# Patent

## Title
Method for treating insulin resistance, abdominal obesity, hypertension, hyperinsulinemia, and elevated blood lipids with a cortisol inhibitor

## Abstract

The invention concerns the use of ketoconazole and derivatives having a corresponding biological activity, and combinations thereof, in the treatment of abdominal obesity, hypertension, hyperinsulinemia, and elevated blood lipids.

## Background
RELATED APPLICATIONS
This application is divisional of application Ser. No. 10/654,809, filed Sep. 4, 2003, which is a division of 09/712,472, filed Nov. 14, 2000, now U.S. Pat. No. 6,642,236, which is a division of application Ser. No. 09/211,282, filed Dec. 14, 1998, now U.S. Pat. No. 6,166,017, which is a continuation of application Ser. No. 08/776,983, filed Feb. 6, 1997, now U.S. Pat. No. 5,849,740, and a continuation of PCT/SE94/00729, filed Aug. 9, 1994, the disclosures of which are incorporated herein by reference.


The present invention relates to the use of ketoconazole or molecules resembling ketoconazole but with some side-chains, not affecting the biological activity compared to ketoconazole, changed for manufacturing drugs for treatment of diabetes mellitus type II.
The drug ketoconazole (e.g., under the FungoralTM brand) is a well-documented drug for treatment of fungal infections. The process of making ketoconazole is well known and described. In this invention FungoraTM capsules aimed at oral administration should be used. This means that FungoralTM should be administered the same way (oral) and in the same composition that is already well-known on the market for treatment of fungal infections the oral route. Therefor it is not considered necessary to further describe the process of making FungoralTM. For the same reason it is not considered necessary to give a full, clear, concise and exact term of this drug, since it is already well known for persons skilled in the art of medicine.
The drug comprising ketoconazole (e.g., under the FungoralTM brand) and chemically closely related substances, the mode of operation of which is to influence the normal cortisol synthesis in the adrenal glands in such a way that the production of biologically perfectly acting cortisol is partly inhibited, is intended to be used for medical treatment of diabetes mellitus type II in men and women as well as for counter-acting the risk factors which are parts of the Metabolic Syndrome (also known as “the deadly quartet” or “Syndrome X” or the “Insulin Resistance Syndrome”), which is characterised by an accumulation of risk factors for cardiovascular disease, stroke and diabetes mellitus type II, i.e. insulin resistance, hyperinsulinemia, abdominal obesity, (caused by an accumulation of intra-abdominal fat), elevated serum lipids, and raised blood pressure, as well as reducing the risk of development of these diseases.
In this new invention ketoconazole shall be administered the oral route in doses of 100-800 mg daily. The drug can be administered once or several times daily. At present a dose of 400 mg administered in the evening has been proven to be the best mode. However, we also claim that administration at other points of time, and in other doses (100-800 mg) can be equally effective.
Since ketoconazole is also inhibiting the normal production of testosterone in men, it is possible that this sex needs a certain amount of testosterone supplementation when treated with ketoconazole, to have an optimal effect of the treatment.
We have investigated a group of people with diabetes mellitus type II. They have been treated with ketoconazole during 2 and 6 weeks, respectively. Investigations before and after treatment have shown a decrease in blood glucose measured either in the fasting state or at 2 hours after an intravenous glucose infusion, and most important, a remarkable improvement of insulin sensitivity. More exact data from these studies are given in the tests described below. Since a decreased insulin sensitivity is a central part of “The metabolic syndrome”, also known as “The deadly quartet”, “Syndrome X” or the “Insulin Resistance Syndrome” we also claim that fungoral treatment to people with risk factors according to this syndrome should be expected to be effective also for treatment of these specific risk factors (abdominal obesity, hypertension, elevated blood lipids) as well as for decreasing the risk for diseases caused by these risk factors (Cardiovascular disease such as coronary artery disease, other arteriosclerotic manifestations including stroke).
The mechanism of the action of ketoconazole is that the substance influence the cortisol synthesis of the adrenal glands in such a way that a sub-fraction of a biologically non-perfect substance similar to cortisol, so called “crippled cortisol”, is formed instead of the normal cortisol molecule.
The cortisol antagonistic effect of the drug is considered to have a central importance for the positive effects on the risk factors mentioned above, decreasing the metabolic activity of fat inside the abdominal cavity, which in turn leads to a decreased fat infiltration of the liver, improving the glucose homeostasis over the liver and peripherally in the tissues in turn leading to improvement of diabetes mellitus type II (decreasing blood glucose and increasing insulin sensitivity), reducing the serum lipids through improvement of the regulating mechanisms in the liver and also inhibiting cholesterol synthesis by a direct effect on the adrenal glands. A positive effect on the blood pressure can also be expected via the cortisol-antagonistic effect.


The scientific basis for these effects can be explained by an inhibition of the physiologically increased cortisol secretion rate that is known to be present under the conditions described above. (The metabolic syndrome and its synonyms described above). This increased cortisol secretion can per se explain all the parts of the syndrome described including the development of diabetes mellitus type II. The scientific explanation for the beneficial effects of ketoconazole on the treatment of diabetes mellitus type II is its effects of decreasing the secretion of biologically active cortisol.
The basic substance is ketoconazole in the chemical form which is known and well documented in the literature. This substance can be further chemically modified while maintaining the same biological effects by exchange of different molecular side chains. These substances similar to ketoconazole can then be expected to have similar and/or better effects on the cortisol inhibiting mechanism, which is described above.
A positive effect on the treatment of patients with diabetes mellitus type II with ketoconazole has been shown in that after the administration of ketoconazole a reduction of the insulin insensitivity (resistance), which is often associated with this disease, has been measured. This has been measured as an improved (i.e., reduced) insulin resistance measured with a so called euglychemic glucose clamp method. Thus, the examined patients have improved with regard to their diabetes, measured in the above described way, which in parallell also have resulted in lower blood glucose after treatment compared to before treatment.
The category of patients, that would have an especially good use of ketoconazole are patients with diabetes mellitus type II with insulin insensitivity and despite treatment with usual anti-diabetic drugs and/or insulin still have remaining elevated glucose values in the blood in fasting condition as well as after a meal. The investigated patients had decreased insulin sensitivity compared to healthy persons, measured by euglychemic glucose clamp. Supply of ketoconazole to this category of patients has been shown to have a positive and specific effect on the insulin insensitivity in such a way that their diabetes mellitus type II was improved. This was measured as improved insulin sensitivity and lower blood glucose.
Other positive effects have also been detected among these patients: Reduced cholesterol levels in the plasma as well as decreasing blood pressure values.
Results of Clinical tests of women with diabetes mellitus type II, treated with ketoconazole.
Group 1 consists of 3 patients (mean age: 46 years) treated with ketoconazole for 2 weeks, administered orally 22:00 in the evening in the dose of 400 mg.
Group 2 consists of 5 patients (mean age: 51 years) treated with ketoconazole for 6 weeks, administered orally 22:00 in the evening in the dose of 400 mg. Results are expressed as mean values within groups.














Group 1
Group 2












Before
After
Before
After


Variables studied
t.
t.
t.
t.














Fasting blood glucose (mmol/L)
10.20
8.77
7.20
7.10


Blood glucose
9.73
7.90
6.48
5.76


(mmol/L) 2 hours after start


of an i.v. glucose in-fusion


GIR (glucose infusion rate
0.9
1.85
2.97
4.32


during euglycemic glucose


clamp expressed as mg


glucose per minute divided


by lean body mass), indicating


insulin sensitivity


Fasting serum total cholesterol
5.80
5.67
4.80
4.10


(mmol/L)


Systolic blood pressure (mm Hg)
140
135
125
123


measured after 5 min. in supine


position.


2 measurements averaged


Diastolic blood pressure (mm Hg)
70
70
75
72


measured after 5 min. in supine


position.


2 measurements averaged


Serum-ASAT (μkat/L)
0.36
0.33
0.26
0.25


Serum-ALAT (μkat/L)
0.61
0.52
0.40
0.37









The foregoing description is meant to be illustrative and not limiting. Various changes, modifications, and additions may become apparent to the skilled artisan upon a perusal of this specification, and such are meant to be within the scope and spirit of the invention as defined by the claims.

## Claims

1. A method for treating a patient, comprising:
identifying a patient with metabolic syndrome, wherein said metabolic syndrome is characterized by a presence of the combination of insulin resistance, hyperinsulinemia, abdominal obesity, elevated serum lipids, and raised blood pressure; and
administering to the patient for at least two weeks an amount of ketoconazole effective to treat metabolic syndrome in the patient by reducing the presence of at least one of said characteristics of metabolic syndrome.

2. A method for treating a patient, comprising:
identifying a patient with metabolic syndrome, wherein said metabolic syndrome consists essentially of the combination of insulin resistance, hyperinsulinemia, abdominal obesity, elevated serum lipids, and raised blood pressure; and
administering to the patient for a duration of at least two weeks an amount of ketoconazole effective for decreasing insulin resistance in the patient.

3. A method for treating a patient, comprising:
identifying a patient having hyperinsulinemia, wherein said hyperinsulinemia is due to type II diabetes mellitus; and
administering to the patient for a duration of at least two weeks an amount of ketoconazole effective to decrease said hyperinsulinemia and thereby treat type II diabetes mellitus in the patient.

4. A method for treating a human patient, comprising:
identifying a human patient having an increased insulin resistance;

identifying that the increased insulin resistance is part of a disorder that consists of type II diabetes mellitus; and
administering to the human patient for a duration of at least two weeks an amount of ketoconazole effective to decrease insulin resistance.

5. A method for treating a human patient, comprising:
identifying a human patient having increased insulin resistance;
identifying that the increased insulin resistance is part of a disorder that consists of metabolic syndrome; and
administering to the human patient for a duration of at least two weeks an amount of ketoconazole effective to decrease insulin resistance.

6. A method for treating a patient, comprising:
identifying a patient having a hyperinsulinemia disorder that is part of a metabolic syndrome; and
administering to the patient for a duration of at least two weeks an amount of ketoconazole effective to decrease hyperinsulinemia, thereby treating hyperinsulinemia in the patient.

7. A method for treating a patient, comprising:
identifying a patient having type II diabetes mellitus;
determining that an insulin treatment of said patient does not result in lowering an elevated level of blood glucose in the patient; and
administering to the patient for a duration of at least two weeks an amount of ketoconazole effective to decrease insulin resistance in the patient, thereby treating the type II diabetes.

8. A method for treating a patient, comprising:
identifying a patient having insulin resistance, wherein said insulin resistance is attributed to a disorder consisting of type II diabetes mellitus; and
administering to the patient for a duration of at least two weeks a composition, wherein said composition comprises a single treatment for type II diabetes mellitus, wherein said treatment essentially consists of an amount of ketoconazole effective to decrease insulin resistance.

9. The method of claim 1, wherein the daily dose of ketoconazole effective to reduce the presence of at least one of said characteristics is an amount between about 100 mg and about 800 mg.

10. The method of claim 9, wherein about 400 mg of ketoconazole is administered to the patient in the evening.

11. The method of claim 1, wherein the patient is a male and said method further comprises providing testosterone and administering the testosterone in an amount effective to reduce any decrease in the patient's testosterone caused by administration of ketoconazole.

12. The method of claim 2, wherein the daily dose of ketoconazole effective to decrease insulin resistance is an amount between about 100 mg and about 800 mg.

13. The method of claim 12, wherein about 400 mg of ketoconazole is administered to the patient in the evening.

14. The method of claim 2, wherein the patient is a male and said method further comprises providing testosterone and administering the testosterone in an amount effective to reduce any decrease in the patient's testosterone caused by administration of ketoconazole.

15. The method of claim 3, wherein the daily dose of ketoconazole effective to decrease hyperinsulinemia is an amount between about 100 mg and about 800 mg.

16. The method of claim 15, wherein about 400 mg of ketoconazole is administered to the patient in the evening.

17. The method of claim 3, wherein the patient is a male and said method further comprises providing testosterone and administering the testosterone in an amount effective to reduce any decrease in the patient's testosterone caused by administration of ketoconazole.

18. The method of claim 4, wherein the daily dose of ketoconazole effective to decrease insulin resistance is an amount between about 100 mg and about 800 mg.

19. The method of claim 18, wherein about 400 mg of ketoconazole is administered to the patient in the evening.

20. The method of claim 4, wherein the patient is a male and said method further comprises providing testosterone and administering the testosterone in an amount effective to reduce any decrease in the patient's testosterone caused by administration of ketoconazole.

21. The method of claim 5, wherein the daily dose of ketoconazole effective to decrease insulin resistance is an amount between about 100 mg and about 800 mg.

22. The method of claim 21, wherein about 400 mg of ketoconazole is administered to the patient in the evening.

23. The method of claim 5, wherein the patient is a male and said method further comprises providing testosterone and administering the testosterone in an amount effective to reduce any decrease in the patient's testosterone caused by administration of ketoconazole.

24. The method of claim 6, wherein the daily dose of ketoconazole effective to decrease hyperinsulinemia is an amount between about 100 mg and about 800 mg.

25. The method of claim 24, wherein about 400 mg of ketoconazole is administered to the patient in the evening.

26. The method of claim 6, wherein the patient is a male and said method further comprises providing testosterone and administering the testosterone in an amount effective to reduce any decrease in the patient's testosterone caused by administration of ketoconazole.

27. The method of claim 7, wherein the daily dose of ketoconazole effective to decrease insulin resistance is an amount between about 100 mg and about 800 mg.

28. The method of claim 27, wherein about 400 mg of ketoconazole is administered to the patient in the evening.

29. The method of claim 7, wherein the patient is a male and said method further comprises providing testosterone and administering the testosterone in an amount effective to reduce any decrease in the patient's testosterone caused by administration of ketoconazole.

30. The method of claim 8, wherein the daily dose of ketoconazole effective to decrease insulin resistance is an amount between about 100 mg and about 800 mg.

31. The method of claim 30, wherein about 400 mg of ketoconazole is administered to the patient in the evening.

32. The method of claim 8, wherein the patient is a male and said method further comprises providing testosterone and administering the testosterone in an amount effective to reduce any decrease in the patient's testosterone caused by administration of ketoconazole.

33. The method of claim 1, wherein the duration is at least six weeks.

34. The method of claim 2, wherein the duration is at least six weeks.

35. The method of claim 3, wherein the duration is at least six weeks.

36. The method of claim 4, wherein the duration is at least six weeks.

37. The method of claim 5, wherein the duration is at least six weeks.

38. The method of claim 6, wherein the duration is at least six weeks.

39. The method of claim 7, wherein the duration is at least six weeks.

40. The method of claim 8, wherein the duration is at least six weeks.