Lactate-protected hypoglycemia to treat glycolysis-dependent pathological conditions, particularly cancer

Abstract

To provide a kit for treating a glycolysis-dependent pathological condition in a human or animal.SOLUTION: A kit for treating a glycolysis-dependent pathological condition includes a lactic acid, insulin and glucose, and optionally includes one or more components selected from a glucagon inhibitor, an α-β adrenergic blocker and an antidiabetic agent. The treatment includes intravascular, particularly intravenous, delivery of the lactic acid, insulin and glucose into circulation of a human or animal to be treated in order to induce hypoglycemia and hyperlactatemia. The glycolysis-dependent pathological condition is selected from a group consisting of cancer, bacterial infection and parasite infection.SELECTED DRAWING: None

Description

[Technical field]

[0001] The present invention relates to a kit comprising multiple components for the treatment of a glycolysis-dependent condition in a human or animal. [Background technology]

[0002] Cancer is the number one cause of death worldwide, with incidence rates continuing to increase, responsible for over 8 million deaths in 2015. Nearly 1 in 6 deaths worldwide is due to cancer. There are many different forms of cancer, as well as various forms of treatment, including surgery, chemotherapy, radiation therapy, hormonal therapy, immunotherapy, and other forms of targeted therapy. Because many forms of cancer cannot be cured and not all therapies work equally well for all patients, there remains a great need for new treatment modalities.

[0003] The aim of the present invention is to directly interfere with the metabolism of cancer cells and tissues. Whereas normal tissues may intermittently produce significant amounts of lactate by glycolysis under limited aerobic conditions, many cancers continuously produce significant amounts of lactate by glycolysis even in the presence of sufficient oxygen. This predominant aerobic glycolysis by cancers is called the Warburg effect. The Warburg effect is a unique characteristic of cancers and is defined as the uptake of huge amounts of glucose by tumors, even in the presence of sufficient oxygen, while simultaneously producing large amounts of lactate.

[0004] 18F-deoxyglucose positron emission tomography (FDG-PET) scanning detects malignant tissues that have increased glucose uptake as a result of the Warburg effect. The routine use of FDG-PET for the diagnosis and / or follow-up of cancer has become highly widespread. FDG-PET scans reveal the Warburg effect in cancers of the biliary tract, bladder, bone, breast, central nervous system, cervix, colon, esophagus, kidney, larynx, liver, lung, nasopharynx, oropharynx, ovary, pancreas, prostate, rectum, skin, soft tissue, stomach, testis, thyroid, and uterus. FDG-PET also reveals the Warburg effect in more disseminated malignancies such as Hodgkin's lymphoma, leukemia, melanoma, multiple myeloma, and non-Hodgkin's lymphoma. The fact that this list represents the vast majority of cancer types underscores the central role of the Warburg effect in cancer.

[0005] The degree of FDG-PET positivity is strongly associated with tumor acidosis, and since both the degree of FDG-PET positivity and tumor acidosis are associated with worse clinical prognosis, FDG-PET is directly associated with the Warburg effect and prognosis.

[0006] High production of lactate by cancer cells can result in acidification of extracellular tumor tissue and its environment. This localized acidosis and increase in lactate, regardless of the presence or absence of hypoxia, certainly characterizes many tumors, where more pronounced acidosis is associated with enhanced invasive potential. Localized lactic acidosis has also been shown to act to degrade tissue surrounding the cancer by inducing apoptosis and necrosis of non-malignant cells.

[0007] Even when malignant cells have sufficient ATP produced by oxidative phosphorylation, they still use and require glucose for specialized glycolysis-powered processes that are often membrane-bound. These glycolysis-powered processes (e.g., the rapid efflux of chemotherapeutic agents by so-called ABC transporters) serve invasive (translocation) and self-defense purposes for tumor cells, facilitating resistance to chemotherapy. Similarly, glycolysis also facilitates resistance to radiation therapy and immunotherapy by allowing tumors to create hypoxic and acidic microenvironments that reduce tumor sensitivity to radiation and impede the effectiveness of immune cells to attack cancer.

[0008] For this reason, strategies have been proposed to inhibit glycolysis as an anticancer treatment. In vitro, the effect of glucose depletion is potently tumoricidal, but in vivo, severe hypoglycemia itself can be immediately lethal due to the host's normal need for glucose. This has led to the proposal to provide a "salvage fuel" for non-malignant tissues, while at the same time lowering systemic glucose levels with insulin, thus denying the necessary fuel for tumor growth. Compounds such as glycerol have been proposed, but glycerol does not bypass glycolysis and may even induce elevated glucose levels.

[0009] Glycolysis can be much faster than oxidative phosphorylation. Thus, lactate acts as an essential buffer that allows these two ATP-producing processes to operate optimally independently under physiological or pathophysiological conditions in humans and animals. Thus, the "lactate shuttle" exists at the microscopic and macroscopic levels, i.e., from the cellular to the systemic level. Thus, like glucose, lactate is the main fuel oxidized by organs such as the heart, skeletal muscle, brain, kidney, and liver.

[0010] The role of lactate as a buffer fuel defines the body's ability to metabolize large amounts of endogenous or exogenous lactate, as shown in patients undergoing so-called continuous venovenous hemofiltration (CVVH) with large volumes of lactate replacement fluids: patients undergoing CVVH are able to metabolize lactate in the long term at a rate that allows for metabolic maintenance.

[0011] Cancer cells preferentially produce ATP via glycolysis and are accustomed to producing lactate but not to consuming lactate, so cancer cells that exhibit the Warburg effect may have difficulty utilizing lactate as fuel. For this reason, it was hypothesized by Nijsten & Van Dam that local or systemic induction of hypoglycemia induced by insulin combined with lactate (sodium) administration as rescue fuel would not harm normal tissues but would adversely affect the growth of tumors that exhibit the Warburg effect (Medical Hypotheses 73 (2009) pp. 48-51).

[0012] Two important side effects are known from acid-base and electrolyte physiology from the intravenous administration of large amounts of sodium lactate: systemic metabolic alkalosis and hypernatremia. These side effects are unacceptable and make sodium lactate unsuitable for inducing sustained hyperlactatemia in patients or animals. Summary of the Invention [Problem to be solved by the invention]

[0013] Therefore, the objective of the present invention is to create a feasible and safe protocol to reach a lactate-protected hypoglycemic state in which cancer cells are deprived of an energy source and thus are significantly inhibited in their ability to proliferate or are damaged and even killed. Glucose deprivation may also enhance several established and important cancer treatments, such as chemotherapy or radiotherapy, since chemotherapy or radiotherapy resistance is often glycolysis-dependent. In addition, it is expected that immunotherapy will be more effective when the majority of cancer cells are destroyed or the factors directly or indirectly responsible for maintaining the immunosuppressive acidic environment within the tumor are significantly disrupted by the damaging effects of temporary hypoglycemic periods.

[0014] The present invention provides a kit containing multiple components that, when used in a specific sequence, induce an effective hypoglycemic state protected by hyperlactatemia. The kit includes lactate (HLa), insulin, glucose, and optionally, an alpha-beta blocker and a glucagon inhibitor. The kit may further include an antidiabetic agent.

[0015] It has been found that administering high doses of HLa instead of sodium lactate (NaLa) does not result in metabolic alkalosis or hypernatremia that may be damaging to the patient. HLa can be used in this way or in combination with a small fraction of NaLa. Of the total lactate delivered, the fraction of NaLa should preferably be less than 20%, but may be greater than 20% when the risk of metabolic alkalosis and hypernatremia is low or reduced by additional treatment, or when only short-term hypoglycemic conditions are required.

[0016] Continuous administration of HLa in amounts required to primarily support host metabolism has not previously been achieved.

[0017] HLa administration requires a system dedicated to avoiding acute hemolysis. Such a system is, for example, an ex vivo perfusion circuit to avoid acute hemolysis at the contact of red blood cells with concentrated HLa. Suitably, this can be achieved by a dialysis circuit in which HLa is mixed with ultrafiltrate before being recombined with whole blood, as described by Zanella et al. (Anesthesiology 2014;120:416-24). The HLa is then thoroughly mixed with the blood. Blood lactate levels usually vary between 0.5 and 1.5 mmol / L. In the treatment of the present invention, this value is increased to 8-10 mmol / L, although it is envisaged that both higher and lower values ​​will be useful.

[0018] Insulin is used to lower the body's glucose levels in order to deprive tumor cells of their preferred energy source. Glucose levels are lowered to about 25% of normal levels in a controlled manner. In one embodiment, insulin is administered together with glucose by the so-called "clamp" technique. Clamping allows for much better control of glucose levels. Clamping techniques are widely used for scientific purposes, but have never been used for therapeutic purposes or to achieve the extremely low glucose levels achieved by the present invention.

[0019] According to the present invention, extremely low (i.e., <2 mmol / L) hypoglycemic levels maintained for several hours around a pre-set target are readily achieved by the use of strong, rapidly reversible inhibition of counter-responses and the co-administration of glucose to stabilize glucose levels at any target value above 0.5 mmol / L.

[0020] This (very large) insulin bolus alone makes it very difficult to achieve the desired glucose target, as well as the desired maintenance period. Both overshoot and undershoot can easily occur when insulin is administered alone.

[0021] When the body detects impending hypoglycemia, glucose is released from both the liver and kidneys through gluconeogenesis and glycogenolysis. Under physiological conditions, hypoglycemia induces the release of glucagon, which antagonizes the effect of insulin by stimulating hepatic glucose release, and subsequently raises blood glucose levels above the hypoglycemic range. In the treatment of the present invention, this action of glucagon is suppressed by a glucagon inhibitor, which is part of the kit.

[0022] The second component of the physiological counter-response to hypoglycemia is the adrenergic stress response, which involves the release of adrenaline (epinephrine), which also stimulates hepatic glucose release. Thus, alpha-beta adrenergic blockers are included to inhibit this component of the compensatory response.

[0023] Additionally, it is preferred to include an anti-diabetic agent that inhibits gluconeogenesis, which is administered prior to insulin administration to facilitate reduced insulin doses.

[0024] In one embodiment, the patient's glycogen levels are made as low as possible before treatment begins, which can be accomplished by fasting prior to treatment.

[0025] Thus, the present invention relates to a kit of parts that contains a unique combination of pharmaceutical compounds that are administered to a patient in a specific sequence and in specific doses to reach a lactate-protected hypoglycemic (LPH) state, which is then maintained for a specific period of time to cause sufficient damage to cancer cells.

[0026] The present invention can be used to treat many different cancers in which the Warburg effect plays a role and therefore the maintenance of the cancer is dependent on glycolysis. In particular, the present invention is useful in treating cancers and other conditions that are strongly or completely dependent on glycolysis. By strongly dependent on glycolysis, we mean that although the cancer or condition may utilize other sources to generate energy or increase its biomass, glycolysis serves as a critical pathway that allows the cancer or infection to progress much faster than it would in the absence of glucose.

[0027] Thus, the present invention is particularly useful in treating cancers of the biliary tract, bladder, bone, breast, central nervous system, cervix, colon, esophagus, kidney, larynx, liver, lung, nasopharynx, oropharynx, ovary, pancreas, prostate, rectum, skin, soft tissue, stomach, testis, thyroid, and uterus. The Warburg effect is also observed in more disseminated malignancies such as Hodgkin's lymphoma, leukemia, melanoma, multiple myeloma, and non-Hodgkin's lymphoma, and these malignancies may also be treated according to the present invention.

[0028] The kits of the present invention and the resulting metabolic state are also suitable for the treatment of other glycolysis-dependent conditions in humans or animals, including certain bacterial infections and specific parasitic infections such as malaria or trypanosomiasis. Similar to FDG-PET positive cancers, these pathogens are preferentially or exclusively dependent on glucose and would therefore be adversely affected by glucose restriction.

[0029] The four parasites that cause malaria in humans (Plasmodium falciparum, Plasmodium malariae, Plasmodium ovale, and Plasmodium vivax) are all strictly dependent on glucose for ATP production. Thus, inhibition of glucose metabolism has improved malaria outcomes. In the main pathogens of human trypanosomiasis (Trypanosoma brucei and Trypanosoma cruzi), glucose is essentially both the sole carbon source and the sole source of ATP, making the pathogens susceptible to limited glucose availability. Thus, these parasitic infections can also be treated according to the present invention.

[0030] Many bacteria that can cause disease in humans use large amounts of glucose for both growth and ATP production. These bacteria include Gram-positive bacteria (e.g., Staphylococcus spp. and Streptococcus spp.), Gram-negative bacteria (e.g., many Enterobacteriaceae, including E. coli, Enterobacter spp., and Proteus spp.), Pseudomonas spp., and anaerobic bacteria (e.g., Clostridium spp., Lactobacillus spp., Bacteroides spp.).

[0031] Similarly, in many fungi and yeasts (e.g., Aspergillus spp. and Candida spp.), glucose serves as an important carbon source for growth and ATP production. Even during infection in humans and animals, blood and tissue glucose levels constitute an abundant source of nutrition under virtually all circumstances. Thus, targeting glucose availability through reduction of circulating levels provides a theoretical means to combat infection. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0032] Therefore, the present invention relates to a kit containing a number of components for use in a method of treatment resulting in hyperlactatemia and hypoglycemia. This method may be used for the treatment of pathologies dependent on glycolysis. During glycolysis, energy is produced from glucose. If a patient is deprived of glucose and protected by elevated levels of lactate as an alternative energy source, especially in conjunction with certain other treatments, pathogenic processes dependent on glucose as an energy source will be disrupted, leading to the death of cancer cells, bacteria, fungi, yeasts or parasites.

[0033] The first component of the kit is HLa. This compound is administered first, and optionally after the patient has been administered a drug to reduce glucose release by the liver and / or after the patient has fasted to reduce liver glycogen content. The lactate component, NaLa (Na + +La - ) is metabolized to bicarbonate after lactate is completely oxidized. When infused in large quantities, the resulting accumulation of sodium bicarbonate can quickly lead to both undesirable hypernatremia and undesirable metabolic alkalosis. In contrast to NaLa, HLa (pKa 3.8) is completely oxidized to CO2. However, HLa is highly acidic and completely dissociates (H) at physiological pH. + +La - ) Because the amount of HLa required is equivalent to a concentrated large proton load, HLa is delivered in a manner that prevents cellular damage such as acute hemolysis.

[0034] HLa is suitably administered as pure HLa or mixed with NaLa in a diluent such as water or 0.9% saline, in a ratio of at least 75:25 HLa:NaLa, preferably at least 80:20, more preferably at least 90:10, most preferably at least 95:5. By varying the ratio of injected HLa:NaLa, it is possible to bring the host's arterial pH into a desired range, which may vary from acidosis (e.g., pH 7.30) to alkalosis (e.g., pH 7.55) depending on what is considered most effective for the (adjuvant) treatment of the tumor. The diluent is selected from water and 0.9% NaCl. Preferably, the diluent is water.

[0035] To prevent fluid overload, HLa must be administered in a concentrated manner. Preferably, the concentration of the HLa solution ranges from 1000 mmol / L to 4400 mmol / L. The delivery rate of the HLa solution in the blood circulation ranges from 0 to 10 mmol / min, preferably 4 mmol / kg / h, i.e. 5 mmol / min, i.e. 300 mmol / h, in an adult patient of average weight 75 kg. The desired circulating level of lactate to be obtained in the body is 5 to 20 mmol / L, preferably 6 to 15 mmol / L, more preferably 8 to 10 mmol / L. This latter level may take between 15 and 60 minutes, usually about 30 minutes, to reach.

[0036] Once the desired hyperlactatemia state has been achieved, the body's glucose levels are lowered using an insulin bolus followed by an insulin infusion combined with measures to prevent physiological hypoglycemic counteraction. Preferably, a short-acting insulin is used and the amount of insulin administered is based on the weight and baseline glucose levels of the patient being treated. Suitably, a loading dose is administered initially, followed by smaller maintenance doses. The number of units (U) of insulin administered as the initial bolus may be in the range of 0.2-4 U / kg, preferably in the range of 0.4-1 U / kg, most preferably 0.5 U / kg. Insulin is commercially available in concentrations such as 100 or 500 U / mL and is diluted with a pharma- ceutically acceptable diluent.

[0037] Since normal human fasting blood glucose levels are 4.0-6.5 mmol / L, the target value of 1.5 mmol / L is only one-quarter to one-third of the normal value. This target value of 1.5 mmol / L is expected to have a sufficient damaging effect on the cancer, especially if this value is maintained for a long time. If a lower or higher value of glucose (i.e., 0.5-2.5 mmol / L) is desired, this value is achieved using the same clamp technique with the administration of more or less insulin and less or more glucose. After 30-120 minutes, usually 90 minutes, from the start of treatment, the glucose value reaches the target value of 1.5±0.1 mmol / L. This low value of glucose is maintained for a certain period of time. This period of hypoglycemia may be for a period of 0.5-12 hours, preferably for a period of 2-8 hours, and most preferably for a period of 4 hours, since it is expected that most cancer cells susceptible to hypoglycemia will have been damaged or killed by that time. The shortest optimal time may vary between various types and / or sizes of tumors and can be established during the LPH procedure, for example, either by "trial and error" or by using diagnostic methods. In a preferred embodiment, the desired glucose value is maintained using a "clamp" technique. Clamping involves administering both glucose and insulin simultaneously to achieve more stable glucose values. To prevent fluid overload, glucose is preferably administered as a concentrated solution (40%-50%), preferably a 50% solution. Glucose is administered initially at a rate of 2-20 μmol / kg / min, typically 12 μmol / kg / min (i.e., 54 mmol / h or 10 g / h in a 75 kg adult), and then adjusted based on regular blood glucose measurements. Preferably, a minimal amount of glucose is administered.

[0038] The coadministration of glucose also provides additional safety, as blood glucose levels may rise rapidly in the event of suspected adverse effects resulting from hypoglycemia.

[0039] A further component of the kit is an alpha-beta blocker, i.e. a combined alpha and beta adrenergic blocker. The alpha-beta blocker may be selected from a range of alpha-beta blockers, such as labetalol, carvedilol, and dilevalol. In a preferred embodiment, the combined alpha-beta blocker is labetalol. Labetalol is administered intravenously at a rate that results in a reduction in baseline heart rate, preferably a reduction in baseline heart rate of about 10 / min. To achieve this physiological target, the labetalol infusion rate can vary from 0.05 to 1.5 mg / kg / hour, and will typically be 0.2 mg / kg / hour. Labetalol may be dissolved in a suitable diluent, such as 0.9% NaCl or 5% glucose.

[0040] The kit further comprises a glucagon inhibitor. The glucagon inhibitor may be selected from the group of somatostatin analogs such as octreotide, lanreotide, or pasireotide, or may be somatostatin itself. Since a short biological duration of action is desirable, the preferred embodiment of the glucagon inhibitor is intravenously administered octreotide or somatostatin, most preferably octreotide. The dose of intravenously administered octreotide is 0.1-1 μg / kg bolus, preferably 0.2 μg / kg-0.6 μg / kg, most preferably 0.4 μg / kg. Next, by using the glucose level as an index, the sustained intravenous delivery rate of the octreotide solution is in the range of 0 μg / kg / hour-1 μg / kg / hour, preferably 0.05 μg / kg / hour-0.8 μg / kg / hour, most preferably 0.05 μg / kg / hour-0.3 μg / kg / hour. The octreotide is preferably in solution at 500 μg octreotide in 50 mL of 0.9% NaCl.

[0041] In an additional embodiment, the kit comprises an oral antidiabetic compound, preferably an oral biguanide antidiabetic compound such as metformin or phenformin. In a preferred embodiment, the antidiabetic compound is metformin. The antidiabetic drug metformin inhibits glucose production in the liver through inhibition of gluconeogenesis. Metformin may also reduce the dosage of insulin required to achieve a desired hypoglycemic level. The enteral dose of metformin administered ranges from 500 mg to 1500 mg, preferably 1000 mg. Metformin is administered as tablet(s), preferably in a conventional non-controlled release dosage form, although controlled release dosage forms may also be used. The timing of metformin administration is 24 hours to 1 hour, preferably 12 hours to 2 hours, most preferably 6 hours to 4 hours before the desired time point at which the intended hypoglycemic state is achieved. If a first dose of 500 mg to 1500 mg of metformin can be administered more than 6 hours before the desired hypoglycemic state is expected to be achieved, a second dose of the same drug can be administered up to 2 hours before the desired hypoglycemic state is expected to be achieved.

[0042] Thus, in one embodiment, the treatment optionally comprises inhibiting glucose output from the liver of the human or animal, administering lactate to the human or animal by continuous infusion, and when a steady state of hyperlactatemia is reached in which the vital organs of the human or animal consume sufficiently large amounts of lactate as an energy source, administering insulin to the human or animal to lower glucose levels until a hypoglycemic state is reached, maintaining the hypoglycemic state for a period of time, terminating the insulin administration, and administering glucose to the human or animal until normal blood glucose levels are reached, and terminating the lactate administration.

[0043] In one embodiment, the treatment comprises: a) an optional pretreatment step of fasting; b) optionally administering metformin, in particular one day before the start of administration of lactic acid; c) subsequently administering lactic acid or a combination of lactic acid and sodium lactate to raise the lactate concentration in the human or animal body to about 5-20 mmol / L, preferably about 8-10 mmol / L; d) subsequently administering a loading dose of insulin to lower blood glucose levels to about 0.5-2.5 mmol / L, preferably about 1.5 mmol / L, followed by continuous administration of insulin to maintain glucose levels at 0.5-2.5 mmol / L, preferably 1.5 mmol / L, to achieve a hypoglycemic state; e) maintaining the hypoglycemic state for 0.5 to 12 hours, preferably about 4 hours, by "clamping"; f) stopping the insulin administration and, if necessary, administering glucose to restore physiological glucose levels in the human or animal body and stopping the lactate administration. Includes.

[0044] Suitably, octreotide and / or labetalol are administered prior to and / or during administration of insulin.

[0045] Octreotide is suitably administered after step c) Labetalol is suitably administered after step b).

[0046] In one embodiment, administration of octreotide and / or labetalol is stopped prior to step f).

[0047] Lactic acid is preferably administered using an ex vivo perfusion circuit.

[0048] The LPH state is maintained for a certain period of time, particularly for 30 minutes to 12 hours, preferably for 2 hours to 8 hours, and most preferably for 3 hours to 5 hours.

[0049] The body's normal blood glucose concentration is then restored by administration of glucose, preferably the same concentrated glucose solution for use during the hypoglycemic clamp as described above, in addition to ceasing insulin administration, ceasing glucagon inhibition, and ceasing α-β adrenergic receptor inhibition. The delivery rate of the intravenous glucose solution during this recovery phase ranges from 5-40 μmol / kg / min, preferably 10-20 μmol / kg / min, and is rapidly tapered to 0 μmol / kg / min after achievement of normoglycemia.

[0050] If the method of treatment includes a fasting step prior to delivery of the components of the kit, the human or animal does not eat for 6 to 48 hours, preferably 12 to 36 hours, most preferably 24 hours.

[0051] Prior to delivery of the components, the human or animal may optionally be anesthetized.

[0052] The present invention will be further described in the following examples, which are not intended to limit the invention in any way. In the examples, the following abbreviations have been used: [Glu] Circulating glucose mmol / L (multiply by 18 to calculate mg / dL) [Lac] Circulating lactate concentration mmol / L HG-HL Hypoglycemia + Hyperlactatemia HG(1.5)HL(8) HG-HL state with [Glu] of 1.5mmol / L (27mg / dL) and [Lac] of 8mmol / L HLa Lactate etCO2 end-tidal CO2 concentration EXAMPLES

[0053] Introduction Inducing significant hyperlactemia (i.e., 8-10 mmol / L) may protect the body from the deleterious effects of hypoglycemia. A combined state of hypoglycemia and hyperlactemia (HG-HL) is metabolically feasible, as clearly demonstrated by observations in multiple pathologies in humans (Oldenbeuving et al., Anaesth Intensive Care 2014;42:507-11). In animals and humans, syndromes typically involving liver failure can be characterized by the HG-HL state. This unique state has been termed lactate-protected hypoglycemia (LPH), since it has been recognized that the HG-HL state, as extreme HG (0.7 mmol / L)-HL (25 mmol / L), is accompanied by clear consciousness. LPH may be much more important than a mere scientific curiosity, since tumors exhibiting the Warburg effect may be specifically susceptible to low glucose levels, whereas cancers, unlike normal vital tissues of the body, may not be able to use lactate. Induction of HG-HL for 4 hours is predicted to cause profound and rapid changes in cancer metabolism, leading to irreversible damage to the tumor.

[0054] Briefly, hypoglycemia was induced by intravenous administration of a loading dose of insulin under pharmacological inhibition (hepatic) counter reaction. Sodium lactate (NaLa) has been mainly used in experiments to induce short-term or mild hyperlactemia. However, high doses of NaLa or sustained doses of NaLa quickly lead to severe hypernatremia and metabolic alkalosis. Therefore, sustained hyperlactemia was achieved here by administering large amounts of lactate (HLa) via an extracorporeal system.

[0055] In the current state of scientific knowledge and available technical means, the achievement of HG-HL in a controlled manner and the subsequent restoration of normoglycemia is only feasible in large animal models. In this example, a porcine model is used.

[0056] In this study, 30 kg pigs were anesthetized and administered a concentrated HLa (pH 1.6) solution to achieve a [Lac] of 8 mmol / L. After initiation of anesthesia, a bolus of octreotide was administered, followed by a continuous infusion of octreotide and labetalol to inhibit the hypoglycemic counter-reaction. Then, after establishing hyperlactatemia, a bolus of insulin and a continuous infusion of insulin were gradually increased to achieve a [Glu] between 1.3-1.7 mmol / L (25-30 mg / dL). Once a HG (1.5 mmol / L) HL (8 mmol / L) state was achieved, this state was maintained for 4 hours. Then, normoglycemia was restored.

[0057] A 50% concentrated glucose infusion was performed together with insulin to facilitate stabilization of glucose levels both during and after hypoglycemia. This clamp principle is very common in experiments designed to achieve stable excessive, normal, or mild hypoglycemic levels. As is common in clamps, the glucose and insulin infusion rates are periodically adjusted based on the latest [Glu].

[0058] In addition to [Glu] and [Lac], important metabolites such as pH, blood gases, calcium, and phosphate were frequently measured in arterial blood samples.

[0059] Materials and Methods In this example, in a pig with a [Lac] of 8 mmol / L, a [Glu] of approximately 1.5 mmol / L was achieved and this state was maintained for 4 hours.

[0060] The preparation began at 17:00 on the day before the intervention. After this time the pigs were not fed.

[0061] On the morning of the intervention, pigs were fed a small amount of high-fat chow combined with 500 mg of metformin, the inhibitory effect of metformin on gluconeogenesis expected to begin within 3 hours.

[0062] Induction of anesthesia was started with the initiation of an extracorporeal circuit for ventilation and administration of concentrated HLa. A bolus of medetomidine 0.03 mg / kg, a bolus of tiletamine-zolazepam 4 mg / kg, and a bolus of 1% propofol 2-2.5 mg / kg were delivered intravenously. After intubation, volume-controlled ventilation was started. Respiratory rate was controlled with a target etCO2 of 35-45 mmHg and a target tidal volume of 8-10 mL / kg. Tidal volume was subsequently adjusted as required for etCO2, pCO2, and pH. A double-lumen dialysis catheter was then surgically placed in the internal jugular vein. A bolus of unfractionated heparin 5000 IU (200 IU / kg) was administered, and CVVH was started at 1 mL / h with unfractionated heparin (400 IU / mL) and titrated to an activated clotting time (ACT) of 250-300 seconds.

[0063] Hyperlactatemia (HL 8 mmol / L) was induced by incremental administration of 40% HLa, initiated at 50 mL / h via a veno-venous (VV) extracorporeal circuit.

[0064] Inhibition of the counter response is then achieved by intravenously delivering labetalol (5 mg / mL) at 3 mL / h, titrated to achieve a relative decrease in heart rate of 10 beats per minute, and administering an intravenous bolus of 25 μg octreotide (10 μg / mL), followed by a continuous infusion of octreotide, adjusted relative to maintain [Glu] in the desired hypoglycemic range.

[0065] Once [Lac] was 8–10 mmol / L, delivery of 40% HLa was adjusted to between 20–50 mL / h.

[0066] Induction of the desired hypoglycemic levels was achieved using a loading dose of 10-50 U insulin depending on the initial [Glu] and an initial administration of 50% glucose at 5 mL / h. The insulin infusion rate was then varied between 0-60 U / h depending on [Glu]. If necessary, an additional bolus dose of insulin was administered at least 30 min after the initial delivery using the same criteria as above.

[0067] When [Glu] reached 1.3-1.7 and [Lac] reached 8-10 mmol / L, this HG(1.5)HL(8) state was maintained for 4 hours using the clamp technique. 1 / 2 However, insulin T 1 / 2 Because the duration of the octreotide infusion was longer than that of the control group, and because persistent suppression of the hypoglycemic counter-response by octreotide could prolong the period of 50% glucose support during the euglycemic recovery phase, octreotide infusion was stopped approximately midway through the HG(1.5)HL(8) phase.

[0068] During the HG-HL phase, sliding scale adjustments of insulin and 50% glucose pumps were made. Towards the end of the HG-HL phase, the insulin and labetalol pumps were stopped, and the HLa infusion was reduced and stopped after the end of the scheduled 4-hour HG-HL period. The 50% glucose infusion rate was adjusted and eventually tapered to 0 until stable euglycemia was achieved.

[0069] Ninety minutes after the end of the HG-HL phase, normoglycemia was achieved without the support of exogenous glucose or lactate.

[0070] Throughout this experiment, arterial pH and sodium values ​​were maintained within the desired range, in contrast to the values ​​that would be observed after pure NaLa infusion. Furthermore, no hemodynamic instability, electrocardiogram disturbances, or rhythm abnormalities were observed, as only hypoglycemia can induce cardiac conduction / repolarization abnormalities.

[0071] Further embodiments are as follows. [Embodiment 1] 1. A kit for use in the treatment of a glycolysis-dependent condition in a human or animal, comprising: A kit comprising lactate, insulin and glucose, and optionally one or more components selected from a glucagon inhibitor, an alpha-beta adrenergic blocker and an antidiabetic agent. [Embodiment 2] The kit of embodiment 1, wherein the treatment comprises delivering lactate, insulin and glucose via a blood vessel, in particular a vein, into the circulation of the human or animal being treated to induce hypoglycemia and hyperlactatemia. [Embodiment 3] The kit of embodiment 2, wherein the glucose is concentrated glucose, which is administered to the human or animal together with insulin to achieve stable reduced glucose values ​​using a so-called "clamp". [Embodiment 4] The kit of embodiment 2 or 3, wherein the treatment optionally comprises inhibiting glucose output from the liver of the human being or animal, administering lactate to the human being or animal by continuous infusion, administering insulin to the human being or animal to lower glucose levels until a hypoglycemic state is reached when the vital organs of the human being or animal reach a steady state in which they use large amounts of lactate as an energy source, maintaining the hypoglycemic state for a period of time, terminating the insulin administration, and administering glucose to the human being or animal until a normal blood glucose level is reached, and terminating the lactate administration. [Embodiment 5] The kit according to any one of embodiments 2 to 4, wherein the excretion of glucose by the liver or kidneys of the human or animal before and / or during the induction of hypoglycemia is inhibited by administration of a glucagon inhibitor. [Embodiment 6] The kit of any one of embodiments 1 to 5, wherein the glucagon inhibitor is somatostatin or a somatostatin analogue such as octreotide, lanreotide or pasireotide. [Embodiment 7] The kit according to any one of embodiments 2 to 6, wherein the excretion of glucose by the liver or kidneys of the human or animal is inhibited by administration of an alpha-beta adrenergic blocker before and / or during the induction of hypoglycemia. [Embodiment 8] The kit of any one of embodiments 1-7, wherein the alpha-beta adrenergic blocker is selected from the group consisting of labetalol, carvedilol and dilevalol. [Embodiment 9] The kit according to any one of embodiments 2 to 8, wherein the treatment further comprises reducing gluconeogenesis in the human or animal body by pre-administration of an antidiabetic agent. [Embodiment 10] The kit according to any one of the preceding embodiments, wherein the antidiabetic agent is selected from the group consisting of metformin and phenformin. [Embodiment 11] The kit of embodiment 9 or 10, wherein the antidiabetic agent is administered one day prior to the start of administration of lactic acid. [Embodiment 12] A kit according to any one of embodiments 2 to 11, wherein the treatment further comprises reducing the glycogen content of the human or animal body by fasting before the start of administration of the components of the kit. [Embodiment 13] 13. The kit according to any one of the preceding embodiments, wherein the kit comprises lactic acid or a combination of lactic acid and sodium lactate in a ratio of HLa:NaLa of at least 75:25, preferably at least 80:20, more preferably at least 90:10, and most preferably at least 95:5. [Embodiment 14] The treatment, a) an optional pretreatment step of fasting; b) optionally administering metformin, in particular one day before the start of administration of lactic acid; c) subsequently administering lactic acid or a combination of lactic acid and sodium lactate to raise the lactate concentration in the human or animal body to about 5-20 mmol / L, preferably about 8-10 mmol / L; d) subsequently administering a loading dose of insulin to lower blood glucose levels to about 0.5-2.5 mmol / L, preferably about 1.5 mmol / L, followed by continuous administration of insulin to maintain glucose levels at 0.5-2.5 mmol / L, preferably 1.5 mmol / L, to achieve a hypoglycemic state; e) maintaining the hypoglycemic state for 0.5 to 12 hours, preferably about 4 hours, by "clamping"; f) stopping the insulin administration, administering glucose to restore physiological glucose levels in the human or animal body, and stopping the lactate administration. The kit according to any one of embodiments 1 to 13, comprising: [Embodiment 15] The kit of embodiment 14, wherein octreotide and / or labetalol are administered before and / or during administration of insulin. [Embodiment 16] The kit of embodiment 15, wherein octreotide is administered after step c) of embodiment 14. [Embodiment 17] The kit of embodiment 15, wherein labetalol is administered after step b) of embodiment 14. [Embodiment 18] The kit of embodiment 15, wherein administration of octreotide and / or labetalol is stopped prior to step f). [Embodiment 19] The kit of any one of embodiments 1 to 17, wherein the lactate is administered using an ex vivo perfusion circuit. [Embodiment 20] The kit according to any one of embodiments 1 to 18, wherein the glycolysis-dependent pathology is selected from the group consisting of cancer, bacterial infection, fungal infection, yeast infection and parasitic infection. [Embodiment 21] 21. The kit of embodiment 20, wherein the cancer is selected from the group consisting of biliary tract, bladder, bone, breast, central nervous system, cervical, colon, esophageal, kidney, larynx, liver, lung, nasopharyngeal, oropharyngeal, ovarian, pancreatic, prostate, rectal, skin, soft tissue, stomach, testicular, thyroid and uterine cancer. [Embodiment 22] The kit of embodiment 20, wherein the cancer is selected from the group consisting of Hodgkin's lymphoma, non-Hodgkin's lymphoma, leukemia, melanoma, and multiple myeloma. [Embodiment 23] 21. The kit according to embodiment 20, wherein the bacterial, fungal or yeast infection is selected from the group of diseases caused by Gram-positive bacteria, in particular Staphylococcus spp. and Streptococcus spp., Gram-negative bacteria, in particular Escherichia coli, Enterobacteriaceae including Enterobacter spp. and Proteus spp., and Pseudomonas spp., as well as anaerobic bacteria (e.g. Clostridium spp., Lactobacillus spp., Bacteroides spp.), fungi (e.g. Aspergillus spp.), and yeasts (e.g. Candida spp.). [Embodiment 24] 21. The kit of embodiment 20, wherein the parasitic infection is selected from the group consisting of malaria caused by Plasmodium falciparum, Plasmodium malariae, Plasmodium ovale, or Plasmodium vivax, and trypanosomiasis caused by Trypanosoma brucei and Trypanosoma cruzi.

Claims

1. 1. A kit for use in a method for inducing hypoglycemia and hyperlactatemia in a human or animal, comprising: A kit comprising lactate, insulin and glucose.

2. further comprising a glucagon inhibitor, an alpha-beta adrenergic blocker, and an antidiabetic agent; the glucagon inhibitor is octreotide, lanreotide or pasireotide; the α-β adrenergic blocker is labetalol, carvedilol or dilevalol; The kit of claim 1 , wherein the antidiabetic agent is metformin or phenformin.

3. 3. The kit of claim 1 or 2, wherein the method comprises intravascular delivery of lactate, insulin and glucose into the circulation of a human or animal to induce hypoglycemia and hyperlactemia.

4. The kit of claim 3 , wherein the blood vessel is a vein.

5. 5. The kit of claim 3 or 4, wherein the glucose is concentrated glucose, which is administered to the human or animal together with insulin to achieve stable reduced glucose values ​​using a so-called "clamp".

6. 6. The kit according to any one of claims 3 to 5, wherein the method comprises administering lactate to the human or animal by continuous infusion, and when a steady state is reached in which the vital organs of the human or animal are using large amounts of lactate as an energy source, administering insulin to the human or animal to lower glucose levels until a hypoglycemic state is reached, after which the hypoglycemic state is maintained for a period of time, terminating the insulin administration, administering glucose to the human or animal until normal blood glucose levels are reached, and terminating the lactate administration.

7. The kit of claim 6, wherein the method further comprises inhibiting glucose output from the liver of a human or animal.

8. A kit according to any one of claims 3 to 6, wherein the excretion of glucose by the liver or kidneys of a human or animal is inhibited by administration of octreotide, lanreotide or pasireotide before and / or during the induction of hypoglycemia.

9. 9. The kit according to any one of claims 3 to 8, wherein the excretion of glucose by the liver or kidneys of a human or animal before and / or during the induction of hypoglycemia is inhibited by administration of labetalol, carvedilol or dilevalol.

10. The kit according to any one of claims 3 to 9, wherein the method further comprises reducing gluconeogenesis in the human or animal body by pre-administration of metformin or phenformin.

11. The kit of claim 10, wherein metformin or phenformin is administered one day prior to the start of administration of lactic acid.

12. The kit according to any one of claims 3 to 11, wherein the method further comprises reducing the glycogen content of the human or animal body by fasting before starting the administration of the components of the kit.

13. The kit of any one of claims 1 to 12, wherein the kit comprises a combination of lactic acid and sodium lactate in a ratio of lactic acid to sodium lactate (HLa:NaLa) of at least 75:

25.

14. The method further comprising: a) administering lactic acid or a combination of lactic acid and sodium lactate to raise the lactate concentration in the human or animal body to between 5 and 20 mmol / L; b) subsequently administering a loading dose of insulin to lower blood glucose levels to 0.5-2.5 mmol / L, followed by continuous administration of insulin to maintain glucose levels at 0.5-2.5 mmol / L to achieve a hypoglycemic state; c) maintaining the hypoglycemic state for 0.5 to 12 hours by a "clamp"; d) stopping the insulin administration, administering glucose to restore physiological glucose levels in the human or animal body, and stopping the lactate administration. The kit according to any one of claims 1 to 13, comprising:

15. 15. The kit of claim 14, wherein the method further comprises administering metformin.

16. 16. The kit of claim 15, wherein metformin is administered one day prior to the start of administration of lactic acid.

17. The kit according to any one of claims 14 to 16, wherein the method further comprises a step of fasting as a pretreatment.

18. The kit of claim 14, wherein octreotide and / or labetalol are administered before and / or during administration of insulin.

19. The kit of claim 18, wherein octreotide is administered after step a) of claim 14.

20. 20. The kit of claim 18, wherein labetalol is administered prior to step a) of claim 14.

21. 20. The kit of claim 18, wherein administration of octreotide and / or labetalol is stopped prior to step d).

22. The kit of any one of claims 1 to 20, wherein the lactate is administered using an ex vivo perfusion circuit.