# Patent

## Title
Methods of treating oral mucositis

## Abstract

Methods and kits for treating oral mucositis are disclosed. The treatment comprises administering to a patient in need thereof a Reactive Oxygen Species scavenger in a pharmaceutically acceptable formulation.

## Background
CROSS-REFERENCE TO RELATED APPLICATIONS
This application claims priority from U.S. Provisional Application Ser. No. 60/829,291 filed Oct. 12, 2006, which is incorporated herein by reference.


STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT
Not Applicable.
INCORPORATION-BY-REFERENCE OF MATERIAL SUBMITTED ON A COMPACT DISC
Not Applicable.
BACKGROUND OF THE INVENTION
1. Field of the Invention
This invention relates generally to the treatment of oral mucositis and, more particularly, to methods for treating oral mucositis with a Reactive Oxygen Species (“ROS”) scavenger. The compositions and methods are useful in treating oral mucositis.
2. Description of Related Art
Oral ulcerative mucositis is a common, painful, dose-limiting toxicity of drug and radiation therapy for cancer (1). The disorder is characterized by breakdown of the oral mucosa that results in the formation of ulcerative lesions. In granulocytopenic patients, the ulcerations that accompany mucositis are frequent portals of entry for indigenous oral bacteria often leading to sepsis or bacteremia (2). Mucositis occurs to some degree in more than one third of patients receiving anti-neoplastic drug therapy (3). The frequency and severity are significantly greater among patients who are treated with induction therapy for leukemia or with many of the conditioning regimens for bone marrow transplant (4). Among these individuals, moderate to severe mucositis can occur in more than three-quarters of patients. Moderate to severe mucositis occurs in virtually all patients who receive radiation therapy for tumors of the head and neck and typically begins with cumulative exposures of 15 Gy and then worsens as total doses of 60 Gy or more are reached (1-4).
Clinically mucositis progresses through three stages:

    1. Atrophic changes accompanied by painful mucosal erythema, which can respond to local anesthetics.
    2. Painful ulceration with pseudomembrane formation and, in the case of myelosuppressive treatment, potentially life-threatening sepsis, requiring antimicrobial therapy. Pain is often of such intensity as to require parenteral narcotic analgesia.
    3. Spontaneous healing, occurring about 2-3 weeks after cessation of anti-neoplastic therapy.


Standard therapy for mucositis is predominantly palliative, including application of topical analgesics such as lidocaine and/or systemic administration of narcotics and antibiotics. At present, the only approved treatment for oral mucositis is palifermin (Kepivance) which is a member of the fibroblast growth factor (FGF) superfamily of molecules. Palifermin's approval is limited to the treatment of oral mucositis in the patients undergoing conditioning regimens prior to hematopoietic stem cell transplants for the treatment of hematologic malignancies.
The complexity of mucositis as a biological process has only been recently appreciated (5-7). It has been suggested that the condition represents a sequential interaction of oral mucosal cells and tissues, reactive oxygen species, pro-inflammatory cytokines, mediators of apoptosis and local factors such as saliva and the oral microbiota. While epithelial degeneration and breakdown ultimately result in mucosal ulceration, it appears that the early changes associated with radiation-induced mucosal toxicity occur within the endothelium, and connective tissue of the submucosa. For example, electron microscopic evaluation of mucosa within 1 week of radiation shows damage to both endothelium and connective tissue, but not epithelium. It appears that the overall mechanism for mucositis development is similar for both radiation and chemotherapy (8).
Recently, a superoxide dismutase mimetic, M40403, was shown to be effective in an animal models of inflammation (Salvemini et al., Science 286:304-306, 1999) and, more specifically, in an animal model of rheumatoid arthritis (Salvemini et al., Arthritis & Reumatism 44:2909-2921, 2001). Nevertheless, treatment of oral mucositis using M40403 has neither been reported nor suggested.
BRIEF SUMMARY OF THE INVENTION
The present teachings provide methods for treating oral mucositis. A method comprises administering to a patient in need thereof, a superoxide dismutase mimetic. In accordance with one aspect of the invention, the superoxide dismutase mimetic can be represented by the formula:




wherein
(i) R1, R′1, R2, R′2, R3, R′3, R4, R′4, R5, R′5, R6, R′6, R7, R′7, R8, R′5, R9, R′9, R10, and R′10 are independently:
(ia) hydrogen; or
(ib) a moiety independently selected from the group consisting of alkenyl, alkenylcycloalkenyl, alkenylcycloalkyl, alkyl, alkylcycloalkenyl, alkylcycloalkyl, alkynyl, aralkyl, aryl, cycloalkenyl, cycloalkyl, cycloalkylalkyl, cycloalkylcycloalkyl, cycloalkenylalkyl, heterocyclyl, and aralkyl radicals and radicals attached to the α-carbon or α-amino acids; or
(ic) a moiety independently selected from the group consisting of —OR11, —NR11R12, —COR11, —CO2R11, —CONR11R12, —SR11, —SOR11, —SO2R11, —SO2NR11R12, —N(OR11)(R12), —P(O)(OR11)(OR12), —P(O)(OR11)(R12), —OP(O)(OR11)(OR12), and substituents attached to the α-carbon of α-amino acids, wherein R11 and R12 are independently hydrogen or alkyl; and
(ii) optionally, one or more of R1 or R′1 and R2 or R′2, R3 or R′3 and R4 or R′4, R5 or R′5 and R6 or R′6, R7 or R′7 and R8 or R′8, R9 or R′9 and R10 or R′10 together with the carbon atoms to which they are attached independently form a substituted or unsubstituted and saturated, partially saturated, or unsaturated cycle or heterocycle having 3 to 20 carbon atoms; and
(iii) optionally, one or more of R1 and R′1, R2 and R′2, R3 and R′3, R4 and R′4, R5 and R′5, R6 and R′6, R7 and R′7, R8 and R′8, R9 and R′9, and R10 and R′10, together with the carbon atom to which they are attached independently form a substituted or unsubstituted and saturated, partially saturated, or unsaturated cycle or heterocycle having 3 to 20 carbon atoms; and
(iv) optionally, one or more of R10 or R′10 and R1 or R′1, R2 or R′2 and R3 or R′3, R4 or R′4 and R5 or R′5, R6 or R′6 and R7 or R′7, or R8 or R′8 and R9 or R′9 together with the carbon atoms to which they are attached independently form a substituted or unsubstituted nitrogen containing heterocycle having 3 to 20 carbon atoms, which may be an aromatic heterocycle in which case the hydrogen attached to the nitrogen which is both part of the heterocycle and the macrocycle and the R groups attached to the carbon atoms which are both part of the heterocycle and the macrocycle are absent; and
(v) optionally, one or more of R1, R′1, R2, R′2, R3, R′3, R4, R′4, R5, R′5, R6, R′6, R7, R′7, R8, R′8, R9, R′9, R10, and R′10, together with a different one of R1, R′1, R2, R′2, R3, R′3, R4, R′4, R5, R′5, R6, R′6, R7, R′7, R8, R′8, R9, R′9, R10, and R′10, which is attached to a different carbon atom in the macrocyclic ligand may be bound to form a strap represented by the formula:

—(CH2)I-Q-(CH2)J—R—(CH2)K—S—(CH2)L—

wherein
I, J, K and L independently are integers from 0 to 10 and Q, R and S are independently selected from the group consisting of alkenyl, alkenylcycloalkenyl, alkenylcycloalkyl, alkyl, alkylcycloalkenyl, alkylcycloalkyl, alkynyl, aralkyl, aryl, cycloalkenyl, cycloalkyl, cycloalkylalkyl, cycloalkylcycloalkyl, cycloalkenylalkyl, and heterocyclyl, aza, amide, ammonium, oxa, thia, sulfonyl, sulfinyl, sulfonamide, phosphoryl, phosphinyl, phosphino, phosphonium, keto, ester, alcohol, carbamate, urea, thiocarbonyl, borates, boranes, boraza, silyl, siloxy, silaza, and combinations thereof; and
(vi) combinations of any of (i) through (v) above;
wherein
M is a transition metal;
X, Y and Z are independently selected from the group consisting of halide, oxo, aquo, hydroxo, alcohol, phenol, dioxygen, peroxo, hydroperoxo, alkylperoxo, arylperoxo, ammonia, alkylamino, arylamino, heterocycloalkyl amino, heterocycloaryl amino, amine oxides, hydrazine, alkyl hydrazine, aryl hydrazine, nitric oxide, cyanide, cyanate, thiocyanate, isocyanate, isothiocyanate, alkyl nitrile, aryl nitrile, alkyl isonitrile, aryl isonitrile, nitrate, nitrite, azido, alkyl sulfonic acid, aryl sulfonic acid, alkyl sulfoxide, aryl sulfoxide, alkyl aryl sulfoxide, alkyl sulfenic acid, aryl sulfenic acid, alkyl sulfinic acid, aryl sulfinic acid, alkyl thiol carboxylic acid, aryl thiol carboxylic acid, alkyl thiol thiocarboxylic acid, aryl thiol thiocarboxylic acid, alkyl carboxylic acid, aryl carboxylic acid, urea, alkyl urea, aryl urea, alkyl aryl urea, thiourea, alkyl thiourea, aryl thiourea, alkyl aryl thiourea, sulfate, sulfite, bisulfate, bisulfite, thiosulfate, thiosulfite, hydrosulfite, alkyl phosphine, aryl phosphine, alkyl phosphine oxide, aryl phosphine oxide, alkyl aryl phosphine oxide, alkyl phosphine sulfide, aryl phosphine sulfide, alkyl aryl phosphine sulfide, alkyl phosphonic acid, aryl phosphonic acid, alkyl phosphinic acid, aryl phosphinic acid, alkyl phosphinous acid, aryl phosphinous acid, phosphate, thiophosphate, phosphite, pyrophosphite, triphosphate, hydrogen phosphate, dihydrogen phosphate, alkyl guanidino, aryl guanidino, alkyl aryl guanidino, alkyl carbamate, aryl carbamate, alkyl aryl carbamate, alkyl thiocarbamate, aryl thiocarbamate, alkylaryl thiocarbamate, alkyl dithiocarbamate, aryl dithiocarbamate, alkylaryl dithiocarbamate, bicarbonate, carbonate, perchlorate, chlorate, chlorite, hypochlorite, perbromate, bromate, bromite, hypobromite, tetrahalomanganate, tetrafluoroborate, hexafluoroantimonate, hypophosphite, iodate, periodate, metaborate, tetraaryl borate, tetra alkyl borate, tartrate, salicylate, succinate, citrate, ascorbate, saccharinate, amino acid, hydroxamic acid, thiotosylate, and anions of ion exchange resins, or the corresponding anions thereof; or
X, Y and Z are independently selected from the group consisting of charge-neutralizing anions which are derived from any monodentate or polydentate coordinating ligand and a ligand system and the corresponding anion thereof; or
X, Y and Z are independently attached to one or more of R1, R′1, R2, R′2, R3, R′3, R4, R′4, R5, R′5, R6, R′6, R7, R′7, R8, R′8, R9, R′9, R10, and R′10; and
n is an integer from 0 to 3.
Preferably, M is selected from the group consisting of Mn2+, Mn3+, Mn4+, Mn6+, Mn7+, Fe2+, Fe3+, Fe4+, Fe6+, Ni2+, Ni3+, Cu1+, Cu2+, V2+, V3+, V4+, and V5+.
In an alternative, the superoxide dismutase mimetic can be represented by the formula:




wherein
(i) a nitrogen of the macrocycle and two adjacent carbon atoms to which the nitrogen is attached independently form a substituted or unsubstituted, saturated, partially saturated or unsaturated nitrogen-containing heterocycle W having 2 to 20 carbon atoms, which may be an aromatic heterocycle in which case the hydrogen attached to the nitrogen which is both part of the heterocycle and the macrocycle and the R groups attached to the carbon atoms which are both part of the heterocycle and the macrocycle are absent; and
(ii) one or more of R1, R2, R′2, R3, R′3, R4, R′4, R5, R′5, R6, R′6, R7, R′7, R8, R′8, R9, R′9, and R10 are independently:
(iia) hydrogen; or
(iib) a moiety independently selected from the group consisting of alkenyl, alkenylcycloalkenyl, alkenylcycloalkyl, alkyl, alkylcycloalkenyl, alkylcycloalkyl, alkynyl, aralkyl, aryl, cycloalkenyl, cycloalkyl, cycloalkylalkyl, cycloalkylcycloalkyl, cycloalkenylalkyl, heterocyclyl, and aralkyl radicals and radicals attached to the α-carbon or α-amino acids; or
(iic) a moiety independently selected from the group consisting of —OR11, —NR11R12, —COR11, —CO2R11, —CONR11R12, —SOR11, —SO2R11, —SO2NR11R12, —N(OR11)(R12), —P(O)(OR11)(OR12), —P(O)(OR11)(R12), —OP(O)(OR11)(OR12), and substituents attached to the α-carbon of α-amino acids, wherein R11 and R12 are independently hydrogen or alkyl; and
(iii) optionally, one or more of R1 and R2 or R′2, R3 or R′3 and R4 or R′4, R5 or R′5 and R6 or R′6, R7 or R′7 and R8 or R′8, R9 or R′9 and R10 together with the carbon atoms to which they are attached independently form a substituted or unsubstituted and saturated, partially saturated, or unsaturated cycle or heterocycle having 3 to 20 carbon atoms; and
(iv) optionally, one or more of R2 and R′2, R3 and R′3, R4 and R′4, R5 and R′5, R6 and R′6, R7 and R′7, R8 and R′8, and R9 and R′9, together with the carbon atom to which they are attached independently form a substituted or unsubstituted and saturated, partially saturated, or unsaturated cycle or heterocycle having 3 to 20 carbon atoms; and
(v) optionally, one or more of R2 or R′2 and R3 or R′3, R4 or R′4 and R5 or R′5, R6 or R′6 and R7 or R′7, or R8 or R′8 and R9 or R′9 together with the carbon atoms to which they are attached independently form a substituted or unsubstituted nitrogen containing heterocycle having 3 to 20 carbon atoms, which may be an aromatic heterocycle in which case the hydrogen attached to the nitrogen which is both part of the heterocycle and the macrocycle and the R groups attached to the carbon atoms which are both part of the heterocycle and the macrocycle are absent; and
(vi) optionally, one or more of R1, R2, R′2, R3, R′3, R4, R′4, R5, R′5, R6, R′6, R7, R′7, R8, R′8, R9, R′9, and R10, together with a different one of R1, R2, R′2, R3, R′3, R4, R′4, R5, R′5, R6, R′6, R7, R′7, R8, R′9, R9, R′9, and R10, which is attached to a different carbon atom in the macrocyclic ligand may be bound to form a strap represented by the formula:

—(CH2)I-Q-(CH2)J—R—(CH2)K—S—(CH2)L—

wherein
I, J, K and L independently are integers from 0 to 10 and Q, R and S are independently selected from the group consisting of alkenyl, alkenylcycloalkenyl, alkenylcycloalkyl, alkyl, alkylcycloalkenyl, alkylcycloalkyl, alkynyl, aralkyl, aryl, cycloalkenyl, cycloalkyl, cycloalkylalkyl, cycloalkylcycloalkyl, cycloalkenylalkyl, and heterocyclyl, aza, amide, ammonium, oxa, thia, sulfonyl, sulfinyl, sulfonamide, phosphoryl, phosphinyl, phosphino, phosphonium, keto, ester, alcohol, carbamate, urea, thiocarbonyl, borates, boranes, boraza, silyl, siloxy, silaza, and combinations thereof; and
(vii) optionally, one or more of R1, R2, R′2, R3, R′3, R4, R′4, R5, R′5, R6, R′6, R7, R′7, R8, R′8, R9, R′9, and R10, may be bound to an atom of heterocycle W to form a strap represented by the formula:

—(CH2)I-Q-(CH2)J—R—(CH2)K—S—(CH2)L—

wherein
I, J, K and L independently are integers from 0 to 10 and Q, R and S are independently selected from the group consisting of alkenyl, alkenylcycloalkenyl, alkenylcycloalkyl, alkyl, alkylcycloalkenyl, alkylcycloalkyl, alkynyl, aralkyl, aryl, cycloalkenyl, cycloalkyl, cycloalkylalkyl, cycloalkylcycloalkyl, cycloalkenylalkyl, and heterocyclyl, aza, amide, ammonium, oxa, this, sulfonyl, sulfinyl, sulfonamide, phosphoryl, phosphinyl, phosphino, phosphonium, keto, ester, alcohol, carbamate, urea, thiocarbonyl, borates, boranes, boraza, silyl, siloxy, silaza, and combinations thereof; and
(viii) combinations of any of (i) through (vii) above;
wherein
M is a transition metal;
X, Y and Z are independently selected from the group consisting of halide, oxo, aquo, hydroxo, alcohol, phenol, dioxygen, peroxo, hydroperoxo, alkylperoxo, arylperoxo, ammonia, alkylamino, arylamino, heterocycloalkyl amino, heterocycloaryl amino, amine oxides, hydrazine, alkyl hydrazine, aryl hydrazine, nitric oxide, cyanide, cyanate, thiocyanate, isocyanate, isothiocyanate, alkyl nitrile, aryl nitrile, alkyl isonitrile, aryl isonitrile, nitrate, nitrite, azido, alkyl sulfonic acid, aryl sulfonic acid, alkyl sulfoxide, aryl sulfoxide, alkyl aryl sulfoxide, alkyl sulfenic acid, aryl sulfenic acid, alkyl sulfinic acid, aryl sulfinic acid, alkyl thiol carboxylic acid, aryl thiol carboxylic acid, alkyl thiol thiocarboxylic acid, aryl thiol thiocarboxylic acid, alkyl carboxylic acid, aryl carboxylic acid, urea, alkyl urea, aryl urea, alkyl aryl urea, thiourea, alkyl thiourea, aryl thiourea, alkyl aryl thiourea, sulfate, sulfite, bisulfate, bisulfite, thiosulfate, thiosulfite, hydrosulfite, alkyl phosphine, aryl phosphine, alkyl phosphine oxide, aryl phosphine oxide, alkyl aryl phosphine oxide, alkyl phosphine sulfide, aryl phosphine sulfide, alkyl aryl phosphine sulfide, alkyl phosphonic acid, aryl phosphonic acid, alkyl phosphinic acid, aryl phosphinic acid, alkyl phosphinous acid, aryl phosphinous acid, phosphate, thiophosphate, phosphite, pyrophosphite, triphosphate, hydrogen phosphate, dihydrogen phosphate, alkyl guanidino, aryl guanidino, alkyl aryl guanidino, alkyl carbamate, aryl carbamate, alkyl aryl carbamate, alkyl thiocarbamate, aryl thiocarbamate, alkylaryl thiocarbamate, alkyl dithiocarbamate, aryl dithiocarbamate, alkylaryl dithiocarbamate, bicarbonate, carbonate, perchlorate, chlorate, chlorite, hypochlorite, perbromate, bromate, bromite, hypobromite, tetrahalomanganate, tetrafluoroborate, hexafluoroantimonate, hypophosphite, iodate, periodate, metaborate, tetraaryl borate, tetra alkyl borate, tartrate, salicylate, succinate, citrate, ascorbate, saccharinate, amino acid, hydroxamic acid, thiotosylate, and anions of ion exchange resins, or the corresponding anions thereof; or
X, Y and Z are independently selected from the group consisting of charge-neutralizing anions which are derived from any monodentate or polydentate coordinating ligand and a ligand system and the corresponding anion thereof; or
X, Y and Z are independently attached to one or more of R1, R2, R′2, R3, R′3, R4, R′4, R5, R′5, R6, R′6, R7, R′7, R8, R′8, R9, R′9, and R10; and
n is an integer from 0 to 3.
Preferably, M is selected from the group consisting of Mn2+, Mn3+, Mn4+, Mn6+, Mn7+, Fe2+, Fe3+, Fe4+, Fe6+, Ni2+, Ni2+, Cu1+, Cu2+, V2+, V3+, V4+, and V5+, and W is a substituted or unsubstituted pyridino moiety.
In yet another alternative, the superoxide dismutase mimetic can be represented by the formula:




wherein
(i) a nitrogen of the macrocycle and two adjacent carbon atoms to which the nitrogen is attached independently form a substituted or unsubstituted, saturated, partially saturated or unsaturated nitrogen-containing heterocycle W having 2 to 20 carbon atoms, which may be an aromatic heterocycle in which case the hydrogen attached to the nitrogen which is both part of the heterocycle and the macrocycle and the R groups attached to the carbon atoms which are both part of the heterocycle and the macrocycle are absent; and
(ii) two sets of two adjacent carbon atoms of the macrocycle independently form substituted or unsubstituted, saturated, partially saturated or unsaturated, cycles or heterocycles U and V having 3 to 20 carbon atoms; and
(iii) R1, R2, R′2, R3, R4, R5, R′5, R6, R′6, R7, R8, R9, R′9, and R10 are independently:
(iiia) hydrogen; or
(iiib) a moiety independently selected from the group consisting of alkenyl, alkenylcycloalkenyl, alkenylcycloalkyl, alkyl, alkylcycloalkenyl, alkylcycloalkyl, alkynyl, aralkyl, aryl, cycloalkenyl, cycloalkyl, cycloalkylalkyl, cycloalkylcycloalkyl, cycloalkenylalkyl, heterocyclyl, and aralkyl radicals and radicals attached to the α-carbon or α-amino acids; or
(iiic) a moiety independently selected from the group consisting of —OR11, —NR11R12, —COR11, —CO2R11, —CONR11R12, —SR11, —SOR11, —SO2R11, —SO2NR11R12, —N(OR11)(R12), —P(O)(OR11)(OR12), —P(O)(OR11)(R12), —OP(O)(OR11)(OR12), and substituents attached to the α-carbon of α-amino acids, wherein R11 and R12 are independently hydrogen or alkyl; and
(iv) optionally, one or more of R1 and R2 or R′2, R5 or R′5 and R6 or R′6, R9 or R′9 and R10 together with the carbon atoms to which they are attached independently form a substituted or unsubstituted and saturated, partially saturated, or unsaturated cycle or heterocycle having 3 to 20 carbon atoms; and
(v) optionally, one or more of R2 and R′2, R5 and R′5, R6 and R′6, and R9 and R′9, together with the carbon atom to which they are attached independently form a substituted or unsubstituted and saturated, partially saturated, or unsaturated cycle or heterocycle having 3 to 20 carbon atoms; and
(vi) optionally, one or more of R2 or R′2 and R3, R4 and R5 or R′5, R6 or R′6 and R7, or R8 and R9 or R′9 together with the carbon atoms to which they are attached independently form a substituted or unsubstituted nitrogen containing heterocycle having 3 to 20 carbon atoms, which may be an aromatic heterocycle in which case the hydrogen attached to the nitrogen which is both part of the heterocycle and the macrocycle and the R groups attached to the carbon atoms which are both part of the heterocycle and the macrocycle are absent; and
(vii) optionally, one or more of R1, R2, R′2, R3, R4, R5, R′5, R6, R′6, R7, R8, R9, R′9, and R10, together with a different one of R1, R2, R′2, R3, R4, R5, R′5, R6, R′6, R7, R8, R9, R′9, and R10, which is attached to a different carbon atom in the macrocyclic ligand may be bound to form a strap represented by the formula:

—(CH2)I-Q-(CH2)J—R—(CH2)K—S—(CH2)L—

wherein
I, J, K and L independently are integers from 0 to 10 and Q, R and S are independently selected from the group consisting of alkenyl, alkenylcycloalkenyl, alkenylcycloalkyl, alkyl, alkylcycloalkenyl, alkylcycloalkyl, alkynyl, aralkyl, aryl, cycloalkenyl, cycloalkyl, cycloalkylalkyl, cycloalkylcycloalkyl, cycloalkenylalkyl, and heterocyclyl, aza, amide, ammonium, oxa, thia, sulfonyl, sulfinyl, sulfonamide, phosphoryl, phosphinyl, phosphino, phosphonium, keto, ester, alcohol, carbamate, urea, thiocarbonyl, borates, boranes, boraza, silyl, siloxy, silaza, and combinations thereof; and
(viii) optionally, one or more of R1, R2, R′2, R3, R4, R5, R′5, R6, R′6, R7, R8, R9, R′9, and R10, may be individually bound to an atom of heterocycles U, V and W to form a strap represented by the formula:

—(CH2)I-Q-(CH2)J—R—(CH2)K—S—(CH2)L—

wherein
I, J, K and L independently are integers from 0 to 10 and Q, R and S are independently selected from the group consisting of alkenyl, alkenylcycloalkenyl, alkenylcycloalkyl, alkyl, alkylcycloalkenyl, alkylcycloalkyl, alkynyl, aralkyl, aryl, cycloalkenyl, cycloalkyl, cycloalkylalkyl, cycloalkylcycloalkyl, cycloalkenylalkyl, and heterocyclyl, aza, amide, ammonium, oxa, thia, sulfonyl, sulfinyl, sulfonamide, phosphoryl, phosphinyl, phosphino, phosphonium, keto, ester, alcohol, carbamate, urea, thiocarbonyl, borates, boranes, boraza, silyl, siloxy, silaza, and combinations thereof; and
(ix) combinations of any of (i) through (viii) above;
wherein
M is a transition metal;
X, Y and Z are independently selected from the group consisting of halide, oxo, aquo, hydroxo, alcohol, phenol, dioxygen, peroxo, hydroperoxo, alkylperoxo, arylperoxo, ammonia, alkylamino, arylamino, heterocycloalkyl amino, heterocycloaryl amino, amine oxides, hydrazine, alkyl hydrazine, aryl hydrazine, nitric oxide, cyanide, cyanate, thiocyanate, isocyanate, isothiocyanate, alkyl nitrile, aryl nitrile, alkyl isonitrile, aryl isonitrile, nitrate, nitrite, azido, alkyl sulfonic acid, aryl sulfonic acid, alkyl sulfoxide, aryl sulfoxide, alkyl aryl sulfoxide, alkyl sulfenic acid, aryl sulfenic acid, alkyl sulfinic acid, aryl sulfinic acid, alkyl thiol carboxylic acid, aryl thiol carboxylic acid, alkyl thiol thiocarboxylic acid, aryl thiol thiocarboxylic acid, alkyl carboxylic acid, aryl carboxylic acid, urea, alkyl urea, aryl urea, alkyl aryl urea, thiourea, alkyl thiourea, aryl thiourea, alkyl aryl thiourea, sulfate, sulfite, bisulfate, bisulfite, thiosulfate, thiosulfite, hydrosulfite, alkyl phosphine, aryl phosphine, alkyl phosphine oxide, aryl phosphine oxide, alkyl aryl phosphine oxide, alkyl phosphine sulfide, aryl phosphine sulfide, alkyl aryl phosphine sulfide, alkyl phosphonic acid, aryl phosphonic acid, alkyl phosphinic acid, aryl phosphinic acid, alkyl phosphinous acid, aryl phosphinous acid, phosphate, thiophosphate, phosphite, pyrophosphite, triphosphate, hydrogen phosphate, dihydrogen phosphate, alkyl guanidino, aryl guanidino, alkyl aryl guanidino, alkyl carbamate, aryl carbamate, alkyl aryl carbamate, alkyl thiocarbamate, aryl thiocarbamate, alkylaryl thiocarbamate, alkyl dithiocarbamate, aryl dithiocarbamate, alkylaryl dithiocarbamate, bicarbonate, carbonate, perchlorate, chlorate, chlorite, hypochlorite, perbromate, bromate, bromite, hypobromite, tetrahalomanganate, tetrafluoroborate, hexafluoroantimonate, hypophosphite, iodate, periodate, metaborate, tetraaryl borate, tetra alkyl borate, tartrate, salicylate, succinate, citrate, ascorbate, saccharinate, amino acid, hydroxamic acid, thiotosylate, and anions of ion exchange resins, or the corresponding anions thereof; or
X, Y and Z are independently selected from the group consisting of charge-neutralizing anions which are derived from any monodentate or polydentate coordinating ligand and a ligand system and the corresponding anion thereof; or
X, Y and Z are independently attached to one or more of R1, R2, R′2, R3, R4, R5, R′5, R6, R′6, R7, R8, R9, R′9, and R10; and
n is an integer from 0 to 3.
Preferably, M is selected from the group consisting of Mn2+, Mn3+, Mn4+, Mn6+, Mn7+, Fe2+, Fe3+, Fe4+, Fe6+, Ni2+, Ni3+, Cu1+, Cu2+, V2+, V3+, V4+, and V3+. In accordance with a further aspect of the invention, U and V are saturated cycloalkyl heterocycles having 3 to 20 carbon atoms preferably saturated cycloalkyl heterocycles having 4 to 10 carbon atoms, and still more preferably U and V are trans-cyclohexanyl fused rings. In yet another aspect of the present invention, W is a substituted or unsubstituted pyridino moiety, more preferably, U and V are trans-cyclohexanyl fused rings and W is a substituted pyridino moiety. Preferably, the superoxide dismutase mimetic can be represented by the formula:




The ROS scavenger can be administered in an amount of at most 0.015 mg/kg, or preferably at most 2 mg/kg. In yet another aspect, the pharmaceutically acceptable formulation is a pharmaceutically acceptable oral formulation and administering comprises administering orally. Preferably, the patient is a human patient and the oral mucositis is a result of chemotherapy or radiation therapy.
Another aspect of the invention can be a method of treating a cancer, the method comprising: a) administering to a subject in need of cancer treatment a pharmaceutical composition comprising a superoxide dismutase mimetic; and b) administering to the subject an effective amount of a cancer treatment, whereby the superoxide dismutase mimetic prevents or reduces oral mucositis in the subject. The cancer treatment can be comprised of radiation therapy and chemotherapy. In said method of treating a cancer, the superoxide dismutase mimetic can be a reactive oxygen species scavenger, and the pharmaceutical composition can further comprise at least one additional reactive oxygen species scavenger selected from the group consisting of amifostine and N-acetylcysteine. Additionally, the method of treating a cancer can further comprise administering a pharmaceutical composition which upregulates expression of at least one transcription factor which increases expression of one or more genes controlling at least one naturally occurring antioxidant pathway. The composition which upregulates expression of at least one transcription factor can be palifermin, and the transcription factor upregulated can be Nrf-2.
In yet another aspect of the present invention, a kit can be provided for treating oral mucositis, the kit comprising: (a) a ROS scavenger, wherein the ROS scavenger can be a superoxide dismutase; (b) one additional pharmaceutical compound selected from the group consisting of a chemotherapeutic agent; (c) a non-superoxide dismustase mimetic radical scavenger; and (d) instructions for administering the superoxide dismutase to a subject in need of cancer therapy. A chemotherapeutic agent can be selected from a group consisting of all-trans retinoic acid, azacitidine, azathioprine, bleomycin, carboplatin, capecitabine, cisplatin, chlorambucil, cyclophosphamide, cytarabine, daunorubicin, docetaxel, doxifluridine, doxorubicin, epirubicin, epothilone, etoposide, fluorouracil, gemcitabine, hydroxyurea, idarubicin, imatinib, mechlorethamine, mercaptopurine, methotrexate, mitoxantrone, oxaliplatin, paclitaxel, pemetrexed, teniposide, tiguanine, valrubicin, vinblastine, vincristine, vindesine, vinorelbine. A non-superoxide dismutase mimetic radical scavenger can be selected from the group of amifostine and N-acetylcysteine. A superoxide dismutase mimetic can be M40403.
These and other features, aspects and advantages of the present invention will become better understood with reference to the following description, examples and appended claims.



BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 1 is a timeline of a study for treatment groups 1-6 to evaluate the effect of M40403, administered by either ip or topical routes. The grade of mucositis was scored, beginning on day 6, and for every second day thereafter, through and including day 28.
FIG. 2 is a validated photographic scale for mucositis scoring.
FIG. 3 illustrates the percent daily weight change for the groups treated with intraperitoneal (ip) injection of M40403 (i.e. groups 1, 2, 3, and 6), including the control group, and for the groups treated topically with M40403 (i.e. groups 4 and 5).
FIG. 4 illustrates the mean percent weight gain for the groups treated ip with M40403 (i.e. groups 1, 2, 3, and 6), including the control group, and for the groups treated topically with M40403 (i.e. groups 4 and 5).
FIG. 5 illustrates the mean daily mucositis scores the groups treated ip with M40403 (i.e. groups 1, 2, 3, and 6), including the control group, and for the groups treated topically with M40403 (i.e. groups 4 and 5).
FIG. 6 illustrates the percentage of animal days with a mucositis score of 3 or higher for groups treated ip with M40403 (i.e. groups 1, 2, 3, and 6), including the control group, and for the groups treated topically with M40403 (i.e. groups 4 and 5).
FIG. 7 is a timeline of a study for treatment groups 1-9 to evaluate the effect of M40403, administered by either ip or topical routes. The grade of mucositis was scored, beginning on day 6, and for every second day thereafter, through and including day 28.
FIG. 8 is a validated photographic scale for mucositis scoring.
FIG. 9 illustrates the percent daily weight change for the groups treated ip with M40403 (i.e. groups 2-9) and for the control group (i.e. group 1).
FIG. 10 illustrates the mean percent weight gain for the groups treated ip with M40403 (i.e. groups 2-9) and for the control group (i.e. group 1).
FIG. 11 illustrates the mean daily mucositis scores the groups treated ip with M40403 (i.e. groups 2-9) and for the control group (i.e. group 1).
FIG. 12 illustrates the percentage of animal days with a mucositis score of 3 or higher for groups treated ip with M40403 (i.e. groups 2-9) and for the control group (i.e. group 1).



DETAILED DESCRIPTION OF THE INVENTION
Abbreviations and Definitions
To facilitate understanding of the invention, a number of terms and abbreviations as used herein are defined below as follows:
The term “alkenyl”, alone or in combination, means an alkyl substituent having one or more double bonds. Examples of such alkenyl substituents include, but are not limited to, ethenyl, propenyl, 1-butenyl, cis-2-butenyl, trans-2-butenyl, iso-butylenyl, cis-2-pentenyl, trans-2-pentenyl, 3-methyl-1-butenyl, 2,3-dimethyl-2-butenyl, 1-pentenyl, 1-hexenyl, 1-octenyl, decenyl, dodecenyl, tetradecenyl, hexadecenyl, cis- and trans-9-octadecenyl, 1,3-pentadienyl, 2,4-pentadienyl, 2,3-pentadienyl, 1,3-hexadienyl, 2,4-hexadienyl, 5,8,11,14-eicosatetraenyl, and 9,12,15-octadecatrienyl.
The term “alkyl”, alone or in combination, means a straight-chain or branched-chain alkyl substituent containing from 1 to about 22 carbon atoms, prefarably from about 1 to about 18 carbon atoms, and most preferably from about 1 to about 12 carbon atoms. Examples of such substituents include, but are not limited to, methyl, ethyl, n-propyl, isopropyl, n-butyl, isobutyl, sec-butyl, tert-butyl, pentyl, iso-amyl, hexyl, octyl, nonyl, decyl, dodecyl, tetradecyl, hexadecyl, octadecyl and eicosyl.
The terms “alkylcycloalkyl” and “alkenylcycloalkyl” mean a cycloalkyl substituent as defined above which is substituted by an alkyl or alkenyl substituent as defined above. Examples of alkylcycloalkyl and alkenylcycloalkyl substituents include, but are not limited to, 2-ethylcyclobutyl, 1-methylcyclopentyl, 1-hexylcyclopentyl, 1-methylcyclohexyl, 1-(9-octadecenyl)cyclopentyl and 1-(9-octadecenyl)cyclohexyl.
The terms “alkylcycloalkenyl” and “alkenylcycloalkenyl” means a cycloalkenyl substituent as defined above which is substituted by an alkyl or alkenyl substituent as defined above. Examples of alkylcycloalkenyl and alkenylcycloalkenyl substituents include, but are not limited to, 1-methyl-2-cyclopentyl, 1-hexyl-2-cyclopentenyl, 1-ethyl-2-cyclohexenyl, 1-butyl-2-cyclohexenyl, 1-(9-octadecenyl)-2-cyclohexenyl and 1-(2-pentenyl)-2-cyclohexenyl.
The term “alkynyl”, alone or in combination, means an alkyl substituent having one or more triple bonds. Examples of such alkynyl groups include, but are not limited to, ethynyl, propynyl (propargyl), 1-butynyl, 1-octynyl, 9-octadecynyl, 1,3-pentadiynyl, 2,4-pentadiynyl, 1,3-hexadiynyl, and 2,4-hexadiynyl.
The term “aralkyl”, alone or in combination, means an alkyl or cycloalkyl substituent as defined above in which one hydrogen atom is replaced by an aryl substituent as defined above, such as benzyl, 2-phenylethyl, and the like.
The term “aryl”, alone or in combination, means a phenyl or naphthyl substituent which optionally carries one or more substituents selected from alkyl, cycloalkyl, cycloalkenyl, aryl, heterocycle, alkoxyaryl, alkaryl, alkoxy, halogen, hydroxy, amine, cyano, nitro, alkylthio, phenoxy, ether, trifluoromethyl and the like, such as phenyl, p-tolyl, 4-methoxyphenyl, 4-(tert-butoxy)phenyl, 4-fluorophenyl, 4-chlorophenyl, 4-hydroxyphenyl, 1-naphthyl, 2-naphthyl, and the like.
The term “cycloalkenyl”, alone or in combination, means a cycloalkyl substituent having one or more double bonds. Examples of cycloalkenyl substituents include, but are not limited to, cyclopentenyl, cyclohexenyl, cyclooctenyl, cyclopentadienyl, cyclohexadienyl and cyclooctadienyl.
The terms “cyclic”, “cycle” or “cycylyl” means a ring structure containing 3 to 20 carbon atoms, preferably 5 to 10 carbon atoms, which may be heterocyclic. The cyclic, cycle or cycylyl can also contain more than one ring.
The term “cycloalkenylalkyl” means an alkyl substituent as defined above which is substituted by a cycloalkenyl substituent as defined above. Examples of cycloalkenylalkyl substituents include, but are not limited to, 2-cyclohexen-1-ylmethyl, 1-cyclopenten-1-ylmethyl, 2-(1-cyclohexen-1-yl)ethyl, 3-(1-cyclopenten-1-yl)propyl, 1-(1-cyclohexen-1-ylmethyl)pentyl, 1-(1-cyclopenten-1-yl)hexyl, 6-(1-cyclohexen-1-1-yl)hexyl, 1-(1-cyclopenten-1-yl)nonyl and 1-(1-cyclohexen-1-yl)nonyl.
The term “cycloalkyl”, alone or in combination means a cycloalkyl radica containing from 3 to about 10, preferably from 3 to about 8, and most preferably from 3 to about 6, carbon atoms. Examples of such cycloalkyl substituents include, but are not limited to, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, cycloheptyl, cyclooctyl, and perhydronaphthyl.
The term “cycloalkylalkyl” means an alkyl substituent as defined above which is substituted by a cycloalkyl substituent as defined above. Examples of cycloalkylalkyl substituents include, but are not limited to, cyclohexylmrthyl, cyclopentylmethyl, (4-isopropylcyclohexyl)methyl, (4-t-butyl-cyclohexyl)methyl, 3-cyclohexylpropyl, 2-cyclohexylmethylpentyl, 3-cyclopentylmethylhexyl, 1-(4-neopentylcyclohexyl)methylhexyl, and 1-(4-isopropylcyclohexyl)methylheptyl.
The term “cycloalkylcycloalkyl” means a cycloalkyl substituent as defined above which is substituted by another cycloalkyl substituent as defined above. Examples of cycloalkylcycloalkyl substituents include, but are not limited to, cyclohexylcyclopentyl and cyclohexylcyclohexyl.
The term “halide” means chloride, fluoride, iodide, or bromide.
The term “heterocyclic”, “heterocycle” or “heterocycylyl” means a cyclic, cycle or cycylyl containing at least one other kind of atom, in addition to carbon, in the ring. Such atoms include, but are not limited to, nitrogen, oxygen and sulfur. The heterocyclic can also contain more than one ring. Examples of heterocyclics include, but are not limited to, pyrrolidinyl, piperidyl, imidazolidinyl, tetrahydrofuryl, tetrahydrothienyl, furyl, thienyl, pyridyl, quinolyl, isoquinolyl, pyridazinyl, pyrazinyl, indolyl, imidazolyl, oxazolyl, thiazolyl, pyrazolyl, pyridinyl, benzoxadiazolyl, benzothiadiazolyl, triazolyl and tetrazolyl groups.
The term “nitrogen containing heterocycle” means a ring structure in which 2 carbons and a nitrogen of the ring are shared with the fifteen-membered macrocyclic ligand. The nitrogen containing heterocycle can contain 2 to 20, preferably 4 to 10, carbon atoms, can be substituted or unsubstituted, saturated, partially saturated or unsaturated, and can also contain nitrogen, oxygen and/or sulfur atoms in the portion of the ring which is not also part of the fifteen-membered macrocyclic ligand.
The term “oral mucositis” shall also include stomatitis, small intestine-titis, large intestine-titis, proctitis, and similar conditions affecting the mucosal lining of the entire gastrointestinal tract, and related conditions.
The term “R groups” means the group of variable substituents designated as “R” attached to the carbon atoms of the macrocycle, i.e., R1, R′1, R2, R′2, R3, R′3, R4, R′4, R5, R′5, R6, R′6, R7, R′7, R8, R′8, R9, R′9, R10, and R′10.
The term “saturated, partially saturated or unsaturated cycle or heterocycle” means a fused ring structure in which 2 carbons of the ring are also part of the fifteen-membered macrocyclic ligand in which the ring can contain no double bonds (in the case of a saturated ring structure) or at least one double bond, which may be conjugated or unconjugated with another double bond. The ring structure can contain 3 to 20 carbon atoms, preferably 5 to 10 carbon atoms, which may be heterocyclic. The cyclic can also contain more than one ring.
In addition, the following abbreviations have the following meanings:
















AUC
Area under the curve



bid
Twice daily



FGF
Fibroblast growth factor



g, mg, ml, kg
Gram, milligram, milliliter, kilogram



Gy
Gray



ip
Intraperitoneal



ma
Milliamp



mM
Millimolar



mm, cm
Millimeter, centimeter



SEM
Standard error of the mean



top
Topical










Methods for Treating Oral Mucositis
The present invention involves the administration of a ROS scavenger in the treatment of oral mucositis. A ROS scavenger of the present invention is a superoxide dismutase mimetic, a non-proteinaceous molecule that catalyzes the conversion the of the superoxide radical, O2−, to molecular oxygen and hydrogen peroxide. Such a molecule can, like a native superoxide dismutase enzyme, reduce cell injury resulting from superoxide radical found in diseases involving oxidative stress such as inflammation (Salvemini et al, Arthritis & Rheumatism 44:2909-2921, 2001). The ROS scavengers of the present invention can be pentaaza-macrocyclic complexes, and more specifically, those compositions as disclosed in U.S. Pat. Nos. 5,610,293, 5,637,578, 5,874,421, 5,976,498, 6,084,093, 6,180,620, 6,204,259, 6,214,817, 6,245,758, 6,395,725, and 6,525,041, each of which is incorporated herein by reference in its entirety.
The superoxide dismutase mimetics of the present invention can be represented by the following formula:




wherein
(i) R1, R′1, R2, R′2, R3, R′3, R4, R′4, R5, R′5, R6, R′6, R7, R′7, R8, R′8, R9, R′9, R10, and R′10 are independently:
(ia) hydrogen; or
(ib) a moiety independently selected from the group consisting of alkenyl, alkenylcycloalkenyl, alkenylcycloalkyl, alkyl, alkylcycloalkenyl, alkylcycloalkyl, alkynyl, aralkyl, aryl, cycloalkenyl, cycloalkyl, cycloalkylalkyl, cycloalkylcycloalkyl, cycloalkenylalkyl, and aralkyl radicals and radicals attached to the α-carbon or α-amino acidsheterocyclyl; or
(ic) a moiety independently selected from the group consisting of —OR11, —NR11R12, —COR11, —CO2R11, —CONR11R12, —SR11, —SOR11, SO2R11, —SO2NR11R12, —N(OR11)(R12), —P(O)(OR11)(OR12), —P(O)(OR11)(R12), —OP(O)(OR11)(OR12), and substituents attached to the α-carbon of α-amino acids, wherein R11 and R12 are independently hydrogen or alkyl; and
(ii) optionally, one or more of R1 or R′1 and R2 or R′2, R3 or R′3 and R4 or R′4, R5 or R′5 and R6 or R′6, R7 or R′7 and R8 or R′8, R9 or R′9 and R10 or R′10 together with the carbon atoms to which they are attached independently form a substituted or unsubstituted and saturated, partially saturated, or unsaturated cycle or heterocycle having 3 to 20 carbon atoms; and
(iii) optionally, one or more of R1 and R′1, R2 and R′2, R3 and R′3, R4 and R′4, R5 and R′5, R6 and R′6, R7 and R′7, R8 and R′8, R9 and R′9, and R10 and R′10, together with the carbon atom to which they are attached independently form a substituted or unsubstituted and saturated, partially saturated, or unsaturated cycle or heterocycle having 3 to 20 carbon atoms; and
(iv) optionally, one or more of R10 or R′10 and R1 or R′1, R2 or R′2 and R3 or R′3, R4 or R′4 and R5 or R′5, R6 or R′6 and R7 or R′7, or R8 or R′8 and R9 or R′9 together with the carbon atoms to which they are attached independently form a substituted or unsubstituted nitrogen containing heterocycle having 3 to 20 carbon atoms, which may be an aromatic heterocycle in which case the hydrogen attached to the nitrogen which is both part of the heterocycle and the macrocycle and the R groups attached to the carbon atoms which are both part of the heterocycle and the macrocycle are absent; and
(v) optionally, one or more of R1, R′1, R2, R′2, R3, R′3, R4, R′4, R5, R′5, R6, R′6, R7, R′7, R8, R′8, R9, R′9, R10, and R′10, together with a different one of R1, R′1, R2, R′2, R3, R′3, R4, R′4, R5, R′5, R6, R's, R7, R′7, R8, R′8, R9, R′9, R10, and R′10, which is attached to a different carbon atom in the macrocyclic ligand may be bound to form a strap represented by the formula:

—(CH2)I-Q-(CH2)J—R—(CH2)K—S—(CH2)L—

wherein
I, J, K and L independently are integers from 0 to 10 and Q, R and S are independently selected from the group consisting of alkenyl, alkenylcycloalkenyl, alkenylcycloalkyl, alkyl, alkylcycloalkenyl, alkylcycloalkyl, alkynyl, aralkyl, aryl, cycloalkenyl, cycloalkyl, cycloalkylalkyl, cycloalkylcycloalkyl, cycloalkenylalkyl, and heterocyclyl, aza, amide, ammonium, oxa, this, sulfonyl, sulfinyl, sulfonamide, phosphoryl, phosphinyl, phosphino, phosphonium, keto, ester, alcohol, carbamate, urea, thiocarbonyl, borates, boranes, boraza, silyl, siloxy, silaza, and combinations thereof; and
(vi) combinations of any of (i) through (v) above.
Thus, the pentaaza-macrocyclic ligand compositions useful in the present invention can have any combinations of substituted or unsubstituted R groups, saturated, partially saturated or unsaturated cyclics, heterocyclics, nitrogen containing heterocycles, or straps as defined above.
M can be a transition metal, preferably Mn2+, Mn3+, Mn4+, Mn6+, Mn7+, Fe2+, Fe3+, Fe4+, Fe6+, Ni2+, Ni3+, Cu1+, Cu2+, V2+, V3+, V4+, or V5+. X, Y and Z can independently be selected from the group consisting of halide, oxo, aquo, hydroxo, alcohol, phenol, dioxygen, peroxo, hydroperoxo, alkylperoxo, arylperoxo, ammonia, alkylamino, arylamino, heterocycloalkyl amino, heterocycloaryl amino, amine oxides, hydrazine, alkyl hydrazine, aryl hydrazine, nitric oxide, cyanide, cyanate, thiocyanate, isocyanate, isothiocyanate, alkyl nitrile, aryl nitrile, alkyl isonitrile, aryl isonitrile, nitrate, nitrite, azido, alkyl sulfonic acid, aryl sulfonic acid, alkyl sulfoxide, aryl sulfoxide, alkyl aryl sulfoxide, alkyl sulfenic acid, aryl sulfenic acid, alkyl sulfinic acid, aryl sulfinic acid, alkyl thiol carboxylic acid, aryl thiol carboxylic acid, alkyl thiol thiocarboxylic acid, aryl thiol thiocarboxylic acid, alkyl carboxylic acid, aryl carboxylic acid, urea, alkyl urea, aryl urea, alkyl aryl urea, thiourea, alkyl thiourea, aryl thiourea, alkyl aryl thiourea, sulfate, sulfite, bisulfate, bisulfite, thiosulfate, thiosulfite, hydrosulfite, alkyl phosphine, aryl phosphine, alkyl phosphine oxide, aryl phosphine oxide, alkyl aryl phosphine oxide, alkyl phosphine sulfide, aryl phosphine sulfide, alkyl aryl phosphine sulfide, alkyl phosphonic acid, aryl phosphonic acid, alkyl phosphinic acid, aryl phosphinic acid, alkyl phosphinous acid, aryl phosphinous acid, phosphate, thiophosphate, phosphite, pyrophosphite, triphosphate, hydrogen phosphate, dihydrogen phosphate, alkyl guanidino, aryl guanidino, alkyl aryl guanidino, alkyl carbamate, aryl carbamate, alkyl aryl carbamate, alkyl thiocarbamate, aryl thiocarbamate, alkylaryl thiocarbamate, alkyl dithiocarbamate, aryl dithiocarbamate, alkylaryl dithiocarbamate, bicarbonate, carbonate, perchlorate, chlorate, chlorite, hypochlorite, perbromate, bromate, bromite, hypobromite, tetrahalomanganate, tetrafluoroborate, hexafluoroantimonate, hypophosphite, iodate, periodate, metaborate, tetraaryl borate, tetra alkyl borate, tartrate, salicylate, succinate, citrate, ascorbate, saccharinate, amino acid, hydroxamic acid, thiotosylate, and anions of ion exchange resins, or the corresponding anions thereof; or
X, Y and Z are independently selected from the group consisting of charge-neutralizing anions which are derived from any monodentate or polydentate coordinating ligand and a ligand system and the corresponding anion thereof; or
X, Y and Z are independently attached to one or more of R1, R′1, R2, R′2, R3, R′3, R4, R′4, R5, R′5, R6, R′6, R7, R′7, R8, R′8, R9, R′9, R10, and R′10. n is preferably an integer from 0 to 3.
Alternatively, the superoxide dismutase mimetic can be represented by the formula:




wherein
(i) a nitrogen of the macrocycle and two adjacent carbon atoms to which the nitrogen is attached independently form a substituted or unsubstituted, saturated, partially saturated or unsaturated nitrogen-containing heterocycle W having 2 to 20 carbon atoms, which may be an aromatic heterocycle in which case the hydrogen attached to the nitrogen which is both part of the heterocycle and the macrocycle and the R groups attached to the carbon atoms which are both part of the heterocycle and the macrocycle are absent; and
(ii) one or more of R1, R2, R′2, R3, R′3, R4, R′4, R5, R′5, R6, R′6, R7, R′7, R8, R′8, R9, R′9, and R10 are independently:
(iia) hydrogen; or
(iib) a moiety independently selected from the group consisting of alkenyl, alkenylcycloalkenyl, alkenylcycloalkyl, alkyl, alkylcycloalkenyl, alkylcycloalkyl, alkynyl, aralkyl, aryl, cycloalkenyl, cycloalkyl, cycloalkylalkyl, cycloalkylcycloalkyl, cycloalkenylalkyl, heterocyclyl, and aralkyl radicals and radicals attached to the α-carbon or α-amino acids; or
(iic) a moiety independently selected from the group consisting of —OR11, —NR11R12, —COR11, —CO2R11, —CONR11R12, —SR11, —SOR11, —SO2R11, —SO2NR11R12, —N(OR11)(R12), —P(O)(OR11)(OR12), —P(O)(OR11)(R12), —OP(O)(OR11)(OR12), and substituents attached to the α-carbon of α-amino acids, wherein R11 and R12 are independently hydrogen or alkyl; and
(iii) optionally, one or more of R1 and R2 or R′2, R3 or R′3 and R4 or R′4, R5 or R′5 and R6 or R′6, R7 or R′7 and R8 or R′8, R9 or R′9 and R10 together with the carbon atoms to which they are attached independently form a substituted or unsubstituted and saturated, partially saturated, or unsaturated cycle or heterocycle having 3 to 20 carbon atoms; and
(iv) optionally, one or more of R2 and R′2, R3 and R′3, R4 and R′4, R5 and R′5, R6 and R′6, R7 and R′7, R8 and R′8, and R9 and R′9, together with the carbon atom to which they are attached independently form a substituted or unsubstituted and saturated, partially saturated, or unsaturated cycle or heterocycle having 3 to 20 carbon atoms; and
(v) optionally, one or more of R2 or R′2 and R3 or R′3, R4 or R′4 and R5 or R′5, R6 or R′6 and R7 or R′7, or R8 or R′8 and R9 or R′9 together with the carbon atoms to which they are attached independently form a substituted or unsubstituted nitrogen containing heterocycle having 3 to 20 carbon atoms, which may be an aromatic heterocycle in which case the hydrogen attached to the nitrogen which is both part of the heterocycle and the macrocycle and the R groups attached to the carbon atoms which are both part of the heterocycle and the macrocycle are absent; and
(vi) optionally, one or more of R1, R2, R′2, R3, R′3, R4, R′4, R5, R′5, R6, R′6, R7, R′7, R8, R′8, R9, R′9, and R10, together with a different one of R1, R2, R′2, R3, R′3, R4, R′4, R5, R′5, R6, R′6, R7, R′7, R8, R′8, R9, R′9, and R10, which is attached to a different carbon atom in the macrocyclic ligand may be bound to form a strap represented by the formula:

—(CH2)I-Q-(CH2)J—R—(CH2)K—S—(CH2)L—

wherein
I, J, K and L independently are integers from 0 to 10 and Q, R and S are independently selected from the group consisting of alkenyl, alkenylcycloalkenyl, alkenylcycloalkyl, alkyl, alkylcycloalkenyl, alkylcycloalkyl, alkynyl, aralkyl, aryl, cycloalkenyl, cycloalkyl, cycloalkylalkyl, cycloalkylcycloalkyl, cycloalkenylalkyl, and heterocyclyl, aza, amide, ammonium, oxa, thia, sulfonyl, sulfinyl, sulfonamide, phosphoryl, phosphinyl, phosphino, phosphonium, keto, ester, alcohol, carbamate, urea, thiocarbonyl, borates, boranes, boraza, silyl, siloxy, silaza, and combinations thereof; and
(vii) optionally, one or more of R1, R2, R′2, R3, R′3, R4, R′4, R5, R′5, R6, R′6, R7, R′7, R8, R′8, R9, R′9, and R10, may be bound to an atom of heterocycle W to form a strap represented by the formula:

—(CH2)I-Q-(CH2)J—R—(CH2)K—S—(CH2)L—

wherein
I, J, K and L independently are integers from 0 to 10 and Q, R and S are independently selected from the group consisting of alkenyl, alkenylcycloalkenyl, alkenylcycloalkyl, alkyl, alkylcycloalkenyl, alkylcycloalkyl, alkynyl, aralkyl, aryl, cycloalkenyl, cycloalkyl, cycloalkylalkyl, cycloalkylcycloalkyl, cycloalkenylalkyl, and heterocyclyl, aza, amide, ammonium, oxa, thia, sulfonyl, sulfinyl, sulfonamide, phosphoryl, phosphinyl, phosphino, phosphonium, keto, ester, alcohol, carbamate, urea, thiocarbonyl, borates, boranes, boraza, silyl, siloxy, silaza, and combinations thereof; and
(viii) combinations of any of (i) through (vii) above.
Thus, the pentaaza-macrocyclic ligand compositions useful in the present invention can have any combinations of substituted or unsubstituted R groups, saturated, partially saturated or unsaturated cyclics, heterocyclics, nitrogen containing heterocycles, or straps as defined above, which may or may not independently connect the W loop and the pentaaza macrocycle.
M can be a transition metal, preferably Mn2+, Mn3+, Mn4+, Mn6+, Mn7+, Fe2+, Fe3+, Fe4+, Fe6+, Ni2+, Ni3+, Cu1+, Cu2+, V2+, V3+, V4+, or V5+. X, Y and Z can independently be selected from the group consisting of halide, oxo, aquo, hydroxo, alcohol, phenol, dioxygen, peroxo, hydroperoxo, alkylperoxo, arylperoxo, ammonia, alkylamino, arylamino, heterocycloalkyl amino, heterocycloaryl amino, amine oxides, hydrazine, alkyl hydrazine, aryl hydrazine, nitric oxide, cyanide, cyanate, thiocyanate, isocyanate, isothiocyanate, alkyl nitrile, aryl nitrile, alkyl isonitrile, aryl isonitrile, nitrate, nitrite, azido, alkyl sulfonic acid, aryl sulfonic acid, alkyl sulfoxide, aryl sulfoxide, alkyl aryl sulfoxide, alkyl sulfenic acid, aryl sulfenic acid, alkyl sulfinic acid, aryl sulfinic acid, alkyl thiol carboxylic acid, aryl thiol carboxylic acid, alkyl thiol thiocarboxylic acid, aryl thiol thiocarboxylic acid, alkyl carboxylic acid, aryl carboxylic acid, urea, alkyl urea, aryl urea, alkyl aryl urea, thiourea, alkyl thiourea, aryl thiourea, alkyl aryl thiourea, sulfate, sulfite, bisulfate, bisulfite, thiosulfate, thiosulfite, hydrosulfite, alkyl phosphine, aryl phosphine, alkyl phosphine oxide, aryl phosphine oxide, alkyl aryl phosphine oxide, alkyl phosphine sulfide, aryl phosphine sulfide, alkyl aryl phosphine sulfide, alkyl phosphonic acid, aryl phosphonic acid, alkyl phosphinic acid, aryl phosphinic acid, alkyl phosphinous acid, aryl phosphinous acid, phosphate, thiophosphate, phosphite, pyrophosphite, triphosphate, hydrogen phosphate, dihydrogen phosphate, alkyl guanidino, aryl guanidino, alkyl aryl guanidino, alkyl carbamate, aryl carbamate, alkyl aryl carbamate, alkyl thiocarbamate, aryl thiocarbamate, alkylaryl thiocarbamate, alkyl dithiocarbamate, aryl dithiocarbamate, alkylaryl dithiocarbamate, bicarbonate, carbonate, perchlorate, chlorate, chlorite, hypochlorite, perbromate, bromate, bromite, hypobromite, tetrahalomanganate, tetrafluoroborate, hexafluoroantimonate, hypophosphite, iodate, periodate, metaborate, tetraaryl borate, tetra alkyl borate, tartrate, salicylate, succinate, citrate, ascorbate, saccharinate, amino acid, hydroxamic acid, thiotosylate, and anions of ion exchange resins, or the corresponding anions thereof. n is preferably an integer from 0 to 3. W can be a substituted or unsubstituted pyridino moiety.
In another alternative, the superoxide dismutase mimetic can be represented by the formula:




wherein
(i) a nitrogen of the macrocycle and two adjacent carbon atoms to which the nitrogen is attached independently form a substituted or unsubstituted, saturated, partially saturated or unsaturated nitrogen-containing heterocycle W having 2 to 20 carbon atoms, which may be an aromatic heterocycle in which case the hydrogen attached to the nitrogen which is both part of the heterocycle and the macrocycle and the R groups attached to the carbon atoms which are both part of the heterocycle and the macrocycle are absent; and
(ii) two sets of two adjacent carbon atoms of the macrocycle independently form substituted or unsubstituted, saturated, partially saturated or unsaturated, cycles or heterocycles U and V having 3 to 20 carbon atoms; and
(iii) R1, R2, R′2, R3, R4, R5, R′5, R6, R′6, R7, R8, R9, R′9, and R10 are independently:
(iiia) hydrogen; or
(iiib) a moiety independently selected from the group consisting of alkenyl, alkenylcycloalkenyl, alkenylcycloalkyl, alkyl, alkylcycloalkenyl, alkylcycloalkyl, alkynyl, aralkyl, aryl, cycloalkenyl, cycloalkyl, cycloalkylalkyl, cycloalkylcycloalkyl, cycloalkenylalkyl, heterocyclyl, and aralkyl radicals and radicals attached to the α-carbon or α-amino acids; or
(iiic) a moiety independently selected from the group consisting of —OR11, —NR11R12, —COR11, —CO2R11, —CONR11R12, —SR11, —SO2NR11R12, —N(OR11)(R12), —P(O)(OR11)(OR12), —P(O)(OR11)(R12), —OP(O)(OR11)(OR12), and substituents attached to the α-carbon of α-amino acids, wherein R11 and R12 are independently hydrogen or alkyl; and
(iv) optionally, one or more of R1 and R2 or R′2, R5 or R′5 and R6 or R′6, R9 or R′9 and R10 together with the carbon atoms to which they are attached independently form a substituted or unsubstituted and saturated, partially saturated, or unsaturated cycle or heterocycle having 3 to 20 carbon atoms; and
(v) optionally, one or more of R2 and R′2, R5 and R′5, R6 and R′6, and R9 and R′9, together with the carbon atom to which they are attached independently form a substituted or unsubstituted and saturated, partially saturated, or unsaturated cycle or heterocycle having 3 to 20 carbon atoms; and
(vi) optionally, one or more of R2 or R′2 and R3, R4 and R5 or R′5, R6 or R′6 and R7, or R8 and R9 or R′9 together with the carbon atoms to which they are attached independently form a substituted or unsubstituted nitrogen containing heterocycle having 3 to 20 carbon atoms, which may be an aromatic heterocycle in which case the hydrogen attached to the nitrogen which is both part of the heterocycle and the macrocycle and the R groups attached to the carbon atoms which are both part of the heterocycle and the macrocycle are absent; and
(vii) optionally, one or more of R1, R2, R′2, R3, R4, R5, R′5, R6, R′6, R7, R8, R9, R′9, and R10, together with a different one of R1, R2, R′2, R3, R4, R5, R′5, R6, R′6, R7, R8, R9, R′9, and R10, which is attached to a different carbon atom in the macrocyclic ligand may be bound to form a strap represented by the formula:

—(CH2)I-Q-(CH2)J—R—(CH2)K—S—(CH2)L—

wherein
I, J, K and L independently are integers from 0 to 10 and Q, R and S are independently selected from the group consisting of alkenyl, alkenylcycloalkenyl, alkenylcycloalkyl, alkyl, alkylcycloalkenyl, alkylcycloalkyl, alkynyl, aralkyl, aryl, cycloalkenyl, cycloalkyl, cycloalkylalkyl, cycloalkylcycloalkyl, cycloalkenylalkyl, and heterocyclyl, aza, amide, ammonium, oxa, thia, sulfonyl, sulfinyl, sulfonamide, phosphoryl, phosphinyl, phosphino, phosphonium, keto, ester, alcohol, carbamate, urea, thiocarbonyl, borates, boranes, boraza, silyl, siloxy, silaza, and combinations thereof; and
(viii) optionally, one or more of R1, R2, R′2, R3, R4, R5, R′5, R6, R′6, R7, R8, R9, R′9, and R10, may be individually bound to an atom of heterocycles U, V and W to form a strap represented by the formula:

—(CH2)I-Q-(CH2)J—R—(CH2)K—S—(CH2)L—

wherein
I, J, K and L independently are integers from 0 to 10 and Q, R and S are independently selected from the group consisting of alkenyl, alkenylcycloalkenyl, alkenylcycloalkyl, alkyl, alkylcycloalkenyl, alkylcycloalkyl, alkynyl, aralkyl, aryl, cycloalkenyl, cycloalkyl, cycloalkylalkyl, cycloalkylcycloalkyl, cycloalkenylalkyl, and heterocyclyl, aza, amide, ammonium, oxa, thia, sulfonyl, sulfinyl, sulfonamide, phosphoryl, phosphinyl, phosphino, phosphonium, keto, ester, alcohol, carbamate, urea, thiocarbonyl, borates, boranes, boraza, silyl, siloxy, silaza, and combinations thereof; and
(ix) combinations of any of (i) through (viii) above;
Thus, the pentaaza-macrocyclic ligand compositions useful in the present invention can have any combinations of substituted or unsubstituted R groups, saturated, partially saturated or unsaturated cyclics, heterocyclics, nitrogen containing heterocycles, or straps as defined above, which may or may not independently connect the W, U or V loops and the pentaaza macrocycle.
M can be a transition metal, preferably Mn2+, Mn3+, Mn4+, Mn6+, Mn7+, Fe2+, Fe3+, Fe4+, Fe6+, Ni2+, Ni3+, Cu1+, Cu2+, V2+, V3+, V4+, or V5+. X, Y and Z can independently be selected from the group consisting of halide, oxo, aquo, hydroxo, alcohol, phenol, dioxygen, peroxo, hydroperoxo, alkylperoxo, arylperoxo, ammonia, alkylamino, arylamino, heterocycloalkyl amino, heterocycloaryl amino, amine oxides, hydrazine, alkyl hydrazine, aryl hydrazine, nitric oxide, cyanide, cyanate, thiocyanate, isocyanate, isothiocyanate, alkyl nitrile, aryl nitrile, alkyl isonitrile, aryl isonitrile, nitrate, nitrite, azido, alkyl sulfonic acid, aryl sulfonic acid, alkyl sulfoxide, aryl sulfoxide, alkyl aryl sulfoxide, alkyl sulfenic acid, aryl sulfenic acid, alkyl sulfinic acid, aryl sulfinic acid, alkyl thiol carboxylic acid, aryl thiol carboxylic acid, alkyl thiol thiocarboxylic acid, aryl thiol thiocarboxylic acid, alkyl carboxylic acid, aryl carboxylic acid, urea, alkyl urea, aryl urea, alkyl aryl urea, thiourea, alkyl thiourea, aryl thiourea, alkyl aryl thiourea, sulfate, sulfite, bisulfate, bisulfite, thiosulfate, thiosulfite, hydrosulfite, alkyl phosphine, aryl phosphine, alkyl phosphine oxide, aryl phosphine oxide, alkyl aryl phosphine oxide, alkyl phosphine sulfide, aryl phosphine sulfide, alkyl aryl phosphine sulfide, alkyl phosphonic acid, aryl phosphonic acid, alkyl phosphinic acid, aryl phosphinic acid, alkyl phosphinous acid, aryl phosphinous acid, phosphate, thiophosphate, phosphite, pyrophosphite, triphosphate, hydrogen phosphate, dihydrogen phosphate, alkyl guanidino, aryl guanidino, alkyl aryl guanidino, alkyl carbamate, aryl carbamate, alkyl aryl carbamate, alkyl thiocarbamate, aryl thiocarbamate, alkylaryl thiocarbamate, alkyl dithiocarbamate, aryl dithiocarbamate, alkylaryl dithiocarbamate, bicarbonate, carbonate, perchlorate, chlorate, chlorite, hypochlorite, perbromate, bromate, bromite, hypobromite, tetrahalomanganate, tetrafluoroborate, hexafluoroantimonate, hypophosphite, iodate, periodate, metaborate, tetraaryl borate, tetra alkyl borate, tartrate, salicylate, succinate, citrate, ascorbate, saccharinate, amino acid, hydroxamic acid, thiotosylate, and anions of ion exchange resins, or the corresponding anions thereof. n is preferably an integer from 0 to 3. W can be a substituted or unsubstituted pyridino moiety. U and V can be independently saturated cycloalkyl heterocycles having 3 to 20 carbon atoms, more preferably 4 to 10 carbon atoms, still more preferably trans-cyclohexanyl fused rings. U and V can be trans-cyclohexanyl fused rings while W is a substituted pyridino moiety.
In certain embodiments, the superoxide dismutase mimetic can be the compound identified as M40403, which can be represented by the formula:




The present invention can involve administration of a ROS scavenger, in particular, M40403 or a suitable derivative or analog thereof as described above, to a patient in need thereof. Administration of the ROS scavenger, in particular M40403, can be by numerous routes of administration well known to those of skill in the art.
Administration of the ROS scavenger can be by any suitable route of administration such as, for example, oral, buccal, sublingual, intranasal, inhalation, rectal, intravaginal, transdermal, intradermal, subcutaneous, intramuscular, intraperitoneal, intravenous, intraarterial, intrasternal, intrathecal and the like.
Pharmaceutically acceptable formulations for parenteral or nonparenteral drug delivery are known in the art such as, for example, are set forth in Remington's Pharmaceutical Sciences, 18th Edition, Mack Publishing (1990). For pharmaceutical compositions and methods of treatment disclosed herein, dosage forms and administration regimes can be determined using standard methods known to skilled artisans, for example as set forth in standard references such as Remington: the Science and Practice of Pharmacy (Alfonso R. Gennaro ed. 19th ed. 1995); Hardman, J. G., et al., Goodman & Gilman's The Pharmacological Basis of Therapeutics, Ninth Edition, McGraw-Hill, 1996; and Rowe, R. C., et al., Handbook of Pharmaceutical Excipients, Fourth Edition, Pharmaceutical Press, 2003.
Pharmaceutical compositions can be formulated to be compatible with the intended route of administration. Solutions or suspensions used for parenteral, intradermal or subcutaneous application can include: a sterile diluent, such as water for injection, saline solution, fixed oils, polyethylene glycols, glycerine, propylene glycol or other synthetic solvents; antibacterial agents, such as benzyl alcohol or methyl parabens; antioxidants, such as ascorbic acid or sodium bisulfite; chelating agents, such as ethylenediaminetetraacetic acid (EDTA); buffers such as acetates, citrates or phosphates, and agents for the adjustment of tonicity, such as sodium chloride or dextrose. Suitable carriers include physiological saline, bacteriostatic water, Cremophor® EL (BASF, Parsippany, N.J.) or phosphate buffered saline (PBS). The compositions can be stable during manufacture and storage and preserved against contamination from microorganisms, such as bacteria and fungi. Proper fluidity can be maintained, for example, by using a coating such as lecithin; by maintaining the required particle size in the case of dispersion, and by using surfactants. Various antibacterial and antifungal agents, such as parabens, chlorobutanol, phenol, ascorbic acid, and thimerosal, can control microorganism contamination. Isotonic agents, such as sugars, polyalcohols such as manitol, sorbitol, and sodium chloride can be included in the composition. Compositions that delay absorption can be prepared by including such agents as aluminum monostearate and gelatin.
Sterile injectable solutions can be prepared by incorporating the active compound (e.g., an SCMP) in an appropriate solvent with one or more ingredient, followed by sterilization. Generally, dispersions are prepared by incorporating the active compound into a sterile vehicle that contains a basic dispersion medium and any other required ingredients. Sterile powders for the preparation of sterile injectable solutions include vacuum- and freeze-drying that yield a powder containing the active ingredient and any desired ingredient from a sterile solution. The concentration of active drug, i.e. the ROS scavenger, can be from about 0.1% to about 90% by weight, from about 5% to about 20% by weight, from about 5% to about 17% by weight, from about 8% to about 14% by weight or, in certain embodiments, about 10% by weight.
Oral compositions generally include an inert diluent or an edible carrier. They can be enclosed in gelatin capsules or compressed into tablets. For the purpose of oral therapeutic administration, the active compound can be incorporated with excipients and used in the form of tablets, troches, or capsules. Oral compositions can also be prepared using a fluid carrier for use as a mouthwash, wherein the compound in the fluid carrier is applied orally. Pharmaceutically compatible binding agents, and/or adjuvant materials can be included. Tablets, pills, capsules, troches and the like can contain any of the following ingredients, or compounds of a similar nature: a binder such as microcrystalline cellulose, gum tragacanth or gelatin; an excipient such as starch or lactose, a disintegrating agent such as alginic acid, primogel, or corn starch; a lubricant such as magnesium stearate or sterotes; a glidant such as colloidal silicon dioxide; a sweetening agent such as sucrose or saccharin; or a flavoring agent such as peppermint, methyl salicylate, or orange flavoring. The concentration of active drug, i.e. the ROS scavenger, can be from about 0.1% to about 99% by weight, from about 5% to about 95% by weight, from about 10% to about 90% by weight, from about 15% to about 85% by weight, from about 20% to about 80% by weight, from about 25% to about 75% by weight, from about 30% to about 70% by weight, from about 35% to about 64% by weight or from about 40% to about 60% by weight.
Administration by inhalation, can be by aerosol spray from a nebulizer or a pressurized container that contains a suitable propellant, e.g., a gas such as carbon dioxide.
Systemic administration can also be transmucosal or transdermal. For transmucosal or transdermal administration, penetrants that can permeate the target barrier(s) are selected. Transmucosal penetrants include detergents, bile salts and fusidic acid derivatives. Nasal sprays or suppositories can be used for transmucosal administration. For transdermal administration, the active compounds are formulated into ointments, salves, gels or creams.
The compounds can also be prepared as suppositories (with bases such as cocoa butter and other glycerides) or retention enemas for rectal delivery.
In various embodiments, the active compounds can be prepared with carriers that protect the compound against rapid elimination from the body, such as a controlled release formulation, including implants and microencapsulated delivery systems. Biodegradable, biocompatible polymers can be used, such as ethylene vinyl acetate, polyanhydrides, polyglycolic acid, collagen, polyorthoesters, and polylactic acid (Alza Corporation; Mountain View, Calif. and Nova Pharmaceuticals, Inc.; Lake Elsinore, Calif.). Liposomal suspensions can also be used as pharmaceutically acceptable carriers (Eppstein, 1985).
Oral formulations or parenteral compositions in unit dosage form can be created to facilitate administration and dosage uniformity. Unit dosage form refers to physically discrete units suited as single doses for a subject to be treated, containing a therapeutically effective quantity of active compound in association with the required pharmaceutical carrier. The specification for unit dosage forms are dictated by, and directly dependent on, the unique characteristics of the active compound and the particular desired therapeutic effect, and the inherent limitations of compounding the active compound.
A typical dose of the ROS scavenger can be from about 0.1 mg up to about 1000 mg or from about 0.001 up to about 10 mg/kg body weight. Doses of 5 mg/kg and 10 mg/kg administered intraperitoneally have shown to produce beneficial effects in rats treated with type II collagen to induced arthritis (Salvemini et al., Arthritis & Rheumatism, 44:2909-2921, 2001). A dose of 2 mg/kg produced less of an effect that was nevertheless significantly different from that in placebo animals. Low doses of a ROS scavenger can be doses of less than about 5 mg/kg or doses equal to or less than about 2 mg/kg body weight, in particular, a dose of about 0.1 mg, about 0.2 mg, about 0.5 mg, about 0.8 mg, about 1 mg, about 2 mg, about 5 mg, about 8 mg, about 10 mg, about 20 mg, about 50 mg, about 80 mg, about 100 mg or about 200 mg or about 0.001 mg/kg, about 0.002 mg/kg, about 0.005 mg/kg, about 0.01 mg/kg, about 0.02 mg/kg, about 0.05 mg/kg, about 0.1 mg/kg, about 0.2 mg/kg, about 0.5 mg/kg, about 1 mg/kg, about 2 mg/kg, about 3 mg/kg or about 4 mg/kg body weight.
Total daily doses of the ROS scavenger can be administered in single or divided doses and in amounts such as, for example, from about 1 to about 2 mg/kg body weight daily and more usually about 0.05 to 1 mg/kg. Dosage unit compositions may contain such amounts of submultiples thereof to make up the total dose. However, one skilled in the art will recognize that the total dosage will vary on the particular composition the particular ROS scavenger administered.
Individuals receiving treatment are, typically, human patients, however, patients receiving treatment can also be animal including companion animal such as dogs and cats, farm animal such as cows, horses, swine as well as birds and exotic animal such as zoo animals.
The amount of active ingredients that may be combined with the carrier materials to produce a single dosage form can vary depending upon the host treated and the particular mode of administration. It will be appreciated that the unit content of active ingredients contained in an individual dose of each dosage form need not in itself constitute an effective amount, as the necessary effective amount could be reached by administration of a number of individual doses. The selection of dosage depends upon the dosage form utilized, the condition being treated, and the particular purpose to be achieved according to the determination of those skilled in the art.
The dosage regimen for treating a disease condition with the compounds and/or compositions of this invention can be selected in accordance with a variety of factors, including the type, age, weight, sex, diet and medical condition of the patient, the route of administration, pharmacological considerations such as the activity, efficacy, pharmacokinetic and toxicology profiles of the particular compound employed, whether a drug delivery system is utilized and whether the compound is administered as part of a drug combination. Thus, the dosage regimen actually employed can, therefore, can deviate from the preferred dosage regimen set forth above.
In various embodiments, the present invention can also involve kits. Such kits can include pharmaceutical compositions and, in addition in certain embodiments, instructions for administration. When supplied as a kit, the different components of the composition can be packaged in separate containers and admixed immediately before use. Such packaging of the components separately can, in certain instances, permit long-term storage without losing activity of the components. In addition, if more than one route of administration is intended or more than one schedule for administration is intended, the different components can be packaged separately and not mixed prior to use. In various embodiments, the different components can be packaged in one composition for administration together.
Kits may also include reagents in separate containers such as, for example sterile water or saline to be added to a lyophilized active component packaged separately. For example, sealed glass ampules may contain lyophilized ROS scavenger, sterile water, sterile saline or sterile each of which has been packaged under a neutral non-reacting gas, such as nitrogen. Ampules may consist of any suitable material, such as glass, organic polymers, such as polycarbonate, polystyrene, etc., ceramic, metal or any other material typically employed to hold reagents. Other examples of suitable containers include bottles that may be fabricated from similar substances as ampules, and envelopes that may consist of foil-lined interiors, such as aluminum or an alloy. Other containers include test tubes, vials, flasks, bottles, syringes, etc. Containers may have a sterile access port, such as a bottle having a stopper that can be pierced by a hypodermic injection needle. Other containers may have two compartments that are separated by a readily removable membrane that upon removal permits the components to mix. Removable membranes may be glass, plastic, rubber, etc.
In certain embodiments, kits can be supplied with instructional materials. Instructions may be printed on paper or other substrate, and/or may be supplied as an electronic-readable medium, such as a floppy disc, mini-CD-ROM, CD-ROM, DVD-ROM, Zip disc, videotape, audio tape, etc. Detailed instructions may not be physically associated with the kit; instead, a user may be directed to an internet web site specified by the manufacturer or distributor of the kit, or supplied as electronic mail.
EXAMPLES
Without further elaboration, it is believed that one skilled in the art can, using the preceding description, utilize the present invention to its fullest extent. The following specific examples are offered by way of illustration and not by way of limiting the remaining disclosure.
Example 1
Objective
The objective of this study is to evaluate the effect of M40403, administered by either ip or topical routes, with 2 different schedules, on the frequency, severity and duration of oral mucositis induced in hamsters by acute radiation.
Summary
M40403 was given as an intraperitoneal (ip) injection at a 30 mg/kg/dose twice daily (a) from day −1 to day 15, or (b) day −1 to day 3. M40403 was also given by ip injection at a dose of 3 mg/kg twice daily from day −1 to day 15. In addition, M40403 was given as a topical dose directed to the buccal mucosa in 0.2 ml doses of either 3 mg/ml or 30 mg/ml twice daily from day −1 to day 15. The greatest reduction in oral mucositis was seen in the group treated with M40403 at 30 mg/kg/dose ip twice daily from day −1 to day 3. This group had a statistically significant reduction in the number of animal days with a mucositis score of 3 or higher (P<0.001) and significantly lower mean mucositis scores than the control group on days 18 (P=0.041), 20 (P<0.001), 22 (P<0.001), 24(P<0.001) and 26 (P=0.002). No other treatment groups in this study showed a reduction in mucositis either by long term (day −1 to day 15) ip dosing or by topical dosing. This study establishes a schedule-dependant dosing method for the treatment of oral mucositis with M40403.
Acute Radiation Model
The acute radiation model in hamsters, developed by the Principal Investigator, has proven to be an accurate, efficient and cost-effective technique to provide a preliminary evaluation of anti-mucositis compounds (9). The course of mucositis in this model is well defined and results in peak scores approximately 14-16 Days following radiation. The acute model has little systemic toxicity, resulting in few hamster deaths, thus permitting the use of smaller groups (N=7-8) for initial efficacy studies. It has also been used to study specific mechanistic elements in the pathogenesis of mucositis. Molecules that show efficacy in the acute radiation model may be further evaluated in the more complex models of fractionated radiation, chemotherapy, or concomitant therapy.
In this study, an acute radiation dose of 40 Gy on day 0 was administered locally to the cheek pouch. Clinically significant mucositis was observed on days 12 through 28.
Protocol Summary
Forty-eight male Syrian Golden Hamsters were divided randomly into 6 groups of 8 animals and given an acute radiation dose of 40 Gy directed to their left buccal cheek pouch. This was accomplished by anesthetizing the animals and everting the left buccal pouch, while protecting the rest of the animal with a lead shield. Test materials were given topically or by ip injection twice daily as detailed in Table 1. Mucositis was evaluated clinically starting on Day 6, and continued on alternate days until day 28.
Evaluation
Mucositis Evaluation
The grade of mucositis was scored, beginning on day 6, and for every second day thereafter, through and including day 28 (for scoring scheme, see Table 2 and FIG. 2). The effect on mucositis of each drug treatment compared to ip vehicle-treated controls was assessed according to the following parameters:
The difference in the number of days hamsters in each group have ulcerative (score≧3) mucositis.
On each evaluation day, the number of animals with a blinded mucositis score of ≧3 in each drug treatment group was compared to the vehicle-treated control group. Differences were compared on a cumulative basis and statistical significance was determined by chi-square analysis. Efficacy, in this analysis, is defined as a significant reduction in the number of days that a group of animals had ulcerations (scores ≧3) when compared to the control group.







TABLE 2







Table 2 ACT-02: Mucositis Scoring.








Score:
Description:





0
Pouch completely healthy. No erythema or vasodilation.


1
Light to severe erythema and vasodilation. No erosion of



mucosa.


2
Severe erythema and vasodilation. Erosion of superficial aspects



of mucosa leaving denuded areas. Decreased stippling of



mucosa.


3
Formation of off-white ulcers in one or more places. Ulcers may



have a yellow/gray due to pseudomembrane. Cumulative size of



ulcers should equal about 1⁄4 of the pouch. Severe erythema



and vasodilation.


4
Cumulative seize of ulcers should equal about 1⁄2 of the pouch.



Loss of pliability. Severe erythema and vasodilation.


5
Virtually all of pouch is ulcerated. Loss of pliability (pouch can



only partially be extracted from mouth).









Rank Sum Differences in Daily Mucositis Scores.
For each evaluation day the scores of the control group were compared to those of the treated groups using non-parametric rank sum analysis. Treatment success was considered as a statistically significant lowering of scores in the treated group on 2 or more days from day 6 to day 28.
Weights and Survival
All animals were weighed daily and their survival recorded, in order to assess possible differences in animal weight among treatment groups as an indication for mucositis severity and/or possible toxicity resulting from the treatments.
Study Design
All forty-eight (48) male Syrian Golden Hamsters were given an acute radiation dose of 40 Gy directed to their left buccal cheek pouch. This was accomplished by anesthetizing the animals and everting the left buccal pouch, while protecting the rest of the animal with a lead shield. Test materials were given either topically or by ip injection twice daily as detailed in Table 1. Mucositis was evaluated clinically starting on day 6, and continuing on alternate days until day 28. The study timeline is depicted in FIG. 1. Dose levels were determined based on the results of a previous acute toxicity study (data not shown), and the levels shown in Table 1.







TABLE 1







Table 1. ACT-02. Study Design











Group
Number of

Treatment
Volume


Number
Animals
Treatment
Schedule*
(mL)





1
8 males
Vehicle, ip, bid
Day −1 to 15
Adjust per






body weigh


2
8 males
M40403, ip, bid
Day −1 to 15
Adjust per




3 mg/kg

body weigh


3
8 males
M40403, ip, bid
Day −1 to 15
Adjust per




30 mg/kg

body weigh


4
8 males
M40403, topical, bid
Day −1 to 15
0.2 ml per




3 mg/ml

dose


5
8 males
M40403, topical, bid
Day −1 to 15
0.2 ml per




30 mg/ml

dose


6
8 males
M40403, ip, bid
Day −1 to 3
Adjust per




30 mg/kg

body weigh





*The first does on day 0 was performed 30 minutes prior to radiation. The second dose was given at least 4 hours after radiation.






At the end of the study on day 28, the animals in group 1 were used in a modified pK study as follows: Two animals were injected with vehicle and blood was drawn 30 minutes after the injection. Six animals were injected with 30 mg/kg of M40403. At 15, 30 and 90 minutes post injection, 2 animals from this group were sacrificed and blood was obtained by cardiac puncture. Blood was collected in lithium heparin, kept on ice for 30 minutes and the plasma was obtained after centrifugation. Plasma was transferred to labeled tubes, snap frozen in liquid nitrogen and shipped to ActivBiotics.
Material and Methods
Location of Study Performance
The study was performed at Biomodels AAALAC accredited facility in Cambridge Mass. The IACUC approval number 04-0624-2 for this study was obtained from Biomodels IACUC.
Animals
Male LVG Syrian Golden Hamsters (Charles River Laboratories), aged 5 to 6 weeks, with average body weight of 84.1 g at study commencement, were used. Animals were individually numbered using an ear punch and housed in small groups of approximately 8 animals per cage. Animals were acclimatized prior to study commencement. During this period of 2 days, the animals were observed daily in order to reject animals that presented in poor condition.
Housing
The study was performed in animal rooms provided with filtered air at a temperature of 70° F.+/−5 of and 50%+/−20% relative humidity. Animal rooms were set to maintain a minimum of 12 to 15 air changes per hour. The room was on an automatic timer for a light/dark cycle of 12 hours on and 12 hours off with no twilight. Bed-O-Cobs® bedding was used. Bedding was changed a minimum of once per week. Cages, tops, bottles, etc. were washed with a commercial detergent and allowed to air dry. A commercial disinfectant was used to disinfect surfaces and materials introduced into the hood. Floors were swept daily and mopped a minimum of twice weekly with a commercial detergent. Walls and cage racks were sponged a minimum of once per month with a dilute bleach solution. A cage card or label with the appropriate information necessary to identify the study, dose, animal number and treatment group marked all cages. The temperature and relative humidity was recorded during the study, and the records were retained.
Diet
Animals were fed with a Purina Labdiet® 5061 rodent diet and water was provided ad libitum. Animal randomization and allocations.
Animals were randomly and prospectively divided into eight (8) treatment groups prior to irradiation. Each animal was identified by an ear punch corresponding to an individual number. For more consistent identification, ear punch numbering was used rather than tagging, since tags may become dislodged during the course of the study. A cage card was used to identify each cage and was marked with the study number, treatment group number and animal numbers.
Dosing and Drug Application
Dosing solutions were made immediately prior to use. Aseptic technique was used for all preparation procedures. A 26-mM sodium bicarbonate buffer solution was prepared as the vehicle. The resultant pH was approximately 8.1 to 8.3.
Mucositis Induction
Mucositis was induced using a standardized acute radiation protocol. A single dose of radiation (40 Gy/dose) was administered to all animals on day 0. Radiation was generated with a 250 kilovolt potential (15-ma) source at a focal distance of 50 cm, hardened with a 0.35 mm Cu filtration system. Irradiation targeted the left buccal pouch mucosa at a rate of 3.2 Gy/minute. Prior to irradiation, animals were anesthetized with an intra-peritoneal injection of Ketamine (160 mg/kg) and Xylazine (8 mg/kg). The left buccal pouch was everted, fixed and isolated using a lead shield.
Mucositis Scoring
The mucositis score, weight change and survival were measured throughout the study as described above. For the evaluation of mucositis, the animals were anesthetized with isoflurane and the left pouch everted. Mucositis was scored visually by comparison to a validated photographic scale (FIG. 2), ranging from 0 for normal, to 5 for severe ulceration (clinical scoring). In descriptive terms, this scale is defined as follows:
A score of 1-2 is considered to represent a mild stage of the disease, whereas a score of 3-5 is considered to indicate moderate to severe mucositis. Following visual scoring, a photograph was taken of each animal's mucosa using a standardized technique. At the conclusion of the experiment, all films were developed and the photographs randomly numbered. At least two independent trained observers graded the photographs in blinded fashion using the above described scale (blinded scoring).
Results and Discussion
Survival
Five deaths occurred during this study. Two animals, hamsters 8 and 23, in the vehicle control group and the group treated with M40403 at 30 mg/kg twice a day from day −1 to day 15 died on day 0 from apparent anesthesia overdoses. In addition, two animals (hamsters 45 and 46) died in the group treated with M40403 at 30 mg/kg twice daily from day −1 to day 3. Hamster 45 died during radiation and hamster 46 was found dead the following morning. Both deaths appeared to be the result of anesthesia overdose, in the case of hamster 46 the response was delayed. The occurrence of anesthesia deaths in this model is anticipated in the experimental design. Hamster 19, in the group treated ip with M40403 at 30 mg/kg twice a day from day −1 to day 15 died on day 12. This death resulted after an extended period of failure to gain weight and may reflect toxicity of this dosing regimen as all animals in this group showed lack of weight gain (see FIGS. 3 and 4 below).
Weight change (FIGS. 3 and 4).
The percent daily weight change for each group is shown in FIG. 3. The groups treated by ip injection were groups 1, 2, 3 and 6. The control animals (group 1) gained an average of 64.0% of their starting weights by the end of the study. The animals treated ip with M40403 at 3 mg/kg/dose twice daily from day −1 to day 15 (group 2) gained an average of 66.0% of their starting weight during the study. The group treated ip with M40403 at 30 mg/kg/dose twice daily from day −1 to day 15 (group 3) gained an average of 33.9% of their starting weight by day 28. The group treated ip with M40403 at 30 mg/kg/dose twice daily from day 1 to day 3 gained an average of 54.7% of their starting weight during the study. In both groups treated by ip injection with 30 mg/kg M40403, there was a general lack of weight gain during dosing.
In the 2 groups treated topically with M40403 (groups 4 and 5) there was no apparent change in weight gain when compared to the control group. The animals treated topically with M40403 at 3 mg/ml twice daily from day −1 to day 15 gained an average of 65.8% of their starting weight by day 28. The group treated topically with M40403 at 30 mg/ml twice daily from day −1 to day 15 gained an average of 71.9% of their starting weight during the study.
The significance of these differences was evaluated by calculating the mean area under the curve for the percentage weight gain for each animal and comparing the groups using a OneWay ANOVA test. There was a significant difference between the control group and group 3 treated by ip injection with M40403 twice daily (30 mg/kg) on days −1 to 15 (P<0.001). There was also a significant difference between the control group and the group treated by ip injection with M40403 twice daily at 30 mg/kg/dose from day −1 to day 3 (P=0.018). No other significant differences were seen. The topical treatment groups (groups 4 and 5) showed no significant weight differences when compared with the control group. The AUC data is shown in FIG. 4. Many of the groups with a significant reduction in weight gain are the same groups in which animal deaths were observed.







TABLE 4







Table 4. ACT-02. The significance of group differences observed in daily mucositis scores was determined using


the Mann-Whitney rank sum test. This nonparametric statistic is appropriate for the visual mucositis scoring scale.


The p values for each calculation are shown.









Day



















Group Comparison
6
8
10
12
14
16
18
20
22
24
26
28






















Control v
0.099
0.630
0.950
0.286
0.983
0.630
0.436
0.571
0.754
0.325
0.516
0.070


M40403 ip 3 mg/kg














day −1 to 15














Control v
0.055
0.981
0.981
0.055
0.856
0.938
0.221
0.622
0.698
0.067
0.979
0.225


M40403 ip 30 mg/kg














day −1 to 15














Control v
0.099
0.099
0.630
0.463
0.463
0.438
0.983
0.983
0.163
0.632
0.517
0.139


M40403 top 3 mg/ml














day −1 to 15














Control v
0.630
0.099
0.002
0.573
0.465
0.571
0.884
0.884
0.573
0.632
0.754
0.884


M40403 top 30 mg/ml














day −1 to 15














Control v
0.127
0.059
0.546
0.936
0.221
0.312
0.041
<0.001
<0.001
<0.001
0.002
0.551


M40403 ip 30 mg/kg














day −1 to 3





















Mucositis (FIGS. 5 & 6, Tables 3 & 4)
Mean daily mucositis scores for each group are shown in FIG. 5. The groups treated by ip injection were groups 1, 2, 3 and 6. The control animals (group 1) had a peak mean mucositis score of 2.8 which occurred on day 16. The animals treated with M40403 at 3 mg/kg/dose ip twice daily from day −1 to day 15 (group 2) had a peak mucositis score of 2.8 on day 18, and the overall progression of mucositis severity in this group was very similar to that observed in the control group. The group treated with M40403 at 30 mg/kg/dose twice daily from day −1 to day 15 (group 3) had a peak mucositis score of 3.0 on day 18 and had a mucositis progression that was indistinguishable from that observed in groups 1 and 2. The group treated with M40403 at 30 mg/kg/dose ip twice daily from day −1 to day 3 had a peak mucositis score of 3.0 on day 14, but from day 16 to day 28, the mucositis severity in this group decreased much more rapidly than the control group suggesting that this schedule of treatment was efficacious.
In the 2 groups treated topically with M40403 (groups 4 and 5) there was no apparent effect of treatment on the course of mucositis. The animals treated topically with M40403 at 3 mg/ml twice daily from day −1 to day 15 had mucositis scores that closely paralleled those in the control group. The group treated topically with M40403 at 30 mg/ml twice daily from day −1 to day 15 showed a reduction of mucositis severity on day 10. However, from day 12 to the end of the study, the scores in this group were only slightly less than those in the control group.
The significance of the reductions in the mucositis scores seen in the groups treated with M40403 were evaluated by calculating the percentage of animal days with a score of 3 or higher. The results of this analysis are shown in FIG. 6 and Table 3. In the control group, the percentage of animal days with a mucositis score of 3 or higher was 31%. Treatment by ip injection with M40403 at 3 mg/kg/dose twice daily from day −1 to day 15 resulted in a percentage of animal days with a score of 3 or higher of 34%. Treatment by ip injection with M40403 at 30 mg/kg/dose twice daily from day to −1 to day 15 resulted in 37% percent of animal days with a score of 3 or higher. Treatment by ip injection with M40403 at 30 mg/kg twice daily from day −1 to day 3 (group 6) resulted in a decrease in the number of animal days with a score of 3 or higher to 17%.







TABLE 3







Table 3. ACT-02. Chi-square analysis of the total number of days the animals in each


group spent with a mucositis score of 3 or more. This statistic is a measure of severity of


ulceration, a clinically important outcome.

















% Days
Chi Sq



Group
Days >=3
Days <3 
Total Days
>=3
v control
P Value
















Vehicle ip control 
52
116
168
0.31
—
—


day −1 to 15








M40403 ip 3 mg/kg
66
126
192
0.34
0.3440
0.563


day −1 to 15








M40403 ip 30 mg/kg
56
96
152
0.37
0.9890
0.320


day −1 to 15








M40403 top 3 mg/ml
73
119
192
0.38
1.6760
0.196


day −1 to 15








M40403 top 30 mg/ml
64
128
192
0.33
0.136
0.712


day −1 to 15








M40403 ip 30 mg/kg
24
120
144
0.17
7.83
0.005


day −1 to 3









In the animals receiving M40403 topically, there were no apparent reductions of mucositis severity at either dosing level. Topical treatment with M40403 at 3 mg/ml twice daily from day −1 to day 15 resulted in an increase in the number of animal days with a score of 3 or higher to 38%. Topical treatment with M40403 at 30 mg/ml twice daily from days −1 to 15 resulted in 33% of animal days with a score of 3 or higher.
When compared using a chi-squared test, the group treated by ip injection with M40403 at 30 mg/kg/dose twice daily on days −1 to day 3 had the greatest reduction in mucositis and significantly fewer days with a score of 3 or higher (P=0.005). No other study group exhibited a reduction in mucositis severity and no group demonstrated a significant difference in mucositis severity by this analysis.
Further analysis of the mucositis scores was performed by comparing the scores for the M40403 treated groups with the control on each day of scoring using the Mann-Whitney Rank Sum test. The results of this analysis are shown in Table 4. The group treated by ip injection with M40403 at 30 mg/kg/dose twice daily on days −1 to day 3 (group 6) had the greatest reduction in mucositis and significantly lower scores than the control group on days 18 (P=0.041), 20 (P<0.001), 22 (P<0.001), 24 (P<0.001) and 26 (P=0.002). No other study group had more than a single day showing a significant lowering of mucositis severity. Given that group 2 received the same dose of drug for a longer duration, these results suggest that the schedule of dosing M40403 is crucial in establishing an effective treatment for mucositis.
Conclusions
1. Based on observations of mortality and body weight, ip injections of M40403, twice daily, at 30 mg/kg appear to show some toxicity. The longer dosing in group 3 resulted in mortality and significant weight loss. When dosed for the shorter period of day −1 to day 3 (group 6), the weight loss was reversed after the cessation of dosing.
2. Topical dosing of M40403 did not appear to have any effect on either weight or mucositis severity. It appears the topical dosing, in the formulation used here, is an ineffective method of delivery of M40403 in this model.
3. The group treated by ip injection with M40403 at 30 mg/kg/dose twice daily on days 1 to 3 had a statistically significant reduction in the number of animal days with a mucositis score of 3 or higher (P=0.005) and significantly lower mucositis scores than the control group on days 18 (P=0.041), 20 (P<0.001), 22 (P<0.001), 24 (P<0.001) and 26 (P=0.002). This result suggests that M40403 may be an effective agent in the treatment of oral mucositis. Further studies of dose and schedule may be required to optimize the efficacy of M40403.
Example 2
Repeat of day −1 to 3 of 30 mg/kg IV of Example 1 study
Acute Radiation Model
The acute radiation model in hamsters, developed by the Principal Investigator, has proven to be an accurate, efficient and cost-effective technique to provide a preliminary evaluation of anti-mucositis compounds (9). The course of mucositis in this model is well defined and results in peak scores approximately 14-16 Days following radiation. The acute model has little systemic toxicity, resulting in few hamster deaths, thus permitting the use of smaller groups (N=7-8) for initial efficacy studies. It has also been used to study specific mechanistic elements in the pathogenesis of mucositis. Molecules that show efficacy in the acute radiation model may be further evaluated in the more complex models of fractionated radiation, chemotherapy, or concomitant therapy.
In this study, an acute radiation dose of 40 Gy on day 0 was administered locally to the cheek pouch. Clinically significant mucositis was observed on days 12 through 28.
Protocol Summary
Seventy-two male Syrian Golden Hamsters were divided randomly into 9 groups of 8 animals and given an acute radiation dose of 40 Gy directed to their left buccal cheek pouch. This was accomplished by anesthetizing the animals and everting the left buccal pouch, while protecting the rest of the animal with a lead shield. Test materials were given topically or by ip injection twice daily as detailed in Table 5. Mucositis was evaluated clinically starting on Day 6, and continued on alternate days until day 28.







TABLE 5







Table 1. ACT-03. Study Design











Group
Number of

Treatment
Volume


Number
Animals
Treatment
Schedule*
(mL)





1
8 males
Vehicle, ip, bid
Day −1 to 3
Adjust per






body weigh


2
8 males
M40403, ip, QD
Day −1 to 3
Adjust per




30 mg/kg

body weigh


3
8 males
M40403, ip, bid
Day −1 to 3
Adjust per




3 mg/kg

body weigh


4
8 males
M40403, ip, bid
Day −1 to 3
Adjust per




10 mg/kg

body weigh


5
8 males
M40403, ip, bid
Day −1 to 3
Adjust per




30 mg/kg

body weigh


6
8 males
M40403, ip, QD
Day 0 to 3
Adjust per




30 mg/kg

body weigh


7
8 males
M40403, ip, bid
Day 0 to 3
Adjust per




30 mg/kg

body weigh


8
8 males
M40403, ip, bid
Day 0
Adjust per




30 mg/kg

body weigh


9
8 males
M40403, ip, bid
Day 0 and Day 7
Adjust per




30 mg/kg

body weigh





*For BID dosing the first dose on day 0 will be performed 30 minutes prior to radiation. The second dose will be given at least 4 hours after radiation. For QD dosing, the dose will be administered on day 0 at 30 minutes prior to irradiation.






Evaluation
Mucositis Evaluation
The grade of mucositis was scored, beginning on day 6, and for every second day thereafter, through and including day 28 (for scoring scheme, see Table 6 and FIG. 8). The effect on mucositis of each drug treatment compared to ip vehicle-treated controls was assessed according to the following parameters:
The difference in the number of days hamsters in each group have ulcerative (score≧3) mucositis.
On each evaluation day, the number of animals with a blinded mucositis score of ≧3 in each drug treatment group was compared to the vehicle-treated control group. Differences were compared on a cumulative basis and statistical significance was determined by chi-square analysis. Efficacy, in this analysis, is defined as a significant reduction in the number of days that a group of animals had ulcerations (scores≧3) when compared to the control group.







TABLE 6







Table 2 ACT-03: Mucositis Scoring.








Score:
Description:





0
Pouch completely healthy. No erythema or vasodilation.


1
Light to severe erythema and vasodilation. No erosion of



mucosa.


2
Severe erythema and vasodilation. Erosion of superficial aspects



of mucosa leaving denuded areas. Decreased stippling of



mucosa.


3
Formation of off-white ulcers in one or more places. Ulcers may



have a yellow/gray due to pseudomembrane. Cumulative size of



ulcers should equal about 1⁄4 of the pouch. Severe erythema



and vasodilation.


4
Cumulative seize of ulcers should equal about 1⁄2 of the pouch.



Loss of pliability. Severe erythema and vasodilation.


5
Virtually all of pouch is ulcerated. Loss of pliability (pouch can



only partially be extracted from mouth).









Rank Sum Differences in Daily Mucositis Scores.
For each evaluation day the scores of the control group were compared to those of the treated groups using non-parametric rank sum analysis. Treatment success was considered as a statistically significant lowering of scores in the treated group on 2 or more days from day 6 to day 28.
Weights and Survival
All animals were weighed daily and their survival recorded, in order to assess possible differences in animal weight among treatment groups as an indication for mucositis severity and/or possible toxicity resulting from the treatments.
Study Design
All seventy-two (72) male Syrian Golden Hamsters were given an acute radiation dose of 40 Gy directed to their left buccal cheek pouch. This was accomplished by anesthetizing the animals and everting the left buccal pouch, while protecting the rest of the animal with a lead shield. Test materials were given either topically or by ip injection twice daily as detailed in Table 5. Mucositis was evaluated clinically starting on day 6, and continuing on alternate days until day 28. The study timeline is depicted in FIG. 7. Dose levels were determined based on the results of a previous acute toxicity study (data not published), and in the prior mucositis study of Example 1, shown in Table 5.
Material and Methods
Location of Study Performance
The study was performed at Biomodels AAALAC accredited facility in Cambridge Mass. The IACUC approval number 04-0624-2 for this study was obtained from Biomodels IACUC.
Animals
Male LVG Syrian Golden Hamsters (Charles River Laboratories), aged 5 to 6 weeks, with average body weight of 92.7 at study commencement, were used. Animals were individually numbered using an ear punch and housed in small groups of approximately 8 animals per cage. Animals were acclimatized prior to study commencement. During this period of 3 days, the animals were observed daily in order to reject animals that presented in poor condition.
Housing
The study was performed in animal rooms provided with filtered air at a temperature of 70° F.+/−5 of and 50%+/−20% relative humidity. Animal rooms were set to maintain a minimum of 12 to 15 air changes per hour. The room was on an automatic timer for a light/dark cycle of 12 hours on and 12 hours off with no twilight. Bed-O-Cobs® bedding was used. Bedding was changed a minimum of once per week. Cages, tops, bottles, etc. were washed with a commercial detergent and allowed to air dry. A commercial disinfectant was used to disinfect surfaces and materials introduced into the hood. Floors were swept daily and mopped a minimum of twice weekly with a commercial detergent. Walls and cage racks were sponged a minimum of once per month with a dilute bleach solution. A cage card or label with the appropriate information necessary to identify the study, dose, animal number and treatment group marked all cages. The temperature and relative humidity was recorded during the study, and the records were retained.
Diet
Animals were fed with a Purina Labdiet® 5061 rodent diet and water was provided ad libitum. Animal randomization and allocations.
Animals were randomly and prospectively divided into eight (8) treatment groups prior to irradiation. Each animal was identified by an ear punch corresponding to an individual number. For more consistent identification, ear punch numbering was used rather than tagging, since tags may become dislodged during the course of the study. A cage card was used to identify each cage and was marked with the study number (ACT-03), treatment group number and animal numbers.
Dosing and Drug Application
Dosing solutions were made immediately prior to use. Aseptic technique was used for all preparation procedures. A 26-mM sodium bicarbonate buffer solution was prepared as the vehicle. The resultant pH was approximately 8.1 to 8.3.
Mucositis Induction
Mucositis was induced using a standardized acute radiation protocol. A single dose of radiation (40 Gy/dose) was administered to all animals on day 0. Radiation was generated with a 250 kilovolt potential (15-ma) source at a focal distance of 50 cm, hardened with a 0.35 mm Cu filtration system. Irradiation targeted the left buccal pouch mucosa at a rate of 3.2 Gy/minute. Prior to irradiation, animals were anesthetized with an intra-peritoneal injection of Ketamine (160 mg/kg) and Xylazine (8 mg/kg). The left buccal pouch was everted, fixed and isolated using a lead shield.
Mucositis Scoring
The mucositis score, weight change and survival were measured throughout the study as described above. For the evaluation of mucositis, the animals were anesthetized with isoflurane and the left pouch everted. Mucositis was scored visually by comparison to a validated photographic scale (FIG. 8), ranging from 0 for normal, to 5 for severe ulceration (clinical scoring). In descriptive terms, this scale is defined as follows:
A score of 1-2 is considered to represent a mild stage of the disease, whereas a score of 3-5 is considered to indicate moderate to severe mucositis. Following visual scoring, a photograph was taken of each animal's mucosa using a standardized technique. At the conclusion of the experiment, all films were developed and the photographs randomly numbered. At least two independent trained observers graded the photographs in blinded fashion using the above-described scale (blinded scoring).
Results and Discussion
Survival
Seven deaths occurred during this study, all on the day of radiation (Day 0). Two animals each died in the group treated with M40403 at 30 mg/kg once daily from day −1 to day 3, the group treated with M40403 at 30 mg/kg twice daily from day −1 to day 3 and the group treated with M40403 at 30 mg/kg once daily from day 0 to day 3. One animal died in the group treated with M40403 at 30 mg/kg once daily on day 0 and day 7
Weight Change (FIGS. 9 and 10).
The percent daily weight change for each group is shown in FIG. 9. The control animals (group 1) gained an average of 62.5% of their starting weights by the end of the study. The animals treated ip with M40403 at 30 mg/kg/dose once daily from day −1 to day 3 (group 2) gained an average of 60.7% of their starting weight during the study. The group treated ip with M40403 at 3 mg/kg/dose twice daily from day −1 to day 3 (group 3) gained an average of 59.3% of their starting weight by day 28. The group treated ip with M40403 at 10 mg/kg/dose twice daily from day −1 to day 3 (group 4) gained an average of 56.2% of their starting weight during the study. The group treated ip with M40403 at 30 mg/kg/dose twice daily from day −1 to day 3 (group 5) gained an average of 52.9% of their starting weight during the study. The group treated ip with M40403 at 30 mg/kg/dose once daily from day 0 to day 3 (group 6) gained an average of 54.8% of their starting weight during the study. The group treated ip with M40403 at 30 mg/kg/dose twice daily from day 0 to day 3 (group 7) gained an average of 58.1% of their starting weight during the study. The group treated ip with M40403 at 30 mg/kg/dose twice daily on day 0 (group 8) gained an average of 59.3% of their starting weight during the study. The group treated ip with M40403 at 30 mg/kg/dose twice daily on day 0 and on day 7 (group 9) gained an average of 57.3% of their starting weight during the study.
The significance of these differences was evaluated by calculating the mean area under the curve for the percentage weight gain for each animal and comparing the groups using a One-Way ANOVA test. There were significant differences between the vehicle control group and the group treated with M40403 at 30 mg/kg/dose once daily from day −1 to day 3 (P=0.039), he group treated with M40403 at 3 mg/kg/dose twice daily from day −1 to day 3 (P=0.040), the group treated with M40403 at 10 mg/kg/dose twice daily from day −1 to day 3 (0.018), the group treated with M40403 at 30 mg/kg/dose twice daily from day −1 to day 3 (P<0.001), the group treated with M40403 at 30 mg/kg/dose once daily from day 0 to day 3 (P=0.009) and the group treated with M40403 at 30 mg/kg/dose twice daily from day 0 to day 3 (P=0.002). The results of this analysis are shown in FIG. 10.
Mucositis (FIGS. 11 & 12, Tables 7 & 8)
Mean daily mucositis scores for each group are shown in FIG. 11. The control animals (group 1) had a peak mean mucositis score of 3.1 on day 16. The animals treated ip with M40403 at 30 mg/kg/dose once daily from day −1 to day 3 (group 2) had a peak mean mucositis score of 2.8 on day 16. The group treated ip with M40403 at 3 mg/kg/dose twice daily from day −1 to day 3 (group 3) had a peak mean mucositis score of 2.9, which occurred on days 16 and 18. The group treated ip with M40403 at 10 mg/kg/dose twice daily from day −1 to day 3 (group 4) had a peak mean mucositis score of 3.0 on day 16. The group treated ip with M40403 at 30 mg/kg/dose twice daily from day −1 to day 3 (group 5) had a peak mean mucositis score of 2.8 on day 16. The group treated ip with M40403 at 30 mg/kg/dose once daily from day 0 to day 3 (group 6) had a peak mean mucositis score of 3.2 on day 16. The group treated ip with M40403 at 30 mg/kg/dose twice daily from day 0 to day 3 (group 7) had a peak mean mucositis score of 2.2 on day 16. The group treated ip with M40403 at 30 mg/kg/dose twice daily on day 0 (group 8) had a peak mean mucositis score of 2.4 on day 14. The group treated ip with M40403 at 30 mg/kg/dose twice daily on day 0 and on day 7 (group 9) had a peak mean mucositis score of 2.4 which occurred on days 16 and 18.
The significance of the reductions in the mucositis scores seen in the groups treated with M40403 were evaluated by calculating the percentage of animal days with a score of 3 or higher. The results of this analysis are shown in FIG. 12 and Table 7. In the control group, the percentage of animal days with a mucositis score of 3 or higher was 36.5%. Treatment by ip injection with M40403 at 30 mg/kg/dose once daily from day −1 to day 3 (group 2) or M40403 at 3 mg/kg/dose twice daily from day −1 to day 3 (group 3) resulted in a percentage of animal days with a score of 3 or higher of 25%. Treatment with M40403 at 10 mg/kg/dose twice daily from day −1 to day 3 (group 4) resulted in a percentage of animal days with a score of 3 or higher of 29.2%. Treatment with M40403 at 30 mg/kg/dose twice daily from day −1 to day 3 (group 5) resulted in a percentage of animal days with a score of 3 or higher of 22.2%. Treatment with M40403 at 30 mg/kg/dose once daily from day 0 to day 3 (group 6) resulted in a percentage of animal days with a score of 3 or higher of 30.6%. Treatment with M40403 at 30 mg/kg/dose twice daily from day 0 to day 3 (group 7) resulted in a percentage of animal days with a score of 3 or higher of 9.4%. Treatment with M40403 at 30 mg/kg/dose twice daily on day 0 (group 8) resulted in a percentage of animal days with a score of 3 or higher of 13.5%. Treatment with M40403 at 30 mg/kg/dose twice daily on day 0 and on day 7 (group 9) resulted in a percentage of animal days with a score of 3 or higher of 15.5%. When compared using a chi-squared test, significant reductions in the number of animal days with a score of 3 or higher were seen in the groups treated with M40403 at 30 mg/kg/dose once daily from day −1 to day 3 (group 2, P=0.034), M40403 at 3 mg/kg/dose twice daily from day −1 to day 3 (group 3, P=0.020), M40403 at 30 mg/kg/dose twice daily from day −1 to day 3 (group 5, P=0.007), M40403 at 30 mg/kg/dose twice daily from day 0 to day 3 (group 7, P<0.001), M40403 at 30 mg/kg/dose twice daily on day 0 (group 8, P<0.001) and M40403 at 30 mg/kg/dose twice daily on day 0 and on day 7 (group 9, P<0.001). This data is shown in FIG. 12 and Table 7.







TABLE 7







Table 3. ACT-03. Chi-square analysis of the total number of days the animals in each group spent


with a mucositis score of three or more. This statistic is a measure of severity of ulceration, a 


clinically important outcome.

















% Days
Chi Sq



Group
Days >=3
Days <3
Total Days
>=3
v control
P Value
















Vehicle ip control bid
70
122
192
36.46%
—
—


day −1 to 3








M40403 ip 30 mg/kg qd
36
108
144
25.00%
4.4860
0.034


day −1 to 3








M40403 ip 3 mg/kg bid
48
144
192
25.00%
5.3950
0.020


day −1 to 3








M40403 ip 10 mg/kg bid
56
136
192
29.17%
1.1996
0.158


day −1 to 3








M40403 ip 30 mg/kg bid
32
112
144
22.22%
7.229
0.007


day −1 to 3








M40403 ip 30 mg/kg qd
44
100
144
30.56%
1.029
0.310


day 0 to 3








M40403 ip 30 mg/kg bid
18
174
192
9.38%
38.3440
<0.001


day 0 to 3








M40403 ip 30 mg/kg bid
26
166
192
13.54%
25.681
<0.001


day 0








M40403 ip 30 mg/kg bid
26
142
166
15.48%
19.113
<0.001


day 0 & 7









Further analysis of the mucositis scores was performed by comparing the scores for the M40403 treated groups with the control on each day of scoring using the Mann-Whitney Rank Sum test. The results of this analysis are shown in Table 8. The groups treated with M40403 at 30 mg/kg/dose once daily from day −1 to day 3 (group 2), M40403 at 10 mg/kg/dose twice daily from day −1 to day 3 (group 4) and M40403 at 30 mg/kg/dose once daily from day 0 to day 3 (group 6) did not show any days with significant differences relative to controls. The scores for the group treated with M40403 at 3 mg/kg/dose twice daily from day −1 to day 3 (group 3) were significant different from controls on days 14 (P=0.013), 22 (P=0.047) and 28 (P=0.012). The group treated with M40403 at 30 mg/kg/dose twice daily from day −1 to day 3 (group 5) was significant different from controls on days 24 (P=0.048). The group treated with M40403 at 30 mg/kg/dose twice daily from day 0 to day 3 (group 7) had significantly lower scores than the control group on days 14 (P<0.001), 16 (P=0.001), 18 (P=0.007), 20 (P=0.001), 22 (P<0.001), 24 (P=0.006), 26 (P=0.001) and 28 (P=0.012). The group treated with M40403 at 30 mg/kg/dose twice daily on day 0 (group 8) had significantly lower scores than the control group on days 16 (P=0.001), 18 (P=0.033), 20 (P=0.002), 22 (P<0.001), 24 (P=0.010), 26 (P<0.001) and 28 (P=0.009). The group treated with M40403 at 30 mg/kg/dose twice daily on day 0 and on day 7 (group 9) had significantly lower scores than the control group on days 14 (P=0.004), 16 (P=0.047), 20 (P<0.001), 22 (P=0.015) and 26 (P=0.047).







TABLE 8







Table 4. ACT-03. The significance of group differences observed in daily mucositis scores was determined using


the Mann-Whitney rank sum test. This nonparametric statistic is appropriate for the visual mucositis scoring scale.


The p values for each calculation are shown. Significant improvements are shown underlined









Day



















Group Comparison
6
8
10
12
14
16
18
20
22
24
26
28






















Control v
0.467
0.655
0.944
0.499
 0.097
0.231
0.233
 0.315
 0.235
0.294
 0.273
0.253


M40403 ip 30 mg/kg qd














day −1 to 3














Control v
0.985
0.231
0.985
0.748
 0.013
0.297
0.865
 0.459
 0.047
0.610
 0.283
0.012


M40403 ip 3 mg/kg bid














day −1 to 3














Control v
0.230
0.985
0.985
0.865
 0.506
0.955
0.437
 0.414
 0.354
0.595
 0.463
0.584


M40403 ip 10 mg/kg bid














day −1 to 3














Control v
0.725
0.655
0.410
0.428
 0.097
0.141
0.216
 0.097
 0.170
0.048
 0.053
0.066


M40403 ip 30 mg/kg bid














day −1 to 3














Control v
0.981
0.944
0.798
0.834
 0.361
0.870
0.592
 0.981
 0.437
0.388
 0.362
0.798


M40403 ip 30 mg/kg qd














day 0 to 3














Control v
0.776
0.555
0.472
0.940
<0.001
0.001
0.007
 0.001
<0.001
0.006
 0.001
0.012


M40403 ip 30 mg/kg bid














day 0 to 3














Control v
0.776
0.985
0.374
0.519
 0.061
0.001
0.033
 0.002
<0.001
0.010
<0.001
0.009


M40403 ip 30 mg/kg bid














day 0














Control v
0.415
0.721
0.156
0.851
 0.004
0.047
0.091
<0.001
 0.015
0.163
 0.047
0.219


M40403 ip 30 mg/kg bid 














day 0 & 7









Conclusions
1. Based on observations of body weight, ip injections of M40403, appear to show some toxicity. The only groups that did not exhibit some statistically significant reductions in growth rate were those dosed with M40404 on day 0 only or on day 0 and day 7. Some mortality was noted on the day of radiation, but it is not clear whether this was related to treatment with M40403, or simply accidental death during the anesthesia process
2. The groups treated with M40403 at 30 mg/kg/dose once daily from day −1 to day 3, M40403 at 10 mg/kg/dose twice daily from day −1 to day 3 or M40403 at 30 mg/kg/dose once daily from day 0 to day 3 did not generally show any significant reduction in the course of mucositis relative to controls, although the group treated with M40403 at 30 mg/kg/dose once daily from day −1 to day 3 showed a significant reduction in the number of animals days with a score of 3 or higher (P=0.034).
3. The group treated with M40403 at 3 mg/kg/dose twice daily from day −1 to day 3 had significant lower mucositis scores from controls on days 14 (P=0.013), 22 (P=0.047) and 28 (P=0.012), and had a significant reduction in the number of animals days with a score of 3 or higher (P=0.020).
4. The group treated with M40403 at 30 mg/kg/dose twice daily from day −1 to day 3 had significantly lower scores than the control group on day 24 (P=0.048) and had a significant reduction in the number of animals days with a score of 3 or higher (P=0.007).
5. The group treated with M40403 at 30 mg/kg/dose twice daily from day 0 to day 3 (group 7) had significantly lower scores than the control group on days 14 (P<0.001), 16 (P=0.001), 18 (P=0.007), 20 (P=0.001), 22 (P<0.001), 24 (P=0.006), 26 (P=0.001) and 28 (P=0.012) and had a significant reduction in the number of animals days with a score of 3 or higher (P<0.001).
6. The group treated with M40403 at 30 mg/kg/dose twice daily on day 0 (group 8) had significantly lower scores than the control group on days 16 (P=0.001), 18 (P=0.033), 20 (P=0.002), 22 (P<0.001), 24 (P=0.010), 26 (P<0.001) and 28 (P=0.009) and had a significant reduction in the number of animals days with a score of 3 or higher (P<0.001).
7. The group treated with M40403 at 30 mg/kg/dose twice daily on day 0 and on day 7 had significantly lower scores than the control group on days 14 (P=0.004), 16 (P=0.047), 20 (P<0.001), 22 (P=0.015) and 26 (P=0.047) and had a significant reduction in the number of animals days with a score of 3 or higher (P<0.001).
Other Embodiments
The detailed description set-forth above is provided to aid those skilled in the art in practicing the present invention. However, the invention described and claimed herein is not to be limited in scope by the specific embodiments herein disclosed because these embodiments are intended as illustration of several aspects of the invention. Any equivalent embodiments are intended to be within the scope of this invention. Indeed, various modifications of the invention in addition to those shown and described herein will become apparent to those skilled in the art from the foregoing description which do not depart from the spirit or scope of the present inventive discovery. Such modifications are also intended to fall within the scope of the appended claims.
References Cited
All publications, patents, patent applications and other references cited in this application are incorporated herein by reference in their entirety for all purposes to the same extent as if each individual publication, patent, patent application or other reference was specifically and individually indicated to be incorporated by reference in its entirety for all purposes. Citation of a reference herein shall not be construed as an admission that such is prior art to the present invention.

    1. Knox J J, Puodziunas A L, Feld R. Chemotherapy-induced oral mucositis. Prevention and management. Drugs Aging 2000; 17(4):257-67.
    2. Peterson D E. Research advances in oral mucositis. Curr Opin Oncol 1999; 11(4):261-6.
    3. Plevova P. Prevention and treatment of chemotherapy- and radiotherapy-induced oral mucositis: a review. Oral Oncol 1999; 35(5):453-70.
    4. Sonis S T, Oster G, Fuchs H, Bellm L, Bradford W Z, Edelsberg J, et al. Oral mucositis and the clinical and economic outcomes of hematopoietic stem-cell transplantation. J Clin Oncol 2001; 19(8):2201-5.
    5. Eldor A, Fuks Z, Matzner Y, Witte L D, Vlodaysky I. Perturbation of endothelial functions by ionizing irradiation: effects on prostaglandins, chemoattractants and mitogens. Semin Thromb Hemost 1989; 15(2):215-25.
    6. Sonis S T, Van Vugt A G, McDonald J, Dotoli E, Schwertschlag U, Szklut P, et al. Mitigating effects of interleukin 11 on consecutive courses of 5-fluorouracil-induced ulcerative mucositis in hamsters. Cytokine 1997; 9(8):605-12.
    7. Sonis S T, Van Vugt A G, Brien J P, Muska A D, Bruskin A M, Rose A, et al. Transforming growth factor-beta 3 mediated modulation of cell cycling and attenuation of 5-fluorouracil induced oral mucositis. Oral Oncol 1997; 33(1):47-54.
    8. Sonis S T, Peterson R L, Edwards L J, Lucey C A, Wang L, Mason L, et al. Defining mechanisms of action of interleukin-11 on the progression of radiation-induced oral mucositis in hamsters. Oral Oncol 2000; 36(4):373-81.
    9. Sonis S T, Tracey C, Shklar G, Jenson J, Florine D. An animal model for mucositis induced by cancer chemotherapy. Oral Surg Oral Med Oral Pathol 1990; 69(4):437-448


Appendices







APPENDIX 1





Animal Weights







Animal Weights from a first study











DAY























Group
Animal
−1
0
1
2
3
4
5
6
7
8
9
10
11
12
13





1
1
89
92
92
90
101
102
107
110
113
110
118
119
121
110
126


1
2
94
101
101
108
109
109
116
116
118
122
121
125
126
123
134


1
3
93
98
98
99
102
105
107
104
112
115
115
118
120
118
118


1
4
88
92
90
93
98
98
99
101
102
106
106
109
110
132
114


1
5
96
98
98
102
106
109
113
108
117
123
123
127
129
130
130


1
6
97
102
101
107
109
111
116
118
121
123
125
127
130
131
130


1
7
87
95
90
94
97
98
105
104
101
105
105
105
107
110
109


1
8
91
96
97
100
102
103
105
109
111
115
115
117
119
126
126


2
9
100
dead















2
10
91
93
90
95
91
93
92
99
101
106
107
107
108
114
115


2
11
89
89
87
88
83
86
86
91
93
96
99
103
105
110
111


2
12
98
99
98
109
106
108
116
117
121
103
123
125
126
125
130


2
13
98
104
102
106
109
110
118
120
123
126
127
129
132
145
139


2
14
101
102
98
98
97
98 
106
110
112
117
119
120
122
128
128


2
15
76
76
75
74
77
79
81
82
84
86
86
88
89
92
93


2
16
90
dead















3
17
93
99
96
98
99
103
105
103
106
108
107
111
113
116
116


3
18
94
95
98
97
98
100
103
107
108
109
107
108
108
115
116


3
19
96
98
100
101
105
107
109
118
114
115
113
116
119
121
121


3
20
99
99
102
97
106
105
113
117
120
124
123
125
127
134
134


3
21
91
93
95
104
99
102
105
107
110
115
113
113
115
120
123


3
22
105
104
95
110
112
115
120
124
128
132
130
138
138
144
145


3
23
92
93
93
97
99
102
103
104
106
107
110
112
116
114
117


3
24
93
91
93
90
96
99
101
105
107
109
107
107
110
101
105










Animal Weights from a first study











DAY























Group
Animal
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28





1
1
120
120
130
132
133
137
138
139
143
140
144
140
149
100
149


1
2
134
134
138
140
144
148
151
151
155
156
158
160
182
162
164


1
3
119
123
124
127
130
131
129
133
135
137
139
142
144
142
138


1
4
115
118
117
121
124
126
134
129
132
133
132
133
138
136
139


1
5
133
135
138
141
142
148
147
150
153
154
158
165
163
163
159


1
6
131
131
136
138
141
141
142
143
146
149
149
152
153
171
157


1
7
111
112
116
116
120
121
122
123
127
128
128
130
134
128
138


1
8
129
130
130
132
137
137
140
141
145
147
148
150
153
154
154


2
9

















2
10
116
116
119
121
121
122
124
125
127
129
132
137
133
135
135


2
11
112
113
118
120
121
124
126
127
133
131
136
160
140
142
143


2
12
131
133
135
138
142
147
149
151
155
156
158
134
165
164
168


2
13
140
142
144
147
149
154
150
156
160
162
165
166
166
166
174


2
14
129
129
132
135
125
138
139
140
144
145
146
150
151
152
155


2
15
99
95
99
101
101
103
108
106
109
111
109
110
114
115
116


2
16

















3
17
117
118
119
121
124
124
126
127
129
130
132
133
136
138
139


3
18
116
118
120
123
125
128
130
132
136
138
140
142
145
148
148


3
19
122
125
128
131
132
135
137
138
140
143
143
140
147
149
151


3
20
132
134
138
140
143
145
148
149
152
154
156
160
160
162
165


3
21
123
125
127
129
132
132
134
136
138
142
143
144
148
147
148


3
22
149
150
155
158
160
164
168
169
172
174
176
179
181
183
182


3
23
117
116
117
120
120
126
126
126
130
131
132
136
136
139
140


3
24
105
110
112
115
117
118
124
126
129
132
134
137
138
138
143










Animal Weights from a first study











DAY























Group
Animal
−1
0
1
2
3
4
5
6
7
8
9
10
11
12
13





4
25
96
97
95
93
96
98
102
106
107
110
111
113
115
119
118


4
26
89
89
88
90
93
92
97
99
101
104
103
102
103
110
108


4
27
93
96
93
98
102
105
106
107
109
116
118
119
120
123
119 


4
28
99
100
99
98
100
103
106
110
112
115
118
121
122
122
125


4
29
90
91
90
96
100
102
100
101
104 
107
107 
108
110 
112
111


4
30
93
98
95
99
102
103
106
111
111
116
116
119
121
125
122


4
31
93
94
89 
91
95
98
99
103
105 
108
109
112
116
116
114 


4
32
91
92
91 
95
98
100
102
102
105
109
111
112
114
114
116


5
33
74
dead















5
34
85
83
84
83
86
88
87
90
94
97
98
100
102
106
108


5
35
96
96
96
100
101
102
100
103
108
111
116
115
116
119
118


5
36
90
92
91
94
97
98
95
96
101
104
105
107
109
114
113


5
37
100
dead















5
38
96
101
100
98
101
103
104
108
110
114
117
119
120
128
129


5
39
87
84
82
79
78
79
81
84
86
91
93
94
99
97
98


5
40
89
82
79
78
79
82
81
86
87
91
94
98
100
101
102


6
41
94
92
96
97
99
102
98
98
103
108
109
110
112
116
115


6
42
94
95
93
98
99
101
104
103
109
111 
113
114
116
119
119


6
43
101
101
101
107
109 
110
115
117
122
126
127
129
130
134
134


6
44
90
dead















6
45
89
88
88
90
91
96
94
92
95
99
102
102
105
105
102


6
46
93
94
92
103
102
102
102
104
108 
110 
112 
114 
116 
119
119 


6
47
99
101
98
97
108
109
111
111
119
118
119
123
126
125
126


6
48
91 
dead























Animal Weights from a first study











DAY























Group
Animal
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28





4
25
121
124
128
130
131
132
133
134
137
139
140
142
145
145
144


4
26
109
110
112
117
111
117
119
119
121
128
125
126
127
130
128


4
27
123
124
128
131
130
135
138
137
143
145
145
146
150
156
152


4
28
128
129
133
135
137
139
140
140
144
145
148
150
152
151
152


4
29
117
119
121
124 
125
129
131
128
133
134
136
140
141
140
142


4
30
121
126
131
134
134
136
141
141
145
148
149
152
154
158
157


4
31
117 
120 
123 
125 
128
127 
131 
130 
132 
132 
134 
136
138
130
139


4
32
118
120
125
128
127
130
133
134
137
138
141
143
145
133
146


5
33

















5
34
107
108
109
111
120
118
120
120
126
129
128
130
134
134
134


5
35
120
119
123
125
129
129
130
129
134
137
137
139
140
141
142


5
36
116
117
119
121
120
125
127
127
131
133
133
135
139
134
140


5
37

















5
38
134
134
138
140
152
144
146
144
149
152
154
156
159
161
161


5
39
100
103
106
108
117
113
118
115
121
122
123
124
130
132
130


5
40
104
103
104
105
116
113
112
111
115
117
118
119
125
128
124


6
41
114
116
117
119
129
125
127
128
136
134
136
140 
142
151
144


6
42
120
121
124
127
133
132
133
133
141
140
142
143
146
149
150


6
43
135
138
141
142
150
150
154
155
160
160
164
165
172
172
172


6
44

















6
45
101
98
100
103
105
104
106
106
111
111
111
113
115
114
115


6
46
122 
123 
125 
128
132
131
134
132
138
139
141 
145
146
159
144


6
47
130
131
135
137
138
140 
143
142
147
150
152
153
156
141
160










Animal Weights from a first study











DAY























Group
Animal
−1
0
1
2
3
4
5
6
7
8
9
10
11
12
13





7
49
91
94
91
95
101
104
98
102
106
107
108
113
115
119
120


7
50
93
95
92
91
93
93
98
104
103
105
106
109
111
115
118


7
51
90
87
86
87
97
98
95
95
99
101
103
107
108 
113
113


7
52
95
99
95
99
102
104
107
108
113
115
114
113
115
120
120


7
53
92
93
68
89
91
93
90
93
97
99
101
102
106
109
108


7
54
98
101
98
102
105
108
101
108
109 
112
113
116
119
121
122


7
66
91
93
90
93
99
101
98
101
104
108
109
111
113
117
118


7
56
88
87
81
83
78
81
78
80
82
85
86
92
95
94
99


8
57
94
97
93
99
102
105
105
108
112
113
114 
117
119 
120
121


8
58
88
90
84
89
93
95
98
104
105
106
107
111
114
116
118


8
59
88
92
84
91
93
97
97
100
102 
105
103
105
108
110
112


8
60
86
89
86
96
95
96
99
100
105
106
106
108
111
114
114


8
61
94
94
91
97
99
103
103
108
110
113
116
117
119
125
124


8
62
93
94
88
93
98
101
104
108
111
108
112
118
120
122
121


8
63
91
94
91
96
99
100
103
106
109
110
113
115
117
118
120


8
64
98
101
96
101
107
107
111
113
117
118
119
125
127
124
124


9
65
98
101
100
104
108
110
113
115
116
114
117
119
131
124
124


9
66
94
98
94
98
102
105
107
110
112
113
114
117
118
125
124


9
67
89
93
90
95
98
101
104 
106
108
105
109
112
115
115
116


9
68
93
96
91
95
100
103
105
104
111
109
112
113
116
117
119


9
69
98
99
98
102
106
109
110
114
118
119
121
124
129
131
129


9
70
92
dead















9
71
91
92
89
94
98
100
102
105
106
104
107
110
111
116
120


9
72
95
96
95
98 
101
105
106
109
111
111
114 
114
116
116
120










Animal Weights from a first study











DAY























Group
Animal
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28





7
49
127
130
131
133
135
140 
141
142
148
149
150 
152
156 
158
158


7
50
118
117
124
127
120
128
129
129
135
137
138
140
143
142
146


7
51
118
121 
118
121
125
127
133
131
137
138
138 
140
144
146
145


7
52
124
122
128
131 
132
133
137
136 
143
142
143
145
148 
140
149


7
53
110
112 
117
120
118
121
124
124
128
129
130 
133
135
138
137


7
54
125
126
129
129
135
137
138
138
142
144
146
147
151
145
152


7
66
120
123
125
127
130
130 
132
133
139
140
142
145
148
146
150


7
56
100
102
105
108
111
112
113
113
116
121
123
124
127
121
130


8
57
123
125 
128
131
138
132
137
137 
139
140
143
143
147
147
148


8
58
119
120
120
124
128
128
131
131
134
134
135
137
139
135
142


8
59
111
115
118
121
122
118
122
121
123
126
127
131
129
126
127


8
60
117
118
122
124
125
128
131
131
136
138
139
143
145
146
146


8
61
126
128
126
130
138
137
139
141
142
144
144
146
151
151
153


8
62
122
126
128
130
134
133
137
138
138
142
145
147
147
154
153


8
63
123
125
127
131
129
132
135
135
137
138
139
147
143
145
146


8
64
125
126
127
130
131
135
137
135
139
142
142
144
147
142
151


9
65
127
125
133
137
135
136
138
139
141
142
144
146
149
148
151


9
66
127
129
130
134
137
139
141
139
143
145
148
150
152
144
152


9
67
119
118 
123
126
125
128
130
130
132
135
136
137
140
128
143


9
68
120
119
121
124
129
127
130
129
131
122
133
136
134
122
136


9
69
133
134
138
141 
142
146 
152
149
151
153
155
159
162
165
166


9
70

















9
71
122
122 
125
128 
128
131 
143
134 
137
139
139
141
145
142
147


9
72
120
120
121
124
133
128
129
125
129
132
154
137
138
138
140










Animal Weights from a second study











DAY























Group
Animal
−1
0
1
2
3
4
5
6
7
8
9
10
11
12
13





1
1
88
92
91
94
96
98
102
103
103
106
108
110
114
113
116


1
2
89
93
92
96
100
102
103
107
109
110
114
116
119
117
120


1
3
96
98
98
101
105
108
110
112
115
120
122
125
126
125
123


1
4
95
97
97
102
103
107
108
111
114
117
118
121
125
123
126


1
5
88
91
88
91
94
97
98
100
103
105
106
110
112
109
111


1
6
90
95
93
98
101
104
107
108
111
114
115
122
122
121
124


1
7
88
89
88
91
94
96
92
99
103
102
104
108
110
108
111


1
8
92
AOD















2
9
85
86
86
90
93
96
95
110
104
107
109
111
113
112
113


2
10
66
89
86
91
94
96
97
100
104
106
107
108
112
112
114


2
11
68
91
91
94
96
97
98
103
104
105
107
109
112
112
115


2
12
100
104
102
106
105
112
113
116
121
121
124
129
132
129
132


2
13
77
81
80
84
87
86
84
95
97
98
101
104
107
108
105


2
14
92
93
96
101
103
106
108
112
111
115
116
117
118
117
120


2
15
68
91
69
93
95
95
97
101
102
104
106
109
111
113
115


2
16
94
97
97
100
102
105
106
113
112
115
116
120
123
123
126


3
17
90
99
90
96
97
96
95
90
99
90
97
101
100
90
99


3
18
88
91
86
69
92
94
94
94
98
99
96
97
93
91
93


3
19
90
93
90
90
92
94
82
80
84
84
85
82
87
dead



3
20
68
91
85
89
82
84
88
79
81
80
78
80
81
80
82


3
21
101
102
98
100
101
103
101
101
107
108
104
107
108
103
106


3
22
92
96
87
93
92
95
94
88
91
86
82
83
80
78
80


3
23
65
dead















3
24
92
95
91
95
97
99
99
100
104
103
100
101
100
98
100










Animal Weights from a second study











DAY























Group
Animal
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28





1
1
115
115
117
119
119
114
115
116
117
118
121
122
123
124
127


1
2
124
124
125
129
131
131
135
136
136
138
140
141
147
149
148


1
3
131
132
137
142
145
144
148
152
153
155
159
161
161
163
169


1
4
124
123
124
129
130
131
134
138
139
140
143
147
145
149
152


1
5
111
112
113
117
119
119
123
127
127
128
131
132
133
136
136


1
6
127
125
124
128
130
130
134
136
139
141
128
147
148
149
153


1
7
113
112
114
116
117
118
123
123
124
125
145
128
139
133
134


1
8

















2
9
116
115
121
123
125
127
133
135
138
139
142
144
146
149
152


2
10
118
117
118
121
123
125
129
130
132
135
139
142
143
147
146


2
11
119
116
117
119
120
121
125
126
128
129
131
134
134
138
139


2
12
134
135
135
138
142
140
145
144
150
150
154
155
156
162
160


2
13
112
111
113
117
119
117
122
125
124
122
129 
130
132
136
136


2
14
118
120
122
123
127
128
131
134
135
138
140
144
142
144
150


2
15
118
120
121
123
124
126
129
131
132
135
135
137
138
140
142


2
16
127
126
128
129
131
131
135
136
136
140
143
145
143
113
151


3
17
99
97
94
90
102
102
100
113
115
117
121
124
124
127
131


3
18
91
86
84
84
88
91
95
99
101
104
108
111
112
115
118


3
19

















3
20
83
78
77
79
81
85
89
93
97
99
103
99
106
110
115


3
21
103
99
99
98
106
107
112
115
119
117
127
128
129
132
135


3
22
79
74
72
75
79
81
85
88
91
93
97
106
107
108
109


3
23

















3
24
102
99
101
105
108
110
114
117
121
123
127
130
132
135
138










Animal Weights from a second study











DAY























Group
Animal
−1
0
1
2
3
4
5
6
7
8
9
10
11
12
13





4
25
86
90
88
91
93
95
99
97
102
105
103
109
105
110
114


4
26
92
95
93
99
102
103
106
109 
112
113
116
121
120
119
123


4
27
85
87
86
89
90
94
94
98
99
102
119
97
107
105
108


4
28
94
98
96
101
103
106
107
111
113
115
119
120
127
125
127


4
29
94
96
96
99
101
104
107
110
112
117
117
123
122
121
123


4
30
91
94
95
99
102
104
104
100
109
113
115
117
119
118
119


4
31
93
85
84
88
89
93
94
99
97
98
100
105
105
104
106


4
32
74
74
75
79
79
82
86
87
92
94
95
103
98
95
98


5
33
83
83
83
89
89
98
95
98
101
104
105
115
110
108
111


5
34
79
80
79
83
86
88
90
93
95
102
99
101
104
103
106


5
35
83
87
85
90
93
95
97
94
101
102
103
105
106
105
109


5
36
84
86
86
91
93
97
100
102
107
111
110
109
115
118
114


5
37
85
86
85
88
89
91
93
102
99
101
102
106
108
107
111


5
38
78
79
79
82
84
88
88
97
95
101
99
103
105
102
104


5
39
85
87
87
90
94
94
99
101
104
106 
107
111
112
111
113


6
40
81
83
82
87
69
90
93
95
97
100
101
107
107
107
109


6
41
86
87
81
85
93
97
78
82
85
89
91
96
98
100
102


6
42
91
93
88
93
95
99
102
107
112
114 
116
120
122
120 
123


6
43
84
87
84
83
79
78
84
93
89
93
95
98
102
103
107


6
44
91
94
92
92
93
94
96
101
104
106
103
113
114
114
119


6
45
78 
dead















6
46
86
89
dead














6
47
89
93
86
91
79
91
92
99
101
105
109
112
114
114
116


6
48
88
92
87
89
92
86
90
97
100
109
106
111
114
114
118










Animal Weights from a second study











DAY























Group
Animal
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28





4
25
115
116
119
124
125
123
129
131
133 
133
137
138
140
145
146


4
26
123
124
129
134
134
133
141
144
145
143
150
151
152
156
160


4
27
110
110
111
114
116
114
118
121
123
124
126
130
131
133
136


4
28
129
127
129
132
132
135
138
142
143
143
128
148
158
148
154


4
29
125
125
130
132
135
135
142
142
145
149
151
153
157
160
161


4
30
122
120
126
127
130
127
134
138
139
139
142
142
144
146
149


4
31
111
109
112
114
116
117
120
123
124 
122
129
130
130
133
135


4
32
107
104
108
111
112
112
116
119
122
126
125
125
124
126
132


5
33
112
111
114
118
119
120
124
124
124 
128
131 
132
138
141
140


5
34
111
110
114
118
119
121
123
127
126
128
132
133
134
137
139


5
35
120
113
114
116
118
119
124
126
125
128 
130
132
137
134
138


5
36
120
121
124
127
130
132
135
137
139
144
145
148
150
152
156


5
37
110
108
111
115
117
116
121
123
124
124
129
129
131
134
136


5
38
107
108
110
114
117
116
122
125
125
128
131
134
133
137
139


5
39
113
118
121
125 
125
127
130
132
132 
134
136
137
146
142
148


6
40
112
110
113
116
118
116
121
123
124
125
128
128
130
133
135


6
41
106
107
110
112
116
117
120
121
123
125
128
128
130
136
136


6
42
118
117
115
108
106
104
104
103
104
104
106
108
108
109
110


6
43
109
108
112
115
115
116
122
124
124
125
127
130
129
131
134


6
44
120
120
123
125
127
128
132
133
135
137
137
138
136
139
142


6
45

















6
46

















6
47
124
124 
127
129
133
133
137
137
138
138
141
143
142
150
146


6
48
122
122
126
129
129
131
136
137
138
139
142
145
143
146
149
















APPENDIX 2







Mucositis Scores


Cheek pouch photographs were scored by 2 independent scorers in a blinded manner, 


resulting in 2 scores for each animal at each time point.











DAY




















Group
Animal
6
8
10
12
14
16
18
20
22
24
26
28










ACT-03 Blinded Scores


Mucositis scores from a first study























1
1
0
0
0
2
3
3
3
3
3
2
2
1


1
1
0
0
0
1
3
3
3
3
3
2
1
1


1
2
1
0
1
2
3
3
4
3
3
3
2
2


1
2
0
0
0
2
3
3
3
3
3
3
2
1


1
3
1
0
1
2
3
4
3
3
3
2
2
2


1
3
0
0
0
1
3
4
4
3
3
1
2
1


1
4
1
0
0
2
3
3
3
4
2
2
2
2


1
4
0
0
0
1
3
3
3
3
2
2
2
1


1
5
0
1
1
2
3
3
3
3
3
2
2
2


1
5
0
0
1
2
3
3
3
3
3
1
1
1


1
6
0
0
1
2
3
3
4
3
2
2
2
2


1
6
0
0
1
2
3
3
3
3
2
2
2
1


1
7
0
0
1
2
3
3
2
2
1
1
1
1


1
7
0
0
1
2
3
3
1
1
1
1
1
1


1
8
1
0
1
1
2
3
3
3
3
2
2
2


1
8
0
0
1
0
2
3
3
3
3
2
2
1


2
9
dead













2
9














2
10
0
0
1
2
2
3
2
2
1
1
1
1


2
10
0
0
1
1
2
3
2
2
1
1
1
1


2
11
0
0
1
2
3
3
3
3
3
2
1
1


2
11
0
0
0
1
3
3
3
3
3
2
2
2


2
12
0
0
1
1
3
3
3
3
2
2
2
1


2
12
0
0
0
1
3
3
3
3
2
1
2
1


2
13
0
0
1
2
3
3
3
3
3
2
2
1


2
13
0
1
0
2
3
3
3
3
3
2
2
1


2
14
0
0
1
2
3
3
3
3
2
2
1
0


2
14
1
1
0
1
2
3
3
3
2
2
2
1


2
15
0
0
1
2
2
2
2
2
2
1
1
1


2
15
0
0
0
1
2
2
2
2
2
1
1
2


2
16
dead













2
16














3
17
0
0
1
1
1
3
3
3
2
2
1
0


3
17
1
0
1
1
2
3
3
3
2
2
2
1


3
18
0
0
1
1
2
3
3
3
3
3
2
0


3
18
1
1
1
1
2
3
3
3
3
3
2
1


3
19
0
0
1
2
3
3
3
3
2
2
2
0


3
19
1
1
0
2
3
3
3
3
2
2
1
2


3
20
0
0
1
1
2
3
4
3
2
1
2
1


3
20
0
0
1
2
2
3
3
3
2
1
1
2


3
21
0
0
0
1
2
2
2
2
2
1
2
0


3
21
0
0
0
1
2
2
2
2
2
2
2
1


3
22
0
0
1
2
1
2
2
2
1
1
1
0


3
22
0
1
0
1
2
2
2
2
2
2
1
1


3
23
0
0
0
3
3
4
4
3
2
2
2
0


3
23
0
1
0
3
3
4
4
3
2
2
1
1


3
24
0
0
1
2
3
3
3
3
2
1
2
0


3
24
1
1
0
2
3
3
3
3
2
1
1
1


4
25
0
0
1
2
1
1
1
1
1
1
2
1


4
25
0
0
0
2
1
1
1
1
2
2
1
2


4
26
0
0
0
0
3
3
3
3
2
1
2
1


4
26
0
0
0
0
3
3
3
3
2
2
1
2


4
27
0
0
1
2
2
3
3
3
3
2
2
0


4
27
0
1
0
2
2
4
3
3
3
2
2
1


4
28
0
0
2
2
3
3
3
3
3
2
2
1


4
28
0
0
2
2
3
3
3
3
3
2
2
2


4
29
0
0
1
2
3
3
4
3
2
2
2
0


4
29
0
0
0
1
3
4
3
3
2
2
1
1


4
30
0
0
1
2
3
3
3
3
2
2
2
0


4
30
0
0
0
1
3
4
3
3
2
2
2
2


4
31
0
0
1
2
3
3
2
2
2
2
2
1


4
31
0
0
0
2
3
3
2
2
2
2
1
2


4
32
0
0
1
2
3
3
3
3
3
2
2
1


4
32
0
0
0
2
3
4
3
3
3
2
1
2


5
33
dead













5
33














5
34
0
0
0
2
3
3
3
2
2
1
1
0


5
34
0
0
0
2
3
3
3
2
2
2
1
1


5
35
0
0
1
2
3
3
3
3
2
2
2
1


5
35
0
0
0
2
3
4
3
3
2
2
1
2


5
36
0
0
1
2
2
2
2
2
0
1
1
1


5
36
0
0
0
1
2
2
2
2
1
1
0
2


5
37
dead













5
37














5
38
0
0
0
2
2
2
2
2
2
0
2
0


5
38
1
0
0
1
2
2
1
2
1
0
1
1


5
39
0
0
0
1
3
3
3
3
3
1
1
0


5
39
0
1
0
0
3
3
3
3
3
0
1
1


5
40
1
0
2
1
2
3
3
3
3
2
2
0


5
40
0
1
1
1
2
3
3
3
3
2
2
1


6
41
0
0
1
1
3
3
3
3
3
2
2
0


6
41
1
0
1
0
3
3
3
3
3
2
2
1


6
42
0
0
1
2
3
3
3
4
2
2
2
1


6
42
0
0
1
1
3
3
3
3
2
2
1
2


6
43
0
0
0
2
3
3
2
2
2
2
2
1


6
43
1
0
0
2
3
3
2
2
2
1
2
2


6
44
dead













6
44














6
45
0
0
1
2
2
4
4
4
4
4
3
2


6
45
1
0
0
2
2
4
4
4
4
4
3
2


6
46
0
0
0
2
3
3
3
3
2
2
2
0


6
46
0
0
0
2
3
3
3
3
2
2
2
1


6
47
0
0
1
2
2
3
2
2
0
2
2
2


6
47
0
1
0
0
2
3
2
2
1
2
1
1


6
48
dead













8
48














7
49
0
0
1
2
2
1
1
1
0
1
1
1


7
49
0
1
0
2
2
1
0
0
1
0
1
1


7
50
0
0
0
2
2
2
3
1
1
0
0
0


7
50
1
0
0
2
2
1
3
0
2
1
1
1


7
51
0
0
1
1
2
3
1
2
1
0
0
0


7
51
1
0
0
0
2
3
2
1
2
0
1
1


7
52
0
0
0
2
2
2
2
2
1
0
0
0


7
52
1
1
0
2
2
2
1
0
2
1
1
1


7
53
0
0
1
1
2
3
3
3
2
1
1
0


7
53
0
1
0
0
2
3
3
3
2
2
1
1


7
54
0
0
2
2
2
3
3
3
2
0
1
0


7
54
0
0
0
2
2
3
3
3
1
2
1
2


7
55
0
0
0
2
3
2
2
2
2
1
2
0


7
55
0
0
0
2
3
2
2
1
2
2
1
2


7
56
0
0
1
2
2
2
1
1
1
2
2
0


7
56
0
0
1
1
2
2
1
1
1
2
1
1


8
57
0
0
0
2
3
3
3
3
1
1
0
1


8
57
0
1
0
2
3
3
3
3
1
2
0
2


8
58
1
0
0
2
2
2
2
2
1
1
1
1


8
58
1
0
0
2
2
2
2
2
1
2
0
1


8
59
0
0
1
2
1
1
1
1
1
1
2
0


8
59
1
0
0
2
1
2
1
2
1
1
2
1


8
60
0
0
1
1
3
3
3
1
1
0
0
0


8
60
0
0
0
1
3
3
3
2
1
2
0
1


8
61
0
0
1
2
2
2
3
2
1
1
1
0


8
61
0
0
0
2
2
2
3
1
1
1
1
1


8
62
0
0
0
2
3
2
1
2
2
0
1
0


8
62
0
0
0
1
3
2
2
1
2
2
0
1


8
63
0
0
1
2
2
2
1
2
2
0
1
0


8
63
1
0
1
2
2
2
1
1
2
2
0
1


8
64
0
0
1
2
3
3
3
3
2
0
2
0


8
64
1
0
0
2
3
3
3
3
2
1
0
1


9
65
0
0
1
2
2
3
3
2
2
0
2
1


9
65
1
0
0
2
2
3
3
2
2
1
1
2


9
66
0
0
0
2
2
2
2
2
0
1
1
0


9
66
1
0
0
1
1
1
1
1
1
2
0
1


9
67
0
0
0
2
1
1
2
1
0
0
1
0


9
67
1
0
0
1
1
1
1
1
1
1
0
1


9
68
1
1
2
2
2
3
3
2
1
1
2
0


9
68
1
0
0
1
2
3
3
1
2
2
1
1


9
69
0
0
0
2
3
3
3
3
3
3
2
1


9
69
1
1
0
1
3
3
3
3
3
3
1
2


9
70














9
70














9
71
0
0
1
2
2
2
2
2
2
1
2
0


9
71
0
0
0
2
2
2
2
2
2
2
1
2


9
72
0
0
0
2
3
4
3
1
2
2
2
1


9
72
0
0
0
2
3
3
3
2
2
1
1
2










ACT-02 Blinded Scores


Mucositis scores from a second study























1
1
0
1
1
2
2
2
2
2
2
1
0
0


1
1
0
1
1
2
2
2
2
2
2
1
0
0


1
2
0
1
1
2
3
3
2
2
2
2
2
1


1
2
0
1
1
2
3
3
2
2
2
2
2
1


1
3
0
1
1
2
3
3
3
3
3
2
2
2


1
3
0
1
1
2
3
3
3
3
3
2
2
2


1
4
0
1
1
2
3
3
3
3
3
2
2
1


1
4
0
1
1
2
3
3
3
3
3
2
2
1


1
5
0
1
2
2
3
3
3
3
3
2
2
1


1
5
0
1
2
2
3
3
3
3
3
2
2
1


1
6
0
0
1
2
3
3
3
3
3
3
2
2


1
6
0
0
1
2
3
3
3
3
3
3
2
2


1
7
1
1
1
1
2
3
3
3
2
2
2
1


1
7
1
1
1
1
2
3
3
3
2
2
2
1


1
8














1
8














2
9
0
1
1
2
3
3
3
3
2
2
2
2


2
9
0
1
1
2
3
3
3
3
2
2
2
2


2
10
1
0
1
2
3
3
3
3
3
2
2
2


2
10
1
0
1
2
3
3
3
3
3
2
2
2


2
11
0
1
1
1
3
3
3
3
3
3
2
2


2
11
0
1
1
1
3
3
3
3
3
3
2
2


2
12
1
1
1
2
3
3
3
3
3
3
2
1


2
12
1
1
1
2
3
3
3
3
3
3
2
1


2
13
1
1
1
1
3
3
3
3
2
2
3
2


2
13
0
1
1
1
3
3
3
3
2
2
3
2


2
14
0
1
2
2
3
3
3
3
2
2
2
1


2
14
0
1
2
2
3
3
3
3
2
2
2
1


2
15
1
1
1
1
1
2
2
1
2
2
2
2


2
15
0
1
1
1
1
2
2
1
2
2
2
2


2
16
1
0
1
2
2
2
3
3
3
2
1
1


2
16
1
0
1
2
2
2
3
3
3
2
1
1


3
17
0
1
1
2
2
3
3
3
3
3
2
2


3
17
0
1
1
2
2
3
3
3
3
3
2
2


3
18
1
1
1
2
3
3
3
3
3
3
1
1


3
18
1
1
1
2
3
3
3
3
3
3
1
1


3
19
1
1
1
1










3
19
1
1
1
1










3
20
1
1
1
1
3
3
3
3
3
3
3
2


3
20
1
1
1
1
3
3
3
3
3
3
3
2


3
21
0
1
1
1
3
3
3
3
3
3
2
2


3
21
0
1
1
1
3
3
3
3
3
3
2
2


3
22
1
1
2
2
3
3
3
3
2
2
2
1


3
22
1
1
2
2
3
3
3
3
2
2
2
1


3
23














3
23














3
24
0
0
1
1
2
2
3
2
2
1
1
1


3
24
0
0
1
1
2
2
3
2
2
1
1
1


4
25
1
0
1
2
3
3
3
3
3
3
3
3


4
25
1
0
1
2
3
3
3
3
3
3
3
3


4
26
1
1
2
3
3
3
3
3
3
2
2
2


4
26
1
1
2
3
3
3
3
3
3
2
2
2


4
27
0
1
1
2
3
3
3
3
3
3
2
2


4
27
0
1
1
2
3
3
3
3
3
3
2
2


4
28
0
0
1
1
3
3
3
3
3
1
1
1


4
28
0
0
1
1
3
3
3
3
3
1
1
1


4
29
0
0
1
3
3
3
3
3
2
1
1
1


4
29
0
0
1
3
3
3
3
3
2
1
1
1


4
30
1
1
1
2
3
2
3
3
2
2
2
1


4
30
1
1
1
2
3
3
3
3
2
2
2
1


4
31
1
0
1
2
3
2
2
2
2
2
2
1


4
31
1
0
1
2
3
2
2
2
2
2
2
1


4
32
0
1
2
2
2
2
1
1
2
3
3
2


4
32
0
1
2
2
2
2
1
1
2
3
3
2


5
33
0
1
1
2
3
3
3
3
3
2
1
1


5
33
0
0
1
2
3
3
3
3
3
2
1
1


5
34
0
0
0
1
1
1
1
1
3
2
2
2


5
34
0
1
0
1
1
1
1
1
3
2
2
2


5
35
1
0
0
2
3
3
3
3
3
3
2
1


5
35
1
0
0
2
3
3
3
3
3
3
2
1


5
36
1
1
0
2
3
3
3
3
3
3
3
1


5
36
1
1
1
2
3
3
3
3
3
3
3
1


5
37
0
1
1
2
3
3
3
3
2
3
2
1


5
37
0
1
0
2
3
3
3
3
2
3
2
1


5
38
0
0
0
3
3
3
3
3
2
2
2
1


5
38
0
0
0
3
3
3
3
3
2
2
2
1


5
39
0
0
0
1
1
2
1
1
2
1
1
1


5
39
0
0
0
1
1
2
1
1
2
1
1
1


5
40
0
1
1
1
2
3
3
3
1
1
1
1


5
40
0
1
1
1
2
3
3
3
1
1
1
1


6
41
1
1
1
2
3
3
3
2
2
1
1
1


6
41
1
1
1
2
3
3
3
2
2
1
1
1


6
42
1
0
1
1
3
3
3
2
1
1
1
1


6
42
1
0
1
1
3
3
3
2
2
1
1
1


6
43
0
1
1
2
3
3
2
2
2
1
1
1


6
43
0
0
1
2
3
3
2
2
1
1
1
1


6
44
0
0
1
2
3
3
2
1
1
1
1
1


6
44
0
0
1
2
3
3
2
1
1
1
1
1


6
45














6
45














6
46














6
46














6
47
0
0
1
2
3
1
1
1
1
1
1
1


6
47
0
0
1
2
3
1
1
1
1
1
1
1


6
48
1
1
1
2
3
1
1
1
1
1
1
1


6
48
1
1
1
2
3
1
1
1
1
1
1
1

## Claims

1. A method of lessening the severity of an oral mucositis in a mammal afflicted with cancer, the method comprising:
parenterally administering a dose of a pentaaza macrocyclic ring complex to the mammal on the day before or the day of, but prior to or simultaneous with the mammal receiving a radiation dose for cancer treatment, the dose of the pentaaza macrocyclic ring complex being therapeutically sufficient, without requiring the administration of any additional doses of the pentaaza macrocyclic ring complex after the delivery of the radiation dose, to lessen the severity of oral mucositis resulting from the delivered radiation dose, and
wherein the pentaaza macrocyclic ring complex is a compound represented by the formula:





wherein
W is an unsubstituted pyridino moiety;
U and V are trans-cyclohexanyl fused rings;
R1, R2, R′2, R3, R4, R5, R′5, R6, R′6, R7, R8, R9, R′9, and R10 are each independently selected from the group consisting of hydrogen, alkenyl, alkenylcycloalkenyl, alkenylcycloalkyl, alkyl, alkylcycloalkenyl, alkylcycloalkyl, alkynyl, aralkyl, aryl, cycloalkenyl, cycloalkyl, cycloalkylalkyl, cycloalkylcycloalkyl, cycloalkenylalkyl, and heterocyclyl, and aralkyl radicals and radicals attached to the α-carbon or α-amino acids,
M is Mn2+ or Mn3+;
and X, Y and Z are independently selected from the group consisting of halide, oxo, aquo, hydroxo, alcohol, phenol, dioxygen, peroxo, hydroperoxo, alkylperoxo, arylperoxo, ammonia, alkylamino, arylamino, heterocycloalkyl amino, heterocycloaryl amino, amine oxides, hydrazine, alkyl hydrazine, aryl hydrazine, nitric oxide, cyanide, cyanate, thiocyanate, isocyanate, isothiocyanate, alkyl nitrile, aryl nitrile, alkyl isonitrile, aryl isonitrile, nitrate, nitrite, azido, alkyl sulfonic acid, aryl sulfonic acid, alkyl sulfoxide, aryl sulfoxide, alkyl aryl sulfoxide, alkyl sulfenic acid, aryl sulfenic acid, alkyl sulfinic acid, aryl sulfinic acid, alkyl thiol carboxylic acid, aryl thiol carboxylic acid, alkyl thiol thiocarboxylic acid, aryl thiol thiocarboxylic acid, alkyl carboxylic acid, aryl carboxylic acid, urea, alkyl urea, aryl urea, alkyl aryl urea, thiourea, alkyl thiourea, aryl thiourea, alkyl aryl thiourea, sulfate, sulfite, bisulfate, bisulfite, thiosulfate, thiosulfite, hydrosulfite, alkyl phosphine, aryl phosphine, alkyl phosphine oxide, aryl phosphine oxide, alkyl aryl phosphine oxide, alkyl phosphine sulfide, aryl phosphine sulfide, alkyl aryl phosphine sulfide, alkyl phosphonic acid, aryl phosphonic acid, alkyl phosphinic acid, aryl phosphinic acid, alkyl phosphinous acid, aryl phosphinous acid, phosphate, thiophosphate, phosphite, pyrophosphite, triphosphate, hydrogen phosphate, dihydrogen phosphate, alkyl guanidino, aryl guanidino, alkyl aryl guanidino, alkyl carbamate, aryl carbamate, alkyl aryl carbamate, alkyl thiocarbamate, aryl thiocarbamate, alkylaryl thiocarbamate, alkyl dithiocarbamate, aryl dithiocarbamate, alkylaryl dithiocarbamate, bicarbonate, carbonate, perchlorate, chlorate, chlorite, hypochlorite, perbromate, bromate, bromite, hypobromite, tetrahalomanganate, tetrafluoroborate, hexafluoroantimonate, hypophosphite, iodate, periodate, metaborate, tetraaryl borate, tetra alkyl borate, tartrate, salicylate, succinate, citrate, ascorbate, saccharinate, amino acid, hydroxamic acid, thiotosylate, and anions of ion exchange resins, or the corresponding anions thereof;
or X, Y and Z are independently selected from the group consisting of charge-neutralizing anions which are derived from any monodentate or polydentate coordinating ligand and a ligand system and the corresponding anion thereof;
or X, Y and Z are independently attached to one or more of R1, R2, R′2, R3, R4, R5, R′5, R6, R′6, R7, R8, R9, R′9, and R10;
and n is an integer from 0 to 3.

2. A method in accordance with claim 1, wherein R1, R2, R′2, R3, R4, R5, R′5, R6, R′6, R7, R8, R9, R′9, and R10 are each hydrogen.

3. A method in accordance with claim 1, wherein the pentaaza macrocyclic ring complex is a compound represented by the formula:

4. A method in accordance with claim 1, wherein the mammal is a human patient.

5. A method in accordance with claim 1, wherein the pentaaza macrocyclic ring complex is administered on the day before or the day of, but prior to the radiation dose.

6. A method in accordance with claim 1, wherein the pentaaza macrocyclic ring complex is administered at least 30 minutes prior to the radiation dose.

7. A method in accordance with claim 3, wherein the pentaaza macrocyclic ring complex is administered on the day before or the day of, but prior to the radiation dose.

8. A method in accordance with claim 3, wherein the pentaaza macrocyclic ring complex is administered at least 30 minutes prior to the radiation-dose.

9. A method in accordance with claim 1, wherein the cancer treatment further comprises a chemotherapy treatment.