U.S. patent application number 17/483250 was filed with the patent office on 2022-03-24 for sustained release biodegradable intracanalicular inserts comprising a hydrogel and cyclosporine.
The applicant listed for this patent is Ocular Therapeutix, Inc.. Invention is credited to Charles D. Blizzard, Rami El-Hayek, Michael Goldstein, Peter Jarrett, Andrew Vanslette.
Application Number | 20220087932 17/483250 |
Document ID | / |
Family ID | |
Filed Date | 2022-03-24 |
United States Patent
Application |
20220087932 |
Kind Code |
A1 |
Blizzard; Charles D. ; et
al. |
March 24, 2022 |
SUSTAINED RELEASE BIODEGRADABLE INTRACANALICULAR INSERTS COMPRISING
A HYDROGEL AND CYCLOSPORINE
Abstract
Provided herein are sustained release biodegradable
intracanalicular insert comprising a hydrogel and cyclosporine,
methods of treating or preventing an ocular disease in a subject in
need thereof by administering such inserts as well as methods of
manufacturing such inserts.
Inventors: |
Blizzard; Charles D.;
(Nashua, NH) ; El-Hayek; Rami; (Norwood, MA)
; Goldstein; Michael; (Cambridge, MA) ; Jarrett;
Peter; (Burlington, MA) ; Vanslette; Andrew;
(Bolton, MA) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Ocular Therapeutix, Inc. |
Bedford |
MA |
US |
|
|
Appl. No.: |
17/483250 |
Filed: |
September 23, 2021 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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63082505 |
Sep 24, 2020 |
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63124204 |
Dec 11, 2020 |
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International
Class: |
A61K 9/00 20060101
A61K009/00; A61K 38/13 20060101 A61K038/13; A61P 27/02 20060101
A61P027/02 |
Claims
1. A method of treating dry eye disease in a human subject in need
thereof, the method comprising inserting into the canaliculus of
the human subject a sustained release biodegradable
intracanalicular insert comprising a hydrogel and cyclosporine,
wherein the cyclosporine is in the form of particles and wherein
the cyclosporine particles are dispersed within the hydrogel.
2. The method of claim 1, wherein the cyclosporine particles have a
d50 value of less than about 50 .mu.m.
3. The method of claim 2, wherein the cyclosporine particles have a
d50 value ranging from 3 to 17 .mu.m.
4. The method of claim 1, wherein the hydrogel comprises a polymer
network comprising crosslinked polymer units that are identical or
different, and the crosslinked polymer units are polyethylene
glycol units.
5. The method of claim 4, wherein the polymer network comprises
polyethylene glycol units having an average molecular weight in the
range from about 2,000 to about 100,000 Daltons.
6. The method of claim 4, wherein the polymer network comprises one
or more crosslinked multi-arm polymer units comprising one or more
2- to 10-arm polyethylene glycol units.
7. The method of claim 6, wherein the four arms of the 4-arm
polyethylene glycol units are connected to a core molecule of
pentaerythritol.
8. The method of claim 6, wherein the polymer network is formed by
reacting an electrophilic group-containing multi-arm-polymer
precursor with a nucleophilic group-containing cross-linking
agent.
9. The method of claim 8, wherein the electrophilic group is an
N-hydroxysuccinimidyl (NHS) ester group.
10. The method of claim 8, wherein the nucleophilic
group-containing crosslinking agent is a small molecule amine with
a molecular weight below 1,000 Da.
11. The method of claim 10, wherein the nucleophilic
group-containing crosslinking agent is a labeled trilysine.
12. The method of claim 6, wherein the multi-arm polymer units
comprise 4a20kPEG units and the cross-linking units comprise
fluorescein-conjugated trilysine amide units.
13. The method of claim 4, wherein the polymer network is obtained
by reacting 4a20kPEG-SG or 4a20kPEG-SAP with fluorescein-conjugated
trilysine in a molar ratio ranging from about 1:2 to about 2:1.
14. The method of claim 1, wherein the insert in a dried state
contains from about 15% to about 80% by weight of the cyclosporine
based on the total weight of the insert and from about 20% to about
60% by weight polymer units based on the total weight of the
insert.
15. A method of treating dry eye disease in a human subject in need
thereof, the method comprising inserting into the canaliculus of
the human subject a sustained release biodegradable
intracanalicular insert comprising a hydrogel and cyclosporine,
wherein the insert in a dried state contains from about 40% to
about 80% by weight of the cyclosporine based on the total weight
of the insert.
16. The method of claim 15, wherein the insert in a dried state
contains from 45% to 55% by weight of the cyclosporine based on the
total weight of the insert.
17. The method of claim 1, wherein the insert contains a
surfactant.
18. The method of claim 16, wherein the insert contains a
surfactant.
19. The method of claim 18, wherein the insert in a dried state
contains from about 0.01% to about 5% by weight of a surfactant
based on the total weight of the insert.
20. The method of claim 19, wherein the insert contains a non-ionic
surfactant.
21. The method of claim 20, wherein the cyclosporine content as
measured by HPLC after at least 3 months at a temperature of from 2
to 8.degree. C. is from about 300 to about 410 .mu.g by weight.
22. The method of any claim 21, wherein the amount of impurities as
measured by HPLC after at least 3 months of storage at a
temperature of from 2 to 8.degree. C. is not more than 3.0%.
23. The method of claim 22, wherein the insert is in the form of a
fiber, wherein the fiber has an average length of about 1.5 mm to
about 4.0 mm and an average diameter of not more than 0.8 mm in its
dried state.
24. The method of claim 23, wherein the insert after at least 3
months at a temperature of from 2 to 8.degree. C. is in the form of
a fiber that has an average length of about 2.5 mm to about 2.9 mm
and an average diameter of not more than 0.62 mm in its dried
state.
25. The method of claim 24, wherein the insert is in the form of a
fiber that has an average diameter of at least 1.0 mm in expanded
state after 10 minutes of hydration or of at least 1.3 mm in
equilibrium state after 24 hours of hydration in vitro in
phosphate-buffered saline at a pH of 7.4 at 37.degree. C.
26. The method of claim 25, wherein the insert disintegrates in the
canaliculus within about 1 to about 6 months after insertion.
27. The method of claim 26, wherein the insert after insertion to
the canaliculus releases a therapeutically effective amount of
cyclosporine over a period of at least about 1 month after
insertion.
28. The method of claim 27, wherein cyclosporine is released from
the insert after insertion to a human subject at an average rate of
about 0.1 .mu.g/day to about 10 .mu.g/day.
29. A method of treating dry eye disease in a human subject in need
thereof, the method comprising the steps of: (a) inserting a first
biodegradable insert into a first canaliculus of a first eye of the
subject, wherein the insert comprises: (1) a hydrogel; (2) from
about 100 .mu.g to about 800 .mu.g cyclosporine dispersed in the
hydrogel; (3) wherein the cyclosporine releases from the insert
over a period of at least about 2-months from the date of inserting
the first insert in the subject, at an average rate of about 0.1
.mu.g/day to about 10 .mu.g/day; and (b) after at least about
2-months from the date of inserting the first insert, inserting a
second insert into the first canaliculus of the first eye in the
subject, wherein the second insert is substantially similar to the
first insert.
30. The method of claim 29, wherein said first insert is removed
prior to complete disintegration and a second insert is inserted to
replace the removed first insert or said first insert is left to
remain in the canaliculus until complete disintegration.
Description
TECHNICAL FIELD
[0001] The present invention relates to the treatment of ocular
diseases, such as diseases affecting the ocular surface such as dry
eye or dry eye disease "DED". According to the present invention,
ocular diseases are treated by administering e.g.,
intracanalicularly an insert that is biodegradable and provides
sustained release of cyclosporine.
BACKGROUND
[0002] Ocular diseases and disorders, in particular those affecting
the ocular surface, are widespread. For example, dry eye disease
(DED), also known as Keratoconjunctivitis Sicca (KCS), is one of
the most common ophthalmic disorders. Patients who visit ophthalmic
clinics frequently report symptoms of dry eye, making it a growing
public health problem and one of the most common conditions seen by
eye care practitioners. Prevalence increases significantly with age
and with female sex. It is estimated that more than 16 million
United States (US) adults have been diagnosed with the disorder,
with 9 million being classified as moderate to severe.
[0003] DED is a multifactorial disorder of the tear film and ocular
surface that may result in eye discomfort symptoms such as dryness,
burning sensation, itching, redness, stinging, blurred vision,
grittiness, pain, foreign body sensation, visual disturbances, tear
film instability, ocular fatigue and often ocular surface damage.
DED can also make it difficult or impossible for a patient to wear
contact lenses, read, work on a computer or drive at night.
[0004] Inflammation of both the lacrimal gland and ocular surface
has been shown to play a role in dry eye. Factors that adversely
affect tear film stability and osmolarity can induce ocular surface
damage and initiate an inflammatory cascade that generates innate
and adaptive immune responses. These immunoinflammatory responses
lead to further ocular surface damage and the development of a
self-perpetuating inflammatory cycle. For instance, inflammation of
the ocular surface results in a reduction of tear production, which
further deteriorates the conditions and potentially leads in turn
to inflammation of ocular surface and epithelial cell damage. In
animal models, T-cell-mediated inflammation was indeed both a cause
and result of dry eye. In humans, dry eye was found to be
associated with the presence of conjunctival T-cells and elevated
levels of inflammatory cytokines in the tears compared with
controls, supportive of inflammation as a driving source of the
disorder.
[0005] DED can be categorized as acute, episodic or chronic. In
some cases, it can be categorized as chronic with acute flares.
Chronic DED can require year-round attention. Several
pharmacological therapies for DED have been explored and include a
stepped approach starting with over the counter lubricants and
artificial tear replacements (delivered as drops), progressing to
topical anti-inflammatory therapy and lacrimal occlusion using
punctal plugs to block tear drainage.
[0006] Artificial tears increase the tear volume, but the tear
volume may return to its original state due to tear drainage and
fluid loss by, e.g., evaporation or absorption through ocular
epithelia, and thus require frequent administration. While the
residence time could be increased by addition of viscosity
enhancers, a high viscosity tear replacement may cause blurred
vision. Although punctal plugs have been shown to be effective in
patients with DED, plugs can be lost (show poor retention) and may
rarely migrate into the nasolacrimal duct, resulting in
inflammation or other critical conditions. In some cases, the
punctum can be surgically closed with high temperature cautery in
an effort to treat DED. Additional approved therapies for DED
patients in US are Restasis.RTM. (cyclosporine) which increases
tear production, Cequa.RTM. (cyclosporine) which increases tear
production, and Xiidra.RTM. (lifitegrast) for signs and symptoms of
DED. Recently Eysuvis' (loteprednol) was approved for acute
treatment of DED.
[0007] Cyclosporine A is a cyclic polypeptide calcineurin inhibitor
immunosuppressant/immunomodulatory agent found in soil fungi, and
its immunomodulatory activity is used in the treatment of
immune-based disorders, such as transplant rejection, psoriasis,
ulcerative colitis, and rheumatoid arthritis. Calcineurin is an
enzyme that activates T-cells, which play a key role in
cell-mediated immunity. Because calcineurin inhibitors suppress the
immune system they are known as immunosuppressants.
[0008] The exact mechanism through which cyclosporine acts to
ameliorate signs and symptoms of keratoconjunctivitis sicca (KCS)
has not been fully established, but it is thought to act as partial
immunomodulator. In DED, cyclosporine can inhibit lymphocytic
infiltration, decrease the immune inflammatory response and inhibit
apoptosis of the lacrimal and conjunctival epithelial cells.
Cyclosporine affects immune function by interfering with the
activity and growth of T-cells, by entering T-cells and binding
cyclophilin. The complex affects T-cell activity by blocking the
action of calcineurin and preventing NFATc dephosphorylation and
the regulation of the production of pro-inflammatory cytokines such
as IL-2, IL-4, interferon-gamma and TNF-alpha.
[0009] Topical administration of cyclosporine A has been shown to
increase tear fluid secretion, possibly by promoting the local
release of parasympathetic nervous system-associated
neurotransmitters. A clinical field trial was conducted by
veterinary ophthalmologists in 124 dogs afflicted with KCS
evaluated efficacy following twice a day treatment with either 2.0
mg/mL cyclosporine (OPTIMMUNE.RTM. Ophthalmic Ointment, Intervet
Inc.) or vehicle ophthalmic ointment for approximately 90 days,
resulting in increased tear fluid production, although some dogs
improved clinically without a tear fluid increase.
[0010] This is thought to occur through suppression of inflammation
by cyclosporine on the ocular surface. Overall improvement was
noted in 81% of eyes treated with OPTIMMUNE.RTM. Ophthalmic
Ointment (vs % treated with vehicle) and withdrawal of therapy
resulted in rapid clinical regression in all but one test eye
indicating the need for long-term continual therapy. In the
management of KCS in dogs, the mechanism by which cyclosporine
causes an increase in lacrimation is poorly understood, but
clinical improvement is considered to be not necessarily dependent
on an increase in tear production. In humans, the beneficial
effects of cyclosporine A treatment in DED are better established
and findings of several clinical trials indicate that long-term
treatment with topical cyclosporine can yield positive results with
regard to e.g. corneal surface staining, Schirmer test, blurred
vision, frequency of artificial tear application, but also with
respect to cellular and molecular markers of disease severity.
Cyclosporine for ophthalmic use was first approved in 1995 for the
treatment of KCS in dogs. In 2003, it was approved for ophthalmic
use in humans as Restasis.RTM. (cyclosporine ophthalmic emulsion
0.5 mg/mL, Allergan) and is indicated for increased tear production
in patients whose tear production is presumed to be suppressed due
to ocular inflammation associated with KCS. Topical cyclosporine
eye drops were shown to decrease inflammatory mediators and
increase tear production. Commercial and marketed topical
cyclosporine eye drops are sold around the world for the treatment
of DED/KCS, Vernal Keratoconjunctivitis (VKC), and ocular
inflammation. Cyclosporine ophthalmic solution is currently on the
market for topical use for multiple products in multiple
jurisdictions as shown below.
TABLE-US-00001 Product Name Company Indication Region Marketed
since Restasis .RTM. Allergan DED (KCS with presumed US, Canada,
and 33 2003 (0.5 mg/ml) suppression of tear other contries
substitutes) Ikervis .RTM. Santen DED (Severe keratitis Europe 2015
(1.0 mg/ml) Pharmaceutical which has not improved with tear
substitutes) Papilock mini .RTM. Santen VKC Japan 2005 (1.0 mg/ml)
Pharmaceutical Modusik-A Ofteno .RTM. Laboratorios KCS with a
functional Mexico, Chile 2003 (1.0 mg/ml) Sophia decrease of
lacrimal glands Columbia, Peru, Ecuador, Argentina Lacrinmune .RTM.
Bausch & Lomb, Inc. KCS with a functional Argentina NA (0.5
mg/ml) decrease of lacrimal glands TJ Cyporin .RTM. Taejoon Pharma
Ocular inflammation South Korea 2003 (0.5 mg/ml) Co, Ltd associated
with KCS Cyporin .RTM. Aristopharma, Ltd Ocular inflammation
Bangladesh NA (0.5 mg/ml) associated with KCS Cyclorin .RTM. Ibn
Sina Pharmaceutical Ocular inflammation Bangladesh NA (0.5 mg/ml)
Industry, Ltd. associated with KCS Optimmune .RTM. Intervet, Inc.
Chronic KCS and superficial WW 1995 (2.0 mg/ml) (Merck Animal
Health) keratitis in dog Cequa .RTM. Sun Ophthalmics DED (KCS with
presumed US 2018 (0.9 mg/ml) suppression of tear production)
[0011] However, there are limitations with the application of
topical drops, which affect patient management. These limitations
include difficulty with handling the bottle, limited instillation
accuracy, potential washout of drops, and limited bioavailability
of topical eye drops (Aldrich et al, 2013, Ophthalmic preparations,
USP, 39(5), pp. 1-21). Specific issues with currently available eye
drop formulations of cyclosporine are tolerability issues such as
burning and stinging, and slow onset of action which can be from
many weeks to months. The high frequency of administration (e.g.
several times per day) highly affects daily life of patients In
humans, the bioavailability from topical eye drops reaching the
ocular tissues is less than 5%. Other limitations include a delayed
onset of action (many weeks to months), as well as the high drug
dose in the drops, which may be the cause for adverse reactions,
such as ocular burning associated with topical cyclosporine eye
drops (Restasis.RTM. NDA #021023).
[0012] There is thus an unmet need for a form of cyclosporine A
treatment that overcomes the disadvantages of current commercial,
topical formulations, in particular for dosage forms that allow a
sustained release of cyclosporine A and associated less frequent
administration that increases quality of life and patient
compliance, has less risk of infections and adverse effects such as
burning and stinging in the eyes.
[0013] Drug delivery from punctal plugs are beneficial over topical
drops in that they allow for a sustained release of the drug over
time by forming a depot from which the drug is slowly being
released. Administration consists of a one-time administration of
the plug, which addresses the above-mentioned limitations inherent
to long-term administration of topical eye-drops.
[0014] However, intracanalicular plugs are also associated with
challenges. The intracanalicular administration route has certain
anatomically implied restrictions (it needs to be small enough to
enter the lacrimal punctum) and it is difficult to develop an
ophthalmic intracanalicular plug that is easy to administer and to
remove once the drug depot is depleted if necessary, fits well,
i.e. provides appropriate retention so that it is not
unintentionally lost, but at the same time does not cause any
discomfort or unintended administration site reactions such as
inflammation.
[0015] In addition, drug release needs to be appropriate and
consistent over a sustained period of time. In view of the small
size of the plug, it is challenging to formulate to include an
adequate drug load and sustained-release properties.
[0016] Against this background, it is clear that there is a demand
for alternative cyclosporine dosage forms which are effective in
the treatment of ocular diseases such as DED.
[0017] All references disclosed herein are hereby incorporated by
reference in their entireties for all purposes.
OBJECTS AND SUMMARY OF THE INVENTION
[0018] It is an object of certain embodiments of the present
invention to provide an intracanalicular insert comprising
cyclosporine that is effective for treating an ocular disease, and
in particular DED, in a patient for an extended period of time.
[0019] It is also an object of certain embodiments of the present
invention to provide an intracanalicular insert comprising
cyclosporine that is effective for treating an ocular disease, and
in particular blepharitis, in a patient for an extended period of
time.
[0020] It is also an object of certain embodiments of the present
invention to provide an intracanalicular insert comprising
cyclosporine that is effective for treating an ocular disease, and
in particular blepharitis, allergic conjunctivitis and in
particular atopic keratoconjunctivitis and vernal
keratoconjunctivitis, in a patient for an extended period of
time.
[0021] As outlined above, one of the major drawbacks of current
commercial cyclosporine formulations, e.g. topical eye drops, is
the necessity of frequent administration. The present invention
aims to address this by enabling effective, prolonged therapy by a
one-time administration of a single insert releasing the active
continuously that lasts an extended period of time such as several
weeks.
[0022] Thus, another object of certain embodiments of the present
invention is to provide an intracanalicular insert comprising
cyclosporine that provides for sustained release of cyclosporine to
the ocular surface.
[0023] In order to ensure effective therapy over the wearing period
of the insert, the cyclosporine release should remain at a
substantially constant level (e.g., within the therapeutic window)
providing therapeutic effect.
[0024] Another object of certain embodiments of the present
invention thus is to provide an intracanalicular insert comprising
cyclosporine that provides for sustained release and in particular
a constant release of cyclosporine to the ocular surface.
[0025] Another object of certain embodiments of the present
invention is also to provide an intracanalicular insert comprising
cyclosporine that has a faster onset of action, e.g. within days or
even within hours.
[0026] In addition, the present invention also aims at respecting
and improving patient compliance, which has still room for
improvement in the current commercial products.
[0027] Therefore, another object of certain embodiments of the
present invention is to provide an intracanalicular insert
comprising cyclosporine that is well tolerated and does not provide
intolerable discomfort during or after insertion to the
canaliculus.
[0028] It is also another object of certain embodiments of the
present invention to provide an intracanalicular insert comprising
cyclosporine that is easy to administer, i.e. is easily inserted in
the canaliculus.
[0029] Another object of certain embodiments of the present
invention is to provide an intracanalicular insert comprising
cyclosporine that is easy to handle and does not spill like an eye
drop, or break easily.
[0030] Another object of certain embodiments of the present
invention is to provide an intracanalicular insert comprising
cyclosporine that is not prone to incorrect administration by the
patient and thus avoids over- and under-dosing.
[0031] Another object of certain embodiments of the present
invention is to provide an intracanalicular insert comprising
cyclosporine that fits well in the canaliculus once inserted, and
is not easily lost or inadvertently drained through the lacrimal
duct.
[0032] Another object of certain embodiments of the present
invention is to provide an intracanalicular insert comprising
cyclosporine that is easy to remove or to replace, or which does
not need to be removed.
[0033] Another object of certain embodiments of the present
invention thus is to provide an intracanalicular insert comprising
cyclosporine that has reduced side effects such as ocular burning,
stinging or itching when compared to common treatments such as
ophthalmic drops.
[0034] Another object of certain embodiments of the present
invention thus is to provide an intracanalicular insert comprising
cyclosporine that has reduced associated risks such as ocular
infections or systemic toxicity when compared to common treatments
such as ophthalmic drops.
[0035] Another object of certain embodiments of the present
invention thus is to provide an intracanalicular insert comprising
cyclosporine that has no or reduced impairment of quality of life,
e.g. through therapy-associated restrictions such as impossibility
or limited possibility of wearing contact lenses, or of reading,
working on a computer or driving at night.
[0036] Another object of certain embodiments of the present
invention is to provide an intracanalicular insert comprising
cyclosporine that is simple to manufacture.
[0037] Another object of certain embodiments of the present
invention is to provide an intracanalicular insert comprising
cyclosporine that is easily stored and is stable upon storage.
[0038] Another object of certain embodiments of the present
invention is to provide an intracanalicular insert comprising
cyclosporine that increases tear production and provides for an
appropriate tear fluid level in a patient for an extended period of
time.
[0039] Another object of certain embodiments of the present
invention is to provide an intracanalicular insert comprising
cyclosporine that resolves or reduces symptoms of an ocular surface
disease, in particular DED, such as eye dryness, burning sensation,
itching, redness, stinging, grittiness, pain, foreign body
sensation, visual disturbances, tear film instability, ocular
fatigue and ocular surface damage, in a patient for an extended
period of time.
[0040] Another object of certain embodiments of the present
invention is to provide a method of treating or preventing an
ocular disease, and in particular DED, in a patient for an extended
period of time, which may address one or more of the issues
referred to in the objects listed above.
[0041] It is also an object of certain embodiments of the present
invention to provide a method of treating an ocular disease, and in
particular blepharitis, in a patient for an extended period of
time, which may address one or more of the issues referred to in
the objects listed above.
[0042] It is also an object of certain embodiments of the present
invention to provide a method of treating an ocular disease, and in
particular blepharitis, allergic conjunctivitis and in particular
atopic keratoconjunctivitis and vernal keratoconjunctivitis, in a
patient for an extended period of time, which may address one or
more of the issues referred to in the objects listed above.
[0043] Another object of certain embodiments of the present
invention is to provide a method of treating or preventing DED
comprising inserting into the canaliculus of a patient a
biodegradable insert comprising a hydrogel and cyclosporine,
wherein the method may address one or more of the issues listed
above for the objects directed to providing an intracanalicular
insert.
[0044] Another object of certain embodiments of the present
invention is to provide a method of treating or preventing DED
comprising inserting into the canaliculus of a patient a
biodegradable insert comprising a hydrogel and cyclosporine, and
inserting into the same canaliculus a second biodegradable insert
comprising a hydrogel and cyclosporine after an extended period of
time such as at least about 2 months, wherein the method may
address one or more of the issues listed above for the objects
directed to providing an intracanalicular insert.
[0045] Another object of certain embodiments of the present
invention is to provide a method of treating or preventing an
ocular disease, and in particular DED, in a patient for an extended
period of time, wherein a therapeutic effect is achieved that is
more than a therapeutic effect achieved by a treatment consisting
in the combination of a punctal occlusion by a drug-free punctal
plug and administration of cyclosporine eye drops.
[0046] Another object of certain embodiments of the present
invention is to provide a method of manufacturing an
intracanalicular insert, which may address one or more of the
issues referred to in the objects related to an intracanalicular
insert as listed above.
[0047] One or more of these objects of the present invention and
others are solved by one or more embodiments as disclosed and
claimed herein.
[0048] The individual aspects of the present invention are
disclosed in the specification and claimed in the independent
claims, while the dependent claims claim particular embodiments and
variations of these aspects of the invention. Details of the
various aspects of the present invention are provided in the
detailed description below.
BRIEF DESCRIPTION OF THE DRAWINGS
[0049] FIG. 1 is a schematic representation of an eye and the
lacrimal system.
[0050] FIG. 1.2A depicts dry and hydrated insert fibers prepared in
Example 1.2 (Run 1 and Run 2).
[0051] FIG. 1.2B depicts dry and hydrated insert fibers prepared in
Example 1.2 (Run 3).
[0052] FIG. 1.2C depicts dry and hydrated insert fibers prepared in
Example 1.2 (Low, Medium and High Dose). The main portion of the
prepared dry insert fibers independent of the dose showed a
particulate, cylindrical shape without any visible surface defects
(left). In addition, also the inserts with the highest surface
deformations per dose are presented (right).
[0053] FIG. 1.3 depicts dry and hydrated insert fibers prepared in
Example 1.3.
[0054] FIGS. 1.4A to 1.4E depicts the insert dry density and the
drug load per insert, the dry diameter, the dry density,
microscopic images as well as a chart showing the dry and hydrated
diameters of the insert fibers prepared in Example 1.4 in
dependency of the hydration time, respectively.
[0055] FIG. 2 depicts chromatograms illustrating the conversion of
NHS-fluorescein into the fluorescein-trilysine conjugate.
[0056] FIG. 3.1 depicts the results of tear production as followed
over time by a Schirmer's Tear Test of Example 3.4.
[0057] FIGS. 3.2A and 3.2B depict the cyclosporine A (CsA)
concentration over time measured in beagle tear fluid of Example
3.5.
[0058] FIG. 3.3 depicts the cyclosporine A (CsA) concentration over
time measured in beagle tear fluid of Example 3.6.
[0059] FIG. 4A depicts a general schematic of the human clinical
study outline of Example 4.
[0060] FIG. 4B depicts an exemplary general schematic of the insert
placement within the canaliculus of a human eye.
[0061] FIGS. 5A to 5D depict an exemplary schematic of the steps
needed for insert placement within the canaliculus of a human
eye.
[0062] FIGS. 6A and 6B depict the results of tear production as
followed over time by a Schirmer's Tear Test of Example 4.1 for the
study (FIG. 6A) and the non-study eye (FIG. 6B). The solid black
line represents the mean Schirmer's score for all individuals
analyzed, wherein the dashed lines represent the Schirmer's score
for the single individuals.
[0063] FIGS. 7A and 7B depict the total Corneal Fluorescein
Staining (tCFS) values (mean values over all eyes) in terms of
absolute values as well as in terms of change from baseline
followed over time of Example 4.1.
[0064] FIGS. 8A and 8B depict the results of eye dryness severity
score on a visual analogue scale (VAS) in terms of absolute values
as well as in terms of change from baseline followed over time of
Example 4.1.
[0065] FIG. 9 depicts the results of eye dryness frequency score on
a visual analogue scale (VAS) in terms of absolute values followed
over time of Example 4.1.
[0066] FIG. 10 depicts the results of OSDI in terms of mean
absolute values followed over time of Example 4.1.
[0067] FIG. 11 depicts the results of SPEED score in terms of mean
absolute values followed over time of Example 4.1.
DEFINITIONS
[0068] The term "intracanalicular insert" as used herein refers to
an object that contains an active agent, specifically cyclosporine
and that is administered, i.e. inserted to the lacrimal canaliculus
where it remains for a certain period of time while it releases the
active agent into the surrounding environment. An insert can be of
any predetermined shape, most often rod-like shape before being
inserted, which shape may be maintained to a certain degree upon
placing the insert into the desired location, although dimensions
of the insert (e.g. length and/or diameter) may change after
administration due to hydration as further disclosed herein. In
other words, what is inserted into the eye is not a solution or
suspension, but an already shaped, coherent object. The insert has
thus been completely formed, e.g., according to the methods
disclosed herein, prior to being administered. An intracanalicular
insert can be designed to be biodegradable over the course of time
(as disclosed below), and thus may thereby soften, change its shape
and/or decrease in size, and in the end might be eliminated either
by dissolution or disintegration upon which the remainder of the
insert will be drained down the lacrimal duct. In the present
invention the term "insert" is used to refer both to an insert in a
hydrated (also called "swollen") state when it contains water (e.g.
after the insert has been (re-)hydrated once administered to the
eye or otherwise immersed into an aqueous environment) and to an
insert in its dry (dried/dehydrated) state, e.g., when it has been
dried to a low water content of e.g. not more than 1% by
weight.
[0069] The term "ocular" as used in the present invention refers to
the eye in general, or any part or portion of the eye (as an
"ocular insert" can in principle be administered to any part or
portion of the eye). The present invention in certain embodiments
is directed to intracanalicular injection of an ocular insert, and
to the treatment of dry eye disease (DED), as further disclosed
below.
[0070] The term "biodegradable" refers to a material or object
(such as the intracanalicular insert according to the present
invention) which becomes degraded in vivo, i.e., when placed in the
human or animal body. In the context of certain embodiments of the
present invention, as disclosed in detail herein below, the insert
comprising the hydrogel within which cyclosporine is contained,
slowly biodegrades over time once administered into the canaliculus
of the eye. In certain embodiments, biodegradation takes place at
least in part via ester hydrolysis in the aqueous environment of
the canaliculus. The insert slowly softens and disintegrates,
resulting in clearance through the nasolacrimal duct.
[0071] A "hydrogel" is a three-dimensional network of one or more
hydrophilic natural or synthetic polymers (as disclosed herein)
that can swell in water and hold an amount of water while
maintaining or substantially maintaining its structure, e.g., due
to chemical or physical cross-linking of individual polymer chains.
Due to their high-water content, hydrogels are soft and flexible,
which makes them very similar to natural tissue. In the present
invention the term "hydrogel" is used to refer both to a hydrogel
in the hydrated state when it contains water (e.g. after the
hydrogel has been formed in an aqueous solution, or after the
hydrogel has been hydrated or (re-)hydrated once inserted into the
eye or otherwise immersed into an aqueous environment) and to a
hydrogel in its dry (dried/dehydrated) state, e.g., when it has
been dried to a low water content of e.g. not more than 1% by
weight. In the present invention, wherein an active principle is
contained (e.g. dispersed) in a hydrogel, the hydrogel may also be
referred to as a "matrix".
[0072] The term "polymer network" describes a structure formed of
polymer chains (of the same or different molecular structure and of
the same or different molecular weight) that are cross-linked with
each other. The types of polymers suitable for the purposes of the
present invention are disclosed herein below.
[0073] The term "amorphous" refers to a polymer or polymer network,
which does not exhibit crystalline structures in X-ray or electron
scattering experiments.
[0074] The term "semi-crystalline" refers to a polymer or polymer
network, which possesses some crystalline character, i.e., exhibits
some crystalline properties in X-ray or electron scattering
experiments.
[0075] The term "precursor" herein refers to those molecules or
compounds that are reacted with each other and that are thus
connected via crosslinks to form a polymer network and thus a
hydrogel matrix. While other materials might be present in the
hydrogel, such as active agents or buffers, they are not referred
to as "precursors".
[0076] The parts of the precursor molecules that are still present
in a final polymer network are also called "units" herein. The
"units" are thus the building blocks or constituents of a polymer
network forming the hydrogel. For example, a polymer network
suitable for use in the present invention may contain identical or
different polyethylene glycol units as further disclosed
herein.
[0077] The term "sustained release" for the purposes of the present
invention is meant to characterize products which are formulated to
make cyclosporine available over an extended period of time,
thereby allowing a reduction in dosing frequency compared to an
immediate release dosage form, such as a solution of cyclosporine
that is topically applied onto the eye (i.e.
cyclosporine-comprising eye drops). Other terms that may be used
herein interchangeably with "sustained release" are "extended
release" or "controlled release". Within the meaning of the
invention, the term "sustained release" comprises constant
cyclosporine release, tapered cyclosporine release as well as any
combination thereof such as a constant cyclosporine followed by a
tapered cyclosporine release. Within the meaning of the invention,
the term "tapered" or "tapering" refers to a decrease of
cyclosporine release over time.
[0078] The term "extended period of time" as used herein refers to
any period of time that would be considered by those of ordinary
skill in the art as being extended with respect to treating a
disease, and in particular refers to periods such as at least about
1 week, or at least about 1 month or longer, such as up to about 12
months, or any intermediate periods such as about 1 to about 6
months, about 2 to about 4 months, about 2 to about 3 months or
about 3 to about 4 months.
[0079] The term "wearing time" as used herein refers to the period
of time the intracanalicular insert is present in the canaliculus,
i.e. the period from administration of the insert until elimination
of the insert from the canaliculus. In certain embodiments,
elimination of the insert can be achieved by removal of the insert
(which may be intentional or unintentional but would not occur
spontaneously without external application of force) or by
spontaneous clearance after an extended period of time once the
insert is either completely biodegraded, completely disintegrated,
or substantially disintegrated so that the remaining part(s) of the
insert is/are drained away. In certain embodiments, the wearing
time is at least about 1 week, or at least about 1 month or longer,
such as up to about 12 months, or any intermediate periods such as
about 1 to about 6 months, about 2 to about 4 months, about 2 to
about 3 months or about 3 to about 4 months.
[0080] The term "visualization agent" as used herein refers to a
molecule or composition that is contained within the hydrogel of an
insert providing the possibility to easily visualize the insert
when inserted into the canaliculus of the eye. The visualization
agent may be a fluorophore such as fluorescein, rhodamine,
coumarin, and cyanine. In certain embodiments the visualization
agent is fluorescein or includes a fluorescein moiety.
[0081] As used herein, "ocular surface" includes the conjunctiva
and/or the cornea, together with elements such as the lacrimal
apparatus, including the lacrimal punctum, as well as the lacrimal
canaliculus and associated eyelid structures.
[0082] As used herein, the terms "tear fluid" or "tears" refer to
the liquid secreted by the lacrimal glands, which lubricates the
eyes and thus forms the tear film. Tears are made up of water,
electrolytes, proteins, lipids, and mucins.
[0083] As used herein, in the context of the present invention, the
terms "administration", "insertion", "administering" and
"inserting" are used synonymously and refer to the placement of the
inserts into the lacrimal canaliculus, and in particular in the
vertical part of the canaliculus, e.g. in accordance with the
procedure as described in Example 4.11. (Insert placement).
[0084] As used herein, the term "bilaterally" or "bilateral"
refers--in the context of administration of the inserts of the
present invention- to an administration of the inserts into both
eyes of a patient. Independent for each eye, the inserts may be
inserted into the superior or inferior canaliculus of the eye, or
into both superior and inferior canaliculus of the eye.
[0085] The term "plug" refers to a device, which is capable of
providing an occlusion, substantial occlusion or partial occlusion
of the tear ducts ("lacrimal occlusion") thereby preventing or
reducing draining of tears, which helps to keep the eyes moist.
Plugs can be classified into "punctal plug" and "intracanalicular
plugs". Intracanalicular plugs are also referred to as "canalicular
plugs" in literature. Both plug classes are inserted through the
upper and/or lower punctum of the eye. Punctal plugs rest at the
punctal opening making them easily visible and, hence, removable
without much difficulty. However, punctal plugs show poor retention
rates and can be contaminated with microbes due to their exposed
composition, rarely resulting in infection. In contrast,
intracanalicular plugs are not visible and provide a better
retention rate compared to punctal plugs as they are placed inside
either the vertical or the horizontal canaliculus. However,
intracanalicular plugs are not easy to remove and provide an
increased risk of migration. Commercially available plugs are often
made of collagen, acrylic, or silicone.
[0086] The terms "canaliculus" (plural "canaliculi") or
alternatively "tear duct" as used herein refer to the lacrimal
canaliculus, i.e. the small channels in each eyelid that drain tear
fluid from the lacrimal punctum to the nasolacrimal duct (see also
FIG. 1). Canaliculi therefore form part of the lacrimal apparatus
that drains lacrimal fluid from the surface of the eye to the nasal
cavity. The canaliculus in the upper eyelid is referred to as
"superior canaliculus" or "upper canaliculus", whereas the
canaliculus in the lower eyelid is referred to as "inferior
canaliculus" or "lower canaliculus". Each canaliculus comprises a
vertical region, referred to as "vertical canaliculus" following
the lacrimal punctum and a horizontal region, referred to as
"horizontal canaliculus" following the vertical canaliculus,
wherein the horizontal canaliculus merges into the nasolacrimal
duct.
[0087] The term "punctum" (plural "puncta") refers to the lacrimal
punctum, a minute opening on the margins of the eyelids,
representing the entrance to the canaliculus. As tears are
produced, some fluid evaporates between blinks, and some is drained
through the lacrimal punctum. Both the upper and the lower eyelid
show the lacrimal punctum, the puncta therefore referred to as
"upper punctum" or "superior punctum" and "lower punctum" or
"inferior punctum", respectively (see also FIG. 1).
[0088] The term "intracanalicular insert" refers to an insert that
can be administered through the upper or lower punctum or through
both upper and lower puncta into the superior or inferior
canaliculus of the eye or into both the superior and inferior
canaliculus of the eye, in particular into the superior or inferior
vertical canaliculus of the eye or into the superior and inferior
vertical canaliculus of the eye. Due to the intracanalicular
localization of the insert, the insert blocks tear drainage by way
of lacrimal occlusion as observed for intracanalicular plugs. In
certain embodiments, the intracanalicular inserts of the present
invention are inserted bilaterally into the inferior vertical
canaliculi of the eyes. According to certain embodiments of the
invention, the intracanalicular insert is a sustained release
biodegradable insert.
[0089] The terms "API", "active (pharmaceutical) ingredient",
"active (pharmaceutical) agent", "active (pharmaceutical)
principle", "(active) therapeutic agent", "active", and "drug" are
used interchangeably herein and refer to the substance used in a
finished pharmaceutical product (FPP) as well as the substance used
in the preparation of such a finished pharmaceutical product,
intended to furnish pharmacological activity or to otherwise have
direct effect in the diagnosis, cure, mitigation, treatment or
prevention of a disease, or to have direct effect in restoring,
correcting or modifying physiological functions in a patient.
[0090] The API used according to the present invention is
cyclosporine A. The term "cyclosporine" as used herein refers to
cyclosporine A and in particular does not refer to cyclosporine B,
C, D, E, H, and L, which are metabolites of cyclosporine A, and
also does not refer to cyclosporine U, G, Dihydrocyclosporine A or
Isocyclosporine A, which can be contained as impurities in
cyclosporine A. In certain embodiments, cyclosporine A may contain
cyclosporine B, C, D, E, G, H, L and U, Dihydrocyclosporine A and
Isocyclosporine A as impurities in a concentration of not more than
1.0% each or not more than 0.7% each, may further contain unknown
impurities in a concentration of not more than 0.3% each or not
more than 0.1% each, and may contain impurities overall in a total
amount of not more than 2.5% or not more than 1.5%.
[0091] The molecular formula of cyclosporine A is
C.sub.62H.sub.111N.sub.11O.sub.12 and its IUPAC name is
30-ethyl-33-(1-hydroxy-2-methylhex-4-enyl)-1,4,7,10,12,15,19,25,28-noname-
thyl-6,9,18,24-tetrakis(2-methylpropyl)-3,21-di(propan-2-yl)-1,4,7,10,13,1-
6,19,22,25,28,31-undecazacyclotritriacontane-2,5,8,11,14,17,20,23,26,29,32-
-undecone (CAS No. 59865-13-3). Its molecular weight is 1203
Daltons. It has the following chemical structure:
##STR00001##
[0092] Cyclosporine is a white to practically white powder which is
soluble in various organic solvents such as acetone, methanol and
ethanol (96% v/v), but practically insoluble in water. In certain
embodiments, cyclosporine is micronized.
[0093] For the purposes of the present invention, cyclosporine in
all its possible forms, including polymorphs or any
pharmaceutically acceptable salts, anhydrates, hydrates, other
solvates or derivatives, can be used. Whenever in this description
or in the claims cyclosporine is referred to without further
specification, even if not explicitly stated, it also refers to
cyclosporine A (see above) in the form of any such polymorphs,
pharmaceutically acceptable salts, anhydrates, solvates (including
hydrates) or derivatives of cyclosporine. With respect to
cyclosporine, suitable solid forms include without limitation the
pure substance form in any physical form known to the person of
ordinary skill in the art. For example, cyclosporine may be in the
form of particles. Particles can be amorphous or crystalline, or
present a mixture of the two forms, and can be made of any size
which could be without limitation classified as coarse, fine or
ultrafine particles, the dimensions of which may be in particular
visible to the naked eye or under the microscope, and have shapes
such as single grains and agglomerates. Particles may also be
micronized. As used herein, the term "micronized" refers to
small-size particles, in particular those of microscopic scale,
which are without limitation reduced in particle size, by e.g. jet
milling, jaw crushing, hammer milling, wet milling, precipitation
in non solvent, cryomilling (milling with liquid nitrogen or dry
ice) and ball milling. Cyclosporine can also be present in
dissolved or dispersed state, e.g. within a solvent or in an
aqueous medium, for example in the form of particles dispersed in
an aqueous suspension which may optionally include further
excipients such as a surfactant.
[0094] As used herein, the term "therapeutically effective" refers
to the amount of cyclosporine needed to produce a desired
therapeutic result after administration. For example, in the
context of the present invention, one desired therapeutic result
would be the reduction of symptoms associated with DED, e.g., as
measured by in vivo tests known to the person of ordinary skill in
the art, such as an increase of a Schirmer's tear test score, a
reduction of Staining values as measured by conjunctival lissamine
green staining or corneal fluorescein staining, a reduction of the
eye dryness severity and/or eye dryness frequency score on a visual
analogue scale (VAS), a reduction of the Ocular Surface Disease
Index and/or the Standard Patient Evaluation of Eye Dryness score
as well as a reduction of the best corrected visual acuity. In one
embodiment, "therapeutically effective" refers to an amount of
cyclosporine in a sustained release intracanalicular insert capable
of achieving a tear fluid concentration of 0.236 .mu.g/mL (which is
considered to be required for immunomodulation, Tang-Liu and
Acheampong, Clin. Pharmacokinet. 44(3), pp. 247-261) over an
extended period of time and in particular over substantially the
whole remaining wearing period of the insert once said tear fluid
concentration is achieved.
[0095] As used herein, the values "d10", "d50", "d90" and "d100"
refer to a value characterizing the amount of particles in a
particle size distribution meeting a certain particle size. In a
given particle size distribution, 10% of the particles present a
particle size of d10 or less, 50% of the particles present a
particles size of d50 or less, 90% of the particles present a
particles size of d90 or less, and substantially all particles
present a particles size of d100 or less. The percentages may be
given by different parameters known to the person of ordinary skill
in the art, e.g. the percentages may be based on volume, weight, or
the number of the particles. Thus, d50 may exemplarily be the
volume-based, the weight-based or the number-based median particle
size. For example, a volume-based d90 of 43 .mu.m means that 90% of
the particles by volume have a particle size of 43 .mu.m or less.
In certain embodiments, the d10, d50 and d90 are volume-based
values. The particle size distribution PSD can be commonly measured
by methods as known to the person of ordinary skill in the art, and
includes sieving as well as laser diffraction methods. In certain
embodiments, the PSD is measured by laser diffraction in accordance
with USP <429> Light Diffraction Measurement of Particle
Size. In certain embodiments, the PSD is measured by laser
diffraction using a Beckman Coulter LS 13 320 based on the optical
model "Fraunhofer.rf780z" with an obscuration value ranging from 7
to 9%.
[0096] As used herein, the term "about" in connection with a
measured quantity, refers to the normal variations in that measured
quantity, as expected by one of ordinary skill in the art in making
the measurement and exercising a level of care commensurate with
the objective of measurement and the precision of the measuring
equipment.
[0097] The term "at least about" in connection with a measured
quantity refers to the normal variations in the measured quantity,
as expected by one of ordinary skill in the art in making the
measurement and exercising a level of care commensurate with the
objective of measurement and precisions of the measuring equipment
and any quantities higher than that.
[0098] As used herein, the singular forms "a," "an," and "the"
include plural references unless the context clearly indicates
otherwise.
[0099] The term "and/or" as used in a phrase such as "A and/or B"
herein is intended to include both "A and B" and "A or B".
[0100] Open terms such as "include," "including," "contain,"
"containing" and the like mean "comprising." These open-ended
transitional phrases are used to introduce an open ended list of
elements, method steps, or the like that does not exclude
additional, unrecited elements or method steps.
DETAILED DESCRIPTION
I. The Intracanalicular Insert
[0101] The intracanalicular inserts of the present invention in
accordance with certain embodiments are characterized in that they
provide sustained release, are biodegradable and comprise a
hydrogel and cyclosporine.
[0102] As also outlined in the definitions section above, providing
sustained release means in the context of the present invention
that the inserts are capable of making cyclosporine available over
an extended period of time. The inserts are administered into the
eye and release the cyclosporine slowly into the tear fluid. As the
latter is slowly renewed by production of new tear fluid from the
lacrimal glands, replacing already present tear fluid on the ocular
surface which is drained through the lacrimal duct, the
cyclosporine present in the insert is slowly released into the tear
fluid, with each blink of the eye, without the need of the patient
taking any action. Thus, the inserts provide an advantageous
hands-free alternative to traditional eye drops.
[0103] Typically, sustained release is maintained, e.g., over
several weeks, so that the current product's dosing frequency of
multiple times a day (due to the product being in the form of
topical eye drops that are prone to fast wash-out) can be
dramatically reduced. This means that a patient can benefit from
the therapeutic effect of the insert without the need to remind
oneself several times a day to self-administer eye-drops, which in
itself is a huge advantage, but in addition reduces the risk of
incorrect dosing due to inexact instillation or incorrect
handling/administration as well as the risk of infections due to
the repeated use of the eye drops bottle.
[0104] Further, as again also outlined in the definitions section
above, the inventive inserts in certain embodiments are designed to
slowly biodegrade over a pre-specified time once administered. This
means that the inserts can remain in the canaliculus and do not
need to be explanted. Normally there is no need for removing the
insert, but the patient can simply leave the insert until it is
cleared away. On the other hand, in the unexpected event of e.g. an
allergic reaction, wearing discomfort or other adverse events such
as irritating sensations etc., the (partially biodegraded) insert
can be removed by applying slight pressure to expulse the insert
through the punctum to the outside or to move the insert further
down canaliculus to be cleared through the nasolacrimal duct. The
ability for removal and/or ease of removal is also advantageous in
case the cyclosporine in the insert is depleted at the end of the
wearing time so that the insert needs to be replaced by a new
insert in order to maintain the therapeutic effect.
[0105] The intracanalicular inserts of the present invention also
comprise a hydrogel. A hydrogel as explained in detail in the
definitions section is able to absorb water and to transition from
a dried to a hydrated state. In certain embodiments, hydration of
the hydrogel results in the insert to change its shape. In
particular embodiments, the insert swells in diameter and shrinks
in length, so that the thin, rod-shaped insert in its dried state
can be easily inserted into the canaliculus, and, once administered
and positioned correctly, swells in the canaliculus in diameter so
that it firmly fits and reduces the risk of migration or loss of
the insert. The hydrated insert is soft and thus comfortable to
wear despite being firmly secured in position.
[0106] In certain embodiments, the hydrogel comprises a polymer
network. Details on the polymer network are provided further
below.
[0107] The principle of such hydrogel plugs that are high-swelling
to be firmly positioned have been disclosed, for instance, in U.S.
Pat. No. 8,409,606 (hereby incorporated by reference for all
purposes with the instant specification prevailing in case of
conflict).
The Active Principle:
[0108] Details on cyclosporine, its chemical structure and its
properties are provided above in the definitions section. As
outlined therein, cyclosporine is practically insoluble in water,
and thus, without wishing to be bound by theory, it is hypothesized
that upon contact with tear fluid, the low drug solubility at
physiological conditions (about 10 .mu.g/mL) in conjunction with
the cross-sectional area of the insert in contact with the tear
fluid as well as the limited volume of the tear fluid is believed
to regulate the rate of drug release.
[0109] On the other hand, the form and amount of the cyclosporine
embedded in the hydrogel may still affect dissolution of the
cyclosporine and reaching of a therapeutically effective rate of
release.
[0110] One aspect of certain embodiments of the present invention
is a sustained release biodegradable intracanalicular insert
comprising a hydrogel and cyclosporine, wherein the cyclosporine is
in the form of particles and wherein the cyclosporine particles are
dispersed within the hydrogel.
[0111] In certain embodiments of the invention, the cyclosporine
particles are uniformly dispersed within the hydrogel. Dispersed
within the hydrogel as used herein refers to the cyclosporine
particles to be present in substantially pure substance form
embedded within the matrix, although it does not exclude a small
amount of cyclosporine being found on the surface of the matrix. In
certain embodiments the cyclosporine particles form a separate
hydrophobic phase that does not contain further excipients other
than the cyclosporine and any impurities that may be present in the
active material as employed, and in particular does not refer to
any microspheres, microparticles or hydrophobic microdomains
entrapping the drug and comprising further materials such as an
oil, fat, fatty acid, wax, fluorocarbon or other water immiscible
phases that have been suggested earlier. The cyclosporine being
present in substantially pure form has the advantage of easy
manufacture, as no further treatment of the active material is
necessary to prepare e.g. microspheres, microparticles or
hydrophobic microdomains.
[0112] The cyclosporine in certain embodiments may have a loss on
drying of not more than 1.5% w/w determined on 100 mg in a
capillary stoppered bottle in vacuum at a pressure not exceeding 5
mm of mercury at 60.degree. C., a heavy metals content of not more
than 0.002%, organic impurities as defined in the product
specification section of Example 2, and in particular a sum of all
impurities as determined by HPLC of not more than 1.5%, a
cyclosporine content of not less than 97.0% and not more than
101.5% as determined by HPLC, and residual acetone of not more than
4500 ppm and residual ethyl acetate of not more than 2000 ppm as
measured by GC Headspace.
[0113] The inventive inserts are, in certain embodiments and as
also shown in the examples (see in particular Example 2), stable
upon storage, and the cyclosporine content does not change
substantially upon long term storage.
[0114] Thus, in certain embodiments, the cyclosporine content as
measured by HPLC after at least 3 months, after at least 6 months,
or after at least 12 months of storage at a temperature of from 2
to 8.degree. C. as well as the initial cyclosporine content as
measured by HPLC directly before storage is from about 300 to about
410 .mu.g.
[0115] In certain embodiments, the cyclosporine content as measured
by HPLC after at least 3 months, after at least 6 months, or after
at least 12 months of storage at a temperature of from 2 to
8.degree. C. is within 90 to 110% by weight, or within 95 to 105%
by weight, or within 98 to 102% by weight of the initial
cyclosporine content as measured by HPLC directly before
storage.
[0116] In certain embodiments, the amount of impurities as measured
by HPLC after at least 3 months, after at least 6 months, or after
at least 12 months of storage at a temperature of from 2 to
8.degree. C. is not more than 3.0%.
[0117] In certain embodiments of the invention, the cyclosporine is
in the form of particles. In certain embodiments the particles are
micronized particles. Without wishing to be bound by theory, it is
believed that cyclosporine particles, and in particular small
cyclosporine particles, in a dispersed state enable dissolution of
the active that is fast enough to allow for a fast onset of
action.
[0118] In certain embodiments of the invention, the cyclosporine
particles have a d50 value of less than about 50 .mu.m or a d90
value of less than about 43 .mu.m or a d100 value of less than
about 45 .mu.m as measured by laser diffraction. As demonstrated by
the Examples (see Example 1.4), large particles are believed to
have an impact on the mechanical properties of the intracanalicular
inserts. In addition, large particles also tend to block the tubes
so that casting the precursor mixture (as outlined further below)
gets difficult to impossible.
[0119] In certain embodiments of the invention, the cyclosporine
particles have a d50 value ranging from about 3 to about 17 .mu.m,
or from about 4 to about 12 .mu.m, or from about 5 to about 8
.mu.m. As demonstrated by the Examples (see Example 1.4), the
particle size has a substantial impact on the density, swelling
behavior as well as surface quality of the inserts, and high
densities and smoother insert surfaces, which can be achieved by
smaller particles, need to be weighed up against better hydration
and swelling behavior of large particles.
[0120] In certain embodiments, the d50, d90 and d100 values refer
to those of the cyclosporine particles used to manufacture the
inserts, or to those of the cyclosporine particles present in the
inserts.
[0121] In terms of the amount of cyclosporine contained in the
insert, a high concentration of active in the insert is desirable
in certain embodiments as it will allow a high dose of active
(resulting in the sustained release to last longer and/or at a
constant rate, as will be further discussed below) at the same
insert dimensions, or the same dose but smaller product dimensions,
the latter being preferable in terms of ease of administration and
wearing comfort. On the other hand, the concentration has a
non-negligible impact on the insert quality, as demonstrated in
Example 1.1. I.e., too high or too low concentrations tend to
result in the manufactured inserts being "strawed", having large
dry diameters and hollow holes. In addition, lower drug
concentrations appear to result in improved swelling/hydration
behavior.
[0122] In certain embodiments of the invention, the insert in a
dried state contains from about 15% to about 80%, or from about 30%
to about 65% by, or from about 45% to about 55% by weight of the
cyclosporine based on the total weight of the insert.
[0123] One aspect of the present invention is a sustained release
biodegradable intracanalicular insert comprising a hydrogel and
cyclosporine, wherein the insert in a dried state contains from
about 40% to about 80% by weight of the cyclosporine based on the
total weight of the insert.
[0124] In terms of absolute amount of active, the dose is an
important factor for achieving sustained release.
[0125] In certain embodiments of the invention, the insert
comprises the cyclosporine in an amount ranging from about 100
.mu.g to about 800 .mu.g.
[0126] The cyclosporine is contained in the insert of the invention
in a range of doses, e.g., from about 100 .mu.g to about 800 .mu.g,
from about 100 .mu.g to about 300 .mu.g, from about 300 .mu.g to
about 450 .mu.g, or from about 500 .mu.g to about 800 .mu.g. Any
amount within these ranges may be used, such as about 250 .mu.g,
about 360 .mu.g, about 600 .mu.g, or about 670 .mu.g, all values
also including a variance of +25% and -20%, or a variance of
+/-15%. or a variance of +/-10%.
[0127] The disclosed amounts of cyclosporine, including the
mentioned variances, refer to both the final content of the active
principle in the insert, as well as to the amount of active
principle used as a starting component when manufacturing the
insert.
The Polymer Network:
[0128] As indicated above, in certain embodiments, the hydrogel
comprises a polymer network. The hydrogel may be formed from
precursors having functional groups that form crosslinks to create
such a polymer network. These crosslinks between polymer strands or
arms may be chemical (i.e., may be covalent bonds) and/or physical
(such as ionic bonds, hydrophobic association, hydrogen bridges
etc.) in nature.
[0129] The polymer network may be prepared from precursors, either
from one type of precursor or from two or more types of precursors
that are allowed to react. Precursors are chosen in consideration
of the properties that are desired for the resultant hydrogel.
There are various suitable precursors for use in making the
hydrogels. Generally, any pharmaceutically acceptable and
crosslinkable polymers forming a hydrogel may be used for the
purposes of the present invention. The hydrogel and thus the
components incorporated into it, including the polymers used for
making the polymer network, should be physiologically safe such
that they do not elicit e.g. an immune response or other adverse
effects. Hydrogels may be formed from natural, synthetic, or
biosynthetic polymers.
[0130] Natural polymers may include glycosaminoglycans,
polysaccharides (e.g. dextran), polyaminoacids and proteins or
mixtures or combinations thereof.
[0131] Synthetic polymers may generally be any polymers that are
synthetically produced from a variety of feedstocks by different
types of polymerization, including free radical polymerization,
anionic or cationic polymerization, chain-growth or addition
polymerization, condensation polymerization, ring-opening
polymerization etc. The polymerization may be initiated by certain
initiators, by light and/or heat, and may be mediated by
catalysts.
[0132] Generally, for the purposes of the present invention one or
more synthetic polymers of the group comprising one or more units
of polyethylene glycol (PEG), polyethylene oxide, polypropylene
oxide, polyvinyl alcohol, poly (vinylpyrrolidinone), polylactic
acid, polylactic-co-glycolic acid, random or block copolymers or
combinations/mixtures of any of these can be used, while this list
is not intended to be limiting.
[0133] To form covalently crosslinked polymer networks, the
precursors may be covalently crosslinked with each other. In
certain embodiments, precursors with at least two reactive centers
(for example, in free radical polymerization) can serve as
crosslinkers since each reactive group can participate in the
formation of a different growing polymer chain.
[0134] The precursors may have biologically inert and hydrophilic
portions, e.g., a core. In the case of a branched polymer, a core
refers to a contiguous portion of a molecule joined to arms that
extend from the core, where the arms carry a functional group,
which is often at the terminus of the arm or branch. Multi-armed
PEG precursors are examples of such precursors and are further
disclosed herein below.
[0135] Thus a hydrogel for use in the present invention can be made
e.g. from one multi-armed precursor with a first (set of)
functional group(s) and another multi-armed precursor having a
second (set of) functional group(s). By way of example, a
multi-armed precursor may have hydrophilic arms, e.g., polyethylene
glycol units, terminated with primary amines (nucleophile), or may
have activated ester end groups (electrophile). The polymer network
according to the present invention may contain identical or
different polymer units crosslinked with each other. The precursors
may be high-molecular weight components (such as polymers having
functional groups) or low-molecular weight components (such as
low-molecular amines, thiols, esters etc.).
[0136] Certain functional groups can be made more reactive by using
an activating group. Such activating groups include (but are not
limited to) carbonyldiimidazole, sulfonyl chloride, aryl halides,
sulfosuccinimidyl esters, N-hydroxysuccinimidyl (NHS) ester,
succinimidyl ester, epoxide, aldehyde, maleimides, imidoesters,
acrylates and the like. The NHS esters are useful groups for
crosslinking of nucleophilic polymers, e.g., primary
amine-terminated or thiol-terminated polyethylene glycols. An
NHS-amine crosslinking reaction may be carried out in aqueous
solution and in the presence of buffers, e.g., phosphate buffer (pH
5.0-7.5), triethanolamine buffer (pH 7.5-9.0), borate buffer (pH
9.0-12), or sodium bicarbonate buffer (pH 9.0-10.0).
[0137] In certain embodiments, each precursor may comprise only
nucleophilic or only electrophilic functional groups, so long as
both nucleophilic and electrophilic precursors are used in the
crosslinking reaction. Thus, for example, if a crosslinker has only
nucleophilic functional groups such as amines, the precursor
polymer may have electrophilic functional groups such as
N-hydroxysuccinimides. On the other hand, if a crosslinker has
electrophilic functional groups such as sulfosuccinimides, then the
functional polymer may have nucleophilic functional groups such as
amines or thiols. Thus, functional polymers such as proteins, poly
(allyl amine), or amine-terminated di- or multifunctional
poly(ethylene glycol) can be also used to prepare the polymer
network of the present invention.
[0138] In one embodiment of the present invention a precursor for
the polymer network forming the hydrogel in which the cyclosporine
is dispersed to form the insert according to the present invention
has about 2 to about 16 nucleophilic functional groups each (termed
functionality), and in another embodiment a precursor has about 2
to about 16 electrophilic functional groups each (termed
functionality). Reactive precursors having a number of reactive
(nucleophilic or electrophilic) groups as a multiple of 4, thus for
example 4, 8 and 16 reactive groups, are particularly suitable for
the present invention. Any number of functional groups, such as
including any of 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, or
16 groups, is possible for precursors to be used in accordance with
the present invention, while ensuring that the functionality is
sufficient to form an adequately crosslinked network.
Peg Hydrogels:
[0139] In a certain embodiment of the present invention, the
polymer network forming the hydrogel contains polyethylene glycol
(PEG) units. PEGs are known in the art to form hydrogels when
crosslinked, and these PEG hydrogels are suitable for
pharmaceutical applications e.g. as matrix for drugs intended to be
administered to all parts of the human or animal body.
[0140] The polymer network of the hydrogel inserts of the present
invention may comprise one or more multi-arm PEG units having from
2 to 10 arms, or 4 to 8 arms, or 4, 5, 6, 7 or 8 arms. In certain
embodiments, the PEG units used in the hydrogel of the present
invention have 4 and/or 8 arms. In certain particular embodiments,
a 4-armed PEG is utilized.
[0141] The number of arms of the PEG used contributes to
controlling the flexibility or softness of the resulting hydrogel.
For example, hydrogels formed by crosslinking 4-arm PEGs are
generally softer and more flexible than those formed from 8-arm
PEGs of the same molecular weight. In particular, if stretching the
hydrogel prior to (or also after) drying as disclosed herein below
in the section relating to the manufacture of the insert is
desired, a more flexible PEG unit may be used, such as a 4-arm PEG,
optionally in combination with another multi-arm PEG, such as an
8-arm PEG as disclosed above, or another (different) 4-arm PEG.
[0142] In certain embodiments of the present invention,
polyethylene glycol units used as precursors have an average
molecular weight in the range from about 2,000 to about 100,000
Daltons, or in a range from about 10,000 to about 60,000 Daltons.
In certain particular embodiments the polyethylene glycol units
have an average molecular weight in a range from about 10,000 to
about 40,000 Daltons. In specific embodiments, the polyethylene
glycol units used for making the hydrogels according to the present
invention have a molecular weight of about 20,000 Daltons.
[0143] The molecular weight of polyethylene glycol and polyethylene
glycol derivatives can be determined by several methods, including
gel electrophoresis such as SDS-PAGE (sodium dodecyl
sulphate-polyacrylamide gel electrophoresis), gel permeation
chromatography (GPC), GPC with dynamic light scattering (DLS) as
well as Matrix-assisted laser desorption/ionization-time of flight
(MALDI-TOF) spectrometry. The molecular weight of polyethylene
glycol precursors as disclosed herein can be determined by any
method known to the person of ordinary skill in the art, including
SDS-PAGE, GPC and MALDI-TOF, and in particular is determined by GPC
using a PEG standard of known molecular weight (determined e.g. by
MALDI-TOF) and polydispersity (determined e.g. by GPC). In case a
high accuracy is needed, MALDI-TOF can be used.
[0144] The molecular weight of the polyethylene glycol refers to an
average molecular weight, which may be selected from various
average values known to the person of ordinary skill in the art,
including number average molecular weight (Mn), weight average
molecular weight (Mw), and peak average molecular weight. Any of
such average values, and in particular the three aforementioned
average molecular weights can be used in the context of the present
invention. In certain embodiments, the average molecular weight of
the polyethylene glycol units and precursors as disclosed herein is
given as number average molecular weight.
[0145] Multi-arm PEG units with a specified molecular weight as
used herein may be abbreviated in the form of e.g. 4a20kPEG,
referring to a 4-arm PEG unit with a molecular weight of
20,000.
[0146] In a 4-arm PEG, each of the arms may have an average arm
length (or molecular weight) of the total molecular weight of the
PEG divided by 4. A 4a20kPEG precursor, which is a particularly
suitably precursor for use in the present invention thus has 4 arms
with an average molecular weight of about 5,000 Daltons each. An
8a20k PEG precursor, which could also be used in combination with
or alternatively to the 4a20kPEG precursor in the present
invention, thus has 8 arms each having an average molecular weight
of 2,500 Daltons. Longer arms may provide increased flexibility as
compared to shorter arms. PEGs with longer arms may swell more as
compared to PEGs with shorter arms. A PEG with a lower number of
arms also may swell more and may be more flexible than a PEG with a
higher number of arms. In certain particular embodiments, only a
4-arm PEG precursor is utilized in the present invention. In
certain particular embodiments, two different 4-arm PEG precursors
are utilized in the present invention. In certain other
embodiments, a combination of a 4-arm PEG precursor and an 8-arm
precursor is utilized in the present invention. In addition, longer
PEG arms have higher melting temperatures when dry, which may
provide more dimensional stability during storage.
[0147] In certain embodiments, electrophilic end groups for use
with PEG precursors for preparing the hydrogels of the present
invention are N-hydroxysuccinimidyl (NETS) esters, including but
not limited to NHS dicarboxylic acid esters such as the
succinimidylmalonate group, succinimidylmaleate group,
succinimidylfumarate group, "SAZ" referring to a
succinimidylazelate end group, "SAP" referring to a
succinimidyladipate end group, "SG" referring to a
succinimidylglutarate end group, and "SS" referring to a
succinimidylsuccinate end group.
[0148] Thus, in certain embodiments, the PEG-precursor is an NHS
dicarboxylic acid ester-terminated multi-arm PEG precursor that can
be represented by the formula:
##STR00002##
[0149] wherein n is determined by the molecular weight of the
respective PEG-arm, m is an integer from 0 to 10, and specifically
is 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10, and x is the number of arms
(and thus can be, e.g., 2, 4, 8, etc., see above). Where m is 1,
each arm is terminated with a succinimidylsuccinate (SS) end group,
where m is 2, each arm is terminated with a succinimidylglutarate
(SG) group, where m is 3, each arm is terminated with a
succinimidyladipate (SAP) group, and where m is 6, each arm is
terminated with a succinimidylazelate (SAZ) group. With these
specific electrophilic end groups, multi-arm PEG units may be
abbreviated in the form of e.g. 4a20kPEG-SAP, referring to a 4-arm
PEG with a succinimidyadipate end group and a molecular weight of
20,000 (4 arms, about 5,000 Daltons each). In the above formula, R
is a core structure appropriate to provide the desired number of
arms. For 4-arm PEG units and precursors, R can be a
pentaerythritol structure, whereas for 8-arm PEG units and
precursors, R can be a hexaglycerol structure.
[0150] In certain embodiments, the PEG precursor is 4a20kPEG-SG or
4a20kPEG-SAP.
[0151] In certain embodiments, nucleophilic end groups for use with
electrophilic group-containing PEG precursors for preparing the
hydrogels of the present invention are amine (denoted as
"NH.sub.2") end groups. Thiol (--SH) end groups or other
nucleophilic end groups are also possible.
[0152] In certain embodiments, 4-arm PEGs with an average molecular
weight of about 20,000 Daltons and electrophilic end groups as
disclosed above (such as the SAZ, SAP, SG and SS end groups) are
crosslinked for forming the polymer network and thus the hydrogel
according to the present invention.
[0153] Reactions of e.g. nucleophilic group-containing crosslinkers
and electrophilic group-containing PEG units, such as a reaction of
amine group-containing crosslinkers with activated ester-group
containing PEG units, result in a plurality of PEG units being
crosslinked by the crosslinker via an amide group.
[0154] In the case of PEGs with NHS-ester end groups such as
succinimidylazelate (SAZ)-, succinimidyladipate (SAP)- or
succinimidylgluatarate-(SG)-terminated PEG units (see above), the
reaction with amine group-containing crosslinkers result in a
plurality of PEG units being crosslinked by the crosslinker via a
hydrolyzable linker having the formula:
##STR00003##
wherein m is an integer from 0 to 10, and specifically is 1, 2, 3,
4, 5, 6, 7, 8, 9, or 10. For a SAZ-end group, m would be 6. For a
SAP-end group, m would be 3, for a SG-end group, m would be 2 and
for an SS-end group, m would be 1.
[0155] In particular embodiments, the SG or the SAP end group is
utilized in the present invention. The SG end group may provide for
a shorter time until the hydrogel is biodegraded when compared to
the use of the other succinimidyl end groups (except the SS group),
such as the SAZ end group, which provides for a higher number of
carbon atoms in the linker and may thus be more hydrophobic and
therefore less prone to ester hydrolysis than the SG end group.
[0156] In certain embodiments, an electrophilic group-containing
multi-arm polymer precursor, and in particular a multi-arm PEG
precursor having an SG or an SAP end group (as defined above) is
crosslinked with a nucleophilic group-containing crosslinking
agent. The nucleophilic group can be an amine and in particular a
primary amine.
[0157] In certain embodiments, the nucleophilic group-containing
crosslinking agent is a nucleophilic group-containing multi-arm
polymer precursor.
[0158] In certain other embodiments, the crosslinking agent used is
a low-molecular weight component containing nucleophilic end
groups, such as amine or thiol end groups. In certain embodiments,
the nucleophilic group-containing crosslinking agent is a small
molecule amine with a molecular weight below 1,000 Da, comprising
two or more primary aliphatic amine groups. A particular
crosslinking agent for use in the present invention is, e.g.,
dilysine, trilysine, tetralysine, ethylenediamine,
1,3-diaminopropane, 1,3-diaminopropane, diethylenetriamine,
trimethylhexamethylenediamine, their pharmaceutically acceptable
salts, hydrates, but also derivatives such as conjugates (as long
as sufficient nucleophilic groups for crosslinking remain present),
and any mixtures thereof. In certain preferred embodiments,
trilysine is used as crosslinking agent. It is understood that
trilysine as used herein refers to trilysine in any form including
a trilysine salt, such as trilysine acetate or a trilysine
derivative such as a labeled trilysine.
[0159] In certain embodiments, the nucleophilic group-containing
crosslinking agent is a labeled crosslinking agent and in
particular is a labeled trilysine. The crosslinking agent can be
labeled with a visualization agent to aid the physician in
confirming the presence of the insert e.g. in the course of control
examinations. Fluorophores such as fluorescein, rhodamine,
coumarin, and cyanine can be used as visualization agent for
labeling the crosslinking agent. Labeling can be achieved e.g. by
chemical conjugation, and in particular by using the nucleophilic
groups of the crosslinking agent for conjugation with the label.
Since a sufficient amount of the nucleophilic groups (at least more
than one molar equivalent) are necessary for crosslinking,
"conjugated" or "conjugation" in general includes partial
conjugation, meaning that only a part of the nucleophilic groups
are used for conjugation with the label. Thus, in certain
embodiments, the crosslinking agent is trilysine labeled by partial
conjugation with a visualization agent, wherein in particular about
1% to about 20%, or about 5% to about 10%, or about 8% of the
trilysine amine groups are conjugated with a visualization
agent.
[0160] In certain embodiments, the nucleophilic group-containing
crosslinking agent is fluorescein-conjugated trilysine. The
fluorescein-conjugated trilysine can be obtained by reacting
trilysine acetate with N-hydroxysuccinimide (NHS)-fluorescein.
[0161] In certain embodiments, the multi-arm polymer units comprise
4a20kPEG units and the cross-linking units comprise
fluorescein-conjugated trilysine amide units.
[0162] In certain embodiments, the polymer network is obtained by
reacting 4a20kPEG-SG with fluorescein-conjugated trilysine in a
molar ratio ranging from about 1:2 to about 2:1. In certain other
embodiments, the polymer network is obtained by reacting
4a20kPEG-SS or 4a20kPEG-SAZ with fluorescein-conjugated trilysine
in a molar ratio ranging from about 1:2 to about 2:1.
[0163] In certain embodiments, the molar ratio of the nucleophilic
and the electrophilic end groups reacting with each other is about
1:1, i.e., one amine group is provided per one electrophilic group
such as the SG or the SAP end group. In the case of 4a20kPEG-SG or
4a20kPEG-SAP as electrophilic group-containing polymer unit and
fluorescein-conjugated trilysine, this results in a molar ratio of
the two components of about 1:1, assuming a partial conjugation of
the trilysine utilizing one of the four primary amines on average,
as the trilysine then has three primary amine groups that may react
with the electrophilic SG or SAP ester group. However, an excess of
either the electrophilic (e.g. the NHS end groups, such as the SG)
end group precursor or of the nucleophilic (e.g. the amine) end
group precursor may be used.
[0164] Thus, in certain embodiments, the polymer network is
obtained by reacting 4a20kPEG-SG with fluorescein-conjugated
trilysine in a molar ratio ranging from about 1:2 to about 2:1, and
in particular in molar ratio of about 1:1.
[0165] In certain embodiments, the polymer network is obtained by
reacting 4a20kPEG-SAP with fluorescein-conjugated trilysine in a
molar ratio ranging from about 1:2 to about 2:1, and in particular
in molar ratio of about 1:1.
Surfactant:
[0166] One aspect of the present invention is a sustained release
biodegradable intracanalicular insert comprising a hydrogel and
cyclosporine, wherein the insert contains a surfactant.
[0167] As outlined further above, cyclosporine is a hydrophobic
active that is practically non-miscible with the hydrophilic
hydrogel material, and in certain embodiments, is present in the
form of dispersed particles with a specific particle size. It has
been shown that a certain particle size is advantageous in terms of
the insert properties. However, small particles are also prone to
agglomeration. Without wishing to be bound by theory, the presence
of a surfactant is believed to prevent agglomeration and to improve
content uniformity of the hydrogel.
[0168] In addition, experimental results indicate that the presence
of a surfactant aids in preventing undesirable tube adhesion of the
casted hydrogel during manufacture of the inserts (see Example 1.2)
and improves the insert quality.
[0169] Thus, in certain embodiments, the insert contains a
surfactant.
[0170] In certain embodiments, the insert in a dried state contains
from about 0.01% to about 5% by weight or from about 0.01% to about
2% by weight or from about 0.2% to about 2% by weight or from about
0.05% to about 0.5% by weight of a surfactant based on the total
weight of the insert.
[0171] As shown in Example 1.2, the surfactant type may be
important in view of the ability to prevent cyclosporine particle
aggregation. In certain embodiments, the insert contains a
non-ionic surfactant. The non-ionic surfactant may comprise a
poly(ethylene glycol) chain. Exemplary non-ionic surfactants which
can be used herein are poly(ethylene glycol) sorbitan monolaurate
commercially available as Tween.RTM. (and in particular
Tween.RTM.20, a PEG-20-sorbitan monolaurate, or Tween.RTM.80, a
PEG-80-sorbitan monolaurate), poly(ethylene glycol) ester of castor
oil commercially available as Cremophor (and in particular
Cremophor40, which is PEG-40-castor oil), and an ethoxylated
4-tert-octylphenol/formaldehyde condensation polymer which is
commercially available as Tyloxapol.
Additional Ingredients:
[0172] The insert of the present invention may contain, in addition
to the polymer units forming the polymer network as disclosed
above, the active principle and the surfactant, other additional
ingredients. Such additional ingredients are for example salts
originating from buffers used during the preparation of the
hydrogel, such as phosphates, borates, bicarbonates, or other
buffer agents such as triethanolamine. In certain embodiments of
the present invention sodium phosphate buffers (specifically, mono-
and dibasic sodium phosphate) are used.
[0173] Optionally, preservatives may be used for the inserts of the
present invention. However, as demonstrated also in the Examples by
way of storage stability test data as well as by clinical results
demonstrating that the inserts remain safe, the inventive inserts
do not require the presence of preservatives in contrast to e.g.
certain eye drops. As preservatives are believed to be also a cause
for discomfort to the subject such as stinging and irritation of
the eyes, in one embodiment of the invention, the inserts are free
or essentially free of preservatives.
Formulation:
[0174] In certain embodiments, inserts according to the present
invention comprise cyclosporine, a polymer network made from one or
more polymer precursors as disclosed herein above in the form of a
hydrogel, and optional additional components such as a surfactant,
but also salts etc. remaining in the insert from the production
process (such as phosphate salts used as buffers etc.).
[0175] In certain embodiments, the insert according to the present
invention in a dried state contains from about 15% to about 80% by
weight of the cyclosporine based on the total weight of the insert
and from about 20% to about 60% by weight polymer units based on
the total weight of the insert, or from about 30% to about 65% by
weight of the cyclosporine based on the total weight of the insert
and from about 25% to about 50% by weight polymer units based on
the total weight of the insert, or from about 45% to about 55% by
weight of the cyclosporine based on the total weight of the insert
and from about 37% to about 47% by weight polymer units based on
the total weight of the insert.
[0176] In one further particular embodiment, on a dry weight basis
the cyclosporine to PEG ratio is from about 50% to 60% by weight
cyclosporine to approximately 40% by weight PEG based on the total
weight of the insert, the balance being phosphate salt and other
excipients.
[0177] In certain embodiments, the balance of the insert in its
dried state (i.e., the remainder of the formulation when
cyclosporine, polymer hydrogel, such as PEG hydrogel, and the
optional surfactant have already been taken account of) may be
salts remaining from buffer solutions as disclosed above. In
certain embodiments, such salts are phosphate, borate or (bi)
carbonate salts. In one embodiment the buffer salt is sodium
phosphate (mono- and/or dibasic).
[0178] The amounts of the cyclosporine and the polymer(s) may be
varied, and other amounts of cyclosporine and the polymer hydrogel
may be used to prepare inserts according to the invention.
[0179] In certain embodiments, the amount of drug within the
formulation is less than about two times the amount of the polymer
(e.g., PEG) units, but may be higher in certain cases, but it is
desired that the mixture comprising, e.g., the precursors, buffers
and drug (in the state before the hydrogel has gelled completely)
can be uniformly cast into a mold or tubing.
[0180] In one embodiment of the invention, the hydrogel after being
formed and prior to being dried, i.e., in a wet state, comprises
from about 3% to about 20% polyethylene glycol representing the
polyethylene glycol weight divided by the fluid weight.times.100.
In one embodiment, the hydrogel in a wet state comprises about 7.5%
to about 15% polyethylene glycol representing the polyethylene
glycol weight divided by the fluid weight.times.100.
[0181] In certain embodiments, solid contents of about 10% to about
30% (w/v) (wherein "solids" means the combined weight of polymer
precursor(s), salts and the drug in solution) are utilized for
forming the hydrogel for the inserts according to the present
invention.
[0182] In certain embodiments, the water content of the hydrogel in
its dry (dehydrated/dried) state, e.g. prior to insertion into the
canaliculus of the eye, may be very low, such as not more than 1%
by weight of water. In other words, in certain embodiments, the
insert in a dried state contains not more than about 1% by weight
water. The water content may in certain embodiments also be lower
than that, e.g. not more than 0.25% by weight or not more than 0.1%
by weight, based on the total weight of the insert.
Dimensions of the Insert and Dimensional Change Upon Hydration
Through Stretching:
[0183] The dried insert may have different geometries, depending on
the method of manufacture, such as the use of mold or tubing into
which the mixture comprising the hydrogel precursors including the
cyclosporine is cast prior to complete gelling. In one embodiment,
the insert has an cylindrical or essentially cylindrical shape,
with a round or essentially round cross-section. The shape of the
insert may also be described as a fiber (as the length of the
cylinder is much in excess of the diameter) or rod.
[0184] The polymer network, such as the PEG network, of the
hydrogel insert according to certain embodiments of the present
invention may be semi-crystalline in the dry state at or below room
temperature, and amorphous in the wet state. Even in the stretched
form, the dry insert may be dimensionally stable at or below room
temperature, which may be advantageous for inserting the insert
into the canaliculus.
[0185] Upon hydration of the insert in the eye (which can be
simulated by immersing the insert into PBS, pH 7.4 at 37.degree.
C.) the dimensions of the insert according to the invention may
change: generally, the diameter of the insert may increase, while
its length may decrease or at least may stay the same or
essentially the same. An advantage of this dimensional change is
that, while the insert in its dry state is sufficiently thin for an
easy insertion into the canaliculus, once it has been placed in the
canaliculus, the insert does not only become shorter to improve
wearing comfort with respect to the short, vertical part of the
canaliculus and the corresponding limited space available, but also
becomes larger in diameter, so that it tightly fits against the
canaliculus walls, locks the insert in place and thus prevents
unintentional migration and loss of the insert. As it also may
become softer, it is comfortable to wear despite the tight fit. In
certain embodiments, the dimensional change is enabled at least in
part by the "shape memory" effect introduced into the insert by
means of stretching the insert in the longitudinal direction during
its manufacture (as also disclosed below in the section "Method of
manufacture"). In certain embodiments, the stretching may either be
performed in the dry or in the wet state, i.e., after drying the
hydrogel insert, or before drying. It is noted that if no
stretching is performed, and the hydrogel insert is only dried and
cut into a desired length, the dimensions of the insert may not
change substantially, or the insert may increase in both diameter
and length upon hydration. If this is not desired, the hydrogel
fiber may be dry or wet stretched, i.e. stretched prior to or after
drying. In particular, the fiber may be stretched prior to
drying.
[0186] In pre-formed dried hydrogels, a degree of molecular
orientation may be imparted by dry-stretching the material then
allowing it to solidify, locking in the molecular orientation. This
can be accomplished in certain embodiments by drawing the material
(optionally while heating the material to a temperature above the
melting point of the crystallizable regions of the material), then
allowing the crystallizable regions to crystallize. Alternatively,
in certain embodiments the glass transition temperature of the
dried hydrogel can be used to lock in the molecular orientation for
polymers such as PVA that have a suitable glass transition
temperature. Still another alternative is to stretch the gel prior
to complete drying (also referred to as "wet stretching") and then
drying the material while under tension. The molecular orientation
provides one mechanism for anisotropic swelling upon introduction
into a hydrating medium such as the vitreous. Upon hydration the
insert of certain embodiments will swell only in the radial
dimension, while the length will either decrease or be maintained
or essentially maintained. The term "anisotropic swelling" means
swelling preferentially in one direction as opposed to another, as
in a cylinder that swells predominantly in diameter, but does not
appreciably expand (or does even contract) in the longitudinal
dimension.
[0187] The degree of dimensional change upon hydration may depend
inter alia on the stretch factor. The stretch factor as used herein
refers to the factor the hydrogel is stretched at as measured in
stretching direction, i.e. the change in length and not in
diameter, immediately before and after stretching, without taking
any eventual further dimensional change (e.g. due to drying or
re-hydration) into account. As an example, stretching at e.g. a
stretch factor of about 1.3 (e.g. by means of wet stretching) may
have a less pronounced effect or may not change the length during
hydration to a large extent. In contrast, stretching at e.g. a
stretch factor of about 1.8 (e.g. by means of wet stretching) may
result in a markedly shorter length during hydration. Stretching at
e.g. a stretch factor of 4 (e.g. by means of dry stretching) could
result in a much shorter length upon hydration (such as, for
example, a reduction in length from 15 to 8 mm). One skilled in the
art will appreciate that other factors besides stretching can also
affect swelling behavior.
[0188] One aspect of the present invention is a sustained release
biodegradable intracanalicular insert comprising a hydrogel and
cyclosporine in the form of a fiber, wherein the fiber has been
stretched.
[0189] In certain embodiments, the fiber has been stretched by a
stretch factor in the longitudinal direction of from about 1.0 to
about 4.0, or from about 1.5 to about 3.0, or of about 2.7.
[0190] Among other factors influencing the possibility to stretch
the hydrogel and to elicit dimensional change of the insert upon
hydration is the composition of the polymer network. In the case
PEG precursors are used, those with a lower number of arms (such as
4-armed PEG precursors) contribute in providing a higher
flexibility in the hydrogel than those with a higher number of arms
(such as 8-armed PEG precursors). If a hydrogel contains more of
the less flexible components (e.g. a higher amount of PEG
precursors containing a larger number of arms, such as the 8-armed
PEG units), the hydrogel may be firmer and less easy to stretch
without fracturing. On the other hand, a hydrogel containing more
flexible components (such as PEG precursors containing a lower
number of arms, such as 4-armed PEG units) may be easier to stretch
and softer, but also swells more upon hydration. Thus, the behavior
and properties of the insert once it has been placed into the eye
(i.e., once the hydrogel becomes (re-)hydrated) can be tailored by
means of varying structural features as well as by modifying the
processing of the insert after it has been initially formed.
[0191] Exemplary dimensions of inserts used in the Examples herein
below are provided in Table 2.1 of the Examples section. The dried
insert dimensions inter alia depend on the amount of cyclosporine
incorporated as well as the ratio of cyclosporine to polymer units
and can also be controlled by the diameter and shape of the mold or
tubing in which the hydrogel is allowed to gel. Furthermore, the
diameter of the insert is further determined inter alia by (wet or
dry) stretching of the hydrogel fiber once formed. The dried fiber
(after stretching) is cut into segments of the desired length to
form the insert. The diameter and the length of the insert can thus
be adapted as desired. On the other hand, the anatomical dimensions
of the lacrimal canaliculus provide certain dimensional
requirements to an intracanalicular insert to be met.
[0192] In certain embodiments, the insert is in the form of a
fiber. The fiber may have an average length of about 1.5 mm to
about 4.0 mm and an average diameter of not more than 0.8 mm in its
dried state, an average length of about 2.0 mm to about 2.5 mm and
an average diameter of not more than 0.62 mm in its dried state, or
an average length of about 2.5 mm to about 2.9 mm and an average
diameter of not more than 0.62 mm in its dried state.
[0193] The inventive inserts are in certain embodiments, as also
shown in the examples (see in particular Example 2), stable upon
storage, and the product dimensions do not change or do not
substantially upon long term storage.
[0194] Thus, in certain embodiments, the insert after at least 3
months, at least 6 months or at least 12 months of storage at a
temperature of from 2 to 8.degree. C. is in the form of a fiber
that has an average length of about 2.5 mm to about 2.9 mm and an
average diameter of not more than 0.62 mm in its dried state.
[0195] The insert dimensions can e.g. be adjusted by selecting an
appropriate active concentration in view of the dose of
cyclosporine to be incorporated in the insert. By increasing the
active concentration, the insert dimensions can be reduced. On the
other hand, the active concentration also affects the release
behavior as well as insert properties and qualities such as
swelling behavior or diameter after drying (see in particular
Example 1.1). The inventors have surprisingly found in certain
embodiments that certain combinations of insert dimensions, active
concentration and/or dose would result not only in high quality
inserts with appropriate swelling behavior allowing easy
manufacture, easy administration and high wearing comfort, but
would also provide an effective release over an extended period of
time.
[0196] In view of the above, one aspect of the present invention is
a sustained release biodegradable intracanalicular insert
comprising a hydrogel and cyclosporine in an amount of about 360 in
the form of a fiber (or cylinder) that has an average length of
about 2.5 mm to about 2.9 mm and an average diameter of not more
than about 0.62 mm in its dried state. Also one aspect of the
present invention is a sustained release biodegradable
intracanalicular insert comprising a hydrogel and from about 45% to
about 55% by weight of cyclosporine based on the total weight of
the insert, in the form of a fiber (or cylinder) that has an
average length of about 2.5 mm to about 2.9 mm and an average
diameter of not more than about 0.62 mm in its dried state.
[0197] Such inserts, but also the inventive inserts in certain
other embodiments may decrease in length and increase in diameter
upon hydration in vivo in the eye, i.e. in the lacrimal
canaliculus, or in vitro (wherein hydration in vitro is measured in
phosphate-buffered saline at a pH of 7.4 at 37.degree. C. after 24
hours) to an average diameter of at least 1.0 mm in expanded state
after 10 minutes of hydration in vitro in phosphate-buffered saline
at a pH of 7.4 at 37.degree. C., or to an average diameter of at
least 1.3 mm in equilibrium state after 24 hours of hydration in
vitro in phosphate-buffered saline at a pH of 7.4 at 37.degree. C.
In one embodiment, this dimensional change can be achieved by dry
stretching the hydrogel fiber at a stretch factor of about 1 to
about 4, or a factor of about 1.5 to about 3.0, or of about
2.7.
[0198] In certain embodiments, the stretching thus creates a shape
memory, meaning that the insert upon hydration when administered
into the lacrimal canaliculus, will shrink in length (also referred
to as snap-back) and widen in diameter until it approaches (more or
less) its equilibrium dimensions, which are determined by the
original molded dimensions and compositional variables. While the
narrow dry dimensions facilitate insertion of the product into the
canaliculus, the widened diameter and shortened length after
administration yield a shorter and thicker insert that is
comfortable to wear and still is firmly locked in place so that the
risk of unintended migration is minimized. Thus, in one aspect the
present invention also relates to a method of imparting shape
memory to a hydrogel mixture fiber comprising cyclosporine
particles dispersed in the hydrogel by stretching the hydrogel
mixture fiber in the longitudinal direction.
In Vitro Release:
[0199] The in vitro-release of cyclosporine from the inserts of the
invention can be determined by various methods and e.g. under
non-sink simulated physiological conditions in PBS
(phosphate-buffered saline, pH 7.4) at 37.degree. C., with daily
replacement of PBS in a volume comparable to the tear fluid in the
human eye.
[0200] The in vitro release tests may be used to compare different
inserts (e.g. of different production batches, of different
composition, and of different dosage strength etc.) with each
other, for example for the purpose of quality control or other
qualitative assessments.
In Vivo Release and Persistence:
[0201] In an embodiment of the present invention, when the dried
insert of the present invention is inserted to the canaliculus, it
becomes hydrated and changes its dimensions as disclosed above, and
is then over time biodegraded and disintegrates until it has been
fully disintegrated and any remains have been drained down the
lacrimal duct. When the insert is biodegraded, such as through
ester hydrolysis, it gradually may swell and soften. As recognized
by the inventors from the clinical studies presented in the
Examples section herein below, an insert according to certain
embodiments of the invention may persist several months, such as
about 2 to about 4 months or longer, enabling a sustained release
of cyclosporine again over several months.
[0202] After full disintegration of the insert, any remaining
undissolved cyclosporine particles may be drained through the
lacrimal excretory system. Thus, the length of sustained release
can be inter alfa designed by way of adjusting the disintegration
time if a sufficient amount of cyclosporine is included that lasts
over the time the insert needs for complete disintegration. If in
certain embodiments two inserts are used to treat one eye, e.g.,
one insert per each of the lower and upper canaliculus, to achieve
a desired total dose, they may be designed to disintegrate over the
same or substantially the same time.
[0203] In the lacrimal canaliculus, the insert of the invention in
certain embodiments disintegrates within an extended period of
time, e.g. within about 1 to about 6 months after insertion, or
within about 2 to about 4 months after insertion, or within about 2
to about 3 months after insertion, or within about 3 to about 4
months after insertion. This has been demonstrated in the clinical
trials, see the Examples section, in particular Example 4.
[0204] In one embodiment, the insert after insertion to the
canaliculus releases a therapeutically effective amount of
cyclosporine over a period of at least about 1 month, at least
about 2 months, at least about 3 months, or at least 4 months after
insertion.
[0205] In one embodiment of the invention, cyclosporine is released
from the insert after insertion at an average rate of about 0.1
.mu.g/day to about 10 .mu.g/day, or about 1 .mu.g/day to about 5
.mu.g/day, or about 2 .mu.g/day to about 4 .mu.g/day.
[0206] In one embodiment of the invention, cyclosporine is released
from the insert after insertion to a human subject at an average
rate of about 0.1 .mu.g/day to about 10 .mu.g/day, or about 1
.mu.g/day to about 5 .mu.g/day, or about 2 .mu.g/day to about 4
.mu.g/day.
[0207] Pre-clinical studies in animals as well as clinical studies
in humans, as presented in the Examples section herein, have shown
that the inserts of certain embodiments of the invention may
continuously release therapeutically effective amounts of
cyclosporine over an extended period of time, until the inserts are
fully disintegrated. In certain embodiments, however, the entire
amount of cyclosporine contained in the insert is released from the
insert prior to complete biodegradation of the insert.
[0208] One aspect of the present invention is a sustained release
biodegradable intracanalicular insert comprising a hydrogel and
cyclosporine in an amount of about 360 .mu.g dispersed within the
hydrogel, wherein the insert after insertion to the canaliculus
releases a therapeutically effective amount of cyclosporine over a
period of at least about 3 months after insertion.
[0209] In certain embodiments, the tear fluid concentration of
cyclosporine after insertion to a human subject ranges from about
0.1 .mu.g/mL to about 10 .mu.g/mL.
[0210] In certain embodiments, the tear fluid concentration of
cyclosporine after insertion of the insert ranges from about 0.1
.mu.g/mL to about 10 .mu.g/mL, or from about 1 .mu.g/mL to about 5
.mu.g/mL.
[0211] In certain embodiments, the insert disintegrates in the
canaliculus prior to complete solubilization of the cyclosporine
particles contained in the insert.
[0212] The insert of the invention in certain embodiments may be
designed to disintegrate in the lacrimal canaliculus within about 1
to about 6 months after insertion, or within about 2 to about 4
months after insertion, or within about 2 to about 3 months after
insertion, or within about 3 to about 4 months after insertion.
[0213] In one embodiment, where the polymer network of the hydrogel
is crosslinked based on linking groups derived from NHS ester end
groups such as the SG-, the SAP or similar groups as disclosed
above, the persistence of the hydrogel within an aqueous
environment and in the canaliculus depends inter alia on the
hydrophobicity of the carbon chain in proximity to the degradable
ester group. In the inserts used in the Examples herein, this
carbon chain comprises 3 or 4 carbon atoms as it stems from the SG
and SAP functional group of the 4a20k PEG precursor. This may
provide an extended persistence in the human eye of from about 2 to
about 3 months or from about 3 to about 4 months, respectively. In
other embodiments, different precursors than the 4a20kPEG-SG-/-SAP
and the crosslinker trilysine may be used to prepare hydrogel
inserts that biodegrade in the human eye and have similar or
different persistence as the inserts exemplified in the
Examples.
[0214] In certain embodiments, the hydrogel insert softens over
time as it degrades, which may depend inter alia on the structure
of the linker that crosslinks the PEG units in the hydrogel. An
insert as used in the examples of the present application formed
from a 4a20kPEG-SAZ and an 8a20kPEG-NH.sub.2 softens rather slowly
over time.
Mechanism of Release:
[0215] Without wishing to be bound by theory, the mechanism of
release of cyclosporine from an insert of the invention may be
explained as follows:
[0216] As outlined above, the hydrophobic active agent cyclosporine
is practically non-miscible with the hydrophilic hydrogel material.
Once inserted and placed in the canaliculus, the insert is in
contact with tear fluid, which slowly imbibes and penetrates the
hydrophilic hydrogel. Biodegradation, i.e. the hydrolytic
degradation of the hydrogel matrix leads to the hydrogel getting
softer and allows the tear fluid to penetrate even further, but the
hydrophobic active, in particular in form of uniformly dispersed
cyclosporine particles, remains entrapped within the hydrogel
matrix and is released by slow partitioning into the hydrogel due
to the low solubility in aqueous solutions.
[0217] Also, it is believed, without wishing to be bound to a
particular theory, that the tear fluid on top of an
intracanalicular insert provides a fluid column that tends to allow
active release to be limited by the cross-sectional area of the
proximal portion of the plug. The walls of the canaliculus seem to
release the drug at a rate that is much slower relative to the
depletion of the therapeutic agent through the fluid column, and/or
the canaliculus walls may become saturated with the drug so that
release through the walls is slowed. Thus, in certain embodiments,
the intracanalicular insert of the present invention does not
necessitate and in particular does not comprise any barrier or
reservoir system (e.g. a coating on the side wall of the insert
blocking and limiting release of the active to a release from the
cross-sectional area) as has been previously proposed, which are
complex and more difficult to manufacture.
[0218] Drug release from the cross-sectional area of the insert
into the tear fluid may happen first at the outer region of the
hydrogel (i.e., the drug particles that are located in the region
of the hydrogel closer to the punctum get dissolved and diffuse out
first, while those located closer to the other end of the insert,
closer to the lacrimal duct diffuse out last) that is in contact
with the liquid environment. Thereby, in certain embodiments, the
region of the hydrogel closer to the punctum becomes devoid of drug
particles. This region is therefore also called the "clearance
zone", which is limited to dissolved drug only, with a
concentration at or below the solubility of the drug.
[0219] In certain embodiments in which a clearance zone has formed
upon drug dissolution and diffusion out of the hydrogel, this area
of the hydrogel develops voids and becomes softer and weaker.
Concurrently with the drug diffusing out of the hydrogel, the
hydrogel may also be slowly degraded by means of, e.g., ester
hydrolysis in the aqueous environment of the eye. This degradation
occurs uniformly throughout the bulk of the hydrogel. At advanced
stages of degradation, distortion and erosion (also termed
disintegration as used herein) of the hydrogel begins to occur. As
this happens, the hydrogel becomes softer and more liquid (and thus
its shape becomes distorted) until the hydrogel finally
disintegrates completely and any remaining bits of the hydrogel
and/or active are cleared away by the lacrimal drainage system.
[0220] As cyclosporine is a relatively low solubility drug,
undissolved cyclosporine particles may remain at the time the
insert is fully disintegrated, i.e. the insert may disintegrate in
the canaliculus prior to complete solubilization of the
cyclosporine particles contained in the insert, but as outlined
above, in such a case any remaining active particles are cleared
away by the lacrimal drainage system.
[0221] In one embodiment, however, the entire amount of
cyclosporine is released prior to the complete disintegration of
the hydrogel. As the hydrogel may hold the cyclosporine particles
in place and prevent them from agglomeration, the release of
cyclosporine from the hydrogel can be maintained at a relatively
constant rate.
II. Manufacture of the Insert
[0222] In certain embodiments, the present invention also relates
to a method of manufacturing a sustained release biodegradable
intracanalicular insert comprising a hydrogel and cyclosporine as
disclosed herein. In certain embodiments, the method comprises the
steps of [0223] a) preparing a precursor mixture containing
hydrogel precursors and cyclosporine particles dispersed in the
precursor mixture, [0224] b) shaping the precursor mixture and
allowing the hydrogel precursors to cross-link to form a polymer
network and to obtain a shaped hydrogel mixture comprising the
polymer network, and [0225] c) drying the hydrogel mixture to
provide the insert.
[0226] In one embodiment, the cyclosporine particles may be used in
micronized form for preparing the insert, i.e. they are employed in
the form of micronized particles and dispersed to prepare a
precursor mixture wherein the micronized particles are
homogeneously dispersed. In another embodiment, the cyclosporine
may be used in non-micronized form for preparing the insert.
Further details on the active principle cyclosporine have been
disclosed in detail above and apply to the active used for the
manufacture in all aspects.
[0227] The precursors for forming the hydrogel of certain
embodiments have been disclosed in detail above in the section
relating to the insert itself.
[0228] In certain embodiments, in step a) the precursor mixture is
prepared by mixing an electrophilic group-containing
multi-arm-polymer precursor with a nucleophilic group-containing
crosslinking agent in a buffered aqueous solution in the presence
of micronized cyclosporine particles.
[0229] In certain embodiments, in step a) the buffered aqueous
precursor solution is prepared by dissolving the multi-arm-polymer
precursor in an aqueous buffer solution and is then mixed with the
buffered aqueous precursor suspension comprising the nucleophilic
group-containing cross-linking agent and micronized cyclosporine
particles within, e.g., 60 minutes.
[0230] In case PEG precursors are used to prepare a crosslinked PEG
network, the method of manufacturing the insert in certain
embodiments may comprise mixing an electrophilic group-containing
multi-arm polyethylene glycol, such as 4a20kPEG-SG or 4a20kPEG-SAP,
with a nucleophilic group-containing crosslinking agent such as
trilysine in a buffered aqueous solution in the presence of
micronized cyclosporine particles.
[0231] In certain embodiments, the molar ratio of the electrophilic
groups to the nucleophilic groups in the PEG precursors is about
1:1, but the nucleophilic groups (such as the amine groups) may
also be used in excess of the electrophilic groups, or vice versa,
e.g. in a molar ratio ranging from about 1:2 to 2:1. In certain
embodiments, the method comprises reacting 4a20kPEG-SG or
4a20kPEG-SAP with fluorescein-conjugated trilysine in a weight
ratio ranging from about 30:1 to about 50:1
[0232] As shown in Example 1.4, treatment of the precursor mixture
by vacuum degassing turned out to have a high impact on the insert
quality. In particular, agglomeration of cyclosporine particles
could be prevented. Thus, in certain embodiments, in step a) the
precursor mixture containing cyclosporine particles is degassed
under vacuum after mixing its component.
[0233] In certain embodiments, once the precursor mixture has been
prepared as outlined for step a) above, the mixture can be shaped
in step b) by casting into a suitable mold or tubing prior to
complete gelling in order to provide the desired final shape of the
hydrogel, i.e. in step b) the shaping of the precursor mixture
consists of filling the precursor mixture into a mold or tubing
prior to complete cross-linking in order to provide the desired
final shape of the hydrogel mixture and allowing the hydrogel
precursors to cross-link.
[0234] In case the insert should have the shape of a fiber, the
reactive mixture may be filled into a fine diameter tubing, such as
a polyurethane (PU) tubing, in order to provide for the extended
cylindrical shape. Different geometries and diameters of the tubing
may be used, depending on the desired final cross-sectional
geometry of the hydrogel fiber, its initial diameter (which may
still be decreased by means of stretching), and depending also on
the ability of the reactive mixture to uniformly fill the
tubing.
[0235] Thus, the inside of the tubing may have a round geometry or
a non-round geometry such as a cross-shaped geometry. The tubing
may have a round geometry with an inner diameter of, e.g., about 1
mm to about 3 mm or about 2.0 mm.
[0236] In certain embodiments, after the hydrogel has formed and
has been left to cure to complete gelling, the hydrogel may be
longitudinally stretched in the wet or dry state as already
disclosed in detail herein above in the section relating to the
dimensional change of the insert upon hydration. In certain
embodiments, a stretching factor may be in a range of about 1 to
about 4.5, or within other ranges also as disclosed above. When dry
stretching is performed in certain embodiments, the hydrogel is
first dried and then stretched. When wet stretching is performed in
certain embodiments, the hydrogel is stretched in the wet
(essentially undried) state and then left to dry under tension.
Optionally, heat may be applied upon stretching. Further
optionally, the fiber may additionally be twisted.
[0237] In certain embodiments, the insert is obtainable by
preparing a precursor mixture containing hydrogel precursors and
cyclosporine, filling the precursor mixture into a tubing, allowing
the hydrogel precursors to crosslink in the tubing to provide a
hydrogel mixture shaped as a fiber, and stretching the hydrogel
mixture fiber to provide the insert.
[0238] In certain embodiments, the insert maintains its dimensions
even after stretching as long as it is kept in the dry state at or
below room temperature.
[0239] In certain embodiments, the inserts are separately packaged
and sterilized e.g. by means of gamma irradiation.
[0240] The shape memory effect of the stretching has already been
disclosed in detail above with respect to the properties of the
insert. In certain embodiments, the degree of shrinking upon
hydration depends inter alia on the stretch factor as already
disclosed above.
[0241] In certain embodiments, the present invention thus also
relates to a method of imparting shape memory to a hydrogel mixture
fiber comprising cyclosporine particles dispersed in the hydrogel
by stretching the hydrogel mixture fiber in the longitudinal
direction.
[0242] Stretch factors for use in these methods of the invention
may be utilized as already disclosed above.
III. Therapy
[0243] In certain embodiments, the present invention is further
directed to a method of treating or preventing an ocular disease in
a patient in need thereof, the method comprising administering to
the patient a first sustained release biodegradable
intracanalicular insert comprising a hydrogel and a cyclosporine as
disclosed above.
[0244] In certain embodiments, said first insert is left to remain
in the canaliculus until complete disintegration, or is removed
prior to complete disintegration. In certain embodiments, said
first insert may be designed to disintegrate in the canaliculus
within an extended period of time, e.g. within about 1 to about 6
months, within about 2 to about 4 months, or within about 2 to
about 3 months, or within about 3 to about 4 months after
insertion, although in some cases it will take longer to
disintegrate. Under normal circumstances, since the inserts
disintegrate without the need of any action from the patient's
side, the insert may remain in the canaliculus until complete
disintegration. This is advantageous as the patient does not need
to consult a physician or optician in order to have the insert
removed. On the other hand, ongoing biodegradation will soften the
insert, thus facilitating a premature removal if necessary by
applying slight pressure to expulse the insert through the punctum
to the outside or to move the insert further down canaliculus to be
cleared through the nasolacrimal duct, in the unexpected event of
e.g. an allergic reaction, wearing discomfort or other adverse
events such as irritating sensations etc. Also, the softness of the
first insert allows inserting a second insert without the need of
prior removal of the first insert. By inserting the second insert,
the first insert is further pushed into the canaliculus and remains
there without wearing discomfort until disintegration is completed,
or is pushed down the lacrimal drainage system. The second insert
can be inserted e.g. as soon as the intended treatment period of
the first insert has passed, or if the patient feels that the
therapeutic effect wears off.
[0245] Thus, in certain embodiments, a second insert can be
inserted after at least 1 month or at least 2 months without prior
removal of said first insert. In other embodiments, said first
insert is removed prior to complete disintegration and a second
insert is administered to replace the removed first insert.
[0246] One aspect of the invention is a method of treating dry eye
disease in a subject, the method comprising the steps of: [0247]
(a) inserting a first biodegradable insert into a first canaliculus
of a first eye of the subject, wherein the insert comprises: [0248]
(1) a biodegradable hydrogel; [0249] (2) from about 100 .mu.g to
about 800 .mu.g cyclosporine dispersed in the hydrogel; [0250] (3)
wherein the cyclosporine releases from the insert over a period of
at least about 2-months from the date of inserting the first insert
in the subject, at an average rate of about 0.1 .mu.g/day to about
10 .mu.g/day; and [0251] (b) after at least about 2-months from the
date of inserting the first insert, inserting a second insert into
the first canaliculus of the first eye in the subject, wherein the
second insert is similar or substantially similar to the first
insert.
[0252] In certain embodiments, said first insert is designed to
disintegrate in the canaliculus within about 2 to about 3 months
after insertion and said first insert is removed within 2 months
after administration.
[0253] In certain embodiments the dose of cyclosporine per eye
administered once for a treatment period of at least 2 months is
from about 300 .mu.g to about 400 .mu.g cyclosporine. Other
appropriate doses are disclosed further above.
[0254] In certain embodiments the ocular disease is a disorder of
the tear film and ocular surface.
[0255] In certain embodiments the ocular disease is dry eye
disease. In alternative embodiments, inserts and methods of the
present invention can be used to treat other ocular surface
diseases, such as blepharitis, allergic conjunctivitis and in
particular atopic keratoconjunctivitis and vernal
keratoconjunctivitis.
[0256] In some embodiments the ocular disease is associated with
one or more conditions selected from the group consisting of
burning sensation, itching, redness, singing, pain, foreign body
sensation, visual disturbances, inflammation of the lacrimal gland,
inflammation of the ocular surface, T-cell-mediated inflammation,
presence of conjunctival T-cells in the tears and elevated levels
of inflammatory cytokines in the tears.
[0257] In some embodiments the sustained release biodegradable
intracanalicular insert comprising the hydrogel and cyclosporine of
the present invention can be applied in preventing such ocular
conditions in subjects at the risk of developing dry eye disease or
any associated conditions, e.g. subjects wearing contact
lenses.
[0258] In some embodiments the treatment is effective in improving
tear production as measured by Schirmer's tear test in a patient
with a Schirmer's score of less than 10 mm prior to administration,
and/or is effective in reducing eye dryness symptoms as determined
by one or more assessments selected from the group consisting of
rating of the severity of symptoms of eye dryness on a visual
analogue scale, rating of the frequency of symptoms of eye dryness
on a visual analogue scale, determination of tear film break up
time, Corneal Fluorescein Staining, Conjunctival Lissamine Green
Staining, best corrected visual acuity, determination of ocular
surface disease index and standard patient evaluation of eye
dryness.
[0259] In some embodiments the treatment is effective in improving
tear production as measured by Schirmer's tear test in a patient
with a Schirmer's score of less than 10 mm prior to
administration.
[0260] In certain embodiments, the dose per eye administered once
for the treatment period is contained in one or in two inserts.
[0261] In certain embodiments, the insert is inserted into the
lower canaliculus, or into the upper canaliculus, or one insert is
inserted each into the lower and upper canaliculus. The insert may
be inserted into the vertical part of the canaliculus.
[0262] Cyclosporine, per eye administered once for the treatment
period may be contained in one or two inserts.
[0263] In certain embodiments the dose per eye administered once
for the treatment period is contained in one insert as for instance
in one insert comprising a dose of about 250 .mu.g or about 360
.mu.g cyclosporine.
[0264] In certain embodiments, the insert may be inserted into the
canaliculus with the aid of a grasping device selected from the
group consisting of a forceps, a tweezer, and an applicator
[0265] In embodiments wherein two inserts are administered, the
inserts are inserted concurrently as disclosed herein above. The
inserts inserted concurrently can be the same or different.
[0266] In certain embodiments, the treatment period is at least 1
month, at least 2 months or at least 3 months. "Treatment period"
according to one embodiment of the invention means that the
therapeutic effect of an insert of the present invention once
inserted is maintained or essentially maintained over that period
of time. In other words, only one insertion (of the insert of the
present invention) is required in certain embodiments for
maintaining a therapeutic effect during the extended period of time
referred to herein as "treatment period". This is a considerable
advantage over currently used eye drops for treating dry eye
disease, which require a much more frequent administration of
several times a day, and thus substantially improves the patient's
quality of life.
[0267] One aspect of the present invention is a method of treating
dry eye disease in a patient in need thereof, the method comprising
administering to the patient a sustained release biodegradable
intracanalicular insert comprising a hydrogel and cyclosporine,
wherein punctal occlusion and cyclosporine release to the eye
provide a synergistic effect.
[0268] Such a synergistic effect may consist in a higher
bioavailability of the cyclosporine when compared to administration
of eye drops containing cyclosporine designed to provide the same
daily release of cyclosporine, which can e.g. be determined by the
amount of cyclosporine released to the tear fluid as calculated
based on cyclosporine tear fluid concentration over time.
[0269] In certain embodiments the systemic concentration of
cyclosporine is below quantifiable amounts. As systemic
concentrations of cyclosporine are kept at a minimum, the risk of
drug-to-drug interactions or systemic toxicity is also kept at a
minimum. Therefore, in one embodiment additional medication(s)
taken by the patients do not provide a significant risk. This is
especially beneficial in older patients who are frequently
suffering from ocular diseases and are additionally taking other
medications.
[0270] One aspect of the present invention is the use of a
sustained release biodegradable intracanalicular insert comprising
a hydrogel and cyclosporine as disclosed above in the preparation
of a medicament for the treatment of an ocular disease in a patient
in need thereof as disclosed above, or for the treatment of dry eye
disease/keratoconjunctivitis Sicca in a patient in need thereof as
disclosed above.
[0271] One aspect of the present invention is a sustained release
biodegradable intracanalicular insert comprising a hydrogel and
cyclosporine as disclosed above for use in the treatment of an
ocular disease in a patient in need thereof as disclosed above or
for use in the treatment of dry eye disease/keratoconjunctivitis
Sicca in a patient in need thereof as disclosed above.
[0272] One aspect of the present invention is a method of
increasing tear production as measured by Schirmer's tear test in a
patient with a Schirmer's score of less than 10 mm prior to
administration, the method comprising administering to the patient
the sustained release biodegradable intracanalicular insert
comprising a hydrogel and cyclosporine as disclosed above.
[0273] In certain embodiments, in such a method, the Schirmer's
score may increase by at least 2 mm at 6 weeks or by at least 3 mm
at 12 weeks after insertion of the insert.
[0274] One aspect of the present invention is a method of reducing
eye dryness symptoms as determined by one or more assessments
selected from the group consisting of rating of the severity of
symptoms of eye dryness on a visual analogue scale, rating of the
frequency of symptoms of eye dryness on a visual analogue scale,
determination of tear film break up time, Corneal Fluorescein
Staining, Conjunctival Lissamine Green Staining, best corrected
visual acuity, determination of ocular surface disease index OSDI,
and standard patient evaluation of eye dryness SPEED, the method
comprising administering to the patient the sustained release
biodegradable intracanalicular insert comprising a hydrogel and
cyclosporine as disclosed above.
[0275] In certain embodiments, in such a method, the total Corneal
Fluorescein Staining value tCFS may decrease by at least 1.5 at 6
weeks or by at least 3 at 12 weeks after insertion of the
insert.
[0276] In certain embodiments, in such a method, the rating of the
severity of symptoms of eye dryness on a visual analogue scale may
decrease by at least 10 at 2 weeks, or by at least 15 at 6 weeks
after insertion of the insert.
EXAMPLES
[0277] The following Examples are included to demonstrate certain
aspects and embodiments of the invention as described in the
claims. It should be appreciated by those of skill in the art,
however, that the following description is illustrative only and
should not be taken in any way as a restriction of the
invention.
Example 1: Preparation of Cyclosporine Inserts
[0278] The cyclosporine inserts of the present application are
essentially cylindrical (shaped as a fiber), with cyclosporine
homogeneously dispersed and entrapped within a PEG-based hydrogel
matrix to provide sustained release of cyclosporine based on its
low solubility in the tear fluid.
I. Example 1.1: Evaluation of Drug Concentration
[0279] In order to evaluate the influence of drug concentration,
three different formulations were prepared with a low, a medium and
a high dose of cyclosporine. The composition of the three
formulations is shown in Table 1.1.1 below.
TABLE-US-00002 TABLE 1.1.1 Composition of cyclosporine insert
formulations Hydrogel precursor mixture (pre-drying) Low dose
Medium Dose High Dose Cyclosporine 5.12% 9.90% 14.58% Concentration
(% w/w) 4a20K PEG SG 7.96% 7.55% 7.13% Concentration (% w/w) Sodium
Phosphate Dibasic 0.55% 0.52% 0.50% Concentration (% w/w) TLA
Concentration (% w/w) 0.22% 0.21% 0.20% NHS-Fluorescein 0.07% 0.07%
0.06% Concentration (% w/w) Sodium Phosphate monobasic 0.22% 0.21%
0.19% Concentration (% w/w) Solids content 14.13% 18.46% 22.66%
Dried Insert Drug Loading (% w/w) 36.2% 53.6% 64.3%
[0280] The inserts of Low, Medium and High Dose were prepared
essentially in accordance with the manufacturing process as
outlined for the study product inserts (see Example 1.5 below).
However, no tyloxapol was used, the cyclosporine-containing syringe
was first mixed with the syringe containing the multi-arm PEG
solution before mixing with the trilysine acetate (TLA)/fluorescein
solution-containing syringe, and no vacuum degassing was
conducted.
[0281] Once casted, the hydrogel was cured, i.e. allowed to
cross-link, and the strands of tubing were then stretched and dried
in an incubator under a flow of nitrogen. The dried strands were
removed from the flexible tubing and cut to length. The dimensional
and physical properties were as follows:
TABLE-US-00003 TABLE 1.1.2 Dimensional and physical properties of
Low, Medium and High Dose inserts Dry Dry Dry Dry Dry Dry Aspect
Dry Dry Run Length Diameter Diameter Diameter Volume Ratio Mass
Density Name (mm) 1 (mm) 2 (mm) Ave (mm) (mm.sup.3) (-) (mg)
(mg/mm.sup.3) Low 3.54 .+-. 0.51 0.56 .+-. 0.04 0.57 .+-. 0.05 0.57
.+-. 0.04 0.92 .+-. 0.26 0.97 .+-. 0.03 0.56 .+-. 0.15 0.61 Dose
Medium 3.57 .+-. 0.36 0.47 .+-. 0.03 0.68 .+-. 0.07 0.58 .+-. 0.03
0.91 .+-. 0.15 0.7 .+-. 0.1 0.83 .+-. 0.13 0.90 Dose High 3.59 .+-.
0.34 0.81 .+-. 0.11 0.89 .+-. 0.13 0.85 .+-. 0.12 2.09 .+-. 0.7
0.91 .+-. 0.06 0.89 .+-. 0.3 0.43 Dose
[0282] The Low and High Dose formulations resulted in fibers with
an undesirable "strawing", i.e. these fibers had large dry
diameters and showed hollow holes in the middle of the fibers. As a
result, the density of the strawed fibers was low.
[0283] In order to determine the "roundness" of the fibers, the
cross-section diameter was measured on the thick as well as on the
thin side, the lower diameter value was identified as diameter 1,
the higher one as diameter 2, and the aspect ratio calculated
as
Aspect Ratio Diameter 1/Diameter 2
[0284] While the medium dose formulation did not show evidence of
strawing, it produced flat fibers with a very low aspect ratio. The
aspect ratio was 0.7 indicating a lack of roundness. Though the
strawed fibers of Low and High Dose formulations were rounder, the
low density produced much larger fibers than desired. The drug
concentration had also an effect on the hydration properties of the
inserts as summarized in Table 1.1.3 below:
TABLE-US-00004 TABLE 1.1.3 Hydration properties of Low, Medium and
High Dose inserts Wet Wet Wet Wet Equilibrium Equilibrium (10 min)
(10 min) Shrink (24 hr) (24 hr) Shrink Run Length Diameter Factor
Length Diameter Factor Name (mm) (mm) (%) (mm) (mm) (%) Low 2.46
.+-. 0.29 1.78 .+-. 0.05 30% .+-. 3% 2.55 .+-. 0.34 1.86 .+-. 0.04
27.9% .+-. 2%.sup. Dose Medium 2.99 .+-. 0.28 1.59 .+-. 0.09 16.3%
.+-. 2.1% 2.93 .+-. 0.3 1.7 .+-. 0.09 .sup. 18% .+-. 1.5% High 3.19
.+-. 0.3 1.61 .+-. 0.12 11.1% .+-. 2.2% 3.14 .+-. 0.26 1.63 .+-.
0.09 12.3% .+-. 2.3% Dose
[0285] As can be seen, hydrated diameters were all significantly
above the target of 1.45 mm and decreased with increasing dose, and
the shrink factor also decreased with increasing dose.
II. Example 1.2: Evaluation of Surfactants
Presence of Surfactant
[0286] In order to evaluate the influence of surfactants being
present in the insert, three different formulations were prepared,
wherein one of the formulations contained no surfactant (control,
Run 1), one contained 0.05% Tween.RTM. 20 (Run 2), and the third
contained no surfactant but was prepared using ethanol (Run 3). The
composition of the three formulations is shown in Table 1.2.1
below.
TABLE-US-00005 TABLE 1.2.1 Composition of cyclosporine insert
formulations with and without surfactant Hydrogel precursor mixture
(pre-drying) Run 1 Run 2 Run 3 Cyclosporine 9.79% 9.84% 10.66%
Concentration (% w/w) 4a20K PEG SG 7.56% 7.58% 8.24% Concentration
(% w/w) Sodium Phosphate Dibasic 0.52% 0.52% 0.57% Concentration (%
w/w) TLA Concentration (% w/w) 0.21% 0.21% 0.22% NHS-Fluorescein
0.07% 0.07% 0.07% Concentration (% w/w) Sodium Phosphate monobasic
0.21% 0.21% 0.21% Concentration (% w/w) Tween .RTM. 20 0.000%
0.050% 0.000% Concentration (% w/w) Solids content 18.35% 18.48%
19.98% 4a20K PEG SG 9.27% 9.30% 9.28% Concentration (% w/w) Dried
Insert Drug Loading 53.3% 53.3% 53.4% (% w/w)
[0287] The inserts of Runs 1 to 3 were prepared essentially in
accordance with the manufacturing process as outlined for the study
product inserts (see Example 1.5 below), i.e. by preparing one
hydrogel suspension pre-cursor syringe containing a cyclosporine
suspension in a trilysine acetate (TLA)/fluorescein aqueous
solution (Run 1: containing no tyloxapol; Run 2: containing
Tween.RTM. 20 instead of tyloxapol; Run 3: containing no tyloxapol
but dissolved in ethanol instead of water) and a second hydrogel
solution pre-cursor syringe containing a multi-arm PEG aqueous
solution, mixing these two syringes and then casting into a subset
of flexible tubing pieces by injecting the liquid suspension before
the material cross-links and solidifies. No vacuum degassing was
conducted. Once casted, the hydrogel was cured, i.e. allowed to
cross-link, and the strands of tubing were then stretched and dried
in an incubator under a flow of nitrogen. The dried strand was
removed from the flexible tubing and cut to length. The dimensional
and physical properties were as follows:
TABLE-US-00006 TABLE 1.2.2 Dimensional and physical properties of
inserts with and without surfactant Dry Dry Dry Dry Dry Aspect Dry
Dry Run Length Diameter Diameter Diameter Ratio Mass Density # (mm)
1 (mm) 2 (mm) Ave (mm) (-) (mg) (mg/mm.sup.3) No 1 3.12 .+-. 0.03
0.41 .+-. 0.02 0.72 .+-. 0.04 0.57 .+-. 0.02 0.57 .+-. 0.05 0.76
.+-. 0.05 1.02 Surfactant 0.05% 2 3.16 .+-. 0.03 0.53 .+-. 0.02
0.54 .+-. 0.01 0.53 .+-. 0.01 0.96 .+-. 0.01 0.76 .+-. 0.05 1.07
Tween-20 Ethanol 3 3.3 .+-. 0.18 0.76 .+-. 0.12 0.79 .+-. 0.18 0.77
.+-. 0.15 0.95 .+-. 0.06 1.63 .+-. 0.62 1.01
[0288] In order to determine the "roundness" of the fibers, the
cross-section diameter was measured on the thick as well as on the
thin side, the lower diameter value was identified as diameter 1,
the higher one as diameter 2, and the aspect ratio calculated
as
Aspect Ratio Diameter 1/Diameter 2
[0289] As can be seen, the addition of Tween.RTM. 20 led to a high
aspect ratio, indicating round fibers. The average diameter was
lower than the control and the density was higher, which is
advantageous in terms of ease of insertion of the product. The
control fiber of Run 1 stuck to the tubing during drying and had a
low aspect ratio indicating flat fibers (see FIG. 1.2A).
[0290] Run 3, which investigated the use of ethanol, encountered
major issues. The solution started evaporating within 1 minute of
starting the cure, creating air bubbles in the fiber. The fibers
were all broken and deformed when removed from the incubator which
can be seen in FIG. 1.2B.
Drug Concentration in the Presence of Surfactant
[0291] In order to evaluate the influence of drug concentration in
the presence of surfactant, three different formulations were
prepared with a low, a medium and a high dose of cyclosporine in
the presence of 0.05% Tween.RTM. 20. The composition of the three
formulations is shown in Table 1.2.3 below.
TABLE-US-00007 TABLE 1.2.3 Composition of cyclosporine insert
formulations comprising surfactant Hydrogel precursor mixture
(pre-drying) Low Medium High Dose Dose Dose Cyclosporine 5.70%
10.84% 15.20% Concentration (% w/w) 4a20K PEG SG 7.87% 7.45% 7.08%
Concentration (% w/w) Sodium Phosphate Dibasic 0.54% 0.51% 0.49%
Concentration (% w/w) TLA Concentration (% w/w) 0.22% 0.20% 0.19%
NHS-Fluorescein 0.07% 0.07% 0.06% Concentration (% w/w) Sodium
Phosphate monobasic 0.21% 0.20% 0.19% Concentration (% w/w) Tween
.RTM. 20 0.053% 0.051% 0.049% Concentration (% w/w) Solids content
14.67% 19.33% 23.27% 4a20K PEG SG 9.23% 9.23% 9.23% Concentration
(% w/v) Dried Insert Drug Loading (% w/w) 38.9% 56.1% 65.3%
[0292] The three inserts of Runs 1 to 3 were prepared essentially
in accordance with the manufacturing process as outlined for the
study product inserts (see Example 1.5 below), except that
Tween.RTM. 20 was used instead of tyloxapol. No vacuum degassing
was conducted. Once casted, the hydrogel was cured, i.e. allowed to
cross-link, and the strands of tubing were then stretched and dried
in an incubator under a flow of nitrogen. The dried strand was
removed from the flexible tubing and cut to length. No
sterilization was conducted. The dimensional and physical
properties were as follows:
TABLE-US-00008 TABLE 1.2.4 Dimensional and physical properties of
inserts comprising surfactant Dry Dry Dry Dry Dry Dry Aspect Dry
Dry Length Diameter Diameter Diameter Volume Ratio Mass Density
(mm) 1 (mm) 2 (mm) Ave (mm) (mm3) (-) (mg) (mg/mm.sup.3) Low 2.72
.+-. 0.03 0.47 .+-. 0.02 0.47 .+-. 0.02 0.47 .+-. 0.02 0.48 .+-.
0.04 0.98 .+-. 0.01 0.54 .+-. 0.05 1.13 Dose Medium 2.73 .+-. 0.02
0.57 .+-. 0.02 0.56 .+-. 0.01 0.56 .+-. 0.01 0.69 .+-. 0.04 0.95
.+-. 0.03 0.72 .+-. 0.04 1.05 Dose High 2.71 .+-. 0.03 0.64 .+-.
0.07 0.65 .+-. 0.05 0.64 .+-. 0.05 0.89 .+-. 0.14 0.92 .+-. 0.08
0.87 .+-. 0.14 0.98 Dose
[0293] The aspect ratios were all above 0.9 indicating round
fibers. The dry fiber diameters increased with increasing dose.
However, the dry fiber diameters were all slightly elevated which
is likely related to the fiber densities, which decreased with
increasing dose.
[0294] FIG. 1.2C shows dry and hydrated inserts produced in this
run. As can be seen, the higher the drug concentration, the more
agglomeration seems to take place.
[0295] Table 1.2.5 below shows the hydrated insert characteristics
at 10 minutes and 24 hours after hydration with PBS at 37.degree.
C. As can be seen, both hydrated diameter and shrink factor
decrease with increasing dose. This indicates that the drug content
has significant adverse effects on rehydration rate.
TABLE-US-00009 TABLE 1.2.5 Hydration properties of Low, Medium and
High Dose inserts Wet (10 min) Wet equilibrium (24 hours) Shrink
Shrink Length Diameter Factor Length Diameter Factor (mm) (mm) (%)
(mm) (mm) (%) Low 2.11 .+-. 0.09 1.65 .+-. 0.04 22.4% .+-. 2.8%
2.14 .+-. 0.12 1.74 .+-. 0.05 21.5% .+-. 4.1% Dose Medium 2.49 .+-.
0.04 1.46 .+-. 0.03 8.7% .+-. 1.8% 2.47 .+-. 0.03 1.49 .+-. 0.02
9.1% .+-. 1.7% Dose High 2.62 .+-. 0.05 1.37 .+-. 0.04 3.3% .+-.
1.9% 2.56 .+-. 0.08 1.41 .+-. 0.06 5.4% .+-. 3.5% Dose
Surfactant Type
[0296] In order to address agglomeration, the effect of various
surfactants on the particle size of cyclosporine was determined.
Surfactants were tested at maximum surfactant concentration per FDA
guidance.
[0297] Stock solutions containing 0.05% Tween.RTM. 20 (PEG-20
sorbitan monolaurate), 4% Tween.RTM. 80 (PEG-80 sorbitan
monolaurate), 0.5% Cremophor RH 40 (PEG-40 hydrogenated castor oil)
and 0.3% Tyloxapol (ethoxylated 4-tert-octylphenol/formaldehyde
condensation polymer) were prepared by adding PBS to a known weight
of surfactant in glass vials. The surfactant solutions were then
vortexed and sonicated. Solutions containing about 9-10% (w/w) of
Cyclosporine were prepared by adding approximately 1 mL of
surfactant/buffer stock solutions to about 100 mg of Cyclosporine
in a vial. Controls were prepared with distilled water (DIW) or
phosphate buffered saline (PBS) and did not contain surfactant.
This solution was then vortexed and the particle size was measured
by laser diffraction using a Beckman Coulter LS 13 320 based on the
optical model "Fraunhofer.rf780z" with an obscuration value ranging
from 7 to 9%.
[0298] Table 1.2.6 shows the solution concentrations and particle
size. As can be seen, the use of surfactants significantly
decreased the particle size suggesting decreased agglomeration. Of
the surfactants tested, Tyloxapol showed the greatest reduction in
particle size. Additionally, the particle size measured using
tyloxapol was closest to those provided by the supplier which
indicated a D10, D50, and D90 of 0.5, 2.1, and 7.5 .mu.m
respectively.
TABLE-US-00010 TABLE 1.2.6 Effect of surfactants on particle size
of cyclosporine Surfactant solution -- -- Tween .RTM. Tween .RTM.
Chemophor Cyclosp. Surfactant (DIW) (PBS) 20 80 RH 40 Tyloxapol
Specific. Surfactant Added (mg) 0 0 4.1 201.87 36.7 11.16
Surfactant 0.000% 0.000% 0.050% 3.826% 0.496% 0.298% Concentration
(%) Cyclosporine A 9.782% 9.581% 9.654% 9.711% 8.683% 10.128%
Concentration (%) D90 [Average] 31.6 31.8 26.7 22.7 9.5 5.4 7.5
(.mu.m) D50 [Average] 17.4 16.9 11.8 4 3 2.3 2.1 (.mu.m) D10
[Average] 4 4.1 1.7 1.1 0.9 0.9 0.5 (.mu.m) D90 [StDev] 2.8 2.4 1.7
13.4 0.1 0.1 (.mu.m) D50 [StDev] 1.6 1.9 0 0.1 0.1 0.1 (.mu.m) D10
[StDev] 0.6 0.8 0 0 0 0 (.mu.m)
I. Example 1.3: Evaluation of Vacuum Degassing
[0299] In order to evaluate the effect of vacuum degassing, 600
.mu.s dose cyclosporine inserts were prepared with a hydrogel
precursor mixture concentration of 0.3% (w/w) for Tyloxapol as well
as 9% (w/v) for the 4a20k PEG-SG. The composition of the insert
formulation is shown in Table 1.3.1 below.
TABLE-US-00011 TABLE 1.3.1 Composition of cyclosporine insert
formulations for evaluating vacuum degassing Hydrogel precursor
mixture Dry (pre-drying) Insert Cyclosporine 15.34% 64.825%
Concentration (% w/w) 4a20K PEG SG 7.10% 30.013% Concentration (%
w/w) Sodium Phosphate Dibasic 0.49% 2.077% Concentration (% w/w)
TLA Concentration (% w/w) 0.20% 0.829% NHS-Fluorescein 0.06% 0.271%
Concentration (% w/w) Sodium Phosphate monobasic 0.18% 0.759%
Concentration (% w/w) Tyloxapol 0.290% 1.225% Concentration (% w/w)
Solids Content 23.67% 100.000% Dried Insert Drug Loading (% w/w)
64.8%
[0300] Three different sets of inserts were prepared using the same
manufacturing process, except for the following details concerning
the treatment of the hydrogel suspension pre-cursor syringe
containing cyclosporine, tyloxapol and trilysine
acetate/fluorescein after mixing its component and before further
mixing with the PEG-containing hydrogel solution pre-cursor.
[0301] For the first set of inserts, the hydrogel suspension
contained in the syringe was treated by (i) priming the syringe (as
is customary done for all formulations), vortexing the suspension
for 3 minutes and manually degassing. Manual degassing was
conducted by pulling back the plunger of the syringe that has been
closed with a cap in order to create vacuum and then uncapping the
syringe, thus releasing the vacuum and collapsing large air
bubbles. As a next step (ii), the hydrogel suspension pre-cursor
was put in a vacuum chamber and degassed before mixing with the
hydrogel solution pre-cursor. The hydrogel suspension pre-cursor
for the second set of inserts was treated essentially in the same
way, except that the hydrogel suspension pre-cursor was further
sonicated in a step (iii) after step (ii). The hydrogel suspension
pre-cursor of the third set of inserts was prepared in the same way
as for the second set, except that step (ii) of degassing in the
vacuum chamber was omitted. A summary of the preparation steps is
given in Table 1.3.2 below
TABLE-US-00012 TABLE 1.3.2 Evaluation of vacuum degassing First set
Second set Third set Steps of Insert of Insert of Insert (i) prime
syringe, vortex 3 Yes Yes Yes minutes, then manually degas (ii)
degassing in vacuum chamber Yes Yes No (iii) sonication No Yes
Yes
[0302] The first set of inserts, obtained with merely vacuum
degassing, had little to no agglomerates. The second set of
inserts, obtained with both vacuum degassing and sonication, had
many large agglomerates and would not fit in the cutting device.
The third set of inserts obtained with sonication but no vacuum
degassing had some agglomerates but looked otherwise good (FIG.
1.3).
II. Example 1.4: Evaluation of Drug Particle Size
[0303] Further inserts have been prepared to evaluate and to
determine the optimal particle size of the drug substance.
Effect of Sieving Cyclosporine Large Particles
[0304] In order evaluate the effect of sieving to exclude larger
particles, 400 .mu.g dose cyclosporine inserts were prepared with a
hydrogel precursor mixture concentrations of 0.3% (w/w) for
Tyloxapol as well as 9% (w/v) for the 4a20k PEG-SG. The composition
of the formulation is shown in Table 1.4.1 below.
TABLE-US-00013 TABLE 1.4.1 Composition of cyclosporine insert
formulations for evaluating sieving effect Hydrogel precursor
mixture Dry (pre-drying) Insert Cyclosporine 9.818% 53.010%
Concentration (% w/w) 4a20K PEG SG 7.530% 40.656% Concentration (%
w/w) Sodium Phosphate Dibasic 0.525% 2.833% Concentration (% w/w)
TLA Concentration (% w/w) 0.206% 1.110% NHS-Fluorescein 0.069%
0.371% Concentration (% w/w) Sodium Phosphate monobasic 0.065%
0.351% Concentration (% w/w) Tyloxapol 0.309% 1.670% Concentration
(% w/w) Solids Content 18.521% 100.000% Dried Insert Drug Loading
(% w/w) 53.01%
[0305] The cyclosporine used was sieved and the particle size
fractions indicated in Table 1.4.1 below were used. During
manufacture, certain of the casted strands broke and could not be
used, as summarized also in Table 1.4.2 below. The dry density and
the drug load per insert is shown in FIG. 1.4A.
TABLE-US-00014 TABLE 1.4.2 Fractions of Particle size used and
breakage failures of casted strands Fraction 1 Fraction 2 Fraction
3 Particle size fraction 25-32 .mu.m 32-53 .mu.m 53-76 .mu.m Rate
of breakage failure 1/2* 1/6 All strands in casted strands broke
*Other causes of breakage failure identified, e.g. air entrainment
in the gel during casting
[0306] It can thus be concluded that high particle size has severe
negative impacts.
Effect of Cyclosporine Particle Size on Hydration, Dry Density and
Mechanical Failure
[0307] In order to evaluate the effect of different particle sizes,
inserts were prepared using micronized cyclosporine particles with
five different particle size distributions (PSDs). The composition
of the five formulations is shown in Table 1.4.3 below.
TABLE-US-00015 TABLE 1.4.3 Composition of cyclosporine insert
formulations Hydrogel precursor mixture (pre-drying) Small 1 Small
2 Medium-small Medium Large Cyclosporine 9.88% 14.01% 9.78% 9.86%
9.89% Concentration (% w/w) Multi-arm PEG 4a20K PEG SG 7.58% 3.79%
3.77% 3.77% 3.78% 4a20K PEG SAP -- 3.97% 3.79% 3.77% 3.78%
Concentration (% w/w) Sodium Phosphate Dibasic 0.52% 0.50% 0.52%
0.52% 0.52% Concentration (% w/w) TLA Concentration (% w/w) 0.21%
0.20% 0.21% 0.21% 0.21% NHS-Fluorescein 0.07% 0.07% 0.07% 0.07%
0.07% Concentration (% w/w) Sodium Phosphate monobasic 0.07% 0.06%
0.07% 0.07% 0.07% Concentration (% w/w) Tyloxapol 0.31% 0.29% 0.31%
0.31% 0.31% Concentration (% w/w) Solids content 22.34% 22.34%
18.66% 18.58% 18.63% Dried Insert Drug Loading (% w/w) 53.00%
62.70% 52.43% 53.07% 53.07%
[0308] The d10, d50 and d90 values of the cyclosporine used are
indicated in Table 1.4.4 below.
TABLE-US-00016 TABLE 1.4.4 Particle sizes of cyclosporine used
Small 1 Small 2 Medium-small Medium Large d10 [.mu.m] 1.0 1.1 1.3
1.5 1.8 d50 [.mu.m] 4.4 5.57 8.7 12.3 17.9 d90 [.mu.m] 28.9 37.6
34.8 38.4 43.2
[0309] The following has been observed upon manufacturing: inserts
prepared with larger CSI particles tended to have a larger dry
diameter (see FIG. 1.4B) while the density decreases with CSI
particle size (see FIG. 1.4C). Smaller CSI particles resulted in
smoother insert surface (see FIG. 1.4D showing microscopic images
taken under a stereomicroscope with a camera). Inserts from small
and small/medium particles on surface looked covered with PEG.
Rough surface with significant irregularities and deformations were
spotted on inserts prepared with medium and large particles. The
medium particles led to the highest breakage rate during drying.
Larger particles resulted in better hydration behavior and swelling
(see FIG. 1.4E).
[0310] In conclusion, while larger particle improved the swelling
and snap-back, it also led to more strand breakage. Additionally,
high dose formulation demonstrated more breakage than low and
medium dose formulations, and the removal of very large
particulates (>45 microns) via sieving significantly improved
breakage.
[0311] All in all, a particle size between "small" and "medium"
balances both the density gains and fiber smoothness from small
particles and the rehydration rates of medium particles which
achieve reduced strand breakage.
III. Example 1.5: Preparation of Clinical Trial Supporting
Inserts
[0312] In the following, the preparation process of the study
product inserts will be described that are used in the human
clinical study (Formulations 1, 2A, 2B and 3, see Example 4) and in
the high dose beagle dog study (Formulations 4A and 4B, see Example
3.6). The study product inserts are based on a medium-persistent
cyclosporine/hydrogel-formulation based on PEG-SG (Formulations 1
and 4A, designed to last approximately 2 to 3 months), a
long-persistent cyclosporine/hydrogel-formulation based on PEG-SAP
(Formulation 2A and 4B, designed to last approximately 3 to 4
months), and two hydrogel vehicle (HV) formulations without
cyclosporine, serving as placebo, one long-persistent formulation
based on PEG-SAP (Formulation 2B, designed to last approximately 3
to 4 months) and a short-persistent formulation based on PEG-SS
(Formulation 3, designed to last approximately 1 week).
[0313] The cyclosporine-containing inserts had a target diameter of
0.55 mm.+-.0.03 mm and a target length of 2.72 mm.+-.0.08 mm, while
the HV inserts had a target diameter of 0.41 mm.+-.0.05 mm and a
target length of 2.72 mm.+-.0.08 mm. The composition of the
formulations is shown in Table 1.5 below.
TABLE-US-00017 TABLE 1.5 Composition of cyclosporine study product
insert formulations Nominal Composition (.mu.g, dry basis) Form. 1,
Form. 2A, Form. 2B, Form. 3, Form. 4A Form. 4B Ingredient SG SAP
SAP SS SG SAP Cyclosporine 384 390 0 0 773 772 PEG 4-arm 20K PEG SG
295 -- -- -- 389 -- 4-arm 20K PEG SAP -- 300 307 -- -- 389 4-arm
20K PEG SS -- -- -- 350 -- -- Trilysine Acetate 8 8 8 10 11 11
Sodium Phosphate 21 56 58 24 27 27 Dibasic, USP Sodium Phosphate 3
3 3 3 3 3 Monobasic, USP NHS-Fluorescein 3 3 3 3 4 4 Tyloxapol, USP
12 12 13 14 16 16 TOTAL 725 771 390 404 1222 1221
I. Brief Summary of Preparation Process
[0314] To form the polymer network of the cyclosporine-comprising
inserts, two pre-cursor syringes were prepared: one hydrogel
suspension pre-cursor syringe containing a cyclosporine suspension
in a tyloxapol and trilysine acetate (TLA)/fluorescein solution,
and a second hydrogel solution pre-cursor syringe containing a
multi-arm PEG (4 arm 20K PEG based on a pentaerythritol core
structure, containing amine reactive NHS groups) solution. The two
syringes were mixed and then casted into a subset of flexible
tubing pieces by injecting the liquid suspension before the
material cross-links and solidifies. Once casted, the hydrogel was
cured, i.e. allowed to cross-link. The strands of tubing containing
the cyclosporine entrapped within the hydrogel network were then
stretched and dried in an incubator under a flow of nitrogen. The
dried strand was removed from the flexible tubing, cut to length,
and stored in vials. The drug product was then packaged in a
protective foam carrier which was heat-sealed under a nitrogen
environment into a laminated foil pouch. The drug product was
sterilized using e-beam radiation for cyclosporine containing
formulations and gamma irradiation for HV formulations.
[0315] The HV placebo inserts were prepared in the same way, except
that the amount of excipients used was adapted in accordance with
the composition of Table 1 (variation in the multi-arm PEG), and in
particular that no cyclosporine was used.
II. Preparation of Hydrogel Suspension Pre-Cursor Syringe
[0316] The same procedure and quantities are used for Formulations
1 and 2A with the exception of the type of multi-arm PEG and the
amount of sodium phosphate dibasic used. For Formulations 4 and 5,
the amount of cyclosporine was also adapted in accordance with the
composition given in Table 1.5 above.
[0317] The hydrogel suspension pre-cursor syringe consisted of a
mixture of two different additional pre-cursor syringes.
[0318] One syringe contained micronized cyclosporine suspended in a
tyloxapol solution, prepared by weighing and suspending 704.8
mg.+-.5.0 mg of micronized cyclosporine (d50: 5.about.8 .mu.m,
d100: 45 .mu.m) in 2,775.0 mg.+-.20.0 mg of a 0.8 wt-% solution of
tyloxapol in water for injection (WFI). For the HV formulations
(formulations 2B and 3), the syringe contained the 0.8 wt-%
tyloxapol solution only.
[0319] The other syringe contained a trilysine-fluorescein
conjugate solution buffered with sodium phosphate dibasic, prepared
by (i) mixing 25.0 mg.+-.0.5 mg NHS-fluorescein with 8,025.0
mg.+-.5.0 mg of a solution comprising 97.5 mg.+-.2.5 mg trilysine
acetate and 243.75 mg.+-.2.5 mg (Formulations 1 and 3) or 690
mg.+-.5.0 mg (Formulations 2A and 2B) sodium phosphate dibasic in
9,750.0.+-.10.0 mg WFI, (ii) allowing the resulting mixture to
react for 1 to 24 hours at room temperature, (iii) filtering the
solution and (iv) filling syringes with portions of 1,575.0
mg.+-.10.0 mg of the obtained solution per syringe. Completion of
the reaction in step (ii) was confirmed by a reversed-phase (RP)
HPLC method using UV detection which allows discriminating between
the unreacted components and the product amide by retention time
(RT). After step (ii), no quantifiable peak remained with a RT
consistent with NHS-fluorescein (RT 6.6 min) and a new peak created
by the formation of the product amide emerged at a higher RT
(RT.apprxeq.8.2 minutes). In an initial study, results demonstrated
conversion to the amide after 1 hour and showed that the reaction
product was stable at up to 7 days in solution (FIG. 2).
[0320] The two additional pre-cursor syringes were connected with a
female-to-female luer lock connector, and their content was mixed
together by passing back and forth between each syringe for a total
of 25 times, to form the hydrogel suspension pre-cursor syringe.
Tyloxapol, USP is added to the solution used to suspend the
cyclosporine to aid in dispersing the cyclosporine and reducing any
agglomeration as cyclosporine is highly insoluble in water and
prone to agglomeration, as well as in preventing adhesion of the
hydrogel mixture to the inner wall of the tubes which is believed
to be a cause for flat-shaped inserts with low aspect ratio.
III. Preparation of Hydrogel Solution Pre-Cursor Syringe
[0321] The hydrogel solution pre-cursor syringe contained a
buffered solution of PEG prepared by combining 1,565.0 mg.+-.10.0
mg of a solution comprising 24.5 mg.+-.1.0 mg sodium phosphate
monobasic in 7,985.0 mg.+-.50.0 mg WFI with 542.0 mg.+-.5.0 mg of
the 4a20K PEG-SG (a 20 kDa PEG with 4 arms with a
N-hydroxysuccinimidyl glutarate end group, employed for Formulation
1) or of the 4a20K PEG-SAP (a 20 kDa PEG with 4 arms with a
N-hydroxysuccinimidyl adipate end group, employed for Formulation
2A).
IV. Casting, Stretching and Drying
[0322] To form the hydrogel/cyclosporine suspension, the hydrogel
suspension pre-cursor syringe comprising cyclosporine, tyloxapol
and the trilysine-fluorescein conjugate, as well as the hydrogel
solution pre-cursor syringe comprising the 4a20k PEG-SG, the 4a20k
PEG-SAP or the 4a20k PEG-SS were first degassed by placing into a
vacuum chamber and exposing to a programed vacuum cycle and then
connected with a female-to-female luer lock connector. The content
of the pre-cursor syringes was mixed together by passing back and
forth between each syringe for a total of 25 times, and the thus
created suspension of hydrogel/cyclosporine was transferred into a
single syringe.
[0323] The hydrogel/cyclosporine suspension syringe was then
connected to the barb fitting on an autoclave-sterilized
polyurethane tubing with 2.0 mm inner diameter and 2.8 mm outer
diameter, cut to appropriate length, and the suspension was casted
through the prepared tubing before the material cross-links and
solidifies.
[0324] Once the tubing was full, the tubing was removed from the
syringe and the barb fitting on the tube was capped. Gelling time
was confirmed by performing a gel tap test. For the gel tap test, a
small amount of remaining hydrogel/cyclosporine suspension was
placed on a glass slide and tapped with a pipette tip until the
suspension began to strand, indicating that polymerization has
started (i.e., remains connected to the pipette tip during a
complete tapping cycle) in approximately 2-8 minutes when the
suspension gels.
[0325] The filled tube containing the hydrogel/cyclosporine
suspension, in the following referred to as "casted strands", were
placed vertically and stored in a curing chamber (ambient
temperature and humidity) for 3 to 6 hours to allow the gel to
cure.
[0326] Once the cure time has elapsed, the casted strands were
placed in the stretching fixture and secured in place with dynamic
clamps. The casted strands were stretched to the fixed length of
the stretching fixture which was about 2.7 times the original
tubing length. The stretching fixtures were then moved and placed
vertically within an incubator set to 32.0.+-.2.0.degree. C. with a
nitrogen flow rate of 53.+-.3 SCFH (standard cubic feet per hour)
for drying. The casted strands remained in the incubator for
several days to allow them to dry completely.
V. Cutting, Packaging, Sterilization and Inspection
[0327] The dried casted strands were removed from the tubing and
cut into approximately 2.7 mm lengths. A 100% in-process visual and
dimensional inspection of inserts was performed using a Vision
System under 10.times. magnification (acceptance criteria:
particulate, cylindrical shape, free of visible surface defects,
0.55 mm.+-.0.03 mm diameter for the cyclosporine-containing
inserts, 0.41 mm.+-.0.05 mm diameter for the HV-inserts, and 2.72
mm.+-.0.08 mm length for all inserts).
[0328] Inserts that met all in-process specifications were packaged
with a single insert in a foam carrier and sealed in an
aluminum-LDPE foil pouch that can be peeled open by the user. To
hold the insert, the foam carrier had a V-notch with an opening at
the bottom, into which an insert was placed with forceps with a
portion of the insert protruding for easy removal. The foam carrier
with insert was placed into a foil pouch. The unsealed foil pouch
was transferred into a glovebox providing an inert nitrogen
environment to reduce residual moisture from the foam and pouch
material, stored therein for a minimum duration of 16 hours and not
to exceed 96 hours, and then sealed within the glovebox using a
pouch sealer to create a complete, continuous seal on the pouch.
The pouch seal was inspected and the packages stored at 2-8.degree.
C. until sterilization.
[0329] The packaged inserts were e-beam or gamma irradiation
sterilized and stored at 2-8.degree. C. until final quality
inspection.
[0330] Once the pouched inserts were sterilized, a final quality
inspection was performed on the drug product.
Example 2: Insert Specifications
[0331] The obtained inserts were characterized by way of a
visibility test, microscopy analysis, HPLC analysis, as well as a
storage stability test.
I. Visibility Test
[0332] The inserts were visually inspected in order to confirm that
the inserts can be visually seen through a surrogate test model
when illuminated with a blue light.
II. Microscopy Analysis
[0333] The inserts were inspected microscopically using a Unitron
Z850/NSZ-606 microscope to confirm product dimensions in dry state,
as well as in hydrated state after 10 minutes (Expansion state) and
24 hours (Equilibrium state) hydration in phosphate-buffered saline
at a pH of 7.4 at 37.degree. C. (Table 2.1).
TABLE-US-00018 TABLE 2.1 Results of microscopy analysis for the
different formulations Batch analysis Target Form. 1 Form. 2A Form.
2B Form. 3 specification SG SAP SAP SS Dimensions Dried Diameter
.ltoreq.0.62 mm Passes Passes Passes Passes Length 2.5-2.90 mm
Passes Passes Passes Passes Hydrated (Expansion, 10 min.) Diameter
.gtoreq.1.00 mm Passes Passes Passes Passes Length To be reported
Hydrated (Equilibrium, 24 hours) Diameter .gtoreq.1.30 mm Passes
Passes Passes Passes Length To be reported
III. Further Product Specification Tests
[0334] Further product specification has been tested and reported
in accordance with Table 2.2 below.
TABLE-US-00019 TABLE 2.2 Results of further product specification
tests Batch analysis Product specification test Target
specification Form. 1 SG Form. 2A SAP Form. 2B SAP Form. 3 SS HPLC:
Identity RT .+-. 0.5 minutes* Pass Pass N/A N/A Assay (%) 85.0 to
115.0% .sup. 96% 101% N/A N/A Assay (absolute) 306-414 .mu.g
(target: 360 .mu.g) 346 .mu.g 362 .mu.g N/A N/A Impurities As
specified below** Pass Pass N/A N/A Water content (Karl Fischer -
USP <921>) <1.0% 0.37% 0.58% 0.30% 0.49% Subvisible
Particulate Matter .gtoreq.10 .mu.m: NMT 6000 particles/insert 78
128 22 81 (Light Obscuration - USP <788>) .gtoreq.25 .mu.m:
NMT 600 particles/insert 4 10 2 44 Visible Particulate matter
Solutions of inserts essentially Pass Pass Pass Pass (Visual - USP
<790>) free of visible particulates Endotoxin .ltoreq.0.5
EU/insert Pass Pass Pass Pass (Kinetic Chromogenic LAL - USP
<85>) Sterility USP <71> No microbial growth Pass Pass
Pass Pass *RT (retention time) of cyclosporine peak corresponds to
reference standard .+-. 0.5 minutes **Target specification for the
impurities were as follows: Isocyclosporine A, .ltoreq.1.0%
Cyclosporine C, .ltoreq.1.0% Cyclosporine B, .ltoreq.1.0%
DihydrocyclosporineA/Geclosporine, .ltoreq.1.4% Cyclosporine D,
.ltoreq.1.0% Any individual impurity: .ltoreq.1.0% Total
impurities: .ltoreq.6.0%
IV. Storage Stability Test
[0335] The stability of cyclosporine-containing inserts in
accordance with formulations 1 and 2A has been evaluated over 12
months under refrigerated conditions (2-8.degree. C.).
[0336] Results of the storage stability test can be found in Tables
2.3.1 and 2.3.2 (Formulation 1) as well as 2.3.3 and 2.3.4
(Formulation 2A).
TABLE-US-00020 TABLE 2.3.1 Results Storage Stability Test:
Appearance, Dimensions, assay and identity (Formulation 1) Test
Acceptance Time Point (Months) Description Criteria 0 3 6 9 12 18
24 Appearance Light yellow to Pass Pass Pass Pass Pass -- --
yellow/orange, essentially free of visible particulates Dry
Dimensions Diameter: .ltoreq.0.62 mm Diameter (mm) Diameter (mm)
Diameter (mm) Diameter (mm) Diameter (mm) -- -- Avg: 0.55 Avg: 0.56
Avg: 0.54 Avg: 0.55 Avg: 0.54 Min: 0.53 Min: 0.52 Min: 0.49 Min:
0.50 Min: 0.51 Max: 0.57 Max: 0.59 Max: 0.58 Max: 0.57 Max: 0.57
Length: 2.50-2.90 mm Length (mm) Length (mm) Length (mm) Length
(mm) Length (mm) -- -- Avg: 2.68 Avg: 2.68 Avg: 2.70 Avg: 2.72 Avg:
2.66 Min: 2.57 Min: 2.62 Min: 2.64 Min: 2.67 Min: 2.62 Max: 2.76
Max: 2.76 Max: 2.75 Max: 2.76 Max: 2.69 Expansion Diameters:
.gtoreq.1.00 mm Diameter (mm) Diameter (mm) Diameter (mm) Diameter
(mm) Diameter (mm) -- -- Avg: 1.29 Avg: 1.27 Avg: 1.26 Avg: 1.26
Avg: 1.23 Min: 1.21 Min: 1.20 Min: 1.19 Min: 1.21 Min: 1.17 Max:
1.36 Max: 1.36 Max: 1.35 Max: 1.33 Max: 1.30 Equilibrium Diameter:
Report Results Diameter (mm) Diameter (mm) Diameter (mm) Diameter
(mm) Diameter (mm) -- -- Diameter Avg: 1.47 Avg: 1.40 Avg: 1.39
Avg: 1.35 Avg: 1.39 Min: 1.39 Min: 1.34 Min: 1.31 Min: 1.30 Min:
1.32 Max: 1.51 Max: 1.48 Max: 1.50 Max: 1.40 Max: 1.50 Length:
Report Results Length (mm) Length (mm) Length (mm) Length (mm)
Length (mm) -- -- Avg: 2.48 Avg: 2.56 Avg: 2.56 Avg: 2.61 Avg: 2.57
Min: 2.35 Min: 2.42 Min: 2.47 Min: 2.53 Min: 2.48 Max: 2.63 Max:
2.63 Max: 2.62 Max: 2.66 Max: 2.65 Visibility Insert can be
visually Pass Pass Pass Pass Pass -- -- seen through a surrogate
test model when illuminated with a blue light Assay Cyclosporine
Content 360 360 354 355 360 -- -- 360 .+-. 54 .mu.g Identity
Retention time of Pass Pass Pass Pass Pass -- -- cyclosporine peak
corresponds to reference standard .+-. 2 minutes
TABLE-US-00021 TABLE 2.3.2 Results Storage Stability Test;
impurities and further specifications (Formulation 1) Test
Acceptance Time Point (Months) Description Criteria 0 3 6 9 12 18
24 Impurities Total impurities: NMT 3.0% 1.6% 1.6% 1.9% 1.9% 1.8%
-- -- Isocyclosporine A (RRT 0.53): NMT 1.0% 0.1% 0.4% 0.4% 0.3%
0.4% -- -- Cyclosporine C (RRT 0.87): NMT 1.0% NR NR NR NR NR -- --
Cyclosporine B (RRT 0.90): NMT 1.0% ND NR NR 0.3% 0.3% -- --
Dihydrocyclosporine A/Geclosporine 0.6% 0.6% 0.5% 0.6% 0.5% -- --
(RRT 1.07): NMT 1.0% Cyclosporine D (RRT 1.11): NMT 1.0% 0.3% 0.2%
0.3% 0.3% 0.3% -- -- Unknown (RRT 0.55): NMT 1.0% 0.1% ND ND ND ND
-- -- Unknown (RRT 0.67): NMT 1.0% ND 0.1% 0.1% 0.1% ND -- --
Unknown (RRT 0.95) NMT 1.0% 0.2% ND 0.3% ND ND -- -- Unknown D (RRT
1.31): NMT 1.0% 0.3% 0.3% 0.3% 0.3% 0.3% -- -- In Vitro Release
Report Results at 4 Hours and Day 1: 32% Day 1: 25% * 4 Hours: 13%
4 Hours: 10% -- -- Days 1, 2, 3, 4, 7, 8, 9.sup.1 Day 2: 51% Day 2:
43% Day 1: 26% Day 1: 22% Day 3: 64% Day 3: 55% Day 2: 36% Day 2:
32% Day 4: 81% Day 6: 84% Day 3: 46% Day 3: 42% Day 7: 96% Day 7:
92% Day 4: 54% Day 4: 49% Day 8: 102% Day 8: 95% Day 7: 73% Day 7:
58% Day 10: 102% Day 8: 84% Day 8: 66% Day 11: 103% Day 9: 96% Day
9: 70% Water Content NMT 1% 0.41% 0.34% 0.37% 0.40% 0.46% -- --
Endotoxin .ltoreq.0.5 EU/insert <0.1 EU/Insert Sterility No
Microbial Growth Conforms Seal Strength Foil pouch must have a
minimum seal Pass strength of 1.0 lbf Whole Package Foul pouch must
withstand bubble emission Pass Integrity while pressurized at 10
.+-. 2 inches H2O. .sup.1T = 0 and T = 3 data reported prior to
specification finalization; T = 3, 4 hour interval and 9 day
samples not pulled *no data available, samples inadvertently not
tested at 6 mos. NMT: No more than NR: Not reportable ND: None
detected TBD: to be determined -- Not yet tested
TABLE-US-00022 TABLE 2.3.3 Results Storage Stability Test:
Appearance, Dimensions, assay and identity (Formulation 2A) Test
Acceptance Time Point (Months) Description Criteria 0 3 6 9 12 18
24 Appearance Light yellow to Pass Pass Pass Pass Pass -- --
yellow/orange, essentially free of visible particulates Dry
Dimensions Diameter: .ltoreq.0.62 mm Diameter (mm) Diameter (mm)
Diameter (mm) Diameter (mm) Diameter (mm) -- -- Avg: 0.54 Avg: 0.56
Avg: 0.54 Avg; 0.55 Avg 0.55 Min: 0.51 Min: 0.53 Min: 0.49 Min:
0.53 Min: 0.50 Max: 0.57 Max: 0.58 Max: 0.56 Max: 0.57 Max: 0.57
Length: 2.50-2.90 Length (mm) Length (mm) Length (mm) Length (mm)
Length (mm) -- -- Avg: 2.70 Avg: 2.68 Avg: 2.71 Avg: 2.68 Avg 2.65
Min: 2.66 Min: 2.61 Min: 2.65 Min: 2.63 Min: 2.61 Max: 2.74 Max:
275 Max: 2.79 Max: 2.73 Max: 2.69 Expansion Diameter: .gtoreq.1.00
mm Diameter (mm) Diameter (mm) Diameter (mm) Diameter (nun)
Diameter (mm) -- -- Avg: 1.25 Avg: 1.24 Avg: 1.20 Avg: 1.20 Avg
1.17 Min: 1.16 Min: 1.16 Min: 1.14 Min: 1.11 Min: 1.12 Max: 1.32
Max: 1.30 Max: 1.26 Max: 1.33 Max: 1.22 Equilibrium Diameter:
Report Results Diameter (mm) Diameter (mm) Diameter (mm) Diameter
(mm) Diameter (mm) -- -- Diameter Avg: 1.54 Avg: 1.45 Avg: 1.44
Avg: 1.40 Avg 1.36 Min: 1.47 Min: 1.39 Min: 1.35 Min: 1.34 Min:
1.30 Max: 1.63 Max: 1.51 Max: 1.54 Max: 1.52 Max: 1.50 Length:
Report Results Length (mm) Length (mm) Length (mm) Length (mm)
Length (mm) Avg: 2.48 Avg: 2.53 Avg: 2.58 Avg: 2.62 Avg 2.58 Min:
2.31 Min: 2.37 Min: 2.35 Min: 2.55 Min: 2.50 Max: 2.61 Max: 2.67
Max: 2.70 Max: 2.69 Max: 2.68 Visibility Insert can be visually
Pass Pass Pass Pass Pass -- -- seen through a surrogate test model
when illuminated with a blue light Assay Cyclosporine Content 360
350 345 348 356 -- -- 360 .+-. 54 .mu.g
TABLE-US-00023 TABLE 2.3.4 Restults Storage Stability Test:
impurities and further specifications (Formulation 2A) Test
Acceptance Time Point (Months) Description Criteria 0 3 6 9 12 18
24 Identity Retention time of cyclosporine Pass Pass Pass Pass Pass
-- -- peak corresponds to reference standard .+-. 2 minutes
Impurities Total impurities: NMT 3.0% 1.4% 1.5% 1.9% 1.8% 1.7% --
-- IsocyClosporine A (RRT 0.53): NMT 1.0% 0.1% 0.3% 0.4% 0.4% 0.4%
-- -- Cyclosporine C (RRT 0.87): NMT 1.0% NR NR NR NR NR -- --
Cyclosporine B (RRT 0.90): NMT 1.0% ND ND 0.1% 0.2% 0.2% -- --
Dihydrocyclosporine A/Geclosporine 0.6% 0.6% 0.5% 0.6% 0.5% -- --
(RRT 1.07): NMT 1.0% Cyclosporine D (RRT 1.11): NMT 1.0% 0.3% 0.2%
0.3% 0.3% 0.3% -- -- Unknown (RRT 0.55): NMT 1.0% 0.1% ND ND NR ND
-- -- Unknown (RRT 0.66): NMT 1.0% ND 0.1% 0.1% ND ND -- -- Unknown
(RRT 1.04) NMT 1.0% ND 0.1% NR ND ND -- -- Unknown D (RRT 1.31):
NMT 1.0% 0.3% 0.3% 0.3% 0.3% 0.3% -- -- In Vitro Release Report
Results at 4 Hours and Day 1: 37% Day 1: 32% * 4 Hours: 16% 4
Hours: 13% -- -- Days 1, 2, 3, 4, 7, 8, 9.sup.1 Day 2: 61% Day 2:
53% Day 1: 33% Day 1: 31% Day 3: 74% Day 3: 66% Day 2: 47% Day 2:
42% Day 4: 88% Day 6: 89% Day 3: 59% Day 3: 54% Day 7: 97% Day 7:
94% Day 4: 69% Day 4: 63% Day 8: 98% Day 8: 96% Day 7: 80% Day 7:
69% Day 10: 95% Day 9: 96% Day 8: 89% Day 8: 77% Day 11: 98% Day 9:
93% Day 9: 80% Water Content NMT 1% 0.59% 0.61% 0.58% 0.60% 0.68%
-- -- Endotoxin .ltoreq.0.5 EU/Insert <0.1 EU/Insert Slerility
No Microbial Growth Conforms Seal Strength Foil pouch must have a
minimum seal Pass strength of 1.0 lbf Whole Package Foil pouch must
withstand bubble Pass Integrity emission while pressurized at 10
.+-. 2 inches TI2O .sup.1T = 0 and T = 3 data reported prior to
specification finalization. *no data available, samples
inadvertently not tested at 6 mos. NMT: No More than, NR: Not
reportable, ND: None detected, TBD: to be determined, -- Not yet
tested
[0337] Stability data obtained through 12 months continue to meet
the predetermined stability specifications. In accordance with the
ICH Q1E, for refrigerated products, where the long-term data shows
little or no change over time and shows little or no variability,
the proposed shelf life can be up to two times but should not be
more than 12 months when the proposal is backed by the result of
the analysis and relevant supporting data. The real time long term
stability data was trended against the upper and lower limits of
the stability specifications with 95% Confidence Intervals (CI).
Overall there were minimal to no trends observed in the
quantitative data. The statistical analysis demonstrate that the
product will meet a 23 month shelf life based on the degradation
analysis of assay showing a possible intercept at 23 months. All
other stability indicating parameters show possible intercepts
beyond 36 months. Therefore, a shelf life of at least 23 months can
be expected.
Example 3: Evaluation of Cyclosporine Inserts in Beagle Dogs
[0338] In order to study the pharmacokinetics of
cyclosporine-containing inserts, different formulations have been
tested in beagle dog pharmacokinetic studies.
[0339] Six different beagle dog studies were conducted, wherein the
amount of drug released from the insert and/or the concentrations
of cyclosporine in the tear fluid over the study durations has been
determined. An overview of the studies and the formulations is
given in Table 3.
TABLE-US-00024 TABLE 3 Overview of beagle studies Beagle Study
Study design Example 3.1: N = 4 Beagles Proof-of-Concept 0.7 mg
cyclosporine dose in 12.7% (w/v) 4a20K PK study SAZ/trilysine PEG
hydrogel 10-week bilateral dosing Tear fluid sampling at weeks 2,
4, 6, 8 and 10 Subset of inserts removed at 6 weeks Example 3.2: N
= 20 Beagles Proof-of-Concept 0.44 mg cyclosporine dose in 9% (w/v)
4a20K PK study SG/trilysine PEG hydrogel 28-day bilateral dosing
Tear fluid at days 1,7, 14, 21 and 28 Removed inserts at day 32
Example 3.3: N = 11 Beagles Proof-of-Concept 0.67 mg cyclosporine
dose in 9% (w/v) 4a20K PK study SG/trilysine PEG hydrogel 28 and
50-day dosing Removed inserts at days 28 and 50 Example 3.4: N = 12
Beagles Dry eye model 12 eyes per arm study 0.36 mg cyclosporine
dose in 9% (w/v) 4a20K SG/trilysine Formulation 1 28-day bilateral
dosing Group 1: Surgical dry eye is right eye (OD) Group 2: Healthy
eye is left eye (OS) Example 3.5: N = 24 Beagles PK study 12 per
group 0.36 mg cyclosporine dose Formulations 1 and 2A 12-week
bilateral dosing Group 1: Formulation 1 inserts (9% (w/v) 4a20K
SG/trilysine) Group 2: Formulation 2A inserts (9% (w/v) 4a20K
SAP/trilysine) Example 3.6: N = 54 Beagles High dose study 12 M/12
F active, 12 M/12 F control, 3 M/3 F sham 90-Day Dosing 0.7 mg
cyclosporine dose Formulation 4A inserts in OD eyes (9% (w/v) 4a20K
SG/trilysine) Formulation 4B inserts in OS eyes (9% (w/v) 4a20K
SAP/trilysine)
Example 3.1: Proof of Concept PK Study
[0340] Inserts with a nominal dose of 0.7 mg cyclosporine were
administered to beagle dogs as summarized in Table 3.
[0341] The amount of drug released from the inserts was evaluated
over time and the concentrations of cyclosporine in the tear fluid
were determined over the study duration.
[0342] The median tear fluid concentrations of cyclosporine ranged
from 1.1 to 1.9 .mu.g/over the study duration, see Table 3.1 below.
A subset of inserts was removed at 6 weeks to determine the amount
of remaining drug compared to the administered dose. The average
amount of cyclosporine released in 6 weeks was 0.37 mg. This
calculates to an estimated daily delivered dose of 8.8 .mu.g/day
assuming consistent daily release rates over that dosing period as
supported by the tear fluid concentration which remained relatively
constant.
TABLE-US-00025 TABLE 3.1 Cyclosporine Tear Fluid Concentrations in
Beagle Eyes Time Median (.mu.g/mL) SD (.mu.g/mL) 2 weeks 1.5 0.7 4
weeks 1.2 0.6 6 weeks 1.4 0.9 8 weeks 1.9 1.4 10 weeks 1.1 0.5
Example 3.2: Proof of Concept PK Study
[0343] Inserts with a nominal dose of 0.44 mg cyclosporine were
administered to beagle dogs as summarized in Table 3.
[0344] The amount of drug released from the inserts was evaluated
over time and the concentrations of cyclosporine in the tear fluid
were determined over the study duration.
[0345] The mean tear fluid concentrations of cyclosporine ranged
from 1.1 to 2.8 .mu.s over the study duration, see Table 3.2 below.
Inserts were removed at 32 days to determine the amount of
remaining drug compared to the administered dose. The average
amount of cyclosporine released in 32 days was 0.2 mg. This
calculates to an estimated daily delivered dose of 6.3 .mu.g/day
assuming consistent daily release rates over that dosing
period.
TABLE-US-00026 TABLE 3.2 Cyclosporine Tear Fluid Concentrations in
Beagle Eyes Time Mean (.mu.g/mL) SD (.mu.g/mL) 1 day 2.7 1.8 7 days
2.1 1.8 14 days 2.8 1.5 21 days 1.7 1.4 28 days 1.1 0.3
Example 3.3: Proof of Concept PK Study
[0346] The initial cyclosporine dose in the insert prior to
administration was 671.+-.13 .mu.g (mean and standard deviation)
for n=10 total samples. Four and five inserts were removed at 28
and 50 days, respectively, and the cyclosporine content was
analyzed. Left and right eyes provided similar results, thus a mean
over all removed inserts was calculated, resulting in a released
amount (initial amount minus the amount left in the removed insert
of 576.+-.18 .mu.g and 494.+-.32 .mu.g, respectively) of 3.4 and
3.5 .mu.g, respectively, as shown in Table 3.3. The average daily
release rate was determined by comparing the initial dose to the
released dose. Study results demonstrate that over 28 and 50 days
the daily estimated delivered dose was approximately 3.5 .mu.g/day.
The range of drug release for the inserts over the study period was
from a low of 2.7 to a high of 4.4 .mu.g/day.
TABLE-US-00027 3.3: Cyclosporine Released from inserts in Beagles
Cyclosporine Cyclosporine Cyclosporine per insert Released per Day
per insert Mean .+-. SD Mean (Min, Max) Day OD OS [.mu.m] [.mu.g]
28 578 576 .+-. 18 3.4 (2.7, 4.2) 579 596 553 50 451 494 .+-. 32
3.5 (3.0, 4.4) 507 520 471 521
Example 3.4: Dry Eye Model Study
[0347] Inserts with a nominal dose of 0.36 mg cyclosporine and 1.5
mm hydrated diameter and 2.5 mm hydrated length were administered
to beagle dogs as summarized in Table 3.
[0348] The lacrimal glands on the right eye were previously
surgically removed in the beagles to create an artificial dry eye
model. The left eye remained untreated and thus served as a healthy
control. Tear production was followed over time by Schirmer's Tear
Test and showed that tear production in the right eyes decreased to
near zero, providing proof of concept for the dry eye model (see
FIG. 3.1). The amount of drug released from the inserts was
evaluated over time and the concentrations of cyclosporine in the
tear fluid was determined over the study duration.
[0349] The mean tear fluid concentrations of cyclosporine ranged
from 0.8 to 1.4 .mu.g/mL in healthy eyes and ranged from 1.4 to 4.8
.mu.g/mL in dry eyes, see Table 3.4 below. The higher tear fluid
cyclosporine concentration in the beagle dry eye model (compared to
the healthy eyes) demonstrates both that cyclosporine can be
successfully transported into the tear fluid and most likely the
ocular surface from the insert under dry eye-conditions and that
concentrations of cyclosporine on the ocular surface may be higher
under dry eye-conditions when compared to cyclosporine
concentrations observed in healthy eyes due to reduced tear volume
(as resulting from the reduced tear production) and thus lower drug
dilution.
TABLE-US-00028 TABLE 3.4 Cyclosporine Tear Fluid Concentrations in
Beagles in Dry and Healthy Eyes Mean Min Median Max SD 95% Cl Eye
Time N (.mu.g/mL) (.mu.g/mL) (.mu.g/mL) (.mu.g/mL) (.mu.g/mL) CV
(.mu.g/mL) Dry 3 hours 12 1.4 0.0 1.4 3.5 0.9 63% 0.5 Eye 1 day 12
3.3 0.3 1.8 19.9 5.3 163% 3.0 (OD) 7 days 12 4.8 0.0 2.3 18.5 6.1
125% 3.4 14 days 10 2.8 0.3 1.3 12.3 3.8 135% 2.3 28 days 5 4.8 0.8
5.4 8.5 3.1 65% 2.7 Healthy 3 hours 12 1.4 0.5 1.0 3.1 0.8 61% 0.5
Eye 1 day 12 1.1 0.5 1.0 2.2 0.5 49% 0.3 (OS) 7 days 11 0.8 0.3 0.6
2.8 0.7 85% 0.4 14 days 11 0.9 0.4 0.7 2.5 0.7 72% 0.4 28 days 7
1.1 0.4 0.6 3.3 1.0 92% 0.8
Example 3.5: Pharmacokinetic Study
[0350] Inserts of formulations 1 and 2A (PEG-SG and PEG-SAP
hydrogels, 0.36 mg cyclosporine) were administered bilaterally in
24 beagle dogs, as summarized in Table 3. Tear fluid samples were
taken post-dose at 1, 3, and 6 hours, days 1 and 3, weeks 1, 2, 4,
6, 8, 10 and 12. Results are shown in Table 3.5 as well as in FIGS.
3.2A and 3.2B below. Cyclosporine was released from the inserts
into the tear fluid of the beagles over 12 weeks for both
Formulation 1 (Group 1) as well as Formulation 2A (Group 2). The
results demonstrate a comparable maximum of tear fluid
concentration of 2.7 .mu.g/mL occurring at about 3 hours between
the two formulations. The drug release profile and tear fluid
concentrations appear comparable (within the 95% confidence
interval) between the two formulations over the first six
weeks.
[0351] A potential reduction in cyclosporine tear fluid
concentrations in beagles is noted in the SG hydrogel relative to
the SAP hydrogel formulation between weeks 8 to 12. This difference
could be due to the faster degradation of the SG hydrogel compared
to the SAP hydrogel.
TABLE-US-00029 3.5: Cyclosporine Tear Fluid Concentrations in
Beagles Mean .+-. 95% CI (.mu.g/mL) Time Formulation 1 inserts
Formulation 2 inserts 1 hour 1.4 .+-. 0.4 2.4 .+-. 1.1 3 hours 2.7
.+-. 0.5 2.7 .+-. 0.9 6 hours 2.1 .+-. 1.0 2.5 .+-. 1.0 1 day 1.5
.+-. 0.4 1.1 .+-. 0.2 3 days 1.2 .+-. 0.3 1.3 .+-. 0.4 1 week 1.1
.+-. 0.3 1.8 .+-. 0.9 2 weeks 1.1 .+-. 0.4 1.6 .+-. 0.5 4 weeks 1.0
.+-. 0.2 2.4 .+-. 1.4 6 weeks 1.3 .+-. 0.7 0.9 .+-. 0.3 8 weeks 0.4
.+-. 0.2 1.0 .+-. 0.5 10 weeks 0.3 .+-. 0.1 0.8 .+-. 0.5 12 weeks
0.5 .+-. 0.4 1.3 .+-. 0.5
Example 3.6: High Dose Study
[0352] Inserts with an elevated dose (0.7 mg cyclosporine) in
accordance with the two hydrogel formulations 4A and 4B (PEG-SG and
PEG-SAP) were assessed for pharmacokinetics in a GLP compliant
toxicology study, as summarized in Table 3.
[0353] Tear fluid samples were taken pre-dose and post-dose at 1 h,
2 h, 4 h, 24 h and days 7, 30, 60, 90 and 104 days. Cyclosporine
concentrations in tear fluid are shown in Table 3.6.1 as well as
FIG. 3.3. Results demonstrate comparable (within 95% confidence
intervals) tear fluid concentrations in this beagle study between
the two formulations over the study duration and drug levels are
below the lower limit of quantitation (LLOQ=30 ng/mL) in the
recovery animals (test articles were removed two weeks prior to
sampling at 104 days).
[0354] The pharmacokinetic profile is comparable between the two
formulations and demonstrates a continual steady state dose
exposure over the study duration. No true maximum concentration is
evident as the tear fluid concentrations reach an apparent steady
state within one hour of dose exposure over the study duration
during the dosing period.
TABLE-US-00030 3.6.1 Cyclosporine Tear Fluid Concentrations in
Beagles Mean .+-. 95% CI (.mu.g/mL) Time Formulation 4A inserts
Formulation 4B inserts Pre-dose Not detected Not detected 1 hour
2.9 .+-. 1.2 3.1 .+-. 1.7 2 hours 3.1 .+-. 1.0 2.9 .+-. 0.9 4 hours
2.7 .+-. 0.7 2.7 .+-. 1.0 1 day 3.5 .+-. 1.0 3.4 .+-. 1.4 7 days
2.4 .+-. 0.7 2.2 .+-. 0.7 30 days 3.1 .+-. 0.9 3.1 .+-. 0.6 60 days
2.3 .+-. 0.8 2.3 .+-. 0.8 90 days 3.3 .+-. 1.1 4.1 .+-. 1.1 104
days <LLOQ <LLOQ
Example 4: Randomized, Multi-Center, Double-Masked,
Vehicle-Controlled, Human Phase 1/2 Clinical Study
[0355] A randomized, multi-center, double-masked,
vehicle-controlled, phase 1/2 clinical study was designed to
evaluate the safety, tolerability, and efficacy of the cyclosporine
inserts for intracanalicular use for the treatment of subjects with
DED, comprising 145 subjects (290 eyes) enrolled in two cohorts,
i.e. Cohort 1, an open-label group consisting of approximately 5
subjects (10 eyes) treated with formulation 2A
hydrogel/cyclosporine inserts, and Cohort 2, a randomized,
double-masked group consisting of approximately 140 subjects,
treated with the 2 different formulations 1 and 2A
hydrogel/cyclosporine inserts as well as the 2 different
formulations 2B and 3 HV inserts.
[0356] Both eyes are treated with the same treatment/formulation.
If both eyes qualify in terms of dry eye symptoms, the eye having
the higher total corneal fluorescein staining score is designated
as the study eye and the other eye designated as the non-study eye.
If both eyes have the same total corneal fluorescein staining
score, the study eye is determined by the biostatistician prior to
the analysis. If only one eye qualifies, that eye will be the study
eye, but both eyes will still receive the same
treatment/formulation.
[0357] The treatment is summarized in Table 4 below.
TABLE-US-00031 TABLE 4 Treatment summary (HV = Hydrogel Vehicle)
Number of Formulation Cohort Number Subjects Treatment Number 1 5
Hydrogel/Cyclosporine 2A Open-label 2 40 Hydrogel/Cyclosporine 1
Randomized, 40 Hydrogel/Cyclosporine 2A double-masked 40 HV
(Placebo) 2B 20 HV (Placebo) 3
I. Study Schedule
[0358] Both Cohort groups follow essentially the same study
schedule. Subjects were eligible in case of: [0359] a self-reported
history or clinically confirmed diagnosis of dry eye disease by an
eye care professional in both eyes for .gtoreq.6 months, [0360]
ongoing dry eye disease in the study eye at screening visit as
defined by a visual analogue scale (VAS) eye dryness severity score
of .gtoreq.30, and [0361] a total Corneal Fluorescein Staining
(tCFS) score of .gtoreq.6 and .ltoreq.15 (NEI scale, see
Assessments section below) and a Schirmer's score (unanesthetized)
of >0 mm and .ltoreq.10 mm wetting at 5 minutes, in the same
qualifying eye or in both eyes, wherein [0362] Further inclusion
and exclusion criteria apply.
[0363] The subjects undergo Screening 14 days prior to
Insertion/Day 1 (Visit 2) and eligibility is confirmed at Visit 2
(Insertion/Day 1). Subjects in Cohort 2 are randomly assigned to
one of the four treatment arms in a 2:2:2:1 ratio at Visit 2.
Further treatment follow-up visits (Visits 3 to 8) are scheduled
from Week 2 to Week 16 in regular intervals for all subjects in
order to inter alfa determine insert presence, wherein the presence
of the inserts is assessed in a non-invasive manner by irradiating
corresponding regions with a blue light and using a yellow
filter.
[0364] For both cohorts, if the insert is visualized at Week 16
(Visit 8) the subject returns to the clinic in 30 days (.+-.10
days; Visit 9) and continues returning to the clinic every 30 days
as needed until the insert can no longer be visualized and the
physician has determined that there is no evidence of biological
activity. If the insert cannot be visualized at Week 16 (Visit 8)
and the physician has determined that there is no evidence of
biological activity, the subject exits the study.
[0365] A general schematic of the study is represented in FIG.
4A.
[0366] Various assessments are conducted at each Visit. In
particular, all ophthalmic assessments outlined under point III
below are conducted at all Visits 1 to 8 as well as Visit 9 (in
case Visit 9 takes place for the individual patient), except the
TBUT assessment (which takes place only at Visits 1, 2, 5 and
7).
[0367] The occurrence of any adverse event is likewise assessed at
each visit from insertion day/day 1 onward (any signs, symptoms and
conditions occurring prior to insertion on Day 1 being captured as
medical history) in accordance with point III below.
II. Insert Placement
[0368] The ophthalmic inserts are placed in the vertical part of
the canaliculus (see FIG. 5B). In the clinical studies disclosed
herein, the inserts were placed in the lower punctum.
[0369] To place the inserts in the canaliculus, lateral pressure
was applied to elongate the canalicular system, and the skin was
pulled down temporally near the punctum (FIG. 5A). The lower
punctum was dilated using a punctal dilator in towards the nose,
ensuring the system was elongated, and the canaliculus was dilated
deeper through the punctum for depth, as well as width, rotating
the dilator in a spinning motion to help with the dilating process,
if necessary (FIG. 5B).
[0370] The surface around the punctal opening was dried using an
ophthalmic sponge (FIG. 5C).
[0371] The hydrogel/cyclosporine or HV inserts were inserted with
forceps at a slight angle towards the nose (FIG. 5D), aiming for
70% of insertion within the first motion, and using the forceps to
tap or push insert the remainder of the way in, avoiding excessive
squeezing of the insert to prevent deformation. The insert was
confirmed to be localized slightly beneath the punctal opening.
[0372] In case the insert hydrated before placement slightly below
the punctal opening (resembling a trumpet shape), or hydrated
before ideal positioning or in case a portion of the insert was
protruding and unable to be inserted, the insert was discarded and
a new insert was used.
[0373] The level of ease of insertion of the ophthalmic insert was
graded as "easy" (1), "moderate" (2) or "difficult" (3).
III. Assessments
[0374] The study employed the following assessments:
Schirmer's Tear Test
[0375] The Schirmer's test determines the amount of tears produced
and works by capillary action, which allows the tear liquid to
travel along the length of the paper test strip. The rate of travel
along the test strip is proportional to the rate of tear
production. The subject is asked to look up and the bent end of the
test strip is applied such that it rests between the inferior
palpebral conjunctiva of the lower eyelid and the bulbar
conjunctiva of the eye. After five minutes, the patient is asked to
open both eyes and look upward and the test strips are removed. The
Schirmer's test score is determined by the length of the moistened
area of the strips. Both eyes are tested at the same time. When
anesthetized, only basal tear secretion is being measured.
[0376] A Schirmer's score of .gtoreq.10 mm wetting is considered
normal, while a score of <5 mm indicates tear deficiency.
Tear Film Break Up Time (TBUT) and Total Corneal Fluorescein
Staining (tCFS)
[0377] The time required for the tear film to break up following a
blink is called TBUT. It is a quantitative test for measurement of
tear film stability. The normal time for tear film breakup is over
15 seconds. To assess TBUT, a fluorescein strip is moistened with
saline and applied to the inferior cul-de-sac. After a couple of
blinks, the tear film is examined using a broad-beam of slit lamp
with a blue filter for the appearance of the first dry spots on the
cornea.
[0378] TBUT values of less than 5-10 seconds indicate tear
instability and are observed in patients with mild to moderate dry
eye disease.
[0379] The total Corneal Fluorescein Staining (tCFS) value is
measured to assess the condition of the cornea. Damages such as
abrasions on the corneal surface, which may result e. g. from dry
eyes, are made visible by a fluorescein dye staining.
[0380] To assess tCFS, a fluorescein strip is wetted with saline
solution/eye wash, the subject is asked to look up and the
moistened strip is applied to the inferior palpebral conjunctiva
without touching the strip to the bulbar conjunctiva. Since TBUT is
also assessed by applying fluorescein, if the tCFS measurement is
done closely following the TBUT, then an additional application of
fluorescein dye is not required. The subject is asked to blink
several times to distribute the fluorescein dye, and after 2 to 3
minutes wait time, the cobalt blue illumination and the Wratten
yellow filter is used to assess the corneal staining for each of
the 5 regions of the cornea, central, inferior, nasal, temporal,
and superior using the NEI (National Eye Institute) 0-3 scoring
scale (0=No Staining, 1=Mild Staining, 2=Moderate Staining,
3=Severe Staining), wherein the CFS total score is the sum of the
five areas (0 to 15).
[0381] The higher the tCFS score, the higher the damages on the
corneal surface.
Conjunctival Lissamine Green Staining (LGS)
[0382] The LGS value is measured to assess the condition of the
conjunctiva. A Lissamine strip is wetted with saline solution/eye
wash, the subject is asked to look up and the moistened strip is
applied to the inferior palpebral conjunctiva without touching the
strip to the bulbar conjunctiva. The subject is asked to blink
several times to distribute the lissamine dye, and after 1 to 4
minutes wait time, the moderate illumination is used to assess the
conjunctival staining for each of the 6 regions of the conjunctiva,
temporal, superior temporal, inferior temporal as well as superior
nasal, inferior nasal, and nasal using the NEI 0-3 scoring scale,
wherein the LGS total score is the sum of the six areas (0 to
18).
[0383] The staining produced by an elevated pinguecula may not
improve. The staining associated with the pinguecula may be
consistently excluded from the total Lissamine score.
[0384] The higher the LGS score, the higher the damages on the
conjunctival surface.
Best Corrected Visual Acuity BCVA
[0385] Visual acuity testing should precede any examination
requiring contact with the eye or instillation of study dyes. Log
MAR visual acuity must be assessed using an Early Treatment
Diabetic Retinopathy Study (ETDRS) or modified ETDRS chart,
consisting of lines of five letters each, each line representing a
0.1 log unit of the minimum angle of resolution (log MAR) at a
given test distance.
[0386] Visual acuity testing is performed using an Early Treatment
Diabetic Retinopathy Study (ETDRS) or modified ETDRS chart with
best correction using subject's own corrective lenses (spectacles
only) or pinhole refraction. The ETDRS or modified ETDRS chart
consists of lines of five letters each, each line representing a
0.1 log unit of the minimum angle of resolution (log MAR) at a
given test distance.
[0387] Visual acuity (VA) is scored as a log MAR value, wherein the
last line in which a letter is read correctly will be taken as the
base log MAR reading, to which N.times.0.02 is added, with N being
the total number of letters missed up to and included in the last
line read. This total sum (base log MAR+N.times.0.02) represents
the BCVA for that eye.
[0388] The lower the BCVA score, the better the visual acuity.
Eye Dryness Score/Visual Analogue Scale VAS
[0389] In order to assess the eye dryness score the subject is
asked to rate the severity and the frequency of symptom of eye
dryness in percent by placing a vertical mark on a horizontal line
(representing values from 0 to 100%) to indicate the level of eye
discomfort that they are experiencing in both eyes currently and
how often the eye dryness is experienced, wherein 0% corresponds to
"no discomfort" and 100% corresponds to "maximal (the most)
discomfort".
Ocular Surface Disease Index OSDI.COPYRGT.
[0390] The OSDI allows to quickly assess the symptoms of ocular
irritation in dry eye disease based on a 12-item questionnaire
assessing dry eye symptoms and the effects it has on vision-related
function in the past week of the subject's life (see e.g. by R. M.
Schiffman et al. in Arch Ophthalmol. 2000; 118(5):615-621 hereby
incorporated by reference).
[0391] The higher the final score, the greater the disability.
Standard Patient Evaluation of Eye Dryness (SPEED) Evaluation
[0392] The SPEED questionnaire (see Korb and Blackie, Ocular
Surgery News Europe Edition. 2012 hereby incorporated by reference)
is another assessment for monitoring dry eye symptoms over time,
with a score from 0 to 28 resulting from 8 items that assess
frequency and severity of symptoms including dryness, grittiness,
scratchiness, irritation, burning, watering, soreness, and eye
fatigue.
[0393] Higher scores indicate greater disability.
IV. Adverse Events
[0394] An adverse event (AE) is any untoward medical occurrence in
a patient or clinical investigation subject administered a
pharmaceutical product and that does not necessarily have a causal
relationship with this treatment. An AE can therefore be any
unfavorable and unintended sign (including an abnormal laboratory
finding), symptom, or disease temporally associated with the use of
a medicinal (investigational) product, whether or not related to
the medicinal (investigational) product.
[0395] A serious adverse event (SAE) is any untoward medical
occurrence that at any dose: [0396] Results in death [0397] Is
life-threatening (referring to an event in which the subject was at
risk of death at the time of the event, but not an event which
hypothetically might have caused death if it were more severe)
[0398] Requires in-patient hospitalization or prolongation of
existing hospitalization. (hospitalizations for elective surgeries
do not constitute an SAE) [0399] Results in persistent or
significant disability/incapacity. [0400] Is a congenital
abnormality/birth defect.
[0401] During each visit, the subjects are questioned about adverse
events using an open question taking care not to influence the
subject's answers.
[0402] Any AE as well as SAE experienced by the subject from Visit
2 (Insertion/Day 1) through Visit 9 (30-day follow-up visit) is
recorded regardless of the severity of the event or its
relationship to study treatment.
[0403] Any AEs already documented at a previous assessment and
designated as ongoing, is reviewed at subsequent visits as
necessary, and if these have resolved, this is documented.
[0404] Changes in intensity or frequency of AEs are recorded as
separate events (i.e., a new record is started).
[0405] Any SAE ongoing when the subject completed the study or
discontinued from the study is followed until the event has
resolved, stabilized, or returned to baseline status.
[0406] All events are assessed to determine whether the event meets
the criteria for an SAE, the severity of the event as well as the
relationship of the event to study treatment.
Example 4.1: Cohort 1--Open Label, Single-Center Phase 1 Study
[0407] Cohort 1 was an open-label phase 1 study intended to
evaluate safety, tolerability, durability and biological activity
of the hydrogel/cyclosporine insert, and treatment assignment was
known to the sponsor, investigator and subjects and the study
schedule as outlined above under I. Study Schedule was followed.
All 5 enrolled subjects (10 eyes) in Cohort 1 received Formulation
2A inserts at Visit 2 in accordance with the procedure as outlined
above under II. Insert placement after eligibility was
confirmed.
I. Safety and Tolerability
[0408] All subjects completed the 16-week study period with no
drop-outs. No serious adverse effects were reported. The inserts
were observed to be well-tolerated, and there were no adverse
events of stinging, irritation, blurred vision or tearing reported
or observed. No replacement inserts were required. The level of
ease of insertion of the insert was rated as follows: [0409] 8
eyes: Easy [0410] 1 eye: Moderate [0411] 1 eye: Difficult
[0412] The moderate and difficult rating was for the same subject's
right and left eye. This shows that the overall insert dimensions
and swelling behavior were excellently adjusted for an easy
administration of the insert.
II. Durability
[0413] All inserts were last visualized at Visit 8.
III. Biological Activity/Efficacy
[0414] Efficacy of the insert treatment was evaluated based on the
ophthalmic assessments conducted at each visit.
[0415] Tear production as measured by the Schirmer's test
(unanesthetized) improved from a mean value of 4.2 mm at baseline
to 8.2 mm at Week 12, wherein one of five (20%) subjects had a
.gtoreq.10 mm increase in Schirmer's score at Week 12 from baseline
(see FIGS. 6A and 6B).
[0416] The subjects demonstrated an improvement in signs of Dry Eye
Disease (DED) as measured by tCFS. The tCFS improved from a mean
value of 6.7 at baseline to a mean value of 2.7 at Week 12 (see
FIG. 7A), resulting in a Change from Baseline (CFB) of -4.0 at Week
12 (see FIG. 7B).
[0417] The symptoms of DED also improved, as measured by [0418] (i)
the visual analog scale (VAS) eye dryness severity score, which
improved from a mean value of 51 at baseline to a mean value of 33
at Week 12 (see FIGS. 8A and 8B), and [0419] (ii) the VAS dry eye
frequency score, which improved from a mean value of 51 at
baseline, to a mean value of 31 at Week 12 (see FIG. 9).
[0420] The onset of action of the inserts was seen as early as two
weeks for both signs and symptoms of DED (as measured by the VAS
eye dryness severity and frequency score), and continued over the
16 week study period.
[0421] In addition, both the ocular surface disease index (OSDI)
and standard patient evaluation of eye dryness (SPEED) score
decreased across the 16-week period (See FIGS. 10 and 11).
Example 4.2: Cohort 2--Randomized, Multi-Center, Double-Masked,
Vehicle-Controlled, Phase 2 Study
[0422] Cohort 2 is an ongoing randomized double-masked
vehicle-controlled phase 2 study intended to evaluate safety,
tolerability and efficacy of the hydrogel/cyclosporine insert, and
treatment assignment was masked to subjects as well as
investigators and their staff and Sponsor's personnel, and the
study schedule as outlined above under I. Study Schedule was
followed.
[0423] A randomization schedule was computer-generated by a
qualified biostatistician independent of the study conduct or
project team and the hydrogel/cyclosporine as well as HV inserts
administered to subjects at randomization in the double-masked
treatment phase was comparable in appearance. Study subjects as
well as investigators and their staff are masked to the identity of
treatment until the final database is locked, and the Sponsor's
personnel involved with the conduct and monitoring of the study
remains masked until completion of the study and database lock.
[0424] At visit 2, the 140 enrolled subjects in Cohort 2 received
one of the inserts (Formulations 1, 2A, 2B and 3) in accordance
with the randomization schedule at Visit 2, after eligibility was
confirmed. The procedure as outlined above under II. Insert
placement was followed for insert administration.
[0425] If unmasking is required, the integrity of the study
assessments and objectives are maintained by limiting access to the
unmasked data to two individuals (Sponsor Medical Monitor and
Sponsor Statistician) who are not involved in the study conduct or
directly by the investigator if required in an emergency.
IV. Safety and Tolerability
[0426] Adverse events including the occurrence of stinging,
irritation, blurred vision or tearing were continuously
assessed.
V. Durability
[0427] The durability of the inserts is assessed by monitoring the
presence of the inserts.
VI. Biological Activity/Efficacy
[0428] Efficacy of the insert treatment is evaluated based on the
ophthalmic assessments conducted at each visit. The efficacy
endpoints are determined as follows:
Primary Endpoint
[0429] Change from baseline (CFB) and absolute value at week 12 in
Schirmer's test (unanesthetized)
Secondary Endpoints
Signs:
[0429] [0430] Percent of subjects with .gtoreq.10 mm increase in
Schirmer's score at Week 12 [0431] CFB and absolute values of total
Corneal Fluorescein Staining (tCFS) using NEI scale at each
post-baseline study visit [0432] CFB and absolute values of Corneal
Fluorescein Staining sub-regions using NEI scale, at each
post-baseline visit. [0433] CFB and absolute values of Conjunctival
Lissamine Green Staining using NEI Scale, at each post-baseline
visit. Symptoms (subject-reported): [0434] CFB and absolute values
of Eye Dryness Score (VAS) at each post-baseline study visit [0435]
CFB and absolute values of Ocular Surface Disease Index
(OSDI.COPYRGT. total score, each of the three domains, and
individual questions), at each post-baseline visit. [0436] CFB of
SPEED questionnaire (overall score and individual questions), at
each post-baseline visit.
Exploratory:
[0436] [0437] CFB of Tear Film Break Up Time (TBUT) at Week 12
[0438] Presence of insert at all post-baseline visits [0439] Ease
of insertion as assessed by the Investigator [0440] Ease of
visualization as assessed by the Investigator
[0441] While having described a number of embodiments of this, it
is apparent that our basic examples may be altered to provide other
embodiments that utilize the compounds and methods of this
disclosure. Therefore, it will be appreciated that the scope of
this disclosure is to be defined by the appended claims rather than
by the specific embodiments that have been represented by way of
example.
[0442] Throughout this application various references are cited.
The disclosures of these references are hereby incorporated by
reference into the present disclosure.
[0443] The invention relates in particular to the following further
embodiments: [0444] 1. A sustained release biodegradable
intracanalicular insert comprising a hydrogel and cyclosporine,
wherein the cyclosporine is in the form of particles and wherein
the cyclosporine particles are dispersed within the hydrogel.
[0445] 2. The sustained release biodegradable intracanalicular
insert of Embodiment 1, wherein the cyclosporine particles are
uniformly dispersed within the hydrogel. [0446] 3. The sustained
release biodegradable intracanalicular insert of Embodiment 1 or 2,
wherein the cyclosporine particles have a d50 value of less than
about 50 .mu.m. [0447] 4. The sustained release biodegradable
intracanalicular insert of Embodiment 3, wherein the cyclosporine
particles have a d50 value ranging from 3 to 17 .mu.m. [0448] 5.
The sustained release biodegradable intracanalicular insert of
Embodiment 4, wherein the cyclosporine particles have a d50 value
ranging from 4 to 12 .mu.m. [0449] 6. The sustained release
biodegradable intracanalicular insert of Embodiment 5, wherein the
cyclosporine particles have a d50 value ranging from 5 to 8 .mu.m.
[0450] 7 The sustained release biodegradable intracanalicular
insert of any one of Embodiments 1 to 6, wherein the cyclosporine
particles have a d90 value of less than 43 .mu.m. [0451] 8. The
sustained release biodegradable intracanalicular insert of any one
of Embodiments 1 to 7, wherein the cyclosporine particles have a
d100 value of less than 45 .mu.m. [0452] 9. The sustained release
biodegradable intracanalicular insert of any one of Embodiments 1
to 8, comprising the cyclosporine in an amount ranging from about
100 .mu.g to about 800 [0453] 10. The sustained release
biodegradable intracanalicular insert of Embodiment 9, comprising
the cyclosporine in an amount ranging from 100 .mu.g to 300 .mu.g.
[0454] 11. The sustained release biodegradable intracanalicular
insert of Embodiment 9, comprising the cyclosporine in an amount
ranging from 300 .mu.g to 450 .mu.g. [0455] 12. The sustained
release biodegradable intracanalicular insert of Embodiment 9,
comprising the cyclosporine in an amount ranging from about 500
.mu.g to about 800 .mu.g. [0456] 13. The sustained release
biodegradable intracanalicular insert of Embodiment 9, comprising
the cyclosporine in an amount of about 250 .mu.g. [0457] 14. The
sustained release biodegradable intracanalicular insert of
Embodiment 9, comprising the cyclosporine in an amount of about 360
.mu.g. [0458] 15. The sustained release biodegradable
intracanalicular insert of Embodiment 9, comprising the
cyclosporine in an amount of about 600 .mu.g. [0459] 16. The
sustained release biodegradable intracanalicular insert of
Embodiment 9, comprising the cyclosporine in an amount of about 670
.mu.g. [0460] 17. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 1 to 16, wherein
the insert is for insertion into the lower and the upper
canaliculus. [0461] 18. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 1 to 16, wherein
the insert is for insertion into the lower canaliculus. [0462] 19.
The sustained release biodegradable intracanalicular insert of any
one of Embodiments 1 to 16, wherein the insert is for insertion
into the upper canaliculus. [0463] 20. The sustained release
biodegradable intracanalicular insert of any one of Embodiments 17
to 19, wherein the insert is for insertion into the vertical part
of the canaliculus. [0464] 21. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 1 to 20, wherein
the insert is in a dried state prior to insertion and becomes
hydrated once inserted into the eye. [0465] 22. The sustained
release biodegradable intracanalicular insert of any one of
Embodiments 1 to 21, wherein the hydrogel comprises a polymer
network. [0466] 23. The sustained release biodegradable
intracanalicular insert of Embodiment 22, wherein the hydrogel
comprises a polymer network comprising one or more units of
polyethylene glycol, polyethylene oxide, polypropylene oxide,
polyvinyl alcohol, poly (vinylpyrrolidinone), polylactic acid,
polylactic-co-glycolic acid, random or block copolymers or
combinations or mixtures of any of these, or one or more units of
polyaminoacids, glycosaminoglycans, polysaccharides, or proteins.
[0467] 24. The sustained release biodegradable intracanalicular
insert of Embodiment 22 or 23, wherein the hydrogel comprises a
polymer network that comprises crosslinked polymer units that are
identical or different. [0468] 25. The sustained release
biodegradable intracanalicular insert of Embodiment 24, wherein the
crosslinked polymer units are one or more crosslinked polyethylene
glycol units. [0469] 26. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 22 to 25, wherein
the polymer network comprises polyethylene glycol units having an
average molecular weight in the range from about 2,000 to about
100,000 Daltons. [0470] 27. The sustained release biodegradable
intracanalicular insert of Embodiment 26, wherein the polyethylene
glycol units have an average molecular weight in the range from
about 10,000 to about 60,000 Daltons. [0471] 28. The sustained
release biodegradable intracanalicular insert of Embodiment 27,
wherein the polyethylene glycol units have an average molecular
weight in the range from about 20,000 to about 40,000 Daltons.
[0472] 29. The sustained release biodegradable intracanalicular
insert of Embodiment 28, wherein the polyethylene glycol units have
an average molecular weight of about 20,000 Daltons. [0473] 30. The
sustained release biodegradable intracanalicular insert of any one
of Embodiments 22 to 29, wherein the polymer network comprises one
or more crosslinked multi-arm polymer units. [0474] 31. The
sustained release biodegradable intracanalicular insert of
Embodiment 30, wherein the multi-arm polymer units comprise one or
more 2- to 10-arm polyethylene glycol units. [0475] 32. The
sustained release biodegradable intracanalicular insert of
Embodiment 31, wherein the multi-arm polymer units comprise one or
more 4- to 8-arm polyethylene glycol units. [0476] 33. The
sustained release biodegradable intracanalicular insert of
Embodiment 32, wherein the multi-arm polymer units comprise one
4-arm polyethylene glycol units. [0477] 34. The sustained release
biodegradable intracanalicular insert of Embodiment 33, wherein the
four arms of the 4-arm polyethylene glycol units are connected to a
core molecule of pentaerythritol. [0478] 35. The sustained release
biodegradable intracanalicular insert of any one of Embodiments 22
to 34, wherein the polymer network further comprises one or more
cross-linking units. [0479] 36. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 22 to 35, wherein
the polymer network is formed by reacting an electrophilic
group-containing multi-arm-polymer precursor with a nucleophilic
group-containing cross-linking agent. [0480] 37. The sustained
release biodegradable intracanalicular insert of Embodiment 36,
wherein the electrophilic group is an activated ester group. [0481]
38. The sustained release biodegradable intracanalicular insert of
Embodiment 37, wherein the electrophilic group is an
N-hydroxysuccinimidyl (NHS) ester group. [0482] 39. The sustained
release biodegradable intracanalicular insert of Embodiment 38,
wherein the electrophilic group is selected from the group
consisting of succinimidylmalonate group, succinimidylsuccinate
(SS) group, succinimidylmaleate group, succinimidylfumarate group,
succinimidylglutarate (SG) group, succinimidyladipate (SAP) group,
succinimidylpimelate group, succinimidylsuberate group and
succinimidylazelate (SAZ) group. [0483] 40. The sustained release
biodegradable intracanalicular insert of any one of Embodiments 36
to 39, wherein the nucleophilic group-containing crosslinking agent
is nucleophilic group-containing multi-arm polymer precursor.
[0484] 41. The sustained release biodegradable intracanalicular
insert of any one of Embodiments 36 to 39, wherein the nucleophilic
group-containing crosslinking agent is an amine. [0485] 42. The
sustained release biodegradable intracanalicular insert of
Embodiment 41, wherein the nucleophilic group-containing
crosslinking agent is a small molecule amine with a molecular
weight below 1,000 Da, comprising two or more primary aliphatic
amine groups. [0486] 43. The sustained release biodegradable
intracanalicular insert of Embodiment 42, wherein the nucleophilic
group-containing crosslinking agent is a small molecule amine
selected from the group consisting of dilysine, trilysine,
tetralysine, ethylenediamine, 1,3-diaminopropane,
1,3-diaminopropane, diethylenetriamine, and
trimethylhexamethylenediamine. [0487] 44. The sustained release
biodegradable intracanalicular insert of Embodiment 43, wherein the
nucleophilic group-containing crosslinking agent is a trilysine.
[0488] 45. The sustained release biodegradable intracanalicular
insert of Embodiment 44, wherein the nucleophilic group-containing
crosslinking agent is trilysine acetate. [0489] 46. The sustained
release biodegradable intracanalicular insert of Embodiment 44,
wherein the nucleophilic group-containing crosslinking agent is a
labeled trilysine. [0490] 47. The sustained release biodegradable
intracanalicular insert of Embodiment 46, wherein the trilysine is
labeled with a visualization agent. [0491] 48. The sustained
release biodegradable intracanalicular insert of Embodiment 47,
wherein the trilysine is labeled with a visualization agent
selected from the group consisting of a fluorophore such as
fluorescein, rhodamine, coumarin, and cyanine. [0492] 49. The
sustained release biodegradable intracanalicular insert of
Embodiment 48, wherein the nucleophilic group-containing
crosslinking agent is fluorescein-conjugated trilysine. [0493] 50.
The sustained release biodegradable intracanalicular insert of
Embodiment 49, wherein the fluorescein-conjugated trilysine is
obtained by reacting trilysine acetate with N-hydroxysuccinimide
(NHS)-fluorescein. [0494] 51. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 46 to 50, wherein
the trilysine is labeled by partial conjugation with a
visualization agent. [0495] 52. The sustained release biodegradable
intracanalicular insert of Embodiment 51, wherein about 1% to about
20% of the trilysine amine groups are conjugated with a
visualization agent. [0496] 53. The sustained release biodegradable
intracanalicular insert of Embodiment 52, wherein 5% to 10% of the
trilysine amine groups are conjugated with a visualization agent.
[0497] 54. The sustained release biodegradable intracanalicular
insert of Embodiment 53, wherein 8% of the trilysine amine groups
are conjugated with a visualization agent. [0498] 55. The sustained
release biodegradable intracanalicular insert of any one of
Embodiments 30 to 54, wherein the multi-arm polymer units comprise
4a20kPEG units and the cross-linking units comprise
fluorescein-conjugated trilysine amide units. [0499] 56. The
sustained release biodegradable intracanalicular insert of any one
of Embodiments 22 to 55, wherein the polymer network is obtained by
reacting 4a20kPEG-SG with fluorescein-conjugated trilysine in a
molar ratio ranging from about 1:2 to about 2:1. [0500] 57. The
sustained release biodegradable intracanalicular insert of
Embodiment 56, wherein the polymer network is obtained by reacting
4a20kPEG-SG with fluorescein-conjugated trilysine in a molar ratio
of about 1:1. [0501] 58. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 22 to 55, wherein
the polymer network is obtained by reacting 4a20kPEG-SAP with
fluorescein-conjugated trilysine in a molar ratio ranging from
about 1:2 to about 2:1. [0502] 59. The sustained release
biodegradable intracanalicular insert of Embodiment 58, wherein the
polymer network is obtained by reacting 4a20kPEG-SAP with
fluorescein-conjugated trilysine in a molar ratio of about 1:1.
[0503] 60. The sustained release biodegradable intracanalicular
insert of any one of Embodiments 1 to 59, wherein the insert in a
dried state contains from about 15% to about 80% by weight of the
cyclosporine based on the total weight of the insert and from about
20% to about 60% by weight polymer units based on the total weight
of the insert. [0504] 61. The sustained release biodegradable
intracanalicular insert of Embodiment 60, wherein the insert in a
dried state contains from 30% to 65% by weight of the cyclosporine
based on the total weight of the insert and from 25% to 50% by
weight polymer units based on the total weight of the insert.
[0505] 62. The sustained release biodegradable intracanalicular
insert of Embodiment 61, wherein the insert in a dried state
contains from 45% to 55% by weight of the cyclosporine based on the
total weight of the insert and from 37% to 47% by weight polymer
units based on the total weight of the insert. [0506] 63. A
sustained release biodegradable intracanalicular insert comprising
a hydrogel and cyclosporine, wherein the insert in a dried state
contains from about 40% to about 80% by weight of the cyclosporine
based on the total weight of the insert. [0507] 64. The sustained
release biodegradable intracanalicular insert of any one of
Embodiments 1 to 63, wherein the insert in a dried state contains
from 45% to 55% by weight of the cyclosporine based on the total
weight of the insert. [0508] 65. The sustained release
biodegradable intracanalicular insert of any one of Embodiments 1
to 64, wherein the insert in a dried state contains from about 20%
to about 60% by weight polymer units based on the total weight of
the insert. [0509] 66. The sustained release biodegradable
intracanalicular insert of Embodiment 65, wherein the insert in a
dried state contains from 25% to 50% by weight polymer units based
on the total weight of the insert. [0510] 67. The sustained release
biodegradable intracanalicular insert of Embodiment 66, wherein the
insert in a dried state contains from 37% to 47% by weight polymer
units based on the total weight of the insert. [0511] 68. The
sustained release biodegradable intracanalicular insert of any one
of Embodiments 1 to 67, wherein the insert contains a surfactant.
[0512] 69. A sustained release biodegradable intracanalicular
insert comprising a hydrogel and cyclosporine, wherein the insert
contains a surfactant. [0513] 70. The sustained release
biodegradable intracanalicular insert of Embodiment 68 or 69,
wherein the insert in a dried state contains from about 0.01% to
about 5% by weight of a surfactant based on the total weight of the
insert. [0514] 71. The sustained release biodegradable
intracanalicular insert of Embodiment 70, wherein the insert in a
dried state contains from 0.2% to 2% by weight of a surfactant
based on the total weight of the insert.
[0515] 72. The sustained release biodegradable intracanalicular
insert of any one of Embodiments 68 to 71, wherein the insert
contains a non-ionic surfactant. [0516] 73. The sustained release
biodegradable intracanalicular insert of Embodiment 72, wherein the
insert contains a non-ionic surfactant comprising a poly(ethylene
glycol) chain. [0517] 74. The sustained release biodegradable
intracanalicular insert of Embodiment 73, wherein the insert
contains a surfactant selected from the group consisting of
poly(ethylene glycol) sorbitan monolaurate, poly(ethylene glycol)
ester of castor oil, and an ethoxylated
4-tert-octylphenol/formaldehyde condensation polymer. [0518] 75.
The sustained release biodegradable intracanalicular insert of
Embodiment 74, wherein the surfactant is selected from the group
consisting of poly(ethylene glycol)-20-sorbitan monolaurate,
poly(ethylene glycol)-80-sorbitan monolaurate, poly(ethylene
glycol)-35 ester of castor oil and an ethoxylated
4-tert-octylphenol/formaldehyde condensation polymer. [0519] 76.
The sustained release biodegradable intracanalicular insert of
Embodiment 75, wherein the insert contains an ethoxylated
4-tert-octylphenol/formaldehyde condensation polymer. [0520] 77.
The sustained release biodegradable intracanalicular insert of any
one of Embodiments 1 to 76, wherein the insert contains one or more
phosphate, borate or carbonate salt(s). [0521] 78. The sustained
release biodegradable intracanalicular insert of Embodiment 77,
wherein the insert contains phosphate salt originating from
phosphate buffer used during the preparation of the hydrogel.
[0522] 79. The sustained release biodegradable intracanalicular
insert of any one of Embodiments 1 to 78, wherein the insert in a
dried state contains not more than about 1% by weight water based
on the total weight of the insert. [0523] 80. The sustained release
biodegradable intracanalicular insert of any one of Embodiments 1
to 79, wherein the insert has an essentially cylindrical shape with
an essentially round cross-section. [0524] 81. The sustained
release biodegradable intracanalicular insert of any one of
Embodiments 1 to 80, wherein the cyclosporine content as measured
by HPLC after at least 3 months of storage at a temperature of from
2 to 8.degree. C. is from about 300 to about 410 .mu.g. [0525] 82.
The sustained release biodegradable intracanalicular insert of any
one of Embodiments 1 to 81, wherein the cyclosporine content as
measured by HPLC after at least 6 months of storage at a
temperature of from 2 to 8.degree. C. is from about 300 to about
410 .mu.g. [0526] 83. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 1 to 82, wherein
the cyclosporine content as measured by HPLC after at least 12
months of storage at a temperature of from 2 to 8.degree. C. is
from about 300 to about 410 .mu.g. [0527] 84. The sustained release
biodegradable intracanalicular insert of any one of Embodiments 1
to 83, wherein the cyclosporine content as measured by HPLC after
at least 3 months of storage at a temperature of from 2 to
8.degree. C. is from about 90 to about 110% by weight. [I have kept
more of the ranges in the specification] [0528] 85. The sustained
release biodegradable intracanalicular insert of any one of
Embodiments 1 to 84, wherein the cyclosporine content as measured
by HPLC after at least 6 months of storage at a temperature of from
2 to 8.degree. C. is from about 90 to about 110% by weight. [0529]
86. The sustained release biodegradable intracanalicular insert of
any one of Embodiments 1 to 85, wherein the cyclosporine content as
measured by HPLC after at least 12 months of storage at a
temperature of from 2 to 8.degree. C. is from about 90 to about
110% by weight. [0530] 87. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 1 to 86, wherein
the amount of impurities as measured by HPLC after at least 3
months of storage at a temperature of from 2 to 8.degree. C. is not
more than 3.0%. [0531] 88. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 1 to 87, wherein
the amount of impurities as measured by HPLC after at least 6
months of storage at a temperature of from 2 to 8.degree. C. is not
more than 3.0%. [0532] 89. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 1 to 88, wherein
the amount of impurities as measured by HPLC after at least 12
months of storage at a temperature of from 2 to 8.degree. C. is not
more than 3.0%. [0533] 90. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 1 to 89, wherein
the insert is in the form of a fiber. [0534] 91. The sustained
release biodegradable intracanalicular insert of Embodiment 90,
wherein the insert is in the form of a fiber that has an average
length of about 1.5 mm to about 4.0 mm and an average diameter of
not more than 0.8 mm in its dried state. [0535] 92. The sustained
release biodegradable intracanalicular insert of Embodiment 91,
wherein the insert is in the form of a fiber that has an average
length of 2.0 mm to 2.5 mm and an average diameter of not more than
0.62 mm in its dried state. [0536] 93. The sustained release
biodegradable intracanalicular insert of Embodiment 92, wherein the
insert is in the form of a fiber that has an average length of 2.5
mm to 2.9 mm and an average diameter of not more than 0.62 mm in
its dried state. [0537] 94. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 1 to 93, wherein
the insert after at least 3 months of storage at a temperature of
from 2 to 8.degree. C. is in the form of a fiber that has an
average length of about 2.5 mm to about 2.9 mm and an average
diameter of not more than 0.62 mm in its dried state. [0538] 95.
The sustained release biodegradable intracanalicular insert of any
one of Embodiments 1 to 94, wherein the insert after at least 6
months of storage at a temperature of from 2 to 8.degree. C. is in
the form of a fiber that has an average length of about 2.5 mm to
about 2.9 mm and an average diameter of not more than 0.62 mm in
its dried state. [0539] 96. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 1 to 95, wherein
the insert after at least 12 months of storage at a temperature of
from 2 to 8.degree. C. is in the form of a fiber that has an
average length of about 2.5 mm to about 2.9 mm and an average
diameter of not more than 0.62 mm in its dried state. [0540] 97.
The sustained release biodegradable intracanalicular insert of any
one of Embodiments 1 to 96, wherein the insert is in the form of a
fiber that has an average diameter of at least 1.0 mm in expanded
state after 10 minutes of hydration in vitro in phosphate-buffered
saline at a pH of 7.4 at 37.degree. C. [0541] 98. The sustained
release biodegradable intracanalicular insert of any one of
Embodiments 1 to 97, wherein the insert is in the form of a fiber
that has an average diameter of at least 1.3 mm in equilibrium
state after 24 hours of hydration in vitro in phosphate-buffered
saline at a pH of 7.4 at 37.degree. C. [0542] 99. The sustained
release biodegradable intracanalicular insert of any one of
Embodiments 1 to 98, wherein the insert is inserted into the
canaliculus with the aid of a grasping device selected from the
group consisting of a forceps, a tweezer, and an applicator. [0543]
100. The sustained release biodegradable intracanalicular insert of
any one of Embodiments 1 to 99, wherein upon hydration in vivo in
the eye or in vitro the diameter of the insert is increased, or the
length of the insert is decreased while its diameter is increased.
[0544] 101. The sustained release biodegradable intracanalicular
insert of Embodiment 100, wherein hydration is measured in vitro in
phosphate-buffered saline at a pH of 7.4 at 37.degree. C. after 24
hours. [0545] 102. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 1 to 101, wherein
the insert disintegrates in the canaliculus within about 1 to about
6 months after insertion. [0546] 103. The sustained release
biodegradable intracanalicular insert of Embodiment 102, wherein
the insert disintegrates in the canaliculus within 2 to 4 months
after insertion. [0547] 104. The sustained release biodegradable
intracanalicular insert of Embodiment 103, wherein the insert
disintegrates in the canaliculus within 2 to 3 months after
insertion. [0548] 105. The sustained release biodegradable
intracanalicular insert of Embodiment 103, wherein the insert
disintegrates in the canaliculus within 3 to 4 months after
insertion. [0549] 106. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 1 to 105, wherein
the insert after insertion to the canaliculus releases a
therapeutically effective amount of cyclosporine over a period of
at least about 1 month after insertion. [0550] 107. The sustained
release biodegradable intracanalicular insert of Embodiment 106,
wherein the insert after insertion to the canaliculus releases a
therapeutically effective amount of cyclosporine over a period of
at least 2 months after insertion. [0551] 108. The sustained
release biodegradable intracanalicular insert of Embodiment 107,
wherein the insert after insertion to the canaliculus releases a
therapeutically effective amount of cyclosporine over a period of
at least 3 months after insertion. [0552] 109. The sustained
release biodegradable intracanalicular insert of any one of
Embodiments 1 to 108, wherein cyclosporine is released from the
insert after insertion to a human subject at an average rate of
about 0.1 .mu.g/day to about 10 .mu.g/day. [0553] 110. The
sustained release biodegradable intracanalicular insert of any one
of Embodiments 1 to 108, wherein cyclosporine is released from the
insert after insertion at an average rate of about 0.1 .mu.g/day to
about 10 .mu.g/day. [0554] 111. The sustained release biodegradable
intracanalicular insert of Embodiment 109 or 110, wherein
cyclosporine is released from the insert after insertion at an
average rate of 1 .mu.g/day to 5 .mu.g/day. [0555] 112. The
sustained release biodegradable intracanalicular insert of
Embodiment 111, wherein cyclosporine is released from the insert
after insertion at an average rate of 2 .mu.g/day to 4 .mu.g/day.
[0556] 113. The sustained release biodegradable intracanalicular
insert of any one of Embodiments 1 to 112, wherein the tear fluid
concentration of cyclosporine after insertion to a human subject
ranges from about 0.1 .mu.g/mL to about 10 .mu.g/mL. [0557] 114.
The sustained release biodegradable intracanalicular insert of any
one of Embodiments 1 to 112, wherein the tear fluid concentration
of cyclosporine after insertion of the insert ranges from about 0.1
.mu.g/mL to about 10 .mu.g/mL. [0558] 115. The sustained release
biodegradable intracanalicular insert of Embodiment 113 or 114,
wherein the tear fluid concentration of cyclosporine after
insertion of the insert ranges from about 1 .mu.g/mL to about 5
.mu.g/mL. [0559] 116. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 1 to 115, wherein
the insert disintegrates in the canaliculus prior to complete
solubilization of the cyclosporine particles contained in the
insert. [0560] 117. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 1 to 116, wherein
the insert is obtainable by preparing a precursor mixture
containing hydrogel precursors and cyclosporine, filling the
precursor mixture into a tubing, allowing the hydrogel precursors
to cross-link in the tubing to provide a hydrogel mixture shaped as
a fiber, and stretching the hydrogel mixture fiber to provide the
insert. [0561] 118. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 1 to 117, wherein
the fiber has been stretched prior to or after drying. [0562] 119.
The sustained release biodegradable intracanalicular insert of
Embodiment 118, wherein the fiber has been stretched prior to
drying. [0563] 120. A sustained release biodegradable
intracanalicular insert comprising a hydrogel and cyclosporine in
the form of a fiber, wherein the fiber has been stretched. [0564]
121. The sustained release biodegradable intracanalicular insert of
any one of Embodiments 118 to 120, wherein the fiber has been
stretched by a stretch factor in the longitudinal direction of from
about 1.0 to about 4.0. [0565] 122. The sustained release
biodegradable intracanalicular insert of Embodiment 121, wherein
the fiber has been stretched by a stretch factor in the
longitudinal direction of from about 1.5 to about 3.0. [0566] 123.
The sustained release biodegradable intracanalicular insert of
Embodiment 122, wherein the fiber has been stretched by a stretch
factor in the longitudinal direction of about 2.7. [0567] 124. A
sustained release biodegradable intracanalicular insert comprising
a hydrogel and cyclosporine in an amount of about 360 .mu.g
dispersed within the hydrogel, wherein the hydrogel comprises a
polymer network comprising polyethylene glycol units, and wherein
the insert is in a dried state prior to insertion. [0568] 125. A
sustained release biodegradable intracanalicular insert comprising
a hydrogel and cyclosporine in an amount of about 360 .mu.g, in the
form of a fiber that has an average length of about 2.5 mm to about
2.9 mm and an average diameter of not more than 0.62 mm in its
dried state. [0569] 126. A sustained release biodegradable
intracanalicular insert comprising a hydrogel and from about 45% to
about 55% by weight of cyclosporine based on the total weight of
the insert, in the form of a fiber that has an average length of
about 2.5 mm to about 2.9 mm and an average diameter of not more
than 0.62 mm in its dried state. [0570] 127. A sustained release
biodegradable intracanalicular insert comprising a hydrogel and
cyclosporine in an amount of about 360 .mu.g dispersed within the
hydrogel, wherein the insert after insertion to the canaliculus
releases a therapeutically effective amount of cyclosporine over a
period of at least about 3 months after insertion. [0571] 128. A
sustained release biodegradable intracanalicular insert comprising
a hydrogel and cyclosporine, wherein [0572] the cyclosporine is in
the form of particles [0573] the cyclosporine particles are
dispersed within the hydrogel and have a d50 value of less than
about 50 .mu.m, and wherein [0574] the cyclosporine is released
from the insert after insertion to a human subject at an average
rate of about 0.1 .mu.g/day to about 10 .mu.g/day. [0575] 129. A
sustained release biodegradable intracanalicular insert comprising
[0576] a hydrogel comprising a polymer network, the polymer network
comprising [0577] one or more crosslinked multi-arm polymer units
comprising about 300 .mu.g 4a20K PEG units and [0578] cross-linking
units comprising fluorescein-conjugated trilysine amide units,
and
[0579] and cyclosporine in an amount of about 360 .mu.g, [0580] in
the form of a fiber that has an average length of about 2.5 mm to
about 2.9 mm and an [0581] average diameter of not more than 0.62
mm in its dried state. [0582] 130. A sustained release
biodegradable intracanalicular insert comprising [0583] a hydrogel
comprising a polymer network obtained by reacting 4a20kPEG-SG with
fluorescein-conjugated trilysine in a molar ratio of about 1:1
[0584] and cyclosporine in an amount of about 360 .mu.g, [0585] in
the form of a fiber that has an average length of about 2.5 mm to
about 2.9 mm and an average diameter of not more than 0.62 mm in
its dried state. [0586] 131. A sustained release biodegradable
intracanalicular insert comprising [0587] a hydrogel comprising a
polymer network obtained by reacting 4a20kPEG-SAP with
fluorescein-conjugated trilysine in a molar ratio of about 1:1
[0588] and cyclosporine in an amount of about 360 .mu.g, [0589] in
the form of a fiber that has an average length of about 2.5 mm to
about 2.9 mm and an average diameter of not more than 0.62 mm in
its dried state. [0590] 132. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 1 to 131, wherein
the hydrogel comprises a polymer network which is semi-crystalline
in the dry state at or below room temperature, and amorphous in the
wet state. [0591] 133. The sustained release biodegradable
intracanalicular insert of any one of Embodiments 1 to 132, wherein
the insert has undergone wet or dry stretching during manufacture,
and wherein the insert in the stretched form is dimensionally
stable when in the dry state at or below room temperature. [0592]
134. A method of treating or preventing an ocular disease in a
subject in need thereof, the method comprising inserting into the
canaliculus of the subject a first sustained release biodegradable
intracanalicular insert comprising a hydrogel and a cyclosporine
according to any one of Embodiments 1 to 132. [0593] 135. The
method of Embodiment 134, wherein said first insert is left to
remain in the canaliculus until complete disintegration. [0594]
136. The method of Embodiment 134 or 135, wherein said first insert
is designed to disintegrate in the canaliculus within about 3 to
about 4 months after insertion. [0595] 137. The method of any one
of Embodiments 134 to 136, wherein a second insert is inserted
after at least 2 months without prior removal of said first insert.
[0596] 138. A method of treating dry eye disease in a subject, the
method comprising the steps of: [0597] (a) inserting a first
biodegradable insert into a first canaliculus of a first eye of the
subject, wherein the insert comprises: [0598] (1) a hydrogel;
[0599] (2) from about 100 .mu.g to about 800 .mu.g cyclosporine
dispersed in the hydrogel; [0600] (3) wherein the cyclosporine
releases from the insert over a period of at least about 2-months
from the date of inserting the first insert in the subject, at an
average rate of about 0.1 .mu.g/day to about 10 .mu.g/day; and
[0601] (b) after at least about 2-months from the date of inserting
the first insert, inserting a second insert into the first
canaliculus of the first eye in the subject, wherein the second
insert is substantially similar to the first insert. [0602] 139.
The method of Embodiment 138, wherein said first insert is removed
prior to complete disintegration. [0603] 140. The method of
Embodiment 139, wherein said first insert is removed prior to
complete disintegration and a second insert is inserted to replace
the removed first insert. [0604] 141. The method of any one of
Embodiments 138 to 140, wherein said first insert is designed to
disintegrate in the canaliculus within about 2 to about 3 months
after insertion. [0605] 142. The method of any one of Embodiments
134 to 141, wherein said first insert is left to remain in the
canaliculus until complete disintegration. [0606] 143. The method
of any one of Embodiments 134 to 142, wherein a second insert is
inserted after at least 2 months without prior removal of said
first insert. [0607] 144. The method of any one of Embodiments 134
to 142, wherein said first insert is removed prior to complete
disintegration and a second insert is inserted to replace the
removed first insert. [0608] 145. The method of any one of
Embodiments 134 to 142, wherein said first insert is designed to
disintegrate in the canaliculus within about 2 to about 3 months
after insertion and wherein said first insert is removed within 2
months after insertion. [0609] 146. The method of any one of
Embodiments 134 to 145, wherein the dose per eye administered once
for a treatment period of at least 2 months is from about 300 .mu.g
to about 400 .mu.g of the cyclosporine. [0610] 147. The method of
any one of Embodiments 134 to 146, wherein the ocular disease is a
disorder of the tear film and ocular surface. [0611] 148. The
method of any one of Embodiments 134 to 146, wherein the ocular
disease is dry eye disease. [0612] 149. The method of any one of
Embodiments 134 to 146, wherein the ocular disease is associated
with one or more conditions selected from the group consisting of
burning sensation, itching, redness, singing, pain, foreign body
sensation, visual disturbances, inflammation of the lacrimal gland,
inflammation of the ocular surface, T-cell-mediated inflammation,
presence of conjunctival T-cells in the tears and elevated levels
of inflammatory cytokines in the tears. [0613] 150. The method of
any one of Embodiments 134 to 149, wherein the treatment is
effective in improving tear production as measured by Schirmer's
tear test in a subject with a Schirmer's score of less than 10 mm
prior to insertion of the insert. [0614] 151. The method of any one
of Embodiments 134 to 150, wherein the treatment is effective in
reducing eye dryness symptoms as determined by one or more
assessments selected from the group consisting of rating of the
severity of symptoms of eye dryness on a visual analogue scale,
rating of the frequency of symptoms of eye dryness on a visual
analogue scale, determination of tear film break up time, Corneal
Fluorescein Staining, Conjunctival Lissamine Green Staining, best
corrected visual acuity, determination of ocular surface disease
index and standard patient evaluation of eye dryness. [0615] 152.
The method of any one of Embodiments 134 to 151, wherein the dose
per eye administered once for the treatment period is contained in
one insert. [0616] 153. The method of any one of Embodiments 134 to
151, wherein the dose per eye administered once for the treatment
period is contained in two inserts. [0617] 154. The method of any
one of Embodiments 134 to 153, wherein the insert is inserted into
the lower canaliculus. [0618] 155. The method of any one of
Embodiments 134 to 154, wherein the treatment period is at least 1
month, at least 2 months or at least 3 months. [0619] 156. A method
of treating dry eye disease in a subject in need thereof, the
method comprising inserting to the canaliculus of a subject a
sustained release biodegradable intracanalicular insert comprising
a hydrogel and cyclosporine, wherein punctal occlusion and
cyclosporine release to the eye provide a synergistic effect.
[0620] 157. The method of Embodiment 156, wherein the synergistic
effect consists in a higher bioavailability of the cyclosporine
when compared to administration of eye drops containing
cyclosporine designed to providing the same daily release of
cyclosporine. [0621] 158. The method of Embodiment 157, wherein the
higher bioavailability is determined by the amount of cyclosporine
released to the tear fluid as calculated based on cyclosporine tear
fluid concentration over time. [0622] 159. A method of
manufacturing a sustained release biodegradable intracanalicular
insert comprising a hydrogel and cyclosporine according to any one
of Embodiments 1 to 133, the method comprising the steps of [0623]
a) preparing a precursor mixture containing hydrogel precursors and
cyclosporine particles dispersed in the precursor mixture, [0624]
b) shaping the precursor mixture and allowing the hydrogel
precursors to cross-link to form a polymer network and to obtain a
shaped hydrogel mixture comprising the polymer network, and [0625]
c) drying the hydrogel mixture to provide the insert. [0626] 160.
The method of Embodiment 159, wherein the cyclosporine particles
are micronized particles homogeneously dispersed within the
precursor mixture. [0627] 161. The method of Embodiment 159 or 160,
wherein in step a) the precursor mixture is prepared by mixing an
electrophilic group-containing multi-arm-polymer precursor with a
nucleophilic group-containing cross-linking agent in a buffered
aqueous solution in the presence of micronized cyclosporine
particles. [0628] 162. The method of Embodiment 161, wherein in
step a) the electrophilic group-containing multi-arm-polymer
precursor is provided in a buffered aqueous precursor solution and
the nucleophilic group-containing cross-linking agent is provided
in a buffered aqueous precursor suspension comprising the
micronized cyclosporine particles. [0629] 163. The method of
Embodiment 161 or 162, wherein in step a) the buffered aqueous
precursor solution is prepared by dissolving the multi-arm-polymer
precursor in an aqueous buffer solution and is then mixed with the
buffered aqueous precursor suspension comprising the nucleophilic
group-containing cross-linking agent and micronized cyclosporine
particles within 60 minutes. [0630] 164. The method of any one of
Embodiments 159 to 163, wherein in step a) the precursor mixture
containing cyclosporine particles is degassed under vacuum after
mixing its component. [0631] 165. The method of any one of
Embodiments 159 to 164, comprising reacting 4a20kPEG-SAP with
fluorescein-conjugated trilysine in a weight ratio ranging from
about 30:1 to about 50:1. [0632] 166. The method of any one of
Embodiments 159 to 164, comprising reacting 4a20kPEG-SG with
fluorescein-conjugated trilysine in a weight ratio ranging from
about 30:1 to about 50:1. [0633] 167. The method of any one of
Embodiments 159 to 166, wherein in step b) the shaping of the
precursor mixture consists of filling the precursor mixture into a
mold or tubing prior to complete cross-linking in order to provide
the desired final shape of the hydrogel mixture and allowing the
hydrogel precursors to cross-link. [0634] 168. The method of any
one of Embodiments 159 to 167, wherein in step b) the precursor
mixture is filled into a fine diameter tubing in order to prepare a
hydrogel mixture fiber. [0635] 169. The method of Embodiment 168,
wherein the inside of the tubing has a round geometry. [0636] 170.
The method of Embodiment 169, wherein the inside of the tubing has
a round geometry with an inner diameter of about 2.0 mm. [0637]
171. The method of Embodiment 169, wherein the inside of the tubing
has a non-round geometry. [0638] 172. The method of any one of
Embodiments 159 to 171, wherein the method further comprises
stretching the hydrogel mixture fiber. [0639] 173. The method of
Embodiment 172, wherein the stretching is performed prior to or
after drying the hydrogel mixture. [0640] 174. The method of
Embodiment 172 or 173, wherein the fiber is stretched by a stretch
factor of about 1 to about 4.5. [0641] 175. A sustained release
biodegradable intracanalicular insert obtainable by the method of
any one of Embodiments 159 to 174. [0642] 176. A method of
imparting shape memory to a hydrogel mixture fiber comprising
cyclosporine particles dispersed in the hydrogel by stretching the
hydrogel mixture fiber in the longitudinal direction. [0643] 177.
Use of a sustained release biodegradable intracanalicular insert
comprising a hydrogel and cyclosporine according to any one of
embodiments 1 to 133 in the preparation of a medicament for the
treatment of an ocular disease in a subject in need thereof
according to any one of embodiments 134 to 158. [0644] 178. A
sustained release biodegradable intracanalicular insert comprising
a hydrogel and cyclosporine according to any one of embodiments 1
to 133 for use in the treatment of an ocular disease in a subject
in need thereof according to any one of embodiments 134 to 158.
[0645] 179. A method of increasing tear production as measured by
Schirmer's tear test in a subject with a Schirmer's score of less
than 10 mm prior to insertion of an intracanalicular insert, the
method comprising administering to the subject the sustained
release biodegradable intracanalicular insert comprising a hydrogel
and cyclosporine according to any one of embodiments 1 to 133.
[0646] 180. The method of embodiment 179, wherein the Schirmer's
score increases by at least 2 mm at 6 weeks after insertion. [0647]
181. The method of embodiment 180, wherein the Schirmer's score
increases by at least 3 mm at 12 weeks after insertion. [0648] 182.
A method of reducing eye dryness symptoms as determined by one or
more assessments selected from the group consisting of rating of
the severity of symptoms of eye dryness on a visual analogue scale,
rating of the frequency of symptoms of eye dryness on a visual
analogue scale, determination of tear film break up time, Corneal
Fluorescein Staining, Conjunctival Lissamine Green Staining, best
corrected visual acuity, determination of ocular surface disease
index OSDI, and standard patient evaluation of eye dryness SPEED,
the method comprising administering to the subject the sustained
release biodegradable intracanalicular insert comprising a hydrogel
and cyclosporine according to any one of embodiments 1 to 133.
[0649] 183. The method of claim 182, wherein the total Corneal
Fluorescein Staining value tCFS decreases by at least 1.5 at 6
weeks after insertion. [0650] 184. The method of claim 183, wherein
the total Corneal Fluorescein Staining value tCFS decreases by at
least 3 at 12 weeks after insertion. [0651] 185. The method of any
one of claims 182 to 184, wherein the rating of the severity of
symptoms of eye dryness on a visual analogue scale decreases by at
least 10 at 2 weeks after insertion. [0652] 186. The method of
claim 185, wherein the rating of the severity of symptoms of eye
dryness on a visual analogue scale decreases by at least 15 at 6
weeks after insertion.
* * * * *