U.S. patent application number 10/194805 was filed with the patent office on 2004-01-15 for transdermal botulinum toxin compositions.
This patent application is currently assigned to Allergan, Inc.. Invention is credited to Donovan, Stephen.
Application Number | 20040009180 10/194805 |
Document ID | / |
Family ID | 30114842 |
Filed Date | 2004-01-15 |
United States Patent
Application |
20040009180 |
Kind Code |
A1 |
Donovan, Stephen |
January 15, 2004 |
Transdermal botulinum toxin compositions
Abstract
Pharmaceutical compositions for transdermal administration of
neurotoxins to a patient include a neurotoxin, such as a botulinum
toxin, and an enhancing agent that facilitates absorption of the
neurotoxin through the skin of the patient and does not eliminate
the bioactivity associated with the neurotoxin. The pharmaceutical
compositions are topically applied on a patient, and may be
provided in a transdermal patch.
Inventors: |
Donovan, Stephen;
(Capistrano Beach, CA) |
Correspondence
Address: |
STEPHEN DONOVAN
ALLERGAN, INC.
2525 Dupont Drive, T2-7H
Irvine
CA
92612
US
|
Assignee: |
Allergan, Inc.
|
Family ID: |
30114842 |
Appl. No.: |
10/194805 |
Filed: |
July 11, 2002 |
Current U.S.
Class: |
424/184.1 |
Current CPC
Class: |
A61P 1/02 20180101; A61K
38/4893 20130101; A61P 25/14 20180101; A61P 25/02 20180101; A61K
31/045 20130101; A61P 25/04 20180101; A61K 47/10 20130101; A61P
9/14 20180101; A61P 17/00 20180101; A61P 25/06 20180101; A61P 29/00
20180101; A61K 9/127 20130101; A61P 25/00 20180101; A61K 9/7084
20130101; Y02A 50/30 20180101; A61P 21/02 20180101; A61K 41/0028
20130101; A61N 7/00 20130101; A61P 27/02 20180101; A61P 21/00
20180101 |
Class at
Publication: |
424/184.1 |
International
Class: |
A61K 039/00; A61K
039/38; A61K 009/70; A61F 013/00 |
Claims
I claim:
1. A pharmaceutical composition comprising: a stabilized botulinum
toxin; and at least one enhancing agent for facilitating
transdermal delivery of the botulinum toxin into a human patient by
enhancing the permeability of the patient's skin.
2. The composition of claim 1, wherein the botulinum toxin is
selected from the group consisting of botulinum toxin types A, B,
C.sub.1, D, E, F and G.
3. The composition of claim 1, wherein the botulinum toxin is
botulinum toxin type A.
4. The composition of claim 1, wherein the botulinum toxin is a
purified botulinum toxin.
5. The composition of claim 1, wherein the composition comprises
between about 1 units to about 20,000 units of botulinum toxin.
6. The composition of claim 1, wherein the composition comprises an
amount of botulinum toxin to achieve a therapeutic effect lasting
between 1 month and 5 years.
7. The composition of claim 1, wherein the enhancing agent is an
alcohol.
8. The composition of claim 7, wherein the alcohol is a
polyalcohol.
9. The composition of claim 1, wherein the enhancing agent
comprises a transfersome.
10. The composition of claim 1, wherein the composition comprises a
plurality of enhancing agents.
11. A pharmaceutical composition in a transdermal patch, the
pharmaceutical composition comprising: a stabilized botulinum toxin
that permeates through a human patient's skin without permeating in
significant amount through a blood vessel when the botulinum toxin
interacts with an enhancing agent provided in the transdermal patch
to cause a therapeutic effect of a disorder associated with
exocytosis of a molecule from a cell.
12. The composition of claim 11, wherein the botulinum toxin is
provided in a dry state in the transdermal patch before the patch
is applied to the patient's skin.
13. The composition of claim 11, wherein the botulinum toxin is
botulinum toxin type A.
14. The composition of claim 11, wherein the botulinum toxin is
mixed with the enhancing agent after the transdermal patch is
applied to the patient's skin.
15. The composition of claim 14, wherein the botulinum toxin mixes
with an enhancing agent that is applied to the patient's skin
before the transdermal patch is applied to the patient's skin.
16. A transdermal patch, comprising a pharmaceutical composition,
which comprises: a stabilized botulinum toxin; and an enhancing
agent that facilitates transdermal administration of the botulinum
toxin in a bioactive form to a subdermal target site of a human
patient without being administered to the patient's circulatory
system; and an adhesive disposed on one side of the transdermal
patch to removably secure the patch to the patient's skin.
17. The transdermal patch of claim 16, wherein the adhesive is
disposed around a depot containing the pharmaceutical
composition.
18. The transdermal patch of claim 16, further comprising a
plurality of needles extending from one side of the patch that is
applied to the skin, wherein the needles extend from the patch to
project through the stratum corneum of the skin without rupturing a
blood vessel.
19. The transdermal patch of claim 18, wherein the botulinum toxin
is provided in a depot in the patch so that pressure applied to the
patch causes botulinum toxin to be directed through the needles and
under the stratum corneum.
20. The transdermal patch of claim 16, wherein the botulinum toxin
is provided in a dry state in a plurality of wells, each of the
wells covered by a membrane that is dissolvable with a fluid, and
wherein the enhancing agent mixes with the botulinum toxin as the
membrane over a well dissolves so that the absorption of the
botulinum toxin is enhanced.
21. The transdermal patch of claim 16, wherein the botulinum toxin
is botulinum toxin type A.
22. A method of reducing neurotransmitter release in a subdermal
structure of a patient, the method comprising the steps of: (a)
non-chemically disrupting the stratum corneum of the patient's skin
to reduce impermeability of the stratum corneum; and (b) applying
botulinum toxin to the skin of the patient in an area that has had
the stratum corneum disrupted in step (a).
23. The method of claim 22, wherein the stratum corneum is
disrupted by abrasively removing the stratum corneum.
24. The method of claim 22, wherein the stratum corneum is
disrupted by applying an adhesive material to the patient's skin,
and removing the adhesive material applied thereto.
25. The method of claim 22, wherein the stratum corneum is
disrupted by applying ultrasound at a frequency between 20 kHz and
less than 10 MHz at an intensity that does not permanently damage
the patient's skin.
26. The method of claim 22, wherein the stratum corneum is
disrupted by passing electrical current from a first point on the
patient's skin to a second point on the patient's skin.
27. The method of claim 26, wherein the electrical current is
passed to create a plurality of pores in the stratum corneum to
enhance passage of botulinum toxin to the subdermal structures.
28. The method of claim 22, wherein the botulinum toxin is selected
from a group of botulinum toxins consisting of types A, B, C, D, E,
F, and G.
29. The method of claim 22, wherein the botulinum toxin is applied
in a pharmaceutical composition comprising an enhancing agent for
enhancing the delivery of the botulinum toxin through the skin.
30. The method of claim 22, wherein the botulinum toxin is
incorporated into a transfersome.
31. A method of relieving pain in a patient caused by a spastic
muscle, the method comprising the steps of: (a) applying ultrasound
at a frequency between about 10 kHz and 1 MHz to the patient's skin
overlying the spastic muscle; and (b) applying botulinum toxin to
the patient's skin that has received the ultrasound in step
(a).
32. The method of claim 31, further comprising a step of abrasively
removing portions of the stratum corneum of the patient's skin that
received the ultrasound.
33. The method of claim 31, wherein the botulinum toxin is
botulinum toxin type A.
34. The method of claim 31, wherein the botulinum toxin is
administered in a composition comprising an enhancing agent that
facilitates penetration of the botulinum toxin through the
patient's skin.
35. The method of claim 31, wherein the botulinum toxin is applied
in a transdermal patch applied to the patient's skin.
Description
[0001] The present invention relates to pharmaceutical compositions
containing neurotoxins. In particular, the present invention
relates to compositions containing clostridial neurotoxins, such as
botulinum toxin, for transdermal topical administration to
patients.
BACKGROUND
[0002] Botulinum Toxin
[0003] The genus Clostridium has more than one hundred and twenty
seven species, grouped according to their morphology and functions.
The anaerobic, gram positive bacterium Clostridium botulinum
produces a potent polypeptide neurotoxin, botulinum toxin, which
causes a neuroparalytic illness in humans and animals referred to
as botulism. The spores of Clostridium botulinum are found in soil
and can grow in improperly sterilized and sealed food containers of
home based canneries, which are the cause of many of the cases of
botulism. The effects of botulism typically appear 18 to 36 hours
after eating the foodstuffs infected with a Clostridium botulinum
culture or spores. The botulinum toxin can apparently pass
unattenuated through the lining of the gut and attack peripheral
motor neurons. Symptoms of botulinum toxin intoxication can
progress from difficulty walking, swallowing, and speaking to
paralysis of the respiratory muscles and death.
[0004] Botulinum toxin type A is the most lethal natural biological
agent known to man. About 50 picograms of a commercially available
botulinum toxin type A (purified neurotoxin complex).sup.1 is a
LD.sub.50 in mice (i.e. 1 unit). One unit of BOTOX.RTM. contains
about 50 picograms (about 56 attomoles) of botulinum toxin type A
complex. Interestingly, on a molar basis, botulinum toxin type A is
about 1.8 billion times more lethal than diphtheria, about 600
million times more lethal than sodium cyanide, about 30 million
times more lethal than cobra toxin and about 12 million times more
lethal than cholera. Singh, Critical Aspects of Bacterial Protein
Toxins, pages 63-84 (chapter 4) of Natural Toxins II, edited by B.
R. Singh et al., Plenum Press, New York (1976) (where the stated
LD.sub.50 of botulinum toxin type A of 0.3 ng equals 1 U is
corrected for the fact that about 0.05 ng of BOTOX.RTM. equals 1
unit). One unit (U) of botulinum toxin is defined as the LD.sub.50
upon intraperitoneal injection into female Swiss Webster mice
weighing 18 to 20 grams each.
[0005] Seven botulinum neurotoxins have been characterized, these
being respectively botulinum neurotoxin serotypes A, B, C.sub.1, D,
E, F and G each of which is distinguished by neutralization with
type-specific antibodies. The different serotypes of botulinum
toxin can vary in the animal species that they affect and in the
severity and duration of the paralysis they evoke. Botulinum toxin
apparently binds with high affinity to cholinergic motor neurons,
is translocated into the neuron and blocks the release of
acetylcholine. .sup.1Available from Allergan, Inc., of Irvine,
Calif. under the tradename BOTOX.RTM. in 100 unit vials)
[0006] Regardless of serotype, the molecular mechanism of toxin
intoxication appears to be similar and to involve at least three
steps or stages. In the first step of the process, the toxin binds
to the presynaptic membrane of the target neuron through a specific
interaction between the heavy chain, H chain, and a cell surface
receptor; the receptor is thought to be different for each type of
botulinum toxin and for tetanus toxin. The carboxyl end segment of
the H chain, H.sub.C, appears to be important for targeting of the
toxin to the cell surface.
[0007] In the second step, the toxin crosses the plasma membrane of
the poisoned cell. The toxin is. first engulfed by the cell through
receptor-mediated endocytosis, and an endosome containing the toxin
is formed. The toxin then escapes the endosome into the cytoplasm
of the cell. This step is thought to be mediated by the amino end
segment of the H chain, HN, which triggers a conformational change
of the toxin in response to a pH of about 5.5 or lower. Endosomes
are known to possess a proton pump which decreases intra-endosomal
pH. The conformational shift exposes hydrophobic residues in the
toxin, which permits the toxin to embed itself in the endosomal
membrane. The toxin (or at a minimum the light chain) then
translocates through the endosomal membrane into the cytoplasm.
[0008] The last step of the mechanism of botulinum toxin activity
appears to involve reduction of the disulfide bond joining the
heavy chain, H chain, and the light chain, L chain. The entire
toxic activity of botulinum and tetanus toxins is contained in the
L chain of the holotoxin; the L chain is a zinc (Zn++)
endopeptidase which selectively cleaves proteins essential for
recognition and docking of neurotransmitter-containing vesicles
with the cytoplasmic surface of the plasma membrane, and fusion of
the vesicles with the plasma membrane. Tetanus neurotoxin,
botulinum toxin types B, D, F, and G cause degradation of
synaptobrevin (also called vesicle-associated membrane protein
(VAMP)), a synaptosomal membrane protein. Most of the VAMP present
at the cytoplasmic surface of the synaptic vesicle is removed as a
result of any one of these cleavage events. Botulinum toxin
serotype A and E cleave SNAP-25. Botulinum toxin serotype C.sub.1
was originally thought to cleave syntaxin, but was found to cleave
syntaxin and SNAP-25. Each of the botulinum toxins specifically
cleaves a different bond, except botulinum toxin type B (and
tetanus toxin) which cleave the same bond.
[0009] Botulinum toxins have been used in clinical settings for the
treatment of neuromuscular disorders characterized by hyperactive
skeletal muscles. A botulinum toxin type A complex (BOTOX.RTM.) has
been approved by the U.S. Food and Drug Administration for the
treatment of blepharospasm, strabismus and hemifacial spasm,
cervical dystonia and treatment of glabellar wrinkles. A type B
botulinum toxin (MYOBLOC.TM.) has also been approved by the FDA for
the treatment of cervical dystonia. Non-type A botulinum toxin
serotypes apparently have a lower potency and/or a shorter duration
of activity as compared to botulinum toxin type A. Clinical effects
of peripheral intramuscular botulinum toxin type A are usually seen
within a day or a few hours after injection. The typical duration
of symptomatic relief from a single intramuscular injection of
botulinum toxin type A averages about three to four months.
[0010] Although all the botulinum toxins serotypes apparently
inhibit release of the neurotransmitter acetylcholine at the
neuromuscular junction, they do so by affecting different
neurosecretory proteins and/or cleaving these proteins at different
sites. For example, botulinum types A and E both cleave the 25
kiloDalton (kD) synaptosomal associated protein (SNAP-25), but they
target different amino acid sequences within this protein.
Botulinum toxin types B, D, F and G act on vesicle-associated
protein (VAMP, also called synaptobrevin), with each serotype
cleaving the protein at a different site. Finally, botulinum toxin
type C.sub.1 has been shown to cleave both syntaxin and SNAP-25.
These differences in mechanism of action may affect the relative
potency and/or duration of action of the various botulinum toxin
serotypes. Apparently, a substrate for a botulinum toxin can be
found in a variety of different cell types. See e.g. Biochem, J
1;339 (pt 1):159-65:1999, and Mov Disord, 10(3):376:1995
(pancreatic islet B cells contains at least SNAP-25 and
synaptobrevin).
[0011] The molecular weight of the botulinum toxin protein
molecule, for all seven of the known botulinum toxin serotypes, is
about 150 kD. Interestingly, the botulinum toxins are released by
Clostridial bacterium as complexes comprising the 150 kD botulinum
toxin protein molecule along with associated non-toxin proteins.
Thus, the botulinum toxin type A complex can be produced by
Clostridial bacterium as 900 kD, 500 kD and 300 kD forms. Botulinum
toxin types B and C.sub.1 is apparently produced as only a 700 kD
or 500 kD complex. Botulinum toxin type D is produced as both 300
kD and 500 kD complexes. Finally, botulinum toxin types E and F are
produced as only approximately 300 kD complexes. The complexes
(i.e. molecular weight greater than about 150 kD) are believed to
contain a non-toxin hemaglutinin protein and a non-toxin and
non-toxic nonhemaglutinin protein. These two non-toxin proteins
(which along with the botulinum toxin molecule comprise the
relevant neurotoxin complex) may act to provide stability against
denaturation to the botulinum toxin molecule and protection against
digestive acids when toxin is ingested. Additionally, it is
possible that the larger (greater than about 150 kD molecular
weight) botulinum toxin complexes may result in a slower rate of
diffusion of the botulinum toxin away from a site of intramuscular
injection of a botulinum toxin complex.
[0012] In vitro studies have indicated that botulinum toxin
inhibits potassium cation induced release of both acetylcholine and
norepinephrine from primary cell cultures of brainstem tissue.
Additionally, it has been reported that botulinum toxin inhibits
the evoked release of both glycine and glutamate in primary
cultures of spinal cord neurons and that in brain synaptosome
preparations botulinum toxin inhibits the release of each of the
neurotransmitters acetylcholine, dopamine, norepinephrine
(Habermann E., et al., Tetanus Toxin and Botulinum A and C
Neurotoxins Inhibit Noradrenaline Release From Cultured Mouse
Brain, J Neurochem 51 (2);522-527:1988) CGRP, substance P and
glutamate (Sanchez-Prieto, J., et al., Botulinum Toxin A Blocks
Glutamate Exocytosis From Guinea Pig Cerebral Cortical
Synaptosomes, Eur J. Biochem 165;675-681:1897. Thus, when adequate
concentrations are used, stimulus-evoked release of most
neurotransmitters is blocked by botulinum toxin. See e.g. Pearce,
L. B., Pharmacologic Characterization of Botulinum Toxin For Basic
Science and Medicine, Toxicon 35(9);1373-1412 at 1393; Bigalke H.,
et al., Botulinum A Neurotoxin Inhibits Non-Cholinergic Synaptic
Transmission in Mouse Spinal Cord Neurons in Culture, Brain
Research 360;318-324:1985; Habermann E., Inhibition by Tetanus and
Botulinum A Toxin of the release of [.sup.3H]Noradrenaline and
[.sup.H]GABA From Rat Brain Homogenate, Experientia
44;224-226:1988, Bigalke H., et al., Tetanus Toxin and Botulinum A
Toxin Inhibit Release and Uptake of Various Transmitters, as
Studied with Particulate Preparations From Rat Brain and Spinal
Cord, Naunyn-Schmiedeberg's Arch Pharmacol 316;244-251:1981, and;
Jankovic J. et al., Therapy With Botulinum Toxin, Marcel Dekker,
Inc., (1994), page 5.
[0013] Botulinum toxin type A can be obtained by establishing and
growing cultures of Clostridium botulinum in a fermenter and then
harvesting and purifying the fermented mixture in accordance with
known procedures. All the botulinum toxin serotypes are initially
synthesized as inactive single chain proteins which must be cleaved
or nicked by proteases to become neuroactive. The bacterial strains
that make botulinum toxin serotypes A and G possess endogenous
proteases and serotypes A and G can therefore be recovered from
bacterial cultures in predominantly their active form. In contrast,
botulinum toxin serotypes C.sub.1, D and E are synthesized by
nonproteolytic strains and are therefore typically unactivated when
recovered from culture. Serotypes B and F are produced by both
proteolytic and nonproteolytic strains and therefore can be
recovered in either the active or inactive form. However, even the
proteolytic strains that produce, for example, the botulinum toxin
type B serotype only cleave a portion of the toxin produced. The
exact proportion of nicked to unnicked molecules depends on the
length of incubation and the temperature of the culture. Therefore,
a certain percentage of any preparation of, for example, the
botulinum toxin type B toxin is likely to be inactive, possibly
accounting for the known significantly lower potency of botulinum
toxin type B as compared to botulinum toxin type A.
[0014] High quality crystalline botulinum toxin type A can be
produced from the Hall A strain of Clostridium botulinum with
characteristics of .gtoreq.3.times.10.sup.7 U/mg, an
A.sub.260/A.sub.278 of less than 0.60 and a distinct pattern of
banding on gel electrophoresis. The known Shantz process can be
used to obtain crystalline botulinum toxin type A, as set forth in
Shantz, E. J., et al, Properties and use of Botulinum toxin and
Other Microbial Neurotoxins in Medicine, Microbiol Rev.
56;80-99:1992. Generally, the botulinum toxin type A complex can be
isolated and purified from an anaerobic fermentation by cultivating
Clostridium botulinum type A in a suitable medium. The known
process can also be used, upon separation out of the non-toxin
proteins, to obtain pure botulinum toxins, such as for example:
purified botulinum toxin type A with an approximately 150 kD
molecular weight with a specific potency of 1-2.times.10.sup.8
LD.sub.50 U/mg or greater; purified botulinum toxin type B with an
approximately 156 kD molecular weight with a specific potency of
1-2.times.10.sup.8 LD.sub.50 U/mg or greater, and; purified
botulinum toxin type F with an approximately 155 kD molecular
weight with a specific potency of 1-2.times.10.sup.7LD.sub.50 U/mg
or greater.
[0015] Botulinum toxins and/or botulinum toxin complexes can be
obtained from Allergan Inc (Irvine, Calif.), Ipsen Beaufour
(France), Elan Pharmaceuticals (Ireland), List Biological
Laboratories, Inc., Campbell, Calif.; the Centre for Applied
Microbiology and Research, Porton Down, U.K.; Wako (Osaka, Japan),
Metabiologics (Madison, Wis.) as well as from Sigma Chemicals of St
Louis, Mo.
[0016] Though somewhat labile, pure botulinum toxin can be used to
prepare a pharmaceutical composition and like the botulinum toxin
complexes, such as the toxin type A complex, is susceptible to
denaturation due to surface denaturation, heat, and alkaline
conditions. Inactivated toxin forms toxoid proteins which may be
immunogenic. The resulting antibodies can render a patient
refractory to toxin injection.
[0017] As with enzymes generally, the biological activities of the
botulinum toxins (which are intracellular peptidases) is dependent,
at least in part, upon their three dimensional conformation. Thus,
botulinum toxin type A is detoxified by heat, various chemicals
surface stretching and surface drying. Additionally, it is known
that dilution of the toxin complex obtained by the known culturing,
fermentation and purification to the much, much lower toxin
concentrations used for pharmaceutical composition formulation
results in rapid detoxification of the toxin unless a suitable
stabilizing agent is present. Dilution of the toxin from milligram
quantities to a solution containing nanograms per milliliter
presents significant difficulties because of the rapid loss of
specific toxicity upon such great dilution. Since the toxin may be
used months or years after the toxin containing pharmaceutical
composition is formulated, the toxin can be stabilized with a
stabilizing agent such as albumin and gelatin.
[0018] A commercially available botulinum toxin containing
pharmaceutical composition is sold under the trademark BOTOX.RTM.
(available from Allergan, Inc., of Irvine, Calif.). BOTOX.RTM.
consists of a purified botulinum toxin type A complex, albumin and
sodium chloride packaged in sterile, vacuum-dried form. The
botulinum toxin type A is made from a culture of the Hall strain of
Clostridium botulinum grown in a medium containing N-Z amine and
yeast extract. The botulinum toxin type A complex is purified from
the culture solution by a series of acid precipitations to a
crystalline complex consisting of the active high molecular weight
toxin protein and an associated hemagglutinin protein. The
crystalline complex is re-dissolved in a solution containing saline
and albumin and sterile filtered (0.2 microns) prior to
vacuum-drying. The vacuum-dried product is stored in a freezer at
or below -5.degree. C. BOTOX.RTM. can be reconstituted with
sterile, non-preserved saline prior to intramuscular injection.
Each vial of BOTOX.RTM. contains about 100 units (U) of Clostridium
botulinum toxin type A purified neurotoxin complex, 0.5 milligrams
of human serum albumin and 0.9 milligrams of sodium chloride in a
sterile, vacuum-dried form without a preservative.
[0019] To reconstitute vacuum-dried BOTOX.RTM., sterile normal
saline without a preservative; (0.9% Sodium Chloride Injection) is
used by drawing up the proper amount of diluent in the appropriate
size syringe. Since BOTOX.RTM. may be denatured by bubbling or
similar violent agitation, the diluent is gently injected into the
vial. For sterility reasons BOTOX.RTM. is preferably administered
within four hours after the vial is removed from the freezer and
reconstituted. During these four hours, reconstituted BOTOX.RTM.
can be stored in a refrigerator at about 2.degree. C. to about
8.degree. C. Reconstituted, refrigerated BOTOX.RTM. has been
reported to retain its potency for at least about four weeks.
Dermatol Surg 1996 Jan;22(1):39-43.
[0020] It has been reported that botulinum toxin type A has been
used in clinical settings as follows:
[0021] (1) about 75-125 units of BOTOX.RTM. per intramuscular
injection (multiple muscles) to treat cervical dystonia;
[0022] (2) 5-10 units of BOTOX.RTM. per intramuscular injection to
treat glabellar lines (brow furrows) (5 units injected
intramuscularly into the procerus muscle and 10 units injected
intramuscularly into each corrugator supercilii muscle);
[0023] (3) about 30-80 units of BOTOX.RTM. to treat constipation by
intrasphincter injection of the puborectalis muscle;
[0024] (4) about 1-5 units per muscle of intramuscularly injected
BOTOX.RTM. to treat blepharospasm by injecting the lateral
pre-tarsal orbicularis oculi muscle of the upper lid and the
lateral pre-tarsal orbicularis oculi of the lower lid.
[0025] (5) to treat strabismus, extraocular muscles have been
injected intramuscularly with between about 1-5 units of
BOTOX.RTM., the amount injected varying based upon both the size of
the muscle to be injected and the extent of muscle paralysis
desired (i.e. amount of diopter correction desired).
[0026] (6) to treat upper limb spasticity following stroke by
intramuscular injections of BOTOX.RTM. into five different upper
limb flexor muscles, as follows:
[0027] (a) flexor digitorum profundus: 7.5 U to 30 U
[0028] (b) flexor digitorum sublimus: 7.5 U to 30 U
[0029] (c) flexor carpi ulnaris: 10 U to 40 U
[0030] (d) flexor carpi radialis: 15 U to 60 U
[0031] (e) biceps brachii: 50 U to 200 U. Each of the five
indicated muscles has been injected at the same treatment session,
so that the patient receives from 90 U to 360 U of upper limb
flexor muscle BOTOX.RTM. by intramuscular injection at each
treatment session.
[0032] (7) to treat migraine, pericranial injected (injected
symmetrically into glabellar, frontalis and temporalis muscles)
injection of 25 U of BOTOX.RTM. has showed significant benefit as a
prophylactic treatment of migraine compared to vehicle as measured
by decreased measures of migraine frequency, maximal severity,
associated vomiting and acute medication use over the three month
period following the 25 U injection.
[0033] Additionally, intramuscular botulinum toxin has been used in
the treatment of tremor in patients with Parkinson's disease,
although it has been reported that results have not been
impressive. Marjama-Jyons, J., et al., Tremor-Predominant
Parkinson's Disease, Drugs & Aging 16(4);273-278:2000.
[0034] It is known that botulinum toxin type A can have an efficacy
for up to 12 months (European J. Neurology 6 (Supp 4):
S111-S1150:1999), and in some circumstances for as long as 27
months. The Laryngoscope 109:1344-1346:1999. However, the usual
duration of an intramuscular injection of Botox.RTM. is typically
about 3 to 4 months. The success of botulinum toxin type A to treat
a variety of clinical conditions has led to interest in other
botulinum toxin serotypes. See e.g. Eur J Neurol 1999 Nov;6(Suppl
4):S3-S10.
[0035] In addition to having pharmacologic actions at the
peripheral location, botulinum toxins may also have inhibitory
effects in the central nervous system. Work by Weigand et al,
Nauny-Schmiedeberg's Arch. Pharmacol. 1976; 292, 161-165, and
Habermann, Nauny-Schmiedeberg's Arch. Pharmacol. 1974; 281, 47-56
showed that botulinum toxin is able to ascend to the spinal area by
retrograde transport. As such, a botulinum toxin injected at a
peripheral location, for example intramuscularly, may be retrograde
transported to the spinal cord.
[0036] U.S. Pat. No. 5,989,545 discloses that a modified
clostridial neurotoxin or fragment thereof, preferably a botulinum
toxin, chemically conjugated or recombinantly fused to a particular
targeting moiety can be used to treat pain by administration of the
agent to the spinal cord.
[0037] Botulinum toxin is most frequently administered as a
therapeutic agent by injecting a composition containing botulinum
toxin into a patient using a needle or syringe. However, other
modes of administration have been considered for botulinum toxins
as well as botulinum toxins coupled with non-botulinum toxin
receptor legends. Some modes of administration include topical
application of botulinum toxin (e.g., see U.S. Pat. No. 6,063,768;
U.S. Pat. No. 5,670,484; and German Patent Publication DE 198 52
981). German Patent Publication DE 198 52 981 discloses a
composition containing botulinum toxin type A and a 50% dimethyl
sulphoxide (DMSO) solution for the treatment of hyperhydrosis.
Although DE 198 52 981 discusses that botulinum toxin may be used
to treat hyperhydrosis by being topically applied to the skin, it
is unclear whether the botulinum toxin permeated through the
epidermis of the person, or if the effects were mediated by
botulinum toxin passing through pores of the sweat glands. In any
case, although DE 198 52 981 discloses that topical administration
of botulinum toxin in a DMSO solution can be used to treat
hyperhydrosis, compositions containing DMSO are not desirable
because DMSO can irritate the skin. In addition, although U.S. Pat.
No. 5,670,484 discloses topical application of botulinum toxin to
treat skin lesions, it does not disclose a composition containing
botulinum toxin and an enhancing agent, as described herein.
Furthermore, U.S. Pat. No. 5,670,484 only discloses that topical
administration of botulinum toxin may inhibit cell proliferation.
It is silent to topical application of botulinum toxin to treat
disorders associated with neurosecretion of intracellular
molecules. See also WO 00/15245 and Grusser Von O-J., Die ersten
systematischen Beschreibungen und tierexperimentellen
Untersuchungen des Botulismus, Sudhoffa Archiv (1986), 70(2),
167-186.
[0038] Transdermal Delivery
[0039] Human skin comprises the dermis and the epidermis. The
epidermis has several layers of tissue, namely, stratum corneum,
stratum lucidum, stratum granulosum, stratum spinosum, and stratum
basale (identified in order from the outer surface of the skin
inward). The stratum corneum presents the most significant hurdle
in transdermal delivery of medications. The stratum corneum is
typically about 10-15 .mu.m thick, and it consists of flattened,
keratised cells (corneocytes) arranged in several layers. The
intercellular space between the corneocytes is filled with lipidic
structures, and may play an important role in the permeation of
substances through skin (Bauerova et al., Chemical enhancers for
transdermal drug transport, European Journal of Drug Metabolism and
Pharmacokinetics, 2001, 26(1/2): 85-94). The rest of the epidermis
below the stratum corneum is approximately 150 .mu.m thick. The
dermis is about 1-2 mm thick and is located below the epidermis.
The dermis is innervated by various capillaries as well as neuronal
processes.
[0040] Transdermal administration of pharmaceuticals has been the
subject of research in attempt to provide an alternative route of
administration of medications without undesirable consequences
associated with injections and oral delivery. For example, needles
often cause localized pain, and potentially exposes patients
receiving injections to blood borne diseases. Oral administration
suffers from poor bioavailability of medications due to the
extremely acidic environment of the patient's stomach. Transdermal
administration techniques attempt to overcome these shortcomings by
providing noninvasive administration of pharmaceuticals. It is
desirable with transdermal administration to reduce damage to a
patient's skin. Thus, transdermal administration of medication may
reduce or eliminate pain associated with injections, reduce the
likelihood of blood contamination, and improve the bioavailability
of drugs once they are incorporated systemically.
[0041] Attempts at transdermal administration of medication have
attempted to improve the permeability of the stratum corneum. Most
attempts of transdermal therapy are directed at administering
pharmaceutical agents that are incorporated into a patient's
circulatory system, and thus are systemically administered through
the skin. Some attempts have included using chemical enhancing
agents that increase the permeability of molecules through the
skin. Some attempts have included using mechanical apparatus to
bypass or ablate portions of the stratum corneum. In addition,
attempts have included use of ultrasound or iontophoresis to
facilitate the permeation of pharmaceuticals through the skin. As
indicated above, the goal of these therapeutic methods is to
deliver a pharmaceutical agent, typically a small molecule, through
the skin so that an agent may pass to the capillary bed in the
dermis where the agent may be systemically incorporated into the
patient to achieve a therapeutic effect.
[0042] Although small molecules have been a major focus of
transdermal administration techniques, it is important to note that
it appears that large molecules, such as polypeptides, and protein
complexes, are also amenable to transdermal administration.
Erythropoietin, which is about 48 kD, has also been successfully
transdermally administered (Mitragotri et al., Ultrasound-mediated
transdermal protein delivery, Science, 1995, 269: 850-853; U.S.
Pat. No. 5,814,599; and 6,002,961).
[0043] What is needed therefore are pharmaceutical compositions or
formulations containing therapeutically effective amounts of
neurotoxins which enable the neurotoxin to permeate the skin of a
patient and retain the neurotoxin's bioactivity to cause a
therapeutic effect without undesirable pain associated with the
administration of the neurotoxin.
SUMMARY
[0044] The present invention addresses this need and provides
pharmaceutical compositions comprising a neurotoxin, which are able
to be transdermally administered. The compositions of the present
invention may be used to deliver the neurotoxin to a subdermal
structure, such as an subdermal muscle, a subdermal sweat gland, or
a subdermal sensory neuron. Thus, the composition disclosed herein
may be used to effectively treat neuromuscular disorders associated
with spastic muscles, treat sympathetic neuronal disorders, such as
disorders associated with hyperactive sweat glands, or to reduce
inflammation or pain associated with inflammation, and thus, the
neurotoxin may be used as an analgesic.
[0045] The following definitions apply herein:
[0046] "About" means approximately or nearly and in the context of
a numerical value or range set forth herein means .+-.10% of the
numerical value or range recited or claimed.
[0047] "Local administration" means direct administration of a
pharmaceutical at or to the vicinity of a site on or within an
animal body, at which site a biological effect of the
pharmaceutical is desired. Local administration excludes systemic
routes of administration, such as intravenous or oral
administration. Topical administration is a type of local
administration in which a pharmaceutical agent is applied to a
person's skin. Topical administration of a neurotoxin, such as
botulinum toxin, excludes systemic administration of the
neurotoxin. In other words, and unlike conventional therapeutic
transdermal methods, topical administration of botulinum toxin does
not result in significant amounts, such as the majority of, the
neurotoxin passing into the circulatory system of the patient.
[0048] "Neurotoxin" means a biologically active molecule with a
specific affinity for a neuronal cell surface receptor. Neurotoxin
includes Clostridial toxins both as pure toxin and as complexed
with one to more non-toxin, toxin associated proteins.
[0049] "Stabilized botulinum toxin" means a botulinum toxin that is
still biologically active or that still is capable of binding to a
target cell so that the botulinum toxin can effectively reduce or
prevent exocytosis of intracellular molecules, such as
neurotransmitters or peptides, from the cell to which the botulinum
toxin is bound. Stabilized botulinum toxins are not cytotoxic.
[0050] "Enhancing agent" refers to an agent that enhances the
permeability of a patient's skin so that botulinum toxin can be
absorbed by the skin to achieve a therapeutic effect. In reference
to the disclosure herein, enhancing agent specifically excludes
dimethylsulfoxide (DMSO) or a combination of pluronic lecithin
organizer (PLO) and DMSO. An enhancing agent may include, and is
not limited to, alcohols, such as short chain alcohols, long chain
alcohols, or polyalcohols; amines and amides, such as urea, amino
acids or their esters, amides, AZONE.RTM.), derivatives of
AZONE.RTM., pyrrolidones, or derivatives of pyrrolidones; terpenes
and derivatives of terpenes; fatty acids and their esters;
macrocyclic compounds; tensides; or sulfoxides other than
dimethylsulfoxide, such as, decylmethylsulfoxide; liposomes;
transfersomes; lecithin vesicles; ethosomes; water; surfactants,
such as anionic, cationic, and nonionic surfactants; polyols; and
essential oils.
[0051] A suitable neurotoxin used in the pharmaceutical
compositions disclosed herein may be a neurotoxin made by a
bacterium, for example, the neurotoxin may be made from a
Clostridium botulinum, Clostridium butyricum, or Clostridium
beratti. In certain embodiments of the invention, the composition
may contain botulinum toxin, which may be a botulinum toxin type A,
type B, type C.sub.1, type D, type E, type F, or type G. The
botulinum toxin is present in the composition in an amount that
results in between about 10.sup.-3 U/kg and about 10 U/kg of
botulinum toxin permeating through the skin. The composition may
contain an amount of botulinum toxin that causes a therapeutic
effect to persist for between about 1 month and 5 years.
[0052] Other neurotoxins include recombinantly produced
neurotoxins, such as botulinum toxins produced by E. coli. In
addition or alternatively, the neurotoxin can be a modified
neurotoxin, that is a neurotoxin which has at least one of its
amino acids deleted, modified or replaced, as compared to a native
or the modified neurotoxin can be a recombinant produced neurotoxin
or a derivative or fragment thereof. The neurotoxins are still able
to inhibit neurotransmitter release.
[0053] The composition containing a neurotoxin, as disclosed
herein, is topically administered to a patient. Because the
neurotoxin is topically administered the composition is preferably
applied at or near a site that is painful or is moist from
sweating. For example, if a spastic muscle is causing pain, the
composition may be applied to the skin above the spastic muscle to
chemodenervate the underlying spastic muscle. Or, if a particular
site is inflamed, such as caused by neuronal release of substance P
or calcitonin gene related peptide (CGRP), the composition may be
administered at the inflammation site. In addition, if a person's
sweat glands are excessively secreting fluid, the composition may
be applied in proximity of the sweaty area to reduce the neuronal
innervation of the sweat glands. For example, the composition may
be applied to one or more arm pits, palms, or any other sweaty
structure.
[0054] I have surprisingly found that a botulinum toxin, such as
botulinum toxin type A, can be transdermally administered to
alleviate disorders experienced by a human patient. The botulinum
toxin used is administered in an amount so that between about
10.sup.-3 U/kg and 10 U/kg pass through a patient's skin.
Preferably, the botulinum toxin is present in an amount so that
between about 10.sup.-2 U/kg and about 1 U/kg are transdermally
pass through the patient's skin. More preferably, the botulinum
toxin is present in an amount so that between about 10.sup.-1 U/kg
and about 1 U/kg pass through the patient's skin. Most preferably,
the botulinum toxin is present in an amount so that between about
0.1 unit and about 5 units pass through the patient's skin to a
subdermal target. Significantly, the therapeutic effects of the
toxin in the composition can persist for between about 2 months to
about 6 months when administration is of aqueous solution of the
neurotoxin, and for up to about five years when the neurotoxin is
administered in a composition that retains the toxin and slowly
releases the toxin after it has passed through the skin. See e.g.
U.S. Pat. No. 6,312,708.
[0055] Advantageously, I have discovered that by topically applying
compositions containing botulinum toxin, potential complications,
such as systemic toxicity or botulism poisoning, are avoided even
upon administration of relatively high dosages since the stratum
corneum of the skin still retains some impermeability. Thus,
dosages of botulinum toxin (including types A, B, C, D, E, F, or G)
can range from as low as about 1 unit to as high as about 20,000
units, without fear of adverse side effects that may threaten the
patient. The particular dosages may vary depending on the condition
being treated, and the particular enhancing agent and therapeutic
regime being utilized. For example, treatment of subdermal,
hyperactive muscles may require high dosages (e.g., 1000 units to
20,000 units) of botulinum toxin topically applied in a composition
containing an enhancing agent. In comparison, treatment of
neurogenic inflammation or hyperactive sweat glands may require
relatively small topical dosages (e.g. about 1 unit to about 1,000
units) of botulinum toxin.
[0056] An embodiment of the present invention can be a
pharmaceutical composition comprising a stabilized botulinum toxin
and at least one enhancing agent for facilitating transdermal
delivery of the botulinum toxin into a human patient by enhancing
the permeability of the patient's skin. The botulinum toxin can be
selected from the group consisting of botulinum toxin types A, B,
C.sub.1, D, E, F and G, a pure or purified (i.e. about 150 kD)
botulinum toxin, as well as a native or recombinantly made
botulinum toxin. The composition can comprise between about 1 units
to about 20,000 units of the botulinum toxin, and the composition
can comprises an amount of botulinum toxin sufficient to achieve a
therapeutic effect lasting between 1 month and 5 years.
[0057] Notably, the enhancing agent can be an alcohol, such as a
polyalcohol. Alternately, the enhancing agent can comprise a
transfersome. Additionally, the composition can comprise a
plurality of enhancing agents.
[0058] A detailed embodiment of the present invention can comprise
a pharmaceutical composition in a transdermal patch, including a
stabilized botulinum toxin that permeates through a human patient's
skin without permeating in significant amount through a blood
vessel when the botulinum toxin interacts with an enhancing agent
provided in the transdermal patch to cause a therapeutic effect of
a disorder associated with exocytosis of a molecule from a cell.
"Without permeating in significant amount" means that less than 25%
and preferably less than 5% of the botulinum toxin present in the
pharmaceutical composition permeates into a blood vessel upon
application of the transdermal patch
[0059] The botulinum toxin in the composition can be provided in a
dry state in the transdermal patch before the patch is applied to
the patient's skin. The botulinum toxin can be mixed with the
enhancing agent after the transdermal patch is applied to the
patient's skin. Thus, the botulinum toxin can mix with an enhancing
agent that is applied to the patient's skin before the transdermal
patch is applied to the patient's skin.
[0060] A further embodiment of the present invention includes a
transdermal patch, comprising a pharmaceutical composition, which
comprises a stabilized botulinum toxin; and an enhancing agent that
facilitates transdermal administration of the botulinum toxin in a
bioactive form to a subdermal target site of a human patient
without being administered to the patient's circulatory system; and
an adhesive disposed on one side of the transdermal patch to
removably secure the patch to the patient's skin. The adhesive can
be is disposed around a depot containing the pharmaceutical
composition.
[0061] The transdermal patch can further comprise a plurality of
needles extending from one side of the patch that is applied to the
skin, wherein the needles extend from the patch to project through
the stratum corneum of the skin without rupturing a blood vessel.
The botulinum toxin can be provided in a depot in the patch so that
pressure applied to the patch causes botulinum toxin to be directed
through the needles and under the stratum corneum. Furthermore, the
botulinum toxin can be provided in a dry state in a plurality of
wells, each of the wells covered by a membrane that is dissolvable
with a fluid, and wherein the enhancing agent mixes with the
botulinum toxin as the membrane over a well dissolves so that the
absorption of the botulinum toxin is enhanced.
[0062] The present invention also encompasses a method of reducing
neurotransmitter release in a subdermal structure of a patient, the
method comprising the steps of non-chemically disrupting the
stratum corneum of the patient's skin to reduce impermeability of
the stratum corneum; and applying botulinum toxin to the skin of
the patient in an area that has had the stratum corneum disrupted
in the first step. The stratum corneum can be disrupted by
abrasively removing the stratum corneum. Thus, the stratum corneum
can be disrupted by applying an adhesive material to the patient's
skin, and removing the adhesive material applied thereto.
Alternately, the stratum corneum can be disrupted by applying
ultrasound at a frequency between 20 kHz and less than 10 MHz at an
intensity that does not permanently damage the patient's skin. Or
the stratum corneum can be disrupted by passing electrical current
from a first point on the patient's skin to a second point on the
patient's skin. The electrical current can be passed to create a
plurality of pores in the stratum corneum to enhance passage of
botulinum toxin to the subdermal structures. And the botulinum
toxin can be applied in a pharmaceutical composition comprising an
enhancing agent for enhancing the delivery of the botulinum toxin
through the skin. Thus, the botulinum toxin can be is incorporated
into a transfersome.
[0063] The present invention also encompasses a method of relieving
pain in a patient caused by a spastic muscle, the method comprising
the steps of (a) applying ultrasound at a frequency between about
10 kHz and 1 MHz to the patient's skin overlying the spastic
muscle; and (b)
[0064] applying botulinum toxin to the patient's skin that has
received the ultrasound in step (a). Thus method can further
comprise a step of abrasively removing portions of the stratum
corneum of the patient's skin that received the ultrasound.
DESCRIPTION
[0065] The pharmaceutical composition of the present invention is
capable of delivering a botulinum toxin, such as a purified 150 kD
botulinum toxin molecule or as a 300-900 kD botulinum toxin
complex, through a person's skin. The pharmaceutical composition
contains an enhancing agent that facilitates the permeation of the
botulinum toxin through the patient's skin. The pharmaceutical
composition is suitable for topical administration so that the
composition may penetrate the skin and transdermally denervate an
underlying target structure, such as a structure innervated by a
neuron. The composition may be a component of a patch that may be
adhesively secured to the skin so that the toxin can pass from the
patch to and through the skin to denervate an underlying
target.
[0066] The present invention is based on the discovery that
pharmaceutical compositions containing botulinum toxin and an
enhancing agent can successfully treat several types of disorders
associated with neurotransmitter release when applied to a person's
skin. Examples of disorders amenable to treatment by the topical
administration of the compositions set forth herein include, and
are not limited to, wrinkles, such as brow furrows, headaches, such
as migraine, headache pain, cervical dystonia, focal hand dystonia,
neurogenic inflammation, hyperhydrosis, blepharospasm, strabismus,
hemifacial spasm, eyelid disorder, cerebral palsy, focal
spasticity, limb spasticity, tics, tremors, bruxism, anal fissure,
fibromyalgia, dysphagia, lacrimation, and pain from muscle spasms.
The topical administration of the toxin reduces the pain
experienced by the patient when the toxin is administered because
the patient does not need to be stuck with a needle that activates
sensory pain neurons below the skin. The compositions disclosed
herein provide localized relief with a botulinum toxin, without
risking systemic administration of the botulinum toxin.
[0067] The neurotoxins used in accordance with the invention
disclosed herein are neurotoxins that inhibit transmission of
chemical or electrical signals. The neurotoxins preferably are not
cytotoxic to the cells that are exposed to the neurotoxin. The
neurotoxin may inhibit neurotransmission by reducing or preventing
exocytosis of neurotransmitter from the neurons exposed to the
neurotoxin. The suppressive effects provided by the neurotoxin
should persist for a relatively long period of time, for example,
for more than two months, and potentially for several years.
[0068] Examples of neurotoxins used in the compositions, include,
and are not limited to, neurotoxins made from Clostridium bacteria,
such as Clostridium botulinum, Clostridium butyricum and
Clostridium beratti. In addition, the neurotoxins used in the
methods of the invention may be a botulinum toxin selected from a
group of botulinum toxin types A, B, C, D, E, F, and G. In one
embodiment of the invention, the neurotoxin administered to the
patient is botulinum toxin type A. Botulinum toxin type A is
desirable due to its high potency in humans, ready availability,
and known use for the treatment of skeletal and smooth muscle
disorders when locally administered by intramuscular injection. The
present invention also includes the use of (a) neurotoxins obtained
or processed by bacterial culturing, toxin extraction,
concentration, preservation, freeze drying, and/or reconstitution;
and/or (b) modified or recombinant neurotoxins, that is neurotoxins
that have had one or more amino acids or amino acid sequences
deliberately deleted, modified or replaced by known
chemical/biochemical amino acid modification procedures or by use
of known host cell/recombinant vector recombinant technologies, as
well as derivatives or fragments of neurotoxins so made. These
neurotoxin variants should retain the ability to inhibit
neurotransmission between or among neurons, and some of these
variants may provide increased durations of inhibitory effects as
compared to native neurotoxins, or may provide enhanced binding
specificity to the neurons exposed to the neurotoxins. These
neurotoxin variants may be selected by screening the variants using
conventional assays to identify neurotoxins that. have the desired
physiological effects of inhibiting neurotransmission.
[0069] Botulinum toxins for use according to the present invention
can be stored in lyophilized, vacuum dried form in containers under
vacuum pressure or as stable liquids. Prior to lyophilization the
botulinum toxin can be combined with pharmaceutically acceptable
excipients, stabilizers and/or carriers, such as albumin. The
lyophilized material can be reconstituted with saline or water to
create a solution or composition containing the botulinum toxin to
be administered to the patient.
[0070] Although the composition may only contain a single type of
neurotoxin, such as botulinum toxin type A, as the active
ingredient to suppress neurotransmission, other therapeutic
compositions may include two or more types of neurotoxins, which
may provide enhanced therapeutic effects of the disorders. For
example, a composition administered to a patient may include
botulinum toxin type A and botulinum toxin type B. Administering a
single composition containing two different neurotoxins may permit
the effective concentration of each of the neurotoxins to be lower
than if a single neurotoxin is administered to the patient while
still achieving the desired therapeutic effects.
[0071] An enhancing agent used in combination with the neurotoxin
in the pharmaceutical composition may be any non-DMSO based
enhancing agent that enhances the permeability of the skin so that
bioactive neurotoxin may act at a desired target structure. The
enhancing agent preferably does not injure the skin, and more
preferably, temporarily permeabilizes the skin so that once the
neurotoxin has been delivered through the skin, the skin reduces
its permeability to other factors.
[0072] In one embodiment of the invention, the enhancing agent is
an alcohol. Examples of alcohols include short chain alcohols, such
as alcohols having between about 2-5 carbon atoms. Some short chain
alcohols include ethanol, isopropanol, methanol, and isobutanol, or
combinations thereof. The alcohols may be mixed in the composition
so that the concentration of alcohol in the composition is between
about 10% and 40%. The alcohol may be admixed with glycerin to
reduce potential irritation caused by higher concentrations of
alcohol. Long chain alcohols are also useful to enhance the
transdermal administration of neurotoxins, such as botulinum
toxins. Examples of long-chain alcohols include alcohols having
between about 8 and 12 carbon atoms, and some specific examples
include n-dodekano, klenbuterol, and albuterol. Polyalcohols may
also be used with the neurotoxin. Examples include propylene
glycol, glycerol, polyethylene glycol, and dexpantheol, and
combinations thereof.
[0073] In another embodiment, an enhancing agent may be a vesicle
that is able to store the neurotoxin within the vesicle. The
vesicle can diffuse through the skin and thereby deliver the
neurotoxin to the target site. The vesicle may be a lipid vesicle.
In one specific embodiment, the neurotoxin is incorporated into a
transfersome, which are deformable carries containing lipids and
membrane softeners (e.g., Hofer et al., New Ultradeformable Drug
Carriers for Potential Transdermal Application of Interleukin-2 and
Interferon-.alpha.: Theoretic and Practical Aspects, World J. Surg.
24, 1187-1189 (2000); and U.S. Pat. No. 6,165,500). Surprisingly,
it has been discovered that transfersomes sufficiently transport
neurotoxins, including botulinum toxin complexes, across the skin
to achieve a therapeutic effect. In other words, the neurotoxin is
able to be delivered to a target site and still be bioactive after
diffusing through the skin.
[0074] The compositions of the invention may be used in an
application device that permits application of the composition to a
target site on the skin without applying the composition to
non-target site areas of the skin. For example, a device may be
employed that allows the composition to be applied without first
applying the composition to one's fingers, which may lead to
undesirable paralysis of the fingers. Suitable devices include
spatulas, swabs, syringes without needles, and adhesive patches.
Use of spatulas or swabs, or the like may require the device to be
inserted into a container containing the composition. Using
syringes or adhesive patches may be accomplished by filling the
syringe or patch with the composition. The composition may then be
topically spread by the spatulas or swabs, or may be expelled from
the syringes onto the person's skin.
[0075] In one embodiment of the invention, the composition
containing the neurotoxin and the enhancing agent is provided in an
adhesive patch. Some examples of adhesive patches are well known.
For example, see U.S. Patent Nos. Des. 296,006; 6,010,715;
5,591,767; 5,008,110; 5,683,712; 5,948,433; and 5,965,154.
Transdermal patches are generally characterized as having an
adhesive layer, which will be applied to a person's skin, a depot
or reservoir for holding a pharmaceutical agent, and an exterior
surface that prevents leakage of the pharmaceutical from the depot.
The exterior surface of a patch is typically non-adhesive.
[0076] In accordance with the present invention, the neurotoxin is
incorporated into the patch so that the neurotoxin remains stable
for extended periods of time. The neurotoxin may be incorporated
into a polymeric matrix that stabilizes the neurotoxin, and permits
the neurotoxin to diffuse from the matrix and the patch. The
neurotoxin may also be incorporated into the adhesive layer of the
patch so that once the patch is applied to the skin, the neurotoxin
may diffuse through the skin. In accordance with such an
embodiment, the adhesive preferably comprises an enhancing agent,
as disclosed herein. In one embodiment, the adhesive layer may be
heat activated where temperatures of about 37 degrees Celsius cause
the adhesive to slowly liquefy so that the neurotoxin diffuses
through the skin. The adhesive may remain tacky when stored at less
than 37 degrees Celsius, and once applied to the skin, the adhesive
loses its tackiness as it liquefies. The administration of the
toxin is complete once the patch no longer adheres to the skin.
[0077] Alternatively, the neurotoxin may be provided in one or more
wells or pockets disposed near the surface of the patch that will
contact the skin. In one embodiment, the neurotoxin is stored in
the wells in a dried, or lyophilized state. Storing such patches in
a cooled atmosphere (e.g., about 4 degrees Celsius) maintains the
stability of the neurotoxin. A patch may be removed from the cool
atmosphere when needed, and applied to a person's skin where the
neurotoxin may be solubilized upon the mixing with fluid, such as
water or saline. The fluid may be provided separately or as a
component of the patch. For example, fluid may be provided on a
person's skin so that when the patch containing the dried
neurotoxin interacts with the fluid, the neurotoxin is exposed to
the fluid and is solubilized. The solubilized neurotoxin may then
be able to be absorbed by the skin. As another example, the patch
may contain one or more wells or pockets to hold fluid in the
patch. The fluid may be forced from the wells or pockets to cause
the fluid to mix with the dried neurotoxin. In such embodiments,
the enhancing agent may be provided in the fluid to enhance the
permeability of the skin to the neurotoxin. For example, the fluid
may be provided in a pocket in the patch. Pressure exerted on the
patch causes the pocket to rupture and release the fluid so that it
mixes with the dried neurotoxin. The composition containing the
neurotoxin may thus diffuse through the patient's skin. As another
example, fluid, including gels and creams containing water may be
applied to the skin at a target site. The patch containing the
dried neurotoxin may then be applied to the skin where the fluid
mixes with the neurotoxin and the composition diffuses into the
skin.
[0078] In patches containing wells of dried neurotoxin, it is
desirable to seal the wells so that the neurotoxin remains in the
wells until the neurotoxin is to be administered. Accordingly, the
wells are sealed with a membrane or film that prevents the
neurotoxin from diffusing from the wells in the neurotoxin's dry
state, but that permits the neurotoxin to diffuse from the wells
when it is solubilized. The membrane may either be porous or
nonporous. In one embodiment, the membrane comprises cellulose or
starch, and more particularly, the membrane may contain polyvinyl
alcohol, polyethylene oxide, and hydroxypropyl methyl cellulose.
The membrane is thin (ranging in thickness from about 1 .mu.m to
about 1 mm) and dissolves upon contacting fluid. Thus, fluid placed
on the person's skin or fluid directed from a pocket in the patch
may contact the cellulose membrane and cause the membrane to
dissolve. After dissolving, the fluid mixes with the dried
neurotoxin and solubilizes the neurotoxin. The composition then
diffuses through the patient's skin.
[0079] Additionally, the transdermal patch may include a plurality
of small needles that extend through the stratum corneum, but do
not extend into the dermis to rupture blood vessels. The needles
may be between 20 .mu.m and 1 mm long when extending from the
dermal surface of the patch. Thus, the needles extend through the
stratum corneum, but terminate before the dermis where the
capillary beds are located. The needles may be solid or hollow.
Hollow needles may have a lumen extending along their length so
that the composition can pass from the depot in the patch to the
end of the needle in the epidermis. Solid needles may be used to
permit the composition to diffuse along the outer surface of the
needle into the epidermis. Surprisingly, it has been discovered
that this length of needles is optimal to reduce potential pain
caused by longer needles activating sensory pain fibers. Thus, the
composition containing the neurotoxin may be applied subdermally
without significant, if any, pain to the patient.
[0080] Accordingly, methods of inhibiting neurotransmitter release
in subdermal structures may include steps of disrupting the stratum
corneum to reduce the impermeability of the stratum corneum, and
applying a botulinum toxin to the skin location in which the
stratum corneum has been disrupted. Disrupting the stratum corneum
refers to either completely removing the stratum corneum from a
region of a patient's skin, or partially removing portions of the
stratum corneum at a location on the patient's skin so that
relatively small stratum corneum-free regions of skin are present.
The skin may be disrupted using any suitable method without
imparting significant pain to the patient. In preferred embodiments
of the methods, the stratum corneum is non-chemically disrupted.
For example, the stratum corneum may be abrasively scrubbed to
disrupt the laminar barrier of the stratum corneum. Or, the stratum
corneum may be disrupted by applying an adhesive, such as adhesive
tape or wax, to the skin, and subsequently removing the adhesive
from the skin. Because such methods of disrupting the stratum
corneum may cause some pain, it may be desirable to provide a
topical anesthetic to the skin, such as lidocaine cream, to
temporarily reduce any pain that may be caused by the
disruption.
[0081] Additional transdermal methods that non-chemically enhance
the skin's permeability include low frequency ultrasound (20 kHz to
1 MHz). Ultrasound is defined as sound at a frequency of between
about 20 kHz and 10 MHz, with intensities of between 0 and 3
W/cm.sup.2. Low frequency ultrasound, as used herein, refers to
ultrasound at a frequency that is less than 1 MHz, and preferably
in the range of 20 kHz to 40 kHz. The ultrasound is delivered in
pulses, for example, 100 msec pulses at a frequency of 1 Hz. The
intensity of the ultrasound may vary between 0 and 1 W/cm.sup.2,
and frequently varies between 12.5 mW/cm.sup.2 and 225 mW/cm.sup.2.
Typical duration of exposure to ultrasound is between about 1 and
about 10 minutes. The ultrasound is applied without causing an
increase in skin temperature greater than about 1 degree Celsius.
Low frequency ultrasound may be used alone or in combination with
the composition to improve the permeability of the skin to the
neurotoxin. Examples of ultrasound techniques for improving skin
permeability may be found in U.S. Pat. Nos. 6,002,961 and
5,814,599. Surprisingly, it has been discovered that low frequency
ultrasound, when applied in conjunction with a composition
containing a botulinum toxin, permeabilizes the skin but does not
substantially alter the three dimensional conformation of the
neurotoxin, such as purified botulinum toxin or botulinum toxin
complexes. Thus, the bioactivity of the neurotoxin is maintained
and the disorder is substantially treated.
[0082] Additionally, the ultrasound may be delivered prior to
application of the botulinum toxin to the skin. It has been
discovered that low frequency ultrasound when applied before the
topical application of botulinum toxin, temporarily disrupts the
stratum corneum so that subsequent topical application of botulinum
toxin achieves a therapeutic effect. In other words, the disruption
caused by the ultrasound persists for several minutes, for example
between about 10 and 30 minutes, to provide relatively easy
transdermal delivery of botulinum toxin to the patient. After about
30 minutes, the stratum corneum begins to resume its natural
structure, and the permeability of the stratum corneum temporally
decreases. Thus, one method of the invention, includes the step of
applying low frequency ultrasound to one or more regions of the
skin, and subsequently topically applying botulinum toxin to those
regions of the skin that were exposed to the low frequency
ultrasound, where the botulinum toxin is provided in a composition
containing an enhancing agent, which facilitates prolonged
penetration of the botulinum toxin to the patient.
[0083] Additional approaches include iontophoresis which can help
deliver the botulinum toxin to a subdermal target site by passing
electrical current across a patch containing a composition
comprising botulinum toxin. In one embodiment, an electrode may be
applied on the external surface of the transdermal patch, and a
ground electrode is provided elsewhere on a patient's skin. Small
direct current is applied through the electrode positioned on the
transdermal patch to urge the botulinum toxin in the composition
through the patient's skin. The amount of current is typically less
than 1 mA/cm.sup.2, and in a preferred embodiment, the current is
applied in an amount between 0.3 mA/cm.sup.2 and 0.7 mA/cm.sup.2.
Because the effectiveness of transdermal delivery of the botulinum
toxin through the skin is at least partially dependent on the
polarity of the botulinum toxin, it may be desirable to increase
the acidity of the composition to lower the pH of the composition
and impart a charge on the botulinum toxin to facilitate the
effectiveness of the electrical current in transporting the toxin
through the skin. The pH of the composition containing the
botulinum toxin can be lowered to as low as 4 without significantly
compromising the bioactivity of the molecule; however, preferred pH
ranges are between 5.5 and 7.2. Additionally, the current is passed
through the electrodes for a time that does not permanently damage
(e.g., burn) the skin. For example, the current may be passed for a
period of time between about 1 minute and 15 minutes. For longer
applications, it is desirable to pulse the current to reduce
potentially damaging effects caused by the electricity.
[0084] The neurotoxin may be topically administered by any suitable
method as determined by the attending physician. The methods of
administration permit the neurotoxin to be administered locally to
a selected target tissue. Methods of administration include coating
the skin with the composition so that the composition covers at
least a portion of the target site. Administration methods also
include applying a transdermal patch to the target site of the skin
and causing the neurotoxin in the transdermal patch to diffuse into
the skin. For extended applications, adhesive patches are utilized
so that the composition can slowly diffuse into the skin without
repeated applications of the patch. For example, a patch may
include a microprocessor that provides periodic release of
neurotoxin from the patch. Microprocessor patches may be especially
advantageous in patches that have the microneedles or low frequency
ultrasound devices, as discussed above. The microprocessor can
provide a timed release of the composition depending on the
particular condition being treated. An example of a microprocessor
controlled pharmaceutical treatment device may be found in U.S.
Pat. No. 6,334,856.
[0085] Diffusion of biological activity of a botulinum toxin within
a tissue appears to be a function of dose and can be graduated.
Jankovic J., et al Therapy With Botulinum Toxin, Marcel Dekker,
Inc., (1994), page 150. Thus, diffusion of botulinum toxin can be
controlled to reduce potentially undesirable side effects that may
affect the patient's disorder. For example, the neurotoxin may be
administered so that the neurotoxin primarily effects sensory
neurons involved in inflammation, and does not affect other
subdermal targets. In such a case, the composition may be applied
for a relatively short period of time (e.g., 1-4 hours) to permit
only local diffusion into the dermis of the patient where the
sensory neurons terminate. The neurotoxin may thus act on the
sensory neurons to decrease the release of substance P or CGRP to
reduce inflammation and pain associated with inflammation.
[0086] Without wishing to be bound by any particular theory, a
mechanism can be proposed for the therapeutic effects achieved with
the composition practiced according to the present invention. The
enhancing agents disclosed herein appear to solubilize the stratum
corneum of the epidermis and increase the fluidity of the
neurotoxin thus maintaining the bioactivity of the neurotoxin when
it reaches the subdermal target. Importantly, the compositions and
methods herein of topically administering the neurotoxin permit the
neurotoxin to be administered to a patient without resulting in
systemic toxicity. As indicated herein, prior art approaches of
transdermally administering non-botulinum toxin therapeutic agents
have addressed systemic administration of the therapeutic agents
via the skin. In addition, prior art approaches for topically
applying botulinum toxin to patients have not included the use of
enhancing agents, as disclosed herein.
[0087] As set forth above, I have discovered that compositions
containing a neurotoxin and an enhancing agent surprisingly
provides effective and long lasting treatment of disorders
associated with neuronal activity near a patient's skin, and
reduces the symptoms associated with the disorder. In its most
preferred embodiment, the present invention is practiced by topical
administration of botulinum toxin type A.
EXAMPLES
[0088] The following examples set forth specific compositions and
methods encompassed by the present invention to treat patients, and
are not intended to limit the scope of the invention. For example,
although the following examples are directed to compositions
containing botulinum toxin type A, I have discovered that botulinum
toxin types B, C, D, E, F, and G are equally effective in being
transdermally administered in the compositions set forth herein. It
is noted that the dosages of the particular type of botulinum toxin
may be adjusted as needed from the particular dosages disclosed
herein, as understood by persons of ordinary skill in the art. As
indicated above, the transdermal administration methods disclosed
herein permit a relatively broad range of concentrations of
botulinum toxin without risking the patient's health.
Example 1
[0089] One hundred units of botulinum toxin type A are dissolved in
1 mL of water are mixed with 1 mL of 90% ethanol and 1 mL of
polyethylene glycol. A syringe is filled with the composition of
the botulinum toxin. The viscous solution is expelled from the
syringe onto a patient's palm who is complaining of sweaty palms.
The solution is spread with a spatula over the entire palmar
surface. The patient's hand is covered with a plastic bag with an
airtight seal for about one hour to reduce the rate of evaporation
of the composition. The bag is removed and the patient washes his
hand. Approximately 2 days later, the patient notices that the hand
receiving treatment no longer is sweaty while the untreated hand
remains sweaty. The reduction in sweat is maintained for about 6
weeks, and then gradually returns. The procedure is repeated for
both hands, and both hands show a marked reduction in sweating
after a period of about 2 days.
Example 2
[0090] A 1 mL 10% suspension of transfersomes is made from 85.8 mg
natural phosphatidyl choline and 14.2 mg sodium cholate.
Approximately 0.9 mL of phosphate buffer is added to solubilize the
lipids. The suspension is filtered several times to achieve a
suspension of approximately uniform sized vesicles. Approximately
1000 units of botulinum toxin type A (BOTOX.RTM.) are added to the
vesicles and are stored at 4 degrees Celsius for at least two days
and up to about 30 days.
[0091] A patient with brow furrows requests botulinum toxin to
reduce the wrinkles. The patient is asked to lay down. A suspension
of BOTOX.RTM. and transfersomes as described above is topically
applied to the patient's forehead. After about 1 hour, the
suspension has evaporated. The patient is instructed to wash his
face approximately 6 hours later. In about 2-3 days, the patient
begins to notice that the forehead wrinkles are reduced in number.
At about 7 days, the wrinkles are gone. The effects of the
BOTOX.RTM. last for about 4 months.
Example 3
[0092] Lyophilized BOTOX.RTM. is provided in a plurality of wells
located on a dermal side of a transdermal adhesive patch. The
transdermal patch has dimensions of approximately two inches by
three inches (5 cm.times.7.5 cm). The wells are organized in grids
of approximately 1 cm.sup.2 on the dermal side of the patch (i.e.,
the side of the patch that will be adjacent the skin). Each grid
contains approximately 100 wells. The dermal side of the patch is
fabricated from polyethylene terephthalate (PET). Each well
contains between about 50-100 units of lyophilized BOTOX. The wells
are sealed with a dissolvable membrane film made of polyvinyl
alcohol, polyethylene oxide, and hydroxypropyl methyl cellulose. An
adhesive border is provided around the grid. The adhesive border is
approximately 1 cm wide and comprises a rubber adhesive, such as
R1072 from B. F. Goodrich Co. A patch containing the lyophilized
BOTOX in a plurality of wells may be stored at 4 degrees Celsius
for several months without affecting the bioactivity of the
toxin.
[0093] Two patches, as described above, are applied to the skin of
a patient's lower back on either side of the spinal cord at a
location demonstrating extreme muscle hyperactivity. Prior to
application, the skin is prepared by cleaning the site with 95%
ethanol. A gel containing water, 80% ethanol, and polyethylene
glycol is applied in an area about one inch by two inches on either
side of the spinal cord. Each patch is adhesively applied to the
back where the gel is located. The patch is left in place for 5-7
days. The gel dissolves the membrane and solubilizes the botulinum
toxin in the wells. After about 4 days, the patient notices
relaxation of his lower back muscles, and a reduction in pain
associated with the muscle contractions. By 7 days, the patient
indicates the pain is completely gone. The pain relieving effect
persists for about 5 months.
Example 4
[0094] A patient with cervical dystonia receives four transdermal
patches, each having dimensions of approximately 2 inches by 3
inches, applied to the skin overlying the rigid muscles. The
transdermal patches contain a depot of dried BOTOX.RTM., and a
pocket of saline. An ultrasound device is applied over the patch.
Ultrasound is applied to the patch and the patient's skin at a
frequency of 15 kHz for a period of 10 minutes. The ultrasound
energy is pulsed to reduce damaging the patient's skin. After 10
minutes, the physician removes the ultrasound device, and applies
pressure to the transdermal patches to cause the pocket of saline
to rupture. The saline that is expelled from the pocket mixes with
the botulinum toxin to solubilize the toxin. The composition is
delivered through the skin by diffusion. The patches are left in
place for about 5 hours. Approximately 2-3 days after the
treatment, the patient experiences some relief of pain and
relaxation of the muscles. Approximately 7 days after treatment,
the pain is almost completely relieved. The therapeutic effects
persist for about 3 months.
Example 5
[0095] A patient with suffering from palmar hyperhydrosis requests
botulinum toxin therapy. The physician evaluates the patient and
determines that the patient is a reasonable candidate for botulinum
toxin therapy. The physician abrasively scrubs the patient's palms
with a pumice stone. After the majority of the skin has been
roughened, the physician applies a saline based gel containing
approximately 10 units of BOTOX.RTM. to the patient's palm. The
patient's hands are kept in plastic bags that have been sealed
around the patient's wrists to prevent rapid evaporation of the
gel. The patient's hands are left in the bags for about 4 hours.
About 2 days after treatment, the patient notices a reduction in
the hyperhydrosis of his palms. By 7 days, the sweating is
completely eliminated, and the patient does not report any
appreciable loss of muscle activity. The hyperhydrosis alleviating
effects persist for about six to eight weeks.
Example 6
[0096] A transdermal patch containing approximately 1000 units of
BOTOX.RTM. is applied to a patient's inflammed elbow after the skin
of the elbow has been prepared by abrasively scrubbing the skin
with a pumice stone. After scrubbing the skin, a gel is applied to
the elbow before the transdermal patch is applied. The patch is
applied to the elbow in a flexed position. The gel dissolves the
cellulose membrane of the patch and solubilizes the botulinum toxin
contained therein. About 1 hour after the patch is applied to the
elbow, enough time for the membrane to dissolve and the toxin to be
solubilized, an electrode is placed on the outer surface of the
patch. A ground electrode is attached to the patient's torso.
Current is passed through the electrode at an intensity of 0.5
mA/cm.sup.2 for 5 minutes. After resting for 2 minutes, current is
again passed through the electrode for 5 minutes. The patient
leaves the physician's office, and is asked to leave the patch in
place for about 4 days. After about 2 days, the patient notices a
reduction of inflammation accompanied by a reduction in pain. By
about 7 days, the pain is almost completely alleviated. The relief
provided by the botulinum toxin persists for about 4 months.
[0097] Transdermal compositions containing botulinum toxin and
methods of administering such compositions according to the
invention disclosed herein have many benefits and advantages,
including the following:
[0098] 1. the symptoms, such as the symptoms associated with
hyperactive neuronal systems associated with spastic muscles,
inflammation, or hyperhydrosis can be dramatically reduced.
[0099] 2. the symptoms can be reduced for from about two to about
five months per application of neurotoxin to the skin and for from
about one year to about five years upon use of slow release
compositions and patches.
[0100] 3. the administered neurotoxin shows little or no tendency
to diffuse or to be transported away from subdermal site.
[0101] 4. few or no significant undesirable side effects occur from
topical administration of the neurotoxin.
[0102] 5. the suppressant effects of the compositions can result in
the desirable side effects of greater patient mobility, a more
positive attitude, and an improved quality of life.
[0103] 6. high, therapeutic doses of a neurotoxin can be delivered
to subdermal target tissue over a prolonged period without systemic
toxicity.
[0104] Although the present invention has been described in detail
with regard to certain preferred methods, other embodiments,
versions, and modifications within the scope of the present
invention are possible. For example, a wide variety of neurotoxins
can be effectively used in the compositions and methods of the
present invention.
[0105] All references, articles, patents, applications and
publications set forth above are incorporated herein by reference
in their entireties.
[0106] Accordingly, the spirit and scope of the following claims
should not be limited to the descriptions of the preferred
embodiments set forth above.
* * * * *