ZA200101752B - Methods of treating or preventing ophthalmi infections with moxifloxacin. - Google Patents

Description

. x | WO 00/18386 PCT/US99/22622

Lo

ANTIBIOTIC COMPOSITIONS FOR

TREATMENT OF THE EYE, EAR AND NOSE

Background of the Invention

The present invention is directed to the provision of topical antibiotic pharmaceutical compositions for the treatment of ophthalmic, otic and nasal infections, particularly bacterial infections, and to methods of treating ophthalmic, otic and nasal infections by applying those compositions to the affected tissues. The compositions and methods of the invention are based on the use of a new class of antibiotics. The compositions of the present invention may also contain one or more anti-inflammatory agents,

The use of quinolone antibiotics to treat infections represents the current state of the art in the field of ophthalmic pharmaceutical compositions and methods of treatment. } 20 For example, a topical ophthalmic composition containing the quinolone ciprofloxacin is marketed by Alcon Laboratories, Inc. under the name CILOXANT (Ciprofloxacin . 0.3%) Ophthalmic Solution. The following quinolones have also been utilized in ophthalmic antibiotic compositions:

Quinolone Product Manufacturer

Ofloxacin OCUFLOX™ Allergan

Norfloxacin CHIBROXIN™ Merck

Lomefloxacin LOMEFLOX™ Senju ~The foregoing quinolone antibiotic compositions are generally effective in treating ophthalmic infections, and have distinct advantages over prior ophthalmic antibiotic compositions, particularly those having relatively limited spectrums of antimicrobial activity, such as: neomycin, polymyxin B, gentamicin and tobramycin,

which are primarily useful against gram negative pathogens; and bacitracin, gramicidin, I and erythromycin, which are primarily active against gram positive pathogens. However, despite the general efficacy of the ophthalmic quinolone therapies currently available, there is a need for improved compositions and methods of treatment based on the use of antibiotics that are more effective than existing antibiotics against key ophthalmic pathogens, and less prone to the development of resistance by those pathogens.

There is an even greater need for effective topical compositions and methods for treating otic and nasal infections, particularly bacterial infections. The use of oral antibiotics to treat otic infections in children has limited efficacy, and creates a serious risk of pathogen resistance to the orally administered antibiotics.

Ophthalmic, otic and nasal infections are frequently accompanied by inflammation of the infected ophthalmic, otic and nasal tissues and perhaps even surrounding tissues. Similarly, ophthalmic, otic and nasal surgical procedures that create a risk of microbial infections frequently also cause inflammation of the affected tissues.

Thus, there is also a need for ophthalmic, otic and nasal pharmaceutical compositions that combine the anti-infective activity of one or more antibiotics with the anti- inflammatory activity of one or more steroid or non-steroid agents in a single composition.

Summary of the Invention

The invention is based on the use of a potent new class of antibiotics to treat ophthalmic, otic and nasal infections, as well as the prophylactic use of these antibiotics following surgery or other trauma to ophthalmic, otic or nasal tissues. The compositions of the present invention may also be administered to the affected tissues during ophthalmic, otic or nasal surgical procedures to prevent or alleviate post-surgical infection.

The compositions preferably also contain one or more anti-inflammatory agents to treat inflammation associated with infections of ophthalmic, otic or nasal tissues. The

. i WO 00/18386 PCT/US99/22622

E ha 8 anti-inflammatory component of the compositions is also useful in treating inflammation associated with physical trauma to ophthalmic, otic or nasal tissues, including inflammation resulting from surgical procedures. The compositions of the present invention are therefore particularly useful in treating inflammation associated with trauma to ophthalmic, otic or nasal tissues wherein there is either an infection or a risk of an infection resulting from the trauma.

Examples of ophthalmic conditions that may be treated with the compositions of the present invention include conjunctivitis, keratitis, blepharitis, dacyrocystitis, hordeolum and corneal ulcers. The compositions of the invention may also be used prophylactically in connection with various ophthalmic surgical procedures that create a risk of infection.

Examples of otic conditions that may be treated with the compostions of the present invention include otitis externa and otitis media. With respect to the treatment of . otitis media, the compositions of the present invention are primarily useful in cases where the tympanic membrane has ruptured or tympanostomy tubes have been implanted. The : : compositions may also be used to treat infections associated with otic surgical procedures, such as tympanostomy, or to prevent such infections.

The compositions of the present invention are specially formulated for topical application to ophthalmic, otic and nasal tissues. The compositions are preferably sterile, and have physical properties (e.g., osmolality and pH) that are specially suited for application to ophthalmic, otic and nasal tissues, including tissues that have been compromised as the result of preexisting disease, trauma, surgery or other physical conditions.

Detailed Description of the Invention Fo :

The antibiotics used in the compositions and methods of the present invention have the following formula: (I) x! o 2

F Lr

B V

R wherein:

A is CH, CF, CCl, C-OCH,;, or N;

X'is H, halogen, NH,, or CH;;

R'is C, to Cj alkyl, FCH,CH,, cyclopropyl or phenyl, optionally mono-, di- or tri- substituted by halogen, or A and R, together can form a bridge of formula C-O-

CH,-CH(CH5;);

R?is H, C, to C4 alkyl (optionally substituted by OH, halogen or NH,), or 5- ] methyl-2-o0xo0-1,3-dioxol-4-yl-methyl; and

B is a selected from the group consisting of:

N N N

R3N Y, R4N Y R4N Y __/ __/ _/

N N abl am

R4N Y R4N Y __/ __/ and 40

PY WO 00/18386 PCT/US99/22622 . Ua wherein:

Y is O or CH;

R’is C,-C; alkoxyl, CH,-CO-C¢H;s, CH,CH,CO;R', R'O,C-CH=C-CO,R,

CH=CH-CO,R' or CH,CH,-CN, wherein:

R'is Hor C, to C5 alkyl;

R'is H, C, to Cy alkyl, C,-Cs alkoxyl, CH,-CO-C¢H;s, CH,CH,CO,R,

R'O,C-CH=C-CO,R', CH=CH-CO,R', CH,CH,-CN or 5-methyl-2-oxo- 1,3-dioxol-4-yl-methyl, wherein:

R'is Hor C; to C; alkyl; and their pharmaceutically useful hydrates and salts. } The compound Moxifloxacin is most preferred. Moxifloxacin has the following

Structure: . 25 0 . F

MeO " / \

Further details regarding the structure, preparation, and physical properties of

Moxifloxacin and other compounds of formula (I) are provided in United States Patent

No. 5,607,942.

The concentrations of the antibiotics of formula (I) in the compositions of the present invention will vary depending on the intended use of the compositions (e.g., treatment of existing infections or prevention of post-surgical infections), and the relative antimicrobial activity of the specific antibiotic selected. The antimicrobial activity of ’ antibiotics is generally expressed as the minimum concentration required to inhibit the growth of a specified pathogen. This concentration is also referred to as the “minimum inhibitory concentration” or “MIC”. The term “MIC90” refers to the minimum concentration of antibiotic required to inhibit the growth of ninety percent (90%) of the strains of a species. The concentration of an antibiotic required to totally kill a specified bacteria is referred to as the “minimum bactericidal concentration” or “MBC”. The minimum inhibitory concentration of Moxifloxacin for several bacteria commonly associated with ophthalmic, otic and nasal infections are provided in the following table:

Microorganism MIC

S. aureus/methicillin sensitive 0.13

S. aureus/methicillin resistant 4.0

S. aureus/quinolone resistant 4.0

S. epidermidis/methicillin sensitive 0.25 ’

S. epidermidis/methicillin resistant 4.0

S. pneumoniae/penicillin sensitive 0.25

S. pneumoniae/penicillin resistant 0.25

P. aeruginosa 8.0

H. influenzae/B-lactamase positive 0.06

H influenzae/Blactamase negative 0.06

All of the foregoing concentrations are expressed as micrograms per milliliter (“mcg/ml”).

- ad WO 00/18386 PCT/US99/22622

N PM. The appropriate antibiotic concentration for ophthalmic compositions will generally be an amount of one or more antibiotics of formula (I) sufficient to provide a concentration in the aqueous humor and lacrimal fluid of the eye equal to or greater than the MIC90 level for the selected antibiotic(s), relative to gram-negative and gram- positive organisms commonly associated with ophthalmic infections. The appropriate concentration for otic and nasal compositions will generally be an amount of one or more antibiotics of formula (I) sufficient to provide a concentration in the infected tissues equal to or greater than the MIC90 level for the selected antibiotic(s), relative to gram- negative and gram-positive organisms commonly associated with otic or nasal infections.

Such amounts are referred to herein as “an antimicrobial effective amount”. The compositions of the present invention will typically contain one or more compounds of formula (I) in a concentration of from about 0.1 to about 1.0 percent by weight (“wt. %”) of the compositions.

The compositions of the present invention may also contain one or more anti- y inflammatory agents. The anti-inflammatory agents utilized in the present invention are broadly classified as steroidal or non-steroidal. The preferred steroidal anti-inflammatory

So agents are glucocorticoids.

The preferred glucocorticoids for ophthalmic and otic use include dexamethasone, loteprednol, rimexolone, prednisolone, fluorometholone, and hydrocortisone. The preferred glucocorticoids for nasal use include mometasone, fluticasone, beclomethasone, flunisolide, triamcinolone and budesonide.

The dexamethasone derivatives described in U.S. Patent No. 5,223,493 (Boltralik) are also preferred steroidal anti-inflammatory agents, particularly with respect to compositions for treating ophthalmic inflammation. The following compounds are especially preferred: i o— N . oO 0 .

TI AL-1529 oO

YD

Oo

These compounds are referred to herein as “21-ether derivatives of dexamethasone”. The 21-benzyl ether derivative (i.e., compound AL-2512) is particularly preferred. 5 .

The preferred non-steroidal anti-inflammatory agents are: prostaglandin H synthetase inhibitors (Cox I or Cox II), also referred to as cyclooxygenase type I and type :

II inhibitors, such as diclofenac, flurbiprofen, ketorolac, suprofen, nepafenac, amfenac, indomethacin, naproxen, ibuprofen, bromfenac, ketoprofen, meclofenamate, piroxicam, sulindac, mefanamic acid, diflusinal, oxaprozin, tolmetin, fenoprofen, benoxaprofen, nabumetome, etodolac, phenylbutazone, aspirin, oxyphenbutazone, NCX-4016,

HCT-1026, NCX-284, NCX-456, tenoxicam and carprofen; cyclooxygenase type II selective inhibitors, such as NS-398, vioxx, celecoxib, P54. etodolac, L-804600 and S- 33516; PAF antagonists, such as SR-27417, A-137491, ABT-299, apafant, bepafant, minopafant, E-6123, BN-50727, nupafant and modipafant; PDE IV inhibitors, such as ariflo, torbafylline, rolipram, filaminast, piclamilast, cipamfylline, CG-1088, V-11294A,

CT-2820, PD-168787, CP-293121, DWP-205297, CP-220629. SH-636, BAY-19-8004, and roflumilast; inhibitors of cytokine production, such as inhibitors of the NFkB transcription factor; or other anti-inflammatory agents known to those skilled in the art.

Lo a8 WO 00/18386 PCT/US99/22622 h er The concentrations of the anti-inflammatory agents contained in the compositions of the present invention will vary based on the agent or agents selected and the type of inflammation being treated. The concentrations will be sufficient to reduce inflammation in the targeted ophthalmic, otic or nasal tissues following topical application of the compositions to those tissues. Such an amount is referred to herein as “an anti- inflammatory effective amount”. The compositions of the present invention will typically contain one or more anti-inflammatory agents in an amount of from about 0.01 to about 1.0 wt.%.

The compositions are typically administered to the affected ophthalmic, otic or nasal tissues by topically applying one to four drops of a sterile solution or suspension, or a comparable amount of an ointment, gel or other solid or semisolid composition, one to four times per day. However, the compositions may also be formulated as irrigating solutions that are applied to the affected ophthalmic, otic or nasal tissues during surgical procedures. . The ophthalmic, otic and nasal compositions of the present invention will contain one or more compounds of formula (I) and preferably one or more anti-inflammatory : g agents, in pharmaceutically acceptable vehicles. The compositions will typically have a ’ pH in the range of 4.5 to 8.0. The ophthalmic compositions must also be formulated to have osmotic values that are compatible with the aqueous humor of the eye and ophthalmic tissues. Such osmotic values will generally be in the range of from about 200 to about 400 milliosmoles per kilogram of water (“mOsm/kg”), but will preferably be about 300 mOsm/kg.

Ophthalmic, otic and nasal pharmaceutical products are typically packaged in multidose form. Preservatives are thus required to prevent microbial contamination during use. Suitable preservatives include: polyquaternium-1, benzalkonium chloride, thimerosal, chlorobutanol, methyl paraben, propyl paraben, phenylethyl alcohol, edetate disodium, sorbic acid, or other agents known to those skilled in the art. The use of polyquaternium-1 as the antimicrobial preservative is preferred. Typically such preservatives are employed at a level of from 0.001% to 1.0% by weight.

The solubility of the components of the present compositions may be enhanced by a surfactant or other appropriate co-solvent in the composition. Such co-solvents include polysorbate 20, 60, and 80, polyoxyethylene/polyoxypropylene surfactants (e.g., Pluronic

F-68, F-84 and P-103), cyclodextrin, or other agents known to those skilled in the art. s Typically such co-solvents are employed at a level of from 0.01% to 2% by weight.

The use of viscosity enhancing agents to provide the compositions of the invention with viscosities greater than the viscosity of simple aqueous solutions may be desirable to increase ocular absorption of the active compounds by the target tissues or increase the retention time in the eye, ear or nose. Such viscosity building agents include, for example, polyvinyl alcohol, polyvinyl pyrrolidone, methyl cellulose, hydroxy propyl methylcellulose, hydroxyethyl cellulose, carboxymethyl cellulose, hydroxy propyl cellulose or other agents know to those skilled in the art. Such agents are typically employed at a level of from 0.01% to 2% by weight.

The following examples are provided to further illustrate the ophthalmic, otic and nasal compositions of the present invention.

Example 1

Ingredient Amount (wt. %)

Moxifloxacin 0.35

Sodium Acetate 0.03

Acetic Acid 0.04

Mannitol 4.60

EDTA 0.05 - Benzalkonium Chloride 0.006

Water g.s. 100

. aN WO 00/18386 PCT/US99/22622

Example 2

Ophthalmic/Otic/Nasal Suspension

Ingredient Amount (wt. %)

Moxifloxacin 0.3

Dexamethasone, Micronized USP 0.10

Benzalkonium Chloride 0.01

Edetate Disodium, USP 0.01

Sodium Chloride, USP 0.3

Sodium Sulfate, USP 1.2

Tyloxapol, USP 0.05

Hydroxyethylcellulose 0.25

Sulfuric Acid and/or

Sodium Hydroxide, NF g.s. for pH adjustment to 5.5

Purified Water, USP g.s. to 100

Example 3

Ophthalmic Ointment « 20 Ingredient Amount (wt.%)

Moxifloxacin 0.35

Mineral Oil, USP 2.0

White petrolatium, USP q.s 100

Example 4 .

Ophthalmic Ointment

Ingredient Amount (wt.%)

Moxifloxacin 0.3

Fluorometholone Acetate, USP 0.1

Chlorobutanol, Anhydrous, NF 0.5

Mineral Oil,USP 5

White Petrolatum, USP q.s. 100

The invention has been described herein by reference to certain preferred embodiments. However, as obvious variations thereon will become apparent to those skilled in the art, the invention is not to be considered as limited thereto.

S12 -

Claims (14)

1. A composition for use in a method of treating or preventing ophthalmic infections, which comprises moxifloxacin at a concentration of 0.1 to 1.0 wt. % and an ophthalmically acceptable vehicle therefor.

2. A composition according to Claim 1, which is topically applied to an eye that is afflicted with a condition selected from the group consisting of: conjunctivitis, keratitis, blepharitis, dacyrocystitis, hordeolum, and corneal ulceration.

3. A composition according to Claim 1, which is topically applied to an eye of a patient in connection with an ophthalmic surgical procedure.

4. A composition according to any one of Claims 1 to 3, which further includes an anti-inflammatory effective amount of a steroidal or non-steroidal anti-inflammatory agent for treating or preventing inflammation.

5. A composition according to Claim 4, wherein the anti-inflammatory agent comprises a glucocorticoid.

6. A composition according to Claim 5, wherein the glucocorticoid is selected from the group consisting of dexamethasone, rimexolone, prednisolone, fluorometholone, hydrocortisone, mometasone, fluticasone, beclomethasone, flunisolide, triamcinolone and budesonide.

7. A composition according to Claim 4, wherein the anti-inflammatory agent comprises a non-steroidal agent selected from the group consisting of prostaglandin H synthetase inhibitors, PAF antagonists, and PDE IV inhibitors. - 13 - Amended Sheet 21/02/2002

8. A composition according to Claim 4, wherein the anti-inflammatory agent comprises dexamethasone.

9. A composition according to Claim 4, wherein the anti-inflammatory agent comprises a 21-ether derivative of dexamethasone.

10. A composition according to Claim 9, wherein the anti-inflammatory agent comprises a 21-benzyl ether derivative of dexamethasone.

11. A composition according to Claim 4, wherein the anti-inflammatory agent comprises nepafenac.

12. A composition according to Claim 4, wherein the anti-inflammatory agent comprises ketorolac.

13. A composition according to Claim 4, wherein the anti-inflammatory agent comprises diclofenac.

14. The use of a composition according to any one of Claims 1 to 13 for use in a method of making a medicament for use in a method of treating or preventing ophthalmic infections, the method comprising topically applying a therapeutically effective amount of the sterile ophthalmic composition to the affected ophthalmic tissue. -14 - Amended Sheet 21/02/2002