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USRE38115E1 - Dextromethorphan and an oxidase inhibitor for treating intractable conditions - Google Patents

Dextromethorphan and an oxidase inhibitor for treating intractable conditions Download PDF

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USRE38115E1
USRE38115E1 US10/052,698 US5269802A USRE38115E US RE38115 E1 USRE38115 E1 US RE38115E1 US 5269802 A US5269802 A US 5269802A US RE38115 E USRE38115 E US RE38115E
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dextromethorphan
quinidine
pharmaceutically acceptable
hydroxylase inhibitor
patient
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Richard Alan Smith
Jonathan M. Licht
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Avanir Pharmaceuticals Inc
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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
    • A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
    • A61K31/47—Quinolines; Isoquinolines
    • A61K31/485—Morphinan derivatives, e.g. morphine, codeine
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
    • A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
    • A61K31/47—Quinolines; Isoquinolines
    • A61K31/49—Cinchonan derivatives, e.g. quinine
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
    • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P11/00—Drugs for disorders of the respiratory system
    • A61P11/14—Antitussive agents
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P15/00—Drugs for genital or sexual disorders; Contraceptives
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P17/00—Drugs for dermatological disorders
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P25/00—Drugs for disorders of the nervous system
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P25/00—Drugs for disorders of the nervous system
    • A61P25/02—Drugs for disorders of the nervous system for peripheral neuropathies
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P25/00—Drugs for disorders of the nervous system
    • A61P25/04—Centrally acting analgesics, e.g. opioids
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P27/00—Drugs for disorders of the senses
    • A61P27/16—Otologicals
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P43/00—Drugs for specific purposes, not provided for in groups A61P1/00-A61P41/00

Definitions

  • This invention relates to pharmacology. More specifically, the invention relates to compositions of matter useful for preparing medicaments for the treatment of various disorders.
  • a number of chronic disorders have symptoms which are known to be very difficult to treat, and often fail to respond to safe, non-addictive, and non-steroid medications.
  • Such disorders such as intractable coughing, fail to respond to conventional medicines and must be treated by such drugs as codeine, morphine, or the anti-inflammatory steroid prednisone.
  • These drugs are unacceptable for long-term treatment due to dangerous side-effects, long-term risks to the patient's health, or the danger of addiction.
  • Other disorders such as dermatitis, have no satisfactory treatment for the severe itching and rash at this time. Drugs such as prednisone and even tricyclic antidepressants, as well as topical applications, have been tried, but do not appear to offer substantial and consistent relief.
  • dextromethorphan or (+)-3-methoxy-N-methylmorphinan
  • Dextromethorphan has also been tested as a potential therapeutic agent for stroke, and progressive neurodegenerative diseases such as Parkinson's disease, Alzheimer's disease and amyotrophic lateral sclerosis.
  • progressive neurodegenerative diseases such as Parkinson's disease, Alzheimer's disease and amyotrophic lateral sclerosis.
  • the effectiveness of dextromethorphan for the treatment of any disorder has been limited because it is rapidly broken down by the liver and excreted in most individuals.
  • the present invention provides compounds which are useful in the preparation of medicaments for the treatment of a variety of disorders including intractable coughing, dermatitis, chronic pain, tinnitus and sexual dysfunction. These compounds are a therapeutically effective dosage of dextromethorphan and a therapeutically effective dosage of a second agent, an inhibitor of enzymatic dextromethorphan oxidation. This combination of compounds can be administered together, or individually. A preferred combination is dextromethorphan and the oxidative inhibitor quinidine. Inhibitors which may also be used include quinine, yohimbine, fluoxetine, haloperidol, ajmaline, lobeline, and pipamperone.
  • FIG. 1 shows the relationship between DM oral dosages and DM plasma concentrations in patients receiving 150 mg/day of quinidine orally.
  • DM dextromethorphan
  • antioxidants or “oxidative inhibitors” refers to inhibitors capable of inhibiting the oxidation of DM by the liver enzyme debrisoquin hydroxylase.
  • intractable or “refractory” coughing refers to coughing that will not respond adequately to non-addictive, non-steroid medications.
  • the term “dermatitis” or “eczema” refers to a skin condition which includes visible skin lesions which may be accompanied by an itching or burning sensation on the skin. This condition does not readily respond to non-prescription drugs, lotions, or ointments.
  • chronic pain refers to long-term pain resulting from conditions such as stroke, cancer and trauma, as well as neuropathic pain due to deterioration of nerve tissue such as postherpetic neuralgia (PHN) resulting from herpes zoster infection, and diabetic neuropathy resulting from long-time diabetes.
  • PPN postherpetic neuralgia
  • the term “tinnitus” refers to a syndrome characterized by a high-pitched ringing in the ears thought to be induced by loss of motility of the outer hair cells of the cochlea of the ear.
  • compositions for use in the preparation of medicaments for the effective treatment of a variety of chronic and intractable disorders which failed to respond to other treatments are a therapeutically effective dosage of dextromethorphan (DM), or a pharmaceutically acceptable salt or analog thereof, in combination with a therapeutically effective dosage of an inhibitor of enzymatic dextromethorphan oxidation by the liver enzyme debrisoquin hydroxylase.
  • DM dextromethorphan
  • the chronic and intractable disorders which have responded to medicaments containing a dextromethorphan/antioxidant combination include intractable coughing, dermatitis, chronic pain and tinnitus.
  • Relatively potent antioxidants include quinidine and quinine.
  • Other antioxidants which are milder include yohimbine, fluoxetine, haloperidol, ajmaline, lobeline, pipamperone.
  • Dextromethorphan (hereinafter DM) is the common name for (+)-3-methoxy-N-methylmorphinan. This compound is described in detail in Rodd et al., Chemistry of Carbon Compounds, Elsevier Publ., New York (1960), for example, which is herein incorporated by reference.
  • DM is a non-addictive opioid having a dextrorotatory enantiomer (mirror image) of the morphinan ring structure which forms the molecular core of most opiates.
  • DM has been used as an ingredient of cough suppressant in over-the-counter cough syrup.
  • the cough-suppressing activity of DM is thought to be due primarily to its actions as an agonist on a class of neuronal receptors known as sigma receptors or high-affinity dextromethorphan receptors. Although these receptors are sometimes referred to as sigma opiate receptors, it is not clear whether they are in fact opiate receptors.
  • Sigma receptors are inhibitory receptors and the activation of these receptors by DM or other sigma agonists causes the suppression of certain types of nerve signals.
  • Dextroinethorphan is also thought to act on another class of receptors known as N-methyl-D-aspartate (NDMA) receptors, which are one type of excitatory amino acid (EAA) receptor.
  • NDMA N-methyl-D-aspartate
  • EAA excitatory amino acid
  • DM acts as an antagonist at NMDA receptors, suppressing the transmission of nerve impulses mediated through NMDA receptors. Since NMDA receptors are excitatory receptors, the action of DM as an NMDA antagonist also results in the suppression of nerve signals.
  • DM has been reported to suppress activity at neuronal calcium channels. It is the antagonist activity of DM at NMDA receptors which is through to be one of the common links between some of the various conditions which respond to medicaments containing a DM/antioxidant combination.
  • DM When used in therapeutic applications, DM disappears rapidly from the bloodstream of most individuals, as described in Dayer et al., Clin. Pharmacol. Ther. 56:34-30 (1989), Vetticaden et al., Pharmaceut. Res. 6:13-19 (1989), and Ramachander et al., J. Pharm. Sci. 66: 1047-1049 (1977), which are herein incorporated by reference.
  • DM is broken down in the liver into several metabolites. DM can be oxidized by O-dimethylation, in which one of the methyl groups is removed and two metabolites, dextrorphan and 3-methoxymorphinan, are produced. If the second methyl group is removed, the resulting metabolite is 5-hydroxymorphinan.
  • Dextrorphan is known to have many of the biological activities of DM.
  • dextrorphan and 5-hydroxymorphinan become covalently bonded to other compounds in the liver, primarily glutathione to form glucuronide or sulfate conjugates, which can not readily cross the blood-brain barrier and which are quickly eliminated from the body in the urine.
  • the particular enzyme primarily responsible for DM oxidation is debrisoquin hydroxylase, also known as sparteine monooxygenase, and also referred to in the literature variously as cytochrome P-450 DB , as cytochrome P-450db1 (or db1 ), and as cytochrome P-4502D6.
  • this enzyme is referred to as debrisoquin hydroxylase.
  • Debrisoquin hydroxylase belongs to the family “cytochrome P-450” enzymes, or as “cytochrome oxidase” enzymes. These enzymes typically found in high concentrations in liver cells primarily in liver microsomes, and in lower concentrations in various other organs and tissues such as the lungs.
  • cytochrome oxidase enzymes By oxidizing lipophilic compounds, cytochrome oxidase enzymes eliminate compounds from the body that might otherwise act as toxins or accumulate to undesired levels. Typically, oxidation renders lipophilic compounds more soluble in water and therefore, more easily eliminated in the urine or in aerosols exhaled out of the lungs.
  • the debrisoquin hydroxylase enzyme apparently is also present in brain tissue (Fonne-Pfister et al., Biochem. Biophys. Res. Communic. 148: 1144-1150 (1987), Niznik et al., Arch. Biochem. Biophys. 26:424-432 (1990), Tyndate et al., Mol. Pharmacol. 40:63-68 (1991)), although its function in the brain is not fully understood.
  • Dextromethorphan is widely available over-the-counter in cough syrups, at dosages up to about 120 mg/day for an adult.
  • This invention anticipates DM dosages in the range of about 20 mg/day to about 200 mg/day, preferably in the range of 20 to 150 mg/day, depending on factors such as the weight of the patient, the severity of the disorder, and the potency and dosage of the antioxidant agent used in conjunction with DM.
  • Quinidine is a dextrorotatory steroisomer of quinine. Quinidine is commonly used to treat cardiac arrhythmias, and is considered a relatively strong cardiac medicine. Quinidine is commercially available from a number of sources, for example, A H. Robins, Richmond, Va., but is available to the public only with a doctor's prescription. Both DM and quinidine are commercially available in powder form, and capsules of a specific dosage can be prepared as desired by commercial vendors. The dosage of quinidine which was found to provide a major increase in DM concentration in the blood of most patients was equal to or less than 150 mg/day, depending on the individual.
  • the present invention contemplates dosages ranging from 50 mg/day to 300 mg/day, preferably from 50 mg/day to 150 mg/day. In some patients a dosage of about 50 mg/day is found to be effective. In contrast the dosage used for anti-arrhythmic control in cardiac patients is between 600-1200 mg/day.
  • agents with a K i value (Michaelis-Menton inhibition values) of 50 micromolar or lower include nortriptyline, chlorpromazine, domperidone, haloperidol, pipamperone, labetalol, metaprolol, oxprenolol, propranolol, timolol, mexiletine, quinine, diphenhydramine, ajmaline, lobeline, papaverine, and yohimbine.
  • Preferred compounds having particularly potent inhibitory activities include yohimbine, haloperidol, ajmaline, lobeline, and pipamperone, which have K i values ranged from 4 to 0.33 ⁇ M. In comparison, the K i value of quinidine is 0.06 ⁇ M. of these inhibitors quinine sulfate, disulfiram, cimetidine, fluoxetine, propranolol, and nortriptyline were tested for the ability to stabilize the concentration of DM in the blood stream, as described in detail in Example 4 below. As expected, the results of these studies show an increase in levels of DM which is not as pronounced as that when DM is co-administered with quinidine.
  • fluoxetine sold by Eli Lilly and Co. under the trade name Prozac, is effective in increasing DM concentrations in the blood of some people. For example, a single patient who was taking 20 mg fluoxetine twice a day registered a blood level of 40 ng/ml of DM when administered DM according to the testing outlined in Example 4.
  • the optimal dosage of both dextromethorphan and any of the antioxidant to be administered to specific patient can be determined by administering various dosages of each drug and then (1) analyzing blood samples to determine the concentration of DM in the circulating blood, and/or (2) evaluating the patient's progress to determine which combination of dosages provides the best result in effectively suppress the symptoms being targeted.
  • DM and antioxidant A number of factors influence the dosage of DM and antioxidant which would be appropriate for a particular individual.
  • One very important factor is the individual's ability to metabolize DM. It is known that a substantial fraction of the general public, estimated from 7 to 10%, do not have a properly functioning gene encoding the debrisoquin hydroxylase enzyme. These persons are referred to by doctors and pharmacologists as “poor metabolizers”, while those having the gene encoding debrisoquin hydroxylase are known as “extensive metabolizers”. “Poor metabolizers” are regarded as somewhat high-risk patients who must be treated with special care and attention, since they are overly sensitive to certain drugs that can be prescribed safely to people who have the full set of cytochrome P450 enzymes.
  • cytochrome P450 isozymes are also likely to be suppressed by quinidine or other inhibitors, with varying levels of binding affinity. This is described in articles such as Kupfer et al., Lancet ii:517-518 (1984) and Guttendorf et al., Ther. Drug. Monit. 10:490-498 (1988), which are herein incorporated by reference.
  • cytochrome P-450 enzymes are non-specific to the extent that a single isozyme can react with numerous substrates having widely different chemical structures, and various isozymes are known to have overlapping activity on a single substrate. Accordingly, even though quinidine exerts its most marked effect on debrisoquin hydroxylase, it may suppress a number of other cytochrome P450 enzymes as well, thereby subjecting a patient to a more general loss of normal and desirable liver activity.
  • DM is considered to be a safe drug which is readily available as an over-the-counter medication, it can be used as a convenient tool or probe drug for determining whether a patient is a extensive metabolizer or a poor metabolizer.
  • diagnostic tests are performed so that a patient who is a “poor metabolizer” can be identified and protected against various drugs which he or she cannot metabolize properly.
  • a patient is taking a drug such as quinidine, the level of enzymes will be inhibited, and the diagnostic test for identifying “poor metabolizers” will not be accurate, and will reflect the presence of the inhibitor.
  • DM may cause side effects in some people such as diarrhea, drowsiness, lightheadedness, or loss of appetite, and in some cases, impotence in male patients.
  • side-effects will be increased by antioxidants, in direct proportion to the potency of the antioxidant used. Therefore, the DM-quinidine combination or DM-antioxidant combinations disclosed herein is currently anticipated for use only under the supervision of a physician, who would determine the appropriateness of the treatment. All the appropriate precautions should be taken with the use of any antioxidant, as would be appreciated by a physician and others of skill in the art.
  • the dosage of quinidine that provides a substantial increase in DM concentration in the blood is only a fraction of the dosages normally used for anti-arrhythmic action.
  • DM and antioxidants other than quinidine are preferred for preparing medicaments.
  • individual may not tolerate quinidine or quinidine-DM combinations, for example, when a patient may be allergic to quinidine, or if a patient is suffering from a heart condition known as a prolonged QT interval, and therefore cannot tolerate quinidine.
  • Less potent oxidation inhibitors are also preferred in combination with DM for example, as a second agent that can be alternated with quinidine to avoid developing a tolerance that would require increasing dosages of quinidine; or for patients who have a moderate condition such as coughing that will not respond adequately to other treatments, but which is not severe enough to require a potent enzyme inhibitor.
  • Emotional lability is a complex problem in which patients suffering from bilateral neurological damage typically due to a stroke or head injury or a neurologic disease such as ALS or Alzheimer's disease are unable to control spasmodic emotional outbursts such as explosive laughing or uncontrollable weeping. In patients suffering from brain damage leading to emotional lability, such outbursts often occur at very inappropriate times and without provocation.
  • the ability of DM in conjunction with quinidine to control emotional lability is described in U.S. Pat. No. 5,206,248, issued on Apr. 27, 1993, which is herein incorporated by reference. This effect of DM-quinidine in controlling emotional lability was not observed in any patients who received DM alone.
  • a DM/antioxidant combination can be used to effectively treat severe or intractable coughing, which has not responded adequately to non-addictive, non-steroid medications.
  • Intractable coughing is a consequence of respiratory infections, asthma, emphysema, and other conditions affecting the pulmonary system.
  • Example 5 Tests using a DM-quinidine combination to treat intractable coughing in human patients is described in Example 5 below.
  • treatment with a combination of DM and an antioxidant provided highly beneficial results with minimal side-effects.
  • This invention also discloses the use of DM in combination with an antioxidant in preparing medicaments for treating dermatitis.
  • dermatitis or “eczema” is a skin condition characterized by visible skin lesions and/or an itching or burning sensation on the skin.
  • the effectiveness of the DM-quinidine combination for treating dermatitis was first observed as an unexpected beneficial side effect during testing on an ALS patient who happened to suffer from severe dermatitis. This drug combination showed a beneficial effect on dermatitis when subsequently tested by a dermatologic specialist on a non-ALS patient suffering from severe dermatitis. After these initial results, an additional study was conducted on several patients suffering from dermatitis, by administering DM-quinidine capsules orally. The results showed marked relief from the rash and itching. Topical administration of DM or DM-antioxidant containing medicaments is contemplated for person suffering from dermatitis. These results are described in more detail in Example 6.
  • DM alone can be effective in treating dermatitis for certain patients who are classified as “poor metabolizers” due to a genetic inability to express functional copies of the debrisoquin hydroxylase enzyme.
  • DM alone at safe dosages, will be sufficient to treat the dermatitis effectively without requiring concomitant use of an antioxidant to increase DM levels in the blood.
  • the present invention also provides for the use of DM and an antioxidant in medicaments for the treatment of chronic pains from conditions such as stroke, trauma, cancer, and pain due to neuropathies such as herpes zoster infections, and diabetes.
  • Neuropathic pain includes postherpetic neuralgia, and diabetic neuropathy.
  • Postherpetic neuralgia is a complication of shingles and occurs in approximately 10 percent of patients with herpes zoster. The incidence of PHN increases with age.
  • Diabetic neuropathy is a common complication of diabetes which increases with the duration of the disease.
  • the pain for these types of neuropathies can be described as the following: burning steady pain often punctuated with stabbing pains, pins and needles pain, or toothache-like pain.
  • the skin can be sensitive with dysesthetic sensations to even light tough and clothing.
  • the pain can be exacerbated by activity, temperature change or emotional upset. The pain can be so severe as to preclude daily activities or result in sleep disturbance or anorexia.
  • the mechanisms involving in producing pain of these types are not well understood, but may involve degeneration of myelinated nerve fibers. It is known that in diabetic neuropathy both small and large nerve fibers deteriorate and therefore the thresholds for tolerance of thermal sensitivity, pain, and vibration are reduced over time. Dysfunction of both large and small fiber functions is more severe in the lower limbs when pain develops. Most of the physiological measurement of nerves that can be routinely done in patients experiencing neuropathic pain demonstrate a slowing of nerve conduction over time. To date, treatment for neuropathic pain has been less than universally successful.
  • DM-antioxidants containing medicaments are contemplated for the treatment of sexual dysfunctions including priapism or premature ejaculation.
  • the medicaments used for treating the various disorders described above are prepared from DM and an appropriate antioxidant, or alternatively from the salts and analogs of DM and the various antioxidants.
  • the terms “salt” and “analog” are used in their conventional pharmaceutical sense, and are limited to pharmacologically acceptable and therapeutically effective salts and analogs of dextromethorphan or an antioxidant as discussed herein.
  • pharmacologically acceptable embraces those characteristics which make a salt or analog suitable and practical for administration to humans; for example, such compounds must be sufficiently chemically stable under reasonable storage conditions to have an adequate shelf life, they must be physiologically acceptable when orally ingested, and they must not be addictive or cause unacceptable side effects.
  • Acceptable salts can include alkali metal salts as well as salts of free acids or free bases.
  • Acids that may be employed to form acid addition salts include inorganic acids such as sulfate or chloride salts, as well as organic acids.
  • Alkali metal salts or alkaline earth metal salts might include, for example, sodium, potassium, calcium or magnesium salts. All of these salts can be prepared by conventional means.
  • Various salts of the compounds described herein which are currently in widespread pharmaceutical use are listed in sources well-known to those of skill in the art such as The Merck Index.
  • the constituent used to make a salt of an active drug discussed herein is not critical, provided that it is non-toxic and does not substantially interfere with the desired activity.
  • a pharmaceutical analog refers to a molecule that resembles a referent compound but which has been modified to replace one or more moieties of the referent molecule with alternate moieties or other substituents that do not ionize and dissociate readily, as occurs in salts. For example, if a hydrogen or chloride moiety is replaced by a methyl group, the resulting molecule would be regarded as an analog. To be covered herein, the analog-producing substituent must not destroy the anti-tussive or anti-dermatitis or other activities of the referent molecule.
  • Administration of the medicaments to be prepared from the compounds described herein can be by any method capable of introducing the compounds into the bloodstream. Administration can be orally, or by parenteral, intravenous, or subcutaneous injection, for example, as well as by topical or inhalant formulations. In particular topical administration as lotions or ointments is contemplated to treat dermatitis. Likewise, inhalable aerosols are contemplated for treating intractable coughing.
  • An injectable, topical, or inhalant formulation contains a mixture of active compounds with pharmaceutically acceptable carriers or diluents.
  • Various other formulations for oral and injectable medicaments have been described in U.S. Pat. No. 5,166,207 to Smith, which is herein incorporated by reference.
  • Examples 1 to 3 The initial testing described in Examples 1 to 3 were preformed on patients having amyotrophic lateral sclerosis (ALS, also called Lou Gehrig's disease). At the time it was thought that DM might have an effect in arresting the progression of ALS and other neurological disorders. Although the studies described in Examples 1 to 3 were done on patients suffering from ALS, most of whom are adults more than 40 years old, no differences were detected in the metabolism of DM in ALS patients, compared to reported findings involving adults who do not have ALS or to one-day tests involving healthy volunteers as a control population.
  • ALS amyotrophic lateral sclerosis
  • DM dextromethorphan
  • DR dextrorphan
  • DM and DR urinary levels without quinidine were determined by adding 40 mg of thebaine as an internal standard to 1 mL of urine. To this was added 2000 units of betaglucuronidase in 1 mL of acetate buffer (0.1M, pH 5.0). The mixture was incubated for 18 hours at 37° C. and then extracted by adding 1 mL of phosphate buffer (pH 12, 0.10M) and 7 mL of n-butanol/hexane (10:90 v/v). After mixing and centrifugation, the organic layer was transferred to a clean tube, acidified with 400 uL of 0.01N HCL and 20 microliters (uL) of aqueous phase injected into a high performance liquid chromatography (HPLC) system.
  • HPLC high performance liquid chromatography
  • the HPLC used a phenyl column equilibrated with a mobile phase of acetonitrile:water (51:49 v/v) containing 10 mM KHPO 4 , 10 mM hexane sulfonic acid, pH 4.0 (flow rate 1.2 mL/min). Detection of thebaine, dextromethorphan and dextrorphan was achieved by fluorescence (Kratos FS-980 Fluorometer) with an excitation wavelength of 228 nm and no emission cutoff filter.
  • a gas chromatograph/mass spectroscopy (gc/ms) assay was employed for determining dextromethorphan and dextrorphan levels in the presence of quinidine. Briefly, 0.5 ml urine samples were spiked with 500 nanograms (ng) of dimethacrine. The urine pH was adjusted to 0.5 with 0.1M acetate buffer (usually about 1.0 ml), and beta-glucuronidase was added (2000 units/ml urine). The mixture was incubated and shaken at 37° C. for 18 hours. The urine was subsequently adjusted to pH 10-11 with 1.0 mL of phosphate buffer and the urine extracted with 5 mL of dichloromethane.
  • the dichloromethane extract was evaporated under nitrogen, reconstituted in 300 uL of BSTFA and injected onto a gc/ms analyzer equipped with a capillary SE-30 column.
  • Gas chromatographic conditions were: injector and transfer line temperature 250° C., oven 70° C. to 260° C. at 20° C. per minute, and source temperature 180° C.
  • Detection was by selected ion monitoring at m/z 271 for dextromethorphan, 294 for the internal standard, and 329 for dextrorphan. Typical standard curves for dextromethorphan and dextrorphan were provided.
  • Assay sensitivity was 100 ng/ml for dextromethorphan and 400 ng/ml for dextrorphan.
  • DM was administered at a constant dosage to various individuals, all were healthy volunteers.
  • DM was taken both before and after a candidate antioxidant was taken, and urine samples were collected at appropriate times and analyzed to determine the quantity of DM and its principle metabolite dextrorphan (DRP) in the urine.
  • DRP principle metabolite dextrorphan
  • a candidate antioxidant was administered. These agents included quinine sulfate, disulfiram, cimetidine, fluoxetine, propranolol, and nortriptyline. After an appropriate delay, a second urine sample was obtained and analyzed. Each agent was administered to two patients.
  • the DM/DRP ration increased from 0.02 (pre-quinine baseline) to 0.09; in the other subject, the DM/DRP ration increased from 0.00 to 0.05.
  • the results indicated high levels of variability between different individuals. For example, in the two subjects who took fluoxetine, the DM/DRP ratio for one increased from 0.00 (pre-drug baseline) to 0.11, while in the other, the ratio decreased from 0.03 to 0.00. In the two subjects who took propranolol, the DM/DRP ratio increased from 0.00 to 0.02 in one, while in the other it decreased from 0.02 to 0.00.
  • Patient EAR a 70 year old female, had suffered from a recurrent persistent non-productive cough for several years. This cough would respond to prednisone administration, but it would return shortly after the prednisone was discontinued, and continuous medication with prednisone was deemed to be unacceptable. She had tried various cough syrups, with little benefit, and her cough had not responded well to albuteral (a beta-adrenergic bronchodilator) or ipratropium bromide (an anticholinergic bronchodilator); both were administered using a nebulizer-type inhaler. When she was given 1 capsule per day of 75 mg quinidine and 60 mg DM, the cough initially stopped but returned after several days. When the dosage was increased to 2 capsules/day, the cough stopped and did not return. She reported no side effects.
  • albuteral a beta-adrenergic bronchodilator
  • ipratropium bromide an anticholinergic bronchodilator
  • Patient SP a 38 year old male nonsmoker with no history of asthma, had suffered for about 8 months from a persistent non-productive cough. It receded temporarily when he was given penicillin and a cough syrup with codeine, but it returned after he stopped taking codeine. When he began taking 1 capsule per day of 75 mg quinidine and 60 mg DM, and after a few days, the cough stopped almost completely, and he coughed only rarely during the day. He reported no side effects.
  • Patient RC a 43 year old male nonsmoker with no history of asthma, suffered for about 5 months from a cough, which initially began with an upper respiratory viral infection followed by a bacterial infection. The coughing became so severe that it led to fractured ribs. When he first sought medical attention, the cough produced yellow phlegm. The phlegm was cleared up by antibiotics but the cough persisted despite inhalation treatment for a suspected asthma condition with flunisolide (an anti-inflammatory steroid) and inhalation treatment with albuterol. The cough did not substantially improve when the patient took only 1 capsule/day, but when he began taking 2 capsules/day, it improved by roughly 90% within a few days. Although he occasionally coughed, his condition improved so much that he sometimes forgot to take his medication. He reported no side effects.
  • flunisolide an anti-inflammatory steroid
  • patient BT a Caucasian female in her 60's who was suffering from ALS, suffered from a severe dermatologic condition involving lesions which appear in small patches.
  • Her condition had been diagnosed as atopic dermatitis. The etiology is unknown.
  • the patient reported that the lesions were severely itchy, and she had been suffering from it for roughly ten years.
  • She had been prescribed a number of drugs (including various steroids such as prednisone) in an effort to control the itching; the most recent prescription was “Doxepin,” a tricyclic antidepressant. None of those agents offered much relief.
  • the patient began an initial treatment of quinidine alone (150 mg/day) for a week. After it had been established that she did not have an adverse reaction, she began to receive DM as well, beginning at 30 mg/day, and increasing after 1 month to 120 mg/day.
  • DM/quinidine were taken in capsule form of 30 mg DM and 75 mg quinidine per capsule. The patient was usually re-examined in two weeks, and then again six weeks or more after the initial exam and receiving the DM/quinidine capsules.
  • Patient #1 was a 40 year old female patient who suffered from atopic eczema since birth, which flares up with stress. The patient was initially evaluated using the standardized disease activity scoring system and filling out the subjective itching/rash analysis forms. The initial score was 42. The patient indicated the initial itching score as severe, and rash as severe to moderate.
  • Patient #2 was a fifty five year old male with a 20 year history of chronic eczema. The rash was located mainly on the thighs. The initial total standardized disease activity score was initially 12. The patient received a 30 mg/75 mg dosage of DM/quinidine once a day for 5 days, then every 12 hours for the duration. The patient initially reported severe itching and moderate rash. After about 1 month the lesion score remained at 12, but the patient reported itching was reduced to the low moderate range and the rash was reduced to the moderate to slight range. The medications were eventually discontinued due to side effects.
  • Patient #3 was a fifty four year old male who began suffering from eczema seven or eight years ago.
  • the initial physical exam showed fairly generalized excoriated eczematory dermatitis, which was especially severe on his lower legs. The rash was prone to a secondary infection.
  • the initial lesion score was 112.
  • the patient initially rated his itching as moderate and rash as low moderate.
  • the patient received a 30 mg DM/75 mg quinidine capsule once a day for five days, then every 12 hours for the duration.
  • the patient was again evaluated, and received a lesion score of 90.
  • the overall appearance was reported to be improved, and the rash less red.
  • the patient reported the same degree of itching and rashes.
  • the patient reported some side effects, most of which disappeared after a few days.
  • the patient reported a delay in reaching orgasm, a side-effect which persisted as long as the medications were continued.
  • the following pain studies were undertaken to determine if the dextromethorphan/quinidine composition moderates or arrests chronic pain.
  • the effect of the treatment was determined by a patient questionnaire and clinical assessment of the patients by a study physician.
  • the patient questionnaire asks the patient to assess his or her current level of pain using a linear visual analog scale of 10 where the pain is rated from 10, “pain as bad as it could be” to 0, “no pain”. After taking the medications for several weeks, the patients are asked to indicate the current level of pain, as well as to indicate the degree of pain abatement using a linear visual analog pain relief scale of 10 rated from 10, no pain relief to complete 0, pain relief.
  • the DM dosage administered to the subjects of the study were a total daily dose up to 120 mg of DM, varying with the individual, taken in a capsule formulation in combination with quinidine.
  • Quinidine was administered twice daily with DM up to a total daily dosage 150 mg, varying with the individual subject.
  • Patient #1 was a 73-year-old female, with a history of diabetes diagnosed ten years earlier. She reported burning and tingling of her feet for two years, which had been increasingly bothersome in the past year. The patient noticed the sensations particularly when she was walking or standing and also at night. The patient did not notice any similar sensations in her hands and denied any significant neck or back pain.
  • the neurological exam was normal, except for the sensory portion of the exam which showed decreased appreciation of pinprick, light touch, and vibratory sense in her distal lower extremities.
  • the neurophysiological assessment confirmed a diagnosis of sensorimotor polyneuropathy.
  • the patient Prior to going on medication, the patient filled out a visual analog scale, describing her level of pain both on April 11 and shortly before beginning medication on April 25.
  • the patient initially assessed her pain as 3-4 on the pain scale, with 10 indicating pain as bad as it could be.
  • the patient started her medication shortly thereafter, taking 30 mg of dextromethorphan and 75 mg of quinidine once a day.
  • the follow up exam was give approximately a month later on May 9. The patient reported to be feeling better with much less pain. She noted the tingling in her feet and pain in her right leg was alleviated. Her sleep patterns were the same. She reported there were no side effects taking DM/quinidine at a dosage of 30 mg/75 mg twice a day. At that point her dosages were increased to 60 mg of dextromethorphan and 75 mg of quinidine twice a day.
  • Patient #2 was a 53-year-old male with painful sensations on his right side. This patient had suffered from a stroke in 1991. A CT scan at the time showed a left posterior cerebral infarct. The patient also had coronary artery disease and bypass surgery in 1991, and suffered from diabetes and hypertension. Neurological findings included visual and sensory loss, and right-sided weakness. Over the past 4 to 5 months, the patient had noted a buzzing sensation on his right side and an icy or heat sensation, which affected the right side of his face, arm, chest and leg. His left side was unaffected. This unpleasant sensation was particularly bothersome at night occurring for up to five minutes at a time, and off and on all day long. The buzzing sensation was generally always present.
  • the patient was assessed by the examining physician as having classic symptoms of Dejerine-Roussy Syndrome, which is pain emanating from a diseased thalamus secondary to stroke.
  • Patient #3 was a 63 year old male who had been diagnosed with diabetes for 25 years. He also suffered from arthritis and hypertension. The patient complained of numbness in his hands for two years. In addition, the patient noted that his feet hurt for the past three years. Throbbing pain interfered with sleep and required pain pills. He also had pain at the tip of his buttocks and intermittent neck pain. The neurological examination was remarkable for markedly decreased pinprick sensation in the patient's feed and distal fingers, with normal position sense and slightly decreased vibration sense. The clinical assessment was that the patient had primarily a sensory neuropathy secondary to his diabetes.
  • the patient Prior to starting the DM-quinidine treatment at a dosage of 30 mg dextromethorphan and 75 mg quinidine at twelve hour intervals, the patient completed two visual analog scales describing his level of pain, one on April 11 and one shortly before beginning his medication on May 9. The patient initially rated his pain at between 5 and 6, and one month later as between 6 and 7, with 10 indicating the pain was as bad as it could be. The patient began taking DM-quinidine in the dosage of one tablet of 30 mg of dextromethorphan and 75 of quinidine twice a day.
  • Patient #2 from the pain study described in Example 7 also had suffered from chronic ringing in the ears, known as tinnitus, for a number of years.
  • this patient had taken 30 mg DM/75 mg quinidine capsules twice a day to relieve thalamic pain syndrome resulting from a stroke three years earlier.
  • this patient reported an unexpected and total cessation of his chronic tinnitus.

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EP0788359B1 (fr) 2006-07-12
EP0788359A4 (fr) 1998-08-19
US5863927A (en) 1999-01-26
EP0788359A1 (fr) 1997-08-13
ES2268686T3 (es) 2007-03-16
JPH10505864A (ja) 1998-06-09
EP1634597A1 (fr) 2006-03-15
AU8071894A (en) 1996-04-09
WO1996009044A1 (fr) 1996-03-28

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