Inhaled Sodium Pyruvate for the Treatment of Cystic Fibrosis.

Cystic fibrosis (CF) is the most common, lethal inherited disease of Caucasians.
Approximately 30,000 people in the United States and 70,000 worldwide have a diagnosis of
CF. It is caused by mutations in the cystic fibrosis transmembrane regulator (CFTR) gene.
The clinical manifestations characteristic of CF include progressive bronchiectatic lung
disease with thick mucus production and colonization by Pseudomonas aeruginosa. The CFTR
gene mutation results in altered cell transport properties, which affect both chloride and
glutathione secretion. Chronic inflammation, associated with activated neutrophils and
macrophages, is a common feature of CF. Highly reactive toxic oxygen (superoxide anion, free
hydroxyl radical, hydrogen peroxide) and nitrogen species (nitric oxide, peroxynitrites) are
abundant in the chronic inflammatory response in CF and appear to play a prominent role in
the pathogenesis of this disease. These reactive oxygen and nitrogen species have been shown
to be directly toxic to various mammalian tissues, including lung, via DNA damage and cell
membrane lipid peroxidation. In addition, elevated levels of hydrogen peroxide and nitric
oxide have been demonstrated in sputum and bronchoalveolar lavage fluid of patients with CF,
asthma, and chronic obstructive pulmonary disease. Clearly reactive oxygen and nitrogen
species are implicated in the pathogenesis of a variety of lung diseases including CF.

Sodium pyruvate is an antagonist of both reactive oxygen and nitrogen species. It also has
the potential to increase intracellular levels of thiol compounds, major sources of
intracellular anti-oxidants. Sodium pyruvate has been shown to act as an anti-inflammatory
agent that can reduce the number of infiltrating neutrophils and levels of oxygen radicals
at wound sites, thereby limiting the production of pro-inflammatory mediators. Thus, it is
hypothesized that the inhalation of sodium pyruvate will reduce lung damage in patients with
CF by its ability to reduce levels of toxic reactive oxygen and nitrogen species associated
with the chronic inflammatory component of the disease.

The trial is a Phase I Safety Study that will be conducted in three Stages. The study is
designed to assess the safety of administering sodium pyruvate inhalation therapy to CF
subjects once a day for one day, then twice a day for one day, and finally, twice a day for
four weeks. All testing, including the screening visit and Stage 1, and Stages 2 and 3, will
be conducted at the University of Minnesota (UMN) General Clinical Research Center GCRC).

Stage 1 - Single dose inhalation - 24 hours (n=15) Participants with CF will receive a
single dose of sodium pyruvate (5 ml in physiological saline) via a Pari-Jet hand-held
nebulizer (Pari LC Plus® nebulizer system) , and will be followed at UMN GRC for four hours
with a follow up telephone interview at 24 hours. Three concentrations (0.5 mM, 1.5 mM, and
5.0 mM) of sodium pyruvate solution will be studied. Five subjects will receive the lowest
concentration of sodium pyruvate solution; then another five subjects will receive the
middle dose of sodium pyruvate solution; and finally a third group of five subjects will
receive the highest dose of sodium pyruvate solution.

Patients enrolled in Stage 1 will have one 6-hour visit at UMN GCRC. Following
administration of a single 5-mL dose of either 0.5 mM, 1.5 mM, or 5.0 mM sodium pyruvate in
0.9% saline solution, the following tests will be performed:

Post Inhalation of Study Drug

Spirometry:

- Post inhalation 0.5 Hr

- Post inhalation 1 Hr

- Post inhalation 2 Hr

- Post inhalation 4 Hr

Sputum Induction:

- Post inhalation 1 Hr

SaO2:

- Post inhalation 0.5 Hr

- Post inhalation 1 Hr

- Post inhalation 2 Hr

- Post inhalation 4 Hr

End of Visit.

Blood and Urine Analysis

- Post inhalation 4 Hr

Electrocardiogram

- Post inhalation 4 Hr

Vital Signs

- Post inhalation 4 Hr

The parameters for safety monitoring will include spirometry, vital signs, ECG, SaO2, and
routine blood and urine analysis, which will be conducted pre- and post- inhalation of
sodium pyruvate. Follow up telephone interviews will also be conducted for each stage.

With regard to efficacy, spirometry, and induced sputum samples will be monitored pre- and
post- inhalation of sodium pyruvate. Induced sputum samples will be evaluated for cellular
content (total WBC and differential) and the fluid content assessed for total protein, total
DNA, elastase, glutathione (GSH and GSSG), H2O2 and inflammatory cytokines (IL-1, IL-6, and
IL-8, TNF-alpha).