TECHNICAL FIELD The present invention is related generally to the control and treatment of pulmonary disorders. More particularly, the present invention is related to combat¬ ing pulmonary dysfunction, disease or disorder by augment¬ ing reduced glutathione (GSH) levels in the tissues of the lower respiratory tract by direct aerosol administration of glutathione through inhalation.

BACKGROUND OF THE INVENTION In the lung, GSH is present in high concentrations in the epithelial lining fluid (ELF) of the lower respira¬ tory tract, with normal levels in human ELF being more than 40-fold greater than that in plasma. As such, ELF GSH is a major component of the antioxidarit screen that protects the pulmonary epithelium from oxidants released by inflammatory cells as well as inhaled oxidants. In addition, ELF GSH helps maintain the normal function of the immune components of the pulmonary epithelial host defense system. However, in certain conditions, such as idiopathic fibrosis and AIDS patients, there is found to be a substantial ELF GSH deficiency. A problem in aug¬ menting GSH levels in the lungs is that oral administra- tion of GSH does not achieve significant elevation of GSH level in the lungs and intravenous administration of GSH is associated with a very short plasma half-life of the molecule.

SUMMARY OF THE INVENTION It is, therefore, an object of the present inven¬ tion to provide a novel, efficacious method of delivering GSH in the lungs.

It is a further object of the present invention to provide a substantially non-toxic, aerosol composition of GSH for direct administration to human lungs.

It is another object of the present invention to provide a method of combating pulmonary dysfunction, disorder or disease where increased level of GSH is deemed

beneficial by directly administering aerosol GSH to the lungs.

Various other objects and advantages of the present invention will become evident from the following detailed description of the invention.

BRIEF DESCRIPTION OF THE DRAWINGS These and other objects, features, and many of the attendant advantages of the invention will be better understood upon a reading of the following detailed description when considered in connection with the accom¬ panying drawings wherein:

Figure 1 shows the baseline glutathione levels in sheep. Shown are the concentrations of reduced glutathi¬ one (GSH) in venous plasma, lung lymph, epithelial lining fluid, and urine. The data represents the averaged duplicate values from 23 sheep.

Figures 2 _A t _h roug _h 2D ^{show the} reduced glutathione (GSH) levels in sheep following intravenous administration of 600 mg GSH. The GSH concentration in venous plasma, lung lymph, lung epithelial lining fluid (ELF) and urine were evaluated before and at intervals after intravenous GSH administration. Each data point represents the average of duplicate determinations from 11 sheep.

Figure 3 is an evaluation of the effect of aero- solization on glutathione. The output of the aerosol generator was collected in phosphate buffered saline. Shown is the proportion of total glutathione in the reduced form for the preaerosol glutathione ('•before") and the aerosol generated with room air ("after") . Each data point represents the average of triplicate determinations.

Figures 4A through 4Dshow reduced glutathione (GSH) levels in sheep following aerosol administration of 600 mg GSH. The concentrations of GSH in lung epithelial lining fluid

(ELF) , lung lymph, venous plasma, and urine were evaluated before and at intervals after aerosol GSH administration. Each data point represents the average of duplicate determinations from 12 sheep.

SUBSTITUTE SHEET

Figure 5 shows the level of GSH in the lungs of two HIV-infected, non-symptomatic patients before GSH administration and one hour after administration of 600 mg GSH by aerosol twice daily for 3 days. DETAILED DESCRIPTION OF THE INVENTION

The above and various other objects and advantages of the present invention are achieved by a non-toxic aerosol composition of GSH suitable for direct administra¬ tion to human lungs through inhalation. An aerosol composition of GSH comprises an effective amount of GSH in a pharmaceutically acceptable carrier in the form of an aerosol suitable for safe administration to the lungs by inhalation.

Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by 'one of ordinary skill in the art to which this invention belongs. Although any methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, the preferred methods and materials are now described. All publications mentioned hereunder are incorporated herein by reference. Unless mentioned otherwise, the techniques employed or contemplated herein are standard methodologies well known to one of ordinary skill in the art. The materials, methods and examples are illustrative only and not limiting.

The term "aerosol" as used herein means droplets of a liquid suspended in air. It is understood that the droplet size would be appropriate for deposition of the aerosol in the upper and lower respiratory tract as deemed necessary for the clinical condition for which the aerosol containing GSH is to be used.

MATERIALS AND METHODS Glutathione Preparation The reduced form of glutathione was obtained as a free acid (tissue culture grade; Sigma) and stored at 4°C. The percentage of reduced glutathione in this preparation prior to each experiment was constantly >96% (vide infra) .

Experimental Model

Female mixed breed sheep (n=23; 33 ± 1 kg) were anesthetized with intravenous sodium thiopental. Intrave¬ nous catheters were placed in a jugular vein and in a vein of the hind limb, and a catheter was inserted into the bladder. The trachea was intubated with a cuffed endotra- cheal tube attached to a positive pressure ventilator. Animals were ventilated at a tidal volume of 12 ml/kg body weight with 5 cm of H ₂ 0 positive end-expiratory pressure at a rate of 16/min. Electrocardiogram and inspiratory pressure were monitored throughout the study. Anesthesia was maintained with 1.0-1.5% fluothane and 50% oxygen. Lung lymph was collected from the caudal efferent lymphat¬ ic duct cannulated with a heparinized silastic catheter by the technique of Staub et al. (1975, J. Surq. Res. 19, 315-320) , a method that permits selective sampling, pf lung lymph draining the pulmonary interstitium. Lower respira¬ tory tract ELF was obtained by bronchoalveolar lavage through a fiberoptic bronchoscope (length: 1 m, external diameter: 5.3 mm; Machida) using a single 50 ml aliquot of 0.9% NaCl. Blood samples were obtained from the catheter in the jugular vein, and urine samples were obtained from the bladder catheter. Venous plasma, lung lymph, ELF and urine were obtained before GSH administra- tion, and at intervals up to 180 min following intravenous administration or aerosolization of 600 mg of GSH. A total of 23 sheep were evaluated; the number of sheep used for each set of experiments are indicated with the data. All intravenous and aerosol studies were performed with the chest closed and the animal in the prone posi¬ tion. After baseline bronchoalveolar lavage fluid, blood, lung lymph and urine samples were obtained, 600 mg gluta¬ thione in 4 ml of saline was administered either intrave¬ nously into a vein of the hind leg or by aerosol into the inspiratory limb of the ventilation circuit over a 25 min period. Bronchoalveolar lavage fluid, blood, lymph, and urine samples were then obtained at various intervals over a 3 hr. period. Lavage samples at different time points

were obtained from different sites. All measurements were carried out in duplicate. Lymph, blood, and urine values are referenced to the volumes of the fluids analyzed. Lower respiratory tract values were referenced to the volume of epithelial lining fluid recovered as assessed by the urea method (Rennard et al, 1986, J. Appl. Phvsiol. 60, 532-538) . All data is presented as mean ± standard error of the mean; all statistical comparisons were made using the two-tailed Student's t-test. Aerosol Generating System

Reduced glutathione was put into a form capable of reaching the lower respiratory tract with a nebulizer (Ultravent, Mallinckrodt) capable of generating aerosol droplets of a size appropriate for deposition in the alveolar regions (Hubbard et al, 1989, Proc. Natl. Acad. Sci. USA 86, 680-684) . To generate the aerosol containing the reduced glutathione, 4 ml of a solution of GSH at a concentration of 150 mg/ml in 0.9% NaCl was placed in the reservoir of the nebulizer and the nebulizer was driven at 40 psi with compressed air. The size distribution of aerosol droplets determined by laser particle-size analy¬ sis demonstrated a mass median aerodynamic diameter of the droplets of 2.8 μm with a geometric standard deviation of 1.3 μm. The relative proportion of the GSH preparation that remained in the reduced form was evaluated by col¬ lecting the aerosolized droplets in phosphate buffered saline, pH 7.4, as previously described (Hubbard et al, supra) . Glutathione Levels and Form Glutathione levels in venous plasma, lung lymph, bronchoalveolar lavage fluid and urine were quantified with minor modifications of standard methods (Cantin et al, 1987, J. Appl. Physiol. 63, 152-157; Adams et al, 1983, J. Pharmacol. Exp. Ther. 227, 749-754; Sies et al, 1984, Methods Enzymol 105, 445-451; Martensson et al, 1989, Proc. Natl. Acad. Sci. USA 86, 5296-5300). In brief, to determine the total glutathione levels [i.e., reduced glutathione + glutathione disulfide (GSSG) ] , the

various fluids were mixed with an equal amount of 10 mM 5,5'-dithiobis(2-nitrobenzoic acid) (DTNB) in 0.1 M potas¬ sium phosphate, pH 7.5, containing 17.5 mM ethylenedi- aminetetraacetic acid (EDTA) . The samples were centri- fuged (2000 g, 10 min) , and aliquots (50 μl) of the supernatants were added to cuvettes containing 0.5 U of GSSG reductase in 0.1 M potassium phosphate, pH 7.5, containing 5 mM EDTA. After incubation for 1 min, 25°C, the assay reaction was started by adding 220 nM of reduced ?-ricotinamide adenine dinucleotide phosphate (NADPH) in 0.1 M potassium phosphate, pH 7.5, containing 5 mM EDTA in a final volume of 1 ml. The rate of reduction of DTNB was recorded spectrophotometrically at a wavelength of 412 n (Beckman DU-70 spectrophotometer) . Determination of the total glutathione concentration was based on standard curves generated' rom known concentrations of GSSG (0.125 to 4μM) is phosphate buffered saline, pH 7.4.

To quantify glutathione disulfide, the various fluids were mixed, immediately after recovery, with an equal volume of 10 mM N-ethylmaleimide (NEM) in 0.1 M potassium phosphate, pH 6.5, containing 17.5 mM EDTA. The samples were then centrifuged at 2000 g, 10 min, and 250 μl of the supernatent was passed through a SEP-PAK C18 cartridge (Waters Associates) that had been washed with 3 ml methanol followed by 3 ml distilled water, and the effluent was collected. GSSG was eluted from the column with 1 ml of 0.1 M potassium phosphate, pH 7.5, containing 5 mM EDTA. An aliquot (750 μl) of the combined effluent and eluate was mixed with 250 μl 0.1 M potassium phos- phate, pH 7.5, containing 5 mM EDTA. 800 μM DTNB, 2 U/ml glutathione reductase, and 1 mM NADPH, and the rate of reduction of DTNB was recorded spectrophotometrically at 412 nm. Standard curves were derived from dilutions of known concentrations of GSSG (0.125 to 4 μM) that had been mixed with 10 mM NEM and chromatographed with SEP-PAK C18 cartridges as described above. If values above the range of the standard curve were observed, parallel runs of samples diluted with 0.9% NaCl were performed. The amount

of GSH was obtained by subtracting the amount of GSSG from the total glutathione levels. For both the total gluta¬ thione and GSSG assays, standard curves generated in the various fluids were parallel, i.e., the values from all fluids were comparable.

RESULTS Baseline Glutathione Levels in Sheep

The reduced glutathione levels in venous p_r~.ma and in lung lymph were in a similar range, although the plasma levels were slightly higher (p>0.1; Figαre . ^• . Urine levels were much lower. Strikingly, as in h.'.r.ians (Cantin et al, supra; Buhl et al. 1989, Lancet II, 8675; Cantin et al, 1989, Am. Rev. Respir. Pis. 139, 370--372) , lung epithelial lining fluid GSH concentrations were several-fold greater than those in plasma or lung lymph. In both plasma and> lung lymph, GSH accounted for >95% of the total glutathione (plasma 97 ± 2% reduced; lymph 95 t 3% reduced) . In ELF 75 ± 4% of the baseline total gluta¬ thione was in the reduced form, while in urine 59 ± 6% was in the reduced form.

Intravenous Administration of Glutathione

To evaluate the intravenous route as a possible way of augmenting GSH levels of lung epithelial lining fluid, single doses of 600 mg GSH were given intravenously to sheep. Levels of GSH in plasma increased following the injection, but returned to baseline by 45 min (p<0.05, 15 min compared to baseline, all other values p>0.1, ^* Figures 2 through 2D)Some GSH diffused into the lung, transiently raising lung lymph levels (p<0.05, 15 min compared to baseline), but like the plasma GSH, by 30 min the values went to baseline (p>0.l, all times other than 15 min). Although the average lung epithelial lining fluid values were variable, they did not change significantly during the observation period (p>0.1, all comparisons to baseline values) . As expected, urine excretion was rapid with high levels at 15 min (p<0.02, compared to baseline). This was also transient, with baseline values thereafter (p>0.1). Evaluation of the total glutathione levels in plasma,

lymph, ELF and urine demonstrated a pattern similar to that of reduced glutathione (data not shown) . Together, these observations indicate that the intravenous route is not an efficacious means of delivering GSH to the epithe- lial surface of the lung.

Effect of Aerosolization on GSH

To use aerosolization to deliver GSH to the lower respiratory tract, at least three main criteria must be fulfilled. First, the solution of GSH must be placed into an aerosol composed of droplets of an optimal size for deposition on the alveolar surface. This requirement was fulfilled with the Ultravent nebulizer used in these studies, but can be achieved with other nebulizers or the like which produce aerosols with similar characteristics as is well known to one of ordinary skill in the art. Second, the aerosol should not alter the GSH, i.e., it must remain reduced and therefore functional. Third, the aerosolic composition should be non-toxic, that is suit¬ able for human use. In vitro evaluation of the aerosol- ized GSH revealed that the aerosolization process itself did not alter the structure of the glutathione molecule. In this regard, the total glutathione in the pre-aerosol preparations contained 98.2± 0.1% glutathione in reduced form, while the post-aerosol glutathione in the collected aerosolized droplets had 97.0 ± 0.6% in the reduced form (p>0.1; Figure 3). Together, these observations demon¬ strate that the aerosol was composed of fully functioning reduced glutathione within droplets of an optimal size for reaching the alveolar regions of the lung. Aerosol Administration of Glutathione

Single doses of 600 mg reduced glutathione in 4 ml of 0.9% NaCl given by aerosol over 25 min to sheep (n=12) increased the GSH levels in the epithelial lining fluid of the lower respiratory tract over 7-fold within 30 minutes (p<0.001, pre-aerosol compared to 30 min post-aerosol; Figure 4) . ELF GSH levels remained greater than baseline for up to 2 hr (p<0.01, 60 min and 90 min post-aerosol, both comparisons to baseline) . Levels in lung lymph

increased only transiently at 30 min, but were not signif¬ icantly different from the baseline (p>0.1) and levels in venous plasma and urine did not change significantly following aerosolization (p>0.l, all comparisons to baseline). As a control, only saline was aerosolized; GSH levels in ELF remained unchanged from baseline over a 3 hr period (p>0.1, all comparisons).

At each time point where ELF GSH levels were significantly above the baseline, evaluation of the otal glutathione levels in ELF demonstrated higher levels than reduced glutathione. For example, at 30 min the reduced glutathione levels in ELF were 65 ± 7% that of the total levels (p<0.001). Overall, at 60, 90 and 120 min, reduced glutathione levels were 62 to 65% that of the total levels (P<0.005, all comparisons). Since the aerosolization process itself did not alter, t.he relative proportions of GSH from that in the pre-aerosol preparation (Figure 3) , yet a proportion of the recovered GSH was not reduced, it is likely that the GSH encountered an oxidant burden when impacting on the epithelial surface of the sheep lung.

However, independent of this observation, it is clear beyond doubt that the aerosolization of GSH results in a marked augmentation of GSH levels in ELF (Figures 4A through

Together, these data demonstrate that aerosoliza- tion .of glutathione is a feasible and effective method for targeting reduced glutathione to the ELF of the lower respiratory tract. In regards to the safety of the therapy, the mean and peak inspiratory pressures remained stable throughout the procedure. Aerosolization of GSH did not result in inflammation of the lower respiratory tract, as judged by visual inspection of the mucous mem¬ branes of the respiratory tract. Further, there was no apparent "leak" of the epithelial barrier, as determined by measurements of ELF volumes of pre- and post-aerosol bronchial lavage fluids (p>0.1, all comparisons to base¬ line values) .

STUDY OF AEROSOLIZED GLUTATHIONE IN HUMANS

SUBSTITUTESHEET

It has been found that in such patients as with idiopathic pulmonary fibrosis (IPF) , the ELF glutathione concentration is approximately four-fold lower suggesting that in the context of the increased oxidant burden found in IPF, there is a marked oxidant-antioxidant deficiency at the alveolar surface (Cantin et al, supra) . Similarly, GSH deficiency has been observed in the ELF of HlV-sero- positive individuals. There is an inflammatory cell- derived increased oxidant burden together with a deficient antioxidant screen of the epithelial surface of the lower respiratory tract in patients with IPF and in HlV-seropos- itive individuals. Together, these processes most likely play a role in the epithelial damage seen in these pa¬ tients. Other conditions where administration of the increased level of GSH in the lungs may be deemed desir¬ able include cystic fibrosis, acute and chronic bronchi¬ tis, adult respiratory distress syndrome, all forms of lung infection including bacterial and viral pneumonias, opportunistic infections, mycoplasma, Legionella, mycobac- teria and fungal infections and the like.

The present study was undertaken with the follow¬ ing main objectives:

1. To demonstrate the safety of the administra¬ tion of increasing amounts of aerosolized GSH to patients with idiopathic pulmonary fibro¬ sis or individuals seropositive for the HIV virus, monitoring history and physical exami¬ nation, chemistry, hematology and coagulation profiles, and pulmonary function and using bronchoalveolar lavage to evaluate any ab¬ normal inflammatory reaction in the lung.

2. To determine that a dose of glutathione that likely will be clinically efficacious for those disorders can be safely administered to the lung by aerosol and evaluate the subse¬ quent bioavailability of the GSH in the lower respiratorytractusingbronchoalveoloar lavage. STUDY DESIGN:

A. Part 1 - Evaluation of Increasing Doses of GSH. Each patient to receive a single aerosol of reduced gluta¬ thione every 24 hr for four successive doses at four successive doses levels (in the absence of unaccept- able toxicity) .

The schedule of dose administrations is as follows: Day of Study Dose

1 10 mg

2 50 mg 3 200 mg

4 600 mg

It should be noted, however, that the dosage can be adjusted to any level of GSH which is tolerated without substantial adverse effect by the patient. Thus, dosages up to 2,500 mg or higher could be considered by the physician if such high levels would produce the desirable result in the patient.

All patients will begin treatment at 10 mg and will be dose escalated in each successive treatment if not accompanied by Grade II toxicity or Grade III toxici¬ ty. Up to 2 patients will be treated simultaneously. If toxicity occurs in either individual, four addi¬ tional patients will be treated at that dose level before further dose escalation can occur. If toxicity occurs in a second individual, no escalation in dose will occur until the source of the toxicity is deter¬ mined and removed.

B. Part II - Evaluation of Bioavailability of GSH.

Each patient will receive 600 mg or the maximum toler- ated dose 12 hr apart for 6 doses.

C. Administration of GSH

Each patient will receive aerosolized GSH at a partic¬ ular dosage. A physician will be in attendance during aerosol administration to manage any adverse reaction. Direction for the Administration of Aerosolized Glutathi¬ one A. Dilution Vehicle

Dilution vehicle is sterile 0.9% sodium chloride.

B. Dosing Instructions

Vials will be reconstituted immediately before use and any excess will be discarded. Separate vials of glutathione will be allocated per patient dose. In each case the desired dose will be 4 ml of the recon¬ stituted solution as follows:

10 mg: reconstituted 50 mg/vial with 20 ml 50 mg: reconstituted 50 mg/vial with 4 ml 200 mg: reconstituted 600 mg/vial with 12 ml 600 mg: reconstituted 600 mg/vial with 4 ml

Following reconstitution, 4 ml of the solution will be placed in the reservoir of a pneumatic aerosol genera¬ tor (Ultravent; Mallinckrodt) . The generator will be driven with compressed air at 40 psi, generating 10 liters/min of aerosol. Using a series of one-way valves, nose clips, and mouth piece, the system will be closed; that is all gas, including aerosolized GSH will either be inspired or expired through a filter to collect all expired drug. RESULT

Figure 5 shows the results of the aerosolization of glutathione to two individuals seropositive for the HIV virus (but asymptomatic, i.e., they are "pre-AIDS") . As shown in Figure 5, these two individuals received 600 mg of glutathione aerosol twice daily for 3 days for a total of 6 doses. The lung epithelial lining fluid was assessed by bronchoalveolar lavage before any therapy and then 1 hour after the 6th dose following the same procedures as described herein supra. Both individuals started with glutathione levels in the lung fluid less than the normal range, but with therapy increased significantly, i.e., "correcting" the deficiency state. No adverse or toxic effects were observed in the treated patients.

In summary, it is clear from both the animal and the human studies that pulmonary ELF GSH level is signifi¬ cantly augmented by aerosolized administration of GSH.

It is understood that the examples and embodiments described herein are for illustrative purposes only and

that various modifications or changes in light thereof will be suggested to persons skilled in the art and are to be included within the spirit and purview of this applica¬ tion and scope of the appended claims.

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