WO2017083800A1

WO2017083800A1 - Occult cnv size as a predictor for treatment with squalamine

Info

Publication number: WO2017083800A1
Application number: PCT/US2016/061741
Authority: WO
Inventors: Jason S. SLAKTER; Samuel I. Backenroth; Glenn L. Stoller
Original assignee: Ohr Pharmaceutical, Inc.
Priority date: 2015-11-13
Filing date: 2016-11-14
Publication date: 2017-05-18
Also published as: TW201720446A; AR106690A1

Abstract

The invention relates to the discovery of occult CNV size as a predictor for the level of success to be achieved in treating eye conditions by administration of ophthalmic formulations of squalamine dilactate alone or in combination with therapeutic agents. The invention also relates to a method of preventing or delaying the development of an ophthalmic condition in at risk patients by administration of ophthalmic formulations of squalamine dilactate.

Description

Occult CNV Size as a Predictor for Treatment with Squalamine

CROSS REFERENCE TO RELATED APPLICATIONS

[0001] This application is technically related to U.S. Published Patent Application No. 20130281420 and U.S. Patent Nos. 5,192,756; 6,962,909; 7,981,876; and 8,716,270, each of which is incorporated by reference in its entirety.

FIELD OF THE INVENTION

[0002] The invention relates to the discovery of occult CNV size as a predictor for the level of success to be achieved in treating eye conditions by administration of ophthalmic formulations of squalamine dilactate alone or in combination with therapeutic agents, such as anti-angigenic agents. The invention also relates to a method of delaying or preventing the development of ophthalmic conditions in at risk patients by administration of ophthalmic formulations of squalamine dilactate.

BACKGROUND OF THE INVENTION

[0003] Age-related macular degeneration (AMD) is the leading cause of irreversible central vision loss among people in the United States aged 52 or older and is the most common overall cause of blindness in the United States, Canada, Great Britain and Australia. AMD encompasses several types of abnormalities that develop in the macula of affected individuals. Two forms of macular degeneration exist: dry (also known as atrophic) and wet (also known as disciform, exudative, subretinal neovascular or choroidal neovascular). The dry form, which may be a precursor to the wet form, results from an inability of the pigment epithelium of the macula to remove waste materials generated by the retina. The wet form occurs when new blood vessels grow under the retina, particularly the macula.

[0004] Multiple genetic variants, as well as environmental and lifestyle factors, contribute to the risk of AMD, each adding a small to moderate amount of increased risk (Seddon, J.M., et ai, "Epidemiology of age-related macular degeneration", Albert & Jakobiec's Principles and Practice of Ophthalmology, Philadelphia:WB Saunders; 413-422 (2007)). The risk of developing the disease is three-fold higher in people who have a family member with AMD than in those without a first-degree relative with AMD (Seddon, J.M., et al, "Familial aggregation of age-related maculopathy", Am. J. Ophthalmol. 123(2): 199-206 (1997)).

[0005] Since 2005, several genetic variants have been consistently associated with AMD. The common coding variant Y402H in the complement factor H (CFH) gene was the first identified. The odds ratio associated with being homozygous for the risk variant for all categories of AMD is estimated to be between 2.45 and 3.33; the odds ratios are higher, between 3.5 and 7.4, for advanced dry and wet forms of AMD (Edwards, A.O., et al, "Complement factor H polymorphism and age-related macular degeneration", Science 308(5720): 421-4 (2005); Klein, R.J., et al, "Complement factor H polymorphism in age-related macular degeneration", Science 308(5720): 385-9 (2005); Haines, J.L., et al, "Complement factor H variant increases the risk of age-related macular degeneration", Science 308(5720): 419-21 (2005); Hageman, G.S., et al, "A common haplotype in the complement regulatory gene factor H (HF1/CFH) predisposes individuals to age-related macular degeneration", Proc. Natl. Acad. Sci. USA 102(20): 7227-32 (2005); Jorgenson, E., et al, "B4-4: Genome-Wide Association Study of Macular Degeneration: Early Results from the Kaiser

Permanente Research Program on Genes, Environment, and Health (RPGEH)", Clin. Med. Res. 11(3): 146-7 (2013)).

[0006] Several other genetic loci in the alternative complement cascade have also been consistently shown to affect AMD risk. These include other variants in CFH (Mailer, J., et al, "Common variation in three genes, including a noncoding variant in CFH, strongly influences risk of age-related macular degeneration", Nat. Genet. 38(9): 1055-9 (2006)) as well as other genes: factor B (BF)/complement component 2 (C2) (Mailer, J., et al, "Common variation in three genes, including a noncoding variant in CFH, strongly influences risk of age-related macular degeneration", Nat. Genet. 38(9): 1055-9 (2006); Gold, B., et al, "Variation in factor B (BF) and complement component 2 (C2) genes is associated with age-related macular degeneration", Nat. Genet. 38(4): 458-62 (2006)) complement component 3 (C3) (Mailer, J.B., et al, "Variation in complement factor 3 is associated with risk of age- related macular degeneration", Nat. Genet. 39(10): 1200-1(2007); Yates, J.R, et al, "Complement C3 variant and the risk of age-related macular degeneration", N. Engl. J. Med. 357(6): 553-61 (2007)) and complement factor I (CFI) (Fagerness, J.A., et al, "Variation near complement factor I is associated with risk of advanced AMD", Eur. J. Hum. Genet. 17(1): 100-4 (2009); Seddon, J.M., et al., "Rare variants in CFI, C3 and C9 are associated with high risk of advanced age-related macular degeneration", Nat. Genet. 45(11): 1366-70 (2013); Helgason, H., et al., "A rare nonsynonymous sequence variant in C3 is associated with high risk of age-related macular

degeneration", Nat. Genet. 45(11): 1371-4 (2013); Zhan, X., et al, "Identification of a rare coding variant in complement 3 associated with age-related macular

degeneration", Nat. Genet. 45(11): 1375-9 (2013)).

[0007] Several genes not involved in the complement cascade have also been implicated. Variation in the HTRA1/ARMS2 locus on chromosome 10 has been convincingly associated with AMD, with an effect size similar to or greater than that seen with CFH (Jakobsdottir, J., et al., "Susceptibility genes for age-related maculopathy on chromosome 10q26", Am. J. Hum. Genet. 77(3): 389-407 (2005); Dewan, A, et al, "HTRA1 promoter polymorphism in wet age-related macular degeneration", Science 314(5801): 989-92 (2006); Yang, Z., et al, "A variant of the HTRA1 gene increases susceptibility to age-related macular degeneration", Science 314(5801): 992-3 (2006)). The function of this gene is not completely understood, but there is evidence that it confers greater risk for wet AMD than for geographic atrophy (Sobrin, L., et al , "ARMS2/HTRA1 locus can confer differential susceptibility to the advanced subtypes of age-related macular degeneration", Am. J. Ophthalmol. (2010)).

[0008] Recently, hepatic lipase C (LIPC) and tissue inhibitor of metalloproteinase 3 (TIMP3) were reported to be associated with AMD in large genome-wide association studies (Neale, B.M., et al, "Genome-wide association study of advanced age-related macular degeneration identifies a role of the hepatic lipase gene (LIPC)", Proc. Natl. Acad. Sci. USA. 107(16): 7395-400 (2010); Chen, W., et al, "Genetic variants near TIMP3 and high-density lipoprotein-associated loci influence susceptibility to age- related macular degeneration", Proc. Natl. Acad. Sci. USA. 107(16): 7401-6 (2010)). LIPC, a novel AMD gene, is involved in high-density lipoprotein cholesterol (HDL) metabolism (Neale, B.M., et al, "Genome-wide association study of advanced age- related macular degeneration identifies a role of the hepatic lipase gene (LIPC)", Proc. Natl. Acad. Sci. USA. 107(16): 7395-400 (2010); Reynolds, R, et al, "Serum lipid biomarkers and hepatic lipase gene associations with age-related macular degeneration", Ophthalmology 117(10): 1989-95 (2010)) and TIMP3 is implicated in a Mendelian, early-onset form of macular degeneration known as Sorsby's fundus dystrophy (Weber, B.H., et al, "Mutations in the tissue inhibitor of

metalloproteinases-3 (TIMP3) in patients with Sorsby's fundus dystrophy", Nat. Genet. 8(4):352-6 (1994)).

[0009] The relationship among environmental risk factors, these genetic variants, and AMD has also been explored. In one study, the susceptibility to advanced AMD associated with CFH Y402H was modified by body mass index (BMI), and both BMI and smoking increased the risk of advanced AMD within the same genotype (Seddon, J.M., et al, "CFH gene variant, Y402H, and smoking, body mass index,

environmental associations with advanced age-related macular degeneration", Hum. Hered. 61(3): 157-65 (2006)). However, statistical interactions between smoking and either the CFH Y402H or HTRA1/ARMS2 genotypes have not been observed (Seddon, J.M., et al, "CFH gene variant, Y402H, and smoking, body mass index, environmental associations with advanced age-related macular degeneration", Hum. Hered. 61(3): 157-65 (2006); Francis, P.J., et al, "The LOC387715 gene, smoking, body mass index, environmental associations with advanced age-related macular degeneration", Hum. Hered. 63(3-4): 212-8 (2007)).

[0010] Patients at risk of developing an ophthalmic condition that may result in neovascular complications, such as those associated with AMD, display changes in the eye that indicate the degree of pathology in the affected tissues include the number, type, and extent of drusen along with the presence or absence of pigmentary changes. Studies have shown that classifying eyes based on these features can provide a risk profile for development of advanced AMD, including neovascular disease (Ophthalmology 112(4): 533-539 (2005); and Arch Ophthalmol. 123(11): 1570-1574 (2005)). Given that the risk factors are systemic in nature in each individual, the greatest risk for development of neovascularization in an eye is the presence of CNV in the fellow eye (Ophthalmology 120(10): 2035-2041 (2013); Ophthalmologica 226(3): 110-8 (2011); and Arch Ophthalmol. 115(6): 741-747 (1997)).

[0011] Many diseases affecting parts of the body other than the eye have a direct or indirect impact on the eye. Known systemic diseases with ocular manifestations include, but are not limited to, skin and mucous membrane diseases, acne rosacea, albinism, atopic dermatitis, Behcet's disease, cicatricial pemphigoid, Ehlers-Danlos syndrome, epidermolysis bullosa, erythema multiforme, Goltz-Gorlin syndrome, ichthyosis, incontinentia pigmenti, Nevus of Ota, pemphigus, pseudoxanthoma elasticum, psoriasis, Stevens-Johnson syndrome (erythema multiforme major), Vogt- Koyanagi-Harada syndrome, xeroderma pigmentosum, phacomatoses, angiomatosis retinae (Von Hippel-Lindau disease) (retinocerebellar capillary hemangiomatosis), ataxia telangiectasia (Louis-Bar syndrome), encephalotrigeminal angiomatosis (Sturge-Weber syndrome) (encephalofacial cavernous hemangiomatosis), neurofibromatosis (von Recklinghausen's disease), tuberous sclerosis (Bourneville's syndrome), Wyburn-Mason syndrome (racemose hemangiomatosis), collagen diseases, ankylosing spondylitis, dermatomyositis, periarteritis nodosa, reactive arthritis, rheumatoid arthritis, sarcoidosis, scleroderma, systemic lupus erythematosus, temporal arteritis, relapsing polychondritis, granulomatosis with polyangiitis, systemic viral infections, varicella (chickenpox), rubeola (measles), rubella (German measles), variola (smallpox), vaccinia, herpes simplex, herpes zoster, mumps, infectious mononucleosis, influenza, cytomegalic inclusion disease,

pharyngoconjunctival fever (adenovirus 3), epidemic keratoconjunctivitis (adenovirus 8), human immunodeficiency virus (acquired immunodeficiency syndrome), systemic bacterial infections, gonorrhea (ophthalmia neonatorum), brucellosis, diphtheria, Lyme disease, septicemia bacterial metastatic endophthalmitis, tularemia, leprosy (Hansen's disease), tuberculosis, syphilis, systemic protozoal infections,

lymphogranuloma venereum (chlamydial), inclusion conjunctivitis (chlamydial), malaria, toxoplasmosis, systemic fungal infections, Candida albicans, histoplasmosis, coccidioidomycosis, cryptococcus, metastatic fungal endophthalmitis, actinomyces, streptothrix, systemic cestode and nematode infections, cysticercosis (tapeworm), echinococcosis (hydatid cyst), toxocariasis (toxocara), trichinosis (trichinella), onchocerciasis, Loiasis (loa loa), chromosomal disorders and genetic syndromes, Cri- du chat syndrome, Schmid-Fraccaro syndrome, Turner's syndrome, ring-D chromosome, monosomy-G syndrome, trisomy 13 (Patau's syndrome, D-syndrome), trisomy 18 (Edwards' syndrome, E-syndrome), trisomy 21 (Down's syndrome), deletion of long arm of chromosome 18, ciliopathic genetic syndromes, hematologic diseases, anemia, cardiovascular diseases, arteriosclerosis, hypertension, preeclampsia (toxemia of pregnancy), occlusive vascular disease (sudden), emboli and thrombi, central retinal artery occlusion, cardiac myxoma, cranial arteritis, sickle cell attack, occlusive vascular disease (slow, progressive), carotid artery disease, arterial spasm (TIA), diabetes mellitus, venous occlusive disease, thrombosis, endocarditis, myxoma, aortic arch syndrome (takayasu), pre-eclampsia (toxemia of pregnancy), thromboangiitis obliterans, hereditary telangiectasia (Rendu-Osler-Weber syndrome), endocrine diseases, Cushing's disease, Addison's disease, hyperparathyroidism, hypoparathyroidism, hyperthyroidism, hypothyroidism, gastrointestinal and nutritional disorders, alcoholism, Crohn's disease, liver disease, malnutrition, peptic ulcer disease, pancreatic disease, regional enteritis or ulcerative colitis, vitamin A deficiency, vitamin B deficiency, vitamin C deficiency, hypervitaminosis A, B, and D, Whipple's disease, metabolic disorders, albinism, alkaptonuria, amyloidosis, Chediak-Higashi syndrome, cystinosis, Fabry's disease, galactosemia, Gaucher's disease, gout, hemochromatosis, histiocytosis, homocystinuria, lipidoses, Marian's syndrome, Weill-Marchesani syndrome, mucopolysaccharidosis, Niemann-Pick disease, osteogenesis imperfecta, Wilson's disease, musculoskeletal disease, Albright's disease (fibrous dysplasia of bone), Apert syndrome, Conradi's syndrome, craniofacial syndromes, facial deformity syndrome, muscular dystrophy disorders, myasthenia gravis, osteogenesis imperfecta, Paget's disease, pulmonary diseases, asthma, bronchogenic carcinoma, bronchiectasis, cystic fibrosis of the pancreas, emphysema, pneumonias, renal disease, Alport's syndrome, azotemia (acute and chronic pyelonephritis), Lowe's syndrome, medullary cystic disease, nephrotic syndrome (acute glomerulonephritis, diabetic kidney, system lupus erythematosus), renal transplantation, Wilms' tumor (nephroblastoma), neoplastic diseases and carcinoma and sites of primary lesions.

[0012] Exudative AMD develops when choroidal capillaries begin growing through Bruch's membrane, a phenomenon commonly referred to as choroidal

neovascularization (CNV). Neovascular (wet) AMD is categorized according to its appearance using the photographic imaging technique of fluorescence angiography into classic lesion types and occult lesion types. The more aggressive classic lesion type is generally associated with early and substantial vision loss due to direct photoreceptor damage, whereas the occult lesion type is typically in the sub-retinal pigment epithelium (sub-RPE) and associated with a lesser degree of vision loss. [0013] There are significant variations in the natural course of AMD with respect to occult and classic neovascularization, depending on the composition of the neovascular lesion. In addition, both the size and the location of the lesion in relation to the central macula are factors in determining the course of the condition. Loss of visual acuity occurs most rapidly in patients who have either classic choroidal neovascularization without occult neovascularization or predominantly classic choroidal neovascularization (i.e. , the area of classic choroidal neovascularization is > 50% of the area of the entire lesion). In contrast, the loss of visual acuity is slower in patients who have either occult choroidal neovascularization without classic neovascularization or predominantly occult choroidal neovascularization (i.e. , the area of occult choroidal neovascularization is > 50% of the area of the entire lesion).

[0014] Lesion size in a verteporfin (Visudyne®) photodynamic therapy trial was observed to be a predictor of the magnitude of treatment benefit in patients with subfoveal CNV due to age-related macular degeneration and having occult with no classic and minimally classic lesion compositions. (K.J. Blinder et al, Am. J.

Ophthalmol. 136(3): 407-18 (2003)).

[0015] Squalamine (IUPAC Name: ([6-[(3S,5R,7R, 10S, 13R,14S)-3-[3-(4- aminobutylamino)propylamino] -7-hy droxy-10, 13-dimethyl-

2,3,4,5,6,7,8,9,11,12,14,15, 16,17-tetradecahydro-lH-cyclopenta[a]phenanthrene-17- yl]-2-methylheptan-3-yl] hydrogen sulfate) is an aminosterol exhibiting anti- angiogenic properties that has been utilized as an intravenous infusion for the effective treatment of wet AMD where it functions to prevent the neovascularization and aberrant blood vessel formation in the retina that characterize the progression of the disease (Sills Jr. et al, "Squalamine Inhibits Angiogenesis and Solid Tumor Growth in Vivo Perturbs Embryonic Vasculature", Cancer Research 58: 2784-2792 (1998); Higgins et al , "Squalamine Improves Retinal Neovascularization",

Investigative Ophthalmology & Visual Science 41(6), 1507-1512 (2000);

PRNEWSWIRE, "Genaera Reports Squalamine Continues to Improve Vision at Four Months Timepoint in Age-Related Macular Degeneration",

http : //www. ev esi ghtnews . com/topic/28. html (Oct. 7, 2003)). Squalamine is the subject of U.S. Patent No. 5,192,756 to Zasloff et al , the disclosure of which is herein incorporated by reference in its entirety. The total chemical synthesis of squalamine is described in U.S. Patent Nos. 6,262,283 and 6,610,866, which are incorporated herein by reference in their entireties.

[0016] It would clearly be desirable from a patient-use and risk standpoint to have a topical formulation available for direct application to the eye as opposed to an intravenous infusion, or especially the current standard of care which requires monthly injections directly into the eye. Topical formulations in the form of, for example, solutions, suspensions, creams or ointments are easily self-administered by patients as compared to more invasive techniques, such as intravitreal injections, which require costly administration under medical supervision and which can result in serious complications such as endophthalmitis and retinal detachment. The general problem with ocular eye drops, however, is that after their administration, typically less than 5% of the drug in the eye drop penetrates the cornea and reaches intraocular tissues. Instead, a major fraction of the administered dose is eliminated due to solution drainage and systemic absorption (Jarvinen K. et al, "Ocular absorption following topical delivery", Adv. Drug Deliv. Rev. 16(1): 3-19 (1995); Conroy C.W.,

"Sulfonamides do not reach the retina in therapeutic amounts after topical application to the cornea", Ocul. Pharmacol. Ther. 13(5): 465- 472 (1997); and Maurice D.M., "Drug delivery to the posterior segment from drops", Surv. Ophthalmol. 47(suppl. 1): S41- S52 (2002)).

[0017] In addition, a previous clinical trial to test the efficacy of squalamine for the treatment of AMD by IV infusion revealed potential problems for long term use. The intravenous dosing regimen in the IV formulation was deemed to be sub-optimal based on pharmacokinetic analyses and was determined not to be commercially viable for a variety of reasons. For one, the short plasma half-life of squalamine in human subjects at a 40-mg dose resulted in concentrations in the choroid that were likely insufficient to block CNV after 4-6 days. When the dosing was spaced out to monthly "maintenance" infusions, there was potentially only up to one week of inhibition of CNV, followed by three weeks or more of active new angiogenesis. This regimen produced good gains in visual acuity after the first four to five weeks of

administration, followed by a decline in the rate of improvement after the fifth week. Intravenous dosing caused local infusion-site reactions due to the dosing being orders of magnitude higher than the dose to be administered in the topical formulation. In a "real world" situation, it would be unrealistic to expect an elderly and/or disabled patient with wet AMD to travel to a clinic on a weekly basis for a prolonged infusion session. In addition, most retinal ophthalmic practices are not set up for such intravenous infusions.

[0018] Compared to the above-indicated disadvantages associated with intravenous dosing, the present invention represents a safe ocular formulation for topical administration that achieves selected delivery of a therapeutic agent to the back of the eye for treatment of an ophthalmic disorder associated with, for example, partial or total occult CNV.

[0019] The current standard of care for wet AMD is the injection of an anti-VEGF compound such as ranibizumab (Lucentis) directly into the eye. This treatment is effective in slowing the progression of the disease, but repeated injections are typically required. Safe and effective eye drops that could be repeatedly administered topically by the patient, optionally in combination with an anti-VEGF and/or an anti- platelet-derived growth factor (anti-PDGF) compound or other therapeutic agents, such as other anti-angiogenic compounds, would provide a highly desirable and significantly improved method of treatment.

[0020] The present invention reflects the unexpected discovery of occult CNV size as a reliable predictor for the level of success to be achieved in the treatment of conditions of the eye, such as conditions associated with choroidal neovascularization, by administration of ophthalmic formulations of squalamine dilactate, optionally in combination with other therapeutic agents, such as anti-angiogenic agents, including anti-VEGF compounds and/or anti-PDGF drugs.

[0021] In addition to the treatment and/or prevention of established ophthalmic conditions, it would be highly desirable to prevent the visual loss associated with these conditions, such as neovascular AMD, by preventing the development of the choroidal neovascular complex that is the recognized hallmark of this disease. All current therapies are directed to an already established neovascular complex exhibiting associated exudative and pre-fibrotic features that limit the potential for improved vision even with maximum therapeutic intervention. Therefore, to provide optimal outcomes for visual acuity in patients with AMD, there is a need to inhibit the initial formation of the neovascular lesion.

[0022] With current therapeutics, this goal is theoretically achievable with prophylactic fixed dosing of intravitreal anti-VEGF agents in patients susceptible to high risk dry AMD. This approach, however, is impractical for several reasons including the fact that the inherent risks associated with intra- vitreal injections render this strategy potentially hazardous to large numbers of patients exhibiting otherwise good visual function. Furthermore, the delivery of care burden to both the patient and the physician make this method of treatment both unsustainable and untenable. In contrast, a patient self-administered topical anti-angiogenic eye drop would be ideally suited for this indication. This approach would provide patients with a safe and noninvasive method of delivery that can be performed in their homes and during normal daily activities.

[0023] Topical squalamine with its calmodulin-mediated multi-target growth factor inhibition is uniquely well suited to shut down early ocular angiogenesis

(Grossniklaus, H.E., et al, "Clinicopathologic correlations of surgically excised type 1 and type 2 submacular choroidal neovascular membranes", Am. J. Ophthalmol. 126: 59-69 (1998)). Phase 2 data supports the ability of squalamine to improve visual outcomes by modifying the neovascular process in patients with established CNV. Thus, squalamine would be a good candidate for use as a prophylactic therapy for inhibiting the conversion of dry AMD to the more severe neovascular form of the disease (wet AMD).

[0024] Choroidal angiogenesis is the hallmark of wet AMD and is also commonly referred to as choroidal neovascularization (CNV). It is well known that CNV lesions vary in their appearance on fluorescein angiography (FA), indocyanine green angiography (ICG), histologic sections and most recently optical coherence tomography - angiography (OCTA). CNV lesions were originally classified based on their appearance on FA, which is dependent on the location of the CNV relative to the retinal pigment epithelium (RPE). Classic CNV membranes are clearly visible on FA and tend to develop more rapidly and leak significantly, leading to fluid accumulation in the sub-retinal space (i.e. , between the RPE and the photoreceptors) and rapid changes in visual acuity. In contrast, occult CNV membranes are less visible on FA and tend to develop more slowly, with less leakage, and in the sub-RPE space (i.e., without interruption of the contact between the RPE and the photoreceptors). In addition, classic and occult lesions can exist together.

[0025] Histopathological evaluation of CNV membranes confirmed that classic CNV corresponds to fibrovascular tissue in the sub-retinal space (i.e. , a type 2 lesion), and occult CNV corresponds to fibrovascular tissue in the sub-RPE space (i.e. , a type 1 lesion) (Grossniklaus, H.E., et al, "Clinicopathologic correlations of surgically excised type 1 and type 2 submacular choroidal neovascular membranes", Am. J. Ophthalmol. 126: 59-69 (1998); Lafaut, B.A, et al, "Clinicopathological correlation in exudative age related macular degeneration: histological differentiation between classic and occult choroidal neovascularisation", Br. J. Ophthalmol. 84: 239-243 (2000)). Notably, RPE layer integrity may persist in pure occult lesions.

Retrospective analysis of FA data suggests that some CNV lesions progress from occult in the early stages of the disease to classic in later stages possibly due to loss of RPE integrity (Schneider, U., et al, "Natural course of occult choroidal

neovascularization in age-related macular degeneration: development of classic lesions in fluorescein angiography", Acta Ophthalmol. Scand. 83: 141-147 (2005); Pieramici, D.J., et al, "Occult with no classic subfoveal choroidal neovascular lesions in age-related macular degeneration: clinically relevant natural history information in larger lesions with good vision from the Verteporfin in Photodynamic Therapy (VIP) Trial: VIP Report No. 4", Arch. Ophthalmol. 124: 660-664 (2006)).

[0026] The location of the lesions relative to the RPE has also been confirmed using optical coherence tomography (OCT). Furthermore, the differing response to therapeutic intervention between classic and occult CNV therapy has also been demonstrated with multiple therapeutic modalities such as thermal laser ("Occult choroidal neovascularization. Influence on visual outcome in patients with age-related macular degeneration. Macular Photocoagulation Study Group, Arch Ophthalmol. 114(4): 400-12 (1996); Reichel, E., et al., "Transpupillary thermotherapy of occult subfoveal choroidal neovascularization in patients with age related macular degeneration", Ophthalmology 106(10): 1908-1914 (1999)) and photodynamic therapy (PDT) with Visudyne. In a treatment and prevention (TAP) study, PDT significantly reduced the rate of vision loss in patients with predominantly classic CNV (Bressler, N.M. et al, "Treatment of Age-Related Macular Degeneration with Photodynamic Therapy (TAP) Study Group). Photodynamic therapy of subfoveal choroidal neovascularization in age-related macular degeneration with verteporfin: two-year results of 2 randomized clinical trials-tap report 2", Arch. Ophthalmol. 119: 198-207 (2001)).

[0027] In contrast, vision outcomes in patients with pure occult and minimally classic lesions were poor by comparison as indicated on the Visudyne® product label (Bressler, N.M. et al, "Treatment of Age-Related Macular Degeneration with

Photodynamic Therapy (TAP) Study Group). Photodynamic therapy of subfoveal choroidal neovascularization in age-related macular degeneration with verteporfin: two-year results of 2 randomized clinical trials-tap report 2", Arch. Ophthalmol. 119: 198-207 (2001)). However, the verteporfin in photodynamic therapy (VIP) study revealed that, similar to patients with predominantly classic lesions, patients with smaller pure occult lesions (e.g., <4 disc areas [10.16 mm²]) also benefited from PDT, but patients with larger occult lesions did not (Arnold et al, 2001). The difference in response between classic and occult CNV extends to anti-VEGF therapy. Non- response correlates with the presence of occult (type 1) CNV (Otsuji, T., et al, "Initial non-responders to ranibizumab in the treatment of age-related macular degeneration (AMD)", Clin. Ophthalmol. 7: 1487-1490 (2013)) and fibrovascular pigment epithelial detachment (PED, a type of occult CNV), and sub-RPE fluid resolves more slowly than sub-retinal fluid (Freeman, W.R., et al, "Prognostic implications of pigment epithelial detachment in bevacizumab (avastin)-treated eyes with age-related macular degeneration and choroidal neovascularization", Retina 31 : 1812-1818 (2011)). This observation could reflect preservation of RPE barrier function in these lesions, which may limit drug penetration (Suzuki, M., et al , "Predictive factors for non-response to intravitreal ranibizumab treatment in age-related macular degeneration", Br. J.

Ophthalmol. 98: 1186-1191 (2014)).

[0028] Given the difference in the anatomy and histology of classic versus occult CNV and the numerous cited prior examples of their differing response to therapeutic intervention, it is not surprising that squalamine has demonstrated a difference in efficacy depending on the CNV lesion type. More specifically, the data from a phase 2 trial suggest that classic-containing and pure occult lesions respond differently to squalamine when used in combination with Lucentis® PRN treatment. Moreover, the data also suggest that the size of the occult lesion component is the determining factor in the clinical responses to a squalamine combination therapy, independent of the presence of a classic component. This response is also independent of number of Lucentis® injections. It would therefore seem likely that the effect of squalamine on occult CNV is based not only on its unique mechanism of action but also on its physiochemical properties, such as the amphipathic nature of squalamine that exhibits both hydrophobic and hydrophilic elements. This property makes squalamine extremely well suited to reach occult blood vessels which are surrounded by and invested with RPE cells. (Miller et al., "Newly-formed subretinal vessels. Fine structure and fluorescein leakage", Invest Ophthalmol. Vis. Sci. 27: 204-213 (1986); Miller et al., "The role of the retinal pigment epithelium in the involution of subretinal neovascularization", Invest. Ophthalmol. Vis. Sci. 27: 1644-1652 (1986)). The RPE cells and possibly the multiple layers of the bruch's membrane act as a physical barrier toward current biologic anti-VEGF agents that limit their efficacy. However, squalamine is able to freely penetrate this barrier because it is amphipathic and attacks the occult choroidal neovascular complex. Squalamine may also have enhanced effects on occult CNV through its anti-PDGF properties. It is known that RPE cells secrete PDGF particularly when participating in wound healing or in the presence of an underlying retinal detachment (Campochiaro et al., "Platelet-derived growth factor is an antocrine stimulator in retinal pigmented epithelial cells", J. Cell Sci. 107(9): 2459-6 (1994)). These conditions are more commonly seen in occult CNV than in classic CNV and therefore occult CNV may be in a higher PDGF milieu than classic CNV. This therapeutic effect in established neovascular tissue would provide a basis for the role of squalamine in inhibiting small neovascular lesions, particularly those located at the level of the choroid, i.e. , the initial site of new vessel growth.

[0029] Beyond these effects, in studies not previously disclosed, we observed a novel non-calmodulin-mediated mechanism of action that specifically targets the earliest events in the transition of dry AMD to wet AMD. In studies by McLean et al.

(unpublished results) confluent human umbilical vein endothelial cells (HUVECs), which serve as a model of mature endothelial cells found in established blood vessels, were compared to sub-confluent HUVECs, which serve as a model of the endothelial cells found in immature and newly sprouting blood vessels. The investigators observed a novel mechanism of squalamine cellular uptake and novel cellular morphological changes in the sub-confluent actively dividing HUVECs that were not seen in the confluent HUVECs. The sub-confluent cells exhibit squalamine located diffusely through the cells, not just in a peri-nuclear location as is traditionally seen with calmodulin mediated binding uptake. This diffuse uptake was not seen in the confluent HUVECs. Moreover, the sub confluent cells demonstrate overt cellular pathology and gross morphologic changes which do not occur in the confluent cells. This behavior represents a novel anti-angiogenic mechanism of action whereby squalamine selectively targets sparsely plated endothelial cells (Figure 1),

representing the earliest reservoirs of endothelial cells required to form the neovascular tubules that ultimately are assembled into the choroidal neovascular complex. The actively dividing immature endothelial cells are killed via oncosis due to increased permeability of the plasma and nuclear membranes. These observations represent a novel anti-angiogenic mechanism of action of squalamine against the actively dividing immature vascular endothelial cells that would ultimately result in the formation of CNV and therefore the clinical condition of neovascular AMD and other ophthalmic conditions that involve angiogenesis.

[0030] Taken together, the existing clinical data on the efficacy of squalamine in improving visual outcomes in patients with established CNV, the in vitro data on the effect of squalamine on immature endothelial cells, and the patient-preferred noninvasive topical approach to drug delivery made possible by the described squalamine dilactate ophthalmic solution provides an ideal potential therapeutic agent for the treatment of patients at increased risk of developing neovascular-related ophthalmic conditions, such as, for example, the complications associated with AMD.

SUMMARY OF THE INVENTION

[0031] An aspect of the invention is a method of selectively delivering squalamine or a pharmaceutically acceptable salt thereof to the posterior sclera and choroid of the eye(s) of a mammal in need thereof in an amount therapeutically effective to treat an ophthalmic condition, the method comprising: administering to one or both eyes of the mammal a composition comprising: squalamine dilactate; a buffering agent; a mucoadhesive agent; and a cyclodextrin, wherein the mammal has one or more lesions with occult CNV of less than 10 mm² in area. [0032] Another aspect of the invention is a method for treating an ophthalmic condition in a mammal, the method comprising: administering to the eye(s) of a mammal in need thereof an amount of a composition sufficient to treat the condition, the composition comprising: squalamine dilactate; a buffering agent; a mucoadhesive agent; and a cyclodextrin, wherein the mammal has one or more lesions with occult CNV of less than 10 mm² in area.

[0033] In an exemplary embodiment, the compositions are aqueous compositions.

[0034] In an exemplary embodiment, the lesions with occult CNV are less than 9 mm² in area, such as less than 8 mm² in area, such as less than 7 mm² in area, such as less than 6 mm² in area, such as less than 5 mm² in area, such as less than 4 mm² in area, such as less than 3 mm² in area, such as less than 2 mm² in area, such as less than 1 mm² in area.

[0035] In an exemplary embodiment, the lesions are present as a result of the ophthalmic condition.

[0036] In an exemplary embodiment, the lesions have occult CNV but do not contain any classic CNV.

[0037] In an exemplary embodiment, the lesions also contain classic CNV.

[0038] In an exemplary embodiment, the composition is administered topically to the eye(s) of the mammal.

[0039] In an exemplary embodiment, the composition is in the form of eye drops.

[0040] In an exemplary embodiment, a significantly lower concentration of the composition is present in the aqueous humor or vitreous humor compared to other locations within the eye after administration of the composition to the eye(s) of the mammal.

[0041] In an exemplary embodiment, the mucoadhesive agent in the composition is Povidone K-30.

[0042] In an exemplary embodiment, the cyclodextrin in the composition is 2- hydroxpropyl- -cyclodextrin. [0043] In an exemplary embodiment, the buffering agent is a phosphate, such as a alkali metal (e.g. , lithium, sodium or potassium) phosphate, such as sodium phosphate, such as sodium phosphate heptahydrate and/or sodium phosphate monobasic monohydrate.

[0044] In an exemplary embodiment, the ophthalmic condition is selected from the group consisting of wet age-related macular degeneration (wet AMD), dry age-related macular degeneration (dry AMD), diabetic retinopathy, proliferative diabetic retinopathy, ischemic retinopathy (which includes retinal artery occlusion and carotid artery occlusion), cystoid macular edema, diabetic macular edema, rubeosis iridis, retinopathy of prematurity, retinal vascular occlusive disease (which includes central and branch retinal vein occlusions), inflammatory/infectious retinal

neovascularization/edema (which includes posterior uveitis, sarcoid, toxoplasmosis, histoplasmosis, Vogt-Koyanagi-Harada Disease, chronic posterior uveitis, punctate and multifocal inner choroidopathy), retinoblastoma, ocular melanoma, ocular tumors, retinal detachment, myopic neovascularization, angioid streaks, Eales disease, choroidal rupture and any combination thereof.

[0045] In an exemplary embodiment, the ophthalmic condition is wet age-related macular degeneration (wet AMD).

[0046] In an exemplary embodiment, the mammal is a human.

[0047] In an exemplary embodiment, the composition further comprises one or more of edetate disodium, sodium chloride and benzalkonium chloride.

[0048] In an exemplary embodiment, the composition is administered in combination with an anti-angiogenic agent.

[0049] In an exemplary embodiment, the anti-angiogenic agent is selected from the group consisting of: Abicipar, Pegpleranib (Fovista®), Zimura®, RTH258 (formerly, ESBA1008), X-82, Nesvacumab + Aflibercept (EYLEA®), RG7716, rAAV.sFlt-1, Retaane (Anecortave Acetate), Rapamune (Sirolimus), Inversine (Mecamylamine), Idantirx (AGX-51), NT-503-3, iSONEP, Palomid 529, Pazopanib (VOTRIENT®), AdGVPEDF. l lD, JSM6427, TK001, PAN-90806, Luminate, APL-2R, Conbercept, Vatalanib (PTK787) and ALG-1001. [0050] In an exemplary embodiment, the anti-angiogenic agent is an anti-VEGF drug. In a particular embodiment, the anti-VEGF drug is selected from the group consisting of Ranibizumab (Lucentis®), Bevacizumab (Avastin®), Aflibercept (EYLEA®), DARPin® MP0112 and RTH258 (formerly, ESBA1008).

[0051] In an exemplary embodiment, the anti-angiogenic agent is an anti-PDGF drug. In a particular embodiment, the anti-PDGF drug is Pegpleranib (Fovista®).

[0052] In an exemplary embodiment, the anti-angiogenic is administered by any conventional means into the mammalian eye. In particular embodiments, such conventional means include by direct injection or by topical administration.

[0053] In an exemplary embodiment, the composition is administered before administration of the anti-angiogenic agent.

[0054] In an exemplary embodiment, the composition is administered at the same time as the administration of the anti-angiogenic agent.

[0055] In an exemplary embodiment, the composition is administered subsequent to the administration of the anti-angiogenic agent.

[0056] In an exemplary embodiment, the composition is administered BID subsequent to the administration of the anti-angiogenic agent.

[0057] In an exemplary embodiment, the anti-angiogenic agent is an anti-VEGF drug or an anti-PDGF drug.

[0058] Another aspect of the invention is a method of reducing risk of developing an ophthalmic condition in an eye of a mammal, where an ophthalmic condition already exists in the other eye of the mammal, the method comprising: administering to the eye that does not have the ophthalmic condition an amount of a composition sufficient to prevent or delay the development of the ophthalmic condition, the composition comprising: squalamine dilactate; a buffering agent; a mucoadhesive agent; and a cyclodextrin.

[0059] Another aspect of the invention is a method of reducing risk of developing an ophthalmic condition in a mammal, where an abnormal pathological or angiogenic process is detected in one or both eyes of the mammal which may lead to the ophthalmic condition, the method comprising: administering to the one or the both eyes an amount of a composition sufficient to prevent or delay further progress of the abnormal pathological or angiogenic process, the composition comprising:

squalamine dilactate; a buffering agent; a mucoadhesive agent; and a cyclodextrin.

[0060] Another aspect of the invention is a method of prophylactically treating a mammal at risk of an abnormal pathogenic or angiogenic process in one or both eyes based on a systemic condition or disorder, family medical history or genetic predisposition, the method comprising: administering to the one or the both eyes an amount of a composition sufficient to prevent or delay the abnormal pathological or angiogenic process, the composition comprising: squalamine dilactate; a buffering agent; a mucoadhesive agent; and a cyclodextrin.

[0061] In an exemplary embodiment, the composition comprises: squalamine dilactate; sodium phosphate; edetate disodium; sodium chloride; benzalkonium chloride; 2-hydroxypropyl- -cyclodextrin; and water.

[0062] In an exemplary embodiment, the composition consists of: squalamine dilactate; sodium phosphate; edetate disodium; sodium chloride; benzalkonium chloride; 2-hydroxypropyl- -cyclodextrin; and water.

[0063] In an exemplary embodiment, one or more of the lesions has only classic CNV (i.e. , 100%) or less than 100% such as 95%, such as 90%, such as 85%, such as 80%, such as 75%, such as 70%, such as 65%, such as 60%, such as 55%, such as 50%, such as 45%, such as 40%, such as 35%, such as 30%, such as 25%, such as 20%, such as 15%, such as 10%, such as 5%, such as greater than 0%.

[0064] In an exemplary embodiment, the presence of occult CNV in the lesion at the beginning of treatment is measured by fluorescein angiography as being less than 10 mm² in area, such as 9 mm², such as 8 mm², such as 7 mm², such as 6 mm², such as 5

2 2 2 2 2

mm , such as 4 mm , such as 3 mm , such as 2 mm , such as 1 mm , and including a zero amount of occult CNV in the lesion.

[0065] In an exemplary embodiment, the composition is the composition of

Formulation 1. [0066] In a particular embodiment, the composition is the composition of

Formulation 1A.

[0067] In a particular embodiment, the composition is the composition of

Formulation IB.

[0068] In an exemplary embodiment, the composition of Formulation 1 , Formulation 1 A or Formulation IB is administered in the form of eye drops.

[0069] In a particular embodiment, the composition (Formula 1) comprises:

0.05 to 0.3% squalamine dilactate w/v;

0.15 to 0.35% sodium phosphate heptahydrate w/v;

0.03 to 0.12% sodium phosphate monobasic monohydrate w/v;

0.8 to 1.4% Povidone K-30 w/v;

0.005 to 0.05% edetate disodium w/v;

0.3 to 1.5% sodium chloride w/v;

0.001 to 0.01% benzalkonium chloride w/v;

0.5 to 2.0% 2-hydroxypropyl- -cyclodextrin w/v; and

purified water qs,

where the pH = 6.5 to 7.5 or 6.7 to 7.1 and the osmolality = 280 to 340 mOsm/kg.

[0070] In a particular embodiment, the composition (Formulation 1 A) comprises:

0.2% squalamine dilactate w/v;

0.27% sodium phosphate heptahydrate w/v;

0.06% sodium phosphate monobasic monohydrate w/v;

1.2% Povidone K-30 w/v;

0.01% edetate disodium w/v;

0.80% sodium chloride w/v;

0.005% benzalkonium chloride w/v;

1.0% 2-hydroxypropyl^-cyclodextrin w/v; and

purified water qs,

where the pH = 6.70 and the osmolality = 315 mOsm/kg.

[0071] In another particular embodiment, the composition (Formulation IB) comprises: 0.2% squalamine dilactate;

0.188% sodium phosphate heptahydrate w/v;

0.1 % sodium phosphate monobasic monohydrate w/v;

1.2% Povidone K-30 w/v;

0.01% edetate disodium;

0.005% benzalkonium chloride w/v;

1.0% 2-hydroxypropyl- -cyclodextrin w/v; and

purified water qs,

where the pH = 6.70 and the osmolality = 315 mOsm/kg.

[0072] In an embodiment of the invention, a significantly lower concentration of the composition of Formulation 1 , Formulation 1A or Formulation IB is present in the aqueous humor or vitreous humor after administration of the composition to the eye of the mammal compared to other locations within the eye.

[0073] An aspect of the invention is a method of selectively delivering squalamine present in the composition of Formulation 1, Formulation 1A or Formulation IB to the posterior sclera and choroid of the eye(s) of a mammal in need thereof in an amount therapeutically effective to treat an ophthalmic condition, the method comprising: topically administering the composition of Formulation 1 , Formulation 1 A or Formulation IB to the eye(s) of the mammal, optionally in combination with an anti-angiogenic agent, wherein the ophthalmic condition is selected from the group consisting of wet age-related macular degeneration (wet AMD), dry age-related macular degeneration (dry AMD), diabetic retinopathy, proliferative diabetic retinopathy, ischemic retinopathy (which includes retinal artery occlusion and carotid artery occlusion), cystoid macular edema, diabetic macular edema, rubeosis iridis, retinopathy of prematurity, retinal vascular occlusive disease (which includes central and branch retinal vein occlusions), inflammatory/infectious retinal

[0074] An aspect of the invention is a method of preventing the development of AMD in a patient at risk of advanced AMD development comprising administering to the eye or eyes of the patient in need thereof a therapeutically effective amount of a composition of Formulation 1, Formulation 1A or Formulation IB.

BRIEF DESCRIPTION OF THE DRAWINGS

[0075] The figures merely illustrate particular embodiments of the invention and are not intended to otherwise limit the scope of the overall invention as described herein.

[0076] Figure 1 illustrates the selective uptake of propidium iodide (Prl) by squalamine-treated (1 μΜ squalamine), sparsely plated HUVAC cells, which is an indication of cell oncosis.

[0077] Figure 2 illustrates the correlation between the area of the lesion with occult CNV (in mm²) and observed visual acuity in patients receiving combination treatment with Lucentis® and the composition of Formulation 1A.

[0078] Figure 3A illustrates the mean change in visual acuity through Week 36 in a patient population containing a lesion with occult CNV measuring less than 10 mm² in area after combination treatment with Lucentis® and the composition of

Formulation 1A (labeled as "Form-IA") versus treatment with Lucentis® and a placebo formulation (labeled as "Placebo").

[0079] Figure 3B illustrates the percent of the patients with a > 3-line gain in visual acuity through Week 36 after combination treatment with Lucentis® and the composition of Formulation 1A (labeled as "Form-IA") versus treatment with Lucentis® and a placebo formulation (labeled as "Placebo"), where the patient population is limited to those individuals containing a lesion with occult CNV measuring less than 10 mm² in area.

[0080] Figure 3C illustrates the percent of the patients with a > 4-line gain or a > 5- line gain in visual acuity at Week 36 after combination treatment with Lucentis® and the composition of Formulation 1A (labeled as "Form-IA") versus treatment with Lucentis® and a placebo formulation (labeled as "Placebo"), where the patient population is limited to those individuals containing a lesion with occult CNV measuring less than 10 mm² in area. [0081] Figure 4A illustrates the effect of occult CNV size (5 mm², 7.5 mm², 10 mm² and 12.5 mm²) on the visual acuity outcome after Week 36 after combination treatment with Lucentis® and the composition of Formulation 1A (labeled as "Form- 1A").

[0082] Figure 4B illustrates the percent of the patients benefiting from combination treatment with Lucentis® and the composition of Formulation 1A (labeled as "Form- 1 A") through Week 36, where the patient populations are separated by occult CNV sizes of 5 mm², 7.5 mm², 10 mm² and 12.5 mm².

DETAILED DESCRIPTION OF THE INVENTION

[0083] The formulations/compositions of the present invention possess the desired and unique characteristics needed to effectively deliver squalamine, which is applied to the front of the eye via the ophthalmic compositions described herein, to the rear of the eye where the therapeutic concentrations of the squalamine are those required for treatment of the targeted disorder. The inventors unexpected found that the sum total of the contribution from each of the individual excipients present in the ophthalmic formulations of the invention, in unison with the inherent physicochemical properties of the squalamine molecule itself, such as its zwitterionic characteristics, provided the highly desirable selective bioavailability /biodistribution/tolerability profile achieved in the eye at therapeutic levels. Thus, while the conventional art may separately describe one or more of the excipients of the ophthalmic formulations of the invention as well known, there was no prior appreciation or prediction of the unique properties of the assembly of these particular excipients observed by the inventors of the ophthalmic formulations described herein.

[0084] The described formulations/compositions are stable, and after sterilization, may be packaged, stored and used directly. In an exemplary embodiment, the formulations are in drop form in the manner typically used to apply eye drops. The normal squeeze-type liquid drop application devices are perfectly suited for use in applying the ophthalmic formulations of the invention. In an exemplary embodiment, the formulations are conveniently administered by dropwise addition of the formulations into the affected eye(s) of the user.

[0085] The formulations of the present invention containing preservatives are especially advantageous for use in multi-dose containers. Multi-dose containers, as used herein, refer to containers which allow two or more separate applications of the ophthalmic formulation present within the container. Such containers are resealable - i.e., the container cap may be removed for a first application, and then the cap may be replaced onto the container, thereby providing a substantially liquid impermeable seal again. In an exemplary embodiment, an antimicrobial preservative is present in an amount sufficient to reduce microbial concentrations for a period of about 12 hours to about 72 hours, such as about 12 hours to about 48 hours, such as about 12 hours to about 24 hours.

[0086] The pharmaceutical compositions of the invention may be formulated in any conventional ophthalmologically compatible vehicles, such as, for example, an ointment, cream, suspension, lotion, powder, solution, paste, gel, spray, aerosol or oil.

[0087] As defined herein, a "therapeutically effective amount" is an amount of an active agent (such as squalamine) which inhibits, totally or partially, the progression of the condition or alleviates, at least partially, one or more symptoms of the condition. A therapeutically effective amount can also be an amount that is prophylactically effective. The amount that is therapeutically effective will depend upon the patient's size and gender, the condition to be treated, the severity of the condition and the result sought. For a given patient, a therapeutically effective amount can be determined by methods known to those of skill in the art. The concentration of squalamine dilactate will typically be about 0.01 to about 5.0 weight percent, such as about 0.01 to about 4.0 weight percent, such as about 0.02 to about 3.0 weight percent, such as about 0.03 to about 2.0 weight percent, such as about 0.05 to about 1.0 weight percent.

[0088] The dilactate salt of squalamine present in the compositions of the invention may exist in an amorphous form or in a crystalline form. In an exemplary

embodiment of the invention, the crystalline form of the dilactate salt exists as a solvate. In another exemplary embodiment, the crystalline form exists as a hydrate, and in a further embodiment the dilactate salt exists as a solvate and a hydrate. The crystalline forms of squalamine dilactate may exist as solvates where solvent molecules are incorporated within the crystal structure. As an example, when the solvent contains ethanol, the crystal may contain ethanol molecules. In another embodiment, the solvate may contain water, and the crystal may be a hydrate containing water in the crystal structure. In another embodiment, the crystal may be both a solvate and a hydrate. A discussion of various crystalline forms of squalamine dilactate may be found in U. S. Patent No. 7,981 ,876, which is incorporated by reference in its entirety.

[0089] As defined herein, the term "ophthalmic condition" or "ophthalmic disorder" includes, but is not limited to, wet age-related macular degeneration (wet AMD), dry age-related macular degeneration (dry AMD), diabetic retinopathy, proliferative diabetic retinopathy, ischemic retinopathy (which includes retinal artery occlusion and carotid artery occlusion), cystoid macular edema, diabetic macular edema, rubeosis iridis, retinopathy of prematurity, retinal vascular occlusive disease (which includes central and branch retinal vein occlusions), inflammatory/infectious retinal neovascularization/edema (which includes posterior uveitis, sarcoid, toxoplasmosis, histoplasmosis, Vogt-Koyanagi-Harada Disease, chronic posterior uveitis, punctate and multifocal inner choroidopathy), retinoblastoma, ocular melanoma, ocular tumors, retinal detachment, myopic neovascularization, angioid streaks, Eales disease, choroidal rupture and any combination thereof.

[0090] The phrase "pharmaceutically acceptable salt" as used herein is well known and refers to any salt of a chemical compound that is safe for use in mammals.

Pharmaceutically acceptable salts include, but are not limited to, salts of acidic and/or basic groups present in the chemical compound. Exemplary pharmaceutically acceptable acid addition salts include, but are not limited to, hydrochloride, hydrobromide, hydroiodide, nitrate, sulfate, bisulfate, phosphate, acetate, lactate, salicylate, citrate, tartrate, ascorbate, succinate, maleate, fumarate, gluconate, formate, benzoate, methanesulfonate, ethanesulfonate, benzensulfonate and p-toluenesulfonate. Pharmaceutically acceptable salts compounds also include quaternary ammonium salts of the formula -NRR'R"⁺Z ^", wherein each of R, R' and R" is independently, for example, hydrogen, alkyl or alkylaryl, and Z is a counter ion, including, but not limited to, chloride, bromide, iodide, alkoxide, p-toluenesulfonate, methylsulfonate, sulfonate, phosphate, or carboxylate.

[0091] The phrase "family medical history" as used herein is well known and refers to genetic relationships within a family combined with the medical history of individual family members.

[0092] The phrase "genetic predisposition" as used herein is well known and refers to an inherited genetic partem that makes one susceptible to a particular disease or disorder.

[0093] Suitable buffering agents for use in the ophthalmic formulations of the present invention include, but are not limited to, buffers prepared from sodium, potassium bicarbonate, phosphate, acetate, citrate, borate salts and/or phosphoric acid, acetic acid, citric acid or boric acid. In an exemplary embodiment, the buffer is sodium dihydrogen phosphate or disodium phosphate or boric acid/sodium borate. The buffering agent should be present in an amount sufficient to produce and maintain a product pH of about 5.5 to about 8.0, such as about 5.7 to about 7.7, such as about 6.0 to about 7.4, such as about 6.3 to about 7.1, such as about 6.7 to 7.1, such as about 6.7 to about 6.8, and including a pH of about 5.7, about 5.9, about 6.1, about 6.3, about 6.5, about 6.7, about 6.9, about 7.1, about 7.3, about 7.5, about 7.7 or about 7.9.

[0094] Suitable mucoadhesive agents, when present in the described formulations, typically enhance corneal contact time, bioavailability and/or provide a lubricating effect, and include, but are not limited to acrylic acid polymers, methylcellulose, ethylcellulose, Povidone K-30, hydroxypropyl methylcellulose,

hydroxyethylcellulose, Carbopol® polymers (such as, for example, Carbopol® 674, 676, 690, 980 NF, EZ-2, EZ-3, EZ-4, Aqua 30 and Novethix™ L-10), hydroxypropyl cellulose, polyvinyl alcohol, gelatin, sodium chondroitin sulfate, or any combination thereof.

[0095] Solubilizing or resuspension agents may also be added to the formulations of the present invention. Suitable solubilizing or resuspension agents include, but are not limited to, cyclodextrins (CDs), such as hydroxypropyl γ-cyclodextrin

(Cavasol®), sulfobutyl ether 4 β-cyclodextrin (Captisol®), and hydroxypropyl β- cyclodextrin (Kleptose®) (such as 2-hydroxypropyl β-cyclodextrin), Polysorbate 80 (Tween80^®) or hyaluronic acid or hyaluronate salts. The cyclodextrins in particular may also exhibit penetration enhancing properties, although cyclodextrins are also known to retard the uptake of steroidal compounds (such as hydrocortisone) into ocular tissues (Masson, M., et ai, Proc. of the 9^th Intl. Symposium on Cyclodextrins, Kluwer Academic Publishers 363-369 (1999); Loftsson, T., et al, Acta

Ophthalmologica Scandinavica 144-150 (2003); International Journal of

Pharmaceutics 156, 201-209 (1997)).

[0096] A penetration enhancer may optionally be present in the described

formulations and includes, but is not limited to, laurocapram (azone), bile acids and their alkali metal salts, including chenodeoxycholic acid, cholic acid, taurocholic acid, taurodeoxy cholic acid, tauroursodeoxy cholic acid or ursodeoxycholic acid, glycocholate, n-dodecyl- -D-maltoside, sucrose dodecanoate, octyl maltoside, decyl maltoside, tridecyl maltoside, tetradecyl maltoside, hexamethylene lauramide, hexamethylene octanamide, glycerol monolaurate, PGML (polyethylene glycol monolaurate), dimethyl sulfoxide, methylsulfonylmethane, sodium fusidate, saponins or any combinations thereof.

[0097] An exemplary listing of typical carriers, stabilizers and adjuvants known to those of skill in the art that may be useful in the ophthalmic compositions described herein may be found in Gennaro (2005) Remington: The Science and Practice of Pharmacy, Mack Publishing, 21^st ed.

[0098] In vivo administration of the compositions of the invention may be effected in one dose, multiple doses, continuously or intermittently throughout the course of treatment. Methods of determining the most effective dosage of administration are well known to those of skill in the art and will vary with the composition used for therapy, the purpose of the therapy and the subject being treated. Single or multiple administrations can be carried out with the dose level and pattern being selected by the treating physician.

[0099] Various particularized and non-limiting formulations described in the examples below. These formulations are merely illustrative of the described invention and are not intended to limit the scope of the described invention.

[00100] In an exemplary embodiment, the present invention reflects the unexpected observation that patients treated for an ophthalmic condition using combination therapy of an anti-VEGF drug such as Lucentis® and a composition of Formula 1 as described herein experience a higher success rate when the patients have occult CNV of less than 10 mm² in area. This phenomenon was not observed when only Lucentis® monotherapy was used.

[00101] In another exemplary embodiment, the present invention relates to the treatment of patients for an ophthalmic condition using combination therapy of an anti-PDGF drug and a composition of Formula 1 as described herein, where the patients have occult CNV of less than 10 mm² in area.

[00102] The observed results allow for the use of occult CNV size as a predictor for the level of success to be achieved in the treatment of conditions of the eye associated with choroidal neovascularization using ophthalmic formulations of squalamine dilactate, optionally in combination with anti-angiogenic agents, such as conventional anti-angiogenic agents.

EXAMPLES

Example 1 - Formulation 1

[00103] Formulation 1 contained the following components:

0.05 to 0.25% squalamine dilactate w/v;

0.15 to 0.35% sodium phosphate heptahydrate w/v and 0.03 to 0.12% sodium phosphate monobasic monohydrate w/v;

0.8 to 1.4% Povidone K-30 w/v;

0.005 to 0.05% edetate disodium w/v;

0.3 to 1.5% sodium chloride w/v;

0.001 to 0.01% benzalkonium chloride w/v;

0.5 to 2.0% 2-hydroxypropyl- -cyclodextrin w/v; and

purified water qs.

The pH = 6.5 to 7.5 or 6.7 to 7.1 and the osmolality = 280 to 340 mOsm/kg.

[00104] A particular embodiment of Formulation 1 (referred to as Formulation 1A) contained 0.2% squalamine dilactate w/v; 0.27% sodium phosphate heptahydrate w/v; 0.06% sodium phosphate monobasic monohydrate w/v; 1.2% Povidone K-30 w/v; 0.01% edetate disodium w/v; 0.80% sodium chloride w/v; 0.005% benzalkonium chloride w/v; 1.0% 2-hydroxypropyl- -cyclodextrin w/v; and purified water qs. The pH = 6.70 and the osmolality = 315 mOsm/kg. [00105] Another particular embodiment of Formulation 1 (referred to as Formulation IB) contained 0.2% squalamine dilactate; 0.188% sodium phosphate heptahydrate w/v and 0.1 % sodium phosphate monobasic monohydrate w/v; 1.2% Povidone K-30 w/v; 0.01 % edetate disodium; 0.005% benzalkonium chloride w/v; 1.0% 2- hydroxypropyl- -cyclodextrin w/v; and purified water qs. The pH = 6.70 and the osmolality = 315 mOsm/kg.

[00106] Preparation of Formulation 1A. Approximately 50 mL of purified water was placed in a 250 mL graduated glass beaker with a stir bar. 0.27 g of sodium phosphate heptahydrate was added to the beaker and stirred until it dissolved. 0.06 g of sodium phosphate monobasic monohydrate was added to the beaker and stirred until it dissolved. 0.005 g of benzalkonium chloride was added to the beaker and stirred until it dissolved. 0.01 g of disodium EDTA was added to the beaker and stirred until it dissolved. 0.8 g of sodium chloride was added to the beaker and stirred until it dissolved. 1.2 g of Povidone K-30 was added to the beaker and stirred until it dissolved. 1.0 g of 2-hydroxypropyl- -cyclodextrin was added to the beaker and stirred until it dissolved. 0.200 g of squalamine dilactate was added to the beaker and stirred until it dissolved. Approximately 40 mL of purified sterile water was added to the beaker and the pH was adjusted to 6.7 using 2 N NaOH and 1 N HC 1 (as needed). The volume was made up to 100 mL with sufficient quantity of water for injection or purified water USP. The solution was sterile filtered through 0.22 micron filter before use.

[00107] Preparation of Formulation IB. This formulation was prepared in a manner similar to that of Formulation 1A.

Example 2 - Clinical Testing of Formulation 1

[00108] The studies described below represent a nine-month Phase II clinical trial evaluation of the safety and efficacy of Formulation 1A for the treatment of wet- AMD. The two treatment arms were Formulation 1A drops administered twice daily plus Lucentis® ("Formulation 1A" arm or group, and labeled in the figures as "Form- 1A") versus placebo eye drops administered twice daily plus Lucentis® ("Lucentis® monotherapy" arm or group, and labeled in the figures as "Placebo"). All patients in the study received an initial Lucentis® injection. 142 patients were randomized into the study, with 90% of the patients completing the nine month treatment protocol. Formulation 1A was generally well tolerated, with only two treatment related discontinuations in the study.

[00109] The visual acuity outcomes for patients completing the nine-month treatment period were analyzed. In the population having lesions with occult CNV of less than 10 mm² in area (94 patients), mean gains in visual acuity at month nine were +11 letters for the Formulation 1A arm and +5.7 letters with Lucentis® monotherapy, a clinically meaningful benefit of 5.3 letters (Figure 2A). In addition, 40% of these patients receiving Formulation 1A combination therapy achieved a >3 line vision gain at nine months, as compared to 26% in the Lucentis® monotherapy group (Figure 2B). This positive effect on visual acuity was observed early in the course of treatment and continued to increase through the end of the study.

[00110] The data for patients having lesions containing occult CNV of less than 10 mm² in area also showed a more pronounced separation between the Formulation 1A and Lucentis® monotherapy groups for those patients who achieved >4 and >5 line vision gains. Of the patients receiving Formulation 1 A, 17% achieved a >4 line gain and 10% achieved >5 line gains, at nine months, as compared to 6% with a >4 line gain and 4% with a >5 line gain for those who received Lucentis® monotherapy (Figure 2C)

[00111] The effect of occult CNV size on the outcome of visual acuity is depicted in Figures 3A and 3B, which show that patients having lesions with occult CNV of 5 mm² in area experienced a significantly better outcome than patients having lesions with occult CNV of 12.5 mm² in area. A strong correlation was observed between the baseline size of occult CNV and the visual acuity outcomes. Notably, the impact of occult CNV size on the outcome of visual acuity was not observed in patients receiving only the Lucentis® monotherapy. Thus, upon subset evaluation of the clinical results, it was determined that patients having lesions with occult CNV measuring less than 10 mm² in area represented a preferred patient population.

[00112] All patents/publications cited herein are incorporated by reference in their entireties.

Claims

IN THE CLAIMS:

1. A method of selectively delivering squalamine or a pharmaceutically acceptable salt thereof to the posterior sclera and choroid of the eye(s) of a mammal in need thereof in an amount therapeutically effective to treat an ophthalmic condition, the method comprising:

administering to one or both eyes of the mammal a composition comprising: squalamine dilactate;

a buffering agent;

a mucoadhesive agent; and

a cyclodextrin,

wherein the mammal has one or more lesions with occult CNV of less than 10 mm² in area.

2. A method for treating an ophthalmic condition in a mammal, the method comprising:

administering to the eye(s) of a mammal in need thereof a composition in an amount sufficient to treat the condition, the composition comprising:

squalamine dilactate;

a buffering agent;

a mucoadhesive agent; and

a cyclodextrin,

3. The method according to claim 1 or claim 2, wherein the mammal has one or more lesions with occult CNV of less than 8 mm² in area.

4. The method according to claim 1 or claim 2, wherein the mammal has one or more lesions with occult CNV of less than 5 mm² in area.

5. The method according to claim 1 or claim 2, wherein the lesions also contain classic CNV.

6. The method according to claim 1 or claim 2, wherein the composition is administered topically to the eye of the mammal.

7. The method according to claim 1 or claim 2, wherein the composition is in the form of eye drops.

8. The method according to claim 1 or claim 2, wherein the mucoadhesive agent is Povidone K-30.

9. The method according to claim 1 or claim 2, wherein the cyclodextrin is 2- hydroxpropyl- -cyclodextrin.

10. The method according to claim 1 or claim 2, wherein the buffering agent is a phosphate.

1 1. The method according to claim 1 or claim 2, wherein the ophthalmic condition is selected from the group consisting of wet age-related macular degeneration, dry age-related macular degeneration, diabetic retinopathy, proliferative diabetic retinopathy, ischemic retinopathy, cystoid macular edema, diabetic macular edema, rubeosis iridis, retinopathy of prematurity, retinal vascular occlusive disease, inflammatory/infectious retinal neovascularization/edema, retinoblastoma, ocular melanoma, ocular tumors, retinal detachment, myopic neovascularization, angioid streaks, Eales disease, choroidal rupture and any combination thereof.

12. The method according to claim 1 or claim 2, wherein the ophthalmic condition is wet age-related macular degeneration (wet AMD).

13. The method according to claim 1 or claim 2, wherein the mammal is a human.

14. The method according to claim 1 or claim 2, wherein the composition further comprises one or more of edetate disodium, sodium chloride and benzalkonium chloride.

The method according to claim 1 or claim 2, wherein the composition i administered in combination with an anti-angiogenic agent.

16. The method according to claim 15, wherein the composition is administered before administration of the anti-angiogenic agent.

17. The method according to claim 15, wherein the composition is administered at the same time as the administration of the anti-angiogenic agent.

18. The method according to claim 15, wherein the composition is administered subsequent to the administration of the anti-angiogenic agent.

19. The method according to claim 15, where the anti-angiogenic agent is an anti- VEGF drug or an anti-PDGF drug.

20. A method of reducing risk of developing an ophthalmic condition in an eye of a mammal, where an ophthalmic condition already exists in the other eye of the mammal, the method comprising:

administering to the eye that does not have the ophthalmic condition an amount of a composition sufficient to prevent or delay the development of the ophthalmic condition, the composition comprising:

squalamine dilactate;

a buffering agent;

a mucoadhesive agent; and

a cyclodextrin.

21. A method of reducing risk of developing an ophthalmic condition in a mammal, where an abnormal pathological or angiogenic process is detected in one or both eyes of the mammal which may lead to the ophthalmic condition, the method comprising:

administering to the one or the both eyes an amount of a composition sufficient to prevent or delay further progress of the abnormal pathological or angiogenic process, the composition comprising:

squalamine dilactate;

a buffering agent; a mucoadhesive agent; and

a cyclodextrin.

22. A method of prophylactically treating a mammal at risk of an abnormal pathogenic or angiogenic process in one or both eyes based on a systemic condition or disorder, family medical history or genetic predisposition, the method comprising: administering to the one or the both eyes an amount of a composition sufficient to prevent or delay the abnormal pathological or angiogenic process, the composition comprising:

squalamine dilactate;

a buffering agent;

a mucoadhesive agent; and

a cyclodextrin.

23. The method according to any one of claims 20 to 22, wherein the composition is administered topically to the eye of the mammal.

24. The method according to any one of claims 20 to 22, wherein the composition is in the form of eye drops.

25. The method according to any one of claims 20 to 22, wherein the

mucoadhesive agent is Povidone K-30.

26. The method according to any one of claims 20 to 22, wherein the cyclodextrin is 2-hydroxpropyl- -cyclodextrin.

27. The method according to any one of claims 20 to 22, wherein the buffering agent is a phosphate.

28. The method according to claim 20 or claim 21, wherein the ophthalmic condition is selected from the group consisting of wet age-related macular degeneration, dry age-related macular degeneration, diabetic retinopathy, proliferative diabetic retinopathy, ischemic retinopathy, cystoid macular edema, diabetic macular edema, rubeosis iridis, retinopathy of prematurity, retinal vascular occlusive disease, inflammatory/infectious retinal neovascularization/edema, retinoblastoma, ocular melanoma, ocular tumors, retinal detachment, myopic neovascularization, angioid streaks, Eales disease, choroidal rupture and any combination thereof.

29. The method according to any one of claims 20 to 22, wherein the composition further comprises one or more of edetate disodium, sodium chloride and

benzalkonium chloride.

30. The method according to any one of claims 20 to 22, wherein the composition is administered in combination with an anti-angiogenic agent.

31. The method according to claim 30, wherein the composition is administered before administration of the anti-angiogenic agent.

32. The method according to claim 30, wherein the composition is administered at the same time as the administration of the anti-angiogenic agent.

33. The method according to claim 30, wherein the composition is administered subsequent to the administration of the anti-angiogenic agent.

34. The method according to claim 30, where the anti-angiogenic agent is an anti- VEGF drug or an anti-PDGF drug.

35. The method according to any one of claims 1, 2, 20, 21 and 22, wherein the compositions are aqueous compositions.

36. The method according to any one of claims 1, 2, 20, 21 and 22, wherein the composition comprises:

squalamine dilactate;

sodium phosphate;

edetate disodium;

sodium chloride;

benzalkonium chloride; and

2-hydroxypropyl- -cyclodextrin.