USOO8759291B2
`
`(12) United States Patent
`Young et al.
`
`(10) Patent No.:
`(45) Date of Patent:
`
`US 8,759,291 B2
`*Jun. 24, 2014
`
`(54) METHODS OF TREATMENT USING
`EXENDIN PEPTIDES OR GLP-1. PEPTDES
`
`(75) Inventors: Andrew A. Young, Research Triangle
`Park, NC (US); Will Vine, Poway, CA
`(US); Kathryn Prickett, Foster City, CA
`(US); Nigel R.A. Beeley, Solana Beach,
`CA (US)
`(73) Assignees: Amylin Pharmaceuticals, LLC, San
`Diego, CA (US); AstraZeneca
`Pharmaceuticals LP, Wilmington, DE
`(US)
`Subject to any disclaimer, the term of this
`patent is extended or adjusted under 35
`U.S.C. 154(b) by 541 days.
`This patent is Subject to a terminal dis
`claimer.
`
`(*) Notice:
`
`(21) Appl. No.: 13/080,051
`(22) Filed:
`Apr. 5, 2011
`
`(65)
`
`Prior Publication Data
`US 2011 FO195904 A1
`Aug. 11, 2011
`
`Related U.S. Application Data
`(60) Continuation of application No. 12/247,141, filed on
`Oct. 7, 2008, now Pat. No. 7,928,065, which is a
`continuation of application No. 10/656,093, filed on
`Sep. 5, 2003, now Pat. No. 7,442,680, which is a
`division of application No. 09/622,105, filed as
`application No. PCT/US99/02554 on Feb. 5, 1999,
`now Pat. No. 6,703,359.
`(60) Provisional application No. 60/075,122, filed on Feb.
`13, 1998.
`Foreign Application Priority Data
`
`(30)
`
`May 24, 2004 (KR) ........................ 10-2004-0O36855
`
`(2006.01)
`(2006.01)
`
`(51) Int. Cl.
`A6 IK38/22
`C07K I4/575
`(52) U.S. Cl.
`USPC ........ 514/11.7: 514/15.4; 514/15.7; 514/16.4
`(58) Field of Classification Search
`None
`See application file for complete search history.
`
`(56)
`
`References Cited
`
`U.S. PATENT DOCUMENTS
`
`6/1995 Eng
`5,424,286 A
`4, 1996 Chen et al.
`5,512,549 A
`8/1996 Buckley et al.
`5,545,618 A
`5,574,008 A 11/1996 Johnson et al.
`5,846,937 A 12/1998 Drucker
`5,955.480 A
`9/1999 Chang
`6,703,359 B1
`3/2004 Young et al.
`7,105,490 B2
`9/2006 Beeley et al.
`
`7,153,825 B2
`7,442,680 B2
`7,928,065 B2*
`
`12/2006 Young et al.
`10/2008 Young et al.
`4/2011 Young et al. ................... 5.14?6.7
`
`FOREIGN PATENT DOCUMENTS
`
`WO
`WO
`
`WO98,05351
`WO99,074.04
`
`2, 1998
`2, 1999
`
`OTHER PUBLICATIONS
`
`Barragan at al., Interactions of Exendin-(9-39) with the effects of
`glucagon-like peptide-1-(7-36) amide and of Exendin-4 on arterial
`blood pressure and heart rate in rats, Regulatory Peptides 67:63-68
`(1996).
`Bhaysar et al., Inhibition of gastric emptying and of food intake
`appear to be independently controlled in rodents, Soc. Neurosci.
`Abstr. 21:460 (Abstract 188.8) (1995).
`D'Alessio et al., Elimination of the Action of Glucagon-like Peptide
`1 Causes an Impairment of Glucose Tolerance after Nutrient Inges
`tion by Healthy Baboons, J. Clin. Invest. 97(1): 133-138 (1996).
`Edwards et al., Cardiovascular and Pancreatic Endocrine Responses
`to Glucagon-Like Peptide-1 (7-36) Amide in the Conscious Calf, Exp.
`Physiol. 82:709-716 (1997).
`Eissele at al., Rat Gastric Somatostatin and Gastrin Release: Interac
`tions of Exendin-4 and Truncated Glucagon-Like Peptide-1 (GLP-1)
`Amide, Life Sci. 55(8):629-634 (1994).
`Enget al., Purification and Structure of Exendin-3, a New Pancreatic
`Secretagoguge Isolated from Heloderma horridum Venom, J. Biol.
`Chem. 265(33): 20259-20262 (1990).
`Enget al., Isolation and Characterization of Exendin-4, an Exendin-3
`Analogue, from Heloderma suspectum Venom, J. Biol. Chem..
`267(11):7402-7405 (1992).
`Fehmann et al., Stable Expression of the Rat GLP-1 (7-36)-Amide,
`Oxyntomodulin, Exendin-4, and Exendin (9-39), Peptides,
`15(3):453-456 (1994).
`Ferguson et al., Cell-Surface Anchoring of Proteins via
`Glycosylphosphatidylinositol Structures, Annu. Rev. Biochem.
`57:285-320 (1988).
`
`(Continued)
`
`Primary Examiner — Jeffrey E. Russel
`(74) Attorney, Agent, or Firm — Womble, Carlyle,
`Sandridge & Rice LLP; Mark J. Pino; Alireza Behrooz
`
`ABSTRACT
`(57)
`Methods for increasing urine flow are disclosed, comprising
`administration of an effective amount of GLP-1, an exendin,
`or an exendin or GLP-1 agonist. Methods for increasing uri
`nary Sodium excretion and decreasing urinary potassium con
`centration are also disclosed. The methods are useful for
`treating conditions or disorders associated with toxic hyper
`Volemia, Such as renal failure, congestive heart failure, neph
`rotic syndrome, cirrhosis, pulmonary edema, and hyperten
`sion. The present invention also relates to methods for
`inducing an inotropic response comprising administration of
`an effective amount of GLP-1, an exendin, or an exendin or
`GLP-1 agonist. These methods are useful for treating condi
`tions or disorders that can be alleviated by an increase in
`cardiac contractility Such as congestive heart failure. Pharma
`ceutical compositions for use in the methods of the invention
`are also disclosed.
`
`15 Claims, 18 Drawing Sheets
`
`MYLAN INST. EXHIBIT 1017 PAGE 1
`
`MYLAN INST. EXHIBIT 1017 PAGE 1
`
`

`

`US 8,759,291 B2
`Page 2
`
`(56)
`
`References Cited
`
`OTHER PUBLICATIONS
`Göke et al., Exedin-4 is a High Potency Agonist and Truncated
`Exenin-(9-39)-amide an Antagonist at the Glucagon-like Peptide
`1-(7-36)-amide Receptor of Insulin-secreting B Cells, J. Biol. Chem.
`268(26): 19650-19655 (1993).
`Knudsen et al., Potent Derivatives of Glucagon-like Peptide-1 with
`Pharmacokinetic Properties Suitable for Once Daily Administration,
`J. Med. Chem.43:1664-1669 (2000).
`Kolligs et al., Reduction of the Incretin Effecty in Rats by the
`Glucagon-Like Peptide 1 Receptor Angatonist Exendin (9-39)
`Amide, Diabetes 44:16-19 (1995).
`Malhotra et al., Exendin-4, a new peptide from Heloderma suspectum
`venom, potentiates cholecystokinin-induced amylase release from
`rat pancreatic acini, Regulatory Peptides 41:149-156 (1992).
`Montrose-Rafizadeh et al., Structure-Function Analysis of Exendin-4
`/ GLP-1 analogs, Diabetes 45(Suppl. 2): 152A (1996).
`O'Halloran et al., Glucagon-Like Peptide-1 (7-36)-NH: a physi
`ological inhibitor of gastric acid secretaion in man, J. Endocrinology
`126:169-173 (1990).
`Orskov et al., Biological Effects and Metabolic Rates of Glucagon
`like Peptide-1 7-36 Amide and Glucagonlike Peptide-1 7-37 in
`Healthy Subjects are Indistinguishable, Diabetes 42:658-661 (1993).
`Raufman et al., Exendin-3, a Novel Peptide from Heloderma hor
`ridum Venom, Interacts with Vasoactive Intestinal Peptide Receptors
`and a Newly Described Receptor on Dispersed Acini from Guinea
`Pig Pancreas, J. Biol. Chem., 266(5):2897-2902 (1991).
`Raufman et al., Truncated Glucagon-Like Peptide-1 Interacts with
`Exendin Receptors in Dispersed Acini from Guinea Pig Pancreas, J.
`Biol. Chem. 267(30):21432-21437 (1992).
`Schepp et al., Exendin-4 and Exendin-(9-39)NH: Agonist and
`Antagonist, Respectively, at the Rat Parietal Cell Receptor for
`Glucagon-Like Peptide-1-(7-36)NH2, Eur: J. Pharm. 269:183-191
`(1994).
`
`Schinzel et al., The Phosphate Recognition Site of Escherichia coli
`Maltodextrin Phosphorylase, FEBS Letters 286:125-128 (1991).
`Schjoldager et al., GLP-1 (Glucagon-like Peptide 1) and Truncated
`GLP-1, Fragments of Human Proglucagon. Inhibit Gastric Acid
`Secretion in Humans, Digestive Disease and Sciences 34(5):703-708
`(1989).
`Singh et al., Use of I-Y|Exendin-4 to characterize receptors on
`dispersed pancreatic acini and gastric chief cells from guinea pig,
`Regulatory Peptides 53:47-59 (1994).
`Tang-Christensen et al., Central administration of GLP-1-(7-36)
`amide inhibits food and water intake in rats, Am. J. Physiol.
`271:R848-R856 (1996).
`Thorens et al., Expression cloning of the Pancreatic B Cell Receptor
`for the gluco-incretin hormone glucagon-like peptide 1. Proc. Natl.
`Acad. Sci. USA 88:8641-8645 (1992).
`Thorenset al., Cloning and Functional Expression of the Human Islet
`GLP-1 Receptor, Diabetes 42:1678-1682 (1993).
`Turton et al., A Role for Glucagon-like peptide-1 in the central
`regulation of feeding, Nature 379:69-72 (1996).
`Wang et al., Glucagon-like Peptide-1 is a Physiological incretin in
`Rat, J. Clin. Invest. 95:417-421 (1995).
`Wettergren et al., Truncated GLP-1 (Proglucagon 78-107-Amide)
`Inhibits Gastric and Pancreatic Functions in Man, Digestive Diseases
`and Sciences 38(4):665-673 (1993).
`Whims et al., Gastric emptying, Glucose Responses, and Insulin
`Secretion after a Liquid Test Meal: Effects of Exogenous Glucagon
`Like Peptide-1 (GLP-1-(7-36) Amide iNType 2 (Noninsulin-Depen
`dent) Diabetic Patietns, J. Clin. Endocrinol Metab. 81(1):327-332
`(1996).
`Young et al., Preclinical Pharmacology of Pramlintide in the Rat:
`Comparisons with Human and and Rat Amylin, Drug Development
`Research 37:231-248 (1996).
`* cited by examiner
`
`MYLAN INST. EXHIBIT 1017 PAGE 2
`
`MYLAN INST. EXHIBIT 1017 PAGE 2
`
`

`

`U.S. Patent
`
`Jun. 24, 2014
`
`Sheet 1 of 18
`
`US 8,759,291 B2
`
`Response of MAP to GLP-1
`
`
`
`
`
`
`
`-- 165 g GP1
`-o- 16.5g GP1
`-- 1.65 g GLP1
`-- 0.165g GLP1
`-0-0.0165 g GLP
`
`100
`
`-15
`
`-10
`
`-05
`
`10
`5
`OO
`hours post v dose
`
`1.5
`
`20
`
`25
`
`FIGURE 1A
`
`MYLAN INST. EXHIBIT 1017 PAGE 3
`
`MYLAN INST. EXHIBIT 1017 PAGE 3
`
`

`

`U.S. Patent
`
`Jun. 24, 2014
`
`Sheet 2 of 18
`
`US 8,759,291 B2
`
`Dose-response curve
`MAP to GP-1
`
`300
`
`
`
`EDss 1.2-0.27.u.
`
`logy dose (pg)
`
`FIGURE 1B
`
`MYLAN INST. EXHIBIT 1017 PAGE 4
`
`MYLAN INST. EXHIBIT 1017 PAGE 4
`
`

`

`U.S. Patent
`
`Jun. 24, 2014
`
`Sheet 3 of 18
`
`US 8,759,291 B2
`
`notropic effect of GLP-1
`
`140
`
`
`
`30
`
`FIGURE 2
`
`MYLAN INST. EXHIBIT 1017 PAGE 5
`
`MYLAN INST. EXHIBIT 1017 PAGE 5
`
`

`

`U.S. Patent
`
`Jun. 24, 2014
`
`Sheet 4 of 18
`
`US 8,759,291 B2
`
`Response of urine flow to GLP-1
`
`-- 165 g GP1
`-o- 16.5g GLP1
`-- 1.65 g GLP1
`-T-0.165 g GP
`-0-0,0165 g GLP1
`O-Saline
`
`2500
`
`2000
`
`g
`
`1500
`S.
`
`
`
`1000
`
`500
`
`t
`
`O
`
`RIGURE 3A
`
`MYLAN INST. EXHIBIT 1017 PAGE 6
`
`MYLAN INST. EXHIBIT 1017 PAGE 6
`
`

`

`U.S. Patent
`
`Jun. 24, 2014
`
`Sheet 5 of 18
`
`US 8,759,291 B2
`
`Dose-response curve:
`Urine flow to GLP-1
`
`EDs=0.71:026 lu,
`
`
`
`og tv dose (g)
`
`FIGURE3B
`
`MYLAN INST. EXHIBIT 1017 PAGE 7
`
`MYLAN INST. EXHIBIT 1017 PAGE 7
`
`

`

`U.S. Patent
`
`Jun. 24, 2014
`
`Sheet 6 of 18
`
`US 8,759,291 B2
`
`Response of sodium excretion to GLP-1
`
`r-O-Saline
`-o-0.0165ug GP1
`-- 0.165 g GLP1
`-- 1.65 pig GP1
`-0-16.5 pig GP1
`-- 165 g GLP
`
`
`
`
`
`C
`9, 2000
`g
`3.
`5.
`gs
`1000
`
`
`
`-10
`
`-5
`
`CO
`
`OS
`hours postly dose
`
`15
`
`20
`
`25
`
`FGURE 4A
`
`MYLAN INST. EXHIBIT 1017 PAGE 8
`
`MYLAN INST. EXHIBIT 1017 PAGE 8
`
`

`

`U.S. Patent
`
`Jun. 24, 2014
`
`Sheet 7 of 18
`
`US 8,759,291 B2
`
`Dose-response Curve:
`Sodium excretion to GLP-1
`
`3000
`
`
`
`2000
`
`ED-0.77+0.05.u.
`
`3
`
`2
`
`s
`
`O
`log tv dose (g)
`
`2
`
`3.
`
`FIGURE 4B
`
`MYLAN INST. EXHIBIT 1017 PAGE 9
`
`MYLAN INST. EXHIBIT 1017 PAGE 9
`
`

`

`U.S. Patent
`
`Jun. 24, 2014
`
`Sheet 8 of 18
`
`US 8,759,291 B2
`
`Response of trine potassium concentration to GLP-1
`150
`
`25
`
`100
`
`5075
`
`
`
`-- 165g GLP
`-o- 6.5g GP
`--d- 1.65 g GP1
`--0.165pg GP
`-o-0.0185g GLP1
`-O-sans
`
`O
`
`05
`
`t
`OS
`:ours post tv dose
`
`1S
`
`25
`
`FIGURESA
`
`MYLAN INST. EXHIBIT 1017 PAGE 10
`
`MYLAN INST. EXHIBIT 1017 PAGE 10
`
`

`

`U.S. Patent
`
`Jun. 24, 2014
`
`Sheet 9 of 18
`
`US 8,759,291 B2
`
`Dose-response curve:
`Urine potassium concentration to GLP-1
`
`GO
`
`
`
`ED50.25-0.341.u.
`
`-3
`
`2
`
`-
`log v dose (g)
`
`2
`
`3.
`
`FIGURE 5B
`
`MYLAN INST. EXHIBIT 1017 PAGE 11
`
`MYLAN INST. EXHIBIT 1017 PAGE 11
`
`

`

`U.S. Patent
`
`Jun. 24, 2014
`
`Sheet 10 of 18
`
`US 8,759,291 B2
`
`Response of MAP to Exendin-4
`
`
`
`140
`g 130
`C f2O
`Cl
`
`10
`s 100
`
`90
`
`--210 pig exendin-4
`-O-21 g exendin-4
`--21 g exendin-4
`A - 0.21 pig exendin-4
`7- 0.02) g exerdin-4
`-- 0.0021 g exendin-4
`-O-Saline
`
`8O
`-10
`
`-0.5
`
`.0
`O.S
`O.O
`hours post iv. dose
`
`5
`
`20
`
`25
`
`FGURE BA
`
`MYLAN INST. EXHIBIT 1017 PAGE 12
`
`MYLAN INST. EXHIBIT 1017 PAGE 12
`
`

`

`U.S. Patent
`
`Jun. 24, 2014
`
`Sheet 11 of 18
`
`US 8,759,291 B2
`
`Dose-Response Curve:
`MAP to Exerdin-4
`
`75
`
`
`
`ED500,240.24.U.
`
`logy dose (g)
`
`FGURE 63
`
`MYLAN INST. EXHIBIT 1017 PAGE 13
`
`MYLAN INST. EXHIBIT 1017 PAGE 13
`
`

`

`U.S. Patent
`
`Jun. 24, 2014
`
`Sheet 12 of 18
`
`US 8,759,291 B2
`
`lonotropic effect of exendin-4
`
`
`
`1.5
`
`2.0
`
`3.0
`2.5
`Days of treatment
`
`3.5
`
`Figure 7
`
`MYLAN INST. EXHIBIT 1017 PAGE 14
`
`MYLAN INST. EXHIBIT 1017 PAGE 14
`
`

`

`U.S. Patent
`
`Jun. 24, 2014
`
`Sheet 13 of 18
`
`US 8,759,291 B2
`
`Response of Urine Flow to Exerdin-4
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`t
`
`-r-210 g exendin-4
`-O-21 g exendin-4
`-T-2.1 g exendin-4
`A- 0.2 pig extendin-4
`-- 0,021 pig exendin-4
`rt- 0.0021 g exendin1
`-O-Saline
`
`s
`
`-5
`
`O
`S
`1.
`s
`hours post tv dose
`
`2.
`
`25
`
`FGRE8A
`
`MYLAN INST. EXHIBIT 1017 PAGE 15
`
`MYLAN INST. EXHIBIT 1017 PAGE 15
`
`

`

`U.S. Patent
`
`Jun. 24, 2014
`
`Sheet 14 of 18
`
`US 8,759,291 B2
`
`Dose-Response Curve:
`Urine Flow to Exendit-4
`
`500
`
`
`
`400
`
`E
`w S 300
`SS a si aw
`
`200
`
`e
`t
`s
`
`O
`
`ED50=0.210.8 .i.
`
`FGURE 8B
`
`MYLAN INST. EXHIBIT 1017 PAGE 16
`
`MYLAN INST. EXHIBIT 1017 PAGE 16
`
`

`

`U.S. Patent
`
`Jun. 24, 2014
`
`Sheet 15 of 18
`
`US 8,759,291 B2
`
`Response of Sodium Excretion to Exendin-4
`
`250
`
`2000
`
`
`
`--210 g exendin-4
`2 g exendin-4
`T-2.1 g exendin-4
`A 021 g exendin-4
`-W-0.021 g exendin-4
`0.0021 pig exendin-4
`-O-Saline
`
`-10
`
`-0.5
`
`0.0
`
`10
`0.5
`hours postiv dose
`
`15
`
`20
`
`2.5
`
`FIGURE 9A
`
`MYLAN INST. EXHIBIT 1017 PAGE 17
`
`MYLAN INST. EXHIBIT 1017 PAGE 17
`
`

`

`U.S. Patent
`
`Jun. 24, 2014
`
`Sheet 16 of 18
`
`US 8,759,291 B2
`
`Does-Response Curve:
`Sodi
`Excretic to Exeira
`
`
`
`ESO-O.S.S.u.
`
`| -
`
`logy case (pg)
`
`RE8
`
`MYLAN INST. EXHIBIT 1017 PAGE 18
`
`MYLAN INST. EXHIBIT 1017 PAGE 18
`
`

`

`U.S. Patent
`
`Jun. 24, 2014
`
`Sheet 17 of 18
`
`US 8,759,291 B2
`
`Response of trine Potassium Concentration to Exerdin-4
`
`
`
`-er 20 g exerdin-4
`--21 g exercir
`2.1 g exercir-4
`mar (,2: ig exercir
`Yr 8.92 pig exercir-4
`-t-). CO2 ig exerdi-4
`MC-r Saire
`is
`
`to
`
`is
`
`on
`
`is
`to
`as
`Otis post iw iuse:
`
`2
`
`FGURE A
`
`MYLAN INST. EXHIBIT 1017 PAGE 19
`
`MYLAN INST. EXHIBIT 1017 PAGE 19
`
`

`

`U.S. Patent
`
`Jun. 24, 2014
`
`Sheet 18 of 18
`
`US 8,759,291 B2
`
`Dose-Response Curve:
`Urine Potassium Concentration to Exendin-4
`
`-2 OO
`
`
`
`ED500,070,26.
`
`logy dose (g)
`
`FIGURE 10B
`
`MYLAN INST. EXHIBIT 1017 PAGE 20
`
`MYLAN INST. EXHIBIT 1017 PAGE 20
`
`

`

`US 8,759,291 B2
`
`1.
`METHODS OF TREATMENT USING
`EXENDINPEPTDES OR GLP-1. PEPTDES
`
`RELATED APPLICATIONS
`
`This application is a continuation of U.S. application Ser.
`No. 12/247,141 filed Oct. 7, 2008, issued as U.S. Pat. No.
`7.928,065, which is a continuation of U.S. application Ser.
`No. 10/656,093 filed Sep. 5, 2003, issued as U.S. Pat. No.
`7,442,680, which is a divisional of U.S. application Ser. No.
`09/622,105 filed Sep. 22, 2000, issued as U.S. Pat. No. 6,703,
`359, which is a S371 of PCT/US99/02554 filed Feb. 5, 1999,
`which claims the benefit of U.S. Provisional Application No.
`60/075,122 filed Feb. 13, 1998. All applications are incorpo
`rated herein by reference.
`
`10
`
`15
`
`FIELD OF THE INVENTION
`
`2
`GLP-1 did not have this effect. (Tand-Christensen et al., Am.
`J. Physiol., 271:R848-56, 1996). GLP-17-37, which has an
`additional glycine residue at its carboxy terminus, also stimu
`lates insulin secretion in humans (Orskov, et al., Diabetes,
`42:658-61, 1993). A transmembrane G-protein adenylate
`cyclase-coupled receptor believed to be responsible for the
`insulinotropic effect of GLP-1 has been cloned from a f-cell
`line (Thorens, Proc. Natl. Acad. Sci., USA 89:8641-45,
`1992).
`Glucagon and glucagon-like peptides have been found to
`have different cardiovascular effects. Glucagon has been
`reported to have positive inotropic and chronotropic effects,
`produce a slight increase in arterial blood pressure in normal
`individuals, and affect regional blood circulation. GLP-1 has
`been found to produce a moderate increase in both systolic
`and diastolic blood pressure, while GLP-2 has no effect on
`those parameters. GLP-1, administered through the jugular
`vein, has been reported to induce an increase in Systolic and
`diastolic blood pressure and heart rate. (Reviewed in Bar
`ragán, J. M., et al., Regul. Peptides, 67:63-68, 1996).
`Exendins are peptides that are found in the venom of the
`Gila-monster, a lizard endogenous to Arizona, and the Mexi
`can Beaded Lizard. Exendin-3 is present in the venom of
`Heloderma horridum, and exendin-4 is present in the venom
`of Heloderma suspectum (Eng., J., et al., J. Biol. Chen., 265:
`20259-62, 1990; Eng., J., et al., J. Biol. Chem., 267:7402-05,
`1992). The exendins have some sequence similarity to several
`members of the glucagon-like peptide family, with the high
`est homology, 53%, being to GLP-1 (Goke, et al., J. Biol.
`Chem., 268: 19650-55, 1993).
`Exendin-4 is a potentagonist at GLP-1 receptors on insu
`lin-secreting BTC1 cells, at dispersed acinar cells from guinea
`pig pancreas, and at parietal cells from Stomach; the peptide
`also stimulates Somatostatin release and inhibits gastrin
`release in isolated stomachs (Goke, et al., J. Biol. Chem.
`268:19650-55, 1993: Schepp, et al., Eur: J. Pharmacol.,
`69:183-91, 1994: Eissele, et al., Life Sci., 55:629-34, 1994).
`Exendin-3 and exendin-4 were found to be GLP-1 agonists in
`stimulating cAMP production in, and amylase release from,
`pancreatic acinar cells (Malhotra, R., et al., Regulatory Pep
`tides, 41:149-56, 1992; Raufman, et al., J. Biol. Chem. 267:
`21432-37, 1992: Singh, et al., Regul. Pept. 53:47-59, 1994).
`The use of the insulinotropic activities of exendin-3 and exen
`din-4 for the treatment of diabetes mellitus and the prevention
`of hyperglycemia has been proposed (Eng., U.S. Pat. No.
`5,424,286).
`Truncated exendin peptides such as exendin9-39, a car
`boxyamidated molecule, and fragments 3-39 through 9-39
`have been reported to be potent and selective antagonists of
`GLP-1 (Goke, et al., J. Biol. Chem., 268: 19650-55, 1993:
`Raufman, J. P., et al., J. Biol. Chem. 266:2897-902, 1991;
`Schepp, W., et al., Eur: J. Pharm. 269:183-91, 1994; Mon
`trose-Rafizadeh, et al., Diabetes, 45(Suppl. 2): 152A, 1996).
`Exendin9-39 blocks endogenous GLP-1 in vivo, resulting
`in reduced insulin secretion. Wang, et al., J. Clin. Invest.,
`95:417-21, 1995; D'Alessio, et al., J. Clin. Invest., 97:133-38,
`1996). The receptor apparently responsible for the insulino
`tropic effect of GLP-1 has been cloned from rat pancreatic
`islet cells (Thorens, B., Proc. Natl. Acad. Sci. USA 89:8641
`8645, 1992). Exendins and exendin9-39 bind to the cloned
`GLP-1 receptor (rat pancreatic B-cell GLP-1 receptor: Feh
`mann HC, et al., Peptides 15(3): 453-6, 1994; human GLP-1
`receptor: Thorens B, et al., Diabetes 42 (11): 1678-82, 1993).
`In cells transfected with the cloned GLP-1 receptor, exen
`din-4 is an agonist, i.e., it increases cAMP, while exendin9
`39 is an antagonist, i.e., it blocks the stimulatory actions of
`exendin-4 and GLP-1. Id.
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`The present invention relates to methods for increasing
`urine flow comprising administration of an effective amount
`of glucagon-like peptide-1 (7-36 amide (abbreviated “GLP
`7-36NH or simply “GLP-1), an exendin, or an exendinor
`GLP-1 agonist. Methods for increasingurinary Sodium excre
`tion and decreasing urinary potassium concentration are also
`disclosed. The methods are useful for treating conditions or
`disorders associated with toxic hypervolemia, Such as renal
`failure, congestive heart failure, nephrotic syndrome, cirrho
`sis, pulmonary edema, and hypertension. Pharmaceutical
`compositions for use in the methods of the invention are also
`disclosed.
`The present invention also relates to methods for inducing
`an inotropic response comprising administration of an effec
`tive amount of an exendin, GLP-1, or an exendin or GLP-1
`agonist. These methods are useful for treating conditions or
`disorders that can be alleviated by an increase in cardiac
`contractility, such as congestive heart failure.
`The following description Summarizes information rel
`evant to the present invention. It is not an admission that any
`of the information provided herein is prior art to the presently
`claimed invention, nor that any of the publications specifi
`cally or implicitly referenced are prior art to that invention.
`Glucagon-like peptide-1 (7-36 amide (also referred to as
`GLP-1 (7-36NH or GLP-1) is a product of the proglucagon
`gene. It is secreted into plasma mainly from the gut and
`produces a variety of biological effects related to pancreatic
`and gastrointestinal function. The parent peptide, progluca
`gon (PG), has numerous cleavage sites that produce other
`peptide products dependent on the tissue of origin including
`glucagon (PG|32-62) and GLP-17-36NH. (PG|72-107)
`in the pancreas, and GLP-17-37 (PG|78-108) and GLP-1
`7-36NH. (PG 78-107) in the L cells of the intestine where
`GLP-17-36NH (78-107 PG) is the major product.
`GLP-17-36NH, also known as proglucagon 78-107, or
`commonly, just “GLP-1. as used herein, has an insulinotro
`pic effect, Stimulating insulin secretion from pancreatic
`B-cells; GLP-1 also inhibits glucagon Secretion from pancre
`atic C-cells (Orskov, et al., Diabetes, 42:658-61, 1993;
`D’Alessio, et al., J. Clin. Invest., 97:133-38, 1996). GLP-1 is
`reported to inhibit gastric emptying (Williams B, et al., J. Clin
`Endocrinol Metab 81 (1): 327-32, 1996; WettergrenA, et al.,
`Dig Dis Sci 38 (4): 665-73, 1993), and gastric acid secretion.
`(Schjoldager BT, et al., Dig Dis Sci 34 (5): 703-8, 1989;
`O'Halloran DJ, et al., J Endocrinol 126 (1): 169-73, 1990;
`Wettergren A, et al., Dig Dis Sci 38 (4): 665-73, 1993). A
`diuretic, antidypsogenic effect of intracerebroVentricular
`65
`administration of GLP-1 has been reported, however, this
`report claims that a peripheral, intraperitoneal injection of
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`Exendin9-39 also acts as an antagonist of the full length
`exendins, inhibiting stimulation of pancreatic acinar cells by
`exendin-3 and exendin-4 (Raufman, et al., J. Biol. Chem.
`266:2897-902, 1991; Raufman, et al., J. Biol. Chem., 266:
`21432-37, 1992). Exending-39 inhibits the stimulation of
`plasma insulin levels by exendin-4, and inhibits the Soma
`to statin release-stimulating and gastrin release-inhibiting
`activities of exendin-4 and GLP-1 (Kolligs, F., et al., Diabe
`tes, 44:16-19, 1995; Eissele, et al., Life Sciences, 55:629-34,
`1994). Exendin-4, administered through the jugular vein, has
`been reported to induce an increase in Systolic, diastolic and
`mean arterial blood pressure, and in heart rate (Barragán, et
`al., Regul. Pep. 67:63-68, 1996).
`Exendins have recently been found to inhibit gastric emp
`tying (U.S. patent application Ser. No. 08/694,954, filed Aug.
`15
`8, 1996, which enjoys common ownership with the present
`invention and is hereby incorporated by reference). Exendin
`9-39 has been used to investigate the physiological rel
`evance of central GLP-1 in control of food intake (Turton, M.
`D. et al., Nature, 379:69-72, 1996). GLP-1 administered by
`intracerebroventricular (ICV) injection inhibits food intake in
`rats. This satiety-inducing effect of GLP-1 delivered by
`intracerebroventricular injection is reported to be inhibited by
`ICV injection of exendin9-39 (Turton, supra). However, it
`has been reported that GLP-1 does not inhibit food intake in
`mice when administered by peripheral injection (Turton, M.
`D., Nature 379:69-72, 1996; Bhavsar, S. P., Soc. Neurosci.
`Abstr. 21:460 (188.8), 1995). Administration of exendins and
`exendin agonists has also recently been found to reduce food
`intake (U.S. Provisional Patent Application Ser. No. 60/034,
`905, filed Jan. 7, 1997, which enjoys common ownership with
`the present invention and is hereby incorporated by refer
`ence).
`Agents that increase urine flow, or diuretics, are useful for
`treating conditions or disorders that are associated with toxic
`hypervolemic states. Such conditions or disorders include
`renal failure, congestive heart failure, nephrotic syndrome,
`cirrhosis, pulmonary edema, and hypertension. Diuretics are
`also employed to treat conditions in pregnancy, Such as pre
`eclampsia and eclampsia. Further uses of diuretics include
`their use to reduce Volume before some Surgical procedures
`Such as ocular Surgery and neuroSurgery.
`One difficulty encountered with many diuretics such as
`thiazides, loop diuretics, carbonic anhydrase inhibitors, and
`osmotic diuretics, is that although they may be employed to
`45
`increase Sodium excretion, they also result in an increase of
`urinary potassium loss. Examples of the effects of potassium
`loss include muscular weakness, paralysis (including the
`paralysis of respiratory muscles), electrocardiographic
`abnormalities, cardiac dysrhythmia, and cardiac arrest.
`Another difficulty encountered with some diuretics is their
`slow rate of action, which is not conducive to their use in an
`emergency setting.
`Thus, there is a need for a method of increasing urine flow
`that does not deplete potassium concentration in the patient
`and which has a rapid mode of action. Such methods, and
`compounds and compositions which are useful therefore,
`have been invented and are described and claimed herein.
`Compounds that induce inotropic effects (e.g., increase of
`force of contraction of the heart) have been recognized as
`being useful for the treatment of for example, congestive
`heart failure. Congestive heart failure, which is one of the
`most common causes of death and disability in industrialized
`nations, has a mortality rate of about 50% at five years (Good
`man and Gilman's The Pharmacological Basis of Therapeu
`tics, 9th Ed. McGraw Hill, New York, pp. 809-838). Inotropic
`agents currently in clinical use include digitalis, sympatho
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`US 8,759,291 B2
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`mimetic amines and amrinone (Harrison's Principles of Inter
`nal Medicine, 12th Edition, 1991, McGraw Hill, New York,
`pp. 894-899).
`Digotoxin, a cardiac glycoside, an ancient but effective
`therapy for cardiac failure, was initially derived from the
`foxglove leaf, Digitalis purpurea and Digitalis lanata. Cardiac
`glycosides are potent and highly selective inhibitors of the
`active transport of sodium and potassium ions across cell
`membranes (Goodman and Gilman, Supra). Cardiac glyco
`sides have been reported to increase the velocity of shortening
`of cardiac muscle, resulting in an improvement in Ventricular
`function; this effect has been reported to be due to an increase
`in the availability during systole of cytosolic Ca" to interact
`with contractile proteins to increase the velocity and extent of
`sarcomere shortening (Goodman and Gilman, Supra).
`Digotoxin and related cardiac glycosides (e.g. digitoxin)
`have useful durations of action because their excretion,
`mainly via the kidneys, results in plasma t/2 of 1.5-5 days.
`But the therapeutic index of these drugs is very low with
`mildly toxic:minimally-effective dose ratio being 2:1 and
`lethal:minimally-effective dose ratio being between 5:1 and
`10:1. Urinary potassium loss due to use of thiazide and loop
`diuretics may seriously enhance the dangers of digitalis
`intoxication, including Susceptibility to cardiac arrhythmia,
`and potassium-sparing diuretics are often necessary. Slow
`elimination of cardiac glycosides can prolong the period of
`jeopardy during digitalis intoxication, which has been
`reported to occur in 20% of hospital patients on these drugs.
`Absorption and onset of action for all cardiac glycosides
`except ouabain is somewhat prolonged, and this may be a
`disadvantage in emergency cardiac conditions.
`Sympathomimetic amines, which generally include epi
`nephrine, isoproterenol, dopamine and dobutamine, can be
`useful in an acute setting to stimulate myocardial contractil
`ity, but they usually require constant intravenous infusion and
`continuous intensive monitoring of the patient. They typically
`lose their effectiveness after -8 hours, apparently due to
`receptor downregulation.
`Amrinone, a noncatecholamine, non-glycoside agent also
`requires continuous intravenous administration.
`This description of available inotropic agents illustrates the
`need for, and desirability of therapies that are (1) inotropic,
`with (2) rapid onset of action, with (3) prolonged duration of
`action (including a persistent effect, with absence of tachy
`phylaxis), with (4) low toxicity (a high ratio of toxic to thera
`peutic dose), with (5) rapid and profound diuretic effect, with
`(6) a sparing of urinary potassium loss, and with (7) a conve
`nient (non-intravenous) route of administration. We have dis
`covered that exendin and GLP-1 fulfill these criteria.
`
`SUMMARY OF THE INVENTION
`
`The present invention concerns the Surprising discovery
`that exendins, GLP-1, and agonists of these compounds have
`rapid inotropic and diuretic effects. Although GLP-1 has been
`reported to not have a diuretic effect when administered
`peripherally, we have found, surprisingly, that GLP-1 does in
`fact have a diuretic effect after peripheral administration. This
`diuretic effect of exendins, GLP-1, and exendin and GLP-1
`agonists, is accompanied by an increase in urinary Sodium
`concentration. This diuretic effect is also accompanied by a
`decrease in urinary potassium concentration which is unan
`ticipated as many diuretics have been found to cause a pro
`found increase in urinary potassium concentration.
`The present invention is directed to novel methods for
`increasing urine flow comprising the administration of an
`exendin, for example, exendin-3 SEQID NO. 1: His Ser Asp
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`MYLAN INST. EXHIBIT 1017 PAGE 22
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`MYLAN INST. EXHIBIT 1017 PAGE 22
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`US 8,759,291 B2
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`GlyThr Phe Thr Ser Asp Leu Ser Lys Gln Met Glu Glu Glu
`Ala Val Arg Leu Phe Ile Glu Trp Leu Lys Asn Gly Gly Pro Ser
`Ser Gly Ala Pro ProPro Ser-NH), orexendin-4SEQID NO.
`2: His Gly Glu GlyThr Phe Thr Ser Asp Leu Ser Lys Gln Met
`Glu Glu Glu Ala Val Arg Leu Phe Ile Glu Trp Leu Lys Asn Gly
`Gly Pro Ser Ser Gly Ala Pro Pro Pro Ser-NH), or other
`compounds which effectively bind to the receptor at which
`exendin exerts its action on increasing urine flow (exendin
`agonists). The present invention is also directed to novel
`methods for increasing urine flow comprising the administra
`tion of GLP-1 SEQID NO. 3: His Ala Glu Gly Thr Phe Thr
`Ser Asp Val Ser Ser Tyr Leu Glu Gly Glin Ala Ala Lys Glu Phe
`Ile Ala Trp Leu Val Lys Gly Arg-NH), or other compounds
`which effectively bind to the receptor at which GLP-1 exerts
`its action on increasing urine flow (GLP-1 agonists).
`In a first aspect, the invention features a method of increas
`ing urine flow in an individual comprising administering to
`the individual atherapeutically effective amount of an exen
`din or an exendin agonist. In one preferred aspect, said exen
`din is exendin-3. More preferably, said exendin is exendin-4.
`By an “exendinagonist' is meanta compound that mimics the
`effects of exendin on increasing urine flow, increasing sodium
`excretion, and/or decreasing urinary potassium concentra
`tion, (the potassium concentration in excreted urine) by bind
`ing to the receptor or receptors where exendin causes this
`effect. Certain novel exendin agonist compounds are
`described in U.S. Provisional Patent Application Ser. No.
`60/055,404, filed Aug. 8, 1997, which was filed as PCT/98/
`16387, on Aug. 6, 1998 and nationalized as U.S. patent appli
`cation Ser. No. 10/181,102, on Jul. 11, 2001 and enjoys com
`30
`mon ownership with the present invention and is hereby
`incorporated by this reference. Certain other novel exendin
`agonist compounds are described in U.S. Provisional Patent
`Application Ser. Nos. 60/066,029 and 60/065,442, both filed
`Nov. 14, 1997, which were filed as PCT/US98/24210, on
`Nov. 13, 1998 and nationalized as U.S. patent application Ser.
`No. 09/554,531, on Aug. 8, 2000, and as PCT/US98/24273 on
`Nov. 13, 1998 and nationalized as U.S. patent application Ser.
`No. 09/554,533, on May 11, 2000, respectively, and enjoy
`common ownership with the present invention and are hereby
`incorporated by this reference. Preferred exendin agonist
`compounds include those described in U.S. Provisional
`Patent Application Ser. Nos. 60/055.404 and 60/065,442.
`In one preferred aspect the exendin or exendinagonist used
`in the methods of the present invention is exendin-4. In
`another preferred aspect, the exendin is exendin-3. In other
`preferred aspects, the exendin or exendin agonist is a com
`pound of the formula (I) SEQID NO. 4):
`Xaa1 Xaa-2 Xaa3. Gly Xaas Xaa, Xaa, Xaas Xaag Xaa10
`Xaa11 Xaa12Xaa13 Xaa14Xaa1s Xaa16Xaa17 Ala
`
`6
`Xaa-Ser Ser Gly Ala Xaa-Z, Gly Gly Xaa, Ser Ser Gly
`Ala Xaa, Xaa,-Z, Gly Gly Xaa, Ser Ser Gly Ala Xaa,
`Xaa, Xaas-Z, or Gly Gly Xaas Ser Ser Gly Ala Xaa
`Xaa-7 Xaass Xaaso-Z2
`whe