CA2490386A1 - Method for producing analgesia comprising administration of an opioid receptor agonist in rotation with an opioid receptor like-1 receptor agonist - Google Patents
Method for producing analgesia comprising administration of an opioid receptor agonist in rotation with an opioid receptor like-1 receptor agonist Download PDFInfo
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- CA2490386A1 CA2490386A1 CA002490386A CA2490386A CA2490386A1 CA 2490386 A1 CA2490386 A1 CA 2490386A1 CA 002490386 A CA002490386 A CA 002490386A CA 2490386 A CA2490386 A CA 2490386A CA 2490386 A1 CA2490386 A1 CA 2490386A1
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- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
- A61M5/00—Devices for bringing media into the body in a subcutaneous, intra-vascular or intramuscular way; Accessories therefor, e.g. filling or cleaning devices, arm-rests
- A61M5/14—Infusion devices, e.g. infusing by gravity; Blood infusion; Accessories therefor
- A61M5/142—Pressure infusion, e.g. using pumps
- A61M5/14244—Pressure infusion, e.g. using pumps adapted to be carried by the patient, e.g. portable on the body
- A61M5/14276—Pressure infusion, e.g. using pumps adapted to be carried by the patient, e.g. portable on the body specially adapted for implantation
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K31/00—Medicinal preparations containing organic active ingredients
- A61K31/33—Heterocyclic compounds
- A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
- A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
- A61K31/44—Non condensed pyridines; Hydrogenated derivatives thereof
- A61K31/4427—Non condensed pyridines; Hydrogenated derivatives thereof containing further heterocyclic ring systems
- A61K31/4436—Non condensed pyridines; Hydrogenated derivatives thereof containing further heterocyclic ring systems containing a heterocyclic ring having sulfur as a ring hetero atom
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- A61K31/33—Heterocyclic compounds
- A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
- A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
- A61K31/44—Non condensed pyridines; Hydrogenated derivatives thereof
- A61K31/4427—Non condensed pyridines; Hydrogenated derivatives thereof containing further heterocyclic ring systems
- A61K31/4439—Non condensed pyridines; Hydrogenated derivatives thereof containing further heterocyclic ring systems containing a five-membered ring with nitrogen as a ring hetero atom, e.g. omeprazole
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- A61K31/00—Medicinal preparations containing organic active ingredients
- A61K31/33—Heterocyclic compounds
- A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
- A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
- A61K31/44—Non condensed pyridines; Hydrogenated derivatives thereof
- A61K31/445—Non condensed piperidines, e.g. piperocaine
- A61K31/4468—Non condensed piperidines, e.g. piperocaine having a nitrogen directly attached in position 4, e.g. clebopride, fentanyl
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- A—HUMAN NECESSITIES
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- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K31/00—Medicinal preparations containing organic active ingredients
- A61K31/33—Heterocyclic compounds
- A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
- A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
- A61K31/44—Non condensed pyridines; Hydrogenated derivatives thereof
- A61K31/445—Non condensed piperidines, e.g. piperocaine
- A61K31/4523—Non condensed piperidines, e.g. piperocaine containing further heterocyclic ring systems
- A61K31/4535—Non condensed piperidines, e.g. piperocaine containing further heterocyclic ring systems containing a heterocyclic ring having sulfur as a ring hetero atom, e.g. pizotifen
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- A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
- A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
- A61K31/47—Quinolines; Isoquinolines
- A61K31/485—Morphinan derivatives, e.g. morphine, codeine
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- A61K38/04—Peptides having up to 20 amino acids in a fully defined sequence; Derivatives thereof
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- A61K38/08—Peptides having 5 to 11 amino acids
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- A61K38/04—Peptides having up to 20 amino acids in a fully defined sequence; Derivatives thereof
- A61K38/10—Peptides having 12 to 20 amino acids
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- A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
- A61P25/00—Drugs for disorders of the nervous system
- A61P25/04—Centrally acting analgesics, e.g. opioids
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- A61P25/30—Drugs for disorders of the nervous system for treating abuse or dependence
- A61P25/36—Opioid-abuse
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- A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
- A61M2202/00—Special media to be introduced, removed or treated
- A61M2202/04—Liquids
- A61M2202/0468—Liquids non-physiological
- A61M2202/048—Anaesthetics
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- A—HUMAN NECESSITIES
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- A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
- A61M2205/00—General characteristics of the apparatus
- A61M2205/35—Communication
- A61M2205/3507—Communication with implanted devices, e.g. external control
- A61M2205/3523—Communication with implanted devices, e.g. external control using telemetric means
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- A—HUMAN NECESSITIES
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- A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
- A61M5/00—Devices for bringing media into the body in a subcutaneous, intra-vascular or intramuscular way; Accessories therefor, e.g. filling or cleaning devices, arm-rests
- A61M5/14—Infusion devices, e.g. infusing by gravity; Blood infusion; Accessories therefor
- A61M5/168—Means for controlling media flow to the body or for metering media to the body, e.g. drip meters, counters ; Monitoring media flow to the body
- A61M5/16804—Flow controllers
- A61M5/16827—Flow controllers controlling delivery of multiple fluids, e.g. sequencing, mixing or via separate flow-paths
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
- A61M5/00—Devices for bringing media into the body in a subcutaneous, intra-vascular or intramuscular way; Accessories therefor, e.g. filling or cleaning devices, arm-rests
- A61M5/14—Infusion devices, e.g. infusing by gravity; Blood infusion; Accessories therefor
- A61M5/168—Means for controlling media flow to the body or for metering media to the body, e.g. drip meters, counters ; Monitoring media flow to the body
- A61M5/16877—Adjusting flow; Devices for setting a flow rate
Abstract
A method of producing analgesia in a mammal is provided by rotational (alternating) intrathecal administration to the mammal of a pharmaceutically effective dose of at least one opioid receptor agonist, such as a .mu.-, .delta.- or .kappa.-opioid receptor agonist for a first period of time, followed by intrathecal administration to the mammal of a pharmaceutically effective dose of at least one opioid receptor-like receptor 1 (ORL-1) agoni st for a second period of time. The intrathecal drug administration of the firs t and second periods of time may be repeated a plurality of times without attaining tolerance in the mammal to either drug. Implantable apparatus for rotational administration of the active agents is also disclosed.
Description
METHOD FOR INDUCING ANALGESIA COMPRISING ADMINISTRATION ALTERNATIVELY OF AN
AN IMPLANTABLE INFUSION PUMP
FIELD OF THE INVENTION
The present invention relates to methods and apparatus for the administration of intrathecal analgesics to achieve pain relief while delaying the onset of drug tolerance.
BACKGROUND OF THE INVENTION
In mammals, the receptors that respond selectively to noxious stimuli are known as nociceptors. Two distinct sets of peripheral sensory neurons are primarily responsible for the sensation of pain. The first, Ab-nociceptive neurons, contain myelinated axons and are aroused primarily by noxious heat and mechanical stimuli. The second set of nociceptive neurons, which possess unmyelinated axons and are lcnov~m as C
fibers, are activated by high intensity, mechanical, chemical and thermal stimulation.
Each of these sets of neurons has their cell bodies in the dorsal root ganglia. Their processes are pseudounipolar, with one axon that terminates in the periphery and one that terminates on neurons in the dorsal horn of the spinal cord.
Analgesia is the loss of sensitivity to pain without loss of consciousness. In recent years, the convergence of various lines of research demonstrates that analgesia can be produced by exogenous opioids, such as morphine, or endogenous opioids. This research has resulted in a model that explains the mechanism whereby pain is inhibited.
See, fox example, Kelly, D., "Central Representations Of Pain and Analgesia", P~°incipals of Neural Science, Kandel and Schwartz, Eds. (1985).
The first means known to man for inducing analgesia was through the use of plant-derived opioid narcotics such as morphine. Postsynaptic opioid receptors have been characterized and include the following three basic subtypes: mu (~.), delta (8) and kappa (~c). Endogenous opioids that bind these opioid receptors and thereby produce analgesia include the met- and leu-enlcephalins, as well as (3-endorphin. Most of the clinically used opiates, such as morphine, activate the ~,-opioid receptor subtype.
Stimulation of C-fiber primary afferent neurons associated with pain results in the release of the potent neuropeptides substance P, calcitonin gene related peptide (CGRP) and somatostatin, as well as the "fast" neurotransmitter glutamate. The activated enlcephalinergic inhibitory neurons in turn exert presynaptic iWibitory control over the release of these neurotransmitters, thus blocking the sensation of pain.
Opioid compounds (opiates) such as morphine, while effective in producing analgesia for many types of pain, are not always effective since the development of tolerance occurs in most patients. The development of tolerance to the effects of opioids is one of the major problems in chronic pain management today. Regardless of the route of opioid delivery, patients complain of decreasing pain relief with time.
Although recent studies suggest that constant delivery of opioids (e.g., infusion or transdermal patch) produces less tolerance than intermittent dosing (e.g., short-acting opioids, such as Vicodin) (Jhamandas, KH et al., "Spinal amino acid release and precipitated withdrawal in rats chronically infused with spinal morphine," JNeurosci 16:2758-2766 (1996); lbulci T et al., "Effect of transient naloxone antagonism on tolerance development in rats receiving continuous spinal morphine infusion," Paiu 70:125-132 (1997)), tolerance is still a significant issue. Recent studies with patients receiving chronic intrathecal opioids demonstrate that in some patients an increase in dose of up to 2-3 fold over a period of .months is necessary to maintain adequate analgesic levels (Winlcehnuller M et al., "Long-term effects of continuous intrathecal opioid treatment in chronic pain of nomnalignant etiology," J Neurosm°g 85:458-467 (1996); Paice JA et al., "Clinical realities and economic considerations: efficacy of intrathecal pain therapy," J Pain SyuzP
Manage 14:514-26 (1997); Sallerin-Caute B et al., "Does intrathecal morphine in the treatment of cancer pain induce the development of tolerance?," Neuf osm°geyy 42:44-49 (1998)). A
recent study of the intra-operative use of remifentanil indicates that rapid (within hours) tolerance to this ~,-opioid agonist can occur (Guignard B. et al., "Acute opioid tolerance:
intraoperative remifentanil increases postoperative pain and morphine requirement,"
Anesthesiology 93:409-417 (2000)). Basic research on human cell lines indicates that a 30% reduction in ~-opioid receptor molecular signaling pathways occurs as early as 24 hours in culture with a ~.-opioid agonist (Elliot J. et al., "Tolerance to ~,-opioid agonists in human neuroblastoma SH-SYSY cells as determined by changes in guanosine-5'-0-(3-[35S]-thio) triphosphate binding," B~~. J. Pha~~zacol. 121:1422-1428 (1997)).
However, most researchers would agree that tolerance develops more rapidly in rats than in humans.
For example, many patients have been successfully treated with stable-dose morphine for more than six days (which is the time-course for the development of morphine tolerance in rats) without becoming completely tolerant to the analgesic effects of morphine.
_2_ While escalating opioid use is not only a medicolegal issue for many physicians, escalating intrathecal opioids can result in side effects, such as myoclonus (Glavina MJ et al., "Myoclonic spasms following intrathecal morphine," Anaesthesia 43:389-390 (1988);
De Conno F et al., "Hyperalgesia and myoclonus with intrathecal infusion of high-dose morphine," Pain 47:337-339 (1991)). This side effect does not usually occur if the dose of intrathecal opioids is limited to a morphine equivalent of 60-70 mg/day.
Although most patients start at intrathecal doses of less than 5 mg/day, even a 2-fold increase per year results in toxic doses within four years. At high doses, these compounds additionally produce side effects, such as respiratory depression, which can be life-threatening. Opioid drugs also frequently produce physical dependence in patients.
Dependence appears to be related to the dose of opioid taken and the period of time over which the subject talces it. For this reason, alternate therapies for the management of chronic pain are widely sought. In addition, compounds which serve as either a replacement for, or as an adjunct to, opioid treatment in order to decrease the dosage of analgesic compound required, have utility in the treatment of pain, particularly pain of the . chronic, intractable type.
Non-opioid drugs, such as the non-steroidal anti-inflammatory drugs (NSAIDs) provide an alternative therapy for the treatment of pain. The mode of action of NSAIDs is believed to be through inhibition of cyclooxygenase, the enzyme responsible for biosynthesis of the prostaglandins. As analgesics, the NSAIDs lack many of the side effects on the CNS that are associated with the opioids and they do not result in the development of dependence. They are only effective, however, on low to moderate intensity pain, and are not generally useful for intense pain. In addition, they have undesirable side effects, including the propensity to induce gastric or intestinal ulceration as well as disturbances of platelet function.
Despite the wide range of analgesic substances available, still lacking are drugs and drug administration regimes that are effective in reducing severe pain without requiring dose escalation due to the development of tolerance.
SUMMARY OF THE INVENTION
It has now been discovered that a new treatment regimen, termed "rotational analgesia," helps delay the development of tolerance to intrathecal opioids.
In one aspect of the present invention, a method of producing analgesia in a maxmnal is provided comprising alternating intrathecal administration to the mammal of a pharmaceutically effective dose of at least one opioid receptor agonist, followed by intrathecal administration to the mammal of a pharmaceutically effective dose of at least one opioid receptor-like receptor 1 (ORL-1) agonist. The periods of alternating administration of each agent may then be repeated as many times or cycles as desired. Each period of administration of the opioid receptor agonist or the ORL-1 agonist is designed to be insufficient in duration to induce significant tolerance in the marninal to either drug, thereby delaying the development of tolerance. In one embodiment of the invention the opioid receptor agonist i's selected from ~-opioid receptor agonists, 8-opioid receptor agonists, x-receptor agonists and mixtures thereof.
In other aspects, an implantable, non-invasive, rate-adjustable dual reservoir pump is provided for rotational intrathecal delivery of the opioid receptor agonist and ORL-1 agonist drugs of the present invention.
BRIEF DESCRIPTION OF THE DRAWINGS
The foregoing aspects and many of the attendant advantages of this invention will become more readily appreciated by reference to the following detailed description, when ~talcen in conjunction with the accompanying drawings, wherein:
FIGURE 1 is a schematic illustration in block diagram form of m implantable, rate-adjustable, dual reservoir pump system in accordance with the present invention; and FIGURE 2 is a graphical representation of the hindpaw withdrawal latencies (HWL) of rats to thermal (FIGURES 2A and 2B) and mechanical (FIGURES 2C and 2D) stimulation using intrathecal morphine (8 ~.g) alone (shown as ~ in FIGURES 2A-2D), intrathecal nociceptin (10 mnol) alone (shomz as ~ in FIGURES 2A-2D), or rotating morphine for 2 days, nociceptin for 2 days and then repeating the cycle (shown as o in FIGURES 2A-2D), as described in Example 1.
FIGURE 3 is a graphical representation of HWL of rats to thermal (FIGURES 3A
and 3B) and mechanical (FIGURES 3C and 3D) stimulation after twice daily administration of a combination of half doses of morphine (4 ~,g) and nociceptin (5 nmol), as described in Example 2.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT
In the practice of rotational analgesia, the administration of an intrathecal opioid drug is rotated with administration of another drug that has potent analgesic effects, but that exhibits minimal cross-tolerance with the opioid drug. To exhibit minimal cross-tolerance, for example, the opioid drug must not significantly bind to the rotational drug's receptor. Similarly, the rotational drug must not significantly bind to the opioid drug's receptor. Also of importance is that the overall effect on the pain pathways in the spinal cord are sufficiently similar that the patient does not go through withdrawal from the opioid during the rotation to the alternate drug. These two lcey factors limit the type of drug that can successfully be rotated with opioids in the practice of the invention.
Consider receptor activation and second messenger system initiation as the early stage of the drug's effect and neuronal inhibition and decreased cyclic AMP levels as the late stages in the effect of the drug. Although not wishing to be bound by any particular theory, it is presently believed to be important that the rotated drugs have dissimilar early stages and highly similar late stages to avoid cross-tolerance, yet also avoid drug withdrawal. A presently preferred example of a drug that can be rotated successfully with an opioid drug in the practice of the invention is an ORL-1 agonist.
In one aspect the present invention relates to methods and apparatus for delaying the onset of tolerance in the administration of opioid and opioid-lilce receptor-1 (ORL-1) agonist drugs by rotating the administration of at least one opioid receptor agonist, such as a ~,-opioid receptor agonist, a ~-opioid receptor agonist, a K-opioid receptor agonist or mixtures thereof, with the administration of at least one ORL-1 agonist.
Suitable opioid receptor agonists for administration in rotation with the at least one ORL-1 agonist include those opioid agonists that exhibit a minimal degree of cross-tolerance with the administered ORL-1 agonist, and that exhibit overall effects on the pain pathways in the spinal cord that are sufficiently similar to the effects exhibited by the administered ORL-1 agonist such that the patient does not go through withdrawal from the opioid agonist during the rotation to the ORL-1 agonist. As further described and illustrated by the Examples set forth herein below, ~,-opioid receptor agonists and ORL-1 agonists can be beneficially administered in rotation in accordance with the present invention to extend duration to tolerance. It is also theorized that b-opioid receptor agonists and/or x-opioid receptor agonists may also be suitably rotated with ORL-1 agonists in accordance with the present invention, provided these opioid agonists are demonstrated to exhibit minimal cross-tolerance with ORL-1 agonists and similar effects on pain pathways.
In a first preferred embodiment of the invention, at least one ~,-opioid receptor agonist is administered in rotation with at least one ORL-1 receptor agonist.
The ~,-opioid agonists, such as morphine, are rotated with an ORL-1 receptor agonist, such as nociceptin, since the ~.-opioid receptor agonists do not bind to the ORL-1 receptor and nociceptin does not bind to ~,-opioid receptors, therefore cross-tolerance is not lilvely (Hao JX et al., "Laclv of cross-tolerance between the antinociceptive effect of intrathecal orphanin FQ and morphine in the rat," Neu~osci Lett 223:49-52 (1997)). Both drugs decrease cyclic AMP levels and both are potent analgesics when applied intrathecally.
Therefore, these two drug classes when administered intrathecally in accordance with the rotational intrathecal delivery regime of the present invention afford longer pain relief than when using either drug alone by delaying the onset of tolerance.
In other embodiments of the invention, at least one b-opioid receptor agonist is administered in rotation with at least one ORL-1 receptor agonist. The intrathecal administration of orphanin FQ (nociceptin) had been observed to increase the duration of the antinociceptive response evolved by intrathecal administration of the b-opioid receptor agonist deltorphin (Jhamandas, KH et al, "Antinociceptive and morphine modulatory actions of spinal orphanin FQ," Ca~c. J. Physiol. Pha~macol. 76:314-324 (1998)). While the potential for exhibiting minimal cross-tolerance and similar effect on pain pathways needs to be determined in accordance with the present invention, it is theorized that 8-~ opioid receptor agonists may be useful for rotation with ORL-1 agonists.
In still other embodiments of the invention; at least one x-opioid receptor agonist is administered in rotation with at least one ORL-1 receptor agonist. Again, the potential for minimal cross-tolerance and similar effect on pain pathways needs to be evaluated in determining the suitability for rotation of K-opioid receptor agonists with ORL-1 agonists in accordance with the methods of the present invention.
Thus, in accordance with one aspect, the present invention provides a method of treating a mammal in need of analgesia comprising intrathecally administering to the mammal a pharmaceutically effective dose of either at least one opioid receptor agonist or at least one ORL-1 agonist for a first period of time, and intrathecally administering to the mammal a pharmaceutically effective dose of the other at least one opioid receptor agonist or at least one ORL-1 agonist for a second period of time (i.e., the analgesic agent not administered during the first period of time). In one embodiment, the second period of time serially follows the first period of time. In other embodiments, the end of the first period of time may overlap the beginning of the second period of time, and vice versa.
The cycle of alternating intrathecal administration is preferably repeated for a plurality of treatment periods, for as long as desired in a particular application. If desired, the dosage level of drug being administered may be tapered down at the end of its administration period, while simultaneously tapering up the dosage level of the drug being rotated into the cycle, thereby providing a cross-over period during which both the opioid receptor agonist and the ORL-1 agonist are being administered to the mammal.
Suitable dosage levels for the opioid receptor agonists and the ORL-1 agonists of the invention will be determined by the prescribing physician depending on the needs of the patient, and include the dosage levels conventionally used for these analgesic agents, as is well lcnown to those skilled in the art. For example, the ~,-opioid receptor agonists may be administered at daily dosage levels of about 0.5 to about 25 mg/day, and more preferably at dosage levels of about 3 to about 20 mg/day. The ORL-1 agonists may be administered at daily dosage levels of about 1 to about 1,000 ~g/day, more preferably about 5 to about 500 ~g/day, and most preferably about 20 to about 100 ~.g/day. The daily dosage of the opioid receptor agonists or the ORL-1 agonists may be administered substantially continuously or intermittently.
Preferably, the first and second periods of administration for the opioid receptor agonists and the ORL-1 agonists are insufficient in duration to achieve significant 'tolerance in the patient to the analgesic effects of the administered drugs.
As used herein, the term "tolerance" means a noticeable or measurable effect in the patient to become less responsive to the opioid receptor agonists or the ORL-1 agonists of the invention. Thus, a tolerance condition is characterized by the necessity to increase successive drug doses in order to produce identical analgesic effects, and by the apparent loss of potency of the drug observed during the course of successive administrations.
For example, the ~,-opioid receptor agonist is preferably administered for a period of time insufficient to develop tolerance to the ~,-opioid receptor agonist, such as for a period of from 1 to 30 days, more preferably from 1 to 20 days, and most preferably from 1 to 10 days, followed by administration of the ORL-1 agonist for a period of time insufficient to develop tolerance to the ORL-1 agonist, such as for a period of from 1 to days more preferably from 1 to 20 days, and most preferably from 1 to 10 days.
The cycle of rotational intrathecal delivery of the p,-opioid receptor agonist followed by delivery of the ORL-1 agonist may then be repeated for similar periods of time, for as 30 many cycles as desired, and is preferably repeated for at least a plurality of cycles. It is theorized that these same cycles may be suitable for rotation of ~-opioid receptor agonists or x-opioid receptor agonists with ORL,-1 agonists.
One common ~.-opioid receptor agonist for use in the practice of the invention is morphine, although other ~,-opioid receptor agonists may be used in the practice of the invention. Suitable ~,-opioid receptor agonists for use in the practice of the invention include, for example, hydromoiphone, fentanyl, sufentanil, methadone, meperidine and Try-D-Ala-Gly-[N-MePhe]-NH(CH2)-OH ("DAMGO").
Potentially suitable S-opioid receptor agonists may include, by way of example, deltoiphin and [D-Pent, D-Penj]enlcephalin ("DPDPE"). One exemplary K-opioid receptor agonist that may be suitable for use in the present invention is (trans)-3,4dichloro-N-methyl-N[2-(1-pyrrolidynl)cyclohexyl]-benzene acetamide ("U-50,488H").
Suitable ORL-1 agonists for use in the practice of the invention include, for example, nociceptin (orphanin FQ) and other agents that bind to the ORL-1 receptor with high affinity, but that do not bind to the ~,-opioid receptor with affinity sufficient to result in cross-tolerance. Depending on their binding properties, the following agents may potentially possess the required properties: Phepsi ([Phelpsi(CH2-NH)Gly2]nociceptin-(1-13)-NH2 (Chioce, J. Biomed. Sci. 7(3):232-(2000))); (lS,3aS)8-(2,3,3a,4,5,6-hexahydro-1H-phenalen-1-yl)-1-phenyl-1,3,8-triaza-spiro[4,5]decan-4-one ("RO 64-6198") (Jenclc F. et al., PNAS 97(9):4938-4943 (2000);
and the 1-phenyl-1,3,8-triaza-spiro[4.5]decan-4-ones (Rover S., J. Med. Clzem.
43(7):1329-1338 (2000)). Suitable ORL-1 agonists may be either peptidergic, e.g., nociceptin, or non-peptidergic, e.g., RO 64-6198.
Pharmaceutical compositions suitable for intrathecal injection may be sterilized solutions containing an effective amount of the compounds used according to the invention dissolved in a physiologically acceptable isotonic saline solution (for example, containing about 0.9% by wt. sodium chloride). Usually these solutions are adopted in a known manner to the physiological characteristics of the site of administration.
The analgesic agents of the invention may be administered intrathecally by any means lmown in the art. For example, intrathecal administration of the centrally acting analgesic agents of the invention may be accomplished via an externalized spinal catheter, a spinal catheter connected to an external infiision pump, a spinal catheter connected to a fully implanted infusion pump and other related systems lcnown in the art to be therapeutically effective for the treatment of chronic pain. Direct intrathecal delivery of the analgesic agents is preferred to reduce systemic side effects caused by _g_ relatively high dosage systemic delivery. In this way, the active drugs are delivered in a concentrated manner and at low doses to their specific site of action on receptors in the neuraxis, minimizing systemic side effects as outlined above.
Implantable drug infusion devices may be used to provide patients with a constant or programmable long-term dosage or infusion of the analgesic agents of the invention.
Such devices may be categorized as either active or passive.
Active drug or programmable infusion devices typically feature a pump or a metering system to deliver the drug into the patient's system. An example of such an active drug infusion device currently available is the SynchroMedTM
programmable pump (Medtronic Incorporated, Minneapolis, Minnesota). Such pumps typically include a drug reservoir, a peristaltic pump to pump out the drug from the reservoir, and a catheter port to transport the pumped out drug from the reservoir via the pump to a patient's anatomy. Such devices also typically include a battery to power the pmnp as well as an electronic module to control the flow rate of the pump. The SynchroMedTM
pump further includes an antenna to permit the remote programming of the pump.
Passive drug infusion devices, in contrast, do not feature a pmnp, but rather rely upon a pressurized drug reservoir to deliver the drug. Thus such devices tend to be both smaller as well as cheaper as compared to active devices. An example of such a device includes the Medtronic IsoMedTM device (Medtronic Incorporated, Mimleapolis, Minnesota). This device delivers the drug into the patient through the force provided by a pressurized reservoir. In particular, this reservoir is pressurized with a drug to between 20 to 40 psi (1.3 to 2.5 bar) and is used to deliver the drug into the patient's system.
Typically the flow path of the drug from the reservoir to the patient includes a flow restrictor, which permits a constant flow rate. The flow rate, however, is only constant if the pressure difference between reservoir and patient does not change. Factors that could impact this pressure difference include temperature, pressure-volume dependence of reservoir and altitude, among others. The selected pressure for the reservoir is thus typically quite high, so that absolute pressure changes only cause small and acceptable errors in flow rate. Suitable infusion pumps for use in the practice of the invention include the infusion pump disclosed in U.S. Patent No. 5,820,589 of Medtronic, Inc., that is implantable and noninvasively programmable by means of radio frequency telemetry or other means of noninvasive telemetry. The disclosure of this patent is hereby incorporated herein by this reference.
In a presently particularly preferred embodiment, the analgesic agents of the invention may be administered by an implantable medical pump having at least two fluid reservoirs, one for the ~.-, ~-, or ~c-opioid receptor agonists of the invention and the other for the ORL-1 agonists of the invention, together with means for releasing the agonists from their respective reservoirs in an alternating manner in accordance with the rotational administration regime of the invention. In accordance with this aspect of the invention, the pump may comprise, for example:
(a) a first fluid reservoir for containing a first drug to be rotationally administered, e.g. the ~,-, 8-, or ~c-opioid receptor agonists of the invention;
(b) a regulator assembly adjustable to a plurality of flow rate settings for regulating the flow of fluid from the first fluid reservoir;
(c) a second fluid reservoir for containing a second drug to be rotationally administered, e.g., the ORL-1 agonists of the invention;
(d) a regulator assembly adjustable to a plurality of flow rate settings for regulating the flow of fluid from the second fluid reservoir; and (e) electromechanical control means for changing the passive regulator assemblies from a first flow rate setting to a second flow rate setting when the electromechanical control means receives an induced voltage in response to control signals, wherein the flow rate setting regulating the flow from the first fluid reservoir is set to zero when there is positive flow from the second fluid reservoir, and the flow rate setting regulating the flow from the second fluid reservoir is set to zero when there is positive flow from the first fluid reservoir, and wherein the electromechanical control means changes the flow rate settings from the first and second fluid reservoirs to zero in an alternating manner.
In accordance with this aspect of the invention, a drug infusion pump suitable for use in connection with the invention may comprise a first fluid reservoir, a second fluid reservoir and septums which serve, for example, as access ports to the reservoirs during the filling of the reservoirs with the first drug (e.g., p,-, ~-, or K- opioid receptor agonists) and the second drug (e.g., ORL-1 agonists) of the invention, respectively, to be delivered to a specific desired location within a patient's body. If desired, the pump may further comprise a telemetry antenna or receiver preferably comprising a coil of wire within which a voltage may be induced when the receiver is in the presence of a transmitted signal. Such a signal is created, for example, by an assembly including a programmer operatively coupled to a radio frequency head disposed proximate to a pump implanted within the body of a patient near the skin.
The pump may further comprise a system that regulates the flow of fluid from the first reservoir and the second reservoir. Preferably, the flow regulating system comprises a valve network assembly adjustable to a plurality of flow rate settings, and includes a plurality of bi-stable valves that control the flow of fluid to a plurality of flow restrictors.
The valves may be similar to, but not restricted to those described by Wagner, et al. See.
Wagner, B. et al., "Bistable Microvalve with Pneumatically Coupled Membranes,"
IEEE
0-7803-2985-6/96, pp. 384-88, which is incorporated herein by reference. The restrictors may be similar to, but not limited to capillary tube technology used in the commercially available Infusaid and Anschutz fixed rate pumps. Alternatively, micro-machined etching technology can also be used to manufacture the restrictor.
In addition, the pump preferably comprises control circuitry for changing the state of one or more of the valves of the system in response to a received telemetry signal. The control circuitry preferably includes elements required to communicate with the transmitter, transform the signal from the transmitter to energy required to change valve states according to the telemetry received via the transmitter, and verify valve states and overall pump performance.
FIG. 1 shows a schematic illustration of an implantable rate-adjustable pump system in accordance with the present invention. As shown therein, the pump 10 preferably comprises a first fluid reservoir 12 for containing a solution of one of the analgesic agents of the invention, such as a solution of a p,-opioid receptor agonist, and a second fluid reservoir 14 for containing a solution of the rotated analgesic agent of the invention, such as a solution of an ORL-1 agonist. Sensors 16, 18 are provided for sensing fluid levels in the reservoirs 12, 14, respectively, and providing fluid level information along paths 20, 22 to integrated circuit controller 24. Fluid flow restrictors 26, 28 are provided for regulating the flow of analgesic agents from the first and second fluid reservoirs 12, 14 to a patient, at flow rates determined by controller 24 and sensors 27, 29. If desired, the pump system may be provided with an implantable RF
receiver 30 adapted to receive signals from external RF transmitter 32 as set by a programmer 34, to regulate the flow patterns of analgesic agents from reservoirs 12, 14 in an alternating manner in accordance with the rotational intrathecal analgesic administration methods of the present invention.
IN vIYO RAT HINDPAW WITHDRAWAL LATENCY (HWL) STUDY
Experiments were performed on male Sprague-Dawley rats having a weight of 200-250 g. The rats were housed in cages with free access to food and water.
Roorn temperature was maintained at 24 ~ 2°C and a 12 hr light/darlc cycle was maintained. All experiments were conducted according to the guidelines of the Committee on Animal Research at the University of California at San Francisco. Every effort was made to minimize animal suffering.
INTRATHECAL INJECTIONS.
A polyethylene catheter (Intramedic PE 10) was permanently implanted intrathecally with the inner tip at L3 to LS in each animal. Rats displaying movement disorders following placement of the catheter were not used in the study.
Injection volume was 10 ~,L of drug solution followed by 10 ~.L of 0.9% saline to flush the catheter. Intrathecal injections were performed every 12 hrs (morning and night).
In the morphine only group, 8 ~g morphine HCl was injected every 12 hrs until complete tolerance developed and in the nociceptin only group, 10 nmol nociceptin was injected every 12 hrs until complete tolerance developed. These doses were chosen from previous studies that determined ari equianalgesic dosing for these two drugs.
In the rotational analgesia group (shown as Morphine + Nociceptin in Tables 1 and 2, below), 8 ~g morphine was injected every 12 hrs for the first two days, followed by 10 nmol nociceptin every 12 hrs for the next two days. The same pattern was repeated until complete tolerance developed.
Solutions for intrathecal injection were prepared with sterilized saline (0.9%).
Nociceptin was obtained from Tocris, Balwin, MO, morphine HCl was obtained from Shenyang First Pharmaceutical Factory, Shenyang, China.
NOCICEPTIVE TESTING
The rats were trained with the testing conditions for five days prior to the experiments to decrease the stress response caused by handling and measurements and to obtain baseline responses. The hindpaw withdrawal latency (HWL) was measured for both thermal and mechanical stimulation. Thermal stimulation was achieved using the hot-plate test. The entire ventral surface of the rat's left or right hindpaw was placed on the hotplate, which was maintained at a temperature of 52°C (51.8-52.2°C). The Randall Selitto Test (UGO Basile, Type 7200, Italy) was used to assess HWL to mechanical stimulation. A wedge shaped probe with a loading rate of 30 g/second was applied to the dorsal surface of the manually handled hindpaw and the mechanical stimulation required to initiate the struggle response was assessed. The HWL is expressed in seconds, i.e., latency to withdrawal from the start of stimulation. The HWL,s were measured 15 min after the second intrathecal injection on a daily basis.
Data from the hindpaw withdrawal latency tests are presented in the following Tables l and 2 as average + standard error of the mean (SEM). The HWL to thermal (Figures 2A and 2B) and mechanical (Figures 2C and 2D) stimulation is expressed as percentage of the basal level for each rat. Each rat was tested with both types of stimulation.
CHANGES OF HWL TO MECHANICAL STIMULATION
Left Right Morphine Morphine + +
Days NociceptinMorphine Nocice~ NociceptinMorphine Nociceptin 1 44.777.6553.992.9669.904.1143.33+7.1956.04+3.3861.263.85 2 37.91+2.8847.692.5431.285.0341.083.81 46.742.5230.79+6.58 3 41.56+2.6633.851.6010.590.9340.19+1.3333.44+1..0310.081.05 4 37.81+2.0631.37+2.02-0.621.4538.331.53 28.84+2.73-0.762.32 5 38.473.0715.301.39 39.36+2.8416.541.26 6 33.953.513.261.86 34.57+1.992.72+1.94 7 33.902.06 34.632.06 8 30.971.77 32.17+2.08 9 28.361.38 28.281.32 10 20.092.32 18.671.00 11 12.342.26 10.863.00 12 3.71 a;1.81 3.612.48 13 -1.12aØ99 -2.1911.15 14 -0.61 -0.841.61 a1.86 CHANGES OF HWL TO THERMAL STIMULATION
MINUTES AFTER INTRATHECAL INJECTION
Left Right Morphine + Morphine +
Days Nociceptin Morphine Nociceptin Nocice~ Morphine Nociceptin 1 91.617.98 66.262.20 93.493.77 85.148.32 66.661.51 90.422.65 2 81.171.86 61.253.05 39.913.66 80.684.62 63.110.64 43.022.12 3 86.943.42 51.661.73 9.46+2.31 85.403.69 48.742.40 12.01+1.48 4 77.483.10 43.631.38 -2.182.07 79.152.74 42.45+1.70 -3.67+1.61 5 77.25+3.05 23.851.03 79.79+4.65 25.07+2.07 6 57.123.64 -1.302.36 56.402.84 0.511.61 7 49.641.37 54.01+1.89 8 41.543.60 42.733.58 9 33.071.35 31.532.06 10 20.081.77 17.17+1.85 11 16.782.93 17.752.57 12 6.28+2.19 6.812.77 13 -1.250.93 -1.020.84 Morphine alone on day 1 produces an HWL increase of approximately 67% using thermal stimulation (Figures 2A and 2B) and 55% using mechanical stimulation (Figures 2C and 2D). Both right and left hindpaws had similar HWLs. Both 10 mechanical and thermal HWLs gradually decrease with each successive day, such that by day 6, total tolerance to intrathecal morphine exists. Nociceptin alone on day 1 produces an HWL increase of approximately 90% using thermal stimulation (Figures 2A and 2B) and 60-70% using mechanical stimulation (Figures 2C and 2D). Both mechanical and thermal HWLs rapidly decrease with successive days, such that by day 4, complete tolerance to intrathecal nociceptin exists. -As shown in Figures 2A-2D, rotating morphine with nociceptin produces a dramatically different result. Whereas a similar decrease in HWL compared to the morphine alone group between days 1 and 2 is measured, day 3 using nociceptin instead of morphine returns the HWL back to day 1 levels. Although tolerance is indeed observed for both medications with time, the time to complete tolerance is lengthened to 13 days. Similar time courses are observed for both hindpaws and for both types of stimulation.
This example, as well as other reported studies in the literature, demonstrates that rats become completely tolerant to intrathecal morphine by day 6. By alternating equipotent doses of morphine and nociceptin intrathecally every two days (i.e., days 1 and 2 morphine, days 3 and 4 nociceptin, days 5 and 6 morphine, etc.), this example demonstrates that complete tolerance develops in 13 days, a greater than 100%
increase in the length of time to complete tolerance compared with morphine alone and a greater than 200% increase compared to nociceptin alone. Interestingly, nociceptin tolerance is extremely rapid. In the nociceptin alone group, by day 2, 50% tolerance had already developed. This dramatic decrease in HWL is not seen on the second day of dosing nociceptin in the rotational analgesia group, (e.g., day 3 to day 4). Although not wishing to be bound by any pa~.-ticular theory, this decrease in nociceptin tolerance after treatment with morphine may be due to the upregulation of nociceptin receptors (ORL-1 receptors) in the dorsal horn of the spinal cord following intrathecal morphine treatment (Gouarderes C et al., "Nociceptin receptors in the rat spinal cord during morphine tolerance," Brain Res 838:85-94 (1999)). Because of the rapid development of tolerance, ORL-1 agonists may not be clinically useful as single agents intrathecally;
however, by rotating a ~,-opioid receptor agonist in accordance with the present invention, the development of ORL-1 agonist tolerance can be significantly lengthened.
Although ~.-opioid receptor agonists, such as morphine, are currently used as single agents intrathecally, the issues of tolerance and dose escalation are problematic clinically as mentioned earlier.
COMBINATION THERAPY
Hindpaw withdrawal latency (HWL) tests using the materials and methods of Example 1 for both thermal and mechanical stimulation were conducted on a group of eight rats that were treated by intrathecal injections of half doses of morphine (4 ~,g) and nociceptin (5 nmol) every 12 hours. The results are shown in the following Table 3 and in FIGURES 3A-3D.
AN IMPLANTABLE INFUSION PUMP
FIELD OF THE INVENTION
The present invention relates to methods and apparatus for the administration of intrathecal analgesics to achieve pain relief while delaying the onset of drug tolerance.
BACKGROUND OF THE INVENTION
In mammals, the receptors that respond selectively to noxious stimuli are known as nociceptors. Two distinct sets of peripheral sensory neurons are primarily responsible for the sensation of pain. The first, Ab-nociceptive neurons, contain myelinated axons and are aroused primarily by noxious heat and mechanical stimuli. The second set of nociceptive neurons, which possess unmyelinated axons and are lcnov~m as C
fibers, are activated by high intensity, mechanical, chemical and thermal stimulation.
Each of these sets of neurons has their cell bodies in the dorsal root ganglia. Their processes are pseudounipolar, with one axon that terminates in the periphery and one that terminates on neurons in the dorsal horn of the spinal cord.
Analgesia is the loss of sensitivity to pain without loss of consciousness. In recent years, the convergence of various lines of research demonstrates that analgesia can be produced by exogenous opioids, such as morphine, or endogenous opioids. This research has resulted in a model that explains the mechanism whereby pain is inhibited.
See, fox example, Kelly, D., "Central Representations Of Pain and Analgesia", P~°incipals of Neural Science, Kandel and Schwartz, Eds. (1985).
The first means known to man for inducing analgesia was through the use of plant-derived opioid narcotics such as morphine. Postsynaptic opioid receptors have been characterized and include the following three basic subtypes: mu (~.), delta (8) and kappa (~c). Endogenous opioids that bind these opioid receptors and thereby produce analgesia include the met- and leu-enlcephalins, as well as (3-endorphin. Most of the clinically used opiates, such as morphine, activate the ~,-opioid receptor subtype.
Stimulation of C-fiber primary afferent neurons associated with pain results in the release of the potent neuropeptides substance P, calcitonin gene related peptide (CGRP) and somatostatin, as well as the "fast" neurotransmitter glutamate. The activated enlcephalinergic inhibitory neurons in turn exert presynaptic iWibitory control over the release of these neurotransmitters, thus blocking the sensation of pain.
Opioid compounds (opiates) such as morphine, while effective in producing analgesia for many types of pain, are not always effective since the development of tolerance occurs in most patients. The development of tolerance to the effects of opioids is one of the major problems in chronic pain management today. Regardless of the route of opioid delivery, patients complain of decreasing pain relief with time.
Although recent studies suggest that constant delivery of opioids (e.g., infusion or transdermal patch) produces less tolerance than intermittent dosing (e.g., short-acting opioids, such as Vicodin) (Jhamandas, KH et al., "Spinal amino acid release and precipitated withdrawal in rats chronically infused with spinal morphine," JNeurosci 16:2758-2766 (1996); lbulci T et al., "Effect of transient naloxone antagonism on tolerance development in rats receiving continuous spinal morphine infusion," Paiu 70:125-132 (1997)), tolerance is still a significant issue. Recent studies with patients receiving chronic intrathecal opioids demonstrate that in some patients an increase in dose of up to 2-3 fold over a period of .months is necessary to maintain adequate analgesic levels (Winlcehnuller M et al., "Long-term effects of continuous intrathecal opioid treatment in chronic pain of nomnalignant etiology," J Neurosm°g 85:458-467 (1996); Paice JA et al., "Clinical realities and economic considerations: efficacy of intrathecal pain therapy," J Pain SyuzP
Manage 14:514-26 (1997); Sallerin-Caute B et al., "Does intrathecal morphine in the treatment of cancer pain induce the development of tolerance?," Neuf osm°geyy 42:44-49 (1998)). A
recent study of the intra-operative use of remifentanil indicates that rapid (within hours) tolerance to this ~,-opioid agonist can occur (Guignard B. et al., "Acute opioid tolerance:
intraoperative remifentanil increases postoperative pain and morphine requirement,"
Anesthesiology 93:409-417 (2000)). Basic research on human cell lines indicates that a 30% reduction in ~-opioid receptor molecular signaling pathways occurs as early as 24 hours in culture with a ~.-opioid agonist (Elliot J. et al., "Tolerance to ~,-opioid agonists in human neuroblastoma SH-SYSY cells as determined by changes in guanosine-5'-0-(3-[35S]-thio) triphosphate binding," B~~. J. Pha~~zacol. 121:1422-1428 (1997)).
However, most researchers would agree that tolerance develops more rapidly in rats than in humans.
For example, many patients have been successfully treated with stable-dose morphine for more than six days (which is the time-course for the development of morphine tolerance in rats) without becoming completely tolerant to the analgesic effects of morphine.
_2_ While escalating opioid use is not only a medicolegal issue for many physicians, escalating intrathecal opioids can result in side effects, such as myoclonus (Glavina MJ et al., "Myoclonic spasms following intrathecal morphine," Anaesthesia 43:389-390 (1988);
De Conno F et al., "Hyperalgesia and myoclonus with intrathecal infusion of high-dose morphine," Pain 47:337-339 (1991)). This side effect does not usually occur if the dose of intrathecal opioids is limited to a morphine equivalent of 60-70 mg/day.
Although most patients start at intrathecal doses of less than 5 mg/day, even a 2-fold increase per year results in toxic doses within four years. At high doses, these compounds additionally produce side effects, such as respiratory depression, which can be life-threatening. Opioid drugs also frequently produce physical dependence in patients.
Dependence appears to be related to the dose of opioid taken and the period of time over which the subject talces it. For this reason, alternate therapies for the management of chronic pain are widely sought. In addition, compounds which serve as either a replacement for, or as an adjunct to, opioid treatment in order to decrease the dosage of analgesic compound required, have utility in the treatment of pain, particularly pain of the . chronic, intractable type.
Non-opioid drugs, such as the non-steroidal anti-inflammatory drugs (NSAIDs) provide an alternative therapy for the treatment of pain. The mode of action of NSAIDs is believed to be through inhibition of cyclooxygenase, the enzyme responsible for biosynthesis of the prostaglandins. As analgesics, the NSAIDs lack many of the side effects on the CNS that are associated with the opioids and they do not result in the development of dependence. They are only effective, however, on low to moderate intensity pain, and are not generally useful for intense pain. In addition, they have undesirable side effects, including the propensity to induce gastric or intestinal ulceration as well as disturbances of platelet function.
Despite the wide range of analgesic substances available, still lacking are drugs and drug administration regimes that are effective in reducing severe pain without requiring dose escalation due to the development of tolerance.
SUMMARY OF THE INVENTION
It has now been discovered that a new treatment regimen, termed "rotational analgesia," helps delay the development of tolerance to intrathecal opioids.
In one aspect of the present invention, a method of producing analgesia in a maxmnal is provided comprising alternating intrathecal administration to the mammal of a pharmaceutically effective dose of at least one opioid receptor agonist, followed by intrathecal administration to the mammal of a pharmaceutically effective dose of at least one opioid receptor-like receptor 1 (ORL-1) agonist. The periods of alternating administration of each agent may then be repeated as many times or cycles as desired. Each period of administration of the opioid receptor agonist or the ORL-1 agonist is designed to be insufficient in duration to induce significant tolerance in the marninal to either drug, thereby delaying the development of tolerance. In one embodiment of the invention the opioid receptor agonist i's selected from ~-opioid receptor agonists, 8-opioid receptor agonists, x-receptor agonists and mixtures thereof.
In other aspects, an implantable, non-invasive, rate-adjustable dual reservoir pump is provided for rotational intrathecal delivery of the opioid receptor agonist and ORL-1 agonist drugs of the present invention.
BRIEF DESCRIPTION OF THE DRAWINGS
The foregoing aspects and many of the attendant advantages of this invention will become more readily appreciated by reference to the following detailed description, when ~talcen in conjunction with the accompanying drawings, wherein:
FIGURE 1 is a schematic illustration in block diagram form of m implantable, rate-adjustable, dual reservoir pump system in accordance with the present invention; and FIGURE 2 is a graphical representation of the hindpaw withdrawal latencies (HWL) of rats to thermal (FIGURES 2A and 2B) and mechanical (FIGURES 2C and 2D) stimulation using intrathecal morphine (8 ~.g) alone (shown as ~ in FIGURES 2A-2D), intrathecal nociceptin (10 mnol) alone (shomz as ~ in FIGURES 2A-2D), or rotating morphine for 2 days, nociceptin for 2 days and then repeating the cycle (shown as o in FIGURES 2A-2D), as described in Example 1.
FIGURE 3 is a graphical representation of HWL of rats to thermal (FIGURES 3A
and 3B) and mechanical (FIGURES 3C and 3D) stimulation after twice daily administration of a combination of half doses of morphine (4 ~,g) and nociceptin (5 nmol), as described in Example 2.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT
In the practice of rotational analgesia, the administration of an intrathecal opioid drug is rotated with administration of another drug that has potent analgesic effects, but that exhibits minimal cross-tolerance with the opioid drug. To exhibit minimal cross-tolerance, for example, the opioid drug must not significantly bind to the rotational drug's receptor. Similarly, the rotational drug must not significantly bind to the opioid drug's receptor. Also of importance is that the overall effect on the pain pathways in the spinal cord are sufficiently similar that the patient does not go through withdrawal from the opioid during the rotation to the alternate drug. These two lcey factors limit the type of drug that can successfully be rotated with opioids in the practice of the invention.
Consider receptor activation and second messenger system initiation as the early stage of the drug's effect and neuronal inhibition and decreased cyclic AMP levels as the late stages in the effect of the drug. Although not wishing to be bound by any particular theory, it is presently believed to be important that the rotated drugs have dissimilar early stages and highly similar late stages to avoid cross-tolerance, yet also avoid drug withdrawal. A presently preferred example of a drug that can be rotated successfully with an opioid drug in the practice of the invention is an ORL-1 agonist.
In one aspect the present invention relates to methods and apparatus for delaying the onset of tolerance in the administration of opioid and opioid-lilce receptor-1 (ORL-1) agonist drugs by rotating the administration of at least one opioid receptor agonist, such as a ~,-opioid receptor agonist, a ~-opioid receptor agonist, a K-opioid receptor agonist or mixtures thereof, with the administration of at least one ORL-1 agonist.
Suitable opioid receptor agonists for administration in rotation with the at least one ORL-1 agonist include those opioid agonists that exhibit a minimal degree of cross-tolerance with the administered ORL-1 agonist, and that exhibit overall effects on the pain pathways in the spinal cord that are sufficiently similar to the effects exhibited by the administered ORL-1 agonist such that the patient does not go through withdrawal from the opioid agonist during the rotation to the ORL-1 agonist. As further described and illustrated by the Examples set forth herein below, ~,-opioid receptor agonists and ORL-1 agonists can be beneficially administered in rotation in accordance with the present invention to extend duration to tolerance. It is also theorized that b-opioid receptor agonists and/or x-opioid receptor agonists may also be suitably rotated with ORL-1 agonists in accordance with the present invention, provided these opioid agonists are demonstrated to exhibit minimal cross-tolerance with ORL-1 agonists and similar effects on pain pathways.
In a first preferred embodiment of the invention, at least one ~,-opioid receptor agonist is administered in rotation with at least one ORL-1 receptor agonist.
The ~,-opioid agonists, such as morphine, are rotated with an ORL-1 receptor agonist, such as nociceptin, since the ~.-opioid receptor agonists do not bind to the ORL-1 receptor and nociceptin does not bind to ~,-opioid receptors, therefore cross-tolerance is not lilvely (Hao JX et al., "Laclv of cross-tolerance between the antinociceptive effect of intrathecal orphanin FQ and morphine in the rat," Neu~osci Lett 223:49-52 (1997)). Both drugs decrease cyclic AMP levels and both are potent analgesics when applied intrathecally.
Therefore, these two drug classes when administered intrathecally in accordance with the rotational intrathecal delivery regime of the present invention afford longer pain relief than when using either drug alone by delaying the onset of tolerance.
In other embodiments of the invention, at least one b-opioid receptor agonist is administered in rotation with at least one ORL-1 receptor agonist. The intrathecal administration of orphanin FQ (nociceptin) had been observed to increase the duration of the antinociceptive response evolved by intrathecal administration of the b-opioid receptor agonist deltorphin (Jhamandas, KH et al, "Antinociceptive and morphine modulatory actions of spinal orphanin FQ," Ca~c. J. Physiol. Pha~macol. 76:314-324 (1998)). While the potential for exhibiting minimal cross-tolerance and similar effect on pain pathways needs to be determined in accordance with the present invention, it is theorized that 8-~ opioid receptor agonists may be useful for rotation with ORL-1 agonists.
In still other embodiments of the invention; at least one x-opioid receptor agonist is administered in rotation with at least one ORL-1 receptor agonist. Again, the potential for minimal cross-tolerance and similar effect on pain pathways needs to be evaluated in determining the suitability for rotation of K-opioid receptor agonists with ORL-1 agonists in accordance with the methods of the present invention.
Thus, in accordance with one aspect, the present invention provides a method of treating a mammal in need of analgesia comprising intrathecally administering to the mammal a pharmaceutically effective dose of either at least one opioid receptor agonist or at least one ORL-1 agonist for a first period of time, and intrathecally administering to the mammal a pharmaceutically effective dose of the other at least one opioid receptor agonist or at least one ORL-1 agonist for a second period of time (i.e., the analgesic agent not administered during the first period of time). In one embodiment, the second period of time serially follows the first period of time. In other embodiments, the end of the first period of time may overlap the beginning of the second period of time, and vice versa.
The cycle of alternating intrathecal administration is preferably repeated for a plurality of treatment periods, for as long as desired in a particular application. If desired, the dosage level of drug being administered may be tapered down at the end of its administration period, while simultaneously tapering up the dosage level of the drug being rotated into the cycle, thereby providing a cross-over period during which both the opioid receptor agonist and the ORL-1 agonist are being administered to the mammal.
Suitable dosage levels for the opioid receptor agonists and the ORL-1 agonists of the invention will be determined by the prescribing physician depending on the needs of the patient, and include the dosage levels conventionally used for these analgesic agents, as is well lcnown to those skilled in the art. For example, the ~,-opioid receptor agonists may be administered at daily dosage levels of about 0.5 to about 25 mg/day, and more preferably at dosage levels of about 3 to about 20 mg/day. The ORL-1 agonists may be administered at daily dosage levels of about 1 to about 1,000 ~g/day, more preferably about 5 to about 500 ~g/day, and most preferably about 20 to about 100 ~.g/day. The daily dosage of the opioid receptor agonists or the ORL-1 agonists may be administered substantially continuously or intermittently.
Preferably, the first and second periods of administration for the opioid receptor agonists and the ORL-1 agonists are insufficient in duration to achieve significant 'tolerance in the patient to the analgesic effects of the administered drugs.
As used herein, the term "tolerance" means a noticeable or measurable effect in the patient to become less responsive to the opioid receptor agonists or the ORL-1 agonists of the invention. Thus, a tolerance condition is characterized by the necessity to increase successive drug doses in order to produce identical analgesic effects, and by the apparent loss of potency of the drug observed during the course of successive administrations.
For example, the ~,-opioid receptor agonist is preferably administered for a period of time insufficient to develop tolerance to the ~,-opioid receptor agonist, such as for a period of from 1 to 30 days, more preferably from 1 to 20 days, and most preferably from 1 to 10 days, followed by administration of the ORL-1 agonist for a period of time insufficient to develop tolerance to the ORL-1 agonist, such as for a period of from 1 to days more preferably from 1 to 20 days, and most preferably from 1 to 10 days.
The cycle of rotational intrathecal delivery of the p,-opioid receptor agonist followed by delivery of the ORL-1 agonist may then be repeated for similar periods of time, for as 30 many cycles as desired, and is preferably repeated for at least a plurality of cycles. It is theorized that these same cycles may be suitable for rotation of ~-opioid receptor agonists or x-opioid receptor agonists with ORL,-1 agonists.
One common ~.-opioid receptor agonist for use in the practice of the invention is morphine, although other ~,-opioid receptor agonists may be used in the practice of the invention. Suitable ~,-opioid receptor agonists for use in the practice of the invention include, for example, hydromoiphone, fentanyl, sufentanil, methadone, meperidine and Try-D-Ala-Gly-[N-MePhe]-NH(CH2)-OH ("DAMGO").
Potentially suitable S-opioid receptor agonists may include, by way of example, deltoiphin and [D-Pent, D-Penj]enlcephalin ("DPDPE"). One exemplary K-opioid receptor agonist that may be suitable for use in the present invention is (trans)-3,4dichloro-N-methyl-N[2-(1-pyrrolidynl)cyclohexyl]-benzene acetamide ("U-50,488H").
Suitable ORL-1 agonists for use in the practice of the invention include, for example, nociceptin (orphanin FQ) and other agents that bind to the ORL-1 receptor with high affinity, but that do not bind to the ~,-opioid receptor with affinity sufficient to result in cross-tolerance. Depending on their binding properties, the following agents may potentially possess the required properties: Phepsi ([Phelpsi(CH2-NH)Gly2]nociceptin-(1-13)-NH2 (Chioce, J. Biomed. Sci. 7(3):232-(2000))); (lS,3aS)8-(2,3,3a,4,5,6-hexahydro-1H-phenalen-1-yl)-1-phenyl-1,3,8-triaza-spiro[4,5]decan-4-one ("RO 64-6198") (Jenclc F. et al., PNAS 97(9):4938-4943 (2000);
and the 1-phenyl-1,3,8-triaza-spiro[4.5]decan-4-ones (Rover S., J. Med. Clzem.
43(7):1329-1338 (2000)). Suitable ORL-1 agonists may be either peptidergic, e.g., nociceptin, or non-peptidergic, e.g., RO 64-6198.
Pharmaceutical compositions suitable for intrathecal injection may be sterilized solutions containing an effective amount of the compounds used according to the invention dissolved in a physiologically acceptable isotonic saline solution (for example, containing about 0.9% by wt. sodium chloride). Usually these solutions are adopted in a known manner to the physiological characteristics of the site of administration.
The analgesic agents of the invention may be administered intrathecally by any means lmown in the art. For example, intrathecal administration of the centrally acting analgesic agents of the invention may be accomplished via an externalized spinal catheter, a spinal catheter connected to an external infiision pump, a spinal catheter connected to a fully implanted infusion pump and other related systems lcnown in the art to be therapeutically effective for the treatment of chronic pain. Direct intrathecal delivery of the analgesic agents is preferred to reduce systemic side effects caused by _g_ relatively high dosage systemic delivery. In this way, the active drugs are delivered in a concentrated manner and at low doses to their specific site of action on receptors in the neuraxis, minimizing systemic side effects as outlined above.
Implantable drug infusion devices may be used to provide patients with a constant or programmable long-term dosage or infusion of the analgesic agents of the invention.
Such devices may be categorized as either active or passive.
Active drug or programmable infusion devices typically feature a pump or a metering system to deliver the drug into the patient's system. An example of such an active drug infusion device currently available is the SynchroMedTM
programmable pump (Medtronic Incorporated, Minneapolis, Minnesota). Such pumps typically include a drug reservoir, a peristaltic pump to pump out the drug from the reservoir, and a catheter port to transport the pumped out drug from the reservoir via the pump to a patient's anatomy. Such devices also typically include a battery to power the pmnp as well as an electronic module to control the flow rate of the pump. The SynchroMedTM
pump further includes an antenna to permit the remote programming of the pump.
Passive drug infusion devices, in contrast, do not feature a pmnp, but rather rely upon a pressurized drug reservoir to deliver the drug. Thus such devices tend to be both smaller as well as cheaper as compared to active devices. An example of such a device includes the Medtronic IsoMedTM device (Medtronic Incorporated, Mimleapolis, Minnesota). This device delivers the drug into the patient through the force provided by a pressurized reservoir. In particular, this reservoir is pressurized with a drug to between 20 to 40 psi (1.3 to 2.5 bar) and is used to deliver the drug into the patient's system.
Typically the flow path of the drug from the reservoir to the patient includes a flow restrictor, which permits a constant flow rate. The flow rate, however, is only constant if the pressure difference between reservoir and patient does not change. Factors that could impact this pressure difference include temperature, pressure-volume dependence of reservoir and altitude, among others. The selected pressure for the reservoir is thus typically quite high, so that absolute pressure changes only cause small and acceptable errors in flow rate. Suitable infusion pumps for use in the practice of the invention include the infusion pump disclosed in U.S. Patent No. 5,820,589 of Medtronic, Inc., that is implantable and noninvasively programmable by means of radio frequency telemetry or other means of noninvasive telemetry. The disclosure of this patent is hereby incorporated herein by this reference.
In a presently particularly preferred embodiment, the analgesic agents of the invention may be administered by an implantable medical pump having at least two fluid reservoirs, one for the ~.-, ~-, or ~c-opioid receptor agonists of the invention and the other for the ORL-1 agonists of the invention, together with means for releasing the agonists from their respective reservoirs in an alternating manner in accordance with the rotational administration regime of the invention. In accordance with this aspect of the invention, the pump may comprise, for example:
(a) a first fluid reservoir for containing a first drug to be rotationally administered, e.g. the ~,-, 8-, or ~c-opioid receptor agonists of the invention;
(b) a regulator assembly adjustable to a plurality of flow rate settings for regulating the flow of fluid from the first fluid reservoir;
(c) a second fluid reservoir for containing a second drug to be rotationally administered, e.g., the ORL-1 agonists of the invention;
(d) a regulator assembly adjustable to a plurality of flow rate settings for regulating the flow of fluid from the second fluid reservoir; and (e) electromechanical control means for changing the passive regulator assemblies from a first flow rate setting to a second flow rate setting when the electromechanical control means receives an induced voltage in response to control signals, wherein the flow rate setting regulating the flow from the first fluid reservoir is set to zero when there is positive flow from the second fluid reservoir, and the flow rate setting regulating the flow from the second fluid reservoir is set to zero when there is positive flow from the first fluid reservoir, and wherein the electromechanical control means changes the flow rate settings from the first and second fluid reservoirs to zero in an alternating manner.
In accordance with this aspect of the invention, a drug infusion pump suitable for use in connection with the invention may comprise a first fluid reservoir, a second fluid reservoir and septums which serve, for example, as access ports to the reservoirs during the filling of the reservoirs with the first drug (e.g., p,-, ~-, or K- opioid receptor agonists) and the second drug (e.g., ORL-1 agonists) of the invention, respectively, to be delivered to a specific desired location within a patient's body. If desired, the pump may further comprise a telemetry antenna or receiver preferably comprising a coil of wire within which a voltage may be induced when the receiver is in the presence of a transmitted signal. Such a signal is created, for example, by an assembly including a programmer operatively coupled to a radio frequency head disposed proximate to a pump implanted within the body of a patient near the skin.
The pump may further comprise a system that regulates the flow of fluid from the first reservoir and the second reservoir. Preferably, the flow regulating system comprises a valve network assembly adjustable to a plurality of flow rate settings, and includes a plurality of bi-stable valves that control the flow of fluid to a plurality of flow restrictors.
The valves may be similar to, but not restricted to those described by Wagner, et al. See.
Wagner, B. et al., "Bistable Microvalve with Pneumatically Coupled Membranes,"
IEEE
0-7803-2985-6/96, pp. 384-88, which is incorporated herein by reference. The restrictors may be similar to, but not limited to capillary tube technology used in the commercially available Infusaid and Anschutz fixed rate pumps. Alternatively, micro-machined etching technology can also be used to manufacture the restrictor.
In addition, the pump preferably comprises control circuitry for changing the state of one or more of the valves of the system in response to a received telemetry signal. The control circuitry preferably includes elements required to communicate with the transmitter, transform the signal from the transmitter to energy required to change valve states according to the telemetry received via the transmitter, and verify valve states and overall pump performance.
FIG. 1 shows a schematic illustration of an implantable rate-adjustable pump system in accordance with the present invention. As shown therein, the pump 10 preferably comprises a first fluid reservoir 12 for containing a solution of one of the analgesic agents of the invention, such as a solution of a p,-opioid receptor agonist, and a second fluid reservoir 14 for containing a solution of the rotated analgesic agent of the invention, such as a solution of an ORL-1 agonist. Sensors 16, 18 are provided for sensing fluid levels in the reservoirs 12, 14, respectively, and providing fluid level information along paths 20, 22 to integrated circuit controller 24. Fluid flow restrictors 26, 28 are provided for regulating the flow of analgesic agents from the first and second fluid reservoirs 12, 14 to a patient, at flow rates determined by controller 24 and sensors 27, 29. If desired, the pump system may be provided with an implantable RF
receiver 30 adapted to receive signals from external RF transmitter 32 as set by a programmer 34, to regulate the flow patterns of analgesic agents from reservoirs 12, 14 in an alternating manner in accordance with the rotational intrathecal analgesic administration methods of the present invention.
IN vIYO RAT HINDPAW WITHDRAWAL LATENCY (HWL) STUDY
Experiments were performed on male Sprague-Dawley rats having a weight of 200-250 g. The rats were housed in cages with free access to food and water.
Roorn temperature was maintained at 24 ~ 2°C and a 12 hr light/darlc cycle was maintained. All experiments were conducted according to the guidelines of the Committee on Animal Research at the University of California at San Francisco. Every effort was made to minimize animal suffering.
INTRATHECAL INJECTIONS.
A polyethylene catheter (Intramedic PE 10) was permanently implanted intrathecally with the inner tip at L3 to LS in each animal. Rats displaying movement disorders following placement of the catheter were not used in the study.
Injection volume was 10 ~,L of drug solution followed by 10 ~.L of 0.9% saline to flush the catheter. Intrathecal injections were performed every 12 hrs (morning and night).
In the morphine only group, 8 ~g morphine HCl was injected every 12 hrs until complete tolerance developed and in the nociceptin only group, 10 nmol nociceptin was injected every 12 hrs until complete tolerance developed. These doses were chosen from previous studies that determined ari equianalgesic dosing for these two drugs.
In the rotational analgesia group (shown as Morphine + Nociceptin in Tables 1 and 2, below), 8 ~g morphine was injected every 12 hrs for the first two days, followed by 10 nmol nociceptin every 12 hrs for the next two days. The same pattern was repeated until complete tolerance developed.
Solutions for intrathecal injection were prepared with sterilized saline (0.9%).
Nociceptin was obtained from Tocris, Balwin, MO, morphine HCl was obtained from Shenyang First Pharmaceutical Factory, Shenyang, China.
NOCICEPTIVE TESTING
The rats were trained with the testing conditions for five days prior to the experiments to decrease the stress response caused by handling and measurements and to obtain baseline responses. The hindpaw withdrawal latency (HWL) was measured for both thermal and mechanical stimulation. Thermal stimulation was achieved using the hot-plate test. The entire ventral surface of the rat's left or right hindpaw was placed on the hotplate, which was maintained at a temperature of 52°C (51.8-52.2°C). The Randall Selitto Test (UGO Basile, Type 7200, Italy) was used to assess HWL to mechanical stimulation. A wedge shaped probe with a loading rate of 30 g/second was applied to the dorsal surface of the manually handled hindpaw and the mechanical stimulation required to initiate the struggle response was assessed. The HWL is expressed in seconds, i.e., latency to withdrawal from the start of stimulation. The HWL,s were measured 15 min after the second intrathecal injection on a daily basis.
Data from the hindpaw withdrawal latency tests are presented in the following Tables l and 2 as average + standard error of the mean (SEM). The HWL to thermal (Figures 2A and 2B) and mechanical (Figures 2C and 2D) stimulation is expressed as percentage of the basal level for each rat. Each rat was tested with both types of stimulation.
CHANGES OF HWL TO MECHANICAL STIMULATION
Left Right Morphine Morphine + +
Days NociceptinMorphine Nocice~ NociceptinMorphine Nociceptin 1 44.777.6553.992.9669.904.1143.33+7.1956.04+3.3861.263.85 2 37.91+2.8847.692.5431.285.0341.083.81 46.742.5230.79+6.58 3 41.56+2.6633.851.6010.590.9340.19+1.3333.44+1..0310.081.05 4 37.81+2.0631.37+2.02-0.621.4538.331.53 28.84+2.73-0.762.32 5 38.473.0715.301.39 39.36+2.8416.541.26 6 33.953.513.261.86 34.57+1.992.72+1.94 7 33.902.06 34.632.06 8 30.971.77 32.17+2.08 9 28.361.38 28.281.32 10 20.092.32 18.671.00 11 12.342.26 10.863.00 12 3.71 a;1.81 3.612.48 13 -1.12aØ99 -2.1911.15 14 -0.61 -0.841.61 a1.86 CHANGES OF HWL TO THERMAL STIMULATION
MINUTES AFTER INTRATHECAL INJECTION
Left Right Morphine + Morphine +
Days Nociceptin Morphine Nociceptin Nocice~ Morphine Nociceptin 1 91.617.98 66.262.20 93.493.77 85.148.32 66.661.51 90.422.65 2 81.171.86 61.253.05 39.913.66 80.684.62 63.110.64 43.022.12 3 86.943.42 51.661.73 9.46+2.31 85.403.69 48.742.40 12.01+1.48 4 77.483.10 43.631.38 -2.182.07 79.152.74 42.45+1.70 -3.67+1.61 5 77.25+3.05 23.851.03 79.79+4.65 25.07+2.07 6 57.123.64 -1.302.36 56.402.84 0.511.61 7 49.641.37 54.01+1.89 8 41.543.60 42.733.58 9 33.071.35 31.532.06 10 20.081.77 17.17+1.85 11 16.782.93 17.752.57 12 6.28+2.19 6.812.77 13 -1.250.93 -1.020.84 Morphine alone on day 1 produces an HWL increase of approximately 67% using thermal stimulation (Figures 2A and 2B) and 55% using mechanical stimulation (Figures 2C and 2D). Both right and left hindpaws had similar HWLs. Both 10 mechanical and thermal HWLs gradually decrease with each successive day, such that by day 6, total tolerance to intrathecal morphine exists. Nociceptin alone on day 1 produces an HWL increase of approximately 90% using thermal stimulation (Figures 2A and 2B) and 60-70% using mechanical stimulation (Figures 2C and 2D). Both mechanical and thermal HWLs rapidly decrease with successive days, such that by day 4, complete tolerance to intrathecal nociceptin exists. -As shown in Figures 2A-2D, rotating morphine with nociceptin produces a dramatically different result. Whereas a similar decrease in HWL compared to the morphine alone group between days 1 and 2 is measured, day 3 using nociceptin instead of morphine returns the HWL back to day 1 levels. Although tolerance is indeed observed for both medications with time, the time to complete tolerance is lengthened to 13 days. Similar time courses are observed for both hindpaws and for both types of stimulation.
This example, as well as other reported studies in the literature, demonstrates that rats become completely tolerant to intrathecal morphine by day 6. By alternating equipotent doses of morphine and nociceptin intrathecally every two days (i.e., days 1 and 2 morphine, days 3 and 4 nociceptin, days 5 and 6 morphine, etc.), this example demonstrates that complete tolerance develops in 13 days, a greater than 100%
increase in the length of time to complete tolerance compared with morphine alone and a greater than 200% increase compared to nociceptin alone. Interestingly, nociceptin tolerance is extremely rapid. In the nociceptin alone group, by day 2, 50% tolerance had already developed. This dramatic decrease in HWL is not seen on the second day of dosing nociceptin in the rotational analgesia group, (e.g., day 3 to day 4). Although not wishing to be bound by any pa~.-ticular theory, this decrease in nociceptin tolerance after treatment with morphine may be due to the upregulation of nociceptin receptors (ORL-1 receptors) in the dorsal horn of the spinal cord following intrathecal morphine treatment (Gouarderes C et al., "Nociceptin receptors in the rat spinal cord during morphine tolerance," Brain Res 838:85-94 (1999)). Because of the rapid development of tolerance, ORL-1 agonists may not be clinically useful as single agents intrathecally;
however, by rotating a ~,-opioid receptor agonist in accordance with the present invention, the development of ORL-1 agonist tolerance can be significantly lengthened.
Although ~.-opioid receptor agonists, such as morphine, are currently used as single agents intrathecally, the issues of tolerance and dose escalation are problematic clinically as mentioned earlier.
COMBINATION THERAPY
Hindpaw withdrawal latency (HWL) tests using the materials and methods of Example 1 for both thermal and mechanical stimulation were conducted on a group of eight rats that were treated by intrathecal injections of half doses of morphine (4 ~,g) and nociceptin (5 nmol) every 12 hours. The results are shown in the following Table 3 and in FIGURES 3A-3D.
CHANGES OF HWL
Thermal Stimulation Mechanical Stimulation D~a Left Right Left Ri~ht 1 43.3111.50 45.5310.33 35.177.78 51.3120.07 2 41.289.90 43.0214.04 33.1211.45 25.6817.32 3 38.5310.09 50.7814.80 35.9010.13 39.6516.61 4 30.324.71 25.966.96 11.686.88 17.958.54 21.632.40 12.596.18 3.525.26 12.558.98 6 6.408.23 9.786.65 11.1911.37 10.363.75 7 7.146.54 7.5215.23 6.167.97 3.666.27 Interestingly, by combining half doses of intrathecal (IT) morphine and IT
5 nociceptin, less total analgesia is obtained than with full doses of each drug administered individually. An average HWL increase of 40% is seen using thermal stimulation and an average 40% HWL increase is also seen with mechanical stimulation using the combination of IT drugs. Combining the two drugs does not appear to prolong tolerance development. Therefore, rotational administration is advantageous when compared to combinational administration.
Example 3 Human Stud A test panel of five adult male humans suffering from high levels of chronic pain is treated by intrathecally administering 3 mg/day of morphine for a period of 7 days. On days 8 through 14, administration of the morphine is stopped and instead the panel is treated by intrathecal administration of 30 ~.g/day of nociceptin. On days 15 through 196, the treatment regimen of days 1 through 14 is repeated, rotating between intrathecal administration of morphine and nociceptin. Throughout the 196-day treatment regimen, a substantial reduction is obtained in the levels of experienced pain without significant ~ tolerance development to either the morphine or nociceptin drugs.
Thermal Stimulation Mechanical Stimulation D~a Left Right Left Ri~ht 1 43.3111.50 45.5310.33 35.177.78 51.3120.07 2 41.289.90 43.0214.04 33.1211.45 25.6817.32 3 38.5310.09 50.7814.80 35.9010.13 39.6516.61 4 30.324.71 25.966.96 11.686.88 17.958.54 21.632.40 12.596.18 3.525.26 12.558.98 6 6.408.23 9.786.65 11.1911.37 10.363.75 7 7.146.54 7.5215.23 6.167.97 3.666.27 Interestingly, by combining half doses of intrathecal (IT) morphine and IT
5 nociceptin, less total analgesia is obtained than with full doses of each drug administered individually. An average HWL increase of 40% is seen using thermal stimulation and an average 40% HWL increase is also seen with mechanical stimulation using the combination of IT drugs. Combining the two drugs does not appear to prolong tolerance development. Therefore, rotational administration is advantageous when compared to combinational administration.
Example 3 Human Stud A test panel of five adult male humans suffering from high levels of chronic pain is treated by intrathecally administering 3 mg/day of morphine for a period of 7 days. On days 8 through 14, administration of the morphine is stopped and instead the panel is treated by intrathecal administration of 30 ~.g/day of nociceptin. On days 15 through 196, the treatment regimen of days 1 through 14 is repeated, rotating between intrathecal administration of morphine and nociceptin. Throughout the 196-day treatment regimen, a substantial reduction is obtained in the levels of experienced pain without significant ~ tolerance development to either the morphine or nociceptin drugs.
In summary, rapid tolerance occurs to intrathecal morphine and very rapid tolerance occurs to intrathecal nociceptin. By rotating the intrathecal dosing of these agents in accordance with the present invention, the length of time to tolerance development is dramatically increased compared to each drug alone.
While the preferred embodiment of the invention has been illustrated and described, it will be appreciated that various changes can be made therein without departing from the spirit and scope of the invention.
While the preferred embodiment of the invention has been illustrated and described, it will be appreciated that various changes can be made therein without departing from the spirit and scope of the invention.
Claims (28)
1. ~A method of producing analgesia in a mammal comprising alternating intrathecal administration to the mammal of a pharmaceutically effective dose of at least one opioid receptor agonist for a first period of time, and intrathecal administration to the mammal of a pharmaceutically effective dose of at least one opioid receptor-like receptor 1 agonist for a second period of time, wherein the first and second time periods are selected to delay the development of tolerance in the mammal to the at least one opioid receptor agonist and the at least one opioid receptor-like receptor 1 agonist.
2. ~The method of Claim 1 wherein the second period of time serially follows the first period of time.
3. ~The method of Claim 1 wherein the administrations of the first and second periods of time are repeated for a plurality of treatment periods.
4. ~The method of Claim 1 wherein the first period of time is a period of from 1 to 30 days.~
5. ~The method of Claim 1 wherein the second period of time is a period of from 1 to 30 days.
6. ~The method of Claim 1, wherein the at least one opioid receptor agonist comprises a µ-opioid receptor agonist.
7. ~The method of Claim 6 wherein the µ.-opioid receptor agonist is selected from the group consisting of morphine, fentanyl, sufentanil and Try-D-Ala-Gly-[N-MePhe]-NH(CH2)-OH.
8. ~The method of Claim 7 wherein the µ-opioid receptor agonist is morphine.
9. ~The method of Claim 8 wherein the opioid receptor-like receptor 1 agonist is nociceptin.
10. The method of Claim 8 wherein the opioid receptor-like receptor 1 agonist is RO 64-6198.
11. The method of Claim 1 wherein the opioid receptor-like receptor 1 agonist is nociceptin.
12. The method of Claim 1 wherein the opioid receptor-like receptor 1 agonist is RO 64-6198.
13. A method of producing analgesia in a mammal comprising alternating intrathecal administration to the mammal of a pharmaceutically effective dose of a first analgesic drug for a first period of time, and intrathecal administration to the mammal of a pharmaceutically effective dose of a second analgesic drug for a second period of time, wherein the first analgesic drug and the second analgesic drug exhibit minimal cross-tolerance, effects of the first and second analgesic drugs on pain pathways in the spinal cord of the mammal are sufficiently similar such that the mammal does not go through withdrawal from one of the analgesic drugs during administration of the other of the analgesic drugs, and the first and second time periods are selected to delay the development of tolerance in the mammal to the first and second analgesic drugs.
14. A method of producing analgesia in a mammal comprising alternating intrathecal administration to the mammal of a pharmaceutically effective dose of at least one opioid receptor agonist for a first period of time insufficient to result in tolerance in the mammal to the at least one opioid receptor agonist, and intrathecal administration to the mammal of a pharmaceutically effective dose of at least one opioid receptor-like receptor 1 agonist for a second period of time insufficient to result in tolerance in the mammal to the at least one opioid receptor-like receptor 1 agonist.
15. A method of producing analgesia in a mammal comprising alternating intrathecal administration to the mammal of a pharmaceutically effective dose of a first analgesic drug for a first period of time insufficient to result in tolerance in the mammal to the first analgesic drug, and intrathecal administration to the mammal of a pharmaceutically effective dose of a second analgesic drug for a second period of time insufficient to result in tolerance in the mammal to the second analgesic drug, wherein the first analgesic drug and the second analgesic drug exhibit minimal cross-tolerance and effects of the first and second analgesic drugs on pain pathways in the spinal cord of the mammal are sufficiently similar such that the mammal does not go through withdrawal from one of the analgesic drugs during administration of the other of the analgesic drug.
16. ~An implantable infusion pump, comprising:
(a) a first fluid reservoir for containing an opioid receptor agonist;
a first regulator assembly adjustable to a plurality of flow rate settings for regulating the flow of fluid from the first fluid reservoir;
(b) a second fluid reservoir for containing an opioid receptor-like receptor 1 agonist;
(c) a second regulator assembly adjustable to a plurality of flow rate settings for regulating the flow of fluid from the second fluid reservoir; and (d) electromechanical control means for changing the first and second regulator assemblies from a first flow rate setting to a second flow rate setting in response to control signals, wherein the flow rate setting regulating the flow from the first fluid reservoir is set to zero when there is positive flow from the second fluid reservoir, and the flow rate setting regulating the flow from the second fluid reservoir is set to zero when there is positive flow from the first fluid reservoir, and wherein the electromechanical control means changes the flow rate settings from the first and second fluid reservoirs to zero in an alternating manner.
(a) a first fluid reservoir for containing an opioid receptor agonist;
a first regulator assembly adjustable to a plurality of flow rate settings for regulating the flow of fluid from the first fluid reservoir;
(b) a second fluid reservoir for containing an opioid receptor-like receptor 1 agonist;
(c) a second regulator assembly adjustable to a plurality of flow rate settings for regulating the flow of fluid from the second fluid reservoir; and (d) electromechanical control means for changing the first and second regulator assemblies from a first flow rate setting to a second flow rate setting in response to control signals, wherein the flow rate setting regulating the flow from the first fluid reservoir is set to zero when there is positive flow from the second fluid reservoir, and the flow rate setting regulating the flow from the second fluid reservoir is set to zero when there is positive flow from the first fluid reservoir, and wherein the electromechanical control means changes the flow rate settings from the first and second fluid reservoirs to zero in an alternating manner.
17. An implantable infusion pump, comprising:
(a) a first fluid reservoir for containing a first analgesic drug;
(b) a first regulator assembly adjustable to a plurality of flow rate settings for regulating the flow of fluid from the first fluid reservoir;
(c) a second fluid reservoir for containing a second analgesic drug;
(d) a second regulator assembly adjustable to a plurality of flow rate settings for regulating the flow of fluid from the second fluid reservoir; and (e) electromechanical control means for changing the first and second regulator assemblies from a first flow rate setting to a second flow rate setting in response to control signals, wherein the flow rate setting regulating the flow from the first fluid reservoir is set to zero when there is positive flow from the second fluid reservoir, and the flow rate setting regulating the flow from the second fluid reservoir is set to zero when there is positive flow from the first fluid reservoir, and wherein the electromechanical control means changes the flow rate settings from the first and second fluid reservoirs to zero in an alternating manner.
(a) a first fluid reservoir for containing a first analgesic drug;
(b) a first regulator assembly adjustable to a plurality of flow rate settings for regulating the flow of fluid from the first fluid reservoir;
(c) a second fluid reservoir for containing a second analgesic drug;
(d) a second regulator assembly adjustable to a plurality of flow rate settings for regulating the flow of fluid from the second fluid reservoir; and (e) electromechanical control means for changing the first and second regulator assemblies from a first flow rate setting to a second flow rate setting in response to control signals, wherein the flow rate setting regulating the flow from the first fluid reservoir is set to zero when there is positive flow from the second fluid reservoir, and the flow rate setting regulating the flow from the second fluid reservoir is set to zero when there is positive flow from the first fluid reservoir, and wherein the electromechanical control means changes the flow rate settings from the first and second fluid reservoirs to zero in an alternating manner.
18. An implantable infusion pump, comprising:
(a) a first fluid reservoir for containing a first analgesic drug;
(b) a second fluid reservoir for containing a second analgesic drug;
(c) at least one fluid outlet;
(d) at least one regulator assembly fluidly connected to the first and second fluid reservoirs and the at least one fluid outlet, and adjustable between a first configuration to permit flow of the first analgesic drug from the first fluid reservoir to the outlet while blocking flow of the second analgesic drug from the second fluid reservoir to the outlet, and a second configuration to permit flow of the second analgesic drug from the second fluid reservoir to the outlet while blocking flow of the first analgesic drug from the first fluid reservoir to the outlet; and (e) a controller operable to control the at least one regulator assembly for selective adjustment of the regulator assembly between the first and second configurations.
(a) a first fluid reservoir for containing a first analgesic drug;
(b) a second fluid reservoir for containing a second analgesic drug;
(c) at least one fluid outlet;
(d) at least one regulator assembly fluidly connected to the first and second fluid reservoirs and the at least one fluid outlet, and adjustable between a first configuration to permit flow of the first analgesic drug from the first fluid reservoir to the outlet while blocking flow of the second analgesic drug from the second fluid reservoir to the outlet, and a second configuration to permit flow of the second analgesic drug from the second fluid reservoir to the outlet while blocking flow of the first analgesic drug from the first fluid reservoir to the outlet; and (e) a controller operable to control the at least one regulator assembly for selective adjustment of the regulator assembly between the first and second configurations.
19. The pump of Claim 18 wherein the at least one regulator assembly comprises first and second regulators.
20. The pump of Claim 18 wherein the controller is operable to configure the at least one regulator assembly to alternately remain in the first configuration for a first period of time and the second configuration for a second period of time.
21. The pump of Claim 18 wherein the controller is operable such that the first and second period of times are determinable to delay the development of tolerance to the first and second analgesic drugs when the pump is implanted in a patient in need thereof for intrathecal administration of the first and second analgesic drugs.
22. The pump of Claim 18 wherein the controller is operable to automatically adjust the at least one regulator assembly between the first and second configurations.
23. ~A method of producing analgesia in a mammal comprising alternating intrathecal administration to the mammal of a pharmaceutically effective dose of at least one µ-opioid receptor agonist for a first period of time, and intrathecal administration to the mammal of a pharmaceutically effective dose of at least one opioid receptor-like receptor 1 agonist for a second period of time, wherein the first and second time periods are selected to delay the development of tolerance in the mammal to the at least one µ-opioid receptor agonist and the at least one opioid receptor-like receptor 1 agonist.
24. ~A method of producing analgesia in a mammal comprising alternating intrathecal administration to the mammal of a pharmaceutically effective dose of at least one µ-opioid receptor agonist, selected from the group consisting of morphine, hydromorphone, fentanyl, sufentanil, methadone, meperidine and DAMGO, for a first period of time, and intrathecal administration to the mammal of a pharmaceutically effective dose of at least one opioid receptor-like receptor 1 agonist for a second period of time, wherein the first and second time periods are selected to delay the development of tolerance in the mammal to the at least one µ-opioid receptor agonist and the at least one opioid receptor-like receptor 1 agonist.
25. ~A method of producing analgesia in a mammal comprising alternating intrathecal administration to the mammal of a pharmaceutically effective dose of at least one µ-opioid receptor agonist, selected from the group consisting of morphine, hydromorphone, fentanyl, sufentanil, methadone, meperidine and DAMGO, for a first period of time, and intrathecal administration to the mammal of a pharmaceutically effective dose of at least one opioid receptor-like receptor 1 agonist, selected from the group consisting of nociceptin, Phepsi; RO 64-6198, and 1-phenyl-1,3,8-triaza-spiro[4.5]decan-4-ones, for a second period of time, wherein the at least one opioid receptor-like receptor 1 agonist and the first and second time periods are selected to delay the development of tolerance in the mammal to the at least one µopioid receptor agonist and the at least one opioid receptor-like receptor 1 agonist.
26. ~A method of producing analgesia in a mammal comprising alternating intrathecal administration to the mammal of a pharmaceutically effective dose of at least one µ-opioid receptor agonist, .delta.-opioid receptor agonist, or x-opioid receptor agonist for a first period of time, and intrathecal administration to the mammal of a pharmaceutically effective dose of at least one opioid receptor-like receptor 1 agonist for a second period of time, wherein the first and second time periods are selected to delay the development of tolerance in the mammal to the at least one opioid receptor agonist and the at least one opioid receptor-like receptor 1 agonist.
27. ~A method of producing analgesia in a mammal comprising alternating intrathecal administration to the mammal of a pharmaceutically effective dose of at least one µ-opioid receptor agonist, selected from the group consisting of morphine, hydromorphone, fentanyl, sufentanil, methadone, meperidine and DAMGO, one .delta.-opioid receptor agonist, selected from the group consisting of deltorphin and DPDPE, or the .KAPPA.
opioid receptor agonist U-50,488H for a first period of time, acid intrathecal administration to the mammal of a pharmaceutically effective dose of at least one opioid receptor-like receptor 1 agonist for a second period of time, wherein the first and second time periods are selected to delay the development of tolerance in the mammal to the at least one opioid receptor agonist and the at least one opioid receptor-like receptor 1 agonist.
opioid receptor agonist U-50,488H for a first period of time, acid intrathecal administration to the mammal of a pharmaceutically effective dose of at least one opioid receptor-like receptor 1 agonist for a second period of time, wherein the first and second time periods are selected to delay the development of tolerance in the mammal to the at least one opioid receptor agonist and the at least one opioid receptor-like receptor 1 agonist.
28. ~A method of producing analgesia in a mammal comprising alternating intrathecal administration to the mammal of a pharmaceutically effective dose of at least one µ-opioid receptor agonist, selected from the group consisting of morphine, hydromorphone, fentanyl, sufentanil, methadone, meperidine and DAMGO, one .delta.-opioid receptor agonist, selected from the group consisting of deltorphin and DPDPE, or a .KAPPA.-opioid receptor agonist U-50,488H, for a first period of time, and intrathecal administration to the mammal of a pharmaceutically effective dose of at least one opioid receptor-like receptor 1 agonist, selected from the group consisting of nociceptin, Phepsi;
RO 64-6198, and 1 phenyl-1,3,8-triaza-spiro[4.5]decan-4-ones, for a second period of time, wherein the at least one opioid receptor-like receptor 1 agonist and the first and second time periods are selected to delay the development of tolerance in the mammal to the at least one opioid receptor agonist and the at least one opioid receptor-like receptor 1 agonist.
RO 64-6198, and 1 phenyl-1,3,8-triaza-spiro[4.5]decan-4-ones, for a second period of time, wherein the at least one opioid receptor-like receptor 1 agonist and the first and second time periods are selected to delay the development of tolerance in the mammal to the at least one opioid receptor agonist and the at least one opioid receptor-like receptor 1 agonist.
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| US30279601P | 2001-07-02 | 2001-07-02 | |
| US60/302,796 | 2001-07-02 | ||
| PCT/US2002/006721 WO2003004034A1 (en) | 2001-07-02 | 2002-02-28 | Method for inducing analgesia comprising administration alternatively of an opioid receptor agonist and an opioid receptor like receptor 1 agonist for and an implantable infusion pump |
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| CA2490386A1 true CA2490386A1 (en) | 2003-01-16 |
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| EP (1) | EP1406629A1 (en) |
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| US20040077996A1 (en) * | 2002-10-22 | 2004-04-22 | Jasperson Keith E. | Drug infusion system with multiple medications |
| US6902544B2 (en) | 2003-01-22 | 2005-06-07 | Codman & Shurtleff, Inc. | Troubleshooting accelerator system for implantable drug delivery pumps |
| US20050038415A1 (en) * | 2003-08-06 | 2005-02-17 | Rohr William L. | Method and apparatus for the treatment of obesity |
| US7763626B2 (en) * | 2004-06-18 | 2010-07-27 | Trustees Of Dartmouth College | Compositions and method for enhancing the therapeutic activity of opiods in treatment of pain |
| US20060039946A1 (en) * | 2004-08-20 | 2006-02-23 | Medtronic Inc. | Drug eluting medical device |
| US20090123508A1 (en) * | 2007-10-04 | 2009-05-14 | Boston Scientific Scimed, Inc. | Implantable Drug Depot for Intrathecal Drug Delivery System for Pain Management |
| US9953138B2 (en) | 2010-06-29 | 2018-04-24 | Codman Neuro Sciences Sarl | Drug component admixture library for a drug infusion delivery system |
| US9456916B2 (en) | 2013-03-12 | 2016-10-04 | Medibotics Llc | Device for selectively reducing absorption of unhealthy food |
| US9067070B2 (en) | 2013-03-12 | 2015-06-30 | Medibotics Llc | Dysgeusia-inducing neurostimulation for modifying consumption of a selected nutrient type |
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| US5512578A (en) | 1992-09-21 | 1996-04-30 | Albert Einstein College Of Medicine Of Yeshiva University, A Division Of Yeshiva University | Method of simultaneously enhancing analgesic potency and attenuating dependence liability caused by exogenous and endogenous opiod agonists |
| US5752930A (en) | 1995-04-28 | 1998-05-19 | Medtronic, Inc. | Implantable techniques for infusing equal volumes of agents to spaced sites |
| US5821219A (en) | 1995-08-11 | 1998-10-13 | Oregon Health Sciences University | Opioid antagonists and methods of their use |
| US5798114A (en) | 1996-04-30 | 1998-08-25 | Medtronic Incorporated | Refillable body powered drug delivery techniques |
| US5711316A (en) | 1996-04-30 | 1998-01-27 | Medtronic, Inc. | Method of treating movement disorders by brain infusion |
| US5735814A (en) | 1996-04-30 | 1998-04-07 | Medtronic, Inc. | Techniques of treating neurodegenerative disorders by brain infusion |
| US5820589A (en) | 1996-04-30 | 1998-10-13 | Medtronic, Inc. | Implantable non-invasive rate-adjustable pump |
| US5713923A (en) | 1996-05-13 | 1998-02-03 | Medtronic, Inc. | Techniques for treating epilepsy by brain stimulation and drug infusion |
| US5782798A (en) | 1996-06-26 | 1998-07-21 | Medtronic, Inc. | Techniques for treating eating disorders by brain stimulation and drug infusion |
| CA2226058C (en) | 1997-01-30 | 2008-01-29 | F. Hoffmann-La Roche Ag | 8-substituted-1,3,8-triaza-spiro[4.5]decan-4-one derivatives |
| US5975085A (en) | 1997-05-01 | 1999-11-02 | Medtronic, Inc. | Method of treating schizophrenia by brain stimulation and drug infusion |
| DK1041987T3 (en) | 1997-12-22 | 2006-08-21 | Euro Celtique Sa | Oral pharmaceutical dosage form comprising a combination of an opioid agonist and naltrexone |
| US6283944B1 (en) | 1998-04-30 | 2001-09-04 | Medtronic, Inc. | Infusion systems with patient-controlled dosage features |
| EP0963987B1 (en) | 1998-06-12 | 2002-08-28 | F. Hoffmann-La Roche Ag | Spiro(piperidine-4,1'-pyrrolo(3,4-c)pyrrole) |
| DK0970957T3 (en) | 1998-06-12 | 2001-12-03 | Hoffmann La Roche | Diazaspiro [3.5] nonane derivatives |
| US6262066B1 (en) | 1998-07-27 | 2001-07-17 | Schering Corporation | High affinity ligands for nociceptin receptor ORL-1 |
| MA26659A1 (en) | 1998-08-06 | 2004-12-20 | Pfizer | NOVEL BENZIMIDAZOLE DERIVATIVES, PHARMACEUTICAL COMPOSITIONS CONTAINING THEM AND PROCESS FOR THEIR PREPARATION. |
| US6348050B1 (en) * | 1999-04-30 | 2002-02-19 | Medtronic, Inc. | Infusion systems for creating microenvironments in a living body |
| WO2000066204A1 (en) * | 1999-04-30 | 2000-11-09 | University Of Southern California | Implantable microbolus infusion pump |
| US6340681B1 (en) | 1999-07-16 | 2002-01-22 | Pfizer Inc | 2-benzimidazolylamine compounds as ORL-1-receptor agonists |
| WO2001093852A2 (en) | 2000-06-09 | 2001-12-13 | The Regents Of The University Of California | Method of treating pain using nalbuphine and opioid antagonists |
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| US20030040486A1 (en) | 2003-02-27 |
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| US20030032651A1 (en) | 2003-02-13 |
| JP2005502619A (en) | 2005-01-27 |
| WO2003004034A1 (en) | 2003-01-16 |
| JP2009102396A (en) | 2009-05-14 |
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