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Definitions

• Adrenergic receptors mediate physiological responses to the catecholamines, norepinephrine and epinephrine, and are members of the superfamily of G protein- coupled receptors having seven transmembrane domains. These receptors, which are divided pharmacologically into ⁇ -1, ⁇ -2 and ⁇ -adrenergic receptor types, are involved in diverse physiological functions including functions of the cardiovascular and central nervous systems.
• ⁇ -1 adrenergic receptors are typically excitatory post-synaptic receptors which generally mediate responses in an effector organ, while ⁇ -2 adrenergic receptors are located postsynaptically as well as presynaptically, where they inhibit release of neurotransmitters.
• ⁇ -2 adrenergic receptors are located postsynaptically as well as presynaptically, where they inhibit release of neurotransmitters.
• the ⁇ -adrenergic receptors also mediate vascular constriction.
• Agonists of ⁇ -2 adrenergic receptors currently are used clinically in the treatment of hypertension, glaucoma, spasticity, and attention-deficit disorder, in the suppression of opiate withdrawal, as adjuncts to general anesthesia and in the treatment of cancer pain.
• ⁇ -2 adrenergic receptors are present in various bodily organs, including eyes and nose. It is believed that they play a role in nasal congestion, among many other diseases.
• ⁇ -2 adrenergic receptors are presently classified into three subtypes based on their pharmacological and molecular characterization: ⁇ -2A/D ( ⁇ -2A in human and ⁇ -2D in rat); ⁇ -2B; and ⁇ -2C (Bylund et al., Pharmacol. Rev. 46:121-136 (1994); and Hein and Kobilka, Neuropharmacol. 34:357-366 (1995)).
• the ⁇ -2A, ⁇ -2B, and a-2C subtypes appear to regulate arterial and/or venular contraction in some vascular beds, and the ⁇ - 2A and ⁇ -2C subtypes mediate feedback inhibition of norepinephrine release from sympathetic nerve endings.
• brimonidine which has been used for lowering intraocular pressure in patients with open-angle glaucoma or ocular hypertension
• guanfacine which has been used to control high blood pressure
• dexmedetomidine which has been used as a sedative, analgesic, sympatholytic and anxiolytic
• methyl dopa which has been used as a centrally -acting adrenergic antihypertensive
• Nasal conditions such as nasal congestion, cause inconveniences and
• the present invention provides compositions and methods for treating a nasal condition by administering low concentrations of highly selective ⁇ -2 adrenergic receptor agonists to a patient in need thereof.
• compositions and methods utilize low concentrations of highly selective ⁇ -2 adrenergic receptor agonists having a binding affinity of 100 fold or greater for ⁇ -2 over ⁇ -1 adrenergic receptors.
• concentration of the selective ⁇ -2 adrenergic receptor agonist is preferably below the concentration at which ⁇ -1 adrenergic receptors are activated sufficiently enough to cause adverse ischemic vasoconstrictive consequences.
• concentration of the selective ⁇ -2 adrenergic receptor agonist is below about 0.05% weight by volume of the composition.
• the selective ⁇ -2 adrenergic receptor agonist is selected from the group consisting of apraclonidine, mivazerol, clonidine, brimonidine, alpha methyl dopa, guanfacine, dexmedetomidine, (+)-(S)-4-[1-(2,3- dimethyl-phenyl)-ethyl]-1 ,3-dihydro-imidazole-2-thione, 1 -[ ⁇ imidazolidin-2- yl)imino]indazole, and mixtures of these compounds.
• a pH of the composition comprising the selective ⁇ -2 adrenergic receptor agonist is between about 4.0 and about 8.5. If it is desired to achieve a more effective topical mucosal application with minimal mucosal penetration (for example, in such conditions as vasomotor rhinitis or nasal congestion), then it is generally preferred to maintain pH of the composition between about 4.0 and about 6.5. If, on the other hand, it is desired to achieve a deeper mucosal penetration (for example, in such conditions as allergic rhinitis or sleep apnea), then a preferred pH of the composition is between about 6.5 and about 8.0.
• compositions of the invention can be administered by nasal delivery. In another embodiment of the invention, the compositions of the invention can be administered by topical ophthalmic delivery.
• Figure 1 is a graphical representation of the effects of activating ⁇ -1 adrenergic receptors
• Figure 2 is a graphical representation of the effects of preferentially activating ⁇ -2 adrenergic receptors.
• low concentrations refers to concentrations from between about 0.0001% to about 0.05%; more preferably, from about 0.001% to about 0.025%; even more preferably, from about 0.01% to about 0.025%; and even more preferably, from about 0.01% to about 0.02% weight by volume of the composition.
• brimonidine encompasses, without limitation, brimonidine salts and other derivatives, and specifically includes, but is not limited to, brimonidine tartrate, 5- bromo-6-(2-imidazolin-2-ylamino)quinoxaline D-tartrate, AlphaganTM, and UK14304.
• treating and “treatment” refer to reversing, alleviating, inhibiting, or slowing the progress of the disease, disorder, or condition to which such terms apply, or one or more symptoms of such disease, disorder, or condition.
• nasal condition refers to any disease, disorder, or condition which affects and/or involves the nose. This term includes, but is not limited to, such conditions as nasal congestion, diseases and/or conditions associated with swollen nasal turbinates, all types of rhinitis including but not limited to vasomotor rhinitis and allergic rhinitis, sleep apnea, acute or chronic sinusitis, nasal polyposis, and any disease and/or condition associated with nasal discharge.
• substantially enlargement of nasal turbinates refers to a significant enlargement of nasal turbinates, for example, more than about 50% compared to the baseline level of the patient so that it negatively affects the patient's breathing.
• preventing and prevention refer to prophylactic use to reduce the likelihood of a disease, disorder, or condition to which such term applies, or one or more symptoms of such disease, disorder, or condition. It is not necessary to achieve a 100% likelihood of prevention; it is sufficient to achieve at least a partial effect of reducing the risk of acquiring such disease, disorder, or condition.
• ⁇ -2 adrenergic receptor agonists which are interchangeably referred to as " ⁇ -2 agonists" throughout the application
• ⁇ -2 agonists extremely high selectivity for ⁇ -2 adrenergic receptors at sufficiently low concentrations and at pH of between about 4.0 and about 8.5
• Nasal congestion is turbinate mucosal swelling which is caused by, or is contributed by, vasodilation of blood vessels. While not wishing to be bound to any particular theory, it is believed that vasodilation is primarily associated with ⁇ -1 adrenergic receptors activity. Thus, unless the binding affinity of ⁇ -2 agonists for ⁇ -2 over ⁇ -1 adrenergic receptors is sufficiently high, insufficiently highly selective ⁇ -2 agonists cause undesirable ⁇ -1 receptor stimulation with attendant vasodilation. Accordingly, the invention is directed to compositions and methods which employ highly selective ⁇ -2 agonists that have minimal ⁇ -1 agonist activity. The compositions of the present invention preferentially stimulate ⁇ -2 adrenergic receptors so that ⁇ -1 adrenergic receptors are not stimulated sufficiently enough to cause vasodilation.
• the invention provides a method of treating a nasal condition comprising administering to a patient in need thereof a selective ⁇ -2 adrenergic receptor agonist having a binding affinity of 100 fold or greater for ⁇ -2 over ⁇ -1 adrenergic receptors, or a pharmaceutically acceptable salt thereof, wherein said selective ⁇ -2 adrenergic receptor agonist is present at a concentration below about 0.05% weight by volume.
• the invention provides compositions formulated for treating a condition associated with swollen nasal turbinates.
• Compositions particularly useful for these purposes preferably comprise brimonidine at concentrations of from 0.01% to about 0.04%, and more preferably, from 0.02% to about 0.035%.
• the condition associated with swollen nasal turbinates is selected from the group consisting of nasal congestion, allergic rhinitis, asthma, sleep disorders, and sleep apnea.
• a preferred pH of the composition formulated for the condition associated with swollen nasal turbinates is between about 6.5 and about 8.5.
• Selective ⁇ -2 Adrenergic Receptor Agonists Suitable for the Purposes of the Invention Selective ⁇ -2 agonists that may be used for the purposes of the present invention have extremely high selectivity for ⁇ -2 adrenergic receptors, defined by their binding affinities (K i ) for ⁇ -2 over ⁇ -1 receptors of more than 100:1, more preferably 300:1 ; more preferably 500:1, even more preferably 700:1, even more preferably 1000:1 or greater, and most preferably, 1500:1 or greater.
• adrenergic receptor agonists for the purposes of the present invention are highly selective for ⁇ -2B and/or ⁇ -2C receptors, as opposed to ⁇ -2A receptors.
• the selective ⁇ -2 adrenergic receptor agonist is a compound which has binding affinity of about 100 fold or greater for ⁇ -2 over ⁇ -1 adrenergic receptors, preferably about 500 fold or greater, more preferably about 700 fold or greater, even more preferably about 1000 fold or greater, and most preferably, about 1500 fold or greater.
• the selective ⁇ -2 adrenergic receptor agonist may be present at a concentration from between about 0.0001% to about 0.05%; more preferably, from about 0.001% to about 0.025%; even more preferably, from about 0.01% to about 0.025%; and even more preferably, from about 0.01 % to about 0.02% weight by volume.
• a concentration of a selective ⁇ -2 adrenergic receptor agonist be below its vasoconstriction vs. concentration plateau.
• the optimal concentration is 10% to 90% above the minimal threshold of measurable vasoconstriction for a particular ⁇ -2 agonist, or below that of the plateau maximum concentration, and is preferably within the about 25% to about 75% range of either of these benchmarks.
• plateau maximum concentration means the concentration above which there is no or minimal further vasoconstriction effect.
• Other considerations in choosing a selective ⁇ -2 adrenergic receptor agonist are blood brain permeability and any possible side effects and other systemic reactions.
• the selective ⁇ -2 adrenergic receptor is selected from the group consisting of apraclonidine, mivazerol, clonidine, brimonidine, alpha methyl dopa, guanfacine, dexmedetomidine, (+)-(S)-4-[1-(2,3-dimethyl-phenyl)-ethyl]-1 ,3-dihydro- imidazole-2-thione, 1-[(imidazolidin-2-yl)imino]indazole, and mixtures of these compounds. Analogs of these compounds that function as highly selective ⁇ -2 agonists may also be used in compositions and methods of the present invention.
• the selective ⁇ -2 adrenergic receptor is brimonidine in the form of a salt.
• the salt is tartrate salt.
• the invention provides a composition comprising a selective ⁇ -2 adrenergic receptor agonist having a binding affinity of 100 fold or greater for ⁇ -2 over ⁇ -1 adrenergic receptors, or a pharmaceutically acceptable salt thereof, for treating nasal congestion.
• said selective ⁇ -2 adrenergic receptor agonist is present at a concentration below about 0.05% weight by volume, and more preferably, between about 0.001% to about 0.05% weight by volume.
• the selective ⁇ -2 adrenergic receptor agonist is selected from the group consisting of lofexidine, apraclonidine, mivazerol, clonidine, brimonidine, alpha methyl dopa, guanfacine, dexmedetomidine, (+)-(S)-4-[1-(2,3-dimethyl-phenyl)- ethyl]-1,3-dihydro-imidazole-2-thione, 1- ⁇ (imidazolidin-2-yl)imino]indazole, and mixtures of these compounds.
• the composition comprises brimonidine at a concentration between about 0.001% and about 0.025% weight by volume.
• a pH of the composition comprising the selective ⁇ -2 adrenergic receptor agonist is between about 4.0 and about 8.5.
• Log D refers to a lipophilicity value at a given pH. This measurement is especially useful to determine the level of topical lipophilicity and resultant permeability of a topical composition.
• the pH is relatively low, e.g. between about 4.0 and about 6.5, the selective ⁇ -2 agonist is relatively less lipophilic and more ionized.
• pH range of 4.0 to about 6.5, and more preferably 4.0 to 5.8, is preferred for the formulations for the treatment of nasal conditions involving serous nasal discharge without substantial turbinate swelling, such as vasomotor rhinitis.
• a preferred pH of the composition is between about 6.5 and about 8.5. At this higher pH, a greater proportion of the ⁇ -2 agonist will be non- ionized and more lipophilic, resulting in the greater permeation of the ⁇ -2 agonist through the lipophilic mucosal epithelial cell membranes.
• pH range of 6.5 to 8.5, and more preferably, 7.5 to 8.5 is preferred for formulations for the treatment of allergic rhinitis, sleep apnea, and other disorders associated with substantial enlargement of nasal turbinates and/or physical blockage of nasal passages, for example due to venous sinusoidal dilation.
• a moderate lipophilicity which is associated with pH of between about 5.6 and 6.2.
• Dexmedetomidine has the following Log D values at different pH:
• Log D pH 6.2 to 8.0: Log D is 2.28 to 3.00. The lower the Log D value is, the less is lipophilicity and the more is surface retention and mucosal effectiveness. Conversely, the higher the Log D value is, the more is lipophilicity, and the more is mucosal penetration and submucosal permeation.
• Brimonidine has the following Log D values at different pH:
• the moderate lipophilicity is achieved at pH of between 6.2 and 6.8.
• a pH of less than 6.2 is preferred to achieve greater mucosal surface retention, and a pH of greater than 6.8 is preferred to achieve greater mucosal penetration and submucosal permeation.
• the invention provides an aqueous composition for treating a nasal condition consisting essentially of brimonidine, wherein said brimonidine concentration is from between about 0.01% to about 0.02% weight by volume, wherein pH of said composition is between about 6.2 and about 6.8.
• the invention provides an aqueous composition for treating nasal congestion comprising brimonidine and from between about 0.1 to about 0.5% weight by volume of potassium chloride, wherein said brimonidine concentration is from between about 0.01% to about 0.025% weight by volume, wherein pH of said composition is between about 6.2 and about 6.8.
• compositions of the present invention are preferably formulated for a mammal, and more preferably, for a human.
• compositions of the present invention further include potassium (i.e., K + ).
• potassium i.e., K +
• the term “potassium” includes, but is not limited to, potassium salt.
• potassium is in the form of potassium chloride and its concentration is between about 0.2% to about 0.9% weight by volume.
• compositions of the present invention further include calcium (i.e., Ca 2+ ).
• calcium i.e., Ca 2+
• the term "calcium” includes, but is not limited to, calcium salt.
• calcium is calcium chloride.
• compositions of the present invention contain the electrolyte KCL in a concentration range of 0.1% - 0.8% weight by volume, preferably 0.25% weight by volume for a more prolonged duration of action.
• compositions of the invention also comprise a solubility stabilizer which preferably contains an anionic component, such as peroxide class preservatives.
• the solubility stabilizer allows one to achieve greater penetration of lipophilic membranes, such as those present at the vascular endothelial surface.
• the solubility stabilizer comprises a stabilized oxychloro complex, chlorite, and sodium perborate.
• compositions of the present invention comprise nitrous oxide inhibitors.
• the nitrous oxide inhibitors are selected from the group consisting of L-NAME (L-N G -Nitroarginine methyl ester), L- NIL (N6-(1-lminoethyl)-L-fysine dihydrochloride), L-NIO (N5-(1-lminoethyl)-L-ornithine dihydrochloride), and L-canavine, or combinations thereof.
• concentration of the nitrous oxide inhibitors is between about 0.005% and about 0.5% weight by volume.
• compositions of the invention may also include additional components, which include, but are not limited to, preservatives, delivery vehicles, tonicity adjustors, buffers, pH adjustors, antioxidants, and water.
• the preservatives include, but are not limited to, benzalkonium chloride, chlorobutanol, thimerosal, phenylmercuric acetate, or phenylmercuric nitrate.
• Vehicles useful in a topical composition include, but are not limited to, polyvinyl alcohol, povidone, hydroxypropyl methyl cellulose, poloxamers, carboxymethyl cellulose, hydroxyethyl cellulose and purified water. It is also possible to use a physiological saline solution as a major vehicle.
• a tonicity adjuster also can be included, if desired, in a topical composition of the invention.
• a tonicity adjuster can be, without limitation, a salt such as sodium chloride, potassium chloride, mannitol or glycerin, or another pharmaceutically or ophthalmicalty acceptable tonicity adjuster.
• отно ⁇ buffers and means for adjusting pH can be used to prepare topical compositions of the invention.
• Such buffers include, but are not limited to, acetate buffers, citrate buffers, phosphate buffers and borate buffers. It is understood that acids or bases can be used to adjust the pH of the composition as needed.
• Topically acceptable antioxidants useful in preparing a topical composition include, yet are not limited to, sodium metabisulfrte, sodium thiosulfate, acetylcysteine, butylated hydroxyanisole and butylated hydroxytoluene.
• compositions of the invention may be administered through nasal delivery or delivered as ophthalmic solutions into the eyes.
• the provided composition is an aerosolized composition. It is within a skill in the art to prepare aerosolized compositions of the present invention.
• the aerosolized compositions of the present invention are generally delivered via an inhaler, jet nebulizer, or ultrasonic nebulizer which is able to produce aerosol particles with size of between about 1 and 10 ⁇ m.
• topical compositions of the present invention one can simply dilute, using methods known in the art, more concentrated solutions of selective ⁇ -2 agonists.
• the precise method of carrying out the dilutions is not critical. Any commonly used diluents, including preservatives described above in the application, suitable for topical solutions can be used.
• compositions of the present invention are concentration- dependent. To determine the specific dose for a particular patient, a skilled artisan would have to take into account kinetics and absorption characteristics of the particular highly selective ⁇ -2 adrenergic receptor agonist.
• FIG. 1 is a graphical representation of the effects of activating ⁇ -1 adrenergic receptors. As FIG. 1 demonstrates, administering ⁇ -1 adrenergic receptor agonists leads to constriction of the proximal arteriole (on the left side) which in turn decreases the flow of blood through the capillaries and causes ischemia for the tissues
• FIG. 2 is a graphical representation of the effects of preferentially activating ⁇ -2 adrenergic receptors.
• administering ⁇ -2 adrenergic receptor agonists leads to constriction of the pre-capillary/terminal arteriole (on the left side) and constriction of the venule (on the right side).
• Ischemia is decreased, as compared to stimulating ⁇ -1 adrenergic receptors because the arteriole is open and some oxygen is available to surrounding tissues by means of the through-flow vessels that connect the arterioles and the venules.
• Pre-venule constriction may reduce the ischemic effect and reduce vasodilation that may contribute to nasal congestion.
• decongestants can be used to achieve significant drug concentrations in nasal turbinates, as drug flows through the nasolacrimal duct into the nasal turbinates.
• the results of the experiment are as follows. At the initial 5 min assessment, eight of eight subjects reported reduced hyperemia and increased whiteness in the eye to which brimonidine was administered. At the four hour assessment, eight of eight subjects reported reduced hyperemia and increased whiteness in the eye to which brimonidine was administered. Also, at the four hour assessment, six of eight subjects reported reduced nasal congestion in the nostril on the same side as the eye into which the drug was administered.

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