WO2018111324A1

WO2018111324A1 - Methods and ingestible devices for the regio-specific release of tlr agonists at the site of gastrointestinal tract disease

Info

Publication number: WO2018111324A1
Application number: PCT/US2017/025086
Authority: WO
Inventors: Mitchell Lawrence Jones; Sharat Singh; Christopher Loren WAHL; Harry Stylli
Original assignee: Progenity Inc.
Priority date: 2016-12-14
Filing date: 2017-03-30
Publication date: 2018-06-21

Abstract

This disclosure features methods and compositions for treating diseases of the gastrointestinal tract with a TLR agonist.

Description

METHODS AND INGESTIBLE DEVICES FOR THE REGIO-SPECIFIC RELEASE OF TLR AGONISTS AT THE SITE OF GASTROINTESTINAL TRACT DISEASE

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims priority to U.S. Provisional Application No. 62/434,366, filed on December 14, 2016. The disclosure of the prior application is incorporated in its entirety into this application.

TECHNICAL FIELD

This disclosure features methods and compositions for treating diseases of the gastrointestinal tract with a TLR agonist. Background

Toll-like receptor 9 (TLR9, also knowns as CD289 (cluster of differentiation 289)) is a member of the toll-like receptor (TLR) family. TLR9 is present inside immune cells, as well as on the surface of epithelial cells. TLR9 has been implicated in progression of Crohn's disease and ulcerative colitis.

The gastrointestinal (GI) tract generally provides a therapeutic medium for an individual's body. At times, therapeutic drugs may need to be dispensed to specified locations within the small intestine or large intestine, which is more effective than oral administration of the therapeutic drugs to cure some medical conditions. For example, therapeutic drugs applied directly within the small intestine would not be contaminated, digested or otherwise compromised in the stomach, and thus allow a higher dose to be delivered at a specific location within the small intestine. However, dispensing therapeutic drugs directly within the small intestine inside a human body can be difficult, because a device or mechanism (e.g., special formulation) is needed to carry a therapeutically effective dose of drug to a desired location within the small intestine and then automatically deliver the therapeutic drug at the desired location. Such a device or mechanism also needs to be operated in a safe manner as the device or mechanism needs to enter the human body.

Provided herein in one embodiment is a novel treatment paradigm for inflammatory conditions of the gastrointestinal tract. The methods and compositions described herein allow for the region-specific release of therapeutic drugs at or near the site of disease in the gastrointestinal tract. By releasing a therapeutic drug locally instead of systemically, the bioavailability of said drug can be increased at the site of injury and/or relative to a decrease in circulation; thereby, resulting in improved overall safety and/or efficacy and fewer side effects. Advantages may include one or more of increased drug engagement at the target, leading to new and more efficacious treatment regimens; and/or lower systemic drug levels, which means reduced toxicity and reduced immunogenicity in the case of biologies. For patients, clinicians and payors, this means an easier route of administration, fewer co- medicaments (e.g., immunomodulators), fewer side effects, and/or better outcomes.

Summary

Provided herein in one embodiment is a method of treating a disease of the gastrointestinal tract in a subject, comprising:

delivering a TLR agonist at a location in the gastrointestinal tract of the subject, wherein the method comprises administering to the subject a pharmaceutical composition comprising a therapeutically effective amount of the TLR agonist.

Provided herein in one embodiment is a method of treating a disease of the large intestine in a subject, comprising:

delivering a TLR agonist at a location in the proximal portion of the large intestine of the subject,

wherein the method comprises administering endoscopically to the subject a therapeutically effective amount of the TLR agonist.

releasing a TLR agonist at a location in the gastrointestinal tract of the subject that is proximate to one or more sites of disease,

wherein the method comprises administering to the subject a pharmaceutical composition comprising a therapeutically effective amount of the TLR agonist.

wherein the method comprises administering to the subject a pharmaceutical composition comprising a therapeutically effective amount of the TLR agonist, wherein the pharmaceutical composition is an ingestible device, and the method comprises administering orally to the subject the pharmaceutical composition.

releasing a TLR agonist at a location in the gastrointestinal tract of the subject that is proximate to one or more sites of disease, wherein the method comprises administering to the subject a pharmaceutical composition comprising a therapeutically effective amount of the TLR agonist, wherein the method provides a concentration of the TLR agonist in the plasma of the subject that is less than 3 μg/ml.

releasing a TLR agonist at a location in the proximal portion of the large intestine of the subject that is proximate to one or more sites of disease,

In another aspect of the present invention, there is provided a TLR agonist for use in a method of treating a disease of the gastrointestinal tract in a subject, wherein the method comprises orally administering to the subject an ingestible device loaded with the TLR agonist, wherein the TLR agonist is released by the device at a location in the gastrointestinal tract of the subject that is proximate to one or more sites of disease.

In another aspect, the present invention provides a composition comprising or consisting of an ingestible device loaded with a therapeutically effective amount of a TLR agonist, for use in a method of treatment, wherein the method comprises orally administering the composition to the subject, wherein the TLR agonist is released by the device at a location in the gastrointestinal tract of the subject that is proximate to one or more sites of disease.

In another aspect, the present invention provides an ingestible device loaded with a therapeutically effective amount of a TLR agonist, wherein the device is controllable to release the TLR agonist at a location in the gastrointestinal tract of the subject that is proximate to one or more sites of disease. The device may be for use in a method of treatment of the human or animal body, for example, any method as described herein. In still another aspect, the present invention provides an ingestible device for use in a method of treating a disease of the gastrointestinal tract in a subject, wherein the method comprises orally administering to the subject the ingestible device loaded with a therapeutically effective amount of a TLR agonist, wherein the TLR agonist is released by the device at a location in the gastrointestinal tract of the subject that is proximate to one or more sites of disease.

An ingestible device as used in the present invention may comprise one or more mechanical and/or electrical mechanisms which actively control release of the TLR agonist. For example, in any of the above aspects and embodiments, the ingestible device as used in the present invention may comprise a release mechanism for release of the TLR agonist (e.g., from a reservoir comprising the TLR agonist) and an actuator controlling the release mechanism.

In one embodiment, the ingestible device comprises:

an ingestible housing comprising a reservoir having a therapeutically effective amount of the TLR agonist stored therein;

a release mechanism having a closed state which retains the TLR agonist in the reservoir and an open state which releases the TLR agonist from the reservoir to the exterior of the device; and

an actuator which changes the state of the release mechanism from the closed to the open state.

In one embodiment, the ingestible device comprises

a housing defined by a first end, a second end substantially opposite from the first end;

a reservoir located within the housing and containing the TLR agonist wherein a first end of the reservoir is attached to the first end of the housing;

a mechanism for releasing the TLR agonist from the reservoir;

and

an exit valve configured to allow the TLR agonist to be released out of the housing from the reservoir.

Here, the exit valve can be considered as the release mechanism having a closed state which retains the TLR agonist in the reservoir and an open state which releases the TLR agonist from the reservoir to the exterior of the device, and the mechanism for releasing the TLR agonist from the reservoir can be considered as the actuator. In some embodiments of methods of treatment as described herein, the one or more disease sites may have been pre-determined (e.g., determined in a step preceding the administration of the composition of the present invention). The disease site(s) may have been determined by imaging the gastrointestinal tract. For example, the disease site(s) may have been predetermined by endoscopy (e.g., a step of colonoscopy, enteroscopy, or using a capsule endoscope). Determination that the device is proximate to the disease site may therefore comprise a determining that the device is in a location corresponding to this previously- determined disease site.

In some embodiments, the location of the device in the gut may be detected by tracking the device. For example, the device may comprise a localization mechanism which may be a communication system for transmitting localization data, e.g., by radiofrequency transmission. The device may additionally or alternatively comprise a communication system for receiving a signal remotely triggering the actuator and thus causing release of the TLR agonist. The signal may be sent when it is determined that the device is in the correct location in the gut.

Thus, the ingestible device may comprise:

a release mechanism having a closed state which retains the TLR agonist in the reservoir and an open state which releases the TLR agonist from the reservoir to the exterior of the device;

a communication system for transmitting localization data to an external receiver and for receiving a signal from an external transmitter; and an actuator which changes the state of the release mechanism from the closed to the open state and which can be triggered by the signal.

In other embodiments, the ingestible device as used in the present invention may comprise an environmental sensor for detecting the location of the device in the gut and/or for detecting the presence of disease in the GI tract. For example, the environment sensor may be an image sensor for obtaining images in vivo.

Detecting the presence of disease may comprise, for example, detecting the presence of inflamed tissue, and/or lesions such as ulceration e.g., aphthoid ulcerations, "punched-out ulcers" and/or superficial ulcers of the mucosa, cobblestoning, stenosis, granulomas, crypt abscesses, fissures, e.g., extensive linear fissures, villous atrophy, fibrosis, and/or bleeding.

Detecting the presence of disease may also comprise molecular sensing, such as detecting the amount of an inflammatory cytokine or other marker of inflammation. Such a marker can be measured locally from a biopsy or systemically in the serum.

Where the ingestible device comprises an environmental sensor, actuation of the release mechanism may be triggered by a processor or controller communicably coupled to the environmental sensor. Thus, in some embodiments, the device may not require any external signal or control in order to release the drug.

In one embodiment, the ingestible device may comprise:

an actuator which controls the transition of the release mechanism from the closed to the open state;

a detector for detecting the location of the device in the gut and/or the presence of diseased tissue; and

a processor or controller which is coupled to the detector and to the actuator and which triggers the actuator to cause the release mechanism to transition from its closed state to its open state when it is determined that the device is in the presence of diseased tissue and/or in a location in the gut that has been predetermined to be proximal to diseased tissue.

In another embodiment, there is provided:

a detector coupled to the ingestible housing, the detector configured to detect when the ingestible housing is proximate to a respective disease site of the one of the one or more sites of disease;

a valve system in fluid communication with the reservoir system; and a controller communicably coupled to the valve system and the detector, the controller configured to cause the valve system to open in response to the detector detecting that the ingestible housing is proximate to the respective disease site so as to release the therapeutically effective amount of the TLR agonist at the respective disease site.

As above, detection that the ingestible housing is proximate to the respective disease site may be based on environmental data indicating the location of the device in the GI tract (and reference to a pre-determined disease site) or on environmental data directly indicating the presence of diseased tissue.

Additionaly or alternatively, the device may further comprise a communication system adapted to transmit the environment data to an external receiver (e.g., outside of the body). This data may be used, for example, for diagnostic purposes. The external receiver may comprise means for displaying the data.

In some embodiments, this data may be analyzed externally to the device and used to determine when the drug should be released: an external signal may then be sent to the device to trigger release of the drug. Thus, the communication system may further be adapted to receive a signal remotely triggering the actuator and thus causing release of the TLR agonist. The signal may be sent from an external transmitter in response to receipt/analysis and/or assessment of the environmental data, e.g., data indicating that the device has reached the desired location of the gut (where the location of the diseased tissue has been pre-determined) and/or data indicating the presence of diseased tissue. "External" may be "outside of the body".

Thus, in another embodiment, the ingestible device may comprise:

an ingestible housing comprising a reservoir having a a therapeutically effective amount of the TLR agonist stored therein;

an environmental detector for detecting environmental data indicating the location of the device in the gut and/or the presence of diseased tissue;

a communication system for transmitting the environmental data to an external receiver and for receiving a signal from an external transmitter; and an actuator which controls the transition of the release mechanism from the closed to the open state in response to the signal. It will be understood from the above that when the device comprises one or more environmental detectors, e.g., comprises an image detector, the compositions may be used both for disease detection and for disease treatment.

Accordingly, in a further embodiment, there is provided a TLR agonist for use in a method of detecting and treating a disease of the gastrointestinal tract in a subject, wherein the method comprises orally administering to the subject an ingestible device loaded with the TLR agonist, wherein the ingestible device comprises an environmental sensor for determining the presence of diseased tissue in the GI tract, and wherein the TLR agonist is released by the device at a location in the gastrointestinal tract of the subject that is proximate to one or more sites of disease, as detected by the environmental sensor. The device may be according to any of the embodiments described herein.

In another embodiment, there is provided a composition for use in a method of detecting and treating a disease of the gastrointestinal tract in a subject, wherein the composition comprises or consists of an ingestible device loaded with a therapeutically effective amount of a TLR agonist, wherein the ingestible device comprises an environmental sensor for determining the presence of diseased tissue in the GI tract, and wherein the TLR agonist is released by the device at a location in the gastrointestinal tract of the subject that is proximate to one or more sites of disease, as detected by the environmental sensor. Again, the device may be according to any of the embodiments described herein.

In some embodiments, where the ingestible device as used in the present invention comprises an environmental sensor for detecting the presence of disease in the GI tract and a communication system as described above, the method of treatment may comprise:

i) receiving at an external receiver from the ingestible device a signal transmitting the environmental data;

ii) assessing the environmental data to confirm the presence of the disease; and iii) when the presence of the disease is confirmed, sending from an external transmitter to the ingestible device a signal triggering release of the TLR agonist.

For example, the presence of disease may be confirmed based on the presence of inflamed tissue and/or lesions associated with any of the disease states referred to herein. For example, the presence of disease may be confirmed based on the presence of inflammation, ulceration e.g., aphthoid ulcerations, "punched-out ulcers" and/or superficial ulcers of the mucosa, cobblestoning, stenosis, granulomas, crypt abscesses, fissures, e.g., extensive linear fissures, villous atrophy, fibrosis, and/or bleeding. In some embodiments, the present invention may relate to a system comprising: an ingestible device loaded with a therapeutically effective amount of a TLR agonist, a release mechanism for release of the TLR agonist (e.g., from a reservoir comprising the TLR agonist), an actuator controlling the release mechanism, an environmental sensor for determining the location of the device in the gut and/or for detecting the presence of diseased tissue and a communication system adapted to transmit the environment data and receive a signal triggering the actuator;

a receiver and display module for receiving and displaying outside of the body the environment data from the ingestible device;

a transmitter for sending to the ingestible device a signal triggering the actuator.

In any of the above embodiments, the ingestible device may further comprise an anchoring system for anchoring the device or a portion thereof in a location and an actuator for the anchoring system. This may be triggered in response to a determination that the device is at a location in the gastrointestinal tract of the subject proximate to one or more sites of disease. For instance, this may be detected by the environmental sensor. The triggering may be controlled by a processor in the device, that is, autonomously. A device where the triggering is controlled by a processor in the device is said to be an autonomous device. Alternatively, it may be controlled by a signal sent from outside of the body, as described above.

In any of the above aspects and embodiments, disease of the GI tract may be an inflammatory bowel disease.

In some embodiments, the disease of the GI tract is ulcerative colitis.

In some embodiments, the disease of the GI tract is Crohn's disease.

In general, apparatuses, compositions, and methods disclosed herein are useful in the treatment of diseases of the gastrointestinal tract. Exemplary gastrointestinal tract diseases that can be treated include, without limitation, inflammatory bowel disease (IBD), Crohn's disease (e.g., active Crohn's disease, refractory Crohn's disease, or fistulizing Crohn's disease), ulcerative colitis, indeterminate colitis, microscopic colitis, infectious colitis, drug or chemical-induced colitis, diverticulitis, and ischemic colitis, gastritis, peptic ulcers, stress ulcers, bleeding ulcers, gastric hyperacidity, dyspepsia, gastroparesis, Zollinger-Ellison syndrome, gastroesophageal reflux disease, short-bowel (anastomosis) syndrome, a hypersecretory state associated with systemic mastocytosis or basophilic leukemia or hyperhistaminemia, Celiac disease (e.g., nontropical Sprue), enteropathy associated with seronegative arthropathies, microscopic colitis, collagenous colitis, eosinophilic

gastroenteritis, colitis associated with radiotherapy or chemotherapy, colitis associated with disorders of innate immunity as in leukocyte adhesion deficiency-1, chronic granulomatous disease, food allergies, gastritis, infectious gastritis or enterocolitis (e.g., Helicobacter pylori- infected chronic active gastritis), other forms of gastrointestinal inflammation caused by an infectious agent, pseudomembranous colitis, hemorrhagic colitis, hemolytic-uremic syndrome colitis, diversion colitis, irritable bowel syndrome, irritable colon syndrome, and pouchitis. In some embodiments, apparatuses, compositions, and methods disclosed herein are used to treat one gastrointestinal disease. In some embodiments, apparatuses, compositions, and methods disclosed herein are used to treat more than one gastrointestinal disease. In some embodiments, apparatuses, compositions, and methods disclosed herein are used to treat multiple gastrointestinal diseases that occur in the same area of the gastrointestinal tract (e.g., each disease can occur in the small intestine, large intestine, colon, or any sub-region thereof). In some embodiments, apparatuses, compositions, and methods disclosed herein are used to treat multiple gastrointestinal diseases that occur in different areas of the

gastrointestinal tract. In some embodiments, administration (e.g., local administration to the gastrointestinal tract) of TLR agonist is useful in the treatment of gastrointestinal diseases including, but not limited to, inflammatory bowel disease (IBD), ulcerative colitis, Crohn's disease, or any of the other gastrointestinal diseases described herein.

Aspects and embodiments as described herein are intended to be freely combinable.

For example, any details or embodiments described herein for methods of treatment apply equally to a TLR agonist, composition or ingestible device for use in said treatment. Any details or embodiments described for a device apply equally to methods of treatment using the device, or to a TLR agonist or composition for use in a method of treatment involving the device.

Brief Description of the Drawings

FIG. 1 provides an exemplary structural diagram illustrating aspects of an ingestible device 100 having a piston to push for drug delivery, according to some embodiments described herein.

FIG. 2 provides another exemplary structural diagram illustrating aspects of an ingestible device 100 having a piston to push for drug delivery, according to some embodiments described herein. Detailed description Definitions:

By "ingestible", it is meant that the device can be swallowed whole.

"Gastrointestinal inflammatory disorders" are a group of chronic disorders that cause inflammation and/or ulceration in the mucous membrane. These disorders include, for example, inflammatory bowel disease (e.g., Crohn's disease, ulcerative colitis, indeterminate colitis and infectious colitis), mucositis (e.g., oral mucositis, gastrointestinal mucositis, nasal mucositis and proctitis), necrotizing enterocolitis and esophagitis.

"Inflammatory Bowel Disease" or "IBD" is a chronic inflammatory autoimmune condition of the gastrointestinal (GI) tract. The GI tract can be divided into four main different sections, the oesophagus, stomach, small intestine and large intestine or colon. The small intestine possesses three main subcompartments: the duodenum, jejunum and ileum. Similarly, the large intestine consists of six sections: the cecum, ascending colon, transverse colon, ascending colon, sigmoid colon, and the rectum. The small intestine is about 6 m long, its diameter is 2.5 to 3 cm and the transit time through it is typically 3 hours. The duodenum has a C-shape, and is 30 cm long. Due to its direct connection with the stomach, it is physically more stable than the jejunum and ileum, which are sections that can freely move. The jejunum is 2.4 m in length and the ileum is 3.6 m in length and their surface areas are 180 m² and 280 m² respectively. The large intestine is 1.5 m long, its diameter is between 6.3 and 6.5 cm, the transit time though this section is 20 hours and has a reduced surface area of approximately 150 m². The higher surface area of the small intestine enhances its capacity for systemic drug absorption.

The etiology of IBD is complex, and many aspects of the pathogenesis remain unclear. The treatment of moderate to severe IBD poses

significant challenges to treating physicians, because conventional therapy with

corticosteroids and immunomodulator therapy (e.g., azathioprine, 6 mercaptopurine, and methotrexate administered via traditional routes such as tablet form, oral suspension, or intravenously) is associated with side effects and intolerance and has not shown proven benefit in maintenance therapy (steroids). Monoclonal antibodies targeting tumor necrosis factor alpha (TNF-a), such as infliximab (a chimeric antibody) and adalimumab (a fully human antibody), are currently used in the management of CD. Infliximab has also shown efficacy and has been approved for use in UC. However, approximately 10%-20% of patients with CD are primary nonresponders to anti TNF therapy, and another ~20%-30% of CD patients lose response over time (Schnitzler et al., Gut 58:492-500 (2009)). Other adverse events (AEs) associated with anti TNFs include elevated rates of bacterial infection, including tuberculosis, and, more rarely, lymphoma and demyelination (Chang et al., Nat Clin Pract Gastroenterol Hepatology 3:220 (2006); Hoentjen et al, World J. Gastroenterol. 15(17):2067 (2009)). No currently available therapy achieves sustained remission in more than 20%-30% of IBD patients with chronic disease (Hanauer et al, Lancet 359: 1541-49 (2002); Sandborn et al, N Engl J Med 353: 1912-25 (2005)). In addition, most patients do not achieve sustained steroid-free remission and mucosal healing, clinical outcomes that correlate with true disease modification.

Although the cause of IBD remains unknown, several factors such as genetic, infectious and immunologic susceptibility have been implicated. IBD is much more common in Caucasians, especially those of Jewish descent. The chronic inflammatory nature of the condition has prompted an intense search for a possible infectious cause. Although agents have been found which stimulate acute inflammation, none has been found to cause the chronic inflammation associated with IBD. The hypothesis that IBD is an autoimmune disease is supported by the previously mentioned extraintestinal manifestation of IBD as joint arthritis, and the known positive response to IBD by treatment with therapeutic agents such as adrenal glucocorticoids, cyclosporine and azathioprine, which are known to suppress immune response. In addition, the GI tract, more than any other organ of the body, is continuously exposed to potential antigenic substances such as proteins from food, bacterial byproducts (LPS), etc.

A chronic inflammatory autoimmune condition of the gastrointestinal (GI) tract presents clinically as either ulcerative colitis (UC) or Crohn's disease (CD). Both IBD conditions are associated with an increased risk for malignancy of the GI tract.

"Crohn's disease" ("CD") is a chronic transmural inflammatory disease

with the potential to affect any part of the entire GI tract, and UC is a mucosal

inflammation of the colon. Both conditions are characterized clinically by frequent bowel motions, malnutrition, and dehydration, with disruption in the activities of daily living.

CD is frequently complicated by the development of malabsorption, strictures, and fistulae and may require repeated surgery. UC, less frequently, may be complicated by severe bloody diarrhea and toxic megacolon, also requiring surgery. The most prominent feature Crohn's disease is the granular, reddish-purple edematous thickening of the bowel wall. With the development of inflammation, these granulomas often lose their circumscribed borders and integrate with the surrounding tissue. Diarrhea and obstruction of the bowel are the predominant clinical features. As with ulcerative colitis, the course of Crohn's disease may be continuous or relapsing, mild or severe, but unlike ulcerative colitis, Crohn's disease is not curable by resection of the involved segment of bowel. Most patients with Crohn's disease require surgery at some point, but subsequent relapse is common and continuous medical treatment is usual. Crohn's disease may involve any part of the alimentary tract from the mouth to the anus, although typically it appears in the ileocolic, small-intestinal or colonic- anorectal regions. Histopathologically, the disease manifests by discontinuous

granulomatomas, crypt abscesses, fissures and aphthous ulcers. The inflammatory infiltrate is mixed, consisting of lymphocytes (both T and B cells), plasma cells, macrophages, and neutrophils. There is a disproportionate increase in IgM- and IgG-secreting plasma cells, macrophages and neutrophils.

To date, the primary outcome measure in Crohn's Disease clinical trials is the Crohn's

Disease Activity Index (CDAI), which has served as the basis for approval of multiple drug treatments, including for example, vedolizumab and natalizumab. The CDAI was developed by regressing clinician global assessment of disease activity on eighteen potential items representing patient reported outcomes (PROs) (i.e. abdominal pain, pain awakening patient from sleep, appetite), physical signs (i.e. average daily temperature, abdominal mass), medication use (i.e. loperamide or opiate use for diarrhea) and a laboratory test (i.e.

hematocrit). Backward stepwise regression analysis identified eight independent predictors which are the number of liquid or soft stools, severity of abdominal pain, general well-being, occurrence of extra-intestinal symptoms, need for anti diarrheal drugs, presence of an abdominal mass, hematocrit, and body weight. The final score is a composite of these eight items, adjusted using regression coefficients and standardization to construct an overall CDAI score, ranging from 0 to 600 with higher score indicating greater disease activity. Widely used benchmarks are: CDAI <150 is defined as clinical remission, 150 to 219 is defined as mildly active disease, 220 to 450 is defined as moderately active disease, and above 450 is defined as very severe disease (Best WR, et al, Gastroenterology 77:843-6, 1979).

Vedolizumab and natalizumab have been approved on the basis of demonstrated clinical remission, i.e. CDAI < 150. Although the CDAI has been in use for over 40 years, and has served as the basis for drug approval, it has several limitations as an outcome measure for clinical trials. For example, most of the overall score comes from the patient diary card items (pain, number of liquid bowel movements, and general well-being), which are vaguely defined and not standardized terms (Sandler et al, J. Clin. Epidemiol 41 :451-8, 1988; Thia et al.,

Inflamm Bowel Dis 17: 105-11, 2011). In addition, measurement of pain is based on a four- point scale rather than an updated seven-point scale. The remaining 5 index items contribute very little to identifying an efficacy signal and may be a source of measurement noise.

Furthermore, concerns have been raised about poor criterion validity for the CDAI, a reported lack of correlation between the CDAI and endoscopic measures of inflammation (which may render the CDAI as a poor discriminator of active CD and irritable bowel syndrome) and high reported placebo rates (Korzenik et al, N Engl J Med. 352:2193-201, 2005; Sandborn WJ, et al, N Engl J Med 353 : 1912-25, 2005; Sandborn WJ, et al, Ann Intern 19; 146:829-38, 2007, Epub 2007 Apr 30; Kim et al, Gastroenterology 146: (5 supplement 1) S-368, 2014).

It is, thus, generally recognized that additional or alternative measures of CD symptoms are needed, such as new PRO tools or adaptations of the CDAI to derive a new PRO. The PR02 and PR03 tools are such adaptations of the CDAI and have been recently described in Khanna et al., Aliment Pharmacol. Ther. 41 :77-86, 2015. The PR02

evaluates the frequency of loose/liquid stools and abdominal pain {Id). These items are derived and weighted accordingly from the CDAI and are the CDAI diary card items, along with general well-being, that contribute most to the observed clinical benefit measured by CDAI (Sandler et al, J. Clin. Epidemiol 41 :451-8, 1988; Thia et al, Inflamm Bowel Dis 17: 105-11, 2011; Kim et al, Gastroenterology 146: (5 supplement 1) S-368,

2014). The remission score of < 11 is the CDAI-weighted sum of the average stool frequency and pain scores in a 7-day period, which yielded optimum sensitivity and specificity for identification of CDAI remission (score of < 150) in a retrospective data

analysis of ustekinumab induction treatment for moderate to severe CD in a Phase II clinical study (Gasink C, et al, abstract, ACG Annual Meeting 2014). The PR02 was shown to be sensitive and responsive when used as a continuous outcome measure in a retrospective data analysis of MTX treatment in active CD (Khanna R, et al, Inflamm Bowel Dis 20: 1850-61, 2014) measured by CDAI. Additional outcome measures include the Mayo Clinic Score, the Crohn disease endoscopic index of severity (CDEIS), and the Ulcerative colitis endoscopic index of severity (UCEIS). Additional outcome measures include Clinical remission, Mucosal healing, Histological healing (transmural), MRI or ultrasound for measurement or evaluation of bowel wall thickness, abscesses, fistula and histology.

An additional means of assessing the extent and severity of Crohn's Disease is endoscopy. Endoscopic lesions typical of Crohn's disease have been described in numerous studies and include, e.g., aphthoid ulcerations, "punched-out ulcers," cobblestoning and stenosis. Endoscopic evaluation of such lesions was used to develop the first validated endoscopic score, the Crohn's Disease Endoscopic Index of Severity (CDEIS) (Mary et al, Gut 39:983-9, 1989). More recently, because the CDEIS is time-consuming, complicated and impractical for routine use, a Simplified Endoscopic Activity Score for Crohn's Disease (SES- CD) was developed and validated (Dapemo et al, Gastrointest. Endosc. 60(4):505-12, 2004). The SES-CD consists of four endoscopic variables (size of ulcers,

proportion of surface covered by ulcers, proportion of surface with any other lesions (e.g., inflammation), and presence of narrowings [stenosis]) that are scored in five ileocolonic segments, with each variable, or assessment, rated from 0 to 3.

To date, there is no cure for CD. Accordingly, the current treatment goals for CD are to induce and maintain symptom improvement, induce mucosal healing, avoid surgery, and improve quality of life (Lichtenstein GR, et al., Am J Gastroenterol 104:465-83, 2009; Van Assche G, et al, J Crohns Colitis. 4:63-101, 2010). The current therapy of IBD usually involves the administration of antiinflammatory or immunosuppressive agents, such as sulfasalazine, corticosteroids, 6- mercaptopurine/azathioprine, or cyclosporine, all of which are not typically delivered by localized release of a drug at the site or location of disease. More recently, biologies like TNF-alpha inhibitors and IL-12/IL-23 blockers, are used to treat IBD. If anti-inflammatory/immunosuppressive/biologic therapies fail, colectomies are the last line of defense. The typical operation for CD not involving the rectum is resection (removal of a diseased segment of bowel) and anastomosis (reconnection) without an ostomy. Sections of the small or large intestine may be removed. About 30% of CD patients will need surgery within the first year after diagnosis. In the subsequent years, the rate is about 5% per year. Unfortunately, CD is characterized by a high rate of recurrence; about 5% of patients need a second surgery each year after initial surgery.

Refining a diagnosis of inflammatory bowel disease involves evaluating the progression status of the diseases using standard classification criteria. The classification systems used in IBD include the Truelove and Witts Index (Truelove S. C. and Witts, L.J. Br Med J. 1955;2: 1041-1048), which classifies colitis as mild, moderate, or severe, as well as Lennard- Jones. (Lennard- Jones JE. Scand J Gastroenterol Suppl 1989; 170:2-6) and the simple clinical colitis activity index (SCCAI). (Walmsley et. al. Gut. 1998;43:29-32) These systems track such variables as daily bowel movements, rectal bleeding, temperature, heart rate, hemoglobin levels, erythrocyte sedimentation rate, weight, hematocrit score, and the level of serum albumin.

There is sufficient overlap in the diagnostic criteria for UC and CD that it is sometimes impossible to say which a given patient has; however, the type of lesion typically seen is different, as is the localization. UC mostly appears in the colon, proximal to the rectum, and the characteristic lesion is a superficial ulcer of the mucosa; CD can appear anywhere in the bowel, with occasional involvement of stomach, esophagus and duodenum, and the lesions are usually described as extensive linear fissures.

In approximately 10-15% of cases, a definitive diagnosis of ulcerative colitis or Crohn's disease cannot be made and such cases are often referred to as "indeterminate colitis." Two antibody detection tests are available that can help the diagnosis, each of which assays for antibodies in the blood. The antibodies are "perinuclear anti-neutrophil antibody" (pANCA) and "anti-Saccharomyces cervisiae antibody" (ASCA). Most patients with ulcerative colitis have the pANCA antibody but not the ASCA antibody, while most patients with Crohn's disease have the ASCA antibody but not the pANCA antibody. However, these two tests have shortcomings as some patients have neither antibody and some Crohn's disease patients may have only the pANCA antibody. A third test, which measures the presence and accumulation of circulating anti-microbial antibodies - particularly flagellin antibodies, has proven to be useful for detecting susceptibility to Crohn's Disease before disease

development. See Choung, R. S., et al. "Serologic microbial associated markers can predict Crohn's disease behaviour years before disease diagnosis." Alimentary pharmacology & therapeutics 43.12 (2016): 1300-1310.

"Ulcerative colitis (UC)" afflicts the large intestine. The course of the disease may be continuous or relapsing, mild or severe. The earliest lesion is an inflammatory infiltration with abscess formation at the base of the crypts of Lieberkuhn. Coalescence of these distended and ruptured crypts tends to separate the overlying mucosa from its blood supply, leading to ulceration. Symptoms of the disease include cramping, lower abdominal pain, rectal bleeding, and frequent, loose discharges consisting mainly of blood, pus and mucus with scanty fecal particles. A total colectomy may be required for acute, severe or chronic, unremitting ulcerative colitis. The clinical features of UC are highly variable, and the onset may be insidious or abrupt, and may include diarrhea, tenesmus and relapsing rectal bleeding. With fulminant involvement of the entire colon, toxic megacolon, a life-threatening emergency, may occur. Extraintestinal manifestations include arthritis, pyoderma gangrenoum, uveitis, and erythema nodosum.

The terms "antibody" and "immunoglobulin" are used interchangeably in the broadest sense and include monoclonal antibodies (for example, full length or intact monoclonal antibodies), polyclonal antibodies, multivalent antibodies, multispecific antibodies (e.g., bispecific, trispecific etc. antibodies so long as they exhibit the desired biological activity) and may also include certain antibody fragments (as described in greater detail herein). An antibody can be human, humanized and/or affinity matured.

"Antibody fragments" comprise only a portion of an intact antibody, where in certain embodiments, the portion retains at least one, and typically most or all, of the functions normally associated with that portion when present in an intact antibody. In one embodiment, an antibody fragment comprises an antigen binding site of the intact antibody and thus retains the ability to bind antigen. In another embodiment, an antibody fragment, for example one that comprises the Fc region, retains at least one of the biological functions normally associated with the Fc region when present in an intact antibody, such as FcRn binding, antibody half-life modulation, ADCC function and complement binding. In one embodiment, an antibody fragment is a monovalent antibody that has an in vivo half-life substantially similar to an intact antibody. For example, such an antibody fragment may comprise on antigen binding arm linked to an Fc sequence capable of conferring in vivo stability to the fragment.

The term "monoclonal antibody" as used herein refers to an antibody obtained from a population of substantially homogeneous antibodies, i.e., the individual antibodies comprising the population are identical except for possible naturally occurring mutations that may be present in minor amounts. Monoclonal antibodies are highly specific, being directed against a single antigen. Furthermore, in contrast to polyclonal antibody preparations that typically include different antibodies directed against different determinants (epitopes), each monoclonal antibody is directed against a single determinant on the antigen.

The monoclonal antibodies herein specifically include "chimeric" antibodies in which a portion of the heavy and/or light chain is identical with or homologous to corresponding sequences in antibodies derived from a particular species or belonging to a particular antibody class or subclass, while the remainder of the chain(s) is identical with or homologous to corresponding sequences in antibodies derived from another species or belonging to another antibody class or subclass, as well as fragments of such antibodies, so long as they exhibit the desired biological activity (U.S. Patent No. 4,816,567; and Morrison et al, Proc. Natl. Acad. Sci. USA 81 :6851-6855 (1984)).

"Treatment regimen" refers to a combination of dosage, frequency of administration, or duration of treatment, with or without addition of a second medication.

"Effective treatment regimen" refers to a treatment regimen that will offer beneficial response to a patient receiving the treatment.

"Patient response" or "patient responsiveness" can be assessed using any endpoint indicating a benefit to the patient, including, without limitation, (1) inhibition, to some extent, of disease progression, including slowing down and complete arrest; (2) reduction in the number of disease episodes and/or symptoms; (3) reduction in lesional size; (4) inhibition (i.e., reduction, slowing down or complete stopping) of disease cell infiltration into adjacent peripheral organs and/or tissues; (5) inhibition (i.e., reduction, slowing down or complete stopping) of disease spread; (6) decrease of auto-immune response, which may, but does not have to, result in the regression or ablation of the disease lesion; (7) relief, to some extent, of one or more symptoms associated with the disorder; (8) increase in the length of disease-free presentation following treatment; and/or (9) decreased mortality at a given point of time following treatment. The term "responsiveness" refers to a measurable response, including complete response (CR) and partial response (PR).

As used herein, "complete response" or "CR" means the disappearance of all signs of inflammation or remission in response to treatment. This does not necessarily mean the disease has been cured.

"Partial response" or "PR" refers to a decrease of at least 50% in the severity of inflammation, in response to treatment.

A "beneficial response" of a patient to treatment with a therapeutic agent and similar wording refers to the clinical or therapeutic benefit imparted to a patient at risk for or suffering from a gastrointestinal inflammatory disorder from or as a result of the treatment with the agent. Such benefit includes cellular or biological responses, a complete response, a partial response, a stable disease (without progression or relapse), or a response with a later relapse of the patient from or as a result of the treatment with the agent. As used herein, "non-response" or "lack of response" or similar wording means an absence of a complete response, a partial response, or a beneficial response to treatment with a therapeutic agent.

"A patient maintains responsiveness to a treatment" when the patient' s responsiveness does not decrease with time during the course of a treatment.

A "symptom" of a disease or disorder (e.g., inflammatory bowel disease, e.g., ulcerative colitis or Crohn's disease) is any morbid phenomenon or departure from the normal in structure, function, or sensation, experienced by a subject and indicative of disease. TLR Agonists

The term "TLR agonist" is an agent that binds to and activates a toll-like receptor (TLR) expressed in a mammalian cell (e.g., a human cell). In some embodiments, the TLR agonist binds to and activates TLR1. In some embodiments, the TLR agonist binds to and activates TLR2. In some embodiments, the TLR agonist binds to and activates TLR3. In some embodiments, the TLR agonist binds to and activates TLR4. In some embodiments, the TLR agonist binds to and activates TLR5. In some embodiments, the TLR agonist binds to and activates TLR6. In some embodiments, the TLR agonist binds to and activates TLR7. In some embodiments, the TLR agonist binds to and activates TLR8. In some embodiments, the TLR agonist binds to and activates TLR9. In some embodiments, the TLR agonist binds to and activates TLR10. In some embodiments, the TLR agonist binds to and activates TLR11. In some embodiments, the TLR agonist binds to and activates two or more (e.g., three, four, five, six, seven, eight, nine, ten, or eleven) TLRs (e.g., two or more of any of TLR1, TLR2, TLR3, TLR4, TLR5, TLR6, TLR7, TLR8, TLR9, TLR10, and TLR11 (in any combination)).

In some embodiments, the TLR agonist is a synthetic TLR agonist, a TLR mimic, or a small molecule. Non-limiting examples of TLR agonists are described in Bhardwaj et al., Cancer J. 16(4):382-391, 2010; Meyer et al, Exp. Opin. Investig. Drugs 17(7): 1051-1065, 2008; Adams, Immunotherapy 1(6): 949-964, 2009; Hennessy et al, Nat. Rev. Drug Discov. 9:293-307, 2010; and U.S. Patent Nos. 7,498,409; 9,421,254; 8,409,813; 8,361,986;

8,795,678; 8,728,486; 8,636,979; 8,999,946; 9,359,360; 9,050,376; and 9,556,167; US 2014/0322271; US 2016/0206690; US 2009/0253622; US 2011/0135669; US 2011/0250175; US 2014/0220074; and US 2012/0219615; each incorporated in its entirety herein. In some embodiments, the TLR agonist is a peptide or a fusion protein (Huleatt et al, Vaccine 25: 763-775, 2007). In some embodiments, a TLR agonist specifically binds to and activates a single TLR (e.g., TLR4, TLR7, TLR8, or TLR9; Zhu et al, J. Clin. Invest. 120:607-616, 2010; Zhu et al, PNAS 105: 16260-16265, 2008; Wang et al, J. Virol. 79(22): 14355-14370, 2005). In some embodiments, the TLR agonist binds to and activates more than one TLR (e.g., Bacillus of Calmette-Guerin, Myobacterium bovis (BCG); Morton et εά., Αηη. Surg. 180(4):635-643, 1974; Mortoon et al, J. Clin. Oncol. ASCO Ann. Meeting Proceedings Part 125(18 Suppl), 2007). In some embodiments, the TLR agonist is a TLR2/TLR6 agonist (e.g., Parri2CSK4 or MALP-2 (Agnihotri et al, J. Med. Chem. 54: 8148-8160, 2011; Wu et al, J. Med. Chem. 53: 3198-3213, 2010)).

In some embodiments, the TLR agonist is administrated in combination with another composition (Dowling et al., Clin. Transl. Immunol. 5:e85, 2016). In some embodiments, the TLR agonist is an endogenous molecule released from dead cells (e.g., a heat shock protein (HSP) and mobility group box 1 (HMGB1); Asea et al., J. Biol. Chem. 277: 15028-15034, 2002; Kepp et al, Cancer Metastasis 30: 61-69, 2011).

TLR3 Agonists

In some embodiments, the TLR agonist specifically binds and activates TLR3 (e.g., a synthetic agonist). Non-limiting examples of TLR agonists that bind and activate TLR3 are described in Nicodemus et al, Immunotherapy 2: 137-140, 2010. In some embodiments, the TLR3 agonist is a synthetic double-stranded RNA (dsRNA) complex (e.g., polyribosinic: polyribocytidic acid (polyLC); Sivori et al, PNAS 101 : 10116-10121, 2004; Sloat et al, Pharmaceutical Res. 23: 1217-1226, 2006; Ichinohe et al, Microbes and infection/ Institut Pasteur 9: 1333-1340, 2007; Robinson et al., J. Natl. Cancer Inst. 57(3):599-602, 1976). In some embodiments, the TLR3 agonist is a TLR3 mimic (e.g., polyadenosine-polyuridylic acid (poly A:U) (Veyrat et al, Oncotarget 7(50):82580-82593, 2016; Alizadeh et al, Iran J. Allergy Asthma Immunol. 12(2): 161-167, 2013); rintatolimod (polyl: polyCU, Ampligen®) (Steinman et al., Nature 449: 419-426, 2007; Jasani et al, Vaccine 27(25-26):3401-3404, 2009; Strayer et al, PLoS One 7(3): e31334, 2012). In some embodiments, the TLR3 mimic is polyionisinic-polycytidylic acid stabilized with poly-L-lysine and carboxymethylcellulose (Poly-ICLC, Hiltonol®; Hawkins et al, J. Biol. Resp. Mod. 4:664-668, 1985; Butowski et al, J. Neurooncol. 91 : 175-182, 2009; Jeong et al., J. Neurochem. doi.10.1111, 2015). In some embodiments, the TLR3 agonist is RGCIOO (Naumann et al, Clin. Dev. Immunol. 283649, 2013), IPH-3102 (Basith et al, Exp. Opin. Ther. Pat. 21 : 927-944, 2011), or a variant thereof. In some embodiments, the TLR3 agonist is CQ-07001 (Clinquest). In some embodiments, the TLR3 agonist is Ampligen poly(I):poly(C12U) (Hemispherx Biopharma). In some embodiments, the TLR3 agonist is IPH-31XX (Innate Pharma). In some embodiments, the TLR3 agonist is MCT-465-dsRNA (MultiCell Technologies).

TLR4 Agonists

In some embodiments, the TLR agonist specifically binds to and activates TLR4 (Peri et al, J. Med. Chem. 57(9):3612-3622, 2014). In some embodiments, the TLR4 agonist is bacterial lipopolysaccharide (LPS) or a variant thereof. In some embodiments, the TLR4 agonist is monophosphoryl lipid A (MPL, MPLA, GLA, GLA-SE) (Ribi et al, J. Immunol. 6:567-572, 1984; Okemoto et al, J. Immunol. 176: 1203-1208, 2006; Matzner et al, Int. J. Cancer 138: 1754-1764, 2016; Cauwelaert et al, PLoS One l l(l):e0146372, 2016). In some embodiments, the TLR agonist is AS15 or AS02b (Brichard et al, Vaccine 25(Suppl. 2):B61- B71, 2007; Kruit et al, J. Clin. Oncol. 26(Suppl): Abstract 9065, 2008). In some

embodiments, the TLR agonist is an aminoalkyl glucosaminide 4-phosphate (e.g., RC-529, Ribi.529, E6020) or a variant thereof (Baldridge et al, J. Endotoxin Res. 8:453-458, 2002; Morefi eld et al, Clin. Vaccine Immunol. 14: 1499-1504, 2007). In some embodiments, the TLR agonist is picibanil (OK-432) (Hazim et al, Med. J. Malaysia 71(6):328-330, 2016; Tian et al., Asian Pac J. Cancer Prev. 16(11):4537-4542, 2015; Rebuffini et al, Dent Res e. J. 9(Suppl. 2):S192-S196, 2012). In some embodiments, the TLR4 agonist is Spirulina complex polysaccharide (Kwanishi et al, Microbiol. Immunol. 57:63-73, 2013). In some embodiments, the TLR4 agonist is chitohexaose or a variant thereof (Panda et al,

8:el002717, 2012; Barman et al, Cell Death Dis. 7:e2224, 2016). In some embodiments, the TLR4 agonist is E5564 (Eritoran) (Eisai). In some embodiments, the TLR4 agonist is CRX- 675 or CRX-527 (GSK).

TLR5 Agonists

In some embodiments, the TLR agonist binds and activates TLR5. In some embodiments, the TLR5 agonist is flagellin or a variant thereof (e.g., entolimod (CBLB502)) (Yoon et al, Science 335: 859-864, 2012; Fukuzawa et al, J. Immunol. 187:3831-3839,

2011; Brackett et al., PNAS l 13(7):E874-E883, 2015; Leigh et al, PLoS One 9(l):e85587, 2014; Hossain et al, Blood 120:255, 2012). In some embodiments, the TLR5 agonist is flagellin HuHa (Vaxinate) or flagellin HuM2e (Vaxinate). TLR7/8 Agonists

In some embodiments, the TLR agonist binds and activates TLR7/8 (e.g., TLR7 agonist, TLR8 agonist, or a TLR7 and TLR8 agonist). In some embodiments, the TLR7/8 agonist is ANA975 (isotorabine) (Anadys/Novartis), ANA773 (Anadys/Novartis),

In some embodiments, the TLR7/8 agonist is an imidazoquinoline or a variant thereof (e.g., imiquimod (Aldara™; Kaspari et al., British J. Dermatology 147: 757-759, 2002;

Smorlesi et al., Gene Therapy 12: 1324-133, 2005; Prins et al., J. Immunol. 176: 157-164, 2006; Shackleton et al, Cancer Immun. 4:9, 2004; Green et al, Br. J. Dermatol. 156(2):337- 345, 2007; Geisse et al, Am. Acad. Dermatol. 50(5):722-733, 2004; Wolf et al, Arch.

Dermatol. 139(3):273-276, 2003), resiquimod (R848; Hemmi et al, Nat. Immunol. 3: 196- 200, 2002; Jurk et al, Nat. Immunol. 3:49, 2002; Rook et al, Blood 126(12): 1452-1461, 2015; Dovedi et al, Blood 121 : 251-259, 2013). In some embodiments, the TLR agonist is a synthetic imiadzoquinoline mimicking viral single stranded RNA (ssRNA) (852A) or a variant thereof (Dudek et al., Clin. Cancer Res. 13(23):7119-7125, 2007; Dummer et al..

Clin. Cancer Res. 14(3):856-864, 2008; Weigel et al, Am. J. Hematol. 87(10):953-956, 2012; Geller et al, Cancer Immunol. Immunother. 59(12): 1877-1884, 2010; Inglefield et al., J. Interferon Cytokine Res. 28(4):253-263, 2008). In some embodiments, the TLR agonist is a small molecule. In some embodiments, the small molecule mimics viral ssRNA (e.g., motolimod (VTX-2337)) or a variant thereof (Dietsch et al, Clin. Cancer Res. 21(24):5445- 5452, 2015; Northfelt et al, Clin. Cancer Res. 20(14):3683-3691, 2014; Lu et al, Clin.

Cancer Res. 18(2):499-509, 2012). In some embodiments, the small molecule is GS-9620 or a variant thereof (Bam et al, Antimicrob Agents Chemother. 61(l):e01369, 2016;

Rebbapragada et al, PLoS One 1 l(l):e0146835, 2016; Gane et al, J. Hepatol. 63(2): 320- 328, 2015; Fosdick et al, J. Med. Chem. 56(18):7324-7333, 2013). In some embodiments, the small molecule is SCI (Wiedemann et al., Oncoimmunology 5(7):el 189051, 2016; Hamm et al, J. Immunol. 6(4):257-265, 2009). In some embodiments, the small molecule is gardiquimod (Ma et al, Cell. Mol. Immunol. 7:381-388, 2010; Hjelm et al, Hum. Vaccin. Immunother. 10(2): 410-416, 2014; Buitendijk et al., AIDS Res. Hum. Retroviruses

29(6):907-918, 2013), CL075 (Philbin et al, J. Allergy Clin. Immunol. 130: 195-204, 2012; Dowling et al, PLoS One 8(3): e58164, 2013), CL097 (Gorden et al, J. Immunol. 174: 1259- 1268, 2005; Gorski et al, Int. Immunol. 2006; Levy et al, Blood 108: 1284-1289, 2006; Wille-Reece et al, J. Exp. Med. 203: 1249-1258, 2006), loxoribine (Pope et al, Cell Immunol. 162:333, 1995; Heil et al, Eur. J. Immunol. 33:2987-2997, 2003; Lee et al., PNAS 100:6646-6651, 2003), or VTX-294 (Dowling et al., PLoS One 8(3):e58164, 2013). In some embodiments, the TLR7/8 agonist is IMO-9200. In some embodiments, the TLR7 agaonist is IPH-32XX (Innate Pharma).

TLR9 Agonists

In some embodiments, the TLR agonist binds and activates TLR9. In some embodiments, the TLR9 agonist is a synthetic oligonucleotide. In some embodiments, the synthetic oligonucleotide contains unmethylated CpG dinucleotide (CpG-ODN) (Krieg, J. Clin. Invest. 117: 1184-1194, 2007; Carpentier et al, Neuro-oncol. 8(l):60-66, 2006; Link et al, J. Immunother. 29(5): 558-568, 2006; Pashenkov et al., J. Clin. Oncol. 24(36): 5716- 5724, 2006; Meng et al, BMC Biotechnol. 11:88, 2011). In some embodiments, the TLR9 agonist is PF-3512676 or a variant thereof (Hofmann et al., J. Immunother. 31(5):520-527, 2008; Molenkamp et al, Clin. Caner. Res. 14(14):4532-4542, 2008). In some embodiments, the TLR9 agonist is IMO-2055 (EMD1201801) or a variant thereof (Machiels et al., Investig. New Drugs 31: 1207-1216, 2013). In some embodiments, the TLR9 agonist is DIMS0150 (Atreya et al, J. Crohns Colitis 10(11): 1294-1302, 2016). In some embodiments, the TLR9 agonist is CpG7909 (Vaximmune) (Coley, GSK, Novartis, DARPA). In some embodiments, the TLR9 agonist is IMO-9200. In some embodiments, the TLR9 agonist is AVE0675 (Coley, Sanofi Aventis). In some embodiments, the TLR9 agonist is Amplivax (Idera).

Microbial Products as TLR Agonists

In some embodiments, the TLR agonist is a bacterial or viral component. In some embodiments, the TLR agonist is derived from the cell wall Mycobacterium bovis (BCG). In some embodiments, the Mycobacterium bovis cell wall component is a TLR2 and/or TLR4 agonist (e.g., SMP105 (Murata et al, Cancer Sci. 99: 1435-1440, 2008; Miyauchi et al, Drug Discov. Ther. 6: 218-225, 2013; Tsuji et al., Infect Immun. 68: 6883-6890, 2000; Smith et al., Cancer Immunol. Immunother. 63(8):787-796, 2014). Additional examples of TLR agonists are known in the art.

TLR Antagonists

By the term "TLR antagonist" means an agent that decreases the binding of a TLR agonist to TLR4 or TLR9 expressed in a mammalian cell (e.g., a human cell). In some embodiments, any of the compositions, devices, or kits described herein can include a TLR antagonist. For example, a TLR antagonist can be a TLR4 antagonist. In other examples, a TLR antagonist is a TLR9 antagonist. Non-limiting examples of TLR antagonists are described in Fukata et al, Mucosal Immunity 6:451-463, 2013.

A non-limiting example of a TLR4 antagonist is 1A6 (Ungaro et ?&., Am. J. Physiol. Gastrointest. Liver Physiol. 296: Gl 167-G1179, 2009) or CRX-526 (Fort et al. , J. Immunol. 174:6416-6423, 2005). Additional examples of TLR4 antagonists include eritoran tetrasodium (E5564) (Sun et al, Investigative Ophthalmol. Visual Sci. 50(3): 1247-1254, 2009), small heat shock protein B8 (HSP22) (Roelofs et al., J. Immunol. 176(11):7021-7027, 2006), CRX-527 (Bazin et al, Bioorganic Med. Chem. Letters 18(2):5350-5354, 2008), E5564 (Kitazawa et al, J. Gastroentrol. Hepatol. 25(5):1009-1012, 2010), IAXO-102 (Huggins et al., Atherosclerosis 242(2):563-570, 2015), AG-411 (Kondo et al, Trends Immunol. 33(9):449-458, 2012), CRX-52624 (Alderson et al., J. Endotoxin Res. 12(5):313- 319, 2006), E5531 (Becker et al, Toxicol. Appl. Pharmacol. 207(2):269-275, 2005).

A non-limiting example of a TLR9 antagonist is adenoviral oligodeoxynucleotides (AV-ODN) (Obermeier et al, Gastroenterology 129:913-927, 2005). Additional examples of TLR9 antagonists include ODN 2088, ODN 4084-F, ODN INH-1, ODN INH-18, ODN TTAGGG (A151), and G-ODN (each commercially available from InvivoGen). In some embodiments, the TLR9 antagonist is CpG-ODN c41 (Li et al, Vaccine 29:2193-2198, 2011). In some embodiments, the TLR9 antagonist is COV08-0064 (Shaker et al,

Biochemical Pharmacol. 112:90-101, 2016; Hoque et al, J. Immunol. 190(8):4297-4304, 2013); ODN 1585, ODN 1826, ODN 2395, and ODN 2088 (Boivin et al., Antiviral Res. 96(3):414-421, 2012); IMO-8400 (Zhu et al., J. Immunol. 188(1):119, 2012); IRS869 (Mandl et al, Nature Med. 14(10: 1077-1087, 2008); IMO-3100 (Hennessy et al, Nature Rev. Drug Discov. 9(4):293-307, 2010); TTAGGG (Carvalho et al, PLoS One 6(1 l):e28256, 2011); and CpG ODN 2088 (David et al, J. Neurotrauma 31(21): 1800-1806, 2014).

Exemplary embodiments:

The following exemplary embodiments 1) - 94) are provided herein:

1) A method of treating a disease of the gastro-intestinal tract in a subject, comprising: delivering a TLR agonist at a location in the gastrointestinal tract of the subject,

wherein the method comprises administering orally to the subject a pharmaceutical composition comprising a therapeutically effective amount of the TLR agonist. 2) The method of exemplary embodiment 1, wherein the disease of the GI tract is an inflammatory bowel disease.

3) The method of exemplary embodiment 1, wherein the disease of the GI tract is

ulcerative colitis.

4) The method of exemplary embodiment 1, wherein the disease of the GI tract is

Crohn's disease.

5) The method of any one of exemplary embodiments 1, 2, or 3, 4, wherein the TLR agonist is delivered at a location in the large intestine of the subject.

6) The method of exemplary embodiment 5, wherein the location is in the proximal portion of the large intestine.

7) The method of exemplary embodiment 5, wherein the location is in the distal portion of the large intestine.

8) The method of any one of exemplary embodiments 1, 2, or 3, 4, wherein the TLR agonist is delivered at a location in the ascending colon of the subject.

9) The method of exemplary embodiment 8, wherein the location is in the proximal portion of the ascending colon.

10) The method of exemplary embodiment 8, wherein the location is in the distal portion of the ascending colon.

11) The method of any one of exemplary embodiments 1, 2, or 3, 4, wherein the TLR agonist is delivered at a location in the cecum of the subject.

12) The method of exemplary embodiment 11, wherein the location is in the proximal portion of the cecum.

13) The method of exemplary embodiment 11, wherein the location is in the distal portion of the cecum.

14) The method of any one of exemplary embodiments 1, 2, or 3, 4, wherein the TLR agonist is delivered at a location in the sigmoid colon of the subject.

15) The method of exemplary embodiment 14, wherein the location is in the proximal portion of the sigmoid colon.

16) The method of exemplary embodiment 14, wherein the location is in the distal portion of the sigmoid colon.

17) The method of any one of exemplary embodiments 1, 2, or 3, 4, wherein the TLR agonist is delivered at a location in the transverse colon of the subject. 18) The method of exemplary embodiment 17, wherein the location is in the proximal portion of the transverse colon.

19) The method of exemplary embodiment 17, wherein the location is in the distal portion of the transverse colon.

20) The method of any one of exemplary embodiments 1, 2, or 3, 4, wherein the TLR agonist is delivered at a location in the descending colon of the subject.

21) The method of exemplary embodiment 20, wherein the location is in the proximal portion of the descending colon.

22) The method of exemplary embodiment 20, wherein the location is in the distal portion of the descending colon.

23) The method of any one of exemplary embodiments 1, 2, or 3, 4, wherein the TLR agonist is delivered at a location in the small intestine of the subject.

24) The method of exemplary embodiment 23, wherein the location is in the proximal portion of the small intestine.

25) The method of exemplary embodiment 23, wherein the location is in the distal portion of the small intestine.

26) The method of any one of exemplary embodiments 1, 2, or 3, 4, wherein the TLR agonist is delivered at a location in the duodenum of the subject.

27) The method of exemplary embodiment 26, wherein the location is in the proximal portion of the duodenum.

28) The method of exemplary embodiment 26, wherein the location is in the distal portion of the duodenum.

29) The method of any one of exemplary embodiments 1, 2, or 3, 4, wherein the TLR agonist is delivered at a location in the jejunum of the subject.

30) The method of exemplary embodiment 29, wherein the location is in the proximal portion of the jejunum.

31) The method of exemplary embodiment 29, wherein the location is in the distal portion of the jejunum.

32) The method of any one of exemplary embodiments 1, 2, or 3, 4, wherein the TLR agonist is delivered at a location in the ileum of the subject.

33) The method of exemplary embodiment 32, wherein the location is in the proximal portion of the ileum. 34) The method of exemplary embodiment 32, wherein the location is in the distal portion of the ileum.

35) The method of any one of the preceding exemplary embodiments, wherein the

location is proximate to one or more sites of disease.

36) The method of exemplary embodiment 35, further comprising identifying the one or more sites of disease by a method comprising imaging of the gastrointestinal tract.

37) The method of any one of the preceding exemplary embodiments, wherein the TLR agonist is delivered to the location by mucosal contact.

38) The method of any one of the preceding exemplary embodiments, wherein the TLR agonist is delivered to the location by a process that does not comprise systemic transport of the TLR agonist.

39) The method of any one of the preceding exemplary embodiments, wherein the amount of the TLR agonist that is administered is from about 1 mg to about 300 mg.

40) The method of exemplary embodiment 39, wherein the amount of the TLR agonist that is administered is from about 1 mg to about 100 mg.

41) The method of exemplary embodiment 40, wherein the amount of the TLR agonist that is administered is from about 5 mg to about 40 mg.

42) The method of any one of exemplary embodiments 1 to 41 , wherein the amount of the TLR agonist is less than an amount that is effective when the TLR agonist is administered systemically.

43) The method of any one of the preceding exemplary embodiments, comprising

administering (i) an amount of the TLR agonist that is an induction dose.

44) The method of exemplary embodiment 43, further comprising (ii) administering an amount of the TLR agonist that is a maintenance dose following the administration of the induction dose.

45) The method of exemplary embodiment 43 or 44, wherein the induction dose is

administered once a day.

46) The method of exemplary embodiment 43 or 44, wherein the induction dose is

administered once every three days.

47) The method of exemplary embodiment 43 or 44, wherein the induction dose is

administered once a week.

48) The method of exemplary embodiment 44, wherein step (ii) is repeated one or more times. 49) The method of exemplary embodiment 44, wherein the induction dose is equal to the maintenance dose.

50) The method of exemplary embodiment 44, wherein the induction dose is greater than the maintenance dose.

51) The method of exemplary embodiment 44, wherein the induction dose is 5 greater than the maintenance dose.

52) The method of exemplary embodiment 44, wherein the induction dose is 2 greater than the maintenance dose.

53) The method of any one of the preceding exemplary embodiments, wherein the method comprises delivering the TLR agonist at the location in the gastrointestinal tract as a single bolus.

54) The method of any one of exemplary embodiments 1 to 52, wherein the method

comprises delivering the TLR agonist at the location in the gastrointestinal tract as more than one bolus.

55) The method of any one of exemplary embodiments 1 to 52, wherein the method

comprises delivering the TLR agonist at the location in the gastrointestinal tract in a continuous manner.

56) The method of exemplary embodiment 55, wherein the method comprises delivering the TLR agonist at the location in the gastrointestinal tract over a time period of 20 or more minutes.

57) The method of any one of the preceding exemplary embodiments, wherein the method provides a concentration of the TLR agonist in the plasma of the subject that is less than 3 μg/ml.

58) The method of exemplary embodiment 57, wherein the method provides a

concentration of the TLR agonist in the plasma of the subject that is less than 0.3

59) The method of exemplary embodiment 58, wherein the method provides a

concentration of the TLR agonist in the plasma of the subject that is less than 0.01 60) The method of any one of exemplary embodiments 1 to 59, wherein the method does not comprise delivering a TLR agonist rectally to the subject.

61) The method of any one of exemplary embodiments 1 to 59, wherein the method does not comprise delivering a TLR agonist via an enema to the subject. 62) The method of any one of exemplary embodiments 1 to 59, wherein the method does not comprise delivering a TLR agonist via suppository to the subject.

63) The method of any one of exemplary embodiments 1 to 59, wherein the method does not comprise delivering a TLR agonist via instillation to the rectum of the subject.

64) The method of exemplary embodiment 63, wherein the TLR9 agonist is a TLR9

agonist.

65) The method of exemplary embodiment 63, wherein the TLR9 agonist is selected from cobitolimod (Kappaproct® or DIMS0150, InDex Pharmaceuticals); generic equivalents thereof; modifications thereof having at least 90% sequence homology; modifications thereof having at least 90% sequence homology; and modifications thereof having one or more nucleotide insertions, deletions, or modifications.

66) The method of any one of the preceding exemplary embodiments, wherein the

pharmaceutical composition is an ingestible device, comprising:

a housing defined by a first end, a second end substantially opposite from the first end, and a wall extending longitudinally from the first end to the second end;

a storage reservoir located within the housing and containing the TLR agonist, wherein a first end of the storage reservoir is connected to the first end of the housing; a mechanism for releasing the TLR agonist from the storage reservoir;

and;

an exit valve configured to allow the TLR agonist to be released out of the housing from the storage reservoir.

67) The method of exemplary embodiment 66, wherein the ingestible device further

comprises:

an electronic component located within the housing; and

a gas generating cell located within the housing and adjacent to the electronic component,

wherein the electronic component is configured to activate the gas generating cell to generate gas.

68) The method of exemplary embodiment 66 or 67, wherein the ingestible device further comprises:

a safety device placed within or attached to the housing,

wherein the safety device is configured to relieve an internal pressure within the housing when the internal pressure exceeds a threshold level. 69) The method of exemplary embodiment 66, wherein the pharmaceutical composition is an ingestible device, comprising:

an electronic component located within the housing;

wherein the electronic component is configured to activate the gas generating cell to generate gas;

a storage reservoir located within the housing,

wherein the storage reservoir stores a dispensable substance and a first end of the storage reservoir is connected to the first end of the housing;

an exit valve located at the first end of the housing,

wherein the exit valve is configured to allow the dispensable substance to be released out of the first end of the housing from the storage reservoir; and

a safety device placed within or attached to the housing,

wherein the safety device is configured to relieve an internal pressure within the housing when the internal pressure exceeds a threshold level.

70) The method of exemplary embodiment 66, wherein the pharmaceutical composition is an ingestible device, comprising:

an electronic component located within the housing,

a storage reservoir located within the housing,

an injection device located at the first end of the housing,

wherein the jet injection device is configured to inject the dispensable substance out of the housing from the storage reservoir; and a safety device placed within or attached to the housing,

wherein the safety device is configured to relieve an internal pressure within the housing.

71) The method of exemplary embodiment 66, wherein the pharmaceutical composition is an ingestible device, comprising:

an optical sensing unit located on a side of the housing,

wherein the optical sensing unit is configured to detect a reflectance from an environment external to the housing;

an electronic component located within the housing;

wherein the electronic component is configured to activate the gas generating cell to generate gas in response to identifying a location of the ingestible device based on the reflectance;

a storage reservoir located within the housing,

a membrane in contact with the gas generating cell and configured to move or deform into the storage reservoir by a pressure generated by the gas generating cell; and

a dispensing outlet placed at the first end of the housing,

wherein the dispensing outlet is configured to deliver the dispensable substance out of the housing from the storage reservoir.

72) The method of any one of exemplary embodiments 1-71, wherein the pharmaceutical composition is an ingestible device as disclosed in US Patent Application Ser. No. 62/385,553, incorporated by reference herein in its entirety.

73) The method of any one of exemplary embodiments 1-71, wherein the pharmaceutical composition is an ingestible device comprising a localization mechanism as disclosed in international patent application PCT/US2015/052500, incorporated by reference herein in its entirety.

74) The method of any one of exemplary embodiments 1-73, wherein the pharmaceutical composition is not a dart-like dosage form. 75) A method of treating a disease of the large intestine of a subject, comprising:

delivering of a TLR agonist at a location in the proximal portion of the large intestine of the subject,

76) The method of exemplary embodiment 75, wherein the disease of the large intestine is an inflammatory bowel disease.

77) The method of exemplary embodiment 75, wherein the disease of the large intestine is ulcerative colitis.

78) The method of exemplary embodiment 75, wherein the disease the large intestine is

Crohn's disease.

79) The method of any one of exemplary embodiments 75 to 78, wherein the TLR agonist is delivered at a location in the proximal portion of the ascending colon.

80) The method of any one of exemplary embodiments 75 to 78, wherein the TLR agonist is delivered at a location in the proximal portion of the cecum.

81) The method of any one of exemplary embodiments 75 to 78, wherein the TLR agonist is delivered at a location in the proximal portion of the sigmoid colon.

82) The method of any one of exemplary embodiments 75 to 78, wherein the TLR agonist is delivered at a location in the proximal portion of the transverse colon.

83) The method of any one of exemplary embodiments 75 to 78, wherein the TLR agonist is delivered at a location in the proximal portion of the descending colon.

84) The method of any one of the preceding exemplary embodiments, further comprising administering a second agent orally, intravenously or subcutaneously, wherein the second agent is the same TLR agonist as in exemplary embodiment 1 or 75; a different TLR agonist; or an agent having a different biological target from TLR.

85) The method of any one of the preceding exemplary embodiments, further comprising administering a second agent orally, intravenously or subcutaneously, wherein the second agent is an agent suitable for treating an inflammatory bowel disease.

86) The method of exemplary embodiment 84 or 85, wherein the TLR agonist is

administered prior to the second agent.

87) The method of exemplary embodiment 84 or 85, wherein the TLR agonist is

administered after the second agent. 88) The method of exemplary embodiment 84 or 85, wherein the TLR agonist and the second agent are administered substantially at the same time.

89) The method of any one of exemplary embodiments 84 to 88, wherein the second agent is administered intravenously.

90) The method of any one of exemplary embodiments 84 to 88, wherein the second agent is administered subcutaneously.

91) The method of any one of exemplary embodiments 84 to 90, wherein the amount of the second agent is less than the amount of the second agent when the TLR agonist and the second agent are both administered systemically.

92) The method of exemplary embodiment 91, wherein the second agent is an

immunosuppressant.

93) In some aspects of these embodiments, the second agent is methotrexate.

94) The method of any one of exemplary embodiments 1 to 83, wherein the method does not comprise administering a second agent.

Endoscopes. Ingestible Devices, and Reservoirs containing the drug

Direct visualization of the GI mucosa is useful to detect subtle mucosal alterations, as in inflammatory bowel diseases, as well as any flat or sessile lesions. The GI tract can be imaged using endoscopes, or more recently ingestible devices that are swallowed.

The technology behind standard colonoscopy consists of a long, semi-rigid insertion tube with a steerable tip (stiff if compared to the colon), which is pushed by the physician from the outside. However, invasiveness, patient discomfort, fear of pain, and -more often than not- the need for conscious sedation limit the take-up of screening colonoscopy.

Diagnosis and treatment in the GI tract are dominated by the use of flexible endoscopes. A few large companies, namely Olympus Medical Systems Co. (Tokyo, Japan), Pentax Medical Co. (Montvale, NJ, USA), Fujinon, Inc. (Wayne, NJ, USA) and Karl Storz GmbH & Co. KG (Tuttlingen, Germany), cover the majority of the market in flexible GI endoscopy.

In a review of robotic endoscopic capsules, Journal of Micro-Bio Robotics 11.1-4 (2016): 1-18, Ciuti et al. state that progress in micro-electromechanical systems (MEMS) technologies have led to the development of new endoscopic capsules with enhanced diagnostic capabilities, in addition to traditional visualization of mucosa (embedding, e.g. pressure, pH, blood detection and temperature sensors).

Endoscopes may comprise a catheter. As an example, the catheter may be a spray catheter. As an example, a spray catheter may be used to deliver dyes for diagnostic purposes. As an example, a spray catheter may be used to deliver a therapeutic agent at the site of disease in the GI tract. For example, the Olypmus PW-205V is a ready-to-use spray catheter that enables efficient spraying for maximal differentiation of tissue structures during endoscopy, but may also be used to deliver drugs diseased tissue.

FIG. 1, disclosed in US Provisional Application No. 62/385,553, incorporated by reference herein in its entirety, illustrates an example of an ingestible device for localized delivery of pharmaceutical compositions disclosed herein, in accordance with particular implementations. The ingestible device 100 includes a piston or drive element 134 to push for drug delivery, in accordance with particular implementations described herein. The ingestible device 100 may have one or more batteries 131 placed at one end 102a of a housing 101 to provide power for the ingestible device 100. A printed circuit board (PCB) 132 may be placed adjacent to a battery or other power source 131, and a gas generating cell 103 may be mounted on or above the PCB 132. The gas generating cell 103 may be sealed from the bottom chamber (e.g., space including 131 and 132) of the ingestible device 100. A movable piston 134 may be placed adjacent to the gas generating cell 103. In this way, gas generation from the gas generating cell 103 may propel a piston 134 to move towards another end 102b of the housing 101 such that the dispensable substance in a reservoir compartment 135 can be pushed out of the housing through a dispensing outlet 107, e.g., the movement is shown at 136, with the piston 134 at a position after dispensing the substance. The dispensing outlet 107 may comprise a plug. The reservoir compartment 135 can store the dispensable substance (e.g., drug substance), or alternatively the reservoir compartment can house a storage reservoir 161 which comprises the dispensable substance. The reservoir

compartment 135 or storage reservoir 161 may have a volume of approximately 600μί or even more dispensable substance, which may be dispensed in a single bolus, or gradually over a period of time.

The battery cells 131 may have a height of 1.65 mm each, and one to three batteries may be used. The height of the piston may be reduced with custom molded part for around 1.5mm to save space. If the gas generating cell 103 is integrated with the piston 134, the overall height of the PCB, batteries and gas generating cell in total can be reduced to around 5 mm, thus providing more space for drug storage. For example, for an ingestible device of 7.8 mm in length (e.g., from end 102a to the other end 102b), a reservoir compartment 135 or a storage reservoir 161 of approximately 600μί may be used for drug delivery. For another example, for an ingestible device of 17.5 mm in length, a reservoir compartment 135 or a storage reservoir 161 of approximately 1300μί may be used for drug release.

In some implementations, at the reservoir 135 or 161 for storing a therapeutically effective amount of the TLR agonist forms at least a portion of the device housing 101. The therapeutically effective amount of the TLR agonist can be stored in the reservoir 135 or 161 at a particular pressure, for example, determined to be higher than a pressure inside the GI tract so that once the reservoir 135 or 161 is in fluid communication with the GI tract, the TLR agonist is automatically released. In certain implementations, the reservoir

compartment 135 includes a plurality of chambers, and each of the plurality of the chambers stores a different dispensable substance or a different storage reservoir 161.

In certain embodiments, the storage reservoir 161 is a compressible component or has compressible side walls. In particular embodiments, the compressible component can be composed, at least in part, or coated (e.g., internally) with polyvinyl chloride (PVC), silicone, DEHP (di-2-ethylhexyl phthalate), Tyvek, polyester film, poly olefin, polyethylene, polyurethane, or other materials that inhibit the TLR agonist from sticking to the reservoir and provide a sterile reservoir environment for the TLR agonist. The storage reservoir 161 can be hermetically sealed. The reservoir compartment 135 or storage reservoir 161 can be configured to store TLR agonist in quantities in the range of 0.01 mL - 2 mL, such as 0.05 mL - 2 mL, such as 0.05 mL - 2 mL, such as 0.6mL - 2 mL. In some embodiments, the storage reservoir 161 is attachable to the device housing 101, for example, in the reservoir compartment. Accordingly, the storage reservoir 135 can be loaded with the TLR agonist prior to being positioned in and/or coupled to the ingestible device housing 101. The ingestible device housing 101 includes one or more openings configured as a loading port to load the dispensable substance into the reservoir compartment. In another embodiment, the ingestible device housing 101 includes one or more openings configured as a vent.

In certain embodiments, the ingestible device housing 101 includes one or more actuation systems (e.g., gas generating cell 103) for pumping the TLR agonist from the reservoir 135. In some embodiments, the actuation system can include a mechanical, electrical, electromechanical, hydraulic, and/or fluid actuation system. For example, a chemical actuation means may use chemical reaction of mixing one or more reagents to generate a sufficient volume of gas to propel the piston or drive element 134 for drug release. The actuation system can be integrated into the reservoir compartment 135 or can be an auxiliary system acting on or outside of the reservoir compartment 135. For example, the actuation system can include pumping system for pushing/pulling the TLR agonist out of the reservoir compartment 135 or the actuation system can be configured to cause the reservoir compartment 135 to change structurally so that the volume inside of the reservoir compartment 135 changes, thereby dispensing the TLR agonist from the reservoir compartment 135. The actuation system can include an energy storage component such as a battery or a capacitor for powering the actuation system. The actuation system can be actuated via gas pressure or a system storing potential energy, such as energy from an elastic reservoir component being expanded during loading of the reservoir and after being positioned in the ingestible device housing 101 being subsequently released from the expanded state when the ingestible device housing is at the location for release within the GI tract. In certain embodiments, the reservoir compartment 135 can include a membrane portion, whereby the TLR agonist is dispensed from the reservoir compartment 135 or storage reservoir 161 via osmotic pressure.

In particular embodiments the storage reservoir 161 is in a form of a bellow that is configured to be compressed via a pressure from the gas generating cell. The TLR agonist may be loaded into the bellow, which may be compressed by gas generation from the gas generating cell or other actuation means to dispense the dispensable substance through the dispensing outlet 107 and out of the housing 101. In some embodiments, the ingestible device includes a capillary plate placed between the gas generating cell and the first end of the housing, and a wax seal between the gas generating cell and the reservoir, wherein the wax seal is configured to melt and the dispensable substance is pushed through the capillary plate by a pressure from the gas generating cell. The shape of the bellow may aid in controlled delivery. The reservoir compartment 135 includes a dispensing outlet, such as a valve or dome slit 162 extending out of an end of the housing 101, in accordance with particular implementations. Thus when the bellow is being compressed, the dispensable substance may be propelled out of the bellow through the valve or the dome slit.

In certain embodiments, the reservoir compartment 135 includes one or more valves (e.g. a valve in the dispensing outlet 107) that are configured to move or open to fluidly couple the reservoir compartment 135 to the GI tract. In certain embodiments, a housing wall of the housing 101 can form a portion of the reservoir compartment 135. In certain embodiments, the housing walls of the reservoir serve as a gasket. One or more of the one or more valves are positioned in the housing wall of the device housing 101, in accordance with particular implementations. One or more conduits may extend from the reservoir 135 to the one or more valves, in certain implementations.

In certain embodiments, a housing wall of the housing 101 can be formed of a material that is configured to dissolve, for example, in response to contact at the disease site. In certain embodiments, a housing wall of the housing 101 can be configured to dissolve in response to a chemical reaction or an electrical signal. The one or more valves and/or the signals for causing the housing wall of the housing 101 to dissolve or dissipate can be controlled by one or more processors or controllers positioned on PCB 132 in the device housing 101. The controller is communicably coupled to one or more sensors or detectors configured to determine when the device housing 101 is proximate to a disease site. The sensors or detectors comprise a plurality of electrodes comprising a coating, in certain implementations. Releasing of the TLR agonist from the reservoir compartment 135 is triggered by an electric signal from the electrodes resulting from the interaction of the coating with the one or more sites of disease site. The one or more sensors can include a chemical sensor, an electrical sensor, an optical sensor, an electromagnetic sensor, a light sensor, and/or a radiofrequency sensor.

In particular embodiments, the device housing 101 can include one or more pumps configured to pump the therapeutically effective amount of the TLR agonist from the reservoir compartment 135. The pump is communicably coupled to the one or more controllers. The controller is configured to activate the pump in response to detection by the one or more detectors of the disease site and activation of the valves to allow the reservoir 135 to be in fluid communication with the GI tract. The pump can include a fluid actuated pump, an electrical pump, or a mechanical pump.

In certain embodiments, the device housing 101 comprises one or more anchor systems for anchoring the device housing 101 or a portion thereof at a particular location in the GI tract adjacent the disease site. In some embodiments, a storage reservoir comprises an anchor system, and the storage reservoir comprising a releasable substance is anchored to the GI tract. The anchor system can be activated by the controller in response to detection by the one or more detectors of the disease site. In certain implementations, the anchor system includes legs or spikes configured to extend from the housing wall(s) of the device housing 101. The spikes can be configured to retract and/or can be configured to dissolve over time. An example of an attachable device that becomes fixed to the interior surface of the GI tract is described in PCT Patent Application PCT/US2015/012209, "Gastrointestinal Sensor Implantation System", filed January 21, 2015, which is hereby incorporated by reference herein in its entirety.

In certain embodiments, the reservoir is an anchorable reservoir, which is a reservoir comprising one or more anchor systems for anchoring the reservoir at a particular location in the GI tract adjacent the disease site. In certain embodiments, the anchor system includes legs or spikes or other securing means such as a piercing element, a gripping element, a magnetic-flux-guiding element, or an adhesive material, configured to extend from the anchorable reservoir of the device housing. The spikes can be configured to retract and/or can be configured to dissolve over time. In some embodiments, the anchorable reservoir is suitable for localizing,positioning and/or anchoring. In some embodiments, the anchorable reservoir is suitable for localizing, and positioning and/or anchoring by an endoscope. In some embodiments, the anchorable reservoir is connected to the endoscope. In some embodiments, the anchorable reservoir is connected to the endoscope in a manner suitable for oral administration. In some embodiments, the anchorable reservoir is connected to the endoscope in a manner suitable for rectal administration. Accordingly, provided herein in some embodiments is an anchorable reservoir is connected to an endoscope wherein the anchorable reservoir comprises a therapeutically effective amount of the TLR agonist. In some embodiments the endoscope is fitted with a spray catheter.

Exemplary embodiments of anchorable reservoirs are as follows. In more particular examples of the following exemplary embodiments the reservoir is connected to an endoscope.

In one embodiment, the anchorable reservoir comprises an implant capsule for insertion into a body canal to apply radiation treatment to a selected portion of the body canal. The reservoir includes a body member defining at least one therapeutic treatment material receiving chamber and at least one resilient arm member associated with the body member for removably engaging the body canal when the device is positioned therein.

In one embodiment the anchorable reservoir has multiple suction ports and permits multiple folds of tissue to be captured in the suction ports with a single positioning of the device and attached together by a tissue securement mechanism such as a suture, staple or other form of tissue bonding. The suction ports may be arranged in a variety of configurations on the reservoir to best suit the desired resulting tissue orientation.

In some embodiments an anchorable reservoir comprises a tract stimulator and/or monitor IMD comprising a housing enclosing electrical stimulation and/or monitoring circuitry and a power source and an elongated flexible member extending from the housing to an active fixation mechanism adapted to be fixed into the GI tract wall is disclosed. After fixation is effected, the elongated flexible member bends into a preformed shape that presses the housing against the mucosa so that forces that would tend to dislodge the fixation mechanism are minimized. The IMD is fitted into an esophageal catheter lumen with the fixation mechanism aimed toward the catheter distal end opening whereby the bend in the flexible member is straightened. The catheter body is inserted through the esophagus into the GI tract cavity to direct the catheter distal end to the site of implantation and fix the fixation mechanism to the GI tract wall. The IMD is ejected from the lumen, and the flexible member assumes its bent configuration and lodges the hermetically sealed housing against the mucosa. A first stimulation/sense electrode is preferably an exposed conductive portion of the housing that is aligned with the bend of the flexible member so that it is pressed against the mucosa. A second stimulation/sense electrode is located at the fixation site.

In some embodiments a reservoir for sensing one or more parameters of a patient is anchored to a tissue at a specific site and is released from a device, using a single actuator operated during a single motion. As an example, a delivery device may anchor the capsule to the tissue site and release the reservoir from the delivery device during a single motion of the actuator.

In some embodiments a device is provided comprising: a reservoir configured to contain a fluid, the reservoir having at least one outlet through which the fluid may exit the reservoir; a fluid contained within the reservoir; a primary material contained within the reservoir and having a controllable effective concentration in the fluid; and at least one electromagnetically responsive control element located in the reservoir or in a wall of the reservoir and adapted for modifying the distribution of the primary material between a first active form carried in the fluid and a second form within the reservoir in response to an incident electromagnetic control signal, the effective concentration being the concentration of the first active form in the fluid, whereby fluid exiting the reservoir carries the primary material in the first active form at the effective concentration.

In some embodiments systems and methods are provided for implementing or deploying medical or veterinary devices or reservoirs (a) operable for anchoring at least partly within a digestive tract, (b) small enough to pass through the tract per vias natural es and including a wireless-control component, (c) having one or more protrusions positionable adjacent to a mucous membrane, (d) configured to facilitate redundant modes of anchoring, (e) facilitating a "primary" material supply deployable within a stomach for an extended and/or controllable period, (f) anchored by one or more adaptable extender modules supported by a subject's head or neck, and/or (g) configured to facilitate supporting at least a sensor within a subject's body lumen for up to a day or more.

In certain embodiments, the reservoir is attachable to an ingestible device. In certain embodiments, the ingestible device comprises a housing and the reservoir is attachable to the housing. In certain embodiments, the attachable reservoir is also an anchorable reservoir, such as an anchorable reservoir comprising one or more anchor systems for anchoring the reservoir at a particular location in the GI tract as disclosed hereinabove.

Accordingly, in certain embodiments, provided herein is a TLR agonist for use in a method of treating a disease of the gastrointestinal tract as disclosed herein, wherein the TLR agonist is contained in a reservoir suitable for attachment to a device housing, and wherein the method comprises attaching the reservoir to the device housing to form the ingestible device, prior to orally administering the ingestible device to the subject.

In certain embodiments, provided herein is an attachable reservoir containing a TLR agonist for use in a method of treating a disease of the gastrointestinal tract, wherein the method comprises attaching the reservoir to a device housing to form an ingestible device and orally administering the ingestible device to a subject, wherein the TLR agonist is released by device at a location in the gastrointestinal tract of the subject that is proximate to one or more sites of disease.

In certain embodiments, provided herein is an attachable reservoir containing a TLR agonist, wherein the reservoir is attachable to a device housing to form an ingestible device that is suitable for oral administration to a subject and that is capable of releasing the TLR agonist at a location in the gastrointestinal tract of the subject that is proximate to one or more sites of disease.

In particular implementation the ingestible device includes cameras (e.g., video cameras) that affords inspection of the entire GI tract without discomfort or the need for sedation, thus avoiding many of the potential risks of conventional endoscopy. Video imaging can be used to help determine one or more characteristics of the GI tract, including the location of disease (e.g., presence or location of inflamed tissue and/or lesions associated with inflammatory bowel disease). In some embodiments, the ingestible device 101 may comprise a camera for generating video imaging data of the GI tract which can be used to determine, among other things, the location of the device. Examples of video imaging capsules include Medtronic's PillCam™, Olympus' Endocapsule®, and IntroMedic's MicroCam™. For a review of imaging capsules, see Basar et al. "Ingestible Wireless Capsule Technology: A Review of Development and Future Indication" International Journal of Antennas and Propagation (2012); 1-14). Other imaging technologies implemented with the device 101 can include thermal imaging cameras, and those that employ ultrasound or Doppler principles to generate different images (see Chinese patent application

CN104473611 : "Capsule endoscope system having ultrasonic positioning function".

Ingestible devices can be equipped with sources for generating reflected light, including light in the Ultraviolet, Visible, Near-infrared and/or Mid-infrared spectrum, and the corresponding detectors for spectroscopy and hyperspectral imaging. Likewise, autofluorescense may be used to characterize GI tissue (e.g., subsurface vessel information), or low-dose radiation (see Check-Cap™) can be used to obtain 3D reconstructed images.

Device Components

An ingestible device in accordance with particular embodiments of the present invention may comprise a component made of a non-digestible material and containing the TLR agonist. In some embodiments, the material is plastic.

It is envisaged that the device is single-use. The device is loaded with a drug prior to the time of administration. In some embodiments, it may be preferred that there is provided a medicinal product comprising the device pre-filled with the drug.

Localization components

Various implementations may be used for localization of ingestible devices within the GI tract. For example, certain implementations can include one or more electromagnetic sensor coils, magnetic fields, electromagnetic waves, electric potential values, ultrasound positioning systems, gamma scintigraphy techniques or other radio-tracker technology have been described by others. Alternatively, imaging can be used to localize, for example, using anatomical landmarks or more complex algorithms for 3D reconstruction based on multiple images. Other technologies rely on radio frequency, which relies on sensors placed externally on the body to receive the strength of signals emitted by the capsule. Ingestible devices may also be localized based on reflected light in the medium surrounding the device; pH;

temperature; time following ingestion; and/or acoustic signals. Anchoring components

Several systems may actively actuate and control the capsule position and orientation in different sections of the GI tract. Examples include leg-like or anchor-like mechanisms that can be deployed by an ingestible device to resist peristaltic forces in narrowed sections of the GI tract, such as the intestine, and anchor the device to a location. Other systems employ magnetic shields of different shapes that can interact with external magnetic fields to move the device. These mechanisms may be particularly useful in areas outside of the small intestine, like the cecum and large intestine.

An anchoring mechanism may be a mechanical mechanism. For example, a device may be a capsule comprising a plurality of legs configured to steer the capsule. The number of legs in the capsule may be, for example, two, four, six, eight, ten or twelve. The aperture between the legs of the device may be up to about 35 mm; about 30 to about 35 mm; about 35 to about 75 mm; or about 70 to about 75 mm. The contact area of each leg may be varied to reduce impact on the tissue. One or more motors in the capsule may each actuate a set of legs independently from the other. The motors may be battery-powered motors.

An anchoring mechanism may be a non-mechanical mechanism. For example, a device may be a capsule comprising a permanent magnet located inside the capsule. The capsule may be anchored at the desired location of the GI tract by an external magnetic field.

An anchoring mechanism may comprise a non-mechanical mechanism and a mechanical mechanism. For example, a device may be a capsule comprising one or more legs, one or more of which are coated with an adhesive material.

Locomotion components

Ingestible devices can be active or passive, depending on whether they have controlled or non-controlled locomotion. Passive (non-controlled) locomotion is more commonly used among ingestible devices given the challenges of implementing a locomotion module. Active (controlled) locomotion is more common in endoscopic ingestible capsules. For example, a capsule may comprise a miniaturized locomotion system (internal locomotion). Internal locomotion mechanisms may employ independent miniaturized propellers actuated by DC brushed motors, or the use of water jets. As an example, a mechanism may comprise flagellar or flap-based swimming mechanisms. As an example, a mechanism may comprise cyclic compression/extension shape-memory alloy (SMA) spring actuators and anchoring systems based on directional micro-needles. As an example, a mechanism may comprise six SMA actuated units, each provided with two SMA actuators for enabling bidirectional motion. As an example, a mechanism may comprise a motor adapted to electrically stimulating the GI muscles to generate a temporary restriction in the bowel.

As an example, a capsule may comprise a magnet and motion of the capsule is caused by an external magnetic field. For example, a locomotion system may comprise an ingestible capsule and an external magnetic field source. For example, the system may comprise an ingestible capsule and magnetic guidance equipment such as, for example, magnetic resonance imaging and computer tomography, coupled to a dedicated control interface. In some embodiments drug release mechanisms may also be triggered by an external condition, such as temperature, pH, movement, acoustics, or combinations thereof.

Use of an endoscope or an ingestible device in biopsy and surgery

Ingestible devices may comprise a mechanism adapted to permit the collection of tissue samples. In some examples, this is achieved using electro-mechanical solutions to collect and store the sample inside an ingestible device. As an example, a biopsy mechanism may include a rotational tissue cutting razor fixed to a torsional spring or the use of microgrippers to fold and collect small biopsies. As an example, Over-the-scope clips (OTSC®) may be used to perform endoscopic surgery and/or biopsy. As an example of the methods disclosed herein, the method may comprise releasing a TLR agonist and collecting a sample inside the device. As an example, the method may comprise releasing a TLR agonist and collecting a sample inside the device in a single procedure.

Communication systems

An ingestible device may be equipped with a communication system adapted to transmit and/or receive data, including imaging and/or localization data. As an example, a communication system may employ radiofrequency transmission. Ingestible devices using radiofrequency communication are attractive because of their efficient transmission through the layers of the skin. This is especially true for low frequency transmission (UHF-433 ISM and lower, including the Medical Device Radio Communication Service band (MDRS) band 402-406MHz). In another embodiment, acoustics are used for communications, including the transmission of data. For example, an ingestible capsule may be able to transmit information by applying one or more base voltages to an electromechanical transducer or piezoelectric (e.g., PZT, PVDF, etc.) device to cause the piezoelectric device to ring at particular frequencies, resulting in an acoustic transmission. A multi-sensor array for receiving the acoustic transmission may include a plurality of acoustic transducers that receive the acoustic transmission from a movable device such as an ingestible capsule as described in US Patent Application No. 11/851214 filed September 6, 2007, incorporated by reference herein in its entirety.

As an example, a communication system may employ human body communication technology. Human body communication technology uses the human body as a conductive medium, which generally requires a large number of sensor electrodes on the skin. As an example, a communication system may integrate a data storage system.

Environmental Sensors

In some embodiments the device may comprise environmental sensors to measure pH, temperature, transit times, or combinations thereof. Other examples of environmental sensors include, but are not limited to a capacitance sensor, an impedance sensor, a heart rate sensor, acoustic sensor such as a microphone or hydrophone, image sensor, and/or a movement sensor. In one embodiment, the ingestible device comprises a plurality of different environmental sensors for generating different kinds of environmental data.

In order to avoid the problem of capsule retention, a thorough past medical and surgical history should be undertaken. In addition, several other steps have been proposed, including performing investigations such as barium follow-through. In cases where it is suspected that there is a high risk of retention, the patient is given a patency capsule a few days before swallowing an ingestible device. Any dissolvable non-endoscopic capsule may be used to determine the patency of the GI tract. The patency capsule is usually the same size as the ingestible device and can be made of cellophane. In some embodiments, the patency capsule contains a mixture of barium and lactose, which allows visualization by x-ray.

The patency capsule may also include a radiotag or other label, which allows for it to be detected by radio-scanner externally. The patency capsule may comprise wax plugs, which allow for intestinal fluid to enter and dissolve the content, thereby dividing the capsule into small particles.

Accordingly, in some embodiments, the methods herein comprise (a) identifying a subject having a disease of the gastrointestinal tract and (b) evaluating the subject for suitability to treatment. In some embodiments, the methods herein comprise evaluating for suitability to treatment a subject identified as having a disease of the gastrointestinal tract. In some embodiments, evaluating the subject for suitability to treatment comprises determining the patency of the subject's GI tract.

In some embodiments, an ingestible device comprises a tissue anchoring mechanism for anchoring the ingestible device to a subject's tissue. For example, an ingestible device could be administered to a subject and once it reaches the desired location, the tissue attachment mechanism can be activated or deployed such that the ingestible device, or a portion thereof, is anchored to the desired location. In some embodiments, the tissue anchoring mechanism is reversible such that after initial anchoring, the tissue attachment device is retracted, dissolved, detached, inactivated or otherwise rendered incapable of anchoring the ingestible device to the subject's tissue. In some embodiments the attachment mechanism is placed endoscopically.

In some embodiments, a tissue anchoring mechanism comprises an osmotically- driven sucker. In some embodiments, the osmotically-driven sucker comprises a first valve on the near side of the osmotically-driven sucker (e.g., near the subject's tissue) and a second one-way valve that is opened by osmotic pressure on the far side of the osmotically-driven sucker, and an internal osmotic pump system comprising salt crystals and semi-permeable membranes positioned between the two valves. In such embodiments, osmotic pressure is used to adhere the ingestible device to the subject's tissue without generating a vacuum within the ingestible capsule. After the osmotic system is activated by opening the first valve, fluid is drawn in through the sucker and expelled through the second burst valve. Fluid continues to flow until all the salt contained in the sucker is dissolved or until tissue is drawn into the sucker. As liminal fluid is drawn through the osmotic pump system, solutes build up between the tissue and the first valve, reducing osmotic pressure. In some embodiments, the solute buildup stalls the pump before the tissue contacts the valve, preventing tissue damage. In some embodiments, a burst valve is used on the far side of the osmotically-driven sucker rather than a one-way valve, such that luminal fluid eventually clears the saline chamber and the osmotic flow reverses, actively pushing the subject's tissue out of the sucker. In some embodiments, the ingestible device may be anchored to the interior surface of tissues forming the GI tract of a subject. In one embodiment, the ingestible device comprises a connector for anchoring the device to the interior surface of the GI tract. The connector may be operable to ingestible device to the interior surface of the GI tract using an adhesive, negative pressure and/or fastener. In some embodiments a device comprises a tract stimulator and/or monitor IMD comprising a housing enclosing electrical stimulation and/or monitoring circuitry and a power source and an elongated flexible member extending from the housing to an active fixation mechanism adapted to be fixed into the GI tract wall is disclosed. After fixation is effected, the elongated flexible member bends into a preformed shape that presses the housing against the mucosa so that forces that would tend to dislodge the fixation mechanism are minimized. The IMD is fitted into an esophageal catheter lumen with the fixation mechanism aimed toward the catheter distal end opening whereby the bend in the flexible member is straightened. The catheter body is inserted through the esophagus into the GI tract cavity to direct the catheter distal end to the site of implantation and fix the fixation mechanism to the GI tract wall. The IMD is ejected from the lumen, and the flexible member assumes its bent configuration and lodges the hermetically sealed housing against the mucosa. A first stimulation/sense electrode is preferably an exposed conductive portion of the housing that is aligned with the bend of the flexible member so that it is pressed against the mucosa. A second stimulation/sense electrode is located at the fixation site.

In some embodiments a device includes a fixation mechanism to anchor the device to tissue within a body lumen, and a mechanism to permit selective de-anchoring of the device from the tissue anchoring site without the need for endoscopic or surgical intervention. An electromagnetic device may be provided to mechanically actuate the de-anchoring mechanism. Alternatively, a fuse link may be electrically blown to de-anchor the device. As a further alternative, a rapidly degradable bonding agent may be exposed to a degradation agent to de-anchor the device from a bonding surface within the body lumen.

In some embodiments a device is as disclosed in patent publication

WO2015112575A1, incorporated by reference herein in its entirety. The patent publication is directed to a gastrointestinal sensor implantation system. In some embodiments an orally - administrable capsule comprises a tissue capture device or reservoir removably coupled to the orally-administrable capsule, where the tissue capture device including a plurality of fasteners for anchoring the tissue capture device to gastrointestinal tissue within a body

In some embodiments, the ingestible device contains an electric energy emitting means, a radio signal transmitting means, a medicament storage means and a remote actuatable medicament releasing means. The capsule signals a remote receiver as it progresses through the alimentary tract in a previously mapped route and upon reaching a specified site is remotely triggered to release a dosage of medicament. Accordingly, in some embodiments, releasing the TLR agonist is triggered by a remote electromagnetic signal.

In some embodiments, the ingestible device includes a housing introducible into a body cavity and of a material insoluble in the body cavity fluids, but formed with an opening covered by a material which is soluble in body cavity fluids. A diaphragm divides the interior of the housing into a medication chamber including the opening, and a control chamber. An electrolytic cell in the control chamber generates a gas when electrical current is passed therethrough to deliver medication from the medication chamber through the opening into the body cavity at a rate controlled by the electrical current. Accordingly, in some embodiments, releasing the TLR agonist is triggered by generation in the composition of a gas in an amount sufficient to expel the TLR agonist.

In some embodiments, the ingestible device includes an oral drug delivery device having a housing with walls of water permeable material and having at least two chambers separated by a displaceable membrane. The first chamber receives drug and has an orifice through which the drug is expelled under pressure. The second chamber contains at least one of two spaced apart electrodes forming part of an electric circuit which is closed by the ingress of an aqueous ionic solution into the second chamber. When current flows through the circuit, gas is generated and acts on the displaceable membrane to compress the first chamber and expel the active ingredient through the orifice for progressive delivery to the gastrointestinal tract.

In some embodiments, the ingestible device includes an ingestible device for delivering a substance to a chosen location in the GI tract of a mammal includes a receiver of electromagnetic radiation for powering an openable part of the device to an opened position for dispensing of the substance. The receiver includes a coiled wire that couples the energy field, the wire having an air or ferrite core. In a further embodiment the invention includes an apparatus for generating the electromagnetic radiation, the apparatus including one or more pairs of field coils supported in a housing. The device optionally includes a latch defined by a heating resistor and a fusible restraint. The device may also include a flexible member that may serve one or both the functions of activating a transmitter circuit to indicate dispensing of the substance; and restraining of a piston used for expelling the substance.

In some embodiments, the ingestible device is a device a swallowable capsule. A sensing module is disposed in the capsule. A bioactive substance dispenser is disposed in the capsule. A memory and logic component is disposed in the capsule and in communication with the sensing module and the dispenser.

In some embodiments, localized administration is implemented via an electronic probe which is introduced into the intestinal tract of a living organism and which operates autonomously therein, adapted to deliver one or more therapy agents. In one embodiment, the method includes loading the probe with one or more therapy agents, and selectively releasing the agents from the probe at a desired location of the intestinal tract in order to provide increased efficacy over traditional oral ingestion or intravenous introduction of the agent(s).

In some embodiments, the ingestible device includes electronic control means for dispensing the drug substantially to the diseased tissue sites of the GI tract, according to a pre-determined drug release profile obtained prior to administration from the specific mammal. Accordingly, in some embodiments, releasing the TLR agonist is triggered by an electromagnetic signal generated within the device. The releasing may occur according to a pre-determined drug release profile.

In some embodiments, the ingestible device can include at least one guide tube, one or more tissue penetrating members positioned in the guide tube, a delivery member, an actuating mechanism and a release element. The release element degrades upon exposure to various conditions in the intestine so as to release and actuate the actuating mechanism. Embodiments of the invention are particularly useful for the delivery of drugs which are poorly absorbed, tolerated and/or degraded within the GI tract.

In some embodiments, the ingestible device includes an electronic pill comprising at least one reservoir with a solid powder or granulate medicament or formulation, a discharge opening and an actuator responsive to control circuitry for displacing medicine from the reservoir to the discharge opening. The medicament or formulation comprises a dispersion of one or more active ingredients~e.g., solids in powder or granulate form-in an inert carrier matrix. Optionally, the active ingredients are dispersed using intestinal moisture absorbed into the pill via a semi-permeable wall section.

In some embodiments, the ingestible device includes a sensor comprising a plurality of electrodes having a miniature size and a lower power consumption and a coating exterior to the electrodes, wherein the coating interacts with a target condition thereby producing a change in an electrical property of the electrodes, wherein the change is transduced into an electrical signal by the electrodes. Accordingly, in some embodiments, releasing the TLR agonist is triggered by an electric signal by the electrodes resulting from the interaction of the coating with the one or more sites of disease. Further provided herein is a system for medication delivery comprising such sensor and a pill.

In some embodiments, the ingestible device includes an electronic pill comprising a plurality of reservoirs, each of the reservoirs comprising a discharge opening covered by a removable cover. The pill comprises at least one actuator responsive to control circuitry for removing the cover from the discharge opening. The actuator can for example be a spring loaded piston breaking a foil cover when dispensing the medicament. Alternatively, the cover can be a rotatable disk or cylinder with an opening which can be brought in line with the discharge opening of a reservoir under the action of the actuator.

In some embodiments, the ingestible device includes an electronically and remotely controlled pill or medicament delivery system. The pill includes a housing; a reservoir for storing a medicament; an electronically controlled release valve or hatch for dispensing one or more medicaments stored in the reservoir while traversing the gastrointestinal tract; control and timing circuitry for opening and closing the valve; and a battery. The control and timing circuitry opens and closes the valve throughout a dispensing time period in accordance with a preset dispensing timing pattern which is programmed within the control and timing circuitry. RF communication circuitry receives control signals for remotely overriding the preset dispensing timing pattern, reprogramming the control and timing circuitry or terminating the dispensing of the medicament within the body. The pill includes an RFID tag for tracking, identification, inventory and other purposes.

In some embodiments, the ingestible device includes an electronic capsule which has a discrete drive element comprising: a housing, electronics for making the electronic capsule operable, a pumping mechanism for dosing and displacing a substance, a power source for powering the electronic capsule and enabling the electronics and the pumping mechanism to operate, and a locking mechanism; and a discrete payload element comprising: a housing, a reservoir for storing the substance, one or more openings in the housing for releasing the substance from the reservoir and a locking mechanism for engaging the drive element locking mechanism. Engagement of the drive element locking mechanism with the payload element locking mechanism secures the drive element to the payload element, thereby making the electronic capsule operable and specific.

In some embodiments, the ingestible device may be a mucoadhesive device configured for release of an active agent.

In some embodiments, the ingestible device includes an apparatus that includes an ingestible medical treatment device, which is configured to initially assume a contracted state having a volume of less than 4 cm³. The device includes a gastric anchor, which initially assumes a contracted size, and which is configured to, upon coming in contact with a liquid, expand sufficiently to prevent passage of the anchor through a round opening having a diameter of between 1 cm and 3 cm. The device also includes a duodenal unit, which is configured to pass through the opening, and which is coupled to the gastric anchor such that the duodenal unit is held between 1 cm and 20 cm from the gastric anchor.

In some embodiments, the ingestible device includes a medical robotic system and method of operating such comprises taking intraoperative external image data of a patient anatomy, and using that image data to generate a modeling adjustment for a control system of the medical robotic system (e.g., updating anatomic model and/or refining instrument registration), and/or adjust a procedure control aspect (e.g., regulating substance or therapy delivery, improving targeting, and/or tracking performance).

In one embodiment the ingestible device may also include one or more environmental sensors. Environmental sensor may be used to generate environmental data for the environment external to device in the gastrointestinal (GI) tract of the subject. In some embodiments, environmental data is generated at or near the location within the GI tract of the subject where a drug is delivered. Examples of environmental sensor include, but are not limited to a capacitance sensor, a temperature sensor, an impedance sensor, a pH sensor, a heart rate sensor, acoustic sensor, image sensor (e.g., a hydrophone), and/or a movement sensor (e.g., an accelerometer). In one embodiment, the ingestible device comprises a plurality of different environmental sensors for generating different kinds of environmental data. In one embodiment, the image sensor is a video camera suitable for obtaining images in vivo of the tissues forming the GI tract of the subject. In one embodiment, the

environmental data is used to help determine one or more characteristics of the GI tract, including the location of disease (e.g., presence or location of inflamed tissue and/or lesions associated with inflammatory bowel disease). In some embodiments, the ingestible device may comprise a camera for generating video imaging data of the GI tract which can be used to determine, among other things, the location of the device.

In another embodiment, the ingestible device described herein may be localized using a gamma scintigraphy technique or other radio-tracker technology as employed by Phaeton Research's Enterion™ capsule (See Teng, Renli, and Juan Maya. "Absolute bioavailability and regional absorption of ticagrelor in healthy volunteers." Journal of Drug Assessment 3.1 (2014): 43-50), or monitoring the magnetic field strength of permanent magnet in the ingestible device (see T. D. Than, et al, "A review of localization systems for robotic endoscopic capsules," IEEE Trans. Biomed. Eng., vol. 59, no. 9, pp. 2387-2399, Sep. 2012).

In one embodiment, drug delivery is triggered when it encounters the site of disease in the GI tract.

In one embodiment, the one or more environmental sensors measure pH, temperature, transit times, or combinations thereof.

In some embodiments, releasing the TLR agonist is dependent on the pH at or in the vicinity of the location. In some embodiments the pH in the jejunum is from 6.1 to 7.2, such as 6.6. In some embodiments the pH in the mid small bowel is from 7.0 to 7.8, such as 7.4. In some embodiments the pH in the ileum is from 7.0 to 8.0, such as 7.5. In some embodiments the pH in the right colon is from 5.7 to 7.0, such as 6.4. In some embodiments the pH in the mid colon is from 5.7 to 7.4, such as 6.6. In some embodiments the pH in the left colon is from 6.3 to 7.7, such as 7.0. In some embodiments, the gastric pH in fasting subjects is from about 1.1 to 2.1, such as from 1.4 to 2.1, such as from 1.1 to 1.6, such as from 1.4 to 1.6. In some embodiments, the gastric pH in fed subjects is from 3.9 to 7.0, such as from 3.9 to 6.7, such as from 3.9 to 6.4, such as from 3.9 to 5.8, such as from 3.9 to 5.5, such as from 3.9 to 5.4, such as from 4.3 to 7.0, such as from 4.3 to 6.7, such as from 4.3 to 6.4, such as from 4.3 to 5.8, such as from 4.3 to 5.5, such as from 4.3 to 5.4. In some embodiments, the pH in the duodenum is from 5.8 to 6.8, such as from 6.0 to 6.8, such as from 6.1 to 6.8, such as from 6.2 to 6.8, such as from 5.8 to 6.7, such as from 6.0 to 6.7, such as from 6.1 to 6.7, such as from 6.2 to 6.7, such as from 5.8 to 6.6, such as from 6.0 to 6.6, such as from 6.1 to 6.6, such as from 6.2 to 6.6, such as from 5.8 to 6.5, such as from 6.0 to 6.5, such as from 6.1 to 6.5, such as from 6.2 to 6.5.

In some embodiments, releasing the TLR agonist is not dependent on the pH at or in the vicinity of the location. In some embodiments, releasing the TLR agonist is triggered by degradation of a release component located in the capsule. In some embodiments, the TLR agonist is not triggered by degradation of a release component located in the capsule. In some embodiments, wherein releasing the TLR agonist is not dependent on enzymatic activity at or in the vicinity of the location. In some embodiments, releasing the TLR agonist is not dependent on bacterial activity at or in the vicinity of the location.

In some embodiments, the pharmaceutical composition is an ingestible device, comprising:

a reservoir located within the housing and containing the TLR agonist,

wherein a first end of the reservoir is attached to the first end of the housing;

a mechanism for releasing the TLR agonist from the reservoir;

and;

In some embodiments, the ingestible device further comprises:

an electronic component located within the housing; and

In some embodiments, the ingestible device further comprises:

a safety device placed within or attached to the housing,

a housing defined by a first end, a second end substantially opposite from the first end, and a wall extending longitudinally from the first end to the second end; an electronic component located within the housing;

a reservoir located within the housing,

wherein the reservoir stores a dispensable substance and a first end of the reservoir is attached to the first end of the housing;

an exit valve located at the first end of the housing,

wherein the exit valve is configured to allow the dispensable substance to be released out of the first end of the housing from the reservoir; and

a safety device placed within or attached to the housing,

an electronic component located within the housing,

a reservoir located within the housing,

an injection device located at the first end of the housing,

wherein the jet injection device is configured to inject the dispensable substance out of the housing from the reservoir; and

a safety device placed within or attached to the housing,

wherein the safety device is configured to relieve an internal pressure within the housing. In some embodiments, the pharmaceutical composition is an ingestible device, comprising: a housing defined by a first end, a second end substantially opposite from the first end, and a wall extending longitudinally from the first end to the second end;

an optical sensing unit located on a side of the housing,

an electronic component located within the housing;

a reservoir located within the housing,

a membrane in contact with the gas generating cell and configured to move or deform into the reservoir by a pressure generated by the gas generating cell; and

a dispensing outlet placed at the first end of the housing,

wherein the dispensing outlet is configured to deliver the dispensable substance out of the housing from the reservoir.

In some embodiments, the pharmaceutical composition is an ingestible device as disclosed in US Patent Application Ser. No. 62/385,553, incorporated by reference herein in its entirety.

In some embodiments, the pharmaceutical composition is an ingestible device comprising a localization mechanism as disclosed in international patent application

PCT/US2015/052500, incorporated by reference herein in its entirety.

In some embodiments, the pharmaceutical composition is not a dart-like dosage form.

In case of conflict between the present specification and any subject matter incorporated by reference herein, the present specification, including definitions, will control.

Locations of treatment In some embodiments, the TLR agonist is delivered at a location in the large intestine of the subject. In some embodiments, the location is in the proximal portion of the large intestine. In some embodiments, the location is in the distal portion of the large intestine.

In some embodiments, the TLR agonist is delivered at a location in the ascending colon of the subject. In some embodiments, the location is in the proximal portion of the ascending colon. In some embodiments, the location is in the distal portion of the ascending colon.

In some embodiments, the TLR agonist is delivered at a location in the cecum of the subject. In some embodiments, the location is in the proximal portion of the cecum. In some embodiments, the location is in the distal portion of the cecum.

In some embodiments, the TLR agonist is delivered at a location in the sigmoid colon of the subject. In some embodiments, the location is in the proximal portion of the sigmoid colon. In some embodiments, the location is in the distal portion of the sigmoid colon.

In some embodiments, the TLR agonist is delivered at a location in the transverse colon of the subject. In some embodiments, the location is in the proximal portion of the transverse colon. In some embodiments, the location is in the distal portion of the transverse colon.

In some embodiments, the TLR agonist is delivered at a location in the descending colon of the subject. In some embodiments, the location is in the proximal portion of the descending colon. In some embodiments, the location is in the distal portion of the descending colon.

In some embodiments, the TLR agonist is delivered at a location in the small intestine of the subject. In some embodiments, the location is in the proximal portion of the small intestine. In some embodiments, the location is in the distal portion of the small intestine.

In some embodiments, the TLR agonist is delivered at a location in the duodenum of the subject. In some embodiments, the location is in the proximal portion of the duodenum. In some embodiments, the location is in the distal portion of the duodenum.

In some embodiments, the TLR agonist is delivered at a location in the jejunum of the subject. In some embodiments, the location is in the proximal portion of the jejunum. In some embodiments, the location is in the distal portion of the jejunum.

In some embodiments, the TLR agonist is delivered at a location in the duodenum of the subject and is not delivered at other locations in the gastrointestinal tract. In some embodiments, the TLR agonist is delivered at a location in the duodenum of the subject and is not delivered at other locations in the gastrointestinal tract, wherein a site of disease is in the duodenum and no site of disease is present at other locations in the gastrointestinal tract.

In some embodiments, the TLR agonist is delivered at a location in the duodenum of the subject and is not delivered at other locations in the gastrointestinal tract, wherein a first site of disease is in the duodenum and a second site of disease is in the stomach and no site of disease is present at other locations in the gastrointestinal tract.

In some embodiments, the TLR agonist is delivered at a location in the proximal duodenum of the subject and is not delivered at other locations in the gastrointestinal tract. In some embodiments, the TLR agonist is delivered at a location in the proximal duodenum of the subject and is not delivered at other locations in the gastrointestinal tract, wherein a site of disease is in the duodenum and no site of disease is present at other locations in the gastrointestinal tract. In some embodiments, the TLR agonist is delivered at a location in the proximal duodenum of the subject and is not delivered at other locations in the

gastrointestinal tract, wherein a first site of disease is in the duodenum and a second site of disease is in the stomach and no site of disease is present at other locations in the

gastrointestinal tract.

In some embodiments, the TLR agonist is delivered at a location in the jejunum of the subject and is not delivered at other locations in the gastrointestinal tract. In some embodiments, the TLR agonist is delivered at a location in the jejunum of the subject and is not delivered at other locations in the gastrointestinal tract, wherein a site of disease is in the jejunum and no site of disease is present at other locations in the gastrointestinal tract. In some embodiments, the TLR agonist is delivered at a location in the jejunum of the subject and is not delivered at other locations in the gastrointestinal tract, wherein a first site of disease is in the jejunum and a second site of disease is in the ileum and no site of disease is present at other locations in the gastrointestinal tract.

In some embodiments, the TLR agonist is delivered at a location in the proximal portion of the jejunum of the subject and is not delivered at other locations in the

gastrointestinal tract. In some embodiments, the TLR agonist is delivered at a location in the proximal portion of the jejunum of the subject and is not delivered at other locations in the gastrointestinal tract, wherein a site of disease is in the jejunum and no site of disease is present at other locations in the gastrointestinal tract. In some embodiments, the TLR agonist is delivered at a location in the proximal portion of the jejunum of the subject and is not delivered at other locations in the gastrointestinal tract, wherein a first site of disease is in the jejunum and a second site of disease is in the ileum and no site of disease is present at other locations in the gastrointestinal tract.

In some embodiments, the TLR agonist is delivered at a location in the distal portion of the jejunum of the subject and is not delivered at other locations in the gastrointestinal tract. In some embodiments, the TLR agonist is delivered at a location in the distal portion of the jejunum of the subject and is not delivered at other locations in the gastrointestinal tract, wherein a site of disease is in the jejunum and no site of disease is present at other locations in the gastrointestinal tract. In some embodiments, the TLR agonist is delivered at a location in the distal portion of the jejunum of the subject and is not delivered at other locations in the gastrointestinal tract, wherein a first site of disease is in the jejunum and a second site of disease is in the ileum and no site of disease is present at other locations in the

gastrointestinal tract.

In some embodiments, the TLR agonist is delivered at a location in the ileum of the subject. In some embodiments, the location is in the proximal portion of the ileum. In some embodiments, the location is in the distal portion of the ileum.

In some embodiments, the TLR agonist is delivered at a location in the ileum of the subject and is not delivered at other locations in the gastrointestinal tract. In some embodiments, the TLR agonist is delivered at a location in the ileum of the subject and is not delivered at other locations in the gastrointestinal tract, wherein a site of disease is in the ileum and no site of disease is present at other locations in the gastrointestinal tract. In some embodiments, the TLR agonist is delivered at a location in the ileum of the subject and is not delivered at other locations in the gastrointestinal tract, wherein a first site of disease is in the ileum and a second site of disease is in the cecum and no site of disease is present at other locations in the gastrointestinal tract. In some embodiments, the TLR agonist is delivered at a location in the ileum of the subject and is not delivered at other locations in the

gastrointestinal tract, wherein a first site of disease is in the ileum and a second site of disease is in the cecum and/or ascending colon, and no site of disease is present at other locations in the gastrointestinal tract.

In some embodiments, the TLR agonist is delivered at a location in the proximal portion of the ileum of the subject and is not delivered at other locations in the

gastrointestinal tract. In some embodiments, the TLR agonist is delivered at a location in the proximal portion of the ileum of the subject and is not delivered at other locations in the gastrointestinal tract, wherein a site of disease is in the ileum and no site of disease is present at other locations in the gastrointestinal tract. In some embodiments, the TLR agonist is delivered at a location in the proximal portion of the ileum of the subject and is not delivered at other locations in the gastrointestinal tract, wherein a first site of disease is in the ileum and a second site of disease is in the cecum and no site of disease is present at other locations in the gastrointestinal tract. In some embodiments, the TLR agonist is delivered at a location in the proximal portion of the ileum of the subject and is not delivered at other locations in the gastrointestinal tract, wherein a first site of disease is in the ileum and a second site of disease is in the cecum and/or ascending colon, and no site of disease is present at other locations in the gastrointestinal tract.

In some embodiments, the TLR agonist is delivered at a location in the distal portion of the ileum of the subject and is not delivered at other locations in the gastrointestinal tract. In some embodiments, the TLR agonist is delivered at a location in the distal portion of the ileum of the subject and is not delivered at other locations in the gastrointestinal tract, wherein a site of disease is in the ileum and no site of disease is present at other locations in the gastrointestinal tract. In some embodiments, the TLR agonist is delivered at a location in the distal portion of the ileum of the subject and is not delivered at other locations in the gastrointestinal tract, wherein a first site of disease is in the ileum and a second site of disease is in the cecum and no site of disease is present at other locations in the gastrointestinal tract. In some embodiments, the TLR agonist is delivered at a location in the distal portion of the ileum of the subject and is not delivered at other locations in the gastrointestinal tract, wherein a first site of disease is in the ileum and a second site of disease is in the cecum and/or ascending colon, and no site of disease is present at other locations in the

gastrointestinal tract.

In some embodiments, the TLR agonist is delivered at a location in the cecum of the subject and is not delivered at other locations in the gastrointestinal tract. In some embodiments, the TLR agonist is delivered at a location in the distal portion of the cecum of the subject and is not delivered at other locations in the gastrointestinal tract, wherein a site of disease is in the cecum and/or ascending colon, and no site of disease is present at other locations in the gastrointestinal tract. In some embodiments, the TLR agonist is delivered at a location in the distal portion of the ileum or the proximal portion of the ascending colon of the subject and is not delivered at other locations in the gastrointestinal tract, wherein a first site of disease is in the cecum and a second site of disease is in the ascending colon, and no site of disease is present at other locations in the gastrointestinal tract. In some embodiments, the location at which the TLR agonist is delivered is proximate to a site of disease. The site of disease may be, for example, an injury, inflamed tissue, or one or more lesions. In some embodiments, the location at which the TLR agonist is delivered is proximate to one or more sites of disease. In some embodiments, the TLR agonist is delivered 50 cm or less from the one or more sites of disease. In some embodiments, the TLR agonist is delivered 40 cm or less from the one or more sites of disease. In some embodiments, the TLR agonist is delivered 30 cm or less from the one or more sites of disease. In some embodiments, the TLR agonist is delivered 20 cm or less from the one or more sites of disease. In some embodiments, the TLR agonist is delivered 10 cm or less from the one or more sites of disease. In some embodiments, the TLR agonist is delivered 5 cm or less from the one or more sites of disease. In some embodiments, the TLR agonist is delivered 2 cm or less from the one or more sites of disease. In some embodiments, the method further comprises identifying the one or more sites of disease by a method comprising imaging of the gastrointestinal tract. In some embodiments, imaging of the gastrointestinal tract comprises video imaging. In some embodiments, imaging of the gastrointestinal tract comprises thermal imaging. In some embodiments, imaging of the gastrointestinal tract comprises ultrasound imaging. In some embodiments, imaging of the gastrointestinal tract comprises Doppler imaging.

In some embodiments the method does not comprise releasing more than 20 % of the TLR agonist at a location that is not proximate to a site of disease. In some embodiments the method does not comprise releasing more than 10 % of the TLR agonist at a location that is not proximate to a site of disease. In some embodiments the method does not comprise releasing more than 5 % of the TLR agonist at a location that is not proximate to a site of disease. In some embodiments the method does not comprise releasing more than 4 % of the TLR agonist at a location that is not proximate to a site of disease. In some embodiments the method does not comprise releasing more than 3 % of the TLR agonist at a location that is not proximate to a site of disease. In some embodiments the method does not comprise releasing more than 2 % of the TLR agonist at a location that is not proximate to a site of disease.

In some embodiments the method comprises releasing the TLR agonist at a location that is proximate to a site of disease, wherein the TLR agonist and, if applicable, any carriers, excipients or stabilizers admixed with the TLR agonist, are substantially unchanged, at the time of release of the TLR agonist at the location, relatively to the time of administration of the composition to the subject.

In some embodiments the method comprises releasing the TLR agonist at a location that is proximate to a site of disease, wherein the TLR agonist and, if applicable, any carriers, excipients or stabilizers admixed with the TLR agonist, are substantially unchanged by any physiological process (such as, but not limited to, degradation in the stomach), at the time of release of the TLR agonist at the location, relatively to the time of administration of the composition to the subject.

In some embodiments, the TLR agonist is delivered to the location by mucosal contact.

In some embodiments, the TLR agonist is delivered to the location by a process that does not comprise systemic transport of the TLR agonist.

In some embodiments, the amount of the TLR agonist that is administered is from about 1 mg to about 500 mg. In some embodiments, the amount of the TLR agonist that is administered is from about 1 mg to about 100 mg. In some embodiments, the amount of the TLR agonist that is administered is from about 5 mg to about 40 mg. In some embodiments, the amount of cobitolimod that is administered is about 30 mg.

In some embodiments, the amount of the TLR agonist that is administered is less than an amount that is effective when the TLR agonist is delivered systemically.

In some embodiments, the amount of the TLR agonist that is administered is an induction dose. In some embodiments, such induction dose is effective to induce remission of the TNF and cytokine storm and healing of acute inflammation and lesions. In some embodiments, the induction dose is administered once a day. In some embodiments, the induction dose is administered once every three days. In some embodiments, the induction dose is administered once a week. In some embodiments, the induction dose is administered once a day, once every three days, or once a week, over a period of about 6-8 weeks.

In some embodiments, the method comprises administering (i) an amount of the TLR agonist that is an induction dose, and (ii) an amount of the TLR agonist that is a maintenance dose, in this order. In some embodiments, step (ii) is repeated one or more times. In some embodiments, the induction dose is equal to the maintenance dose. In some embodiments, the induction dose is greater than the maintenance dose. In some embodiments, the induction dose is five times greater than the maintenance dose. In some embodiments, the induction dose is two times greater than the maintenance dose. In some embodiments an induction dose of TLR agonist and a maintenance dose of TLR agonist are each administered to the subject by administering a pharmaceutical composition comprising a therapeutically effective amount of the TLR agonist, wherein the pharmaceutical composition is a device. In some embodiments an induction dose of TLR agonist is administered to the subject in a different manner from the maintenance dose. As an example, the induction dose may be administered systemically. In some embodiments, the induction dose may be administered other than orally. As an example, the induction dose may be administered rectally. As an example, the induction dose may be administered intravenously. As an example, the induction dose may be administered subcutaneously. In some embodiments, the induction dose may be administered by spray catheter.

In some embodiments, the concentration of the TLR agonist delivered at the location in the gastrointestinal tract is 10%, 25%, 50%, 75%, 100%, 200%, 300%, 400%, 500%, 1000%, 2000% greater than the concentration of TLR agonist in plasma.

In some embodiments, the method provides a concentration of the TLR agonist at a location that is a site of disease or proximate to a site of disease that is 2-100 times greater than at a location that is not a site of disease or proximate to a site of disease.

In some embodiments, the method comprises delivering the TLR agonist at the location in the gastrointestinal tract as a single bolus.

In some embodiments, the method comprises delivering the TLR agonist at the location in the gastrointestinal tract as more than one bolus.

In some embodiments, the method comprises delivering the TLR agonist at the location in the gastrointestinal tract in a continuous manner.

In some embodiments, the method comprises delivering the TLR agonist at the location in the gastrointestinal tract over a time period of 20 or more minutes.

In some embodiments, the method provides a concentration of the TLR agonist in the plasma of the subject that is less than 10 μg/ml. In some embodiments, the method provides a concentration of the TLR agonist in the plasma of the subject that is less than 3 μg/ml. In some embodiments, the method provides a concentration of the TLR agonist in the plasma of the subject that is less than 1 μg/ml. In some embodiments, the method provides a concentration of the TLR agonist in the plasma of the subject that is less than 0.3 μg/ml. In some embodiments, the method provides a concentration of the TLR agonist in the plasma of the subject that is less than 0.1 μg/ml. In some embodiments, the method provides a concentration of the TLR agonist in the plasma of the subject that is less than 0.01 μg/ml. In some embodiments, the values of the concentration of the TLR agonist in the plasma of the subject provided herein refer to Ctrough, that is, the lowest value of the concentration prior to administration of the next dose.

In some embodiments, the method does not comprise delivering a TLR agonist rectally to the subject.

In some embodiments, the method does not comprise delivering a TLR agonist via an enema to the subject.

In some embodiments, the method does not comprise delivering a TLR agonist via suppository to the subject.

In some embodiments, the method does not comprise delivering a TLR agonist via instillation to the rectum of a subject.

In some embodiments, the methods disclosed herein comprise producing a therapeutically effective degradation product of the TLR agonist in the gastrointestinal tract. In some embodiments, the degradation product is a therapeutic antibody fragment. In some embodiments, a therapeutically effective amount of the degradation product is produced.

In some embodiments, the methods comprising administering the TLR agonist in the manner disclosed herein disclosed herein result in a reduced immunosuppressive properties relative to methods of administration of the TLR agonist systemically.

In some embodiments, the methods comprising administering the TLR agonist in the manner disclosed herein disclosed herein result in reduced immunogenicity relative to methods of administration of the TLR agonist systemically.

Markers

In some embodiments, the methods provided herein comprise monitoring the progress of the disease. In some embodiments, monitoring the progress of the disease comprises measuring the levels of IBD serological markers. In some embodiments, monitoring the progress of the disease comprises determining mucosal healing at the location of release. In some embodiments, monitoring the progress of the disease comprises determining the Crohn's Disease Activity Index (CDAI) over a period of about 6-8 weeks, or over a period of about 52 weeks, following administration of the TLR agonist. In some embodiments, monitoring the progress of the disease comprises determining the Harvey-Bradshaw Index (HBI) following administration of the TLR agonist. Possible markers may include the following: anti-glycan antibodies: anti-Saccharomices cerevisiae (ASCA); anti- laminaribioside (ALCA); anti-chitobioside (ACCA); anti-mannobioside (AMCA); anti- laminarin (anti-L); anti-chitin (anti-C) antibodies: anti-outer membrane porin C (anti-OmpC), anti-Cbirl flagellin; anti-12 antibody; autoantibodies targeting the exocrine pancreas (PAB); perinuclear anti-neutrophil antibody (pANCA). In some embodiments, monitoring the progress of the disease comprises measuring TLR agonist levels in serum over a period of about 1-14 weeks, such as about 6-8 weeks following administration of the TLR agonist, including at the 6-8 week time point. In some embodiments, monitoring the progress of the disease comprises measuring TLR agonist levels in serum over a period of about 52 weeks following administration of the TLR agonist, including at the 52 week time point.

Patients condition, diagnosis and treatment

In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the gastrointestinal tract that is proximate to one or more sites of disease comprises one or more of the following:

a) identifying a subject having a disease of the gastrointestinal tract, for example by endoscopy or colonoscopy;

b) determination of the severity of the disease, for example with reference to the Mayo Clinic Score, the Crohn's Disease Activity Index (CDAI), the Harvey-Bradshaw Index (HBI), or a combination of the above;

c) determination of the location of the disease, for example as determined by the

presence of lesions indicative of the disease;

d) evaluating the subject for suitability to treatment, for example by determining the patency of the subject's GI tract, for example if the indication is small intestinal diseases, pancolitis, Crohn's disease, or if the patients has strictures or fistulae;

e) administration of an induction dose or of a maintenance dose of a drug, such as the TLR agonist or such as another drug that is effective in the treatment of IBD conditions;

f) monitoring the progress of the disease, for example with reference to the Mayo Clinic Score, the Crohn's Disease Activity Index (CDAI), the Harvey-Bradshaw Index (HBI), the PRO, PR02 or PR03 tools, or a combination of the above; and/or g) optionally repeating steps e) and f) one or more times, for example over a period of about 1-14 weeks, such as about 6-8 weeks following administration of the TLR agonist, including at the 6-8 week time point, or over a period of about 52 weeks following administration of the TLR agonist, including at the 52 week time point.

As used herein, an induction dose is a dose of drug that may be administered, for example, at the beginning of a course of treatment, and that is higher than the maintenance dose administered during treatment. An induction dose may also be administered during treatment, for example if the condition of the patients becomes worse.

As used herein, a maintenance dose is a dose of drug that is provided on a repetitive basis, for example at regular dosing intervals.

In some embodiments the TLR agonist is released from an ingestible device.

In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the gastrointestinal tract that is proximate to one or more sites of disease comprises a) hereinabove.

In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the gastrointestinal tract that is proximate to one or more sites of disease comprises b) hereinabove.

In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the gastrointestinal tract that is proximate to one or more sites of disease comprises c) hereinabove.

In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the gastrointestinal tract that is proximate to one or more sites of disease comprises d) hereinabove.

In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the gastrointestinal tract that is proximate to one or more sites of disease comprises e) hereinabove.

In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the gastrointestinal tract that is proximate to one or more sites of disease comprises f) hereinabove.

In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the gastrointestinal tract that is proximate to one or more sites of disease comprises g) hereinabove.

In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the gastrointestinal tract that is proximate to one or more sites of disease comprises a) and b) hereinabove. In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the gastrointestinal tract that is proximate to one or more sites of disease comprises a) and c) hereinabove. In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the gastrointestinal tract that is proximate to one or more sites of disease comprises a) and d) hereinabove. In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the gastrointestinal tract that is proximate to one or more sites of disease comprises a) and e) hereinabove. In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the gastrointestinal tract that is proximate to one or more sites of disease comprises a) and f) hereinabove. In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the

gastrointestinal tract that is proximate to one or more sites of disease comprises a) and g) hereinabove. In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the

gastrointestinal tract that is proximate to one or more sites of disease comprises b) and c) hereinabove. In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the

gastrointestinal tract that is proximate to one or more sites of disease comprises b) and d) hereinabove. In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the

gastrointestinal tract that is proximate to one or more sites of disease comprises b) and e) hereinabove. In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the

gastrointestinal tract that is proximate to one or more sites of disease comprises b) and f) hereinabove. In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the

gastrointestinal tract that is proximate to one or more sites of disease comprises b) and g) hereinabove. In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the

gastrointestinal tract that is proximate to one or more sites of disease comprises c) and d) hereinabove. In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the

gastrointestinal tract that is proximate to one or more sites of disease comprises c) and e) hereinabove. In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the

gastrointestinal tract that is proximate to one or more sites of disease comprises c) and f) hereinabove. In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the

gastrointestinal tract that is proximate to one or more sites of disease comprises c) and g) hereinabove. In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the

gastrointestinal tract that is proximate to one or more sites of disease comprises d) and e) hereinabove. In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the

gastrointestinal tract that is proximate to one or more sites of disease comprises d) and f) hereinabove. In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the

gastrointestinal tract that is proximate to one or more sites of disease comprises d) and g) hereinabove. In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the

gastrointestinal tract that is proximate to one or more sites of disease comprises e) and f) hereinabove. In some embodiments herein, the method of treating a disease of the gastrointestinal tract that comprises releasing a TLR agonist at a location in the

gastrointestinal tract that is proximate to one or more sites of disease comprises g) hereinabove.

In some embodiments, one or more steps a) to e) herein comprise endoscopy of the gastrointestinal tract. In some embodiments, one or more steps a) to e) herein comprise colonoscopy of the gastrointestinal tract. In some embodiments, one or more steps a) to e) herein is performed one or more times. In some embodiments, such one or more of such one or more steps a) to e) is performed after releasing the TLR agonist at the location in the gastrointestinal tract that is proximate to one or more sites of disease.

In some embodiments, the method comprises administering one or more maintenance doses following administration of the induction dose in step e). In some embodiments an induction dose of TLR agonist and a maintenance dose of TLR agonist are each administered to the subject by administering a pharmaceutical composition comprising a therapeutically effective amount of the TLR agonist. In some embodiments an induction dose of TLR agonist is administered to the subject in a different manner from the maintenance dose. As an example, the maintenance dose may be administered systemically, while the maintenance dose is administered locally using a device. In one embodiment, a maintenance dose is administered systemically, and an induction dose is administered using a device every 1, 2, 3, 4, 5, 6, 7, 10, 15, 20, 25, 30, 35, 40, or 45 days. In another embodiment, a maintenance dose is administered systemically, and an induction dose is administered when a disease flare up is detected or suspected.

In some embodiments, the induction dose is a dose of the TLR agonist administered in an ingestible device as disclosed herein. In some embodiments, the maintenance dose is a dose of the TLR agonist administered in an ingestible device as disclosed herein.

In some embodiments, the induction dose is a dose of the TLR agonist administered in an ingestible device as disclosed herein. In some embodiments, the maintenance dose is a dose of the TLR agonist delivered systemically, such as orally with a tablet or capsule, or subcutaneously, or intravenously.

In some embodiments, the induction dose is a dose of the TLR agonist delivered systemically, such as orally with a tablet or capsule, or subcutaneously, or intravenously. In some embodiments, the maintenance dose is a dose of the TLR agonist administered in an ingestible device as disclosed herein.

In some embodiments, the induction dose is a dose of the TLR agonist administered in an ingestible device as disclosed herein. In some embodiments, the maintenance dose is a dose of a second agent as disclosed herein delivered systemically, such as orally with a tablet or capsule, or subcutaneously, or intravenously.

In some embodiments, the induction dose is a dose of a second agent as disclosed herein delivered systemically, such as orally with a tablet or capsule, or subcutaneously, or intravenously. In some embodiments, the maintenance dose is a dose of the TLR agonist administered in an ingestible device as disclosed herein.

In one embodiment of the methods provided herein, the patient is not previously treated with a TLR agonist. In one embodiment, the gastrointestinal inflammatory disorder is an inflammatory bowel disease. In one embodiment, the inflammatory bowel disease is ulcerative colitis or Crohn's disease. In one embodiment, the inflammatory bowel disease is ulcerative colitis and the response is selected from clinical response, mucosal healing and remission. In certain embodiments, remission in the patient is determined to be induced when the Mayo Clinic Score < 2 and no individual subscore >1, which is also referred to as clinical remission. In certain embodiments, mucosal healing is determined to have occurred when the patient is determined to have an endoscopy subscore of 0 or 1 as assessed by flexible sigmoidoscopy. In certain such embodiments, patients who experience mucosal healing are determined to have an endoscopy subscore of 0. In certain embodiments, clinical response is determined to have occurred when the patient experiences a 3 -point decrease and 30% reduction from baseline in MCS and > 1 -point decrease in rectal bleeding subscore or absolute rectal bleeding score of 0 or 1.

In some embodiments, the method comprises identifying the disease site substantially at the same time as releasing the TLR agonist.

In some embodiments, the method comprises monitoring the progress of the disease. In some embodiments, monitoring the progress of the disease comprises measuring the weight of the subject over a period of about 1-14 weeks, such as about 6-8 weeks following administration of the TLR agonist, including at the 6-8 week time point, or over a period of about 52 weeks following administration of the TLR agonist, including at the 52 week time point. In some embodiments, monitoring the progress of the disease comprises measuring the food intake of the subject; measuring the level of blood in the feces of the subject; measuring the level of abdominal pain of the subject; and/or a combination of the above, for example over a period of about 1-14 weeks, such as about 6-8 weeks following administration of the TLR agonist, including at the 6-8 week time point, or over a period of about 52 weeks following administration of the TLR agonist, including at the 52 week time point.

In some embodiments, the method comprises administering a TLR agonist with a spray catheter. For example, administering a TLR agonist with a spray catheter may be performed in step (e) hereinabove.

In some embodiments, the method does not comprise administering a TLR agonist with a spray catheter. Pharmaceutical Formulations

As used herein, a "formulation" of a TLR agonist may refer to either the TLR agonist in pure form - such as, for example, the lyophilized TLR agonist - or a mixture of the TLR agonist with one or more physiologically acceptable carriers, excipients or stabilizers. Thus, therapeutic formulations or medicaments can be prepared by mixing the TLR agonist having the desired degree of purity with optional physiologically acceptable carriers, excipients or stabilizers (Remington's Pharmaceutical Sciences 16th edition, Osol, A. Ed. (1980)), in the form of lyophilized formulations or aqueous solutions. Acceptable carriers, excipients, or stabilizers are nontoxic to recipients at the dosages and concentrations employed, and include buffers such as phosphate, citrate, and other organic acids; antioxidants including ascorbic acid and methionine; preservatives (such as octadecyldimethylbenzyl ammonium chloride; hexamethonium chloride; benzalkonium chloride, benzethonium chloride; phenol, butyl or benzyl alcohol; alkyl parabens such as methyl or propyl paraben; catechol; resorcinol;

cyclohexanol; 3-pentanol; and m-cresol); low molecular weight (less than about 10 residues) antibody; proteins, such as serum albumin, gelatin, or immunoglobulins; hydrophilic polymers such as polyvinylpyrrolidone; amino acids such as glycine, glutamine, asparagine, histidine, arginine, or lysine; monosaccharides, disaccharides, and other carbohydrates including glucose, mannose, or dextrins; chelating agents such as EDTA; sugars such as sucrose, mannitol, trehalose or sorbitol; salt- forming counter-ions such as sodium; metal complexes (e.g. , Zn- protein complexes); and/or non-ionic surfactants such as TWEEN™, PLURONICS™ or polyethylene glycol (PEG). Exemplary pharmaceutically acceptable carriers herein further include insterstitial drug dispersion agents such as soluble neutral- active hyaluronidase glycoproteins (sHASEGP), for example, human soluble PH-20 hyaluronidase glycoproteins, such as rHuPH20 (HYLENEX<®>, Baxter International, Inc.). Certain exemplary sHASEGPs and methods of use, including rHuPH20, are described in US Patent Publication Nos. 2005/0260186 and 2006/0104968. In one aspect, a sHASEGP is combined with one or more additional glycosaminoglycanases such as chondroitinases. Exemplary lyophilized formulations are described in US Patent No. 6,267,958. Aqueous formulations include those described in US Patent No. 6,171,586 and WO2006/044908, the latter formulations including a histidine-acetate buffer.

A formulation of a TLR agonist as disclosed herein, e.g., sustained-release formulations, can further include a mucoadhesive agent, e.g., one or more of polyvinyl pyrolidine, methyl cellulose, sodium carboxyl methyl cellulose, hydroxyl propyl cellulose, carbopol, a polyacrylate, chitosan, a eudragit analogue, a polymer, and a thiomer. Additional examples of mucoadhesive agents that can be included in a formulation with a TLR agonist are described in, e.g., Peppas et al, Biomaterials 17(16): 1553-1561, 1996; Kharenko et al, Pharmaceutical Chemistry J. 43(4):200-208, 2009; Salamat-Miller et A., Adv. DrugDeliv. Reviews 57(11): 1666-1691, 2005; Bernkop-Schnurch, 4<iv. Drug Deliv. Rev. 57(1 1): 1569- 1582, 2005; and Harding et al, Biotechnol. Genet. Eng. News 16(l):41-86, 1999.

In some embodiments, components of a formulation may include any one of the following components, or any combination thereof:

Acacia, Alginate, Alginic Acid, Aluminum Acetate, an antiseptic, Benzyl Alcohol, Butyl Paraben, Butylated Hydroxy Toluene, an antioxidant. Citric acid, Calcium carbonate, Candelilla wax, a binder, Croscarmellose sodium, Confectioner sugar, Colloidal silicone dioxide, Cellulose, Carnuba wax, Corn starch, Carboxymethylcellulose calcium, Calcium stearate, Calcium disodium EDTA, Chelation agents, Copolyvidone, Castor oil hydrogenated, Calcium hydrogen phosphate dehydrate, Cetylpyridine chloride, Cysteine HC1,

Crosspovidone, Dibasic Calcium Phosphate, Disodium hydrogen phosphate, Dimethicone, Erythrosine Sodium, Ethyl Cellulose, Gelatin, Glyceryl monooleate, Glycerin, Glycine, Glyceryl monostearate, Glyceryl behenate, Hydroxy propyl cellulose, Hydroxyl propyl methyl cellulose, Hypromellose, HPMC Pthalate, Iron oxides or ferric oxide, Iron oxide yellow, Iron oxide red or ferric oxide, Lactose (hydrous or anhydrous or monohydrate or spray dried), Magnesium stearate, Microcrystalline cellulose, Mannitol, Methyl cellulose,, Magnesium carbonate, Mineral oil, Methacrylic acid copolymer, Magnesium oxide, Methyl paraben, PEG, Polysorbate 80, Propylene glycol, Polyethylene oxide, Propylene paraben, Polaxamer 407 or 188 or plain, Potassium bicarbonate, Potassium sorbate, Potato starch, Phosphoric acid, Polyoxy l40 stearate, Sodium starch glycolate, Starch pregelatinized, Sodium crossmellose, Sodium lauryl sulfate, Starch, Silicon dioxide, Sodium benzoate,, Stearic acid, Sucrose base for medicated confectionery, a granulating agent, Sorbic acid, Sodium carbonate, Saccharin sodium, Sodium alginate, Silica gel, Sorbiton monooleate, Sodium stearyl fumarate, Sodium chloride, Sodium metabisulfite, Sodium citrate dehydrate, Sodium starch, Sodium carboxy methyl cellulose, Succinic acid, Sodium propionate, Titanium dioxide, Talc, Triacetin, Triethyl citrate.

Accordingly, in some embodiments of the method of treating a disease as disclosed herein, the method comprises administering to the subject a pharmaceutical composition that is a formulation as disclosed herein. In some embodiments the formulation is a dosage form, which may be, as an example, a solid form such as, for example, a capsule, a tablet, a sachet, or a lozenge; or which may be, as an example, a liquid form such as, for example, a solution, a suspension, an emulsion, or a syrup. In some embodiments the formulation is not comprised in an ingestible device. In some embodiments wherein the formulation is not comprised in an ingestible device, the formulation may be suitable for oral administration. The formulation may be, for example, a solid dosage form or a liquid dosage form as disclosed herein. In some embodiments wherein the formulation is not comprised in an ingestible device, the formulation may be suitable for rectal administration. The formulation may be, for example, a dosage form such as a suppository or an enema. In embodiments where the formulation is not comprised in an ingestible device, the formulation releases the TLR agonist at a location in the gastrointestinal tract of the subject that is proximate to one or more sites of disease. Such localized release may be achieved, for example, with a formulation comprising an enteric coating. Such localized release may be achieved, an another example, with a formulation comprising a core comprising one or more polymers suitable for controlled release of an active substance. A non-limiting list of such polymers includes: poly(2-(diethylamino)ethyl methacrylate, 2- (dimethylamino)ethyl methacrylate, poly(ethylene glycol), poly(2-aminoethyl methacrylate), (2-hydroxypropyl)methacrylamide, poly( -benzyl-l-aspartate), poly(N-isopropylacrylamide), and cellulose derivatives.

In some embodiments the formulation is comprised in an ingestible device as disclosed herein. In some embodiments wherein the formulation is comprised in an ingestible device, the formulation may be suitable for oral administration. The formulation may be, for example, a solid dosage form or a liquid dosage form as disclosed herein. In some embodiments the formulation is suitable for introduction and optionally for storage in the device. In some embodiments the formulation is suitable for introduction and optionally for storage in the reservoir comprised in the device. In some embodiments the formulation is suitable for introduction and optionally for storage in the reservoir comprised in the device. Thus, in some embodiments, provided herein is a reservoir comprising a therapeutically effective amount of a TLR agonist, wherein the reservoir is configured to fit into an ingestible device. In some embodiments, the reservoir comprising a therapeutically effective amount of a TLR agonist is attachable to an ingestible device. In some embodiments, the reservoir comprising a therapeutically effective amount of a TLR agonist is capable of anchoring itself to the subject's tissue. As an example, the reservoir capable of anchoring itself to the subject's tissue comprises silicone. As an example, the reservoir capable of anchoring itself to the subject's tissue comprises polyvinyl chloride. In some embodiments the formulation is suitable for introduction in the spray catheters disclosed herein.

The formulation/medicament herein may also contain more than one active compound as necessary for the particular indication being treated, for example, those with

complementary activities that do not adversely affect each other. For instance, the formulation may further comprise another TLR agonist or a chemotherapeutic agent. Such molecules are suitably present in combination in amounts that are effective for the purpose intended.

The active ingredients may also be entrapped in microcapsule prepared, for example, by coacervation techniques or by interfacial polymerization, for

example, hydroxymethylcellulose or gelatin-microcapsule and poly-(methylmethacylate) microcapsule, respectively, in colloidal drug delivery systems (for example, liposomes, albumin microspheres, microemulsions, nano-particles and nanocapsules) or in

macroemulsions. Such techniques are disclosed in Remington's Pharmaceutical Sciences 16th edition, Osol, A. Ed. (1980).

The formulations to be used for in vivo administration must be sterile. This is readily accomplished by filtration through sterile filtration membranes.

Sustained-release preparations may be prepared. Suitable examples of sustained- release preparations include semipermeable matrices of solid hydrophobic polymers containing the TLR agonist, which matrices are in the form of shaped articles, e.g., films, or microcapsule. Examples of sustained-release matrices include polyesters, hydrogels (for example, poly(2- hydroxy ethyl-methacrylate), or poly(vinylalcohol)), polylactides (U.S. Pat. No. 3,773,919), copolymers of L-glutamic acid and γ ethyl-L-glutamate, non-degradable ethylene-vinyl acetate, degradable lactic acid-gly colic acid copolymers such as the LUPRON DEPOT™ (injectable microspheres composed of lactic acid-gly colic acid copolymer and leuprolide acetate), and poly-D-(-)-3-hydroxybutyric acid. While polymers such as ethylene- vinyl acetate and lactic acid-gly colic acid enable release of molecules for over 100 days, certain hydrogels release proteins for shorter time periods. When encapsulated TLR agonists remain in the body for a long time, they may denature or aggregate as a result of exposure to moisture at 37°C, resulting in a loss of biological activity and possible changes in immunogenicity. Rational strategies can be devised for stabilization depending on the mechanism involved. For example, if the aggregation mechanism is discovered to be intermolecular S-S bond formation through thio-disulfide interchange, stabilization may be achieved by modifying sulfhydryl residues, lyophilizing from acidic solutions, controlling moisture content, using appropriate additives, and developing specific polymer matrix compositions.

Pharmaceutical formulations may contain one or more TLR agonists. The pharmaceutical formulations may be formulated in any manner known in the art. In some embodiments the formulations include one or more of the following components: a sterile diluent (e.g., sterile water or saline), a fixed oil, polyethylene glycol, glycerin, propylene glycol, or other synthetic solvents, antibacterial or antifungal agents, such as benzyl alcohol or methyl parabens, chlorobutanol, phenol, ascorbic acid, thimerosal, and the like, antioxidants, such as ascorbic acid or sodium bisulfite, chelating agents, such as

ethylenediaminetetraacetic acid, buffers, such as acetates, citrates, or phosphates, and isotonic agents, such as sugars (e.g., dextrose), polyalcohols (e.g., mannitol or sorbitol), or salts (e.g., sodium chloride), or any combination thereof. Liposomal suspensions can also be used as pharmaceutically acceptable carriers (see, e.g., U.S. Patent No. 4,522,811, incorporated by reference herein in its entirety). The formulations can be formulated and enclosed in ampules, disposable syringes, or multiple dose vials. Where required, proper fluidity can be maintained by, for example, the use of a coating, such as lecithin, or a surfactant. Controlled release of the TLR agonist can be achieved by implants and microencapsulated delivery systems, which can include biodegradable, biocompatible polymers (e.g., ethylene vinyl acetate, polyanhydrides, polyglycolic acid, collagen, polyorthoesters, and polylactic acid; Alza Corporation and Nova Pharmaceutical, Inc.).

In some embodiments, the TLR agonist is present in a pharmaceutical formulation within the device.

In some embodiments, the TLR agonist is present in solution within the device. In some embodiments, the TLR agonist is present in a suspension in a liquid medium within the device.

In some embodiments, data obtained from cell culture assays and animal studies can be used in formulating an appropriate dosage of any given TLR agonist. The effectiveness and dosing of any TLR agonist can be determined by a health care professional or veterinary professional using methods known in the art, as well as by the observation of one or more disease symptoms in a subject (e.g., a human). Certain factors may influence the dosage and timing required to effectively treat a subject (e.g., the severity of the disease or disorder, previous treatments, the general health and/or age of the subject, and the presence of other diseases).

In some embodiments, the subject is further administered an additional therapeutic agent (e.g., any of the additional therapeutic agents described herein). The additional therapeutic agent can be administered to the subject at substantially the same time as the TLR agonist or pharmaceutical composition comprising it is administered and/or at one or more other time points. In some embodiments, the additional therapeutic agent is formulated together with the TLR agonist (e.g., using any of the examples of formulations described herein).

In some embodiments, the subject is administered a dose of the TLR agonist at least once a month (e.g., at least twice a month, at least three times a month, at least four times a month, at least once a week, at least twice a week, three times a week, once a day, or twice a day). The TLR agonist may be administered to a subject chronically. Chronic treatments include any form of repeated administration for an extended period of time, such as repeated administrations for one or more months, between a month and a year, one or more years, more than five years, more than 10 years, more than 15 years, more than 20 years, more than 25 years, more than 30 years, more than 35 years, more than 40 years, more than 45 years, or longer. Alternatively, or in addition, chronic treatments may be administered. Chronic treatments can involve regular administrations, for example one or more times a day, one or more times a week, or one or more times a month. For example, chronic treatment can include administration (e.g., intravenous administration) about every two weeks (e.g., between about every 10 to 18 days).

A suitable dose may be the amount that is the lowest dose effective to produce a desired therapeutic effect. Such an effective dose will generally depend upon the factors described herein. If desired, an effective daily dose of TLR agonist can be administered as two, three, four, five, or six or more sub-doses administered separately at appropriate intervals throughout the day, optionally, in unit dosage forms.

Combination therapy:

The TLR agonists disclosed herein may be optionally be used with additional agents in the treatment of the diseases disclosed herein. Nonlimiting examples of such agents for treating or preventing inflammatory bowel disease in such adjunct therapy (e.g., Crohn's disease, ulcerative colitis) include substances that suppress cytokine production, down- regulate or suppress self-antigen expression, or mask the MHC antigens. Examples of such agents include 2- amino-6-aryl-5 -substituted pyrimidines (see U.S. Patent No. 4,665,077); non-steroidal antiinflammatory drugs (NSAIDs); ganciclovir; tacrolimus; lucocorticoids such as Cortisol or aldosterone; anti-inflammatory agents such as a cyclooxygenase inhibitor; a 5 - lipoxygenase inhibitor; or a leukotriene receptor antagonist; purine antagonists such as azathioprine or mycophenolate mofetil (MMF); alkylating agents such as cyclophosphamide; bromocryptine; danazol; dapsone; glutaraldehyde (which masks the MHC antigens, as described in U.S. Patent No. 4,120,649); anti-idiotypic antibodies for MHC antigens and MHC fragments; cyclosporine; 6-mercaptopurine; steroids such as corticosteroids or glucocorticosteroids or glucocorticoid analogs, e.g., prednisone, methylprednisolone, including SOLU-MEDROL®, methylprednisolone sodium succinate, and dexamethasone; dihydrofolate reductase inhibitors such as methotrexate (oral or subcutaneous); anti-malarial agents such as chloroquine and hydroxychloroquine; sulfasalazine; leflunomide; cytokine or cytokine receptor antibodies or antagonists including anti-interferon-alpha, -beta, or -gamma antibodies, anti -tumor necrosis factor(TNF)-alpha antibodies (infliximab (REMICADE®) or adalimumab), anti-TNF- alpha immunoadhesin (etanercept), anti-TNF-beta antibodies, anti- interleukin-2 (IL-2) antibodies and anti-IL-2 receptor antibodies, and anti-interleukin-6 (IL-6) receptor antibodies and antagonists; anti-LFA-1 antibodies, including anti-CD 1 la and anti- CD 18 antibodies; anti- L3T4 antibodies; heterologous anti-lymphocyte globulin; pan-T antibodies, anti-CD3 or anti- CD4/CD4a antibodies; soluble peptide containing a LFA-3 binding domain (WO 90/08187 published Jul. 26, 1990); streptokinase; transforming growth factor-beta (TGF-beta); streptodomase; RNA or DNA from the host; FK506; RS-61443; chlorambucil; deoxyspergualin; rapamycin; T-cell receptor (Cohen et al, U.S. Patent No. 5,114,721); T-cell receptor fragments (Offner et al, Science, 251 : 430-432 (1991); WO 90/11294; laneway, Nature, 341 : 482 (1989); and WO 91/01133); BAFF antagonists such as BAFF or BR3 antibodies or immunoadhesins and zTNF4 antagonists (for review, see Mackay and Mackay, Trends Immunol, 23: 113-5 (2002) and see also definition below); biologic agents that interfere with T cell helper signals, such as anti-CD40 receptor or anti- CD40 ligand (CD 154), including blocking antibodies to CD40-CD40 ligand.(e.g., Durie et al, Science, 261 : 1328-30 (1993); Mohan et al, J. Immunol, 154: 1470-80 (1995)) and

CTLA4-Ig (Finck et al, Science, 265: 1225-7 (1994)); and T-cell receptor antibodies (EP 340,109) such as T10B9. Non-limiting examples of adjunct agents also include the following: budenoside; epidermal growth factor; aminosalicylates; metronidazole; mesalamine; olsalazine; balsalazide; antioxidants; thromboxane inhibitors; IL-1 receptor antagonists; anti-IL-1 monoclonal antibodies; growth factors; elastase inhibitors; pyridinyl- imidazole compounds; TNF antagonists; IL-4, IL-10, IL-13 and/or TGFfi cytokines or agonists thereof (e.g., agonist antibodies); IL-11 ; glucuronide- or dextran-conjugated prodrugs of prednisolone, dexamethasone or budesonide; ICAM-I antisense phosphorothioate oligodeoxynucleotides (ISIS 2302; Isis Pharmaceuticals, Inc.); soluble complement receptor 1 (TPIO; T Cell Sciences, Inc.); slow-release mesalazine; antagonists of platelet activating factor (PAF); ciprofloxacin; and lignocaine. Examples of agents for UC are sulfasalazine and related salicylate-containing drugs for mild cases and corticosteroid drugs in severe cases. Topical administration of either salicylates or corticosteroids is sometimes effective, particularly when the disease is limited to the distal bowel, and is associated with decreased side effects compared with systemic use. Supportive measures such as administration of iron and antidiarrheal agents are sometimes indicated. Azathioprine, 6-mercaptopurine and methotrexate are sometimes also prescribed for use in refractory corticosteroid-dependent cases.

In other embodiments, a TLR agonist as described herein can be administered with one or more of: a CHST15 inhibitor, a IL-6 receptor inhibitor, an IL-12/IL-23 inhibitor, an integrin inhibitor, a JAK inhibitor, a SMAD7 inhibitor, a IL-13 inhibitor, an IL-1 receptor inhibitor, a TNF inhibitor, an immunosuppressant, or a stem cell. In other embodiments, a TLR agonist as described herein can be administered with a vitamin C infusion, one or more corticosteroids, and optionally thiamine.

In some embodiments, the methods disclosed herein comprise administering (i) the TLR agonist as disclosed herein, and (ii) a second agent orally, intravenously or

subcutaneously, wherein the second agent in (ii) is the same TLR agonist in (i); a different TLR agonist; or an agent having a different biological target from the TLR agonist.

In some embodiments, the methods disclosed herein comprise administering (i) the TLR agonist in the manner disclosed herein, and (ii) a second agent orally, intravenously or subcutaneously, wherein the second agent in (ii) is an agent suitable for treating an inflammatory bowel disease.

In some embodiments, the TLR agonist is administered prior to the second agent. In some embodiments, the TLR agonist is administered after the second agent. In some embodiments, the TLR agonist and the second agent are administered substantially at the same time. In some embodiments, the TLR agonist is delivered prior to the second agent. In some embodiments, the TLR agonist is delivered after the second agent. In some

embodiments, the TLR agonist and the second agent are delivered substantially at the same time.

In some embodiments, the second agent is an agent suitable for the treatment of a disease of the gastrointestinal tract. In some embodiments, the second agent is an agent suitable for the treatment of an inflammatory bowel disease. In some embodiments, the second agent is administered intravenously. In some embodiments, the second agent is administered subcutaneously. In some embodiments, the second agent is methotrexate.

In some embodiments, delivery of the TLR agonist to the location, such as delivery to the location by mucosal contact, results in systemic immunogenicity levels at or below systemic immunogenicity levels resulting from administration of the TLR agonist systemically. In some embodiments comprising administering the TLR agonist in the manner disclosed herein and a second agent systemically, delivery of the TLR agonist to the location, such as delivery to the location by mucosal contact, results in systemic immunogenicity levels at or below systemic immunogenicity levels resulting from administration of the TLR agonist systemically and the second agent systemically. In some embodiments, the method comprises administering the TLR agonist in the manner disclosed herein and a second agent, wherein the amount of the second agent is less than the amount of the second agent when the TLR agonist and the second agent are both administered systemically. In some aspects of these embodiments, the second agent is a TLR agonist.

In some embodiments, the method comprises administering the TLR agonist in the manner disclosed herein and does not comprise administering a second agent.

Examples:

Example 1 - Preclinical Murine Colitis Model

Experimental Induction of Colitis

Colitis is experimentally induced to in mice via the dextran sulfate sodium (DSS)- induced colitis model. This model is widely used because of its simplicity and many similarities with human ulcerative colitis. Briefly, mice are subjected to DSS via cecal catheterization, which is thought to be directly toxic to colonic epithelial cells of the basal crypts, for several days until colitis is induced. Groups

Mice are allocated to one of seven cohorts, depending on the agent that is administered:

1. Control (no agent)

2. Cobitolimod (2.5 mg/kg)

3. Cobitolimod (5 mg/kg)

4. Cobitolimod (10 mg/kg)

The control or agent is applied to a damaged mucosal surface of the bowel via administration through a cecal catheter at the dose levels described above.

Additionally, for each cohort, the animals are separated into two groups. One group receives a single dose of the control or agent on day 10 or 12. The other group receives daily (or similar) dosing of the control or agent.

Analysis

For each animal, efficacy is determined (e.g., by endoscopy, histology, etc.), and TLR levels are determined in blood, feces, and tissue (tissue levels are determined after animal sacrifice). For tissue samples, levels HER2 are additionally determined, and the level of TLR is normalized to the level of HER2. Additionally, other cytokine levels are determined in tissue (e.g., phospho STAT 1, STAT 3 and STAT 5), in plasma (e.g., VEGF, VCAM, ICAM, IL-6), or both.

Pharmacokinetics are determined both systemically (e.g., in the plasma) and locally (e.g., in colon tissue). For systemic pharmacokinetic analysis, blood and/or feces is collected from the animals at one or more timepoints after administration (e.g., plasma samples are collected at 15 minutes, 30 minutes, 1 hour, 2 hours, 4 hours, and/or 8 hours after administration). Local/colon tissue samples are collected once after animal sacrifice.

Example 2a - Development of Preclinical Porcine Colitis Model

Experimental Induction of Colitis

Female swine weighing approximately 35 to 45 kg at study start are fasted at least 24 hours prior to intra-rectal administration of trinitrobenzene sulfonic acid (TNBS). Animals are lightly anesthetized during the dosing and endoscopy procedure. An enema to clean the colon is used, if necessary. One animal is administered 40 ml of 100% EtOH mixed with 5 grams of TNBS diluted in 10 ml of water via an enema using a ball-tipped catheter. The enema is deposited in the proximal portion of the descending colon just past the bend of the transverse colon. The TNBS is retained at the dose site for 12 minutes by use of two Foley catheters with 60-ml balloons placed in the mid-section of the descending colon below the dose site. A second animal is similarly treated, but with a solution containing 10 grams of TNBS. An Endoscope is employed to positively identify the dose site in both animals prior to TNBS administration. Dosing and endoscopy are performed by a veterinary surgeon

Seven (7) days after TNBS administration, after light anesthesia, the dose site and mucosal tissues above and below the dose site are evaluated by the veterinary surgeon using an endoscope. Pinch Biopsies are obtained necessary, as determined by the surgeon. Based on the endoscopy findings, the animals may be euthanized for tissue collection on that day, or may proceed on study pending the results of subsequent endoscopy exams for 1 to 4 more days. Macroscopic and microscopic alterations of colonic architecture, possible necrosis, thickening of the colon, and substantial histologic changes are observed at the proper TNBS dose.

Clinical signs (e.g., ill health, behavioral changes, etc.) are recorded at least daily during acclimation and throughout the study. Additional pen-side observations are conducted twice daily (once-daily on weekends). Body weight is measured for both animals Days 1 and 7 (and on the day of euthanasia if after Day 7).

On the day of necropsy, the animals are euthanized via injection of a veterinarian- approved euthanasia solution. Immediately after euthanasia in order to avoid autolytic changes, colon tissues are collected, opened, rinsed with saline, and a detailed macroscopic examination of the colon is performed to identify macroscopic finings related to TNBS- damage. Photos are taken. Tissue samples are taken from the proximal, mid, and distal transverse colon; the dose site; the distal colon; the rectum; and the anal canal. Samples are placed into NBF and evaluated by a board certified veterinary pathologist.

Example 2b - Pharmacokinetic/Pharmacodynamic and Bioavailability of Cobitolimod After Topical Application

Animal Model

Animals are subjected to intra-rectal administration of trinitrobenzene Sulfonic acid (TNBS) to induce chronic colitis on Day -6. All animals are fasted prior to colitis induction on Day -7. The TNBS is dissolved in 25% ethanol then instilled into the colon intra-rectally using a flexible plastic ball-tip gavage needle. Approximately seven (7) days after induction, macroscopic and microscopic alterations of colonic architecture are apparent: some necrosis, thickening of the colon, substantial histologic changes that only partially resolve by Day 60.

Groups

Sixteen (16) swine (approximately 35 to 45 kg at study start) are allocated to one of five groups:

1. Vehicle Control: (3.2 mL saline); intra-rectal; (n=2)

2. Treated Control: Cobitolimod (40mg in 3.2mL saline); subcutaneous; (n=2)

3. Cobitolimod (low): Cobitolimod (40mg in 3.2mL saline); intra-rectal; (n=4)

4. Cobitolimod (med): Cobitolimod (80mg in 3.2 mL saline); intra-rectal; (n=4)

5. Cobitolimod (high): Cobitolimod (160mg in 3.2 mL saline); intra-rectal;

(n=4)

On Day 0, the test article is applied to a damaged mucosal surface of the bowel via intra-rectal administration or subcutaneous injection by a veterinary surgeon at the dose levels and volume described above.

Clinical Observations and Body Weight

Clinical observations are conducted at least once daily. Clinical signs (e.g., ill health, behavioral changes, etc.) are recorded on all appropriate animals at least daily prior to the initiation of experiment and throughout the study until termination. Additional clinical observations may be performed if deemed necessary. Animals whose health condition warrants further evaluation are examined by a Clinical Veterinarian. Body weight is measured for all animals Days -6, 0, and after the last blood collections.

Samples

Blood:

Blood is collected (cephalic, jugular, and/or catheter) into EDTA tubes during acclimation on Day-7, just prior to dose on Day 0, and 0.5, 1, 2, 4, 6, 8, 12, 24, and 48 hours post-dose. The EDTA samples are split into two aliquots and one is centrifuged for pharmacokinetic plasma and either analyzed immediately, or stored frozen (-80°C) for later pharmacokinetic analyses. The remaining sample of whole blood is used for pharmacodynamic analyses.

Feces:

Feces is collected Day -7, 0 and 0.5, 1, 2, 4, 6, 8, 12, 24 and 48 hours post-dose, and either analyzed immediately, or flash-frozen on liquid nitrogen and stored frozen at -70°C pending later analysis of drug levels and inflammatory cytokines.

Tissue:

Immediately after euthanasia in order to avoid autolytic changes, colon tissues are collected, opened, rinsed with saline, and a detailed macroscopic examination of the colon is performed to identify macroscopic finings related to TNBS-damage. Triplicate samples of normal and damaged tissues are either analyzed immediately, or are flash-frozen on liquid nitrogen and stored frozen at -70°C pending later analysis of drug concentration, inflammatory cytokines and histology.

Samples are analyzed for cobitolimod levels (local mucosal tissue levels and systemic circulation levels), and for levels of TLR.

Terminal Procedures

Animals are euthanized as per the schedule in Table AA, where one animal each of Vehicle and Treated Control groups is euthanized at 6 and 48 hours post-dose, and one animal of each the cobitolimod groups are euthanized at 6, 12, 24 and 48 hours post-dose. Animals are discarded after the last blood collection unless retained for a subsequent study.

Table AA

Claims

Claims:

1. A method of treating a disease of the gastrointestinal tract in a subj ect, comprising: releasing a TLR agonist at a location in the gastrointestinal tract of the subject that is proximate to one or more sites of disease, wherein the method comprises administering to the subject a pharmaceutical composition comprising a therapeutically effective amount of the TLR agonist, wherein the pharmaceutical composition is an ingestible device and the method comprises administering orally to the subject the pharmaceutical composition.

2. The method of claim 1, wherein the pharmaceutical composition is an ingestible device and the method comprises administering orally to the subject the pharmaceutical composition.

3. The method of claim 1 or 2, wherein the method does not comprise releasing more than 10% of the TLR agonist at a location that is not proximate to a site of disease.

4. The method of claim 1 or 2, wherein the method provides a concentration of the TLR agonist at a location that is a site of disease or proximate to a site of disease that is 2-100 times greater than at a location that is not proximate to a site of disease.

5. The method of any one of the preceding claims, wherein the method provides a concentration of the TLR agonist in the plasma of the subject that is less than 3 μg/ml.

6. The method of claim 5, wherein the method provides a concentration of the TLR agonist in the plasma of the subject that is less than 0.3 μg/ml.

7. The method of claim 6, wherein the method provides a concentration of the TLR agonist in the plasma of the subject that is less than 0.01 μg/ml.

8. The method of any one of claims 1 to 4, wherein the method provides a C24 value of the TLR agonist in the plasma of the subject that is less than 3 μg/ml.

9. The method of claim 8, wherein the method provides a C24 value of the TLR agonist in the plasma of the subject that is less than 0.3 μg/ml.

10. The method of claim 9, wherein the method provides a C24 value of the TLR agonist in the plasma of the subject that is less than 0.01 μg/ml.

11. The method of any one of claims 1 to 10, wherein the TLR agonist is a synthetic TLR agonist.

12. The method of any one of claims 1 to 10, wherein the TLR agonist is a TLR mimic.

13. The method of any one of claims 1 to 10, wherein the TLR agonist is a small molecule.

14. The method of any one of claims 1 to 10, wherein the TLR agonist is a peptide.

15. The method of any one of claims 1 to 10, wherein the TLR agonist is a fusion protein.

16. The method of any one of claims 2 to 15, wherein the TLR agonist is present in a pharmaceutical formulation within the device.

17. The method of claim 16, wherein the formulation is a solution of the TLR agonist in a liquid medium.

18. The method of claim 17, wherein the formulation is a suspension of the TLR agonist in a liquid medium.

19. The method of any one of claims 1 to 18, wherein the disease of the GI tract is an inflammatory bowel disease.

20. The method of any one of claims 1 to 18, wherein the disease of the GI tract is ulcerative colitis.

21. The method of any one of claims 1 to 18, wherein the disease of the GI tract is Crohn's disease.

22. The method of any one of claims 1 to 21, wherein the TLR agonist is released at a location in the large intestine of the subject.

23. The method of claim 22, wherein the location is in the proximal portion of the large intestine.

24. The method of claim 22, wherein the location is in the distal portion of the large intestine.

25. The method of any one of claims 1 to 21, wherein the TLR agonist is released at a location in the ascending colon of the subject.

26. The method of claim 25, wherein the location is in the proximal portion of the ascending colon.

27. The method of claim 25, wherein the location is in the distal portion of the ascending colon.

28. The method of any one of claims 1 to 21, wherein the TLR agonist is released at a location in the cecum of the subject.

29. The method of claim 28, wherein the location is in the proximal portion of the cecum.

30. The method of claim 28, wherein the location is in the distal portion of the cecum.

31. The method of any one of claims 1 to 21, wherein the TLR agonist is released at a location in the sigmoid colon of the subject.

32. The method of claim 31, wherein the location is in the proximal portion of the sigmoid colon.

33. The method of claim 31, wherein the location is in the distal portion of the sigmoid colon.

34. The method of any one of claims 1 to 21, wherein the TLR agonist is released at a location in the transverse colon of the subject.

35. The method of claim 34, wherein the location is in the proximal portion of the transverse colon.

36. The method of claim 34, wherein the location is in the distal portion of the transverse colon.

37. The method of any one of claims 1 to 21, wherein the TLR agonist is released at a location in the descending colon of the subject.

38. The method of claim 37, wherein the location is in the proximal portion of the descending colon.

39. The method of claim 37, wherein the location is in the distal portion of the descending colon.

40. The method of any one of claims 1 to 21, wherein the TLR agonist is released at a location in the small intestine of the subject.

41. The method of claim 40, wherein the location is in the proximal portion of the small intestine.

42. The method of claim 40, wherein the location is in the distal portion of the small intestine.

43. The method of any one of claims 1 to 21, wherein the TLR agonist is released at a location in the duodenum of the subject.

44. The method of claim 43, wherein the location is in the proximal portion of the duodenum.

45. The method of claim 43, wherein the location is in the distal portion of the duodenum.

46. The method of any one of claims 1 to 21, wherein the TLR agonist is released at a location in the jejunum of the subject.

47. The method of claim 46, wherein the location is in the proximal portion of the jejunum.

48. The method of claim 46, wherein the location is in the distal portion of the jejunum.

49. The method of any one of claims 1 to 21, wherein the TLR agonist is released at a location in the ileum of the subject.

50. The method of claim 49, wherein the location is in the proximal portion of the ileum.

51. The method of claim 49, wherein the location is in the distal portion of the ileum.

52. The method of any one of the preceding claims, wherein the location at which the TLR agonist is released is 10 cm or less from one or more sites of disease.

53. The method of any one of the preceding claims, wherein the location at which the TLR agonist is released is 5 cm or less from one or more sites of disease.

54. The method of any one of the preceding claims, wherein the location at which the TLR agonist is released is 2 cm or less from one or more sites of disease.

55. The method of any one of the preceding claims, wherein the TLR agonist is released by mucosal contact.

56. The method of any one of the preceding claims, wherein the TLR agonist is delivered to the location by a process that does not comprise systemic transport of the TLR agonist.

57. The method of any one of the preceding claims, further comprising identifying the one or more sites of disease by a method comprising imaging of the gastrointestinal tract.

58. The method of claim any one of the preceding claims, wherein the method comprises identifying the disease site prior to administering the pharmaceutical composition.

59. The method of claim 58, wherein the method comprises releasing the TLR agonist substantially at the same time as identifying the disease site.

60. The method of any one of the preceding claims, comprising (a) identifying a subject having a disease of the gastrointestinal tract and (b) evaluating the subject for suitability to treatment.

61. The method of any one of claims 1 or 3 to 15 or 17 to 60, wherein releasing the TLR agonist is triggered by one or more of: a pH in the jejunum from 6.1 to 7.2, a pH in the mid small bowel from 7.0 to 7.8, a pH in the ileum from 7.0 to 8.0, a pH in the right colon from 5.7 to 7.0, a pH in the mid colon from 5.7 to 7.4, a pH in the left colon from 6.3 to 7.7, such as 7.0.

62. The method of any one of claims 1 to 60, wherein releasing the TLR agonist is not dependent on the pH at or in the vicinity of the location.

63. The method of any one of claims 1 or 3 to 15 or 17 to 60, wherein releasing the TLR agonist is triggered by degradation of a release component located in the device.

64. The method of any one of claims 1 to 60, wherein releasing the TLR agonist is not triggered by degradation of a release component located in the device.

65. The method of any one of claims 1 to 60, wherein releasing the TLR agonist is not dependent on enzymatic activity at or in the vicinity of the location.

66. The method of any one of claims 1 to 60, wherein releasing the TLR agonist is not dependent on bacterial activity at or in the vicinity of the location.

67. The method of any one of claims 1 to 60, wherein the composition comprises a plurality of electrodes comprising a coating, and releasing the TLR agonist is triggered by an electric signal by the electrodes resulting from the interaction of the coating with the one or more sites of disease.

68. The method of any one of claims 1 to 60, wherein releasing the TLR agonist is triggered by a remote electromagnetic signal.

69. The method of any one of claims 1 to 60, wherein releasing the TLR agonist is triggered by generation in the composition of a gas in an amount sufficient to expel the TLR agonist.

70. The method of any one of claims 1 to 60, wherein releasing the TLR agonist is triggered by an electromagnetic signal generated within the device according to a predetermined drug release profile.

71. The method of any one of claims 2 to 60, wherein the ingestible device comprises an ingestible housing, wherein a reservoir storing the TLR agonist is attached to the housing.

72. The method of claim 71, further comprising:

detecting when the ingestible housing is proximate to a respective disease site of the one of the one or more sites of disease,

wherein releasing the TLR agonist comprises releasing the therapeutically effective amount of the TLR agonist from the reservoir proximate the respective disease site in response to the detection.

73. The method of claim72, wherein detecting comprises detecting via one or more sensors coupled to the ingestible housing.

74. The method of claim 73, wherein the one or more sensors comprise a plurality of coated electrodes and wherein detecting comprises receiving an electric signal by one or more of the coated electrodes responsive to the one or more electrode contacting the respective disease site.

75. The method of claim 72, wherein releasing comprises opening one or more valves in fluid communication with the reservoir.

76. The method of claim 75, wherein the one or more valves is communicably coupled to a processor positioned in the housing, the processor communicably coupled to one or more sensors configured to detect the one or more sites of disease.

77. The method of claim 72, wherein releasing comprises pumping the therapeutically effective amount of the TLR agonist from the reservoir via pump positioned in the ingestible housing.

78. The method of claim 77, wherein the pump is communicably coupled to a processor positioned in the housing, the processor communicably coupled to one or more sensors configured to detect the one or more sites of disease.

79. The method of claim 71, wherein the therapeutically effective amount of the TLR agonist is stored in the reservoir at a reservoir pressure higher than a pressure in the gastrointestinal tract of the subject.

80. The method of claim 71, further comprising anchoring the ingestible housing at a location proximate to the respective disease site in response to the detection.

81. The method of claim 80, wherein anchoring the ingestible housing comprises one or more legs to extend from the ingestible housing.

82. The method of any one of the preceding claims, wherein the amount of the TLR agonist that is administered is from about 1 mg to about 500 mg.

83. The method of any one of the preceding claims, wherein the TLR9 agonist is a TLR9 agonist.

84. The method of claim 83, wherein the TLR9 agonist is selected from cobitolimod (Kappaproct® or DIMS0150, InDex Pharmaceuticals); generic equivalents thereof;

modifications thereof having at least 90% sequence homology; modifications thereof having at least 90% sequence homology; and modifications thereof having one or more nucleotide insertions, deletions, or modifications.

85. The method of any one of claims 1 to 84, wherein the amount of the TLR agonist is less than an amount that is effective when TLR agonist is administered systemically.

86. The method of any one of the preceding claims, comprising administering (i) an amount of the TLR agonist that is an induction dose.

87. The method of claim 86, further comprising (ii) administering an amount of the TLR agonist that is a maintenance dose following the administration of the induction dose.

88. The method of claim 86 or 87, wherein the induction dose is administered once a day.

89. The method of claim 86 or 87, wherein the induction dose is administered once every three days.

90. The method of claim 86 or 87, wherein the induction dose is administered once a week.

91. The method of claim 87, wherein step (ii) is repeated one or more times.

92. The method of claim 87, wherein step (ii) is repeated once a day over a period of about 6-8 weeks.

93. The method of claim 87, wherein step (ii) is repeated once every three days over a period of about 6-8 weeks.

94. The method of claim 87, wherein step (ii) is repeated once a week over a period of about 6-8 weeks.

95. The method of claim 87, wherein the induction dose is equal to the maintenance dose.

96. The method of claim 87, wherein the induction dose is greater than the maintenance dose.

97. The method of claim 87, wherein the induction dose is 5 times greater than the maintenance dose.

98. The method of claim 87, wherein the induction dose is 2 times greater than the maintenance dose.

99. The method of any one of the preceding claims, wherein the method comprises releasing the TLR agonist at the location in the gastrointestinal tract as a single bolus.

100. The method of any one of claims 1 to 98, wherein the method comprises releasing the TLR agonist at the location in the gastrointestinal tract as more than one bolus.

101. The method of any one of claims 1 to 98, wherein the method comprises delivering the TLR agonist at the location in the gastrointestinal tract in a continuous manner.

102. The method of claim 101, wherein the method comprises delivering the TLR agonist at the location in the gastrointestinal tract over a time period of 20 or more minutes.

103. The method of any one of claims 1 to 102, wherein the method does not comprise delivering a TLR agonist rectally to the subject.

104. The method of any one of claims 1 to 102, wherein the method does not comprise delivering a TLR agonist via an enema to the subject.

105. The method of any one of claims 1 to 102, wherein the method does not comprise delivering a TLR agonist via suppository to the subject.

106. The method of any one of claims 1 to 102, wherein the method does not comprise delivering a TLR agonist via instillation to the rectum of the subject.

107. The method of any one of claims 1 to 102, wherein the method does not comprise surgical implantation.

108. The method of any one of claims 1 to 107, wherein the TLR agonist is a TLR3 agonist.

109. The method of any one of claims 1 to 107, wherein the TLR agonist is a TLR4 agonist.

110. The method of any one of claims 1 to 107, wherein the TLR agonist is a TLR5 agonist.

111. The method of any one of claims 1 to 107, wherein the TLR agonist is a TLR7/8 agonist.

112. The method of any one of claims 1 to 107, wherein the TLR agonist is a TLR9 agonist.

113. The method of any one of claims 1 to 67 or 69 to 112, wherein the composition is an autonomous device.

114. The method of any one of claims 1 to 113, wherein the composition comprises a mechanism capable of releasing the TLR agonist.

115. The method of any one of claims 1 to 114, wherein the composition comprises a tissue anchoring mechanism for anchoring the composition to the location.

116. The method of claim 115, wherein the tissue anchoring mechanism is capable of activation for anchoring to the location.

117. The method of claim 115 to 116, wherein the tissue anchoring mechanism comprises an osmotically-driven sucker.

118. The method of claim 115, 116, or 117, wherein the tissue anchoring mechanism comprises a connector operable to anchor the composition to the location.

119. The method of claim 118, wherein the connector is operable to anchor the composition to the location using an adhesive, negative pressure and/or fastener.

120. The method of claim 71, wherein the reservoir is an anchorable reservoir.

121. The method of any one of claims 1 to 60, wherein the pharmaceutical composition is an ingestible device, comprising:

a housing; a reservoir located within the housing and containing the TLR agonist;

a mechanism for releasing the TLR agonist from the reservoir, and;

122. The method of claim 121, wherein the ingestible device further comprises:

an electronic component located within the housing; and

123. The method of claim 121 or 122, wherein the ingestible device further comprises: a safety device placed within or attached to the housing,

124. The method of claim 1 to 60, wherein the pharmaceutical composition is an ingestible device, comprising:

an electronic component located within the housing;

a reservoir located within the housing,

an exit valve located at the first end of the housing,

a safety device placed within or attached to the housing, wherein the safety device is configured to relieve an internal pressure within the housing when the internal pressure exceeds a threshold level.

125. The method of claim 1 to 60, wherein the pharmaceutical composition is an ingestible device, comprising:

an electronic component located within the housing,

a reservoir located within the housing,

an injection device located at the first end of the housing,

a safety device placed within or attached to the housing,

126. The method of claim 1 to 60, wherein the pharmaceutical composition is an ingestible device, comprising:

an optical sensing unit located on a side of the housing,

an electronic component located within the housing;

a gas generating cell located within the housing and adjacent to the electronic component, wherein the electronic component is configured to activate the gas generating cell to generate gas in response to identifying a location of the ingestible device based on the reflectance;

a reservoir located within the housing,

a dispensing outlet placed at the first end of the housing,

127. The method of any one of claims 1 to 60, wherein the pharmaceutical composition is an ingestible device as disclosed in US Patent Application Ser. No. 62/385,553, incorporated by reference herein in its entirety.

128. The method of any one of claims 1 to 60, wherein the pharmaceutical composition is an ingestible device comprising a localization mechanism as disclosed in international patent application PCT/US2015/052500, incorporated by reference herein in its entirety.

129. The method of any one of claims 1 to 60, wherein the pharmaceutical composition is not a dart-like dosage form.

130. A method of treating a disease of the large intestine of a subject, comprising:

wherein the method comprises administering endoscopically to the subject a therapeutically effective amount of the TLR agonist, wherein the method does not comprise releasing more than 20% of the TLR agonist at a location that is not proximate to a site of disease.

131. A method of treating a disease of the gastrointestinal tract in a subj ect, comprising: releasing a TLR agonist at a location in the proximal portion of the large intestine of the subject that is proximate to one or more sites of disease, wherein the method comprises administering endoscopically to the subject a pharmaceutical composition comprising a therapeutically effective amount of the TLR agonist, wherein the pharmaceutical composition is an ingestible device.

132. The method of claim 130 or 131, wherein the method does not comprise releasing more than 20% of the TLR agonist at a location that is not proximate to a site of disease

133. The method of claim 130, 131 or 132 wherein the method does not comprise releasing more than 10% of the TLR agonist at a location that is not proximate to a site of disease.

134. The method of any one of claims 130, 131 or 132, wherein the method provides a concentration of the TLR agonist at a location that is a site of disease or proximate to a site of disease that is 2-100 times greater than at a location that is not proximate to a site of disease.

135. The method of any one of claims 130 to 134, wherein the method provides a concentration of the TLR agonist in the plasma of the subject that is less than 3 μg/ml.

136. The method of claim 135, wherein the method provides a concentration of the TLR agonist in the plasma of the subject that is less than 0.3 μg/ml.

137. The method of claim 136, wherein the method provides a concentration of the TLR agonist in the plasma of the subject that is less than 0.01 μg/ml.

138. The method of any one of claims 130 to 134, wherein the method provides a C24 value of the TLR agonist in the plasma of the subject that is less than 3 μg/ml.

139. The method of any one of claims 130 to 134, wherein the method provides a C24 value of the TLR agonist in the plasma of the subject that is less than 0.3 μg/ml.

140. The method of any one of claims 130 to 134, wherein the method provides a C24 value of the TLR agonist in the plasma of the subject that is less than 0.01 μg/ml.

141. The method of any one of claims 130 to 134, wherein the composition does not comprise an enteric coating.

142. The method of any one of claims 130 to 141, wherein the TLR agonist is not a cyclic peptide.

143. The method of any one of claims 130 to 141, wherein the TLR agonist is present in a pharmaceutical formulation within the device.

144. The method of claim 143, wherein the formulation is a solution of the TLR agonist in a liquid medium.

145. The method of claim 143, wherein the formulation is a suspension of the TLR agonist in a liquid medium.

146. The method of any one of claims 130 to 145, wherein the disease of the large intestine is an inflammatory bowel disease.

147. The method of any one of claims 130 to 145, wherein the disease of the large intestine is ulcerative colitis.

148. The method of any one of claims 130 to 145, wherein the disease the large intestine is Crohn's disease.

149. The method of any one of claims 130 to 148, wherein the TLR agonist is released at a location in the proximal portion of the ascending colon.

150. The method of any one of claims 130 to 148, wherein the TLR agonist is released at a location in the proximal portion of the cecum.

151. The method of any one of claims 130 to 148, wherein the TLR agonist is released at a location in the proximal portion of the sigmoid colon.

152. The method of any one of claims 130 to 148, wherein the TLR agonist is released at a location in the proximal portion of the transverse colon.

153. The method of any one of claims 130 to 148, wherein the TLR agonist is released at a location in the proximal portion of the descending colon.

154. The method of any one of claims 130 to 148, wherein the method comprises administering to the subject a reservoir comprising the therapeutically effective amount of the TLR agonist, wherein the reservoir is connected to the endoscope.

155. The method of any one of the preceding claims, further comprising administering a second agent orally, intravenously or subcutaneously, wherein the second agent is the same TLR agonist; a different TLR agonist; or an agent having a different biological target from the TLR agonist, wherein the second agent is an agent suitable for treating an inflammatory bowel disease.

156. The method of claim 155, wherein the TLR agonist is administered prior to the second agent.

157. The method of claim 155, wherein the TLR agonist is administered after the second agent.

158. The method of claim 155, wherein the TLR agonist and the second agent are administered substantially at the same time.

159. The method of any one of claims 155, wherein the second agent is administered intravenously.

160. The method of any one of claims 155, wherein the second agent is administered subcutaneously.

161. The method of any one of claims 155 to 160, wherein the amount of the second agent is less than the amount of the second agent when the TLR agonist and the second agent are both administered systemically.

162. The method of claim 161, wherein the second agent is a TLR agonist.

163. The method of claim 161, wherein second agent is methotrexate.

164. The method of any one of claims 1 to 154, wherein the method does not comprise administering a second agent.

165. The method of any one of claims 119 to 164, wherein the method comprises identifying the disease site prior to endoscopic administration.

166. The method of any one of claims 119 to 164, wherein the method comprises identifying the disease site substantially at the same time as releasing the TLR agonist.

167. The method of any one of the preceding claims, wherein the method comprising monitoring the progress of the disease.

168. The method of claim 167, wherein monitoring the progress of the disease comprises measuring the weight of the subject over a period of about 1-14 weeks, such as about 6-8 weeks following administration of the TLR agonist.

169. The method of claim 167 or 168, wherein monitoring the progress of the disease comprises measuring the food intake of the subject over a period of about 1-14 weeks, such as about 6-8 weeks following administration of the TLR agonist.

170. The method of claim 167, 168 or 169, wherein monitoring the progress of the disease comprises measuring the level of blood in the feces of the subject over a period of about 1-14 weeks, such as about 6-8 weeks following administration of the TLR agonist.

171. The method of claim 167, 168 or 169, wherein monitoring the progress of the disease comprises measuring the level of abdominal pain of the subject over a period of about 1-14 weeks, such as about 6-8 weeks following administration of the TLR agonist.

172. The method of any one of claims 1 to 171, wherein the method does not comprise administering a TLR agonist with a spray catheter.

173. The method of any one of claims 1 to 172, wherein the method comprises administering a TLR agonist with a spray catheter.

174. A method of treating a disease of the gastrointestinal tract in a subject, comprising: releasing a TLR agonist at a location in the gastrointestinal tract of the subject that is proximate to one or more sites of disease, wherein the method comprises administering to the subject a pharmaceutical composition comprising a therapeutically effective amount of the TLR agonist the method comprising one or more of the following steps:

a) identifying a subject having a disease of the gastrointestinal tract;

b) determination of the severity of the disease;

c) determination of the location of the disease;

d) evaluating the subject for suitability to treatment;

e) administration of an induction dose of the TLR agonist;

f) monitoring the progress of the disease; and/or

g) optionally repeating steps e) and f) one or more times.

175. The method of claim 174, wherein the pharmaceutical composition is an ingestible device and the method comprises administering orally to the subject the pharmaceutical composition.

176. The method of claim 174 or 175, wherein the method comprises administering one or more maintenance doses following administration of the induction dose in step e).

177. The method of claim 176, wherein the induction dose is a dose of the TLR agonist administered in an ingestible device.

178. The method of claim 176 or 177, wherein the maintenance dose is a dose of the TLR agonist administered in an ingestible device as disclosed herein.

179. The method of claim 176 or 177, wherein the maintenance dose is a dose of the TLR agonist delivered systemically.

180. The method of claim 176, wherein the induction dose is a dose of the TLR agonist delivered systemically.

181. The method of claim 176 or 180, wherein the maintenance dose is a dose of the TLR agonist administered in an ingestible device.

182. The method of claim 176, wherein the induction dose is a dose of a second agent as delivered systemically.

183. The method of claim 176 or 180, wherein the maintenance dose is a dose of the TLR agonist administered in an ingestible device.

184. An TLR agonist delivery apparatus comprising:

an ingestible housing comprising a reservoir having a pharmaceutical composition comprising a therapeutically effective amount of the TLR agonist stored therein;

a valve system in fluid communication with the reservoir system; and

a controller communicably coupled to the valve system and the detector, the controller configured to cause the valve system to open in response to the detector detecting that the ingestible housing is proximate to the respective disease site so as to release the therapeutically effective amount of the TLR agonist at the respective disease site.

185. The TLR agonist delivery apparatus according to claim 184, further comprising a pump positioned in the ingestible housing, the pump configured to pump the therapeutically effective amount of the TLR agonist from the reservoir in response to activation of the pump by the controller responsive to detection by the detector of the ingestible housing being proximate to the respective disease site.

186. The TLR agonist delivery apparatus according to claim 185, wherein the controller is configured to cause the pump to pump the therapeutically effective amount of the TLR agonist from the reservoir according to the following protocol.

187. The TLR agonist delivery apparatus according to claim 184, wherein the valve system comprises a dissolvable coating.

188. The TLR agonist delivery apparatus according to claim 184, wherein the valve system comprises one or more doors configured for actuation by at least one of sliding, pivoting, and rotating.

189. The TLR agonist delivery apparatus according to claim 184, wherein the valve system comprises an electrostatic shield.

190. The TLR agonist delivery apparatus according to claim 184, wherein the reservoir comprises a pressurized cell.

191. The TLR agonist delivery apparatus according to claim 184, further comprising at least one actuatable anchor configured to retain the ingestible housing at the respective disease site upon actuation.

192. The TLR agonist delivery apparatus according to claim 184, herein the actuatable anchor is retractable.

193. A composition comprising a therapeutically effective amount of the TLR agonist of any one of the preceding claims, wherein the composition is capable of releasing the TLR agonist at a location in the gastrointestinal tract of the subject.

194. The composition of claim 193, wherein the composition comprises a tissue anchoring mechanism for anchoring the composition to the location.

195. The composition of claim 194, wherein the tissue anchoring mechanism is capable of anchoring for anchoring to the location.

196. The composition of claim 194 or 195, wherein the tissue anchoring mechanism comprises an osmotically-driven sucker.

197. The composition of claim 194, 195 or 196, wherein the tissue anchoring mechanism comprises a connector operable to anchor the composition to the location.

198. The composition of claim 197, wherein the connector is operable to anchor the composition to the location using an adhesive, negative pressure and/or fastener.

199. An TLR agonist for use in a method of treating a disease of the gastrointestinal tract in a subject, wherein the method comprises orally administering to the subject an ingestible device loaded with the TLR agonist, wherein the TLR agonist is released by the device at a location in the gastrointestinal tract of the subject that is proximate to one or more sites of disease.

200. The TLR agonist for use of claim 199, wherein the TLR agonist is contained in a reservoir suitable for attachment to a device housing, and wherein the method comprises attaching the reservoir to the device housing to form the ingestible device, prior to orally administering the ingestible device to the subject.

201. An attachable reservoir containing a TLR agonist for use in a method of treating a disease of the gastrointestinal tract, wherein the method comprises attaching the reservoir to a device housing to form an ingestible device and orally administering the ingestible device to a subject, wherein the TLR agonist is released by device at a location in the gastrointestinal tract of the subject that is proximate to one or more sites of disease.

202. A composition comprising or consisting of an ingestible device loaded with a therapeutically effective amount of a TLR agonist, for use in a method of treatment, wherein the method comprises orally administering the composition to the subject, wherein the TLR agonist is released by the device at a location in the gastrointestinal tract of the subject that is proximate to one or more sites of disease.

203. The TLR agonist for use according to claim 199 or 200, the attachable reservoir compartment for use according to claim 201, or the composition for use according to claim 202, wherein the sites of disease have been pre-determined.

204. The TLR agonist for use according to claim 199 or 200, the attachable reservoir compartment for use according to claim 201, or the composition for use according to claim 202, wherein the ingestible device further comprises an environmental sensor and the method further comprises using the environmental sensor to identify the location of one or more sites of disease.

205. The TLR agonist for use, the attachable reservoir compartment for use the composition for use, according to claim 204, wherein the environmental sensor is an imaging sensor and the method further comprising imaging the gastrointestinal tract to identify the location of one or more sites of disease.

206. The TLR agonist for use, the attachable reservoir compartment for use, or the composition for use, according to claim 205, wherein the imaging detects inflamed tissue and/or lesions associated with a disease of the gastrointestinal tract.

207. The TLR agonist for use, the attachable reservoir compartment for use or the composition for use, according to any one of claims 199 to 205, wherein the disease of the GI tract is one or more of an inflammatory bowel disease, ulcerative colitis and Crohn's disease.

208. An ingestible device loaded with a therapeutically effective amount of a TLR agonist, wherein the device is controllable to release the TLR agonist at a location in the

gastrointestinal tract of the subject that is proximate to one or more sites of disease.

209. The device of claim 208 for use in a method of treatment of the human or animal body.

210. The TLR agonist for use, the attachable reservoir compartment for use or the composition for use according to any one of claims 199 to 207, or the device according to claim 208 or claim 209, wherein the ingestible device comprises:

a reservoir located within the housing and containing the TLR agonist wherein a first end of the reservoir is connected to the first end of the housing;

a mechanism for releasing the TLR agonist from the reservoir, and;

an exit value configured to allow the TLR agonist to be released out of the housing from the reservoir.

211. The TLR agonist for use, the attachable reservoir compartment for use or the composition for use according to any one of claims 199 to 207, or the device according to claim 208 or claim 209, wherein the ingestible device comprises:

an ingestible housing comprising a reservoir compartment having a therapeutically effective amount of the TLR agonist stored therein; a release mechanism having a closed state which retains the TLR agonist in the reservoir and an open state which releases the TLR agonist from the reservoir to the exterior of the device; and

212. The TLR agonist for use, the attachable reservoir compartment for use, the composition for use, or the device according to claims 210 or 211, wherein the ingestible device further comprises an environmental sensor for detecting the location of the device in the gut and/or for detecting the presence of disease in the GI tract.

213. The TLR agonist for use, the attachable reservoir compartment for use, the composition for use, or the device according to claim 212, wherein the ingestible device further comprises a communication system for transmitting data from the environmental sensor to an external receiver.

214. The TLR agonist for use, the attachable reservoir compartment for use, the composition for use, or the device according to claim 212 or 213, wherein the ingestible device further comprises a processor or controller which is coupled to the environmental sensor and to the actuator and which triggers the actuator to cause the release mechanism to transition from its closed state to its open state when it is determined that the device is in the presence of diseased tissue and/or is in a location in the gut that has been predetermined to be proximal to diseased tissue.

215. The TLR agonist for use, the attachable reservoir compartment for use, the composition for use, or the device according to claim 213, wherein the communication system further comprises means for receiving a signal from an external transmitter, and wherein the actuator is adapted to be triggered in response to the signal.

216. The TLR agonist for use, the attachable reservoir compartment for use, the composition for use, or the device according to any one of claims 210 to 215, wherein the ingestible device further comprises a communication system for transmitting localization data to an external receiver.

217. The TLR agonist for use, the attachable reservoir compartment for use, the composition for use, or the device according to any one of claims 210 to 213, wherein the ingestible device further comprises a communication system for transmitting localization data to an external receiver and for receiving a signal from an extemal transmitter; wherein the actuator is adapted to be triggered in response to the signal.

218. The TLR agonist for use, the attachable reservoir compartment for use, the composition for use, or the device according to any one of claims 119 to 217, wherein the ingestible device further comprises a deployable anchoring system and an actuator for deploying the anchoring system, wherein the anchoring system is capable of anchoring or attaching the ingestible device to the subject's tissue.