Use of fumagillol and derivatives thereof for preparing medicaments against intestinal infections

The invention relates to the use of fumagillol and the esters formed by fumagillol and saturated or unsaturated (C.sub.1 -C.sub.12) alkylcarboxylic or (C.sub.1 -C.sub.12) alkyldicarboxylic acids, and their pharmaceutically acceptable salts, for the preparation of medicaments for combating intestinal infections caused by microsporidia and/or cryptosporidia.

The present invention relates to a novel use of fumagillol and its 
derivatives, especially fimagillin. 
Fumagillin is an antibiotic, first described in 1951 (The Merck Index 11th 
Edition, no. 4199), which is used especially for preventing or controlling 
parasitic diseases in fish farming and beekeeping and which has also been 
used in man for the local treatment, in an eye lotion, of 
keratoconjunctivitis due to Encephalitozoon hellem (J. Ophtal., 1993, 115, 
293). However, it has been found to be inactive as a carcinolytic agent 
(Antibiotic Annual, 1958-1959, 541-546). 
It has now been found that fumagillol and certain esters formed with this 
compound, when formulated in a drug, especially an oral drug, are capable 
of resolving very serious infectious conditions of the intestine due to 
microsporidia or cryptosporidia. 
It has also been found, surprisingly, that fuimagillol and the esters 
formed by fumagillol and saturated or unsaturated (C.sub.1 -C.sub.12) 
alkylcarboxylic or (C.sub.1 -C.sub.12) alkyldicarboxylic acids are capable 
of inducing eradication of Enterocytozoon bieneusi in patients affected by 
HIV. This discovery is surprising and decisive because there is currently 
no known remedy for this type of infection, which constitutes 95% of the 
intestinal infections due to microsporidia which result in cachexia and 
death in patients suffering from AIDS. 
Thus, according to one of its features, the present invention relates to 
the use of fumagillol or esters formed by fuimagillol and saturated or 
unsaturated (C.sub.1 -C.sub.12) alkylcarboxylic or (C.sub.1 -C.sub.12) 
alkyldicarboxylic acids, and their pharmaceutically acceptable salts, for 
the preparation of drugs for combating intestinal infections due to 
microsporidia and/or cryptosporidia. 
More particularly and advantageously, according to its preferred feature, 
the present invention relates to the use of fumagillol or esters formed by 
fumagillol and saturated or unsaturated (C.sub.1 -C.sub.12) 
alkylcarboxylic or (C.sub.1 -C.sub.12) alkyldicarboxylic acids, and their 
pharmaceutically acceptable salts, for the preparation of drugs for 
combating intestinal infections for which the parasite Enterocytozoon 
bieneusi is principally responsible. 
"Saturated or unsaturated (C.sub.1 -C.sub.12) alkylcarboxylic or (C.sub.1 
-C.sub.12) alkyldicarboxylic acids" are understood as meaning carboxylic 
or dicarboxylic acids of linear or branched alkyls, it being possible for 
said alkyls to contain one or more double bonds. 
Examples of such acids are acetic, propionic, butyric, valeric, pivalic, 
malonic, succinic, acrylic, crotonic, isocrotonic, oleic, maleic, fumaric 
and 2,4,6,8-decatetraenedioic acids. 
The ester of fumagillol and 2,4,6,8-decatetraenedioic acid, fumagillin, is 
a particularly advantageous compound. 
The esters of the present invention are easily prepared by reacting 
fumagillol with the appropriate acid under the normal esterification 
conditions described in the literature. 
Fumagillol, either as such or esterified with a (C.sub.1 -C.sub.12) 
alkylcarboxylic or (C.sub.1 -C.sub.12) alkyldicarboxylic acid, can be 
administered in the form of the free acid or else in the form of one of 
its salts with a pharmaceutically acceptable base. 
For their administration to patients suffering from an infection due to 
microsporidia or cryptosporidia, fumagillol or the esters formed therewith 
are mixed with pharmaceutical excipients commonly used for the preparation 
of pharmaceutical formulations, preferably for oral administration. 
Advantageously, the compounds of the present invention are formulated as 
active principles in dosage units, for example tablets or gelatin 
capsules, containing from 1 to 200 mg of active principle, advantageously 
from 2 to 100 mg, more advantageously from 5 to 50 mg or preferably from 
7.5 to 30 mg per dosage unit. 
The pharmaceutical compositions for oral administration constitute a 
further subject of the present invention. 
In the pharmaceutical compositions of the present invention for oral 
administration, the active principle can be administered in the 
above-mentioned unit forms of administration, mixed with conventional 
pharmaceutical carriers, for the treatment of the above-mentioned 
diseases. The appropriate unit forms of administration include oral forms 
such as tablets, which may be scored, gelatin capsules, powders, granules 
and solutions or suspensions to be taken orally. 
When a solid composition is prepared in the form of tablets, which is one 
of the preferred forms, the main active ingredient is mixed with a 
pharmaceutical vehicle such as gelatin, starch, lactose, magnesium 
stearate, talcum, gum arabic or the like. The tablets can be coated with 
sucrose or other appropriate substances or else they can be treated so as 
to have a prolonged or delayed activity and so as to release a 
predetermined amount of active principle continuously. These delayed 
action or controlled release tablets represent another very advantageous 
form. 
A preparation in the form of gelatin capsules, which is another 
particularly advantageous form, is obtained by mixing the active 
ingredient with a diluent and pouring the resulting mixture into soft or 
hard gelatin capsules. 
A preparation in the form of a syrup or elixir can contain the active 
ingredient together with a sweetener, which is preferably calorie-free, 
methylparaben and propylparaben as antiseptics, as well as a flavoring and 
an appropriate color. 
The water-dispersible granules or powders can contain the active ingredient 
mixed with dispersants or wetting agents or with suspending agents such as 
polyvinylpyrrolidone, as well as with sweeteners or taste correctors. 
The active principle can also be formulated as microcapsules, optionally 
with one or more carriers or additives. 
In the pharmaceutical compositions according to the present invention, the 
active principle can also be in the form of an inclusion complex in 
cyclodextrins, their ethers or their esters. 
Pharmaceutical compositions for oral administration, containing from 1 to 
200 mg, preferably from 2 to 100 mg, from 5 to 50 mg or from 7.5 to 30 mg, 
of fumagillol, an ester formed by fumagillol and one of the acids 
mentioned above, especially fimagillin, or one of their pharmaceutically 
acceptable salts as the active principle, in a form selected from tablets, 
delayed action tablets, controlled release tablets and gelatin capsules, 
constitute a further subject of the present invention. 
The compounds of the present invention can be administered with other drugs 
generally used during the development of AIDS, and can also be formulated 
in association with other antiparasitics or antibiotics or with drugs 
having an anti-HIV action. 
The therapeutic activity of the compounds of the present invention was 
demonstrated by administering different doses of the pharmaceutical 
composition of Example I to four homosexual patients of the male sex 
presenting a high immune deficiency with an average CD4 level of 66 
(11-158). Three patients had recognized AIDS and one patient had an ARC 
(Aids Related Complex). The average age was 40 years. 
Prior to inclusion, all these patients had consecutive stool examinations 
which were positive for microsporidia. Two patients concomitantly 
presented an intestinal infection with cryptosporidia. The test for 
microsporidia in the urine remained negative in all the patients, these 
factors favoring the diagnosis of infection with Enterocytozoon bieneusi. 
All the patients had a duodenal fibroscopy with biopsies. In three 
patients, microsporidia were identified on these biopsies in histology and 
in direct parasitology, as well as by electron microscopy. In the fourth 
case, only electron microscopy revealed the presence of Enterocytozoon 
bieneusi. 
The four patients received 20 mg of fumagillin three times a day, i.e. 60 
mg/d, for 21 days. 
Eradication of the parasite from the stool was observed in all the patients 
in the control examinations after 15, 17 and 21 days of treatment. 
Microsporidia were still absent from the patients' stool one month after 
cessation of the treatment. 
Of the two patients who presented cryptosporidia in their stool prior to 
inclusion, only one transitorily tested negative on his stool, 
cryptosporidia reappearing one month after cessation of the treatment. 
All the patients had a control duodenal fibroscopy to assess the 
disappearance of the parasites at tissue level. Also, in two cases, a 
negative result was observed in histology, with the persistence of very 
rare microsporidia in direct parasitology (probably cadavers of 
microsporidia). The electron microscopy study confirmed the total 
disappearance of Enterocytozoon bieneusi in all four patients. 
Another group of patients was recruited for a tolerance/toxicology study. 
Doses of 10, 20, 40 and 60 mg of fumagillin were administered to 
twenty-four patients (six per dose level). 
The treatment was tolerated well. In particular, no hepatic toxicity, 
cardiac toxicity (ECG) or renal toxicity (creatininemia) was observed. 
Even a very slight decrease in the serum alkaline phosphatase level was 
noted, which could correspond to a beneficial effect of the treatment on 
cholangitis due to microsporidia. 
The troublesome side effect observed was of the hematological type, namely 
thrombopenia which varied in degree but was never very severe (except in 
one case which caused the administration to be interrupted in the above 
group of four patients) and whose evolution was spontaneously regressive 
in 10 to 14 days after cessation of the treatment. This side effect, which 
is not immunological but due solely to a direct toxicity towards the 
platelets, can be corrected by an appropriate choice of treatment 
protocol. 
In conclusion, eradication of the parasite from the stool was observed for 
the first time in this opportunistic infection; this eradication persists 
for at least one month after cessation of the treatment and seems to be 
accompanied by eradication of the parasite from the duodenal biopsies. 
This result has never been achieved with other antiparasitics. 
The clinical benefit is difficult to evaluate in these patients in view of 
the multiple associated infections and the pursuance of symptomatic 
treatments. A very marked clinical benefit was nevertheless obtained in 
the patients treated, who all gained several kilograms and whose diarrhea 
stopped at the end of the treatment. 
Consequently, spectacular parasitological results were obtained with 
fumagillin in Enterocytozoon bieneusi infections in the course of AIDS, 
with an excellent clinical result in some cases.

EXAMPLE 1 
Pharmaceutical composition in the form of gelatin capsules each containing 
20 mg of fumagillin acid 
14 g of purified and pre-sieved fumagillin acid are gradually diluted to a 
volume of 210 ml with the requisite amount of colloidal silica 
(AEROSIL.RTM.). The powder obtained is mixed thoroughly and the 
homogeneous powder prepared in this way is divided up into no. 3 opaque 
hard gelatin capsules. This gives 700 gelatin capsules each containing 20 
mg of flimagillin acid.