Methods relating to the use of remote ischemic conditioning

The invention contemplates, inter alia, the use of remote ischemic conditioning in the treatment of a variety of disorders.

FIELD OF THE INVENTION

The invention provides methods and compositions for treatment of various conditions using ischemic conditioning.

SUMMARY OF INVENTION

Remote ischemic conditioning (RIC) has a beneficial effect on human diseases involving ischemia and reperfusion injury. These effects are believed to be mediated, in part, by direct cellular activation of pro-survival pathways. These effects are also believed to be mediated, in part, by modification of the ischemic milleu, including modification of cytokine and pro-inflammatory markers, blood vessel function, platelet function, and neutrophil function.

The chronic use of RIC strategies to modify particular human disease has been reported in the context of modification of remodelling after myocardial infarction presumably, long-term outcomes showing reduction of recurrent stroke after an initial embolic stroke event, and reduction in morbidity and mortality when RIC is used at the time of cardiovascular surgery or other interventions.

The invention is based, in part, on the unexpected and surprising finding that RIC, including chronic RIC, can be used to treat other conditions as well based on a variety of mechanisms.

Thus, in one aspect, the invention provides a method comprising performing remote ischemic conditioning (RIC) or a RIC-like intervention on a subject having or at risk of developing a neurodegenerative disorder. In some embodiments, the neurodegenerative disorder is Alzheimer's disease, Huntington's disease, multiple sclerosis, or Parkinson's disease.

In another aspect, the invention provides a method comprising performing remote ischemic conditioning (RIC) or a RIC-like intervention on a subject having or at risk of developing cancer.

In another aspect, the invention provides a method comprising performing remote ischemic conditioning (RIC) or a RIC-like intervention on a subject having or at risk of developing an infectious disease. In one embodiment, the infectious disease is bacterial meningitis.

In another aspect, the invention provides a method comprising performing remote ischemic conditioning (RIC) or a RIC-like intervention on a subject having or at risk of developing a lysosomal storage disorder. In some embodiments, the lysosomal storage disorder is GM1 gangliosidosis or Tay-Sachs disease.

In another aspect, the invention provides a method comprising performing remote ischemic conditioning (RIC) or a RIC-like intervention on a subject having or at risk of developing kidney disease.

In another aspect, the invention provides a method comprising performing remote ischemic conditioning (RIC) or a RIC-like intervention on a subject having or at risk of developing a skin condition. In some embodiments, the skin condition is eczema, seborrheic dermatitis, skin cancer including non-melanoma skin cancer, basal cell carcinoma, and psoriasis.

In another aspect, the invention provides a method comprising performing remote ischemic conditioning (RIC) or a RIC-like intervention on a subject having or at risk of developing transplant rejection.

In some embodiments, RIC is performed on the subject. In some embodiments, RIC is chronic RIC. In some embodiments, RIC is acute RIC. In some embodiments, RIC is performed on a daily basis. In some embodiments, RIC is performed more than once a day.

In some embodiments, RIC is performed on at least a daily basis for at least one month, two months, three months, four months, five months, six months, seven months, eight months, nine months, ten months, eleven months, or a year.

In some embodiments, RIC is performed every other day for at least one month, two months, three months, four months, five months, six months, seven months, eight months, nine months, ten months, eleven months, or a year.

In some embodiments, RIC comprises 1, 2, 3, 4, 5 or more cycles, each cycle comprising an blood occlusion period and a reperfusion period. In some embodiments, RIC comprises one or more cycles, each cycle comprising a 5 minute blood occlusion period and a 5 minute reperfusion period.

In some embodiments, RIC is performed repeatedly at the same site. In some embodiments, RIC is performed repeatedly on an upper limb. In some embodiments, RIC is performed repeatedly on a lower limb.

In some embodiments, a RIC-like intervention is performed on the subject. In some embodiments, the RIC-like intervention is non-invasive electrical nerve stimulation.

In some embodiments, the subject is receiving a second therapy. In some embodiments, the second therapy is administered at less than a maximum tolerable dose. In some embodiments, the second therapy is administered at greater than the maximum tolerable dose.

In some embodiments, the second therapy is enzyme replacement therapy. In some embodiments, the second therapy is antibody-based therapy. In some embodiments, RIC is acute RIC.

In some embodiments, one or more RIC regimens is performed within 48 hours, within 24 hours, within 12 hours, within 6 hours, within 4 hours, within 2 hours, within 1 hour or within 30 minutes prior to administration of the second therapy.

DETAILED DESCRIPTION OF INVENTION

The invention contemplates new uses for remote ischemic conditioning (RIC) including chronic RIC. RIC may be used as a prophylactic and/or therapeutic for a number of select conditions.

Heretofore, RIC has been contemplated primarily for use in the treatment of ischemic and/or reperfusion injury. Thus, RIC has been contemplated for use primarily for myocardial infarction and ensuing heart failure, restenosis, and traumatic injury including trauma associated with hypovolemic shock. RIC has also been contemplated as an adjunct to surgery such as cardiovascular surgery. RIC has also been reported to provide performance enhancement to healthy subjects including elite swimmers as well as subjects having conditions that impair exercise (e.g., cardiovascular disease). In some instances, the subjects to be treated according to the invention may be subjects that would not have been previously contemplated for RIC therapy.

Given the emphasis on the beneficial effects of RIC on conditions having an underlying ischemia/reperfusion injury, it is surprising that RIC would have beneficial effects in other conditions in which ischemia/reperfusion injury is not known to play a significant role, if any.

The invention is premised, in part, on the ability of RIC to modulate the blood-brain barrier (BBB). RIC may be used to increase the permeability of the BBB. Increasing the number of cycles within a RIC regimen (or increasing the number of regimens of RIC) increases the levels of protective factor(s) released in the circulatory system. In some cases, these increased numbers may involve the use of shorter cycles (i.e., shorter ischemic periods and/or shorter reperfusion periods per cycle or per overall regimen). While not intending to be bound by any particular theory, RIC may modulate the state of the BBB and when performed with increased frequency as discussed above may result in increased permeability of the BBB.

The invention contemplates that in some instances, including in adult subjects, increasing the number of RIC cycles increases the permeability of the BBB and thereby makes the brain accessible to agents, including endogenous agents and exogenous agents, that are otherwise not capable of crossing the BBB (or do so with limited success). Endogenous agents, as used herein, refer to agents that naturally exist in the body of the subject. These include proteins or other agents. Exogenous agents, as used herein, refer to agents that are administered to a subject. These include pharmaceuticals and biologics (e.g., antibodies or other protein therapy). Various antibody-based therapies are provided herein and the invention contemplates use of RIC in combination with these in order to enhance the therapeutic efficacy of such treatments including for example to expand the use of such treatments to brain metastases. Acute RIC may be performed in these various subjects, as described below.

The agents, whether endogenous or exogenous may have a large molecular weight, or they may have other characteristics that preclude their movement across the BBB including for example their charge (e.g., they may be polar). It is to be understood that the invention also contemplates the use of RIC to increase permeability of other tissues with reduced permeability.

Subjects and conditions that are treated using protein-based therapies are particularly contemplated according to this aspect of the invention. As an example, patients with lysosomal storage disorders that either have a non-neuronal form of the disease (e.g., Gaucher disease) or no neurological involvement (e.g., Fabry's and Pompe's disease) can be successfully treated by enzyme replacement therapy (Desnick et al. Annu Rev Genomics Hum Genet, 2012. 13: p. 307-35). The invention contemplates that these subjects may derive even greater benefit from their current treatment regimen when it is combined with RIC. Other subjects such as those with genetic diseases such as lysosomal storage disorders exemplified by GM1 gangliosidosis or Tay-Sachs disease as well as others with nervous system involvement are not currently treated with enzyme replacement therapy because the BBB precludes access to these therapeutic enzymes (van Gelder et al. Expert Opin Pharmacother, 2012. 13(16): p. 2281-99). Acute RIC could be used to transiently increase the permeability of the BBB thereby facilitating entry of these therapeutic enzymes.

In other subjects, RIC may be used to decrease BBB permeability. The BBB is reportedly compromised in subjects having various neurological conditions such as Parkinson's disease, Alzheimer's disease, multiple sclerosis, or bacterial meningitis, and in subjects that have experienced or are experiencing a stroke (Weiss et al. Biochim Biophys Acta, 2009. 1788(4): p. 842-57). Accordingly, the invention contemplates the use of RIC to decrease the permeability of the BBB in these subjects.

The invention contemplates using RIC including acute RIC or chronic RIC in order to modulate the permeability of other barriers. Such other barriers include but are not limited to the retinal blood barriers (RBB) and the spinal cord blood barriers (SCBB). Both have cellular (pericytes) and protein components (VE-cadherin) in common with the BBB. The SCBB and RBB have been found to be impaired in ALS (Garbuzova-Davis et al. Brain Res, 2012. 1469: p. 114-28) and diabetic retinopathy (Frey et al. Antioxid Redox Signal, 2011. 15(5): p. 1271-84). RIC may be used in subjects having these and other diseases that are characterized by decreased permeability leading to decreased edema (diffusion of molecules) and/or invasion by white blood cells.

The invention is also premised, in part, on the finding that RIC modulates the proteostatis network (PN). The PN consists of hundreds of proteins involved in the folding and assembly of proteins, their transport, and the removal of misfolded and aggregated proteins by the proteasome (Hartl et al. Nature, 2011. 475(7356): p. 324-32). Pharmacologically modulating components of the PN has been proposed in order to increase folding efficiency of mutant proteins or increase clearance of aggregated proteins (Calamini et al. Curr Top Med Chem, 2013).

Chronic RIC represents a means to modulate the PN and as a result may be used to treat neurodegenerative disorder such as Alzheimer's disease, Parkinson's disease or Huntington's disease, all of which involve protein aggregation.

The unfolded protein response involves the upregulation of a network of proteins in response to either misfolded proteins in the endoplasmic reticulum (Wang et al. J Cell Biol, 2012. 197(7): p. 857-67; Walter et al. Science, 2011. 334(6059): p. 1081-6), cytosol (Pellegrino et al. Biochim Biophys Acta, 2013. 1833(2): p. 410-6) or other organelles such as the mitochondrion (Pellegrino et al. Biochim Biophys Acta, 2013. 1833(2): p. 410-6). Protein homeostasis may be restored by increasing the level of chaperones that can assist in the folding of proteins, down-regulate translation in the short term to prevent further accumulation of misfolded proteins, and in the case of prolonged ER stress initiate apoptosis. Increasing levels of chaperones has been shown to facilitate the folding of mutant proteins (Calamini et al. Nat Chem Biol, 2012. 8(2): p. 185-96). RIC can be used to modulate levels of chaperones or other components of the PN, and it can thereby facilitate folding of mutant proteins. This in turn can increase their activity, e.g., in lysosomal storage disorders (Boyd et al. J Med Chem, 2013), congenital muscular dystrophies (Clement et al. Neuromuscul Disord, 2012. 22(6): p. 522-7), or prevent inappropriate interactions as in ALS, alpha-1-antitrypsin deficiency, familial Parkinson's or Alzheimer's disease (Balch et al. Science, 2008. 319(5865): p. 916-9). The efficacy of the PN in maintaining protein homeostasis declines with age (Rajalingam et al. EMBO J, 2011. 30(15): p. 2983-5). Hypoxic preconditioning was recently shown to restore the angiogenic potential of aged (>50 yr old) mesenchymal stem cells (Barros et al. Mol Ther, 2013. 21(2): p. 399-408). The invention therefore contemplates that chronic RIC can be used to increase the efficiency of the PN and augment protein folding and thereby limit protein aggregation.

The invention is further premised, in part, on the finding that RIC modulates levels of O-GlcNAcylation in different contexts. Specific Thr and Ser residues on nuclear and cytosolic proteins or epitopes can be modified by the addition of N-acetylglucosamine (O-GlcNAc) through the action of an O-GlcNAc transferase (OGT) which adds a sugar and an O-glucosaminidase which removes an O-linked sugar (Vocadlo et al. Curr Opin Chem Biol, 2012. 16(5-6): p. 488-97).

In Alzheimer's disease (AD), decreased O-GlcNAcylation and increased phosphorylation lead to increased aggregation of tau associated with the disease (Yuzwa et al. Nat Chem Biol, 2012. 8(4): p. 393-9). Increased O-GlcNAcylation following treatment with O-GlcNAcase inhibitor (thiamet G) slows removal of the O-GlcNAc (Yuzwa et al. Nat Chem Biol, 2012. 8(4): p. 393-9). This resulted in reduced aggregation of tau. Oxygen glucose deprivation in cultured neurons results in increased levels of O-GlcNAcylation (Cheung et al. J Biol Chem, 2008. 283(19): p. 13009-20; Gong et al. Proc Natl Acad Sci USA, 2012. 109(43): p. 17319-20).

Aspects of the invention are therefore also premised in part on the ability of RIC to increase O-GlcNAcylation in the brain. RIC may modify AD progression by modulating the activities of OGT in the brain and thereby increasing O-GlcNAcylation of tau proteins. RIC represents a non-invasive means for modulating the levels of O-GlcNAcylation for beneficial effect in different contexts. AD is but one example of this.

The full repertoire of proteins affected by O-GlcNAcylation is not known (Trinidad et al. Mol Cell Proteomics, 2012. 11(8): p. 215-29). Both histones and transcription factors are modified by O-GlcNAc (Hanover et al. Nat Rev Mol Cell Biol, 2012. 13(5): p. 312-21). The functional affects of O-GlcNAcylation are diverse, ranging from controlling gene expression, protein folding, and nutrient sensing (Darley-Usmar et al. J Mol Cell Cardiol, 2012. 52(3): p. 538-49; Hart et al. Annu Rev Biochem, 2011. 80: p. 825-58; Lima et al. J Am Soc Hypertens, 2009. 3(6): p. 374-87). Increased O-GlcNAcylation favours differentiation. Increased O-GlcNAcylation in a metastatic cell has reportedly resulted in a more fibrolast like characteristic and growth retardation (Yehezkel et al. J Biol Chem, 2012. 287(34): p. 28755-69). Increasing O-GlcNAcylation by RIC in subjects having cancers with metastatic potential may also result in differentiation and growth retardation of cancerous cells.

The invention contemplates treating subjects using RIC and/or a RIC-like intervention alone or in combination with one or more other therapies used for such conditions, examples of which are provided herein. RIC may be performed chronically (chronic RIC) or it may performed acutely (acute RIC).

The invention contemplates treating subjects having or at risk of developing any of the conditions recited herein. Subjects at risk of developing one (or more) of these conditions may be at risk due to family history (where a genetic inheritable component has been recognized), or due to exposure to one or more agents, or due to lifestyle and environment.

A subject includes but is not limited to humans and other non-human animals including, for example, companion animals such as dogs, cats, domesticated pigs, ferrets, hamsters, and the like; primates such as monkeys, and the like; agricultural animals such as cattle, pigs, horses, sheep, goats, birds (e.g., chickens, ducks, geese, and/or turkeys); prize-winning animals such as thoroughbreds, and the like. In important embodiments, the subject is a human subject.

In some instances, the subjects may not be experiencing, have experienced or be at risk of experiencing a myocardial infarction, or a restenotic event, or a traumatic injury. Generally, to treat, as used herein, encompasses to prevent, to delay, or to ameliorate, as appropriate, development or continuance or aggravation of a condition in a subject or to relieve, reduce or alleviate at least one symptom of a condition. For example, treatment can be diminishment of one or several symptoms of such a condition or complete eradication of the condition. Within the meaning of the present invention, the term treat also denotes to arrest, delay the onset (i.e., the period prior to clinical manifestation of a condition) and/or reduce the risk of developing or worsening a condition.

Conditions to be treated using RIC (acute or chronic) and/or RIC-like intervention are recited above.

Remote Ischemic Conditioning (RIC)

Remote ischemic conditioning (RIC), as used herein, refers to a non-invasive process of deliberately inducing an ischemic event or period (typically by occluding arterial blood flow) followed by a reperfusion event or period (typically where blood is allowed to reperfuse) that is typically performed on an upper or lower limb or on a region of the body that is remote from an organ or tissue that is intended to benefit from the process itself. RIC may be contrasted with local ischemic conditioning which involves blood flow occlusion and reperfusion in a tissue or organ or region of the body to be protected from an existing or a future anticipated ischemia/reperfusion injury and it is typically an invasive procedure. An example is local IC of the heart prior to cardiac surgery.

RIC may be performed as a single cycle (i.e., one ischemic event followed by one reperfusion event) or as multiple cycles. Multiple cycles include but are not limited to two, three, four, five or more cycles. The one or multiple cycles, when performed consecutively without significant delay, are referred to a RIC regimen or treatment.

The blood flow restriction (or occlusion) typically takes the form of an applied pressure to the limb that is sufficient to occlude blood through the limb. In some instances, the occlusive blood pressure is above systolic pressure (i.e., supra-systolic pressure). It may be about 5, about 10, about 15, about 20, or more mmHg above (or greater than) systolic pressure. In some instances, the occlusive blood pressure may be at or below systolic pressure. Since systolic pressure will differ between subjects, the absolute pressure needed to induce ischemia will vary between subjects. In other embodiments the pressure may be preset at, for example, 200 mmHg. The blood flow restriction may be accomplished using any method or device provided it is capable of inducing transient ischemia and reperfusion, whether manually or automatically. Such devices include without limitation a manually inflatable cuff, or an automated device as described below. The devices comprise cuffs of standard width or cuffs of greater than standard width.

The induced ischemic event or period is transient. That is, it may have a duration of about 1, about 2, about 3, about 4, about 5, or more minutes. Similarly, the reperfusion event or period may have a duration of about 1, about 2, about 3, about 4, about 5, or more minutes.

One or both upper limbs or one or both lower limbs may be used although in some instances one or both upper limbs are preferred. In some instances, RIC is performed on two different sites on the body, in an overlapping or simultaneous manner.

Devices for performing RIC are also known in the art, and include those described in U.S. Pat. No. 7,717,855 and U.S. patent application publication 2012/0265240 A1, both of which are incorporated herein by reference in their entirety. Briefly, this system comprises a cuff configured to retract about a limb of a subject, an actuator connected to the cuff that when actuated causes the cuff to contract about the limb of the subject to reduce blood flow therethrough, and a controller that controls the actuator according to a treatment protocol. The treatment protocol typically includes a plurality of treatment cycles, each of which may comprise a cuff actuation period during which the actuator contracts the cuff about the limb of the subject to a pressure that occludes blood flow through the limb, an ischemic duration period during which the actuator maintains the cuff contracted about the limb at a set pressure point to occlude blood flow through the limb, a cuff release period during which the actuator releases the cuff to allow blood flow through the limb, and a reperfusion period during which the cuff is maintained about the limb in a relaxed state to allow blood flow through the limb.

Acute RIC

Acute RIC, as used herein, refers to the use of RIC in a relatively short time frame around a particular event. The event may be but is not limited to administration of an agent such as but not limited to a therapeutic enzyme used in enzyme replacement therapy, or an antibody or antibody fragment used in cancer immunotherapy. When performed acutely, RIC may be performed one or more times within 1 week, within 5 days, within 4 days, within 3 days, within 2 days, within 1 day, within 12 hours, within 6 hours, within 4 hours, within 2 hours, within 1 hour, or within 30 minutes of the event (e.g., the administration of an agent).

Chronic RIC

The invention contemplates treating various conditions and diseases recited herein using chronic RIC. As used herein, chronic RIC means performing a RIC regimen (which itself may comprise 1, 2, 3, 4, 5, or more cycles of ischemia and reperfusion) more than once over the course of more than one day. Chronic RIC encompasses daily performance of a RIC regimen, weekly performance of a RIC regimen, bi-weekly performance of a RIC regimen, monthly performance of a RIC regimen, including performance that is more or less frequent. Chronic RIC also encompasses performing a RIC regimen every other day, every third day, every fourth day, every fifth day, or every sixth day. The RIC regimens may be identical to each other or they may differ. Chronic RIC encompasses scheduled RIC regimens (e.g., non-random RIC regimens) or random RIC regimens (e.g., performing RIC when a subject feels the need rather than on a set schedule). Chronic RIC also contemplates that more than one RIC regimen may be performed on a single day.

RIC-like interventions include but are not limited to non-invasive electrical nerve stimulation such as transcutaneous electrical nerve stimulation, direct nerve stimulation such as femoral nerve stimulation, electro-acupuncture, nociceptive c-fiber stimulation for example via topical capsaicin, and intra-arterial adenosine.

As used herein, non-invasive electrical nerve stimulation may be a single cycle of nerve stimulation followed by a rest period during which no current is applied to the subject, or it may be repeated cycles of nerve stimulation followed by a rest period. The repeated cycles may comprise 2, 3, 4, 5 or more cycles of nerve stimulation followed by a rest period. For clarity, two cycles of non-invasive electrical nerve stimulation would consist of a nerve stimulation period, a rest period, a nerve stimulation period, and a rest period. The invention contemplates that, in some embodiments, a single nerve stimulation period may be sufficient to achieve the desired therapeutic, prophylactic or performance endpoints.

The nerve stimulation period and the rest period may each range from 30 seconds to several minutes or hours. Either or both periods may be up to or about 30 seconds, or 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55 or 60 minutes in duration, or longer. The two periods may or may not be of the same duration. An exemplary non-invasive electric nerve stimulation comprises 4 or 5 cycles of 5 minutes of nerve stimulation followed by 5 minutes of rest. Another exemplary non-invasive electrical nerve stimulation comprises 4 or 5 cycles of 4 minutes of nerve stimulation followed by 4 minutes of rest.

The non-invasive electrical nerve stimulation device may be operated under any number of pulse amplitude (or intensity), pulse width, and pulse frequency settings. As an example, the pulse amplitude may range from 1 to 200 mA, including typically from 1 to 100 mA, from 1 to 90 mA, from 1-80 mA, from 1-70 mA, from 1-60 mA, from 1-50 mA, from 1-40 mA, from 1-30 mA, from 1-20 mA, from 1-15 mA, from 1-10 mA, from 1-9 mA, from 1-8 mA, from 1-7 mA, from 1-6 mA, from 1-5 mA, from 1-4 mA, from 1-3 mA, or from 1-2 mA. The pulse frequency may range from 1 to 300 Hz, including typically from 1 to 150 Hz, from 1-140 Hz, from 1-130 Hz, from 1-120 Hz, from 1-110 Hz, from 1-100 Hz, from 1-90 Hz, from 1-80 Hz, from 1-70 Hz, from 1-60 Hz, from 1-50 Hz, from 1-40 Hz, from 1-30 Hz, from 1-20 Hz, from 1-10 Hz, from 1-9 Hz, from 1-8 Hz, from 1-7 Hz, from 1-6 Hz, from 1-5 Hz, from 1-4 Hz, from 1-3 Hz, or from 1-2 Hz. The pulse width may range up to 1 to 1600 microseconds, including typically from 1 to 800 microseconds, from 1-700 milliseconds, from 1-600 milliseconds, from 1-500 milliseconds, from 1-400 milliseconds, from 1-300 milliseconds, from 1-200 milliseconds, from 1-100 milliseconds, and from 1-50 milliseconds. The device may also operate at a voltage typically up to 80 V, including typically up to 40 V, up to 30 V, up to 20 V, up to 10 V, and up to 5 V. Exemplary settings include a pulse amplitude of 2-3 mA, a pulse frequency of 3.1 Hz, and a pulse width of 500 microseconds.

Non-invasive electrical nerve stimulation may be performed at any site on the body that is amenable to the non-invasive procedure. It may be performed on any outer surface of the body, including but not limited to arms, legs, feet, hands, torso, chest, back, and the like. It may be performed at a remote site (i.e., a site that is distal to the area of the body experiencing or likely to experience the ischemic and/or reperfusion injury). In other words, the placement of the electrodes may be distal to the region of the body being treated. As an example, the electrodes may be placed on the legs in order to reduce injury in the heart. Typically at least two electrodes are placed within proximity of each other in order to allow current to flow therebetween. Additional paired electrodes may be used at the same or different surface region of the body at the same or different time.

Repeated non-invasive electrical nerve stimulations may be performed at a single, identical site or at multiple, different sites on the body. As an example, a first stimulation may be performed on the right upper arm, followed by a second stimulation performed on the left upper arm. In some embodiments, the non-invasive electrical nerve stimulation is not performed on the chest. Repeated non-invasive electrical nerve stimulations may alternate between two sites or they may cycle through more than two sites. In some instances, non-invasive electrical nerve stimulation may be performed on a subject at two different sites at overlapping times including simultaneously. The use of more than one location may be determined a priori or it may be random. When multiple locations are used simultaneously, one or more devices may be used.

Cancers

In another embodiment, the cancer is selected from the group consisting of bladder cancer, breast cancer, colon cancer, endometrial cancer, head and neck cancer, leukemia, lung cancer, lymphoma, melanoma, ovarian cancer, prostate cancer and rectal cancer.

In another embodiment, the cancer is a refractory cancer. Examples of refractory cancers include but are not limited to leukemias, melanomas, renal cell carcinomas, colon cancer, liver (hepatic) cancers, pancreatic cancer, Non-Hodgkin's lymphoma, and lung cancer. In still other embodiments, the cancer is an immunogenic cancer.

In still another embodiment, the cancer is a metastasis.

Neurodegenerative Disorders

Neurodegenerative disorders to be treated with RIC and/or a RIC-like intervention include but are not limited to Alzheimer's disease, Huntington's disease, multiple sclerosis, and Parkinson's disease.

Infectious Diseases

Infectious diseases may be treated with RIC and/or a RIC-like intervention. The infectious disease may be selected from the group consisting of a bacterial infection, a mycobacterial infection, a viral infection, a fungal infection and a parasitic infection, but it is not so limited. The infection may be but is not limited to bacterial meningitis.

In one embodiment, the bacterial infection is selected from the group consisting of anE. coliinfection, aStaphylococcalinfection, aStreptococcalinfection, aPseudomonasinfection,Clostridium difficileinfection,Legionellainfection,Pneumococcusinfection,Haemophilusinfection,Klebsiellainfection,Enterobacterinfection,Citrobacterinfection,Neisseriainfection,Shigellainfection,Salmonellainfection,Listeriainfection,Pasteurellainfection, Streptobacillusinfection,Spirilluminfection,Treponemainfection,Actinomycesinfection,Borreliainfection,Corynebacteriuminfection,Nocardiainfection,Gardnerellainfection,Campylobacterinfection,Spirochaetainfection,Proteusinfection,Bacteriodesinfection,H. pyloriinfection, andanthraxinfection.

The mycobacterial infection may be tuberculosis or leprosy respectively caused by theM. tuberculosisandM. lepraespecies, but is not so limited.

In one embodiment, the viral infection is selected from the group consisting of an HIV infection, a Herpes simplex virus 1 infection, a Herpes simplex virus 2 infection, cytomegalovirus infection, hepatitis A virus infection, hepatitis B virus infection, hepatitis C virus infection, human papilloma virus infection, Epstein Barr virus infection, rotavirus infection, adenovirus infection, influenza A virus infection, respiratory syncytial virus infection, varicella-zoster virus infections, small pox infection, monkey pox infection and SARS infection.

Other Conditions

The invention contemplates treatment of subjects having conditions that require enzyme replacement therapy, or antibody therapy, or other biologic-type therapy.

Examples of such conditions include lysosomal storage disorders that either have a non-neuronal form of the disease (e.g., Gaucher disease) or no neurological involvement (e.g., Fabry's and Pompe's disease), and lysosomal storage disorders such as GM1 gangliosidosis and Tay-Sachs disease.

The invention further contemplates use of RIC and/or RIC-like intervention in the treatment of multiple sclerosis.

The invention further contemplates use of RIC and/or a RIC-like intervention in the treatment of kidney disease.

The invention further contemplates use of RIC and/or a RIC-like intervention in the treatment of skin conditions. Examples include eczema, seborrheic dermatitis, skin cancer including non-melanoma skin cancer, basal cell carcinoma, and psoriasis.

The invention further contemplates use of RIC and/or a RIC-like intervention in the treatment of transplant rejection.

RIC and RIC-Like Interventions as Adjunct Therapy or in Combination Therapy

The invention contemplates the use of RIC and/or RIC-like interventions in the treatment of conditions (including infectious diseases). RIC and/or RIC-like interventions may be used as a stand alone or in combination with another therapy. When used together with another therapy, in some instances, RIC and/or RIC-like interventions may modulate the BBB and/or other barrier permeability, thereby rendering a subject responsive (or more responsive) to a therapy. When used together with another therapy, in some instances, RIC and/or RIC-like interventions may reduce the adverse effects of the other therapy. In other instances, RIC and/or RIC-like therapy may synergize with the other therapy, resulting in a greater than additive effect when both therapies are used together (as compared to when they are used separately and thus independently). In some instances, the invention contemplates using RIC and/or RIC-like interventions with a dose of another therapy that is less than the dose that would otherwise be required if the other therapy was administered alone. Dose reductions may be 1%, 2%, 3%, 3%, 4%, 5%, 6%, 7%, 8%, 9%. 10%, 20% or more. Dose reductions can also take the form of less frequent administration of the other therapy.

Various therapies are known for the conditions provided herein and contemplated by the invention. A non-limiting list of such therapies are provided herein. It is intended that RIC and/or RIC-like interventions may be used with any of these therapies. RIC may be used, for example, acutely when used together with one of the following therapies in order to increase the delivery of the therapy, including for example across the BBB.

Combination therapy may include antimicrobials agents if the condition is an infectious disease. Examples of anti-microbials include anti-bacterials, anti-mycobacterials, anti-virals, anti-fungal, and anti-parasites.

The other therapies may be anti-cancer therapies if the condition is a cancer or other condition characterized by abnormal cell proliferation. Anti-cancer therapies include chemotherapy, surgery and/or radiation.

Other chemotherapeutics are taxanes (e.g., paclitaxel and docetaxel). Another important category of chemotherapeutic is annonaceous acetogenin.

Other chemotherapeutics include hormonal manipulation, particularly for breast and gynecological cancers, such as but not limited to tamoxifen or aromatase inhibitor arimidex (i.e., anastrozole).

Other chemotherapeutics include enzyme inhibitor agents such as CDK inhibitors, tyrosine kinase inhibitors, MAP kinase inhibitors, and EGFR inhibitors (e.g., C225).

In some embodiments, RIC and/or RIC-like intervention is used to enhance immune-based therapies. Such enhancement may be a result of or may be independent of the effect of RIC (including acute or chronic RIC) on the BBB and/or other barrier permeability.

Immune-based therapies may be used to treat a variety of the conditions provided herein including but not limited to cancer. Immune-based therapies include vaccine therapies in which antigens are administered to a subject to induce an antigen-specific immune response. Immune-based therapies also include antibody therapies in which antibodies are administered to a subject to induce an antibody-based response such as antibody dependent cell-mediated cytoxicity (ADCC). A variety of immune-based therapies are known in the art. Non-limiting examples are provided below.

In one important embodiment, the antibody or antibody fragment is an anti-HER2 antibody, and preferably it is trastuzumab. In another important embodiment, the antibody or antibody fragment is an anti-CD20 antibody, and preferably it is rituximab.

The antibody or antibody fragment may conjugated (covalently or otherwise) to a toxin derived from plant, fungus, or bacteria. The toxin may be selected from the group consisting of A chain toxin, deglycosylated A chain toxin, ribosome inactivating protein, α-sarcin, aspergillin, restrictocin, ribonuclease, diptheria toxin andPseudomonasexotoxin, but is not so limited.

The antibody or antibody fragment may also conjugated to a chemotherapeutic agent, a radioisotope or a cytotoxin. The chemotherapeutic agent may be selected from the group consisting of an anti-metabolite, an anthracycline, a vinca alkaloid, an antibiotic, an alkylating agent, and an epipodophyllotoxin, but is not so limited. An example is an anti-HER2 antibody conjugated to a toxin.

The immune-based therapy may be a vaccine such as vaccine comprising a cancer antigen. Cancer antigens can be classified in a variety of ways. Cancer antigens include antigens encoded by genes that have undergone chromosomal alteration. Many of these antigens are found in lymphoma and leukemia. Even within this classification, antigens can be characterized as those that involve activation of quiescent genes. These include BCL-1 and IgH (Mantel cell lymphoma), BCL-2 and IgH (Follicular lymphoma), BCL-6 (Diffuse large B-cell lymphoma), TAL-1 and TCR or SIL (T-cell acute lymphoblastic leukemia), c-MYC and IgH or IgL (Burkitt lymphoma), MUN/IRF4 and IgH (Myeloma), PAX-5 (BSAP) (Immunocytoma).

Still other cancer antigens are cancer testis (CT) antigens that are expressed in some normal tissues such as testis and in some cases placenta. Their expression is common in tumors of diverse lineages and as a group the antigens form targets for immunotherapy. Examples of tumor expression of CT antigens include MAGE-A1, -A3, -A6, -A12, BAGE, GAGE, HAGE, LAGE-1, NY-ESO-1, RAGE, SSX-1, -2, -3, -4, -5, -6, -7, -8, -9, HOM-TES-14/SCP-1, HOM-TES-85 and PRAME. Still other examples of CT antigens and the cancers in which they are expressed include SSX-2, and -4 (Neuroblastoma), SSX-2 (HOM-MEL-40), MAGE, GAGE, BAGE and PRAME (Malignant melanoma), HOM-TES-14/SCP-1 (Meningioma), SSX-4 (Oligodendrioglioma), HOM-TES-14/SCP-1, MAGE-3 and SSX-4 (Astrocytoma), SSX member (Head and neck cancer, ovarian cancer, lymphoid tumors, colorectal cancer and breast cancer), RAGE-1, -2, -4, GAGE-1, -2, -3, -4, -5, -6, -7 and -8 (Head and neck squamous cell carcinoma (HNSCC)), HOM-TES14/SCP-1, PRAME, SSX-1 and CT-7 (Non-Hodgkin's lymphoma), and PRAME (Acute lymphoblastic leukemia (ALL), acute myelogenous leukemia (AML) and chronic lymphocytic leukemia (CLL)).

Other cancer antigens are not specific to a particular tissue or cell lineage. These include members of the carcinoembryonic antigen (CEA) family: CD66a, CD66b, CD66c, CD66d and CD66e. These antigens can be expressed in many different malignant tumors and can be targeted by immunotherapy.

Still other cancer antigens are viral proteins and these include Human papilloma virus protein (cervical cancer), and EBV-encoded nuclear antigen (EBNA)-1 (lymphomas of the neck and oral cancer).

Still other cancer antigens are mutated or aberrantly expressed molecules such as but not limited to CDK4 and beta-catenin (melanoma).

The invention also embraces immune-based therapies that utilize antibodies that are specific for any of the foregoing cancer antigens.

OTHER EMBODIMENTS