This invention relates to a method for the treatment and prevention of climacteric disorders during aging in males, such as increased incidence of cardiovascular diseases, etc., which may be associated with the continuous reduction in serum testosterone levels in men as they age, and becomes problematic in middle-age, with a nitric oxide synthase substrate (e.g., L-arginine), a nitric oxide donor or both, in combination with androgen hormone replacement therapy (HRT) and/or an aromatase inhibitor, which provides an increase in endogenous testosterone levels.
It is now well known that HRT, such as estrogen treatment, improves or reverses the adverse effects of the decrease in sex steroid secretion by the ovaries during menopause in women. Estrogens have also been shown to improve mood and psychological well-being in postmenopausal women and they also prevent atrophic changes in the genital tract. Estrogens have been shown to effect arterial tone and this may help to explain the reduction in hot flushes observed in postmenopausal women with estrogen therapy.
One of the most exciting recent advances in biology and medicine is the discovery that nitric oxide is produced by endothelial cells and that it is involved in the regulation of vascular tone, platelet aggregation, neurotransmission and immune activation (Furchgott and Zawadzki, 1980; Moncada, Palmer and Higgs, 1991; Ignarro, 1991). Nitric oxide is an important mediator of relaxation of the muscular smooth muscle (Montada, Palmer and Higgs, 1991) and was formerly known as EDRF (endothelin-derived relaxing factor) (Furchgott and Zawadzki, 1980; Moncada, Palmer and Higgs, 1991). Nitric oxide is synthesized by the oxidative deamination of a guanidino nitrogen of L-arginine by at least three different isoforms of a flavin-containing enzyme, nitric oxide synthase (Moncada, Palmer and Higgs, 1991). Synthesis of nitric oxide has been shown to be competitively inhibited by analogues of L-arginine; NG-nitro-L-arginine methyl ester (L-NAME), NG-monoethyl-L-arginine (LMMA), N-iminoethyl-L-ornithine (L-NIO), L-monomethyl-L-arginine (L-NNMA) and L-NG-methylarginine (LNMA) and Nw-nitro-L-arginine (L-NA).
Nitric oxide elevates levels of cGMP (1,3,5-cyclic guanosine monophosphate) within the vascular smooth muscle to produce relaxation and to reduce blood vessels tone (Moncada, Palmer and Higgs, 1991). Nitric oxide binds to heme and thus activates soluble guanylate cyclase (Ignarro, 1991) to increase the cellular content of cGMP. It has long been recognized that nitrovasodilators, such as nitroprusside and nitroglycerin, inhibit vascular smooth muscle contractility to produce relaxation or to reduce vascular tone. These agents have been used since the late 1800's as vasodilators. However, only recently has the mechanism of action of these compounds been realized. Nitrovasodilators are now classified as nitric oxide donors because they are metabolized to release nitric oxide (Moncada, Palmer and Higgs, 1991). The long-used nitrovasodilators may be regarded as substitution therapy for a failing physiological mechanism. Nitric oxide is also produced by macrophages and other immune cells.
There is a substantial body of evidence from animal experiments that a deficiency in nitric oxide contributes to the pathogenesis of a number of diseases, including hypertension, atherosclerosis and diabetes, and erectile dysfunction in men (Moncada, Palmer and Higgs, 1991). There are many recent studies showing that the inhibition of nitric oxide synthase dramatically increases blood pressure. The inhibition of nitric oxide synthesis with L-NNMA, L-NA or L-NAME causes long-lasting elevation in blood pressure and suggests that its reduction may contribute to the pathogenesis of hypertension (Moncada and Palmer, 1992). Furthermore, L-NAME-treatment potentiates presser responses to angiotensin II, vasopressin and norepinephrine. Also, in patients with pregnancy-induced hypertension, release of nitric oxide by umbilical vessels in blunted (Pinto et al, 1991) and the physiological decrease in blood pressure in pregnant spontaneous hypertensive rats was shown to depend on endothelial nitric oxide (Ahokas, Merces and Sibai, 1991). Additionally, infusion of L-NA increases blood-pressure in pregnant rats and potentiates responses to vasopressors (Molnar and Hertelendy, 1992). These studies suggest that impaired nitric oxide synthesis may be an important mechanism in the etiology of cardiovascular problems.
Nitric oxide synthesis and nitric oxide effector system (cGMP-dependent relaxation mechanism) are thought to be regulated by steroid hormones. There is an increase in cardiovascular diseases in women following menopause and which may be related to the decrease in sex steroids and an alteration in nitric oxide. Female steroid hormones have been shown to modulate endothelium-dependent relaxation of vascular smooth muscle by nitric oxide. Estradiol treatment of rats causes increased nitric oxide production by vascular tissues, whereas progesterone counteracts this phenomenon (Miller and Van Houtte, 1991). It is well known that pregnancy is associated with an increase in cardiac output and a decrease in the resistance of virtually all the vascular beds in the body. Although the mechanism of this phenomenon is not known, it could be associated with changes in nitric oxide production or effects as a result of elevated steroid hormone levels. One important observation with regard to the above mechanism is that antiprogestins (RU 486) elevate blood pressure in animals (Kalimi, 1989) and they produce hot flushes in humans, both males (Grunberg et al., 1993) and females (Kettel et al., 1991). The hot flushes may be mediated by the steroid action on the release of nitric oxide. Hot flushes are a primary symptom in menopausal and postmenopausal women and they are relieved by both estrogen and progesterone (Avis et al., 1993).
Another symptom of climacterium in both men and women is osteoporosis. There is also growing evidence that nitric oxide mediates steroid (estrogen and/or progestin) effects on bones (C. W. G. M. Lowik et al., J. Clin. Invest., 93:1465-1472 (1994); T. P. Kasten et al., Proc. Natl. Acad. Sci. USA 88:2936-2940 (1991); M. Zaidi et al., Bone 14:97-102 (1993); A. S. M. Towhidul Alam et al., Bioscience Reports 12:369 (1992)).
The studies described in U.S. patent application Ser. No. 153,345, filed Nov. 16, 1993, show that nitric oxide and the subsequent relaxation of the uterus is controlled by progesterone. The relaxation effects of the nitric oxide substrate, L-arginine, are greater in late pregnancy when progesterone levels are elevated in pregnant rats. Also there is greater uterine relaxation with L-arginine when uterine strips are taken from nonpregnant, ovariectomized rats treated with progesterone. In addition, treatment with pregnant rats with the nitric oxide inhibitor produces signs and symptoms of preeclampsia (e.g., hypertension, fetal retardation and proteinuria--the classical triad of preeclampsia). These symptoms are related to the decrease in vascular resistance and placental perfusion. Preeclampsia is a well known model of atherosclerosis as the decrease in placental perfusion is accompanied by increased fibrin deposition in placental vessels and increased thrombus formation (Roberts et al., 1989). Thus, nitric oxide substrates and/or donors alone or in combination with estrogen and progesterone are particularly efficacious for hormone replacement therapy to prevent climacteric symptoms (climacterium) such as atherosclerosis, hypertension, hot flushes, etc. in women.
EP 0441 119 A2 discloses the use of L-arginine in the treatment of hypertension and other vascular disorders. It suggests that the mechanism by which L-arginine is effective for this purpose is because it may be the physiological precursor of "the most powerful endothelial-derived releasing factor, nitric oxide." The use of L-arginine in combination with other pharmaceutically active agents is not discussed in this publication.