EA042188B1 - COMPOSITION OF LONG-LASTING ACTION - Google Patents

Description

The technical field to which the invention belongs

The present invention relates to pharmaceutical compositions for administration by intramuscular or subcutaneous injection, comprising micro- or nanoparticles of an ATP synthase inhibitor compound, bedaquiline (marketed as Sirturo®, where bedaquiline is in the form of its fumarate salt), suspended in an aqueous pharmaceutically acceptable carrier, and the use of such pharmaceutical compositions in the treatment of bacterial infections such as tuberculosis and the like.

Prerequisites for the invention

Bedaquiline is a well-known anti-tuberculosis drug used in various combinations. It may be formulated in the form of a pharmaceutically acceptable salt, such as bedaquiline fumarate, marketed as Sirturo®. It is believed to act as an inhibitor of ATP synthase with a selectivity index of over 20,000 for mycobacterial ATP synthase compared to eukaryotic mitochondrial ATP synthase.

It has already been reported that bedaquiline is useful in the treatment of mycobacterial infections, and is also useful in the destruction of dormant, latent, persistent mycobacteria, in particular Mycobacterium tuberculosis, and therefore can be used to treat latent TB. Such use of bedaquiline has been described in several publications, including international patent documents WO 2004/011436 and WO 2006/067048. Bedaquiline is also known to be bactericidal against Mycobacterium leprosy, for example, as described in Bacterial Activities of R207910 and other Antimicrobial Agents against Mycobacterium leprae in Mice, Antimicrobial agents and Chemotherapy, April 2006, p 1558, and The Diarylquinolone R207910 is Bactericidal against Mycobacterium leprae in mice and at Low Dose Administered Intermittently, Antimicrobial agents and Chemotherapy, Sept 2009, p3989.

The goal of sustained release formulations may be to reduce drug loading. This is especially applicable for treatment regimens that may last several months.

The number and/or volume of dosage forms to be administered is generally referred to as the number of dose units to be administered. A large number of dose units to be taken is undesirable for many reasons, such as the frequency of administration, often coupled with the inconvenience of having to swallow a large number of dosage forms, and the need to store and transport a large number or volume of pills. A large number of dose units taken increases the risk that patients will not take their full dose and, therefore, will not be able to comply with the prescribed drug regimen. In addition to reducing the effectiveness of treatment, this also leads to the emergence of resistance (eg, in the case of bedaquiline, bacterial resistance).

It would be tempting to provide therapy involving administration of dosage forms at long time intervals, such as one week or longer, or even one month or longer.

Various formulations are known in the art, including sustained release formulations. For example, micro- and nano-suspension technology is known for producing sustained-release formulations in the field of HIV drugs, for example, as described in international patent applications WO 2007/147882 and WO 2012/140220. In addition, nanoparticles known from the prior art have been described, for example, in EP-A-0499299. Such particles have an average particle size in the submicron range and consist of crystalline drug particles having a surface modifier adsorbed on their surface. Nanoparticles have also been used to formulate poorly water-soluble active ingredients.

Sustained release formulations based on the anti-tuberculosis drug bedaquiline have now been described. It has now been found that the bedaquiline compound can be formulated as micro- or nanoparticles and that such formulations can be used as sustained-release (or depot) formulations that may find use in the treatment of various bacterial infections including, for example, tuberculosis.

It would be considered that there are problems for such formulations based on the pharmacokinetic (PK) properties of anti-tuberculosis drugs, including bedaquiline, and it is necessary to maintain plasma levels above the minimum level given these PK properties. The mean terminal half-life of bedaquiline and the N-monodesmethyl metabolite (also known as the M2 metabolite) is approximately 5.5 months. This long terminal elimination phase likely reflects the slow release of bedaquiline and M2 from peripheral tissues. In October 2016, at the UNION conference in Liverpool, Susan Swindells from the University of Nebraska Medical Center presented the report Experience from Long-Acting HIV Drug Development, which summarized that existing drugs for tuberculosis are not ideal candidates (for long-acting) and reliable pharmacodynamic models are missing.

The present invention further relates to the fractional administration of such micro- or nanoparticulate formulations at time intervals of one week or more, such that when

- 1 042188 leads to plasma levels that may be sufficient to inhibit the growth of mycobacterial infection. This provides for a reduced number of administrations, which is thus favorable in terms of the number of dose units taken by the patient and patient compliance with the drug regimen. Therefore, the bedaquiline micro- or nanoparticle formulations of the present invention may be useful in the long-term treatment of mycobacterial infections (eg, tuberculosis, including latent tuberculosis and leprosy).

Intermittent administration of bedaquiline micro- or nanoparticulate formulations at time intervals of one week or more further results in plasma levels that may be sufficient to ensure prevention of transmission of mycobacterial infection. Also in this case, a reduced number of administrations is required, which again is advantageous in terms of the number of dose units taken by the patient and the compliance of the individual at risk of infection with the drug regimen.

Brief description of the invention

The present invention relates to a pharmaceutical composition for administration by intramuscular or subcutaneous injection, comprising a therapeutically effective amount of bedaquiline or a pharmaceutically acceptable salt thereof, in the form of a micro- or nanoparticulate suspension, comprising (a) bedaquiline or a pharmaceutically acceptable salt thereof in micro- or nanoparticle form, and surface modifier; and (b) a pharmaceutically acceptable aqueous carrier, which composition may be referred to herein as the composition(s) of the present invention.

The composition of the present invention is a suspension, by which we mean that the active ingredient bedaquiline is suspended in a pharmaceutically acceptable aqueous vehicle.

The composition of the present invention (ie suspension) contains a surface modifier that can be adsorbed on the surface of the bedaquiline active ingredient.

Therefore, in one embodiment, the present invention may relate to a pharmaceutical composition for administration by intramuscular or subcutaneous injection, containing a therapeutically effective amount of bedaquiline or a pharmaceutically acceptable salt thereof in the form of a suspension of micro- or nanoparticles, containing (a) bedaquiline or a pharmaceutically acceptable salt thereof in the form of micro- or nanoparticles and the surface modifier adsorbed on its surface; and (b) a pharmaceutically acceptable aqueous carrier; where the active ingredient bedaquiline is suspended.

The present invention further relates to a method of treating a subject infected with a pathogenic mycobacterium such as Mycobacterium tuberculosis, M. bovis, M. leprae, M. avium, and M. marinum. In one embodiment, the mycobacterium is Mycobacterium tuberculosis (including latent or dormant form) or Mycobacterium leprae. The compositions of the present invention may be particularly suitable for the treatment of Mycobacterium leprae and latent or dormant forms of Mycobacterium tuberculosis. This is because for the treatment of these specific infections, a lower plasma concentration of bedaquiline may be effective against such infection, for example, as described in Antimicrobial Agents and Chemotherapy, Sept 2009, p. 3989-3991 by Robert Gelber, Koen Andries et al (the contents of which are incorporated herein by reference and which, in fact, describe that the introduction of a low and fractional dose of bedaquiline is promising for patients with leprosy; while the minimum dose that eliminates 99% bacilli for M. tuberculosis is 30 mg/kg/week, for M. lepra it is <5.0 mg/kg/week, and therefore a once-monthly dose may be as effective as 5 days a week, other publications on the effects of bedaquiline on Mycobacterium leprae in mice include Antimicrobial Agents and Chemotherapy, April 2006, p.15581560 by Baohong Ji, Koen Andries et al - the contents of which are also incorporated herein by reference). Therefore, the compositions of the present invention may be particularly suitable in accordance with the method of treating a subject infected with Mycobacterium leprae or a latent/dormant form of Mycobacterium tuberculosis. Such methods of treating a subject infected with a pathogenic mycobacterium include administering, by intramuscular or subcutaneous injection, a therapeutically effective amount of a pharmaceutical composition as described above or hereinafter. Or, alternatively, the present invention relates to the use of a pharmaceutical composition, as defined herein above or below, for the manufacture of a medicinal product intended for the treatment of a pathogenic mycobacterial infection (or for the use of this medicinal product in a specific treatment regimen, as described in this document). In one embodiment, the composition is for long-term treatment of a pathogenic mycobacterial infection. In one embodiment, the pathogenic mycobacterial infection may be as described above or hereinafter, such as an infection that requires long-term treatment (in a further embodiment, an infection that can be further treated at relatively low concentration levels bedaquiline or its active metabolite in plasma, e.g. latent/dormant Mycobacterium tuberculosis or, in a particular embodiment, Mycobacterium leprae).

In another aspect, a method is provided for the long-term treatment of a subject infected with a pathogenic mycobacterium such as Mycobacterium tuberculosis, M. bovis, M. leprae, M. avium, and M. marinum, said method comprising administering an effective amount of a pharmaceutical composition as defined above or below. herein, for administration by intramuscular or subcutaneous injection; where the composition is administered, or it is to be administered intermittently with a time interval that is in the range from one week to one year or from one week to two years. Or, alternatively, the present invention relates to the use of a pharmaceutical composition as defined herein above or below for the manufacture of a medicament for the long-term treatment of a subject infected with a pathogenic mycobacterium such as Mycobacterium tuberculosis, M. bovis, M. leprae , M. avium and M. marinum, for administration by intramuscular or subcutaneous injection, where the composition is administered, or it is to be administered intermittently at a time interval that ranges from one week to one year or from one week to two years. Therefore, it will be understood that the term long-term treatment refers to treatment where a single dose or single administration (e.g. via intramuscular or subcutaneous injection) will provide a sustained therapeutic effect over a period of time as described herein, e.g. a sustained therapeutic effect for several hours, weeks, or months (eg, in one embodiment, for a period of at least or no more than one month, three months, or six months); see examples. In other words, long-term treatment may mean, when there is more than one dose/administration, a long period of time (as described herein) between doses/administrations, ie. intervals are a long period of time, as described in this document.

In another aspect, a method is provided for the long-term treatment of a subject infected with a pathogenic mycobacterium (e.g., any of the types as described herein) as described herein (e.g., above) where indicated/required (and has a lasting effect, e.g., for time period described herein) a single dose or administration (eg, in the amount described herein, eg, later herein). In another aspect, such a long-term treatment regimen is provided in which two such doses or administrations are provided/required, while the doses/administrations are provided at intervals where the time interval is as described herein, for example, a period of at least or not more than one month, three months or six months - for example, during the period of time during which a persistent therapeutic effect lasts). In a further embodiment, a long-term treatment regimen is provided/necessary for three such doses or administrations at such intervals as described herein. In yet another further embodiment, a long-term treatment regimen is provided as described herein, but preceded by an initial treatment phase (which is not a long-term treatment regimen, e.g., a once-a-day course lasting for one week, two weeks, three weeks or one month).

The present invention further relates to a method for preventing a pathogenic mycobacterial infection in a subject at risk of becoming infected with a pathogenic mycobacterial infection, said method comprising administering to said subject an amount of a pharmaceutical composition effective to prevent a pathogenic mycobacterial infection as described above or as further specified hereinafter. Or, alternatively, the present invention relates to the use of a pharmaceutical composition as defined herein above or as further specified hereinafter for the manufacture of a medicament for preventing a pathogenic mycobacterial infection in a subject at risk of becoming infected with a pathogenic mycobacterial infection.

In another aspect, the present invention relates to a method for the long-term prevention of a pathogenic mycobacterial infection in a subject at risk for infection with a pathogenic mycobacterial infection, said method comprising administering to said subject an effective amount of a pharmaceutical composition as defined above or as further specified hereinafter, wherein the composition enter, or it is to be entered periodically with a time interval that is in the range from one week to one year or from one week to two years.

The present invention further relates to the use of a pharmaceutical composition as defined above, or as further defined hereinafter, for the manufacture of a medicament for the long-term prevention of a pathogenic mycobacterial infection in a subject at risk of becoming infected with a pathogenic mycobacterial infection, wherein the composition is administered, or it is to be administered intermittently at a time interval that ranges from one week to one year, or from one week to two years.

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In one embodiment, the present invention relates to a use or method as defined herein, wherein the pharmaceutical composition is administered, or is to be administered at a time interval that is in the range of one week to one month, or in the range of one month to three months, or in the range of three months to six months, or in the range of six months to twelve months, or in the range of 12 months to 24 months.

In another embodiment, the present invention relates to a use or method as defined herein, wherein the pharmaceutical composition is administered or is to be administered once every two weeks, or once a month, or once every three months.

Additional pharmaceutical compositions, methods of treatment or prevention, as well as ways of using for the manufacture of drugs based on such compositions will be described in this document below and are part of the present invention.

The present invention is also described with reference to the following figures.

Fig. 1. Kinetics of plasma TMC207 (bedaquiline; BDQ) and M2 (bedaquiline metabolite; see herein) in mouse after a single dose of 30 mg/kg.

Fig. 2. Kinetics of TMC207 in mouse plasma when administered with IM or SC using formulations of 200 mg/ml (specifically formulations from examples 1A and 1B, i.e. nano- and microsuspension, respectively) at a dose of 160 mg/kg (TMC207 indicated in the figure as UD).

Fig. 3. Kinetics of M2 in mouse plasma upon administration of IM or SC using formulations of 200 mg/ml (specifically the formulations of examples 1A and 1B, i.e. nano- and microsuspension, respectively) at a dose of 160 mg/kg (M2 indicated in the figure as met).

Fig. 4. Kinetics of TMC207 in mouse blood plasma when administered with IM or SC using formulations of 100 mg/ml (specifically formulations from examples 1C and 1D, i.e. nano- and microsuspension, respectively) at a dose of 80 mg/kg (TMC207 indicated in the figure as UD).

Fig. 5. Kinetics of M2 in mouse plasma upon administration of IM or SC using formulations of 100 mg/ml (specifically the formulations of examples 1C and 1D, i.e. nano- and microsuspension, respectively) at a dose of 80 mg/kg (M2 indicated in the figure as met).

Fig. 6. Kinetics of TMC207 in blood plasma in male rats when administered with IM or SC using a microformulation of 200 mg/ml (see example 1, composition 1B, i.e. microsuspension) at a dose of 40 mg/kg and Kinetics of TMC207 in plasma blood in male rats with the introduction of IM or SC using a nano formulation of 200 mg/ml (see example 1, formulation 1A, i.e. nanosuspension) at a dose of 40 mg/kg.

Fig. 7. Plasma kinetics of TMC207 in male beagle dogs when administered with IM or SC using a microformulation of 200 mg/ml (see Example 1, Formulation 1B) at a dose of 40 mg/kg and Plasma kinetics of TMC207 in male dogs beagle breeds when administered with IM or SC using a 200 mg/ml nanocomposition (see example 1, formulation 1 A) at a dose of 40 mg/kg.

Detailed description of the invention

The compound used in the present invention is a TMC207 compound, also referred to as bedaquiline.

Bedaquiline may be used in its non-salt form or in a suitable pharmaceutically acceptable salt form such as an acid addition salt form or a base addition salt form. In one embodiment, bedaquiline is in its non-salt form in the compositions of the present invention.

Pharmaceutically acceptable acid addition salts are defined as containing the therapeutically active non-toxic acid addition salt forms that bedaquiline is able to form. Said acid addition salts can be obtained by treating the free form of bedaquiline with suitable acids, for example inorganic acids, for example hydrohalic acid, in particular hydrochloric acid, hydrobromic acid, sulfuric acid, nitric acid and phosphoric acid; organic acids, e.g. acetic acid, hydroxyacetic acid, propionic acid, lactic acid, pyruvic acid, oxalic acid, malonic acid, succinic acid, maleic acid, fumaric acid, malic acid, tartaric acid, citric acid, methanesulfonic acid, ethanesulfonic acid, benzenesulfonic acid, p-toluenesulfonic acid, cyclamic acid, salicylic acid, p-aminosalicylic acid and pamoic acid. In particular, the fumarate salt is considered, provided that this is the form used in the Sirturo® product already on the market.

Possible therapeutically active non-toxic base addition salt forms can be obtained by treatment with suitable organic and inorganic bases. Suitable base salt forms include, for example, ammonium salts, alkali and alkaline earth metal salts, in particular lithium, sodium, potassium, magnesium and calcium salts, salts of organic bases, for example, benzathine, K-methyl-O-glucamine, hydrabamine salts, and salts with amino acids such as arginine and lysine.

Conversely, said acid and base addition salt forms can be converted into free forms by treatment with an appropriate base or acid.

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The term addition salt as used herein also encompasses the solvates that bedaquiline is capable of forming, as well as its salts. Such solvates are, for example, hydrates and alcoholates.

Whenever bedaquiline (or TMC207) is mentioned herein, it refers to the single stereoisomeric form that is used in the marketed Sirturo® product and that is disclosed in WO 2004/011436 as an antimycobacterial agent.

It has been found that the physicochemical properties of bedaquiline make it possible to prepare suspensions based on micro- or nanoparticles that have unique pharmacokinetic properties, so that nanosuspensions can be used for the long-term treatment of pathogenic mycobacterial infection, as well as for the long-term prevention of pathogenic mycobacterial infection, while only a small number of drug administrations are required for this purpose. This is favorable in terms of the number of dose units taken by the patient, as well as patient compliance with the prescribed drug regimen.

As used herein, the term treatment of a pathogenic mycobacterial infection refers to the treatment of a subject infected with a pathogenic mycobacterial infection.

The term prevention of a pathogenic mycobacterial infection refers to preventing or preventing a subject from becoming infected with a pathogenic mycobacterial infection. The source of infection may be different, for example, material containing a pathogenic mycobacterial infection.

The terms therapeutically effective amount, amount effective to prevent pathogenic mycobacterial infection, and like terms refer to amounts or concentrations of the compositions of the present invention (or amounts/concentrations of the active ingredient bedaquiline in such compositions) that result in effective plasma levels. By effective plasma levels is meant those plasma levels of bedaquiline that provide effective treatment or effective prevention of pathogenic mycobacterial infection. This is because the amount/dose/administration provided may be related to the required exposure levels or the required plasma levels for effective treatment/prevention, eg as described herein (see eg examples).

The term subject specifically refers to a human.

The term micro- or nanoparticles refers to particles in the micrometer or nanometer range. The particle size should be below the maximum size above which administration by subcutaneous or intramuscular injection becomes difficult or even impossible. The specified maximum size depends, for example, on the limitation imposed by the diameter of the needle, or on adverse reactions of the body to large particles, or both. In one embodiment, the pharmaceutical compositions of the present invention contain bedaquiline in microparticulate form. In another embodiment, the pharmaceutical compositions of the present invention contain bedaquiline in the form of a nanoparticle.

The average effective particle size for the micro- or nanoparticles of the present invention may be less than about 50 microns, or less than about 20 microns, or less than about 10 microns, or less than about 1000 nm, or less than about 500 nm, or less than about 400 nm, or less than about 300 nm, or less than about 200 nm. The lower limit of the average effective particle size may be low, such as as little as about 100 nm or as little as about 50 nm. In one embodiment, the average effective particle size ranges from about 50 nm to about 50 µm, or from about 50 nm to about 20 µm, or from about 50 nm to about 10 µm, or from about 50 nm to about 1000 nm, about 50 nm to about 500 nm, or about 50 nm to about 400 nm, or about 50 nm to about 300 nm, or about 50 nm to about 250 nm, or about 100 nm to about 250 nm, or from about 150 nm to about 220 nm, or from 100 to 200 nm, or from about 150 nm to about 200 nm, for example, about 130 nm or about 150 nm. For example, both after receipt and after a period of time of not more than 3 months (for example, when stored at temperatures of approximately 5°C, 25°C and 40°C) in general:

microsuspensions may have, in one embodiment, a D90 of about 3 to 10 µm (e.g., about 3.5, 4, or 5 µm) and a D50 of about 2 to 4 µm (e.g., about 3 µm) nanosuspensions may have, in one embodiment, a D90 of about 0.5 to 1.5 µm (e.g., about or less than 1 µm or about or less than about 1000 nm) and a D50 of about 0.1 to 0.5 µm (eg, about or less than about 0.3 µm or less than about 300 nm).

In one embodiment, microparticles are used wherein the average effective particle size as measured by D10, D50 and/or D90 (measured by D50 in one embodiment) is less than about 50 microns or less than about 20 microns and greater than about 0.1 µm (100 nm). In one embodiment, the range for such microparticles used in the composition of the present invention is from about 20 µm to about 0.1 µm (in a further embodiment, from about 15 µm to more than about 0.2 µm (200 nm), and in a further embodiment, from about 10 µm to more than 0.5 µm (500 nm), for example, from about 10 µm to more than 1 µm, or less than about 1000 nm, or less than about 500 nm, or less than about 400 nm , or less than about 300 nm, or less than about 200 nm.The above values refer to measurements after acquisition.However, in one embodiment, they may also refer to measurements after a time period of not more than 3 months (for example, after 5 days, one week , two weeks, one month, two months or three months) and stored at various temperatures (for example, at temperatures of approximately 5°C, 25°C and 40 °C).

As used herein, the term effective average particle size has a conventional meaning known to one of ordinary skill in the art and can be measured using particle size measurement techniques known in the art such as, for example, sediment flow force fractionation, photon correlation spectroscopy, laser diffraction or disc centrifugation. The average effective particle sizes mentioned herein may be related to particle volumetric distributions. In this case, an effective average particle size of less than about 50 microns means that at least 50% of the particles by volume have a particle size less than an effective average particle size of 50 microns, and the same applies to other effective particle sizes mentioned. Likewise, the average effective particle sizes can be related to the distribution of particles by weight, but usually this will result in the same or approximately the same values of the average effective particle size.

The pharmaceutical compositions of the present invention provide for the release of the active ingredient of bedaquiline over an extended period of time and may therefore also be referred to as sustained or delayed release compositions. After administration, the compositions of the present invention remain in the body and provide a continuous release of bedaquiline while maintaining such levels of this active ingredient in the patient's system for an extended period of time, which provides treatment or prevention of pathogenic mycobacterial infection. Due to the fact that the pharmaceutical compositions of the present invention remain in the body and provide a continuous release of bedaquiline (and its active metabolite, referred to herein as M2; see hereinafter for the methyl-substituted metabolite), they can be considered as pharmaceutical compositions useful in as long-acting formulations (or depots).

As used herein, an extended period of time refers to a period (or period of time) which may range from one week to one year or up to two years, or a period in the range of one to two weeks, or two to three weeks, or three to four weeks, or a period in the range of one to two months, or two to three months, or three to four months, or three to six months, or six months to 12 months, or 12 months up to 24 months, or a period that is within a few days, such as 7, 10 or 12 days, or several weeks, such as 2, 3 or 4 weeks, or one month, or several months, such as 2, 3, 4, 5 or six months, or even longer, such as 7, 8, 9 or 12 months.

The pharmaceutical compositions of the present invention can be used in the long-term treatment or long-term prevention of a pathogenic mycobacterial infection, or in other words, they can be used in the treatment of a pathogenic mycobacterial infection or in the prevention of a pathogenic mycobacterial infection for an extended period of time. The compositions of the present invention are effective in treating or preventing a pathogenic mycobacterial infection for an extended period of time, such as for at least about one week or longer, or for about 1 month or longer. By the phrase effective for at least about one week or longer is meant that the plasma level of the active ingredient bedaquiline (and/or its active metabolite M2) must be above a threshold value. In the case of therapeutic use, this cut-off value is the lowest plasma level at which bedaquiline (and/or its active metabolite M2) provides effective treatment for a pathogenic mycobacterial infection. When used in the prevention of pathogenic mycobacterial infection, this threshold represents the lowest plasma level at which bedaquiline (and/or its active metabolite M2) is effective in preventing transmission of pathogenic mycobacterial infection.

By prolonged, for example, as used in relation to the long-term prevention of a pathogenic mycobacterial infection or the long-term treatment of a pathogenic mycobacterial infection, or similar terminology, is meant periods that can range from

- 6 042188 one week up to one year, or up to two years, or longer, for example up to five or 10 years. In particular, in the case of the treatment of a pathogenic mycobacterial infection, such periods will be long, on the order of one or more months, one year or more. Such periods may also be relatively short, in particular in the case of a warning. Shorter terms are those that are several days, such as 7, 10 or 12 days, or several weeks, such as 2, 3 or 4 weeks, or one month, or several months, such as 2, 3, 4, 5 or six months or even longer, such as 7, 8, 9 or 12 months. In one embodiment, the methods and routes of administration according to the present invention are intended to prevent a pathogenic mycobacterial infection for one month or several months, such as 2, 3, 4, 5 or six months, or even longer, such as 7, 8, 9 or 12 months.

Pharmaceutical compositions of the present invention can be administered at various time intervals. When used in the prevention of pathogenic mycobacterial infection, the pharmaceutical compositions of the present invention may be administered only once or a limited number of times, such as twice, three, four, five or six times or more. This may be recommended in cases where an alert is needed for a limited period of time, such as a period during which there is a risk of infection.

The pharmaceutical compositions of the present invention may be administered at the time intervals mentioned above, such as a time interval that is in the range of one week to one month, or in the range of one month to three months, or in the range of three months to six months, or ranging from six months to twelve months. In one embodiment, the pharmaceutical composition can be administered once every two weeks, or once a month, or once every three months. In another embodiment, the time interval is in the range of one to two weeks, or two to three weeks, or three to four weeks, or the time interval is in the range of one to two months, or two to three months, or three to four months, or three to six months, or six months to 12 months, or 12 months to 24 months. The time interval may be at least one week, but may also be several weeks, such as 2, 3, 4, 5 or 6 weeks, or intervals of one month or several months, such as 2, 3, 4, 5 or 6 months or even longer, such as 7, 8, 9 or 12 months. In one embodiment, the pharmaceutical compositions of the present invention are administered at intervals of one, two or three months. Such longer periods between each administration of the pharmaceutical compositions of the present invention provide additional improvements in terms of the number of dose units taken by the patient and adherence to therapeutic recommendations. To further improve compliance with therapeutic recommendations, patients should be instructed to take the medication on a specific day of the week if the composition is administered on a weekly schedule, or on a specific day of the month in the case of a monthly schedule.

The length of time intervals between each administration of the composition of the present invention may vary. For example, these time intervals can be selected depending on the levels in the blood plasma. Intervals may be shorter if plasma levels of bedaquiline (and/or its active metabolite M2) are judged to be too low, for example if they are approaching the minimum plasma level set forth herein below. Intervals may be longer if plasma levels of bedaquiline (and/or its active metabolite M2) are judged to be too high. In one embodiment, the compositions of the present invention are administered at equal time intervals. The compositions may be administered without any intermediate additional administrations, or in other words, the compositions may be administered at specific time points separated from each other by a period of time of varying or equal length, for example, a period of at least one week, or any other period the time specified herein during which additional bedaquiline is not administered. With time intervals of the same length, the advantage is that the administration schedule is simple, eg administration occurs on the same day of the week or the same day of the month. Therefore, such an administration schedule allows for a limited number of dose units to be taken by the patient, thereby beneficially influencing patient compliance with the prescribed dosing regimen.

The plasma concentration (or C) of bedaquiline (and/or its active metabolite M2) in a subject being treated with it is generally expressed as mass per unit volume, typically in nanograms per milliliter (ng/mL). For convenience, this concentration may be referred to herein as the blood plasma drug concentration or blood plasma concentration.

The dose (or amount) of bedaquiline administered depends on the amount of bedaquiline in the pharmaceutical compositions of the present invention or on the amount of said composition that is administered. If higher plasma levels are required, one can either administer a composition with a higher concentration of bedaquiline, or administer a larger amount of said composition, or

- 7 042188 apply both. They act in the opposite direction if lower plasma levels are required. Also, a combination of varying time intervals and varying dosages can be selected to achieve specific desired plasma levels.

The dose (or amount) of bedaquiline administered also depends on the frequency of administration (ie the time interval between each administration). Usually the dose will be higher with less frequent injections. All of these parameters can be used to ensure that plasma levels reach the desired values.

The dosage regimen also depends on whether the pathogenic mycobacterial infection is being prevented or treated. In the case of therapy, the dose of bedaquiline administered or the frequency of dosing, or both, is chosen so as to maintain the concentration of bedaquiline in blood plasma above the minimum level in blood plasma. The term plasma trough (or Cmin) here refers to the plasma level of bedaquiline (and/or its active metabolite M2) that provides effective treatment for a pathogenic mycobacterial infection. In particular, the plasma level of bedaquiline (and/or its active metabolite M2) is maintained at a level above the minimum plasma level of about 10 ng/mg, or above about 15 ng/ml, or above about 20 ng/ml, or greater than about 40 ng/mL. Plasma levels of bedaquiline (and/or its active metabolite M2) can be maintained above a trough plasma level that is higher, for example, higher than about 50 ng/mL, or higher than about 90 ng/mL, or higher than about 270 ng /ml, or higher than about 540 ng/ml. In one embodiment, plasma levels of bedaquiline (and/or its active metabolite M2) are maintained above about 13.5 ng/mL or maintained above about 20 ng/mL. Alternatively, plasma levels of bedaquiline (and/or its active metabolite M2) can be maintained within certain ranges, in particular ranges starting from a minimum plasma level selected from the levels mentioned above and ending at higher plasma levels. selected from the levels mentioned above and selected from 500 ng/mL and 1000 ng/mL (e.g., 10 to 15, 10 to 20, 10 to 40, etc., or 15 to 20, or 15 up to 40, or from 15 to 90, etc., or from 20 to 40, from 20 to 90, or from 20 to 270, etc., or from 40 to 90, from 40 to 270, or from 40 up to 540, etc., each time from approximately the indicated value in ng/ml to approximately the indicated value in ng/ml). In one embodiment, said range is from about 10 to about 20, from about 20 to about 90, from 90 to 270, from 270 to 540, from 540 to 1000, each time from about the indicated value in ng/ml to about the indicated values in ng/ml.

Plasma levels of bedaquiline (and/or its active metabolite M2) should be maintained above the aforementioned minimum plasma levels, since at lower levels, bacteria can no longer be sufficiently suppressed so that they can proliferate with additional risk of mutations.

In the case of warning, the term plasma trough (or Cmin) here refers to the lowest effective plasma level of bedaquiline (and/or its active metabolite M2) that provides effective treatment/prevention of infection.

In particular, in the event of a warning, plasma levels of bedaquiline (and/or its active metabolite M2) can be maintained at a level above the previously mentioned minimum plasma level relative to therapy. However, plasma levels of bedaquiline (and/or its active metabolite M2) can be maintained at a lower level, for example, above about 4 ng/ml, or about 5 ng/ml, or about 8 ng/ml, for prevention. Plasma levels of bedaquiline (and/or its active metabolite M2) should preferably be maintained above such trough plasma levels, since at lower levels the drug may no longer be effective, thereby increasing the risk of infection transmission. Plasma levels of bedaquiline (and/or its active metabolite M2) can be maintained at slightly higher levels to have a margin of safety. Such higher levels start at about 50 ng/mL or more. Plasma levels of bedaquiline (and/or its active metabolite M2) can be maintained within the ranges indicated above for therapy, but lower limits include plasma levels of approximately 4 ng/mL, or approximately 5 ng /ml, or approximately 8 ng/ml.

The advantage of bedaquiline (and/or its active metabolite M2) is that it can be administered to relatively high plasma levels without any significant side effects. Plasma concentrations of bedaquiline (and/or its active metabolite M2) can reach relatively high levels but, as with any drug, should not exceed the maximum plasma level (or C _max ), which is the plasma level in which bedaquiline (and/or its active metabolite M2) causes significant side effects. In addition, tissue release of the compound must be taken into account, which is not taken into account in relation to plasma levels. As used herein, the expression "significant side effects" means that in the relevant group of patients side effects are observed on such a scale that side effects affect normal functioning.

- 8 042188 patients. In one embodiment, the number and frequency of administrations of bedaquiline (and/or its active metabolite M2) to be administered are chosen such that plasma concentrations are maintained over a long period of time at a level within the range of the maximum plasma level (or C _max , as above) to a minimum plasma level (or C _min as above).

In some cases, it may be necessary to maintain plasma levels of bedaquiline (and/or its active metabolite M2) at relatively low levels, for example, as close as possible to the minimum plasma levels specified herein. This will make it possible to reduce the frequency of administrations and/or the amount of bedaquiline (and/or its active metabolite M2) administered with each administration. It will also avoid unwanted side effects, which will make the dosage forms acceptable to the majority of the target populations, who are healthy people at risk of infection and therefore less likely to tolerate side effects. Plasma levels of bedaquiline (and/or its active metabolite M2) can be maintained at relatively low levels if warned. One embodiment relates to routes of administration or methods of preventing infection as set forth herein above or below, wherein the minimum plasma level of bedaquiline (and/or its active metabolite M2) is as set forth herein and the maximum level in blood plasma is approximately equal to the lowest blood plasma level that provides a therapeutic effect of the active ingredient, as also indicated herein.

In other embodiments, plasma levels of bedaquiline (and/or its active metabolite M2) are maintained below a maximum low plasma level of about 10 ng/mL, more specifically about 15 ng/mL, even more specifically about 20 ng/mL. ml, even more specifically about 40 ng/ml. In a specific embodiment, the plasma level of bedaquiline (and/or its active metabolite M2) is maintained below a level of approximately 13.5 ng/mL. In one embodiment, the blood plasma level of bedaquiline (and/or its active metabolite M2) is maintained between the lower maximum blood level set above and the minimum blood plasma levels mentioned in relation to the warning. For example, plasma levels of bedaquiline (and/or its active metabolite M2) are maintained below about 10 ng/ml and above a minimum level of about 4 ng/ml.

In other cases, it may be appropriate to maintain plasma levels of bedaquiline (and/or its active metabolite M2) at relatively higher levels, for example, if there is a high risk of infection and more frequent and/or higher doses are not a problem. In such cases, the trough plasma level may be equal to the lowest plasma level of bedaquiline (and/or its active metabolite M2) that provides effective treatment of the pathogenic mycobacterial infection, such as the specific levels mentioned herein.

In case of warning, the dose to be administered should be calculated from about 0.2 mg/day to about 50 mg/day, or 0.5 mg/day to about 50 mg/day, or from about 1 mg/day to about 10 mg/day, or from about 2 mg/day to about 5 mg/day, for example, about 3 mg/day. This corresponds to a weekly dose of from about 1.5 mg to about 350 mg, in particular from about 3.5 mg to about 350 mg, in particular from about 7 mg to about 70 mg, or from about 14 mg to about 35 mg, for example, about 35 mg, or a monthly dose of 6 mg to about 3000 mg, in particular, from about 15 mg to about 1500 mg, more specifically from about 30 mg to about 300 mg, or from about 60 mg to about 150 mg, for example, about 150 mg. Doses for other dosing regimens can easily be calculated by multiplying the daily dose by the number of days between each administration.

In the case of therapy, the dose to be administered should be calculated from a dose of about 1 mg/day to about 150 mg/day, or from about 2 mg/day to about 100 mg/day, or from about 5 mg/day to about 50 mg /day or about 10 mg/day to about 25 mg/day, for example, about 15 mg/day. Appropriate weekly or monthly doses can be calculated as described above. For prevention routes, dosages may be lower, although the same dosages as for therapeutic routes may be used. In one embodiment, the dose/administration is given at monthly or three month or six month intervals for a total treatment duration of three, six or 12 months. In cases where the dose/administration is given monthly, once every three months, or once every six months, in one embodiment, the dose provided (eg, to human subjects) is calculated based on a daily dose of 400 mg administered over 2 weeks. Therefore, the total amount of bedaquiline provided per dose may be approximately 5600 mg (eg, in the range of 3000 to 8000 mg), but it may be

- 9 042188 not more than one-fifth of such an amount (for example, in the range from 500 to 2000 mg, for example, from about 1000 to 1500 mg).

In another embodiment, in the case of prevention or, in particular, therapy, doses can also be expressed in mg/kg. For example, in the examples, specific doses may be administered based on weight (e.g., mammal and, as shown in the examples herein, mice) and therefore doses of 1 mg/kg to 1000 mg/kg may be used (e.g., doses of 40, 80, 160 mg/kg, 320 or 480 mg/kg), and such doses can remain effective for a period of 4 weeks, 8 weeks or 12 weeks (for example, as shown in the examples). For example, one dose can be taken once every 4 weeks (actually considered as a 12 week treatment regimen, i.e. three doses in total) or one single dose can be taken that effectively provides sufficient treatment (for example, as determined by the reduction in the number of CFU, see examples), which can be confirmed by controls over a period of 12 weeks. Therefore, in one aspect, a single dose (for example, from 1 to 1000 mg/kg, for example, from 2 to 500 mg/kg) can be taken to treat a bacterial infection, or one such dose can be taken every 4 weeks (for example, take two or three such doses). This dose depends on the bacterial infection being treated. For example, in the treatment of latent tuberculosis or leprosy, lower doses may be needed (compared to, for example, multidrug-resistant tuberculosis), given that a lower amount of bedaquiline is needed to control bacteria. Such an example is described in this document below (Example 3), where it is indicated that in mice a single dose of 160 mg/kg can sufficiently reduce the number of CFU in a mouse model of latent tuberculosis infection - it has also been seen that two or three doses of 160 mg/kg (second and third doses given at 4 and 8 weeks, respectively) were also effective in this model.

Plasma levels of bedaquiline (and/or its active metabolite M2) have been found to be more or less stable after single administration, i. they fluctuate within limited limits. Plasma levels have been found to reach a more or less steady state or approach more or less a zero order release rate over an extended period of time. By steady state is meant such a situation in which the amount of drug present in the blood plasma of a subject remains at more or less the same level for an extended period of time. Plasma levels of bedaquiline (and/or its active metabolite M2) are generally not shown to fall below the minimum plasma level at which the drug is effective. The term remains at more or less the same level does not exclude that there may be small deviations in plasma concentrations within an acceptable range, for example, deviations in the range of approximately ± 30%, or approximately ± 20%, or approximately ± 10%, or approximately ±10%.

In some cases, after administration, an initial peak plasma concentration may be observed, after which the plasma levels reach a steady state, as mentioned below in this document.

The compositions of the present invention show good local tolerance and ease of administration. Good local tolerance refers to minimal irritation and inflammation at the injection site; ease of administration refers to the size of the needle and the length of time required to administer a dose of a particular drug formulation. In addition, the compositions of the present invention exhibit good stability and an acceptable shelf life.

The micro- or nanoparticles of the present invention have a surface modifier adsorbed on their surface. The function of the surface modifier is to act as a wetting agent as well as a stabilizer for the colloidal suspension.

In one embodiment, the micro- or nanoparticles in the composition of the present invention mainly contain crystalline bedaquiline or a salt thereof; and a surface modifier, the total amount of which may be at least about 50%, or at least about 80%, or at least about 90%, or at least about 95%, or at least about 99% micro- or nanoparticles. As defined herein, in one embodiment, bedaquiline is in its non-salt (or free) form, and in a further embodiment, it is in its crystalline non-salt (or free) form. In this respect, as stated herein, bedaquiline can be prepared as such using the procedures described in international patent application WO 2004/011436 (or WO 2006/125769, which describes optical separation using a chiral reagent). According to this procedure, bedaquiline is obtained by precipitation from toluene/ethanol, indicating that the product is crystallizing. This form of bedaquiline can be used to prepare the compositions of the present invention and, in addition, this form can be a single crystal polymorph with the following characteristic features:

(i) melting endotherm at 181.5°C (endotherm start) and DSC curve indicating melting

- 10 042188 product at approximately 182.5°C (followed by immediate decomposition; measured by differential scanning calorimetry (DSC) by transferring approximately 3 mg of the compound into a standard TA-Instrument aluminum sample cuvette, the sample cuvette was closed with a suitable lid and the curve was recorded DSC on a TA-Instruments Q2000 MTDSC equipped with an RCS cooler using the following parameters: initial temperature 25°C, heating range 10°C/min, final temperature 300°C, nitrogen flow 50 ml/min);

(ii) infrared (IR) peaks at, among others, approximately 1600 cm ^-1 , approximately 1450 cm ^-1 , approximately 1400 cm ^-1 , approximately 1340 cm ^-1 and approximately 1250 cm ^-1 (where the sample was analyzed using a suitable instrument microATR using 32 scans, 1 cm ^-1 separation, Thermo Nexus 670 FTIR spectrometer, DTGS with KBr, Ge window detector on KBr beam splitter and microATR fixture (Harrick Split Pea with Si crystal) and/or (iii) X-ray powder diffraction ( XRPD) with characteristic peaks of approximately 11.25° 2-theta, approximately 18° 2-theta, approximately 18.5° 2-theta, approximately 19° 2-theta, approximately 20.25° 2-theta, approximately 21.25 ° 2-theta, approx. 22.25° 2-theta, approx. Philips) X'PertPRO MPD, and the instrument is equipped with a Cu LFF X-ray tube and the compound is dispensed into a zero background sample holder; the device parameters were as follows: generator voltage - 45 kV; generator current - 40 mA; geometry - Bragg-Brentano; step - rotation step; scanning mode - continuous; scan range 3-50° 2θ; step size 0.02°/step; counting time 30 s/step; time of one rotation of the rotator - 1 s; radiation type CuKa).

Therefore, in one embodiment, the bedaquiline used according to the method for preparing the compositions of the present invention (ie, prior to conversion to micro-/nanoparticles) is in a crystalline form (eg, the specific form described above). In a further embodiment of the present invention, the bedaquiline used in the compositions of the present invention (ie, after being converted to micro/nanoparticles, eg, by milling) is also in crystalline form (eg, the specific form described above).

In a further aspect, the present invention relates to a pharmaceutical composition for administration by intramuscular or subcutaneous injection, comprising a therapeutically effective amount of bedaquiline or a pharmaceutically acceptable salt thereof in the form of a particulate suspension, essentially consisting of (1) bedaquiline or a pharmaceutically acceptable salt thereof in micro- or nanoparticle form and a surface modifier adsorbed on its surface; and (2) a pharmaceutically acceptable aqueous carrier wherein the active ingredient is suspended.

Suitable surface modifiers may be selected from known organic and inorganic pharmaceutical excipients, including various polymers, low molecular weight oligomers, natural products, and surfactants. Specific surface modifiers include non-ionic and anionic surfactants. Illustrative examples of surface modifiers include gelatin, casein, lecithin, salts of negatively charged phospholipids, or their acidic form (such as phosphatidylglycerol, phosphatidyl linositol, phosphatidylserine, phosphorus-containing acid, and their salts, such as alkali metal salts, e.g., their sodium salts, e.g., egg phosphatidylglycerin sodium, such as the product available under the trade name Lipoid™ EPG), gum arabic, stearic acid, benzalkonium chloride, polyoxyethylene alkyl ethers, eg macrogol esters such as cetomacrogol 1000, polyoxyethylene derivatives of castor oil; polyoxyethylene stearates, colloidal silicon dioxide, sodium dodecyl sulfate, sodium carboxymethyl cellulose, bile salts such as sodium taurocholate, sodium deoxytaurocholate, sodium deoxycholate; methylcellulose, hydroxyethylcellulose, hydroxypropylcellulose, hydroxypropylmethylcellulose, magnesium aluminum silicate, polyvinyl alcohol (PVA), poloxamers such as Pluronic™ F68, F108 and F127 which are block copolymers of ethylene oxide and propylene oxide; tyloxapol; vitamin E-TGPS (α-tocopheryl polyethylene glycol succinate, in particular α-tocopheryl polyethylene glycol succinate 1000); poloxamines such as Tetronic™ 908 (T908), which is a tetrafunctional block copolymer obtained from the sequential addition of ethylene oxide and propylene oxide to ethylenediamine; dextran; lecithin; dioctyl ester of sodium sulfosuccinic acid, such as products sold under the trade name Aerosol OT™ (AOT); sodium lauryl sulfate (Duponol™ P); alkylarylpolyethersulfonate available under the tradename Triton™ X-200; polyoxyethylene sorbitan fatty acid esters (Tweens™ 20, 40, 60 and 80); sorbitan fatty acid esters (Span™ 20, 40, 60 and 80 or Arlacel™ 20, 40, 60 and 80); polyethylene glycols (such as those sold under the trade name Carbowax™ 3550 and 934); mixtures of sucrose stearate and sucrose distearate, such as the product available under the trade name Crodesta™ F110 or Crodesta™ SL-40; hexyldecyltrimethylammonium chloride (STAC); polyvinylpyrrolidone (PVP). If necessary, two or more surface modifiers may be used in combination.

Specifically, surface modifiers are selected from poloxamers, α-tocopheryl polyethylene glycol succinates, polyoxyethylene sorbitan fatty acid esters, and salts of negatively charged phospholipids or their acid form. More specifically, the surface modifiers are selected from Pluronic™ F108, Vitamin E TGPS, Tween™ 80 and Lipoid™ EPG (and in a particular embodiment, it is Vitamin E TPGS). One or more of these surface modifiers may be used. Pluronic™ F108 corresponds to poloxamer 338 and is a polyoxyethylene, polyoxypropylene block copolymer that generally corresponds to the formula HO-[CH ₂ CH ₂ O] _x -[CH(CH ₃ )CH ₂ O] _y -[CH ₂ CH ₂ O] _z -H, in which the average values of x, y and z are respectively 128, 54 and 128. Other commercial names for poloxamer 338 are Hodag Nonionic 1108-F and Synperonic PE/F108. In one embodiment, the surface modifier comprises a combination of a polyoxyethylene sorbitan fatty acid ester and a phosphatidylglycerol salt (particularly sodium egg phosphatidylglycerol).

The optimal relative amount of bedaquiline to surface modifier depends on the selected surface modifier, the specific surface area of the bedaquiline slurry, which is determined by the average effective particle size and bedaquiline concentration, the critical micelle concentration of the surface modifier if it forms micelles, etc. The relative amount (w/w) of bedaquiline to surface modifier is preferably in the range from 1:2 to about 20:1, in particular in the range from 1:1 to about 10:1, for example about 4:1.

The particles of this invention can be produced by micronization/particle size reduction/nanoionization by mechanical means and by controlled deposition from a supersaturated solution or by using supercritical fluids such as in the GAS technique or any combination of such techniques. In one embodiment, a method is used comprising the steps of dispersing the bedaquiline in a liquid dispersion medium and applying mechanical means in the presence of an abrasive to reduce the particle size of the bedaquiline to an effective average particle size of less than about 50 microns, in particular less than about 1000 nm. The particle size can be reduced in the presence of a surface modifier.

The general procedure for obtaining particles according to this invention includes (a) obtaining bedaquiline in micronized form;

(b) adding micronized bedaquiline to the liquid medium to form the preblend/predispersion; and (c) mechanically treating the preblend in the presence of an abrasive to reduce the effective mean particle size.

Bedaquiline in micronized form is prepared using techniques known in the art. Preferably, the average effective particle size of the bedaquiline active agent in the pre-dispersion is less than about 100 microns, as determined by particle size analysis. When the average effective particle size of the micronized bedaquiline is greater than about 100 microns, it is preferred that the particles of the bedaquiline compound be reduced in size to less than 100 microns (eg, to the size or range of sizes described herein).

The micronized bedaquiline can then be added to a liquid medium in which it is substantially insoluble to form a pre-dispersion. The concentration of bedaquiline in the liquid medium (percent wt./wt.) can vary widely and depends on the chosen surface modifier and other factors. Suitable concentrations of bedaquiline in the compositions range from about 0.1% to about 60%, or from about 1% to about 60%, or from about 10% to about 50%, or from about 10% to about 30%, for example about 10 %, 20% or 30% (each % in this paragraph refers to w/v).

The premix can be used directly by subjecting it to mechanical means to reduce the effective average particle size in the dispersion to less than 2000 nm. Preferably, the pre-blend is used directly when a ball mill is used for attrition. Alternatively, the bedaquiline and optionally the surface modifier may be dispersed in the liquid medium using suitable agitation, such as for example with a roller mill, until a uniform dispersion is achieved.

The mechanical means used to reduce the effective average particle size of bedaquiline may conveniently be in the form of a dispersion mill. Suitable dispersion mills include ball mill, pulverizer/disc mill, vibratory mill, planetary mill, abrasive mills such as sand mill and bead mill.

- 12 042188 mill. An abrasive mill is preferred due to the relatively shorter grinding time required to achieve the desired particle size reduction. The granules are preferably ZrO ₂ granules. For example, for nanoparticles, the ideal granule size is approximately 0.5 mm, and for microparticles, the ideal granule size is approximately 2 mm.

The abrasive material for the particle size reduction step can be selected from a hard material, preferably in the form of spheres or particles in a shape having an average size of less than 3 mm and more preferably less than 1 mm (granules no larger than 200 μm). Desirably, such a material can provide the particles of the present invention with shorter processing times and cause less wear on the grinding equipment. Examples of the abrasive are ZrO ₂ such as magnesium oxide stabilized or yttrium stabilized 95% ZrO ₂ , zirconium silicate, glass based abrasive, polymer beads, stainless steel, titanium dioxide, alumina, and the like. Preferably the abrasive material has a density greater than 2.5 g/cm ³ and contains 95% magnesium oxide stabilized ZrO ₂ and polymer beads.

The wear time can vary widely and depends mainly on the specific mechanical means and the selected processing conditions. Rolling mills may require processing times of up to two days or more.

The particle size should be reduced at a temperature that does not result in significant degradation of the bedaquiline compound. Processing temperatures of less than 30-40°C are generally preferred. If necessary, the processing equipment can be cooled using conventional cooling equipment. The process is conveniently carried out at ambient temperature conditions and at processing pressures that are safe and effective for the grinding process.

Pharmaceutical compositions according to the present invention contain an aqueous carrier, which is preferably pharmaceutically acceptable. Said aqueous carrier comprises sterile water, optionally in admixture with other pharmaceutically acceptable ingredients. The latter include any ingredients for use in injectable formulations. Such ingredients are optional. Such ingredients may be selected from one or more of a suspending agent, a buffer, a pH adjusting agent, a preservative, an isotonizing agent, and the like. In one embodiment, said ingredients are selected from one or more of a suspending agent, a buffer, a pH adjusting agent, and optionally a preservative, and an isotonizing agent. Particular ingredients may act as two or more of these agents at the same time, such as behaving like a preservative and a buffer, or behaving like a buffer and an isotonic agent.

Suitable optional buffering agents and pH adjusting agents should be used in an amount sufficient to maintain the acidity level of the dispersion from neutral to very slightly basic (up to pH 8.5), preferably in the pH range of 7-7.5. Particular buffers are salts of weak acids. The buffering and pH adjusting agents that may be added may be selected from tartaric acid, maleic acid, glycine, sodium lactate/lactic acid, ascorbic acid, sodium citrates/citric acid, sodium acetate/acetic acid, sodium bicarbonate/carbonic acid , sodium succinate/succinic acid, sodium benzoate/benzoic acid, sodium phosphates, tris(hydroxymethyl)aminomethane, sodium bicarbonate/sodium carbonate, ammonium hydroxide, benzenesulfonic acid, sodium benzoate/acid, diethanolamine, gluconodelta lactone, hydrochloric acid, hydrogen bromide , lysine, methanesulfonic acid, monoethanolamine, sodium hydroxide, tromethamine, gluconic, glyceric, glutaric, glutamic, ethylenediaminetetraacetic (EDTA), triethanolamine, including mixtures thereof. In one embodiment, the compositions of the present invention do not contain a buffering agent.

Suitable optional preservatives include antimicrobials and antioxidants which may be selected from the group consisting of benzoic acid, benzyl alcohol, butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), chlorobutol, gallate, hydroxybenzoate, EDTA, phenol, chlorocresol, metacresol, chloride benzethonium, myristyl-y-picolinium chloride, phenylmercuracetate and thimerosal. Radical scavengers include BHA, BHT, vitamin E and ascorbyl palmitate, as well as mixtures thereof. Oxygen scavengers include sodium ascorbate, sodium sulfite, L-cysteine, acetylcysteine, methionine, thioglycerol, sodium acetone bisulfite, isoascorbic acid, hydroxypropylcyclodextrin. Chelating agents include sodium citrate, sodium EDTA, and malic acid. In one embodiment of the present invention, the compositions of the present invention do not contain a preservative.

An isotonic agent or isotonizing agent may be present to make the pharmaceutical compositions of the present invention isotonic and include sugars such as glucose, dextrose, sucrose, fructose, trehalose, lactose; polyhydric sugar alcohols, preferably trihydric sugar alcohols or alcohols with a large number of hydroxyl groups, such as glycerol, erythritol, arabitol, xylitol, sorbitol and mannitol. Alternatively, sodium chloride, sodium sulfate, or other suitable inorganic salts may be used to make the solutions isotonic. These isotonizing additives can be used alone or in combination. For convenience, the suspensions contain from 0 to 10% (w/v), in particular from 0 to 6% of an isotonizing agent. Non-ionic isotonizing additives such as glucose are of interest because electrolytes can affect the stability of the colloid. In one embodiment of the present invention, the compositions of the present invention contain an isotonizing agent or an isotonizing agent, which, in a further embodiment, is a non-ionic isotonizing agent such as a suitable sugar, eg mannitol.

A necessary feature for the pharmaceutical composition of the present invention is ease of administration. The viscosity of the pharmaceutical compositions of the present invention should be low enough to allow administration by injection. In particular, they should be designed so that they can be easily drawn into a syringe (for example, from a vial), injected through a fine needle (for example, through a 20 G 1/4, 21 G 1/4, 22 G 2 or 22 G 11/ ₄ ) for a not too long period of time. In one embodiment, the viscosity of the compositions of the present invention is less than about 75 mPa-s or less than 60 mPa-s. Aqueous suspensions of this viscosity or less will generally meet the above criteria.

Ideally, the aqueous suspensions according to the present invention will contain as much bedaquiline (or a pharmaceutically acceptable salt thereof) as is acceptable to keep the injectable volume to a minimum, in particular between 3% and 70% (w/v), or 3 to 60% (w/v), or 3 to 40% (w/v), or 10 to 40% (w/v) of bedaquiline (or a pharmaceutically acceptable salt thereof). In one embodiment, the aqueous suspensions of the present invention contain about 50-70% (w/v) bedaquiline (or a pharmaceutically acceptable salt thereof), or about 40-60% (w/v) bedaquiline (or a pharmaceutically acceptable salt thereof). salt), or about 30-50% (w/v) of bedaquiline (or a pharmaceutically acceptable salt thereof).

In one embodiment, aqueous suspensions may contain, by weight, based on the total volume of the composition (a), from 10 to 70% (w/v), or from 20 to 60% (w/v), or from 20 to 50% (w/v), or 20 to 40% (w/v) bedaquiline (or a pharmaceutically acceptable salt thereof);

(b) 0.5 to 20% or 2 to 15% or 20% (w/v) or 5 to 15% (w/v) of a wetting agent;

(c) 0 to 10% or 0 to 5% or 0 to 2% or 0 to 1% of one or more buffering agents;

(d) 0 to 20% or 2 to 15% or 20% (w/v) or 5 to 15% (w/v) of an isotonizing agent;

(e) 0 to 2% (w/v) preservatives; and (f) water for injection in sufficient amounts up to 100%.

In one embodiment, aqueous suspensions may contain, by weight, based on the total volume of the composition (a), from 3 to 50% (w/v), or from 10 to 40% (w/v), or from 10 to 30% (w/v) bedaquiline (or a pharmaceutically acceptable salt thereof);

(b) 0.5 to 10% or 0.5 to 2% (w/v) of a wetting agent;

(c) 0 to 10% or 0 to 5% or 0 to 2% or 0 to 1% of one or more buffering agents;

(d) 0 to 10% or 0 to 6% (w/v) of an isotonizing agent;

(e) 0% to 2% (w/v) preservatives; and (f) water for injection in sufficient amounts up to 100%.

Optionally, some acid or base may be added to the suspension to adjust the pH to about pH 7. Suitable acids or bases are any of those physiologically acceptable, eg HCl, HBr, sulfuric acid, alkali metal hydroxides such as NaOH. In one embodiment, such an acid or base need not be added to the compositions of the present invention.

The administration of bedaquiline (or a pharmaceutically acceptable salt thereof) as in the present invention may be sufficient to treat a pathogenic mycobacterial infection, although co-administration of other anti-TB drugs may be recommended in some cases.

In some cases, the treatment of a pathogenic mycobacterial infection may be limited to only administering a composition of bedaquiline (and/or its metabolite) in accordance with the present invention, i.e. as monotherapy without co-administration of additional drugs against TB. This option may be recommended, for example, in the case of certain mycobacterial infections, where a low concentration of the active ingredient may provide treatment against bacteria (eg, for latent/dormant TB or in the case of Mycobacterium leprae).

In a further aspect, the present invention relates to the use of a pharmaceutical composition comprising an effective amount of bedaquiline or a pharmaceutically acceptable thereof.

- 14 042188 salts, in accordance with the present invention for the manufacture of a medicinal product intended for maintenance therapy of a subject infected with a pathogenic mycobacterial infection, where the composition is administered or it is to be administered periodically with a time interval that is in the range from one week to one year or from one week to two years.

Thus, in a further aspect, the present invention provides a method for long-term treatment of a patient infected with a pathogenic mycobacterial infection, said method comprising (i) treating said patient with a combination of anti-TB drugs followed by (ii) fractional administration of a pharmaceutical composition containing an effective an amount of bedaquiline or a pharmaceutically acceptable salt thereof, according to the present invention, wherein the composition is administered at a time interval of at least one week.

If treatment is directed to Mycobacterium leprae, then the treatment regimen can again be provided as monotherapy or in combination with existing drugs applicable for the treatment of Mycobacterium leprae (eg, rifapentine). The composition of the present invention can be administered by injection once or not more than three times, for example, at monthly intervals. Benefits are associated with acceptance, no resistance to dapsone withdrawal, no prejudice associated with clofazimine withdrawal.

The present invention also relates to a pharmaceutical composition as described herein above for use as a medicament in the treatment or prevention of a pathogenic mycobacterial infection.

In addition, the present invention relates to the use of a pharmaceutical composition as described herein for the preparation of a medicament for the prevention or treatment of a pathogenic mycobacterial infection.

The present invention further relates to a method of treating a subject infected with a pathogenic mycobacterial infection, said method comprising administering a therapeutically effective amount of a pharmaceutical composition described herein.

As used herein, the word essentially does not completely exclude, for example, a composition that is essentially free of Y may be completely free of Y. If necessary, the word essentially can be omitted from the definition of the present invention. It is understood that an expression approximately in relation to a numeric value has its usual meaning in relation to the numeric value. If necessary, the word approximately can be replaced by a numerical value of ±10%, or ±5%, or ±2%, or ±1%.

All documents referenced in this document are incorporated by reference in their entirety.

The following examples are intended to illustrate the present invention and should not be construed as limiting the present invention.

Example 1. Obtaining micro- and nanosuspensions.

The active ingredient bedaquiline may be used as such or may be converted into a pharmaceutically acceptable salt thereof such as the fumarate salt (eg the form used in the marketed Sirturo® product). When mentioned in this document, bedaquiline is used in its non-salt form, unless otherwise indicated.

The prototype composition based on bedaquiline is as follows.

Preparation of 200 and 100 mg/ml nano- and microsuspensions.

Materials used:

0.5 mm zirconium beads (to facilitate the process), sterile water for injection (Viaflo), bedaquiline (not ground/ground), PEG 1000 tocopheryl succinate - excipient, 2 mm zirconium beads (to facilitate the process), mannitol (parenteral) - excipient.

Glass vials and ZrO ₂ beads (either 0.5 mm or 2 mm, depending on the desired nano- or micro-suspensions) used as abrasive material were sterilized in an autoclave. The drug substance (amount depending on the formulation to be prepared; see e.g. composition/suspension below) was placed in a glass vial, as well as a solution of PEG 1000 tocopheryl succinate in water (amount depending on the required/required concentration; see eg formulation/suspension below) for injection. Added granules ZrO ₂ with an average particle size of 500 μm or 2 mm (depending on whether required/required micro-or nanosuspension). The vial was placed on a roller mill. The slurry was micronized/nanonized at 100 rpm for a time period of up to 72 hours. min in

- 15 042188 for a period of time not exceeding 46 hours (for example, approximately 40 hours). At the end of the milling process, the concentrated micro- or nano-suspension was removed with a syringe and filled into vials. The formulations obtained (based on nanosuspension and microsuspension) are described in the following tables. The determination of the concentration was carried out using HPLC/UV. If necessary, dilution was made to a final concentration of 200 mg/ml of bedaquiline active ingredient. The resulting suspension was protected from light. Other concentrations were also prepared and tested, including 300 mg/ml and 100 mg/ml nano and micro formulations.

Such formulations have been (and will be) administered intramuscularly and subcutaneously to PK study animals to investigate possible long-term effects (eg, in the treatment of leprosy).

The measurement of the physical stability of the suspension will be followed by the measurement of the particle size after storage under various conditions.

Some embodiments of the formulation(s) have the following features:

microsuspension using 2 mm Zr beads;

milling at 200 mg/ml (otherwise the concentration may be too high, eg 300 mg/ml);

longer grinding, which leads to nanosuspension;

a suitable surface modifier, eg selected based on physical stability, eg in one embodiment it is TPGS and in another embodiment it is Tween.

Examples of micro- and nanosuspensions based on bedaquiline 200 mg/ml nano- and microsuspensions, referred to in this document as example 1A (nano) and example 1B (micro)

mg/ml Bedaquiline 200 TPGS 50 Mannitol 50 Sterile water for injection In sufficient quantity

100 mg/ml nano- and microsuspensions mentioned in this document ___________ as example 1C (nano) and example 1D (micro) ___________

mg/ml Bedaquiline 100 TPGS 25 Mannitol 50 Sterile water for injection In sufficient quantity

Particle Size Distribution (PSD) of the above formulations Where applicable, n.d. = not defined.

____________PSD for 200 mg/ml microsuspension (Example 1B)________

Storage temperature (°C) Storage time D10 (µm) D50 (µm) D90 (µm) After receiving 1.316 3.283 9.623 5 3 days 1.256 2.539 5.991 14 days 1.142 2.582 7.386 1 month 1.157 2.423 5,850 3 months 1.065 2.225 5.141 25 3 days 1.150 2.348 5.447 14 days 1.073 2.308 5,824 1 month 1.098 2.322 5.665 3 months 1.178 2.452 5.826 40 3 days 1.110 2.227 4.913 14 days 1.054 2.211 5.115 1 month 1.182 2.254 4.626 3 months 0.998 1.89 3.734

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PSD for 200 mg/ml nanosuspension (Example 1A)

Temperature Time D10 (µm) D50 (µm) D90 (µm) storage (°C) After receiving 5 25 40 P storage 3 days 14 days 1 month 3 months 3 days 14 days 1 month 3 months 3 days 14 days 1 month 3 months SD for 100 mg/m 0.074 0.076 0.081 0.075 0.076 0.111 But. But. But. 0.097 0.1 0.089 0.088 l microsuspension 0.175 0.185 0.219 0.176 0.183 41.364 But. But. But. 0.483 0.642 0.294 0.274 ii (example id) 1.693 1.920 8.995 1.281 1.884 226.147 But. But. But. 168.316 240.375 63.986 4.279 Storage temperature (°C) Storage time D10 (µm) D50 (µm) D90 (µm) After receiving 1.267 2.557 6.236 5 3 days 1.157 2.376 5.506 14 days 0.125 0.320 0.993 1 month 1.1 2.337 5.625 3 months 1.048 2.236 5.269 25 3 days 0.697 1.906 4.324 14 days 0.151 1,770 4.351 1 month 0.171 1.797 4.253 3 months 1.104 2.266 5.142 40 3 days 0.547 1.657 3.502 14 days 0.203 1.709 3.881 1 month 1.016 1.996 4.199 3 months 1.025 1.936 3.867

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PSD for 100 mg/ml nanosuspension (Example 1C)

Storage temperature (°C) Storage time D10 (µm) D50 (µm) D90 (µm) After receiving 0.072 0.159 0.576 5 3 days 0.074 0.173 0.765 14 days 0.080 0.213 7.889 1 month 0.075 0.177 0.780 3 months 0.074 0.172 0.919 25 3 days 0.076 0.181 0.872 14 days 0.080 0.202 1.351 1 month 0.080 0.203 1.673 3 months 0.083 0.222 1.691 40 3 days 0.077 0.187 1.017 14 days 0.082 0.226 2.893 1 month 0.084 0.235 2.356 3 months 0.084 0.239 2.472

Example 2 Pharmacokinetic Studies.

Study A - pharmacokinetic profile in mice.

A single dose of bedaquiline was administered orally to mice and the plasma kinetics of bedaquiline itself (also referred to as TMC207) and its major metabolite, N-monodesmethyl (also referred to as M2) were measured over a period of 168 hours. M2 appears to be an active metabolite and its formation following administration of bedaquiline (TMC207) has been observed in at least the following species: mouse, rat/dog and human (its formation is highest in mice and lowest in humans).

The results are described in FIG. 1: Kinetics of TMC207 and M2 in mouse plasma after a single dose of 30 mg/kg.

It can be seen that the kinetic parameters of TMC207 and M2 in blood plasma are slow; the formation of M2 is also slow;

plasma M2 exposure (AUC) is greater than TMC207 exposure;

the concentration of M2 in the lungs is much higher than the concentration of TMC207 in the lungs;

after a period of 168 hours, the plasma concentration of TMC207 is approximately 0.01 μg/ml and M2 is approximately 0.1 μg/ml.

As described in example 1, 200 mg/ml and 100 mg/ml micro- and nanosuspensions (examples 1A, 1B, 1C and 1D) were tested in mice, where the mice also received:

a dose of 80 mg/kg (in this case 100 mg/ml suspensions were used, i.e. examples 1C and 1D) or 160 mg/kg (in this case 200 mg/ml suspensions were used, i.e. examples 1A and 1B);

the dose was administered intramuscularly (IM) or subcutaneously (SM).

Formulations 1A, 1B, 1C, and 1D were each tested in suspension by API analysis prior to mouse administration and found to be in the range of 75-142% (an unusually wide range). However, in mice, plasma levels of bedaquiline and its metabolite could still be measured and assessed after administration of such formulations.

Phase 1 results - up to 672 hours

Fig. 2. Kinetics of TMC207 in plasma in mice when administered with IM or SC using formulations of 200 mg/ml (specifically formulations of examples 1A and 1B, i.e. nano- and microsuspension, respectively) at a dose of 160 mg/kg (TMC207 is designated on the figure as UD).

Fig. 3. Kinetics of M2 in mouse blood plasma when IM or SC is administered with formulations of 200 mg/ml (specifically formulations of examples 1A and 1B, i.e. nano- and microsuspension, respectively) at a dose of 160 mg/kg (M2 is denoted on the figure as met).

In general, it can be seen that for TMC207 concentrations, C _max ranges from about 3000 ng/mL (highest value when IM microsuspension is administered) to about 100 ng/mL (lowest value when SC microsuspension is administered);

after 672 hours, there was still a measurable TMC207 concentration ranging from about 200 ng/mL (highest value with IM microsuspension) to about 50 ng/mL (lowest value with SC microsuspension);

for M2 concentrations, C _max ranges from about 3000 ng/mL (highest value when IM microsuspension is administered) to about 300 ng/mL (lowest value when SC microsuspension is administered);

after 672 hours, there was still a measurable M2 concentration ranging from approximately 1000 ng/mL (highest with the IM microsuspension) to approximately

200 ng/mL (lowest with SC microsuspension).

Fig. 4. Kinetics of TMC207 in mouse plasma when administered with IM or SC using formulations of 100 mg/ml (specifically formulations of examples 1C and 1D, i.e. nano- and microsuspension, respectively) at a dose of 80 mg/kg (TMC207 is designated on the figure as UD).

Fig. 5. Kinetics of M2 in mouse plasma upon administration of IM or SC using formulations of 100 mg/ml (specifically formulations of examples 1C and 1D, i.e. nano- and microsuspension, respectively) at a dose of 80 mg/kg (M2 is denoted on the figure as met).

In general, it can be seen that for TMC207 concentrations, _Cmax ranges from about 2000 ng/mL (highest value with IM nanosuspension) to about 400 ng/mL (lowest with SC nano- and microsuspension);

after 672 hours, there was still a measurable TMC207 concentration ranging from about 100 ng/mL (highest with IM microsuspension) to about 30 ng/mL (lowest with SC microsuspension);

in the case of concentrations of M2 C _max is in the range from about 2000 ng/ml (highest value with the introduction of nanosuspension IM) to about 300 ng/ml (lowest value with the introduction of microsuspension SC);

after 672 hours, there was still a measurable M2 concentration ranging from about 500 ng/mL (highest with the IM microsuspension) to about 100 ng/mL (lowest with the SC microsuspension).

Phase 2 results - up to 2184 h.

The mice in these studies were further monitored up to 2184 hours, which gave the following results:

in the case of composition 1A, i.e. nanosuspension at a concentration of 200 mg/ml, and administration of SC at 160 mg/kg (StDev=standard deviation) and IM at 160 mg/kg

Time (h) The concentration of bedaquiline (BDQ) or its metabolite (M2) in plasma SC at 160 mg/kg IM at 160 mg/kg BDQ StDev M2 StDev BDQ StDev M2 StDev 1 493 305 59.3 49.6 1517 710 171 71 4 676 384 284 188 1588 662 708 332 7 728 269 484 312 1408 519 1063 456 24 726 53 956 289 1022 299 2071 828 168 239 28 1240 475 219 63 1399 557 336 138 66 759 282 99.0 33.2 597 301 504 122 53 503 178 66.1 26.1 418 209 672 109 22 383 136 79.0 34.8 405 211 840 100.8 42.5 196.0 76.5 69.6 58.5 119.2 60.3 1176 70.3 31.0 117.8 50.0 34.7 13.8 65.7 30.9 1512 58.5 20.1 91.2 42.5 23.4 8.4 40.3 18.1 1848 40.6 16.6 86.3 41.7 17.4 7.3 29.7 15.8 2184 35.2 21.4 65.1 36.6 14.5 6.7 27.3 13.2 T shah (h) 4-24 168 1-4 24 Stakh 862 202 1240 475 1723 764 2071 828

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Time (h) The concentration of bedaquiline (BDQ) or its metabolite (M2) in plasma SC at 160 mg/kg IM at 160 mg/kg BDQ StDev M2 StDev BDQ StDev M2 StDev (ng/ml) tl/2 (h) 910 442 1024 573 964 572 794 403 AUClast (ng*h/ml) 247783 54315 702286 173934 207109 69394 696089 302612 AUCinf (ng*h/ml) 301991 107533 815741 282889 231176 89366 728091 318248

in the case of composition 1C, i.e. nanosuspension with a concentration of 100 mg/ml, and administration of SC at 80 mg/kg and

IM at 80 mg/kg

Time (h) The concentration of bedaquiline (BDQ) or its metabolite (M2) in plasma SC at 80 mg/kg IM at 80 mg/kg BDQ StDev M2 StDev BDQ StDev M2 StDev 1 261 66 22.0 3.5 1515 568 177 51 4 538 288 222 88 1572 470 684 239 7 480 281 342 108 1458 314 1049 256 24 205 109 545 185 1114 299 2186 834 168 65.6 30.9 298 130 186 46 1393 744 336 42.5 21.5 192 122 89.0 23.1 609 342 504 46.3 38.3 178 165 54.9 15.0 400 198 672 41.9 36.9 145 136 57.2 27.3 285 121 840 33.9 20.3 70.5 59.2 52.6 40.5 107 54 1176 25.4 15.9 47.2 37.5 28.2 17.8 50.4 29.9 1512 22.2 12.5 43.8 31.7 17.0 11.0 33.8 21.8 1848 14.1 7.3 28.8 18.8 12.6 9.1 23.2 17.4 2184 12.9 6.8 24.1 14.3 7.28 18.3 14.2 T max (h) 4-7 24 1-7 24 Stax (ng/ml) 557 265 545 185 1806 473 2186 834 tl/2 (h) 1051 390 796 147 581 159 650 122 AUClast (ng*h/ml) 84121 43933 238239 136814 186882 61016 669899 325833 AUCinf (ng*h/ml) 102985 47867 264292 149139 196358 68907 688601 344341

- 20 042188 in the case of composition 1B, i.e. microsuspension at 200 mg/mL, and administration of SC at 160 mg/kg (StDev=cmaHgapmHoe deviation) and IM at 160 mg/kg

Time (h) The concentration of bedaquiline (BDQ) or its metabolite (M2) in plasma SC at 160 mg/kg IM at 160 mg/kg BDQ StDev M2 StDev BDQ StDev M2 StDev 1 71.1 15.1 6.53 2.02 1737 1752 206 247 4 101 7 37.5 7.1 2258 1229 908 734 7 102 12 55.3 17.7 1764 1103 1474 795 24 130 19 186 36 1306 407 2926 1143 168 78.7 5.3 276 61 391 137 2643 1087 336 53.8 3.5 226 45 293 131 1693 798 504 51.1 8.3 196 37 222 101 1526 773 672 67.4 12.8 266 52 231 115 1202 680 840 65.7 28.9 114.3 36.6 163.5 74.1 387.8 198.0 1176 55.1 36.2 104.6 51.3 121.9 48.7 255.0 137.4 1512 38.2 13.6 95.6 34.4 94.0 60.7 165.2 91.2 1848 36.9 11.0 66.7 22.8 65.6 23.3 146.4 80.8 2184 30.7 10.4 60.9 21.9 51.5 26.1 112 62 T shah (h) 24 168- 672 1-4 24-168 Stax (ng/ml) 130 19 309 thirty 2364 1447 3002 1139 tl/2 (h) 1545 253 1294 383 719 70 848 273 AUClast (ng*h/ml) 117569 30034 300334 63219 447361 174979 1689422 755169 AUCinf (ng*h/ml) 188153 60663 412456 107222 500850 201928 1823672 836740

- 21 042188 in the case of composition 1D, i.e. microsuspension at 100 mg/mL, and administration of SC at 80 mg/kg (StDev=cmaHgapTHoe deviation) and IM at 80 mg/kg

Time (h) The concentration of bedaquiline (BDQ) or its metabolite (M2) in plasma SC at 80 mg/kg IM at 80 mg/kg BDQ StDev M2 StDev BDQ StDev M2 StDev 1 133 114 6.70 463 186 29.7 12.1 4 415 533 130 175 873 221 264 41 7 350 412 232 310 850 200 459 60 24 162 47 360 364 709 228 1101 341 168 53.2 18.3 226 112 209 44 1050 405 336 28.7 6.8 107 35 112 12 547 150 504 28.2 0.8 109 27 71.8 17.5 398 121 672 28.6 5.8 105 33 87.0 17.0 444 127 840 25.9 6.8 56.3 22.9 70.9 19.6 130 36 1176 25.3 4.5 42.9 15.8 41.5 8.4 91.2 27.4 1512 20.2 6.9 42.1 16.4 31.1 9.5 68.8 26.8 1848 19.6 8.0 31.5 14.7 24.0 7.0 43.7 15.2 2184 15.2 5.4 32.7 16.1 26.3 14.2 42.2 16.7 T shah (h) 4-24 24-168 4-7 24-168 Stax (ng/ml) 433 517 383 348 925 192 1139 366 tl/2 (h) 1423 535 1082 437 916 337 734 322 AUClast (ng*h/ml) 69275 7996 175236 48413 192325 36480 586546 165428 AUCinf (ng*h/ml) 103115 29066 226669 50867 225966 51489 632846 193499

Study B - pharmacokinetic profile in rats and beagle dogs.

In this study, formulations with a concentration of 200 mg/ml were used, both nanosuspension (formulation 1A) and microsuspension (formulation 1B), as shown in example 1 above (i.e. using in addition to micro- and nanoparticles (active bedaquiline ) at a concentration of 200 mg/ml, TPGS (4:1 bedaquiline : TPGS) and 50 mg/ml mannitol in WFI (water for injection)).

Such studies demonstrate that the formulations described in Example 1 (specifically nano- and micro-formulations 1A and 1B) lead to steady-state plasma levels over an extended period of time in male rats and male beagle dogs when administered subcutaneously (SC) and intramuscular (IM).

Male rats.

The first experiment was performed on male rats, where each suitable 200 mg/ml nanosuspension and microsuspension mentioned above were administered subcutaneously (SC) and intramuscularly (IM) at a concentration of 40 mg/kg (0.2 ml/kg). An interim analysis was performed after 3 months, and the results were monitored after 6 months. Twelve rats were used in the study. Six rats were injected intramuscularly (IM), three of these rats were injected with a 200 mg/ml nanosuspension (see example 1, formulation 1A above), and the other three rats were given a 200 mg/ml microsuspension (see example 1, formulation 1B above). Six rats were injected subcutaneously (SC), three of these rats were injected with a 200 mg/ml nanosuspension (see Formulation 1A above) and the other three rats were given a 200 mg/ml microsuspension (see Formulation 1B above).

Phase 1 results - up to 2200 h.

Fig. 6. Kinetics of TMC207 in blood plasma in male rats when administered with IM or SC using a microformulation of 200 mg/ml (see example 1, formulation 1B, i.e. microsuspension) at a dose of 40 mg/kg and Kinetics of TMC207 in plasma blood in male rats when administered with IM or SC using a nano formulation of 200 mg/ml (see example 1, formulation 1A, i.e. nanosuspension) at a dose of 40 mg/kg.

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The following parameters were calculated. for TMC207 (see Fig. 6).

Microsuspension (Form IB) SC Microsuspension (Form IB) IM Nanosuspension (Form 1A) SC Nanosuspension (form ΙΑ) IM η 3 3 3 3 Stach (NG/ML) 68.1 ± 17.6 215±66.7 337±57.0 505 ± 96.6 T _max ^a (h) 24 (24.00-24.00) 18 (7.00-24.00) 24 (24.00-24.00) 16 (1.00-24.00) Tlast ^a= OKOnO 3 months (h) 2184(2184-2184) 2184(2184-2184) 2184(2184-2184) 2184(2184-2184) AUCo-2184 h (3 months) (ng.h/ml) 34700± 1770 91500±13200 75400 ±5070 77900 ±8930

Average values are presented where applicable (with min □ max values in parentheses).

In general, it can be seen that after administration of the microsuspension, the AUC is higher (2.6-fold) after IM than after SC. Following administration of the nanosuspension, AUC values were similar after SC or IM;

in terms of bioavailability (comparing with IV 5 mg/kg), in the case of the lowest (SC microsuspension) = 56%, in the case of the other 3 >100%;

M2, which is not shown in the graphs in FIG. 6 has the same profiles as TMC207, except that t _max is later, AUC M2 is 1.5-2 times lower than TMC207; in general, this ratio is comparable with the route of administration of PO.

Also compared with oral (RO) administration in rats, which can also be considered as a 13 week toxicity study, the following result was observed.

Exposure rates (C _max and AUC) at 3 months after a single IM or SC for both formulations are much lower than the total exposure after PO administration at the highest dose of the 13 week study: IM/SC 34500-91500 ng.h/ml compared with a total exposure of PO=2385383 ng.h./ml during the same period of time (3 months), see above for M2.

Beagle dog breeds.

A second experiment was performed on male beagle dogs where each of the appropriate 200 mg/ml nanosuspension and microsuspension mentioned above was administered subcutaneously (SC) and intramuscularly (IM) at a concentration of 40 mg/kg (0.2 ml/kg). An interim analysis was performed after 3 months, and the results were monitored after 6 months. Twelve (12) healthy male Beagle dogs with body weights ranging from 8 to 16 kg at baseline were used. Each dog was identified by a tattoo with a number on the ears. Six dogs were injected intramuscularly (IM) in the left and right m. biceps femoris, three of these dogs were treated with a 200 mg/ml nanosuspension (see example 1 formulation 1A above) and the other three were treated with a 200 mg/ml microsuspension (see example 1 formulation 1B above). Six dogs were injected subcutaneously (SC) in the left and right chest region, three of these dogs were injected with a 200 mg/ml nanosuspension (see Formulation 1A above), and the other three were given a 200 mg/ml microsuspension (see Formulation 1B above).

Blood samples of 3 ml were taken from the left jugular vein of all dogs on day 0 at 0 o'clock (prior to administration), 20 min, 1 hr, 3 hr, 8 hr and 24 hr after administration and additionally at days 2, 3, 6, 8, 10, 13, 16, 20, 23, 27, 29, 36, 43, 50, 57, 64, 71, 78, 85 and 92 at approximately 8 am. Blood samples were placed in EDTA, EDTA Vacuette Greiner, cat. No. 454086, Greiner Labortechnik N.V.). Within 2 hours of blood sampling, samples were centrifuged at room temperature at approximately 1900xg for 10 minutes until plasma separation was achieved. The blood plasma was immediately transferred to a second tube and stored in a freezer for 2 hours after the start of centrifugation. Blood plasma samples were analyzed separately for TMC207 and for its metabolite M2 using a validated LC-MS/MS method.

Fig. 7. Kinetics of TMC207 in blood plasma in male beagle dogs when administered with IM or SC using a microformulation of 200 mg/ml (see example 1, formulation 1B) at a dose of 40 mg/kg and Plasma kinetics of TMC207 in male beagle dogs with the introduction of IM or SC using a 200 mg/ml nanocomposition (see example 1, formulation 1A) at a dose of 40 mg/kg.

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The following parameters were calculated for TMC207 (see Fig. 7).

Microsuspension (Form IB) SC Microsuspension (Form IB) IM Nanosuspension (Form 1A) SC Nanosuspension (form IB) IM η 3 3 3 3 Stach (NG/ML) 219±237 822±211 692±217 4150±1290 T _max ^a (h) 620 (168.00-840.00) 3.0 (1.00-7.00) 168 (168.00-168.00) 2.0 (1.00-4.00) Tlast ^a= OKOnO 3 months (h) 2184(2184-2184) 2184(2184-2184) 2184(2184-2184) 2184(2184-2184) AUCiast (ng.h./ml) 268000±250000 519000 ± 64300 483000 ±65300 549000 ±26200

Average values are presented where applicable (with min max values in parentheses).

In general, it can be seen that after administration of the microsuspension, the AUC is higher (2-fold) after IM than after SC;

after administration of the nanosuspension, AUC values were similar after SC or IM;

in terms of C _max its values were higher after IM than after SC for both formulations;

in terms of bioavailability (compared to IV 1 mg/kg) >100%;

M2 has the same profiles as TMC207, except that t _max is later, AUC is 3-4 times lower than TMC207; in general, this ratio is comparable with the route of administration of PO.

Also compared with oral (PO) administration in rats, which can be considered as a 13 week toxicity study, the following result was observed:

the highest C _max after IM administration of the nanosuspension is similar to the C _max after RO at 18 mg/kg; in terms of exposure, much higher exposure after PO compared to IM/SC: IM/SC 268,000-549,000 ng.h/mL compared to total exposure PO=13988,520 ng.h/mL over the same time period;

see above for M2.

Based on the intermediate results for 3 months, the following conclusions are made. After IM/SC administration of nanosuspension/microsuspension:

in rats, AUC: IM micro > SC nano ~= IM nano (faster decline) > SC micro;

in dogs, AUC: IM mukpo > SC nano ~= IM nano > SC micro (similar reduction for 4 profiles).

At 40 mg/kg after IM/SC administration of nanosuspension/microsuspension, C _max and AUC of TMC207/M2 are covered by oral toxicity studies in both species, except for C _max TMC207 in dogs after IM administration of nanosuspension, which is similar to PO and IM.

Phase 2 results - up to 4400 hours.

In all cases, the plasma concentration of BDQ or M2 is calculated as the average of the three animals (rats or dogs) in the respective study.

Rat study: for formulation 1B, i.e. microsuspension at 200 mg/mL and administration of SC at 40 mg/kg (StDev=standard deviation) and IM at 40 mg/kg.

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Time (h) The concentration of bedaquiline (BDQ) or its metabolite (M2) in plasma SC at 40 mg/kg IM at 40 mg/kg BDQ StDev M2 StDev BDQ StDev M2 StDev 1 22.1 5.36 0.589 NC 139 33.2 5.11 2.24 4 36.9 7.42 6.62 1.69 172 47.2 18.8 5.98 7 40.7 6.27 8.59 1.46 185 24.2 28.7 7.57 24 68.1 17.6 24.0 1.14 212 70.6 77.3 23.5 168 16.5 4.84 9.03 1.81 98.0 19.1 91.5 33.1 336 18.1 3.30 9.28 2.10 69.7 10.2 54.9 16.8 504 22.8 3.96 9.68 2.85 52.2 4.05 37.9 16.5 672 14.7 0.964 7.32 1.34 42.6 6.85 29.5 14.8 840 15.1 1.74 7.40 2.46 33.6 6.39 22.3 10.6 1008 14.7 3.47 6.82 2.06 28.5 6.24 20.2 11.2 1176 13.2 2.99 5.96 1.76 24.1 7.04 16.6 9.37 1344 12.4 2.34 6.10 1.79 20.7 3.07 14.1 8.88 1512 12.0 0.917 5.81 1.81 19.7 5.98 13.4 7.16 1680 12.3 1.95 5.42 2.01 18.4 3.30 11.5 5.77 1848 10.6 0.83 5.18 1.51 14.3 1.35 11.4 6.39 2016 9.83 2.06 4.30 2.03 14.9 1.75 9.86 3.75 2184 10.2 2.42 4.55 1.36 12.6 0.755 8.87 3.37 2520 9.45 2.16 5.54 1.82 11.6 2.06 9.27 3.53 2856 8.26 0.737 4.78 1.61 10.5 2.65 7.49 3.02 3192 6.82 1.38 4.04 1.02 8.67 2.71 6.28 2.52 3528 6.83 2.27 4.02 1.05 6.92 2.09 5.68 2.79 3864 6.69 0.794 3.95 0.866 5.90 2.21 5.00 2.53 4200 6.41 1.72 3.49 0.987 4.41 2.04 3.74 2.03 ~cv% 8-29 NC-47 6-46 26-63 T shah (h) 24 24 18 120 83 Stax (ng/ml) 68.1 17.6 24.0 1.14 215 66.7 94.2 33.3 T last (h) 4200 4200 4200 4200 AUClast (ng*h/ml) 50200 4240 24800 5520 109000 12300 75200 28700 AUCo-2856 (ng*h/ml) 41000 2880 19300 4150 99200 13200 67600 26100 AUCinf (ng*h/ml) NC NC 121000 11400 85500 28800

Rat study: for formulation 1A, i.e. nanosuspension at 200 mg/mL and administration of SC at 40 mg/kg (StDev=standard deviation) and IM at 40 mg/kg (in this case a small sample size is used to calculate the outcome variable).

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Time (h) The concentration of bedaquiline (BDQ) or its metabolite (M2) in plasma SC at 40 mg/kg IM at 40 mg/kg BDQ StDev M2 StDev BDQ StDev M2 StDev 1 42.1 11.4 BOL ^a NC 329 256 12.0 5.77 4 81.5 17.0 11.7 3.50 365 176 39.5 16.7 7 98.7 25.2 20.3 4.15 385 124 68.6 30.4 24 337 57.0 127 20.8 436 41.2 217 36.3 168 92.4 33.6 100 17.7 94.9 25.1 89.9 21.8 336 62.7 5.61 62.9 25.3 53.0 13.0 48.6 21.2 504 42.1 6.21 45.8 30.7 36.2 7.49 26.6 12.0 672 28.4 1.04 32.4 22.5 22.4 3.35 15.8 5.31 840 20.8 3.67 21.1 13.4 25.9 2.48 11.1 2.50 1008 16.5 4.56 16.2 12.0 12.0 1.55 8.13 1.82 1176 12.7 4.58 12.7 10.0 9.05 1.23 5.74 1.07 1344 12.0 7.04 10.1 9.35 7.33 0.739 4.20 1.18 1512 7.02 2.77 7.61 6.32 4.69 0.384 3.05 0.640 1680 6.05 2.79 6.02 NC 4.57 0.378 2.63 0.242 1848 4.95 2.56 5.35 5.22 4.05 0.192 1.56 NC 2016 4.36 2.12 4.08 NC 3.21 0.646 1.92 0.246 2184 3.77 1.94 3.49 NC 2.50 0.0231 1.80 0.102 2520 2.72 1.67 2.97 2.62 2.27 0.437 1.45 0.121 2856 2.51 0.880 2.50 2.16 1.56 0.335 0.926 0.0759 3192 1.51 0.892 2.14 NC 1.26 0.275 0.841 0.0826 3528 1.50 NC 1.28 NC 1.37 NC BOL ^a NC 3864 0.887 NC BOL ^a NC BOL ^a NC BOL ^a NC 4200 0.753 NC BOL ^a NC BOL ^a NC BOL ^a NC ~cv% NC-61 NC-90 1-78 NC-48 T shah (h) 24 24 16 24 Stax (ng/ml) 337 57.0 127 20.8 505 96.6 217 36.3 T last (h) 3900 580 3500 670 3500 340 3300 190 AUClast (ng*h/ml) 79100 3100 67200 33600 80400 8260 53400 10700 AUCo-2856 (ng*h/ml) 77300 4240 65400 31200 79400 8800 53000 10700 AUCinf (ng*h/ml) 80100 2890 68600 34500 81200 8230 54000 10700

NC=He calculated

BOL ^a = below the limit of quantitation (0.75 ng/mL or 1.5 ng/mL) microsuspension at 200 mg/mL and administration of SC at 40 mg/kg (StDev=standard deviation) and IM at 40 mg/kg.

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Time (h) The concentration of bedaquiline (BDQ) or its metabolite (M2) in plasma SC at 40 mg/kg IM at 40 mg/kg BDQ StDev M2 StDev BDQ StDev M2 StDev 1 1.55 0.0794 BOL ^a NC 765 136 BOL ^a NC 4 5.43 1.48 BOL ^a NC 703 292 14.9 5.87 7 8.80 2.48 BOL ^a NC 735 274 21.2 8.72 24 21.9 13.0 BOL ^a NC 349 28.3 27.7 9.76 168 192 261 32.9 40.1 351 65.6 69.8 11.6 336 160 173 47.1 46.9 355 30.2 94.2 7.02 504 149 151 50.4 51.5 338 30.0 93.8 13.2 672 123 109 46.2 43.1 284 37.8 90.6 16.9 840 161 138 53.1 48.2 315 30.1 96.2 3.24 1008 125 104 50.1 40.1 227 25.2 80.7 4.11 1176 116 96.4 42.8 34.9 187 45.1 60.8 13.0 1344 BY 96.2 40.4 31.9 172 38.7 52.8 11D 1512 108 93.5 41.0 35.7 171 34.4 62.1 14.2 1680 136 107 39.7 31.9 183 37.6 51.8 6.85 1848 93.0 75.4 37.4 30.4 135 43.4 46.9 9.40 2016 89.5 71.4 35.9 26.0 121 31.1 41.2 7.86 2184 82.0 59.8 28.6 23.4 108 28.4 37.1 9.31 2520 83.1 58.8 29.8 24.3 88.0 28.4 29.2 7.60 2856 75.3 53.5 28.8 23.2 74.3 23.5 26.4 5.30 3192 60.3 36.1 23.8 15.4 58.7 17.6 22.1 5.17 3528 59.1 34.3 20.3 13.4 54.0 17.2 18.9 6.60 3864 52.8 26.0 20.1 11.0 45.4 15.8 16.4 5.17 4200 51.7 30.2 20.4 13.2 40.9 14.6 15.6 4.63 ~cv% 5-136 NC-122 8-42 3-41 T shah (h) 620 390 780 260 3.0 620 260 Stax (ng/ml) 219 237 55.3 47.7 822 211 103 6.58 T last (h) 4200 4200 4200 4200 AUClast (ng*h/ml) 402000 335000 138000 114000 652000 105000 193000 27900 AUCinf (ng*h/ml) NC NC NC 690000 NC NC NC

NC=He calculated

BOL ^a = below the limit of quantitation (3.75 ng/mL) Canine study: for Formulation 1A, i. nanosuspension at 200 mg/mL and administration of SC at 40 mg/kg (StDev=standard deviation) and IM at 40 mg/kg (in this case a small sample size is used to calculate the outcome variable).

Time (h) The concentration of bedaquiline (BDQ) or its metabolite (M2) in plasma SC at 40 mg/kg IM at 40 mg/kg BDQ StDev M2 StDev BDQ StDev M2 StDev 1 274 466 BOL ^a NC 4000 1510 11.1 1.35

- 27 042188

4 194 197 BOL ^a NC 3570 620 41.7 7.25 7 157 134 4.94 NC 2690 842 51.5 10.6 24 167 52.6 8.68 6.84 742 82.3 62.6 17.2 168 692 217 127 54.6 568 142 108 27.1 336 386 55.4 132 29.0 412 19.2 112 24.4 504 318 76.8 BY 7.77 321 13.1 98.4 21.0 672 244 28.4 93.8 14.9 240 29.6 84.1 25.0 840 255 29.7 93.0 5.84 254 12.7 89.4 24.5 1008 197 40.6 74.8 2.20 172 23.4 63.7 16.2 1176 158 21.4 59.5 4.92 149 10.0 58.7 13.0 1344 133 19.5 47.3 2.10 139 13.2 47.1 12.8 1512 124 25.4 46.4 5.82 120 8.62 41.6 10.6 1680 136 24.0 43.6 3.40 126 17.0 44.5 I,7 1848 89.6 23.8 33.8 3.53 95.2 2.14 32.7 4.60 2016 84.5 18.8 31.6 3.04 89.9 16.7 31.7 7.72 2184 80.5 25.4 27.9 3.52 78.4 5.66 24.5 6.07 2520 59.7 14.8 21.1 2.04 57.4 4.47 19.4 3.07 2856 53.9 18.0 19.6 4.25 54.8 3.04 18.7 2.77 3192 45.2 16.7 16.4 4.19 42.9 4.32 14.5 2.80 3528 40.0 12.3 14.9 3.55 36.1 1.40 12.4 2.06 3864 34.5 13.1 12.8 3.20 32.3 2.42 11.5 1.82 4200 31.1 14.1 12.1 4.02 25.4 1.37 9.49 1.42 ~cv% 12-170 NC-79 2-38 12-30 T shah (h) 168 280 97 3 2.0 280 97 Stax (ng/ml) 692 217 140 42.8 4150 1290 121 21.7 T last (h) 4200 4200 4200 4200 AUClast (ng*h/ml) 580000 82500 186000 8740 641000 27700 174000 32900 AUCinf (ng*h/ml) NC NC 215000 NC 677000 24800 193000 32200

NC=He calculated

BOL ^a = below the limit of quantitation (0.75 ng/mL)

Example 3

Evaluation of an injectable composition based on long-acting bedaquiline in a mouse model of the oligobacillary form of latent tuberculosis infection.

The aim of this study was to use a mouse model of oligobacillary latent tuberculosis infection (LTBI) to compare the bactericidal activity of a bedaquiline long-acting (BLA) formulation administered every 4 weeks for a total of 1, 2, or 3 doses with that of a daily (5 days per week) oral administration of dose B at the standard dose of 25 mg/kg or lower doses corresponding to the total doses of the drug administered as BLA. The original scheme of the study is presented in Table. 1. The BLA used for this study is as described in Example 1B above, ie. microsuspension with a concentration of 200 mg/ml). The primary outcome is a reduction in the number of CFUs of Mycobacterium tuberculosis in the lungs during treatment.

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Table 1

An original study design to assess the bactericidal activity of B _LA in a mouse model of the oligobacillary form of LTBI

Treatment regimen LTBI* The number of mice that were sacrificed for lung CFU counting at the following time points: Total number of mice Total dose B for 12 weeks (mg/kg) BCG Immunization Not infected with M.tb. Start of treatment During treatment Week -12 A week - 6 Day 0 Week 4 Week 8 Week 12 no processing and 5 5 5 5 5 5 thirty N. d. Rio(5/7) 5 5 5 15 N. d. Р15Н50 (1/7) 5 5 5 15 N. d. At ₂₅ (5/7) 5 5 5 15 1500 At ₈ (5/7) 5 5 5 15 480 At ₅ , zz (5/7) 5 5 5 15 320 At 2.67 (5/7) 5 5 5 15 160 In la-160 (1/28) x 3 5 5 480 In la-160 (1/28) x 2 5 5 10 320 BlA-160 (1/28) x 1 5 5 5 15 160 Total number of mice 5 5 5 40 45 50 150

*R, rifampicin, R, rifapentine, H, isoniazid, B, bedaquiline, B _LA , long-acting formulation of bedaquiline

All doses of the drug in mg / kg are indicated by a line index

Fractions in brackets indicate the frequency of administration in days B _LA was administered by intramuscular injection, all other drugs were administered by tube N.d. -no data

Justification of regimes.

Untreated mice were used to determine the level and stability of oligobacillary infection.

R ₁₀ (5/7) is an alternative treatment regimen for LTBI in the US and Canada for 4 months. It was used here as a control to qualify the model.

P ₁₅ H ₅₀ (1/7) is an alternative LTBI treatment regimen in the USA given once a week for 3 months (12 doses) It has been found to be at least as effective as 9 months of isoniazid treatment It is the most fractional of the currently recommended regimens and serves as a second control.

B ₂₅ (5/7) is B daily at the human equivalent dose previously studied in the oligobacillary model. It suggests a total dose of 500 mg/kg every 28 days.

B ₈ (5/7) is B daily at a dose that is reduced to provide the same total dose (480 mg/kg) as the B _LA dose (i.e. 160 mg/kg) administered every 28 days x 3 doses.

B ₅ , ₃₃ (5/7) is B daily at a dose that is reduced to provide the same total dose (320 mg/kg) as the B _LA dose (i.e. 160 mg/kg) administered every 28 days x 2 doses.

B ₂ , ₆₇ (5/7) is B daily at a dose that is reduced to provide the same total dose

- 29 042188 (160 mg/kg), which is the dose of composition B _LA (ie 160 mg/kg) administered once.

B _LA-160 (1/28) x 3 is formulation B _LA given at 160mg/kg every 28 days for a total of 3 doses. interval.

B _LA-160 (1/28) x 2 is a formulation of B _LA given at 160 mg/kg every 28 days for a total of 2 doses starting on day 0. Thus the total dose of B given at week 12 (320 mg/kg kg) will be the same as in group B ₅ , ₃₃ (5/7).

B _LA-160 (1/28) x 1 is a formulation of B _LA administered at 160 mg/kg once daily 0 only. Thus, the total dose B administered at week 12 (160 mg/kg) would be the same as in group B ₂ , ₆₇ (5/7).

End Results

All data for calculating the number of CFU were finally approved and are presented in Table 1 below. 2. Due to delays in the approval of legal agreements and receipt of supplies of B _LA , treatment was not started until approximately 13 weeks after infection with M. tuberculosis infection, and the timeline in Table. 2 has been adjusted accordingly. For comparison between different treatment groups, statistical significance was assessed using a one-way ANOVA adjusted for Bonferroni's multiple hypothesis testing.

table 2

End-point data on the number of M. tuberculosis CFUs in the lung

Treatment regimen LTBI* Mean (SD) logio M. tuberculosis CFU/lung at the following time points: Total dose B for 12 weeks (mg/kg) Immunization BCG Infection M.tb. Start of treatment During treatment Week -19 Week -13 Day 0 A week 4 A week 8 A week 12 no processing and N d. 2.11 (0.09) 4.75 (0.27) 4.71 (0.48) 4.60 (0.27) 4.94 (0.29) N d. Rio(5/7) 3.39 (0.46) 2.74 (0.62) 1.27 (0.85) N d Р15Н50 (1/7) 2.67 (0.25) 0.79 (0.80) 0.28 (0.41) N d. At ₂₅ (5/7) 3.01 (0.45) 0.82 (0.49) 0.07 (0.09) 1500 At ₈ (5/7) 3.30 (0.12) 2.42 (0.26) 0.69 (0.43) 480 B5,zz (5/7) 3.83 (0.25) 3.15 (0.47) 1.98 (0.17) 320 At _2.67 (5/7) 3.96 (0.35) 3.52 (0.38) 3.16 (0.24) 160 Vl-160 (1/28) x 3 1.23 (0.16) 480 Vl-160 (1/28) x 2 2.31 (0.40) 1.63 (0.40) 320 Vl-160 (1/28) x 1 3.55 (0.32) 3.31 (0.38) 1.83 (0.34) 160

*R, rifampicin; R, rifapentine; H, isoniazid; B, bedaquiline, B _LA , extended release formulation of bedaquiline

All doses of the drug in mg / kg are indicated by a line index

Fractions in brackets indicate the frequency of administration in days. SD, standard deviation N.d. - no data

BCG immunization. One hundred and fifty female BALB/c mice were infected by aerosolization with M. bovis rBCG30. The culture suspension with an OD ₆₀₀ of 1.03 was diluted 10-fold and then used for aerosol infection. The concentration of the bacterial suspension was 6.88 log ₁₀ cfu/ml,

- 30 042188 resulting in a mean implantation of 3.05 (SD 0.10) log ₁₀ cfu/lung. Six weeks later, at the time of challenge with M. tuberculosis infection, the mean BCG load in the lungs of the mice was 4.95 (SD 0.11) logio cfu. By day 0, BCG loading decreased and stabilized at 3.27 (SD 0.45) log ₁₀ cfu/lung, with similar lung loadings seen in untreated mice at 4, 8 and 12 weeks. Thus, low levels of stable BCG infection were found in the lungs of these mice, as expected.

M. tuberculosis infection. Six weeks after the BCG immunization, mice were aerosolized with M. tuberculosis H37Rv. The culture suspension with an OD ₆₀₀ of 0.850 was diluted ~100-fold and then used for aerosol infection. The concentration of the bacterial suspension was 4.73 log ₁₀ cfu/ml, resulting in a mean implantation of 2.11 (SD 0.09) log ₁₀ cfu/lung. This implantation was approximately 1 log ₁₀ CFU higher than expected. By day 0, M. tuberculosis load had stabilized at about 4.8 log ₁₀ cfu/lung, with similar lung loads seen in untreated mice at 4, 8 and 12 weeks. Thus, despite higher implantation, persistent M. tuberculosis infection was established in the lungs of these mice, with a stabilized CFU load correspondingly nearly 1 log ₁₀ CFU higher than observed in previous experiments (1-3).

Assessment of bactericidal activity (Table 2). Compared to the M. tuberculosis cfu numbers in the lungs of untreated mice, the R ₁₀ (5/7) control regimen resulted in a reduction in the mean cfu number of about 1, 2, and 3 logio cfu/lung after 4, 8, and 12 weeks of treatment, respectively. The control regimen P ₁₅ H ₅₀ (1/7) resulted in a decrease of approximately 2, 3 and 4.5 log ₁₀ cfu after 4, 8 and 12 weeks of treatment, respectively. The relative reductions in lung CFU for both control regimens are in line with expectations based on a previous study (1,2). At ₂₅ (5/7) resulted in a reduction of approximately 1.7, 4.0 and 4.9 log10 cfu/lung after 4, 8 and 12 weeks of treatment, results that were also expected based on the previous study (1-2) . Thus, higher implantation and CFU values on day 0 did not affect the relative potency of drugs against this stabilized bacterial population in the lungs of mice.

For all studied treatment regimens with B, activity increased with increasing dose, which was observed at 4, 8 and 12 weeks. For mice that received one or two doses of B _L A-16 ₀ (1/28), the reduced number of CFUs in the lung compared to untreated mice was equivalent to a decrease in mice that received the same total oral dose, B8 (5/7) within 4 or 8 weeks, respectively (p>0.05 at both time points). A single dose of B _LA _ ₁₆₀ delivering 160 mg/kg on day 0 resulted in a reduction of approximately 1.3 log ₁₀ CFU/lung, and four weeks of B ₈ (5/7) resulted in a reduction of approximately 1.5 log ₁₀ cfu/lung. After two doses of B _LA _ ₁₆₀ (1/28) or 8 weeks of B ₈ (5/7), the number of CFU in the lungs was further reduced by 1 log ₁₀ in mice that were also treated according to one of these regimens. After 12 weeks of treatment, the number of CFUs in the lungs was lower in mice that received a single dose of B _LA _ ₁₆₀ than in mice that received the same total dose of bedaquiline (160 mg/kg) at a daily dose of B ₂ , ₆₇ (5/ 7) (p=0.0002) with the first regimen resulting in a decrease of approximately 3 log ₁₀ cfu/lung and the latter regime leading to a decrease of 1.7 log ₁₀ cfu/lung compared to lung counts in untreated control mice . In mice treated with a total dose of bedaquiline of 320 mg/kg, either after two doses of B _LA _ ₁₆₀ or after daily administration of B ₅ , ₃₃ (5/7), the reduction in CFU in the lung was the same, approximately 3 log ₁₀ CFU /light (p>0.05). For mice that received a total dose of bedaquiline of 480 mg/kg with three doses of B _LA _ ₁₆₀ (1/28), the number of CFU in the lungs was higher than in mice that received an equivalent total dose with daily administration of B ₈ (5/28). 7), although the difference was not statistically significant.

After 12 weeks of treatment, almost all of the studied regimens were characterized by bactericidal activity equivalent to the treatment regimen R ₁₀ (5/7), while only regimen B ₂ , ₆₇ (5/7) was significantly less bactericidal than this control (p<0, 0001). Study regimen B ₈ (5/7) showed equivalent bactericidal activity for both P15H50 (1/7) and B ₂₅ (5/7) treatment regimens, while all other studied regimens provided significantly less bactericidal activity, than any of these control regimens at week 12. However, recorded CFU data at 12 weeks may not reflect the overall efficacy of extended-release bedaquiline-based regimens. In mice that received a single dose of B _LA _ _160b day 0, bacterial eradication was still observed 12 weeks after administration. Thus, it can be assumed that the bacterial load in the lungs of mice that received 2 and 3 doses of B _LA _ ₁₆₀ will still further decrease for at least 12 weeks after the last dose (if not longer). It is also of interest that a single dose of B _LA - ₁₆₀ appears to exhibit greater bactericidal activity from weeks 1 to 4 and from weeks 9 to 12 compared to weeks 5 to 8 after administration, suggesting the possibility of biphasic B release kinetics. from a sustained-release carrier medium.

Conclusions.

Despite higher bacterial implantation than expected, resistant M. tuberculosis infection was established in BALB/c mice, which were suitable for evaluating treatment regimens.

LTBI.

After 12 weeks of treatment, the once-monthly dosage of B _LA - ₁₆₀ demonstrated superior or equivalent bactericidal activity compared to daily administration of a total dose of bedaquiline of 160 or 320 and 480 mg/kg, respectively.

The bactericidal activity observed with a single dose of B _LA-160 was expressed for at least 12 weeks after administration, and it is likely that the number of CFU continued to decrease in the lungs of mice that received 2 and 3 doses. Taken in conjunction with the higher than expected baseline bacterial load in this experiment, these results indicate that a cure after 2 or 3 injections may be possible. Thus, it will be necessary to evaluate the sterilizing activity of such B _LA- based regimens over longer periods of time to truly understand their potential for use in the treatment of LTBI.

literary sources.

1) Zhang, T., Li, S., Williams, K., Andries, K., Nuermberger, E. 2011. Short-course chemotherapy with TMC207 and rifapentine in a murine model of latent tuberculosis infection. Am. J Respir. Crit. Care Med. 184:732-737.

2) Lanoix, J.P., Betoudji, F., Nuermberger, E. 2014. Novel regimens identified in mice for treatment of latent tuberculosis infection in contacts of multidrug-resistant tuberculosis cases. Antimicrob. Agents Chemother. 58:2316-2321.

3) Zhang, T., M. Zhang, I. M. Rosenthal, J. H. Grosset, and E. L. Nuermberger. 2009. Short-course therapy with daily rifapentine in a murine model of latent tuberculosis infection. Am. J Respir. Crit Care Med. 180:11511157.

Claims (15)

CLAIM 1. Pharmaceutical composition for administration by intramuscular or subcutaneous injection, containing a therapeutically effective amount of bedaquiline or its pharmaceutically acceptable salt in the form of a micro- or nanoparticle suspension, containing (a) bedaquiline or its pharmaceutically acceptable salt in the form of micro- or nanoparticles and a surface modifier; and (b) a pharmaceutically acceptable aqueous carrier. 2. The composition of claim 1, wherein the surface modifier is selected from the group of poloxamers, α-tocopheryl polyethylene glycol succinates, polyoxyethylene sorbitan fatty acid esters, and salts of negatively charged phospholipids. 3. The composition according to claim 1 or 2, wherein the bedaquiline is in its non-salt form, or in free form, or in the form of a fumarate salt. 4. A composition according to any one of claims 1 to 3, wherein the surface modifier is selected from 338 Pluronic™ F108 poloxamer, TGPS α-tocopheryl polyethylene glycol vitamin E succinate, Tween™ 80 polyoxyethylene sorbitan ester, and Lipoid™ EPG sodium egg phosphatidylglycerol. 5. A composition according to any one of claims 1 to 4, wherein the average effective particle size of the micro- or nanoparticles of bedaquiline or a pharmaceutically acceptable salt thereof is less than about 50 microns, in particular less than about 200 nm. 6. A composition according to any one of claims 1 to 4, wherein the average effective particle size of the micro- or nanoparticles of bedaquiline or a pharmaceutically acceptable salt thereof is approximately 130 nm. 7. The composition according to claim 1 or 2, containing by weight in terms of the total volume of the composition: (a) 10 to 70% w/v, or 20 to 60% w/v, or 20 to 50% w/v, or 20 to 40% w/v. bedaquiline or a pharmaceutically acceptable salt thereof; but the proportion of weight./about. calculated from its non-salt form; (b) 0.5 to 20% or 2 to 15% or 20% w/v or 5 to 15% w/v. wetting agent; (c) 0 to 10% or 0 to 5% or 0 to 2% or 0 to 1% of one or more buffering agents; (d) 0 to 20% or 2 to 15% or 20% w/v or 5 to 15% w/v. isotonic agent; (e) 0 to 2% w/v preservatives and (f) water for injection in sufficient quantities up to 100%. 8. The use of a pharmaceutical composition according to any one of claims 1 to 7 for the manufacture of a medicinal product intended for the treatment of a pathogenic mycobacterial infection. 9. Use according to claim 8, where the medicinal product is intended for the long-term treatment of Mycobacterium tuberculosis or Mycobacterium leprae. 10. Use according to claim 8, where the drug is intended for administration by intramuscular or subcutaneous injection; wherein the composition is administered intermittently at intervals of one week to two years. 11. Use according to claim 8, where the pharmaceutical composition is administered at an interval of at least - 32 042188 from one month to one year. 12. Use according to claim 8, wherein the pharmaceutical composition is administered at a time interval that is in the range of one week to one month, or in the range of one month to three months, or in the range of three months to six months, or in the range six months to twelve months, or in the range of 12 months to 24 months. 13. Use according to claim 8, wherein the pharmaceutical composition is administered once every two weeks, or once a month, or once every three months. 14. Use according to claim 8, where the medicinal product is intended for long-term treatment of Mycobacterium tuberculosis in a latent/dormant form. 15. The method of obtaining a pharmaceutical composition according to any one of claims 1 to 7, including (a) obtaining bedaquiline or its pharmaceutically acceptable salt in micronized form; (b) adding micronized bedaquiline or a pharmaceutically acceptable salt thereof to the liquid medium to form a premix/predispersion; and (c) mechanically treating the premix in the presence of an abrasive to reduce the effective mean particle size.