Abstract:
A therapeutic composition for the treatment of the symptoms of Williams Syndrome and the method for preparing the therapeutic agents is disclosed. The therapeutic composition is a stable pharmaceutical composition comprising one or more digestive and/or pancreatic enzymes. The therapeutic composition may be manufactured by a variety of encapsulation technologies. Delivery of the therapeutic composition may be made orally, through injection, by adherence of a medicated patch or other method. Further, a method of using fecal chymotrypsin level as a biomarker for the presence of Williams Syndrome, or the likelihood of an individual to develop Williams Syndrome is disclosed.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application claims priority under 35 U.S.C. §119 to U.S. Provisional Application 61/075,869, filed Jun. 26, 2008, incorporated by reference in its entirety herein. 
    
    
     TECHNICAL FIELD 
     This disclosure relates to a treatment for the symptoms of Williams Syndrome (WS), and more particularly, to the use of pharmaceutical compositions comprising one or more digestive enzymes, such as one or more pancreatic enzymes, in the treatment of the symptoms of Williams Syndrome. The disclosure also relates to a method of making pharmaceutical compositions comprising one or more digestive enzymes. The disclosure further relates to the use of an individual&#39;s fecal chymotrypsin level as a diagnostic marker for determining whether an individual has WS, as well as to predict whether an individual will be beneficially treated with the described pharmaceutical compositions. 
     BACKGROUND 
     Dysautonomias can result in symptoms in which one or more areas of the body are innervated by the autonomic nervous system. While some dysautonomias are well known, other conditions have yet to be determined as a dysautonomia. 
     Symptoms of known dysautonomias include: palpitations, chest pain, tachycardia, excessive fatigue, severe fluctuations in blood pressure, excessive sweating, fainting, exercise intolerance, shortness of breath, visual disturbances including blurred vision, tunneling, and double vision, migraines, dizziness, insomnia, gastrointestinal problems including diarrhea, and constipation, bloody stools, fainting/near fainting, frequent urination, convulsions, and cognitive impairment. Other symptoms such as depression, dysthymia, obsessive compulsive tendencies, and difficulty with ambulation and other symptoms may also be a part of the dysautonomic picture. 
     Conditions such as familial dysautonomia (FD), also known also as Riley-Day syndrome, Parkinson&#39;s disease, Guillaine-Barre syndrome (GBS), Dopamine-b-Hydroxalase deficiency, baroreflex failure, Guillaine-Barre Syndrome, neuroblastoma and other tumors which affect the neuroendocrine system, Aromatic L-Amino Acid Decarboxylase deficiency, Tetrahydrobiopterin deficiency, Familial Paraganglioma syndrome, “Shy-Drager Syndrome,” also referred to as “Multiple System Atrophy” or MSA, Neurally Mediated Syncope, also known as Neurocardiogenic Syncope, fetal fatal insomnia (FFI), diabetic cardiovascular neuropathy, hereditary sensory and autonomic neuropathy type III (HSAN III), Menke&#39;s disease, monoamine oxidase deficiency states, and other disorders of dopamine metabolism, dysautonomic syndromes and disorders of the cardiovasular system, Chaga&#39;s disease, diabetic autonomic failure, and pure autonomic failure, are well known as conditions associated with or primarily due to a dysautonomia. 
     Williams Syndrome (WS) is a rare genetic disorder characterized by mild to moderate mental retardation or learning difficulties, a distinctive facial appearance, and a unique personality that combines overfriendliness and high levels of empathy with anxiety. The most significant medical problem associated with WS is cardiovascular disease caused by narrowed arteries. WS is also associated with elevated blood calcium levels in infancy. A random genetic mutation (deletion of a small piece of chromosome 7), rather than inheritance, most often causes the disorder. However, individuals who have WS have a 50 percent chance of passing it on if they decide to have children. 
     The characteristic facial features of WS include puffiness around the eyes, a short nose with a broad nasal tip, wide mouth, full cheeks, full lips, and a small chin. People with WS are also likely to have a long neck, sloping shoulders, short stature, limited mobility in their joints, and curvature of the spine. Some individuals with WS have a star-like pattern in the iris of their eyes. Infants with WS are often irritable and colicky, with feeding problems that keep them from gaining weight. Chronic abdominal pain is common in adolescents and adults. By age 30, the majority of individuals with WS have diabetes or pre-diabetes and mild to moderate sensorineural hearing loss (a form of deafness due to disturbed function of the auditory nerve). For some people, hearing loss may begin as early as late childhood. WS also is associated with a characteristic “cognitive profile” of mental strengths and weaknesses composed of strengths in verbal short-term memory and language, combined with severe weakness in visiospatial construction (the skills used to copy patterns, draw, or write). Within language, the strongest skills are typically in concrete, practical vocabulary, which in many cases is in the low average to average range for the general population. Abstract or conceptual-relational vocabulary is much more limited. Most older children and adults with WS speak fluently and use good grammar. More than 50% of children with WS have attention deficit disorders (ADD or ADHD), and about 50% have specific phobias, such as a fear of loud noises. The majority of individuals with WS worry excessively. 
     There is no cure for Williams Syndrome, nor is there a standard course of treatment. Treatments are based on an individual&#39;s particular symptoms. People with WS require regular cardiovascular monitoring for potential medical problems, such as symptomatic narrowing of the blood vessels, high blood pressure, and heart failure. 
     SUMMARY 
     It has been determined by the present inventor that the gastrointestinal tract of dysautonomic individuals is impaired, and that the proper levels of pancreatic enzymes and/or their precursors including the zymogens and bicarbonate ions are not present in sufficient quantities to allow proper digestion. While that impairment is relevant to the digestion of carbohydrates, fats and proteins, it is most specific and most severe with respect to protein digestion. Accordingly, while not being bound by theory, the present inventor believes that many, if not all, dysautonomias have a GI component, and thus that dysautonomias may actually have their etiology in gastrointestinal dysfunction. For example, with Guillaine-Barre syndrome, it is postulated that a GI pathogen is a causative factor in the formation of the Guillaine Barre dysautonomia. Similarly, it has been found by the present inventor that populations of autistic children suffer from GI disturbances and other conditions which are dysautonomic in nature. In general, these findings represent a possible link between the etiology of autism and autonomic dysfunction. Thus, the inventor believes that other dysautonomic conditions also have GI primary etiologies. 
     The symptoms of dysautonomic conditions, however, may have various manifestations due to the genetic makeup of the individuals suffering from the conditions. Various gene sequences in the genetic code of the individual will result in manifestation of certain diseases or symptoms that are expressed uniquely in each individual. For example, if amino acid pool deficits due to improper protein digestion and gastrointestinal dysfunction are manifested differently in different individuals, a “disease state” may appear different depending upon the genetic makeup of the individual. Neurological expression may be all that is seen in some individuals, whereas other manifestations may demonstrate a hybrid of gastrointestinal dysfunction as well as neurological or other dysfunctions. 
     Accordingly, while not bound by theory, the present inventor believes that WS may have a dysautonomic component and that the etiology of WS may be related to gastrointestinal dysfunction. 
     Given the above, it is a goal of the present disclosure to provide therapeutic methods and pharmaceutical compositions for the treatment of the symptoms of Williams Syndrome. It is also a goal of the present disclosure to provide therapeutic methods and pharmaceutical compositions for the treatment of Pervasive Development Disorders such as Autism, ADD, and ADHD, and for Dysautonomias such as Familial Dysautonomia, Parkinson&#39;s, and Guillaine Barre Syndrome. 
     Another goal of the present disclosure is the provision of pharmaceutical compositions for the treatment of the above disorders, wherein the compositions comprise one or more digestive enzymes, e.g., one or more enzymes selected from amylases, proteases, cellulases,  papaya , papain, bromelain, lipases, chymotrypsin, trypsin, and hydrolases. In some embodiments, the pharmaceutical compositions are lipid encapsulated. 
     Yet another goal of the present disclosure is to provide methods for making the described pharmaceutical compositions using methods such as: direct compression, microencapsulation, lipid encapsulation, wet granulation or other methods including the use of Prosolv® (silicified microcrystalline cellulose), and other known excipients and additives to accomplish microencapsulation, lipid encapsulation, direct compression, wet or dry granulation or other suitable technology. 
     A further goal of the present disclosure is to provide means to deliver the pharmaceutical compositions, which can include the use of rapid dissolution (rapid dissolve), time release, or other delivery methods including oral, injection, patch, or other method. Further, the delivery of the pharmaceutical compositions may be in the form of a tablet, capsule, sprinkles, sachet, or other oral delivery method. 
     An additional goal of the disclosure is to demonstrate the use of fecal chymotrypsin level as a biomarker for the presence of Williams Syndrome, or the likelihood of an individual to develop Williams Syndrome. 
     Accordingly, provided herein is a method for treating one or more symptoms associated with WS in a patient diagnosed with WS comprising administering to the patient a therapeutically effective amount of a pharmaceutical composition comprising one or more digestive enzymes. In some embodiments, the pharmaceutical composition may be lipid-encapsulated. In some embodiments, the one or more digestive enzymes comprise one or more enzymes selected from the group consisting of proteases, amylases, celluloses, sucrases, maltases,  papaya , papain, bromelain, hydrolases, and lipases. In some embodiments, the one or more digestive enzymes comprise one or more pancreatic enzymes. In some embodiments, the pharmaceutical composition comprises one or more proteases, one or more lipases, and one or more amylases. In some embodiments, the one or more proteases comprise chymotrypin and trypsin. 
     The one or more digestive enzymes are, independently, derived from an animal source, a microbial source, or a plant source, or are synthetically prepared. In some embodiments, the animal source is a pig, e.g., a pig pancreas. 
     In some embodiments, the pharmaceutical composition comprises at least one amylase, a mixture of proteases comprising chymotrypsin and trypsin, at least one lipase, and papain. In some embodiments, the pharmaceutical composition further comprises  papaya . In some embodiments, the pharmaceutical composition comprises, per dose: amylases from about 10,000 to about 60,000 U.S.P; proteases from about 10,000 to about 70,000 U.S.P; lipases from about 4,000 to about 30,000 U.S.P; chymotrypsin from about 2 to about 5 mg; trypsin from about 60 to about 100 mg; papain from about 3,000 to about 10,000 USP units; and  papaya  from about 30 to about 60 mg. 
     In some embodiments, the pharmaceutical composition comprises at least one protease and at least one lipase, wherein the ratio of total proteases to total lipases (in USP units) ranges from about 1:1 to about 20:1. In some embodiments, the ratio of proteases to lipases ranges from about 4:1 to about 10:1. 
     In some embodiments, the one or more symptoms of WS are selected from chronic abdominal pain, sensorineural hearing loss, severe weakness in visiospatial construction, attention deficit disorders, phobias, and a combination thereof. 
     In some embodiments, the pharmaceutical composition is a dosage formulation selected from the group consisting of: pills, tablets, capsules, microcapsules, mini-capsules, time released capsules, mini-tabs, sprinkles, and a combination thereof. 
     Also provided is a method of diagnosing a patient comprising: a. obtaining a fecal sample from the patient; b. determining a level of chymotrypsin present in the fecal sample; and c. diagnosing the patient as having WS if the determined fecal chymotrypsin level is 8.4 U/gram or less and the patient exhibits at least one symptom associated with WS. In some embodiments, the fecal chymotrypsin level is between 8.4 and 4.2 U/gram. In some embodiments, the fecal chymotrypsin level is less than 4.2 U/gram. In some embodiments, the level of chymotrypsin present in the fecal sample is determined using an enzymatic photospectrometry method. In some embodiments, the method further comprises administering to the patient an effective amount of a pharmaceutical composition comprising one or more digestive enzymes if the patient is diagnosed as having WS. In some embodiments, the method further comprises determining if the administration of the pharmaceutical composition reduces or ameliorates one or more symptoms associated with WS. 
     Also provided is a method of identifying a patient likely to benefit from administration of a pharmaceutical composition comprising one or more digestive enzymes comprising: a. obtaining a fecal sample from the patient; b. determining a level of chymotrypsin present in the fecal sample; and c. identifying the patient as likely to benefit from administration of the pharmaceutical composition if the determined fecal chymotrypsin level is 8.4 U/gram or less and the patient is diagnosed with WS. In some embodiments, the method further comprises determining if the patient exhibits one or more symptoms of WS. In some embodiments, the benefit comprises a reduction or amelioration of one or more symptoms associated with WS. In some embodiments, the method further comprises administering to the patient an effective amount of a pharmaceutical composition comprising one or more digestive enzymes. 
     Also provided is a pharmaceutical composition comprising one or more digestive enzymes, wherein the one or more digestive enzymes comprise at least one lipase and at least one protease, and wherein the ratio of total proteases to total lipases (in USP units) ranges from about 1:1 to about 20:1. In some embodiments, the ratio of total proteases to total lipases ranges from about 4:1 to about 10:1. In some embodiments, the pharmaceutical composition is lipid encapsulated. 
     Also provided is a pharmaceutical composition comprising at least one amylase, a mixture of proteases comprising chymotrypsin and trypsin, at least one lipase, and papain. In some embodiments, the pharmaceutical composition further comprises  papaya . In some embodiments, the ratio of total proteases to total lipases ranges from about 1:1 to about 20:1. 
     The features and advantages described herein are not all-inclusive and, in particular, many additional features and advantages will be apparent to one of ordinary skill in the art in view of the specification, and claims. Moreover, it should be noted that the language used in the specification has been principally selected for readability and instructional purposes, and not to limit the scope of the inventive subject matter. 
    
    
     DETAILED DESCRIPTION 
     The present disclosure provides pharmaceutical compositions and methods for treating symptoms associated with WS, Pervasive Development Disorders, and Dysautonomias. The pharmaceutical compositions described herein include one or more digestive enzymes, which are postulated by the present inventor to assist in proper digest protein and thus to ameliorate the gastrointestinal dysfunction that is associated with the described disorders. 
     In certain embodiments, the pharmaceutical compositions can include one or more digestive enzymes, wherein the one or more digestive enzymes comprise at least one lipase and at least one protease, and wherein the ratio of total proteases to total lipases (in USP units) ranges from about 1:1 to about 20:1. In some cases, the ratio of total proteases to total lipases ranges from about 4:1 to about 10:1. 
     In some cases, a pharmaceutical composition for use herein comprises at least one amylase, at least one protease, and at least one lipase. In certain embodiments, the pharmaceutical composition includes multiple proteases, including, without limitation, chymotrypsin and trypsin. In certain embodiments, the composition can further include one or more hydrolases, papain, bromelain,  papaya , celluloses, pancreatin, sucrases, and maltases. 
     The one or more enzymes can be independently derived from animal, plant, microbial, or synthetic sources. In some embodiments, one or more of the one or more enzymes are derived from pig, e.g., pig pancreas. 
     One exemplary formulation for the treatment of the symptoms of Williams Syndrome is as follows: 
     Amylase 10,000-60,000 U.S.P 
     Protease 10,000-70,000 U.S.P 
     Lipase 4,000-30,000 U.S.P 
     Chymotrypsin 2-5 mg 
     Trypsin 60-100 mg 
     Papain 3,000-10,000 USP units/mg 
       Papaya  30-60 mg 
     Additional formulations comprising one or more digestive enzymes may be advantageous including formulations in which the ratio of total proteases to total lipases (in USP units) is from about 1:1 to about 20:1. In some embodiments, the ratio of total proteases to total lipases is from about 4:1 to about 10:1. Such formulations are useful for treating symptoms of WS as well as dysautonomias (e.g., familial dysautonomia, Parkinson&#39;s, Guillaine-Barre Syndrome, Aromatic-L-amino acid decarboxylase deficiency, tetrahydrobiopterin deficiency, familial paranganglioma syndrome; multiple system atrophy, dysautonomic symptoms associated with tumors such as pheochromocytoma, chemodectoma, and neuroblastoma; neurally mediated syncope, and SIDS) and pervasive development disorders such as autism, ADHD, ADD, and Asperger&#39;s. 
     Patients below the age of 18 are typically given a dosage such that the formulation would deliver at least 5,000 USP Units of protease and no more than 10,000 USP Units of lipase per kilogram weight of patient, per day. Beneficially the formulation would deliver at least 5,000 USP Units of protease and no more than 7,500 USP units of lipase per Kilogram weight of patient per day. Patients above the age of 18 are typically given no less than 5,000 USP units of protease per kilogram weight of patient per day. 
     The dosage formulation may be administered by an oral preparation including, but not limited to, an encapsulated tablet, mini-tabs, microcapsule, mini-capsule, time released capsule, sprinkle or other methodology. In one embodiment, the oral preparation is encapsulated using lipid. Alternatively, the oral preparation may be encapsulated using enteric coating or organic polymers. A formulation may also be prepared using lipid encapsulation, direct compression, dry granulation, wet granulation, and/or a combination of these methods. 
     Fecal chymotrypsin level is a sensitive, specific measure of proteolytic activity; see, e.g., U.S. Pat. No. 6,660,831, incorporated by reference herein. Normal levels of chymotrypsin are considered be greater than 8.4 U/gram. Decreased values (less than 4.2 U/gram) suggest diminished pancreatic output (pancreatic insufficiency), hypoacidity of the stomach or cystic fibrosis. Elevated chymotrypsin values suggest rapid transit time, or less likely, a large output of chymotrypsin from the pancreas. 
     For the fecal chymotrypsin test, a stool sample is collected from each of the subjects. Each stool sample can be analyzed using an enzymatic photospectrometry analysis to determine the level of fecal chymotrypsin in the stool; in some cases the assay is performed at 30° C.; see, e.g., U.S. Pat. No. 6,660,831, incorporated by reference herein. Alternatively, other methods, such as the calorimetric method, use of substrates, use of assays, and/or any other suitable method may be used to measure the fecal chymotrypsin levels. The levels of fecal chymotrypsin in the samples of the individuals having Williams Syndrome are compared to the levels of fecal chymotrypsin in individuals not diagnosed with Williams Syndrome to determine if the individuals having Williams Syndrome would benefit from the administration of digestive enzymes. 
     EXAMPLES 
     In a study conducted by the inventor, four children diagnosed with Williams Syndrome were examined. Each was administered a pharmaceutical composition as described herein that included digestive enzymes comprising lipases, amylases and proteases. The subjects were given a dosage of 900-2700 mg of digestive enzymes per day. The dosages were taken 3 to 4 times a day with food. 
     Table 1 illustrates the children&#39;s starting fecal chymotrypsin (FCT) levels, prior to administration of the pharmaceutical compositions. 
     
       
         
               
               
               
               
               
             
               
               
               
               
               
             
           
               
                   
                 TABLE 1 
               
               
                   
                   
               
               
                   
                 SUBJECT 
                 AGE 
                 SEX 
                 FCT LEVELS 
               
               
                   
                   
               
             
             
               
                   
               
             
          
           
               
                   
                 1 
                 7 
                 F 
                 3.8 
               
               
                   
                 2 
                 4 
                 M 
                 1.2 
               
               
                   
                 3 
                 9 
                 F 
                 2 
               
               
                   
                 4 
                 17 
                 F 
                 2.2 
               
               
                   
                   
               
             
          
         
       
     
     As seen in Table 1, the fecal chymotrypsin levels of the four subjects are less than 8.4 U/gram, and in fact less than 4.2 U/gram. 
     As previously discussed, individuals diagnosed with Williams Syndrome have certain mental strengths and weaknesses. Referring to Table 2 below, it can be seen that the subjects had difficulties in concentrating prior to the administration of any digestive enzymes. The inability to concentrate was measured on a scale of 0 to 10, with 0 being an inability to concentrate most of the time and 10 being the ability to concentrate without any trouble. The subjects were monitored at 30, 60, and 90 day intervals of treatment. Over the course of the 90 day treatment, the subjects&#39; ability to concentrate increased. 
     
       
         
               
               
               
               
               
             
               
               
               
               
               
             
           
               
                 TABLE 2 
               
               
                   
               
               
                   
                 PRE-ENZYME 
                   
                   
                   
               
               
                   
                 CONCENTRATION 
               
               
                 SUBJECT 
                 LEVEL 
                 30 DAYS 
                 60 DAYS 
                 90 DAYS 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 1 
                 0 
                 5 
                 6 
                 8 
               
               
                 2 
                 2 
                 5 
                 5 
                 9 
               
               
                 3 
                 4 
                 5 
                 6 
                 10 
               
               
                 4 
                 3 
                 4 
                 9 
                 9 
               
               
                   
               
               
                 10 = CAN CONCENTRATE WITHOUT ANY TROUBLE 
               
               
                 0 = CAN NOT CONCENTRATE MOST OF THE TIME 
               
             
          
         
       
     
     As previously discussed, individuals diagnosed with Williams Syndrome commonly experience chronic abdominal pain. Referring to Table 3 below, it can be seen that the subjects had stomach pains prior to the administration of any digestive enzymes. The pain was measured on a scale of 0 to 10, with 0 being no pain and 10 being in pain for all or most of the time. The subjects were monitored at 30, 60, and 90 day intervals of treatment. Over the course of the 90 day treatment, the subjects&#39; pain level decreased. 
     
       
         
               
               
               
               
               
             
               
               
               
               
               
             
           
               
                 TABLE 3 
               
               
                   
               
               
                   
                 PRE-ENZYME 
                   
                   
                   
               
               
                   
                 STOMACH ACHE 
               
               
                 SUBJECT 
                 LEVELS 
                 30 DAYS 
                 60 DAYS 
                 90 DAYS 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 1 
                 9 
                 7 
                 5 
                 2 
               
               
                 2 
                 8 
                 3 
                 2 
                 0 
               
               
                 3 
                 10 
                 8 
                 7 
                 4 
               
               
                 4 
                 7 
                 4 
                 2 
                 0 
               
               
                   
               
               
                 10 = PAIN ALL OR MOST OF THE TIME 
               
               
                 0 = NO PAIN OR DISCOMFORT 
               
             
          
         
       
     
     The foregoing description of the embodiments of the disclosure has been presented for the purposes of illustration and description. It is not intended to be exhaustive or to limit the disclosure to the precise form disclosed. Many modifications and variations are possible in light of this disclosure. It is intended that the scope of the disclosure be limited not by this detailed description, but rather by the claims appended hereto.