AU2011322255A1

AU2011322255A1 - Inflammatory disease

Info

Publication number: AU2011322255A1
Application number: AU2011322255A
Authority: AU
Inventors: Robin Mark Bannister; John Brew; Wilson Capaross-Wanderley; Olga Pleguezuelos Mateo; Gregory Alan Stoloff
Original assignee: Infirst Healthcare Ltd
Current assignee: Infirst Healthcare Ltd
Priority date: 2010-10-29
Filing date: 2011-10-31
Publication date: 2013-05-23
Also published as: SG189551A1; RU2013124514A; EP2632431A1; WO2012056251A1; GB2487808A; BR112013010441A2; CN103282021A; MX2013004817A; GB201113728D0; JP2013544802A; CA2816564A1; GB201018289D0

Abstract

The invention relates to the treatment of inflammatory diseases, and especially Th-1 mediated inflammatory diseases. In particular, the invention relates to the treatment of Th-1 mediated inflammatory diseases using a range of compositions, and to the use of these compositions in methods of treatment. The invention extends to adjuvants, for use in treating a wide variety of medical conditions. The invention also provides pharmaceutical compositions and medicaments comprising the adjuvant, and to uses of the adjuvant in methods of treatment and for eliciting an immune response.

Description

WO 2012/056251 PCT/GB2011/052115 INFLAMMATORY DISEASE The present invention relates to the treatment of inflammatory diseases, and especially Th-1 mediated inflammatory diseases. In particular, the invention relates to the treatment of Th-1 mediated inflammatory diseases using a range of compositions, and 5 to the use of these compositions in methods of treatment. The invention extends to adjuvants, and in particular to adjuvants for use in treating a wide variety of medical conditions. The invention also provides pharmaceutical compositions and medicaments comprising the adjuvant, and to uses of the adjuvant in methods of treatment and for eliciting an immune response. 10 The defence against disease is critical for the survival of all animals, and the mechanism employed for this purpose is the animal immune system. The immune system is complex, and involves two main divisions, (i) innate immunity, and (ii) adaptive immunity. The innate immune system includes the cells and mechanisms that defend 15 the host from infection by invading organisms, in a non-specific manner. Leukocytes, which are involved with the innate system, include inter alia phagocytic cells, such as macrophages, neutrophils and dendritic cells. The innate system is fully functional before a pathogen enters the host. 20 In contrast, the adaptive system is only initiated after the pathogen has entered the host, at which point it develops a defence specific to that pathogen. The cells of the adaptive immune system are called lymphocytes, the two main categories of which are B cells and T Cells. B cells are involved in the creation of neutralising antibodies that circulate in blood plasma and lymph and form part of the humoral immune response. T cells 25 play a role in both the humoral immune response and in cell-mediated immunity. There are several subsets of activator or effector T cells, including cytotoxic T cells (CD8+) and "helper" T cells (CD4+), of which there are two main types known as Type 1 helper T cells (Th1) and Type 2 helper T cell (Th2). 30 Th1 cells promote a cell-mediated adaptive immune response, which involves the activation of macrophages and stimulates the release of various cytokines, such as IFNy, TNF-oc and IL-12, in response to an antigen. These cytokines influence the WO 2012/056251 PCT/GB2011/052115 -2 function of other cells in the adaptive and innate immune responses, and result in the destruction of micro-organisms. Generally, Th1 responses are more effective against intracellular pathogens, such as viruses and bacteria present inside host cells. A Th2 response, however, is characterised by the release of IL-4, which results in the 5 activation of B cells to make neutralising antibodies, which lead the humoral immunity. Th2 responses are more effective against extracellular pathogens, such as parasites and toxins located outside host cells. Accordingly, the humoral and cell-mediated responses provide quite different mechanisms against an invading pathogen. 10 Interleukin-10 (L-10), also known as human cytokine synthesis inhibitory factor (CSIF), is an anti-inflammatory cytokine. It is produced primarily by monocytes and, to a lesser extent, by lymphocytes, and has pleiotropic effects in immunoregulation and inflammation. IL-10 down-regulates the expression of Th1 cytokines (such as IFNy, TNF-oc and IL-12), MHC class II antigens, and co-stimulatory molecules on 15 macrophages. It also enhances B cell survival, proliferation, and antibody production. Furthermore, IL-10 can block NF-xB activity, and is involved in the regulation of the JAK-STAT signaling pathway. Knockout studies in mice have suggested the function of IL-10 as an essential immunoregulator in the intestinal tract, and patients with Crohn's disease react favorably towards treatment with bacteria producing recombinant 20 IL-10, showing the importance of this cytokine for counteracting excessive immunity in the human body. IL-10 is a validated target in inflammatory disease, and has been shown to be essential for immunotolerance and the control of Thi immunity (O'Garra et al., 2008, Immunol. 25 Rev., 223:114-31). Systemic administration of exogenous IL-10 in early clinical trials showed some initial promise in the treatment of various diseases, including rheumatoid arthritis, Crohn's disease, psoriasis and cystic fibrosis. However, problems associated with these early trials were that systemically administered exogenous IL-10 did not dampen exaggerated Thi responses as predicted, possibly because tissue levels of IL-10 30 were too low (the half-life of IL-10 is short), or because IL-10 was not presented in the correct manner. Hence, concentrations of IFNy, TNF-oc and IL-12 actually increased to deleterious levels. It will be appreciated that these cytokines are pro-inflammatory.

WO 2012/056251 PCT/GB2011/052115 -3 Furthermore, a significant side effect of administering too much exogenous IL-10 is that it actually suppresses the immune system, rather than positively modulating it, and so results in serious immune-related problems. It will be appreciated that IL-10, IL-4 and TGF-p are anti-inflammatory. 5 In view of these problems, there is, therefore, clearly a need in the art for improved medicaments for use in the treatment of Th1 -mediated diseases, and especially Th1 mediated inflammatory disorders, which do not suffer the immune-related problems observed in previous IL-10 trials. The inventors investigated, using in vivo mouse 10 studies, the effects of non-steroidal anti-inflammatory drugs (NSAID), such as ibuprofen, on mice that had been previously challenged with influenza virus. The inventors formulated ibuprofen in combination with a highly lipophilic pharmaceutically acceptable vehicle, or adjuvant, which was then orally administered to challenged test mice. They observed that ibuprofen administered orally in an oily 15 formulation (i.e. the adjuvant) resulted in surprisingly positive effects on the percentage survival rate compared to the control mice which had been administered with just the oily vehicle or just ibuprofen (not in oil). The inventors also determined with in vivo assays that the concentration of IL-10 in the lungs of the surviving animals dramatically increased in mice administered with the oily ibuprofen composition. 20 Hence, in a first aspect, there is provided a pharmaceutical composition comprising a therapeutically effective amount of a compound which is capable of increasing interleukin- 10 (IL- 10) production, and a pharmaceutically acceptable vehicle comprising a lipid and an alcohol, for use in treating a Thi-mediated disease, wherein the IL-10 is 25 endogenously produced by Th2 cells, dendritic cells and/or macrophages. In a second aspect of the invention, there is provided a method of preventing, treating and/or ameliorating a Thi-mediated disease, the method comprising administering, to a subject in need of such treatment, a pharmaceutical composition comprising a 30 therapeutically effective amount of a compound which is capable of increasing interleukin- 10 (IL- 10) production, and a pharmaceutically acceptable vehicle comprising WO 2012/056251 PCT/GB2011/052115 -4 a lipid and an alcohol, wherein the IL-10 is endogenously produced by Th2 cells, dendritic cells and/or macrophages. In a third aspect, there is provided use of a pharmaceutical composition for treating a 5 Th1-mediated disease, the composition comprising a therapeutically effective amount of a compound which is capable of inducing endogenous production of interleukin- 10 ([L-10) by Th2 cells, dendritic cells and/or macrophages and a pharmaceutically acceptable vehicle comprising a lipid and an alcohol. 10 Surprisingly, as shown in Figure 1, when ibuprofen is administered orally in a lipophilic formulation (e.g. at least 30% w/w lipid), or the adjuvant of the invention, it is shown to be very effective in the treatment of influenza-induced respiratory collapse in mice. Indeed, application of a single dose of the pharmaceutical composition of the invention converted the 80% mortality model to an astounding 80% survival outcome, and this 15 was totally unexpected. Although the inventors do not wish to be bound by any theory, they believe that an explanation for this surprising observation may be due to the lipophilicity of NSAIDs, such as ibuprofen (i.e. log P 3.5), which, when delivered in an oily formulation having a high lipid content (e.g. at least 30% (w/w) lipid), results in them being rapidly absorbed into the systemic circulation via the lymphatic system. 20 When a drug/lipid formulation is swallowed, the lipids are mixed with bile in the stomach, containing bile salts, and form complexes called micelles or chylomicrons, which are large lipoprotein particles that consist of triglycerides, phospholipids, cholesterol and proteins, and the NSAID. 25 The resultant oil/drug/bile salt complex (i.e. micelles or chylomicron) may then be absorbed by the proximal gut into the enteric lymphatic system. These micelles/chylomicrons, carrying the compound which stimulates IL-10 production, are believed to be transported via the gut lymphatic system to the central venous vasculature, and then rapidly to the heart, which pumps the active compound-rich 30 venous blood to the lung. As a result, the drug is delivered in high concentrations in oxygenated blood directly to the lung increasing its bioavailability.

WO 2012/056251 PCT/GB2011/052115 -5 The inventors believe that lymphatic absorption of the active compound (e.g. ibuprofen) may be acting as a passive system of distribution of the drug directly to the lung, exposing the lung to high concentrations of the compound. The inventors believe that this delivery mechanism does not occur when using standard oral formulations, 5 which contain no, or only low levels of lipid, which are instead absorbed via the hepatic portal vein, with liver-regulated venous absorption, which releases the drug into systemic circulation relatively slowly. Accordingly, the inventors believe that the high concentration of lipids in the pharmaceutical vehicle used in the composition of the first aspect may be the reason for the efficacy of the orally-administered ibuprofen in 10 the influenza-induced respiratory collapse assay in mice, as described in the Examples. As shown in Figure 2, administration of the pharmaceutical composition of the invention results in a dramatic increase in the production of endogenous IL-10 in the lungs of influenza-challenged mice, and this was totally unexpected. Clearly, when 15 compared to the concentrations of IL-10 that were produced in the control mice (i.e. animals that had been administered with just the oily vehicle or just ibuprofen and no oil), the IL-10 concentrations produced in animals administered with the active agent in lipid were much more than additive, suggesting that a synergistic effect has occurred. 20 As described in Example 4, and as shown in Figures 5-7, the inventors have demonstrated that NSAIDs (such as ibuprofen), when they are formulated in an oil and alcohol (e.g. ethanol) adjuvant, activate endogenous IL-10 production from macrophages. Thus, it is preferred that the compositions of the invention are adapted, in use, to stimulate endogenous production of IL-10 from dendritic cells and/or 25 macrophages. One advantage of the compositions of the invention is that they allow certain active compounds (i.e. drugs) to be formulated in lipid and taken orally such that they are preferentially loaded into macrophages and dendritic cells. Numerous disease conditions are believed to be associated with low levels of IL-10 (i.e. hypo-IL 10 disorders), or in situations where an increase in IL-10 concentration is either too 30 slow or insufficient, and any of these conditions may be treated in accordance with the invention. Example 5 describes the effects of the compositions of the invention in an anti-collagen antibody induced arthritis (ACAIA) murine model. Thus, the Thi- WO 2012/056251 PCT/GB2011/052115 -6 mediated disease, which may be treated, may be a Th1 -mediated inflammatory disease, and preferably systemic inflammatory disease. The composition of the invention therefore may be an anti-inflammatory pharmaceutical composition. 5 The disease to be treated may be selected from a group of Th1-mediated diseases consisting of rheumatoid arthritis (RA); psoriatic arthritis; psoriasis; inflammatory bowel syndrome (IBD); Crohn's disease; ulcerative colitis; multiple sclerosis (MS); flu, including pandemic flu; respiratory disorders, for example those caused by viruses, such as respiratory syncytial virus (RSV); cystic fibrosis (CF); herpes, including genital 10 herpes; asthma and allergies; sepsis and septic shock; bacterial pneumonia; bacterial meningitis; dengue hemorrhagic fever; diabetes Type I; endometriosis; prostatitis; uveitis; uterine ripening; alopecia areata; ankylosing spondylitis; coeliac disease; dermatomyositis; diabetes mellitus Type 1; Goodpasture's syndrome; Graves' disease; Guillain-Barr6 syndrome; juvenile idiopathic arthritis; Hashimoto's thyroiditis; 15 idiopathic thrombocytopenic purpura; Lupus erythematosus; mixed connective tissue disease; myasthenia gravis; narcolepsy; osteoarthritis; pemphigus vulgaris; pernicious anaemia; polymyositis; primary biliary cirrhosis; relapsing polychondritis; Sj6gren's syndrome; temporal arteritis; vasculitis; Wegener's granulumatosis; and age-related macular degeneration. 20 The Th1-mediated disease may be virally, bacterially or chemically (e.g. environmentally) induced. For example, a virus causing the Th1-mediated disease may cause a chronic or acute infection, which may cause a respiratory disorder. Suitably, the virus causing the Th1 -mediated disease may be Influenza. 25 Preferably, the Th1-mediated disease, which may be treated, is systemic inflammatory disease, for example inflammatory bowel syndrome (BD), rheumatoid arthritis (RA) or cystic fibrosis (CF). The Th1 -mediated disease, which may be treated, is preferably IBD. 30 The inventors carried out investigations on a number of different compounds that can induce IL-10 production, as they were aware that IL-10 production is a characteristic WO 2012/056251 PCT/GB2011/052115 -7 that indicates a switch from a Thi to a Th2 response, and that such compounds could be used to treat Thi-mediated diseases. They have demonstrated that inducing the switch from a Thi to a Th2 response by up-regulating IL-10 production can be used to help treat Thi-mediated hyper-inflammation. Indeed, Figure 3 clearly shows that 5 administration of the composition of the invention not only increases IL-10 production, it also results in increased IL-4 production, proving that the switch from a Thi to a Th2 response has been induced. Advantageously, by stimulating a Th2 response, by inducing the endogenous release of IL-10 of Th2 cells, macrophages and/or dendritic cells, B cells are activated, which produce neutralising antibodies, 10 which lead the humoral immunity. It will be appreciated that Th2 responses are much more effective against extracellular pathogens, such as parasites and toxins located outside host cells, than Thi responses. By way of example, Thi-mediated hyper-inflammation occurs during viral infections 15 (e.g. influenza, as demonstrated in the Examples), and so the inventors believe that endogenously producing IL-10 by the Th2 cells, macrophages and/or dendritic cells upon administration of the composition to the subject could be used to treat a respiratory collapse caused by a viral infection. It is known that some viruses, such as Herpes Simplex Virus (HSV), maintain their presence in the body by stimulating Thi 20 immunity, and that therefore, triggering a switch to Th2 immunity would help treat herpes infections by allowing the body to attack the virus through natural killer cell immunity. The inventors are of the view that IL-10 is a paracrine cytokine, and that, therefore, the 25 compound used in the first, second and third aspects of the invention can be effectively used to increase endogenous IL-10 production in a paracrine manner. It will be appreciated that paracrine signalling can be a form of cell signalling in which the target cell is near or local to the signal-releasing cell. Thus, IL-10 can control the immune response at sites of inflammation in tandem with cell-cell interactions. 30 The compound, which is capable of increasing endogenous IL-10 production, may be recognised by Th2 cells, dendritic cells and/or macrophages. Preferably, however, the WO 2012/056251 PCT/GB2011/052115 compound, which is capable of increasing endogenous IL- 10 production, is recognised by dendritic cells and/or macrophages. Th2 cells, dendritic cells and/or macrophages may phagocytise the compound (such as a lipid/drug chylomicron), react with pathways in each of these cell types, and thereby endogenously produce IL-10. Preferably, 5 therefore, the IL-10 is produced by Th2 cells, dendritic cells and/or macrophages, which are immuno-competent. Advantageously, in contrast to producing IL-1 0 by non immune cells, which causes an imbalance in the immune system leading to infections and, in some cases cancer, endogenous production of IL-10 by immuno-competent Th2 cells, dendritic cells and/or macrophages, ensures that the immune system remains 10 balanced, thereby avoiding infection. Hence, the immune system is capable of regulating itself naturally, thereby reducing the risk of infections and cancer. As shown in Figures 4-6, the levels of IL-10 generated due to the regulatory process and feedback loops may modulate (e.g. decrease) Th1 15 cytokine concentration, such as IFNy, TNF-oc and IL-12, but not suppress their production completely. This may be important because these Th1 cytokines are needed to protect the body from infection. Thus, by stimulating production of IL-10 endogenously, it is possible to overcome the significant immune-related problems that are observed when the cytokine is added exogenously, resulting in over-production of 20 IFNy, TNF-oc and IL-12. The compound which is capable of inducing endogenous production of interleukin- 10 (IL-10) by Th2 cells, dendritic cells and/or macrophages may be a non-steroidal anti inflammatory drug (NSAID). The NSAID may be a propionic acid derivative, an acetic 25 acid derivative, an enolic acid derivative, a fenamic acid derivative, or a selective- or non-selective cyclo-oxygenase (COX) inhibitor. The NSAID may be a profen. Examples of suitable propionic acid NSAID derivatives may include Ibuprofen; Naproxen; Fenoprofen; Ketoprofen; Flurbiprofen; or Oxaprozin. Examples of suitable 30 acetic acid NSAID derivatives may include Aceclofenac; Acemetacin; Actarit; Alcofenac; Amfenac; Clometacin; Diclofenac; Etodolac; Felbinac; Fenclofenac; Indometacin; Ketorolac; Metiazinic acid; Mofezolac; Naproxen; Oxametacin; Sulindac; WO 2012/056251 PCT/GB2011/052115 -9 or Zomepirac. Examples of suitable enolic acid NSAID derivatives may include Piroxicam; Meloxicam; Tenoxicam; Droxicam; Lornoxicam; or Isoxicam. Examples of Fenamic acid NSAID derivatives may include Mefenamic acid; Meclofenamic acid; Flufenamic acid; or Tolfenamic acid. 5 In embodiments where the NSAID is a cyclooxygenase (COX) inhibitor, it may be either a cyclooxygenase 1 (COX 1) inhibitor or a cyclooxygenase 2 (COX 2) inhibitor. Examples of suitable COX inhibitors may include Ibuprofen; Celecoxib; Etoricoxib; Lumiracoxib; Meloxicam; Rofecoxib; or Valdecoxib. 10 The NSAID may be selected from a group consisting of: Alminoprofen; Benoxaprofen; Dexketoprofen; Flurbiprofen; Ibuprofen; Indoprofen; Ketoprofen; Loxoprofen; Pranoprofen; Protizinic acid; Suprofen; Aceclofenac; Acemetacin; Actarit; Alcofenac; Amfenac; Clometacin; Diclofenac; Etodolac; Felbinac; Fenclofenac; Indometacin; 15 Ketorolac; Metiazinic acid; Mofezolac; Naproxen; Oxametacin; Sulindac; Zomepirac; Celecoxib; Etoricoxib; Lumiracoxib; Meloxicam; Rofecoxib; Valdecoxib; Aloxipirin; Aminophenazone; Antraphenine; Aspirin; Azapropazone; Benorilate; Benzydamine; Butibufen; Chlorthenoxacin; Choline Salicylate; Diflunisal; Emorfazone; Epirizole; Feclobuzone; Fenbufen; Glafenine; Hydroxylethyl salicylate; Lactyl phenetidin; 20 Mefenamic acid; Metamizole; Mofebutazone; Nabumetone; Nifenazone; Niflumic acid; Phenacetin; Pipebuzone; Propyphenazone; Proquazone; Salicylamide; Salsalate; Tiaramide; Tinoridine; and Tolfenamic acid. A preferred NSAID may be Alminoprofen, Benoxaprofen, Dexketoprofen, 25 Flurbiprofen, Ibuprofen, Indoprofen, Ketoprofen, Loxoprofen, Pranoprofen protizininic acid, or Suprofen. Preferably, the NSAID is Ibuprofen. The NSAID may be used in the form of a pharmaceutically acceptable salt, solvate, or solvate of a salt, e.g. the hydrochloride. 30 WO 2012/056251 PCT/GB2011/052115 - 10 NSAIDs described herein may be provided as racemates, or as individual enantiomers, including the R- or S-enantiomer. Thus, the NSAID may comprise R-ibuprofen or S ibuprofen, or a combination thereof. 5 In one embodiment, S-ibuprofen may be used for the treatment of immune-mediated diseases which involve pain that is responsive to COX inhibitors, such as those described herein (e.g. Celecoxib; Etoricoxib; Lumiracoxib; Meloxicam; Rofecoxib; or Valdecoxib). Examples of such diseases may include arthritis, rheumatoid arthritis, osteoarthritis, psoriatic arthritis and endometriosis. 10 In another embodiment, R-ibuprofen may be used for the treatment of immune mediated diseases which do not involve pain that is responsive to COX inhibitors. Examples of such diseases ma include psoriasis, inflammatory bowel disease, multiple sclerosis, pandemic flu, respiratory syncytial virus, cystic fibrosis, genital herpes, asthma, 15 bacterial pneumonia, bacterial meningitis, dengue hemorrhagic fever, type I diabetes, prostatitis and pre-term labour. The pharmaceutical vehicle may comprise at least about 10%, 20%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95% or at least about 99% 20 (w/w) lipid. The vehicle may comprise between about 35% and 99% (w/w) lipid, or between about 45% and 99% (w/w) lipid, or between about 50% and 99% (w/w) lipid, or between about 60% and 98% (w/w) lipid, or between about 70% and 97% (w/w) lipid, or between about 80% and 96% (w/w) lipid, or between about 85% and 95% (w/w) lipid, or between about 85% and 95% (w/w) lipid, or between about 88% and 25 94% (w/w) lipid, or between about 89% and 93% (w/w) lipid. The pharmaceutical vehicle may comprise a lipid component selected from a group consisting of: an oil or oil-based liquid; a fat; a fatty acid (e.g. oleic acid, stearic acid or palmitic acid etc.), a fatty acid ester, a fatty alcohol, a glyceride (mono-, di- or tri 30 glyceride); a phospholipid; a glycol ester; a sucrose ester; a wax; a glycerol oleate derivative; a medium chain triglyceride; or a mixture thereof. A triglyceride is an ester WO 2012/056251 PCT/GB2011/052115 - 11 derived from glycerol and three fatty acids, and is the main constituent of vegetable oil and animal fats. The term "oil" can refer to a fat that is liquid at normal room temperature, and can be 5 used for any substance that does not mix with water, and which has a greasy feel. The term "fat" can refer to a fat that is solid at normal room temperature. The term "lipid" can therefore refer to a liquid or solid fat, as well as to other related substances. A suitable oil, which may be used as the lipid component in the pharmaceutical vehicle, 10 may be a natural oil or a vegetable oil. Examples of suitable natural oils may be selected from a group consisting of linseed oil; soyabean oil; fractionated coconut oil; mineral oil; triacetin; ethyl oleate; a hydrogenated natural oil; or a mixture thereof. Examples of suitable vegetable oils may be selected from a group consisting of rapeseed oil; olive oil; peanut oil; soybean oil; corn oil; safflower oil; arachis oil; sunflower oil; canola oil; 15 walnut oil; almond oil; avocado oil; castor oil; coconut oil; corn oil; cottonseed oil; rice bran oil; sesame oil; and refined palm oil; or a mixture thereof. Each of these oils is commercially available from a number of sources well recognized by those skilled in the art. 20 The lipid component of the pharmaceutical vehicle may comprise a fatty acid comprising between 8 and 24 carbon atoms, between 10 and 22 carbon atoms, between 14 and 20 atoms, or between 16 and 20 atoms. The lipid may be saturated or unsaturated, for example with one, two, three or more double bonds. The lipid may comprise a fatty acid selected from a group consisting of myristic acid (C 14:0); palmitic 25 acid (C 16:0); palmitoleic acid (C 16:1); stearic acid (C 18:0); oleic acid (C 18:1); linoleic acid (C 18:2); linolenic acid (C 18:3) and arachidic acid (C 20:0); or a mixture thereof. It will be appreciated that the first number provided in the brackets corresponds to the number of carbon atoms in the fatty acid, and that the second number corresponds to the number of double bonds (i.e. unsaturation). 30 The melting point of the oil is largely determined by the degree of saturation/unsaturation. The melting points of oleic acid WO 2012/056251 PCT/GB2011/052115 - 12 (CH 3

(CH

2

)

7

CH=CH(CH

2

)

7 COOH), linoleic acid

(CH

3

(CH

2

)

4

(CH=CHCH

2

)

2

(CH

2

)

6 COOH), and of linolenic acid

(CH

3

CH

2

(CH=CHCH

2

)

3

(CH

2

)

6 COOH), are about 16'C, -5'C and -11'C, respectively. Thus, the melting point of the lipid may be between about -20'C and 20'C, or between 5 about -15'C and 16'C. The lipid may comprise rapeseed oil. Rapeseed oil is derived from Brassica napus, and contains both omega-6 and omega-3 fatty acids in a ratio of about 2:1. However, in the Examples, the inventors found that linseed oil was particularly effective, and so linseed 10 oil may be preferred. Linseed oil, also known as flax seed oil, is a clear to yellowish oil obtained from the dried ripe seeds of the flax plant (Linum usitatissimum, Linaceae). The oil is obtained by cold pressing, sometimes followed by solvent extraction. Linseed oil is a mixture of various triglycerides that differ in terms of their fatty acid constituents. For linseed oil, the constituent fatty acids are of the following types: (i) the saturated 15 acids palmitic acid (about 7%) and stearic acid (3.4-4.6%); (ii) the monounsaturated oleic acid (18.5-22.6%); (iii) the doubly unsaturated linoleic acid (14.2-17%); and (iii) the triply unsaturated omega-3 fatty acid oc-linolenic acid (51.9-55.2%). Linseed oil is also rich in omega-6 fatty acid. The structure of a representative triglyceride found in linseed oil may be represented by formula I: 20 0I 0 0 Thus, the lipid component of the pharmaceutical vehicle may comprise omega 3 25 and/or omega 6 fatty acid. Omega-3 fatty acids are a family of unsaturated fatty acids that have in common a final carbon-carbon double bond in the n-3 position, i.e. the third bond from the methyl end of the fatty acid, and can be represented by formula II.

WO 2012/056251 PCT/GB2011/052115 - 13 0 II Omega-6 fatty acids, on the other hand, are a family of unsaturated fatty acids that have in common a final carbon-carbon double bond in the n-6 position, i.e. the sixth bond, counting from the end opposite the carboxyl group, and can be represented by formula 5 III. 0 Omega-3 and omega-6 fatty acids are derivatives of linolenic acid, the main difference being the number and exact position of the double bonds. Accordingly, omega-3 and 10 omega-6 will have substantially the same melting points as linolenic acid. The vehicle may comprise less than about 90%, 80%, 70%, 65%, 60%, 55%, 50%, 45%, 40%, 35%, 30%, 25%, 20%, 15%, 10%, 5%, or less than about 10% (w/w) alcohol. The vehicle may comprise between about 10% and 90% alcohol (w/w), or between about 10% 15 and 70% (w/w) alcohol, or between about 10% and 60% (w/w) alcohol, or between about 1% and 50% (w/w) alcohol, or between about 2% and 40% (w/w) alcohol, or between about 4% and 30% (w/w) alcohol, or between about 6% and 20% (w/w) alcohol, or between about 8% and 15% (w/w) alcohol. The alcohol may be an aliphatic alcohol. 20 The alcohol may be a C1 20 alcohol, a CI15 alcohol, a C1io alcohol, a C1_5 alcohol, or a C 2 4 alcohol. The alcohol may be menthol, or a sugar alcohol, such as glycerol, sorbitol, erythritol, xylitol, mannitol, isomalt or maltitol. 25 The alcohol may be ethanol, propanol or butanol. In one preferred embodiment, the alcohol is ethanol.

WO 2012/056251 PCT/GB2011/052115 - 14 In one embodiment, the vehicle may comprise between approximately 60% and 95% (w/w) lipid and between about 5% and 40% (w/w) alcohol. In another embodiment, the vehicle may comprise between approximately 80% and 95% (w/w) lipid and between about 5% and 20% (w/w) alcohol. 5 In one embodiment, the vehicle may comprise between approximately 60% and 95% (w/w) oil and between about 5% and 40% (w/w) alcohol. In another embodiment, the vehicle may comprise between approximately 80% and 95% (w/w) lipid and between about 5% and 20% (w/w) alcohol. For example, the vehicle may comprise between 10 approximately 80% and 95% (w/w) olive oil, rapeseed oil or linseed oil, and between approximately 5% and 20% (w/w) ethanol. In another embodiment, the vehicle may comprise between approximately 88% and 92% (w/w) lipid, and between approximately 8% and 12% (w/w) alcohol. For example, the vehicle may comprise between approximately 88% and 92% (w/w) olive oil, rapeseed oil or linseed oil, and 15 between approximately 8% and 12% (w/w) ethanol. In another embodiment, the vehicle may comprise approximately 90% (w/w) lipid, and approximately 10% (w/w) alcohol. For example, the vehicle may comprise approximately 90% (w/w) olive oil, rapeseed oil or linseed oil, and approximately 10% (w/w) ethanol, and optionally water. 20 The inventors believe that water has a tendency to increase the instability of NSAIDs. Thus, in a preferred embodiment, the vehicle is substantially anhydrous. Advantageously, the absence of water in embodiments of the vehicle mean that the stability of the NSAID in the composition is not compromised, thereby providing an improved product. 25 However, in some embodiments, the vehicle may optionally comprise water. The vehicle may comprise less than about 70%, 65%, 60%, 55%, 50%, 45%, 40%, 35%, 30%, 25%, 20%, 15%, 10%, 5%, or less than about 1% (w/w) water. The vehicle may comprise between about 10% and 70% (w/w) water, or between about 10% and 60% 30 (w/w) water, or between about 1% and 50% (w/w) water, or between about 2% and 40% (w/w) water, or between about 4% and 30% (w/w) water, or between about 6% and 20% (w/w) water, or between about 8% and 15% (w/w) water.

WO 2012/056251 PCT/GB2011/052115 - 15 It will be appreciated that the composition may be used to treat a Th1 -mediated disease in a monotherapy (i.e. use of the composition alone). Alternatively, the compositions may be used as an adjunct to, or in combination with, known therapies used in treating 5 Th1-mediated diseases. The composition may have a number of different forms depending, in particular, on the manner in which the composition is to be used. Thus, for example, the composition may be in the form of a powder, tablet, capsule, liquid, ointment, cream, 10 gel, hydrogel, aerosol, spray, micellar solution, transdermal patch, liposome suspension or any other suitable form that may be administered to a person or animal in need of treatment. It will be appreciated that the vehicle for medicaments according to the invention should be one which is well-tolerated by the subject to whom it is given, and preferably enables delivery of the agents across the blood-brain barrier, or the lungs. 15 Compositions comprising the active compound and the lipid and alcohol vehicle (i.e. the adjuvant) may be used in a number of ways. For instance, oral administration may be required in which case the compound may be contained within a composition that may, for example be ingested orally in the form of a tablet, capsule or liquid. 20 Alternatively, the composition may be administered by injection into the blood stream. Injections may be intravenous (bolus or infusion) or subcutaneous (bolus or infusion). Alternatively, the composition comprising the active compound may be administered by inhalation (e.g. intranasally, or by mouth). 25 Compositions may also be formulated for topical use. For instance, ointments may be applied to the skin. Topical application to the skin is particularly useful for treating infections of the skin or as a means of transdermal delivery to other tissues. Preferably, the composition is orally administrable, i.e. for oral administration, as 30 opposed to administration by injection or inhalation etc.

WO 2012/056251 PCT/GB2011/052115 - 16 It will be appreciated that the amount of the active compound that is required is determined by its biological activity and bioavailability, which in turn depends on the mode of administration, the physicochemical properties of the compound and whether the compound is being used as a monotherapy, or in a combined therapy. The 5 frequency of administration will also be influenced by the above-mentioned factors and particularly the half-life of the active compound within the subject being treated. Optimal dosages to be administered may be determined by those skilled in the art, and will vary with the particular active compound in use, the strength of the preparation, 10 the mode of administration, and the advancement of the disease condition. Additional factors depending on the particular subject being treated will result in a need to adjust dosages, including subject age, weight, gender, diet, and time of administration. It will be appreciated that a skilled person will be able to calculate required doses, and 15 optimal concentrations of the active compound at a target tissue, based upon the pharmacokinetics of the active. Known procedures, such as those conventionally employed by the pharmaceutical industry (e.g. in vivo experimentation, clinical trials, etc.), may be used to establish specific formulations of the active compound and precise therapeutic regimes (such as daily doses of the compounds and the frequency of 20 administration). Generally, a daily dose of between 0.001 tg/kg of body weight and 60mg/kg of body weight of the active compound may be used for treating Th1-mediated diseases depending upon which compound is used. Suitably, the daily dose is between 25 0.01 tg/kg of body weight and 40mg/kg of body weight, more suitably between 0.01 tg/kg of body weight and 30mg/kg of body weight or between 0.1 tg/kg and 20 mg/kg body weight, and most suitably between approximately 0.1 pg/kg and 15 mg/kg body weight. 30 Daily doses of the active compound may be given as a single administration (e.g. a single daily oral dosage form). A suitable daily dose may be between 0.07[tg and WO 2012/056251 PCT/GB2011/052115 - 17 3200mg (i.e. assuming a body weight of 70kg), or between 0.70[tg and 1600mg, or between 10mg and 800mg. It is envisaged that the composition may be administered more than once to the subject 5 in need of treatment. The composition may require administration twice or more times during a day. As an example, the composition may be administered as two (or more depending upon the severity of the Th1-mediated disease being treated) daily doses of between 0.07[tg and 3200mg (i.e. assuming a body weight of 70kg). A patient receiving treatment may take a first dose upon waking and then a second dose in the evening (if 10 on a two dose regime) or at 3- or 4-hourly intervals thereafter, and so on. It is envisaged that the composition may be administered every day (more than once if necessary) after the trigger for the Th1 -mediated inflammation. Alternatively, a slow release device may be used to provide optimal doses of 15 compounds according to the invention to a patient without the need to administer repeated doses. The inventors also believe that compositions of the invention may be immobilised on or in a support substrate or matrix forming a lipid-rich formulation, which may be used 20 as a delivery device to treat Th1-mediated disorders. Hence, in a fourth aspect of the invention, there is provided a drug delivery device comprising: (i) a pharmaceutical composition comprising a therapeutically effective 25 amount of a compound which is capable of increasing endogenous interleukin 10 (IL-10) production by Th2 cells, dendritic cells and/or macrophages, and a pharmaceutically acceptable vehicle comprising a lipid and an alcohol; and (ii) a support matrix. 30 The delivery device may be a pessary or a vaginal ring or the like, which may be worn by a subject requiring treatment of a Th1-mediated condition. For example the device WO 2012/056251 PCT/GB2011/052115 - 18 may be used to treat any disease characterised by a drop in IL-10 concentrations. It is known that the concentration of IL-10 decreases in pregnant women, as a result of foetus tolerance, and this initiates labour during child birth. Thus, the delivery device may be used by pregnant women to prevent or delay premature labour. 5 The support matrix may be made of a substrate material which is suitable for supporting the composition therein or thereon. The composition may be immobilised on the matrix. In one embodiment, the matrix may comprise any material capable of melting at, or around, body temperature, such that, over time, the matrix dissolves 10 thereby releasing the composition, which is absorbed by the subject. The support matrix may a suitable gel or wax. For example, conventional materials for vaginal administration may be used, such as glycerol, gelatin, glyco-gelatin, macrogols (polyethylene glycols), natural, synthetic or semi-synthetic hard fats, and fractionated 15 palm kernel oil. Based on their findings that the compositions described herein may be used to increase the levels of endogenous production of IL-10 by Th2 cells, dendritic cells and/or macrophages, and thereby reduce the levels of Thi cytokines, such as TNF-a and IL 20 12, to trigger the Thi to Th2 switch, the inventors believe that these effects of the compounds may be harnessed and used in the manufacture of clinically useful compositions. As shown in Figures 4-6, the inventors hypothesise that NSAIDs, when formulated in oil and alcohol, activate IL-10 production from macrophages. 25 A "therapeutically effective amount" of the active compound is any amount which, when administered to a subject, results in increased levels of IL-10 and IFN-y, and preferably decreased concentrations of TNF-a and IL-12, and thereby provides treatment of a Thi -mediated disease. 30 For example, the therapeutically effective amount of the active compound used may be from about 0.07 jig to about 3200 mg, and preferably from about 0.7 jig to about 1600 WO 2012/056251 PCT/GB2011/052115 - 19 mg. The amount of the active compound is from about 7 jig to about 1200mg, or from about 7 jig to about 800 mg. A "subject" may be a vertebrate, mammal, or domestic animal, and is preferably a 5 human being. Hence, medicaments according to the invention may be used to treat any mammal, for example human, livestock, pets, or may be used in other veterinary applications. A "pharmaceutically acceptable vehicle" as referred to herein can be any combination 10 of compounds known to those skilled in the art to be useful in formulating pharmaceutical compositions, but which comprises a lipid (e.g. at least 30% (w/w) lipid) and an alcohol. In one embodiment, the pharmaceutically acceptable vehicle may be a solid, and the 15 composition may be in the form of a powder or tablet. In addition to the lipid component and alcohol, a solid pharmaceutically acceptable vehicle may comprise one or more substances which may also act as flavouring agents, lubricants, solubilisers, suspending agents, dyes, fillers, glidants, compression aids, inert binders, sweeteners, preservatives, dyes, coatings, or tablet-disintegrating agents. The vehicle may also be an 20 encapsulating material. In powders, the vehicle may be a finely divided solid that is in admixture with the finely divided active agent (i.e. the compound which stimulates endogenous IL-10 production). In tablets, the active agent may be mixed with a vehicle having the necessary compression properties in suitable proportions and compacted in the shape and size desired. Suitable solid vehicles may comprise, for example calcium 25 phosphate, magnesium stearate, talc, sugars, lactose, dextrin, starch, gelatin, cellulose, polyvinylpyrrolidine, low melting waxes and ion exchange resins. In yet another embodiment, the pharmaceutical vehicle may be a liquid, and the pharmaceutical composition may be in the form of a solution. Liquid vehicles are used 30 in preparing solutions, suspensions, emulsions, syrups, elixirs and pressurized compositions. The active compound may be dissolved or suspended in a WO 2012/056251 PCT/GB2011/052115 - 20 pharmaceutically acceptable liquid vehicle such as water, an organic solvent, a mixture of both, or pharmaceutically acceptable oils or fats. In addition to the lipid component, the liquid vehicle may also comprise other suitable pharmaceutical additives such as solubilisers, emulsifiers, buffers, preservatives, sweeteners, flavouring agents, 5 suspending agents, thickening agents, colours, viscosity regulators, stabilizers or osmo regulators. Suitable examples of liquid vehicles for oral administration may include water (partially containing additives as above, e.g. cellulose derivatives, preferably sodium carboxymethyl cellulose solution), alcohols (including monohydric alcohols and polyhydric alcohols, e.g. glycols) and their derivatives, and oils (e.g. fractionated 10 coconut oil and arachis oil). The vehicle can also be an oily ester, such as ethyl oleate or isopropyl myristate. The composition is preferably administered orally in the form of a sterile solution or suspension containing other solutes or suspending agents (for example, enough saline 15 or glucose to make the solution isotonic), bile salts, acacia, gelatin, sorbitan monoleate, polysorbate 80 (oleate esters of sorbitol and its anhydrides copolymerized with ethylene oxide), and the like. However, the composition may or may not comprise a surfactant. Preferably, the 20 composition is not emulsified. Examples of surfactants which may or not be included in the composition include a phospholipid, such as phosphatidylcholine (lecithin) and phosphatidyl ethanolamine; soaps and detergents, including fatty alkali metal, ammonium, and triethanolamine salts, and detergents, including (a) cationic detergents such as, dimethyl dialkyl ammonium halides, and alkyl pyridinium halides; (b) anionic 25 detergents such as alkyl, aryl, and olefin sulfonates, alkyl, olefin, ether, and monoglyceride sulfates, and sulfosuccinates; (c) non-ionic detergents such as fatty amine oxides, fatty acid alkanolamides, and polyoxyethylenepolypropylene copolymers; and (d) amphoteric detergents such as alkyl-b-aminopropionates, and 2-alkyl imidazoline quaternary ammonium salts. Another example of a detergent may include 30 sodium dodecyl sulphate dimethyl sulphoxide. Preferably, the vehicle or adjuvant of the invention does not comprise any of these surfactants.

WO 2012/056251 PCT/GB2011/052115 - 21 Many surfactants have certain safety implications, i.e. many are not GRAS (generally regarded as safe). Therefore, avoiding the use of a surfactant circumvents such safety concerns for the compositions of the invention. In addition, although not wishing to be bound by theory, the inventors hypothesise that exclusion of a surfactant results in 5 improved uptake and bioavailability of the active agent in the subject being treated. The inventors believe that the pharmaceutically acceptable vehicle may preferably comprise at least 30% (w/w) lipid, possibly in the absence of ethanol. 10 Thus, in a fifth aspect, there is provided a pharmaceutical composition comprising a therapeutically effective amount of a compound which is capable of increasing interleukin- 10 (IL- 10) production, and a pharmaceutically acceptable vehicle comprising at least 30% (w/w) lipid, for use in treating a Th1 -mediated disease, wherein the IL-10 is endogenously produced by Th2 cells, dendritic cells and/or macrophages. 15 In a sixth aspect, there is provided a drug delivery device comprising: (i) a pharmaceutical composition comprising a therapeutically effective amount of a compound which is capable of increasing endogenous interleukin-10 (IL-10) production by Th2 cells, dendritic cells and/or 20 macrophages, and a pharmaceutically acceptable vehicle comprising at least 30% (w/w) lipid; and (ii) a support matrix. In a seventh aspect, there is provided a method of preventing, treating and/or 25 ameliorating a Th1-mediated disease, the method comprising administering, to a subject in need of such treatment, a pharmaceutical composition comprising a therapeutically effective amount of a compound which is capable of increasing interleukin-10 (L-10) production, and a pharmaceutically acceptable vehicle comprising at least 30% (w/w) lipid, wherein the IL-10 is endogenously produced by Th2 cells, dendritic cells and/or 30 macrophages.

WO 2012/056251 PCT/GB2011/052115 - 22 In eighth aspect, there is provided use of a pharmaceutical composition for treating a Th1-mediated disease, the composition comprising a therapeutically effective amount of a compound which is capable of inducing endogenous production of interleukin- 10 ([L-10) by Th2 cells, dendritic cells and/or macrophages and a pharmaceutically 5 acceptable vehicle comprising at least 30% (w/w) lipid. Based on the results demonstrating the surprising immunomodulatory effects of the lipid/alcohol vehicle described herein (see Figures 2-6), the inventors believe that they have effectively developed a novel adjuvant, which can be used to enhance the 10 immunomodulatory activity of a wide range of immunogenic compounds. Thus, according to a ninth aspect of the invention, there is provided an oral adjuvant, for use in a pharmaceutical composition comprising an immunogen, wherein the adjuvant comprises a lipid and an alcohol, and stimulates uptake of the immunogen by 15 dendritic cells and/or macrophages such that they modulate immunomodulatory cytokines, and wherein the immunomodulatory activity of the immunogen in the presence of the adjuvant is greater than its immunomodulatory activity in the absence of the adjuvant. 20 It will be appreciated that an adjuvant is a pharmacological or immunological agent, which modifies the effect of other active agents, such as a drug or a vaccine, while having few, if any, direct effects when administered by itself. Adjuvants are frequently included in vaccines to enhance the recipient's immune response to an administered antigen or immunogen, while keeping the administered foreign material to a minimum. 25 Although such immunological adjuvants have traditionally been viewed as substances that aid the immune response to an antigen or immunogen, adjuvants have also evolved as substances that can aid in stabilising formulations of antigens, especially vaccines administered for animal health. 30 The most commonly used adjuvants act by providing a long-lived cache of antigen or immunogen, which counteracts the typical characteristic of rapid clearance and degradation of free antigen. Consideration of which adjuvant to use must take into WO 2012/056251 PCT/GB2011/052115 - 23 account the concomitant negative side-effects of adjuvants, such as undesirable inflammatory outcomes. For example, many patients suffer "flu-like" symptoms or swelling and tenderness at an injection site occurring after a vaccination. Reducing such systemic and local unwanted side-effects, while still providing maximal enhancement of 5 an immune response, is especially important and continues to drive much of the research and development of new, improved adjuvants. The adjuvant of the ninth aspect may be immunostimulatory and/or immunoinhibiting. Advantageously, the adjuvant may be capable of enhancing the immunomodulatory 10 activity of a subject administered with the adjuvant, resulting in the stimulation of the immune system, for treating hypo-immune conditions, such as cancer and immuno suppression, as well as inhibiting the immune system, for treating hyper-immune conditions. Loading immunostimulating drugs (i.e. the immunogen) in macrophages and dendritic cells will promote their phenotype to enhance their capacity to clear 15 cancer cells, bacteria and virus. Advantageously, as shown in the Figures, the oily adjuvant of the ninth aspect displays not only greater efficacy for promoting the immunological activity of an antigen or immunogen (e.g. ibuprofen), but also exhibits improved stability-conferring 20 characteristics on the antigen or immunogen, and does not induce negative side-effects in subjects administered with the adjuvant. The term "oral adjuvant" can mean that it is orally administrable, i.e. for oral administration, as opposed to administration by injection or inhalation etc. 25 According to a tenth aspect of the invention, there is provided a pharmaceutical composition comprising an immunogen and the adjuvant according to the ninth aspect. According to an eleventh aspect, there is provided a pharmaceutical composition 30 according to the tenth aspect, for use in therapy.

WO 2012/056251 PCT/GB2011/052115 - 24 According to a twelfth aspect, there is provided a pharmaceutical composition according to the tenth aspect, for use in treating Th1 -mediated disease, cancer, or a bacterial or viral infection. 5 According to a thirteenth aspect, there is provided a method of eliciting, in a subject, an effective immune response, the method comprising administering, to a subject, an effective amount of the pharmaceutical composition of the tenth aspect. The lipid and alcohol components of the adjuvant may be selected from any of the 10 lipids (oil or fat) or alcohols described herein, in any of the described amounts. For example, the adjuvant may comprise at least about 10%, 20%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95% or at least about 99% (w/w) lipid. The adjuvant may comprise between about 35% and 99% (w/w) lipid, or between about 45% and 99% (w/w) lipid, or between about 50% and 99% (w/w) lipid, or 15 between about 60% and 98% (w/w) lipid, or between about 70% and 97% (w/w) lipid, or between about 80% and 96% (w/w) lipid, or between about 85% and 95% (w/w) lipid, or between about 85% and 95% (w/w) lipid, or between about 88% and 94% (w/w) lipid, or between about 89% and 93% (w/w) lipid. 20 A suitable oil, which may be used as the lipid component in the adjuvant, may be a natural oil or a vegetable oil. Examples of suitable natural oils may be selected from a group consisting of linseed oil; soyabean oil; fractionated coconut oil; mineral oil; triacetin; ethyl oleate; a hydrogenated natural oil; or a mixture thereof. Examples of suitable vegetable oils may be selected from a group consisting of rapeseed oil; olive oil; 25 peanut oil; soybean oil; corn oil; safflower oil; arachis oil; sunflower oil; canola oil; walnut oil; almond oil; avocado oil; castor oil; coconut oil; corn oil; cottonseed oil; rice bran oil; sesame oil; and refined palm oil; or a mixture thereof. In one preferred embodiment, the lipid may comprise linseed oil. 30 The adjuvant may comprise less than about 90%, 80%, 70%, 65%, 60%, 55%, 50%, 45%, 40%, 35%, 30%, 25%, 20%, 15%, 10%, 5%, or less than about 1% (w/w) alcohol. The adjuvant may comprise between about 1% and 90% alcohol (w/w), or between WO 2012/056251 PCT/GB2011/052115 - 25 about 1% and 70% (w/w) alcohol, or between about 10% and 60% (w/w) alcohol, or between about 1% and 50% (w/w) alcohol, or between about 2% and 40% (w/w) alcohol, or between about 4% and 30% (w/w) alcohol, or between about 6% and 20% (w/w) alcohol, or between about 8% and 15% (w/w) alcohol. 5 The alcohol may be an aliphatic alcohol. The alcohol may be a C 1

-

2 0 alcohol, a C1_15 alcohol, a C1_1o alcohol, a C1_5 alcohol, or a C 24 alcohol. The alcohol may be menthol, or a sugar alcohol, such as glycerol, sorbitol, erythritol, xylitol, mannitol, isomalt or maltitol. The alcohol may be ethanol, propanol or butanol. In one preferred 10 embodiment, the alcohol is ethanol. The adjuvant may or may not comprise water. Preferably, the adjuvant is anhydrous. Preferably, the adjuvant does not comprise a hydrophilic surfactant, or any of the surfactants described herein. 15 The adjuvant is capable, in use, of stimulating or inducing the dendritic cells and/or macrophages in a subject treated with the pharmaceutical composition, to take up the immunogen, such that the concentration of immunomodulatory cytokines is modulated. The immunomodulatory cytokine which is modulated may be selected from 20 a group of cytokines including IL- 10; IL4; TNF-c; and IFN-y. As illustrated in Figures 2, 3, 4 and 5, in one embodiment, the adjuvant may stimulate the dendritic cells and/or macrophages in the subject to produce or increase production of an immunomodulatory cytokine. For example, the cytokine which is 25 produced or increased may be IL-10 and/or TNF- o and/or IL-4. As illustrated in Figure 6, in another embodiment, the adjuvant may stimulate the dendritic cells and/or macrophages in the subject to stop or decrease production of an immunomodulatory cytokine. For example, the cytokine for which production is 30 decreased or prevented may be IFN-y.

WO 2012/056251 PCT/GB2011/052115 - 26 The immunogen present in the composition may be a pharmaceutically active agent having a log P value of greater than 2.0 and/or a polar surface area of between about 25 A2 and 70 A2. The immunogen may preferably be a small molecule having a molecular weight of less than 1000 Da. 5 The term "log P value" will be known to the skilled person, and can refer to the ratio of concentrations of a compound (i.e. the immunogen) in the two phases of a mixture of two immiscible solvents at equilibrium. The immunogen may have a log P value which is greater than 3.0, 4.0, 5.0 or 6.0. The immunogen may have a log P value which is less 10 than 7.0, 6.0, 5.0, 4.0 or 3.0. In one embodiment, the immunogen may have a log P value of between 2.0 and 7.0, or between 3.0 and 6.0, or between 3.0 and 5.0. The immunogen may have a log P value of between 2.0 and 4.0, or between 2.1 and 4.0, or between 2.2 and 4.0, or between 2.3 and 4.0. In another embodiment, the immunogen may have a log P value of between 2.5 and 4.0, or between 3.0 and 4.0, or between 3.1 15 and 4.0. In another embodiment, the immunogen may have a log P value of between 3.3 and 4.0, or between 3.5 and 4.0. In yet another embodiment, the immunogen may have a log P value of between 2.0 and 3.0, or between 2.0 and 2.7, or between 2.0 and 2.5. In a further embodiment, the immunogen may have a log P value of between 2.2 and 2.5. 20 The term "polar surface area" will also be known to the skilled person, and can refer to the surface sum over all of the polar atoms in its structure (usually oxygen and nitrogen), also including attached hydrogens. In one embodiment, the immunogen may have a polar surface area of between 35 A2 and 65 A2, or between 40 A2 and 60 A2, or 25 between 45 A2 and 55 A2. In another embodiment, the immunogen may have a polar surface area of between 30 A2 and 50 A2, or between 35 A2 and 45 A2, or between 40 A2 and 60 A2. In one embodiment, the immunogen may comprise a peroxidase proliferator-activator 30 receptor gamma (PPAR-y) agonist.

WO 2012/056251 PCT/GB2011/052115 - 27 The term "PPAR-y agonist" can mean any molecule that is capable of binding to, and triggering a response from, the peroxidase proliferator-activator receptor gamma (PPAR-y). This receptor is also known as the glitazone receptor, or nuclear receptor subfamily 1, group C, member 3 (NR1 C3). PPAR-y is a type II nuclear receptor that, in 5 humans, is encoded by the PPAR-y gene. Two isoforms of PPAR-y are detected in humans, i.e. PPAR-yl, which is found in nearly all tissues except in muscle, and PPAR y 2 , which is mostly found in adipose tissue and the intestine. The PPAR-y agonist present in the composition may be capable of binding to either PPAR-yl or PPAR-y2. 10 The table below provides a list of preferred PPAR-y agonists, which may be used in the compositions of the invention. Thus, the PPAR-y agonist may be a compound selected from the table. Table 1 - PPAR-y agonists Drug C Log P Gemfibrozil 3.8 Bezafibrate 3.8 Ciprofibrate 3.4 Clofibrate 3.3 Fenofibrate 5.2 Ibuprofen 3.5 Diclofenac 4.4 Indomethacin 4.3 Monascin 3.2 Irbesartan 4.1 Telmisartan 6.9 Mycophenolic acid 3.2 Resveratrol 3.1 Delta(9)- 7.0 tetrahydrocannabinol Cannabidiol 6.5 Curcumin 3.2 Cilostazol 3.1 Benzbromarone 5.7 6-shogaol 3.7 Glycyrrhetinic acid 6.4 15 In one preferred embodiment, the PPAR-y agonist may be a fibrate. Ogata et al., 2009, Atherosclerosis 205(2): 413-419, describes the PPAR-y agonist properties of the WO 2012/056251 PCT/GB2011/052115 - 28 fibrates, gemfibrozil and bezafibrate. The fibrate may be selected from the group of fibrates consisting of bezafibrate; ciprofibrate; clofibrate; gemfibrozil; and fenofibrate. In yet another embodiment, the PPAR-y agonist may be selected from the group of 5 agonists including Monascin; Irbesartan; Telmisartan; Mycophenolic acid; Resveratrol; Delta(9)-tetrahydrocannabinol; Cannabidiol; Curcumin; Cilostazol; Benzbromarone; 6 shogaol; and Glycyrrhetinic acid. In another embodiment, the immunogen may be a non-steroidal anti-inflammatory 10 drug (NSAID). The immunogen may be any of the NSAIDs described herein, for example ibuprofen. All of the features described herein (including any accompanying claims, abstract and drawings), and/or all of the steps of any method or process so disclosed, may be 15 combined with any of the above aspects in any combination, except combinations where at least some of such features and/or steps are mutually exclusive. Embodiments of the invention will now be further described, by way of example only, with reference to the following Examples, and to the accompanying diagrammatic 20 drawings, in which: Figure 1 shows the effect of one embodiment of the composition of the first aspect (i.e. ibuprofen in lipid, which is denoted herein as BC1054), on survival against Influenza A/PR/8/34 lethal challenge. 33 5tg of ibuprofen in a lipid adjuvant (BC1054 adjuvant oral) was administered to the challenged mice. Two controls were used, i.e. 3 3 5tg of 25 ibuprofen in the absence of the lipid adjuvant (BC1054 oral) and lipid adjuvant only in the absence of ibuprofen (control oral); Figure 2 shows the effect of the formulation comprising 3 3 5tg ibuprofen in lipid vehicle (BC1054 lipid oral) in vivo on the IL-10 levels in the lungs of surviving mice. Two controls were used, i.e. 33 5tg of ibuprofen in the absence of the lipid adjuvant 30 (BC1054 oral) and lipid vehicle only (vehicle oral); Figure 3 shows the effect of the formulation comprising 3 3 5tg ibuprofen in lipid vehicle (BC1054 lipid oral) in vivo on the IL-4 levels in the lungs of surviving mice. Two WO 2012/056251 PCT/GB2011/052115 - 29 controls were used, i.e. 3 3 5tg of ibuprofen in the absence of the lipid adjuvant (BC1054 oral) and lipid vehicle only (vehicle oral); Figure 4 is a graph showing the effect of the BC1054 formulation on IL-10 levels in the lungs of surviving mice; 5 Figure 5 is a graph showing the effect of the BC1054 formulation on TNF-alpha levels in the lungs of surviving mice; Figure 6 is a graph showing the effect of the BC1054 formulation on IFN-gamma levels in the lungs of surviving mice; and Figure 7 is a graph showing the effects of the BC1054 formulation in an anti-collagen 10 antibody induced arthritis (ACAIA) murine model. Examples The inventors carried out a range of in vivo mouse experiments in order to determine the effects of ibuprofen on influenza-challenged mice. The inventors have 15 convincingly demonstrated in the results described below that ibuprofen, when administered orally in an oil-based formulation (90% linseed oil; 10% ethanol), results in a surprising increase in the concentration of endogenous IL-10 and IL-4. They observed a concomitant reduction in the viral symptoms (i.e. increase in survival rate), and believe that this is because of the elevated IL-10 concentration. 20 Example 1 - In vivo mouse survival studies Protocol: Five groups (n--10) of C57BLK/6 female mice (6-7 weeks old), were divided into five experimental groups containing ten animals each. On day 1, animals received an 25 intranasal lethal dose (50 1d total, 25 1d nostril) of Influenza A/PR/8/34 under halothane-induced anaesthesia. On day 3, post-challenge with the virus, the animals received the following treatments: Group A received an oral gavage of ibuprofen at a dose of 335.6kg/animal 30 (equivalent to 20mg/kg/day ; i.e. 1200 mg per person day as maximum standard dose) dissolved in 100[d of 10% Ethanol, and 90% linseed oil; WO 2012/056251 PCT/GB2011/052115 - 30 * Group B was the first control in which mice received vehicle only (gavage of 10% Ethanol and 90% linseed oil); and e Group C was the second control in which mice were orally administered with a dose of 335.6kg/animal in 10[1 DMSO (no lipid). 5 The animals were weighed, and monitored for signs of infection daily up to day 6 when all animals were culled. Figure 1 represents the average animal survival, and plotted in Figure 1. 10 Figure 1 clearly shows that the first control (i.e. oral administration of the lipid vehicle only) had an 80% mortality rate, and that the second control (i.e. oral administration of ibuprofen only) exhibited a mortality rate of 60%. However the inventors were surprised to observe that a single dose of BC1054 (i.e. ibuprofen in oil) converted the 80% mortality rate of the first negative control to an 80% survival rate, and this was 15 totally unexpected. Example 2 - Determination of IL-10 and IL-4 concentrations Lungs collected at the end of the in vivo phase of the experiment described in Example 1 were homogenized at 40C, and the supernatant was collected and stored at -700C. 60 20 LL of capture antibody diluted in coating buffer was added per well. The plate was sealed and incubated overnight at 4'C. Wells were then aspirated and washed with 300 L/of well wash buffer. After the last wash, the plates were inverted and blotted on absorbent paper to remove any residual buffer. Plates were washed with 180 L/well of assay diluents and incubated at room temperature for 1 hour. Samples 25 were vortexed for 30secs immediately before adding to the plate. Serial dilutions were performed within the plate with both the sample and the standards by pipetting 60 L of assay diluent into each well. The plate was sealed and incubated for 2 hours at room temperature. IL-4 and IL-10 assays were then carried out. For IL-4, 60 L of working detector was added (Detection Antibody + SAv-HRP reagent) to each well. The plate 30 was sealed and incubated for 1 hour at room temperature. For IL-10, 60 L of detection antibody was diluted in assay diluent to each well.

WO 2012/056251 PCT/GB2011/052115 - 31 Plates were washed and 60 L of SAv-HRP enzyme was diluted in assay diluent and added to the plate. The plate was sealed and incubated for 20 minutes at room temperature. Plates were then washed ten times. 60[d of substrate solution were added to each well and the plate was incubated for 30minutes at room temperature in the 5 dark. 60[1 of stop solution was added to each well and absorbance was read at 450nm. IL-10 and IL-4 concentrations were expressed as pg/mg of lung tissue, and then plotted in Figures 2 and 3. As can be seen in Figure 2, the two controls (i.e. oral administration of ibuprofen only, 10 and oral administration of the lipid vehicle only) resulted in only 2600pg/mg and 2000pg/mg IL-10, respectively. However, the inventors were astounded to see that the test compound, BC1054, resulted in an IL-10 concentration of 6000pg/mg. Clearly, this value of IL-10 is much higher than would have been expected if the activity of the lipid vehicle and ibuprofen was merely additive (the value would have been only 15 4600pg/mg). The fact that the IL-10 concentration in BC1054-administered animals was 6000pg/mg suggests that the effects are synergistic (i.e. 24% higher than expected). The inventors postulate that this increase in endogenous IL-10 production has at least contributed to the significant increase in survival shown in Figure 1. 20 Referring to Figure 3, there is shown the respective concentrations of IL-4 in the surviving animals from the assay of Figure 1. IL-4 is a Th2 cytokine, and it can be seen that mice administered with BC1054 had much higher concentrations of IL-4 than either of the two control groups. Accordingly, the inventors have demonstrated that the switch from a Thi to a Th2 response has been induced. Inducing the switch from a 25 Thi to a Th2 response by up-regulating IL-10 production (and IL-4) can be used to help treat Thi-mediated hyper-inflammation. Example 3 - Pessary The inventors have prepared a delivery device made of a support matrix onto which the 30 lipid-rich BC1054 composition is immobilised, and which can be easily used for treating any Thi-mediated disorder. The delivery device is formed in the shape of a pessary, with a waxy support matrix. Conventional materials for vaginal administration that have WO 2012/056251 PCT/GB2011/052115 - 32 been used include glycerol/gelatin, glyco-gelatin, macrogols (polyethylene glycols), natural, synthetic or semi-synthetic hard fats, and fractionated palm kernel oil, each having BC1054 immobilised thereon. The support matrix melts at body temperature, so that, over time, the composition is released and absorbed by the subject. 5 The inventors are aware that premature labour can be caused in pregnant mothers due to a drop in IL-10 concentrations. Therefore, the pessary can be worn by a pregnant woman, such that the BC1 054 formulation is released, resulting in an increase in endogenous IL-10 production, thereby preventing premature labour. 10 Example 4 - IL10, TNF-alpha and IFN-gamma The inventors carried out further experiments to show which cytokines are stimulated upon administration of the BC1054 formulation. 15 Lungs were taken from fatally H1N1 infected mice, and IL-10, TNFoc and IFNy levels of mice subsequently treated with BC1054 (formulation of the invention) and ibuprofen (not in oil/ethanol vehicle) were measured. The data are shown in Figures 4 6. The levels are related to the effect of each treatment on lethality (i.e. a surrogate for the anti-inflammatory activity of IL-10). 20 As shown in Figure 4, administration to the mice of either ibuprofen on its own, or the BC1054 formulation, resulted in increased IL-10 levels. However, the inventors observed that these increases in IL-10 were associated with very different pharmacodynamic effects. The pattern of pro-inflammatory cytokine reduction 25 highlights the source of the IL-10 and its relevance to the effect on the viral survival model. Importantly, as shown in Figure 6, the levels of IFNy (which is a lymphocyte derived cytokine) were markedly lowered in the ibuprofen-treated mice compared to BC1054-treated mice, which was associated with a poor outcome. 30 Moreover, as shown in Figure 5, TNFoc (which is macrophage-related cytokine) was not as markedly inhibited. However, in BC1 054-treated mice, TNFc levels were markedly lowered in the BC1054-treated mice whilst IFNy levels were largely unaffected. This WO 2012/056251 PCT/GB2011/052115 - 33 demonstrates that the BC1054 is having its protective effect on the lethality of H1N1 through macrophage-derived IL-10 levels rather than lymphocyte-derived ILl 0 ("Immunobiology, 5th edition - The Immune System in Health and Disease", Charles A Janeway Jr), Paul Travers, Mark Walport and Mark J Shlomchik. New York: Garland 5 Science; 2001). Example 5 - Anti-collagen antibody induced arthritis (ACAIA) murine model The inventors investigated the effects of the BC1054 formulation in an ACAIA mouse 10 model, a model showing similarities with system inflammation. Materials and Methods BALB/c mice, on day 0, were intravenously injected with a single inoculation with anti collagen II monoclonal antibody (2 mg in 200 l), followed by an intraperitoneal 15 injection of lipopolysaccaride (LPS, 50 tg in 200 [l) at day 3. From day 3 and daily until day 8 and then on days 10 and 12, paw volumes (plethysmography) and arthritis scores were taken. The same animals were also treated daily from days 0 to day 11, with either oral gavage of vehicle (10% methylcellulose or BC1054 vehicle), 10 mg/kg of positive control, Enbrel (intraperitoneal), 40 mg/kg ibuprofen (oral), 20 mg/kg BC1054 or 30 20 mg/kg BC1054. Through the entire experiment (12 days), animals were checked daily for clinical signs (general observations of the health of the animal) and body weights. Total arthritis scores are determined by summing the arthritis scores of individual paws using the following grades: 0 = no signs of arthritis, 1 = mild but definite redness and swelling of the ankle/wrist or apparent redness or swelling limited to individual digits, 25 regardless of the number of affected digits, 2 = moderate to severe redness and swelling of the ankle/wrist, 3 = redness and swelling of the entire paw including digits, 4 maximally inflamed limb with involvement of multiple joints. The results of this experiment are shown in Figure 7. As can be seen, as expected, the 30 positive control, Enbrel, showed the best results, with the lowest paw thicknesses at about 1.6mm on day 12. The two test formulations (i.e. 20 mg/kg BC1054 or 30 mg/kg BC1054) displayed the next best results, with 30 mg/kg BC1054 producing a paw WO 2012/056251 PCT/GB2011/052115 - 34 thickness of only 1.7mm, and_20 mg/kg BC1054 producing a paw thickness of about 1.73mm. The negative controls (i.e. PBS, 40mg/kg ibuprofen alone, vehicle alone, and vehicle methoxycellulose) performed significantly worse than BC1054 with paw thicknesses of 1.9mm and over. Therefore, these data clearly demonstrate that the 5 formulation of the invention can be used to treat systemic inflammation, such as arthritis. Summary In summary, the inventors were surprised to observe that ibuprofen, when 10 administered orally in a lipophilic excipient (i.e. linseed oil), significantly increased endogenous IL-10 production, and thus surprisingly improved survival in influenza challenged mice. The encouraging results of the in vivo mouse studies clearly demonstrate that mice infected with a H1N1 virus can be effectively treated by administration of a single oral dose of ibuprofen present in an oily formulation. Hence, 15 any compound which is capable of increasing IL- 10 production, when formulated in a carrier having a high concentration of lipid, and orally administered will result in a much higher bioavailability in the lung. Achieving a high concentration of an NSAID for example, such as ibuprofen, in the lung will be advantageous, when treating Th1 mediated disorders, for example a respiratory disorder caused by viral infections. 20 However, only in the BC 1054-treated animals, is the IL-10 signal accompanied by an improvement in survival. In the same lungs, there is a more pronounced down regulation of IFN-gamma (i.e. a T-cell-derived cytokine) for ibuprofen-treated mice, demonstrating that IL-10 in the ibuprofen mice is likely to come from T 25 cells. However, in BC1054-treated mice, there is a more pronounced down-regulation of pulmonary TNF-alpha (i.e. a macrophage-derived cytokine), demonstrating that IL 10 in BC1054-treated mice is more likely to come from macrophages, which results in the profound anti-inflammatory effects that were observed. 30 In summary, therefore, this is evidence that ibuprofen present in the oral lipid adjuvant of the invention is more preferentially taken up by macrophages, resulting in the new WO 2012/056251 PCT/GB2011/052115 - 35 and surprising anti-inflammatory pharmacology as demonstrated by IBD and RA model data.

Claims

1. An oral adjuvant, for use in a pharmaceutical composition comprising an immunogen, wherein the adjuvant comprises a lipid and an alcohol, and stimulates uptake of the immunogen by dendritic cells and/or macrophages such that they 5 modulate immunomodulatory cytokines, and wherein the immunomodulatory activity of the immunogen in the presence of the adjuvant is greater than its immunomodulatory activity in the absence of the adjuvant.

2. An adjuvant according to claim 1, wherein the adjuvant comprises at least about 10 10%, 20%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95% or at least about 99% (w/w) lipid.

3. An adjuvant according to either claim 1 or 2, wherein the adjuvant comprises between about 35% and 99% (w/w) lipid, or between about 45% and 99% (w/w) lipid, 15 or between about 50% and 99% (w/w) lipid, or between about 60% and 98% (w/w) lipid, or between about 70% and 97% (w/w) lipid, or between about 80% and 96% (w/w) lipid, or between about 85% and 95% (w/w) lipid, or between about 85% and 95% (w/w) lipid, or between about 88% and 94% (w/w) lipid, or between about 89% and 93% (w/w) lipid. 20

4. An adjuvant according to any preceding claim, wherein the adjuvant comprises a natural oil or a vegetable oil.

5. An adjuvant according to claim 4, wherein the natural oil is selected from a 25 group consisting of linseed oil; soyabean oil; fractionated coconut oil; mineral oil; triacetin; ethyl oleate; a hydrogenated natural oil; or a mixture thereof. Examples of suitable vegetable oils may be selected from a group consisting of rapeseed oil; olive oil; peanut oil; soybean oil; corn oil; safflower oil; arachis oil; sunflower oil; canola oil; walnut oil; almond oil; avocado oil; castor oil; coconut oil; corn oil; cottonseed oil; rice 30 bran oil; sesame oil; and refined palm oil; or a mixture thereof.