WO2008109026A1

WO2008109026A1 - Pharmaceutical compositions for the localized treatment of neurogenic dysfunction

Info

Publication number: WO2008109026A1
Application number: PCT/US2008/002783
Authority: WO
Inventors: Bryan Jones
Original assignee: Mt Cook Pharma
Priority date: 2007-03-05
Filing date: 2008-03-03
Publication date: 2008-09-12

Abstract

The invention relates to compositions and methods for the treatment of neuropathic or neurogenic pain and /or disorders at least partially associated with neurogenic dysfunction comprising the use of a pharmaceutical composition comprising at least one homovanilloid compound and at least one permeation enhancer. The use of the permeation enhancer in the compositions of the invention improves penetration of the homovanilloid compound through tissues, in particular mucosal membranes, enabling effective topical or localized treatment methodologies and affording a reduction in side effects commonly associated with homovanilloid therapies. In specific embodiments of the invention, the homovanilloid compound is RTX, TYX, 20-homovanillyl-mezerein or 20-homovanillyl-12-deoxyphorbol-13-phenylacetate, and the permeation enhancer is hyaluronidase ('HAse'). The methods and formulations of the invention are effective in a trans-membrane or trans-mucosal delivery method, in particular for the treatment of neuropathic or neurogenic disorders in a mammal.

Description

PHARMACEUTICAL COMPOSITIONS FOR THE LOCALIZED TREATMENT OF NEUROGENIC DYSFUNCTION

1. FIELD OF THE INVENTION

[0001] The invention relates to compositions and methods for the treatment of neuropathic or neurogenic pain and /or disorders at least partially associated with neurogenic dysfunction comprising the use of a pharmaceutical composition comprising at least one homovanilloid compound and at least one permeation enhancer. The use of the permeation enhancer in the compositions of the invention improves penetration of the homovanilloid compound through tissues, in particular mucosal membranes, enabling effective topical or localized treatment methodologies and affording a reduction in side effects commonly associated with homovanilloid therapies. In specific embodiments of the invention, the homovanilloid compound is RTX, TYX, 20-homovanillyl-mezerein or 20- homovanillyl-12-deoxyphorbol-13-phenylacetate, and the permeation enhancer is hyaluronidase ("HAse"). The methods and formulations of the invention are effective in a trans-membrane or trans-mucosal delivery method, in particular for the treatment of neuropathic or neurogenic disorders in a mammal.

2. BACKGROUND OF THE INVENTION

[0002] Capsaicin ("CAP"), the active component of the red pepper of the genus

Capsicum, has long been recognized to have analgesic properties, and has been studied for the topical or localized treatment of pain due to a number of conditions including cluster headaches, herpes zoster, menstrual cramps and muscular pain (U.S. Patent Nos. 5,431,914 and 5,665,378; Sicuteri et al., 1989, Clin. J. Pain 5:49; and Watson et al., 1988, Pain 33:333, each of which is incorporated herein by reference in its entirety). CAP activity is mediated through a specific cellular receptor known as the vanilloid receptor (known in the art as VRl or TRPVl; "VR"). VR is expressed almost exclusively by primary sensory neurons involved in noiception and neurogenic inflammation, and has also been shown to respond to various other noxious stimuli including proton and thermal stimuli (Tominaga et al., 1998, Neuron 21:513-543). Because of the relatively limited expression of VR, CAP exerts selective activity on afferent nerve fibers of thin unmyelinated or myelinated nerve (C- fibers or A-fibers, respectively) in the area of contact. Although the detailed mechanism of action is not known, CAP effects are believed to be mediated by the initial activation and eventual desensitization of noiceptors in peripheral tissues to one or more stimulus modalities. Accordingly, CAP has been investigated as a method to treat patients for general pain, acute pain, and chronic pain as well as for conditions/disorders with neurogenic components. For use, CAP is usually applied or contacted locally; however, CAP is not suitable for routine usage because it can be associated with intense burning and pain on application, which is believed caused by intense activation and temporary sensitization of the peripheral noiceptors at the site of application (in particular where the site of application is a mucosal membrane). Additionally, for certain treatments, CAP can cause an initial period wherein symptoms worsen prior to improving; for example, in the treatment of urinary incontinence associated with various bladder/lower urinary tract disorders, CAP treatment by intravesicular installation can result in an initial 2-4 days wherein symptoms actually deteriorate prior to improving.

[0003] Studies of compounds related to CAP, the homovanilloid compounds, have shown physiological effects similar to capsaicin (CAP) but at much lower dosages, thereby minimizing side effects common to homovanilloid application. Depending on the physiological response measured, the homovanilloids may be more potent than CAP, on a molar basis, by a factor of 10-10,000. In particular, the homovanillyl diterpene esters resiniferatoxin (RTX) and tinyatoxin (TYX), and other homovanilloids have been shown to be effective for desensitizing sensory nerves to in a manner similar to CAP but at much lower dosage (U.S. Pat. Nos. 4,939,149; 5,021,450; and 6,630,515, each of which is incorporated herein by reference in its entirety).

[0004] Although use of homovanillyl diterpene esters has resulted in better tolerated therapies, the side effects common to homovanilloid therapies, e.g., a burning sensation or other irritation at or near the site of application may still be reported. Lipid vehicles have been investigated as a means delivery of therapeutics with irratiative side effects, including vanilloids, in efforts to minimize or eliminate such side effects; however, the use of lipids vehicles for pharmaceutical preparations involves complex preparation and purification procedures (U.S. Patent No. 7,063,860 and U.S. Patent Application No. 2007/0003610, each of which is hereby incorporated by reference in its entirety). In contrast, the use of permeation enhancers in combination with homovanilloid therapies offers a means of minimizing side effects without complex preparation requirements. In particular, the use of a permeation enhancer, depending on the treatment, allows lower dosages or shorter contact times of homovanilloid therapies, thereby minimizing common side effects. Further, the use of a permeation enhancer will allow potentially new homovanilloid therapies to be investigated wherein target tissues are separated from the site of application by one or more tissue layers/types, e.g., separated by membranes, mucosal membranes, the dura mater (e.g., during use in epidural procedures). [0005] The patent literature is replete with examples of permeation enhancers which effectively increase permeability of drugs through tissue. However, many if not all of these references involve transdermal delivery and/or irritation reduction of skin in transdermal delivery therapies. Skin is the most robust and resilient barrier in the body and offers little resemblance to mucosal or other membranes of the body encompassed by the present invention, e.g., the dura mater, membranes of the gastro-intestinal tract, the bladder mucosa, the vaginal cavity. The present invention relates to compositions and methods for the delivery of a homovanilloid compound, in particular a homovanillyl diterpene ester, in particular RTX, across a membrane of the body, in particular a mucosal membrane or the dura mater.

[0006] Although the use of any permeation enhancer known in the art is encompassed by the invention, in certain embodiments, the use of a modulatory agent of epithelial junction or extracellular matrix physiology is preferred, e.g., an enzyme degrative to specific membrane or extracellular matrix components. In particular, the invention encompasses the use glycosaminoglycanase enzymes ("GAGases") as a permeation/penetration enhancer. When used according to the methods of the present invention compositions comprising at least one permeation enhancer, e.g., a GAGase, serve to increase diffusion of other molecules of the composition, e.g., a homovanilloid compound, across membranes, in particular mucosal membranes, of the body. [0007] In particular, GAGases therapeutically modify glycosaminoglycans (GAGs) within the extracellular matrix of a first tissue, promoting increased diffusion of molecules through said first tissue to allow targeting of tissues distal to the first. GAGs are complex linear polysaccharides of the extracellular matrix (ECM) and are characterized by repeating disaccharide structures of an N-substituted hexosamine and an uronic acid (in the case of hyaluronan (HA), chondroitin sulfate (CS), chondroitin (C), dermatan sulfate (DS), heparan sulfate (HS), and heparin (H)), or a galactose (in the case of keratan sulfate (KS)). Except for HA, all exist covalently bound to core proteins. The GAGs with their core proteins are structurally referred to as proteoglycans (PGs).

[0008] Of particular interest has been the use of hyaluronidases ("HAses"), GAGs specific for HA, as a monotherapeutic or for use in combination with other active agents. HAses have been investigated as a therapeutic not only in the treatment of diseases associated with excess HA but also to enhance the distribution and/or penetration of therapeutic agents at the site of administration. For example, HAses have been used in cancer therapy as a "spreading agent" to enhance the activity of chemotherapeutics and/or the accessibility of tumors to chemotherapeutics (Schuller et al., 1991, Proc. Amer. Assoc. Cancer Res. 32: 173, abstract no. 1034; Czejka et al., 1990, Pharmazie 45:H.9, each of which is hereby incorporated by reference in its entirety) and have been used in combination with other chemotherapeutic agents in the treatment of a variety of cancers including urinary bladder cancer (Horn et al., 1985, J. Surg. Oncol., 28:304 307, hereby incorporated by reference in its entirety).

[0009] HAses are a group of neutral- and acid-active enzymes found throughout the animal kingdom in organisms as diverse as microbes (e.g., Streptococcus pyogenes, Treponema palladium, and nematodes), bees, wasps, hornet, spiders, scorpions, fish, snakes, lizards, and mammals. HAses degrade HA and, to a lesser extent, chondroitin sulfates (for a review, see Kreil et al. 1995 Protein Sci. 4:1666-16669). Vertebrate HAses are separated into two general classes: 1) the neutral-active HAses, such as the predominantly sperm- associated protein PH20 (Liu et al. 1996 Proc. Natl. Acad. Sci. USA 93:7832-7837; Primakoff et al. 1985 J. Cell Biol. 101:2239 44; Lin et al. 1993 Proc. Natl. Acad. Sci. USA 90:10071-10075); and 2) the acid-active HAses, which have a distinct pH optimum between pH 3.5 to 4.0 and have been described in extracts of liver (Fiszer-Szafarz et al. 1995 Acta Biochim Pol. 42:31-33), kidney (Komender et al. 1973 Bull. Acad. Pol. Sci. [Biol.] 21:637- 641), lung (Thet et al. 1983 Biochem. Biophys. Res. Commun. 117:71-77), brain (Margolis et al. 1972 J. Neutrochem. 19:2325-2332), skin (Cashman et al. 1969 Arch. Biochem. Biophys. 135:387-395), placenta, macrophages, fibroblasts (Lien et al. 1990 Biochim Biophys. Acta 1034:318-325; Ruggiero et al. 1987 J. Dent. Res. 66:1283-1287), urine (Fiszer-Szafarz et al. supra) and human plasma (De Salegui et al. 1967 Arch. Biochem. Biophys. 120:60-67). Acid-active HAse activity has also been described in the sera of mammals, though some species exhibit no detectable activity at all (Fiszer-Szafarz et al. 1990 Biol. Cell 68:95-100; De Salegui et al. 1967 supra).

[0010] The invention encompasses compositions and methods for the topical and/or localized treatment of pain generally (e.g., general pain, acute pain, and chronic pain) as well as for conditions/disorders with neurogenic components, e.g., neuropathic pain, postoperative pain, migraine, arthralgia, neuropathies, nerve injury, diabetic neuropathy, neurodegeneration, neurotic skin disorder, stroke, urinary bladder hypersensitiveness, irritable bowel syndrome, a respiratory disorder such as asthma or chronic obstructive pulmonary disease, irritation of skin, eye or mucous membrane, fervescence, stomach- duodenal ulcer, inflammatory bowel disease and inflammatory diseases. In particular, the invention encompasses methods wherein a composition comprising at least one homovanilloid compound and at least one permeation enhancer are applied in proximity to a source of pain and/or abnormal neurogenic/neuropathic activity. The invention improves the local availability of the active ingredient of the composition. Generally, for the localized treatment of pain, medicament must first diffuse from the application site to the target tissue, e.g., nerve tissue. The diffusion can both delay the onset of medicament activity and require large administered doses to ensure that therapeutic concentrations reach the target tissue. For example, in epidural administration, an epidural needle is used to deliver medicament to the epidural space of the patient. The medicament must first penetrate the dura mater and semi-liquid fat to reach the target tissue, i.e., the nerve roots. The diffusion is known to retard the onset of an anesthetic block, and, more importantly, a potential exists for toxicity caused by large doses of medicament necessary to obtain a sufficient block. The present invention affords a clear advantage over such methods of administration by, in part, reducing the time required post-administration for a therapeutic effect to be achieved and decreasing the dose of medicament necessary to achieve said effect.

[0011] The long-lasting effects of homovanilloid compounds are of particular relevance to the treatment of neuropathic pain. Neuropathic pain is a category of chronic pain that has been widely studied. Neuropathic pain occurs when the peripheral and/or central nervous systems are sensitized following an injury to the peripheral system. This initial injury can occur from a wide variety of causes including traumatic physical injury, as well as systematic diseases such as diabetes, interstitial cystitis ("IC"), herpes zoster, AIDS/HIV, syphilis and various other autoimmune diseases.

[0012] Neuropathic pain generally involves abnormalities in the nerve itself, such as degeneration of the axon or sheath. For example, in certain neuropathies the cells of the myelin sheath and/or Schwann cells may be dysfunctional, degenerative and may die, while the axon remains unaffected. Alternatively, in other neuropathies only the axon is dysfunctional, or, in still other neuropathies, both the axon and the cells of the myelin sheath and/or Schwann cells are involved. Neuropathies may also be distinguished by the process by which they occur and their location (e.g. arising in the spinal cord and extending outward or vice versa). Direct injury to the nerves as well as many systemic diseases can produce this condition. Neuropathic pain is often described as a burning or shooting type of pain, or as a tingling or itching pain and may be unrelenting in its intensity and prove more debilitating than the initial injury or the disease process that induced it. Neuropathic pain conditions are characterized by hyperesthesia (enhanced sensitivity to natural stimuli), hyperalgesia (abnormal sensitivity to pain), allodynia (widespread tenderness, characterized by hypersensitivity to tactile stimuli) and/or spontaneous burning pain. Additionally, neuropathic pains tend to be chronic and is generally considered to be nonresponsive or only partially responsive to conventional opioid analgesic regimens. Treatments which work with neuropathic pain are often non-helpful in other pain conditions. Consequently, alternate therapies for the management of neuropathic pain are widely sought. [0013] In certain embodiments, the invention contemplates the treatment disorders characterized by abnormal neurogenic function. For example, many lower urinary tract diseases and/or disorders that present primarily with symptoms comprising urinary incontinence are associated, at least partially, with altered neurogenic function. Accordingly, the invention encompasses the treatment of urinary incontinence wherein the disorder is associated, at least in part, by altered neurogenic function. Urinary incontinence, the inability to maintain voluntary control of micturition, is a condition affecting millions of men and women. The control of micturition is a complex physiological process involving neural reflex pathways (both with and without central nervous system control), smooth muscles, voluntary muscles, and hormonal effects. (See review by DeGroat, 1997 Urology 50:36-52, herein incorporated by reference in its entirety). The clinical term "overactive bladder" is used generally to denote any form of incontinence characterized by increased frequency of micturition or desire to void, whether complete or episodic, and where loss of voluntary control ranges from partial to total. "Urge incontinence" is the involuntary loss of urine associated with an abrupt and powerful desire to void. Urge incontinence is usually, but not always, associated with the urodynamic finding of involuntary (uninhibited) contractions of the detrusor muscle. The detrusor muscle provides the primary force in expelling urine from the bladder. A large subset of patients with uninhibited detrusor has some sort of neurologic impairment, in which case the clinical term is "detrusor hyperreflexia" (DH). Common neurologic disorders associated with detrusor hyperreflexia (DH) are Parkinson's disease, stroke, diabetes, multiple sclerosis (MS), peripheral neuropathy and spinal cord injury. In contrast, the terms "detrusor instability" and/or "unstable detrusor" are normally reserved for conditions wherein no neurologic abnormality can be detected. However, there is evidence to suggest that detrusor instability also results from subclinical neurologic disease or from primary muscle disease (Payne, C. K., 1998, Urology 51:3-10, herein incorporated by reference in its entirety). Alternatively, regardless of a neurogenic component, treatment of symptoms associated with detrusor instability can be effected by the methods of the present invention in that treatment of the bladder mucosa with compositions of the invention will desensitize the sensory neurons of the bladder smooth muscle, minimizing the desire to void and or relex action resulting in micturition as described infra. Accordingly, in certain embodiments, the copositions of the invention are useful for the treatment of a disorder or symptom thereof, e.g., urinary incontinence, by desensitizing sensory neurons and/or receptors. In related embodiments, the compositions of the invention are useful for treating disorders wherein no neurogenic/neurologic disease or dysfunction can be diagnosed by mthods known in the art.

[0014] Other types of urinary incontinence result from hypersensitivity of sensory

(afferent) neurons of the urinary bladder. Such hypersensitivity may or may not be classified as a dysfunction or disorder. The desire to void and the reflexes resulting in micturition are initiated by (afferent) inputs from the urinary bladder including C-fiber transmitted afferent impulses. Certain inflammatory conditions, hormonal imbalance, prostate hypertrophy and the like can cause afferent hypersensitivity of the neurons of the bladder, resulting in increased frequency, unexpected urgency, and the like, leading to incontinence episodes of varying severity. Both DH and sensory hypersensitivity are included in the term "neurogenic urinary dysfunction" herein.

3. SUMMARY OF THE INVENTION

[0015] The present invention encompasses compositions and methods for the improved treatment of pain and/or disorders characterized at least partially by altered neurogenic function comprising topical administration of compositions comprising at least one homovanilloid compound and at least one permeation enhancer. In related aspects of the invention, the at least one homovanilloid compound is RTX. In other related aspects of the invention, the at least one permeation enhancer is a GAGase, preferably a HAse. In specific embodiments, the methods of the invention are used for the treatment or management of pain and/or a disorder characterized by neurogenic dysfunction via epidural injection. In other embodiments, the methods of the invention are used for the management of pain via intrathecal injection. In other embodiments, the invention encompasses methods for the treatment of neuropathic pain. In still other embodiments, the invention encompasses methods for the treatment of pain wherein compositions comprising at least one homovanilloid compound and at least one permeation enhancer are applied to target tissues, to tissues comprising nerves that innervate said target tissues or to tissue surrounding or in the proximity of said target tissue, but that may be separated by one or more membranes, e.g., mucosal membrane, of the body. In a specific embodiment, the invention encompasses the treatment of a disease or disorder at least partially characterized by neurogenic dysfunction by the localized administration of pharmaceutical compositions comprising homovanilloid compounds, in particular resiniferatoxin ("RTX"), tinyatoxin ("TYX"), 20-homovanillyl-mezerein and 20-homovanillyl-12-deoxyphorbol-13- phenylacetate, and a permeation enhancer, in particular a HAse. In a related embodiment, the invention provides compositions and methods for the treatment of pain comprising epidural injection. In another related embodiment, the invention provides compositions and methods for the treatment of urinary incontinence and related conditions, e.g., associated with neurogenic dysfunction, by intravesicular instillation.

[0016] The permeation enhancer component of the disclosed pharmaceutical compositions provides a means of delivery of therapeutic agents that have irritative side effects (e.g., vanilloids such as capsaicin) at a lower dose, for less contact time, and/or with improved tissue-diffusive activity without a similar decrease in therapeutic effectiveness or physiologic response. The side effects common to application of homovanilloid compounds are thus reduced relative to application in absence of the permeation enhancer. In certain embodiments, the permeation enhancer also serves as an emollient of the contacted tissue, e.g., mucosal membrane.

[0017] Any permeation enhancer known in the art to be suitable for effecting increased transport across a membrane, e.g., mucosal membrane, of the body may be used in accordance with the methods of the invention. In certain embodiments, the permeation enhancer is an alcohol, an enamine, an NO donor compound, a long-chain amphipathic molecule, a small hydrophobic penetration enhancer, a sodium or a salicylic acid derivative, a glycerol ester of acetoacetic acid, a cyclodextrin or beta-cyclodextrin derivative, a medium-chain fatty acid, a chelating agent, an amino acid or salt thereof, an N-acetylamino acid or salt thereof, a modulatory agent of epithelial junction physiology (including an enzyme that degrades a selected membrane component (e.g., a GAGase, preferably a HAse)), an inhibitor of fatty acid synthesis, an inhibitor of cholesterol synthesis, a vasodilator agent, a selective transport-enhancing agent, or any combination of the permeability enhancing agents recited herein above. In related embodiments, the pharmaceutical composition of the invention can further comprise any stabilizing delivery vehicle, carrier, support or complex-forming agents described herein or known in the art. [0018] In specific embodiments, the at least one permeation enhancer of the composition is a soluble glycosaminoglycanase enzyme. In related embodiments, the permeation enhancer may be a member of the soluble neutral-active HAse Glycoprotein family, preferably members of the human soluble neutral-active HAse Glycoproteins, e.g., human soluble PH-20. The invention also contemplates use of fragments or portions of GAGase enzymes, e.g., a soluble HAse active domain. It will be appreciated by those of skill in the art that other glycosaminoglycanases such as those described herein or others known in the art can be applied to the methods provided herein. Human soluble GAGases are preferred for applications in which the enzyme is to be employed within the human body, including many medical applications as described and illustrated herein (U.S. Patent Application Publication No.: 2006/0104968, hereby incorporated by reference). In certain embodiments the permeation enhancer for use in the compositions and methods of the invention is a member of the KLA Glycoprotein family, preferably a soluble HAse Glycoprotein. In other embodiments, the soluble HAse is an acidic-active HAse (U.S. Patent Application Publication Nos. 2004/0096921 hereby incorporated by reference). [0019] In specific embodiments, the methods and compositions of the invention are used for the treatment or amelioration of, including but not limited to, general pain, acute pain, chronic pain, inflammatory pain, pain associated with neurogenic components {e.g., neuropathic pain, post-operative pain, migraine, arthralgia, neuropathies, nerve injury, diabetic neuropathy, neurodegeneration, neurotic skin disorder, stroke, urinary bladder hypersensitiveness, interstitial cystitis ("IC"), irritable bowel syndrome, a respiratory disorder such as asthma or chronic obstructive pulmonary disease, trigeminal neuralgia, reflex sympathetic dystrophy, Guillian Barre syndrome, fibromyalgia, phantom limb pain, post-mastectomy pain, chemotherapy-induced, visceral pain {e.g., that associated with gastroesophageal reflex disease, pancreatitis, and various gynecological and urological disorders), dental pain and headache (such as migraine, cluster headache and tension headache), irritation of skin, eye or mucous membrane, fervescence, stomach-duodenal ulcer, inflammatory bowel disease and inflammatory diseases), hyperesthesia, hyperalgesia, allodynia, and/or spontaneous burning pain. In yet another embodiment, the invention encompasses methods and compositions for the treatment of a mammal, preferably a human, susceptible to or afflicted with a disease or disorder that gives rise to pain responses or that relates to neurogenic dysfunction, e.g., imbalances in the maintenance of basal activity of sensory nerves. In a specific embodiment, the compositions of the invention are applied and/or administered locally or in the proximity of the pain/neurogenic dysfunction. [0020] The invention encompasses the treatment of any pain, disease and/or disorder associated, at least in part, with neurogenic dysfunction, e.g., neuropathic pain, including, but not limited to, pain associated with hepatic neuralgia, neuritis, temporomandibular disorder, myofascial pain, back pain, pain induced by inflammatory conditions, hyperalgesia, neuropathy, diabetic neuropathy, noiceptor sensitization, peripheral nerve trauma, spinal cord trauma, entrapment neuropathy, transaction, hemisection, nerve transaction {e.g., surgery causalgia), Lissauer tract section, syrinx, amputation and stump pain, Multiple sclerosis, neuroma, tumor compression, post-choracotomy pain, arteriovenous malformation, dyscraphism, vitamin B 12 deficiency, malignant nerve/plexus invasion, hematomyelia, syphilitic myelitis, ischemic irradiation, commissural myelotomy, connective tissue diseases {e.g., rheumatoid arthritis, systemic lupus erythematosus, polyarteritis nodosa), Wallenberg's syndrome, tuberculoma, Fabry disease, surgical lesions in main sensory nucleus, chemicals (e.g., anticancer therapies), idiopathic, hemorrhage AIDS neuropathy, prolapsed disk/compression, general trauma, postherpetic or trigeminal neuralgia, arachnoiditis, arteriovenous malformation, root avulsion, surgical rhizotomy, polyneuropathies, and mononeuropathies. In a specific embodiment, the invention encompasses the localized treatment of pain associated with cancer (e.g., pain associated with a tumor) and/or pain associated with anticancer therapies. [0021] In embodiments encompassing the treatment of diseases or disorders characterized by urinary incontinence, e.g., lower urinary tract disorders, treatment is conducted by administering the disclosed compositions, preferably comprising RTX (or a functionally equivalent analog such as TYX), topically to the urinary bladder mucosa, by intravesicular instillation. The composition comprising a therapeutically effective amount of a homovanilloid (e.g. RTX) and a permeation enhancer is retained in the bladder for a convenient time interval, e.g. about one-half to about two hours, then excreted. A single such treatment can be effective for an extended period, such that a patient can be maintained by treatments once every 1-6 months.

[0022] In certain embodiments, the advantage of compositions comprising the homovanilloid compound, e.g., RTX or an analog thereof, and a permeation enhancer is that therapeutically effective dosages of the homovanilloid compound are lower and/or require less contact time than those compositions not comprising the permeation enhancer. In related embodiments, the lower dosages or decreased contact times result in a reduction or elimination of side effects commonly associates with homovanilloid therapy such as pain or burning sensations.

[0023] The compositions may further comprise additional bioactive agents including antisense nucleic acids, peptides, drugs (e.g., pain therapeutics, anticancer treatments, or antibiotics), toxins (e.g., botulinum toxin), or other agents. In certain embodiments, the compositions of the invention can comprise any pharmaceutically-accepted carrier or buffers known in the art or described herein. In specific embodiments, the pharmaceutical composition has a pH of about 3 to about 8, about 4 to about 7, or about 4.5 to about 6. [0024] Further encompassed are methods of treating disorders associated with involuntary muscle contraction (e.g., dystonia, dyssynergia, and spasticity). In a specific embodiment, involuntary muscle contractions of the genitourinary tract (e.g., associated with interstitial cystitis ("IC"), urinary detrusor-sphincter dyssynergia ("UDSD"), spastic neurogenic bladder, or related conditions) are treated using the disclosed compositions by administration via intravesicular instillation. [0025] Other applications and advantages afforded by the present invention will be apparent from the detailed description and exemplification hereinbelow.

3.1 Terminology

[0026] As used herein, the term "about" or "approximately" when used in conjunction with a number refers to any number within 1, 5 or 10% of the referenced number.

[0027] As used herein, the term "in combination" in the context of the administration of (a) therapy(ies) to a subject, refers to the use of more than one therapy (e.g., more than one prophylactic agent and/or therapeutic agent). The use of the term "in combination" does not restrict the order in which therapies (e.g., prophylactic and/or therapeutic agents) are administered to a subject (e.g., a subject with neurogenic urinary dysfunction, or a condition or symptom associated therewith). A first therapy (e.g., a first prophylactic or therapeutic agent) can be administered prior to (e.g., 5 minutes, 15 minutes, 30 minutes, 45 minutes, 1 hour, 2 hours, 4 hours, 6 hours, 12 hours before), concomitantly with, or subsequent to (e.g., 5 minutes, 15 minutes, 30 minutes, 45 minutes, 1 hour, 2 hours, 4 hours, 6 hours, 12 hours) the administration of a second therapy (e.g., a second prophylactic or therapeutic agent) to a subject (e.g., a subject with neurogenic urinary dysfunction, or a condition or symptom associated therewith).

[0028] As used herein, the terms "manage," "managing," and "management" refer to the beneficial effects that a subject derives from a therapy (e.g., a prophylactic or therapeutic agent), which does not result in a cure of the disease (e.g. neurogenic urinary dysfunction). In certain embodiments, a subject is administered one or more therapies (e.g., prophylactic or therapeutic agents, such as a composition of the invention) to "manage" neurogenic urinary dysfunction, or a condition or symptom associated therewith so as to prevent the progression or worsening of disease/disorder.

[0029] As used herein the terms "permeation enhancer" and "penetration enhancer" are used interchangeably to refer to chemicals, excipients or other agents (including proteins or proteinaceous agents) that, when used in a liquid composition/formulation, i.e., comprising water, salts and/or common buffers and a homovanilloid compound, produce a formulation that results in an increase in transport of the homovanilloid compound across a biological membrane, e.g., cell layer, mucosal membrane, as measured by the maximum tissue, serum, blood, or fluid concentration (C_max) or by the area under the curve, AUC, in a plot of concentration versus time relative to the C_m2x or AUC of a control formulation. Biological membranes include, but are not limited to, the mucosa of the nasal, oral, intestinal, buccal, bronchopulmonary, vaginal, bladder, and rectal mucosal surfaces and in fact includes all mucus-secreting membranes lining all body cavities or passages that communicate with the exterior. As understood in the art, biological membranes also include those membranes that do not secrete mucus and/or do not communicate with the exterior of the body. Such membranes typically separate tissues of differing types or separate tissues from fluid filled spaces of the body, e.g., the peritoneal membrane separating abdominal organs from the peritoneal space, the dura matter separating the epidural space from the tissues of the spinal cord. As understood in the art, permeation enhancing agents are also sometimes referred to as "carriers." Permeation/penetration enhancing agents also include agents that enhance the release or solubility (e.g., from a formulation delivery vehicle), diffusion rate, penetration capacity (e.g., modulate the timing, uptake, residence time, stability, effective half-life, peak or sustained concentration levels, and/or clearance) and other desired trans-membrane delivery characteristics (e.g., as measured at the site of delivery, or at a selected target site of activity such as distal to the site of application, e.g., on the opposite side of the biological membrane of interest) of the homovanilloid compound. Enhancement of membrane delivery and/or permeation can thus occur by any of a variety of mechanisms, for example by increasing the diffusion, transport, persistence or stability of the homovanilloid compound, increasing membrane fluidity, modulating the availability or action of calcium and other ions that regulate intracellular or paracellular permeation, solubilizing membrane components (e.g., lipids), changing nonprotein and protein sulfhydryl levels in membrane, especially mucosal, tissues, increasing water flux across the membrane surface, modulating epithelial junctional physiology, reducing the viscosity of mucus overlying the mucosal epithelium for trans-mucosal delivery, and other mechanisms.

[0030] As used herein, the terms "prevent", "preventing" and "prevention" refer to the prevention of the recurrence or onset of, or a reduction in one or more symptoms of a disease/disorder (e.g., neurogenic urinary dysfunction) in a subject as result of the administration of a therapy (e.g., a prophylactic or therapeutic composition). [0031] As used herein, the terms "subject" or "patient" are used interchangeably.

As used herein, the terms "subject" and "subjects" refers to an animal (e.g., mammals). In some embodiments, the subject is a mammal including a non-primate (e.g., a camel, donkey, zebra, cow, horse, horse, cat, dog, rat, and mouse) and a primate (e.g., a monkey, chimpanzee, and a human). In some embodiments, the subject is a non-human mammal. In other embodiments the subject is a human.

[0032] As used herein, the terms "therapies" and "therapy" can refer to any protocol(s), method(s), and/or agent(s) that can be used in the prevention, treatment, management, or amelioration of a disease/disorder (e.g., neurogenic urinary dysfunction or a condition or symptom associated therewith). In certain embodiments, the terms "therapies" and "therapy" refer to biological therapy, supportive therapy, and/or other therapies useful in treatment, management, prevention, or amelioration of a disease, an infection or a condition or symptom associated therewith, known to one of skill in the art. [0033] As used herein, the terms "therapeutic agent" and "therapeutic agents" refer to any agent(s) which can be used in the prevention, treatment, management, or amelioration of a disease (e.g. an infection or a symptom thereof (e.g., neurogenic urinary dysfunction or a condition or symptom associated therewith). Preferably, a therapeutic agent is an agent which is known to be useful for, or has been or is currently being used for the prevention, treatment, management, or amelioration of a disease or symptom associated therewith (e.g., neurogenic urinary dysfunction or a condition or symptom associated therewith).

[0034] As used herein, the terms "treat," "treatment," and "treating" in the context of administration of a therapy to a subject for a disease refers to the eradication, reduction or amelioration of symptoms of said disease/disorder.

4. DETAILED DESCRIPTION OF THE INVENTION

[0035] The present invention encompasses pharmaceutical compositions comprising at least one homovanilloid compound combined with at least one permeation enhancer for the topical treatment of pain and /or other disorders at least partially associated with neurogenic dysfunction. The use of the permeation enhancer in the affords a reduction in side effects commonly associated with homovanilloid therapies and improves permeation of the homovanilloid compound through biological membranes or other tissues, e.g., affords more rapid diffusion and/or increases the flux of the homovanilloid compound through said membrane or tissue) relative to the permeation of a control composition. In certain embodiments, the permeation of the composition is tested in an in vitro assay described herein or known in the art (see, Section 4.6). In exemplary embodiments of the invention, the pharmaceutical formulations comprise a therapeutically effective amount of a homovanilloid compound, preferably RTX, and one or more permeation enhancing agents as described herein, preferably HAse, which formulations are effective in a trans-membrane or trans-mucosal delivery method of the invention to treat or manage pain (e.g., chemotherapy-induced or cancer/tumor related) and/or conditions associated with neurogenic dysfunction (e.g., lower urinary tract disorders characterized by urinary incontinence) in a mammalian subject. [0036] The compositions and delivery methods of the invention provide transmembrane, particularly trans-mucosal (e.g., bladder mucosa), delivery of a homovanilloid compound to mammalian subjects. These compositions and methods can involve combinatorial formulation or coordinate administration of one or more homovanilloid compound with one or more permeation enhancing agents. Nonlimiting examples of permeation enhancing agents known to the art include a surfactant, a bile salt, an alcohol, an enamine, an NO donor compound, a long-chain amphipathic molecule, a small hydrophobic penetration enhancer, a sodium or a salicylic acid derivative, a glycerol ester of acetoacetic acid, a cyclodextrin or beta-cyclodextrin derivative, a medium-chain fatty acid, a chelating agent, an amino acid or salt thereof, an N-acetylamino acid or salt thereof, an enzyme that degrades a selected membrane component, an inhibitor of fatty acid synthesis, an inhibitor of cholesterol synthesis, or any combination thereof. As described herein, membrane permeation-enhancing agents also encompass mucolytic or mucus clearing agents, modulatory agents of epithelial junction physiology (e.g., nitric oxide (NO) stimulators, chitosan, and chitosan derivatives), vasodilator agents, and selective transport- enhancing agents. In various embodiments of the invention, the at least one homovanilloid compound is combined with one, two, three, four or more of the permeation enhancers recited hereinabove. The at least one permeation agent may be admixed, alone or together, with the homovanilloid compound, or otherwise combined therewith in a pharmaceutically acceptable formulation. Formulation of a homovanilloid compound with one or more of the permeation-enhancing agents according to the teachings herein provides for increased delivery of the at least one homovanilloid compound to target tissues following application and/or contact thereof to and/or with a membrane surface, e.g., mucosal surface, of a mammalian subject..

4.1 Permeation Enhancers

[0037] Within the pharmaceutical compositions and methods of the invention, various permeation-enhancing agents are employed which enhance transport of the at least one homovanilloid compound into or across a membrane surface, in particular a mucosal surface. In this regard, delivery of the homovanilloid compound across the membrane epithelium, preferably mucosal epithelium, can occur "transcellularly" or "paracellularly." The extent to which these pathways contribute to the overall flux and availability to the target tissue of the homovanilloid compound depends upon the environment of the membrane, e.g., mucosa, the physico-chemical properties the active agent, and the properties of the membrane epithelium, e.g., mucosal epithelium. Paracellular transport involves only passive diffusion, whereas transcellular transport can occur by passive, facilitated or active processes. Generally, hydrophilic, passively transported, polar solutes diffuse through the paracellular route, while more lipophilic solutes use the transcellular route. Absorption and transport (e.g., as reflected by a permeability coefficient or physiological assay), for diverse, passively and actively absorbed solutes, can be readily evaluated, in terms of both paracellular and transcellular delivery components, for any selected homovanilloid compound within the invention. For passively absorbed drugs, the relative contribution of paracellular and transcellular pathways to drug transport depends upon the pKa, partition coefficient, molecular radius and charge of the drug, the pH of the luminal environment in which the drug is delivered, and the area of the absorbing surface. The paracellular route usually represents only a relatively small fraction of the accessible surface area of membranes of the body, in particular mucosal epithelium membranes. In general terms, it has been reported that cell membranes occupy a membrane, e.g., epithelial membrane, surface area that is a thousand times greater than the area occupied by the paracellular spaces. Thus, the smaller accessible area, and the size- and charge-based discrimination against macromolecular permeation would suggest that the paracellular route would be a generally less favorable route than transcellular delivery for agent transport. The methods and compositions of the invention provide for significantly enhanced transport of biotherapeutics into and across membrane epithelia via the paracellular route. Accordingly, the methods and compositions of the invention successfully target both paracellular and transcellular routes, alternatively or within a single method or composition. [0038] The permeation-enhancing agent of the present invention may also be a pH control agent. The pH of the pharmaceutical formulation of the present invention is a factor affecting absorption and/or transport of the at least one homovanilloid compound via paracellular and transcellular pathways. In one embodiment, the pharmaceutical formulation of the present invention is pH adjusted to between about pH 2 to 8. In a further embodiment, the pharmaceutical formulation of the present invention is pH adjusted to between about pH 3.0 to 6.0. In a further embodiment, the pharmaceutical formulation of the present invention is pH adjusted to between about pH 4.0 to 6.0. Generally, the pH is 4.5.+- 0.5.

[0039] While the mechanism of transport promotion may vary with different permeation-enhancing agents of the invention, useful reagents in this context will not substantially adversely affect the membrane, e.g., mucosal, tissue and will be selected according to the physicochemical characteristics of the particular homovanilloid compound or permeation enhancing agent. In this context, agents that increase penetration or permeability of membrane tissues will often result in some alteration of the protective permeability barrier of the membrane itself. For such permeation-enhancing agents to be of value within the invention, it is generally desired that any significant changes in permeability of the mucosa be reversible within a time frame appropriate to the desired duration of drug delivery and/or composition application. Furthermore, there should be no substantial, cumulative toxicity, nor any permanent deleterious changes induced in the barrier properties of the particular membrane tissue, e.g., mucosa, with long-term use. [0040] Additional permeation-enhancing agents that are useful within the methods and formulations of the invention include, but are not limited to nitric oxide donors (e.g., S- nitroso-N-acetyl-DL-penicillamine, NORl, NOR4-which are preferably co-administered with an NO scavenger such as carboxy-PITO or doclofenac sodium); sodium salicylate; glycerol esters of acetoacetic acid (e.g., glyceryl- 1,3-diacetoacetate or 1,2- isopropylideneglycerine-3-acetoacetate); and other release-diffusion or intra- or trans- epithelial penetration-promoting agents that are physiologically compatible for, in particular, mucosal delivery. Other permeation-promoting agents are selected from a variety of carriers, bases and excipients that enhance delivery through biological membranes, or enhance stability, activity or trans-epithelial penetration of the homovanilloid compound. These include, but are not limited to, cyclodextrins and β- cyclodextrin derivatives (e.g., 2-hydroxypropyl-β-cyclodextrin and heptakis(2,6-di-O- methyl-β-cyclodextrin). Additional absorption-enhancing agents adapted for mucosal delivery include medium-chain fatty acids, including mono- and diglycerides (e.g., sodium caprate— extracts of coconut oil, Capmul), and triglycerides (e.g., amylodextrin, Estaram 299, Miglyol 810).

[0041] The therapeutic and prophylactic compositions of the present invention may be supplemented with any suitable permeation-promoting agent that facilitates absorption, diffusion, and/or penetration of homovanilloid compound across membrane {e.g., epithelial, mucosal) barriers. The penetration enhancer may be any enhancer that is pharmaceutically acceptable. Thus, in more detailed aspects of the invention compositions are provided that incorporate one or more penetration-promoting agents selected from sodium salicylate and salicylic acid derivatives (acetyl salicylate, choline salicylate, salicylamide, etc.), amino acids and salts thereof (e.g. monoaminocarboxlic acids such as glycine, alanine, phenylalanine, proline, hydroxyproline, etc.; hydroxyamino acids such as serine; acidic amino acids such as aspartic acid, glutamic acid, etc; and basic amino acids such as lysine etc— inclusive of their alkali metal or alkaline earth metal salts), and N-acetylamino acids {e.g., N-acetylalanine, N-acetylphenylalanine, N-acetylserine, N-acetylglycine, N- acetyllysine, N-acetylglutamic acid, N-acetylproline, N-acetylhydroxyproline, etc.) and their salts (alkali metal salts and alkaline earth metal salts). Also provided as penetration- promoting agents within the methods and compositions of the invention are substances which are generally used as emulsifiers (e.g. sodium oleyl phosphate, sodium lauryl phosphate, sodium lauryl sulfate, sodium myristyl sulfate, polyoxyethylene alkyl ethers, polyoxyethylene alkyl esters, etc.), caproic acid, lactic acid, malic acid and citric acid and alkali metal salts thereof, pyrrolidonecarboxylic acids, alkylpyrrolidonecarboxylic acid esters, N-alkylpyrrolidones, proline acyl esters, and the like.

4.1.1 Degradation Enzymes

[0042] In certain embodiments, degradation enzymes are used as the at least one permeation enhancer. In related aspects of the invention, homovanilloid compounds are formulated or coordinately administered with a penetration enhancing agent selected from a degradation enzyme. For example, degradative enzymes such as phospholipase, hyaluronidase, neuraminidase, and chondroitinase may be employed to enhance membrane, e.g., mucosal, penetration of homovanilloid compounds, preferably RTX, analogs and mimetics without causing irreversible damage to the membrane barrier. In one embodiment, chondroitinase is employed within a method or composition as provided herein to alter glycoprotein or glycolipid constituents of the permeability barrier of the mucosa, thereby enhancing mucosal absorption of homovanilloid compounds. [0043] In preferred embodiments, the permeation enhancer to be used in accordance with the methods of the invention is a GAGase, more preferably an HSase. In related embodiments, the HSase is neutral-active. In other related embodiments, the HSase is acid- active. Methods of preparation, purification and use of GAGases, including HSase, as monotherapeutics or as the active components of a pharmaceutical composition are well known in the art (see, e.g., U.S. Patent Application Publication Nos. 2004/0096921 and 2006/0104968, each hereby incorporated by reference herein in its entirety). In certain embodiments, the use of acid active HAse, e.g., human plasma HSase ("hpHSase"), is preferred to use of neutral active HAses since acid active hpHAse can provide a more controlled degradation of HA substrate and does not degrade all components of the extracellular matrix in the patient. Compositions formulated according to the methods of the invention do not comprise, or comprise only very low levels of heparin, which is a powerful inhibitor of HSase.

[0044] The amount of HAse in the composition of the invention will vary widely according to the particular disease and/or disorder to be treated, and various patient variables including size, weight, age, disease/disorder severity, and sensitivity or responsiveness to therapy. Such determinations are routine to one of ordinary skill in the art (see, for example, Harrison's Principles of Internal Medicine, 1 lth Ed., 1987). [0045] Especially where HAse is to be used in therapy, it may be desirable to modify HAse to provide one or more desirable characteristics. For example, although hpHAse is a serum protein and thus should inherently have a substantial half-life in vivo, e.g., it may be desirable to alter, e.g., increase or decrease, the biological half-life (e.g., serum half-life) of HAse depending on which tissue or body fluid the composition of the invention is expected to contact. Various methods for altering the half-life of a protein are well known in the art and include, for example for increasing half-life, conjugation of the protein to polyethylene glycol moieties, i.e., PEGylation (see, for example, U.S. Pat. No. 4,179,337; U.S. Pat. No. 5,166,322; U.S. Pat. No. 5,206,344; Nucci et al., 1991, Adv. Drug Delivery Rev. 4:133 151; Zalipsky et al., 1991, "Polymeric Drugs and Drug Delivery Systems," ACS); conjugation of the protein to dextran (Maksimenko, 1986, Bull. Exp. Biol. Med. (Russian) 52:567 569), and deglycosylation of the protein by treatment with endoglycosidase F (Lace et al., 1990, Carbohydrate Res. 208:306 311); and for decreasing serum half-life, conjugation of the protein to ubiquitin moieties ( Stack et al., 2000, Nat. Biotechnol. 18:1298-1302) (each of the above-cited references is hereby incorporated by reference herein in its entirety).

[0046] It has been demonstrated that certain HAse glycoproteins, e.g., human PH20, require N-linked glycans for catalytic activity, whereas bovine and bee venom hyaluronidases remain active without such N-linked glycans. Thus classic recombinant DNA technology does not permit the production of a catalytically active human PH20, unlike bee venom hyaluronidase, which can be produced in E. coli.

[0047] Accordingly, the source of the HAse must be known to ensure the biological activity of the enzyme. For example, generation of an N-linked sHAse glycoprotein polypeptide requires using of a cell capable of introducing said N-linked sugar moieties or by introduction of said N-linked moieties on the expressed polypeptide. Methods of identifying properly glycosylated glycoproteins, e.g., HAses, are well known in the art. [0048] The use if HAses as spreading agents in tissues, such as those of the eye, are known in the art. Formulations comprising one or more HAses are typically applied to a target tissue prior to or concomitant with application of an anesthetic, diagnostic, pharmacologic or other agent that is desired to be delivered into or to the vicinity of the target tissue. Further HAse application has been shown to promote the delivery of an agent across a first tissue to target a tissue distal to the first. For example, (i) introduction of an HAse into the episcleral space surrounding the eye prior to or concomitantly with introduction of a pharmacologic or other agent into the episcleral space can be used to promote delivery of the agent across the protective scieral tissue and into the choroid, the retina and/or the vitreous body; and (ii) HAse introduced intradermally can promote the delivery of agents through the subdermal layers and into the bloodstream, which is itself the target tissue (e.g. for blood-modifying agents). In this manner, a number of pharmacologic and/or other agents which are useful for treating conditions of the choroid, retina and/or vitreous can be delivered relatively locally to the target tissues but while using a relatively non-invasive approach. In the instant invention, HAses are used to promote delivery of the active agent, i.e., the homovanilloid compound (preferably RTX), across a first tissue, the bladder mucosa, to target one or more tissues distal to the mucosa (e.g., C-fiber or other noiceptor positive cell).

[0049] Without wishing to be bound by theory, it is believed that the ability of

HAses to cause the degradation of a portion of the glycosaminoglycans in the interstitial spaces between cells results in a temporary opening up of channels within the interstitium, which in turn tends to increase interstitial fluid flow and to concomitantly facilitate the diffusion and/or convective solute transport (convection) of dissolved components within the interstitial fluid or fluid in contact with the mucosa (e.g. RTX or related compounds). As will be appreciated by those of skill in the art, the use of HAses in accordance with the present invention will enhance the permeation of the homovanilloid compound and potentially improve other pharmacokinetic and/or pharmacodynamic properties of such compounds used in the treatment of pain and/or conditions at least partially associated with neurogenic dysfunction, or symptoms thereof, in particular when introduced to the bladder mucosa by intravesicular instillation.

[0050] While the extent and rate of dispersal of a co-formulated or co-administered agent depends in part on the tissue and agent involved, such dispersal can generally be increased by, inter alia, increasing the amount of HAse used, employing a HAse having higher specific activity, employing a HAse that is more resistant to degradation or other inactivation (such as a PEGylated, super-sialated or other such modified HAse), providing a sustained release or depot formulation of the HAse, and other such approaches to increasing the effective activity and/or duration of the applied HAse. In addition, where it is desired that the HAse facilitate the dispersion of an agent into a tissue or location distal to the site of application, e.g., the bladder mucosa, then providing the HAse and/or agent in a significant volume of liquid (such as would partially fill or even slightly distend the site of application), can be used to further promote dispersion through a process of convective transport, as described herein. [0051] In the case of a human HAse being used in the human body, a preferred combination as described herein, the tendency for the human HAse to elicit an immune response can be significantly reduced as compared to, for example, non-human animal- derived enzymes such as bovine or ovine hyaluronidases (i.e. even if those animal-derived enzymes could be completely purified away from other animal-derived proteins, which is difficult to impossible to achieve in practice). Although human HAse thus represent a substantial and very important improvement over animal-derived products, they can for many uses be improved still further by post-translational modifications (PTMs) such as PEGylation to enhance their resistance to degradation or elimination and/or to improve other properties making them even more beneficial for particular applications.

4.1.2 Agents for Modulating Epithelial Junction Structure and/or Physiology

[0052] The present invention provides pharmaceutical composition that contains one or more homovanilloid compounds in combination with permeation enhancing agents disclosed herein formulated in a pharmaceutical preparation for trans-membrane, e.g., mucosal, delivery.

[0053] The permeabilizing agent reversibly enhances membrane, in particular epithelial, paracellular transport, typically by modulating epithelial junctional structure and/or physiology at a epithelial surface in the subject. This effect typically involves inhibition by the permeabilizing agent of homotypic or heterotypic binding between epithelial membrane adhesive proteins of neighboring epithelial cells. Target proteins for this blockade of homotypic or heterotypic binding can be selected from various related junctional adhesion molecules (JAMs), occludins, or claudins. Examples of this are antibodies, antibody fragments or single-chain antibodies that bind to the extracellular domains of these proteins.

[0054] In yet additional detailed embodiments, the invention provides permeabilizing peptides and peptide analogs and mimetics for enhancing membrane, e.g., epithelial, paracellular transport. The subject peptides and peptide analogs and mimetics typically work within the compositions and methods of the invention by modulating epithelial junctional structure and/or physiology in a mammalian subject. In certain embodiments, the peptides and peptide analogs and mimetics effectively inhibit homotypic and/or heterotypic binding of an epithelial membrane adhesive protein selected from a junctional adhesion molecule (JAM), occludin, or claudin.

[0055] One such agent that has been extensively studied is the bacterial toxin from

Vibrio cholerae known as the "zonula occludens toxin" (ZOT). This toxin mediates increased intestinal mucosal permeability and causes disease symptoms including diarrhea in infected subjects. Fasano et al, Proc. Nat. Acad. ScL, U.S.A., 8:5242-5246 (1991). When tested on rabbit ileal mucosa, ZOT increased the intestinal permeability by modulating the structure of intercellular tight junctions. More recently, it has been found that ZOT is capable of reversibly opening tight junctions in the intestinal mucosa (U.S. Pat. No. 5,908,825, hereby incorporated by reference in its entirety).

4.1.3 Vasodilator Agents and Methods

[0056] Yet another class of permeation enhancing agents that shows beneficial utility within the compositions and methods of the invention are vasoactive compounds, more specifically vasodilators. These compounds function to modulate the structure and physiology of the submembrane vasculature, increasing the transport rate of homovanilloid compounds into or through the membrane epithelium and/or to specific target tissues or compartments distal to the application site (e.g., the central nervous system). [0057] Vasodilator agents for use within the invention typically cause submembrane blood vessel relaxation by either a decrease in cytoplasmic calcium, an increase in nitric oxide (NO) or by inhibiting myosin light chain kinase. They are generally divided into 9 classes: calcium antagonists, potassium channel openers, ACE inhibitors, angiotensin-II receptor antagonists, .alpha. -adrenergic and imidazole receptor antagonists, .beta.l- adrenergic agonists, phosphodiesterase inhibitors, eicosanoids and NO donors. [0058] Despite chemical differences, the pharmacokinetic properties of calcium antagonists are similar. Absorption into the systemic circulation is high, and these agents therefore undergo considerable first-pass metabolism by the liver, resulting in individual variation in pharmacokinetics. Except for the newer drugs of the dihydropyridine type (amlodipine, felodipine, isradipine, nilvadipine, nisoldipine and nitrendipine), the half-life of calcium antagonists is short. Therefore, to maintain an effective drug concentration for many of these may require delivery by multiple dosing, or controlled release formulations as is known in the art.

[0059] Various NO donors are known in the art and are useful in effective concentrations within the methods and formulations of the invention. Exemplary NO donors include, but are not limited to, nitroglycerine, nitropruside, NOC5 [3-(2-hydroxy-l-(methyl- ethyl)-2-nitrosohydrazino)- 1 -propanamine] , NOC 12 [N-ethyl-2-( 1 -ethyl-hydroxy-2- nitrosohydrazino)-ethanamine], SNAP [S-nitroso-N-acetyl-DL-penicillamine], NORI and NOR4. Within the methods and compositions of the invention, an effective amount of a selected NO donor is coordinately administered or combinatorially formulated with one or more homovanilloid compounds disclosed herein, to facilitate the enhances permeation of the homovanilloid compound into or through the biological membrane of interest, e.g., mucosal epithelium. Additionally, complexes of NO with nucleophiles called NO/nucleophiles, or NONOates, spontaneously and nonenzymatically release NO when dissolved in aqueous solution at physiologic pH. In contrast, nitro vasodilators such as nitroglycerin require specific enzyme activity for NO release. NONOates release NO with a defined stoichiometry and at predictable rates ranging from <3 minutes for diethylamine/NO to approximately 20 hours for diethylenetriamine/NO (DETANO).

4.1.4 Hsieh and Macrocyclic Permeation Enhancers

[0060] In certain embodiments, the permeation enhancers are not HAses, but "Hsieh enhancers" and are described, for example, in U.S. Pat. No. 5,023,252 and 5,731,303 (each hereby incorporated herein by reference in its entirety). Hsieh enhancers are lipophilic and are "membrane-compatible," meaning that they do not cause damage to the membrane on which the composition of the present invention is to be applied (hereinafter "target membrane," e.g. the bladder mucosa). Such enhancers produce also no or a low level of irritability and, in fact serve as an emollient.

[0061] In certain embodiments, the permeation enhancers used in accordance with the methods of this invention are the cyclic lactones, the cyclic diesters, and the cyclic ketones disclosed in U.S. Patent Application Publication No. 2007/0010425, hereby incorporated by reference in its entirety.

[0062] In other embodiments, the permeation enhancers for use in the present invention are macrocyclic enhancers. The term "macrocyclic" is used herein to refer to cyclic compounds having at least 12 carbons in the ring. Examples of preferred macrocyclic enhancers for use in the present invention include: (A) macrocyclic ketones, for example, 3 methylcyclopentadecanone (muscone), 9-cycloheptadecen-l-one (civetone), cyclohexadecanone, and cyclopentadecanone (normuscone); and (B) macrocyclic esters, for example, pentadecalactones such as oxacyclohexadecan-2-one (cyclopentadecanolide, . omega, -pentadecalactone) .

[0063] Although the above are preferred permeation enhancers, one of ordinary skill in the art would recognize that the instant teachings would also be applicable to other permeation enhancers. Non-limiting examples of other permeation enhancers useful in the instant invention are the simple long chain esters that are Generally Recognized As Safe (GRAS) in the various pharmacopoeial compendia. These may include simple aliphatic, unsaturated or saturated (but preferably fully saturated) esters, which contain up to medium length chains. Non-limiting examples of such esters include isopropyl myristate, isopropyl palmitate, myristyl myristate, octyl palmitate, and the like. The enhancers are of a type that are suitable for use in a pharmaceutical composition. The artisan of ordinary skill will also appreciate that those materials that are incompatible with or irritating to mucous membranes should be avoided.

[0064] The enhancer is present in the composition in a concentration effective to enhance penetration of the homovanilloid compound, e.g., RTX, through the bladder mucosa. Various considerations should be taken into account in determining the amount of enhancer to use. Such considerations include, for example, the amount of flux (rate of passage through the membrane) achieved and the stability and compatibility of the components in the formulations. The enhancer may be used in an amount of about 0.01 to about 0.1 wt %, about 0.01 to about 0.25 wt %, about 0.01 to about 0.50 wt %, about 0.01 to about 0.75 wt %, about 0.01 to about 1.0 wt %, about 0.01 to about 2.0 wt %, about 0.01 to about 5.0 wt %, about 0.01 to about 10 wt %, or about 0.01 to about 25 wt, and more generally in an amount of about 0.1 to about 15 wt. % of the composition.

4.2 Pain Associated with Neurogenic Dysfunction

[0065] The compositions and methods of the present invention can be used for treating various conditions associated with pain by providing pain relief at a specific site due to desensitization activity of homovanilloid compounds. Examples of conditions to be treated include, but are not limited to, nociceptive pain (pain transmitted across intact neuronal pathways), neuropathic pain (pain caused by damage to neural structures), pain from nerve injury (neuromas and neuromas in continuity), pain from neuralgia (pain originating from disease and/or inflammation of nerves), pain from myalgias (pain originating from disease and/or inflammation of muscle), pain associated with painful trigger points, pain from tumors in soft tissues, pain associated with neurotransmitter- dysregulation syndromes (disruptions in quantity/quality of neurotransmitter molecules associated with signal transmission in normal nerves) and pain associated with orthopedic disorders such as conditions of the foot, knee, hip, spine, shoulders, elbow, hand, head and neck.

[0066] The receptors involved in pain detection are aptly enough referred to as nociceptor-receptors for noxious stimuli. These nociceptors are free nerve endings that terminate just below the skin as to detect cutaneous pain. Nociceptors are also located in tendons and joints, for detection of somatic pain and in body organs to detect visceral pain. Pain receptors are very numerous in the skin, hence pain detection here is well defined and the source of pain can be easily localized. In tendons, joints, and body organs the pain receptors are fewer. The source of pain therefore is not readily localized. Apparently, the number of nociceptors also influences the duration of the pain felt. Cutaneous pain typically is of short duration, but may be reactivated upon new impacts, while somatic and visceral pain is of longer duration. It is important to note that almost all body tissue is equipped with nociceptors. Nociceptive pain includes, but is not limited to post-operative pain, cluster headaches, dental pain, surgical pain, pain resulting from severe burns, post-partum pain, angina, genitor-urinary tract pain, pain associated with sports injuries (tendonitis, bursitis, etc. . . . ) and pain associated with joint degeneration and cystitis.

[0067] Neuropathies treatable by the methods of the present invention include but are not limited to: syndromes of acute ascending motor paralysis with variable disturbance of sensory function (e.g., acute idiopathic polyneuritis, Landry-Guillain-Barre Syndrome, acute immune-mediated polyneuritis, infectious mononucleosis polyneuritis, hepatitis polyneuritis; diptheric polyneuropathy; porphyric polyneuropathy; toxic polyneuropathy (e.g., thallium); acute axonal polyneuropathy; acute panautonomic neuropathy; vaccinogenic, serogenic, paraneoplastic, polyarteretic, lupus polyneuropathy); syndromes of subacute sensorimotor paralysis (e.g., deficiency states (e.g., beriberi, pellagra, vitamin B 12); heavy metal/industrial solvent poisonings (e.g., arsenic, lead); drug overdose (e.g., isoniazid, disulfuram, vincristine, taxol, chloramphenicol); uremic polyneuropathy; diabetes; sarcoidosis; ischemic neuropathy and peripheral vascular disease; AIDS; radiation (radiotherapy)); syndromes of acquired forms of chronic sensorimotor polyneuropathy (e.g., carcinoma, myeloma and other malignancies; paraproteinemias; uremia; beriberi (usually subacute), diabetes, hypo/hyperthyroidism; connective tissue disease; amyloidosis; leprosy; sepsis); syndromes of determined forms of genetic chronic polyneuropathy (e.g., dominant mutilating sensory neuropathy (adult); recessive mutilating sensory neuropathy (childhood); congenital insensitivity to pain; spinocerebellar degenerations, Riley Day Syndrome; Universal Anesthesia Syndrome; polyneuropathies w/ metabolic disorder; mixed sensorimotor-autonomic type polyneuropathies); syndromes of recurrent or relapsing polyneuropathy (e.g., idiopathic polyneuritis; porphyria; chronic inflammatory polyradiculoneuropathy; mononeuritis multiplex; beriberi/drug overdose; refsum disease; tangier disease; and syndromes of mononeuropathy or multiple neuropathies (e.g., pressure palsies; traumatic neuropathies (e.g., irradiationor electrical injury); serum, vaccinogenic (e.g., rabies, smallpox); herpes zoster; neoplastic infiltration; leprosy; diptheretic wound infections; migrant sensory neuropathy; shingles; post herpetic neuralgia) (see, Adams and Victor, Principles of Neurology, 4th ed., McGraw-Hill Information Services Company, p. 1036, 1989, hereby incorporated by reference in its entirety).

[0068] In other embodiments, the compositions of the invention are used for the treatment of pain syndromes associated with neurotransmitter-dysregulation. Neurotransmitter -dysregulation pain syndromes, rather than involving abnormal or damaged nerves, result from normal nerves having disruptions in the quantity and/or quality of the various neurotransmitter molecules associated with signal transmission from one neuron to another. More specifically, sensory transmitters are released from the afferent nerve ending of one nerve cell and received by receptors at the afferent end of another nerve cell. Alterations in the quantity of transmitters and neuropeptide release, changes in the afferent receptor, changes of re-uptake of the transmitter and/or neuropeptides can all yield qualitative change of the neural signaling process. As a result, the aberrant signal transmission is interpreted by the body as pain. Neurotransmitter dysregulation syndromes that may be treated by the present invention include, but is not limited to, generalized syndromes (e.g., stump pain, causalgia, reflex sympathetic dystrophy, fibromyalgia or diffuse myofascial pain, burns); localized syndromes (e.g., trigeminal neuralgia; acute herpes zoster; panautonomic neuralgia; geniculate neuralgia (Romsay Hunt Syndrome); glossopharyngeal neuralgia; vagus nerve neuralgia and occipital neuralgia); craniofascial pain (e.g., temporomandibular pain, myofascial syndrome (including cervical sprain, cervical hyperextension (whiplash)), sternocleidomastoid muscle; trapezius muscle; and stylohyoid process syndrome); vascular disease (e.g., Raynaud's disease; Raynaud's phenomenon; frosbite; erythema pernio (chilblains); acrocyanosis and livedo reticularis); rectal, perineum and external genitalia pain (e.g., iliohypogastric neuralgia; ilioinguinal nerve; genotifemoral nerve, testicular pain); and local syndromes of the leg/foot (e.g., lateral cutaneous neuropathy (neuralgia paresthetica); oobturator neuralgia; femoral neuralgia; sciatica neuralgia; interdigital neuralgia of the foot (Morton's metatarsalgia or neurma); injection neuropathy, painful legs and moving toes).

[0069] Fibromyalgia is a common condition characterized by a history of chronic generalized pain and physical exam evidence of at least 11 of 18 defined "tender point" sites in muscles and connective tissue (Wolfe et al., Arthritis Rheum 33:160-72, 1990, hereby incorporated by reference in its entirety). Common conditions associated with fibromyalgia responsive to the methods and composition of the invention include, but are not limited to, irritable bowel syndrome, headache, irritable bladder syndrome (interstitial cystitis), sleep disturbance, and fatigue (Goldenberg, Current Opinion in Rheumatology 8:113-123, 1996; Moldofsky et al., Psychosom Med 37:341-51, 1975; Wolfe et al., 1990; Wolfe et al., J Rheum 23:3, 1996; Yunus et al., Semin Arthritis Rheum 11:151-71, 1981; each of which is hereby incorporated by reference in its entirety).

[0070] In other embodiments, compositions and methods of the invention may be utilized to treat/attenuate pain associated with orthopedic disorders. Orthopedic disorders treatable via the use of the compositions and methods of the invention include but are not limited to disorders of the knee, shoulders, back, hip, spine, elbows, foot, hand and other disorders, which involve pain at a specific site or body space. Orthopedic disorders affecting these locations include, but are not limited to bursitis, tendonitis, osteoarthritis, and rheumatoid arthritis. Orthopedic disorders of the foot include, but are not limited to, heel spurs, corns, bunions, Morton's neuroma, hammertoes, ankle sprain, fractures of the ankle or metatarsals or sesamoid bone or toes, plantar fascitis and injuries to the achilles tendon. Orthopedic disorders of the hand include, but are not limited to, arthritis, carpal tunnel syndrome, ganglion cysts, tendon problems such as lateral epicondylitis, medial epicondylitis, rotator cuff tendonitis, DeQuervian's tenosynovitis, and trigger finger/trigger thumb. Other orthopedic disorders include, but are not limited to, Paget's disease, scoliosis, soft-tissue injuries such as contusions, sprains and strains, long bone fractures and various other sports injuries some of which include patellar tendonitis and lumbar strain. [0071] In still other embodiments compositions and methods of the invention may be utilized to treat/attenuate pain associated with cancer, in particular, associated with tumors of soft tissues. The compositions of the invention can be administered to tumors and/or cancers that are primary or metastatic by any method described herein or that is known in the art. The administration may be directly to the tumor tissue, or to tissues that surround, are contiguous with or are neighboring the tumor tissues. In certain embodiments, the site of administration of the compositions of the invention and the target tissue, e.g., tumor tissue, are separated by one or more biological membranes or tissue types.

[0072] The compositions and methods of the invention can be used to treat/attenuate pain associated with tumors of cancers and/or related disorders including, but not limited to, leukemias including, but not limited to, acute leukemia, acute lymphocytic leukemia, acute myelocytic leukemias such as myeloblastic, promyelocytic, myelomonocytic, monocytic, erythroleukemia leukemias and myelodysplastic syndrome, chronic leukemias such as but not limited to, chronic myelocytic (granulocytic) leukemia, chronic lymphocytic leukemia, hairy cell leukemia; polycythemia vera; lymphomas such as but not limited to Hodgkin's disease, non-Hodgkin's disease; multiple myelomas such as but not limited to smoldering multiple myeloma, nonsecretory myeloma, osteosclerotic myeloma, plasma cell leukemia, solitary plasmacytoma and extramedullary plasmacytoma; Waldenstrom's macroglobulinemia; monoclonal gammopathy of undetermined significance; benign monoclonal gammopathy; heavy chain disease; bone and connective tissue sarcomas such as but not limited to bone sarcoma, osteosarcoma, chondrosarcoma, Ewing's sarcoma, malignant giant cell tumor, fibrosarcoma of bone, chordoma, periosteal sarcoma, soft-tissue sarcomas, angiosarcoma (hemangiosarcoma), fibrosarcoma, Kaposi's sarcoma, leiomyosarcoma, liposarcoma, lymphangiosarcoma, neurilemmoma, rhabdomyosarcoma, synovial sarcoma; brain tumors including but not limited to, glioma, astrocytoma, brain stem glioma, ependymoma, oligodendroglioma, nonglial tumor, acoustic neurinoma, craniopharyngioma, medulloblastoma, meningioma, pineocytoma, pineoblastoma, primary brain lymphoma; breast cancer including, but not limited to, adenocarcinoma, lobular (small cell) carcinoma, intraductal carcinoma, medullary breast cancer, mucinous breast cancer, tubular breast cancer, papillary breast cancer, Paget's disease, and inflammatory breast cancer; adrenal cancer, including but not limited to, pheochromocytom and adrenocortical carcinoma; thyroid cancer such as but not limited to papillary or follicular thyroid cancer, medullary thyroid cancer and anaplastic thyroid cancer; pancreatic cancer, including but not limited to, insulinoma, gastrinoma, glucagonoma, vipoma, somatostatin-secreting tumor, and carcinoid or islet cell tumor; pituitary cancers including but not limited to, Cushing's disease, prolactin-secreting tumor, acromegaly, and diabetes insipius; eye cancers including but not limited to, ocular melanoma such as iris melanoma, choroidal melanoma, and cilliary body melanoma, and retinoblastoma; vaginal cancers, including but not limited to, squamous cell carcinoma, adenocarcinoma, and melanoma; vulvar cancer, including but not limited to, squamous cell carcinoma, melanoma, adenocarcinoma, basal cell carcinoma, sarcoma, and Paget's disease; cervical cancers including but not limited to, squamous cell carcinoma, and adenocarcinoma; uterine cancers including but not limited to, endometrial carcinoma and uterine sarcoma; ovarian cancers including but not limited to, ovarian epithelial carcinoma, borderline tumor, germ cell tumor, and stromal tumor; esophageal cancers including but not limited to, squamous cancer, adenocarcinoma, adenoid cyctic carcinoma, mucoepidermoid carcinoma, adenosquamous carcinoma, sarcoma, melanoma, plasmacytoma, verrucous carcinoma, and oat cell (small cell) carcinoma; stomach cancers including but not limited to, adenocarcinoma, fungating (polypoid), ulcerating, superficial spreading, diffusely spreading, malignant lymphoma, liposarcoma, fibrosarcoma, and carcinosarcoma; colon cancers; rectal cancers; liver cancers including but not limited to hepatocellular carcinoma and hepatoblastoma, gallbladder cancers including but not limited to, adenocarcinoma; cholangiocarcinomas including but not limited to, pappillary, nodular, and diffuse; lung cancers including but not limited to, non-small cell lung cancer, squamous cell carcinoma (epidermoid carcinoma), adenocarcinoma, large-cell carcinoma and small- cell lung cancer; testicular cancers including but not limited to, germinal tumor, seminoma, anaplastic, classic (typical), spermatocytic, nonseminoma, embryonal carcinoma, teratoma carcinoma, choriocarcinoma (yolk-sac tumor), prostate cancers including but not limited to, adenocarcinoma, leiomyosarcoma, and rhabdomyosarcoma; penal cancers; oral cancers including but not limited to, squamous cell carcinoma; basal cancers; salivary gland cancers including but not limited to, adenocarcinoma, mucoepidermoid carcinoma, and adenoidcystic carcinoma; pharynx cancers including but not limited to, squamous cell cancer, and verrucous; skin cancers including but not limited to, basal cell carcinoma, squamous cell carcinoma and melanoma, superficial spreading melanoma, nodular melanoma, lentigo malignant melanoma, acral lentiginous melanoma; kidney cancers including but not limited to, renal cell cancer, adenocarcinoma, hypernephroma, fibrosarcoma, transitional cell cancer (renal pelvis and/or uterer); Wilms' tumor; bladder cancers including but not limited to, transitional cell carcinoma, squamous cell cancer, adenocarcinoma, carcinosarcoma. In addition, cancers include myxosarcoma, osteogenic sarcoma, endotheliosarcoma, lymphangioendotheliosarcoma, mesothelioma, synovioma, hemangioblastoma, epithelial carcinoma, cystadenocarcinoma, bronchogenic carcinoma, sweat gland carcinoma, sebaceous gland carcinoma, papillary carcinoma and papillary adenocarcinomas (for a review of such disorders, see Fishman et al., 1985, Medicine, 2d Ed., J.B. Lippincott Co., Philadelphia and Murphy et al., 1997, Informed Decisions: The Complete Book of Cancer Diagnosis, Treatment, and Recovery, Viking Penguin, Penguin Books U.S.A., Inc., United States of America; each of which is hereby incorporated by reference herein in its entirety).

[0073] Accordingly, the methods and compositions of the invention are also useful in the treatment/alleviation of pain associated with tuomors of a variety of cancers or other abnormal proliferative diseases, including (but not limited to): carcinoma, including that of the bladder, breast, colon, kidney, liver, lung, ovary, pancreas, stomach, cervix, thyroid and skin; including squamous cell carcinoma; hematopoietic tumors of lymphoid lineage, including leukemia, acute lymphocytic leukemia, acute lymphoblastic leukemia, B-cell lymphoma, T-cell lymphoma, Berketts lymphoma; hematopoietic tumors of myeloid lineage, including acute and chronic myelogenous leukemias and promyelocytic leukemia; tumors of mesenchymal origin, including fibrosarcoma and rhabdomyoscarcoma; other tumors, including melanoma, seminoma, tetratocarcinoma, neuroblastoma and glioma; tumors of the central and peripheral nervous system, including astrocytoma, neuroblastoma, glioma, and schwannomas; tumors of mesenchymal origin, including fibrosafcoma, rhabdomyoscarama, and osteosarcoma; and other tumors, including melanoma, xenoderma pegmentosum, keratoactanthoma, seminoma, thyroid follicular cancer and teratocarcinoma. It is also contemplated that pain associated with tumors of cancers caused by aberrations in apoptosis would also be treated/alleviated by the methods and compositions of the invention. Such cancers may include but not be limited to follicular lymphomas, carcinomas with p53 mutations, hormone dependent tumors of the breast, prostate and ovary, and precancerous lesions such as familial adenomatous polyposis, and myelodysplastic syndromes. In certain embodiments, pain associated with tumors resulting from malignancy or dysproliferative changes (such as metaplasias and dysplasias), or hyperproliferative disorders, is treated/alleviated by the methods and compositions of the invention in the ovary, bladder, breast, colon, lung, skin, pancreas, prostate, testes or uterus.

4.3 Urinary Dysfunction

[0074] Effective therapy for urinary dysfunction, in particular those disorders that manifest as urinary incontinence, can be palliative, symptomatic relief, since at present many of the underlying causes, e.g., spinal cord injury, MS, cannot be treated. A useful treatment is judged on practical clinical measurements of voluntary and involuntary urination including such things as patient diaries of frequency and incontinence episodes, frequency of catheterization, number of pads used, weighing pads to assess involuntary urine loss, arbitrary assessment of leakage severity, patient and physician assessment of patient's bladder control. Meaningful outcomes to the patient include reduced frequency, reduction of incontinent episodes and control of bladder functions. Physicians also conduct urodynamic measurements which can provide evidence of improvement and also give valuable information on a patient's bladder function. There are several ways of performing urodynamic measurements but all involve instilling either a gas or liquid into an empty bladder and observing pressure with volume changes. The following are some of the parameters which are typically measured:

[0075] Bladder Capacity: The capacity of a bladder with DH or DI may be reduced because involuntary contractions forcibly eliminate urine before substantial filling occurs. This causes problems not only in urinary frequency but also increases the frequency of required self-catheterization to empty the bladder. If bladder capacity is increased, the frequency of urination or self catheterization can be reduced and the patient should become more continent with less leakage and pad use.

[0076] Pressure at First Desire to Void: is associated with increased bladder capacity. An increase in value gives the patient greater confidence in social situations and provides a very meaningful contribution to quality of life.

[0077] Volume When Uninhibited Detrusor Contractions Occur: reflects the fact that more urine is allowed to accumulate before uninhibited contractions begin. In patients with an unstable bladder uninhibited detrusor contractions would, by reflex, follow the first desire to void. Some physicians diagnose urge incontinence based on uninhibited detrusor contractions.

[0078] Sphincter Abnormalities: One of the many problems associated with detrusor hyperreflexia is detrusor sphincter syssynergia (closure of the bladder sphincter). This increased tonicity may control some involuntary urine loss but it also may cause a reflux of urine back into the kidney and cause hydronephrosis, as an undesirable clinical accompaniment of incontinence.

[0079] Finally, many urge incontinence patients use anticholinergic drugs. Effective therapy can be assessed by monitoring the level of drug use. Lower use indicates improved continence. Since these drugs have serious side-effects, this is important to the patient.

4.4 Homovanilloid Compounds

[0080] In a previous application, now U.S. Patent No. 6,630,515, hereby incorporated by reference, the inventors demonstrated the efficacy of RTX and related homovanillyl diterpene esters or TYX for topical treatment or urinary incontinence by urinary bladder instillation. Effective doses ranged from 0.05 .mu.M-2.0 μM RTX. At higher doses there was increasing risk of bladder areflexia. In addition, higher concentrations of RTX required a larger solvent concentration to maintain the RTX in solution, which in turn increases the potential for causing irritation of the bladder mucosa due to solvent. A single instillation was shown effective for up to 6 months. [0081] In specific embodiments, pharmaceutical compositions of the present invention deliver vanilloid components, e.g., resiniferatoxin, capsaicin, tinyatoxin, and related compounds in combination with a permeation enhancer. In general, the permeation enhancer that is employed is one that enhances the permeation of the homovanilloid composition through the membrane of a body cavity, in particular the bladder [0082] The pharmaceutical composition described herein may further comprise a liquid carrier in a concentration effective to serve as a suitable vehicle. In general, the carrier is used in an amount of about 40 to about 50 wt. %, about 40 to about 60 wt. %, about 40 to about 70 wt. %, about 40 to about 80 wt. %, about 40 to about 90 wt. %, or 40 to about 98 wt. % of the composition. In certain embodiments, the carrier comprises an amount of about 50 to about 98 wt. % of the composition.

[0083] RTX and other homovanilloids are insufficiently soluble in water to permit delivering a therapeutic dose in completely aqueous carrier. However, the compounds are soluble in ethanol. Pure ethanol cannot be instilled into the bladder because it causes severe pain and irritation of the bladder mucosa. However, it has been found that ethanolic solutions of RTX can be diluted into an aqueous medium such as normal saline, such that RTX remains in solution and the ethanol content of the final composition is sufficiently low (not greater than 20% (v/v) ethanol) to avoid significant irritation. RTX can be stably maintained as a stock solution in absolute ethanol, stored in the dark, preferably refrigerated. The stock solution can be diluted into an aqueous medium comprising additional bioactive agents, e.g., a permeation enhancer, or into an aqueous medium comprising a bioactive agent, e.g., a permeation enhancer, and ethanol such that the final ethanol concentration in the composition is at least 10% (v/v). When prepared as described, RTX remains in solution. In specific embodiments, RTX is maintained in solution without the use of ethanol. The foregoing solution, after filter sterilization, can be directly instilled into the urinary bladder. In certain embodiments, instillation volume is 10 ml or less, 25 ml or less, 30 ml or less, 40 ml or less, 50 ml or less, 60 ml or less, 70 ml or less, 80 ml or less, 90 ml or less, or 100 ml or less, although it is possible to instill somewhat larger volumes, as is understood in the art.

[0084] Patients afflicted with urge incontinence vary widely due to the variety of conditions that can cause the problem and the severity of the affliction. Therefore, it will be understood by those skilled in the art that the dosage and frequency of treatment will be customized to the patients' needs, based on clinical evaluations of the treatment. The treatment has been found to be especially effective for patients afflicted with multiple sclerosis. Administration is topical, by contacting the urinary bladder mucosa with a composition comprising RTX (or TYX or other analog) and a permeation enhancer. Any means by which an effective concentration of RTX can be brought into contact with the bladder mucosa can be employed.

4.5 Pharmaceutical Compositions

[0085] Preferably, a composition (e.g., pharmaceutical composition) includes, in admixture, a pharmaceutically acceptable excipient, carrier, or diluent, and one or more of a bioactive agent (e.g., nucleic acid, polypeptide, peptide, or antibody), drug (e.g., resiniferatoxin, capsaicin, tinyatoxin, or other vanilloid compounds), or toxin (e.g., botulinum toxin), as described herein, as an active ingredient. The preparation of pharmaceutical compositions that contain bioactive agents as active ingredients is well understood in the art. Typically, such compositions are prepared as liquid solutions or suspensions, however, solid forms suitable for solution in, or suspension in, liquid prior to administration can also be prepared. The preparation can also be emulsified. The active therapeutic ingredient is often mixed with excipients that are pharmaceutically acceptable and compatible with the active ingredient, e.g., a permeation enhancer. Suitable excipients are, for example, water, saline, dextrose, glycerol, ethanol, or the like and combinations thereof. Preferred carriers, excipients, and diluents of the invention comprise physiological saline (i.e., 0.9% NaCl). In addition, if desired, the composition can contain minor amounts of auxiliary substances such as wetting or emulsifying agents, pH-buffering agents, which enhance the effectiveness of the active ingredient.

[0086] The compositions of the invention include bulk drug compositions useful in the manufacture of pharmaceutical compositions (e.g., impure or non-sterile compositions) and pharmaceutical compositions (i.e., compositions that are suitable for administration to a subject or patient) which can be used in the preparation of unit dosage forms. Such compositions comprise a prophylactically or therapeutically effective amount of a prophylactic and/or therapeutic agent disclosed herein or a combination of those agents and a pharmaceutically acceptable carrier. Preferably, compositions of the invention comprise a prophylactically or therapeutically effective amount of at least one homovanilloid compound and at least one permeation enhancer and, optionally, a pharmaceutically acceptable carrier.

[0087] In one particular embodiment, the pharmaceutical composition comprises of a therapeutically effective amount of at least one homovanilloid compound, at least one permeation enhancer, and a pharmaceutically acceptable carrier.

[0088] In a specific embodiment, the term "pharmaceutically acceptable" means approved by a regulatory agency of the Federal or a state government or listed in the U.S. Pharmacopeia or other generally recognized pharmacopeia for use in animals, and more particularly in humans. The term "carrier" refers to a diluent, excipient, permeation enhancer (in the art as described above), or vehicle with which the therapeutic is administered. Such pharmaceutical carriers can be sterile liquids, such as water and oils, including those of petroleum, animal, vegetable or synthetic origin, such as peanut oil, soybean oil, mineral oil, sesame oil and the like. Suitable pharmaceutical excipients include starch, glucose, lactose, sucrose, gelatin, malt, rice, flour, chalk, silica gel, sodium stearate, glycerol monostearate, talc, sodium chloride, dried skim milk, glycerol, propylene, glycol, water, ethanol and the like. The composition, if desired, can also contain minor amounts of wetting or emulsifying agents, or pH buffering agents. These compositions can take the form of solutions, suspensions, emulsion, tablets, pills, capsules, powders, sustained-release formulations and the like.

[0089] Generally, the ingredients of compositions of the invention are supplied either separately or mixed together in unit dosage form, for example, as a dry lyophilized powder or water free concentrate in a hermetically sealed container such as an ampoule or sachette indicating the quantity of active agent. In certain embodiments, the compositions of the invention further comprise bulking agents such as sodium chloride, mannitol, polyvinylpyrrolidone and the like, to provide sufficient matter for ease of handling after lyophilization

[0090] The compositions of the invention can be formulated as neutral or salt forms.

Pharmaceutically acceptable salts include, but are not limited to those formed with anions such as those derived from hydrochloric, phosphoric, acetic, oxalic, tartaric acids, etc., and those formed with cations such as those derived from sodium, potassium, ammonium, calcium, ferric hydroxides, isopropylamine, triethylamine, 2-ethylamino ethanol, histidine, procaine, etc.

[0091] Pharmaceutical compositions can be administered in a manner compatible with the dosage formulation, and in a therapeutically effective amount. The quantity to be administered depends on the subject to be treated, capacity of the subject's immune system to utilize the active ingredient, and degree of modulation required. Precise amounts of active ingredient required to be administered depend on the judgment of the practitioner and are specific for each individual in light of the relevant circumstances, including the type of pain to be treated, the chosen route of administration, the actual compound administered, the severity of the patient's symptoms, and the like. However, a therapeutically, transmembrane, effective dose of the at least one homovanilloid compound within the pharmaceutical compositions of the present invention comprises, for example, between about 0.01 to about 0.05, about 0.01 to about 0.75, 0.01 to about 0.1, about 0.1 to about 0.2, about 0.1 to about 0.3, about 0.1 to 0.5, about 0.1 to 0.8, about 0.1 to 1, about 0.1 to 2, about 0.1 to 5, about 0.1 to 10, about 0.1 to 15, or about 0.1 to 20, and more preferably one to several milligrams of active ingredient per kilogram body weight of individual per day, ultimately depending on the route of administration. The pharmaceutical compositions of the invention may be administered by any suitable routes including, by way of illustration, transmucosal, transmembrane, subcutaneous, intramuscular, and the like. Depending on the intended route of delivery, the compounds of the invention are preferably formulated as transmucosal, transmembrane (e.g., trans- dural), or injectable compositions. In specific embodiments, the subject is administered maintenance doses every month, every 2 months, every 3 months, every 4 months, every 5 months, every 6 months, or at longer intervals, subsequent to the last priming dose or, where no priming doses are administered, subsequent to the initial administration. In other embodiments, use of the permeation enhancer allows the interval of time between maintenance doses to be increased. In still other embodiments, use of the permeation enhancer allows the contact time of the composition of the invention to be reduced relative to control compositions. In certain embodiments, contact time of the composition is 5 min, 10 min, 15 min, 20 min, 25 min, 30 min, 35 min, 40 min, 45 min, 1 h, 1.1 h, 1.2 h, 1.3 h, 1.4 h, 1.5 h, 1.6 h, 1.7 h, 1.8 h, 1.9 h, 2.0 h or 2.5 h or longer.

[0092] Injectable compositions are typically based upon injectable sterile saline or phosphate-buffered saline or other injectable carriers known in the art.

4.6 Characterization and Demonstration of Therapeutic Utility [0093] Several aspects of the pharmaceutical compositions of the invention are preferably tested in vitro, e.g., in a cell culture system, and then in vivo, e.g., in an animal model organism, such as a rodent animal model system, for the desired therapeutic activity prior to use in humans. For example, assays which can be used to determine whether administration of a specific pharmaceutical composition is indicated, include cell culture assays in which a patient tissue sample is grown in culture, and exposed to or otherwise contacted with a pharmaceutical composition, and the effect of such composition upon the tissue sample is observed. In particular the effects of a particular permeation enhancer on the pharmaceutical composition may be tested in cell culture. For example, an appropriate cell line may be cultured on Millipore Millicell - Culture plate inserts. The cells are cultured on a filter at the bottom of the insert, which insert is then inserted into a tissue culture plate. On confluence, the tissue culture separates and upper chamber (within the insert) and a lower chamber (the tissue culture plate). Compounds added to the upper chamber can be monitored for appearance in the lower chamber by any method known in the art to determine diffusion constants or flux through the confluent cell culture, which mimics the biological membrane of interest. In certain embodiments, compounds that increase diffusion rates, C_max or AUC when added to an assayed composition are permeation enhancers according to the invention. In certain embodiments, the tissue sample can be obtained by biopsy from the patient. This test allows the identification of the therapeutically most effective prophylactic or therapeutic molecule(s) for each individual patient.

[0094] Combinations of prophylactic and/or therapeutic agents can be tested in suitable animal model systems prior to use in humans. Such animal model systems include, but are not limited to, rats, mice, chicken, cows, monkeys, pigs, dogs, rabbits, etc. Any animal system well-known in the art may be used. In a specific embodiment of the invention, combinations of prophylactic and/or therapeutic agents are tested in a rodent model system, e.g., in a rat, mouse, guinea pig, hamster. In related embodiements, combinations of prophylactic and/or therapeutic agents are tested in a rat model system. Such model systems of urinary dysfunction are widely used and well-known to the skilled artisan. Prophylactic and/or therapeutic agents can be administered repeatedly. Several aspects of the procedure may vary such as the temporal regime of administering the prophylactic and/or therapeutic agents, and whether such agents are administered separately or as an admixture.

[0095] Further, any assays known to those skilled in the art can be used to evaluate the prophylactic and/or therapeutic utility of the combinatorial therapies disclosed herein for autoimmune and/or inflammatory diseases.

[0096] In a specific embodiment, efficacy of treatment relative to control is evaluated by a pain intensity assessment scale. Such scales are typically used by those of ordinary skill in the art to evaluate analgesic choices and therapeutic effects. For example, a "Visual Analogue Scale" (VAS) is a measurement instrument that measures a characteristic that is believed to range across a continuum of values and that cannot easily be directly measured, e.g., the amount of pain that a patient feels. Typically such pain is represented as a continuum from none to an extreme, and may be indirectly measured via the use of a VAS. Operationally, a VAS is usually a horizontal line, 100 mm in length, anchored by word descriptors at each end, for example "no pain" at one end and "very severe pain" at the other end. The patient, marks on the line the point that they feel represents their perception of their current state. The VAS score is determined by measuring in millimeters from the left hand end of the line to the point that the patient marks. The 100-mm visual analog scale (VAS), a unidimensional scale that is versatile and easy to use, has been adopted in many settings.

[0097] With respect to animal models, any method known in the art can be used for evaluating the analgesic effects of the compositions of the invention. For example, one test typically used in the art to test analgesic effects of compositions is the vivo model of Phenylquinone ("PQ") Writhing (Siegmund et al., 1957, Proc. Soc. Exp. Biol. Med. 95:729-731, hereby included by reference in its entirety. Typically, a control response is established by an intraperitoneal injection of 2mg/kg of phenylquinone ("PQ") and recording the number of writhes exhibited during the following 5-10 minutes. The control response is compared to the response when the test compound is administered prior to, subsequent to, or concomitantly with PQ injection. Results from the test and control groups are compared by any statistical means known in the art (e.g., Dunnett's test). [0098] Alternatively, in vivo models of mononeuropathy which base response on latency to cold stimulus (response to a cold allodynia assay) may be used. For example, the assay of Bennett, et al., 1988, Pain 33:87-107 (hereby incorporated by reference in its entirety) results in a peripheral mononeuropathy in neuropathic pain in rats that produces pain sensations similar to those seen in man. The peripheral mononeuropathy is induced by loose ligation of the sciatic nerve in anaesthetized rats. Subsequently, e.g., 10-15 days later, nociceptive threshold is evaluated. Test compound is administered 1 hour prior to pain measurement. For comparison, a predose threshold is determined and control vehicle administered. Animals may be tested at later times, e.g., 1-5 hours post compound administration. Predose and postdose average scores are determined and are compared by any statistical method known in the art, e.g., one-way ANOVA, Dunnett's test.

4.7 Toxicity Studies

[0099] The toxicity and/or efficacy of the compositions of the present invention can be determined by standard pharmaceutical procedures in cell cultures or experimental animals, e.g., for determining the LD50 (the dose lethal to 50% of the population) and the ED50 (the dose therapeutically effective in 50% of the population). The dose ratio between toxic and therapeutic effects is the therapeutic index and it can be expressed as the ratio LD50/ED50. Therapies that exhibit large therapeutic indices are preferred. While therapies that exhibit toxic side effects may be used, care should be taken to design a delivery system that targets such agents to the site of affected tissue in order to minimize potential damage to uninfected cells and, thereby, reduce side effects.

[00100] The data obtained from animal studies can be used in formulating a range of dosage of the therapies for use in subjects. The dosage of such agents lies preferably within a range of concentrations that include the ED50 with little or no toxicity. The dosage may vary within this range depending upon the dosage form employed and the route of administration utilized. For any therapy used in the method of the invention, the therapeutically effective dose can be estimated initially from animal assays. A dose may be formulated in animal models to achieve an administered concentration range that includes the IC50 {i.e., the concentration of the test compound that achieves a half-maximal inhibition of symptoms) as determined in animal models. Such information can be used to more accurately determine useful doses in subjects {e.g., humans).

[00101] Further, any assays known to those skilled in the art can be used to evaluate the prophylactic and/or therapeutic utility of a composition, a combination therapy disclosed herein treatment of neurogenic urinary dysfunction or a condition or symptoms associated therewith.

4.8 Kits

[00102] Since the effects of homovanilloid treatment are long-lasting, it will be especially convenient to provide the pharmaceutical composition comprising the therapeutic compound, e.g., RTX, and the permeation enhancer prepackaged for single dose administration. Accordingly, a kit is provided, having a unit dose of the composition present in a storage-stable form, dissolvable or dilutable to the desired instillation volume, e.g., 50 ml, together with appropriate packaging and handling devices for convenience of mixing and to maintain sterility prior to instillation. Such a kit can include, for example, a first container containing active ingredient in a stable storage form, either as a unit dose in a stock solution or a unit dose as lyophilized powder; and a second container containing diluent, or solvent and diluent, either separate or combined, the volume of which will provide a unit dose of therapeutic compound in a volume sufficient for a single intravesicular instillation; means for combining diluent with the stock solution or lyophilized powder; and optionally, means for transferring the instillation dose to the patient. Means for transferring diluent to the stock solution or lyophilized powder can include, but are not limited to, syringes or multi-chambered containers having a breachable internal seal separating active ingredient from diluent. Means for transferring the instillation dose to the patient can include, but are not limited to, sterile tubing and appropriate fittings for connecting the tubing to a patient's catheter.

[00103] The invention provides a pharmaceutical pack or kit comprising one or more containers filled with the pharmaceutical composition of the invention or a portion thereof. Additionally, one or more other prophylactic or therapeutic agents useful for the treatment of a disease or disorder can also be included in the pharmaceutical pack or kit. The invention also provides a pharmaceutical pack or kit comprising one or more containers filled with one or more of the ingredients of the pharmaceutical compositions of the invention. Optionally associated with such container(s) can be a notice in the form prescribed by a governmental agency regulating the manufacture, use or sale of pharmaceuticals or biological products, which notice reflects approval by the agency of manufacture, use or sale for human administration.

[00104] The present invention provides kits that can be used in the above methods. In one embodiment, a kit comprises one or more pharmaceutical compositions of the invention. In another embodiment, a kit further comprises one or more other prophylactic or therapeutic agents useful for the treatment of pain or a disorder associated, at least partially, with neurogenic Dysfunction, e.g., neurogenic urinary dysfunction, in one or more containers. In other embodiments, the prophylactic or therapeutic agent is a biological or hormonal therapeutic.

[00105] The invention therefore includes a method of treating neurogenic urinary dysfunction that comprises contacting urinary bladder mucosa of a patient afflicted with neurogenic urinary dysfunction with an effective dose of a composition comprising homovanilloid compound, in particular a compound selected from the group RTX, TYX, 20-homovanillyl-mezerein or 20-homovanillyl-12-deoxyphorbol-13-phenylacetate, and a permeation enhancer, in particular HAse. The invention includes treatment of urge incontinence due to detrusor hyperreflexia (DH). The invention also includes treatment of sensory hypersensitivity of the bladder resulting from prostate hypertrophy or interstitial cystitis, as well as other neurogenic conditions resulting in increased micturition frequency or decreased bladder capacity, with or without frank incontinence.

[00106] The invention is effective for treatment of urinary incontinence experienced by a patient afflicted with multiple sclerosis.

[00107] The invention also includes a composition comprising a homovanilloid compound, for example RTX, a permeation enhancer, for example HAse, and a physiologically acceptable diluent suitable for urinary bladder instillation. [00108] Although the invention has been disclosed by examples of specific embodiments, other embodiments, methods, compositions, active ingredients, indications, compositions and kits will be apparent to those skilled in the art. All such alterations and extensions are included with the invention as disclosed and claimed herein.

Claims

WHAT IS CLAIMED IS:

1. A pharmaceutical composition comprising a therapeutically effective amount of a homovanilloid compound, a permeation enhancer, and a pharmaceutically acceptable carrier, wherein said composition does not comprise a lipid vehicle.

2. The composition of claim 1, wherein said homovanilloid compound is resiniferatoxin (RTX).

3. The composition of claim 1, wherein said homovanilloid compound is tinyatoxin (TYX).

4. The composition of any one of claims 1-3, wherein the permeation enhancer is a hyaluronidase.

5. The composition of claim 4, wherein the hyaluronidase is neutral-active hyaluronidase.

6. The composition of claim 4, wherein the hyaluronidase is acid-active hyaluronidase.

7. The composition of any one of claims 1-3, wherein the permeation enhancer is a Hsieh enhancer.

8. The composition of any one of claims 1-3, wherein said permeation enhancer is a straight chain or branched compound of the saturated or unsaturated aliphatic type.

9. The pharmaceutical composition of claim 8, wherein said straight chain or branched compound of the saturated or unsaturated aliphatic type is selected from the group consisting of: myristyl myristate, isopropyl myristate, octyl palmitate, and ethyl oleate.

10. The pharmaceutical composition of claim 1, wherein the composition further comprises buffer salts a pH within the normal pH range of human urine.

11. A method for treating neurogenic urinary dysfunction in a patient in need thereof, comprising administering to said patient, by intravesicular instillation, a pharmaceutical composition comprising a therapeutically effective amount of a homovanilloid compound and a permeation enhancer, wherein said composition does not comprise a lipid vehicle.

12. The method of claim 10 wherein the neurogenic urinary dysfunction is characterized as detrusor hyperreflexia.

13. The method of claim 11, wherein the detrusor hyperreflexia is associated with multiple sclerosis.

14. The method of claim 11, wherein the detrusor hyperreflexia is associated with spinal cord injury.

15. The method of claim 10 wherein the neurogenic urinary dysfunction is characterized by hypersensitivity of the bladder afferent nerves.

16. The method of claim 14 wherein the hypersensitivity is associated with prostate hypertrophy.

17. A method for treating pain in a patient in need thereof, comprising administering to said patient a pharmaceutical composition comprising a therapeutically effective amount of a homovanilloid compound and a permeation enhancer, wherein said composition does not comprise a lipid vehicle.

18. The method of claim 17, wherein said administration comprises epidural injection.

19. The method of claim 17, wherein said administration comprises intrathecal injection.

20. The method of claim 17, wherein said patient has been diagnosed with cancer.

21. The method of claim 20, wherein said administration is to tumor tissue.

22. The method of claim 20, wherein said administration is to tissue neighboring or contiguous with tumor tissue.

23. The method of claim 17, wherein said pain is neuropathic pain.

24. The method of claim 10 or 17, wherein said permeation enhancer is a Hsieh enhancer.

25. The method of claim 24, wherein said Hsieh enhancer is cyclopentadecalactone or cylcohexadecanone.

26. The method of claim 10 or 17, wherein said permeation enhancer is a straight chain or branched compound of the saturated or unsaturated aliphatic type.

27. The method of claim 26, wherein said straight chain or branched compound of the saturated or unsaturated aliphatic type is selected from the group consisting of: myristyl myristate, isopropyl myristate, octyl palmitate, and ethyl oleate.

28. The method of claim 10 or 17, wherein said homovanilloid compound is resiniferatoxin, tinyatoxin, 20-homovanillyl-mezerein or 20-homovanillyl-12- deoxyphorbol-13-phenylacetate.