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Wo 2009/071096 A2 (12) INTERNATIONAL APPLICATION PUBLISHED UNDER THE PATENT COOPERATION TREATY (PCT) (19) World Intellectual Property Organization International Bureau (43) International Publication Date PCT (10) International Publication Number 11 June 2009 (11.06.2009) WO 2009/071096 A2 (51) International Patent Classification: (74) Agent: H0IBERG A/S; St. Kongensgade 59A, DK-1264 A61K 38/10 (2006.01) A61P 9/10 (2006.01) Copenhagen K (DK). A61K 31/7076 (2006.01) (81) Designated States (unless otherwise indicated, for every (21) International Application Number: kind of national protection available): AE, AG, AL, AM, PCT/DK2008/050294 AO, AT,AU, AZ, BA, BB, BG, BH, BR, BW, BY, BZ, CA, CH, CN, CO, CR, CU, CZ, DE, DK, DM, DO, DZ, EC, EE, (22) International Filing Date: EG, ES, FI, GB, GD, GE, GH, GM, GT, HN, HR, HU, ID, 5 December 2008 (05.12.2008) IL, IN, IS, JP, KE, KG, KM, KN, KP, KR, KZ, LA, LC, LK, (25) Filing Language: English LR, LS, LT, LU, LY,MA, MD, ME, MG, MK, MN, MW, MX, MY,MZ, NA, NG, NI, NO, NZ, OM, PG, PH, PL, PT, (26) Publication Language: English RO, RS, RU, SC, SD, SE, SG, SK, SL, SM, ST, SV, SY, TJ, TM, TN, TR, TT, TZ, UA, UG, US, UZ, VC, VN, ZA, ZM, (30) Priority Data: ZW PA 2007 01742 5 December 2007 (05.12.2007) DK PA 2007 01744 5 December 2007 (05.12.2007) DK (84) Designated States (unless otherwise indicated, for every PA 2008 0 1105 15 August 2008 (15.08.2008) DK kind of regional protection available): ARIPO (BW, GH, PA 2008 0 1104 15 August 2008 (15.08.2008) DK GM, KE, LS, MW, MZ, NA, SD, SL, SZ, TZ, UG, ZM, (71) Applicant (for all designated States except US): NEU- ZW), Eurasian (AM, AZ, BY, KG, KZ, MD, RU, TJ, TM), ROKEY A/S [DK/DK]; Diplomvej 372, L, DK-2800 Lyn- European (AT,BE, BG, CH, CY, CZ, DE, DK, EE, ES, FI, gby (DK). FR, GB, GR, HR, HU, IE, IS, IT, LT,LU, LV,MC, MT, NL, NO, PL, PT, RO, SE, SI, SK, TR), OAPI (BF, BJ, CF, CG, (72) Inventors; and CI, CM, GA, GN, GQ, GW, ML, MR, NE, SN, TD, TG). (75) Inventors/Applicants (for US only): GOTFRED- SEN, Jacob [DK/DK]; Dampfaergevej 14, 3., DK-2100 Published: Copenhagen (DK). WEBER, Uno Jakob [DK/DK]; — without international search report and to be republished Langemosevej 30, DK-2880 Bagsvaerd (DK). upon receipt of that report (54) Title: COMBINATION OF MEDICAL AND PHYSICAL COOLING TREATMENT OF ISCHEMIC EFFECTS (57) Abstract: The present invention relates to the induction of hypothermia in humans in a predictable and dose responsive fashion by use of combination of physical /mechanical hypothermia therapy and a pharmaceutical composition comprising at least one com- pound selected among a (1) vanilloid receptor agonists, capsaicinoids or capsaicinoid-like agonists reaching and binding to vanilloid receptors, and (2) cannabinoids or cannabimimetic agonists reaching and binding to cannabinoid receptors, and (3) adenosine re- ceptor agonists, and (4) neurotensin receptor agonists, and (5) thyroxine derivatives, and (6) cytochrome c oxidase inhibitors and (7) oxygen tension reducers thereby inducing hypothermia, thus benefiting patients suffering from illnesses characterized by tissue Combination of medical and physical cooling treatment of ischemic effects Field of invention The present invention relates to the use of a combination of mechanical and pharmaceutical hypothermia therapy for the prophylaxis and treatment of ischemia. Ischemia is the lack of oxygenated blood flow to various body parts and may result from apoplexia, cardiac arrest and asphyxia. Background of invention Ischemia is the lack of oxygenated blood flow to various body parts and organs. Cerebral ischemia is an ischemic condition where the brain or parts of the brain do not receive enough blood flow to maintain normal neurological function. Cerebral ischemia can be the result of various serious diseases such as stroke and cardiac arrest, or the result of arterial obstruction such as strangulation. Severe or prolonged cerebral ischemia will result in unconsciousness, brain damage or death. The neuroprotective efficacy of induced hypothermia following or during ischemia of the brain is evident in experimental animal models of stroke [1-1 1]. In humans, two trials conducted in cardiac arrest patients have shown improved neurological outcome of inducing hypothermia [ 12;1 3]. The therapeutic hypothermia did not increase the complication rate in these two trials and the use of induced hypothermia in comatose survivors of cardiac arrest is now recommended internationally [14]. Hypothermia counteracts ischemic brain damage by several mechanisms: 1. Ischemia induces opening of the blood-brain barrier, a process that seems to be very sensitive to brain temperature [ 1 5]. This is evident from studies of tracers and their migration across the blood-brain barrier, in which hypothermia attenuates extravasation several hours after ischemia [16] and prevents vasogenic oedema [ 1 7]. 2. Reperfusion after brain ischemia results in the production of free radicals, which causes peroxidation and destruction of membrane lipids [18]. Hypothermia prevents the production of free radicals such as hydroxyl and nitric oxide during reperfusion after brain ischemia [ 1 9;20;24]. 3. Amino acids, such as glutamate, aspartate, and glycine, act as excitotoxic neurotransmitters by over stimulation of neurons in the vicinity of ischemic damage, which causes further injury. Hypothermia lowers the release and may even cause a more rapid reuptake of these transmitters [21-23]. Release of excitotoxic neurotransmitters might also cause progressive neuronal death in the penumbra in stroke patients [22], and hypothermia after cerebral ischemia could attenuate this process. 4 . During ischemia, cellular metabolism in the penumbra undergoes significant changes. As the neurons continue to fire, potassium ions flood into the extra cellular space, calcium ions flow into the neurons leading to cytoskeletal degradation, and ATP concentrations fall as energy depletion continues [25]. Hypothermia reduces calcium influx and the subsequent breakdown of intracellular structures [26], improves potassium ion homoeostasis [27], and helps metabolic functions such as calcium or calmodulin-dependent protein kinase activity to recover [28;29]. 5 . By lowering of neutrophil and microglial activation after ischemia, hypothermia also has an anti-inflammatory effect [30;31]. 6 . Apoptosis and DNA changes are crucial stages in delayed neuronal death after transient cerebral ischemia [32]. Hypothermia directly inhibits apoptosis [33] and may also increase endogenous production of the anti-apoptotic protein Bcl-2 [34]. Hypothermia may even have effects at the DNA level: A slight lowering of brain temperature results in less DNA fragmentation [35] and less apoptosis [36]. Induction of hypothermia by lowering of the core temperature of the body has been attempted by mechanical cooling devices such as surface cooling and cooling using catheters placed in a large vessel. The regulation of the core temperature of the body by a pharmaceutical composition comprising a combination of compounds capable of inducing hypothermia would not only solve the problem of reducing or preventing the effects of ischemia, such as tissue damaging effects, but also be relevant as a safer and less expensive alternative to the currently employed mechanical methods. Summary of invention The present invention relates to the induction of hypothermia in humans in a predictable and dose responsive fashion by use of a combination of physical hypothermia therapy and a pharmaceutical composition comprising at least one compound capable of inducing hypothermia, thereby benefiting patients suffering from illnesses characterized by tissue anoxia. The inventors have found that such hypothermic effects can be obtained in humans as a result of at least seven classes of compounds: • Vanilloid receptor agonists, capsaicinoids or capsaicinoid-like agonists reaching and binding to vanilloid receptors, and • Cannabinoids or cannabimimetic agonists reaching and binding to cannabinoid receptors. • Adenosine receptor agonists, adenosine analogs or adenosine uptake inhibitors and agonist compounds reaching and binding to adenosine receptors. • Neurotensin receptor agonists, neurotensin analogs and compounds reaching and binding neurotensin receptors. • Thyroxine derivatives, thyroid hormone receptor agonists and trace amine- associated receptor agonists. • Cytochrome c oxidase inhibitors. • Oxygen tension reducers. The induction of hypothermia by cannabinoids and vanilloids alone or in combination is described in WO 2007/140786, WO 2008/040360 and WO 2008/040361 . Thus the present invention discloses the use of a at least one compound, wherein at least one compound is selected among vanilloid receptor agonists and cannabinoids and cannabimimetic compounds and adenosine or adenosine analogs and neurotensin or neurotensin analogs or a compound having at least 50% sequence identity to human neurotensin and thyroxine derivatives and cytochrome c oxidase inhibitors and oxygen tension reducers, when used in combination with physical hypothermia therapy, for the induction of hypothermia for the preparation of a medicament for the treatment of ischemia in an individual. It is also an aspect of the present invention to provide a medicament comprising a at least one compound capable of inducing hypothermia in an individual. A kit of parts comprising the medicament as herein disclosed is yet an aspect of the present invention. Furthermore, the use of the at least one compound for the preparation of a medicament for
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