Patent Grant
10335558
The present invention concerns methods, compositions and apparatus for administering active agents to the lungs of a subject.
Aerosolized medicines are frequently used to treat individuals suffering from respiratory disease. The inhalation of aerosols is an effective approach to deliver therapeutic concentrations of medicines directly to the site of disease (e.g. the airways). Nebulizer devices, such as jet nebulizers, are commonly used to generate respirable aerosol particles (e.g. particles that are <10 mm in diameter) from liquid medication. Examples of Jet Nebulizers include the Pari LC Star and Pari LC Plus which often require 10-20 minutes to deliver a single dose of medication. For subjects with chronic pulmonary disease whom may require multiple daily aerosol treatments, the time burden associated with drug delivery via Jet nebulizers can become substantial (e.g. more than 2 or more hours per day dedicated to aerosol therapy). As an example of such therapy, Elkins et al., N Engl J. Med, 354(3):229-40(2006) showed that delivering 4 ml of 7% hypertonic saline twice a day via Pari LC Plus jet nebulizer to CF patients during their waking hours leads to a decreased rate of pulmonary exacerbations and modest improvement in lung function. At the same time, this treatment adds 30+ minutes spent on treatment per day. Similarly, Ramsey et al., N Engl J Med, 340(1):23-30 (1999) demonstrated that administering 5 ml of sterile tobramycin antibiotic solution via Pari LC PLUS jet nebulizer to CF patients during their waking hours leads to a decreased rate of pulmonary exacerbations and an improvement in lung function. At the same time, this treatment adds 40+ minutes spent on treatment per day.
One strategy to improve the time burden associated with aerosol therapy is via the delivery of medicines by newer, more efficient nebulizer devices. The current state-of-the-art in pulmonary medicine is the delivery of aerosolized medicines more rapidly and efficiently to the airways. The primary goal of these high-efficiency nebulizer systems is to reduce the drug delivery time and minimize the time burden on the patient. Examples of these devices include vibrating mesh nebulizers such as the PARI EFLOW™ nebulizer and the AEROGEN PRONEB™ nebulizer (operating parameters shown in Table 1). Vibrating mesh nebulizers are capable of delivering a dose of an inhaled agent comparable to a jet nebulizer in approximately half the time. The time saving stemming from the more efficient vibrating nebulizers is important for respiratory diseases where patients are exposed to a large treatment burden. Another example of such devices are metered dose inhalers and dry powder inhalers. While these devices have some limitations related to maximum deliverable dose and tolerability compared to nebulizers, they offer additional convenience to the patients via further reduced drug delivery times.
However, time saving due to the use of high-efficiency nebulizers may not be sufficient for respiratory diseases such as cystic fibrosis where patients are often required to take combination of several inhaled treatments, oral treatments, physiotherapy and exercise. It is not uncommon for CF patients to spend 2-3 hours per day on treatments that are recommended by treatment guidelines (Flume et al., Am J Respir Crit Care Med. 2007 Nov. 15; 176(10):957-69; Sawicki et al., J Cyst Fibros. 2009 March; 8(2):91-6). The treatment burden due to this extensive treatment regimen is so large that adding another inhaled treatment during patient's waking hours often leads to displacement of the other treatments or decreased compliance. For this reason, administration of inhaled treatments during patients sleeping hours may be beneficial as it does not contribute to the treatment burden experienced by these patients during the waking hours. Similarly, such overnight aerosol delivery may result in improved compliance associated with improved efficacy of both the overnight treatment and the daily treatments, compared to adding another inhaled treatment to existing treatment regimen.
The most commonly used nebulizer devices (including jet and vibrating mesh nebulizers) deliver aerosolized medicines to patients as concentrated “boluses” over a short time period (e.g. 5 to 20 minutes per treatment). These boluses lead to a rapid increase of the active therapeutic agent in lumen of the lung and the surrounding tissues, often above the necessary therapeutic concentration for a short period of time. Similarly, these boluses lead to systemic exposure to such agents. These peak local and systemic concentrations following bolus administrations of inhaled aerosols can lead to undesirable safety and tolerability profiles which may prevent adoption of the therapy into the standard of care. For example, chronic inhaled corticosteroids have been shown to have disease-modifying impact on the rate of lung function decline in CF (Ren et al., J Pediatr., 153(6):746-5I (2008), de Boeck et al., Eur Respir J., 37(5):1091-5 (2011)) but are accompanied by patients' decreased linear growth, and increased insulin/oral hypoglycemic use due to the systemic exposure. As such, inhaled corticosteroids are not recommended for general treatment of CF lung disease (Flume et al., Am J Respir Crit Care Med. 2007 Nov. 15; 176(10):957-69).
The most commonly used nebulizer devices (including jet and vibrating mesh nebulizers) deliver aerosolized medicines to patients as concentrated “boluses” over a short time period (e.g. 5 to 20 minutes per treatment). However, for many medications “bolus” aerosol delivery is not optimal.
The present invention can address previous shortcomings in the art by providing methods, compositions and apparatus for administering active agents to the lungs of a subject.
A first aspect of the invention is a method of treating at least one lung/the lungs of a subject in need thereof, comprising: administering an active agent to the at least one lung/the lungs of a subject (for example, by sustained administering or infusion administering).
In some embodiments, the administering is carried out by aerosol administration.
In some embodiments, the administering is carried out by inhalation administration.
In some embodiments, the administering step is carried out by a nasal cannula, face mask, or positive airway pressure mask (e.g., a continuous positive airway pressure (CPAP) mask or a bilevel positive airway pressure (biPAP) mask).
In some embodiments, the administering is carried out by administration of the active agent to airway surfaces.
In some embodiments, the administering is effective to enhance mucus clearance from at least one lung of the subject.
One non-limiting example of the invention is a method of enhancing mucus clearance from the lungs of a subject in need thereof, comprising: administering an osmolyte to airway surfaces of the lungs of said subject in an amount (i) sufficient to hydrate said lung airway mucus secretions and (ii) insufficient to substantially dehydrate lung airway epithelia] cells therebeneath, said administering step being carried out and for a time sufficient to enhance mucus clearance from the lungs of said subject. In some embodiments, the administering step is carried out by administering said subject an aerosol comprising said osmolyte such as saline or hypertonic saline.
A further aspect of the invention is an active agent as described herein in a pharmaceutically acceptable carrier (e.g., a liquid carrier, a dry powder carrier) for use in carrying out a method as described herein.
A further aspect of the invention is an aerosol generator or nebulizer (e.g., as described herein) for use in carrying out a method as described herein.
The foregoing is illustrative of the present invention, and is not to be construed as limiting thereof.
The present invention is explained in greater detail in the drawings set forth herein and the specification set forth below. The disclosures of all US Patent references cited herein are incorporated by reference herein in their entirety as if fully set forth.
The accompanying drawings, which are incorporated in and constitute a part of the specification, illustrate embodiments of the invention and, together with the description, serve to explain principles of the invention.
Counter to the current trend to maximize the rate of aerosol drug delivery and reduce the time for aerosolizing medications, the present method relates to delivering aerosolized therapeutic agents as a slow aerosol “infusion”, or at a lower rate over an extended period of time, rather than as a short aerosol “bolus” delivery. The inventive method can provide a greater benefit than short bolus delivery. The deposition of aerosolized therapeutic agents at low rates over an extended period of time can be performed with a nebulizer system designed for delivery of the lower flow rates over a relatively long time period (e.g., 3 hours to 8 hours or overnight).
The present invention relates to a method of delivering an aerosolized active compound at a rate that is significantly slower than currently used and for a duration that is longer than currently used. This approach is counter to the current “faster is better” approach. However, the examples described herein will show that a slower aerosol delivery rate of active compound provides a three-fold benefit. First, the examples show that delivery of aerosolized mediations over an extended period of time are more therapeutically beneficial than a fast delivery rate of active compound for a shorter period of time (e.g., delivery by a conventional jet or vibrating mesh nebulizer). Second, the examples provided herein will show that the method of delivering therapeutic agents as aerosol “infusions” rather than “boluses” will minimize or eliminate undesired off-target effects. Importantly, these off-target effects (e.g. ciliastasis, broncho-constriction, pro-inflammatory agent secretion, high systemic drug exposure) can be eliminated by slow delivery/infusion apparatus. Third, the examples provided herein will demonstrate that the methods of this invention allow therapeutic use agents in formulations and strengths that were previously not usable with existing routes of aerosol delivery. Finally, delivery of aerosols at low flow rates over an extended period is compatible with sleep. As such, the delivery of aerosol “infusions” will reduce the amount of wake time (e.g. treatment or time burden) needed for aerosol therapies if administered overnight.
According to some embodiments, a method of the present invention comprises treating at least one lung/the lungs of a subject in need thereof, comprising: administering an active agent to the at least one lung/the lungs of a subject (for example, by sustained administering or infusion administering).
A further method of the present invention comprises a method of enhancing mucus clearance from a lung of a subject in need thereof, comprising: administering an osmolyte to airway surfaces of said lung of said subject in an amount and at a rate (i) sufficient to hydrate said lung airway mucus secretions and (ii) insufficient to substantially dehydrate lung airway epithelial cells therebeneath, said administering step being carried out and for a time sufficient to enhance mucus clearance from the lungs of said subject.
In some embodiments, a method of enhancing hydration of a surface of a lung of a subject in need thereof is provided, the method comprising: administering an osmolyte to airway surfaces of said lung of said subject in an amount and at a rate (i) sufficient to hydrate said surface and (ii) insufficient to substantially dehydrate lung airway epithelial cells therebeneath, said administering step being carried out and for a time sufficient to enhance hydration of said surface of said lung of said subject.
1. Definitions
Subjects to be treated by the methods of the present invention include both human subjects and animal subjects (e.g., dog, cat, monkey, chimpanzee) for veterinary purposes. The subjects may be male or female and may be any suitable age, e.g., neonatal, infant, juvenile, adolescent, adult, or geriatric. In some embodiments, the subjects are preferably mammalian.
“Osmolyte” active compounds as used herein refers to molecules or compounds that are osmotically active (i.e., are “osmolytes”). “Osmotically active” compounds are known (see, e.g., R. Boucher et al., Multiple Nebulizer System, US Patent Application 20100074881 (published Mar. 25, 2010) and may be membrane-impermeable (i.e., essentially non-absorbable) on the airway or pulmonary epithelial surface.
“Airway surface” and “pulmonary surface,” as used herein, include pulmonary airway surfaces such as the bronchi and bronchioles, alveolar surfaces, and nasal and sinus surfaces.
“Saline” as used herein refers to a solution comprised of, consisting of, or consisting essentially of sodium chloride in water. Saline can be hypertonic, isotonic, or hypotonic. In some embodiments, saline can comprise sodium chloride in an amount of from about 0.1% to about 40% by weight, or any range therein, such as, but not limited to, about 0.1% to about 10%, about 0.5% to about 15%, about 1% to about 20%, about 5% to about 25%, about 10% to about 40%, or about 15% to about 35% by weight. In certain embodiments, sodium chloride is included in a solution in an amount of about 0.1%, 0.2%, 0.3%, 0.4%, 0.5%, 0.6%, 0.7%, 0.8%, 0.9%, 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, 11%, 12%, 13%, 14%, 15%, 16%, 17%, 18%, 19%, 20%, 21%, 22%, 23%, 24%, 25%, 26%, 27%, 28%, 29%, 30%, 31%, 32%, 33%, 34%, 35%, 36%, 37%, 38%, 39%, 40% by weight, or any range therein.
“Hypertonic saline” as used herein refers to a solution comprised of consisting of, or consisting essentially of greater than 0.9 wt % sodium chloride in water. In general, the sodium chloride is included in the solution in an amount of from about 0.9% to about 40% by weight, or any range therein, such as, but not limited to, about 1% to about 15%, about 5% to about 20%, about 5% to about 25%, about 10% to about 40%, or about 15% to about 35% by weight. In certain embodiments, sodium chloride is included in the solution in an amount of about 0.9%, 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, 11%, 12%, 13%, 14%, 15%, 16%, 17%, 18%, 19%, 20%, 21%, 22%, 23%, 24%, 25%, 26%, 27%, 28%, 29%, 30%, 31%, 32%, 33%, 34%, 35%, 36%, 37%, 38%, 39%, 40% by weight, or any range therein.
“Hypotonic saline” as used herein refers to a solution comprised of, consisting of, or consisting essentially of less than 0.9 wt % sodium chloride in water. In some embodiments, sodium chloride is included in the solution in an amount of about 0.9%, 0.8%, 0.7%, 0.6%, 0.5%, 0.4%, 0.3%, 0.2%, 0.1% by weight, or any range therein.
“Isotonic saline” as used herein refers to a solution comprised of, consisting of or consisting essentially of 0.9 wt % sodium chloride in water.
According to some embodiments, saline (e.g., hypertonic saline) can comprise an excipient. An excipient can be a pharmaceutically acceptable excipient. “Pharmaceutically acceptable” as used herein means that the compound or composition is suitable for administration to a subject to achieve the treatments described herein, without unduly deleterious side effects in light of the severity of the disease and necessity of the treatment. Exemplary excipients include, but are not limited to, a buffer and/or a buffering agent (e.g., an anion, a cation, an organic compound, a salt, etc.). Exemplary buffers include, but not limited to, carbonic acid/carbonate/bicarbonate-based buffers, disodium hydrogen phthalate/sodium dihydrogen orthophosphate-based buffers, tris (hydroxylmethyl) aminomethane/hydrochloric acid-based buffers, barbitone sodium/hydrochloric acid-based buffers, and any combination thereof. Exemplary buffering agents include, but are not limited to, carbonic acid, carbonate, bicarbonate, disodium hydrogen phthalate, sodium dihydrogen orthophosphate, tris (hydroxylmethyl) aminomethane, hydrochloric acid, barbitone sodium, dissolved CO2 (e.g., CO2 formulated at a pH of greater than 6.6), and any combination thereof. In certain embodiments, saline comprises a bicarbonate buffer excipient, such as a bicarbonate anion (HCO3−). In some embodiments, hypertonic saline comprises sodium bicarbonate, sodium carbonate, carbonic acid, and/or dissolved CO2 formulated at a pH of greater than 6.5. Additional ingredients can be included as desired depending upon the particular condition being treated, as discussed further below.
“Substantially dehydrate” as used herein with respect to airway epithelial cells refers to cellular dehydration sufficient to result in: (a) a loss of at least 5, 10, 15 or 20 percent of cell volume; (b) inhibition of the beat of cilia projecting from those cells by at least 20 or 40 percent; (c) a decrease in the ability of the dehydrated cells to donate water to, and thereby hydrate, their overlying airway surface liquid/mucus layer; and/or (d) produce pro-inflammatory states such as increased 1 L-8 secretion.
“Hydrate,” “hydration,” and grammatical variants thereof, as used herein, refers to bringing, placing, drawing and/or the like water onto an airway surface of a lung. In certain embodiments, hydration is enhanced by a method of the present invention. Hydration can be enhanced by (a) an increase in the cell volume of airway epithelial cells of at least about 1%, 5%, 10%, 15%, 20%, or more, (b) an increase in the beat of cilia projecting from airway epithelial cells by at least about 1%, 5%, 10%, 15%, 20%, or more, and/or (c) increasing the ability of the airway epithelial cells to donate water to, and thereby hydrate, their overlying airway surface liquid/mucus layer.
2. Active Agents
Embodiments of the invention contemplate a variety of medicaments that can be delivered as aerosols to the lungs including agents that (i) enhance or facilitate mucus clearance; (ii) have antimicrobial activity; (iii) have anti-inflammatory activity; (iv) or have bronchodilator activity. For agents with undesirable safety or tolerability properties due to high local or systemic concentration following bolus administration via nebulizer, administration by inhalation over the course of 8 to 24 hours or overnight to a patient via nasal cannula may improve the therapeutic index for such agents.
Exemplary Agents that Facilitate Mucus Clearance
Adequate mucus clearance (MC) is a crucial factor in the maintenance of normal airway health, is dependent on mucus rheology, airway hydration, and ciliary beat frequency (CBF). Abnormal mucus clearance is an important contributor to the phenotype of patients with chronic bronchitis due to environmental or genetic causes. Normal mucus clearance requires 1) adequate hydration of the airway surface and 2) an absence of strong adhesive interaction between the mucus and cell surface. Hydration is formally defined by the concentrations of mucins in the periciliary and mucus layers. Ion transport properties regulate the amount of salt and water (i.e. the solvent) and goblet cells and glands control the concentration of mucins on the airway surface. Both cystic fibrosis (CF) patients and subjects with chronic bronchitis associated with cigarette smoke exposure, i.e., COPD, exhibit increases in mucus concentration as quantified by % solids, as a result of reduced airway hydration and mucin hypersecretion, consequent to goblet cell and glandular hyperplasia. Both as a function of disease severity, and in acute exacerbations, raised mucin/mucus concentrations produce adherent mucus that sticks to epithelial cells, initiates inflammatory responses and airway wall injury, and serves as a growth medium for pathogenic microorganisms (Boucher, R. C. New concepts of the pathogenesis of cystic fibrosis lung disease. European Respiratory Journal, 2004, 23(1):146-158 and Matsui, H., Grubb, B. R., Tarran, A., Randell, S. H., Gatzy, J. T., Davis, C. W., and Boucher, R. C. 1998. Evidence for periciliary liquid layer depletion, not abnormal ion composition, in the pathogenesis of cystic fibrosis airways disease. Cell 95:1005-1015 and Matsui, H., Wagner, V. E., Hill, D. B., Schwab, U. E., Rogers, T. D., Button, B., Taylor, R. M., 2nd, Superfine, R., Rubinstein, M., Iglewski, B. H., et al. 2006. A physical linkage between cystic fibrosis airway surface dehydration and Pseudomonas aeruginosa biofilms. Proc Natl Acad Sci USA 103:18131-18136).
A. Osmolytes.
A simple means to restore hydration to CF airway surfaces is to inhale hypertonic osmolyte solutions (most frequently 7% hypertonic saline (HS)), which draws water onto the airway surface. Rehydration of the lubricant periciliary layer (PCL) of the airway surface facilitates mucus clearance (MC) and, therefore, the removal of inhaled infectious agents.
Inhaled HS is a unique therapeutic agent as it is used by ˜60% of CF patients nationwide, but is not FDA approved for daily use for pulmonary disease. As such, HS has not undergone the rigorous clinical testing to identify the dose and dosing frequency that are most efficacious and well tolerated. Instead, the HS regime has been optimized in practice by patients and physicians. Most commonly, HS is administered as two 15 minute inhalation treatments of 4 mL of 7% hypertonic saline per treatment. The tonicity of HS used by patients (7% NaCl) has been identified as a maximum concentration that is generally tolerated (i.e. minimal irritation or broncho constriction). Treatments are generally administered by a jet nebulizer (i.e. PARI LC-STAR™ or PLUS™ nebulizers), which are used by patients for other nebulized medicines and are thus available and familiar. Twice daily treatments with HS are common as the time burden for two HS treatments (15 minutes per treatment, plus nebulizer cleaning/sterilization), superimposed on the existing 2-3 hours per day spent on other therapies, is substantial.
aDonaldson et al., N Engl J Med. 2006 Jan. 19; 354(3): 241-50.
bElkins et al., N Engl J Med, 354(3): 229-40(2006).
cThe deposition fraction was taken from the published work of Kellerman et al., Pulm Pharmacol Ther. 2008 August; 21(4): 600-7.
dThe deposition fraction was taken from the published work of Byrne et al., Arch Dis Child, 2003 August; 88(8): 715-8.
eThe aerosol particle size produced by the Pari LC Star and Plus have been reported variable in the literature and are cited as the range reported.
fThe estimated volume delivered is an over-estimation as the nebulizer will have fluid remaining at the end of nebulization.
gThe estimated mass of NaCl delivered is also an over-estimation as some fluid will remain in the nebulizer.
hThe value presented is the FEV1 after 48 weeks of delivery. It is the only value provided but from the FEV1 graph and as stated in the text, the values did not change appreciably from 2 weeks to the end of the study.
Recently, two studies have described (1) the short term (two weeks) beneficial effects of inhaled hypertonic saline (HS) four times daily on pulmonary function, MCC, and quality of life (Donaldson et al., N Engl J Med. 2006 Jan. 19; 354(3):241-50) and (2) the long term (one year) benefits of inhaled HS twice daily on lung function and reduction in pulmonary exacerbations (Elkins et al., N Engl J Med, 354(3):229-40(2006)). A comparison of the Donaldson versus Elkins suggests that the “more salt” delivered, the greater the benefit in lung function. As shown in Table 1, subjects in the Donaldson study exhibited a mean improvement in lung function (147 ml improvement in FEV1) with four times daily administration (3.6 ml of 7% HS predicted pulmonary deposition) that was ˜2-fold greater than achieved in the Elkins study (˜68 ml improvement in FEV1) with B.I.D. dosing (1.58 ml of 7% HS predicted pulmonary deposition). However, four times daily dosing in the Donaldson regimen is not feasible in the current treatment burden environment. Thus, there is reason to believe that the therapeutic benefit of HS has not been maximized. For example, while the Elkins study observed a significant decrease in pulmonary exacerbations for subjects on HS versus placebo, 59% of patients on HS still experienced an exacerbation, suggesting that improvements in adverse event prevention are also needed.
Administration of up to 12% HS has been evaluated previously (Robinson et al., Thorax, 1997 October; 52(10):900-3). However, concentrations higher than 7% HS are not well tolerated with established methods of aerosol delivery. The currently used oral delivery of 7% HS aerosol by traditional jet nebulizers such as Pari LC Star is not tolerated by all CF patients with varying degrees of airway obstruction and reactive airway disease. Lack of tolerability of HS therapy can be related to high rates of emission of NaCl mass from the nebulizer mouthpiece which leads to high exposure of oropharyngeal surfaces to HS. Similarly, the high rates of NaCl mass deposition in the lung lead to adverse events such as chest tightness, cough and acute drops in lung function (Elkins et al.). In COPD, high rates of NaCl delivery initiate histamine release, which contributes to airway spasm (Taube et al., Am J Respir Crit Care Med. 2001 Nov. 15; 164(10 Pt 1):1810-5). On a cellular level, administration of high rate of NaCl mass to the airway epithelium substantially dehydrates the airway epithelial cells which leads to cell shrinkage, inhibition of ciliary beat frequency and release of inflammatory stimuli leading to pulmonary inflammation (Zhou et al., Journal of Cystic Fibrosis Vol. 10 Supplement 1, Page S18). Based on the measured nebulizer efficiency for Pari LC Star by Kellerman et al., the rate of emission of NaCl mass from the nebulizer and the rate of deposition of NaCl mass in the lung was determined for 7% HS administration administered by this jet nebulizer (Table 2).
With the increasing availability of high efficiency vibrating mesh nebulizers such as Pari eFlow, inhaled treatments for CF lung disease originally administered via jet nebulizers are now administered by these faster nebulizers. Based on the published efficiencies for Pari eFlow (Coates et al., J Aerosol Med Pulm Drug Deliv. 2011 June; 24(3):157-63), the rates of emission and pulmonary deposition of NaCl mass per unit of time are even higher for these high efficiency vibrating mesh nebulizers than for the jet nebulizers (Table 2).
aVolume emitted from the nasal cannula
bRate based on residual volume of 1.7 ml
Additionally, using the methods of this invention enables administration of substantially larger mass of NaCl at lower rates into the lung of the patients, if desirable, over 6 to 8 hours while keeping the rates of deposition of NaCl mass in the lung below those for traditional jet or vibrating mesh nebulizers. This is beneficial based on the observation that ˜250 mg of NaCl mass/day deposited in the lung of CF patients (Donaldson et al.) resulted in better efficacy than ˜100 mg of NaCl mass/day deposited in the lung of CF patients (Elkins et al.) (Table 3).
aVolume emitted from the nasal cannula
bRate based on residual volume of 1.7 ml
Lastly, while administering aerosols through a nasal cannula to a subject, a certain amount of the aerosol deposits in the nasal passages. Administration of high concentrations of HS at low rates made possible by the methods of this invention are beneficial as they reduce the volume of aerosol deposited in the nasal passages of a patient.
The low rates for deposition of NaCl mass per unit of time in the lung achieved by the methods of this invention, combined with the higher mass of NaCl that can be deposited in the lung over 6 to 8 hours, lead to improved safety, tolerability and efficacy of HS. Furthermore, due to the low rates of NaCl mass emission from the nebulizer and the low rates of NaCl mass deposition in the lung, HS>7% can be administered by the methods of this invention with favorable safety, tolerability and efficacy profiles previously not achievable by traditional nebulizers.
The rate of the deposition of NaCl onto an airway surface reflects the product of the concentration of NaCl in the aerosol droplet and the droplet density. Both variables can be manipulated to achieve the desired “low” rates of NaCl deposition. For example, one way to achieve slower rates of HS deposition over extended periods of time is by using higher than 7% HS, such as 14% HS or 21% HS, emitted from the device at proportionally slower rates and consequently deposited in the airways at equal designated rates. Delivery of concentrations of HS formulation higher than 7 to 10% HS formulation is not possible via traditional methods of inhaled HS delivery, e.g. via Pan LC Star or eFlow, due to large number of adverse events experienced by the patients.
In practical terms, depending on the measured aerosol output from the CSD-1 device and the measured efficiency of the pulmonary deposition, the concentration of the HS drug product can be adjusted to produce desirable rates of NaCl mass deposition on the surface of the airways. Given the aerosol output characteristics of Parion CSD-1 device and likely in vivo deposition fractions, it may be desirable to nebulize 7, 14 and 21% HS to achieve a deposition rate of 0.1 to 4 mg/min. Note, given the low rates of aerosol presentation to the subject, the 0.5 mg/min deposition rate is still far less than achieved during nebulization of 7% HS in a Pan LC nebulizer—i.e. ˜3.3 mg/min—and mimics that of normal saline delivered by Pan LC Star (˜0.4 mg/min).
One skilled in the art will understand that the final rate of deposition of active pharmaceutical ingredient on the airway surface is the product of 1) the measured deposition efficiency for a given device in a given patient population (deposited dose/emitted dose from device); 2) the concentration of the active pharmaceutical ingredient the drug product (for example, 70 mg/ml of NaCl in 7% HS) and 3) the rate of emission of aerosol from the device (ml/min emitted from the device). The device deposition efficiencies can be measured via imaging of radiolabeled aerosols deposited in the lung of human subjects (Hyder et al., J Aersol Med 1985; 17:811-825). The output of an aerosol from an aerosol delivery device can be measured via direct capture of the aerosol on a filter. A variety of pharmaceutical formulation sciences and analytical methods can be used to formulate drug product and verify the concentration of the API.
One skilled in the art will understand that the osmotic driving force provided by the deposition of an osmolyte on the airway surface is dependent upon the molecular weight (MW) and number of osmoses per molecule (O/M) for any given osmolyte. Thus the low rates for deposition of mass per unit of time in the lung, provided herein for NaCl, can be easily transposed for other osmotic agents. For example, 6.25 mg of mannitol deposited per minute on the airways surface will create approximately the same osmotic driving force as 1 mg of NaCl deposited per minute as calculated below:
Active compounds of the present invention may be ionic osmolytes (i.e., salts), or may be non-ionic osmolytes (i.e., sugars, sugar alcohols, and organic osmolytes). It is specifically intended that both racemic forms of the active compounds that are racemic in nature are included in the group of active compounds that are useful in the present invention. It is to be noted that all racemates, enantiomers, diastereomers, tautomers, polymorphs and pseudopolymorphs and racemic mixtures of the osmotically active compounds are embraced by the present invention.
Active osmolytes useful in the present invention that are ionic osmolytes include any salt of a pharmaceutically acceptable anion and a pharmaceutically acceptable cation. Preferably, either (or both) of the anion and cation are non-absorbable (i.e., osmotically active and not subject to rapid active transport) in relation to the airway surfaces to which they are administered. Such compounds include but are not limited to anions and cations that are contained in FDA approved commercially marketed salts, see, e.g., Remington: The Science and Practice of Pharmacy, Vol. II, pg. 1457 (19.sup.th Ed. 1995), incorporated herein by reference, and can be used in any combination including their conventional combinations.
Pharmaceutically acceptable osmotically active anions that can be used to carry out the present invention include, but are not limited to, acetate, benzenesulfonate, benzoate, bicarbonate, bitartrate, bromide, calcium edetate, camsylate (camphorsulfonate), carbonate, chloride, citrate, dihydrochloride, edetate, edisylate (1,2-ethanedisulfonate), estolate (lauryl sulfate), esylate (1,2-ethanedisulfonate), fumarate, gluceptate, gluconate, glutamate, glycollylarsanilate (p-glycollamidophenylarsonate), hexylresorcinate, hydrabarnine (N,N′-Di(dehydroabietyl)ethylenediamine), hydrobromide, hydrochloride, hydroxynaphthoate, iodide, isethionate, lactate, lactobionate, malate, maleate, mandelate, mesylate, methylbromide, methylnitrate, methylsulfate, mucate, napsylate, nitrate, nitrte, pamoate (embonate), pantothenate, phosphate or diphosphate, polygalacturonate, salicylate, stearate, subacetate, succinate, sulfate, tannate, tartrate, teoclate (8-chlorotheophyllinate), triethiodide, bicarbonate, etc. Particularly preferred anions include chloride sulfate, nitrate, gluconate, iodide, bicarbonate, bromide, and phosphate.
Pharmaceutically acceptable cations that can be used to carry out the present invention include, but are not limited to, organic cations such as benzathine (N,N′-dibenzylethylenediamine), chloroprocaine, choline, diethanolamine, ethylenediamine, meglumine (N-methyl D-glucarnine), procaine, D-lysine, L-lysine, D-arginine, L-arginine, triethylammonium, N-methyl D-glycerol, and the like. Particularly preferred organic cations are 3-carbon, 4-carbon, 5-carbon and 6-carbon organic cations. Metallic cations useful in the practice of the present invention include but are not limited to aluminum, calcium, lithium, magnesium, potassium, sodium, zinc, iron, ammonium, and the like. Particularly preferred cations include sodium, potassium, choline, lithium, meglumine, D-lysine, ammonium, magnesium, and calcium.
Specific examples of osmotically active salts that may be used with the sodium channel blockers described herein to carry out the present invention include, but are not limited to, sodium chloride, potassium chloride, choline chloride, choline iodide, lithium chloride, meglumine chloride, L-lysine chloride, D-lysine chloride, ammonium chloride, potassium sulfate, potassium nitrate, potassium gluconate, potassium iodide, ferric chloride, ferrous chloride, potassium bromide, etc. Either a single salt or a combination of different osmotically active salts may be used to carry out the present invention. Combinations of different salts are preferred. When different salts are used, one of the anion or cation may be the same among the differing salts.
Osmotically active compounds of the present invention also include non-ionic osmolytes such as sugars, sugar-alcohols, and organic osmolytes. Sugars and sugar-alcohols useful in the practice of the present invention include but are not limited to 3-carbon sugars (e.g., glycerol, dihydroxyacetone); 4-carbon sugars (e.g., both the D and L forms of erythrose, threose, and erythrulose); 5-carbon sugars (e.g., both-the D and L forms of ribose, arabinose, xylose, lyxose, psicose, fructose, sorbose, and tagatose); and 6-carbon sugars (e.g., both the D and L forms of altose, allose, glucose, mannose, gulose, idose, galactose, and talose, and the D and L forms of allo-heptulose, allo-hepulose, gluco-heptulose, manno-heptulose, gulo-heptulose, ido-heptulose, galacto-heptulose, talo-heptulose). Additional sugars useful in the practice of the present invention include raffmose, raffinose series oligosaccharides, and stachyose. Both the D and L forms of the reduced form of each sugar/sugar alcohol useful in the present invention are also active compounds within the scope of the invention. For example, glucose, when reduced, becomes sorbitol; within the scope of the invention, sorbitol and other reduced forms of sugar/sugar alcohols (e.g., mannitol, dulcitol, arabitol) are accordingly active compounds of the present invention.
Osmotically active compounds of the present invention additionally include the family of non-ionic osmolytes termed “organic osmolytes.” The term “organic osmolytes” is generally used to refer to molecules used to control intracellular osmolality in the kidney. See e.g., J. S. Handler et al., Comp. Biochem. Physiol, 117, 301-306 (1997); M. Burg, Am. J. Physiol. 268, F983-F996 (1995), each incorporated herein by reference. Although the inventor does not wish to be bound to any particular theory of the invention, it appears that these organic osmolytes are useful in controlling extracellular volume on the airway/pulmonary surface. Organic osmolytes useful as active compounds in the present invention include but are not limited to three major classes of compounds: polyols (polyhydric alcohols), methylamines, and amino acids. The polyol organic osmolytes considered useful in the practice of this invention include, but are not limited to, inositol, myo-inositol, and sorbitol. The methylamine organic osmolytes useful in the practice of the invention include, but are not limited to, choline, betaine, carnitine (L-, D- and DL forms), phosphorylcholine, lyso-phosphorylcholine, glycerophosphorylcholine, creatine, and creatine phosphate. The amino acid organic osmolytes of the invention include, but are not limited to, the D- and L-forms of glycine, alanine, glutamine, glutamate, aspartate, proline and taurine. Additional osmolytes useful in the practice of the invention include tihulose and sarcosine. Mammalian organic osmolytes are preferred, with human organic osmolytes being most preferred. However, certain organic osmolytes are of bacterial, yeast, and marine animal origin, and these compounds are also useful active compounds within the scope of the present invention.
Under certain circumstances, an osmolyte precursor may be administered to the subject; accordingly, these compounds are also useful in the practice of the invention. The term “osmolyte precursor” as used herein refers to a compound which is converted into an osmolyte by a metabolic step, either catabolic or anabolic. The osmolyte precursors of this invention include, but are not limited to, glucose, glucose polymers, glycerol, choline, phosphatidylcholine, lyso-phosphatidylcholine and inorganic phosphates, which are precursors of polyols and methylamines. Precursors of amino acid osmolytes within the scope of this invention include proteins, peptides, and polyamino acids, which are hydrolyzed to yield osmolyte amino acids, and metabolic precursors which can be converted into osmolyte amino acids by a metabolic step such as transamination. For example, a precursor of the amino acid glutamine is poly-L-glutamine, and a precursor of glutamate is poly-L-glutamic acid.
Buffering Systems Used as Excipients to Prevent Decrease in Airway Surface pH for Diseases Associated with CFTR Dysfunction
For the formulation of 7% and >7% hypertonic saline, formulations containing bicarbonate anions may be particularly useful, especially for respiratory disorders with CFTR dysfunction such as CF or COPD. There are two reasons for HCO3− inclusion. First, recent findings indicate that, although the relative ratio of HCO3− conductance/Cl− conductance is between 0.1 and 0.2 for single CFTR channels activated with cAMP and ATP, the ratio in the sweat duct can range from virtually 0 to almost 1.0, depending on conditions of stimulation. That is, combining cAMP+cGMP+α-ketoglutarate can yield CFTR HCO3− conductance almost equal to that of Cl− conductance (Quiton et al, Physiology, Vol. 22, No. 3, 212-225, June 2007). Therefore, CF airways may be HCO3− depleted, or acidic, and in need of replacement therapy. Absent CFTR-dependent bicarbonate secretion can also lead to impaired capacity of CF airways to respond to airway conditions associated with acidification of airway surface liquid layer, (Coakley et al., Proc Natl Acad Sci USA, 100(26):16083-8 (2003)).
Buffering Systems Used as Excipients to Prevent Decrease in Airway Surface pH Following Hyperosmolar Agent Deposition in the Airways
Administration of hyperosmolar agents, such as 7% HS, on the airway surface can cause a transient decrease in the pH of the airway surface liquid layer (ASL,
The hyperosmolar agents deposited as aerosols on the airway surface can cause an efflux of water from the airway epithelium. Efluxed water can rapidly equilibrate with atmospheric CO2 gas [CO2(g)→CO2(l)] which can rapidly form carbonic acid [CO2(l)+H2O(l)→H2CO3(l)]. Subsequently, the carbonic acid can lower the pH of the ASL [H2CO3(l)→HCO3−+H3O+]. To maintain the pH of the ASL, bicarbonate anions can be secreted from the airway epithelial cells via CFTR.
When a hyperosmolar agent is deposited on the airway surfaces at sufficiently high rates, which can cause rapid efflux of water onto the airway surface, the rapid equilibration of CO2 in the ASL and the subsequent ASL acidification can exceed the rate of buffering ion secretion from the airway epithelia. Hence, a transient drop in pH can occur. This phenomenon may be exacerbated in human subjects with decreased CFTR function, such as in CF or COPD patients.
Formulations of hyperosmolar agents with buffering excipients of sufficient buffering capacities can be identified, so that the acidification of the ASL is attenuated or completely prevented. Exemplary buffer systems can comprise, but not limited to, carbonic acid/carbonate/bicarbonate-based buffers; disodium hydrogen phthalate/sodium dihydrogen orthophosphate-based buffers; tris (hydroxylmethyl) aminomethane/hydrochloric acid-based buffers; barbitone sodium/hydrochloric acid-based buffers; and any combination thereof.
Due to this evidence, inclusion of bicarbonate anion in the formulation of 7% or >7% hypertonic saline administered by the method of this invention would be particularly useful. Formulations containing up to 1 to 200 mM concentrations of bicarbonate anions are of particular interest for 7% or >7% HS solutions.
Also intended within the scope of this invention are chemically modified osmolytes or osmolyte precursors. Such chemical modifications involve linking to the osmolyte (or precursor) an additional chemical group which alters or enhances the effect of the osmolyte or osmolyte precursor (e.g., inhibits degradation of the osmolyte molecule). Such chemical modifications have been utilized with drugs or prodrugs and are known in the art. (See, for example, U.S. Pat. Nos. 4,479,932 and 4,540,564; Shek, E. et al., J. Med. Chem. 19:113-117 (1976); Bodor, N. et al., J. Phami, Sci. 67:1045-1050 (1978); Bodor, N. et al., J. Med. Chem. 26:313-318 (1983); Bodor, N. et al., J. Pharm. Sci. 75:29-35 (1986), each incorporated herein by reference.
Buffering Systems Used as Excipients to Prevent Decrease in Airway Surface pH Following Administrations of Acidic Aerosols
Administration of large volumes of unbuffered aerosols on the airway surface can cause a transient decrease in the pH of the airway surface liquid layer (ASL). This transient decrease in pH may cause additional irritation to the airways. Therefore, it may be beneficial to co-formulate any aerosolized drug product with buffering excipients, providing sufficient maintenance of the pH of the aerosol in the neutral range and preventing decreases in the pH of the ASL upon aerosol deposition.
B. Sodium Channel Blockers
Coordinated ion transport by the airway epithelia directly regulates the hydration level of the mucosal surface. Importantly, sodium absorption through the epithelial sodium channel (ENaC) provides the rate-limiting step in hydration. In human subjects with loss of function mutation in ENaC have ‘wet’ airway surfaces and extraordinarily fast mucous clearance (see above) (Kerem et al., N Engl J Med. 1999 Jul. 15; 341(3):156-62). Conversely, increased sodium absorption through ENaC has been shown to be the underlying cause of mucous dehydration and the formation of mucous plugs in the lungs CF patients. Furthermore, transgenic mice that overexpress ENaC in the lungs have dehydrated airway surfaces and reduced/absent mucous clearance that results in death (Hummler et al., Proc Natl Acad Sci USA. 1997 Oct. 14; 94(21):11710-5). As predicted from clinical and experimental data, pharmacological blockade of ENaC conserves liquid on airway surfaces and increases mucus clearance (Hirsh et al., J Pharmacol Exp Ther. 2008; 325(1):77-88). Particular examples include, but are not limited to:
a. Small Molecule Channel Blockers:
Small molecule ENaC blockers are capable of directly preventing sodium transport through the ENaC channel pore. ENaC blocker that can be administered by the methods of this invention include, but are not limited to, amiloride, benzamil, phenamil, and amiloride analogues as exemplified by U.S. Pat. Nos. 6,858,614, 6,858,615, 6,903,105, 6,995,160, 7,026,325, 7,030,117,7,064,129, 7,186,833, 7,189,719, 7,192,958, 7,192,959, 7,241,766, 7,247,636, 7,247,637, 7,317,013 7,332,496, 7,345,044, 7,368,447, 7,368,450 7,368,451,7,375,107, 7,399,766, 7,410,968, 7,820,678, 7,842,697 , 7,868,010, and 7,875,619.
b. Protease Inhibitors:
ENaC proteolysis is well described to increase sodium transport through ENaC. Protease inhibitor block the activity of endogenous airway proteases, thereby preventing ENaC cleavage and activation. Protease that cleave ENaC include furin, meprin, matriptase, trypsin, channel associated proteases (CAPS), and neutrophil elastases. Protease inhibitors that can inhibit the proteolytic activity of these proteases that can be administered by the methods of this invention include, but are not limited to, camostat, prostasin, furin, aprotinin, leupeptin, and trypsin inhibitors.
c. Nucleic Acids and Small Interfering RNAs (siRNA):
Any suitable nucleic acid (or polynucleic acid) can be used to carry out the present invention, including but not limited to antisense oligonucleotide, siRNA, miRNA, miRNA mimic, antagomir, ribozyme, aptamer, and decoy oligonucleotide nucleic acids. See, e.g., US Patent Application Publication No. 20100316628. In general, such nucleic acids may be from 17 or 19 nucleotides in length, up to 23, 25 or 27 nucleotides in length, or more.
Any suitable siRNA active agent can be used to carry out the present invention. Examples include, but are not limited to, those described in U.S. Pat. No. 7,517,865 and US Patent Applications Nos. 20100215588; 20100316628; 20110008366; and 20110104255. In general, the siRNAs are from 17 or 19 nucleotides in length, up to 23, 25 or 27 nucleotides in length, or more.
C. Secretogogues
Mutations in the cystic fibrosis (CF) gene result in abnormal ion transport across the respiratory epithelium (Matsui et al., Cell 1998; 95:1005-15). Excessive absorption of sodium and the inability to secrete chloride by the airway epithelium in patients with CF drives water absorption down an osmotic gradient generated by inappropriate salt absorption, dehydrating airway mucous secretions and reducing the volume of liquid in the PCL. In COPD, cigarette smoke impairs CFTR function, thus creating an acquired phenotype similar to CF.
a. P2Y2 Receptor Agonists:
Agents that that may be administered by the methods of the current invention include a group of P2Y2 agonists. Purinergic (P2Y2) receptors are abundant on luminal surface of human bronchial epithelium (HBE) and are known to stimulate Cl− secretion and inhibit Na+ absorption (Goralski et al., Curr Opin Pharmacol. 2010 June; 10(3):294-9). UTP is an example of an endogenous P2Y2 receptor agonist that provides a robust stimulation of chloride secretion, inhibition of sodium absorption and increase in airway surface liquid layer in airway epithelium, thus increasing the mucus clearance which is the primary defense mechanism of the lung. Early studies using uridine-5-triphosphate (UTP) delivered via aerosol to airway surfaces of CF and primary cilia dyskinesia (PCD) patients suggested the usefulness of UTP in enhancing MC and improving mean cough clearance rates.
However, UTP is rapidly degraded (t1/2=˜45 seconds) by extracellular enzymes lining the lumen of the lung or present as soluble forms in the airway surface liquid layer. Similarly, agents with low potency suffer from submaximal efficacy as they cannot be delivered in sufficient amount to the surface of the lung. Inhalation of such agents may require very frequent dosing regimen that may not be practical. For agents suffering from short half-lives or low potency, administration by inhalation over the course of 8 to 24 hours or overnight to a patient via nasal cannula improves the efficacy for such agents.
Native agonists of P2Y2 receptor are susceptible to enzymatic hydrolysis in vivo by class of extracellular enzymes called ecto-nucleotidases (Lazarowski et al., J Biol Chem. 279(35):36855-64 (2004)) that are present on human epithelial surfaces. Consequently, these agonists have very short half-lives. Similarly, engineered nucleotide-based P2Y2 agonists currently in clinical development are hydrolyzed on the surface of airway epithelium (Yerxa et al., J Pharmacol Exp Ther. 2002 September; 302(3):871-80) and are likely to have intermediate (t1/2=˜30 minutes) half-lives in vivo. Given the enzymatic degradation of native agonists as well as engineered nucleotide-based P2Y2 agonists, ectonucleotidase inhibitors such as ebselen can be administered by the method of this invention in order to prolong half-lives of endogenous (eg ATP) or exogenously delivered P2Y2 agonists.
Receptor desensitization, or decreased responsiveness of a receptor to agonist stimulation, represents a regulatory process with the potential to have a significant impact on cell behavior. P2Y(2), a G-protein-coupled receptor activated by extracellular nucleotides, undergoes desensitization at many tissues (Sanabria at al., Endothelium., 15(1):43-51 2008). Receptor desensitization has been linked to decreased clinical efficacy or duration of action of receptor agonists administered via inhalation. The extent of P2Y2 receptor desensitization is dependent on agonist concentration and increases with the increasing concentrations of agonist. Administering high concentrations of P2Y2 receptor agonist to produce effective concentrations of agonist for prolonged (hours) periods of time is likely to result in receptor desensitization and potentially decreased efficacy when such agonist is used as a therapeutic agent.
P2Y2 agonists that can be administered by the methods of this invention include P2Y2 receptor agonists such as ATP, UTP, UTP-γ-S and dinucleotide P2Y2 receptor agonists (e.g. denufosol or diquafosol) or a pharmaceutically acceptable salt thereof. The P2Y2 receptor agonist is typically included in an amount effective to stimulate chloride and water secretion by airway surfaces, particularly nasal airway surfaces.
A P2Y2 receptor agonist denufosol failed to demonstrate clinical efficacy in a 48-week placebo-controlled study in CF patients when administered via rapid nebulization of 4 ml of 15 mg/ml solution of denufosol by Pari LC Star jet nebulizer three times a day. Such dosing regimen lead to a pulmonary deposition of ˜36 mg of denufosol per day at rate of ˜0.8 mg/min (˜20% deposition efficiency of Pari LC jet nebulizer; three times a day ˜15 minute nebulizations of 60 mg of denufosol in 4 ml of 15 mg/ml solution for inhalation). Deposition of denufosol on the surface of the lung according to the methods of the current invention at rates of 0.004 mg/min to 0.4 mg/min over extended 8 hour aerosol administration can allow for improved efficacy of denufosol. P2Y2 agonists ATP, UTP, diquafosol and other P2Y2 agonists with similar half-lives and potencies can be administered with improved efficacy at similar rates.
Suitable P2Y2 receptor agonists are described in, but are not limited to, U.S. Pat. Nos. 6,264,975, 5,656,256, 5,292,498, 6,348,589, 6,818,629, 6,977,246, 7,223,744, 7,531,525 and U.S. Pat.AP.2009/0306009 each of which is incorporated herein by reference.
b. Activators of Alternative Chloride Channels Such as CaCCs and ClC-2 Class Channels:
CaCCs are broadly expressed in mammalian cells where they are involved in a wide range of physiological functions, including transepithelial fluid secretion, oocyte fertilization, olfactory and sensory signal transduction, smooth muscle contraction, and neuronal and cardiac excitation. Whole cell current analysis indicates several common features between CaCC subfamilies, including slow activation following membrane depolarization, outwardly rectifying steady state currents and greater iodide than chloride permeability. Single channel analysis has suggested four or more distinct CaCC subclasses, with a wide range of reported single channel conductances from less than 2 pS in cardiac myocytes to 50 pS in airway epithelial cells.
The consequences of CaCC activation are cell type specific, for example, chloride secretion in epithelial cells, action potential generation in olfactory receptor neurons, smooth muscle contraction, and prevention of polyspermia in oocytes. In some cell types, such as smooth muscle cells, membrane depolarization activates voltagegated calcium channels, increasing intracellular calcium concentration. Although CaCCs were functionally characterized nearly three decades ago, their molecular identity has remained unclear until recently, with potential candidates including bestrophins (BEST1-BEST4) (Sun et al., Proc Natl Acad Sci USA 99, 4008-4013 (2002) and Tsunenari et al., J Biol Chem 278, 41114-41125 (2003)), the calcium activated chloride channel ClCA family proteins (Gruber et al., Genomics 1998; 54:200-214) and ClC3 (Huang P et al, (2001) Regulation of human CLC-3 channels by multifunctional Ca2+/calmodulin-dependent protein kinase. JBC 276: 20093-100). Three independent laboratories have identified TMEM16A, also called anoctamin1, as a strong candidate for a CaCC (Yang Y D et al. (2008) TMEM16A confers receptor-activated calcium-dependent chloride conductance. Nature. 455: 1210-15; Caputo A et al. (2008) TMEM16A, a membrane protein associated with calcium-dependent chloride channel activity. Science. 322: 590-4; Schroeder B C et al. (2008) Expression cloning of TMEM16A as a calcium-activated chloride channel subunit. Cell. 134: 1019-29). Three different strategies were used: database searching for membrane proteins with multiple transmembrane segments and unknown function (Yang Y D et al. (2008) TMEM16A confers receptor-activated calcium-dependent chloride conductance. Nature. 455: 1210-15), functional genomics following the observation that interleukin 4 (Il4) treated bronchial epithelial cells show increased CaCC activity (Caputo A et al. (2008) TMEM16A, a membrane protein associated with calcium-dependent chloride channel activity. Science. 322: 590-4), and expression cloning using axolotl oocytes that do not have endogenous CaCC activity (Schroeder B C et al. (2008) Expression cloning of TMEM16A as a calcium-activated chloride channel subunit. Cell. 134: 1019-29). There is strong evidence to suggest TMEM16A is a key component of CaCC, including similarity to native CaCCs in its electrophysiological properties, appearance of CaCC currents in various transfected cell systems, reduction in CaCC currents following RNAi knockdown, and its tissue distribution. TMEM16A has eight putative transmembrane segments without domains evidently involved in calcium regulation.
ClC2 is a ubiquitously expressed, inwardly rectifying chloride channel that is activated by cell swelling. ClC2 was thought to be involved in cell volume regulation, but it has different biophysical characteristics from the volume sensitive chloride channels that have been characterized in many tissues. Suitable alternative chloride channel activators are described in U.S. Pat. Nos. 6,015,828, 6,159,969 and 7253295.
c. Modulators of CFTR Activity
The hereditary lethal disease cystic fibrosis is caused mutations in the gene encoding CFTR protein, a cAMP activated chloride channel expressed in the airway epithelia. Various mutations in CFTR cause ion transport dysfunction by limiting the chloride ion secretion to the surface of the airway epithelium via CFTR and by dys-regulation of sodium ion absorption, leading to excessive absorption of sodium cations. These defects in ion transport result in impaired hydration of airway surface liquid layer, decrease in mucus clearance and lead to progressive loss of lung function. Recently, it has been shown that CFTR functional defects are present in cigarette smoke exposed tissue, thus implying the role of CFTR dysfunction in COPD.
Over 1500 putative mutations have been described in CFTR, which can be divided into classes according to the molecular mechanism of the genetic defect (Rowe et al., Pulm Pharmacol Ther., 23(4):268-78 (2010)). An understanding of the biology of each of these mutations has led to therapeutic strategies based on the particular mutation type. Class I mutations include premature termination codons (PTCs, e.g. nonsense mutations) within the coding region of CFTR, which cause premature truncation of normal protein translation. These mutations are found in 10% of CF patients, but are particularly common in Ashkenazi Jews (75% of mutant CFTR alleles). Class II CFTR mutations include F508del CFTR, the most common mutation in humans (accounting for 75% of alleles and found in approximately 90% of CF patients). The deletion of phenylalanine at the 508 position causes CFTR to exhibit abnormal folding characterized by deficient stabilization by domain-domain interactions between the nucleotide binding domain 1 (NBD1) and the transmembrane domains. The misfolded protein is recognized by cellular chaperones within the endoplasmic reticulum (ER), directed to the proteasome, and rapidly degraded prior to reaching its active site at the cell surface. Because the cellular machinery responsible for the recognition and degradation of the misfolded protein is not 100% efficient, particular individuals exhibit low levels of surface expression of F508del CFTR, which may account for partial CFTR activity (and a more mild CF phenotype) observed in individuals homozygous for F508del CFTR, and could represent a population more amenable to protein repair. Even when at the cell surface, F508del CFTR exhibits reduced gating, suggesting that misfolded CFTR also exhibits reduced CFTR ion channel activity. Class III and IV CFTR mutations are characterized by full-length CFTR that reaches the cell surface but exhibit reduced ion transport activity owing to abnormal channel gating (Class III, e.g. G551D) or reduced conductivity of the ion channel pore (Class IV, e.g. R117H). Similarly, splicing mutants (Class V) and mutations within the C-terminus (Class VI) are also full length, but exhibit reduced activity owing to reduced numbers of active channels within the plasma membrane. Although the molecular basis of CFTR mutants is complex and as yet incomplete, the classification of CFTR mutants can be simplified into the therapeutically relevant groups based on the activity of agents in development. Both traditional and high-throughput drug discovery programs have resulted in discovery of novel compounds that address specific mutant CFTR alleles. These ‘CFTR modulators’ are pharmacological agents intended to repair the CFTR protein and are described in each section that follows.
Potentiators of cell-surface cystic fibrosis transmembrane conductance regulator CFTR mutation classes that result in dysfunctional CFTR that resides at the plasma membrane include Class III, IV, V, and VI mutations and represent potential targets for CFTR activators. G551D CFTR represents an archetype CFTR allele for this category of agents, as it exhibits normal surface expression and half-life, but confers a severe defect in channel gating owing to an amino acid substitution in the adenosine triphosphate (ATP) binding pocket within the nucleotide binding domains (Gregory, R. J. et al. (1991) Maturation and function of cystic fibrosis transmembrane conductance regulator variants bearing mutations in putative nucleotide-binding domains 1 and 2. MCB 11: 3886-93; Bompadre, S. G. et al. (2007) G551D and G1349D, two CF-associated mutations in the signature sequences of CFTR, exhibit distinct gating defects. Gen Physiol. 129: 285-298). Flavonoids are well known activators of mutant CFTR and were among the first to be studied for beneficial effects in human individuals (including topical administration). Although agents such as genistein were affected by lack of efficacy in the nasal airway, more recent efforts have demonstrated activity of the flavonoid quercetin in the nose. However, flavonoid agents are challenged by poor solubility and systemic absorption, and are poor development candidates for inhaled therapeutics. More recent discovery strategies have focused on identification of compounds that ‘potentiate’ CFTR activity, restoring endogenous regulation (e.g. cyclic adenosine monosphosphate (cAMP)-dependent regulation) and ion transport without excessive, constitutive activation that may potentially be detrimental (such as excessive CFTR activation seen with certain diarrheal illnesses). Identification of agents of this type is amenable to high-throughput screening-based strategies to discover agents that activate mutant CFTR by measuring the effects on anion conductance in cell-based screening assays. A number of specific strategies have been used for screens of this sort, including chloride sensitive dyes, fluorescence resonance energy transfer-based analysis of membrane potential, and cell conductance of airway monolayers. Identification and characterization of small molecule potentiators of mutant CFTR have led to the development of agents with pronounced activity in vitro and in the clinic.
Significant effort has been directed toward the goal of correcting the folding of F508del CFTR, thus restoring ion channel activity to the misfolded protein. A diverse array of cellular targets have been explored, commensurate with the large number of proteins now known to interact with CFTR biogenesis. Agents such as 4-phenyl butyrate downregulate Hsc70 (or other cell chaperones) central to the folding process, and represent an early example of compounds tested in the clinic. Other more recent efforts have resulted from high-throughput library screens for chloride channel function following incubation of test compounds with F508del expressing cells. A number of these strategies have identified F508del correctors that may address cell biogenesis through chaperone pathways. Pharmacologic activity of such agents has also been reported to augment F508del CFTR half-life in the plasma membrane through altered surface recycling attributed to features of the cellular processing machinery or reduced endocytic trafficking. This class of agents may be potential drug development candidates if their safety in vivo is confirmed. Other compounds have been shown to directly interact with CFTR and may offer greater specificity than agents that alter general aspects of cell folding or cellular quality control. The global cellular response to misfolded protein may also represent a target. Histone deacetylases (HDAC) have far-ranging effects on gene expression, and specific members of the HDAC family are involved in the ER associated degradation pathway promoting degradation of F508del CFTR. Treatment of CF cells with HDAC inhibitors can modulate ER stress, and HDACs such as suberoylanilidehydroxamic acid, as well as siRNA-silencing of HDACs, increase levels of F508del CFTR in the cell membrane. The combination of approaches such as these reveal a number of potential pharmacologic agents for F508del correction. Additive or synergistic rescue of F508del CFTR using more than one such strategy may offer hope of achieving ion transport activity sufficient to confer a normal phenotype in CF respiratory epithelia.
Read-through of premature termination colons (PTCs) represents another exciting approach to address the underlying cause of CF, and many other genetic diseases caused by PTCs. Certain aminoglycosides and other agents have the capacity to interact with the eukaryotic rRNA within the ribosomal subunits. Although this interaction is much weaker than that seen in prokaryotes and is distinct from the primary cause of aminoglycoside toxicity in human individuals, it can modestly reduce the fidelity of eukaryotic translation by interrupting the normal proofreading function of the ribosome. Insertion of a near cognate amino acid at a premature stop codon allows protein translation to continue until one of several stop codons normally present at the end of the mRNA transcript is reached and properly utilized. The specificity of the strategy has been attributed to greater stop codon fidelity at the authentic end of mRNA and has been established in vitro by demonstrating no detectable elongation beyond native stop codons.
CFTR activity modulating compounds that can be administered by the methods of this invention include, but are not limited to, compounds described in US 2009/0246137 A1, US 2009/0253736 A1, US 2010/0227888 A1, U.S. Pat. No. 7,645,789, US 2009/0246820 A1, US 2009/0221597 A1, US 2010/0184739 A1, US 2010/0130547 A1, US 2010/0168094 A1, U.S. Pat. Nos. 7,553,855, U.S. Pat. No. 7,772,259 B2, U.S. Pat. No. 7,405,233 B2, US 2009/0203752, and U.S. Pat. No. 7,499,570.
D. Mucus/Mucin Modifying Agents
a. Reducing Agents:
Mucin proteins are organized into high molecular weight polymers via the formation of covalent (disulfide) and non-covalent bonds. Disruption of the covalent bonds with reducing agents is a well-established method to reduce the viscoelastic properties of mucus in vitro and is predicted to minimize mucus adhesiveness and improve clearance in vivo. Reducing agents are well known to decrease mucus viscosity in vitro and commonly used as an aid to processing sputum samples (Hirsch, S. R., Zastrow, J. E., and Kory, R. C. Sputum liquefying agents: a comparative in vitro evaluation. J. Lab. Clin. Med. 1969. 74:346-353). Examples of reducing agents include sulfide containing molecules or phosphines capable of reducing protein di-sulfide bonds including, but not limited to, N-acetyl cysteine, N-acystelyn, carbocysteine, glutathione, dithiothreitol, thioredoxin containing proteins, and tris (2-carboxyethyl) phosphine.
N-acetyl cysteine (NAC) is approved for use in conjunction with chest physiotherapy to loosen viscid or thickened airway mucus. Clinical studies evaluating the effects of oral or inhaled NAC in CF and COPD have reported improvements in the rheologic properties of mucus and trends toward improvements in lung function and decreases in pulmonary exacerbations (Duijvestijn Y C M and Brand P L P. Systematic review of N-acetyleysteine in cystic fibrosis. Acta Peadiatr 88: 38-41. 1999). However, the preponderance of clinical data suggests that NAC is at best a marginally effective therapeutic agent for treating airway mucus obstruction when administered orally or by inhalation. A recent Cochrane review of the existing clinical literature on the use of NAC found no evidence to support the efficacy of NAC for CF (Nash E F, Stephenson A, Ratjen F, Tullis E. Nebulized and oral thiol derivatives for pulmonary disease in cystic fibrosis. Cochrane Database Syst Rev. 2009; 21(1):CD007168.). The marginal clinical benefit of NAC reflects:
The lack of a clear therapeutic benefit with NAC in clinical studies reflects the ineffectiveness of this molecule on the lung surface. Specifically, NAC does not possess the basic properties of an effective pulmonary drug as NAC (1) is a relatively inefficient reducing agent the airway surface environment (e.g. CF pH 6.5-7.2); and (2) is rapidly metabolized and cleared from the airway surface (Jayaraman S, Song Y, Vetrivel L, Shankar L, Verkman A S. Noninvasive in vivo fluorescence measurement of airway-surface liquid depth, salt concentration, and pH. J Clin Invest. 2001; 107(3):317-24). In more detail, due to its short half-life in the airway, very high concentrations of NAC (200 mM or 3.26%) are required to fully reduce Muc5B, a major gel-forming airway mucin, in vitro over short times representative of the NAC resident time on the surface of the airways following rapid administration via current jet neb or vibrating mesh technologies. In non-clinical studies, 14C-labled NAC, administered by inhalation, exhibits rapid elimination from the lungs with a half-life ranging from 6 to 36 minutes (unpublished observation). Furthermore, in the pH environment of the airway surface (measured in the range of pH 6.0 to 7.2 in CF and COPD airways), NAC exists only partially in its reactive state as a negatively charge thiolate (Jayaraman S, Song Y, Vetrivel L, Shankar L, Verkman A S. Noninvasive in vivo fluorescence measurement of airway-surface liquid depth, salt concentration, and pH. J Clin Invest. 2001; 107(3):317-24).
To overcome its modest activity, NAC is most commonly administered as a concentrated, hypertonic solution (Mucomyst® is a 20% or 1.27 M solution) via aerosol “bolus” (commonly a jet nebulizer with an ˜20% pulmonary deposition fraction). Thus, a conventional 4 mL dose of 20% NAC leads to the pulmonary deposition of ˜160 mg/dose at a rate of ˜10.7 mg/min (˜20% deposition efficiency of Pari LC jet nebulizer; once daily at ˜15 minute nebulizations of 800 mg of NAC in 4 ml of 200 mg/ml solution for inhalation).
However, rapid aerosol delivery of concentrated NAC solutions impact the tolerability of NAC as it (1) possesses an unpleasant sulfur taste/odor; and (2) is associated with side effects including pulmonary irritation and bronchoconstriction which can require co-administration of rescue medications such as bronchodilators.
Administration of the NAC according to the methods of this invention allows an increase in the daily pulmonary dose (to increase efficacy), while decreasing the rate of presentation (to improve tolerability). Deposition of NAC on the surface of the lung according to the methods of the current invention can achieve this effect at rates of 0.005 mg/min to 5.4 mg/min over extended 8 hour aerosol administration can allow for improved efficacy of NAC. Furthermore, co-formulation of NAC with an excipient with buffering capacity to prevent pH decreases on the surface of the lung, as described by the methods of this invention, allows for further improvements in combined safety, tolerability or safety indices.
b. Surfactants:
Surfactants and detergents are spreading agents shown to decrease mucus viscoelasticity, improving mucus clearability. Examples of surfactants include DPPC, PF, palmitic acid, palmitoyl-oleoylphosphatidylglycerol, surfactant proteins (e.g. SP-A, B, or C), or may be animal derived (e.g. from cow or calf lung lavage or extracted from minced pig lung) or combinations thereof. See, e.g., U.S. Pat. Nos. 7,897,577; 5,876,970; 5,614,216; 5,100,806; and 4,312,860. Examples of surfactant products include Exosurf, Pumactant, KL-4, Venticute, Alveofact, Curosurf, Infasurf, and Survanta. Examples of detergents include, but are not limited to, Tween-80 and triton-X 100.
c. Expectorants:
Any suitable expectorant can be used, including but not limited to guaifenesin (see, e.g., U.S. Pat. No. 7,345,051).
d. DNase:
Any suitable deoxyribonuclease can be used, including but not limited to Dornase Alpha. (see, e.g., U.S. Pat. No. 7,482,024).
Exemplary Anti-Infective Agents
Chronic obstructive pulmonary diseases are accompanied by both acute and chronic bacterial infections. Both acute and chronic infections lead to chronic inflammation that has acute flare-ups in the form of pulmonary exacerbations. The underlying inflammation is treated with variety of inhaled anti-inflammatory agents. For example, in cystic fibrosis the most common bacteria causing chronic infection is Pseudomonas aeruginosa (P. aeruginosa) and antibiotics that are effective against this bacteria are a major component of treatment (Flume, Am J Respir Crit Care Med. 176(10):957-69 (2007)). Also bacteria such as Staphylococcus aureus (S. aureus), Burkholderia cepacia (B. cepacia) and other gram negative organisms as well as anaerobes are isolated from respiratory secretions and people with CF may benefit from treatment of these pathogens to maintain their lung health. Anaerobic bacteria are also recognized as a feature of CF airways, sinuses in subjects with chronic sinusitis, and likely airways of subjects with COPD. Similarly, aspirations or microaspirations, especially in elderly population and during sleep, are associated with a chemical pneumonitis, anaerobic infections and subsequent bronchiectasis. An ideal treatment of aspiration-related pneumonitis and anaerobic infection would be an immediate treatment. As such, antibiotics are used to eradicate early infections, during pulmonary exacerbations and as chronic suppressive therapy.
The primary measure of antibiotic activity is the minimum inhibitory concentration (MIC). The MIC is the lowest concentration of an antibiotic that completely inhibits the growth of a microorganism in vitro. While the MIC is a good indicator of the potency of an antibiotic, it indicates nothing about the time course of antimicrobial activity. PK parameters quantify the lung tissue level time course of an antibiotic. The three pharmacokinetic parameters that are most important for evaluating antibiotic efficacy are the peak tissue level (Cmax), the trough level (Cmin), and the Area Under the tissue concentration time Curve (AUC), While these parameters quantify the tissue level time course, they do not describe the killing activity of an antibiotic.
Integrating the PK parameters with the MIC gives us three PK/PD parameters which quantify the activity of an antibiotic: the Peak/MIC ratio, the T>MIC, and the 24 h-AUC/MIC ratio. The Peak/MIC ratio is simply the Cpmax divided by the MIC. The T>MIC (time above MIC) is the percentage of a dosage interval in which the serum level exceeds the MIC. The 24 h-AUC/MIC ratio is determined by dividing the 24-hour-AUC by the MIC. The three pharmacodynamic properties of antibiotics that best describe killing activity are time-dependence, concentration-dependence, and persistent effects. The rate of killing is determined by either the length of time necessary to kill (time-dependent), or the effect of increasing concentrations (concentration-dependent). Persistent effects include the Post-Antibiotic Effect (PAE). PAE is the persistent suppression of bacterial growth following antibiotic exposure.
Using these parameters, antibiotics can be divided into 3 categories:
For Type I antibiotics (AG's, fluoroquinolones, daptomycin and the ketolides), the ideal dosing regimen would maximize concentration, because the higher the concentration, the more extensive and the faster is the degree of killing. Therefore, the 24 h-AUC/MIC ratio, and the Peak/MIC ratio are important predictors of antibiotic efficacy. For aminoglycosides, it is best to have a Peak/MIC ratio of at least 8-10 to prevent resistence. For fluoroquinolonesys gram negative bacteria, the optimal 24 h-AUCIMIC ratio is approximately 125. Versus gram positives, 40 appears to be optimal. However, the ideal 24 h-AUC/MIC ratio for FQ's varies widely in the literature.
Type II antibiotics (beta-lactams, clindamycin, erythromcyin, carbapenems and linezolid) demonstrate the complete opposite properties. The ideal dosing regimen for these antibiotics maximizes the duration of exposure. The T>MIC is the parameter that best correlates with efficacy. For beta-lactams and erythromycin, maximum killing is seen when the time above MIC is at least 70% of the dosing interval.
Type III antibiotics (vancomycin, tetracyclines, azithromycin, and the dalfopristin-quinupristin combination) have mixed properties, they have time-dependent killing and moderate persistent effects. The ideal dosing regimen for these antibiotics maximizes the amount of drug received. Therefore, the 24 h-AUC/MIC ratio is the parameter that correlates with efficacy. For vancomycin, a 24 h-AUC/MIC ratio of at least 125 is necessary.
Given the pharmacokinetic and pharmacodynamic properties for Type II and Type III antibiotics, administration by aerosol “infusion” will improve the efficacy for such agents. For example, carbapenam antibiotics are susceptible to enzymatic hydrolysis in vivo by the enzyme dehydropeptidase-I, thus leading to a short elimination half-life (less than 2 hr). The best measure of efficacy of this class of antibiotics is based on the minimum percentage of time the drug concentration is above the minimum inhibitory concentration (MIC) in the target tissue. Most dose regimens target a time above the MIC (TaM) of at least 50%, thus the need for a continuous infusion. High systemic concentrations of carbapenems can have proconvulsive effects and renal and liver toxicity.
Delivering carbapenems via continuous aerosol to the lungs of patients in need can allow for a safe and convenient way to maintain a high TaM in the lungs while reducing potential for systemic side effects. 500 mg to 2,000 mg of inhaled meropenem administered BID in 4 ml of normal saline via Pari LC jet nebulizers may be used for treatment of CF bacterial infections. Such administrations occur at a rate of 6.7 mg/min to 26.7 mg/min of meropenem deposited in the airway surface during two 15 minute nebulization periods per day. 20 mg to 1,200 mg dose of meropenem, deposited in the lung of CF patients per day and administered at a rate between 0.04 mg/min to 2.5 mg/min of meropenem deposited in the airway surface during 8 hour or longer extended aerosol administration according to method of this invention, can allow for better combined safety, tolerability and efficacy outcomes. Patients including, but not limited to, CF, COPD, non-CF bronchiectasis, aspiration pneumonia, asthma and VAP patients suffering from respiratory infection caused by bacteria susceptible to meropenem may benefit from such treatment. Examples of carbapenam antibiotics are: imipenam, panipenam, meropenam, doripenem, biapenam, MK-826, DA-1131, ER-35786, lenapenam, S-4661, CS-834 (prodrug of R-95867), KR-21056 (prodrug of KR-21012), L-084 (prodrug of LJC 11036) and CXA-101.
Delivering class III antibiotics via continuous aerosol to the lungs of patients in need can allow for a safe and convenient way to maintain a high 24 h-AUC/MIC in the lungs while reducing potential for systemic side effects. For example, 20 to 1,200 mg of vancomycin deposited in the lung of patients per day and administered at a rate between 0.04 mg/min to 2.5 mg/min of vancomycin deposited on the airway surface during 8 hour or longer extended aerosol administration according to method of this invention, can allow for better combined safety, tolerability and efficacy outcomes compared to rapid inhaled delivery or IV infusion. Patients including, but not limited to, CF, COPD, asthma, VAP, HAP, CAP patients and other patients suffering from respiratory infection caused by bacteria susceptible to vancomycin may benefit from such treatment.
The doses and rates for additional antibiotic agents benefiting from administration via aerosol inhalation over extended periods of time according to the methods of this invention are listed in Table 4 below. The rates of deposition of these antibiotic agents were optimized to maintain concentrations above MIC values for relevant bacterial strains and other relevant parameters such at time above MIC or 24-hour AUC/MIC where applicable.
Exemplary Anti-Inflammatory Agents
Inhaled corticosteroids are the standard of chronic care for asthma, COPD and other respiratory diseases characterized by acute and chronic inflammation leading to airflow limitation. Examples of corticosteroids suitable for administration by the method of this invention include beclomethasone, budesonide, and fluticasone. NSAIDs are a group of anti-inflammatory medications that do not contain steroids. NSAIDs do not carry the same risk of side effects as steroidal anti-inflammatory medications, but with long-term use, they may cause internal bleeding or kidney problems.
Products of arachidonic acid metabolism, specifically the leukotrienes (LTs), contribute to pulmonary inflammation. Cysteinylleukotrienes (LTC4, LTD4, and LTE4) are produced predominantly by eosinophils, mast cells, and macrophages. Examples of leukotriene modifiers suitable for administration by the method of this invention include monteleukastzileuton and zafirlukast.
Mast cell stabilizers are cromone medications such as cromolyn (sodium cromoglycate) used to prevent or control certain allergic disorders. They block a calcium channel essential for mast cell degranulation, stabilizing the cell and thereby preventing the release of histamine and related mediators. As inhalers they are used to treat asthma, as nasal sprays to treat hay fever (allergic rhinitis) and as eye drops for allergic conjunctivitis. Finally, in oral form they are used to treat the rare condition of mastocytosis.
PDE4 inhibitors have been shown to modulate pulmonary inflammation and used for treatment of chronic obstructive pulmonary diseases. Examples of PDE4 inhibitors suitable for administration by the method of this invention include theophylline and roflumilast.
Exemplary Bronchodilators
a. NO, NO Donors, NO and Peroxynitrite Scavengers and Inducible NO Synthase Activity Modulators
Nitric oxide (NO) is a potent endogenous vasodilator and bronchodilator that can be exogenously administered via inhalation. It is synthesized by the conversion of the terminal guanidine nitrogen atom of L-arginine via endothelial cell calcium dependent enzyme nitric oxide synthetase and then diffuses across the cell membrane to activate the enzyme guanylatecyclase. This enzyme enhances the synthesis of cyclic guanosine monophosphate (cGMP), causing relaxation of vascular and bronchial smooth muscle and vasodilatation of blood vessels (Palmer, Circ Res., 82(8):852-61 (1998)).
Nitric oxide synthesised in endothelial cells that line blood vessels has a wide range of functions that are vital for maintaining a healthy respiratory and cardiovascular systems (Megson I L et al Expert Opin Investig Drugs. 2002 May; 11(5):587-601.). Reduced nitric oxide availability is implicated in the initiation and progression of many diseases and delivery of supplementary nitric oxide to help prevent disease progression is an attractive therapeutic option. Nitric oxide donor drugs represent a useful means of systemic nitric oxide delivery and organic nitrates have been used for many years as effective therapies for symptomatic relief from angina. However, nitrates have limitations and a number of alternative nitric oxide donor classes have emerged since the discovery that nitric oxide is a crucial biological mediator.
In the respiratory tract, NO is produced by residential and inflammatory cells (Ricciardolo F L et al. Curr Drug Targets 2006 June; 7(6):721-35). NO is generated via oxidation of L-arginine that is catalysed by the enzyme NO synthase (NOS). NOS exists in three distinct isoforms: neuronal NOS (nNOS), inducible NOS (iNOS), and endothelial NOS (eNOS). NO derived from the constitutive isoforms of NOS (nNOS and eNOS) and other NO-adduct molecules (nitrosothiols) are able to modulate bronchomotor tone. NO derived from the inducible isoform of NO synthase, up-regulated by different cytokines via NF-kappaB-dependent pathway, seems to be a pro-inflammatory mediator with immunomodulatory effects. In aging CF patients, expression of iNOS is significantly reduced (Yoon et al., J Clin Invest. 2006 February; 116(2):436-46). This reduced expression of iNOS in chronic CF is associated with emergence of mucoid muc mutant subpopulation of P. aeruginosa. It has been suggested that 15 mM NO2 kills mucA P. Aeruginosa in CF airways at pH 6.5. NO itself or as a precursor to iron-nitrosyl species has been implicated in this antimicrobial effect. Therefore inhaled NO2−, including but not limited inhaled NaNO2, has an appeal as a CF therapy. The production of NO under oxidative stress conditions secondarily generates strong oxidizing agents (reactive nitrogen species) that may amplify the inflammatory response in asthma and COPD. Moreover, NO can be exhaled and levels are abnormal in stable atopic asthma and during exacerbations in both asthma and COPD. Exhaled NO might therefore be a non-invasive tool to monitor the underlying inflammatory process. It is suggested that NOS regulation provides a novel target in the prevention and treatment of chronic inflammatory diseases of the airways such as asthma and COPD.
Examples of NO, NO donors and NO synthase activity modulators suitable for administration by the method of this invention include inhaled NO, agents disclosed in Vallance et al. Fundam Clin Pharmacol. 2003 February; 17(1):1-10, Al-Sa'doni H H et al. Mini Rev Med Chem. 2005 March; 5(3):247-54, Miller M R et al. Br J Pharmacol. 2007 June; 151(3):305-21. Epub 2007 Apr. 2 and Katsumi H et al. Cardiovasc Hematol Agents Med Chem. 2007 July; 5(3):204-8.
Under certain conditions, inducible NO synthase activity leads to overproduction of NO which in turn increases inflammation and tissue injury. Under these conditions, the following inducible NO synthase inhibitors, NO scavengers and peroxynitrite scavengers administered by the methods of this invention are suitable: Bonnefous et al. J. Med. Chem., 2009, 52 (9), pp 3047-3062, Muscara et al AJP-GI June 1999 vol. 276 no. 6 G1313-G1316 or Hansel et al. FASEB Journal. 2003; 17:1298-1300.
a. Beta 2-Adrenergic Receptor Agonists:
It has been established that administration of super-therapeutic concentrations of receptor agonists leads to receptor desensitization and loss of efficacy. For example, this phenomenon has been described for beta 2-adrenoceptor based bronchodilator agents (Duringer et al., Br J Pharmacol., 158(1):169-79 (2009)). High concentration of these receptor agonist agents leads to the receptor phosphorylation, internalization and potential degradation. Administration of receptor agonists, which cause tachyphylaxis following bolus administration via fast nebulizer, by inhalation over the course of 8 to 24 hours or overnight to a patient via nasal cannula improves the efficacy of such agents due to decreased extent of tachyphylaxis. Beta 2-adrenergic receptor agonsists include albuterol, levalbuterol, salbutamol, procaterol, terbutaline, pirbuterol, and metaproterenol
Other Exemplary Therapeutic Agents
Examples of other classes of therapeutic agents suitable for administration by the method of this invention include antivirals such as ribavirin, anti-fungal agents such as amphotericin, intraconazol and voriconazol, anti-rejection drugs such as cyclosporine, tacrolimus and sirolimus, bronchodilators including but not limited to anticholinergic agents such as atrovent, siRNAs, gene therapy vectors, aptamers, endothelin-receptor antagonists, alpha-1-antitrypsin and prostacyclins.
3. METHODS AND APPARATUS
Subjects or patients to be treated by the methods of the present invention include, but are not limited to, those afflicted or at risk of affliction with cystic fibrosis, chronic obstructive pulmonary disease (including chronic bronchitis and emphysema), non-cystic fibrosis bronchiectasis, primary ciliary dyskinesia, sinusitis, rhinosinusitis, nasal dehydration (e.g. due to inhalation administration of oxygen), asthma, emphysema, pneumonia (including ventilator-induced pneumonia and aspiration pneumonia), viral bronchiolitis, infectious agents (e.g., influenza, respiratory syncytial virus, Pseudomonas aeruginosa, Burkholderiacepacia, anthrax, etc. respiratory tract injury due to inhalation of dust, radioactive particles, infections agent, smoke, toxic or corrosive chemicals and/or irritants, etc.
A. Aerosol Administration.
To avoid undesired dehydration of airway epithelial cells, and/or achieve one or more other objects as described herein, nebulizers for administering aerosols for use in carrying out the present invention are preferably low output nebulizers (in contrast to the high output nebulizers such as the Westmed Heart High Output Nebulizer described in Boucher and Johnson, U.S. Patent Application Pub. No. 2009/0104272; and in contrast to the LC STAR™ pressure-driven aerosol nebulizer and the PART EFLOW™ ultrasonic nebulizer described in Boucher et al., Multiple Nebulizer System, U.S. Patent Application 20100074881 (published Mar. 25, 2010). A suitable low output nebulizer includes an aerosol delivery system as described in further detail below.
Exemplary Aerosol Delivery System
In some embodiments, an aerosol delivery system may be capable of maintaining steady aerosol output performance for extended periods of time (0.5 hours to 8 hours per day and up to 24 hours/day). Rainout and sputtering may be reduced over extended periods of treatment times, such as when a subject or patient is sleeping. As used herein, the term “rainout” refers to liquid from an aerosol that collects on a surface. Rainout may occur due to inertial impaction, gravitational sedimentation or condensation on a surface. “Sputtering” refers to rainout that exits from the device, e.g., from the nasal prongs of a nasal cannula. Rainout may reduce the aerosol output of the system, and sputtering may cause patient discomfort.
The aerosol delivery system may deliver an aerosol to the subject's nose via a nasal cannula for pulmonary delivery. In some embodiments, rainout may be reduced without substantially decreasing the aerosol output (volume output) of the system. A desired output may be achieved while limiting or reducing the rainout and sputtering. Accordingly, it may be desirable to employ extended aerosol administration overnight via a nasal cannula while the patient is asleep. Such extended aerosol administration would eliminate the daytime treatment burden presented with conventional bolus aerosol delivery treatments. Furthermore, such extended aerosol administration would enable improvement in efficacy, effectiveness, safety and tolerability for therapeutic agents benefiting from prolonged delivery at slower rates compared to bolus aerosol delivery.
As illustrated in
The aerosol generator 22 may be a nebulizer unit, such as a current jet nebulizer, ultrasonic nebulizer or vibrating mesh nebulizer that is configured to provide an aerosol to the entrainment chamber 20. Commercially available nebulizers include vibrating mesh nebulizers from Aerogen Aeroneb Lab, Pro and Solo, Pari eFlow vibrating mesh technologies, Omron's vibrating horn technologies, vibrating mesh or ultrasonic technologies from Phillips and other manufacturers. The fluid inlet 26 may be connected to a fluid source, such as an air or other gas source for providing an entrainment gas that flows into the entrainment chamber 20 and through the particle selection chamber 40 generally along the fluid pathway 60. The entrainment gas moves generally along the fluid pathway 60 and carries the aerosol from the aerosol generator 22 through the outlet 28, around the baffle 42 and out of the entrainment chamber outlet 44. As shown in
In this configuration, the aerosol generated by the generator 22 may include particles of a wide range of particle sizes. When the entrainment gas carries the aerosol though the outlet 28, the velocity of the gas increases because the first end 28A of the outlet 28 has a cross-sectional area that is larger than the cross-sectional area of the second end 28B. Such narrowing creates a nozzle or a jet which accelerates the movement of the aerosol particles towards the baffle. The diameter of the jet opening 28B can be tuned to achieve different velocities of aerosol particles and consequently increase or decrease the impaction of the aerosol particles on the baffle. The entrainment gas and aerosol is therefore directed toward the baffle 42 with an increased velocity. The baffle 42 is sized and configured such that larger aerosol particles will generally not be able to pass around the baffle 42 when the entrainment gas and aerosol is at a predetermined velocity. Accordingly, smaller aerosol particles may pass around the baffle 42 such that the resulting aerosol particles that pass out of the outlet 44 and into a nasal cannula are generally smaller than the aerosol particles in the entrainment chamber 20.
In some embodiments, the volumetric mean diameter (VMD) of the aerosol particles exiting the particle selection chamber is between 1 and 4 μm, and the percentage of the particles above 4 μm is less than 5%, less than 2% or less than 1% of the total particle volume emitted from the particle selection chamber 40 into the cannula. As used herein, the term “volumetric median diameter” or “VMD” is the particle size diameter such that half the mass of the aerosol particles is contained in particles with larger diameter and half is contained in a particles with smaller diameter. The flow rate entering the inlet 26 may be between 0.5 L/min to 5 L/min and more preferably between 1 and 3 L/min. The baffle 42 may be circular, although baffles may be provided that are spherical, triangular, rectangular, pentagonal, hexagonal, 6+n-gonal where n≥1 with the baffle mounted in cruciform or other suitable fashion. For flow rates between 1-5 L/min, the nozzle diameter is preferably between 0.5 to 5 mm in diameter. Nozzle diameters that are too small may prevent efficient cleaning of the device, and nozzle diameters that are too large may require too high an airflow for effective particle selection. High airflows may not be well tolerated by patients.
As shown in
In some embodiments, the volumetric mean diameter (VMD) of the aerosol may be reduced from about 6 μm out of the nebulizer less than about 2 μm as the aerosol exits the particle selection chamber outlet 44 and into, for example, a nasal cannula. In particular, the percentage of particles larger than 3 to 4 μm may be decreased. Since a large amount of aerosol volume and mass is located in these large particles, filtering out of large particles above certain size leads to decrease in the rate of aerosol emission (μl/min) and the rate of emission for the therapeutic agent contained in aerosol (mg/min). Table 5 displays a removal of large particle produced by Aerogen Aeroneb Pro nebulizer with 7% hypertonic saline drug product by a device 10 of this invention. While 75% of volume normalized particles had size above 4 μm for the standalone nebulizer, only 2% of volume normalized particles exiting port 44 of device 10 of this invention were larger than 4 μm. Filtering out of large particles led to a decrease in the aerosol output in terms of volume of aerosolized fluid contained in aerosol particles emitted from particle selection chamber outlet 44 per unit of time (μl/min). Additionally, the output of NaCl mass per unit of time (mg/min) from particle selection chamber outlet 44 decreased accordingly.
As shown in
In some embodiments, ambient air may be used as an entrainment fluid. The entrainment fluid may be dehumidified and/or dried compressed air, and/or oxygen (including low humidity oxygen).
In some embodiments, the impaction baffle is circular in shape while in others it is triangular, square, heptagonal, hexagonal or polygonal with n>6 vertexes, spherical, elliptical or otherwise optimized to provide a steep step function for particle selection.
In some embodiments, the tapered nozzle or jet connecting the aerosol entrainment chamber and the particle selection chamber is sized and configured to increase the velocity of the entrained aerosol and impact it into the baffle to reduce an amount of aerosol particles in the entrainment fluid that are greater than a predetermined diameter. The diameter of such a nozzle or jet facing the particle selection chamber is between 2 to 4 mm for airflow of entrainment fluid of 0.5 to 5 L/minutes.
In some embodiments, when the entrainment fluid exceeds 5 L/min, the diameter of the nozzle or a jet from the entrainment chamber to the particle selection chamber can be smaller than 2 mm. It should be understood that modifications to the nozzle diameter, flow rate and baffle dimensions may be interrelated and each contribute to the resulting aerosol and particle size distribution therein.
In some embodiments, the nasal cannula is heated. It should be understood that the cannula length, tubing diameter of the cannula, the bifurcation and the prongs may be sized and configured and/or matched to the aerosol output from the particle selection chamber in order to reduce rainout in the cannula while increasing the amount of aerosol emitted from the prongs expressed as a percentage of aerosol entering the cannula.
As illustrated in
As illustrated in
Accordingly, as shown in
As illustrated in
In some embodiments, a particle selection chamber is configured to provide a non-linear entrainment fluid pathway that is configured such that aerosol particles having a larger particle size will rain out in the particle selection chamber. As illustrated in
In some embodiments, non-linear fluid pathways may be provided by a particle selection chamber that is configured to create a generally circular or “cyclone” fluid flow. As illustrated in
In some embodiments, mechanical components may be used to provide a non-linear flow pathway in the particle selection chamber. As shown in
a. Nasal Cannata
In some embodiments, nasal cannulas connected to the particle selection chamber are designed for their ability to conduct aerosols over extended periods of time at high aerosol output levels to reduce the rainout. The levels of aerosol output from the prongs of the cannula may preferably be sufficient to elicit a therapeutic benefit. Furthermore, the airflow via such cannulas may be in the range where it can be tolerated by patients over extended periods of time and generally lower than 5 L/min. Representative values for therapeutically relevant levels of output based on inhaled hypertonic saline example are discussed in the section
b. Achieving Sufficient Output from the Prongs of Nasal Cannula During Aerosol Administration Over Extended Periods of Time
An excessive rainout occurring in the cannula reduces the aerosol output from the prongs of the cannula to below therapeutic levels and causes patient irritating sputter when such fluid is ejected from the prongs of the nasal cannula into the patient's nose.
In some embodiments, the nasal cannulas are optimized to reduce gravitational sedimentation of the aerosol particles which in turn accumulates as rainout in the cannula, which may be achieved by increasing the diameter of the tubing used in the cannula and/or increasing the velocity at which the aerosol travels through the nasal cannula via an increase of airflow from 1 to 2 L/min to 3 to 4 L/min and higher.
In some embodiments, the nasal cannulas are optimized to reduce inertial impaction of the aerosol particles which in turn accumulate as rainout in the cannula, e.g., via reducing impaction at a bifurcation point of the supply tubing into face-piece tubing.
In some embodiments, the nasal cannulas are optimized to reduce inertial impaction of the aerosol particles which in turn accumulate as rainout in the cannula, e.g., via use of smooth bore tubing for supply tubing and face-piece tubing.
In some embodiments, the nasal cannulas are optimized to reduce inertial impaction of the aerosol particles which in turn accumulate as rainout in the cannula, e.g., via a single face-piece line entering into the face piece.
It should be understood that the balance between inertial impaction and gravitational sedimentation may be considered and/or optimized to achieve a minimal level of rainout.
In heated air CPAP systems without heated tubing, condensation contributes to additional rainout as the air is cooled in the tubing with subsequent condensation of the moisture on the wall of the tubing. In the embodiments of the current invention where heated air is not used, condensation is not a major contributor to rainout as ambient temperature gas is used and the temperature of the gas and the nasal cannula tubing is similar. In embodiments of this invention where heated air is used, condensation may contribute to rainout in the nasal cannulas and appropriate measures to control condensation may be employed.
A conventional nasal cannula 1600 is illustrated in
As illustrated in
In some embodiments, rainout and/or sputtering the may be reduced by using two separate supply lines. As illustrated in
As shown in
In some embodiments, in order to deliver aerosol via nasal cannula over extended periods of time without causing excessive rainout, the nasal cannula and its ability to conduct aerosol over extended periods of time at sufficient output levels may be matched to the aerosol output from the particle selection chamber. For example, nasal cannulas with larger diameter tubing and fewer impaction surfaces may be capable of conducting aerosols with larger volume of particles above 2, 3 and 4 μm respectively. Similarly, nasal cannulas with smaller diameter tubing and more impaction surfaces are only capable of conducting aerosols over extended periods of time at sufficient output levels with smaller volume of particles above 2, 3, and 4 μm respectively. An improved cannula designed for delivery of aerosol over extended periods of time at high levels of output has the largest diameter tubing still tolerated by the patients to minimize rainout in the cannula due to gravitational sedimentation while also reducing the number of impaction surfaces within the aerosol path inside the cannula to minimize rainout occurring via inertial impaction. Embodiments according to the current invention will now be described with respect to the following non-limiting examples.
c. Rates of Aerosol by Volume Deposition in the Lung During Aerosol Administration Over Extended Periods of Time
To provide a representative value for aerosol rate of deposition on the surface of the lung during extended aerosol delivery, deposition based on inhaled hypertonic saline therapy for CF lung disease was analyzed. It has been demonstrated that ˜110 mg to 250 mg of NaCl deposited in the lung of CF patients led to significant improvements in lung function (Elkins MR., Robinson M., Rose B. R., Harbour C., Moriarty C. P., Marks G. B., Belousova E. G., Xuan W., and Bye P. T. P. 2006. A controlled trial of long-term inhaled hypertonic saline in patients with cystic fibrosis. N Engl Med 354(3):229-240; Donaldson S. H., Bennett W. D., Zeman K. L., Knowles M. R., Tarran R., and Boucher R. C. 2006. Mucus clearance and lung function in cystic fibrosis with hypertonic saline. N Engl Jr Med 354(3):241-250) when administered as a bolus aerosol dose for over up to ˜18 minutes. An extended aerosol administration of the same mass of deposited NaCl over extended times of six to eight hours (and up to twenty four hours per day) may elicit better safety and efficacy. In order to deposit 110 mg of NaCl in the lung of CF patients with 8 hour extended aerosol administration, the rate of NaCl mass deposition on the surface of the lung may be about 0.23 mg/min. For 250 mg NaCl dose deposited in the lung, the rate of NaCl mass deposition on the surface of the lung may be about 0.52 mg/min. These rates of NaCl mass deposition define the rates of aerosol volume deposition on the surface of the airway as a function of concentrations of active pharmaceutical ingredient in the drug product. Table 6 provides such rates for the aerosol volume deposition on the surface of the airways as a function of concentration of HS in an aerosolized solution to provide these NaCl (mg) deposition rates.
d. Achieving Sufficient Output from the Prongs of Nasal Cannula During Aerosol Administration Over Extended Periods of Time
The preceding section provided a summary of rates for NaCl mass and aerosolized NaCl solution volume deposited on the surface of the airways per unit of time. The current section discusses the aerosol volume output from the prongs of the device 10 of this invention that would be needed to achieve the rates of pulmonary deposition described in the preceding section, taking into account different deposition efficiencies. Representative deposition efficiencies may be in the ranges of ˜1% to 25%. Different rates of aerosol emission from the prongs of the nasal cannula of the device of this invention are needed to result in the pulmonary deposition of the targeted 250 mg of NaCl achieved over eight hour extended aerosol administration as a function of concentration of aerosolized NaCl solution and deposition efficiencies. Table 7 below provides values for levels of aerosol output from the prongs of nasal cannula (μl/min) for 7% to 21% hypertonic saline in order to deposit 250 mg of NaCl into the lung of CF patients over 8 hours for deposition efficiencies ranging from 1% to 25% of the emitted dose (deposition efficiency=deposited dose/emitted dose from the prongs). It is apparent that at least 30 μl/min of aerosolized 7% HS emitted from the prongs of nasal cannula would be needed assuming very high 25% depositing of such intranasal aerosol in the lung. Higher outputs than 30 μl/min are desirable for intranasally administered aerosols with pulmonary deposition efficiency below 25%. Additionally, such output would have to be generated consistently without abatement over 8 hours without excessive rainout in order to deliver the desirable therapeutic dose and be well-tolerated by the patients. Should 21% hypertonic saline be used, if the deposition efficiency was 25%, an output of 10 μl/min would support administration of 250 mg of NaCl into the deep lung of CF patients. Similarly, an output of ˜50 μl/min from the prongs of the nasal cannula would be needed to achieve 250 mg of NaCl deposited in the lung with 5% deposition efficiency and 7% hypertonic saline. With 1% deposition efficiency, output of ˜745 μl/min from the prongs of the nasal cannula would be needed to achieve 250 mg of NaCl deposited in the lung. If only 50 mg dose of NaCl mass deposited in the lung of patients during eight hour extended aerosol administration would be therapeutically sufficient, with aerosol deposition efficiency of 25% an output of only 2 μl/min of 21% HS aerosol emitted from the prongs of nasal cannula would be needed. For other more potent therapeutic agents, an output of 10-fold or 100-fold lower magnitude (0.2 and 0.02 μl/min respectively) could be sufficient.
From the rates displayed in Table 7 for aerosolized volumes of NaCl solutions emitted from the prongs of the nasal cannula (ul/min), corresponding rates of NaCl mass emission from the prongs of the cannula can be calculated (NaCl concentration (mg/ul)×aerosol emission rate ul/min). The rates for NaCl mass emission from the prongs of the nasal cannula, required to produce dosing rates in the presumed therapeutic range of 0.52 mg/min of NaCl deposited on the surface of the airways, are displayed in Table 8 as a function of deposition efficiency.
e. Reducing Rainout within Nasal Cannula During Extended Aerosol Delivery by Controlling Particle Size Distribution
One of the challenges for extended aerosol delivery via nasal cannula is achieving a therapeutically relevant output from the prongs of the nasal cannula described above while limiting or reducing fluid accumulation in the nasal cannula. Such accumulated fluid, or rainout, ultimately obstructs the nasal cannula and decreases the aerosol output. Rainout additionally causes sputters, or fluid droplets ejected from the prongs of the cannula, which in turn decreases the tolerability for patients. Only aerosols with small volume-normalized percentage of particles greater than 3 to ˜4 μm and overall VMD of 1.2 to 1.9 μm are suitable for extended administration via nasal cannula and subsequent efficient deposition in the lung.
The current jet nebulizers and vibrating mesh nebulizer produce large amount of aerosol particles that are likely because of large size to rainout due to inertial impaction and gravitational sedimentation. These large particles lead to excessive fluid accumulation in the nasal cannula and in patients' nasal passages. Therefore, virtually all large particles need to be removed prior to entraining of such aerosol in the nasal cannula and administering such aerosol intranasally.
Additionally, the pulmonary deposition of aerosols via intranasal route points to reduced deposition efficiency in the vicinity of 1% to 25% of the emitted dose from the prongs of the nasal cannula. The removal of the large aerosol particles, which contain large amount of the aerosol mass, combined with low deposition efficiency, creates a challenge to achieve a sufficient output in terms of aerosol volume/min emitted from the prongs of the nasal cannula without creating excessive rainout in the nasal cannula.
Filtering out larger aerosol particles prior to aerosol entry into the nasal cannula limits the rainout in the cannula and enables stable output over extended aerosol delivery. Tuning of the devices in
In the examples provided below, several cannulas were tested with the device from
f: Limiting Sputter from the Prongs of Nasal Cannula During Extended Aerosol Delivery
An excessive rainout within nasal cannula during extended aerosol delivery ultimately leads to a sputter or ejection of rained out fluid from the prongs of the nasal cannula into patients' nares. Such events, if occurring too frequently, are likely to cause patient discomfort and decrease the tolerability of such aerosol delivery over extended periods of time, especially if patients are asleep. Therefore limiting the sputter from the prongs of the nasal cannula is desirable. A range of 1-2 sputters/hour may be tolerable over extended periods of time while a sputter once every five to ten minutes, and worse yet every minute, is likely to decrease to tolerability of such aerosol delivery over extended periods of time. A properly tuned device as shown in
g. Exemplary Embodiments
A Particle Size Distribution from a Representative Vibrating Mesh Nebulizer
Conventional jet nebulizers, ultrasonic nebulizers and vibrating mesh nebulizers typically produce particles with a relatively wide distribution of particle sizes.
Particle Size Distribution from the Device 10 of this Invention Designed for Stable Aerosol Output Over Extended Aerosol Delivery
The aerosol delivery system 10 as illustrated in
Stable Aerosol Output from Device 10 of this Invention Designed for Stable Aerosol Output Over Extended Aerosol Delivery
The ability to maintain stable output was tested in the course of a 30 minute run with the device 10 of this invention with the specific dimensions of the device in
Diminished Rainout in the Nasal Cannula with the Device 10 of this Invention with 2.5 mm Nozzle
In the 30-minute experiment described above, the mass of the rained out fluid in the nasal cannula after the completion of the 30 minute run was determined by weighing the nasal cannula before and after the 30 minute run. The mass of the liquid rained out in the nasal cannula was approximately 4.4-fold higher in a device in which the entrainment chamber outlet 28 had a diameter at a distal exit end 28B of 3.5 mm nozzle compared with a 2.5 mm diameter distal exit end 28B (241 mg of rained out liquid in the setup with the 2.5 mm diameter end 28B compared to 1,059 mg of rained out liquid in the setup with the 3.5 mm diameter end 28B as shown in
Tuning the Aerosol Output Exiting Port 44 of the Device 10 by Changing the Diameter of the Nozzle 28B
As described in the 30-minute experiment above, changing the diameter of the nozzle 28B enables the tuning of the device 10 performance with regards to the particle size distribution, the steady aerosol output and rainout accumulated within the nasal cannula. The end 28B may be provided as a separate piece from the entrainment chamber 20 and particle selection chamber 40. in some embodiments, the end 28B may be removable such that different sizes of nozzles may be inserted into the chambers 20, 40 for tuning the chamber for increased adjustability and tuning. However, it should be understood that the end 28B may also be integrated into the device 10 without departing from the scope of the invention.
The Dimensions of the Aerosol Entrainment and Particle Selection Chambers of the Device 10
Two sizes of the aerosol delivery system 10 were assembled (
The performance of the smaller device 10 from
Impact of Stable Vs. Pulsatile Airflow on the Performance of Incorporated Nebulization Chamber in
Commonly available peristaltic, diaphragm or rotary vane pumps are often characterized by an average airflow per unit of time such as L/min. However, such average is often a result of pulsatile or oscillating airflow instead of a steady output. Often a compliance chamber, a container of certain volume exceeding multiple times a volume ejected per single operating cycle of such pump, is used to smooth out the amplitudes and produce a stable, uniform output.
To assess flow pulsatility of a peristaltic Pump 130 used in testing of devices in
The ability of the integrated nebulization chamber from
In order to produce a steady airflow from the devices of this invention from
Cannulas for Extended Aerosol Delivery Tested with Device 10 with Dimensions from
Previously, nasal cannulas have been designed to minimize condensation of fully humidified gases passing through them or to enable high gas flow through them as is the case with high flow supplemental oxygen. However, the physics of accumulation of rainout from aerosols, dominated by gravitational sedimentation and inertial impaction, is fundamentally different than the condensation of water vapor that dominates liquid accumulation with humidified gases passing through a nasal cannula. Thus, new nasal cannula designs were implemented to minimize rainout from aerosols passing through the nasal cannula.
In order to deliver aerosol via nasal cannula over extended periods of time without causing excessive rainout, the nasal cannula and its ability to conduct aerosol over extended periods of time at sufficient output levels may be carefully matched to the aerosol output from the particle selection chamber. Nasal cannulas with larger diameter tubing and fewer impaction surfaces are capable of conducting aerosols with larger volume of particles above 2, 3 and 4 μm respectively without rainout. Similarly, nasal cannulas with smaller diameter tubing and more impaction surfaces are only capable of conducting aerosols over extended periods of time at sufficient output levels with smaller volume of particles above 2, 3, and 4 μm respectively without rainout. A cannula designed for delivery of aerosol over extended periods of time at high levels of output should have (1) the largest diameter tubing tolerated by the patients to minimize rainout in the cannula due to gravitational sedimentation and (2) a reduced number of impaction surfaces within the aerosol path inside the cannula to minimize rainout occurring via inertial impaction.
Standard supplemental oxygen nasal cannula such as Salter HF1600 contains 3-9 feet of supply tubing 1610, a bifurcation junction 1620, face-piece tubing 1630, a face piece and prongs 1640 as shown in
Due to such suboptimal performance of existing supplemental oxygen nasal cannulas during extended aerosol delivery, custom cannulas were designed with improved aerosol conducting properties over extended periods of time (
Additionally, such cannulas demonstrated improved performance over 8-hour aerosol delivery with stable output without abatement over 8 hours (
Passive Particle Size Selection Provides Aerosols Suitable for Administration Via Nasal Cannulas Irrespective of Starting Particle Size Distribution from the Aerosol Generator
In some embodiments, passive particle size selection may be provided to produce aerosols having a suitable VMD for administration via nasal cannulas over a period of time that is greater than 30 minutes or as long as two, four, six or eight or ten or twenty-four hours or more irrespective of particle size distribution entering the device of this invention from an aerosol generator. As such, embodiments according to the present invention may be capable of incorporating input from a variety of aerosol generators including vibrating mesh nebulizers, jet nebulizers and ultrasonic nebulizers to produce aerosols having a reduced VMD. Any suitable aerosol generator may be used, including, but not limited to, nebulizers based on vibrating mesh technologies from Aerogen Aeroneb™ Lab, Pro and Solo, Pari Eflow™ vibrating mesh technologies, vibrating horn technologies by Omron™, vibrating mesh or ultrasonic technologies from Phillips and other manufacturers. As such, the device in
B. Dry Powder Administration
To avoid undesired dehydration of airway epithelial cells, and/or achieve one or more other objects as described herein, in addition to the preferred liquid-based nebulizers for administering aerosols for use in carrying out the present invention, dry powder inhaler technology may also be utilized to deliver the desired therapeutic agents described in this invention according to the methods of this invention.
According to this embodiment, instead of administering a bolus of dry powder formulation of the therapeutic agents as is customary with dry powder inhaler technology, an infusion of dry powder is administered to patients in needs of such treatment according to preferred rates of pulmonary deposition for the mass of dry powder-formulated therapeutic agents described herein. For example, for dry powder NaCl therapy, the rates for mass of NaCl per unit of time deposited in the tracheobronchial tree of patients in need of such treatment would be in the range of the preferred rates described in the methods of this invention. According to this embodiment, dry powder inhaler technology of the prior art is configured for administration over long time domains.
Alternatively, intermittent pulses of dry powder formulation of the therapeutic agents administered according to the preferred rates for mass per unit of time of pulmonary deposition as described in the methods of this invention are be also used.
Metered dose inhaler systems and apparatus configured for administration over long time domains can also be used instead of the dry powder inhaler technology to carry out the methods of this invention.
In some embodiments, the aerosol (liquid or dry powder) administering step comprises limiting the rate at which said active agent is administered, so that at least one undesired side-effect of said active agent (e.g., dehydration of lung airway epithelial cells, undesirably high system levels of said active agent, receptor desensitization by said active agent, undesirably short residence time in or on a target tissue at sufficiently high concentration, etc.) is reduced.
In some embodiments, the administering step comprises extending the duration for which said active agent is administered so that at least one desired effect of said active agent (e.g., hydration of airway mucus secretions; enhanced mucus clearance; extended residence time in or on a target tissue at sufficiently high concentration) is enhanced (e.g., as compared to the extent of the desired effect achieved when the same amount of said active agent is administered over a shorter period of time, for example: a time of one half, one third, or one quarter the time of the extended duration administration.
Particular parameters of the administering step will depend upon the particular active agent being administered. For example, where the active agent is an osmolyte that comprises a solution of sodium chloride in water, the sodium chloride may be included in an amount of from 0.5, 1, 2 or 4 percent to 8, 10, 12, 20, 30 or 40 percent by weight and the administering may be carried out by depositing from 0.1 to 3 mg of the sodium chloride to the lung surfaces of said subject per minute.
In some embodiments, the administering step is carried out for a time of 1, 2 or 4 minutes up to 30, 40 or 60 minutes.
In some embodiments, the administering step is carried out for a time of from 30, 40 or 60 minutes up to 2, 4, 6 or 8 hours.
In some embodiments, the administering step is carried out for a time of 2, 4, 6 or 8 hours up to 12 or 24 hours.
In some embodiments, the administering step is carried out overnight and/or while said subject is sleeping.
The present invention is explained in greater detail in the following non-limiting Examples.
Counterintuitive to the prior “faster is better” approach, we found that the administration of an HS aerosol at substantially slower rates (than jet and vibrating mesh nebulizers used in practice) over an extended time domain, improves the therapeutic benefit of HS defined as the integrated (total) increase in airway surface liquid (ASL) volume (or height) for a fixed mass of NaCl deposited on the airways surface. Furthermore, we find that decreasing the delivery rate of HS minimizes an unintended consequences of inhibiting ciliary beating (or mucus clearance) and producing pro-inflammatory mediators e.g. IL-8. These data are described below.
The Effects of HS Delivery Rate on ASL Height (Volume)
The data that generated our discoveries emanate from studies of the effects of HS deposition on ASL hydration utilizing well-differentiated, primary human bronchial epithelial (HBE) cell cultures derived from donor lungs. The HBEs recapitulate a number of properties of the airway epithelia in vivo including 1) differentiation into ciliated cells and goblet cells; 2) ion transport mediated ASL volume regulation; 3) the ability to produce mucins and mucus (Davidson et al., Am J Physiol Lung Cell Mol Physiol. 2000 October; 279(4):L766-78 and Bernacki et al., Am J Respir Cell Mol Biol. 1999 April; 20(4):595-604), and 4) facilitate coordinate transport of the mucus layer (Matsui et al., Cell 95:1005-1015).
To test the effects of 7% HS delivery rate in vitro, we designed a modified ultrasonic nebulizer capable of delivering small, nanoliter volumes of 7% HS to cultures that simulate pulmonary deposition rates in vivo from different nebulizer systems.
We compared the change in ASL height (i.e. hydration) following the deposition of 7% HS using deposition rates and delivery times which model what is achieved when HS is administered in vivo from different nebulizer devices. As shown in
Mechanistic Basis for Increased Integrated Efficacy with Slow HS Delivery
The mechanisms mediating this unexpected result are complex. The ASL volume (hydration) response to rates of deposition mimicking the LC Plus, is initially linear with time subsequently plateaus during continued aerosolization, and rapidly returns to baseline after cessation of the aerosol due to the activity of sodium absorption (inhibited by amiloride) (
Molecular Basis for Cell Shrinkage with Rapid HS Delivery
When hypertonic saline is presented to the apical surface of airway epithelia, it raises the osmolarity (tonicity) of the ambient airway surface liquid. Water then flows through water channels contained in the airway epithelia from the submucosal (blood facing side) space to the airway lumen restore the isotonicity of the ASL. Note, the apical membrane is more water permeable than the basolateral membrane, i.e. the cell functions as an “osmometer” that traces ALS osmolarity. If the hypertonic saline is presented at rates faster than water can move from the submucosal space into the cell across the less permeable basolateral membrane, hyperosmolar (hypertonic) liquid on the airway surfaces draws water selectively from the lining airway epithelial cells across the more permeable apical membrane, causing cell shrinkage (collapse). The airway epithelial cells defend themselves from volume depletion and shrinkage by reducing water permeability from the cell membrane contiguous with the airway surface liquid (i.e. the ‘apical’ membrane), limiting the capacity of the cell to conduct water flow. As expected by this hypothesis, we observed that at low deposition rates, the ASL height (volume) reflects what is predicted from the mass of salt delivered and the amount of water drawn from the submucosa to render the ASL isotonic (
Therefore, these in vitro data indicate that when hypertonic saline is delivered at a high rate, the hydrating activity of inhaled hypertonic saline is reduced by: 1) the reduced capacity of the epithelium to conduct water from the isotonic sub-epithelial space (that contains blood vessels) to the hypertonic ASL; and 2) the active transepithelial absorption of NaCl by the airway epithelium as it is delivered and reaches high concentration. In contrast, slow, “gentle” delivery of HS produces more modest increases in airway surface liquid osmolarity (tonicity), so that (1) there is no cell shrinkage induced reduction of the transepithelial osmotic water flow and (2) the concentration of Na+ and Cl− in ASL do not rise to sufficiently high levels to accelerate transepithelial Na+ (and Cl− H2O) adsorption of the aerosol-deposited NaCl.
Slow Delivery of HS Minimizes the Effects of HS on Ciliastasis
Data from several otolaryngology studies indicate that topical application of hypertonic saline (HS) to the nasopharynx results in significant inhibition of ciliary beat frequency (CBF). These studies were done with bolus administrations of HS similar to the method of rapid HS delivery used in current clinical practice. While HS is well documented to increase airways hydration, the inhibition or slowing of ciliary beating would detract from the overall therapeutic goal of increasing mucus clearance. Little is known about how hypertonic solutions affects cilia beating in human lower airway epithelial cells when given in deposition rates consistent with current clinical inhalation nebulizers (i.e. in the range of nanoliters/min/cm2). As shown in
Rapid HS Delivery at Deposition Rates Based on HS Administration Via Pali LC Star and eFlow Leads to Pro-Inflammatory Cytokine Release
The rates of NaCl mass deposition representative of HS administration via Pari LC Star (˜3.4 mg/min/lung in human subjects and 7 μg/min/cm2 in cell culture) and eFlow (˜6.6 mg/min/lung in human subjects and 14 μg/min/cm2 in cell culture) technologies lead to IL-8 cytokine secretion in airway cell culture models (
The Use of Higher than 7% HS Formulations with Proportionally Reduced Aerosol Deposition Rates Leads to Increases in ASL Height
As outlined above, low rates of NaCl mass deposition appear to be key for safe administration of inhaled HS. 110 mg and 250 mg of NaCl administered into the lungs of CF patients via rapid “bolus” administration, previously shown to be therapeutically effective, into the lung of CF patients over 8 hour extended aerosol administration, i.e. at “slow” rates, are unlikely to release IL-8 and induce ciliastasis. One way to achieve such rates is to use higher than 7% HS formulations. To explore the impact of NaCl delivery at an identical rate to cultures utilizing varying HS % at inverse of aerosol deposition rates, the effect of 7% HS (deposited at 100 nl/min/cm2) and 14% HS (deposited at 50 nl/min/cm2) formulations on the airway surface liquid height, ciliastasis and IL-8 release was explored. 7% and 14% HS formulations, administered as aerosols at the rates of 100 nl/min/cm2 versus 50 nl/min/cm2 onto the surface of the airway cell culture model to both achieving NaCl deposition rates of 7 μg/min/cm2, elicited a similar increase in ASL height (
The Use of Higher than 7% HS Formulations with Proportionally Reduced Aerosol Deposition Rates does not Induce IL-8 Secretion
The effects of aerosol delivery rate and % HS formulation on IL-8 secretion were explored (
Slow Extended Administration of HS Aerosol Over 8 Hours Leads to Sustained Restoration of the ASL without Desensitization
The effect of extended administration of HS on the airway surface was explored for sustained increase in ASL height. 7% HS aerosol was delivered onto the airway surface for 8 hours at a “slow” rate of 1.75 μg/min/com2. A sustained increase in ASL height was produced that was maintained without abatement over the 8 hours of extended aerosol administration (
Embodiments of the Invention
A method of treating at least one lung/the lungs of a subject in need thereof,
comprising:
administering an active agent to the at least one lung/the lungs of a subject.
A method according to any preceding embodiment, wherein the administering is carried out by aerosol inhalation over extended periods of time via nasal cannula or face mask.
A method according to any preceding embodiment, wherein the administering is carried out by inhalation administration.
A method according to any preceding embodiment, wherein said administering step is carried out by a nasal cannula, face mask, or positive airway pressure mask (e.g., a continuous positive airway pressure (CPAP) mask or a bilevel positive airway pressure (biPAP) mask).
A method according to any preceding embodiment, wherein the administering is carried out by administration of the active agent to airway surfaces.
A method according to any preceding embodiment, wherein the administering is effective to enhance mucus clearance from at least one lung of the subject.
A method according to any preceding embodiment, wherein the administering step is a sustained administering or infusion administering step.
A method according to any preceding embodiment, wherein the administering step comprises limiting the amount of said active agent administered, and/or limiting the rate at which said active agent is administered, so that at least one undesired side-effect of said active agent (e.g., dehydration of lung airway epithelial cells, undesirably high systemic levels of said active agent, receptor desensitization by said active agent, undesirably short residence time in or on a target tissue at sufficiently high concentration, etc.) is reduced.
A method according to any preceding embodiment, wherein the administering step comprises extending the duration for which said active agent is administered so that at least one desired effect of said active agent (e.g., hydration of airway mucus secretions; enhanced mucus clearance; extended residence time in or on a target tissue at sufficiently high concentration) is enhanced (e.g., as compared to the extent of the desired effect achieved when the same amount of said active agent is administered over a shorter period of time, for example: a time of one half, one third, or one quarter the time of the extended duration administration).
A method according to any preceding embodiment, wherein the active agent is a hydrating agent (e.g., an osmolyte, sodium channel blocker, or secretogogue (e.g., a P2Y2 receptor agonist)), a mucus modifying agent (e.g., a reducing agent, a surfactant, an expectorant, DNase), an anti-infective agent, an anti-inflammatory agent, a bronchodilator, NO or an NO donor, another therapeutic agent, or a combination thereof.
A method according to any preceding embodiment, wherein the active agent is a type II antibiotic (e.g., carbapenems, cephalosporins, erythromycin, linezolid, penicillins, etc.) or a type III antibiotic (e.g., azithromycin, clinndamycin, oxazolidinones, tetracyclines, vancomycin, etc.), another therapeutic agent, or a combination thereof.
A method according to any preceding embodiment, wherein the active agent is antivirals such as ribavirin, bronchodilators, siRNAs, gene therapy vectors, aptamers, endothelia-receptor antagonists, alpha-1-antitrypsin orprostacyclins.
A method according to any preceding embodiment, wherein the active agent is a combination of two or more active agents including any combinations of hydrating agents (e.g., an osmolyte, sodium channel blocker, or secretogogue (e.g., a P2Y2 receptor agonist)), mucus modifying agents (e.g., a reducing agent, a surfactant, an expectorant, DNase), anti-infective agents, anti-inflammatory agents, bronchodilators, NO or an NO donors, type II antibiotics (e.g., carbapenems, cephalosporins, erythromycin, linezolid, penicillins, etc.), type III antibiotics (e.g., azithromycin, clinndamycin, oxazolidinones, tetracyclines, vancomycin, etc.), antivirals such as ribavirin, bronchodilators, siRNAs, gene therapy vectors, aptamers, endothelin-receptor antagonists, alpha-1-antitrypsin, prostacyclins or other therapeutic agents.
A method according to any preceding embodiment, wherein said subject is afflicted with cystic fibrosis, chronic bronchitis, emphysema, sinus-related disorders such as rhinitis and sinusitis, chronic obstructive pulmonary disease, aspiration pneumonitis, asthma, and/or a bacterial, viral or fungal infection of the lungs.
A method according to any preceding embodiment, wherein said administering step is carried out for a time of 1, 2 or 4 minutes up to 30, 40 or 60 minutes.
A method according to any preceding embodiment, wherein said administering step is carried out for a time of from 30, 40 or 60 minutes up to 2, 4, 6 or 8 hours.
A method according to any preceding embodiment, wherein said administering step is carried out for a time of 2, 4, 6 or 8 hours up to 12 or 24 hours.
A method according to any preceding embodiment, wherein said administering step is carried out overnight and/or while said subject is sleeping.
A composition comprising an active agent as described herein in a pharmaceutically acceptable carrier for use in carrying out a method of any preceding embodiment.
An aerosol generator or nebulizer (e.g., as described herein) for use in carrying out a method of any preceding embodiment.
The foregoing is illustrative of the present invention, and is not to be construed as limiting thereof.
This application is a continuation of U.S. Utility Application No.: 13,491,275, filed Jun. 7, 2012, which claims the benefit of and priority from U.S. Provisional Patent Application Ser. No. 61/494,198, filed Jun. 7, 2011, U.S. Provisional Patent Application Ser. No. 61/496,317, filed Jun. 13, 2011, and U.S. Provisional Patent Application Ser. No. 61/639,619, filed Apr. 27, 2012, the contents of each of which are incorporated herein by reference in their entirety.
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