CN1638781A - Carbon monoxide as a biomarker and therapeutic agent - Google Patents

Abstract

The present invention relates to the user of carbon monoxide (CO) as a biomarker and therapeutic agent of heart, lung, liver, spleen, brain, skin and kidney diseases and other conditions and disease states including, for example, asthma, emphysema, bronchitis, adult respiratory distress syndrome, sepsis, cystic fibrosis, pneumonia, interstitial lung diseases, idiopathic pulmonary diseases, other lung diseases including primary pulmonary hypertension, secondary pulmonary hypertension, cancers, including lung, larynx and throat cancer, arthritis, wound healing, Parkinson's disease, Alzheimer's disease, peripheral vascular disease and pulmonary vascular thrombotic diseases such as pulmonary embolism. CO may be used to provide anti-inflammatory relief in patients suffering from oxidative stress and other conditions especially including sepsis and septic shock. In addition, carbon monoxide may be used as a biomarker or therapeutic agent for reducing respiratory distress in lung transplant patients and to reduce or inhibit oxidative stress and inflammation in transplant patients.

Description

Carbon monoxide as a biomarker and therapeutic agent

technical field

The present invention relates to the use of carbon monoxide (CO) as a biomarker and therapeutic agent in heart, lung, liver, spleen, brain, skin and kidney diseases and other disease states including, for example, asthma , emphysema, bronchitis, adult respiratory distress syndrome, sepsis, cystic fibrosis, pneumonia, interstitial lung disease, idiopathic pulmonary disease diseases), other lung diseases including primary pulmonary hypertension, secondary pulmonary hypertension, cancers, including cancers of the lung, larynx and throat, arthritis, wound healing, Parkinson's disease 's disease), Alzheimer's disease, peripheral vascular disease and pulmonary vascular thrombotic diseases such as pulmonary embolism. CO can be used to provide anti-inflammatory relief to patients suffering from oxidative stress and other diseases including, inter alia, sepsis and septic shock. Alternatively, CO can be used to store organs prior to transplantation. In addition, carbon monoxide can be used as a biomarker or therapeutic agent to reduce respiratory distress in lung transplant patients, reduce or inhibit graft oxidative stress, inflammation or rejection in transplant patients.

Background technique

Heme oxygenase (HO) catalyzes the first and rate-limiting step in the degradation of heme to produce equimolar amounts of biliverdin IXa, carbon monoxide (CO), and iron (Choi et al., Am. J. Respir. Cell Mol. Biol. 15:9-19; and Maines, Annu. Rev. Pharmacol. Toxicol. 37:517-554). There are three isoforms of HO: HO-1 is highly inducible, while HO-2 and HO-3 are constitutively expressed (Choi et al., supra, Maines, supra, and McCoubrey et al., E.J. Bioch. 247:725-732). Although heme is the major substrate of HO-1, various non-heme agents including heavy metals, cytokines, hormones, endotoxins and heat shock are also strong inducers of HO-1 expression (Choi et al., supra Maines, supra, and Tenhunen et al., J. Lab. Clin. Med. 75:410-421). This diversity of HO-1 inducers has provided further support for the speculation that HO-1, in addition to its role in heme degradation, may also play a role in maintaining cellular homeostasis. Key role. Furthermore, HO-1 is highly induced by a variety of agents that cause oxidative stress, including hydrogen peroxide, glutathione depletors, UV radiation, endotoxins, and hyperoxia (Choi et al. , supra, Maines, supra, and Keyse et al. Proc. Natl. Acad. Sci. USA. 86:99-103). One explanation for this finding is that HO-1 could serve as a key biomolecule for adaptation to and/or defense against oxidative stress (Choi et al., supra, Lee et al., Proc Natl Acad Sci USA93: 10393-10398; Otterbein et al., Am. J.J.Respir.Cell Mol.Biol.13:595-601; Poss et al., Proc.Natl.Acad.Sci.USA.94:10925-10930; Vile, et al., Proc.Natl.Acad.Sci.91:2607-2610 ; Abraham et al., Proc. Natl. Acad. Sci. USA. 92: 6798-6802; and Vile and Tyrrell, J. Biol. Chem. 268: 14678-14681). Our laboratory and others have demonstrated that induction of endogenous HO-1 confers protection in vitro and in vivo against oxidative stress associated with hyperoxia and lipopolysaccharide-induced tissue damage (Lee et al., supra, Otterbein, et al., supra and Taylor et al., Am. J. Physiol. 18:L582-L591). We also demonstrated that exogenous administration of HO-1 by gene transfer confers protection against oxidant tissue injury and elicits tolerance to hyperoxic stress (Otterbein et al., Am. J. Resp. Crit. Care Med. 157: A565(Abstr)).

Carbon monoxide (CO) is a gas molecule known to be toxic and lethal to living organisms (Haldane, Biochem. J. 21: 1068-1075; and Chance et al., 1970, Ann.NY Acad Sci. 174: 193- 204.). However, unlike what is known about CO toxicity, recent years have seen renewed interest in CO as a regulatory molecule in cells and biological processes based on some key discoveries. Mammalian cells have the ability to generate endogenous CO, primarily through the catalysis of heme by heme oxygenase (HO) (Choi et al., supra and Maines, supra). The total cellular production of CO is mainly produced by the degradation of heme by HO (Marilena, Biochem. Mol. Med. 61: 136-142 and Verma, et al., 1993, Science 259: 381-384). In addition, CO, which is similar to the gas molecule nitric oxide, plays a role in regulating neuronal transmission (Verma et al., supra and Xhuo, et al., Science 260:1946-1950) and in mediating vasomotor tone ( Morita, and Kourembanas, 1995, J.Clin.Invest.96:2676-2682.; Morita et al., 1995 Proc.Natl.Acad.Sci.USA 92:-1479; and Goda et al., 1998, J.Clin.Inv. 101:604-12) play an important role. Other literatures related to the biological effects of CO include Pinsky et al., US Patent 6,316,403, Sato et al., J. Immunol.166:4185-4194 (2001); Fujita et al., Nat.Med.7(5):598-604 (2001); Nachar et al., High Altitude Medicine & Biology 2:377-385 (2001); Vassalli et al., Crit.Care.Med.29:359-366 (2001); Otterbein et al., Am.J.Physiol.Lung Cell Mol.Physiol.276 : L688-L694 (1999); Cardell et al., Brit. J. Pharmacol. 124: 1065-1068 (1998); Otterbein et al., Nat. Med. 6(4): 422-428 (2000); and Otterbein et al., Am . J. Physiol Lung Cell Mol. Physiol, 279: L1029-L1037 (2000).

Septic shock and sepsis syndrome, caused by overstimulation of immune cells, especially monocytes and macrophages, remain one of the leading causes of death in hospitalized patients. Parillo, et al., Ann. Intern. Med. 113, 991-992 (1992). The pathophysiological changes observed in sepsis are usually not due to the infectious agent itself, but to uncontrolled production of pro-inflammatory cytokines and chemokines, including TNF-α, IL-1, and MIP -1, leads to lymphocyte recruitment (recruitment), capillary infiltration and ultimately participates in the lethal effect of sepsis. Beutler et al., 232, 977-980 (1986); Netea et al., Immunology 94, 340-344 (1998); and Wolpe et al., J. Exp. Med. 167, 570-581 (1988). Lipopolysaccharide (LPS), a component of the cell wall of Gram-negative bacteria, is a major cause of sepsis and, when experimentally administered to macrophages or mice, mimicked the same inflammatory response. Following LPS administration, these pro-inflammatory mediators increase rapidly but temporarily, after which they are downregulated by a panel of anti-inflammatory cytokines including interleukin-10 (IL-10) and interleukin-4 (IL-4) Inhibit the synthesis of the pro-inflammatory cytokines and chemokines. J. Exp. Med. 177, 1205-1208 (1993). LPS initially binds CD14 and epidermal receptor-like (toll-like) receptor (TLR) 2 (or 4) on the cell surface, (Yang, et al, Nature 395:284-288 (1998) and Chow, et al, J.Biol .Chem.274:10689-10692 (1999), then shown to activate the mitogen-activated protein (MAP) kinase pathway, which includes p38, p42/p44 ERK and JNK (MAP) kinases. Liu et al., J.Immunol.153 , 2642-2652 (1994); Hambleton et al., Proc.Natl.Acad.Sci.USA.93, 2274-2778 (1996); Han et al., J.Biol.Chem.268, 25009-25014 (1993); , Science 265, 808-811 (1994); Sanghera et al., J.Immunol.156, 4457-4465 (1996), and Raineaud et al., J.Biol.Chem.270, 7420-7426 (1995). These signaling molecules The relationship between activation, expression of downstream cytokines, and physiological function is reflected in the investigation of the active line.

The US Government supported research leading to the present invention under one or more of NIH grant numbers HL60234, AI42365 and HL55330. Accordingly, the US Government reserves certain rights in this invention.

Summary of the invention

The present invention relates to new pharmaceutical compositions for delivery to patients affected by oxidative stress, said compositions comprising effective concentrations of carbon monoxide in a gaseous mixture comprising oxygen and optionally nitrogen (and other small amounts) optional gas components). Another aspect of the invention relates to a method of delaying the onset of oxidative stress, inhibiting or reducing the effects of oxidative stress, said method comprising delivering a therapeutic gas comprising carbon monoxide in an amount and for a time effective to delay the onset of oxidative stress in a patient, inhibiting or Reduces the effects of oxidative stress. It was unexpectedly found that transmissions contained low concentrations (i.e., gas concentrations ranging from about 1 ppb (parts per billion) to about 3,000 ppm (preferably above about 0.1 ppm within this range), preferably from about 1 ppm to about 2,800 ppm, more preferably from about 25ppm to about 750ppm, even more preferably from about 50ppm to about 500ppm, e.g., about 250ppm), the therapeutic gas of carbon monoxide is a therapeutic gas that delays the occurrence of oxidative stress in the patient, inhibits or reverses (reverse) oxidative stress very effective method of effect. This is an unexpected result. It should be noted here that, in the method of the present invention, sometimes also therapeutic gas compositions can be used in which the amount of carbon monoxide exceeds 0.3%, depending on the disease to be treated.

Another aspect of the invention relates to the use of carbon monoxide gas in the preparation of a medicament for the treatment of patients with or susceptible to emphysema, bronchitis, cystic fibrosis, pneumonia, interstitial lung disease, wound healing, Arthritis, Parkinson's disease and/or Alzheimer's disease patients.

Another aspect of the invention relates to the use of carbon monoxide gas for the manufacture of a medicament for the treatment of patients suffering from or susceptible to local inflammation of the kidneys, spleen and/or skin.

The present invention also provides methods for using carbon monoxide as a biomarker to determine that a patient is suffering from oxidative stress, or is susceptible to or suffering from several diseases secondary to or resulting in oxidative stress, such as asthma, pulmonary Emphysema, bronchitis, adult respiratory distress syndrome, sepsis, cystic fibrosis, pneumonia, interstitial lung disease, idiopathic lung disease, other lung diseases including primary pulmonary hypertension, secondary pulmonary hypertension Blood pressure, cancer, including cancer of the lung, larynx, and pharynx, arthritis, wound healing, Parkinson's disease, Alzheimer's disease, peripheral vascular disease and pulmonary vascular thrombotic disease such as pulmonary embolism, and others. The method includes detecting carbon monoxide in a patient's breath to determine whether there is a detectable level of carbon monoxide in the breath. If a patient has detectable levels of carbon monoxide in their breath, the patient is diagnosed as having oxidative stress or possibly having oxidative stress. Oxidative stress manifests as a form of one or more of the diseases mentioned above. Following this diagnosis, appropriate therapeutic or other steps may be taken to reduce or treat the condition responsible for the patient's oxidative stress. In one embodiment, the method includes measuring carbon monoxide in exhaled breath of the patient, wherein an amount of carbon monoxide in the breath of at least about 1 ppm indicates that the patient is susceptible to sepsis or septic shock.

Another aspect of the present invention relates to the discovery in some patients that administration of an effective amount of carbon monoxide to the patient can be used to induce the HO-1 enzyme in the patient and prevent or limit oxidative stress in the patient, especially caused by hyperoxia or sepsis of oxidative stress. The HO-1 enzyme is implicated to maintain the homeostasis of the patient's cells.

Another aspect of the invention relates to the use of carbon monoxide to delay the onset, inhibit or reduce the effects of oxidative stress that occurs in transplant patients, especially organ transplant patients, especially but not exclusively lung transplant patients.

Another aspect of the present invention relates to a method for inhibiting the production of proinflammatory cytokines such as TNF-α, IL-1β, IL-6, and MIP-1β, and enhancing the production (expression) of anti-inflammatory cytokines IL-10 and IL-4 in a patient , the method comprising administering to a patient an effective amount of CO.

Another aspect of the present invention relates to a method of preserving an organ or tissue for transplantation, comprising adding carbon monoxide in a preservation effective amount or concentration to a medium for storing the organ or tissue. In this aspect of the invention, the inclusion of an effective amount of carbon monoxide reduces, inhibits or reduces (alleviate) the formation of reactive oxygen species (reactive oxygen) in storage organs or tissues, thereby prolonging the effective storage of organ grafts without oxidative damage (oxidative damage). )time. In one embodiment, the method comprises providing a medium comprising carbon monoxide, and storing the organ in the medium, wherein the carbon monoxide is present in the medium in an amount sufficient to increase the storage stability of the organ.

Another aspect of the invention relates to a method of preventing or reducing the likelihood of damage caused by oxidative stress associated with hyperoxia in a patient, the method comprising administering to the hyperoxic patient an effective amount of carbon monoxide.

Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. Although suitable methods and materials for the practice or testing of the present invention are described below, other methods and materials similar or similar to those described herein can also be used, well known in the art. All publications, patent applications, patents, and other references mentioned herein are incorporated by reference in their entirety. In case of conflict, the present specification, including definitions, will control. In addition, the materials, methods, and examples described are illustrative rather than limiting.

Contents of the invention

The present invention is described with the following definitions.

The term "carbon monoxide" (or "CO") as used herein describes the carbon monoxide molecule as a gas, compressed into a liquid, or dissolved in an aqueous solution. Throughout the specification, the terms "carbon monoxide composition" or "carbon monoxide-containing pharmaceutical composition" are used to describe gaseous or liquid compositions containing carbon monoxide for administration to a patient and/or organ. A skilled practitioner will recognize which form, eg, gaseous, liquid, or both gaseous and liquid forms of the pharmaceutical composition, is preferred for a particular application.

The terms "effective amount" and "therapeutically effective" as used herein refer to the administration of carbon monoxide in an amount or concentration over a period of time, including acute or chronic administration, periodic or continuous administration, at which it produces the desired effect or physiological The result aspect is valid. For gases, an effective amount of carbon monoxide typically ranges from about 0.0000001% to about 0.3% by weight, e.g., from 0.0001% to about 0.25% by weight, preferably at least about 0.001%, e.g., at least about 0.005%, 0.010%, 0.02% , 0.025%, 0.03%, 0.04%, 0.05%, 0.06%, 0.08%, 0.10%, 0.15%, 0.20%, 0.22%, or 0.24% by weight carbon monoxide. Preferred ranges include, for example, from about 0.001% to about 0.24%, from about 0.005% to about 0.22%, from about 0.005% to about 0.05%, from about 0.010% to about 0.20%, from about 0.02% to about 0.15%, from about From about 0.025% to about 0.10%, or from about 0.03% to about 0.08%, or from about 0.04% to about 0.06%. For liquid solutions of CO, effective amounts typically range from about 0.0001 to about 0.0044 g CO/100 g liquid, e.g., at least about 0.0001, 0.0002, 0.0004, 0.0006, 0.0008, 0.0010, 0.0013, 0.0014, 0.0015, 0.0016, 0.0018, 0.0020, 0.0021, 0.0022, 0.0024, 0.0026, 0.0028, 0.0030, 0.0032, 0.0035, 0.0037, 0.0040, or 0.0042g CO/100g aqueous solution. Preferred ranges include, for example, from about 0.0010 to about 0.0030 g CO/100 g liquid, from about 0.0015 to about 0.0026 g CO/100 g liquid, or from about 0.0018 to about 0.0024 g CO/100 g liquid. An effective amount of carbon monoxide in reducing the production or effect of inflammatory cytokines can be, for example, an amount sufficient to inhibit the production and/or effect of TNF-α, IL-1, L-6 and MIP-1, among others. Alternatively, it may be an amount sufficient to induce or increase the production of anti-inflammatory cytokines such as IL-10 and others. In the case of a transplant patient, an effective amount of carbon monoxide is that amount administered to the transplant patient to reduce the likelihood of rejection due to an adverse immune response. For preserving a banked organ for transplantation, an effective amount of carbon monoxide may be added to, (e.g., bubbled into) the medium in which the transplanted organ is stored, thereby enhancing preservation of the organ , and reduces the likelihood that the organ will suffer a certain amount of oxidative damage. A skilled operator will understand that amounts outside the above ranges may also be used in accordance with the present invention.

The term "patient" as used throughout the specification describes a human or non-human animal to whom treatment is administered according to the methods of the present invention. The present invention is specifically intended to be used in veterinary medicine. This term includes, but is not limited to, mammals such as humans, other primates, pigs, rodents such as mice and rats, rabbits, guinea pigs, hamsters, cows, horses, cats, dogs, sheep and goat.

The term "treating" as used herein is used to describe delaying the onset, inhibiting or lessening the effects of a disease such as emphysema, bronchitis, arthritis, cystic fibrosis, pneumonia, interstitial lung disease, Parkinson's disease , Alzheimer's disease, or inflammation of the kidneys, spleen, or skin. In the context of wound healing, the term describes accelerated wound healing, eg, accelerated healing of skin wounds. Individuals considered susceptible to the diseases described herein may particularly benefit from the present invention, primarily because prophylactic treatment can be initiated before any symptoms of the disease appear. The skilled practitioner will understand that a patient's predisposition to any of the disorders described herein can be determined by any method known in the art, for example, by a physician's diagnosis.

The term "biomarker" is used to describe small and detectable amounts of carbon monoxide produced in a patient's breath that provide evidence that a patient is susceptible to, is in an early stage of, or has already suffered from oxidative stress , susceptible to, or suffering from one or more diseases that are secondary to or can lead to oxidative stress. The amount of carbon monoxide in a patient's breath that can be used as a biomarker can be as low as 0.001 ppm, but is usually at least about 0.1 ppm.

Preparation of gaseous carbon monoxide compositions

The CO composition may be a gaseous carbon monoxide composition. Compressed or pressurized gas useful in the methods of the present invention may be obtained from any commercial source and may be located in any type of vessel suitable for holding compressed gas. For example, the compressed or pressurized gas can be obtained from any source that provides medical compressed gas such as oxygen. A compressed gas containing carbon monoxide used in the method of the invention can be provided so that all gases of the desired final composition (eg CO, _CO2 , _O2 , _N2 ) are mixed in the same vessel. Alternatively, the process of the invention can be carried out with multiple vessels containing the various gases. For example, a single container containing carbon monoxide may be provided, with or without other gases, the contents of which may optionally be mixed with the chamber gas or with the contents of other containers, e.g., containing oxygen, nitrogen, carbon dioxide, helium, compressed gases, or Any other suitable gas or mixture thereof.

Gas compositions administered to patients according to the present invention generally comprise 0% to about 79% by weight nitrogen, about 21% to about 100% by weight oxygen, and about 0.0000001% to about 0.3% by weight (corresponding to about 1 ppb or 0.001 ppm to about 3,000ppm) of carbon monoxide. Preferably, the amount of nitrogen in the gas composition is about 79% by weight, the amount of oxygen is about 21% by weight, and the amount of carbon monoxide is from about 0.0001% to about 0.25% by weight, preferably at least about 0.001%, for example, At least about 0.005%, 0.010%, 0.02%, 0.025%, 0.03%, 0.04%, 0.05%, 0.06%, 0.08%, 0.10%, 0.15%, 0.20%, 0.22%, or 0.24% by weight carbon monoxide. Preferred ranges include 0.005% to about 0.24%, about 0.01% to about 0.22%, and about 0.08% to about 0.20%. It should be noted that gaseous carbon monoxide compositions having a carbon monoxide concentration above 0.3% (eg, 1% or more) may be used for short periods (eg, one or a few breaths) depending on the application.

The gaseous carbon monoxide composition can be used to create an atmosphere comprising carbon monoxide gas. An environment comprising an appropriate level of carbon monoxide gas can be created, for example, by providing a container containing compressed gas containing carbon monoxide gas and releasing the compressed gas from the container into a chamber or space to form carbon monoxide contained within the chamber or space. gas environment. Alternatively, the gas may be released into an apparatus that maximizes the concentration of the gas within the breathing mask or breathing tube, thereby creating an environment containing carbon monoxide gas in the breathing mask or breathing tube to ensure that the patient is the only person in the room exposed to People with appreciable levels of carbon monoxide.

Atmospheric carbon monoxide levels can be measured or detected by any method known in the art. These methods include electrochemical detection, gas chromatography, radioisotope counting, infrared absorption, colorimetry, and electrochemical methods based on selective membranes (see for example Sunderman et al., Clin. Chem. 28:2026-2032, 1982; Ingi et al., Neuron 16:835-842, 1996). Sub-partsper million carbon monoxide levels can be detected by, for example, gas chromatography and radioisotope counting. Additionally, it is known in the art that carbon monoxide levels in the sub-ppm range can be detected within biological tissue using a midinfrared gas sensor (see, e.g., Morimoto et al., Am. J. Physiol. Heart. Circ. Physiol 280: H482- H488, 2001) measurement. Carbon monoxide sensors and gas detection devices are available from many manufacturers.

Preparation of Liquid Carbon Monoxide Compositions

The carbon monoxide composition may be a liquid carbon monoxide composition. The liquid can be dissolved into the liquid by any means known in the art to make the carbon monoxide composition. For example, the liquid can be placed in a so-called " _CO2 incubator" and exposed to a continuous flow of carbon monoxide, preferably equilibrated with carbon dioxide, until the desired concentration of carbon monoxide in the liquid is reached. In another embodiment, carbon monoxide gas can be "blown" directly into the liquid until the desired concentration of carbon monoxide in the liquid is reached. It is known that the amount of dissolved carbon monoxide in an aqueous solution increases with decreasing temperature. In another example, a suitable liquid may flow through tubing that allows diffusion of the gas, where the tubing is placed in an environment containing carbon monoxide (e.g., with a device such as an extracorporeal membrane oxygenator). instrument) to run. Diffusion of carbon monoxide into the liquid produces a liquid carbon monoxide composition.

In one embodiment, the liquid may be any liquid known to those skilled in the art to be suitable for administration to a patient (see, eg, Oxford Textbook of Surgery, Morris and Malt, Eds., Oxford University Press (1994)). Typically, the liquid is an aqueous solution. Examples of suitable solutions include phosphate buffered saline (PBS), Celsior ^™ , Perfadex ^™ , Collins solution, citrate solution, and University of Wisconsin (UW) solution (Oxford Textbook of Surgery, Morris and Malt, Eds., Oxford University Press (1994)).

Any suitable liquid may be saturated with a set of concentrations of carbon monoxide with a gas diffuser. Alternatively, pre-made solutions quality controlled to contain a given level of carbon monoxide may be used. Dosage is accurately controlled by measurement with a gas-permeable but liquid-impermeable membrane connected to a carbon monoxide analyzer. The solution can be saturated to the desired effective concentration and maintained at these levels.

Treating a Patient with a Carbon Monoxide Composition

The patient can be treated with the carbon monoxide composition by any method known in the art for administering gases and/or liquids to the patient. Carbon monoxide compositions can be administered for a diagnosis of, or a determined predisposition to, e.g., emphysema, bronchitis, arthritis, cystic fibrosis, pneumonia, interstitial lung disease, Parkinson's disease, Alzheimer's disease, or Inflammation of the kidneys, spleen, or skin; or to promote wound healing, for example, to heal skin wounds not associated with surgery. The present invention includes systemic administration of a liquid or gaseous carbon monoxide composition to a patient (e.g., by inhalation and/or ingestion), and topical administration of said composition to a patient's lungs (e.g., by inhalation or intratracheal administration), joints (e.g., by (infusion or transdermal administration), skin (e.g., by injection or by applying the composition to the skin surface), and other organs (e.g., by ingestion, insufflation, and/or introduction into the abdominal cavity) .

System delivery (delivery) carbon monoxide

A gaseous carbon monoxide composition can be systemically delivered to a patient. Gaseous carbon monoxide compositions are usually administered intrapulmonarily by inhalation through the oral or nasal passages, where the carbon monoxide exerts its effect directly or is readily absorbed into the patient's bloodstream. The concentration of the active compound (CO) used in the therapeutic gas composition will depend on the rate of carbon monoxide absorption, distribution, inactivation and secretion (usually by respiration) and other factors known to those skilled in the art. It should also be understood that for any specific subject, the specific dosage regimen should be adjusted over time according to individual needs and the professional judgment of the personnel implementing or supervising the administration of the composition, and the aforementioned concentration ranges are exemplary only, and It is not intended to limit the scope or practice of the claimed compositions. The invention also relates to acute, subacute and chronic administration of CO, depending on, for example, the severity and persistence of the patient's disease. The CO can be delivered to the patient for a period of time sufficient to treat the disease and exhibit the desired pharmacological or biological effect, including sporadic administration.

The following are some examples of methods and apparatus that may be used to administer gaseous carbon monoxide compositions to a patient.

ventilator

Medical grade CO can be purchased (in various concentrations) mixed with air or other oxygen-containing gas in a pressurized gas standard tank (eg, 21% _O2 , 79% _N2 ). The gas is non-reactive, and the method of the present invention requires concentrations well below the flammable range (10% in air). In hospitals, it is presumed that the gas is delivered to the bedside where it is mixed with oxygen or room air in a blender to achieve the desired ppm concentration. The patient inhales the gas mixture through a ventilator whose flow rate is set according to the patient's comfort and needs. This flow rate can be determined from a lung map (ie, respiratory rate, tidal volume, etc.). A fail-safe mechanism that prevents the patient from unnecessarily receiving more carbon monoxide than required can be designed into the delivery system. A patient's CO level can be monitored by studying (1) measurable carboxyhemoglobin (COHb) in venous blood, and, (2) exhaled CO collected from the side of the ventilator. CO exposure can be adjusted according to the patient's health status and markers. If necessary, CO can also be washed out by inhaling 100% oxygen. CO is not metabolized, so except for a small part is converted into CO ₂ , no matter how much is inhaled, it is finally exhaled. CO can be mixed with any level of _O2 to deliver CO therapeutically without causing subsequent hypoxic conditions.

Masks and Tents

A gas mixture containing CO was prepared as described above to allow passive inhalation by the patient through a mask or drape. The inhaled concentration can be changed and scrubbed by simply switching to inhaling 100% _O2 . CO levels can be monitored at or near the mask or veil with a fail-safe mechanism that prevents inhalation of excessively high concentrations of CO.

Portable inhaler

The pressurized CO can be packaged into a portable inhaler and inhaled in metered doses, for example to allow intermittent therapy in non-hospitalized recipients. Different concentrations of CO can be packed into containers. The device can be as simple as a small tank (eg, less than 5 kg) containing dilute CO with an on-off valve and tubing from which the patient inhales CO according to standard protocols or as needed.

Intravenous Artificial Lung

Artificial lungs (catheter devices for gas exchange in the blood) designed to deliver _O2 and remove _CO2 can be used for CO delivery. Once implanted, the catheter is positioned in a large vein and can deliver the desired concentration of CO systemically or to a local site. The delivery may be local delivery of high concentrations of CO to a surgical site such as adjacent to the spleen or kidney for a short period of time (the high concentrations are rapidly diluted in the bloodstream), or exposure to lower concentrations of CO over a relatively long period of time. CO (see eg Hattler et al., Artif. Organs 18(11):806-812 (1994); and Golob et al., ASAIO J., 47(5):432-437 (2001 )).

Normobaric chamber

In some cases, whole-body exposure of the patient to CO is required. The patient must be in a closed chamber filled with CO at a level that does not pose a risk to the patient, or at a level that poses an acceptable risk but does not put bystanders at risk of being exposed. After exposure is complete, the chamber is filled with air (eg, 21% _O2 , 79% _N2 ) and samples are analyzed using a CO analyzer to ensure that no CO remains before the patient is allowed to exit the exposure system.

liquid composition

The invention also includes liquid compositions comprising carbon monoxide formulated for systemic administration to a patient, eg, orally and/or by eg, intravenous, intraarterial, intraperitoneal and/or subcutaneous injection into a living organism.

Topical treatment of organs with carbon monohydrogen

Alternatively or additionally, the carbon monoxide composition may be administered directly to an organ, eg, the skin, spleen, lungs, and/or one or more kidneys. The gaseous composition can be administered directly to the interior and/or exterior of the patient's body to treat the patient's organ. The gas composition may be administered directly to the internal organs of the patient by any method known in the art for insufflation of gas into the patient. For example, a gas, such as carbon dioxide, is often insufflated into the patient's abdominal cavity to aid in examination during laproscopic procedures (see, e.g., Oxford Textbook of Surgery, Morris and Malt, Eds., Oxford University Press (1994)). A skilled operator will understand that a similar procedure can be used to administer the carbon monoxide composition directly to the internal organs of a patient. The skin and underlying joints can be topically treated with a gaseous composition by, for example, exposing the gaseous composition in a normal air pressure chamber (described above) to the infected skin, and/or blowing the carbon monoxide composition directly to the skin.

Liquid carbon monoxide compositions may also be administered locally to the patient's organs. Such compositions in liquid form can be administered to a patient by any method known in the art for administering liquids. Like gaseous compositions, liquid compositions can be applied directly to the interior and/or exterior of the body to treat the patient's organs. For example, the liquid form can be administered orally, for example by having a patient ingest an encapsulated or unencapsulated dose of an aqueous carbon monoxide composition. As another example, a fluid, such as a saline solution containing dissolved CO, may be injected into the patient's peritoneal cavity during laparoscopy. Alternatively or additionally, exposureor organs in situ, such as one or more kidneys and spleen, can be performed by any method known in the art, for example, by flushing the organ in situ with a liquid carbon monoxide composition (see Oxford Textbook of Surgery, Morris and Malt, Eds., Oxford University Press (1994)). The skin may be topically treated with a liquid composition by, for example, injecting the liquid composition into the skin. In another embodiment, the skin and underlying joints are topically treated by applying the liquid composition directly to the surface of the skin, for example by pouring or spraying the liquid onto the skin and/or spraying the skin Submerge into said liquid composition.

disease

Carbon monoxide gas can be used to prepare drugs for the treatment of diseases such as asthma, emphysema, bronchitis, adult respiratory distress syndrome, sepsis, cystic fibrosis, pneumonia, interstitial lung disease, idiopathic lung disease , other lung diseases including primary pulmonary hypertension, secondary pulmonary hypertension, cancers including lung cancer, cancers of the larynx and pharynx, arthritis, Parkinson's disease, Alzheimer's disease, peripheral vascular disease and Pulmonary vascular thrombotic disorders such as pulmonary embolism; and for the treatment of patients suffering from or susceptible to inflammation located in an organ such as the kidney, spleen and/or skin. The invention may also be used to aid wound healing, eg, skin wound healing. Of particular interest is the treatment of non-surgical wounds.

The present invention can also be used to delay the occurrence of oxidative stress, or reduce the effect of oxidative stress in transplant patients, especially organ transplant patients, especially lung transplant patients. The carbon monoxide compositions are also useful for treating inflammatory conditions of the lung or inflammation secondary to sepsis or rejection in transplant patients. Without being bound by theory, low doses of CO are thought to inhibit the production and/or effects of pro-inflammatory cytokines such as TNF-α, IL-1, IL-6, MIP-1, and/or stimulate or promote Anti-inflammatory cytokines IL-4 and IL-10, and play the role of anti-inflammatory agents.

The term "oxidative stress" describes a disease caused by an excessive production of reactive oxygen species that is not quenched by endogenous antioxidants. Oxidative stress can lead to permanent tissue damage caused by the action of reactive oxygen species on tissues. Physiological phenomenon of oxidative stress in the form of or present in a variety of diseases: including asthma, emphysema, bronchitis, adult respiratory distress syndrome, sepsis or septic shock, cystic fibrosis, pneumonia, interstitial Pulmonary disease, idiopathic pulmonary disease, other pulmonary diseases including primary pulmonary hypertension, secondary pulmonary hypertension, lung cancer and pulmonary vascular thrombotic disease such as pulmonary embolism or any inflammatory disease of the lung.

The term "sepsis" describes the presence in blood tissues of various pus-forming and other pathogenic organisms or their toxins (generally, lipopolysaccharide or LPS bacterial cell walls). Sepsis often causes oxidative stress in those tissues exposed to the pathogen or its toxins. Sepsis often becomes apparent with the production of anti-inflammatory cytokines such as TNF-α, IL-1, IL-6 and MIP-1, which production is decreased or reversed by administration of effective doses of carbon monoxide.

The present invention can be used to treat inflammation. The term "inflammation" describes the basic pathological process, which includes a dynamic complex of cytological and histological responses in infected blood vessels and surrounding tissues, which is the response to damage or abnormalities caused by physical, chemical or biological agents. Responses to stimuli, which include local reactions and their resulting pathological changes, destruction or removal of injurious material, and responses leading to repair and healing. The term includes various types of inflammation such as acute inflammation, allergic inflammation, alternative (degenerative) inflammation, atrophic inflammation, catarrhal inflammation (most often in the airways), croupous inflammation , Fibrinopurulent inflammation, fibrinous inflammation, immune reaction (immune) inflammation, hyperplastic (hyperplastic orproliferative) inflammation, subacute, serous and serous fibrinous inflammation. Preferentially according to the method of the present invention treatment is located in the liver, heart, skin (such as dermatitis, inflammation caused by bacterial, fungal or viral infection and/or allergy or autoimmune reaction), spleen, brain, kidney (such as bacterial pyelonephritis, interstitial nephritis, and/or glomerulonephritis) and inflammation of the pulmonary tract, especially the lungs, and their associated sepsis or septic shock.

The term "cancer" is used as a general term to describe any of the various types of malignant tumors, most of which invade the surrounding area, metastasize to multiple locations and may recur after attempted removal, and unless properly treated, cause The patient died. Cancers that can be treated with the compositions and methods of the present invention include, for example, stomach, colon, rectum, liver, pancreas, lung, breast, cervix, uterus, ovary, prostate, testis, bladder, kidney, brain/CNS, head and neck, Pharynx, Hodgkins disease, non-Hodgkins leukemia, cutaneous melanoma, multiple sarcomas, small cell lung cancer, choriocarcinoma, mouth/pharynx (pharynx), esophagus (oesophagus), larynx, melanoma, kidney and lymphoma, and others.

The present invention can be used to treat diseases involving the respiratory system, for example, emphysema, bronchitis, cystic fibrosis, pneumonia, and interstitial lung disease. The term "emphysema" as used herein refers to a disease of the lungs characterized by inflation of the alveoli. In this condition, the alveolar walls are destroyed, causing the bronchioles to lose their structural support and collapse during expiration (see eg, The Merek Manual of Diagnosis and Therapy, ^I7th Edition, Section 6, Chapter 68). The term "tracheitis" refers to a lung disease characterized by inflammation of the tracheobronchial tree. Tracheitis can follow an infection, eg, a viral infection, eg, the common cold; or a bacterial infection, or after exposure to an irritant (see eg, The Merck Manual of Diagnosis and Therapy, 17th Edition, Section 6, Chapter 69). The term "cystic fibrosis" refers to an inherited disorder of the exocrine glands. The disease primarily affects the gastrointestinal and respiratory systems and is often characterized by chronic obstructive pulmonary disease (COPD) (see, e.g., The Merck Manual of Diagnosis and Therapy, 17″ Edition, Section 19, Chapter 267). The term "pneumonia" refers to the disease affecting Parenchyma lung diseases also include, for example, bacterial, viral, and aspiration pneumonias (see, for example, The Merck Manual of Diagnosis and Therapy, 17 Edition, Section 6, Chapter 73). The term "intermediate "Interstitial lung disease" or "idiopathic interstitial lung disease" refers to a group of lung disorders of unknown etiology that typically produce diffuse pathology involving interalveolar interstitial tissue (see, e.g., The Merck Manual of Diagnosis and Therapy, 17th Edition, Section 6, Chapter 78).

The term "arthritis" as used herein refers to a disease characterized by joint inflammation and includes, for example, rheumatoid arthritis (RA) (a chronic inflammatory polyarthritis that often results in joint damage), psoriatic arthritis (an inflammatory disease associated with psoriasis) arthritis), ankylosing spondylitis (inflammation of the axial skeleton and large peripheral joints), and ankylosis (immobility or fusion) (see, e.g., The Merck Manual of Diagnosis and Therapy, 17″Edition, respectively Section 5, Chapter 50; Section 5, Chapter 51; Section 5, Chapter 51; and Section9, Chapter 108).

The term "Parkinson's disease" refers to an idiopathic, slowly progressive, degenerative CNS disorder characterized by slow and declining movements, muscular rigidity, resting tremor, and Postural instability. "(The Merck Manual of Diagnosis and Therapy, 17" Edition, Section 14, Chapter 179). The term "Alzheimer's disease" refers to characterized by "progressive, inexorable loss of cognitive function associated with an excess of senile plaques in the cerebral cortex and subcortical gray matter, which also contain tau protein Neurofibrillary tangles and β-amyloid (The Merck Manual of Diagnosis and Therapy, 17th Edition, Section 14, Chapter 171).

The present invention can also use low doses of CO to induce HO-1 enzyme in patients and avoid or limit oxidative stress, especially oxidative stress caused by hyperoxia or sepsis. Induction of HO-1 is suggested to maintain homeostasis in the patient's cells.

Treating organs and tissues to improve storage stability

The invention also relates to the use of CO as a preservative for storing organs or tissues for transplantation. It was an unexpected result that inclusion of low doses of CO in the medium for storing organs to be transplanted sufficiently reduced the likelihood of oxidative damage to the organ during storage and sufficiently extended the time to safely store the transplanted organ from irreversible oxidation. Damage storage time. Thus, in an embodiment of the invention, an effective amount of CO is bubbled into the storage medium before or preferably immediately or shortly thereafter when the organ is first placed in said medium. CO can also be used to increase the storage stability of organs that have been stored in medium for some time, but in those instances the oxidative damage would have become irreversible, limiting the envisioned effect.

Accordingly, the present invention provides methods to increase the storage stability of an organ or tissue. The storage stability is enhanced by exposing the organ or tissue to a liquid and/or gaseous carbon monoxide composition. Exposure of an organ or tissue to a gaseous carbon monoxide composition can be performed in any environmental chamber or area suitable for manufacture that includes a suitable level of carbon monoxide gas. These chambers include, for example, incubators as well as chambers constructed to house organs in storage solutions. As another example, a suitable chamber may be one in which only the gas fed into the chamber is present in the internal environment so that a concentration of carbon monoxide can be achieved and maintained at a known concentration and purity, e.g., where the chamber is hermetically sealed of. For example, a _CO incubator can be used to expose an organ to a carbon monoxide composition, wherein the carbon monoxide gas is provided in a continuous flow from a container containing the gas.

For liquid carbon monoxide compositions, the organ or tissue may be fully or partially submerged in any chamber or space large enough to expose it to the carbon monoxide composition. In embodiments of the invention, the organ may be exposed to the carbon monoxide composition by placing the organ in any suitable container and "washing" the carbon monoxide composition over the organ, thereby rendering the organ Organs are exposed to a continuous stream of carbon monoxide composition. In another embodiment, the organ is perfused with a carbon monoxide composition. The term "perfusion" is an art-recognized term that refers to the passage of a fluid, eg, a blood vessel of a carbon monoxide composition through an organ or tissue. Methods of perfusing organs in vitro and in situ are well known in the art. Organs may be perfused with carbon monoxide compositions in vitro, for example by continuous hypothermic machine perfusion (see Oxford Textbook of Surgery, Morris and Malt, Eds., Oxford University Press (1994)). Alternatively, a wash solution, such as carbon monoxide-free UW solution, may be used to remove donor blood from the organ prior to perfusing the organ with the carbon monoxide composition. This procedure can be manipulated to avoid competition for carbon monoxide by the donor's hemoglobin. Alternatively, the wash solution may be a carbon monoxide composition. As another example, a suitable liquid may be prepared by passing a piping system that allows gas diffusion through an environment containing carbon monoxide (e.g., through a chamber, such as with an extracorporeal membrane oxygenator) to prepare a liquid carbon monoxide composition, which is then An organ may be passed (eg, perfused into an organ by connecting the tubing to the organ).

As another example, the organ may be placed, e.g., submerged in a medium or solution that does not include carbon monoxide, and placed in a chamber such that the medium or solution is exposed to a carbon monoxide-containing environment as described herein. Instead, it is made into a carbon monoxide composition. As another example, the organ may be immersed in a liquid that does not contain carbon monoxide, and the carbon monoxide may be "breathed" into the liquid.

The present invention contemplates that any or all of the above methods of exposing an organ to a liquid carbon monoxide composition, such as washing, immersing or perfusing, may be used in known steps, such as in a single step, to enhance storage stability of the organ or tissue.

Carbon Monoxide as a Diagnostic Tool

In addition to using CO as a therapeutic agent, measuring CO may be a useful diagnostic tool, such as a biomarker, to determine whether a patient is under oxidative stress or is in a diseased state where CO is suggestive of, for example, sepsis or septic shock. Typically, a patient suspected of being or possibly under oxidative stress is monitored to determine whether detectable levels of carbon monoxide can be detected in the patient's exhaled breath. If detectable levels of carbon monoxide are seen (i.e., the amount of carbon monoxide in the patient's breath is at least about 0.01 ppm), then the attending physician or caregiver can initiate therapeutic doses of carbon monoxide to treat oxidative stress. stress or any one or more diseases secondary to or resulting in oxidative stress.

In one embodiment, the patient's exhaled breath is analyzed for the presence of CO. The CO content in the patient's breath is measured by a CO monitor (eg, with a Logan LR2000), which is sensitive to detect CO from 0 to about 1000 ppm (with a sensitivity as low as 1 ppb). In this method, the subject exhales slowly at a constant flow (5-6 l/m) from a functional FVC into a breathalyzer at 20-30 second intervals. Two successful records were made and the mean was used for all calculations. Ambient CO levels are recorded before each breath to provide a control or background value. Any increase in CO levels relative to background values may suggest an actual or incipient state of oxidative stress, with an amount of CO of at least about 1 ppm clearly indicating that the patient is suffering from oxidative stress or is about to suffer from oxidative stress.

Several embodiments of the invention have been described. However, it is understood that various modifications may be made without departing from the spirit and scope of the invention. Accordingly, other implementations are within the scope of the following claims.

Claims (16)

1. Use of carbon monoxide gas for the preparation of a medicament for the treatment of a patient suffering from or susceptible to at least one disease selected from the group consisting of emphysema, bronchitis, cystic fibrosis, pneumonia, interstitial Lung disease, wound healing, arthritis, Parkinson's disease or Alzheimer's disease; or for promoting wound healing in said patient. 2. The method of claim 1, wherein the disease is emphysema. 3. The method of claim 1, wherein the disease is bronchitis. 4. The method of claim 1, wherein the disease is cystic fibrosis. 5. The method of claim 1, wherein the disease is pneumonia. 6. The method of claim 1, wherein the disease is interstitial lung disease. 7. The method of claim 1, wherein the disease is arthritis. 8. The method of claim 1, wherein the disease is Parkinson's disease. 9. The method of claim 1, wherein the disease is Alzheimer's disease. 10. The method of claim 1, wherein the carbon monoxide gas is used in the preparation of a medicament for promoting wound healing in the patient. 11. Use of carbon monoxide gas for the manufacture of a medicament for the treatment of a patient suffering from or susceptible to inflammation in at least one organ selected from the group consisting of: kidney, spleen or skin. 12. The method of claim 11, wherein the organ is a kidney. 13. The method of claim 11, wherein the organ is the spleen. 14. The method of claim 11, wherein the organ is skin. 15. A method of increasing the storage stability of an organ in a medium comprising: providing a medium containing carbon monoxide; and The organ is stored in the medium, wherein the amount of carbon monoxide present in the medium is sufficient to increase the storage stability of the organ. 16. A method of determining whether a patient is susceptible to sepsis or septic shock, comprising: measuring carbon monoxide in exhaled breath from the patient, wherein an amount of carbon monoxide in the breath of at least about 1 ppm indicates that the patient is susceptible to sepsis or septic shock Hemorrhagic shock.