Systémová enzymoterapie pro odborníky

Enzyme Therapy in Diabetic Nephropathy – Experimental and First Clinical Data

Gerhard Stauder*, Gavin Wood*, Leczek Paczek**

* Mucos Pharma, Geretsried, Germany
** Transplantation Institute, University Warsaw, Poland

In: Consolo F, Bellinghieri G, Savica V. (eds.): 6th Taormina Course of Nephrology. Editoriale Bios, Cosenza, (2000); 227-232.

Abstract

Diabetic nephropathy is characterized by cell hypertrophy, thickening of the basement membranes and accumulation of extracellular matrix (ECM), that is attributed to an elevated protein synthesis and an inhibition of protein degradation, the latter due to reduced proteolytic activity.
The main trigger for this process is overexpression of transforming growth factor beta-1 (TGF-b₁). This is induced by numerous factors such as hyperglycemia, stimulation of the RAS, formation of advanced glycation endproducts (AGE), elevated IL-6 levels, and increased mesangial stretch. A reduction of TGF-b₁ levels was documented to be associated with a retardation of disease progression. Based on the findings in endothelial cells that the receptor for AGEs (RAGE) is trypsin-sensitive, the modulatory action of this serine protease was investigated in tubule cells. The distinct overexpression of TGF-b₁ as well as the hypertrophy of the cells, induced by AGE-BSA, were normalized after coincubation with trypsin. In addition, the cellular accumulation of AGEs was markedly reduced. The enzyme therapy (12 mg/day of a mixture of the active ingredients of Phlogenzym^®) was able to reduce the increased intraglomerular TGF-b_ content in rats. In a second study in uninephrectomized, STZ induced diabetes in rats the combination of Phlogenzym^® with the ACE inhibitor enalapril showed an almost 67% reduction of glomerular sclerosis, while single treatment with either enalapril or Phlogenzym^® led to a 20-30% reduction only, indicating clear additive effect.
In human studies (patients with rheumatoid arthritis or myelofibrosis), elevated serum levels of TGF-b_ were diminished by oral enzyme therapy. A clinical pilot study in patients with diabetic nephropathy demonstrated that oral enzyme therapy (2 tablets t.i.d.) is able to reduce enhanced levels of IL-6 both in serum and urine.
A clinical double-blind placebo controlled pilot study on 24 patients with diabetic nephropathy, stages III or IV, was performed in 4 centers in Germany and Poland. Either the enzyme preparation Phlogenzym^® or placebo was administered double-blinded for 16 weeks. 21 patients, mean age 51.3, and 53.5 years, respectively, were evaluated. Five patients in the enzyme group were suffering from diabetes type I, 5 patients from type II; in the placebo group 5 patients were suffering from the type I and 6 patients from type II. Five patients (enzyme group) had stage III nephropathy (microalbuminuria), 5 patients stage IV (macroalbuminuria); in the placebo group 4 patients had stage III, and 7 patients stage IV. At baseline, 7 patients in the enzyme group had proteinuria <1 g/day, 3 patients >1 g/day; in the placebo group 7 patients had proteinuria <1 g/day, and 4 patients >1 g/day. The groups were comparable. Blood glucose and mean blood pressure were controlled effectively.
At baseline, a proteinuria (median) of 0.4 g/day was measured in the enzyme group, 0.8 g/day in the placebo group. After 16 weeks the value was unchanged in the enzyme group (0.36 g/day), whereas it slightly deteriorated to 1.08 g/day in the placebo group (p > 0.05).
The albuminuria tended to lower levels (from 242.5 mg/day to 200.0 mg/day) in the enzyme group; in the placebo group, a slight increase from 508.0 mg/day to 562.0 mg/day was observed (p > 0.05). Creatinine clearance did not change in either group during the 16-week treatment period (which was not at all expected in this short time), while serum creatinine tended to decline in the enzyme group (from 1.05 mg/dl at baseline to 0.95 mg/dl), and remained unchanged (at 1.2 mg/dl) in the placebo group (p = 0.0279).
There were recorded only 2 drug related side effects, 1 under placebo (mild diarrhea) and 1 (mild constipation) under enzyme therapy. Thus, the enzyme therapy proved to be safe.
Another double-blind, placebo controlled clinical trial with Phlogenzym^®will be performed in 16 centers in Europe.


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Zánět a jeho ovlivnění SET Zvýšení využitelnosti antibiotik proteolytickými enzymy Angiologie, flebologie Gynekologie Chirurgie, traumatologie, ortopedie Imunologie Lymfologie ORL Pediatrie Revmatologie Sportovní medicína Stomatologie Urologie Literatura Časopisy s Impact faktorem Ostatní literatura SPC Wobenzym SPC Phlogenzym	Enzyme Therapy in Diabetic Nephropathy – Experimental and First Clinical Data Gerhard Stauder, Gavin Wood, Leczek Paczek** * Mucos Pharma, Geretsried, Germany ** Transplantation Institute, University Warsaw, Poland In: Consolo F, Bellinghieri G, Savica V. (eds.): 6th Taormina Course of Nephrology. Editoriale Bios, Cosenza, (2000); 227-232. Abstract Diabetic nephropathy is characterized by cell hypertrophy, thickening of the basement membranes and accumulation of extracellular matrix (ECM), that is attributed to an elevated protein synthesis and an inhibition of protein degradation, the latter due to reduced proteolytic activity. The main trigger for this process is overexpression of transforming growth factor beta-1 (TGF-b₁). This is induced by numerous factors such as hyperglycemia, stimulation of the RAS, formation of advanced glycation endproducts (AGE), elevated IL-6 levels, and increased mesangial stretch. A reduction of TGF-b₁ levels was documented to be associated with a retardation of disease progression. Based on the findings in endothelial cells that the receptor for AGEs (RAGE) is trypsin-sensitive, the modulatory action of this serine protease was investigated in tubule cells. The distinct overexpression of TGF-b₁ as well as the hypertrophy of the cells, induced by AGE-BSA, were normalized after coincubation with trypsin. In addition, the cellular accumulation of AGEs was markedly reduced. The enzyme therapy (12 mg/day of a mixture of the active ingredients of Phlogenzym^®) was able to reduce the increased intraglomerular TGF-b_ content in rats. In a second study in uninephrectomized, STZ induced diabetes in rats the combination of Phlogenzym^® with the ACE inhibitor enalapril showed an almost 67% reduction of glomerular sclerosis, while single treatment with either enalapril or Phlogenzym^® led to a 20-30% reduction only, indicating clear additive effect. In human studies (patients with rheumatoid arthritis or myelofibrosis), elevated serum levels of TGF-b_ were diminished by oral enzyme therapy. A clinical pilot study in patients with diabetic nephropathy demonstrated that oral enzyme therapy (2 tablets t.i.d.) is able to reduce enhanced levels of IL-6 both in serum and urine. A clinical double-blind placebo controlled pilot study on 24 patients with diabetic nephropathy, stages III or IV, was performed in 4 centers in Germany and Poland. Either the enzyme preparation Phlogenzym^® or placebo was administered double-blinded for 16 weeks. 21 patients, mean age 51.3, and 53.5 years, respectively, were evaluated. Five patients in the enzyme group were suffering from diabetes type I, 5 patients from type II; in the placebo group 5 patients were suffering from the type I and 6 patients from type II. Five patients (enzyme group) had stage III nephropathy (microalbuminuria), 5 patients stage IV (macroalbuminuria); in the placebo group 4 patients had stage III, and 7 patients stage IV. At baseline, 7 patients in the enzyme group had proteinuria <1 g/day, 3 patients >1 g/day; in the placebo group 7 patients had proteinuria <1 g/day, and 4 patients >1 g/day. The groups were comparable. Blood glucose and mean blood pressure were controlled effectively. At baseline, a proteinuria (median) of 0.4 g/day was measured in the enzyme group, 0.8 g/day in the placebo group. After 16 weeks the value was unchanged in the enzyme group (0.36 g/day), whereas it slightly deteriorated to 1.08 g/day in the placebo group (p > 0.05). The albuminuria tended to lower levels (from 242.5 mg/day to 200.0 mg/day) in the enzyme group; in the placebo group, a slight increase from 508.0 mg/day to 562.0 mg/day was observed (p > 0.05). Creatinine clearance did not change in either group during the 16-week treatment period (which was not at all expected in this short time), while serum creatinine tended to decline in the enzyme group (from 1.05 mg/dl at baseline to 0.95 mg/dl), and remained unchanged (at 1.2 mg/dl) in the placebo group (p = 0.0279). There were recorded only 2 drug related side effects, 1 under placebo (mild diarrhea) and 1 (mild constipation) under enzyme therapy. Thus, the enzyme therapy proved to be safe. Another double-blind, placebo controlled clinical trial with Phlogenzym^®will be performed in 16 centers in Europe.
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