Incremental Treatment Response by Cycle With Collagenase Clostridium Histolyticum for Peyronie's Disease: A Pooled Analysis of Two Phase 3 Trials

OBJECTIVE

To evaluate cumulative and incremental changes in penile curvature after each treatment cycle of collagenase clostridium histolyticum (CCH) in men with Peyronie's disease (PD).

METHODS

Data from 2 phase 3, randomized, placebo-controlled trials were analyzed post hoc. Treatment was administered in up to 4 treatment cycles (per cycle: 2 injections, 1-3 days apart, of CCH 0.58 mg or placebo; subsequent penile modeling) at 6-week intervals. Penile curvature was measured at baseline and after each treatment cycle (weeks 6, 12, 18, and 24). Successful response was defined as ≥20% reduction from baseline penile curvature.

RESULTS

Overall, 832 men (CCH, n = 551; placebo, n = 281) were included in the analysis. After each cycle, mean cumulative percent reduction from baseline penile curvature was significantly greater with CCH vs placebo (P <.001). Following one cycle, 29.9% of CCH recipients exhibited a successful response. Among nonresponders, additional cycles of injections led to further successful responses: 60.8% of first cycle failures achieved response after fourth cycle (8 injections), 42.7% of cycle 1-2 failures achieved response after fourth cycle, and 23.5% of cycle 1-3 failures achieved response after fourth cycle.

CONCLUSION

Data showed incremental benefits from each of the 4 CCH treatment cycles. Completion of a full series of 4 CCH treatment cycles may optimize improvements in penile curvature in men with PD, including among those who did not clinically respond to previous treatment cycles.

Human Pharmacokinetics and Safety of Subcutaneous Collagenase Clostridium Histolyticum in Women

BACKGROUND

Clostridium collagenase histolyticum (CCH) is being evaluated in women as a cellulite treatment.

OBJECTIVE

To report preclinical safety and human pharmacokinetics (PK) and safety data for CCH.

METHODS

Across 3 PK studies, 41 women received 12 subcutaneous injections per thigh/buttock in 1 session (up to 3.36 mg/dose). Blood samples were taken at baseline; at 5, 10, 20, and 30 minutes postdose; and at 1, 2, 4, 8, 12, 24, 48, 168, and 504 hours postdose. In a preclinical study, rats received 0, 0.029, 0.13, or 0.29 mg/dose of CCH intravenously (IV) every other day (QOD) for 16 days (total, 8 doses) and were evaluated for histopathologic changes.

RESULTS

In human PK studies, no quantifiable plasma concentrations of AUX-I or AUX-II were observed postdose (n= 39 evaluable). Adverse events were injection site&ndash;related (bruising [97.6%], pain [87.8%], and edema/swelling [46.3%]). Antidrug antibodies were seen in most women at 504 hours postdose. In rats, plasma concentrations of AUX-I and AUX-II (CCH components) were measurable for 30 minutes and 1-2 hours, respectively, after IV administration. At &ge;43&times; proposed human therapeutic dose on a mg/kg basis, rats experienced elevated liver enzyme levels, increased liver weights, and histologic changes that were mostly reversed during a 14-day recovery period.

CONCLUSIONS

In human studies, no quantifiable circulating CCH levels were observed after a single subcutaneous dose of CCH up to 3.36 mg. Preclinical data indicated that repeat IV dosing (QOD; 8 doses) at &ge;43&times; proposed human dose on a mg/kg basis for CCH was generally well tolerated.J Drugs Dermatol. 2020;19(9):852-856. doi:10.36849/JDD.2020.5048THIS ARTICLE HAD BEEN MADE AVAILABLE FREE OF CHARGE. PLEASE SCROLL DOWN TO ACCESS THE FULL TEXT OF THIS ARTICLE WITHOUT LOGGING IN. NO PURCHASE NECESSARY. PLEASE CONTACT THE PUBLISHER WITH ANY QUESTIONS.

Health Care Spending in Patients With Stage 3 and Stage 4 Pressure Injuries and Patients With Diabetic Foot Ulcers Treated Early With Clostridial Collagenase Ointment: A Retrospective Data Review

INTRODUCTION

Clostridial collagenase ointment (CCO) is the only enzymatic agent indicated for debriding chronic dermal ulcers that is approved by the United States Food and Drug Administration.

OBJECTIVE

The objective of this study is to estimate health care spending among patients with Stage 3 and Stage 4 pressure injuries (PIs) and patients with diabetic foot ulcers (DFUs) who experienced early (ie, within 30 days of index diagnosis) versus late (31 to 90 days of index diagnosis) initiation of CCO.

METHODS

Patients with PIs and DFUs between January 2007 and March 2017 were identified. One-to-one matched cohorts were used to compare all-cause health care spending and disease-related health care spending between the early initiation and late initiation groups.

RESULTS

Compared to the early CCO initiation group, all-cause health care spending for the late CCO initiation group was higher in both patients with PIs and in patients with DFUs within the 12-month follow-up period. Compared to the early CCO initiation group, disease-related health care spending for the late CCO initiation group was higher in both patients with PIs and in patients with DFUs within the 12-month follow-up period. All computations were statistically significant.

CONCLUSIONS

Early initiation of CCO provides both all-cause and disease-related health care savings to payers and persons managing patients with PIs or DFUs. Payers, providers, and facilities should consider mechanisms to encourage the early use of CCO to lower costs.

Treatment of Dupuytren's contracture: a systematic review

Aims

Dupuytren's contracture is a benign, myoproliferative condition affecting the palmar fascia that results in progressive contractures of the fingers. Despite increased knowledge of the cellular and connective tissue changes involved, neither a cure nor an optimum form of treatment exists. The aim of this systematic review was to summarize the best available evidence on the management of this condition.

Materials and Methods

A comprehensive database search for randomized controlled trials (RCTs) was performed until August 2017. We studied RCTs comparing open fasciectomy with percutaneous needle aponeurotomy (PNA), collagenase clostridium histolyticum (CCH) with placebo, and CCH with PNA, in addition to adjuvant treatments aiming to improve the outcome of open fasciectomy. A total of 20 studies, involving 1584 patients, were included.

Results

PNA tended to provide higher patient satisfaction with fewer adverse events, but had a higher rate of recurrence compared with limited fasciectomy. Although efficacious, treatment with CCH had notable recurrence rates and a high rate of transient adverse events. Recent comparative studies have shown no difference in clinical outcome between patients treated with PNA and those treated with CCH.

Conclusion

Currently there remains limited evidence to guide the management of patients with Dupuytren's contracture. Cite this article: Bone Joint J 2018;100-B:1138-45.

Clostridial collagenase ointment and medicinal honey utilization for pressure ulcers in US hospitals

AIMS

To describe the utilization of clostridial collagenase ointment (CCO) and medicinal honey debridement methods in real-world inpatient and outpatient hospital settings among pressure ulcer (PU) patients and compare the frequency of healthcare re-encounters between CCO- and medicinal honey-treated patients.

MATERIALS AND METHODS

De-identified hospital discharge records for patients receiving CCO or medicinal honey methods of debridement and having an ICD-9 code for PU were extracted from the US Premier Healthcare Database. Multivariable analysis was used to compare the frequency of inpatient and outpatient revisits up to 6 months after an index encounter for CCO- vs medicinal honey-treated PUs.

RESULTS

The study identified 48,267 inpatients and 2,599 outpatients with PUs treated with CCO or medicinal honeys. Among study inpatients, n = 44,725 (93%) were treated with CCO, and n = 3,542 (7%) with medicinal honeys. CCO and medicinal honeys accounted for 1,826 (70%) and 773 (30%), respectively, of study outpatients. In adjusted models, those treated with CCO had lower odds for inpatient readmissions (OR = 0.86, 95% CI = 0.80-0.94) after inpatient index visits, and outpatient re-encounters both after inpatient (OR = 0.73, 95% CI = 0.67-0.79) and outpatient (OR = 0.78, 95% CI = 0.64-0.95) index visits in 6 months of follow-up.

LIMITATIONS

The study was observational in nature, and did not adjust for reasons why patients were hospitalized initially, or why they returned to the facility. Although the study adjusted for differences in a variety of demographic, clinical, and hospital characteristics between the treatments, we are not able to rule out selection bias.

CONCLUSION

Patients with CCO-treated PUs returned to inpatient and outpatient hospital settings less often compared with medicinal honey-treated PUs. These results from real-world administrative data help to gain a better understanding of the clinical characteristics of patients with PUs treated with these two debridement methods and the economic implications of debridement choice in the acute care setting.

Successful Treatment of Residual Curvature in Peyronie Disease in Men Previously Treated With Intralesional Collagenase Clostridium Histolyticum

OBJECTIVE

To determine the success and feasibility of surgically correcting residual curvature after intralesional collagenase clostridium histolyticum (CCH) for the treatment of Peyronie disease (PD).

METHODS

We performed a retrospective analysis of patients who had intralesional CCH treatment for PD and who subsequently underwent penile plication (PP), plaque incision and grafting (PIG), or inflatable penile prosthesis (IPP) placement.

RESULTS

Ten men who underwent PP, PIG, or IPP for the treatment of residual curvature after intralesional CCH were identified. Six patients underwent PP; 1 patient underwent PIG; and 3 patients underwent IPP with ancillary straightening maneuvers. The mean time from the last CCH injection to surgical correction was 150.9 days, or 5 months. The mean pre-CCH curvature was 67 degrees and the mean post-CCH curvature was 51 degrees. Eight of 10 patients had no residual curvature after surgical treatment. The mean postprocedure curvature was 4.5 degrees. The mean operative time was 72.1 minutes. The mean estimated blood loss was 20 mL. Increased fibrosis with increased surgical difficulty was noted in 3 (all <6 months post CCH treatment) of 10 patients. No postoperative complications were noted.

CONCLUSION

The surgical treatment of PD after intralesional CCH is safe and effective. If surgery is considered, this should be performed at least 6 months after the last CCH injection, given the potential for an increased inflammatory reaction in this area.

CORR® ORS Richard A. Brand Award: Clinical Trials of a New Treatment Method for Adhesive Capsulitis

BACKGROUND

Conservative and even surgical management of adhesive capsulitis often is prolonged and painful. Management of adhesive capsulitis is lacking evidence-based controlled clinical trials.

QUESTIONS/PURPOSES

We asked: (1) Does a collagenase clostridium histolyticum (CCH) injection lyse shoulder capsule collagen in adhesive capsulitis and at what dose? (2) Can a shoulder capsule injection be administered extraarticularly? (3) Do CCH injections result in better scores for pain and function than can be achieved with physical therapy among patients with adhesive capsulitis?

METHODS

First, 60 patients with adhesive capsulitis were evaluated by clinical examination. To make the diagnosis of adhesive capsulitis, a patient had to have restricted active ROM of at least 60° in total active ROM in the affected shoulder compared with the unaffected contralateral shoulder; with the scapula stabilized, external rotation with the elbow at the side was a very important determinant. Patients were randomized to receive a single injection of 0.5 mL placebo or 0.145, 0.29, or 0.58 mg CCH. All 60 patients were followed up at 30 days. After that, if patients did not attain treatment thresholds they were eligible for up to five open-label 0.58-mg collagenase injections. For the longer-term followup in the open-label phase, 53 patients (83%) were followed to 12 months, 46 (77%) for 24 months, 36 (60%) for 36 months, 37 (62%) for 48 months, and 25 (42%) for 60 months. The extraarticular injection was directed at the anterior shoulder capsule with the patient in the supine position. To prove that these injections could be delivered reliably to the anterior shoulder capsule extraarticularly, the next study involved volunteers without adhesive capsulitis, in which 10 volunteers received a 10-mL injection of normal saline under ultrasound guidance. Finally, to determine the efficacy and dosing of CCH, four cohorts of 10 patients received up to three ultrasound-guided injections separated by 21 days. These injections were administered at one of four dose-volume levels. A fifth cohort of 10 patients was used as a control group and performed standardized home shoulder exercises only. All patients performed standardized home shoulder exercises three times daily. For Study 3, followup was at 22, 43, 64, and 92 days. No patients were lost to followup.

RESULTS

In the first study, a single CCH injection did not provide clinically important improvements from baseline in active ROM, passive ROM, and function and pain scores compared with patients who received placebo. Ultrasound guidance confirmed extraarticular injection of the shoulder capsule in Study 2. The CCH injection was more effective than exercise therapy alone at 0.58 mg/1 mL and 0.58 mg/2 mL compared with exercise only in the primary measure of efficacy (active forward flexion) as shown in Study 3. For active forward flexion the mean in degrees in the 0.58 mg/2 mL group was 38° compared with 12° in the exercise-only group (p = 0.03). For active forward flexion the mean in the 0.58 mg/1mL group was 43° compared with 12° in the exercise-only group (p = 0.01).

CONCLUSIONS

Extraarticular injections of CCH for treatment of adhesive capsulitis were well tolerated and seem effective compared with exercise therapy. Future FDA-regulated clinical trials must verify CCH injection therapy for adhesive capsulitis.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Effectiveness and safety of collagenase Clostridium histolyticum in Dupuytren's disease : an observational study in Belgium

Dupuytren's disease is a connective tissue disorder leading to contractures. It can be treated surgically or through injections of collagenase Clostridium histolyticum (CCH). Patients with Dupuytren's contracture (> 20°) and a palpable cord were included in this observational study, aiming to characterise the Belgian patient population and to assess the effectiveness and safety of CCH. Overall, 108 patients (114 joints) received at least one injection of CCH, and 104 patients completed the study. The percentages of joints achieving a degree of contracture of 5° or less, or a relative contracture reduction of at least 50% after the extension procedure were 64.9% and 90.1%, respectively. The mean number of injections per cord was 1.0. The Unité Rhumatologique des Affections de la Main score decreased from 29.4 ± 11.0 to 12.9 ± 6.3 (mean ± SD ; p < 0.0001). CCH was demonstrated to be effective, safe and able to increase quality of life.

Patient Satisfaction With Collagenase

PURPOSE

To establish patient satisfaction after collagenase clostridium histolyticum (CCH) injection.

METHODS

In a cross-sectional study, 213 patients who had been treated for Dupuytren disease with CCH were reviewed between 37 and 1421 days after injection.

RESULTS

A total of 73% of the patients were very satisfied or satisfied, and 21% were dissatisfied; 75% would probably or definitely have CCH again, whereas 17% probably or definitely would not. We found that satisfaction and willingness to undergo a second treatment decreased over time and had a negative relationship with recurrence. Dissatisfaction was greater in those with a poor initial outcome but not in those with an initial complication. Of 212 patients, 78 had previously experienced surgery for Dupuytren disease of whom 71% would prefer CCH to surgery and 15% the converse. Satisfaction shows a relationship with function as measured by both QuickDASH and the Southampton Dupuytren Scoring Scheme.

CONCLUSIONS

Patient satisfaction with CCH is generally high but deteriorates over time as the disease recurs. To manage patient expectation, this issue should be made explicit to patients in the consent process.

CLINICAL RELEVANCE

Overall satisfaction with CCH is high, with initial satisfaction rates especially good. Forewarning of complications and recurrence can help maintain satisfaction levels.

The Efficacy and Safety of Concurrent Collagenase Clostridium Histolyticum Injections for 2 Dupuytren Contractures in the Same Hand: A Prospective, Multicenter Study

PURPOSE

To evaluate efficacy and safety of concurrent administration of 2 collagenase clostridium histolyticum (CCH) injections to treat 2 joints in the same hand with Dupuytren fixed flexion contractures (FFCs).

METHODS

Patients with 2 or more contractures in the same hand caused by palpable cords participated in a 60-day, multicenter, open-label, phase 3b study. Two 0.58 mg CCH doses were injected into 1 or 2 cords in the same hand (1 injection per affected joint) during the same visit. Finger extension was performed approximately 24, 48, or 72 or more hours later. Changes in FFC and range of motion, incidence of clinical success (FFC ≤ 5°), and adverse events (AEs) were summarized.

RESULTS

The study enrolled 715 patients (725 treated joint pairs), and 714 patients (724 joint pairs) were analyzed for efficacy. At day 31, mean total FFC (sum of 2 treated joints) decreased 74%, from 98° to 27°. Mean total range of motion increased from 90° to 156°. The incidence of clinical success was 65% in metacarpophalangeal joints and 29% in proximal interphalangeal joints. Most treatment-related AEs were mild to moderate, resolving without intervention; the most common were swelling of treated extremity, contusion, and pain in extremity. The incidence of skin lacerations was 22% (160 of 715). Efficacy and safety were similar regardless of time to finger extension.

CONCLUSIONS

Collagenase clostridium histolyticum can be used to effectively treat 2 affected joints concurrently without a greater risk of AEs than treatment of a single joint, with the exception of skin laceration. The incidence of clinical success in this study after 1 injection per joint was comparable to phase 3 study results after 3 or more injections per joint. Two concurrent CCH injections may allow more rapid overall treatment of multiple affected joints, and the ability to vary the time between CCH injection and finger extension may allow physicians and patients greater flexibility with scheduling treatment.

[Dupuytren's disease treatment]

Dupuytren's disease is a hereditary fibroproliferative disease commonly affecting the palmar fascia of the hand, which results in progressive and irreversibly fixed flexion contractures of the hand. It may occur in the sole of the foot or in the penis. Generally, treatment has been up against a high frequency of complications and recurrence, but promising results are reported from less invasive treatment options, e.g. needle fasciotomy and enzymatic fasciotomy with collagenase. This is a detailed, comparative review of available non-operative and surgical treatments with focus on the enzymatic fasciotomy.

A retrospective study of the effects of clostridial collagenase ointment and negative pressure wound therapy for the treatment of chronic pressure ulcers

Nonhealing, chronic pressure ulcers present a continuous challenge in the global health care venue, with decreased mobility and the effects of aging on skin placing the elderly at particular risk. Debridement is an important process to decrease risk of infection and promote healing. Enzymatic debridement with, for example, clostridial collagenase ointment (CCO) has been shown to assist with the achievement and maintenance of a clean wound bed in preparation for closure. Negative pressure wound therapy (NPWT) has also been used successfully for the treatment of wounds. Although conclusive research has demonstrated positive independent effects of both CCO and NPWT as treatments for chronic pressure ulcers, there are no known published studies that have investigated the 2 as a conjunctive treatment.

MATERIALS AND METHODS

A retrospective analysis of 114 adult patients was conducted to assess wound healing of chronic pressure ulcers in a setting with medically complex patients. Two groups were established comparing those who received NPWT alone to those who received NPWT plus CCO. The study sample included 67 patients treated with NPWT + CCO and 47 patients who received only NPWT.

RESULTS

Results were similar for both treatment groups with mean values indicating the cohorts were closely aligned with respect to wound size, complexity, length of long-term acute care hospital stay, and duration of NPWT. The patients who received NPWT + CCO demonstrated statistically significant changes in several key areas including initial Bates-Jensen Wound Assessment Tool (BWAT) score, changes in the overall BWAT score and in the necrotic tissue domain.

CONCLUSION

Data analysis from this retrospective study indicates patients who received both therapies (NPWT + CCO) demonstrated improved outcomes in speed of debridement and rate of wound closure compared to those who received NPWT alone.

Collagenase clostridium histolyticum in patients with Dupuytren's contracture: results from POINT X, an open-label study of clinical and patient-reported outcomes

In POINT X, a study designed to reflect clinical practice and patient treatment choices, 254 European patients received open-label collagenase for Dupuytren's contracture. The most severely affected joint was treated first in 74% of patients. In total, 52%, 41%, 7%, and 1% of patients selected the little, ring, middle, and index finger, respectively; 79% had one or two joints treated. Only 9% of patients (n = 24) received 4 or 5 injections. The mean improvement in total passive extension deficit (TPED) was 34° on day 1, improving further by day 7 to 42°. This secondary improvement was maintained by day 90 and month 6. The mean number of injections/joint was 1.2 for the metacarpophalangeal joint and 1.25 for the proximal interphalangeal joint. Median time to recovery was 4 days; the mean improvement in hand function was clinically relevant as measured by the Unité Rhumatologique des Affections de la Main (URAM) score. In total, 87% and 86% of patients and physicians, respectively, were very satisfied or satisfied with treatment at month 6, although correlation between TPED and patient satisfaction was weak (Spearman -0.18, 95% CI -0.32 to -0.06). Collagenase was well tolerated, with 10 (3.9%) patients experiencing severe adverse events. As a real-world study, the POINT X findings can be generalized to the at-large population.

[Dupuytren's disease]

Dupuytren's disease is a fibromatosis affecting the hand. The disease affects the hand and fingers and may present with a contracture causing increasing disability of the hand. We can treat the symptoms but not its cause. In this article we review the background, diagnosis and methods of treatment of the disease. Although the mainstay of treatment accepted by most is surgical, use of collagenase injections aimed at chemically disintegrating pathologic cords may emerge as an important addition to the armamentarium of treatments for Dupuytren's disease.

Efficacy and safety of collagenase clostridium histolyticum injection for Dupuytren contracture: short-term results from 2 open-label studies

PURPOSE

The JOINT I (United States) and JOINT II (Australia and Europe) studies evaluated the efficacy and safety of collagenase clostridium histolyticum (CCH) injection for the treatment of Dupuytren contracture.

METHODS

Both studies used identical open-label protocols. Patients with fixed-flexion contractures of metacarpophalangeal (MCP) (20° to 100°) or proximal interphalangeal (PIP) joints (20° to 80°) could receive up to three 0.58-mg CCH injections per cord (up to 5 total injections per patient). We performed standardized finger extension procedures to disrupt injected cords the next day, with follow-up 1, 2, 6, and 9 months thereafter. The primary end point (clinical success) was reduction in contracture to within 0° to 5° of full extension 30 days after the last injection. Clinical improvement was defined as 50% or more reduction from baseline contracture.

RESULTS

Dupuytren cords affecting 879 joints (531 MCP and 348 PIP) in 587 patients were administered CCH injections at 14 U.S. and 20 Australian/European sites, with similar outcomes in both studies. Clinical success was achieved in 497 (57%) of treated joints using 1.2 ± 0.5 (mean ± SD) CCH injections per cord. More MCP than PIP joints achieved clinical success (70% and 37%, respectively) or clinical improvement (89% and 58%, respectively). Less severely contracted joints responded better than those more severely contracted. Mean change in contracture was 55° for MCP joints and 25° for PIP joints. With average contracture reductions of 73% and improvements in range of motion by 30°, most patients (92%) were "very satisfied" (71%) or "quite satisfied" (21%) with treatment. Physicians rated change from baseline as "very much improved" (47%) or "much improved" (35%). The CCH injections were well tolerated, causing no tendon ruptures or systemic reactions.

CONCLUSIONS

Collagenase clostridium histolyticum was an effective, minimally invasive option for the treatment of Dupuytren contracture of a broad range of severities. Most treated joints (625 of 879) required a single injection. Treatment earlier in the course of disease provided improved outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Efficacy of collagenase in patients who did and did not have previous hand surgery for Dupuytren's contracture

Collagenase Clostridium histolyticum (CCH) is a non-surgical, efficacious therapy for Dupuytren's contracture (DC). This study evaluated the efficacy and safety of CCH in patients with previous DC surgery. Data from 12 CCH clinical trials were pooled. At screening, patients provided details about the type/date of previous DC surgery. Reviewers coded descriptions to the Operated Hand, finger, and joint. Of 1082 patients, 422 (39%) had previous DC surgery. For these patients with previous surgery, the CCH treatment was coded on the Operated (n = 206) or Non-operated Hand (n = 196). End-points included changes in fixed-flexion contracture (FFC) and range of motion (ROM). Adverse events (AEs) were monitored. After treatment with CCH, FFC at metacarpophalangeal joints was reduced by 75% in previously Operated Hands and by 80% for Non-operated Hands (p = 0.6). Improvements in ROM were 32° and 32°, respectively (p = 0.9). For proximal inter-phalangeal joints, the reductions in FFC for the Operated and Non-operated Hands were 52% and 50%, respectively (p = 0.6); improvements in ROM were 24° and 26°, respectively (p = 0.3). Some AE rates were significantly higher in the Operated vs Non-operated Hand groups, but were not clinically relevant. There were no between-group significant differences in AE duration (p > 0.08). Previous surgery for DC does not affect efficacy or safety of CCH, suggesting CCH is an option in patients with recurring DC. Some AE rates were significantly higher, but not clinically relevant.

Collagenase-1 injection improved tumor distribution and gene expression of cationic lipoplex

Elevated interstitial fluid pressure (IFP) in a tumor is a barrier to tumor accumulation of systemic delivery of nanocarriers. In this study, we investigated whether intravenous injection of type I collagenase (collagenase-1) reduced IFP in tumors and increased the accumulation and gene expression of cationic liposome/plasmid DNA complex (lipoplex) in tumors after intravenous injection into mice bearing mouse lung carcinoma LLC tumors. Collagenase-1 reduced the amount of type I collagen in the tumor, and significantly decreased IFP by 65% at 1h after injection. Therefore, collagenase-1 induced 1.5-fold higher accumulation and 2-fold higher gene expression of lipoplex in tumors after intravenous injection. These findings indicated that intravenous injection of collagenase-1 improved the accumulation of lipoplex by decreasing IFP in tumors. These results support the potential use of collagen digestion as a strategy to improve systemic gene delivery into tumors.

▾Xiapex for Dupuytren's contracture

Dupuytren's contracture is a benign, progressive disabling condition of the hands. Traditionally, surgery (e.g. fasciotomy, fasciectomy, joint fusion and amputation) has been the only effective treatment but it is not an option for every patient. A potential alternative intervention is a formulation of collagenase Clostridium histolyticum (▾Xiapex--Pfizer Limited), which has been licensed for injection directly into the affected joint as treatment for adults with Dupuytren's contracture.5 Here we review the evidence for collagenase C. histolyticum and discuss its place in the management of this condition.

[Efficacy of enzyme treatment in patients with haemophthalmos]

70 patients with haemophthalmos in arterial hypertension were examined using ultrasonography for estimation of blood area in the vitreous and for treatment efficacy evaluation. Enzyme treatment with collalizine periocular injections was performed in combination with conventional resorption therapy. The efficacy of complex resorption treatment of haemophthalmos is proved.

Cartilage damage pattern in relation to subchondral plate thickness in a collagenase-induced model of osteoarthritis

OBJECTIVE

To see how initial differences in subchondral bone phenotype influence the development of cartilage damage and changes in subchondral bone architecture in an osteoarthritis (OA)-induced mouse model.

METHOD

Intra-articular collagenase injections (right knee joint) and saline controls (left knee joint) were applied in the knees of two mouse strains known to have either a low or a high bone mass phenotype: the low bone mass C57Bl/6 mice with a thin subchondral bone plate and high bone mass C3H/HeJ mice with a thick subchondral bone plate. The ages of the mice were 16 and 30 weeks, with n=8 per group. The collagenase injection induced an osteoarthritic phenotype that was evaluated 4 weeks later in the tibia using histological analyses and micro-computed tomography (micro-CT).

RESULTS

Both strains developed cartilage damage in the collagenase-injected right knee joints to a comparable extent, however, the spatial distribution of cartilage damage differed significantly: C57Bl/6 mice had most damage at the postero-lateral side, whereas in C3H/HeJ mice the postero-medial region was the most affected. Spontaneous cartilage damage was found in the saline-injected left control knees of C57Bl/6 mice, but in C3H/HeJ mice spontaneous cartilage damage was virtually absent. In both strains the subchondral bone plate of collagenase-injected joints became thinner, independent of the site of cartilage damage. TRAP-positive osteoclasts were observed underneath the subchondral bone plate, in line with the observed decreased thickness. No link was found between subchondral bone plate thickness and cartilage damage in the collagenase-injected joints. The subchondral trabecular architecture only changed in the high bone mass C3H/HeJ mice, with thinning of trabeculae and increased trabecular spacing.

CONCLUSION

Thinning of the subchondral bone plate was found as a common observation 4 weeks after OA had been induced in two strains of mice having either a high or low bone phenotype, but no relation was found with the amount of cartilage damage. In addition, this study shows that different strains of mice can react differently to instability-induced OA with respect to the spatial arrangement of cartilage damage and changes in subchondral trabecular structure.

Antiadhesive effects of mitomycin C and streptopeptidase A in rats with intraperitoneal adhesions

Intraabdominal adhesion formation is a frequent problem after major abdominal surgery. For many years, there have been various attempts to decrease adhesions by using systemic and local drugs and mechanical barriers. In this study we aimed to evaluate the antifibrinolytic antiadhesive effects of mitomycin C (MMC) and streptopeptidase A (SA) against intraabdominal adhesions. Forty-eight rats were divided into six groups, each with eight rats. Group 1 (sham group) rats were laparotomized by transverse incision only. In Group 2 (laparotomy and talcum powder), 2 ml talcum powder was scattered equally onto the intestinal surface after laparotomy. Group 3 (SA only), 2 g SA was introduced onto the intestinal surface. Group 4 (talcum powder and SA), 2 ml talcum powder was scattered onto the intestinal surface and then 2 g SA was applied on the same area. Group 5 (MMC only), 2 ml MMC was introduced onto the intestinal surface. Group 6 (talcum powder and MMC), 2 ml talcum powder was scattered onto intestinal surface and then MMC was applied onto same area. We assessed adhesion grades macroscopically, as well as, hydroxproline levels biochemically. Macroscopicaly, the number of rats with moderate or severe adhesions was significantly higher in the control group than all other groups (P < 0.05). SA and MMC groups had only mild adhesions. No intraabdominal problem was detected in rats with SA or MMC. Hydroxyproline (HP) levels were significantly higher in control group than all other groups (P < 0.05). There was no statistical significance between the rats with SA and MMC (P > 0.05) according to the HP measurements. MMC and SA may have potential antiadhesive effects. Both substances could be beneficial against adhesion formation after laparotomies.

Intra-lesional injections of collagenase are ineffective in the treatment of keloid and hypertrophic scars

The treatment of keloid and hypertrophic scars remains difficult. Enzymatic digestion of keloid scars has been previously proposed as an effective treatment strategy for reducing the volume of keloid scars. To test this, we administered intra-lesional injections of pure collagenase (between 600 and 4500 units for each scar) into the keloid and hypertrophic scars of seven human volunteers (five keloid and two hypertrophic scars). Five patients (three keloid and two hypertrophic) received more than one injection of collagenase. The treatment resulted in a temporary reduction in scar volume for three of the patients with keloid scars. However, scar volumes for these three patients returned to the same (or greater) levels after 6 months of follow-up. Treatment with collagenase produced no change in scar volume for the two patients with hypertrophic scar. Side effects were numerous and severe including; pain, swelling, blistering, ulceration and ecchymosis at the site of injection. One patient required admission to hospital for 48 h after the first injection. Maximum length of follow-up was 6 months. None of the seven patients completed the study and returned for final follow-up at 2 years. This pilot study suggests that treatment of keloid and hypertrophic scars with intra-lesional injections of collagenase is ineffective.

[Hemophthalmia in patients with hypertensive disease]

A hundred patients with hemophthalmia were examined by ultrasound B-scanning to estimate the volume of the blood that had bled into the vitreous body and to check up the efficiency of conservative treatment. The latter used the enzyme collalysine as parabulbar injections in combination with resolving therapy. There is evidence that complex resolving therapy is an effective treatment of hemophthalmia.

[The enzyme therapy within a complex treatment of hemophthalmos in patients with diabetes mellitus]

The efficiency of the enzyme therapy was studied in patients with hemophthalmos concurrent with diabetes mellitus of different types. Sixty-eight patients received parabulbar injections of the hemase and collelizin enzymes and another 25 patients underwent the routine therapy comprising injections of dicynone, emoxipin and heparinum. The method of ultrasound B-scanning was used to determine the area of hemorrhage spread into the vitreous body. A high efficiency of the enzyme therapy, as used within the complex treatment of hemophthalmos in patients with diabetes mellitus, was demonstrated. Ultrasound B-scanning is a highly informative technique in evaluating the enzyme-therapy efficiency. The enzyme therapy can be recommended as the most effective method for the treatment of hemophthalmos in patients with diabetes mellitus.

Collagenase plaque digestion for facilitating guide wire crossing in chronic total occlusions

BACKGROUND

Chronic total occlusions (CTOs) are associated with significant angina, impaired left ventricular function, and worse long-term outcomes. Percutaneous coronary interventions in CTO are unsuccessful in up to 50% of cases, primarily because of inability to cross the lesion with a guide wire. Collagen is the predominant component of the atherosclerotic plaque. The objective of this study was to determine the efficacy and toxicity of local delivery of a collagen-degrading enzyme to facilitate guide wire crossing in CTO.

METHODS AND RESULTS

Type IA collagenase (100 or 450 microg) or placebo was locally administered to 45 CTOs in a rabbit femoral artery model. Mean occlusion duration was 16+/-5 weeks. Attempts to cross the CTO (mean length, 28+/-9 mm) with conventional guide wires were assessed at 72 hours after treatment. An additional 3 arteries per group were assessed for collagenase effects at 24 hours after treatment. Successful guide wire crossings were significantly higher in collagenase-treated arteries (13 of 21, 62%) than in placebo-treated arteries (7 of 24, 29%) (P=0.028). No adverse effects on arterial structure were observed in collagenase-treated arteries. At 24 hours, collagenase-treated arteries demonstrated increased collagenase protein, gelatinase activity, and collagen fragments.

CONCLUSIONS

Local delivery of collagenase can safely facilitate guide wire crossing of CTO. This novel approach could lead to higher percutaneous coronary intervention success rates in CTO.

Effectiveness of collagenase in the treatment of sacrococcygeal pilonidal sinus disease

PURPOSE

Sacrococcygeal pilonidal sinus disease (SPSD) is a disease affecting young patients, which results in a long-term loss of productive power, and also tends to have high rates of morbidity since it has no ideal treatment. The main purpose of this study was to investigate the effectiveness of topical collagenase in the treatment of SPSD.

METHODS

In the present study, 40 patients admitted to our department were separated into two groups. Excision and marsupialization with dressing by bacterial collagenase was performed in the first group, while the treatment was excision and marsupialization without dressing by bacterial collagenase in the second group.

RESULTS

We determined that the healing in terms of the width and depth of the wound in the first week and in depth of wound in the second week was better in group 1 than in group 2 ( P = 0.040, P = 0.020, P = 0.048, respectively). The duration of wound healing was 21.9 +/- 1.3 days in group 1, and 28.1 +/- 1.3 days in group 2 ( P = 0.0001). The recurrence rate in the intergluteal area, which heals by granulation and has no hair follicles, tends to decrease when a partial closure is obtained.

CONCLUSION

We therefore recommend an excision, marsupialization, and dressing with bacterial collagenase, in cases with noncomplicated SPSD.

Collagen as a clinical target: nonoperative treatment of Dupuytren's disease

The cellular events leading to abnormal synthesis of collagen are important to our understanding of pathologic processes leading to impaired joint function. The contracture of Dupuytren's disease is a notable example. In a series of controlled phase-2 clinical trials, excessive collagen deposition in Dupuytren's disease has been targeted by a unique nonoperative method using enzyme (Clostridial collagenase) injection therapy to lyse and rupture finger cords causing metacarpophalangeal and/or proximal interphalangeal joint contractures. Forty-nine patients were treated in a random, placebo-controlled trial of one dose of collagenase versus placebo at one center. Subsequently 80 patients were treated in a random, placebo-controlled, dose-response study of collagenase at 2 test centers. The results of these studies indicate that nonoperative collagenase injection therapy for Dupuytren's disease is both a safe and effective method of treating this disorder in the majority of patients as an alternative to surgical fasciectomy. Phase-3 efficacy trials are now being planned to further develop and test this method under Food and Drug Administration regulatory guidelines. The findings of our study may lead to simpler and less invasive nonoperative treatments of joint limitation in which collagen plays a major pathologic role.

[Clinical efficacy of alprostan in combination with "Bioptron-II" rays and iruxol-miramistin in the treatment of the diabetic foot complicated by atherosclerosis]

Experience of clinical treatment of 9 patients with diabetes mellitus and diabetic angiopathy using alprostan in combination with rays "Bioptron-II" and iruxol-miramistinum in conditions of polyclinic was summarized. Antidiabetic preparations, mainly insulin, were administered to all patients together with abovementioned treatment. Optimal scheme of treatment constitutes daily slow (no less than 6 h) dropper intravenous infusion of alprostan in 0.1 mg dosage in 150-200 ml isotonic solution of sodium chloride during 15 days. Before and after infusion of alprostan ulcer was locally irradiated using "Bioptron-II" lamp from 5 cm distance during 6 min, bandage with iruxol-miramistinum ointment was applied in ratio 1:1. In 6 patients pain in lower extremities disappeared, ulcers epithelized, in 3--ulcers reduced by 50%.

[Experimental study and preliminary clinical application of bacterial collagenase in catabolizing scars]

OBJECTIVE

To investigate the mechanism of collagenase in degradation of hypertrophic scars and observe the clinical effects of this therapy.

METHODS

Both animal experiment and clinical trial were conducted.

RESULTS

The injection of collagenase into the hypertrophic scar tissues in nude mice resulted in 86% volume reduction after two injections within two weeks, while the control tissues reduced only by 35% during the same time. Clinically, 13 cases were treated with intralesional injection of bacterial collagenase. The volume reduction rate was 46.92% in average within two weeks. The volume reduction in 4 of 13 cases was above 50%. Three to sixteen months' follow-up of five patients revealed that only one case of keloid recurred after treatment in the second month. Examinations of histological sections and TEM showed the dissolved collagen fiber clearly.

CONCLUSION

Collagenase can degrade collagen fiber directly. The prompt significant effects and the mild complications make it a prospective therapy.

[The rehabilitation of children with the initial forms of conductive hypoacusis due to recurrent acute otitis media]

The aim of the trial was study and rehabilitation of sound conduction functional disorders in 3-10-year-olds after recurrent acute otitis media. Tympanometry findings allowed to differentiate various alterations in the auditory tube and scarring in the middle ear. Treatment of the children was decided depending on the process in the middle ear. It is concluded that early diagnosis of adhesive phenomena is achieved with active search for latent auditory and tubular dysfunctions in children who previously had recurrences of acute otitis media. Children with sound conduction system dysfunction are recommended to be on the follow-up with control study of the auditory and tubular function once in 6 months and have repeat courses of corrective therapy up to stable effect.

Intra-articular injection of collagenase induces experimental osteoarthritis in mature rabbits

OBJECTIVE

The induction of osteoarthritis-like changes by intra-articular injections of collagenase in the knee joint of mature rabbits was examined.

METHODS

Collagenase (0.5, 1.0 or 2.0 mg) was intra-articularly injected twice into the right knee, and the cartilage and synovia was histologically examined at 6 weeks after the initiation of collagenase injections. In addition, 1 mg of collagenase was intra-articularly injected twice into rabbits, and histological examinations of the cartilage and synovia were performed at various time points. In other experiments, articular cartilage was digested in 5 ml of 0.4 mg/ml collagenase in vitro, and biochemical analyses of the cartilage were performed.

RESULTS

The degeneration of the cartilage and synovia were found to be dependent on the dose of collagenase. The cartilage degeneration of the femoral condyle and tibial plateau was more severe at the lateral side than at the medial side. The degeneration of the cartilage progressed, whereas the degeneration of the synovia lessened with time. In the biochemical analyses of the digested cartilage in vitro, the proportion of water increased, and the dry weight of the collected cartilage, the amounts of hydroxyproline and sulfated glycosaminoglycan decreased with the digesting time.

CONCLUSION

These results suggest that collagenase injected intra-articularly digests cartilage directly and stimulates an inflammatory reaction of joint tissues at an early stage, and then cartilage degeneration proceeds. This experimental osteoarthritis is a useful animal model, since the cartilage degeneration is similar to the corresponding lesion in human osteoarthritis, and it is conveniently induced by a dose of collagenase lower than that of papain used, within a short period.

[The efficacy of using an Iruxol ointment in treating alveolitis]

Analysis of the results of treatment of 150 alveolitis patients has demonstrated the advantages of the method using iruxol ointment (75 patients) as against the routine one (reference group--75 patients). Therapy with this ointment resulted in complete arrest of the painful syndrome in 2.11 +/- 0.15 days, whereas in the reference group it was attained in but 5.40 +/- 0.18 days. The temperature reaction normalized in all the test group patients within 3 days, whereas in the reference group such results were attained in only 74.36% of the patients. Inflammatory symptoms in the paramaxillary soft tissues were liquidated with iruxol ointment in 5.96 +/- 0.14 days, whereas in routine therapy this was observed in only 7.46 +/- 0.18 days.

[Comparison of bidirectional collagenase perfusion with one way perfusion in the isolation of periportal or perivenous hepatocytes in rats]

To selectively isolate hepatocytes from the periportal (PP) and perivenous (PV) regions of rat liver acinus, we compared two different perfusion methods with collagenase: the bidirectional perfusion method (2-P) and the one way perfusion method (1-P). We determined the optimal conditions for each method on the basis of the zonal selectivity of isolated hepatocytes with a hematoxylin-eosin stained liver specimen. By both methods, hepatocytes were selectively isolated from the PP and PV regions. Comparing cell yield and cell viability after the two perfusion methods, 1-P was found to be better than 2-P. Density gradient centrifugation with Percoll was found to be an effective procedure for removing the damaged hepatocytes. We concluded that 1-P could isolate viable PP and PV hepatocytes with a normal glucagon-cyclic AMP response and ultrafine structure in high yield from rat liver.

TIMP-2 reduces proteolytic opening of blood-brain barrier by type IV collagenase

Intracerebral hemorrhage occurs in tumors, stroke and head trauma. Proteolysis of the extracellular matrix around cerebral capillaries by naturally occurring mammalian 72-kDa type IV collagenase may initiate this pathologic event. To investigate this hypothesis adult rats underwent intracerebral injection of type IV collagenase purified from human melanoma cells. Histologically, at 4 h there was perivascular cellular infiltration with hemorrhage, and by 24 h there was infarction with necrosis, edema and hemorrhage. Ultrastructurally, the basal lamina of endothelial cells was disrupted at 2 h. Brain uptake of [14C]dextran and [3H]sucrose increased after intracerebral injection of type IV collagenase compared to controls (P less than 0.0001). Tissue inhibitor of metalloproteinase-2 (TIMP-2) reduced the tracer uptake (P less than 0.02). Metalloproteinase inhibitors reduce extracellular matrix proteolysis and protect the blood-brain barrier.

[Chemonucleolysis using chymopapain and collagenase. 3-year results of a prospective randomized study]

100 patients were prospectively and randomized treated by chemonucleolysis either by collagenase (n = 50/400 ABC-U/disc) or by chymopapain (n = 50/4000 I.U.). The success rate after 1 year was 70% for collagenase and 78% after chymopapain, and 72%/80% after 3 years, respectively. Successful results increased significantly during the first year after treatment and remained stable after that point. After chymopapain, one case of successfully treated anaphylaxis (2%) occurred. After collagenase, 3 cases of secondary sequestrations were observed in cases with primarily closed discograms with intact dorsal longitudinal ligament.

Rapid induction of early osteoarthritic-like lesions in the rabbit knee by continuous intra-articular infusion of mammalian collagenase or interleukin-1

Aminophenyl mercuric acetate (APMA)-activated collagenase (C) (60 U/ml) obtained from in vitro cultures of human skin fibroblasts or recombinant interleukin-1 beta (IL-1 beta) (200 U/ml) was infused continuously for 7 days into the rabbit knee synovial space by means of an implanted Alzet osmotic pump. In stability studies in vitro, activated C or IL-1 incubated for 7 days at 37 degrees C, showed no significant loss of biological activity. Alterations in knee cartilage morphology and proteoglycan (PG) content were determined histologically, and the incidence of cartilage damage calculated. C or IL-1 vehicles infused for 7 days, caused no damage. Incidences of damage for C or IL-1 (n = 8-9), respectively, were as follows: loss PG: 88% and 100%; chondrocyte disorganization and loss, 50% and 78%, fissures and or fraying, 25% and 78%; and convergence of inflammatory cells, 25% and 66%. These results confirm the important role of C and IL-1 in cartilage damage.

[Wound healing with Iruxol. Results of a multicenter study]

In a multicenter study, a total of 100 wounds in 94 patients were treated with Iruxol ointment over a period of 3 weeks. The ointment was applied to the wound surface once or twice daily. The target parameters, wound debridement, granulation and epithelialization were assessed qualitatively. The area of the ulcers was determined quantitatively and approximately. In wounds considered to be uncomplicated, the results were clearly better than in so-called problem wounds, in which the blood supply obviously played a considerable role in the healing process. Postoperatively the wounds shrank by only two-thirds, while the area of problem wounds, i.e. "skin ulcerations", was reduced by only about 46%. On the whole Iruxol ointment was well tolerated. However, in two out of 32 patients with leg ulcers treatment had to be terminated due to contact dermatitis.

In vivo and in vitro collagenolytic activity of Acanthamoeba castellanii

Axenic cultures of Acanthamoeba castellanii contained a collagenolytic enzyme that digested collagen shields and purified collagen in vitro. Specificity of biologic activity was determined by the addition of selected enzyme inhibitors to the assays and revealed that the parasite-conditioned medium contained both collagenase and lower concentrations of other proteolytic enzymes. However, most of the collagenolytic and pathogenic activity was directly attributable to specific collagenase. Intrastromal injection of sterile, Acanthamoeba-conditioned culture medium into naive Lewis rats produced corneal lesions clinically similar to and closely resembling those found in biopsy specimens of human patients diagnosed with acanthamoebic keratitis. Histopathologic analysis revealed moderate-to-severe neutrophil infiltration, disruption of stromal lamellae, and edema. Identical pathologic sequelae were produced by intrastromal injection of purified collagenase (25 units/ml). The pathogenicity of the soluble parasite-derived product was removed by passage over affinity columns armed with antibody specific for collagenase. These results indicated that soluble parasite-derived factors were capable of producing lesions characteristic of acanthamoebic keratitis and that the pathogenicity of these factors was either directly or indirectly attributable to specific collagenase activity.