STATEMENT REGARDNG FEDERALLY SPONSORED RESEARCH

Work relating to this application was supported by a grant from the U.S. Government (NIH grant no. AA021667). The government may have certain rights in the invention.

FIELD OF THE INVENTION

This invention relates to treatment methods and compositions for ameliorating substance use disorders, abuse, and/or dependence. More specifically, this invention relates to treatment methods and compositions for reducing excessive intake of substances such as alcohol.

BACKGROUND OF THE INVENTION

1. Introduction

The following description in this Background section includes information that may be useful in understanding the present invention. It is not an admission that any such information is prior art, or relevant, to the presently claimed inventions, or that any publication specifically or implicitly referenced is prior art. In this specification, a number of documents including patent applications are cited. The disclosures of these documents, while not considered relevant for the patentability of this invention, are hereby incorporated by reference in their entirety. More specifically, all referenced documents are incorporated by reference to the same extent as if each individual document was specifically and individually indicated to be incorporated by reference.

2. Background

In the United States, with an estimated 6.8 percent of the population aged 12 or older classified as having alcohol dependence or abuse (1), alcohol remains the most prevalent abused substance in the USA (1). Few pharmacotherapies for alcohol abuse are currently available, and those that exist have shown only limited efficacy, poor patient compliance, etc. (2-4). Thus, the development of more efficacious and safe alcohol abuse/dependence medications is a significant unmet medical need (5).

Carbenoxolone (3P-hydroxy-l l-oxoolean-12-en-30-oic acid 3 -hemi succinate) is the hemi succinate derivative of 18P-glycyrrhetinic acid (GA), a metabolite of the natural product glycyrrhizin present in licorice (6). Carbenoxolone has long been used for the treatment of gastritis and peptic ulcers (7). Subsequent studies focused on elucidating the mechanism of action of carbenoxolone have highlighted that carbenoxolone modulates glucocorticoid metabolism in target tissues by inhibiting 1 Ιβ-hydroxy steroid dehydrogenases (1 Ιβ-HSD) (8) and, at potencies several orders of magnitude higher, gap junction communication (9). 11β- HSD interconverts 11-hydroxi (active) glucocorticoids (Cortisol in humans and corticosterone in rodents) and inert 11-keto glucocorticoids (cortisone in humans and 11β- dehydrocorticosterone in rodents) in target cells, thus acting as pre-receptor (8). In particular, there are at least two known isozymes of Ι ΐβ-HSD: type 1 (Ι Ιβ-HSDl) and type 2 (11β- HSD2). In vivo, Ι Ιβ-HSDl catalyses the regeneration of Cortisol in humans and corticosterone in rodents from cortisone in humans and 1 Ιβ-dehydrocorticosterone in rodents using the cofactor NADPH, while 11β-Η8ϋ2 catalyses the reverse reaction using the cofactor NAD+ (8). An 11β-Η8ϋ3 isozyme has also been described, whose physiological function remains unclear (10). Carbenoxolone inhibits 1 Ιβ-HSD isozymes in an isozyme non-selective manner (11).

Glucocorticoids are key in the regulation of stress responses, carbohydrate, lipid and protein metabolism and turnover, blood pressure, cell growth and differentiation, neuronal and immune functions, and alcohol and drug abuse (12-14). A complex regulatory network is involved in the regulation of glucocorticoid actions, with Ι ΐβ-HSD enzymes regulating intracellular glucocorticoid levels and receptor access (8).

Impaired glucocorticoid regulation has been implicated in the pathogenesis of several diseases and, thus, modulation of intracellular glucocorticoid levels is a potential therapeutic strategy to treat glucocorticoid-dependent diseases. Ι Ιβ-HSDl is expressed primarily in the liver, brain, and adipose tissue (8). Inhibition of Ι Ιβ-HSDl reduces the intracellular availability of active glucocorticoids such as Cortisol in humans and corticosterone in rodents (8). In both humans and rodents, elevated Ι Ιβ-HSDl activity has been associated with metabolic disorders (9, 15-18) and age-related cognitive impairments (19, 20). 11β-Η8ϋ2 is expressed in classic mineral ocorticoid target tissues including the kidney, colon, sweat and salivary glands (21). 11β-Η8ϋ2 is also expressed in the placenta, where it protects the fetus from excess glucocorticoids (22-24), as well as in inflamed tissue and several tumors and cancer cell lines (21). Inhibition of 11β-Η8ϋ2 is responsible for the adverse effects of enhanced renal sodium retention and elevated blood pressure in patients with mutations of HSD11B2 (25) and in individuals ingesting high amounts of licorice, which contains the non- selective Ι ΐβ-HSD inhibiting triterpenoid glycyrrhetinic acid (GA) and in some patients treated with the non-selective Ι ΐβ-HSD inhibitor carbenoxolone (26-28). However, recent evidence indicates potential beneficial effects of l ip-HSD2 inhibition in chronic inflammatory diseases of the colon and on colon cancer cell proliferation. In particular, 11β- HSD2 regulates the activity of several enzymes involved in inflammatory and other responses such as NfKB (29) and COX (30). Furthermore, a recent clinical study suggested that l ip-HSD2 inhibition promotes potassium excretion and prevents hyperkalemia in chronic hemodialysis patients (31). Thus, l ip-HSD2 inhibition may also be therapeutically useful.

It is also understood that alcohol use disrupts glucocorticoid regulation in rodents (32, 33) as well as humans (34-37). Regardless of what is known about the functional consequences of such a dysregulation, there is a significant lack of understanding regarding this particular regulation cascade. However, it has been reported that glucocorticoid activation by alcohol is associated with escalation of alcohol intake in dependent rats and alcohol-seeking and drinking during protracted abstinence (13). In that study, mifepristone (RU38486), a glucocorticoid receptor antagonist with progesterone partial agonist activity, was used to antagonize glucocorticoid activation and the blocking of activation by systemic glucocorticoid receptor (GR) antagonism blocked escalated alcohol drinking and compulsive response for alcohol (35). In still another study, in humans, high adrenal sensitivity, as expressed by a high Cortisol to corticotropin ratio at rest (neutral, relaxed conditions), was found to correlate with greater susceptibility of relapse to heavy drinking (37).

Only a limited number of drugs exist with clinical efficacy for alcohol abuse (5). Expansion of available therapeutic options is needed to improve treatment success at different stages of disease progression and, optimally, to bring about individualized therapies based on patient genetic makeup and disease stage (5, 38). Given that there is an ongoing need for effective medications for treating and ameliorating substance use disorder, abuse, and/or dependence for substances such as alcohol, this invention provides a new solution for treating alcohol substance abuse through the novel discovery that compounds capable of inhibiting 1 Ιβ-hydroxy steroid dehydrogenases (Ι ΐβ-HSD) can be used to ameliorate excessive alcohol intake.

Thus, as described below, methods and compositions are provided for reducing dependence and otherwise excessive intake of alcohol in mammals including humans.

SUMMARY OF THE INVENTION In a first aspect, the invention relates to new and more effective treatment methods for treating mammals, particularly humans, for alcohol use disorders, abuse, and/or dependence.

In a second aspect, the invention concerns compositions for treating alcohol use disorders, abuse, and/or dependence. In preferred embodiments, such compositions comprise formulations of an inhibitor of 1 Ιβ-hydroxy steroid dehydrogenase (1 Ιβ-HSD) activity, such as, for example, carbenoxolone or a carbenoxolone derivatives, or other such inhibitors as described herein.

In a third aspect, the invention involves methods for reducing alcohol use disorders, abuse, and/or dependence by administering to a mammal (particularly a human) in need thereof an effective amount of an inhibitor of 1 Ιβ-hydroxy steroid dehydrogenases (11β- HSD) activity, such as by administration of a carbenoxolone formulation to cause inhibition of 1 Ιβ-hydroxy steroid dehydrogenases (1 Ιβ-HSD) activity, thereby resulting in a reduction of alcohol intake in the mammal.

Other features and advantages of the invention will be apparent from the following description and from the claims. The invention will be further described in the following examples, which do not limit the scope of the invention described in the claims.

BRIEF DESCRIPTION OF THE DRAWINGS

Figure 1A is a graph showing acute, systemic administration of carbenoxolone decreases in alcohol self-administration both in dependent and nondependent rats. Figures IB and 1C are graphs showing acute, systemic administration of carbenoxolone does not affect self-administration of saccharin-sweetened water. A) Acute, systemic administration of CBX decreases operant alcohol self-administration both in dependent and non-dependent rats. B) CBX did not influence water intake in any group. C) Acute, systemic administration of CBX does not affect operant self-administration of saccharin-sweetened water. Rats were given CBX (0, 20, and 40 mg/kg or 0 and 40 mg/kg; IP) 90 min prior to alcohol (10%, w/v), water or saccharin (0.004%) self-administration (30 min session; FR1). The data represent means and SEM. * <0.05, significant difference from respective vehicle; ⁺ <0.05, significant difference from vehicle (saline) -treated non-dependent rats. N = 9-10 per group.

Figure 2 is a graph showing acute CBX reduces ethanol intake in non-dependent and dependent mice in a limited access 2-bottle choice paradigm. Mice trained to drink alcohol in a limited access (2 h) 2-bottle choice paradigm were either exposed to alcohol vapor to induce dependence or air for the purpose of control, and tested for the effect of CBX on drinking. CBX reduced ethanol intake in non-dependent mice at doses of 20 and 40 mg/kg IP (left), and in dependent mice at 40 mg/kg, IP (right). Two-way ANOVA revealed a significant effect of vapor exposure (F ₂₃₅ = 33.38, <0.0001), dose (F ₂₃₅ = 13.04, <0.0001), and interaction of vapor exposure and dose (F ₂₃₅ = 3.902, =0.0295). * <0.05, ** <0.01, *** <0.001, significant difference from the respective vehicle saline-treated group; ⁺⁺ <0.01, ⁺⁺⁺ <0.001, significant difference from respective non-dependent group.

Figures 3A-H are graphs showing activity of 18a-glycyrrhetinic acid and 18β- glycyrrhetinic on mouse and human Ι Ιβ-HSDl and 2. We tested the IC50 of a and β- glycyrrhetinic acid (GA) against human and mouse Ι Ιβ-HSDl and 11β-Η802 by means of homogeneous time-resolved fluorescence (HTRF) assays. A,C) a-GA yielded IC50 values of 532.1 nM for human Πβ-HSDl and 6.63 for mouse Πβ-HSDl. B,D) a-GA yielded IC50 values of 942.6 nM for human 1 ^-HSD2 and 159.7 nM for mouse 1 ^-HSD2. E,G) β -GA yielded IC50 values of 232.3 nM for human Πβ-HSDl and 5.85 ^M for mouse 11β- HSD1. F,H) β -GA yielded IC50 values of 674.5 nM for human 1 ^-HSD2 and 79.7 nM for mouse 1 ^-HSD2.

Figures 4A-D are graphs showing activity of carbenoxolone (CBX, 18β- glycyrrhetinic acid and aCBX (18a-glycyrrhetinic acid 3β-0-

hemisuccinate) on mouse and human Ι Ιβ-HSDl and 2. We tested the IC50 of 18α-18β- glycyrrhetinic acid 3 against human and mouse Ι Ιβ-HSDl and 11β-Η802 by means of homogeneous time-resolved fluorescence (HTRF) assays. A,C) CBX yielded IC50 values of 753.1 nM for human Πβ-HSDl and 4.62 ^M for mouse Πβ-HSDl. B,D) CBX yielded IC50 values of 379.6 nM for human 1 ^-HSD2 and 628.7nM for mouse 11β- HSD2. E,G) aCBX yielded IC50 values of 15.92 ^M for human Πβ-HSDl and 48.25 ^M for mouse Πβ-HSDl. F,H) aCBX yielded IC50 values of 30.67 ^M for human 1 ^-HSD2 and 1.06 μΜ for mouse 11β-Η802. Results for CBX are the average of 2-3 independent replicates; results for aCBX are the average of 3-4 independent replicates.

Figures 5A-D are graphs showing CBX and aCBX reduce ethanol intake in mice in the drinking in the dark (DID) paradigm. A-B) CBX reduced ethanol intake in the DID binge-like drinking paradigm. A) CBX effect on ethanol intake in the first 2 hours of the 4 h drinking session effect on ethanol intake for the 4 h drinking session aCBX effect on ethanol intake in the first 2 h

of the 4 h drinking session effect on ethanol intake for the 4 h drinking session (F _{3 86} = 18.51, <0.0001). The effects of CBX and aCBX were more pronounced in the first 2 hours of the session, suggesting an effect on initiation of drinking. * <0.05, ** <0.01, *** <0.001, significant difference from respective saline vehicle (N = 11-15).

Figure 6 is a graph showing acute, systemic administration of probenecid decreases alcohol self-administration in alcohol dependent but not in nondependent alcohol self- administering rats. "*" means liferent from vehicle-treated dependent rats (p<0.05, n=6-8).

DETAILED DESCRIPTION OF THE INVENTION

Turning now to the invention, provided are methods and compositions for treating alcohol use disorders, abuse, and/or dependence. This invention is based on the surprising discovery that compounds that have an antagonizing effect on 1 Ιβ-HSD, in its various forms, when administered to a mammal, particularly a human, there is induced a reduction in alcohol intake in the subject. In one example, administration of carbenoxolone, having an antagonizing effect on 1 Ιβ-HSD, reduces the intake behavior of alcohol in test mammals.

The term "treating" refers to any indication of success in the treatment or amelioration of a pathology or condition, including any objective or subjective parameter such as abatement; remission, decrease of symptoms in the pathology or condition so as to make physical conditions more tolerable to the patient. The term "treating" also refers to the lessening of negative effects of the pathology or condition making the final point of efficacy less debilitating so as to improve a patient's physical well-being.

Inhibition of 1 Ιβ-HSD "synthesis or activity" refers to the inhibition of 1 Ιβ-HSD at the protein level, to prevent or down-regulate the production of the protein, and/or at least one biological activity of any protein produced.

Regarding the activity of 1 Ιβ-HSD, any small molecule, nucleic acid such as an interfering RNA, enzyme or protein that increases activity is necessarily an agonist of that activity. Similarly, any small molecule, nucleic acid, enzyme or protein that reduces the activity is an antagonist, i.e., inhibitor. Thus, the substance disclosed in the methods and compositions below is an antagonist of 1 Ιβ-HSD, i.e., is capable of decreasing or reducing the activity of 11 β-HSD.

The term "antagonist" generally means a compound that binds to an enzyme and inhibits the activity of that enzyme. As used here, however, the term is intended to refer broadly to any agent that inhibits the activity of a molecule, by any mechanism. Accordingly, it includes agents that affect the expression of a protein such as 1 Ιβ-HSD, or the biosynthesis of a molecule such as 1 Ιβ-HSD, or the expression of modulators of the activity of 1 Ιβ-HSD. The specific activity inhibited can be any activity that is characteristic of the enzyme or molecule, for example, a dehydrogenase activity of 1 Ιβ-HSDl . Activity assays for these are known to those skilled in the art. As used herein, in general, the term "antagonist" includes but is not limited to agents such as an atom or molecule, wherein a molecule may be inorganic or organic, a biological effector molecule and/or a nucleic acid encoding an agent such as a biological effector molecule, a protein, including, but not limited to, a structural protein, an enzyme, a cytokine (such as an interferon and/or an interleukin), a polypeptide, a peptide, a nucleic acid, a peptide nucleic acid (PNA), a virus, a virus-like particle, a nucleotide, a ribonucleotide, a synthetic analogue of a nucleotide, a synthetic analogue of a ribonucleotide, a modified nucleotide, a modified ribonucleotide, an amino acid, an amino acid analogue, a modified amino acid, a modified amino acid analogue, a steroid, a proteoglycan, a lipid, a fatty acid, or a carbohydrate or any small molecule capable of modifying the biosynthesis, degradation or activity of 1 Ιβ-HSD, including 1 Ιβ-HSDl, 11β- HSD2 and 1 Ιβ-HSDS. An agent may be in solution or in suspension (e.g., in crystalline, colloidal or other particulate form). The agent may be in the form of a monomer, dimer, oligomer, etc, or otherwise in a complex.

The antagonist may bind to and compete for one or more sites on the relevant molecule, for example, a 1 Ιβ-HSD molecule, to reduce one or more of its activities

(including dehydrogenase activity). The antagonist need not specifically bind directly to a catalytic site, and may bind for example to an adjacent site, another protein (for example, a protein which is complexed with the enzyme) or other entity on or in the cell, so long as its binding reduces the activity of the enzyme or molecule.

The term "antagonist" is also intended to include, an antibiotic, a polyclonal or monoclonal antibody, or an effective part thereof, such as an Fv fragment, which antibody or part thereof may be natural, synthetic or humanized, a peptide hormone, a receptor, a signaling molecule or other protein; a nucleic acid, as defined below, including, but not limited to, an oligonucleotide or modified oligonucleotide, an antisense oligonucleotide or modified antisense oligonucleotide, cDNA, genomic DNA, an artificial or natural chromosome (e.g., a yeast artificial chromosome) or a part thereof, RNA, including mRNA, tRNA, rRNA or a ribozyme, or a peptide nucleic acid (PNA); a virus or virus-like particles; a nucleotide or ribonucleotide or synthetic analogue thereof, which may be modified or unmodified; an amino acid or analogue thereof, which may be modified or unmodified; a non-peptide (e.g., steroid) hormone; a proteoglycan; a lipid; or a carbohydrate. Small molecules, including inorganic and organic chemicals, which bind to and occupy the active site of the polypeptide thereby making the catalytic site inaccessible to substrates such that normal biological activity is prevented, are also included. Examples of small molecules include but are not limited to small peptides or peptide-like molecules.

In a second embodiment, a mammal can be treated for alcohol use disorder, abuse, and/or dependence by administration of a composition comprising carbenoxolone. Examples of formulations and dosages for systemic delivery to a patient to reduce craving for alcohol include such as, preferably administration at a rate of at or about 100 mg every 8 to 24 hours, preferably over a course of 4 weeks or more or it can also be administered on an as-needed basis. The formulations can alternatively be administered to an individual at or about 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, 7.5, 8, 8.5, 9, 9.5 or 10 mg/kg/day. Dosages may even be between 20, 40 and 60 mg/kg/day. In one preferred embodiment, carbenoxolone is administered to an individual at a rate of about 4.5 mg/kg/day.

A pharmaceutically or therapeutically effective amount is an amount of a composition which achieves the desired effect in an animal or human. As is well known to those of skill in the art, the specific amount to achieve efficacy will vary depending upon a number of factors. Using the guidance provided herein and knowledge of the art, determining of a pharmaceutically effective amount of carbenoxolone is within the ordinary skill of a physician. Pharmaceutically effective amounts designed for particular applications may be packaged as unit doses to facilitate administration.

Inhibition of 1 ip-HSD2 by carbenoxolone in some individuals - approximately 20% of subjects (39) - has been associated with various physiological conditions including increased blood pressure due to increased aldosterone activity (11). Thus, to assist efficacy of carbenoxolone in treating alcohol abuse, it may be administered in a formulation with other active agents such as an anti-kaliuretic-diuretic agent. Preferably, the diuretic is such that it selectively enhances the excretion of sodium ions without causing an increase in excretion of potassium ions. Anti-kaliuretic-diuretics, also known as "potassium-sparing diuretics", comprise a class of drugs capable of blocking the exchange of sodium for potassium and hydrogen ions in the distal tubule, causing an increase in the excretion of sodium and chloride with a negligible increase in potassium excretion.

In preferred embodiments, agents used with carbenoxolone administration are capable of modulating the inhibition of carbenoxolone on 1 ip-HSD2, preferably down-regulating, most preferably reversing such inhibition. Preferably, this secondary agent is not capable of binding to mineralocorticoid receptors; more preferably the second agent is not capable of blocking mineralocorticoid receptors.

A composition comprising carbenoxolone, can be delivered by conventional medicinal approaches, preferably in the form of a pharmaceutical composition. A

pharmaceutical composition in the context of the present invention is a composition of matter comprising at least an inhibitor or antagonist of 1 Ιβ-HSD alone or together with a second agent which comprises a diuretic, preferably an anti-kaliuretic-diuretic, as an active ingredient, as well as a carrier, excipient, and/or diluent.

Administration can be in any convenient manner such as by the oral, intravenous (where water soluble), intramuscular, subcutaneous, intranasal, intradermal, or suppository routes or implanting. In some embodiments, the tablets are coated or scored and are formulated so as to provide slow or controlled release of the active ingredient therein.

Depending on the route of administration, the active ingredients can be required to be coated in a material to protect said ingredients from the action of enzymes, acids and other natural conditions which can inactivate said ingredient. In a preferred embodiment, carbenoxolone is administered orally.

The prevention of the action of microorganisms can be brought about by various antibacterial and antifungal agents, for example, parabens, chlorobutanol, phenyl, sorbic acid, thimerosal, and the like. In preferred embodiments, isotonic agents, for example, sugars or sodium chloride, can be included. Prolonged absorption of the injectable compositions can be brought about by the use in the compositions of agents delaying absorption, for example, aluminum monostearate and gelatin.

Sterile injectable solutions are prepared by incorporating the active compound in the required amount in the appropriate solvent with various of the other ingredients enumerated above, as required, followed by filtered sterilization. Generally, dispersions are prepared by incorporating the sterilized active ingredient into a sterile vehicle which contains the basic dispersion medium and the required other ingredients from those enumerated above. In the case of sterile powders for the preparation of sterile injectable solutions, the preferred methods of preparation are vacuum drying and the freeze-drying technique which yield a powder of the active ingredient plus any additional desired ingredient from previously sterile- filtered solution thereof.

When the combination of polypeptides is suitably protected as described above, it can be orally administered, for example, with an inert diluent or with an assimilable edible carrier, or it can be enclosed in hard or soft shell gelatin capsules, or it can be compressed into tablets, or it can be incorporated directly with the food of the diet. For oral therapeutic administration, the active compound can be incorporated with excipients and used in the form of ingestible tablets, buccal tablets, troches, capsules, elixirs, suspensions, syrups, wafers, and the like. The amount of active compound in such therapeutically useful compositions is such that a suitable dosage will be obtained.

The tablets, troches, pills, capsules and the like can also contain the following: a binder such as gum tragacanth, acacia, corn starch or gelatin; excipients such as dicalcium phosphate, a disintegrating agent such as corn starch, potato starch, alginic acid and the like, a lubricant such as magnesium stearate; and a sweetening agent such as sucrose, lactose or saccharin may be added or a flavoring agent such as peppermint, oil of wintergreen, and other flavorings. When the dosage unit form is a capsule, it can contain, in addition to materials of the above type, a liquid carrier.

Various other materials can be present as coatings or to otherwise modify the physical form of the dosage unit. For instance, tablets, pills, or capsules can be coated with shellac, sugar or both. A syrup or elixir can contain the active compound, sucrose as a sweetening agent, methyl and propylparabens as preservatives, a dye and flavoring such as cherry or orange flavor. Of course, any material used in preparing any dosage unit form should be pharmaceutically pure and substantially non-toxic in the amounts employed. In addition, the active compound can be incorporated into sustained-release preparations and formulations.

As used herein "pharmaceutically acceptable carrier and/or diluent" includes any and all solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents and the like. The use of such media and agents for pharmaceutical active substances is well known in the art. Except insofar as any conventional media or agent is incompatible with the active ingredient, use thereof in the therapeutic compositions is contemplated. Supplementary active ingredients can also be incorporated into the

compositions.

It is especially advantageous to formulate parenteral compositions in dosage unit form for ease of administration and uniformity of dosage. Dosage unit form as used herein refers to physically discrete units suited as unitary dosages for the mammalian subjects to be treated; each unit containing a predetermined quantity of active material calculated to produce the desired therapeutic effect in association with the required pharmaceutical carrier. The specification for the novel dosage unit forms are dictated by and directly dependent on (a) the unique characteristics of the active material and the particular therapeutic effect to be achieved, and (b) the limitations inherent in the art of compounding such as active material for the treatment of disease in living subjects having a diseased condition in which bodily health is impaired.

The principal active ingredients are compounded for convenient and effective administration in effective amounts with a suitable pharmaceutically acceptable carrier in dosage unit form. In the case of compositions containing supplementary active ingredients, the dosages are determined by reference to the usual dose and manner of administration of the said ingredients.

In some embodiments, the first agent which is an antagonist of 1 Ιβ-HSD, namely carbenoxolone or derivative thereof and a possible second agent, if any, which comprises a diuretic such as, but not liomited to, an anti-kaliuretic-diuretic can be provided in the form of a pharmaceutical composition.

Such first and second agents can be administered separately or as a single

pharmaceutical formulation. Thus, the invention includes pharmaceutical compositions comprising a first agent that is an antagonist of 1 Ιβ-HSD, together with a second agent that comprises, for example, a diuretic, preferably an anti-kaliuretic-diuretic. Alternatively, a treatment regimen involving first and second agents can involve administration of each agent in its own composition, which may be administered before, concurrently, or after the other agent(s).

Such pharmaceutical compositions are useful for delivery of the first or second agents, or both, preferably in the form of a composition as described, to an individual for the treatment or alleviation of symptoms as described.

Carbenoxolone and modes of administration thereof are described in previous studies that aimed at inhibiting Ι Ιβ-HSDl systemically for therapeutic purposes in humans, including in Walker et al., "Carbenoxolone Increases Hepatic Insulin Sensitivity in Man: A Novel Role for 11-oxosteroid Reductase in Enhancing Glucocorticoid Receptor Activation," (18) and "1 Ιβ-hydroxy steroid dehydrogenase inhibition improves cognitive function in healthy elderly men and type 2 diabetics" (20). Both these studies used an oral dose of 100 mg three times per day (18, 20), which is a conventional dose of carbenoxolone for peptic ulcer (39). This dose of carbenoxolone in one study was combined with amiloride (10 mg/day) to prevent the occurrence of renal mineralocorticoid excess (20), which is seen in approximately 20% of subjects chronically treated with carbenoxolone at the dose of 100 mg three times per day (39).

The effective amount of agent depends on the age, weight and condition of a patient. In general, the daily oral dose of agent is less than 1200 mg, and more than 50 mg. The preferred daily oral dose is about 100-600 mg. Oral formulations are conveniently presented in a unit dosage form and can be prepared by any method known in the art of pharmacy. The composition can be formulated together with a suitable pharmaceutically acceptable carrier into any desired dosage form. Typical unit dosage forms include tablets, pills, powders, solutions, suspensions, emulsions, granules, capsules, suppositories. In general, the formulations are prepared by uniformly and intimately bringing into association the agent composition with liquid carriers or finely divided solid carriers or both, and as necessary, shaping the product. The active ingredient can be incorporated into a variety of basic materials in the form of a liquid, powder, tablets or capsules to give an effective amount of active ingredient to treat the disease. In a highly preferred embodiment, carbenoxolone is administered to an individual at a rate of about 100 mg 1-3 times a day, preferably 3 times a day every 8 hours, or at a rate of about 4.5 mg/kg/day. Carbenoxolone can also be administered on an as-needed basis to reduce craving for alcohol in an individual.

A second agent capable of modulating the inhibition of l ip-HSD2 by carbenoxolone or another non-selective Ι ΐβ-HSD inhibitor may also be administered with carbenoxolone or another non-selective Ι ΐβ-HSD inhibitor to prevent - preferably down-regulating, most preferably reversing - such inhibition of l ip-HSD2. Preferably, the second agent is not capable of binding to mineralocorticoid receptors; more preferably the second agent is not capable of blocking mineralocorticoid receptors. Such agents may include an anti-kaliuretic- diuretic that enhances the excretion of sodium ions without causing an increase in excretion of potassium ions such as a pyrazine-carbonyl-guanidine like amiloride (3,5-diamino-6- chloro-N-(diami- nomethylene) pyrazinecarboxamide), or a salt or ester thereof, preferably more preferably dihydrate. Alternatively, such agent may include an aldosterone antagonist, such as an androstadiene-spiro-furan like spironolactone ( 17-hydroxy-7alpha-mercapto-3 -oxo- 17alpha-pregn-4-ene-21 -carboxylic acid gamma-lactone) or a salt or ester thereof, preferably spironolactone-acetate, or Eplerenone.

Other inhibitors of 1 Ιβ-hydroxy steroid dehydrogenase have been described and they include the compounds in Table I, including 18a-and 18P-glycyrrhetinic acid (40) and various of their derivatives, e.g., (41-44); furosemide, naringenin, found in grapefruit juice, ethacrynic acid, and chenodeoxycholic acid (45); Ι ΐβ-aminoprogesterone derivatives (46); benzazol-2-yl piperazine sulfonamides (47);arylsulphonamidothiazoles (48); 3,3- disubstituted-(8-aza-bicyclo[3.2.1]oct-8-yl)-[5-(lH-pyrazol- 4-yl)-thi- ophen-3-yl]- methanone, 3,3-disubstituted-(6-aza-bicyclo[3.1.1]hept-6-yl)-[5-(lH-pyr azol-4-yl)-th- iophen-3-yl]-methanone, and 4,4-disubstituted piped din- l-yl)-[5-(lH-pyrazol-4-yl)-thiophen- 3-yl]-methanone compounds that selectively inhibit Ι Ιβ-HSDl (Patent application number: 20130123268); Amido-Thiophene Compounds that selectively inhibit l lp-HSDl (Patent application numbers: 20130012545; 20110015178; 20100267696); (4-phenyl-piperidin-l-yl)- [5-(lH-pyrazol-4-yl)-thiophen-3-yl]-methanone compounds that selectively inhibit 11β- HSD1 (Patent application number: 20120172393); compounds that selectively inhibit 11β- HSD1 (Patent application number: 20120095046); as well as other structures including adamantyl triazoles, octyltriazoles, phenyl triazoles, among others (17, 49-54). Any one of these Ι ΐβ-HSD inhibitors can be used to treat alcohol use disorders. All of these cited publications are hereby incorporated by reference in their entirety.

Table I, below, provides a list of 11 β-HSD inhibitors that, because of their inhibition activity, use of any of them is contemplated in the context of the invention for treating a patient who is in need of decreasing intake of alcohol due to an alcohol abuse disease or disorder.

Table 1 : Chemical stmcture of 1 Ιβ-HSD inhibitor families.

Carbenoxolone is also known to block gap junctions and pannexins (100). Table II, below, provides a list of gap junction and pannexin inhibitors that because of their inhibition activity, use of any of them is contemplated in the context of the invention to be used for treating a patient who is in need of decreasing intake of alcohol due to an alcohol abuse disease or disorder.

Table II: Chemical structure of Pannexin inhibitors

The antigout drug probenecid inhibits Pannexin 1 and prevents inflammasome activation in neurons and astrocytes (101, 102). Other nonselective transporter inhibitors including sulfinpyrazone and benzbromarone (100). Pannexin 1 is also inhibited by other classes of drugs including Gap junction blockers, transport blockers, CI- channel blockers, malaria drugs, thiol reagents and others (Dahl, et al. 2013) and "mimetic" peptides" such as Gap27, Gap24, PanxElb, Panxl (103). Other gap junction inhibitors including flufenamic acid (FFA) were tested on Pannexin 1 and were found to inhibit the channel (104). ATP inhibits Pannexin 1 in a form of negative feedback (105). More potent ATP analogues such as the nonhydrolyzable BZATP inhibit Pannexin 1 more effectively than ATP. The ATP- dependent negative feedback on Pannexin 1 serves two functions. First, negative feedback on Pannexin 1 stops the channel from being open for prolonged periods of time and thus prevents rundown of ionic gradients and cell death (105). Second, the negative feedback ensures that ATP release through Pannexin 1 is transient and elicits a controlled response. The most selective and least detrimental Pannexin 1 inhibitor currently known is the blue dye Brilliant Blue G (BBG or Coomassie Blue) (105). The food dye Brilliant Blue FCF (BBFCF) is structurally similar to BBG and has been hypothesized to have similar effects to those of BBG (106).

A composition for use in accordance with the invention may include the first agent which is an antagonist of 1 Ιβ-HSD, optionally together with a second agent which comprises a diuretic, preferably an anti-kaliuretic-diuretic, or a fragment, homologue, variant or derivative thereof, a structurally related compound, or an acidic salt of either. The pharmaceutical formulations comprise an effective amount of the first and/or second agent, fragment, homologue, variant or derivative thereof, together with one or more

pharmaceutically-acceptable carriers. An "effective amount" is the amount sufficient to alleviate at least one symptom of a disease as described, for example, lessening of alcohol intake and or craving for alcohol.

The effective amount will vary depending upon the particular disease or syndrome to be treated or alleviated, as well as other factors including the age and weight of the patient, how advanced the disease state is, the general health of the patient, the severity of the symptoms, and whether the first and/or second agent or variant or derivative thereof is being administered alone or in combination with other therapies.

Suitable pharmaceutically acceptable carriers are well known in the art and vary with the desired form and mode of administration of the pharmaceutical formulation. For example, they can include diluents or excipients such as fillers, binders, wetting agents, disintegrators, surface-active agents, lubricants and the like. Typically, the carrier is a solid, a liquid or a vaporizable carrier, or a combination thereof. Each carrier should be "acceptable" in the sense of being compatible with the other ingredients in the formulation and not injurious to the patient. The carrier should be biologically acceptable without eliciting an adverse reaction (e.g., immune response) when administered to the host.

EXAMPLES

The following examples are provided for illustrative purposes only and not to limit the scope of the claims provided herein.

Specifically, adult male Wistar rats (Charles River), weighing 225-275 g at the beginning of the experiments, were housed in groups of 2-3 per cage in a temperature- controlled (22°C) vivarium on a 12 hr/12 hr light/dark cycle (lights on at 8:00 P.M.) with ad libitum access to food and water except during behavioral testing. Male wild-type C57BL/6J obtained from Jackson Laboratories were used for chronic intermittent ethanol exposure (CIE) and the drinking in the dark (DID) procedure.

All behavioral tests were conducted during the dark phase of the light/dark cycle. All procedures adhered to the National Institutes of Health Guide for the Care and Use of Laboratory Animals. Rat operant self-administration of alcohol. Self-administration sessions were conducted in standard operant conditioning chambers (Med Associates). The rats were trained to self-administer alcohol as previously reported (13). First, the rats were given free- choice access to alcohol (10% w/v) and water for 1 day in their home cages to habituate them to the taste of alcohol. Second, the rats were subjected to an overnight session in the operant chambers with access to one lever (right lever) that delivered water in a fixed-ratio 1 (FRl) schedule where every lever press is reinforced with delivery of 0.1 ml of solution. Food was available ad libitum during this training. Third, after 1 day off, the rats were subjected to a 2 hour session (FRl) for 1 day and a 1 hour session (FRl) the next day, with one lever delivering alcohol (right lever). All of the subsequent sessions lasted 30 min, and two levers were available (left lever: water; right lever: alcohol) until stable levels of intake were reached. Upon completion of this procedure, the animals were allowed to self-administer a 10% (w/v) alcohol solution and water on an FRl schedule of reinforcement.

Rat alcohol vapor chambers. The rats were made dependent by chronic, intermittent exposure to alcohol vapors as previously described (13). They underwent cycles of 14 hours on (blood alcohol levels during vapor exposure ranged between 150 and 250 mg%) and 10 hours off, during which behavioral testing for acute withdrawal occurred (i.e., 6-8 hours after vapor was turned off when brain and blood alcohol levels are negligible (108). In this model, rats exhibit motivational and somatic withdrawal signs (13, 109-111). Dependent rats were exposed to vapor at least for two months before testing. Nondependent rats were not exposed to alcohol vapor. The same rats were also tested during protracted abstinence, where the animals were tested at the same time of the day as for acute withdrawal but 3-6 weeks after the vapor was turned off.

Rat operant self-administration of saccharin. A separate cohort of rats was tested for self-administration of saccharin-sweetened water. A submaximal rewarding saccharin concentration (0.004%>, w/v) was chosen based on previous studies (13) to prevent a "ceiling effect" in any group and maintain similar response rates as alcohol. Training for this experiment was identical as for alcohol described above, except that saccharin solution was used.

Mouse 2-bottle choice procedure and intermittent ethanol exposure (CIE) to model dependent and nondependent drinking. Exposure of mice to repeated cycles of intermittent ethanol vapor in order to induce dependence increases ethanol drinking following withdrawal in a 2-bottle choice paradigm (112, 113). Thus, the CIE paradigm is used to test the effects of a drug on dependent and nondependent drinking in mice. Briefly, C57BL/6J mutant and WT mice had access to two bottles, one containing water and the other containing 15% (w/v) ethanol, for 2 hours starting 3 hours into the dark phase. Following acquisition of stable alcohol intake, half of the mice were subjected to repeated bouts of ethanol vapor exposure consisting of 16 hours per day for 4 days. Before each exposure to ethanol vapor, mice were IP injected with a solution of 20% v/v ethanol and 68.1 mg/kg pyrazole and immediately placed into ethanol vapor chambers (La Jolla Ethanol Research, CA). Tail blood sampling for blood ethanol level (BAL) determination was carried out daily. Target BALs were 150-200 mg%. Seventy -two hours following removal from the chambers, mice received access to water vs. 20% ethanol for 2 hours, and again over the next 4 days. The following week, mice were re-exposed to the ethanol vapor/control conditions and again tested for t2- bottle choice drinking for 5 days. Three vapor bouts followed by 2-bottle choice were carried out. Mice were weighed every 4-6 days throughout the 2-bottle choice sessions and daily during the vapor exposure bouts. Food and water were available ad libitum and mice were group housed except during the ethanol drinking sessions.

Mouse drinking in the dark procedure (DID) to model binge drinking. The DID paradigm capitalizes on the circadian rhythm in drinking of mice utilizing a discrete time of exposure to ethanol to obtain pharmacologically significant ethanol drinking in a four-day procedure (114, 115). It is considered a preclinical model of binge alcohol drinking (116). Blood ethanol levels of C57BL/6J mice in DID are reliably over 100 mg% following the final drinking bout and produce behavioral intoxication in C57BL/6J mice (115). In the DID paradigm, the water bottle is replaced with a bottle containing 20% ethanol for 2 hours in the home cage 3 hours after lights go off. The design involves 3 daily drinking sessions of 2 hours and a fourth of 4 hours (114, 115).

Effect of carbenoxolone (CBX) on alcohol drinking in rats and mice.

Carbenoxolone was administered acutely systemically by intraperitoneal (IP) injection 90 min before testing at doses of 0, 20, and 40 mg/kg to rats and mice, which are in line with the scientific literature (16, 117-119).

Vapor-exposed alcohol dependent rats, as in previous studies, showed increased lever press responding for alcohol compared with nondependent rats (Fig. 1 A; group effect: F(i,i7 ₎ =32.9; p<0.0001). Acute intraperitoneal (IP) administration of CBX 90 min before testing dose-dependently reduced responding for alcohol in both dependent and

nondependent rats (Fig. 1); dose effect: p<0.05). No significant effects were found for water responding (Fig. IB). Additionally, no significant effects were found for self- administration of saccharin-sweetened water (Fig. 1C).

Results in rats showed that carbenoxolone effectively and dose-dependently reduces responding (lever pressing) for alcohol both in dependent and nondependent rats (Figs. 1A and IB). At the highest dose of carbenoxolone used, 40 mg/kg, carbenoxolone did not affect responding for saccharin (Fig. 2B). Carbenoxolone also reduced alcohol drinking in mice in the CIE paradigm (Fig. 3A) and in the DID paradigm of binge drinking (Fig. 3B).

These results indicate that carbenoxolone can be beneficial in two separate stages of alcohol abuse progression, the early stage when alcohol's positive reinforcement predominates and after the insurgence of dependence, when negative reinforcement becomes predominant (120).

Carbenoxolone inhibits both isozymes of Ι ΐβ-HSD (11). Inhibition of Ι ΐβ-HSD type 1 (Ι Ιβ-HSDl), which is expressed in liver and adipose tissue, reduces the intracellular availability of active glucocorticoids such as Cortisol in humans and corticosterone in rodents (8). For this reason, Ι Ιβ-HSDl is characterized as a glucocorticoid pre-receptor (121). Carbenoxolone does not effectively cross the blood brain barrier (BBB), thus its actions in reducing alcohol drinking are likely due to its peripheral actions (122). Therefore, the present results suggest a role of peripheral glucocorticoid receptor activation in motivation for alcohol.

Although carbenoxolone has long been used in the clinic for treating gastritis and peptic ulcer, its use has greatly diminished in favor of other classes of drugs, such as proton pump inhibitors and histamine H2 antagonists. This is in part because of the potential of chronic carbenoxolone intake to induce pseudohyperaldosteronism. The latter is due to carbenoxolone inhibition of 1 Ιβ-HSD type 2 isoform (11β-Η8ϋ2), present in the kidney and other mineralocorticoid target tissues, that performs the reverse reaction as 1 Ιβ-HSDl, preventing glucocorticoids from acting on the mineralocorticoid receptor in cells that express it (26). Thus 11β-Η8ϋ2 inhibition results in the activation of mineralocorticoid receptors (MR) by glucocorticoids (26). However, this side effect of 1 Ιβ-HSD inhibitors can be avoided by use of 1 Ιβ-HSDl -selective inhibitors or by combination of non-selective 11β- HSD inhibitors with an anti-kaliuretic-diuretic, such as amiloride (20). * * *

All of the compositions and methods disclosed and claimed herein can be made and executed without undue experimentation in light of the present disclosure. While the compositions and methods of this invention have been described in terms of preferred embodiments, it will be apparent to those of skill in the art that variations may be applied to the compositions and methods and in the steps or in the sequence of steps of the method described herein without departing from the spirit and scope of the invention. More specifically, the described embodiments are to be considered in all respects only as illustrative and not restrictive.

All similar substitutes and modifications apparent to those skilled in the art are deemed to be within the spirit and scope of the invention as defined by the appended claims.

All patents, patent applications, and publications mentioned in the specification are indicative of the levels of those of ordinary skill in the art to which the invention pertains. All patents, patent applications, and publications, including those to which priority or another benefit is claimed, are herein incorporated by reference to the same extent as if each individual publication was specifically and individually indicated to be incorporated by reference.

The invention illustratively described herein suitably may be practiced in the absence of any element(s) not specifically disclosed herein. Thus, for example, in each instance herein any of the terms "comprising", "consisting essentially of, and "consisting of may be replaced with either of the other two terms. The terms and expressions which have been employed are used as terms of description and not of limitation, and there is no intention that use of such terms and expressions imply excluding any equivalents of the features shown and described in whole or in part thereof, but it is recognized that various modifications are possible within the scope of the invention claimed. Thus, it should be understood that although the present invention has been specifically disclosed by preferred embodiments and optional features, modification and variation of the concepts herein disclosed may be resorted to by those skilled in the art, and that such modifications and variations are considered to be within the scope of this invention as defined by the appended claims. References

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