Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/557—Eicosanoids, e.g. leukotrienes or prostaglandins
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/185—Acids; Anhydrides, halides or salts thereof, e.g. sulfur acids, imidic, hydrazonic or hydroximic acids
  • A61K31/19—Carboxylic acids, e.g. valproic acid
  • A61K31/192—Carboxylic acids, e.g. valproic acid having aromatic groups, e.g. sulindac, 2-aryl-propionic acids, ethacrynic acid 
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/0012—Galenical forms characterised by the site of application
  • A61K9/007—Pulmonary tract; Aromatherapy
  • A61K9/0073—Sprays or powders for inhalation; Aerolised or nebulised preparations generated by other means than thermal energy
  • A61K9/0078—Sprays or powders for inhalation; Aerolised or nebulised preparations generated by other means than thermal energy for inhalation via a nebulizer such as a jet nebulizer, ultrasonic nebulizer, e.g. in the form of aqueous drug solutions or dispersions
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/0012—Galenical forms characterised by the site of application
  • A61K9/007—Pulmonary tract; Aromatherapy
  • A61K9/0073—Sprays or powders for inhalation; Aerolised or nebulised preparations generated by other means than thermal energy
  • A61K9/008—Sprays or powders for inhalation; Aerolised or nebulised preparations generated by other means than thermal energy comprising drug dissolved or suspended in liquid propellant for inhalation via a pressurized metered dose inhaler [MDI]
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/10—Dispersions; Emulsions
  • A61K9/12—Aerosols; Foams
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P11/00—Drugs for disorders of the respiratory system
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P43/00—Drugs for specific purposes, not provided for in groups A61P1/00-A61P41/00
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P9/00—Drugs for disorders of the cardiovascular system
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P9/00—Drugs for disorders of the cardiovascular system
  • A61P9/12—Antihypertensives

Definitions

• the present application relates to methods and kits for therapeutic treatment and, more particularly, to therapeutic methods involving administering treprostinil using a metered dose inhaler and related kits.
• pulmonary hypertension Generally, pulmonary hypertension is defined through observations of pressures above the normal range pertaining in the majority of people residing at the same altitude and engaged in similar activities.
• Pulmonary hypertension may occur due to various reasons and the different entities of pulmonary hypertension were classified based on clinical and pathological grounds in 5 categories according to the latest WHO convention, see e.g. Simonneau G., et al. J. Am. Coll. Cardiol. 2004; 43(12 Suppl S):5S-12S.
• Pulmonary hypertension can be a manifestation of an obvious or explicable increase in resistance, such as obstruction to blood flow by pulmonary emboli, malfunction of the heart's valves or muscle in handling blood after its passage through the lungs, diminution in pulmonary vessel caliber as a reflex response to alveolar hypoxia due to lung diseases or high altitude, or a mismatch of vascular capacity and essential blood flow, such as shunting of blood in congenital abnormalities or surgical removal of lung tissue.
• certain infectious diseases such as HIV and liver diseases with portal hypertension may cause pulmonary hypertension.
• Autoimmune disorders such as collagen vascular diseases, also often lead to pulmonary vascular narrowing and contribute to a significant number of pulmonary hypertension patients.
• idiopathic pulmonary hypertension primary pulmonary hypertension
• iPAH primary pulmonary hypertension
• iPAH primary pulmonary hypertension
• the cases of idiopathic pulmonary arterial hypertension tend to comprise a recognizable entity of about 40% of patients cared for in large specialized pulmonary hypertension centers. Approximately 65% of the most commonly afflicted are female and young adults, though it has occurred in children and patients over 50.
• Pulmonary hypertension refers to a condition associated with an elevation of pulmonary arterial pressure (PAP) over normal levels. In humans, a typical mean PAP is approximately 12-15 mm Hg. Pulmonary hypertension, on the other hand, can be defined as mean PAP above 25mmHg, assessed by right heart catheter measurement. Pulmonary arterial pressure may reach systemic pressure levels or even exceed these in severe forms of pulmonary hypertension. When the PAP markedly increases due to pulmonary venous congestion, i.e. in left heart failure or valve dysfunction, plasma can escape from the capillaries into the lung interstitium and alveoli. Fluid buildup in the lung (pulmonary edema) can result, with an associated decrease in lung function that can in some cases be fatal. Pulmonary edema, however, is not a feature of even severe pulmonary hypertension due to pulmonary vascular changes in all other entities of this disease.
• Pulmonary hypertension may either be acute or chronic.
• Acute pulmonary hypertension is often a potentially reversible phenomenon generally attributable to constriction of the smooth muscle of the pulmonary blood vessels, which may be triggered by such conditions as hypoxia (as in high-altitude sickness), acidosis, inflammation, or pulmonary embolism.
• Chronic pulmonary hypertension is characterized by major structural changes in the pulmonary vasculature, which result in a decreased cross-sectional area of the pulmonary blood vessels.
• This may be caused by, for example, chronic hypoxia, thromboembolism, collagen vascular diseases, pulmonary hypercirculation due to left-to-right shunt, HIV infection, portal hypertension or a combination of genetic mutation and unknown causes as in idiopathic pulmonary arterial hypertension.
• Pulmonary hypertension has been implicated in several life-threatening clinical conditions, such as adult respiratory distress syndrome ("ARDS") and persistent pulmonary hypertension of the newborn (“PPHN”).
• ARDS adult respiratory distress syndrome
• PPHN persistent pulmonary hypertension of the newborn
• Zapol et al. Acute Respiratory Failure, p. 241-273, Marcel Dekker, New York (1985); Peckham, J. Ped. 93:1005 (1978).
• PPHN a disorder that primarily affects full-term infants, is characterized by elevated pulmonary vascular resistance, pulmonary arterial hypertension, and right-to-left shunting of blood through the patent ductus arteriosus and foramen ovale of the newborn's heart.
• Mortality rates range from 12-50%.
• Pulmonary hypertension may also ultimately result in a potentially fatal heart condition known as "cor pulmonale,” or pulmonary heart disease.
• cor pulmonale or pulmonary heart disease.
• One embodiment is a method of delivering to a subject in need thereof a therapeutically effective amount of treprostinil, or treprostinil derivative or a pharmaceutically acceptable salt thereof comprising administering to the subject a therapeutically effective amount of the treprostinil or treprostinil derivative or a pharmaceutically acceptable salt thereof using a metered dose inhaler.
• Another embodiment is a method for treating pulmonary hypertension comprising administering to a subject in need thereof treprostinil or its derivative, or a pharmaceutically acceptable salt thereof using a metered dose inhaler.
• kits comprising a metered dose inhaler containing a pharmaceutical formulation comprising treprostinil or treprostinil derivative, or a pharmaceutically acceptable salt thereof.
• kits for treating pulmonary hypertension in a subject comprising (i) an effective amount of treprostinil or its derivative, or a pharmaceutically acceptable salt thereof; (ii) a metered dose inhaler; (iii) instructions for use in treating pulmonary hypertension.
• Administration of treprostinil using a metered dose inhaler can provide patients, such as pulmonary hypertension patients, with a high degree of autonomy.
• FIGURE 1 pulmonary and systemic changes in hemodynamics following the inhalation of placebo (open circles), 30 ⁇ g treprostinil (triangles), 45 ⁇ g treprostinil (squares) or 60 ⁇ g TREprostinil (black circles) applied by a Metered Dose Inhaler (MDI-TRE).
• MDI-TRE Metered Dose Inhaler
• a single short inhalation of treprostinil induced sustained reduction of PAP and PVR that outlasted the observation period of 120 minutes at doses of 45 and 60 ⁇ g MDI-TRE.
• Systemic arterial pressure and resistance were not significantly affected.
• PAP mean pulmonary artery pressure
• PVR pulmonary vascular resistance
• SAP mean systemic arterial pressure
• SVR systemic vascular resistance.
• Data are given as mean value ⁇ standard error of the mean (SEM).
• FIG. 2 presents hemodynamic changes induced by the inhalation of placebo (open circles), 30 ⁇ g treprostinil (triangles), 45 ⁇ g treprostinil (squares) or 60 ⁇ g treprostinil (black circles) applied by a metered dose inhaler.
• Treprostinil induced sustained elevation of cardiac output.
• Heart rate was rather unchanged as a sign for low spillover of MDI-TRE to the systemic circulation. Gas exchange was not negatively affected.
• CO cardiac output
• HR heart rate
• SaO2 arterial oxygen saturation
• SvO2 central venous oxygen saturation.
• Data are given as mean value ⁇ SEM.
• FIG. 3 shows areas under the curve for changes in pulmonary vascular resistance (PVR) calculated for an observation period of 120 minutes after inhalation treprostinil using a metered dose inhaler. PVR was markedly lowered by treprostinil inhalation. The increased pulmonary vasodilation over time with the two highest doses mainly relies on the more sustained effect over time. Data are shown as mean value ⁇ 95% confidence intervals.
• FIG. 4 demonstrates Ventilation-perfusion matching measured with the multiple inert gas elimination technique.
• the PVR decrease with treprostinil was delayed and prolonged, compared to iloprost. Due to carryover effects from the first period, in the second period, the effects of both drugs appeared shortened. Data are shown as percent of baseline values (mean value ⁇ 95% confidence interval).
• FIG. 7 presents hemodynamic response to inhalation of treprostinil vs. iloprost.
• Data from n 44 patients, who inhaled both drugs in randomized order, shown as percent of baseline values (mean value ⁇ 95% confidence interval).
• PVR pulmonary vascular resistance
• PAP mean pulmonary arterial pressure
• SAP mean systemic arterial pressure
• CO cardiac output.
• FIG. 8 presents pharmacodynamics after treprostinil inhalation vs. placebo.
• Placebo or treprostinil in doses of 30 ⁇ g, 60 ⁇ g or 90 ⁇ g were inhaled (means ⁇ 95 % confidence intervals). Maximal decrease of PVR was comparable for all doses. The duration of pulmonary vasodilation (PVR-decrease) appeared to be dose dependent.
• PVR pulmonary vascular resistance
• PAP mean pulmonary arterial pressure
• SAP mean systemic arterial pressure
• CO cardiac output
• SaO2 arterial oxygen saturation
• SvO2 mixed venous oxygen saturation.
• FIG. 9 presents Areas Between the placebo and the treprostinil Curves (ABC). ABCs were calculated for a 3-hour period after inhalation of TRE or placebo from the relative changes of hemodynamic parameters (means ⁇ 95 % confidence intervals).
• PVR pulmonary vascular resistance
• PAP mean pulmonary arterial pressure
• SAP mean systemic arterial pressure
• SVR systemic vascular resistance.
• FIG. 10 presents hemodynamic responses to the inhalation of 15 ⁇ g treprostinil.
• the inhalation time by increasing treprostinil concentration.
• a pulse of aerosol was generated every 6 seconds.
• Placebo data correspond to Figure 8. Data are shown as means ⁇ 95 % confidence intervals.
• PVR pulmonary vascular resistance
• PAP mean pulmonary arterial pressure
• SAP mean systemic arterial pressure
• CO cardiac output.
• FIG. 11 presents areas between the placebo curve and the responses to 15 ⁇ g treprostinil applied at increasing concentrations to minimize inhalation time.
• Mean ⁇ SEM of relative changes of hemodynamic parameters observation time 120 min.
• PAP pulmonary arterial pressure
• SAP systemic arterial pressure
• PVR pulmonary vascular resistance
• CO cardiac output
• SaO2 systemic arterial oxygen saturation
• SvO2 pulmonary arterial oxygen saturation.
• FIG. 12 presents pharmacokinetics of treprostinil after a single inhalation.
• Data with error bars represent mean values ⁇ SEM.
• one embodiment of the invention is a method of delivering to a subject in need thereof, such as a human being, a therapeutically effective amount of treprostinil comprising administering to the subject a formulation comprising a therapeutically effective amount of treprostinil, its derivative or a pharmaceutically acceptable salt thereof using a metered dose inhaler.
• Treprostinil can be administered via a metered dose inhaler to a subject affected with a condition or disease, which can be treated by treprostinil, such as asthma, pulmonary hypertension, peripheral vascular disease or pulmonary fibrosis.
• a condition or disease which can be treated by treprostinil, such as asthma, pulmonary hypertension, peripheral vascular disease or pulmonary fibrosis.
• Another embodiment of the invention is a method for treating pulmonary hypertension, comprising administering to a subject in need thereof, such as a human being, treprostinil or its derivative, or a pharmaceutically acceptable salt using a metered dose inhaler.
• Treprostinil or 9-deoxy-2',9-alpha-methano-3-oxa-4,5,6-trinor-3,7-(l '3'- interphenylene)-13,14-dihydro-prostaglandin Fl, is a prostacyclin analogue, first described in US patent 4,306,075.
• US Patent No. 5,153,222 describes use of treprostinil for treatment of pulmonary hypertension.
• Treprostinil is approved for the intravenous as well as subcutaneous route, the latter avoiding septic events associated with continuous intravenous catheters.
• 6,521,212 and 6,756,033 describe administration of treprostinil by inhalation for treatment of pulmonary hypertension, peripheral vascular disease and other diseases and conditions.
• US patent No. 6,803,386 discloses administration of treprostinil for treating cancer such as lung, liver, brain, pancreatic, kidney, prostate, breast, colon and head-neck cancer.
• US patent application publication No. 2005/0165111 discloses treprostinil treatment of ischemic lesions.
• US patent No. 7,199,157 discloses that treprostinil treatment improves kidney functions.
• US patent application publication No. 2005/0282903 discloses treprostinil treatment of neuropathic foot ulcers.
• Acid derivative is used herein to describe C 1-4 alkyl esters and amides, including amides wherein the nitrogen is optionally substituted by one or two C 1-4 alkyl groups.
• the present invention also encompasses methods of using Treprostinil or its derivatives, or pharmaceutically acceptable salts thereof.
• a method uses Treprostinil sodium, currently marketed under the trade name of REMODULIN ® .
• the FDA has approved Treprostinil sodium for the treatment of pulmonary arterial hypertension by injection of dose concentrations of 1.0 mg/mL, 2.5 mg/mL, 5.0 mg/mL and 10.0 mg/mL.
• the chemical structure formula for Treprostinil sodium is:
• Treprostinil sodium is sometimes designated by the chemical names: (a) [(IRaRMS ⁇ aSyi ⁇ aA ⁇ a-hQxahydro-l-hydroxy-l-iiSSyS-hydroxyoctyYl-lH- benz[/]inden-5-yl]oxy]acetic acid; or (b) 9-deoxy-2',9- ⁇ -methano-3-oxa-4,5,6-trinor- 3,7-(l ',3'-interphenylene)-13,14-dihydro-prostaglandin F 1 .
• Treprostinil sodium is also known as: UT-15; LRX-15; 15AU81; UNIPROSTTM; BW A15AU; and U- 62,840.
• the molecular weight of Treprostinil sodium is 390.52, and its empirical formula is C 23 H 34 O 5 .
• treprostinil can be administered in combination with one or more additional active agents.
• such one or more additional active agents can be also administered together with treprostinil using a metered dose inhaler.
• such one or more additional active agents can be administered separately from treprostinil.
• Particular additional active agents that can be administered in combination with treprostinil may depend on a particular disease or condition for treatment or prevention of which treprostinil is administered.
• the additional active agent can be a cardiovascular agent such as a calcium channel blocker, a phosphodiesterase inhibitor, an endothelial antagonist, or an antiplatelet agent.
• the present invention extends to methods of using physiologically acceptable salts of Treprostinil, as well as non-physiologically acceptable salts of Treprostinil that may be used in the preparation of the pharmacologically active compounds of the invention.
• salts of inorganic bases can be, for example, salts of alkali metals such as sodium or potassium; alkaline earth metals such as calcium and magnesium or aluminum; and ammonia.
• Salts of organic bases can be, for example, salts trimethylamine, triethylamine, pyridine, picoline, ethanolamine, diethanolamine, and triethanolamine.
• Salts of inorganic acids can be, for example, salts of hydrochloric acid, hydroboric acid, nitric acid, sulfuric acid, and phosphoric acid.
• Salts of organic acids can be, for example, salts of formic acid, acetic acid, trifluoroacetic acid, fumaric acid, oxalic acid, lactic acid, tartaric acid, maleic acid, citric acid, succinic acid, malic acid, methanesulfonic acid, benzenesulfonic acid, and p-toluenesulfonic acid.
• Salts of basic amino acids can be, for example, salts of arginine, lysine and ornithine.
• Salts of acidic amino acids can include, for example, salts of aspartic acid and glutamic acid.
• Quaternary ammonium salts can be formed, for example, by reaction with lower alkyl halides, such as methyl, ethyl, propyl, and butyl chlorides, bromides, and iodides, with dialkyl sulphates, with long chain halides, such as decyl, lauryl, myristyl, and stearyl chlorides, bromides, and iodides, and with aralkyl halides, such as benzyl and phenethyl bromides.
• lower alkyl halides such as methyl, ethyl, propyl, and butyl chlorides, bromides, and iodides
• dialkyl sulphates with long chain halides, such as decyl, lauryl, myristyl, and stearyl chlorides, bromides, and iodides
• aralkyl halides such as benzyl and phenethy
• Treprostinil can be administered by inhalation, which in the present context refers to the delivery of the active ingredient or a combination of active ingredients through a respiratory passage, wherein the subject in need of the active ingredient(s) through the subject's airways, such as the subject's nose or mouth.
• a metered dose inhaler in the present context means a device capable of delivering a metered or bolus dose of respiratory drug, such as treprostinil, to the lungs.
• a metered or bolus dose of respiratory drug such as treprostinil
• One example of the inhalation device can be a pressurized metered dose inhaler, a device which produces the aerosol clouds for inhalation from solutions and/or suspensions of respiratory drugs in chlorofluorocarbon (CFC) and/or hydrofluoroalkane (HFA) solutions.
• CFC chlorofluorocarbon
• HFA hydrofluoroalkane
• the inhalation device can be also a dry powder inhaler.
• the respiratory drug is inhaled in solid formulation, usually in the form of a powder with particle size less than 10 micrometers in diameter or less than 5 micrometers in diameter.
• the metered dose inhaler can be a soft mist inhaler (SMI), in which the aerosol cloud containing a respiratory drug can be generated by passing a solution containing the respiratory drug through a nozzle or series of nozzles.
• SMI soft mist inhaler
• Examples of soft mist inhalers include the Respimat ® Inhaler (Boeringer Ingelheim GmbH), the AERx ® Inhaler (Aradigm Corp.), the MysticTM Inhaler (Ventaira Pharmaceuticals, Inc) and the AiraTM Inhaler (Chrysalis Technologies Incorporated).
• SMI soft mist inhaler
• the aerosol for SMI can be generated from a solution of the respiratory drug further containing pharmaceutically acceptable excipients.
• the respiratory drug is treprostinil, its derivative or a pharmaceutically acceptable salt thereof, which can be formulated in SMI is as a solution.
• the solution can be, for example, a solution of treprostinil in water, ethanol or a mixture thereof.
• the diameter of the treprostinil-containing aerosol particles is less than about 10 microns, or less than about 5 microns, or less than about 4 microns.
• Treprostinil concentration in an aerosolable formulation, such as a solution, used in a metered dose inhaler can range from about 500 ⁇ g/ml to about 2500 ⁇ g/ml, or from about 800 ⁇ g/ml to about 2200 ⁇ g/ml, or from about 1000 ⁇ g/ml to about 2000 ⁇ g/ml.
• the dose of treprostinil that can be administered using a metered dose inhaler in a single event can be from about 15 ⁇ g to about 100 ⁇ g or from about 15 ⁇ g to about 90 ⁇ g or from about 30 ⁇ g to about 90 ⁇ g or from about 30 ⁇ g to about 60 ⁇ g.
• Administering of treprostinil in a single event can be carried out in a limited number of breaths by a patient.
• treprostinil can be administered in 20 breaths or less, or in 10 breaths or less, or than 5 breaths or less.
• treprostinil is administered in 3, 2 or 1 breaths.
• the total time of a single administering event can be less than 5 minutes, or less than 1 minute, or less than 30 seconds.
• Treprostinil can be administered a single time per day or several times per day.
• the method of treatment of pulmonary hypertension can further comprise administering at least one supplementary agent selected from the group consisting of sildenafil, tadalaf ⁇ l, calcium channel blockers (diltiazem, amlodipine, nifedipine), bosentan, sitaxsentan, ambrisentan, and pharmaceutically acceptable salts thereof.
• the supplementary agents can be included in the treprostinil formulation and, thus, can be administered simultaneously with treprostinil using a metered dose inhaler.
• the supplementary agents can be administered separately from treprostinil.
• the application of intravenous prostacyclin (flolan), intravenous iloprost or intravenous or subcutaneous treprostinil can be administered in addition to treprostinil administered via inhalation using a metered dose inhaler.
• the present invention also provides a kit that includes a metered dose inhaler containing a pharmaceutical formulation comprising treprostinil or its derivative, or a pharmaceutically acceptable salt thereof.
• Such a kit can further include instructions on how to use the metered dose inhaler for inhaling treprostinil.
• Such instructions can include, for example, information on how to coordinate patient's breathing, and actuation of the inhaler.
• the kit can be used by a subject, such as human being, affected with a disease or condition that can be treated by treprostinil, such as asthma, pulmonary hypertension, peripheral vascular disease or pulmonary fibrosis.
• the kit is a kit for treating pulmonary hypertension, that includes (i) a metered dose inhaler containing a pharmaceutical formulation comprising treprostinil or its derivative, or a pharmaceutically acceptable salt thereof; and (ii) instructions for use of the metered dose inhaler containing treprostinil in treating pulmonary hypertension.
• instructions for use shall mean any FDA- mandated labeling, instructions, or package inserts that relate to the administration of Treprostinil or its derivatives, or pharmaceutically acceptable salts thereof, for treatment of pulmonary hypertension by inhalation.
• instructions for use may include, but are not limited to, indications for pulmonary hypertension, identification of specific symptoms associated with pulmonary hypertension, that can be ameliorated by Treprostinil, recommended dosage amounts for subjects suffering from pulmonary hypertension and instructions on coordination of individual's breathing and actuation of the metered dose inhaler.
• SMI-TRE soft mist inhaler
• TRE doses of 30 ⁇ g, 45 ⁇ g and 60 ⁇ g reduced pulmonary vascular resistance (PVR) to 84.4 ⁇ 8.7 %, 71.4 ⁇ 17.5 % and 77.5 ⁇ 7.2 % of baseline values, respectively (mean ⁇ 95% confidence interval).
• the 120 minute area under the curve for PVR for placebo, 30 ⁇ g, 45 ⁇ g and 60 ⁇ g TRE was 1230 ⁇ 1310, -870 ⁇ 940, -2450 ⁇ 2070 and - 2000 ⁇ 900 min %, respectively.
• Reduction of PVR by a single inhalation of the two higher doses outlasted the observation period of 120 minutes. Reduction of systemic vascular resistance and pressure was negligible, showing a high pulmonary selectivity for SMI-TRE.
• Intrapulmonary selectivity was also provided by SMI-TRE as ventilation/perfusion matching, assessed by the multiple inert gas elimination technique in 5 patients with gas exchange problems, was not significantly different after SMI-TRE compared to inhaled nitric oxide or no treatment. No significant side effects were observed. [0055] Conclusions: The acute application of inhaled treprostinil with a metered dose inhaler in 2-3 breaths was safe, well tolerated and induced a strong and sustained pulmonary selective vasodilation.
• PAP pulmonary artery pressure
• PVR pulmonary vascular resistance
• PAWP pulmonary artery wedge pressure
• CO central venous oxygen saturation
• SvO2 central venous oxygen saturation
• iPAH idiopathic PAH
• CTEPH chronic thromboembolic pulmonary hypertension
• the aerosol sizes before (placebo) and after filling (treprostinil) were unchanged.
• the aerosol particles mass median aerodynamic diameter of treprostinil-aerosol was 4-5 ⁇ m, which can be at the upper limit for alveolar deposition.
• the aerosol volume delivered by one cycle from the SMI was 15 ⁇ l.
• the solution used for aerosol generation was prepared from treprostinil sodium salt using a standard protocol.
• the different doses were applied as 2 puffs lOOO ⁇ g/ml (30 ⁇ g), 3 puffs lOOO ⁇ g/ml (45 ⁇ g) and 2 puffs 2000 ⁇ g/ml (60 ⁇ g).
• the placebo was inhaled as 2 puffs from a placebo-SMI. Hemodynamics and gas-exchange parameters were recorded for 120 minutes after TRE inhalation. This study used the Respimat ® device, because the implemented "soft mist" technology was well suited for the deposition of such highly active drugs like prostanoids.
• treprostinil sodium from the metered dose inhaler was well tolerated, only mild and transient cough for a maximum of one minute was reported. No systemic side effects like headache, flush, nausea or dizziness were observed.
• Treprostinil is tolerated at high doses with no systemic side effects.
• the application of an effective amount of treprostinil in only few or even one single breath was achieved with a highly concentrated treprostinil sodium solution.
• Treprostinil can be applied by a metered dose inhaler, such as Respimat ® soft mist inhaler.
• the mean pulmonary artery pressure of the enrolled patients was about 50 mmHg. Hemodynamics and patient characteristics were similar in all studies.
• TRE and Iloprost (ILO) at an inhaled dose of 7.5 ⁇ g, displayed comparable PVR decrease, with a significantly different time course (p ⁇ 0.001), TRE exhibiting a more sustained effect on PVR (p ⁇ 0.0001) and less systemic side effects.
• placebo 30 ⁇ g, 60 ⁇ g, 90 ⁇ g or 120 ⁇ g TRE were applied with drug effects being observed for 3 hours after inhalation. A near-maximal acute PVR decrease was observed at 30 ⁇ g TRE.
• TRE was inhaled with a pulsed ultrasonic nebulizer, mimicking a metered dose inhaler.
• 15 ⁇ g TRE was inhaled with 18 pulses (TRE concentration lOO ⁇ g/ml), 9 pulses (200 ⁇ g/ml), 3 pulses (600 ⁇ g/ml), 2 pulses (lOOO ⁇ g/ml) or 1 pulse (2000 ⁇ g/ml), each mode achieving comparable, sustained pulmonary vasodilation.
• Inhaled treprostinil exerts sustained pulmonary vasodilation with excellent tolerability at doses, which may be inhaled in a few or even one breath.
• Inhaled treprostinil is advantageous to inhaled iloprost in terms of duration of effect and systemic side effects.
• Inhaled treprostinil is well tolerated in concentrations up to 2000 mg/ml (bringing down inhalation time to a single breath) and in high doses (up to 90 ⁇ g).
• Group 1 corresponds to study i); randomized crossover study comparing inhaled iloprost (ILO) and inhaled treprostinil (TRE).
• ILO inhaled iloprost
• TRE inhaled treprostinil
• a 7.5g ILO vs. 7.5 ⁇ g TRE
• b 7.5g ILO vs. 15 ⁇ g TRE (6 min inhalation time)
• c 7.5g ILO vs. 15 ⁇ g TRE (3 min inhalation time).
• Group 2 corresponds to study ii); evaluation of maximal tolerated dose of TRE.
• a placebo inhalation
• b 30 ⁇ g TRE
• c 60 ⁇ g TRE
• d 90 ⁇ g TRE
• e 120 ⁇ g TRE.
• Group 3 corresponds to study iii); reduction of inhalation time by increase of TRE concentration, aiming at a total inhaled dose of 15 ⁇ g.
• Etiology of pulmonary hypertension was classified as idiopathic PAH (i), PAH of other causes (o), chronic thromboembolic PH (t), and pulmonary fibrosis (f).
• this corresponds to a total inhaled dose of 7.5 ⁇ g iloprost and treprostinil (4 ⁇ g/ml) and 15 ⁇ g treprostinil (8 ⁇ g/ml and 16 ⁇ g/ml), respectively.
• Study ii) was a randomized, open-label, single blind, placebo controlled study.
• the primary objectives were to describe the pharmacodynamic and pharmacokinetic effects of inhaled treprostinil at a well tolerated dose (30 ⁇ g) and to explore the highest tolerated single dose.
• Study iii) was a randomized, open-label, single blind study. The primary objective was to explore the shortest possible inhalation time for a 15 ⁇ g dose of inhaled treprostinil. A total of 48 patients inhaled one dose of TRE during right heart catheter investigation. The drug was applied in 18, 9, 3, 2 or 1 breaths.
• the aerosol was generated by a pulsed ultrasonic nebulizer (Ventaneb, Nebutec, Elsenfeld, Germany) in cycles consisting of 2 seconds aerosol production (pulse) and 4 seconds pause.
• the device included an opto-acoustical trigger for the patient to synchronize the inspiration to the end of the aerosol pulse, thereby providing exact dosage.
• Treprostinil plasma concentrations were assessed in study ii) at 10, 15, 30, 60 and 120 minutes after inhalation.
• Treprostinil quantification was done by Alta Analytical Laboratory (El Dorado Hills, California, USA) with a validated liquid chromatography atmospheric-pressure ionization tandem mass spectrometry as previously described Wade M., et al. J. Clin. Pharmacol. 2004;44:503-9.
• Mixed venous blood was drawn at the depicted time points ( Figure 11) after inhalation, centrifuged and the plasma frozen at -80 0 C until temperature controlled shipping on dry ice.
• SAP Systemic arterial pressure
• PAP was reduced to 84.2 ⁇ 4.5% (18 pulses, lOO ⁇ g/ml), 84.2 ⁇ 4.1% (9 pulses, 200 ⁇ g/ml), 81.1 ⁇ 4.1% (3 pulses, 600 ⁇ g/ml), 86 ⁇ 4% (2 pulses, lOOO ⁇ g/ml) and 88 ⁇ 5.4% (1 pulse, 2000 ⁇ g/ml). Cardiac output was moderately increased in all groups, whereas systemic arterial pressure was not significantly affected.
• Inhaled treprostinil can be applied in high doses (up to 90 ⁇ g) with a minimal inhalation time. Inhaled treprostinil exerts high pulmonary selectivity and leads to a long-lasting pulmonary vasodilation.

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