Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/56—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids
  • A61K31/58—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids containing heterocyclic rings, e.g. danazol, stanozolol, pancuronium or digitogenin
  • A61K31/585—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids containing heterocyclic rings, e.g. danazol, stanozolol, pancuronium or digitogenin containing lactone rings, e.g. oxandrolone, bufalin
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/56—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids
  • A61K31/565—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids not substituted in position 17 beta by a carbon atom, e.g. estrane, estradiol
  • A61K31/568—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids not substituted in position 17 beta by a carbon atom, e.g. estrane, estradiol substituted in positions 10 and 13 by a chain having at least one carbon atom, e.g. androstanes, e.g. testosterone
  • A61K31/569—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids not substituted in position 17 beta by a carbon atom, e.g. estrane, estradiol substituted in positions 10 and 13 by a chain having at least one carbon atom, e.g. androstanes, e.g. testosterone substituted in position 17 alpha, e.g. ethisterone
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/56—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids
  • A61K31/58—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids containing heterocyclic rings, e.g. danazol, stanozolol, pancuronium or digitogenin
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P1/00—Drugs for disorders of the alimentary tract or the digestive system
  • A61P1/16—Drugs for disorders of the alimentary tract or the digestive system for liver or gallbladder disorders, e.g. hepatoprotective agents, cholagogues, litholytics
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P11/00—Drugs for disorders of the respiratory system
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P13/00—Drugs for disorders of the urinary system
  • A61P13/12—Drugs for disorders of the urinary system of the kidneys
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P15/00—Drugs for genital or sexual disorders; Contraceptives
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/06—Antimigraine agents
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P3/00—Drugs for disorders of the metabolism
  • A61P3/08—Drugs for disorders of the metabolism for glucose homeostasis
  • A61P3/10—Drugs for disorders of the metabolism for glucose homeostasis for hyperglycaemia, e.g. antidiabetics
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P5/00—Drugs for disorders of the endocrine system
  • A61P5/24—Drugs for disorders of the endocrine system of the sex hormones
  • A61P5/28—Antiandrogens
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P5/00—Drugs for disorders of the endocrine system
  • A61P5/38—Drugs for disorders of the endocrine system of the suprarenal hormones
  • A61P5/42—Drugs for disorders of the endocrine system of the suprarenal hormones for decreasing, blocking or antagonising the activity of mineralocorticosteroids
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P7/00—Drugs for disorders of the blood or the extracellular fluid
  • A61P7/10—Antioedematous agents; Diuretics
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P9/00—Drugs for disorders of the cardiovascular system
  • A61P9/04—Inotropic agents, i.e. stimulants of cardiac contraction; Drugs for heart failure
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P9/00—Drugs for disorders of the cardiovascular system
  • A61P9/10—Drugs for disorders of the cardiovascular system for treating ischaemic or atherosclerotic diseases, e.g. antianginal drugs, coronary vasodilators, drugs for myocardial infarction, retinopathy, cerebrovascula insufficiency, renal arteriosclerosis
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P9/00—Drugs for disorders of the cardiovascular system
  • A61P9/12—Antihypertensives

Definitions

• the present invention relates to methods for the treatment and/or prophylaxis of one or more pathogenic effects in a subject resulting from the action of endogenous aldosterone, especially in the presence of an elevated sodium level. More particularly, the invention relates to the use of epoxy-steroidal compounds that are aldosterone antagonists, such as eplerenone, for the treatment and/or prophylaxis of hypertension, cardiovascular disease and/or renal dysfunction in a human subject having a sub-normal aldosterone level, salt sensitivity and/or an elevated dietary sodium intake.
• aldosterone antagonists such as eplerenone
• Essential hypertension is a major vascular disease throughout the world and represents a significant public health problem. Elevated blood pressure associated with hypertension has been linked to the incidence of coronary heart disease and stroke. For example, Blumenfeld JD and Laragh JH. Congestive heart failure: pathophysiology, diagnosis and management, 1 st ed. Caddo (OK): Professional Communications, Inc.; 1994, reported that hypertension triples the risk for developing heart failure. Similarly, MacMahon S et al.: Lancet 1990;335:765-71 , reported that a prolonged reduction of only 5 mm Hg in diastolic blood pressure results in a reduction of at least 20 percent of the risk for developing coronary heart disease and at least 33 percent of the risk for developing stroke.
• Hypertension also has been linked to end-stage renal disease.
• End- stage renal disease caused by hypertension and/or diabetic nephropathy is an enormous public health burden, with an incidence and prevalence that is increasing alarmingly in many countries including the United States.
• United States Renal Data System. Excerpts from United States Renal Data System 1999 Annual Data Report. Am J Kidney Dis 1999;34 Suppl ⁇ SI- SI 76 The incidence of hypertension-induced end-stage renal disease has increased despite the substantive decrease in other complications of hypertension, such as stroke and coronary heart disease, due to improved blood pressure awareness and control.
• the renin-angiotensin-aldosterone system plays a major role in the development and progression of hypertension.
• the RAAS plays a pivotal role in nearly all physiologic responses to deficits in extracellular fluid volume and hypotension.
• a decrease in blood volume or arterial blood pressure causes a release of renal renin that acts on angiotensinogen to form angiotensin I.
• Angiotensin converting enzyme then converts angiotensin I into angiotensin II, which causes several peripherally and centrally mediated responses that restore blood volume and pressure.
• angiotensin II acts on smooth muscle cells resulting in vasocontriction to increase blood pressure.
• angiotensin II acts to increase sympathetic outflow and vasopressin release. Although the conversion of angiotensin I to angiotensin II occurs primarily in the lung with angiotensin II then circulating peripherally and centrally to target tissues, this conversion can also occur in regions of the brain.
• Angiotensin II also stimulates the zona glomerulosa of the adrenal cortex, resulting in increased synthesis and secretion of the mineralocorticoid aldosterone.
• Aldosterone acts on the distal and collecting tubules to cause sodium retention and excretion of potassium and hydrogen. Such sodium retention results in increased blood volume.
• Aldosterone plays a role in the pathophysiology of heart failure and has been linked to high blood pressure, cardiac hypertrophy, cardiac and vascular fibrosis, and ventricular arrhythmias (Dzau VJ et al.: Circulation 1981 ; 63:645-651). In patients with heart failure, high aldosterone levels appeared to correspond to increased mortality in those patients.
• Aldosterone blocks myocardial norepinephrine uptake, increases plasma norepinephrine, and promotes ventricular ectopic activity.
• Rocha R et al.: Am J Hypertension 1999;12:76A reported that aldosterone affected baroreceptor function and causes cerebro- and renal- vascular damage as well as endothelial dysfunction in rats.
• Aldosterone also reportedly increases plasminogen activator inhibitor levels and thereby may impede fibrinolysis.
• ACE inhibitor angiotensin-converting enzyme inhibitor
• aldosterone escape occurs because there are other important determinants of aldosterone release, such as serum potassium.
• serum potassium Pant B. Cardiovascular Drugs and Therapy 1995;9:145-149.
• Greene E, et al.: J Clin Invest 1996;98:1063-8 have argued that, although much evidence has accumulated to implicate angiotensin II in mediating renal disease, aldosterone also may be associated with progressive renal disease through both hemodynamic effects and direct cellular actions.
• Greene et al evaluated four treatment groups (sham-operated rats, untreated partial-nephrectomized ["remnant”] rats, remnant rats treated with losartan and enalapril, and remnant rats treated with losartan and enalapril followed by an infusion of aldosterone) to distinguish the relative importance of aldosterone in the progression of renal injury.
• remnant rats undergoing treatment with losartan and enalapril manifested suppressed aldosterone levels, with a decrease in proteinuria, hypertension, and glomerulosclerosis compared with the remnant rats not given these agents.
• remnant rats receiving losartan and enalapril treatment followed by an infusion of aldosterone, the degree of proteinuria, hypertension, and glomerulosclerosis was similar to that of untreated remnant rats.
• a variety of drugs selected from a number of different drug classes can be used to treat hypertension, heart failure and renal dysfunction. (Joint National Committee. The sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. NIH Publication No. 98-4080 November 1997).
• drugs include diuretics (such as chlorthalidone, hydrochlorothiazide, metolazone and the like), vasodilators (such as hydrolazine, minoxidil, sodium nitroprusside, dizaoxide and the like), ⁇ -adrenergic receptor antagonists (such as propranolol, metoprolol, labetalol, acebutolol and the like), calcium channel blockers (such as verapamil, diltiazem, nifedipine and the like), and angiotensin-ll receptor antagonists (such as losartan and the like), as well as ACE inhibitors (such as captopril, enalapril, lisinopril, quinapril and the like).
• ACE inhibitors such as captopril, enalapril, lisinopril, quinapril and the like.
• the choice of the initial drug therapy for an individual hypertensive patient
• ACE inhibitors are commonly used as standard therapy and have been shown to have a beneficial effect on survival and hospitalization in patients with heart failure.
• CONSENSUS Cooperative North Scandinavian Enalapril Survival Study
• mortality at one year was reduced by 31% in patients with severe heart failure, New York Heart Association (NYHA) Functional Class IV, treated with enalapril (an ACE inhibitor) plus diuretics having no substantial aldosterone antagonistic activity compared to placebo plus diuretics having no substantial aldosterone antagonistic activity.
• CONSENSUS patients with high baseline plasma aldosterone levels had a higher mortality than patients with low baseline levels.
• In the group treated with enalapril mortality was reduced only in the group with baseline aldosterone plasma levels above the median.
• the anti-hypertensive drug spironolactone is less commonly used for therapy than ACE inhibitors. It is an aldosterone receptor antagonist that was developed as a treatment for hyperaldosteronism which can occur with hypertension and edematous conditions associated with congestive heart failure, and liver cirrhosis. (Swedberg K, et al Circulation 1990;82:1730-6). Pitt B., et al.:, The New England J. of Med. 1999;341(10): 709-717, recently reported that addition of spironolactone to standard therapy of ACE inhibitor plus loop diuretic having no substantial aldosterone antagonistic activity reduced morbidity and mortality among patients with severe heart failure.
• selected individuals have low plasma-renin levels or low plasma-renin activity yet manifest hypertension.
• This form of hypertension can be found, for example, in Blacks, the Japanese and the elderly.
• Such hypertension often is referred to as "low renin hypertension” (or “sodium and volume dependent low renin hypertension” as sodium down-regulates the renin system).
• low renin hypertension or “sodium and volume dependent low renin hypertension” as sodium down-regulates the renin system.
• increased sodium intake is followed by an increase in blood pressure despite the fact that renin plasma concentrations are normal or low.
• Agents active in treating essential hypertension such as ACE inhibitors or angiotensin II receptor antagonists, are relatively ineffective in treating low renin hypertension
• the present invention addresses this need and provides a new drug therapy comprising the administration of one or more epoxy-steroidal compounds that are aldosterone antagonists to treat hypertension, heart failure, end-stage renal disease and other pathogenic conditions in a population of subjects characterized by salt sensitivity and/or an elevated dietary sodium intake.
• the various aspects of the invention are methods for the treatment or prophylaxis of one or more aldosterone-mediated pathogenic effects in a subject suffering from or susceptible to the pathogenic effect or effects wherein the subject has one or more conditions selected from the group consisting of a sub-normal endogenous aldosterone level, salt sensitivity and an elevated dietary sodium intake.
• the methods comprise administering to the subject a therapeutically effective amount of one or more epoxy-steroidal compounds that are aldosterone antagonists.
• the invention comprises methods for the prophylaxis of one or more aldosterone-mediated pathogenic effects in a subject suffering from or susceptible to the pathogenic effect or effects wherein (a) the pathogenic effect or effects are selected from the group consisting of hypertension, cardiovascular disease, renal dysfunction, liver disease, cerebrovascular disease, vascular disease, retinopathy, neuropathy, insulinopathy, edema, endothelial dysfunction, baroreceptor dysfunction, migraine headaches, hot flashes, and and premenstrual tension, and (b) the subject has one or more conditions selected from the group consisting of a sub-normal endogenous aldosterone level, salt sensitivity and an elevated dietary sodium intake.
• the pathogenic effect or effects are selected from the group consisting of hypertension, cardiovascular disease, renal dysfunction, liver disease, cerebrovascular disease, vascular disease, retinopathy, neuropathy, insulinopathy, edema, endothelial dysfunction, baroreceptor dysfunction, migraine headaches, hot flashes, and and premenstrual tension
• the methods comprise administering to the subject a therapeutically effective amount of one or more epoxy-steroidal compounds that are aldosterone antagonists.
• the invention comprises methods for the treatment or prophylaxis of hypertension in a subject suffering from or susceptible to hypertension wherein the subject has salt sensitivity or an elevated dietary sodium intake, or both.
• the methods comprise administering to the subject a therapeutically effective amount of one or more epoxy-steroidal compounds that are aldosterone antagonists.
• the invention comprises methods for the treatment or prophylaxis of cardiovascular disease in a subject suffering from or susceptible to cardiovascular disease wherein the subject has salt sensitivity or an elevated dietary sodium intake, or both.
• the methods comprise administering to the subject a therapeutically effective amount of one or more epoxy-steroidal compounds that are aldosterone antagonists.
• the invention comprises methods for the treatment or prophylaxis of heart failure in a subject suffering from or susceptible to cardiovascular disease wherein the subject has salt sensitivity or an elevated dietary sodium intake, or both.
• the methods comprise administering to the subject a therapeutically effective amount of an ACE inhibitor, a loop diuretic having no substantial aldosterone antagonistic activity, and one or more epoxy-steroidal compounds that are aldosterone antagonists.
• the invention comprises methods for the treatment or prophylaxis of salt sensitivity in a subject in need thereof.
• the methods comprise administering to the subject a therapeutically-effective amount of one or more epoxy-steroidal compounds that are aldosterone antagonists.
• the invention comprises methods for reducing sodium appetite in a subject in need thereof.
• the methods comprise administering to the subject an appetite-suppressing amount of one or more epoxy-steroidal compounds that are aldosterone antagonists.
• the invention comprises methods for reducing or reversing the progression of salt sensitivity in a subject suffering from or susceptible to salt sensitivity.
• the methods comprise administering to the subject a therapeutically-effective amount of one or more epoxy-steroidal compounds that are aldosterone antagonists.
• the invention comprises methods for the treatment or prophylaxis of a subject to reduce or prevent one or more pathogenic effects resulting, in whole or in part, from aberrant aldosterone levels in brain.
• the methods comprise administering to the subject a therapeutically-effective amount of one or more epoxy-steroidal compounds that are aldosterone antagonists.
• the invention comprises methods for the treatment or prophylaxis of a subject to reduce or prevent one or more pathogenic effects resulting, in whole or in part, from aberrant sodium retention in the kidney.
• the methods comprise administering to the subject a therapeutically-effective amount of one or more epoxy-steroidal compounds that are aldosterone antagonists.
• the invention comprises methods for the prophylaxis of one or more aldosterone-mediated pathogenic effects in a subject susceptible to the pathogenic effect or effects wherein the subject has one or more conditions selected from the group consisting of a subnormal endogenous aldosterone level, salt sensitivity and an elevated dietary sodium intake.
• the methods comprise administering to the subject a prophylactically effective amount of one or more epoxy-steroidal compounds that are aldosterone antagonists.
• Fig. 1-A shows X-ray powder diffraction patterns of Form H eplerenone.
• Fig. 1-B shows X-ray powder diffraction patterns of Form L eplerenone.
• Fig. 1-C shows X-ray powder diffraction patterns of the methyl ethyl ketone solvate of eplerenone.
• Fig. 2-A shows a differential scanning calorimetry (DSC) thermogram of non-milled Form L directly crystallized from methyl ethyl ketone.
• Fig. 2-B shows a differential scanning calorimetry (DSC) thermogram of non-milled Form L prepared by desolvation of a solvate obtained by crystallization of a high purity eplerenone from methyl ethyl ketone.
• DSC differential scanning calorimetry
• Fig. 2-C shows a differential scanning calorimetry (DSC) thermogram of Form L prepared by crystallizing a solvate from a solution of high purity eplerenone in methyl ethyl ketone, desolvating the solvate to yield Form L, and milling the resulting Form L.
• DSC differential scanning calorimetry
• Fig. 2-D shows a differential scanning calorimetry (DSC) thermogram of non-milled Form H prepared by desolvation of a solvate obtained by digestion of low purity eplerenone from appropriate solvents.
• Fig. 3-A shows the infrared spectra (diffuse reflectance, DRIFTS) of Form H eplerenone.
• Fig. 3-B shows the infrared spectra (diffuse reflectance, DRIFTS) of Form L eplerenone.
• Fig. 3-C shows the infrared spectra (diffuse reflectance, DRIFTS) of the methyl ethyl ketone solvate of eplerenone.
• Fig. 3-D shows the infrared spectra (diffuse reflectance, DRIFTS) of eplerenone in chloroform solution.
• Fig. 4 shows 13 C NMR spectra for Form H of eplerenone.
• Fig. 5 shows 13 C NMR spectra for Form L of eplerenone.
• Fig. 6-A shows the thermogravimetry analysis profile for the methyl ethyl ketone solvate.
• Fig. 7 shows an X-ray powder diffraction pattern of a crystalline form of 7-methyl hydrogen 4 ⁇ ,5 ⁇ :9 ⁇ ,11 ⁇ -diepoxy-17-hydroxy-3-oxo-17 ⁇ - pregnane-7 ⁇ ,21-dicarboxylate, ⁇ -lactone isolated from methyl ethyl ketone.
• Fig. 8 shows an X-ray powder diffraction pattern of the crystalline form of 7-methyl hydrogen 11 ⁇ ,12 ⁇ -epoxy-17-hydroxy-3-oxo-17 ⁇ -pregn-4- ene-7 ⁇ ,21-dicarboxylate, ⁇ -lactone isolated from isopropanol.
• Fig. 9 shows an X-ray powder diffraction pattern of the crystalline form of 7-methyl hydrogen 17-hydroxy-3-oxo-17 ⁇ -pregna-4,9(11 )-diene-7 ⁇ ,21-dicarboxylate, ⁇ -lactone isolated from n-butanol.
• Fig. 10 shows the change in systolic blood pressure plotted as a function of the eplerenone dose for a human subject.
• Fig. 11 shows the change in diasytolic blood pressure plotted as a function of the eplerenone dose for a human subject.
• Fig. 12 shows the change in plasma renin activity and serum aldosterone plotted as a function of the eplerenone dose for one human subject.
• Fig. A-1 shows systolic blood pressure before and after initiation of L-NAME treatment on days 1 , 5, 9 and 13.
• Fig. A-2 shows plasma renin activity (A) and plasma aldosterone levels (B) determined after sacrifice.
• Fig. A-3 shows cardiac histopathology of (A) myocardial necrotic lesions induced by L-NAME/Angiotensin ll/NaCl treatment; (B) of myocardium of an animal receiving L-NAME/Angiotensin ll/NaCl treatment in the presence of the mineralocorticoid receptor antagonist eplerenone showing no necrotic lesions; C staining of the hearts from figure A with the collagen specific dye; and (D) staining of the hearts from figure 27 B with the collagen specific dye.
• Fig. A-4 shows histopathologic scores for myocardial necrosis.
• Fig. A-5 shows urinary protein excretion in samples collected on the day of sacrifice (Day 14).
• Fig. A-6 show (A) renal histopathology stained with PAS of mid- coronal kidney section from an animal receiving L-NAME/Angiotensin ll/NaCl treatment and (B) renal cortex of a rat receiving L- ⁇
• NAME/Angiotensin ll/NaCl plus eplerenone NAME/Angiotensin ll/NaCl plus eplerenone.
• Fig. A-7 shows histopathologic scores for renal vascular injury.
• Fig. A-8 shows inflammatory lesions in coronary arteries of aldosterone/salt uninephrectomized rats.
• Fig. A-9 shows inflammatory lesions in eplerenone-treated coronary arteries of aldosterone/salt uninephrectomized rats.
• Fig. A-10 shows myocardial injury in aldosterone/salt uninephrectomized rats.
• Fig. A-11 shows survival in saline-drinking stroke-prone SHR rats.
• Fig. A-12 shows SBP in saline-drinking stroke-prone SHR rats.
• Fig. A-13 shows cerebral injury in saline-drinking stroke-prone SHR rats.
• Fig. A-14 shows cerebral injury in saline-drinking stroke-prone SHR rats.
• Fig. A-15 shows preterminal (A) systolic arterial blood pressure (SBP) and (B) urinary protein excretion (UPE) in stroke-prone spontaneously hypertensive rats receiving chronic treatment with either eplerenone (100 mg/kg/d) or vehicle from 8.4 to 13.1 weeks of age.
• Fig. A-16 shows representative photomicrographs of hematoxylin and eosin-stained mid-coronal kidney sections from saline-drinking stroke- prone spontaneously hypertensive rats after 5 weeks of eplerenone or vehicle treatment starting at 8 weeks of age (original magnification, x 130).
• Fig. A-17 shows (A) systolic arterial blood pressure and (B) urinary protein excretion in saline-drinking stroke-prone spontaneously hypertensive rats during treatment with captopril plus vehicle (CAP), captopril plus Angiotensin II (CAP + Angiotensin II), or captopril plus Angiotensin II plus eplerenone (CAP + Angiotensin II + EPL).
• CAP captopril plus vehicle
• CAP + Angiotensin II captopril plus Angiotensin II
• CAP + Angiotensin II + EPL captopril plus Angiotensin II plus eplerenone
• Fig. A-18 shows plasma aldosterone levels in stroke-prone spontaneously hypertensive rats that were started on captopril treatment (50 mg/kg/d) and 1% NaCI/Stroke-Prone Rodent Diet starting at 8.3 weeks of age.
• Fig. A-19 shows representative photomicrographs of hematoxylin and eosin-stained renal cortex from saline-drinking stroke-prone spontaneously hypertensive rats (A) treated with captopril plus vehicle and (B) Captopril-treated animals.
• Fig. A-20 shows the population effect on PK profile (Cmax) of eplerenone.
• Fig. A-21 shows the population effect on PK profile (AUCIqc) of eplerenone.
• Fig. A-22 shows the population effect on PK profile (AUC i ⁇ f ) of eplerenone.
• Fig. A-23 shows the population effect on PK profile (CL/F) of eplerenone.
• Fig. A-24 shows the population effect on PK profile (Vol/F) of eplerenone.
• Fig. A-25 shows the population effect on PK profile (Cmax) of the open ring lactone form of eplerenone.
• Fig. A-26 shows the population effect on PK profile (AUCIqc) of the open ring lactone form of eplerenone.
• Fig. A-27 shows the population effect on PK profile (AUC lnf ) of the open ring lactone form of eplerenone.
• Fig. A-28 shows the population effect on PK profile (CL/F) of the open ring lactone form of eplerenone.
• Fig. A-29 shows the population effect on PK profile (Vol/F) of the open ring lactone form of eplerenone.
• Fig. A-30 shows mean eplerenone plasma concentrations following multiple dose administration.
• Fig. C-1 shows the X-ray powder diffraction patterns for the wet cake (methyl ethyl ketone solvate) obtained from (a) 0%, (b) 1%, (c) 3%, and (d) 5% diepoxide-doped methyl ethyl ketone crystallizations.
• Fig. C-2 shows the X-ray powder diffraction patterns for the dried solids obtained from (a) 0%, (b) 1%, (c) 3%, and (d) 5% diepoxide-doped methyl ethyl ketone crystallizations.
• Fig. C-3 shows the X-ray powder diffraction patterns for the dried solids from the methyl ethyl ketone crystallization with 3% doping of diepoxide (a) without grinding of the solvate prior to drying, and (b) with grinding of the solvate prior to drying.
• Fig. C-4 shows the X-ray powder diffraction patterns for the wet cake (methyl ethyl ketone solvate) obtained from (a) 0%, (b) 1%, (c) 5%, and (d) 10% 11 , 12-epoxide-doped methyl ethyl ketone crystallizations.
• Fig. C-5 shows the X-ray powder diffraction patterns for the dried solids obtained from (a) 0%, (b) 1%, (c) 5%, and (d) 10% 11 ,12-epoxide- doped methyl ethyl ketone crystallizations.
• Fig. C-6 shows a cube plot of product purity, starting material purity, cooling rate and endpoint temperature based on the data reported in Table 7A.
• Fig. C-7 shows a half normal plot prepared using the cube plot of
• Fig. C-8 is an interaction graph based on the results reported in Table 7A showing the interaction between starting material purity and cooling rate on final material purity.
• Fig. C-9 shows a cube plot of Form H weight fraction, starting material purity, cooling rate and endpoint temperature based on the data reported in Table 7A.
• Fig. C-10 shows a half normal plot prepared using the cube plot of Fig. 18 to determine those variables having a statistically significant effect on the purity of the final material.
• Fig. C-11 is an interaction graph based on the results reported in Table 7A showing the interaction between starting material purity and endpoint temperature on final material purity.
• Fig. C-12 shows an X-ray diffraction pattern of amorphous eplerenone.
• Fig. C-13 shows a DSC thermogram of amorphous eplerenone.
• Fig. D-1 shows mean change from baseline in DBP.
• Fig. D-2 shows mean change from baseline in SBP.
• Fig. D-3. shows dose range factorial design study design.
• Fig. D-4. shows dose range factorial design; mean change in DBP at final visit.
• Fig. D-5. shows dose range factorial design mean change in SBP at final visit.
• Fig. D-6 shows titrated dose of eplerenone vs enalapril; study design.
• Fig. D-7 shows titrated dose of eplerenone vs enalapril; mean change from baseline in BP (week 24).
• Fig. D-8. shows titrated dose of eplerenone vs enalapril; mean change from baseline in BP (month 12).
• Fig. D-9. shows titrated dose of eplerenone vs enalapril; adverse events of special interest.
• Fig. D-10 shows eplerenone vs. enalapril vs. combination with (LVH); study design.
• Fig. D-11. shows eplerenone vs. enalapril vs. combination with (LVH); mean change from baseline Ivm.
• Fig. D-12. shows eplerenone vs. enalapril vs. combination with (LVH); mean change from baseline LVM: final visit.
• Fig. D-13 shows eplerenone vs. enalapril vs. combination with (LVH); mean change from baseline in LVM.
• Fig. D-14. shows eplerenone vs. enalapril vs. combination with
• Fig. D-15 shows eplerenone vs. enalapril vs. combination with (LVH); events of special interest.
• Fig. D-16 shows low renin hypertension; mean change from baseline in BP: week 8 (monotherapy endpoint).
• Fig. D-17 shows low renin hypertension; mean change from baseline in BP week 16 (final visit).
• Fig. D-18 shows low renin hypertension: percentage of patients receiving add-on hctz.
• Fig. D-19 shows low renin hypertension; responder rates.
• Fig. D-20 shows low renin hypertension; adverse events of special interest.
• Fig. D-21 shows comparison in Black and White populations; study design.
• Fig. D-22 shows comparison in Black and White populations; mean change from baseline: Whites; final visit.
• Fig. D-23 shows comparison in Black and White populations ; mean change from baseline: Blacks; final visit.
• Fig. D-24 shows comparison in Black and White populations; mean change from baseline: all patients final visit.
• Fig. D-25 shows comparison in black and white populations; adverse events of special interest.
• Fig. D-26 shows study design.
• Fig. D-28 shows geometric mean of uacr (ug/g) at week 8 and week 24.
• Fig. D-29 shows mean change from baseline in SBP at week 8 and week 24.
• Fig. D-30 shows mean change from baseline in DBP at week 8 and week 24.
• Fig ⁇ D-31 shows adverse events of special interest.
• Fig. D-32 shows eplerenone vs. amlodipine in elevated SBP; study design.
• Fig. D-33 shows eplerenone vs. amlodipine in elevated SBP; mean change from baseline in BP (week 24).
• Fig. D-34 shows eplerenone vs. amlodipine in elevated SBP; mean change from baseline in 24-hour mean BP ABPM measurements.
• Fig. D-35 shows eplerenone vs. amlodipine in elevated SBP; mean change from baseline in 24-hour mean pp ABPM measurements; pulse pressure.
• Fig. D-36 shows shows eplerenone vs. amlodipine in elevated SBP; mean change from baseline: carotid-femoral PWV.
• Fig. D-37 shows eplerenone vs. amlodipine in elevated SBP; mean change from baseline: carotid-radial PWV.
• Fig. D-38 shows eplerenone vs. amlodipine in elevated SBP.
• Fig. D-39 shows adverse events of special interest.
• Fig. D-40 shows co-administration with ACE-I or ARB; study design.
• Fig. D-41 shows mean change in BP (each visit) in patients not controlled with ACE-I.
• Fig. D-42 shows co-administration with ACE-I or ARB; mean change from baseline in BP; week 8 (final visit)
• Fig. D-43 shows mean change from baseline in BP week 8 (final visit).
• Fig. D-44 shows mean change in BP (each visit) in patients not controlled with ARB.
• Fig. D-45 shows mean change from baseline: laboratory values.
• Fig. D-46 shows change in serum potassium values in patients not controlled with ACE-I.
• Fig. D-47 shows change in serum potassium values in patients not controlled with ARB.
• D-48 shows adverse events of interest.
• Fig. D-49 shows serious adverse events.
• Fig. D-50 shows mean change in heart rate.
• Fig. D-51 shows mean active renin and aldosterone levels.
• Fig. D-52 shows mean active renin and aldosterone levels.
• Fig. D-53 shows reason for withdrawal.
• Fig. D-54 shows percent of patients responding to treatment: DBP.
• Fig. D-55 shows co-administration with ACE-I and ARB.
• Fig. D-56 shows co-administration with CCB or ⁇ -blocker.
• Fig. D-57 shows co- administration with CCB or ⁇ -blocker.
• Fig. D-58 shows co-administration with CCB or ⁇ -blocker.
• Fig. D-59 shows long-term, open label safety study design.
• Fig. D-60 shows mean change in DBP.
• Fig. D-61 shows mean change in SBP.
• Fig. D-62 shows adverse events of special interest.FicL D-63 shows eplerenone vs. amlodipine in ABPM study design. Fig. D-64 shows eplerenone vs. amlodipine in ABPM DBP: mean change from baseline (ABPM).Fig. D-65 shows eplerenone vs. amlodipine in ABPM SBP: mean change from baseline (ABPM).
• Fig. D-66 shows eplerenone vs. amlodipine in ABPM SBP: mean change from baseline (24-hour ABPM).
• Fig. D-67 shows eplerenone vs. amlodpine in ABPM DBP: mean change from baseline (24-hour ABPM).
• Fig. D-68 shows eplerenone vs. amlodipine in ABPM SBP: hourly baseline mean (24 hour ABPM).
• Fig. D-69 shows eplerenone vs. amlodipine in ABPM
• DBP hourly baseline mean (24 hour ABPM).
• Fjg_. D-70 shows eplerenone vs. amlodipine in ABPM SBP: hourly endpoint mean (24 hour ABPM).
• Fig. D-71 shows eplerenone vs. amlodipine in ABPM SBP: hourly endpoint mean (24 hour ABPM).
• Fig. D-72 shows eplerenone vs. amlodipine in ABPM adverse events of special interest.
• Fig. D-73 shows study schematic.
• Fig. D-74 shows mean change from baseline: cuff BP week 12 (final visit).
• Fig. D-75 shows mean change from baseline (ABPM).
• Fig. D-76 shows adjusted mean change from baseline in cuff seDBP.
• Fig. D-77 shows adjusted mean change from baseline in cuff seSBP.
• Fig. D-78 shows events of special interest.
• aldosterone disorders mediated by aldosterone conventionally have been considered to be limited to primary and secondary hyperaldosteronism.
• hyperaldosteronism an excessive level of aldosterone is generally believed to be a causative agent leading to hypertension through a mechanism involving high levels of mineralocorticoid receptor occupancy by aldosterone that leads to epithelial sodium channel (“EnaC”) activation and increased sodium retention.
• EnaC epithelial sodium channel
• Individuals affected by hyperaldosteronism are also at increased risk of renal and heart disease. These diseases were previously believed to be a consequence of hypertension.
• endogenous aldosterone at any level is pathogenic in a human subject. It also has been discovered that the development, rapidity of onset and development, and/or severity of the pathogenic effect meditated by endogenous aldosterone in a human subject is further enhanced when the subject has an elevated level of sodium, regardless of whether the aldosterone is present at an elevated, normal or sub-normal level.
• the pathogenicity of endogenous aldosterone is particularly notable in a human subject having salt sensitivity and/or an elevated dietary sodium intake.
• a therapeutically effective amount of one or more epoxy-steroidal compounds that are aldosterone antagonists is administered to a human subject in need thereof to treat or prevent one or more pathogenic effects resulting from the action of endogenous aldosterone, including pathogenic effects resulting from the action of a subnormal level of endogenous aldosterone.
• the epoxy-steroidal compound preferably is eplerenone.
• the subject preferably is an individual having salt sensitivity and/or an elevated dietary sodium intake.
• the pathogenic effect or effects preferably result from the action of endogenous aldosterone in the presence of an elevated sodium level.
• the elevated sodium level preferably is an elevated level of intracellular sodium, particularly intracellular sodium in one or more of the heart, kidney and brain.
• subject as used herein includes a mammal, preferably a human, who has been the object of treatment, observation or experiment.
• treatment includes any process, action, application, therapy, procedure or the like, wherein a mammal, particularly a human, is subjected to medical aid with the object of improving the mammal's condition, directly or indirectly.
• prophylaxis and “prevention” include either preventing the onset of a clinically evident pathogenic, effect altogether or preventing the onset of a preclinically evident stage of a pathogenic effect in individuals. These terms encompass the prophylactic treatment of a subject at risk, possibly due to genetic, environmental, social or other factors, of developing a pathogenic effect such as, but not limited to, hypertension and heart failure.
• the phrase "therapeutically-effective" qualifies the amount of the aldosterone antagonist that will achieve the goal of improvement in condition or disorder while avoiding adverse side effects typically associated with alternative therapies.
• sodium or “salt” as used herein includes sodium in any form, particularly in the form of sodium chloride.
• aldosterone antagonist and "aldosterone receptor antagonist” include a compound that inhibits the binding of aldosterone to mineralocorticoid receptors thereby blocking the biological effects of aldosterone.
• the aldosterone antagonist is a selective aldosterone antagonist, such as eplerenone.
• a selective aldosterone antagonist is an aldosterone antagonist that selectively binds to the mineralocorticoid receptor relative to other steroid hormone receptors.
• microvascular dysfunction is believed to be the result of microvascular constriction and micro-ischemia. Accordingly, these microvascular changes progress through maladaptive mechanisms to cause various pathogenic effects.
• endogenous aldosterone at any level is pathogenic in a human subject, particularly in the presence of an elevated level of sodium.
• This level of endogenous aldosterone can be on a localized level (for example, an intracellular level of endogenous aldosterone in a specific organ) or it can be more widespread or even systemic. Accordingly, the pathogenic effect or effects of endogenous aldosterone can be localized (for example in the brain, heart or kidney), partially but not entirely localized, or even systemic.
• the endogenous aldosterone level of a subject can be determined using conventional testing methods.
• endogenous aldosterone can be measured in a subject as circulating (plasma, serum, or whole blood) aldosterone, urinary aldosterone, and the like.
• Various commercial kits and/or published standard assays are available for this determination.
• Plasma aldosterone levels for example, can be measured by radio-immunoassay.
• Commercial kits are available for this determination, such as the radio-immunoassay kit marketed by Dinabot Co. (Tokyo, Japan) for measuring plasma aldosterone.
• Serum aldosterone levels can be determined, for example, by conventional immunoassay methods.
• Urinary aldosterone levels likewise can be determined, for example, by radio-immunoassay with antiserum from Diagnostic Products Corp. Aldosterone-18-glucuronide typically is hydrolyzed overnight at pH 1 to generate free aldosterone which is then measured by RIA. (Prat JH et al.: Hypertension. 1999;34;315-319). Urinary aldosterone can be expressed as total excretion in a 24 hour sample or it may be normalized to creatinine.
• Normal aldosterone values will depend upon the specific assay and population group selected, but these values typically are published in the literature and are readily available to one of ordinary skill in the art. For example, The Merck Manual at pp. 1526-2528 (17 th Ed. 1999), reports that normal laboratory values for serum aldosterone as measured by immunoassay typically are less than about 16 ng/dL for subjects in the supine position and between about 4 to about 31 ng/dL for subjects in the upright position (for subjects having a dietary sodium intake of about 100 to about 200 mEq/day). The Merck Manual describes such values as mean values in a healthy population + two standard deviations. Similarly, Review of Medical Physiology, 6 th Edition, Lange Medical Publications, Los Altos, California; William F Ganong, lists normal aldosterone levels as typically ranging between 3 and 10 ng/dL.
• the mean of a country which consists of a large portion of salt sensitive individuals may be lower than country consisting of a small portion of salt sensitive individuals (e.g. Sweden).
• regional populations may have differences in dietary sodium consumption, which will also result in differences in aldosterone levels.
• a subnormal level of a protein e.g. aldosterone or renin
• the pathogenic effects mediated by aldosterone include, but are not limited to, hypertension, cardiovascular disease, renal dysfunction, liver disease, cerebrovascular disease, vascular disease, retinopathy, neuropathy (such as peripheral neuropathy), insulinopathy, edema, endothelial dysfunction, baroreceptor dysfunction, migraine headaches, hot flashes, premenstrual tension, and the like.
• Cardiovascular disease includes, but is not limited to, heart failure (such as congestive heart failure), arrhythmia, diastolic dysfunction (such as left ventricular diastolic dysfunction, diastolic heart failure, and impaired diastolic filling), systolic dysfunction, ischemia, hypertrophic cardiomyopathy, sudden cardiac death, myocardial and vascular fibrosis, impaired arterial compliance, myocardial necrotic lesions, vascular damage, myocardial infarction, left ventricular hypertrophy, decreased ejection fraction, cardiac lesions, vascular wall hypertrophy, endothelial thickening, fibrinoid necrosis of coronary arteries, and the like.
• heart failure such as congestive heart failure
• arrhythmia such as left ventricular diastolic dysfunction, diastolic heart failure, and impaired diastolic filling
• systolic dysfunction ischemia, hypertrophic cardiomyopathy, sudden cardiac death, myocardial and vascular fibro
• Renal dysfunction includes, but is not limited to, glomerulosclerosis, end-stage renal disease, diabetic nephropathy, reduced renal blood flow, increased glomerular filtration fraction, proteinuria, decreased glomerular filtration rate, decreased creatinine clearance, microalbuminuria, renal arteriopathy, ischemic lesions, thrombotic lesions, global fibrinoid necrosis, focal thrombosis of glomerular capillaries, swelling and proliferation of intracapillary (endothelial and mesangial) and/or extracapillary cells (crescents), expansion of reticulated mesangial matrix with or without significant hypercellularity, malignant nephrosclerosis (such as ischemic retraction, thrombonecrosis of capillary tufts, arteriolar fibrinoid necrosis, and thrombotic microangiopathic lesions of affecting glomeruli and microvessels), and the like.
• malignant nephrosclerosis such as ische
• Liver disease includes, but is not limited to, liver cirrhosis, liver ascites, hepatic congestion, and the like.
• Cerebrovascular disease includes, but is not limited to stroke.
• Vascular disease includes, but is not limited to, thrombotic vascular disease (such as mural fibrinoid necrosis, extravasation and fragmentation of red blood cells, and luminal and/or mural thrombosis), proliferative arteriopathy (such as swollen myointimal cells surrounded by mucinous extracellular matrix and nodular thickening), atherosclerosis, decreased vascular compliance (such as stiffness, reduced ventricular compliance and reduced vascular compliance), endothelial dysfunction, and the like.
• thrombotic vascular disease such as mural fibrinoid necrosis, extravasation and fragmentation of red blood cells, and luminal and/or mural thrombosis
• proliferative arteriopathy such as swollen myointimal cells surrounded by mucinous extracellular
• Edema includes, but is not limited to, peripheral tissue edema, hepatic congestion, splenic congestion, liver ascites, respiratory or lung congestion, and the like.
• Insulinopathies include, but are not limited to, insulin resistance, Type I diabetes mellitus, Type II diabetes mellitus, glucose sensitivity, pre-diabetic state, syndrome X, and the like.
• the pathogenic effects preferably are selected from the group consisting of hypertension, cardiovascular disease, renal dysfunction, edema, cerebrovascular disease, and insulinopathies; more preferably, the pathogenic effects are selected from the group consisting of hypertension, cardiovascular disease, stroke, and Type II diabetes mellitus; and still more preferably, the pathogenic effects are selected from the group consisting of hypertension, heart failure (particularly heart failure post myocardial infarction), left ventricular hypertrophy, and stroke.
• the method comprises administering a therapeutically-effective amount of one or more epoxy-steroidal compounds that are aldosterone antagonists to treat or prevent one or more aldosterone-mediated pathogenic effects in a human subject suffering from or susceptible to the pathogenic effect or effects, wherein the subject has a sub-normal endogenous aldosterone level.
• the pathogenic effect or effects preferably are selected from the group consisting of hypertension, cardiovascular disease, cerebrovascular disease, and Type II diabetes mellitus; and more preferably, the pathogenic effects are selected from the group consisting of hypertension, heart failure (particularly heart failure post myocardial infarction), left ventricular hypertrophy, and stroke.
• the epoxy-steroidal compound preferably is eplerenone.
• the subject of the treatment or prophylaxis preferably is an individual having salt sensitivity and/or an elevated dietary sodium intake
• the method comprises administering a therapeutically-effective amount of one or more epoxy-steroidal compounds that are aldosterone antagonists to treat or prevent one or more aldosterone-mediated pathogenic effects in a human subject suffering from or susceptible to the pathogenic effect or effects, wherein the subject is an individual having salt sensitivity and/or an elevated dietary sodium intake.
• the pathogenic effect or effects preferably are as previously set forth; more preferably, they are selected from the group consisting of hypertension, cardiovascular disease, cerebrovascular disease, and Type II diabetes mellitus; and still more preferably, they are selected from the group consisting of hypertension, heart failure (particularly heart failure post myocardial infarction), left ventricular hypertrophy, and stroke.
• the epoxy-steroidal compound preferably is eplerenone.
• the average daily intake of sodium by the subject is at least about 50 milliequivalents, preferably at least about 100 milliequivalents, more preferably at least about 150 milliequivalents, and still more preferably at least about 200 milliequivalents.
• Factors preventing a change in diet may include, for example, the following: (1 ) lack of availability of low sodium chloride foods where geographical or other restrictions prevent or hinder access to low sodium chloride foods; (2) lack of refrigeration requiring use of high sodium chloride levels to preserve food (e.g., pickling); (3) cultural environment, such as the need to honor traditional and religious requirements in food preparation and content, leading to the consumption of foods containing high levels of sodium chloride; and (4) cost restrictions due to poverty, preventing purchase of more expensive foods with lower sodium chloride content (e.g. imported foods).
• Such individuals find themselves with no alternative to the consumption of high sodium chloride foods, except to undergo life-threatening malnutrition or starvation, must succumb to this pathological condition by eating a diet high in sodium chloride.
• the methods of the present invention can be used for the treatment or prophylaxis of aldosterone-mediated pathologic effects in such individuals where a reduction in dietary sodium intake is not or cannot be attained.
• the effect of sodium is particularly pronounced in salt sensitive individuals.
• Such individuals are likely to have an impaired pressure- natriuresis response or an increased vascular response to sodium and be at higher risk of becoming hypertensive.
• Elevated sodium intake also can adversely affect the response of a subject to pharmaco-therapy.
• TOMHS Treatment of Mild Hypertension Study
• Five classes of drugs used to treat hypertensive Black patients (Neaton JD, et al.: JAMA 1993;270:713-24).
• the study showed that the patients responded better to chlorthiazide, calcium channel blockers, or a beta-adrenergic receptor antagonist with intrinsic sympathomimetic activity than to ACE inhibitors or alpha- adrenergic receptor antagonists (Grim CE, et al.: J Chronic Dis 1980;33:87-94).
• Black and white patients showed a potentiation of pharmaco-therapies with a reduction of sodium intake.
• a reduction of sodium intake has other effects on pharmaco-therapy. For example, such reduction results in an improved withdrawal from anti-hypertensive therapy, especially in salt sensitive patients (van Brummelen P, Schalekamp M, de Graeff J. v4cfa Mec ScancM978;204:151-7). Even a modest reduction of sodium can result in a reduction in effective dose (Weinberger MH, et al.: JAMA 1988;6:2561-5).
• the methods of the present invention can be used either monotherapically or in combination therapies, such as in conventional pharmaco-therapies that are not effective for the subject treated due to, for example, salt sensitivity and/or elevated dietary sodium intake.
• the invention comprises a method for the treatment or prophylaxis of hypertension in a human subject having salt sensitivity.
• a therapeutically effective amount of an epoxy-steroidal compound that is an aldosterone antagonist is administered to a salt sensitive individual suffering from or susceptible to hypertension.
• Hypertension in salt sensitive individuals is a pathological condition that is differentiated from other forms of hypertension in that it is induced by a common dietary ingredient, sodium chloride. If left untreated, patients who suffer from this condition also suffer an increased incidence of myocardial infarction, stroke, heart failure, renal dysfunction, organ dysfunction and other cardiovascular pathologies.
• Salt sensitive hypertension can be easily diagnosed, for example, by measuring the change in blood pressure in a patient under conditions of low sodium chloride intake (such as about 1 to 3 g/day for several days) followed by a high sodium chloride intake (such as about 12-15 g/day). An increase in blood pressure of about 10% or more with increased sodium chloride intake is indicative of salt sensitive hypertension.
• the change in blood pressure of the subject can be monitored over a period of 24 hours using an ambulatory blood pressure measuring device. Patients with salt sensitive hypertension do not display the circadian decrease (or "dip") in blood pressure that normally occurs during the sleeping period. Instead, the blood pressure of the salt sensitive hypertensive patient remains elevated during the whole 24 hour period.
• the invention comprises a method for the treatment or prophylaxis of hypertension in a human subject having an elevated dietary sodium intake.
• a therapeutically effective amount of an epoxy-steroidal compound that is an aldosterone antagonist is administered to a subject having an elevated dietary sodium intake and who is suffering from or susceptible to hypertension.
• the invention comprises a method for the treatment or prophylaxis of cardiovascular disease, particularly heart failure post-myocardial infarction, in a human subject in need thereof.
• a therapeutically effective amount of an epoxy-steroidal compound that is an aldosterone antagonist is administered to a subject having salt sensitivity and/or an elevated dietary sodium intake wherein said subject is suffering from or susceptible to cardiovascular disease.
• the invention comprises a method for the treatment or prophylaxis of renal dysfunction in a human subject in need thereof.
• a therapeutically effective amount of an epoxy-steroidal compound that is an aldosterone antagonist is administered to a subject having salt sensitivity and/or an elevated dietary sodium intake wherein said subject is suffering from or susceptible to renal dysfunction.
• salt insensitive individuals also referred to as “salt resistant individuals”
• salt resistant individuals an increase in dietary sodium intake results in increased sodium excretion with no measurable increase, or only a minimal increase in blood pressure.
• salt sensitive individuals In salt sensitive individuals blood pressure generally rises and falls with increased and decreased sodium consumption, respectively. Salt sensitive normotensive individuals may even be more likely to become hypertensive over time when consuming a typical North American diet. (Sullivan JM, 1991 ; Hypertension 17 (Suppl. l):l61-68).
• Sullivan JM 1991 ; Hypertension 17 (Suppl. l):l61-68.
• renal blood flow may either fail to increase or may decrease, such that both vascular resistance and filtration fraction increase, with glomerular filtration rate persisting unchanged or increasing.
• Weir MR et al.: Hypertension 1990; 16:235-44 Identification of Salt Sensitive Individuals.
• Suitable tests for determining salt sensitivity are generally known to those of ordinary skill in the art. See, for example, Brenner, K. "A method for distinguishing salt- sensitive from non-salt-sensitive forms of human and experimental hypertension", Curr. Opin. Nephrol. Hypertens. 1993 May;2(3):341-349. Such identification can be accomplished through, for example, clinical testing (such as a salt challenge test) or by examination of family history and/or ethnic origin. Clinical testing can be done using uni-directional or bi- directional analyses.
• One illustrative non-limiting manner of determining salt sensitivity is through a salt challenge test.
• Uni-directional salt challenge testing can be accomplished by placing an individual on a low sodium diet (e.g. 40 mmol/day for one week; "low salt regimen"). Because individuals with free access to sodium often demonstrate poor compliance, this phase of testing is best performed in an in-patient environment.
• An in-patient environment is one wherein the individual being tested does not have free access to sodium sources and the diet is determined by a dietician or one skilled in the art to determine the sodium content. Additionally, all dietary sources of sodium ingested are carefully measured.
• systolic and diastolic blood pressure are determined in resting condition in triplicate.
• the individuals are placed again on a controlled dietary regimen wherein total sodium ingested is 220 mmol/day ("high salt regimen").
• high salt regimen a controlled dietary regimen wherein total sodium ingested is 220 mmol/day
• systolic and diastolic blood pressure are determined as during the low salt regimen.
• Subjects who demonstrate an increase in either systolic blood pressure or diastolic blood pressure or both, of more than 5 mm Hg are deemed salt sensitive.
• Bi-directional salt challenge testing can be accomplished by placing an individual on the low salt regimen and high salt regimen as described above for the uni-directional testing, and then immediately placing the individual on a controlled, low sodium diet similar to the low salt regimen and then determining systolic and diastolic blood pressure as described for the uni-directional testing. Individuals who demonstrate both an increase of 5 mm Hg or more in systolic or diastolic blood pressure or both at the end of the high salt regimen and a decrease of 5 mm Hg or more in systolic or diastolic blood pressure or both at the end of the subsequent controlled, low salt diet are deemed to be salt sensitive.
• Another method of identifying salt sensitive individuals is to perform a reverse uni-directional analysis wherein the individual is first placed on a high sodium regimen followed by the low sodium regimen. Individuals who demonstrate a 10% decrease in systolic or diastolic blood pressure or both at the end of the low sodium regimen are deemed to be salt sensitive.
• the uni-directional, bi-directional, and reverse uni-directional salt challenge tests described above can be further modified where desirable.
• subjects instead of an in-patient setting, subjects can be permitted to perform normal activities (i.e. eat, sleep, work, etc.) in their otherwise normal environment. Compliance with the dietary regimen is determined by analysis of 24 hour urine collections. Alternatively, compliance can be monitored by subjective questionnaires and record keeping by the test individuals.
• Other modifications of the above testing methods include reducing the one week intervals for each regimen of the test to either 3, 4, 5, or 6 days.
• Still other modifications of the above testing include adjusting the high salt regimen intake of sodium, for example to eight to sixteen grams of sodium per day.
• a lower threshold for change in systolic or diastolic blood pressure (such as 5, 6, 7, 8, or 9%) can be used and, if desired, individuals can be scored as positive for salt sensitivity if meeting such a lowered threshold on two independent uni-directional test determinations.
• Another illustrative non-limiting manner of determining salt sensitivity is through a rapid volume expansion and contraction test such as, for example, the protocol described in Grim et al;. Hypertension 1979; 1 :476- 85; as modified by Strazzullo et al.: J Nephrol 2000; 13:46-53.
• subjects are hospitalized for four days and receive 50 mmol/day of sodium.
• subjects On Day 1 , subjects also receive additional sodium in the form of Slow-Na tablets to achieve a total intake of 150 mmol sodium.
• sodium intake is again fixed at 150 mmol and the subject is given a constant rate intravenous infusion of 2 L of 0.9% sodium chloride over four hours.
• Blood pressure determinations (mean of five measurements at three minute intervals) are taken at the start and the end of the sodium chloride infusion using an automatic blood pressure recorder. Urinary sodium excretion is measured during the three hours before and during the saline infusion. Body weight, hematocrit, plasma renin activity, and aldosterone are measured before and after the infusion. On Day 3, sodium and volume depletion are effected by sodium restriction (50 mmol/day) in diet plus three doses of 37.5 mg of furosemide at 10:00 a.m., 02:00 p.m. and 06:00 p.m. The subjects are asked to drink no more than 25 mL of tap water per kg body weight.
• risk factors include, but are not limited to, a family history consisting of one or more relatives with hypertension or a genealogy traceable to an ethnic group showing a prevalence of salt-sensitivity greater than the general world-wide population.
• Such genealogy includes Blacks, American Blacks, American Indians, and Japanese. (Powers DR et al.: Arch Intern Med 1998 158:793-800)
• salt sensitivity phenotype through suitable genetic testing methods can also be used to determine salt sensitivity in an individual.
• Rutledge et al. have described an association between this phenotype and the Hpa11 mutation in the atrial natriuretic peptide in African Americans. (J Hypertens. 1995; 13:953-5).
• Svetkey et al. have reported concordance between diastolic blood pressure response to sodium loading/volume depletion to the beta 2-adrenergic receptor locus in African Americans. (Hypertension. 1997; 29:918-22).
• a study of sibling pairs in Italy reported concordance between an alpha- adducin mutation (1460 Trp) and salt sensitivity. (Cusi D et al;.
• Endothelial cells function importantly in the regulation of vascular tone and homeostasis. This function, in part, is mediated through the secretion of vasoactive substances. Endothelins (which are produced by endothelial cells) are potent vasoconstrictors and are peptides coded by three different genes. (Yanagiawa M et al.: Nature 1988 332:411-5). Endothelin-1 (“ET-1”) is the predominant member produced by the endothelium and acts in an autocrine and paracrine manner.
• ET-1 receptors i.e., Et A and ET B
• smooth muscle cells mediate the contractile, proliferative, and hypertrophy-inducing effects of ET-1 (De Nucci G et al.: Proc Natl Acad Sci USA 1988, 85:9797-800).
• endothelin plasma levels are usually normal. (Schiffrin EL et al.: Am J Hypertens 1991 4:303-8). In severely hypertensive individuals and in Blacks, however, plasma immunoreactive ET-1 is often elevated. Salt sensitive individuals respond to an increased salt load by exhibiting elevated plasma ET-1 levels. (Elijovich F et al.: Hypertension 1999; 33:1075). Accordingly, another method of identifying salt sensitive individuals is through testing of plasma immunoreactive endothelin levels. Elevated plasma immunoreactive endothelin levels, particularly elevated plasma immunoreactive endothelin ET-1 levels, often are present in salt sensitive individuals.
• subjects who can benefit from treatment or prophylaxis in accordance with the present invention are generally human subjects who have (i) a sub-normal endogenous aldosterone level, (ii) salt sensitivity regardless of the endogenous aldosterone level, and/or (iii) elevated dietary sodium intake regardless of the endogenous aldosterone level.
• a sub-normal endogenous aldosterone level e.g., a sub-normal endogenous aldosterone level
• salt sensitivity regardless of the endogenous aldosterone level
• dietary sodium intake regardless of the endogenous aldosterone level
• subjects who can benefit from treatment or prophylaxis in accordance with the method of the present invention are human subjects generally exhibiting one or more of the following characteristics:
• the average daily intake of sodium chloride by the subject is at least about 4 grams, particularly where this condition is satisfied over any one month interval for at least one or more monthly intervals over a given annual period.
• the average daily intake of sodium by the subject preferably is at least about 6 grams, more preferably at least about 8 grams, and still more preferably at least about 12 grams.
• the subject exhibits an increase in systolic blood pressure and/or diastolic blood pressure of at least about 5%, preferably at least about 7%, and more preferably at least about 10%, when daily sodium chloride intake by the subject is increased from less than about 3 g/day to at least about 10 g/day.
• the activities ratio of plasma aldosterone (ng/dL) to plasma renin (ng/ml/hr) in the subject is greater than about 30, preferably greater than about 40, more preferably greater than about 50; and still more preferably greater than about 60.
• the subject has low plasma renin levels; for example, the morning plasma renin activity in the subject is less than about 1.0 ng/dL/hr, and/or the active renin value in the subject is less than about 15 pg/mL.
• the subject suffers from or is susceptible to elevated systolic and/or diastolic blood pressure.
• the systolic blood pressure (measured, for example, by seated cuff mercury sphygmomanometer) of the subject is at least about 130 mm Hg, preferably at least about 140 mm Hg, and more preferably at least about about 150 mm Hg
• the diastolic blood pressure (measured, for example, by seated cuff mercury sphygmomanometer) of the subject is at least about 85 mm Hg, preferably at least about 90 mm Hg, and more preferably at least about 100 mm Hg.
• the urinary sodium to potassium ratio (mmol/mmol) of the subject is less than about 6, preferably less than about 5.5, more preferably less than about 5, and still more preferably less than about 4.5.
• the urinary sodium level of the subject is at least 60 mmol per day, particularly where this condition is satisfied over any one month interval for at least one or more monthly intervals over a given annual period.
• the urinary sodium level of the subject preferably is at least about 100 mmol per day, more preferably at least about 150 mmol per day, and still more preferably 200 mmol per day.
• Plasma concentration of one or more endothelins, particularly plasma immunoreactive ET-1, in the subject is elevated.
• Plasma concentration of ET-1 preferably is greater than about 2.0 pmol/L, more preferably greater than about 4.0 pmol/L, and still more preferably greater than about 8.0 pmol/L.
• the subject has blood pressure that is substantially refractory to treatment with an ACE inhibitor; particularly a subject whose blood pressure is lowered less than about 8 mm Hg, preferably less than 5 mm Hg, and more preferably less than 3 mm Hg, in response to 10 mg/day enalapril compared to the blood pressure of the subject on no antihypertensive therapy.
• the subject has blood volume-expanded hypertension or blood volume-expanded borderline hypertenision, that is, hypertension wherein increased blood volume as a result of increased sodium retension contributes to blood pressure.
• the subject is a non-modulating individual, that is, the individual demonstrates a blunted positive response in renal blood flow rate and/or in adrenal production of aldosterone to an elevation in sodium intake or to angiotensin II administration, particularly when the response is less than the response of individuals sampled from the general geographical population (for example, individuals sampled from the subject's country of origin or from a country of which the subject is a resident), preferably when the response is less than 40% of the mean of the population, more preferably less than 30%, and more preferably still less than 20%.
• the general geographical population for example, individuals sampled from the subject's country of origin or from a country of which the subject is a resident
• the subject has or is susceptible to renal dysfunction, particularly renal dysfunction selected from one or more members of the group consisting of reduced glomerular filtration rate, microalbuminuria, and proteinuria.
• cardiovascular disease particularly cardiovascular disease selected from one or more members of the group consisting of heart failure, left ventricular diastolic dysfunction, hypertrophic cardiomyopathy, and diastolic heart failure.
• the subject has or is susceptible to liver disease, particularly liver cirrhosis.
• the subject has or is susceptible to edema, particularly edema selected from one or more members of the group consisting of peripheral tissue edema, hepatic or splenic congestion, liver ascites, and respiratory or lung congestion.
• edema particularly edema selected from one or more members of the group consisting of peripheral tissue edema, hepatic or splenic congestion, liver ascites, and respiratory or lung congestion.
• the subject has or is susceptible to insulin resistance, particularly Type I or Type II diabetes mellitus, and/or glucose sensitivity.
• the subject is at least 55 years of age, preferably at least about 60 years of age, and more preferably at least about 65 years of age.
• the subject is, in whole or in part, a member of at least one ethnic group selected from the Asian (particularly from the Japanese) ethnic group, the American Indian ethnic group, and the Black ethnic group.
• the subject has one or more genetic markers associated with salt sensitivity.
• the subject is obese, preferably with greater than 25% body fat, more preferably with greater than 30% body fat, and even more preferably with greater than 35% body fat.
• the subject has one or more 1 sl , 2 nd , or 3 rd degree relatives who are or were salt sensitive, wherein 1 st degree relatives means parents or relatives sharing one or more of the same parents, 2 nd degree relatives means grandparents and relatives sharing one or more of the same grandparents, and 3 rd degree relatives means great-grandparents and relatives sharing one or more of the same great-grandparents.
• 1 st degree relatives means parents or relatives sharing one or more of the same parents
• 2 nd degree relatives means grandparents and relatives sharing one or more of the same grandparents
• 3 rd degree relatives means great-grandparents and relatives sharing one or more of the same great-grandparents.
• such individuals have four or more salt sensitive 1 st , 2 nd , or 3 rd degree relatives; more preferably, eight or more such relatives; even more preferably, 16 or more such relatives; and even more preferably still, 32 or more such relatives.
• the values listed above preferably represent an average value, more preferably a daily average value based on at least two measurements.
• the subject in need of treatment satisfies at least two or more of the above-characteristics, more preferably, at least three or more of the above-characteristics, and still more preferably, at least four or more of the above-characteristics.
• the subject in need of treatment is salt sensitive and satisfies two or more of the following conditions: (i) the average daily intake of sodium chloride by the subject is at least about 4 grams, particularly where this condition is satisfied over any one month interval for at least one or more monthly intervals over a given annual period; and/or (ii) the activities ratio of plasma aldosterone (ng/dL) to plasma renin (ng/ml/hr) in the subject is greater than about 30; (iii) the morning plasma renin activity in the subject is less than about 1.0 ng/dL/hr, and/or the active renin value in the subject is less than about 15 pg/mL; and/or (iv) the systolic blood pressure of the subject is at least about 130 mm Hg and the diastolic blood pressure of the subject is at least about 85 mm Hg; and/or (v) the subject has or is susceptible to cardiovascular disease, particularly cardiovascular disease selected from one or more
• the subject in need of treatment is salt sensitive and satisfies the following conditions: (i) the activities ratio of plasma aldosterone (ng/dL) to plasma renin (ng/ml/hr) in the subject is greater than about 30; and (ii) the morning plasma renin activity in the subject is less than about 1.0 ng/dL/hr, and/or the active renin value in the subject is less than about 15 pg/mL.
• the subject in need of treatment is salt sensitive and satisfies at least two of the following conditions: (i) the average daily intake of sodium chloride by the subject is at least about 4 grams, particularly where this condition is satisfied over any one month interval for at least one or more monthly intervals over a given annual period; and/or (ii) the systolic blood pressure of the subject is at least about 130 mm Hg and the diastolic blood pressure of the subject is at least about 85 mm Hg; and/or (iii) the subject has or is susceptible to cardiovascular disease, particularly cardiovascular disease selected from one or more members of the group consisting of heart failure, left ventricular diastolic dysfunction, hypertrophic cardiomyopathy, ischaemic heart disease, and diastolic heart failure.
• cardiovascular disease particularly cardiovascular disease selected from one or more members of the group consisting of heart failure, left ventricular diastolic dysfunction, hypertrophic cardiomyopathy, ischaemic heart disease, and diastolic heart failure.
• the subject preferably is a member, in whole or in part, of the Japanese ethnic group or the Black ethnic group.
• Hypertension in Japan is a significant problem.
• One recent estimate suggests that around 30 million Japanese adults suffer from hypertension. (Saruta T. J Clin Ther Med 1997;13:4024-9).
• Trends in blood pressure and urinary sodium and potassium excretion in Japan reinvestigation in the 8th year after the Intersalt Study.
• Nakagawa H, et al. Hum Hypertens 1999 Nov;13(11 ):735-41 , recommended that the Japanese population increase dietary potassium and decrease dietary sodium.
• the Japanese show two broad groups, salt sensitive and salt insensitive (Preventive nutritional factors in epidemiology: interaction between sodium and calcium. Mizushima S, Clin Exp Pharmacol Physiol 1999;26:573). Many Japanese hypertensives are believed to be salt sensitive. Accordingly, members of the Japanese ethnic group who exhibit the combination of salt sensitivity, high sodium intake and failure to voluntarily limit sodium consumption are particularly benefited by the therapy of the present invention.
• the subject in need of treatment is salt sensitive individual who is, in whole or in part, a member of the Japanese ethnic group, and, inter alia, has or is susceptible to hypertension and/or cardiovascular disease, particularly cardiovascular disease selected from one or more members of the group consisting of heart failure, left ventricular diastolic dysfunction, hypertrophic cardiomyopathy, and diastolic heart failure.
• cardiovascular disease particularly cardiovascular disease selected from one or more members of the group consisting of heart failure, left ventricular diastolic dysfunction, hypertrophic cardiomyopathy, and diastolic heart failure.
• the subject in need of treatment is salt sensitive individual who is, in whole or in part, a member of the Japanese ethnic group, and, inter alia, the average daily intake of sodium chloride by the subject is at least about 4 grams, particularly where this condition is satisfied over any one month interval for at least one or more monthly intervals over a given annual period.
• Hypertension in Blacks similarly is a significant problem. Many hypertensive and normotensive Blacks are salt sensitive (Svetkey, LP et al.: Hypertension. 1996;28:854-8). Accumulated epidemiologic data indicate that the prevalence of hypertension among Blacks is greater than among whites in almost all age- and sex-matched groups. Hypertensive Blacks generally have a higher incidence of left ventricular dysfunction, stroke, and renal damage (but a lower incidence of ischemic heart disease) than do hypertensive whites. (Eisner, GM.
• Hypertension among Blacks generally is initially managed by restricting sodium intake in the diet. If dietary control is insufficient, administration of an antihypertensive agent with 24-hour efficacy and that lowers vascular peripheral resistance, promotes sodium excretion, and potentially improves renal hemodynamics is recommended. (Eisner, GM. Am J Kidney Dis 1990; 16(4 Suppl 1):35-40). Blacks, however, generally respond differently to antihypertensive agents as compared to white. In general, beta-adrenergic receptor antagonists or ACE inhibitors monotherapies are less effective in Blacks than in whites. Black males tend to be even less responsive to ACE inhibitors than Black females (Eisner, GM. Am J Kidney Dis 1990;16(4 Suppl 1):35-40). Accordingly, members of the Black ethnic group who exhibit the combination of salt sensitivity, high sodium intake and failure to voluntarily limit sodium consumption are particularly benefited by the therapy of the present invention.
• the subject in need of treatment is salt sensitive individual who is, in whole or in part, a member of the Black ethnic group, and, inter alia, has or is susceptible to hypertension and/or cardiovascular disease, particularly cardiovascular disease selected from one or more members of the group consisting of heart failure, left ventricular diastolic dysfunction, hypertrophic cardiomyopathy, and diastolic heart failure.
• cardiovascular disease particularly cardiovascular disease selected from one or more members of the group consisting of heart failure, left ventricular diastolic dysfunction, hypertrophic cardiomyopathy, and diastolic heart failure.
• the subject in need of treatment is salt sensitive individual who is, in whole or in part, a member of the Black ethnic group, and, inter alia, the average daily intake of sodium chloride by the subject is at least about 4 grams, particularly where this condition is satisfied over any one month interval for at least one or more monthly intervals over a given annual period.
• the subject in need of treatment is salt sensitive individual who is, in whole or in part, a member of the Black ethnic group, and, inter alia, exhibits a diminished incremental decrease in blood pressure in response to standard anti-hypertensive therapy, particularly where such therapy comprises the administration of an ACE inhibitor.
• Non-Modulating Individuals As noted above, a non-modulating individual demonstrates a blunted positive response in renal blood flow rate and adrenal production of aldosterone to a high sodium intake or angiotensin II administration. Such non-modulating individuals additionally may exhibit increased fasting insulin levels and increased increment in glucose-stimulated insulin levels. (Ferri et al.: Diabetes 1999; 48:1623-30). Insulin resistance is also associated with increased risk of myocardial infarction.
• the subject in need of treatment is a salt sensitive and non-modulating individual that, inter alia, (i) has or is susceptible to insulin resistance, particularly Type I or Type II diabetes mellitus, and/or glucose sensitivity, and/or (ii) has or is susceptible to cardiovascular disease.
• the subject in need of treatment is a salt sensitive individual at least 55 years of age, preferably at least about 60 years of age, and more preferably at least about 65 years of age, and, inter alia, has or is susceptible to insulin resistance, particularly Type I or Type II diabetes mellitus, and/or glucose sensitivity.
• Detoxified and recovering alcoholics also commonly are salt sensitive (Genaro C et al.: Hypertension 2000: 869-874). Accordingly, in another embodiment of the present invention the subject in need of treatment is a salt sensitive individual and, inter alia, is a detoxified or recovering alcoholic.
• the present invention also relates to use of an epoxy-steroidal compound that is a aldosterone antagonist to reduce and/or reverse the progression of salt sensitivity.
• Salt sensitivity is an independent risk factor for death from cardiovascular disease including stroke, regardless of whether the salt-sensitive person is hypertensive, smokes or has high cholesterol. (Myron H. Weinberger , 54 th Annual Conference of the American Heart Association's Council for High Blood Pressure Research, Washington, D.C., 2000).
• the subject in need of treatment is a salt sensitive individual who has, more or less, a normal clinical presentation.
• Normal clinical presentation means an individual who is not markedly hypertensive, and does not have any marked evidence of ongoing disease of the kidney, heart, cardiovasculature, cerebrovasculature, or any indicies of insulinopathies.
• eplerenone according to the present invention in such an individual will prevent development of aldosterone/salt mediated pathologies.
• an epoxy-steroidal compound in accordance with the present invention will reduce and/or reverse the progression of the salt sensitivity and related conditions such as, but not limited to, an increase in blood pressure response to elevated sodium intake and renal, cardiovascular and brain pathologies.
• the administration of the epoxy- steroidal aldosterone antagonist will reduce and/or reverse the progression of age related effects. Furthermore, such administration will also reduce and/or reverse the genetic and dietary impact of salt sensitivity in such individuals on the progression of renal, cardiovascular and brain pathologies.
• the present invention also relates to the use of an epoxy-steroidal compound to suppress the sodium appetite in individuals in need thereof.
• an epoxy-steroidal compound to suppress the sodium appetite in individuals in need thereof.
• aldosterone is hypertensigenic in the brain, particularly in individuals with an elevated level of intracellular sodium in the brain. Such an elevated level of aldosterone is especially likely to occur in salt sensitive individuals.
• the hypertensigenic action of aldosterone in the brain (“central aldosterone") of an individual is believed to be mediated, in part, to increased neurogenic vasomotor tone and impaired arterial baroflexes.
• HPA hypothalamic-pituitary-adrenal
• the present invention comprises the use of epoxy- steroidal aldosterone antagonists to functionally inactivate aldosterone in the brain of an individual, especially an individual who has or is susceptible to an elevated intracellular sodium level in the brain. Such an elevated level is especially likely to occur in salt sensitive individuals and individuals having an elevated dietary sodium intake. "Functionally inactivate” means to partially or completely blockade one or more of the actions meditated by aldosterone.
• This invention particularly encompasses the use of epoxy-steroidal aldosterone antagonists in the treatment or prophylaxis of an individual who is hypertensive as a result of one or more of the following: an activated HPA axis, increased neurogenic vasomotor tone, or impaired arterial baroflexes.
• the invention further encompasses the use of epoxy-steroidal aldosterone antagonists in the treatment or prophylaxis of salt sensitive hypertensive individuals to reduce and/or prevent the adverse effects of aberrant aldosterone levels in brain.
• the present invention also relates to the use of epoxy-steroidal compounds to treat hypertensive subjects who have an elevated level of intracellular sodium thereby preventing aberrant renal sodium retention. Accordingly, the present invention encompasses the use of epoxy-steroidal compounds to functionally inactivate aldosterone in the kidney of a human subject, especially a subject having salt sensitivity and/or an elevated dietary sodium intake. "Functionally inactivate” means to partially or completely blockade one or more of the actions meditated by aldosterone.
• RAAS renin and aldosterone levels
• renin and aldosterone levels are relatively low because, in part, sodium retention is not necessary.
• inhibitors of the RAAS upstream of aldosterone e.g., ACE inhibitors and angiotensin II receptor antagonists
• ACE inhibitors and angiotensin II receptor antagonists have limited efficacy.
• the basic biochemical defect underlying low renin/salt sensitive hypertension is unclear, aberrant renal sodium retention in these individuals contributes to hypertension. Attempts at adequate therapeutic control often involve combination therapies, which can result in increased negative side effects over single therapy.
• Aldosterone is hypertensigenic in the kidney, especially in individuals having an elevated level of intracellular sodium.
• Such individuals especially include salt sensitive individuals.
• Novel methods of the present invention effectively block the hypertensive effects of both unstimulated as well as stimulated aldosterone.
• Administration of the epoxy steroidal compounds in accordance with present method can correct the defective natriuretic regulation in the kidney and restore blood pressure, despite high sodium intake which confounds standard antihypertensive therapy.
• the pathogenic effect results, in whole or in part, from the action of aldosterone in the presence of an elevated level of sodium.
• the pathogenic effect results, in whole or in part, from the action of aldosterone in the presence of an elevated level of intracellular sodium.
• the pathogenic effect is mediated, in whole or in part, by aldosterone present in the brain.
• the pathogenic effect results, in whole or in part, from the action of aldosterone in the presence of an elevated level of intracellular sodium. More preferably, the pathogenic effect is selected from hypertension and stroke.
• the pathogenic effect is mediated, in whole or in part, by aldosterone present in the kidney.
• the pathogenic effect results, in whole or in part, from the action of aldosterone in the presence of an elevated level of intracellular sodium. More preferably, the pathogenic effect is selected from renal hypertension and nephrosclerosis. In another embodiment of the invention, the pathogenic effect results, in whole or in part, from the combined action of aldosterone and elevated dietary sodium intake in the subject.
• a therapeutically effective amount of an epoxy steroidal compound is administered to a subject in need thereof to treat or prevent organ damage (such as in heart, kidney, brain, liver and lungs) mediated in whole or in part by aldosterone.
• organ damage such as in heart, kidney, brain, liver and lungs
• the subject exhibits one or more of the characteristics previously described for subjects who can benefit from treatment or prophylaxis.
• angiotensin II receptor blocker such as losartan
• the epoxy steroidal compound is administered to such subjects in combination with an angiotensin II receptor blocker.
• the epoxy steroidal compound can be administered, for example, at a dose effective to reduce the magnitude of one or more of a group of clinical features consisting of pulse pressure, carotid-femoral pulse wave velocity, microalbuminuria, peripheral edema, or clinically meaningful symptoms of distress.
• the epoxy steroidal compound administered to treat or prevent end organ damage preferably is administered in an amount effective to reduce urinary albumin to creatinine ratio ("UACR") in the subject by at least about 10%, preferably at least about 15%, more preferably at least about 20%, still more preferably at least about 30%, still more preferably at least about 40%, still more preferably at least about 50%, and still more preferably at least about 60%, within 12 weeks after initiating treatment relative to baseline UACR before initiating treatment.
• UCR urinary albumin to creatinine ratio
• a therapeutically effective amount of an epoxy steroidal compound is administered to a subject in need thereof to treat or prevent renal dysfunction selected from the group consisting of reduced glomerular filtration rate, microalbuminuria and proteinuria (particularly microalbuminuria).
• the subject exhibits one or more of the characteristics previously described for subjects who can benefit from treatment or prophylaxis.
• One group of subjects of specific interest for whom such therapy is effective are subjects having or susceptible to insulin resistance (particularly Type I or Type II diabetes mellitus) and/or glucose sensitivity.
• the epoxy steroidal compound is administered in an amount effective to reduce UACR by at least about 10%, preferably at least about 15%, more preferably at least about 20%, still more preferably at least about 30%, still more preferably at least about 40%, still more preferably at least about 50%, and still more preferably at least about 60%, within 12 weeks after initiating treatment relative to baseline UACR before initiating treatment.
• a therapeutically effective amount of an epoxy steroidal compound is administered to a subject in need thereof to treat or prevent end stage renal disease.
• the subject exhibits one or more of the characteristics previously described for subjects who can benefit from treatment or prophylaxis.
• One group of subjects of specific interest for whom such therapy is effective are subjects having or susceptible to insulin resistance (particularly Type I or Type II diabetes mellitus) and/or glucose sensitivity.
• the epoxy steroidal compound is administered in an amount effective to reduce UACR by at least about 10%, preferably at least about 15%, more preferably at least about 20%, still more preferably at least about 30%, still more preferably at least about 40%, still more preferably at least about 50%, and still more preferably at least about 60%, within 12 weeks after initiating treatment relative to baseline UACR before initiating treatment.
• a therapeutically effective amount of an epoxy steroidal compound is administered to a subject in need thereof to treat or prevent left ventricular hypertrophy.
• the subject exhibits one or more of the characteristics previously described for subjects who can benefit from treatment or prophylaxis.
• One group of subjects of specific interest for whom such therapy is effective are subjects having or susceptible to insulin resistance (particularly Type I or Type II diabetes mellitus) and/or glucose sensitivity.
• the epoxy- steroidal compound can be administered in combination with an ACE inhibitor (such as enalapril).
• the epoxy steroidal compound is administered to such subjects in an amount sufficient to achieve one or both of the following: (a) a reduction in the measure of collagen turnover of at least about 5%, preferably at least about 7%, and more preferably at least about 10%, within 12 weeks after initiating treatment relative to baseline collagen turnover before initiating treatment, and (b) a reduction in UACR of at least about 10%, preferably at least about 20%, and more at least about preferably 30%, within 12 weeks after initiating treatment relative to baseline UACR before initiating treatment.
• a therapeutically effective amount of an epoxy steroidal compound is administered to improve vascular compliance in a subject.
• the subject exhibits one or more of the characteristics previously described for subjects who can benefit from treatment or prophylaxis.
• One group of subjects of specific interest for whom such therapy is effective are subjects having or susceptible to insulin resistance (particularly Type I or Type 11 diabetes mellitus) and/or glucose sensitivity.
• a therapeutically effective amount of an epoxy steroidal compound is administered to reduce systolic blood pressure in a subject.
• the subject exhibits one or more of the characteristics previously described for subjects who can benefit from treatment or prophylaxis.
• One group of subjects of specific interest for whom such therapy is effective are subjects having or susceptible to insulin resistance (particularly Type I or Type II diabetes mellitus) and/or glucose sensitivity.
• the epoxy steroidal compound is administered- in an amount effective to reduce systolic blood pressure by at least about 1%, preferably at least about 3%, more preferably at least about 5%, still more preferably at least about 7%, still more preferably at least about 8%, still more preferably at least about 9%, and still more preferably at least about 10%, within 12 weeks after initiating treatment relative to baseline systolic blood pressure before initiating treatment.
• a therapeutically effective amount of an epoxy steroidal compound is administered to a subject in need thereof to treat or prevent systemic effects of aldosterone in the subject.
• Such systemic effects include systemic pathologic responses to aldosterone affecting two or more of organs selected from the group consisting of heart, kidney, brain, liver, lungs and vascular system.
• the subject exhibits one or more of the characteristics previously described for subjects who can benefit from treatment or prophylaxis.
• One group of subjects of specific interest exhibit microalbuminuria, particularly where the subject further exhibits one or more conditions selected from the group consisting of elevated blood pressure, cardiovascular dysfunction, left ventricular hypertrophy, myocardial infarction, stroke, peripheral vascular disease, retinopathy, and end-stage renal disease.
• a therapeutically effective amount of epoxy steroidal compound is administered to a subject in need thereof to treat or prevent cardiovascular disorders selected from the group consisting of congenital disorders, valvular disorders, coronary artery disorders, nosocomial disorders, surgically-induced disorders, cardiomyopathic disorders, viral-induced disorders, bacterial-induced disorders, anatomic disorders, vascular disorders, transplantation-induced disorders, ischemic disorders, cardiac arrhythmia disorders, conduction disorders, thrombotic disorders, aortic disorders, coagulation disorders, connective tissue disorders, neuromuscular disorders, hematologic disorders, hypobaric disorders, endocrine disorders, pulmonary disorders, non-malignant tumor disorders, malignant tumor disorders and pregnancy- induced disorders.
• cardiovascular disorders selected from the group consisting of congenital disorders, valvular disorders, coronary artery disorders, nosocomial disorders, surgically-induced disorders, cardiomyopathic disorders, viral-induced disorders, bacterial-induced disorders, anatomic disorders, vascular disorders, transplantation-induced disorders, ischemic disorders, cardiac ar
• a group of cardiovascular disorders of interest comprises cardiovascular disorders selected from the group consisting of coronary artery disorders, cardiomyopathic disorders, aortic disorders, and connective tissue disorders.
• Another group of cardiovascular disorders of interest comprises cardiovascular disorders selected from the group consisting of congenital disorders, valvular disorders, nosocomial disorders, surgically-induced disorders, viral-induced disorders, bacterial-induced disorders, anatomic disorders, transplantation-induced disorders, conduction disorders, coagulation disorders, neuromuscular disorders, hematologic disorders, hypobaric disorders, endocrine disorders, pulmonary disorders, non-malignant tumor disorders, malignant tumor disorders and pregnancy-induced disorders.
• another group of subjects of specific interest for whom such therapy is effective are subjects who are substantially refractory to treatment with standard therapy for cardiac- or renal-related conditions (e.g., monotherapies or combination therapies for treating hypertension or heart failure involving administration of one or more compounds having activity as a diuretic, a calcium channel blocker, a ⁇ - adrenergic receptor blocker, an ⁇ -blocker, or otherwise having activity as an antagonist of RAAS (such as an ACE inhibitor or angiotensin receptor antagonist)).
• monotherapies or combination therapies for treating hypertension or heart failure involving administration of one or more compounds having activity as a diuretic, a calcium channel blocker, a ⁇ - adrenergic receptor blocker, an ⁇ -blocker, or otherwise having activity as an antagonist of RAAS (such as an ACE inhibitor or angiotensin receptor antagonist)).
• RAAS such as an ACE inhibitor or angiotensin receptor antagonist
• the epoxy-steroidal compound can be combined with standard therapy (particularly administration of an ACE inhibitor, with or without a thiazide) to beneficial effect.
• a less than satisfactory response would encompass, for example, a decrease of blood pressure in subject less than at least about 4%, preferably at least about 5%, and more preferably at least about 6%, in response to therapy with an angiotensin II receptor blocker (such as losartan), and/or a progression in UACR.
• epoxy-steroidal aldosterone antagonist compounds used in the method of the present invention generally have a steroidal nucleus substituted with an epoxy-type moiety.
• epoxy-type moiety is intended to embrace any moiety characterized in having an oxygen atom as a bridge between two carbon atoms, examples of which include the following moieties:
• steroidal denotes a nucleus provided by a cyclopenteno-phenanthrene moiety, having the conventional "A", “B", “C” and “D” rings.
• the epoxy-type moiety may be attached to the cyclopentenophenanthrene nucleus at any attachable or substitutable positions, that is, fused to one of the rings of the steroidal nucleus or the moiety may be substituted on a ring member of the ring system.
• epoxy-steroidal is intended to embrace a steroidal nucleus having one or a plurality of epoxy-type moieties attached thereto.
• Epoxy-steroidal aldosterone antagonists suitable for use in the present methods include a family of compounds having an epoxy moiety fused to the "C" ring of the steroidal nucleus. Especially preferred are 20- spiroxane compounds characterized by the presence of a 9 ⁇ ,11 ⁇ - substituted epoxy moiety. Compounds 1 through 11 listed in Table 1 below are illustrative 9 ⁇ ,11 ⁇ -epoxy-steroidal compounds that may be used in the present methods. These epoxy steroids may be prepared by procedures described in Grob et al., U.S. Patent No. 4,559,332.
• Eplerenone is an aldosterone receptor antagonist and has a higher specificity for aldosterone receptors than does, for example, spironolactone. Selection of eplerenone as the aldosterone antagonist in the present method would be beneficial to reduce certain side-effects such as gynecomastia that occur with use of aldosterone antagonists having less specificity.
• the epoxy-steroidal compound selected can be administered in any of its solid state forms, either as one or more solid state forms per se or in the form of a pharmaceutical composition comprising one or more solid state forms of eplerenone.
• novel solid state forms include, but are not limited to, solvated crystalline forms, non-solvated crystalline forms, and the amorphous form.
• the epoxy-steroidal compound administered in accordance with the methods of the present invention is a non-solvated crystalline form of eplerenone having the X-ray powder diffraction pattern set forth in Table 1 A below (referred to herein as the "higher melting point polymorph” or "Form H").
• the eplerenone administered in accordance with the methods of the present invention is a non-solvated crystalline form of eplerenone having the X-ray powder diffraction pattern set forth in Table 1 B below (referred to herein as the "lower melting point polymorph” or "Form L").
• Unformulated Form H exhibits a faster dissolution rate (approximately 30% higher) at lower temperatures (i.e., temperatures below the enantiotropic transition temperature as later discussed) than, for example, unformulated Form L.
• dissolution of eplerenone in the gastrointestinal tract is the rate-controlling step for delivery of the eplerenone to the target cells
• faster dissolution generally results in improved bioavailability.
• Form H therefore, can provide an improved bioavailability profile relative to Form L.
• selection of a solid state form of eplerenone having a faster dissolution rate likewise provides greater flexibility in the selection of excipients for, and in the formulation of, immediate release pharmaceutical compositions relative to other solid state forms having a slower dissolution rate.
• Form L possesses greater physical stability at lower temperatures (i.e., at temperatures below the enantiotropic transition temperature as later discussed) than, for example, Form H.
• Solid state forms of eplerenone such as Form L that do not require the use of special processing or storage conditions, and that avoid the need for frequent inventory replacement, are desirable. For example, selection of a solid state form of eplerenone that is physically stable during the manufacturing process (such as during milling of eplerenone to obtain a material with reduced particle size and increased surface area) can avoid the need for special processing conditions and the increased costs generally associated with such special processing conditions.
• selection of a solid state form of eplerenone that is physically stable at different conditions of storage can help avoid polymorphic or other degradative changes in the eplerenone that can lead to product loss or deterioration of product efficacy. Therefore, the selection of a solid state form of eplerenone such as Form L having greater physical stability provides a meaningful benefit over less stable eplerenone forms.
• the eplerenone administered in accordance with the methods of the present invention is a solvated crystalline form of eplerenone.
• the solvated crystalline forms are substantially exclusive of solvents that are not pharmaceutically-acceptable solvents. Because Form H and Form L typically are more physically stable than the crystalline solvates at room temperature and under atmospheric pressure, the solvated crystalline forms used in such compositions generally comprise a pharmaceutically acceptable higher boiling and/or hydrogen bonding solvent such as, but not limited to, butanol.
• the solvated crystalline forms collectively can offer a range of different dissolution rates and, where dissolution of eplerenone in the gastrointestinal tract is the rate-controlling step for delivery of the eplerenone to the target cells, bioavailabilities relative to Form H and Form L.
• the eplerenone administered in accordance with the methods of the present invention is amorphous eplerenone. It is hypothesized that amorphous eplerenone possesses a different dissolution rate and, where dissolution of eplerenone in the gastrointestinal tract is the rate-controlling step for delivery of the eplerenone to the target cells, bioavailability relative to Form H and Form L.
• the eplerenone administered in accordance with the methods of the present invention is a combination comprising a first solid state form of eplerenone and a second solid state form of eplerenone.
• the first and second solid state forms of eplerenone are selected from Form H, Form L, solvated eplerenone and amorphous eplerenone.
• Such combinations may further comprise additional solid state forms of eplerenone and are useful, for example, in the preparation of pharmaceutical compositions having differing dissolution profiles, including controlled release compositions.
• the weight ratio of said first solid state form to said second solid state form preferably is at least about 1 :9, more preferably at least about 1:1 , still more preferably at least about 2:1 , still more preferably at least about 5:1, and still more preferably at least about 9:1.
• the eplerenone is administered in the form of a pharmaceutical composition wherein the entire amount of eplerenone contained in the composition is present as phase pure Form H.
• the eplerenone is administered in the form of a pharmaceutical composition wherein the entire amount of eplerenone contained in the composition is present as phase pure Form L
• the eplerenone is administered in the form of a pharmaceutical composition wherein the entire amount of eplerenone contained in the composition is present as a phase pure solvated crystalline eplerenone.
• the eplerenone is administered in the form of a pharmaceutical composition wherein the entire amount of eplerenone contained in the composition is present as amorphous eplerenone.
• the eplerenone is administered in the form of a pharmaceutical composition wherein the composition comprises a first solid state form of eplerenone and a second solid state form of eplerenone, and the first and second solid state forms of eplerenone are selected from Form H, Form L, solvated eplerenone and amorphous eplerenone.
• the weight ratio of said first solid state form to said second solid state form preferably is at least about 1 :9, preferably about 1:1, more preferably at least about 2:1 , more preferably at least about 5:1 , and still more preferably at least about 9:1.
• the eplerenone is administered in the form of a pharmaceutical composition wherein the composition comprises both Form H and Form L.
• the ratio of the amount of Form L to Form H in the composition generally is between about 1 :20 to about 20:1. In other embodiments, for example, this ratio is between about 10:1 to about 1 :10; about 5:1 to about 1 :5; about 2:1 to about 1 :2; or about 1 :1.
• each of the above embodiments can embrace the administration of a solid state form of eplerenone over a broad range of eplerenone particle sizes
• coupling the selection of the solid state form of eplerenone with a reduction of the eplerenone particle size can improve the bioavailability of unformulated eplerenone and pharmaceutical compositions comprising that solid state form of eplerenone.
• the D go particle size of the unformulated eplerenone or the eplerenone used as a starting material in the pharmaceutical composition generally is less than about 400 microns, preferably less than about 200 microns, more preferably less than about 150 microns, still more preferably less than about 100 microns, and still more preferably less than about 90 microns.
• the D 90 particle size is between about 40 microns to about 100 microns.
• the D go particle size is between about 30 microns to about 50 microns.
• the D 90 particle size is between about 50 microns to about 150 microns.
• the D 90 particle size is between about 75 microns to about 125 microns.
• the D 90 particle size of the unformulated eplerenone or the eplerenone used as a starting material in the pharmaceutical composition generally is less than about 15 microns, preferably less than about 1 micron, more preferably less than about 800 nm, still more preferably less than about 600 nm, and still more preferably less than about 400 nm. In another embodiment, the D 90 particle size is between about 10 nm to about 1 micron. In another embodiment, the D 90 particle size is between about 100 nm to about 800 nm. In another embodiment, the D 90 particle size is between about 200 nm to about 600 nm. In another embodiment, the D 90 particle size is between about 400 nm to about 800 nm.
• Solid state forms of eplerenone having a particle size less than about 15 microns can be prepared in accordance with applicable particle size reduction techniques known in the art. Such techniques include, but are not limited to those described in U.S. Patents 5,145,684, 5,318,767, 5,384,124 and 5,747,001. U.S. Patents 5,145,684, 5,318,767, 5,384,124 and 5,747,001 are expressly incorporated by reference as if fully set forth at length.
• particles of suitable size are prepared by dispersing the eplerenone in a liquid dispersion medium and wet-grinding the mixture in the presence of grinding media to reduce the particles to the desired size. If necessary or advantageous, the particles can be reduced in size in the presence of a surface modifier.
• amorphous refers to a solid state wherein the eplerenone molecules are present in a disordered arrangement and do not form a distinguishable crystal lattice or unit cell. When subjected to X-ray powder diffraction, amorphous eplerenone does not produce any characteristic crystalline peaks.
• boiling point means the boiling point of the substance or solution under the applicable process conditions.
• crystalline form refers to a solid state form wherein the eplerenone molecules are arranged to form a distinguishable crystal lattice (i) comprising distinguishable unit cells, and (ii) yielding diffraction peaks when subjected to X-ray radiation.
• crystallization can refer to crystallization and/or recrystallization depending upon the applicable circumstances relating to the preparation of the eplerenone starting material.
• the term "digestion” means a process in which a slurry of solid eplerenone in a solvent or mixture of solvents is heated at the boiling point of the solvent or mixture of solvents under the applicable process conditions.
• direct crystallization refers to the crystallization of eplerenone directly from a suitable solvent without the formation and desolvation of an intermediate solvated crystalline solid state form of eplerenone.
• particle size refers to particle size as measured by conventional particle size measuring techniques well known in the art, such as laser light scattering, sedimentation field flow fractionation, photon correlation spectroscopy, or disk centrifugation.
• D go particle size means the particle size of at least 90% of the particles as measured by such conventional particle size measuring techniques.
• purity means the chemical purity of eplerenone according to conventional HPLC assay.
• low purity eplerenone generally means eplerenone that contains an effective amount of a Form H growth promoter and/or a Form L growth inhibitor.
• high purity eplerenone generally means eplerenone that does not contain, or contains less than an effective amount of, a Form H growth promoter and/or a Form L growth inhibitor.
• phase purity means the solid state purity of eplerenone with regard to a particular crystalline or amorphous form of the eplerenone as determined by the infrared spectroscopy analytical methods described herein.
• XPRD means X-ray powder diffraction
• T m means melting temperature
• Single crystal X-ray analysis indicates that the eplerenone molecular conformation differs between Form H and Form L, particularly with respect to the orientation of the ester group at the 7-position of the steroid ring.
• the orientation of the ester group can be defined by the C8-C7-C23-02 torsion angle.
• the eplerenone molecule adopts a conformation in which the methoxy group of the ester is approximately aligned with the C-H bond at the 7-position and the carbonyl group is approximately positioned over the center of the B-steroid ring.
• the C8-C7- C23-02 torsion angle is approximately -73.0° in this conformation.
• the carbonyl oxygen atom of the ester group (01) is in close contact with the oxygen atom of the 9,11-epoxide ring (04).
• the 01-04 distance is about 2.97 A, which is just below the van der Waal's contact distance of 3.0 A (assuming van der Waal's radii of 1.5A for the oxygen).
• the eplerenone molecule adopts a conformation in which the ester group is rotated approximately 150° relative to that of Form H and has a C8-C7-C23-02 torsion angle of approximately +76.9°.
• the methoxy group of the ester is directed toward the 4,5-alkene segment of the A-steroid ring.
• the distance between either oxygen atom of the ester group (01 ,02) and the oxygen atom of the 9,11-epoxide ring is increased relative to the distance determined for Form H.
• the 02-04 distance is approximately 3.04A, falling just above the van der Waal's contact distance.
• the 01-04 distance is about 3.45A.
• the eplerenone molecule appears to adopt a conformation characteristic of Form L in the solvated crystalline forms analyzed by single crystal X-ray diffraction to date.
• the various crystalline forms of eplerenone were analyzed with either a Siemens D5000 powder diffractometer or an Inel Multipurpose Diffractometer.
• Siemens D500 powder diffractometer the raw data was measured for 2q values from 2 to 50, with steps of 0.020 and step periods of two seconds.
• Inel Multipurpose Diffractometer samples were placed in an aluminum sample holder and raw data was collected for 30 minutes at all two theta values simultaneously.
• Tables 1A, 1B and 1C set out the significant parameters of the main peaks in terms of 2q values and intensities for the Form H (prepared by desolvation of the ethanol solvate obtained by digestion of low purity eplerenone), Form L (prepared by desolvation of the methyl ethyl ketone solvate obtained by recrystallization of high purity eplerenone), and methyl ethyl ketone solvate (prepared by room temperature slurry conversion of high purity eplerenone in methyl ethyl ketone) crystalline forms of eplerenone, respectively (X-ray radiation at a wavelength of 1.54056 Angstroms).
• Form H is isolated from a solvate prepared by digestion of crude eplerenone. This method results in a lower overall chemical purity (approximately 90%) of the Form H.
• the solvated forms of eplerenone are expected to show some shifting in the positioning of the diffraction peaks due to the increased mobility of the solvent molecules within the solvent channels in the crystal lattice.
• FIG. 1 -A, 1-B, and 1-C Graphical examples of the x-ray diffraction patterns for Form H, Form L, and the methyl ethyl ketone solvate crystalline forms of eplerenone are shown in Figs. 1 -A, 1-B, and 1-C, respectively.
• Form H shows distinguishing peaks at 7.0 ⁇ 0.2, 8.3 ⁇ 0.2, and 12.0 ⁇ 0.2 degrees two theta.
• Form L shows distinguishing peaks at 8.0 ⁇ 0.2, 12.4 ⁇ 0.2, 12.8 ⁇ 0.2, and 13.3 ⁇ 0.2 degrees two theta.
• the methyl ethyl ketone solvated crystalline form shows distinguishing peaks at 7.6 ⁇ 0.2, 7.8 ⁇ 0.2, and 13.6 ⁇ 0.2 degrees two theta.
• the temperatures of melting and/or decomposition of non-solvated eplerenone crystalline forms were determined using a TA Instruments 2920 differential scanning calorimeter. Each sample (1 -2 mg) was placed in either a sealed or unsealed aluminum pan and heated at 10°C/minute. Melting/decomposition ranges were defined from the extrapolated onset to the maximum of the melting/decomposition endotherm.
• Form H and Form L The melting of the non-solvated eplerenone crystals forms (Form H and Form L) was associated with chemical decomposition and loss of trapped solvent from the crystal lattice.
• the melting/decomposition temperature also was affected by the manipulation of the solid prior to analysis.
• non-milled Form L approximately D 90 particle size of about 180-450 microns
• non-milled Form L prepared by direct crystallization from an appropriate solvent or from desolvation of a solvate obtained from crystallization of high purity eplerenone in an appropriate solvent or mixture of solvents generally had a melting range of about 237-242°C.
• Milled Form L (approximate D 90 particle size of about 80-100 microns) (Form L prepared by crystallizing a solvate from a solution of high purity eplerenone in an appropriate solvent or mixture of solvents, desolvating the solvate to yield Form L, and milling the resulting Form L) generally had a lower and broader melting/decomposition range of about 223-234°C.
• Non-milled Form H (approximate D 90 particle size of about 180-450 microns) prepared by desolvation of a solvate obtained by digestion of low purity eplerenone generally had a higher melting/decomposition range of about 247-251 °C.
• Examples of the DSC thermograms of (a) non-milled Form L directly crystallized from methyl ethyl ketone, (b) non-milled Form L prepared by desolvation of a solvate obtained by crystallization of a high purity eplerenone from methyl ethyl ketone, (c) Form L prepared by milling a desolvated solvate obtained by crystallization of high purity eplerenone from methyl ethyl ketone, and (d) non-milled Form H prepared by desolvation of a solvate obtained by digestion of low purity eplerenone from methyl ethyl ketone are given in Figures 2-A, 2-B, 2-C and 2-D, respectively.
• thermograms of solvated forms of eplerenone were determined using a Perkin Elmer Pyris 1 differential scanning calorimeter. Each sample (1-10 mg) was placed in an unsealed aluminum pan and heated at 10°C/minute. One or more endothermal events at lower temperatures were associated with enthalpy changes that occurred as solvent was lost from the solvate crystal lattice. The highest temperature endotherm or endotherms were associated with the melting/decomposition of Form L or Form H eplerenone. 4. Infrared Absorption Spectroscopy
• Infrared absorption spectra of the non-solvated forms of eplerenone were obtained with a Nicolet DRIFT (diffuse reflectance infrared fourier transform) Magna System 550 spectrophotometer. A Spectra-Tech Collector system and a microsample cup were used. Samples (5%) were analyzed in potassium bromide and scanned from 400-4000 cm "1 . Infrared absorption spectra of eplerenone in dilute chloroform solution (3%) or in the solvated crystal forms were obtained with a Bio-rad FTS-45 spectrophotometer. Chloroform solution samples were analyzed using a solution cell of 0.2 mm path length with sodium chloride salt plates.
• Solvate FTIR spectra were collected using an IBM micro-MIR (multiple internal reflectance) accessory. Samples were scanned from 400-4000 cm "1 . Examples of the infrared absorption spectra of (a) Form H, (b) Form L, (c) the methyl ethyl ketone solvate, and (d) eplerenone in chloroform solution are shown in Figures 3-A, 3-B, 3-C and 3- D, respectively.
• Table 2 discloses illustrative absorption bands for eplerenone in the Form H, Form L, and methyl ethyl ketone solvate crystal forms. Illustrative absorption bands for eplerenone in chloroform solution are also disclosed for comparison. Differences between Form H and either Form L or the methyl ethyl ketone solvate were observed, for example, in the carbonyl region of the spectrum.
• Form H has an ester carbonyl stretch of approximately 1739 cm "1 while both Form L and the methyl ethyl ketone solvate have the corresponding stretch at approximately 1724 and 1722 cm " respectively. The ester carbonyl stretch occurs at approximately 1727 cm "1 in the eplerenone in chloroform solution.
• the change in stretching frequency of the ester carbonyl between Form H and Form L reflects the change in orientation of the ester group between the two crystal forms.
• the stretch of the ester of the conjugated ketone in the A-steroid ring shifts from approximately 1664-1667 cm “1 in either Form H or the methyl ethyl ketone solvate to approximately 1655 cm "1 in Form L.
• the corresponding carbonyl stretch occurs at approximately 1665 cm "1 in dilute solution.
• Form H has an absorption at approximately 1399 cm “1 which is not observed in Form L, the methyl ethyl ketone solvate, or the eplerenone in chloroform solution.
• the 1399 cm “1 stretch occurs in the region of CH 2 scissoring for the C2 and C21 methylene groups adjacent to carbonyl groups.
• 13 C NMR spectra were obtained at a field of 31.94 MHz. Examples of the 13 C NMR spectra of Form H and Form L eplerenone are shown in Figs.4 and 5, respectively.
• the Form H eplerenone analyzed to obtain the data reflected in Fig. 4 was not phase pure and included a small amount of Form L eplerenone.
• Form H is most clearly distinguished by the carbon resonances at around 64.8 ppm, 24.7 ppm and 19.2 ppm.
• Form L is most clearly distinguished by the carbon resonances at around 67.1 ppm and 16.0 ppm.
• thermogravimetry analysis of solvates was performed using a TA Instruments TGA 2950 thermogravimetric analyzer. Samples were placed in an unsealed aluminum pan under nitrogen purge. Starting temperature was 25°C with the temperature increased at a rate of about 10°C/minute. An example of the thermogravimetry analysis profile for the methyl ethyl ketone solvate is shown in Fig. 6-A. 7. Unit Cell Parameters
• Tables 3A, 3B and 3C below summarize the unit cell parameters determined for Form H, Form L, and several solvated crystalline forms.
• the unit cell of the solvate is composed of four eplerenone molecules.
• the stoichiometry of the eplerenone molecules and solvent molecules in the unit cell is also reported in Table 4 above for a number of solvates.
• the unit cell of Form H is composed of four eplerenone molecules.
• the unit cell of Form L is composed of two eplerenone molecules.
• the solvate unit cells are converted during desolvation into Form H and/or Form L unit cells when the eplerenone molecules undergo translation and rotation to fill the spaces left by the solvent molecules. Table 4 also reports the desolvation temperatures for a number of different solvates.
• Selected impurities in eplerenone can induce the formation of Form H during the desolvation of the solvate.
• the effect of the following two impurity molecules was evaluated: 7-methyl hydrogen 4 ⁇ ,5 ⁇ :9 ⁇ ,11 ⁇ -diepoxy-17-hydroxy-3-oxo-17 ⁇ -pregnane-7 ⁇ ,21-dicarboxylate, Y- lactone 3 (the "diepoxide”); and 7-methyl hydrogen 11 ⁇ ,12 ⁇ -epoxy-17- hydroxy-3-oxo-17 ⁇ -pregn-4-ene-7 ⁇ ,21-dicarboxylate, ⁇ -lactone 4 (the "11,12-epoxide").
• the diepoxide, 11 ,12-olefin and 9,11-olefin can be prepared as set forth, for example, in Examples 47C, 47B and 37H of Ng et al., W098/25948, respectively.
• a single crystal form was isolated for each impurity compound.
• Representative X-ray powder diffraction patterns for the crystal forms isolated for the diepoxide, 11 ,12-epoxide and 9,11-olefin are given in Figs. 7, 8,and 10, respectively.
• the X-ray powder diffraction pattern of each impurity molecule is similar to the X-ray powder diffraction pattern of Form H, suggesting that Form H and the three impurity compounds have similar single crystal structures.
• Single crystals of each impurity -compound also were isolated and subjected to X-ray structure determination to verify that these three compounds adopt single crystal structures similar to that of Form H.
• Single crystals of the diepoxide were isolated from methyl ethyl ketone.
• Single crystals of the 11 ,12-epoxide were isolated from isopropanol.
• Single crystals of the 9,11-olefin were isolated from n-butanol.
• Crystal structure data determined for the crystalline form of each impurity compound are given in Table 5. The resulting crystal system and cell parameters were substantially the same for the Form H, diepoxide, 11 ,12-epoxide, and 9,11- olefin crystalline forms.
• Eplerenone starting material used to prepare the novel crystalline forms of the present invention can be prepared using the methods set forth in Ng et al.: WO97/21720; and Ng et al.: WO98/25948, particularly scheme 1 set forth in WO97/21720 and W098/25948.
• the solvated crystalline forms of eplerenone can be prepared by crystallization of eplerenone from a suitable solvent or a mixture of suitable solvents.
• a suitable solvent or mixture of suitable solvents generally comprises an organic solvent or a mixture of organic solvents that solubilizes the eplerenone together with any impurities at an elevated temperature, but upon cooling, preferentially crystallizes the solvate.
• the solubility of eplerenone in such solvents or mixtures of solvents generally is about 5 to about 200 mg/mL at room temperature.
• the solvent or mixtures of solvents preferably are selected from those solvents previously used in the process to prepare the eplerenone starting material, particularly those solvents that would be pharmaceutically acceptable if contained in the final pharmaceutical composition comprising the eplerenone crystalline form.
• a solvent system comprising methylene chloride that yields a solvate comprising methylene chloride generally is not desirable.
• Each solvent used preferably is a pharmaceutically acceptable solvent, particularly a Class 2 or Class 3 solvent as defined in "Impurities: Guideline For Residual Solvents", International Conference On Harmonisation Of Technical Requirements For Registration Of Pharmaceuticals For Human Use (Recommended for Adoption at Step 4 of the ICH Process on July 17, 1997 by the ICH Steering Committee).
• the solvent or mixture of solvents is selected from the group consisting of methyl ethyl ketone, 1-propanol, 2-pentanone, acetic acid, acetone, butyl acetate, chloroform, ethanol, isobutanol, isobutyl acetate, methyl acetate, ethyl propionate, n-butanol, n-octanol, isopropanol, propyl acetate, propylene glycol, t-butanol, tetrahydrofuran, toluene, methanol and t-butyl acetate. Still more preferably, the solvent is selected from the group consisting of methyl ethyl ketone and ethanol.
• an amount of the eplerenone starting material is solubilized in a volume of the solvent and cooled until crystals form.
• the solvent temperature at which the eplerenone is added to the solvent generally will be selected based upon the solubility curve of the solvent or mixture of solvents. For most of the solvents described herein, for example, this solvent temperature typically is at least about 25°C, preferably from about 30°C to the boiling point of the solvent, and more preferably from about 25°C below the boiling point of the solvent to the boiling point of the solvent.
• hot solvent may be added to the eplerenone and the mixture can be cooled until crystals form.
• the solvent temperature at the time it is added to the eplerenone generally will be selected based upon the solubility curve of the solvent or mixture of solvents. For most of the solvents described herein, for example, the solvent temperature typically is at least 25°C, preferably from about 50°C to the boiling point of the solvent, and more preferably from about 15°C below the boiling point of the solvent to the boiling point of the solvent.
• the amount of the eplerenone starting material mixed with a given volume of solvent likewise will depend upon the solubility curve of the solvent or mixture of solvents. Typically, the amount of eplerenone added to the solvent will not completely solubilize in that volume of solvent at room temperature. For most of the solvents described herein, for example, the amount of eplerenone starting material mixed with a given volume of solvent usually is at least about 1.5 to about 4.0 times, preferably about 2.0 to about 3.5 times, and more preferably about 2.5 times, the amount of eplerenone that will solubilize in that volume of solvent at room temperature.
• the solution After the eplerenone starting material has completely solubilized in the solvent, the solution typically is cooled slowly to crystallize the solvated crystalline form of eplerenone.
• the solution is cooled at a rate slower than about 20°C/minute, preferably at a rate of about 10°C/minute or slower, more preferably at a rate of about 5°C/minute or slower, and still more preferably at a rate of about 1°C/minute or slower.
• the endpoint temperature at which the solvated crystalline form is harvested will depend upon the solubility curve of the solvent or mixture of solvents. For most of the solvents described herein, for example, the endpoint temperature typically is less than about 25°C, preferably less than about 5°C, and more preferably less than about -5°C. Decreasing the endpoint temperature generally favors the formation of the solvated crystalline form.
• solvate may be prepared by other techniques. Examples of such techniques include, but are not limited to, (i) dissolving the eplerenone starting material in one solvent and adding a co-solvent to aid in the crystallization of the solvate crystalline form, (ii) vapor diffusion growth of the solvate, (iii) isolation of the solvate by evaporation, such as rotary evaporation, and (iv) slurry converstion.
• the crystals of the solvated crystalline form prepared as described above can be separated from the solvent by any suitable conventional means such as by filtration or centrifugation. Increased agitation of the solvent system during crystallization generally results in smaller crystal particle sizes.
• Form L eplerenone can be prepared directly from the solvated crystalline form by desolvation.
• Desolvation can be accomplished by any suitable desolvation means such as, but not limited to, heating the solvate, reducing the ambient pressure surrounding the solvate, or combinations thereof. If the solvate is heated to remove the solvent, such as in an oven, the temperature of the solvate during this process typically does not exceed the enantiotropic transition temperature for Form H and Form L. This temperature preferably does not exceed about 150°C.
• the desolvation pressure and time of desolvation are not narrowly critical.
• the desolvation pressure preferably is about one atmosphere or less.
• the temperature at which the desolvation can be carried out and/or the time of desolvation likewise is reduced.
• drying under vacuum will permit the use of lower drying temperatures.
• the time of desolvation need only be sufficient to allow for the desolvation, and thus the formation of Form L, to reach completion.
• the eplerenone starting material typically is a high purity eplerenone, preferably substantially pure eplerenone.
• the eplerenone starting material used to prepare Form L eplerenone generally is at least 90% pure, preferably at least 95% pure, and more preferably at least 99% pure. As discussed in greater detail elsewhere in this application, certain impurities in the eplerenone starting material can adversely affect the yield and Form L content of the product obtained from the process.
• the crystallized eplerenone product prepared in this manner from a high purity eplerenone starting material generally comprises at least 10% Form L, preferably at least 50% Form L, more preferably at least 75% Form L, still more preferably at least 90% Form L, still more preferably at least about 95% Form L, and still more preferably substantially phase pure Form 3.
• a product comprising Form H can be prepared in substantially the same manner as set forth above for the preparation of Form L by (i) using a low purity eplerenone starting material instead of a high purity eplerenone starting material, (ii) seeding the solvent system with phase pure Form H crystals, or (iii) a combination of (i) and (ii).
• the selected impurity generally is a Form H growth promoter or Form L growth inhibitor. It may be contained in the eplerenone starting material, contained in the solvent or mixture of solvents before the eplerenone starting material is added, and/or added to the solvent or mixture of solvents after the eplerenone starting material is added. Bonafede et al.: J Amer Chem Soc 1995;117:30 discusses the use of growth promoters and growth inhibitors in polymorph systems and is incorporated by reference herein.
• the impurity generally comprises a compound having a single crystal structure substantially identical to the single crystal structure of Form H.
• the impurity preferably is a compound having an X-ray powder diffraction pattern substantially identical to the X-ray powder diffraction pattern of Form H, and more preferably is selected from the group consisting of the diepoxide, the 11 ,12-epoxide, the 9,11-olefin and combinations thereof.
• the amount of impurity needed to prepare Form H crystals typically can depend, in part, upon the solvent or mixture of solvents and the solubility of the impurity relative to eplerenone.
• the weight ratio of diepoxide to low purity eplerenone starting material typically is at least about 1:100, preferably at least about 3:100, more preferably between about 3:100 and about 1:5, and still more preferably between about 3:100 and about 1 :10.
• the 11 ,12-epoxide has a higher solubility in methyl ethyl ketone than the diepoxide and generally requires a larger amount of the 11 ,12-epoxide generally is necessary to prepare Form H crystals.
• the weight ratio of the diepoxide to the low purity eplerenone starting material typically is at least about 1 :5, more preferably at least about 3:25, and still more preferably between about 3:25 and about 1 :5.
• the weight ratio of each impurity to the eplerenone starting material may be lower than the corresponding ratio when only that impurity is used in the preparation of the Form H crystals.
• a mixture of Form H and Form L is generally obtained when a solvate comprising the selected impurity is desolvated.
• the weight fraction of Form H in the product resulting from the initial desolvation of the solvate typically is less than about 50%. Further treatment of this product by crystallization or digestion, as discussed below, generally will increase the weight fraction of Form L in the product.
• Form H crystals also can be prepared by seeding the solvent system with phase pure Form H crystals (or a Form H growth promoter and/or Form L growth inhibitor as previously discussed above) prior to crystallization of the eplerenone.
• the eplerenone starting material can be either a low purity eplerenone or a high purity eplerenone.
• the weight fraction of Form H in the product typically is at least about 70% and may be as great as about 100%.
• the weight ratio of Form H seed crystals added to the solvent system to the eplerenone starting material added to the solvent system generally is at least about 0.75:100, preferably between about 0.75:100 to about 1:20, and more preferably between about 1:100 to about 1:50.
• the Form H seed crystals can be prepared by any of the methods discussed in this application for the preparation of Form H crystals, particularly the preparation of Form H crystals by digestion as discussed below.
• the Form H seed crystals may be added at one time, in multiple additions or substantially continually over a period of time.
• the addition of the Form H seed crystals generally is completed before the eplerenone begins to crystallize from solution, i.e., the seeding is completed before the cloud point (the lower end of the metastable zone) is reached.
• Seeding typically is performed when the solution temperature ranges from about 0.5°C above the cloud point to about 10°C above the cloud point, preferably within about 2°C to about 3°C above the cloud point. As the temperature above the cloud point at which the seeds are added increases, the amount of seeding needed for crystallization of Form H crystals generally increases.
• the seeding preferably occurs not only above the cloud point, but within the metastable zone.
• Both the cloud point and the metastable zone are dependent on the eplerenone solubility and concentration in the solvent or mixture of solvents.
• the high end of the metastable zone generally is between about 70°C to about 73°C and the lower end of the metastable zone (i.e., the cloud point) is between about 57°C and 63°C.
• the metastable zone is even narrower because the solution is supersaturated.
• the cloud point of the solution occurs at about 75°C to about 76°C. Because the boiling point of methyl ethyl ketone is about 80°C under ambient conditions, seeding for this solution typically occurs between about 76.5°C and the boiling point.
• Example C-7 An illustrative non-limiting example of seeding with Form H is set forth below in Example C-7.
• the crystallized eplerenone product obtained using a Form H growth promoter or Form L growth inhibitor, and/or Form H seeding generally comprises at least 2% Form H, preferably at least 5% Form H, more preferably at least 7% Form H, and still more preferably at least about 10% Form H.
• the remaining crystallized eplerenone product generally is Form L.
• Form H Prepared By Grinding Eplerenone
• a small amount of Form H can be prepared by suitable grinding eplerenone. Concentrations of Form H in ground eplerenone as high as about 3% have been observed.
• a product having a greater Form L content can be prepared from low purity eplerenone in substantially the same manner as set forth above for the preparation of Form H by seeding the solvent system with phase pure Form L crystals, or by using a Form L growth promoter and/or Form H growth inhibitor.
• the seeding protocol and the weight ratio of the amount of Form L seed crystals added to the solvent system to the amount of the eplerenone starting material added to the solvent system generally are similar to those ratios previously discussed above for the preparation of Form H eplerenone by seeding with phase pure Form H crystals.
• the crystallized eplerenone product prepared in this manner generally comprises at least 10% Form L, preferably at least 50% Form L, more preferably at least 75% Form L, more preferably at least 90% Form L, still more preferably at least about 95% Form L, and still more preferably substantially phase pure Form L.
• the seeding protocols described in this section and in the prior section relating to the preparation of Form H eplerenone also may allow for improved control of the particle size of the crystallized eplerenone.
• Form L eplerenone also can be prepared by the direct crystallization of eplerenone from a suitable solvent or mixture of solvents without the formation of an intermediate solvate and the accompanying need for desolvation.
• the solvent has a molecular size that is incompatible with the available channel space in the solvate crystal lattice
• the eplerenone and any impurities are soluble in the solvent at elevated temperatures, and (iii) upon cooling, results in the crystallization of the non- solvated Form L eplerenone.
• the solubility of eplerenone in the solvent or mixture of solvents generally is about 5 to about 200 mg/mL at room temperature.
• the solvent or mixture of solvents preferably comprises one or more solvents selected from the group consisting of methanol, ethyl acetate, isopropyl acetate, acetonitrile, nitrobenzene, water and ethyl benzene.
• an amount of the eplerenone starting material is solubilized in a volume of the solvent and cooled until crystals form.
• the solvent temperature at which the eplerenone is added to the solvent generally will be selected based upon the solubility curve of the solvent or mixture of solvents. For most of the solvents described herein, for example, this solvent temperature typically is at least about 25°C, preferably from about 30°C to the boiling point of the solvent, and more preferably from about 25°C below the boiling point of the solvent to the boiling point of the solvent.
• hot solvent may be added to the eplerenone and the mixture can be cooled until crystals form.
• the solvent temperature at the time it is added to the eplerenone generally will be selected based upon the solubility curve of the solvent or mixture of solvents. For most of the solvents described herein, for example, the solvent temperature typically is at least 25°C, preferably from about 50°C to the boiling point of the solvent, and more preferably from about 15°C below the boiling point of the solvent to the boiling point of the solvent.
• the amount of the eplerenone starting material mixed with a given volume of solvent likewise will depend upon the solubility curve of the solvent or mixture of solvents. Typically, the amount of eplerenone added to the solvent will not completely solubilize in that volume of solvent at room temperature. For most of the solvents described herein, for example, the amount of eplerenone starting material mixed with a given volume of solvent usually is at least about 1.5 to about 4.0 times, preferably about 2.0 to about 3.5 times, and more preferably about 2.5 times, the amount of eplerenone that will solubilize in that volume of solvent at room temperature.
• the eplerenone starting material generally is a high purity eplerenone.
• the eplerenone starting material preferably is at least 65% pure, more preferably at least 90% pure, still more preferably at least 98% pure, and still more preferably at least 99% pure.
• the solution After the eplerenone starting material has completely solubilized in the solvent, the solution typically is cooled slowly to crystallize the solvated crystalline form of eplerenone.
• the solution is cooled at a rate slower than about 1.0°C/minute, preferably at a rate of about 0.2°C/minute or slower, and more preferably at a rate between about 5°C/minute and about O.rC/minute.
• the endpoint temperature at which the Form L crystals are harvested will depend upon the solubility curve of the solvent or mixture of solvents. For most of the solvents described herein, for example, the endpoint temperature typically is less than about 25°C, preferably less than about 5°C, and more preferably less than about -5°C.
• Form L crystals may be prepared using other techniques. Examples of such techniques include, but are not limited to, (i) dissolving the eplerenone starting material in one solvent and adding a co- solvent to aid in the crystallization of Form L eplerenone, (ii) vapor diffusion growth of Form L eplerenone, (iii) isolation of Form L eplerenone by evaporation, such as rotary evaporation, and (iv) slurry conversion.
• the crystals of the solvated crystalline form prepared as described above can be separated from the solvent by any suitable conventional means such as by filtration or centrifugation.
• Form L eplerenone also can be prepared by digesting (as described below) a slurry of high purity eplerenone in methyl ethyl ketone and filtering the digested eplerenone at the boiling point of the slurry.
• Form H Directly From Solution It is hypothesized that if the crystallization is performed above the enantiotropic transition temperature (T t ) for Form H and Form L, particularly if Form H growth promoters or Form L growth inhibitors are present or the solvent is seeded with phase pure Form H crystals, Form H should crystallize directly from solution since Form H is more stable at these higher temperatures.
• the solvent system used preferably comprises a high boiling solvent such as nitrobenzene.
• Suitable Form H growth promoters would include, but would not be limited to, the diepoxide and the 11 ,12-olefin.
• the solvated crystalline forms, Form H and Form L of eplerenone also can be prepared by digestion of an eplerenone starting material in a suitable solvent or mixture of solvents.
• a slurry of eplerenone is heated at the boiling point of the solvent or mixture of solvents.
• an amount of eplerenone starting material is combined with a volume of solvent or mixture of solvents, heated to reflux, and the distillate is removed while an additional amount of the solvent is added simultaneously with the removal of the distillate.
• the distillate can be condensed and recycled without the addition of more solvent during the digestion process.
• the slurry is cooled and solvated crystals form.
• the solvated crystals can be separated from the solvent by any suitable conventional means such as by filtration or centrifugation. Desolvation of the solvate as previously described yields either Form H or Form L eplerenone depending upon the presence or absence of the selected impurities in the solvated crystals.
• a suitable solvent or mixture of solvents generally comprises one or more of the solvents previously disclosed herein.
• the solvent may be selected, for example, from the group consisting of methyl ethyl ketone and ethanol.
• the amount of eplerenone starting material added to the solvent used in the digestion process generally is sufficient to maintain a slurry (i.e., the eplerenone in the solvent or mixture of solvents is not completely solubilized) at the boiling point of the solvent or mixture of solvents.
• Illustrative values include, but are not limited to, about one gram of eplerenone per four mL methyl ethyl ketone and about one gram of eplerenone per eight mL ethanol.
• the solution generally is cooled slowly once solvent turnover is complete to crystallize the solvated crystalline form of eplerenone.
• the solution is cooled at a rate slower than about 20°C/minute, preferably about 10°C/minute or slower, more preferably about 5°C/minute or slower, and still more preferably about 1 °C/minute or slower.
• the endpoint temperature at which the solvated crystalline form is harvested will depend upon the solubility curve of the solvent or mixture of solvents. For most of the solvents described herein, for example, the endpoint temperature typically is less than about 25°C, preferably less than about 5°C, and more preferably less than about -5°C.
• a high purity eplerenone starting material typically is digested.
• the high purity eplerenone starting material preferably is at least 98% pure, more preferably at least 99% pure, and still more preferably at least 99.5% pure.
• the digested eplerenone product prepared in this manner generally comprises at least 10% Form L, preferably at least 50% Form L, more preferably at least 75% Form L, more preferably at least 90% Form L, still more preferably at least about 95% Form L, and still more preferably substantially phase pure Form L.
• a low purity eplerenone starting material typically is digested.
• the low purity eplerenone starting material generally contains only as much Form H growth promoter and/or Form L growth inhibitor as is needed to yield Form H.
• the low purity eplerenone starting material is at least 65% pure, more preferably at least 75% pure, and still more preferably at least 80% pure.
• the digested eplerenone product prepared in this manner generally comprises at least 10% Form H, preferably at least 50% Form H, more preferably at least 75% Form H, more preferably at least 90% Form H, still more preferably at least about 95% Form H, and still more preferably substantially phase pure Form H.
• Amorphous eplerenone can be prepared in small quantities by suitable comminution of solid eplerenone, such as by crushing, grinding and/or micronizing.
• Phase pure amorphous eplerenone can be prepared, for example, by lyophilizing a solution of eplerenone, particularly an aqueous solution of eplerenone.
• the amount of aldosterone antagonist that is administered and the dosage regimen for the methods of this invention depend on a variety of factors, including the age, weight, sex and medical condition of the subject, the severity of the pathogenic effect, the route and frequency of administration, and the particular aldosterone antagonist employed, and thus may vary widely.
• the amount of aldosterone antagonist that is administered to a human subject typically will range from about 0.1 to 2000 mg, preferably from about 0.5 to 500 mg, still more preferably from about 0.75 to 250 mg, and still more preferably from about 1 to 100 mg.
• a daily dose of aldosterone antagonist that produces no substantial diuretic and/or anti-hypertensive effect in a subject is specifically embraced by the present method.
• the daily dose can be administered in one to four doses per day.
• Dosing of the aldosterone antagonist can be determined and adjusted based on measurement of blood pressure or appropriate surrogate markers (such as natriuretic peptides, endothelins, and other surrogate markers discussed below). Blood pressure and/or surrogate marker levels after administration of the aldosterone antagonist can be compared against the corresponding baseline levels prior to administration of the aldosterone antagonist to determine efficacy of the present method and titrated as needed.
• the primary surrogate markers useful in the method are surrogate markers for renal and cardiovascular disease.
• the degree of pathogenicity of aldosterone in individuals with an increased level of intracellular sodium will depend upon the presence of the then-existing pathology. Accordingly, individuals are first evaluated for hypertension, microvascular dysfunction, and pathologies associated with microvascular dysfunction. Such pathologies can include renal and cardiac pathology, neuropathy, and retinopathy.
• the aldosterone antagonist prophylatically, particularly where the subject is susceptible to one or more pathogenic effects mediated by aldosterone in the presence of elevated sodium levels, prior to a diagnosis of said pathogenic effects and to continue administration of the aldosterone antagonist during the period of time the subject is susceptible to the pathogenic effects.
• Individuals with no remarkable clinical presentation but that are nonetheless susceptible to pathologic effects therefore can be placed upon a prophylatic dose of epoxy-steroidal compound.
• Such prophylactic doses of the aldosterone antagonist may, but need not, be lower than the doses used to treat the specific pathogenic effect of interest.
• Hypertension Dosing For the treatment of hypertension in human subjects having salt sensitivity and/or high sodium intake, individuals are first identified as normotensive, borderline hypertensive, or hypertensive based on blood pressure determinations (seated cuff mercury sphygmomanometer).
• individuals may be deemed normotensive when systolic blood pressure and diastolic blood pressure are less than 125 mm Hg and less than 80 mm Hg, respectively; borderline hypertensive when systolic blood pressure and diastolic blood pressure are in the range of about 125 to 140 mm Hg and 80 to 90 mm Hg, respectively; and hypertensive when systolic blood pressure and diastolic blood pressure are greater than 140 mm Hg and 90 mm Hg, respectively.
• the dose of epoxy-steroidal compound administered is increased. Based on post-administration blood pressure measurements, the dose of the epoxy-steroidal compound administered is titrated. After an initial evaluation of the individual's response to treatment, the dose may be increased or decreased accordingly to achieve the desired blood pressure lowering effect.
• appropriate dosing can be determined by monitoring systolic blood pressure. As shown in Figure 10, increasing doses of eplerenone result in decreased systolic blood pressure. Accordingly, subjects can be treated with doses of one or more epoxy-steroidal compounds according to the present invention by increasing doses of such compounds in a step-wise manner until a minimal levels of systolic blood pressure decrease are achieved while, at the same time, also maintaining serum levels of potassium within the normal range.
• appropriate dosing can also be determined by monitoring diastolic blood pressure. As shown in Figure 11, increasing doses of eplerenone result in decreased diastolic blood pressure. Accordingly, subjects can be treated with doses of one or more epoxy-steroidal compounds according to the present invention by increasing doses of such compounds in a step-wise manner until a minimal level of diastolic blood pressure change are achieved while, at the same time, also maintaining serum levels of potassium within the normal range.
• natriuretic peptides are a group of structurally similar but genetically distinct peptides that have diverse actions in cardiovascular, renal, and endocrine homeostasis.
• Atrial natriuretic peptide (“ANP”) and brain natriuretic peptide (“BNP”) are of myocardial cell origin and C-type natriuretic peptide (“CNP”) is of endothelial origin.
• ANP and BNP bind to the natriuretic peptide-A receptor ("NPR-A"), which, via 3',5'-cyclic guanosine monophosphate (cGMP), mediates natriuresis, vasodilation, renin inhibition, antimitogenesis, and lusitropic properties. Elevated natriuretic peptide levels in the blood, particularly blood BNP levels, generally are observed in subjects under conditions of blood volume expansion and after vascular injury such as acute myocardial infarction and remain elevated for an extended period of time after the infarction. (Uusimaa et al.: Int. J. Cardiol 1999; 69: 5-14).
• a decrease in natriuretic peptide level relative to the baseline level measured prior to administration of the aldosterone antagonist indicates a decrease in the pathologic effect of aldosterone and therefore provides a correlation with inhibition of the pathologic effect.
• Blood levels of the desired natriuretic peptide level therefore can be compared against the corresponding baseline level prior to administration of the aldosterone antagonist to determine efficacy of the present method in treating the pathologic effect.
• dosing of the aldosterone antagonist can be adjusted to reduce the cardiovascular pathologic effect.
• cardiac pathologies can also be identified, and the appropriate dosing determined, based on circulating and urinary cGMP Levels. An increased plasma level of cGMP parallels a fall in mean arterial pressure. Increased urinary excretion of cGMP is correlated with the natriuresis.
• Cardiac pathologies also can be identified by a reduced ejection fraction or the presence of myocardial infarction or heart failure or left ventricular hypertrophy.
• Left ventricular hypertrophy can be identified by echo-cardiogram or magnetic resonance imaging and used to monitor the progress of the treatment and appropriateness of the dosing.
• the methods of the present invention can be used to reduce natriuretic peptide levels, particularly BNP levels, thereby also treating related cardiovascular pathologies.
• Dosing to treat pathologies of renal function can be determined and adjusted based on measurement of proteinuria, microalbuminuria, decreased glomerular filtration rate (GFR), or decreased creatinine clearance.
• Proteinuria is identified by the presence of greater than 0.3 g of urinary protein in a 24 hour urine collection.
• Microalbuminuria is identified by an increase in immunoassayable urinary albumin. Based upon such measurements, dosing of the aldosterone antagonist can be adjusted to reduce the renal pathologic effect.
• Neuropathy especially peripheral neuropathy, can be identified by and dosing adjustments based on, neurologic exam of sensory deficit or sensory motor ability.
• Retinopathy can be identified by, and dosing adjustments based on, opthamologic exam.
• subjects treated according to the present invention are initially dosed with an amount of one or more epoxy-steroidal compounds during an initial evaluation period (i.e. the period during which a subject receives one or more epoxy-steroidal compounds at an initial daily dose).
• the initial evaluation period may be about one to four weeks, preferably about one to two weeks, in duration.
• blood and urine samples are obtained for routine evaluation (i.e., commonly known as blood and urine chemistries). If there are no contraindications to a dose increase (e.g. hyperkalemia), the daily dose of one or more epoxy- steroidal compounds will be increased, if necessary.
• Appropriate dosing can also be determined by monitoring plasma renin activity. As shown in Figure 12, increasing doses of eplerenone result in increased levels of plasma renin activity. Accordingly, subjects can be treated with doses of one or more epoxy-steroidal compounds according to the present invention by increasing doses of such compounds in a step- wise manner until the desired level of plasma renin activity is achieved while, at the same time, maintaining serum levels of potassium within the normal range.
• Appropriate dosing can also be determined by monitoring serum aldosterone levels. As shown in Figure 12, increasing doses of eplerenone result in increased levels of serum aldosterone. Accordingly, subjects can be treated with doses of one or more epoxy-steroidal compounds according to the present invention by increasing doses of such compounds in a step- wise manner until the desired level of serum aldosterone is achieved while, at the same time, also maintaining serum levels of potassium within the normal range.
• Administration may be accomplished by any appropriate route such as oral administration, or administration by intravenous, intramuscular or subcutaneous injections.
• the pharmaceutical composition may be in the form of, for example, a tablet, capsule, suspension or liquid.
• the pharmaceutical composition is preferably made in the form of a dosage unit containing a particular amount of the active ingredient. Examples of such dosage units are tablets or capsules.
• a suitable daily dose for a mammal may vary widely depending on the condition of the patient and other factors.
• the active ingredients may be administered by injection as a composition wherein, for example, saline, dextrose or water may be used as a suitable carrier.
• the formulation may be in the form of a bolus, or in the form of aqueous or non-aqueous isotonic sterile injection solutions or suspensions.
• solution and suspensions may be prepared from sterile powders or granules having one or more pharmaceutically- acceptable carriers or diluents, or a binder such as gelatin or hydroxypropyl-methyl cellulose, together with one or more of a lubricant, preservative, surface-active or dispersing agent.
• pharmaceutically acceptable is used adjectivally herein to mean that the modified noun is appropriate for use in a pharmaceutical product.
• Pharmaceutically acceptable cations include metallic ions and organic ions. More preferred metallic ions include, but are not limited to appropriate alkali metal salts, alkaline earth metal salts and other physiologically acceptable metal ions. Exemplary ions include aluminum, calcium, lithium, magnesium, potassium, sodium and zinc in their usual valences.
• Preferred organic ions include protonated tertiary amines and quaternary ammonium cations, including in part, trimethylamine, diethylamine, N,N'-dibenzy1ethylenediamine, chloroprocaine, choline, diethanolamine, ethylenediamine, meglumine (N-methylglucamine) and procaine.
• Exemplary pharmaceutically acceptable acids include without limitation hydrochloric acid, hydrobromic acid, phosphoric acid, sulfuric acid, methanesulfonic acid, acetic acid, formic acid, tartaric acid, maleic acid, malic acid, citric acid, isocitric acid, succinic acid, lactic acid, gluconic acid, glucuronic acid, pyruvic acid, oxalacetic acid, fumaric acid, propionic acid, aspartic acid, glutamic acid, benzoic acid, and the like.
• the active components of this invention are ordinarily combined with one or more adjuvants appropriate to the indicated route of administration.
• the components may be admixed with lactose, sucrose, starch powder, cellulose esters of alkanoic acids, cellulose alkyl esters, talc, stearic acid, magnesium stearate, magnesium oxide, sodium and calcium salts of phosphoric and sulfuric acids, gelatin, acacia gum, sodium alginate, polyvinylpyrrolidone, and/or polyvinyl alcohol, and then tableted or encapsulated for convenient administration.
• Such capsules or tablets may contain a controlled-release formulation as may be provided in a dispersion of active compound in hydroxypropylmethyl cellulose.
• Formulations for parenteral administration may be in the form of aqueous or non-aqueous isotonic sterile injection solutions or suspensions. These solutions and suspensions may be prepared from sterile powders or granules having one or more of the carriers or diluents mentioned for use in the formulations for oral administration.
• the components may be dissolved in water, polyethylene glycol, propylene glycol, ethanol, corn oil, cottonseed oil, peanut oil, sesame oil, benzyl alcohol, sodium chloride, and/or various buffers.
• Other adjuvants and modes of administration are well and widely known in the pharmaceutical art.
• the methods of the present invention may further comprise the administration of other active ingredients or therapies in combination with the administration of the epoxy-steroidal aldosterone antagonist.
• the aldosterone antagonists employed in the present methods can be administered to the subject in combination with other active drugs used in the treatment of hypertension and cardiovascular and renal conditions and disorders.
• the active drugs administered with the aldosterone antagonist can include, for example, the drugs selected from the group consisting of renin inhibitors, angiotensin II antagonists, ACE inhibitors, diuretics having no substantial aldosterone antagonist effect, and retinoic acid.
• combination therapy when used with respect to drug combinations, is intended to embrace the administration of each agent in a sequential manner in a regimen that will provide beneficial effects of the drug combination, and is intended as well to embrace co-administration of these agents in a substantially simultaneous manner, such as in a single capsule or injection having a fixed ratio of these active agents or in multiple, separate capsules or injections for each agent.
• angiotensin II antagonist includes, for examples, those angiotensin II antagonists described in WO96/40257.
• angiotensin converting enzyme inhibitor includes an agent or compound, or a combination of two or more agents or compounds, having the ability to block, partially or completely, the enzymatic conversion of the decapeptide form of angiotensin ("angiotensin I”) to the vasoconstrictive octapeptide form of angiotensin (“angiotensin II").
• Blocking the formation of angiotensin II can affect the regulation of fluid and electrolyte balance, blood pressure and blood volume by removing the primary actions of angiotensin II. Included in these primary actions of angiotensin II are stimulation of the synthesis and secretion of aldosterone receptor by the adrenal cortex and raising blood pressure by direct constriction of the smooth muscle of the arterioles.
• ACE inhibitors that can be used in the combination therapy include, but are not limited to, the following compounds: AB-103, ancovenin, benazepriiat, BRL-36378, BW-A575C, CGS-13928C, CL- 242817, CV-5975, Equaten, EU-4865, EU-4867, EU-5476, foroxymithine, FPL 66564, FR-900456, Hoe-065, 15B2, indolapril, ketomethylureas, KRI- 1177, KRI-1230, L-681176, libenzapril, MCD, MDL-27088, MDL-27467A, moveltipril, MS-41 , nicotianamine, pentopril, phenacein, pivopril, rentiapril, RG-5975, RG-6134, RG-6207, RGH-0399, ROO-911 , RS-10085-197, RS- 2039, RS
• a group of ACE inhibitors of particular interest consists of alacepril, benazepril, captopril, cilazapril, delapril, enalapril, enalaprilat, fosinopril, fosinoprilat, imidapril, lisinopril, perindopril, quinapril, ramipril, saralasin acetate, temocapril, trandolapril, ceranapril, moexipril, quinaprilat and spirapril.
• ACE inhibitors are commercially available.
• a highly preferred ACE inhibitor, captopril is sold by E.R. Squibb & Sons, Inc., Princeton, N.J., now part of Bristol-Myers-Squibb, under the trademark "CAPOTEN", in tablet dosage form at doses of 12.5 mg, 50 mg and 100 mg per tablet.
• Enalapril or Enalapril Maleate, and Lisinopril are two more highly preferred ACE inhibitors sold by Merck & Co, West Point, Pa.
• Enalapril is sold under the trademark "VASOTEC” in tablet dosage form at doses of 2.5 mg, 5 mg, 10 mg and 20 mg per tablet.
• Lisinopril is sold under the trademark "PRINIVIL” in tablet dosage form at doses of 5 mg, 10 mg, 20 mg and 40 mg per tablet.
• the diuretic may be selected from several known classes, such as thiazides and related sulfonamides, potassium-sparing diuretics, loop diuretics and organic mercurial diuretics.
• thiazides are bendroflumethiazide, benzthiazide, chlorothiazide, cyclothiazide, hydrochlorothiazide, hydroflumethiazide, methylclothiazide, polythiazide and trichlormethiazide.
• Nonlimiting examples of sulfonamides related to thiazides are chlorthalidone, quinethazone and metolazone.
• potassium-sparing diuretics are triameterene and amiloride.
• Nonlimiting examples of loop diuretics i.e., diuretics acting in the ascending limb of the loop of Henle of the kidney, are furosemide and ethynacrylic acid.
• Nonlimiting examples of organic mercurial diuretics are mercaptomerin sodium, merethoxylline, procaine and mersalyl with theophylline.
• the combination therapy comprises administering an ACE inhibitor, an epoxy-steroidal compound that is an aldosterone receptor antagonist and a loop diuretic having no substantial aldosterone antagonistic activity to a human subject having salt sensitivity and/or a high sodium intake, wherein the ACE inhibitor, the epoxy-steroidal compound and the loop diuretic are administered at doses that in combination result in one or more of the following: (1 ) a statistically significant reduction in the death rate as compared to said combination therapy without the epoxy-steroidal compound; (2) a statistically significant reduction in the number of non-fatal hospitalizations as compared to said combination therapy without the epoxy-steroidal compound; (3) a statistically significant reduction in the death rate or the number of non-fatal hospitalizations as compared to said combination therapy without the epoxy-steroidal compound; (4) a statistically significant reduction in the rate of deaths resulting from sudden death in subjects afflicted with or susceptible to elevated heart rate variability as compared to said combination therapy without the epoxy-steroidal compound; (5) a statistically significant
• the subject receiving the combination therapy (1) is susceptible to sudden death; (2) is classified in New York Heart Association class III or class IV prior to combination therapy; (3) has a left ventricular ejection fraction greater than about 26%; and/or (4) is susceptible to or suffering from clinically significant cough due to elevated pulmonary arterial fibrosis or low levels of pulmonary blood pressure.
• Such combination therapy would be useful, for example, to reduce the death rate or the number of non-fatal hospitalizations or to prevent or retard, in subjects having salt sensitivity and/or a high sodium intake, the development of heart failure that typically arises from essential hypertension or from heart conditions following myocardial infarct.
• a diuretic agent having no substantial aldosterone antagonistic activity may also be used in conjunction with an ACE inhibitor and the epoxy-steroidal compound.
• the combination therapy may comprise administering a therapeutically-effective amount of an ACE inhibitor, a therapeutically- effective amount of an epoxy-steroidal compound, a therapeutically-effective amount of a loop diuretic having no substantial aldosterone antagonistic activity and a therapeutically-effective amount of digoxin to a human subject having salt sensitivity and/or a high sodium intake.
• the eplerenone starting material used in each working example primarily comprises or comprised the Form L polymorph and contains or contained less than about 10% of the Form H polymorph. For most examples, the eplerenone material used contains or contained no detectible amount of the Form H polymorph (i.e., less than about 3% Form H polymorph).
• Example A-1 Use of Eplerenone To Block Myocardial Infarction And Renal Arteriopathy Independently of Blood Pressure
• Eplerenone was supplied by G.D. Searle Pharmaceuticals (St. Louis, MO), dissolved in 0.5% methylcellulose and administered twice a day by gavage.
• Dexamethasone was dissolved in sesame oil and administered as a single subcutaneous dose (12 ⁇ g/kg/day) every day. This dose of dexamethasone has been reported to maintain normal weight gain, glomerular filtration rate, and fasting plasma glucose and insulin levels in adrenalectomized rats.
• Angiotensin II and aldosterone were administered via Alzet osmotic minipumps (Models 2001 and 2002, respectively, Alza Co, Palo Alto, CA) which were implanted subcutaneously at the nape of the neck in animals anesthetized with isofluorane.
• concentrations of Angiotensin II and aldosterone used to fill the pumps were calculated based on the mean pump rate provided by the manufacturer, the body weight of the animals on the day before implantation of the pumps, and the dose planned.
• Angiotensin II human, 99% peptide purity
• Dexamethasone, aldosterone and L-NAME were purchased from Sigma Chemical Co. (St. Louis, MO). The concentration of L-NAME in the drinking water was adjusted daily to provide a dose of 40 mg/kg/day based on the daily fluid intake and the body weight of the rats.
• stolic blood pressure was measured in awake animals by tail-cuff plethysmography using a Natsume KN-210 manometer and tachometer (Peninsula Laboratories Inc, Belmont, CA). Rats were warmed at 37°C for 10 minutes and allowed to rest quietly in a Lucite chamber before measurement of blood pressure.
• Urinary protein concentration was determined in urine collected on the last day of the experiment using the sulfosalicylic acid turbidity method. Urinary protein excretion was calculated as the product of the urinary concentration times the urine output/24 hours.
• Plasma aldosterone concentration was determined using a standard radioimmunoassay-kit from Diagnostic Products Co. (Los Angeles, CA). Plasma renin activity (“PRA”) was determined by radioimmunoassay detection of generated angiotensin I (DiaSorin Inc., Stillwater, MN).
• Hearts were stained with collagen specific dye Sirius red for determination of fibrosis as reported elsewhere. (Young M et al. Am. J. Physiol 1995 269:E657-E662). Interstitial collagen was determined using an automated image analyzer. The hearts were also stained with hematoxylin and eosin for light microscopic analysis. Two or three slices of different sections of the heart containing both right and left ventricle were analyzed from each animal. A scale from 0 to 4 was used to score the level of myocardial injury with 0 representing no damage.
• a score of 1 represented the presence of myocytes demonstrating early necrotic changes such as nuclear pyknosis or karyolysis, non-contracting marginal wavy fibers and eosinophilic staining of the cytoplasm, associated with the presence of scattered neutrophilic infiltrates.
• a score of 2 was given when one clear area of necrosis (loss of myocardial cells with heavy neutrophilic infiltrates) was observed. When two or more separate areas of necrosis were found (implicating the presence of two different myocardial infarctions in the same heart), but the areas were localized and compromised less than 50% of the ventricular wall, the hearts received a score of 3.
• a score of 4 was assigned to hearts that demonstrated extensive areas of necrosis compromising more than 50% of either the left or the right ventricle.
• Coronal sections of kidney were cut at 3 to 4 mm, and at least three to four of these were prepared as paraffin embedded blocks. Histologic sections (2-3 ⁇ m) were stained with periodic acid-Schiff reagent and examined by light microscopy at 10x and 40x by a pathologist who had no knowledge of the different experimental protocols.
• Glomerular damage, when present, was characterized as the presence of either segmental or global sclerosis with ischemic or thrombotic changes. Renal arterial and arteriolar damage was categorized as the presence of fibrinoid necrosis of the vascular wall.
• renal arterial and arteriolar profiles presenting damage were counted and the number of injured vessels per section was divided by the number of glomeruli in the same section in order to normalize for the amount of tissue examined. Renal vascular lesions were expressed as the number of injured vessels per 100 glomeruli.
• Two additional groups of NaCI-drinking rats were adrenalectomized three days before initiation of L-NAME/Angiotensin II treatment.
• Plasma renin activity and aldosterone levels Plasma renin activity and aldosterone levels.
• FIG. A-3A Myocardial necrosis was characterized by loss of cross striation of myofibers, homogenization of cytoplasm, loss of cellular membranes, pyknosis and eventually karyolysis of nuclei, and influx of inflammatory cells including polymorphonuclear cells and monocytes. Fibrinoid necrosis was present in small coronary arteries and arterioles (not shown).
• administration of aldosterone to adrenalectomized rats completely restored the effects of L- NAME/Angiotensin ll/NaCl treatment on proteinuria. Histopathologic evaluation of the kidneys also demonstrated significant differences among the groups, PO.001 ( Figures A-6 and A-7).
• Adrenalectomy significantly reduced renal arteriopathy induced by L-NAME/Angiotensin H/NaCf treatment to levels that were not significantly different from NaCI-drinking controls ( Figure A-7). As was observed in the heart, in the kidneys when aldosterone was infused into adrenalectomized, L-NAME/Angiotensin ll/NaCI-treated rats, damage was significantly increased.
• epoxy-steroidal compounds prevent or reduce the development of the acute cardiovascular lesions in L-NAME/Angiotensin ll/NaCI-treated rats.
• L-NAME/Angiotensin ll/NaCl treatment is highly effective in inducing hypertension and end organ damage at the level of the heart and the kidney.
• Eplerenone is effective in preventing such an effect.
• eplerenone did not appreciably alter systolic blood pressure, the therapeutic effect is independent of its effect on sodium retention, volume expansion and hypertension.
• the data suggest that the effect of eplerenone is not to prevent fibrosis but instead to reduce medial fibrinoid necrosis in small arteries and arterioles and subsequent tissue necrosis. Fibrosis may be a reparative process.
• the antimineralocorticoid pharmacological activity was determined in saline-loaded adrenalectomized rats treated with aldosterone. Test compound was given by gavage 30 minutes before the aldosterone injection. Urinary sodium, potassium and water excretion were measured. The results are expressed as the ratio of excreted urinary sodium to potassium (Na/K) ⁇ SEM (Table A-2A).
• Example A-3 Comparison of Subcutaneous vs. Oral Administration of Eplerenone to Rats
• Subcutaneous injection provided better efficacy than oral administration (Tables XVIII and XIX).
• Example A-4 Hypertension Model: Volume Expanded Hypertensive Rats
• Uninephrectomized rats were given 1% NaCI drinking water and infused s.c. with aldosterone (0.5 g/kg/hr) via an Alza osmotic pump, Model 2002.
• Test compound was administered by s.c. injection twice a day.
• Blood pressure and heart rate were evaluated continuously by telemetry via an implanted transmitter connected to a pressure transducer cannulated to the abdominal aorta.
• Eplerenone reduced blood pressure in this rodent model at both doses tested, when measured by continuous monitoring using telemetry (Table A-4A, data averaged for 24 hours after three weeks). Eplerenone did not produce a significant change in the heart rate.
• Example A-5 Effect of Eplerenone in Stroke Prone Spontaneously Hypertensive Rat (SHR-SP), a Genetic Model of Hypertension and Stroke
• Results The results are shown in Table A-5A. Both groups of animals had similar and elevated systolic blood pressure at the initiation of the study. The systolic blood pressure continued to increase during the three week duration of the experiment in animals treated with only vehicle. In contrast, systolic blood pressure of animals treated with eplerenone remained at pretreatment levels. These data demonstrate that eplerenone is an effective antihypertensive agent in this model of genetic hypertension and stroke.
• Example A-6 Aldosterone receptor antagonist to treat myocardial injury.
• Sprague Dawley rats 250 g were uninephrectomized and provided with 1 % NaCI-solution as the only source of water. The rats were then implanted with Alzet mini pump that subcutaneously delivered either aldosterone (0.75ug/hr) or vehicle. These two treatment groups were further divided into those that received normal rat chow or or chow containing eplerenone (100 mg/k d). Blood pressure was measured by radio telemetry units implanted in abdominal aorta. Rats were sacrificed for examination of the hearts.
• myocardial damage in uninephrectomized rats requires high salt intake and aldosterone; Sodium alone does not cause myocardial damage and aldosterone blockade by the administration of eplerenone prevents the aldosterone plus high sodium myocardial damage.
• Example A-7 Use of eplerenone to prevent stroke and cerebrovascular damage.
• FIG. A-13 histopathologic analysis of the brains revealed the presence of liquofactive neorosis in all vehicle-treated SHRSP, associated with fibrinoid necrotic lesions in cerebral arteries and arterioles with focal hemorrhages. These lesions were markedly reduced by administration of eplerenone.
• a score of 3.5 ⁇ 3 was observed in vehicle-treated rats vs a score of 0.5 ⁇ 2 in the animals receiving eplerenone (PO.001).
• eplerenone provides a vascular protective action in the brain in saline-drinking SHRSP, through mechanisms not associated with decreases in arterial blood pressure.
• Example A-8 Vascular protective effect eplerenone in stroke-prone spontaneously hypertensive rats.
• exogenous angiotensin II was chronically infused.
• endogenous mineralocorticoids mediate the progression of renal injury in saline-drinking SHRSP independent of angiotensin II and its effect on blood pressure.
• Protocol 1 Effect of Eplerenone on Renal Pathologic Changes
• Eplerenone was suspended at 50 mg/ml in a solution of 0.5% methylcellulose (Sigma Chemical Co., St. Louis, MO) and was administered twice daily by gavage to provide a total daily dose of 100 mg/kg. Since eplerenone, unlike spironolactone, does not produce active metabolites, a higher dose was used. Vehicle-control littermates received 2 ml/kg/d of the 0.5% methylcellulose solution. Animals were housed individually in metabolic cages so that measurements of 24-h urine output and protein excretion could be made. Animals were examined each day for neurologic signs of stroke. Systolic arterial pressure and heart rate were measured each week in awake rats. The experiment was terminated after 5 weeks of treatment when the animals were 13.1 weeks of age.
• Trunk blood was collected into chilled EDTA tubes following rapid decapitation of the animals between 10:00 am and 12:00 pm. Blood was stored at -20°C for later measurement of plasma aldosterone levels. The kidneys were rapidly removed, weighed, and then preserved in fixative for later histologic examination.
• Protocol 2 Effect of Eplerenone on Angiotensin ll-lnduced Renal
• SHRSP SHRSP were placed on Stroke-Prone Rodent Diet (#39- 288, Zeigler Bros Inc., Gardners, PA) and 1% NaCI drinking solution ad libitum starting at 8.3 weeks of age.
• captopril Sigma Chemical Co., St. Louis, MO was added to the drinking solution of all animals to provide a dose of 50 mg/kg/d.
• Kidneys were preserved in 10% phosphate-buffered formalin. Coronal sections (2-3 ⁇ m) were stained with hematoxylin and eosin and examined by light microscopy in a blinded fashion as previously described (Stier CT et al. J Pharmacol Exp Ther (1992) 260:1410-1415). Glomerular damage was categorized as ischemic or thrombotic. Ischemic lesions were defined as retraction of glomerular capillary tufts with or without appreciable mesangiolysis.
• Glomerular thrombotic lesions were defined as any one of a combination of the following: segmental to global fibrinoid necrosis, focal thrombosis of glomerular capillaries, swelling and proliferation of intracapillary (endothelial and mesangial) and/or extracapillary cells (crescents), and expansion of reticulated mesangial matrix with or without significant hypercellularity.
• Vascular damage was assessed by counting the total number of arterial and arteriolar profiles that showed thrombotic and/or proliferative arteriopathy in the same mid-coronal section.
• Vascular thrombotic lesions were defined as any one or a combination of the following: mural fibrinoid necrosis, extravasation and fragmentation of red blood cells, and luminal and/or mural thrombosis.
• Proliferative arteriopathy was characterized by proliferation of markedly swollen myointimal cells with swollen round to ovoid vesicular nuclei surrounded by mucinous extracellular matrix ("onion skinning") often resulting in nodular thickening.
• Vascular damage was expressed as the number of arteries and arterioles with lesions per 100 glomeruli. The presence of casts and tubular (ischemic) retraction and simplification was assessed semiquantitatively.
• Figure A-15 shows the results for preterminal systolic blood pressure and urinary protein excretion in SHRSP chronically treated with eplerenone (100 mg/kg/d) or vehicle.
• This bar graphs showing preterminal (A) systolic arterial blood pressure (SBP) and (B) urinary protein excretion (UPE) in stroke-prone spontaneously hypertensive rats receiving chronic treatment with either eplerenone (100 mg/kg/d) or vehicle from 8.4 to 13.1 weeks of age. Animals were given 1 % NaCI to drink and Stroke-Prone Rodent Diet ad libitum starting at 8.1 weeks of age. *** P ⁇ .001 compared with vehicle- treated littermates. Values are mean ⁇ SEM.
• Eplerenone prevented the development of proteinuria (85 ⁇ 11 v 16 ⁇ 2 mg/d, P ⁇ .001) but not severe hypertension (227 ⁇ 4 v 219 ⁇ 6 mm Hg) as compared with the littermate controls.
• Systolic blood pressure and heart rate also did not differ between the eplerenone- and vehicle-treated groups during the study.
• Table A-8A summarizes the results from the histologic analysis for renal lesions. Kidneys from vehicle-treated, saline-drinking SHRSP exhibited ischemic or thrombotic damage in 35 ⁇ 5% of glomeruli and showed extensive thrombotic and proliferative damage in small arteries and arterioles as illustrated in Figure A-16A.
• This Figure shows representative photomicrographs of hematoxylin and eosin-stained mid-coronal kidney sections from saline-drinking stroke-prone spontaneously hypertensive rats after 5 weeks of eplerenone or vehicle treatment starting at 8 weeks of age (original magnification, x 130).
• Renal cortex from animals treated with vehicle demonstrate typical findings of malignant nephrosclerosis such as ischemic retraction (small arrow), thrombonecrosis of capillary tufts (large arrow), and arteriolar fibrinoid necrosis with fragmented and extravasated erythrocytes, and concentric proliferative arteriopathy (arrowheads).
• malignant nephrosclerosis such as ischemic retraction (small arrow), thrombonecrosis of capillary tufts (large arrow), and arteriolar fibrinoid necrosis with fragmented and extravasated erythrocytes, and concentric proliferative arteriopathy (arrowheads).
• Protein casts were present in 10 ⁇ 5% of tubules in vehicle-treated SHRSP and 0.11 ⁇ 0.04% of tubules in eplerenone-treated SHRSP ⁇ P ⁇ .001 ).
• 48 ⁇ 7% of the tubules in vehicle-treated SHRSP displayed ischemic retraction and simplification compared with only 0.5 ⁇ 0.2% of the tubules in eplerenone-treated SHRSP (P ⁇ .001).
• the plasma concentration of aldosterone did not differ significantly between the groups and averaged 305 + 68 pg/ml in vehicle-treated SHRSP and 315 ⁇ 35 pg/ml in eplerenone-treated SHRSP.
• Six of the nine vehicle-treated SHRSP showed definite signs of stroke whereas none of eplerenone-treated SHRSP showed evidence of stroke (P ⁇ .01 , Fisher's Exact Test).
• Body weight was not affected by eplerenone through the first 3 weeks of treatment (data not shown). Thereafter, body weight declined in the vehicle-treated group but was maintained or increased in eplerenone- treated SHRSP. Absolute kidney weight at autopsy averaged 2.42 ⁇ 0.11 g in vehicle-treated SHRSP and 2.58 ⁇ 0.06 g in eplerenone-treated SHRSP and was not affected by the chronic administration of eplerenone. Because terminal body weight was lower in vehicle-treated SHRSP than in eplerenone-treated SHRSP (220 ⁇ 7 g v 279 ⁇ 7 g, P ⁇ .001 ), the kidney- weight to body-weight ratio was significantly higher in that group.
• Figure A-17A shows the systolic blood pressure of captopril-treated, saline-drinking SHRSP that received an infusion of either vehicle (saline) or angiotensin II with or without concomitant oral administration of eplerenone.
• Figure A-17 contains a line graph showing (A) systolic arterial blood pressure and (B) urinary protein excretion in saline-drinking stroke-prone spontaneously hypertensive rats during treatment with captopril plus vehicle (CAP), captopril plus Angiotensin II (CAP + angiotensin II), or captopril plus angiotensin II plus eplerenone (CAP + angiotensin II + EPL).
• CAP captopril plus vehicle
• CAP + angiotensin II captopril plus Angiotensin II
• CAP + angiotensin II + EPL captopril plus angiotensin II + EPL
• Captopril treatment 50 mg/kg/d was started at 8.3 weeks of age.
• angiotensin II did not further increase blood pressure over captopril plus vehicle. Additionally, blood pressure measurements were similar in captopril-treated SHRSP receiving angiotensin II plus eplerenone. Urinary protein excretion remained at low levels in all three groups through 9.5 weeks of age, which was 2 days after initiation of angiotensin II infusion
• Figure A-18 is a bar graph showing plasma aldosterone levels in stroke-prone spontaneously hypertensive rats that were started on captopril treatment (50 mg/kg/d) and 1 % NaCI/Stroke-Prone Rodent Diet starting at 8.3 weeks of age.
• Alzet osmotic minipumps containing vehicle or angiotensin II (25 ng/min) were implanted subcutaneously at 9.3 weeks of age and concomitant treatment with or without eplerenone was started. Animals were sacrificed 2 weeks later (* P ⁇ .05 compared with animals treated with captopril alone). These values were significantly elevated relative to the group receiving captopril alone (107 ⁇ 26 pg/ml; P ⁇ .05) and were similar to those observed in Protocol 1.
• Figure A-19 shows representative photomicrographs of the histologic changes in kidneys from saline-drinking, captopril-treated SHRSP (hematoxylin and eosin-stained renal cortex from saline-drinking stroke-prone spontaneously hypertensive rats (SHRSP) (original magnification, x 130).
• SHRSP hematoxylin and eosin-stained renal cortex from saline-drinking stroke-prone spontaneously hypertensive rats
• Body weight showed no difference among the groups over the course of the study and was 258 ⁇ 6 g in the captopril plus vehicle-treated group, 223 ⁇ 7 g in the captopril plus angiotensin II plus vehicle-treated group, and 234 ⁇ 5 g in the captopril plus angiotensin II plus eplerenone- treated group at the end of the experiment.
• Absolute kidney weight at autopsy was 2.56 ⁇ 0.06 g in the captopril plus vehicle-treated group, 2.12 ⁇ 0.06 g in captopril plus angiotensin II plus vehicle-treated group, and 2.00 ⁇ 0.03 g in captopril plus angiotensin II plus eplerenone-treated SHRSP.
• Stroke-prone spontaneously hypertensive rats were chronically treated with either eplerenone (100 mg/kg/d, by gavage, divided between two doses) or vehicle (0.5% methylcellulose, 2 ml/kg/d, by gavage) starting at 8.4 weeks of age. All animals were maintained on a 1% NaCI drinking solution and Stroke-Prone Rodent Diet starting at 8.1 weeks of age and the experiment was terminated 5 weeks later when rats were 13.1 weeks old. *** P ⁇ .001 compared with vehicle. Values are mean ⁇ SEM.
• Saline-drinking stroke-prone spontaneously hypertensive rats were treated with captopril (50 mg/kg/d) starting at 8.3 weeks of age.
• captopril 50 mg/kg/d
• osmotic minipumps containing angiotensin II 25 ng/min were implanted subcutaneously in all of the animals and treatment with eplerenone (100 mg/kg/d) or vehicle was started. All animals were maintained on a 1% NaCI drinking solution and Stroke-Prone Rodent Diet and were sacrificed 2 weeks later.
• Saline-drinking SHRSP treated with eplerenone showed markedly diminished proteinuria and exhibited almost complete prevention of glomerular and renal vascular lesions. Patchy, possibly ischemic, contraction (retraction) and simplification of tubules observed in the vehicle- treated animals also was largely prevented by eplerenone treatment. Consonant with the ability of eplerenone to protect against renal lesion development in saline-drinking SHRSP is the close parallelism between malignant nephrosclerosis that develops in these rats and those with mineralocorticoid-salt hypertension, a low-renin model of severe hypertension.
• angiotensin II in both of these groups should be similar, as endogenous angiotensin II formation is suppressed and exogenous angiotensin II infusion is constant.
• Infusion of a low dose of angiotensin II 25 ng/min was effective in inducing proteinuria and the development of thrombotic and proliferative arteriopathy associated with ischemic as well as thrombotic lesions of glomeruli despite concomitant captopril treatment.
• low doses of angiotensin II ie, 25 ng/min did not elevate blood pressure in SHRSP.
• Angiotensin II has an established role as a pathogenic factor in hypertensive vascular disease. Angiotensin II acts not only as a potent vasoconstrictor, but also as a facilitator of adrenergic responses. The beneficial effects of ACE inhibitors have typically been attributed to reductions in the vascular actions of angiotensin II; however, these agents also can suppress plasma aldosterone levels. SHRSP receiving angiotensin II with or without eplerenone maintained plasma aldosterone levels that were significantly elevated relative to captopril-treated SHRSP and were similar to those observed in vehicle-treated SHRSP from Protocol 1.
• angiotensin II infusion was associated with renal lesion development, an effect that was largely attenuated by MR antagonism with eplerenone.
• Our studies were performed in SHRSP, which typically show an impaired inhibition of the RAAS when fed a high-salt diet. This phenomenon could account for the differences observed in our experiment.
• the present studies reveal a critical contribution of endogenous mineralocorticoids to the progression of renal injury in SHRSP induced by the infusion of Angiotensin II at a low dose.
• chronic administration of eplerenone is efficacious in reducing proteinuria, renal lesions of malignant nephrosclerosis, and stroke signs in saline-drinking SHRSP.
• chronic exogenous administration of a low dose of Angiotensin II reversed the known ability of captopril treatment to reduce plasma aldosterone levels and to prevent the development of renal vascular injury in saline-drinking SHRSP.
• angiotensin II to induce renal lesions was largely attenuated by selective aldosterone blockade with eplerenone.
• Example A-9 Mechanism and Specificity of Action: Mineralocorticoid Receptor Binding In Vivo.
• the pharmacokinetics and metabolism of eplerenone were investigated in the male and female rat after IV and oral administration of [ 1 C]eplerenone as an aqueous solution at a dose of 15 mg/kg.
• Plasma, urine and fecal samples were analyzed for total radioactivity.
• concentrations of eplerenone and the open lactone-ring form of eplerenone in unacidified pooled plasma were analyzed by an LC/MS/MS procedure.
• concentrations of "total eplerenone" the lactone ring closed form plus the open form) in acidified pooled plasma were analyzed by a separate LC/MS/MS procedure.
• the elimination half-lives of eplerenone after IV administration were 0.803 and 1.14 hours in the male and female rat, respectively.
• the corresponding values for total eplerenone were 1.01 and 1.14 hour, respectively.
• the plasma clearance (CL) values of eplerenone were 1.22 and 1.20 L/kg/hr in the male and female rat, respectively.
• the corresponding values for total eplerenone were 0.983 and 0.694 L/kg/hr, respectively.
• Eplerenone was rapidly absorbed achieving C ma ⁇ of 1.71 ⁇ g/mL at 0.5 hours in male rats and 3.54 ⁇ g/mL at one hour in the female rats.
• the systemic availabilities of eplerenone were 25.6% and 66.1% in the male and female rat, respectively.
• the C max of total eplerenone were 3.20 and 6.35 ⁇ g/mL in the male and female rat, respectively.
• the systemic availabilities of total eplerenone were 29.4% and 74.2% in the male and female rat, respectively
• a rat tissue distribution study was conducted after oral administration of [ 14 C]eplerenone to the pigmented male rat (Long-Evans Hooded) at a dose of 20 mg/kg as an aqueous solution.
• the rate of tissue uptake of the radioactive dose was rapid, with most of the tissues reaching C ma ⁇ at 0.5 hours.
• the mean C max in blood and plasma were 4.90 and 8.64 ⁇ g equivalents/g, respectively.
• the tissues with the highest mean C ma ⁇ values, excluding the gastrointestinal tract tissues, were liver, pancreas, and kidneys, with concentrations of 41.1 , 12.1 , and 10.1 ⁇ equivalents/g, respectively.
• the tissues with the lowest C max values were eye (minus lens), brain and spinal cord with concentrations of 0.045, 0.516 and 0.630 ⁇ g equivalents/g, respectively.
• concentrations of radioactivity were below the limit of detection in all tissues except cecum, kidneys, large intestine and liver, which all showed values of less than 0.024 ⁇ g equivalents/g.
• Example A-10 Selective Aldosterone Receptor Blockade Improves Endothelial Function in Diet Induced Atherosclerosis:
• eplerenone in improving nitric oxide bio-availability was tested to determine whether eplerenone improves or prevents endothelial dysfunction that occurs with atherosclerosis.
• Methods New Zealand white rabbits were randomized to four treatment groups. 32 Rabbits were placed on normal (NC) or 1% cholesterol chow (HC) for a duration of 8 weeks. After the first 2 weeks 16 rabbits were randomized to receive either saline (S) or eplerenone (E, 50 mg/kg twice daily) by gavage feeding for an additional 6 weeks.
• NC normal
• HC cholesterol chow
• Eplerenone improves endothelial function and reduces O 2 ' generation in diet induced atherosclerosis. These data provide evidence that Eplerenone will provide an additional therapeutic strategy for conditions where endothelial function is compromised.
• the Ex-Japan trials included (i) a single dose tolerability trial, and (ii) a multiple dose tolerability trial, and (iii) a food effect study.
• the single dose Ex-Japan trial investigated the administration of 10, 50, 100, 300 or 1000 mg doses of eplerenone.
• a single oral dose of eplerenone was given to 40 healthy male subjects.
• the Ex-Japan multiple dose tolerability trial investigated the multiple dose effects of eplerenone given for 11 days at doses of 100, 300 and 1000 mg. Eplerenone was given to 24 healthy males administered in a dose escalating fashion.
• the ex-Japan food effect study was conducted in 12 healthy males who received single oral 100 mg doses of eplerenone on two separate occasions in a crossover fashion, either following an overnight fast or immediately after consuming a high fat (75 g) meal.
• the Japanese single dose tolerability trial investigated the administration of single oral eplerenone doses of 50, 100, 200, 400 and 600 mg in 32 subjects. Six subjects who received the 100 mg dose also participated in the food effect treatment arm of the single dose tolerability trial. These six subjects received a single 100 mg oral dose of eplerenone on two separate occasions in a crossover fashion; either following an overnight fast or immediately after consuming a fat meal.
• the multiple dose tolerability trial (JE3-99-06-401) was conducted in 6 healthy male subjects who received 7 once-daily doses of eplerenone 400mg.
• Figures A-20 through A-24 and A-25 through A-29 display graphically derived single dose pharmacokinetic parameters versus dose for eplerenone and the inactive open lactone ring form of eplerenone, respectively.
• Tables A-11 A and A-11 B present the least squares means of the single dose pharmacokinetic parameters of eplerenone and its inactive open lactone ring in the Ex-Japan studies and Japan studies. No statistically significant differences were noted between the Japan and ex- Japan population for any of the derived parameters evaluated.
• Table A-11 C contains the geometric least squares means for the fed and fasting regimens, the ratios of means and the corresponding 95% confidence intervals (Cl) for the ratios of the means for the Japan and Ex- Japan food effect trials.
• An analysis of variance (ANOVA) model with effects for sequence, subject nested within sequence, period and regimen was used to analyze C ma ⁇ and AUC parameters, and consequently to obtain the geometric least squares means, the ratios of the means and the 95% Cl for the ratio of the means.
• Tables A-11 D and A-11 E present the arithmetic mean of the dose normalized pharmacokinetic parameters for the Ex-Japan 100, 300 and 1000 mg eplerenone doses and the Japan 400 mg eplerenone dose trials. No formal statistical analyses were performed and the actual derived data is presented for comparison purposes only.
• This study was a single-blind, randomized, placebo-controlled, rising oral dose, sequential panel study in which 40 healthy Japanese male subjects were exposed to one of five panels of eplerenone doses (50, 100, 200, 400 and 600 mg). Each panel consisted of six subjects who were given eplerenone and two subjects who were given placebo. The effect of food was also evaluated in the same study in six subjects in a crossover design by administering a single dose of 100 mg eplerenone in the fasted and fed states. Serial blood and urine samples were collected over a 48- hour period to evaluate the pharmacokinetics of eplerenone.
• Example A-12 Multiple Dose Japanese Pharmacokinetic Study
• a multiple-dose, safety and pharmacokinetic study among Japanese subjects was conducted in Japan. This was a single-blind, randomized, placebo-controlled study. A total of eight Japanese male subjects participated in this study (six of them received a single daily dose of 400 mg of eplerenone and two of them received placebo for seven consecutive days). Serial blood and urine samples were collected throughout the study for measurement of pharmacokinetic, renal, and hormonal parameters after a single dose on Day 1 and after seven days of dosing.
• the subjects were maintained on a controlled salt diet (50 mEq sodium and 80 mEq potassium per day) from five days prior to the first dose of study drug until the end of the dosing period. Creatinine clearance rate and sodium excretion rate were determined at baseline and for each 24- hour period during study drug administration.
• the eplerenone bioavailability in moderately hepatic-impaired subjects was compared with that in healthy subjects mainly based on ratio of geometric means and 95% confidence intervals for the ratio of means for those log-normal pharmacokinetic response variables.
• the ratio of geometric means and 95% confidence intervals for the ratio of means were derived according to the following steps: using LSMEANS option of SAS GLM procedure to obtain the least differences and their corresponding standard error estimate obtained from the ANCOVA to construct 95% confidence intervals for mean difference; anti-log transforming the mean differences and the endpoints of the confidence intervals for the mean differences to obtain ratios of geometric means and the 95% confidence intervals for ratio of means.
• Trough plasma concentration (C m j n ) data were summarized for eplerenone on Days 4-8 for the two hepatic groups separately. Repeated measures analyses were performed on C m in data for eplerenone on Days 6- 8 to assess whether steady-state for eplerenone had been achieved by the fourth day of eplerenone 400 mg QD multiple dosing.
• subjects were primarily Caucasian (> 82%). Subjects ranged in age from 32 to 64 years, with the mean age in each group being approximately 46-51 years. The majority of the subjects in each group were male (> 65%).
• hepatic impairment was determined to be primarily alcoholic cirrhosis (56%), followed by infectious cirrhosis (17%), chronic active hepatitis (6%), and other (17%).
• Subjects with moderate hepatic impairment had been diagnosed for a mean of 6.6 years.
• Smoking was reported for 28% (5/18) of the subjects with moderate impairment compared to 35% (6/17) of the matched normal subjects.
• Eplerenone plasma concentrations were consistently greater among subjects with moderate hepatic impairment than among normal subjects after three hours following single dosing and at all time points following multiple dosing (Figure A-30)
• Subjects with moderate hepatic impairment experienced statistically significant increases in AUC values compared to matched normal subjects following both single (AUCo-oo, 43578.3 vs. 29114.1 ng/mL hr) and multiple (AUCo- 24 , 43765,9 vs. 30066.4 ng/mL hr) dosing.
• mean eplerenone AUC values were 41-50% higher following single dosing and 46% higher following multiple dosing compared to matched normal subjects.
• mean peak eplerenone plasma concentrations (C max ) and the time to reach eplerenoneC ma ⁇ (T max ) were not statistically significant different between the subjects groups.
• Eplerenone administration the exposures of eplerenone in plasma (as represented by AUC) were statistically significantly greater among subjects with moderate hepatic impairment than matched normal subjects (41-50% greater for Eplerenone. Steady-state plasma concentrations of eplerenone were reached by the fourth day following multiple 400 mg QD dosing of eplerenone. Although the exposure of eplerenone among subjects with moderate impairment was greater than that among normal subjects, the study medication appeared to be equally well tolerated in the two subject groups.
• Example A-14 Clinical Efficacy of Eplerenone in Treating Hypertension A multicenter, randomized, double-blind, parallel group study was conducted in patients with hypertension.
• the study was designed to compare the effects on blood pressure (BP), tolerability and safety of a range of doses of eplerenone (EPL) to placebo (PL).
• Spironolactone (SPL) was administered as an active control.
• the study consisted of a two-week pretreatment period for completion of screening procedures and discontinuation of any current antihypertensive medication(s). The screening period was followed by a four-week single-blind placebo lead-in treatment period. Randomization was followed by an eight-week double- blind active or placebo treatment period.
• the primary efficacy measure was the change from baseline in cuff diastolic blood pressure measured at trough as compared to placebo. Secondary efficacy measures included changes in cuff assessed trough systolic blood pressure and changes in average 24-hour diastolic and systolic blood pressure assessed by ambulatory blood pressure monitoring. Safety was assessed by conducting routine clinical lab tests, physical exams, ECGs, and monitoring for adverse events.
• the adjusted mean change in blood pressure (mm Hg) from baseline to final visit is described in Table A-14A.
• Table A-14A Blood Pressure Changes During Double-Blind Treatment with Eplerenone, Spironolactone, and Placebo
• Subgroup analyses of the primary and secondary efficacy measures can be performed with respect to subgroups based on, for example, baseline recordings of such factors as race (black, non-black, Japanese, etc.), sex, age, plasma renin levels, aldosterone/renin activities ratio, urinary sodium to potassium ratio, presence of diabetes, history of hypertension, history of heart failure, history of renal dysfunction, and the like.
• Subgroups based on continuous measures such as age can be dichotomized at the median value.
• Example A-15 Comparison Study of the Efficacy and Safety of Eplerenone and Enalapril Alone and in Combination With Each Other in Patients With Left Ventricular Hypertrophy and Essential Hypertension.
• a clinical study is conducted to evaluate the effect of enalapril and eplerenone, given alone and in combination with each other, following nine months of treatment on change in blood pressure (BP) and on change in left ventricular mass (LVM) as measured by magnetic resonance imaging (MRI) in patients with left ventricular hypertrophy (LVH) and with essential hypertension.
• the study is a multicenter, randomized, double-blind, placebo run-in, parallel group trial involving a minimum of 150 completed patients with LVH and essential hypertension and consisting of a one- to two-week pretreatment screening period followed by a two-week single- blind placebo run-in period and a nine-month double-blind treatment period.
• the dose of study medication will be force-titrated for all patients at Week 2 to (1 ) eplerenone 100 mg plus placebo, (2) enalapril 20 mg plus placebo, or (3) eplerenone 100 mg plus enalapril 10 mg.
• the dose of study medication will be force-titrated for all patients to (1) eplerenone 200 mg plus placebo, (1) enalapril 40 mg plus placebo, or (3) eplerenone 200 mg plus enalapril 10 mg).
• Table A-15A illustrates forth the above-described dosing scheme.
• HCTZ hydrochlorothiazide
• a patient If a patient is taking double-blind treatment alone and experiences symptomatic hypotension at any time during the trial, the patient will be withdrawn. Those patients taking open-label medications will have the open-label medications down-titrated in the reverse sequence as they were added until hypotension is resolved. If after all open-label medications are discontinued symptomatic hypotension is still present, the patient will be withdrawn from the trial. At any time during the study, if serum potassium level is elevated (>5.5 mEq/L) on repeat measurement (with BUN and creatinine levels drawn as well, sample split and sent to local and central laboratories, treatment decision based on local value) at two consecutive visits 1-3 days apart, the patient will be withdrawn.
• a neurohormone profile (plasma renin [total and active], serum aldosterone, and plasma cortisol) and special studies (PIIINP, PAI, microalbuminuria, and tPA) will be done at Weeks 0, 12, and at Months 6 and 9.
• a blood sample for genotyping will be collected at Week 0.
• An MRI to assess changes in LV mass, a blood sample for storage retention, a blood sample for thyroid stimulating hormone (TSH), and a 24-hour urine collection for albumin, potassium, sodium, and creatinine will be done at Week 0 and at Month 9.
• a 24-hour urine collection for urinary aldosterone will be done at Weeks 0, 12 and at Months 6 and 9.
• an MRI and blood sample for TSH will be done for those patients who have received double-blind treatment for at least three months.
• pharmacoeconomic data will be collected on all patients.
• efficacy is the change from baseline in LVM, as assessed by MRI, in the eplerenone group versus the enalapril group. Additionally, efficacy will be evaluated with respect to the patient's degree of salt sensitivity by fertile (wherein tertiles are empirically determined by the increment of blood pressure response to salt challenge).
• the primary objective of the study is to compare the effect of enalapril versus eplerenone on change in left ventricular mass (LVM) in patients with LVH and with essential hypertension.
• the secondary objectives of the study are the following: (1 ) to compare the change from baseline in LVM among the three treatment groups; (2) to compare the antihypertensive effect among the three treatment groups as measured by seated trough cuff DBP and SBP; (3) to compare the effect of the three treatment groups on aortic compliance and ventricular filling parameters as measured by MRI; (4) to compare the effect of the three treatment groups on plasma markers of fibrosis by measuring the aminoterminal propeptide of Type III procollagen (PIIINP), on renal glomerular function by measuring microalbuminuria, and on fibrinolytic balance by measuring plasminogen activator inhibitor (PAI) and tissue plasminogen activator (tPA); and (5) to compare the long-term safety and tolerability of the three treatment groups.
• PIIINP propeptide of Type
• Subgroup analyses of the primary and secondary efficacy measures can be performed with respect to other subgroups based on, for example, baseline recordings of such factors as sex, age, plasma renin levels, aldosterone/renin activities ratio, urinary sodium to potassium ratio, presence of diabetes, history of hypertension, history of heart failure, history of renal dysfunction, and the like. Subgroups based on continuous measures such as age can be dichotomized at the median value.
• Example A-16 Comparison Study of Eplerenone and Losartan in Patients With Low Renin Hypertension
• a clinical study is conducted to compare the antihypertensive effects of eplerenone and losartan in patients with low renin hypertension.
• the study is a multicenter, double-blind, randomized, placebo run-in, parallel group trial involving a minimum of 150 completed patients. Each patient will be tested for salt sensitivity by salt challenge-unidirectional testing.
• the trial will also consist of a one- to three-week pretreatment screening period followed by a two- to three-week single-blind placebo run-in period and a 16-week double-blind treatment period.
• BP blood pressure
• HCTZ hydrochlorothiazide
• Heart rate, BP, serum potassium levels, and adverse events will be assessed at every visit (Weeks 0, 2, 4, 6, 8, 10, 12, 14, and 16).
• Week 0 a blood sample for genotyping and storage retention, and 24-hour urine samples for assessment of aldosterone, potassium, sodium, creatinine, and creatinine clearance will be collected; an aliquot of the Week 0 24-hour urine collection will be retained for storage.
• Plasma renin will be determined at screening; serum aldosterone, plasma renin, and plasma cortisol will be determined at Weeks 0, 8, and 16. Additional laboratory assessments for clinical safety (hematology, blood chemistry, and urinalysis) will be done at Weeks 0, 4, 8, 12, and 16.
• a 12-lead electrocardiogram will be done at Weeks 0 and 16. Physical examinations will be completed at screening and at Week 16.
• the primary measure of efficacy will be the mean change from baseline in trough cuff seDBP between eplerenone and losartan at Weeks 8 and 16. Additionally, efficacy will be evaluated with respect to the patient's degree of salt sensitivity by fertile (wherein tertiles are empirically determined by the increment of blood pressure response to salt challenge).
• Other secondary measures can be used to evaluate the association between the change from baseline in seDBP and pre-treatment aldosterone/renin ratios and 24-hour urine tests (urinary aldosterone, potassium, sodium, and creatinine, and creatinine clearance) in eplerenone and losartan treated patients, and to evaluate the safety and tolerability of eplerenone and losartan as assessed by reported adverse events, clinical laboratory assessments, physical examination, and electrocardiogram.
• HCTZ hydrochlorothiazide
• the primary objective of this study is to compare the mean change from baseline in seated trough cuff diastolic BP (seDBP) of eplerenone vs losartan in patients with low renin hypertension at Weeks 8 and 16.
• Subgroup analyses of the primary and secondary efficacy measures can be performed with respect to subgroups based on, for example, baseline recordings of such factors as race (black, non-black, Japanese, etc.), sex, age, urinary sodium to potassium ratio, presence of diabetes, history of hypertension, history of heart failure, history of renal dysfunction, and the like. Subgroups based on continuous measures such as age can be dichotomized at the median value.
• Example A-17 Comparison Study of the Antihypertensive Effect and Safety of Eplerenone Versus Placebo and Versus Losartan in Black and White Hypertensive Patients
• a clinical study is conducted to compare the antihypertensive effect and the safety and tolerability of eplerenone versus placebo and versus losartan in hypertensive black patients and in hypertensive white patients.
• DBP diastolic blood pressure
• SBP seated systolic blood pressure
• the trial will further consist of a one- to two-week pretreatment screening period followed by a two- to four-week single-blind placebo run-in period and a 16-week double-blind treatment period.
• Black patients and white patients will be entered into the study in approximately a 2:1 ratio balanced and pre-stratified within each study center.
• eligible patients will be randomized to receive either eplerenone, placebo, or losartan.
• For the first four weeks of double-blind treatment patients will receive eplerenone 50 mg, losartan 50 mg, or matching placebo.
• BP blood pressure
• DBP blood pressure
• the dose of study medication will be increased to eplerenone 100 mg, losartan 100 mg, or matching placebo. The dose will not be changed for patients with adequate BP control.
• Table A-17A illustrates the above-described dosing scheme.
• symptomatic hypotension i.e., lightheadedness, dizziness, or syncope associated with low BP
• Patients will receive study medication for a total of 16 weeks. Patients will return to the clinic for evaluations at Weeks 0, 2, 4, 6, 8, 10, 12, 14, 16, and 17. Heart rate, BP, serum potassium levels, and adverse events will be assessed at each visit. Hematology and biochemistry evaluations and urinalysis for safety will be taken at Weeks 0, 16, and 17, or at Final Visit. Additionally, a neurohormone profile (plasma renin [total and active], serum aldosterone, and plasma cortisol) will be collected at Weeks 0 and 16, or at Final Visit. A spot urine for measurement of microalbuminuria will be done at Weeks 0 and 16 or at Final Visit. A 12-lead electrocardiogram and physical examination will be done at screening and at Week 17, or at Final Visit.
• plasma renin [total and active] serum aldosterone, and plasma cortisol
• the second blood sample will be collected one hour after the initial dose of study drug; for Visits 3A and 5A, the patient will take the study drug in the morning at his/her regularly scheduled time prior to returning to the clinic, and two blood samples will be collected one hour apart. At Visits 3A and 5A, patients will be scheduled for either one morning or one afternoon visit.
• the dose may be lowered to the next lower dose of the study drug; however, if the patient is on the minimum dose (eplerenone 50 mg or losartan 50 mg or matching placebo), he/she must be withdrawn.
• BP is uncontrolled (DBP ⁇ 90 mmHg or SBP ⁇ 140 mmHg) before Week 12 or DBP ⁇ 95 mmHg or SBP ⁇ 150 mmHg at Week 1 2 or thereafter and the patient is on the maximum dose of study drug, he she must be withdrawn from the study.
• the primary measure of efficacy will be the mean change from baseline in seated trough cuff DBP between eplerenone versus placebo at Week 16 in all patients (black and white). Additionally, efficacy will be evaluated with respect to the patient's degree of salt sensitivity by fertile (wherein tertiles are empirically determined by the increment of blood pressure response to salt challenge). The primary safety endpoints are serious and non-serious adverse events, withdrawals, and laboratory abnormalities over the 16-week period.
• Secondary endpoints will be the following: (1) The mean change from baseline in seated trough cuff DBP between eplerenone versus placebo within and between racial groups at Week 16; (2) The mean change from baseline in seated trough cuff DBP between eplerenone versus losartan in all patients and within and between racial groups at Week 16; (3) The mean change from baseline in seated trough cuff SBP between eplerenone versus placebo or losartan in all patients and within and between racial groups at Week 16; (4) The mean change from baseline in microalbuminuria as measured by urinary albumin to creatinine ratio between eplerenone versus placebo or losartan in all patients and within and between racial groups at Week 16; (6) The mean change from baseline in serum potassium, magnesium, sodium, albumin, and creatinine between eplerenone versus placebo or losartan in all patients and within and between racial groups at Week 16; (7) The mean change from baseline in neurohormone profile
• the primary objectives of this study are (1 ) to compare the antihypertensive effect of eplerenone versus placebo in all patients (black and white) with mild to moderate hypertension as measured by seated diastolic blood pressure (DBP) at Week 16; and (2) to compare the safety and tolerability of eplerenone versus placebo in all patients during 16 weeks of therapy.
• the secondary objectives of this study are (1) to compare the antihypertensive effect of eplerenone versus placebo within and between black and white hypertensive patients as measured by DBP; (2) to compare the antihypertensive effect of eplerenone versus losartan in all patients and within and between black and white hypertensive patients as measured by DBP; (3) to compare the antihypertensive effect of eplerenone versus placebo or losartan in all patients and within and between black and white hypertensive patients as measured by seated systolic blood pressure (SBP); (4) to compare the effect of eplerenone versus placebo or losartan in all patients and within and between black and white hypertensive patients on renal effects, as measured by a spot urine for measurement of microalbuminuria; (5) to compare the effect of eplerenone versus placebo or losartan in all patients and within and between black and white hypertensive patients on renal effects, as measured by serum potassium, magnesium, sodium, albumin, and creatinine levels;
• Subgroup analyses of the primary and secondary efficacy measures can be performed with respect to subgroups based on, for example, baseline recordings of such factors as sex, age, plasma renin levels, aldosterone/renin activities ratio, urinary sodium to potassium ratio, presence of diabetes, history of hypertension, history of heart failure, history of renal dysfunction, and the like. Subgroups based on continuous measures such as age can be dichotomized at the median value.
• Example A-18 Comparison Study of the Antihypertensive. Renal, and Metabolic Effects of Eplerenone Versus Enalapril in Patients With Type 2 Diabetes Mellitus, Albuminuria, and Hypertension.
• a clinical study is conducted to compare the antihypertensive, renal, and metabolic effects of eplerenone and enalapril, and the combination, in patients with Type 2 diabetes mellitus, albuminuria, and hypertension.
• the study is a multicenter, randomized, double-blind, active-controlled, placebo run-in, parallel group trial involving a minimum of 200 randomized patients with Type 2 diabetes mellitus, albuminuria, and hypertension.
• Each patient will be tested for salt sensitivity by salt challenge-unidirectional testing.
• the trial will further consist of a one- to two-week pretreatment screening period followed by a two- to four-week single-blind placebo run-in period and a 24-week double-blind treatment period.
• eligible patients will be randomized to one of three groups: eplerenone plus placebo, enalapril plus placebo, or eplerenone plus enalapril.
• eplerenone plus placebo For the first two weeks of double-blind treatment patients will receive eplerenone 50 mg plus placebo, enalapril 10 mg plus placebo, or eplerenone 50 mg plus enalapril 10 mg.
• the study medication dose will be force titrated to eplerenone 100 mg plus placebo, enalapril 20 mg plus placebo, or eplerenone 100 mg plus enalapril 10 mg.
• the dose will be force titrated to eplerenone 200 mg plus placebo, enalapril 40 mg plus placebo, or eplerenone 200 mg plus enalapril 10 mg.
• Table A-18A illustrates the above-described dosing scheme.
• BP blood pressure
• HCTZ hydrochlorothiazide
• the add-on medication may be withdrawn in the reverse sequence as it was added until hypotension resolves. If the patient is not taking open-label medication, he/she must be withdrawn from the study.
• Patients will return to the clinic for evaluations at Weeks 0, 2, 4, 6, 8, 10, 12, 15, 18, 21, 24, and 25.
• Heart rate, BP, body weight, serum potassium, and adverse events will be assessed at each visit.
• Hematology and biochemistry evaluations and urinalysis for safety will be at Weeks 0, 4, 6, 8, 10, 15, 21, 24, and 25.
• Collagen markers (aminoterminal propeptide of Type III procollagen [PIIINP], 7S domain of Type IV collagen [7SIVC], and Type I collagen telopeptide [ICTP]), fibrinolytic balance (plasminogen activator inhibitor [PAI-1] and tissue plasminogen activator [t-PA]), insulin, and glycosylated hemoglobin will be measured at Weeks 0, 8, 15, and 24.
• the primary measure of efficacy will be the change from baseline in urinary albumin excretion between eplerenone and enalapril, or the combination, at Week 24. Additionally, efficacy will be evaluated with respect to the patient's degree of salt sensitivity by tertile (wherein tertiles are empirically determined by the increment of blood pressure response to salt challenge).
• This double-blind, active-controlled study is designed to determine the net effect of eplerenone on the insulin resistance, glycemic control, renal function, and lipid profile of hypertensive patients with NIDDM and albuminuria as compared to enalapril.
• the primary objective of this study is to compare the mean change from baseline in urinary albumin excretion in patients treated with eplerenone versus enalapril or the combination at Week 24.
• the secondary objectives of this study are to (1) compare the effect on mean change from baseline of trough cuff seDBP and seSBP of eplerenone versus enalapril or the combination at Weeks 8 and 24; (2) compare the effects of eplerenone versus enalapril, or the combination, as measured by mean change from baseline of collagen markers (aminoterminal propeptide of Type III procollagen [PIIINP], 7S domain of Type IV collagen [7SIVC], and Type I collagen telopeptide [ICTP]); fibrinolytic balance (plasminogen activation inhibitor [PAI-1], tissue plasminogen activator [t-PA]), and metabolic effects (insulin, glycosylated hemoglobin, fasting serum glucose, and lipids [triglycerides, total cholesterol, and HDL cholesterol]) at Week 24; (3) measure any difference in mean change from baseline in antihypertensive, metabolic, or urinary albumin excretion response of eplerenone versus enalapril or the
• Subgroup analyses of the primary and secondary efficacy measures can be performed with respect to other subgroups based on, for example, baseline recordings of such factors as race (black, non-black, Japanese, etc.), sex, age, plasma renin levels, aldosterone/renin activities ratio, urinary sodium to potassium ratio, history of heart failure, and the like. Subgroups based on continuous measures such as age can be dichotomized at the median value.
• Example A-19 Comparison Study of the Antihypertensive Effect of Eplerenone Versus Amlodipine in Patients With Elevated Systolic Blood Pressure.
• a clinical study is conducted to compare the effect of eplerenone versus amlodipine on systolic blood pressure in patients with systolic hypertension.
• SBP seated systolic blood pressure
• PP pulse pressure
• DBP diastolic blood pressure
• Each patient will be tested for salt sensitivity by salt challenge- unidirectional testing.
• the trial will further consist of a one- to two-week pretreatment screening period followed by a two- to four-week single-blind placebo run-in period and a 24- week double-blind treatment period.
• eligible patients After completing the single-blind placebo run-in period, eligible patients will be randomized to receive either eplerenone or amlodipine. Patients will receive eplerenone 50 mg or amlodipine 2.5 mg for the first two weeks of double-blind treatment.
• SBP SBP
• the dose of study medication will be increased by one dose level to eplerenone 100 mg or amlodipine 5 mg; the dose will not be changed for patients with adequate BP control.
• SBP 140 mmHg
• the dose of study medication will be increased by one dose level to eplerenone 100 mg or amlodipine 5 mg if not done at Week 2, or to eplerenone 200 mg or amlodipine 10 mg if already increased at Week 2. The dose will not be changed for patients with adequate SBP control.
• symptomatic hypotension i.e., lightheadedness, dizziness, or syncope associated with low BP
• Heart rate, BP, serum potassium levels, concomitant medications and adverse events will be assessed at each visit. Hematology and biochemistry evaluations and urinalysis for safety will be performed at screening, Weeks 0, 24, and 25. Special studies: collagen markers [aminoterminal propeptide of type III procollagen (PIIINP), 7S domain of type IV collagen (7SIVC), and type I collagen telopeptide (ICTP)], plasma activator inhibitor (PAI-1), tissue plasminogen activator (t-PA), microalbuminuria, and at selected sites, Ambulatory Blood Pressure Monitoring (ABPM) and arterial compliance will be done at Weeks 0, 14, and 24 or at Final Visit.
• PIIINP propeptide of type III procollagen
• 7SIVC 7S domain of type IV collagen (7SIVC), and type I collagen telopeptide
• ICTP type I collagen telopeptide
• PAI-1 plasma activator inhibitor
• t-PA tissue plasminogen activator
• microalbuminuria and at selected sites
• Quality of Life Questionnaires will be done at visit 2A (beginning of single blind) and Weeks 0, 14, and 24 or at Final Visit.
• DNA genotyping will be performed at baseline.
• a 12-lead electrocardiogram and physical examination will be done at screening and at Week 25 or at Final Visit.
• the patient At any time during the study, the patient must be withdrawn if at two consecutive visits, one to three days apart, the SBP is > 200 mmHg or DBP > 110 mmHg.
• eplerenone or amlodipine may be down titrated to next lower dose. However, if SH occurs on the lowest dose of study medication (50 mg of eplerenone or 2.5 mg of amlodipine), the patient must be withdrawn.
• SH symptomatic hypotension
• the study drug may be reduced by one level. If the potassium remains > 5.5 mEq L on two consecutive visits, one to three days apart, the patient must be withdrawn. If the potassium level on two consecutive visits, one to three days apart, is > 5.0 mEq/L but ⁇ 5.5 mEq/L, the study drug must not be titrated upward. In this case, if the SBP > 140 mmHg before Week 10, or > 170 mmHg at Week 10 or thereafter, the patient must be withdrawn.
• Secondary endpoints will be the following: (1 ) mean change from baseline in pulse pressure (SBP-DBP) between eplerenone versus amlodipine at Week 24; (2) mean change from baseline in seated trough cuff diastolic BP (DBP) between eplerenone versus amlodipine at Week 24; (3) mean change from baseline of heart rate (HR), PP, SBP, and DBP between eplerenone versus amlodipine as measured by ABPM recordings at Week 24; (4) mean change from baseline in arterial compliance between eplerenone versus amlodipine at Week 24; (5) mean change from baseline in PAI-1 , t-PA, and collagen markers between eplerenone versus amlodipine at Week 24; (6) mean change from baseline in microalbuminuria as measured by urinary albumin to creatin
• efficacy (items 1 - 9, above) will be evaluated with respect to the patient's degree of salt sensitivity by tertile (wherein tertiles are empirically determined by the increment of blood pressure response to salt challenge).
• This trial in a population with systolic hypertension is designed to determine the antihypertensive effect of eplerenone relative to amlodipine treatment, to compare the quality of life on eplerenone treatment versus amlodipine, to compare the side effect profile of eplerenone versus amlodipine in the elderly, and to assess arterial compliance, plasma activator inhibitor (PAI-1), and markers of collagen metabolism in the two groups.
• the primary objective of this study is to compare the effect of eplerenone versus amlodipine on SBP as measured by mean change from baseline in seated trough cuff SBP at Week 24.
• the secondary objectives of this study are to: (1 ) compare the effect of eplerenone versus amlodipine on mean change from baseline in pulse pressure (SBP-DBP) at Week 24; (2) compare the antihypertensive effect of eplerenone versus amlodipine as measured by mean change from baseline in seated trough cuff DBP at Week 24; (3) compare from ABPM recordings, the mean change from baseline of HR, PP, SBP, and DBP between eplerenone versus amlodipine at Week 24; (4) compare the effect of eplerenone versus amlodipine on arterial compliance as measured by mean change from baseline at Week 24; (5) compare the effect of eplerenone versus amlodipine on PAI-1, tissue plasminogen activator (t-PA), and collagen markers [aminoterminal propeptide of type III procollagen (PIIINP), 7S domain of type IV collagen (7SIVC), and type I collagen telopeptide (ICTP)], as measured by mean
• Subgroup analyses of the primary and secondary efficacy measures can be performed with respect to other subgroups based on, for example, baseline recordings of such factors as race (black, non-black, Japanese, etc.), sex, age, plasma renin levels, aldosterone/renin activities ratio, urinary sodium to potassium ratio, presence of diabetes, history of heart failure, history of renal dysfunction, and the like.
• Subgroups based on continuous measures such as age can be dichotomized at the median value.
• Example A-20 Dose-Ranging Study of Eplerenone Vs. Placebo in Patients With Symptomatic Heart Failure
• a clinical study is conducted to evaluate the safety and tolerability of a range of doses of eplerenone, to assess their effect on neurohormonal function, and to examine their potential for improving signs and symptoms in patients with heart failure concurrently treated with an ACE inhibitor and a loop diuretic. Additionally, each of the above paramteres will be evaluated with respect to the patient's degree of salt sensitivity by tertile (wherein tertiles are empirically determined by the increment of blood pressure response to salt challenge).
• the study is a randomized, double-blind, multicenter, placebo-controlled parallel group trial evaluating three different daily doses of eplerenone vs. placebo.
• the study will enroll at least 100 patients. Each patient will be tested for salt sensitivity by salt challenge-unidirectional testing.
• the measures for evaluation of neurohormones will be determinations of N-terminal atrial natriuretic peptide (N-terminal ANP), brain natriuretic peptide (BNP and pro-BNP), plasma renin (total and active), and plasma and urine aldosterone. Assessment of patients' signs and symptoms will be made using the NYHA Functional Class. Safety will be evaluated by the assessment of incidence of hyperkalemia and symptomatic hypotension, other adverse experiences, and clinical laboratory abnormalities. The study is structured to detect differences between eplerenone and placebo treatment in the neurohormone levels and in major changes in clinical signs and symptoms.
• the primary objectives of this study are (1 ) to evaluate the safety and tolerability of a range of doses of eplerenone in patients with HF concurrently treated with an ACE inhibitor and a loop diuretic; (2) to evaluate the effect of a range of doses of eplerenone given measurements of neurohormonal function [N-terminal atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP) and its pro-form (pro-BNP), serum and urine aldosterone, and plasma renin (total and active)] in patients with HF concurrently treated with an ACE inhibitor and a loop diuretic; and (3) to evaluate the efficacy of a range of doses of eplerenone given over 12 weeks in improving the signs and symptoms of HF as assessed by change from baseline in NYHA Functional Classification.
• the secondary objectives of this study are (1 ) to evaluate the effect of a range of doses of eplerenone co-administered with an ACE inhibitor and a loop diuretic on heart rate (HR), BP, and body weight; and (2) to evaluate the effect of eplerenone on the changes in dosing of ACE inhibitors and diuretics when they are given concurrently with eplerenone.
• Concurrent therapy includes ACE-I + loop diuretic
• alterations in the dose of concomitant medications should be considered prior to dose adjustment of study medication.
• concomitant medications e.g., potassium supplements, ACE-I, etc.
• serum potassium level is 6.0 mEq/L
• study medication is to be temporarily withheld.
• the patient is to discontinue study medication.
• elevated potassium levels are observed ⁇ 6.0 mEq/L, potassium supplements, if any, should be stopped and the patient should continue to receive study medication. If study medication is stopped, concurrent medications should be reviewed and the doses adjusted if possible according to good clinical practice.
• Table A-20A summarizes necessary dosing changes for serum potassium levels. Serum potassium will be determined within one week following initiation of treatment and within one week following any dose change. If at any time during the study the serum potassium is
• the dose of study drug will be reduced to the next lower dose level, i.e., 1 tablet QD to 1 tablet QOD or 1 tablet QOD to temporarily stopped.
• Study medication is to be restarted at 1 tablet QOD when the serum potassium level is ⁇ 5.5 mEq/L and increased according to the scheme presented in Table A-20B.
• the potassium level may be repeated if the potassium increase is thought to be spurious ⁇ i.e., due to hemolysis or recent dosing with a potassium supplement).
• Subgroup analyses of the primary and secondary efficacy measures can be performed with respect to other subgroups based on, for example, baseline recordings of such factors as sex, age, plasma renin levels, aldosterone/renin activities ratio, urinary sodium to potassium ratio, presence of diabetes, history of hypertension, history of renal dysfunction, and the like. Subgroups based on continuous measures such as age can be dichotomized at the median value.
• Example A-21 Efficacy and Safety Evaluation of a Range of Doses of Eplerenone in the Treatment of Mild to Moderate Hypertension
• a multicenter, randomized, double-blind, placebo-controlled, parallel group trial is conducted to evaluate the safety and efficacy of three different total daily doses (50, 100, and 200 mg) of eplerenone to placebo.
• the study consists of a two-week pretreatment period for washout of any current antihypertensive medication(s) and for completion of screening procedures.
• Each patient will be tested for salt sensitivity by salt challenge- unidirectional testing after washout. Salt sensitivity testing is followed by a four-week, single-blind, placebo lead-in treatment, prior to randomization to an eight-week, double-blind, active versus placebo treatment period.
• Table A-21 A illustrates the above-described dosing scheme.
• symptomatic hypotension i.e., lightheadedness, dizziness, or syncope associated with low blood pressure (BP)
• SBP systolic blood pressure
• DBP diastolic blood pressure
• serum potassium level is elevated > 5.5 mmol/L on repeat measurement (sample split and sent to local and central laboratories, treatment decision based on local value) at two consecutive visits, one to three days apart, the patient must be withdrawn.
• the primary efficacy measure will be the change from baseline in cuff DBP measured at trough as compared to placebo.
• Secondary efficacy measures will include changes in cuff assessed trough SBP, and changes in average 24-hour DBP and SBP assessed by ambulatory BP monitoring (performed at selected investigational sites only). Changes in neurohormones (plasma renin, serum aldosterone) after eight weeks of dosing will also be a secondary efficacy measure. Efficacy will be also evaluated with respect to the patient's degree of salt sensitivity by tertile (wherein tertiles are empirically determined by the increment of blood pressure response to salt challenge).
• the primary objective of this study is to evaluate the antihypertensive effect of once daily doses of 50, 100, and 200 mg of eplerenone as compared to placebo, when administered for eight weeks to patients with mild to moderate hypertension using change from baseline in trough cuff DBP measurements.
• the secondary objectives of this study are (1 ) to evaluate change from baseline in trough cuff SBP; (2) to determine the 24-hour antihypertensive effect of eplerenone relative to placebo using Ambulatory Blood Pressure Monitoring (ABPM); (3) to evaluate change in plasma renin and serum aldosterone levels; and (4) to establish the safety and tolerability of eplerenone for antihypertensive treatment as assessed by reported adverse events, clinical laboratory values, physical examination, vital signs, and electrocardiogram.
• ABPM Ambulatory Blood Pressure Monitoring
• Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Visit 7
• ABPM Ambulatory Blood Pressure Monitoring
• Subgroup analyses of the primary and secondary efficacy measures can be performed with respect to other subgroups based on, for example, baseline recordings of such factors as sex, age, plasma renin levels, aldosterone/renin activities ratio, urinary sodium to potassium ratio, presence of diabetes, history of heart failure, history of renal dysfunction, and the like. Subgroups based on continuous measures such as age can be dichotomized at the median value.
• Example A-22 Safety And Efficacy Of Eplerenone In Patients With Heart Failure Following Acute Myocardial Infarction.
• a clinical trial is conducted to compare the effect of eplerenone plus standard therapy versus placebo plus standard therapy on the rate of all cause mortality in patients with heart failure (HF) after an acute myocardial infarction (AMI). Secondary endpoints include cardiovascular morbidity and mortality.
• the study is a multicenter, randomized, double-blind, placebo- controlled, two-arm, parallel group trial will continue until 1 ,012 deaths occur, which is estimated to require approximately 6,200 randomized patients followed for an average of approximately 2.5 years.
• Eligible patients may be identified for inclusion at any time following emergency room evaluation and presumptive diagnosis of AMI with HF.
• Patients who qualify for this study will be randomized between 3 (>48 hours) and 10 days post-AMI if their clinical status is stable, e.g., no vasopressors, inotropes, intra-aortic balloon pump, hypotension (systolic blood pressure [SBP] ⁇ 90 mmHg), or recurrent chest pain likely to lead to acute coronary arteriography. Patients with implanted cardiac defibrillators are excluded.
• Patients will receive standard therapy which may include ACE inhibitors, diuretics, nitrates, and ⁇ -blockers, and may have received anticoagulants and antiplatelet agents, and may have received thrombolytics or emergency angioplasty. Patients will be randomized to receive eplerenone 25 mg QD (once daily) or placebo. At four weeks, the dose of study drug will be increased to 50 mg QD (two tablets) if serum potassium ⁇ 5.0 mEq/L.
• standard therapy may include ACE inhibitors, diuretics, nitrates, and ⁇ -blockers, and may have received anticoagulants and antiplatelet agents, and may have received thrombolytics or emergency angioplasty.
• Patients will be randomized to receive eplerenone 25 mg QD (once daily) or placebo. At four weeks, the dose of study drug will be increased to 50 mg QD (two tablets) if serum potassium ⁇ 5.0 mEq/L.
• the dose of study drug will be reduced to the next lower dose level, i.e., 50 mg QD to 25 mg QD (one tablet), 25 mg QD to 25 mg QOD (every other day), or 25 mg QOD to temporarily withheld.
• the serum potassium 6.0 mEq/L
• study medication should be temporarily withheld, and may be restarted at 25 mg QOD when serum potassium is ⁇ 5.5 mEq/L.
• Serum potassium will be determined at 48 hours after initiation of treatment, at 1 and 5 weeks, at all other scheduled study visits, and within one week following any dose change.
• Study visits will occur at screening, baseline (randomization), 1 and 4 weeks, 3 months, and every 3 months thereafter until the study is terminated.
• Medical history, cardiac enzymes, Killip class, time to reperfusion (if applicable), documentation of AMI and of HF, determination of LVEF, and a serum pregnancy test for women of childbearing potential will be done at screening.
• a physical examination and 12-lead ECG will be done at screening and at the final visit cessation of study drug).
• Hematology and biochemistry evaluations and urinalysis for safety will be done at screening, Week 4, Months 3 and 6, and every 6 months thereafter until the study is terminated.
• An additional blood sample for DNA analysis will be collected during screening.
• the primary endpoint is all cause mortality.
• the trial is structured to detect an 18.5% reduction in all cause mortality, and requires 1 ,012 deaths before terminating the study.
• Secondary endpoints include (1 ) cardiovascular mortality; (2) sudden cardiac death; (3) death due to progressive heart failure; (4) all cause hospitalizations; (5) cardiovascular hospitalizations; (6) heart failure hospitalizations; (7) all cause mortality plus all cause hospitalizations; (8) cardiovascular mortality plus cardiovascular hospitalizations; (9) cardiovascular mortality plus heart failure hospitalizations; (10) new diagnosis of atrial fibrillation; (11 ) hospitalization for recurrent non-fatal AMI and fatal AMI; (12) hospitalization for stroke; and (13) quality of life.
• the primary objective of this study is to compare the effect of eplerenone plus standard therapy versus placebo plus standard therapy on the rate of all cause mortality in patients with heart failure after AMI.
• the secondary objectives of this study are to compare the two treatment groups for include (1 ) cardiovascular mortality; (2) sudden cardiac death; (3) death due to progressive heart failure; (4) all cause hospitalizations; (5) cardiovascular hospitalizations; (6) heart failure hospitalizations; (7) all cause mortality plus all cause hospitalizations; (8) cardiovascular mortality plus cardiovascular hospitalizations; (9) cardiovascular mortality plus heart failure hospitalizations; (10) new diagnosis of atrial fibrillation; (11) hospitalization for recurrent non-fatal AMI and fatal AMI; (12) hospitalization for stroke; and (13) quality of life.
• Patients will receive eplerenone 25 mg QD or placebo (one tablet) for the first four weeks of treatment.
• Table A-22A summarizes mandated dosing changes for serum potassium levels. Serum potassium will be determined at 48 hours after initiation of treatment, at 1 and 5 weeks, and within one week following any dose change. If at any time during the study the serum potassium is >5.5 mEq/L, the dose of study drug will be reduced to the next lower dose level, i.e., 50 mg QD to 25 mg QD, 25 mg QD to 25 mg QOD, or 25 mg QOD to temporarily stopped. Study medication is to be restarted at 25 mg QOD when the serum potassium level is ⁇ 5.5 mEq/L and increased according to the scheme presented in Table A-22A. The potassium level may be repeated if the potassium increase is thought to be spurious (i.e., due to hemolysis or recent dosing with a potassium supplement).
• alterations in the dose of concomitant medications should be considered prior to dose adjustment of study medication.
• concomitant medications e.g., potassium supplements, ACE-I, etc.
• serum potassium level is 6.0 mEq/L
• study medication is to be temporarily withheld.
• the patient is to discontinue study medication.
• elevated potassium levels are observed ⁇ 6.0 mEq/L, potassium supplements, if any, should be stopped and the patient should continue to receive study medication. If study medication is stopped, concurrent medications should be reviewed and the doses adjusted if possible according to good clinical practice.
• Subgroup analyses of the primary and secondary endpoints will be performed. Subgroups will be based on baseline recordings of race (black, non-black), sex, age, presence of diabetes, ejection fraction, serum potassium, serum creatinine, use of ⁇ -blockers, use of digoxin, use of potassium supplements, first versus subsequent AMI, Killip class, reperfusion status, history of hypertension, history of HF, history of smoking, history of angina, time from index AMI to randomization, and geographic region. Subgroups based on continuous measures such as age, ejection fraction, serum potassium, and serum creatinine will be dichotomized at the median value.
• Example A-22 Eplerenone to Prevent or Treat Endothelial Dysfunction: After 20 minutes of supine rest, the nondominant brachial artery is cannulated under local anesthesia. After 30 minutes of saline infusion, baseline forearm blood flow is measured by forearm venous-occlusion plethysmography. Drugs are then infused into the study arm with a constant rate infuser. Forearm blood flow is measured at each baseline and during the last two minutes of each drug infusion. Blood pressure is measured in the non-infused (control) arm at regular intervals throughout the study.
• acetylcholine endothelium-dependant vasodilator
• sodium nitroprusside endothelium independent vasodilator
• N-monoethyl-L- arginine L-NMMA; competitive NO synthase inhibitor
• angiotensin I vaconstrictor only through conversion to angiotensin II
• the drug infusion is flushed with saline for 20 to 30 minutes to allow sufficient time for the forearm blood flow to return to baseline values
• An oral dosage may be prepared by screening and then mixing together the following list of ingredients in the amounts indicated. The dosage may then be placed in a hard gelatin capsule.
• An oral dosage may be prepared by mixing together granulating with a 10% gelatin solution.
• the wet granules are screened, dried, mixed with starch, talc and stearic acid, screened and compressed into a tablet.
• An oral dosage may be prepared by screening and then mixing together the following list of ingredients in the amounts indicated. The dosage may then be placed in a hard gelatin capsule.
• An oral dosage may be prepared by mixing together granulating with a 10% gelatin solution.
• the wet granules are screened, dried, mixed with starch, talc and stearic acid, screened and compressed into a tablet.
• a 25 mg dose immediate release tablet (tablet diameter of 7/32") was prepared having the following composition:

Landscapes

• Health & Medical Sciences (AREA)
• Public Health (AREA)
• Life Sciences & Earth Sciences (AREA)
• Veterinary Medicine (AREA)
• Chemical & Material Sciences (AREA)
• General Health & Medical Sciences (AREA)
• Medicinal Chemistry (AREA)
• Animal Behavior & Ethology (AREA)
• Pharmacology & Pharmacy (AREA)
• Engineering & Computer Science (AREA)
• Bioinformatics & Cheminformatics (AREA)
• Chemical Kinetics & Catalysis (AREA)
• General Chemical & Material Sciences (AREA)
• Nuclear Medicine, Radiotherapy & Molecular Imaging (AREA)
• Organic Chemistry (AREA)
• Diabetes (AREA)
• Cardiology (AREA)
• Endocrinology (AREA)
• Epidemiology (AREA)
• Heart & Thoracic Surgery (AREA)
• Neurology (AREA)
• Biomedical Technology (AREA)
• Urology & Nephrology (AREA)
• Hematology (AREA)
• Neurosurgery (AREA)
• Vascular Medicine (AREA)
• Pain & Pain Management (AREA)
• Hospice & Palliative Care (AREA)
• Obesity (AREA)
• Emergency Medicine (AREA)
• Reproductive Health (AREA)
• Gastroenterology & Hepatology (AREA)
• Pulmonology (AREA)
• Pharmaceuticals Containing Other Organic And Inorganic Compounds (AREA)
• Steroid Compounds (AREA)
• Medicines That Contain Protein Lipid Enzymes And Other Medicines (AREA)

Priority Applications (9)

Applications Claiming Priority (1)

Publications (1)

Family

ID=21743121

Family Applications (1)

Country Status (9)

Cited By (3)

Families Citing this family (1)

Citations (2)

• 2001
  • 2001-12-13 JP JP2003552305A patent/JP2005516015A/ja not_active Withdrawn
  • 2001-12-13 IL IL16239301A patent/IL162393A0/xx unknown
  • 2001-12-13 MX MXPA04005803A patent/MXPA04005803A/es unknown
  • 2001-12-13 WO PCT/US2001/048419 patent/WO2003051372A1/en not_active Application Discontinuation
  • 2001-12-13 AU AU2002249804A patent/AU2002249804A1/en not_active Abandoned
  • 2001-12-13 EP EP01998044A patent/EP1453522A1/en not_active Withdrawn
  • 2001-12-13 CA CA002469950A patent/CA2469950A1/en not_active Abandoned
  • 2001-12-13 BR BR0117195-0A patent/BR0117195A/pt not_active IP Right Cessation
  • 2001-12-13 KR KR10-2004-7009192A patent/KR20040071723A/ko not_active Application Discontinuation

Patent Citations (2)

Non-Patent Citations (4)

Also Published As

Similar Documents

Legal Events