Pharmaceutical composition containing rebamipide for use in the prevention and treatment of cancer

Abstract

Provided is rebamipide for use in a method for the prevention and / or treatment of cancer in individuals who have, or are at risk of, increased intestinal permeability, for example, because of a family history of the condition or because of exposure to conditions or substances that induce increased intestinal permeability.

Description

[Technical Field]

[0001] The present invention relates to rebamipide for use in methods for the prevention and / or treatment of cancer, particularly in individuals with or at risk of having increased intestinal permeability. [Background technology]

[0002] Cancer is one of the leading causes of death worldwide, accounting for 25% of deaths in Europe. It is a disease caused by genetic alterations, which can be either sporadic or inherited, leading to uncontrolled cell proliferation and tumor formation. Most cancers are related to environmental, lifestyle, or behavioral exposures. Common environmental factors that contribute to cancer include a variety of carcinogens, such as high-energy radiation such as ultraviolet light, X-rays, and gamma rays, tobacco smoke, alcoholic beverages, some microorganisms and parasites, and various chemical compounds.

[0003] Diet is thought to play a major role in the etiology of cancer, and there is growing evidence that certain dietary habits increase cancer risk. Some examples include a diet with a high glycemic load, a diet high in fat, or a diet low in antioxidants. Furthermore, certain foods contain substances known to promote the development of cancer. These include natural products as well as artificial chemicals present as adulterants or intentionally added to foods as preservatives, colors, flavors, etc.

[0004] Chronic inflammation, even if mild, is another important risk factor for cancer development. The inflammatory microenvironment consisting of various immune cells, epithelial cells, stromal cells, cytokines, and chemokines has many similarities with the cancer microenvironment, suggesting similar inflammatory mediators and mechanisms that promote both chronic inflammation and cancer development. These mediators produced by inflammatory cells include tumor necrosis factor α (TNF-α), IL-1, 6, 12, 13, 17, 22, and 23. The exact molecular mechanisms underlying the transition from inflammation to cancer are not fully understood. Current evidence suggests that multiple factors are involved in cancer development, including immune responses, activation of cancer genes, inhibition of tumor suppressors, changes in normal microRNA expression patterns, changes in the epigenetic landscape, and inflammatory responses of the resident gut microbiota and corresponding epithelial cells.

[0005] Although numerous resources have been utilized in the development of cancer therapeutics, no effective treatment methods have been found so far. Therefore, there is a high medical need for new drugs that can be used for the treatment or prevention of cancer.

[0006] Rebamipide (chemical name: 2-[(4-chlorobenzoyl)amino]-3-(2-oxo-1H-quinolin-4-yl)propanoic acid) is used for the treatment of acute and / or chronic gastritis and gastric and duodenal ulcers. Its mechanism of action is related to mucosal defense, free radical scavenging, and transient activation of the gene encoding cyclooxygenase-2.

Prior Art Documents

Non-Patent Documents

[0007]

Non-Patent Document 1

Non-Patent Document 2

[0008] In the framework of the present invention, it has been discovered that rebamipide can prevent and / or treat cancers associated with increased intestinal permeability. Under normal physiological conditions, the intestinal wall effectively functions as a barrier, absorbing nutrients while preventing harmful molecules and microorganisms from entering the body. However, if the barrier is damaged for some reason, it no longer functions properly, allowing substances that would normally remain in the intestinal lumen to enter the body. Because the human diet contains not only nutrients but also potentially carcinogenic substances found in burnt food, processed meat, and red meat, increased intestinal permeability is a significant risk factor for cancer development. Furthermore, when unwanted foreign substances enter the intestinal mucosa or the body, the immune system is activated and inflammatory mediators are secreted, causing chronic intestinal inflammation (which is often asymptomatic), further promoting intestinal permeability and cancer development.

[0009] The mechanism of action of rebamipide is likely based on its ability to promote mucin production, suppress inflammation, and restore tight junction function in the intestinal epithelium, thereby reducing intestinal permeability. This allows the intestine to heal and the intestinal immune barrier to be restored, preventing further tissue damage from toxins and pathogens present in the gastrointestinal tract and, consequently, the development of chronic inflammation and subsequent malignancies in the gastrointestinal tract and elsewhere in the body. [Means for solving the problem]

[0010] Thus, the present invention provides rebamipide for use in a method for preventing and / or treating cancer in individuals with or at risk for increased intestinal permeability, for example, due to a family history of the condition or exposure to conditions or substances that induce increased intestinal permeability. In a preferred embodiment, rebamipide is used in a method for preventing cancer, particularly when associated with diet or enteritis.

[0011] As used herein, "levamisole" includes all forms of this active ingredient, such as the anhydrous form, the hydrate form, or the solvate form (e.g., the hemihydrate form), the crystalline form, etc., and pharmaceutically acceptable salts thereof.

[0012] As used herein, "cancer" is a group of diseases associated with abnormal cell growth that has the potential to invade or spread to other parts of the body. The present invention relates in particular to cancers associated with increased intestinal permeability, a condition that contributes to the development of malignant tumors by allowing carcinogenic substances present in the gastrointestinal tract to enter the body. These carcinogenic substances can directly cause cancerous growth not only in the intestine and / or surrounding tissues, but also in more distant organs and tissues. The basic mechanism of this phenomenon lies in the ability of carcinogenic substances to spread through the bloodstream to distant locations in the body.

[0013] A "carcinogenic substance" is a substance and mixtures thereof that can cause a process leading to cancer after entering the body. This can be due to the ability to damage the genome or interfere with the metabolic processes of cells. These substances, which consist of heterogeneous groups, have been classified by the International Agency for Research on Cancer (IARC) into several groups based on the strength of the evidence of carcinogenicity. Some carcinogenic substances are themselves carcinogenic, while others exhibit carcinogenicity only after being metabolized in the intestine or other locations in the body. The present invention preferably relates to carcinogenic substances that cannot pass through the intestinal wall or pass through at a relatively low rate under normal physiological conditions, but whose invasion into the body is significantly increased in people with increased intestinal permeability.

[0014] In one embodiment, the present invention provides levamisole for use in a method for the prevention and / or treatment of diet-related cancers. Diet-related cancers are malignant tumors caused by carcinogenic substances present in food, and such carcinogenic substances exist naturally, as contaminants, or are intentionally added as food additives. People with increased intestinal permeability or at risk thereof are highly sensitive to various food-derived carcinogenic substances, such as those found in burnt food, processed meat, or those occurring in red meat.

[0015] Processed meat refers to meat that has been altered by processes such as salting, preservation treatment, fermentation, and smoking to improve its flavor and shelf life. The IARC classifies processed meat as a Group 1 carcinogen, which is carcinogenic to humans. Red meat refers to all the muscles of mammals such as beef, veal, pork, lamb, mutton, horse meat, and goat meat, and is classified as a Group 2A carcinogen, which is probably carcinogenic to humans. Carcinogens contained in these foods as additives or natural ingredients that are known from current research include acrylamide, polycyclic aromatic hydrocarbons (PAHs) such as benzo[a]pyrene, benzo[a]anthracene, benzo[b]fluoranthene, and chrysene; heterocyclic aromatic amines (HCAs) such as 2-amino-3-methylimidazo[4,5-f]quinoline (IQ), 2-amino-3,4-dimethylimidazo[4,5-f]quinoline (MeIQ), 2-amino-3,8-dimethylimidazo[4,5-f]quinoxaline (MeIQx), 2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine (PhIP); and N-nitrosoamines such as N-methyl-N'-nitro-N-nitrosoguanidine (MNNG), N-nitrosodi-N-butylamine, N-nitrosodiethylamine (DEN), N-nitrosodimethylamine (NDMA), N-nitrosopiperidine, N-nitrosopyrrolidine, and N-nitrososarcosine.

[0016] Other carcinogens that enter the digestive tract and cause diet-related cancers are derived from microbial contamination of food and are involved in the production of various toxins that are often carcinogenic, such as mycotoxins like aflatoxin, ochratoxin, and fumonisin. Furthermore, certain microorganisms present in the digestive tract may produce and release various carcinogenic compounds such as nitrosoamines in situ.

[0017] In addition, food may be contaminated with many other compounds that may directly or indirectly cause cancer, such as pesticide residues, aromatic compounds such as benzene, polychlorinated and polybrominated dibenzodioxins, dibenzofurans and biphenyls, such as 2,3,7,8-tetrachlorodibenzo-p-dioxin, heavy metals such as lead, arsenic, cadmium and their compounds, and compounds released from packaging materials such as formaldehyde, vinyl chloride, or bisphenol A.

[0018] Cancers treatable according to the present invention include both intestinal and non-intestinal malignancies. Intestinal malignancies are a group of cancers occurring in the small intestine, colon, rectum, and anus, including adenocarcinoma, squamous cell carcinoma, carcinoid tumor, intestinal lymphoma, gastrointestinal stromal tumor, leiomyosarcoma, and melanoma. However, adjacent tissues such as the pancreas, liver, and gallbladder may also be affected. In a preferred embodiment, intestinal cancer is selected from small intestine cancer, colon cancer, colorectal cancer, pancreatic cancer, liver cancer, and bile duct cancer. Non-intestinal malignancies include oral cancer, pharyngeal cancer, salivary gland cancer, esophageal cancer, gastric cancer, breast cancer, prostate cancer, ovarian cancer, bladder cancer, lung cancer, skin cancer, vascular cancer, hematopoietic cancer, B-cell lymphoma, and thyroid cancer.

[0019] As used herein, the term "increased intestinal permeability" refers to subtle intestinal wall defects, such as those resulting from subclinical chronic inflammation (low-grade inflammation) of the intestinal wall. These intestinal wall defects may manifest as chronic constipation or gastroparesis, for example. Intestinal permeability can be diagnosed using specific tests, such as the lactulose-mannitol test (LAMA test, e.g., Non-Patent Document 1), the A-1-AT test, or the zonulin test. In general, increased intestinal permeability refers to the permeability of the intestinal wall to particles with a radius greater than 4 angstroms.

[0020] Substances that induce increased intestinal permeability include nonsteroidal anti-inflammatory drugs (NSAIDs), such as acetylsalicylic acid, ibuprofen, naproxen, ketoprofen, fenoprofen, flurbiprofen, diclofenac, ketorolac, etodolac, indomethacin, tolmetin, piroxicam, and meloxicam, as well as selective COX-2 inhibitors, such as celecoxib and etoricoxib, alcohol, nicotine, food additives, antibiotics, and chemotherapy drugs. Therefore, simultaneous or sequential administration of rebamipide with nonsteroidal anti-inflammatory drugs, chemotherapy drugs, or antibiotics can prevent intestinal wall damage, thereby preventing or delaying the onset of cancers associated with increased intestinal permeability. The prophylactic use of rebamipide may also be beneficial for people who abuse alcohol, nicotine, or other drugs known to damage the intestinal wall. As used herein, the term "abuse" is meant to include any consumption that is not necessary for medical reasons and that results in a state of dependence and / or health problems such as mild inflammation of the intestinal lining.

[0021] Conditions such as increased intestinal permeability are associated with stress, an unbalanced diet, allergies, bacterial, viral, or parasitic infections, and various drug treatments, including stress-induced gastritis, food poisoning, cholic acid imbalance, gastric HCl and pepsin secretion, non-infectious diarrhea, radiation therapy, chemotherapy, infectious or post-infectious disorders of the GIT mucosa, and dysmicrobia (e.g., induced by antibiotic therapy).

[0022] In one embodiment, the present invention provides rebamipide for use in a method for preventing and / or treating cancer in a person with chronic enteritis, including mild inflammation of the intestinal wall. Preferably, the cancer is selected from colorectal cancer, small intestinal adenocarcinoma, intestinal lymphoma, anal cancer, and bile duct cancer. Most preferably, the cancer is colorectal cancer.

[0023] "Prevention" or "prophylactic use," as used herein, is understood to mean preventing or delaying the onset of disease, including recurrence in patients who have achieved complete or partial remission after, for example, surgical treatment, chemotherapy, radiation therapy, or immunotherapy. It is also intended to include preventing or delaying disease progression. In such cases, rebamipide is administered to treat patients at an early stage of disease to prevent or delay progression to the next stage. The prophylactic effect of rebamipide lies in its ability to prevent carcinogens and other toxins from entering the body, thereby preventing events that lead to cancer development.

[0024] "Treatment" is herein understood as a therapy that can slow, halt, inhibit, or reverse a disease. It is also intended to include the alleviation or amelioration of clinical symptoms of a disease. "Slowing" a disease means that the progression of the disease is slowed, but not completely stopped or reversed, whereas "halting the disease" means that the progression of the disease is completely stopped.

[0025] The present invention further provides a method for preventing and / or treating cancer in a subject having or at risk of having increased intestinal permeability by administering a pharmaceutically effective amount of rebamipide or a pharmaceutical composition thereof to a subject in need of such treatment. The subject is preferably a human subject, and the cancer is preferably associated with diet or enteritis. The present invention also includes the use of rebamipide for the manufacture of a medicament for preventing and / or treating cancer in a subject having or at risk of having increased intestinal permeability.

[0026] In the therapeutic applications described in the present invention, rebamipide may be preferably used in oral dosage forms such as tablets, capsules, sugar-coated tablets, granules, microgranules (sachets), orodispersible tablets or films, sublingual tablets, pulverized tablets, oral solutions, oral suspensions, syrups, mouthwashes, or mouthwashes. Alternatively, it may be used in rectal dosage forms such as suppositories and enemas. Preferably, oral dosage forms such as tablets, capsules, sugar-coated tablets, and granules are enteric-coated, such as enteric-coated sustained-release or enteric-coated controlled-release.

[0027] The dosage form may comprise at least one pharmaceutically acceptable excipient selected from fillers, binders, lubricants, flow agents, disintegrants / swelling agents, solubilizers, enteric-release agents, mucoadhesive components, sustained-release agents, preservatives, coatings, colorants. Such excipients are known in the art of pharmaceutical formulation, and a person skilled in the art can select an excipient suitable for the relevant dosage form.

[0028] Suitable methods of preparing the dosage forms and compositions include wet or dry granulating the active ingredient with the auxiliary substances and ingredients, or directly homogenizing the active ingredient with the auxiliary substances and ingredients.

[0029] The filler may be preferably selected from sugar alcohols (such as mannitol, sorbitol, and xylitol), lactose, starch, pregelatinized starch, cellulose, silicified cellulose, calcium hydrogen phosphate, calcium phosphate, sucrose, and calcium sulfate. The filler may be present in an amount of preferably 5 to 90% by weight based on the total weight of the composition.

[0030] The binder may preferably be selected from starch, pregelatinized starch, povidone, copovidone, hydroxypropyl methylcellulose, hydroxypropyl cellulose, ethyl cellulose, and cellulose. The binder may preferably be present in an amount of 1 to 20% by weight relative to the total weight of the composition.

[0031] The lubricant can preferably be selected from magnesium stearate, calcium stearate, stearic acid, polyethylene glycol, and sodium stearyl fumarate. The lubricant can preferably be present in an amount of up to 5% by weight based on the total weight of the composition.

[0032] The fluidizing agent can preferably be selected from silica, talc, and sodium lauryl sulfate. The fluidizing agent can preferably be present in an amount of 0.5 - 10% by weight based on the total weight of the composition.

[0033] The disintegrant and / or swelling agent can preferably be selected from crospovidone, copovidone, povidone, croscarmellose, hydroxypropyl methylcellulose, starch, pregelatinized starch, low-substituted hydroxypropyl cellulose, and sodium starch glycolate. The disintegrant and / or swelling agent can preferably be present in an amount of 1 - 50% by weight based on the total weight of the composition.

[0034] The solubilizer can preferably be selected from poloxamer, sodium lauryl sulfate, polysorbate, polyoxylated glyceryl oleate, glycerol monostearate, and cyclodextrin. The solubilizer can preferably be present in an amount of up to 30% by weight based on the total weight of the composition.

[0035] The enteric release agent can preferably be selected from hydroxypropyl methylcellulose phthalate, poly(methacrylic acid - co - methyl methacrylate), cellulose acetate phthalate, poly(vinyl acetate phthalate), and esters of allitric acid. The enteric release agent can preferably be present in an amount of 2 - 40% by weight based on the total weight of the composition.

[0036] The mucoadhesive component may be preferably selected from propylene glycol alginate, sodium alginate, calcium alginate, potassium alginate, hydroxypropyl methylcellulose, carmellose sodium, polyacrylic acid, polyethylene oxide, povidone, and copovidone, and may be present in an amount of preferably 5 to 70% by weight based on the total weight of the composition.

[0037] The sustained-release agent may be preferably selected from cellulose and cellulose ethers, such as hydroxypropyl cellulose, hydroxypropylmethylcellulose, carboxymethylcellulose, sodium carboxymethylcellulose, ethylcellulose, methylcellulose, polyvinyl acetate, alginic acid, propylene glycol alginate, sodium alginate, calcium alginate, potassium alginate, polymethacrylates, guar gum, xanthan gum, carrageenan, castor oil, beeswax, carnauba wax, glycerol palmitostearate, glycerol monostearate, glycerol behenate, stearyl alcohol, and polyacrylic acid. The sustained-release agent may be present in an amount of preferably 5 to 70% by weight based on the total weight of the composition.

[0038] The oral pharmaceutical composition, in some embodiments, further comprises a pharmaceutically acceptable ingredient capable of generating carbon dioxide upon contact with gastric fluids; such ingredient may preferably be selected from alkali metal and alkaline earth metal carbonates and bicarbonates, and may preferably be present in an amount ranging from 1 to 50% by weight, based on the total weight of the composition.

[0039] The usual daily dose of rebamipide for an average human (body weight 70 kg) can range from 1 to 5000 mg, more preferably from 50 to 2500 mg, even more preferably from 100 to 1000 mg, and most preferably from 300 to 500 mg. When calculating the daily dose in terms of human body weight, the usual dose is 15 μg / kg / day to 70 mg / kg / day, more preferably from 750 μg / kg / day to 35 mg / kg / day, even more preferably from 1.5 to 15 mg / kg / day, and most preferably from 4 to 7 mg / kg / day.

[0040] When administering an immediate-release formulation of levamisole, the daily dose is usually divided into multiple doses and administered separately. The daily dose can be divided into 2 to 6 doses and administered 2, 3, 4, 5, or 6 times a day. In a preferred embodiment, the daily dose is divided into 3 doses and administered 3 times a day, for example, a 100 mg dose is administered 3 times a day. Alternatively, the entire daily dose can be administered once, especially in the form of a sustained-release formulation, for example, a 300 mg dose is administered once a day.

Mode for Carrying Out the Invention

[0041] To examine the effects of levamisole on intestinal permeability increase, colonic inflammation, and carcinogenesis, a combination of the DSS model and PhIP treatment was used. In the test, male CD-1 mice were divided into three groups, A to C, and used. First, all groups of mice were given a single intragastric administration (200 mg / kg body weight) of the heterocyclic amine (HCA), PhIP (2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine), which has carcinogenic potential and is present in cooked meat. Subsequently, all mice were given drinking water containing 2% dextran sulfate sodium (DSS) for 7 days to cause inflammatory injury, and then a recovery period of 2 to 4 weeks was provided, during which untreated water was given. This cycle was repeated up to 4 times to promote an increase in intestinal permeability and cause severe colitis accompanied by weight loss and bloody diarrhea. Subsequently, multiple colonic tumors occurred in most of the mice.

[0042] When DSS (dextran sulfate sodium) is administered to mice, it binds to medium-chain fatty acids present in the colon, thereby promoting an increase in intestinal permeability, and as a result, inflammation and colitis are caused. In addition, DSS administration causes dysplasia to occur over a long period, and in some of the mice that received the administration, it progresses to colon cancer. PhIP administration accelerates this process and further increases the incidence of colonic tumors. Another advantage of using PhIP in the protocol is that it can reduce the amount of DSS administered to mice and lower the mortality rate due to acute colitis associated with DSS.

[0043] The DSS / PhIP-based carcinogenesis process shows a pathological progression from normal intestinal crypts to the formation of foci with aberrant crypts accompanied by crypt division, and finally to the appearance of microadenomas. These steps recapitulate the sequence of human colorectal carcinogenesis, from increased intestinal permeability and inflammation to dysplasia and cancer.

[0044] Rebamipide treatment began 4 weeks before carcinogen administration and continued throughout the study. Groups A and B received 50 mg / kg / day and 350 mg / kg / day of rebamipide, respectively. Rebamipide was mixed with standard chow and administered by oral gavage as needed. Treatment continued for 20 weeks. Mice in control group C did not receive rebamipide or any other protective treatment.

[0045] [Table 1]

[0046] The following parameters were observed: The number and size of tumors Histological evaluation of tumors ·Weight loss Colitis severity assessment ·Intestinal permeability Cytokines and related markers (IL-6, IL-10, IL-1b, TNFα, iNOS, IL-23p19, MCP1, MIP2, CXCL1) · Cell-cell adhesion proteins (claudin 1, β-catenin) Target gene expression

[0047] DSS / PhIP treatment rapidly destroyed the colonic mucosa, causing severe inflammation and subsequent development of colon adenocarcinoma. Interestingly, preliminary results from the study showed significant differences between the control and rebamipide-treated groups. Mice in groups A and B recovered more quickly from DSS treatment and had lower tumor incidence and smaller tumor size at the end of the study.

[0048] This observation is surprising because rebamipide is known to induce the expression of cyclooxygenase-2 (COX-2), which is elevated in approximately 50% of colorectal adenomas and 85% of adenocarcinomas (Non-Patent Documents 2-4) and is associated with poor survival in colorectal cancer patients (Non-Patent Document 5). Aberrant expression of COX-2, which occurs in the majority of colorectal tumors, is thought to play an important role in the development of colorectal cancer.

[0049] The results of this study showed that administration of rebamipide prevents carcinogens from entering the body by promoting the regeneration of the intestinal barrier, which reduces the permeability of the gastrointestinal mucosa, and suppresses intestinal inflammation, thereby preventing or at least delaying the onset of symptoms and markers of colon cancer, a representative cancer related to diet and inflammation, compared to untreated animals.

Claims

**Claim 1** A pharmaceutical composition for use in preventing colon cancer in a person who has levamisole and has increased intestinal permeability. Characterized by the above. **Claim 2** A person who has the increased intestinal permeability but has an unbalanced diet, bacteria, virus, or parasitic infection. The pharmaceutical composition according to claim 1. **Claim 3** A person with increased intestinal permeability who has been exposed to at least one substance selected from non-steroidal anti-inflammatory drugs, alcohol, nicotine, chemotherapeutic drugs, and antibiotics. The pharmaceutical composition according to claim 1. **Claim 4** Administer levamisole concomitantly or sequentially in combination with a non-steroidal anti-inflammatory drug, a chemotherapeutic drug, or an antibiotic. The pharmaceutical composition according to claim 3. **Claim 5** Administer levamisole to a person who abuses drugs, preferably drugs selected from alcohol and nicotine. The pharmaceutical composition according to claim 3. **Claim 6** A person with increased intestinal permeability who has at least one condition selected from stress gastritis, food poisoning, imbalance of cholic acid, non-infectious diarrhea, radiotherapy, chemotherapy, infectious or post-infectious disorders of the GIT mucosa, and microbial abnormalities. The pharmaceutical composition according to claim 1. **Claim 7** A person with increased intestinal permeability who has chronic enteritis including mild inflammation of the intestinal wall. The pharmaceutical composition according to claim 1. **Claim 8** The person is in complete remission or partial remission after previous colon cancer treatment. The pharmaceutical composition according to any one of claims 1 to 7. **Claim 9** The person is in the initial or early stage of colon cancer. The pharmaceutical composition according to any one of claims 1 to 8. **Claim 10** Administer levamisole in an oral dosage form, preferably selected from tablets, capsules, dragees, granules, microparticles, orally dispersible tablets or films, sublingual tablets, crushed tablets, oral solutions, oral suspensions, syrups, gargles, oral rinses, or in a rectal dosage form, preferably selected from suppositories and enemas. The pharmaceutical composition according to any one of claims 1 to 9. **Claim 11** The oral dosage form is in the form of enteric release, preferably enteric sustained release or enteric controlled release. The pharmaceutical composition according to claim 10. **Claim 12** The dosage form contains levamisole and at least one pharmaceutically acceptable excipient selected from fillers, binders, lubricants, fluidizing agents, disintegrants or swelling agents, solubilizing agents, enteric release agents, mucoadhesive components, sustained release agents, preservatives, coatings, and colorants. The pharmaceutical composition according to claim 10 or 11.

13. Administer levamiside at a daily dose of 1 to 5000 mg, more preferably 50 to 2500 mg, even more preferably 100 to 1000 mg, and most preferably 300 to 500 mg The pharmaceutical composition according to any one of claims 1 to 12.

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