United States Patent [191 [11] Patent Number: 4,761,417 Maroko [45] Date of Patent: Aug. 2, 1988

[54] COMPOUNDS, COMPOSITIONS AND 1187733 4/1970 United Kingdom ...... 546/71 METHOD OF TREATMENTS FOR IMPROVING CIRCULATORY OTHER PUBLICATIONS PERFORMANCE Soto et al—-Rev. Assoc. Med Argent, 41:3062-3068 Inventor: Peter R. Maroko, 1765 Garwood (1933). [76] Soto et al-Rev. Assoc. Med Argent 47: 2494-2501, Dr., Cherry Hill, NJ. 08003 (1933). [21] App]. No.: 788,507 Chopra-4nd. Jour. Med. Res., XIX, 4, Apr. 1932, pp. 1193-1203. [22] Filed: Oct. 18, 1985 Williams-Jour. A.M.A., Jan. 4, 1908. Kulkarni et al—Japan J. Pharmacol. 22, 11-16 (1972). Related US. Application Data Chemical & Pharmaceutical Bulletin, vol. 18, No. 7, Jul. [63] Continuation of Ser. No. 378,122, May 14, 1982, aban 1970, pp. 1299—1304—Fukuda et al. doned. J. Pharmacol. Exp. Then, 71: 178-186 (1941), Jang. Mercier et al-Comptes Rendus Societe de Biologie, [51] Int. Cl.4 ...... A61K 31/44; A61K 31/705 127: 1022-1024, (1938). [52] US. Cl...... 514/284; 514/280 [58] Field of Search ...... 514/280, 284, 26 Primary Examiner-Frederick E. Waddell Attorney, Agent, or Firm—Weiser & Stapler [56] References Cited U.S. PATENT DOCUMENTS [57] ABSTRACT 3,326,920 6/1967 Stanaback et a1...... 546/71 A method of increasing the contractility of the mamma~ 3,346,582 10/1967 Brown et al. .. lian heart as shown by a positive inotropic affect is 3,933,826 1/ 1976 Karnetani .. 424/258 disclosed, employing protoberberine such as 4,013,666 3/1977 Lenz ...... 546/71 berberrubine or tetrahydropalmitane, alone or in combi nation with cardiac glycosides such as ouabain, digoxin, FOREIGN PATENT DOCUMENTS digitoxin or delanoside. 37976 4/ 1967 Japan ...... 546/71 105699 7/1972 Japan ...... 546/71 18 Claims, 17 Drawing Sheets US. Patent Aug. 2, 1988 Sheet 1 0f 17 4,761,417

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9.0| no.0I 4,761,417 1 2 ence. For further details relating to disorders of the COMPOUNDS, COMPOSITIONS AND METHOD heart, reference is made to Harrison ’s Principles of Inter OF TREATMENTS FOR IMPROVING nal Medicine, Thorne, Adams, Braunwald, Isselbacher CIRCULATORY PERFORMANCE and Petersdorf, McGraw-Hill Book Company, 8th Ed., Part 7, (“Harrison’s”) Disease of the Organ Systems, This application is a continuation of application Ser. Disorder of the Heart, Chap. 231 through 248, which are No. 378,122 ?led May 14, 1982, now abandoned. referred to speci?cally herein and incorporated herein This invention relates to berberine-type alkaloids, by reference. particularly protoberberine drug compositions and their Reference shall also be made herein to the following use in the treatment and diagnosis of circulatory disor clinical books, namely Veterinary Pharmacology and ders. The compounds of the invention are of special Therapeutics, Jones, Booth and McDonald, Iowa State interest in prophylactic, therapeutic and other applica University Press, 4th Ed., 1977; Physicians’ Desk Refer tions to prevent, minimize, control, alleviate, corect, ence “PDR” Medical Economics Company, 36th Ed. remedy and so on, various disorders or symptoms of 1982; and Veterinary Pharmaceuticals and Biologicals, circulatory disorders, including cardiovascular origins “VPB”, 1980/ 1981, Aronson, Harwal Publishing Com or types. The invention relates in terms of subjects (or pany, Media, Pa., 1980. patients) to the ?eld of mammals, i.e. human and veteri The direct cardiac action of drugs may be divided nary ?elds. into four major areas: (1) an effect on contractility (ino The invention also encompasses distinct and valuable tropic effect), re?ecting alterations in the myocardial embodiments like compositions (and compounds and 20 force-velocity relation at any given initial muscle methods of use) for chronic and acute heart failure and length; (2) an effect on heart rate expressed as an alter other pathologic states that will bene?t from an im ation in the rhythmicity, i.e., the frequency of discharge provement in cardiac performance; for the treatment of of normal pacemaker tissue, generally in the sinoatrial shock (cardiogenic and non-cardiogenic shock); for the node; (3) an effect on conductivity, i.e., on the velocity treatment of arrythmias (whether of natural causes or 25 with which the depolarization wave travels through the caused by a drug); for increasing the usefulness of car myocardium and the atrial ventricular conduction sys diac glycosides (like of the digitalis types) including tem; (4) an effect on irritability, i.e. the tendency to broadening their usually limited therapeutic index; for provoke ectopic pacemaker activity, which is depen controlling or correcting A-V (atrio-ventricular blocks, dent on the rate of diastolic depolarization and the to be de?ned later herein) block in mammals. 30 threshold potential. The unique, unobvious and remarkable aspects of the One of the most serious consequences of all types of invention are quite numerous and will become apparent cardiovascular diseases involves the pathophysiological hereinafter, but at the outset it is most noteworthy that state in which the heart fails in its prime function as a the compounds of the invention are antiarrhythmo muscle acting as a pump. In general, heart failure is the genic, a remarkable utility in and by itself. Another result of severe primary depression of myocardial con aspect, is that the compounds of the invention have a tractility or extreme ventricular hemodynamic over remarkable combination of beneficial properties, such load combined with secondary diminution of the con as, concurrently, having a positive inotropic effect and tractile state. For a description of the basics and disor being antiarrythmogenic. Another unusual aspect is that ders of the myocardial function, especially cardiac con the compounds of the invention are useful both in acute 40 traction see Harrison’s, chapter 236. ventricular failure and also in chronic congestive heart Knowledge of the biochemical and physiological failure. These aspects are of course described in ‘greater changes in heart failure has advanced considerably in detail hereinafter. recent years. Unfortunately, the development of phar The invention also relates to other biochemical or macological agents with clinically useful positive prop biomedical applications. The other aspects, to which erties on cardiac contractility (positive inotropic the invention relates, will become apparent to one of agents) has not kept pace. Nearly two centuries have average skill in the art from the teaching herein. passed since W. Withering described the cardiovascular One important, but not the only important ?eld to effects of Digitalis purpurea in 1787. Since then, the which the invention relates is the cardiovascular ?eld, basic treatment of congestive heart failure remains with both in humans and animals. Today cardiovascular the cardiac glycosides as is described in greater detail diseases, which have reached epidemic proportions, herein. Although literally hundreds of cardiac glyco account for a very high proportion of all deaths in the sides have been investigated, not one has been found world, especially in industrialized nations. Approxi with a wide therapeutic index. The most commonly mately one of every ?ve persons has some form of car used cardia glycosides digoxin and digitoxin, have a diovascular ailment such as heart disease, cerebrovascu 55 very narrow therapeutic index of less than 2, with life lar disease or hypertension. threatening cardiac arrhythmias as the ?rst manifesta Cardiovascular disease not only is fatal but causes tion of toxicity. It is clear that a cardiotonic agent with prolonged suffering and disability in even a larger pro a wide therapeutic index is needed, especially one that portion of the population. In the United States alone, does not have the drawbacks of the glycosides at all or cardiovascular disease was responsible for almost one has them at least to a milder extent. million fatalities in 1979, well over one-half of all re For the treatment of vascular diseases and the phar ported deaths. Almost 5 million persons afflicted with macology of cardiac glycosides, reference is made here cardiovascular disease are hospitalized annually. The to Braunwald, Chapter 16, pages 515-538; Harrison, cost of this disease in terms of human annual costs due chapter 239, pages 1207-1210 and Goodman and to morbidity amount to over 8 billion dollars. Braun 65 Gilman, The Pharmacological Basis of Therapeutics, wald, Heart Disease, A Textbook of Cardiovascular Medi MacMillan Publishing Co., Inc., 5th Ed. which is incor cine, W. B. Saunders Company, Philadelphia, 1980 porated herein by reference, 1975, Section VI, pages (“Braunwald”) which is incorporated herein by refer 653-682, (“Goodman”). ~ 4,761,417 3 4 Because the cardiac glycosides are the classical most heart and vascular diseases, especially for a positive common positive inotropic agents, a further discussion inotropic drug. is presented below. There is no teaching or recognition in the prior art of The catecholamines like norepinephrine, isoprotere a berberine which is cardiotonic, positive ino nol, dopamine and dobutamine have a limited role in the tropic, and which has the spectrum of cardiovascular treatment of patients with chronic congestive heart properties of the compounds or compositions disclosed failure. They are inactive orally and have a short dura herein. Nor is there such teaching or recognition of the tion of action when given intravenously. Their major therapeutic treatments disclosed herein. There is no use is in the treatment of acute ventricular failure such teaching or disclosure of compounds (or compositions as a low cardiac output state after cardiac surgery and -or methods of use-) like those of the invention which shock associated with sepsis or acute myocardial infarc have the combination of properties disclosed herein or tion. The arrhythmogenic and calorigenic properties of of certain speci?c properties disclosed herein or which the catecholamines and lack of activity in patients pre naturally ?ow or result from these properties. treated with beta-adrenergic blocking agents, such as A review of the state of the art shows the following: propranolol further limit the use of these agents. 1. Akhter, Sabir, Bhide: “Possible Mechanism of An The positive inotropic activity of glucagon was ?rst tidiarrheal Effect of Berberine”, Indian J. Med. Res. 70: demonstrated by Farah and Tuttle more than 15 years 233-241, 1979. Possible mechanism of the antidiarrheal ago. Since then there has been interest in the possible effect of berberine was studied. Subjects were dogs and role of this agent in the treatment of congestive heart rats. failure. Although the initial clinical studies with gluca 2. Creasy, W. A.: “Biochemical Effects of Berber gon were promising, further evaluation indicated that the clinical role of glucagon as a cardiotonic agent was ine”, Biochem. Pharmacol. 128: 1081-1084, 1979. Ber limited. Glucagon was found to be inactive in patients berine inhibits the biosynthesis of DNA, RNA, proteins with chronic congestive heart failure. and lipids, as well as the oxidation of glucose to CO2 when incubated with S180 cells in vitro. Also tested for Other drugs which play a role in the treatment of 25 heart diseases are the beta-adrenergic blocking agent, inhibitory activity: thalicarpine and d-tetradrine. often used as antiarrhythmic agents. The most com 3. Cohen, H. G. Seifen, E. E., Straub, K. D., Tiefen monly used is propanolol, Goodman, chapter 26 and bach, C., Stermitz, F. R.: “Structural Speci?city of the pages 609-704. Recently it was reported that Timolol, a NaK-ATPase Inhibition by , an Isoquino I beta-blocker was approved by the Food and Drug Ad line Benzophenanthridine Alkaloid”, Biochem. Phar ministration (“FDA”) as preventive against recurrence macol. 27: 2555-2558, 1978. Discussion of structural in patients who had suffered a ?rst heart attack. The speci?city of the NaK-ATPase inhibition by sanguina Wall Street Journal, Nov. 27, 1981. rine, an benzophenanthridine alkaloid by Amrinone, a S-amino-[3,4'-bipyridin]-6(lI-I)-one, a comparing the compound to other quinolines and non-glycoside and non-catechol in nature, has been 35 including berberine. Berberine is inactive reported to have positive inotropic effects. Farah, with respect to inhibition of NaK-ATPase activity. Alousi, New Cardiotonic Agents: A Search For Digita Study of acridine, acri?arine chloride, , lis Substitute Life Sci, 1978; 22: 1139-48; Alousi, Farah, capaurine, corycavine oxalate, coralyne chloride, Lesher, Opalka Jr., Cardiotonic activity of amrinone- , ethidium bromide, d-tetrahydropalmatine, Win 40680 (5-amino-3,4'-bipyridin-6(II-I)-One)), Circ. 40 boldine, chelidonine, , hydrastine, emetine Res. 1979; 45: 666-77; DeGuzman, Munoz, Palmer, hydrochloride, nitidine and fagaronine yielded varied Davolos, Alousi, Clinical evaluation of amrinone-a results. new inotropic agent (abst), Circulation 1978; 58 (Suppl 4. Davidson, M. W., LOpp, 1., Alexander, S., Wilson, II): 11-183; Benotti, Grossman, Braunwald, Davolos, W. D.: “The Interaction of Plant Alkaloids with DNA. Alousi, Hemodynamic assessment of amrinone, a new 45 II. Berberinium Chloride", Nucl. Acid Res 2697-2712, inotropic agent, New Engl. J. Med. 1978, 299: 1373-7, 1977. Other substances studied include quinacrine, quin LeJemtel, Keung, Sonnenblick, Ribner, Matsumoto, oline methanol, me?oquine, putrescine, coralyne and Davis, Schwartz, Alousi, Davolos, Amrinone: a new pro?avine. Systems studied include cows and chickens. non-glycosidic, non-adrenergic cardiotonic agent effec Data suggests that a large portion of the berberinium tive in the treatment of intractable myocardial failure in ring system intercalcates into DNA. man, Circulation 1979, 59: 1098-104. 5. Sheppard, H., Brughardt., C. R.: “The Dopamine It was recently reported that an application for a sensitive Adenylate Cyclase of the Rat Caudate Nu NDA has been ?led with the FDA for Inocor, a brand cleus. The effect of and Protoberberines”, of amrinone. Previously, clinical trials had been sus Biochem. Pharmacol. 27: 1113-1116, 1978. Protoberbe pended because the drug promoted blood platelet ag rines are fairly potent as inhibitors of the DA-cyclase gregation, The Wall Street Journal, Oct. 28, 1981. with little effects on the beta system. ana Recent calcium antagonists, like verapamil and logues were tested. nifedipine have been proposed to affect coronary perfu 6. Kovar, J., Skursky, L: “Fluorescence Study of sion, primarily by direct action on the coronary vascu Liver-Alcohol~Dehydrogenase Complexes with Ber lature. They too have hemodynamic features which are berine and Other Ligands”, Eur. J. Biochem, 40: not desirable. For instance, verapamil is known to re 233-244, 1973. Dissociation constant of liver-alcohol duce contractility and may induce atrio-ventricular dehydrogenase-berberine complex was determined. block. Composition study of complex made with NAD, Diuretics are also used for the management of heart NADH, o-phenanthroline, pelargonic and capric acids. failure. Such duretic therapy is not without complica 65 Fluorescence of berberine found to be typical for hy tions. Braunwald, page 544 and seq. drophobic probes, indicating that berberine interacts It is evident, from the state of the art, that there is a with a hydrophobic site of the liver-dehydrogenase serious need for a effective drug for the treatment of enzyme.