JP5367202B2 - Use of anticoagulants in extracorporeal blood treatment - Google Patents

Description

(Technical field)
The present invention relates to the use of anticoagulants in the extracorporeal circulation of blood.

(Background technology)
In extracorporeal circulation, blood comes into contact with extraneous surfaces. This activates factor XII and platelets through the blood clotting system, eg, the intrinsic pathway of the coagulation cascade. Blood clots. Preventing this is the role of the anticoagulant normally administered in such situations.

  As a clinical practice, it is practically always heparin and heparin-like drugs used for this purpose, but its use has several problems. Patients treated with heparin require particularly continuous monitoring due to the commonly known risk of HIT (heparin-induced thrombocytopenia), osteoporosis, lipid metabolism disorders, and hemorrhagic complications . In general, complex dose prescriptions need to be observed. Thus, after an initial bolus of 10-20 U / kg, patients typically receive an additional 5-10 U / kg / hour to maintain a predetermined level in the blood (Mehta RL, ASAIO Journal, 931- 935 (1994)).

  In view of these drawbacks, the search for alternatives to heparin has been made and so-called low molecular weight heparins have been found in particular, which not only have an increased blood half-life but also an increased aXa / aIIa ratio. doing. Experiments with other glycosaminoglycans such as heparan sulfate, dermatan sulfate, chondroitin sulfate, and mixtures thereof were aimed in the same direction. Thus, for example, Olgaran has an aXa / aIIa ratio of 22, while low molecular weight heparin ranges from 1 to 5 (Beijering et al., Seminars in Thrombosis and Hemostasis). , Vol. 23, No. 2, 225-233 (1997)).

  A corresponding search for long half-life substances has been successful with hirudins. In contrast to the glycosaminoglycans mentioned above, these are peptides, for example medical hirudin, natural hirudin obtained from the salivary glands of Hirudo medicinaliis, or recombinant hirudin (EP 0 158 564). In connection with this, there have also been attempts to extend the relatively short residence time of hirudin in animal or human body, for example, to seek derivatized hirudin. In this sense, EP 0 345 616 describes dextran- and sepharose-derivatized hirudin. EP 0 372 670 embodies hirudins that are sulfated and sulfonated and optionally PEGylated. The PEGylated hirudin mutein described in EP 0 502 962 was also developed with the aim of achieving a longer half-life without decreasing activity (Esslinger H.-U., et al .: Thromb. Haemost 77 (5) (1997) 911-919; Esslinger H.-U., et al .: Ann. Hematol. 76 (Suppl. I) (1998) A97).

  Because of its anticoagulant effect, the above compounds can always be beneficial if an anticoagulant effect is desired. Thus, according to EP 0 502 962, in the case of PEG-hirudin, its efficacy and effect are generally listed as an anticoagulant, and precisely used for extracorporeal blood circulation, such as hemodialysis or cardiopulmonary bypass (Heidrich JP, et al .; Clinical Chemistry and Laboratory Medicine 36 (1998) 847-854). In the area of coronary tissue transplantation, a coating based on polylactic acid has already been treated with PEG-hirudin (Schmidmaier G., et al .: Journal of the American College of Cardiology, 29/2 (1997) 354A).

  Despite being effectively protected during actual dialysis, the frequency of reports on high incidence of disproportionate vascular complications is increasing, especially in patients with chronic kidney disease. With regard to the incidence of serious vascular complications, statistical studies show a high risk of 20-30% per year for dialysis patients receiving long-term treatment. In the United States, about 40-50% of all artificial access (sideways) implanted as a link between extracorporeal circulation and the vascular system must be replaced every year due to functional decline (eg, due to obstruction). I must. In these hemodialysis patients, mortality from vascular complications is about 12% per year. This is due to the survival of only 6 years for patients with chronic kidney disease and who require regular hemodialysis. This survival corresponds to the survival for the metastasized tumor.

  The object on which the present invention is based is to provide supplementary prophylactic, especially combined treatment and prevention, for a broader protection of patients undergoing extracorporeal circulation and, in particular, dialysis patients receiving long-term treatment. This is achieved through the use of a coagulant.

(Disclosure of the Invention)
Accordingly, the present invention relates to the use of at least one anticoagulant for the prophylactic treatment of individuals who are sometimes undergoing extracorporeal circulation of blood.

  Prophylactic treatment is particularly useful to avoid (reduce) vascular complications. The purpose of this treatment is to at least considerably reduce the risk that can occur in the vascular system, in particular to reduce its occurrence. This treatment is particularly important when the individual's blood is not undergoing extracorporeal circulation. Accordingly, this treatment is, in a sense, a post-treatment of an individual who has undergone extracorporeal blood circulation. This supplements the anticoagulant defenses that are always required during extracorporeal circulation, and as a result, often preventive protective effects against the occurrence and presence of vascular complications when blood is not in the extracorporeal circulation. Demonstrate.

(Best Mode for Carrying Out the Invention)
Although the treatment according to the invention can be carried out with an anticoagulant that is different from the anticoagulant used during extracorporeal circulation, in an advantageous embodiment of the invention, certain treatments both during and after extracorporeal circulation are used. Use anticoagulants.

  Accordingly, the present invention relates to the use of at least one anticoagulant for the treatment of an individual by extracorporeal circulation as an anticoagulant during the extracorporeal circulation and for the prevention of vascular complications after extracorporeal circulation. . This corresponds to a method for treating an individual undergoing extracorporeal circulation, in which case at least one anticoagulant is used as an anticoagulant during extracorporeal circulation and for the prevention of vascular complications after extracorporeal circulation. Is used.

  According to the present invention, the treatment period is divided into a treatment stage in which the blood of the individual to be treated passes through the extracorporeal circulation (extracorporeal treatment stage) and a treatment stage in which the blood does not pass through the extracorporeal circulation (internal treatment stage).

  Extracorporeal circulation means diverting blood outside the individual's body. The purpose is usually to exclude body segments from the bloodstream and / or to perform extracorporeal processing of blood. The use of the former is particularly adapted for cardiac incision or main blood vessel surgery, for example, for primary separation of the heart by an artificial heart-lung machine (cardiopulmonary machine). The latter application applies to the treatment of renal function outside the blood kidney, for example hemodialysis in the case of renal failure or other symptoms such as dialysis of patients undergoing lipid apheresis.

  When blood is in extracorporeal circulation, there is contact between the blood or blood component and the extracorporeal system surface, which can lead to activation of blood coagulation, among others. From a medical point of view, this situation requires anticoagulant means, which are particularly focused on blood in the extracorporeal system at the extracorporeal stage. The anticoagulant according to the invention is used as an anticoagulant for this purpose. Anticoagulant effects are particularly relevant in this regard to the prevention of thrombus formation and, where appropriate, to the reduction of thrombus growth in extracorporeal systems.

  Furthermore, it is possible to take a more convenient anticoagulation means during the extracorporeal stage using a specific anticoagulant. The convenience and necessity of further anticoagulant measures is left to expert evaluation. Thus, additional anticoagulants in addition to specific anticoagulants may be used in the framework of additional anticoagulant means. A particular type of further anticoagulant means consists of equipping an extracorporeal system or part thereof with an anticoagulant, for example a coating surface.

  The term “anticoagulation” has a generally accepted meaning for the purposes of the present invention. Accordingly, anticoagulants include generally accepted anticoagulants and agents that have a similar effect on blood clotting in vertebrates, preferably mammals, especially humans.

  A particular class of anticoagulants comprises direct thrombin inhibitors such as hirudins and hirudin derivatives, especially PEG-hirudin.

In one aspect of the invention, anticoagulants with an extended half-life in the organism to be treated are advantageous for certain treatment formulations according to the invention. Suitable for this purpose in the present invention is an anticoagulant with a longer half-life than heparin, especially unfractionated heparin, especially the terminal half-life of intravenous administration is at least about 4 hours, more preferably about 5 hours, In particular at least about 6 hours. The defined terminal half-life is related to substantially complete renal function, in other words, renal removal efficiency that is normal and corresponds to a creatinine clearance CL _CR of at least about 100 ml / min.

  In another aspect of the present invention, anticoagulants with sustained pharmacodynamic activity in the organism to be treated are advantageous for certain treatment formulations according to the present invention. An agent with pharmacodynamic activity is an agent with minimal prophylactic activity according to the present invention, ie, an agent that provides a clinically relevant reduction in vascular complications compared to an untreated control group. Sustained means in particular the length of time that extends beyond the extracorporeal phase, in particular, in the case of periodic repetitions of the extracorporeal and intracorporeal phase, the length of time that is advantageously extended to the next extracorporeal phase. means.

  The half-life and pharmacodynamics of the anticoagulant are not only dependent on the drug selected, but are also controlled within the framework of the treatment and especially within the mode of administration, for example by pharmaceutical means. Thus, agents that themselves have a short half-life or short pharmacodynamic activity can be administered as a suitable slow release formulation.

  Anticoagulants with extended half-life and / or sustained pharmacodynamic activity are described, for example, in EP 0 345 616 and consist of hirudin and a soluble carrier as a drug with a delayed action Related to certain hirudin derivatives. The contents of these documents, and in particular the hirudin derivatives described therein, in particular the complexes of the formula I, are composed of polyalkylene glycols or polyalkylene glycol derivatives and hirudin, desulfato hirudin or anticoagulant hirudin muteins. And forms part of this disclosure.

Use of anticoagulants with extended half-life and / or sustained pharmacodynamic activity is useful as anticoagulants during extracorporeal circulation and for prevention of vascular complications after extracorporeal circulation As an advantage, any of them can be used. Thus, the treatment according to the invention is preferably carried out with a single agent.
It is particularly preferred in the present invention to use PEG-hirudin.

  PEG-hirudin means a complex of hirudin and polyethylene glycol. The term hirudin is used herein to refer to a series of anticoagulants based on polypeptides derived from hirudin itself, ie, medical leeches, natural hirudin obtained from Hirudo medicinaliis. . Thus, the term hirudin according to the invention encompasses recombinant mutants (γ-hirudin) and mutants (hirudin muteins). Suitable for conjugation with polyethylene glycol are the polypeptides of the formula II described in EP 0 502 962, and of these, in particular of SEQ ID NO: 1 according to the invention. The polyethylene glycol is preferably conjugated via a lysine residue; if appropriate, a suitable linker is used, such as that shown in EP 0 502 962, which is under physiological conditions. Conveniently stable.

According to the present invention, it is particularly preferred to use PEG-L-Luzin which is also associated with the above polypeptide having SEQ ID NO: SEQ ID NO: 1, in which the polyethylene glycol residue is in each case a lysine at position 27 And lysine at position 33. The linkage can occur, for example, via a urethane-like linker. The polyethylene glycol residue is represented by the following formula:
_{-CO-O-CH 2 -CH 2} - [O-CH 2 -CH 2 -] nOR
(Wherein n is an integer from 50 to 200, preferably 75 to 150, especially 110 to 120; R is preferably alkyl having 1 to 4 carbon atoms). R is in particular methyl. These polyethylene glycol residues are preferably bound to the ε-amino group of the lysine residue. Thus, the term PEG-hirudin refers to a typically heterogeneous mixture of PEGylated peptides having various polyethylene glycol residues. The diversity of polyethylene glycol residues is due in particular to the PEG chain length, depending on the value of n, the amount is in the range of about 2000 to about 9000, preferably about 3000 to about 7000, especially in the range of about 5000 ± 1000 Da. Will change.

  According to one aspect of the invention, one embodiment of PEG-hirudin has a weight average molecular weight determined by exclusion chromatography (Superose 12; calibrated by PEG; Pharmacia) of about 17,000 ± 1000 Da. It is.

  According to another aspect of the invention, in an advantageous embodiment of PEG-hirudin, the antithrombotic activity for the protein is 10,000-14,000 ATU / mg.

  There are several possibilities for joining the extracorporeal system to the vasculature of the individual to be treated. Conventional alternatives are arteriovenous (AV), venous vein (VV) and venous artery (VA) type joints, whereby the direction of blood flow is drawn based on the body vasculature in each case. For example, arteriovenous junctions depict an extracorporeal system that removes arterial blood from an individual's body, returning blood to the body's venous system, if necessary, after appropriate processing. AV and VV junctions are usually preferred in the area of hemodialysis and hemofiltration. Extracorporeal VV and VA systems are usually operated with external pumps, but extracorporeal AV systems do not require this—but arterial blood pressure needs to be sufficient. The doses of anticoagulant and adjuvant anticoagulant differ for different types of conjugation; for example, higher doses require the use of a pump.

Access to the body's vasculature may be achieved, for example, by introducing a tubular suction line into the body's blood vessels. A suitable example is a cannula or catheter whose dimensions, in other words its length and inner diameter, can be adapted to a particular system. For example, a short bore wide catheter is suitable for an AV system and a double hole catheter is suitable for a VV system. Usually so-called shunts are used as a suitable means of access to the body's vasculature, for example in the form of an artificial blood vessel insertion tube or a fistula.

  In some cases, blood flows or passes through a filter or membrane. The membrane must be selected according to the anticoagulant used. The preferred use of PEG-hirudin according to the present invention is particularly suitable for conventional membranes and filtration systems used in the areas of hemodialysis and hemofiltration. These membranes include natural materials such as cellulose derivatives such as cellulose triacetate membranes and synthetic materials such as membranes such as polysulfone, polyamide, polyacrylonitrile. It is an example of the structure in which a plate-like filter and hollow fiber arrangement are possible. One advantage of using PEG-hirudin is suitable for both HF membrane (high flow) extracorporeal systems and LF membrane (low flow) extracorporeal systems. A further advantage is that PMMA membranes such as poly (methyl acrylate) or poly (methyl methacrylate) copolymers as described in DE 197 15 504 A1, such as Toray's membranes known for this purpose, can be added to PEG-Hirudin. Due to its special binding properties, it can be used as a functional antidote for the rapid removal of PEG-hirudins, for example in the case of intolerance reactions or overdose.

  The purpose of the anticoagulant use according to the present invention is to prevent secondary vascular complications after extracorporeal circulation, in addition to the purpose of inhibiting coagulation during extracorporeal circulation.

  Vascular complications, according to the present invention, include brain, heart, mesentery and peripheral blood vessel dysfunction, and associated pathological conditions, and symptoms thereof. These include, for example, thrombus formation in the vasculature of the individual to be treated, in particular venous and arterial thrombosis, especially deep vein thrombosis, peripheral occlusive disease, shunt thrombosis, catheter thrombosis, thromboembolism, myocardium Infarcts, unstable angina, and seizures. Therefore, the use of anticoagulants according to the present invention is particularly advantageous for individuals at high risk of vascular complications. Increased risk factors include coagulation disorders, particularly AT-III deficiency and elevated fibrinogen levels, thrombocytosis, HIT, and high blood pressure and existing disorders such as coronary heart disease, diabetes or other vascular disorders .

  The use of anticoagulants according to the invention for the prevention of vascular complications extends at least from the time of extracorporeal circulation to the later period, and according to certain embodiments of the invention, directly to the period leading to it. In the case of multiple occasions, i.e. a regularly interrupted extracorporeal circulation, i.e. in the case of a regular series of extracorporeal and intracorporeal phases, this period ideally extends to the next extracorporeal phase. . According to a particular embodiment of the invention, the anticoagulant is used to treat an individual by alternating between multiple in vitro and in vivo stages, but as an anticoagulant in the in vitro stage and in the vascular system in the in vivo stage. Used to prevent illness. To be complete, use as an anticoagulant in the extracorporeal phase can also be claimed to be a prophylactic treatment of vascular complications; in fact, always.

  The use of the anticoagulant according to the invention consists of one method within the framework of the treatment. This method involves administering an appropriate amount of one or more anticoagulants, usually formulated according to the practice of human medicine or veterinary medicine, to the individual to be treated, preferably animals, especially humans, livestock animals or livestock. You need to do.

  The administration of the anticoagulant can be carried out in accordance with the administration method of a systemic drug, which is usually required. The possible routes of administration include the oral route, including the oral route, as a conventional possibility of administering an appropriate amount of anticoagulant, injecting into the dialysis system via the parenteral route, specifically, the introduction means, especially from the bloodstream tip That is.

  In view of extracorporeal circulation, the appropriate amount of anticoagulant to be administered is particularly determined by the blood level anticoagulant effect obtained. According to one aspect of the invention, values in the therapeutic range are convenient. The term “treatment” as used herein means an action capable of resisting thrombotic stimulation that occurs during extracorporeal circulation. Beneficial in this sense are anti-IIa based blood levels (minimum blood levels) of at least about 400 ng / ml, preferably at least about 500 ng / ml, especially at least about 600 ng / ml. The APTT measurement indicates an APTT that is advantageously stretched at least about 1.3 times, preferably at least about 1.6 times, and in particular at least about 1.8 times. The measured value of ECT is at least about 1.2 times, preferably at least about 1.6 times, and especially at least about 1.8 times, indicating an advantageously extended ECT.

  According to a further aspect of the invention, a convenient value is a value at which the treated individual continues to place the risk of bleeding within limits. In this sense, the blood level is about 5 minutes after administration of the anticoagulant, based on anti-IIa, with a maximum value of about 2400 ng / ml, preferably a maximum value of about 1700 ng / ml, in particular a maximum value of about 1500 ng / ml. It is advantageous to be. The APTT measurement shows a maximum value of about 5.0 times, preferably a maximum value of about 3.3 times, in particular a maximum value of about 2.7 times, advantageously showing a prolonged APTT. The measured value of ECT shows a maximum value of about 5.5 times, preferably a maximum value of about 4.5 times, in particular a maximum value of about 4.0 times, advantageously showing an extended ECT.

  The above values need not be maintained throughout the period in the extracorporeal phase-if medically determinable. According to an advantageous embodiment of the invention, the amount of anticoagulant to be administered is such that the minimum blood level is obtained at the end of extracorporeal circulation. According to a further advantageous aspect of the invention, the above values apply for a time period which is limited on the one hand by reaching the maximum blood level and on the other hand by the end of the extracorporeal phase.

  The timing of administration of the anticoagulant and, if appropriate, further anticoagulants are appropriately selected so that the anticoagulant action is ensured even in the initial stage of extracorporeal circulation. For this purpose, administration can take place prior to joining the extracorporeal system. It is also possible to administer directly at the time of joining the extracorporeal system, and in this case, for convenience, it may be conducted via the extracorporeal system. If administration is performed directly at the time of extracorporeal system conjugation, this is usually done at the tip of the bloodstream, or if the patient's residual level of anticoagulant allows it from a medical point of view-immediately thereafter. Administration via an extracorporeal system should be included in the present invention within the scope of the term parenteral administration--when joining a vein to the extracorporeal system-especially within the scope of the term intravenous administration. It is.

  In view of the treatment after extracorporeal circulation according to the invention, the suitable amount of anticoagulant to be administered is particularly determined by the prophylactic effect of the blood levels obtained. The preventive effect associated with this is antithrombotic action, which can be adapted to relatively weak thrombotic stimulation after extracorporeal circulation. During the extracorporeal treatment phase, it is usually possible to choose a level whose blood level is lower than that obtained during extracorporeal circulation. According to one aspect of the invention, a range of prophylactic activity is possible-relative to the therapeutic blood level obtained during extracorporeal circulation. Advantageous in this sense is the blood level of anticoagulant based on anti-IIa in extracorporeal circulation, the value of which is at least about 150 ng / ml, preferably at least about 300 ng / ml, especially at least about 400 ng / ml. APTT measurements indicate at least about 1.2 times, preferably at least about 1.3 times, especially at least about 1.5 times, advantageously extended APTT. The measured value of ECT is at least about 1.1 times, preferably at least about 1.3 times, especially at least about 1.4 times, indicating an advantageously extended ECT. In particular, the blood level at the extracorporeal stage varies between the blood level after the end of the extracorporeal circulation and the above minimum value. Blood levels usually decrease as a function of time.

  These values do not necessarily need to be maintained throughout the whole extracorporeal phase. According to another advantageous embodiment of the invention, the amount of anticoagulant to be administered is such that the blood levels obtained at the end of the internal phase are in the order of a constant interval between the external phase and the internal phase, the anti-IIa. Based on at least about 150 ng / ml, preferably at least about 300 ng / ml, especially at least about 400 ng / ml. APTT measurements indicate at least about 1.2 times, preferably at least about 1.3 times, especially at least about 1.5 times, advantageously extended APTT. The measured value of ECT is at least about 1.1 times, preferably at least about 1.3 times, especially at least about 1.4 times, indicating an advantageously extended ECT. On the other hand, advantageous blood levels at this point are based on anti-IIa, with a maximum value of about 1000 ng / ml, preferably a maximum value of about 700 ng / ml, and especially a maximum value of about 600 ng / ml. The measured value of APTT shows a maximum value of about 3.5 times, preferably a maximum value of about 2.8 times, in particular a maximum value of about 2.5 times, advantageously extended APTT. The measured value of ECT shows a maximum value of about 4.0 times, preferably a maximum value of about 3.0 times, in particular a maximum value of about 2.5 times, advantageously extended ECT.

  Due to the therapeutic blood level present at the end of the extracorporeal circulation, quasi-therapeutic blood levels are usually obtained only after a certain transient period after extracorporeal circulation. The transition period from treatment to quasi-treatment, and especially prophylactic blood levels, depend on the anticoagulant being removed naturally from the blood of the treated individual or, if appropriate, artificially removed .

Certain aspects of the invention include treatment of individuals with renal failure. Renal failure, according to the present invention, means that the removal efficiency of the kidney is inappropriate or absent. These are in particular individuals with a creatinine clearance CL _CR of less than 100 ml / min, in particular less than 50 ml / min, in particular less than 10 ml / min.

  According to one aspect of the invention, individuals with acute renal failure, i.e. individuals with inadequate or absent renal removal efficiency, are treated. In this case, the blood of the affected individual is subjected to extracorporeal treatment until proper renal removal efficiency is restored. The duration of the extracorporeal stage naturally varies from case to case and is an average of several days. This type of treatment is referred to as continuous blood filtration in the present invention. A continuous treatment period of at least about 3 days, particularly at least about 5 days, represents a particular embodiment of the present invention.

  A further particular aspect of the invention is aimed at treating individuals with chronic renal failure. These are individuals whose kidney removal efficiency is permanently inadequate or absent. In this case, extracorporeal circulation is a steady event. The duration of the extracorporeal phase, and the gap between the extracorporeal phases corresponding to the extracorporeal treatment phase according to certain aspects of the present invention, is matched to the individual's symptoms, especially considering the remaining renal removal efficiency. The present invention particularly relates to individuals who have undergone extracorporeal circulation at least once a week, individuals who have advanced chronic renal failure, and therefore those who have undergone extracorporeal circulation on average, at least about twice a week, especially about three times. Goal. This type of treatment is referred to as intermittent (periodic) hemodialysis in the present invention and, according to a particular embodiment of the present invention, represents a long-term treatment consisting of extracorporeal and intracorporeal treatment steps.

  Within the scope of this aspect relating to intermittent hemodialysis, suitable blood levels are given as a single dose, or with multiple doses, in particular 2, 3 or 4 doses, with the appropriate amount of anticoagulant per cycle. It can be achieved by administration. According to a particular embodiment of the invention, the anticoagulant is administered in the form of a vehicle dose per cycle and thus once per hemodialysis.

  A cycle consists of an extracorporeal phase and an internal phase. Administration is preferably carried out at the start of the cycle, i.e. at the start of the extracorporeal phase, especially in the case of a single dose. However, administration may occur at other points in the cycle, for example after the end of extracorporeal circulation. Another possibility is to administer the anticoagulant at the start of the extracorporeal phase and after the end of extracorporeal circulation. The dose of a single dose, preferably as a bolus, can be advantageous to give a new dose of anticoagulant at the start of each case's next cycle. Underlying each possible dose is the respective blood level of the anticoagulant specifically measured before the start of the cycle, especially in the case of a single dose to be administered at the start of the cycle. Corresponding blood levels are increased by administering that dose. The level reaches a maximum value which is in a range appropriate for the purpose of the anticoagulant means. In the case of a single dose to be administered at the beginning of the cycle, an advantageous blood level 5 minutes after administration is based on anti-IIa, at least about 600 ng / ml, preferably at least about 700 ng / ml, especially at least about 800 ng / ml. The APTT measurement indicates an APTT that is advantageously stretched at least about 1.5 times, preferably at least about 1.9 times, especially at least about 2.3 times. The measured value of ECT is at least about 1.5 times, preferably at least about 2.0 times, in particular at least about 2.5 times, advantageously indicating an extended ECT.

  On the other hand, these maximum values should be kept as low as possible in view of the risk of bleeding. One advantage of using PEG-Hirudin is that these maximum values can be up to about 2400 ng / ml, preferably up to about 1700 ng / ml, and especially up to about 1500 ng / ml based on anti-IIa. Thus, APTT can be extended up to about 5.0 times, preferably up to about 3.3 times, and in particular up to about 2.7 times, and for ECT up to about 5.5 times, preferably about 4 times. It is possible to extend up to .5 times, especially up to about 4.0 times.

  Blood levels decrease as a function of time during the extracorporeal phase. The blood level advantageously remains in the therapeutic range during the extracorporeal phase. In this connection, the above blood levels are also advantageous here. On the other hand, an advantageous blood level at the end of the extracorporeal phase, based on anti-IIa, has a maximum value of about 2000 ng / ml, preferably a maximum value of about 1500 ng / ml, especially a maximum value of about 1100 ng / ml. The measured value of APTT shows a maximum value of about 4.5 times, preferably a maximum value of about 3.6 times, in particular a maximum value of about 2.5 times, and advantageously a prolonged APTT. The measured value of ECT shows a maximum value of about 4.0 times, preferably a maximum value of about 3.5 times, in particular a maximum value of about 3.0 times, advantageously extended ECT.

  According to the present invention, a single dose can remain substantially the same from cycle to cycle when using anticoagulants within the framework of intermittent hemodialysis. Accordingly, an individual is administered an amount of an anticoagulant that remains substantially constant from cycle to cycle. This amount may be based on individual parameters, particularly parameters that affect the dosage, eg, the body weight of the individual to be treated, although it is possible to use a constant dose for each individual. However, the fact that adaptation to the anticoagulant used according to the invention is necessary at the start of treatment must be taken into account. Thus, for example, in order to regularly administer PEG-hirudin to patients with chronic renal failure and obtain suitable blood levels, a relatively high dose must be selected at the start of administration. As a result, the dosage can be maintained at a substantially constant level during subsequent regular administration of PEG-hirudin from cycle to cycle. The adaptation phase is usually several cycles, preferably less than 15 cycles, especially less than 10 cycles, but after about 5 cycles, the dose is advantageously about ± 25% or especially ± 10% of the maximum value, Preferably it can be selected at a substantially desired constant dose.

  If the anticoagulant is administered at a dose that remains substantially the same, the individual's monitor can be limited to checking for specific blood levels prior to the extracorporeal phase, where appropriate. Check for specific blood levels after administration of a single dose. The former check has a particular role as the basis for the required dose, and the latter is to avoid an increased risk of bleeding due to excessive blood levels. It can be mentioned in this context that the use of PEG-hirudin advantageously offers the possibility of removing the ability of PEG-hirudin from the blood of an individual. The membrane referred to for this purpose is the membrane described above and is a known membrane.

  According to a particular embodiment of the present invention, the single dose administered for hemodialysis, preferably at the start thereof, is based on anti-IIa on hemodialysis and the concentration of anticoagulant is about 400 ng / ml. To about 2400 ng / ml, preferably about 500 ng / ml to about 1700 ng / ml, especially about 600 ng / ml to about 1500 ng / ml. In this sense, the measured APTT is in the range of about 1.3 times to about 5.0 times, preferably in the range of about 1.6 times to about 3.3 times, especially about 1.8 times to about 2.times. Stretched in the range of 7 times, or measured ECT in the range of about 1.2 times to about 5.5 times, preferably in the range of about 1.6 times to about 4.5 times, especially about 1 It is stretched in the range of .8 times to about 4.0 times.

  According to another particular embodiment of the present invention, for hemodialysis, preferably a single dose administered at the start is based on anti-IIa after the end of hemodialysis until the next dialysis. The concentration of the coagulant is varied in the range of about 2000 ng / ml to about 150 ng / ml, preferably in the range of about 1500 ng / ml to about 300 ng / ml, especially about 1100 ng / ml to about 400 ng / ml. In this sense, the measured APTT is in the range of about 4.5 times to about 1.2 times, preferably in the range of about 3.0 times to about 1.3 times, in particular, about 2.5 times to about 1. Stretched in the range of 5 times or measured ECT in the range of about 4.5 times to about 1.1 times, preferably in the range of about 3.5 times to about 1.3 times, especially about 3 It is stretched in the range of 0.0 times to about 1.4 times.

  Within the specific embodiments of the invention above, a single dose administered for hemodialysis is preferably about at least about 5 minutes after administration, with the anticoagulant concentration being anti-IIa. 600 ng / ml, preferably at least about 700 ng / ml, especially at least about 800 ng / ml. The APTT measurement indicates an APTT that is advantageously stretched at least about 1.5 times, preferably at least about 1.9 times, especially at least about 2.3 times. The measured value of ECT is at least about 1.5 times, preferably at least about 2.0 times, in particular at least about 2.5 times, advantageously indicating an extended ECT.

  Such blood levels are usually obtained by bolus administration in the range of about 200 to about 1400 ATU / kg of body weight, preferably about 400 ATU / kg to about 1200 ATU / kg, especially about 600 ATU / kg to about 1000 ATU / kg. . After adaptation, for individuals with chronic renal failure, a dose of about 200 to about 1000 ATU / kg per body weight, preferably about 200 ATU / kg to about 800 ATU / kg, especially about 400 ATU / kg, by an extracorporeal circulation three times a week on average. To about 600 ATU / kg. The abbreviation ATU means an antithrombin unit based on the WHO I thrombin standard.

  In particular, individuals with chronic renal failure, after an adaptation of about 0.02 to about 1.0 mg of PEG-hirudin, in each case based on 1 kg body weight, with an extracorporeal circulation 3 times a week Has a specific activity of PEG-hirudin of about 10,000 to 14,000 ATU / mg as a protein and, in particular, a specific activity of about 13,350 ATU / mg as a protein at a dose of about 0.03 to about 0.06 mg. Can be processed.

  The invention also relates to the use of an anticoagulant for producing a medicament for the treatment according to the invention, in particular a pharmaceutical composition. Thus, the anticoagulant is usually administered in the form of a pharmaceutical composition containing at least one excipient suitable for the preparation in addition to the drug. This type of composition or medicament can be manufactured and formulated by techniques well known to those skilled in the art.

  Pharmaceutical compositions suitable for parenteral administration are preferably administered in liquid dosage forms. Particularly preferred are drug solutions in aqueous media such as water or saline.

  For practical use, the anticoagulant, especially PEG-hirudin, can be supplied separately from its solvent as a solid form, particularly as a lyophilized product. Drugs and solvents should be packaged in suitable containers, such as vials, so that they can be reconstituted into solutions of known known concentrations. Suitable in view of the above preferred dosages are, for example, 2 to 10 ml containers each containing 5-50 mg PEG-hirudin; vials containing 50 mg PEG-hirudin are supplied as frequent dose containers (Drug back with stock solution).

  The term blood level refers to a specific amount of an individual's blood anticoagulant, eg, by using one or several approved values of activity, where appropriate, by using quantitation methods described in the literature. Can be represented.

  The approved concentration of anti-coagulant based on anti-IIa is related to the protein content of PEG-hirudin used. Equivalent amounts apply to other substances with anti-IIa activity.

  Measurement of ECT (ecarin clot formation time) refers to the use of a direct thrombin inhibitor according to the present invention.

  The certified blood level represents an average value associated with at least about 10 individuals as a group. Thus, due to the variability of organisms, the value of a single individual is usually different from the statistical average approved within the framework of statistical evaluation, but can still be assigned to the average.

  The certified blood level is a guideline value that can vary within the range of measurement accuracy even when related to the same measurement sample. The measurement accuracy of the individual quantification method is shown in the reference example. This variation is represented by adding “about” to the beginning of each value.

The intention of the following examples is to illustrate the invention and not to limit it.
Example 1
Treatment of Dialysis Patients with PEG-Hirudin Twenty 18- to 75-year-old male and female patients who had to undergo hemodialysis regularly were selected. PEG with an antithrombin specific activity of 13,354 ATU / mg as protein per kg body weight after first treatment with heparin (UHF = unfractionated heparin) followed by PEG-hirudin treatment and immediately before the first dialysis -A dose of hirudin of 0.08 mg / kg was administered by intravenous injection. Subsequently, hemodialysis was continued for an average of 4 hours three times a week, and hemodialysis was performed with a GFS plus 16 dialyzer using a HemoPhan low flow membrane. At the end of dialysis and before performing the next dialysis, the PEG-hirudin concentration in the patient's blood was first quantified. This measurement was based on the amount of PEG-hirudin to be administered immediately before each hemodialysis. The remaining PEG-hirudin concentration increased initially and the dose could be reduced from the original 0.08 mg / kg (body weight) to 0.03 to 0.05 mg / kg (body weight). What has become clear is that this dose is suitable for obtaining blood levels of PEG-hirudin in the range of about 500 to 1000 ng / ml of whole blood after the end of each dialysis three times a week. It is that you are. The blood concentration of residual PEG-hirudin in each patient between hemodialysis and hemodialysis ensured preventive protection against vascular complications.
The results are summarized in Tables 1-3.

Reference example 1
APTT Quantification Quantification of activated partial thromboplastin time (APTT) is based on plasma fibrin formation induced by adding partial thromboplastin (actin FS) and calcium ions to plasma. Ellagic acid is used as an activator.

  Carefully mix 9 volumes of venous blood + 1 volume of citrate (0.13 mol / L) and centrifuge at 1600 × g, 2-10 ° C. for 10 minutes. The sample volume is at least 450 μl. If necessary, quickly freeze the sample and store it in the freezer.

  Controls used include normal range control plasma, therapeutic range control plasma, low therapeutic range control plasma, and normal range quality control, eg, commercially available control from Dade, Citrol ) 1, Citrol 2, Citrol 3, and Coag Trol N.

The measurement is performed with ACL3000.
ACl3000 is a fully automated microcomputer controlled centrifugal analysis system. After the start of the analysis cycle, the sample and actin are pipetted separately into a half cuvette of an acrylic glass reaction rotor consisting of 20 cuvettes, mixed and then incubated. After incubation, pipette calcium chloride into the cuvette, mix and measure. The measurement is performed while rotating the rotor. The turbidimetric light source is a light emitting diode (LED) whose light beam is directed to the measurement cuvette via a light guide system (λ = 660 nm). The distribution of scattered light is measured at an angle of 90 ° with respect to the light source by means of a semiconductor sensor placed under the rotor carrier. The measurement results can also be expressed as a ratio and are described as the ratio of the current value to the individual baseline value of the patient before dialysis with PEG-hirudin.
The measurement accuracy is + 10% to −10%.

Reference example 2
Quantification of anti-IIa activity Quantification of anti-IIa activity is based on the measurement of activity remaining after adding excess thrombin to the sample. Heparin and other non-thrombin serine proteases are neutralized by adding protamine chloride and aprotinin to the sample prior to assay. The remaining thrombin cleaves the chromogenic substrate S223B added to the sample.

  Nine volumes of venous blood and 1 volume of citrate (0.13 mol / L) are mixed carefully and centrifuged at 1600 × g, 2-10 ° C. for 10 minutes. The sample volume is about 100 μl. Samples should be quickly frozen if necessary and stored in the freezer.

The following standards are used for quantification of PEG-hirudin:
Standard A: PEG-hirudin concentration [C] = 26.6 mg / ml; specific protein activity, 11,696 ATU / mg
Standard B: [C] = 500 μg / ml (Standard A diluted 1: 53.3 with 0.5% BSA)
Standard C: [C] = 50 μg / ml (Standard B diluted 1:10 with 0.5% BSA)
Standard D: [C] = 1000 ng / ml (standard C diluted 1:50 in normal human citrated plasma)
Standards BD are partially frozen and stored until use.

Calibration samples with concentrations of 100, 200, 400, 600 and 800 ng / ml are prepared by appropriately diluting standard D with normal human citrated plasma.
This method can be standardized accordingly for the determination of other anticoagulants.

The measurement is carried out with ACL 3000 (incubation time: 120 seconds; interval between lamps: 3 seconds; delay time: 3 seconds; acquisition time: 120 seconds; speed: 600 rpm). Absorbance is measured using a 405 nm filter at a constant rotor speed.
The measurement accuracy is +20 to -10%.

Reference example 3
ECT quantification ECT quantification (ecarin clot formation time) is based on inhibition of coagulation activity of meizothrombin. Ecarin is a purified fraction of Echis carinatus snake venom, which produces meizothrombin by cleavage of prothrombin in plasma. The time from ecarin-induced fibrinogen clotting is measured.

  Nine volumes of venous blood and 1 volume of citrate (0.13 mol / L) are mixed carefully and centrifuged at 1600 × g, 2-10 ° C. for 10 minutes. The sample volume is about 100 μl. Samples should be quickly frozen if necessary and stored in the freezer.

The following standards are used for quantification of PEG-hirudin:
Standard A: PEG-hirudin concentration [C] = 26.6 mg / ml; specific protein activity, 11,696 ATU / mg
Standard B: [C] = 500 μg / ml (Standard A diluted 1: 53.3 with 0.5% BSA)
Standard C: [C] = 50 μg / ml (Standard B diluted 1:10 with 0.5% BSA)
Standard E: [C] = 2500 ng / ml (standard C diluted 1:20 in normal human citrated plasma)
Standards B to E are partially frozen and stored until use.

Calibration samples with concentrations of 250, 500, 1500, 2000 and 2500 ng / ml are prepared by appropriately diluting standard E with normal human citrated plasma.
This method can be standardized accordingly for the determination of other anticoagulants.

  The measurement is carried out with ACL 3000 (incubation time: 120 seconds; interval between lamps: 3 seconds; delay time: 3 seconds; acquisition time: 800 seconds; speed: 1200 rpm).

The measurement results can also be expressed as a ratio and are described as the ratio of the current value to the individual baseline value of the patient before dialysis with PEG-hirudin.
The measurement accuracy is + 30% to -10%.

Reference example 4
Quantitative terminal half-life tau _1/2 of terminal half-life tau _1/2 is calculated from 0.693 / [lambda] z. λz represents the terminal removal rate determined by linear regression of a log plot of blood related drug concentration versus time as the terminal slope of the concentration-time curve. For example, λz is calculated to be 0.086 1 / hour and τ _1/2 is calculated to be 8.04 hours based on the concentration change with time shown in Table 4 below.

  According to patient 15 example, shows dose of PEG-hirudin administered from 1 to 50 dialysis (bar graph) and blood level of PEG-hirudin measured after completion of some dialysis (black dots) ;   According to the example of patient 16, the dose of PEG-hirudin administered from 1 to 47 dialysis (bar graph) and the blood level of PEG-hirudin measured after the end of some dialysis (black dots) ;   According to the example of patient 18, PEG-hirudin doses (bar graph) administered from 1 to 49 dialysis and blood levels of PEG-hirudin measured after completion of some dialysis (black dots) ;   According to the example of patient 20, the dose of PEG-hirudin administered from 1 to 31 dialysis (bar graph) and the blood level of PEG-hirudin measured after the end of some dialysis (black dots) ;

Claims (8)

PEG for the manufacture of a medicament for treating individuals with chronic kidney failure (polyethylene glycol) - Use of a hirudin, and cycle the individual body to repeat the extracorporeal step individual blood is circulated extracorporeally, the individual because the blood require intermittent hemodialysis including the in-vivo step not circulated extracorporeally, other Me effective anticoagulation defense between the extracorporeal circulation, and the prevention of vascular complications after extracorporeal circulation The PEG-hirudin is applied to be administered at the start of hemodialysis in the form of a single dose per cycle, the single dose for the one cycle being obtained at the end of the body stage Use of the PEG-hirudin, applied such that the blood level of PEG-hirudin is at least 150 ng / ml .
Use according to claim 1, wherein the vascular complication is thrombus formation in the vasculature of an individual.
The vascular complication is selected from venous and arterial thrombosis, deep venous thrombosis, peripheral occlusive disease, shunt thrombosis, catheter thrombosis, thromboembolism, myocardial infarction, unstable angina, and stroke The use according to claim 1.
4. Use according to any one of claims 1 to 3 , wherein the PEG-hirudin has a terminal half-life of at least 4 hours.
The use according to any one of claims 1 to 4 , wherein the PEG-hirudin is derived from recombinant hirudin.
Single dose administration for one cycle, according to any one of claims 1 to 5 to 2.7-fold the activated partial thromboplastin time (APTT) is extended 1.8 times during hemodialysis Use of.
Single dosage administered upon hemodialysis is administered activated partial thromboplastin time until the next hemodialysis (APTT) as extended at least 1.2 times, any one of claims 1 to 6, Use as described in.
The pharmaceutical for treating the individual of chronic renal failure formed by formulating the PEG-hirudin of the shape used for use of any one of Claims 1-7.

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