CHS Pharma Inc. (CHS) is a Biotechnology Development Company located in South Florida. CHS owns an Intellectual property portfolio for potential treatments related to Ischemic Stroke, Dry Macular Degeneration as well as other age related disorders such as Alzheimer’s disease. These technologies were developed by Dr. Jang-Yen Wu, Dr. Howard Prentice and their colleagues. Dr. Wu is a Senior Fellow and Distinguished Professor at Florida Atlantic University’s Charles E. Schmidt College of Medicine. Dr. Prentice is an Associate Professor of Biomedical Science in the Charles E. Schmidt College of Medicine. Dr. Wu has published more than 300 papers in journals such as Science, Nature, PNAS, among others. He has made a great impact in biomedical sciences, particularly in basic and translational neuroscience and is recognized as one of the most cited scientists in the world identified by Current Contents/ISI (2002). In translational neuroscience, Dr. Wu and his team have developed several mechanism-based treatments for neurodegenerative diseases including Parkinson’s disease, Ischemic Stroke, Alzheimer’s disease and Epilepsy. His inventions are quite novel and several patents have been awarded to him and his team. Dr. Prentice has over 70 publications in numerous journals including PNAS, EMBO Journal, Cell, Molecular Neurobiology, and Molecular and Cell Biology. Dr. Prentice’s principal research interests are in tissue hypoxia and ischemia and in molecular pathways of neuroprotection in stroke therapy.
According to a market research report published by Transparency Market Research “Acute Ischemic Stroke Diagnosis and Treatment Market - Global Industry Analysis, Size, Share, Growth, Trends and Forecast, 2014 - 2020” the global acute ischemic stroke diagnosis and treatment market was valued at USD 1.2 billion in 2013 and is estimated to reach a market worth of USD 1.9 billion in 2020, growing at a CAGR of 6.3% from 2014 to 2020. Based on geography, the acute ischemic stroke diagnosis and treatment market is segmented as North America, Europe, Asia-Pacific and Rest of the World (RoW). North America represented the largest regional market for acute ischemic stroke primarily due to the increase in ischemic stroke surgeries and introduction of technologically advanced medical devices and products. For instance, (THE) American Heart Association stated that stroke is considered the third leading cause of death in developed nations of the world such as the U.S. and Canada. Moreover, it has also stated that there are around 795,000 patients diagnosed with stroke in the U.S. every year, where 85% of the total cases were identified as acute ischemic stroke. The National Institute of Health (NIH) stated that healthcare cost for the treatment of stroke exceeds USD 73 billion in the U.S. every year. Europe accounted for the second largest share in the global acute ischemic stroke diagnosis and treatment market. Large geriatric population base is one of the key factors driving the growth of acute ischemic stroke diagnosis and treatment market in this region. Asia-Pacific is expected to grow at the highest CAGR from 2014 to 2020, owing to rising awareness among people and presence of a substantial number of potential population with ischemic stroke
Multi-drug Combination Therapy for Traumatic brain injury (TBI) and Stroke Treatment
Traumatic brain injury (TBI) and stroke is the third leading cause of death and the leading cause of disability in the USA. Much progress has been made regarding the mechanism of brain injury induced by ischemia/hypoxia, a major pathophysiology of TBI and stroke. It is generally believed that excitotoxicity caused by excessive release of excitatory neurotransmitter glutamate plays an important role in ischemia/reperfusion induced neuronal death. Despite extensive research to develop medicines for stroke based on the known mechanisms either as glutamate receptor antagonists, calcium channel blockers, enzyme inhibitors, inhibitors of apoptotic pathways, or ROS scavengers, etc., these efforts have been disappointing. Part of the reasons for the disappointing results is due to the fact that the underpinning mechanism of TBI and stroke-induced neuronal injury is multi-factorial and hence it needs multi-drugs therapeutic intervention to address the multi-factorial nature of the disease. Hence, we proposed to use a multidrug approach by combining granulocyte colony-stimulating factor (G-CSF), a stem cell enhancer and facilitator, S-methyl-N, N-diethylthiolcarbamate sulfoxide (DETC-MeSO), a NMDA receptor partial antagonist and anti-excitotoxicity agent and sulindac, a potent catalytic anti-oxidant, representing three distinct classes of drugs as multi-drug combination therapy for treatment of TBI and stroke. G-CSF is a growth factor known to stimulate the proliferation and survival of hematopoietic cells. G-CSF can penetrate the blood brain barrier and plays a prominent role in the CNS. G-CSF and its receptor are expressed in neurons throughout the brain, and their expression is induced by ischemia suggesting an autocrine protective signaling mechanism. Increasing evidence from recent studies indicates that G-CSF is neuroprotective in vivo and in vitro. For example, G-CSF protects against neurodegeneration in a number of neurological disease models such as Parkinson’s Disease, Huntington’s disease and cerebral ischemia. G-CSF stimulated neural progenitor response in vivo and markedly improved long-term behavioral outcome after cortical ischemia. Peripheral infusion of G-CSF enhanced the recruitment of progenitor cells from the lateral ventricle wall into the ischemic area of the neocortex in rats. Previously we have shown that DETC-MeSO which is an active metabolite of disulfiram, a widely used drug for treatment of alcoholism for more than 50 years, is a NMDA receptor partial antagonist and can protect glutamate-induced neuronal injury in cultured neurons as well as preventing seizure induced by hyperbaric oxygen and methionine sulfoximine. Recently, we have also found another novel neuroprotective agent, namely sulindac, which is a substrate of methionine sulfoxide reductase (Msr) and serves as a catalytic anti-oxidant. Sulindac is a FDA approved drug and has been used as an anti-inflammatory agent. In our preliminary study, we also found that sulindac could protect neurons from glutamate-induced neuronal injury. In addition, we have previously demonstrated that sulindac will also decrease cardiac myocyte cell death following exposure to hypoxia and re-oxygenation.
Based on these findings, we planned to address the following question: Can G-CSF/ DETC-MeSO/Sulindac multi-drug treatment prevent, attenuate or restore ischemia-induced brain injury and functional impairment? Information obtained from the proposed studies will not only shed new light
regarding the mode of action of G-CSF/DETC-MeSO/sulindac in neuronal protection and neuronal regeneration but also provide an effective and novel multi-drug treatment for TBI and stroke.
GCSF affords high level protection against focal brain ischemia:
Using the middle cerebral artery occlusion (MCAO) model in rat we have established that G-CSF treatment protected against focal ischemia by reducing endoplasmic reticulum (ER) stress induced apoptosis and preserving the ER integrity. G-CSF treatment significantly attenuated the expression of key proteins involved in the ER stress induced apoptosis pathway; ATF4, ATF6, p-p38MAPK and CHOP as well as reducing the level of the intraluminal ER stress sensor, GRP78. In this model, G-CSF also reduced the general cellular stress marker HSP27. In the MCAO model this G-CSF mechanism-based therapy was found to afford ischemic protection through preventing tissue damage at the level of ER-stress. Our ongoing studies on GCSF are aimed at elucidating the relative contributions of major stress pathways including ER stress, mitochondrial stress including mediators of mitochondrial fission and fusion, and autophagy related signaling events.
DETC-MeSO protects against ischemic damage through inhibition of a restricted set of ER stress pathways
To examine the mechanisms underlying ischemic protection by DETC-MeSO we employed western blot to analyze the major pro-survival pathways and ER stress pathway components. The anti-apoptotic protein Hsp27 was greatly increased by DETC-MeSO pointing to a role for this molecular chaperone in cooperating with anti-apoptotic Bcl-2 family members. Levels of key ER stress proteins that included p-PERK, p- eIF2-alpha, ATF4, XBP-1 and CHOP were found to decline after administration of DETC-MeSO.
Protective actions of Sulindac through pro-survival signaling in the MCAO stroke model
In our studies on the individual actions of Sulindac alone in the MCAO model we examined the hypothesis that Sulindac, an anti-inflammatory drug (NSAID) treatment would prevent, attenuate or repair ischemia induced brain injury and reverse functional impairment in focal animal model of stroke. Our data on the MCAO model indicated that administration of sulindac resulted in decreased infarct size with a central protective role for the molecular chaperone Hsp27, the pro-survival kinase Akt and the anti-apoptotic component Bcl-2 in mediating these effects.
Multi-drug combination therapy
In addition to the neuroprotective action of these three drugs individually, there was very clear protection afforded by the combination of the 3 drugs G-CSF, DETC-MeSO and Sulindac. In our in vivo analysis of the multidrug strategy for stroke we employed DETC-MeSO, Sulindac and GCSF either in a pretreatment protocol or a post-treatment protocol. For pretreatment, DETC-MeSO was administered 12 hour before surgery, sulindac was administered 2 days before surgery and GCSF was administered 1 day before surgery. For post-treatment all drugs were administered 24 hours after surgery with continued daily administration for 4 days. Both pretreatment and post-treatment resulted in high level tissue protection and were found to decrease infarct size to less than 40% of the volume found with infarcts from non-drug stroke animals. Pretreatment resulted in decreased ER stress markers as well as decreased pro-apoptotic
Bax expression. Post-treatment was found to decrease indices of apoptosis and of ER stress as well as to enhance levels of the pro-survival chaperone Hsp27. In our ongoing multi-drug studies we are focusing neuroprotection through inhibition of through three types of mechanism cellular namely: autophagy, mitochondrial stress and ER stress. These mechanism based multi-drug therapeutic strategies for stroke are remarkable in their efficacious properties firstly because high level protection was obtained with low doses of each drug (approximately 10% of the established clinical doses) and secondly our post-administration strategy was successful-even at 24 hours after stroke. Hence the post-stroke administration intervention would be highly clinically applicable.
In summary, we determined an important role for DETC-MeSO, G-CSF and sulindac in selectively inhibiting different combinations of ER stress pathways in parallel with eliciting a decrease in infarct size in the rat middle cerebral artery occlusion (MCAO) model. Importantly each agent administered individually elicited potent pro-survival responses. Furthermore, combinations of G-CSF, DETC-MESO plus sulindac also resulted in strong protection even when the agents were employed at low doses compared to the respective standard drug doses.
Currently 15 million Americans suffer from signs and symptoms of AMD, and an estimated 27 to 30 million are affected worldwide. Based upon the pattern of progression and pathophysiology, macular degeneration can be divided into two basic types: "dry" and "wet". Approximately 85% to 90% of the cases of AMD are the "dry" (atrophic) type. In the dry form of AMD, areas of focal RPE cell loss develop in the central region termed the macula followed by a loss of the adjacent photoreceptor cells. This phenomena leads to a thinning of the macula, causing loss of function. The resulting blind areas expand at a slow rate but eventually there is significant loss of vision. According to National Eye Institute, the global market to treat “dry” AMD is expected to be $2.1 billion with a compound annual growth rate of 10.3% in 2016. The “dry” AMD market has the potential of achieving more than $5 billion, especially with the increase in population of the elderly resulting in a doubling of AMD cases by 2050. Since currently there is no known cure for “dry” AMD, blockbuster status would most likely be guaranteed to a drug that can tackle this disease.
The Opportunity: A novel ischemic preconditioning agent that protects Retinal Pigmented Epithelial (RPE) cells against oxidative damage.
Sulindac one of the early non-steroidal anti-inflammatory drugs (NSAIDS) in studies on the mechanisms
that cells use to protect against oxidative damage we found that Sulindac has a unique new function in that it can protect certain cells by initiating an Ischemic Pre-Conditioning response (IPC). Cells that have high rates of oxidative metabolism, such as heart, brain and lung have been shown to possess an IPC. This is a response to sub-lethal ischemic exposure that will protect the cell from oxidative damage that can result from a severe ischemic episode or from other sources. Initial published studies showed that Sulindac can protect the heart against oxidative damage caused by ischemia/reperfusion and that this protection was because Sulindac initiated an IPC response. This new activity of Sulindac was obtained at doses of Sulindac (based on mg of drug/ kgm of weight) was well below that needed for its NSAID activity. Since Sulindac is a relatively non-toxic substance it seemed reasonable to see if Sulindac could protect other cells known to have an IPC response
Studies with RPE cells
It is known that both the lens and retina cells are extremely sensitive to oxidative stress that arises from the generation of reactive oxygen species from metabolism as well as from UV and light exposure. Eye diseases such as cataracts and age related macular degeneration (AMD) are good examples of such diseases. There is currently no treatment for the dry form of AMD, which as mentioned before accounts for 80-90% of the AMD patients, although the progression of the wet form can be delayed by inhibiting angiogenesis with Lucentis or Avastin. It has also been reported that retinal cells have an IPC response which made it an ideal candidate to test Sulindac. Thus far the experiments have been performed with RPE cells in culture and recent in-vivo studies have shown extremely encouraging results. It was important to ascertain what the mechanism of this protection was, since Sulindac is an NSAID. To accomplish this we used a Sulindac metabolite, Sulindac Sulfone, which is not an NSAID and showed that it also protected the RPE cells similar to Sulindac. We have now obtained more direct evidence that the Sulindac effect is due to an IPC response. It is known that the IPC response in cells involves a protein kinase, called PKC epsilon, and we have shown that inhibiting this enzyme prevents the protection of the cells by Sulindac.