# Patent

## Title
Method of treating the syndrome of lipodystrophy

## Abstract

Methods of treating a human suffering from the Syndrome of Lipodystrophy or one or more HIV-related abnormalities included therein are provided. One method may include administering, by a pharmaceutically effective mode, a drug composition comprising an opioidergic agent, or alternatively, an opioidergic agent and an insulin secretagogue. The method may also include administering, by a pharmaceutically effective mode, a drug composition comprising an opiate agonist and opiate antagonist, or alternatively, an opiate agonist, opiate antagonist and an insulin secretagogue.

## Background
CROSS-REFERENCE TO RELATED APPLICATIONS
This application is a continuation-in-part of U.S. patent application Ser. No. 09/878,834 filed on Jun. 11, 2001, now U.S. Pat. No. 6,528,520, which is a continuation-in-part of and claims priority to U.S. application Ser. No. 09/639,061 filed on Aug. 15, 2000, which issued as U.S. Pat. No. 6,262,062. This application claims the benefit of priority of U.S. Pat. application Ser. No. 09/878,834 filed on Jun. 11, 2001; U.S. Pat. No. 6,262,062 to which the 09/878,834 application claims priority; U.S. patent application Ser. No. 09/878,751 filed on Jun. 11, 2001; and U.S. patent application Ser. No. 09/638,930 filed on Aug. 15, 2000. Accordingly, the subject matter of each of these patent applications and patents is hereby fully incorporated by reference.


BACKGROUND OF THE INVENTION
Coronary Heart Disease Risk Factors (CHDRFs) are major causes of death in the industrialized world. CHD risk factors include Type 2 Diabetes (and its precursor, Impaired Glucose Tolerance (IGT)), hyperlipidemia or dyslipidemia, overweight, obesity and essential hypertension, i.e., a form of hypertension that occurs without a discoverable organic cause. The CHDRF syndrome may, therefore, be defined as a group of interrelated disorders: Type 2 Diabetes, IGT, Dyslipidemia, Overweight, Obesity and essential hypertension. It has also become apparent that Type 2 Diabetes, by itself, represents a syndrome of various, in part sequential, disease states which interact with other components of the CHDRF syndrome. However, the exact interrelationships between the disease states that make up these syndromes are not fully understood. A wide variety of chemical and physical abnormalities associated with these syndromes exist. They include elevations in fasting blood glucose and gluconeogenesis in spite of significant increases in fasting insulin and C-peptide concentrations and increases in lipogenesis. Typically associated with lipogenesis are increases in levels of fasting Free Fatty Acid (FFA), fasting triglycerides (TG) and total cholesterol concentrations, increases in levels of fasting Low Density Lipoprotein (LDL)-cholesterol, decreases in levels of fasting High Density Lipoprotein (HDL)-cholesterol, an increased LDL/HDL ratio, increases in body weight and increases in systolic and diastolic blood pressure.
Although these syndromes are interrelated and typically result from derangements in nutrient metabolism, all the associated symptoms may not be present in individual patients. Accordingly, in some patients lipid metabolism problems may predominate, while in others, carbohydrate metabolism problems may be predominant. While these factors, which lend one aspect of the syndrome to dominate over another, are not well understood, it is clear that each portion of the syndrome, or combinations of portions of the syndrome, represents risk factors in coronary heart disease.
Insulin Resistance/Beta-Cell Dysfunction/Type 2 Diabetes/CHDRF Syndrome
Common denominators in the etiology of the syndromes of Type 2 Diabetes and the CHDRFs appear to be Insulin Resistance (IR) and Beta-Cell Dysfunction. IR is characterized as a state in which a normal amount of insulin produces a subnormal biological response in carbohydrate metabolism. This may be the case for subjects afflicted with the non-insulin-dependent diabetes form of Type 2 Diabetes, in pre-diabetic subjects affected by Impaired Fasting Glucose (IFG) or Impaired Glucose Tolerance (IGT), and in overweight and obese subjects. These subjects require (and endogenously produce) higher than normal levels of insulin to compensate for their insulin resistance and Beta-Cell Dysfunction to normalize their blood glucose levels. Traditionally, IR has been expressed as the insulin/glucose ratio (I/G). More recently, several more complex models have been proposed to define Insulin Resistance or the Insulin Sensitivity Index. Only recently have other biological functions of insulin become the focus of more intense scientific interest, e.g. the role of insulin in endogenous lipogenesis. Although an interaction between insulin resistance and the CHDRF components has been established, the cause and effect relationship between insulin resistance, obesity, dyslipidemia and IGT/Type 2 Diabetes is still subject to debate. IR increases FFA and Triglyceride (TG) levels, which further contribute to IR, thereby creating a vicious circle. Therapeutic modalities for lowering any one of the lipid fractions in dyslipidemia have not proven capable of correcting the entire hyperlipidemic complex with a single therapeutic agent.
Compared to Type 1 juvenile) Diabetes, the Type 2 Diabetes syndrome, particularly its non-insulin-dependent mellitus (NIDDM) forms, is characterized by relatively inadequate endogenous insulin concentrations. However, insulin concentrations in Type 2 diabetics may, in fact, be higher than in the normal population. A possible explanation for this apparent discrepancy is that Type 2 diabetics, as well as subjects afflicted with IFG, IGT, Overweight or Obesity typically require more insulin to control their blood sugar levels. Temporary increases in certain diabetogenic mediators, such as glucagon, growth hormones and catecholamines may initially cause the requirement for more insulin. These mediators communicate their specific control functions as agonists to target tissue or cells through compatible cell bound receptors. Continued, long-term agonist load eventually leads to ‘down-regulation’ of such receptors, i.e. the receptor response and/or sensitivity are decreased. Depending on the agonist involved, this mechanism can lead to tolerance or addiction. As a result, increasing doses are required to achieve the same effect. Antagonists have equivalent receptor specificity as their agonist counterparts, but do not convey any agonist-type control message. In contrast to agonists, prolonged exposure of such receptors to their specific antagonists can restore receptor response or sensitivity, a process called receptor ‘up-regulation’.
As long as any agonists load by mediators, such as hormones, neuro-transmitters or neuro-modulators prevails for infrequent, short durations, the respective receptors for such mediators can ‘up-regulate’ between such temporary agonist loads. In other words, the receptors can resume their normal sensitivity between ‘receptor-ligand’ interactions. The early stage of IR may be characterized by temporary increases in diabetogenic mediators such as catecholamines, endogenous opiates, cortisol and/or glucagon.
Another early pathophysiologic indicator of the emergence of the CHDRF Syndrome is a condition called Beta-Cell Dysfunction. Non-diabetics experience a bi-phasic insulin response to an oral glucose challenge, i.e. an acute, first phase governed by a rise in blood glucose, and second, proportional phase characterized by a more sustained insulin release, following, in a quasi proportional manner, the post-prandial glucose excursion. Overweight and IGT subjects already have a significantly reduced first phase insulin release, which virtually disappears altogether once the subject becomes obese and or diabetic. This condition exaggerates the Insulin Resistance related hyperglycemia and hyperinsulinemia and accelerates the severity of the CHDRF Syndrome.
The impairment or loss of first phase insulin secretion is the primary defect in BetaCell Dysfunction
A pharmacologic restoration of the vitally important first phase insulin release has, to this date, been an elusive scientific undertaking.
Resistance to the action of insulin in the control of glucose may not carry over to the action of insulin on lipogenesis. Even though the individual is resistant to the action of insulin in controlling glucose, the response of lipid metabolism to insulin may remain at the normal level. As temporary agonist ‘loads’ become more frequent or sustained, the affected receptors will down-regulate. As a result, IR may become a permanent metabolic burden and, with additional diabetogenic factors, such as cortisol, may accelerate progressive increases in hepatic gluconeogenesis (GNG) and glucose production (GP). The IR dependent insulin excess in the face of hyper-gluconeogenesis caused hyperglycemia then becomes a blueprint for hyper- or dyslipidemia, overweight and obesity. Gradually, the β-cells' secretory capacity to produce and secrete insulin will diminish, resulting in a slow but steady rise in fasting glucose levels until, eventually, such secretory capacity will be exhausted, at which time the subject becomes ‘insulin dependent’, i.e. dependent on exogenous insulin injections.
Dyslipidemia
Dyslipidemia is characterized by any of the following, and combinations thereof: elevated levels of total and LDL-cholesterol, elevated levels of TG, a high LDL/HDL ratio and elevated levels of FFA and low levels of HDL-cholesterol. Lipid metabolism is rather complex. While it is clear that dyslipidemia is associated with the development of coronary heart disease, there is no clear understanding of the pathogenic causes and pathways leading up to the manifestation of the various lipid disorders. The relative roles of lipid ingestion versus endogenous lipogenesis in the etiology of lipid abnormalities have not been fully understood.
Overweight/Obesity
Obesity is a disease of major proportions and severe economic consequences. No longer is obesity considered merely a physical or cosmetic inconvenience. Obesity is second only to cigarette smoking as a preventable cause of premature death, and its complications add in excess of $100 billion to U.S. health care costs. Obesity can not be treated effectively by willpower alone, and currently available pharmaceutical drugs are only marginally effective. Moreover, several obesity drugs have recently been withdrawn from the market because of their risk of potentially fatal side-effects, e.g. pulmonary hypertension or heart defects in connection with dexfenfluramine, fenfluramine or phentermine.
Six out of ten people (approximately 130 million) in the United States are overweight, close to 90 million are clinically obese and 22 million are morbidly obese.
The definitions of obesity and overweight are somewhat arbitrary. The symptoms of overweight or obesity are characterized by excessive body fat, i.e. the body contains a level of fat beyond that considered normal. Body weight in relationship to height and build is used as a surrogate measure of obesity and overweight. Being 20% over the standard height weight tables is considered obese. The body mass index (BMI) is commonly used in defining normal weight. The BMI is calculated by dividing a subject weight in kilograms by the square of height in meters (kg/m2) or (lbs.×705/inches2). A BMI of 25 is considered normal, a BMI of 26-29 is considered overweight, a BMI of 30-40 is obese, and a BMI>40 is considered morbid. A therapeutic intervention is considered effective if it produces a weight reduction of >10%, or a reduction by >5% if ‘co-morbid’ factors are also improved, e.g. any of the blood analyte concentrations related to IGT, Type 2 Diabetes or dyslipidemia.
Despite the recognized interaction between the various CHD risk factors, the pharmaceutical modalities currently available to treat the symptoms of Type 2 Diabetes generally have had no beneficial effect on hyper- or dyslipidemia; in fact, some of the medicines widely used to treat Type 2 Diabetes, e.g. sulfonylureas, tend to increase hyperlipidemia and may, therefore, further contribute to overweight and obesity, thereby increasing the CHD risk. Conversely, medicines presently available to treat various forms of hyper- or dyslipidemia have little or no impact on IFG, IGT, Type 2 Diabetes, overweight or obesity.
Moreover, no single pharmaceutical agent has been able to treat and correct the entire complex of hyper- or dyslipidemia. Drugs such as clofibrate/gemfibrozil can lower TG levels, but have little or no effect on FFA levels, and no effect on total cholesterol levels. Other drugs may shift the proportion of cholesterol found in the form of low and high density lipoprotein cholesterol. For example, certain drugs may actually increase already elevated levels of low density lipoprotein cholesterol. On the other hand, drugs like lovastatin lower the levels of both total and low density lipoprotein cholesterol, while only slightly increasing the level of high density lipoprotein cholesterol. However, these drugs have no effect on FFA and little or no effect on TG levels.
As a result, it is desirable to provide an improved method for treating the syndrome of coronary heart disease risk factors. A new method for treating the early morning rise in hepatic gluconeogenesis and endogenous glucose production is also desired. In other words, an improved method of treatment is desired that lowers high glucose levels resulting from rises in gluconeogenesis and glucose production, and impaired insulin secretion in patients afflicted with CHD risk factors in humans. A new method is also desired wherein the administration of a drug composition does not require a priming dose.
Lipodystrophy
Congenital lipodystrophy is an uncommon disorder characterized by defective lipid metabolism, accompanied by loss of subcutaneous and/or redistribution of body fat. A novel, acquired form of this disorder is now commonly encountered in up to 80% of HIV-infected patients in general, and particularly those receiving the Highly Active Antiretroviral Therapy (HAART). The introduction of HAART with protease inhibitors and nucleoside reverse transcriptase inhibitors has converted the high mortality Acquired Immuno Deficiency Syndrome (AIDS) to the chronic, high morbidity acquired Lipodystrophy Syndrome (LS). This acquired form of Lipodystrophy (LS) is now recognized not only by its changes in body habitus as a result of fat redistribution, but also as a heterogeneous combination of additional abnormalities, including disturbances in lipid and carbohydrate metabolism. As a result, the suspected pathophysiologic cause and effect relationships, as well as the therapeutic consequences are becoming even more complex.
Lipodystrophy Syndrome and Atherogenic Dyslipidemia
Atherogenic dyslipidemia (AD) is a central defect of the lipodystrophy syndrome, LS, and an independent coronary heart disease risk factor. It is also associated with, and contributing to the pathogenesis of any of the conditions included in this syndrome, including, but not limited to hypertriglyceridemia (HTG), insulin resistance (IR), impaired glucose tolerance (IGT) and type 2 diabetes mellitus (DM-2). Because of the central role of AD in the progression of the metabolic abnormalities associated with LS, an effective treatment of the LS related form of AD will be of utmost importance. Data for the HIV-uninfected population suggest LS may further include high levels of total cholesterol, low-density-lipoprotein (LDL) cholesterol and triglycerides, and low levels of high-density-lipoprotein (HDL) cholesterol. Because of these established risks, the National Cholesterol Education Program (NCEP) has issued guidelines for the treatment of AD for (non-HIV-infected) patients at risk.
There have been theories as to why lipid abnormalities occur in the HIV-infected population, but these have yet to be verified, and the unknown pathogenesis of dyslipidemia in HIV-infected patients may make them, for a variety of reasons, refractory to traditional pharmacotherapy of atherogenic dyslipidemia. Furthermore, NCEP's emphasis on diet and exercise is unrealistic for many HIV-infected subjects who are struggling to maintain their body weight. This dilemma is further aggravated by the fact that currently available drugs, including bile acid resins, statins, niacin and fibric acid derivatives, to treat hyper- or dyslipidemia pose significant safety risks in HIV-infected patients, particularly those receiving HAART, due to the known incompatibility of these drugs with HAART components, and because of their enhanced liver toxicity in HIV-infected patients, who are already afflicted by severely impaired liver function.
SUMMARY OF THE INVENTION
The present invention provides improved methods of treating a human suffering from one or more conditions included within the Coronary Heart Disease Risk Factor (CHDRF) syndrome. The invention provides a method including administering, by a pharmaceutically effective mode, a drug composition comprising an opioidergic agent (e.g. on opiate antagonist, an opiate having μ-agonist activity, or a combination thereof) and an insulin secretagogue.
The invention further provides a method of treating a human suffering from one or more conditions included within the Coronary Heart Disease Risk Factor (CHDRF) syndrome by administering, by a pharmaceutically effective mode, a drug composition comprising an opiate antagonist and an insulin secretagogue.
The invention further provides a method of treating a human suffering from one or more conditions included within the Coronary Heart Disease Risk Factor (CHDRF) syndrome by administering, by a pharmaceutically effective mode, a drug composition comprising an opiate agonist and an insulin secretagogue.
The invention further provides a method of treating a human suffering from the Syndrome of Lipodystrophy or one or more HIV-related abnormalities included therein. The method includes administering, by a pharmaceutically effective mode, a drug composition comprising an opioidergic composition. The opioidergic composition may include at least one of an opiate antagonist, opiate agonist and a combination thereof.
In another aspect, the invention provides a method of treating a human suffering from the Syndrome of Lipodystrophy or one or more HIV-related abnormalities included therein. The method includes administering, by a pharmaceutically effective mode, a drug composition comprising an opioidergic composition and at least one insulin secretagogue. The opioidergic composition may include at least one of an opiate antagonist, opiate agonist and a combination thereof. A wide variety of insulin secretagogues are available for administration.
In yet another aspect, the invention provides a method of treating a human suffering from the Syndrome of Lipodystrophy or one or more HIV-related abnormalities included therein. The method comprises administering, by a pharmaceutically effective mode, a drug composition comprising at least one opiate agonist; and at least one opiate antagonist. The drug composition may further include at least one insulin secretagogue.
Before embodiments of the invention are explained in detail, it is to be understood that the invention is not limited in its application to the details of the compositions and concentrations of components set forth in the following description. The invention is capable of other embodiments and of being practiced or being carried out in various ways. Also, it is understood that the phraseology and terminology used herein is for the purpose of description and should not be regarded as limiting.
The patents, references and articles cited herein are hereby fully incorporated by reference. In the case of conflict between the present disclosure and the incorporated patents, references and articles, the present disclosure should control.



BRIEF DESCRIPTION OF DRAWING
FIG. 1 is a graph showing the daily blood glucose profile of a 72-year subject afflicted with Type 2 Diabetes and dyslipidemia after treatments with an opioidergic drug composition in combination with an insulin secretagogue. The blood glucose (BG) of the subject was measured in mg/dL over several time intervals measured in hours (h).



DETAILED DESCRIPTION OF THE INVENTION
As used herein, the term “insulin secretagogue” is meant to refer to any drug composition which stimulates, participates in the stimulation of, or potentiates, the secretion of insulin by the pancreatic Beta-Cells. Insulin secretagogues include insulinotropic agents and insulin secretion or release potentiators. Examples are provided below.
As used herein, the terms “opioids,” “opioid agonists,” “opiate agonists,” “opiates having agonist activity” and “agonists” are meant to refer to opioid-like substances, natural or synthetic, that bind to centrally and/or peripherally located opioid receptors to produce an agonist action.
As used herein, the terms “μ”, “δ” and “κ” refer to the specific types of opiate or opioid receptors of cells such as brain, spinal cord, pancreas and large intestine.
As used herein, the terms “opiates having μ-agonist activity,” “opioids having μ-agonist activity” and “μ-agonists” are meant to refer to opioid-like substances, natural or synthetic, that bind to the μ opiate receptor to produce an agonist action.
As used herein, the terms “opiates having agonist activity” and “agonists” are meant to refer to substances, natural or synthetic, that bind to the opioid receptor to produce an agonist action.
As used herein, the terms “opioid antagonists,” “opiate antagonists,” “anti-opioids,” “antiopiates,” “opiates having antagonist activity” and “antagonists” are meant to refer to opioid-like substances that bind to opioid receptors, but produce little or no agonist activity.
As used herein, the terms “opiates having κ antagonist activity,” “opioids having κ antagonist activity” and “κ antagonists” are meant to refer to opioid-like substances that bind to the κ opioid receptor, but produce little or no agonist activity.
As used herein, the terms “opioidergic agent,” “opiodergic composition” and “opioidergic drug composition” are meant to refer to any of the above opioid-like substances as well as combinations thereof.
“Pharmaceutically effective modes” are meant to include, but not be limited to, the application of a drug composition as a solution in an innocuous pharmaceutically acceptable solvent, as an emulsion, as a suspension, as a dispersion in suitable carriers, as a patch or in the form of pills, or capsules with solid, liquid or gel carriers, and other such methods well-known in the art. The formulations of this invention may include pharmaceutically acceptable excipients such as stabilizers, anti-oxidants, binders, coloring agents, emulsifiers, and other such excipients well-known in the art. The drugs and drug compositions comprising the agonists and antagonists described above and below, may be administered in any pharmaceutically effective mode.
Opiate antagonists are molecular structures similar to opiates but do not have appreciable direct agonist activity. Antagonists have the ability to reduce or prevent the receptor binding of opiate agonists, thus neutralizing their biologic effect. Anti-opioids, or narcotic antagonists, are characterized by their ability to displace narcotic agonists from the respective receptors. Since most narcotics possess several agonist actions, e.g. μ, δ, and κ, anti-opioids may possess antagonist capabilities for those (and other) receptors as well. In general, the antagonist activity, or effectiveness of anti-opioids is not equal at the various receptor sites and may vary significantly, often times by more than an order of magnitude. For example, the μ receptor binding effectiveness for naltrexone may be 12 times higher than its effectiveness to bind to a κ receptor, which may result in a 12-fold increase of agonist displacement at the μ receptor over the κ receptor. Since the μ receptor is known to control (amongst others) euphoria, a suppression of this action 12-fold over any action controlled by κ, e.g. for various metabolic functions, can actually result in disphoria, if the antiopioid dosage has to be increased sufficiently to achieve the desired effect at the κ site.
The pharmnacologic effect of opioids on their respective receptors is a complex process and depends on several factors, including, but not limited to, the binding characteristics of opioidergic agents, i.e. opiate agonist, or antagonist, respectively, and the binding characteristics of the target cells. The pharmacologic effect of any opioidergic agent may, therefore, vary with target cells, and between corresponding cells in different species. The IC50 measurement system can be used to compare the receptor binding characteristics of different opioidergic agents to a reference cell type.
IC50 is defined as the concentration of a compound at which 50% of the standard molecule is displaced from the target receptor. For each receptor there is a prototype ligand. To measure the IC50 for a given anti-opioid, one measures the concentration of the anti-opioid which will drive 50% of the prototype ligand from the target receptor. For the μ receptor the prototype ligand is DHM (dihydromorphine). For the δ receptor, the prototype ligand is DADLE (D-Ala+D-Leu-Enkephalin), and for the κ receptor, the prototype ligand is EKC (ethylketocyclazocine).
The receptor binding on μ, δ, and κ opioid receptors for Naloxone, Naltrexone and Nalmefene, as determined in homogenates of rat brain minus cerebellum, are:















μ IC50
δ IC50
κ IC50





















Naloxone
3.8 × 10−9M
2.7 × 10−8M
6.0 × 10−8M



Naltrexone
1.0 × 10−9M
1.0 × 10−8M
1.2 × 10−8M



Nalmefene
1.0 × 10−9M
6.1 × 10−9M
5.3 × 10−9M










There are several types of opiate receptor sites and the opiate antagonists do not, generally, have an equipotent effect on all the different receptor sites. In evaluating opiate antagonists and agonists for use in the treatment of any or all of the CHDRF'S as well as the Syndrome of Liposdystrophy (LS) and the HIV-related abnormalities included therein (discussed in more detail below), their interaction with the μ, δ, and κ opiate receptors is most important. Opiate antagonists, such as naloxone and naltrexone, which exert their greatest effect, by slightly more than an order of magnitude, upon the μ receptors, may be used to treat the CHDRFS or LS, but may have undesirable CNS side effects due to their dominant antagonism at the μ receptor versus the δ, and κ opioid receptors, resulting in a more dominant endogenous κ agonist action. Pharmacologically administered opioid antagonists which have approximately equal effects on the μ, δ, and κ receptors, or resulting in an endogenous opioidergic agonist effect of μ>κ at the respective opioid receptors, are more useful for the treatment of CHDRFS and LS in humans. It has, further, been discovered that a reduced κ opiate action, or an enhanced-agonist action is important in optimizing the opioidergic effect on the CHDRFS or on Lipodystrophy Syndrome. It is, therefore, preferred that the anti-opioids have an effect upon the κ opiate receptor as strong as or stronger than effect upon the μ, and δ opiate receptors. Since a strong inhibitory effect means that the anti-opioid is effective at low concentrations, it is desirable that the anti-opioids have a lower IC50 for the κ opiate receptor than for the μ, and δ opiate receptors.
The relationship between the IC50 levels for the μ, δ, κ opiate receptors may also be expressed in terms of a ratio. For example, if the IC50 level for the μ-opiate receptor is within a factor of 3 of the IC50 level for the δ opiate receptor, then the ratio of the IC50 level for the μ opiate receptor to the IC50 level for the δ opiate receptor may be expressed in the following manner: 1⁄3<(IC50δ/IC50μ)<3. This method of treating LS reduces or avoids any incremental stimulation of the neuro-endocrine stress modulator Cortisol release by endogenous κ opiate agonists. The preferred anti-opioids or anti-opioid combinations for use in the treatment of CHDRFS have a ratio of IC50 for the κ opiate receptor to the IC50 for the μ or δ receptors of 10 or less and most preferably 3 or less. These preferred compositions may be expressed as a ratio of IC50 values: {(IC50κ/IC50 μ)<10}, and {(IC50κ/IC50δ)<10}; and the most preferred compositions have IC50 values: {(IC50κ/IC50μ)<3}, and {(IC50κ/IC50δ)<3}. The preferred anti-opioids or anti-opioid combinations for use in the treatment of LS, such as nalmefene, may be expressed as a ratio of IC50 values: {(IC50κ/IC50μ)<6.0}, and {(IC50κ/IC50 δ)<7.0}; and the most preferred compositions have IC50 values: {(IC50κ/IC50μ)<1.0}, and {(IC50δ/IC50μ)<7.0}. A κ selective opioid antagonist such as nor-binaltorphimine is useful in the treatment of any or all of the conditions which make up the CHDRFS or LS. It may be used alone, or in combination with other anti-opioid or opiodergic drugs. When used as part of a combination drug, it serves to add further inhibition of the κ opioid receptors to the properties of the combination.
An endogenous opioidergic agonist effect of μ>κ can also be enhanced by supplementing a non-selective anti-opioid composition, such as nalmefene, with a μ-agonist or an opioidergic composition with predominant μ-agonist activity. The pharmacologic use of a combination of multiple opioidergic agents generally necessitates a compatibility of the pharmacologically effective half lives of the respective compositions in order to achieve the desired pharmacokinetic effect. Such compatibility may call for a matching of such half lives: it may also involve dissimilar half lives in order to obtain a desired cycling effect.
Prolonged stimulation of receptors, e.g. μ-opioid receptors by μ-opioid agonists, results in a desensitization or down-regulation of the respective receptor. Conversely, such down-regulation can oftentimes be reversed by the administration of respective antagonists.
Metformin hydrochloride is a non-sulfonylurea type antihyperglycemic agent, which improves glucose tolerance in type 2 diabetic subjects, primarily by decreasing hepatic gluconeogenesis and glucose production (Edelman, S. V.: Clinical Diabetes; 16,1:37-40). The major side effects are potential lactic acidosis, and the impact of the required massive therapeutic doses on liver and kidney function. Metfornin is, therefore, contraindicated for patients with hepatic and renal insufficiency, which is aggravated by the fact that a typical daily dose ranges between 1,500 and 2,500 mg.
During the investigations into, and development of, non-addictive morphine based analgesics, typically requiring a combination of agonistic and antagonistic actions at various opiate receptor sites, i.e. μ, δ and κ receptors, a variety of so-called ‘pure’ antagonists have evolved as by-products, and some of these narcotic antagonists, or anti-opioids, have been shown to have potential in the treatment of a variety of disease conditions.
U.S. Pat. No. 4,272,540 discloses various 14-methoxy substituted 3-hydroxy or 3-methoxy-6-one morphinans, which are variously useful as analgesics, narcotic antagonists, and mixed analgesics and narcotic antagonists.
U.S. Pat. No. 4,451,470 discloses 14-fluoromorphinans which are useful as analgesic, narcotic antagonists and/or anorexigenic agents.
U.S. Pat. No. 4,478,840 discloses 17-cycloalkylmethyl-4,-5α-epoxymorphinan-3,14-diol compounds useful for suppression of appetite in mammals.
U.S. Pat. No. 4,619,936 discloses pharmaceutical compositions containing (5α,6α)7,8-didehydro-4,5-epoxy-17-(2-propanyl)-morphinano-3,6-diol for the purpose of appetite reduction.
U.S. Pat. No. 4,882,335 discloses a method useful as an adjunct in the treatment of alcoholism. The method involves having the patient drink alcoholic beverages, while an opiate antagonist blocks the positive reinforcement effects of ethanol in the brain.
U.S. Pat. No. 5,086,058 discloses a method for treating alcoholism. The method involves having the patient drink alcoholic beverages while nalmefene, an opiate antagonist, blocks the positive reinforcement effects of ethanol in the brain.
In order to address the dramatic increases in diabetes, obesity and other CHDRFs, and their effects on patient morbidity/mortality and national health care expenditures, the focus of pharmaceutical research is shifting from post symptomatic stabilization to prevention and intervention. The pathophysiology of the syndrome CHDRFs is a progressive process with changing conditions, as physiologic control functions become strained, exhausted and, eventually, supplemented or replaced by other compensatory mechanisms. Therefore, the different stages in this progression necessitate different interventive measures tailored to retain or restore those functions still viable.
U.S. Pat. No. 5,727,570 discloses a method of treatment of humans suffering from hyperlipidemia by administering a drug composition selected from a group consisting of opiate antagonists and drugs which substantially equally reduce the amount of catecholamines bound to catecholamine binding sites. In a model case study, conducted with a pure anti-opioid, this method was applied during the pre-diabetic stage of IFG combined with IR, and resulted in significant improvements in all carbohydrate and lipid control functions, restoring all relevant Blood Analyte Concentrations (BAC) to normal physiologic levels, with a reduction of FBG to 95 mg/dL.
U.S. Pat. No. 5,878,750 discloses a method of treating humans suffering from the Coronary Heart Disease Risk Factor syndrome by administering a drug composition selected from the group of opiate antagonists or anti-opioids and drugs which substantially equally reduce the amounts of catecholamines bound to all catecholamine binding sites. A model case study involved the administration of a pure opioid antagonist to an overweight subject with early stage Type 2 Diabetes and dyslipidemia, having a fasting blood glucose level (FBG) of 138 mg/dL, which is exceeding the criteria for IFB and IGT. Although all carbohydrate and lipid metabolism related BACs, as well as overweight and hypertension, showed significant improvements, all were restored back to normal, with the exception of FBG which, despite its 13% improvement, only dropped from 138 mg/dL to 120 mg/dL, still within the IGT range.
U.S. Pat. No. 6,026,817 discloses a method of treatment of humans suffering from the syndrome of Coronary Heart Disease Risk Factors which comprises the steps of 1) administering a priming dose of a drug composition selected from the group consisting of opioid antagonists and 2) administering a maintenance dose of said drug. It also discloses a method of combining said dosing sequence with a method of improving the balance between or equalizing the IC-50 values of an anti-opioid composition for its respective target receptors, by adding small amounts of one or more drugs with opioid agonist activity whereby the agonist competes with the antagonist for the particular receptor, and diminishes, but does not totally remove any of the respective antagonist properties of the anti-opioid composition.
U.S. Pat. No. 4,888,346 discloses a method of treating humans infected with the HTLV-III (AIDS) virus by improving the immunologic function, thereby also improving the subjects immuno-defence system to resist opportunistic secondary infections like Kaposi's sarcoma. This invention does not treat the Lipodystrophy Syndrome.
U.S. Pat. No. 5,013, 739, a Continuation-in-Part of the above, discloses the treatment of a variety of immune disorders, including chronic herpes viral infections, rheumatoid arthritis, and multiple sclerosis.
U.S. Pat. No. 5,356,900, a Continuation-in-Part of the above, discloses the treatment of the immune disorder Chronic Herpes Virus Infection.
U.S. Pat. No. 5,830,895 discloses a method for detecting abnormalities in prolactin daily rhythms, and methods for normalizing a subject's daily prolactin rhythm to treat metabolic disorders, by using a combination of prolactin inhibitors and prolactin stimulators.
U.S. Pat. No. 6,190,691 discloses screening methods for evaluating compounds capable of suppressing cytokine (alpha-TNF) production, and that the application of loperamide.
In one aspect, the present invention provides an improved method of treating the Syndrome of CHD risk factors, by the administration of insulin secretagogues in combination with an opioidergic drug composition. The syndrome of CHD risk factors includes the various disease states of Type 2 Diabetes, as well as hyper- or dyslipidemia, overweight, obesity and/or essential hypertension. The disease states of the Type 2 Diabetes syndrome progress through insulin resistance (IR) and Beta-Cell dysfunction, impaired fasting glucose (IFG), excessive hepatic gluconeogenesis (GNG) and glucose production (GP), and impaired glucose tolerance (IGT) to the clinical form of Type 2 Diabetes. The improved method provides a treatment for any number of individual conditions within the syndromes of CHDRF and Type 2 Diabetes. This invention also provides a method of treating the early morning increase in gluconeogenesis and increased glucose production which, in the presence of relatively impaired insulin secretion, results in elevated fasting glucose levels. This invention further provides a method to restore the physiologic acute, first phase insulin release.
In another aspect, the invention provides a method of treating the Syndrome of Lipodystrophy, by the administration of opioidergic drug compositions, or the administration of opioidergic drug compositions in combination with insulin secretagogues. Any of the opiodergic agents, and more particularly, the opiate agonists and antagonists described herein may be suitable for treating LS. Similarly, any of the insulin secretagogues described herein may be suitable for treating LS. The syndrome of LS may include a variety of HIV-related abnormalities in lipid and carbohydrate metabolism, the exact pathophysiology of which are not well understood. The HIV-related abnormalities may include atherogenic dyslipidemia (AD), hypertriglyceridemia (HTG), elevated levels of cholesterol (Chol), low density lipoprotein cholesterol (LDL) and low levels of high density lipoprotein cholesterol (HDL), body fat re-distribution, insulin resistance (IR), elevated endogenous glucose production and/or gluconeogenesis, beta-cell dysfunction, impaired glucose tolerance (IGT) and Type 2 Diabetes. The present invention provides a method for the treatment for any number of individual conditions within the syndromes of LS. This invention further provides a method to restore the physiologic acute, first phase insulin release associated with beta cell dysfunction, as this abnormality emerges during the progression of lipodystrophy.
More particularly, the Syndrome of Lipodystrophy as well as one or more of the HIV-related abnormalities included therein may be treated through the administration of a drug composition comprising an opioidergic agent, or alternatively, an opiodergic agent and an insulin secretagogue. More particularly, drug compositions comprising an agonist and an antagonist may be helpful in treating the LS and its HIV-related abnormalities. Furthermore, drug compositions comprising one or more agonists, antagonists and insulin secretagogues may also be useful in treating LS and its HIV-related abnormalities. Any of the opioidergic agents and insulin secretagogues discussed herein are suitable for use in the application. Any of the pharmaceutically effective modes discussed above may be suitable.
During the treatment of lipodystrophy with an opiodergic composition, the preferred dose of the drug composition is typically below 2 milligrams per day, and preferably below 1 milligram per day, although it may vary from patient to patient. Stronger and more potent opioidergic agents will require smaller dosages. The relative strength and potency of these opioidergic agents are well-known within the art, and accordingly, the dosage may vary. Dosages for specific opiodergic agents and compositions can be found, inter alia, in the Examples below. Typically, administration occurs one time per day, preferably between dinner time and bed time, such that their pharmacological effectiveness covers the early morning hours through noon the following day. Treatment depends on the pharmacologic characteristics of the composition, like IC-50 value, effective half-life, and the responsiveness of the patient. Any of the pharmaceutically effective modes defined above may be used to administer the opiodergic agents. Preferred pharmaceutically effective modes, however, include using a caplet, pill, capsule with solid, liquid, gel carriers or other such methods known in the art.
Because the Lipodystrophy Syndrome is chronic, treatment will typically be long-term and indefinite until or unless changed by a physician or one of ordinary skill in the art. Lipid and blood glucose levels should be monitored closely, and administration of the drug compositions discussed herein modified accordingly. In addition, physicians may be able to monitor lipid and carbohydrate metabolism, i.e., reduced glucose levels, reduced cholesterol levels, reduced LDL levels and elevated HDL levels to determine the effectiveness of treatment. The same and similar considerations apply to all of the drug compositions discussed-herein. Patients may tend to see some improvement in terms of blood glucose and lipid levels within days or weeks of administration of any of the drug compositions discussed herein.
It is customary to titrate the optimum dosing characteristics for any particular composition selected, during the dose finding and dose ranging studies portion of clinical trials. An opiodergic composition comprising a μ-agonist (such as loperamide with a pharmacologic half life of approximately 40 hours) may be administered alone or in combination with a the non-selective opioid antagonist (such as nalmefene having a pharmacologic half-life of approximately 10 hours). Antagonists may be administered alone as well. Preferably, treatment of lipodystrophy primarily characterized by atherogenic dyslipidemia (AD) takes place prior to the manifestation of hyperglycemia or type 2 diabetes. A combination of μ-agonist and an antagonist (e.g. a combination of loperamide and nalmefene) may result in a cycling of the μ-activity versus the κ- and δ-receptor activities. The respective doses of loperamide and nalmefene, as well as any other agonist/antagonist combination should be selected to allow the administration after dinner, and before bed-time, and to produce a peak μ-receptor agonist activity between midnight and breakfast. The exact dosing is dependent on the receptor sensitivity of the subject to be treated, which may, in part, be dependent on his or her receptor down-regulation consequent to prolonged stress, use of narcotics, or other neuro-endocrine stimulants. The daily maintenance doses of the agonist and antagonist (loperamide and nalmefene) are, typically, in the microgram range for the duration of the desired treatment. Another aspect of this invention is the temporary use of a non-selective anti-opioid, (e.g. nalmefene), in the milligram range, for a period of up to 6 weeks, to permit an up-regulation of the μ, κ and δ receptors prior to the initiation of the maintenance dose of the drug composition.
Another aspect of this invention is the combination of an opioidergic composition with an insulin secretagogue, primarily for subjects with LS whose disorder has progressed to the stage of impaired glucose tolerance (IGT) or type 2 diabetes (DM-2). Any of the insulin secretagogues discussed herein are suitable for use in the application, and any of the pharmaceutically effective modes discussed above may be suitable. One example comprises an opioidergic composition including the μ-agonist loperamide with a pharmacologic half life of approximately 40 hours, and a non-selective opioid antagonist (such as nalmefene) having a pharmacologic half-life of approximately 10 hours, in combination with an extended release form of glipizide or glyburide is preferred for the treatment of lipodystrophy with atherogenic dyslipidemia (AD) and IGT or DM-2. When administering an opioidergic composition and insulin secretagogue combination, the typical dosage of the opioidergic composition is the same as that set forth above. In other words, typically the dosage is below 2 milligrams, and more preferably below 1 milligram, although it depends on the opioidergic composition's pharmacological effectiveness (namely, its strength and potency). The typical dosage of the insulin secretagogue, when used in combination with an opioidergic agent, is typically less than half of the dosage used for the same insulin secretagogue when used alone in monotherapy. Any of the pharmaceutically effective modes defined above are suitable, although using a caplet, pill, capsule, solid, liquid, gel carriers or other such methods known in the art are preferred.
Another preferred composition for the treatment of lipodystrophy is the opioidergie composition including a non-selective opioid antagonist (such as nalmefene) with an agonist (such as a μ-agonist hydrocodone or oxycodone), either of these μ-agonists in an extended release form to make their pharmacologically effective half life compatible with that of nalmefene. The preferred administration of drug compositions comprising an opioidergic composition and an insulin secretagogue are before bed time, and such that their pharmacological effectiveness covers the early morning hours through noon the following day. This opioidergic composition alone will be used for the treatment of LS with AD, and, in combination with an insulin secretagogue, for the treatment of LS with AD and IGT or LS with AD and DM-2. Overall, proper administration of the drug compositions claimed herein will depend on the patient being treated.
When administering a drug composition comprising an opiate agonist and an opiate antagonist, the same administration considerations apply. Again, typically less than 2 milligrams, and more preferably, less than 1 milligram of the drug composition will be administered. Based on the Examples below it is possible to extrapolate the exact dosage of these drug compositions depending on the relative strength and potency of the different agonists and antagonists. When also using an insulin secretagogue in combination with an opioidergic agent, the insulin secretagogue is typically less than half of the dosage used for the same insulin secretagogue when used alone in monotherapy. Any of the defined pharmaceutically effective modes may be used to administer the agonist/antagonist or agonist/antagonist/insulin secretagogue composition. Again, using a caplet, pill, capsule, solid, liquid, gel carriers or other such methods known in the art are preferred. Treatment will most likely be continued and indefinite.
Non-glucose dependent insulin secretagogues, such as sulphonylureas, stimulate insulin secretion regardless of the blood glucose level and are, therefore, prone to produce potentially deleterious hypoglycemia, particularly so, because such insulin secretagogues primarily increase the second phase insulin release with no improvement in first phase insulin secretion.
This invention of administering, by a pharmaceutically effective mode, opioidergic drug compositions in combination with non-glucose dependent insulin secretagogues, such as sulphonylureas, can confer a more glucose dependent, bi-phasic insulin release pattern on such secretagogues, and significantly reduce the likelihood of producing hypoglycemia.
Another aspect of this invention is to provide an improved first pass insulinization of the liver, resulting in a restoration of enzyme functions involved in hepatic fuel processing, including carbohydrate oxidation and storage.
Drugs which are useful in the methods of the present invention, i.e., methods for treating humans suffering from CHD risk factors or LS and its associated abnormalities, include opioid drug compositions of non-selective or selective opioid antagonists, with or without the supplementation of centrally or peripherally-acting μ-agonist activity, and with or without supplementation with insulin secretagogues, including insulinotropic agents and/or insulin secretion or release potentiators. Insulin secretagogues include, but are not limited to, sulphonylureas, such as tolbutamide, chlorpropamide, glimepiride, glipizide, and glyburide, (all listed in Merck Index, 12th Edition, 1996), repaglinide, (Raskin P et.al.: Diabetes Care 23[7]:979-83), meglitinides, morphilinoguanide and pramlintide (Evans A J and Kreutz A J: Drugs RD 2[2]:75-94), acetylcholine (Tae Niwa et. al.: Diabetes 47: 1699-1706), muscarinic agonists, e.g. carbachol (Hiriart M and Ramirez-Medeles M C: Mol Cell Endocrinol 93[1]: 63-9), bethanechol (Physicians Desk Reference [PDR]), beta-L-glucose pentaacetate, (Malaisse W J et.al.: American Journal of Physiology 276[6/1]:E993-E1006), chiro-inositol (Lamer J. et.al. U.S. Pat. No. 5,428,066), myo-inositol (Szkudelski T and Kandulska K.: Arch. Physiol. Biochem. 107[4]:334-7), GIP (Kindmark H et.al.:J Clin Endocrinol Metab 86[5]:2015-9), GLP-1 and Extendin-4 (Parkes D G et.al.: Metabolism 50[5]:583-9).
Bi-directional effects of opioids are known to exist, in particular between μ and κ agonists, such as μ-agonists producing euphoria and κ agonists producing the opposite, namely disphoria. Conversely, μ antagonists can antagonize euphoria and enhance the effect of the κ agonist, while the κ antagonist can produce or enhance euphoria. Examples of this phenomenon also include the opposing effects of μ and κ opiates in motivational processes (Herz A.: NIDA Res Monogr 90:17-26), or in opioid reward mechanisms (Herz A.: Can J Physiol Pharmacol 76,3:252-8), and other μ-opposing actions of the κ-opioid receptor (Pan Z. Z.: Trends Pharmacol Sci; 19,3: 94-8).
Opioids having selective or predominant κ-antagonist activity include, but are not limited to, nalmefene, naltrexone, nor-binaltorphimine, (Portoghese, P. S., Lipkowski, A. W., Takemori, A. E.; Life Sciences 40: 1287-92); guanidylated naltrindole (GNTI), (Jones R. M., Hjorth, A. S., Schwartz, T. W., and Portoghese, P. S.; Journal of Medicinal Chemistry 41,25: 4911-4), (−)-(1R,5R,9R)-5,9-diethyl-2-(3-furylmethyl)-2-hydroxy-6,7-benzomorphan (MR 2266) (Merz, H., Langbein, A., Stockhaus, K., Walther, G., & Wick, H.; Advances in biochemical psychopharmacology, Vol 8: 91-107), a triethylenedioxy derivative of naltrexamine (TENA), (Portoghese, P. S., Takemori, A. E.; Life Sciences 36: 801-5) and buprenorphine.
Opioids having selective or predominant μ-agonist activity include, but are not limited to, dihydromorphine, morphine, hydromorphone, methadone, fentanyl, sufentanyl, buprenorphine, demorphine, codeine, ethylmorphine, etonitazene, hydrocodone, levorphanol, norcodeine, normorphine, loperamide, {D-Ala2-N-Me-Phe4-Gly5-ol)-Enkephalin} (DAMGO), oxycodone and tramadol. Most opioids pass the Blood Brain Barrier (BBB) and are, therefore both, centrally and peripherally active, i.e. they can act upon CNS sites as well as peripheral sites, such as the gut and hormone producing glands, including the endocrine pancreas and the adrenal medulla. Some opioids, e.g. loperamide, do not pass the BBB and are, therefore, only or predominantly peripherally active with little or no CNS effect. Since drug addiction generally requires a central effect, peripherally-acting opioid agonists are typically not addictive and generally not ‘scheduled’ as narcotics.
Buprenorphine is a mixed agonist-antagonist having high affinity at the μ opiate receptor with partial agonist activity, and at the κ receptor with antagonist activity. Because of its κ receptor antagonist activity and low partial μ activity it will produce minimal and perhaps clinically insignificant physical dependence. Bupreprohine has been used as an effective analgesic for the treatment of moderate to severe pain and of opioid dependence. (Lewis J. W.: Drug and Alcohol Dependence; 14:363-372). Elevations in cortisol and glucose, caused by surgical stress, have been observed to decline following the administration of buprenorphine to treat analgesia during and following total hip replacement (McQuay H. J. et. al.: Br J Anaesth; 52:1013-19).
Loperamide is a synthetic opioid used for the treatment of diarrhea, which is more effective and safe than other opioid drugs in the treatment of diarrhea of various causes (Ruppin H: Acta Physiol Scand; 127,3:275-9) Loperamide is a ‘non-scheduled’ opioid with μ-agonist activity as opposed to most other opioid agonists which are listed as ‘controlled substances.’ Loperamide is reported to raise blood glucose concentrations at dose levels required for the acute treatment of diarrhea (Caldara R. et. al.: Eur J Clin Pharmacol; 21,3:185-8), and has been used in the “Loperamide test”: a simple and highly specific screening test for hypercortisolism in children and adolescents” (Buzi F. et. al.: Acta Paediatr; 86,11: 1177-80).
The invention results in an improved method of treating coronary disease risk factors and an improvement toward normal values of fasting blood glucose, C-peptide, fasting total cholesterol, fasting LDL-cholesterol, fasting HDL-cholesterol, LDL/HDL ratio, fasting TG, fasting FFA, body weight, systolic blood pressure and/or diastolic blood pressure.
EXAMPLE 1
The example is being described for purely illustrative purposes, and is in no way meant to limit the scope of the invention.
The daily blood glucose profile of a 72 year old subject with Type 2 Diabetes and dyslipidemia was monitored following the early morning oral administration of 0.15 mg Hydrocodone, a centrally-acting μ-agonist in combination with sulfonylurea type insulin secretagogue. The glucose profile of the subject was monitored on the second day after the treatment had been initiated. Sufficient time was allowed after the earlier treatment to eliminate any carry-over effect.
Treatment 1
(—O—) no drug treatment.
Breakfast: 08:40-09:00; lunch: 12:25-12:50; dinner: 18:40-19:00


















time [h]
08:10
10:00
12:20
14:00
18:30
20:00


BG [mg/dL]
132
156
104
150
98
117









Treatment 2

(—▪—) 0.15 Hydrocodone, a centrally-acting μ-agonist in combination with 1.0 mg Glipizide, administered 2 hours before breakfast
Breakfast: 09:00-0915; lunch: 12:10-12:30; dinner: 19:20-19:50


























Time
08:45
09:00
09:15
09:50
10:35
11:05
12:10
12:30
13:00
14:05
19:25
19:50
20:25
20:55


[h]


BG
103
102
102
108
116
104
109
100
108
94
92
88
105
89


[mg/dL]









FIG. 1 and the supporting data demonstrate that post prandial peaks in glucose concentration have been virtually normalized with the administration of 0.15 mg of hydrocodone in combination with 1.0 mg of the sulfonylurea type insulin secretagogue glipizide. The administration of the μ-agonist in combination with the insulin secretagogue also results in very significant increases in first phase insulin release, as can be derived from the pronounced decreases of blood glucose concentrations throughout the intake of the meals, and from the reduced duration and excursions of the post-prandial peaks, compared to placebo.
Type 2 Diabetes, IGT, overweight and obesity are associated with defective or lacking first phase insulin release, as is Type 1 Diabetes. In contrast to Type 1 Diabetes, all these afflictions, except late stage Type 2 Diabetes, retain second, proportional phase insulin secretory capacity. The restoration of hepatic carbohydrate oxidation and storage in Type 1 Diabetics requires appropriately controlled exogenous insulin infusions.
According to the present invention, such restoration of hepatic carbohydrate oxidation storage in subjects afflicted with the CHD risk factors is achieved by administration of opioidergic drug compositions in combination with insulin secretagogues. The opioidergic drug compositions useable in the present invention may be single substances or may also be any combination of opioid agonists, antagonists or mixed agonist/antagonists as long as their respective pharmacodynamics are, or have been rendered, compatible, in order to avoid significant variations in their respective, and combined, biologic effectiveness throughout their decline in biologic action.
The effective dose of the μ-agonist loperamide is, typically, less than 0.5 mg per day, or smaller by more than an order of magnitude than the typical dose required for the treatment of diarrhea, and the effective dose for hydrocodone is, typically, less than 1 mg. The effective dose for these and other μ-agonists, or single- or multi-molecular mixed μ-agonist/κ-antagonist compositions as well as the insulin secretagogues may vary depending upon factors such as the (patho-)physiology of the subject being treated, receptor binding, the absorption rate, bio-availability, excretion rate and the rate of metabolism of the drug. The pharmacokinetic compatibility between the opioidergic agent and the insulin secretagogue is less critical, but the preferred biologic half life of the insulin secretagogue is less than 4 hours. The preferred method of administration is such that the peak plasma concentration of the drug combination occurs before or during breakfast.
The effective dose for the supplementary insulin secretagogues is, typically, equal or less than the dose for such agents used in monotherapy.
The examples are being described for purely illustrative purposes, and are in no way meant to limit the scope of the invention.
While the above example was directed to the treatment of CHDRF, the same or a similar administration may be used for the treatment of the Syndrome of Lipodystrophy or one or more of the HIV-related abnormalities included therein.
EXAMPLE 2
Treatment of Lipodystrophy Associated with Atherogenic Dyslipidemia
Subjects with lipodystrophy associated with atherogenic dyslipidemia are administered a pre-treatment regimen of 10 mg of nalmefene, given once daily between dinner and bedtime for two weeks to improve receptor sensitivity. The subjects are then administered, at bedtime, a daily maintenance dose of an opioidergic composition of 2 μg loperamide and 2 μg nalmefene. Blood glucose and blood lipids levels are monitored. After a treatment period of days or weeks, subject typically shows improved lipid and carbohydrate metabolism, including improved blood glucose and lipid levels, i.e., reduced glucose levels, reduced cholesterol levels, reduced LDL levels and elevated HDL levels. The administration of an opioidergic composition is thus shown to improve lipodystrophy associated with atherogenic dyslipidemia.
EXAMPLE 3
Treatment of Lipodystrophy Associated with Atherogenic Dyslipidemia and Impaired Glucose Tolerance or Type 2 Diabetes
Subjects who are in a normal weight range and have lipodystrophy associated with atherogenic dyslipidemia and either impaired glucose tolerance or type 2 diabetes are administered a pre-treatment regimen of 10 mg of nalmefene, given once daily between dinner and bedtime for two weeks to improve receptor sensitivity. The subjects are then administered, at bedtime, a daily maintenance dose of an opioidergic composition of 2 μg loperamide and 2 μg nalmefene, combined with an extended release form of an insulin secretagogue, e.g., glyburide or glipizide, given at a dosage level that is less than half the typical dosage necessary for sulfonylurea monotherapy. The insulin secretagogue dose is selected to compensate for the reduced level of endogenous insulin synthesis accompanying the patient specific level of IGT or DM-2. The insulin secretagogue composition can be taken as a separate entity, but at the same time of administering the opioidergic composition. A single opiodergic-insulin secretagogue composition is, however, preferred.
After a treatment period of days to weeks, subjects typically show improved lipid and carbohydrate metabolism, including improved blood glucose and lipid levels, i.e., reduced glucose levels, reduced cholesterol levels, reduced LDL levels and elevated HDL levels. The administration of an opioidergic composition is thus shown to improve lipodystrophy associated with atherogenic dyslipidemia and impaired glucose tolerance or type 2 diabetes.
The opioidergic doses indicated in examples #2 and #3 are for reference purposes and may vary between 0.1 and 100 micrograms, depending on the characteristics of the patient and the opioidergic agents used. The above examples are provided with respect to specific compounds within the class of opioidergic agents, similar results are expected with the other opioidergic agents, although administration of up to 1 to 2 milligrams may be required. Amounts may be generally proportional to the amounts set forth in the examples, relative to the strength and potency of the particular opioidergic agent as well-known within the art.

## Claims

1. A method of treating a human suffering from the Syndrome of Lipodystrophy or one or more HIV-related abnormalities included therein, the method comprising:
administering, by a pharmaceutically effective mode, a drug composition comprising an opioidergic composition.

2. The method of claim 1, wherein the opioidergic composition includes at least one of an opiate antagonist, an opiate agonist and a combination thereof.

3. The method of claim 2, wherein the opiate antagonist comprises a single molecular entity.

4. The method of claim 2, wherein the opiate antagonist comprises a combination of molecular entities.

5. The method of claim 2, wherein the drug composition comprises an opiate antagonist and the opiate antagonist has drug opiate antagonist IC50 values, and the IC50 values for the μ, δ and κ opiate receptors have ratios such that:


{(IC50κ/IC50μ)<10}, and {(IC50κ/IC50δ)<10}.

6. The method of claim 2, wherein the opiate agonist comprises a single molecular entity.

7. The method of claim 2, wherein the opiate agonist comprises a combination of molecular entities.

8. The method of claim 1, wherein the opioidergic composition comprises a peripherally-acting μ-agonist.

9. The method of claim 8, wherein the opioidergic composition comprises loperamide.

10. The method of claim 1, wherein the opioidergic composition comprises a centrally-acting μ-agonist.

11. The method of claim 1, wherein the opioidergic composition comprises an opiate having mixed μ-agonist and κ antagonist activity.

12. The method of claim 11, wherein the opiate having mixed μ-agonist and κ antagonist activity is buprenorphine.

13. The method of claim 1 wherein the opioidergic composition includes at least one of the following:
i) dihydromorphine; 
ii) morphine; 
iii) hydromorphone; 
iv) methadone; 
v) fentanyl; 
vi) sufentanyl; 
vii) buprenorphine; 
viii) demorphine; 
ix) codeine; 
x) ethylmorphine; 
xi) etonitazene; 
xii) hydrocodone; 
xiii) levorphanol; 
xiv) norcodeine; 
xv) normorphine; 
xvi) (D—Ala2—N—Me—Phe4—Gly3—ol)-Enkephalin (DAMGO); 
xvii) oxycodone; and 
xviii) tramadol.

14. The method of claim 1, wherein the opioidergic composition includes at least one of the following:
i) nalmefene; 
ii) naltrexone; 
iii) nor-binaltorphimine; 
iv) (−)-(1R,5R,9R)-5,9-diethyl-2-(3-furylmethyl)-2-hydroxy-6,7-benzomorphan (MR 2266); 
v) a triethylenedioxy derivative of B-naltrexamine (TENA); and 
vi) guanidylated naltrindole (GNTI).

15. The method of claim 1, wherein the HIV-related abnormality included in the Syndrome of Lipodystrophy is atherogenic dyslipidemia (AD).

16. The method of claim 1, wherein the HIV-related abnormality included in the Syndrome of Lipodystrophy is hypertriglyceridemia (HTG).

17. The method of claim 1, wherein the HIV-related abnormality included in the Syndrome of Lipodystrophy is elevated levels of cholesterol (Chol).

18. The method of claim 1, wherein the HIV-related abnormality included in the Syndrome of Lipodystrophy is elevated levels of low-density-lipoprotein cholesterol (LDL).

19. The method of claim 1, wherein the HIV-related abnormality included in the Syndrome of Lipodystrophy is low levels of high-density lipoprotein cholesterol (HDL).

20. The method of claim 1, wherein the HIV-related abnormality included in the Syndrome of Lipodystrophy is insulin resistance (IR).

21. The method of claim 1, wherein the HIV-related abnormality included in the Syndrome of Lipodystrophy is beta-cell dysfunction.

22. The method of claim 1, wherein the HIV-related abnormality included in the Syndrome of Lipodystrophy is the loss of first phase insulin secretion.

23. The method of claim 1, wherein the HIV-related abnormality included in the Syndrome of Lipodystrophy is impaired glucose tolerance (IGT).

24. The method of claim 1, wherein the HIV-related abnormality included in the Syndrome of Lipodystrophy is Type 2 Diabetes.

25. The method of claim 1, wherein the HIV-related abnormality included in the Syndrome of Lipodystrophy is elevated endogenous glucose production.

26. The method of claim 1, wherein the HIV-related abnormality included in the Syndrome of Lipodystrophy is excessive gluconeogenesis.

27. The method of claim 1, further comprising a pre-treatment regimen comprising the daily administration of nalmefene in the range of 1-10 mg for a period of up to 6 weeks.

28. A method of treating a human suffering from the Syndrome of Lipodystrophy or one or more HIV-related abnormalities included therein, the method comprising:
administering, by a pharmaceutically effective mode, a drug composition comprising an opioidergic composition and at least one insulin secretagogue.

29. The method of claim 28, wherein the insulin secretagogue includes at least one of the following:
i. sulphonylureas; 
ii. tolbutamide; 
iii. chlorpropamide; 
iv. glimepiride; 
v. glipizide; 
vi. glyburide; 
vii. meglitinides; 
viii. repaglinide; 
ix. pramlintide; 
x. morphilinoguanide; 
xi. acetylcholine; 
xii. muscarinic agonists; 
xiii. carbachol; 
xiv. bethanechol; 
xv. beta-L-glucose pentaacetate; 
xvi. chiro-inositol; 
xvii. myo-inositol; 
xviii. GIP; 
xix. GLP-1; and 
xx. Extendin-4.

30. The method of claim 28, wherein the insulin secretagogue is a non-glucose dependent insulin secretagogue, the method producing insulin release patterns capable of attaining glucose dependent, bi-phasic release characteristics with reduced likelihood of producing hypoglycemia.

31. The method of claim 28, wherein the insulin secretagogue comprises sulphonylurea.

32. The method of claim 28, wherein the opioidergic composition includes at least one of an opiate antagonist, an opiate agonist and a combination thereof.

33. The method of claim 28, wherein the opiate antagonist comprises a single molecular entity.

34. The method of claim 28, wherein the opiate antagonist comprises a combination of molecular entities.

35. The method of claim 28, wherein the opioidergic composition includes at least one of the following:
i) dihydromorphine; 
ii) morphine; 
iii) hydromorphone; 
iv) methadone; 
v) fentanyl; 
vi) sufentanyl; 
vii) demorphine; 
viii) codeine; 
ix) ethylmorphine; 
x) etonitazene; 
xi) hydrocodone; 
xii) levorphanol; 
xiii) norcodeine; 
xiv) normorphine; 
xv) (D—Ala2—N—Me—Phe4—Gly3—ol) -Enkephalin (DAMGO); 
xvi) oxycodone; and 
xvii) tramadol.

36. The method of claim 28, wherein the opioidergic composition includes at least one of the following:
i) nalmefene ii) naltrexone; 
iii) nor-binaltorphimine; 
iv) (−)-(1R,5R,9R)-5,9-diethyl-2-(3-furylmethyl)-2-hydroxy-6,7-benzomorphan (MR 2266); 
v) a triethylenedioxy derivative of B-naltrexamine (TENA); and 
vi) guanidylated naltrindole (GNTI).

37. The method of claim 28, wherein the HIV-related abnormality included in the Syndrome of Lipodystrophy includes at least one of atherogenic dyslipidemia (AD), hypertriglyceridemia (HTG), elevated levels of cholesterol (Chol), elevated levels of low-density-lipoprotein cholesterol (LDL), low levels of high-density lipoprotein cholesterol (HDL), insulin resistance (IR), beta-cell dysfunction, impaired or loss of first phase insulin secretion, impaired glucose tolerance (IGT), Type 2 Diabetes, elevated endogenous glucose production, and excessive gluconeogenesis.

38. The method of claim 28, wherein the drug composition is a single agent having opioidergic activity and insulinotropic activity.

39. A method of treating a human suffering from the Syndrome of Lipodystrophy or one or more HIV-related abnormalities included therein, the method comprising:
administering, by a pharmaceutically effective mode, a drug composition comprising 
at least one opiate agonist; and 
at least one opiate antagonist.

40. The method of claim 39, wherein the drug composition further comprises at least one insulin secretagogue.

41. The method of claim 39, wherein the insulin secretagogue includes at least one of the following:
i. sulphonylureas; 
ii. tolbutamide; 
iii. chlorpropamide; 
iv. glimepiride; 
v. glipizide; 
vi. glyburide; 
vii. meglitinides; 
viii. repaglinide; 
ix. pramlintide; 
x. morphilinoguanide; 
xi. acetylcholine; 
xii. muscarinic agonists; 
xiii. carbachol; 
xiv. bethanechol; 
xv. beta-L-glucose pentaacetate; 
xvi. chiro-inositol; 
xvii. myo-inositol; 
xviii. GIP; 
xix. GLP-1; and 
xx. Extendin-4.

42. The method of claim 40, wherein the insulin secretagogue is a non-glucose dependent insulin secretagogue, the method producing insulin release patterns capable of attaining glucose dependent, bi-phasic release characteristics with reduced likelihood of producing hypoglycemia.

43. The method of claim 40, wherein the insulin secretagogue includes sulphonylurea.

44. The method of claim 39, wherein the opiate agonist includes a μ-agonist.

45. The method of claim 39, wherein the opiate agonist includes loperamide.

46. The method of claim 39, wherein the opiate agonist includes at least one of a centrally-acting μ agonist and a peripherally-acting μ agonist.

47. The method of claim 39, wherein the opiate agonist includes at least one of the following:
xviii) dihydromorphine; 
xix) morphine; 
xx) hydromorphone; 
xxi) methadone; 
xxii) fentanyl; 
xxiii) sufentanyl; 
xxiv) demorphine; 
xxv) codeine; 
xxvi) ethylmorphine; 
xxvii) etonitazene; 
xxviii) hydrocodone; 
xxix) levorphanol; 
xxx) norcodeine; 
xxxi) normorphine; 
xxxii) (D—Ala2—N—Me—Phe4—Gly3—ol)-Enkephalin (DAMGO); 
xxxiii) oxycodone; and 
xxxiv) tramadol.

48. The method of claim 39, wherein the HIV-related abnormality included in the Syndrome of Lipodystrophy is at least one of atherogenic dyslipidemia (AD), hypertriglyceridemia (HTG), elevated levels of cholesterol (Chol), elevated levels of low-density-lipoprotein cholesterol (LDL), low levels of high-density lipoprotein cholesterol (HDL), insulin resistance (IR), beta-cell dysfunction, impaired or loss of first phase insulin secretion, impaired glucose tolerance (IGT), Type 2 Diabetes, elevated endogenous glucose production, and excessive gluconeogenesis.