Abstract:
The present invention relates to a system and device for preventing stenosis and/or restenosis after an invasive procedure in a body vessel or cavity having an inner wall surface, the system comprising inserting a device coated with a growth arresting, lipid-derived, bioactive substance at a desired location along the inner wall surface of the body vessel or cavity. The present invention provides for the use of c-Jun aminoterminal kinase inhibitor (“JNK Inhibitor”) and certain analogs as restenosis inhibitors, incorporated into a stent.

Description:
BACKGROUND OF THE INVENTION 
       [0001]    Percutaneous coronary intervention (PCI) is used to treat obstructive coronary artery disease by compressing atheromatous plaque to the sides of the vessel wall. PCI is widely used with an initial success rate of over 90%. Approximately 1.2 million angioplasties were conducted in the United States alone in 2000. Despite the frequent application of this procedure and its high initial success rate, the long-term success of PCI is limited by intraluminal renarrowing or restenosis at the site of the procedure. 
         [0002]    The American Heart Association in their 2006 Heart Disease and Stroke Statistics also show long term upward trends in the several main types of cardiovascular procedures and operations. 
         [0003]    Vascular restenosis is a major long-term complication following surgical intervention of blocked arteries by percutaneous transluminal coronary angioplasty (PTCA), atherectomy, laser angioplasty and arterial bypass graft surgery. In about 35% of the patients who undergo PTCA, reocclusion occurs within three to six months after the procedure. The current strategies for treating vascular restenosis include mechanical intervention by devices such as stents or pharmacologic therapies including heparin, low molecular weight heparin, coumarin, aspirin, fish oil, calcium antagonist, steroids, and prostacyclin. 
         [0004]    In-stent restenosis is believed to be due to neointimal hyperplasia (Serruys et al., 1994, N. Engl. J. Med., 331:489). Stent-induced mechanical arterial injury and a foreign-body response to the prosthesis are believed to result in acute and chronic inflammation in the vessel wall, leading to production of cytokines and growth factors (Serruys et al., 1994, N. Engl. J. Med., 331:489). These are believed to activate multiple signaling pathways, inducing vascular smooth muscle cell (VSMC) proliferation, which is believed to result in neointimal hyperplasia (Serruys et al., 1994, N. Engl. J. Med., 331:489). In addition to VSMC proliferation, VSMC migration and phenotypic differentiation, as well as extracellular matrix formation and degradation are believed to determine the extent of neointimal formation (Newby and George, 1996, Curr. Opin. Cardiol., 11:547). The predominant feature of late restenosis lesions is a large amount of extracellular matrix with a reduced number of smooth muscle cells, whereas in the early stages of intimal thickening formation the number of smooth muscle cells is increased (Pauletto et al., 1994, Clin. Sci., 87:467). To successfully prevent neointimal formation and restenosis, compounds that exert multifactorial effects on cellular activation and extracellular matrix constituents are likely to be necessary, and restenosis prevention using an approach that targets only one causative factor is believed to lack promise (Rosanio et al., 1999, Thromb. Haemost., 82(S1):164). 
         [0005]    In the pathogenesis of restenosis excessive cell proliferation and migration occurs as a result of growth factors produced by cellular constituents in the blood and the damaged arterial vessel wall that mediate the proliferation of smooth muscle cells in vascular restenosis. Agents that inhibit the proliferation and/or migration of smooth muscle are useful in the treatment and prevention of restenosis. Further, agents that inhibit the inflammatory response of smooth muscle are useful in the treatment and prevention of restenosis. 
         [0006]    Stent placement has largely supplanted balloon angioplasty because it is able to more widely restore intraluminal dimensions, which has the effect of reducing restenosis by approximately 50%. Ironically, stent placement actually increases neointimal growth at the treatment site, but because a larger lumen can be achieved with stent placement, the tissue growth is more readily accommodate, and sufficient luminal dimensions are maintained, so that the restenosis rate is nearly halved by stent placement compared with balloon angioplasty alone. 
         [0007]    The pathophysiological mechanisms involved in restenosis are not fully understood. While a number of clinical, anatomical and technical factors have been linked to the development of restenosis, at least 50% of the process has yet to be explained. However, it is known that following endothelial injury, a series of repair mechanisms are initiated. Within minutes of the injury, a layer of platelets and fibrin is deposited over the damaged endothelium. Within hours to days, inflammatory cells begin to infiltrate the injured area. Within 24 hours after an injury, vascular smooth muscle cells (SMCs) located in the vessel media commence DNA synthesis. A few days later, these activated, synthetic SMCs migrate through the internal elastic lamina towards the luminal surface. A neointima is formed by these cells by their continued replication and their production of extracellular matrix. An increase in the intimal thickness occurs with ongoing cellular proliferation matrix deposition. When these processes of vascular healing progress excessively, the pathological condition is termed intimal hyperplasia or neointimial hyperplasia. Histological studies in animal models have identified neointimal hyperplasia as the central element in restenosis. 
         [0008]    The responses to vascular injury that lead to restenosis have certain features in common with the processes leading to the development of the vascular lesions of atherosclerosis. Currently, it is understood that the lesions of atherosclerosis are initiated by some form of injury to arterial endothelium, whether due to hemodynamic factors, endothelial dysfunction or a combination of these or other factors (Schoen, “Blood vessels,” pp. 467-516 in Pathological Basis of Disease (Philadelphia: Saunders, 1994)). Inflammation has been implicated in the formation and progression of atherosclerotic lesions. Several inflammatory products, including IL-1.beta., have been identified in atherosclerotic lesions or in the endothelium of diseased coronary arteries (Galea, et al. (1996) Arterioscler Thromb Vasc Biol. 16:1000-6). Also, serum concentrations of IL-1.beta. are elevated in patients with coronary disease (Hasdai, et al. (1996) Heart, 76:24-8). Realizing the importance of inflammatory processes in the final common pathways of vascular response to injury allows analogies to be drawn between the lesions seen in restenosis and those seen in atherosclerosis. 
         [0009]    Historically, approximately 1.2 million patients per year undergo PCI procedures. Restenosis and progressive atherosclerosis are the most common mechanisms for late failure in these reconstructions. Accordingly, there remains a need for devices and therapeutic methods to reduce restenosis as brought about by cell growth and inflammation that lead to arteriosclerosis. 
         [0010]    Since the first performance of percutaneous transluminal coronary angioplasty (PTCA) in 1977, this procedure has become a widely accepted treatment modality for coronary artery disease (CAD) managing both single and multivessel disease. 
         [0011]    However, all percutaneous techniques, regardless of the mode of intervention, have rather high rates of repeat interventions at long-term follow-up, representing a principle limitation of such a strategy. Stents appeared to the only device impacting, significantly, both acute and longterm outcome. Nevertheless, stents did not resolve the problem of restenosis which still occurs in at least 20-30% of the patients undergoing stent assisted percutaneous coronary interventions (PCI). 
         [0012]    The advent of drug-eluting stents (DES) has dramatically reduced restenosis. A pooled analysis documented a 74% reduction in the risk of target lesion revascularization from the use of sirolimus-eluting stents (SES) (Cypher, Johnson &amp; Johnson, Miami Lakes, Fla.) or paclitaxel-eluting stents (PES) (TAXUS, Boston Scientific Corp., Natick, Mass.) compared to bare-metal stents (BMS). However, certain subset of patient still has significant restenosis rate after being treated with DES, such as diabetic, small vessel, and bifurcation lesion. 
         [0013]    Based on a number of clinical reports, concerns have been raised about an increased risk of stent thrombosis with DES compared to BMS. Stent thrombosis is an uncommon but often devastating complication of coronary stent implantation. Numerous studies have sought to determine the causes of stent thrombosis, as well as any predictors of risk. Premature discontinuation of antiplatelet therapy is strongly associated with the development of stent thrombosis. The delayed healing of the endothelium by the currently available DES due to potent antiproliferative effect of the drugs are other possible causes of late stent thrombosis. 
         [0014]    Of the currently approved drug-eluting stents, the TAXAS stent uses the antiproliferative paclitaxel, while the CYPHER sirolimus-eluting coronary stent elutes a substance that limits the overgrowth of normal tissue. Some of the remaining problems with current stents include the toxicity of some of the antiproliferatives, and the rather limited shelf life of these products. 
         [0015]    Accordingly, there still remains a need for drug-eluting stents that have reduced toxicity and greater shelf life, while offering equal or greater restenosis prevention or amelioration performance. 
       SUMMARY OF THE INVENTION 
       [0016]    The present invention relates to a system and device for preventing stenosis and/or restenosis after an invasive procedure in a body vessel or cavity having an inner wall surface, the system comprising inserting a device coated with a growth arresting, lipid-derived, bioactive substance at a desired location along the inner wall surface of the body vessel or cavity. The present invention provides for the use of c-Jun aminoterminal kinase inhibitor of either JNK 1 and/or JNK 2 (“JNK Inhibitor”) and certain analogs as restenosis inhibitors, incorporated into a stent. 
         [0017]    Included in the present invention is a stent for implantation into body tissue, preferably comprising a surface and a coating disposed on the surface, wherein the coating comprises at least one JNK Inhibitor. 
         [0018]    The JNK Inhibitor may be selected from any such compositions, such as pyrazoloanthrone and derivatives thereof, such as those described in United States Patent Application Nos. 20040176434 and 20040072888 (hereby incorporated by reference), and including by example anthra(1,9-cd)pyrazol-6(2H)-one 1,9-pyrazoloanthrone or analogue thereof (identified as SP600125, commercially available from A.G. Scientific or San Diego, Calif.). Anthra(1,9-cd)pyrazol-6(2H)-one1,9-pyrazoloanthrone (SP600125) (described in SP600125, an anthrapyrazolone inhibitor of Jun N-terminal kinases: B. L. Bennett, et al.;  Proc. Natl. Acad. Sci. U.S.A.  98, 13681 (2001); hereby incorporated herein by reference), a pharmacological inhibitor of the c-Jun N-terminal kinase (JNK), can reduce plaque formation in animal model. See Requirement of JNK2 for Scavenger Receptor A-Mediated Foam Cell Formation in Atherogenesis: R. Ricci, et al.;  Science  306, 1558 (2004), which is hereby incorporated herein by reference. 
         [0019]    SP600125 (chemical formula: C 14 H 8 N 2 O) is a potent, cell permeable, selective, and reversible inhibitor of c-Jun N-terminal kinase (JNK) (IC50=40 nM for JNK-1 and JNK-2 and 90 nM for JNK-3), and exhibits over 300-fold greater selectivity for JNK as compared to ERK1 and p38. It is described in B. L. Bennett, et al.; PNAS 98, 13681 (2001), which is hereby incorporated herein by reference. 
         [0020]    Using SP600125 as the main drug or in combination with at least one other drug (particularly at a lower dosage of sirolimus) on the drug-eluting stent (DES) of the present invention, will expand the efficacy and safety beyond that in current DES systems. 
         [0021]    The stent may be made in accordance with techniques known and used in the art for making drug-eluting stents, especially those adapted to elute relatively hydrophobic materials. Examples are discussed in The Handbook of Drug-Eluting Stents, by Ong, Lemos, Gerschlick and Serruys, Martin Dunitz Ltd. (2005), hereby incorporated herein by reference, and as described in the patents referenced herein. 
         [0022]    The stent coating may also be in the form of a polymer containing the JNK inhibitor(s). Acceptable polymers may be biodegradable or non-biodegradable. It is preferred that the polymer forms a biocompatible matrix to allow elution of the anthra(1,9-cd)pyrazol-6(2H)-one 1,9-pyrazoloanthrone or analogue thereof. Other stents that may be used include stents of biodegradable magnesium. 
         [0023]    While any concentration of the JNK inhibitor(s) may be used in the polymer with due regard to the release rate and intended vascular environment, in most cases the coating is preferably adapted to release a dosage sufficient to inhibit at least 50% of the enzyme activity (typically measured in vitro), such as at least about 5 nanograms of anthra(1,9-cd)pyrazol-6(2H)-one 1,9-pyrazoloanthrone or analogue thereof per milliliter of blood volume at a selected stent implantation site, and preferably within a range of from about 5 to about 10 nanograms of anthra(1,9-cd)pyrazol-6(2H)-one 1,9-pyrazoloanthrone or analogue thereof per milliliter of blood volume at a selected angioplasty or stent implantation site. The concentration should be sufficient to release a dosage of anthra(1,9-cd)pyrazol-6(2H)-one 1,9-pyrazoloanthrone or analogue thereof sufficient to inhibit the phosphorylation of c-Jun and the expression of at least one of the inflammatory genes COX-2, IL-2, IFN-g and TNF-a (IC50=5-10 mM) in Jurkat T cells, preferably at a level of I.C. 50 (that being sufficient to reduce the activity of the enzyme at least 50 percent). 
         [0024]    The present invention also includes a stent as described herein for implantation into body tissue comprising an open-ended tubular structure having a sidewall with apertures therein, wherein the sidewall comprises an outer surface having a coating disposed thereon; the coating comprises anthra (1,9-cd)pyrazol-6(2H)-one 1,9-pyrazoloanthrone or analogue thereof and a polymer, and the coating releases a dosage of about 5 to 10 nanograms of anthra (1,9-cd)pyrazol-6(2H)-one 1,9-pyrazoloanthrone or analogue thereof per milliliter of blood volume at a selected stent implantation site. 
         [0025]    The present invention also includes a method of treating or inhibiting restenosis comprising administering to an individual in need thereof an effective amount of an active ingredient selected from the group consisting of at least one c-Jun amino terminal kinase inhibitor, through insertion into the individual of a drug-eluting stent comprising said active ingredient. 
         [0026]    It is preferred that the c-Jun inhibitor comprises anthrax (1,9-cd)pyrazol-6(2H)-one 1,9-pyrazoloanthrone or analogue thereof. The dosage may be any effective amount as described above, and typically is administered at a dosage level of that at least that sufficient to reduce the activity of the JNK enzyme. 
         [0027]    The JNK inhibitor may be administered contemporaneous with a stent placement, the day of angioplasty procedure or placement, or even after such procedure or placement. 
         [0028]    In another aspect, the invention provides a method of treating a mammalian subject to prevent stenosis or restenosis of a blood vessel, comprising the step of administering to a mammalian subject in need of treatment to prevent stenosis or restenosis of a blood vessel a composition comprising a JNK inhibitor, in an amount effective to prevent stenosis or restenosis of the blood vessel, by implanting an intravascular stent in the mammalian subject, where the stent is coated or impregnated with the composition as described herein. 
         [0029]    Exemplary materials for constructing a drug-coated or drug-impregnated stent are described in literature cited herein and reviewed in Lincoff et al., Circulation, 90: 2070-2084 (1994), incorporated herein by reference. 
         [0030]    In another preferred embodiment, the composition comprises microparticles composed of biodegradable polymers such as PGLA, non-degradable polymers, or biological polymers (e.g., starch) which particles encapsulate or are impregnated by the JNK inhibitor. Such particles are delivered to the intravascular wall using, e.g., an infusion angioplasty catheter. Other techniques for achieving locally sustained drug delivery are reviewed in Wilensky et al., Trends Caridovasc. Med., 3:163-170 (1993), incorporated herein by reference. 
         [0031]    Administration via one or more intravenous injections subsequent to the angioplasty, bypass or stent-inserting procedure also is contemplated. 
         [0032]    In yet another embodiment, the invention provides the use of a JNK inhibitor for the manufacture of a medicament for the treatment or prevention of stenosis or restenosis of a blood vessel. It is preferred that the medicament include at least one other antiproliferative or anti-inflammatory agent. One of the advantages of this embodiment of the present invention is that these additional agents may be used at concentrations lower than that is stents currently in use. For instance, the stent may use an antiproliferative, such as paclitaxel, at a dosage level lower than that in the TAXAS stent. It may also contain sirolimus, used at a dosage level lower than that currently used in the CYPHER sirolimus-eluting coronary stent. 
     
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT 
       [0033]    The present invention is based on the discovery that when one or more JNK inhibitor is incorporated into a stent to be administered through elution to a mammal that has suffered a vascular trauma, such as the trauma that can occur during conventional balloon angioplasty procedures or stent implantation, restenosis of the injured vessel is reduced or eliminated. 
         [0034]    The JNK inhibitor may be incorporated into a stent using a polymeric matrix that is used to coat the stent body, in accordance with designs known and used in the art. 
         [0035]    As the JNK inhibitor used in accordance with the present invention includes pyrazoloanthrone and derivatives thereof, one may use any polymer or combinations thereof adapted to contain and elute substances of this type. Suitable polymers may include hydrophobic polymers or mixtures of polymers or co-polymers having some hydrophobic character. Examples include a pegylated styrenic block copolymer matrix as described in U.S. Pat. No. 6,918,929, hereby incorporated herein by reference. 
         [0036]    The concentration of the pyrazoloanthrone or derivative may be provided in the polymeric matrix so as to provide an effective dosage to tissue in the region of the stent site. The drug-polymer coating may comprise between 0.5 percent and 50 percent of the pyrazoloanthrone or derivative by weight. The drug-polymer coating typically has a thickness between 0.5 microns and 20 microns on the stent surface. 
         [0037]    In the preferred embodiment, the stent of the present invention is provided with sufficient JNK inhibitor (i.e., an inhibitor of either JNK1 or JNK2) sufficient to provide and I.C. 50 level; an amount sufficient to inhibit 50% of the JNK enzyme. 
         [0038]    It is also preferred that the stent contain at least one additional active ingredient selected from the group consisting of antiproliferatives, most preferably at levels lower than that used in current stent formulations. The stent may also contain additional anti-inflammatory agents. One of the advantages of this embodiment is that lower levels of those active ingredients, such as antiproliferatives, may be used in combination while lowering the overall toxic effect of the stent. The combination of the JNK inhibitor(s) with an antiproliferative will be able to achieve better results that the use of the JNK inhibitor(s) alone, while having overall reduced toxicity associated higher dosage levels of antiproliferatives as in current stent formulations. 
         [0039]    The preferred concentration of the JNK inhibitor is that effective to provide a concentration in the range of from about 5 to about 10 nanograms per milliliter at the site of the stent. 
         [0040]    The methods and devices described above can be accomplished with many embodiments of stents. Additionally, many stent materials and ancillary drug compounds may be substituted for the supplementary drugs described. Thus, while the preferred embodiments of the devices and methods have been described in reference to the environment in which they were developed, they are merely illustrative of the principles of the inventions. Other embodiments and configurations may be devised without departing from the spirit of the inventions and the scope of the appended claims. 
       REFERENCES 
       [0041]    The following references are hereby incorporated herein by reference: 
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         [0292]    PAT. NO. Title
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