Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/48—Preparations in capsules, e.g. of gelatin, of chocolate
  • A61K9/50—Microcapsules having a gas, liquid or semi-solid filling; Solid microparticles or pellets surrounded by a distinct coating layer, e.g. coated microspheres, coated drug crystals
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/56—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids
  • A61K31/57—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids substituted in position 17 beta by a chain of two carbon atoms, e.g. pregnane or progesterone
  • A61K31/573—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids substituted in position 17 beta by a chain of two carbon atoms, e.g. pregnane or progesterone substituted in position 21, e.g. cortisone, dexamethasone, prednisone or aldosterone
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K47/00—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/0012—Galenical forms characterised by the site of application
  • A61K9/0053—Mouth and digestive tract, i.e. intraoral and peroral administration
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/48—Preparations in capsules, e.g. of gelatin, of chocolate
  • A61K9/50—Microcapsules having a gas, liquid or semi-solid filling; Solid microparticles or pellets surrounded by a distinct coating layer, e.g. coated microspheres, coated drug crystals
  • A61K9/5005—Wall or coating material
  • A61K9/5015—Organic compounds, e.g. fats, sugars
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/48—Preparations in capsules, e.g. of gelatin, of chocolate
  • A61K9/50—Microcapsules having a gas, liquid or semi-solid filling; Solid microparticles or pellets surrounded by a distinct coating layer, e.g. coated microspheres, coated drug crystals
  • A61K9/5005—Wall or coating material
  • A61K9/5021—Organic macromolecular compounds
  • A61K9/5036—Polysaccharides, e.g. gums, alginate; Cyclodextrin
  • A61K9/5042—Cellulose; Cellulose derivatives, e.g. phthalate or acetate succinate esters of hydroxypropyl methylcellulose
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/48—Preparations in capsules, e.g. of gelatin, of chocolate
  • A61K9/50—Microcapsules having a gas, liquid or semi-solid filling; Solid microparticles or pellets surrounded by a distinct coating layer, e.g. coated microspheres, coated drug crystals
  • A61K9/5005—Wall or coating material
  • A61K9/5021—Organic macromolecular compounds
  • A61K9/5036—Polysaccharides, e.g. gums, alginate; Cyclodextrin
  • A61K9/5042—Cellulose; Cellulose derivatives, e.g. phthalate or acetate succinate esters of hydroxypropyl methylcellulose
  • A61K9/5047—Cellulose ethers containing no ester groups, e.g. hydroxypropyl methylcellulose
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/48—Preparations in capsules, e.g. of gelatin, of chocolate
  • A61K9/50—Microcapsules having a gas, liquid or semi-solid filling; Solid microparticles or pellets surrounded by a distinct coating layer, e.g. coated microspheres, coated drug crystals
  • A61K9/5073—Microcapsules having a gas, liquid or semi-solid filling; Solid microparticles or pellets surrounded by a distinct coating layer, e.g. coated microspheres, coated drug crystals having two or more different coatings optionally including drug-containing subcoatings
  • A61K9/5078—Microcapsules having a gas, liquid or semi-solid filling; Solid microparticles or pellets surrounded by a distinct coating layer, e.g. coated microspheres, coated drug crystals having two or more different coatings optionally including drug-containing subcoatings with drug-free core
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P5/00—Drugs for disorders of the endocrine system
  • A61P5/06—Drugs for disorders of the endocrine system of the anterior pituitary hormones, e.g. TSH, ACTH, FSH, LH, PRL, GH
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P5/00—Drugs for disorders of the endocrine system
  • A61P5/38—Drugs for disorders of the endocrine system of the suprarenal hormones
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P5/00—Drugs for disorders of the endocrine system
  • A61P5/38—Drugs for disorders of the endocrine system of the suprarenal hormones
  • A61P5/44—Glucocorticosteroids; Drugs increasing or potentiating the activity of glucocorticosteroids

Definitions

• the invention relates to pharmaceutical compositions comprising hydrocortisone and their use in the treatment of adrenal insufficiency in a paediatric or elderly subject.
• Adrenal failure occurs in approximately 1/10,000 of the adult population and 1/16,000 of infants. It may be due to either primary adrenal failure (e.g. Addison's disease commonly occurring following autoimmune damage to the adrenal gland) or tuberculosis; or secondary adrenal failure which occurs due to pituitary failure which may be caused by a pituitary tumour or surgery. In primary adrenal failure, ACTH levels from the pituitary will be high and in secondary adrenal failure ACTH levels are inappropriately low. Tertiary adrenal failure is another common cause of adrenal failure and leads to suppression of the normal pituitary-adrenal axis by steroid therapy such as that used in chemotherapy, rheumatoid arthritis and asthma.
• primary adrenal failure e.g. Addison's disease commonly occurring following autoimmune damage to the adrenal gland
• tuberculosis e.g. Addison's disease commonly occurring following autoimmune damage to the adrenal gland
• secondary adrenal failure which occurs due to pituitary failure which may be caused by a pituit
• GABA glucocorticoid-remediable aldosteronism
• the treatment of children suffering adrenal insufficiency is problematic for a number of reasons and treatment regimens used to treat adult subjects suffering adrenal failure are not equivalent when applied to non-adults [e.g. neonates, infants, small child, and pre-pubescent child].
• the treatment of paediatric adrenal insufficiency has particular problems and requires pharmaceutical formulations that address the pharmacokinetic and pharmacodynamic problems of dosing infants. Hepatic microsomal enzyme processes are not fully developed in infants who may require alternative dosage and administration regimens of one, two or more doses of drug. In drugs that are cleared by the liver there is a gradual increase in drug clearance rate throughout childhood to the fully mature adult which once again requires careful monitoring of dose and dosage regimen.
• hydrocortisone cannot adequately replace Cortisol deficiency especially in the paediatric population because the formulations used do not allow the flexibility of (low) dose hydrocortisone to reproduce physiological levels of Cortisol.
• a common dose of hydrocortisone prescribed in the United Kingdom is 7.5mg per day divided into three equal doses (i.e. 3 x 2.5mg per day).
• the smallest hydrocortisone tablet currently available in the United Kingdom and most of Europe is 10mg hydrocortisone (5mg hydrocortisone - Cortef ® in the US).
• crushed hydrocortisone tablets can give rise to dosing inconsistency as the poor solubility of the drug requires the use of suspension delivery methods which can lead to dose in homogeneity.
• Individual case reports have shown poor control of congenital adrenal hyperplasia with either excessive Cortisol levels or low Cortisol levels in association with poor androgen control after oral administration of crushed tablets.
• infants and children do not like the taste of hydrocortisone making administration difficult and compliance unreliable.
• Studies investigating the bioavailability/pharmacokinetics on the stability of these tablets, when divided have shown suboptimal treatment questioning the efficacy and ethics of such practice, particularly in the most vulnerable patients of all, neonates and infants.
• hydrocortisone formulations that are substantially immediate release, are palatable and useful in the treatment of adrenal insufficiency in paediatric patients.
• the present disclosure relates to a further formulation not disclosed in WO2013/072707 and which has an improved properties.
• regimens that show improved disease control in paediatric or elderly subjects, improved compliance and reduced side effect profile.
• a pharmaceutical composition adapted for oral administration comprising: a micro- particulate carrier comprising an effective amount of hydrocortisone and a binding agent and contacting said micro- particulate carrier a sealing polymer layer wherein the sealing polymer layer separates the microparticulate carrier and a taste masking polymer layer.
• a paediatric subject includes neonates (0-28 days old), infants (1 - 24 months old), young children (2 - 6 years old) and prepubescent [7-14 years old].
• An elderly subject includes those over about the age of 60 years old.
• an effective amount of hydrocortisone is between about 0.25mg w/w and 30mg w/w hydrocortisone per unit dose.
• said effective amount is about 0.25mg w/w, 0.5mg w/w, 1.0mg w/w, 2.0mg w/w, 5.0mg w/w, 10mg w/w, 20mg w/w or 30mg w/w/ per unit dose.
• said carrier comprises microcrystalline cellulose particles wherein the diameter of said particles is between 350-500 ⁇
• the diameter of said particles is selected from the group consisting of: 350 ⁇ , 375 ⁇ , 400 ⁇ , 425 ⁇ , 450 ⁇ , 475 ⁇ or 500 ⁇ .
• the binding agent is between 0.60-0.70% w/w of the composition, preferably about 0.67% w/w.
• the binding agent is hydroxypropylmethylcellulose.
• the sealing layer comprises hydroxyproplymethylcellulose.
• the sealing layer is 15-25% w/w of the composition.
• said sealing layer is: 15% w/w, 16% w/w, 17% w/w, 18% w/w, 19% w/w, 20% w/w, 21 % w/w, 22% w/w, 23% w/w, 24%w/w or 25% w/w of the composition.
• the sealing layer is about 20% w/w of the composition.
• said sealing layer comprises or consists essentially of about 18% w/w hydroxyproplymethylcellulose and about 2% magnesium stearate.
• Taste masking or flavour enhancement of medication is known in the art and typically involves the use of molecules/polymers to mask the taste of the active or by disguising the taste by adding the medication to a flavoured food or drink.
• taste masking molecules can be selected from the Handbook of Excipients [2010] which are compatible with use in the paediatric population and represents common general knowledge.
• masking the taste of the active could include the use of flavoured drinks or food, for example, combining the formulation with sugar favoured drink, e.g. fruit juice, flavoured water or cordial, semi-solid foods such as sauces, e.g. apple sauce, vegetable extracts e.g. Marmite ® , dairy products such as yogurts, creme fraiche, cream.
• composition When administered to neonates, infants and young children the composition is administered by opening up the capsule and adding the composition directly into an aqueous or semi-aqueous vehicle as a suspension.
• the composition and vehicle combination can be administered by metered spoon (disposable / re-useable), via pre-filled spoon, via syringe, via dropper, via straw, or via dose-specific method.
• the taste masking polymer layer is a combination of hydroxyproplymethylcellulose and ethylcellulose.
• the taste masking polymer layer is provided between 0.5%-1.5% w/w of the composition.
• the taste masking polymer layer is provided at about 1 % w/w of the composition.
• hydroxyproplymethylcellulose is provided at about 0.2% w/w and ethylcellulose is provided at about 0.8% w/w of the composition.
• the ratio of ethylcellulose to hydroxyproplymethylcellulose is 4: 1 in the taste masking layer.
• a carrier consisting essentially of at least 80-81 %w/w micro- particulates wherein said micro- particulates are 350-500 ⁇ in diameter;
• a drug layer consisting essentially of at least 0.64-0.66%w/w hydrocortisone and at least 0.64-0.66% w/w hydroxyproplymethylcellulose contacting the carrier;
• a sealing layer consisting essentially of at least 14-16%w/w hydroxyproplymethylcellulose and at least 1.0-2.0% w/w magnesium stearate contacting said drug layer;
• a taste masking layer consisting essentially of at least 0.14-0.16%w/w hydroxyproplymethylcellulose, at least 0.58-0.62%w/w ethylcellulose and at least 0.20- 0.25% w/w magnesium stearate contacting said sealing layer.
• said composition comprises: i) a carrier consisting of 81 %w/w micro- particulates;
• a drug layer consisting of 0.66% w/w hydrocortisone and at 0.66% w/w hydroxyproplymethylcellulose contacting the carrier;
• a sealing layer consisting of 15%w/w hydroxyproplymethylcellulose and 1.5% magnesium stearate contacting said drug layer;
• composition is adapted for substantially immediate release of hydrocortisone.
• hydrocortisone is not substantially released before about 5 minutes in aqueous conditions in the mouth.
• hydrocortisone is released after swallowing.
• composition according to the invention for use in the treatment of adrenal insufficiency.
• the adrenal insufficiency is caused by a condition selected from the group consisting of: primary or secondary or tertiary adrenal failure, congenital adrenal hyperplasia, late-onset congenital adrenal hyperplasia, polycystic ovarian failure, Glucocorticoid-remediable aldosteronism (GRA).
• GAA Glucocorticoid-remediable aldosteronism
• adrenal insufficiency is caused by congenital adrenal dysfunction.
• compositions suitable for oral administration may be presented as discrete units, such as capsules, tablets, mini-tablets, lozenges, each containing a predetermined amount of the active.
• said composition is a tablet or capsule; preferably a capsule.
• compositions include suspensions in aqueous liquids or non-aqueous liquids.
• Liquid dosage forms for oral administration include pharmaceutically acceptable emulsions, solutions, suspensions, syrups and elixirs.
• the liquid dosage forms may contain inert diluents commonly used in the art such as water or other solvents, solubilizing agents and emulsifiers such as ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1 ,3-butylene glycol, glycerol, tetrahydrofurfuryl alcohol, polyethylene glycols and fatty acid esters of sorbitan and mixtures thereof.
• the oral compositions may also include adjuvants such as wetting agents, emulsifying and suspending agents, sweetening, flavoring and perfuming agents.
• Suspensions in addition to the active compounds, may contain suspending agents such as ethoxylated isostearyl alcohols, polyoxyethylene sorbitol and sorbitan esters, microcrystalline cellulose, aluminum metahydroxide, bentonite, agar-agar, and tragacanth and mixtures thereof.
• hydrocortisone preparation When administered the hydrocortisone preparation is administered in pharmaceutically acceptable preparations.
• Such preparations may routinely contain pharmaceutically acceptable concentrations of salt, buffering agents, preservatives and compatible carriers.
• the hydrocortisone preparation used contains an effective amount of drug for producing the desired response in a unit of weight or volume suitable for administration to a patient.
• hydrocortisone administered to a subject can be chosen in accordance with different parameters, in particular the state of the subject, their body surface area, and also their weight. Other factors include the desired period of treatment. In the event that a response in a subject is insufficient at the initial doses applied, higher doses (or effectively higher doses by a different, more localized delivery route) may be employed to the extent that patient tolerance permits.
• Administration of hydrocortisone preparations to mammals other than humans, (e.g. for testing purposes or veterinary therapeutic purposes), is carried out under substantially the same conditions as described above although dosages will vary in accordance with the size of the animal treated. Steroid treatment is used in animals both for any cause of adrenal insufficiency but in addition for any cause of inflammation, joint disease, and cancer.
• a subject, as used herein, is a mammal, preferably a human, and including a non-human primate, cow, horse, pig, sheep, goat, dog, cat or rodent.
• the hydrocortisone preparation When administered, the hydrocortisone preparation is administered in pharmaceutically- acceptable amounts and in pharmaceutically-acceptable compositions.
• pharmaceutically acceptable means a non-toxic material that does not interfere with the effectiveness of the biological activity of the active ingredients. Such preparations may routinely contain salts, buffering agents, preservatives, compatible carriers, and optionally other therapeutic agents.
• the salts When used in medicine, the salts should be pharmaceutically acceptable, but non-pharmaceutically acceptable salts may conveniently be used to prepare pharmaceutically-acceptable salts thereof and are not excluded from the scope of the invention.
• Such pharmacologically and pharmaceutically- acceptable salts include, but are not limited to, those prepared from the following acids: hydrochloric, hydrobromic, sulfuric, nitric, phosphoric, maleic, acetic, salicylic, citric, formic, malonic, succinic, and the like.
• pharmaceutically-acceptable salts can be prepared as alkaline metal or alkaline earth salts, such as sodium, potassium or calcium salts.
• Hydrocortisone preparations may be combined, if desired, with a pharmaceutically- acceptable carrier.
• pharmaceutically-acceptable carrier means one or more compatible solid or liquid fillers, diluents or encapsulating substances which are suitable for administration into a human and are typically inert.
• carrier denotes an organic or inorganic ingredient, natural or synthetic, with which the active ingredient is combined to facilitate the application.
• the components of the pharmaceutical compositions also are capable of being co-mingled with hydrocortisone, and with each other, in a manner such that there is no interaction which would substantially impair the desired pharmaceutical efficacy.
• the multiparticulate core matrix is combined with pharmaceutically acceptable excipients, which may include: (a) fillers such as lactose, manitose, dicalcium phosphate, microcrystalline cellulose, starch, pre-gelatanised starch, (b) binders such as hydroxypropylmethyl cellulose, polyvinyl pyrrolidone, polyvinyl acetate, (c) powder flow enhancers such colloidal silicon dioxide (d) lubricants such as magnesium stearate, sodium stearyl fumarate (e) disintegrants such as sodium starch glycollate and polyvinyl pyrrolidone and (f) anti-sticking agents such as talc (g) taste masking agents such as sucrose, cellulose acetate, cellulose butyrate, polyvinyl acetate, polyvinyl alcohol, polymetharylates.
• excipients may include: (a) fillers such as lactose, manitose, dicalcium phosphate,
• a treatment regimen for the control of adrenal insufficiency in a paediatric subject comprising: administering an effective amount of a composition according to the invention to a subject in need of treatment for adrenal insufficiency at least once a day.
• composition is administered three to four times a day at approximately six hour intervals.
• Binding agent is a substance used to cause adhesion of powder particles in tablet granulations such as: Alginic acid, carboxymethylcellulose, sodium compressible sugar, ethylcellulose gelatin, liquid glucose, metylcellulose, povidone, pregelatinized starch.
• Micro-particulate carrier is defined as a particulate dispersions or solid particles with a size in the range of 1-1000 ⁇ on which the desired drug is dissolved, entrapped, encapsulated or attached to a microparticle matrix.
• “Sealing polymer coat” provides a moisture barrier and a hard tablet surface to prevent attritional effects. Coating materials include sugar, waxes, shellac, cellulose derivatives, gelatin, organic acids, aminoalkyl aryl polymers or polyvinylstyrene compounds.
• immediate release a dosage form that is intended to release the active ingredient(s) on administration or after a short delay with no enhanced, delayed or extended release effect.
• Figure 1 illustrates the dose proportionality of hydrocortisone administered to dexamethasone suppressed adult subjects
• Dissolution testing of Hydrocortisone Immediate Release multi-particulates was conducted using USP Apparatus II (Paddles), with a total of 900 mL of dissolution media, involving two subsequent sequential media changes, and a paddle speed of 75 rpm. Dissolution was conducted initially in 700 mL of simulated gastric fluid (USP, pH 1.2) for 2 hours
• the concentration of hydrocortisone in the multi-particulates and released during the dissolution evaluation was determined using the following method.
• the hydrocortisone solution was diluted in the mobile phase solution comprising tetrahydrofu ran/water (20:80 v/v).
• the resulting solution was into a HPLC, set-up with a Phenomenex Luna column C18(2), 5 ⁇ , 150 mm x 4.6 mm, equilibrated at 45°C.
• the samples were run using Isocratic conditions employing tetrahydrofuran/water (20:80 v/v) as the mobile phase at a flow rate of 1.5 mL/minute. Detection is by UV at a wavelength of 254 nm.
• hydrocortisone is usually administered in a dose of 12 to 18 mg/m2 body surface area per day.
• infants may require up to 25 mg/m2/day of hydrocortisone to reduce markedly elevated adrenal hormones.
• This dose range exceeds the daily Cortisol secretory rate of normal infants and children, which is estimated to be 7 to 9 mg/m2 body surface area in neonates and 6 to 7 mg/m2 body surface area in children and adolescents.
• the treatment is usually split into three or four doses. In a premature infant you might use 0.25mg four times daily given six hourly. In a normal sized neonate you would be looking at 0.5mg to 1.0mg thrice or four times daily (6 hourly).
• dosing would be between 1.0 to 2.0 mg three times daily with the first dose given on waking the second at midday and the third in the evening; a larger dose usually being given in the morning. The same is true for adolescents but the total daily dose would be increased according to body surface area to between 5 to 20mg. In the dosing regimen would be best given thrice daily as illustrated in table 1.
• Dexamethasone reduces ACTH release from the pituitary gland therefore leading to suppressed Cortisol output from the adrenals.
• ACTH samples were collected prior to IMP dosing to confirm ACTH output had been suppressed. Since the administration of dexamethasone took place over a single 14 hr period in each of 5 treatment periods (separated by at least 7 days), it was considered that this non-continuous regimen would not lead to a risk of adrenal suppression and the total dose of dexamethasone was less than that used in clinical practice in tests of Cortisol secretion.
• a washout period of a minimum of 7 days was considered adequate based on the half- life (ti 2 ) of hydrocortisone being -100 minutes. This washout period was also considered sufficient to allow hormone levels to return to normal.
• Each investigational medicinal product (IMP) was administered to each subject in a randomised crossover manner. Each subject received their scheduled IMP on the morning of Day 2 at ⁇ 07.00 hrs (fasted). Treatments were administered as displayed in Table 4.
• hydrocortisone immediate release capsules were opened, the entire contents (multiparticulate granules) emptied onto a dosing spoon, administered to the back of the subject's tongue and swallowed with 200 ml_ water (100 ml_ to swallow the treatment and 100 ml_ rinse).
• the hydrocortisone tablets were swallowed whole with 200 ml_ water.
• Each subject also received 1 mg dexamethasone (to suppress endogenous Cortisol production) at approximately 22.00 hrs on Day 1 , and at approximately 06.00 hrs and 12.00 hrs on Day 2. All doses were administered with 200 ml_ water. Selection of Doses in the Study
• Hydrocortisone immediate release is a newly-developed formulation of immediate release hydrocortisone for use in the paediatric population.
• the formulation chosen is a dry hydrocortisone multi-particulate formulation stored in capsules where the capsule contents (the multi-particulates) may be administered either directly into the patient's mouth or placed on a (dry) spoon and then administered into the patient's mouth.
• Multi-particulates offer flexible dosing in 0.5 mg, 1 mg, 2 mg and 5 mg strengths.
• Multi-particulates will be presented as different-coloured capsules for different doses, thus minimizing the risk of dosing errors.
• Multi-particulates will have a water soluble layer allowing taste masking and rapid dissolution once ingested.
• dosing units are envisaged: 0.5 mg, 1 mg, 2 mg and 5 mg. This range has been chosen as being suitable to cover the dosing needs of children from birth to ⁇ 6 years, hydrocortisone immediate release was studied in healthy adult subjects, to enable the relative bioavailability and key PK parameters of the new formulation to be assessed, prior to evaluation in the paediatric population.
• hydrocortisone immediate release was used to compare the PK of this new formulation with that of the marketed immediate-release 10 mg hydrocortisone tablet.
• Hydrocortisone at a dose of 10 mg is a standard dose used in the clinical setting.
• Dexamethasone at a dose of 1 mg is the lower end of the standard dosage used in the clinical setting. Timing of Dose for Each Subject
• Doses of IMP were administered at approximately 07:00 hrs on Day 2 during each treatment period (taking dosing intervals between subjects into account).
• Dexamethasone 1 mg was administered orally at ⁇ 22:00 hrs on Day 1 and at ⁇ 06:00 hrs and ⁇ 12:00 hrs on Day 2
• PK blood sampling was performed during the study were collected on Day 2 pre-dose (-1 hr and - 0.5 hr) and 0 hr (07.00 hrs), 0.5, 1 , 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, 7.5, 8, 9, 10, 1 1 and 12 hr post-dose.
• Blood samples (2.7 ml_) for determination of serum Cortisol levels were collected from a forearm vein into plain blood collection tubes at each time point, and kept frozen at approximately -20°C pending analysis. Samples were analysed using a validated method, the specificity of which was checked against co-administered dexamethasone.
• PK End-points were determined: Maximum plasma concentration (Cmax); time at which Cmax occurs (tmax); area under the concentration-time curve (AUC) to the time of last observed concentration (AUCO-t) and extrapolated to infinity (AUCO-inf). Plasma ACTH
• Blood samples (2.7 ml_) for determination of plasma ACTH levels were collected from a forearm vein into iced Sarstedt K3 ethylene-diamine-tetraacetic acid (EDTA) Monovette® at each time point and kept frozen at -20°C until analysis. Blood samples were analysed within 30 days of the sample being taken, using a validated method. Blood samples for measurement of ACTH levels were collected on Day 2 at 0 hr ( -07.00 hrs).
• EDTA ethylene-diamine-tetraacetic acid
• hydrocortisone immediate release is bioequivalent with Hydrocortisone equivalent doses of 10 mg were given to subjects as described in Materials and Methods. As shown in Table 5, 10 mg hydrocortisone immediate release was considered bioequivalent to the reference hydrocortisone formulation.
• Dose proportionality of hydrocortisone immediate release was tested by administering different concentrations of hydrocortisone immediate release and determining PK values and ACTH serum levels. As shown in Table 6 and illustrated graphically in Figure 1 , when the four doses of hydrocortisone immediate release were tested for dose- proportionality, over the 0.5 mg - 10 mg dose range C max , AUC 0 .t and AUC 0 -inf were shown to increase in a linear fashion (Table 1 , Figure 1). Similarly, ACTH serum levels decrease over time on a linear scale.
• hydrocortisone immediate release micro-particulate granules were safe, well tolerated and of neutral taste when administered to human volunteers.

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