Methods of Treating Lung Disease by an Aerosol Containing Benzamil or Phenamil

These inventions relate to a method of hydrating lung mucous secretions by administering benzamil to the lungs of a subject, and a method of hydrating lung mucous secretions by administering phenamil to the lungs of a subject.

In cystic fibrosis several functions of airway epithelia are abnormal, and deficiencies in both CL.sup.- transport and Na.sup.+ absorption are well documented. See, e.g. Knowles et al., Science 221, 1067 (1983); Knowles et al., J. Clin. Invest. 71, 1410 (1983). Regulation of ion transport might have potential therapeutic benefit in lung diseases characterized by abnormalities in epithelial ion transport, e.g., cystic fibrosis.

One therapeutic goal in cystic fibrosis and other pulmonary diseases in which the water content of the mucous is altered is to hydrate the lung mucous secretions, so that the secretions may be thereafter more easily removed from the lungs by mucociliary action or simple coughing. The use of aerosolized amiloride to hydrate mucous secretions is described in U.S. Pat. No. 4,501,729. Amiloride appears to block Na.sup.+ reabsorption by airway epithelial cells, and therefore inhibits water absorption from the mucous. While an important breakthrough in providing treatments for cystic fibrosis, a potential problem with amiloride treatments is the relatively short duration of action of amiloride.

A different therapeutic approach for hydrating lung mucous secretions is exemplified by techniques that involve the administration of ATP or UTP, which appear to stimulate chloride secretion from respiratory epithelial cells. See, e.g., U.S. Pat. No. 5,292,498 to Boucher.

In view of the large numbers of people afflicted with cystic fibrosis, there is an ongoing need for new methods for providing methods of hydrating lung mucous secretions and thereby facilitating lung mucous clearance.

A first aspect of the present invention is a method of hydrating mucous secretions in the lungs of a subject in need of such treatment. The method comprises administering benzamil to the lungs of the subject in an amount effective to hydrate lung mucous secretions.

A second aspect of the present invention is a method of treating cystic fibrosis in a human subject in need of such treatment, comprising administering by inhalation an aerosol suspension of respirable particles to the respiratory system of the subject, the particles comprised of benzamil, the benzamil administered in an amount effective to hydrate retained lung mucous secretions in the lungs of the subject, whereby the retained mucous secretions are more easily transported from the lungs via mucociliary action.

A third aspect of the present invention is the use of benzamil for the manufacture of a medicament for carrying out a therapeutic method of treatment as given above.

A fourth aspect of the present invention is a pharmaceutical composition, comprising, together in a pharmaceutically acceptable carrier, (i) benzamil in an amount effective to inhibit the reabsorption of water from lung mucous secretions; and (ii) UTP or an analog thereof in an amount effective to hydrate lung mucous secretions.

A fifth aspect of the present invention is a method of hydrating mucous secretions in the lungs of a subject in need of such treatment. The method comprises administering phenamil to the lungs of the subject in an amount effective to hydrate lung mucous secretions.

A sixth aspect of the present invention is a method of treating cystic fibrosis in a human subject in need of such treatment, comprising administering by inhalation an aerosol suspension of respirable particles to the respiratory system of the subject, the particles comprised of phenamil, the phenamil administered in an amount effective to hydrate retained lung mucous secretions in the lungs of the subject, whereby the retained mucous secretions are more easily transported from the lungs via mucociliary action.

A seventh aspect of the present invention is the use of phenamil for the manufacture of a medicament for carrying out a therapeutic method of treatment as given above.

An eighth aspect of the present invention is a pharmaceutical composition, comprising, together in a pharmaceutically acceptable carrier, (i) phenamil in an amount effective to inhibit the reabsorption of water from lung mucous secretions; and (ii) UTP or an analog thereof in an amount effective to hydrate lung mucous secretions.

FIG. 1 shows the log concentration-effect curves (percentage change in I.sub.sc from basal levels) of amiloride, benzamil, phenamil and 5-(N,N,-hexamethylene)amiloride (or EIPA) applied to the apical surface of human nasal epithelium.

FIG. 2 shows a comparison of the persistence of the Na.sup.+ absorption blockade after the washout of amiloride, benzamil and phenamil. The time needed for the washout of phenamil and benzamil as compared to the time needed to wash out amiloride is illustrated.

The method of the present invention may be used to remove mucous secretions retained in the lungs of a subject for any reason, including (but not limited to) retention of secretions arising from airway diseases such as cystic fibrosis, chronic bronchitis, asthma, and bronchiectasis. Two compounds, phenamil and benzamil, were identified as particularly potent blockers of airway epithelial Na.sup.+ channels, having K.sub.i 's of <10.sup.-7 M in human airway epithelial preparations. The novel features of benzamil and phenamil as compared to amiloride are that these compounds are 1-1.5 log-concentration units more potent than amiloride. Additionally, they appear to bind more avidly to the Na.sup.+ channel and thus have longer durations of action during intermittent dose regimens.

The method of the present invention can be used to facilitate (i.e., enhance, speed, assist) the clearance of mucous secretions from the lungs of a subject in need of such treatment for any reason, including (but not limited to) retained secretions arising from airway diseases such as cystic fibrosis, chronic bronchitis, asthma, bronchiectasis, post-operative atelectasis (plugging of airways with retained secretions after surgery), and Kartagener's syndrome.

The present invention is concerned primarily with the treatment of human subjects, but may also be employed for the treatment of other mammalian subjects, such as dogs and cats, for veterinary purposes.

Benzamil (also known as 3,5-diamino-6-chloro-N-(benzylaminoaminomethylene)pyrazinecarboxamide) and phenamil (also known as 3,5-diamino-6-chloro-N-(phenylaminoaminomethylene)pyrazinecarboxamide) are known compounds and are disclosed in U.S. Pat. No. 3,313,813 to E. Cragoe (applicant specifically intends that the disclosure of this and all other patents cited herein be incorporated herein by reference).

The terms "benzamil" and "phenamil" as used herein, include the pharmaceutically acceptable salts thereof, such as (but not limited to) benzamil hydrochloride or phenamil hydrochloride. Pharmaceutically acceptable salts are salts that retain the desired biological activity of the parent compound and do not impart undesired toxicological effects. Examples of such salts are (a) acid addition salts formed with inorganic acids, for example hydrochloric acid, hydrobromic acid, sulfuric acid, phosphoric acid, nitric acid and the like; and salts formed with organic acids such as, for example, acetic acid, oxalic acid, tartaric acid, succinic acid, maleic acid, fumaric acid, gluconic acid, citric acid, malic acid, ascorbic acid, benzoic acid, tannic acid, palmitic acid, alginic acid, polyglutamic acid, naphthalenesulfonic acid, methanesulfonic acid, p-toluenesulfonic acid, naphthalenedisulfonic acid, polygalacturonic acid, and the like; and (b) salts formed from elemental anions such as chlorine, bromine, and iodine.

Benzamil or phenamil used to prepare compositions for the present invention may alternatively be in the form of a pharmaceutically acceptable free base of benzamil or phenamil. Because the free base of the compound is less soluble than the salt, free base compositions are employed to provide more sustained release of benzamil or phenamil to the lungs. Benzamil or phenamil present in the lungs in particulate form which has not gone into solution is not available to induce a physiological response, but serves as a depot of bioavailable drug which gradually goes into solution.

The active compounds disclosed herein may be administered to the lungs of a patient by any suitable means, but are preferably administered by administering an aerosol suspension of respirable particles comprised of the active compound, which the subject inhales. The respirable particles may be liquid or solid. The quantity of benzamil or phenamil included may be an amount sufficient to achieve dissolved concentrations of benzamil or phenamil on the airway surfaces of the subject of from about 10.sup.-7 to about 10.sup.-3 Moles/liter, and more preferably from about 10.sup.-6 to about 10.sup.-4 Moles/liter.

In one embodiment of the invention, the particulate benzamil or phenamil composition may contain both a free base of phenamil or benzamil and a pharmaceutically acceptable salt such as benzamil hydrochloride or phenamil hydrochloride to provide both early release of and sustained release of benzamil or phenamil for dissolution into the mucous secretions of the lungs. Such a composition serves to provide both early relief to the patient, and sustained relief over time. Sustained relief, by decreasing the number of daily administrations required, is expected to increase patient compliance with a course of benzamil or phenamil treatments.

Solid or liquid particulate benzamil or phenamil prepared for practicing the present invention should include particles of respirable size: that is, particles of a size sufficiently small to pass through the mouth and larynx upon inhalation and into the bronchi and alveoli of the lungs. In general, particles ranging from about 1 to 5 microns in size (more particularly, less than about 4.7 microns in size) are respirable. Particles of non-respirable size which are included in the aerosol tend to be deposited in the throat and swallowed, and the quantity of non-respirable particles in the aerosol is preferably minimized. For nasal administration, a particle size in the range of 10-500 .mu.m is preferred to ensure retention in the nasal cavity.

The dosage of active compound will vary depending on the condition being treated and the state of the subject, but generally may be an amount sufficient to achieve dissolved concentrations of active compound on the airway surfaces of the subject of from about 10.sup.-7 to about 10.sup.-3 Moles/liter, and more preferably from about 10.sup.-6 to about 3.times.10.sup.-4 Moles/liter. Depending upon the solubility of the particular formulation of active compound administered, the daily dose may be divided among one or several unit dose administrations. The daily dose by weight may range from about 1 to 20 milligrams of respirable benzamil or phenamil particles for a human subject, depending upon the age and condition of the subject. A currently preferred unit dose is about 2 milligrams of respirable benzamil or phenamil particles given at a regimen of four administrations per day. The dosage may be provided as a prepackaged unit by any suitable means (e.g., encapsulating in a gelatin capsule).

In the manufacture of a formulation according to the invention, active agents or the physiologically acceptable salts or free bases thereof are typically admixed with, inter alia, an acceptable carrier. The carrier must, of course, be acceptable in the sense of being compatible with any other ingredients in the formulation and must not be deleterious to the patient. The carrier may be a solid or a liquid, or both, and is preferably formulated with the compound as a unit-dose formulation, for example, a capsule, which may contain from 0.5% to 99% by weight of the active compound. One or more active compounds may be incorporated in the formulations of the invention, which formulations may be prepared by any of the well-known techniques of pharmacy consisting essentially of admixing the components.

Aerosols of liquid particles comprising the active compound may be produced by any suitable means, such as with a pressure-driven aerosol nebulizer or an ultrasonic nebulizer. See, e.g., U.S. Pat. No. 4,501,729. Nebulizers are commercially available devices which transform solutions or suspensions of the active ingredient into a therapeutic aerosol mist either by means of acceleration of compressed gas, typically air or oxygen, through a narrow venturi orifice or by means of ultrasonic agitation. Suitable formulations for use in nebulizers consist of the active ingredient in a liquid carrier, the active ingredient comprising up to 40% w/w of the formulation, but preferably less than 20% w/w. The carrier is typically water (and most preferably sterile, pyrogen-free water) or a dilute aqueous alcoholic solution, preferably made isotonic with body fluids by the addition of, for example, sodium chloride. Optional additives include preservatives if the formulation is not made sterile, for example, methyl hydroxybenzoate, antioxidants, flavoring agents, volatile oils, buffering agents and surfactants.

Aerosols of solid particles comprising the active compound may likewise be produced with any solid particulate medicament aerosol generator. Aerosol generators for administering solid particulate medicaments to a subject produce particles which are respirable, as explained above, and generate a volume of aerosol containing a predetermined metered dose of a medicament at a rate suitable for human administration. One illustrative type of solid particulate aerosol generator is an insufflator. Suitable formulations for administration by insufflation include finely comminuted powders which may be delivered by means of an insufflator or taken into the nasal cavity in the manner of a snuff. In the insufflator, the powder (e.g., a metered dose thereof effective to carry out the treatments described herein) is contained in capsules or cartridges, typically made of gelatin or plastic, which are either pierced or opened in situ and the powder delivered by air drawn through the device upon inhalation or by means of a manually-operated pump. The powder employed in the insufflator consists either solely of the active ingredient or of a powder blend comprising the active ingredient, a suitable powder diluent, such as lactose, and an optional surfactant. The active ingredient typically comprises from 0.1 to 100 w/w of the formulation. A second type of illustrative aerosol generator comprises a metered dose inhaler. Metered dose inhalers are pressurized aerosol dispensers, typically containing a suspension or solution formulation of the active ingredient in a liquified propellant. During use these devices discharge the formulation through a valve adapted to deliver a metered volume, typically from 10 to 150 .mu.l to produce a fine particle spray containing the active ingredient. Suitable propellants include certain chlorofluorocarbon compounds, for example, dichlorodifluoromethane, trichlorofluoromethane, dichlorotetrafluoroethane and mixtures thereof. The formulation may additionally contain one or more co-solvents, for example, ethanol, surfactants, such as oleic acid or sorbitan trioleate, antioxidants and suitable flavoring agents.

Compositions containing respirable dry particles of micronized benzamil or phenamil may be prepared by grinding the dry phenamil or benzamil with a mortar and pestle, and then passing the micronized composition through a 400 mesh screen to break up or separate out large agglomerates.

The aerosol, whether formed from solid or liquid particles, may be produced by the aerosol generator at a rate of from about 10 to 150 liters per minute, more preferably from about 30 to 150 liters per minute, and most preferably about 60 liters per minute. Aerosols containing greater amounts of medicament may be administered more rapidly.

The particulate benzamil or phenamil composition may optionally contain a dispersant which serves to facilitate the formation of an aerosol. A suitable dispersant is lactose, which may be blended with the benzamil or phenamil in any suitable ratio (e.g., a 1 to 1 ratio by weight).

If desired, the benzamil or phenamil may be concurrently administered with UTP or an analog thereof (including the pharmaceutically acceptable salts thereof) in an amount effective to stimulate chloride secretion from respiratory epithelial cells (and thereby further hydrate the lung mucous secretions), and formulations containing benzamil or phenamil may also contain UTP or an analog thereof in an amount effective to stimulate chloride secretion from respiratory epithelial cells. UTP and analogs thereof that may be used to carry out this technique are disclosed in U.S. Pat. No. 5,292,498 to Boucher. In general, such compounds are of the structure of Formula (I) below, or a pharmaceutically acceptable salt (as given above) thereof: ##STR1## wherein:

X.sub.1, X.sub.2, and X.sub.3 are each independently either O.sup.- (i.e., OH) or S.sup.- (i.e., SH). Preferably X.sub.2 and X.sub.3 are O.sup.-.

R.sub.1 is O, imido, methylene, dihalomethylene (e.g., dichloromethylene, difluoromethylene). Preferably, R.sub.1 is oxygen.

R.sub.2 is H or Br. Preferably, R.sub.2 is H.

A particularly preferred compound of Formula (I) above is the UTP analog uridine 5'-O-(3-thiotriphosphate) (or "UTP.gamma.S").

The present invention is explained in greater detail in the Examples which follow. These examples are intended as illustrative of the invention, and are not to be taken as limiting thereof. Amiloride was obtained from Sigma Chemicals (St. Louis, Mo.); benzamil and phenamil were a gift from Dr. Thomas Kleyman of the University of Pennsylvania. The composition of Krebs bicarbonate Ringer's solution (KBR) was 140 milliMolar (mM) Na.sup.+, 120 mM Cl.sup.-, 5 2 mM K.sup.+, 25 mM HCO.sub.3.sup.-, 2.4 mM HPO.sub.4.sup.2-, 0.4 mM H.sub.2 PO.sub.4.sup.-, 1.1 mM Ca.sup.2+, and 5 mM glucose.

Nasal specimens are obtained from human subjects and are typically inferior turbinates removed for sleep apnea syndromes or plastic reconstruction. The cell culture procedures used in this example are performed as described in Willumsen, N. J., et al., Am. J. Physiol. 256:C1033-C1044 (Cell. Physiol. 25) (1989) and Yankaskas, J. R., et al., Am. Rev. Respir. Dis. 132:1281-1287 (1985). Cells from freshly excised specimens are protease isolated with protease XIV (Sigma, St, Louis, Mo.), concentrated, and plated on collagen membranes in the bottom of plastic-tissue culture cups. The cells are fed for 5 days with serum-free F-12 medium containing the following additives (F-12/7X): insulin, epidermal growth factor, cholera toxin, transferrin, hydrocortisone, triiodothyronine, and endothelial cell growth substance. Subsequently, they are fed with F-12/7X media supplemented (1:1) with 3T3 fibroblast-conditioned media containing 1% fetal bovine serum. After the fifth day in culture, the transepithelial potential difference (PD) developed by the culture is measured daily to detect the occurrence of confluency. Cell preparations are routinely studied within 1 day of the development of the maximal PD.

The transepithelial electrophysiological techniques used in this example have been described in Willumsen, N. J., et al., Am. J. Physiol. (Cell Physiol. 25) 256:C1033-C1053 (1989).

The tissue preparation described in Example 1 is mounted in a modified (superfusion, not recirculating), miniature Ussing chamber interfaced to a voltage clamp that measures transepithelial PD and the PD response to constant current (I) pulses. The chamber contains 1 ml of bathing solution for each (apical; basolateral) surface of the preparation. The solution used as the vehicle for drug delivery is a Krebs bicarbonate Ringer solution (KBR) which approximates the ionic composition of plasma. This solution is warmed (37.degree.) and gassed (95% oxygen, 5% CO.sub.2) to maintain pH 7.4. The cultured cells are superfused on both surfaces with KBR. Drugs are delivered by adding drug selectively to the apical or basolateral perfusate and monitoring the preparation for 5 minutes with a drug expected to affect transepithelial sodium transport (here, amiloride, benzamil, phenamil or 5-(N,N,-hexamethylene)amiloride (EIPA)).

The measurement of sodium transport rates is performed by recording the spontaneous transepithelial PD (V.sub.t) and responses of the PD to constant current pulses. From the relationship between V.sub.t and induced V.sub.t deflections, the transepithelial resistance (R.sub.t) is calculated. The short-circuit current (I.sub.sc), or measure of sodium transport rate, is determined as I.sub.sc =V.sub.t /R.sub.t. Measurements of transepithelial unidirectional isotopic Na+ fluxes, in cultures matched on the basis of V.sub.t and R.sub.t (<25% difference), mounted in Ussing chambers, bathed by KBR, gassed with a 95% O.sub.2 -5% CO.sub.2 gas mixture, and warmed to 37.degree. C., confirmed that I.sub.sc is a measure of Na.sup.+ transport.

Each cultured human airway epithelial preparation is exposed to different concentrations (10.sup.-8 M-10.sup.-3 M) of a sodium-channel blocking drug on either the basolateral or apical surface for the dose response studies. To construct concentration-effect relationships of the response to the drugs, it was assumed that the same maximum response to a drug could be induced from each tissue culture preparation from the same individual.

Effects of Benzamil and Phenamil on Sodium Absorption as Compared with Amiloride

FIG. 1 shows the log concentration-effect curves (percentage of maximum inhibition of sodium absorption as a function of the log of drug concentration) of amiloride, benzamil, phenamil and 5-(N,N,-hexamethylene)amiloride (or EIPA) applied to the apical surface of human nasal epithelium. Data points represented by inverted triangles indicate the effect of EIPA on sodium absorption; upright triangles indicate benzamil; circles represent phenamil and squares represent amiloride.

These results illustrate the comparative effects of amiloride, benzamil and phenamil on the steady-state inhibition of Na.sup.+ transport rates by human nasal epithelia. Sodium uptake is inhibited less than 10% by EIPA; that is, EIPA has very little effect on sodium transport rate. Amiloride appears to be a potent blocker of apical Na.sup.+ channels in Na.sup.+ -absorbing epithelia, but is significantly less potent than benzamil or phenamil, which achieve the same level of complete sodium channel blocking at approximately one log concentration less.

Persistence of Efficacy of Benzamil, Phenamil and Amiloride

In vivo, drug is delivered to the lungs as a single bolus. Hence, the duration of drug action in vivo will reflect (1) the retention of the drug in the airway surface liquid compartment, and (2) binding of drug to the target site within the airway epithelium. This Example illustrates the contribution of binding of drug to the target site (2) to the duration of drug action.

A protocol was designed to measure the duration of drug action after removal of drug from the airway surface liquid compartment. For this protocol, human airway epithelial preparations as described in Example 1 are mounted in modified Ussing chambers and interfaced to voltage clamps as described above in Example 2. Basal measurements of I.sub.sc in KBR are made and the steady state response to a 5 minute administration of a single maximal effective concentration (10.sup.-5 M) of drug delivered to the luminal surface is measured. Following this step, administration of the drug is stopped, the lumen is perfused with standard KBR solutions, and the time required for I.sub.sc to return to baseline or basal levels is measured. The percent washout time for each drug is calculated as: ##EQU1## where T.sub.rb =time to return to basal I.sub.sc after cessation of drug administration; T.sub.cd =time at which administration of drug ceases; X=test drug (benzamil or phenamil); and A=amiloride.

FIG. 2 illustrates a comparison of the persistence of the Na.sup.+ absorption blockade after the washout of amiloride, benzamil and phenamil. The time needed for the washout of phenamil and benzamil as compared to the time needed to wash out amiloride is shown. Benzamil and phenamil have a significantly longer duration of activity than amiloride, with benzamil and phenamil remaining effective in sodium-absorbing channels almost twice as long as amiloride.

The foregoing Examples are illustrative of the present invention, and are not to be construed as limiting thereof. The invention is defined by the following claims, with equivalents of the claims to be included therein.