Patent Application
20120015939
The invention is directed to the treatment of pain associated with diseases of the nervous system, including length dependent and other neuropathies, and painful diabetic neuropathy such as may result from diabetes and other conditions.
A variety of diseases can affect the peripheral nervous system. Many of these disorders are not painful, but if the pain signaling system is affected, then pain may result. One of the prototype painful neuropathies stems from diabetes. One of the most common effects on the nervous system is a length dependent neuropathy. This means that the longer the sensory axon the more likely the axon may be affected. Given that the axons that go to the feet are the longest primary afferents in the body, these fibers are affected first. As the disease progresses, other axons shorter in length are affected. The length dependent neuropathies may be caused by a variety of diseases. The most common (60-70%) is diabetes. These neuropathies may also be caused by a large variety of disorders and include kidney disease, hormonal imbalances, vitamin deficiencies, alcoholism, autoimmune disorders, toxins, chemotherapy, and infections (e.g., AIDS). These are not sympathetically maintained pain.
Other neuropathies are not length dependent and may be associated with etiologies such as herpes zoster infection (shingles and post-herpetic neuropathy), nerve trauma, and nerve compression. Complex regional pain syndrome (CRPS) is a poorly understood disorder that has many of the features of neuropathic pain. This disorder may be associated with a frank lesion of the nervous system (Type II) or not (Type I). Though a specific nerve lesion may not be obvious in Type I CRPS, it is strongly suspected that an underlying neuropathic disorder underlies the genesis of this problem. Oral drugs such as amitriptyline, duloxetine, gabapentin and pregabalin are recommended as first-line treatment options for treatment of neuropathic pain on the basis of the results of randomized clinical trials.
As knowledge about neuropathy and pain increases it is evident that different pathophysiological mechanisms are at play. Some are peculiar to the specific form of neuropathic pain, but others are shared across the various neuropathic pain disorders. Thus, in the case of different treatments, such as with oral gabapentin, some patients respond well and many others do not across the broad spectrum of neuropathic disorders. Heretofore, it has not been clear why one patient responds and the other does not. The clinician is forced to undertake an empiric trial of the drug to determine whether the drug will work. This is clearly suboptimal and leads to suffering and delay in finding efficacious treatment.
As a specific example, painful diabetic neuropathy (PDN) is more accurately considered to be a collection of diseases. This is logical given the protean manifestations of diabetic neuropathy and for that matter the other 'opathies of diabetes as well (retinopathy, nephropathy, vasculopathy, etc). A simple conception of PDN is illustrated in
Pain often develops from diseases that affect the somatosensory system. One disease that is often implicated is diabetes mellitus. Diabetes may affect the nervous system in different ways but one of the classical disorders is a length dependent neuropathy. Here the longer sensory nerve fibers are preferentially involved in a neuropathy which is associated with both degeneration and a sensitization of nociceptors. The classic feature is burning pain typically involving the feet since the axons to the feet represent the longest primary afferents in the body. This problem may occur early or late in the disease, as well as in so-called pre-diabetes which is a condition representing a disorder of glucose metabolism without strictly meeting the criteria for diabetes mellitus. It is appreciated that diabetes is but one cause of a length dependent neuropathy. For example, it is clear that chemotherapy used to treat cancer can also induce a length dependent neuropathy. The painful symptoms that accompany these disorders, including an idiopathic small fiber neuropathy, are nearly identical with that seen in diabetes mellitus. Treatments directed at the diabetes mellitus itself may help slow the progression of the neuropathy but do not necessarily address the pain. There are no known treatments for idiopathic length dependent small fiber neuropathy. Certain chemotherapeutic drugs induce a length dependent neuropathy associated with pain. This pain may limit dosing and thus affect the adequacy of the cancer treatment.
Clearly there is a great need to have therapies that address the pain symptoms. Systemic treatments of pain include use of opioids, anticonvulsants, antidepressants, and membrane stabilizers. These therapies suffer from two drawbacks: they may relieve the pain inadequately and they may be poorly tolerated due to side effects. Systemic therapies can be given orally or by patches applied to the skin.
Some prior attempts have been made to treat painful diabetic neuropathy with clonidine, a potent alpha2-adrenergic partial agonist used primarily for the treatment of hypertension. Clonidine has been applied topically to areas remote to the painful area as an alternative to oral delivery for effecting systemic delivery. For example, in a placebo-controlled cross-over pain trial in patients with painful diabetic neuropathy, no statistically significant difference between patients receiving systemic clonidine administered with transdermal patches and patients receiving placebo patches was observed (Zeigler et al. Pain 48:403-408 (1992)). In a follow-up placebo controlled pain study in similar patients with painful diabetic neuropathy, transdermal patches delivering systemic levels of clonidine were evaluated using a two-stage enriched enrollment design (Byas-Smith et al. Pain 60: 267-274 (1995)). Twelve of forty-one patients (29%) who completed the initial course of treatment were considered clonidine responders. These twelve clonidine responders were then rechallenged in a second placebo controlled study which used the highest dosage available with the transdermal patch system. The pain reduction relative to placebo tended to be modest although statistically significant (p<0.015). The site of action of clonidine was not determined in this study. In principal the site of action could be central or peripheral. In other pain conditions a central analgesic action of clonidine has been determined. It is important to emphasize that this treatment involved systemic delivery of clonidine with a transdermal patch applied remotely to the painful area which is expected to result in systemic blood levels exceeding 0.2 ng/ml. Other therapies with oral medications have been shown to be effective to treat neuropathic pain. These include gabapentin, pregabalin, and duloxetine.
Each of these therapies work only in certain patients. Moreover, systemic side effects may make these therapies of limited value. Dosing was limited because of the systemic delivery of the clonidine.
Other than an empiric trial of simply looking to see if a given patient responds to the treatment, no technique has been provided to identify the responsive patients. Moreover, none of the existing therapies has any means evolved to determine who will respond to what treatment. This is frustrating because it may take months of trial and error to determine the best treatment for a given patient.
A further issue is that there is still only a rudimentary understanding about how and why neuropathic pain occurs. For example, with diabetes of similar severity some patients develop neuropathy and others do not. In some cases the neuropathy is dominated by motor findings and in others sensory systems are affected primarily. As well, some patients have small fiber sensory neuropathy while others have large fiber neuropathy (tactile sense, loss of vibratory sense, and proprioception). Finally pain may be the dominant symptom of the neuropathy where in others there is no pain at all. Therefore it is clear that neuropathy is not a “monolithic” disease state but instead refers to a collection of diseases. The ability to distinguish these different diseases is logically linked to different responses to therapy.
Heretofore, the treatment of neuropathic pain, including PDN, is largely empiric. The clinician tries the drug and if it works the treatment is continued.
It is therefore an object of the present invention to provide methods and compositions to effectively treat or alleviate pain in length dependent or other neuropathies, as may be associated with diabetes, by topical local delivery to the painful area of an alpha-2 adrenergic agonist, and to provide a means of diagnosis and selection of patients who are responders to such treatment.
Alpha-2 adrenergic agonists such as clonidine may be used to treat the pain associated with painful diabetic neuropathy (PDN) and other neuropathies only in a subset of these patients. In one group nociceptors are expressed functionally in the skin and are likely sensitized. This group responds to topical clonidine with significant relief because the targeted alpha-2 adrenergic receptor is expressed in the skin in the nociceptors, activity in which generates the patient's pain. Many patients with PDN have severe degeneration and the targeted nociceptors are not expressed in the skin. The presence of the targeted nociceptors may be determined by topical application of a TRPV1 agonist such as capsaicin which induces a sensation of burning pain. Patients who detect the capsaicin as a painful stimulus applied in the area at or near the painful area have expression in the skin of the requisite targeted nociceptors and the targeted alpha-2 adrenergic receptors. The test is referred to as a capsaicin challenge test. Responders can be treated for pain due to length dependent or other neuropathy by local or topical delivery of concentrations of compounds that are agonists of the alpha-2 adrenergic receptors, especially an alpha2 adrenergic agonist such as clonidine, to the painful area, without producing systemic levels as appropriate for treating disorders such as hypertension.
Alpha-2 adrenergic agonists such as clonidine may be used to treat the pain associated with painful diabetic neuropathy (PDN) and other neuropathies only in a subset of these patients. In one group nociceptors are expressed functionally in the skin and are likely sensitized. This group responds to topical clonidine with significant relief because the targeted alpha-2 adrenergic receptor is expressed in the skin in the nociceptors, activity in which generates the patient's pain. Many patients with PDN have severe degeneration and the targeted nociceptors are not expressed in the skin. The patients still have pain but the pain signaling has moved to proximal levels of the neural axis. If the pain signals are along the nerve, in the dorsal root ganglion, or the central nervous system, then a topical therapy designed to reach the skin is not likely to impact on the patient's pain. It is therefore desirable to have a means to identify the patients that have functional nociceptors in the skin, activity in which is causing at least a portion of the patient's pain. The response to topical clonidine of patients with pain from neuropathy in whom there is severe degeneration does not differ statistically from that seen with placebo. Targeted nociceptors (pain fibers) must be functionally expressed and likely sensitized in the skin in order for clonidine to have a therapeutic effect.
Alpha-2 adrenergic agonists such as clonidine may be used to treat the pain associated with painful diabetic neuropathy (PDN) and other neuropathies only in a subset of these patients. In one group nociceptors are expressed functionally in the skin and are likely sensitized. This group responds to topical clonidine with significant relief because the targeted alpha-2 adrenergic receptor is expressed in the skin in the nociceptors, activity in which generates the patient's pain. Many patients with PDN have severe degeneration and the targeted nociceptors are not expressed in the skin. The presence of the targeted nociceptors may be determined by topical application of a TRPV1 agonist such as capsaicin which induces a sensation of burning pain. Patients who detect the capsaicin as a painful stimulus applied in the area at or near the painful area have expression in the skin of the requisite targeted nociceptors and the targeted alpha-2 adrenergic receptors. The test is referred to as a capsaicin challenge test. The test is based on the understanding that abnormal signaling arises from functional nociceptors in the skin. If there is advanced degeneration in the cutaneous nociceptive afferents, topical capsaicin will evoke little to no pain, as illustrated in
Responders can be treated for pain due to length dependent or other neuropathy by local or topical delivery of concentrations of compounds that are agonists of the alpha-2 adrenergic receptors, especially an alpha2 adrenergic agonist such as clonidine, to the painful area, without producing systemic levels as appropriate for treating disorders such as hypertension. The compounds are delivered to or adjacent to painful areas in patients who have functional/sensitized nociceptors in the skin. In a patient with painful diabetic neuropathy where the complaint is burning pain in the feet, the alpha-2 agonist is topically applied to the feet in the painful region. A preferred formulation for the treatment of patients with painful diabetic neuropathy with expression of functional nociceptors in the targeted region is clonidine applied in an ointment, gel, lotion, spray, or transdermal patch, wherein the dosage is sufficient to provide an effective dose in the painful area or immediately adjacent areas, preferably without producing pharmacologically active systemic blood levels.
The presence of the targeted nociceptors may be determined by topical application of a TRPV1 agonist such as capsaicin, preferably Resiniferatoxin, which induces a sensation of burning pain. Patients who detect the capsaicin as a painful stimulus applied in the area at or near the painful area have expression in the skin of the requisite targeted nociceptors and the targeted alpha-2 adrenergic receptors. The test is referred to as a capsaicin challenge test. The test is based on the understanding that abnormal signaling arises from functional nociceptors in the skin. If there is advanced degeneration in the cutaneous nociceptive afferents, topical capsaicin will evoke little to no pain, as illustrated in
In an alternative embodiment, the presence of nociceptors is determined with application of heat, electrical, cooling or cold pain, noxious chemical, monofilament, or mechanical stimuli to the skin.
This test has been used to determine that there are two subtypes of patients with neuropathic pain. The response to topical clonidine as a therapy depends on the status of this nociceptor innervation as determined with the topical capsaicin challenge test (
It has not previously been known that these two subgroups exist, and that there is a way to distinguish the two groups in a clinically useful manner. A method to identify clinical criteria to identify patients who would respond well to this therapy and thus provide clinicians with the means for the rational use of ARC-4558 in PDN patients was developed in the course of developing a topical treatment for PDN, topical clonidine gel (ARC-4558). Topical capsaicin is an ideal way to identify the appropriate patients for treatment. Capsaicin induces a burning pain sensation when applied to the skin in normal subjects. If the subject does not feel capsaicin then the functionality of the nociceptor is in question.
In a Phase IIb, multicenter, randomized, double-blinded, placebo-controlled, parallel-group study of ARC-4558 for the treatment of pain associated with PDN, 179 subjects were randomly assigned in a 1:1 ratio to receive 12 weeks of one of two treatments: clonidine 0.1% gel or placebo gel.
Capsaicin is an example of a TRPV1 agonist that activates nociceptors and induces a burning pain sensation. This is a commonly known property as capsaicin accounts for the burning pain sensation in the mouth when hot peppers are eaten. Capsaicin 0.1% was applied to the pretibial area between the knee and ankle in each patient. The area was occluded for 30 minutes, at which time patients rated the painfulness of the capsaicin stimulus. It was reasoned that in patients with PDN that the afferented group would detect and rate the capsaicin stimulus as painful, while the deafferented group would fail to detect the stimulus.
Histological techniques can also be used to measure the amount of deafferentation by application of TRPV1 agonist at or near the painful site.
The validity of capsaicin as a test of nociceptor function is evident in the study of the skin biopsy data (
It was discovered that the response to topical capsaicin challenge was a predictive indicator of the reduction in pain resulting from treatment with ARC-4558 (topical clonidine).
Capsaicin is the pungent ingredient in chili peppers. It is a highly selective agonist for transient receptor potential vanilloid 1 receptor (TRPV1; formerly known as vanilloid receptor 1 (VR1)), a ligand-gated, non-selective cation channel preferentially expressed on small-diameter sensory neurons, especially those C-fibers which specialize in the detection of painful or noxious sensations. TRPV1 responds to noxious stimuli including capsaicin, heat, and extracellular acidification, and will integrate simultaneous exposures to these stimuli. (See: Caterina et al. Annu Rev Neurosci. 2001. 24:487-517). The initial effects of the activation of TRPV1-expressing (capsaicin-sensitive) nociceptors are burning sensations, hyperalgesia, allodynia, and erythema. Analogs of capsaicin with similar physiological properties are known. For example, resiniferatoxin is described as a capsaicin analog by U.S. Pat. Nos. 5,290,816, 4,812,446, and 4,424,205. Ton et al., British Journal of Pharmacology, 10, 175-182 (1955) discuss pharmacological actions of capsaicin and its analogs. In another embodiment, the TRPV1 agonist is specific for TRPA1 receptors. Examples include cinnamaldehyde and allyl isothiocyanate.
The presence, function and/or role of cutaneous generators of the pain in the skin can also be determined by local administration of anesthesia to the skin. In a preferred embodiment, the anesthetic is a local anesthetic such as lidocaine.
The TRV1 agonist or anesthetic can be applied as a solution, ointment, gel, cream, spray or in a device such as a Finn chamber, transdermal patch or wound dressing such as a bandaid.
The method of treating or reducing the symptoms (i.e. burning, pain) associated with length dependent neuropathies includes locally or topically administering an effective amount of an alpha2-adrenergic agonist or combination thereof. Alpha2-adrenergic agonists are known to those skilled in the art. See, for example, The Pharmacological Basis of Therapeutics, 8th Edition, Gill, A. G., T. W. Rall, A. S. Nies, P. Taylor, editors (Pergamon Press, Co., Inc., NY 1990).
Agents with alpha-2 adrenoreceptor agonist activity are represented by Formula I:
wherein A4 may be selected from aryl, and heteroaryl, which may be substituted by one or more radicals selected from alkyl, branched alkyl, cycloalkyl, hydroxyl, alkoxy, cycloalkylalkyl, alkoxyalkyl, aryl, alkanoyl, alkoxycarbonyl, carboxyl, amino, cyano, halogen, thioalkyl, dialkylamino, arylamino, alkylsulfinyl, alkylsulfonyl, arylsulfinyl or arylsulfonyl; wherein X is selected from thio, imino, or methylene; wherein R7 is selected from hydrogen, lower alkyl, or oxygen-containing heterocycle; and wherein n is either 2 or 3; or a pharmaceutically acceptable salt thereof.
A preferred class of compounds of Formula I consists of those compounds wherein A4 is phenyl; wherein A4 is substituted phenyl, on which positions 2 and 6 of the phenyl ring may be independently substituted by a radical selected from hydrogen, chloro, methyl, ethyl, or cycloalkyl, and positions 3, 4, and 5 may be independently substituted by a radical selected from hydrogen, methyl, trifluoromethyl, fluoro, or cyano; wherein A4 is 3-thienyl, on which positions 2 and 4 are independently substituted by a radical selected from hydrogen, chloro, methyl, ethyl, or cycloalkyl; wherein A4 is 1-naphthyl, 5,6,7,8-tetrahydronaphthyl-1-yl, pyrrolyl, oxazolyl, isoxazolyl, indol-3-yl, indazol-3-yl, quinolinyl, quinazolinyl, quinoxazolinyl, benzoxazolyl, and benzothiophen-3-yl; wherein A4 is pyrimidin-4-yl, on which positions 3 and 5 are independently substituted by hydrogen, chloro, methyl, ethyl, cycloalkyl, or methoxy; wherein R7 is either hydrogen or tetrahydropyran-2-yl; wherein X is thio or imino; and wherein n is 2.
An especially preferred class of compounds of Formula I consists of compounds wherein A4 is selected from phenyl, 2,6-dichlorophenyl, 2,6-dimethylphenyl, 2,6-diethylphenyl, 3,4-dihydroxyphenyl, 3-fluoro-6-methylphenyl, 2-chloro-5-trifluoromethylphenyl, 2-chloro-4-methylphenyl, 3-chloro-4-methylthien-3-yl, 5,6,7,8-tetrahydronaphth-1-yl, and 4-chloro-5-methoxy-2-methylpyrimidin-4-yl; wherein R7 is hydrogen or tetrahydropyran-2-yl; wherein X is thio or imino; and wherein n is 2.
A specifically preferred class of compounds of Formula I consists of xylazine, flutonidine, moxonidine, tramazoline, tolonidine, piclonidine, tiamenidine, and clonidine.
Topical administration is described for treatment of sympathetically maintained pain in U.S. Pat. No. 5,447,947 issued Sep. 5, 1995 to Campbell, and in U.S. Pat. No. 6,534,048 issued Mar. 18, 2003 to Borgman and U.S. Pat. No. 6,147,102 issued Nov. 15, 2000 to Borgman.
In the method described herein, the compounds are administered locally or topically directly to or adjacent the painful area, in a suitable pharmaceutical carrier, many of which are known to those skilled in the art. The carrier can be in the form of a lotion, ointment, gel, solution, or transdermal patch, or a topical spray. The topical application allows the drug to reach high concentration at the painful area or tissue immediately adjacent thereto, avoiding many of the side effects of these compounds observed following systemic administration.
Formulation of drugs is discussed in, for example, Hoover, John E., Remington's Pharmaceutical Sciences, Mack Publishing Co., Easton, Pa. (1975), and Liberman, H. A. and Lachman, L., Eds., Pharmaceutical Dosage Forms, Marcel Decker, New York, N.Y. (1980). Pharmaceutical compositions may be formulated in conventional manner using one or more physiologically acceptable carriers comprising excipients and auxiliaries which facilitate processing of the active compounds into preparations which can be used pharmaceutically.
The preferred embodiment of the formulation consists of:
Clonidine hydrochloride USP 0.1%
Benzyl alcohol NF 1.0%
Carbopol 980 NF 0.6%
Sodium hydroxide NF adjust to pH 8
Hydrochloric acid NF adjust to pH 8 (if necessary)
Purified water USP qs ad 100%
Patients may be screened with the capsaicin test. Patients who report pain to the capsaicin test will have an excellent chance of responding favorably to the topical alpha-2 adrenergic agonist treatment.
The method of treating or reducing the symptoms (i.e. burning, pain) associated with neuropathies includes locally or topically administering an effective amount of an alpha2-adrenergic agonist to the painful site. This screening clarifies the group of patient that will respond to this therapy. The therapy is not effective in all patients with PDN, but rather only works when it is applied to the patients that have innervations.
The dosage formulation is administered from once a day to several times a day, depending on the patient. In one embodiment, the therapeutic agent is clonidine administered in a concentration between 0.05 and 10% clonidine. The dose is determined by the region of pain. Because the effect of the clonidine is local it must be applied to the painful area. Thus in patients with broader areas of pain a higher dose of clonidine will be necessary though the percent concentration remains constant. The area treated is constrained by the systemic dosing. In the study done with 0.1% and 0.2% clonidine, the mean blood level was well below 0.1 ng/mg (one third of patients had no detectable clonidine in the blood), whereas the blood levels exceed 0.2 ng/ml with systemic delivery.
In study CLO-027, blood samples for PK analysis were obtained at baseline, and at Weeks 2 and 12 of treatment. The blood levels of clonidine were below the limit of detection in more than 75% of the subjects at both weeks 2 and weeks 12 (limit of detection for the clonidine assay was 0.010 ng/mL). The mean blood level at two weeks was 0.017 ng/mL (n=83; SD 0.024). Excluding one outlier, the mean level at week 12 was 0.019 ng/mL (n=79; SD 0.038). Thus the 2 and 12 week PK levels were nearly identical and several standard deviations below the lower threshold value considered necessary to treat hypertension (0.200 ng/ml).
Unless defined otherwise, all technical and scientific terms used herein have the same meanings as commonly understood by one of skill in the art to which the disclosed invention belongs. Although any methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, the preferred methods devices, and materials are as described. Those skilled in the art will recognize or be able to ascertain using no more than routine experimentation many equivalents to the specific embodiments of the invention described herein. Such equivalents are intended to be encompassed by the following claims.
This application claims priority under 35 U.S.C. 119 to U.S. Ser. No. 61/365,656 “Topical Treatment of Neuropathic Pain and Methods of Diagnosis” filed Jul. 19, 2010 by James N. Campbell.
| Number | Date | Country | |
|---|---|---|---|
| 61365656 | Jul 2010 | US |
