Patent Application: US-92883201-A

Abstract:
the present invention relates to igf - 1 treatment of an individual , such as e . g . a human being , suffering from an acute or chronic liver disease including hepatic cirrhosis . acute and chronic liver disease according to the invention are characterized by low circulating igf - 1 and igfbp3 levels . according to one preferred embodiment of the present invention , igf - 1 is administrered to a human being subcutaneously , preferably in the thigh or the abdominal skin , and preferably in two daily doses of about 50 microgram / kg twice a day . the present invention demonstrates that this dosis regime is able to restore normal igf - 1 levels in patients with liver cirrhosis , and the dose is well - tolerated by the patients .

Description:
in one embodiment there is provided a method of treatment of an individual , preferably a human being , suffering from a liver disease , or at risk of contracting a liver disease unless treated , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . the liver disease may be an acute liver disease or it may be a chronic liver disease . examples of acute liver disease according to the invention are liver failure . the acute liver disease may occur in combination with malnutrition , in combination with with insulin resistance , or in combination with igf - 1 deficiency . when the liver disease is a chronic liver disease it may e . g . be cirrhosis of the liver , fibrosis of the liver , or chronic hepatitis . the chronic liver disease may occur in combination with any one or more secondary conditions and indications such as e . g . a metabolic disorder , malnutrition , insulin resistance , diabetes mellitus , igf - 1 deficiency , hepatic encephalopathy , hepatic encephalopathy and ascites , portal hypertension , portal hypertension and ascites , hepatic nephropathy , as well as hepatic nephropathy and ascites . igf - 1 deficiency as used herein signifies an individual having a serum concentration of circulating igf - 1 of less than about 180 microgram per litre , such as less than 175 microgram per litre , for example less than 170 microgram per litre , such as less than 165 microgram per litre , for example less than 160 microgram per litre , such as less than 155 microgram per litre , for example less than 150 microgram per litre , such as less than 145 microgram per litre , such as less than 140 microgram per litre , for example less than 135 microgram per litre , such as less than 130 microgram per litre , for example less than 125 microgram per litre , for example less than 120 microgram per litre , such as less than 115 microgram per litre , for example less than 110 microgram per litre , such as less than 105 microgram per litre , for example less than 100 microgram per litre such as less than 95 microgram per litre , for example less than 90 microgram per litre , such as less than 85 microgram per litre , for example less than 80 microgram per litre such as less than 75 microgram per litre , for example less than 70 microgram per litre , such as less than 65 microgram per litre , for example less than 60 microgram per litre , such as less than 55 microgram per litre , for example less than 50 microgram per litre , such as less than 45 microgram per litre , for example a serum concentration of circulating igf - 1 of less than 40 microgram per litre . in one preferred aspect of the present invention there is provided a method of treatment of an individual , preferably a human being , that is deficient in igf - 1 , or at risk of becoming deficient in igf - 1 unless treated , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . the method according to the invention is preferably selected from a method of treatment that is prophylactic , a method of treatment that is ameliorating , and a method of treatment that is curative . the igf - 1 according to the invention , preferably comprised in a pharmaceutical composition , is preferably administrered to the individual to be treated by means of subcoutaneous injection , preferably once or twice a day . however other means of injection , such as e . g . running infusion or slow infusion may also be used , and injections more than twice a day can also be performed when there is a need for this . the pharmaceutically effective amount of igf - 1 is preferably less than 1200 microgram per day per kilogram of treated individual , such as less than 1150 microgram per day per kilogram of treated individual , for example less than 1100 microgram per day per kilogram of treated individual , such as less than 1050 microgram per day per kilogram of treated individual , for example less than 1000 microgram per day per kilogram of treated individual , such as less than 950 microgram per day per kilogram of treated individual , for example less than 900 microgram per day per kilogram of treated individual , such as less than 850 microgram per day per kilogram of treated individual , for example less than 800 microgram per day per kilogram of treated individual , such as less than 750 microgram per day per kilogram of treated individual , for example less than 700 microgram per day per kilogram of treated individual , such as less than 650 microgram per day per kilogram of treated individual , for example less than 600 microgram per day per kilogram of treated individual , such as less than 550 microgram per day per kilogram of treated individual , for example less than 500 microgram per day per kilogram of treated individual , such as less than 480 microgram per day per kilogram of treated individual , for example less than 460 microgram per day per kilogram of treated individual , such as less than 440 microgram per day per kilogram of treated individual , for example less than 420 microgram per day per kilogram of treated individual , such as less than 400 microgram per day per kilogram of treated individual , for example less than 380 microgram per day per kilogram of treated individual , such as less than 360 microgram per day per kilogram of treated individual , for example less than 340 microgram per day per kilogram of treated individual , such as less than 320 microgram per day per kilogram of treated individual , for example less than 300 microgram per day per kilogram of treated individual , such as less than 290 microgram per day per kilogram of treated individual , for example less than 280 microgram per day per kilogram of treated individual , such as less than 270 microgram per day per kilogram of treated individual , for example less than 260 microgram per day per kilogram of treated individual , such as less than 250 microgram per day per kilogram of treated individual , for example less than 1000 microgram per day per kilogram of treated individual , such as less than 240 microgram per day per kilogram of treated individual , for example less than 230 microgram per day per kilogram of treated individual , such as less than 220 microgram per day per kilogram of treated individual , for example less than 210 microgram per day per kilogram of treated individual , such as less than 200 microgram per day per kilogram of treated individual , for example less than 190 microgram per day per kilogram of treated individual , such as less than 180 microgram per day per kilogram of treated individual , for example less than 170 microgram per day per kilogram of treated individual , such as less than 160 microgram per day per kilogram of treated individual , for example less than 150 microgram per day per kilogram of treated individual , such as less than 145 microgram per day per kilogram of treated individual , for example less than 140 microgram per day per kilogram of treated individual , such as less than 135 microgram per day per kilogram of treated individual , for example less than 130 microgram per day per kilogram of treated individual , such as less than 125 microgram per day per kilogram of treated individual , for example less than 120 microgram per day per kilogram of treated individual , such as less than 115 microgram per day per kilogram of treated individual , for example less than 110 microgram per day per kilogram of treated individual , such as less than 105 microgram per day per kilogram of treated individual , for example about 100 microgram per day per kilogram of treated individual , for example less than about 100 microgram per day per kilogram of treated individual , such as less than 95 microgram per day per kilogram of treated individual , for example less than 90 microgram per day per kilogram of treated individual , such as less than 85 microgram per day per kilogram of treated individual , for example less than 80 microgram per day per kilogram of treated individual , such as less than 75 microgram per day per kilogram of treated individual , for example less than 70 microgram per day per kilogram of treated individual , such as less than 65 microgram per day per kilogram of treated individual for example less than 60 microgram per day per kilogram of treated individual , such as less than 55 microgram per day per kilogram of treated individual , for example less than about 50 microgram per day per kilogram of treated individual , and preferably more than about 25 microgram per day per kilogram of treated individual , such as more than about 30 microgram per day per kilogram of treated individual , for example more than about 35 microgram per day per kilogram of treated individual , such as more than about 40 microgram per day per kilogram of treated individual . in one embodiment the pharmaceutically effective amount of igf - 1 is administrered to the individual to be treated once or twice a day by subcutaneous injection at least during prolonged periods of an essentially life - long treatment regime . prolonged periods may range from several weeks to several months to several years . it is desirable to reduce the period of treatment , and in one embodiment the pharmaceutically effective amount of igf - 1 is administrered to the individual to be treated once or twice a day by subcutaneous injection for a period of treatment lasting less than 6 months , such as less than 5 months , for example less than 4 months , such as less than 3 months , for example less than 2 months , such as less than 1 month , for example less than 2 weeks , such as a treatment period of about 1 week . in one preferred embodiment the composition is administrered to the individual prior to , during , or after liver transplantation treatment . igf - 1 according to the invention can be isolated from any source including any source capable of producing said igf - 1 by recombinant dna techniques . recombinant igf - 1 , or a variant thereof , produced by recombinant dna technology is particularly preferred according to the present invention . the recombinant igf - 1 is preferably recombinant human igf - 1 , or a variant thereof . the pharmaceutical composition according to the invention may further comprise at least one igf - 1 binding protein ( igfbp ) selected from the group consisting of igfbp - 1 , igfbp - 2 , igfbp - 3 , igfbp - 4 , igfbp - 5 , and igfbp - 6 , including any variant thereof . a composition further comprising igfbp - 3 , or a variant thereof is preferred . it is much preferred that the composition comprises a complex formed of at least some of said igf - 1 and some of said igfbp - 3 comprised in the composition . the composition in one embodiment may further comprise acid labile subunit ( als ) capable of forming a complex with igf - 1 and igfbp - 3 . in another preferred embodiment the composition further comprises a protease inhibitor capable of inhibiting proteases having an affinity for igf - 1 . when a variant of igf - 1 is used , such a variant is in one embodiment a variant comprising at least one conservative amino acid substitution , such as a plurality of conservative amino acid substitutions . the variant may be at least 96 percent identical or homologous homologous to human igf - 1 , such as at least 98 percent identical or homologous to igf - 1 . the composition may further comprise a pharmaceutically acceptable carrier such as e . g . a sterile , isotonic solution containing a citrate buffer of ph about 6 . in a number of preferred embodiments the present invention provides treatment of specific conditions present in the individual treated according to the invention . such specific treatments of an individual suffering from an acute or chronic liver disease are described herein below and involve , but is not limited to , methods comprising : treating insulin resistence in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating diabetes mellitus in in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating diabetes mellitus and insulin resistence in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating hyperinsulinaemiae in in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating hyperaminoacidemiae in an individual suffering from a chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating hyperinsulinaemiae and hyperaminoacidemiae in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating hyperaminoacidemiae and reducing muscle proteolysis in an individual suffering from a chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating a metabolic disorder in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating malnutrition in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating malnutrition and a metabolic disorder in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . restoring normal physiological serum levels of igf - 1 in an individual suffering from acute or chronic liver disease , said method comprising the step of treating the individual by administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating hepatic encephalopathy in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating hepatic encephalopathy in combination with ascites in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating hepatic nephropathy in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating hepatic nephropathy in combination with ascites in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating portal hypertension in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating portal hypertension in combination with ascites in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating hepatic encephalopathy and hepatic nephropathy in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating hepatic encephalopathy and hepatic nephropathy in combination with ascites an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating hepatic encephalopathy and portal hypertension in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating hepatic encephalopathy and portal hypertension in combination with ascites in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating hepatic nephropathy and portal hypertension in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating hepatic nephropathy and portal hypertension in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating hepatic nephropathy and portal hypertension in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating hepatic nephropathy and portal hypertension in combination with ascites in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating hepatic encephalopathy and hepatic nephropathy and portal hypertension in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . treating hepatic encephalopathy and hepatic nephropathy and portal hypertension in combination with ascites in an individual suffering from acute or chronic liver disease , said method comprising the step of administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . reducing serum glucose concentrations in an individual suffering from acute or chronic liver disease , said method comprising the step of treating the individual by administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . increasing hepatic amino acid conversion in an individual suffering from acute or chronic liver disease , said method comprising the step of treating the individual by administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . reducing serum glucose concentrations and increasing hepatic amino acid conversion in an individual suffering from acute or chronic liver disease , said method comprising the step of treating the individual by administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . reducing muscle proteolysis in an individual suffering from a chronic liver disease , said method comprising the step of treating the individual by administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . reducing increased levels of growth hormone in an individual suffering from a chronic liver disease , said method comprising the step of treating the individual by administering to the individual a composition comprising a pharmaceutically effective amount of igf - 1 , or a variant thereof . in another aspect of the invention there is provided igf - 1 , or a composition comprising igf - 1 , or a variant thereof , for use in any method of the invention . the composition preferably comprises an igf - 1 produced by recombinant dna technology , more preferably recombinant human igf - 1 . the composition may further comprise at least one igf - 1 binding protein ( igfbp ) selected from the group consisting of igfbp - 1 , igfbp - 2 , igfbp - 3 , igfbp - 4 , igfbp - 5 , and igfbp - 6 , including any variant thereof . more preferred the composition further comprises igfbp - 3 , or a variant thereof . a complex is preferably formed of at least some of said igf - 1 and some of said igfbp - 3 comprised in the composition that may even further comprise acid labile subunit ( als ) capable for forming a complex with igf - 1 and igfbp - 3 . to avoid igf - 1 proteolysis the composition may comprise a protease inhibitor capable of inhibiting proteases having an affinity for igf - 1 . when a variant of igf - 1 is comprised in the composition it is preferably a variant comprising at least one conservative amino acid substitution , or an igf - 1 variant that is at least 98 percent homologous to human igf - 1 . in yet another aspect there is provided the use of igf - 1 , or a variant thereof , for the manufacture of a medicament for treatment of acute or chronic liver disease in an individual , preferably a human being , in need of said treatment . there is also provided the use of a composition according to the invention for the manufacture of a medicament for treatment of acute or chronic liver disease in an individual , preferably a human being , in need of said treatment . the liver disease may be any acute liver disease or any chronic liver disease as described herein above , and the liver disease may occur in combination with any secondary condition or indication referred to herein above . the treatment may involve administration of the medicament by means of subcutaneous injection , preferably once or twice a day . the pharmaceutically effective amount of igf - 1 is as stated herein above , and the period of treatment is also as stated herein above . igf - 1 is directly administered to an individual including a human being by any suitable technique , including parenteral administration , and can be administered locally or systemically . the specific route of administration will depend , e . g ., on the medical history of the patient , including any perceived or anticipated side effects using igf - 1 . examples of parenteral administration include subcutaneous , intramuscular , intravenous , intraarterial , and intraperitoneal administration . preferably , the administration is by continuous infusion ( using , e . g ., minipumps such as osmotic pumps and a subcutaneous route ), or by a single injection or multiple ( e . g ., 2 - 4 ) injections using , e . g ., intravenous or subcutaneous means . preferably , the administration is subcutaneous for igf - 1 . the administration may also be as a single bolus or by slow - release depot formulation . in addition , the igf - 1 is suitably administered together with any one or more of its binding proteins , for example , those currently known , i . e ., igfbp - 1 , igfbp 2 , igfbp - 3 , igfbp - 4 , igfbp - 5 , or igfbp - 6 . the preferred binding protein for igf - 1 administration in accordance with the invention is igfbp - 3 , which is described in wo 89 / 09268 published oct . 5 , 1989 and by martin and baxter , j . biol . chem ., 261 . 8754 - 8760 ( 1986 ). this glycosylated igfbp - 3 protein is an acid - stable component of about 53 kd on a non - reducing sds - page gel of a 125 - 150 kd glycoprotein complex found in human plasma that carries most endogenous igf . the igf - 1 may also be suitably coupled to a receptor or antibody or antibody fragment for administration . the administration of the igf binding protein with igf - 1 is in one embodiment accomplished by the method described in u . s . pat . no . 5 , 187 , 151 , the disclosure of which is incorporated herein by reference . briefly , the igf - 1 and igfbp are administered in effective amounts by subcutaneous bolus injection in a molar ratio of from about 0 . 5 : 1 to about 3 : 1 , preferably about 1 : 1 . the igf - 1 composition to be used in the therapy will be formulated and dosed in a fashion consistent with good medical practice , taking into account the clinical condition of the individual patient ( especially the side effects of treatment with igf - 1 alone ), the site of delivery of the igf - 1 composition , the method of administration , the scheduling of administration , and other factors known to practitioners . the “ effective amount ” of igf - 1 for purposes herein is thus determined by such considerations . as a general proposition , the total pharmaceutically effective amount of the igf - 1 administered parenterally will be in the range of daily doses of from about 50 microgram per kilogram body weight of the individual to which the igf - 1 is administered ( i . e . 50 μg igf - 1 / kg / day ) to less than about 1200 μg / kg / day of patient body weight , although , as noted above , this will be subject to therapeutic discretion . more preferably , this dose is at least 75 μg / kg / day , and most preferably for humans between about 100 and 300 μg / kg / day . if given continuously or semi - continuously the igf - 1 is typically administered at a dose rate of about 1 μg / kg / hour to about 50 μg / kg / hour , either by 1 - 4 bolus injections or per day , by running infusion , or by slow infusion such as by continuous subcutaneous infusions using , for example , a mini - pump or a drop . an intravenous bag solution may also be employed . the key factor in selecting an appropriate dose is the result obtained , as measured at least by amelioration of the acute or chronic liver disease in question . the igf - 1 composition according to the invention may also be administered by sustained - release systems . suitable examples of sustained - release compositions include semi - permeable polymer matrices in the form of shaped articles , e . g ., films , or microcapsules . sustained - release matrices include polylactides ( u . s . pat . no . 3 , 773 , 919 , ep 58 , 481 ), copolymers of l - glutamic acid and gamma - ethyl - l - glutamate ( sidman et al ., biocolymers , 22 , 547 - 556 [ 1983 ]), poly ( 2 - hydroxyethyl methacrylate ) ( langer et al ., j . biomed . mater . res ., 15 : 167 - 277 [ 1981 ], and langer , chem . tech ., 12 : 98 - 105 [ 1982 ]), ethylene vinyl acetate ( langer et al ., supra ) or poly - d -(−)- 3 - hydroxybutyric acid ( ep 133 , 988 ). sustained - release igf - 1 compositions also include liposomally entrapped igf - 1 . liposomes containing igf - 1 are prepared by methods known per se : de 3 , 218 , 121 ; epstein et al ., proc . natl . acad . sci . u . s . a ., 82 : 3688 - 3692 ( 1985 ); hwang et al ., proc . natl . acad . sci . u . s . a ., 77 : 4030 - 4034 ( 1980 ); ep 52 , 322 ; ep 36 , 676 ; ep 88 , 046 ; ep 143 , 949 ; ep 142 , 641 ; japanese pat . appln . 83 - 118008 ; u . s . pat . nos . 4 , 485 , 045 and 4 , 544 , 545 ; and ep 102 , 324 . ordinarily , the liposomes are of the small ( about 200 - 800 angstroms ) unilamellar type in which the lipid content is greater than about 30 mol . percent cholesterol , the selected proportion being adjusted for the optimal igf - 1 therapy . for parenteral administration , in one embodiment , the igf - 1 is formulated generally by mixing it at the desired degree of purity , in a unit dosage injectable form ( solution , suspension , or emulsion ), with a pharmaceutically acceptable carrier , i . e ., one that is non - toxic to recipients at the dosages and concentrations employed and is compatible with other ingredients of the formulation . for example , the formulation preferably does not include oxidizing agents and other compounds that are known to be deleterious to polypeptides . generally , the formulations are prepared by contacting the igf - 1 uniformly and intimately with liquid carriers or finely divided solid carriers or both . then , if necessary , the product is shaped into the desired formulation . preferably the carrier is a parenteral carrier , more preferably a solution that is isotonic with the blood of the recipient . examples of such carrier vehicles include water , saline , ringer &# 39 ; s solution , and dextrose solution . non - aqueous vehicles such as fixed oils and ethyl oleate are also useful herein , as well as liposomes . the carrier suitably contains minor amounts of additives such as substances that enhance isotonicity and chemical stability . such materials are non - toxic to recipients at the dosages and concentrations employed , and include buffers such as phosphate , citrate , succinate , acetic acid , and other organic acids or their salts ; antioxidants such as ascorbic acid ; low molecular weight ( less than about ten residues ) polypeptides , e . g ., polyarginine or tripeptides ; proteins , such as serum albumin , gelatin , or immunoglobulins ; hydrophilic polymers such as polyvinylpyrrolidone ; amino acids , such as glycine , glutamic acid , aspartic acid , or arginine ; monosaccharides , disaccharides , and other carbohydrates including cellulose or its derivatives , glucose , mannose , or dextrins ; chelating agents such as edta ; sugar alcohols such as mannitol or sorbitol ; counterions such as sodium ; and / or nonionic surfactants such as polysorbates , polyoxamers , or peg . the igf - 1 is typically formulated in such vehicles at a concentration of about 0 . 1 mg / ml to 100 mg / ml , preferably about 1 to 10 mg / ml , at a ph of about 3 to 8 . full - length igf - 1 is generally stable at a ph of no more than about 6 ; des ( 1 - 3 ) igf - 1 is stable at about 3 . 2 to 5 . it will be understood that use of certain of the foregoing excipients , carriers , or stabilizers will result in the formation of igf - 1 salts . in addition , the igf - 1 , preferably the full - length igf - 1 , is suitably formulated in an acceptable carrier vehicle to form a pharmaceutical composition , preferably one that does not contain cells . recombinant , full length igf - 1 , preferably recombinant , full length human igf - 1 , or a variant thereof , is preferred for such a composition . in one embodiment , the buffer used for formulation will depend on whether the composition will be employed immediately upon mixing or stored for later use . if employed immediately , the full - length igf - 1 can be formulated in mannitol , glycine , and phosphate , ph 7 . 4 . if this mixture is to be stored , it is formulated in a buffer at a ph of about 6 , such as citrate , with a surfactant that increases the solubility of the igf - 1 at this ph , such as 0 . 1 % polysorbate 20 or poloxamer 188 . the final preparation may be a stable liquid or lyophilized solid . igf - 1 to be used for therapeutic administration must be sterile . sterility is readily accomplished by filtration through sterile filtration membranes ( e . g ., 0 . 2 micron membranes ). therapeutic igf - 1 compositions generally are placed into a container having a sterile access port , for example , an intravenous solution bag or vial having a stopper pierceable by a hypodermic injection needle . igf - 1 ordinarily will be stored in unit or multi - dose containers , for example , sealed ampoules or vials , as an aqueous solution , or as a lyophilized formulation for reconstitution . as an example of a lyophilized formulation , 10 - ml vials are filled with 5 ml of sterile - filtered 1 % ( w / v ) aqueous igf - 1 solution , and the resulting mixture is lyophilized . the infusion solution is prepared by reconstituting the lyophilized igf - 1 using bacteriostatic water - for - injection . in one embodiment of the present invention the treatment may result in a change of biochemical values indicative of hepatic disease . preferably , the biochemical values may be improved . biochemical values may for example be selected from the group consisting of albumin , coagulation factor 3 , 7 and 10 ( inr ), alanine aminotransferase ( alat ), aspartate aminotransferase ( asat ) and γ - glutamyl transferase ( ggt ) for example measured in blood samples . in one embodiment the treatment results in an increase in substrate exchange , for example forearm substrate exchange . the substrate may for example be glucose or amino - n . the increase in substrate exchange may for example be determined as described in the examples . the increase may for example be 1 . 1 fold , such as 1 . 1 to 1 . 2 fold , for example 1 . 2 to 1 . 5 fold , such as 1 . 5 to 2 fold , for example 2 to 3 fold , such as 3 to 5 fold . preferably , however the increase is more than 1 . 5 fold . 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[ 0414 ] 112 ko g t , szeto c c , yeung v t , chow c c , chan h , cockram c s : autoimmune polyglandular syndrome and primary biliary cirrhosis . br j clin pract 50 : 344 - 46 , 1996 . hu 113 pohl r , junge u : primary sclerosing cholangitis with chronic pancreatitis . dtsch med wochenschr 122 : 778 - 82 , 1997 . [ 0416 ] 114 kay m , wyllle r , michener w , caulfield m , steffen r : associated ulcerative colitis , sclerosing cholangitis , and insulin - dependent diabetes mellitus . cleve clin j med 60 : 473 - 78 , 1993 . [ 0417 ] 115 lvarsson s a , eridsson s , kockum i , lernmark a , lindgren s , nilsson k o , sundkvist g , wassmuth r : hla - dr3 , dq2 homozygosity in two patients with insulin - dependent diabetes mellitus superimposed with ulcerative colitis and primary sclerosing cholangitis . j intem med 233 : 281 - 86 , 1993 . [ 0418 ] 116 kawashima c , nagamine t , takezawa j , kon y , yamada s , higuchi t , mori m , ohshima k : studies on the glucose tolerance and the endocrine function of the pancreas in primary sclerosing cholangitis . nippon shokakibyo gakkai zaasshi 89 : 1425 - 32 , 1992 . [ 0419 ] fig1 illustrates hepatic amino - n degradation ( fhnc , litre / hour ) for placebo and individuals treated with igf - 1 according to the invention . [ 0420 ] fig2 illustrates insulin sensitivity ( m - value ) for placebo and individuals treated with igf - 1 according to the invention . [ 0421 ] fig3 illustrates selected biochemical values indicative of hepatic disease in 8 cirrhotic patients after 8 days of igf - 1 treatment . [ 0422 ] fig4 illustrates the glucose uptake across the human forearm in cirrhotic patients treated with igf - 1 or with placebo . [ 0423 ] fig5 illustrates the exchange of amino acids across the human forearm in cirrhotic patients treated with igf - 1 or with placebo . the following examples demonstrate experimental procedures and preferred embodiments of the invention . the examples are illustrative only and should not be interpreted in any way that would confine the invention to the exact methods and results described therein . energy expenditure is assessed by indirect calometri before (− 30 to 0 ) and just after ( 240 - 270 ) the gluc ose clamp . a comp uterized , open circuit system is employed to measure gas exchanges across a 25 - l canopy ( deltatrac , datex instrumentarium inc ., helsinki , finland ). the monitor determines carbon dioxide production and oxygen consumption by multiplying dry air flow through the canopy with the alterations in gas concentrations over the canopy . after a baseline period , insulin ( insulin actrapid ; novo - noridsk , copenhagen , denmark ) was infused intravenously at a constant rate of 0 . 6 mu / kg / min for 180 min . before baseline measurements , a bolus dose ( 17 μci of [ 3 - 3h ] glucose ( dupont - new england nuclear , boston , mass ., usa ) was injected , followed by a constant rate infusion ( 0 . 17 μci / min ) throughout the experiment . plasma glucose was clamped at 5 mmol / l as described by defronzo et al . in order to minimize rapid dilution of the labelled glucose pool with uniabelled glucose , [ 3 - 3h ] glucose was added to the glucose infused during the clamp . to estimate hepatic amino acid metabolism urea nitrogen synthesis rate ( unsr ) and blood alfa - amino nitrogen levels is measured before , during and after a 4 h constant iv infusion of alanine ( 2 mmol / kg bw × h ). unsr was estimated hourly as urinary excretion corrected for accumulation in body water . the slope of the linear relationship between unsr and circulating alanine levels represents the hepatic components of conversion of amino nitrogen and is denoted the functional hepatic nitrogen clearance ( fhnc ). alanine ( 2 mmol / kg bodyweight ) ( ajinomoto co . inc ., tokyo , japan ), given by volumetric pump ( terufusion stc - 503 , rødovre , denmark ) through a catheter inserted in an antecubutal vein , was used to stimulate amino nitrogen conversion as measured by the fhnc . alanine infusions were initiated at 0800 h and continued for 3 h , implying that the 3 h ( from 0800 - 1100 h ) with increasing amino acid concentrations and the following 2 h ( from 1100 - 1300 h ) with decreasing amino acid concentrations could be incorporated in the calculation of fhnc . the urea nitrogen synthesis rate ( unsr ) ( mmol / h ) was calculated as urinary excretion rate ( e ), corrected for accumulation ( a ) in total body water ( tbw ) and for the fractional intestinal loss ( l ): where e =( urine flow , l / h )×( urinary urea - n , mmol / h ), a =( change in blood urea - n , mmol /( l × h ))×( tbw , litre ). tbw was assessed from body weight ( bw , kg ), body height ( bh , cm ) and age ( y , years ), by the formula { 157 }: body weight did not change during or between investigations , so it was assumed that tbw also remained stable . fhnc ( l / h ) was calculated as the slope of the linear regression analysis of unsr on corresponding mean blood a - amino nitrogen concentrations . this measure standardises urea nitrogen synthesis rate with regard to changes in blood a - amino nitrogen concentration . six data sets were available for each determination . catheters ( venflon , viggo , helsingborg , sweden ) for measurements of forearm arterio - deep venous substrate balances were placed as described previously { 724 }: at 0630 h a catheter was inserted retrogradely into a deep antecubital vein of one arm for sampling blood derived from the forearm muscles . the criteria for satisfactory positioning were that the tip of the catheter could not be palpated , and that the oxygen saturation in blood drawn from the catheter was below 70 %. in the contralateral arm , one catheter was placed retrogradely in a heated dorsal hand vein for sampling of arterialized blood . oxygen saturation in the blood drawn from the heated dorsal vein was consistently above 92 %. finally one catheter was placed in an antecubital vein of the heated arm for all infusions . in each individual the same veins were used for insertion on each occasion . preceding every deep venous sample , total ipsilateral forearm blood flow is determined by means of venous occlusion plethysmography . hand blod flow is interrupted by a wrist cuff inflated to a pressure of 250 mm hg immediately before every blood flow determination and 1 min before every deep venous blood sample . substrate balances across the deep forearm tissues are calculated as the production of blood flow ( milliliters per 100 ml tissue / min ) to the tissues drained by the deep forearm vein and change in the total blood content ( arterialized blood minus deep venous blood ) of each metabolite across the forearm . for these calculations it is assumed that the relative blood flow ( milliliters per 100 ml / min ) to the tissues drained by the deep forearm vein equals 0 . 47 × total forearm blood flow + 0 . 83 . in each investigation urea nitrogen synthesis rate ( unsr ) and blood a - amino nitrogen concentration were measured in 6 consecutive 60 min intervals ( from − 60 to 300 min ). blood samples were drawn from the catheter inserted in the heated dorsal hand vein . blood concentrations of urea nitrogen and a - amino nitrogen were measured at time − 60 , − 45 , − 15 and 0 the first hour , and every 60 minutes for the rest of the experiment ; a - amino nitrogen represents the sum of all amino acids . blood samples for measurements of serum - insulin , c - peptide , growth hormone , ghbp , igfbp &# 39 ; s , nefa , 3 - hydroxybutyrate , glycerol , lactate , alanine , glucose , glucagons and glucose specific activity were taken at time − 60 , and every hour through the rest of the experiments . samples were immediately frozen after centrifugation at − 80 ° c . until assayed . the hourly blood samples were obtained with exact time registration , immediately after voiding each one hour urine sample ( see below ). subjects drank a minimum of 200 ml tapwater pr . hour to keep urine production above 120 ml / h . the bladder was emptied by voiding at 60 min intervals , urine volumes were measured and samples frozen for later determination of urea nitrogen concentration . preceding every deep venous sample , total ipsilateral forearm blood flow was determined by means of venous occlusion plethysmography { 724 }. hand blod flow was interrupted by a wrist cuff inflated to a pressure of 250 mm hg immediately before every blood flow determination and 1 min before every deep venous blood sample . arterialized and deep venous blood samples were drawn simultaneously at the following time points : − 60 , 0 , 120 , 240 , 360 urea nitrogen concentration in urine and blood was measured by the urease - berthelot method { 191 }. serum insulin concentrations were measured in duplicate by a two - site immunospecific insulin elisa . plasma glucagon concentrations were measured using radioimmunoassays as described by ørskov et al . { 783 } plasma glucose were analysed in duplicate by use of a beckman glucoanalyzer immediately after sampling ( beckman instruments , palo alto , calif ., usa ). after counting the plasma specific activity of glucose the non - steady state equation of steele as modified by debodo et al . was used for calculation of glucose appearance / disposal rates . a pool fraction of 0 . 65 and a distribution volume of 220 ml / kg were assumed . net lipid oxidation and glucose oxidation rates were computed from the above measurements , and non - oxidative glucose disposal was calculated by subtracting the glucose oxidation rates from total isotopically determined glucose disposal . igf - i concentrations increased 5 fold after treatment ( 48 ± 5 vs 260 ± 25 ng / ml , p & lt ; 0 . 05 ). basal plasma glucose concentrations were significantly higher in control situation compared to igf - i treatment ( 112 ± 5 mg / 100 ml vs 96 ± 5 mg / 100 ml , p & lt ; 0 . 05 ). serum insulin concentrations during baseline were more than twice as high in placebo compared to igf - i ( 98 ± 8 pmol / l vs 41 ± 6 pmol / l , p & lt ; 0 . 05 ), and serum c - peptide followed the same pattern . basal hepatic glucose production ( hgp ) decreased by 25 % after igf - i ( 2 . 91 ± 0 , 1 vs 2 . 11 ± 0 . 1 mg / kg / min , p & lt ; 0 . 05 ), and by 70 % during hyperinsulinaemia (( 0 . 81 ± 0 . 1 vs 0 . 19 ± 0 . 1 mg / kg / min , p & lt ; 0 . 05 ). basal rates of glucose disposal increased by 30 % after igf - i ( 1 . 41 ± 0 . 1 vs 2 . 01 ± 0 . 1 mg / kg / min , p & lt ; 0 . 05 ). the ability of insulin to stimulate whole - body glucose disposal was also significantly increased after igf - i treatment ( 2 . 31 ± 0 . 3 vs 4 . 81 ± 0 . 45 mg / kg / min , p & lt ; 0 . 05 ). both basal and insulin stimulated glucose oxidation were increased after igf - i treatment . non - oxidative glucose disposal were markedly increased after igf - i , suggesting that part of the increased glucose utilisation was caused by increased glycogen formation in muscles and part of it as glycogen synthsized in the liver . all in all this means that glucose metabolism was markedly improved after treatment with igf - i . glucagon decreased by 33 % after igf - i ( 130 ± 12 vs 87 ± 11 pg / ml , p & lt ; 0 . 05 ). growth hormone decreased almost 3 fold after igf - i ( 3 . 1 ± 1 . 2 vs 1 . 31 ± 0 . 5 , p & lt ; 0 . 05 ). igfbp - i doubled after igf - i treatment , probably due to the decrease in insulin levels ( 12 vs 23 ?, p & lt ; 0 . 05 ). igfbp - 3 and ghbp did not change . baseline blood a - amino - n concentrations were slightly higher in the placebo situation compared to the igf - i situation when alanine was infused in the control experiment there was a gradual increase to a maximum of 7 . 4 ± 0 . 3 mmol / l at 240 min . after igf - i treatment the rise was less pronounced with a maximum of 5 . 9 ± 0 . 17 mmol / l , ( p & lt ; 0 . 05 by students t - test ). according to the same pattern , infusion of alanine gradually increased unsr to a different maximum value of 100 ± 6 mmol / h during placebo treatment and to 123 ± 13 mmol / h during igf - i treatment ( p & lt ; 0 . 05 ). the functional hepatic nitrogen clearance ( fhnc ) increased on average by 30 % after treatment with igf - i , meaning that the hepatic efficacy for amino acid disposal was markedly improved in cirrhotic patients treated with igf - i . potentially , this could avoid the development of hepatic encephalopathy in advanced liver disease . insulin - like growth factor - 1 improves glucose metabolism and hepatic amino acid - n conversion in patients with liver cirrhosis reduced bioavailability of insulin - like growth factor - 1 ( igf - 1 ) together with disturbances in intermediary glucose and amino acid metabolism are common features in patients with liver cirrhosis . one objective of the present invention was to compare the effect of igf - 1 with placebo on glucose and amino acid metabolism in a randomly sequenced cross over design . 6 patients with alchoholic liver cirrhosis were investigated twice after 7 days placebo ( vehicle ) and after 7 days with igf - 1 ( 0 . 1 mg / kg / day ). the functional hepatic nitrogen clearance ( fhnc ) which describes substrate independent changes in hepatic amino acid conversion and the hyperinsulinaemic euglycemic clamp ( insulin infusion rate : 0 . 6 mu / kg min for 180 min ) to determine insulin sensitivity were performed . igf - 1 treatment increased both fhnc ( 13 . 3 ± 4 compared to placebo : 7 . 7 ± 4 l / h , p & lt ; 0 . 01 ) and insulin - stimulated glucose disposal ( 4 . 8 ± 0 . 4 compared to 2 , 1 ± 0 . 4 mg / kg min ) markedly . hepatic glucose output ([ 3 - 3h ] glucose ) was nearly halved and basal levels of insulin , c - peptide , glucagon and growth hormone decreased during igf - 1 treatment . igf - 1 increases hepatic amino acid - n conversion and improves glucose disposal in cirrhotic patients . the amelioration of these fundamental metabolic consequenses of cirrhosis has implications for the pathophysiological understanding of impairment of liver function , and may indicate new treatment principles of cirrhosis . improved forearm substrate exchange and biochemical values in cirrhotic patients after treatment with igf - 1 8 patients suffering from cirrhosis classified as either child &# 39 ; s class a or b were treated for 8 days with placebo ( vehicle ) or with igf - 1 ( 0 . 1 mg / kg / day ). after 8 days of treatment individuals were tested for their biochemical values indicative of hepatic disease as well as for forearm substrate exchange rates as described in example 1 . in particular the glucose exchange and amino - n exchange were deternined as well as the biochemical values in blood samples for albumin , coagulation factor 3 , 7 and 10 ( inr ), alanine aminotransferase ( alat ), aspartate amino - transferase ( asat ) and γ - glutamyl transferase ( ggt ). after 8 days of igf - 1 treatment the biochemical values for albumin , inr , alat , asat and ggt , which are all indicative of hepatic disease were improved although not significantly ( fig3 ). igf - 1 treatment increased the glucose uptake across the human forearm almost 3 fold compared to placebo in the basal state ( see fig3 ). furthemore , igf - 1 treatment increased the exchange of amino acids across the human forearm almost 2 fold compared to placebo . these results indicates beneficial effects of igf - 1 treatment on muscle protein build up . all patents , patent applications and non patent references cited anywhere in this specification , including but not limited to ser . no . 60 / 237 , 715 and dk pa 2000 01317 , are hereby incorporated by reference in their entirety .