PCT
`INTERNATIONAL APPLICATION PUBLISHED UNDER THE PATENT COOPERATION TREATY (PCT)
`WO 99/40788
`
`WORLD INTELLECTUAL PROPERTY ORGANIZATION
`International Bureau
`
`(SI) International Patent Classification 6 :
`AOlN 37/18
`
`(11) International Publication Number:
`
`Al
`
`(43) International Publication Date:
`
`19 August 1999 (19.08.99)
`
`(81) Designated States: AL, AM, AT, AU, AZ, BA, BB, BG, BR,
`BY, CA, CH, CN, CU, CZ, DE, DK, EE, ES, FI, GB, GD,
`GE, GH, GM, HR, HU, ID, IL, IN, IS, JP, KE, KG, KP,
`KR, KZ, LC, LK, LR, LS, LT, LU, LV, MD, MG, MK,
`MN, MW, MX, NO, NZ, PL, PT, RO, RU, SD, SE, SG,
`SI, SK, SL, TJ, TM, TR, TT, UA, UG, US, UZ, VN, YU,
`ZW, ARIPO patent (GH, GM, KE, LS, MW, SD, SZ, UG.
`ZW), Eurasian patent (AM, AZ, BY, KG, KZ, MD, RU, TJ,
`TM), European patent (AT, BE, CH, CY, DE, DK, ES, Fl,
`FR, GB, GR, IE, IT, LU, MC, NL, PT, SE), OAPI patent
`(BF, BJ, CF, CG, CI, CM, GA, GN, GW, ML, MR, NE,
`SN, TD, TG).
`
`Published
`With international search report.
`
`(21) International Application Number:
`
`PCT/US99/02554
`
`(22) International Filing Date:
`
`5 February 1999 (05.02.99)
`
`(30) Priority Data:
`60/075,122
`
`13 February 1998 (13.02.98)
`
`us
`
`(71) Applicant (for all designated States except US): AMYLIN
`PHARMACEUTICALS, INC. [US/US]; 9373 Towne Centre
`Drive, San Diego, CA 92121 (US).
`
`(72) Inventors; and
`(75) Inventors/Applicants (for US only): YOUNG, Andrew, A.
`[US/US]; 95 14 Easter Way, San Diego, CA 92121 (US).
`VINE, Will [US/US]; 14537 Crestline Drive, Poway, CA
`92064 (US). BEELEY, Nigel, R., A. [US/US]; 227 Lorna
`Corta Drive, Solana Beach, CA 92075 (US). PRICKETT,
`Kathryn [US/US]; 7612 Trailbrush Terrace, San Diego, CA
`92126 (US).
`
`(74) Agents: MUNSON, Peter, R. et al.; Lyon & Lyon LLP, Suite
`4700, 633 West Fifth Street, Los Angeles, CA 90071-2066
`(US).
`
`(54) Title: INOTROPIC AND DIURETIC EFFECTS OF EXENDIN AND GLP-1
`
`(57) Abstract
`
`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 concentration are also
`disclosed. The methods are useful for treating conditions or disorders associated with toxic hypervolernia, such as renal failure, congestive
`heart failure, nephrotic syndrome, cirrhosis, pulmonary edema, and hypertension. 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 conditions or disorders that can be alleviated by an increase in cardiac contractility such as congestive heart
`failure. Pharmaceutical compositions for use in the methods of the invention are also disclosed.
`
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`

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`FOR THE PURPOSES OF INFORMATION ONLY
`
`Codes used to identify States party to the PCT on the front pages of pamphlets publishing international applications under the PCT.
`
`AL
`AM
`AT
`AU
`AZ
`BA
`BB
`BE
`BF
`BG
`BJ
`BR
`BY
`CA
`CF
`CG
`CH
`CI
`CM
`CN
`cu
`CZ
`DE
`DK
`EE
`
`Albania
`Annenia
`Austria
`Australia
`Azerbaijan
`Bosnia and Herzegovina
`Barbados
`Belgium
`Burkina Faso
`Bulgaria
`Benin
`Brazil
`Belarus
`Canada
`Central African Republic
`Congo
`Switzerland
`Cate d'Ivoire
`Cameroon
`China
`Cuba
`Czech Republic
`Gennany
`Denmark
`Estonia
`
`ES
`Fl
`FR
`GA
`GB
`GE
`GH
`GN
`GR
`HU
`IE
`IL
`IS
`IT
`JP
`KE
`KG
`KP
`
`KR
`KZ
`LC
`LI
`LK
`LR
`
`Spain
`Finland
`France
`Gabon
`United Kingdom
`Georgia
`Ghana
`Guinea
`Greece
`Hungary
`Ireland
`Israel
`Iceland
`Italy
`Japan
`Kenya
`Kyrgyz.stan
`Democratic People's
`Republic of Korea
`Republic of Korea
`Kazaksran
`Saint Lucia
`Liechtenstein
`Sri Lanka
`Liberia
`
`LS
`LT
`LU
`LY
`MC
`MD
`MG
`MK
`
`ML
`MN
`MR
`MW
`MX
`NE
`NL
`NO
`NZ
`PL
`PT
`RO
`RU
`SD
`SE
`SG
`
`Lesotho
`Lithuania
`Luxembourg
`Latvia
`Monaco
`Republic of Moldova
`Madagascar
`The former Yugoslav
`Republic of Macedonia
`Mali
`Mongolia
`Mauritania
`Malawi
`Mexico
`Niger
`Netl1erlands
`Norway
`New Zealand
`Poland
`Ponugal
`Romania
`Russian Federation
`Sudan
`Sweden
`Singapore
`
`SI
`SK
`SN
`sz
`TD
`TG
`TJ
`TM
`TR
`TT
`UA
`UG
`us
`uz
`VN
`YU
`zw
`
`Slovenia
`Slovakia
`Senegal
`Swaziland
`Chad
`Togo
`Tajikistan
`Turkmenistan
`Turkey
`Trinidad and Tobago
`Ukra.ine
`Uganda
`Unired States of America
`Uzbekistan
`Vier Nam
`Yugoslavia
`Zimbabwe
`
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`

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`WO 99/40788
`
`PCT/US99/02554
`
`DESCRIPTION
`
`INOTROPIC AND DIURETIC EFFECTS OF EXENDIN AND GLP-1
`
`s
`
`FIELD OF THE INVENTION
`
`The present invention relates to methods for increasing urine flow comprising
`
`administration of an effective amount of glucagon-like peptide- I [7-36] amide (abbreviated
`
`"GLP-[7-36]NH/' or simply "GLP-1 "), an exendin, or an exendin or GLP-1 agonist.
`
`Methods for increasing urinary sodium excretion and decreasing urinary potassium
`
`1 O
`
`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, cirrhosis, 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
`
`15
`
`comprising administration of an effective 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 relevant to the present
`
`invention. It is not an admission that any of the information provided herein is prior art to
`
`2 O
`
`the presently claimed invention, nor that any of the publications specifically or implicitly
`
`referenced are prior art to that invention.
`
`GLP-1
`
`Glucagon-like peptide-I [7-36] amide (also referred to as GLP-1[7-36]NH2 or
`2 5 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, proglucagon (PG), has numerous cleavage sites that produce
`
`other peptide products dependent on the tissue of origin including glucagon (PG[32-62])
`
`and GLP-1 [7-36]NH2 (PG[72-107]) in the pancreas, and GLP- 1 [7-37] (PG[78-108]) and
`30 GLP-1[7-36]NH2 (PG [78-107]) in the L cells of the intestine where GLP-1[7-36]NH2 (78-
`107 PG) is the major product.
`
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`GLP-1 [7-36]NH2, also known as proglucagon [78-107), or commonly, just GLP-
`
`1," as used herein, has an insulinotropic effect, stimulating insulin secretion from
`
`pancreatic -cells; GLP-1 also inhibits glucagon secretion from pancreatic -cells (Orskov,
`
`et al., Diabetes, 42:658-61, 1993; D' Alessio, et al., J. Clin. Invest., 97: 133-38, 1996).
`
`5
`
`GLP-1 is reported to inhibit gastric emptying (Williams B, et al., J Clin Endocrinol Metab
`
`81 (1): 327-32, 1996; Wettergren A, et al., Dig Dis Sci 38 (4): 665-73, l 993), and gastric
`
`acid secretion. (Schjoldager BT, et al., Dig Dis Sci 34 (5): 703-8, l 989; 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 administration of GLP-
`
`1 O
`
`1 has been reported, however, this report claims that a peripheral, intraperitoneal injection
`
`of GLP-1 did not have this effect. (Tand-Christensen et al., Am. J. Phvsiol., 271 :R848-56,
`
`1996). GLP-1[7-37), which has an additional glycine residue at its car boxy terminus, also
`
`stimulates insulin secretion in humans (Orskov, et al., Diabetes, 42:658-61, 1993). A
`
`transmembrane G-protein adenylate-cyclase-coupled receptor believed to be responsible
`
`15
`
`for the insulinotropic effect of GLP-1 has been cloned from a -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
`
`2 o
`
`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
`
`Barragan, J.M., et al., Regul. Peptides, 67:63-68, 1996).
`
`25
`
`EXENDIN
`
`Exendins are peptides that are found in the venom of the Gila-monster, a lizard
`
`endogenous to Arizona, and the Mexican Beaded Lizard. Exendin-3 is present in the
`
`venom of Heloderma horridum, and exendin-4 is present in the venom of Heloderma
`
`3 O
`
`suspectum (Eng, J., et al., J. Biol. Chem., 265:20259-62, 1990; Eng., J., et al., J. Biol.
`
`Chem., 267:7402-05, 1992). The exendins have some sequence similarity to several
`
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`members of the glucagon-like peptide family, with the highest homology, 53%, being to
`
`GLP-1 (Goke, et al., J. Biol. Chem., 268: 19650-55, 1993).
`
`Exendin-4 is a potent agonist at GLP-1 receptors on insulin-secreting TCI cells, at
`
`dispersed acinar cells from guinea pig pancreas, and at parietal cells from stomach; the
`
`5
`
`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 Peptides,
`
`10
`
`41: 149-56, I 992; Raufman, et al., J. Biol. Chem. 267:21432-37, I 992; Singh, et al., Regul.
`
`Pept. 53:47-59, 1994). The use of the insulinotropic activities of exendin-3 and exendin-4
`
`for the treatment of diabetes mellitus and the prevention of hyperglycemia has been
`
`proposed (Eng, U.S. Patent No. 5,424,286).
`
`Truncated exendin peptides such as exendin[9-39], a carboxyamidated molecule,
`
`15
`
`and fragments 3-39 through 9-39 have been reported to be potent and selective antagonists
`
`of GLP-1 (Ooke, 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;
`
`Montrose-Rafizadeh, et al., Diabetes, 45(Suppl. 2): 152A, 1996). Exendin[9-39] blocks
`
`endogenous GLP-1 in vivo, resulting in reduced insulin secretion. Wang, et al., J. Clin.
`
`2 0
`
`Invest., 95:417-21 , 1995; D'Alessio, et al., J. Clin. lnvest., 97:133-38, 1996). The receptor
`
`apparently responsible for the insulinotropic effect of OLP-1 has been cloned from rat
`
`pancreatic islet cells (Thorens, B., Proc. Natl. Acad. Sci. USA 89:8641-8645, 1992).
`
`Exendins and exendin[9-39) bind to the cloned OLP- I receptor (rat pancreatic -cell OLP-
`
`I receptor: Fehmann HC, et al., Peptides 15 (3): 453-6, 1994; human OLP-I receptor:
`
`2 5
`
`Thorens B, et al., Diabetes 42 (11 ): I 678-82, 1993 ). In cells transfected with the cloned
`
`OLP-1 receptor, exendin-4 is an agonist, i.e., it increases cAMP, while exendin[9-39] is an
`
`antagonist, i.e., it blocks the stimulatory actions of exendin-4 and GLP-1. Id.
`
`Exendin[9-39] 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.
`
`30
`
`Chem. 266:2897-902, 1991; Raufman, et al., J. Biol. Chem., 266:21432-37, 1992).
`
`Exendin[9-39] inhibits the stimulation of plasma insulin levels by exendin-4, and inhibits
`
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`the somatostatin release-stimulating and gastrin release-inhibiting activities of exendin-4
`
`and GLP-1 (Kolligs, F., et al., Diabetes, 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
`
`5
`
`(Barragan, et al., Regul. Pep. 67:63-68, 1996).
`
`Exendins have recently been found to inhibit gastric emptying (U.S. Patent
`
`Application Serial No. 08/694,954, filed August 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 relevance of central GLP-1
`
`10
`
`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 exendin[9-39) (Turton, supra). However, it has been
`
`reported that GLP-1 does not inhibit food intake in mice when administered by peripheral
`
`15
`
`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 Serial No.
`
`60/034,905, filed January 7, 1997, which enjoys common ownership with the present
`
`invention and is hereby incorporated by reference).
`
`20
`
`DIURETICS
`
`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
`
`25
`
`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
`
`3 o
`
`employed to increase sodium excretion, they also result in an increase of urinary
`
`potassium loss. Examples of the effects of potassium loss include muscular weakness,
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`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.
`
`5
`
`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.
`
`Inotropic Compounds
`
`1 o
`
`Compounds that induce inotropic effects (~, 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 (Goodman and Gilman s The Pharmacological Basis of Therapeutics, 9th Ed.
`
`15 McGraw Hill, New York, pp. 809-838). Inotropic agents currently in clinical use include
`
`digitalis, sympathomimetic amines and amrinone (Harrison s Principles oflntemal
`
`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.
`
`2 O 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 glycosides 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 Ca2
`
`+ to interact with
`
`2 5
`
`contractile proteins in increase the velocity and extent of sarcomere shortening (Goodman
`
`and Gilman, supra).
`
`Digotoxin and related cardiac glycosides (~ digitoxin) have useful durations of
`
`action because their excretion, mainly via the kidneys, results in plasma t of 1.5-5 days.
`
`But the therapeutic index of these drugs is very low with mildly toxic:minimally-effective
`
`3 O
`
`dose ratio being 2: 1 and lethal:minimally-effective dose ratio being between 5: l and 10: 1.
`
`Urinary potassium loss due to use of thiazide and loop diuretics may seriously enhance
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`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
`
`5
`
`cardiac glycosides except ouabain is somewhat prolonged, and this may be a disadvantage
`
`in emergency cardiac conditions.
`
`Sympathomimetic amines, which generally include epinephrine, isoproterenol,
`
`dopamine and dobutamine, can be useful in an acute setting to stimulate myocardial
`
`contractility, but they usually require constant intravenous infusion and continuous
`
`1 O
`
`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
`
`15
`
`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 tachyphylaxis),
`
`with (4) low toxicity (a high ratio of toxic to therapeutic dose), with (5) rapid and profound
`
`diuretic effect, with (6) a sparing of urinary potassium loss, and with (7) a convenient
`
`(non-intravenous) route of administration. We have discovered that exendin and GLP-1
`
`2 o
`
`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
`
`25
`
`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 unanticipated as
`
`3 O many diuretics have been found to cause a profound increase in urinary potassium
`
`concentration.
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`7
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`The present invention is directed to novel methods for increasing urine flow
`
`comprising the administration of an exendin, for example, exendin-3 [SEQ ID NO. l: His
`
`Ser Asp Gly Thr 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-NH2] , or exendin-4
`[SEQ ID NO. 2: His Gly Glu Gly Thr Phe Thr Ser Asp Leu Ser Lys Gin Met Glu Glu Glu
`
`5
`
`Ala Val Arg Leu Phe Ile Glu Trp Leu Lys Asn Gly Gly Pro Ser Ser Gly Ala Pro Pro Pro
`
`Ser-NH2] , 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 administration of GLP-
`
`10
`
`I [SEQ ID NO. 3: His Ala Glu Gly Thr Phe Thr Ser Asp Val Ser Ser Tyr Leu Glu Gly
`
`Gin Ala Ala Lys Glu Phe Ile Ala Trp Leu Val Lys Gly Arg-NH2], 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 increasing urine flow in an
`
`1 5
`
`individual comprising administering to the individual a therapeutically effective amount of
`
`an exendin or an ex end in agonist. In one preferred aspect, said exendin is exendin-3.
`
`More preferably, said exendin is exendin-4. By an exendin agonist is meant a compound
`
`that mimics the effects of exendin on increasing urine flow, increasing sodium excretion,
`
`and/or decreasing urinary potassium concentration, (the potassium concentration in
`
`2 O
`
`excreted urine) by binding to the receptor or receptors where exendin causes this effect.
`
`Certain novel exendin agonist compounds are described in U.S. Provisional Patent
`
`Application Serial No. 60/055,404, filed August 8, 1997, which enjoys common
`
`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
`
`2 5 Application Serial Nos. 60/066,029 and 60/065,442, both filed November 14, 1997 which
`
`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 Serial Nos. 60/055,404 and 60/065,442.
`
`In one preferred aspect the exendin or exendin agonist used in the methods of the
`
`3 O
`
`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 compound of the formula (I)
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`WO 99/40788
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`[SEQ ID NO. 4]:
`
`8
`
`PCT/US99/02554
`
`Xaa, Xaa2 Xaa3 Gly Xaa5 Xaa6 Xaa7 Xaa8 Xa~ Xaa10
`Xaa, 1 Xaa,2 Xaa 13 Xaa 14 Xaa, 5 Xaa 16 Xaa17 Ala Xaa 19 Xaa20
`Xaa21 Xaa22 Xaa23 Xaa24 Xfil½s Xaa26 Xaa27 Xaa28-Z1; wherein
`5 Xaa1 is His, Arg or Tyr;
`Xaa2 is Ser, Gly, Ala or Thr;
`Xaa3 is Asp or Glu;
`Xaa5 is Ala or Thr;
`Xaa6 is Ala, Phe, Tyr or naphthylalanine;
`
`1 O Xa~ is Thr or Ser;
`
`Xaa8 is Ala, Ser or Thr;
`
`Xa~ is Asp or Glu;
`
`Xaa10 is Ala, Leu, Ile, Val, pentylglycine or Met;
`Xaa1 1 is Ala or Ser;
`15 Xaa12 is Ala or Lys;
`Xaa13 is Ala or Gin;
`
`Xaa 14 is Ala, Leu, Ile, pentylglycine, Val or Met;
`
`Xaa15 is Ala or Glu;
`
`Xaa,6 is Ala or Glu;
`2 o Xaa17 is Ala or Glu;
`Xaa,9 is Ala or Val;
`Xfil½0 is Ala or Arg;
`
`Xaa21 is Ala or Leu;
`
`Xaa22 is Phe, Tyr or naphthylalanine;
`
`25 Xaa23 is Ile, Val, Leu, pentylglycine, tert-butylglycine
`
`or Met;
`
`Xa3i4 is Ala, Glu or Asp;
`
`Xaa25 is Ala, Trp, Phe, Tyr or naphthylalanine;
`Xaa26 is Ala or Leu;
`3 o Xaa27 is Ala or Lys;
`Xaa28 is Ala or Asn;
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`WO99/40788
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`PCT /US99/02554
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`9
`
`Z 1 is-OH,
`-NH2,
`Gly-Z2,
`Gly Gly-Z2,
`Gly Gly Xaa31 -Z2,
`Gly Gly Xaa31 Ser-Z2,
`Gly Gly Xaa31 Ser Ser-Z2,
`Gly Gly Xaa31 Ser Ser Gly-Z2 ,
`Gly Gly Xaa31 Ser Ser Gly Ala-Z2,
`Gly Gly Xaa31 Ser Ser Gly Ala Xaa36-Z2,
`Gly Gly Xaa31 Ser Ser Gly Ala Xaa36 Xaa37-Z2,
`Gly Gly Xaa31 Ser Ser Gly Ala Xaa36 Xaa37 Xaa38-Z2, or
`Gly Gly Xaa31 Ser Ser Gly Ala Xaa36 Xaa37 Xaa38 Xaa39-Z2;
`wherein X~ 1, Xaa36, X~7 and Xaa38 are independently
`selected from the group consisting of Pro,
`
`homoproline, 3Hyp, 4Hyp, thioproline,
`
`N-alkylglycine, N-alkylpentylglycine and
`
`N-alkylalanine; Xaa39 is Ser, Thr or Tyr; and
`Z2 is -OH or -NH2; and pharmaceutically acceptable salts thereof;
`provided that no more than three ofXaa3, Xaa5, Xaa6, Xaa8, Xaa10, Xaa11 , Xaa12, Xaa13,
`Xaa14, Xaa,5, Xaa16, Xaa17, Xaa19, Xaa20, Xaa21, Xaa24 , Xaa25, Xaa26, Xaa27, and Xaa28 are
`Ala; and provided also that the compound is not exendin-3 [SEQ ID NO. 1] or exendin-4
`
`[SEQ ID NO. 2). In other aspects of the invention, the increase in urine flow is
`
`accompanied by an increase in sodium excretion in said individual. In most preferred
`
`5
`
`10
`
`15
`
`20
`
`2 5
`
`aspects, the increase in urine flow does not increase urinary potassium concentration in
`
`said individual.
`
`In other embodiments of the invention, a method is provided for decreasing the
`
`concentration of potassium in the urine of an individual comprising administering to said
`
`individual a therapeutically effective amount of an exendin or an exendin agonist.
`
`30
`
`In yet another aspect of the invention, a method is provided for preventing or
`
`alleviating a condition or disorder associated with toxic hypervolemia in an individual,
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`WO 99/40788
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`PCT/US99/02554
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`10
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`comprising administering to said individual a therapeutically effective amount of an
`
`exendin or an exendin agonist.
`
`By condition or disorder associated with toxic hypervolemia is meant any
`
`condition or disorder in a subject that is either caused by, complicated by, or aggravated by
`
`5
`
`a relatively high extracellular volume. Such conditions or disorders include, but are not
`
`limited to, renal failure, congestive heart failure, nephrotic syndrome, pulmonary edema,
`
`cirrhosis, and hypertension.
`
`The present invention also provides a method of inducing rapid diuresis in an
`
`individual comprising administering to said individual a therapeutically effective amount
`
`1 o
`
`of an exendin or an exendin agonist. One preferred use of this method is in preparation of
`
`a patient for a surgical procedure where a reduction in extracellular volume is desired,
`
`such as in some ocular surgical procedures or in some neurosurgical procedures. Thus, the
`
`present invention provides a method of preparing an individual for a surgical procedure
`
`comprising administering to said individual a therapeutically effective amount of an
`
`15
`
`exendin or an exendin agonist. Preferably, said exendin or exendin agonist is administered
`
`to said individual before said surgical procedure.
`
`In other preferred aspects, a method is provided for increasing renal plasma flow
`
`and glomerular filtration rate in an individual comprising administering to said individual
`
`a therapeutically effective amount of an exendin or an exendin agonist.
`
`20
`
`In yet other preferred aspects, a method is provided for treating pre-eclampsia or
`
`eclampsia of pregnancy in an individual comprising administering to said individual a
`
`therapeutically effective amount of an exendin or an exendin agonist.
`
`The preferred mode of administration of said exendin or exendin agonist is by
`
`peripheral (subcutaneous or intravenous) administration. Preferably, said exendin or
`
`2 5
`
`exendin agonist is administered subcutaneously. Preferably, about 1 g- 30 g to about 10-
`
`20 mg of the exendin or exendin agonist is administered per dose. More preferably, about
`
`30 g to about IO mg, or about 300 g to about 5mg of the exendin or exendin agonist is
`
`administered per dose. Most preferably, about 30 g to about I mg of the exendin or
`
`exendin agonist is administered per dose.
`
`3 O
`
`In other preferred aspects, said peripheral administration is selected from the group
`
`consisting ofbuccal, nasal, pulmonary, oral, intraocular, rectal, and transdermal
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`administration.
`
`1 1
`
`PCT/US99/02554
`
`The present invention also provides pharmaceutical compositions for use in the
`
`treatment of conditions or disorders associated with hypervolemia comprising a
`
`therapeutically effective amount of an exendin or exendin agonist in association with a
`
`5
`
`pharmaceutically acceptable carrier.
`
`In yet other aspects, the invention provides pharmaceutical compositions for use in
`
`increasing urine flow in an individual comprising a therapeutically effe.ctive amount of an
`
`exendin or exendin agonist in association with a pharmaceutically acceptable carrier.
`
`In further aspects, the invention provides pharmaceutical compositions for use in
`
`1 O
`
`treating pre-eclampsia or eclampsia of pregnancy in an individual comprising a
`
`therapeutically effective amount of an exendin or exendin agonist in association with a
`
`pharmaceutically acceptable carrier.
`
`Preferably, these pharmaceutical compositions comprise exendin-3. More
`
`preferably, these pharmaceutical compositions comprise exendin-4.
`
`15
`
`Preferably, these pharmaceutical compositions comprise an exendin agonist of
`
`formula I [SEQ ID NO. 4].
`
`The present invention is also directed to novel methods for increasing urine flow
`
`comprising the administration of GLP-1 .
`
`In one embodiment the invention features a method of increasing urine flow in an
`
`2 o
`
`individual comprising administering to the individual a therapeutically effective amount of
`
`GLP-1 or GLP-1 agonist. By GLP-1 agonist is meant a compound that mimics the
`
`effects of GLP-1 on increasing urine flow, increasing sodium excretion, and/or decreasing
`
`urinary potassium concentration, by binding to the receptor or receptors where GLP-1
`
`causes this effect. Certain GLP-1 agonists are described in Chen et al., U.S. Patent No.
`
`25
`
`5,512,549, issued April 30, 1996, entitled Glucagon-Like Insulinotropic Peptide Analogs,
`
`Compositions and Methods of Use. Other GLP-1 agonists are described in Johnson et al.,
`
`U.S. Patent No. 5,574,008, issued November 12, 1996, entitled, Biologically Active
`
`Fragments of Glucagon-Like Insulinotropic Peptide. Still other GLP-1 agonists are
`
`described in Buckley et al., U.S. Patent No. 5,545,618, issued August 13, 1996, entitled
`
`3 0
`
`GLP-1 Analogs Useful for Diabetes Treatment. All three referenced U.S. patents are
`
`incorporated herein by this reference.
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`WO 99/40788
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`PCT /US99/02554
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`12
`
`In other aspects of the invention, the increase in urine flow is accompanied by an
`
`increase in sodium excretion in said individual. In most preferred aspects, the increase in
`
`urine flow does not increase urinary potassium concentration in said individual.
`
`In other embodiments of the invention, a method is provided for decreasing the
`
`5
`
`concentration of potassium in the urine of an individual comprising administering to said
`
`individual a therapeutically effective amount of GLP-1 or a GLP-1 agonist.
`
`In yet another aspect of the invention, a method is provided for preventing or
`
`alleviating a condition or disorder associated with toxic hypervolemia in an individual,
`
`comprising administering to said individual a therapeutically effective amount of GLP-1
`
`1 o
`
`or a GLP-1 agonist.
`
`The present invention also provides a method of inducing rapid diuresis in an
`
`individual comprising administering to said individual a therapeutically effective amount
`
`of GLP-1 or a GLP-1 agonist. One preferred use of this method is in preparation of patient
`
`for surgical procedures where a reduction in extracellular volume is desired, such as in
`
`15
`
`some ocular surgical procedures and some neurosurgical procedures. Thus, the present
`
`invention provides a method of preparing an individual for a surgical procedure
`
`comprising administering to said individual a therapeutically effective amount of GLP-1
`
`or a GLP-1 agonist. Preferably, said GLP-1 or GLP-1 agonist is administered to said
`
`individual before said surgical procedure.
`
`20
`
`In other preferred aspects, a method is provided for increasing renal plasma flow
`
`and glomerular filtration rate in an individual comprising administering to said individual
`
`a therapeutically effective amount of GLP-1 or GLP-1 agonist.
`
`In yet other preferred aspects, a method is provided for treating pre-eclampsia or
`
`eclampsia of pregnancy in an individual comprising administering to said individual a
`
`2 5
`
`therapeutically effective amount of GLP-1 or GLP-1 agonist.
`
`The preferred mode of administration of said GLP-1 or GLP-1 agonist is by
`
`peripheral administration. Preferably, said GLP-1 or GLP-1 agonist is administered
`
`subcutaneously or intravenously. Preferably, about I g-30 g to about I 0-20 mg of GLP-1
`
`or GLP-1 agonist is administered per dose. More preferably, about 30 g to about 10mg,
`
`3 O
`
`or about 300 g to about 5mg o