Investigational New Drug Enabling Nonclinical Safety Assessment of the Iminosugar UV-4, a Broad-Spectrum Host-Targeted Antiviral Agent.

The iminosugar UV-4 is a broad-spectrum antiviral drug candidate with activity in vitro and in vivo against multiple, diverse viruses. The toxicological profile of UV-4, dosed as the hydrochloride salt, was evaluated in single-dose and repeat-dose oral toxicity studies in mice, rats, dogs, and non-human primates (NHP). No moribundity or deaths were associated with the drug up to the maximum tolerated dose. No treatment-related adverse effects were observed following single oral doses in dogs, rats, and mice up to 250, 400, 1000 mg/kg, respectively, and in NHP up to 180 mg/kg administered three times daily for 10 days. UV-4-related findings were generally seen at higher doses after 7- or 14-day exposure. The most common clinical pathology findings (increase in aspartate aminotransferase and decreased platelet count) were consistently found across species and each appeared dose related. The kidney, mesenteric lymph nodes, stomach including gastrointestinal tract, and thymus were identified as target organs in mice, rats, and dogs. In 14-day repeat-dose toxicology studies in mice and dogs conducted in compliance with Good Laboratory Practice regulations, the dog was considered to be the most sensitive species to UV-4 exposure based on the treatment-related adverse effects noted in the identified target organs. The results of these studies demonstrate the safety profile of UV-4 hydrochloride and supported the selection of starting and maximal doses for a single ascending dose first-in-human clinical study.

Investigational New Drug Enabling Nonclinical Safety Pharmacology Assessment of the Iminosugar UV-4, a Broad-Spectrum Host-Targeted Antiviral Agent.

UV-4 (N-(9-methoxynonyl)-1-deoxynojirimycin) is a broad-spectrum antiviral drug candidate with demonstrated activity in vitro and in vivo against multiple, diverse viruses. Nonclinical safety pharmacology studies were conducted to support the filing of an Investigational New Drug (IND) application. Preliminary in vitro pharmacology testing evaluating potential for binding to "off-target" receptors and enzymes indicated no significant liability for advanced development of UV-4. The safety pharmacology of UV-4 was evaluated in the in vitro human ether-à-go-go-related gene (hERG) assay, in a central nervous system (CNS) study in the mouse (modified Irwin test), in a respiratory safety study in conscious mice using whole body plethysmography, and in a cardiovascular safety study in conscious, radiotelemetry-instrumented beagle dogs. There were no observed adverse treatment-related effects following administration of UV-4 as the hydrochloride salt in the hERG potassium channel assay, on respiratory function, in the CNS study, or in the cardiovascular assessment. Treatment-related cardiovascular effect of decreased arterial pulse pressure after 50 or 200 mg of UV-4/kg was the only change outside the normal range, and all hemodynamic parameters returned to control levels by the end of the telemetry recording period. These nonclinical safety pharmacology assessments support the evaluation of this host-targeted broad-spectrum antiviral drug candidate in clinical studies.

Preclinical Development of EBI-005: An IL-1 Receptor-1 Inhibitor for the Topical Ocular Treatment of Ocular Surface Inflammatory Diseases.

OBJECTIVE: Topical interleukin (IL)-1 receptor (R)1 blockade is therapeutically active in reducing signs and symptoms of dry eye disease. Herein, we describe in vitro and in vivo nonclinical Investigational New Drug (IND)-enabling studies of EBI-005, a novel protein chimera of IL-1ß and IL-1 receptor antagonist (IL-1Ra or anakinra) that potently binds IL-1R1 and blocks signaling. These studies provide an assessment of receptor affinity, drug bioavailability, immunogenic response, safety, and tolerability in mice and rabbits. METHODS: In vitro and in silico along with Good Laboratory Practices (GLP) and non-GLP in vivo studies in mice and rabbits assessed the topical ocular and systemic immunogenicity and toxicology of EBI-005. Animals were treated with EBI-005 once daily subcutaneously or four times daily by topical ocular administration for up to 6 weeks (with 2-week recovery phase). RESULTS: EBI-005 has 500 times higher affinity than anakinra to IL-1R1. Predictive immunogenicity testing suggested that EBI-005 is not more immunogenic. Systemic bioavailability of EBI-005 is low (1.4% in mice and 0.2% in rabbits) after topical ocular administration. EBI-005 penetrated into the anterior ocular tissues within 15 min of topical ocular administration. However, it is low or undetectable after 4 hr and does not form a depot after repeated topical ocular administration. EBI-005 was safe and well tolerated, and exposure to drug was maintained despite an antidrug antibody response after systemic administration, based on IND-enabling toxicology and safety pharmacology studies. CONCLUSIONS: Ocular doses of EBI-005 at 50 mg/mL in mice and rabbits totaling 0.15 mg/eye in mice and 1.5 mg/eye in rabbits, administered 4 times daily, did not produce adverse effects, and demonstrated excellent bioavailability in target tissues with low systemic exposure. In addition, immunogenic response to the drug did not cause adverse effects or diminish the drug's activity in most cases. The results support drug administration of the highest anticipated human clinical study dose of a 20 mg/mL solution (40 µL 3 times daily in each eye).

Reproductive and developmental toxicology studies of iminosugar UV-4.

UV-4 (N-(9-methoxynonyl)-1-deoxynojirimycin) is a host-targeted antiviral agent, which targets mammalian proteins (endoplasmic reticulum glucosidases) rather than virally encoded proteins. This mechanism confers both broad-spectrum activity and low potential for generation of viral drug resistance mutations. Reproductive and developmental studies of UV-4 evaluated effects on fertility and early embryonic development in rats, embryo-fetal development in rats and rabbits, and pre- and postnatal development including maternal function in rats. All reproductive and developmental studies conducted achieved dose levels where parental toxicity (generally decreased body weight, decreased food consumption and adverse clinical signs) were observed. Toxicokinetic evaluations confirmed UV-4 crossed the placenta exposing fetal rats and rabbits in utero. Adverse findings in reproductive and developmental studies included decreases in sperm motility with histopathology correlates, visceral and skeletal malformations, changes in eye opening, air drop reflex, vaginal opening and preputial separation. The combined results of the fertility and early embryonic developmental study and pre- and postnatal study suggested that there may be an increased risk for male fertility. These effects are similar to those reported in pre-clinical studies of the structurally related drug Miglustat (N-butyl-1-deoxynojirimycin), therefore UV-4 may have risk of developmental or reproductive adverse outcomes in humans similar to existing approved agents in this drug class.

Evaluation of a patient education booklet (SimpleStart) effect on postprandial glucose control in type 2 diabetes.

BACKGROUND: Post-meal hyperglycemia is emerging as a cardiovascular risk factor and may be elevated despite a hemoglobin A1C (A1C) of <7%. The Simple Start DVD (LifeScan, Milpitas, CA) was developed to educate patients about glycemic targets and dietary changes that could lessen glycemic excursions. We evaluated SimpleStart in a controlled, randomized, prospective trial using continuous glucose monitoring (CGM). METHODS: Thirty subjects with type 2 diabetes mellitus having an A1C of <7.0% (mean 6.0%) were recruited from the Center's population. Subjects were randomized to either Simple Start DVD presentation and a 30-min diet education course (SS Group) or just the latter (Control Group). Subjects were seen at baseline and during weeks 6 and 12 by an investigator. Life-style and medication changes were advised based on history and self-monitored blood glucose downloaded meter data. CGM and A1C were done at baseline and during weeks 6 and 12. RESULTS: Twenty-eight subjects completed the 12-week study with 14 subjects in the SS Group and Control Group being compared. There was no significant difference in the baseline or subsequent A1C levels or overall CGM glucose values between groups or over time. SMBG frequency was significantly increased in the SS Group from <1.0 per day to 2.0 per day (P < 0.001). At week 12, the mean glucose for the 4-h after-meal period was significantly lower in the SS Group than in the Control Group at breakfast and lunch in those subjects with adequate CGM tracings (P < 0.05). CONCLUSION: An educational program incorporating Simple Start facilitates patient behavioral changes, decreasing post-meal hyperglycemia.

Exploring methods to extend the reach of diabetes specialist expertise into primary care clinics.

The purpose of this article is to describe a pilot program using centralized diabetes specialist services to guide primary care treatment of diabetes. The program demonstrated the feasibility of disseminating diabetes treatment guidance from a centralized diabetologist clinic. Across all participating sites, approximately 50% of patients achieved HbA1c values of 6.9% or lower. Approximately 80% of all patients participating achieved low-density lipoprotein cholesterol values of 129 mg/dL or lower, and 50% had systolic blood pressure values of 129 mm Hg or lower. Results of the program are promising and deserve further study. Hallmarks of the program include dissemination of diabetes care through midlevel practitioners in primary care offices, using standardized algorithms, and computer-assisted guidance of therapy.

A Novel Iminosugar UV-12 with Activity against the Diverse Viruses Influenza and Dengue (Novel Iminosugar Antiviral for Influenza and Dengue).

Iminosugars are capable of targeting the life cycles of multiple viruses by blocking host endoplasmic reticulum α-glucosidase enzymes that are required for competent replication of a variety of enveloped, glycosylated viruses. Iminosugars as a class are approved for use in humans with diseases such as diabetes and Gaucher's disease, providing evidence for safety of this class of compounds. The in vitro antiviral activity of iminosugars has been described in several publications with a subset of these demonstrating in vivo activity against flaviviruses, herpesviruses, retroviruses and filoviruses. Although there is compelling non-clinical in vivo evidence of antiviral efficacy, the efficacy of iminosugars as antivirals has yet to be demonstrated in humans. In the current study, we report a novel iminosugar, UV-12, which has efficacy against dengue and influenza in mouse models. UV-12 exhibits drug-like properties including oral bioavailability and good safety profile in mice and guinea pigs. UV-12 is an example of an iminosugar with activity against multiple virus families that should be investigated in further safety and efficacy studies and demonstrates potential value of this drug class as antiviral therapeutics.

Genetic damage detected in CD-1 mouse pups exposed perinatally to 3'-azido-3'-deoxythymidine or dideoxyinosine via maternal dosing, nursing, and direct gavage: II. Effects of the individual agents compared to combination treatment.

We previously reported extraordinary increases in micronucleated erythrocytes in CD-1 mouse pups exposed to 3'-azido-3'-deoxythymidine (AZT) and dideoxyinosine (ddI; 50/250, 75/375, 150/750 mg/kg/day AZT/ddI) by gavage throughout gestation and lactation, followed by direct pup dosing beginning postnatal day (PND) 4 (Bishop et al. [2004]: Environ Mol Mutagen 43: 3-9). That study was conducted to explore the potential for genetic damage in newborns exposed perinatally to antiretrovirals in order to reduce maternal-infant transmission of HIV-1. Because dramatic increases in frequencies of micronucleated erythrocytes were seen in exposed pups, additional studies were conducted to clarify the relative contribution of each drug to the observed damage. Pregnant CD-1 mice were administered AZT (50, 75, 150 mg/kg/day) or ddI (250, 375, 750 mg/kg/day) by gavage twice daily in equal fractions beginning prior to mating and continuing throughout gestation and lactation. Direct pup dosing (same regimens) began on PND 4. Peripheral blood erythrocytes of male pups were screened for micronuclei on PNDs 1, 4, 8, and 21. Significant increases in micronucleated erythrocytes were observed in pups and dams exposed to AZT at all doses and sampling times. The highest micronucleus levels were observed in pups on PND 8 after the initiation of direct dosing. In contrast, effects seen in pups and dams treated with ddI were minimal. These results demonstrate that AZT, a component of many anti-HIV combination therapies, induces chromosomal damage in perinatally exposed neonatal mice. Comparison of micronucleated cell frequencies induced by AZT alone or in combination with ddI suggests that ddI potentiates AZT-induced chromosomal damage following direct exposure.

Genetic damage detected in CD-1 mouse pups exposed perinatally to 3'-azido-3'-deoxythymidine and dideoxyinosine via maternal dosing, nursing, and direct gavage.

Human immunodeficiency virus (HIV)-infected pregnant women are administered nucleoside-analogue antiretrovirals to reduce maternal-infant viral transmission. The current protocol recommends treating newborns for 6 additional weeks postpartum. The treatment is effective, but the risk of drug-induced chromosomal damage in neonates remains undefined. We used a mouse model to investigate this concern. In a multigeneration reproductive toxicity study, female CD-1 mice received 3'-azido-3'-deoxythymidine (AZT) and dideoxyinosine (ddI) (50/250, 75/375, 150/750 mg/kg/day AZT/ddI) by gavage twice daily in equal fractions beginning prior to mating and continuing throughout gestation and lactation. Direct pup dosing (same regimen) began on postnatal day (PND) 4. Peripheral blood erythrocytes of male pups were screened for micronuclei, markers of chromosomal damage, on PNDs 1, 4, 8, and 21. Extraordinary increases in micronucleated cells were noted in pups for each treatment group at each sampling time; treated dams exhibited smaller yet significant increases in micronucleated erythrocytes. The frequencies of micronucleated cells in untreated pups were higher than in the untreated dams, and all pups had markedly elevated levels of circulating reticulocytes compared to dams. These observations suggest that fetal and neonatal mouse hematopoietic precursor cells have heightened sensitivity to genotoxic agents, perhaps due to rapid cell proliferation during the perinatal period of development. The amount of genetic damage observed in treated pups raises concern for the potential of similar damage in humans. Investigations of chromosomal integrity in exposed newborns and children are recommended.

Pharmacokinetics and immunologic consequences of exposing macaques to purified homologous butyrylcholinesterase.

Exposure to organophosphorus compounds (OPs), in the form of nerve agents and pesticides poses an ever increasing military and civilian threat. In recent years, attention has focused on the use of exogenously administered cholinesterases as an effective prophylactic treatment for protection against OPs. Clearly, a critical prerequisite for any potential bioscavenger is a prolonged circulatory residence time, which is influenced by the size of protein, the microheterogeneity of carbohydrate structures, and the induction (if any) of anti-enzyme antibodies following repeated injections of the enzyme. Previously, it was demonstrated that multiple injections of equine butyrylcholinesterase (BChE) into rabbits, rats, or rhesus monkeys, resulted in a mean residence time spanning several days, and variable immune responses. The present study sought to assess the pharmacokinetics and immunological consequences of administration of purified macaque BChE into macaques of the same species at a dose similar to that required for preventing OP toxicity. An i.v. injection of 7,000 U of homologous enzyme in monkeys demonstrated much longer mean residence times in plasma (MRT = 225 +/- 19 h) compared to those reported for heterologous Hu BChE (33.7 +/- 2.9 h). A smaller second injection of 3,000 U given four weeks later, attained predicted peak plasma levels of enzyme activity, but surprisingly, the MRT in the four macaques showed wide variation and ranged from 54 to 357 h. No antibody response was detected in macaques following either injection of enzyme. These results bode well for the potential use of human BChE as a detoxifying drug in humans.

Neurobehavioral assessment of mice after developmental AZT exposure.

Azidothymidine (AZT) is administered to pregnant women with HIV to prevent the spread of infection to their fetuses. Since gestation is a period of critical neurodevelopment, it is important to determine the risk AZT exposure may pose to neurobehavioral function of the offspring. The current study focused on teratological risks of developmental AZT exposure to neurocognitive function. Male and female Swiss mice were administered AZT or vehicle (0, 100, or 200 mg/kg/day po given twice daily in equal amounts for 32 weeks before and during gestation). Adult male and female offspring (n = 10/sex/treatment group) underwent neurobehavioral testing focused on determining learning and memory capabilities in the radial-arm maze. AZT exposure did not cause significant deficits during radial-arm maze acquisition. No impairment was seen in asymptotic levels of choice accuracy indicative of working memory function. Attempts to unmask subtle learning impairments following developmental AZT by the introduction of behavioral challenges such as reduction of motivational state (food restriction either 4-6 h or 22-24 h) or imposition of intrasession delays of 1.5 min to 2.5 h were unsuccessful. With a 4-week intersession delay, a significant AZT Treatment x Delay effect was seen with a significantly greater decline seen in the controls as compared to the 100 mg/kg/day AZT group. Locomotor activity on the radial-arm maze was significantly affected by AZT treatment (100 mg/kg/day) during the acquisition phase, but not during the other test phases. No behavioral alterations were seen related to stress as measured by the elevated plus maze. Vestibulomotor functioning on the balance beam remained unaltered. Using an extended dosing regimen including dosing of both sires and dams, as well as placing a greater demand on reproductive system performance with three continuous breedings, this study detected only subtle neurobehavioral impairments in mice after prenatal AZT exposure at clinically relevant doses.

HIV/AIDS and HIV nephropathy.

HIV is a profound disease. The impact of HIV on the renal system is also profound, requiring nephrology nurses to have an increased awareness and understanding of the challenges and issues facing HIV-infected patients. Comorbid conditions, such as anemia, HIVAN, and even stress can further impair an already compromised patient. The nephrology nurse can provide meaningful and efficacious care through an enhanced knowledge of drug and treatment interventions known to improve outcomes in HIV.

How much do I give? Dose estimation formulas for once-nightly insulin glargine and premeal insulin lispro in type 1 diabetes mellitus.

OBJECTIVE: To evaluate the mathematical relationships between dosing factors in type 1 diabetic patients using multiple daily injections. METHODS: In this single-center, prospective study in type 1 diabetic patients, the basal continuous glucose monitoring glucose target was less than 130 mg/dL with fewer than 10% of 24-hour readings at less than 70 mg/dL. Basal glucose for the 4-hour meal periods was obtained from once-daily serial meal omissions. On an isocaloric, 50% carbohydrate, fixed diet, the insulin to carbohydrate ratio was adjusted to achieve a 2- to 4-hour postbolus glucose value within ±20% of premeal glucose. For determining dosing formulas, the slope of the linear regression line comparing the variables of weight, total daily dose (TDD), total basal dose (TBD), insulin-to-carbohydrate ratio (ICR), and correction factor (CF) was determined. RESULTS: Forty-nine patients were included. Titrating insulin glargine to the morning glucose led to hypoglycemia during the rest of the day (2 PM to 4 AM). Therefore the basal glucose target was the nondawn phenomenon portion of the day. The resulting estimation formulas could be rounded to the following: TBD = 0.2 x weight (kg) | TBD = 0.33 x TDD | 90/TBD = ICR = CF/4.5. CONCLUSIONS: Smaller insulin glargine doses to achieve control are in contrast to those much larger doses reported in clinical trials in multiple daily injection-treated type 1 diabetes in which the morning fasting glucose is the basal insulin target.

Contribution of the dawn phenomenon to the fasting and postbreakfast hyperglycemia in type 1 diabetes treated with once-nightly insulin glargine.

OBJECTIVE: To observe the effect of the dawn phenomenon on basal glucose and postbreakfast hyperglycemia in patients with type 1 diabetes treated with once-nightly insulin glargine and premeal insulin lispro. METHODS: In 49 study subjects consuming a fixed isocaloric (50% carbohydrate) diet of usual food, the insulin glargine dose was titrated from daily continuous glucose monitoring downloads to achieve a basal glucose goal of <130 mg/dL 4 hours after meals and during serial meal omissions but with fewer than 10% of readings at <70 mg/dL during 24 hours. Patients also performed self-monitoring of plasma glucose 7 times a day (before and 2 hours after each meal or omitted meal and at bedtime). RESULTS: The target mean basal glucose level was achieved only during the non-dawn phenomenon period (1400 hours to 0400 hours). During the dawn phenomenon, the mean (standard deviation) basal glucose level increased from 118 (57) mg/dL at 0400 hours to 156 (67) mg/dL before the breakfast meal, a 32% increase (P = .00149). The mean self-monitored plasma glucose level with meal omission was 63.8% of that increase with a breakfast meal. CONCLUSION: The fasting morning glucose concentration is considerably elevated because of the dawn phenomenon. Targeting insulin titration to this glucose level may result in excessive basal insulin dosing for the non-dawn phenomenon periods of the day. The dawn phenomenon is a large component of the postbreakfast hyperglycemia. Rather than increasing the morning premeal insulin bolus, consideration should be given to pretreating the earlier dawn phenomenon with an insulin pump with use of a variable basal insulin rate.

The number of basal rates required to achieve near-normal basal glucose control in pump-treated type 2 diabetes.

BACKGROUND: It has been reported that most pump-treated patients with type 2 diabetes require only two or fewer basal rates. Using daily continuous glucose monitoring (CGM)-directed titration, this premise was re-evaluated at near-normal glycemic control. PATIENTS AND METHODS: Thirty subjects who were insulin-naive (n = 10), on basal insulin (n = 10), or on basal-bolus insulin therapy (n=10) ate a fixed diet. The basal rate was started as a single rate and then adjusted to a basal glucose goal of 70-130 mg/dL. The insulin-to-carbohydrate ratio (ICR) (in g/U) was adjusted to 2-4-h postmeal CGM glucose goal of 80-120% of premeal glucose. RESULTS: The mean (SE) CGM basal glucose was 99.9 (4.9) mg/dL, and 4.5% (1.4%) of the readings were <70 mg/dL. The mean 2-4-h postmeal glucose was 113.3% (4.8%) of the premeal glucose. Only six subjects (20%) required two basal rates, while the remainder needed only one. The mean (SE) dosing relationships were as follows: total basal dose (TBD) (in U/day) = 0.226(0.018) × weight (in kg); TBD (in U/day) = 0.339(0.012) × total daily dose (TDD) (in U/day); ICR (in g/U) = 126(8)/TBD (in U/day); and ICR (in g/U) = 365(14)/TDD (in U/day). CONCLUSIONS: This study confirms that one basal rate is adequate for the majority of subjects with type 2 diabetes. The mathematical proportionality between dosing factors closely agrees with those obtained in CGM-titrated pump-treated type 1 diabetes but differs from those derived from clinical studies in which insulin titration was based on infrequent self-monitored plasma glucose testing and while on an unstructured diet.