal wheezing PO2=94%. After rest and recovery, PO2 was 96%.
Post nebulization the subject climbed the stairs for the first time in many years, presenting an O2 saturation of 97%.
In addition, subject 9 was subjected to spirometry tests prior to nebulization and 60 minutes after nebulization with Ibu-Arg solution. The results of these tests are exhibited in
The next week begins with post-COVID dyspnea and nebulizations. The subject is a sportswoman (biking, trekking, Crossfit).
Pathological personal history: cholecystectomy and hysterectomy surgeries. Post-COVID insulin-dependent diabetes. Previously suffered from type 2 diabetes (+). HBP (+).
Treatment: sertraline, topiramate (to treat dysthymia).
Toxic background: tobacco (−); alcohol (−); drugs (−).
Three months ago the subject started receiving nebulizations with 5 mL of AHI solutions every 8 h (basal state: PO2=92-93%, RF=24, CFq=85, BP=120/90). The subject suffered from dyspnea.
On Sep. 11, 2021 the subject received a nebulization treatment with 3 mL of Ibu-Arg solution. During nebulization the PO2 was 98-99%, RF was 18, and CFq was 80. The subject was less agitated.
Four hours after nebulization the PO2 was still at 98-99%, RF was 17, CFq was 82, and BP was 110/70. The subject is not agitated and mentions that can breathe through the nose. Notable clinical improvement. The subject could climb up and down stairs.
with the favorite formulation of the present invention on the O2 saturation, heart rate, respiratory rate, and blood pressure in a subject with Bronchial Asthma.
Basal state: PO2=95%, RF=17, CFq=71, and BP=165/100. The subject suffered from Dyspnea.
The subject received a nebulization treatment with 3 ml of 100 mM arginine solution at pH 7. PO2 remained at 95%, RF=19, CFq=63, and BP=160/100. No changes were observed after 2 h.
Later, the subject received a nebulization treatment with 3 ml of 100 mM arginine solution at pH 8.5. Once again PO2 remained at 95% and no changes were observed after 2 h.
Finally, the subject received nebulization treatment with 3 ml of Ibu-Arg solution at pH 8.5. Immediately after nebulization: PO2=100%, RF=18, CFq=67. Six hours after nebulization: PO2=100%, RF=18, CFq=68. and BP=150/100. Eight hours after nebulization: PO2 was still at 100%.
Basal state: PO2=93%, RF=20, CFq=78, and BP=135/74. The subject suffered from dyspnea on exertion. Some isolated rhonchi were also detected.
The subject received a nebulization treatment with 3 ml of 100 mM arginine solution at pH 7. PO2 remained at 93-94%, RF=20, CFq=70, and BP=133/75. No clinical changes were observed after 2 h.
Then, the subject received a nebulization treatment with 3 ml of 100 mM arginine solution at pH 8.5. The PO2 increased from 94 to 98% for 30 seconds and fell rapidly (decreased to 93% at the end of nebulization). RF=21, CFq=66.
Later, the subject received nebulization treatment with 3 ml of Ibu-Arg solution at pH 8. Immediately after nebulization: PO2=97%, RF=19, CFq=65, and BP=134/75. Six hours after nebulization: PO2=96%, RF=20, CFq=69, and BP=132/73.
Note: In this case, the amount of Na2CO3 added to the Ibu-Arg solution described in Example 2 was reduced so the final pH of the solution was 8.
Finally, the subject received nebulization treatment with 3 ml of Ibu-Arg solution at pH 8.5. Immediately after nebulization: PO2=96%, and CFq=64. Six hours after nebulization: PO2=96%, RF=24, CFq=78, and BP=135/75. Eight hours after nebulization PO2 was 95-98%, RF=17, CFq=75, and BP=130/70.
Basal state: PO2=88-93%, RF=25, CFq=84, and BP=157/95. Observations: bibasilar crackles.
The subject received a nebulization treatment with 3 ml of 100 mM arginine solution at pH 7. PO2 remained at 92-93%. No changes were observed.
Then, the subject received a nebulization treatment with 3 ml of 100 mM arginine solution at pH 8.5. After 5 min, the PO2 increased from 94% to 98% and decreased to 93% at the end of nebulization.
Later, the subject received nebulization treatment with 3 ml of Ibu-Arg solution at pH 8.5. Immediately after nebulization: PO2 increased from 93% to 98-100%, RF=24, CFq=85, and BP=130/87. Six hours after nebulization: PO2=97%, RF=21, CFq=89, and BP=134/88. Eight hours after nebulization: PO2=94%, RF=22, CFq=82, and BP=134/90.
Finally, the subject received nebulization treatment with 3 ml of Ibu-Arg solution at pH 9. Immediately after nebulization: PO2=99%, RF=23, CFq=83, and BP=132/89. Six hours after nebulization: PO2=96%, RF=22, CFq=80, and BP=133/89.
Note: In this case, the amount of Na2CO3 added to the favorite Ibu-Arg solution described in Example 2 was increased so the final pH of the solution was 9.
Three subjects suffering from bilateral pneumonia by SARS-COV-2, PCR (+), were treated. First, they were nebulized with AHI solution every 8 h for 48 hours, then the response was measured through changes in pulse oximetry. Subsequently, they were nebulized with Ibu-Arg solutions with different arginine concentrations. These solutions were prepared by varying the amount of arginine hydrochloride added to the formulation described in Example 2. Again at the end of nebulization, the response was measured through changes in pulse oximetry.
The mechanism of oxidative stress, which has been widely recognized as a key factor in the genesis and development of various lung diseases, is inhibited by the formulation of the present invention. To measure the synergistic effect of the ibuprofen-arginine combination on oxidative stress and determine its synergy ranges, the inhibitory effect of reactive oxygen species in living cells stimulated by LPS that have been exposed to the formulation was studied, thus correlating the reduction of ROS with the therapeutic effect of the formulation of the present invention.
The selected method measures the fluorescence of DHE generated from its interaction with superoxide anion (O2−) to determine the inhibitory effect of the different formulations on the generation of O2− in murine macrophages that have been stimulated with LPS. This method has been selected because, as Chen et al. [Chen, J., et al. (2013). Analysis of kinetics of dihydroethidium fluorescence with superoxide using xanthine oxidase and hypoxanthine assay. Annals of Biomedical Engineering, 41 (2), 327-337. https://doi.org/10.1007/s10439-012-0653-x], can be used to detect O2− concentration without interference from pathways in the cellular system and is useful for determining cumulative O2− concentrations and for predict damage to cellular systems.
The commercial cell line RAW 264.7 (murine macrophages) of passage number between 20-30 was used. Sixty thousand cells per well of a 96-well plate were seeded and incubated overnight with DMEM/F12 growth medium (Gibco) supplemented with 0.1% fetal bovine serum (Internegocios) and antibiotic/antimycotic mixture. The next morning, the growth medium was removed, the cells were washed with phosphate buffer (PBS) and incubated for 30 min at 37° C. with dihydroethidium fluorescent dye (DHE; Invitrogen) at a final concentration of 5 M in PBS. After this incubation, the cells were washed and incubated for one hour with the solutions to be tested: Ibuprofen (10, 50, 100 μM), Arginine (5-100 μM; SIGMA) and their combinations, all prepared in PBS solution. Ibuprofen in PBS solutions were obtained by dilution of the formulation described in Example 1 and arginine in PBS solutions were prepared with arginine hydrochloride. Apocynin (50 μM; SIGMA), an uncoupling agent of NAD(P)H oxidase, an inhibitor of superoxide anion production, was included as a control.
After this incubation, basal fluorescence was measured on a Fluoroskan Ascent plate reader, Labsystems using λex=485 nm and λem=538 nm. LPS (25 μg/mL: SIGMA) was immediately added to each well, leaving unstimulated controls, and incubated at 37° C. for 60 minutes. The fluorescence of the plate was then re-recorded using the same filter as in the basal condition.
For the analysis of the results, the value corresponding to the basal fluorescence for each well was subtracted from each final time value.
Statistical analysis was performed using GraphPad Prism 6.0 software. A p-value <0.05 was considered statistically significant. One-way ANOVA followed by Tukey's multiple comparisons post-test was performed. Data represent the mean±standard error of the mean (SEM) of two independent experiments.
Murine macrophages were stimulated with LPS (25 μM/mL) and treated with arginine 50 μM alone or with different concentrations of alkaline hypertonic ibuprofen (10, 50, and 100 μM) in PBS saline solution. The cells were loaded with dihydroethidium (DHE) for 30 min at 37° C. and after 60 min of stimulation, normalized fluorescence was determined with the basal reading.
As it can be observed from
Murine macrophages were stimulated with LPS (25 μM/mL) and treated with alkaline hypertonic Ibuprofen 10 μM alone or combined with different concentrations of arginine (5, 10, 20, 50, 65, 85 and 100 μM) in PBS saline solution. The cells were loaded with dihydroethidium (DHE) for 30 min at 37° C. and after 60 min of stimulation, normalized fluorescence was determined with the basal reading.
As It can be concluded from
Examples 16 and 17 clearly demonstrate that the formulation of the present invention presents a new synergistic effect reducing the concentration of ROS in living cells. However, it only happens when arginine is in a solution together with the ibuprofen molecule and in a certain concentration range.
| Filing Document | Filing Date | Country | Kind |
|---|---|---|---|
| PCT/IB2022/061638 | 12/1/2022 | WO |
| Number | Date | Country | |
|---|---|---|---|
| 63284909 | Dec 2021 | US |
