METHOD OF TREATING POLYCYSTIC OVARIAN SYNDROME USING IGF/IGFBP-3

Abstract: Methods and compositions are provided for the treatment of polycystic ovarian syndrome (PCOS) by long term administration of IGF/IGFBP-3 complex. Also provided are methods and compositions for increasing serum levels of sex hormone binding globuline.

Description: METHOD OF TREATING POLYCYSTIC OVARIAN SYNDROME USING IGF/IGFBP-3 FIELD OF THE INVENTION The invention relates generally to the field of medical treatments and compositions, and more particularly to the treatment of polycystic ovarian syndrome (PCOS). BACKGROUND OF THE INVENTION IGF IGF -I and IGF-II are growth factors that have related amino acid sequence and structure, with each polypeptide having a molecular weight of approximately 7.5 kilodaltons (Kd). IGF -I mediates the major effects of growth hormone, and thus is the primary mediator of growth after birth. IGF-I has also been implicated in the actions of various other growth factors, since treatment of cells with such growth factors leads to increased production of IGF-I. In contrast, IGF-II is believed to have a major role in fetal growth. Both IGF-I and IGF-II have insulin-like activities (hence their names), and are mitogenic (stimulate cell division) and/or are trophic (promote recovery/survival) for cells in neural, muscular, reproductive, skeletal and other tissues. Unlike most growth factors, IGFs are present in substantial quantity in the circulation, but only a very small fraction of this IGF is free in the circulation or in other body fluids. Most circulating IGF is bound to the IGF -binding protein IGFBP-3. IGF-I may be measured in blood serum to diagnose abnormal growth-related conditions, e.g., pituitary gigantism, acromegaly, dwarfϊsm, various growth hormone deficiencies, and the like. Although IGF-I is produced in many tissues, most circulating IGF-I is believed to be synthesized in the liver. IGF is known to bind to at least three different cellular receptors; the type 1 IGF receptor, the type 2 IGF receptor, and the insulin receptor (to which IGF binds with much lower affinity than the type 1 or 2 receptor). Mutants of IGF-I have been described which have altered binding to one or more of these cellular receptors. Mutations at residue 24 (normally tyrosine) to non-aromatic residues or replacement of residues 28-37 selectively affects binding to the type 1 receptor, while mutations at residues 49-51 can selective reduce type 2 receptor binding. Mutations at residue 60 (from tyrosine to non-aromatic amino acids) can alter binding to the type 1 and 2 IGF receptors as well as the insulin receptor (Cascieri et al. (1988) Biochemistry 27:3229-3233; Cascieri et al. (1989) JBiol. Chem. 264:2199-2202; Bayne et al. (1988) JBiol. Chem. 264:11004-11008; Bayne et al. (1990) J. Biol. Chem. 265:15648-15652). Almost all IGF circulates in a non-covalently associated ternary complex composed of IGF-I or IGF-II, IGFBP-3, and a larger protein subunit termed the acid labile subunit (ALS). The IGF/IGFBP-3/ALS ternary complex is composed of equimolar amounts of each of the three components. ALS has no direct IGF binding activity and appears to bind only to the IGF/IGFBP-3 binary complex. The IGF/IGFBP-3/ALS ternary complex has a molecular weight of approximately 150 Kd. This ternary complex is thought to function in the circulation "as a reservoir and a buffer for IGF-I and IGF-II preventing rapid changes in the concentration of free IGF" (Blum et al, pp. 381-393, MODERN CONCEPTS IN INSULIN-LIKE GROWTH FACTORS (E.M. Spencer, ed., Elsevier, New York, 1991 ). Some mutant IGF-Is exhibit altered binding to IGFBP-3 and/or alterations in the ability to form the ternary complex. For example, mutations at residues 3, 4, 8, 9, 12, 15, 16 and 24 (B domain mutants) and mutations at residues 49-51 reduce formation of the binary complex, while mutations involving residues 55 and 56, as well as IGF-I where residues 63-70 (1-62 IGF-I) were deleted or residues 28-37 were replaced with a Gly 4 linker (l-27-Gly 4 -38-70 IGF-I) or where both changes were made (l-27-Gly 4 -38-62 IGF-I)) and mutants thereof (for example, 1-62 IGF-I where residue 24 was also changed) actually have increased binding to IGFBP-3. Some of these mutants, particularly the 1-62 IGF-I with a mutation at residue 24, have a reduced capacity for formation of the ternary complex, even though formation of the binary complex is increased (Baxter et al. (1992) J. Biol. Chem. 267:60-65). Nearly all of the IGF-I, IGF-II and IGFBP-3 in the circulation is in complexed form, so very little free IGF is detected. Moreover, a high level of free IGF in blood is undesirable. High blood levels of free IGF would lead to serious hypoglycemia due to the insulin-like activities of IGF. In contrast to the IGFs and IGFBP-3, there is a substantial pool of free ALS in plasma which assures that IGF/IGFBP-3 complex entering the circulation immediately forms the ternary complex. IGFBP-3 is the most abundant IGF binding protein in the circulation, but at least five other distinct IGF binding proteins (IGFBPs) have been identified in various tissues and body fluids. Although these proteins bind IGFs, they each originate from separate genes and have unique amino acid sequences. Thus, the binding proteins are not merely analogs or derivatives of a common precursor. Unlike IGFBP-3, the other IGFBPs in the circulation are not saturated with IGFs. Moreover, none of the IGFBPs other than IGFBP-3 can form the 150 Kd ternary complex. IGF-I and IGFBP-3 may be purified from natural sources or produced by recombinant means. For instance, purification of IGF-I from human serum is well known in the art (Rinderknecht et al. (1976) Proc. Natl. Acad. Sci. USA 73:2365-2369). Production of IGF-I by recombinant processes is shown in EP 0 128 733, published in December of 1984. IGFBP-3 may be purified from natural sources using a process such as that shown in Baxter et al. (1986, Biochem. Biophys. Res. Comm. 139:1256-1261). Alternatively, IGFBP-3 may be synthesized by recombinantly as discussed in Sommer et al., pp. 715-728, MODERN CONCEPTS OF INSULIN-LIKE GROWTH FACTORS (E.M. Spencer, ed., Elsevier, New York, 1991). Recombinant IGFBP-3 binds IGF-I in a 1:1 molar ratio. Topical administration of IGF-I/IGFBP-3 complex to rat and pig wounds is significantly more effective than administration of IGF-I alone (Id.). Subcutaneous administration of IGF-I/IGFBP-3 complex to hypophysectomized, ovariectomized, and normal rats, as well as intravenous administration to cynomolgus monkeys, "substantially prevents the hypoglycemic effects" of IGF-I administered alone (Id.). IGF has been proposed as a treatment for a wide variety of indications. U.S. Patents Nos. 5,434,134, 5,128,320, 4,988,675, 5,106,832, 5,534,493, 5,202,119 and 5,273,961 and have disclosed the use of IGF for the treatment of cardiomyopathy and myocardial infarction, steroid-induced catabolism, type II (insulin resistant) diabetes, renal disorders, pancreatic disorders, for increasing humoral immune response and for prevention of acute renal failure, respectively. Additionally, European Patents Nos. EP 434 625, EP 436469 and EP 560 723 and International Patent Applications Nos. WO 93/23071, WO 91/12018, WO 92/00754, WO 93/02695 and WO 93/08826 disclose the use of IGF for the treatment of bone disorders, type I (juvenile or insulin-responsive) diabetes and gastrointestinal disorders. The use of IGF complexed with IGFBP-3 has also been described for use in the treatment of a variety of conditions. U.S. Patents Nos. 5,200,509, 5,187,151, 5,407,913, and 5,527,776 disclose the use of IGF/IGFBP-3 complex for the treatment of osteoporosis, for inducing an anabolic state when given by subcutaneous bolus injection, for increasing tissue repair when given systemically, and for treating anemia. International Patent Applications Nos. WO 95/03817, WO 95/08567, WO 95/13823, WO 95/13824, WO 96/02565 disclose the use of IGF/IGFBP-3 complex for the treatment of disorders of the reproductive, immunologic, neural, renal, and skeletal systems. In addition to its activities in other organ systems, IGF has trophic effects on the cells of the peripheral and central nervous system. IGF's trophic effects on neural cells include promoting the survival of a variety of neuronal cell types as well as promoting neurite outgrowth in motor neurons. U.S. Patents Nos. 5,093,317, 5,420,112, 5,068,224, and International Patent Applications Nos. WO 93/02695, WO 93/08826 and WO 95/13823 describe the use of IGF or IGF complexed to IGFBP-3 for the treatment of disorders of the nervous system, exploiting IGF's trophic activity on the cells of nervous tissues. None of these patents or publications disclose or suggest the use of IGF for the treatment of psychological disorders or memory loss. Other disorders exist which would benefit from a reduction in the levels of IGF. For example, some cancer cells are dependent on IGF for continued survival (Resnicoff et al (1994) Cancer Res. 54:2218-2222). Reduction in circulating IGF levels could result in tumor progression, as IGF-dependent tumor cells undergo apoptosis. In autoimmune disorders, reduction in IGF levels could reduce symptoms of these disorders, as IGF is known to have stimulatory effects on the immune system. Polycystic Ovarian Syndrome Polycistic ovarian syndrome ("PCOS", also known as polycystic ovarian disease or "PCOD") is the most common disorder of women of reproductive age, affecting 5-10% of premenopausal women. The diagnostic criteria for PCOS include hyperandrogenism (high levels of androgenic, or male, sex hormones) and chronic anovulation. Generally, women with PCOS are also obese, infertile, and subject to hirsutism (excess body and facial hair growth). Additionally, PCOS is associated with hyperinsulinemia (high levels of insulin) and high levels of leutinizing hormone and estrogen due to extragonadal synthesis of these hormones. A number of studies have suggested that drugs useful for the treatment of type II diabetes (non-insulin dependent diabetes mellitus, or NIDDM) are also useful for the treatment of PCOS (Dunaif et al., 1996, J Clin. Endocrinol. Metab. 81(9):3299-3306). There exists in the art a need for effective treatments for PCOS. DETAILED DESCRIPTION OF THE INVENTION DEFINITIONS As used herein, "IGF" refers to insulin-like growth factor from any species. IGF includes both IGF-I and IGF-II, in native-sequence or variant form, including but not limited to naturally-occurring allelic variants. IGF may be from any source, whether natural, synthetic or recombinant. As used herein, "IGF-I" refers to insulin-like growth factor I from any species, including bovine, ovine, porcine and human, in native-sequence or variant form, including but not limited to naturally-occurring allelic variants. IGF-I may be from any source, whether natural, synthetic or recombinant, provided that it will bind IGFBP-3 at the appropriate site. Preferred herein is human native-sequence, mature IGF-I, preferably without an amino-terminal methionine. More preferably, the native sequence, mature IGF-I is produced recombinantly, for example, as described in PCT publication WO 95/04076. As used herein, "IGF-II" refers to insulin-like growth factor II from any species, including bovine, ovine, porcine and human, in native-sequence or variant form, including but not limited to naturally-occurring allelic variants. IGF-II may be from any source, whether natural, synthetic or recombinant, provided that it will bind IGFBP-3 at the appropriate site. Preferred herein is human native-sequence, mature IGF-II, preferably without an amino-terminal methionine. More preferably, the native sequence, mature IGF-I is produced recombinantly, for example, as described in PCT publication WO 95/04076. As used herein, "IGFBP-3" refers to insulin-like growth factor binding protein 3. IGFBP-3 is a member of the insulin-like growth factor binding protein family. IGFBP-3 may be from any species, including bovine, ovine, porcine and human, in native-sequence or variant form, including but not limited to naturally-occurring allelic variants. Prefered IGFBP-3 embodiments include native sequence human IGFBP-3 and variants of human IGFBP-3 wherein the one or more of the asparagine residues which form the normal N- linked glycosylation sites (positions 89, 109 and 172) are changed to aspartate (e.g. : N89D; N109D; N172D; N89D,N109D; N89D,N172D; N109D,N172D; and N89D,N109D,N172D variants) or to other amino acid residues (e.g. : N89X; N109X; N172X; N89X,N109X; N89X,N172X; N109X,N172X; and N89X,N109X,N172X variants) as well as variants which have been altered to improve resistance to degradation, such as alterations at positions 116 and 135 (e.g., Dl 16E, D135E and Dl 16E,D135E), or alterations which affect the nuclear localization signal (NLS) of IGFBP-3, which is located at residues 215 through 232 (Radulescu, 1994, Trends Biochem Sci. 19(7):278). Examples of preferred NLS variant IGFBP-3s include K228E, R230G, K228E,R230G, K228X, R230X, and K228X,R230X, as well as variations at residues 215, 216 and 231. Of course, a variant IGFBP-3 may include more than one type of variation (e.g., a variant IGFBP-3 may be both ND variant and degradation resistant variant). IGFBP-3 can form a binary complex with IGF, and a ternary complex with IGF and the acid labile subunit (ALS). IGFBP-3 may be from any source, whether natural, synthetic or recombinant, provided that it will bind IGF-I and ALS at the appropriate sites. Preferably, IGFBP-3 is produced recombinantly, as described in PCT publication WO 95/04076. A "therapeutic composition," as used herein, is defined as comprising IGF-I complexed with its binding protein, IGFBP-3 (IGF-I/IGFBP-3 complex). The therapeutic composition may also contain other substances such as water, minerals, carriers such as proteins, and other excipients known to one skilled in the art. "PCOS" or "polycystic ovarian syndrome", as used herein, refers to a syndrome of reproductive age women wherein the affected women experience hyperandrogenism and chronic anovulation. Obesity, hirustism, infertility, amennorrhea, hyperinsulinemia, insulin resistance, and acanthosis nigricans may also be present in subjects with PCOS. MODES OF CARRYING OUT THE INVENTION The inventor has found that long term administration (e.g., for periods greater than four weeks) of IGF/IGFBP-3 complex can increase serum levels of sex hormone binding globulin (SHBG). Accordingly, long term administration of IGF/IGFBP-3 complex is useful for the treatment of disorders wherein normalization of sex steroid hormones would alleviate or eliminate the symptoms of the disorders. In one embodiment, the invention provides methods and compositions for the treatment of subjects having polycystic ovarian syndrome (PCOS), a condition characterized by hyperandrogenism and chronic anovulation. PCOS patients are treated by long term administration of IGF/IGFBP-3 (e.g. , four weeks of administration or longer). Long term administration of IGF/IGFBP-3 complex alleviates or eliminates the symptoms of PCOS. While not wishing to be bound by any single theory, the inventors believe that administration of the complex alleviates or eliminates the symptoms of PCOS by increasing serum levels of sex hormone binding globulin (SHBG), thereby reducing serum levels of free (and therefore active) sex hormones. The inventive methods disclosed herein provide for the parenteral administration of IGF or IGF/IGFBP-3 complex to subjects in need of such treatment. Parenteral administration includes, but is not limited to, intravenous (IV), intramuscular (IM), subcutaneous (SC), intraperitoneal (IP), intranasal, and inhalant routes. IV, IM, SC, and IP administration may be by bolus or infusion, and in the case of SC, may also be by slow release implantable device, including, but not limited to pumps, slow release formulations, and mechanical devices. The formulation, route and method of administration, and dosage will depend on the disorder to be treated and the medical history of the patient. In general, a dose that is administered by subcutaneous injection will be greater than the therapeutically-equivalent dose given intravenously or intramuscularly. Preferably, the dose of IGF administered will be from about 25 μg/kg to about 2 mg/kg of body weight. More preferably, the dose of IGF will be from about 50 μg/kg to about 1 mg/kg. Most preferably the dose of IGF will be from about 100 μg/kg to about 400 μg/kg. Long term administration of IGF/IGFBP-3 (such as to PCOS patients) may be continuous, such as by continuous infusion, implanted depot, slow release formulation, or daily bolus administration. Alternately, IGF/IGFBP-3 may be administered on a discontinuous schedule, wherein the complex is administered in cycles which include days on which the complex is administered ("on" days) and days on which the complex is not administered ("off days). With respect to PCOS patients, the period of long term administration of IGF/IGFBP-3 complex is calculated including the entire length of an administration cycle (i.e., including both on and off days). Discontinuous administration cycles are extensively used in the medical arts (particularly in the area of medical oncology), and are thus well known in the art. Examples of discontinuous administration cycles include: every other day; once every three days; on for two days and off for three days, on for one week and off for 10 days, and the like. The IGF is preferably IGF-I. A composition comprising equimolar amounts of IGF-I and IGFBP-3 is preferred. Preferably the IGF-I and IGFBP-3 are complexed prior to administration. Preferably, the complex is formed by mixing approximately equimolar amounts of IGF-I and IGFBP-3 dissolved in physiologically compatible carriers such as normal saline, or phosphate buffered saline solution. More preferably, a concentrated solution of rhIGF-I and a concentrated solution of rhIGFBP-3 are mixed together for a sufficient time to form an equimolar complex. Most preferably, rhIGF-I and rhIGFBP-3 are combined to form a complex during purification, as described in International Patent Application No. WO 96/40736. For parenteral administration, compositions of the complex may be semi-solid or liquid preparations, such as liquids, suspensions, and the like. Physiologically compatible carriers include, but are not limited to, normal saline, serum albumin, 5% dextrose, plasma preparations, and other protein-containing solutions. Optionally, the carrier may also include detergents or surfactants. EXAMPLES Example 1 24 elderly women (age 65-90 years) who had fractured hips (subsequently surgically repaired) were randomized into three groups: placebo (acetate buffer diluent); low dose (0.5 mg/kg/day rhIGF-I/IGFBP-3); or high dose (1 mg/kg/day). Each group was dosed by continuous subcutaneous infusion using a portable minipump for eight weeks immediately following surgical treatment. Serum samples were obtained immediately before the initiation of treatment (baseline) and at the end of four weeks of treatment, although serum samples were not available for testing from all subjects. Serum samples were assayed using commercially-available immunassay kits according to the manufacturer's instructions (Diagnostic Systems Laboratories, Webster, TX). Results, calculated as percentage of baseline to reduce the effect of inter-subject variability, are shown below in Table 1. The assay results indicate that long term administration (four weeks) of rhIGF-I/IGFBP-3 significantly increases SHBG serum levels and significantly decreases IGF-II serum levels. Interestingly, serum acid labile subunit (ALS) levels were significantly decreased. Table 1 Assay Placebo (n=7) Low dose (n=6) High dose (n=8) IGF-I 105.3 450.7* 533.5** IGF-II 113.6 64.5** 46.0** SHBG 150.1 241.0 241.4* ALS 131.7 96.8* 66.5** * p < 0.05 compared to placebo ** p < 0.001 compared to placebo The patents, patent applications, and publications cited throughout the disclosure are incorporated herein by reference in their entirety. The present invention has been detailed both by direct description and by example. Equivalents and modifications of the present invention will be apparent to those skilled in the art, and are encompassed within the scope of the invention.

Claims: CLAIMS We claim: 1. A method for alleviating the symptoms of polycystic ovarian syndrome (PCOS) in a subject, comprising: administering an effective dose of insulin-like growth factor/insulin-like growth factor binding protein 3 (IGF/IGFBP-3) complex to said subject, wherein said IGF/IGFBP- 3 complex is administered for a period of at least four weeks. 2. A method for increasing sex hormong binding globulin (SHBG) in a subject, comprising: administering an effective dose of insulin-like growth factor/insulin-like growth factor binding protein 3 (IGF/IGFBP-3) complex to said subject, wherein said IGF/IGFBP- 3 complex is administered for a period of at least four weeks. 3. The method of either of claims 1 or 2 wherein said IGF is IGF-I. 4. The method of claim 3 wherein said IGF-I is human IGF-I. 5. The method of claim 4 wherein said IGF-I is recombinant human IGF-I (rhIGF-I). 6. The method of any of claims 1-5 wherein said IGFBP-3 is human IGFBP-3. 7. The method of claim 6 wherein said IGFBP-3 is recombinant human IGFBP-3. 8. The method of any of claims 1-7 wherein said IGF/IGFBP-3 is administered daily. 9. The method of any of claims 1-7 wherein said IGF/IGFBP-3 is administered on a discontinuous schedule. 10. The use of insulin-like growth factor/insulin-like growth factor binding protein 3 (IGF/IGFBP-3) complex for the manufacture of a medicament for the treatment of polycystic ovarian syndrome (PCOS), wherein said IGF/IGFBP-3 complex is administered for a period of at least four weeks. 11. The use of insulin-like growth factor/insulin-like growth factor binding protein 3 (IGF/IGFBP-3) complex for the manufacture of a medicament for increasing serum levels of sex hormone binding globulin (SHBG), comprising, wherein said IGF/IGFBP-3 complex is administered for a period of at least four weeks. 12. The use of any of claims 10-11 wherein said IGF is IGF-I. 13. The method of claim 12 wherein said IGF-I is human IGF-I. 14. The method of claim 13 wherein said IGF-I is recombinant human IGF-I (rhIGF-I). 15. The method of any of claims 10-14 wherein said IGFBP-3 is human IGFBP- 3. 16. The method of claim 15 wherein said IGFBP-3 is recombinant human IGFBP-3. 17. The method of any of claims 10-16 wherein said IGF/IGFBP-3 is administered daily. 18. The method of any of claims 10-16 wherein said IGF/IGFBP-3 is administered on a discontinuous schedule.

Inventors: MASCARENHAS DESMOND, MASCARENHAS, DESMOND
Applicants: CELTRIX PHARMA, CELTRIX PHARMACEUTICALS, INC.
Application year: 1999
Main classification: A61K38
IPC codes: A61K38, A61P15