MX2007016370A - Airway administration of tissue factor pathway inhibitor in inflammatory conditons affecting the respiratory tract - Google Patents

Abstract

The present invention provides methods for the local treatment of acute and chronic extravascular pulmonary fibrin deposition and/or reducing unwanted effects associated with systemic administration of natural anticoagulants to a subject via airway administration to the subject by intratracheal, intrabronchial or intraalveolar routes of natural anticoagulants or biologically active derivatives thereof. The present invention provides methods for the local treatment of acute and chronic extravascular pulmonary fibrin deposition and/or reducing unwanted effects associated with systemic administration of natural anticoagulants to a subject via airway administration to the subject by intratracheal, intrabronchial or intraalveolar routes of natural anticoagulants or biologically active derivatives thereof. A method and apparatus for stored message delivery are taught. The method and apparatus can be configured to accomplish the steps of receiving a Session Initiation Protocol (SIP) message, as a received SIP message, encapsulating the received SIP message in a Message Session Relay Protocol (MSRP) message, as an encapsulated SIP message;and transmitting the encapsulated SIP message to an intended recipient.

Description

ADMINISTRATION TO THE RESPIRATORY ROUTES OF THE. XB3HXBIDOR B LA PATH OF THE TISSUE FACTOR EM CQE3DICIOB3ES IÍM LAMAORIAS THAT AFFECT THE RESPIRATORY TRACT Field of the Invention The present invention provides methods for stopping the deposition of acute, recurrent and chronic fibrin in the alveoli of the respiratory tract, in particular the alveoli and / or bronchioles, in any disease associated with sedimentation in children and adults. These diseases include inflammatory diseases of the lungs such as acute lung injury (ALI), which can be directly or indirectly related to pulmonary trauma, for example, after ventilator therapy (ventilator-induced lung injury (VILI, for its acronyms), inflammatory conditions such as autoimmune diseases, pancreatitis, aspiration pneumonitis, inhalation of toxic fumes, acute respiratory distress syndrome (ARDS), which is a more severe manifestation of ALI, infections such as sepsis, severe sepsis and shock septic; pneumonia of any cause; Acute and chronic bronchoalveolar diseases, fibrous alveolitis, bronchiolitis, cystic fibrosis and also diseases with severe respiratory tract hyperactivity, for example, bronchial asthma and drug-induced pulmonary insufficiency, RE "§183858 for example, after chemotherapy such as bleomycin . In the methods of the present invention, anticoagulants such as tissue factor pathway inhibitor, whether these agents are derived from plasma or prepared by recombinant DNA technology, are administered intratracheally, intrabronchially, or the alveolar space by means of administration to the respiratory tract. These methods are useful in clinical medicine, especially critical or intensive care medicine and respiratory medicine.

Background of the Invention Fibrin sedimentation in the alveoli of the respiratory tract, particularly the alveolar and bronchial alveoli, is a frequent complication of systemic inflammatory conditions such as those resulting from trauma, sepsis, severe sepsis and septic shock, drug-induced ALI. , ARDS or pneumonitis (for example, due to methotrexate, bleomycin or sirolimus) (Amigues L, Klouche K, Massanet P, Gaillard N, Garrigue V, Beraud JJ, Mourad G. Sirolimus-associated acute respiratory distress syndrome in a renal transplant recipient Transplant Proc. 2005; 37: 2830-1.) And ventilated-induced lung injury (VILI) (Maclntyre NR, Current issues in mechanical ventilation for respiratory failure, Chest. 2005; 128: 561S-567S) and lung injury that follows to mechanical ventilation (VILI (The Acute Respiratory Distress Syndrome Network: Ventilation with lower tidal volumes as compared with traditional tidal volumes for lung injury an d the acute respiratory distress syndrome. N Engl J Med. 2000; 342: 1301-1308. These conditions lead to a systemic activation of coagulation, ultimately resulting in fibrin sedimentation in the intravascular and extravascular spaces, that is, in the alveolar and bronchial compartments. At the same time, inflammatory activation causes the release of pro-inflammatory cytokines such as tumor necrosis factor alpha (TNF-a), interleukin 1-beta (IL-lß), interleukin 6 (IL-6) and interleukin 8 ( IL-8) from activated inflammatory cells. The deposition of intravascular fibrin and the release of pro-inflammatory cytokines in the alveoli of the lungs causes a tissue injury characterized by increased permeability of the alveolar-capillary membrane with diffuse alveolar damage and accumulation in the alveoli of rich edema fluid in plasma proteins, including the components of the blood coagulation system, and a reduction in the production of surfactants. As a result, the fibrin-rich hyaline membrane is formed in the alveolar ducts and alveoli. In the last phase, massive infiltration of neutrophils and other inflammatory cells occurs, after the organization of exudates and fibrosis. This pathological sequence has been described and reviewed by Bellingan GJ, 2002: "The pathogenesis of ALI / ARDS", Thorax 57: 540-546. The clinical conditions that correspond to their pathology are called ALI or ARDS, they differ only in that ARDS is more severe and is characterized by greater hypoxemia in such a way that the ratio of arterial P02 to a fraction of inspired oxygen (Pa02 / Fl02) = 200 mmHg. ALI and ARDS is presented as part of the systemic inflammatory response syndrome (SIRS), which may be due to infect or non-infect causes such as pancreatitis or direct or indirect lung trauma; When the cause of SIRS is infectious, it is called sepsis, which, when associated with organ dysfunction, is defined as severe sepsis, and when it is associated with significant hypotension, such as septic shock. A similar sequence of pathological events occurs in pneumonias due to a variety of causes, including viral, bacterial and fungal agents, for example Pneumocystis carinii pneumonia (PCP), bronchiolitis (for example following viral pneumonitis and / or graft-versus-disease). pulmonary host (GVHD)), which leads to alveolar exudates and fibrin sedimentation in those regions of the lung affected by the inflammatory process. It has been pointed out (for example by Levi M et al., 2003: "Bronchoalveolar coagulation and fibrinolysis in endotoxemia and pneumonia", Crit Care Med 31: S238-S242) that the lung is particularly susceptible to fibrin sedimentation in sepsis, which shows this phenomenon to a greater degree than other organs. Sedimentation of extensive local fibrin suggests that local activation of coagulation or disturbance of local physiological regulatory systems may be involved. In the bronchoalveolar compartment, tissue factor (TF), expressed locally in alveolar cells and in the epithelium, is seen as having an essential role in the initiation of coagulation, while physiological anticoagulation is due to antithrombin and the system of protein C is dysfunctional. It has been documented that the protein C system breaks down markedly in patients with ALI / ARDS of both septic and non-septic causes and there is evidence of both circulatory and intra-alveolar alterations in the path of protein C in ALI / ARDS (Ware LB et al., 2003: "Protein C and thrombomodulin in human lung injury", Am J Physiol Lung Cell Mol Physiol 285: L514-L521). At the same time, there is a marked depression of local fibrinolysis, that is, coagulation is locally overregulated in the injured lung, whereas fibrinolytic activity is markedly depressed.

Brief Description of the Invention The purpose of the present invention to improve the treatment of ALI, ARDS, pneumonia and inflammatory pulmonary diseases by directing the local pulmonary activation of the coagulation system and the local deficiency anticoagulatorios mechanisms, by applying the relevant anticoagulants, or agents capable of blocking the local initiation of coagulation, by local administration in the respiratory tract. Thus a high local concentration of these agents can be achieved in the affected airways, so that sedimentation of extravascular fibrin can be inhibited more effectively than by systemic administration of the same agents (IV), but avoiding or reducing the effects systemic adverse Administration to the respiratory tract of these agents can occur either alone or as a complement to the intravenous administration of the same or other agents. Due to the "interference" between coagulation and inflammation, administration to the respiratory tract of these agents is also expected to modulate local lung inflammation, by reducing the activation of local thrombin and in certain cases also by the direct anti-inflammatory action . One aspect of the present invention relates to a method for reducing sedimentation of extravascular fibrin airways, especially the alveolar or bronchoalveolar spaces, in human subjects with inflammatory and / or infectious pulmonary conditions that lead to such deposition of fibrin, The method comprises the administration by the respiratory tract of anticoagulants, either purified from the plasma or obtained by recombinant DNA technology.

Detailed Description of 1 Invention The present invention relates to administration to the respiratory tract, by any suitable method including, but not limited to, intratracheal, intrabronchial or intraalveolar administration, to a human subject including both adults and children, to inhibit the trajectory of purified or concentrated natural human tissue factor (TFPI), or derivatives thereof, however prepared, to prevent or reduce the deposition of extravascular fibrin in the respiratory tract, especially the alveolar alveoli or bronchoalveolar. Such fibrin sedimentation can result from an acute condition, a recurrent condition or a chronic condition and can be due to a variety of causes, including but not limited to trauma, direct or indirect, inflammation or infection, due to fibrin sedimentation induced by drug in the respiratory tract and pulmonary interstitium, congenital diseases type cystic fibrosis, or due to a combination of such possible causes. For example, it is considered that the methods of the present invention will be useful in the treatment of alveolar fibrin sedimentation characteristic of ALI or ARDS that occurs in a large proportion of patients with sepsis of varying degrees, in patients with severe pneumonias, bronchiolitis. obstructive and in fibrous alveolitis.

Definitions Affinity: The resistance of the bond between the receptors and their ligands, for example between an antibody and its antigen. Amino acid residue: That part of the amino acid that occurs in the polypeptide chain in which the amino acid is linked to other amino acids by peptide (amide) bonds. The amino acid residues described herein are preferably in the "L" isomeric form. However, the amino acid encompasses each amino acid such as amino acid L, amino acid D, alpha amino acid, beta amino acid, gamma amino acid, natural amino acid and synthetic amino acid or the like, so that the desired functional property is maintained by the polypeptide. Also included are natural or synthetic amino acids that have been modified. NH2 refers to the free amino group present at the amino termini of a polypeptide. COOH refers to the free carboxy group present at the carboxy terminus of the polypeptide. Standard polypeptide abbreviations for amino acid residues are used herein.

It should be noted that all sequences of amino acid residues represented herein by the formulas have a left to right orientation in the conventional direction from the amino terminal to the carboxy terminus. Additionally, it will be noted that a point at the start or end of an amino acid residue sequence indicates a peptide bond to an additional sequence of one or more amino acid residues or a covalent bond to an amino terminal group or a covalent bond to a group of amino terminal such as NH2 or acetyl or a carboxy terminal group such as COOH. Modified amino acid: An amino acid where an arbitrary group of it is chemically modified. In particular, a chemically modified amino acid that is modified at the alpha carbon atom to an alpha amino acid is preferred. Polypeptide: The phrase "polypeptide" refers to a molecule comprising amino acid residues that do not contain ligatures other than the amide linkers between adjacent amino acid residues. The phrase peptide is used accordingly.

TFPI Molecule The present invention relates to the use of molecules TFPI in the manufacture of a drug for the local treatment of acute and extravascular pulmonary fibrin sedimentation. The term "TFPI molecule" is used herein to refer to any molecule capable of binding to, and directly or indirectly inhibiting the clotting factors Vlla, Xa and / or tissue factor (TF). Normally, TFPI exists in plasma both as a full-length molecule and as truncated terminally variable carboxy forms. TFPI also circulates in complex with plasma lipoproteins. Methods for evaluating the functional activity of TFPI molecules for use in the present invention include those described by Bajaj et al. , J Clin Invest 79, p 1874-1878, 1987; Sandset et al., Thromb Res 47, p 389-400, 1987. It is understood that the activity of TFPI molecules for use in the present invention may be less potent or more potent than natural TFPI. TFPI is an endogenous serine protease inhibitor, synthesized and secreted by endothelial cells, which is also known as lipoprotein-associated coagulation inhibitor (LACI), tissue factor inhibitor (TFI), and intrinsic path inhibitor (EPI) . TFPI has anticoagulant properties. Human TFPI is a 276 amino acid polypeptide, which contains 18 cysteine residues and forms 9 disulfide bridges when properly folded. The primary sequence contains three consensus glycosylation sites linked to N (Asn-X-Ser / Thr). The asparagine residues of the glycosylation sites are located at positions 145, 195 and 256. The TFPI polypeptide contains three Kunitz enzyme inhibitor domains. The present invention further includes the use of human TFPI peptides produced recombinantly or synthetically or transgenically. Thus in one embodiment, the TFPI molecule is a TFPI homologue. The human tissue factor pathway inhibitor that is intended to be administered according to the present invention comprises naturally occurring human tissue factor pathway inhibitor, or biologically active analogues thereof, if they are plasma prepared or recombinantly produced or transgenically or synthetically. The recombinant tissue factor pathway inhibitor may incorporate modifications (e.g., amino acid substitutions and / or deletions and / or additions of heterologous amino acid sequences), which may result in analogues with increased biological activity. For example, TFPI can be produced using eukaryotic cell culture systems (eg, human kidney 293, HEPG-2, SKHep, LLC-MK2, CHO or AV12 cells), transgenic animals, transgenic plants, or in vitro systems. In these systems, the protein can be produced as an inactive precursor, which, after purification, unfolds proteolytically and is formulated for administration or in its mature form. Production details, purification, activation, and TFPI formulation are known in the art and are described, for example, in US Pat. No. 5,212,091, which is incorporated herein by reference in its entirety. Also, TFPI genes and plasmids that can be used in these methods are described in the U.S. Patent. Nos. 4,966,852, which are also incorporated herein by reference. The tissue factor trajectory inhibitor can also be obtained from commercial sources. For example, a specific example of a TFPI that can be used in the invention is produced by Chiron Corporation, under the name of Tifacogin (TM) (recombinant tissue factor path inhibitor). In a preferred embodiment of the present invention, the TFPI molecule is a TFPI analog. An "TFPI analog" is defined as a molecule having one or more (such as 20 or less, for example 17 or less, such as 15 or less, for example 13 or less, such as 11 or less, for example 9 or less, such as 7 or less, for example 5 or less, such as 3 or less, for example 2 or less, such as 1 or less) amino acid substitutions, deletions, inversions, or additions related to TFPI and may include forms of amino acid D. TFPI analogs have also been described in U.S. Patent No. 5,106,833, where the analogs and fragments are described, US Pat. Nos. 5,312,736 and 5,378,614, and WO 2004/062689, which are hereby incorporated by reference in their entirety. Preferred TFPI molecules used in the present invention also include TFPI analogs in which one or more amino acids that do not occur in the original sequence are added or deleted, and derivatives thereof. In one embodiment of the present invention, the TFPI analog exhibits an increasing anticoagulant activity compared to the wild-type protein. In a preferred embodiment, the analogue has a higher binding affinity for its binding partners, such as for example Factor Vlla, Xa and TF, than the wild-type protein. In a further embodiment the modifications result in a stabilization of the TFPI analog. The TFPI analogs can be used according to the present invention alone or in combination with other TFPI analogs and homologs and / or derivatives and / or conjugates. For example, an TFPI analog with a high binding affinity for factor Vlla, Xa and / or TF can be used in combination with a stabilized TFPI homolog. In another preferred embodiment of the present invention, the TFPI molecule is a TFPI derivative. A "TFPI derivative" is defined as a molecule having the amino acid sequence of TFPI or a TFPI analog, but additionally comprises chemical modification of one or more of its amino acid side groups, alpha carbon atoms, terminal amino group, or terminal carboxylic acid group. A chemical modification includes, but is not limited to, added chemical portions, creations of new bonds, and elimination of chemical portions. Modifications in amino acid side groups include, without limitation, acylation of epsilon amino groups lysine, N alkylation of arginine, histidine, or lysine, alkylation of carboxylic, aspartic or glutamic acid groups, and deamidation of glutamine or asparagine. Modifications of the amino terminus include, without limitation, des-amino, lower alkyl N, lower alkyl di N, and modifications of acyl N. Modifications of the carboxy terminal group include, without limitation, amide, lower alkyl amide, amide of dialkyl, and modifications of lower alkyl ester. Lower alkyl is C1-C4 alkyl. In addition, one or more side groups, or terminal groups, can be protected by protecting groups known to the ordinarily skilled protein chemist. The alpha carbon of an amino acid can be mono or dimethylated.

Homologues of TFPI molecules A homologue of one or more of the sequences specified herein may vary in one or more amino acids as compared to the defined sequences, but is capable of performing the same function, that is, a homolog can be contemplated as a functional equivalent of a predetermined sequence. Thus, in a preferred embodiment of the present invention, the TFPI molecule is a homolog of any of the molecules described herein, such as a homolog of any of the molecules of the group consisting of: o TFPI ° Tifacogin Thus, in a Preferred embodiment of the present invention, the TFPI molecule is a peptide that contains one or more amino acid substitutions, reversal, additions and / or deletions, compared to any of the molecules described herein, such as a molecule selected from the group consisting of of: o TFPI ° Tifacogin In one embodiment, the number of substitutions, deletions, or additions is 20 amino acids or less, such as 15 amino acids or less, for example 10 amino acids or less, such as 9 amino acids or less, for example 8 amino acids or less, such as 7 amino acids or less, for example 6 amino acids or less, such as 5 amino acids or less, for example 4 amino acids or less, such as 3 amino acids or less, for example 2 amino acids or less (such as 1), or any integer between these amounts. In one aspect of the invention, the substitutions include one or more conservative substitutions, such as 20 or fewer conservative substitutions, for example 18 or less, such as 16 or less, for example 14 or less, such as 12 or less, for example 10 or less, such as 8 or less, for example 6 or less, such as 4 or less, for example 3 or less, such as 2 or less conservative substitutions. A "conservative" substitution denotes the replacement of one amino acid residue by another, related amino acid residue belongs to the same group of amino acids, such as those with a hydrophobic side chain, those with an aromatic side chain, those with a basic side chain, those with a an acid side chain, those with a hydroxyl side chain and those with a non-ionized polar side chain. Examples of conservative substitution include the substitution of a hydrophobic residue, such as isoleucine, valine, leucine or methionine by another, or the substitution of a basic residue by another, such as the substitution of lysine by arginine, or the substitution of a residue. acid by another, such as glutamic acid by aspartic acid, or the substitution of a non-ionized polar waste by another, such as the substitution of glutamine by asparagine, and the like. The following table lists illustratively, but does not limit, conservative amino acid substitutions.

Other TFPI homologs suitable for the uses and methods of the present invention are peptide sequences having greater than 50% sequence identity, and preferably greater than 90% sequence identity (such as greater than 91% sequence identity, example greater than 92% sequence identity, such as greater than 93% sequence identity, for example greater than 94% sequence identity, such as greater than 95% sequence identity, eg greater than 96% sequence identity, such as greater than 97% sequence identity, for example greater than 98% sequence identity, such as greater than 99% sequence identity, eg greater than 99.5% sequence identity), to any of the molecules described herein, such as a molecule selected from the group consisting of: o TFPI or Tifacogin As used herein, sequence identity refers to a comparison made between two molecules using standard algorithms well known in tea technique The preferred algorithm for calculating sequence identity by the present invention is the Smith-Waterman algorithm, where the reference sequence is used to define the percentage identity of polypeptide homologs over its length. The choice of parameter values for matches, no matches, and inserts or deletions are arbitrary, through some parameter values have been found to produce more biologically realistic results than others. A preferred set of parameter values for the Smith-Waterman algorithm is set in the approximate "maximum similarity segments", which use values of 1 for a matching residue and -1/3 for a mismatched residue (a residue that is already be a single nucleotide or single amino acid) (Waterman, Bull, Math, Biol. 46, 473-500 (1984)). Insertions and deletions (indels), x, are weighted as Xk = 1 + k / 3, where k is the number of residues in a given insert or elimination (Id.). For example, a sequence that is identical to a sequence of 42 amino acid residues, except for 18 amino acid substitutions and an insertion of 3 amino acids, should have an identical percentage given by: [(1x42 matches) - (1/3 x 18 no matches) - (1 + 3/3 indels)] / 42 = 81% identity In a preferred embodiment of the present invention, the truncations at the end of the molecule are not taken into account when calculating the sequence identity ( that is, if one molecule is larger than another, only the overlapping lengths of the molecules are used in sequence identity analysis); in another preferred embodiment of the present invention, the truncations are counted as eliminations. An analogue of TFPI may include amino acid D forms and may be a molecule having one or more amino acid substitutions, deletions, inversions, or additions relative to any of the molecules described herein, such as a molecule selected from the group consisting of of: • TFPI -Tifacogin In a preferred embodiment of the present invention, the TFPI molecule is a peptide that contains one or more amino acid substitutions, inversion, additions or deletions, compared to TFPI. In one embodiment, the number of substitutions, deletions or additions is 20 amino acids or less, such as 15 amino acids or less, for example 10 amino acids or less, such as 9 amino acids or less, for example, 8 amino acids or less such as 7 amino acids or less. amino acid or less, for example, 6 amino acids or less, such as 5 amino acids or less, for example, 4 amino acids or less, such as 3 amino acids or less, for example, 2 amino acids or less (such as 1), or any integer between these amounts. In one aspect of the invention, the substitutions include one or more conservative substitutions. Examples of suitable conservative substitutions are given above. Other TFPI homologs suitable for the uses and methods of the present invention are peptide sequences derived from TFPI protein sequences having more than 50% sequence identity and preferably more than about 90% sequence identity (such as more than about 91% sequence identity, for example, more than about 92% sequence identity, such as more than about 93% sequence identity, for example, more than about 94% identity of sequence, such as more than about 95% sequence identity, for example, more than about 96% sequence identity, such as more than about 97% sequence identity, for example, more than about 98 % sequence identity, such as more than about 99% sequence identity, eg, more than about 99.5% sequence identity) up to (1) SEQ ID NO: l / o (2) for truncated sequences thereof. As used herein, sequence identity refers to a comparison made between two molecules using standard algorithms well known in the art. The preferred algorithm for calculating the sequence identity by the present invention is the Smith-Waterman algorithm, as described above. A TFPI homolog may also be a molecule having one or more amino acid substitutions, deletions, inversions, or additions relative to human TFPI and may include amino acid forms D. In another embodiment of the present invention, the homolog of any of the sequences predetermined herein, such as SEQ ID NO: 1 can be defined as: i) homologs comprising an amino acid sequence capable of selectively binding to the coagulation factors Vlla, Xa and / or TF, and / or ii) homologs having substantially similar or high-binding affinity to the Vlla, Xa and / or TF coagulation factors that human TFPI and / or iii) homologs having a substantially similar, high or lower half-life after airway sedimentation.

Chemically Derived TFPI Molecules It will further be understood that TFPI molecules suitable for use in the present invention can be chemically derived or altered, for example, peptides with unnatural amino acid residues (eg, taurine residue, beta and gamma amino acid residues and amino acid residues D), modifications of the C-terminal functional group, such as amides, esters and modifications of C-terminal ketone and modifications of the N-terminal functional group, such as acylated amines, Schiff bases, or cyclization, such as are found , for example, in the pyroglutamic acid of the amino acid.

Conjugates of the TFPI molecule The TFPI molecules of the present invention can also be modified with portions without polypeptide to provide the TFPI compounds having an increased resistance to inactivation eg, proteolytic degradation. Thus, in one embodiment of the present invention, the TFPI molecule used is a N-glycosylated TFPI peptide or an analog thereof. In another embodiment of the present invention, the molecule TFPI is a glycosylated TFPI peptide or analog thereof. In another embodiment of the present invention, the molecule TFPI used is a TFPI polypeptide or an analog thereof also contains N-linked or O-linked fatty acids.

TFPI Fragments In one embodiment the TFPI molecule can be a TFPI fragment. A fragment is a portion of TFPI, TFPI homolog or TFPI derivative. Examples of the fragments include Kunitz 1, 2 or 3 domains, Kunitz I and 2 or 2 and 3 domains, or deletions of the N-terminal or C-terminal or both. The TFPI fragments comprise at least 20 consecutive amino acids of SEQ ID NO: 1. For example, a fragment may be 20 amino acids or more, such as 25 amino acids or more, for example, 30 amino acids or more, such as 50 amino acids or more, for example, 100 amino acids or more, such as 150 amino acids or more, example, 200 amino acids or more, such as 250 amino acids or more, for example, 275 amino acids in length or any integer between these amounts.

Intratracheal, intrabronchial or intraalveolar administration Methods of administration include, but are not limited to, spraying, washing, inhaling, jet washing or installation, using as the fluid a physiologically acceptable composition in which the blood coagulation factor (s) also dissolves. When used herein the terms "intratracheal, intrabronchial or intraalveolar administration" include all forms of such administration therefore the coagulation factor is applied in the trachea, the bronchus or the alveolus, respectively, either by the installation of a Factor solution, by applying the factor in a powder form, or by allowing the factor to extend the relevant part of the respiratory tract by inhaling the factor as an aerosol or nebulizer solution or powder or gel, with or without adding stabilizers or other excipients.

In another embodiment, intratracheal, intrabronchial, intraalveolar administration does not include inhalation of the product but the instillation or application of a factor solution or a powder or gel containing the factor in the lower respiratory tract or in the trachea. Methods of intrabronchial / alveolar administration include, but are not limited to the administration (BAL) of bronchoalveolar lavage according to methods well known to those of skill in the art, using as a washing fluid a physiologically acceptable composition in which the TFPI and / or homologous TFPI and / or derivative and / or conjugate are dissolved or actually by any other effective form of intrabronchial administration including the use of nebulizer powders containing the anticoagulant in dry form, with or without excipients, or direct application of the anticoagulant in the form of a solution or powder or gel during bronchoscopy. Methods of intratracheal administration include, but are not limited to, blind tracheal lavage with a similar solution of the dissolved tissue factor pathway inhibitor, or inhalation of nebulized aerosol fluid droplets containing the dissolved tissue factor pathway inhibitor obtained by the use of any suitable nebulizer apparatus for this purpose. The present invention provides a new useful addition for methods for treating ALI, ARDS, pneumonia and other conditions associated with bronchial-alveolar fibrin sedimentation. In addition, the administration of anticoagulants via the respiratory tract is expected to avoid the undesirable haemorrhagic adverse effects of the systemic administration of anticoagulants such as TFPI, whose intravenous use is associated with a significant incidence of internal bleeding including cerebral hemorrhage. At the same time, the application of anticoagulants via the respiratory tract is expected to enhance its effect on the deposition of extravascular fibrin in the lungs when compared to its systemic administration. It is expected that the total dose of an anticoagulant and anti-inflammatory agent such as TFPI can only be used crazily within the airways or can be divided between the conventional intravenous route and the airway route of the present invention to obtain the optimal balance between the local systemic and pulmonary effects of the treatment and reduce the incidence of the adverse effect of the drug, for example, in patient with severe sepsis, septic shock and ARDS. In addition, the time interval ("window of opportunity") during which intravenous use of TFPI is probably beneficial is limited. A long interval time of the drug response can be expected when the agent is used in the post-septic phase or even in the ARDS phase later by the alveolar fibrin sedimentation, for example, as observed in ALI and ARDS. A preferred embodiment of the present invention comprises local intrabronchial administration to human patients with ARDS of TFPI by means of bronchoalveolar lavage with lavage fluid (eg, 25 ml to 100 ml isotonic saline) in which a suitable dose (e.g. , 2 mg to 5 mg or more) of TFPI also dissolve. This administration was repeated at intervals one or more days dependent on the duration of either earlier or later phases of ALI or ARDS. As supplementary or combination treatments in patients who comply with the indications for intravenous administration of TFPI, TFPI can also be given by intravenous infusion. Other preferred methods of administration may include using the following devices: 1. Using pressurized nebulizers comprising an air / oxygen mixture. 2. Ultrasonic nebulizers. 3. Electronic micropump nebulizers (for example, Aeroneb professional nebulizer) 4. Measured dose inhaler (MDI) 5. Dry powder inhaler (DPI) systems, The aerosol can be released by means of a) facial masks or b) by means of of endotracheal tubes in patients intubated during mechanical ventilation (device 1, 2 and 3). Devices 4 and 5 can also be used by the patient without assistance on the condition that the patient can by himself activate the aerosol device. Preferred concentrations for a solution comprising TFPI and / or homologs and / or TFPI derivatives are in the range of 0.1 μg to 10000 μg of active ingredient per ml of the solution. Using monomeric forms of the compounds, suitable concentrations are frequently in the range from about 0.1 μg to 5000 μg per ml of the solution, such as in the range from about 0.1 μg to 3000 μg per ml of the solution and especially in the range from about 0.1 μg to 1000 μg per ml of the solution, such as in the range from about 0.1 μg to 250 μg per ml of the solution. A preferred concentration should be around 0.1 to about 5.0 mg, preferably from about 0.3 mg to about 3.0 mg, such as from about 0.5 to about 1.5 mg and especially in the range from 0.8 to 1.0 mg per ml of the solution. Using multimeric forms of the compounds, suitable concentrations are frequently in the range from 0.1 μg to 1000 μg per ml of the solution, such as in the range from about 0.1 μg to 750 μg per ml of the solution and especially in the range from about 0.1 μg to 500 μg per ml of the solution, such as in the range from about 0.1 μg to 250 μg per ml of the solution. A preferred concentration should be from about 0.1 to about 5.0 mg, preferably from about 0.3 mg to about 3.0 mg, such as from about 0.5 to 1.5 mg and especially in the range from 0.8 to 1.0 mg per ml of the solution.

Indications An aspect of the present invention relates to a method for treating or preventing sedimentation of extravascular fibrin in the respiratory tract. Thus, the present invention relates to the treatment of individuals suffering from or at risk of suffering from extravascular fibrin depositions caused by an inflammatory lung disease. In a preferred aspect inflammatory lung disease is cted from the group consisting of: ALI ARDS Pneumonia Acute bronchial-alveolar disease Chronic bronchial-alveolar disease Fibrous alveoliths or Bronchial asthma Alveolitis Bronchiolitis Organized pneumonia due to bronchiolitis obliterans (BOPA) Graft-versus-host disease (GVHD) Pneumonia due Pneumocystis carinii (PCP) Pneumonitis, for example, aspiration pneumonitis Drug-induced pneumonitis (for example, due to methotrexate, bleomycin, or sirolimus) Fibrous, acute, or chronic alveolitis Cystic fibrosis Idiopathic pulmonary fibrosis In another embodiment, the inflammatory disease of the lung is related to a condition cted from the group consisting of: Direct or indirect pulmonary trauma Pancreatitis Pneumonitis aspiration sepsis severe sepsis and / or septic shock Pneumocystis carinii pneumonia (PCP) as a prophylactic adjuvant or therapy preventive or as a treatment of ARDS manifest by PCP, induced by PCP, that is, before or early in the PCP phase or in ARDS manifestation concomitant with antibiotic therapy anti-Pneumocystis with for example, Sulfamethoxazole with Trimethoprim.

Pharmaceutical Compositions Pharmaceutical compositions of formulations for use in the present invention include a TFPI preparation in combination with, preferably dissolved in, a pharmaceutically acceptable carrier, preferably an aqueous carrier or diluent. The pharmaceutical composition can be a solid, liquid, a gel or an aerosol. A variety of aqueous carriers can be used, such as 0.9% saline, buffered saline, physiologically compatible buffer solutions and the like, the compositions can be sterilized by conventional techniques well known to those skilled in the art. The resulting aqueous solutions can be packaged for use or filtered under aseptic conditions and freeze-dried, the frozen-dried preparation is dissolved in a sterile aqueous solution prior to administration. The compositions may contain pharmaceutically acceptable adjuvants or auxiliaries, including, without limitation, pH adjusting agents and buffering agents and / or tonicity adjusting agents, such as, for example, sodium acetate, sodium lactate, Sodium chloride, potassium chloride, calcium chloride, etc. The formulations may contain pharmaceutically acceptable carriers and excipients including microspheres, liposomes, microcapsules, nanoparticles or the like. Conventional liposomes are typically composed of phospholipids (neutrally or negatively charged) and / or cholesterol. Liposomes are vesicular structures based on lipid bilayers wrapped in aqueous compartments. They can vary in their physicochemical properties such as size, lipid composition, surface charge and number and fluidity of the phospholipid bilayers. The most frequently used lipid for liposome formation are: 1, 2-Dilauriol-sn-Glycero-3-phosphocholine (DLPC), 1,2-Dimyristoyl-sn-Glycero-3-phosphocholine (DMPC), 1,2-Dipalmitoil -sn-Glycero-3-phosphocholine (DPPC), 1,2-Distearoyl-sn-Glycero-3-phosphocholine (DSPC), 1,2-Dioleoyl-sn-Glycero-3-phosphocholine (DOPC), 1, 2- Dimiristoil-sn-Glycero-3-phosphoethanolamine (DMPE), 1,2-Dipalmitoyl-sn-Glycero-3-phosphoethanolamine (DPPE), 1,2-Dioleoyl-sn-Glycero-3-phosphoethanolamine (DOPE), 1, 2 -Dimiristoil-sn-Glycero-3-phosphate (Monosodium Salt) (DMPA), 1,2-Dipalmitoyl-sn-Glycero-3-phosphate (Monosodium Salt) (DPPA), 1,2-Dioleoyl-sn-Glycero-3-Phosphate (Monosodium Salt) (DOPA), 1,2-Dimyristoyl-sn-Glycer-3- [phospho-rac- (l-glycerol)] (Sodium salt ) (DMPG), 1,2-Dipalmitoyl-sn-Glycero-3- [Phospho- rac- (1-glycerol)] (Sodium salt) (DPPG), 1,2-Dioleoyl-sn-Glycero-3- [ phospho-rac- (1-glycerol)] (Sodium salt) (DOPG), 1,2-Dimyristoyl-sn-Glycero-3- [phospho-L-Serine] (Sodium salt) (DMPS), 1, 2 -Dipalmitoyl-sn-Glycero-3- [phospho-L-Serine] (Sodium Salt) (DPPS), 1,2-Dioleoyl-sn-Glycero-3- [phospho-L-Serine] (Sodium Salt) ( DOPS), 1,2-Dioleoyl-sn-Glycero-3-phosphoethanolamine-N- (glutaryl) (Sodium salt) and 1, 1 ', 2, 2'-Tetramyristoyl Cardiolipin (Ammonium salt). Composite formulations of DPPC in combination with other lipids or liposome modifiers are preferred, for example, in combination with cholesterol and / or phosphatidylcholine.

The long-circulation liposomes are characterized by their ability to extravasate sites in the body where the permeability of the vascular wall increases. The most popular means of producing long-circulation liposomes is to bind polyethylene glycol hydrophilic polymer (PEG) covalently to the outer surface of the liposome. Some of the preferred lipids are: 1, 2-Dipalmitoyl-sn-Glycero-3-Phosphoethanolamine-N- [Methoxy (Polyethylene glycol) -2000] (Ammonium salt), 1,2-Dipalmitoyl-sn-Glycero-3- Phosphoethanolamine-N- [Methoxy (Polyethylene glycol) -5000] (Ammonium salt), 1,2-Dioleoyl-3-trimethylammonium-Propane (Salt Chloride) (DOTAP). Possible lipids applicable for liposomes are supplied by Avanti, Polar Lipids, Inc., Alabaster, AL. Additionally, the liposome suspension can include lipid protection agents which protect the lipids against free radicals and damage by lipid peroxidation in storage. Lipophilic free radical quenchers, such as alpha-tocopherol and specific water-soluble iron chelators, such as ferrioxianin, are preferred. A variety of methods are available for preparing liposomes, as described in, for example, Szoka et al., Ann. Rev. Biophys. Bioeng. 9: 467 (1980), Pat. E.U. Nos. 4,235,871, 4,501,728 and 4,837,028, all of which are incorporated herein by reference. Another method produces multilamellar vesicles of heterogeneous sizes. In this method, the vesicle forming lipids are dissolved in a suitable organic solvent or solvent system and dried under vacuum or in an inert gas to form a thin lipid film. If desired, the film can be again dissolved in a suitable solvent, such as tertiary butanol, and then lyophilized to form a more homogeneous lipid mixture which is in a more easily hydrated form as a powder. This film is covered with an aqueous solution of the target drug and the target component and allowed to hydrate, typically over a period of 15-60 minutes with agitation. The distribution size of the resulting muitilamellar vesicle can be changed to smaller sizes by hydrating the lipids under more vigorous agitation conditions or by adding solubilizing detergents such as deoxycholate. The micelles are formed by surfactants (molecules that contain a hydrophobic portion and one or more ionic or otherwise strongly hydrophilic groups) in aqueous solution. Common surfactants well known to one of skill in the art can be used in the micelles of the present invention. Suitable surfactants include sodium laureate, sodium oleate, sodium lauryl sulfate, octaoxyethylene glycol monododecyl ether, octoxynol 9 and PLURONIC F-127 (Wyandotte Chemicals Corp.). Preferred surfactants are nonionic polyoxyethylene and polyoxypropylene detergents compatible with IV injection such as, TWEEN-80, PLURONIC F-68, n-octyl-beta-D-glucopyranoside, and the like, In addition, phospholipids, such as those described for use in the production of liposomes, can also be used for of micelos. In some cases, it will be advantageous to include a compound, which promotes the delivery of the substance to its objective Dosage regimens The preparations are administered in a manner compatible with the dosage formulation, and in such amount as will be therapeutically effective. The amount to be administered depends on the subject to be treated, including, for example, the weight and age of the subject, the disease to be treated and the stage of the disease. Suitable dosage ranges are per kilogram of body weight usually of the order of several hundred μg of active ingredient per administration with a preferred range of about 0. lμg to 100OOμg per kilo of body weight. Using monomeric forms of the compounds, the appropriate dosage is frequently in the range of 0. lμg to 5000μg per kilo of body weight, such as in the range of about 0. lμg to 3000μg per kilo of body weight, and especially in the range of about 0. lμg to lOOOμg per kilo of body weight. Using multimeric forms of the compounds, suitable dosage is obtained in the range of about 0.1 μg to 750 μg per kilo of body weight, and especially in the range of about 0.1 μg to 500 μg per kilo of body weight as in the range of about 0.1 μg to 250 μg per kilo of body weight. A preferred dosage would be from about 0.1 to about 5.0 mg, preferably from about 0.3 mg to about 3.0 mg, such as from about 0.5 to about 1.5 mg and especially in the range from 0.8 to 1.0 per administration. Administration will be performed once or may be followed by subsequent administrations. The dosage also depends on the route of administration and will vary according to the age, sex and weight of the subject to be treated. A preferred dosage of multimeric forms would be in the range of 1 mg to 70 mg per 70 kg of body weight. The proper daily dosage ranges are per kilogram of weight per day, usually in the order of several hundred μg of active ingredient per day with a preferred range of about 0.1 μg to 10000 μg per kilo of body weight per day. Using monomeric forms of the compounds, the appropriate dosage is obtained in the range of about 0.1 μg to 5000 μg per kilo of body weight per day, such as in the range of about 0.1 μg to 3000 μg per kilo of body weight, and especially in the range of 0.1 μg to 1000 μg per kilo of body weight per day. Using multimeric forms of the compounds, the appropriate dosage is obtained in the range of about 0.1 μg to 1000 μg per kilo of body weight per day, such as in the range of about 0.1 μg to 750 μg per kilo of body weight per day, and especially in the range of about 0.1 μg to 500 μg per kilo of body weight per day, such as in the range of about 0.1 μg to 250 μg per kilo of body weight per day. A preferred dosage would be from about 0.1 to about 100 μg, preferably from about 0.1 to about 50 μg, such as from about 0.3 μg to about 30 μg and especially in the range from 1.0 to 10 μg per kilogram. body weight per day. Administration will be performed once or may be followed by subsequent administrations. The dosage also depends on the route of administration and will vary with the age, sex and weight of the subject to be treated. A preferred dosage of multimeric forms would be in the range of 1 mg per 70 kilograms of body weight per day.

Medical packaging The compounds used in the invention can be administered alone or in combination with pharmaceutically acceptable carriers or excipients, in either single or multiple doses. The formulations can be conveniently presented in unit dosage form by methods known to those skilled in the art. It is preferred that the compounds according to the invention are provided in a kit. Such a kit typically contains an active compound in dosage forms for administration. A dosage form contains a sufficient amount of active compound such that a desired effect can be obtained when administered to the subject. Thus, it is preferred that the medical package comprises a quantity of dosage units corresponding to the relevant dosage regimen. Thus, in one embodiment, the medical package comprises a pharmaceutical composition comprising a compound as defined above or a pharmaceutically acceptable salt thereof and pharmaceutically acceptable carriers, vehicles and / or excipients, the package comprising from 1 to 7 units of dosage, therefore it has dosage units for one or more days, or from 7 to 21 dosage units, or multiple thereof, therefore it has dosage units for a week of administration or several weeks of administration. The dosage units can be as defined above. Medical packages can be in any form suitable for intratracheal, intrabronchial or intraalveolar administration. In a preferred embodiment the package is in the form of a vial, ampoule, tube, bubble pack, cartridge or capsule. When the medical package comprises more than one dosage unit, it is preferred that the medical package be provided with a mechanism for adjusting each administration for one dosage only. Preferably, a kit contains instructions indicating the use of the dosage form to achieve a desired affect and the amount of dosage form to be taken during a specific period of time. Accordingly, in one embodiment the medical package comprises instructions for administering the pharmaceutical composition.

EXAMPLES Example 1 Protocol for local pulmonary therapy with TFPI through bronchoalveolar lavage (BAL) I. Group of patient to be treated: Patients with ventilator-associated pneumonia following pneumonia Strep. bacterial, Pneunocystis carinii pneumonia (PCP) or other types of pneumonia or ARDS that follows sepsis, disseminated intravascular coagulation (DIC), trauma, pulmonary aspiration pneumonitis, severe pancreatitis or ARDS-induced bleomycin with ongoing treatment with mechanical ventilation , with development of ARDS with reduced oxygenation capacity as revealed by a Pa02 / FiC2 ratio, this is < 200 mmHg (arterial oxygen tension in mmHg over fraction of oxygen aspirated) despite treatment with complete antibiotic coverage towards the isolated microbiological agent or treatment of fundamental disease.

II. Treatment regimen: Local administration of 5 mg TFPI dissolved in 20 ml of normal saline by means of bronchoalveolar lavage (BAL).

III. Analysis of results: a) Monitor oxygenation capacity as when monitoring the Pa02 / Fi02 ratio (arterial oxygen tension in mmHg over fraction of oxygen aspirated). A successful treatment results in an increase in oxygen capacity with a Pa02 / Fi02 ratio, that is > 200 mmHg. b) X-ray of the pulmonary field before and after treatment. Since patients have infiltrations in the lung, a successful treatment leads to the reduction of these infiltrations as monitored by radiography.

Example 2 Protocol for local pulmonary therapy with TFPI through inhalation I. Group of patient to be treated: Patients with ventilator-associated pneumonia following bacterial Strep pneumonia, Pneumocystis carinii pneumonia or other types of pneumonia or ARDS that follows sepsis, disseminated intravascular coagulation (DIC), trauma or pneumonitis due to pulmonary aspiration or severe pancreatitis or ARDS induced by bleomycin with ongoing treatment with mechanical ventilation, with development of ARDS with reduced oxygenation capacity as revealed by a Pa02 / Fi02 ratio, this is <; 200 mmHg (arterial oxygen tension in mmHg over fraction of oxygen aspirated) despite treatment with complete antibiotic cover to the isolated microbiological agent or treatment of fundamental disease.

ITEM. Treatment regime: Local administration of 3 x 5 mg TFPI by means of a nebulizer (Aeroneb®).

ITT. Analysis of results: a) Monitor oxygenation capacity as when monitoring the Pa02 / Fi02 ratio (arterial oxygen tension in mmHg over fraction of oxygen aspirated). A successful treatment results in an increase in oxygen capacity with a Pa02 / Fi02 ratio, that is > 200 mmHg. b) X-ray of the pulmonary field before and after treatment. As patients have infiltrations in the lung, a successful treatment leads to the reduction of these infiltrations as monitored by radiography. It is noted that in relation to this date, the best method known to the applicant to carry out the aforementioned invention, is that which is clear from the present description of the invention.

Claims (12)

1. Claims Having described the invention as above, the content of the following claims is claimed as property: 1. The use of a pathway inhibitor of the human tissue factor or a biologically active derivative thereof as the sole active ingredient for the manufacture of a medicament for use in treating or preventing the deposition of extracellular fibrin in the alveolar or bronchioalveolar spaces, in a human by administration through the respiratory tract by means of intratracheal, intrabronchial or intraalveolar administration.
2. 2. The use according to claim 1, wherein the fibrin sedimentation is caused by an inflammatory lung disease.
3. 3. The use according to claim 2, wherein the inflammatory lung disease is selected from the group consisting of: ALI, ARDS, pneumonia, acute bronchial-alveolar diseases, chronic bronchial-alveolar diseases, fibrous alveolitis or bronchial asthma.
4. 4. The use according to any of the preceding claims, wherein the inflammatory lung disease is related to a condition selected from the group consisting of: direct or indirect lung trauma, pancreatitis, aspiration pneumonitis, sepsis, severe sepsis and / or septic shock.
5. 5. The use according to any of the preceding claims, wherein the tissue factor pathway inhibitor is administered by bronchoalveolar lavage with a solution of the tissue factor path inhibitor.
6. 6. The use according to any of the preceding claims, wherein the tissue factor pathway inhibitor is administered by blind trachea lavage with a solution of the tissue factor pathway inhibitor.
7. The use according to any of the preceding claims, wherein the tissue factor path inhibitor is administered by causing inhalation of a nebulizer solution of the tissue factor path inhibitor.
8. The use according to any of the preceding claims, wherein the tissue factor pathway inhibitor is administered by causing inhalation of the tissue factor path inhibitor in an inhaled powder form.
9. The use according to any of the preceding claims, wherein the tissue factor pathway inhibitor is administered by the direct application of the tissue factor pathway inhibitor during bronchoscopy.
10. 10. The use according to any of claims 1 to 9, wherein the human is an adult.
11. 11. The use according to any of claims 1 to 9, wherein the human is a child.
12. 12. The use according to any of the preceding claims, wherein the TFPI is administered in an amount of 0.1 μg / kg to about 10 mg / kg of body weight per day. Resiament of the Invention The present invention provides methods for the local treatment of chronic and acute extravascular pulmonary fibrin sedimentation and / or reduction of undesired effects associated with the systemic administration of natural anticoagulants to a subject by means of administration to the respiratory tract of the subject by intratracheal, intrabronchial or intraalveolar routes of natural anticoagulants or biologically active derivatives thereof.