Compositions containing G-CSF and TNF binding protein

Abstract: The present invention is directed to products containing G-CSF or a pharmaceutically acceptable salt thereof and a TNF binding protein or a pharmaceutically acceptable salt thereof and, if desired a pharmaceutically acceptable carrier as a combined preparation, the use of a G-CSF or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for the prophylaxis and/or treatment of septic shock of patients receiving a TNF binding protein or a pharmaceutically acceptable salt thereof, the use of a TNF binding protein or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for the prophylaxis and treatment of septic shock of patients receiving a G-CSF and a method of treating and/or preventing septic shock which method comprises administering both a TNF binding protein or a pharmaceutically active salt thereof and a G-CSF or a pharmaceutically active salt thereof.

Description: The present invention is directed to products containing Granulocyte Colony Stimulating Factor (G-CSF) or a pharmaceutically acceptable salt thereof and a Tumor Necrosis Factor (TNF) binding protein (TNF-BP) or a pharmaceutically acceptable salt thereof as a combined preparation, especially in the prophylaxis and/or therapy of septic shock. G-CSF is a fundamental factor in the differentiation and maturation of granulocytes [Metcalf, D., Blood 67 , 257-267 (1986)]. Therapy with G-CSF has been shown to result in rapid improvement of the immune status in both animal models of induced neutropenia [Cohen A.M. et al., Proc. Natl. Acad. Sci. USA 84 , 2484-2488 (1987)] and neutropenic patients [Gabrilove, J.L. et al., N. Engl. J. Med. 318 , 1414-1422 (1988)]. In line with this, G-CSF proved to diminish the incidence of febrile episodes and nosocomially acquired infections in patients with neutropenia and cancer patients undergoing cytostatic chemotherapy [Crawford, J. et al., N. Engl. J. Med. 325 , 164-170 (1991)]. However, the effects of G-CSF on neutrophils are not limited on differentiation and proliferation. It became increasingly clear that it plays also an important role in the regulation of functions in mature leukocytes [Lopez, A.F. et al., J. Immunol. 131 , 2983 (1983)]. G-CSF was recently found to reduce lethality in lipopolysaccharide (LPS)-induced septic shock in animals [Görgen, I. et al., J. Immunol. 149 , 918-924 (1992)]. This is also known for soluble TNF-receptor (TNFR) fragments or chimaeric polypeptides comprising such soluble fragments [Lesslauer, W. et al., Eur. J. Immunol. 21 , 2883-2886 (1991)]. Models of LPS-induced shock have been widely used for the identification of compounds that could have a potential in prophylaxis and therapy of shock in humans. However, it seems that models of infection-induced septic shock are more related to the clinical situation than those of LPS-induced shock [Zanetti, G. et al., J. Immunol. 148 , 1890-1897 (1992)]. Accordingly G-CSF and such a chimaeric polypeptide have been investigated in a model in which the shock event is elicited by generalizing Escherichia coli peritonitis. Whereas G-CSF and the aforementioned chimaeric polypeptide alone did not show a significant increase in the survival rate, it has been surprisingly found that when G-CSF and the chimaeric polypeptide were applied both in the same model situation that a marked improvement in protection was seen. Accordingly it is an object of the present invention to provide products containing G-CSF or a pharmaceutically acceptable salt thereof and a TNF-BP or a pharmaceutically acceptable salt thereof as a combined preparation for simultaneous, separate or sequential use in the prophylaxis and/or therapy of septic shock. The term G-CSF in the context of the present specification and claims is used in its broadest sense in view of the biological activity understood by the skilled artisan and comprises polypeptides (either of natural or synthetic including recombinant origin, either modified or not) as defined and described (including their preparation and use) in the scientific literature and, e.g., in any of the following patent publications: DE 30 27 105, EP 169 566, EP 215 126, EP 237 545, EP 396 158, EP 220 520, EP 217 404, EP 230 980, EP 231 819, DE 37 23 781, EP 263 490, EP 344 796, EP 355 811, EP 373 679, EP 401 384, EP 456 812, EP 459 630, EP 459 516, EP 459 795, EP 243 153, EP 272 703, EP 331 186, EP 335 423, WO 93/15211. A G-CSF as disclosed in EP 237 545 [human pluripotent G-CSF (hpG-CSF)] i.e. a recombinant molecule, optionally containing a methionin residue at its N-terminus is preferred. Most particularly preferred is a G-CSF having the specific amino acid sequence and being encoded by DNA-sequences given in EP 237 545. In other words the term G-CSF in addition to G-CSF of natural origin comprises any G-CSF coded by a DNA-sequence which upon expression in a prokaryotic or eukaryotic host cell yields a polypeptide product having at least a part of the primary structure and one or more of the biological properties of naturally-occurring hpG-CSF as defined in EP 237 545, said DNA sequence being selected from among: (a) the DNA sequence set out in Table VII of EP 237 545 or the complementary strands thereof; (b) DNA sequences which hybridize under any suitable hybridization conditions, e.g., as illustrated in EP 237 545 or described in "Molecular Cloning" of Sambrook et al. 1989, Cold Spring Harbor Laboratory Press, Cold Spring Harbor and (c) DNA sequences which, but for the degeneracy of the genetic code, would hybridize to the DNA sequences defined in (a) or (b) and which sequences code for a polypeptide having the same amino acid sequences. DNA-sequences which hybridise with the ones defined above, so called mutant DNA-sequences, can be prepared by random or site directed mutagenesis or by chemical synthesis or by the polymerase chain reaction (PCR)-technology using primers defined on the basis of the DNA-sequences given in EP 237 545 by methods known in the art and described, e.g., by Sambrook et al. (s.a.) or for the PCR-technology by Innis et al. [PCR Protocols: A Guide to Methods and Applications, Academic Press, Inc. (1990)]. Thus using such mutant DNA-sequences mutant G-CSFs which are comprised by the term "G-CSF" can be prepared by methods known in the art and described, e.g., in the above mentioned patent publications. Mutant G-CSFs are defined and their preparations are described especially in EP 243 153, WO 90/12874, WO 89/05824, EP 272 703 or EP 456 200. As stated above the term G-CSF comprises G-CSF, either of natural or recombinant origin, also in modified form, e.g., when coupled to chemical entities which without altering the basic biological activity of G-CSF are modifying it in a therapeutically advantageous way. A preferred and well known modification of polypeptides such as G-CSF is the coupling to water soluble polymers, e.g., polyethylene glycols or polypropylene glycols, within a wide range of molecular weight of, e.g., from 500 to 20'000 daltons. This leads to protected G-CSFs, e.g., pegylated G-CSF, which could be substantially non-immunogenic. Several modes of coupling the polymer with G-CSF via different linkers are available in the state of the art and described, e.g., in general in "Perspectives in Bioconjugate Chemistry", edt. by C.F. Meares, American Chemical Society, Washington 1993, and specifically, e.g., in U.S. Patent No. 4,179,337. Modified G-CSFs and their preparation are described, e.g., in EP 401 384, EP 335 423 and EP 473 268. Modified G-CSF also comprises, e.g., G-CSF which shows a different glycosylation pattern as known for naturally occurring or recombinant G-CSF in the form of at least one additional polycarbohydrate chain as described, e.g., in EP 370 205. The term TNF binding protein (TNF-BP) comprises any protein or fragment of a protein being composed of sufficient amino acids so that a structure can be formed which allows binding of human TNF irrespective of wherefrom or how it is obtained. Such TNF-BP can be, e.g., an antibody to TNF like a monoclonal antibody but also any type of chimaeric antibody to human TNF as described, e.g., in WO 91/02078. Such chimaeric antibody is an antibody in which different parts of the molecule have different species origin, namely human and animal, e.g., mouse, rat or rabbit. In a preferred embodiment in such antibodies only the complementary determining regions are of non-human origin, and if desired additional amino acids in the variable regions. They can be prepared according to methods known in the art and as described, e.g., in EP 239 400 or in WO 90/07861. A TNF-BP as defined above can be also any naturally occurring or recombinantly made TNF-receptor or a part thereof, preferably a protein which comprises a part of or is derived from a part of the human p55- or p75-TNFR, which part still binds TNF as, e.g., a soluble part of these receptors or, e.g., so called chimaeric polypeptides which comprise a soluble part of these receptors and all or parts of the constant domains, but at least one constant domain, of the heavy or the light chain of human immunoglobulin. Preferred are such chimaeric polypeptides wherein the TNF binding part is a part of or derived from the human p55-TNFR. Furthermore such chimaeric polypeptides are preferred wherein the immunoglobulin part comprises all domains except the first domain of the constant region of the heavy chain of human immunoglobulin such as IgG, IgA, IgM or IgE, especially IgG, e.g., IgG1 or IgG3. A man skilled in the art is very well aware of the fact that any amino acid of the immunoglobulin part or the TNF binding part can be deleted or substituted by one or more amino acids or one or more amino acids can be added as long as the TNF binding part still binds TNF and the immunoglobulin parts shows one or more of its characteristic properties. The same is true for a TNF-BP as defined above without an immunoglobulin part. TNF-BPs, their isolation from natural sources or their preparation by recombinant methods including the preparation of specific constructs like, e.g., in the form of chimaeric polypeptides comprising in addition to the TNF binding part also an immunoglobulin part, are described, e.g., in the following patent publications: EP 308 378, EP 422 339, GB 2 218 101, EP 393 438, WO 90/13575, EP 398 327, EP 412 486, WO 91/03553, EP 418 014, JP 127,800/1991, EP 433 900, U.S. Patent No. 5,136,021, GB 2 246 569, EP 464 533, WO 92/01002, WO 92/13095, WO 92/16221, EP 512 528, EP 526 905, WO 93/07863, EP 568 928, WO 93/21946, WO 93/19777 and EP 417 563. Specifically preferred are TNF-BPs in the form of recombinant soluble parts of the hTNFR, especially the p55-TNFR, which still binds TNF, or chimaeric polypeptides comprising such soluble parts and immunoglobulin parts as defined above and as described in EP 417 563. A man skilled in the art will understand that the definition of TNF-BP of the present invention will also comprise such TNF-BPs which have been modified chemically in a way as described above for G-CSF, e.g., by linkage to a water soluble polymer, e.g., polyethyleneglycol or polypropylenglycol by methods described in the state of the art, e.g., in WO 92/16221. Furthermore it is an object of the present invention to provide products as defined above wherein the G-CSF and/or the TNF-BP are/is in the form of (a) pharmaceutically acceptable salt(s). As used herein the term "pharmaceutically acceptable salt" refers to both salts of the products of the present invention. Such salts of a carboxyl group may be formed by means known in the art and include inorganic salts, for example, sodium, calcium, ammonium, ferric or zinc salts, and the like, and salts with organic bases as those formed, for example, with amines, such as triethanolamine, arginine or lysine, piperdine, procaine and the like. Acid addition salts include, for example, salts with mineral acids such as, for example, hydrochloric acid or sulfuric acid, and salts with organic acic or sulfuric acid, and salts with forganic acids such as, for example, acetic acid or oxalic acid. Further objects of the present invention are the use of G-CSF or a pharmaceutically acceptable salt thereof in the manufacture of a medicament, especially for the prophylaxis and/or treatment of septic shock of patients receiving a TNF-BP or a pharmaceutically acceptable salt thereof as defined above as well as the use of a TNF binding protein or a pharmaceutically acceptable salt thereof as defined above in the manufacture of a medicament, especially for the treatment and/or prophylaxis of septic shock of patients receiving G-CSF or a pharmaceutically acceptable salt thereof. The products containing G-CSF and TNF-BP are in the form of a combination, preferably in the form of a "kit-of-parts" arrangement containing the active ingredients in separate compartments intended for the simultaneous, separate or successive administration, especially in the prophylaxis and/or therapy of septic shock. This means that to a patient G-CSF and TNF-BP are separately applied at the same time (simultaneously) or separately applied in a successive manner having a synergistic effect. However, the combination comprises also combinations in which G-CSF and TNF-BP are in the form of a mixture in the same compartment. In the prophylaxis and/or treatment of septic shock by above mentioned method G-CSF may be administered to a patient by any route known in the state of the art, e.g., intramuscularly, intravenously, subcutaneously, e.g., by a subcutaneous implant as described, e.g., in EP 246 322, orally in the form of a specific oral dosage form as described, e.g., in EP 459 516 and EP 459 795, pernasally as described, e.g., in EP 565 722 or by pulmonary administration as described, e.g., in EP 505 123. G-CSF may be formulated in a suitable dosage form according to the specific route of administration selected. When G-CSF is obtained as a G-CSF containing solution by any of the known methods it is preferentially kept in solution at about 4°C but, dependent on the type of G-CSF obtained it may be also stored in a frozen state. Alternatively, the solution may be stored in lyophilized form after being dehydrated by freeze-drying or vacuum drying as described, e.g., for PEG-G-CSF in EP 335 423. If desired, the G-CSF may be kept in an appropriate buffer, followed by aseptic filtration through a millipore filter or any other suitable means so as to formulate an injectable preparation. In order to formulate a dosage form that is suitable for administration to the patient through a certain route, the G-CSF to be used in the method of treatment of the present invention may contain appropriate additives selected from known pharmaceutical carriers, excipients, diluents, stabilizers, e.g., in the form of proteins, e.g., human serum albumin, anti-adsorption agents, preservatives, solubilizers and emulsifiers as described, e.g., in DE 37 23 781 or is in the form of a stabilized hydrophobic formulation as described, e.g., in EP 373 679 or in the form of a sustained release particulate preparation as described, e.g., in EP 263 490 or EP 58 481 or for pegylated G-CSF as described, e.g., in EP 473 268. The level of dosage and the frequency of adminsitration of the G-CSF may be appropriately determined in consideration of various factors such as the severity of the shock state to be treated, body weight, age and sex of the patient, and the route of administration. Typically a dosage containing about 10-2000 µg/kg, preferably about 50-1500 µg/kg, of mostly preferably about 10-250µg G-CSF/kg body weight may be administered. The TNF-BP of the present invention is preferably administered parenterally by injection, although other effective administration forms, such as intraarticular injection, orally active formulations, transdermal iontophoresis or suppositories, are also possible. One preferred carrier is physiological saline solution, but it is contemplated that other pharmaceutically acceptable carriers may also be used. The primary solvent in such a carrier may be either aqueous or non-aqueous in nature. In addition, the carrier may contain other pharmacologically acceptable excipients for modifying or maintaining the pH, osmolarity, viscosity, clarity, color, sterility, stability, rate of dissolution, or odor of the formulation. Similarly, the carrier may contain still other pharmacologically acceptable excipients for modifying or maintaining the stability, rate of dissolution, release, or absorption of the TNF inhibitor. Such excipients are those substances usually and customarily employed to formulate dosages for parental administration in either unit dose or multidose form. Once the therapeutic composition has been formulated, it may be stored in sterile vials as a solution, suspension, gel, emulsion, solid, or dehydrated or lyophilized powder. Such formulations may be stored either in a ready to use form or a form requiring reconstitution immediately prior to administration. The preferred storage of such formulations is at temperatures at least as low as 4°C and preferably at -70°C. It is also preferred that such formulations containing TNF-BPs are stored and administered at or near physiological pH. In certain embodiments, the administration is designed in order to create a preselected concentration range of TNF-BP in the patient's blood stream. It is believed that the maintenance of circulating concentrations of TNF-BP of more than 0.01 ng per ml of plasma is necessary in order to be effective. A possible dosage range for the treatment of septic shock may be between about 0.1-200 mg per kg of patient body weight per 24 hours administered in equal doses between about 4-15 times per 24 hours. The frequency of dosing and the optimal dose will depend on pharmacokinetic parameters of the TNF-BP in the formulation used. The treatment for septic shock should begin, under either mode of treatment, as soon as possible after septicemia has occurred or possible septicemia is diagnosed. For example, treatment may begin immediately following surgery or an accident or any other event that may include a risk of septic shock. Regardless of the manner of administration, the specific dose is calculated according to the approximate body weight of the patient. Further refinement of the calculations necessary to determine appropriate dosage for treatment involving each of the above mentioned formulations is routinely made by the man skilled in the art. Example Septic shock induced by generalized E. coli peritonitis Swiss albino mice (Jbm MoRo, weight 16 to 20 g) were injected with aqueous solution of G-CSF (Neupogen, Hoffmann-La Roche, Basle, CH; 0.1 mg/kg sc) and/or TNFR/IgG3 (a TNF-BP as described in EP 417 563 consisting of the first 182 amino acids of the human p55-TNFR fused to the hinge region of human IgG3 heavy chain and expressed in mouse J558L myeloma cells; 2.5 mg/kg ip) as designated in Table 1. Peritonitis was induced by intraperitoneal injection of 10 6 CFUs (colony-forming units) of an overnight culture of E . coli 25922, which is about 500 times the number of organisms required to kill 50 % of unmedicated animals within 72 hours. Control and treatment groups were composed of 5-10 mice each. The developing generalized infection was stopped in all animals by the administration of ceftriaxone (Hoffmann-La Roche, Basel, CH; 1 mg/kg sc) 3.8 hours after bacterial challenge. This resulted in bacterial clearance of the bloodstream, but was too late to prevent lethal septic shock in >80 % of unprotected animals. Surviving mice received an additional ceftriaxone treatment 24 hours after challenge. The rate of survival was read 24, 48 and 72 hours after infection. Animals that were severely sick and unable to eat and drink 21 hours or later after challenge were sacrificed and registered as therapeutic failures. For control heart blood was taken from at least one dead or sacrificed mouse in the treatment groups and the control group and cultivated on agar. The summarized data of several experiments performed with G-CSF and the specific TNF-BP mentioned are presented in Table 1. When given as single compounds, G-CSF yielded a 20 % rate of survival and the specific TNF-BP a 22 % survival rate. These differences to the saline control group with 10 % rate of survival are not significant. A marked improvement in protection was achieved by combining G-CSF and the specific TNF-BP. All mice survived when G-CSF was given thrice, i.e. 48 h, 24 h, and 2 h before infection, in the combination regimen. All these animals showed visible signs of beginning septic shock 3 hours after infection as did the control animals. However, they did not die and began to recover about 24 hours after challenge. When the last dose of G-CSF 2 h before infection was omitted in the combined regimen, the rate of protection decreased to 65 %. The viable bacterial count 3.8 h after challenge when the septicemia was stopped by the administration of ceftriaxone, was only slightly lower in the G-CSF plus the specific TNF-BP group than in the saline group (2.6 x 10 8 CFU/ml vs. 3.5 x 10 8 CFU/ml, respectively). The endotoxin content of G-CSF (25 µg/ml) and TNFR/IgG3 (250 µg/ml) has been determined in a limulus amebocyte lysate assay (sensititvity: 0.06 EU/ml) as known in the art to be <0.05 EU/ml. Accordingly desensitization against LPS can be excluded. Dose dependency of G-CSF in E. coli-induced shock in Swiss albino mice is shown in Table 2 (G-CSF was administered in varying doses as indicated 48 hs, 24 hs and 2hs before challenge and 50 µg TNFR/IgG3/mouse were administered 2 hs before callenge). Pretreatment Challenge E.coli [ATCC 25922] Survivors/total Saline + 1/10 G-CSF (5.00 µg) + TNFR/IgG3 + 8/10 G-CSF (1.00 µg) + TNFR/IgG3 + 7/10 G-CSF (0.20 µg) + TNFR/IgG3 + 7/10 G-CSF (0.04 µg) + TNFR/IgG3 + 3/10

Claims: Products containing G-CSF or a pharmaceutically acceptable salt thereof and a TNF binding protein or a pharmaceutically acceptable salt thereof and, if desired a pharmaceutically acceptable carrier as a combined preparation. Products according to claim 1 for simultaneous, separate or sequential use in the therapy and/or prophylaxis of septic shock. Products according to claim 1or 2 wherein the TNF binding protein comprises the TNF-receptor or a part thereof which still binds TNF. Products according to any of claims 1 to 3 wherein the TNF binding protein comprises a part of the p55- or p75-TNF-receptor which part still binds TNF. Products according to claim 4 wherein the TNF binding protein is a soluble part of the p55- or the p75-TNF-receptor which soluble part still binds TNF. Products according to claim 4 wherein the TNF binding protein is a chimaeric polypeptide which comprises a soluble part of the p55- or the p75-TNF-receptor and all or parts of the constant domains of the heavy or light chain of human immunoglobulin. Products according to claim 6 wherein the chimaeric polypeptide comprises all domains except the first domain of the constant region of the heavy chain of human immunoglobulin such as IgG, IgA, IgM or IgE. Products according to claim 7 wherein the human immunoglobulin is IgG, especially IgG1 or IgG3. Products according to claim 1 or 2 wherein the TNF binding protein is an antibody to TNF. Products according to any of claims 1 to 9 wherein the G-CSF is natural G-CSF or the product of its prokaryotic or eukaryotic expression. Products according to claim 10 wherein the G-CSF is the product of prokaryotic expression. Products according to claim 10 or 11 wherein the G-CSF is modified. Products according to claim 12 wherein the G-CSF is pegylated. The use of a G-CSF as defined in any of claims 10 to 13 or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for the prophylaxis and/or treatment of septic shock of patients receiving a TNF binding protein as defined in any of claims 3 to 9 or a pharmaceutically acceptable salt thereof. The use of a TNF binding protein as defined in any of claims 3 to 9 or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for the prophylaxis and treatment of septic shock of patients receiving a G-CSF as defined in any of claims 10 to 13.

Inventors: ALBER GOTTFRIED, ANGEHRN PETER, ALBER, GOTTFRIED, ANGEHRN, PETER
Applicants: HOFFMANN LA ROCHE, F. HOFFMANN-LA ROCHE AG
Application year: 1995
Main classification: A61K38
IPC codes: A61K39, A61K38