A uric acid-lowering drug composition and its application

Abstract

This invention discloses a uric acid-lowering drug composition, which comprises one or more of the following: levocarnitine, levocarnitine derivatives, pharmaceutically acceptable salts of levocarnitine or its derivatives, glucocorticoids, colchicine, nonsteroidal anti-inflammatory drugs, IL-1β inhibitors, drugs that inhibit uric acid production, drugs that promote uric acid excretion, and uricase. The composition has the effects of lowering uric acid, protecting liver and kidney function, and inhibiting leukopenia.

Description

Technical Field

[0001] This invention relates to the field of pharmaceuticals, and more specifically to the use of a uric acid-lowering pharmaceutical composition in the preparation of drugs for treating hyperuricemia and gout. Background Technology

[0002] Currently, the number of drugs available for the treatment of hyperuricemia and gout in China is very limited. The main treatment relies on nonsteroidal anti-inflammatory drugs (NSAIDs) such as indomethacin, colchicine, glucocorticoids such as dexamethasone, xanthine oxidase (XO) inhibitors such as allopurinol and febuxostat, and uricosuric drugs such as probenecid and benzbromarone. Most of these drugs were developed and marketed in the 1950s and have significant toxic side effects, which limits their application to some extent. Several novel anti-gout drugs approved for marketing abroad, such as topipustine, lesinurad, pegylated recombinant uricase, and recombinant aflatoxin uricase, are not yet available in China. Topipustine is currently undergoing Phase III clinical trials, and its safety data is incomplete. Lesinurad has been shown to have significant toxicity in clinical studies, and the US FDA has issued a black box warning in its product information. This drug is currently undergoing import registration in China but has not yet begun clinical trials. Pegylated recombinant uricase and recombinant aflatoxin uricase are uricase analogues, primarily used for severe hyperuricemia and refractory gout, but they are prone to inducing acute gout attacks. Furthermore, these drugs are antigenic, easily causing hypersensitivity reactions and drug resistance; currently, due to safety concerns, they have not yet been registered as new drugs or imported drugs in China.

[0003] Indomethacin and colchicine are only suitable for the treatment of acute gout attacks. They not only cause common gastrointestinal damage, but also have hepatotoxicity and nephrotoxicity. They should be used with caution in patients with renal insufficiency.

[0004] The glucocorticoid dexamethasone is only suitable for acute gout attacks, but it has many contraindications and a series of side effects on the cardiovascular, digestive, and nervous systems. It carries the risk of cardiovascular accidents, is not suitable for long-term or repeated use, and symptoms may rebound after discontinuation.

[0005] Allopurinol, a non-selective xanthine oxidase (XO) inhibitor, commonly has side effects such as gastrointestinal reactions, leukopenia, drug rash, and bone marrow suppression. It is contraindicated in patients with severe renal insufficiency and is not suitable for acute gout attacks. On October 18, 2013, the State Food and Drug Administration issued the 57th issue of the "Adverse Drug Reaction Information Bulletin," highlighting the safety issues of allopurinol causing severe drug rash and advising that close monitoring should be conducted during clinical use due to the numerous serious adverse reactions of allopurinol.

[0006] Febuxostat, a selective xanthine oxidase (XO) inhibitor, was approved by the FDA in 2009 for the long-term treatment of hyperuricemia in patients with gout. It is not suitable for the treatment of secondary hyperuricemia and is not recommended for asymptomatic hyperuricemia. Compared to allopurinol, it is more effective in lowering uric acid and significantly reduces the size of gouty tophi. However, febuxostat does not eliminate the risk of triggering gout attacks. Clinically, it needs to be used in combination with colchicine or glucocorticoids during gout attacks. Aside from this, its safety profile is... Comprehensive data on febuxostat is lacking. Some studies suggest that febuxostat is safer than allopurinol, while others indicate that the incidence of adverse reactions is lower with a 40mg dose than with allopurinol, but higher with a 80mg dose. The most common adverse reactions are abnormalities in cardiac and hepatic function and vascular events (cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke). The U.S. Food and Drug Administration issued a black box warning on February 21, 2019, stating that febuxostat increases the risk of cardiac-related death and all-cause mortality. Therefore, close monitoring of liver function and signs and symptoms of myocardial infarction (MI) and stroke is still necessary with febuxostat. Topixate is currently undergoing phase 3 clinical trials in China, and safety data are still incomplete.

[0007] The uricosuric drugs probenecid, benzbromarone, and lesinurad are only suitable for use during the intercritical period of gout attacks and for chronic gout. They also have side effects such as gastrointestinal reactions, liver and kidney toxicity. Probenecid is nephrotoxic and is contraindicated in patients with renal insufficiency and those allergic to sulfonamides. Benzbromarone is hepatotoxic; the State Food and Drug Administration issued a special notice on December 31, 2014, reminding patients to pay attention to the risk of liver damage from benzbromarone. Lesinurad, used alone or at high doses, is a major risk factor for acute renal failure and is not recommended for patients with a creatinine clearance of less than 45 ml / min. The approved dosage of lesinurad in the United States and the European Union is 200 mg / day. Treatment with lesinurad at 400 mg / day significantly increases the incidence of adverse events and serious adverse events, especially renal and cardiovascular events. Therefore, the US FDA included a boxed warning in the lesinurad product information that treatment with lesinurad 400 mg / day carries a risk of acute renal failure, particularly in patients not using an XOI (allopurinol or febuxostat). The EU regulatory authorities have also issued similar safety recommendations and requested enhanced post-marketing safety monitoring of lesinurad, especially in patients with cardiovascular disease.

[0008] Uricase drugs mainly include recombinant aflatoxin uricase and pegloticized recombinant uricase. Both drugs have a rapid and potent effect in lowering blood uric acid and are mainly used for severe hyperuricemia and refractory gout, but they are prone to inducing acute gout attacks. In addition, these drugs are antigenic and can easily cause hypersensitivity reactions and drug resistance.

[0009] In summary, existing drugs for the prevention and treatment of hyperuricemia and gout have significant side effects such as liver and kidney toxicity, skin rashes, induction of acute gout attacks, cardiovascular accidents, and drug resistance, which limit their clinical application. Finding new, highly effective, low-toxic drugs suitable for the prevention and treatment of hyperuricemia and gout remains a challenge in pharmaceutical research, and developing new drugs for the treatment of hyperuricemia and gout has become an urgent task.

[0010] L-carnitine is a compound with multiple physiological functions, primarily promoting fatty acid β-oxidation, glucose oxidation and utilization, and aerobic metabolism. L-carnitine and its derivatives are well-known compounds and have been clinically used to treat carnitine deficiency from various causes. It is a FDA-approved safe substance in the United States, and in my country, L-carnitine is also listed as a food and drug in national standards. The oral dosage is 1-3g / day; the injectable dosage is 50-300mg / kg, with good safety profiles. Furthermore, there are numerous clinical reports of its use in treating chronic renal failure, protecting renal function, myocarditis, heart failure, coronary heart disease, myocardial infarction, anti-fatigue, improving exercise endurance, anti-oxidation, and anti-cancer effects, indicating that L-carnitine has a positive clinical therapeutic effect on common comorbidities of gout, especially metabolic and cardiovascular diseases.

[0011] Chinese patent CN200710021408.7, entitled "Pharmaceutical Compositions Containing L-carnitine or its Derivatives Thereof and Their Uses", discloses that L-carnitine at concentrations of 250 mg / kg, 500 mg / kg, and 1000 mg / kg can reduce serum uric acid in mice with hyperuricemia. Summary of the Invention

[0012] The first objective of this invention is to provide a uric acid-lowering drug composition, and the second objective is to provide the application of the uric acid-lowering drug composition in the preparation of drugs for treating hyperuricemia and gout.

[0013] The uric acid-lowering drug composition of the present invention comprises one or more of levocarnitine, levocarnitine derivatives, pharmaceutically acceptable salts of levocarnitine or its derivatives, and one or more of glucocorticoids, colchicine, nonsteroidal anti-inflammatory drugs, IL-1β inhibitors, drugs that inhibit uric acid production, drugs that promote uric acid excretion, and uricase drugs.

[0014] The levocarnitine derivatives described in this invention are selected from acetyllevocarnitine, propionyllevocarnitine, valeratelevocarnitine, isovaleryllevocarnitine, butyryllevocarnitine, isobutyryllevocarnitine, and their pharmaceutically acceptable salts and pharmaceutically acceptable salts of levocarnitine. Levocarnitine, acetyllevocarnitine, and their pharmaceutically acceptable salts are preferred. Levocarnitine and its pharmaceutically acceptable salts are particularly preferred. The pharmaceutically acceptable salts of levocarnitine described in this invention comprise hydrochloride, hydrobromide, hydroiodide, sulfate, nitrate, phosphate, acetate, maleate, fumarate, citrate, citrate, oxalate, succinate, tartrate, malate, mandelate, trifluoroacetate, pantothenate, methanesulfonate, and p-toluenesulfonate.

[0015] The glucocorticoids mentioned in this invention are selected from prednisone, methylprednisone, betamethasone, beclomethasone dipropionate, dexamethasone, prednisolone, hydrocortisone, and dexamethasone; the nonsteroidal anti-inflammatory drugs are selected from aspirin, acetaminophen, indomethacin, naproxen, naproxen, diclofenac, ibuprofen, nimesulide, rofecoxib, and celecoxib; the drugs that inhibit uric acid production are selected from allopurinol, febuxostat, and topiptostat; the drugs that promote uric acid excretion are selected from probenecid, sulfadiazine, benzbromarone, and lesinurad; and the uric acid oxidases are selected from Puricase and Rasburicase.

[0016] The pharmaceutical compositions of this invention are administered orally, by injection, or topically. Oral administration includes tablets, granules, capsules, oral solutions, syrups, inhalers, and sprays; injectable administration includes lyophilized powder for injection, suspensions for injection, emulsions for injection, and solutions for injection; topical administration includes aerosols, ointments, lotions, suppositories, patches, liniments, eye drops, and vaginal effervescent tablets.

[0017] The dosage of each drug component in the pharmaceutical composition of the present invention is based on the dosage recorded in the instructions for use of the drug products for which these components are already on the market. Alternatively, the preferred weight ratio range or specific proportion of each drug component can be determined through limited scientific experiments.

[0018] L-carnitine and its derivatives are well-known compounds and have been used clinically to treat carnitine deficiency from various causes. It is a FDA-approved safe substance in the United States, and in my country, L-carnitine is also listed as a food and drug in national standards. The oral dosage is 1-3g / day; the injectable dosage is 50-300mg / kg, with good safety profiles. L-carnitine has a wide range of clinical applications, with numerous reports of its use in treating chronic renal failure, protecting kidney function, myocarditis, heart failure, coronary heart disease, myocardial infarction, anti-fatigue, improving exercise endurance, anti-oxidation, and anti-cancer effects. Liver and kidney damage, metabolic diseases, and cardiovascular diseases are common comorbidities of gout. Combining L-carnitine, its derivatives, or its pharmaceutically acceptable salts with existing clinically used drugs for treating hyperuricemia and gout, or using them in combination, not only has significant anti-inflammatory, analgesic, and uric acid-lowering effects on gout itself, but also provides comprehensive protection and prevention against liver and kidney damage, cardiovascular events, and comorbid liver and kidney damage, metabolic diseases, and cardiovascular diseases caused by long-term use of chemical drugs for gout treatment. This allows for the simultaneous treatment of gout and its comorbidities, an advantage not currently available with other chemical drugs for gout.

[0019] The researchers of this invention have demonstrated through animal experiments that when levocarnitine or its derivatives or pharmaceutically acceptable salts are used in combination with gout treatment drugs such as allopurinol and probenecid, they have a synergistic effect and reduced toxicity compared to single-component drugs.

[0020] Rats were fed a yeast diet and administered potassium oxonate (a uricase inhibitor) via gavage to induce hyperuricemia. The therapeutic effects of this combination of L-carnitine and different doses of allopurinol were then observed. The results showed that L-carnitine combined with allopurinol via gavage had a good synergistic effect in reducing uric acid levels in hyperuricemic rats. Furthermore, L-carnitine combined with allopurinol via gavage had a very good antagonistic effect on the hepatotoxicity and nephrotoxicity induced by allopurinol in rats and on the side effects of leukopenia. Detailed Implementation

[0021] The following examples are merely illustrative of the invention and are not intended to limit the scope of the invention.

[0022] Example 1: Effects of L-carnitine combined with allopurinol on a rat model of hyperuricemia.

[0023] 1. Preparation of a rat model of hyperuricemia

[0024] After 3 days of acclimatization, SD rats were weighed and administered a 0.5% CMCNa2 suspension (1.5 g / kg potassium oxonate + 300 mg / kg uric acid) by gavage once daily for 20 days to establish a hyperuricemia model. On day 20, 1 ml of blood was collected from the rat's orbital sinus, centrifuged at 3000 rpm for 5 minutes, and serum was collected. The uric acid level of the rats was measured using a uric acid ELISA kit. When the uric acid level remained above 300 μmol / ml, the model was considered successfully established. Unfit animals with low uric acid levels were culled, and rats with the target uric acid level were randomly assigned to other groups.

[0025] 2. Grouping and administration

[0026] Normal control group: physiological saline

[0027] Model control group: physiological saline

[0028] Allopurinol monotherapy groups: allopurinol 20 mg / kg group, allopurinol 30 mg / kg group, allopurinol 40 mg / kg group, allopurinol 60 mg / kg group.

[0029] Combination therapy groups: allopurinol 20mg + levofloxacin 500mg / kg, allopurinol 30mg + levofloxacin 500mg / kg, allopurinol 40mg + levofloxacin 500mg / kg, and allopurinol 60mg + levofloxacin 500mg / kg. A total of 10 groups, 10 animals per group. Administration volume: 5ml / kg, by gavage, twice daily, for 14 consecutive days.

[0030] 3. Observation Indicators

[0031] On the night of the 13th day after drug administration, rats were placed in metabolic cages to collect urine, which was used for routine urinalysis. On the 14th day, one hour after the last drug administration, blood was collected to perform routine blood tests. Serum was used to detect various biochemical indicators such as uric acid, liver function (alanine aminotransferase, aspartate aminotransferase, etc.), and kidney function.

[0032] 4. Experimental Results

[0033] After 20 days of modeling using the uricase inhibitor potassium oxonate plus uric acid via gavage, uric acid levels in rats significantly increased, reaching approximately 292 mmol / L, more than three times higher than the normal group. While maintaining the model, rats were treated with allopurinol at doses of 20 mg / kg, 30 mg / kg, 40 mg / kg, and 60 mg / kg, plus L-carnitine at this dose, via gavage twice daily for 14 consecutive days. Blood test results are as follows:

[0034] 4.1 Effects of allopurinol monotherapy combined with levocarnitine on uric acid levels in rats

[0035] Effects on uric acid: The uric acid level of the normal control group rats was around 98 mmol / L. As shown in Table 1, the dosage of allopurinol monotherapy started from 20 mg / kg and increased to a maximum of 60 mg / kg. After 14 days of treatment, the uric acid level decreased with the increase of allopurinol dosage, indicating that allopurinol monotherapy has a good effect on lowering uric acid levels. On the basis of different dosages of allopurinol monotherapy, the combination with the same dose (500 mg / kg) of L-carnitine will make the uric acid-lowering effect of allopurinol more obvious. Compared with monotherapy, the combination of different doses of allopurinol and L-carnitine can further reduce uric acid by about 10-15%.

[0036] Table 1. Effects of allopurinol monotherapy and levocarnitine combination therapy on uric acid levels in rats

[0037]

[0038] 4.2 Effects of combined allopurinol and levocarnitine on renal function in rats

[0039] Effects on creatinine and blood urea nitrogen: Low doses of allopurinol have little effect on renal function. However, at higher doses (60 mg / kg), creatinine and blood urea nitrogen levels increase, indicating that high doses of allopurinol can cause some damage to renal function. At this dose, the combined use of L-carnitine, compared to allopurinol monotherapy, resulted in lower creatinine and blood urea nitrogen levels, suggesting that L-carnitine offers some protection against renal damage caused by high doses of allopurinol alone.

[0040] Table 2. Effects of allopurinol monotherapy combined with levocarnitine on uric acid and renal function in rats (X±s, n=10)

[0041]

[0042] Compared with the model group: ***P<0.001; Δ P<0.05 compared with single drug.

[0043] 4.3 Effects of combined allopurinol and levocarnitine on liver function in rats with hyperuricemia

[0044] Compared with normal rats, hyperuricemia did not affect rat transaminase levels, and the transaminase levels in the model group were similar to those in the normal group. Allopurinol alone and in combination did not significantly affect aspartate aminotransferase (AST); however, it did affect alanine aminotransferase (ALT). When L-carnitine and allopurinol were used in combination, AST levels were lower than when allopurinol was used alone. Especially at higher doses of allopurinol, the combination with L-carnitine significantly reduced AST levels (P<0.05), suggesting that L-carnitine may have a role in mitigating liver damage caused by allopurinol.

[0045] Table 3. Effects of allopurinol monotherapy and levocarnitine combination therapy on liver function in rats (x±s, n=10)

[0046]

[0047] Compared with the model group: *P<0.05, ***P<0.001

[0048] 4.4 Effects of combined allopurinol and levocarnitine on blood routine tests in rats with hyperuricemia

[0049] Allopurinol has a significant side effect of reducing human leukocytes. In this experiment, its effect on reducing leukocytes in rats was also very pronounced. As shown in Table 3, with the increase of the single-drug dose of allopurinol, the leukocyte count decreased sharply. The normal leukocyte count in rats is 21 × 10⁻⁶. 9 / L, when the allopurinol dose was 20 mg / kg, the white blood cell count decreased to 15.5 × 10 / L. 9 / L; At a dose of 30 mg / kg, allopurinol reduced the white blood cell count to 9.17 × 10⁹ / L. 9 / L; while at the highest dose of 60 mg / kg, the decrease in white blood cell count was only 4.04 × 10⁹ / L; 9 / L, the reduction was very significant. When levocarnitine was used in combination with allopurinol, the trend of leukopenia was significantly slowed down. At the other three doses of allopurinol below 60 mg / kg, there was no decrease in white blood cell count in the combination group. At the high dose of allopurinol up to 60 mg / kg, the white blood cell count in the combination group was significantly higher than that in the monotherapy group (P<0.001).

[0050] The experiment also found that hyperuricemia had no effect on the number of red blood cells, platelets, and hemoglobin in rats; allopurinol alone and in combination with L-carnitine also had no effect on the number of red blood cells, platelets, and hemoglobin (Table 4).

[0051] Table 4. Effects of combined administration of levocarnitine and allopurinol on complete blood counts in rats with hyperuricemia (x±s, n=10)

[0052]

[0053] Compared with the model control group, ***P<0.001, compared with the single-drug group ΔΔΔ P<0.001

[0054] 5. Experimental Conclusions

[0055] L-carnitine combined with allopurinol administered via gavage showed a good synergistic effect in reducing uric acid levels in rats with hyperuricemia. Furthermore, L-carnitine combined with allopurinol administered via gavage effectively antagonized the hepatotoxicity and nephrotoxicity induced by allopurinol in rats, as well as its effect on leukopenia.

[0056] Example 2

[0057] A hyperuricemia model was established according to the method in Example 1. Mice were randomly divided into four groups: L-carnitine 300 mg / kg group, febuxostat 2 mg / kg group, benzbromarone 2.5 mg / kg group, allopurinol (10 mg / kg allopurinol + 2 mg / kg benzbromarone) group, L-carnitine 300 mg / kg + febuxostat 2 mg / kg group, L-carnitine 300 mg / kg + benzbromarone 2.5 mg / kg group, and L-carnitine 300 mg / kg + allopurinol (10 mg / kg allopurinol + 2 mg / kg benzbromarone) group. Administered via gavage for 14 consecutive days. One hour after the last administration, blood was collected from the fundus venous plexus of the mice, serum was separated, and serum uric acid levels were measured.

[0058] The results are as follows:

[0059] Table 5. Uric acid-lowering effect in a rat model of hyperuricemia

[0060]

[0061] Experimental conclusion: L-carnitine has a significant synergistic effect when used in combination with different uric acid-lowering drugs.

[0062] Example 3: Effect of sodium urate (MSU) on paw edema induced in rats

[0063] SD rats were randomly divided into 5 groups: model group (5 ml / kg saline), colchicine group (1 mg / kg / d), dexamethasone group (5 mg / kg / d), L-carnitine group (200 mg / kg / d), L-carnitine + colchicine group, and L-carnitine + dexamethasone group, with 10 animals in each group. Administered the drugs by gavage for 7 consecutive days.

[0064] One hour after the last administration, a mark was made on the right hind limb ankle joint with a marker. The right ankle joint was then placed into the test cup of the plantar volume measuring instrument up to the mark, and the pre-inflammatory plantar water displacement was recorded. Then, the right hind paw of the rat was disinfected with 75% alcohol, and 0.1 ml (100 mg / ml) of pre-sterilized sodium urate suspension was injected subcutaneously into the rat's paw to induce inflammation. The plantar water displacement of the rat's right hind paw was measured at 1, 2, 3, 4, and 5 hours after inflammation, and the swelling rate was calculated according to the formula. The average of the five measurements after inflammation in each group was taken to calculate the swelling inhibition rate.

[0065] Swelling rate (%) = (Post-inflammatory plantar volume - Pre-inflammatory plantar volume) / Pre-inflammatory plantar volume × 100%

[0066] Swelling inhibition rate (%) = (Swelling rate of the model group - Swelling rate of the drug treatment group) / Swelling rate of the model group × 100%.

[0067] Experimental results:

[0068] Table 6. Effect of L-carnitine on the degree of paw edema after MSU-induced inflammation in SD rats (n=10); x ± s )

[0069]

[0070] *P<0.05, **P<0.01, ***P<0.001 (Comparison with the model group)

[0071] Experimental conclusion: L-carnitine administered by gavage significantly reduced paw edema in rats induced by urate injection. It also showed a good inhibitory effect on acute gout induced by sodium urate.

[0072] The results of the above report clearly demonstrate the unexpected synergistic and toxicity-reducing effects of the compositions of the present invention relative to individual components.

Claims

1. The use of a uric acid-lowering pharmaceutical composition in the manufacture of a medicament for the treatment of hyperuricemia, gout, characterized in that, The pharmaceutical composition comprises levocarnitine and allopurinol, the dose of levocarnitine is 500 mg / kg, and the dose of allopurinol is 20 mg / kg, 30 mg / kg or 40 mg / kg. The pharmaceutical composition comprises levocarnitine and allopurinol, the dose of levocarnitine is 500 mg / kg, and the dose of allopurinol is 20 mg / kg, 30 mg / kg or 40 mg / kg. The pharmaceutical composition comprises levocarnit

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