United States Patent (10) Patent No.: US 9,555,047 B2 Bodick Et Al

Home , Betamethasone phosphate, Butixocort, Ciprocinonide, Domoprednate, Halopredone, Meclorisone

USO09555047B2

(12) United States Patent (10) Patent No.: US 9,555,047 B2 Bodick et al. (45) Date of Patent: Jan. 31, 2017

(54) CORTICOSTEROIDS FOR THE 7,153,520 B2 12/2006 Seo et al. TREATMENT OF JOINT PAN 7,261,529 B2 8/2007 Persyn et al. 7,758,778 B2 7/2010 Persyn et al. 8,828,440 B2 9/2014 Bodick et al. (71) Applicant: Flexion Therapeutics, Inc., Burlington, 2004/0105821 A1 6/2004 Bernstein et al. MA (US) 2004/0224030 A1 11, 2004 Shastri 2005/OO31549 A1 2/2005 Quay et al. (72) Inventors: Neil Bodick, Boston, MA (US); Robert 2005, 0043706 A1 2/2005 Eaton et al. C. Blanks. Auburndale, MA (US); 2005, OO69591 A1 3/2005 Bernstein et al. Anjali Kumar Belmont MA (US). 2007/0053990 A1 3/2007 Persyn et al. s s s 2007/0264343 A1 11/2007 Bernstein et al. Michael D. Clayman, Gloucester, MA 2008/0248122 A1 10/2008 Rashba-Step et al. (US); Mark Moran, Orinda, CA (US) 2008/0317805 A1 12/2008 McKay et al. 2009, OO35253 A1 2/2009 Wright et al. (73) Assignee: FLEXION THERAPEUTICS, INC., 38885.7 A. 358 A. al Burlington,s MA (US) 2010.006.3179 A1 3/2010 Atkinsonorne et al...... A61K9/5031 (*) Notice: Subject to any disclaimer, the term of this 2011/0206773 A1 8, 2011 Lavik et al. 523,332 patent is extended or adjusted under 35 2012/0282298 A1 11/2012 Bodick et al. U.S.C. 154(b) by 0 days. 2012/0288534 A1 11/2012 Bodick et al. 2014/0242170 A1 8, 2014 Bodick et al. (21) Appl. No.: 14/461,883 2014/0356437 A1 12/2014 Bodick et al. y x- - - 9 (22) Filed: Aug. 18, 2014 FOREIGN PATENT DOCUMENTS (65) Prior Publication Data ES 66 A. 3E JP 2006-503865. A 2, 2006 US 2015/OO25050 A1 Jan. 22, 2015 WO WO95/13799 A1 5, 1995 WO WO-95.13799 A1 5, 1995 Related U.S. Application Data WO WO 99.12571 A1 3, 1999 WO WO O2,36168 5, 2002 (60) Division of application No. 13/422,994, filed on Mar. (Continued) 16, 2012, now Pat. No. 8,828,440, which is a continuation of application No. 13/198,168, filed on OTHER PUBLICATIONS Aug. 4, 2011, now abandoned. Hickey, T, et al., “Dexamethasone/PLGA microspheres for con (60) Provisional application No. 61/370,666, filed on Aug. tinuous delivery of an anti-inflammatory drug for implantable 4, 2010. medical devices'. Biomaterials, 23(7): 1649-1656 (2002). Horisawa, E., et al. "Prolonged anti-inflammatory action of DL (51) Int. Cl. lactide? glycolide copolymer nanospheres containing betamethasone A6 IK 9/14 (2006.01) Sodium phosphate for an intra-articular delivery system in antigen A 6LX 9/50 (2006.01) inst arthritic rabbit'. Pharmaceutical Research, 19(4):403-409 A6 IK3I/56 2006.O1 A 6LX 3/573 ((2006.01) ) Extended European Search Report in corresponding Application A6 IK 9/16 (2006.01) No. EP11815323.8, dated Dec. 17, 2013. Aly, M. N. S. “Intra-articular drug delivery: A fast growing A6 IK3I/58 (2006.01) approach”. Recent Patents on Drug Delivery & Formulation, A6 IK 9/00 (2006.01) Bentham Science Publishers Ltd., NL 2(3):231-237 (2008). A6 IK 47/34 (2006.01) (Continued) (52) U.S. Cl. CPC ...... A61K 31/58 (2013.01); A61K 9/0019 Primary Examiner Tigabu Kassa (2013.01); A61K 9/0024 (2013.01); A61K 9/14 (74), Attorney, Agent, or Firm — Cooley LLP. Ivor R. (2013.01); A61K 9/1641 (2013.01); A61 K Elrifi 9/1647 (2013.01); A61K 9/1694 (2013.01); (57) ABSTRACT A61 K3I/573 (2013.01); test." Corticosteroid microparticle formulations are provided for use for treating pain, including pain caused by inflammatory (58) Field ofO ClassificationSSCO SSea h diseases Such as osteoarthritis or rheumatoid arthritis, and None for slowing, arresting or reversing structural damage to See application file for complete search history. tissues caused by an inflammatory disease, for example damage to articular and/or peri-articular tissues caused by (56) References Cited osteoarthritis or rheumatoid arthritis. Corticosteroid U.S. PATENT DOCUMENTS microparticle formulations are administered locally as a Sustained release dosage form (with or without an immediate 4.293,539 A 10, 1981 Ludwig et al. release component) that results in efficacy accompanied by 4,530,840 A * 7/1985 Tice ...... A61sg clinically insignificant or no measurable effect on endog 6,214,387 B1 * 4/2001 Berde ...... 5' enous cortisol production. 424/426 9 Claims, 30 Drawing Sheets US 9,555,047 B2 Page 2

(56) References Cited La Rochelle et al. “Recovery of the Hypothalamic-Pituitary-Adre nal (HPA) Axis in Patients with Rheumatic Diseases Receiving FOREIGN PATENT DOCUMENTS Low-Dose Prednisone.” Am. J. Med. 95(1993):258-264. Lo et al. "Bone Marrow Lesions in the Knee are Associated with WO WO 2007/030545 A2 3, 2007 Increased Local Bone Density.” Arth. Rheum. 52.9(2005):2814 WO WO 2008,157.057 A2 12/2008 2821. WO WO 2009,026539 2, 2009 Lo et al. “The Ratio of Medial to Lateral Tibial Plateau Bone WO WO 2009,026539 A1 2, 2009 Mineral Density and Compartment-Specific Tibiofemoral WO WO 2009,15O136 A1 12/2009 Osteoarthritis.” OsteoArth. Cartilage. 14(2006):984–990. WO WO 2010/085.609 T 2010 Meibohm et al. “Mechanism-Based PK/PD Model for the WO WO 2011/084518 T/2011 WO WO 2012/O19009 A1 2, 2012 Lymphocytopenia Induced by Endogenous and Exogenous Corticosteroids.” Int. J. Clin. Pharmacol. Ther. 37.8(1999):367 376. OTHER PUBLICATIONS Morlocket al. “Erythropoietin Loaded Microspheres Prepared from Da Silva-Junior, A A et al., “Thermal behavior and stability of Biodegradable LPLG-PEO-LPLG Triblock Copolymers: Protein biodegradable spray-dried microparticles containing Stabilization and in-vitro Release Properties.” J. Control. Release. 56.1-3(1998): 105-115. triamcinolone'. International Journal of Pharmaceutics, Elsevier Rojas et al. “Microdialysis of Triamcinolone Acetonide in Rat BV, NL, 368(1-2):45-55 (2009). Muscle.” J. Pharm. Sci. 92.2(2003):394-397. Cilurzo, F. et al: “Design of Methylprednisolone Biodegradable van den Berg et al. “Synovial Mediators of Cartilage Damage and Microspheres Intended for Intra-articular Administration'. AAPS Pharmscitech, val. 9, No. 4, Nov. 14, 2008 (Nov. 14, 2008), pp. Repair in Osteoarthritis.” Osteoarthritis. Brandt et al., eds. Oxford: 1136-1142. Oxford University Press. 7.2.3 (2003): 147-155. Khaled K. A. et al., “Prednisolone-Loaded PLGA Microspheres. In Yeh. “The Stability of Insulin in Biodegradable Microparticles Vitro Characterization and In Vivo Application in Adjuvant-Induced Based on Blends of Lactide Polymers and Polyethylene Glycol.” J. Arthritis in Mice.” AAPS PharmSciTech., Jun. 19, 2010 (Jun. 19, Microencapsul. 17.6(2000):743-756. 2010), pp. 859-869. Zentner et al. “Biodegradable Block Copolymers for Delivery of Anderson et al. “Biodegradation and Biocompatibility of PLA and Proteins and Water-Insoluble Drugs.” J. Control. Release. PLGA Microspheres.” Adv. Drug Deliv Rev. 28(1997):5-24. 72(2001):203-215. Ayral et al. “Synovitis: A Potential Predictive Factor of Structural Aly, M. N. S., “Intra-Articular Drug Delivery: A Fast Growing Progression of Medial Tibiofemoral Knee Osteoarthritis—Results Approach.” Recent Patents on Drug Delivery & Formulation, vol. of a 1 Year Longitudinal Arthroscopic Study in 422 Patients.” 2(3): 231-237 (2008). OsteoArth. Cartilage. 13(2005):361-367. Bandi, N. et al., “Intratracheal budesonide-poly(lactide-co Bouissou et al. “Poly(lactic-co-glycolic acid) Microspheres.” Poly glycolide) microparticles reduce oxidative stress, VEGF expression, mers in Drug Delivery. Chapter 7(2006):81-99. and vascular leakage in a benzo(a)pyrene-fed mouse model.” Jour Cleek et al. “Microparticles of Poly(DL-lactic-co-glycolic acid)/ nal of Pharmacy and Pharmacology, vol. 57(7):851-860 (2005). poly(ethylene glycol) Blends for Controlled Drug Delivery.” J. Chaw, C.S. et al., “Water soluble betamethasone-loaded Control. Relase. 48(1997):259-268. poly(lactide-co-glycolide) hollow microparticles as a Sustained Coopman et al. “Identification of Cross-Reaction Patterns in Aller release dosage form.” Journal of Encapsulation, vol. 20(3):349-359 gic Contact Dermatitis from Topical Corticosteroids.” Br: J. Dermatol. 121 (1989):27-34. (2003). Derendorf et al. “Clinical PKPD Modelling as a Tool in Drug Cilurzo, F. et al., “Design of methylprednisolone biodegradable Development of Corticosteroids.” Int. J. Clin. Pharmacol. Ther. microspheres intended for intra-articular administration.” AAPS 35.10(1997):481-488. Pharmscitech, vol. 9(4): 136-1142 (2008). Derendorf et al. “Pharmacokinetics and Pharmacodynamics of Da Silva-Junior, A. A. et al., “Thermal behavior and stability of Glucocorticoid Suspensions After Intra-Articular Administration.” biodegradable spray-dried microparticles containing Clin. Pharmacol. Ther. 39.3(1986):313-317. triamcinolone.” International Journal of Pharmaceutics, vol. Eckstein et al. “Magnetic Resonance Imaging (MRI) of Articular 368(1-2):45-55 (2009). Cartilage in Knee Osteoarthritis (OA): Morphological Assessment.” Hickey, T. et al., “Dexamethasone/PLGA microspheres for continu OsteoArth. Cartilage. 14(2006): A46-A75. ous delivery of an anti-inflammatory drug for implantable medical Foti et al. “Contact Allergy to Topical Corticosteroids: Update and devices.” Biomaterials, vol. 23(7): 1649-1656 (2002). Review on Cross-Sensitization.” Recent Pat. Inflamm. Allergy Drug Horisawa, E., et al., “Prolonged anti-inflammatory action of DL Discov. 3.1(2009):33-39. lactide? glycolide copolymer nanospheres containing betamethasone Habib. "Systemic Effects of Intra-Articular Corticosteroids.” Clin. Sodium phosphate for an intra-articular delivery system in antigen Rheumatol. 28.7(2009):749-756. induced arthritic rabbit.” Pharmaceutical Research, vol. 19(4):403 Hepper et al. “The Efficacy and Duration of Intra-Articular 409 (2002). Corticosteroid Injection for Knee Osteoarthritis: A Systematic Jaraswekin, S. et al., “Effect of poly(lactide-co-glycolide) molecular Review of Level I Studies.” J. Am. Acad. Orthop. Surg. weight on the release of dexamethasone sodium phosphate from 17.10(2009):638-646. microparticles,” Journal of Microencapsulation, vol. 24(2): 117-128 Hill et al. “Synovitis Detected on Magnetic Resonance Imaging and (2007). its Relation to Pain and Cartilage Loss in Knee Osteoarthritis.” Ann. Khaled, K. A. et al., “Prednisolone-loaded PLGA microspheres. In Rheum. Dis. 66(2007): 1599-1603. vitro characterization and in vivo application in adjuvant-induced Hou et al. “In Situ Gelling Hydrogels Incorporating Microparticles arthritis in mice.” AAPS PharmSciTech, vol. 111(2):859-869 (2010). as Drug Delivery Carriers for Regenerative Medicine.” J. Pharm. Yeo and Park, “Control of Encapsulation Efficiency and Initial Burst Sci. 97.9(2008):3972-3980. in Polymeric Microparticle Systems.” Arch Pharm Res, vol. 27(1): Kirwan et al. “Effects of Glucocorticoids on Radiological Progres 1-12 (2004). sion in Rheumatoid Arthritis.” Cochrane Database Syst. Rev. (2009). * cited by examiner U.S. Patent Jan. 31, 2017 Sheet 1 of 30 US 9,555,047 B2

FIG. 1

filtra-articuia COficeritratif

Hs ------Intra-articular concentration required for efficacy

Concentration in plasma associated with PA axis suppression - U - - - - H H H H H H re------

Concentration in plasma Tire post intra articular injection of sustained release corticosteroid

FIG. 2 TCA 40mg EC50 (ng/mL)

- TCA 40mg EC50 (ng/mL)

O 50 1OO 150 200 250 300 350 400 Time (h) U.S. Patent Jan. 31, 2017 Sheet 2 of 30 US 9,555,047 B2

FIG. 3 -BPA 7mg EC50 (ng/mL) ---TCA 40 mg EC50 (ng/mL) -THCA 20 mg EC50 (ng/mL)

1 5

O 50 100 150 200 250 300 350 400 ine (h U.S. Patent Jan. 31, 2017 Sheet 3 of 30 US 9,555,047 B2

s w was &s s

$ 8s & is S&&

& se

s a. ######38% E. r

U.S. Patent Jan. 31, 2017 Sheet 4 of 30 US 9,555,047 B2

???;

S. U.S. Patent Jan. 31, 2017 Sheet 5 Of 30 US 9,555,047 B2

www.saw s

s % As SS

U.S. Patent Jan. 31, 2017 Sheet 6 of 30 US 9,555,047 B2

FIG. 5

100 r.c ; 90 m. 3. 80 mu-o- 7O ------04-...------60 eaco S$ 50 $ 40 - 74-mm. -0-25%. TCAPLGA75:25 is 30 20 10 O O 10 2O 30 Days

FIG. 6 25%. TCAPLGA 75:25

-0-Adjusted Dose (mg/day) - - - 5% COrtisol Inhibition - - - -35% COrtisol Inhibition DOSe

OAO DOD 40% COrtisol Inhibition DOSe 50% COrtisol Inhibition Dose U.S. Patent Jan. 31, 2017 Sheet 7 Of 30 US 9,555,047 B2

-0- Adjusted Dose (mg/day) - - - 5% COrtisol Inhibition - - - - 35% COrtisol Inhibition DOSe

DOO D D 40% COrtisol Inhibition DOse 50% COrtisol Inhibition DOSe

FIG. 8

1 OO 90 8O 70 60 50 40 -0-25%. TCAPLGA 75:25 30 20 10

Days U.S. Patent Jan. 31, 2017 Sheet 8 of 30 US 9,555,047 B2

FIG. 9 25%. TCAPLGA 75:25

-0-Adjusted Dose (mg/day) - - -5% COrtisol Inhibition - - - -35% COrtisol Inhibition DOSe

DOD D 40% COrtisol Inhibition DOSe 50% COrtisol Inhibition DOSe -100 10 20 3O

FIG 10 25%. TCAPLGA 75:25

-0-Adjusted Dose (mg/day) - - - 5% COrtisol Inhibition - - - -35% COrtisol Inhibition DOse

ODD D 40% COrtisol Inhibition DOSe 50% COrtisol Inhibition DOSe U.S. Patent Jan. 31, 2017 Sheet 9 Of 30 US 9,555,047 B2

FIG 11

25%. TCA 5% PEG 1450 IPLGA 75:25 1 OO 90 8O 7O 60 25% TCA 5%PEG 50 145O/PLGA75:25 40 30 20 10 z 10 2O 30 Days

FIG. 12 25%. TCA 10% PEG 335OIPLGA 75:25

1 OO 90 8O 70 - 25%TCA 10%PEG 6O 3350/PLGA75:25 5O 40 3O 2O 1O U.S. Patent Jan. 31, 2017 Sheet 10 of 30 US 9,555,047 B2

F.G. 13

25%. TCA 5% PEG 1450/PLGA 75:25

-0-Adjusted Dose (mg/day) - - - 5% COrtisol Inhibition - - - -35% COrtisol Inhibition DOSe

O 40% COrtisol Inhibition DOSe

- - - - 50% COrtisOl Inhibition Dose - 10 9 1O 20 30

FIG. 14 25%. TCA 10% PEG 3350/PLGA 75:25

-0- Adjusted Dose (mg/day) - - - 5% COrtisol Inhibition - - - -35% COrtisol Inhibition DOse

O 40% COrtisol Inhibition DOSe 50% COrtisOl Inhibition DOSe U.S. Patent Jan. 31, 2017 Sheet 11 of 30 US 9,555,047 B2

FIG. 15 25%. TCA 5% PEG 1450IPLGA 75:25

-0-Adjusted Dose (mg/day) - - - 5% COrtisol Inhibition - - - -35% COrtisol Inhibition Dose

D DOA DD D 40% COrtisol Inhibition DOSe 50% COrtisol Inhibition DOSe

25%. TCA 10% PEG 335OIPLGA 75:25 3.5 3.0 -- Adjusted Dose (mg/day) 2.5 - - - 5% COrtisol 2.0 T- Inhibition K------35% COrtisol 15 | Inhibition DOSe 1.O IN - - - - 40% COrtisol O5 N Inhibition Dose 0.0 - - - Ny 50% COrtisol Inhibition Dose U.S. Patent Jan. 31, 2017 Sheet 12 of 30 US 9,555,047 B2

FIG. 17

1OO

90 -- : 80 I - c 7 ear to 1. 41------5 60 / / 1 -A- 40% TCAPLGA 75:25 50 M ------O - 0 - 25%. TCAPLGA 75:25 e 40 / - ---20% TCAPLGA 75:25 3O M 1 20 / ------0 --O-- 15% TCAPLGA 75:25 8 l (e1, ...... -- -H - - - - 10% TCAPLGA75:25 1O .------+ - - - - w a O O 5 1O 15 20 25 30 Days

-0-25%. TCAPLGA 75:25 (54 kDA) -X - 25%. TCAPLGA 75:25 (29 kDa) U.S. Patent Jan. 31, 2017 Sheet 13 of 30 US 9,555,047 B2

-- 2% CA, GA 50:5 3. --O-- 25%. CAGASOS 3 "H 39, CA GA 50:5 coo S$ - 0 - 35% "CAGASSO s ->e 25% OA GA 50:5 s (ester enti-Capped) -A - 3%, CA G 335f. GASO:5 -H 25%, CA PGA 75:25

-- 3 A, CA GA 50:50 (18 kDa)

40% TCA PLGA 75:25 plus Triblock 10) 90 g 80 70 g-F 2 so //a -0-40% CA PGA 2.25 + 0% S$ SO T3 $ 40 / --45%. CAGA 2.25 + 2% 30 2). ) - O - g

O 3O AO Days U.S. Patent Jan. 31, 2017 Sheet 14 of 30 US 9,555,047 B2

FIG 21 CAA 5:5 is 3 4.000 is 3,500 E 3.000 - - - PLGA 75:25 10%TB-TCM 5 2.500 (Batch 2) ; - - - 5%COrtiSol Inhibition 2,000 1.500 - - - - 35%COrtiSolnhibition DOSe

O.5001.000 \ . 40%COrtisolCOSO IOIOinhibition DLOSe 0.000-HS-H ...... 50%COrtisol inhibition DOSe

lay

FIG. 22 CASA S-S 2, 10.000 a 9.000 S, 8.000 --PLGA 75:25.20%TB-TCM 5 (.000 (Batch 3) S; 6.OOO - - - 5%COrtisOnhibition : 5990 4,000 - - - - 35%COrtisol inhibition DOSe 3.000 3, 2.000 V.A. ------40%COrtisol inhibition DOSe 1.000 O.000 50%COrtisol inhibition DOSe U.S. Patent Jan. 31, 2017 Sheet 15 Of 30 US 9,555,047 B2

CASA S.25 - 3 3.500 is 3,000 PLGA 75:25 10%TB-TCM 2.500 (Batch 2) 2000 - - - 5%COrtisOnhibition to 1500 - - - - 35%COrtisol inhibition DOSe 1.000 5 0.500 - V 40%COrtisol inhibition DOSe O.OOO HAS-0---, ------50%COrtisol inhibition DOSe

FIG. 24 CAGA 5:25 A, 3

3.5OO 3.OOO PLGA 75:25 10%TB-TCM 2.500 (Batch 2) -- - - - 5%COrtisol inhibition 2.OOO 1500 - - - - 35%Cortisol inhibition DOSe 1.OOO 40%COrtisol inhibition DOSe O.500 - - - 50%COrtisol inhibition DOSe OOOO 80 U.S. Patent Jan. 31, 2017 Sheet 16 of 30 US 9,555,047 B2

FIG. 25 A GAfs: ixei iwis 120 1 2468O O O 1O 20 30 40 50 60 7O 80 90 1OO ite in Days

FIG. 26 CA Vixed Ma?ecular Weight PGA 75:25 S 7.OOOO 6.0000 S. --TCA Mixed MW E. 5.OOOO PLGA75:25 S; 4.0000 - - 5%COrtisol inhibition O 3.0000 - - - 35%COrtisol inhibition 9, 2.0000 DOSe g N N - 40%COrtisol inhibition 1.OOOO DOSe OOOOO-F RF a S RAFFFFFF ------50%COrtisol inhibition O 1O 2O 30 40 50 60 DOSe U.S. Patent Jan. 31, 2017 Sheet 17 Of 30 US 9,555,047 B2

FIG. 27 TCA Mixed Molecular Weight PLGA 75:25 3.5000 3.0000 TCAMixed MW S. 2.5000 PLGA75:25 S 5%Cortisol inhibition o 2.0000 35%Cortisol inhibition 3 1.5000 Dose 5 an | -- 40%COrtisol inhibition 50%COrtisol inhibition 0.5000 - a ------DOSe 0.0000

120

100

-- TCAPCL H TCAMixed MW PLGA 75:25 46 OO - A - TCAPLGA 50:50 --X - TCAPLGA85:15

2 O

35 U.S. Patent Jan. 31, 2017 Sheet 18 of 30 US 9,555,047 B2

F G. 2 9

PRED-PLGA 50:50 1OO 90 8O 7O 60 50 40 30 20 g O 5 10 15 20 25 30 35 Time in Days

FIG. 30 PRED-PLGA 50:50 8.00 7.OO -- PLGA 50:50-PRED 6.00 - - - 5%COrtisOnhibition 5.00 4.00 - - - - 35%COrtisol inhibition DOSe 3.OO 40%COrtisOnhibition 2.00 DOSe 1.OO 50%COrtisol inhibition DOSe O.OO U.S. Patent Jan. 31, 2017 Sheet 19 Of 30 US 9,555,047 B2

PRED-PLGA 50:50 8.OO S 7.00 - - - PLGA 50:50-PRED S 6.00 g 5%COrtiSO Inhibition St 5.00 3 4.00 - - - - 35%COrtisol inhibition ? DOSe 3.00 \ . 40%COrtisol inhibition 2 2.00 DOSe 3 1.00 \, , -1-1 50%COrtisol inhibition DOSe O.OO

Beta-PLGA50:50 90 8O 70 60 50 40 D 2030 10 SS 0 O 5 10 15 2O 25 30 35 Time in Days U.S. Patent Jan. 31, 2017 Sheet 20 of 30 US 9,555,047 B2

BETAPLGA 50:50 3.50 a 3.00 -- PLGA 50:50-BETA g g 2.50 5% COtisol inhibition a 2.00 3 - - - - 35%COrtisol inhibition 150 DOSe

. 1.00 -----A-r------a - " 40%COrtisolDOSe inhibition 0.50 / \ / ...... 50%COrtisol inhibition O.OO DOSe

BETA-PLGA 50:50 2.00 is 1.80 -- PLGA 50:50-BETA g 1.60 140 5%COrtisol inhibition 1.20 3 1.00 - - - - 35%COrtisol inhibition O.80 DOSe i | \ " 40%COrtisol inhibition g DOSe E 0.40 a N. Alla ------50%COrtisol inhibition 0.20 DOSe O.OO U.S. Patent Jan. 31, 2017 Sheet 21 of 30 US 9,555,047 B2

120 O ge 100 SS 80 D i? 60 40 E 2O s U O O 5 1O 15 20 25 3O 35 Time in Days

FLUT-PLGA50:50 (200 mg) 5.OOO a 4.5OO S. 4.OOO -- PLGA 50:50-FLUT 200mg E 3.500 3.000 5%COrtisOnhibition 8 25OO 2.000 - - - - 35%COrtisol inhibition 1.500 DOSe is 1.000 ------. 40%COrtisol inhibition 0.500 DOSe O.OOO - FEEE2FE SAE ------50%COrtisol inhibition O 10 20 30 40 DOSe U.S. Patent Jan. 31, 2017 Sheet 22 of 30 US 9,555,047 B2

FIG. 37 FLUT-PLGA50:50 (200 mg) 1200 a 1.000 -- PLGA 50:50-FLUT 200mg C G 0.800 - - - 5%COrtisol inhibition G t 0600 ---- 35%COrtisol inhibition 0.400 DOSe ------40%COrtisol inhibition 0200 DOSe 50%COrtisol inhibition O.OOO DOSe

120.00 FLUT Formulations

100.00

80.00

-0-75/25 16.7%FLUT ---50/50 16.7%FLUT

-A-50/50 28.6%FLUT

Days U.S. Patent Jan. 31, 2017 Sheet 23 of 30 US 9,555,047 B2

FIG. 39 DEXA-PLGA50:50 60 s 350 gs 40 25 30 s S. 20 RE O X 10 O O O 5 1O 15 20 25 30 35 Time in Days

FIG. 40 DEXA-PLGA50:50

18O s 1.60 -- PLGA 50:50-DEXA S 140 g 120 - - - 5%COrtisol inhibition 1. 3 OO ---- 35%COrtisol inhibition O.80 DOSe 0.60- / ... 40%COrtisolnhibition 3. O.40 DOSe 3 0.20/\\ 1 / ...... 50%COrtisol inhibition O.OO DOSe U.S. Patent Jan. 31, 2017 Sheet 24 of 30 US 9,555,047 B2

FIG. 41A -A-FX006 (0.28 mg) -0-FX006 (0.56 mg)-O-FX006 (1.125 mg) -A-TCAIR (0.18 mg) -O-TCAIR (1.125 mg)

Slower delivery of TCA with FX006

O 144 288 432 576 720 864 1008

FIG. 41B -A-FX006 (0.28 mg) -0-FX006 (0.56 mg)--FX006 (1.125 mg)

-a-TCAIR (0.18 mg) -o-TCAIR (1.125 mg)

144 288 432 576 720 864 1008 U.S. Patent Jan. 31, 2017 Sheet 25 Of 30 US 9,555,047 B2

FIG. 41C -- FX006 (0.28 mg) -o-FX006 (0.56 mg) -O-FX006 (1.125 mg)

-A-TCA R (0.18 mg) -O-TCAIR (1.125 mg)

1OO

1 O

Time (h)

FIG. 41D -- FX006 (0.28 mg) -o-FX006 (0.56 mg)--FX006 (1.125 mg)

-a-TCAIR (0.18 mg) -o-TCAIR (1.125 mg)

1 O O

5 O U.S. Patent Jan. 31, 2017 Sheet 26 of 30 US 9,555,047 B2

--FX006 placebo (A) - (- FX006 (0.56 mg) -A-FX006 (1.125 mg) -K-TCA (1.125 mg) - TCA (0.18 mg) -O-FX006 (0.28mg)

O 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 Time (days) FIG. 43

g 80 SER COrtiCOStOCOSterOne g vs. Mean

O.O1 O.1 1 1O 100 1OOO Mean (ng/mL) U.S. Patent Jan. 31, 2017 Sheet 27 Of 30 US 9,555,047 B2

FIG. 44A --No Reactivation -O-Vehicle -HFX006 (4.67 mg/ml) -A-FX006 (2 mg/ml) -o-FX006 (0.5 mg/ml)

O 5

O.O Day 1 Day 2 Day 4 Day 14 Day 15 Day 16 Day 18 Day 28 Day 29 Da Days Post Reactivation

-H NO Reactivation -0- Vehicle -A-Triamcinolone (0.5 mg/ml) -- FX006 (4.67 mg/ml)

Days Post Reactivation U.S. Patent Jan. 31, 2017 Sheet 28 of 30 US 9,555,047 B2

-H NO Reactivation FIG. 44C -(). Vehicle -o-Triamcinolone (1 mg/ml) A-Triamcinolone (0.5 mg/ml) --FX006 (4.67 mg/ml) -A-FX006 (2 mg/ml) -e-FX006 (0.5 mg/ml)

i N A ^

s t -

EDay Day 2 Day 4 Day 14 Day 15 Day 16 Day 18 Day 28 Day 29 Day 30 Day 32 -0.5 Days Post Reactivation

FIG 45

4 -O-No reactivation 3.5 ("normal") 3 - HVehicle

35 2.5 -A-TCAIR (0.06 mg) is 2 t 15 -e-TCAIR (0.03 mg) 1 -le-FX006 (0.28 mg) O.5 O -O-FX006 (0.12 mg) Day 1 Day 15 Day 29 -HFX006 (0.03 mg) Peak pain response upon reactivation of knee arthritis U.S. Patent Jan. 31, 2017 Sheet 29 Of 30 US 9,555,047 B2

-H Primed no reactivation

-. Vehicle w -o-Triamcinolone (1 mg/ml) -A-Triamcinolone (0.5 mg/ml) as an -z-FX006 (4.67 mg/ml) -- fa 5: -o- FX006 (0.5 mg/ml) 1. t 3. 80% room #y / \|al - Aft/ .9ii., 4:/fetzf / / A e E5 no N-22'S,2N-Xf 7 Z at-- - 1 I say1 2 -40% 26 ng 1 -H P -80% t -120% O 4 8 12 16 20 24 28 32 Time (days)

FIG. 47A

-G-TCAIR 0.06 mg A-TCAIR 0.03 mg --FX006 0.28 mg -A-FX006 0.12 mg -O-FX006 0.03 mg

O 4 8 12 16 20 24 28 Time (days) U.S. Patent Jan. 31, 2017 Sheet 30 of 30 US 9,555,047 B2

FIG. 47B

| <= co

~co | C~C-)

12 16 20 24 28 Time (days)

FIG. 48

Z inflammation N. Pannus Cartilage Damage o Bone Resorption

Ø %20ZZZZZZZ ````S Ø Primed no ehicle Tramcinolone`N Triamcinolone```` FX006 FX006 O06 reactivation (1 mg/ml) (0.5mg/ml) (4.67 mg/ml) (2 mg/ml) `N(0.5 mg/ml) Treatment Group US 9,555,047 B2 1. 2 CORTICOSTEROIDS FOR THE are effective at treating pain and/or inflammation with TREATMENT OF JOINT PAN minimal long-term side effects of corticosteroid administra tion, including for example, prolonged Suppression of the RELATED APPLICATIONS HPA axis. The corticosteroid microparticle formulations are Suitable for administration, for example, local administra This application is a divisional of U.S. patent application tion by injection into a site at or near the site of a patients Ser. No. 13/422,994, now issued as U.S. Pat. No. 8,828,440, pain and/or inflammation. The corticosteroid microparticle which is a continuation of U.S. patent application Ser. No. formulations provided herein are effective in slowing, arrest 13/198,168, filed Aug. 4, 2011, which claims the benefit of ing, reversing or otherwise inhibiting structural damage to U.S. Provisional Application No. 61/370,666, filed Aug. 4. 10 tissues associated with progressive disease with minimal 2010. The contents of these applications are hereby incor long-term side effects of corticosteroid administration, porated by reference in their entireties. including for example, prolonged suppression of the HPA axis. The corticosteroid microparticle formulations are Suit FIELD OF THE INVENTION able for administration, for example, local administration by 15 injection into a site at or near the site of structural tissue This invention relates to the use of corticosteroids to treat damage. As used herein, prolonged’ Suppression of the pain, including pain caused by inflammatory diseases Such HPA axis refers to levels of cortisol suppression greater than as osteoarthritis or rheumatoid arthritis, and to slow, arrest or 35% by day 14 post-administration, for example post reverse structural damage to tissues caused by an inflam injection. The corticosteroid microparticle formulations pro matory disease, for example damage to articular and/or vided herein deliver the corticosteroid in a dose and in a peri-articular tissues caused by osteoarthritis or rheumatoid controlled or sustained release manner such that the levels of arthritis. More specifically, a corticosteroid is administered cortisol suppression are at or below 35% by day 14 post locally as a Sustained release dosage form (with or without administration, for example post-injection. In some embodi an immediate release component) that results in efficacy ments, the corticosteroid microparticle formulations pro accompanied by clinically insignificant or no measurable 25 vided herein deliver the corticosteroid in a dose and in a effect on endogenous cortisol production. controlled or sustained release manner such that the levels of cortisol Suppression are negligible and/or undetectable by 14 BACKGROUND OF THE INVENTION post-administration, for example post-injection. In some embodiments, the corticosteroid microparticle formulations Corticosteroids influence all tissues of the body and 30 provided herein deliver the corticosteroid in a dose and in a produce various cellular effects. These steroids regulate controlled or sustained release manner such that the levels of carbohydrate, lipid, protein biosynthesis and metabolism, cortisol suppression are negligible at any time post-injec and water and electrolyte balance. Corticosteroids influenc tion. Thus, the corticosteroid microparticle formulations in ing cellular biosynthesis or metabolism are referred to as these embodiments are effective in the absence of any glucocorticoids while those affecting water and electrolyte 35 significant HPA axis Suppression. Administration of the balance are mineralocorticoids. Both glucocorticoids and corticosteroid microparticle formulations provided herein mineralocorticoids are released from the cortex of the adre can result in an initial “burst' of HPA axis suppression, for nal gland. example, within the first few days, within the first two days The administration of corticosteroids, particularly for and/or within the first 24 hours post-injection, but by day 14 extended periods of time, can have a number of unwanted 40 post-injection, suppression of the HPA axis is less than 35%. side effects. The interdependent feedback mechanism In certain embodiments, a Sustained release form of between the hypothalamus, which is responsible for secre corticosteroids is administered locally to treat pain and tion of corticotrophin-releasing factor, the pituitary gland, inflammation. Local administration of a corticosteroid which is responsible for secretion of adrenocorticotropic microparticle formulation can occur, for example, by injec hormone, and the adrenal cortex, which secretes cortisol, is 45 tion into the intra-articular space, peri-articular space, soft termed the hypothalamic-pituitary-adrenal (HPA) axis. The tissues, lesions, epidural space, perineural space, or the HPA axis may be suppressed by the administration of foramenal space at or near the site of a patient’s pain. In corticosteroids, leading to a variety of unwanted side effects. certain embodiments, the formulation additionally contains Accordingly, there is a medical need to extend the local an immediate release component. In certain preferred duration of action of corticosteroids, while reducing the 50 embodiments of the invention, a sustained release form of systemic side effects associated with that administration. corticosteroids is administered (e.g., by single injection or as Thus, there is a need in the art for methods and compositions sequential injections) into an intra-articular space for the for the Sustained local treatment of pain and inflammation, treatment of pain, for example, due to osteoarthritis, rheu Such as joint pain, with corticosteroids that results in clini matoid arthritis, gouty arthritis, bursitis, tenosynovitis, epi cally insignificant or no measurable HPA axis Suppression. 55 condylitis, synovitis or other joint disorder. In certain pre In addition, there is a medical need to slow, arrest, reverse ferred embodiments of the invention, a sustained release or otherwise inhibit structural damage to tissues caused by form of corticosteroids is administered (e.g., by single inflammatory diseases such as damage to articular tissues injection or as sequential injections) into Soft tissues or resulting from osteoarthritis or rheumatoid arthritis. lesions for the treatment of inflammatory disorders, for 60 example, the inflammatory and pruritic manifestations of SUMMARY OF THE INVENTION corticosteroid-responsive dermatoses such as psoriasis. In certain preferred embodiments of the invention, a Sustained Described herein are compositions and methods for the release form of corticosteroids is administered (e.g., by treatment of pain and inflammation using corticosteroids. single injection or as sequential injections) into an epidural The compositions and methods provided herein use one or 65 space, a perineural space, a foramenal space or other spinal more corticosteroids in a microparticle formulation. The space for the treatment of corticosteroid-responsive degen corticosteroid microparticle formulations provided herein erative musculoskeletal disorders such as Neurogenic Clau US 9,555,047 B2 3 4 dication. In certain preferred embodiments of the invention, twice as long, at least three times as long, or more than three a Sustained release form of corticosteroids is administered times as long as the residency period for the corticosteroid (e.g., by single injection or as sequential injections) into an and/or the corticosteroid microparticle formulation. In some intra-articular space or into Soft tissues to slow, arrest, embodiments, the Sustained, steady state release of corti reverse or otherwise inhibit structural damage to tissues 5 costeroid will not adversely suppress the HPA axis. associated with progressive disease such as, for example, the In some embodiments, a controlled or Sustained-release damage to cartilage associated with progression of osteoar formulation is provided wherein a microparticle matrix thritis. (such as PLGA, hydrogels, hyaluronic acid, etc.) incorpo In certain embodiments of the invention, a combination of rates a corticosteroid, and the formulation may or may not an immediate release form and a Sustained release form of 10 exhibit an initial rapid release, also referred to herein as an corticosteroids is administered (e.g., by single injection or as initial “burst' of the corticosteroid for a first length of time sequential injections) into an intra-articular space for the of between 0 and 14 days, for example, between the begin treatment of pain, for example, due to osteoarthritis, rheu ning of day 1 through the end of day 14, in addition to the matoid arthritis or other joint disorder(s). In certain embodi Sustained, steady state release of the corticosteroid for a ments of the invention, a combination of an immediate 15 second length of time of at least two weeks, preferably at release form and a Sustained release form of corticosteroids least three weeks, including up to and beyond 30 days, or 60 is administered (e.g., by single injection or as sequential days, or 90 days. It should be noted that when corticosteroid injections) into an intra-articular space or into Soft tissues to levels are measured in vitro, an occasional initial burst of slow, arrest, reverse or otherwise inhibit structural damage corticosteroid release from the microparticle formulation to tissues associated with progressive disease Such as, for can be seen, but this initial burst may or may not be seen in example, the damage to cartilage associated with progres vivo. In another embodiment, a controlled or Sustained sion of osteoarthritis. The formulations and methods of release formulation is provided wherein a microparticle embodiments of the invention can achieve immediate relief matrix (such as PLGA, hydrogels, hyaluronic acid, etc.) of the acute symptoms (e.g., pain and inflammation) of these incorporates a corticosteroid, and the formulation may or diseases or conditions and additionally provide a Sustained 25 may not exhibit an initial rapid release, also referred to or long term therapy (e.g., slowing, arresting, reversing or herein as an initial "burst' of the corticosteroid for a first otherwise inhibiting structural damage to tissues associated length of time of between 0 and 14 days, e.g., between the with progressive disease), while avoiding long term sys beginning of day 1 through the end of day 14, in addition to temic side effects associated with corticosteroid administra the sustained, steady state release of the corticosteroid for a tion, including HPA Suppression. 30 second length of time of at least two weeks, preferably at In one aspect, a formulation is provided wherein a least three weeks, including up to and beyond 30 days, or 60 microparticle matrix (such as PLGA, PLA, hydrogels, days, or 90 days where the sustained, steady state release of hyaluronic acid, etc.) incorporates a corticosteroid, and the corticosteroid is released at a rate that does not suppress the corticosteroid microparticle formulation provides at least HPA axis at a level greater than 50% at day 14 post two weeks, preferably at least three weeks, including up to 35 administration. In some embodiments, the Sustained, steady and beyond 30 days, or 60 days, or 90 days of a sustained, state release of corticosteroid will not adversely suppress the steady state release of the corticosteroid. In one aspect, a HPA axis, for example, the level of HPA axis suppression at formulation is provided wherein a microparticle matrix or less than 35% by day 14 post-administration. In some (such as PLGA, PLA, hydrogels, hyaluronic acid, etc.) embodiments, the Sustained, steady state release of corti incorporates a corticosteroid, and the corticosteroid 40 costeroid does not significantly Suppress the HPA axis, for microparticle formulation provides at least two weeks, pref example, the level of HPA axis suppression is negligible erably at least three weeks, including up to and beyond 30 and/or undetectable by day 14 post-injection. In some days, or 60 days, or 90 days of a Sustained, steady state embodiments, the Sustained, steady state release of corti release of the corticosteroid at a rate that does not adversely costeroid does not significantly Suppress the HPA axis, for suppress the HPA axis. 45 example, the level of HPA axis Suppression is negligible at The corticosteroid microparticle formulation retains sus all times post-injection. In some embodiments, the length of tained efficacy even after the corticosteroid is no longer sustained release is between 21 days and 90 days. In some resident at the site of administration, for example, in the embodiments, the length of sustained release is between 21 intra-articular space, and/or after the corticosteroid is no days and 60 days. In some embodiments, the length of longer detected in the systemic circulation. The corticoster 50 Sustained release is between 14 days and 30 days. In some oid microparticle formulation retains Sustained efficacy even embodiments, the length of release of the initial “burst' after the corticosteroid microparticle formulation is no lon component is between 0 and 10 days, for example between ger resident at the site of administration, for example, in the the beginning of day 1 through the end of day 10. In some intra-articular space, and/or the corticosteroid microparticle embodiments, the length of release of the initial “burst' formulation is no longer detected in the systemic circulation. 55 component is between 0 and 6 days, for example between The corticosteroid microparticle formulation retains sus the beginning of day 1 through the end of day 6. In some tained efficacy even after the corticosteroid microparticle embodiments, the length of initial “burst, component is formulation ceases to release therapeutically effective between 0 and 2 days, for example between the beginning of amounts of corticosteroid. For example, in Some embodi day 1 through the end of day 2. In some embodiments, the ments, the corticosteroid released by the microparticle for 60 length of initial “burst’ component is between 0 and 1 day, mulation retains efficacy for at least one week, at least two for example between the beginning of day 1 through the end weeks, at least three weeks, at least four weeks, at least five of day 1. weeks, at least six weeks, at least seven weeks, at least eight The corticosteroid microparticle formulations provided weeks, at least nine weeks, at least twelve weeks, or more herein can be used in combination with any of a variety of than twelve-weeks post-administration. In some embodi 65 therapeutics, also referred to herein as "co-therapies. For ments, the corticosteroid released by the microparticle for example, the corticosteroid microparticle formulations can mulation retains efficacy for a time period that is at least be used in combination with an immediate release corticos US 9,555,047 B2 5 6 teroid solution or Suspension, which provides high local nent and the plasma levels of the corticosteroid does not exposures for between 1 day and 14 days following admin adversely suppress the HPA axis. istration and which produce systemic exposures that may be In some embodiments, the length of Sustained release is associated with transient suppression of the HPA axis. For between 21 days and 90 days. In some embodiments, the example, 40 mg of immediate release triamcinolone length of sustained release is between 21 days and 60 days. acetonide co-administered with the corticosteroid micropar In some embodiments, the length of Sustained release is ticle formulation in the intra-articular space would be between 14 days and 30 days. In some embodiments, the expected to produce high local concentrations lasting for length of release of the immediate release form is between about 12 days. These high local concentrations would be 1 day and 14 days. In some embodiments, the length of associated with peak plasma concentration of triamcinolone 10 release of the immediate release form is between 1 day and acetonide of approximately 10 ng/ml on day 1, and over the 10 days. In some embodiments, the length of release of the course of the first 12 days of release of the triamcinolone immediate release form is between 1 day and 8 days. In acetonide from the intra-articular space would be associated Some embodiments, the length of release of the immediate with transient suppression of the HPA axis with a maximal release form is between 1 day and 6 days. In some embodi effect of approximately 60% suppression of cortisol on day 15 ments, the length of release of the immediate release form is 1-2 (Derendorf et al., “Pharmacokinetics and pharmacody between 1 day and 4 days. namics of glucocorticoid Suspensions after intra-articular The invention provides populations of microparticles administration.” Clin Pharmacol Ther. 39 (3) (1986):313-7). including a Class B corticosteroid or a pharmaceutically By day 12, the contribution of the immediate release com acceptable salt thereof incorporated in, admixed, encapsu ponent to the plasma concentration would be small, less than lated or otherwise associated with a lactic acid-glycolic acid 0.1 ng/ml, and the contribution to the intra articular con copolymer matrix, wherein the Class B corticosteroid is centration of the immediate release component would also between 22% to 28% of the microparticles. be small. However at day 12 and beyond, the corticosteroid The invention also provides controlled or sustained microparticle formulation would continue to release corti release preparation of a Class B corticosteroid that include costeroid in the intra articular space at a rate that extends the 25 a lactic acid-glycolic acid copolymer microparticle contain duration of therapeutic effect and does not suppress the HPA ing the Class B corticosteroid, wherein the Class B corti axis. In some embodiments, the same corticosteroid is used costeroid is between 22% to 28% of the lactic acid-glycolic in both the immediate release and Sustained release compo acid copolymer microparticle matrix. nents. In some embodiments, the immediate release com The invention also provides formulations that include (a) ponent contains a corticosteroid that is different from that of 30 controlled- or Sustained-release microparticles comprising a the Sustained release component. In some embodiments, the Class B corticosteroid and a lactic acid-glycolic acid copo sustained, steady state release of corticosteroid will not lymer matrix, wherein the Class B corticosteroid comprises adversely suppress the HPA axis. In some embodiments, the between 22% to 28% of the microparticles and wherein the period of sustained release is between 21 days and 90 days. lactic acid-glycolic acid copolymer has one of more of the In some embodiments, the period of Sustained release is 35 following characteristics: (i) a molecular weight in the range between 21 days and 60 days. In some embodiments, the of about 40 to 70 kDa; (ii) an inherent viscosity in the range period of sustained release is between 14 days and 30 days. of 0.3 to 0.5 dL/g; (iii) a lactide:glycolide molar ratio of In some embodiments, the high local exposure attributable 80:20 to 60:40; and/or (iv) the lactic acid-glycolic acid to the immediate release component lasts for between 1 day copolymer is carboxylic acid endcapped. and 14 days. In some embodiments, the high local exposure 40 In some embodiments of these populations, preparations attributable to the immediate release component lasts for and/or formulations, the copolymer is biodegradable. In between 1 day and 10 days. In some embodiments, the high Some embodiments, the lactic acid-glycolic acid copolymer local exposure attributable to the immediate release compo is a poly(lactic-co-glycolic) acid copolymer (PLGA). In nent lasts between 1 days and 8 days. In some embodiments, Some embodiments, the lactic acid-glycolic acid copolymer the high local exposure attributable to the immediate release 45 has a molar ratio of lactic acid:glycolic acid from the range component lasts between 1 days and 6 days. In some of about 80:20 to 60:40. In some embodiments, the lactic embodiments, the high local exposure attributable to the acid-glycolic acid copolymer has a molar ratio of lactic immediate release component lasts for between 1 day and 4 acid:glycolic acid of 75:25. days. The invention also provides populations of microparticles Upon administration, the corticosteroid microparticle for 50 including a Class B corticosteroid or a pharmaceutically mulation may provide an initial release of corticosteroid at acceptable salt thereof incorporated in, admixed, encapsu the site of administration, for example, in the intra-articular lated or otherwise associated with a mixed molecular weight space and/or peri-articular space. Once the initial release of lactic acid-glycolic acid copolymer matrix, wherein the corticosteroid has subsided, the controlled or sustained Class B corticosteroid is between 12% to 28% of the release of the corticosteroid microparticle formulations con 55 microparticles. In some embodiments, the corticosteroid tinues to provide therapeutic (e.g., intra-articular and/or microparticle formulation includes a Class B corticosteroid peri-articular) concentrations of corticosteroid to Suppress and a microparticle made using 75:25 PLGA formulation inflammation, maintain analgesia, and/or slow, arrest or with two PLGA polymers, one of low molecular weight and reverse structural damage to tissues for an additional period one of high molecular weight in a two to one ratio, respec of therapy following administration (FIG. 1, top tracings). 60 tively. The low molecular weight PLGA has a molecular However, the systemic exposure associated with the Sus weight of range of 15-35 kDa and an inherent viscosity tained release component does not suppress the HPA axis range from 0.2 to 0.35 dL/g and the high molecular weight (FIG. 1, bottom tracings). Thus, the invention includes PLGA has a range of 70-95 kDa and an inherent viscosity therapies and formulations that may exhibit an initial release range of 0.5 to 0.70 dL/g. In these TCA/75:25 PLGA of corticosteroid followed by controlled or sustained release 65 corticosteroid microparticle formulations, the microparticles where the therapy comprises a period of therapy wherein the have a mean diameter in the range of 10-100 uM. In some corticosteroid is released from the Sustained release compo embodiments, the microparticles have a mean diameter in US 9,555,047 B2 7 8 the range of 20-100 uM, 20-90 uM, 30-100 uM, 30-90 uM, uM, 20-90 uM, 30-100 uM, 30-90 uM, or 10-90 uM. It is or 10-90 uM. It is understood that these ranges refer to the understood that these ranges refer to the mean diameter of all mean diameter of all microparticles in a given population. microparticles in a given population. The diameter of any The diameter of any given individual microparticle could be given individual microparticle could be within a standard within a standard deviation above or below the mean diam 5 deviation above or below the mean diameter. eter. In some embodiments, the microparticles further com The invention also provides populations of microparticles prise a polyethylene glycol (PEG) moiety, wherein the PEG including a Class B corticosteroid or a pharmaceutically moiety comprises between 25% to 0% weight percent of the acceptable salt thereof incorporated in, admixed, encapsu microparticle. In some embodiments of the microparticles lated or otherwise associated with a lactic acid-glycolic acid 10 copolymer matrix containing 10-20% triblock (PEG-PLGA that include a PEG moiety, the populations, preparations PEG) having an inherent viscosity in the range from 0.6 to and/or formulations of the invention do not require the 0.8 dL/g, wherein the Class B corticosteroid is between 22% presence of PEG to exhibit the desired corticosteroid sus to 28% of the microparticles. In some embodiments, the tained release kinetics and bioavailability profile. corticosteroid microparticle formulation includes a Class B 15 In one embodiment of these populations, preparations corticosteroid and a microparticle made using 75:25 PLGA and/or formulations, the corticosteroid microparticle formu formulation and containing 10-20% triblock (PEG-PLGA lation includes triamcinolone acetonide (TCA) and a PEG) having an inherent viscosity in the range from 0.6 to microparticle made using 75:25 PLGA formulation having 0.8 dL/g. In these TCA/75:25 PLGA corticosteroid an inherent viscosity in the range from 0.3 to 0.5 dL/g and/or microparticle formulations, the microparticles have a mean a molecular weight in the range of 40-70 kDa, for example diameter in the range of 10-100 uM. In some embodiments, between 50-60 kDa. In these TCA/75:25 PLGA corticoster the microparticles have a mean diameter in the range of oid microparticle formulations, the microparticles have a 20-100 uM, 20-90 uM, 30-100 uM, 30-90 uM, or 10-90 uM. mean diameter in the range of 10-100 uM. In some embodi It is understood that these ranges refer to the mean diameter ments, the microparticles have a mean diameter in the range of all microparticles in a given population. The diameter of 25 of 20-100 uM, 20-90 uM, 30-100 uM, 30-90 uM, or 10-90 any given individual microparticle could be within a stan uM. It is understood that these ranges refer to the mean dard deviation above or below the mean diameter. diameter of all microparticles in a given population. The These Class B corticosteroid microparticle formulations, diameter of any given individual microparticle could be preparations, and populations thereof, when administered to within a standard deviation above or below the mean diam a patient, exhibit reduced undesirable side effects in patient, 30 eter. for example, undesirable effects on a patient’s cartilage or For the TCA/75:25 PLGA microparticle formulations, the other structural tissue, as compared to the administration, for range of TCA load percentage is between 22-28%. In one example administration into the intra-articular space of a embodiment, the load percentage of TCA in the micropar joint, of an equivalent amount of the Class B corticosteroid ticles in 25%. absent any microparticle or other type of incorporation, 35 The microparticles in the TCA PLGA microparticle for admixture, or encapsulation. mulations can be formulated using PLGA polymers having In some embodiments, the Class B corticosteroid is tri a range of molecular weights from 40 to 70 kDa, most amcinolone acetonide or a commercially available chemical preferably from 50 to 60 kDa and range of inherent viscosi analogue or a pharmaceutically-acceptable salt thereof. In ties from 0.5 to 0.5 dI/g, most preferably from 0.38 to 0.42 Some embodiments, the total dose of corticosteroid con 40 dL/g. tained in the microparticles is in the range of 10-90 mg. For the TCA/75:25 PLGA microparticle formulations, the where the Class B corticosteroid is between 12-28% of the total dose of corticosteroid contained in the microparticles is microparticle, for example, between 22-28% of the in the range of 10-90 mg, where TCA is between 22-28% of microparticle (i.e., when the corticosteroid is 28% of the the microparticle (i.e., when TCA is 25% of the micropar microparticle, the microparticle is in the range of 35.7-321.4 45 ticle, the microparticle is in the range of 40-360 mgs, when mgs, and so on for all values between 22-28% load dose, TCA is 22% of the microparticle, the microparticle is in the when the corticosteroid is 25% of the microparticle, the range of 45.5-409.1 mgs, when TCA is 28% of the micropar microparticle is in the range of 40-360 mgs, when the ticle, the microparticle is in the range of 35.7-321.4 mgs, and corticosteroid is 22% of the microparticle, the microparticle so on for all values between 22-28% load dose). In some is in the range of 45.5-409.1 mgs, when the corticosteroid is 50 embodiments, total dose of corticosteroid contained in the 12% of the microparticle, the microparticle is in the range of microparticles is in a range selected from 10-80 mg, 10-70 83.3-750 mgs, and so on for all values between 12-28% load mg, 10-60 mg, 10-50 mg, 10-40 mg, 10-30 mg, 10-20 mg. dose). In some embodiments, the Class B corticosteroid 20-90 mg, 20-80 mg, 20-70 mg, 20-60 mg, 20-50 mg, 20-40 contained in the microparticles is 12-28% of the micropar mg, 20-30 mg, 30-90 mg, 30-80 mg, 30-70 mg, 30-60 mg. ticle, for example, between 22-28% of the microparticle and 55 30-50 mg, 30-40 mg, 40-90 mg, 40-80 mg. 40-70 mg, 40-60 the total dose of corticosteroid is in a range selected from mg, 40-50 mg, 50-90 mg, 50-80 mg, 50-70 mg, 50-60 mg. 10-80 mg, 10-70 mg, 10-60 mg, 10-50 mg, 10-40 mg, 10-30 60-90 mg. 60-80 mg. 60-70 mg, 70-90 mg, 70-80 mg, and mg, 10-20 mg, 20-90 mg, 20-80 mg, 20-70 mg, 20-60 mg. 80-90 mg. 20-50 mg, 20-40 mg, 20-30 mg, 30-90 mg, 30-80 mg, 30-70 In some embodiments of the TCA/75:25 PLGA micropar mg, 30-60 mg, 30-50 mg, 30-40 mg, 40-90 mg, 40-80 mg. 60 ticle formulations, the microparticles further comprise a 40-70 mg, 40-60 mg, 40-50 mg, 50-90 mg, 50-80 mg, 50-70 polyethylene glycol (PEG) moiety, wherein the PEG moiety mg, 50-60 mg. 60-90 mg, 60-80 mg. 60-70 mg, 70-90 mg. comprises between 25% to 0% weight percent of the 70-80 mg, and 80-90 mg. In some embodiments, the Class microparticle. In some embodiments of the microparticles B corticosteroid is released for between 14 days and 90 days. that include a PEG moiety, the populations, preparations In some embodiments, the microparticles have a mean 65 and/or formulations of the invention do not require the diameter of between 10 um to 100 um, for example, the presence of PEG to exhibit the desired corticosteroid sus microparticles have a mean diameter in the range of 20-100 tained release kinetics and bioavailability profile. US 9,555,047 B2 10 In one embodiment of these populations, preparations having a range of inherent viscosities from 0.35 to 0.5 dI/g and/or formulations, the corticosteroid microparticle formu and approximated molecular weights from 40 kDa to 70 lation includes triamcinolone acetonide (TCA) and a kDa. microparticle made using 75:25 PLGA formulation and These Class A, C or D corticosteroid microparticle for containing 10-20% triblock (PEG-PLGA-PEG) having an mulations, preparations, and populations thereof, when inherent viscosity in the range from 0.6 to 0.8 dL/g. In these administered to a patient, exhibit reduced undesirable side TCA/75:25 PLGA corticosteroid microparticle formula effects in patient, for example, undesirable effects on a tions, the microparticles have a mean diameter in the range patient’s cartilage or other structural tissue, as compared to of 10-100 uM. In some embodiments, the microparticles the administration, for example administration into the intra 10 articular space of a joint, of an equivalent amount of the have a mean diameter in the range of 20-100 uM, 20-90 LM, Class A, C or D corticosteroid absent any microparticle or 30-100 uM, 30-90 uM, or 10-90 uM. It is understood that other type of incorporation, admixture, or encapsulation. these ranges refer to the mean diameter of all microparticles The invention provides populations of microparticles in a given population. The diameter of any given individual including a Class A corticosteroid or a pharmaceutically microparticle could be within a standard deviation above or 15 acceptable salt thereof incorporated in, admixed, encapsu below the mean diameter. lated or otherwise associated with a lactic acid-glycolic acid In one embodiment of these populations, preparations copolymer matrix, wherein the Class A corticosteroid is and/or formulations, the corticosteroid microparticle formu between 15% to 30% of the microparticles. lation includes triamcinolone acetonide (TCA) and a The invention also provides controlled or sustained microparticle made using 75:25 PLGA formulation with two release preparations of a Class A corticosteroid including a PLGA polymers, one of low molecular weight and one of lactic acid-glycolic acid copolymer microparticle containing high molecular weight in a two to one ratio, respectively. the Class A corticosteroid, wherein the Class A corticoster The low molecular weight PLGA has a molecular weight of oid is between 10% to 40%, for example between 15% to range of 15-35 kDa and an inherent viscosity range from 0.2 30% of the lactic acid-glycolic acid copolymer microparticle to 0.35 dL/g and the high molecular weight PLGA has a 25 matrix. range of 70-95 kDa and an inherent viscosity range of 0.5 to The invention provides formulations that include (a) 0.70 dL/g. In these TCA/75:25 PLGA corticosteroid controlled- or Sustained-release microparticles including a microparticle formulations, the microparticles have a mean Class A corticosteroid and a lactic acid-glycolic acid copo diameter in the range of 10-100 uM. In some embodiments, lymer matrix, wherein the Class A corticosteroid is between 30 15% to 30% of the microparticles and wherein the lactic the microparticles have a mean diameter in the range of acid-glycolic acid copolymer has one of more of the fol 20-100 uM, 20-90 uM, 30-100 uM, 30-90 uM, or 10-90 uM. lowing characteristics: (i) a molecular weight in the range of It is understood that these ranges refer to the mean diameter about 40 to 70 kDa; (ii) an inherent viscosity in the range of of all microparticles in a given population. The diameter of 0.35 to 0.5 dL/g; (iii) a lactide:glycolide molar ratio of 60:40 any given individual microparticle could be within a stan 35 to 45:55; and/or (iv) the lactic acid-glycolic acid copolymer dard deviation above or below the mean diameter. is carboxylic acid endcapped These TCA microparticle formulations, preparations, and In some embodiments, the copolymer is biodegradable. In populations thereof, when administered to a patient, exhibit Some embodiments, the lactic acid-glycolic acid copolymer reduced undesirable side effects in patient, for example, is a poly(lactic-co-glycolic) acid copolymer (PLGA). In undesirable effects on a patient’s cartilage or other structural 40 Some embodiments, the lactic acid-glycolic acid copolymer tissue, as compared to the administration, for example has a molar ratio of lactic acid:glycolic acid from the range administration into the intra-articular space of a joint, of an of about 60:40 to 45:55. In some embodiments, the lactic equivalent amount of TCA absent any microparticle or other acid-glycolic acid copolymer has a molar ratio of lactic type of incorporation, admixture, or encapsulation. acid:glycolic acid of 50:50. In another embodiment, the corticosteroid microparticle 45 In some embodiments, the Class A corticosteroid is pred formulation includes a Class A, C, or D corticosteroid and a nisolone or a commercially available chemical analogue or microparticle made using 50:50 PLGA formulation. For a pharmaceutically-acceptable salt thereof. In some embodi example, in some embodiments, the Class A corticosteroid is ments, total dose of the Class A corticosteroid contained in prednisolone. In some embodiments, the Class C corticos the microparticles is in a range selected from 10-250 mg. teroid is betamethasone. In some embodiments, the Class D 50 where the Class A corticosteroid is between 10-40%, for corticosteroid is fluticasone or fluticasone propionate. In example, between 15-30% of the microparticle (i.e., when these Class A, C, or D corticosteroid microparticle formu the corticosteroid is 10% of the microparticle, the micropar lations, the microparticles have a mean diameter in the range ticle is in the range of 100-2500 mgs, when the corticoster of 10-100 uM. In some embodiments, the microparticles oid is 15% of the microparticle, the microparticle is in the have a mean diameter in the range of 20-100 uM, 20-90 LM, 55 range of 66.7-1666.7 mgs, when the corticosteroid is 20% of 30-100 uM, 30-90 uM, or 10-90 uM. It is understood that the microparticle, the microparticle is in the range of these ranges refer to the mean diameter of all microparticles 50-1250 mgs, when the corticosteroid is 25% of the in a given population. The diameter of any given individual microparticle, the microparticle is in the range of 40-1000 microparticle could be within a standard deviation above or mgs, when the corticosteroid is 30% of the microparticle, the below the mean diameter. 60 microparticle is in the range of 33.3-833.3 mgs, when the For the Class A and/or Class C PLGA microparticle corticosteroid is 40% of the microparticle, the microparticle formulations, the range of corticosteroid load percentage is is in the range of 25-625 mgs and so on for all values between 10-40%, for example, between 15%-30%. For the between 10-40% load dose). For example, in some embodi Class D PLGA microparticle formulations, the range of ments, the total dose of corticosteroid is in the range of corticosteroid load percentage is between 8-20%. 65 10-225 mg, 10-200 mg, 10-175 mg, 10-150 mg, 10-120 mg. The microparticles in the Class A, C or DPLGA micropar 10-100 mg, 10-75 mg, 10-50 mg, 10-25 mg, 20-250 mg. ticle formulations can be formulated using PLGA polymers 20-225 mg, 20-200 mg, 20-175 mg, 20-150 mg, 20-125 mg. US 9,555,047 B2 11 12 20-100 mg, 20-75 mg, 20-50 mg, 30-250 mg, 30-225 mg. lymer matrix, wherein the Class C corticosteroid is between 30-200 mg, 30-175 mg, 30-150 mg, 30-120 mg, 30-100 mg, 15% to 30% of the microparticles and wherein the lactic 30-75 mg, 30-50 mg, 40-250 mg, 40-225 mg, 40-200 mg. acid-glycolic acid copolymer has one of more of the fol 40-175 mg, 40-150 mg, 40-120 mg, 40-100 mg, 40-75 mg. lowing characteristics: (i) a molecular weight in the range of 50-250 mg, 50-225 mg, 50-200 mg, 50-175 mg, 50-150 mg, about 40 to 70 kDa; (ii) an inherent viscosity in the range of 50-120 mg, 50-100 mg, 50-75 mg, 60-250 mg, 60-225 mg. 0.35 to 0.5 dL/g; (iii) a lactide:glycolide molar ratio of 60:40 60-200 mg, 60-175 mg, 60-150 mg, 60-120 mg. 60-100 mg. to 45:55; and/or (iv) the lactic acid-glycolic acid copolymer 60-75 mg, 70-250 mg, 70-225 mg, 70-200 mg, 70-175 mg, is carboxylic acid endcapped. 70-150 mg, 70-120 mg, 70-100 mg, 80-250 mg, 80-225 mg, In one embodiment of these populations, preparations 80-200 mg, 80-175 mg, 80-150 mg, 80-120 mg, 80-100 mg, 10 90-250 mg,90-225 mg, 90-200 mg,90-175 mg, 90-150 mg, and/or formulations, the copolymer is biodegradable. In or 90-120 mg. In some embodiments, the Class A corticos Some embodiments, the lactic acid-glycolic acid copolymer teroid is released for between 14 days and 90 days. is a poly(lactic-co-glycolic) acid copolymer (PLGA). In In some embodiments, the microparticles have a mean Some embodiments, the lactic acid-glycolic acid copolymer diameter of between 10 um to 100 um, for example, the 15 has a molar ratio of lactic acid:glycolic acid from the range microparticles have a mean diameter in the range of 20-100 of about 60:40 to 45:55. In some embodiments, the lactic uM, 20-90 uM, 30-100 uM, 30-90 uM, or 10-90 uM. It is acid-glycolic acid copolymer has a molar ratio of lactic understood that these ranges refer to the mean diameter of all acid:glycolic acid of 50:50. microparticles in a given population. The diameter of any In some embodiments, the Class C corticosteroid is given individual microparticle could be within a standard betamethasone or a commercially available chemical ana deviation above or below the mean diameter. logue or a pharmaceutically-acceptable salt thereof. In some In some embodiments, the microparticles further com embodiments, total dose of the Class C corticosteroid con prise a polyethylene glycol (PEG) moiety, wherein the PEG tained in the microparticles is in a range selected from 2-250 moiety comprises between 25% to 0% weight percent of the mg, where the Class C corticosteroid is between 10-40%, for microparticle. In some embodiments of the microparticles 25 example, between 15-30% of the microparticle (i.e., when that include a PEG moiety, the populations, preparations the corticosteroid is 10% of the microparticle, the micropar and/or formulations of the invention do not require the ticle is in the range of 20-2500 mgs, when the corticosteroid presence of PEG to exhibit the desired corticosteroid sus is 15% of the microparticle, the microparticle is in the range tained release kinetics and bioavailability profile. of 13.3-1666.7 mgs, when the corticosteroid is 20% of the In one embodiment of these populations, preparations 30 microparticle, the microparticle is in the range of 10-1250 and/or formulations, the corticosteroid microparticle formu mgs, when the corticosteroid is 25% of the microparticle, the lation includes prednisolone and a microparticle made using microparticle is in the range of 8-1000 mgs, when the 50:50 PLGA formulation having a molecular weight in the corticosteroid is 30% of the microparticle, the microparticle range of 40 kDa to 70 kDa. In these prednisolone/50:50 is in the range of 6.67-833.3 mgs, when the corticosteroid is PLGA corticosteroid microparticle formulations, the 35 40% of the microparticle, the microparticle is in the range of microparticles have a mean diameter in the range of 10-100 5-625 mgs and so on for all values between 10-40% load LM. In some embodiments, the microparticles have a mean dose). For example, in Some embodiments, the total dose of diameter in the range of 20-100 uM, 20-90 uM, 30-100 uM, corticosteroid is in the range of 2-225 mg, 2-200 mg, 2-175 30-90 uM, or 10-90 uM. mg, 2-150 mg, 2-120 mg, 2-100 mg, 2-75 mg, 2-60 mg, 2-55 For the prednisolone/50:50 PLGA microparticle formu 40 mg, 2-50 mg, 2-45 mg, 2-40 mg, 2-35 mg, 2-30 mg, 2-25 lations, the range of prednisolone load percentage is mg, 2-20 mg, 2-15 mg, 2-10 mg, 4-225 mg, 4-200 mg, 4-175 between 10-40%, for example, between 15-30%. mg, 4-150 mg, 4-120 mg, 4-100 mg, 4-75 mg, 4-60 mg, 4-55 In some embodiments of the prednisolone/50:50 PLGA mg, 4-50 mg, 4-45 mg, 4-40 mg, 4-35 mg, 4-30 mg, 4-25 microparticle formulations, the microparticles further com mg, 4-20 mg, 4-15 mg, 4-10 mg, 5-225 mg, 5-200 mg, 5-175 prise a polyethylene glycol (PEG) moiety, wherein the PEG 45 mg, 5-150 mg, 5-120 mg, 5-100 mg, 5-75 mg, 5-60 mg, 5-55 moiety comprises between 25% to 0% weight percent of the mg, 5-50 mg, 5-45 mg, 5-40 mg, 5-35 mg, 5-30 mg, 5-25 microparticle. In some embodiments of the microparticles mg, 5-20 mg, 5-15 mg, 5-10 mg, 6-225 mg, 6-200 mg. 6-175 that include a PEG moiety, the populations, preparations mg, 6-150 mg. 6-120 mg. 6-100 mg, 6-75 mg, 6-60 mg. 6-55 and/or formulations of the invention do not require the mg, 6-50 mg, 6-45 mg, 6-40 mg, 6-35 mg, 6-30 mg, 6-25 presence of PEG to exhibit the desired corticosteroid sus 50 mg, 6-20 mg. 6-15 mg. 6-10 mg. 8-225 mg. 8-200 mg. 8-175 tained release kinetics and bioavailability profile. mg. 8-150 mg. 8-120 mg. 8-100 mg. 8-75 mg. 8-60 mg. 8-55 The invention provides populations of microparticles mg, 8-50 mg. 8-45 mg. 8-40 mg. 8-35 mg. 8-30 mg. 8-25 including a Class C corticosteroid or a pharmaceutically mg. 8-20 mg. 8-15 mg. 8-10 mg, 10-225 mg, 10-200 mg. acceptable salt thereof incorporated in, admixed, encapsu 10-175 mg, 10-150 mg, 10-120 mg, 10-100 mg, 10-75 mg, lated or otherwise associated with a lactic acid-glycolic acid 55 10-50 mg, 10-25 mg, 20-250 mg, 20-225 mg, 20-200 mg. copolymer matrix, wherein the Class C corticosteroid is 20-175 mg, 20-150 mg, 20-125 mg, 20-100 mg, 20-75 mg. between 10% to 40% of the microparticles, for example 20-50 mg, 30-250 mg, 30-225 mg, 30-200 mg, 30-175 mg. between 15% to 30% of the microparticles. 30-150 mg, 30-120 mg, 30-100 mg, 30-75 mg, 30-50 mg, The invention also provides controlled or sustained 40-250 mg, 40-225 mg, 40-200 mg, 40-175 mg, 40-150 mg. release preparations of a Class C corticosteroid including a 60 40-120 mg, 40-100 mg, 40-75 mg, 50-250 mg, 50-225 mg. lactic acid-glycolic acid copolymer microparticle containing 50-200 mg, 50-175 mg, 50-150 mg, 50-120 mg, 50-100 mg, the Class C corticosteroid, wherein the Class C corticoster 50-75 mg, 60-250 mg. 60-225 mg. 60-200 mg, 60-175 mg. oid is between 15% to 30% of the lactic acid-glycolic acid 60-150 mg, 60-120 mg. 60-100 mg, 60-75 mg, 70-250 mg. copolymer microparticle matrix. 70-225 mg, 70-200 mg, 70-175 mg, 70-150 mg, 70-120 mg, The invention provides formulations that include (a) 65 70-100 mg, 80-250 mg, 80-225 mg, 80-200 mg, 80-175 mg, controlled- or Sustained-release microparticles having a 80-150 mg, 80-120 mg, 80-100 mg, 90-250 mg, 90-225 mg. Class C corticosteroid and a lactic acid-glycolic acid copo 90-200 mg, 90-175 mg, 90-150 mg. or 90-120 mg. In some US 9,555,047 B2 13 14 embodiments, the Class C corticosteroid is released for to 0.5 dL/g; (iii) a lactide:glycolide molar ratio of 60:40 to between 14 days and 90 days. 45:55; and/or (iv) the lactic acid-glycolic acid copolymer is In some embodiments, the microparticles have a mean carboxylic acid endcapped. diameter of between 10 um to 100 um, for example, the In one embodiment of these populations, preparations microparticles have a mean diameter in the range of 20-100 and/or formulations, the copolymer is biodegradable. In uM, 20-90 uM, 30-100 uM, 30-90 uM, or 10-90 uM. It is Some embodiments, the lactic acid-glycolic acid copolymer understood that these ranges refer to the mean diameter of all is a poly(lactic-co-glycolic) acid copolymer (PLGA). In microparticles in a given population. The diameter of any Some embodiments, the lactic acid-glycolic acid copolymer given individual microparticle could be within a standard has a molar ratio of lactic acid:glycolic acid from the range deviation above or below the mean diameter. 10 In some embodiments, the microparticles further com of about 60:40 to 45:55. In some embodiments, the lactic prise a polyethylene glycol (PEG) moiety, wherein the PEG acid-glycolic acid copolymer has a molar ratio of lactic moiety comprises between 25% to 0% weight percent of the acid:glycolic acid of 50:50. microparticle. In some embodiments of the microparticles In some embodiments, the Class D corticosteroid is that include a PEG moiety, the populations, preparations 15 fluticasone propionate, fluticasone, or a commercially avail and/or formulations of the invention do not require the able chemical analogue or a pharmaceutically-acceptable presence of PEG to exhibit the desired corticosteroid sus salt thereof. In some embodiments, total dose of the Class D tained release kinetics and bioavailability profile. corticosteroid contained in the microparticles is in a range In one embodiment of these populations, preparations selected from 1-250 mg, where the Class D corticosteroid is and/or formulations, the corticosteroid microparticle formu between 8-20% of the microparticle (i.e., when the corti lation includes betamethasone and a microparticle made costeroid is 8% of the microparticle, the microparticle is in using 50:50 PLGA formulation having a molecular weight in the range of 12.5-3125 mgs, when the corticosteroid is 10% the range of 40 kDa to 70 kDa. In these betamethasone/50: of the microparticle, the microparticle is in the range of 50 PLGA corticosteroid microparticle formulations, the 10-2500 mgs, when the corticosteroid is 15% of the microparticles have a mean diameter in the range of 10-100 25 microparticle, the microparticle is in the range of 6.67 LM. In some embodiments, the microparticles have a mean 1666.7 mgs, when the corticosteroid is 20% of the micropar diameter in the range of 20-100 uM, 20-90 uM, 30-100 uM, ticle, the microparticle is in the range of 5-1250 mgs, and so 30-90 uM, or 10-90 LM. It is understood that these ranges on for all values between 10-20% load dose). For example, refer to the mean diameter of all microparticles in a given in some embodiments, the total dose of corticosteroid is in population. The diameter of any given individual micropar 30 the range of 1-225 mg, 1-200 mg, 1-175 mg, 1-150 mg. ticle could be within a standard deviation above or below the 1-120 mg, 1-100 mg, 1-75 mg, 1-60 mg, 1-55 mg, 1-50 mg. mean diameter. 1-45 mg, 1-40 mg, 1-35 mg, 1-30 mg, 1-25 mg, 1-20 mg. For the betamethasone/50:50 PLGA microparticle formu 1-15 mg, 1-10 mg, 2-225 mg, 2-200 mg, 2-175 mg, 2-150 lations, the range of prednisolone load percentage is mg, 2-120 mg, 2-100 mg, 2-75 mg, 2-60 mg, 2-55 mg, 2-50 between 10-40%, for example, between 15-30%. 35 mg, 2-45 mg, 2-40 mg, 2-35 mg, 2-30 mg, 2-25 mg, 2-20 In some embodiments of the betamethasone/50:50 PLGA mg, 2-15 mg, 2-10 mg, 3-225 mg, 3-200 mg. 3-175 mg. microparticle formulations, the microparticles further com 3-150 mg. 3-120 mg. 3-100 mg, 3-75 mg, 3-60 mg. 3-55 mg. prise a polyethylene glycol (PEG) moiety, wherein the PEG 3-50 mg. 3-45 mg, 3-40 mg, 3-35 mg, 3-30 mg, 3-25 mg. moiety comprises between 25% to 0% weight percent of the 3-20 mg. 3-15 mg. 3-10 mg, 4-225 mg, 4-200 mg, 4-175 mg. microparticle. In some embodiments of the microparticles 40 4-150 mg, 4-120 mg, 4-100 mg, 4-75 mg, 4-60 mg, 4-55 mg. that include a PEG moiety, the populations, preparations 4-50 mg, 4-45 mg, 4-40 mg, 4-35 mg, 4-30 mg, 4-25 mg. and/or formulations of the invention do not require the 4-20 mg, 4-15 mg, 4-10 mg, 5-225 mg, 5-200 mg, 5-175 mg. presence of PEG to exhibit the desired corticosteroid sus 5-150 mg, 5-120 mg, 5-100 mg, 5-75 mg, 5-60 mg, 5-55 mg. tained release kinetics and bioavailability profile. 5-50 mg, 5-45 mg, 5-40 mg, 5-35 mg, 5-30 mg, 5-25 mg. The invention provides populations of microparticles 45 5-20 mg, 5-15 mg, 5-10 mg, 6-225 mg, 6-200 mg. 6-175 mg. including a Class D corticosteroid or a pharmaceutically 6-150 mg. 6-120 mg. 6-100 mg, 6-75 mg, 6-60 mg. 6-55 mg. acceptable salt thereof incorporated in, admixed, encapsu 6-50 mg, 6-45 mg, 6-40 mg, 6-35 mg, 6-30 mg, 6-25 mg. lated or otherwise associated with a lactic acid-glycolic acid 6-20 mg. 6-15 mg. 6-10 mg. 8-225 mg. 8-200 mg. 8-175 mg. copolymer matrix, wherein the Class D corticosteroid is 8-150 mg. 8-120 mg. 8-100 mg. 8-75 mg. 8-60 mg. 8-55 mg. between 8% to 20% of the microparticles, for example, 50 8-50 mg. 8-45 mg. 8-40 mg. 8-35 mg. 8-30 mg. 8-25 mg. between 10% to 20% of the microparticles. 8-20 mg. 8-15 mg. 8-10 mg, 10-225 mg, 10-200 mg, 10-175 The invention also provides controlled or sustained mg, 10-150 mg, 10-120 mg, 10-100 mg, 10-75 mg, 10-50 release preparation of a Class D corticosteroid including a mg, 10-25 mg, 20-250 mg, 20-225 mg, 20-200 mg, 20-175 lactic acid-glycolic acid copolymer microparticle containing mg, 20-150 mg, 20-125 mg, 20-100 mg, 20-75 mg, 20-50 the Class D corticosteroid, wherein the Class D corticoster 55 mg, 30-250 mg, 30-225 mg, 30-200 mg, 30-175 mg, 30-150 oid is between 8% to 20%, for example, between 10% to mg, 30-120 mg, 30-100 mg, 30-75 mg, 30-50 mg, 40-250 20% of the microparticles of the lactic acid-glycolic acid mg, 40-225 mg, 40-200 mg, 40-175 mg, 40-150 mg, 40-120 copolymer microparticle matrix. mg, 40-100 mg, 40-75 mg, 50-250 mg, 50-225 mg, 50-200 The invention provides formulations including (a) con mg, 50-175 mg, 50-150 mg, 50-120 mg, 50-100 mg, 50-75 trolled- or Sustained-release microparticles having a Class D 60 mg, 60-250 mg, 60-225 mg, 60-200 mg, 60-175 mg, 60-150 corticosteroid and a lactic acid-glycolic acid copolymer mg, 60-120 mg. 60-100 mg. 60-75 mg, 70-250 mg, 70-225 matrix, wherein the Class D corticosteroid is between 8% to mg, 70-200 mg, 70-175 mg, 70-150 mg, 70-120 mg, 70-100 20% of the microparticles, for example, between 10% to mg, 80-250 mg, 80-225 mg, 80-200 mg, 80-175 mg, 80-150 20% of the microparticles, and wherein the lactic acid mg, 80-120 mg, 80-100 mg,90-250 mg, 90-225 mg, 90-200 glycolic acid copolymer has one of more of the following 65 mg, 90-175 mg, 90-150 mg. or 90-120 mg. In some embodi characteristics: (i) a molecular weight in the range of about ments, the Class D corticosteroid is released for between 14 40 to 70 kDa; (ii) an inherent viscosity in the range of 0.35 days and 90 days. US 9,555,047 B2 15 16 In some embodiments, the microparticles have a mean able salt thereof incorporated in a lactic acid-glycolic acid diameter of between 10 um to 100 um, for example, the copolymer matrix, wherein the Class C corticosteroid com microparticles have a mean diameter in the range of 20-100 prises between 15% to 30% of the microparticles; and (iv) uM, 20-90 uM, 30-100 uM, 30-90 uM, or 10-90 uM. It is a population of microparticles comprising a Class D corti understood that these ranges refer to the mean diameter of all costeroid or a pharmaceutically acceptable salt thereof microparticles in a given population. The diameter of any incorporated in a lactic acid-glycolic acid copolymer matrix, given individual microparticle could be within a standard wherein the Class D corticosteroid comprises between 8% to deviation above or below the mean diameter. 20% of the microparticles. In some embodiments, the popu In some embodiments, the microparticles further com lation of microparticles releases the corticosteroid for at prise a polyethylene glycol (PEG) moiety, wherein the PEG 10 least 14 days at a rate that does not adversely suppress the moiety comprises between 25% to 0% weight percent of the hypothalamic-pituitary-adrenal axis (HPA axis). In some microparticle. In some embodiments of the microparticles embodiments, the population of microparticles releases the that include a PEG moiety, the populations, preparations corticosteroid in a controlled or Sustained release manner and/or formulations of the invention do not require the such that the levels of cortisol suppression are at or below presence of PEG to exhibit the desired corticosteroid sus 15 35% by day 14 post-administration, for example post tained release kinetics and bioavailability profile. administration. In some embodiments, the population of In one embodiment of these populations, preparations microparticles releases the corticosteroid in a controlled or and/or formulations, the corticosteroid microparticle formu sustained release manner such that the levels of cortisol lation includes fluticaSone propionate or fluticaSone, and a Suppression are negligible and/or undetectable by 14 post microparticle made using 50:50 PLGA formulation having a administration. In some embodiments, the population of molecular weight in the range of 40 kDa to 70 kDa. In these microparticles releases the corticosteroid in a controlled or fluticasone or fluticasone propionate/50:50 PLGA corticos sustained release manner such that the levels of cortisol teroid microparticle formulations, the microparticles have a Suppression are negligible at any time post-administration. mean diameter in the range of 10-100 uM. In some embodi The invention provides methods of treating pain or ments, the microparticles have a mean diameter in the range 25 inflammation in a patient comprising administering to said of 20-100 uM, 20-90 uM, 30-100 uM, 30-90 uM, or 10-90 patient a therapeutically effective amount of a controlled or uM. It is understood that these ranges refer to the mean Sustained release preparation selected from the following diameter of all microparticles in a given population. The preparations: (i) a controlled or Sustained release preparation diameter of any given individual microparticle could be of a Class B corticosteroid comprising a lactic acid-glycolic within a standard deviation above or below the mean diam 30 acid copolymer microparticle containing the Class B corti eter. costeroid, wherein the Class B corticosteroid comprises For the fluticasone or fluticasone propionate/50:50 PLGA between 22% to 28% of the lactic acid-glycolic acid copo microparticle formulations, the range of prednisolone load lymer microparticle matrix; (ii) a controlled or Sustained percentage is between 10-20%. release preparation of a Class A corticosteroid comprising a In some embodiments of the fluticasone or fluticasone 35 lactic acid-glycolic acid copolymer microparticle containing propionate/50:50 PLGA microparticle formulations, the the Class A corticosteroid, wherein the Class A corticoster microparticles further comprise a polyethylene glycol (PEG) oid comprises between 15% to 30% of the lactic acid moiety, wherein the PEG moiety comprises between 25% to glycolic acid copolymer microparticle matrix; (iii) a con 0% weight percent of the microparticle. In some embodi trolled or sustained release preparation of a Class C ments of the microparticles that include a PEG moiety, the 40 corticosteroid comprising a lactic acid-glycolic acid copo populations, preparations and/or formulations of the inven lymer microparticle containing the Class C corticosteroid, tion do not require the presence of PEG to exhibit the desired wherein the Class C corticosteroid comprises between 15% corticosteroid sustained release kinetics and bioavailability to 30% of the lactic acid-glycolic acid copolymer micropar profile. ticle matrix; and (iv) a controlled or Sustained release These embodiments of corticosteroid microparticle for 45 preparation of a Class D corticosteroid comprising a lactic mulations have been selected because the combination of acid-glycolic acid copolymer microparticle containing the class of corticosteroid, type of microparticle, molecular Class D corticosteroid, wherein the Class D corticosteroid weight of polymers used to create the microparticles lactide: comprises between 8% to 20% of the lactic acid-glycolic glycolide molar ratio, and/or load percentage of the corti acid copolymer microparticle matrix. In some embodiments, costeroid exhibit the desired release kinetics. These embodi 50 the controlled or Sustained release preparation releases the ments also exhibit the desired release kinetics with minimal corticosteroid for at least 14 days at a rate that does not prolonged HPA axis Suppression. adversely suppress the hypothalamic-pituitary-adrenal axis The invention provides methods of treating pain or (HPA axis). In some embodiments, the controlled or sus inflammation in a patient comprising administering to said tained release preparation releases the corticosteroid in a patient a therapeutically effective amount of a population of 55 controlled or sustained release manner such that the levels of microparticles selected from the following populations: (i) a cortisol suppression are at or below 35% by day 14 post population of microparticles comprising a Class B corticos administration, for example post-administration. In some teroid or a pharmaceutically acceptable salt thereof incor embodiments, the controlled or Sustained release preparation porated in a lactic acid-glycolic acid copolymer matrix, releases the corticosteroid in a controlled or Sustained wherein the Class B corticosteroid comprises between 22% 60 release manner Such that the levels of cortisol Suppression to 28% of the microparticles; (ii) a population of micropar are negligible and/or undetectable by 14 post-administra ticles comprising a Class A corticosteroid or a pharmaceu tion. In some embodiments, the controlled or Sustained tically acceptable salt thereof incorporated in a lactic acid release preparation releases the corticosteroid in a controlled glycolic acid copolymer matrix, wherein the Class A or sustained release manner such that the levels of cortisol corticosteroid comprises between 15% to 30% of the 65 Suppression are negligible at any time post-administration. microparticles; (iii) a population of microparticles compris The invention provides methods of treating pain or ing a Class C corticosteroid or a pharmaceutically accept inflammation in a patient comprising administering to said US 9,555,047 B2 17 18 patient a therapeutically effective amount of a formulation ticosteroids are released for a period of time at a rate that selected from the following preparations: (i) a formulation does not suppress (e.g., adversely and/or measurably) the comprising (a) controlled- or Sustained-release micropar HPA axis. ticles comprising a Class B corticosteroid and a lactic In another aspect, a method of treating pain and/or inflam acid-glycolic acid copolymer matrix, wherein the Class B mation in a joint of a patient is provided that includes corticosteroid comprises between 22% to 28% of the administering intra-articularly (e.g., by one or more injec microparticles and wherein the lactic acid-glycolic acid tions) a therapeutically effective amount of one or more copolymer has one of more of the following characteristics: corticosteroids in a formulation to a patient with joint (1) a molecular weight in the range of about 40 to 70 kDa; disease (e.g., osteoarthritis or rheumatoid arthritis). The (2) an inherent viscosity in the range of 0.5 to 0.5 dL/g; or 10 formulation has a Sustained release microparticle formula (3) a lactide:glycolide molar ratio of 80:20 to 60:40; (ii) a tion that may or may not release detectable levels of corti formulation comprising (a) controlled- or Sustained-release costeroid for a length of time following administration and microparticles comprising a Class A corticosteroid and a that releases a detectable amount of corticosteroid(s) fol lactic acid-glycolic acid copolymer matrix, wherein the lowing administration, where the rate of corticosteroid Class Acorticosteroid comprises between 15% to 30% of the 15 release from the Sustained release microparticle formulation microparticles and wherein the lactic acid-glycolic acid does not adversely suppress the HPA axis. In some embodi copolymer has one of more of the following characteristics: ments, corticosteroid released from the Sustained release (1) a molecular weight in the range of about 40 to 70 kDa; microparticle formulation will not measurably suppress the (2) an inherent viscosity in the range of 0.35 to 0.5 dL/g; or HPA axis. (3) a lactide:glycolide molar ratio of 60:40 to 45:55; (iii) a According to certain embodiments of the foregoing meth formulation comprising (a) controlled- or Sustained-release ods, the formulation comprises a population of biodegrad microparticles comprising a Class C corticosteroid and a able polymer microparticles that contain the corticosteroids. lactic acid-glycolic acid copolymer matrix, wherein the In some embodiments, the corticosteroids are 2% to 75% Class C corticosteroid comprises between 15% to 30% of (w/w) of the microparticles, preferably about 5% to 50% the microparticles and wherein the lactic acid-glycolic acid 25 (w/w) of the microparticles, and more preferably 5% to 40% copolymer has one of more of the following characteristics: or 10% to 30% (w/w) of the microparticles. In some (1) a molecular weight in the range of about 40 to 70 kDa; embodiments, the microparticles have a mass mean diameter (2) an inherent viscosity in the range of 0.35 to 0.5 dL/g; or of between 10 um to 100 um. In some embodiments, the (3) a lactide:glycolide molar ratio of 60:40 to 45:55; and (iv) microparticles are formed from a hydrogel, hyaluronic acid, a formulation comprising (a) controlled- or Sustained-re 30 PLA or PLGA. For example, the microparticles are formed lease microparticles comprising a Class D corticosteroid and from PLGA with a lactide to glycolide co-polymer ratio of a lactic acid-glycolic acid copolymer matrix, wherein the about 45:55 to about 80:20. In some embodiments, the Class D corticosteroid comprises between 8% to 20% of the corticosteroid is betamethasone, dexamethasone, triamcino microparticles and wherein the lactic acid-glycolic acid lone acetonide, triamcinolone hexacetonide, prednisolone, copolymer has one of more of the following characteristics: 35 methylprednisolone, budenoside, mometasone, ciclesonide, (1) a molecular weight in the range of about 40 to 70 kDa; fluticasone, salts thereof, esters thereof or combinations (2) an inherent viscosity in the range of 0.35 to 0.5 dL/g; or thereof. (3) a lactide:glycolide molar ratio of 60:40 to 45:55. In some In yet another aspect, a composition is provided that embodiments, the formulation releases the corticosteroid for includes a population of biodegradable polymer micropar at least 14 days at a rate that does not adversely suppress the 40 ticles that contain corticosteroid(s). For example, the corti hypothalamic-pituitary-adrenal axis (HPA axis). In some costeroid is betamethasone, dexamethasone, triamcinolone embodiments, the formulation releases the corticosteroid in acetonide, triamcinolone hexacetonide, prednisolone, meth a controlled or Sustained release manner Such that the levels ylprednisolone, budenoside, mometaSone, ciclesonide, flu of cortisol suppression are at or below 35% by day 14 ticasone, salts thereof, esters thereof or combinations post-administration, for example post-administration. In 45 thereof. When the composition is administered intra-articu Some embodiments, the formulation releases the corticos larly (e.g., by one or more injections), a therapeutically teroid in a controlled or Sustained release manner Such that effective amount of corticosteroid(s) is released for a period the levels of cortisol Suppression are negligible and/or of time at a rate that does not suppress the HPA axis. In some undetectable by 14 post-administration. In some embodi embodiments, the corticosteroid(s) released will not ments, the formulation releases the corticosteroid in a con 50 adversely suppress the HPA axis. In some embodiments, the trolled or sustained release manner such that the levels of corticosteroid(s) released will not measurably Suppress the cortisol Suppression are negligible at any time post-admin HPA axis. istration. In yet a further aspect, a composition is provided that In some embodiments, the population of microparticles, includes a population of biodegradable polymer micropar the controlled or Sustained release preparation or formula 55 ticles that contain corticosteroid(s). For example, the corti tion is administered as one or more intra-articular injections. costeroid is betamethasone, dexamethasone, triamcinolone In some embodiments, the patient has osteoarthritis, rheu acetonide, triamcinolone hexacetonide, prednisolone, meth matoid arthritis, acute gouty arthritis, and synovitis. In some ylprednisolone, budenoside, mometaSone, ciclesonide, flu embodiments, the patient has acute bursitis, Sub-acute bur ticasone, salts thereof, esters thereof or combinations sitis, acute nonspecific tenosynovitis, or epicondylitis. 60 thereof. When the composition is administered intra-articu In one aspect, a method of treating pain and/or inflam larly (e.g., by one or more injections), therapeutically effec mation in a joint of a patient is provided that includes tive amounts of corticosteroid(s) are released following administering intra-articularly (e.g., by one or more injec administration from a first component for a first length of tions) to a patient with joint disease (e.g., osteoarthritis or time and from a Sustained release component for a second rheumatoid arthritis) a formulation that contains one or more 65 length of time. Furthermore, the rate of corticosteroid(s) corticosteroids, such as those formulations described herein. released from the Sustained release component does not Therapeutically effective amounts of the one or more cor Suppress the HPA axis. In some embodiments, the corticos US 9,555,047 B2 19 20 teroid(s) released from the Sustained release component lymer microparticle containing the Class A corticosteroid, during the second length of time will not adversely suppress wherein the Class A corticosteroid comprises between 15% the HPA axis. In some embodiments, the corticosteroid(s) to 30% of the lactic acid-glycolic acid copolymer micropar released from the Sustained release component during the ticle matrix; (iii) a controlled or Sustained release prepara second length of time will not measurably suppress the HPA tion of a Class C corticosteroid comprising a lactic acid axis. In some embodiments, the first component comprises glycolic acid copolymer microparticle containing the Class a corticosteroid containing Solution or Suspension. In some C corticosteroid, wherein the Class C corticosteroid com embodiments, the first component contains a corticosteroid prises between 15% to 30% of the lactic acid-glycolic acid that is different from that of the sustained release compo copolymer microparticle matrix; and (iv) a controlled or nent. In other embodiments, the same corticosteroid is used 10 Sustained release preparation of a Class D corticosteroid in both the first and Sustained release components. comprising a lactic acid-glycolic acid copolymer micropar According to certain embodiments of the foregoing com ticle containing the Class D corticosteroid, wherein the positions, the corticosteroids are 2% to 75% (w/w) of the Class D corticosteroid comprises between 8% to 20% of the microparticles, preferably about 5% to 50% (w/w) of the lactic acid-glycolic acid copolymer microparticle matrix. In microparticles, and more preferably 5% to 40% (w/w) of the 15 Some embodiments, the controlled or Sustained release microparticles. In some embodiments, the microparticles preparation releases the corticosteroid for at least 14 days at have a mass mean diameter of between 10 um to 100 um. In a rate that does not adversely Suppress the hypothalamic Some embodiments, the microparticles are formed from a pituitary-adrenal axis (HPA axis). hydrogel, hyaluronic acid, PLA or PLGA. For example, the The invention also provides methods of slowing, arresting microparticles are formed from PLGA with a lactide to or reversing progressive structural tissue damage associated glycolide co-polymer ratio of about 45:55 to about 80:20. In with chronic inflammatory disease in a patient comprising Some embodiments, the compositions further comprise a administering to said patient a therapeutically effective corticosteroid containing Solution or Suspension. In some amount of a formulation selected from the following prepa embodiments, the corticosteroid containing solution or Sus rations: (i) a formulation comprising (a) controlled- or pension contains a corticosteroid that is different from that 25 Sustained-release microparticles comprising a Class B cor found in the microparticles. ticosteroid and a lactic acid-glycolic acid copolymer matrix, The invention also provides methods of slowing, arresting wherein the Class B corticosteroid comprises between 22% or reversing progressive structural tissue damage associated to 28% of the microparticles and wherein the lactic acid with chronic inflammatory disease in a patient comprising glycolic acid copolymer has one of more of the following administering to said patient a therapeutically effective 30 characteristics: (1) a molecular weight in the range of about amount of a population of microparticles selected from the 40 to 70 kDa; (2) an inherent viscosity in the range of 0.3 to following populations: (i) a population of microparticles 0.5 dL/g; or (3) a lactide:glycolide molar ratio of 80:20 to comprising a Class B corticosteroid or a pharmaceutically 60:40; (ii) a formulation comprising (a) controlled- or Sus acceptable salt thereof incorporated in a lactic acid-glycolic tained-release microparticles comprising a Class A corticos acid copolymer matrix, wherein the Class B corticosteroid 35 teroid and a lactic acid-glycolic acid copolymer matrix, comprises between 22% to 28% of the microparticles; (ii) a wherein the Class A corticosteroid comprises between 15% population of microparticles comprising a Class A corticos to 30% of the microparticles and wherein the lactic acid teroid or a pharmaceutically acceptable salt thereof incor glycolic acid copolymer has one of more of the following porated in a lactic acid-glycolic acid copolymer matrix, characteristics: (1) a molecular weight in the range of about wherein the Class A corticosteroid comprises between 15% 40 40 to 70 kDa; (2) an inherent viscosity in the range of 0.35 to 30% of the microparticles; (iii) a population of micropar to 0.5 dI/g; or (3) a lactide:glycolide molar ratio of 60:40 to ticles comprising a Class C corticosteroid or a pharmaceu 50:50; (iii) a formulation comprising (a) controlled- or tically acceptable salt thereof incorporated in a lactic acid Sustained-release microparticles comprising a Class C cor glycolic acid copolymer matrix, wherein the Class C ticosteroid and a lactic acid-glycolic acid copolymer matrix, corticosteroid comprises between 15% to 30% of the 45 wherein the Class C corticosteroid comprises between 15% microparticles; and (iv) a population of microparticles com to 30% of the microparticles and wherein the lactic acid prising a Class D corticosteroid or a pharmaceutically glycolic acid copolymer has one of more of the following acceptable salt thereof incorporated in a lactic acid-glycolic characteristics: (1) a molecular weight in the range of about acid copolymer matrix, wherein the Class D corticosteroid 40 to 70 kDa; (2) an inherent viscosity in the range of 0.35 comprises between 8% to 20% of the microparticles. In 50 to 0.5 dI/g; or (3) a lactide:glycolide molar ratio of 60:40 to Some embodiments, the population of microparticles 50:50; and (iv) a formulation comprising (a) controlled- or releases the corticosteroid for at least 14 days at a rate that Sustained-release microparticles comprising a Class D cor does not adversely Suppress the hypothalamic-pituitary ticosteroid and a lactic acid-glycolic acid copolymer matrix, adrenal axis (HPA axis). wherein the Class D corticosteroid comprises between 8% to The invention also provides methods of slowing, arresting 55 20% of the microparticles and wherein the lactic acid or reversing progressive structural tissue damage associated glycolic acid copolymer has one of more of the following with chronic inflammatory disease in a patient comprising characteristics: (1) a molecular weight in the range of about administering to said patient a therapeutically effective 40 to 70 kDa; (2) an inherent viscosity in the range of 0.35 amount of a controlled or Sustained release preparation to 0.5 dI/g; or (3) a lactide:glycolide molar ratio of 60:40 to selected from the following preparations: (i) a controlled or 60 50:50. In some embodiments, the formulation releases the Sustained release preparation of a Class B corticosteroid corticosteroid for at least 14 days at a rate that does not comprising a lactic acid-glycolic acid copolymer micropar adversely suppress the hypothalamic-pituitary-adrenal axis ticle containing the Class B corticosteroid, wherein the Class (HPA axis). B corticosteroid comprises between 22% to 28% of the In some embodiments, the population of microparticles, lactic acid-glycolic acid copolymer microparticle matrix; (ii) 65 the controlled or Sustained release preparation or formula a controlled or Sustained release preparation of a Class A tion is administered as one or more intra-articular injections. corticosteroid comprising a lactic acid-glycolic acid copo In some embodiments, the patient has osteoarthritis, rheu US 9,555,047 B2 21 22 matoid arthritis, acute gouty arthritis, and synovitis. In some example, the spinning disk is the spinning disk as described embodiments, the patient has acute bursitis, Sub-acute bur in U.S. Pat. Nos. 7,261,529 and 7,758,778. sitis, acute nonspecific tenosynovitis, or epicondylitis. For the Class B corticosteroid microparticle formulations, The invention also provides methods to slow, arrest, in some embodiments where the Class B corticosteroid is reverse or otherwise inhibit progressive structural tissue TCA, the microparticles are manufactured using a solid in damage associated with chronic inflammatory disease, for oil in water emulsion process wherein TCA is dispersed in example, damage to cartilage associated with osteoarthritis. a lactic acid-glycolic acid copolymer organic Solution and In one embodiment, the method includes the administration added to an aqueous solvent to produce microparticles. to a patient, for example local administration, of a thera For the Class A, C and/or D corticosteroid microparticle peutically effective amount of one or more corticosteroids in 10 formulations, in some embodiments, the microparticles are a formulation, wherein the formulation releases the corti manufactured as described in the Examples provided below. costeroid(s) for at least 14 days at a rate that does not For Class A, C and/or D corticosteroid formulations, in some adversely suppress the hypothalamic-pituitary-adrenal axis embodiments, the microparticles are manufactured as described in PCT Publication No. WO95/13799, the con (HPA axis). The methods to assess the effect of corticoster 15 tents of which are hereby incorporated by reference in their oid formulations on disease progression include controlled entirety. For example, the microparticles are manufactured clinical studies that assess clinical end points and/or employ using a solid in oil in water emulsion process wherein the imaging technologies such as, for example Magnetic Reso Class Acorticosteroid, Class C corticosteroid and/or Class D nance Imaging (MRI), to determine effects on the structure corticosteroid is dispersed in a lactic acid-glycolic acid in chronically inflamed tissues, for example the effects on copolymer organic solution and added to an aqueous solvent cartilage Volume and other articular and peri-articular struc to produce microparticles. tures in osteoarthritis and rheumatoid arthritis. (See e.g., It is contemplated that whenever appropriate, any Eckstein F, et al. “Magnetic resonance imaging (MRI) of embodiment of the present invention can be combined with articular cartilage in knee osteoarthritis (OA): morphologi one or more other embodiments of the present invention, cal assessment.” Osteoarthritis Cartilage 14 Suppl A 25 even though the embodiments are described under different (2006): A46-75; Lo GH, et al. “Bone marrow lesions in the aspects of the present invention. knee are associated with increased local bone density.” Arthritis Rheum 52 (2005): 2814-21; and Lo GH, et al. “The BRIEF DESCRIPTION OF THE FIGURES ratio of medial to lateral tibial plateau bone mineral density and compartment-specific tibiofemoral osteoarthritis.” 30 FIG. 1 is a graph depicting the intra-articular concentra Osteoarthritis Cartilage 14 (2006): 984-90 the contents of tions (top Solid line) and the systemic concentrations (bot each of which are hereby incorporated by reference in their tom solid line) of the glucocorticoid administered according entirety.) The corticosteroid microparticle formulations pro to certain embodiments of the present invention following vided herein appear to exhibit little to no negative effects, intra-articular injection. The systemic glucocorticoid con e.g., structural tissue damage, and from preliminary data and 35 centration associated with clinically significant Suppression studies described in the Examples below, these corticoster of the HPA axis is shown as the bottom dotted line. The top oid microparticle formulations appear to have a positive dotted line represents the minimal intra-articular concentra effect, e.g., slowing, arresting or reversing structural tissue tion required to maintain efficacy (defined as relief of pain damage. and inflammation, or slowing, arrest, or reversal of structural The invention also provides methods of treating pain 40 damage to tissues caused by inflammatory diseases. Sus and/or inflammation of a patient by administering to the tained release of the corticosteroid provides sufficient intra patient a therapeutically effective amount of one or more articular concentrations to maintain efficacy in the longer corticosteroids in a formulation, wherein the formulation term, and has transient, clinically insignificant effect on the releases the corticosteroid(s) for at least 14 days at a rate that HPA axis. does not adversely Suppress the hypothalamic-pituitary 45 FIG. 2 is a graph depicting the change in sensitivity over adrenal axis (HPA axis). time to Suppression of endogenous cortisol production The invention also provides methods of manufacturing (ECs (ng/mL) vs. time) for triamcinolone acetonide 40 mg the corticosteroid microparticle formulations. The micropar given by intra-articular administration. ticle formulations provided herein can be manufactured FIG. 3 is a graph depicting the change in sensitivity over using any of a variety of Suitable methods. 50 time to Suppression of endogenous cortisol production For the Class B corticosteroid microparticle formulations, (ECso (ng/mL) vs. time) for various corticosteroids admin in Some embodiments, the microparticles are manufactured istered as a single, intra-articular injection in the listed dose. as described in the Examples provided below. For the Class FIGS. 4A-4F are a series of graphs depicting plasma B corticosteroid microparticle formulations, in some levels of endogenous cortisol over time, without (FIGS. 4A, embodiments, the microparticles are manufactured as 55 4C, and 4E) adjustment for a change in the sensitivity of the described in U.S. Pat. Nos. 7,261,529 and 7,758,778, the HPA axis after intra-articular corticosteroids and with contents of each of which are hereby incorporated by (FIGS. 4B, 4D, and 4F) adjustment for a change in the reference in their entirety. For example, the microparticles sensitivity of the HPA axis after intra-articular corticoster are manufactured using a solvent evaporation process oids. These data demonstrate that the sensitivity of the HPA wherein the Class B corticosteroid is dispersed in a lactic 60 axis varies with corticosteroid, dose, and time with clinically acid-glycolic acid copolymer organic Solution and the mix important implications for the selection of doses for Sus ture is treated to remove the solvent from the mixture, tained delivery into an intra-articular space. thereby producing microparticles. FIG. 5 is a graph depicting the cumulative percent release In some embodiments, the solvent evaporation process of a nominal 25% (w/w) triamcinolone acetonide in PLGA utilizes a spray drying or fluid bed apparatus to remove the 65 75:25 microparticles. Solvent and produce microparticles. In some embodiments, FIG. 6 is a graph depicting the calculated human dose to the solvent evaporation process utilizes a spinning disk. For achieve transient cortisol Suppression and within 14 days US 9,555,047 B2 23 24 achieve less than 35% cortisol Suppression using nominal FIG. 17 is a graph depicting cumulative percent triamci 25% TCA PLGA 75:25 microparticles. The dotted lines nolone acetonide release of nominal 40%, 25%. 20%, 15% represent, from top to bottom of the graph, 50% cortisol and 10% TCA containing PLGA 75:25 microparticles. inhibition dose, 40% cortisol inhibition dose, 35% cortisol FIG. 18 is a graph depicting cumulative percent release of inhibition dose and 5% cortisol inhibition dose. nominal 25% TCA PLGA 75:25 (29 kDa) and PLGA 75:25 FIG. 7 is a graph depicting calculated human dose that (54 kDa) containing microparticles. does not affect the HPA axis, less than 35% cortisol Sup FIG. 19 is a graph depicting cumulative percent release of pression using nominal 25% TCA PLGA 75:25 micropar triamcinolone acetonide in PLGA 50:50 microparticle for ticles. The dotted lines represent, from top to bottom of the mulations. 10 FIG. 20 is a graph depicting cumulative percent release of graph, 50% cortisol inhibition dose, 40% cortisol inhibition nominal 28.6% triamcinolone acetonide in PLGA 75:25 plus dose, 35% cortisol inhibition dose and 5% cortisol inhibition Triblock microparticle formulations. dose. FIG. 21 is a graph depicting calculated human dose to FIG. 8 is a graph depicting cumulative percent release of achieve transient cortisol Suppression and within 14 days a second preparation of nominal 25% triamcinolone 15 achieve less than 35% cortisol Suppression using nominal acetonide in PLGA 75:25 microparticles using an alternate 28.6% TCA 10% Triblock/PLGA 75:25 microparticles. The preparation. dotted lines represent, from top to bottom of the graph, 50% FIG. 9 is a graph depicting calculated human dose to cortisol inhibition dose, 40% cortisol inhibition dose, 35% achieve transient cortisol Suppression and within 14 days cortisol inhibition dose and 5% cortisol inhibition dose. achieve less than 35% cortisol Suppression using a second FIG. 22 is a graph depicting calculated human dose to preparation of nominal 25% TCA PLGA 75:25 micropar achieve transient cortisol Suppression and within 14 days ticles made by an alternate preparation. The dotted lines achieve less than 35% cortisol Suppression using nominal represent, from top to bottom of the graph, 50% cortisol 28.6% TCA 20% Triblock/PLGA 75:25 microparticles. The inhibition dose, 40% cortisol inhibition dose, 35% cortisol dotted lines represent, from top to bottom of the graph, 50% inhibition dose and 5% cortisol inhibition dose. 25 cortisol inhibition dose, 40% cortisol inhibition dose, 35% FIG. 10 is a graph depicting: calculated human dose that cortisol inhibition dose and 5% cortisol inhibition dose. does not affect the HPA axis, less than 35% cortisol Sup FIG. 23 is a graph depicting calculated human dose that pression using a second preparation of nominal 25% TCA does not affect the HPA axis, less than 35% cortisol Sup PLGA 75:25 microparticles made by an alternate prepara pression using nominal 28.6% TCA 10% Triblock/PLGA tion. The dotted lines represent, from top to bottom of the 30 75:25 microparticles. The dotted lines represent, from top to graph, 50% cortisol inhibition dose, 40% cortisol inhibition bottom of the graph, 50% cortisol inhibition dose, 40% dose, 35% cortisol inhibition dose and 5% cortisol inhibition cortisol inhibition dose, 35% cortisol inhibition dose and 5% dose. cortisol inhibition dose. FIG. 11 is a graph depicting cumulative percent release of FIG. 24 is a graph depicting calculated human dose that nominal 25% triamcinolone acetonide in 5% PEG 1450/ 35 does not affect the HPA axis, less than 35% cortisol Sup PLGA 75:25 microparticles. pression using nominal 28.6% TCA 20% Triblock/PLGA FIG. 12 is a graph depicting cumulative percent release of 75:25 microparticles. The dotted lines represent, from top to nominal 25% triamcinolone acetonide in 10% PEG 33507 bottom of the graph, 50% cortisol inhibition dose, 40% PLGA 75:25 microparticles. cortisol inhibition dose, 35% cortisol inhibition dose and 5% FIG. 13 is a graph depicting calculated human dose to 40 cortisol inhibition dose. achieve transient cortisol Suppression and within 14 days FIG.25 is a graph depicting cumulative percent release of achieve less than 35% cortisol Suppression using nominal nominal 16.7% triamcinolone acetonide in mixed molecular 25% TCA 5% PEG 1450/PLGA 75:25 microparticles. The weight PLGA 75:25 microparticle formulations. dotted lines represent, from top to bottom of the graph, 50% FIG. 26 is a graph depicting calculated human dose to cortisol inhibition dose, 40% cortisol inhibition dose, 35% 45 achieve transient cortisol Suppression and within 14 days cortisol inhibition dose and 5% cortisol inhibition dose. achieve less than 35% cortisol Suppression using nominal FIG. 14 is a graph depicting calculated human dose to 16.7%TCA mixed molecular weight PLGA 75:25 micropar achieve transient cortisol Suppression and within 14 days ticles. The dotted lines represent, from top to bottom of the achieve less than 35% cortisol Suppression using nominal graph, 50% cortisol inhibition dose, 40% cortisol inhibition 25% TCA 10% PEG 3350/PLGA 75:25 microparticles. The 50 dose, 35% cortisol inhibition dose and 5% cortisol inhibition dotted lines represent, from top to bottom of the graph, 50% dose. cortisol inhibition dose, 40% cortisol inhibition dose, 35% FIG. 27 is a graph depicting calculated human dose that cortisol inhibition dose and 5% cortisol inhibition dose. does not affect the HPA axis, less than 35% cortisol Sup FIG. 15 is a graph depicting calculated human dose that pression using nominal 16.7% TCA mixed molecular weight does not affect the HPA axis, less than 35% cortisol Sup 55 PLGA 75:25 microparticles. The dotted lines represent, from pression using nominal 25% TCA 5% PEG 1450/PLGA top to bottom of the graph, 50% cortisol inhibition dose, 75:25 microparticles. The dotted lines represent, from top to 40% cortisol inhibition dose, 35% cortisol inhibition dose bottom of the graph, 50% cortisol inhibition dose, 40% and 5% cortisol inhibition dose. cortisol inhibition dose, 35% cortisol inhibition dose and 5% FIG. 28 is a graph depicting cumulative percent release of cortisol inhibition dose. 60 nominal 28.6% triamcinolone acetonide in various polymer FIG. 16 is a graph depicting calculated human dose that microparticle formulations. does not affect the HPA axis, less than 35% cortisol Sup FIG. 29 is a graph depicting cumulative percent release of pression using nominal 25% TCA 10% PEG 3350/PLGA nominal 28.6% Prednisolone in PLGA 50:50 microparticle 75:25 microparticles. The dotted lines represent, from top to formulation. bottom of the graph, 50% cortisol inhibition dose, 40% 65 FIG. 30 is a graph depicting calculated human dose to cortisol inhibition dose, 35% cortisol inhibition dose and 5% achieve transient cortisol Suppression and within 14 days cortisol inhibition dose. achieve less than 35% cortisol Suppression using nominal US 9,555,047 B2 25 26 28.6% PRED PLGA 50:50 microparticles. The dotted lines pared to TCA IR. Concentrations for the first 72 hr are represent, from top to bottom of the graph, 50% cortisol presented in FIGS. 41C and 41D on a larger time scale. inhibition dose, 40% cortisol inhibition dose, 35% cortisol FIG. 42 is a graph depicting corticosteroid inhibition and inhibition dose and 5% cortisol inhibition dose. recovery with TCA IR (immediate release) and FX006 FIG. 31 is a graph depicting calculated human dose that (microparticle formulation) in rats. does not affect the HPA axis, less than 35% cortisol Sup FIG. 43 is a graph depicting the pharmacokinetic/phar pression using nominal 28.6% PRED PLGA 50:50 macodynamic (PK/PD) relationship of systemic TCA levels microparticles. The dotted lines represent, from top to bot and corticosterone inhibition. tom of the graph, 50% cortisol inhibition dose, 40% cortisol FIGS. 44A-44C are a series of graphs depicting the gait inhibition dose, 35% cortisol inhibition dose and 5% cortisol 10 analysis scores, an indicator of pain, in rats injected with inhibition dose. doses of either immediate release triamcinolone acetonide FIG. 32 is a graph depicting cumulative percent release of (TCA IR) or TCA microparticles (FX006) in a model of nominal 28.6% Betamethasone PLGA 50:50 microparticle osteoarthritis. In FIG. 44A, FX006 at 0.28, 0.12 and 0.03 mg formulation. (TCA doses) is expressed as TCA concentrations of the 15 dosing formulation (4.67. 2 and 0.5 mg/ml). In FIG. 44B, FIG. 33 is a graph depicting calculated human dose to FX006 at 0.28 mg (TCA dose) is expressed as TCA con achieve transient cortisol Suppression and within 14 days centrations of the dosing formulation (4.67 mg/ml). Simi achieve less than 35% cortisol Suppression using nominal larly, TCAIR at 0.03 mg is expressed as triamcinolone at 0.5 28.6% BETA PLGA 50:50 microparticles. The dotted lines mg/ml. In FIG. 44C, FX006 at 0.28, 0.12 and 0.03 mg (TCA represent, from top to bottom of the graph, 50% cortisol doses) is expressed as TCA concentrations of the dosing inhibition dose, 40% cortisol inhibition dose, 35% cortisol formulation (4.67. 2 and 0.5 mg/ml). Similarly, TCAIR at inhibition dose and 5% cortisol inhibition dose. 0.06 and 0.03 mg is expressed as triamcinolone at 1 and 0.5 FIG. 34 is a graph depicting calculated human dose that mg/ml. does not affect the HPA axis, less than 35% cortisol Sup FIG. 45 is a graph depicting peak pain response following pression using nominal 28.6% BETAPLGA 50:50 micropar 25 repeated reactivations of arthritis in the right knee. All ticles. The dotted lines represent, from top to bottom of the treatments were administered as a single IA dose in the right graph, 50% cortisol inhibition dose, 40% cortisol inhibition knee on Day 0. dose, 35% cortisol inhibition dose and 5% cortisol inhibition FIG. 46 is a graph depicting the time course of corticos dose. terone recovery for various groups in the rat Study in a model FIG. 35 is a graph depicting cumulative percent release of 30 of osteoarthritis. nominal 16.7% Fluticasone Propionate PLGA 50:50 FIGS. 47A-47B are a series of graphs depicting the microparticle formulation. plasma TCA concentration-time data for various groups in FIG. 36 is a graph depicting calculated human dose to the rat study in a model of osteoarthritis. Only the groups achieve transient cortisol Suppression and within 14 days that received injections of TCA microparticles (FX006 achieve less than 35% cortisol Suppression using nominal 35 groups) are shown in FIG. 47B on an expanded scale. 16.7% FLUT PLGA 50:50 microparticles. The dotted lines FIG. 48 is a graph depicting the end-of-study histopathol represent, from top to bottom of the graph, 50% cortisol ogy scores for various treatment groups in the rat Study in a inhibition dose, 40% cortisol inhibition dose, 35% cortisol model of osteoarthritis. inhibition dose and 5% cortisol inhibition dose. FIG. 37 is a graph depicting calculated human dose that 40 DETAILED DESCRIPTION OF THE does not affect the HPA axis, less than 35% cortisol Sup INVENTION pression using nominal 16.7% FLUT PLGA 50:50 micropar ticles. The dotted lines represent, from top to bottom of the The invention provides compositions and methods for the graph, 50% cortisol inhibition dose, 40% cortisol inhibition treatment of pain and inflammation using corticosteroids. dose, 35% cortisol inhibition dose and 5% cortisol inhibition 45 The compositions and methods provided herein use one or dose. more corticosteroids in a microparticle formulation. The FIG.38 is a graph depicting cumulative percent release of corticosteroid microparticle formulations provided herein various Fluticasone Propionate PLGA microparticle formu are effective at treating pain and/or inflammation with lations. minimal prolonged Suppression of the HPA axis and/or other FIG. 39 is a graph depicting cumulative percent release of 50 long term side effects of corticosteroid administration. The nominal 28.6% DEX PLGA 50:50 microparticle formula corticosteroid microparticle formulations provided herein tion. are effective in slowing, arresting, reversing or otherwise FIG. 40 is a graph depicting calculated human dose to inhibiting structural damage to tissues associated with pro achieve transient cortisol Suppression and within 14 days gressive disease with minimal prolonged suppression of the achieve less than 35% cortisol suppression and does not 55 HPA axis and/or other long term side effects of corticoster affect the HPA axis, less than 35% cortisol suppression using oid administration. The corticosteroid microparticle formu nominal 28.6% DEX PLGA 50:50 microparticles. The dot lations provided herein deliver the corticosteroid in a dose ted lines represent, from top to bottom of the graph, 50% and in a Sustained release manner Such that the levels of cortisol inhibition dose, 40% cortisol inhibition dose, 35% cortisol suppression are at or below 35% by day 14 post cortisol inhibition dose and 5% cortisol inhibition dose. 60 injection. In some embodiments, the corticosteroid FIGS. 41A-41D are a series of graphs depicting the mean microparticle formulations provided herein deliver the cor concentration-time profiles of various doses of TCAIR and ticosteroid in a dose and in a controlled or Sustained release FX006 in rat plasma following single intra-articular doses. manner Such that the levels of cortisol Suppression are A microparticle formulation of TCA in 75:25 PLGA formu negligible and/or undetectable by 14 post-injection. Thus, lation microparticles, referred to as FX006, dosed at 1.125 65 the corticosteroid microparticle formulations in these mg resulted in a very slow absorption of TCA in the embodiments are effective in the absence of any significant systemic circulation and a markedly lower C as com HPA axis suppression. Administration of the corticosteroid US 9,555,047 B2 27 28 microparticle formulations provided herein can result in an ordinary skill in the art to which this invention belongs. In initial “burst' of HPA axis suppression, for example, within the case of conflict, the present Specification will control. the first few days, within the first two days and/or within the Definitions first 24 hours post-injection, but by day 14 post-injection, The terms below have the following meanings unless suppression of the HPA axis is less than 35%. indicated otherwise. The use of microparticles to administer corticosteroids is An amount of a corticosteroid that does not “suppress the known (See, e.g., U.S. Patent Application Publication. No. hypothalamic-pituitary-adrenal axis (HPA axis) refers to 20080317805). In addition, corticosteroids are known to be the amount of the sustained release corticosteroid delivered useful for the symptomatic treatment of inflammation and locally to relieve pain due to inflammation, which provides 10 a systemic concentration that will not have a clinically pain. New data also suggest that synovitis may be associated significant effect or “adverse effect on the HPA axis. with the structural damage, for example, the deterioration of Suppression of the HPA axis is generally manifested by a cartilage and other peri-articular associated with the pro reduction in endogenous glucocorticoid production. It is gression of osteoarthritis and rheumatoid arthritis. (See e.g., useful to consider both basal and augmented production of Hill CL, et al. “Synovitis detected on magnetic resonance 15 endogenous glucocorticoids. Under ordinary, “unstressed imaging and its relation to pain and cartilage loss in knee conditions, glucocorticoid production occurs at a normal, osteoarthritis.” Ann Rheum Dis 66 (2007): 1599-603; van basal level. There is some natural variation of production den Berg W B, et al. “Synovial mediators of cartilage during the course of the 24-hour day. Under extraordinary, damage and repair in osteoarthritis.” In: Brandt K D. 'stressed’ conditions associated with, e.g., infection or Doherty M, Lohmander LS, eds. Osteoarthritis. Second ed. trauma and the like, augmented endogenous production of Oxford: Oxford University Press (2003): 147-55; Ayral X, et glucocorticoids occurs. Endogenous cortisol production al. “Synovitis: a potential predictive factor of structural may be determined by measuring glucocorticoid concentra progression of medial tibiofemoral knee osteoarthritis— tions in plasma, saliva, urine or by any other means known results of a 1 year longitudinal arthroscopic study in 422 in the art. It is known that systemic concentrations of patients.” Osteoarthritis Cartilage 13 (2005):361-7; and 25 corticosteroids can Suppress the HPA axis. For example, on Kirwan JR, et al. “Effects of glucocorticoids on radiological day 3 after an intra-articular injection of 20 mg triamcino progression in rheumatoid arthritis.” Cochrane Database lone hexacetonide plasma levels, of approximately 3-4 Syst Rev 2007: CD006356). ng/mL have been observed. These resulted in a transient but The administration of corticosteroids, particularly for highly statistically significant 75% HPA-axis suppression extended periods of time, can have a number of unwanted 30 (Derendorf et al., “Pharmacokinetics and pharmacodynam side effects. The HPA axis, the interdependent feedback ics of glucocorticoid Suspensions after intra-articular admin mechanism between the hypothalamus, the pituitary gland istration.” Clin Pharmacol Ther. 39 (3) (1986):313-7) and the adrenal cortex, may be suppressed by the adminis which, however, does not necessarily portend complete HPA tration of corticosteroids, leading to a variety of unwanted failure (Habib, "Systemic effects of intra-articular corticos side effects. The extent of HPA axis suppression, and related 35 teroids.” Clin Rheumatol 28 (2009): 749-756, see p 752 col. inhibition of endogenous cortisol production, has been 1, para 2, final sentence). While Such transient Suppression attributed to the potency of the corticosteroid, the dose, is generally considered to be acceptable without clinically systemic concentration, protein binding, rate of elimination significant effect, more persistent Suppression, i.e., weeks, (Meibohm et al. “Mechanism-based PK/PD model for the would be deemed clinically detrimental. In embodiments of lymphocytopenia induced by endogenous and exogenous 40 the present invention, administration of the formulation may corticosteroids.” IntJ Clin Pharmacol Ther. 37 (8) (1999): result in a clinically acceptable HPA Suppression, particu 367–76) and, for one corticosteroid, a change in sensitivity larly during the initial release period of the therapy. In some of the HPA axis (Derendorfetal. “Clinical PK/PD modelling embodiments of the present invention, administration of the as a tool in drug development of corticosteroids.” Int J Clin formulation will not result in any significant level of HPA Pharmacol Ther: 35 (10) 1997: 481-8). Furthermore, intra 45 Suppression, including no detectable HPA Suppression, par articular doses of corticosteroids associated with only lim ticularly during the initial release period of the therapy. ited anti-inflammatory and short-term analgesic benefit During the Subsequent or Sustained release period of the (Hepper et al. “The efficacy and duration of intra-articular therapy, additional corticosteroid may be released into the corticosteroid injection for knee osteoarthritis: a systematic plasma. However, the plasma levels during this period will review of level I studies.' J Am Acad Orthop Surg. 17 (10) 50 generally be less than those during the initial release period, 2009: 638-46) have been associated with HPA axis suppres if any corticosteroid release occurs, and will not be associ sion (Habib, "Systemic effects of intra-articular corticoster ated with HPA axis suppression. Further, the adverse events oids.” Clin Rheumatol. 28 (7) (2009): 749-56). associated with exogenous corticosteroid administration, The changes in sensitivity to corticosteroid effects over e.g., hyperglycemia, hypertension, altered mood, etc. will time should alter clinical steroid dosing, but prior to the 55 generally not be observed. Preferably, the number of clinical instant invention, this has not been understood. adverse events during this period will not substantially The details of one or more embodiments of the invention exceed the number achieved by an immediate release for are set forth in the accompanying description below. mulation alone or by KENALOGTM or its bioequivalent and Although any methods and materials similar or equivalent to will, preferably, be fewer than during the prior, initial release those described herein can be used in the practice or testing 60 period of the therapy, if any corticosteroid release occurs. of the present invention, the methods and materials are now Alternatively, one can determine the Suppression of the described. Other features, objects, and advantages of the formulation on HPA by measuring endogenous cortisol invention will be apparent from the description. In the production. Thus, the formulation can be considered as specification, the singular forms also include the plural avoiding clinically significant (or adverse) Suppression of unless the context clearly dictates otherwise. Unless defined 65 the HPA axis where the endogenous cortisol level is sub otherwise, all technical and scientific terms used herein have stantially the same in the steady state between a patient the same meaning as commonly understood by one of population receiving a therapeutically beneficial amount of US 9,555,047 B2 29 30 an immediate release formulation and those receiving a tion of symptoms as well as complete alleviation of the therapeutically beneficial amount of a Sustained release symptoms for a time period. The time period can be hours, formulation. Such a formulation would be deemed to have days, months, or even years. no clinically significant effect on the HPA axis. Alternatively By an “effective” amount or a “therapeutically effective or additionally, a small but measurable reduction in steady amount of a drug or pharmacologically active agent is state glucocorticoid production can result from the formu meant a nontoxic but Sufficient amount of the drug or agent lation during the sustained release period of the therapy with to provide the desired effect, e.g., analgesia. An appropriate adequate preservation of the augmented, stress response “effective” amount in any individual case may be deter needed during infection or trauma can be deemed a clini mined by one of ordinary skill in the art using routine 10 experimentation. cally insignificant Suppression of the HPA axis. Endogenous “Site of a patient’s pain” refers to any area within a body glucocorticoid production may be assessed by administering causing pain, e.g., a knee joint with osteoarthritis, nerve root various doses of adrenocorticotropin hormone or by other causing Sciatic pain, nerve fibers growing into annular tears tests known to those skilled in the art. Embodiments of the in discs causing back pain, temporomandibular joint (TMJ) current invention provide for controlling the release of 15 pain, for example TMJ pain associated with temporoman corticosteroid, as may be desired, to achieve either no dibular joint disorder (TMD) or pain radiating from epidural measurable effect on endogenous glucocorticoid production or perineural spaces. The pain perceived by the patient may or a target, or a measurable effect that is, however, without result from inflammatory responses, mechanical stimuli, adverse clinical consequence. In this regard, it has been chemical stimuli, thermal stimuli, as well as allodynia. found that intra-articular doses of corticosteroids that Sup Additionally, the site of a patient's pain can comprise one press cortisol production by 20-35%, and sometimes more, or multiple sites in the spine, such as between the cervical, provide very useful Sustained anti-inflammatory and anal thoracic, or lumbar vertebrae, or can comprise one or gesic activity. These benefits are achieved without acute multiple sites located within the immediate area of inflamed risks of hypoadrenalism and without excessive risks, after or injured joints such as the shoulder, hip, or other joints. Sustained intra-articular dosing, of developing an adrenal 25 A “biocompatible' material refers to a material that is not unresponsiveness in times of stress or of developing frank toxic to the human body, it is not carcinogenic and it should adrenal failure. induce limited or no inflammation in body tissues. A “bio As shown further below, the studies presented herein have degradable' material refers to a material that is degraded by demonstrated that the HPA axis sensitivity appears to dimin bodily processes (e.g., enzymatic) to products readily dis 30 posable by the body or absorbed into body tissue. The ish with time, Steroid, and dose. In this regard, it has been biodegraded products should also be biocompatible with the determined that standard doses of familiar corticosteroids, body. In the context of intra-articular drug delivery systems when examined from the viewpoint of steady-state HPA axis for corticosteroids, such polymers may be used to fabricate, Suppression (i.e., after desensitization has occurred), provide without limitation: microparticles, micro-spheres, matrices, clinically useful benchmarks. For example, while oral pred 35 microparticle matrices, micro-sphere matrices, capsules, nisolone given at 20 mg QD produces a 73% cortisol hydrogels, rods, wafers, pills, liposomes, fibers, pellets, or suppression, even 5 mg QD (considered a “low dose”) is other appropriate pharmaceutical delivery compositions that associated with a 40% suppression of endogenous cortisol a physician can administer into the joint. The biodegradable production. Doses at or below 5 mg of prednisolone per day polymers degrade into non-toxic residues that the body are generally considered to be well tolerated and are not 40 easily removes or break down or dissolve slowly and are associated with clinically meaningful HPA axis Suppression cleared from the body intact. The polymers may be cured (La Rochelle et al., “Recovery of the hypothalamic-pitu ex-vivo forming a solid matrix that incorporates the drug for itary-adrenal (HPA) axis in patients with rheumatic diseases controlled release to an inflammatory region. Suitable bio receiving low-dose prednisolone.” Am. J. Med. 95 (1993): degradable polymers may include, without limitation natural 258-264). Therefore, up to approximately 40% suppression 45 or synthetic biocompatible biodegradable material. Natural will be clinically well tolerated and very unlikely to be polymers include, but are not limited to, proteins such as associated with importantly adverse clinical events such as albumin, collagen, gelatin synthetic poly(aminoacids), and hypoadrenalism or soft-tissue or bony or metabolic changes prolamines; glycosaminoglycans, such as hyaluronic acid indicative of long-term glucocorticoid excess. and heparin; polysaccharides, such as alginates, chitosan, “Patient” refers to a human diagnosed with a disease or 50 starch, and dextrans; and other naturally occurring or chemi condition that can be treated in accordance to the inventions cally modified biodegradable polymers. Synthetic biocom described herein. In some embodiments it is contemplated patible biodegradable materials include, but are not limited that the formulations described herein may also be used in to, poly(lactide-co-glycolide) (PLGA), polylactide (PLA), horses. polyglycolide (PG), polyhydroxybutyric acid, poly(trimeth “Delivery” refers to any means used to place the drug into 55 ylene carbonate), polycaprolactone (PCL), polyvalerolac a patient. Such means may include without limitation, tone, poly(alpha-hydroxy acids), poly(lactones), poly placing matrices into a patient that release the drug into a (amino-acids), poly(anhydrides), polyketals poly(arylates), target area. One of ordinary skill in the art recognizes that poly(orthoesters), polyurethanes, polythioesters, poly(or the matrices may be delivered by a wide variety of methods, thocarbonates), poly(phosphoesters), poly(ester-co-amide), e.g., injection by a syringe, placement into a drill site, 60 poly(lactide-co-urethane, polyethylene glycol (PEG), poly catheter or canula assembly, or forceful injection by a gun vinyl alcohol (PVA), PVA-g-PLGA, PEGT-PBT copolymer type apparatus or by placement into a Surgical site in a (polyactive), methacrylates, poly(N-isopropylacrylamide), patient during Surgery. PEO-PPO-PEO (pluronics), PEO-PPO-PAA copolymers, The terms “treatment” and “treating a patient refer to and PLGA-PEO-PLGA blends and copolymers thereof and reducing, alleviating, stopping, blocking, or preventing the 65 any combinations thereof. The biocompatible biodegradable symptoms of pain and/or inflammation in a patient. As used material can include a combination of biocompatible bio herein, “treatment” and “treating includes partial allevia degradable materials. For example, the biocompatible bio US 9,555,047 B2 31 32 degradable material can be a triblock, or other multi-block, idiopathic nephrotic syndrome, or to induce diuresis or formation where a combination of biocompatible biodegrad remission of proteinuria in lupus erythematosus, berylliosis, able polymers are joined together. For example, the triblock symptomatic sarcoidosis, fulminating or disseminated pull can be PLGA-PEG-PLGA. monary tuberculosis (when used concurrently with appro Diseases that May be Treated Using the Formulations of 5 priate antituberculous chemotherapy), idiopathic eosino this Invention philic pneumonias, symptomatic sarcoidosis, Descriptions of various embodiments of the invention are dermatomyositis, polymyositis, and systemic lupus erythe given below. Although these embodiments are exemplified matosus, post-operative pain and Swelling. In one embodiment, the corticosteroid microparticle for with reference to treat joint pain associated with osteoar mulations provided herein are useful in treating, alleviating thritis, rheumatoid arthritis and other joint disorders, it 10 a symptom of ameliorating and/or delaying the progression should not be inferred that the invention is only for these of Sciatica. In one embodiment, corticosteroid microparticle uses. Rather, it is contemplated that embodiments of the formulations provided herein are useful in treating, allevi present invention will be useful for treating other forms of ating a symptom of ameliorating and/or delaying the pro joint pain by administration into articular and periarticular gression of temporomandibular joint disorder (TMD). spaces. In addition, it will be understood that for some 15 In one embodiment, the corticosteroid microparticle for embodiments injection near a joint may be equivalent to mulations provided herein are useful in treating, alleviating injections in that joint. It is also contemplated that embodi a symptom of ameliorating and/or delaying the progression ments of the present invention may be useful for injection or of neurogenic claudication secondary to lumbar spinal administration into Soft tissues or lesions. Any and all uses stenosis (LSS). LSS implies spinal canal narrowing with of specific words and references are simply to detail different possible Subsequent neural compression (classified by embodiments of the present invention. anatomy or etiology). Neurogenic Claudication (NC) is a Local administration of a corticosteroid microparticle hallmark Symptom of lumbar Stenosis, in which the column formulation can occur, for example, by injection into the of the spinal cord (or the canals that protect the nerve roots) intra-articular space, peri-articular space, Soft tissues, narrows at the lower back. This narrowing can also occur in lesions, epidural space, perineural space, or the foramenal 25 the spaces between the vertebrae where the nerves leave the space at or near the site of a patient’s pain and/or structural spine to travel to other parts of the body. The microparticles of the invention are used to treat, tissue damage. Local injection of the formulations described alleviate a symptom of ameliorate and/or delay the progres herein into articular or periarticular spaces may be useful in sion patients suffering from NC secondary to LSS. The the treatment of, for example, juvenile rheumatoid arthritis, corticosteroid microparticle formulations can be adminis sciatica and other forms of radicular pain (e.g., arm, neck, 30 tered, for example, by epidural steroid injection (ESI). lumbar, thorax), psoriatic arthritis, acute gouty arthritis, Administration of a corticosteroid microparticle formula Morton's neuroma, acute and subacute bursitis, acute and tion, e.g., a TCA microparticle formulation, to a patient Subacute nonspecific tenosynovitis and epicondylitis, acute Suffering from an inflammatory disease Such as osteoarthritis rheumatic carditis and ankylosing spondylitis. Injection of or rheumatoid arthritis, is considered Successful if any of a the microparticles described herein into soft tissues or 35 variety of laboratory or clinical results is achieved. For lesions may be useful in the treatment of for example, example, administration of a corticosteroid microparticle alopecia greata, discoid lupus, erythematosus; keloids, local formulation is considered successful if one or more of the ized hypertrophic, infiltrated inflammatory lesions of granu symptoms associated with the disease is alleviated, reduced, loma annulare, lichen planus, lichen simplex chronicus inhibited or does not progress to a further, i.e., worse, state. (neurodermatitis), psoriasis and psoriatic plaques; necrobio 40 Administration of a corticosteroid microparticle formulation sis lipoidica diabeticorum, and psoriatic arthritis. Injection is considered successful if the disease, e.g., an arthritic or of the microparticles described herein into epidural spaces other inflammatory disease, enters remission or does not may be useful in the treatment of for example, neurogenic progress to a further, i.e., worse, state. claudication. Intramuscular or other Soft tissues or lesions Also, any and all alterations and further modifications of injections may also be useful in providing systemic expo 45 the invention, as would occur to one of ordinary skill in the Sures that are effective in the control of incapacitating art, are intended to be within the scope of the invention allergic conditions (including but not limited to asthma, Selection of Corticosteroids and Drug Dosage atopic dermatitis, contact dermatitis, drug hypersensitivity Corticosteroids associated with embodiments of the pres reactions, seasonal or perennial allergic rhinitis, serum sick ent invention can be any naturally occurring or synthetic ness, transfusion reactions), bullous dermatitis herpetifor 50 steroid hormone. Naturally occurring corticosteroids are mis, exfoliative dermatitis, mycosis fungoides, pemphigus, secreted by the adrenal cortex or generally the human body. severe erythema multiforme (Stevens-Johnson syndrome), Corticosteroid molecules have the following basic struc Primary or secondary adrenocortical insufficiency in con ture: junction with mineralocorticoids where applicable; congeni tal adrenal hyperplasia, hypercalcemia associated with can 55 cer, nonsupportive thyroiditis, exacerbations of regional

(I) enteritis and ulcerative colitis, acquired (autoimmune) hemolytic anemia, congenital (erythroid) hypoplastic ane mia (Diamond blackfan anemia), pure red cell aplasia, select cases of secondary thrombocytopenia, trichinosis with neu 60 rologic or myocardial involvement, tuberculous meningitis with subarachnoid block or impending block when used concurrently with appropriate antituberculous chemo therapy, palliative management of leukemias and lympho mas, acute exacerbations of multiple Sclerosis, cerebral 65 edema associated with primary or metastatic brain tumor or craniotomy, to induce diuresis or remission of proteinuria in US 9,555,047 B2 33 34 Corticosteroids have been classified into four different predone acetate, itrocinonide, loteprednol etabonate, maZ groups (A, B, C, and D). (See e.g., Foti et al. “Contact ipredone, meclorisone, meclorisone dibutyrate, medrysone, Allergy to Topical Corticosteroids: Update and Review on meprednisone, mometasone, mometasone furoate, mometa Cross-Sensitization.” Recent Patents on Inflammation & Sone furoate monohydrate, nivacortol, paramethasone, Allergy Drug Discovery 3 (2009): 33-39; Coopman et al., paramethasone acetate, prednazoline, prednicarbate, predni “Identification of cross-reaction patterns in allergic contact Solone, prednylidene, procinonide, rofileponide, rimexolone, dermatitis to topical corticosteroids.” Br J Dermatol 121 timobesone, tipredane, tiXocortol, tiXocortol pivalate and (1989): 27-34). Class A corticosteroids are hydrocortisone tralonide. types with no modification of the D ring or C20-C21 or short Embodiments of the invention include using Sustained chain esters on C20-C21. Main examples of Class A corti 10 costeroids include prednisolone, hydrocortisone and meth release corticosteroids delivered to treat pain at dosages that ylprednisolone and their ester acetate, sodium phosphate and do not adversely suppress the HPA axis. Such amounts Succinate, cortisone, prednisone, and tixocortol pivalate. delivered locally to relieve pain due to inflammation, will Class B corticosteroids are triamcinolone acetonide (TCA) provide a systemic concentration that does not have a types with cis/ketalic or diolic modifications on C16-C17. 15 measurable adverse effect on the HPA axis (differences if Main examples of Class B corticosteroids include triamci any are not significant because any such differences are nolone acetonide (TCA), fluocinolone acetonide, amcinon within normal assay variability) or, as desired, may have a ide, desonide, fluocinonide, halcinonide, budesonide, and measurable but clinically insignificant effect on the HPA axis flunisolide. Class C corticosteroids are betamethasone types (basal cortisol is Suppressed to Some measurable extent but with a —CH3 mutilation on C16, but no esterification on stress responses are adequately preserved). Further embodi C17-C21. Main examples of Class C corticosteroids include ments of the invention include doses during a second period betamethasone, dexamethasone, desoxymethasone, fluocor of time selected to adjust for a change in sensitivity of the tolone, and halomethasone. Class D corticosteroids are HPA axis to Suppression following exposure during a first clobetasone or hydrocortisone esterified types with a long period of time to the corticosteroid (FIG. 1). chain on C17 and/or C21 and with no methyl group on C16. 25 Additional embodiments include doses during first and/or Main examples of Class D corticosteroids include flutica the second period of time selected to adjust for corticoster Sone, clobetaSone butyrate, clobetasol propionate, hydrocor oid-specific (or corticosteroid- and potentially dose-specific) tisone-17-aceponate, hydrocortisone-17-butyrate, beclom changes in the rate of change of sensitivity of the HPA axis ethasone dipropionate, betamethasone-17-valerate, to suppression that begin with initial exposure. For clinically betamethasone dipropionate, methylprednisolone ace 30 ponate, and prednicarbate. effective corticosteroids, the rate of change of the sensitivity For the present invention non-limiting examples of cor of the HPA axis to exogenous corticosteroids is both non ticosteroids may include: betamethasone, betamethasone uniform and non-linear (FIG. 2). The rate and pattern of acetate, betamethasone dipropionate, betamethasone 17-val change in Such sensitivity varies widely as a function of the erate, cortivaZol, dexamethasone, dexamethasone acetate, 35 particular corticosteroid that is selected (FIG. 3). dexamethasone sodium phosphate, hydrocortisone, hydro Finally, it is possible to usefully characterize the change cortisone aceponate, hydrocortisone acetate, hydrocortisone in sensitivity vs. time mathematically as the (non-linear, butyrate, hydrocortisone cypionate, hydrocortisone probu exponential) “decay” of the sensitivity from the initial to final value, wherein the decay parameters (Table 1) has been tate, hydrocortisone sodium phosphate, hydrocortisone determined from the data further described herein. Sodium Succinate, hydrocortisone Valerate, methylpredniso 40 lone, methylprednisolone aceponate, methylprednisolone acetate, methylprednisolone sodium Succinate, predniso TABLE 1. lone, prednisolone acetate, prednisolone metasulphobenzo HPA Axis Change-in-Sensitivity Decay-Parameter 8 vs. Corticosteroid ate, prednisolone sodium phosphate, prednisolone steaglate, and Dose' prednisolone tebutate, triamcinolone, triamcinolone 45 acetonide, triamcinolone acetonide 21-palmitate, triamcino Corticosteroid Decay Parameter ö (time') lone benetonide, triamcinolone diacetate, triamcinolone Betamethasone Phosphate/Acetate (7 mg) O.O24 hexacetonide, alclometasone, alclometaSone dipropionate, Triamcinolone Acetonide (40 mg) O.OOS amcinonide, amelometaSone, beclomethasone, beclometha Triamcinolone Hexacetonide (20 mg) O.O70 Sone dipropionate, beclomethasone dipropionate monohy 50 *The inhibition of endogenous cortisol synthesis can be related to the exogenous corticosteroid concentration by the following equations: drate, budesonide, butiXocort, butiXocort propionate, cicle 1. E = (E - C')/(EC50) + C wherein E = effect, E = maximal effect, C = Sonide, ciprocinonide, clobetasol, clobetasol propionate, concentration of exogenous corticosteroid, EC50= concentration at/2E, and n = the Hill “shape', or “slope”) factor; and clocortolone, clobetaSone, clobetaSone butyrate, clocor ECso final = EC50-initial + (EC50 final - EC50 initial (1 – e''" tolone pivalate, cloprednol, cortisone, cortisone acetate, deflazacort, domoprednate, deprodone, deprodone propi 55 Using this approach permits the determination of “6”, the onate, desonide, desoximethasone, desoxycortone, desoxy parameter describing the exponential decay from the initial cortone acetate, dichlorisone, diflorasone, diflorasone diac to the final ECs. Minimization of least-squares differences etate, diflucortolone, difluprednate, fluclorolone, was utilized to obtain the best-fit Ö. fluclorolone acetonide, fludrocortisone, fludrocortisone These new findings regarding the rate and pattern of acetate, fludroxycortide, flumethasone, flumethasone piva 60 change of sensitivity to inhibition and the lack of predict late, flunisolide, fluocinolone, fluocinolone acetonide, fluo ability of such rates and patterns on the basis of for cortin, fluocortolone, fluorometholone, fluticasone, flutica example, steroid potency, have significant implications for Sone furoate, fluticaSone propionate, fluorometholone clinically appropriate dose-selection. Those skilled in the art acetate, fluoxymesterone, fluperolone, fluprednidene, flu will appreciate the importance of a changing sensitivity to prednidene acetate, fluprednisolone, formocortal, halcinon 65 HPA axis suppression and will also appreciate both the ide, halobetasol propionate, halometasone, halopredone, complexity and counterintuitive aspects of several of these halopredone acetate, hydrocortamate, isoflupredone, isoflu new findings (Table 1). US 9,555,047 B2 35 36 As a result of these clinical findings, the dose range to calculated in Table 3 were purely hypothetical calculations achieve clinically useful analgesia, with minimal or con based on human data with immediate release-level doses trolled modulation of the HPA axis, at steady state concen from the literature. With sustained release dosages, more trations of various corticosteroids has been determined drug may be able to be delivered without seeing an increased (Table 2). In particular, it appears that the daily corticoster level of cortisol inhibition after the initial burst period. A oid doses at steady state concentrations, are approximately given level of plasma concentration may actually provide 3- to 7-times greater than are predicted by prior art (Mei less inhibition that would have been predicted or calculated bohm, 1999). using the human IR levels from the literature.

TABLE 2 10 TABLE 3 Dose (mg/d), adjusted for individual intra-articular corticosteroid Plasma corticosteroid concentrations associated with target levels of characteristics, for expected Suppression of endogenous cortisol production cortisol inhibition at steady state. at steady state. Corticosteroid Concentration Cortisol Inhibition (% 15 in Plasma (ng/mL) associated with the Target Levels of Corticosteroid 59% 10% 20% 35% SO% Cortisol Inhibition (% betamethasone (mg/d) O.1 O.2 O.S 1.O 1.8 Corticosteroid 59 10% 20%. 35% 50% budesonide (mg/d) O.1 O.2 O6 1.2 2.2 des-ciclesonide (mg/d) 3.0 6.3 14.3 30.7 57.0 betamethasone (ng mL) O.33 O.70 1.57 3.38 6.27 dexamethasone (mg/d) O.1 O.2 0.4 O.9 1.6 budesonide (ng/mL) O60 1.27 2.85 6.14 11.40 flunisonide (mg/d) O.3 O.S 1.2 2.6 4.8 des-ciclesonide (ng/mL) 0.55 1.16 2.61 S.63 10.45 fluticaSone (mg/d) O.1 O.1 O.3 O.6 1.1 dexamethasone (ng/mL) O.21 0.44 1.00 2.15 3.99 mometaSone (mg/d) O.2 0.4 O.9 2.0 3.7 flunisonide (ng/mL) O.18 O.38 O.86 1.84 3.42 methylprednisolone (mg/d) O.3 0.7 1.6 3.5 6.5 fluticaSone (ng/mL) O.04 O.08 O.19 O41 O.76 prednisolone (mg/d) 0.4 O.8 1.9 4.0 7.5 25 mometaSone (ng/mL) O.15 O.32 O.71 1.54 2.85 triamcinolone acetonide O.2 0.4 O.8 1.7 3.2 methylprednisolone (ng/mL) O.68 1.44 3.23 6.96 12.92 (mg/d) prednisolone (ng/mL) 1.64 3.46 7.79 16.79 31.16 triamcinolone hexacetonide 0.1 O.2 0.4 O.9 1.6 triamcinolone acetonide O.19 O.40 O.90 1.9S 3.61 (mg/d) (ng/mL) triamcinolone hexacetonide O.10 O.21 O.48 1.02 1.90 (ng/mL) 30 TABLE 2A The studies presented herein demonstrate for the first time Total Dose Delivered (mg/month), adjusted for individual intra-articular the discovery of the time-course of changes in sensitivity of corticosteroid characteristics, for expected Suppression of endogenous the HPA axis to exogenous corticosteroids. In addition, both cortisol production at steady state. 35 the mean doses and mean plasma levels shown in Tables 2 Cortisol Inhibition (% and 3 above are those after steady state has been achieved, requiring approximately 4 to 24 days depending upon the Corticosteroid 59% 10% 20% 35% SO% corticosteroid in question. The companion post-dose but betamethasone 3.0 6.O 1S.O 3O.O S4O pre-steady-state transients for several corticosteroids have budesonide 3.0 6.O 18.0 36.0 66.O 40 des-ciclesonide 90.0 1890 429.0 921.O. 1710.O been described in FIGS. 2, 3, and 4A-4F. It is also important dexamethasone 3.0 6.O 12.0 27.0 48.0 to note that the data Suggest that the carefully controlled flunisonide 9.0 1S.O 36.0 78.O 144.0 benefits from the intra-articular, Sustained release of a cor fluticaSone 3.0 3.0 9.O 18.0 33.0 nonetaSone 6.O 12.0 27.0 6O.O 111.0 ticosteroid of interest will persist as long as release contin CS. methylprednisolone 9.0 21.0 48.0 1OSO 195.0 45 prednisolone 12.0 24.0 57.0 12O.O 225.0 In one preferred embodiment, a single component Sus triamcinolone acetonide 6.O 12.0 24.0 S1.O 96.O tained release formulation releases a dose (in mg/day) that triamcinolone hexacetonide 3.0 6.O 12.0 27.0 48.0 suppresses the HPA axis by no more than between 5-40% at steady state as shown in Table 2, more preferably no more That higher doses of corticosteroids can be administered 50 than between 10-35% at steady state as shown in Table 2. Successfully by intra-articular injection, maximizing the These doses are therapeutically effective without adverse likelihood of observing anti-inflammatory and analgesic side effects. responses while minimizing or eliminating adverse events In another preferred embodiment, a single component from HPA axis suppression or otherwise excessive tissue Sustained release formulation releases a dose (in mg/day) exposure, is of profound clinical consequence for improving 55 that does not measurably suppress the HPA axis at steady the treatment of patients with arthritis. state. These doses are therapeutically effective without In addition, with these continuous daily doses of intra adverse side effects. articular corticosteroids, it is possible to determine the In another embodiment where both an immediate release related systemic plasma level concentrations (Table 3) that component and Sustained release component of the formu will produce the target cortisol inhibition and not beyond, 60 lation are present, immediate release dose would be as this while retaining clinically important anti-inflammatory shown in Table 4 and the sustained release dose would be a and analgesic activity within the joint. These plasma con dose (in mg/day) that Suppresses the HPA axis by no more centrations were predicted on the basis of data from short than between 5-40% as shown in Table 2, more preferably term (i.e., less than 8 days) exposure to corticosteroids. With no more than between 10-35% as shown in Table 2. In longer exposure to corticosteroids, the “decay” (i.e., decline) 65 addition, it is expected that Sustained release doses described of the sensitivity to corticosteroids may continue resulting in previously will follow immediate release doses as shown in values higher than those listed in Table 3. The levels Table 4. US 9,555,047 B2 37 38 TABLE 4 In the coacervation process, a Suitable biodegradable polymer is dissolved in an organic solvent. Suitable organic Immediate release relative doses (ng solvents for the polymeric materials include, but are not Immediate Release Dose limited to acetone, halogenated hydrocarbons such as chlo Corticosteroid (mg) roform and methylene chloride, aromatic hydrocarbons such as toluene, halogenated aromatic hydrocarbons such as betamethasone' S-20 budesonide 7-28 chlorobenzene, and cyclic ethers such as dioxane. The des-ciclesonide 177-713 organic solvent containing a suitable biodegradable polymer dexamethasone’ S-20 is then mixed with a non-solvent such as silicone based flunisonide? 15-60 10 Solvent. By mixing the miscible non-solvent in the organic fluticasone’ 3-12 mometasone’ 11-44 Solvent, the polymer precipitates out of Solution in the form methylprednisolone' 40-160 of liquid droplets. The liquid droplets are then mixed with prednisolone' 2S-100 another non-solvent, such as heptane or petroleum ether, to triamcinolone acetonide' 1O-40 form the hardened microparticles. The microparticles are triamcinolone hexacetonide' 1O-40 15 then collected and dried. Process parameters such as solvent 'clinical doses and non-solvent selections, polymer/solvent ratio, tempera 'calculated doses tures, stirring speed and drying cycles are adjusted to achieve the desired particle size, Surface Smoothness, and Sustained Release Delivery Platforms narrow particle size distribution. The manufacture of microparticles or methods of making In the phase separation or phase inversion procedures biodegradable polymer microparticles are known in the art. entrap dispersed agents in the polymer to prepare micropar Microparticles from any of the biodegradable polymers ticles. Phase separation is similar to coacervation of a listed below can be made by, but not limited to, spray drying, biodegradable polymer. By addition of a nonsolvent Such as Solvent evaporation, phase separation, spray drying, fluid petroleum ether, to the organic solvent containing a Suitable ized bed coating or combinations thereof. 25 biodegradable polymer, the polymer is precipitates from the In certain embodiments of the invention, the micropar organic solvent to form microparticles. ticles are made from a biodegradable polymer that may In the salting out process, a suitable biodegradable poly include, without limitation, natural or synthetic biocompat mer is dissolved in an aqueous miscible organic solvent. ible biodegradable materials. Natural polymers include, but Suitable water miscible organic solvents for the polymeric are not limited to, proteins such as albumin, collagen, gelatin 30 materials include, but are not limited to acetone, as acetone, synthetic poly(aminoacids), and prolamines; glycosamino acetonitrile, and tetrahydrofuran. The water miscible organic glycans, such as hyaluronic acid and heparin; polysaccha solvent containing a suitable biodegradable polymer is then rides, such as alginates, chitosan, starch, and dextrans; and mixed with an aqueous solution containing salt. Suitable other naturally occurring or chemically modified biodegrad salts include, but are not limited to electrolytes such as 35 magnesium chloride, calcium chloride, or magnesium able polymers. Synthetic biocompatible biodegradable acetate and non-electrolytes such as Sucrose. The polymer materials include, but are not limited to the group compris precipitates from the organic solvent to form microparticles, ing of poly(lactide-co-glycolide) (PLGA), polylactide which are collected and dried. Process parameters such as (PLA), polyglycolide (PG), polyhydroxybutyric acid, poly Solvent and salt selection, polymer/solvent ratio, tempera (trimethylene carbonate), polycaprolactone (PCL), poly 40 tures, stirring speed and drying cycles are adjusted to Valerolactone, poly(alpha-hydroxy acids), poly(lactones), achieve the desired particle size, Surface Smoothness, and poly(amino-acids), poly(anhydrides), polyketals poly(ary narrow particle size distribution. lates), poly(orthoesters), poly(orthocarbonates), poly(phos Alternatively, the microparticles may be prepared by the phoesters), poly(ester-co-amide), poly(lactide-co-urethane, process of Ramstack et al., 1995, described in published polyethylene glycol (PEG), polyvinyl alcohol (PVA). PVA 45 international patent application WO95/13799, the disclo g-PLGA, PEGT-PBT copolymer(polyactive), polyure sure of which is incorporated herein in its entirety. The thanes, polythioesters, methacrylates, poly(N-isopropy Ramstacket al. process essentially provides for a first phase, lacrylamide), PEO-PPO-PEO (pluronics), PEO-PPO-PAA including an active agent and a polymer, and a second phase, copolymers, and PLGA-PEO-PLGA blends and copolymers that are pumped through a static mixer into a quench liquid thereof, multi-block polymer configurations such as PLGA 50 to form microparticles containing the active agent. The first PEG-PLGA, and any combinations thereof. These polymers and second phases can optionally be substantially immis may be used in making controlled release or Sustained cible and the second phase is preferably free from solvents release compositions disclosed herein. for the polymer and the active agent and includes an aqueous In a preferred embodiment, the microparticles are formed Solution of an emulsifier. from poly(d.1-lactic-co-glycolic acid) (PLGA), which is 55 In the spray drying process, a suitable biodegradable commercially available from a number of sources. Biode polymer is dissolved in an organic solvent and then sprayed gradable PLGA copolymers are available in a wide range of through nozzles into a drying environment provided with molecular weights and ratios of lactic to glycolic acid. If not sufficient elevated temperature and/or flowing air to effec purchased from a supplier, then the biodegradable PLGA tively extract the solvent. Adding Surfactants, such as copolymers may be prepared by the procedure set forth in 60 Sodium lauryl Sulfate can improve the Surface Smoothness of U.S. Pat. No. 4.293,539 (Ludwig, et al.), the disclosure of the microparticles. which is hereby incorporated by reference in its entirety. Alternatively, a suitable biodegradable polymer can be Ludwig prepares Such copolymers by condensation of lactic dissolved or dispersed in Supercritical fluid. Such as carbon acid and glycolic acid in the presence of a readily removable dioxide. The polymer is either dissolved in a suitable organic polymerization catalyst (e.g., a strong acid ion-exchange 65 Solvent, such as methylene chloride, prior to mixing in a resin such as Dowex HCR-W2-H). However, any suitable suitable supercritical fluid or directly mixed in the super method known in the art of making the polymer can be used. critical fluid and then sprayed through a nozzle. Process US 9,555,047 B2 39 40 parameters such as spray rate, nozzle diameter, polymer/ water, saline, syrup, methyl cellulose, and carboxymethyl Solvent ratio, and temperatures, are adjusted to achieve the cellulose. An excipient for modulating the release rate of a desired particle size, Surface Smoothness, and narrow par corticosteroid from the biodegradable drug depot may also ticle size distribution. include without limitation pore formers, pH modifiers, In a fluidized bed coating, the drug is dissolved in an reducing agents, antioxidants, and free radical scavengers. organic solvent along with the polymer. The Solution is then processed, e.g., through a Wurster air Suspension coating Delivery of Corticosteroid Microparticles apparatus to form the final microcapsule product. Parenteral administration of formulations of the invention The microparticles can be prepared in a size distribution can be effected by intra-articular injection or other injection range suitable for local infiltration or injection. The diameter 10 using a needle. To inject the microparticles into a joint, and shape of the microparticles can be manipulated to needles having a gauge of about 14-28 gauge are suitable. It modify the release characteristics. In addition, other particle will be appreciated by those skilled in the art that formula shapes, such as, for example, cylindrical shapes, can also tions of the present invention may be delivered to a treat modify release rates of a sustained release corticosteroid by ment site by other conventional methods, including cath virtue of the increased ratio of Surface area to mass inherent 15 eters, infusion pumps, pens devices, injection guns and the to such alternative geometrical shapes, relative to a spherical like. shape. The microparticles have a mass mean diameter rang ing between about 0.5 to 500 microns. In a preferred All references, patents, patent applications or other docu embodiment, the microparticles have a mass mean diameter ments cited are hereby incorporated by reference. of between 10 to about 100 microns. Biodegradable polymer microparticles that deliver sus EXAMPLES tained release corticosteroids may be suspended in Suitable aqueous or non-aqueous carriers which may include, but is not limited to water, Saline, pharmaceutically acceptable The present invention is further defined in the following oils, low melting waxes, fats, lipids, liposomes and any other 25 Examples. It should be understood that these Examples, pharmaceutically acceptable Substance that is lipophilic, while indicating preferred embodiments of the invention, are substantially insoluble in water, and is biodegradable and/or given by way of illustration only. From the above discussion eliminatable by natural processes of a patient’s body. Oils of and these Examples, one skilled in the art can ascertain the plants such as Vegetables and seeds are included. Examples essential characteristics of this invention, and without include oils made from corn, Sesame, cannoli, soybean, 30 departing from the spirit and scope thereof, can make castor, peanut, olive, arachis, maize, almond, flax, saflower, various changes and modifications of the invention to adapt sunflower, rape, coconut, palm, babassu, and cottonseed oil; it to various uses and conditions. waxes such as carnoba wax, beeswax, and tallow; fats Such as triglycerides, lipids such as fatty acids and esters, and liposomes such as red cell ghosts and phospholipid layers. 35 Example 1 Corticosteroid Loading of and Release from Biodegradable Polymer Microparticles Sustained-Release Betamethasone or Triamcinolone When an intra-articularly delivered corticosteroid is Acetonide Microparticles incorporated into a biodegradable polymer for Sustained release into a joint at a dosage that does not suppress the 40 HPA axis, preferred loadings of said corticosteroid are from In one embodiment, the microparticle formulation con about 5% to about 40% (w/w) of the polymer, preferably tains a copolymer of DL-lactide (or L-lactide) and glycolide about 5% to about 30%, more preferably about 5% to about in a 45:55 molar ratio (up to 75:25 molar ratio) with an 28% of the polymer. inherent viscosity ranging from 0.15 to 0.60 dL/g with either As the biodegradable polymers undergo gradual bio 45 an ester or acid end group plus either the corticosteroid erosion within the joint, the corticosteroid is released to the betamethasone or triamcinolone acetonide. If betametha inflammatory site. The pharmacokinetic release profile of sone is used, then the betamethasone is in the form of either the corticosteroid by the biodegradable polymer may be first betamethasone acetate, betamethasone diproprionate or a order, Zero order, bi- or multi-phasic, to provide desired combination thereof. The total amount of betamethasone or treatment of inflammatory related pain. In any pharmacoki 50 triamcinolone acetonide incorporated into the microparticle netic event, the bio-erosion of the polymer and Subsequent ranges from 10% to 30% (w/w). The microparticles are release of the corticosteroid may result in a controlled formulated to mean mass range in size from 10 to 100 release of a corticosteroid from the polymer matrix. The rate microns. The population of microparticles is formulated to of release at dosages that do not suppress the HPA axis are be delivered through a 19 gauge or higher needle. Additional described above. 55 Excipients excipients may be added such as, but not limited to, car The release rate of the corticosteroid from a biodegrad boxymethylcellulose sodium, mannitol, polysorbate-80, able polymer matrix can be modulated or stabilized by Sodium phosphate, sodium chloride, polyethylene glycol to adding a pharmaceutically acceptable excipient to the for achieve isotonicity and promote Syringeability. If betame mulation. An excipient may include any useful ingredient 60 thasone is used, then the betamethasone incorporated into added to the biodegradable polymer depot that is not a the microparticle population provides an initial release corticosteroid or a biodegradable polymer. Pharmaceutically (burst) of about 5-20 mg of drug over a period of 1 to 12 acceptable excipients may include without limitation lac hours, followed by a steady state release of drug at a rate of tose, dextrose. Sucrose, Sorbitol, mannitol, starches, gum about 0.1 to 1.0 mg/day over a period of 14 to 90 days. If acacia, calcium phosphate, alginates, tragacanth, gelatin, 65 triamcinolone acetonide is used, then the drug incorporated calcium silicate, microcrystalline cellulose, PEG, polysor into the microparticle population provides an initial release bate 20, polysorbate 80, polyvinylpyrrolidone, cellulose, (burst) of about 10-40 mg of drug over a period of 1 to 12 US 9,555,047 B2 41 42 hours, followed by a steady state release of drug at a rate of micro-droplets by adding the dispersion to the feed well of about 0.2 to 1.7 mg/day over a period of 14 to 90 days. a rotating disk, rotating at a speed of approximately 3300 rpm inside a temperature controlled chamber maintained at Example 2 38-45° C. The solvent was evaporated to produce solid microparticles. The microparticles were collected using a Sustained-Release Betamethasone or Triamcinolone cyclone separator and, Subsequently, Sieved through a 150 Acetonide Microparticles with an Immediate um sieve. Release Form Particle size of the TCA incorporated microparticles was determined using laser diffraction (Malvern Mastersizer In another embodiment, the microparticle formulation of 10 2000) by dispersing a 250 mg aliquot in water, with the Example 1 is further admixed with an immediate release refractive index (RI) for water and PLGA, set at 1.33 and betamethasone or triamcinolone acetonide component. Such 1.46 respectively. Sonication was maintained as the sample as a betamethasone or triamcinolone acetonide containing was stirred at 2500 rpm and measurements taken every 15 solution. If betamethasone is used, then the betamethasone seconds, with the average of three measurements reported. in the immediate release component is in the form of either 15 10 mg of TCA containing microparticles were added to 10 betamethasone acetate, betamethasone diproprionate or a mL of dimethylsulfoxide (DMSO), mixed until dissolved combination thereof. If betamethasone is used, then the and an aliquot analyzed by HPLC to determine the micropar immediate release component provides an initial release of ticle drug load. Another 4 mg of TCA containing micropar a total of about 5 to 20 mg of betamethasone over the first ticles were suspended in 20 mL of phosphate buffered saline 1-10 days, while the Sustained release component releases (PBS) containing 0.5% sodium dodecyl sulfate (SDS) main betamethasone at a rate of about 0.1 to 1.0 mg/day over the tained at 37° C. 0.5 mL of the media was removed at regular first 14 to 90 days following administration. If triamcinolone intervals, replaced at each interval with an equivalent acetonide is used, then the immediate release component amount of fresh media to maintain a constant volume, and provides an initial release of a total of 10 to 40 mg of drug analyzed by HPLC to determine microparticle in vitro over the first 1-10 days, while the sustained release compo 25 release. Analysis by HPLC was conducted using a C18 nent releases drug at a rate of about 0.2 to 1.7 mg/day over (Waters Nova-Pack C-18, 3.9x150 mm) and 35% acetoni the first 14 to 90 days following administration. trile mobile phase at 1 ml/min flow rate with UV detection Example 3 at 240 nm. The results are shown in Table 5. 30 Determination of Time-Variance in HPA Axis TABLE 5 Sensitivity Analytical Results for 25% Triamcinolone Acetonide PLGA Z5:25 Microparticles Adult volunteers (N=4 to 9 per group) give appropriate PLGA informed consent. Each individual in each group receives a 35 (lactide:glycolide single intra-articular administration of an exogenous corti molar ratio costeroid (triamcinolone acetonide 40 mg. triamcinolone ratio inherent Drug viscosity load Incor hexacetonide 20; betamethasone 7 mg (disodium phosphate molecular (% TCA poration 4 mg/acetate 3 mg). Blood samples for measurement of weight target 96 by efficiency Particle size In vitro release corticosteroid concentrations and/or cortisol concentrations 40 TCA weight) (%) (DV, Im) (%) are drawn at 8 AM at baseline and on days 1, 7, 9, 10, 12, 75:25 carboxylic 24 96 D0.1: 32 m 0.2 day: 5.1 14, 18, and 21. The extent of Suppression of endogenous acid end-capped D0.5:49 lim 1 day: 13.5 cortisol was measured in each subject in each group. The 0.4 dLig D0.9: 73 lim 3 day: 29.6 extent of cortisol Suppression predicted by previously pub 54 kDa 7 day: 52.6 lished models (Meibohm, 1999) was determined and com 45 25% 14 day 70.9 pared to observations (FIGS. 4A, 4C, and 4E). The change 21 day: 76.4 (decrease) in HPA axis sensitivity vs. time is then deter 28 day: 79.1 mined on a day-by-day and final basis (FIGS. 4B, 4D, and 4F), permitting determination of the correct steady-state The in vitro cumulative release profile is graphed in FIG. intra-articular doses of corticosteroid to achieve, or limit, 50 5. HPA axis suppression to the desired level. In one iteration of these data, the amount of TCA released per day was calculated based on a human dose, as exem Example 4 plified in Table 2, that would achieve a transient suppression of endogenous cortisol (greater than 50%) and, within 14 Preparation of Triamcinolone Acetonide 55 days, achieve cortisol Suppression of endogenous cortisol of Microparticles by Spinning Disk less than 35% as shown in FIG. 6. In a second iteration of these data, the amount of triamcinolone acetonide released A pharmaceutical depot was prepared comprised of the per day was calculated based on a human dose, as exem corticosteroid, triamcinolone acetonide (TCA, 9C.-Fluoro plified in Table 2 that would not suppress the HPA axis, i.e. 11B, 16C.17C,21-tetrahydroxy-14-pregnadiene-320-dione 60 endogenous cortisol Suppression never exceeding 35% as 16,17-acetonide; 9C-Fluoro-16C.-hydroxyprednisolone 16C. shown in FIG. 7. These calculated doses equal 376 mg of 17O-acetonide) incorporated into PLGA microparticles. microparticles containing 94 mg of TCA and 80 mg of In one suitable thirty day formulation, 250 mg of triam microparticles containing 20 mg of TCA, respectively. cinolone acetonide and 750 mg of PLGA (lactide:glycolide In a second preparation of the same formulation, analyzed molar ratio of 75:25, inherent viscosity of 0.4 dL/g and 65 and in vitro release plotted in the same manner, the results molecular weight of 54 kDa) were dispersed in 14.25 grams are equivalent as shown in Table 6, and FIGS. 8, 9 and 10. of dichloromethane. The dispersion was atomized into The calculated human dose, as exemplified in Table 2 that US 9,555,047 B2 43 44 would achieve a transient suppression of endogenous corti TABLE 7 sol (greater than 50%) and, within 14 days, achieve cortisol Analytical Results of Nominal 25% Triamcinolone suppression of endogenous cortisol of less than 35% equals Acetonide PLGA 75:25 Microparticles containing 280 mg of microparticles containing 70 mg of TCA. The Polyethylene Glycol (PEG) Additive calculated human dose, as exemplified in Table 2 that would 5 PLGA not suppress the HPA axis, i.e. endogenous cortisol suppres (lactide:glycolide sion never exceeding 35% equals 68 mg of microparticles molar ratio Drug containing 17 mg of TCA. ratio inherent load viscosity/ (% Incor 10 molecular TCA poration TABLE 6 weight/target % by efficiency Particle size In vitro release TCA% PEG weight) (%) (Dv, um) (%) Analytical Results for Alternate Preparation of a Nominal 25% Triamcinolone Acetonide PLGA 75:25 Microparticles 75:25 carboxylic 29.4 118 D0.1: 36.2 pm 0.2 day: 3.6 acid end-capped D0.5: 59.0 m 1 day: 13.8 PLGA 15 0.4 dLig D0.9: 95.5 m 3 day: 30.1 (lactide:glycolide 54 kDa 7 day: 49.5 25% 14 day 65.5 molar ratio Drug 5% PEG 1450 21 day: 74.0 ratio inherent load 28 day: 78.5 viscosity/ (% Incor 75:25 carboxylic 24.5 98 D0.1: 32.0 m 0.2 day: 4.1 molecular TCA poration acid end-capped D0.5: 52.4 lim 1 day: 11.7 weight/target % by efficiency Particle size In vitro release 0.4 dLig D0.9: 79.0 m 3 day: 24.5 TCA weight) (%) (DV, Im) (%) 54 kDa 7 day: 40.8 25% 14 day: 55.8 10% PEG 3350 21 day: 63.7 75:25 carboxylic 27.5 110 D0.1: 30.9 m 0.2 day: 4.8 28 day: 69.5 acid end-capped D0.5: 48.2 pm 1 day: 15 0.4 dLig D0.9: 71.0 m 3 day: 28.5 25 54 kDa 7 day: 50.2 The in vitro cumulative release profile is graphed in FIG. 25% 14 day 67.1 11 and FIG. 12. PEG did not seem to enhance the release of 21 day: 74.2 the TCA in either formulation, as would be expected. In fact, 28 day: 75.7 at higher percentages of PEG, albeit a different molecular 30 weight (higher percentages of PEG 1350 were unmanage Influence of PEG on PLGA 75:25 Formulations: In other able due to the agglomeration of microparticles), the release suitable formulations, polyethylene glycol was added to the rate was slower. PLGA 75:25 polymers while keeping the target amount of In one iteration of these in vitro release data, the amount triamcinolone acetonide constant. PEG/PLGA blends are 35 of TCA released per day was calculated based on a human known to allow for more complete and faster release of dose, as exemplified in Table 2, that would achieve a pharmaceutical agents incorporated into microparticles than temporary suppression of endogenous cortisol (greater than PLGA alone (Cleek et al. “Microparticles of poly(DL-lactic 50%) and, within 14 days, achieve cortisol suppression of coglycolic acid)/poly(ethylene glycol) blends for controlled endogenous cortisol of less than 35% as shown in FIG. 13 drug delivery.” J. Control Release 48 (1997): 259-268; 40 and FIG. 14. These calculated doses equal 296 mg of Morlock, et al. “Erythropoietin loaded microspheres pre microparticles containing 74 mg of TCA and 316 mg of pared from biodegradable LPLG-PEO-LPLG triblock copo microparticles containing 79 mg of TCA, respectively. In a lymers: protein stabilization and in-vitro release properties.” second iteration of these data, the amount of triamcinolone J Control Release, 56 (1-3) (1998): 105-15; Yeh, “The acetonide released per day was calculated based on a human stability of insulin in biodegradable microparticles based on 45 dose, as exemplified in Table 2 that would not suppress the blends of lactide polymers and polyethylene glycol. J. HPA axis, i.e. endogenous cortisol suppression never Microencapsul, 17 (6) (2000): 743-56). exceeding 35% as shown in FIGS. 15 and 16. These calcu In one iteration, 250 mg of triamcinolone acetonide, 50 lated doses equal 68 mg of microparticles containing 17 mg mg of polyethylene glycol (PEG 1450) and 700 mg of PLGA 50 of TCA and 88 mg of microparticles containing 22 mg of (lactide:glycolide molar ratio of 75:25, inherent viscosity of TCA, respectively. 0.4 dL/g and molecular weight of 54 kDa) were dispersed in Other TCA containing formulations were tried with PEG 14 grams of dichloromethane. In another iteration, 250 mg and PLGA 75:25 without success. A PLGA microparticle of triamcinolone acetonide, 100 mg of polyethylene glycol formulation containing 25% TCA and 25% PEG 1450 (PEG 3350) and 650 mg of PLGA (lactide:glycolide molar 55 agglomerated during manufacture and storage. Another ratio of 75:25, inherent viscosity of 0.4 dL/g and molecular PLGA formulation containing 40% TCA and 15% PEG weight of 54 kDa) were dispersed in 13 grams of dichlo 1450 gave similar results to the microparticles containing romethane. The dispersions were atomized into micro-drop 40% TCA and no PEG. lets by adding the dispersion to the feed well of a rotating Influence of Triamcinolone Acetonide Content in PLGA disk, rotating at a speed of approximately 3300 rpm inside 60 75:25 Microparticles: a temperature controlled chamber maintained at 38-45° C. Triamcinolone acetonide containing microparticle depots The solvent was evaporated to produce solid microparticles. were prepared and analyzed, as described above, with the The microparticles were collected using a cyclone separator exception of using 100 mg, 150 mg, 200 mg and 400 mg and, subsequently, sieved through a 150 Lim sieve. 65 triamcinolone acetonide and adding to a 5% PLGA dichlo The microparticles were analyzed as described above and romethane solution. The physical characteristics of these the data is shown in Table 7. formulations are shown in Table 8. US 9,555,047 B2 45 46 TABLE 8 mately 3300 rpm inside a temperature controlled chamber maintained at 38-45° C. The solvent was evaporated to Analytical Results of PLGA 75:25 Microparticles containing produce Solid microparticles. The microparticles were col varying amounts of Triancinolone Acetonide lected using a cyclone separator and, Subsequently, sieved PLGA through a 150 um sieve. (lactide:glycolide Particle size of the TCA incorporated microparticles was molar ratio Drug determined using laser diffraction (Malvern Mastersizer ratio inherent load 2000) by dispersing a 250 mg aliquot in water, with the viscosity (% Incor molecular TCA poration refractive index (RI) for water and PLGA, set at 1.33 and weight target 96 by efficiency Particle size In vitro release 10 1.46 respectively. Sonication was maintained as the sample TCA weight) (%) (DV, Im) (%) was stirred at 2500 rpm and measurements taken every 15 seconds, with the average of three measurements reported. 75:25 carboxylic 43.4 109 D0.1: 40.7 m 0.2 day: 6.6 10 mg of TCA containing microparticles were added to 10 acid end-capped D0.5: 70.7 m ay: 24.2 mL of dimethylsulfoxide (DMSO), mixed until dissolved 0.4 dLig D0.9: 167 m 3 day: 53.8 and an aliquot analyzed by HPLC to determine the micropar 54 kDa 7 day: 82.5 15 40% 14 day 89.4 ticle drug load. Another 4 mg of TCA containing micropar 21 day: 89.6 ticles were suspended in 20 mL of phosphate buffered saline 28 day: 87.5 (PBS) containing 0.5% sodium dodecyl sulfate (SDS) main 75:25 carboxylic 2O2 101 D0.1: 28.7 m 0.2 day: 5.3 acid end-capped D0.5: 45.2 m ay: 13.5 tained at 37° C. 0.5 mL of the media was removed at regular 0.4 dLig D0.9: 70.5 m 3 day: 23.7 intervals, replaced at each interval with an equivalent 54 kDa 7 day: 35.3 amount of fresh media to maintain a constant volume, and 20% 14 day 44.4 analyzed by HPLC to determine microparticle in vitro 21 day: 48.1 release. Analysis by HPLC was conducted using a C18 28 day: 50.6 75:25 carboxylic 15.9 106 D0.1: 30.7 m 0.2 day: 3.9 (Waters Nova-Pack C-18, 3.9x150 mm) and 35% acetoni acid end-capped D0.5: 47.8 m ay: 9.0 trile mobile phase at 1 ml/min flow rate with UV detection 0.4 dLig D0.9: 74.8 m 3 day: 14.2 25 at 240 nm. The results are shown in Table 9. 54 kDa 7 day: 19.3 15% 14 day 22.7 TABLE 9 21 day: 24.6 28 day: 27.6 Analytical Results of a Nominal 25% Triamcinolone 75:25 carboxylic 11.7 117 D0.1: 31.0 m 0.2 day: 2.3 Acetonide PLGA 75:25 (29 kDa) Microparticles acid end-capped D0.5: 57.9 m ay: 4.4 30 0.4 dLig D0.9: 118 m 3 day: 5.9 PLGA 54 kDa 7 day: 7.5 (lactide:glycolide 10% 14 day 9.9 molar ratio Drug 21 day: 11.7 ratio inherent load 28 day: 15.8 viscosity (% Incor 35 molecular TCA poration weight target 96 by efficiency Particle size In vitro release The in vitro cumulative release profiles for these four TCA% PEG weight) (%) (DV, Im) (%) other TCA containing PLGA 75:25 microparticle depots are 75:25 carboxylic 29.4 118 D0.1: 34.1 um 0.2 day: 4.0 graphed in FIG. 17, along with the preferred formulation acid end-capped D0.5: 56.5 m 1 day: 11.3 (25% TCA). The tabulated data and graph show the impact 0.27 dLig D0.9: 95.2 m 3 day: 22.5 of the percent TCA incorporated in the PLGA microparticles 40 29 kDa 7 day: 35.9 on the in vitro release profile. The 10%, 15% and 20% TCA 25% 14 day: 48.3 containing PLGA microparticles exhibit a slower release 21 day: 53.4 profile, with a significant less cumulative release over 28 28 day: 56.5 days, less than 20%, 30% and 55% respectively, than the 25% TCA PLGA depot exemplified in Example 4. The 40% 45 In vitro cumulative release data is graphed in FIG. 18, TCA containing depot exhibits a faster release profile, with along with the preferred formulation using a higher molecu greater than 80% of the triamcinolone released by day 7 with lar PLGA 75:25. The use of lower molecular weight PLGA a similar total cumulative release, than the 25% TCAPLGA (29 kDa) did not improve the release of the triamcinolone depot exemplified in Example 4. acetonide from the microparticles as expected, in fact the Influence of Molecular Weight on TCA PLGA 75:25 50 rate of release decreased and the release was incomplete as Microparticle Formulations: In another microparticle for compared to higher molecular weight PLGA (PLGA, 54 mulation, triamcinolone acetonide was incorporated in kDa). PLGA of the same lactide to glycolide molar ratio as cited In another formulation of low molecular weight PLGA in Example 4 but of a lower molecular weight. Low molecu 75:25 (29 kDa), polyethylene glycol, 10% PEG 3350, was lar weight PLGA is known to allow for more complete and added while maintaining the same amount of triamcinolone faster release of pharmaceutical agents incorporated into 55 acetonide. As shown with other PEG containing formula microparticles than their higher molecular weight counter tions, there was no impact of this additive on the cumulative parts. (Anderson et al. “Biodegradation and biocompatibility percent in vitro release profile as compared to the formula of PLA and PLGA microspheres.” Advanced Drug Delivery tion not containing PEG (data not shown). Reviews 28 (1997): 5-24; Bouissou et al., “Poly(lactic-co Influence of PLGA Lactide to Glycolide Ratio: In other glycolicacid) Microspheres.’ Polymer in Drug Delivery 60 triamcinolone acetonide microparticle formulations, PLGA (2006): Chapter 7). of equimolar lactide to glycolide ratio were employed 250 mg of triamcinolone acetonide and 750 mg of PLGA instead of PLGA (75:25). PLGA (50:50) is known to allow (lactide:glycolide molar ratio of 75:25, inherent viscosity of for faster degradation and release of pharmaceutical agents 0.27 dL/g and molecular weight of 29 kDa) were dispersed incorporated into microparticles than PLGA's with greater in 14.25 grams of dichloromethane. The dispersion was 65 lactide versus glycolide content (Anderson et al. "Biodeg atomized into micro-droplets by adding the dispersion to the radation and biocompatibility of PLA and PLGA micro feed well of a rotating disk, rotating at a speed of approxi spheres.” Advanced Drug Delivery Reviews 28 (1997): 5-24: US 9,555,047 B2 47 48 Bouissou et al., “Poly(lactic-co-glycolicacid) Micro TABLE 10-continued spheres.’ Polymer in Drug Delivery (2006): Chapter 7). Multiple formulations using PLGA 50:50 with differing Analytical Results of Triamcinolone Acetonide PLGA amounts of triamcinolone acetonide, with and without PEG, 50:50 Microparticle Formulations different PLGA molecular weights and different PLGA 5 PLGA endcaps were exemplified. (lactide:glycolide Formulations were prepared with 200 mg, 250 mg. 300 molar ratio Drug ratio inherent load mg and 350 mg of triamcinolone acetonide and correspond viscosity (% Incor ing amount of PLGA (lactide:glycolide molar ratio of 50:50, molecular TCA poration inherent viscosity of 0.48 dL/g and molecular weight of 66 10 weight target 96 by efficiency Particle size In vitro release kDa) to yield 1000 mg total solids were dispersed into a TCA% PEG weight) (%) (DV, Im) (%) quantity of dichloromethane to a achieve a 5% PLGA 20% TCA 14 day: 21.0 solution. In another iteration, 300 mg of triamcinolone 21 day: 23.5 acetonide, 100 mg of polyethylene glycol (PEG 3350) and 28 day: 25.6 15 50:50 carboxylic 23.9 95.6 D0.1: 30.2 m 0.2 day: 4.0 650 mg of PLGA (lactide:glycolide molar ratio of 50:50, acid end-capped D0.5: 48.2 m ay: 7.8 inherent viscosity of 0.48 dL/g and molecular weight of 66 0.48 dLig D0.9: 75.8 m 3 day: 21.1 66 kDa 7 day: 32.1 kDa) were dispersed in 14.25 grams of dichloromethane. In 25% TCA 14 day: 39.2 another iteration, 300 mg of triamcinolone acetonide and 21 day: 40.0 700 mg of PLGA (lactide:glycolide molar ratio of 50:50, 28 day: 40.8 inherent viscosity of 0.18 dL/g and molecular weight of 18 50:50 carboxylic 29.3 97.6 D0.1: 31.5 m 0.2 day: 5.1 acid end-capped D0.5:48.0 m ay: 16.0 kDa) to yield 1000 mg total solids were dispersed in 14.25 0.48 dLig D0.9: 68.9 m 3 day: 33.6 grams of dichloromethane. The dispersions were atomized 66 kDa 7 day: 49.9 into micro-droplets by adding the dispersion to the feed well 30% TCA 14 day: 54.0 of a rotating disk, rotating at a speed of approximately 3300 21 day: 53.2 25 28 day: 52.2 rpm inside a temperature controlled chamber maintained at 50:50 carboxylic 27.2 91 D0.1: 37.6 m 0.2 day: 4.4 38-45° C. The solvent was evaporated to produce solid acid end-capped D0.5: 59.8 m ay: 9.8 microparticles. The microparticles were collected using a 0.18 dLig D0.9: 93.9 m 3 day: 13.8 cyclone separator and, Subsequently, Sieved through a 150 18 kDa 7 day: 17.7 30% TCA 14 day: 21.9 um sieve. 30 21 day: 26.3 Particle size of the TCA incorporated microparticles was 28 day: 36.6 determined using laser diffraction (Malvern Mastersizer 50:50 carboxylic 3O4 101 D0.1: 38.1 m 0.2 day: 4.2 2000) by dispersing a 250 mg aliquot in water, with the acid end-capped D0.5: 56.6 m ay: 14.6 refractive index (RI) for water and PLGA, set at 1.33 and 0.48 dLig D0.9:82.1 um 3 day: 32.2 1.46 respectively. Sonication was maintained as the sample 66 kDa 7 day: 51.0 35 30% TCA 14 day: 60.1 was stirred at 2500 rpm and measurements taken every 15 10% PEG 3350 21 day: 61.1 seconds, with the average of three measurements reported. 28 day: 60.1 50:50 carboxylic 34.4 98.3 D0.1: 35.1 pm 0.2 day: 7.1 10 mg of TCA containing microparticles were added to 10 acid end-capped D0.5: 52.3 lim ay: 23.3 mL of dimethylsulfoxide (DMSO), mixed until dissolved 0.48 dLig D0.9: 75.6 m 3 day: 47.6 and an aliquot analyzed by HPLC to determine the micropar 66 kDa 7 day: 66.9 ticle drug load. Another 4 mg of TCA containing micropar 40 35% TCA 14 day: 69.3 21 day: 68.3 ticles were suspended in 20 mL of phosphate buffered saline 28 day: 66.7 (PBS) containing 0.5% sodium dodecyl sulfate (SDS) main 50:50 ester 23.2 93 D0.1: 34.2 m 0.2 day: 3.1 tained at 37° C. 0.5 mL of the media was removed at regular endcapped D0.5: 51.7 m ay: 7.8 intervals, replaced at each interval with an equivalent 0.4 dLig D0.9: 77.4 m 3 day: 12.5 45 66 kDa 7 day: 15.4 amount of fresh media to maintain a constant volume, and 25% TCA 14 day: 16.2 analyzed by HPLC to determine microparticle in vitro 21 day: 16.0 release. Analysis by HPLC was conducted using a C18 28 day: 16.4 (Waters Nova-Pack C-18, 3.9x150 mm) and 35% acetoni trile mobile phase at 1 ml/min flow rate with UV detection 50 In-vitro release profiles of the various PLGA (50:50) at 240 nm. The results are shown in Table 10. formulations are shown in the FIG. 19. The use of PLGA (50:50) did not improve the release kinetics of the triamci TABLE 10 nolone acetonide as compared to the PLGA (75:25). Unex pectedly, 25% triamcinolone acetonide microparticles in Analytical Results of Triamcinolone Acetonide PLGA PLGA (50:50) release the corticosteroid at a slower rate and 50:50 Microparticle Formulations 55 give an incomplete release as compared to the equivalent PLGA amount of triamcinolone acetonide incorporated in PLGA (lactide:glycolide 75:25. All the PLGA 50:50 formulation show a Substantial molar ratio Drug lag phase, where little or any TCA is being released after 7 ratio inherent load days, which continues to about day 50. As observed with viscosity (% Incor 60 molecular TCA poration TCA PLGA 75:25 formulations, increasing the amount of weight target 96 by efficiency Particle size In vitro release TCA increases the rate of release and allows for more TCA TCA% PEG weight) (%) (DV, Im) (%) to be released before entering the lag phase. Similarly, the addition of PEG has minimal influence on the release rate of 50:50 carboxylic 19.2 96 D0.1: 30.0 m 0.2 day: 2.1 acid end-capped D0.5:48.5 m 1 day: 3.3 TCA, while lower molecular weight PLGA 50:50 decrease 0.48 dLig D0.9: 77.0 m 3 day: 17.0 65 the release rate as observed with PLGA 75:25 formulations. 66 kDa 7 day: 18.7 Based on the studies described herein, the Class B corti costeroid microparticle formulations, for example, the TCA US 9,555,047 B2 49 50 microparticle formulations, exhibiting the desired release (PLGA-PEG-PLGA). Triblock polymer was synthesized kinetics have the following characteristics: (i) the corticos using a method described by Zentner et al 2001 (Zentner et teroid is between 22%-28% of the microparticle; and (ii) the al. “Biodegradable block copolymers for delivery of pro polymer is PLGA having a molecular weight in the range of teins and water-insoluble drugs.' J Control Release 72 about 40 to 70 kDa, having an inherent viscosity in the range 5 (2001): 203-15) and refined by Hou et al 2008 (Hou et al., of 0.3 to 0.5 dL/g, and or having a lactide:glycolide molar “In situ gelling hydrogels incorporating microparticles as ratio of 80:20 to 60:40. drug delivery carriers for regenerative medicine. J Pharm Sci 97 (9) (2008): 3972-80). It is synthesized using a ring Example 5 opening polymerization of cyclic dimmers of D.L-lactide 10 Preparation of Triamcinolone Acetonide PLGA and glycolide with PEG 1,500 kDa in the presence of Microparticles by Solid in Oil in Water (S/O/W) Stannous octoate. In vitro release (lactide:glycolide molar Emulsion ratio of 50:50, inherent viscosity of 0.40 dL/g and molecular weight of 66 kDa). The analytical results for these formu lations are shown in Table 11. A pharmaceutical depot was prepared comprised of the 15 corticosteroid, triamcinolone acetonide (TCA, 9C.-Fluoro 11B, 16C.17C,21-tetrahydroxy-14-pregnadiene-320-dione TABLE 11 16,17-acetonide; 9C-Fluoro-16C.-hydroxyprednisolone 16C. Analytical Results of Nominal 28.6% Triamcinolone Acetonide 17O-acetonide) incorporated into microparticles. in PLGA 75:25 plus Triblock Microparticle Formulations Formulations were prepared by dissolving approximately PLGA 1 gram of PLGA in 6.67 mL of dichloromethane (DCM). To (lactide:glycolide the polymer Solution, 400 mg of triamcinolone acetonide molar ratio Drug was added and Sonicated. Subsequently, the corticosteroid ratio inherent load containing dispersion was poured into 200 mL of 0.3% viscosity (% Incor polyvinyl alcohol (PVA) solution while homogenizing with 25 molecular TCA poration a Silverson homogenizer using a rotor fixed with a Silverson weight target 96 by efficiency Particle size In vitro release Square Hole High Shear ScreenTM, set to rotate at approxi TCA% PEG weight) (%) (DV, Im) (%) mately 2,000 rpm to form the microparticles. After two 75:25 ester 23.8 83.2 D0.1: 38.9 m 1 day: 8.2 endcapped D0.5: 74.7 m 2 day: 14.2 minutes, the beaker was removed, and a glass magnetic 0.71 dLig D0.9: 103.0 m 3 day: 15.7 stirrer) added to the beaker, which was then placed onto a 30 114 kDa 4 day 18.2 multi-way magnetic stirrer and stirred for four hours at 300 28.6% TCA 6 day: 28.8 rpm to evaporate the DCM. The microparticles were then 10% Triblock 9 day: 38.9 12 day: 49.8 washed with 2 liters of distilled water, sieved through a 100 16 day: 61.6 micron screen. The microparticles were then lyophilized for 20 day: 66.4 greater than 96 hours and vacuum packed. 35 24 day: 68.7 Particle size of the TCA incorporated microparticles was 30 day: 72:3 35 day: 72.8 determined using laser diffraction (Beckman Coulter LS 75:25 ester 24.8 86.7 D0.1: 39.5 m 1 day: 5.5 230) by dispersing a 50 mg aliquot in water, with the endcapped D0.5: 74.6 m 2 day: 8.9 refractive index (RI) for water and PLGA, set at 1.33 and 0.71 dLig D0.9: 104.2 m 3 day: 12.8 1.46 respectively. The sample was stirred at the particle size 40 114 kDa 4 day 14.5 28.6% TCA 6 day: 28.4 measurement measurements taken and the results reported. 20% Triblock 9 day: 35.6 Drug load was determined by Suspending a nominal 10 mg (TB) 12 day: 47.8 of microparticles in 8 ml HPLC grade methanol and soni 16 day: 53.0 cating for 2 hours. Samples were then centrifuged at 14,000 20 day: 64.3 24 day: 67.3 g for 15 mins before an aliquot of the Supernatant was 45 30 day: 73.0 assayed via HPLC as described below. Corticosteroid 35 day: 73.0 loaded microparticle samples, nominally 1 g were placed in 22 ml glass vials in 8-20 ml of 0.5% v/v Tween 20 in 100 mM phosphate buffered saline and stored in a 37° C. The in vitro cumulative release profiles for both triblock incubator with magnetic stirring at 130 rpm. Each test 50 containing formulations are shown in FIG. 20. The amount sample was prepared and analyzed in duplicate to monitor of triblock in the tested formulations did not influence the possible variability. At each time point in the release study, cumulative percent release. microparticles were allowed to settle, and an aliquot of In one iteration of these data, the amount of TCA released between 4-16 ml of Supernatant were taken, and replaced per day was calculated based on a human dose, as exem with an equal volume of fresh 0.5% v/v Tween 20 in 100 55 plified in Table 2, that may achieve a temporary Suppression mM phosphate buffered saline. Drug load and in vitro of endogenous cortisol (greater than 50%) and, within 14 release samples were analyzed by HPLC using a Hypersil days, achieve cortisol Suppression of endogenous cortisol of C18 column (100 mm, i.d. 5 mm, particle size 5 um; less than 35%. These calculated doses equal 149 mg of ThermoFisher) and Beckman HPLC. All samples were run microparticles containing 35 mg of TCA and 252 micropar using a sample injection volume of 5 um, and column 60 ticles containing 62 mg of TCA, for the 10% and 20% temperature of 40° C. An isocratic mobile phase of 60% triblock formulations respectively (FIG. 21 and FIG. 22). In methanol and 40% water was used at a flow rate of 1 ml/min, a second iteration of these data, the amount of TCA released with detection at a wavelength of 254 nm. per day was calculated based on a human dose, as exem In one group of Suitable thirty day formulations, the plified in Table 2, that would not have an suppress the HPA PLGA is an ester end capped PLGA (lactide:glycolide molar 65 axis, i.e. endogenous cortisol Suppression more than 35%. ratio of 75:25, inherent viscosity of 0.71 dL/g and molecular These calculated doses equal 66 mg of microparticles con weight of 114 kDa) with 10% or 20% triblock (TB) polymer taining 16 mg of TCA and 47 microparticles containing 12 US 9,555,047 B2 51 52 mg of TCA, for the 10% and 20% triblock formulations 14 days. The PLGA 50:50 microparticles released about respectively (FIG. 23 and FIG. 24). 35% of its content by day 12 and then entered a lag phase In another suitable formulation lasting greater than 30 where no drug was released up to 30 days. The PLGA85:15 days and up to 90 days, the PLGA polymer consists of two microparticles exhibited similar in vitro release kinetics as different molecular weight PLGA 75:25 polymers in a two 5 the PLGA 50:50, releasing about 30% of its content by day to one ratio, PLGA 75:25 (lactide:glycolide molar ratio of 12 and then entered a lag phase where no drug was released 75:25, inherent viscosity of 0.27 dI/g and molecular weight up to 30 days (See FIG. 28). A similar phenomenon is seen of 29 kDa) and ester end capped PLGA 5.5E (lactide: as shown in Example 4, where the mixed molecular weight glycolide molar ratio of 75:25, inherent viscosity of 0.58 PLGA 75:25 unexpectedly exhibits faster initial release of dL/g and molecular weight of 86 kDa), respectively. The 10 the triamcinolone acetonide than PLGA 50:50. formulation was processed as described above with the Based on the studies described herein, the Class B corti exception that 200 mg of triamcinolone acetonide was used costeroid microparticle formulations, for example, the TCA in the formulation instead of 400 mg and similarly analyzed microparticle formulations, exhibiting the desired release as describe for other formulations. The results are shown in kinetics have the following characteristics: (i) the corticos the Table 12. teroid is between 12%-28% of the microparticle; and (ii) the 15 polymer is (1) PLGA having a molecular weight in the range TABLE 12 of about 40 to 70 kDa, having an inherent viscosity in the range of 0.3 to 0.5 dL/g, containing 10%-20% Triblock Analytical Results of a Nominal 16.7% Triamcinolone and/or having a lactide:glycolide molar ratio of 80:20 to Acetonide in Mixed Molecular Weight PLGA 75:25 60:40 or (2) a mixture of low and high molecular weight Microparticle Formulation PLGAs in a two to one ratio. The low molecular weight PLGA PLGA has a molecular weight of range of 15-35 kDa and an (lactide:glycolide inherent viscosity range from 0.2 to 0.35 dL/g, and the high molar ratio Drug molecular weight PLGA has a range of 70-95 kDa and an ratio inherent load inherent viscosity range of 0.5 to 0.70 dL/g. viscosity (% Incor molecular TCA poration 25 weight target 96 by efficiency Particle size In vitro release Example 6 TCA% PEG weight) (%) (DV, Im) (%) Preparation of Prednisolone PLGA Microparticles 75:25 ester 14.6 87.7 D0.1: 36.5 m 1 day: 12.4 endcapped D0.5: 54.0 m 2 day: 21.6 by Solid in Oil in Water (S/O/W) Emulsion 0.58 dLig D0.9: 69.4 m 3 day: 27.3 30 86 kDa 4 day 33.6 A pharmaceutical depot was prepared comprised of the And 6 day: 41.2 corticosteroid, prednisolone (PRED, 11B, 17.21-trihydroxy 75:25 carboxylic 9 day: 50.7 pregna-1,4-diene-320-dione) incorporated into micropar acid endcapped 12 day: 54.3 0.27 dLig 17 day: 62.0 ticles in PLGA 50:50. 29 kDa 20 day: 73.1 35 Formulations were prepared by dissolving approximately 16.7% TCA 25 day: 75.5 1 gram of PLGA 50:50 (lactide:glycolide molar ratio of 30 day: 82.9 50:50, inherent viscosity 0.44 dL/g, MW 56 kDa) in 6.67 mL 35 day: 84.6 of dichloromethane (DCM). To the polymer solution, 400 42 day: 87.4 mg of prednisolone was added and Sonicated. Subsequently, 49 day: 89.2 the corticosteroid containing dispersion was poured into 200 40 mL of 0.3% polyvinyl alcohol (PVA) solution while homog In vitro cumulative percent TCA release data is graphed enizing with a Silverson homogenizer using a rotor fixed in FIG. 25. with a Silverson Square Hole High Shear ScreenTM, set to In one iteration of these in vitro release data, the amount spin at 2,000 rpm to form the microparticles. After two of TCA released per day was calculated based on a human minutes, the beaker was removed, and a glass magnetic dose, as exemplified in Table 2, which may achieve a 45 stirrer) added to the beaker, which was then placed onto a temporary Suppression of endogenous cortisol (greater than multi-way magnetic stirrer and stirred for four hours at 300 50%) and, within 14 days, achieve cortisol suppression of rpm to evaporate the DCM. The microparticles were then endogenous cortisol of less than 35%. This calculated dose washed with 2 liters of distilled water, sieved through a 100 equals 317 mg of microparticles containing 46 mg of TCA. micron screen. The microparticles were then lyophilized for In a second iteration of these data, the amount of TCA 50 greater than 96 hours and vacuum packed. released per day was calculated based on a human dose, as Particle size of the PRED incorporated microparticles was exemplified in Table 2, that would not have an suppress the determined using laser diffraction (Beckman Coulter LS HPA axis, i.e. endogenous cortisol Suppression more than 230) by dispersing a 50 mg aliquot in water, with the 35%. This calculated dose equals 93 mg of microparticles refractive index (RI) for water and PLGA, set at 1.33 and containing 14 mg of TCA. 1.46 respectively. The sample was stirred at the particle size Several other triamcinolone acetonide PLGA depots were 55 measurement measurements taken and the results reported. formulated in the same manner as described above with Drug load was determined by Suspending a nominal 10 mg different polymers including polycaprolactone (14 kDa), of microparticles in 8 ml HPLC grade methanol and soni PLGA 50:50 (carboxylic acid end-capped, 0.44 dL/g, MW cating for 2 hours. Samples were then centrifuged at 14,000 56 kDa), PLGA 85:15 (carboxylic acid end-capped, 0.43 g for 15 mins before an aliquot of the Supernatant was dL/g, 56 kDa) and a mixed molecular weight formulation 60 assayed via HPLC as described below. Corticosteroid using PLGA 75:25 (carboxylic acid end capped, 0.27 dL/g, loaded microparticle samples, nominally 1 g were placed in MW 29 kDa) and PLGA 75:25 (ester end-capped, 0.57 dL/g, 22 ml glass vials in 8-20 ml of 0.5% v/v Tween 20 in 100 MW 86 kDa) in a two to one ratio. The in vitro cumulative mM phosphate buffered saline and stored in a 37° C. percent release of triamcinolone acetonide is shown in FIG. incubator with magnetic stirring at 130 rpm. Each test 28. None of these formulations were suitable for a nominal 65 sample was prepared and analyzed in duplicate to monitor thirty day or longer duration pharmaceutical depot. Poly possible variability. At each time point in the release study, caprolactone release all the triamcinolone acetonide prior to microparticles were allowed to settle, and an aliquot of US 9,555,047 B2 53 54 between 4-16 ml of Supernatant were taken, and replaced Example 7 with an equal volume of fresh 0.5% v/v Tween 20 in 100 mM phosphate buffered saline. Drug load and in vitro Preparation of Betamethasone PLGA Microparticles release samples were analyzed by HPLC using a Hypersil by Solid in Oil in Water (S/O/W) Emulsion C18 column (100 mm, i.d. 5 mm, particle size 5 um; 5 ThermoFisher) and Beckman HPLC. All samples were run A pharmaceutical depot was prepared comprised of the corticosteroid, betamethasone (BETA, 9-Fluoro-11B, 17.21 using a sample injection volume of 5 um, and column trihydroxy-16? 3-methylpregna-1,4-diene-3,20-dione) incor temperature of 40° C. An isocratic mobile phase of 60% porated into microparticles in PLGA 50:50. methanol and 40% water was used at a flow rate of 1 ml/min, A formulation was prepared by dissolving approximately with detection at a wavelength of 254 nm. The analytical 10 1 gram of PLGA 50:50 (lactide:glycolide molar ratio of results are shown in the Table 13. 50:50, inherent viscosity 0.44 dL/g, MW 56 kDa) in 6.67 mL of dichloromethane (DCM). To the polymer solution, 400 TABLE 13 mg of betamethasone was added and Sonicated. Subse quently, the corticosteroid containing dispersion was poured Analytical Results of a Nominal 28.6% Prednisolone in PLGA 15 into 200 mL of 0.3% polyvinyl alcohol (PVA) solution while 50:50 Microparticle Formulation homogenizing with a Silverson homogenizer using a rotor fixed with a Silverson Square Hole High Shear ScreenTM, set PLGA to spin at 2,000 rpm to form the microparticles. After two (lactide:glycolide minutes, the beaker was removed, and a glass magnetic molar ratio Drug stirrer) added to the beaker, which was then placed onto a ratio inherent load multi-way magnetic stirrer and stirred for four hours at 300 viscosity (% Incor rpm to evaporate the DCM. The microparticles were then molecular PRED poration washed with 2 liters of distilled water, sieved through a 100 weight target 96 by efficiency Particle size In vitro release micron screen. The microparticles were then lyophilized for TCA% PEG weight) (%) (DV, Im) (%) greater than 96 hours and vacuum packed. 50:50 carboxylic 19.0 66.4 D0.1: 34.4 lim 1 day: 7.2 25 Particle size of the BETA incorporated microparticles was acid endcapped D0.5: 66.9 lim 2 day: 11.5 determined using laser diffraction (Beckman Coulter LS 0.44 dLig D0.9:87.5 m 3 day: 15.6 230) by dispersing a 50 mg aliquot in water, with the 56 kDa 4 day: 20.2 refractive index (RI) for water and PLGA, set at 1.33 and 28.6% PRED 5 day: 24.0 1.46 respectively. The sample was stirred at the particle size 6 day: 28.4 measurement measurements taken and the results reported. 7 day: 32.7 30 Drug load was determined by Suspending a nominal 10 mg 9 day: 36.5 11 day: 41.4 of microparticles in 8 ml HPLC grade methanol and soni 13 day: 45.0 cating for 2 hours. Samples were then centrifuged at 14,000 15 day: 49.3 g for 15 mins before an aliquot of the Supernatant was 18 day: 52.0 assayed via HPLC as described below. Corticosteroid 21 day: 55.2 35 loaded microparticle samples, nominally 1 g were placed in 24 day: 58.3 22 ml glass vials in 8-20 ml of 0.5% v/v Tween 20 in 100 27 day: 62.3 mM phosphate buffered saline and stored in a 37° C. 30 day: 65.9 incubator with magnetic stirring at 130 rpm. Each test sample was prepared and analyzed in duplicate to monitor possible variability. At each time point in the release study, In vitro release profile of the prednisolone PLGA 40 microparticles were allowed to settle, and an aliquot of microparticles is shown in FIG. 29. This formulation is between 4-16 ml of Supernatant were taken, and replaced suitable for a 30 day formulation or greater. with an equal volume of fresh 0.5% v/v Tween 20 in 100 In one iteration of the cumulative percent in vitro release mM phosphate buffered saline. Drug load and in vitro release samples were analyzed by HPLC using a Hypersil data, the amount of prednisolone released per day was 45 calculated based on a human dose, as exemplified in Table C18 column (100 mm, i.d. 5 mm, particle size 5 um; 2, which may achieve a temporary Suppression of endog ThermoFisher) and Beckman HPLC. All samples were run using a sample injection Volume of 5 um, and column enous cortisol (greater than 50%) and, within 14 days, temperature of 40° C. An isocratic mobile phase of 60% achieve cortisol Suppression of endogenous cortisol of less methanol and 40% water was used at a flow rate of 1 ml/min, than 35% (FIG. 30). The calculated dose equals 699 mg of 50 with detection at a wavelength of 254 nm. The analytical microparticles containing 133 mg of PRED. In a second characteristics of the betamethasone PLGA microparticles iteration of these data, the amount of PRED released per day are shown in the Table 14. was calculated based on a human dose, as exemplified in Table 2 that would not suppress the HPA axis, i.e. endog TABLE 1.4 enous cortisol suppression of less than 35% (FIG. 31). This 55 calculated dose equals 377 mg of microparticles containing Analytical Results of a Nominal 28.6% Betamethasone PLGA 72 mg of PRED. 50:50 Microparticle Formulation Based on the studies described herein, the Class A corti PLGA costeroid microparticle formulations, for example, the pred (lactide:glycolide 60 molar ratio Drug nisolone microparticle formulations, exhibiting the desired ratio inherent load release kinetics have the following characteristics: (i) the viscosity (% Incor corticosteroid is between 10%-40% of the microparticle, for molecular BETA poration example, between 15%-30% of the microparticle; and (ii) weight target 96 by efficiency Particle size In vitro release the polymer is PLGA having a molecular weight in the range TCA% PEG weight) (%) (DV, Im) (%) of about 45 to 75 kDa, having an inherent viscosity in the 65 50:50 carboxylic 22.8 79.7 D0.1: 42.1 lim 1 day: 2.0 range of 0.35 to 0.5 dL/g, and or having a lactide:glycolide acid endcapped D0.5: 71.7 m 2 day: 3.1 molar ratio of 60:40 to 45:55. US 9,555,047 B2 55 56 TABLE 14-continued A formulation was prepared by dissolving approximately 1 gram of PLGA 50:50 (lactide:glycolide molar ratio of Analytical Results of a Nominal 28.6% Betamethasone PLGA 50:50, inherent viscosity 0.45 dL/g, molecular weight 66 50:50 Microparticle Formulation kDa) in 6.67 mL of dichloromethane (DCM). To the polymer PLGA Solution, 200 mg of fluticaSone propionate was added and (lactide:glycolide molar ratio Drug Sonicated. Subsequently, the corticosteroid containing dis ratio inherent load persion was poured into 200 mL of 0.3% polyvinyl alcohol viscosity (% Incor (PVA) solution while homogenizing with a Silverson molecular BETA poration homogenizer using a rotor fixed with a Silverson Square weight target 96 by efficiency Particle size In vitro release 10 TCA% PEG weight) (%) (DV, Im) (%) Hole High Shear ScreenTM, set to spin at 2,000 rpm to form the microparticles. After two minutes, the beaker was 0.44 dLig D0.9: 102.7 m 3 day: 4.8 56 kDa 4 day: 7.7 removed, and a glass magnetic stirrer) added to the beaker, 28.6% BETA 5 day: 12.5 which was then placed onto a multi-way magnetic stirrer and 6 day: 21.4 stirred for four hours at 300 rpm to evaporate the DCM. The 7 day: 30.8 15 9 day: 38.6 microparticles were then washed with 2 liters of distilled 11 day: 43.9 water, sieved through a 100 micron screen. The micropar 13 day: 49.6 ticles were then lyophilized for greater than 96 hours and 15 day: 55.5 vacuum packed. 18 day: 57.5 21 day: 59.2 Particle size of the FLUT incorporated microparticles was 24 day: 60.8 determined using laser diffraction (Beckman Coulter LS 27 day: 62.9 230) by dispersing a 50 mg aliquot in water, with the 30 day: 72.4 refractive index (RI) for water and PLGA, set at 1.33 and 1.46 respectively. The sample was stirred at the particle size 25 measurement measurements taken and the results reported. In vitro release profile of the betamethasone PLGA Drug load was determined by Suspending a nominal 10 mg microparticles is shown in FIG. 32. This formulation is of microparticles in 8 ml HPLC grade methanol and soni suitable for a 30 day formulation or greater. cating for 2 hours. Samples were then centrifuged at 14,000 In one iteration of the in vitro release data, the amount of g for 15 mins before an aliquot of the Supernatant was betamethasone released per day was calculated based on a 30 assayed via HPLC as described below. Corticosteroid human dose, as exemplified in Table 2, which may achieve loaded microparticle samples, nominally 1 g were placed in a temporary suppression of endogenous cortisol (greater 22 ml glass vials in 8-20 ml of 0.5% w/v. Tween 20 in 100 than 50%) and, within 14 days, achieve cortisol suppression mM phosphate buffered saline and stored in a 37° C. of endogenous cortisol of less than 35%. This calculated incubator with magnetic stirring at 130 rpm. Each test dose equals 111 mg of microparticles containing 25 mg of 35 sample was prepared and analyzed in duplicate to monitor betamethasone. In a second iteration of these data, the possible variability. At each time point in the release study, amount of betamethasone released per day was calculated microparticles were allowed to settle, and an aliquot of based on a human dose, as exemplified in Table 2 that would between 4-16 ml of Supernatant were taken, and replaced not suppress the HPA axis, i.e. endogenous cortisol Suppres with an equal volume of fresh 0.5% v/v Tween 20 in 100 40 mM phosphate buffered saline. Drug load and in vitro sion never exceeding 35%. This calculated dose equals 38 release samples were analyzed by HPLC using a Hypersil mg of microparticles containing 9 mg of betamethasone. C18 column (100 mm, i.d. 5 mm, particle size 5 um; These doses are both graphically represented in FIGS. 33 ThermoFisher) and Beckman HPLC. All samples were run and 34. using a sample injection Volume of 5 um, and column Based on the studies described herein, the Class C corti 45 temperature of 40° C. An isocratic mobile phase of 60% costeroid microparticle formulations, for example, the methanol and 40% water was used at a flow rate of 1 ml/min, betamethasone microparticle formulations, exhibiting the with detection at a wavelength of 254 nm. The analytical desired release kinetics have the following characteristics: results of the fluticasone propionate PLGA microparticles (i) the corticosteroid is between 10%-40% of the micropar are shown in Table 15. ticle, for example, between 15%-30% of the microparticle: 50 and (ii) the polymer is PLGA having a molecular weight in TABLE 1.5 the range of about 40 to 70 kDa, having an inherent viscosity in the range of 0.35 to 0.5 dL/g, and or having a lactide: Analytical Results of a Nominal 16.7% FluticasOne PLGA glycolide molar ratio of 60:40 to 45:55. 50:50 Microparticle Formulation 55 PLGA (lactide:glycolide Example 8 molar ratio Drug ratio inherent load viscosity (% Incor Preparation of Fluticasone Propionate PLGA molecular FLUT poration Microparticles by Solid in Oil in Water (S/O/W) 60 weight target 96 by efficiency Particle size In vitro release Emulsion FLUT weight) (%) (DV, Im) (%) 50:50 carboxylic 8.5 S1.1 D0.1: 34.1 um 1 day: 29.5 A pharmaceutical depot was prepared comprised of the acid endcapped D0.5: 65.5 m 2 day: 43.5 0.45 dLig D0.9: 95.0 m 3 day: 46.7 corticosteroid, fluticasone propionate (FLUT, S-(fluorom 66 kDa 4 day: 50.9 ethyl) 6C.9-difluoro-11B,17-dihydroxy-16C.-methyl-3-ox 65 16.7% FLUT 5 day: 55.5 oandrosta-1,4-diene-17f8-carbothioate, 17-propionate) 6 day: 58.6 incorporated into microparticles in PLGA 50:50. US 9,555,047 B2 57 58 TABLE 15-continued 8%-20% of the microparticle, and (ii) the polymer is PLGA having a molecular weight in the range of about 40 to 70 Analytical Results of a Nominal 16.7% FluticasOne PLGA kDa, having an inherent viscosity in the range of 0.35 to 0.5 50:50 Microparticle Formulation dL/g, and or having a lactide:glycolide molar ratio of 60:40 PLGA to 45:55. (lactide:glycolide molar ratio Drug ratio inherent load viscosity (% Incor Example 9 molecular FLUT poration weight target 96 by efficiency Particle size In vitro release 10 FLUT weight) (%) (DV, Im) (%) Preparation of Dexamethasone Microparticles by 7 day: 60.1 Solvent Dispersion in PLGA 9 day: 63 11 day: 66.8 A pharmaceutical depot was prepared comprised of the 13 day: 67.8 15 15 day: 68.7 corticosteroid, dexamethasone (DEX, 9-Fluoro-11B, 17.21 18 day: 73.7 trihydroxy-16C.-methylpregna-1,4-diene-320-dione) incor 21 day: 81.8 porated into microparticles in PLGA 50:50. 24 day: 93.7 26 day: 97.1 A formulation was prepared by dissolving approximately 31 day: 100.8 1 gram of PLGA 50:50 (lactide:glycolide molar ratio of 50:50, inherent viscosity 0.45 dL/g, molecular weight 66 In vitro release profile of the fluticasone propionate PLGA kDa) in 6.67 mL of dichloromethane (DCM). To the polymer microparticles is shown in FIG. 35. This formulation is Solution, 200 mg of dexamethasone was added and Soni suitable for a 30 day formulation or greater. cated. Subsequently, the corticosteroid containing dispersion In one iteration of the in vitro release data, the amount of 25 was poured into 200 mL of 0.3% polyvinyl alcohol (PVA) fluticasone propionate released per day was calculated based Solution while homogenizing with a Silverson homogenizer on a human dose, as exemplified in Table 2, which may using a rotor fixed with a Silverson Square Hole High Shear achieve a temporary Suppression of endogenous cortisol ScreenTM, set to spin at 2,000 rpm to form the microparticles. After two minutes, the beaker was removed, and a glass (greater than 50%) and, within 14 days, achieve cortisol 30 magnetic stirrer) added to the beaker, which was then placed suppression of endogenous cortisol of less than 35%. This onto a multi-way magnetic stirrer and stirred for four hours calculated dose equals 178 mg of microparticles containing at 300 rpm to evaporate the DCM. The microparticles were 15 mg of fluticasone propionate. In a second iteration of then washed with 2 liters of distilled water, sieved through these data, the amount of fluticasone propionate released per a 100 micron screen. The microparticles were then day was calculated based on a human dose, as exemplified 35 lyophilized for greater than 96 hours and vacuum packed. in Table 2 that would not suppress the HPA axis, i.e. Particle size of the DEX incorporated microparticles was endogenous cortisol Suppression never exceeding 35%. This determined using laser diffraction (Beckman Coulter LS calculated dose equals 24 mg of microparticles containing 2 230) by dispersing a 50 mg aliquot in water, with the mg of fluticasone propionate. These doses are both graphi 40 refractive index (RI) for water and PLGA, set at 1.33 and cally represented in FIGS. 36 and 37. 1.46 respectively. The sample was stirred at the particle size Other fluticasone propionate PLGA depots were formu measurement measurements taken and the results reported. lated in the same manner as described above with different Drug load was determined by Suspending a nominal 10 mg PLGA polymers or amounts fluticaSone propionate. In one of microparticles in 8 ml HPLC grade methanol and soni formulation, a PLGA polymer with a higher lactide to 45 cating for 2 hours. Samples were then centrifuged at 14,000 glycolide ratio (PLGA 75:25 (ester end-capped PLGA g for 15 mins before an aliquot of the Supernatant was 75:25, lactide:glycolide molar ratio of 75:25, 0.58 dL/g, assayed via HPLC as described below. Corticosteroid MW 86 kDa) was used instead of the PLGA 50:50 as loaded microparticle samples, nominally 1 g were placed in previously described. Unlike the triamcinolone acetonide 22 ml glass vials in 8-20 ml of 0.5% v/v Tween 20 in 100 preparations described in Example 5, but typically expected 50 mM phosphate buffered saline and stored in a 37° C. as described in the literature, the higher lactide to glycolide incubator with magnetic stirring at 130 rpm. Each test ratio resulted in a slower release, where 30% release in 14 sample was prepared and analyzed in duplicate to monitor days, followed by a Substantial lag phase where little drug is possible variability. At each time point in the release study, released for a minimum of thirty days. In another example, 55 microparticles were allowed to settle, and an aliquot of 400 mg of fluticasone propionate instead of 200 mg was between 4-16 ml of Supernatant were taken, and replaced used in preparation of PLGA 50:50 microparticles (target with an equal volume of fresh 0.5% v/v Tween 20 in 100 drug load 28.6%). Unlike triamcinolone acetonide micropar mM phosphate buffered saline. Drug load and in vitro ticle preparations, the higher drug load did not result in a release samples were analyzed by HPLC using a Hypersil significantly different release of fluticasone propionate; FIG. 60 C18 column (100 mm, i.d. 5 mm, particle size 5 um; 38 shows the in vitro release of all three fluticasone propi ThermoFisher) and Beckman HPLC. All samples were run onate formulations. using a sample injection Volume of 5 um, and column Based on the studies described herein, the Class D cor temperature of 40° C. An isocratic mobile phase of 60% ticosteroid microparticle formulations, for example, the flu methanol and 40% water was used at a flow rate of 1 ml/min, ticasone or fluticaSone propionate microparticle formula 65 with detection at a wavelength of 254 nm. The analytical tions, exhibiting the desired release kinetics have the results for the dexamethasone PLGA microparticles are following characteristics: (i) the corticosteroid is between shown in Table 16. US 9,555,047 B2 59 60 TABLE 16 microparticles containing 8 mg of dexamethasone. The doses are graphically represented in FIG. 40. Analytical Results of a Nominal 28.6% Dexamethasone PLGA 50:50 Microparticle Formulation Example 10 PLGA (lactide:glycolide Pharmacology, Pharmacokinetics and Exploratory molar ratio Drug Safety Study of Corticosteroid Formulations ratio inherent load viscosity (% Incor In an exploratory safety study in rats, single intra-articular molecular DEX poration (IA) doses of TCA immediate release (TCAIR) (0.18 and weight target 96 by efficiency Particle size In vitro release 10 1.125 mg) and doses of TCA in 75:25 PLGA formulation FLUT weight) (%) (DV, Im) (%) microparticles (FX006) (0.28, 0.56 and 1.125 mg (i.e., the 50:50 carboxylic 22.1 77.2 D0.1:41.2 m 1 day: 2.9 maximum feasible dose) of TCA) were evaluated. Blood acid endcapped D0.5: 71.9 m 2 day: 4.6 samples were collected at various time points for determi 0.45 dLig D0.9: 99.1 im 3 day: 6.3 nation of plasma concentrations. Plasma concentration-time 66 kDa 4 day: 8.7 15 28.6% DEX 5 day: 10.9 data from this study and pharmacokinetic (PK) analysis 6 day: 12.7 thereof are shown in FIGS. 41-43 and Tables 17-20. 7 day: 15.0 9 day: 16.4 As seen in FIGS. 41A-41D, FX006 dosed at 1.125 mg 11 day: 18.0 resulted in a very slow absorption of TCA in the systemic 13 day: 20.7 circulation and a markedly lower C as compared to TCA 15 day: 24.6 IR. 18 day: 26.2 21 day: 28.1 As shown in Table 17, the mean AUC, values of TCA 24 day: 30.3 following 1.125 mg administration of FX006 were 2.1-fold 27 day: 34.0 lower than those observed for TCAIR (i.e., 2856 vs. 6065 30 day: 46.3 ngth/mL, respectively). The mean C. values of TCA 25 following 1.125 mg administration of FX006 were 15-fold lower than those observed for TCA IR (i.e., 125 vs. 8.15 In vitro cumulative percent release of the dexamethasone ng/mL, respectively). The absorption of TCA following is shown in 39, and results in suitable formulation for a administration of FX006 was slower than that observed for minimum of thirty days and, assuming linear release, likely TCAIR, with mean T values observed at 3.33 and 1.00 up to 60 days. 30 h, respectively. The elimination half-life of TCA following In one iteration of the in vitro release data, the amount of administration of 1.125 mg FX006 and TCAIR were 451 dexamethasone released per day was calculated based on a and 107 h, respectively. TABLE 17 Summary of TCA Plasma Pharmacokinetic Parameters Treatment FX006 (0.28 mg FX006 (0.56 mg FX006 (1.125 mg) - TCAIR (0.18 mg) - TCAIR (1.125 mg Variable Mean (CV9%) Mean (CV 96) Mean (CV 96) Mean (CV 96) Mean (CV%) AUCo-24 31.0 (76.0) 33.0 (19.1) 136 (6.0). 297 (21.5) 1403 (13.2) (ng himL) AUCo. 356 (62.0) 572 (21.5) 2856 (17.2) 479 (32.6) 6065 (3.7) (ng himL) AUCo. 335 (66.5) 532 (23.8) 2142 (14.4) 456 (31.3) 6013 (3.4) (ng himL) CLF 1308 (96.6) 1014 (244) 403 (19.1) 400 (27.6) 186 (3.6) (mL/h) Cmax 1.82 (66.2) 1.91 (10.2) 8.15 (12.5) 41.6 (25.1) 125 (5.3) (ng/mL) T1/2 99.5 (39.9) 18O (27.0) 451 (20.8) 35.6 (63.5) 107 (56.7) (h) Tmax 17.7 (148.9) 16.7 (162.8) 3.38 (69.3) 2.00 (0.0) 1.00 (0.0) (h) V/F 274215 (117.0) 326966 (30.2) 240481 (17.7) 12069 (53.4) 23829 (34.4) (mL) human dose, as exemplified in Table 2, which may achieve The above results suggest a slower distribution and bio a temporary Suppression of endogenous cortisol (greater availability of TCA in the systemic circulation following than 50%) and, within 14 days, achieve cortisol suppression 60 administration of FX006 as compared to TCAIR. Without of endogenous cortisol of less than 35%. In a second wishing to be bound by theory, the slower distribution iteration of these data, the amount of dexamethasone FX006 into the systemic circulation may be related to the released per day was calculated based on a human dose, as longer residence time of FX006 at the site of injection. This exemplified in Table 2 that would not suppress the HPA axis, is supported by the lesser availability of the FX006 i.e. endogenous cortisol Suppression never exceeding 35%. 65 microparticle formulation in the early “burst' phase, where In the case of dexamethasone, where the data is truncated, only 4-9% of product is released, compared to at least 23% both calculated human doses are the same; 36 mg of of the IR product. US 9,555,047 B2 61 62 Bioavailability of TCA in the systemic circulation fol Placebo-treated rat joints had no cartilage or joint changes lowing administration of FX006 was 3-fold lower than that save for the presence of spontaneous cartilage cysts in a few observed for TCAIR, as shown in Table 18. joints (1 at Day 28, 2 at Day 42) in the right (injected) knees. The left knees in the placebo-treated rat joints were normal. TABLE 1.8 In comparison, both knees in the high dose TCAIR and the high and mid-dose FX006 groups showed some mild bone Bioavailability of TCA in Plasma marrow hypocellularity and growth plate atrophy (dose Absolute Bioavailability Comparison dependent for FX006). Both knees in the low dose TCAIR and FX006 animals were normal. Spontaneous cartilage FX006 (0.28 mg) TCAIR (0.18 mg) 10 cysts noted in placebo animals were also noted in all groups F. (%) 17.9 58.6 dosed with FX006 with no increase in incidence or severity. High dose TCAIR increased cartilage cysts at Day 42 but For the 0.56 and 1.125 mg dose levels of FX006, apparent not at Day 28. In general, FX006-treated animals had normal F% were 23.1% and 58.1%, respectively. The IV data in rats 15 articular cartilage despite the presence of catabolic effects on shown in Table 19 was used as a reference to calculate F. other joint structures, which was likely more readily observed on account of the young age of the animals. TABLE 19 Overall, all observed effects of FX006, especially at the Pharmacokinetic Parameters of TCA in Rat Plasma. After i.v. high dose, such as body weight loss and reduced organ (50 mg/kg bolus + 23 mg/kg/h Infusion) Administration weights were also seen with TCA IR. The time course of of Triancinolone Acetonide Phosphate inhibition of the HPA axis (measured as corticosterone Parameter Rat 1 Rat 2 Rat 3 Mean SD levels) is shown in FIG. 42. It should be noted that at the V (L/kg) O.684 O.856 1.29 O944 - 0.314 lowest dose of FX006 (0.28 mg; circles) corticosterone CL (L/h/kg) 1.15 O.790 O.872 O.937 O.188 25 levels were initially inhibited but recovered back to near k12 (h') 1.64 1.79 1.59 11.67 + O.1O2 baseline by Day 14 post-dose. Similarly, with TCAIR at the k2 (h') 1.04 O640 1.13 O.937 O.261 lowest dose (0.18 mg), corticosterone levels recovered by Tipp (h) 1.55 3.71 2.87 2.71 - 1.09 Day 7 (squares). With the mid (0.56 mg) and high (1.125 f2: O.O84 O-110 O.O85 O.093 OO15 mg) doses of FX006 and the high dose of TCAIR (1.125 from Rojas et al., “Microdialysis of triamcinolone 30 mg), corticosterone levels were inhibited longer as shown in acetonide in rat muscle.” J Pharm Sci 92 (2) (2003):394 FIG. 42. 397. A PK-PD analysis demonstrated that inhibition of corti The initial “burst' (i.e., exposure up to 24 h) accounted costerone was correlated with systemic TCA levels and for less than 10% of the total systemic exposure of FX006. followed a classical inhibitory model as shown in FIG. 43. The initial burst accounted for -23-62% of the total expo 35 The ICso was about 1 ng/mL and the E was achieved at sure for the TCAIR product, as shown in Table 20. 50-80 ng/mL. TABLE 20 Relative Availability of TCA in Plasma (Initial Burst vs. Delayed Release

Treatment

FXOO6 FXOO6 FXOO6 TCAIR TCAIR (0.28 mg) (0.56 mg) (1.125 mg) (0.18 mg) (1.125 mg) Variable Mean Mean Mean Mean Mean AUCo24 (ng himL) 31.0 33.0 136 297 1403 AUCo. (ng himL) 356 572 2856 479 606S AUC2 (ng himL) 325 539 2720 182 4662 %. Initial Burst 8.69 5.76 4.76 62.1 23.1

In this same study, groups of animals were sacrificed 28 Example 11 days after dosing, and the remaining were terminated on Day 42. Body weights were monitored throughout the study and key organs (spleen, adrenal glands, thymus) were weighed 55 Evaluation of Efficacy of Single Doses of TCA upon necropsy. The injected knee and the contralateral Immediate Release and TCA Microparticle control joints were prepared for histological assessment. Formulation in Animal Model of Osteoarthritis Toluidine blue stained sections of joints were evaluated for treatment-related alterations. Histologic changes were The studies described herein were designed to test and described, wherever possible, according to their distribution, 60 evaluate the efficacy of the corticosteroid microparticle severity, and morphologic character. formulations provided herein as compared to immediate Histological analysis demonstrated the following obser release corticosteroid formulations. While the studies herein vations. First, injected joints from placebo (blank PLGA use TCA, it is understood that other corticosteroids, includ microspheres)-treated animals had minimal multifocal mac ing other Class B corticosteroids, Class A corticosteroids, rophage infiltration in associated with 20-130 um diameter 65 Class C corticosteroids, and Class D corticosteroids, can be microspheres, whereas none of the active FX006-injected evaluated using these materials, methods and animal mod joints showed the presence of any microspheres at Day 28. els. US 9,555,047 B2 63 64 Efficacy of single intra-articular (IA) doses of FX006 1, 15 and 29) are plotted. FIG. 46 plots the time course of (TCA in 75:25 PLGA formulation microparticles) and TCA corticosterone recovery for all study groups. On balance, IR (immediate release) was evaluated in a rat model of across all groups that received the corticosteroid, there was osteoarthritis of the knee via sensitization and challenge by recovery. peptidoglycan polysaccharide (PGPS). The model involves 5 Plasma levels of TCA were measured in samples taken priming the animals with an intra-articular injection of from all rats at baseline (Day -4), Days 0 (2 hr post dosing), PGPS in the right knee. The following day, any animals with 1, 3, 8, 14, 17, 21, 28, and 31. Concentration-time curves for no knee discomfort were eliminated from the test article all treatment groups are shown in FIG. 47A. FIG. 47B shows groups and placed into the baseline group. Two weeks later, only the FX006 dose groups on a larger scale since maximal knee inflammation was reactivated by a tail vein injection of 10 plasma concentrations with FX006 were far lower than those PGPS, 2.5 hr following IA dosing with FX006 or TCAIR at with TCAIR the doses selected (n=10/group). Differences in weight Histopathological evaluation of the knees taken from all bearing and gait (as a measure of joint pain experienced by animals at the end of the study (Day 32 at the end of the 3" the animals), histopathology, plasma PK etc. were evaluated. reactivation of arthritis) demonstrated Statistically signifi Doses of FX006 (0.28, 0.12, 0.03 mg) and TCAIR (0.06, 15 cant improvement by FX006 at the high and mid-range 0.03 mg) for this study were selected based on data from the doses (0.28 and 0.12 mg) in the composite histological score study described above in Example 10 and an initial run of and each component score (inflammation, pannus, cartilage the PGPS model in which only TCAIR was evaluated at two damage and bone resorption) as shown in FIG. 48. As IA dose levels. The goals of the present study were to described above, the dose of 0.28 mg FX006 demonstrated demonstrate the following: strong efficacy (i.e. analgesic activity) throughout all 3 FX006 is efficacious at doses that do not inhibit the HPA reactivations, whereas the dose of 0.12 mg was active but to aX1S a lesser degree through all 3 reactivations. At the doses of The duration of efficacy is a function of dose TCAIR used, the duration of efficacy was mostly through FX006 provides more prolonged pain relief as compared the first reactivation of arthritis, with partial efficacy of the to TCAIR Since only about 10% of the TCA payload 25 higher (0.06 mg) dose in the second reactivation, and this is expected to be released from FX006 in the first 24 hr, also translated into a much smaller non-significant improve one TCAIR dose group (0.03 mg) was chosen to match ment in histological scores. Importantly, these data demon 10% of the TCA in FX006 at a dose of 0.28 mg strate that TCA has no deleterious effect on cartilage and as Effects of matched doses of FX006 and TCAIR (0.03 mg) has been described in other settings, it actually reduces The duration of efficacy was assessed by 3 different 30 cartilage damage in an inflammatory milieu. reactivations, 2 weeks apart. After that point, the arthritis In conclusion, the prolonged residence of TCA in the joint observed in the animals becomes more wide-spread making upon IA dosing with FX006 resulted in extending the the efficacy in the index knee more difficult to assess. duration of efficacy in the rat PGPS model of arthritis with At the first reactivation, vehicle treated animals demon a significant histological improvement in inflammation, pan strate painful gait as demonstrated by high pain scores (3.5 35 nus formation, cartilage damage and bone resorption. FX006 out of a maximum of 4 possible) as shown in FIGS. 44A, had these effects without inhibiting HPA axis function as 44B, and 44C. FX006 at 0.28 mg (squares) showed good demonstrated by the return to baseline of corticosterone efficacy. In the previous study described in Example 10, this levels within 14 days after dosing. The clinical implications dose was demonstrated to inhibit the HPA axis immediately for the treatment of patients with osteoarthritis, rheumatoid after dosing but a return to baseline function was demon 40 arthritis and other inflammatory joint disorders are as fol strated by Day 14. Interestingly, this dose of FX006 con lows: tinued to be efficacious upon the 2" and 3" reactivations on Intra-articular injection of Sustained release corticosteroid Days 14 and 28 when the HPA axis function was presumably microparticle formulations provides prolonged pain normal. It should also be noted that since HPA axis function relief relative to intra-articular injection of immediate returned to baseline by Day 7 at a 0.18 mg dose of TCAIR 45 release steroids. in the previous study described in Example 10, the effects of Intra-articular injection of Sustained release corticosteroid the doses of TCAIR used in the present study (0.06 and 0.03 microparticle formulations is efficacious in reducing mg) were also in the presence of normal HPA axis function pain and inflammation at doses that do not inhibit the following an initial transient inhibition. Corticosterone mea HPA axis. surements from the present study (as an indicator of HPA 50 The duration of efficacy of sustained release of intra axis function) are presented as change from baseline for articular corticosteroid microparticle formulations is a each treatment group in FIG. 46. As demonstrated from function of dose. these data, corticosterone levels for all groups recovered by Intra-articular injection of Sustained release corticosteroid Day 14; hence the goal of prolonged efficacy with FX006 in microparticle formulations slows, arrests, reverses, or the presence of normal HPA axis function was achieved. 55 otherwise inhibits structural damage to tissues caused Overall, a clear dose-dependence of response was noted by inflammation. for both FX006 and TCAIR. Also, if less than 10% of this Although particular embodiments have been disclosed dose is available by the day after dosing (Day 1), it should herein in detail, this has been done by way of example for be noted in FIG. 44B that the efficacy of FX006 at 0.28 mg purposes of illustration only, and is not intended to be (squares) is greater than TCAIR at 0.03 mg (triangles) at all 60 limiting with respect to the scope of the appended claims, evaluations. Further, the duration of efficacy of TCA (both which follow. In particular, it is contemplated by the inven FX006 and IR) appears to be a function of dose, however, tors that various Substitutions, alterations, and modifications the prolonged release of TCA from the PLGA microspheres may be made to the invention without departing from the in FX006 results in more sustained efficacy. This is more spirit and scope of the invention as defined by the claims. clearly depicted in another representation of the data in FIG. 65 Other aspects, advantages, and modifications are considered 45 in which peak response for each dose as determined by to be within the scope of the following claims. The claims gait/pain scores on Day 1 following each reactivation (Days presented are representative of the inventions disclosed US 9,555,047 B2 65 66 herein. Other, unclaimed inventions are also contemplated. comprising TCA or a pharmaceutically-acceptable salt Applicants reserve the right to pursue such inventions in thereof and a PLGA matrix wherein the TCA comprises later claims. between 22% to 28% of the microparticles and wherein What is claimed is: the PLGA has the following characteristics: (i) a 1. A method of manufacturing an injectable formulation 5 molecular weight in the range or about 40 to 70 kDa; comprising controlled- or Sustained-release microparticles and (ii) a lactic acid: glycolic acid molar ratio of 80:20 comprising triamcinolone acetonide (TCA) or a pharmaceu to 60:40. tically-acceptable salt thereof and a poly(lactic-co-glycolic) 2. The method of claim 1, wherein step (c) comprises a acid copolymer (PLGA) matrix.; wherein the TCA com Solvent evaporation process to remove the solvent. prises between 22% to 28% of the microparticle and wherein 10 3. The method of claim 2, wherein the solvent evaporation the PLGA has the following characteristics: (i) a molecular process utilizes a drying chamber. weight in the range or about 40 to 70 kDa; and (ii) a lactic 4. The method of claim 1, wherein the solvent is dichlo acid: glycolic acid molar ratio of 80:20 to 60:40, the method romethane. comprising: 5. The method of claim 1 further comprising step (d) (a) dispersing the TCA and the poly(laclic-co-glycolic) 15 collecting the controlled- or Sustained-release microparticles acid copolymer in an organic Solution to produce a using a cyclone separator. TCA-PLGA mixture, wherein the PLGA has a molecu 6. The method of claim 5 further comprising step (e) using lar weight in the range of about 40 to 70 kDa and a a secondary drying step to remove residual solvents. lactic acid: glycolic acid molar ratio of 80:20 to 60:40, 7. The method of claim 6 further comprising step (f) and wherein the ratio of TCA to PLGA to organic sieving the collected controlled- or Sustained-release solution in the TCA-PLGA mixture is 1:3:57: microparticles. (b) atomizing the TCA-PLGA mixture into micro-drop 8. The method of clam 7, wherein step (f) uses a 150 um lets by adding the TCA-PLGA mixture to a spinning sieve. disk; and 9. The method of claim 1, wherein the spinning disk (c) treating the TCA-PLGA mixture to remove the sol 25 rotates at a speed of approximately 3300 rpm inside tem vent, thereby producing an injectable formulation com perature controlled chamber maintained at 38-45° C. prising controlled- or Sustained-release microparticle k k k k k