EA042761B1 - METHOD FOR TREATMENT OF LUNG DISEASES AND SET - Google Patents

Description

Technical field

The invention relates to a method for preventing or treating a lung disease or condition in a subject, comprising the step of administering a pharmaceutical composition containing cyclosporine A in liposomal solubilized form (L-CsA) to said subject, wherein the pharmaceutical composition is administered to the subject by inhalation as an aerosol produced in a nebulizer, containing a vibrating membrane, as well as a mixing chamber. Also provided is a kit for preventing or treating a lung disease or condition in a subject, containing a pharmaceutical composition containing cyclosporin A in a liposomal solubilized form and a nebulizer.

State of the art

WO 2007/065588 A1 describes liquid pharmaceutical compositions comprising a therapeutically effective dose of cyclosporine, an aqueous liquid carrier, a first solubilizer selected from the group of phospholipids, and a second solubilizer selected from the group of nonionic surfactants, suitable, inter alia, for intrapulmonary administration in the form of an aerosol.

Pharmaceutical compositions such as those described above may be administered to a subject in need thereof by inhalation. It should be noted that cyclosporins such as cyclosporin A, like many other macrocyclic immunosuppressive compounds, are extremely potent drugs for suppressing the immune response in a patient in need of said treatment. In other individuals who do not require or are not undergoing immunosuppressive treatment, however, these highly active compounds may cause undesirable, or even health threatening, effects when administered.

In cases where an immunosuppressive or other highly active drug is to be administered by inhalation, a nebulizer is generally required to provide an appropriate aerosol containing said drug, often in the form of an aerosol. With these nebulizers, however, some of the nebulized liquid may be expelled from the nebulizer when the user exhales. In particular, known nebulizers of this type comprise an ambient air port and an exhalation port, each of which contains a one-way valve that allows ambient air to enter the nebulizer during inhalation and to remove air from the nebulizer during exhalation. A nebulizer of this type is described, for example, in European patent EP 1 927 373 B1.

In some instances, as noted above, the nebulizable/aerosolizable liquid may contain compounds that adversely affect individuals who remain in the environment in which the patient breathes, even though they are used to treat a disease in the patient. It is known in the art to use exhalation filters to prevent the removal (excretion) of these components into the environment. One example where said exhalation filter is shown is EP 1 868 570 B1.

In addition, in particular in view of the problem described above and in view of the fact that a macrocyclic immunosuppressant such as cyclosporin A should be administered in the smallest possible amount and exclusively or predominantly in the target tissue, there still remains a need for a pharmaceutical composition containing macrocyclic immunosuppressant, for inhalation, which provides efficient delivery of the selected immunosuppressant, where the maximum possible amount of the administered immunosuppressant is actually delivered to the target tissues, and the minimum amount of the administered compound is exhaled by patients during administration. In addition, there remains a need for improved transport of macrocyclic immunosuppressants, in particular to peripheral lung tissues.

Thus, it is an object of the present invention to provide a method for preventing or treating a lung disease or condition in a subject, comprising administering a pharmaceutical composition comprising cyclosporin A in a liposomal solubilized form, wherein the pharmaceutical composition is administered to the subject by inhalation as an aerosol, and wherein the aerosol is generated by spraying the pharmaceutical composition using a nebulizer, where cyclosporin A in liposomal solubilized form is administered in a form that ensures the delivery of its maximum amount or proportion actually delivered to the target tissue; and the amount or proportion of administered cyclosporin A in liposomal solubilized form that is not delivered to the target tissue and exhaled by the subject is minimized.

Additional objects of the present invention will be clear from the present description, including examples and claims.

Brief description of the invention

According to a first aspect, the present invention provides a method for preventing or treating a lung disease or condition in a subject, comprising the step of administering a pharmaceutical composition containing cyclosporine A in liposomal solubilized form (L-CsA) to said subject,

- 1 042761 where the pharmaceutical composition is administered to the subject by inhalation in the form of an aerosol, and where the aerosol is produced by spraying the pharmaceutical composition using a nebulizer (100) containing:

a) an aerosol generator (101), comprising:

a fluid reservoir (103) or an adapter configured to connect the fluid reservoir and a vibrating membrane (110) having a plurality of holes designed to produce an aerosol containing droplets having a mass median aerodynamic diameter (MMAD) up to to about 4.0 µm when measured using 0.9% (w/v) aqueous sodium chloride solution;

b) a chamber (105) for temporarily accommodating the aerosol produced by the aerosol generator, having an internal cavity with a volume ranging from about 50 to about 150 ml; And

c) a mouthpiece (40) for delivering an aerosol to a subject, wherein the mouthpiece has an exhalation filter (30);

while the mouthpiece (40) contains:

a body (46) defining a fluid channel (47) from an inlet (41) configured to be connected to the chamber (105) to an inhalation hole (42) to be placed in the user's mouth; and an exhalation filter (30) comprising a filter base (31) in fluid communication with a fluid channel (47), an upper filter part (33) detachably connected to the filter base (31), and a filter material (32 ) provided between the base (31) of the filter and the upper part (33) of the filter, and the upper part (33) of the filter has an opening (36) for exhalation, equipped with a one-way valve (39), ensuring the removal of fluid from the channel (47) for fluid media through the filter material (32) out of the mouthpiece (40) when the patient exhales through the inhalation hole;

wherein the filter housing (46) and base (31) are an integrated one-piece unit.

According to a second aspect, the present invention provides a kit for preventing or treating a lung disease or condition in a subject, comprising a pharmaceutical composition comprising cyclosporine A in a liposomal solubilized form; and a nebulizer (100) containing:

a) an aerosol generator (101), comprising:

a reservoir (103) for a fluid medium for storing a pharmaceutical composition or an adapter configured to connect the reservoir for a fluid medium and a vibrating membrane (110) having a plurality of holes designed to produce an aerosol containing droplets having a mass median aerodynamic diameter (MMAD) down to about 4.0 μm when measured using 0.9% (w/v) aqueous sodium chloride solution;

b) a chamber (105) for temporarily housing the aerosol produced by the aerosol generator (101), having an internal cavity with a volume ranging from about 50 to about 150 ml; And

c) a mouthpiece (40) for delivering an aerosol to a subject, the mouthpiece having an exhalation filter (30);

while the mouthpiece (40) contains:

a body (46) defining a fluid channel (47) from an inlet (41) configured to be connected to the chamber (105) to an inhalation hole (42) to be placed in the user's mouth; and an exhalation filter (30) comprising a filter base (31) in fluid communication with a fluid channel (47), an upper filter part (33) detachably connected to the filter base (31), and a filter material (32 ) provided between the base (31) of the filter and the upper part (33) of the filter, and the upper part (33) of the filter has an opening (36) for exhalation, equipped with a one-way valve (39), ensuring the removal of fluid from the channel (47) for fluid media through the filter material (32) out of the mouthpiece (40) when the patient exhales through the inhalation hole;

wherein the housing (46) and the base (31) of the filter are an integrated one-piece unit.

Brief description of graphic materials

In FIG. 1 is a perspective view of a nebulizer suitable for administering an inhaled immunosuppressive macrocyclic active ingredient of the present invention with an exhalation filter connected to the nebulizer via a T-adapter, where the filter is directed to the right when viewed from the front and a separate mouthpiece is connected to the adapter.

In FIG. 2 is a front perspective view of the nebulizer shown in FIG. 1 in which the filter is tilted to the right.

In FIG. 3 is a perspective side view of the nebulizer mouthpiece shown in FIG. 1.

In FIG. 4 is an exploded view of the mouthpiece shown in FIG. 3, and chambers of the nebulizer for mixing.

In FIG. 5 is a longitudinal section through the nebulizer and mouthpiece shown in FIG. 3 and 4.

Detailed description of the invention

The terms consist of, consists of and consisting of in this document are so-called closed formulations, that is, they mean the presence of only the specified components. The terms contain, contains and containing in this document are so-called open statements, that is, they mean that one or more additional components may also be present, but also that they may be absent.

The term active ingredient or active pharmaceutical ingredient (also referred to herein as API) refers to any type of pharmaceutically active compound or derivative that is suitable for preventing, diagnosing, stabilizing, treating, or, in a broad sense, managing a condition, disorder, or disease.

The term therapeutically effective amount as used herein refers to a dose, concentration, or level that is appropriate to provide the desired pharmacological effect. In the context of the present invention, the term therapeutically effective also includes prophylactic activity. The therapeutic dose should be determined taking into account the specific application. The therapeutic dose should be determined taking into account the nature and severity of the disease, the method of application, and the growth and condition of the patient, in a manner known to the specialist.

In the context of the present invention, a pharmaceutical composition is a preparation of at least one API and at least one adjuvant, which, in the simplest case, may be, for example, an aqueous liquid carrier such as water or saline.

The singular forms do not exclude the plural, i.e. it is to be understood that the singular forms include references to a plurality of entities unless the context explicitly states or requires otherwise. In other words, all references to individual characteristics or limitations in the present invention must include the respective combinations of characteristics or limitations, and vice versa, unless the context in which the characteristic or limitation is mentioned expressly states otherwise or otherwise is clearly implied. The singular forms thus have the same meaning as at least one or one or more, unless otherwise specified. For example, the indication of an ingredient includes mixtures of ingredients, and so on.

As used herein, the term approximately or approximately takes into account the margin of error inherent in the pharmaceutical industry and inherent in pharmaceutical products, such as differences in content due to manufacturing process variability and/or product degradation over time. The specified term allows for any deviations that in the field of pharmaceuticals allow the product under evaluation to be considered as bioequivalent to the specified level of the claimed product in a mammal.

Essentially, approximately, approximately, significantly, etc. in relation to a feature or value, include a specific feature or exact value, as well as any features or values that are generally considered to be within the norm or error acceptable in the art. For example, substantially free of water means that water is not intentionally included in the composition, but does not exclude the presence of residual moisture.

In the context of the present invention, a colloidal aqueous solution preferably means an organic solvent-free solution consisting essentially of unilamellar liposomes having an average diameter of not more than 100 nm and/or a polydispersity index (PI) of not more than 0.50, in which at least predominantly dissolved active agent. Preferably, water, or more specifically saline, is the only liquid solvent contained in the formulation. It is further preferred that the preparation is an aqueous solution or an aqueous colloidal solution, i.e. single phase liquid system. Said system is substantially free of dispersed particles larger than colloidal particles. Typically, particles smaller than about 1 micron are considered colloidal particles that do not constitute a separate phase and do not result in the formation of a physical interface between the phases. Sometimes particles slightly larger than 1 µm are also considered colloidal. Preferably, however, the colloidal aqueous solutions used in the present invention are substantially free of particles that are not known to belong to the colloidal particle spectrum, ie, for example, particles with a diameter of 1 μm or more.

According to a first aspect, the present invention provides a pharmaceutical composition comprising an inhaled immunosuppressive macrocyclic active ingredient for use in the prevention or treatment of a lung disease or condition in a subject, wherein the pharmaceutical composition is administered to the subject by inhalation as an aerosol, and the aerosol is produced by spraying the pharmaceutical composition using a nebulizer. (100) containing:

a) an aerosol generator (101), comprising:

a reservoir (103) for a fluid medium for storing a pharmaceutical composition or an adapter configured to connect the reservoir for a fluid medium and a vibrating membrane (110) having a plurality of holes designed to produce an aerosol containing drops having mass median aerodynamic diameter (MMAD) up to about 4.0 μm when measured using 0.9% (w/v) aqueous sodium chloride solution;

b) a chamber (105) for temporarily housing the aerosol produced by the aerosol generator (101), having an internal cavity with a volume ranging from about 50 to about 150 ml; And

c) mouthpiece (40) for delivery to the subject of the aerosol supplied by the nebulizer (100), while the mouthpiece has an exhalation filter (30).

Pharmaceutical compositions for use according to the present invention containing an inhaled immunosuppressive macrocyclic active ingredient are suitable for the prevention or treatment of a wide range of lung diseases or conditions in a subject. The term "subject" as used herein refers to a mammal, more specifically a human, diagnosed with or at risk of developing said diseases or conditions. In specific embodiments, the term subject as used herein refers to a human or patient who has been diagnosed with a lung disease or condition and is in need of treatment.

In specific embodiments, the disease or condition of the lung to be treated by administering the compositions for use according to the present invention is selected from the group consisting of lung disease, asthma, refractory asthma, chronic obstructive bronchitis, parenchymal, fibrotic and interstitial diseases and lung inflammation, bronchiolitis obliterans (BOS) and acute and chronic organ transplant rejection reactions after lung transplantation, and diseases caused by them. In additional specific embodiments, the lung disease or condition is bronchiolitis obliterans (BOS), optionally occurring after acute and chronic organ transplant rejection reactions after lung transplantation or after hematopoietic stem cell transplantation (HSCT).

In additional specific embodiments, a pharmaceutical composition for use according to the present invention is suitable for treating a lung disease or condition, or for preventing or delaying the progression of said lung disease or condition, such as described above, e.g., BOS, in a subject or patient diagnosed with said disease or condition, in particular BOS. The presence of BOS, for example, can be determined based on spirometric measurements of forced expiratory volume (FEV). Preferably, a decrease in forced expiratory volume in one second (FEV1) is considered as an indicator of the presence of BOS and, accordingly, as a risk factor for chronic lung transplant rejection. FEV1 measurements can be made according to the currently used American Thoracic Society (ATS)/European Respiratory Society (ERS) spirometry guidelines. Forced expiratory volume in one second (FEV1) is expressed in liters (l).

Bronchiolitis obliterans (BOS) can be classified according to the degree of progression of said lung disease, as described in Estenne M, et al. Bronchiolitis obliterans syndrome 2001: an update of the diagnostic criteria. J Heart Lung Transplant 2002; 21(3): 297-310. Based on the percentage reduction in forced expiratory volume in one second (FEV1), BOS can be classified as follows:

BOS 0: FEV1 > 90% of baseline,

BOS 0-r: FEV1 81 to 90% of baseline,

BOS 1: FEV1 66 to 80% of baseline,

BOS 2: FEV1 51 to 65% of baseline,

BOS 3: FEV1 50% or less of baseline.

Compositions for use according to the present invention may be particularly suitable for treating or preventing or delaying the progression of BOS grade I (BOS 1) or more severe, more specifically BOS grade I or II, or even more specifically BOS grade I (BOS 1).

Pharmaceutical compositions for use according to the present invention, in particular embodiments, may be liquid compositions. In these embodiments, compositions for use according to the present invention comprise an inhaled immunosuppressive macrocyclic active ingredient and a liquid carrier or vehicle in which the active ingredient can be dissolved, dispersed or suspended. Accordingly, in specific embodiments, a pharmaceutical composition for use according to the present invention is a liquid composition containing an aqueous liquid carrier medium. In additional specific embodiments, the liquid carrier medium is an aqueous liquid carrier medium, which may contain water and optionally one or more physiologically acceptable organic solvents such as ethanol or propylene glycol, etc., preferably, however, ethanol and/or propylene glycol. In additional specific embodiments, the liquid carrier medium contains one or more pharmaceutically acceptable salts such as sodium chloride (NaCl). Accordingly, the liquid carrier medium may contain a saline solution or may consist essentially of a saline solution. In these specific embodiments, as well as in other embodiments in which the aqueous liquid carrier medium contains additional components or solvents, the concentration of sodium chloride may be from about 0.1 to about 7% (w/v), or from about 0.1 to about 3% (w/v), or from about 0.1 to about 0.9% (w/v). Preferably, a saline solution with a sodium chloride concentration of about 0.25% (w/v) is used, where the term w/v. denotes the mass of dissolved sodium chloride per volume of liquid carrier medium contained in the aqueous liquid composition.

Pharmaceutical compositions for use according to the present invention further comprise an inhaled macrocyclic immunosuppressive active ingredient. Examples of such inhaled macrocyclic immunosuppressive active ingredients include, but are not limited to, cyclosporin A (CsA), tacrolimus, sirolimus and/or everolimus, preferably in a therapeutically effective amount. The immunosuppressive compound as defined above may be present as the sole active ingredient or as a mixture of two or more different inhaled immunosuppressive macrocyclic active ingredients, optionally in combination with other active ingredients that are not immunosuppressive and/or macrocyclic. In specific embodiments, however, pharmaceutical compositions for use according to the present invention contain only one inhaled immunosuppressive macrocyclic active ingredient.

In preferred embodiments, however, the inhaled immunosuppressive macrocyclic active ingredient is selected from cyclosporin A (CsA) and tacrolimus. In further preferred embodiments, the inhaled immunosuppressive active ingredient contained in the pharmaceutical compositions for use according to the present invention is cyclosporin A (cyclosporin A; CsA (cyclo-[[(E)-(2S,3R,4R)-3-hydroxy4- methyl-2-(methylamino)-6-octenoyl]-L-2-aminobutyryl-N-methylglycyl-N-methyl-L-leucyl-L-valyl-Nmethyl-L-leucyl-L-alanyl-D-alanyl-N -methyl-L-leucyl-N-methyl-L-leucyl-N-methyl-L-valyl]). A1 and can be obtained accordingly.

In other embodiments, however, the inhaled macrocyclic immunosuppressive active ingredient contained in pharmaceutical compositions for use according to the present invention is tacrolimus.

It should be noted that inhaled macrocyclic immunosuppressants such as those described above, in particular cyclosporin A (CsA) and tacrolimus, are extremely potent compounds that provide immunomodulatory effects in a patient or other individual when exposed to very low amounts or concentrations of these compounds. As noted above, however, it may be detrimental or even threatening to the health of individuals who remain in the environment in which the patient breathes, even though they are used to treat disease in the patient. With this in mind, it is very important to provide a nebulizer or mouthpiece that allows efficient administration of aerosols containing said compounds to a patient while minimizing the risk of adverse effects on individuals other than said patient as a result of exhalation of said compounds, or more particularly that portion of said active ingredients that are not absorbed into the patient's body during inhalation.

In specific embodiments, a pharmaceutical composition for use according to the present invention, more specifically, liquid pharmaceutical compositions for use according to the present invention, contain a selected immunosuppressive macrocyclic active ingredient, in particular cyclosporine A (CsA) or tacrolimus, preferably cyclosporine A (CsA), in concentrations ranging from about 1 to about 10 mg/ml, preferably from about 2 to about 8 mg/ml, more preferably from 2.5 to about 6 mg/ml, even more preferably from 3 to about 4 mg/ml, in in particular, at a concentration of about 4 mg/ml.

In further specific embodiments, the inhaled immunosuppressive active ingredient, in particular cyclosporine A, is present in pharmaceutical compositions for use according to the present invention in liposomal solubilized form (L-CsA). Where liquid, preferably aqueous liquid pharmaceutical compositions for use according to the present invention, contain cyclosporin A in liposomal solubilized form (L-CsA), the appropriate concentration of L-CsA may be from about 3 to about 5 mg/ml, more specifically from about 3.8 to about 4.2 mg/ml.

In additional specific embodiments, in particular, in which the proposed pharmaceutical compositions for use contain an inhaled immunosuppressive macrocyclic active ingredient in a liposomal solubilized form, a pharmaceutical composition in liquid form can be obtained by redissolving a lyophilisate containing said immunosuppressive macrocyclic active ingredient and liposomal forming structures.

Said liposome forming structures may further comprise a membrane forming substance selected from the group of phospholipids, or two or more different membrane forming substances selected from the group of phospholipids. The term substance that forms the membrane in the present

- 5 042761 document means that the specified substance can form a lipid bilayer membrane by self-assembly in an aqueous liquid carrier such as water or saline, and/or can form liposomes in an aqueous liquid carrier under conditions such as described in more detail below.

The liposome-forming structures that may be contained in the proposed pharmaceutical compositions may contain a bilayer membrane derived from a membrane-forming substance selected from the group of phospholipids. Structures forming liposomes may or may not contain a continuous or closed bilayer membrane. In these embodiments, the structures forming the liposomes are at least partially present in a single layer form, or preferably predominantly present in a single layer form. The term "unilamellar" as used herein means that the respective liposome-forming structures contain only a single layer formed by a single lipid bilayer membrane and not by a plurality of lipid bilayer membranes arranged in layers.

In specific embodiments, the inhaled macrocyclic immunosuppressive ingredient, in particular CsA, which may be contained in liposome forming structures such as described above, is at least partially incorporated (or incorporated) into the bilayer membrane of the liposome forming structures. The term is included herein when used in relation to CsA, which is a lipophilic compound, means that the CsA is located or embedded in the inner lipophilic portion of the lipid bilayer membrane, but not in the outer hydrophilic surfaces of the lipid bilayer membrane (where the term surface can refer to both surface or, more specifically, the inner or outer surface of a bilayer membrane forming structures that form liposomes). In further embodiments, the inhaled immunosuppressive macrocyclic active ingredient, particularly CsA or L-CsA, is predominantly (e.g., at least about 90%, or even at least about 95 to about 97.5%) incorporated into a bilayer membrane. structures that form liposomes.

The phospholipids that may be present in the liposome forming structures of the present invention are in particular mixtures of natural or enriched phospholipids, for example lecithins, such as the commercially available Phospholipon® G90, 100 or Lipoid 90, S 100.

Phospholipids are amphiphilic lipids that contain phosphorus. Also called phosphatides, they play an important role in nature, in particular as bilayer components of biological membranes, and phospholipids, which are derivatives of phosphatidic acid obtained by chemical methods, are often used for pharmaceutical purposes. The latter are (usually doubly) acetylated glyceryl-3-phosphate, in which fatty acid residues can have different lengths. Phosphatidic acid derivatives are, for example, phosphocholines or phosphatidylcholines in which the phosphate group is additionally esterified with choline, as well as phosphatidylethanolamine, phosphatidylinositols, etc. Lecithins are natural mixtures of different phospholipids that tend to have a high content of phosphatidylcholines. Preferred phospholipids according to the invention are lecithins as well as pure or enriched phosphatidylcholines such as dimyristoylphosphatidylcholine, dipalmitoylphosphatidylcholine and distearoylphosphatidylcholine. Accordingly, in preferred embodiments, the membrane forming agent selected from the group of phospholipids is a mixture of natural phospholipids.

In preferred embodiments, the membrane forming agent selected from the group of phospholipids is lecithin containing unsaturated fatty acid residues. In further preferred embodiments, the membrane forming agent selected from the group of phospholipids is a lecithin selected from the group consisting of soy lecithin, Lipoid S100, Phospholipon® G90, 100, or a similar lecithin. In further preferred embodiments, the membrane forming agent selected from the group of phospholipids is selected from Lipoid S100, Lipoid S75, in particular Lipoid S100.

Pharmaceutical compositions for use according to the present invention, or more particularly liposome forming structures that may be contained in the proposed pharmaceutical compositions, may additionally contain a solubility enhancer or two or more different solubility enhancers selected from the group of nonionic surfactants. Nonionic surfactants contain - like other surfactants - at least one relatively hydrophilic and at least one relatively lipophilic region of the molecule. They are monomeric low molecular weight nonionic surfactants and nonionic surfactants having an oligomeric or polymeric structure. Examples of nonionic surfactants which are suitable solubilizers of liposome forming structures such as described above include polyoxyethylene alkyl ethers, polyoxyethylene sorbitan fatty acid esters such as, for example, polyoxyethylene sorbitan oleate, esters sorbitan and fatty acids, poloxamers, vitamin E-TPGS (D-a-tocopheryl polyethylene glycol 1000 succinate) and tyloxapol.

In specific embodiments, the solubility enhancer selected from the group of nonionic surfactants is selected from the group of polysorbates and vitamin E-TPGS, preferably selected from the group of polysorbates. In a particularly preferred embodiment, the solubility agent selected from the group of nonionic surfactants is Polysorbate 80.

In specific embodiments of the proposed pharmaceutical compositions, the amount of a membrane forming agent selected from the group of phospholipids, preferably lecithin, exceeds the amount of a solubility agent selected from the group of nonionic surfactants. In exemplary embodiments, the weight ratio of a membrane forming agent (or all membrane forming agents) selected from the group of phospholipids, preferably lecithin, to a solubilizing agent (or all solubilizing agents) selected from the group of nonionic surfactants , preferably to polysorbate, is selected from the range from about 15:1 to about 9:1, preferably from about 14:1 to about 12:1, for example, about 13:1.

In additional specific embodiments, the weight ratio of (total) membrane forming substance(s) selected from the group of phospholipids and a solubilizer selected from the group of nonionic surfactants, on the one hand , to an immunosuppressive macrocyclic active ingredient, preferably CsA, on the other hand, is selected from the range of from about 5:1 to about 20:1, preferably from about 8:1 to about 12:1, and more preferably about 10:1.

In additional specific embodiments, the weight ratio of a membrane forming agent selected from the group of phospholipids, preferably lecithin, to a solubility agent selected from the group of nonionic surfactants, preferably polysorbate, and to an immunosuppressive macrocyclic active ingredient, preferably CsA, selected from the range of about 15:1:1.5 to about 5:0.3:0.5, and preferably about 9:0.7:1.

The pharmaceutical composition for use according to the present invention may additionally contain one or more additional excipients. Suitable adjuvants are known to those skilled in the art. For example, the proposed pharmaceutical compositions may optionally contain pH adjusting agents to adjust the pH, such as physiologically acceptable bases, acids or salts, optionally in the form of buffer mixtures. In this context, the term physiologically acceptable does not mean that one of the excipients must be tolerable on its own in undiluted form, as is the case, for example, with sodium hydroxide solution, but that it must be tolerated at the concentration in which it is contained. in a lyophilized pharmaceutical composition, in particular after reconstitution.

Suitable pH adjusting agents or pH adjusting buffers may be selected, among other things, based on the intended application. Examples of possible suitable excipients from this group include sodium hydroxide solution, basic sodium, calcium or magnesium salts such as, for example, citrates, phosphates, acetates, tartrates, lactates, etc., amino acids, acidic salts such as hydrogen phosphates or dihydrophosphates, in particular sodium, in addition, organic and inorganic acids, such as, for example, hydrochloric acid, sulfuric acid, phosphoric acid, citric acid, cromoglycic acid, acetic acid, lactic acid, tartaric acid, succinic acid, fumaric acid, lysine, methionine, sodium or potassium hydrogen phosphates, etc.

In some embodiments, the liquid aqueous pharmaceutical composition for use according to the present invention contains buffers to maintain a neutral or acidic pH after reconstitution of the pharmaceutical composition. Preferably, the pH of the proposed pharmaceutical composition is not more than about 8.5, or is in the range from about 2.5 to about 7.5. For intrapulmonary or parenteral administration, a pH of about 4 to about 7.5 is preferred, provided this is consistent with other formulation requirements, such as, for example, stability aspects. Particularly preferred is a pharmaceutical composition buffered with a phosphate buffer providing a pH in the range of 6.0 to 7.5 or 6.0 to 7.0, or in the range of 6.3 to 6.7, thus can be significantly improved the stability of the composition, and the formation of unwanted lysolecithin during storage can be effectively reduced.

In addition, the proposed pharmaceutical composition, in particular in aqueous liquid form, may or may not contain osmotically active adjuvants to bring the composition to the desired osmolarity, which is important in some applications, such as inhalation in particular, to ensure good tolerability. These adjuvants are often referred to as isotonic agents, and their addition does not necessarily lead to an isotonic composition.

- 7 042761 after reconstitution, but can provide isotonicity close to physiological osmolarity to achieve the highest possible physiological tolerance.

The most commonly used isotonic agent is sodium chloride. In another embodiment, the proposed pharmaceutical compositions contain an essentially neutral salt as an isotonic agent, which is not sodium chloride, but is, for example, sodium sulfate or sodium phosphate. It should be noted, however, that the isotonic agent may also be contained in an aqueous liquid carrier or carrier liquid such as described above, for example in the form of an aqueous sodium chloride solution (saline solution). In this case, however, salts other than sodium salts may also be preferred. Thus, for example, certain calcium and magnesium salts are known to have a beneficial or adjuvant effect upon inhalation of active agent solutions, possibly due to the fact that they themselves counteract local irritation caused by administration and have a bronchodilatory effect, which is currently described in the clinical literature. (for example, in Hughes et al., Lancet. 2003; 361 (9375): 2114-7), and/or due to the fact that they reduce the adhesion of microorganisms to proteoglycans of the mucous membrane of the respiratory tract and thereby indirectly maintain mucociliary clearance, which is one from the body's natural defense mechanisms against pathogens (K.W. Tsang et al., Eur. Resp. 2003. 21, 932-938). Preferred may be, for example, magnesium sulfate, which is excellently tolerated in the lungs and can be administered by inhalation without any problems, as well as calcium chloride (1-10 mmol).

In additional specific embodiments, pharmaceutical compositions for use according to the present invention contain one or more additional excipients that are selected from buffers and chelating agents. Examples of compounds which are suitable buffers for adjusting the pH of the proposed pharmaceutical compositions after reconstitution include, for example, sodium dihydrogen phosphate dihydrate and/or disodium hydrogen phosphate dodecahydrate, sodium hydroxide solution, basic sodium, calcium or magnesium salts such as, for example, citrates, phosphates, acetates, tartrates, lactates, etc., amino acids, acid salts, such as hydrogen phosphates or dihydrogen phosphates, in particular sodium, in addition, organic and inorganic acids, such as, for example, hydrochloric acid, sulfuric acid, phosphoric acid, citric acid, cromoglycic acid, acetic acid, lactic acid, tartaric acid, succinic acid, fumaric acid, lysine, methionine, sodium or potassium hydrogen phosphates, etc., and additional buffer systems such as described above. In additional specific embodiments, pharmaceutical compositions for use according to the present invention contain one or more additional excipients that are selected from chelating agents, for example, disodium edetate dihydrate, calcium sodium EDTA, preferably disodium edetate dihydrate.

Pharmaceutical compositions for use according to the present invention may be provided in solid form, such as a lyophilisate, which is suitable for reconstitution and may be reconstituted in an aqueous liquid carrier. The term "reconstituted" as used herein means that lyophilized pharmaceutical compositions obtained or made by a solid lyophilization process can be redissolved or redispersed, preferably redispersed, in an aqueous liquid carrier.

In specific embodiments, said lyophilized pharmaceutical compositions suitable for preparing pharmaceutical compositions for use in accordance with the present invention may further comprise at least one disaccharide selected from the group consisting of sucrose (sucrose; the terms sucrose and sucrose in this document have the same meanings and are used as synonyms for β-D-fructofuranosyl-α-D-glucopyranoside; CAS No. 57-50-1), lactose (β-O-galactopyranosyl-(1^4)-O-glucose; CAS No. 63-42-3 ) and trehalose (α-D-glucopyranosyl-(1^1)-α-D-glucopyranoside; CAS No. 99-20-7). In further specific embodiments, at least one disaccharide is present in an amount of at least about 40% by weight of the total weight of the lyophilized composition. In some embodiments, at least one disaccharide is present in an amount of at least about 40 wt.% up to about 95 wt.%, or up to about 90 wt.%, or up to about 85 wt.%, or up to about 80 wt. % based on the total weight of the lyophilized composition.

In additional specific embodiments, freeze-dried compositions suitable for preparing pharmaceutical compositions of the present invention contain sucrose and/or trehalose, preferably sucrose, as a disaccharide that is present in an amount of at least about 40% by weight of the total weight of the freeze-dried composition. . In additional embodiments, lyophilized compositions suitable for preparing the proposed pharmaceutical compositions by reconstitution may contain at least one disaccharide, preferably sucrose and/or lactose, in particular sucrose, in an amount selected from the range of from about 50 to about 80 wt.% , or constituting about 75 wt.% from or relative to the total weight of the lyophilized composition. In additional preferred

- 8 042761 embodiments lyophilized pharmaceutical compositions may contain at least one disaccharide, preferably sucrose and/or lactose, in particular sucrose, in an amount selected from the range from about 60 to about 75 wt.%, even more preferably selected from range from about 65 to about 70 wt.% of the total weight of the lyophilized composition.

In additional specific embodiments, lyophilized compositions containing the inhaled immunosuppressive macrocyclic active ingredient in liposomal solubilized form, preferably L-CsA, which are suitable for preparing the proposed pharmaceutical compositions, are prepared in the presence of at least one disaccharide selected from sucrose, lactose and/or trehalose .

Without wishing to be bound by theory, it is believed that this may be due to the stabilizing effect of a disaccharide selected from the group of sucrose, lactose and trehalose, which is preferably present in an amount of at least 40% by weight of the total weight of the lyophilized pharmaceutical composition. In addition, the advantageous properties of lyophilized pharmaceutical compositions described above, in particular L-CsA, may be due to the fact that a disaccharide selected from the group consisting of sucrose, lactose and trehalose, preferably sucrose, is present externally as well as in the internal cavity of the structures that form the liposome.

In additional embodiments, freeze-dried compositions suitable for preparing the subject pharmaceutical compositions by resolubility may contain CsA in an amount of from about 2 to about 4 wt.%, preferably from about 2.2 to about 3.4 wt.%, or even more preferably from about 2.4 to about 3.4 wt.%, or from about 2.4 wt.% to about 3.0 wt.% by weight of the lyophilized composition. In further specific embodiments, in said lyophilized compositions, the weight ratio of at least one disaccharide to cyclosporin A in the lyophilized composition may be selected from the range of from about 10:1 to about 30:1, or from about 20:1 to about 30:1, or from about 20:1 to about 27.5:1, or even from about 22.5:1 to about 27.5:1.

Lyophilized precursor compositions suitable for the preparation of the disclosed pharmaceutical compositions by reconstitution may be dissolved or, more specifically, dispersed in an aqueous liquid carrier, preferably a sterile aqueous liquid carrier. The aqueous liquid carrier may be water or an aqueous solution of pharmaceutically acceptable salts or isotonic agents, and may preferably be sterile. In preferred embodiments, however, the sterile aqueous liquid carrier is an aqueous sodium chloride solution, preferably with a total sodium chloride content of 0.25% (w/v). In addition, the sterile aqueous liquid carrier may additionally contain one or more buffering agents, preferably as described above. Preferably, the sterile aqueous liquid carrier, in particular an aqueous solution of sodium chloride, has a pH in the range of 4.0 to 7.0 and an osmolarity in the range of about 60 to about 100 mosmol/kg.

Preferably, the sterile aqueous liquid carrier is provided in an amount suitable for the preparation of a pharmaceutical composition for use according to the present invention as an aqueous liposomal inhalable dispersion containing CsA or another immunosuppressive macrocyclic active ingredient, e.g., tacrolimus, in liposomal solubilized form. In specific embodiments, the amounts of lyophilized precursor composition and aqueous liquid carrier may be selected from the ranges, examples of which are described above. In further preferred embodiments, an amount of a selected lyophilized precursor composition containing at least one disaccharide selected from the group consisting of sucrose, lactose, and trehalose, preferably in an amount of at least 40% by weight of the total weight of the lyophilized composition, and the amount of the aqueous liquid carrier may be chosen such that the resulting liquid liposomal dispersion contains at least one disaccharide selected from the group consisting of sucrose, lactose and trehalose, preferably sucrose, from about 5 to about 15% by weight, preferably from about 7.5 to about 12.5 wt.% of the total weight of the resulting pharmaceutical composition for use according to the present invention.

In particularly preferred embodiments, at least one disaccharide selected from the group consisting of sucrose, lactose, and trehalose is present in the resulting liquid liposomal dispersion in an amount in the range of from about 5 to about 10% by weight, or from about 7.5 to about 10 wt.%, or in an amount of about 7.5 wt.% or about 10 wt.%, based on the total weight of the liquid liposomal dispersion.

In proposed embodiments, a sterile aqueous liquid carrier, particularly an aqueous sodium chloride solution such as described above, is provided in an amount of from about 1.10 ml to about 1.50 ml and is combined with about 185 mg aliquot of a lyophilized precursor composition such as described in example 1, containing about 2.7 wt.% CsA (corresponding to 5 mg CsA). In additional proposed embodiments, a sterile aqueous liquid carrier, in particular an aqueous solution of sodium chloride, such as described above, is provided in an amount

- 9 042761 from about 2.20 ml to about 2.80 ml, and it is combined with about 375 mg of an aliquot of a lyophilized precursor composition, such as described in example 1, containing about 2.7 wt.%

CsA (corresponding to 10 mg CsA).

In specific embodiments, pharmaceutical compositions for use according to the present invention may be provided as a liquid liposomal dispersion containing an aqueous liquid carrier or vehicle and a therapeutically effective amount of a selected macrocyclic immunosuppressive active ingredient, preferably CsA in liposomal solubilized form. In further embodiments, the liquid liposomal dispersion is substantially free of visible particles. The liposomes contained in said dispersion may preferably have an average diameter, or more particularly a z-average diameter, of no more than about 100 nm as measured by photon correlation spectroscopy on a Malvern ZetaSizer. Preferably, the liquid liposome dispersion contains liposomes with a z-mean diameter measured by photon correlation spectroscopy (Malvern ZetaSizer) in the range of about 40 to about 100 nm, and even more preferably in the range of about 40 to about 70 nm. Said liposomal dispersion may have a polydispersity index (PI) as measured by photon correlation spectroscopy up to about 0.50, preferably up to about 0.4, and even more preferably in the range of from about 0.1 to about 0.3. In addition, said liquid liposomal dispersions containing the selected macrocyclic immunosuppressive active ingredient, preferably CsA, in liposomal solubilized form, may have an osmolarity in the range from about 300 to about 550 mosmol/kg, preferably in the range from about 430 to about 550 mosmol/kg . The pH value of these liquid liposomal dispersions is preferably in the range from about 6.0 to 7.0. In further embodiments, after a 1:10 dilution, the liquid liposomal dispersion according to this aspect of the invention has a turbidity of up to 200 NTU (nephelometric turbidity units).

In exemplary embodiments, the proposed pharmaceutical compositions for use may contain an inhaled macrocyclic active ingredient, such as tacrolimus or CsA, preferably CsA, in the form of a liquid solution, in particular in the form of an aqueous liquid solution or, more specifically, in the form of a liquid dispersion, such as described above. In additional proposed embodiments, said liquid compositions may contain cyclosporine A (CsA) at a concentration ranging from about 0.2 mg/mL to about 20 mg/mL, often in an amount from about 1 mg/mL to about 10 mg/mL, based on the amount of final nebulized liquid pharmaceutical composition. In the case of cyclosporin A, in particular in liposomal solubilized form (L-CsA), said active ingredient is often present in an amount of from about 2 to about 8 mg/ml, preferably from about 2 to about 6 mg/ml, more preferably from 2 5 to about 6 mg/ml, even more preferably from 3 to about 4 mg/ml, in particular at a concentration of about 4 mg/ml, as already described above.

In many cases, phospholipids or lecithins, such as those described above, may be present in a liquid pharmaceutical composition for use according to the present invention in an amount of from about 0.2 to about 15 wt.%, or from about 1 to about 8 wt.%, based on total the weight of the final sprayable composition.

In addition, nonionic surfactants such as those described above, preferably polysorbates such as Tween 80, may be present in liquid pharmaceutical compositions for use according to the present invention in an amount of from about 0.01 to about 5 wt.% or from about 0 .1 to about 2 wt.%, based on the total weight of the final spray composition.

A pharmaceutical composition for use according to the present invention is administered to a subject by inhalation as an aerosol, as described in more detail below, wherein the aerosol is obtained by nebulization or aerosolization of the proposed pharmaceutical composition. Spraying or aerosolization of the proposed pharmaceutical compositions, preferably of the proposed liquid pharmaceutical compositions, is carried out using a nebulizer. In preferred embodiments, said nebulizer can convert the inventive pharmaceutical compositions containing a macrocyclic immunosuppressive active ingredient such as CsA or tacrolimus in solution, colloidal formulation or suspension form, particularly when provided in a liposomal solubilized form such as described above, into a large number of droplets that can reach the peripheral areas of the lungs.

A nebulizer for producing an aerosol containing a pharmaceutical composition for use according to the present invention comprises as a component a) an aerosol generator comprising a fluid reservoir for storing the pharmaceutical composition or an adapter configured to connect the fluid reservoir and a vibrating membrane having a plurality of apertures designed to produce an aerosol containing droplets having a mass median aerodynamic diameter (MMAD) of up to about 4.0 microns when measured using a 0.9% (w/v) aqueous sodium chloride solution.

- 10 042761

An aerosol generator according to the description of component a) of a nebulizer suitable for nebulizing the proposed pharmaceutical compositions may be a so-called membrane aerosol generator containing a vibrating membrane having a plurality of fine holes in the central region, as described in more detail below. A pharmaceutical composition, in particular a liquid nebulizable pharmaceutical composition, can be applied to one side of the membrane in a central region, the membrane is vibrated using a vibrator (such as a piezoelectric element), typically at a frequency in the range of about 50 to about 300 kHz , more specifically in the range of about 60 kHz to about 200 kHz, or about 80 kHz to about 180 kHz, or about 100 kHz to about 140 kHz. Under the action of vibration, the liquid pharmaceutical composition applied to one side of the membrane passes through the holes and is sprayed through the opposite side of the membrane. Accordingly, in particular embodiments, the aerosol generator comprises a piezoelectric element (such as a piezoelectric crystal) as a vibration generator.

The vibrating membrane of the aerosol generator may have a convex shape curved towards the side of the membrane through which the aerosol is released. In particular embodiments, a vibrating membrane separates the fluid reservoir and chamber. The vibrating membrane may be made of metal, such as steel, or other metals or materials that are compatible with the administration of pharmaceutical compositions, such as compositions for use according to the present invention. In preferred embodiments, however, the vibrating membrane comprises or is made of stainless steel.

The oscillating membrane of the aerosol generator has a plurality of apertures through which transport, and thereby nebulization or aerosolization, of a pharmaceutical composition for use according to the present invention can take place. The plurality of apertures are configured to produce an aerosol containing droplets having a mass median aerodynamic diameter (MMAD) that is typically less than 5 µm, or up to about 4.0 µm, as measured by atomization of 0.9% (w/v). .) an aqueous solution of sodium chloride. In particular embodiments, a plurality of apertures in the vibrating membrane is configured to produce an aerosol containing droplets having a mass median aerodynamic diameter (MMAD) in the range of about 1.5 to about 5.0 microns, such as about 1.5 to about 4.0 µm, or from about 2.0 to about 4.0 µm, or from 2.4 to about 4.0 µm, as measured by spraying 0.9% (w/v) aqueous sodium chloride solution .

In further specific embodiments, the plurality of apertures are configured to produce an aerosol containing droplets having a mass median aerodynamic diameter (MMAD) in the range of about 1.5 to about 3.9 microns, such as 2.0 to about 3.9 microns. or from 2.4 to about 3.9 microns, as measured by spraying 0.9% (w/v) aqueous sodium chloride solution.

In alternative embodiments, the mass median aerodynamic diameter (MMAD) of droplets formed by a vibrating membrane containing a plurality of suitably shaped holes can be determined by spraying or aerosolizing an aqueous solution of liposomal solubilized CsA (L-CsA) at a concentration of CsA 4 .0 mg/ml as described in Example 2.2 below. In these embodiments, the plurality of apertures are configured to produce an aerosol containing droplets having a mass median aerodynamic diameter (MMAD) that is typically less than about 6 microns, such as about 2.0 to about 5.5 microns, or 2.5 to about 4.5 microns, or about 2.8 to about 4.4 microns.

Mass median aerodynamic diameter (MMAD) values herein can typically have a geometric standard deviation (GSD) up to 2.4, more specifically up to 2.2 or up to 2.0, or even less than 2. 0, for example, up to 1.8 or up to 1.7, or more specifically, may have a geometric standard deviation (GSD) in the range of 1.1 up to 2.4, more specifically 1.2 up to 2.2 or from 1.3 up to 2.0. When the GSD value is less than 2.0, the corresponding droplet size distribution produced by the aerosol generator or vibrating membrane, respectively, is referred to as narrow droplet size distribution or monodisperse aerosol distribution.

The term drops as used herein refers to drops or particles of an aerosolized pharmaceutical composition for use according to the present invention containing a selected immunosuppressive macrocyclic active ingredient such as CsA or tacrolimus. In the context of the definition of MMAD drops produced by a vibrating membrane or a plurality of holes, respectively, the term drops can also refer to drops of 0.9% (w/v) aqueous sodium chloride solution.

The mass median aerodynamic diameter (MMAD) and other parameters of aerosolizable pharmaceutical compositions can be determined by methods known to those skilled in the art.

- 11 042761 of the art, for example, using an impactor, such as a cascade impactor, or in a laser diffraction analysis, such as described, for example, in Eur. Pharm. 2.9.44 or in USP, article <1601>. As a cascade impactor, a multistage cascade impactor such as an Andersen cascade impactor (ACI) or preferably a new generation impactor (NGI) can be used. These methods make it possible to determine several parameters of the resulting aerosol containing the proposed pharmaceutical compositions, such as MMAD, as mentioned above, finely dispersed dose or fraction (MDD or MDF), geometric standard deviation (GSD), as well as respirable dose or fraction (RD or RF ).

The use of a multi-stage cascade impactor, such as an ACI or preferably an NGI, allows the determination of aerodynamic parameters, for example, after aerosolization/spraying of a 0.9% (w/v) NaCl solution, as well as after aerosolization/spraying of a liquid pharmaceutical composition for use according to the present invention.

A vibrating membrane suitable for spraying or aerosolizing the pharmaceutical compositions of the invention may typically comprise from about 1000 to about 5000 holes, or from about 2000 to about 4000 holes, often from about 1500 to about 3500 holes. Given that, as a rule, the area of the perforated surface of the said circular membrane is less than about 30 mm ² , preferably from about 5 mm ² to about 30 mm ² , more preferably from about 6 mm ² to about 20 mm ² and even more preferably from about 7 mm ² to about 15 mm ² , the vibrating membrane can typically contain from about 30 to about 700 holes per mm ² , often from about 60 to about 600 or from about 80 to about 500, or from about 100 to about 400 holes per mm ² area of the perforated surface.

The geometric mean aperture diameter as measured by scanning electron microscopy (SEM) can typically be up to 4.0 µm, or more specifically, in the range of from about 1.5 to about 3.0 µm, or from about 1. 6 to about 2.8 µm, or from about 1.8 to about 2.6 µm with a standard deviation that is typically +/- 0.4 µm, or more specifically +/- 0.3 µm, or even +/- 0.2 µm.

In particular embodiments, the plurality of apertures of the vibrating membrane, or more specifically, each aperture in the plurality of apertures, may be in the form of a cone tapering towards the side of the vibratory membrane through which the aerosol is released. Accordingly, the opening may be in the form of a channel that tapers continuously or unevenly towards the side of the vibrating membrane through which the aerosol is released. In further specific embodiments, the apertures or a single aperture in the plurality of apertures of the vibrating membrane, respectively, may have an outlet diameter corresponding to a minimum geometric mean aperture diameter, such as described above.

The aerosol generator further comprises a fluid reservoir for storing a pharmaceutical composition for use according to the present invention or an adapter configured to connect a fluid reservoir containing a pharmaceutical composition for use according to the present invention. In specific embodiments, the aerosol generator further comprises a fluid reservoir for storing a pharmaceutical composition for use according to the present invention. A liquid, such as in particular a liquid pharmaceutical composition for use according to the present invention, can be applied from a fluid reservoir to one side of the central region of the vibrating membrane containing a plurality of holes. The fluid reservoir may be capped and typically may have a volume of from about 1 ml to about 10 ml.

The nebulizer for producing an aerosol containing a pharmaceutical composition for use according to the present invention further comprises as component b) a chamber for temporarily housing an aerosol produced by an aerosol generator having an internal cavity with a volume ranging from about 50 to about 150 ml. In specific embodiments, the internal cavity of the chamber may have a volume of greater than 60 ml and preferably greater than 90 ml, for example, in the range of about 70 to about 130 ml, or in the range of about 75 to about 125 ml, or more specifically, in the range of about 80 up to about 120 ml and, more specifically, in the range from about 90 to about 110 ml, or up to about 100 ml.

In addition, the nebulizer for producing an aerosol containing a pharmaceutical composition for use according to the present invention comprises, as component c), a mouthpiece for delivering an aerosol delivered by the nebulizer to a subject, the mouthpiece having an exhalation filter.

The mouthpiece provides delivery of pharmaceutical compositions for use according to the present invention coming from the nebulizer to the subject being treated and can be attached to the nebulizer. In one aspect, the mouthpiece may include a housing defining a fluid path from an inlet that may be connected to a nebulizer to an inhalation port to be placed in a patient's mouth. In addition, the mouthpiece also has a filter

- 12 042761 exhalation, which may or may not be integrated into the mouthpiece. In specific embodiments, the filter may have a filter base fluidly connected to the fluid passageway, a filter top releasably coupled to the filter base, and filter material provided between the filter base and the filter top. The top of the filter may have an exhalation port provided with a one-way valve to allow fluid to be expelled from the fluid channel through the filter material out of the mouthpiece when the patient exhales through the inhalation port. In one embodiment, the one-way valve may be made using a circular disc made from a flexible material such as silicone or thermoplastic elastomer (TPE) that covers the side of the exhalation port opposite the filter material. Accordingly, in this embodiment, the disc is pushed out of the valve seat (such as fins passing through (overlapping) the exhalation port) upon exhalation, whereby air can be expelled from the mouthpiece. Conversely, when inhaling, the disk is sucked in and, accordingly, presses on the valve, and thus air cannot enter the mouthpiece during inhalation.

In some embodiments, the filter may be built into the mouthpiece. In further embodiments, the mouthpiece housing and filter base may be an integrated one-piece assembly. In other words, in these embodiments, the mouthpiece body and filter base are one piece and cannot be separated from each other. Due to this configuration, the tube connecting the housing and the filter can be kept as short as possible. Thus, the overall height of the mouthpiece can be reduced and the filter does not interfere with the user's view and allows him/her to read and watch TV, for example. In addition, the number of parts is greatly reduced compared to a configuration such as that described in FIG. 1 and 2, and in this case only three parts are used, an integrated one-piece unit consisting of a filter housing and base, filter media and a filter top. In addition, the length can also be reduced, thereby reducing the dead volume.

In a particular embodiment, the integrated one-piece assembly is an injection molded part. Thus, the manufacture of the mouthpiece can be cost effective.

In addition, as described above, the overall length of the mouthpiece can also be reduced, thereby reducing dead volume. According to one aspect, this is facilitated by the fact that the distance between the central axis of the filter base and the inhalation opening of the mouthpiece, when viewed from the side, is at least 30 mm, or in another aspect at least 35 mm, but not more than 50 mm, according to another aspect not more than 40 mm. In this way, a space between the filter base and the inhalation port sufficient for the user's nose to fit into it and not touch the filter base can be provided, while the overall length of the mouthpiece is minimized.

Embedding the filter base into the mouthpiece housing to form an integrated one-piece assembly, in embodiments such as described above, allows the overall height of the mouthpiece to be reduced so as not to obstruct the user's view during inhalation (see above). In one aspect, the height of the mouthpiece as viewed from the side is no more than 90 mm, and in another aspect no more than 85 mm, and in one particular embodiment less than 82 mm. For example, the maximum height may be 81.5 mm.

According to one particular aspect, a mouthpiece retaining rib that is placed behind the user's teeth is provided on the upper side of the housing and/or on the lower side of the housing near the inhalation opening. Said holding rib frees the hands when using the nebulizer.

In order to improve the mouthpiece also ergonomically, according to one aspect, a front edge of the housing is provided, located around the inhalation opening, which is curved when viewed from above and/or from the side. Thus, the inhalation hole has the shape of a fish mouth.

In addition, according to one aspect, the inlet can be tapered and connected by a press fit with a ledge on the nebulizer (similar to a Luer-type connection cone or Luer-lock system).

This configuration of the adapter between the mouthpiece and the nebulizer theoretically allows the mouthpiece to be placed in any direction relative to the nebulizer, for example, the filter can be directed up, down, sideways or tilted. In the case of an integrated one-piece assembly, the orientation of the mouthpiece relative to the nebulizer may preferably be determined by the configuration of the filter base and/or the configuration of the inhalation opening of the mouthpiece, although in general it may be oriented as desired. For example, the filter base may be configured such that, as the mouthpiece rotates relative to the nebulizer protrusion, it engages the nebulizer chamber to prevent or limit said rotation.

As yet another example, the inhalation port may be oval in shape when viewed from the front, the oval having a minor axis and a major axis where the filter base (and/or tubing connecting the housing and filter base) exits the housing along direction along the minor axis. Thus, only the orientation in which the filter is directed upwards (or downwards) is allowed.

In one aspect, the aerosol generator, chamber, and mouthpiece may be arranged in this order along the longitudinal direction of the nebulizer. Thus, the nebulizer as such is relatively long. However, by reducing the overall length of the mouthpiece in the longitudinal direction, as described above, it is possible to reduce the overall length of the nebulizer. Accordingly, the lever arm when holding the nebulizer with the teeth in the region of the inhalation port of the mouthpiece can be reduced, which frees the hands for inhalation.

According to a further aspect, the nebulizer further comprises a fluid reservoir or adapter configured to connect a fluid reservoir, such as described above, where the aerosol generator comprises a vibrating membrane having a plurality of apertures (see above) and separating the fluid reservoir environment and camera.

In a further aspect, the fluid reservoir or adapter and membrane are arranged in this order along the longitudinal direction of the nebulizer. If the fluid reservoir or adapter and membrane are arranged in this order along the longitudinal direction of the nebulizer, then the overall length of the nebulizer is increased. However, the mouthpiece can be shortened by integrating the filter base into the mouthpiece as explained above, thus reducing the overall length of the nebulizer.

Similar considerations apply to the case where the chamber has a length (L _C ) in the longitudinal direction of the nebulizer from 30 to 100 mm, in particular from 50 to 100 mm, and more specifically not less than 70 mm, for example, not less than 80 mm or not less than 90 mm. Again, the use of said chamber, which preferably delivers a sufficiently large single dose to be inhaled by the user, in the chamber results in an elongation of the nebulizer, and hence the lever arm, if the nebulizer is held by the teeth in the area of the inhalation opening of the mouthpiece. Due to the possibility of shortening the mouthpiece including the filter, the length of said lever arm can be reduced or minimized.

In one aspect, the chamber has an ambient air port equipped with a one-way valve that allows ambient air from outside the nebulizer to enter the chamber when the patient inhales through the inhalation port of the mouthpiece.

As mentioned above, the mouthpiece and nebulizer described herein are suitable for administering or spraying/aerosolizing pharmaceutical compositions for use according to the present invention containing an inhaled immunosuppressive macrocyclic active ingredient such as tacrolimus or cyclosporin A, in particular cyclosporin A (CSA).

Additional features and aspects of the invention, in particular the nebulizer and mouthpiece suitable for administering the pharmaceutical compositions for use according to the present invention, are described in more detail below by way of specific examples with reference to the accompanying drawings. In some drawings, the same reference numbers are used to refer to the same and similar elements.

Detailed description of graphic materials

In FIG. 1 and 2 show a pre-development nebulizer 100 similar to that described in European patent EP 1 927 373 B1. Thus, in order to provide an exhalation filter 30, it was initially decided to attach a T-adapter 120 through a connection hole 121 to the chamber 105 of the nebulizer 100 to temporarily accommodate the aerosol produced by the aerosol generator 101 (see FIG. 5). The mouthpiece 40 is connected to the adapter 120 through the protrusion 122 opposite the connection hole 121. In addition, an exhalation filter 30 is provided, comprising a filter base 31, a filter top 33 removably connected to the filter base 31, and a filter material 32 provided between the base 31 filter and the upper part 33 of the filter. The filter base 31 is connected to the filter attachment hole 123 of the adapter 120 located between the connection hole 121 and the protrusion 122.

However, this approach has been deemed unsuccessful for several reasons. First, if the filter is directed upwards (not shown), then it is directly opposite the user's nose and eyes. This is inconvenient due to the fact that the filter is high, in particular if the user plans to read or watch TV during inhalation.

Attempts to turn the filter to the right (alternatively to the left) as shown in FIG. 1 or placing it in a downward direction causes the problem that the nebulizer can no longer be placed on a horizontal surface, since the filter, due to its size, touches the horizontal surface. Installing the filter in an inclined position, as shown in Fig. 2 causes the nebulizer to become unstable when placed on a horizontal surface. Thus, the use of the nebulizer becomes difficult. In addition, in this configuration, many parts are used, namely, a T-adapter, a filter base, a filter material, a filter top, and a mouthpiece (5 parts in total). The nebulizer is inconvenient to use if it needs to be taken apart for cleaning and then reassembled for use. In addition, in this configuration, the overall length of the LO nebulizer is significantly increased. However, the use of these nebulizers often frees up the hands as the nebulizer is held by the teeth in the area of the inhalation opening of the mouthpiece. Thus, the longer the nebulizer, the longer the lever arm, and the more difficult it is to apply the nebulizer without the use of hands. The same reasoning is also true if the filter is placed in an inclined position, as shown in FIG. 2, and if rotated to one side as shown in FIG. 1. This placement creates a twisting load on the teeth, which causes discomfort.

Finally, with this configuration, the dead volume between the connection port 121 and the inhalation port 42 in the mouthpiece 40 increases, in which the aerosol can be deposited and washed out onto the filter when exhaled, thus losing it.

In particular embodiments, the mouthpiece 40 corresponding to component c) of the aerosol generator 100 comprises:

a housing 46 defining a fluid passage 47 from an inlet 41 configured to be connected to the nebulizer 100 to an inhalation port 42 to be placed in the user's mouth; and an exhalation filter 30 comprising a filter base 31 in fluid communication with the fluid passage 47, a filter top 33 releasably connected to the filter base, and a filter material 32 provided between the filter base and the filter top, the top the filter portion has an exhalation port 36 provided with a one-way valve 39 to allow fluid to be expelled from the fluid port through the filter material outward from the mouthpiece when the patient exhales through the inhalation port; where the filter housing and base are an integrated one-piece unit.

The drawings show a nebulizer 100 including an aerosol generator 101 (see FIG. 5) and a chamber (105) for temporarily housing the aerosol generated by the aerosol generator. For example, the aerosol generator 100 includes a vibrating membrane 110 having a plurality of holes in the central region 111. In addition, a piezoelectric ring 112 is provided that causes the membrane 110 to vibrate.

In addition, the nebulizer 100 includes a fluid reservoir 103 from which a liquid (such a liquid pharmaceutical composition for use in the present invention) is applied to one side of the central region 111 of the apertured membrane 110 (see FIG. 5). The fluid reservoir 103 is closed with a lid 104. In general, said nebulizer is described in European patents EP 1 927 373 B1 and EP 1 353 759 B1. Instead of a fluid reservoir, it is also possible to provide an adapter, such as a needle or a sleeve, configured to connect a fluid reservoir, such as an ampoule. This system is described, for example, in European patent EP 1 919 542 B1.

During use, a liquid or fluid, or more particularly pharmaceutical compositions for use according to the present invention, can be applied to one side of the membrane 110 (aerosol generator) and pass through the holes as a result of vibration of the membrane caused by the piezoelectric element 112, resulting in an aerosol is introduced (puffed) into chamber 105. Thus, membrane 110 (aerosol generator) is positioned between fluid reservoir 103 and chamber 105. Chamber 105 is configured to temporarily accommodate the aerosol generated by membrane 110 as a unit dose for inhalation to a subject or patient .

The end on the longitudinal axis of the chamber 105, located opposite the end, which is placed on the membrane 110, contains a protrusion 106 that defines the outlet and has a circular cross section. The protrusion 106 may be cylindrical or cone-shaped, resembling a male cone, similar to the Luer cone system.

In addition, chamber 105 is shaped like a stand that allows the nebulizer 100 to be placed on a horizontal surface such as a tabletop.

In addition, openings for ambient air 113 are located at one end of the chamber 105 in the vicinity of the aerosol generator 101. Said openings 113 are equipped with a one-way valve 114, such as flaps or reed valves, which allow ambient air to enter the chamber 105 when the patient inhales.

If the nebulizer 100 is intended to administer a liquid or fluid, such as a liquid pharmaceutical composition for use according to the present invention, containing a compound that may be harmful to individuals who remain in the environment in which the user breathes, then an exhalation filter 30 becomes necessary.

At the stage of preliminary development, the use of a T-shaped adapter 120 for attaching an exhalation filter 30 has been proposed. The T-shaped adapter 120 includes an inlet 121 having a circular cross section. The inlet 121 has a cylindrical or cone shape resembling an inner cone similar to a female Luer cone. The T-adapter 120 is connected by a press fit through the inlet 121 to the protrusion 106.

- 15 042761

The outlet 122 is located opposite the inlet 121. The outlet 122 is similar to the projection 106 and thus also has a circular cross section and may have a cylindrical or cone shape resembling the outer cone of a male Luer cone system.

The filter attachment port 123 is intermediate between inlet 121 and outlet 122 and is substantially perpendicular to the line between inlet 121 and outlet 122, which defines the T-shape. The filter connection port 123 has a circular cross section and may be cylindrical or cone shaped like the male cone of a Luer cone connection system.

The exhalation filter 30 includes a filter base 31, a filter material 32 (see FIGS. 4 and 5), and a filter top 33. The filter base 31 includes a connecting tube 34 which has a circular cross section and can be either cylindrical or cone shaped like a female Luer connection cone. Accordingly, the exhalation filter 30 may be connected to the filter attachment port 123 by a press fit.

The filter material 32 may be made of polypropylene or the like. As one example, the filter may be made from mixed synthetic fibers, for example attached to a polypropylene nonwoven mesh. Typically, the filter may have a thickness of 1.5 to 5.5 mm, or 2 to 5 mm, or about 3.5 mm. Air permeability at 200 Pa can be from about 400 to about 600 l/m ² s and/or aerodynamic drag can be about 46.0 Pa at an average speed of 9.5 m/min. An example of a filter is the Microstat + 250 MED sold by Riensch & Held, Germany. The filter material 32 is located between the filter base 31 and the filter top 33, as can be clearly seen in FIG. 5. In this way, the filter base 31 and the filter top 33 form a chamber for receiving the filter material 32.

The top part 33 of the filter is removable and mounted on the base 31 of the filter using, for example, a snap connector. The filter material can be replaced by detaching the top part 33 of the filter from the base 31 of the filter.

In addition, the top of the filter may include another protrusion 35 which allows the attachment of a tube or other equipment. However, said protrusion 35 may also be omitted, for example to reduce the height of the device.

In addition, an exhalation port 36 is provided in the top portion 33 of the filter. The exhalation port 36 may have a circular cross section. In one aspect, a plurality of radial ribs 37 (FIG. 5) extend through the exhalation port 36 and a pin 38 is provided at the center of the hole. located on the side of the ribs 37 opposite the chamber and the filter material 32. Thus, the one-way valve 39 allows fluid to flow out of the chamber between the filter base 31 and the filter top 33, while the valve 39 opens (the disk 39 rises from the radial ribs 37 and allows the passage fluid between the ribs 37 through the opening 36 to exhale outwards). However, the valve 39 blocks the flow of fluid in the opposite direction from the environment into the chamber it closes (the disk 39 is pressed against the radial ribs 37, closing the holes between the ribs 37, and thereby blocking the exhalation port 36).

In addition, in FIG. 1 and 2 show a mouthpiece 40 comprising a connector 41 having a circular cross section and a cylindrical or cone shape resembling a female Luer cone, such as a tubing connector used in intensive care units. The connecting piece 41 is connected to the outlet 122 of the T-adapter 120 by means of a press fit. This may provide an airtight connection between the connection hole 41 and the T-adapter 120.

The inhalation port 42 may be provided opposite the connection port 41. The inhalation port 42 has an oval cross-section, as can be clearly seen in FIG. 2. The inhalation port 42 thus comprises a major axis oriented substantially horizontally and/or parallel to the stand 107 and a minor axis perpendicular to the major axis.

In this context, the mouthpiece 40 comprises a transitional cone 43 in which the circular cross section of the connecting opening 41 of the mouthpiece 40 changes to an oval cross section of the inhalation opening 42. Thus, the mouthpiece 40 tapers at the intermediate position 43 to form a substantially flat piece 44 which is placed in the mouth of the subject or patient.

In addition, the retaining ribs 45 are formed on the long sides of an oval cross-section near the inhalation port 42 substantially perpendicular to the piece 44. Thus, the user can bite or pinch behind the retaining ribs 45 with their teeth and hold the nebulizer with their teeth without using their hands.

This pre-designed product, although it provides the desired function of filtering exhaled air, nevertheless, has disadvantages. For example, if filter 30 is directed

- 16 042761 up (not shown), it is directly opposite the user's nose and eyes. In other words, the height H of the nebulizer is too high. This is inconvenient, in particular, if the user plans to read or watch television during inhalation. Attempts to turn the filter to the right (alternatively to the left) as shown in FIG. 1 or placing it downwards causes the problem that the nebulizer can no longer be placed on a horizontal surface with the support 107 due to the size of the filter. Installing the filter in an inclined position, as shown in Fig. 2 causes the nebulizer to become unstable when placed on a horizontal surface. In particular, in said configuration, the nebulizer will often turn over. Thus, the use of the nebulizer becomes difficult.

In addition, in this configuration, many parts are used, namely, the T-adapter 120, the filter base 31, the filter material 32, the filter top 33, and the mouthpiece 40 (a total of 5 parts). The nebulizer is inconvenient to use if it needs to be disassembled for cleaning and then reassembled for use, this can lead to incorrect assembly of parts and incorrect use without a filter and exhalation valve.

In addition, in this configuration, the overall length of the LO nebulizer is significantly increased. However, the use of these nebulizers often frees the hands, as explained above, since the nebulizer is held by the teeth in the area of the inhalation opening of the mouthpiece, thanks to the use of retaining ribs 45. Thus, the longer the nebulizer, the longer the lever arm, and the more difficult it is to use hands free nebulizer. This effect is even more pronounced when using a relatively long mixing chamber 105 having a length L _C of 80 to 100 mm.

Finally, with this configuration, the dead volume between the connection port 121 and the inhalation port 42 in the mouthpiece 40 increases, in which the aerosol can be deposited and washed out onto the filter 32 when exhaled, thus losing it.

Most of these problems can be eliminated, in particular, if the adapter 120 and filter base 31 are built into the mouthpiece 40, as specifically shown in FIG. 3-5 as an integral unit that is directly connected to the chamber 105.

Thus, the mouthpiece 40 according to one aspect includes a body 46 having an inlet 41 shaped like the connection hole 121 of the adapter 120. The inlet 41 can thus be connected to the protrusion 106 of the chamber 105 of the nebulizer 100 by a press fit.

Housing 46 defines a channel 47 for the passage of fluid from the inlet 41 to the hole 42 for inhalation.

In addition, in embodiments such as those shown in FIG. 3-5, the filter base 31 is integrated into the housing 46. In particular, the housing 126 includes a connecting sleeve 48 located perpendicular to the housing 46 in the direction of the minor axis of the inhalation opening 42. The connecting sleeve 48 is similar in shape to the filter attachment protrusion 123 and the connecting hole 35. Thus, the housing, together with the exhalation filter 30, forms an additional passage for the passage of fluid 49 from the opening 50, which communicates with the passage for fluid 47 through the exhalation filter 30 , passes through the filter material 32 and ends with an exhalation port 36.

Thus, according to this preferred embodiment, the filter base 31, the connecting sleeve 48 and the housing 46, including the inhalation opening 42 and the connecting opening 41, form an integrated one-piece unit. According to one aspect, said integrated one-piece assembly is made by injection molding. Accordingly, in this embodiment, the integrated one-piece assembly consisting of the filter housing (46) and the filter base (31) is an integral one-piece assembly that is an injection molded part.

The filter material 32 and the filter top 33 may be the same as described above. The same considerations for the configuration of the mouthpiece also apply to the inhalation port 42, the fins 45, the transition cone 43 and the piece 44.

However, to further improve the ergonomics of the shape of the mouthpiece 40 in the area of the inhalation opening 42, the edge 51 delimiting the inhalation opening 42 is shaped like a fish's mouth. In other words, the edge is curved inward when viewed from the side and outward when viewed from above, as seen excellently in FIG. 3.

In a further embodiment, opening 42 may have at least two ribs placed side by side in the longitudinal direction L for better retention by the teeth.

During application, a liquid, namely a pharmaceutical composition for use according to the present invention, is atomized by the aerosol generator 101 into the chamber 105 in which the aerosol is temporarily stored. When the user inhales through the inhalation opening 42, ambient air enters through the openings 113, due to the opening of the valves 114, into the chamber 105 and mixes with the aerosol that is supplied from the chamber 105 through the protrusion 106 and the connection hole 41 through the channel 47 for passing the fluid and is inhaled through hole 42 for inhalation, which is indicated by arrows

- 17 042761

I in FIG. 5. During inhalation, the disc 39 closes the openings between the radial ribs 37 and thus the exhalation opening 36, as a result, ambient air cannot enter through the exhalation opening 36.

During exhalation, air exhaled by the patient or user enters through the inhalation port 42 and passes through the fluid channels 47 and 49, as indicated by arrow E in FIG. 5, through the opening 50 into the exhalation filter 30, passes through the filter material 32, and exits the exhalation filter 30 through the exhalation opening 36. At this time, the disk 39 rises from the radial fins 37 and allows the exhaled and filtered air to pass and exit through the exhalation port 36. In this case, the valves 14 close the openings 113, so that the exhaled air can only be expelled through the filter 30. In particular, fluids that are particularly toxic must not be vented to the environment and affect others.

By preferentially incorporating the filter base 31 and adapter 120 into the mouthpiece 40, in particular its housing 46, the length LM of the mouthpiece 40 can be reduced compared to the length of the adapter 120 and mouthpiece 40 shown in FIG. 1 and 2. Correspondingly, the overall length LO of the nebulizer 100 can be reduced. As a result, the lever arm can be reduced and the nebulizer 100 becomes easier to use without using your hands, you can hold the nebulizer 100 with your teeth by clamping the holding ribs 45, thereby , allows you to hold a nebulizer 100.

The preferred one-piece configuration of filter base 31, connector sleeve 48, and housing 46, including inhalation port 42 and connector port 41, filters all exhaled air, including generated aerosol, before the aerosol is removed from the device.

In addition, due to the fact that the distance D between the base of the filter 131 and the inhalation opening 42, when viewed from the side (Fig. 5), is maintained at 30 to 50 mm, preferably 35 to 40 mm, there is enough space for so that the user's nose does not touch the exhalation filter 30, while the overall length LM of the mouthpiece 42 is reduced to a minimum level.

In addition, by integrating the filter connection hole 123 and the connecting tube 34 into the housing 46, the filter base 31 can be located closer to the housing 46, whereby the overall height H, as viewed from the side, can be reduced to no more than 90 mm. In the example shown, the maximum height H is 81.5 mm. If the projection 35 is not used, the height can be further reduced to the level H1. The overall height from the filter base to the exhalation filter opening in the mouthpiece can be further reduced. In one aspect, the height of the mouthpiece as viewed from the side (FIG. 5) is no more than 75 mm, in another aspect no more than 70 mm, and in one particular embodiment less than 57 mm. For example, the maximum height may be 56.2 mm.

As a result, the proposed aspects according to the specified implementation variant provide significant advantages, in particular, compared with a device previously developed by the authors, such as described above.

As described above, the inlet 41 forms a female cone in the Luer connection cone (protrusion 106) cooperating with the male cone (protrusion 106). Alternatively, inlet 41 may also be a male Luer cone cooperating with a female cone in chamber 105.

Item Number List:

exhalation filter, filter base, filter material, filter top, connecting tube, connecting hole, exhalation port, radial fins, pin, one-way valve, mouthpiece, inlet, inhalation port, transition cone, flat part, retaining rib, housing mouthpiece, fluid channel, connecting sleeve, additional fluid channel,

- 18 042761 opening for additional fluid passage, front edge of housing,

100 nebulizer,

101 aerosol generators,

103 fluid reservoir,

104 cover,

105 camera,

106 ledge (in the nebulizer),

107 stand,

110 vibrating diaphragm,

111 the central region of the membrane,

112 piezoelectric element,

113 opening for ambient air,

114 one-way valve,

120 T-adapter,

121 connecting holes,

122 ledge,

123 hole for filter attachment.

A nebulizer and mouthpiece, such as those detailed above, allow the administration of pharmaceutical compositions for use in accordance with the present invention. In particular, if the compositions are provided as a solution, colloidal formulation or suspension, the nebulizer and mouthpiece make it possible to obtain an aerosol containing the administered pharmaceutical compositions of the invention in the form of a large number of droplets or particles that can reach the peripheral areas of the lungs (fine fraction; MDF). In specific embodiments, said droplets or particles have a mass average particle diameter of 5 µm or less when measured, for example, by laser diffraction on a Malvern MasterSizer X or using a multi-stage cascade impactor such as an Andersen cascade impactor (ACI) or a new generation impactor (NGI) .

In specific embodiments of a pharmaceutical composition for use according to the present invention, the aerosol that is administered to a patient contains drops, where at least 50%, more specifically, from about 60 to about 95%, or more specifically, from about 70 to about 90% of the total number of droplets have a diameter of up to 5 µm (when measured by laser diffraction or on a multi-stage cascade impactor such as described above) when measured using an aqueous composition containing L-CsA at a concentration of 4 mg/ml, as described below in example 2.2 .

A nebulizer and mouthpiece, such as those detailed above, also allow the administration of pharmaceutical compositions for use according to the present invention with an increased amount of drug available as delivered dose (DD) and respiratory dose (RD) compared to conventional nebulizers such as jet nebulizers. . The term delivered dose (DD) as used herein refers to the proportion of the active ingredient that is filled into the nebulizer for aerosolization and inhalation, which is actually delivered to the target tissue, in the case of the present invention, the lungs or, more specifically, the peripheral tissues of the lungs. Accordingly, in specific embodiments of the present invention, the inhaled immunosuppressive macrocyclic active ingredient, preferably cyclosporin A (CsA), is delivered to the lungs (or lung) of a subject in an amount of at least 60% or even at least 70%, more specifically in an amount in the range from about 70% to about 80% of the amount administered to the subject.

In addition, a nebulizer and mouthpiece such as described above allows the administration of pharmaceutical compositions for use at high total throughput (TOR), which is typically greater than about 150 mg/min, which corresponds to a value of about 0.15 ml/min. for liquid compositions with a relative density of about 1, in the case of the final nebulized and injected pharmaceutical composition. In specific embodiments, the inhaled immunosuppressive macrocyclic active ingredient is administered to a subject at a total throughput (TOR) of at least 200 mg/min, or more specifically, at a total throughput in the range of about 200 to about 300 mg/min, or about 200 to approximately 250 mg/min. Accordingly, a nebulizer and mouthpiece, such as described above, can reduce the duration of nebulization of the proposed liquid pharmaceutical composition. Obviously, the duration of nebulization will depend on the volume of composition to be aerosolized and the capacity of the nebulizer.

The unit dose volume of the pharmaceutical compositions for use according to the present invention is preferably low to reduce the duration of spraying. Volume, also referred to as dose volume or standard dose volume, or unit dose volume, should be interpreted as the volume of aerosolizable or sprayable pharmaceutical composition intended to be used in a single administration. The standard dose is defined as the dose of cyclosporine

- 19 042761 on A in the composition, filled in a nebulizer for a single injection. In particular, the unit dose volume may be less than 10 ml. Preferably, the unit dose volume is from about 0.3 to about 3.5 ml, more preferably from about 1 to about 3 ml. For example, the volume is about 1.25 ml or about 2.5 ml. In case the formulation is prepared by reconstitution, the volume of the reconstituted brine should be adjusted according to the desired volume of the reconstituted formulation.

A unit dose of the macrocyclic immunosuppressive active ingredient, preferably CsA, is typically from about 1 mg to about 15 mg. In specific embodiments, the unit dose of the selected active ingredient, preferably CsA, is about 5 mg or about 10 mg.

Accordingly, in specific embodiments, 1 ml of a pharmaceutical composition containing an inhaled immunosuppressive macrocyclic active ingredient is aerosolized (nebulized) over a period of time up to about 5 minutes, preferably up to about 4 minutes, particularly in the case of administration of a liquid aqueous composition. containing CsA in liposomal solubilized form at a concentration of 4 mg/ml.

In addition to providing a high delivered dose and reduced nebulization time, the nebulizer and mouthpiece for administering the inventive pharmaceutical compositions are designed to prevent contamination of the environment with an immunosuppressive macrocyclic active ingredient such as CsA or tacrolimus due to the presence of an exhalation filter in the mouthpiece. Said exhalation filter may reduce or prevent exhaled macrocyclic immunosuppressive active ingredient such as CsA or tacrolimus from entering the environment. However, due to the high proportion of aerosol droplets actually delivered to the target tissue as described above, the nebulizer and mouthpiece used in accordance with the present invention can significantly reduce the amount of exhaled active ingredient. Accordingly, in specific embodiments of the present invention, the amount of the inhaled immunosuppressive macrocyclic active ingredient exhaled by the subject is up to 10%, more specifically, from about 4 to about 8% of the total amount of the active ingredient filled with the nebulizer, in a standard breathing simulation, when which measures the amount that is typically administered to a subject and can be collected on an exhalation filter.

Accordingly, in a specific embodiment, the present invention provides a pharmaceutical composition comprising an inhaled immunosuppressive macrocyclic active ingredient, in particular cyclosporin A, for use in the prevention or treatment of a lung disease or condition in a subject, wherein the pharmaceutical composition is administered to the subject by inhalation as an aerosol, and where the aerosol is produced by spraying the pharmaceutical composition using a nebulizer (100) containing:

a) an aerosol generator (101), comprising:

a fluid reservoir (103) for storing a pharmaceutical composition or an adapter configured to connect the fluid reservoir and a vibrating membrane (110) having a plurality of holes designed to produce an aerosol containing droplets having a mass median aerodynamic diameter (MMAD) down to about 4.0 μm when measured using 0.9% (w/v) aqueous sodium chloride solution;

b) a chamber (105) for temporarily housing the aerosol produced by the aerosol generator (101), having an internal cavity with a volume ranging from about 50 to about 150 ml; And

c) a mouthpiece (40) for delivering an aerosol delivered by a nebulizer (100) to a subject, wherein the mouthpiece has an exhalation filter (30), wherein said inhaled immunosuppressive macrocyclic active ingredient is administered to the subject at a total throughput (TOR) of at least 200 mg / min, and preferably the amount of inhaled immunosuppressive macrocyclic active ingredient exhaled by the subject is up to 10%, more specifically, from about 4 to about 8% of the total amount of active ingredient, which filled the nebulizer (in standard breathing simulation).

It should be understood that these specific implementation options, like all other implementation options, can also be combined with other features, implementation options and/or aspects, as disclosed herein in relation to, for example, a pharmaceutical composition and/or an inhaled macrocyclic immunosuppressive active ingredient, administered as detailed above and/or in relation to the nebulizer and mouthpiece as disclosed herein. In addition, these embodiments may or may not be combined with the specific features of administering the pharmaceutical composition as such, for example, with a specific embodiment in which 1 ml of a pharmaceutical composition containing an inhaled immunosuppressive macrocyclic active ingredient is converted into aerosol (sprayed) over a period of time up to about 5 minutes, preferably up to about 4 minutes, particularly in cases in which a liquid aqueous composition containing CsA in liposomal solubilized form at a concentration of about 4 mg/mL is administered, as described higher.

Pharmaceutical compositions for use according to the invention may be administered according to a predetermined mode of administration. In particular, the composition may be administered a specific number of times in each week of treatment. For example, the pharmaceutical composition may be administered three times per week. Preferably, the formulation is administered daily. Even more preferably, the composition is administered twice a day.

In a further aspect, the present invention provides a method for preventing or treating a lung disease or condition in a subject, comprising the step of administering an inhaled immunosuppressive macrocyclic active ingredient to said subject by inhalation as an aerosol containing the immunosuppressive macrocyclic active ingredient, wherein the aerosol is produced by spraying a pharmaceutical composition using a nebulizer ( 100) containing:

a) an aerosol generator (101), comprising:

a fluid reservoir (103) or an adapter configured to connect the fluid reservoir and a vibrating membrane (110) having a plurality of holes designed to produce an aerosol containing droplets having a mass median aerodynamic diameter (MMAD) up to up to about 4.0 µm when measured using 0.9% (w/v) aqueous sodium chloride solution;

b) a chamber (105) for temporarily housing the aerosol produced by the aerosol generator, having an internal cavity with a volume ranging from about 50 to about 150 ml; And

c) a mouthpiece (40) for delivering the aerosol delivered by the nebulizer 100 to the subject, the mouthpiece having an exhalation filter (30).

More specifically, the method for preventing or treating a lung disease or condition may further comprise the step of providing a pharmaceutical composition containing the inhaled immunosuppressive macrocyclic active ingredient as an aqueous liquid solution.

It should be understood that according to the specified additional aspect of the present invention, as well as additional aspects such as described below, all features, embodiments and aspects of the present invention, such as described above for the first aspect of the invention, as well as all combinations thereof, are equally applicable. to the proposed method of treatment, as well as to the uses of the pharmaceutical composition according to the present invention and to the set, such as further described below.

According to a third aspect, the present invention provides the use of an inhaled immunosuppressive macrocyclic active ingredient for the preparation of a pharmaceutical composition for preventing or treating a lung disease or condition in a subject by inhalation, wherein the pharmaceutical composition is administered to the subject by inhalation as an aerosol, wherein the pharmaceutical composition is administered to the subject by inhalation as an aerosol aerosol, and where the aerosol is produced by spraying the pharmaceutical composition using a nebulizer (100) containing:

a) an aerosol generator (101), comprising:

a fluid reservoir (103) for storing a pharmaceutical composition or an adapter configured to connect the fluid reservoir and a vibrating membrane (110) having a plurality of holes designed to produce an aerosol containing droplets having a mass median aerodynamic diameter (MMAD) down to about 4.0 μm when measured using 0.9% (w/v) aqueous sodium chloride solution;

b) a chamber (105) for temporarily housing the aerosol produced by the aerosol generator (101), having an internal cavity with a volume ranging from about 50 to about 150 ml; And

c) a mouthpiece (40) for delivering the aerosol supplied by the nebulizer (100) to the subject, the mouthpiece having an exhalation filter (30).

In a fourth aspect, the present invention provides a kit comprising a pharmaceutical composition comprising an inhaled immunosuppressive macrocyclic active ingredient for use in the prevention or treatment of a lung disease or condition in a subject; and a nebulizer (100) containing:

a) an aerosol generator (101), comprising:

a reservoir (103) for a fluid medium for storing a pharmaceutical composition or an adapter,

- 21 042761 configured to connect a fluid reservoir and vibrating membrane (110) having a plurality of holes designed to produce an aerosol containing droplets having a mass median aerodynamic diameter (MMAD) of up to about 4.0 µm at measurement using 0.9% (w/v) aqueous sodium chloride solution;

b) a chamber (105) for temporarily housing the aerosol produced by the aerosol generator (101), having an internal cavity with a volume ranging from about 50 to about 150 ml; And

c) mouthpiece (40) for delivery to the subject of the aerosol supplied by the nebulizer (100), while the mouthpiece has an exhalation filter (30).

In specific embodiments of a kit according to said aspect of the invention, a pharmaceutical composition comprising an inhaled immunosuppressive macrocyclic active ingredient for use in the prevention or treatment of a lung disease or condition in a subject is provided as a pre-formulated liquid aqueous composition.

In further specific embodiments of a kit according to said aspect of the invention, a pharmaceutical composition comprising an inhaled immunosuppressive macrocyclic active ingredient for use in the prevention or treatment of a lung disease or condition in a subject is provided as a lyophilisate comprising the inhaled immunosuppressive macrocyclic active ingredient and a sterile liquid aqueous carrier for redissolving the lyophilizate to obtain a liquid pharmaceutical composition.

The following numbered list shows the embodiments included in the present invention:

1. A pharmaceutical composition containing an inhaled immunosuppressive macrocyclic active ingredient for use in the prevention or treatment of a lung disease or condition in a subject, where the pharmaceutical composition is administered to the subject by inhalation as an aerosol, and where the aerosol is produced by spraying the pharmaceutical composition using a nebulizer (100), containing:

a) an aerosol generator (101), comprising:

a fluid reservoir (103) for storing a pharmaceutical composition or an adapter configured to connect the fluid reservoir and a vibrating membrane (110) having a plurality of holes designed to produce an aerosol containing droplets having a mass median aerodynamic diameter (MMAD) down to about 4.0 μm when measured using 0.9% (w/v) aqueous sodium chloride solution;

b) a chamber (105) for temporarily housing the aerosol produced by the aerosol generator (101), having an internal cavity with a volume ranging from about 50 to about 150 ml; And

c) mouthpiece (40) for delivery to the subject of the aerosol supplied by the nebulizer (100), while the mouthpiece has an exhalation filter (30).

2. A pharmaceutical composition for use according to claim 1, wherein said lung disease or condition is selected from the group consisting of asthma, refractory asthma, chronic obstructive bronchitis, parenchymal, fibrotic and interstitial diseases and lung inflammation, bronchiolitis obliterans (BOS) and acute and chronic organ transplant rejection reactions after lung transplantation, and diseases caused by them.

3. Pharmaceutical composition for use according to claim 1 or 2, wherein said lung disease or condition is bronchiolitis obliterans (BOS), optionally occurring after acute and chronic organ transplant rejection after lung transplantation or after hematopoietic stem cell transplantation (HSCT) .

4. A pharmaceutical composition for use according to any one of the preceding claims, wherein said lung disease or condition is bronchiolitis obliterans (BOS) I or more severe, in particular BOS I or II, in particular BOS I.

5. A pharmaceutical composition for use according to any one of the preceding claims for use in the treatment of a lung disease or condition in a subject.

6. A pharmaceutical composition for use according to any one of the preceding claims, wherein said inhaled immunosuppressive macrocyclic active ingredient is selected from cyclosporin A (CsA) and tacrolimus.

7. A pharmaceutical composition for use according to any of the preceding claims, wherein said inhaled immunosuppressive active ingredient is cyclosporine A.

8. A pharmaceutical composition for use according to any one of the preceding claims, wherein said inhaled immunosuppressive active ingredient is present in liposomal solubilized form (L-CsA).

9. Pharmaceutical composition for use according to any of the preceding claims, in which

- 22 042761 swarm specified composition is a liquid composition containing an aqueous liquid carrier medium.

10. A composition for use according to claim 9, wherein said aqueous liquid carrier medium essentially consists of saline, preferably saline at a concentration of 0.25% (w/v).

11. A pharmaceutical composition for use according to any one of the preceding claims, comprising an immunosuppressive macrocyclic active ingredient at a concentration in the range of about 1 to about 10 mg/ml.

12. A pharmaceutical composition for use according to any one of the preceding claims, wherein said liquid aqueous composition contains cyclosporin A in liposomal solubilized form (L-CsA) at a concentration in the range of about 3 to about 5 mg/mL.

13. A pharmaceutical composition for use according to claim 12, wherein said liquid aqueous composition contains cyclosporin A in liposomal solubilized form (L-CsA) at a concentration ranging from about 3.8 to about 4.2 mg/mL.

14. A pharmaceutical composition for use according to any one of the preceding claims, wherein said aqueous liquid composition containing the inhalable immunosuppressive macrocyclic active ingredient in a liposomal solubilized form is prepared by redissolving a lyophilisate containing the immunosuppressive macrocyclic active ingredient and liposomal forming structures.

15. A pharmaceutical composition for use according to any one of the preceding claims, wherein said composition contains at least one disaccharide selected from the group consisting of sucrose, lactose and trehalose, preferably sucrose.

16. A pharmaceutical composition for use according to claim 15, wherein said composition contains at least one disaccharide selected from the group consisting of sucrose, lactose and trehalose, preferably sucrose, in an amount in the range from about 5 to about 15 wt.% , preferably in the range from about 7.5 to about 12.5 wt.%, based on the total weight of the resulting pharmaceutical composition.

17. A pharmaceutical composition for use according to any one of claims 14 to 16, wherein said liposome-forming structures comprise a bilayer membrane derived from a membrane-forming substance selected from the group of phospholipids.

18. A pharmaceutical composition for use according to any one of claims 14 to 17, wherein said liposome-forming structures are at least partially present in a monolayer form.

19. A pharmaceutical composition for use according to any one of claims 14 to 18, wherein said inhaled immunosuppressive macrocyclic active ingredient is at least partially incorporated (or embedded) in a bilayer membrane of liposome forming structures.

20. A pharmaceutical composition for use according to any one of claims 14-19, wherein said inhaled immunosuppressive macrocyclic active ingredient, in particular CsA or LCsA, is predominantly (e.g., in an amount of at least about 90%, or even at least from about 95 to about 97.5%) is incorporated into bilayer membrane structures forming liposomes.

21. A pharmaceutical composition for use according to any one of claims 17 to 20, wherein said membrane forming agent selected from the group of phospholipids is a mixture of natural phospholipids.

22. A pharmaceutical composition for use according to any one of claims 17 to 21, wherein said membrane forming agent selected from the group of phospholipids is lecithin containing unsaturated fatty acid residues.

23. A pharmaceutical composition for use according to any one of claims 17 to 22, wherein said membrane forming agent selected from the group of phospholipids is a lecithin selected from the group consisting of soy lecithin, Lipoid S75, Lipoid S100, Phospholipon® G90 , 100 or similar lecithin.

24. A pharmaceutical composition for use according to any one of claims 14 to 23, wherein said composition further comprises at least one solubility agent selected from the group of nonionic surfactants.

25. A pharmaceutical composition for use according to claim 24, wherein at least one said nonionic surfactant is selected from the group of polysorbates.

26. A pharmaceutical composition for use according to claim 24 or 25, wherein said solubility agent selected from the group of nonionic surfactants is polysorbate 80.

27. A pharmaceutical composition for use according to any one of claims 24-26, wherein the weight ratio of phospholipid to polysorbate is selected from the range of from about 15:1 to about 9:1, preferably from about 14:1 to about 12:1, for example, approximately 13:1.

28. Pharmaceutical composition for use according to any one of claims 24-27, in which the mass of

- 23 042761 carrying (all) phospholipid(s) and non-ionic surfactant, on the one hand, to an inhaled immunosuppressive macrocyclic active ingredient, in particular to cyclosporine A (CsA), on the other hand, selected from the range of about 5 :1 to about 20:1, preferably from about 8:1 to about 12:1, and more preferably about 10:1.

29. A pharmaceutical composition for use according to any one of claims 24 to 28, wherein the weight ratio of phospholipid (lecithin) to nonionic surfactant and inhaled immunosuppressive macrocyclic active ingredient, in particular cyclosporine A (CsA), is from about 15 :1:1.5 to about 5:0.3:0.5 and preferably about 9:0.7:1.

30. A pharmaceutical composition for use according to any one of the preceding claims, wherein said composition contains one or more additional excipients.

31. A pharmaceutical composition for use according to claim 30, wherein said one or more additional excipients are selected from buffers and chelating agents.

32. A pharmaceutical composition for use according to any one of the preceding claims, wherein said composition is in the form of a dispersion with an osmolarity in the range of about 430 to about 550 mosmol/kg.

33. A pharmaceutical composition for use according to any one of the preceding claims, wherein said composition is in the form of a dispersion with a polydispersity index (PI) measured by photon correlation spectroscopy of up to about 0.50.

34. A pharmaceutical composition for use according to claim 32 or 33, wherein said dispersion is substantially free of visible particles.

35. A pharmaceutical composition for use according to any one of claims 32-34, wherein said dispersion contains liposomes with a z-mean diameter, measured by photon correlation spectroscopy, in the range of about 40 to about 100 nm.

36. A pharmaceutical composition for use according to any one of the preceding claims, wherein said vibrating membrane (110) separates the fluid reservoir (103) from the chamber (105).

37. A pharmaceutical composition for use according to any one of the preceding claims, wherein said vibrating membrane (110) has a convex shape curved towards that side of the membrane through which the aerosol is released.

38. A pharmaceutical composition for use according to any one of the preceding claims, wherein said vibrating membrane (110) contains from about 100 to about 400 holes per mm ² .

39. A pharmaceutical composition for use according to any one of the preceding claims, wherein said plurality of apertures of the vibrating membrane (110) are in the form of a cone tapering towards the side of the vibrating membrane through which the aerosol is released.

40. A pharmaceutical composition for use according to any one of the preceding claims, wherein said apertures in the vibrating membrane (110) have an outlet diameter of up to 4.0 µm as measured by scanning electron microscopy (SEM).

41. A pharmaceutical composition for use according to any one of the preceding claims, wherein said aerosol generator (101) comprises a piezoelectric element (such as a piezoelectric crystal as a vibration generator).

42. A pharmaceutical composition for use according to any of the preceding claims, wherein said inhaled immunosuppressive macrocyclic active ingredient is delivered to the lungs (or lung) of a subject in an amount (delivered dose, DD) of at least 70%, more specifically, in an amount in the range of about 70 to about 80% of the amount administered to the subject.

43. A pharmaceutical composition for use according to any of the preceding claims, wherein said inhaled immunosuppressive macrocyclic active ingredient is administered to a subject at a total throughput (TOR) of at least 200 mg/min, more specifically, a total throughput in the range of about 200 to about 250 mg/min

44. A pharmaceutical composition for use according to any one of the preceding claims, wherein the amount of said inhaled immunosuppressive macrocyclic active ingredient exhaled by the subject is up to 10%, more specifically from about 4 to about 8% of the total amount of active ingredient administered to the subject.

45. A pharmaceutical composition for use according to any one of the preceding claims, wherein said aerosol, which is administered to a patient, contains drops, and wherein at least 50%, more specifically, from about 60 to about 95%, or more specifically, from about 70 to about 90% of the total droplets are up to 5 µm in diameter (when measured by laser diffraction or on a multi-stage cascade impactor such as described above) when measured using an aqueous composition containing L-CsA at a concentration of 4 mg/mL.

46. Pharmaceutical composition for use according to any of the preceding claims, in which

- 24 042761 1 ml of a pharmaceutical composition containing an inhaled immunosuppressive macrocyclic active ingredient is aerosolized (sprayed) over a period of time up to about 5 minutes, in particular in cases in which a liquid aqueous composition containing CsA in liposomal solubilized is administered. form at a concentration of 4 mg / ml.

47. Pharmaceutical composition for use according to any one of the preceding paragraphs, in which the specified mouthpiece (40) contains:

a body (46) defining a fluid channel (47) from an inlet (41) configured to be connected to a nebulizer (100) to an inhalation hole (42) to be placed in the user's mouth; and a filter (30) comprising a filter base (31) in fluid communication with the fluid channel (47), a filter top (33) separably connected to the filter base, and a filter material (32) provided between a filter base and a filter top, where the filter top has an exhalation port (36) equipped with a one-way valve (39) to allow fluid to be expelled from the fluid channel through the filter material out of the mouthpiece when the patient exhales through the inhalation port;

where the filter housing and base are an integrated one-piece unit.

48. Pharmaceutical composition for use according to any one of the preceding claims, wherein the aerosol generator (101), chamber (105) and mouthpiece (40) are located in that order along the longitudinal direction of the nebulizer (100).

49. Pharmaceutical composition for use according to any one of the preceding claims, wherein said fluid reservoir (103) or adapter and chamber (110) are arranged in that order along the longitudinal direction of the nebulizer (100).

50. Pharmaceutical composition for use according to any one of the preceding claims, wherein said chamber (105) has a length (L _C ) along the longitudinal direction of the nebulizer between 20 and 100 mm, in particular between 50 and 100 mm.

51. A pharmaceutical composition for use according to any one of the preceding claims, wherein said chamber (105) comprises an internal cavity with a volume in the range of about 75 to about 125 ml.

52. A pharmaceutical composition for use according to any one of the preceding claims, wherein said chamber (105) is equipped with an ambient air opening (113) with a one-way valve (114) that allows ambient air from outside the nebulizer (100) to enter the chamber (105) when inhalation of the subject through the opening (42) for inhalation of the mouthpiece (40).

53. Pharmaceutical composition for use according to any of claims 47 to 52, wherein said integrated one-piece unit consisting of filter body (46) and filter base (31) is an integral one-piece unit which is an injection molded part.

54. Pharmaceutical composition for use according to any one of claims 47 to 53, wherein the distance (D) between the base (31) of the filter and the inhalation opening (42) of the mouthpiece (40), when viewed from the side, is at least 30 mm, preferably at least 35 mm but not more than 50 mm, preferably not more than 40 mm.

55. A pharmaceutical composition for use according to any one of claims 47 to 54, wherein the maximum height (H) of the mouthpiece (40) as viewed from the side is not more than 90 mm, preferably not more than 85 mm.

56. Pharmaceutical composition for use according to any one of claims 47-55, wherein said retaining rib (45) of the mouthpiece (40), which is placed behind the teeth of the user, is provided on the upper side of the housing (46) and/or on the lower side of the housing ( 46) next to the hole (42) for inhalation.

57. Pharmaceutical composition for use according to any one of claims 47 to 56, wherein the front edge (51) of the housing (46) around the inhalation opening (42) is curved when viewed from above and/or sideways.

58. Pharmaceutical composition for use according to any one of claims 47 to 57, wherein said inlet (41) has the shape of a cone connected by a press fit to the protrusion (106) of the nebulizer (100).

59. Pharmaceutical composition for use according to any one of claims 47 to 58, wherein said inhalation opening (42) is oval in shape when viewed from the front, the oval shape having a minor axis and a major axis where the filter base (31) emerges from body (46) in the direction along the minor axis.

60. A method for preventing or treating a lung disease or condition in a subject, comprising the step of administering an inhaled immunosuppressive macrocyclic active ingredient to said subject by inhalation as an aerosol containing the immunosuppressive macrocyclic active ingredient, wherein the aerosol is produced by spraying a pharmaceutical composition using a nebulizer (100) containing:

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a) an aerosol generator (101), comprising:

a fluid reservoir (103) or an adapter configured to connect the fluid reservoir and a vibrating membrane (110) having a plurality of holes designed to produce an aerosol containing droplets having a mass median aerodynamic diameter (MMAD) up to up to about 4.0 µm when measured using 0.9% (w/v) aqueous sodium chloride solution;

b) a chamber (105) for temporarily housing the aerosol produced by the aerosol generator, having an internal cavity with a volume ranging from about 50 to about 150 ml; And

c) a mouthpiece (40) for delivering the aerosol delivered by the nebulizer 100 to the subject, the mouthpiece having an exhalation filter (30).

61. The method of claim 60, further comprising the step of providing a pharmaceutical composition containing the inhaled immunosuppressive macrocyclic active ingredient as an aqueous liquid solution.

62. The use of an inhaled immunosuppressive macrocyclic active ingredient for the preparation of a pharmaceutical composition for preventing or treating a lung disease or condition in a subject by inhalation, wherein the pharmaceutical composition is administered to a subject by inhalation as an aerosol, wherein the pharmaceutical composition is administered to a subject by inhalation as an aerosol, and wherein the aerosol produced by spraying a pharmaceutical composition using a nebulizer (100) containing:

a) an aerosol generator (101), comprising:

a fluid reservoir (103) for storing a pharmaceutical composition or an adapter configured to connect the fluid reservoir and a vibrating membrane (110) having a plurality of holes designed to produce an aerosol containing droplets having a mass median aerodynamic diameter (MMAD) down to about 4.0 μm when measured using 0.9% (w/v) aqueous sodium chloride solution;

b) a chamber (105) for temporarily housing the aerosol produced by the aerosol generator (101), having an internal cavity with a volume ranging from about 50 to about 150 ml; And

c) mouthpiece (40) for delivery to the subject of the aerosol supplied by the nebulizer (100), while the mouthpiece has an exhalation filter (30).

63. A kit containing a pharmaceutical composition containing an inhaled immunosuppressive macrocyclic active ingredient for use in the prevention or treatment of a lung disease or condition in a subject; and a nebulizer (100) containing:

a) an aerosol generator (101), comprising:

a fluid reservoir (103) for storing a pharmaceutical composition or an adapter configured to connect the fluid reservoir and a vibrating membrane (110) having a plurality of holes designed to produce an aerosol containing droplets having a mass median aerodynamic diameter (MMAD) down to about 4.0 μm when measured using 0.9% (w/v) aqueous sodium chloride solution;

b) a chamber (105) for temporarily housing the aerosol produced by the aerosol generator (101), having an internal cavity with a volume ranging from about 50 to about 150 ml; And

c) mouthpiece (40) for delivery to the subject of the aerosol supplied by the nebulizer (100), while the mouthpiece has an exhalation filter (30).

64. The kit of claim 63, wherein said pharmaceutical composition comprising an inhaled immunosuppressive macrocyclic active ingredient for use in the prevention or treatment of a lung disease or condition in a subject is provided as a pre-formulated liquid aqueous composition.

65. The kit of claim 64, wherein said pharmaceutical composition comprising an inhaled immunosuppressive macrocyclic active ingredient for use in the prevention or treatment of a lung disease or condition in a subject is provided as a lyophilisate comprising the inhaled immunosuppressive macrocyclic active ingredient and a sterile aqueous liquid carrier. for re-dissolution of the lyophilisate to obtain a liquid pharmaceutical composition.

The following examples serve to illustrate the invention; however, it should be understood that they do not limit the scope of the invention.

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Examples

Example 1:

1.1 Step 1: Preparation of liposomal solution of cyclosporin A.

1.1.1 Fill approximately 70% of the production vessel (~104 L) with water for injection. It was degassed by introducing nitrogen gas and heated to a temperature of 40-45°C. 18.0 kg of sucrose, 450.0 g of sodium dihydrogen phosphate dihydrate, 612.0 g of disodium hydrogen phosphate decahydrate and 36.0 g of sodium edetate were added together and about 5% (8.0 L) of water for injection was used for washing. The mixture was stirred until a clear-looking solution was obtained. The solution was cooled to 20-25°C and 6480.0 g of soy lecithin S100 (Lipoid S100) was added and mixed until a homogeneous dispersion was obtained. Then, 504.0 g of polysorbate 80 HP (Tween 80) was added with gentle agitation to avoid foaming, and the container in which the polysorbate was stored was rinsed with about 100 ml of water for injection. Thereafter, 720.0 g of cyclosporine A and about 5% (8 L) of water for injection were added and the mixture was stirred until a homogeneous dispersion was formed.

1.1.2 The resulting dispersion was then cooled to a temperature of 5 to 10°C and homogenized under high pressure of 100 bar (10 MPa, first stage) and 1000 bar (100 MPa, second stage), respectively, in a GEA high pressure homogenizer. The high pressure homogenization procedure was carried out 9 times (cycles).

1.1.3 Then filter the resulting homogenized suspension through a 0.2 µm bioburden filter at least once and transfer to a filling/storage tank.

1.2 Stage 2: Aseptic filling, lyophilization and packaging.

1.2.1 Sterilize glass tubes with a filling volume of 10 ml in a hot air sterilization tunnel, cool and fill with 1.35 ml aliquots (5 mg dosage) of the dispersion obtained according to step 1, as described above, after aseptic sterilization using 2 sterile filters with a pore size of 0.2 µm installed between the filling/storage tank and filling needles. The tubes were then loosely capped with sterilized lyophilization stoppers and placed in a lyophilizer, i. GEA Lyovac FCM, and lyophilized according to a 72 hour lyophilization cycle.

1.2.2 After lyophilization was completed, the tubes were automatically tightly closed in the lyophilization chamber. The tubes were taken and closed with caps with a tear-off pad. Each tube contained approximately 190 mg of an almost white, homogeneous, porous lyophilisate pellet containing 5 mg of cyclosporin A in liposomal solubilized form with a maximum residual moisture content of 2% (w/w) and a shelf life of 3 years.

1.2.3 The composition of the lyophilized drug product obtained as described above is given in table below. 1.

Table 1

Ingredient Quantity per standard dose Quantity, % (w/w) Cyclosporine A 5 mg 2.69 Polysorbate 80 3.5 mg 1.88 Lipoid S100 45 mg 24.18 sucrose 125 mg 67.16 Sodium dihydrogen phosphate dihydrate 3.125 mg 1.68 Disodium hydrogen phosphate dodecahydrate 4.25 mg 2.28 Disodium edetate dihydrate 0.25 mg 0.13 Total 186.125 mg 100.00

Example 2: Redissolution of a lyophilized composition containing cyclosporin A to obtain a colloidal solution of liposomal solubilized cyclosporin A for nebulization and inhalation.

2.1 To obtain a colloidal solution containing 10 mg of liposomal solubilized cyclosporine A, dissolve 372.3 mg of an aliquot of the precipitate of the lyophilisate, such as obtained above according to example 1, in 2.65 ml of a sterile aqueous solution of sodium chloride with a concentration of 0.25% (wt. /v) to obtain a milky-white aqueous solution of liposomal cyclosporine A for inhalation with a CsA concentration of 4 mg/ml.

2.2 The composition of the reconstituted drug product, obtained as described above, is given in table below. 2.

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table 2

Ingredient Quantity per standard dose Quantity, % (w/v) Cyclosporine A 10 mg 0.4 Polysorbate 80 7.5 mg 0.28 Lipoid S100 90 mg 3.6 sucrose 250 mg 10 Sodium dihydrogen phosphate dihydrate 6.25 mg 0.25 Disodium hydrogen phosphate dodecahydrate 8.5 mg 0.34 Disodium edetate dihydrate 0.5 mg 0.02 Sodium chloride 5.6 mg 0.22 or 0.23 Water for injection Up to 2.5 ml Up to 100

Example 3:

3.1 Experiments were carried out to simulate breathing according to Eur. Pharm. 2.9.44 using the Compas 2 breathing simulator (PARI GmbH, Germany) with a respiratory pattern that included 500 ml of tidal volume at a frequency of 15 breaths/minute and an inhalation/exhalation ratio of 50:50.

3.2 Fill 2.4 ml of the composition as described in Example 2.2 above into a vibrating membrane electronic nebulizer containing a membrane designed to produce an aerosol whose particles have a mass median aerodynamic diameter (MMAD) in the range of 2.4 to 4.0 µm when measured using 0.9% (w/v) aqueous sodium chloride solution. The nebulizer further contained a 94 ml mixing chamber. The nebulizer was connected to the sinusoidal pump of the breathing simulator. Droplets of drug-containing aerosol were collected on 2 inspiratory filters connected in series (G300 polypropylene filter pad, PARI, in a 6.5 cm diameter filter housing). An additional filter (BB50 TE, Pall Filtersystems GmbH, Germany) was placed between the inspiratory filter and the breathing simulator.

3.3 After complete spraying, remove the inhalation filters, extract the contents and analyze the extracts.

3.4 The results of breathing simulation experiments, such as those described above, are shown in Table 1 below. 3.

Table 3

Average value Standard deviation (RMS) Total output (TOR) [mg/min] 245 31 Delivered dose (DD) [mg] 6.916 0.322 Delivered dose (DD) [%] 72.0 3.4 Exhaled amount [mg] 0.899 0.271 Exhaled amount [%] 9.4 2.8 Residue in nebulizer [mg] 1.253 0.379 Residue in nebulizer [%] 13.1 4.0 Rep and workable dose (RD < 5 µm) [mg] 5.620 0.465 Resp and workable dose (RD < 5 µm) [%] 58.5 4.8 Completion of aerosol generation [min] 9.64 1.62 Automatic shutdown [min] 9.98 1.58

Example 4:

4.1 In addition, the generated aerosol has been characterized according to USP article <1601> resp. Eur.Pharm.2.9.44, using a new generation impactor (new generation cascade impactor, NGI) to assess the distribution of sprayed aerosol droplets by aerodynamic dimensions at an air flow of 15.0 +/- 0.7 l / min, an air temperature of 23, 0 +/- 2.0°C and relative humidity 50.0 +/-5.0%. The fill volume of a composition such as described in Example 2.2 was 2.4 ml. The USP procedure was amended and the impactor temperature was adjusted to match the aerosol temperature (18.0 +/- 1.0°C). Nebulizers with attached mouthpieces were connected with a rubber connector to an NGI induction port. Spraying was carried out until the nebulizer automatically turned off.

4.2 The results of aerosol characterization experiments (n=5), such as those described above, are shown in Table 1 below. 4.

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Claims (29)

Table 4 Average value Standard deviation (RMS) Mass median aerodynamic diameter (MMAD) [µm] 3.26 0.24 Geometric Standard Deviation (GSD) 1.62 0.04 Fine dose (DMD < 5 µm) [mg] 6.951 0.475 Fine fraction (MDF < 5 µm) [%] 81.2 4.7 Completion of aerosol generation [min] 10.1 1.18 Automatic shutdown [min] 10.41 1.25 Comparison example 1: The procedures according to examples 3 and 4 were repeated using an eFlow® Rapid electronic nebulizer (PARI GmbH, Germany) containing a vibrating membrane designed to produce an aerosol whose particles have a mass median aerodynamic diameter of 4.1 μm when measured at 0.9% (w/v) aqueous sodium chloride solution. The nebulizer further contained a 48 ml mixing chamber. The results are shown below in table. 5. Table 5 Average value Standard deviation (RMS) Total output (TOR) [mg/min] 192 17 Mass median aerodynamic diameter (MMAD) [µm] 3.25 0.15 Geometric Standard Deviation (GSD) 1.54 0.02 Fine fraction (MDF < 5 µm) [%] 86.7 2.2 Delivered dose (DD) [mg] 3.649 0.253 Delivered dose (DD) [%] 36.5 2.5 Exhaled amount [mg] 1.287 0.486 Exhaled amount [%] 12.9 4.9 Residue in nebulizer [mg] 4.704 0.407 Residue in nebulizer [%] 47.0 4.1 Respiratory dose (RD < 5 µm) [mg] 3.161 0.182 Respirable dose (RD < 5 µm) [%] 31.6 1.8 Completion of aerosol generation [min] 6.80 0.54 Automatic shutdown [min] 7.01 0.60 CLAIM 1. A method of preventing or treating a lung disease or condition in a subject, comprising the step of administering a pharmaceutical composition containing cyclosporin A in liposomal solubilized form (L-CsA) to said subject, wherein the pharmaceutical composition is administered to the subject by inhalation as an aerosol, and where the aerosol is produced by spraying pharmaceutical composition using a nebulizer (100) containing: a) an aerosol generator (101), comprising: a fluid reservoir (103) for storing a pharmaceutical composition or an adapter configured to connect the fluid reservoir and a vibrating membrane (110) having a plurality of holes designed to produce an aerosol containing droplets having a mass median aerodynamic diameter (MMAD) down to about 4.0 μm when measured using 0.9% (w/v) aqueous sodium chloride solution; b) a chamber (105) for temporarily housing the aerosol produced by the aerosol generator (101), having an internal cavity with a volume ranging from about 50 to about 150 ml; And c) a mouthpiece (40) for delivering an aerosol to a subject, where the mouthpiece has an exhalation filter (30); while the mouthpiece (40) contains: a body (46) defining a fluid channel (47) from an inlet (41) configured to be connected to the chamber (105) to an inhalation hole (42) to be placed in the user's mouth; and an exhalation filter (30) comprising a filter base (31) in fluid communication with a fluid channel (47), an upper filter part (33) detachably connected to the filter base (31), and a filter material (32 ) provided between the base (31) of the filter and - 29 042761 the upper part (33) of the filter, and the upper part (33) of the filter has an opening (36) for exhalation, equipped with a one-way valve (39), ensuring the removal of fluid from the channel (47) for the fluid through the filter material (32) outward from the mouthpiece (40) when the patient exhales through the inhalation port; wherein the housing (46) and the base (31) of the filter are an integrated one-piece unit. 2. The method of claim 1, wherein said lung disease or condition is selected from the group consisting of asthma, refractory asthma, chronic obstructive bronchitis, parenchymal, fibrotic and interstitial diseases and inflammation of the lungs, bronchiolitis obliterans (BOS) and acute and chronic reactions organ transplant rejection after lung transplantation, and diseases caused by them. 3. The method according to any one of the preceding claims, wherein said lung disease or condition is bronchiolitis obliterans (BOS) grade I or more, in particular grade I or II BOS, in particular grade I BOS. 4. The method of any one of the preceding claims, wherein cyclosporin A in liposomal solubilized form (L-CsA) is contained in the pharmaceutical composition at a concentration in the range of about 1 mg/mL to about 10 mg/mL. 5. The method of any one of the preceding claims, wherein cyclosporin A in liposomal solubilized form (L-CsA) is contained in the liquid aqueous composition at a concentration in the range of about 3 to about 5 mg/mL. 6. The method according to any one of the preceding claims, wherein said composition is a liquid composition containing an aqueous liquid carrier medium. 7. The method according to any of the preceding claims, wherein said aqueous liquid composition containing cyclosporin A in liposomal solubilized form is obtained by re-dissolving a lyophilisate containing cyclosporin A and liposome-forming structures. 8. The method of claim 7 wherein said liposome forming structures comprise a bilayer membrane derived from a membrane forming substance selected from the group of phospholipids. 9. The method of claim 8 wherein said membrane forming agent selected from the group of phospholipids is a mixture of natural phospholipids. 10. The method according to claim 8 or 9, wherein said membrane forming agent selected from the group of phospholipids is lecithin containing unsaturated fatty acid residues. 11. The method of any one of claims 8 to 10, wherein said membrane forming agent selected from the group of phospholipids is a lecithin selected from the group consisting of soy lecithin, Lipoid S75, Lipoid S100, or Phospholipon G90. 12. The method according to any one of claims 8 to 11, wherein said composition further comprises at least one solubility agent selected from the group of nonionic surfactants. 13. The method of claim 12 wherein at least one said nonionic surfactant is selected from the group of polysorbates. 14. The method of claim 12 or 13 wherein said solubility agent selected from the group of nonionic surfactants is polysorbate 80. 15. The method of claim 13 or 14 wherein the weight ratio of phospholipid to polysorbate is selected from the range of from about 15:1 to about 9:1, preferably from about 14:1 to about 12:1, such as about 13:1. 16. The method according to any of the preceding claims, wherein said composition further comprises at least one disaccharide selected from the group consisting of sucrose, lactose and trehalose, preferably sucrose. 17. The method according to claim 16, wherein said composition contains at least one disaccharide selected from the group consisting of sucrose, lactose and trehalose, preferably sucrose, in an amount in the range from about 5 to about 15 wt.%, preferably in range from about 7.5 to about 12.5 wt.%, based on the total weight of the pharmaceutical composition. 18. The method according to any one of claims 7 to 17, wherein said cyclosporin A is at least partially incorporated or embedded in a bilayer membrane of liposome forming structures. 19. A method according to any one of the preceding claims, wherein said vibrating membrane (110) has from about 100 to about 400 holes per mm ² . 20. The method of claim 19, wherein said plurality of apertures of the vibrating membrane (110) are in the form of a cone tapering towards the aerosol release side of the vibrating membrane. 21. The method of claim 19 or 20, wherein said vibratory membrane apertures have an exit diameter in the range of about 1.5 to about 3.0 µm as measured by scanning electron microscopy (SEM). 22. The method according to any one of the preceding claims, wherein the cyclosporin A in the liposomal - 30 042761 solubilized form is delivered to the lungs or lungs of the subject in an amount of at least 70%, in particular in an amount ranging from about 70% to about 80% of the amount administered to the subject. 23. The method according to any one of the preceding claims, wherein the aerosol administered to the patient contains droplets, and wherein from about 60 to about 95% of the total number of droplets have a diameter of up to 5 microns when measured using laser diffraction or on a multi-stage cascade impactor when measured using an aqueous composition containing L-CsA at a concentration of 4 mg/ml. 24. The method according to any one of the preceding claims, in which cyclosporin A in liposomal solubilized form is administered to the subject at a total productivity (TOR) of at least 200 mg/min, in particular at a total productivity in the range from about 200 to about 250 mg/min. min. 25. The method according to any one of the preceding claims, wherein the cyclosporin A in liposomal solubilized form exhaled by the subject constitutes up to 10%, in particular from about 4 to about 8%, of the total active ingredient administered to the subject. 26. The method of any one of the preceding claims, wherein 1 ml of a pharmaceutical composition comprising cyclosporin A in liposomal solubilized form is aerosolized (sprayed) over a period of time up to about 5 minutes. 27. A kit for the prevention or treatment of a lung disease or condition in a subject, containing a pharmaceutical composition containing cyclosporine A in liposomal solubilized form; and a nebulizer (100) containing: a) an aerosol generator (101), comprising: a fluid reservoir (103) for storing a pharmaceutical composition or an adapter configured to connect the fluid reservoir and a vibrating membrane (110) having a plurality of holes designed to produce an aerosol containing droplets having a mass median aerodynamic diameter (MMAD) down to about 4.0 μm when measured using 0.9% (w/v) aqueous sodium chloride solution; b) a chamber (105) for temporarily housing the aerosol produced by the aerosol generator (101), having an internal cavity with a volume ranging from about 50 to about 150 ml; And c) a mouthpiece (40) for delivering an aerosol to a subject, where the mouthpiece has an exhalation filter (30); while the mouthpiece (40) contains: a body (46) defining a fluid channel (47) from an inlet (41) configured to be connected to the chamber (105) to an inhalation hole (42) to be placed in the user's mouth; and an exhalation filter (30) comprising a filter base (31) in fluid communication with a fluid channel (47), an upper filter part (33) detachably connected to the filter base (31), and a filter material (32 ) provided between the base (31) of the filter and the upper part (33) of the filter, and the upper part (33) of the filter has an opening (36) for exhalation, equipped with a one-way valve (39), ensuring the removal of fluid from the channel (47) for fluid media through the filter material (32) out of the mouthpiece (40) when the patient exhales through the inhalation hole; wherein the housing (46) and the base (31) of the filter are an integrated one-piece unit. 28. The kit of claim 27, wherein said pharmaceutical composition comprising cyclosporin A in liposomal solubilized form is provided as a pre-formulated liquid aqueous composition. 29. The kit of claim 27, wherein said pharmaceutical composition containing cyclosporin A in liposomal solubilized form is provided as a lyophilisate containing cyclosporin A in liposomal solubilized form and a sterile liquid aqueous carrier to re-dissolve the lyophilisate to form a liquid pharmaceutical composition. -