Patent Application
20060024271
This invention relates to treatments for viral infections.
Routine vaccinations for smallpox were discontinued in the United States in 1972, and the last documented naturally occurring case of smallpox was recorded in Somalia in 1977. In 1980, the World Health Assembly declared smallpox eradicated (Henderson et al., 1999). It recommended that all routine smallpox vaccinations be suspended on a global scale and mandated that reference samples be retained only in two locations, the United States and the former USSR. All other smallpox stocks were to be destroyed.
Despite its supposed limited availability, smallpox, and other viruses, such as monkeypox, are potential biological weapons of mass destruction. Currently, vaccination is the only preventive and early prophylactic measure available for these diseases.
Vaccination is effective for pre- and post-exposure prophylaxis against smallpox. For post-exposure prophylaxis, though, the vaccine must be administered within four days of exposure (Henderson et al., 1999). Additionally, post-vaccination complications have been reported in 14 to 52 people per million, and one or two of these people may die from the vaccine. Those with deficient immune systems appear to be especially at risk. Complications include eczema vaccinatum, generalized vaccinia, ocular vaccinia, and progressive vaccinia. Complications of vaccination may be treated by administering vaccinia immune globin (VIG) obtained from vaccinated people (Henderson et al., 1999), although this reagent is in short supply and may present safety concerns, such as contamination with other viruses.
Current solutions to the problems that prevention and prophylaxis of viral biological weapons present could include: (1) the production of large stockpiles of current vaccine and VIG stocks; (2) the development of less virulent new vaccines; (3) the development of rapid diagnostic tools for smallpox; and (4) rapid screening and testing of licensed drugs.
Cidofovir, a viral DNA polymerase inhibitor licensed for the treatment of cytomegalovirus infections in AIDS patients, is being tested for use in the treatment of smallpox and post-vaccination complications (Smee and Sidwell, 2003). It has been shown to protect mice against lethal cowpox challenge (Martinez et al., 2000).
While the efficacy of intravenous administration of compounds against poxviral infections is based on mouse and primate studies, Cidofovir has some limitations for biodefense use. First, it is currently available in only intravenous injection form and oral administration has proven difficult. Thus, rapid self-administration of large civilian and military populations may not be possible. Second, severe side effects, including kidney damage, have been reported. Third, Cidofovir failed to completely protect immune deficient animals against lethal poxvirus infection in mice. Finally, Cidofovir-resistant poxviruses have been isolated in the laboratory. Taken together, these complications suggest that there is still a need for alternative drugs to meet the challenge of defending against viral biological weapons, including smallpox and monkeypox.
IFN-γ Human interferon-γ (IFN-γ) (available as ACTIMMUNE®, from InterMune, Brisbane, Calif.) is currently used to reduce the frequency and severity of serious infections associated with chronic granulomatous disease, a genetic disorder of the immune system that makes patients vulnerable to bacterial and fungal infections (Sechier et al., 1988).
INF-γ is a potent antiviral and immunomodulatory cytokine produced primarily by NK and T cells. IFN-γ has been demonstrated to be effective against experimental infections of several viruses including MCMV, RVFV, and poxviruses (Fennie et al., 1988; Morrill et al, 1991; Liu et al., 2004). Mice lacking IFN-γ receptors have been shown to be susceptible to poxvirus infection (Huang et al., 1993). In addition, depletion of IFN-γ with antibodies has been shown to allow more rapid virus dissemination (Karupiah et al., 1993), and recombinant vaccinia viruses expressing IFN-γ are greatly attenuated in immunodefficient mice (Kohonen-Corish et al., 1990). Finally, IFN-γ is capable of inducing nitric oxide (NO)-mediated inhibition of vaccinia virus by macrophages (Karupiah and Harris, 1995).
Other cytokines, IFN-α/β enhance cytotoxicity of NK cells and plays an important role in triggering dendritic cell-mediated acquired immunity (Biron, 1998).
Exogenous IFN-α/β and IFN-γ play an important role in antiviral defense in the following ways (Biron, 1998; Kontsek and Kontsekova, 1997; Billiau and Vandenbroeck, 2001): (1) by inducing an antiviral state through dsRNA-dependent protein kinase (PKR) and 2′, 5′-oligoadenylate synthetase (OAS)/RNAse L pathways; (2) by enhancing the CD8+ T cell-mediated cytolysis of infected cells by up-regulating the expression of MHC I molecules; and (3) by augmenting the migration of early response inflammatory leukocytes to the site of viral infection.
When an infection occurs, the body has an initial, rapid response to it. Before specific antibodies are produced, a branch of the immune system called the “innate immune system” is activated to produce the first proinflammatory reaction. In addition, the innate system instructs the other branch of the immune system, the “adaptive system,” to begin to produce the specific responses of T-cells and B-cells and the production of antibodies. Control of the innate immune system offers many opportunities for intercepting infections in their early stages and preventing some of the most severe effects, such as septic shock.
One aspect of the innate immune system that provides protection against viruses is the action of the antiviral cytokines. IFN-α/β protect neighboring cells from being infected by the same or unrelated viruses (Biron, 1997; Konstek and Konstekova, 1997; Van den Broek, et al., 1995). Mice lacking receptors for IFN-α/β and/or for IFN-γ demonstrate reduced resistance to poxvirus infections (Biron, 1998).
In addition to their direct antiviral activities, cytokines display immunomodulatory functions (Biron, 1997; Xing, 2000). For instance, IFN-α/β, IFN-γ, IL-2, and IL-12 are potent activators of macrophages and NK cells (Karupiah et al., 1991; Ramshaw et al., 1997). Vaccination of monkeys with simultaneous administration of IFN-α/β or the IFN inducer poly(I):poly(C) induced immunity that prevented viremia and alleviated local inflammatory reactions caused by vaccination (Bektemirov, 1980).
NO is a short-lived and short-distance radical gas that can diffuse easily in the absence of specific cellular receptors and provides macrophages with cytolytic or cytotoxic activity against microbes during infection and inflammation (MacMicking et al., 1997). NO functionally inhibits enzymes requiring iron and sulfur prosthetic groups by forming nitrosyl-iron-sulfur complexes (Harris et al., 1995), and may inhibit ribonucleotide reductase, an enzyme required for viral DNA synthesis (Lepivre et al., 1991; Kwon et al., 1991). The latter has been proposed as a mechanism to explain NO-mediated inhibition of vaccinia virus (VV) replication (Karupiah and Harris, 1995; Melkova and Esteban, 1994). NO is produced by inducible NO synthase (iNOS), which catalyzes the conversion of
It has previously been shown that NO-mediated inhibition of viral replication is neither host cell nor virus specific (Harris et al., 1995), and that IFN-γ synergizes with IFN-α/β and TNF-α in NO induction. For mouse peritoneal macrophages, IFN-γ is the only agent reported to date that has been shown to effectively induce NO when tested alone (Ding et al., 1998). A recombinant vaccinia virus expressing iNOS has been found to be attenuated in vivo (Rolph et al., 1996a). It has been speculated that NO induction in macrophages is one of the important antiviral strategies in infectious loci, where neutralizing antibodies are unavailable and macrophages are able to ingest and destroy the immature virus particles, thus preventing virus dissemination (Harris et al., 1995). However, NO production may contribute to the control of vaccinia virus (VV) growth, but other antiviral mechanisms, in the absence of NO, are able to mediate virus clearance. This hypothesis is based on the observation that treatment of VV-infected mice with an iNOS inhibitor does not affect the course of infection (Rolph et al., 1996a; Rolph et al., 1996b). It remains unclear whether the NO cytotoxic effector molecule plays an important role in human macrophage antimicrobial or antitumor activities, as it is difficult to show that human monocytes produce NO following cytokine activation.
Ribavirin Ribavirin, (1-β-D-ribofuranosyl-1, 2-4-triazole-3-carboxamide) (available as COPEGUS@, Hoffmann LaRoche, Inc., Nutley, N.J.), is a broad-spectrum antiviral drug, used for the treatment of RSV and HCV infections (Sidwell, 1980), which has shown certain beneficial effects on progressive vaccinia. It is effective against a least a dozen DNA viruses and 40 RNA viruses (Markland et al., 2000). Ribavirin has been approved as an inhalable antiviral agent for the treatment of RSV infections and can be taken orally, in combination with IFN-α, for the treatment of chronic hepatitis C (HCV) infections (Smee and Sidwell, 2003). Although ribavirin cannot fight HCV on its own, studies have shown that it does help alpha interferon work better. Ribavirin has been shown to suppress W induced tail lesions in a mouse model (DeClerq et al., 1976) and to effectively treat vaccinia keratitis in rabbits (Sidwell et al., 1973). In addition, ribavirin plus anti-vaccinia globulin provided benefit to an immunosupressed patient infected with vaccinia virus (Kesson et al., 1997). Ribavirin also demonstrates synergy with VIG and IFN-α (Smee and Sidwell, 2003). Ribavirin has been shown to protect mice against a lethal infection of a moderate dose of cowpox virus (Smee et al., 2000).
Ribavirin is an inhibitor of IMP dehydrogenase, an enzyme that converts IMP to XMP. This step is crucial for the biosynthesis of GTP and dGTP, thereby inhibiting viral DNA and RNA synthesis (DeClerq, 2001). Ribavirin also inhibits the function of transcriptase or replicase of reovirus (Rankin et al., 1989) as well as the formation of 5′-mRNA cap in W (Goswami et al., 1979). The main side effects of ribavirin include anemia during prolonged treatment in HCV patients (Rizetto, 1999).
Combinations of antiviral agents with different modes of action are likely to generate more potent antiviral efficacy. Antiviral synergy between IFN-α and ribavirin, between IFN-α/β and IFN-γ, and between IFN-γ and ribavirin has been demonstrated in the studies of the hepatitis C virus (HCV) (Moradpour and Blum, 1999), herpes simplex virus 1 (HSV-1) (Sainz et al., 2002), and SARS cronavirus (Sainz et al., 2004).
There is a need in the art for new treatments for viral infections, in particular those that can be used in biological warfare.
The invention aids in fulfilling this need by providing treatments and prophylaxis for viral infections comprising the compounds IFN-α, IFN-β, and IFN-γ, either alone or in combination with each other or with ribavirin. The treatments and prophylaxis of the invention allow for lowered dosages of IFN, reduced pro-inflammatory responses, and delayed the initiation time and reduced frequency of the IFN treatment required for the optimal protection.
Like the protective effect of ribavirin against lethal infection by a moderate dose of cowpox virus in mice (Smee et al., 2000), ribavirin has now been shown to delay the death of mice infected with vaccinia (
This invention includes the finding that mice infected with vaccinia and administered only ribavirin live 2-3 days longer than untreated mice (
The invention provides that combination treatments with ribavirin and IFN-γ reduce the IFN-γ-induced pro-inflammatory responses, such as those caused by cytokine (IL-6) and chemokine (MCP-1) production, which may contribute to the pathogenesis of infected hosts. Further studies with the mouse vaccinia model will demonstrate another feature of the invention, namely the synergy between IFN-γ and ribavirin, as well as the effects of such treatment on the host immune responses in infected mice.
In an embodiment of the invention, a method of treating a patient infected with a virus is provided. The method comprises: (A) administering IFN-α, IFN-γ, IFN-α plus IFN-γ, or ribavirin plus either IFN-α or IFN-γ to the patient; and (B) alleviating the effects of the virus in the patient.
In embodiments of the invention, the effects of the virus include, but are not limited to, death, viral load, fever, pneumonia, edema, malaise, headache, backache, skin lesions, mucous membrane lesions, bleeding, and dehydration.
In an embodiment of the invention, ribavirin and IFN are administered in admixture or sequentially to the patient. In one embodiment, ribavirin is administered before IFN, while in another embodiment, IFN is administered before ribavirin.
In embodiments of the invention, INF-γ is administered to the patient at 150 μg by subcutaneous injections. This treatment can typically last for four weeks or longer. Recombinant INF-γ can also be administered to a patient at doses of 0.01 to 2.5 mg/m2 by alternating intramuscular and intravenous bolus injections with a minimum intervening period of 72 h. As known by those skilled in the art, administration of cytokines by inhalation, as provided for in the invention, will require significantly lower doses than those recited here by injection. These lower doses can reduce any adverse side effects of these cytokines.
IFN-α has been licensed to treat HCV infections. IFN-α can be administered at up to 300 million IU/m2 subcutaneously, without adverse reactions. IFN-α can typically be administered at 2-20 million IU/m2, either intravenously, intramuscularly, or subcutaneously. Treatments with INF-α at these doses can last for four weeks to six months or a year.
In other embodiments of the invention, ribavirin is administered to a patient at 880-1200 mg in two divided doses. In these embodiments, ribavirin can be administered orally, in pill form, or, preferably, it can be inhaled liposomes.
In embodiments of the invention, IFN and ribavirin are administered by other methods, including, but not limited to, intramuscularly, subcutaneously, and intravenously. In a preferred embodiment of the invention, IFN is administered intranasally to allow for self-administration (nasal spray or inhaler delivered powder) of a large number of individuals, for example, during a biological weapon attack.
In embodiments of the invention, IFN or IFN plus ribavirin are administered, sequentially or in admixture, five times daily, intranasally, and optionally, subcutaneously as well. Treatments can be continued for 3 days to 5 days. In the treatment of an existing infection, these compounds can be given one day after exposure to the virus. IFN-γ is also partly effective when the treatment is started two days after infection. In other embodiments, intranasal administration of IFN-γ can be sufficient.
The invention can be used for the treatment of smallpox, monkeypox, and smallpox vaccination related complications. The invention is also useful for the treatment of other respiratory viral infections, including, but not limited to, the common cold, SARS, and respiratory syncytial virus (RSV) infection. The invention can also be used for the treatment of other poxvirus infections including, but not limited to, molluscum contagiosum virus (MCV), which is a world wide opportunistic infection among AIDS patients.
In yet other embodiments of the invention, IFN can be purified recombinant IFN, and can be administered in liposomes, or as micro-encapsulated or pegylated compounds. Other forms that allow for stabilization in the blood are also encompassed by this invention. In a preferred embodiment, IFN-γ can be inhaled in the form of liposomes to increase bioavailability and reduce side effects associated with high dosages. Liposomal IFN-α and IFN-γ have been reported to be more effective against lung cancer and multidrug-resistant TB than native IFNs. In addition, IFNs can be conjugated to polyethylene glycol.
In another embodiment of the invention, the IFN-α, IFN-γ, or IFN plus ribavirin, are administered to achieve prophylaxis. In this embodiment, the compounds are administered sequentially or in a mixture before infection, optionally at least once before infection.
In a further embodiment of the invention, the prophylactic and therapeutic treatments of the invention can be used for individuals at some risk or even high risk for adverse effects of the smallpox vaccine currently available, including but not limited to those with deficient immune systems or suffering from eczema.
In yet other embodiments of the invention, the IFN-α, IFN-γ, IFN-γ plus ribavirin, or IFN-α plus ribavirin can be provided in a pharmaceutical composition including a pharmaceutically acceptable carrier.
A combination of IFN-α and IFN-γ or ribavirin plus either of these IFNs, are the preferred embodiments for treatment of poxvirus, including smallpox, infections.
IFNs are preferably administered intranasally as a therapeutic composition. Other routes of administration include oral, subcutaneous, intramuscular, intravenous, or intraperitoneal.
In one embodiment the composition of the invention can be used for pre-exposure prophylaxis. In another embodiment of the invention the composition is used for post-exposure treatment.
The treatments of the invention also encompass the use of IFN-β alone or in combination with ribavirin.
IFN-β can be used in doses ranging from 6MU of IFN-β, once daily intravenously, for six weeks up to 12 weeks or at 12 MU once daily subcutaneously for four weeks. Alternatively, IFN-β can be used in humans at a dose of 6 MU five times weekly for 24 weeks.
This invention will be described in greater detail in the following Examples.
Groups of five BALB/c mice were treated daily (i.n.) with the indicated amounts of ribavirin via intranasal (i.n.) or subcutaneous (s.c.) route, or with PBS (placebo) for five consecutive days. All animals were infected with 50 LD50 of VV on day 0 and were monitored 21 days for mortality. The treatments started one day after infection.
Groups of 20 BALB/c mice were treated daily (i.n.) with 5×103 U of IFN-α, IFN-γ, or PBS (placebo) for 5 consecutive days. All animals were infected with 8 LD50 of W on day 0 and were monitored 21 days for mortality. The treatments started one day before infection.
Groups of 10 BALB/c mice were treated daily (i.n.) with indicated amounts of IFN-γ (U/mouse), or PBS (placebo) for five consecutive days. All animals were infected with 50 LD50 of W on day 0 and were monitored for 21 days for mortality. The treatments started one day after infection.
Groups of five to ten BALB/c mice were treated daily (i.n.) with IFN-γ (10,000 U/mouse/day), ribavirin (50 mg/kg), with IFN-γ (10,000 U/mouse/day) and ribavirin (50 or 25 mg/kg), or PBS (placebo) for five or three consecutive days. All animals were infected with 50 LD50 of W on day 0 and were monitored for 21 days for mortality. The treatments were started one day after infection.
Groups of ten BALB/c mice were treated daily (i.n.) with IFN-γ (2,000 U/mouse/day), ribavirin (25 and 100 mg/kg), IFN-γ (2,000 U/mouse/day) and Ribavirin (25 mg/kg), or PBS (placebo) for 5 consecutive days. All animals were infected with 8 LD50 of vaccinia virus on day 0 and were monitored for 21 days for mortality. The treatments started one day after infection.
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This application claims the benefit of U.S. provisional application no. 60/536,504, filed Jan. 15, 2004, (attorney docket no. 08675-6045), which is incorporated herein by reference.
This invention was made with Government support under MDA-972-02-C-0067 and W911NF-04-C-0046 awarded by DARPA. The Government has certain rights in the invention.
| Number | Date | Country | |
|---|---|---|---|
| 60536504 | Jan 2004 | US |
