Link:  Pharm/Biotech Resources

Title:  Method for regulation of microvascular tone

United States Patent:  6,916,852

Issued:  July 12, 2005

Inventors:  Moore, II; Bob M. (Nesbit, MS)

Assignee:  University of Tennessee Research Foundation (Knoxville, TN)

Appl. No.:  436028

Filed:  May 12, 2003

Methods and kits for regulating arterial microvascular tone in which a COX-2 inhibitor and a cannabinoid receptor agonist are co-administered to a subject.

FIELD OF THE INVENTION

The invention pertains to the field of administration of pharmacologic chemical compounds to regulate the tone of small blood vessels.

BACKGROUND OF THE INVENTION

The circulatory system in humans and other vertebrate animals includes a heart, which pumps blood throughout the body, and a vascular system, which is a series of tubes supplying blood to all regions of the body. The blood leaves the heart through arteries, which transport the blood under high pressure to the tissues of the body. Blood returns to the heart from the tissues through veins. The arteries repeatedly subdivide into progressively thinner tubes and eventually give rise to arterioles. The arterioles feed into capillaries, which are thin walled structures through which oxygen exchange occurs within tissues. Blood from the capillaries then enters small venous structures called venules, which merge repeatedly to form veins, which carry the blood back to the heart. Collectively, the arterioles, capillaries, and venules are referred to as the "microvasculature".

The arterioles, unlike the other portions of the microvasculature, have smooth muscle fibers in their walls. These fibers regulate blood flow into and through the microvasculature by contracting and dilating as needed. In this way, the arterioles control the distribution of blood in the body and maintain systemic blood volume and arterial blood pressure within physiologic limits.

Shock is a progressive, widespread reduction in tissue perfusion that results from a decrease in effective circulating blood volume causing a decrease in oxygen delivery and exchange within capillaries. If untreated, shock is often fatal.

Shock may be due to several causes, which has led to the classification of shock into several categories. Thus, shock due to loss of blood volume due, for example, to hemorrhage or to microvascular blood pooling, is termed hypovolemic shock. Shock due to failure of the heart to adequately pump blood throughout the body is termed cardiogenic shock. Shock has also been classified as being vasogenic, that is due to a maldistribution of blood to the tissues, such as due to acute vasodilation without a concomitant increase in intravascular volume, resulting in inadequate tissue perfusion. Vasogenic shock is seen with shock due to sepsis, anaphylaxis, and neurogenic injury. Regardless of the cause of shock, however, if untreated shock can lead to severe complications including myocardial depression, acute respiratory distress, renal failure, disseminated intravascular coagulation, and death.

Shock is treated by diagnosing and correcting, if possible, the underlying cause of the shock, such as by controlling bleeding or re-starting the heart, treating the effects of shock, such as administering oxygen and correcting acid-base imbalance, and by supporting vital functions, such as by administering fluids to maintain blood pressure and heart function. Medications that are useful in combating shock include inotropic drugs to increase the strength of cardiac contraction, corticosteroids which stabilize membranes, vasopressors which cause constriction of blood vessels and thus help to maintain arterial blood pressure, and narcotics to relieve pain and anxiety associated with shock.

However even with such treatment, severe shock, due to any or a combination of causes, may progress and result in permanent complications or death. Thus, there is an ongoing need to develop new and additional methods for treating and for preventing shock.

Cannabinoids are a class of chemical compounds that are naturally produced in plants and in animals. Plant produced cannabinoids include Δ⁹-tetrahydrocannabinol (THC) and Δ⁸-tetrahydrocannabinol, the first of which is the psychotropic principle in marijuana. Cannabinoids that are endogenously produced in animals are referred to as endocannabinoids, and include arachidonyl ethanolamide (anandamide) and 2-arachidonyl glycerol (2-AG). Additionally, there are a large number of synthetic cannabinoid analogs, including synhexyl, nabilone, and non-classical cannabinoids, such as CP55940, aminoalkylindole (WIN 55212), and diarylpyrazoles.

Kunos, et al., U.S. Pat. No. 5,939,429, incorporated herein by reference, discloses that cannabinoids may be useful in treating hemodynamic abnormalities such as hypotension or hypertension. As disclosed in Kunos, administration of a cannabinoid receptor agonist, such as anandamide, causes hypotension. Conversely, administration of a cannabinoid receptor antagonist, such as SR141716A, prevents anandamide-induced hypotension. Thus, Kunos concluded that the use of a drug that selectively blocks cannabinoid receptors will be of therapeutic value by preventing or attenuating endotoxin-induced hypotension. Additionally, because agonists of cannabinoid receptors lower blood pressure, Kunos concluded that such agents could be used to treat conditions associated with excessive vasoconstriction, such as hypertension, peripheral vascular disease, or angina pectoris.

The hypotensive effect of cannabinoids has been reported widely in the scientific literature. Each of the following scientific references is incorporated herein by reference and discloses that cannabinoids cause hypotension when administered to animals. (1) Kunos, G., et al., Prostaglandins & other Lipid Mediators, 61:71-84 (2000); (2) Lake, K D, et al., Journal of Pharmacology and Experimental Therapeutics, 281(3):1030-1037 (1997); (3) Hilliard, C J, Journal of Pharmacology and Experimental Therapeutics, 294(1):27-32 (2000); (4) Brown, D J, et al., Journal of Pharmacology and Experimental Therapeutics, 188(3):624-629 (1974); (5) Adams, M D, Journal of Pharmacology and Experimental Therapeutics, 196(3):649-656 (1976); (6) Kunos, G, et al., Chemistry and Physics of Lipids, 108:159-168 (2000); (7) Wagner, J A, et al., Journal of Molecular Medicine, 76:824-836 (1998); (8) Siqueira, S W, et al., European Journal of Pharmacology, 58:351-357 (1979); and (9) Wagner, J A, et al., Nature, 390:518-521 (1997). Adams, reference (5) above, discloses that, although intravenously administered Δ⁹-tetrahydrocannabinol or Δ⁸-tetrahydrocannabinol caused decreases in blood pressure, intra-arterially administered Δ⁹-tetrahydrocannabinol or Δ⁸-tetrahydrocannabinol produced an increase in blood pressure indicative of vasoconstriction. When administered intravenously, Adams reports that THC produced a transient increase in blood pressure that lasted only about one minute and that was followed by a more prolonged hypotensive response. Wagner, reference (8) above, discloses that administration of the cannabinoid THC or HU-210 doubled survival time from about 30 minutes to 60 minutes in rats that were subsequently bled. Wagner states that the mechanism for this improvement in survival is unclear and speculates that it may be due to a favorable redistribution of cardiac output or improved microcirculation by localized vasodilation.

Kunos, U.S. Pat. No. 5,939,429, further suggests that activation of cannabinoid receptors may be beneficial for survival in hemorrhagic shock, probably because the hypotension caused by the cannabinoid agonist counters the excessive compensatory hypertension that occurs following hemorrhage. It is because of this vasodilatory effect that cannabinoid receptor agonists are suggested to be useful in the treatment of hemorrhagic shock and other conditions associated with excessive vasoconstriction, such as hypertension, peripheral vascular disease, and certain forms of angina pectoris.

Information on the blood pressure effects of COX-2 inhibitors is inconclusive. Johnson, D L, The Annals of Pharmacotherapy, 37:442-446 (March 2003) reported on several studies of the effects of COX-2 inhibitors on blood pressure and on reports of elevated blood pressure as an adverse effect of COX-2 inhibitors. Johnson discloses that were inconclusive. Short-term trials suggested that COX-2 inhibitors have no effect on blood pressure on normotensive patients, although these studies may have been flawed because the study subjects were restricted to a low-sodium diet. In another study in which patients were administered either rofecoxib or celecoxib for six weeks, rofecoxib was found to elevate blood pressure and the results on celecoxib were inconclusive. Johnson also reported that some limited data suggests that blood pressure may increase following initiation of therapy with COX-2 inhibitors. Johnson concluded by stated that despite the information provided, it is currently unknown whether an association exists between COX-2 inhibitor therapy and blood pressure elevations. Johnson did not disclose or suggest any effect of COX-2 inhibitors on arterial microvasculature.

Dilger K., et al., Journal of Clinical Pharmacology, 42:985-994 (2002) evaluated the effects of celecoxib, a specific COX-2 inhibitor, and diclofenac, a non-specific COX inhibitor, on blood pressure, renal function, and vasoactive prostanoids in both young and elderly patients. Dilger concluded that their study provided evidence that therapeutic doses of either celecoxib or diclofenac given for 15 days are apparently not associated with significant changes in blood pressure or renal function in healthy young or elderly subjects. Dilger did not disclose or suggest any effect of COX inhibitors on arterial microvasculature.

To date, other than the Adams reference (5) described above which discloses intra-arterial administration of THC, there have been no published reports on the use of either a cannabinoid receptor agonist or a COX-2 inhibitor to cause constriction of arterial microvasculature.

DESCRIPTION OF THE INVENTION

It has been unexpectedly discovered that the microvascular tone, particularly of striated muscle, may be regulated by using a combination of a COX-2 inhibitor and a cannabinoid receptor agonist (CRA). This combination provides a synergistic effect when administered to a vertebrate animal and produces a pronounced, prolonged constriction of arterial microvasculature, especially in the microvasculature of striated muscle. While not wishing to be bound by theory, it is conceived that the combination of COX-2 inhibitor and CRA has a preferential effect in causing constriction of arterial vasculature of striated muscle while having a lesser effect in the splanchnic vasculature. This results in a shunt of blood flow away from skeletal and other striated muscle, which makes a greater volume of blood available for other organs, such as vital organs like the brain and abdominal organs.

In one embodiment, the invention is a method for causing constriction of arterial microvasculature in a vertebrate subject. According to this embodiment, a cannabinoid receptor agonist, hereafter referred to as a cannabinoid or a CRA, is co-administered with a COX-2 inhibitor to a subject in a combined dose effective to cause constriction of arterial microvasculature within the subject.

In another embodiment, the invention is a method for countering the tendency of an administered CRA to cause dilation of arterial microvasculature in a vertebrate subject. According to this embodiment, a COX-2 inhibitor is co-administered with the CRA to a subject in a dose effective to reduce or to block the dilation that would occur if the CRA were administered without the COX-2 inhibitor. Thus, according to this embodiment of the invention, co-administration of a COX-2 inhibitor and a CRA causes a lesser drop in blood pressure compared to that which would otherwise occur following administration of a CRA alone.

In another embodiment, the invention is a method for increasing blood pressure in a vertebrate subject. According to this embodiment, a CRA is co-administered with a COX-2 inhibitor to a subject in a combined dose effective to cause an increase in the blood pressure of the subject. In a preferred embodiment, at the time of the co-administration, the subject is suffering from an acute decrease in blood pressure.

In another embodiment, the invention is a method for treating a bodily disorder associated with hypotension. According to this embodiment, a CRA is co-administered with a COX-2 inhibitor to a vertebrate subject suffering from such a disorder or to a subject at risk of suffering from such a disorder in a combined dose effective to cause an increase in the blood pressure of the subject or to prevent a decrease in the blood pressure of the subject.

In another embodiment, the invention is a kit for regulating microvascular tone. According to this embodiment, the kit includes a package containing a COX-2 inhibitor and a CRA, either in separate containers or combined within a single container. Preferably, the kit further contains instructions for co-administering the COX-2 inhibitor and the CRA to a patient in need thereof in order to achieve any or all of the aims of the above-described methods.

The invention, in any or all of its embodiments, is useful in both a therapeutic and experimental situations. For example, the invention may be used to control acute hypotension, such as that associated with disorders like shock. The invention may also be used to control acute hypotension associated with idiosyncratic reactions to the administration of general, spinal, or epidural anesthetic agents.

The method of the invention is useful in any animal that has a circulatory system containing a splanchnic and striated arterial microvasculature. Thus, the invention is useful in vertebrates, including non-mammal vertebrates such as fish, amphibians, reptiles, and birds. The invention is useful in mammals, such as domestic or non-domestic felines, canines, ungulate ruminants and non-ruminants, non-ungulate ruminants, rodents, lagomorphs, pinnipeds, and human and non-human primates. Further, because interspecies responses to COX-2 inhibitors and to cannabinoid receptor agonists is conserved, data obtained in animal studies relating to responses to either or both of these chemical compounds is applicable to humans.

As used in this specification, the term "COX-2 inhibitor" refers to those chemical agents that inhibit the cyclooxygenase (COX) activity of the inducible isoform of prostaglandin H synthase. For purposes of this specification, a COX-2 inhibitor may have effects other than inhibition of cyclooxygenase-2. For example, a COX-2 inhibitor that is suitable for the present invention may also inhibit the COX-1 isoenzyme or have additional pharmacologic effects unrelated to cyclooxygenase-1 or cyclooxygenase-2. Thus for example, indomethacin, a chemical compound that binds to both COX-1 and COX-2 enzymes, is suitable, although not preferred, as the COX-2 inhibitor of the invention. Similarly, other chemical compounds that are non-specific COX-1 and COX-2 inhibitors, such as piroxicam, brand name FELDENE™ (Pfizer, New York, N.Y., USA) and tenoxicam, are conceived to be suitable for the present invention.

Examples of COX-2 inhibitors that are suitable for present invention include rofecoxib, brand name VIOXX™ (Merck & Co., Inc. Whitehouse Station, N.J., USA); celecoxib, brand name CELEBREX™ (Pfizer); valdecoxib, brand name BEXTRA™ (Pharmacia Corp., Peapack, N.J., USA); paracoxib, brand name DYNASTAT™ (Pharmacia Corp.); etoricoxib, brand name ARCOXIA™ (Merck & Co., Inc.); NS-398 ((N-(2-cyclohexyloxy-4-nitrophenyl) methane sulphonamide); as well as other COX-2 inhibitors, either those that are presently known or those that will be discovered in the future.

As used in this specification, the terms "cannabinoid" and "cannabinoid receptor agonist", which is often abbreviated "CRA", are synonymous. A CRA is a chemical compound that is an agonist ligand of a cannabinoid receptor, either or both of cannabinoid CB-1 or CB-2 receptors. Preferably, the CRA binds to and is an agonist of the CB-1 receptor. CRAs that are suitable for the invention include plant cannabinoids such as Δ⁹-tetrahydrocannabinol (THC) and Δ⁸-tetrahydrocannabinol, endogenous cannabinoids known as endocannabinoids such as anandamide (ANA) and 2-arachidonyl glycerol (2-AG), synthetic cannabinoids including both classical and non-classical cannabinoids, and cannabinoids that are presently known or that are discovered in the future. An example of a preferred CRA is methanandamide.

As used herein, the term "co-administer" as it pertains to a COX-2 inhibitor and a CRA means to administer the COX-2 inhibitor and the CRA to a subject at the same time or close enough in time so that the combination of the COX-2 inhibitor and the CRA will provide its synergistic effect. Thus, the COX-2 inhibitor and the CRA may be administered simultaneously, which is preferred. Such simultaneous administration may be by combining the COX-2 inhibitor and the CRA in the same administrating device such as a syringe or by simultaneous administration from different administrating devices. Alternatively, co-administration may by administration of the COX-2 inhibitor followed by administration of the CRA, or by administration of the CRA followed by administration of the COX-2 inhibitor.

As used herein in reference to the effects of administration of a CRA, a COX-2 inhibitor, or the combination of a CRA and a COX-2 inhibitor, an acute vasoactive effect is one which occurs as a direct result of the administration on the arterial microvasculature. This is in contrast to a chronic or long-term effects on blood pressure of the administration of either or both of the CRA and the COX-2 inhibitor, such as due to a change in glomerular filtration or sodium retention which would cause a change in blood pressure typically occurring over an extended course of treatment.

In accordance with the method of the invention, a CRA and a COX-2 inhibitor are co-administered to a patient in need thereof at a combined dosage effective to cause a constriction of striated muscle arterial microvasculature. The co-administration may be before a subject suffers a decrease in blood pressure, such as prior to anesthesia or following a wound but before sufficient blood has been lost to cause a significant drop in blood pressure, or may be following a decrease in blood pressure, such as in a patient suffering from shock, such as hemorrhagic or other cause of shock.

The amount of each of these two pharmacological agents, the CRA and the COX-2 inhibitor, will vary depending upon several factors, including the size of the patient, whether the administration is provided following the onset of loss of blood pressure or in order to prevent a loss of blood pressure in an at-risk individual, and the particular CRA and COX-2 inhibitor that are utilized.

Generally, the preferred amount of CRA that is administered is that which, without a COX-2 inhibitor, causes a response in the microvasculature of striated muscle. Thus, the preferred amount of Δ⁸-THC to be administered is about 8 mg/kg or higher, more preferably, 10 mg/kg or higher, and most preferably 12 mg/kg. However, lower amounts of Δ⁸-THC may be used in accordance with the invention, if desired, for example if such lower doses provide a constriction of arterial microvasculature, alone or when co-administered with a COX-2 inhibitor.

Generally, the preferred amount of COX-2 inhibitor that is administered is the dosage that is stated in the literature. For example, a preferred dosage of celecoxib disclosed in the Physicians Desk Reference, Medical Economics Company, Inc., Montvale N.J., USA (2001), to be about 100 to 200 mg, which is about 1 to 2 mg/kg. However, lower amounts of celecoxib may be used in accordance with the invention, if desired, for example if such lower doses provide a synergistic effect when co-administered with a CRA.

In accordance with the invention, there is no maximum of either the CRA or the COX-2 inhibitor that is administered. Such maximum dosage of administration is limited, however, by the potential of the occurrence of unwanted pharmacologic effects at high doses.

Constriction of arterial microvascular may be determined by any means that is known or is to be discovered. Such means may be direct or indirect. For example, constriction of arterial microvascular may be determined by studies on the hemodynamic effect in whole animals, perfused vascular beds, or on isolated segments of arteries. Such studies are not preferred because they do not definitively establish that the hemodynamic effect is caused by arteriolar vasoconstriction or do not definitively establish that the response obtained would be that obtained in an intact, whole animal.

Thus, it is preferred that constriction of arterial microvasculature be determined by a technique that provides direct real-time visualization and assessment of microvasculature in vivo. One such technique is intravital microscopy. See, Koller, A. and Johnson, P C, Methods for in vivo mapping and classifying microvascular networks in skeletal muscle, eds. Popel, A S and Johnson P C, Karger, New York (1986), incorporated herein by reference.

Claim 1 of 26 Claims

. A method for causing constriction of arterial microvasculature comprising co-administering to a vertebrate subject an effective amount of a cannabinoid receptor agonist and a COX-2 inhibitor.

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