Compositions and methods for treating gastrointestinal disorders

Abstract: The present invention relates to pharmaceutical compositions useful for treating or preventing gastrointestinal disorders. These compositions comprise a campylobacter-inhibiting anti­ microbial agent such as nitrofurantoin and bismuth subsalicylate, and a histamine-2 receptor blocking anti-secretory agent such as cimetidine. The present invention further relates to methods for treating or preventing gastrointestinal disorders in humans or lower animals by administering a campylobacter-inhibiting antimicrobial agent and a histamine-2 receptor blocking anti-secretory agent.

Description: The present invention relates to pharmaceutical compositions useful for treating or preventing gastrointestinal disorders. These compositions comprise a campylobacter-inhibiting antimicrobial agent and a histamine-2 receptor blocking anti-secretory agent. Factors adversely affecting the function of the gastrointestinal system in humans are exceedingly varied in their nature. Such disorders may arise in the upper or lower gastrointestinal tracts or both. There is a broad range of causes of gastrointestinal disorders, including genetic, physiological, environmental, and psychogenic factors. Accordingly, the diagnosis and management of these disorders can be exceptionally difficult. A detailed discussion of gastrointestinal tract functions, disorders, causes, and treatments can be found in Spiro, Clinical Gastroenterology (3d. edition 1983). Among the chronic disorders of the upper gastrointestinal tract are those which fall under the general categories of gastritis and peptic ulcer disease. Gastritis is, by definition, typified by an inflammation of the stomach mucosa. In practice, though, the disorder is manifested by a broad range of poorly-defined, and heretofore inadequately treated, symptoms such as indigestion, "heart burn", dyspepsia and excessive eructation. A general discussion of gastritis appears in B. J. Marshall and J. R. Warren, "Unidentified Curved Bacilli in the Stomach of Patients with Gastritis and Peptic Ulceration", The Lancet , (1984), pp. 1311-1315, and in R. Greenlaw, et al., "Gastroduodenitis, A Broader Concept of Peptic Ulcer Disease", Digestive Diseases and Sciences , Vol. 25 (1980), pp. 660-672. Peptic ulcers are lesions of the gastrointestinal tract lining, characterized by loss of tissue due to the action of digestive acids and pepsin. It has been generally held that peptic ulcers are caused either by gastric hypersecretion, or (more often) by decreased resistance of the gastric lining to digestive acids and pepsin. The medical literature is replete with methods for treating ulcers, including modification of the diet, surgical removal of the lesions, and the use of drugs. Such drugs include: antacids, which serve to counteract excess gastric secretions; anti-cholinergics, which reduce acid secretion; H₂ antagonists, which also block the release of gastric acids; prostaglandins, which increase the resistance of the gastric lining to digestive fluids, and may also inhibit acid secretion; prokinetic agents, which enhance gastrointestinal tract motility; and compositions which form protective barriers over gastric lesions. Prescription and non-prescription drug therapies are generally described in Garnet, "Antacid Products", Handbook of Non-prescription Drugs , 7th edition (1982), Chapter 3. Regardless of the particular drug composition used in treating gastrointestinal disorders, such as gastritis or peptic ulcer disease, the treatment is often imprecise and incomplete. Actual "cures", i.e., successful treatment resulting in total remission of disease, are very often not effected. See A. J. McLean, et al., "Cyto-protective Agents and Ulcer Relapse", 142 The Medical Journal of Australia , Special Supplement S25-S28 (1985). Furthermore, many conventional treatments may render subject hypochlorhydric (i.e., with low levels of hydrochloric acid in the stomach) which may predispose them to other disorders, e.g., gastrointestinal infection, halitosis, and gastric carcinomas. The treatment of gastrointestinal disorders with histamine-2 (hereinafter "H₂") receptor blocking anti-secretory agents is well-known in the art. For example, cimetidine (marketed under the tradename Tagamet R ; Smith Kline & French Laboratories, Philadelphia, PA.) is an H₂ receptor block anti-secretory agent widely used in the treatment of gastric ulcers. This compound, as well as others of this type, are thought to act by blocking the histamine receptors within the stomach mucosa (labeled H₂ receptors, to distinguish from those histamine receptors generally associated with allergic response) thereby preventing histamine molecules from signalling the stomach cells to secrete acid. H₂ receptor blocking agents which are either more potent and/or longer acting than cimetidine (e.g., ranitidine) are also well-known. (See C&E News , April 12, 1982, pp. 24-26). However, while H₂ receptor blocking anti-secretory agents have demonstrated effectiveness in treating gastrointestinal disorders and therefore are widely prescribed for this purpose, their utility is questioned in light of the poor long-term outcomes associated with their use (e.g., high relapse rate associated with cimetidine treatment of gastric ulcers; see The Lancet , September 1, 1984, pp. 525-526). The treatment of gastrointestinal disorders with agents having antimicrobial properties, including antimicrobial activity against Campylobacter pyloridis , is also known in the art. For example, furazolidone has been used in the treatment of ulcers ( The Lancet , May 4, 1985, pages 1048-1049); bismuth subcitrate (DeNol®; sold by Gist-Brocades, N.V.) has been used to treat gastritis and/or duodenal ulcers in patients having Campylobacter pyloridis infections ( Gastroenterology , 88 (5 Part 2), page 1462 (1985); Aust. and N.Z. J. of Medicine , 14 , p. 907 (1984)); and bismuth-subsalicylate (Pepto-Bismol; sold by The Procter & Gamble Company) has been used to treat gastritis in patients having Campylobacter pyloridis infection ( Gastroenterology , 90 , page 1547 (1986)). Recent research has noted an association between gastritis, peptic ulceration, and the presence of Campylobacter pyloridis and campylobacter-like organisms ( The Lancet , June 16, 1984, pages 1311-1315). This has led to speculation that the high relapse rate observed when treating ulcers with cimetidine is the result of cimetidine allowing healing but adversely affecting the subsequent ability of the gastrointestinal tract to resist ulcerogenic activity of a pathogenic agent ( The Lancet , September 1, 1984, pages 525-526). However, subsequent research indicates that cimetidine inhibits Campylobacter pyloridis growth at low concentrations ( Z. Antimikrob. Antineoplast. Chemother. , 4 (2), pages 45-49 (1986); J. Antimicrob. Chemother. , 17 (3), pages 309-314 (1986)). Furthermore, preliminary findings support the concept that campylobacter-like organisms are not important in the etiology of duodenal ulcer disease ( Gastroenterology , 88 (5 part 2), p. 1462 (1985)). Thus, it is currently not clear whether the high relapse rate associated with cimetidine treatment is, in fact, due to an adverse affect on the ability of the gastrointestinal tract to resist pathogenic agents. Clearly, there remains a continuing need to identify new compositions which are effective for treating and preventing gastrointestinal disorders. The present invention provides such novel pharmaceutical compositions, comprising campylobacter-inhibiting antimicrobial agents and H₂ receptor blocking anti-secretory agents, useful for treating and preventing gastrointestinal disorders. While, as noted hereinbefore, H₂ receptor blocking anti-secretory agents and antimicrobial agents which have activity against Campylobacter pyloridis are individually known for treating and/or preventing gastrointestinal disorders, the compositions and methods of the present invention combine these two agents into compositions and methods which are surprisingly effective for treating and preventing gastrointestinal disorders. It is therefore an object of the present invention to provide novel pharmaceutical compositions comprising campylobacter-inhibiting antimicrobial agents and H₂ receptor blocking anti-secretory agents. An additional object is to provide agents and compositions for use in manufacturing a medicament which have improved ability to treat and prevent gastritis and gastrointestinal ulcers, and to improve the long-term outcomes of ulcer treatments. Finally, an object of the present invention is the use of these agents and compositions for the manufacture of a medicament to reduce the incidence of gastritis following ulcer treatment with H₂ receptor blocking anti-secretory agents and/or reduce the ulcer relapse rate observed following ulcer treatment with H₂ receptor blocking anti-secretory agents. These and other objects will become readily apparent from the detailed description which follows. SUMMARY OF THE INVENTION The present invention relates to pharmaceutical compositions useful for treating or preventing gastrointestinal disorders. These compositions comprise a campylobacter-inhibiting antimicrobial agent (e.g., nitrofurantoin; bismuth subsalicylate), and an H₂ receptor blocking anti-secretory agent (e.g., cimetidine; ranitidine). DETAILED DESCRIPTION OF THE INVENTION Campylobacter-inhibiting Antimicrobial Agents The pharmaceutical compositions of the present invention essentially comprise a campylobacter-inhibiting antimicrobial agent. The term "campylobacter-inhibiting antimicrobial agent", as used herein, means any naturally-occurring, synthetic or semi-synthetic compound or composition, or mixture thereof, which is safe for human use as used in the compositions and methods of the present invention, and is effective in killing or substantially inhibiting the growth of campylobacter-like organisms, e.g., Campylobacter pyloridis , when used in the compositions and methods of this invention. Such campylobacter-like organisms include those described in J. R. Warren and B. J. Marshall, "Unidentified Curved Bacilli on Gastric Epithelium in Active Chronic Gastritis", The Lancet , pages 1273-1275 (1983), and G. Kasper and N. Dickgiesser, "Isolation from Gastric Epithelium of Campylobacter-like Bacteria that are Distinct from 'Campylobacter pyloridis'", The Lancet , pages 111-112 (1985). The effectiveness of antimicrobial agents to kill or substantially inhibit the growth of campylobacter-like organisms for use in the present invention may be demonstrated using the various in vitro or in vivo assays known to those skilled in the art as described more fully hereinafter. Campylobacter-inhibiting antimicrobial agents useful herein include antibiotics, such as penicillin G, gentamicin, erythromycin, and tetracycline; the sulfonamides; nitrofurans, such as nitrofurazone, nitrofurantoin, and furazolidone; and metronidazole, tinidazole, and nimorazole. Campylobacter-inhibiting antimicrobial agents are described in the following publications: Gastroenterology, 88 (5 Part 2), page 1462 (1985); Aust. and N.Z. J. of Medicine , 15 (1 Suppl. 1), page 153 (1985); Z Antimikrob. Antineoplast. Chemother. , 4 (2), pages 45-49 (1986); J. Antimicrob. Chemother. , 17 (3), pages 309-314 (1986); Aust. and N.Z. J. of Medicine , 14 , p. 907 (1984); Gastroenterology , 90 , page 1547 (1986); The Lancet , September 1, 1984, pages 525-526; Remington's Pharmaceutical Sciences (15th Edition; 1975); F. H. Meyers, et. al. Review of Medical Pharmacology (7th Edition; 1980); Gaddum's Pharmacology (8th Edition; 1978); and A. Goodman, et al., The Pharmacological Basis of Therapeutics (6th Edition; 1980). Preferred campylobacter-inhibiting antimicrobial agents for use herein are nitrofurans having the following chemical structure: wherein R is hydrogen or an organic radical, or the salts or hydrates thereof. Antibacterial nitrofuran are disclosed in the following U.S. Patents: 2,319,481 issued to Stillman, Scott & Clampit on May 18, 1943; 2,416,233 issued to Stillman & Scott on February 18, 1947; 2,416,234 issued to Stillman & Scott on February 18, 1947; 2,416,235 issued to Stillman & Scott on February 18, 1947; 2,416,236 issued to Stillman & Scott on February 18, 1947; 2,416,237 issued to Stillman & Scott on February 18, 1947; 2,416,238 issued to Stillman & Scott on February 18, 1947; 2,416,239 issued to Stillman & Scott on February 18, 1947; 2,599,509 issued to Austin & Hastie on June 3, 1952; 2,610,181 issued to Hayes on September 9, 1952; 2,626,258 issued to Ward on January 20, 1953; 2,656,350 issued to Ward & Gever on October 20, 1953; 2,663,710 issued to Hayes on December 22, 1953; 2,707,292 issued to Hayes on January 15, 1955; 2,726,241 issued to Gever & Ward on December 6, 1955; 2,742,462 issued to Gever on April 17, 1956; 2,746,960 issued to Gever & Michels on May 22, 1956; 2,759,932 issued to Ebetino, Gever & Hayes on August 21, 1956; 2,776,979 issued to Michels on January 8, 1957; 2,798,068 issued to Gever on July 2, 1957; 2,802,002 issued to Gever August 6, 1957; 2,808,414 issued to Ward on October 1, 1957; 2,828,309 issued to Gever on March 25, 1958; 2,830,046 issued to Hayes on April 8, 1958; 2,830,047 issued to Hayes on April 8, 1958; 2,847,416 issued to Gever on August 12, 1958; 2,847,424 issued to Ward on August 12, 1958; 2,890,982 issued to Natt on June 16, 1959; 2,906,752 issued to Howard on September 29, 1959; 2,908,689 issued to Gever on October 13, 1959; 2,920,074 issued to Michels on January 5, 1960; 2,943,019 issued to Natt on June 28, 1960; 2,980,704 issued to Gever on April 18, 1961; 3,001,992 issued to Bellamy, Hayes & Michels on September 26, 1961; 3,007,846 issued to Gever & Vincent on November 7, 1961; 3,041,334 issued to Klein on June 26, 1962; 3,043,853 issued to Ebetino on July 10, 1962; 3,075,877 issued to Johnson on January 29, 1963; 3,075,972 issued to Michels on January 29, 1963; 3,075,973 issued to Michels on January 29, 1963; 3,075,974 issued to Michels on January 29, 1963; 3,076,805 issued to Michels on February 5, 1963; 3,091,611 issued to Howard on May 28, 1963; 3,096,347 issued to Wright on July 2, 1963; 3,097,202 issued to Michels on July 9, 1963; 3,105,834 issued to Wei on October 1, 1963; 3,108,122 issued to Ebetino on October 22, 1963; 3,110,649 issued to Johnson on November 12, 1963; 3,110,713 issued to Spencer on November 12, 1963; 3,110,714 issued to Wright on November 12, 1963; 3,121,083 issued to Howard on February 11, 1964; 3,127,420 issued to Ebetino on March 31, 1964; 3,138,593 issued to Burch on June 23, 1964; 3,139,431 issued to Hayes on June 30, 1964; 3,141,878 issued to Hellinghuizer on July 21, 1964; 3,141,889 issued to Ebetino on July 21, 1964; 3,149,119 issued to Ebetino on September 15, 1964; 3,157,645 issued to Spencer on November 17, 1964; 3,159,654 issued to Ward on December 1, 1964; 3,164,595 issued to Burch & Benjamin on January 5, 1965; 3,169,970 issued to Snyder on February 16, 1965; 3,178,453 issued to Snyder on April 13, 1965; 3,196,165 issued to Burch on July 20, 1965; 3,206,461 issued to Ebetino & Gever on September 14, 1965; 3,232,956 issued to Benjamin on February 1, 1966; 3,254,075 issued to Ebetino on May 31, 1966; 3,260,732 issued to Snyder on July 12, 1966; 3,272,840 issued to Benjamin on September 13, 1966; 3,277,082 issued to Benjamin on October 4, 1966; 3,277,110 issued to Burch on October 4, 1966; 3,314,947 issued to Benjamin on April 18, 1967; 3,324,122 issued to Burch on June 6, 1967; 3,335,140 issued to Burch on August 8, 1967; 3,335,141 issued to Burch on August 8, 1967; 3,350,397 issued to Burch on October 31, 1967; 3,367,931 issued to Snyder on February 6, 1968; 3,367,932 issued to Snyder on February 6, 1968; 3,374,239 issued to Burch on March 19, 1968; 3,386,995 issued to Ebetino on June 4, 1968; 3,391,155 issued to Benjamin on July 2, 1968; 3,407,195 issued to Snyder on October 22, 1968; 3,427,329 issued to Burch on February 11, 1969; 3,446,802 issued to Michels on May 27, 1969; 3,450,708 issued to Burch on June 17, 1969; 3,471,510 issued to Benjamin on October 7, 1969; 3,485,830 issued to Snyder on December 23, 1969; 3,542,784 issued to Burch on November 24, 1970; 3,660,384 issued to Johnson on May 2, 1972; 3,723,477 issued to Pelosi on March 27, 1973; 3,748,326 issued to Schwan & White on July 24, 1973; 3,770,740 issued to Burch on November 6, 1973; 3,808,203 issued to Snyder on April 30, 1974; 3,808,204 issued to Snyder on April 30, 1974; 3,808,211 issued to Benjamin on April 30, 1974; 3,822,255 issued to Snyder on July 2, 1974; 3,905,975 issued to Schwan on September 16, 1975; 3,914,220 issued to Snyder on October 21, 1975; 3,980,664 issued to Alaimo on September 14, 1976; and 4,012,409 issued to Alaimo on March 15, 1977. Antibacterial nitrofurans are also disclosed in the following references: Miura, K., and H. K. Reckendorf, "The Nitrofurans", Progress in Medicinal Chemistry , G. P. Ellis and G. B. West (ed.), Plenum Press, New York, NY, (1967), Vol. 5, pp. 320-381; Grunberg, E., and E. H. Titsworth, "Chemotherapeutic Properties of Heterocyclic Compounds: Monocyclic Compounds with Five-Membered Rings", Annual Review of Microbiology , M. P. Starr, J. L. Ingraham and S. Raffel (ed.), Annual Reviews Inc., Palo Alto, CA, (1973), Vol. 27, pp. 317-346; "Nitrofurans: Chemistry, Metabolism, Mutogenesis, and Carcinogenesis", Carcinogenesis , Vol. 4, G. T. Bryan (ed.), Raven Press, New York, NY, (1978); "Antibacterial Agents, Nitrofurans", Kirk-Othmer: Encyclopedia of Chemical Technology , John Wiley & Sons, Inc., Third Edition, Vol. 2, pp. 790-794; and McCalla, D. R., "Nitrofurans", Mechanism of Action of Antibacterial Agents , F. E. Hahn (ed.), Springer-Verlag, New York, NY (1979), pp. 176-213. Antibacterial nitrofurans preferred as components of the present invention include those wherein R is wherein R³, R⁴ and R⁵ are H or lower alkyl; and R⁶ is an organic radical, or salts or hydrates thereof. More preferred are antibacterial nitrofurans conforming to the above chemical structures wherein R⁶ is wherein R⁷ and R⁸ are organic radicals, or are joined to form an organic ring structure, or salts or hydrates thereof. More preferred still are antibacterial nitrofurans conforming to the above chemical structures wherein R⁷ is wherein R⁹ is H, lower alkyl, amine, amino(lower)alkyl, amide, hydroxy, or lower alkoxy; and wherein R⁸ is H, lower alkyl, lower alkyl alcohol, or lower alkyl amine; or wherein R⁹ and R⁸ are joined such that R⁶ is a five membered ring having the following chemical structure: wherein R¹⁰ is H, lower alkyl, -CH₂N(H or lower alkyl)₂, or and X is O or NR¹¹, wherein R¹¹ is H, lower alky, or lower alkyl alcohol, or salts or hydrates thereof. Antibacterial nitrofurans most preferred as components of the present invention include nitrofurantoin which has the chemical structure or its pharmaceutically-acceptable salts or hydrates; nitrofurazone which has the chemical structure: or its pharmaceutically-acceptable salts or hydrates; and furazolidone which has the chemical structure: or its pharmaceutically-acceptable salts or hydrates. Especially preferred is nitrofurantoin which is a well-known antibacterial compound and has been used extensively as an active ingredient in antibacterial pharmaceutical compositions. See, for example, Mintzer, S., E. R. Kadison, W. H. Shlaes & O. Felsenfeld, "Treatment of Urinary Tract Infections with a New Antibacterial Nitrofuran", Antibiotics & Chemotherapy , Vol. 3, No. 2 (February, 1953), pp. 151-157; Richards, W. A., E. Riss, E. H. Kass & M. Finland, "Nitrofurantoin - Clinical and Laboratory Studies in Urinary Tract Infections", Archives of Internal Medicine , Vol. 96 (1955), pp. 437-450; Eudy, W. W., "Correlations Between In Vitro Sensitivity Testing and Therapeutic Response in Urinary Tract Infections", Urology , Vol. II, No. 5, (November, 1973), pp. 519-587; Bush, I.M., W.I. Metzger, I. Garlovsky, R. B. Bush, R. J. Ablin & N. Sadoughi, "Urinary Tract Infection - Antibacterial Susceptability Patterns", Urology , Vol. III, No. 6 (June, 1974), pp. 697-700; Dickey, L., "A Comparison of the In Vitro Effectiveness of Nitrofurantoin and Five Antibiotics Against Bacteria from Urinary Tract Infections", American Journal of Medical Technology , (September-October, 1961), pp. 273-279; Karmali, M. A., S. DeGrandis & P. C. Fleming, "Antimicrobial Susceptibility of Campylobacter jejuni with Special Reference to Resistance Patterns of Canadian Isolates", Antimicrobial Agents and Chemotherapy , Vol. 19, No. 4 (1981), pp. 593-597. Antibiotics are also among the preferred campylobacter-inhibiting antimicrobial agents useful herein. Such antibiotics can be generally classified by chemical composition into the following principal groups: the aminoglycosides, such as gentamicin, neomycin, kanamycin, and streptomycin; the macrolides, such as erythromycin, clindamycin, and rifampin; the penicillins, such as penicillin G, penicillin V, ampicillin, and amoxycillin; the polypeptides, such as bacitracin and polymyxin; the tetracyclines, such as tetracycline, chlortetracycline, oxytetracycline, and doxycycline; the cephalosporins, such as cephalexin and cephalothin; and such miscellaneous antibiotics and chloramphenicol and clindamycin. These antibiotics can be generally said to function in one of four ways: inhibition of cell wall synthesis, alteration of cell wall permeability, inhibition of protein synthesis, or inhibition of nucleic acid synthesis. Campylobacter-inhibiting bismuth-containing agents (as disclosed in the concurrently filed, copending patent application of G. Place having U.S. Patent Application Serial No. 023597 (P&G Case No. 3621) are also preferred campylobacter-inhibiting antimicrobial agents for use herein. Preferred campylobacter-inhibiting bismuth-containing agents are bismuth subcitrate and bismuth subsalicylate. Specific campylobacter-inhibiting antimicrobial agents useful herein are: penicillin G, mezlocillin, ampicillin, cefalothin, cefoxitin, cefotaxime, imipenem, gentamicin, amikacin, erythromycin, ciprofloxacin, tetracyclines, metronidazole, amoxycillin, cephalosporins, nitrofurantoin, nitrofurazone, furazolidone, bismuth subsalicylate, and bismuth subcitrate. The most preferred campylobactor-inhibiting antimicrobial agents for use herein is nitrofurantoin. The pharmaceutical compositions of the present invention typically comprise, by weight, from 0.1% to 99.8% of the campylobacter-inhibiting antimicrobial agent, preferably from 0.1% to 75%, and most preferably from 1% to 50%. H ₂ Receptor Blocking Anti-Secretory Agents In addition to the bismuth-containing agent described hereinbefore, the pharmaceutical compositions of the present invention also comprise an H₂ receptor blocking anti-secretory agent. The H₂ receptor blocking anti-secretory agents useful in the present invention include cimetidine, ranitidine, burimamide, metiamide, tiotidine, and oxmetidine, as well as compounds of the formula: The above structures are well-known in the art (see C&E News , April 12, 1982, pp 24-26. Mixtures of the above H₂ receptor blocking anti-secretory agents may also be employed. The most preferred of these compounds are cimetidine, ranitidine, and mixtures thereof, with cimetidine being especially preferred. The preparation and use of H₂ receptor blocking anti-secretory agents as described hereinbefore are well-known in the art. For example, the preparation and use of cimetidine are discussed in U.S. Patent 3,950,333, to Durant et al., issued April 13, 1976; Brimblecombe, et al., J. Int. Med. Res. , 3 , 86 (1975); Brimblecombe, et al, Brit. J. Pharmacol. , 53 , 435 (1975); and Brogden, et al., Drugs , 15 , 93-131 (1978). Also, for example, the preparation and use of ranitidine are discussed in U.S. Patent 4,128,658, to Price et al., issued December 5, 1978; Bradshaw et al., Brit. J. Pharmacol. , 66 , 464 (1979); Daly, et al., Gut , 21 , 408 (1980); Berstad, et al., Scand. J. Gastroenterol. , 15 , 637 (1980); and Walt, et al., Gut , 22 , 49 (1981). The pharmaceutical compositions of the present invention typically comprise, by weight, from 0.1% to 99.8% of the H₂ receptor blocking anti-secretory agent, preferably from 0.1% to 75%, and most preferably from 1% to 50%. Pharmaceutically-Acceptable Carriers In addition to the campylobacter-inhibiting antimicrobial agent and the H₂ receptor blocking anti-secretory agent as described hereinbefore, the pharmaceutical compositions of the present invention also essentially contain a pharmaceutically-acceptable carrier. The term "pharmaceutically-acceptable carrier", as used herein, means one or more compatible solid or liquid filler diluents or encapsulating substances which are suitable for administration to a human or lower animal. The term "compatible", as used herein, means that the components of the pharmaceutical composition are capable of being commingled with the campylobacter-inhibiting antimicrobial agent and the H₂ receptor blocking anti-secretory agent, and with each other, in a manner such that there is no interaction which would substantially reduce the pharmaceutical efficacy of the pharmaceutical composition under ordinary use situations. Pharmaceutically-acceptable carriers must, of course, be of sufficiently high purity and sufficiently low toxicity to render them suitable for administration to the human or lower animal being treated. A variety of pharmaceutically-acceptable carriers may be included, depending on the particular dosage form to be used. Various oral dosage forms can be used, including such solid forms as tablets, capsules, granules and bulk powders. Tablets can be compressed, tablet triturates, enteric-coated, sugar-coated, film-coated or multiple compressed, containing suitable binders, lubricants, diluents, disintegrating agents, coloring agents, flavoring agents, flow-inducing agents, and melting agents. Liquid oral dosage forms include aqueous solutions, emulsions, suspensions, solutions and/or suspensions reconstituted from non-effervescent granules and effervescent preparations reconstituted from effervescent granules, containing suitable solvents, preservatives, emulsifying agents, suspending agents, diluents, sweeteners, melting agents, coloring, and flavoring agents. Some examples of substances which can serve as pharmaceutically-acceptable carriers are sugars such as lactose, glucose and sucrose; starches such as corn starch and potato starch; cellulose and its derivatives such as sodium carboxymethylcellulose, ethylcellulose, cellulose acetate; powdered tragacanth; malt; gelatin; talc; stearic acid; magnesium stearate; calcium sulfate; vegetable oils such as peanut oil, cottonseed oil, sesame oil, olive oil, corn oil and oil of theobroma; polyols such as propylene glycol, glycerine, sorbitol, mannitol, and polyethylene glycol; agar; alginic acid, pyrogen-free water; isotonic saline; and phosphate buffer solutions, as well as other non-toxic compatible substances used in pharmaceutical formulations. Wetting agents and lubricants such as sodium lauryl sulfate, as well as coloring agents, flavoring agents, excipients, tableting agents, stabilizers, anti-oxidants, and preservatives can also be present. Other compatible pharmaceutical additives and actives (e.g., NSAI drugs; pain killers; muscle relaxants) may be included in the pharmaceutically-acceptable carrier for use in the compositions of the present invention. Specific examples of pharmaceutically-acceptable carriers that may be used to formulate oral dosage forms of the present invention are described in U.S. Patent 3,903,297, Robert, issued September 2, 1975. Techniques and compositions for making dosage forms useful herein are described in the following references: 7 Modern Pharmaceuticals , Chapters 9 and 10 (Banker and Rhodes, Ed., 1979); Lieberman, et al., Pharmaceutical Dosage Forms: Tablets (1981); and Ansel, Introduction to Pharmaceutical Dosage Forms (2nd Edition, 1976). The choice of a pharmaceutically-acceptable carrier to be used in conjunction with the campylobacter-inhibiting antimicrobial agent and H₂ receptor blocking anti-secretory agent combination of the present invention is basically determined by the way the composition is to be administered. The preferred mode of administering the compositions of the present invention is orally. The preferred unit dosage form is therefore tablets, capsules, and the like, comprising a safe and effective amount of the campylobacter-inhibiting antimicrobial agent and the H₂ receptor blocking anti-secretory agent combination of the present invention. Pharmaceutically-acceptable carriers suitable for the preparation of unit dosage forms for oral administration are well known in the art. Their selection will depend on secondary considerations like taste, cost, shelf stability, which are not critical for the purposes of the present invention, and can be made without difficulty by a person skilled in the art. The pharmaceutically-acceptable carrier employed in conjunction with the campylobacter-inhibiting antimicrobial agent and the H₂ receptor blocking anti-secretory agent combination of the present invention is used at a concentration sufficient to provide a practical size to dosage relationship. The pharmaceutically-acceptable carriers, in total, may comprise from 0.1% to 99.8%, by weight, of the pharmaceutical compositions of the present invention, preferably from 25% to 99.8%, and most preferably from 50% to 99%. The term "administering", as used herein, refers to any method which, in sound medical practice, delivers the campylobacter-inhibiting antimicrobial agent and the H₂ receptor blocking anti-secretory agent to the subject to be treated in such a manner so as to be effective in the treatment of the gastrointestinal disorder. Preferably, both these agents are administered orally. The term "gastrointestinal disorder", as used herein, encompasses any disease or other disorder of the upper gastrointestinal tract of a human or lower animal. The term "upper gastrointestinal tract", as used herein, is defined to include the esophagus, the stomach, the duodenum, and the jejunum. Such gastrointestinal disorders include, for example: disorders not manifested by presence of ulcerations in the gastric mucosa (herein "non-ulcerative gastrointestinal disorders"), including chronic or atrophic gastritis, non-ulcer dyspepsia, esophageal reflux disease and gastric motility disorders; and "peptic ulcer disease", i.e., gastric, duodenal and jejunal ulcers. Gastrointestinal disorder especially refers to such disorders of the upper gastrointestinal tract which are conventionally treated with H₂ receptor blocking anti-secretory agents alone. The phrase "safe and effective amount", as used herein, means an amount of a campylobacter-inhibiting antimicrobial agent or H₂ receptor blocking anti-secretory agent, when used in combination with each other according to the compositions and methods of the present invention, high enough to significantly positively modify the condition to be treated but low enough to avoid serious side effects (at a reasonable benefit/risk ratio), within the scope of sound medical judgment. The safe and effective amount of the agents of the present invention will vary with the particular condition being treated, the age and physical condition of the patient being treated, the severity of the condition, the duration of treatment, the nature of concurrent therapy, the specific agents employed, the particular pharmaceutically-acceptable carrier utilized, and like factors within the knowledge and expertise of the attending physician. The of the present invention typically involves the manufacture of a medicament for a treatment comprising administering the campylobacter-inhibiting antimicrobial agent in an amount of from 1 mg to 10,000 mg of antimicrobial agent per day. The specific preferred quantity of antimicrobial depends upon the particular antimicrobial used and its pharmacology. In general, though, the tetracyclines are preferably administered at a level of from 100 mg to 2000 mg per day. Macrolides (such as erythromycin) are preferably administered at a level of from 1000 mg to 4000 mg per day. Penicillins are preferrably administered at a level of from 500 mg to 3000 mg per day. The aminoglycosides (such as neomycin) are, preferably, administered at a level of from 100 mg to 8000 mg per day. Preferably, metronidazole is administered at a level of from 500 mg to 2000 mg per day. Nitrofurans (such as nitrofurantoin) are administered preferably at a level of from 1 mg to 800 mg per day. More particularly, the preferred daily dosage of nitrofurantoin is from 1 mg to 600 mg per day, more preferably from 10 mg to 400 mg per day, and most preferably from 20 mg to 200 mg per day. The use of the present invention typically involves the manufacture of a medicament for a treatment comprising administering the H₂ receptor blocking anti-secretory agent in an amount of from 1 mg to 10 g per day. Preferably from 50 mg to 5000 mg, more preferably from 100 mg to 1500 mg, most preferably from 400 mg to 1200 mg, of cimetidine is administered per day. The use of the present invention comprises the manufacture of a medicament for a treatment comprising administering the campylobacter-inhibiting antimicrobial agent and the H₂ receptor blocking anti-secretory agent concurrently. The term "concurrently", as used herein, means that the two agents are administered within about 1 hour of each other, and most preferably within about 5 minutes of each other; and includes co-administration of the agents by administering a composition of the present invention. The use of the present invention in which the agents are administered concurrently comprise any dosing regimen in which part or all of the dosing of the agents is preformed concurrently. Thus, for example, concurrent dosing of the agents includes: 1. 14 days of administration of a pharmaceutical composition of the present invention. 2. 28 days of administration of the campylobacter-inhibiting antimicrobial agent and the H₂ receptor blocking anti-secretory agent essentially simultaneously (i.e., within about 5 minutes of each other), followed by 7 days of treatment with only the campylobacter-inhibiting antimicrobial agent. 3. 3 days of administration of only the campylobacter-inhibiting antimicrobial agent, followed by 21 days of administration of the campylobacter-inhibiting antimicrobial agent and the H₂ receptor blocking anti-secretory agent essentially simultaneously (i.e., within about 5 minutes of each other). For the use of the present invention, the duration of administration of the agents during concurrent dosing of the agents will vary according to the specific gastrointestinal disorder being treated, but typically is within the range of from 1 to 60 days. In general, however, in methods for treatment of non-ulcerative gastrointestinal disorders the duration of treatment comprises administering the agents for from 3 to 21 days. In methods for treatment of peptic ulcer disease, the duration of treatment comprises administering the agents for from 14 to 56 days. If the compositions of the present application are administered, similar durations are utilized depending on the gastrointestinal disorder to be treated. The following examples further describe and demonstrate the preferred embodiments within the scope of the present invention. Example I Pharmaceutical Compositions in Tablet Form Tablets are prepared by conventional methods, such as mixing and direct compaction, formulated as follows: Ingredients Mg per Tablet Nitrofurantoin 50 Cimetidine 300 Microcrystalline cellulose 100 Sodium starch glycolate 30 Magnesium stearate 3 When one tablet is administered orally 4 times per day for 14 days, the above compositions significantly improve the condition of a patient suffering from gastritis. A significant long-lasting benefit is also acheived by daily administration for 28 days (4 tablets per day) of this composition to a patient suffering from gastric ulcers. Similar results are achieved with tablets formulated as above but replacing the cimetidine with ranitidine. Example II Pharmaceutical Compositions in Capsule Form Capsules are prepared by conventional methods, comprised as follows: Ingredients Mg/Capsule Nitrofurantoin 50 Cimetidine 300 Lactose To fill to volume of capsule One of the above capsules administered orally 4 times a day for 21 days substantially reduces the symptomology of a patient afflicted with a gastric ulcer. Similar results are obtained with capsules formulated above but replacing the cimetidine with ranitidine. Example III Methods Comprising Concurrent Administration A patient suffering from gastritis is treated according to a regimen comprising 28 days of oral administration of 200 mg of nitrofurantoin in the morning and oral administration of 400 mg of cimetidine (as 2 Tagamet R tablets; sold by Smith Kline and French Laboratories) in the evening before bedtime. This regimen significantly improves the condition of the patient being treated. Similar results are obtained when the cimetidine is replaced with ranitidine. Similarly effective treatment of a patient suffering from gastritis is achieved by the following regimens utilizing nitrofurantoin and cimetidine (supplied as Tagamet R ): 21 days of daily oral administration of the two agents within about 5 minutes of each other; 21 days of daily oral administration of the two agents within about 5 minutes of each other followed by 7 days of treatment with only nitrofurantoin; and 7 days of treatment with nitrofurantoin followed by 21 days of daily oral administration of the two agents within about 5 minutes of each other.

Claims: Pharmaceutical compositions useful for treating or preventing gastrointestinal disorders, said compositions comprising : (a) a campylobacter-inhibiting antimicrobial agent ; (b) an H₂ receptor blocking anti-secretory agent ; and (c) a pharmaceutically-acceptable carrier. Pharmaceutical compositions useful for treating or preventing gastrointestinal disorders, according to Claim 1, wherein the campylobacter-inhibiting antimicrobial agent is selected from antibacterial nitrofurans and antibiotics. Pharmaceutical compositions useful for treating or preventing gastrointestinal disorders, according to Claim 1 or 2, wherein the campylobacter-inhibiting antimicrobial agent is nitrofurantoin. Pharmaceutical compositions useful for treating or preventing gastrointestinal disorders, according to any of Claims 1-3, wherein the H₂ receptor blocking anti-secretory agent is selected from cimetidine, ranitidine, and mixtures thereof. Pharmaceutical compositions useful for treating or preventing gastrointestinal disorders, according to any of Claims 1-4, wherein the H₂ receptor blocking anti-secretory agent is cimetidine. The use of a campylobacter-inhibiting antimicrobial agent and a H₂ receptor blocking anti-secretory agent for the manufacture of a medicament for the treatment or prevention of gastrointestinal disorders selected from non-ulcerative gastrointestinal disorders such as chronic or atrophic gastritis, non-ulcer dyspepsia, esophageal reflux disease, gastric motility disorders and peptic ulcer disease, selected from gastric, duodenal and jejunal ulcers, in humans or lower animals, said treatment or prevention comprising administering to said human or lower animal a composition comprising, by weight, from 0.1% to 99.8% of the campylobacter-inhibiting antimicrobial agent and concurrently administering to said human or lower animal a safe and effective amount of an H₂ receptor blocking anti-secretory agent. The use according to Claim 6, wherein the campylobacter-inhibiting antimicrobial agent is selected from antibacterial nitrofurans and antibiotics, and wherein further the H₂ receptor blocking anti-secretory agent is selected from the group consisting of cimetidine, ranitidine, and mixtures thereof. The use according to any of Claims 6-7, wherein the campylobacter-inhibiting antimicrobial agent is nitrofurantoin. The use according to any of Claims 6-8, wherein said gastrointestinal disorder is a non-ulcerative gastrointestinal disorder. The use according to any of Claims 6-8, wherein said gastrointestinal disorder is a peptic ulcer disease. The use according to any of Claims 6-8, wherein the H₂ receptor blocking anti-secretory agent is cimetidine. The use according to any of Claims 6-8, wherein the H₂ receptor blocking anti-secretory agent is ranitidine.

Inventors: PLACE GEOFFREY, PLACE, GEOFFREY
Applicants: PROCTER & GAMBLE, THE PROCTER & GAMBLE COMPANY
Application year: 1988
Main classification: A61K31
IPC codes: A61K31, A61P43, A61P31, A61K33, A61P1, A61K45