USO09555048B2

(12) United States Patent (10) Patent No.: US 9,555,048 B2 Bodick et al. (45) Date of Patent: Jan. 31, 2017

(54) CORTICOSTEROIDS FOR THE 7,758,778 B2 7/2010 Persyn et al. TREATMENT OF JOINT PAN 8,828,440 B2 9/2014 Bodick et al. 2004/O105821 A1 6/2004 Bernstein et al. 2004/0224030 A1 11, 2004 Shastri (71) Applicant: Flexion Therapeutics, Inc., Burlington, 2005/003 1549 A1 2/2005 Quay et al. MA (US) 2005, 0043706 A1 2/2005 Eaton et al. 2005, OO69591 A1 3/2005 Bernstein et al. (72) Inventors: Neil Bodick, Boston, MA (US); Robert 2007/0053990 A1 3/2007 Persyn et al. C. Blanks. Auburndale, MA (US); 2007,0264343 A1 11/2007 Bernstein et al. Aniali K s Bel t MA US 2008/0248122 A1 10/2008 Rashba-Step et al. nail Sumar, Belmon, (US); 2008/0317805 A1 12/2008 McKay et al. Michael D. Clayman, Gloucester, MA 2009/0035253 A1 2/2009 Wright et al. (US); Mark Moran, Orinda, CA (US) 2009/0123546 A1 5/2009 Ashton et al. 2009/0324678 A1 12/2009 Thorne et al.

(73) Assignee: FLEXION THERAPEUTICS, INC., 39; 2839. A. f58. E.OCCK ( ala. Burlington, MA (US) 2012/0288534 A1 11/2012 Bodick et al. c 2014/0242170 A1 8, 2014 Bodick et al. (*) Notice: Subject to any disclaimer, the term of this 2015.OO25050 A1 1/2015 Bodick et al. patent is extended or adjusted under 35 U.S.C. 154(b) by 0 days. FOREIGN PATENT DOCUMENTS (21) Appl. No.: 14/461,884 CN 1215589. A 5, 1999 EP O911025 A1 4f1999 1-1. JP 2006-503865. A 2, 2006 (22) Filed: Aug. 18, 2014 WO WO95/13799 A1 5, 1995 WO WO-95.13799 A1 5, 1995 (65) Prior Publication Data WO WO 99.12571 A1 3, 1999 WO WO O2,36168 5, 2002 US 2014/0356437 A1 Dec. 4, 2014 WO WO 2007/030545 A2 3, 2007 WO WO 2008,157.057 A2 12/2008 Related U.S. Application Data WO WO 2009,026539 2, 2009 (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. C. 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) induced arthritic rabbit'. Pharmaceutical Research, 19(4):403-409 (2002). 3. it,” R Extended European Search Report in corresponding Application ( .01) No. EP11815323.8, dated Dec. 17, 2013. A6 IK3I/58 (2006.01) Continued A6 IK 9/00 (2006.01) (Continued) A6 IK 47/34 (2006.01) (52) U.S. Cl. Primary Examiner — Tigabu Kassa CPC ...... A61 K3I/58 (2013.01); A61K 9/0019 (74) Attorney, Agent, or Firm — Cooley LLP. Ivor R. (2013.01); A61K 9/0024 (2013.01); A61K 9/14 Elrifi (2013.01); A61K 9/1641 (2013.01); A61 K 9/1647 (2013.01); A61K 9/1694 (2013.01); 57 ABSTRACT A61 K3I/573 (2013.01); A61K 47/34 (57) (2013.01) Corticosteroid microparticle formulations are provided for (58) Field of Classification Search use for treating pain, including pain caused by inflammatory None diseases Such as osteoarthritis or rheumatoid arthritis, and See application file for complete search history. for slowing, arresting or reversing structural damage to tissues caused by an inflammatory disease, for example (56) References Cited damage to articular and/or peri-articular tissues caused by osteoarthritis or rheumatoid arthritis. Corticosteroid U.S. PATENT DOCUMENTS microparticle formulations are administered locally as a 4.293,539 A 10/1981 Ludwig et al. Sustained release dosage form (with or without an immediate 4,530,840 A * 7/1985 Tice ...... A61K 9, 1694 release component) that results in efficacy accompanied by 514f179 clinically insignificant or no measurable effect on endog 6,214,387 B1 * 4/2001 Berde ...... A61K 9, 1641 enous cortisol production. 424/426 7,153,520 B2 12/2006 Seo et al. 7,261,529 B2 8/2007 Persyn et al. 20 Claims, 30 Drawing Sheets US 9,555,048 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 2009,026539 A1 2, 2009 Increased Local Bone Density.” Arth. Rheum. 52.9(2005):2814 WO WO 2009,15O136 A1 12/2009 2821. WO WO 2010/085.609 T 2010 Lo et al. “The Ratio of Medial to Lateral Tibial Plateau Bone WO WO 2011/084518 T/2011 Mineral Density and Compartment-Specific Tibiofemoral WO WO 2012/O19009 A1 2, 2012 Osteoarthritis.” OsteoArth. Cartilage. 14(2006):984–990. Meibohm et al. “Mechanism-Based PK/PD Model for the OTHER PUBLICATIONS Lymphocytopenia Induced by Endogenous and Exogenous Aly, M N S, “Intra-articular drug delivery: A fast growing Corticosteroids.” Int. J. Clin. Pharmacol. Ther. 37.8(1999):367 approach”. Recent Patents On Drug Delivery & Formulation, 376. Bentham Science Publishers Ltd., NL 2(3):231-237 (2008). 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. triamcinolone'. International Journal Of Pharmaceutics, Elsevier 56.1-3(1998): 105-115. BV, NL, 368(1-2):45-55 (2009). Rojas et al. “Microdialysis of Triamcinolone Acetonide in Rat Cilurzo, F. et al: “Design of Methylprednisolone Biodegradable Muscle.” J. Pharm. Sci. 92.2(2003):394-397. Microspheres Intended for Intra-articular Administration'. AAPS Van den Berg et al. “Synovial Mediators of Cartilage Damage and PHARMSCITECH, val. 9, No. 4, Nov. 14, 2008 (Nov. 14, 2008), pp. 1136-1142. Repair in Osteoarthritis.” Osteoarthritis. Brandt et al., eds. Oxford: Khaled K. A. et al., “Prednisolone-Loaded PLGA Microspheres. In Oxford University Press. 7.2.3 (2003): 147-155. Vitro Characterization and In Vivo Application in Adjuvant-Induced Yeh. “The Stability of Insulin in Biodegradable Microparticles Arthritis in Mice.” AAPS PharmSciTech., Jun. 19, 2010 (Jun. 19, Based on Blends of Lactide Polymers and Polyethylene Glycol.” J. 2010), pp. 859-869. Microencapsul. 17.6(2000):743-756. Anderson et al. “Biodegradation and Biocompatibility of PLA and Zentner et al. “Biodegradable Block Copolymers for Delivery of PLGA Microspheres.” Adv. Drug Deliv Rev. 28(1997):5-24. Proteins and Water-Insoluble Drugs.” J. Control. Release. Ayral et al. “Synovitis: A Potential Predictive Factor of Structural 72(2001):203-215. Progression of Medial Tibiofemoral Knee Osteoarthritis—Results Aly, M. N. S., “Intra-Articular Drug Delivery: A Fast Growing of a 1 Year Longitudinal Arthroscopic Study in 422 Patients.” Approach.” Recent Patents on Drug Delivery & Formulation, vol. OsteoArth. Cartilage. 13(2005):361-367. 2(3): 231-237 (2008). Bouissou et al. “Poly(lactic-co-glycolic acid) Microspheres.” Poly Bandi, N. et al., “Intratracheal budesonide-poly(lactide-co mers in Drug Delivery. Chapter 7(2006):81-99. glycolide) microparticles reduce oxidative stress, VEGF expression, Cleek et al. “Microparticles of Poly(DL-lactic-co-glycolic acid)/ and vascular leakage in a benzo(a)pyrene-fed mouse model.” Jour poly(ethylene glycol) Blends for Controlled Drug Delivery.” J. nal of Pharmacy and Pharmacology, vol. 57(7):851-860 (2005). Control. Relase. 48(1997):259-268. Chaw, C.S. et al., “Water soluble betamethasone-loaded Coopman et al. “Identification of Cross-Reaction Patterns in Aller poly(lactide-co-glycolide) hollow microparticles as a Sustained gic Contact Dermatitis from Topical Corticosteroids.” Br: J. release dosage form.” Journal of Encapsulation, vol. 20(3):349-359 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. 17.10(2009) weight on the release of dexamethasone sodium phosphate from :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 9,555,048 B2

FIG. 1

tra-articular Cof Cetratior

- - - - - L. L. L. L. ------intra-articular concentration required for efficacy

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

Concentration in plasma ite post intra articiar itection of sustained release corticosteroid

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

O 50 1 OO 150 2OO 250 3OO 350 400 Time (h) U.S. Patent Jan. 31, 2017 Sheet 2 of 30 US 9,555,048 B2

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

O 50 1 OO 150 2OO 250 3OO 350 400 Tire ( U.S. Patent US 9,555,048 B2

8:3Ségg -, U.S. Patent Jan. 31, 2017 Sheet 4 of 30 US 9,555,048 B2

3.358 g( ,

& .38Se. . . U.S. Patent US 9,555,048 B2

U.S. Patent Jan. 31, 2017 Sheet 6 of 30 US 9,555,048 B2

FIG. 5

100 r. 90 ------. 80 7O ------01------60 50 40 - -0-25%. TCAPLGA75:25 30 20 1O O O 10 2O 3O Days

F.G. 6 25%. TCAPLGA 75:25

-0-Adjusted Dose (mg/day) - - - 5% COrtisOl Inhibition - - - -35% COrtisol Inhibition DOSe 40% COrtisol Inhibition DOSe 50% COrtisol Inhibition DOSe U.S. Patent Jan. 31, 2017 Sheet 7 Of 30 US 9,555,048 B2

25%. TCAPLGA 75:25

-0- Adjusted Dose (mg/day) - - - 5% COrtisol Inhibition - - - - 35% COrtisol Inhibition DOSe 40% COrtisol Inhibition DOSe 50% COrtisol Inhibition DOSe

FIG. 8

1OO 90 8O 70 6O 50 40 -0-25%. TCAPLGA 75:25 3O 2O 10

Days U.S. Patent Jan. 31, 2017 Sheet 8 of 30 US 9,555,048 B2

FIG. 9 25%. TCAPLGA 75:25

-0-Adjusted Dose (mg/day) - - -5% COrtisol Inhibition - - - -35% COrtisol Inhibition DOSe 40% COrtisol Inhibition DOSe 50% COrtisOl Inhibition DOSe

FIG. 10 25%. TCAPLGA 75:25

-0-Adjusted Dose (mg/day) - - - 5% COrtisol Inhibition - - - -35% COrtisol Inhibition DOse 40% COrtisol Inhibition DOSe 50% COrtisOl Inhibition DOSe U.S. Patent Jan. 31, 2017 Sheet 9 Of 30 US 9,555,048 B2

FIG 11

25%. TCA 5% PEG 145OIPLGA 75:25 1 OO 90 80 7O 60 25% TCA5%PEG 50 145O/PLGA75:25 40 30 20 1O z 30 Days

FIG. 12 25%. TCA 10% PEG 3350/PLGA 75:25 1 OO 90 80 70 - 25%TCA 10%PEG 60 335O/PLGA75:25 50 40 30 20 1O

20 Days U.S. Patent Jan. 31, 2017 Sheet 10 of 30 US 9,555,048 B2

FIG. 13

25%. TCA 5% PEG 145O/PLGA 75:25

-0-Adjusted Dose (mg/day) - - -5% COrtisol Inhibition - - - -35% COrtisol Inhibition DOSe 40% COrtisol Inhibition DOSe 50% COrtisOl Inhibition DOSe -109 10 2O 3O

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

-0- Adjusted Dose (mg/day) - - - 5% COrtisO Inhibition - - - -35% COrtisol Inhibition DOSe 40% COrtisol Inhibition DOSe 50% COrtisOl Inhibition DOSe U.S. Patent Jan. 31, 2017 Sheet 11 of 30 US 9,555,048 B2

FIG. 15 25%. TCA 5% PEG 1450/PLGA 75:25

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

DDDDDDD 40% COrtisol Inhibition DOSe 50% COrtisO Inhibition DOSe

25%. TCA 10% PEG 335OIPLGA 75:25 3.5 3.0 -0-Adjusted Dose (mg/day) 2.5 - - - 5% COrtisol 2.0 - T. Inhibition 1.5 |AT r - - - -35%Inhibition COrtisol DOSe 1.0 - 40% COrtisol O.5 N. Inhibition DOSe

0.0 - - - Ny REEse O 5 10 15 2O 25 30 U.S. Patent Jan. 31, 2017 Sheet 12 of 30 US 9,555,048 B2

FIG. 17

100

90 -- : 80 A d S- 70 1 -01------C 2 60 / / 1. -A- 40% TCAPLGA 75:25 SS9 50in A / ------0 - 25%. TCAPLGA 75:25 40 / 7-1Y ---20%, TCAPLGA 75:25 5,S 2030 AA141 ------O-----O --0-15%. TCAPLGA 75:25 O or ...... -- H - - - - 10% TCAPLGA 75:25 10 i. i. - see O - O 5 1 O 15 20 25 3O Days

100 90 is a -- d 60 He SSH 50 Y - 2 - - -ox -0-25%. TCAPLGA 75:25 S 40 / -- (54 kDA) 30 / e - 25%. TCAPLGA 75:25 S 20 A (29 kDa) O 10 O O 10 2O 3O U.S. Patent Jan. 31, 2017 Sheet 13 of 30 US 9,555,048 B2

-ie- 2: CA, GA 50:5

--O-- 25%, CA - GA 55 30% CA CASC:5 - 0 - 35%, CA - GA 550

->e 25%, CA GA 5:50 (ester end-capped -A - 30% CA EG 335f. GASOS) --H 25%. ICA GA 75:25

0-3G A, CA PGA 50:5 (18 kDa)

FIG. 20 40% TCA PLGA 75:25 plus Triblock 1) 9. 8.

se -fe 6 // -0-40% CA PGA 72.25 + 1% 5. / B 4. M -- 4% CA PGA 2.25 + .2% 3. ) 4 2

3. 40 Days U.S. Patent Jan. 31, 2017 Sheet 14 of 30 US 9,555,048 B2

CAGA 5:5 a 3 4.000 is 3,500 3.000 - PLGA 75:25 10%TB-TCM E. 2.500 (Batch 2) 3 - - - 5%COrtisol inhibition 2000 1.500 - - - - 35%COrtisonhibition DOSe 1.000 sees O5OO ------40%COrtisolOf a inhibition DOSe 0.000-H.S.-- ...... 50%COrtisol inhibition DOSe 8O ay

CAGAS 2 is 10.000 a 9.000 S. 8,000 --PLGA75:25.20%TB-TCM E 7,000 (Batch 3) 6.OOO - - - 5%COrtisol inhibition 8 5. OOO 4.000 - - - - 35%COrtiSO Inhibition DOSe 3,000 8, 2.000 yAll ------40%COrtisol inhibition DOSe 1.000 OOOO - - - - 50%COrtisol inhibition DOSe U.S. Patent Jan. 31, 2017 Sheet 15 Of 30 US 9,555,048 B2

CAGASS y Es 3.500 is , 3000 PLGA 75:25 10%TB-TCM a 2.500 (Batch 2) 2.OOO - - - 5%COrtisOnhibition - 1500 - - - - 35%COrtisol inhibition DOSe 1.000 5 0.500 - V 40%COrtisol inhibition DOSe 0.000 -HAS-0---, ------50%COrtisol inhibition DOSe

CAPGA 7:25, 3

3.5OO s 3.OOO PLGA 75:25 10%TB-TCM s 2.5OO (Batch 2) - - - - 5%COrtisol inhibition $ 2.000 & 1500 - - - - 35%COrtisol inhibition DOSe s : 1,000 ------40%COrtisol inhibition DOSe E 0.500 & H -Y/A ------50%COrtisol inhibition DOSe OOOO U.S. Patent Jan. 31, 2017 Sheet 16 of 30 US 9,555,048 B2

FIG. 25 A GA 5: fixes is 120

1 O O

8 O 426 OOO O O 1O 2O 30 40 5O 60 70 8O 90 1OO ite in Days

TCA Vixed violeculiar Weight PGA 75:25 7.OOOO S 6.0000 S. --TCAMixed MW E. 5. OOOO PLGA 75:25 34.0000 - - 5%COrtisol inhibition O 3.OOOO - - - 35%COrtisol inhibition ge 2.0000 Dose --N------. 40%COrtisol inhibition 1.OOOO DOSe OOOOO-E. F. ESFSFSFF-EP EE ------50%COrtisol inhibition O 10 20 30 40 50 60 DOSe U.S. Patent Jan. 31, 2017 Sheet 17 Of 30 US 9,555,048 B2

FIG. 27 TCA Mixed Molecular Weight PLGA 75:25

3.5000 3.0000 TCAMixed MW S. 25000 PLGA75:25 S 5%COrtisol inhibition S 2.0000 S; 35%Cortisol Inhibition 3 1.5000 DOSe is a ------40%COrtisol inhibition I a 0.5000 - \ 1 ------50%COrtisolDOSe inhibition O.OOOO

12O

100 t us CD9 80 A C O - -- TCAPCL SS 60 u g 1. H TCAMixed MW PLGA 75:25 40 A --A- TCAPLGA 50:50 s -A-A-A ------A--A --X - TCAPLGA85:15 O f X ::::::::::::... x 2O AKX

O * O 5 10 15 20 25 30 35 U.S. Patent Jan. 31, 2017 Sheet 18 of 30 US 9,555,048 B2

F G. 2 9

PRED-PLGA 50:50 100 9 O

1 O 5 1O 15 2O 25 30 35 Time in Days

FIG. 30 PRED-PLGA 50:50 8. OO 7.00 -- PLGA 50:50-PRED 6.OO - - - 5%COrtiSO Inhibition 5. OO 4.00 - - - - 35%COrtisol inhibition DOSe 3.OO 40%COrtisol inhibition 2.00 DOSe 100 50%COrtisol inhibition DOSe OOO U.S. Patent Jan. 31, 2017 Sheet 19 Of 30 US 9,555,048 B2

PRED-PLGA 50:50 8.OO 1s 7.00 - - - PLGA 50:50-PRED us 9 6.00 2 5%COrtiSO Inhibition St 5.OO d : 4.OO Scotso Inhibition 3.OO ------40%COrtisol inhibition 2.00 DOSe 3 1.00 \, , --1 50%COrtisol inhibition DOSe OOO

Beta-PLGA50:50 90 8O 70 g 60 i 50 40 2030 10 SS O O 5 10 15 2O 25 3O 35 Time in Days U.S. Patent Jan. 31, 2017 Sheet 20 of 30 US 9,555,048 B2

BETA-PLGA 50:50 3.50 3.00 -- PLGA 50:50-BETA 9 2.50 5%COrtiSO Inhibition as 2.00 3 - - - - 35%COrtisOnhibition e 150 DOSe 1.00 - - - - -A-2------A - TT 40%COrtisonhibition . DOSe 0.50 / \ / ...... 50%COrtisol inhibition O.OO DOSe

BETA-PLGA 50:50 2.OO 1.80 -- PLGA 50:50-BETA s 160 g 140 5% COrtiSO Inhibition 120 3 1.00 - - - - 35%COrtisonhibition ? DOSe 0.80 9 0.60 40%COrtisOnhibition g DOSe E 0.40 9 a Ya. All-A ------50%COrtisOnhibition 0.20 DOSe O.OO U.S. Patent Jan. 31, 2017 Sheet 21 of 30 US 9,555,048 B2

FIG. 35 i 12O CD ge 100 SS 80 60 g 40 20 U 0 O 5 10 15 2O 25 3O 35 Time in Days

FIG. 36 FLUT-PLGA50:50 (200 mg) 5.OOO 4.5OO S. 4.OOO -- PLGA 50:50-FLUT 200mg 3.500 3000 5%COrtiSO Inhibition 8 2.5OO is 2,000 - - - - 35%COrtisol inhibition 1,500 DOSe isC 1,000 ------. 40%COrtisol inhibition 0.500 DOSe 0.000 - EP Elsa FE ESA E------50%COrtisol inhibition O 10 20 3O 40 DOSe U.S. Patent Jan. 31, 2017 Sheet 22 of 30 US 9,555,048 B2

FIG. 37 FLUT-PLGA50:50 (200 mg) 12OO a 1.000 -- PLGA 50:50-FLUT 200mg O S. E. O.800 - - - 5%COrtisol inhibition 0600 ---- 35%COrtisol inhibition 0.400 DOSe ------40%COrtisol inhibition 0.200 DOSe 50%COrtisol inhibition OOOO DOSe

12OOO FLUT Formulations

1 OOOO

8OOO

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

-A-5O15O 28.6%FLUT

Days U.S. Patent Jan. 31, 2017 Sheet 23 of 30 US 9,555,048 B2

FIG. 39 DEXAPLGA50:50

4 O 3 O

OOO O 5 10 15 2O 25 3O 35 Time in Days

FIG. 40 DEXA-PLGA50:50

18O S 1.6O -- PLGA 50:50-DEXA S 140 g 1.20 - - - 5%COrtisol inhibition 9. 1.OO 3 ------35%COrtisol inhibition 0.80 DOSe 0.60 - / . 40%COrtisol inhibition 0.40 DOSe 0.20/N - / ...... 50%COrtisol inhibition O.OO DOSe U.S. Patent Jan. 31, 2017 Sheet 24 of 30 US 9,555,048 B2

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

Slower delivery of TCA with FX006

O 144 288 432 576 72O 864 1008

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

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

50

144 288 432 576 720 864 1OO8 Time (h) U.S. Patent Jan. 31, 2017 Sheet 25 Of 30 US 9,555,048 B2

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

1OO

10

Time (h)

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

150- TCAIR (0.18 mg) -O-TCAIR (1.125 mg)

10 O

50 U.S. Patent Jan. 31, 2017 Sheet 26 of 30 US 9,555,048 B2

--FX006 placebo (A) - 0- FX006 (0.56mg) --A-FX006 (1.125 mg) -K-TCA (1.125 mg) - TCA (0.18mg) --O-FX006 (0.28 mg)

- 1 OO%

- 120% O 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 Time (days)

8O SER Corticosterone VS Mean

4 O

2 O

O OO1 O1 1 10 1 OO 1 OOO Mean (ng/mL) U.S. Patent Jan. 31, 2017 Sheet 27 Of 30 US 9,555,048 B2

FIG. 44A --No Reactivation 4.5 -0-Vehicle -HFX006 (4.67 mg/ml) -A-FX006 (2 mg/ml) -o-FX006 (0.5 mg/ml) \ O 5

oo Eisne)DaV-3 1 Day 2 Day 4 Day 14 Day 15 Day 16 Day 18 DayYN 28 Day 29 Day 30 Day 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 9,555,048 B2

-H NO Reactivation FIG. 44C –0. Vehicle -G-Triamcinolone (1 mg/ml) A-Triamcinolone (0.5 mg/ml) 4.5 --FX006 (4.67 mg/ml) A.FX006 (2 mg/ml) -o-FX006 (0.5 mg/ml)

s

us - - - w

A. P w w s

- - - -- W w -- w N ----e. - y 4 Day 14 Day 15 Day 16 Day 18 Day 28 Day 29 Day 30 Day 32 -0.5 E. Dat" Day2' Daya Dayt Davis Davis Davis Day28 Da,2'Daigo'Day 2 Days Post Reactivation

-O-No reactivation ("normal") - HVehicle

-A-TCAIR (0.06 mg)

-e-TCAIR (0.03 mg)

-le-FX006 (0.28 mg)

-O-FX006 (0.12 mg)

-HFX006 (0.03 mg) Peak pain response upon reactivation of knee arthritis U.S. Patent Jan. 31, 2017 Sheet 29 Of 30 US 9,555,048 B2

-H Primed no reactivation --Vehicle -o-Triamcinolone (1 mg/ml) -A-Triamcinolone (0.5 mg/ml) -z-FX006 (4.67 mg/ml)

-A-FX006 (2 mg/ml) -o- FX006 (0.5 mg/ml V ovu ; w y

Time (days)

-o-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 2O 24 28 Time (days) U.S. Patent Jan. 31, 2017 Sheet 30 of 30 US 9,555,048 B2

FIG. 47B

12 16 2O 24 28 Time (days)

FIG. 48 CC

N21S.DI EdiC)dr?Eçu;CUO Èg?& ???? §§§–ÊSe????2:222222222 (1) Ø Primed no Vehicle Tramcinolone`N Triamcinolone FX006 O06 O `N reactivat (1 mg/ml) (0.5 mg/ml) (4.67 mg/ml) (2 mg/ml) (0.5 mg/ml) Treatment Group US 9,555,048 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 9,555,048 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 9,555,048 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 9,555,048 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 9,555,048 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 9,555,048 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 9,555,048 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 9,555,048 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 9,555,048 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 9,555,048 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 copolymer 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 9,555,048 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. No. 7,261,529 and U.S. Pat. No. 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 FIG. 4 is a graph depicting plasma levels of endogenous B corticosteroid microparticle formulations, in some cortisol over time, without (Column 1) adjustment for a embodiments, the microparticles are manufactured as 55 change in the sensitivity of the HPA axis after intra-articular described in U.S. Pat. No. 7,261,529 and U.S. Pat. No. corticosteroids and with (Column 2) adjustment for a change 7.758,778, the contents of each of which are hereby incor in the sensitivity of the HPA axis after intra-articular corti porated by reference in their entirety. For example, the costeroids. These data demonstrate that the sensitivity of the microparticles are manufactured using a solvent evaporation HPA axis varies with corticosteroid, dose, and time with process wherein the Class B corticosteroid is dispersed in a 60 clinically important implications for the selection of doses lactic acid-glycolic acid copolymer organic Solution and the for Sustained delivery into an intra-articular space. mixture is treated to remove the solvent from the mixture, FIG. 5 is a graph depicting the cumulative percent release thereby producing microparticles. of a nominal 25% (w/w) triamcinolone acetonide in PLGA In some embodiments, the solvent evaporation process 75:25 microparticles. utilizes a spray drying or fluid bed apparatus to remove the 65 FIG. 6 is a graph depicting the calculated human dose to Solvent and produce microparticles. In some embodiments, achieve transient cortisol Suppression and within 14 days the solvent evaporation process utilizes a spinning disk. For achieve less than 35% cortisol Suppression using nominal US 9,555,048 B2 23 24 25% TCA PLGA 75:25 microparticles. The dotted lines FIG. 17 is a graph depicting cumulative percent triamci represent, from top to bottom of the graph, 50% cortisol nolone acetonide release of nominal 40%, 25%. 20%, 15% inhibition dose, 40% cortisol inhibition dose, 35% cortisol and 10% TCA containing PLGA 75:25 microparticles. inhibition dose and 5% cortisol inhibition dose. FIG. 18 is a graph depicting cumulative percent release of FIG. 7 is a graph depicting calculated human dose that nominal 25% TCA PLGA 75:25 (29 kDa) and PLGA 75:25 does not affect the HPA axis, less than 35% cortisol Sup (54 kDa) containing microparticles. pression using nominal 25% TCA PLGA 75:25 micropar FIG. 19 is a graph depicting cumulative percent release of ticles. The dotted lines represent, from top to bottom of the triamcinolone acetonide in PLGA 50:50 microparticle for graph, 50% cortisol inhibition dose, 40% cortisol inhibition mulations. 10 FIG. 20 is a graph depicting cumulative percent release of dose, 35% cortisol inhibition dose and 5% cortisol inhibition nominal 28.6% triamcinolone acetonide in PLGA 75:25 plus dose. Triblock microparticle formulations. FIG. 8 is a graph depicting cumulative percent release of FIG. 21 is a graph depicting calculated human dose to a second preparation of nominal 25% triamcinolone achieve transient cortisol Suppression and within 14 days acetonide in PLGA 75:25 microparticles using an alternate 15 achieve less than 35% cortisol Suppression using nominal preparation. 28.6% TCA 10% Triblock/PLGA 75:25 microparticles. The FIG. 9 is a graph depicting calculated human dose to dotted lines represent, from top to bottom of the graph, 50% achieve transient cortisol Suppression and within 14 days cortisol inhibition dose, 40% cortisol inhibition dose, 35% achieve less than 35% cortisol Suppression using a second cortisol inhibition dose and 5% cortisol inhibition dose. preparation of nominal 25% TCA PLGA 75:25 micropar FIG. 22 is a graph depicting calculated human dose to ticles made by an alternate preparation. The dotted lines achieve transient cortisol Suppression and within 14 days represent, from top to bottom of the graph, 50% cortisol achieve less than 35% cortisol Suppression using nominal inhibition dose, 40% cortisol inhibition dose, 35% cortisol 28.6% TCA 20% Triblock/PLGA 75:25 microparticles. The inhibition dose and 5% cortisol inhibition dose. dotted lines represent, from top to bottom of the graph, 50% FIG. 10 is a graph depicting: calculated human dose that 25 cortisol inhibition dose, 40% cortisol inhibition dose, 35% does not affect the HPA axis, less than 35% cortisol Sup cortisol inhibition dose and 5% cortisol inhibition dose. pression using a second preparation of nominal 25% TCA FIG. 23 is a graph depicting calculated human dose that PLGA 75:25 microparticles made by an alternate prepara does not affect the HPA axis, less than 35% cortisol Sup tion. The dotted lines represent, from top to bottom of the pression using nominal 28.6% TCA 10% Triblock/PLGA graph, 50% cortisol inhibition dose, 40% cortisol inhibition 30 75:25 microparticles. The dotted lines represent, from top to dose, 35% cortisol inhibition dose and 5% cortisol inhibition bottom of the graph, 50% cortisol inhibition dose, 40% dose. cortisol inhibition dose, 35% cortisol inhibition dose and 5% FIG. 11 is a graph depicting cumulative percent release of cortisol inhibition dose. nominal 25% triamcinolone acetonide in 5% PEG 1450/ FIG. 24 is a graph depicting calculated human dose that 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 9,555,048 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 9,555,048 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 first 24 hours post-injection, but by day 14 post-injection, DEFINITIONS suppression of the HPA axis is less than 35%. The use of microparticles to administer corticosteroids is The terms below have the following meanings unless known (See, e.g., U.S. Patent Application Publication. No. indicated otherwise. 20080317805). In addition, corticosteroids are known to be An amount of a corticosteroid that does not “suppress the useful for the symptomatic treatment of inflammation and hypothalamic-pituitary-adrenal axis (HPA axis) refers to 10 the amount of the sustained release corticosteroid delivered pain. New data also suggest that synovitis may be associated locally to relieve pain due to inflammation, which provides with the structural damage, for example, the deterioration of a systemic concentration that will not have a clinically cartilage and other peri-articular associated with the pro significant effect or “adverse effect on the HPA axis. gression of osteoarthritis and rheumatoid arthritis. (See e.g., Suppression of the HPA axis is generally manifested by a Hill CL, et al. “Synovitis detected on magnetic resonance 15 reduction in endogenous glucocorticoid production. It is imaging and its relation to pain and cartilage loss in knee useful to consider both basal and augmented production of osteoarthritis.” Ann Rheum Dis 66 (2007): 1599-603; van endogenous glucocorticoids. Under ordinary, “unstressed den Berg W B, et al. “Synovial mediators of cartilage conditions, glucocorticoid production occurs at a normal, damage and repair in osteoarthritis.” In: Brandt K D. basal level. There is some natural variation of production Doherty M, Lohmander LS, eds. Osteoarthritis. Second ed. during the course of the 24-hour day. Under extraordinary, Oxford: Oxford University Press (2003): 147-55; Ayral X, et 'stressed’ conditions associated with, e.g., infection or al. “Synovitis: a potential predictive factor of structural trauma and the like, augmented endogenous production of progression of medial tibiofemoral knee osteoarthritis— glucocorticoids occurs. Endogenous cortisol production results of a 1 year longitudinal arthroscopic study in 422 may be determined by measuring glucocorticoid concentra patients.” Osteoarthritis Cartilage 13 (2005):361-7; and 25 tions in plasma, saliva, urine or by any other means known Kirwan JR, et al. “Effects of glucocorticoids on radiological in the art. It is known that systemic concentrations of progression in rheumatoid arthritis.” Cochrane Database corticosteroids can Suppress the HPA axis. For example, on Syst Rev 2007: CD006356). day 3 after an intra-articular injection of 20 mg triamcino The administration of corticosteroids, particularly for lone hexacetonide plasma levels, of approximately 3-4 extended periods of time, can have a number of unwanted 30 ng/mL have been observed. These resulted in a transient but side effects. The HPA axis, the interdependent feedback highly statistically significant 75% HPA-axis suppression mechanism between the hypothalamus, the pituitary gland (Derendorf et al., “Pharmacokinetics and pharmacodynam and the adrenal cortex, may be suppressed by the adminis ics of glucocorticoid Suspensions after intra-articular admin tration of corticosteroids, leading to a variety of unwanted istration.” Clin Pharmacol Ther. 39(3) (1986):313-7) which, side effects. The extent of HPA axis suppression, and related 35 however, does not necessarily portend complete HPA failure inhibition of endogenous cortisol production, has been (Habib, "Systemic effects of intra-articular corticosteroids.” attributed to the potency of the corticosteroid, the dose, Clin Rheumatol 28 (2009): 749-756, see p 752 col. 1, para systemic concentration, protein binding, rate of elimination 2, final sentence). While Such transient Suppression is gen (Meibohm et al. “Mechanism-based PK/PD model for the erally considered to be acceptable without clinically signifi lymphocytopenia induced by endogenous and exogenous 40 cant effect, more persistent Suppression, i.e., weeks, would corticosteroids.” Int J Clin Pharmacol Ther. 37(8) (1999): be deemed clinically detrimental. In embodiments of the 367–76) and, for one corticosteroid, a change in sensitivity present invention, administration of the formulation may of the HPA axis (Derendorfetal. “Clinical PK/PD modelling result in a clinically acceptable HPA Suppression, particu as a tool in drug development of corticosteroids.” Int J Clin larly during the initial release period of the therapy. In some Pharmacol Ther: 35(10) 1997: 481-8). Furthermore, intra 45 embodiments of the present invention, administration of the articular doses of corticosteroids associated with only lim formulation will not result in any significant level of HPA ited anti-inflammatory and short-term analgesic benefit Suppression, including no detectable HPA Suppression, par (Hepper et al. “The efficacy and duration of intra-articular ticularly during the initial release period of the therapy. corticosteroid injection for knee osteoarthritis: a systematic During the Subsequent or Sustained release period of the review of level I studies.' J Am Acad Orthop Surg. 17(10) 50 therapy, additional corticosteroid may be released into the 2009: 638-46) have been associated with HPA axis suppres plasma. However, the plasma levels during this period will sion (Habib, "Systemic effects of intra-articular corticoster generally be less than those during the initial release period, oids.” Clin Rheumatol. 28(7) (2009): 749-56). if any corticosteroid release occurs, and will not be associ The changes in sensitivity to corticosteroid effects over ated with HPA axis suppression. Further, the adverse events time should alter clinical steroid dosing, but prior to the 55 associated with exogenous corticosteroid administration, instant invention, this has not been understood. e.g., hyperglycemia, hypertension, altered mood, etc. will The details of one or more embodiments of the invention generally not be observed. Preferably, the number of clinical are set forth in the accompanying description below. adverse events during this period will not substantially Although any methods and materials similar or equivalent to exceed the number achieved by an immediate release for those described herein can be used in the practice or testing 60 mulation alone or by KENALOGTM or its bioequivalent and of the present invention, the methods and materials are now will, preferably, be fewer than during the prior, initial release described. Other features, objects, and advantages of the period of the therapy, if any corticosteroid release occurs. invention will be apparent from the description. In the Alternatively, one can determine the Suppression of the specification, the singular forms also include the plural formulation on HPA by measuring endogenous cortisol unless the context clearly dictates otherwise. Unless defined 65 production. Thus, the formulation can be considered as otherwise, all technical and scientific terms used herein have avoiding clinically significant (or adverse) Suppression of the same meaning as commonly understood by one of the HPA axis where the endogenous cortisol level is sub US 9,555,048 B2 29 30 stantially the same in the steady state between a patient tion of symptoms as well as complete alleviation of the population receiving a therapeutically beneficial amount of symptoms for a time period. The time period can be hours, an immediate release formulation and those receiving a days, months, or even years. therapeutically beneficial amount of a Sustained release By an “effective” amount or a “therapeutically effective formulation. Such a formulation would be deemed to have amount of a drug or pharmacologically active agent is no clinically significant effect on the HPA axis. Alternatively meant a nontoxic but Sufficient amount of the drug or agent or additionally, a small but measurable reduction in steady to provide the desired effect, e.g., analgesia. An appropriate state glucocorticoid production can result from the formu “effective” amount in any individual case may be deter lation during the sustained release period of the therapy with mined by one of ordinary skill in the art using routine adequate preservation of the augmented, stress response 10 experimentation. needed during infection or trauma can be deemed a clini “Site of a patient’s pain” refers to any area within a body cally insignificant Suppression of the HPA axis. Endogenous causing pain, e.g., a knee joint with osteoarthritis, nerve root glucocorticoid production may be assessed by administering causing Sciatic pain, nerve fibers growing into annular tears various doses of adrenocorticotropin hormone or by other in discs causing back pain, temporomandibular joint (TMJ) tests known to those skilled in the art. Embodiments of the 15 pain, for example TMJ pain associated with temporoman current invention provide for controlling the release of dibular joint disorder (TMD) or pain radiating from epidural corticosteroid, as may be desired, to achieve either no or perineural spaces. The pain perceived by the patient may measurable effect on endogenous glucocorticoid production result from inflammatory responses, mechanical stimuli, or a target, or a measurable effect that is, however, without chemical stimuli, thermal stimuli, as well as allodynia. adverse clinical consequence. In this regard, it has been Additionally, the site of a patient's pain can comprise one found that intra-articular doses of corticosteroids that Sup or multiple sites in the spine, such as between the cervical, press cortisol production by 20-35%, and sometimes more, thoracic, or lumbar vertebrae, or can comprise one or provide very useful Sustained anti-inflammatory and anal multiple sites located within the immediate area of inflamed gesic activity. These benefits are achieved without acute or injured joints such as the shoulder, hip, or other joints. risks of hypoadrenalism and without excessive risks, after 25 A “biocompatible' material refers to a material that is not Sustained intra-articular dosing, of developing an adrenal toxic to the human body, it is not carcinogenic and it should unresponsiveness in times of stress or of developing frank induce limited or no inflammation in body tissues. A “bio adrenal failure. degradable' material refers to a material that is degraded by As shown further below, the studies presented herein have bodily processes (e.g., enzymatic) to products readily dis demonstrated that the HPA axis sensitivity appears to dimin 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 9,555,048 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 areata, 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 mis, exfoliative dermatitis, mycosis fungoides, pemphigus, steroid hormone. Naturally occurring corticosteroids are severe erythema multiforme (Stevens-Johnson syndrome), secreted by the adrenal cortex or generally the human body. Primary or secondary adrenocortical insufficiency in con Corticosteroid molecules have the following basic struc junction with mineralocorticoids where applicable; congeni ture: tal adrenal hyperplasia, hypercalcemia associated with can 55 cer, nonsupportive thyroiditis, exacerbations of regional enteritis and ulcerative colitis, acquired (autoimmune) (I) 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 9,555,048 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 release corticosteroids delivered to treat pain at dosages that costeroids include prednisolone, hydrocortisone and meth do not adversely suppress the HPA axis. Such amounts ylprednisolone and their ester acetate, sodium phosphate and delivered locally to relieve pain due to inflammation, will Succinate, cortisone, prednisone, and tixocortol pivalate. provide a systemic concentration that does not have a Class B corticosteroids are triamcinolone acetonide (TCA) measurable adverse effect on the HPA axis (differences if types with cis/ketalic or diolic modifications on C16-C17. 15 any are not significant because any such differences are Main examples of Class B corticosteroids include triamci within normal assay variability) or, as desired, may have a nolone acetonide (TCA), fluocinolone acetonide, amcinon measurable but clinically insignificant effect on the HPA axis ide, desonide, fluocinonide, halcinonide, budesonide, and (basal cortisol is Suppressed to Some measurable extent but flunisolide. Class C corticosteroids are betamethasone types stress responses are adequately preserved). Further embodi with a —CH3 mutilation on C16, but no esterification on ments of the invention include doses during a second period C17-C21. Main examples of Class C corticosteroids include of time selected to adjust for a change in sensitivity of the betamethasone, dexamethasone, desoxymethasone, fluocor HPA axis to Suppression following exposure during a first tolone, and halomethasone. Class D corticosteroids are period of time to the corticosteroid (FIG. 1). clobetasone or hydrocortisone esterified types with a long Additional embodiments include doses during first and/or chain on C17 and/or C21 and with no methyl group on C16. 25 the second period of time selected to adjust for corticoster Main examples of Class D corticosteroids include flutica oid-specific (or corticosteroid- and potentially dose-specific) Sone, clobetaSone butyrate, clobetasol propionate, hydrocor changes in the rate of change of sensitivity of the HPA axis tisone-17-aceponate, hydrocortisone-17-butyrate, beclom to suppression that begin with initial exposure. For clinically ethasone dipropionate, betamethasone-17-valerate, effective corticosteroids, the rate of change of the sensitivity betamethasone dipropionate, methylprednisolone ace 30 of the HPA axis to exogenous corticosteroids is both non ponate, and prednicarbate. uniform and non-linear (FIG. 2). The rate and pattern of For the present invention non-limiting examples of cor change in Such sensitivity varies widely as a function of the ticosteroids may include: betamethasone, betamethasone particular corticosteroid that is selected (FIG. 3). acetate, betamethasone dipropionate, betamethasone 17-val Finally, it is possible to usefully characterize the change erate, cortivaZol, dexamethasone, dexamethasone acetate, 35 in sensitivity vs. time mathematically as the (non-linear, dexamethasone sodium phosphate, hydrocortisone, hydro exponential) “decay” of the sensitivity from the initial to cortisone aceponate, hydrocortisone acetate, hydrocortisone final value, wherein the decay parameters (Table 1) has been butyrate, hydrocortisone cypionate, hydrocortisone probu determined from the data further described herein. tate, hydrocortisone sodium phosphate, hydrocortisone Sodium Succinate, hydrocortisone Valerate, methylpredniso 40 lone, methylprednisolone aceponate, methylprednisolone TABLE 1. acetate, methylprednisolone sodium Succinate, predniso HPA Axis Change-in-Sensitivity Decay-Parameter 8 vs. lone, prednisolone acetate, prednisolone metasulphobenzo Corticosteroid and Dose ate, prednisolone sodium phosphate, prednisolone steaglate, Corticosteroid Decay Parameter ö (time') prednisolone tebutate, triamcinolone, triamcinolone 45 acetonide, triamcinolone acetonide 21-palmitate, triamcino Betamethasone Phosphate/Acetate (7 mg) O.O24 lone benetonide, triamcinolone diacetate, triamcinolone Triamcinolone Acetonide (40 mg) O.OOS hexacetonide, alclometasone, alclometaSone dipropionate, Triamcinolone Hexacetonide (20 mg) O.O70 amcinonide, amelometaSone, beclomethasone, beclometha *The inhibition of endogenous cortisol synthesis can be related to the exogenous corticosteroid concentration by the following equations: 1, E = CE 'C')/(EC50)+C" Sone dipropionate, beclomethasone dipropionate monohy 50 wherein E = effect, E = maximal effect, C = concentration of exogenous corticosteroid, drate, budesonide, butiXocort, butiXocort propionate, cicle EC50 = concentration at /2 E, and n = the Hill (“shape, or "slope”) factor; and 2. Sonide, ciprocinonide, clobetasol, clobetasol propionate, ECSofia = ECso initial + (ECsofia - ECso initial Il - e." clocortolone, clobetaSone, clobetaSone butyrate, clocor Using this approach permits the determination of “6”, the tolone pivalate, cloprednol, cortisone, cortisone acetate, parameter describing the exponential decay from the initial deflazacort, domoprednate, deprodone, deprodone propi 55 to the final ECs. Minimization of least-squares differences onate, desonide, desoximethasone, desoxycortone, desoxy was utilized to obtain the best-fit Ö. cortone acetate, dichlorisone, diflorasone, diflorasone diac These new findings regarding the rate and pattern of etate, diflucortolone, difluprednate, fluclorolone, change of sensitivity to inhibition and the lack of predict fluclorolone acetonide, fludrocortisone, fludrocortisone ability of such rates and patterns on the basis of for acetate, fludroxycortide, flumethasone, flumethasone piva 60 example, steroid potency, have significant implications for late, flunisolide, fluocinolone, fluocinolone acetonide, fluo clinically appropriate dose-selection. Those skilled in the art cortin, fluocortolone, fluorometholone, fluticasone, flutica will appreciate the importance of a changing sensitivity to Sone furoate, fluticaSone propionate, fluorometholone HPA axis suppression and will also appreciate both the acetate, fluoxymesterone, fluperolone, fluprednidene, flu complexity and counterintuitive aspects of several of these prednidene acetate, fluprednisolone, formocortal, halcinon 65 new findings (Table 1). ide, halobetasol propionate, halometasone, halopredone, As a result of these clinical findings, the dose range to halopredone acetate, hydrocortamate, isoflupredone, isoflu achieve clinically useful analgesia, with minimal or con US 9,555,048 B2 35 36 trolled modulation of the HPA axis, at steady state concen TABLE 3 trations of various corticosteroids has been determined (Table 2). In particular, it appears that the daily corticoster Plasma corticosteroid concentrations associated with oid doses at steady state concentrations, are approximately target levels of cortisol inhibition at steady state. 3- to 7-times greater than are predicted by prior art (Mei- 5 Corticosteroid Concentration in Plasma (ng/mL) associated with the bohm, 1999). Target Levels of Cortisol Inhibition (% TABLE 2 Corticosteroid 59 10% 20%. 35% 50%

Cortisol Inhibition (% 10 betamethasone (ng mL) O.33 O.70 1.57 3.38 6.27 budesonide (ng/mL) O60 1.27 2.85 6.14 11.40 Corticosteroid 59% 10% 20% 35% SO% des-ciclesonide (ng/mL) 0.55 1.16 2.61 S.63 10.45 dexamethasone (ng/mL) O.21 0.44 1.00 2.15 3.99 Dose (mg/d), adjusted for individual intra-articular corticosteroid flunisonide (ng/mL) O.18 O.38 O.86 1.84 3.42 characteristics, for expected Suppression of endogenous cortisol fluticaSone (ng/mL) O.04 O.08 O.19 O41 O.76 production at steady state. 15 mometaSone (ng/mL) O.15 O.32 O.71 1.54 2.85 methylprednisolone (ng/mL) O.68 1.44 3.23 6.96 12.92 betamethasone (mg/d) O.1 O.2 O.S 1.O 1.8 prednisolone (ng/mL) 1.64 3.46 7.79 16.79 31.16 budesonide (mg/d) O.1 O.2 O.6 1.2 2.2 triamcinolone acetonide O.19 O.40 O.90 1.9S 3.61 des-ciclesonide (mg/d) 3.0 6.3 14.3 30.7 57.0 (ng/mL) dexamethasone (mg/d) O.1 O.2 0.4 O.9 1.6 triamcinolone hexacetonide O.10 O.21 O.48 1.02 1.90 flunisonide (mg/d) O.3 O.S 1.2 2.6 4.8 (ng/mL) fluticaSone (mg/d) O.1 O.1 O.3 O6 1.1 mometaSone (mg/d) O.2 0.4 O.9 2.0 3.7 methylprednisolone (mg/d) O.3 0.7 1.6 3.5 6.5 The studies presented herein demonstrate for the first time prednisolone (mg/d) 0.4 O.8 1.9 4.0 7.5 triamcinolone acetonide O.2 0.4 O.8 1.7 3.2 the discovery of the time-course of changes in sensitivity of (mg/d) the HPA axis to exogenous corticosteroids. In addition, both triamcinolone hexacetonide O.1 O.2 0.4 O.9 1.6 25 the mean doses and mean plasma levels shown in Tables 2 (mg/d) and 3 above are those after steady state has been achieved, A. Total Dose Delivered (mg/month), adjusted for individual intra-articular corticosteroid characteristics, for expected Suppression requiring approximately 4 to 24 days depending upon the of endogenous cortisol production at steady state. corticosteroid in question. The companion post-dose but pre-steady-state transients for several corticosteroids have betamethasone 3.0 6.O 1S.O 3O.O S4O 30 been described in FIGS. 2, 3, and 4. It is also important to budesonide 3.0 6.O 18.0 36.0 66.O des-ciclesonide 90.0 1890 429.0 921.O. 1710.O note that the data Suggest that the carefully controlled dexamethasone 3.0 6.O 12.0 27.0 48.0 benefits from the intra-articular, sustained release of a cor flunisonide 9.0 1S.O 36.0 78.O 144.0 ticosteroid of interest will persist as long as release contin fluticaSone 3.0 3.0 9.O 18.0 33.0 CS. nonetaSone 6.O 12.0 27.0 6O.O 111.0 35 methylprednisolone 9.0 21.0 48.0 1OSO 195.0 In one preferred embodiment, a single component Sus prednisolone 12.0 24.0 57.0 12O.O 225.0 tained release formulation releases a dose (in mg/day) that triamcinolone acetonide 6.O 12.0 24.0 S1.O 96.O suppresses the HPA axis by no more than between 5-40% at triamcinolone hexacetonide 3.0 6.O 12.0 27.0 48.0 steady state as shown in Table 2, more preferably no more than between 10-35% at steady state as shown in Table 2. 40 These doses are therapeutically effective without adverse That higher doses of corticosteroids can be administered side effects. Successfully by intra-articular injection, maximizing the In another preferred embodiment, a single component likelihood of observing anti-inflammatory and analgesic Sustained release formulation releases a dose (in mg/day) responses while minimizing or eliminating adverse events that does not measurably suppress the HPA axis at steady from HPA axis suppression or otherwise excessive tissue 45 state. These doses are therapeutically effective without exposure, is of profound clinical consequence for improving adverse side effects. the treatment of patients with arthritis. In another embodiment where both an immediate release In addition, with these continuous daily doses of intra component and Sustained release component of the formu articular corticosteroids, it is possible to determine the lation are present, immediate release dose would be as related systemic plasma level concentrations (Table 3) that 50 shown in Table 4 and the sustained release dose would be a will produce the target cortisol inhibition and not beyond, dose (in mg/day) that Suppresses the HPA axis by no more than between 5-40% as shown in Table 2, more preferably this while retaining clinically important anti-inflammatory no more than between 10-35% as shown in Table 2. In and analgesic activity within the joint. These plasma con addition, it is expected that Sustained release doses described centrations were predicted on the basis of data from short 55 previously will follow immediate release doses as shown in term (i.e., less than 8 days) exposure to corticosteroids. With Table 4. longer exposure to corticosteroids, the “decay” (i.e., decline) of the sensitivity to corticosteroids may continue resulting in TABLE 4 values higher than those listed in Table 3. The levels calculated in Table 3 were purely hypothetical calculations 60 Immediate release relative doses (ng based on human data with immediate release-level doses Immediate Release Dose from the literature. With sustained release dosages, more Corticosteroid (mg) drug may be able to be delivered without seeing an increased betamethasone' S-20 level of cortisol inhibition after the initial burst period. A budesonide? 7-28 given level of plasma concentration may actually provide 65 des-ciclesonide? 177-713 less inhibition that would have been predicted or calculated dexamethasone’ S-20 using the human IR levels from the literature. US 9,555,048 B2 37 38 TABLE 4-continued roform and methylene chloride, aromatic hydrocarbons such as toluene, halogenated aromatic hydrocarbons such as Immediate release relative doses (ng chlorobenzene, and cyclic ethers such as dioxane. The Immediate Release Dose organic solvent containing a suitable biodegradable polymer Corticosteroid (mg) is then mixed with a non-solvent such as silicone based Solvent. By mixing the miscible non-solvent in the organic flunisonide? 15-60 fluticasone’ 3-12 Solvent, the polymer precipitates out of Solution in the form mometasone’ 11-44 of liquid droplets. The liquid droplets are then mixed with methylprednisolone' 40-160 another non-solvent, such as heptane or petroleum ether, to prednisolone' 25-100 10 form the hardened microparticles. The microparticles are triamcinolone acetonide' 1O-40 then collected and dried. Process parameters such as solvent triamcinolone hexacetonide' 1O-40 and non-solvent selections, polymer/solvent ratio, tempera 'clinical doses tures, stirring speed and drying cycles are adjusted to 'calculated doses achieve the desired particle size, Surface Smoothness, and 15 narrow particle size distribution. Sustained Release Delivery Platforms In the phase separation or phase inversion procedures The manufacture of microparticles or methods of making entrap dispersed agents in the polymer to prepare micropar biodegradable polymer microparticles are known in the art. ticles. Phase separation is similar to coacervation of a Microparticles from any of the biodegradable polymers biodegradable polymer. By addition of a nonsolvent Such as listed below can be made by, but not limited to, spray drying, petroleum ether, to the organic solvent containing a Suitable Solvent evaporation, phase separation, spray drying, fluid biodegradable polymer, the polymer is precipitates from the ized bed coating or combinations thereof. organic solvent to form microparticles. In certain embodiments of the invention, the micropar In the salting out process, a suitable biodegradable poly ticles are made from a biodegradable polymer that may mer is dissolved in an aqueous miscible organic solvent. include, without limitation, natural or synthetic biocompat 25 Suitable water miscible organic solvents for the polymeric ible biodegradable materials. Natural polymers include, but materials include, but are not limited to acetone, as acetone, are not limited to, proteins such as albumin, collagen, gelatin acetonitrile, and tetrahydrofuran. The water miscible organic synthetic poly(aminoacids), and prolamines; glycosamino Solvent containing a suitable biodegradable polymer is then glycans, such as hyaluronic acid and heparin; polysaccha mixed with an aqueous solution containing salt. Suitable rides, such as alginates, chitosan, starch, and dextrans; and 30 salts include, but are not limited to electrolytes such as other naturally occurring or chemically modified biodegrad 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 35 Solvent and salt selection, polymer/solvent ratio, tempera (trimethylene carbonate), polycaprolactone (PCL), poly 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, 40 process of Ramstack et al., 1995, described in published polyethylene glycol (PEG), polyvinyl alcohol (PVA). PVA 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 45 that are pumped through a static mixer into a quench liquid thereof, multi-block polymer configurations such as PLGA 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 50 Solution of an emulsifier. from poly(d.1-lactic-co-glycolic acid) (PLGA), which is 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 55 tively extract the solvent. Adding Surfactants, such as copolymers may be prepared by the procedure set forth in 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 60 dioxide. The polymer is either dissolved in a suitable organic polymerization catalyst (e.g., a strong acid ion-exchange 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 In the coacervation process, a Suitable biodegradable parameters such as spray rate, nozzle diameter, polymer/ polymer is dissolved in an organic solvent. Suitable organic 65 Solvent ratio, and temperatures, are adjusted to achieve the solvents for the polymeric materials include, but are not desired particle size, Surface Smoothness, and narrow par limited to acetone, halogenated hydrocarbons such as chlo ticle size distribution. US 9,555,048 B2 39 40 In a fluidized bed coating, the drug is dissolved in an include without limitation pore formers, pH modifiers, organic solvent along with the polymer. The Solution is then reducing agents, antioxidants, and free radical scavengers. 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 can be effected by intra-articular injection or other injection The microparticles can be prepared in a size distribution 5 using a needle. To inject the microparticles into a joint, range suitable for local infiltration or injection. The diameter needles having a gauge of about 14-28 gauge are suitable. It and shape of the microparticles can be manipulated to will be appreciated by those skilled in the art that formula modify the release characteristics. In addition, other particle tions of the present invention may be delivered to a treat shapes, such as, for example, cylindrical shapes, can also ment site by other conventional methods, including cath modify release rates of a sustained release corticosteroid by 10 eters, infusion pumps, pens devices, injection guns and the virtue of the increased ratio of Surface area to mass inherent like. to such alternative geometrical shapes, relative to a spherical All references, patents, patent applications or other docu shape. The microparticles have a mass mean diameter rang ments cited are hereby incorporated by reference. ing between about 0.5 to 500 microns. In a preferred embodiment, the microparticles have a mass mean diameter EXAMPLES of between 10 to about 100 microns. The present invention is further defined in the following Biodegradable polymer microparticles that deliver sus Examples. It should be understood that these Examples, tained release corticosteroids may be suspended in Suitable while indicating preferred embodiments of the invention, are aqueous or non-aqueous carriers which may include, but is given by way of illustration only. From the above discussion not limited to water, Saline, pharmaceutically acceptable and these Examples, one skilled in the art can ascertain the oils, low melting waxes, fats, lipids, liposomes and any other essential characteristics of this invention, and without pharmaceutically acceptable Substance that is lipophilic, departing from the spirit and scope thereof, can make substantially insoluble in water, and is biodegradable and/or various changes and modifications of the invention to adapt it to various uses and conditions. eliminatable by natural processes of a patient’s body. Oils of 25 plants such as Vegetables and seeds are included. Examples include oils made from corn, Sesame, cannoli, soybean, Example 1 castor, peanut, olive, arachis, maize, almond, flax, saflower, Sustained-Release Betamethasone or Triamcinolone Sunflower, rape, coconut, palm, babassu, and cottonseed oil; Acetonide Microparticles waxes such as carnoba wax, beeswax, and tallow; fats Such 30 as triglycerides, lipids such as fatty acids and esters, and In one embodiment, the microparticle formulation con liposomes such as red cell ghosts and phospholipid layers. tains a copolymer of DL-lactide (or L-lactide) and glycolide Corticosteroid Loading of and Release from Biodegradable in a 45:55 molar ratio (up to 75:25 molar ratio) with an Polymer Microparticles inherent viscosity ranging from 0.15 to 0.60 dL/g with either When an intra-articularly delivered corticosteroid is 35 an ester or acid end group plus either the corticosteroid incorporated into a biodegradable polymer for Sustained betamethasone or triamcinolone acetonide. If betametha release into a joint at a dosage that does not suppress the sone is used, then the betamethasone is in the form of either HPA axis, preferred loadings of said corticosteroid are from betamethasone acetate, betamethasone dipropionate or a about 5% to about 40% (w/w) of the polymer, preferably combination thereof. The total amount of betamethasone or about 5% to about 30%, more preferably about 5% to about 40 triamcinolone acetonide incorporated into the microparticle 28% of the polymer. ranges from 10% to 30% (w/w). The microparticles are As the biodegradable polymers undergo gradual bio formulated to mean mass range in size from 10 to 100 erosion within the joint, the corticosteroid is released to the microns. The population of microparticles is formulated to inflammatory site. The pharmacokinetic release profile of be delivered through a 19 gauge or higher needle. Additional the corticosteroid by the biodegradable polymer may be first 45 excipients may be added such as, but not limited to, car order, Zero order, bi- or multi-phasic, to provide desired boxymethylcellulose sodium, mannitol, polysorbate-80, treatment of inflammatory related pain. In any pharmacoki Sodium phosphate, sodium chloride, polyethylene glycol to netic event, the bio-erosion of the polymer and Subsequent achieve isotonicity and promote Syringeability. If betame release of the corticosteroid may result in a controlled thasone is used, then the betamethasone incorporated into release of a corticosteroid from the polymer matrix. The rate 50 the microparticle population provides an initial release of release at dosages that do not suppress the HPA axis are (burst) of about 5-20 mg of drug over a period of 1 to 12 described above. hours, followed by a steady state release of drug at a rate of Excipients about 0.1 to 1.0 mg/day over a period of 14 to 90 days. If The release rate of the corticosteroid from a biodegrad triamcinolone acetonide is used, then the drug incorporated able polymer matrix can be modulated or stabilized by 55 into the microparticle population provides an initial release adding a pharmaceutically acceptable excipient to the for (burst) of about 10-40 mg of drug over a period of 1 to 12 mulation. An excipient may include any useful ingredient hours, followed by a steady state release of drug at a rate of added to the biodegradable polymer depot that is not a about 0.2 to 1.7 mg/day over a period of 14 to 90 days. corticosteroid or a biodegradable polymer. Pharmaceutically acceptable excipients may include without limitation lac 60 Example 2 tose, dextrose. Sucrose, Sorbitol, mannitol, starches, gum acacia, calcium phosphate, alginates, tragacanth, gelatin, Sustained-Release Betamethasone or Triamcinolone calcium silicate, microcrystalline cellulose, PEG, polysor Acetonide Microparticles with an Immediate bate 20, polysorbate 80, polyvinylpyrrolidone, cellulose, Release Form water, Saline, syrup, methyl cellulose, and carboxymethyl 65 cellulose. An excipient for modulating the release rate of a In another embodiment, the microparticle formulation of corticosteroid from the biodegradable drug depot may also Example 1 is further admixed with an immediate release US 9,555,048 B2 41 42 betamethasone or triamcinolone acetonide component. Such 16, 17-acetonide; 9C-Fluoro-16C.-hydroxyprednisolone 16C. as a betamethasone or triamcinolone acetonide containing 17O-acetonide) incorporated into PLGA microparticles. solution. If betamethasone is used, then the betamethasone In one suitable thirty day formulation, 250 mg of triam in the immediate release component is in the form of either cinolone acetonide and 750 mg of PLGA (lactide:glycolide betamethasone acetate, betamethasone dipropionate or a molar ratio of 75:25, inherent viscosity of 0.4 dL/g and combination thereof. If betamethasone is used, then the molecular weight of 54 kDa) were dispersed in 14.25 grams immediate release component provides an initial release of of dichloromethane. The dispersion was atomized into a total of about 5 to 20 mg of betamethasone over the first micro-droplets by adding the dispersion to the feed well of 1-10 days, while the Sustained release component releases a rotating disk, rotating at a speed of approximately 3300 betamethasone at a rate of about 0.1 to 1.0 mg/day over the 10 first 14 to 90 days following administration. If triamcinolone rpm inside a temperature controlled chamber maintained at acetonide is used, then the immediate release component 38-45° C. The solvent was evaporated to produce solid provides an initial release of a total of 10 to 40 mg of drug microparticles. The microparticles were collected using a over the first 1-10 days, while the sustained release compo cyclone separator and, Subsequently, Sieved through a 150 nent releases drug at a rate of about 0.2 to 1.7 mg/day over 15 um sieve. the first 14 to 90 days following administration. Particle size of the TCA incorporated microparticles was determined using laser diffraction (Malvern Mastersizer Example 3 2000) by dispersing a 250 mg aliquot in water, with the refractive index (RI) for water and PLGA, set at 1.33 and Determination of Time-Variance in HPA Axis 1.46 respectively. Sonication was maintained as the sample Sensitivity was stirred at 2500 rpm and measurements taken every 15 seconds, with the average of three measurements reported. Adult volunteers (N=4 to 9 per group) give appropriate 10 mg of TCA containing microparticles were added to 10 informed consent. Each individual in each group receives a mL of dimethylsulfoxide (DMSO), mixed until dissolved single intra-articular administration of an exogenous corti 25 and an aliquot analyzed by HPLC to determine the micropar costeroid (triamcinolone acetonide 40 mg. triamcinolone ticle drug load. Another 4 mg of TCA containing micropar hexacetonide 20; betamethasone 7 mg (disodium phosphate ticles were suspended in 20 mL of phosphate buffered saline 4 mg/acetate 3 mg). Blood samples for measurement of (PBS) containing 0.5% sodium dodecyl sulfate (SDS) main corticosteroid concentrations and/or cortisol concentrations tained at 37° C. 0.5 mL of the media was removed at regular are drawn at 8 AM at baseline and on days 1, 7, 9, 10, 12, 30 intervals, replaced at each interval with an equivalent 14, 18, and 21. The extent of Suppression of endogenous amount of fresh media to maintain a constant volume, and cortisol was measured in each subject in each group. The analyzed by HPLC to determine microparticle in vitro extent of cortisol Suppression predicted by previously pub release. Analysis by HPLC was conducted using a C18 lished models (Meibohm, 1999) was determined and com (Waters Nova-Pack C-18, 3.9x150 mm) and 35% acetoni pared to observations (FIG. 4 Column 1). The change trile mobile phase at 1 ml/min flow rate with UV detection (decrease) in HPA axis sensitivity vs. time is then deter at 240 nm. The results are shown in Table 5. TABLE 5 Analytical Results for 25% Triancinolone Acetonide PLGA 75:25 Microparticles PLGA (lactide:glycolide molar ratio ratio inherent viscosity/molecular weight target 96 Drug load Incorporation Particle size In vitro release TCA (% TCA by weight) efficiency (%) (Dv, Im) (%) 75:25 carboxylic 24 96 D0.1: 32 m 0.2 day: 5.1 acid end-capped D0.5:49 lim 1 day: 13.5 0.4 dLig D0.9: 73 lim 3 day: 29.6 54 kDa 7 day: 52.6 25% 14 day 70.9 21 day: 76.4 28 day: 79.1 mined on a day-by-day and final basis (FIG. 4, Column 2), 55 The in vitro cumulative release profile is graphed in FIG. permitting determination of the correct steady-state intra 5. articular doses of corticosteroid to achieve, or limit, HPA In one iteration of these data, the amount of TCA released axis Suppression to the desired level. per day was calculated based on a human dose, as exem plified in Table 2, that would achieve a transient suppression Example 4 60 of endogenous cortisol (greater than 50%) and, within 14 days, achieve cortisol Suppression of endogenous cortisol of Preparation of Triamcinolone Acetonide less than 35% as shown in FIG. 6. In a second iteration of Microparticles by Spinning Disk these data, the amount of triamcinolone acetonide released per day was calculated based on a human dose, as exem A pharmaceutical depot was prepared comprised of the 65 plified in Table 2 that would not suppress the HPA axis, i.e. corticosteroid, triamcinolone acetonide (TCA, 9C.-Fluoro endogenous cortisol Suppression never exceeding 35% as 11B, 16C., 17C, 21-tetrahydroxy-1,4-pregnadiene-320-dione shown in FIG. 7. These calculated doses equal 376 mg of US 9,555,048 B2 43 44 microparticles containing 94 mg of TCA and 80 mg of LPLG triblock copolymers: protein stabilization and in-vitro microparticles containing 20 mg of TCA, respectively. release properties.' J Control Release, 56 (1-3) (1998): In a second preparation of the same formulation, analyzed 105-15; Yeh, “The stability of insulin in biodegradable and in vitro release plotted in the same manner, the results microparticles based on blends of lactide polymers and are equivalent as shown in Table 6, and FIGS. 8, 9 and 10. polyethylene glycol. J Microencapsul, 17(6) (2000): 743 The calculated human dose, as exemplified in Table 2 that 56). would achieve a transient Suppression of endogenous corti In one iteration, 250 mg of triamcinolone acetonide, 50 sol (greater than 50%) and, within 14 days, achieve cortisol mg of polyethylene glycol (PEG 1450) and 700 mg of PLGA Suppression of endogenous cortisol of less than 35% equals (lactide:glycolide molar ratio of 75:25, inherent viscosity of 280 mg of microparticles containing 70 mg of TCA. The 10 0.4 dL/g and molecular weight of 54 kDa) were dispersed in calculated human dose, as exemplified in Table 2 that would 14 grams of dichloromethane. In another iteration, 250 mg not suppress the HPA axis, i.e. endogenous cortisol Suppres of triamcinolone acetonide, 100 mg of polyethylene glycol sion never exceeding 35% equals 68 mg of microparticles (PEG 3350) and 650 mg of PLGA (lactide:glycolide molar containing 17 mg of TCA. ratio of 75:25, inherent viscosity of 0.4 dL/g and molecular TABLE 6 Analytical Results for Alternate Preparation of a Nominal 25% Triamcinolone Acetonide PLGA 75:25 Microparticles PLGA ( lactide:glycolide molar ratio ratio inherent viscosity/molecular Drug load weight target 96 (% TCA by Incorporation Particle size In vitro release TCA weight) efficiency (%) (Dv, Im) (%) 75:25 carboxylic 27.5 110 D0.1: 30.9 m O.2 day: 4.8 acid end-capped D0.5: 48.2 m 1 day: 15 0.4 dLig D0.9: 71.0 m 3 day: 28.5 54 kDa 7 day: 50.2 25% 14 day 67.1 21 day: 74.2 28 day: 75.7

Influence of PEG on PLGA 75:25 Formulations: weight of 54 kDa) were dispersed in 13 grams of dichlo In other Suitable formulations, polyethylene glycol was 35 romethane. The dispersions were atomized into micro-drop added to the PLGA 75:25 polymers while keeping the target lets by adding the dispersion to the feed well of a rotating amount of triamcinolone acetonide constant. PEG/PLGA disk, rotating at a speed of approximately 3300 rpm inside blends are known to allow for more complete and faster release of pharmaceutical agents incorporated into micropar a temperature controlled chamber maintained at 38-45° C. ticles than PLGA alone (Cleek et al. “Microparticles of 40 The solvent was evaporated to produce Solid microparticles. poly(DL-lactic-coglycolic acid)/poly(ethylene glycol) The microparticles were collected using a cyclone separator blends for controlled drug delivery.' J Control Release 48 and, Subsequently, sieved through a 150 um sieve. (1997): 259-268; Morlock, et al. “Erythropoietin loaded The microparticles were analyzed as described above and microspheres prepared from biodegradable LPLG-PEO the data is shown in Table 7. TABLE 7 Analytical Results of Nominal 25% Triamcinolone Acetonide PLGA 75:25 Microparticles containing Polyethylene Glycol (PEG) Additive PLGA (lactide:glycolide molar ratio ratio inherent viscosity/molecular Drug load weight target 96 (% TCA by Incorporation Particle size In vitro release TCA% PEG weight) efficiency (%) (Dv, Im) (%) 75:25 carboxylic 29.4 118 D0.1: 36.2 m 0.2 day: 3.6 acid end-capped D0.5: 59.0 m 1 day: 13.8 0.4 dLig D0.9: 95.5 m 3 day: 30.1 54 kDa 7 day: 49.5 25% 14 day 65.5 5% PEG 1450 21 day: 74.0 28 day: 78.5 75:25 carboxylic 24.5 98 D0.1: 32.0 m 0.2 day: 4.1 acid end-capped D0.5: 52.4 lim 1 day: 11.7 0.4 dLig D0.9: 79.0 m 3 day: 24.5 54 kDa 7 day: 40.8 US 9,555,048 B2 45 46 TABLE 7-continued Analytical Results of Nominal 25% Triamcinolone Acetonide PLGA 75:25 Microparticles containing Polyethylene Glycol (PEG) Additive PLGA (lactide:glycolide molar ratio ratio inherent viscosity/molecular Drug load weight target 96 (% TCA by Incorporation Particle size In vitro release TCA% PEG weight) efficiency (%) (Dv, Im) (%) 25% 14 day: 55.8 10% PEG 3350 21 day: 63.7 28 day: 69.5

15 The in vitro cumulative release profile is graphed in FIG. exceeding 35% as shown in FIGS. 15 and 16. These calcu 11 and FIG. 12. PEG did not seem to enhance the release of lated doses equal 68 mg of microparticles containing 17 mg the TCA in either formulation, as would be expected. In fact, of TCA and 88 mg of microparticles containing 22 mg of at higher percentages of PEG, albeit a different molecular TCA, respectively. weight (higher percentages of PEG 1350 were unmanage Other TCA containing formulations were tried with PEG able due to the agglomeration of microparticles), the release and PLGA 75:25 without success. A PLGA microparticle rate was slower. formulation containing 25% TCA and 25% PEG 1450 In one iteration of these in vitro release data, the amount agglomerated during manufacture and storage. Another of TCA released per day was calculated based on a human 25 PLGA formulation containing 40% TCA and 15% PEG dose, as exemplified in Table 2, that would achieve a 1450 gave similar results to the microparticles containing temporary Suppression of endogenous cortisol (greater than 40% TCA and no PEG. 50%) and, within 14 days, achieve cortisol suppression of endogenous cortisol of less than 35% as shown in FIG. 13 Influence of Triamcinolone Acetonide Content in PLGA and FIG. 14. These calculated doses equal 296 mg of 3 75:25 Microparticles: microparticles containing 74 mg of TCA and 316 mg of Triamcinolone acetonide containing microparticle depots microparticles containing 79 mg of TCA, respectively. In a were prepared and analyzed, as described above, with the second iteration of these data, the amount of triamcinolone exception of using 100 mg, 150 mg, 200 mg and 400 mg acetonide released per day was calculated based on a human triamcinolone acetonide and adding to a 5% PLGA dichlo dose, as exemplified in Table 2 that would not suppress the romethane Solution. The physical characteristics of these HPA axis, i.e. endogenous cortisol Suppression never formulations are shown in Table 8. TABLE 8 Analytical Results of PLGA 75:25 Microparticles containing varying amounts of Triamcinolone Acetonide PLGA (lactide:glycolide molar ratio ratio inherent viscosity/molecular Drug load weight target 96 (% TCA by Incorporation Particle size In vitro release TCA weight) efficiency (%) (Dv, Im) (%) 75:25 carboxylic 43.4 109 D0.1: 40.7 m 0.2 day: 6.6 acid end-capped D0.5: 70.7 m ay: 24.2 0.4 dLig D0.9: 167 m 3 day: 53.8 54 kDa 7 day: 82.5 40% 14 day 89.4 21 day: 89.6 28 day: 87.5 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 0.4 dLig D0.9: 70.5 m 3 day: 23.7 54 kDa 7 day: 35.3 20% 14 day 44.4 21 day: 48.1 28 day: 50.6 75:25 carboxylic 15.9 106 D0.1: 30.7 m 0.2 day: 3.9 acid end-capped D0.5: 47.8 m ay: 9.0 0.4 dLig D0.9: 74.8 m 3 day: 14.2 54 kDa 7 day: 19.3 15% 14 day 22.7 21 day: 24.6 28 day: 27.6 75:25 carboxylic 11.7 117 D0.1: 31.0 m 0.2 day: 2.3 acid end-capped D0.5: 57.9 m ay: 4.4 0.4 dLig D0.9: 118 m 3 day: 5.9 US 9,555,048 B2 47 48 TABLE 8-continued Analytical Results of PLGA 75:25 Microparticles containing varying amounts of Triamcinolone Acetonide PLGA (lactide:glycolide molar ratio ratio inherent viscosity/molecular Drug load weight target 96 (% TCA by Incorporation Particle size In vitro release TCA weight) efficiency (%) (Dv, Im) (%) 54 kDa 7 day: 7.5 10% 14 day 9.9 21 day: 11.7 28 day: 15.8

The in vitro cumulative release profiles for these four atomized into micro-droplets by adding the dispersion to the other TCA containing PLGA 75:25 microparticle depots are feed well of a rotating disk, rotating at a speed of approxi graphed in FIG. 17, along with the preferred formulation mately 3300 rpm inside a temperature controlled chamber (25% TCA). The tabulated data and graph show the impact maintained at 38-45° C. The solvent was evaporated to of the percent TCA incorporated in the PLGA microparticles produce Solid microparticles. The microparticles were col on the in vitro release profile. The 10%, 15% and 20% TCA lected using a cyclone separator and, Subsequently, sieved containing PLGA microparticles exhibit a slower release through a 150 um sieve. profile, with a significant less cumulative release over 28 Particle size of the TCA incorporated microparticles was days, less than 20%, 30% and 55% respectively, than the 25 25% TCA PLGA depot exemplified in Example 4. The 40% determined using laser diffraction (Malvern Mastersizer TCA containing depot exhibits a faster release profile, with 2000) by dispersing a 250 mg aliquot in water, with the greater than 80% of the triamcinolone released by day 7 with refractive index (RI) for water and PLGA, set at 1.33 and a similar total cumulative release, than the 25% TCAPLGA 1.46 respectively. Sonication was maintained as the sample depot exemplified in Example 4. 30 was stirred at 2500 rpm and measurements taken every 15 Influence of Molecular Weight on TCA PLGA 75:25 seconds, with the average of three measurements reported. Microparticle Formulations: 10 mg of TCA containing microparticles were added to 10 In another microparticle formulation, triamcinolone mL of dimethylsulfoxide (DMSO), mixed until dissolved acetonide was incorporated in PLGA of the same lactide to and an aliquot analyzed by HPLC to determine the micropar glycolide molar ratio as cited in Example 4 but of a lower 35 ticle drug load. Another 4 mg of TCA containing micropar molecular weight. Low molecular weight PLGA is known to ticles were suspended in 20 mL of phosphate buffered saline allow for more complete and faster release of pharmaceu (PBS) containing 0.5% sodium dodecyl sulfate (SDS) main tical agents incorporated into microparticles than their tained at 37° C. 0.5 mL of the media was removed at regular higher molecular weight counterparts. (Anderson et al. "Bio intervals, replaced at each interval with an equivalent degradation and biocompatibility of PLA and PLGA micro 40 amount of fresh media to maintain a constant volume, and spheres.” Advanced Drug Delivery Reviews 28 (1997): 5-24: analyzed by HPLC to determine microparticle in vitro Bouissou et al., “Poly(lactic-co-glycolicacid) Micro release. Analysis by HPLC was conducted using a C18 spheres.’ Polymer in Drug Delivery (2006): Chapter 7). (Waters Nova-Pack C-18, 3.9x150 mm) and 35% acetoni 250 mg of triamcinolone acetonide and 750 mg of PLGA trile mobile phase at 1 ml/min flow rate with UV detection (lactide:glycolide molar ratio of 75:25, inherent viscosity of at 240 nm. The results are shown in Table 9. TABLE 9 Analytical Results of a Nominal 25% Triamcinolone Acetonide PLGA 75:25 (29 kDa) Microparticles PLGA (lactide:glycolide molar ratio ratio inherent viscosity/molecular Drug load weight target 96 (% TCA by Incorporation Particle size In vitro release weight) efficiency (%) (Dv, Im) (%) 75:25 carboxylic 29.4 118 D0.1: 34.1 m 0.2 day: 4.0 acid end-capped D0.5: 56.5 m 1 day: 11.3 0.27 dLig D0.9: 95.2 m 3 day: 22.5 29 kDa 7 day: 35.9 25% 14 day: 48.3 21 day: 53.4 28 day: 56.5

65 0.27 dL/g and molecular weight of 29 kDa) were dispersed In vitro cumulative release data is graphed in FIG. 18, in 14.25 grams of dichloromethane. The dispersion was along with the preferred formulation using a higher molecu US 9,555,048 B2 49 50 lar PLGA 75:25. The use of lower molecular weight PLGA 650 mg of PLGA (lactide:glycolide molar ratio of 50:50, (29 kDa) did not improve the release of the triamcinolone inherent viscosity of 0.48 dL/g and molecular weight of 66 acetonide from the microparticles as expected, in fact the kDa) were dispersed in 14.25 grams of dichloromethane. In rate of release decreased and the release was incomplete as another iteration, 300 mg of triamcinolone acetonide and compared to higher molecular weight PLGA (PLGA, 54 700 mg of PLGA (lactide:glycolide molar ratio of 50:50, kDa). inherent viscosity of 0.18 dL/g and molecular weight of 18 In another formulation of low molecular weight PLGA kDa) to yield 1000 mg total solids were dispersed in 14.25 75:25(29 kDa), polyethylene glycol, 10% PEG 3350, was grams of dichloromethane. The dispersions were atomized added while maintaining the same amount of triamcinolone into micro-droplets by adding the dispersion to the feed well acetonide. As shown with other PEG containing formula 10 of a rotating disk, rotating at a speed of approximately 3300 tions, there was no impact of this additive on the cumulative rpm inside a temperature controlled chamber maintained at percent in vitro release profile as compared to the formula 38-45° C. The solvent was evaporated to produce solid tion not containing PEG (data not shown). microparticles. The microparticles were collected using a Influence of PLGA Lactide to Glycolide Ratio: cyclone separator and, Subsequently, Sieved through a 150 In other triamcinolone acetonide microparticle formula 15 um sieve. tions, PLGA of equimolar lactide to glycolide ratio were Particle size of the TCA incorporated microparticles was employed instead of PLGA (75:25). PLGA (50:50) is known determined using laser diffraction (Malvern Mastersizer to allow for faster degradation and release of pharmaceutical 2000) by dispersing a 250 mg aliquot in water, with the agents incorporated into microparticles than PLGAs with refractive index (RI) for water and PLGA, set at 1.33 and greater lactide versus glycolide content (Anderson et al. 1.46 respectively. Sonication was maintained as the sample “Biodegradation and biocompatibility of PLA and PLGA was stirred at 2500 rpm and measurements taken every 15 microspheres.” Advanced Drug Delivery Reviews 28 (1997): seconds, with the average of three measurements reported. 5-24; Bouissou et al., “Poly(lactic-co-glycolicacid) Micro 10 mg of TCA containing microparticles were added to 10 spheres.’ Polymer in Drug Delivery (2006): Chapter 7). mL of dimethylsulfoxide (DMSO), mixed until dissolved Multiple formulations using PLGA 50:50 with differing 25 and an aliquot analyzed by HPLC to determine the micropar amounts of triamcinolone acetonide, with and without PEG, ticle drug load. Another 4 mg of TCA containing micropar different PLGA molecular weights and different PLGA ticles were suspended in 20 mL of phosphate buffered saline endcaps were exemplified. (PBS) containing 0.5% sodium dodecyl sulfate (SDS) main Formulations were prepared with 200 mg, 250 mg. 300 tained at 37° C. 0.5 mL of the media was removed at regular mg and 350 mg of triamcinolone acetonide and correspond 30 intervals, replaced at each interval with an equivalent ing amount of PLGA (lactide:glycolide molar ratio of 50:50, amount of fresh media to maintain a constant volume, and inherent viscosity of 0.48 dL/g and molecular weight of 66 analyzed by HPLC to determine microparticle in vitro kDa) to yield 1000 mg total solids were dispersed into a release. Analysis by HPLC was conducted using a C18 quantity of dichloromethane to a achieve a 5% PLGA (Waters Nova-Pack C-18, 3.9x150 mm) and 35% acetoni solution. In another iteration, 300 mg of triamcinolone 35 trile mobile phase at 1 ml/min flow rate with UV detection acetonide, 100 mg of polyethylene glycol (PEG 3350) and at 240 nm. The results are shown in Table 10. TABLE 10 Analytical Results of Triamcinolone Acetonide PLGA 50:50 Microparticle Formulations PLGA (lactide:glycolide molar ratio ratio inherent viscosity/molecular Drug load weight target 96 (% TCA by Incorporation Particle size In vitro release TCA% PEG weight) efficiency (%) (Dv, Im) (%) 50:50 carboxylic 19.2 96 D0.1: 30.0 m 0.2 day: 2.1 acid end-capped D0.5:48.5 m ay: 3.3 0.48 dLig D0.9: 77.0 m 3 day: 17.0 66 kDa 7 day: 18.7 20% TCA 14 day: 21.0 21 day: 23.5 28 day: 25.6 50:50 carboxylic 23.9 95.6 D0.1: 30.2 m 0.2 day: 4.0 acid end-capped D0.5: 48.2 m ay: 7.8 0.48 dLig D0.9: 75.8 m 3 day: 21.1 66 kDa 7 day: 32.1 25% TCA 14 day: 39.2 21 day: 40.0 28 day: 40.8 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 0.48 dLig D0.9: 68.9 m 3 day: 33.6 66 kDa 7 day: 49.9 30% TCA 14 day: 54.0 21 day: 53.2 28 day: 52.2 US 9,555,048 B2 51 52 TABLE 10-continued Analytical Results of Triamcinolone Acetonide PLGA 50:50 Microparticle Formulations PLGA (lactide:glycolide molar ratio ratio inherent viscosity/molecular Drug load weight target 96 (% TCA by Incorporation Particle size In vitro release TCA% PEG weight) efficiency (%) (Dv, Im) (%) 50:50 carboxylic 27.2 91 D0.1: 37.6 m 0.2 day: 4.4 acid end-capped D0.5: 59.8 m 1 day: 9.8 0.18 dLig D0.9: 93.9 m 3 day: 13.8 18 kDa 7 day: 17.7 30% TCA 14 day: 21.9 21 day: 26.3 28 day: 36.6 50:50 carboxylic 30.4 101 D0.1: 38.1 p.m. 0.2 day: 4.2 acid end-capped D0.5: 56.6 m 1 day: 14.6 0.48 dLig D0.9:82.1 um 3 day: 32.2 66 kDa 7 day: 51.0 30% TCA 14 day: 60.1 10% PEG 3350 21 day: 61.1 28 day: 60.1 50:50 carboxylic 34.4 98.3 D0.1: 35.1 Im 0.2 day: 7.1 acid end-capped D0.5: 52.3 lim 1 day: 23.3 0.48 dLig D0.9: 75.6 m 3 day: 47.6 66 kDa 7 day: 66.9 35% TCA 14 day: 69.3 21 day: 68.3 28 day: 66.7 50:50 ester 23.2 93 D0.1: 34.2 m 0.2 day: 3.1 endcapped D0.5: 51.7 m 1 day: 7.8 0.4 dLig D0.9: 77.4 m 3 day: 12.5 66 kDa 7 day: 15.4 25% TCA 14 day: 16.2 21 day: 16.0 28 day: 16.4

35 In-vitro release profiles of the various PLGA (50:50) Example 5 formulations are shown in the FIG. 19. The use of PLGA (50:50) did not improve the release kinetics of the triamci Preparation of Triamcinolone Acetonide PLGA Microparticles by Solid in Oil in Water (S/O/W) nolone acetonide as compared to the PLGA (75:25). Unex- 40 Emulsion pectedly, 25% triamcinolone acetonide microparticles in PLGA (50:50) release the corticosteroid at a slower rate and A pharmaceutical depot was prepared comprised of the give an incomplete release as compared to the equivalent corticosteroid, triamcinolone acetonide (TCA, 9C.-Fluoro 11B, 16C., 17C, 21-tetrahydroxy-1,4-pregnadiene-320-dione amount of triamcinolone acetonide incorporated in PLGA 45 16, 17-acetonide; 9C-Fluoro-16C.-hydroxyprednisolone 16C. 75:25. All the PLGA 50:50 formulation show a Substantial 17C.-acetonide) incorporated into microparticles. lag phase, where little or any TCA is being released after 7 Formulations were prepared by dissolving approximately days, which continues to about day 50. As observed with 1 gram of PLGA in 6.67 mL of dichloromethane (DCM). To TCA PLGA 75:25 formulations, increasing the amount of 50 the polymer Solution, 400 mg of triamcinolone acetonide was added and Sonicated. Subsequently, the corticosteroid TCA increases the rate of release and allows for more TCA containing dispersion was poured into 200 ml, of 0.3% to be released before entering the lag phase. Similarly, the polyvinyl alcohol (PVA) solution while homogenizing with addition of PEG has minimal influence on the release rate of a Silverson homogenizer using a rotor fixed with a Silverson TCA, while lower molecular weight PLGA 50:50 decrease 55 Square Hole High Shear ScreenTM, set to rotate at approxi the release rate as observed with PLGA 75:25 formulations. mately 2,000 rpm to form the microparticles. After two minutes, the beaker was removed, and a glass magnetic Based on the studies described herein, the Class B corti stirrer) added to the beaker, which was then placed onto a costeroid microparticle formulations, for example, the TCA multi-way magnetic stirrer and stirred for four hours at 300 microparticle formulations, exhibiting the desired release 60 rpm to evaporate the DCM. The microparticles were then kinetics have the following characteristics: (i) the corticos washed with 2 liters of distilled water, sieved through a 100 teroid is between 22%-28% of the microparticle; and (ii) the micron screen. The microparticles were then lyophilized for greater than 96 hours and vacuum packed. polymer is PLGA having a molecular weight in the range of Particle size of the TCA incorporated microparticles was about 40 to 70 kDa, having an inherent viscosity in the range 65 determined using laser diffraction (Beckman Coulter LS of 0.3 to 0.5 dL/g, and or having a lactide:glycolide molar 230) by dispersing a 50 mg aliquot in water, with the ratio of 80:20 to 60:40. refractive index (RI) for water and PLGA, set at 1.33 and US 9,555,048 B2 53 54 1.46 respectively. The sample was stirred at the particle size drug delivery carriers for regenerative medicine. J Pharm measurement measurements taken and the results reported. Sci 97(9) (2008): 3972-80). It is synthesized using a ring Drug load was determined by Suspending a nominal 10 mg opening polymerization of cyclic dimmers of D.L-lactide of microparticles in 8 ml HPLC grade methanol and soni cating for 2 hours. Samples were then centrifuged at 14,000 and glycolide with PEG 1,500 kDa in the presence of g for 15 mins before an aliquot of the Supernatant was Stannous octoate. In vitro release (lactide:glycolide molar assayed via HPLC as described below. Corticosteroid ratio of 50:50, inherent viscosity of 0.40 dL/g and molecular loaded microparticle samples, nominally 1 g were placed in weight of 66 kDa). The analytical results for these formu 22 ml glass vials in 8-20 ml of 0.5% v/v Tween 20 in 100 lations are shown in Table 11. TABLE 11 Analytical Results of Nominal 28.6% Triamcinolone Acetonide in PLGA 75:25 plus Triblock Microparticle Formulations PLGA (lactide:glycolide molar ratio ratio inherent viscosity/molecular Drug load weight target 96 (% TCA by Incorporation Particle size In vitro release TCA% PEG weight) efficiency (%) (Dv, Im) (%) 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 0.71 dLig D0.9: 103.0 lim 3 day: 15.7 114 kDa 4 day 18.2 28.6% TCA 6 day: 28.8 10% Triblock 9 day: 38.9 12 day: 49.8 16 day: 61.6 20 day: 66.4 24 day: 68.7 30 day: 72:3 35 day: 72.8 75:25 ester 24.8 86.7 D0.1: 39.5 m 1 day: 5.5 endcapped D0.5: 74.6 m 2 day: 8.9 0.71 dLig D09: 104.2 m 3 day: 12.8 114 kDa 4 day 14.5 28.6% TCA 6 day: 28.4 20% Triblock (TB) 9 day: 35.6 12 day: 47.8 16 day: 53.0 20 day: 64.3 24 day: 67.3 30 day: 73.0 35 day: 73.0 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 containing formulations are shown in FIG. 20. The amount sample was prepared and analyzed in duplicate to monitor 45 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 plified in Table 2, that may achieve a temporary Suppression mM phosphate buffered saline. Drug load and in vitro 50 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 ticles containing 62 mg of TCA, for the 10% and 20% temperature of 40° C. An isocratic mobile phase of 60% 55 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 axis, i.e. endogenous cortisol Suppression more than 35%. ratio of 75:25, inherent viscosity of 0.71 dL/g and molecular 60 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 (PLGA-PEG-PLGA). Triblock polymer was synthesized mg of TCA, for the 10% and 20% triblock formulations using a method described by Zentner et al 2001 (Zentner et respectively (FIG. 23 and FIG. 24). al. “Biodegradable block copolymers for delivery of pro In another suitable formulation lasting greater than 30 teins and water-insoluble drugs.' J Control Release 72 65 days and up to 90 days, the PLGA polymer consists of two (2001): 203-15) and refined by Hou et al 2008 (Hou et al., different molecular weight PLGA 75:25 polymers in a two “In situ gelling hydrogels incorporating microparticles as to one ratio, PLGA 75:25 (lactide:glycolide molar ratio of US 9,555,048 B2 55 56 75:25, inherent viscosity of 0.27 dI/g and molecular weight 12 and then entered a lag phase where no drug was released of 29 kDa) and ester end capped PLGA 5.5E (lactide: up to 30 days (See FIG. 28). A similar phenomenon is seen glycolide molar ratio of 75:25, inherent viscosity of 0.58 as shown in Example 4, where the mixed molecular weight dL/g and molecular weight of 86 kDa), respectively. The PLGA 75:25 unexpectedly exhibits faster initial release of formulation was processed as described above with the the triamcinolone acetonide than PLGA 50:50. exception that 200 mg of triamcinolone acetonide was used Based on the studies described herein, the Class B corti in the formulation instead of 400 mg and similarly analyzed costeroid microparticle formulations, for example, the TCA as describe for other formulations. The results are shown in microparticle formulations, exhibiting the desired release the Table 12. kinetics have the following characteristics: (i) the corticos TABLE 12 Analytical Results of a Nominal 16.7% Triamcinolone Acetonide in Mixed Molecular Weight PLGA 75:25 Microparticle Formulation PLGA (lactide:glycolide molar ratio ratio inherent viscosity/molecular Drug load weight target 96 (% TCA by Incorporation Particle size In vitro release TCA% PEG weight) efficiency (%) (Dv, Im) (%) 75:25 ester 14.6 87.7 D0.1: 36.5 m day: 12.4 endcapped D0.5: 54.0 m day: 21.6 0.58 dLig D0.9: 69.4 m day: 27.3 86 kDa day 33.6 And day: 41.2 75:25 carboxylic day: 50.7 acid endcapped day: 54.3 0.27 dLig day: 62.0 29 kDa day: 73.1 16.7% TCA day: 75.5 day: 82.9 day: 84.6 day: 87.4 day: 89.2

In vitro cumulative percent TCA release data is graphed 35 teroid is between 12%-28% of the microparticle; and (ii) the in FIG. 25. polymer is (1) PLGA having a molecular weight in the range In one iteration of these in vitro release data, the amount of about 40 to 70 kDa, having an inherent viscosity in the of TCA released per day was calculated based on a human range of 0.3 to 0.5 dL/g, containing 10%-20% Triblock dose, as exemplified in Table 2, which may achieve a and/or having a lactide:glycolide molar ratio of 80:20 to temporary Suppression of endogenous cortisol (greater than 40 60:40 or (2) a mixture of low and high molecular weight 50%) and, within 14 days, achieve cortisol suppression of PLGAs in a two to one ratio. The low molecular weight endogenous cortisol of less than 35%. This calculated dose PLGA has a molecular weight of range of 15-35 kDa and an equals 317 mg of microparticles containing 46 mg of TCA. inherent viscosity range from 0.2 to 0.35 dL/g, and the high In a second iteration of these data, the amount of TCA molecular weight PLGA has a range of 70-95 kDa and an released per day was calculated based on a human dose, as 45 inherent viscosity range of 0.5 to 0.70 dL/g. exemplified in Table 2, that would not have an suppress the HPA axis, i.e. endogenous cortisol Suppression more than Example 6 35%. This calculated dose equals 93 mg of microparticles containing 14 mg of TCA. Preparation of Prednisolone PLGA Microparticles Several other triamcinolone acetonide PLGA depots were 50 by Solid in Oil in Water (S/O/W) Emulsion formulated in the same manner as described above with different polymers including polycaprolactone (14 kDa), A pharmaceutical depot was prepared comprised of the PLGA 50:50 (carboxylic acid end-capped, 0.44 dL/g, MW corticosteroid, prednisolone (PRED, 11B, 17.21-trihydroxy 56 kDa), PLGA 85:15 (carboxylic acid end-capped, 0.43 pregna-1,4-diene-320-dione) incorporated into micropar dL/g, 56 kDa) and a mixed molecular weight formulation 55 ticles in PLGA 50:50. using PLGA 75:25 (carboxylic acid end capped, 0.27 dL/g, Formulations were prepared by dissolving approximately MW 29 kDa) and PLGA 75:25 (ester end-capped, 0.57 dL/g, 1 gram of PLGA 50:50 (lactide:glycolide molar ratio of MW 86 kDa) in a two to one ratio. The in vitro cumulative 50:50, inherent viscosity 0.44 dL/g, MW 56 kDa) in 6.67 mL percent release of triamcinolone acetonide is shown in FIG. of dichloromethane (DCM). To the polymer solution, 400 28. None of these formulations were suitable for a nominal 60 mg of prednisolone was added and Sonicated. Subsequently, thirty day or longer duration pharmaceutical depot. Poly the corticosteroid containing dispersion was poured into 200 caprolactone release all the triamcinolone acetonide prior to mL of 0.3% polyvinyl alcohol (PVA) solution while homog 14 days. The PLGA 50:50 microparticles released about enizing with a Silverson homogenizer using a rotor fixed 35% of its content by day 12 and then entered a lag phase with a Silverson Square Hole High Shear ScreenTM, set to where no drug was released up to 30 days. The PLGA85:15 65 spin at 2,000 rpm to form the microparticles. After two microparticles exhibited similar in vitro release kinetics as minutes, the beaker was removed, and a glass magnetic the PLGA 50:50, releasing about 30% of its content by day stirrer) added to the beaker, which was then placed onto a US 9,555,048 B2 57 58 multi-way magnetic stirrer and stirred for four hours at 300 enous cortisol (greater than 50%) and, within 14 days, rpm to evaporate the DCM. The microparticles were then achieve cortisol Suppression of endogenous cortisol of less washed with 2 liters of distilled water, sieved through a 100 than 35% (FIG. 30). The calculated dose equals 699 mg of micron screen. The microparticles were then lyophilized for microparticles containing 133 mg of PRED. In a second greater than 96 hours and vacuum packed. iteration of these data, the amount of PRED released per day Particle size of the PRED incorporated microparticles was was calculated based on a human dose, as exemplified in determined using laser diffraction (Beckman Coulter LS Table 2 that would not suppress the HPA axis, i.e. endog 230) by dispersing a 50 mg aliquot in water, with the enous cortisol suppression of less than 35% (FIG. 31). This refractive index (RI) for water and PLGA, set at 1.33 and calculated dose equals 377 mg of microparticles containing 1.46 respectively. The sample was stirred at the particle size 10 72 mg of PRED. measurement measurements taken and the results reported. Based on the studies described herein, the Class A corti Drug load was determined by Suspending a nominal 10 mg costeroid microparticle formulations, for example, the pred of microparticles in 8 ml HPLC grade methanol and soni nisolone microparticle formulations, exhibiting the desired cating for 2 hours. Samples were then centrifuged at 14,000 release kinetics have the following characteristics: (i) the g for 15 mins before an aliquot of the Supernatant was 15 corticosteroid is between 10%-40% of the microparticle, for assayed via HPLC as described below. Corticosteroid example, between 15%-30% of the microparticle; and (ii) loaded microparticle samples, nominally 1 g were placed in the polymer is PLGA having a molecular weight in the range 22 ml glass vials in 8-20 ml of 0.5% v/v Tween 20 in 100 of about 45 to 75 kDa, having an inherent viscosity in the mM phosphate buffered saline and stored in a 37° C. range of 0.35 to 0.5 dL/g, and or having a lactide:glycolide incubator with magnetic stirring at 130 rpm. Each test molar ratio of 60:40 to 45:55. sample was prepared and analyzed in duplicate to monitor possible variability. At each time point in the release study, Example 7 microparticles were allowed to settle, and an aliquot of between 4-16 ml of Supernatant were taken, and replaced Preparation of Betamethasone PLGA Microparticles with an equal volume of fresh 0.5% v/v Tween 20 in 100 25 by Solid in Oil in Water (S/O/W) Emulsion mM phosphate buffered saline. Drug load and in vitro release samples were analyzed by HPLC using a Hypersil A pharmaceutical depot was prepared comprised of the C18 column (100 mm, i.d. 5 mm, particle size 5 um; corticosteroid, betamethasone (BETA, 9-Fluoro-11B, 17.21 ThermoFisher) and Beckman HPLC. All samples were run trihydroxy-16? 3-methylpregna-1,4-diene-3,20-dione) incor using a sample injection volume of 5 um, and column 30 porated into microparticles in PLGA 50:50. temperature of 40° C. An isocratic mobile phase of 60% A formulation was prepared by dissolving approximately methanol and 40% water was used at a flow rate of 1 ml/min, 1 gram of PLGA 50:50 (lactide:glycolide molar ratio of with detection at a wavelength of 254 nm. The analytical 50:50, inherent viscosity 0.44 dL/g, MW 56 kDa) in 6.67 mL results are shown in the Table 13. of dichloromethane (DCM). To the polymer solution, 400 TABLE 13 Analytical Results of a Nominal 28.6% Prednisolone in PLGA 50:50 Microparticle Formulation PLGA (lactide:glycolide molar ratio ratio inherent viscosity/molecular Drug load (% weight target 96 PRED by Incorporation Particle size In vitro release TCA% PEG weight) efficiency (%) (Dv, Im) (%) 50:50 carboxylic 19.0 66.4 D0.1: 34.4 m ay: 7.2 acid endcapped D0.5: 66.9 m ay: 11.5 0.44 dLig D0.9:87.5 m ay: 15.6 56 kDa ay: 2O2 28.6% PRED ay: 24.0 ay: 28.4 ay: 32.7 ay: 36.5 ay: 41.4 ay: 4S.O ay: 49.3 ay: 52.O ay: 55.2 ay: 58.3 ay: 62.3 ay: 65.9

In vitro release profile of the prednisolone PLGA mg of betamethasone was added and Sonicated. Subse microparticles is shown in FIG. 29. This formulation is quently, the corticosteroid containing dispersion was poured suitable for a 30 day formulation or greater. into 200 mL of 0.3% polyvinyl alcohol (PVA) solution while In one iteration of the cumulative percent in vitro release homogenizing with a Silverson homogenizer using a rotor data, the amount of prednisolone released per day was 65 fixed with a Silverson Square Hole High Shear ScreenTM, set calculated based on a human dose, as exemplified in Table to spin at 2,000 rpm to form the microparticles. After two 2, which may achieve a temporary Suppression of endog minutes, the beaker was removed, and a glass magnetic US 9,555,048 B2 59 60 stirrer) added to the beaker, which was then placed onto a In vitro release profile of the betamethasone PLGA multi-way magnetic stirrer and stirred for four hours at 300 microparticles is shown in FIG. 32. This formulation is rpm to evaporate the DCM. The microparticles were then suitable for a 30 day formulation or greater. washed with 2 liters of distilled water, sieved through a 100 In one iteration of the in vitro release data, the amount of micron screen. The microparticles were then lyophilized for betamethasone released per day was calculated based on a greater than 96 hours and vacuum packed. human dose, as exemplified in Table 2, which may achieve Particle size of the BETA incorporated microparticles was a temporary Suppression of endogenous cortisol (greater determined using laser diffraction (Beckman Coulter LS than 50%) and, within 14 days, achieve cortisol suppression 230) by dispersing a 50 mg aliquot in water, with the of endogenous cortisol of less than 35%. This calculated refractive index (RI) for water and PLGA, set at 1.33 and 10 dose equals 111 mg of microparticles containing 25 mg of 1.46 respectively. The sample was stirred at the particle size betamethasone. In a second iteration of these data, the measurement measurements taken and the results reported. amount of betamethasone released per day was calculated Drug load was determined by Suspending a nominal 10 mg based on a human dose, as exemplified in Table 2 that would of microparticles in 8 ml HPLC grade methanol and soni 15 not suppress the HPA axis, i.e. endogenous cortisol Suppres cating for 2 hours. Samples were then centrifuged at 14,000 sion never exceeding 35%. This calculated dose equals 38 g for 15 mins before an aliquot of the Supernatant was mg of microparticles containing 9 mg of betamethasone. assayed via HPLC as described below. Corticosteroid These doses are both graphically represented in FIGS. 33 loaded microparticle samples, nominally 1 g were placed in and 34. 22 ml glass vials in 8-20 ml of 0.5% v/v Tween 20 in 100 Based on the studies described herein, the Class C corti mM phosphate buffered saline and stored in a 37° C. costeroid microparticle formulations, for example, the incubator with magnetic stirring at 130 rpm. Each test betamethasone microparticle formulations, exhibiting the desired release kinetics have the following characteristics: sample was prepared and analyzed in duplicate to monitor (i) the corticosteroid is between 10%-40% of the micropar possible variability. At each time point in the release study, 25 ticle, for example, between 15%-30% of the microparticle: microparticles were allowed to settle, and an aliquot of and (ii) the polymer is PLGA having a molecular weight in between 4-16 ml of Supernatant were taken, and replaced the range of about 40 to 70 kDa, having an inherent viscosity with an equal volume of fresh 0.5% v/v Tween 20 in 100 in the range of 0.35 to 0.5 dL/g, and or having a lactide: mM phosphate buffered saline. Drug load and in vitro glycolide molar ratio of 60:40 to 45:55. release samples were analyzed by HPLC using a Hypersil 30 C18 column (100 mm, i.d. 5 mm, particle size 5 um; Example 8 ThermoFisher) and Beckman HPLC. All samples were run Preparation of Fluticasone Propionate PLGA using a sample injection volume of 5 um, and column Microparticles by Solid in Oil in Water (S/O/W) temperature of 40° C. An isocratic mobile phase of 60% 35 Emulsion methanol and 40% water was used at a flow rate of 1 ml/min, with detection at a wavelength of 254 nm. The analytical A pharmaceutical depot was prepared comprised of the characteristics of the betamethasone PLGA microparticles corticosteroid, fluticasone propionate (FLUT, S-(fluorom are shown in the Table 14. ethyl) 6.O. 9-difluoro-11 (3,17-dihydroxy-16C.-methyl-3-ox TABLE 1.4 Analytical Results of a Nominal 28.6% Betamethasone PLGA 50:50 Microparticle Formulation PLGA (lactide:glycolide molar ratio ratio inherent viscosity/molecular Drug load (% weight target 96 BETA by Incorporation Particle size In vitro release TCA% PEG weight) efficiency (%) (Dv, Im) (%) 50:50 carboxylic 22.8 79.7 D0.1: 42.1 um ay: 2.0 acid endcapped D0.5: 71.7 m ay: 3.1 0.44 dLig D0.9: 102.7 m ay: 4.8 56 kDa ay: 7.7 28.6% BETA ay: 12.5 ay: 21.4 ay: 30.8 ay: 38.6 11 ay: 43.9 ay: 49.6 15 ay: 55.5 18 ay: 57.5 21 ay: 59.2 24 ay: 60.8 27 ay: 62.9 3O ay: 724 US 9,555,048 B2 61 62 oandrosta-1,4-diene-17f8-carbothioate, 17-propionate) mM phosphate buffered saline. Drug load and in vitro incorporated into microparticles in PLGA 50:50. release samples were analyzed by HPLC using a Hypersil A formulation was prepared by dissolving approximately C18 column (100 mm, i.d. 5 mm, particle size 5 um; 1 gram of PLGA 50:50 (lactide:glycolide molar ratio of 50:50, inherent viscosity 0.45 dL/g, molecular weight 66 is ThermoFisher) and Beckman HPLC. All samples were run kDa) in 6.67 ml, of dichloromethane (DCM). To the polymer using a sample injection Volume of 5 um, and column Solution, 200 mg of fluticaSone propionate was added and temperature of 40° C. An isocratic mobile phase of 60% Sonicated. Subsequently, the corticosteroid containing dis methanol and 40% water was used at a flow rate of 1 ml/min, persion was poured into 200 mL of 0.3% polyvinyl alcohol with detection at a wavelength of 254 nm. The analytical (PVA) solution while homogenizing with a Silverson results of the fluticasone propionate PLGA microparticles homogenizer using a rotor fixed with a Silverson Square are shown in Table 15. TABLE 1.5 Analytical Results of a Nominal 16.7% FluticasOne PLGA 50:50 Microparticle Formulation PLGA (lactide:glycolide molar ratio ratio inherent viscosity/molecular Drug load (% weight target 96 FLUT by Incorporation Particle size In vitro release FLUT weight) efficiency (%) (Dv, Im) (%) 50:50 carboxylic 8.5 S1.1 D0.1: 34.1 um ay: 29.5 acid endcapped D0.5: 65.5 m ay: 43.5 0.45 dLig D0.9: 95.0 m ay: 46.7 66 kDa ay: SO.9 16.7% FLUT ay: 55.5 ay: 58.6 ay: 60.1 ay: 63 11 ay: 66.8 ay: 67.8 15 ay: 68.7 18 ay: 73.7 21 ay: 81.8 24 ay: 93.7 26 ay: 97.1 31 ay: 100.8

Hole High Shear ScreenTM, set to spin at 2,000 rpm to form In vitro release profile of the fluticasone propionate PLGA the microparticles. After two minutes, the beaker was microparticles is shown in FIG. 35. This formulation is removed, and a glass magnetic stirrer) added to the beaker, 40 suitable for a 30 day formulation or greater. which was then placed onto a multi-way magnetic stirrer and In one iteration of the in vitro release data, the amount of stirred for four hours at 300 rpm to evaporate the DCM. The fluticasone propionate released per day was calculated based microparticles were then washed with 2 liters of distilled on a human dose, as exemplified in Table 2, which may water, sieved through a 100 micron screen. The micropar achieve a temporary Suppression of endogenous cortisol ticles were then lyophilized for greater than 96 hours and 5 (greater than 50%) and, within 14 days, achieve cortisol vacuum packed. suppression of endogenous cortisol of less than 35%. This Particle size of the FLUT incorporated microparticles was calculated dose equals 178 mg of microparticles containing determined using laser diffraction (Beckman Coulter LS 15 mg of fluticaSone propionate. In a second iteration of 230) by dispersing a 50 mg aliquot in water, with the these data, the amount of fluticasone propionate released per O day was calculated based on a human dose, as exemplified refractive index (RI) for water and PLGA, set at 1.33 and 5 in Table 2 that would not suppress the HPA axis, i.e. 1.46 respectively. The sample was stirred at the particle size endogenous cortisol Suppression never exceeding 35%. This measurement measurements taken and the results reported. calculated dose equals 24 mg of microparticles containing 2 Drug load was determined by Suspending a nominal 10 mg mg of fluticaSone propionate. These doses are both graphi of microparticles in 8 ml HPLC grade methanol and soni- ss cally represented in FIGS. 36 and 37. cating for 2 hours. Samples were then centrifuged at 14,000 Other fluticasone propionate PLGA depots were formu g for 15 mins before an aliquot of the Supernatant was lated in the same manner as described above with different assayed via HPLC as described below. Corticosteroid PLGA polymers or amounts fluticasone propionate. In one loaded microparticle samples, nominally 1 g were placed in formulation, a PLGA polymer with a higher lactide to 22 ml glass vials in 8-20 ml of 0.5% v/v Tween 20 in 100 60 glycolide ratio (PLGA 75:25 (ester end-capped PLGA mM phosphate buffered saline and stored in a 37° C. 75:25, lactide:glycolide molar ratio of 75:25, 0.58 dL/g, incubator with magnetic stirring at 130 rpm. Each test MW 86 kDa) was used instead of the PLGA 50:50 as sample was prepared and analyzed in duplicate to monitor previously described. Unlike the triamcinolone acetonide possible variability. At each time point in the release study, preparations described in Example 5, but typically expected microparticles were allowed to settle, and an aliquot of 65 as described in the literature, the higher lactide to glycolide between 4-16 ml of Supernatant were taken, and replaced ratio resulted in a slower release, where 30% release in 14 with an equal volume of fresh 0.5% v/v Tween 20 in 100 days, followed by a Substantial lag phase where little drug is US 9,555,048 B2 63 64 released for a minimum of thirty days. In another example, at 300 rpm to evaporate the DCM. The microparticles were 400 mg of fluticasone propionate instead of 200 mg was then washed with 2 liters of distilled water, sieved through used in preparation of PLGA 50:50 microparticles (target a 100 micron screen. The microparticles were then drug load 28.6%). Unlike triamcinolone acetonide micropar lyophilized for greater than 96 hours and vacuum packed. ticle preparations, the higher drug load did not result in a 5 Particle size of the DEX incorporated microparticles was significantly different release of fluticasone propionate; FIG. determined using laser diffraction (Beckman Coulter LS 38 shows the in vitro release of all three fluticasone propi 230) by dispersing a 50 mg aliquot in water, with the onate formulations. refractive index (RI) for water and PLGA, set at 1.33 and Based on the studies described herein, the Class D cor 1.46 respectively. The sample was stirred at the particle size ticosteroid microparticle formulations, for example, the flu- 10 ticasone or fluticaSone propionate microparticle formula measurement measurements taken and the results reported. tions, exhibiting the desired release kinetics have the Drug load was determined by Suspending a nominal 10 mg following characteristics: (i) the corticosteroid is between of microparticles in 8 ml HPLC grade methanol and soni 8%-20% of the microparticle, and (ii) the polymer is PLGA cating for 2 hours. Samples were then centrifuged at 14,000 having a molecular weight in the range of about 40 to 70 15 g for 15 mins before an aliquot of the Supernatant was kDa, having an inherent viscosity in the range of 0.35 to 0.5 assayed via HPLC as described below. Corticosteroid dL/g, and or having a lactide:glycolide molar ratio of 60:40 loaded microparticle samples, nominally 1 g were placed in to 45:55. 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. Example 9 2O incubator with magnetic stirring at 130 rpm. Each test sample was prepared and analyzed in duplicate to monitor Preparation of Dexamethasone Microparticles by possible variability. At each time point in the release study, Solvent Dispersion in PLGA microparticles were allowed to settle, and an aliquot of between 4-16 ml of Supernatant were taken, and replaced A pharmaceutical depot was prepared comprised of the 25 with an equal volume of fresh 0.5% v/v Tween 20 in 100 corticosteroid, dexamethasone (DEX, 9-Fluoro-11B, 17.21 mM phosphate buffered saline. Drug load and in vitro trihydroxy-16C.-methylpregna-1,4-diene-320-dione) incor release samples were analyzed by HPLC using a Hypersil porated into microparticles in PLGA 50:50. C18 column (100 mm, i.d. 5 mm, particle size 5 um; A formulation was prepared by dissolving approximately ThermoFisher) and Beckman HPLC. All samples were run 1 gram of PLGA 50:50 (lactide:glycolide molar ratio of 30 using a sample injection Volume of 5 um, and column 50:50, inherent viscosity 0.45 dL/g, molecular weight 66 temperature of 40° C. An isocratic mobile phase of 60% kDa) in 6.67 ml, of dichloromethane (DCM). To the polymer methanol and 40% water was used at a flow rate of 1 ml/min, Solution, 200 mg of dexamethasone was added and Soni with detection at a wavelength of 254 nm. The analytical cated. Subsequently, the corticosteroid containing dispersion results for the dexamethasone PLGA microparticles are was poured into 200 ml, of 0.3% polyvinyl alcohol (PVA) shown in Table 16. TABLE 16 Analytical Results of a Nominal 28.6% Dexamethasone PLGA 50:50 Microparticle Formulation PLGA (lactide:glycolide molar ratio ratio inherent viscosity/molecular Drug load (% weight target 96 DEX by Incorporation Particle size In vitro release FLUT weight) efficiency (%) (Dv, Im) (%) 50:50 carboxylic 22.1 77.2 D0.1: 41.2 m ay: 2.9 acid endcapped D0.5: 71.9 m ay: 4.6 0.45 dLig D0.9: 99.1 m ay: 6.3 66 kDa ay: 8.7 28.6% DEX ay: 10.9 ay: 12.7 ay: 15.0 ay: 16.4 11 day: 18.0 13 day: 20.7 15 day: 24.6 18 day: 26.2 21 day: 28.1 24 day: 30.3 27 day: 34.0 30 day: 46.3

Solution while homogenizing with a Silverson homogenizer In vitro cumulative percent release of the dexamethasone using a rotor fixed with a Silverson Square Hole High Shear is shown in 39, and results in suitable formulation for a ScreenTM, set to spin at 2,000 rpm to form the microparticles. minimum of thirty days and, assuming linear release, likely After two minutes, the beaker was removed, and a glass 65 up to 60 days. magnetic stirrer) added to the beaker, which was then placed In one iteration of the in vitro release data, the amount of onto a multi-way magnetic stirrer and stirred for four hours dexamethasone released per day was calculated based on a US 9,555,048 B2 65 66 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 administration of FX006 as compared to TCAIR. Without wishing to be bound by theory, the slower distribution of endogenous cortisol of less than 35%. In a second FX006 into the systemic circulation may be related to the iteration of these data, the amount of dexamethasone longer residence time of FX006 at the site of injection. This released per day was calculated based on a human dose, as is supported by the lesser availability of the FX006 exemplified in Table 2 that would not suppress the HPA axis, microparticle formulation in the early “burst' phase, where i.e. endogenous cortisol Suppression never exceeding 35%. only 4-9% of product is released, compared to at least 23% In the case of dexamethasone, where the data is truncated, of the IR product. both calculated human doses are the same; 36 mg of 10 Bioavailability of TCA in the systemic circulation fol microparticles containing 8 mg of dexamethasone. The lowing administration of FX006 was 3-fold lower than that doses are graphically represented in FIG. 40. observed for TCAIR, as shown in Table 18. Example 10 TABLE 1.8 Pharmacology, Pharmacokinetics and Exploratory 15 Bioavailability of TCA in Plasma Safety Study of Corticosteroid Formulations Absolute Bioavailability Comparison In an exploratory safety study in rats, single intra-articular (IA) doses of TCA immediate release (TCAIR) (0.18 and 2O FX006 (0.28 mg) TCAIR (0.18 mg) 1.125 mg) and doses of TCA in 75:25 PLGA formulation F. (%) 17.9 58.6 microparticles (FX006) (0.28, 0.56 and 1.125 mg (i.e., the maximum feasible dose) of TCA) were evaluated. Blood For the 0.56 and 1.125 mg dose levels of FX006, apparent samples were collected at various time points for determi F% were 23.1% and 58.1%, respectively. The IV data in rats nation of plasma concentrations. Plasma concentration-time 25 shown in Table 19 was used as a reference to calculate F. data from this study and pharmacokinetic (PK) analysis thereof are shown in FIGS. 41-43 and Tables 17-20. TABLE 19 As seen in FIGS. 41A-41D, FX006 dosed at 1.125 mg resulted in a very slow absorption of TCA in the systemic Pharmacokinetic Parameters of TCA in Rat Plasma. After i.v. circulation and a markedly lower C as compared to TCA 30 (50 mg/kg bolus + 23 mg/kg/h Infusion) Administration of IR. Triancinolone Acetonide Phosphate As shown in Table 17, the mean AUC values of TCA Parameter Rat 1 Rat 2 Rat 3 Mean SD following 1.125 mg administration of FX006 were 2.1-fold V (Likg) O.684 O.856 1.29 O.944 - 0.314 lower than those observed for TCAIR (i.e., 2856 vs. 6065 CL (L/h/kg) 1.15 O.790 O.872 O.937 O.188 ngth/mL, respectively). The mean C. values of TCA 35 k12 (h') 1.64 1.79 1.59 11.67 + 0.102 k2 (h') 1.04 O640 1.13 O.937 O.261 following 1.125 mg administration of FX006 were 15-fold T1/2B (h) 1.55 3.71 2.87 2.71 - 1.09 lower than those observed for TCA IR (i.e., 125 vs. 8.15 f2: O.O84 O. 110 O.O85 O.093 OO15 ng/mL, respectively). The absorption of TCA following from Rojas et al., “Microdialysis of triamcinolone acetonide in rat muscle.”J Pharm Sci administration of FX006 was slower than that observed for a 92(2) (2003): 394-397. TCAIR, with mean T values observed at 3.33 and 1.00 The initial “burst' (i.e., exposure up to 24 h) accounted h, respectively. The elimination half-life of TCA following for less than 10% of the total systemic exposure of FX006. administration of 1.125 mg FX006 and TCAIR were 451 The initial burst accounted for ~23-62% of the total expo and 107 h, respectively. sure for the TCAIR product, as shown in Table 20. 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 (CV%) Mean (CV 9.6) Mean (CV%) Mean (CV 9.6) 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 (24.4) 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) 180 (27.0) 451 (20.8) 35.6 (63.5) 107 (56.7) (h) Tmax 17.7 (148.9) 16.7 (162.8) 3.33 (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) US 9,555,048 B2 67 68 TABLE 20 Relative Availability of TCA in Plasma (Initial Burst vs. Delayed Release

Treatment FX006 (0.28 mg) FX006 (0.56 mg) FX006 (1.125 mg) TCAIR (0.18 mg) TCAIR (1.125 mg) Variable Mean Mean Mean Mean Mean AUCo-2 (ng himL) 31.0 33.0 136 297 1403 AUCo. (ng himL) 356 572 2856 479 606S AUC24 (ng himL) 325 539 272O 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 15 42. Body weights were monitored throughout the study and Evaluation of Efficacy of Single Doses of TCA key organs (spleen, adrenal glands, thymus) were weighed Immediate Release and TCA Microparticle upon necropsy. The injected knee and the contralateral Formulation in Animal Model of Osteoarthritis control joints were prepared for histological assessment. The studies described herein were designed to test and Toluidine blue stained sections of joints were evaluated for evaluate the efficacy of the corticosteroid microparticle treatment-related alterations. Histologic changes were formulations provided herein as compared to immediate described, wherever possible, according to their distribution, release corticosteroid formulations. While the studies herein severity, and morphologic character. use TCA, it is understood that other corticosteroids, includ 25 ing other Class B corticosteroids, Class A corticosteroids, Histological analysis demonstrated the following obser Class C corticosteroids, and Class D corticosteroids, can be vations. First, injected joints from placebo (blank PLGA evaluated using these materials, methods and animal mod microspheres)-treated animals had minimal multifocal mac els. rophage infiltration in associated with 20-130 um diameter Efficacy of single intra-articular (IA) doses of FX006 microspheres, whereas none of the active FX006-injected 30 (TCA in 75:25 PLGA formulation microparticles) and TCA joints showed the presence of any microspheres at Day 28. IR (immediate release) was evaluated in a rat model of Placebo-treated rat joints had no cartilage or joint changes osteoarthritis of the knee via sensitization and challenge by save for the presence of spontaneous cartilage cysts in a few peptidoglycan polysaccharide (PGPS). The model involves joints (1 at Day 28, 2 at Day 42) in the right (injected) knees. priming the animals with an intra-articular injection of The left knees in the placebo-treated rat joints were normal. 35 PGPS in the right knee. The following day, any animals with In comparison, both knees in the high dose TCAIR and the no knee discomfort were eliminated from the test article high and mid-dose FX006 groups showed some mild bone groups and placed into the baseline group. Two weeks later, marrow hypocellularity and growth plate atrophy (dose knee inflammation was reactivated by a tail vein injection of dependent for FX006). Both knees in the low dose TCAIR PGPS, 2.5 hr following IA dosing with FX006 or TCAIR at 40 the doses selected (n=10/group). Differences in weight and FX006 animals were normal. Spontaneous cartilage bearing and gait (as a measure of joint pain experienced by cysts noted in placebo animals were also noted in all groups the animals), histopathology, plasma PK etc. were evaluated. dosed with FX006 with no increase in incidence or severity. Doses of FX006 (0.28, 0.12, 0.03 mg) and TCAIR (0.06, High dose TCAIR increased cartilage cysts at Day 42 but 0.03 mg) for this study were selected based on data from the not at Day 28. In general, FX006-treated animals had normal 45 study described above in Example 10 and an initial run of articular cartilage despite the presence of catabolic effects on the PGPS model in which only TCAIR was evaluated at two other joint structures, which was likely more readily IA dose levels. The goals of the present study were to observed on account of the young age of the animals. demonstrate the following: Overall, all observed effects of FX006, especially at the FX006 is efficacious at doses that do not inhibit the HPA high dose. Such as body weight loss and reduced organ 50 axis weights were also seen with TCA IR. The time course of The duration of efficacy is a function of dose inhibition of the HPA axis (measured as corticosterone FX006 provides more prolonged pain relief as compared levels) is shown in FIG. 42. It should be noted that at the to TCAIR Since only about 10% of the TCA payload lowest dose of FX006 (0.28 mg; circles) corticosterone is expected to be released from FX006 in the first 24 hr, 55 one TCAIR dose group (0.03 mg) was chosen to match levels were initially inhibited but recovered back to near 10% of the TCA in FX006 at a dose of 0.28 mg baseline by Day 14 post-dose. Similarly, with TCAIR at the Effects of matched doses of FX006 and TCAIR (0.03 mg) lowest dose (0.18 mg), corticosterone levels recovered by The duration of efficacy was assessed by 3 different Day 7 (squares). With the mid (0.56 mg) and high (1.125 reactivations, 2 weeks apart. After that point, the arthritis mg) doses of FX006 and the high dose of TCAIR (1.125 60 observed in the animals becomes more wide-spread making mg), corticosterone levels were inhibited longer as shown in the efficacy in the index knee more difficult to assess. FIG. 42. At the first reactivation, vehicle treated animals demon A PK-PD analysis demonstrated that inhibition of corti strate painful gait as demonstrated by high pain scores (3.5 costerone was correlated with systemic TCA levels and out of a maximum of 4 possible) as shown in FIGS. 44A, followed a classical inhibitory model as shown in FIG. 43. 65 44B, and 44C. FX006 at 0.28 mg (squares) showed good The ICso was about 1 ng/mL and the E was achieved at efficacy. In the previous study described in Example 10, this 50-80 ng/mL. dose was demonstrated to inhibit the HPA axis immediately US 9,555,048 B2 69 70 after dosing but a return to baseline function was demon for the treatment of patients with osteoarthritis, rheumatoid strated by Day 14. Interestingly, this dose of FX006 con arthritis and other inflammatory joint disorders are as fol tinued to be efficacious upon the 2" and 3" reactivations on lows: Days 14 and 28 when the HPA axis function was presumably Intra-articular injection of Sustained release corticosteroid normal. It should also be noted that since HPA axis function 5 microparticle formulations provides prolonged pain returned to baseline by Day 7 at a 0.18 mg dose of TCAIR relief relative to intra-articular injection of immediate in the previous study described in Example 10, the effects of release steroids. the doses of TCAIR used in the present study (0.06 and 0.03 Intra-articular injection of Sustained release corticosteroid mg) were also in the presence of normal HPA axis function microparticle formulations is efficacious in reducing following an initial transient inhibition. Corticosterone mea 10 pain and inflammation at doses that do not inhibit the surements from the present study (as an indicator of HPA HPA axis. axis function) are presented as change from baseline for The duration of efficacy of sustained release of intra each treatment group in FIG. 46. As demonstrated from articular corticosteroid microparticle formulations is a these data, corticosterone levels for all groups recovered by 15 function of dose. Day 14; hence the goal of prolonged efficacy with FX006 in Intra-articular injection of Sustained release corticosteroid the presence of normal HPA axis function was achieved. microparticle formulations slows, arrests, reverses, or Overall, a clear dose-dependence of response was noted otherwise inhibits structural damage to tissues caused for both FX006 and TCAIR. Also, if less than 10% of this by inflammation. dose is available by the day after dosing (Day 1), it should Although particular embodiments have been disclosed be noted in FIG. 44B that the efficacy of FX006 at 0.28 mg herein in detail, this has been done by way of example for (squares) is greater than TCAIR at 0.03 mg (triangles) at all purposes of illustration only, and is not intended to be evaluations. Further, the duration of efficacy of TCA (both limiting with respect to the scope of the appended claims, FX006 and IR) appears to be a function of dose, however, which follow. In particular, it is contemplated by the inven the prolonged release of TCA from the PLGA microspheres 25 tors that various Substitutions, alterations, and modifications in FX006 results in more sustained efficacy. This is more may be made to the invention without departing from the clearly depicted in another representation of the data in FIG. spirit and scope of the invention as defined by the claims. 45 in which peak response for each dose as determined by Other aspects, advantages, and modifications are considered gait/pain scores on Day 1 following each reactivation (Days to be within the scope of the following claims. The claims 1, 15 and 29) are plotted. FIG. 46 plots the time course of 30 presented are representative of the inventions disclosed corticosterone recovery for all study groups. On balance, herein. Other, unclaimed inventions are also contemplated. across all groups that received the corticosteroid, there was Applicants reserve the right to pursue such inventions in recovery. later claims. Plasma levels of TCA were measured in samples taken from all rats at baseline (Day -4), Days 0 (2 hr post dosing), 35 What is claimed is: 1, 3, 8, 14, 17, 21, 28, and 31. Concentration-time curves for 1. A method of treating pain or inflammation in a patient all treatment groups are shown in FIG. 47A. FIG. 47B shows comprising administering to said patient a therapeutically only the FX006 dose groups on a larger scale since maximal effective amount of an injectable formulation comprising plasma concentrations with FX006 were far lower than those controlled- or Sustained-release microparticles comprising with TCAIR 40 triamcinolone acetonide (TCA) or a pharmaceutically-ac Histopathological evaluation of the knees taken from all ceptable salt thereof and a poly(lactic-co-glycolic) acid animals at the end of the study (Day 32 at the end of the 3" copolymer (PLGA) matrix, wherein the TCA comprises reactivation of arthritis) demonstrated Statistically signifi between 22% to 28% of the microparticles and wherein the cant improvement by FX006 at the high and mid-range PLGA has the following characteristics: (i) a molecular doses (0.28 and 0.12 mg) in the composite histological score 45 weight in the range of about 40 to 70 kDa; and (ii) a lactic and each component score (inflammation, pannus, cartilage acid:glycolic acid molar ratio of 80:20 to 60:40. damage and bone resorption) as shown in FIG. 48. As 2. The method of claim 1, wherein the PLGA copolymer described above, the dose of 0.28 mg FX006 demonstrated has a molar ratio of lactic acid:glycolic acid of 75:25. strong efficacy (i.e. analgesic activity) throughout all 3 3. The method of claim 1, wherein the injectable formu reactivations, whereas the dose of 0.12 mg was active but to 50 lation further comprises a pharmaceutically acceptable a lesser degree through all 3 reactivations. At the doses of excipient. TCAIR used, the duration of efficacy was mostly through 4. The method of claim 1, wherein the injectable formu the first reactivation of arthritis, with partial efficacy of the lation is administered as one or more intra-articular injec higher (0.06 mg) dose in the second reactivation, and this tions. also translated into a much smaller non-significant improve 55 5. The method of claim 3, wherein the injectable formu ment in histological scores. Importantly, these data demon lation is administered as one or more intra-articular injec strate that TCA has no deleterious effect on cartilage and as tions. has been described in other settings, it actually reduces 6. The method of claim 1, wherein the TCA is released for cartilage damage in an inflammatory milieu. between at least 14 days and 90 days upon administration to In conclusion, the prolonged residence of TCA in the joint 60 a joint. upon IA dosing with FX006 resulted in extending the 7. The method of claim 6, wherein the formulation duration of efficacy in the rat PGPS model of arthritis with releases the corticosteroid for at least 14 days at a rate that a significant histological improvement in inflammation, pan does not adversely Suppress the hypothalamic-pituitary nus formation, cartilage damage and bone resorption. FX006 adrenal axis (HPA axis). had these effects without inhibiting HPA axis function as 65 8. The method of claim 1, wherein the 22% to 28% of demonstrated by the return to baseline of corticosterone TCA in the microparticles comprises a total TCA load dose levels within 14 days after dosing. The clinical implications between 10 to 50 mg. US 9,555,048 B2 71 72 9. The method of claim 1, wherein the lactic acid-glycolic ized hypertrophic, infiltrated inflammatory lesions of granu acid copolymer has an inherent viscosity in the range of 0.3 loma annulare, lichen planus, lichen simplex chronicus to 0.5 dL/g. (neurodermatitis), psoriasis, psoriatic plaques, or necrobio 10. The method of claim 1, wherein the microparticles sis lipoidica diabeticorum. have a mean diameter of between 10 um to 100 um. 5 20. The method of claim 1, wherein the subject has 11. The method of claim 1, wherein the microparticles asthma, atopic dermatitis, contact dermatitis, drug hyper further comprise a polyethylene glycol (PEG) moiety, sensitivity reactions, seasonal or perennial allergic rhinitis, wherein the PEG moiety comprises between 25% to 0% serum sickness, transfusion reactions, bullous dermatitis weight percent of the microparticle. herpetiformis, exfoliative dermatitis, mycosis fungoides, 12. The method of claim 1, wherein the subject is human. 10 pemphigus, severe erythema multiforme (Stevens-Johnson 13. The method of claim 1, wherein the subject has syndrome), primary or secondary adrenocortical insuffi osteoarthritis, rheumatoid arthritis, gouty arthritis, juvenile ciency in conjunction with mineralocorticoids, congenital arthritis, psoriatic arthritis, ankylosing spondylitis, or syno adrenal hyperplasia, hypercalcemia associated with cancer, Vitis. nonsupportive thyroiditis, exacerbations of regional enteritis 14. The method of claim 1, wherein the subject has a joint 15 and ulcerative colitis, acquired (autoimmune) hemolytic disorder of a joint tissue. anemia, congenital (erythroid), hypoplastic anemia (Dia 15. The method of claim 14, wherein the subject has acute mond blackfan anemia), pure red cell aplasia, secondary bursitis, Sub-acute bursitis, acute nonspecific tenosynovitis, thrombocytopenia, trichinosis with neurologic or myocar epicondylitis, or Morton's neuroma. dial involvement, tuberculosis meningitis with Subarachnoid 16. The method of claim 1, wherein the subject has block or impending block, palliative management of leuke radicular pain, neurogenic claudication secondary to lumbar mias and lymphomas, acute exacerbations of multiple scle spinal Stenosis, or back pain. rosis, cerebral edema associated with primary or metastatic 17. The method of claim 16, wherein the radicular pain is brain tumor or craniotomy, proteinuria in idiopathic neph selected from Sciatica, radicular pain of the arm, radicular rotic syndrome, proteinuria in lupus erythematosus, beryl pain of neck, radicular pain of lumbar, and radicular pain of 25 liosis, symptomatic sarcoidosis, fulminating or disseminated thorax. pulmonary tuberculosis, idiopathic eosinophilic pneumo 18. The method of claim 1, where in the subject has a nias, symptomatic sarcoidosis, dermatomyositis, polymyo disorder of the dermal tissue. sitis, systemic lupus erythematosus, or postoperative pain 19. The method of claim 18, wherein the subject has and Swelling. alopecia areata, discoid lupus, erythematosus, keloids, local