Treatment of rabies after symptoms appear

Abstract

FIELD: virology; neurology.SUBSTANCE: method for treating rabies in humans after symptoms appear has been proposed. The method includes administering to the patient an estradiol-type compound, anti-rabies immunoglobulin, and the preparation Imunofan, performing therapeutic hypothermia, and placing the patient into a therapeutic coma with artificial ventilation of the patient's lungs.EFFECT: increase in the survival rate of rabies patients after the onset of symptoms.3 cl, 1 tbl

Description

[0001] Field of technology to which the invention relates

[0002] The invention relates to the field of medicine, virology and neurology, namely to therapeutic methods for treating rabies in humans after the onset of symptoms [A61K39 / 395, A61P37 / 02, A61F7 / 00].

[0003] State of the art

[0004] The prior art discloses an anti-rabies immune plasma and a method for producing it CN1748711A, published 03 / 22 / 2006, which includes subcutaneous administration of anti-rabies immunoglobulin.

[0005] Also known from the prior art are compositions and methods related to the prevention and treatment of rabies US9290564B2, published 03 / 22 / 2016, including the administration of anti-rabies immunoglobulin.

[0006] A disadvantage of the analogue is the administration of anti-rabies immunoglobulin without the estradiol-based compound, which enhances the penetration and effectiveness of anti-rabies immunoglobulin, which reduces the survival rate of rabies patients. Furthermore, the absence of an immunomodulatory peptide, hypothermia, and induction of a therapeutic coma increases the release of excitotoxic neurotransmitters, which reduces the survival rate of rabies patients after the onset of fatal symptoms.

[0007] The closest in technical essence is the Anti-rabies drug US20110020279A1, published on 17.01.2011, which includes the administration of anti-rabies immunoglobulin and therapeutic hypothermia.

[0008] A disadvantage of the prototype is the administration of anti-rabies immunoglobulin without an estradiol-based compound, which enhances the penetration and effectiveness of anti-rabies immunoglobulin, which reduces the survival rate of rabies patients. Furthermore, the absence of an immunomodulatory peptide and the introduction of a therapeutic coma increases the release of excitotoxic neurotransmitters, which reduces the survival rate of rabies patients after the onset of fatal symptoms.

[0009] Also known from the prior art is A combination of two human monoclonal antibodies eliminates the symptoms of rabies / Guilherme Diaz de Melo, Florian Sontonnax / / EMBO Mol. Med - (2020) 12:e12628 https: / / www.embopress.org / doi / full / 10.15252 / emmm.202012628, which includes the administration of human monoclonal antibodies RVC20 / RVC58.

[0010] A disadvantage of the analogue is the administration of monoclonal antibodies without the estradiol-based compound, which enhances the penetration and effectiveness of anti-rabies immunoglobulin, which reduces the survival rate of rabies patients. Furthermore, the absence of an immunomodulatory peptide, hypothermia, and induction of a therapeutic coma increases the release of excitotoxic neurotransmitters, which reduces the survival rate of rabies patients after the onset of fatal symptoms.

[0011] And from the state of the art, the dissertation of V.V. Lebedev “Imunofan (Development, clinical-experimental study and implementation into practice)” is known https: / / medical-diss.com / medicina / imunofan-razrabotka-kliniko-eksperimentalnoe-izuchenie-i-vnedrenie-v-praktiku, which includes subcutaneous administration of an immunomodulatory peptide.

[0012] The disadvantages of the analogue are the administration of an immunomodulatory peptide without the administration of anti-rabies immunoglobulin, the absence of hypothermia and the introduction of a therapeutic coma, which increases the release of excitotoxic neurotransmitters, reducing the survival of rabies patients after the onset of fatal symptoms.

[0013] Disclosure of the essence of the invention

[0014] The technical problem that the claimed invention is aimed at solving is to eliminate the above-mentioned disadvantages of analogues and to create a method for treating rabies after the onset of symptoms with increased survival of rabies patients after the onset of symptoms.

[0015] The technical result is to increase the survival rate of rabies patients after the onset of symptoms.

[0016] The technical result is achieved due to the fact that the method for treating rabies after the onset of symptoms includes administering to the patient an estradiol series compound selected from estradiol, ethinyl estradiol, or estradiol valerate, an anti-rabies immunoglobulin, the drug "Imunofan", carrying out therapeutic hypothermia, introducing the patient into a therapeutic coma with artificial ventilation of the patient's lungs.

[0017] In particular, the administration of anti-rabies immunoglobulin is carried out after the administration of an estradiol-type compound.

[0018] In particular, the administration of anti-rabies immunoglobulin is carried out in doses exceeding traditional prophylactic doses.

[0019] Implementation of the invention

[0020] Rabies is an acute, progressive viral encephalomyelitis caused by neurotropic viruses of the genus Lyssavirus. Once clinical symptoms appear, rabies is almost always fatal, causing approximately 59,000 deaths worldwide annually, primarily in developing countries. Traditional post-exposure prophylaxis (PEP), including wound care, rabies vaccination, and rabies immunoglobulin (RIG), is effective only when administered before the virus reaches the central nervous system (CNS).

[0021] When the CNS is affected, the virus causes severe neurological symptoms, including hydrophobia, aerophobia, paralysis, and coma, leading to death. The Milwaukee protocol, which involves inducing a coma and intensive supportive care, has resulted in survival in a few isolated cases, but is not consistently effective.

[0022] A multifactorial therapeutic approach targeting various aspects of disease pathogenesis improves survival even after the onset of symptoms. There are cases of people with rabies surviving with delayed post-exposure prophylaxis, when rabies symptoms had already begun to develop but regressed with a multifactorial therapeutic approach. This approach includes hormonal modulation to improve drug delivery to neurons, immunotherapy to enhance the body's antiviral response, neuroprotective strategies to reduce CNS damage, and advanced supportive care for vital functions.

[0023] After the onset of fatal symptoms, a patient diagnosed with rabies is given a comprehensive treatment, which includes the sequential implementation of the steps listed below, and their order is not important.

[0024] Administer an estradiol-type compound, which in this application refers to estradiol and its derivatives and salts, such as the synthetic estradiol analogue ethinyl estradiol, estradiol esters (estradiol valerate, estradiol hemihydrate). The estradiol-type compound is administered using various delivery methods, including orally, for example, as part of a tube feeding in the form of crushed tablets, rectally as extemporaneous suppositories, intravenously, and by other routes. The dosage of the estradiol-type compound is carefully calculated based on the patient's body weight, age, and clinical condition. Potential side effects, such as thromboembolic events, should be monitored due to the use of high doses.

[0025] High-dose rabies immunoglobulin (ARIG) is administered intramuscularly. High-dose ARIG refers to doses exceeding traditional prophylactic doses, correspondingly greater than 20 IU / kg. ARIG is primarily administered after intravenous administration of an estradiol-type compound. Patient monitoring includes assessment for allergic reactions and serum sickness.

[0026] Intramuscular or subcutaneous administration of an immunomodulatory peptide, specifically "Imunofan," which is an analog of the 32-36 region of thymopoietin. Treatment duration and dosage are determined based on the patient's immunological profile and response to therapy. Regular immunological assessments are performed to monitor effectiveness and adjust dosage.

[0027] Therapeutic hypothermia is also induced in the patient to a body temperature of 32-34°C. This is accomplished using cooling blankets, intravenous cold saline, and endovascular cooling devices. The patient's temperature is monitored using core temperature sensors. Slow rewarming is performed at a controlled rate, not exceeding 0.1°C per hour, to prevent arrhythmias and rebound intracranial hypertension.

[0028] Implementation of the Milwaukee protocol with mechanical ventilation, in which therapeutic coma is induced by intravenous administration of sedatives, including ketamine and midazolam, until deep sedation is achieved. The therapeutic coma is maintained with a continuous infusion of sedatives, including ketamine and midazolam, adjusting the dosage based on the depth of sedation and the patient's condition. The patient is connected to a mechanical ventilator, adjusting parameters to achieve optimal oxygenation and ventilation, including maintaining adequate blood oxygen concentration and carbon dioxide levels. In this case, saturation (SpO2) is maintained above 92%, the partial pressure of oxygen in arterial blood (PaO2) is maintained above 60 mmHg, and the partial pressure of carbon dioxide in arterial blood (PaCO2) is maintained at 35-45 mmHg.

[0029] Establish invasive monitoring of intracranial pressure (ICP) and maintain cerebral perfusion pressure (CPP) in the range of 60-70 mmHg.

[0030] Continuous monitoring of neurological status is necessary. Supportive care includes management of electrolyte balance, nutrition, and prevention of secondary infections. Electrolytes are monitored. + , Mg 2+ , Ca 2+ , PO4³ - In case of hypokalemia, potassium chloride is administered intravenously at a rate of 10-20 mEq / h daily under continuous ECG monitoring. Electrolyte levels of magnesium, calcium, and phosphate are adjusted similarly.

[0031] Implementation options

[0032] Option 1: A dog weighing 12 kg is administered estradiol intravenously at a dose of 0.2 mg / kg (2.4 mg). Then, anti-rabies immunoglobulin (ARIG) is administered intramuscularly at a dose of 50 IU / kg (600 IU). After that, the immunomodulatory peptide "Imunofan" is administered subcutaneously at a dose of 100 mcg 1 time per day. Therapeutic hypothermia is induced to 33 ° C using cooling blankets. Coma is induced with midazolam (0.05 mg / kg / h) and ketamine (1 mg / kg / h), connected to a ventilator, SpO2> 92% is maintained. Electrolytes are monitored; at K + <3.2 mmol / l, potassium solution is administered under ECG control.

[0033] Result: after a course of therapy, the dog restores breathing and motor activity, responds to commands and recognizes the owner.

[0034] Option 2: In a 250 g rat, treatment begins with hypothermia to 32.5 °C by cooling the body surface. Ethinyl estradiol is administered orally as part of a tube feeding in the form of crushed tablets at a dose of 0.3 mg / kg (0.075 mg) through a gastric tube. After the administration of ethinyl estradiol, ARIG 100 IU / kg (25 IU) is administered intramuscularly. Then, every other day, Immunofan 10 mcg is administered intramuscularly. To maintain anesthesia, ketamine 1.5 mg / kg / h and midazolam 0.08 mg / kg / h are used; SpO2>92% is maintained.

[0035] Result: After 25 days of therapy, rats demonstrated restoration of activity, successful completion of the maze, and preservation of reward-based play responses.

[0036] Option 3: For a 20 kg dog, treatment begins with 50 mcg of Immunofan subcutaneously. The dog is placed on mechanical ventilation, and an SpO2 of 294% is maintained. Coma is induced with midazolam 0.07 mg / kg / h and ketamine 1.2 mg / kg / h. Ethinyl estradiol 0.25 mg / kg (5 mg) is then administered rectally. ARIG is administered intramuscularly at 70 IU / kg (1400 IU). Hypothermia is induced to 34°C by administering cooled saline. Result: after 3 weeks of treatment, the dog comes out of the coma, regains consciousness, follows commands and demonstrates orientation in space.

[0037] Option 4: A 300 g rat is administered estradiol valerate 0.15 mg / kg (0.045 mg) intravenously, followed by ARIG 50 IU / kg (15 IU). Immunofan 10 mcg is administered intramuscularly daily. To maintain coma, ketamine 2 mg / kg / h and midazolam 0.1 mg / kg / h are used. Hypothermia is induced to 33°C using cooling blankets for 24–48 hours.

[0038] Result: On the 18th day of therapy, rats showed restoration of motor activity, maze completion, and a positive response to food reward.

[0039] Option 5: A 15 kg dog is started on the Milwaukee protocol: a coma is induced with ketamine (1 mg / kg / h) and midazolam (0.05 mg / kg / h), the dog is placed on mechanical ventilation, and an SpO2 of 94% is maintained. Estradiol valerate is then administered orally at 0.2 mg / kg (3 mg) as part of a tube feeding in the form of crushed tablets. Following this, ARIG 80 IU / kg (1200 IU) is administered intramuscularly. Immunofan 100 mcg is administered subcutaneously every other day. Hypothermia is induced to 32.8°C using a combined method (cooling blankets + cold solution).

[0040] Result: after a month, the dog comes out of the coma, is transferred to independent breathing, restores motor activity, and follows commands.

[0041] Justification of the technical result

[0042] Increasing the likelihood of survival of rabies patients after the onset of symptoms is achieved through the synergistic effect on multiple pathophysiological aspects of the disease of several therapeutic strategies - therapy with high doses of immunoglobulin, immune modulation with Immunofan, neuroprotection through hypothermia and induction of induced coma.

[0043] Ethinyl estradiol is a synthetic derivative of estradiol, a major estrogen hormone known for its effects on cell membranes. Estradiol and its derivatives integrate into the lipid bilayer of infected neurons, increasing membrane fluidity and permeability. This enhances the penetration and effectiveness of antirabies immunoglobulins within infected neurons, where the rabies virus replicates and evades the patient's immune system. In addition to increasing neuronal membrane permeability, estradiol and its derivatives exhibit neuroprotective effects, including antioxidant properties and inhibition of apoptotic pathways. Intravenous administration of estradiol and its derivatives ensures rapid delivery of the substance into the patient's bloodstream.

[0044] Administration of high doses of ARIG creates therapeutic levels of anti-rabies immunoglobulins, providing passive immunity by directly binding to rabies virus glycoproteins and neutralizing the virus, preventing its attachment to the patient's cells. Increased neuronal permeability induced by estradiol or its derivative allows ARIG to penetrate the central nervous system and reach infected neurons, where it inhibits rabies virus replication.

[0045] Administration of the immunomodulatory peptide "Imunofan" increases the activity and proliferation of T-lymphocytes and stimulates the production of endogenous interferons and interleukins in patients. Furthermore, Immunofan exhibits antioxidant effects, reducing oxidative stress and subsequent neuronal damage caused by the rabies virus.

[0046] Therapeutic hypothermia reduces the metabolic demands of neuronal tissue, limits neuronal energy depletion and maintains ATP levels, reduces the release of excitotoxic neurotransmitters such as glutamate, and inhibits the production of inflammatory cytokines. This neuroprotective strategy aims to preserve neuronal integrity and function during virus clearance.

[0047] Inducing a therapeutic coma using sedatives and anesthetics combined with mechanical ventilation to support respiratory function reduces brain metabolic activity, limits excitotoxic neuronal damage, and provides a controlled environment for the immune system and administered therapeutic agents to effectively combat the virus. Induced coma provides a window during which therapeutic agents, such as ARIG, Immunofan, estradiol and its derivatives, and therapeutic hypothermia, can exert their effects without the patient succumbing to rapid disease progression. Mechanical ventilation ensures adequate oxygenation and carbon dioxide removal, maintaining homeostasis.

[0048] Invasive intracranial pressure monitoring and maintenance of cerebral perfusion pressure prevents ischemic damage to the patient's brain and ensures the preservation of blood supply to the patient's nervous tissue.

[0049] Examples

[0050] To evaluate the increase in survival and preservation of central nervous system (CNS) functions during the treatment of rabies after the onset of symptoms, an experiment was conducted on laboratory animals.

[0051] The study included 20 animals: 10 laboratory rats and 10 domestic dogs that knew commands and recognized their owner. The subjects were infected with the rabies virus and waited until they developed fatal clinical signs of the disease (aerophobia, paresis, and seizures). The animals were divided into 10 groups (one rat and one dog in each) so that the severity of clinical manifestations was comparable across the groups.

[0052] Treatment of rabies in experimental animals was performed using the test methods. The results were assessed as follows. For dogs, not only survival was assessed but also the integrity of the central nervous system, as determined by the ability to perform previously learned commands ("sit," "come") and by the reaction to the owner (recognition, positive behavioral interaction). For rats, the assessment included completion of a standard maze and participation in reward-based behavioral tests (orientation, food retrieval on cue). The resulting numbers of surviving experimental animals are presented in Table 1.

[0053] The following methods were used as tests:

[0054] - method (A) for treating rabies after the onset of symptoms, including the administration of an estradiol-type compound, the administration of anti-rabies immunoglobulin, the administration of an immunomodulatory peptide, therapeutic hypothermia, and the introduction of a subject into a therapeutic coma with artificial ventilation of the subject's lungs;

[0055] - method (B) of treating rabies after the onset of symptoms, including the administration of an immunomodulatory peptide, the administration of an estradiol-type compound, the administration of anti-rabies immunoglobulin, therapeutic hypothermia, and the introduction of a subject into a therapeutic coma with artificial ventilation of the subject's lungs;

[0056] - method (B) of treating rabies after the onset of symptoms, including therapeutic hypothermia, administration of an immunomodulatory peptide, administration of an estradiol-type compound, administration of anti-rabies immunoglobulin, and placing the subject into a therapeutic coma with artificial ventilation of the subject's lungs;

[0057] - a method (G) for treating rabies after the onset of symptoms, including putting the subject into a therapeutic coma with artificial ventilation of the subject's lungs, performing therapeutic hypothermia, administering an immunomodulatory peptide, administering an estradiol compound, and administering anti-rabies immunoglobulin;

[0058] - method (D) for treating rabies after the onset of symptoms, including the administration of an estradiol-type compound, the administration of anti-rabies immunoglobulin, the introduction of a subject into a therapeutic coma with artificial ventilation of the subject's lungs, the implementation of therapeutic hypothermia, and the administration of an immunomodulatory peptide;

[0059] - a method (E) for treating rabies after the onset of symptoms, comprising administering an immunomodulatory peptide, placing the subject into a therapeutic coma with artificial ventilation of the subject's lungs, performing therapeutic hypothermia, administering an estradiol-type compound, and administering anti-rabies immunoglobulin;

[0060] - a method (G) for treating rabies after the onset of symptoms, including the administration of antirabies immunoglobulin;

[0061] - method (3) of treating rabies after the onset of symptoms, including the administration of anti-rabies immunoglobulin and therapeutic hypothermia;

[0062] - method (I) of rabies after the onset of symptoms, including the administration of an estradiol-type compound, the administration of anti-rabies immunoglobulin, the administration of an immunomodulatory peptide;

[0063] - a method (K) for treating rabies after the onset of symptoms, including the administration of an estradiol-type compound, the administration of antirabies immunoglobulin, the administration of an immunomodulatory peptide, and therapeutic hypothermia.

[0064] Table 1 – Obtained experimental results

[0065] Group Sequence (briefly) N Survived, n Preserved the central nervous system, n A EE → ARIG → IP → Hypot → Coma / ventilator 2 2 (100%) 2 (100%) B IP → EE → ARIG → Hypot → Coma / ventilator 2 2 (100%) 2 (100%) IN Hypot → IP → EE → ARIG → Coma / ventilator 2 2 (100%) 2 (100%) G Coma / ventilator → Hypot → IP → EE → ARIG 2 2 (100%) 2 (100%) D EE → ARIG → Coma / ventilator → Hypot → IP 2 2 (100%) 2 (100%) E IP → Coma / ventilator → Hypot → EE → ARIG 2 2 (100%) 2 (100%) AND Only ARIG 2 0 0 Z ARIG → Hypot 2 0 (50%) 0 AND EE → ARIG → IP 2 1 (50%) 0 TO EE → ARIG → IP → Hypot 2 1 (50%) 1 (100%)

[0066] The data obtained indicate that survival rates with fatal symptoms are higher with the claimed method than with similar treatments. Furthermore, the majority of surviving subjects retained their central nervous system. The data also demonstrate that each characteristic of the claimed method influences the achievement of the technical result.

Claims

1. A method for treating rabies after the onset of symptoms, comprising administering to the patient an estradiol-series compound selected from estradiol, ethinyl estradiol or estradiol valerate, antirabies immunoglobulin, the drug "Imunofan", performing therapeutic hypothermia, and placing the patient into a therapeutic coma with artificial ventilation of the patient's lungs.

2. The method according to paragraph 1, characterized in that the administration of antirabies immunoglobulin is carried out after the administration of an estradiol-type compound.

3. The method according to paragraph 1, characterized in that the administration of anti-rabies immunoglobulin is carried out in doses exceeding traditional prophylactic ones.