KR20060079183A - Use of Human Growth Hormone in Multiple Cranial Nervous System Atrophy - Google Patents

Abstract

The invention relates to the use of a substance, which binds to and initiates signaling of the human growth hormone (hGH) receptor or a substance, which stimulates release or potentiates the activity of endogenous hGH, for treatment and/or prevention of Parkinsonism-Plus Syndromes. In particular, the invention relates to the use of hGH for the treatment and/or prevention of Multiple System Atrophy.

Description

Use of human growth hormone in multiple system atrophy

The present invention belongs to the field of neurologic diseases. More specifically, the present invention relates to the use of human growth hormone for the manufacture of a medicament for the treatment and / or protection of Parkinsonism-Plus Syndrome, in particular Multiple System Atrophy (MSA). It is about a use.

Human growth hormone (hGH), also known as somatropin (INN) or somatotropin, is a protein produced and secreted by the somatotropic cells of the anterior pituitary It is a hormone. Human growth hormone affects the metabolism of proteins, carbohydrates and fats, and plays an important role in childhood somatic growth and adult metabolism.

Human growth hormone is one between Cys-53 and Cys-165, which forms a large loop in the molecule, and the other, ie two disulfide bonds between Cys-182 and Cys-189, which form a small loop near the C-terminal. Is a single polypeptide chain of 191 amino acids. (Bewly et al, 1972) The DNA sequence identifying the amino acid sequence has been reported by Marshall et al. (1979). Purified hGH is a lyophilized white porous powder. It is easily soluble in aqueous buffers at pH 6.5-8.5 (concentration> 10 mg / L).

In solution, hGH is present primarily as a monomer and in small fractions as dimers and high molecular weight oligomers. Under certain conditions, hGH can be induced to form higher amounts of dimers, trimers and higher oligomers.

Several derivatives of hGH are known, naturally occurring derivatives, variants and metabolic products, primary degradation products of biosynthetic hGH and engineered derivatives of hGH produced by genetic methods It includes. One derivative of naturally occurring hGH is GH-V, which is a variant of growth hormone found in the placenta. Other members of the locus have been described by Chen et al. (1989).

Methionyl hGH was the first form of hGH produced by recombinant DNA technology. This compound is actually a derivative of hGH with one methionine residue in addition to the N-terminus.

Naturally occurring variants of hGH, called 20-K-hGH, have been reported to occur in the bloodstream as well as in the pituitary gland (Lewis et al, 1978; Lewis et al. 1980]. This compound lacks 15 amino acid residues of Glu-32 to Gln-46, resulting from alternating splicing of messenger ribonucleic acid (DeNoto et al. 1981). This compound shares many of the biological properties of hGH but not all of it.

20-K-hGH is produced by the pituitary gland and secreted into the blood. This makes up about 5% of adult growth hormone and about 20% of young growth hormone. It has been reported to have growth promoting activity such as 22 kD growth hormone and to have the same or greater amount of lipolytic activity as the 22 kD form. It binds to a growth hormone receptor with the same affinity as the 22 kD growth hormone and has lacticogenic bioactivity (prolactins) of 1/10 of the 22 kD hormone. Unlike 22kD, the 20-k-hGH has weak anti-insulin activity.

Many hGH derivatives arise from proteolytic modifications of the molecule. The primary route for metabolism of hGH is involved in protein degradation. The hGH region near residues 130-150 is very sensitive to proteolysis, in which several derivatives of hGH with nicks and deletions have been described (Thorlacius-Ussing, 1987). This region is in a large loop of hGH, where the breakdown of peptide bonds results in two chains that are linked via disulfide bonds in Cys-53 and Cys-165. Many such two chain forms have been reported to increase biological activity (Singh et al, 1974). Many derivatives of human growth hormone have been artificially made using enzymes. The enzymes trypsin and subtilisin as well as others have been used to modify hGH at various points throughout the molecule [Ruis et al., 1977; Graph et al. 1982. One such derivative, the so-called 2-chain anabolic protein (2-CAP), was formed through controlled proteolysis of hGH using trypsin (Becker et al, 1989). 2-CAP was found to have distinctly different biological properties from those of the intact hGH molecule in that the growth-stimulating activity of hGH was widely retained and most of the effects of carbohydrate metabolism were lost.

Asparagine and glutamine residues of proteins are susceptible to deamidation under appropriate conditions. Pituitary hGH is responsible for this type of reaction, resulting in the conversion of Asn-152 to aspartic acid and less often Gln-137 to glutamic acid (Lewis et al, 1981). Deaminated hGH appears to have a modified sensitivity to proteolysis with the enzyme subtilisin, suggesting that deamination may have a physiological importance in driving proteolytic cleavage of hGH. Biosynthesized hGH is known to disintegrate under certain storage conditions, resulting in deamination in other asparagine (Asn-149). It is also the primary site of deamination or deamination at Asn-152 (Becker et al, 1988). Deamination of Gln-137 has not been reported in biosynthesized hGH.

Methionine residues in proteins are sensitive to oxidation and are primarily sensitive to sulfoxides. Both pituitary induction and biosynthetic hGH undergo sulfoxidation in Met-14 and Met-125 (Becker et al, 1988). Oxidation in Met-170 has also been reported in pituitary hGH but not in biosynthetic hGH. Both desamide hGH and Met-14 sulfoxide hGH were found to exhibit complete biological activity (Becker et al, 1988).

Truncated forms of hGH have been produced through the activity of enzymes or by genetic methods. 2-CAP produced by the regulatory activity of trypsin has the first eight residues at the N-terminus of the hGH removed. Other incomplete forms of hGH have been produced by genetic modification before expression in a suitable host. The first 13 residues have been removed to prepare derivatives with extraordinary biological properties that do not degrade the polypeptide chain (Gertler et al, 1986).

Although human growth hormone was generally obtained from the pituitary gland of carcasses, these preparations are not electrophoretically homogeneous, and antibodies appeared in the serum of patients treated with 50% purity preparations, which were immunogenic. (immunogenicity) is due to inert ingredients. Recombinant DNA technology has made it possible to manufacture and supply hGH without limitation in many different systems. The presence of small amounts of contaminating proteins facilitates the purification of hGH from the culture medium. In fact, it has been shown that hGH can be purified to laboratory level in one purification step on a reversed phase HPLC column (Hsiung et al, 1989).

Recombinant human growth hormone, rhGH, was manufactured by Sereno International SA with SEROSTIM ^® , which is FDA approved to treat weight loss and wasting in AIDS patients. Is accelerating. SAIZEN ^® is a recombinant human growth hormone for the treatment of GH deficiency in young children, turner syndrome in girls and chronic renal failure in children. Genetech, Inc., South San Francisco, CA ProTROPIN ^® , produced by SMC, is slightly different in structure from the natural sequence hGH and has an additional methionine residue at the N-terminus. Recombinant hGH is generally sold in lyophilized form vials containing additional excipients such as glycine and mannitol in addition to hGH. A diluent containing vial is prepared to allow the patient to reconstruct the product to the desired concentration prior to drug administration. Recombinant hGH can also be sold by other well known methods, ie prefilled syringes and the like.

In general, no significant differences were observed in the biological activity or pharmacokinetics of recombinant natural sequence hGH, recombinant N-methionyl-hGH, or human pituitary derived materials (Moore et al, 1988; Jorgensson et al, 1988). ).

In the course of development, endogenous growth hormones promote numerous key events and in fact function and act on all tissues of the body directly or indirectly. Therefore, abundant growth hormone receptors in the mature central nervous system (CNS) may provide new therapeutic strategies. In addition, GH plays an important metabolic role in many species for a long time after major kidney growth occurs. It has long been thought that GH activity is regulated globally through the production of hepatic insulin-like growth factor-1 (IGF-1), but now GH is not only circulating IGF-1 but also It has been evident that by acting in conjunction with locally produced IGF-1 (and possibly many other growth factors), it also has a direct effect on many tissues.

Growth hormones are mainly synthesized in the pituitary gland but are produced in a wide variety of other places in the brain (Johansson et al., 2000). In addition, growth hormone receptors, IGF-1 and IGF-1 receptors frequently occur. The CSF levels of GH, GH-dependent factors and neurotransmitters also change during growth hormone treatment in the CNS. This may indicate that the neuro-endocrine mechanism is associated with physiological as well as physical improvement that can be observed during growth hormone treatment in growth hormone deficient adults.

Early experimental findings have shown that GH increases brain plasticity. For example, studies with radiolabeled GH suggested the presence of specific binding sites in the CNS, but they were studied in a wider distribution but were mainly identified in the hypothalamic region and choroid plexus and had a low excess. Low-abundance (Harvey et al., 1993). The physiological effects of GH in the CNS prohibit its own release as part of the autofeedback circuit (Tannenbaum, 1980).

Patients with growth hormone deficiency (GHD) have serious perceived health problems. As a group, these patients are less energetic, less physically mobile and more socially isolated (Johannsson et al., 2000). In addition, they sleep poorly and exhibit subnormal memory performance. The complains of these patients were mainly fatigue, decreased and lack of initiative, lack of concentration, memory impairment and irritability.

During GH treatment, energy and mood improved as well as memory. Since the energy, mood and memory were observed at similar levels as in the healthy group, the observed changes indicated normalization.

GH deficiency, and especially GH treatment, is associated with a number of changes in major central neurotransmitters, their biosynthetic enzymes, or their receptors (Andersson et al., 1983), but of endogenous GH acting directly on these systems. The physiological role is not yet confirmed. Most often overlooked, GH has a number of neurotrophic actions (stimulating neuronal and glial proliferation, increasing mylelination and increasing brain size). In contrast, GH deficiency is associated with deficiency in brain development (Elias Eriksson, 1985).

In a month of double-blind placebo control studies, GH treatment in patients with GH deficiency previously showed an average 10-fold increase in GH in CSF. In addition, the average increase in IGF-1 concentration in CSF is about 50%, the CSF dopamine metabolite homovanillic acid concentration (Harvey et al., 1993) is reduced and the CSF β-endorphin immune response ( -endorphin immunoreactivity increased during GH treatment. Decreased CSF HVA concentrations affect GH's dopamine turnover in the CNS, which is in line with previous animal studies and studies by Berman et al. (1995). These neuro-endocrine changes may be related to the physiological improvement of GH deficiency adult patients during GH treatment.

Parkinsonism-Plus syndrome, the so-called Parkinsonian-Plus or simple Parkinson-Plus syndrome, forms a disease group, which is clearly distinguished from traditional Parkinson's disease: Progressive Supranuclear Palsy: PSP ), Multiple System Atrophy (MSA), Parkinson's-amyotrophic lateral sclerosis-dementia, Generalized Lewy body disease, Corticobasal degeneration in Parkinson's disease, Guam ganglionic degeneration (CGD), Alzheimer's / Parkinson's overlap syndrome, Huntington's disease: rigid variants, Hallervorden-Spatz disease, Gerstmann- Gerstmann-Strausler syndrome.

For advanced PSP, the onset of symptoms usually develops between 55 and 70 years of age, and inventions before age 50 are rare. Since the initial description of the disease several different sets of clinical criteria have been proposed. The two most characteristic signs underlying clinical diagnosis are supranuclear gaze palsy, and early falling postural instability, including the inability to look towards the tacical stimulus. instability). Due to levodopa therapy, alien hand syndrome, hallucinosis, cortical dementia, cerebellar symptom and early dysautonomic symptom Exclusion criteria, such as fully sustained effects, were established with the criteria proposed in 1996 by Litvan et al. Characteristic microscopic pathology is globus pallidus, substancia nigra, superior colliculus, periaqueductal grey, pretectal area, brain stem and brainstem. Neurofibrillary tangles, neuropil threads and neuropil loss in medulla have been reported.

Pathogenesis of PSP may be associated with abnormal metabolism of neuroskeletal components (neurofilament) due to retention of tau protein in nerve and glial cells. PSP is thought to be a sporadic disorder, but may also be a genetic cause, such as genetic modifications associated with the tau gene. Early signs are bilateral bradykinesia with axial stiffness that may not be present in the limbs. The process of these diseases is always ongoing and less variable than in Parkinson's and MSA. Men are more susceptible to this disease and tend to have a poor prognosis, while women and patients with early onset of the disease may have a somewhat better prognosis. After several years of disease, clinical photography is sometimes more clear evidence. Eye movements, primarily horizontal movements, slow down later vertical movements. Patients focus on the clinician's eye, have difficulty keeping their eyes together, and keep an eye on the involuntary persistence of ocular fixation. After onset, ophthalmoparesis is typically found in PSP due to paralysis of down gaze and square wave jerk. The gait becomes odd when the arms are opened and rotated, with radial and straight body postures. Typical "surprise" signs appear on the face and patients sometimes deny serious problems due to frontal lobe dysfunction. Severe postural instability occurs most prominently during the course of the disease and is a dominant problem. Falling can result in multiple trauma of the arms and legs, even fatal trauma.

Corticobasal degeneration (CBD) was first reported in 1968 and many people consider it the most difficult diagnosis to diagnose early disease. CBD is rare and there is no reliable universal data available. The average age of clinical onset is 60 to 65 years. Clinical photographs related to Parkinson's disease sometimes vary gradually over time. The pathology distinguishes it from Parkinson's disease in the presence of large swollen achromatic neurons as the main finding. Atrophy of both the cortical and basal structure, ie basal ganglia, substantia nigra and the basal structure of the brain stem is found. The onset of symptoms usually begins in one of the upper limbs. The lower limbs of the ipsilateral side are affected before the opposite side is involved. Findings are divided into three criteria: 1) cortex, 2) basal ganglia, or 3) symptoms that affect association with other structures. Dystonia often appears. When there is a single action tremor, the picture can be confused with the necessary tremor. Over time, tremors become myoclonic. Apraxia can sometimes be an early indication of clues to diagnosis, but vascular lesions can also show similar pictures. After several years, the characteristic "alien limb" phenomenon appears. Cortical sensory loss is a late feature, useful for distinguishing symptoms from Parkinson's disease. Other symptoms such as nucleus palsy, dysarthria, dysphagia, and pyramidal symptom are late symptoms of the disease. Symptom asymmetry, however, is consistent and therefore less risk of confusion with symptoms of PSP.

Diffuse Lewy body disease (DLBD) has been shown to be the second most common cause of degenerative dementia in middle age and beyond after Alzheimer's disease (AD). However, the clinical distinction between these diseases is difficult. In the case of DLBD, at the beginning of the disease, psychological and dementia as well as gait damage, stiffness and resting tremor have been reported. In the early stages of the disease, complex visual illusions are particularly characteristic of DLBD. In addition to progressive cognitive decline, two of the following criteria are necessary for the diagnosis of probable DLBD signs and one for the possible diagnosis. 1. Changes in perception from voice and alertness to voice changes, 2. Recurrence, typically well-formed, visual illusions, and 3. Movement characteristics of Parkinson's disease. While not necessary for diagnosis, auxiliary features include repetitive falls, fainting, transient loss of consciousness, neuroleptic sensitivity, systematized delusion, and other types of hallucinations.

Multiple cranial nervous system atrophy (MSA) is a neurodegenerative disorder that results in impairment in the regulation of movement, balance, blood pressure, and sexual and urinary tract function due to degeneration in the brain region.

MSA is a clear clinical pathology presence (Gilman et al., 1998). Patients are designated MSA-P if Parkinson's disease features prevail or MSA-C when cerebellar features prevail.

MSA is typically present between 50 and 70 years of life and is slightly more incidence in men. Patients usually have primary autonomic nervous system dysfunction. Genitourinary dysfunction is the most frequent early complaint in women, while impotence is the most frequent early complaint in men. Orthostatic hypotension is common and can lead to dizziness, dimming of vision, head or neck pain, yawning, temporary confusion, slurred speech, and if hypotension is severe, You may faint as soon as you get out of bed.

MSA differs from traditional Parkinson's disease in several important ways: initial onset (5-10 years younger than Parkinson's patients), marginal response to L-dopa treatment, rapid progression, and rare survival over 7 years after diagnosis. point. The impact of injury in Parkinson's disease is mainly in one system, the nigrostriatal pathway, and in MSA the multiple nervous system is damaged. The incidence of MSA is 5-15: 100000 and may correspond to 10% of clinically idiopathic Parkinson's patients. The cause is unknown and there is no known cure.

It is hypothesized that symptoms of MSA are associated with progressive degeneration of neurons (Holmberg et al., 1998). MSA patients have been shown to raise the labeling level of neurodegenration in cerebrospinal fluid.

Multiple cranial nervous system atrophy (MSA) is perhaps the most frequent differential diagnosis of Parkinson's disease in terms of motion disease, up to 10% of all patients with Parkinson's disease (Quinn 1989). MSA has three parts: Shy-Drager syndrome, Striatonigral degeneration, and Olivepontocerebellar atrophy. As described above, multiple cerebral nervous system atrophy (MSA) is a neurodegenerative disorder in which degeneration in the brain region impairs movement, balance, blood pressure, and regulation of sexual urinary tract function.

The onset of the disease varies. The earliest cases occurred at age 40, but the average onset was 50 years in a body autopsy study (Wenning 1996). Slightly male predominance.

The term MSA includes a chronic degenerative disorder in which the symptoms of the basal ganglia, extrapyramidal symptoms, cerebellum, brain stem and autonomic nervous system are combined differently. Many different naming findings of MSA are diverse, possibly delaying the recognition of the disease. In patients with Parkinson's symptoms, the MSA-SND term was proposed, while MSA-OPCA could be used when cerebellar predominance was found (Quinn 1989). In the 1990s, this naming was further discussed. MSA-P and MSA-C are also terms proposed to describe the various representations of the respective diseases predominantly Parkinson and cerebellum. Another set of diagnostic criteria has been proposed (Quinn 1989). Although the accuracy of the clinical diagnosis of MSA has been retrospectively assessed among neurologists, a systematic assessment of these criteria has not been made so far (Litvan et al., 1997). Although the sensitivity remained low despite repeated assessments, more than 90% specificity for MSA recognition was already found in the primary clinical assessment.

Neuropathological findings include specific gliocytoplasmatic inclusion bodies, gliosis and nerve cell loss of the putamen, melanoma, basis pontis, and haolib ( inferior olives, cerebellar folia, spina cord intermediolateral column and Onuf's nucleus (Daniel, 1999). Other areas affected by the disease include locus ceruleus, dorsal vagal nucleus, pyramidal tract and anterior horn cells (Wenning, 196, Wenning, 1997, Van). der Ecken et al., 1960).

MSA is typically a sporadic disease (Bandmann et al., 1997). The course of the disease is heterogeneous, and the various names of his findings reflect this.

Autonomic dysfunction is commonly found in MSA and can manifest as presyncopal episodes, incontinence or sexual dysfunction (Wenning, 1994). Less specific indications for autonomic disorders include dizziness, myalgia, constipation and

There is fatigue. Cold dusky hands should also suspect MSA (Klein et al., 1997). The prognosis is poor when blood pressure drops with repeated syncope. More than 40% of patients will become wheelchairs within 5 years due to movement disorders.

Each prognosis can vary substantially. MSA patients with disease for more than 20 years were reported, whereas the average survival time of carcasses identified as more aggressive was reported as 6-9 years from onset (Wenning 1997, Wenning 1994).

Depression and anxiety generally appear with good response to antidepressants, both in the early and late stages of all Parkinson's-Plus syndrome.

Laboratory support for diagnostic assistance has, to date, evaluated only clinically diagnosed or postmortem-proven cases with a relatively small study population. High specificity (number of true-positively predicted diagnoses / experiments / total number of patients with the disease) and specificity [number of true-negative predicted diagnoses / experiment / total number of patients without disease] As well as the methods with OB, giving objective quantification to the data can warrant and help clinical diagnosis.

MRI findings have been commonly reported to patients with MSA, where this technique is sometimes useful for distinguishing MSA-P from Parkinson's disease and sprainulear palsy PSP. In particular, the combination of low- and high-strength hypointense putaminal signal changes in T2-loaded MRI sequences has been considered very specific for diagnosis even at low sensitivity (Schrag, 1998; Kraft et al. , 1999). These findings may be useful for distinguishing MSA-P patients with a positive levodopa response from patients with Parkinson's disease. Independent low-intensity changes in the clamshell nuclei are also common but less specific in MSA because they have also been reported in Parkinson's disease and PSP (Schrag et al., 1998). Infratentorial abnormality has also been reported; Transverse pontine fibers, pontine hyperintensity resembling a cross, and diffuse hyperintensity of the middle cerebellar peduncle appear with atrophy (Schrag et al., 1998 ). Changes under these tents can only be used to support a clinical diagnosis, since symptoms typically associated with cerebellar and brain stem related symptoms that already distinguish MSA from Parkinson's disease and PSP tend to appear earlier than these.

Clinical response to levodopa is an important feature in all sets of clinical criteria for Parkinson's disease. Some authors have used single-dose experiments (single-) with apomorphine (Hughes, 1990) or levodopa (Hughes et al., 1991; Rossi et al., 2000) as tools for differential diagnosis and prediction of long-term treatment effects. dose test).

The levodopa test using posturo-locomotion-manual recording provides further diagnostic information. This test is a complex whole-body motor task that requires the patient to walk without assistance.

Markers of neuronal degeneration and gliosis have recently been known as potential methods for the diagnosis, prognosis and evaluation of treatment (Rosengren et al., 1994; Rosengren et al., 1996). Neuronal degeneration and glial reactivity in various conditions of acute or chronic damage to the central nervous system (CNS) can be recognized by high concentrations of various brain-specific proteins in the spinal fluid (CSF) (Rosengren et al., 1999). In addition, they provide data that are essentially independent of clinical diagnostic criteria for various Parkinson's diseases.

Neuromicrofibers are the major structural elements of neurons that maintain axon calibres, neuronal size and shape. Neurofibrillary tangles were detected in CSF patients with high levels of amyotrophic lateral sclerosis and Alzheimer's disease as well as other neurodegenerative diseases, and it has been suggested that the NFL of CSF can be used as a marker of axonal cell degeneration.

GFA protein is the main astroglial protein expressed mainly in fibrillary astrocytes. CSF concentrations of GFA proteins are affected by other pathological conditions in the brain. High levels of GFA protein have been observed as a result of acute CNS injury and disruption of astrocytes (Rosengren et al., 1994). GFA protein levels have been increased in chronic brain diseases with neuroglia such as dementia, multiple sclerosis and chronic encephalopathies (Rosengren et al., 1994, Rosengren et al., 1995). Therefore, GFA proteins can be used as CSF markers for both CNS tissue disruption and astrocytosis (Rosengren et al., 1994).

Kimber et al. (1997) reported that clonidine diagnostic tests were useful for differentiating MSA patients. Repeated measurement of growth hormone (GH) was made after intravenous administration of clonidine. The MSA patient population was found to have a very low reactivity to clonidine as compared to Parkinson's disease patients, and the test indicated loss of medullary catecholaminergic neurons that transport hypothalamus neurons. It has been suggested to be an indicator of central autonomic failure. In a further study (Kimber et al., 2000), the GH concentration after clonidine injection appears to be very low in the MSA patient population when compared to the PSP patient group and the control group, to diagnose MSA from other neurodegenerative diseases. Provide a test.

The present invention is based on the finding that human growth hormone has a beneficial effect on patients suffering from Parkinson's-Plus syndrome, ie diseases belonging to multiple cerebral nervous system atrophy. Therefore, the present invention is directed to the use of a substance that stimulates or enables the release of endogenous hGH or a substance that binds to a human growth hormone (hGH) receptor and initiates a signal for the treatment and / or prevention of Parkinsonism-Plus syndrome. It is about. The material is particularly suitable for the treatment and / or prophylaxis of multiple cerebral nervous system atrophy (MSA), which is an untreated disease that is clearly distinguishable from traditional Parkinson's disease.

The present invention relates to a substance which stimulates or enables the release of endogenous hGH or a substance which binds to a human growth hormone (hGH) receptor and initiates a signal for the treatment and / or prevention of Parkinsonism-Plus syndrome, in particular MSA. A nucleic acid molecule comprising a coding sequence of

Endogenous production of Parkinson's-Plus syndrome, in particular substances that enable or release the activity of endogenous hGH or which bind to and initiate signals of human growth hormone (hGH) receptors for the treatment and / or prevention of MSA The use of vectors to increase and / or induce is also within the scope of the present invention.

The invention also initiates signaling by binding to a substance or human growth hormone (hGH) receptor that enables or stimulates the activation of endogenous hGH for the treatment and / or prevention in Parkinsonism-Plus syndrome, particularly MSA. It relates to a cell genetically modified to produce a substance.

The present invention is based on the fact that multiple cerebral nervous system atrophy (MSA) is a disease belonging to Parkinsonism-Plus syndrome and can be treated with an effective amount of human growth hormone.

Therefore, the present invention binds to a human growth hormone (hGH) receptor or a substance that enables or stimulates the activation of endogenous hGH for the manufacture of a medicament for the treatment and / or prevention of Parkinson's-Plus syndrome. It relates to the use of the disclosed material.

In a preferred embodiment of the present invention, Parkinson's-Plus syndrome is characterized by advanced hypernuclear palsy (PSP), multiple cerebral neurotrophic atrophy (MSA), amyotrophic axon sclerosis-dementia of Parkinson's disease in Guam, systemic Lewy body disease, cortical basal ganglia degeneration (CGD) , Alzheimer's / Parkinson's superposition syndrome, Huntington's disease: rigid variant, Hallerboden-Spartz syndrome, Gerstmann-Straussler syndrome.

These diseases, which can be diagnosed, differentiate each other from each other, and distinguish from other neurological diseases, are detailed in the background of the present invention.

In a particularly preferred embodiment, Parkinson's syndrome is multiple atrophy. MSA is a clear clinicopathological entity characterized by the fact that, unlike patients suffering from Parkinson's disease, MSA patients generally have a limiting response to levodopa treatment (Gilman et al., 1998). . Trials for evaluating clinical response to levodopa are detailed in the "Background of the Invention". The present invention may be in any form of MSA, including MSA-P, MSA-C and MSA-M, MSA-SND or MSA-OPCA, as detailed above in the "Background Art of the Present Invention".

As used herein, the terms "treatment" and "prevention" prevent, prohibit, soothe, partially or totally, the symptoms or diseases or complications associated with Parkinson's-Plus syndrome, as well as the cause or one or more symptoms of Parkinson's-Plus syndrome, It should be understood as improving or converting. When "treating" Parkinson's-Plus syndrome, a substance according to the invention is administered after the onset of the disease, and "prevention" relates to the administration of the substance before the indication of the disease is diagnosed or apparent in the patient.

In a preferred embodiment of the invention, the material is selected from:

a) human growth hormone;

b) a fragment of (a) having an agonistic activity on the hGH receptor;

c) a variant of (a) or (b) having anti-activity on the hGH receptor and having at least 70% sequence identity with (a) or (b);

d) (a) encoded by a DNA sequence that has anti-activity on the hGH receptor and hybridizes to the complement of the native DNA sequence encoding (a) or (b) under moderately stringent conditions Or a variant of (b);

e) salts or functional derivatives of (a), (b), (c) or (d) with counter activity on hGH receptors.

The term "human growth hormone" or "hGH" as used herein refers to 20 kD and 22 kD human growth hormone, GH-V, and human growth gene spots as detailed above in the "Background of the Invention". It is intended to include naturally occurring and synthetic derivatives, including but not limited to, other members of.

hGH may be a naturally occurring human growth hormone or recombinant hGH. Recombinant hGH can be expressed in a suitable host, either prokaryotic or eukaryotic. E. coli is the most suitable host for hGH, for example. Yeast, insect or mammalian cells are more suitable for expression of recombinant growth hormone. Preferably GH is expressed in human or animal cells, such as Chinese Hamster Ovary (CHO) cells.

The term “hGH” or “growth hormone” as used herein also includes functional derivatives, fragments, mutations, analogs, or salts that retain the biological activity of the growth hormone, ie, act as an agent for growth hormone receptors. . On the other hand, they can bind to growth hormone receptors that initiate the signaling activity of the receptor.

The term "functional derivative" or "chemical derivative" as used herein may be prepared from functional groups which occur in the side chain at the residues of the N- or C-terminal groups by means known in the art, and they are pharmaceutically To the extent acceptable to the present invention include derivatives as described herein that do not disrupt the biological activity of hGH, ie the ability to bind to hGH receptors and initiate receptor signals, and which do not impair toxic properties to compositions comprising them. Derivatives may have chemical moieties such as carbohydrate or phosphate residues, provided that such derivatives retain the biological activity of hGH and are pharmaceutically acceptable.

For example, the derivatives are formed from aliphatic esters of carboxyl groups, ammonia or amides of carboxyl groups reacted with primary or secondary amines, acyl moieties (e.g. alkanoyl or carbocyclic aroyl groups: N-acyl derivatives of amino acid residues or free amino groups, or O-acyl derivatives of free hydroxyl groups (e.g. of seryl or threonyl residues) formed with acyl moieties. Such derivatives also include, for example, polyethylene glycol side chains, which may mask antigenic sites and prolong molecular retention in body fluids.

Of particular importance is the growth hormone derived or bound by long-lasting complexing agents. Therefore, a preferred embodiment of the present invention relates to a pegylated version of human growth hormone. Growth hormones genetically engineered to exhibit long lasting activity in the body are also examples of hGH derivatives within the scope of the present invention. Acetylated hGH at the N-terminus was isolated and identified (Lewis et al., 1979). It is not clear whether acylation plays a regulatory role or is simply an artifact of the tablet. However, this molecule is expected to exhibit anti-MSA activity in a form similar to other hGH derivatives. Therefore, in a preferred embodiment, the present invention relates to human growth hormone acetylated at the N-terminus.

More preferred chemical derivatives of the present invention are deamined hGH, or sulfoxidized hGH at one or more methionine residues.

Preferably, the medicaments according to the invention are disulfide dimers, covalent irreversible non-disulfide dimers, non-covalent dimers linked via interchain disulfide bonds. -covalent dimer), and dimers of human growth hormone selected from the group consisting of:

The term "salt" herein relates to both the carboxyl group and the amino group acid addition salt of the hGH molecule or analog. The salts of the carboxyl groups can be formed by means known in the prior art and used for inorganic salts such as sodium, calcium, ammonium, iron or zinc salts and the like, for example amines such as triethanolamine, arginine or lysine, piperidine, pro Salts with organic bases formed with amines such as caine and the like. Acid addition salts include, for example, salts of mineral acids such as hydrochloric acid or sulfuric acid, and salts of organic acids such as, for example, acetic acid, oxalic acid. Of course it must possess the biological activity of the hGH in connection with the present invention, ie the ability to bind to the hGH receptor and initiate receptor signals.

In a more preferred embodiment, the invention relates to fragments of human growth hormone.

A “fragment” of growth hormone according to the invention relates to a subset of molecules, ie shorter peptides possessing the desired biological activity. Fragments can be readily prepared by removing amino acids from either end of the hGH molecule and testing the results for their properties as hGH receptor agonists. Proteases are known which remove a single amino acid from the N- or C-terminus of a polypeptide for a short time, and therefore only routine experimentation to determine fragments possessing the desired biological activity is involved.

Preferably, the hGH fragment according to the present invention will have internal deletion so long as the deletion does not affect the biological activity of hGH, ie the biological activity of binding to and initiating a signal through the hGH receptor. It may be. Preferred fragments according to the invention are those lacking 15 amino acids in glutamic acid (Glu) 32 to glutamic acid 46.

hGH fragments may be more variable at the C- or N-terminus. Also preferred according to the present invention are truncated hGH missing the first eight N-terminal residues or the first 13 N-terminal residues of the human growth hormone.

Short C-terminal hGH fragments are described as retaining the biological activity of hGH (see US 5,869,452). Therefore the use of the C terminal fragment of hGH is preferred according to the invention. Fragments hGH177-191, comprising at least amino acid residues 177-191 (LRIVQCRSVEGSCGF) of hGH, are particularly preferred according to the invention. More preferred are the peptide variants described in US Pat. No. 6,335,319 or WO 99/12969, for example derivatives of this peptide, such as cyclic peptides.

In addition, such polypeptides having such hGH receptor agonist activity may be hGH, analogs or variants thereof, salts thereof, functional derivatives or fragments thereof, and may further comprise amino acid residues flanked by the hGH polypeptide. As long as the resulting molecule retains the hGH receptor agonist capacity of the core polypeptide, routine experimentation can determine which side residues affect the basic and new properties of the core peptide, ie its receptor agonist properties.

An example of a preferred GH variant according to the present invention is methionyl human growth hormone (Met-hGH), which additionally has a methionine residue at the N-terminus of human growth hormone.

Preferred GH variants according to the invention include methionyl hGH, which is a human growth hormone with an additional methionine residue at the N-terminus. More preferred variants are human growth hormones lacking 15 amino acid residues from Glu 32 to Glu 46.

"Variants" of human growth hormone according to the invention relate to molecules that are substantially similar to whole proteins or fragments thereof. Variants may also be called "muteins." The variant may be an isoform of hGH, such as, for example, a variant produced by alternative splicing. Variant (poly) peptides may also be conveniently prepared by direct chemical synthesis of variant peptides using methods well known in the art. Of course, variant human growth hormones can have at least similar hGH receptor binding and signal initiation activity as hGH and therefore can be expected to have similar anti-MSA activity to hGH.

Amino acid sequence variants of human growth hormone can be prepared by mutations in DNA, which encode the synthesized human growth hormone derivatives. Such variants include, for example, deletions, insertions or substitutions of residues in the amino acid sequence. If the final structure has the desired activity, deletions, insertions, and substitutions can be combined to reach the final structure. Clearly, mutations to be made in the DNA encoding the variant peptides should not alter the reading frame.

At the genetic level, these variants are prepared by site-directed mutagenesis of nucleotides of DNA encoding peptide molecules (as exemplified by Adelman et al., 1983) to encode DNA encoding variants. The DNA may be prepared and then expressed in recombinant cell culture. Such variants typically exhibit at least the same qualitative biological activity as the unmutated peptide.

The “analog” of human growth hormone according to the invention relates to non-natural molecules, which are substantially similar to the whole molecule or to the active fragments thereof. Analogues of human growth hormone useful in the present invention will exhibit anti-MSA activity.

Substitution forms that can be made in human growth hormone according to the invention are based on analyzing the frequency of changes in amino acids between homologous proteins of different species. Based on such an analysis, conservative substitution is defined here as an exchange with one of the following five groups:

I. Small, Aliphatic Nonpolar or Slightly Polar Residues:

   Ala, Ser, Thr, Pro, Gly

II. Polar, negatively charged residues and their amides:

   Asp, Asn, Glu, Gln

III. Polar, positively charged residues:

   His, Arg, Lys

IV. Large, Aliphatic Nonpolar Residues:

   Met, Leu, Ile, Val, Cys

V. Large Aromatic Residues

   Phe, Try, Trp

Within the group described above, the following substitutions are considered to be "highly conserved":

Asp / Glu

His / Arg / Lys

Phe / Tyr / Trp

Met / Leu / Ile / Val

Semi-conservative substitutions are defined as the exchange between two of the groups (I)-(IV), in addition to supergroups (A) comprising (I), (II) and (III), said Limited to the supergroup (B) comprising (IV) and (V). Substitutions are not limited to amino acids that are genetically encoded or even naturally occurring. When epitope is prepared by peptide synthesis, the desired amino acid can be used directly. Genetically encoded amino acids can also be modified by reacting with organic derivatizing agents that can react with selected side or terminal residues.

Cysteinyl residues are most commonly reacted with alpha-haloacetate (and corresponding amines), such as chloroacetic acid or chloroacetamide, to form carboxylmethyl or carboxyxamidomethyl derivatives. Cysteinyl residues may also be selected from bromotrifluoroacetone, alpha-bromo-beta- (5-imidazole) propionic acid, chloroacetyl phosphate, N-alkylmaleimide, 3-nitro-2-pyridyl Disulfide, methyl-2-pyridyl disulfide, p-chloromercuribenzoate, 2-chloromercury-4-nitrophenol, or chloro-7-nitrobenzo-2-oxo-1,3-dia It is induced by the reaction with the sol.

Because these reagents are relatively specific to histidyl side chains, histidyl residues are induced by reaction with diethylprocarbonate at pH 5.5-7.0. Parabromophenacyl bromide is also useful; This reaction is preferably carried out in 0.1 M sodium cacodylate at pH 6.0.

Lysinyl and amino terminal residues react with succinic acid or other carboxylic anhydride. Induction with these reagents has the effect of switching the charge of the lysinyl residues. Other reagents suitable for inducing alpha-amino acid-containing moieties include methyl picolinimidate; Pyridoxal posphate; Pyridoxal; Chloroborohydride; Trinitrobenzenesulfonic acid; O-methyliosurea; 2,4-pentanedione (-pentanedion); And imidoesters, such as glyoxylates of transaminase-catalyzed reactions.

Arginyl residues include phenylglyoxal, among one or several conventional reagents; 2,3-butanedione; And by reaction with ninhydrin. Derivatization of arginine residues requires that the reaction be performed under alkaline conditions because of the high pKa of the guanidine functional group. In addition, these reagents can react with lysine groups as well as arginine epsilon-amino groups.

Intensive studies have been made regarding the introduction of spectral labels into tyrosyl residues by specific modifications as tyrosyl residues themselves, in particular by reaction with aromatic diazonium compounds or tetranitromethane. come. Most commonly, N-acetylimidazole and tetranitronetane are used to form O-acetyl tyrosyl specy and ε-nitro derivatives, respectively.

The carboxy side group (aspartyl or glutamy) is 1-cyclohexyl-3- [2-morpholinyl- (4-ethyl)] carbodiimide or And optionally modified by reaction with carbodiimide (R'NCN-R ') such as 1-ethyl-3- (4-azonia-4,4-dimethylpentyl) carbodiimide. In addition, aspartyl and glutamyl residues are converted to asparaginyl and glutaminil residues by reaction with ammonium ions.

Glutaminyl and asparinyl residues are often deamined with the corresponding glutamyl and aspartyl residues. Alternatively, these residues are deaminated under moderately acidic conditions. Any form of these residues is within the scope of the present invention.

Examples of preparation of amino acid substitutions in proteins that can be used to obtain analogs of hGH for use in the present invention include those described in US Pat. No. RE 33,653 to Mark et al .; 4,959,314; 4,959,314; 4,588,585 and 4,737,462; 5,116,943 to Koths et al; No. 4,965,195 to Namen et al .; And well known method processes such as those shown in Lee et al. 5,017,691, and there are lysine substitution proteins set forth in US Pat. No. 4,904,584 (Shaw et al). Another growth hormone variant is described, for example, in US Pat. No. 6,143,523 to Cunningham et al.

Substances that bind and signal to human growth hormone receptors that can be used in accordance with the present invention include all of these growth hormone analogs, and mimetics already known in the following literatures, for example: US Pat. No. 5,851,992 ; No. 5,849,704; 5,849,700; 5,849,700; No. 5,849,535; 5,843,453; 5,834,598; 5,834,598; 5,688,666; 5,688,666; 5,654,010; 5,654,010; 5,635,604; 5,635,604; 5,633,352; 5,633,352; 5,597,709; 5,597,709; And 5,534,617.

Preferably the hGH variant or analog will have a key sequence, which is identical to that of the natural sequence or biologically active fragment thereof, and which comprises an amino acid sequence having at least 70% identity to the natural amino acid sequence and retaining its biological activity Have More preferably such sequence has at least 80%, at least 90%, or more preferably at least 95% identity to the native sequence.

"Identity" reflects a relationship between two or more polypeptide sequences or two or more polynucleotide sequences, determined by comparing sequences. In general, identity represents the exact nucleotide to nucleotide or amino acid to amino acid correspondence of each of two polynucleotides or two polypeptide sequences, respectively, over the compared sequence length.

For sequences that do not have an exact correspondence, it can be determined as "% identity". In general, the two sequences compared are aligned to show the best correlation between these sequences. This involves inserting "gaps" in one or two sequences to increase the degree of alignment. A% identity can be determined over the entire length (so-called global alignment) of each of the sequences being compared, which in particular is of equal or very similar length or shorter, or finite length (so-called local alignment). It is particularly suitable and more suitable for sequences of different lengths.

Methods of comparing the identity and homology of two or more sequences are well known in the art. For example, the Wisconsin Sequence Analysis Package, version 9.1 (Devereux J et al., 1984), eg,% identity between two polynucleotides using the BESTFIT and GAP programs. And% homology between two polypeptides. BESTFIT uses Smith and Waterman (1981) 's "regional homology" algorithm to find the best one region of similarity between two sequences. Other programs for determining identity and / or similarity between sequences are also known in the art and are described, for example, in the BLAST program (Altschul SF et al., 1990, Altschul SF et al, 1997, www.ncbi.nlm. nih.gov. NCBI's website) and FASTA (Pearson WR, 1990; Pearson 1988).

Preferred modifications of the variants or muteins according to the invention are those known as "conservative" substitutions. Conservative amino acid substitutions of growth hormone polypeptides or proteins may include synonymous amino acids in the population whose substitutions between population members have physicochemical properties that are sufficiently similar to preserve the biological function of the molecule (Grantham, 1974). Deletion and insertion of amino acids are amino acids that are important for functional conformation, e.g. if only few amino acids, such as 30 or less, preferably 10 or less amino acids, are involved, without altering their function, in particular. For example, it is evident that the defined sequence can be made without removing or replacing cysteine residues. Proteins and muteins made with such deletions and / or insertions are within the scope of the present invention.

Analogs or variants according to the invention can also be determined according to the following procedure. Natural DNA sequences are known in the art and are found in the literature (Martial et al, 1979). Polypeptides encoded by nucleic acids such as DAN or RNA that hybridize to the complement of native DNA or RNA under very stringent or moderately stringent conditions are within the scope of the present invention as long as the polypeptide maintains the biological activity of the native sequence. Judging.

Strict conditions are a function of the temperature used in the hybridization experiment, the molarity of the monovalent cations and the percentage of formamide in the hybridization solution. To determine the degree of stringency associated with a given condition, 100% expressed as the melting temperature (Tm) of a DNA-DNA hybrid using primarily the equation of Meinkoth et al. (1984). Determine the stability of the hybrid of identity:

Tm = 81.5 ℃ + 16.6 ( _Log M) + 0.41 (% GC)-0.61 (% form) -500 / L

Where M is the molar concentration of the monovalent cation,% GC is the percent of G and C nucleotides in the DNA,% form is the percent of formamide in the hybridization solution, and L is the length of the base pair hybrid. The amount of mismatch granted for each 1 ° C. of Tm reduced from the calculated temperature for the 100% identity hybrid increases by about 1%. Therefore, if the Tm used in a given hybridization experiment at a particular salt and formamide concentration is 10 ° C. lower than the Tm calculated for 100% hybrids according to the Minecos equation, hybridization will occur even if there is a discrepancy of about 10%.

As used herein, slightly stringent conditions are those that are resistant up to about 15% sequence difference, while intermediate stringent conditions are those that are resistant up to about 20% sequence difference. Without limitations, high stringency (12-15 ° C. below the calculated Tm of hybrid) and medium (15-20 ° C. below the calculated Tm of hybrid) conditions are below the calculated Tm of the hybrid with 2X SSC (standard salts) wash solution. Use 0.5% SDS at moderate temperature. In particular, if less stable hybrids are formed with stable hybrids due to the hybridization conditions used, the critical stringency of the conditions is primarily due to wash conditions. Higher wash conditions remove hybrids that are less stable. Typical hybridization conditions that can be used from the high stringency conditions described above to medium stringent wash conditions are 6 X SSC (or 6 X SSPE), 5X Denhardt's reagent, 0.5% SDS, 100 μg / ml modified and fragmented. In the solution of the prepared salmon sperm DNA is hybridized at a temperature of about 20 ~ 25 ℃ below Tm. If mixed probes are used, it is preferred to use tetramethyl ammonium chloride (TMAC) instead of SSC (Ausubel, 1987-1998).

Although the present invention provides a recombinant method for preparing human growth hormone derivatives, these derivatives may also be prepared by conventional protein synthesis methods well known to those skilled in the art.

Human growth hormone, or fragments, variants, analogs or functional derivatives thereof, or salts thereof can be administered in a variety of ways.

In a preferred embodiment, the growth hormone is administered at a dose of about 0.1-10 mg / person / day or about 0.5-6 mg / person / day.

In a more preferred embodiment, the growth hormone is administered at a dose of about 1 mg / person / day.

In even more preferred embodiments, the growth hormone is administered daily or every other day.

In accordance with the present invention, growth hormone may also be administered in varying daily dosages, ie the first dose is greater than the second dose. Preferably, the first dose is about 1 mg / person and the second dose is about 0.5 mg / person.

In another preferred embodiment of the invention, the weekly dose of growth hormone is about 6 mg / person or about 5 mg / person or about 4.5 mg / person.

The growth hormone treatment according to the present invention may consist of administration of exogenous growth hormone, or administration of a substance that directly or indirectly stimulates the production of exogenous growth hormone by inhibiting endogenous somatostatin secretion.

Therefore, in a preferred embodiment of the present invention, a substance or human growth enabling or stimulating the release of endogenous hGH, which is used in the manufacture of a medicament for the treatment and / or prophylaxis of Parkinsonism-Plus syndrome, in particular multiple cranial nervous system atrophy. Substances that bind to and initiate hormone (hGH) receptors are selected from:

(a) human growth hormone releasing hormone (hGHRH);

(b) a fragment of (a) having anti-activity on a hGHRH receptor;

(c) a variant of (a) or (b) having counter activity on the hGHRH receptor and having at least 70% sequence identity with (a) or (b);

(d) (a) or (b) encoded by a DNA sequence that has anti-activity on the hGHRH receptor and hybridizes to the complement of the native DNA sequence encoding (a) or (b) under moderately stringent conditions Variants of; or

(e) Salts or functional derivatives of (a), (b), (c) or (d) having anti-activity on hGHRH receptors.

Human growth hormone releasing hormone (hGHRH) is known to stimulate the release of hGH. Therefore, the biological activity of hGH can be obtained indirectly by administering GHRH or functional derivatives, salts, variants, analogs or fragments thereof that possess the biological activity of GHRH, ie the ability to stimulate the release of growth hormone. Thus, for example, besides GHRH, functional derivatives, analogs or variants thereof may be used according to the above definitions, which have at least 70% sequence identity, preferably 80% or 90% or more preferably 95% sequence identity. While retaining the biological activity of GHRH, or variant or analogue, which variants or analogs hybridize to native DNA encoding GHRH under intermediate stringent conditions, preferably high stringency conditions, in accordance with the above definition. It is a polypeptide encoded by DNA.

In a preferred embodiment of the invention, functional derivatives of hGH or GHRH, or certain active fragments, variants or analogs thereof, comprise at least one moiety attached to one or more functional groups occurring as at least one side chain at the amino acid residue. Include. Attachment of polyethylene glycol (PEG) is preferred. Preferred PEG (peg) GHRH (so-called GRF) molecules that can be used in connection with the present invention are described, for example, in WO 99/27897. The materials of the present invention may be alkylated to increase half-life in the human body.

Particularly preferred preparations according to the invention are long lasting preparations, such as preparations having a half-life (T _H ) group of the active substance for at least 30 hours.

Any of the GHRH or GHRH analogs or agents known in the literature and disclosed to stimulate growth hormone release can also be used in the present invention. Such as US Pat. No. 5,792,747; 5,776,901; 5,776,901; 5,696,089; 5,137,872; 5,137,872; No. 5,767,085; 5,612,470; 5,612,470; No. 846,936; And 5,847,066. See also Toner (Thorner et al: 1997), Felix (al) (1995); See Alba-Roth et al: 1988, Friend et al. (1997).

Other materials that can stimulate in vivo the release of growth hormone that can be used in accordance with the present invention include those disclosed in the following patents: US Pat. No. 5,807,985; 5,804,578; 5,804,578; 5,795,957; 5,795,957; 5,777,112; 5,777,112; 5,767,118; 5,767,118; 5,731,317; 5,731,317; 5,726,319; 5,726,319; 5,726,307; 5,726,307; 5,721,251; 5,721,250 and the like.

Any molecule that binds to the hGH receptor and initiates signal initiation of the receptor can also be used in accordance with the present invention. For example, small molecules, sometimes called so-called secretagogues, are known to have evolved to bind hGH receptors and cause their aggregation to initiate a signal, which is like a natural hGH that binds to the receptor. Such molecules are described, for example, in US Pat. No. 5,773,441; 5,798,337; 5,798,337; No. 5,830,433; 5,767,124; 5,767,124; And 5,723,616. See also Bowers et al: 1991, toner (1997), Kamani (Camanni et al: 1998), Smith (Smith et al: 1993) and Contribution (Ghigo et al: 1998).

Therefore, the present invention includes any substance which binds to and initiates a signal of the hGH receptor ultimately to achieve the same quality effect as administration of native hGH, as far as the treatment of Parkinsonism-Plus syndrome, especially MSA, is concerned. I will try to.

Insulin-like growth factors (IGFs) are well known to belong to the cascade of growth hormones. Two IGFs have been described so far as so-called IGF-I and IGF-II. IGF-I modulates most of the growth-stimulating activity of GH. IGF-I, a potent mitogenic growth factor, has surprising homology to proinsulin. It binds to specific receptors that also bind insulin at lower affinity. The predominant site of GH-stimulated IGF-I production is the liver, while some extrahepatic tissues also synthesize IGF-I. IGF-I regulates GH gene expression and secretion by regulating negative feedback, similar to the inhibition of their respective pituitary trophic hormone by thyroid and adrenal hormones do.

Therefore, the present invention relates to the use of IGF (insulin-like growth factor) for the manufacture of a medicament for the treatment and / or prophylaxis of Parkinsonism-Plus syndrome, in particular multiple cranial nervous system atrophy. Preferably, IGF is selected from IGF-I or IGF-II.

IGF is known to form complexes with specific binding proteins, the so-called IGF binding proteins (IGFBR). These binding proteins transfer IGF to the vasculature and cross intact capillary membrane, confine the IGF to specific tissue and cell forms, and interact with IGF and cell surface receptors. Has been suggested to perform four functions of controlling the activity and regulating the biological activity of IGF (Clemmons et al., 1993). In particular, insulin-like growth factor-binding protein-3 (IGFBP-3) is a major determinant of the circulating level of IGF and assesses GH deficiency and Clinically useful for predicting response.

Therefore, in a preferred embodiment of the present invention, the medicament further comprises IGFBP. Preferably the IGFBP is IGFBP3.

If any of IGF-I, binding of IGF-II, IGFBP with human growth hormone or GHRH, or fragments, variants, functional derivatives or salts thereof are for the treatment and / or prevention of Parkinson's-Plus syndrome, in particular MSA It is further included in. The materials can be used continuously, separately or simultaneously.

The invention binds to a substance or human growth hormone (hGH) receptor that enables or stimulates the activation of endogenous hGH for the manufacture of a medicament for the treatment and / or prophylaxis of Parkinsonism-Plus syndrome, in particular multiple cranial nervous system atrophy. The present invention relates to the use of a nucleic acid molecule comprising a coding sequence of a substance for signal initiation.

The nucleic acid molecule comprises an expression vector, for example a sequence of expression vectors for using gene therapy for administering hGH according to the invention.

Preferably, the medicament of the present invention is administered to the subcutaneous tissue.

It is also desirable to administer the medicament intramuscularly.

In a more preferred embodiment, the substance is administered by an auto-injector. Autoinjectors are devices for facilitating the introduction of a drug into the subcutaneous tissue. Automatic injector may be known in the prior art, to be particularly useful for the injection of hGH example aka easyJet ^® (Easyject ^®). In connection with the present invention it may be administered using certain devices known in the art in addition to injections.

The present invention provides for the preparation of a medicament for the treatment and / or prophylaxis of Parkinson's-Plus syndrome, in particular multiple cranial neurotrophic atrophy, a substance which enables or stimulates the release of endogenous hGH or human growth hormone (hGH). It relates to the use of a vector to induce and / or increase endogenous production of a substance that binds to a receptor and initiates a signal.

The vector comprises a functional regulatory element of the cell required to express the substance of the invention. Such regulatory sequences or elements can be, for example, promoters or enhancers. The regulatory sequence needs to be introduced into the correct locus of the genome by homologous recombination so that the regulatory sequence is operably linked to the gene and needs to induce or increase its expression. This technique is commonly referred to as "Endogenous Gene Activation (EGA)" and is described, for example, in WO 91/109955.

The present invention enables the activity of a substance or endogenous hGH that binds to and initiates a human growth hormone (hGH) receptor for the manufacture of a medicament for the treatment and / or prophylaxis of Parkinson's-Plus syndrome, in particular multiple cranial nervous system atrophy. It relates to the use of genetically modified cells to produce substances that stimulate release.

The invention also relates to a method for treating Parkinsonism-Plus syndrome, in particular multiple cranial nervous system atrophy, which enables the activity of a substance or endogenous hGH that binds to a human growth hormone (hGH) receptor and initiates a signal in a patient, if necessary. An effective amount of a substance to cause or stimulate release to a patient.

Pharmaceutical compositions for administration in accordance with the present invention, in pharmaceutically acceptable form, optionally together with a pharmaceutically acceptable carrier, excipient, stabilzer or auxiliary agent At least one human growth hormone according to the invention.

These compositions can be administered by any means for achieving their intended purpose. The content and diet for the administration of the compositions according to the invention can be readily determined by one skilled in the art of Parkinsonism-Plus syndrome, in particular MSA.

Compositions within the scope of the present invention include all compositions comprising at least one human growth hormone or derivative, an analog or variant according to the present invention in an amount effective to achieve the intended purpose. Although each need is different, it is within the scope of the art to determine the optimum range of effective amounts of each component. Typical dosages include about 0.001 to about 0.1 mg / kg body weight / day. When administered to an MSA patient, hGH anti-MSA therapy may be administered simultaneously with other therapies required for this disease.

In a preferred embodiment of the invention, hGH is administered at a dosage of about 0.1-10 mg or about 0.5-6 mg daily. More preferred dosage is 1 mg of human growth hormone / person / day.

In a more preferred embodiment, the dosage is administered with varying dosages of hGH, i.e., the first dosage is greater than the second dosage. Preferably the first dose is about 1 mg and the second dose is about 0.5 mg. The weekly dosage depends on the needs of the patient and preferably about 6 mg or about 5 mg or about 4.5 mg.

For example, subcutaneous, intravenous, intramuscular, oral, intraperitoneal, aerosol, transdermal, intrathecal, or rectal pathways. Parenteral drug administration is also possible. The dose administered depends on the age, health and weight of the recipient, the form of previous or concurrent treatment, the frequency of treatment, if any, and the nature of the desired effect.

According to the invention, the preferred route of administration is the subcutaneous tissue and muscle route. Particularly preferred route of administration is oral administration.

It should also be understood that the provided therapy is not absolute if it is sufficient and useful to carry out clinical value. If other reagents are less effective for a particular person, in combination with other reagents to increase the total level of protection, or are more stable than competing agents, reagents that treat less than competitive agents are still valuable.

Appropriate dosages of the compositions according to the invention will depend on the age, health and weight of the recipient, the type of concurrent treatment, the frequency of treatment, if any, and the nature of the desired effect. However, the most preferred dosage is to tailor the drug to the individual, which can be understood and determined by one skilled in the art without undue experimentation. This typically involves adjusting the standard dose, eg, reducing the dose if the patient is low in weight.

The total dose required for each treatment may be administered in multiple doses or single doses. The composition may be administered alone or in combination with other therapies associated with the disease or other therapies associated with the symptoms thereof.

In addition to the compounds of the present invention, pharmaceutical compositions may comprise suitable pharmaceutically acceptable carriers such as excipients, carriers and / or adjuvants, which facilitate processing of the active compounds into preparations which can be used pharmaceutically. .

The present invention will now be fully described, and those skilled in the art will appreciate that the present invention can be equally carried out within a wide range of equivalent parameters, concentrations and conditions without undue experimentation without departing from the scope of the present invention.

While the invention is described in conjunction with specific embodiments thereof, it will be understood that further modifications are possible. This application is generally intended to cover any deviations from the present disclosure, ie modifications, uses or adaptations of the invention, which are within the scope of the well-known or practiced art in accordance with the principles of the invention and the appended claims. It may be used for essential components within.

All references, journals or abstracts cited herein, published or unpublished US or foreign patent applications, published US or foreign patents or other references are all incorporated by reference in their entirety, in all the data, tables, Incorporated throughout, including pictures and sentences. In addition, the entire contents of the references cited in the references cited herein are also incorporated by reference in their entirety.

Reference is made to known method steps, and no known or conventional methods are meant to suggest that any of the aspects, descriptions or embodiments of the invention is disclosed, educated or suggested in the relevant technical literature.

The foregoing detailed description of specific embodiments has fully revealed the general nature of the invention and, using the knowledge in the art, allows others to readily modify and modify such specific embodiments in various applications without undue experimentation, without departing from the general concept of the invention. And / or be adaptable. Such adaptations and variations are therefore to be interpreted as being within the scope of equivalents of the disclosed embodiments, based on the teachings and instructions presented herein. The phraseology or terminology used herein is for the purpose of description and not of limitation, so that those skilled in the art may interpret the teachings and instructions presented herein in combination with their knowledge.

The present invention is now described, which will be more readily understood with reference to the following examples of exemplary clinical study summaries provided for illustrative purposes and are not to be construed as limiting the invention.

Example

List of abbreviations

AE side effects

AST Asparatate Transaminase

ALT Alanine Transaminase

CNS Central Nervous System

CPMP Committee for Proprietary Medicinal Products

CRA Clinical Research Associate

CRF Case Report Form

CSF Cerebrospinal Fluid

DER Drug Event Report (form)

FDA US Food and Drug Administration

GCP Good Clinal Practice

GFAP Glial Fibrilary Acid Protein

GH Growth Hormone

Growth Hormone Deficiency

GLP Good Laboratory Practice

hCG Human Chorionic Gonadotrophin

5-HIAA 5-hydroxyindoleacetic acid (5-Hydroxyindoleacetic acid)

HVA Homovanillic acid

ICH International Conference on Harmonisation

IEC Independent Ethis committee

IGF-1 Insulin-like Growth Factor 1

IGFBP-3 Insulin-like Growth Factor Binding Protein 3

IRB Institutional Review Board

IU International Unit

IV Intravous

L-DOPA Levodopa

Long term potentiation

MG mg

MRA Medical Research Associate

MSA Multiple System Atrophy

NFL neurofibrillary protein

NHP Nottingham Health Profile

PLM Posturo-Locomotor Manual Test

r-hGH recombinant human growth hormone

RNA Ribonucleic Acid

SAE Serious adverse event

TD Therapeutic Director

TPN Total Parenteral Nutrition

UPDRS Unified Parkinson's Disease Rating Scale

WHO World Health Organization

Study Outline

Subject, comprising: administering a recombinant human growth hormone (r-hGH) into the subcutaneous tissue in the treatment of multiple cranial nerve atrophy (phase) II, single-center (single center), double-blinded (double-blind), random (randomized), Placebo-controlled study

Plan Phase : Phase II

Indication : Multiple CNS Atrophy

Primary purpose :

1) Laboratory : To determine the therapeutic effect of r-hGH by the labeling of neurodegeneration in the spinal fluid, analysis of GFAP and neuronal microfiber protein (NFL) (Holmberg et al. , 1998).

2) Clinical :

   (a) Stabilizing functional assessments as measured by a unified Parkinson's disease assessment compared to the placebo group (see below).

   (b) Stabilized against placebo in automated test results

Secondary purpose:

   (a) To assess the stability and tolerability of r-hGH in this patient population

   (b) use the body-motor limb test (PLM) to detect differences between groups as the disease progresses.

    (c) Improving the quality of life as measured using Notting Gum Health Index (NHP) (see below).

Sample size: 40 evaluable patients

Study drug: four now ^® (Saizen ^®) [recombinant human growth hormone (r- hGH)]

Therapeutic regimen : 1 mg three times a week for 12 months (if the patient gets very bad, it can be increased gradually at 6 months with varying daily doses of 1 mg and 0.5 mg).

Method of administration : subcutaneous tissue

Procedure : Patients will be required to meet the criteria for clinically probable MSA diagnosis prior to population inclusion. There will be six visits, pre-study evalution, and visits on Day 1, 3, 6, 9 and 12 months of study. Spinal fluid analysis for GFAP and NFL is done at pre-study evaluation, 6 months and 12 months. At day 1, 6 and 12 of the study, patients should answer the NHP's questions, which will be evaluated with regard to functionality regarding UPDRS and autonomic testing will be performed.

Safety and efficacy data will be obtained through routine clinical follow-up, routine blood tests, clinical chemicals and urinalysis, and the specific procedures mentioned below.

purpose

The purpose of the study is:

Primary purpose

. Laboratory : To determine the effectiveness of treatment with r-hGH by analysis of spinal fluid GFAP and NFL (label for neuronal cell degeneration) (Holmberg et al., 1998), ie GFAP in patients receiving r-hGH and Increase of these markers as a sign of stabilization of NFL and continued progression of degeneration in the placebo population

. Clinical :

. Stabilization compared to placebo group in functional assessment as measured by assessment of integrated Parkinson's disease (Appendix F)

. Stabilization as compared to placebo as a result of autonomic testing (Appendix I)

Secondary purpose

. To assess the stability and tolerability of r-hGH in this patient population.

. Detecting differences between groups in disease progression using the body-motor limb test (PLM) (see below)

. Improving quality of life measured using Notting Gum Health Index (NHP) (see below)

Study group

40 patients will be included in the study. Each patient must:

. Within the specified time frame, both the inclusion and exclusion criteria specified in the following sections must be satisfied,

. Receive all of the assigned course of treatment specified in the above summary and perform the required actions, and

Complete the Case Report Form (CRF) and receive and resolve all inquiries regarding the criteria required by the sponsor.

Inclusion Criteria

To be eligible for inclusion in the study, each patient must meet the following criteria within 28 days before the first day of the study:

1) to implement the criteria for clinically probable diagnosis of MSA

2) has a life expectancy of at least one year;

3) must be between the ages of 30 and 75

4) Willingness and ability to meet the experimental design during the study

5) With the understanding that the patient may revoke consent at any time without prejudice to the future medical treatment, the patient must agree in advance to any research-related process that is not part of the patient's normal medical treatment.

6) Female patients:

(a) post-menopausal or surgically removed; or

(b) using hormonal contraceptives, intrauterine devices, diaphragms of spermicides, and spermicide condoms during the study;

And

(c) Not pregnant and not breastfeeding.

Confirmation that the female patient is not pregnant should be confirmed by a negative serum / urine hCG pregnancy test during the 28 days of screening prior to the first day of the study. Pregnancy testing is not necessary if the patient has been removed postmenopausally or surgically.

Exclusion Criteria

Patients who belong to any of the following criteria will be excluded from this study:

1. Clinical evidence of an infectious or inflammatory disease involving blood or spinal fluid

2. Serum creatinine, AST or ALT > 2.5 x values above the normal range (values no longer than one month before the first day of the study)

3. Presence or history of diabetes mellitus (type I or II)

4. The presence or history of any active cancer

5. Hypothyroidism (if not properly treated with thyroid hormone replacement therapy)

6. Benign cranial hypertension

7. History of Carpal Tunnel Syndrome Unresolved by Surgery

8. Patients who lack medical risk due to non-malignant or systemic diseases or significant secondary effects of cancer are not suitable. Patients with clinically significant heart disease (ie, the presence of prescribed heart disease symptoms that require additional stability and marked limitations to control symptoms) are not suitable.

9. Attend any course of study within 3 months before entering the study, or took any other test drug

10.Pre-allergic history of r-hGH

11. Pretreatment with r-hGH.

Number of patients and allocation of treatment groups

As 40 patients enter the study, blinded injections of either SAIZEN ^® or 1 mg of placebo into the subcutaneous tissue will be randomly injected for 12 months (if the patient is very critical, varying the daily dose to 1 mg and 0.5 mg). Incremental administration at 6 months is possible). The treatment given to each patient will be determined according to a computer-generated randomization list. The patient pack and the enclosed vial will be labeled with the identification number of the particular patient.

If the patient is found to be suitable for the study and completes all pre-study procedures, a specific patient identification number will be assigned consecutively in chronological order after the completion of all basic assessments on the first day of the study. Before assigning patient numbers, all patients must be recognized for their initials and birthdays. If patients withdraw from the study after randomization, their identification numbers will not be assigned again.

Research pharmaceuticals

Presentation, manufacturing, storage and Scab

The study drug, (Cyzen ^® or placebo), is a multi-dose preparation or excipient in a glass vial containing 24 IU (8.8 mg) r-hGH and excipients (phosphate or sodium hydroxide diluted from sucrose, 85% phosphoric acid and 85% phosphoric acid). Corresponding placebo glass vials containing bay will be supplied from Sereno. The reprocessing solvent will be supplied in the form of a cartridge containing 0.3% (w / v) methacresol in water for injection.

One vial of study drug will be reprocessed with 1.51 ml diluent. The EasyJet ^® autoinjector will be used for the study and will be supplied to the patient with the reprocessing device and syringe.

Lyophilized products are stored below 25 ° C and away from direct sunlight. All study medication should be stored in a safe place, preferably in a locked, temperature-controlled refrigerator or cold room. The study drug may be appropriately reagentd only by the investigator, pharmacist, or professional personnel authorized by the investigator. Any deviation from the recommended storage conditions should be reported immediately to the sponsor and use of the study drug should be discontinued until the sponsor permits its continued use.

Once reprocessed with bacteriostatic diluent, the drug should be stored between 2 ° C and 8 ° C (36 ° F and 46 ° F) and injected within 21 days.

Labeling and packaging can be manufactured to local control requirements.

Dose, route and schedule of study drug administration

Each patient will preferably be injected into the subcutaneous tissue three times a week (preferably Monday, Wednesday and Friday) at bedtime at a dose of 1 mg for 12 months. However, if the visit at 6 months is very poor with the following clinical signs or findings, the patient will be used with increasing doses, changing the daily injection to 1 mg and 0.5 mg.

. Stuttering, difficulty swallowing, paresis, coordination, rigidity, balance, walking ability, urinary continence or weakness of sexual function

Increased levels of NFL in spinal fluid

. Additional damage to the results of the cardiovascular reflex test

Injection sites should be determined by rotating the abdomen, arms and legs. At the investigator's discretion, the patient or family member / spouse may teach the injection.

Patients should continue to record on the card daily the time of injection, amount injected and any local or symmetrical side effects.

Concomitant therapy

Anticoagulants are not allowed except for aspirin during the study.

As an exception, medications that are determined to be necessary for the welfare of the patient at the investigator's discretion and that do not conflict with the study medication are possible. All accompanying medication should be recorded in the appropriate section of the CRF, with dosage information, route, date of administration, and reason for use. In addition, unplanned diagnosis, treatment or surgical procedures made during the study period should be recorded with the date, instructions and description of the course and the results.

The use of herbal / natural products or other “folk remedies”, vitamins, nutritional supplements and other additional medications should be recorded on the case report form in the same way as conventional drugs.

On an outpatient basis, patients must record in detail any self-medication on the card each day.

Prior consent

Each potential appropriate patient will be informed of the study's purpose and overall requirements. The investigator will fully explain the study to the patient using the patient information leaflet / advance format before proceeding with any of the preliminary tests normally performed in the treatment of the patient. If the patient chooses to participate in the study, he or she should take the time to consider whether to request attendance and a more detailed explanation, and then inform in advance. The informed consent form is signed and dated by both the patient and investigator / sub-investigator. Provide a copy of the signed form to the patient and keep the original with the original document. Nurses may explain to the patients, and the investigator / sub-investigator must attend the discussion with the patient and personally sign and date the informed consent form.

The short CRF must be completed by all patients who sign the informed consent form but do not participate in the study. These patients will be recognized for their initials and birthdays; They will also record their race, gender and reason for exclusion.

Pre-study evaluation

Within 28 days prior to the first day of the study (the first day of r-hGH injection), patients should be evaluated to determine if they are eligible for the study. This assessment should relate to:

. Medical review and history sufficient to meet inclusion and exclusion criteria (laboratory results should be used to meet exclusion criteria 2, creatine, AST / ALT)

. A lumbar punture will be performed and a sample of spinal fluid will be obtained. The sample is sent to a laboratory for analysis of GFAP and NFL levels.

Research first day

The following basic data and assessments should be collected / performed and recorded on the first day of the first pre-infusion study of r-hGH. These include:

. Complete medical history independent of MSA

. History of study conditions, including date of diagnosis, sub-type, if known and previous treatment

. Demographic data, including age, race and gender

. Physical examination including weight and vital signs

. Medical conditions, accompanying medications and processes associated with the current disease

. Routine hematology, clinical chemistry, endocrinology, urine analysis and antibodies to hGH

. Patients must complete the Notting Gum Health Index in the questionnaire on quality of life (see below). Investigators or study nurses explain this to the patient.

. The investigator completes the Unified Parkinson's Disease Assessment (UPDRS) (see below) to assess the patient's functional ability.

. The body-motor limb test (PLM) is performed by the investigator in the manner described below.

. Investigator conducts autonomous test (heart rate change, blood pressure and heart rate response of controlled forced respiration to tilt)

3 months

At the end of three months, proceed as follows (within one week or one week of the scheduled visit):

. Physical examination including vital signs

. Evaluation of side effects, accompanying drugs and courses

. Routine hematology, clinical chemistry and urine analysis

. 6 months

    At the end of six months, the following process (not one week or one week later than the scheduled visit):

. Physical examination including vital signs

. Routine hematology, clinical chemistry and urine analysis and antibodies to r-hGH

. Evaluation of side effects, accompanying drugs and courses

. Perform a lumbar puncture and obtain a sample of spinal fluid. The sample is sent to a laboratory for GFAP and NFL level analysis.

. The patient completes the Notting Gum Health Index of the questionnaire of life. The investigator or research nurse explains this to the patient.

. Investigators complete the Uniform Parkinson's Disease Assessment (UPDRS) to assess the patient's functional capacity.

. The investigator conducts an autonomous test (changes in heart rate, blood pressure, and heart rate response during controlled forced breathing for tilt)

If the patient worsens any of the following clinical signs or findings, the dosage will gradually increase with varying daily infusion from 1 mg to 0.5 mg.

. Stuttering, difficulty swallowing, incomplete paralysis, coordination, stiffness, balance, walking ability, urinary incontinence or worsening of sexual function

. Increasing the CSF-NFL Level

. Additional impairment of the results of the Vaso relaxation test

9 months

At the end of nine months, the following process (not earlier or later than one week before the scheduled visit):

. Physical examination including vital signs

. Evaluation of side effects, accompanying drugs and courses

. Routine hematology, clinical chemistry and urine analysis

12 months

At the end of 12 months the following procedure is performed (not earlier or later than one week of the scheduled visit), ie at the end of treatment of rhGH or at early cancellation of the patient:

. Physical examination including vital signs

. Routine hematology, clinical chemistry, endocrinology, urine analysis and antibodies to hGH

. Evaluation of side effects, accompanying drugs and courses

. Perform a lumbar puncture and obtain a sample of spinal fluid. The sample is sent to a laboratory for GFAP and NFL level analysis.

. The patient completes the Notting Gum Health Index of the questionnaire of life. The investigator or research nurse explains this to the patient.

. Investigators complete the Uniform Parkinson's Disease Assessment (UPDRS) to assess the patient's functional capacity.

. The investigator conducts an autonomous test (changes in heart rate, blood pressure, and heart rate response during controlled forced breathing for tilt)

In the event of adverse events, such as clinically significant laboratory abnormalities, adequate safety until either clinical findings (or investigator judgments) are resolved or for a short period of time, up to 30 days from the last dose of study drug. The evaluation should be repeated more often and / or additional testing should be performed.

Early research discontinuation and replacement policy

Suspension Criteria

Patients will be notified that they have the right to withdraw from the study at any time without prejudice to their medical treatment and that there is no reason to state why. Any withdrawal must be fully documented in the CRF and tracked by the investigator.

In addition, investigators may dismiss a patient at any time if it is determined to be in the patient's best interest.

During the course of the study, patients should be discontinued for the following reasons:

. Investigator's discretion (modified) WHO class 3 or 4 poisoning related to the study drug

Patients are discontinued for the following reasons:

. Admitted to intensive care

. Plan disruptions, including loss of nonconformity and follow-up

. Serious intercurrent illness or severe exacerbation of concurrent illness

. Side effects or

. Administrative reasons

If the patient cannot return to follow-up, the patient must be assured that the reason for the return is not due to side effects. In addition, if the patient decides to stop the study, for example for personal reasons, it should be confirmed that the original reason is not due to side effects (remember that the patient is not obliged to tell why).

If the study drug treatment is discontinued early, the primary reason for discontinuation should be recorded in the appropriate portion of the CRF and all efforts should be made to complete and record the observation as broadly as possible. A fully final assessment should be made in accordance with the withdrawal of the patient described in Section 6.7. Any adverse event must be followed by the shorter of the days until resolution or until 30 days after the last dose of study drug.

Fallback policy

If a patient withdraws from the study, his dog tag is not reassigned. All inadequate (incorrectly included patients who do not meet the appropriate criteria) patients should be replaced again because 40 evaluated patients are needed to evaluate the study.

Side effect report

Justice

Adverse events (AEs) are defined as subjects of clinical investigation to administer a patient's adverse medical condition or a pharmaceutical product that does not need a causal relationship with this treatment. The side effect may therefore be a disease that is temporarily associated with the use of a medicinal (investigative) product, irrespective of undesired and unintended indications (abnormal laboratory findings), symptoms, or relationship with the medicinal (investigational) product.

report

Any serious side effects as well as all of the side effects described above encountered during the clinical study will be reported in the appropriate portion of the CRF. It is important to include the duration of the AE (day of onset / resolution), severity, relationship to the drug (possibly, probable, irrelevant-see below), frequency, and reagent co-treatment (or other actions taken).

Probability : Clinically for cases involving laboratory testing abnormalities, concurrent illnesses or other drugs or chemicals, and subsequent withdrawal [dechallenge], after a reasonable time after administration of the drug. Clinical cases involving reasonable responses. The retried information does not have to meet the above rules.

Possibility : A clinical case involving abnormal laboratory tests after a reasonable time after administration of the drug, but concurrent disease may be explained by other drugs or chemicals.

Possibility : Clinical cases involving temporary laboratory test abnormalities in drug administration, which occur by chance and are likely to provide a plausible explanation for other drugs, chemicals or underlying diseases.

The severity of the side effects is rated according to the revised WHO toxicity rating. If side effects are not listed in these criteria, the investigator will assess the severity using the following rules:

If symptoms (Mild): charina patients find the side effects or symptoms of side effects or symptoms are readily withstand.

Moderate : The patient feels discomfort or severely experiences a decrease in activity with respect to his or her usual activities.

Severe : Serious impairment of function: The patient is unable to perform normal activities.

Life-threatening conditions (Life-threatening): the risk of falls by the side effects of patient life. Adverse event data can be obtained from the patient or any information obtained from the patient's questions. In addition, adverse event data can also be collected using a card daily.

Serious Side Effects Cases

Severe adverse events (SAEs) are defined as harmful medical outbreaks at any dose:

. Eventually die

. Life-threatening conditions (ie, patients are at risk of dying from side effects, which does not mean that they could potentially die if worse),

. Prolonged hospitalization if hospitalization of the inpatient is necessary or a registered patient

. As a result of permanent or severe disability or incapacity

. Congenital anomaly or birth defect

. It is obvious that other medically important conditions (ie, do not result in an immediate life-threatening condition or death or hospitalization but are of great clinical importance. This is a stop therapy to endanger the patient or to prevent one of the other serious consequences). Examples of such cases include intensive care in an emergency room or intensive care at home due to allergic bronchospasm, blood dyscrasias or convulsions, which are hospitalization or drug dependence for inpatients. Or does not develop into drug addiction).

Clinical laboratory parameters

Routine Hematology: Clinical Chemistry:

Hemoglobin sodium

Hematocrit Potassium

Red cell count urea

White cell count creatinine

Neutrophils ¹ Total bilirubin

Lymphocyte ¹ Total Protein

Monocyte ¹ Calcium

Platelets (Eosinophils) ¹ AST (SGOT) and / or ALT (SGPT)

Basophils ¹ Alkaline phosphatase

Thrombobocytes Glucose

Erythrocyte Sedimentation Rate ¹ Endocrinology

Electrophoretic Free Thyroxine (FT4)

Urine analysis (dipstick method) diprotropin (thyroid stimulating hormone: TSH)

Protein Cortisol

Clucose Testosterone (male)

Ketone Follicle Stimulating Hormone (FSH)

PH Luteinsing Hormone (LH)

Blood Insulin-like Growth Factor I (IGF-1)

Insulin-like growth factor binding protein 3 (IGFBP-3)

insulin

Growth hormone antibodies

¹ These tests are performed only at the base visit.

All of the tests in the above list are performed at the frequency described in the study schedule below.

Blood Sample Collection and Serum Preparation

Divisional Laboratory Courses: Hematology, Blood Chemistry, Endocrinology

30 ml of blood are collected (6 serum tubes of 4 ml and 3 plasma EDTA tubes of 3 ml). Samples of hemoglobin, leukocytes, platelets, differential and glucose are analyzed according to the laboratory's general hospital procedures. All other samples are stored at −80 ° C. in Sahlgrenska hospital until evaluated. All analyzes are performed in the laboratory of Salgrenska University Hospital.

term- GH  Serum Samples Collected for Antibodies

Two 5 ml blood samples are collected at intervals indicated in the study plan (below) using tubes without anticoagulant. All serum samples are labeled with a patient identification tag, patient initials, and the date and time of collection of the blood samples. Samples may be collected at a convenient time (ie when indicated on the study day but not at a specific time) but the exact time and date of sample collection should be recorded. The exact time the r-hGH dose was administered prior to sample collection should be recorded in the CRF.

8 ml of blood is drawn and placed in a sterile plain tube (serum) to prepare serum by coagulation in the refrigerator (up to 30 minutes). Centrifuge at 3500 RPM for 10 minutes at room temperature (as instructed by the manufacturer), collect serum and divide into four 1 ml portions. Immediately freeze below -20 ° C until shipping the sample. A portion is sent to the central laboratory (frozen) and three are stored frozen at −20 ° C. or lower at the study site as backup samples. Samples are delivered to a CRA conference central laboratory.

Study Plan

parameter Prior study evaluation First day of study 3 months 6 months 9 months 12 months Prior Agreement X Medical review and medical history to meet the fitness criteria X Disease and Treatment History X ¹ Demographic data X ¹ Physical examination and vital signs X ¹ X X X X Current disease-related medical conditions X ¹ Hematology, Chemistry and Urinalysis X ¹ X X X X endocrinology X ¹ X X antibodies to hGH X X X Lumbar puncture for CSF X X X Assay (GFAP, NFL) Quality of Life NHP X X X Functional Evaluation (UPDRS) X X X PLM Measurement X X Autonomy X X X Research treatment X X ² X X WHO toxicity rating X X X X Side effect report X X X X Joint drugs and courses X X X X X

¹ If this was done 14 days before the first day of the study, this process does not need to be repeated.

² If the patient gets very bad, gradually increase the daily dose to 1 and 0.5 mg.

Integrated Parkinson's Disease Assessment UPDRS )

The use of UPDRS as an assessment tool to follow the longitudinal course of Parkinson's disease is a commonly accepted method. It is made up of mental, behavior and mood, 2) ADL and 3) motor parts. These are evaluated by interviews. Each part needs several classes divided up to the extreme. A total of 199 points are possible. 199 represents the worst (total) disorder, zero-disability.

I. Mental activity, behavior, mood

. Intellectual damage

0-none

1-mildness [forgetfulness of partial recollection of events without other difficulties]

2-moderate memory loss with disorientation and moderate difficulty handing complex problems

3-time and sometimes serious memory loss that confuses places, serious disabilities with problems

4- severe memory loss, confusing only for people, severe memory loss that can't be judged or solved

. Accident disorder

0-none

1- vivid dream

2- insightful “benign” hallucinations

3- Frequent hallucinations or intermittent occurrences of delusions that may relate to daily life

4- persistent hallucinations, forgetfulness or flowering psychosis

. depression

0- none

1- Sorrow or guilt greater than normal, not lasting more than a few days or a week

2- depression lasting longer than a week

3- vegetative symptoms (insomnia, anorexia, abulia, weight loss)

4- suicidality growth symptoms

. Motivation / Initiative

0- normal

1- less stubborn, more passive

2- loss of initiative or indifference to planned action

3- indifference to talking about loss of initiative or (routine) activity

4- withdrawal, complete lack of motivation

II. Everyday life activity

. speaking

0- normal

1- slightly affected, but understand without difficulty

2- may be somewhat affected and may need to be repeated

3- seriously affected and should be repeated frequently

4- I don't understand most of the time

. Saliva (Salivation)

0- normal

1- Slightly noticeable increase may result in drooling at night.

2- some excessive saliva, slight shedding

3- noticeable drooling

. Swallowing

0- normal

1- rare airway choking

2- intermittent airway obstruction

3- soft food requirement

4-NG tube or G-tube requirement

. Handwriting

0- normal

1- slightly smaller or slower

2- all words are small but readable

3- seriously affected, not all readable

4- mostly unreadable

. Cutting Food / Water supply ( Haning  Utensils)

0- normal

1- Somewhat slow and dreaming but no help

2- can cut most foods and need some help

3- You have to cut food, but you can eat your own

4- must be fed

. Dressing

0- normal

1- Slow but no help

2- Sometimes need help with buttons or arms

3- I need considerable help, but I can do something alone

4- disabled

. Hygiene

0- normal

1- Slow but no help

2- need help in the shower or bath, or very slow in hygienic care

3- I need help washing my face, brushing my teeth or going to the bathroom

4- inability

. Turning in Bed / Adjusting Bed Clothes

0- normal

1- Slow but no help

2- You can turn alone or adjust the seat, but you have a big difficulty

3- Sanitary treatment, unable to turn over or adjust alone

4- disabled

. Falling-Unrelated to Freezing

0- none

1- rarely falls

2- intermittent, less than once a day

3- average once a day

4- more than once a day

. Freezing when walking

0- normal

1- rare, hesitant early

2- intermittently falling from rigid state

3- frequent stiffness, sometimes falling

4- often stiff and fall

. walking

0- normal

1- Slightly Difficulty, Reduce Leg Shake or Arm Shake by Day

2- Some difficulty but no need help

3- serious disability needs help

4- Can't walk at all with help

. Tremor

0- none

1- Slightly and rarely, not bothered to patients

2- to some extent, bother patient

3- serious, disturbing many activities

4- outstanding, obstructing many activities

. Sensory Complaints Related to Parkinsonism Parkinsonism )

0- none

1- Sometimes numbness, tingling and slight aching

2- frequent but not painful

3- frequent pain feeling

4-excruciating pain

III. Motor Exam

. speaking

0- normal

1- slight loss of expression, wording, size

2- monotonous, obscure but understandable degree of damage

3- outstanding damage, difficult to understand

4- incomprehensible

. Facial Expression

0- normal

1- slight hypomymia, may be a poker face

2- slightly but obviously reduced abnormal expression

3- mood loss, lip opening for some time

4- Remarkably fixed face, complete loss of facial expression and more than 1/4 inch lip open

. Tremor at Rest

. Face

0- none

1- Appears slightly and most of the time

2- slight and most of the time

3- Appears to some extent and most of the time

4- outstanding and most of the time

. Right Upper Extremity (RUE)

0- none

1- Slightly and infrequent

2- slight and mostly present

3- exist some time and mostly

4- prominent and mostly present

. Left arm LUE )

0- none

1- Slightly and infrequent

2- slight and mostly present

3- exist some time and mostly

4- prominent and mostly present

. RLE

0- none

1- Slightly and infrequent

2- slight and mostly present

3- exist some time and mostly

4- prominent and mostly present

. LLE

0- none

1- Slightly and infrequent

2- slight and mostly present

3- exist some time and mostly

4- prominent and mostly present

. Action or Postural Tremor

. RUE

0- none

1- Slightly and infrequent

2- slight and mostly present

3- exist some time and mostly

4- prominent and mostly present

. LUE

0- none

1- Slightly and infrequent

2- slight and mostly present

3- exist some time and mostly

4- prominent and mostly present

. Rigidity

. neck

0- none

1- slightly or only activation

2- slight / somewhat

3- prominence, full range of behavior

4- serious

.RUE

0- none

1- slightly or active only

2- slight / somewhat

3- prominence, full range of behavior

4- serious

. LUE

0- none

1- slightly or activation

2- slight / somewhat

3- prominence, full range of behavior

4- serious

. RLE

0- none

1- slightly or activation

2- slight / somewhat

3- prominence, full range of behavior

4- serious

. LLE

0- none

1- slightly or activation

2- slight / somewhat

3- prominence, full range of behavior

4- serious

. Beat fingers toktok (Finger taps)

. Right side

0- normal

1- Slightly slow, and / or decrease in amp

2- Damaged to some extent. Sometimes freezes due to pronounced initial fatigue

3- Seriously damaged. Frequent hesitation stops

4- Almost impossible.

. left

0- normal

1- Slightly slow, and / or decrease in amp

2- Some damage. Sometimes freezes due to pronounced initial fatigue

3- Seriously damaged. Frequent hesitation stops

4- Almost impossible.

. Hand and hand movements (open and close hands in rapid succession)

.Right side

0- normal

1- Slightly slow, and / or decrease in amp

2- Some damage. Sometimes freezes due to pronounced initial fatigue

3- Seriously damaged. Frequent hesitation stops

4- Almost impossible.

. left

0- normal

1- Slightly slow, and / or decrease in amp

2- Some damage. Sometimes freezes due to pronounced initial fatigue

3- Seriously damaged. Frequent hesitation stops

4- Almost impossible.

. Rapid movement changes ( pronate and supinate hands)

.Right side

0- normal

1- Slightly slow, and / or decrease in amp

2- Some damage. Sometimes freezes due to pronounced initial fatigue

3- Seriously damaged. Frequent hesitation stops

4- Almost impossible.

. left

0- normal

1- Slightly slow, and / or decrease in amp

2- Damaged to some extent. Sometimes freezes due to pronounced initial fatigue

3- Seriously damaged. Frequent hesitation stops

4- Almost impossible.

. Leg Agility (Heat on the ground, 3 inches wide)

. Right side

0- normal

1- Slightly slow, and / or decrease in amp

2- Some damage. Sometimes freezes due to pronounced initial fatigue

3- Seriously damaged. Frequent hesitation stops

4- Almost impossible.

. left

0- normal

1- Slightly slow, and / or attenuation

2- Some damage. Sometimes freezes due to pronounced initial fatigue

3- Seriously damaged. Frequent hesitation stops

4- Almost impossible.

. Stand up from chair (stand up with arms crossed to chest)

0- normal

1- slow, needs more than one try

2- push up or sit down with your arm

3- tends to go back, requires multiple attempts but can happen without help

4- can't happen without help

. posture

0- normal erection

1- Slightly bent and may be normal for older people.

2- totally abnormal, somewhat bent, tilted to one side

3- severe bends with kyphosis

4- very abnormally posture noticeably bent

. Gait

0- normal

1- Walking slowly, dragging your feet with short steps, no festination or propulsion

2- hard walking, slight or no assistance, weak acceleration walking, short stride or forward rush

3- serious disability, frequent assistance

4- can't walk

. Postural stability ( retropulsion test)

0- normal

1- Return to original

2- May fall if not caught

3- sporadic fall

4- can't stand

. Moderate physical exercise (Body Bradykinesia) / Exercise thrombocytopenia (Hypokinesia)

0- none

1- minimal slow, normal, deliver character

2- slight slowness and poor movement, obvious abnormality or reduced movement width

3- somewhat slow, poor or small width

4. noticeable slowness, poorness or width

Notting gum  Health index

The use of questionnaires is a commonly adopted method of measuring quality of life.

Below is a list of some of the problems people may have in their daily lives. Carefully read the list above and check the box r under "YES" at the moment for problems that apply to you. Check the box under "NO" for issues that do not apply to you. Answer all questions. If it is not clear whether yes or old, mark any answer where it is most likely at the moment.

YES NO

-I'm always tired r r -I'm in pain at night r r -Everything frustrates me r r -There is unbearable pain r r -Take medicine for sleeping r r -I forgot what to enjoy r r -Feel the last r r -Find that changing position is painful r r -Feel lonely r r -Can only walk indoors r r -Difficult to bend r r -Everything requires effort r r -I wake up early in the morning -I can't walk at all r r -I find it difficult to meet people r r -Seems to be going slowly -I have trouble going up or down the stairs -Find it difficult to reach r r -Painful when walking r r -Easily excited these days r r -I feel no one near me r r -I'm lying awake most of the night r r -Feel as if you have lost control -Painful to stand r r -Find it difficult to dress by yourself r r -Straight out of energy r r -Find it difficult to stand long (eg in the kitchen sink, waiting for a bus) r r -There is constant pain r r -It takes a long time to fall asleep r r -Feel heavy burdens on people r r -I stay awake at night with worry -I feel that life is not worth living r r -I can't sleep deep at night r r -I find it difficult to be with people r r -I need help when I go outside (eg walking aid or someone to support me) r r -Painful when going up and down stairs -Wake up depressed r r -Painful when sitting r r

Now go back to the beginning and check that you answered "YES" or "NO" to all the questions.

Description of the body-exercise limb examination Posturo Locomotor Manual Test)

(Johnels B, Ingvarsson P.E, Thorselius M, Valls M, Steg G. Disability profiles and objective quantitative assessment in Parkinson's disease.Acta Neurol. Scand., 1989: 79: 227-238)

Physical-motor limb testing (PLM) is a new method designed to measure the degree of disorder of Parkinson's disease. This uses an opto-electronic camera that records the body movements of freely moving patients. Automatic computer technology quantifies the performance of actions to ensure an objective assessment.

Examination process

The PLM test requires that the subject pick up the object from the floor and move it on a shelf raised to his chin height, causing the body to change posture and move the arm-hand in the desired direction. Compared to the performance of normal subjects of the same age, the test is necessary for physical, mobility and limb movement activities, independent living and the degree of disability of all elementary motor functions that are sometimes deficient in Parkinson's patients. Use to measure

The idea is that Parkinson's disease patients differ from others in the degree and pattern of dopamine neuron degeneration in the brain, and in each case it requires posture, degree of mobility and hand and foot disability, disability profile and treatment. The degree of individualized treatment will vary. If so, the PLM trial should be the basis for rational treatment to record and quantify this profile for each patient.

Description of Autonomic Testing

Holmberg B, Kallio M, Jornell B, Elm M, and cardiovascular echo tests contribute to clinical and differential diagnosis of Parkinson's syndrome (Holmberg B, Kallio M, Johnels B, Elam M. Cardiovscular Reflex Testing contributes to Clinical Evaluation and Differential Diagnosis of Parkinsonian Syndromes

All autonomy trials are conducted in the Department of Clinical Neurophysiology, which is based on the analysis of BP changes in heart rate and time zones for clinical routine testing of autonomic function. Subjects are seated on a tilting table, fixed, and begin recording heart rate and BP. Blood pressure measurement with a non-invasive finger BP (Finapres, Ohmeda Monitoring Systems, Englewood, Colorado, USA) according to the principle of volume-clamp and a cuff above the left arm (sphygomanometric method) (Sphygmomanometer BP-203Y, Nippon Colin Co, Muranaka, Komaki-City, Japan) is used. Heart rate is calculated by a computer program and is measured starting with the pulse signal from Finapres. Sinus arrhythmia is assessed for 60 seconds, while comfortably and deeply breathing (six respiratory rotations per cycle) and calculated according to equation: 100 (HRmax-HRmin) / HRmean.

The orthostatic test is carried out continuously and the tilt table is raised for a limited time of 2 seconds with the 75 ° head up in a horizontal position. Quantitative HR and BP changes over a tilted 8 minute period are based on blood pressure measurement data, because even with a finger cuff at the heart position, it is difficult to avoid hydrostatic errors with the pinnapress device. to be. In some patients, a fast and noticeable upright blood pressure drop was recorded as a pinapress signal, but the cuff pressure data before returning the patient to the horizontal position due to presyncopal symptom is unreliable.

MSA Diagnostic criteria for

. Multiple Cranial Nervous System Atrophy

(Gilman S, Low PA, Quinn N et al. Consensus statement on the diagnosis of multiple system atrophy. J Auton Nerv Syst 1998; 74: 189-192)

Table 1: MSA Clinical areas, features and criteria used in the diagnosis of

I. Autonomic and urinary dysfunction

A. Autonomic Nervous System and Urinary Traits

1. Orthostatic hypotension due to [20 mmHg systolic or 10 mmgHg diastolic]

2. urinary incontinence or bladder emptying

B. Criteria for Autonomic Disorders and Urinary Dysfunction in MSA

Orthostatic hypotension or incontinence of blood pressure due to [30 mmHg contraction or 15 mmHg relaxation air pressure] (continuous, non-voluntary partial or complete urination, accompanied by impotence disorder in men) or both

II Parkinsonism

A. Characteristics of Parkinson's Patients

Slow exercise (spontaneous movement slows down as the speed and width gradually decrease during repetitive behavior)

2. Rigid

3. Postural instability [primary vision, vestibular organ, cerebellum or proprioceptive dysfunction]

4. Tremor (posture, rest or both)

B. Criteria for Parkinsonism in MSA

At least one of 2 to 4 besides exercise

III. Cerebellar dysfunction

A. Cerebellar Features

1. Gait ataxia (Wide, inclined foot posture with abnormal length and direction)

2. Ataxic dysarthria

3. Limb ataxia

4. Sustained gaze-evoked nystagmus

B. Criteria of Cerebellar Dysfunction in MSA

At least one item out of steps 2-4

IV cortical spinal cord dysfunction corticospinal  tract dysfunction)

A. Cortical spinal cord

Extensor plantar responses with hyperreflexia

B. Cortical Spinal Dysfunction of MSA: Cortical spinal cord features are not used to define the diagnosis of MSA

Feature (A) is a disease characteristic and criteria (B) is a limited feature or complex of features required for diagnosis.

Table 2: MSA  Diagnostic criteria

I. Possible MSAs: one criterion plus two features in different areas

When the criterion is Parkinson's disease, poor levodopa response becomes one feature (only one additional feature is required).

II. Probable MSA: Criteria: autonomic nervous system disorders / urinary dysfunction plus poorly developed levodopa reactive Parkinsonism or cerebellar dysfunction

III, Confirmed MSA: Pathologically confirmed by the presence of high-strength glia cytoplasmic inclusions in association with degenerative changes in the coronary striatum and olive limb cerebellum.

Table 3: MSA Criteria for the diagnosis of

I. History

Symptoms under 30 years old

Family history of similar disease

System diseases or other recognizable causes for the features listed in Table 1

Drug-related illusions

II. Physical examination

DSM Criteria for Dementia

Noticeable slowness of vertical saccade or vertical nucleus gaze paralysis

Evidence of focal cortical disfunctions such as aphasia, stranger limb syndrome, and parietal dysfunction

III. Laboratory investigation

Metabolic, genetic molecular and image evidence of other causes of the features listed in Table 1

Results after 6 months

Basic characteristics

Eighteen of 43 total randomized patients were included in the interim analysis for safety purposes (9 placebo, 9 r-hGH). Twelve of these 18 patients were included in the efficacy analysis (6 placebos, 6 r-hGH).

Demography

There was no demographic difference between the two groups. The placebo group was slightly heavier in weight and BMI but had no clinical relationship.

Disease form

There was no difference in distribution of MSA-P or MSA-C between disease types, ie treatment populations. But noteworthy was the overall distribution of disease forms. It is expected that about 2/3 MSA-P patients and 1/3 MSA-C patients will be found in the "normal" population in this disease area. However, half of the 50% were observed in each form in this analysis group. Only one center followed the expected pattern. The other two centers were observed to be slightly closer to MSA-C than to MSA-P.

These differences are not any clinical relevance among the treatment groups.

Disease symptoms

The average duration from the diagnosis of MSA to the first dose of study drug was slightly lower among rhGH patients (about 1.5 years compared to 2 years for placebo). However, when analyzing such data more closely, it was observed that the patients had the disease for about 3-5 years rather than the two years mentioned above, while actually watching the other symptoms used to diagnose MSA.

Efficacy Parameters

Only patients who completed six months of evaluation were eligible for efficacy evaluation, ie patients who withdrew six months ago were excluded. As a result, six patients, three in each treatment group, were excluded. Two patients were reported to die in the treatment phase, one with acute respiratory failure and circulatory failure and the other with acute myocardial infarction. Three patients withdrew from side effects and two withdrew their decision not to study.

Motor Examination

Observing the change in scores from start to 6 months, there was an increase in mean levels in the two treatment groups. However, the placebo group's level was increased more than in r-hGH. Level changes in the rh-GH population were better than expected.

It is therefore concluded that there are clinical differences between the two treatment groups due to the benefits of r-hGH.

UPDRS  Total score

Watching the change from start to 6 months, there was an increase in the mean level between the two treatment groups. However, it was found that the level of the placebo group was increased more than in r-hGH. This was probably recognized as a follow up effect from good results of the motion test scores. An increase of about 10-15 points is common and the average change in the r-hGH population is slightly below this.

Therefore, it was concluded that there were clinical changes among treatment groups due to the benefits of r-hGH.

Autonomy test

Take a deep breath  At rest HRV

There was a decrease in the mean level in the placebo group compared to an increase in the mean level in the r-hGH group, watching for changes in HRV levels during deep breathing from the beginning to 6 months. In fact, the average level in the r-hGH group nearly doubled from baseline to six months.

These results are very promising and indicate that r-hGH is more useful for heart rate control than placebo.

It is therefore concluded that there are clinical differences between treatment groups due to the benefits of r-hGH.

Mean Arterial Pressure (MAP)

There was a decrease in the mean level in the placebo group compared to an increase in the mean level in the r-hGH group when the change in MAP level was observed when taking deep breaths for 6 months from the start.

These results are very promising and indicate that r-hGH is more useful for pressure regulation than placebo.

Therefore, it is concluded that there are clinical differences between treatment groups due to the benefits of r-hGH.

Notting gum  Health index

pain

Looking at the level of change in pain scores from the start to 6 months, the mean level in the placebo group increased slightly compared to a very small change in the mean level in the r-hGH group. This represents the benefit of r-hGH.

emotion

The average level of the placebo group was slightly changed compared to the decrease in the mean level of the r-hGH group when the change in the NHP emotional scores from the beginning to 6 months was observed.

flesh

The mean level in the r-hGH group changed slightly in the r-hGH group, but slightly increased in the placebo group.

SBP Lying posture

When looking at the level of change in supine blood pressure from start to 6 months, there was an increase in the mean level in both groups. The increase level in placebo was slightly lower than that in the r-hGH population.

Therefore, it was concluded that there were clinical differences between the two treatment groups due to the benefits of r-hGH.

SBP  Orthostatic blood pressure

When looking at the level of change in standing blood pressure from start to 6 months, there was an increase in mean levels in both groups. The increase level in the placebo group was much lower than that in the r-hGH group. This tended to be the same as the autonomic nervous system and again showed that it could benefit from r-hGH.

Therefore, it was concluded that there were clinical differences between the two treatment groups due to the benefits of r-hGH.

Conclusion of efficacy

The positive effects of r-hGH on autonomic nervous system variables, ie HRV, MAP and blood pressure, and the effect of motion symptoms on this basis can be observed as a whole. Therefore, hGH is proposed as a new treatment for multiple cranial nervous system atrophy.

Reference

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Claims (38)

Initiation of signaling in combination with human growth hormone (hGH) receptors or substances that enable or stimulate the activation of endogenous hGH for the manufacture of a medicament for the treatment and / or prevention of Parkinsonism-Plus Syndrome Use of the substance. 2. The method of claim 1, wherein Parkinson's-Plus syndrome is eukaryotic nucleus palsy (PSP), multiple cerebral neurotrophic atrophy (MSA), amyotrophic axial sclerosis-dementia of Parkinson's disease in Guam, systemic Lewy body disease, cortical basal ganglia degeneration (CGD), Use of said material characterized in that it is selected from the group consisting of Alzheimer's / Parkinson's superposition syndrome, Huntington's disease: rigid variant, Hallerboden-Spartz syndrome, and Gerstman-Straussler syndrome. 3. The use according to claim 2, wherein said Parkinsonism-Plus syndrome is multiple cranial nervous system atrophy. The method of claim 1, wherein the substance is a) human growth hormone; b) a fragment of (a) having an agonistic activity on the hGH receptor; c) a variant of (a) or (b) having anti-activity on the hGH receptor and having at least 70% sequence identity with (a) or (b); d) (a) encoded by a DNA sequence that has an activity on the hGH receptor and hybridizes to the complement of the native DNA sequence encoding (a) or (b) under moderately stringent conditions variants of (b); e) the use of said substance, characterized in that it is selected from salts or functional derivatives of (a), (b), (c) or (d) having anti-activity on hGH receptors. The use of any one of claims 1 to 4, wherein the substance is a naturally occurring human growth hormone. The use of any one of claims 1 to 4, wherein the substance is a recombinant human growth hormone. 7. Use of the substance according to claim 4 or 6, wherein the fragment is a C-terminal fragment of hGH. 7. Use of the substance according to claim 7 or 6, wherein the C-terminal fragment comprises amino acids 177-191 of hGH. Use according to claim 4 or 6, wherein the variant of human growth hormone comprises a methionine residue in addition to the N-terminus of human growth hormone. Use according to claim 4 or 6, characterized in that the fragment of human growth hormone is a human growth hormone which is deleted from 15 amino acid residues of Glu 32 to Glu 46. 5. Use of the substance according to claim 4, wherein the fragment is a truncated human growth hormone, wherein the first eight amino acid residues at the N-terminus are deleted. 5. Use of the substance according to claim 4, wherein the fragment is an incomplete human growth hormone, wherein the first 13 amino acid residues at the N-terminus are deleted. 5. The dimer of human growth hormone according to claim 4, wherein the functional derivative is selected from the group consisting of disulfide dimers, covalently irreversible non-disulfide dimers, non-covalent dimers and mixtures thereof linked via interchain disulfide bonds. Use of said material, characterized in that it comprises. 5. Use of the substance according to claim 4, wherein the functional derivatives are chemical derivatives of human growth hormone. 15. Use according to claim 14, wherein the human growth hormone is acetylated at the N-terminus. Use according to claim 14 or 15, characterized in that the human growth hormone is deamined. 17. The use according to claim 14 or 16, wherein the human growth hormone is sulfoxide at one or more methionine residues. 18. The use of any one of claims 1 to 17, wherein the growth hormone is administered at a dose of about 0.1-10 mg / person / day or about 0.5-6 mg / person / day. 19. The use according to claim 18, wherein said growth hormone is administered at a dosage of about 1 mg / person / day. 20. Use of the substance according to claim 18 or 19, wherein the growth hormone is administered daily or every other day. 21. The use of any one of claims 1 to 20, wherein the growth hormone is administered while changing the daily dose to more than the first dose. Use of the substance according to claim 21, wherein the first dose is about 1 mg / person and the second dose is about 0.5 mg / person. 23. The use according to any one of claims 1 to 22, wherein the weekly dosage of said growth hormone is about 6 mg / person or about 5 mg / person or about 4.5 mg / person. The method of claim 1, wherein the substance is (a) human growth hormone releasing hormone (hGHRH); (b) a fragment of (a) having anti-activity on a hGHRH receptor; (c) a variant of (a) or (b) having counter activity on the hGHRH receptor and having at least 70% sequence identity with (a) or (b); (d) a variant of (a) or (b) encoded by a DNA sequence that has anti-activity on the hGHRH receptor and hybridizes to the complement of a native DNA sequence encoding (a) or (b) under moderate stringent conditions ; or (f) a salt or functional derivative of (a), (b), (c) or (d) having anti-activity on hGHRH receptor. 25. The method of claim 4 or 24, wherein the functional derivative comprises at least one moiety attached to one or more functional groups, represented by one or more side chains on amino acid residues. Use of the substance. 27. The use of claim 25, wherein the moiety is a polyethylene glycol (PEG) moiety. Use of IGF (insulin-like growth factor), characterized in the manufacture of a medicament for the treatment and / or prophylaxis of Parkinsonism-Plus syndrome, in particular multiple cranial nervous system atrophy. The use of IGF according to claim 27, wherein said IGF is selected from IGF-1 or IGF-II. 29. Use of IGF according to claim 27 or 28, wherein said medicament further comprises IGFBP (insulin-like growth factor binding protein) simultaneously, continuously or separately. 30. The use of IGF according to claim 29, wherein said IGFBP is IGFBP3. 31. The use of IGF according to any one of claims 27 to 30, wherein the medicament further comprises the substance of any one of claims 1 to 26. Initiation of signaling in combination with human growth hormone (hGH) receptors or substances that enable or stimulate the activation of endogenous hGH for the manufacture of a medicament for the treatment and / or prophylaxis of Parkinsonism-Plus syndrome, in particular multiple cranial nervous system atrophy. Use of a nucleic acid molecule, characterized in that it comprises a coding sequence of a substance. 33. The use of any one of claims 32 to 32, wherein the medicament is administered into the subcutaneous tissue. 33. The use of any one of claims 1 to 32, wherein the medicament is administered intramuscularly. 35. Use according to any one of the preceding claims, characterized in that the substance is introduced using an auto-injector. Initiation of signaling in combination with human growth hormone (hGH) receptors or substances that enable or stimulate the activation of endogenous hGH for the manufacture of a medicament for the treatment and / or prophylaxis of Parkinsonism-Plus syndrome, in particular multiple cranial nervous system atrophy. Use of a vector, characterized in that it induces and / or increases the endogenous production of a substance. Initiation of signaling in combination with human growth hormone (hGH) receptors or substances that enable or stimulate the activation of endogenous hGH for the manufacture of a medicament for the treatment and / or prophylaxis of Parkinsonism-Plus syndrome, in particular multiple cranial nervous system atrophy. Use of a cell, characterized in that it is genetically modified to produce a substance. In patients in need thereof as a method for treating Parkinsonism-Plus syndrome, especially multiple cranial nervous system atrophy, signal initiation in combination with human growth hormone (hGH) receptors or substances that enable or stimulate the activation of endogenous hGH A method for treating Parkinson's-Plus syndrome, in particular multiple cranial nerve atrophy, comprising administering an effective amount of a substance.