Field of the Invention

The field of this invention concerns the treatment of systemic lupus erythematosus.

Background

Systemic lupus erythematosus (SLE) is a debilitating autoimmune disease. Patients with SLE manifest various immunological abnormalities which probably reflect the immunopathological processes occurring concurrently in this multi-system disease.

Although several mouse models for lupus-like disease are currently available (Gutierrez-Ramos, Nature (1990) , 346, 27; Lucas, J.A. , J. Clin Invest, Vol. 75; pgs. 2091- 2099 (1985); Siiteri, P.K. , J. Steroid Biochem. , Vol. 12, pgs. 425-432, (1980); Melez, K.A. , Arthritis Rheum., Vol. 23, pgs. 41-48, (1980); and Steinberg A.D., J. Immunol., Vol. 125, pgs. 871-883, (1980)), none of the models appear to presen ⁺ the complex symptomology and pathological conditions observed in human patients having systemic lupus erythematosus.

The symptomology of lupus erythematosus has been extensively ch~ icterized (see, for example, Harrison s Principles of Internal Medicine, J.D. Wilson, et al . , pp. 1432 to 1437, McGraw-Hill, Inc., Twelfth Edition, 1991). Clinical manifestations of systemic lupus erythematosus include, but are not limited to, the following: Systemic — fatigue, malaise, fever, nausea, weight loss; Musculoskeletal — arthralgias/myalgias, non-erosive pc yarthritis, yopathy/myositis, ischemic necrosis of bo _^ .e; Cutaneous — malar rash, oral ulcers, rashes, alopecia, vasculitis; Hematologic — anemia, leukopenia, lymphopenia, splenomegaly, lymphadenopathy; Neurologic — seizures, peripheral neuropathy; Cardiopulmonary

pleurisy, myocarditis, lupus pneumonitis, interstitial fibrosis; Renal — proteinuria (>500 mg/24 hrs.), nephrotic syndrome, renal failure; Gastrointestinal — ascites, abnormal liver enzymes; Thrombosis; Fetal loss; and Ocular — retinal vascul itis , conjunctivitis/episcleritis.

An etiologically important role of sex steroids in SLE has been suggested both by observations in human patients and by manipulation of the sex hormone status of mice with lupus-like disease. Thus, SLE is seen predominantly in women (Lahita R.G., Sex, Age, and Systemic Lupus Erythematosus. In: Lahita, R.G., editor, Systemic Lupus Erythematosus, New York: Churchill Livingstone) , tends to flare during pregnancy (Mund, A. , JAMA, Vol. 183, pgs. 917-925, (1963)) and may correlate with androgen/estrogen ratio (Jungers, P., Arthritis Rheum., Vol. 25, pgs. 454-462, (1983).

Dehydroepiandrosterone (DHEA) is a natural androgen that is an intermediate in the synthetic pathway of cholesterol to testosterone and it is the most abundant secretory product of human adrenal glands (Vande Wiele, et al . Recent Prog . Horm . Res . (1963), 19, 275). However, DHEA has only mild intrinsic androgenic activity (Parker, LN, Endocrin. Metab. Clin. N. AM., Vol. 20, pgs.401-421 (1991)). About 30 mg/day of DHEA is produced by the adrenal glands in the form of the inactive sulfate ester and DHEA serum levels show a striking age-related decline (Barrett-Connor, et al . New Engl . J. Med . (1986), 315, 1519) .

Summary of the Invention

DHEA, metabolites, or derivative thereof (such as DHEA-sulfate) is administered to lupus erythematosus patients at a level to enhance the normal blood level by at least about 10%. One or more doses may be administered daily to maintain the desired concentration, where the DHEA may be administered in conjunction with other drugs

conventionally used for the treatment of lupus erythematosus. The treatment may be continuous, intermittent, or associated with episodic events.

One advantage of the present invention is that the use of DHEA in the treatment of lupus erythematosus allows the reduction of therapeutic levels of corticosteroids.

One embodiment of the invention includes a pharmaceutical formulation comprising dehydroepiandro- sterone or its sulfate ester and a second drug selected from the group consisting of a non-steroidal anti-inflammatory drug, a glucocorticosteroid and an antimalarial drug. This formulation is prepared at a therapeutic dosage for the treatment of lupus erythematosus.

These and other objects and features of the invention will be more fully appreciated when the following detailed description of the invention is read in conjunction with the accompanying drawings.

Brief Description of the Figure

Figure 1 presents SLE-DAI scores (range 1-105) determined on the basis of clinical and laboratory criteria, for ten patients who completed three months of DHEA treatment, and eight who continued for an additional three months. The figure also includes physician and patient overall numerical assessments (1-100) of the treatment.

Detailed Description of the Invention

Lupus erythematosus patients are treated with a therapy comprising dehydroepiandrosterone (DHEA) or a derivative thereof, optionally in combination with other drug regimens employed for the treatment of lupus erythematosus. For the most part, DHEA or the metabolite DHEA sulfate will be employed, individually or in

combination, where the sulfate will be present as a physiologically-acceptable salt.

The DHEA may be administered in a variety of ways, orally, parenterally, or inhalation. For injection, the DHEA may be injected subcutaneously, intraperitoneall , intravascularly, etc . Depending upon the manner of introduction, the DHEA may be formulated in a variety of ways. The proportion of therapeutically active to carrier substance may vary from about 0.5-100 wt.%. The compositions can be prepared in various pharmaceutical forms, such as granules, tablets, pills, suppositories, capsules, suspensions, salves, lotions and the like.

Pharmaceutical grade organic or inorganic carriers and/or diluents suitable for oral and topical use can be used to make up compositions containing the therapeutically-active compounds. Diluents known to the art include vegetable and animal oils and fats. Stabilizing agents, wetting and emulsifying agents, salts for varying the osmotic pressure or buffers for securing an adequate pH value, and skin penetration enhancers can be used as auxiliary agents.

For oral use, the pharmaceutical composition will generally contain from about 5-100% by weight of the active material. For other uses, the composition will generally have from about 0.5-50 wt.% of the active material.

Various carriers include excipients, tocopherol, dimethyl sulfoxide, etc .

The subject compositions will generally be administered daily, in an amount to provide at least about a 10%, usually at least about 25%, increase in the blood level of DHEA. Generally, the total daily dosage will be at least about 10 mg, usually at least about 25 mg, preferably about 50 mg to 250 mg, and not more than about 500 mg.

The amount being administered may vary with the general health of the patient, the response of the patient

to the drug, whether the DHEA is used by itself or in combination with other drugs, and the like. Daily administrations may be one or more times, usually not more than about four times, particularly depending upon the level of drug which is administered.

Other drugs which may be used in accordance with conventional treatments include non-steroidal anti-inflammatory drugs, antimalarials, glucocortico- steroids, etc . These drugs include hydroxychloroquine, prednisone, quinacrine, azathioprine, etc . Dosage for prednisone will generally be from about 1-15, more usually from about 1-12 mg/day. The additional drugs may be administered separately or in conjunction with DHEA and may be formulated in the same formulation with DHEA. Experiments performed in support of the present invention demonstrate the usefulness and efficacy of treating lupus erythematosus with DHEA and DHEA derivatives, such as DHEA-sulfate. For example, most renal lesions in SLE patients are caused by in situ immune-complex formation or deposition of circulating complexes in glomeruli (Harrison-'s Principles of Internal Medicine, supra) . Almost all patients with SLE have such deposits in the glomeruli, approximately half of these develop clinical nephritis, defined by persistent proteinuria.

Proteinuria is considered to be pathological when the protein content of urine is above 150 mg/day; urine protein concentrations of >350 mg/day are considered to be massive proteinuria. Persistent proteinuria at such levels tends to lead to nephrotic syndrome and is suggestive of glomeruli destruction.

Treatment with DHEA or DHEA derivatives appears to assist in the management of proteinuria in patients afflicted with lupus erythematosus. Three patients (in the second study) with significant proteinuria and are described in detail in Example 2. In one patient, initial proteinuria levels ranged from 1700 to 8640 mg/day. After

six months of treatment this had decreased to 430 mg/day. In a second patient, proteinuria had been documented over 12 months prior to the study, with daily protein excretion ranging from 1 to 8 gm/day. After 3 months of treatment protein secretion was at 375 mg/day, and after 6 months at 243 mg/day. In the third patient, improvement was not as dramatic as in the two patients just described, but after three months the levels of proteinuria were reduced and manifestations of nephrotic syndrome were improved. These results demonstrate the usefulness and efficacy of DHEA-based treatment of SLE for the improvement of proteinuria and related clinical manifestations.

The results of the two studies presented below (Examples 1 and 2) show that DHEA was generally well tolerated by the patients under treatment. The use of DHEA coincided with subjective and objective improvement in the clinical status of most patients. Further, corticosteroid requirements decreased in most patients over the 3-6 month treatment period. From the patients' perspective, 8 of 10 felt the medication was helping them.

While the invention has been described with reference to specific methods and embodiments, it will be appreciated that various modifications and changes may be made without departing from the invention.

EXAMPLE 1 Eight Patient Study Eight female pre-menopausal SLE patients with mild to moderate disease were given DHEA 200 mg/day, open label for 3 months, while allowing changes in other medications to be made as clinically indicated. After 3 months, the SLE-disease activity index score (SLE-DAI) had improved by a clinically-significant margin in 5 patients, was unchanged in 2, and had worsened in 1 patient. Of 5 patients who were on prednisone at onset, 3 were able to

significantly reduce the dose during the trial (average daily dose of the 5 patients on prednisone: 19.0 mg at onset vs. 13.6 mg after 3 months on DHEA). 7 patients reported a benefiA.al effect on general well-being, energy level or fatigue, and 5 had significant improvement as determined by a visual analog scale. Physicians' overall assessment of these patients was improved in 5 and unchanged or mixed in 3 patients. Side effects of DHEA in this trial included a transient increase in libido, a transient change in taste perception (1 patient) and mild to moderate acneiform dermatitis. During the 3 months of DHEA therapy, overall, favorable results were seen.

The following tables provide the patient profiles (Table 1) , a summary of the outcome measures (Table 2) , the tolerance and side effects (Table 3) , and medication profiles (Table 4) .

Table 1. Patient profiles.

10

10

Legend to Table 1;

MR - malar rash RP - Raynaud's phenomenon OU - oral ulcers SS - sicca syndrome LAN - lymphadenopathy PS - photosensitivity CNS - CNS involvement

I

Table 2. Summary of outcome measures.

10

15

20

25

In Table 2:

SLE-DAI was scored as improved/worsened if the change was 10% or greater.

5 Physician OA was scored as improved/worsened if the change was 10% or greater.

Patient OA was scored as improved/worsened if the change was 20% or greater.

ESR was scored as improved/worsened only if values were outside the normal range, and cha 10 was 20% or greater.

Corticosteroid dose was scored as improved/worsened if the change was 20% or greater.

Table 3. Tolerance and side effects.

DHEA was overall well tolerated.

Side effects included:

10 Acneiform Dermatitis in 8/15 patients (53%) .

3 of these patients regarded this as significant, and for one it was grounds discontinuation of DHEA.

15 Hirsutism in 2 patients (13%) .

Increase in libido in 1 patient (7%) , transient (< 2 weeks) .

Change in taste perception in 1 patient (7%) , transient (< 2 weeks) . 20

Striae in 1 patient (13%) .

Insomnia in 1 patient (7%) , transient (< 2 weeks) .

25 No changes in menstrual cycle were reported.

Table 4. Medication profiles.

8 patients were on corticosteroids at time of entry (average dose 18.3 mg/day of prednis or equivalent) .

At 3 months, the dose was reduced in 7 and unchanged in 1 (average dose 12.4 mg/day 10 prednisone or equivalent) .

8 patients were on anti-malarials at time of entry (hydroxychloroquine/7, quinacrine/1) . T was unchanged at 3 months.

15 4 patients were on Azathioprine at time of entry (average dose 87.5 mg/day).

At 3 months, azathioprine had been discontinued in one patient, the dose was unchanged in and one additional patient had been started on it.

It is evident from the above results, that treatment with DHEA or metabolite of patients with lupus erythematosus provides for substantial improvements in the general well-being of the patient, while allowing for the reduction in other drugs which have serious side effects. Thus, one can reduce the use of glucocorticosteroids so as to substantially diminish the side effects associated with these compounds.

EXAMPLE 2

Ten Patient Study A. Patient Evaluation.

Ten female patients with SLE by ACR criteria (Tan, E.M., The 1982 revised criteria for the classification of systemic lupus erythematosus, Arthritis Rheum., Vol. 25; pgs. 1271-1276, (1982)) consented to participate in an open-label, non-controlled trial of DHEA. The average age was 35.7 (range, 27-68). Seven were Caucasian, one Black, one Hispanic and one Filipino. Nine patients were premenopausal. SLE manifestations were varied, was to be expected, and are given in Table 5.

TABLE 5 Disease Characteristics

CNS - Central nervous system involvement

GN - Glomerulonephritis IAN - Lymphadenopathy LCV - Leucocytoclastic vasculitis

MR - Malar rash

OU - Oral ulcers

PS - Photosensitivity

RP - Raynaud's phenomenon

SS - Sicca syndrome

All patients were felt to have mild or moderate lupus. Renal disease was present in three patients, consisting of stable proteinuria without abnormalities in the urine sediment and without changes in serum creatinine or creatinine clearance. No overt CNS lupus was present in any of the patients, although mild, subjective cognitive impairment was noted by some, and "lupus headaches" were noted in four.

After screening and documentation of baseline status, patients were given capsules of DHEA 200 mg, to be taken once daily by mouth. DHEA and DHEA-sulfate powders were obtained from the Sigma Chemical Co. (St. Louis, MO) ,

capsules of which were prepared by the Stanford University Hospital pharmacy.

The patients were followed at monthly intervals by the rheumatologist carrying the primary responsibility for the patient as well as one of the investigators. Throughout the study period, patients were treated based on clinical status, per the discretion of the physician carrying the primary responsibility for the patient. Changes in medications were allowed, including changes in dosages or the addition of new medications.

B. Outcome parameters.

The SLE-disease activity index (SLE-DAI) score (Bombardier, C. , Derivation of the SLE-DAI. A disease activity index for lupus patients. The Committee on Prognosis Studies in SLE, Arthritis Rheum., Vol. 35; pgs. 630-640, (1992)) was determined at each visit. Patients and physicians were asked to record their own overall assessment of disease activity, on a scale 1-100 (patients were given a visual analog scale) . Other outcome measures were the medication profile and laboratory parameters.

Outcome measurements are given as means ± standard error. For comparisons between these near-continuous variables the paired, two-sided Student t-test was used.

C. The Effect of DHEA-Treatment on Serum Androgen Levels.

Serum levels of DHEA and DHEA-sulfate (D-S) were determined at monthly intervals. A slow, steady rise of D-S levels over the course of 1-2 months was seen, reaching a plateau at 439-1,659 μg/dl. Levels of DHEA showed similar increases, but were more variable, in keeping with the known marked circadian variation of this hormone (Parker, LN, Control of adrenal androgen secretion, Endocrin Metab Clin. N. AM., Vol. 20:pgs.401- 421, (1991)).

Serum testosterone levels increased in tandem with D- S and DHEA. Baseline levels of DHEA and D-S were

typically low in these patients and steady state levels were obtained slowly.

D. Effects of DHEA therapy on SLE activity parameters.

The SLE-DAI score at the onset of the study averaged

10.4 ± 2.4 range (range 0-24). After three months, the average SLE-DAI score had decreased to 8.3 ± 2.1 range

(range 0.14; p < 0.08). Physicians' overall assessment improved from 37.2 ± 7.0 to 27.2 ± 7.3 (p < 0.05), while the patients' overall assessment showed a statistically non-significant improvement.

Ten patients with mild-moderate SLE were given DHEA 200 mg/day for three months. SLE-DAI score was determined on the basis of clinical and laboratory criteria as referenced, (Bombardier, C. , Derivation of the SLE-DAI. A disease activity index for lupus patients. The Committee on Prognosis Studies in SLE, Arthritis Rheum., Vol. 35; pgs. 630-640, (1992). Physicians were asked for overall assessments on a visual analog scale. A summary of these outcome measures after 3 months of treatment is given in Table 6: values given are mean ± standard error. P values given are for paired two-sided Student t-test.

TABLE 6

Global SLE Activity Parameters At Study Onset And After Three Months of Treatment With DHEA

All ten patients completed three months of DHEA treatment, and eight elected to continue for an additional three months. These eight female patients with mild- moderate SLE received DHEA 200 mg/day for six months.

SLE-DAI score (range 1-105) was determined on the basis of clinical and laboratory criteria as referenced (Bombardier, C. , Derivation of the SLE-DAI. A disease activity index for lupus patients. The Committee on Prognosis Studies in SLE, Arthritis Rheum., Vol. 35; pgs. 630-640, (1992)). Physicians were asked for overall numerical assessments (1-100) . Patients were asked for overall assessments on a visual analog scale (1-100) . The results are presented in Figure 2. In the figure, values are the mean ± standard error; comparisons are with 2- sided paired Student t-test, * = p < 0.10, and ** = p < 0.05.

After 6 months on DHEA, the SLE-DAI scores were significantly lower than at baseline (10.0 ± 2.9 vs. 4.9 ± 1.7, p < 0.02) and the patients in this study felt that DHEA improved overall well-being, fatigue, energy and/or other subjective aspects of their disease.

E. Effect of DHEA therapy on the dose of concurrently administered corticosteroids.

Of ten patients who took DHEA 200 mg/day for 3 months, 8 were on corticosteroids at the onset of the study. Of 8 patients who took DHEA for 6 months, 6 were on corticosteroids at the onset of the study. Dosage changes were made as clinically indicated. Mean dosages are shown in mg/day of prednisone or its equivalent ± standard error.

Comparisons were made using 2-sided paired Student t- test. The following tables show corticosteroid dosages at onset, and after 3 (Table 7) and 6 months (Table 8) of treatment with DHEA.

TABLE 7

Concomitant Use of Glucocorticosteroids Patients who completed 3 months on DHEA (n=8)

TABLE 8

Concomitant Use of Glucocorticosteroids Patients who completed 6 months on DHEA (n=6)

After three months, the average dose (expressed as equivalent dose in mg prednisone/day) had decreased from

14.5 ± 4.1 to 9.4 ± 2.5 (p < 0.10) . Of the patients who completed six months of DHEA treatment, six were on corticosteroids at the onset of the study, and a reduction in the average dose was seen in this small group as well (from 14.8 ±5.5 to 5.6 ±1.9, p < 0.08). Six patients were on antimalarials at the onset of the study, and these remained unchanged. One patient (#5) was on azathioprine at the onset of the study, and this medication was discontinued during the study, while one patient (#7) was started on azathioprine during the study.

F. Effect of DHEA Treatment on Proteinuria. Three patients in this study had significant proteinuria, and are described in more detail. Patient #5. Proteinuria had been first noted 20 months prior to entering the study. 24-hour urine collections had been obtained on 6 occasions during this period, and showed proteinuria ranging from 1700 to 8640 mg/day. She had on several occasions developed nephrotic syndrome. The urinary sediment remained unremarkable throughout and creatinine clearance was consistently normal and unchanged (> 90 ml/min) . The patient declined renal biopsy on two occasions.

Prior to DHEA treatment, prednisone (20 mg daily) had not appreciably changed the level of proteinuria. Moreover, a month long attempt at improving the proteinuria with prednisone 60 mg/day was similarly unsuccessful. When DHEA treatment was initiated, a 24- hour collection of urine showed 4000 mg/day protein.

After six months of treatment this had decreased to 430 mg/day.

Patient #4. Proteinuria had been documented over 12 months prior to this study, with daily protein excretion ranging from 1 to 8 gm/day. Urine sediment was unremarkable, and creatinine clearance was consistently normal (> 90 ml/min) . At the onset of DHEA treatment a 24-hour urine collection showed 1,197 mg protein. After 3 months of treatment this was 375 mg, and after 6 months 243 mg.

Patient #8. Proteinuria, 3217 mg/day, and nephrotic syndrome developed 4 months prior to the study. A prior renal biopsy had shown membranous glomerulonephritis. Prednisone, 30 mg/day, and azathioprine, 150 mg/day, for three months did not significantly change the level of proteinuria. DHEA 200 mg/day was taken for three months concurrently with prednisone (which as tapered from 17.5 to 10 mg/day) . After three months, proteinuria had decreased to 2,342 mg/day and manifestations of the nephrotic syndrome were improved. Unfortunately, the patient had developed moderately severe acneiform dermatitis and opted to discontinue DHEA. She has since required a higher dosage of prednisone to control non- renal manifestations of SLE, but has had no worsening of proteinuria.

G. Side effects and safety.

Four patients developed acneiform dermatitis, which was mild in three and moderate in one. The latter patient decided to discontinue DHEA for this reason, while topical therapy was helpful in all other cases. Mild hirsutism was noted after 5-6 months of treatment in two patients who were receiving prednisone 10-20 mg/day as well as DHEA, and some patients reported a decrease in menstrual blood flow (without change in the cycle _/ . No adverse effects were noted by physical examination or laboratory

evaluation. Specifically, no elevations of fasting blood glucose, and no changes in lipid profile were seen.

Although the foregoing invention has been described in some detail by way of illustration and example for purposes of clarity of understanding, it will be readily apparent to those of ordinary skill in the art in light of the teachings of this invention that certain changes and modifications may be made thereto without departing from the spirit or scope of the appended claims.