ES2361213T3 - PROGESTERONE DOSAGE INDICATION IN THE TREATMENT OF A CHRANEOENCEPHALAL TRAUMATISM. - Google Patents

Abstract

Progesterone intended to be used in the treatment of head trauma in a human subject, said treatment comprising a constant or two-level progesterone dosage regimen where a therapeutically effective amount of progesterone is administered to said human subject by means of an intravenous infusion to achieve a final serum level of progesterone from about 100 ng / ml to about 1000 ng / ml.

Description

FIELD OF THE INVENTION

[0001] The invention relates to methods for treating a traumatic injury to the central nervous system.

BACKGROUND OF THE INVENTION

[0002] Between 1.5 and 2 million Americans suffer a head trauma (TBI) each year (Anonymous, "Traumatic Brain Injury," Center for Disease Control and Prevention, National Center for Injury Prevention and Control, 2003, Vol. 2003). In the US it is estimated that the TCE is responsible for 50,000 deaths and 100,000 hospitalizations annually (Anonymous, "Traumatic Brain Injury," Center for Disease Control and Prevention, National Center for Injury Prevention and Control, 2003, Vol. 2003). Nearly 80,000 become invalid annually, approximately 17,000 of these need specialized help for life (Kraus (1997) "Epidemioxlogy of Head Injury," in Head Injury, ed. Cooper (Williams & Wilkins Co., Baltimore) pp 1-19 ; Selecki et al. (1982) Australian & New Zealand Journal of Surgery 52 (1): 93-102). In addition to the initial injury created by sudden trauma to the brain, excessive biomechanical force initiates a series of deleterious side effects that can dramatically increase the size of the lesion, morbidity, and mortality from days to months after the initial injury (McIntosh et al. (1996) Lab Invest, 74 (2): 315-42; Stambrook et al. (1990) Can J Surg 33 (2): 115-8). Despite the seriousness of the problem, no effective pharmacological treatment for TBI has been discovered.

[0003] Continuous intravenous (IV) infusion allows a rapid supply of drugs and achieves a steady state serum concentration, but this route of progesterone administration is not approved by the FDA in the US. Only three human studies involving the use of progesterone IV in the US have been observed. In an initial phase I clinical trial approved by the FDA (IND 33,580), Choraisten, et al., Used progesterone IV dissolved in a 20% ethanol-Intralipid fat emulsion combined with doxorubicin in approximately 24 hours to 32 cancerous patients without toxic effects (Choraisten et al. (1993) Journal of Clinical Oncology 11 (12): 2417-2426). In a second study, Allolio et al. they observed that stable serum concentrations (Css) of progesterone could be obtained in healthy male volunteers (Allolio et al. (1995) European Journal of Endocrinology 133 (6): 696-700). The third study was done after the study conducted by Choraisten et al, but it was a phase II test that tests the effect of co-administration of progesterone at high doses in the pharmacokinetics of paclitaxel. The manuscript did not present detailed information on progesterone pharmacokinetics.

[0004] Following a traumatic injury to the central nervous system, a series of physiological events leads to neuronal loss including, for example, an inflammatory immune response and excitotoxicity obtained by the initial disruption impact of glutamate, acetylcholine, cholinergic, systems of GABAA and NMDA receptors. In addition, traumatic CNS injury is often followed by cerebral and / or spinal cord edema that increases the cascade reaction of lesions and leads to another death of secondary cells and an increase in patient mortality. Methods are needed for the treatment of traumatic CNS lesions in vivo that are appropriate to provide subsequent trophic support to the tissue of the remaining central system, and thus improve recovery and functional repair, under the complex psychological cascade reaction of events that follow the aggression. initial.

SUMMARY OF THE INVENTION

[0005] The present invention relates to methods provided for treating a subject with a traumatic injury to the central nervous system, more particularly, a head injury. The methods comprise a therapy that includes a constant dosage regimen or two levels of synthetic progesterone or progestin.

[0006] In addition, the method comprises the administration to the subject in need of at least one therapy cycle, wherein said cycle comprises the administration of an intravenous dosing regimen of two therapeutically effective levels of synthetic progesterone or progestin. The two-level dosage regimen may comprise a first period of time where a higher dose of progesterone or synthetic progestin is administered per hour, followed by a second period of time where a lower dose of progesterone is administered to the subject or synthetic progestin per hour. In specific methods, the first period of time comprises an hourly dose of progesterone or synthetic progestin between about 0.1 mg / kg to about 7.1 mg / kg. In other methods, the second period of time comprises an hourly dose of progesterone or synthetic progestin between about 0.05 mg / kg to about 5 mg / kg. In other methods, a third period of time comprising an administration protocol that is gradually reduced is added to the dosage regimen of progesterone or synthetic progestin.

BRIEF DESCRIPTION OF THE DRAWINGS

[0007]

Figure 1 shows that stable concentrations of progesterone can be rapidly obtained using continuous intravenous infusions. The closed circles represent the serum concentration-time profile for a patient receiving progesterone. Solid triangles represent the serum concentration-time profile for a patient receiving a placebo infusion. Progesterone concentrations for patients receiving a placebo infusion remained constant throughout the study period. The CSS concentrations in patients receiving progesterone are achieved quickly and once achieved, they remain stable throughout the infusion period.

Figure 2 shows that there is a significant correlation between predicted and measured CSS. The CSS were provided as a proportion of the infusion index and CL. The expected values were compared with the CSS measured in each patient by plotting each pair of values on the identity line. The Spearman correlation coefficient by ranges for this relationship was 0.946 (p <0.001).

Figure 3 shows the Bland-Altman analysis of the correlation between predicted and measured CSS. Since a plot of predicted versus measured CSS often does not reveal a systematic over or low (diagonal) estimate, a Bland-Altman analysis was carried out. The averages of the measured and expected values (abcissa) are represented compared to the relative difference of the two values (ordered). The solid line is the mean value for the relative difference (-0.8 ± 12.2%; Mean ± SD) and the dotted lines represent 95% of the safe intervals for the data. This graph clearly demonstrates that there is no significant diagonal associated with this prediction method.

Figure 4 shows that CSS values are considerably lower than expected based on pharmacokinetic parameters indicated previously. The CSS measured in the 21 men (solid circles) and 11 women (solid triangles) have been represented individually. The solid and dotted lines represent our original target concentrations of 450 ± 100 ng / mL. These data clearly demonstrate that in patients with TBI, CSS values are significantly lower than expected using the pharmacokinetic parameters indicated previously.

Figure 5 provides an outline of the registration protocol for the selection of treatment for the study of TBI.

DETAILED DESCRIPTION OF THE INVENTION

[0008] The present inventions will be described in more detail hereafter in reference to the attached drawings, in which only some of the embodiments of the invention are shown.

[0009] Many modifications and other embodiments of the invention set forth herein can be imagined by those skilled in the art to whom these inventions belong, having the advantage of the instructions presented in the preceding descriptions and the associated drawings. Therefore, it should be understood that inventions should not be limited to the specific embodiments described.

[0010] The present invention relates to methods for treating a human subject who has a traumatic injury to the central nervous system, more particularly, a head injury. As we will discuss in more detail below, the methods comprise a therapy that includes a dosage regimen of progesterone or synthetic progestin.

[0011] A traumatic CNS lesion is characterized by a physical impact on the central nervous system. For example, a traumatic brain injury occurs when the brain is exposed to a physical force that involves progressive damage to neuronal cells and / or cell death. A head injury can be generated by a blow to the head and manifest as an open wound or as a closed wound. Severe brain damage can occur due to lacerations, skull fractures, and on the other hand, even when there are no external signs of head injuries. Accordingly, the methods of the invention can be used to treat head trauma, including closed trauma, as well as penetrating trauma.

[0012] The physical forces that cause a head injury can have the effect of generating three types of injury: skull fracture, parenchymal injury, and vascular injury. Parenchymal lesions include concussion, direct parenchymal injury and diffuse axonal injury. Concussions are characterized as a clinical syndrome of secondary consciousness alteration of a head trauma typically generated by a change in head movement (movement of the head stopped against an irregular surface). The pathogenesis of the sudden breakdown of nerve activity is unknown, but the physiological and biochemical abnormalities that are generated include, for example, depolarization due to excitatory ionic fluxes mediated by amino acids through cell membranes, adenosine triphosphate depletion mitochondrial, and the alteration of vascular permeability. Post-concussion syndrome may show evidence of direct parenchymal injury, but in some cases there is no evidence of damage.

[0013] Contusion and lacerations are conditions in which direct parenchymal lesion of the brain occurs, either through the transmission of kinetic energy to the brain and bruises analogous to what is seen in soft tissues (contusion) or by penetration of an object and tearing of the tissues (laceration). A stroke on the surface of the brain leads to rapid tissue displacement, alteration of vascular channels and subsequent bleeding, tissue injury and edema. Morphological evidence of neuronal injury in the body includes nucleus picnosis, cytoplasm eosinophilia, and cell disintegration. In addition, axonal inflammation can develop in the vicinity of damaged neurons and also great distances away from the site of impact. The inflammatory response of the damaged tissue follows its usual course with neutrophils that precede the appearance of macrophages.

[0014] In accordance with the methods of the present invention, synthetic progesterone or progestin is used to promote a positive therapeutic response with respect to traumatic central nervous system injury. The "treatment" is intended for any improvement in the subject who has a traumatic CNS lesion including both improved morphological recovery (ie, improved tissue viability) and behavioral recovery. The improvement can be characterized as an increase in the index and / or the extent of anatomical and behavioral recovery after traumatic CNS injury. Therefore, a "positive therapeutic response" includes both complete and partial responses. Several methods for determining whether a complete or partial therapeutic response has been given are discussed in more detail elsewhere in this.

[0015] Neurodegeneration is the progressive loss of neurons in the central nervous system. As used in this case, "neuroprotection" is the arrest and / or reverse progression of neurodegeneration after a traumatic injury to the central nervous system. Several physiological events generate neurodegeneration of CNS tissues after a traumatic CNS lesion. These events include, for example, cerebral edema, destruction of vascular integrity, increased immune and inflammatory response, demyelination, and lipid peroxidation. Therefore, the methods of the invention are also useful for the reduction and / or prevention of physiological events that generate neurodegeneration. Specifically, the present invention provides methods for reducing or eliminating neuronal cell death, edema, ischemia, and increasing the viability of tissue after a traumatic injury to the central nervous system.

[0016] The synthetic progesterone or progestin therapy of the invention is administered to a subject with a traumatic CNS lesion. As defined herein, the subject can be any mammal, preferably a human. In specific embodiments, the human is an adult (over 18 years old), while in other embodiments, the human is a child (under 18 years old). The child can be a newborn, a baby, a child, preteens

or post-adolescents and the age range approximately from birth, from 1 month to approximately 2 years, from approximately 1 year to approximately 5 years, from approximately 4 years to approximately 9 years, from approximately 8 years to approximately 14, or approximately 13 to approximately more than 18 years.

In addition, the human may be approximately 55 to 60, 60 to 70, 70 to 80, 80 to 90, 90 to 95 years or more.

[0017] The present invention provides a method of treating a traumatic CNS lesion by administering a therapeutically effective amount of synthetic progesterone or progestin to a subject. By "therapeutically effective amount" is defined the concentration of a synthetic progesterone or progestin sufficient to elicit a therapeutic effect. Thus, the concentration of a synthetic progesterone or progestin in a dose unit administered in accordance with the present invention is effective in the treatment or prevention of neuronal damage caused by a traumatic injury in the CNS and therefore arouses a neuroprotective effect. The therapeutically effective amount will depend on many factors including, for example, the specific activity of the synthetic progesterone or progestin, the severity and type of traumatic injury, the resulting neuronal damage, the patient's receptivity, the patient's weight, with other intrapersonal variability. , the mode of administration, and the formulation of synthetic progesterone or progestin used.

[0018] The pharmaceutical composition comprising progesterone is administered by infusion preferably over a period of about 1 to about 120 hours. In some embodiments, the infusion of synthetic progesterone or progestin occurs in a period of about 24 to about 72 hours, in a period of about 48 to about 96 hours, or in a period of about 24 to about 120 hours.

[0019] In one embodiment of the present invention, the synthetic progesterone or progestin is administered in a dose of about 0.1 ng to about 100 g per kg of body mass, of about 10 ng to about 50 g per kg. body mass, from about 100 ng to about 1 g per kg of body mass, from about 1 µg to about 100 mg per kg of body mass, from about 1 µg to about 50 mg per kg of body mass, of about 1mg to approximately 500 mg per kg of body mass; and from about 1 mg to about 50 mg per kg of body mass. Alternatively, the amount of progesterone or synthetic progestin administered to achieve an effective therapeutic dose is approximately 0.1 ng, 1 ng, 10 ng, 100 ng, 1 µg, 10 µg, 100 µg, 1 mg, 2 mg, 3 mg , 4 mg, 5 mg, 6 mg, 7 mg, 8 mg, 9 mg, 10 mg, 11mg, 12 mg, 13 mg, 14 mg, 5 mg, 16 mg, 17 mg, 18 mg, 19 mg, 20 mg , 30 mg, 40 mg, 50 mg, 60 mg, 70 mg, 80 mg, 90 mg, 100 mg, 500 mg per kg of body mass or higher.

[0020] Progesterone or synthetic progestin can be administered once or several times a day. The duration of treatment can be once a day for a period of approximately 1, 2, 3, 4, 5, 6, 7 days or more.

[0021] For example, a dosage unit may be administered from about 0 hours to about 1 hour, from about 1 hour to about 24 hours, from 1 to 72 hours, from 1 to 120 hours, or from about 24 hours at less until about 120 hours after the injury. Alternatively, the dosage unit can be administered from about 0.5, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 , 20, 21, 22, 23, 24, 30, 40, 48, 72, 96, 120 hours or more after the injury. Subsequent dose units may be administered at any time after initial administration to achieve a therapeutic effect. For example, other dose units may be administered to protect the subject from the secondary wave of edema that may occur during the first respective days after the injury.

[0022] In specific embodiments of the invention, the subject undergoing synthetic progesterone or progestin therapy is administered a constant synthetic progesterone or progestin dosage regimen. By "Dosing regimen of progesterone or constant synthetic progestin" it is indicated that the subject exposed to therapy with synthetic progesterone or progestin is administered a dose of synthetic progesterone or progestin by total constant infusion every hour throughout the treatment. This dose administered hourly of progesterone or synthetic progestin is divided into a series of equivalent doses that are administered according to an appropriate administration schedule depending on the method of administration. The duration of the constant dosage regimen of progesterone or synthetic progestin is approximately 12, 24, 36, 60, 72, 84, or 120 hours or approximately 1 to 24 hours, approximately 12 to 36 hours, approximately 24 to 48 hours, about 36 to 60 hours, about 48 to 72 hours, about 60 to 96 hours, about 72 to 108 hours, about 96 to 120 hours, or about 108 to 136 hours.

[0023] In other embodiments of the invention, therapy with synthetic progesterone or progestin comprises a "dosage regimen of synthetic progesterone or progestin". By "dosing regimen of progesterone or synthetic progestin" it is indicated that the subject undergoing therapy with synthetic progesterone or progestin receives administration of synthetic progesterone or progestin during two-dose progesterone dosing periods.

or synthetic progestin. The two-stroke periods may have a combined duration of about 12 hours to about 7 days, including, 1, 2, 3, 4, or 5 days or about 15, 15, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, or 144 hours or about 1 to 24 hours, about 12 to 36 hours, approximately 24 to 48 hours, approximately 36 to 60 hours, approximately 48 to 72 hours, approximately 60 to 96 hours, approximately 72 to 108 hours, approximately 96 to 120 hours, or approximately 108 to 136 hours. In one embodiment, the dosage regimen of progesterone or synthetic progestin has a combined duration of about 1 day to about 5 days; In other embodiments, the dosage regimen of progesterone or synthetic progestin has a combined duration of about 1 day to about 3 days.

[0024] In one embodiment, the total dose of synthetic progesterone or progestin that must be administered every hour during the first and second time periods of the dosing regimen of two levels of synthetic progesterone or progestin is chosen such that a Higher total infusion dose of progesterone or synthetic progestin per hour is provided during the first period of time and a lower infusion dose of progesterone or synthetic progestin per hour is provided during the second period of time. The duration of the first and second individual time period of the dosing regimen of two levels of progesterone or synthetic progestin may vary, depending on the health of the individual and the history of the trauma. Generally, a higher total infusion dose of progesterone or synthetic progestin is administered to the subject every hour for at least 1, 2, 3, 4, 5, 6, 12 or 24 hours from the 1st day until the 5th day of the dosage regimen of two levels of synthetic progesterone or progestin. The extension of the second period of time can be adjusted in this way, and ranges, for example, between approximately 12 hours, 24 hours, 36 hours, 48 hours, 60 hours, 72 hours, 84 hours, 96 hours, 108 hours, 120 hours or from about 12 to about 36 hours, about 24 to about 36 hours, about 24 to about 48 hours, about 36 hours to about 60 hours, about 48 hours to about 72 hours, about 60 hours to about 84 hours, about 72 hours to about 96 hours, or from about 108 hours to about 120 hours. Thus, for example, where the dosing regimen of two levels of synthetic progesterone or progestin has a combined duration of 3 days, the highest total doses of synthetic progesterone or progestin can be administered during the first hour, and the dose per hour. Total lower progesterone or synthetic progestin can be administered over a period of 2 to 72 hours.

[0025] In other embodiments also, the total infusion dose of progesterone per hour to be administered during the first and second periods of dosing regimen of two levels of synthetic progesterone or progestin is chosen such that a total dose A lower hourly rate of progesterone or synthetic progestin is provided during the first period of time and a higher hourly dose of progesterone or synthetic progestin is provided during the second period of time.

[0026] The area under the curve (AUC) refers to the area below the curve that follows the concentration of serum (nmol / L) of progesterone or synthetic progestin at a given time following IV administration of the progesterone reference standard or synthetic progestin. By "standard reference of synthetic progesterone or progestin" is meant the formulation of synthetic progesterone or progestin that serves as the basis for the determination of the dose of total synthetic progesterone or progestin per hour to a subject with a central nervous system trauma according with the dosing regimen of constant level or of two levels of synthetic progesterone or progestin to achieve the desired positive effect, that is, an improved positive therapeutic response with respect to what has been observed without the administration of synthetic progesterone or progestin. For the determination of the AUC for the reference standard of progesterone or synthetic progestin, see Experimental Section, Example 1. Therefore, the total dose of synthetic progesterone or progestin to be administered per hour during the dosing regimen of two levels of synthetic progesterone or progestin may thus allow a final serum concentration of progesterone or synthetic progestin of approximately 100 ng / ml to approximately 1000 ng / ml, approximately 1100 ng / ml to approximately 1450 ng / ml, 100 ng / ml to approximately 250 ng / ml, from approximately 200 ng / ml to approximately 350 ng / ml, from approximately 300 ng / ml to approximately 450 ng / ml, from approximately 350 ng / ml to approximately 450 ng / ml, from approximately 400 ng / ml at about 550 ng / ml, from about 500 ng / ml to about 650 ng / ml, from about 600 ng / ml to about 750 ng / ml, about 700 ng / ml to about 850 ng / ml, from a approximately 800 ng / ml to approximately 950 ng / ml, from approximately 900 ng / ml to approximately 1050 ng / ml, from approximately 1000 ng / ml to approximately 1150 ng / ml, approximately 1100 ng / ml to about 1250 ng / ml, from about 1200 ng / ml to about 1350 ng / ml, from about 1300 ng / ml to about 1500 ng / m. In specific embodiments, the serum concentration of progesterone or synthetic progestin comprises approximately 100 ng / ml, 250 ng / ml, 300 ng / ml, 350 ng / ml, 360 ng / ml, 370 ng / ml, 380 ng / ml , 390 ng / ml, 400 ng / ml, 410 ng / ml, 420 ng / ml, 430 ng / ml, 440 ng / ml, 450 ng / ml, 500 ng / ml, 750 ng / ml, 900 ng / ml , 1200 ng / ml, 1400 ng / ml, or 1600 ng / ml.

[0027] The methods of the present invention also contemplate embodiments where a subject undergoing constant therapy of synthetic progesterone or progestin or dosing regimen of two levels of synthetic progesterone or progestin has a time period without dosing of progesterone or synthetic progestin For example, when a dosage regimen of progesterone or synthetic progestin is performed, the period of time without synthetic progesterone or progestin may occur between the conclusion of the first period of the dosing regimen of two levels of synthetic progesterone or progestin and the initiation of the second time period of the dosing regimen of two levels of progesterone or synthetic progestin. For example, administration in the first period of time in a prehospital area may be considered, for example at the site of trauma. The second period of time may be upon arrival at the hospital. In these embodiments, the dosing regimen of two levels of synthetic progesterone or progestin is interrupted such that the dosage of progesterone or synthetic progestin is stopped for a period of approximately 15 minutes, 30 minutes, 1 hour, 2 hours. , 3 hour, 4 hour, 5 hour, 6 hour or more.

[0028] In other embodiments, constant progesterone or synthetic progestin therapy or two-level therapy of synthetic progesterone or progestin comprises a final period in which the administration of synthetic progesterone or progestin is reduced. By "reduction of administration" is meant an administration protocol that reduces the dose of administration to the patient and thus produces a gradual reduction and eventual elimination of synthetic progesterone or progestin, in a fixed period of time or empirically determined time by an evaluation of the doctor based on the regular control of a therapeutic response of a subject with CNS trauma. The period of reduced administration of synthetic progesterone or progestin may be approximately 12, 24, 36, 48 hours or more. Alternatively, the reduced administration period of synthetic progesterone or progestin may vary from about 1 to 12 hours, from about 12 to about 48 hours, or from about 24 to about 36 hours.

[0029] The drug reduction employed may be a "linear" reduction. For example, a linear "10%" reduction of 500 mg would be 500, 450, 400, 350, 300, 250, 200, 150, 100, 50. Alternatively, an exponential reduction can be used, which, if used the program mentioned above as an example, the exponential reduction will be, for example, 500, 450, 405, 365, 329, 296, 266, 239, etc. Accordingly, approximately an exponential or linear reduction of 5%, 10%, 20%, 30%, or 40% can be used in the methods of the invention. Also I know

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it can employ an exponential or linear reduction of about 1% to 5%, about 6% to 10%, about 11% to 15%, about 16% to 20%, about 21% to 25%, about 26% to 30%, approximately 31% to 35%, approximately 36% to 40%. Alternatively, the scale of reduction can be determined based on the physician's evaluation of the patient's response to therapy. Additional methods of reduced administration can be found, for example, in US Provisional Application 60 / 729,663, requested October 24, 2005.

[0030] When a subject exposed to a therapy according to the aforementioned dosage regimens exhibits a partial response, or a relapse after an improvement in the first cycle of therapy, subsequent applications of a synthetic progesterone or progestin therapy may be necessary. to achieve a partial or complete therapeutic response. Thus, after a period of time that is not part of a first treatment period, which may comprise a constant dosage regimen of synthetic progesterone or progestin or a dosing regimen of two levels of synthetic progesterone progesterone, a subject may receive one or more additional treatment periods comprising constant dosing regimens or two levels of synthetic progesterone or progestin. Such a period of rest time between treatment periods is called in this case a period of discontinuation time. It is known that the duration of the discontinuation period depends on the degree of the subject's response (ie, complete, equal, partial) obtained with any period of therapy based on synthetic progesterone or progestin.

[0031] These multiple treatment sessions are defined herein as maintenance cycles, where each maintenance cycle comprises a constant complete dosing regimen or two levels of synthetic progesterone or progestin. By "complete dosing regimen of two levels of synthetic progesterone or progestin" it is understood that the subject has been administered the first period as well as the second dosing period of progesterone or synthetic progestin. The need for multiple maintenance cycles can be assessed by controlling the patient's behavioral and physiological improvement. The duration between maintenance cycles can be approximately 1 h, 15 h, 1 day, 2 days, 3 days, 4 days, 5 days, 6 days or other time periods of this type in the range of approximately 1 to approximately 14 days.

[0032] The term "progesterone" as used herein refers to an element of the progestinic family and comprises a carbon steroid hormone 21. Progesterone is also known as D4-pregnene-3,20dione; 84-pregnene-3,20-dione; or pregn-4- Jan-3,20-dione. and its structure is provided below in formula (I). The progesterone used in the methods of the invention may be of natural or synthetic origin.

image 1

[0033] The methods of the invention further include synthetic progestins. As a "synthetic progestin" is used in this case, it is a molecule whose structure is related to that of progesterone, it synthetically derives and retains the biological activity of progesterone (that is, it treats CNS trauma). Synthetic progestin

Representative includes, but is not limited to, modifications that produce esters 17a-OH (i.e. 17 α

hydroxyprogesterone caproate), as well as, modifications that introduce 6 α-methyl, 6-Me, 6-ene, and 6-chloro progesterone substituents (i.e., medroxyprogesterone acetate, megestrol acetate, and clomadinone acetate). Table 1 provides another non-limiting example of synthetic progestins.

Table 1 Classification of synthetic progestins.

Common classification by generation *

Classification by

First  Second Third

Structure

Stranger

Ethinodiol diacetate (with ethinyl estradiol: Demulen) Norethindrono (Micronor) Norethindrono acetate (Aigestine) - -

Gonanos

Norgestrel (Ovrette) Levonorgestrel (Norplant; Degest it (with ethynyl

with ethinyl estradiol: Alesse, estradiol: Deogenous)

Nordette) Gestodene † Norgestimate (with ethynyl estradiol: Ortho-Cyclen, Ortho Tri-Cyclen)

Pregnanos Acetate ---- Medroxyprogesterone (Provera)

* - The traditional classification is based on time since its introduction in the market and not on physiological and structural differences or efficiencies.

[0034] The composition comprising progesterone or synthetic progestin that is employed in the methods of the invention may also comprise a pharmaceutically acceptable carrier, organic or inorganic, solid or liquid. The carrier may also contain preservatives, humectants, emulsifiers, solubilizers, stabilizers,

5 buffers, solvents and salts. The compositions can be sterilized and exist in the form of solids, particulates or powders, solutions, suspensions or emulsions. In one embodiment, the synthetic progesterone or progestin is dissolved in ethanol, or any other carrier that dissolves the synthetic progesterone or progestin.

[0035] Progesterone or synthetic progestin can be formulated according to known methods for preparing pharmaceutically useful compositions, such as by mixing with a pharmaceutically carrier vehicle

10 acceptable. Suitable vehicles and their formulation are described, for example, in Remington's Pharmaceutical Sciences (16th ed., Osol, A. (ed.), Mack, Easton PA (1980)). To form a pharmaceutically acceptable composition suitable for effective administration, these compositions will include an effective amount of progesterone, either alone, or with a suitable amount of carrier vehicle.

[0036] The pharmaceutically acceptable carrier of the present invention is liquid. Typical liquid carriers include

15 syrup, peanut oil, olive oil, cyclodextrin, intralipids, and similar emulsions. Those skilled in the art are familiar with appropriate carriers for each of the commonly used methods of administration. Furthermore, it is recognized that the total amount of progesterone or synthetic progestin administered as an effective therapeutic dose will depend on the pharmaceutical composition that is administered (i.e., the carrier used) and the mode of administration.

[0037] In one embodiment, the carrier comprises cyclodextrin. For example, the formation may comprise progesterone or synthetic progestin dissolved in 22.5% of 2-hydroxypropyl-β-cyclodextrin (Sigma). See, for example, GOSS et al. (2003) Pharm. Biochem and Behavior 76: 231-242. In another embodiment, the carrier comprises

intralipids In one embodiment, Intralipid ® 20% (Fresenius Kabi pharmaceuticals, Clayton, NC) is used. The lipophilic properties of Intralipid ® 20% allow up to 4 gm of progesterone or synthetic progestin per 1 liter of intralipid to be dissolved in solution.

[0038] Additional pharmaceutical methods can be used to control the duration of action. Controlled release preparations can be achieved by the use of polymers to complex or absorb progesterone or synthetic progestin. Controlled delivery can be performed by appropriate selection of macromolecules (e.g., polyesters, polyamine acids, polyvinylpyrrolidone, ethylene vinyl acetate, methyl cellulose, carboxymethyl cellulose, or

30 protamine) The drug release rate can also be controlled by altering the concentration of such macromolecules.

[0039] Another possible method for controlling the duration of the action comprises incorporating the therapeutic agents into particles of a polymeric substance such as polyesters, polyamine acids, hydrogels, poly (lactic acid) or ethylene vinyl acetate copolymers. Alternatively, the therapeutic agents can be captured in microcapsules prepared for example, by coacervation techniques or by interfacial polymerization, for example, by

use of hydroxymethyl cellulose or gelatin microcapsules or poly (methyl methacrylate) microcapsules, respectively, or in a colloid-based drug delivery system, for example, liposomes, albumin, microspheres, microemulsions, nanoparticles, nanocapsules, or in macroemulsions. Such instructions are described in Remington's Pharmaceutical Sciences (1980).

[0040] In other embodiments of the present invention, at least one additional neuroprotective agent may be combined with synthetic progesterone or progestin to improve neuroprotection after CNS trauma. Such agents include, for example, compounds that reduce glutamate excitotoxicity and improve neuronal regeneration. Such agents can be selected from, but not limited to, the group comprising growth factors. By "growth factors" is defined an extracellular polypeptide signaling molecule that stimulates a cell for growth or proliferation. When synthetic progesterone or progestin is administered together with other pharmaceutically active agents, (ie, other neuroprotective agents) an even lower amount of the synthetic progesterone or progestin can be therapeutically effective.

[0041] The synthetic progesterone or progestin may be administered per se or in the form of a pharmaceutically acceptable salt. When used in medicine, the progesterone or synthetic progestin salts must both be pharmacologically and pharmaceutically acceptable, but pharmaceutically acceptable salts cannot be used properly to prepare the active free compound or pharmaceutically acceptable salts thereof and are not excluded from the scope. of this invention. Such pharmacologically and pharmaceutically acceptable salts can be prepared by reacting a progesterone or a synthetic progestin with an organic or inorganic acid, using standard methods detailed in the literature. Examples of pharmaceutically acceptable salts are salts of organic acids formed from a physiologically acceptable anion, such as tosglate, methanesulfurate, acetate, citrate, malonate, tartarate, succinate, benzoate, etc. Inorganic acid salts may be formed from, for example, hydrochloride, sulfate, nitrate, bicarbonate and carbonate salts. In addition, pharmaceutically acceptable salts may be prepared in the form of alkali metal or alkaline earth salts, such as sodium, potassium, or calcium salts of the carboxylic acid group.

[0042] Thus the present invention also provides pharmaceutical formulations or compositions, both for veterinary use and for medical use with humans, which comprise synthetic progesterone or progestin or a pharmaceutically acceptable salt derived with one or more pharmaceutically acceptable carriers thereof. and optionally any other therapeutic ingredient, such as other neurotrophic agents. The carrier (s) must be pharmaceutically acceptable (s) to the extent that it is compatible with the other ingredients of the formulation and not unduly deleterious to the recipient thereof.

[0043] In one embodiment, micronized progesterone or synthetic progestin is used. The micronization process reduces the particle size and improves its dissolution. Prometrian is an example of a micronized progesterone formulation.

[0044] In addition, the present invention provides liposomal formulations of synthetic progesterone or progestin and derived salts. The technology to form liposomal suspensions is well known in the art. When the synthetic progesterone or progestin or salt thereof is a water soluble salt, using conventional liposome technology, these can be incorporated into lipid vesicles. In this example, due to the water solubility of the compound or salt, the compound or salt will be substantially entrained to the hydrophilic center or core of the liposomes. The lipid layer used may be of any conventional composition and may include cholesterol or not. When the compound or salt of interest is insoluble in water, with the use of conventional liposome formation technology again, the salt can be substantially entrained to the double hydrophobic lipid layer that forms the structure of the liposome. In each example, the size of the liposomes that are produced can be reduced, such as through the use of standard sonication and homogenization techniques. Liposomal formulations containing progesterone or synthetic progestin or derived salts, can be lyophilized to produce a lyophilisate that can be reconstructed with a pharmaceutically acceptable carrier, such as water, to regenerate a liposomal suspension.

[0045] In addition to the ingredients mentioned, the compositions of the invention may also include one or more additional ingredient (s) selected in the group consisting of diluents, buffers, flavorings, binders, disintegrants, surfactants, thickeners, lubricants, preservatives (including antioxidants) and the like.

[0046] Behavioral tests can be used to determine the rate and extent of behavioral recovery in response to treatment. Enhanced patient motor skills, spatial learning performance, cognitive function, sensory perception, speech and / or a reduction in the tendency to suffer a stroke can also be used to measure the neuroprotective effect. Such functional / behavioral tests used to evaluate sensomotor and reflex functions are described in, for example, Bederson et al. (1986) Stroke 17: 472-476, DeRyck et al. (1992) Brain Res. 573: 44-60, Markgraf et al. (1992) Brain Res. 575: 238-246, Alexis et al. (1995) Stroke 26: 2336-2346. The improvement of neuronal survival can also be measured using the Scandinavian Sctus Scale (SSS Scandinavian Scale) or the Barthl index.

[0047] The treatment of a traumatic brain injury can be controlled using a variety of neurological measurements. For example, partial therapeutic responses can be controlled by determining whether, for example, there is an improvement in subjects a) maximum daily on the Glasgow Coma Scale; b) comma duration; 3) daily intracranial pressure - levels of therapeutic intensity; 4) extent of brain mass / edema effect measured in consecutive CT brain scans; and, 5) fan support duration. A brief description of each of these trials is provided below.

[0048] The Glasgow Coma Scale (GCS index) is a reflection on the depth of consciousness affected and is best obtained after an initial resuscitation (oxygenation, rehydration and blood pressure support) but before the use of sedative drugs, agents of neuromuscular block, or endotracheal intubation.

[0049] The duration of the coma will be defined as the number of hours of the injury time in which the subject is unable to respond voluntarily to instructions or mechanical stimulation. For uncoated subjects, this amounts to a GCS score> 8. For intubated patients, this correlates with a GCS motor score> 5. It has been found that the duration of coma allows for functional results (Uhler et al. (1994) Neurosurgery 34 (1): 122-8; Jiang et al. (1996) Brain Res 735 (1): 101-7; and Gonzalez-Vidal et al. (1998) Arch Med Res 29 (2): 117-24). The time elapsed in a pharmacologically induced coma due to other issues that brain trauma should be subtracted in the final analysis.

[0050] Intracranial pressure (ICP) of patients with severe TBI is frequently controlled with an intracranial pressure device. Controlling ICP can provide a measure of cerebral edema. However, the inherent variability and complexities of the analyzes due to therapeutic interventions aimed at reducing ICP are confused with the use of ICP measurements. To adjust these interventions, a therapeutic intensity scale was developed. This scale, known as the therapeutic intensity level (TIL), measures aggressive treatment for high PICs (Allolio et al. (1995) European Journal of Endocrinology 133 (6): 696-700; Adashi et al. (1996 ) Reproductive endocrinology, surgery, and technology Philadelphia: Lippincott-Raven; and, Beers et al. Eds. (1999) The Merck manual of diagnosis and therapy. 17th ed., Merck Sharp & Dohme Research Laboratories, Rahway, NJ).

[0051] The extent of cerebral edema and mass effect can be determined by CT scanners. For example, the volume of focal lesions can be measured. Mass lesions, whether anomalies of high density or mixed density, will be evaluated by measuring the area of the anomaly as a region of interest, multiplying the area by the thickness of the cut, and adding these volumes to contiguous cuts that show the same lesion. Each lesion will be measured three times, and the average volume will be recorded. This technique has been proven reliable (Garcia-Estrada et al. (1993) Brain Res 628 (1-2): 271-8).

[0052] Intracerebral lesions can be further characterized by location (frontal, temporal, occipital parietal, basal ganglia, or any combination). When there is an edematous zone, its volume (the hypodense perimeter) can be measured and analyzed separately. The deviation from the midline will be measured using the septum pellucidum as the midline structure. The proportion of the cerebral ventricle (VBR) will be calculated to quantify the degree of cerebral atrophy. Levin et al. ((1981) Archives of Neurology 38 (10): 623-9) found that the VBR had satisfactory reliability with different examiners, and was related to both the severity of acute injury and a neurobehavioral sequel (Hoffman et al. (1994) J Neurotrauma 11 (4): 417-31).

[0053] The duration of the ventilator support will be defined as the number of hours in which the patient receives positive pressure mechanical ventilation (Uhler et al. (1994) Neurosurgery 34 (1): 122-8; Jiang et al. ( 1996) Brain Res 735 (1): 101-7; and Gonzalez-Vidal et al. (1998) Arch Med Res 29 (2): 117-24). The time spent under fan support for other reasons that a brain trauma will be subtracted in the final analysis.

[0054] In addition to the neurological measurements mentioned above, a partial therapeutic response can also be evaluated through various neuropsychological and functional results. Different standardized measures of functional and neuropsychological performance are known. For example, subjects may show an improvement in results on the Glasgow Results Scale (GOS) / Extended Glasgow Results Scale (GOSE) and / or the "Disability Assessment Scale" (DRS). The Glasgow score of results is one of the most widely used measures for the recovery of brain trauma in the world (Garcia-Estrada et al. (1999) Int J Dev Neurosci 17 (2): p. 145-51). Patients are classified into one of five categories: death, persistent vegetative state, severe disability, moderate disability, and good recovery. It is easy to administer and score, and has a high degree of reliability and validity.

[0055] The Disability Assessment Scale (DRS) offers more precision than GOS to measure the consequences of moderate brain trauma (Goodman et al. (1996) J Neurochem 66 (5): 1836-44). The DRS consists of an evaluation of eight reaction points of alertness and knowledge, daily activities, physical dependence, and employability (Vedder et al. (1999) J Neurochem 72 (6): 2531-8). The reliability among DRS assessors is high (.97 to .98).

[0056] The Measure of Functional Independence (MIF) can be used to assess cognitive and physical disability. This includes 18 points in the following fields: personal care, sphincter control, mobility, locomotion, communication and social cognition (Baulieu ( 1997) Mult Scler 3 (2): 105-12). MIF has demonstrated its reliability and validity as an outcome measure after moderate and severe TBI (Jung-Testas et al. (1994) J Steroid Biochem Mol Biol 48 (1): 145-54).

[0057] The Disease Impact Profile is a method of measuring self-perceived health status (Schumacher et al. (1995) Ciba Found Symp 191: p. 90-112 and Koenig et al. (1995) Science 268 (5216) : 1500-3). It consists of 136 questions divided into 12 categories: sleeping and resting, eating, working, housework, leisure and hobbies, walking, mobility, body and movement care, social interaction, alertness, behavior, emotional behavior, and communication. It has been widely used with a variety of diseases and injuries, including head trauma (Thomas et al. (1999) Spine 24: 2134-8). The results of the Disease Impact Profile (SIP) of the baseline will reflect the state of health before the injury, while the follow-up results will examine the functioning after the injury.

[0058] With this invention described in general, it will be better understood in reference to certain specific examples included herein for purposes of illustration only.

EXPERIMENTAL

Example 1

[0059] In the first step to determine the applicability of progesterone-based therapy in humans, we examined the effects of acute TBI and extracranial trauma on the pharmacokinetics of PG administered by intravenous infusion. Several blood samples were obtained from 11 female and 21 male patients with trauma who received PG and 1 female patient and 3 male patients received placebo infusions for 72h. Values of CSS, CL, t1 / 2 and Vd were obtained using AUC (0-72) and blood samples after infusion. The CSS values were 337 ± 135 ng / mL, which were significantly lower than the target concentration of 450 ± 100 ng / mL. The lower CSS is attributed to the CL, which was higher than anticipated. In addition, t1 / 2 was longer and Vd higher than anticipated. There was no significant gender difference in any of these parameters. These changes are consistent with the hyperkinetic changes associated with the serious injury. Our results show that stable concentrations of PG can be obtained quickly after TCE.

METHODS

Patient Selection:

[0060] This study was approved by the Institutional Research Council of Emory University, the Drug Safety Monitoring Board (NINDS) and the FDA Food and Drug Control Agency (IND # 58,986) . After obtaining informed consent, thirty-six patients who met the inclusion criteria described in the following manner were studied. The treatments were randomized using a 4: 1 progesterone: placebo ratio. The criterion of inclusion required was that each patient was aged ≥18, a closed head trauma due to a closed trauma, a moderate to severe brain trauma (Glasgow Coma Score Index (GCS) 4-12) and which arrived a Emergency and obtained informed consent (from close relatives) in less than 11 hours after the injury. Exclusion criteria included: fatal injury; no neurological activity (GCS 3); Moderate TBI (GCS Index 1315); unknown time of injury; severe intoxication (ETOH ≥250 mg%); spinal cord injury with neurodeficiencies; cardiopulmonary arrest; epileptic state upon arrival; blood pressure <90 systolic - on arrival or for ≥ 5 minutes before admission; hypoxia on arrival p02 <60 - on arrival or for ≥ 5 minutes before admission; pregnant women; active breast or reproductive organ cancers; or known allergy to progesterone, or components of Intralipid® (egg yolk or soybean oil).

Drug preparation:

[0061] Study drug solutions were prepared by the Emory Healthcare Drug Research Service as follows: progesterone was dissolved in 95% ethanol and filtered into sterile vials using a 0.2µ filter. Aliquots of each solution were evaluated to determine the final concentration and sterility. Progesterone / placebo stock solutions were packaged in sets (A, B, C, D or E) that amounted to randomized treatment assignments. Each set contained six vials. Vial 1 contained 15 ml of progesterone

or placebo used to prepare the initial bolus and the first infusion dose. The remaining 5 vials contained 12 ml of progesterone or placebo for the remaining infusions. Since progesterone is soluble only in alcohol, the diluent used to compose the progesterone solution consisted of 95% ethanol. The placebo sets were also formulated with 95% ethanol. Due to the alcoholic concentration, the doses of study drug were mixed with Intralipid® immediately before the infusion. Each infusion dose was administered for 12 hours and repeated every 12 hours for a total of 72 hours. After randomization of a patient, a dosing worksheet based on body weight and final progesterone concentration was used to determine the volume of vial # 1 required for dilution in Intralipid® for a standard load infusion index (14 cc / hour) and the first 11 hours of the maintenance infusion (10 cc / hour). The dosing worksheet was also used to calculate the volume of study medication to be diluted in Intralipid® for each of the remaining infusion tanks at a standard rate of 10 cc / hour.

Stability of progesterone solutions.

[0062] For all stability tests, the method of Segall, et al. with minor modifications (Segall, et al. (1999) Journal of Pharmaceutical & Biomedical Analysis, 19 (5): 803-8). The method was originally validated to assess the stability of medroxyprogesterone acetate and estradiol valerate tablets. It is an isocratic HPLC-UV method that uses external standardization. A 5 micron column, 4.6X250mm BDS-Hypersil C-18 (Keystone Scientific) was used and the analyzes were completed in an Agilent 1100 model HPLC system with photodiode assembly detector. The mobile phase consisted of 40% 0.07M of ammonium acetate buffer, pH 7.2 and 60% acetonitrile. The detection was made in 247nM. A system suitability control produced 2769 plates per meter (minimum requirement> 2500) based on the maximum progesterone value and a relative standard deviation (RSD) of 0.80% (minimum requirement 1.0% or less). The asymmetry factor for the maximum value of progesterone was 0.5. The reproducibility calculated with 10 injections of the same preparation on several different days was always less than 10%.

[0063] For each test, progesterone preparations were diluted from 1 to 10 with ethanol and injected. 1µL of this dilution Under these conditions, progesterone was eluted in approximately 3.5 minutes. A standard five point curve was performed with each analysis.

Drug administration:

[0064] The progesterone study drug solution was injected at the loading rate of 14 mLs / hour (0.71 mg / kg / h) for one hour, followed by a reduction of the infusion rate to 10 mLs / hour (O .Smg / kg / h) in the remaining 71 hours. Although Intralipid solutions containing progesterone were found to be stable within a minimum of 24 hours, the study drug deposits were prepared and changed every 12 hours during the infusion period to minimize the risk of biological contamination. Any interruption in drug administration or other deviations from the protocol were noted in a drug administration treatment scheme and were taken into account during the calculation of the total number of progesterone mg actually administered to each patient.

Sampling Paradigm:

[0065] Nine (5 ml) samples were obtained at the following times during the infusion: pre-infusion (0), 4, 6, 12, 24, 36, 48, 60, and 72 hours. Five additional samples were obtained after cessation of the infusion in: 0.5, 1, 2, 4 and 8 hours. The samples could coagulate, and then be centrifuged. After that, the serum was extracted and stored at -70 ° C until analyzed.

Serum Progesterone Analysis:

[0066] Serum progesterone concentrations were measured using Immulite® enzyme immunoassay by the Immunology Laboratory of the Department of Pathology, Emory University Hospital. Within and between The coefficients of variation along and between days for the trial were both <10%. We confirm the accuracy of our test by comparing the results of 9 samples during the range of 0.5 to 700 ng / mL evaluated in our laboratory with the samples evaluated by a reference laboratory (The Nichols Institute, San Juan Capistrano, CA).

Pharmacokinetic Analysis:

[0067] The primary pharmacokinetic parameter, CL, was estimated as the dose ratio for an area in the serum concentration-time curve (AUC). The AUC's were calculated using the linear trapezoidal rule (Veng-Pedersen (1989) Clin Pharmacokinet, 17 (6): 424-40). The phase elimination index constant, ke, was calculated from serum concentration-time data after the end of the infusion using a repetitive nonlinear regression (WinNonlin®, Pharsight Corporation, Mountain View, CA). The Volume of Distribution was determined as the proportion of CL and ke. The CSS was estimated by the dose ratio and CL. The actual CSS was defined as the concentration obtained when the slope of the serum concentration-time curve for three or more consecutive samples was not different from zero.

Statistic analysis:

[0068] A 't' test for repeated measurements and a Spearman range correlation were used to compare the concentrations of progesterone measured by our laboratory with those measured by the Nichols Institute. The expected CSS concentrations were calculated as the ratio of the infusion / clearance rate. The differences between predicted and measured CSS were made using a 't' test for repeated measurements. A Bland-Altman analysis was carried out to assess the magnitude of any diagonal associated with this method (Bland and Altman (1986) Lancet, 1 (8476): 307-10). Comparisons of pharmacokinetic parameters between men and women were performed using a 't' test for independent media. A p-value less than 0.05 was considered as the minimum level for the rejection of the null hypothesis.

RESULTS

[0069] Thirty-six patients were studied. Thirty-two (21 men and 11 women) received progesterone and four (3 men and 1 woman) received a placebo infusion. Progesterone concentrations in pre-infusion were not very different between women (2.86 ± 1.37ng / mL) and men (2.53 ± 1.73ng / mL) (p <0.5). Progesterone concentrations in pre-infusion of patients receiving placebo were 2.1 ± 0.8ng / mL and there were no significant differences between patients receiving progesterone. In addition, these pre-infusion values did not change significantly over the 84 hours of the study. Figure 1 is a representative serum concentration time profile for a patient receiving progesterone and a patient receiving a placebo infusion and in which a complete sampling paradigm can be obtained. Progesterone concentrations for patients receiving a placebo infusion remained constant throughout the study period. The concentrations of CSS in patients receiving progesterone were rapidly reached and, once achieved, these were stable throughout the infusion period. Full peri-infusion and post-infusion sampling was only possible in 7/11 women and 10/21 men due to the critical nature of the injuries sustained by the study patients. The

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25

30

35

CSS values in the current study were lower than expected values based on those provided for progesterone infusions in cancer patients (Christen et al. (1993) Journal of Clinical Oncology 11 (12): 24172426).

[0070] Table 2 is a summary of the primary and demographic pharmacokinetic data classified by sex. There was no significant difference between men and women with respect to any of the parameters in Table 2 with the exception of body mass. As can be assumed, the mean body mass in men (81.5 ± 16.2 Kg.) Was much higher (p <0.003) than in women (63.9 ± 11.0 Kg.). The clearance values (CL) were calculated from the total dose of progesterone injected and the AUC (0-72h) and not the AUC (0-∞) since post-infusion whole blood sampling was not possible in certain of patients for medical reasons. The mean CL value was determined at 1.73 ± 0.72 L / kg / h and was not different in men (1.66 ± 0.67 L / kg / h) and women (1.88 ± 0.81L / kg / h). Although a direct comparison could not be made since we did not record the height of our patients and therefore we could not calculate the body surface areas, the CL values of the current study are higher than expected with respect to those provided for progesterone infusions in cancer patients (Christen et al. (1993) Journal of Clinical Oncology 11 (12): 2417-2426). The use of the progesterone CL value of the current serum concentration-time data did not produce statistically significant differences between the CSS values predicted by Ro / CL (332 ± 121ng / mL) and the values actually measured (337 ± 135ng / mL ) and were no different in men and women. Figure 2 is a summary of the measured and predicted CSS values shown on the identity line. The Spearman range correlation coefficient for this ratio was 0.946 (p <0.001). The importance of the relationship was confirmed using a Bland-Altman analysis that revealed no systematic diagonal between the measured values and the predicted CSS values. The relative difference between measured and predicted CSS was -0.8 ± 12.2% (mean ± SD) (see figure 3). Figure 4 is a graph of measured CSS, for each patient where it is shown that these concentrations were systematically lower than the expected target concentration range from previous studies (Christen et al. (1993) Journal of Clinical Oncology 11 (12) : 2417-2426; Allolio et al. (1995) European Journal of Endocrinology 133 (6): 696-700). These data suggest that in patients with trauma with moderate to severe head injuries, the resulting hyperkinetic physiological state generates a clinically significant increase in progesterone clearance. These data suggest that to achieve the desired concentration of 450 ± 100 ng / mL, the maintenance infusion rate should be increased from 0.5mg / kg / h to approximately 0.8mg / kg / h.

[0071] The average value for the terminal half-life was 1.78 ± 1.0h. Once again, there was no difference between men (1.60 ± 0.95h) and women (2.03 ± 1.08h) (p <0.4). These values are well above the values provided in cancer patients (Christen et al. (1993) Journal of Clinical Oncology 11 (12): 2417-2426). The volumes of distribution (Vd) in the current study are higher than those anticipated in previous reports due to the elevation in CL and the reduction in the terminal phase elimination index constant. Although the values for men tend to be lower, the Vd were not very different between men (3.76 ± 2.14 L / kg) and women (5.76 ± 4.21 L / kg) (p <0.22).

Table 2. Pharmacokinetic parameters of individual progesterone in patients with TBI. 5

Patient

Sex Age BW (kg) GCS CL (L / kg / h) t1 / 2 (h) Vd (L / kg) Css Measured Css Expected Ro Corrected

ng / mL

ng / mL

mg / kg / h

one

M 25 72 7 1.04 2.70 4.04 423 482 0.47

2

M 29 65 8 2.11 2.56 7.78 2. 3. 4 240 0.95

3

M twenty 57 eleven 3.60 166  139 1.62

4

M 22 fifty 6 1.68 0.92 2.24 249 297 0.76

5

M 48 73 eleven 1.20 472  416 0.54

6

M twenty-one 70 4 1.58 1.20 2.73 331 317 0.71

7

M 19 85  7 1.16 457  432 0.52

8

M 53 fifty 7 2.95 2.43 10.35 195 170 1.33

9

M twenty 55 7 2.25 3.64 11.83 240 222 1.01

10

 M 54 57 4 1.91 296  262 0.86

eleven

 M 24 69 6 1.19 0.77 1.33 415 420 0.54

Half

30  63.9 7 * 1.88 2.03  5.76 316 309 0.85

± SD

14  11.0 4-11 **  0.81 1.08 4.21 110 115 0.37

one

H 52 75 6 1.37 1.14 2.25 412 366 0.61

2

H 24 70 8 3.84 0.73 4.05 123 130 1.73

3

H 47 93 12 0.93 563  538 0.42

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twenty

25

30

4

H 25 70 eleven 1.55 3. 4. 5  323 0.70

5

H 2. 3 80 6 0.98 3.30 4.67 499 510 0.44

6

H 29 70 12 1.07 1.77 2.73 368 467 0.48

7

H twenty 65 10 2.10 2.78 8.43 238 238 0.95

8

H 18 59 6 2.04 1.70 5.01 248 245 0.92

9

H 62 66 6 1.33 2.20 4.22 400 376 0.60

10

 H 76 84 7 1.55 332  322 0.70

eleven

 H 33 100 4 2.33 225  215 1.05

12

 H 25 87.7 6 1.36 268  368 0.61

13

 H 43 112.6 8 1.81 1.44  3.77 225 276 0.82

14

 H 18 73 5 1.24 398  402 0.56

fifteen

 H 46 84 eleven 1.22 441  410 0.55

16

 H 42 75 7 1.87 0.60 1.62 260 268 0.84

17

 H 3. 4 122 9 1.54 0.37 0.82 332 324 0.69

18

 H 42 70 8 1.77 303  283 0.80

19

 H 65 100 4 0.76 800  662 0.34

twenty

 H 33 75 12 2.41 178  207 1.09

twenty-one

 H 42 80 7 1.71 335  292 0.77

Half

38  81.5 #. 7 *  1.66 1.60 3.76 347 344 0.75

± SD

16  16.2 4-12 **  0.67 0.95 2.14 148 125 0.30

*Half; **Rank; #p <0.003 between men and women.

DISCUSSION

[0072] Doctors have long sought an effective neuroprotective agent to deliver in patients shortly after a head injury. The pathophysiology of brain trauma is well understood, but researchers have not discovered any drug that can reliably modulate the pathophysiological cascade of deleterious effects that generate cellular necrosis, cerebral edema, and therefore an increase in intracranial pressure (Chesnut, et al. (1993) Journal of Trauma-Injury Infection & Critical Care, 34 (2): 216-22; Povlishock and Jenkins (1995) Brain Pathology, 5 (4): 415-26). The treatment of traumatic brain injury is essentially a supportive treatment, and revolves around efforts to maintain cerebral perfusion pressure and adequate oxygenation (Brain Trauma Foundation (1996) "Guidelines for the Management of Severe Head Injury , "Journal of Neurotrauma, 13 (11): 643-5; Brain Trauma Foundation B (2000)" Management and Prognosis of Severe Traumatic Brain Injury, Parts I & II, "Journal of Neurotrauma, 17 (June / July): 449 -627).

[0073] A dataset that grows substantially and rapidly indicates that progesterone hormone, a neurosteroid that is naturally found in the brains of men and women, has potent neuroprotective properties. The data presented here were obtained during the first randomized controlled trial of progesterone for the treatment of acute moderate to severe head trauma. In addition to examining whether the drug was safe and effective for this condition, we have tried to determine the pharmacokinetic properties of intravenous progesterone in patients with polytrauma.

[0074] The main findings of our research are: 1) A solution of progesterone in 95% ethyl alcohol is stable for up to 2 years at room temperature; 2) Intralipid® solutions containing progesterone in 95% ethyl alcohol are stable for a minimum of 24 hours; 3) A progesterone CSS can be achieved quickly and maintained in a critically ill patient of acute brain trauma with polytrauma using an intravenous infusion paradigm; 4) CSS progesterone values can be accurately predicted from AUC data; 5) Acute craniocerebral trauma that accompanies physiological hyperkinetic alterations produces significant increases in CL, t1 / 2, and Vd for progesterone; 6) Acute craniocerebral trauma, in itself, does not produce endogenous progesterone release; and 7) Alterations in progesterone pharmacokinetics after acute craniocerebral trauma do not depend on gender. One of the most important objectives in clinical pharmacokinetics is to obtain specific patient estimates of the appropriate pharmacokinetic parameters. One of the most important objectives in clinical pharmacokinetics is to obtain specific patient estimates of appropriate pharmacokinetic parameters. The use of independent method models (AUC) is extremely robust in determining the specific CL of the patient. CL is the primary parameter of interest when drugs are administered by continuous intravenous infusion, since the resulting patient-specific CSS depends only on the rate of infusion and the CL. The current study demonstrates that stable CSS values of progesterone were rapidly obtained with intravenous administration, adjusting the production dosage to perform a practical target concentration in a population of severely injured patients regardless of sex. While the number of patients in this research receiving a placebo infusion is small, repeated tests and analysis show that progesterone concentrations are constant over the 84-hour study period. These data suggest that endogenous progesterone secretion is not significantly stimulated by the head trauma itself. The ultimate goal, of course, is to define the CSS that correlates with an optimal efficacy treatment. Once the pharmacodynamic relationship between the stable serum concentration of progesterone and the clinical outcome has been clarified, the parameters determined in our study can be used to prepare an infusion paradigm that optimizes the chances of survival and functional recovery. Since CSS can be achieved quickly and are stable, patient-specific adjustments in the infusion rate to maintain the target concentration should be possible with a minimum anticipated blood sample. If such pharmacological intervention is shown to be effective, our stability data demonstrate that progesterone stock solutions in ethanol, whose preparation is tedious, can be used safely for up to two years. This would allow immediate access to neurotrauma units for progesterone solutions and to facilitate rapid treatment implementation.

[0075] In 1993, the Brain Injury Foundation assembled an international working group to develop evidence-based guidelines for the treatment of head trauma (Brain Trauma Foundation (1996) "Guidelines for the Management of Severe Head Injury," Journal of Neurotrauma, 13 (11): 643-5; Brain Trauma Foundation B (2000) "Management and Prognosis of Severe Traumatic Brain Injury, Parts I & II," Journal of Neurotrauma, 17 (June / July): 449-627; Roberts , et al. (1998) J Neurol Neurosurg Psychiatry, 65 (5): 729-33). With the exception of mannitol and barbiturates, no pharmacological agent that improved recovery was identified.

[0076] In the current study, other drugs were co-administered to optimize the medical management of these seriously injured patients. Combinations of the drug and dosage regimens were individualized on a patient-specific basis. Thus, a systematic group of these drugs was not administered to all patients. While several classes of additional drug, in particular anticonvulsants and barbiturates, can produce an altered physiology including an increase in hepatic blood flow and an increase in oxidative metabolism, we cannot unequivocally determine whether the increased values for progesterone clearance are due to concomitant drug administration, or head trauma. Finally, the drug is not expensive since it is available in generic forms.

[0077] Using the results of this study together with future discoveries of a dose response efficiency test, researchers will be able to adjust progesterone infusion rates to achieve optimal stabilized concentrations. If it is proven that intravenous infusion of progesterone produces benefits in humans with acute brain lesions, it will represent a breakthrough in the treatment of this common and devastating condition.

Example 2

[0078] A phase II, double-blind, randomized, controlled trial of progesterone was performed for the treatment of head trauma. The administration protocol was performed as described above in Example 1.

[0079] To determine whether a therapeutic response was achieved, the following objectives were controlled:

-

 determined reduction of ICP by calculation of the "therapeutic intensity level" (ICP-TIL);

-

 duration of coma (from injury to wake up);

-

 mortality one month after the injury;

-Neurological results 1 month and 1 year after the injury, as determined by the Glasgow results scale (GOS), the Disability Assessment Scale (DRS) and the Galveston orientation and amnesia test (GOAT).

[0080] Preliminary evaluations are as follows. One hundred patients who had moderate to severe TBI were noted in the study, which had a 4: 1 randomized block design registry. Progesterone administration for three days IV [450 + / nmol / L] in both men and women. The administration of the administered pharmaceutical and protocol composition is described in detail in Example 1. The follow-up regarding the condition occurred in 30 days and in 1 year.

[0081] Control subjects had a 30.4% mortality rate, while subjects who received a progesterone treatment had a 12.9% mortality rate. Brain death was reduced by 60% in the group treated with progesterone. Table 3 summarizes the results.

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40

Four. Five

Table 3

Death

 Treatment

Frequency percentage line Pct Col Pct

TO B Total

Clinical death

5 2 7

5.05

 2.02 7.07

Brain death

4 5 9

4.04

 5.05 9.09

No dead people

67 16 83

67.68

 16.16 83.84

Total

76 2. 3 99

100.00

[0082] For the relevance test of Table 3, the 2 test with 2 df was relevant (p = 0.0471). When the treatment groups were compared to the proportion of subjects who suffer a brain death (with respect to those who suffer a clinical death or who are not dead), it was found that group A has a significantly lower proportion than group B (p = 0.0295 according to Fisher's exact test). When the treatment groups with respect to the proportion of subjects who suffer a clinical death (with respect to those who suffer a brain death or who are not dead), it was discovered that the groups are not statistically relevant. (p = 0.6622 for exact Fischer result).

Example 3

[0083] We conducted a clinical trial to assess the safety of progesterone as a treatment for acute TBI. This phase II, double-blind, randomized, placebo-controlled clinical trial was conducted in an urban center for level I trauma. 100 adults present for 11 hours with a closed ECT with a result according to the Coma Scale Glasgow from 4-12 were registered with the consent of representatives. Subjects randomly received a 4: 1 progesterone base versus placebo. The blind observers closely monitored the patients to avoid incidents of adverse events, and the initial functional results were evaluated 30 days after the injury. The primary safety outcomes were different in rates of adverse events, including mortality. The primary measure of activity was a dichotomized result of the extended Glasgow scale (GOSE) 30 days after the injury. Seventy-seven patients received progesterone; 23 received placebo. The groups had very similar clinical and demographic characteristics. With the exception of mortality, the rate of adverse events was similar in both groups. Laboratory values and psychological parameters were also similar. No serious adverse events were attributed to progesterone. The GOSE and other measures of neurological results were not very different between both groups, but the subjects treated with progesterone had a mortality rate due to all causes of 30 days lower than the controls (index ratio 0.43; 95% confidence interval 0.18-0.99). In this pilot study, progesterone did not cause any observable damage and showed promising signs of activity to treat TBI.

Introduction

[0084] Between 1.5 and 2 million Americans suffer a TBI every year. In the US alone, the TCE is responsible for 50,000 deaths, 235,000 hospitalizations, and 80,000 cases of long-term disability per year. Approximately 37,000 of these victims experience moderate disabilities (Thurman (2001) "The epidemiology and economics of head trauma," in Head Trauma: Basic, Preclinical, and Clinical Directions, ed. Miller (Wiley and Sons); Kraus (1997) "Epidemiology of head injury, "in Head Injury, ed. Cooper (2nd ed, Williams & Wilkins Co., Baltimore); Selecki et al. (1982) Australian & New Zealand Journal of Surgery 52 (1): 93-102; Klauber et al. (1981) Am J Epidemiol 113 (5): 500-509; Max et al. (1991) Journal of Head Trauma Rehabilitation 6 (2): 76-91; Gentleman et al. (1992) Injury 23 (7) : 471-474; Jones et al. (1994) Journal of Neurosurgical Anesthesiology 6 (1): 4-14 .; Cohadon et al. (1991) Journal of the Neurological Sciences 103 Suppl: S27-31; and, Sakata et al . (1991) Brain Injury 4: 411-419.) And 17,000 require specialized help for life. The CDC believes that 5.3 million Americans are alive with disability due to TCE. TCE's lifetime costs are estimated to exceed $ 56 billion per year (Thurman (2001) "The epidemiology and economics of head trauma," in Head Trauma: Basic, Preclinical, and Clinical Directions, ed. Miller (Wiley and Sons)) . We conducted a clinical pilot trial to assess the safety and potential efficacy of intravenous progesterone administration to victims with severe acute traumatic brain injury.

Methods

[0085] Study design: The main objective of this randomized, double-blind, placebo-controlled phase II trial was to assess potential intravenous progesterone administration damage to patients with acute trauma of both sexes. We also expected to detect signs of activity.

[0086] In the US, progesterone IV was authorized for experimental use in only three previous clinical studies, none of which was related to TBI (Aebi et al. (1999) Cancer Chemotherapy & Pharmacology 44 (3): 25926; Allolio et al. (1995) European Journal of Endocrinology 133 (6): 696-700; and, Christen et al. (1993) Journal of Clinical Oncology 11 (12): 2417-2426). The present study shows that IV administration of progesterone after a TBI would not produce an increase in the degree of serious adverse events.

[0087] According to the US Food and Drug Administration, an "adverse event" is any medical event produced during a clinical trial, whether or not it is related to the study drug. This includes events not foreseen at the baseline, or that get worse when they are present at the baseline. "Serious adverse events" are defined as death, the immediate risks of death or suspicion that continued use or use may result in the death of the patient, prolongation of existing hospitalization, persistent or significant disability / disability, or congenital anomaly / defect of birth.

[0088] To detect adverse events, blind observers exposed each study subject to a daily review to identify a wide range of adverse events, including but not limited to those that may plausibly relate to the administration of progesterone. These included any thromboembolic event (deep vein thrombosis, thrombophlebitis, ischemic myocardial infarction, pulmonary embolism, stroke or transient ischemic attack), elevated liver enzymes, temperature rise, allergic reactions and hyperglycemia. All the results of the laboratory tests obtained throughout the treatment were recorded and analyzed to detect abnormal levels or disturbing tendencies. An independent internal security monitor determined whether any adverse event was associated with the study treatment. Both the FDA and an independent data security control table appointed by the NIH reviewed those determinations.

[0089] In addition to controlling the subjects to determine signs of damage, we expected to detect signs of activity. It was assumed that progesterone treatment could reduce 30-day mortality and improve several short-term outcomes after TBI. For this preliminary study, our primary outcomes of interest were the Results of the Glasgow Extended Scale (GOSE) 30 days post-injury. Other outcome measures at 30 days included group mortality, outcome of the Disability Assessment Scale, duration of coma, duration of posttraumatic amnesia, and control of increased intracranial pressure.

[0090] Adjustment: The study was conducted in an urban public hospital with more than 100,000 patient visits per year, the only level I trauma center in the region that serves a metropolitan population of over 4 million.

[0091] Selection of participants: Consecutive adult victims of closed ECT who arrived in Grady 22 hours after an injury with a post-stabilization or "index" of Glasgow Coma Scale (iGCS) score of 4-12 were chosen for tests (Figure 5). Only 3 potentially eligible patients were lost over a 2 and a half year process period (May 28, 2002 and September 17, 2004).

[0092] Whenever a potential candidate was identified, a study investigator would go to the emergency department in 30 minutes to assess eligibility. The exclusion criteria included a blood alcohol concentration of> 250 mg / dl; penetrating brain trauma; age <18 years; an iGCS of <4 or> 12; indeterminate time of injury; pregnancy; Cancer; stroke; spinal cord injury; or inability to obtain the consent of the representative 11 hours after the injury.

[0093] Since patients could not give their consent, a legally authorized representative was requested. The representatives were informed of the basis of the study, design and anticipated risks and benefits. They were assured that participation was voluntary, and that if they did not participate, it would not affect patient care. To help with understanding, our consent form was written at an 8th grade reading level. A Spanish language version was also made. A new drug research authorization to use progesterone intravenously to treat TBI was obtained from the US Food and Drug Administration, and a DSMB appointed by the NIH provided independent supervision and guidance. The Research Supervision Committee of the Hospital and the Institutional Review Board of the University approved our study. Before starting registration, we inform the leaders of several local lawyer organizations. A community advisory council was also convened.

[0094] Interventions: After the consent of the representatives, the patients were divided into 8 clinical subgroups defined by gender (men versus women), race (black versus others) and severity of TBI (moderate versus severe). Within each subgroup, permuted block randomization was used to assign 4 of every 5 consecutive patients progesterone and fifth the placebo (4: 1 randomization). This asymmetric method was adopted by DSMB sampling request appointed by the NIH to increase the number of patients who would receive the study drug while maintaining the blind study.

[0095] To ensure the blind study of all hospital staff, including hospital pharmacists who mixed the infusions of the study, drug sets were prepared elsewhere by a Drug Research Center. The study drug and placebo vials had the same appearance and physical properties. To produce a set of vials, progesterone was dissolved in 95 percent ethanol and filtered into sterile vials using a 0.2 µ filter. The aliquots were evaluated to confirm uniform concentration and sterility. Each study set contained 6 vials of progesterone in ethanol (treatment) or 6 vials of ethanol alone (placebo).

[0096] When a patient was examined, the next set in sequence for that subgroup was used to prepare infusions. The first vial was mixed in 20% of Intralipid ™ to deliver an impregnation dose of 0.71mg / kg of progesterone at a standard rate of 14 mls / hour, followed by a maintenance infusion of 0.5mg / kg / h at a rate 10 mls / hour standard. The remaining vials were used to prepare 5 subsequent infusions of 12 hours at the same standard rate of 10 mls / hour for a total of 3 days of treatment. Details of the drug control are noted elsewhere (Wright et al. (2005) J Clin Pharmacol 45 (6): 640-648).

[0097] The clinical services that treat patients with head trauma in our hospital followed a consensus protocol based on the guidelines of the Brain Trauma Foundation (2000) Journal of Neurotrauma 17 (June / July): 449 -627). This protocol determines the treatment of patients with TBI who came from prehospital centers until hospital discharge. A rigorous step-by-step approach is specified for the treatment of episodes of increased intracranial pressure (ICP). The adoption of this protocol ensured that, with the exception of the allocation of treatment groups, all study participants received standard treatment for a TBI.

[0098] Measurement Methods: to assess the safety of drugs, a personal study conducted daily to document the incidence of adverse events (AEs) or serious adverse events (SAEs). Vital signs were recorded every hour (blood pressure, heart rate, respiratory rate, temperature, and pulse oximetry), intracranial pressure readings, and other parameters (mean blood pressure, cerebral perfusion pressure, and fluid balance), of Each patient record. Laboratory values were obtained from the hospital information system, and concomitant medications and interventions were noted.

[0099] When an SAE occurred, an independent accredited neurosurgeon evaluated its potential relationship to study the treatment in which the predefined scale is used. The SAEs communicated within 24 hours to the Institutional Review Board (IRB), our Data Security Control Board appointed by the NIH (DSMB), and the US Food and Drug Administration. Any other adverse event He communicated weekly.

[0100] The infusion was interrupted when a patient experienced an anaphylactic reaction, a severe thromboembolic event, an unexplained increase in serum aspartate aminotransferase (AST) or alanine aminotransferase (ALT) at levels greater than 5,000 IU, or total bilirubin levels higher at 10 mg / dl. We agreed to prematurely terminate enrollment when either of the 2 interim analyzes revealed that one group or another experienced a significantly increasing level of SAEs, including mortality, with respect to the other. These rules were based on the limits of O'Brien-Fleming (O'Brien and Fleming (1979) Biometrics 35 (3): 549-556), constructed using an alpha spending approach (DeMets and Lan (1994) Statistics in Medicine 13 (13-14): 1341-1352; discussion 1353-1346).

[0101] To determine if the study drug had a positive impact on patients, we collected a variety of functional and physiological measures. These include: intracranial pressure measurements every hour; coma duration, defined as the number of hours elapsed from the injury until waking up (GCS> 8 or motor outcome> 5), and the duration of posttraumatic amnesia, defined as the number of days it took the patient to achieve two scores of tests on Amnesia and Galveston Orientation equal to 75 or higher. Thirty days after each trauma, each Extended GLasgow Outcome Score (GOSE) and Disability Assessment Scale (DRS) were evaluated. Severely injured patients were classified "unfit for testing" - an alternate marker for a negative result. Confidence codes were used to record the reasons for not administering a particular measure, such as physical damage (for example hemiparesis), cognitive damage (for example, that they cannot understand instructions) or poisoning. The results in one year were communicated at a later date.

[0102] Data collection and processing: The data collection was guided by a protocol for data management and a standard operating procedures manual. The data collected in the header were recorded in paper case registration forms (CRFs) and consequently recorded twice in a network-based ORACLE® database. Registered CRFs were not accepted as valid unless double registrations match and all level controls are adjusted. Special editing queries were created to generate transport files for import into SAS® for analysis.

[0103] Outcome measures: The first objective of our study was to evaluate the safety of progesterone treatment. It was assumed that the control and treatment groups would experience similar rhythms of SAE and AE. Our secondary objective was to look for signs of drug activity by evaluating several outcome measures. Our primary a priori outcome measure was the Extended Glasgow Results Scale (GOSE) (Teasdale et al. (1998) Journal of Neurotrauma 15 (8): 587-597). Other outcome measures included: 1) death within 30 days after injury 2) duration of coma (Levin (1995) Journal of Neurotrauma 12 (5): 913-922); 3) duration of posttraumatic amnesia (Levin et al. (1979) Journal of Nervous & Mental Disease 167 (11): 675-684); 4) mean intercranial pressure and intercranial pressure intensity level (PIC-TIL) (Maset et al. (1987) Journal of Neurosurgery 67 (6): 832-840) and 5) Disability Assessment Scale (DRS) ( Hall et al. (2001) Arch Phys Med Rehabil 82 (3): 367374).

[0104] Primary Data Analysis - Treatment and placebo groups were compared with respect to a variety of demographic, historical and prehospital characteristics to ensure that important independent outcome predictions were distributed equally. Subsequently, the groups were compared with respect to the levels of adverse events and serious adverse events, using the Fisher exact test. A generalized linear model analysis using a negative binomial distribution was used to compare the rates of events that occurred many times per patient during the first 30 days (McCullagh and Nelder (1989) Generalized Linear Models (2nd ed, Chapman & Hill) ). Then, the specific differences of groups in results at 30 days. Fisher's exact test was used to analyze dichotomized GOSE scores in "good or moderate recovery" versus all other levels. The Wilcoxon ranks sum test for independent samples was used to compare the specific DRS scores for each group. The mean and median duration of coma and post-traumatic amnesia were compared using the t-test. All analyzes were placed on a priori basis according to the severity of the head injury. (iGCS 4-8 (severe) versus iGCS 9-12 (moderate)). The mixed and longitudinal event models were used to analyze the PIC-TCE as well as other hourly or daily clinical measures of those enrolled throughout the fourth day of treatment.

[0105] To ensure that any observed difference in mortality was associated with the study treatment rather than confusing clinical factors, other multivariate analyzes were performed. The variables determined to be independently associated with the risk of mortality or death related to CNS, such as iGCS (dichotomized to moderate versus severe), the severity score of the lesion and the CT Marshall score were incorporated into a logistic regression analysis step Step. As the GCS often fluctuates during the first hours after the injury, additional step-by-step logistic regressions were performed using dichotomized GCS 1 day after the injury.

Results

[0106] Selection and enrollment - a total of 281 patients were selected. Three potentially eligible patients were lost and 18 patients could not be enrolled due to their unknown identity or could not contact a representative within 11 hours after the injury. It was not possible to enroll six potentially eligible patients who presented in one of the three “withholdings” procedure. One patient was excluded after his consent but before randomization since the treatment team decided that his injuries did not allow survival. Eleven eligible patients did not register as their representatives denied consent. (Figure 1) No participant was chosen with respect to gender, race, and mechanism of injury.

[0107] Characteristics of study subjects - Seventy-one of the patients were men; 34 were black. The average age was 36 years. Seventy-two patients (72%) had an iGCS of 4-8; the rest 9-2. More than 80% of the injuries were caused by a crash or fall of a motor vehicle. Most patients arrived at the hospital in the first hour after the injury; 58 percent by helicopter. As it often took several hours to locate a representative for consent, the average time from the injury to the study of the infusion was 6.3 (95% CI 5.9-6.8) hours in the group treated with progesterone and 6.2 (95 % CI 5.9 - 6.6) hours in the placebo group.

[0108] Randomization - 77 subjects were randomized with progesterone; 23 with placebo. The treatment groups were very similar with respect to gender, age, race, iGCS, mechanism of injury, revised trauma score, severity of injury score, time elapsed from the injury until arrival at the emergency department, time to study the treatment, CT Marshal score (Marshall et al. (1991) J Neurosurgery 75 (suppl): S14-20), and emergency service provision (table 4).

[0109] Dosage and adaptability of the protocol - Our pharmacokinetic conclusions are indicated elsewhere (Wright et al. (2005) J Clin Pharmacol 45 (6): 640-648). A randomized patient with progesterone died before they could start the study drug. It was indicated in our analysis with the motive of "intention to treat". All other members of the treatment group and non-control group members had elevated serum progesterone levels during drug administration. Minor protocol violations, such as brief delays in the exchange of stock I.V. They were habitual. A sufficient solution was provided so that it did not interrupt the infusion.

[0110] There were six major protocol violations. Four prolonged interruptions involved in the infusion, one implied a dose error, and another inappropriate registration of a motor vehicle accident victim. When a repeat CT scan on the second day of hospital revealed an ischemic stroke, his progesterone infusion stopped immediately. A subsequent review of the admission CT scanner nevertheless showed clear signs of stroke, which was traced in a traumatic carotid artery dissection. Due to the predated stroke treatment, this incident was classified as a protocol violation instead of SAE.

[0111] Safety - The aggregate and individual ranges of serious adverse and adverse events were not different in the groups (Table 5). This was the case of AEs and SAEs analyzed for any occurrence or through episodes per subject. The values of the laboratories of treatment groups were remarkably similar, whether analyzed by group means or by the frequency at which a specific test value exceeded the limits specified above. Subjects treated with progesterone experienced a lower increase in average temperature during the infusion interval compared to controls. This was determined by analyzing a treatment for the time interaction period for progesterone versus control patients, with the inclination = -0.0055 (95% CI, -0.010 to 0.001).

[0112] The only adverse events specifically assigned to the administration of progesterone were two cases of superficial phlebitis at site IV. Both resolved spontaneously. Three patients who received progesterone developed deep venous thrombosis between 6 and 23 days after the end of the infusion. All 3 cases were treated without incident. Two patients suffered ischemic strokes. In one of the patients randomized with progesterone, it occurred before treatment with progesterone and was considered a serious infraction of the protocol. The other was a randomized placebo patient. A randomized patient with progesterone suffered a myocardial infarction two days after the study infusion was completed. He was receiving a high dose of neosinephrine at the same time to try to increase his cerebral perfusion pressure. Autopsy revealed no intracoronary thrombosis.

[0113] Beneficial signs - In the first 4 days after the injury, the mean values of intracranial pressure (ICP) of subjects treated with progesterone whose appropriate monitors remained stable, while the average ICP values between subjects treated with placebo with monitors appropriate tended to increase. However, these trends were not statistically significant. The mean PIC-TCE scores were not very different between the groups (Table 6).

[0114] Patients with severe TBI (iGCS 4-8) treated with progesterone remained in a coma for a much longer period than survivors who received placebo (average duration of 10 days (7.7, 12.5) versus 3.9 days (2.5, 5.4) respectively). The minimum duration of posttraumatic amnesia was not very different between the two groups (Table 7). Ten of the 77 patients (13 percent) randomized with progesterone died 30 days after the injury, compared with 7 of 23 patients (30.4 percent) randomized with placebo (index ratio 0.43, 95% CI 0.18 - 0.99). When the analysis was restricted to the 99 subjects receiving the treatment, this difference was no longer significant (index ratio 0.39, 95% confidence interval 0.16, 0.93). Deaths due to neurological causes tended to decrease in the treatment group rather than in the control group (index ratio 0.30, 95% confidence interval 0.08 - 1.12) while there was no difference in deaths not caused by CNS. The association between the treatment group and mortality remained strong in multivariate models, including several based on dichotomized GCS in 24 hours (Table 7).

[0115] We were able to contact 92 percent of the survivors 30 days after the injury to assess their functional status. Our measurements of primary outcomes, dichotomized GOSE, were not very different between groups. The DRS results of patients with severe head trauma were also similar. However, patients with moderate craniocerebral trauma randomized with the study drug achieved significantly better DRS scores, on average, than those who were randomized with placebo (Table 7).

Discussion

[0116] Since progesterone has not been previously used to treat severe head trauma, a phase II pilot trial was conducted to assess potential damage. Arriving patients were carefully selected to assess their eligibility. Ninety-nine percent of potentially eligible patients were selected, and 90 percent of those corresponding to the inclusion criteria were enrolled with the representative's consent. Patients in treatment and control were grouped according to the severity of the injury, the time of treatment and other independent predictors of results.

[0117] The decision to ensure that the representative's consent was obtained instead of restricting the exemption from informed consent delayed the start of treatment by an average of 6.5 hours. Although an animal study suggested that progesterone may produce beneficial effects late 24 hours after the injury, the magnitude of the benefits was even greater when the treatment was administered two hours after the injury (Roof et al. (1996) Exp Neurol 138 (2): 246-251).

[0118] Three members of the treatment group developed deep vein thrombosis 6 days after the infusion. This frequency is adequate in our historical incidence of DVT institution in patients with severe trauma (unpublished data). With the exception of mortality, the treatment and control groups experienced similar levels of AEs and SAEs. They also had very similar physiological values.

[0119] Our secondary objective was to detect signs of drug activity. We chose GOSE as a measure of primary outcomes since it is the standard used mostly in biographies of head trauma. We observe promising signs of activity.

[0120] No difference was found in the PIC average or the PIC-TCE average.

[0121] There was no significant difference between treatment groups with respect to the duration of posttraumatic amnesia and GOSE of 30 days. However, the 30-day mortality rate among randomized subjects in the treatment group was less than half of the control group. This difference persisted after taking into account other predictions of important results.

[0122] Patients with serious brain lesions in the treatment group had a longer average duration of coma compared to those in the control group. This may represent a "survival effect." If progesterone prevents deaths of several patients during the first 30 days of the follow-up period, it is not surprising that these survivors stayed in a coma for a longer period of time. One year survival and functional results will be provided later.

[0123] In retrospect, we would have preferred to enroll patients with the exception of informed consent. This would have allowed us to begin the study much earlier, and enroll patients who were lost since a legally authorized representative could not be found within the framework of enrollment. An earlier administration of the study drug could have produced better evidence of activity. We recognize, however, that this is the first human trial with progesterone in the treatment of severe head trauma and our study was essentially designed to assess the safety of the drug before its activity. For that reason, we enroll patients with the representative's consent and accept significant delays for

5 treatment (up to 11 hours) to maximize recruitment. Based on our encouraging findings regarding safety, we hope to conduct a more important trial according to the federal regulatory framework that allows the exclusion of consent in limited circumstances (Federal Regulations of 21CFR50.24). This will allow starting the treatment beforehand and maximizing the opportunities to detect any evidence of neuroprotective effects.

10 [0124] In summary, this study represents an important step in the evaluation of the usefulness of progesterone to treat acute head injuries. ECT is one of the leading causes of death and disability worldwide. No pharmacological agent has been shown to improve the results. It has been previously indicated that progesterone can be precisely administered intravenously to victims of TBI (Wright et al. (2005) J Clin Phannacol 45 (6): 640-648). This analysis offers preliminary evidence that the treatment does not cause any harm and

15 that you may have a disease modification activity. A clinical trial involving more subjects, 1: 1 randomization, and a short enrollment framework are guaranteed. If you confirm our findings, it will represent a major advance in the care of head trauma.

Table 4: Characteristics by group: Participants in ProTECT ™ (N = 100) Characteristics Total Progesterone Number of Subjects 100 77 Middle Age (X ± sd) 35.8 ± 15.0 35.3 ± 14.3 Male (%) 71% 71% African American (%) 35% 34% Mechanism of injury (%) (n = 100) Motor vehicle 76 74 Pedestrian run over 3 4 3 3 Bicycle fall 7 6 Others 11 13 GCS index (severe%) 72% 73% 24 hours GCS (serious%) 61% 70% Injury severity score (X ± sd) 24.2 ± 9.2 24.5 ± 9.9 Revised trauma score (X ± sd) 6.1 ± 0.6 6.1 ± 0.6 Probability of survival (P ± sd) 0.9 ± 0.2 0.9 ± 0.2 CT score of Marshall67 initial scanner (1- 5) 2.8 ± 1.6 3.0 ± 0.2 Arrival injury time (X ± sd) min 50.3 ± 30.3 49.5 ± 32.3 Infusion injury time (X ± sd) min. 379.2 ± 118.0 380.7 ± 125.6

 Placebo 23 37.4 ± 17,470% 39% 83 0 4 9 4 70% 50% 23.3 ± 6.4 6.2 ± 0.7 0.8 ± 0.1 2.3 ± 0.3 ± 54.3 ± 32.3 374.0 ± 91.2 p value * N / A 0.54 0.86 0.64 0.58 (mvc vs. all others) 0.77 0.23 0.50 0.83 0.53 0.09 0.42 0.78

• p value = progesterone group versus placebo group

Table 5: Degrees of Adverse Events at 30 Days by Progesterone Treatment Group (%) Placebo (%) Relative risks (95% confidence interval)

Acute difficulty syndrome 2.6 4.4 0.60 (0.06, 6.29) respiratory Infection of the central nervous system 1.3 0.0 - Cardiac arrhythmia 5.2 17.4 0.30 (0.08, 1.10) Cholestatic jaundice 6.5 0.0 - Death in 30 days 13.0 30.4 0.43 (0.18, 0.99) Fever 70.1 82.6 0.85 (0.67, 1.08) Gastrointestinal bleeding 5.2 0.0 - Hyperglycemia not DM 27.3 30.4 0.90 (0.44, 1.84) Hypertension 11.7 8.7 1.34 (0.31, 5.79) Hypotension 9.1 21.7 0.42 (0.15, 1.19) Hypothermia 5.2 8.7 0.60 (0.12, 3.06) Hypoxemia 11.7 13.0 0.90 (0.26, 3.04) Enzyme increase in liver 6.5 4.4 1.49 (0.18, 12.15) Phlebitis at the injection site 1.3 0.0 - Rash or Urticaria 2.6 0.0 - Inappropriate ADH syndrome 1.3 0.0 - Attacks 5.2 0.0 - Sepsis 2.6 0.0 - Shock 2.6 0.0 - Suspicions of Pneumonia 11.7 4.4 2.69 (0.46.20.12) Tachycardia 24.7 13.0 1.89 (0.61, 5.83) Thromboembolic disease 3.9 0.0 -

image 1

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Table 7: Variants of Results 30 days after the injury Total N progesterone group 77 placebo group 23 Mortality No.% No.% Proportion degree of risk Risk of Death (ITT) * 10 13.0 7 30.4 0.43 Death risk (TR) # 9 11.8 7 30.4 0.39 Neurological deaths # 4 5.3 4 17.4 Non-neurological deaths # 5 6.6 3 13.0 Survivors> 30 days # 67 88.2 16 69.6

95% Confidence interval 0.18, 0.99 0.16, 0.93

Score of total and dichotomized Glasgow results - Extended Level of disability n%% Nº%% Proportion degree of risk Dead 10 14.2 7 31.8 Vegetative state 5 7.1 0 0 Severe lower 28 40.0 70.0 7 31..8 81.8 Higher serious 6 8.6 18.2 Lower Moderate 8 11.4 4 18.2 1.65 Upper Moderate 7 10.0 30.0 0 0 18.2 Lower Good 3 4.3 0 0 Upper Good 3 4.3 0 0

95% Confidence interval 0.63, 4.29

Disability assessment score GCS Index = 4-8 95% 95% No. Average Confidence Interval No. Average Confidence Interval Application 46 2.7 2.4.2.9 9 2.4 1.9.3.0 Function 46 2.9 2.3.3.5 9 1.8 0.7.2.8 Total DRS 45 10.7 8.0.13.4 9 4.4 2.8.6.1 GCS Index = 9-12 Application 15 1.8 1.1, 2.5 6 3 -Function 15 1.5 0.5.2.6 6 3.8 2.6, 5.1 Total DRS 15 5 1.6, 8.4 6 12.7 7.0, 18.4

Duration of coma (days) 95% 95%

Duration of coma (days)

No. Average Confidence Interval Average No. Confidence Interval

Initial GCS = 55 10.11 7.7, 12.5 16 3.9 2.5, 5.4 4-8

Initial GCS = 20 4.1 1.4.6.8 7 6.1 0, 13.2 9-12

Duration of post-traumatic amnesia (days)

95%

95%

n

Half Confidence interval  n Half Confidence interval

Initial GCS = 4-8

37 18.6 15.2,22.0 9 12.8 5.2,20.4

Initial GCS =

fifteen 10.7 6.2, 15.3 3 18.3 0.46.9

9-12

* Analysis of the intention to treat; # Analysis of the treatment received, a patient died before receiving the study drug.

Claims (18)

one.

Progesterone intended to be used in the treatment of head trauma in a human subject, said treatment comprising a constant or two-level progesterone dosage regimen where a therapeutically effective amount of progesterone is administered to said human subject by means of an intravenous infusion to achieve a final serum level of progesterone from about 100 ng / ml to about 1000 ng / ml.

2.

Progesterone according to claim 1, wherein the treatment reaches a final serum level of progesterone of at least about 200 ng / ml.

3.

Progesterone according to claim 1 or 2, wherein the treatment reaches a final serum level of progesterone not exceeding approximately 9.50 ng / ml.

Four.

Progesterone according to claim 3, wherein the treatment reaches a final serum level of progesterone not exceeding approximately 850 ng / ml.

5.

Progesterone according to any of the preceding claims, wherein the intravenous infusion administers progesterone in doses every hour at at least about 0.1 mg / kg / h.

6.

Progesterone according to claim 5, wherein the infusion administers progesterone at a rate of at least 0.5 mg / kg / h.

7.

Progesterone according to claim 6, wherein the infusion administers progesterone at a rate of at least 0.71 mg / kg / h.

8.

Progesterone according to claim 7, wherein the infusion administers progesterone at a rate of at least 0.8 mg / kg / h.

9.

Progesterone according to any of the preceding claims, wherein the infusion administers progesterone in a proportion not exceeding approximately 7.1 mg / kg / h.

10.

Progesterone according to any of the preceding claims, wherein the duration of treatment is 1 to 7 days.

eleven.

Progesterone according to any of the preceding claims, wherein the progesterone is administered from about 0 hours to about 1 hour after injury.

12.

Progesterone according to any of claims 1-10, wherein the progesterone is administered from about 1 hour to about 120 hours after the injury.

13.

Progesterone according to any of the preceding claims, wherein the progesterone is administered by infusion over a period of about 1 to about 120 hours.

14.

Progesterone according to any of the preceding claims, wherein the treatment comprises a constant dosage regimen of progesterone.

fifteen.

Progesterone according to claim 14, wherein the progesterone is administered at a total constant infusion dose every hour during treatment.

16.

Progesterone according to any of the preceding claims, wherein the progesterone is administered by infusion using a constant dosage regimen with a duration of approximately 1 to 136 hours.

17.

Progesterone according to any of the preceding claims, wherein the treatment comprises multiple maintenance cycles, each maintenance cycle comprising a complete constant progesterone dosage regimen, and wherein the duration between maintenance cycles is between 1 hour and 1 day.

18.

Progesterone according to any of the preceding claims, wherein the progesterone is administered in the form of a composition additionally containing ethyl alcohol.