USOO8828440B2

(12) United States Patent (10) Patent No.: US 8,828,440 B2 Bodick et al. (45) Date of Patent: Sep. 9, 2014

(54) CORTICOSTEROIDS FOR THE TREATMENT OTHER PUBLICATIONS OF JOINT PAIN Anderson et al. “Biodegradation and Biocompatibility of PLA and (75) Inventors: Neil Bodick, Boston, MA (US); Robert PLGA Microspheres.” Adv. Drug Deliv Rev. 28(1997):5-24. C. Blanks, Auburndale, MA (US); Ayral et al. “Synovitis: A Potential Predictive Factor of Structural Anjali Kumar, Belmont, MA (US); Progression of Medial Tibiofemoral Knee Osteoarthritis—Results of Michael D. Clayman, Gloucester, MA a 1 Year Longitudinal Arthroscopic Study in 422 Patients.” (US); Mark Moran, Orinda, CA (US) OsteoArth. Cartilage. 13(2005):361-367. Bouissou et al. “Poly(lactic-co-glycolic acid) Microspheres.” Poly (73) Assignee: Flexion Therapeutics, Inc., Burlington, mers in Drug Delivery. Chapter 7(2006): 81-99. Cleek et al. “Microparticles of Poly(DL-lactic-co-glycolic acid)/ MA (US) poly(ethylene glycol) Blends for Controlled Drug Delivery.” J. Con (*) Notice: Subject to any disclaimer, the term of this trol. Relase. 48(1997): 259-268. Coopman et al. “Identification of Cross-Reaction Patterns in Allergic patent is extended or adjusted under 35 Contact Dermatitis from Topical Corticosteroids.” Br: J. Dermatol. U.S.C. 154(b) by 0 days. 121 (1989):27-34. Derendorfetal. “Clinical PKPDModelling as a Tool in Drug Devel (21) Appl. No.: 13/422,994 opment of Corticosteroids.” Int. J. Clin. Pharmacol. Ther. 35.10(1997):481-488. (22) Filed: Mar 16, 2012 Derendorf et al. “Pharmacokinetics and Pharmacodynamics of Glucocorticoid Suspensions After Intra-Articular Administration.” (65) Prior Publication Data Clin. Pharmacol. Ther: 39.3(1986):313-317. US 2012/O288534 A1 Nov. 15, 2012 Eckstein et al. “Magnetic Resonance Imaging (MRI) of Articular Cartilage in Knee Osteoarthritis (OA): Morphological Assessment.” OsteoArth. Cartilage. 14(2006):A46-A75. Related U.S. Application Data Foti et al. "Contact Allergy to Topical Corticosteroids: Update and (63) Continuation of application No. 13/198,168, filed on Review on Cross-Sensitization.” Recent Pat. Inflamm. Allergy Drug Aug. 4, 2011, now abandoned. Discov. 3.1(2009):33-39. Habib. "Systemic Effects of Intra-Articular Corticosteroids.” Clin. (60) Provisional application No. 61/370,666, filed on Aug. Rheumatol. 28.7(2009):749-756. 4, 2010. Hepper et al. “The Efficacy and Duration of Intra-Articular Corticosteroid Injection for Knee Osteoarthritis: A Systematic (51) Int. Cl. Review of Level I Studies.” J. Am. Acad. Orthop. Surg. A6 IK 9/14 (2006.01) 17.10(2009):638-646. A 6LX 9/50 (2006.01) Hill et al. “Synovitis Detected on Magnetic Resonance Imaging and A6 IK3I/56 (2006.01) its Relation to Pain and Cartilage Loss in Knee Osteoarthritis.” Ann. A 6LX3/573 (2006.01) Rheum. Dis. 66(2007): 1599-1603. A6 IK9/00 (2006.01) Houetal. “In Situ Gelling Hydrogels Incorporating Microparticles as A6 IK 9/16 (2006.01) Drug Delivery Carriers for Regenerative Medicine.” J. Pharm. Sci. (52) U.S. Cl. 97.9(2008):3972-3980. CPC ...... A61 K9/1647 (2013.01); A61 K3I/573 Kirwan et al. “Effects of Glucocorticoids on Radiological Progres (2013.01); A61 K9/0024 (2013.01); A61 K sion in Rheumatoid Arthritis.” Cochrane Database Syst. Rev. (2009). 9/0019 (2013.01); A61 K9/1641 (2013.01); (Continued) A61 K9/1694 (2013.01) USPC ...... 424/489: 424/497: 514/181 (58) Field of Classification Search Primary Examiner — David J Blanchard None Assistant Examiner — Tigabu Kassa See application file for complete search history. (74) Attorney, Agent, or Firm — Cooley LLP (56) References Cited (57) ABSTRACT U.S. PATENT DOCUMENTS Corticosteroid microparticle formulations are provided for 4.293,539 A 10/1981 Ludwig et al. use for treating pain, including pain caused by inflammatory 7,261,529 B2 8/2007 Persyn et al. 7,758,778 B2 7/2010 Persyn et al. diseases such as osteoarthritis or rheumatoid arthritis, and for 2004/O105821 A1* 6/2004 Bernstein et al...... 424/46 slowing, arresting or reversing structural damage to tissues 2005/OO31549 A1 2/2005 Quay et al. caused by an inflammatory disease, for example damage to 2007/0053990 A1 3/2007 Persyn et al. articular and/or peri-articular tissues caused by osteoarthritis 2007,0264.343 A1 11/2007 Bernstein et al. or rheumatoid arthritis. Corticosteroid microparticle formu 2008/0248122 A1 10/2008 Rashba-Step et al. 2008/0317805 A1 12/2008 McKay et al. lations are administered locally as a Sustained release dosage 2009, OO35253 A1 2/2009 Wright et al. form (with or without an immediate release component) that 2009, O123546 A1 5, 2009 Ashton et al. results in efficacy accompanied by clinically insignificant or no measurable effect on endogenous cortisol production. FOREIGN PATENT DOCUMENTS WO WO-95.13799 A1 5, 1995 10 Claims, 30 Drawing Sheets US 8,828.440 B2 Page 2

(56) References Cited Morlocket al. “Erythropoietin Loaded Microspheres Prepared from Biodegradable LPLG-PEO-LPLG Triblock Copolymers: Protein OTHER PUBLICATIONS Stabilization and in-vitro Release Properties.” J. Control. Release. 56.1-3(1998): 105-115. La Rochelle et al. “Recovery of the Hypothalamic-Pituitary-Adrenal Rojas et al. “Microdialysis of Triamcinolone Acetonide in Rat Muscle.” J. Pharm. Sci. 92.2(2003):394-397. (HPA) Axis in Patients with Rheumatic Diseases Receiving Low van den Berg et al. “Synovial Mediators of Cartilage Damage and Dose Prednisone.” Am. J. Med. 95(1993):258-264. Repair in Osteoarthritis.” Osteoarthritis. Brandt et al., eds. Oxford: Lo et al. "Bone Marrow Lesions in the Knee are Associated with Oxford University Press. 7.2.3 (2003): 147-155. Increased Local Bone Density.” Arth. Rheum. 52.9(2005):2814 Yeh. “The Stability of Insulin in Biodegradable Microparticles Based 2821. on Blends of Lactide Polymers and Polyethylene Glycol.” J. Lo et al. “The Ratio of Medial to Lateral Tibial Plateau Bone Mineral Microencapsul. 17.6(2000):743-756. Density and Compartment-Specific Tibiofemoral Osteoarthritis.” Zentner et al. "Biodegradable Block Copolymers for Delivery of OsteoArth. Cartilage. 14(2006):984-990. Proteins and Water-Insoluble Drugs.” J. Control. Release. Meibohm et al. “Mechanism-Based PK/PD Model for the 72(2001):203-215. Lymphocytopenia Induced by Endogenous and Exogenous Corticosteroids.” Int. J. Clin. Pharmacol. Ther: 37.8(1999):367-376. * cited by examiner U.S. Patent Sep. 9, 2014 Sheet 1 of 30 US 8,828,440 B2

FIG. 1

tra-articular COf Cetration

------intra-articular concentration required for efficacy

Concentration in plasma associated with PA axis suppression L. H. ------e

Concentration in piasma ise post in tra articiar injection of sistaired release corticosteroid

FIG. 2 TCA40mg EC50 (ng/mL)

U.S. Patent Sep. 9, 2014 Sheet 2 of 30 US 8,828,440 B2

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

1 5

1.O

O 50 1OO 150 2OO 250 300 350 4OO Time (h) U.S. Patent Sep. 9, 2014 Sheet 3 of 30 US 8,828,440 B2

0'09 88segg. A

&:3SEgg, U.S. Patent Sep. 9, 2014 Sheet 4 of 30 US 8,828,440 B2

U.S. Patent Sep. 9, 2014 Sheet 5 Of 30 US 8,828,440 B2

O?000||O O| ----^ O\-|0.08 |0.07 |0.02

8:35 egg: A U.S. Patent Sep. 9, 2014 Sheet 6 of 30 US 8,828,440 B2

FIG. 5

100 .

; 90 m. 3. 80 70 ------0------60 o S$ 50 $ 40 -/-.-0-25%. TCAPLGA75:25 30 20 s 10 O O 10 2O 3O Days

FIG. 6 25%. TCAPLGA 75:25

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

------40% COrtisol Inhibition DOSe

H - H - H - H - H - - - - a 50% COrtisol Inhibition DOSe 10 15 2O 25 3O U.S. Patent Sep. 9, 2014 Sheet 7 Of 30 US 8,828,440 B2

FIG. 7 25%. TCAPLGA 75:25

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

FIG. 8

100 90 8O 70 1 5060 1 40 / -0-25%. TCAPLGA 75:25 30

10 7

10 20 3O DayS U.S. Patent Sep. 9, 2014 Sheet 8 of 30 US 8,828,440 B2

FIG. 9 25% TCAPLGA 75:25 8.O 7.O -0-Adjusted DOSe (mg/day) 6.O - - -5% COrtisol 5.O Inhibition 4.0 - - - -35% COrtisol 3.O Inhibition DOSe 2.0 40% COrtisol Inhibition DOSe 1.O 50% COrtisOl O.O Inhibition DOSe -10 0

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 Sep. 9, 2014 Sheet 9 Of 30 US 8,828,440 B2

FIG 11

25%. TCA 5% PEG 1450/PLGA 75:25 1 OO 90 8O 70 60 - 25% TCA 5% PEG 50 145O/PLGA75:25 40 30 20 10 z 20 Days

FIG. 12 25%. TCA 10% PEG 335OIPLGA 75:25 1 OO 90 8O 70 - 25%TCA 10%PEG 60 335O/PLGA75:25 50 40 30 2O 10 - 3O Days U.S. Patent Sep. 9, 2014 Sheet 10 of 30 US 8,828,440 B2

FIG. 13

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

-0- Adjusted Dose (mg/day) - - - 5% COrtisol Inhibition - - - -35% COrtisol Inhibition DOSe 40% COrtisol Inhibition DOSe 50% COrtisol O 10 2O 30 Inhibition DOSe -1.0 -

FIG. 14 25% TCA 10% PEG 3350/PLGA 75:25 7.O 6.O M -0- Adjusted(mg/day) Dose 5.0 | \ - - - 5% COrtisO 4.O Inhibition 3.0 ...Y - - - -35% COrtisol -S Inhibition DOSe

2.01.0 seaseO 40%Inhibition COrtisol DOSe 0.0-R F FEF RF FEF - F. F. H. 50% COrtisOl Inhibition DOSe U.S. Patent Sep. 9, 2014 Sheet 11 of 30 US 8,828,440 B2

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

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

D. D. D. D. 50% COrtisol Inhibition DOSe

25% TCA 10% PEG 335O/PLGA 75:25 3.5 3.0 T -0-Adjusted Dose (mg/day) 2.5 - - - 5% COrtisOl 2.0 T- Inhibition 1.5 |AT r - - - -35%Inhibition COrtisol DOSe 1.O N. DO-D O D DD 40% COrtisol O.5 Inhibition DOSe

0.0 - - - Ny R.E.5ase O 5 10 15 20 25 30 U.S. Patent Sep. 9, 2014 Sheet 12 of 30 US 8,828,440 B2

FIG. 17

1OO

90 k : 80 I - CD is to 1. 11------5 60 / / 1. -A- 40% TCAPLGA 75:25 50 M ------0-25% TCAPLGA 75:25 e 40 / e- ---20% TCAPLGA 75:25 - 30 / 2 5s 20 AA / ------O-----O --O-- 15%. TCAPLGA 75:25 8 or ...... -- -H - - - - 10% TCAPLGA 75:25 10 ... . -- it O O 5 10 15 20 25 30 Days

100 : 90 O) -- 5t 7 4 &H 50 / - 2 - - - X -0-25%. TCAPLGA 75:25 S 40 7 - 1 (54 kDA) 30 A - Xe - 25%. TCAPLGA 75:25 20 avy (29 kDa) U 10 O O 10 20 30 U.S. Patent Sep. 9, 2014 Sheet 13 of 30 US 8,828,440 B2

1 OO

3. -e-O, CA (GA 50:5 3. 80 He 3. ------O - 25% CAGA 50:5 70 -Y ------60 /-A-===== 30% CA GA 50:5 is- 50 f(21- st as a ------0-35%. TCAPLGA 50:50 iss 40 y : p s ->e 25% CA (GA 55) 3O 1. (ester end-Capped s - - 1 -YK -A - 30%3 & CA EG di 20 2 Zara 335f. GAS5) 10 S. -H-25%. CAGA 75:25 i -0-30%, CA GA 50:5 5 O 5 O 25 3 (18 kDa) lays

40% TCA PLGA 75:25 plus Triblock OC 90 : 80 : I -a- 5 60 27 -0-40% CA PGA 72.25 + 0% is 50 ?a g 40 / -- 40% CA PGA 72.25 + 2% 30 4 2 . A.) - O -

O 3O 40 lays U.S. Patent Sep. 9, 2014 Sheet 14 of 30 US 8,828,440 B2

FIG 21 CAA S: , 3. 4.000 is 3,500 a 3.000 - 0 - PLGA 75:25 10%TB-TCM E. 2.500 (Batch 2) 3 - - - 5%COrtisOnhibition 8 2.OOO 1.500 - - - - 35%COrtisOnhibition DOSe i 1.OOO 0.500 V 40%COrtisol inhibition DOSe 0.000-HS-H ...... 50%COrtisol inhibition DOSe 8O lay

FIG. 22 CASA S-S 2, 3 10.000 9,000 8.OOO -- PLGA 75:25.20%TB-TCM 7,000 (Batch 3) 6.OOO - - - 5% COrtiSO Inhibition 5.000 4.OOO 35%COrtiSO Inhibition DOSe 3.000 2.OOO 40%COrtisol inhibition DOSe 1000 OOOO 40 60 80 50%COrtisol inhibition DOSe ay U.S. Patent Sep. 9, 2014 Sheet 15 Of 30 US 8,828,440 B2

FIG. 23 At 5: A 3,500 , 3.OOO PLGA 75:25 10%TB-TCM 2.500 (Batch 2) 2.OOO - - - 5%COrtisol inhibition - 1500 - - - - 35%COrtisol inhibition DOSe 1.000 O.500 - N 40%COrtisol inhibition DOSe g 0.000 -HS---, ------50%COrtisol inhibition DOSe

CAGA 5:25, 8

3.500 s 3.000 PLGA 75:25 10%TB-TCM 2.500 (Batch2) S - - - - 5%Cortisol inhibition $ 2.000 5 1500 - - - - 35%COrtisol inhibition DOSe "S 1.000 - - 40%COrtisol inhibition DOSe E 0.500 kg H -V/A ------50%COrtisol inhibition DOSe O.OOO 80 U.S. Patent Sep. 9, 2014 Sheet 16 of 30 US 8,828,440 B2

FIG. 25 A A 5: Kei is 120

1 O O

8 O 426 OOO O O 10 2O 3O 40 50 6O 7O 8O 90 100 ise it says

CA fixed icecar Weight PGA 75:25 a 7.OOOO -S 6.0000 s --TCAMixed MW E. 5.OOOO PLGA75:25 34.0000 - - 5%COrtisol inhibition O 3.OOOO - - - 35%COrtisol inhibition 92 2.0000 Dose - N - - - N ------40%COrtisol inhibition 1.OOOO DOSe OOOOO-FE F SaS FSFF-FFFF ------50%COrtisol inhibition O 1O 20 30 40 50 60 DOSe U.S. Patent Sep. 9, 2014 Sheet 17 Of 30 US 8,828,440 B2

TCAMixed Molecular Weight PLGA 75:25

3.5000 3.0000 a TCAMixed MW S. 2.5000 PLGA 75:25 E 5%Cortisol inhibition S 2.0000 S; 35%Cortisol inhibition 3 1.5000 DOSe 5 a ------40%COrtisol inhibition 1.0000 DOSe 0.5000 - \ 1 ------50%COrtisolDOSe inhibition 0.0000

120

1OO ca C

8 O

6 O - -- TCAPCL Y u- H TCAMixed MWPLGA 75:25 40 A --A- TCAPLGA 50:50 -A-A-A-A-A------A- --X - TCAPLGA 85:15 20 Aber

O * O 5 10 15 20 25 30 35 U.S. Patent Sep. 9, 2014 Sheet 18 of 30 US 8,828,440 B2

F G. 2 9

PRED-PLGA 50:50 100 90 8O 70 60 50 40 30 20 1 8 O 5 1O 15 2O 25 30 35 Time in Days

FIG. 30 PRED-PLGA 50:50 8.00 7.00 -- PLGA 50:50-PRED 6.00 - - - 5%COrtisOnhibition 5.00 4.00 - - - - 35%COrtisol inhibition DOSe 3.00 ODO D D 40%COrtisol inhibition 2.OO DOSe 100 50%COrtisol inhibition DOSe O.OO U.S. Patent Sep. 9, 2014 Sheet 19 Of 30 US 8,828,440 B2

FIG. 31 PRED-PLGA 50:50 8.00 1S 7.00 -- PLGA 50:50-PRED 9 6.00 g - 5%COrtiSO Inhibition St 5.00 O) 3 4.00 - - - - 35%COrtisol inhibition ? DOSe 3.00, \ . 40%COrtisol inhibition 2.00 DOSe 3 1.00 \ , -1-1 Escoriso Inhibition O.OO

Beta-PLGA50:50 : 90 8O 70 2 60 i 50 S 40 2030 10 SS O O 5 10 15 2O 25 30 35 Time in Days U.S. Patent Sep. 9, 2014 Sheet 20 of 30 US 8,828,440 B2

BETA-PLGA 50:50 3.50 3.OO -- PLGA 50:50-BETA 9 250 5%COrtisOnhibition o 2.00 3 - - - - 35%COrtisol inhibition 150 DOSe 1.00 - - - - - A 2-0 ------a -- TTTTT 40%COrtisonhibition B DOSe 0.50 / \ / ...... 50%COrtisol inhibition O.OO DOSe

BETA-PLGA 50:50 2.00 1.80 -- PLGA 50:50-BETA 160 g 140 5%COrtiSO Inhibition o 120 3 1.00 - - - - 35%COrtisOnhibition ? DOSe 0.80 0.60 T 40%COrtisol inhibition g DOSe E. O.40 O A. N. Alla ------50%COrtisol inhibition < 0.20 DOSe OOO U.S. Patent Sep. 9, 2014 Sheet 21 of 30 US 8,828,440 B2

i 120 D ge 100 SS 80 O in 60 g 40 CE 20 U 0 O 5 10 15 2O 25 30 35 Time in Days

FLUT-PLGA50:50 (200 mg) 5.OOO 4.500 S. 4.000 -- PLGA 50:50-FLUT 200mg 3.500 S; 3.000 5%COrtiSO Inhibition g 2,500 2.000 - - - - 35%COrtisol inhibition 1.500 DOSe isC 1.000 ------. 40%COrtisol inhibition C O500 DOSe 0.000 - EEE E2EEEEEE------50%COrtisol inhibition O 10 20 30 40 DOSe U.S. Patent Sep. 9, 2014 Sheet 22 of 30 US 8,828,440 B2

FIG. 37 FLUT-PLGA50:50 (200 mg) 1200 i 1.OOO -- PLGA 50:50-FLUT 200mg G S 0.800 - - - 5%Cortisol inhibition t 0600 ---- 35%COrtisol inhibition C DOSe geg 0.400 40%COrtisol inhibition 0.200 DOSe 50%COrtisol inhibition 0.000 DOSe

120.00 FLUT Formulations -A 1OOOO A A ---- - A A. - A-A -A ----- W 80.00

-(-75/25 16.7%FLUT

---50/50 16.7%FLUT

-A-50/50 28.6%FLUT

Days U.S. Patent Sep. 9, 2014 Sheet 23 of 30 US 8,828,440 B2

FIG. 39 DEXAPLGA50:50

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

FIG. 40 DEXAPLGA50:50

18O s 1.60 -- PLGA 50:50-DEXA S 140 g 120 - - - 5%COrtisol inhibition 9 100 3 ---- 35%COrtisol inhibition O.80 DOSe 0.60 ------40%COrtisol inhibition 2 0.40 DOSe 3 0.20/N 1 / ...... 50%COrtisol inhibition O.OO DOSe U.S. Patent Sep. 9, 2014 Sheet 24 of 30 US 8,828,440 B2

FIG. 41A -A-FX006 (0.28 mg) -0-FX006 (0.56 mg) --FX006 (1.125 mg) -A-TCAIR (0.18 mg) -O-TCAIR (1.125 mg) 1OOO 100- Slower delivery of TCA with FX006 g S. 10 S 1 d

O.1 &

O.O1 O 144 288 432 576 720 864 1008 Time (h)

-- FX006 (0.28 mg) -0-FX006 (0.56 mg)-O-FXOO6 (1.125 mg)

150 -A-TCAIR (0.18 mg) -O-TCA R (1.125 mg) g s, 100 S v d 50 U.S. Patent Sep. 9, 2014 Sheet 25 Of 30 US 8,828,440 B2

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

1OO

10

Time (h)

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

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

50 U.S. Patent Sep. 9, 2014 Sheet 26 of 30 US 8,828,440 B2

FIG. 42 20% --FX006 placebo (A) - (- FX006 (0.56 mg) -A-FX006 (1.125 mg) -K-TCA (1.125 mg) - TCA (0.18 mg) --O-FX006 (0.28mg)

-120% O 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 Time (days) FIG. 43

E 80 SER Corticosterone g VS Mean

60

4. O

2 O

O 0.01 O1 1 10 1OO 1000 Mean (ng/mL) U.S. Patent Sep. 9, 2014 Sheet 27 Of 30 US 8,828,440 B2

FIG. 44A --NO Reactivation 4.5 -0-Vehicle 4. O -HFX006 (4.67 mg/ml) -A-FX006 (2 mg/ml) -o-FX006 (0.5 mg/ml)

O 5

Days Post Reactivation

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

DaV-3EneDay Day 2 Day 4 Day 14 Day 15 Day 16 Day 18 Day 28 Day 29 Day 30 Day 32 Days Post Reactivation U.S. Patent Sep. 9, 2014 Sheet 28 of 30 US 8,828,440 B2

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

ta s s

-- a class

w P w ...... Y- Y - a as s e

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

FIG. 45

-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) Day 1 Day 15 Day 29 --FX006 (0.03 mg) Peak pain response upon reactivation of knee arthritis U.S. Patent Sep. 9, 2014 Sheet 29 Of 30 US 8,828,440 B2

FIG. 46 -H Primed no reactivation

--Vehicle -G-Triamcinolone (1 mg/ml) -A-Triamcinolone (0.5 mg/ml) -z-FX006 (4.67 mg/ml) -- tal -o- Exogi).FX006 (0.5 mg/ml) A z Af

M 2 a 1 TAY-1ACy/S-72 40% N-23SG 7 7 at1 I X guy as 1 2\; x -: y1

-80%

- 120% O 4. 8 12 16 20 24 28 32 Time (days)

FIG. 47A

-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 Sep. 9, 2014 Sheet 30 of 30 US 8,828,440 B2

FIG. 47B

12 16 20 24 28 Time (days)

FIG. 48

CC Z inflammation N PannuS Cartilage Damage o Bone Resorption

>> Ø ````N ØØ Primed no Vehicle Tramcinolone`N TriamCinolone`N FX006 FX006 FX006 reactivation (1 mg/ml) (0.5mg/ml) (4.67 mg/ml) (2 mg/ml) `N(0.5 mg/ml) Treatment Group US 8,828,440 B2 1. 2 CORTICOSTEROIDS FOR THE TREATMENT corticosteroid microparticle formulations are suitable for OF JOINT PAIN administration, for example, local administration by injection into a site at or near the site of a patient’s pain and/or inflam RELATED APPLICATIONS mation. The corticosteroid microparticle formulations pro vided herein are effective in slowing, arresting, reversing or This application is a continuation of U.S. patent applica otherwise inhibiting structural damage to tissues associated tion Ser. No. 13/198,168, filed Aug. 4, 2011 claims the benefit with progressive disease with minimal long-term side effects of U.S. Provisional Application No. 61/370,666, filed Aug. 4. of corticosteroid administration, including for example, pro 2010. The contents of this application are hereby incorpo longed suppression of the HPA axis. The corticosteroid rated by reference in their entirety. 10 microparticle formulations are suitable for administration, for example, local administration by injection into a site at or FIELD OF THE INVENTION near the site of structural tissue damage. As used herein, “prolonged suppression of the HPA axis refers to levels of This invention relates to the use of corticosteroids to treat cortisol Suppression greater than 35% by day 14 post-admin pain, including pain caused by inflammatory diseases such as 15 istration, for example post-injection. The corticosteroid osteoarthritis or rheumatoid arthritis, and to slow, arrest or microparticle formulations provided herein deliver the corti reverse structural damage to tissues caused by an inflamma costeroid in a dose and in a controlled or Sustained release tory disease, for example damage to articular and/or peri manner Such that the levels of cortisol Suppression are at or articular tissues caused by osteoarthritis or rheumatoid arthri below 35% by day 14 post-administration, for example post tis. More specifically, a corticosteroid is administered locally injection. In some embodiments, the corticosteroid micropar as a Sustained release dosage form (with or without an imme ticle formulations provided herein deliver the corticosteroid diate release component) that results in efficacy accompanied in a dose and in a controlled or Sustained release manner Such by clinically insignificant or no measurable effect on endog that the levels of cortisol Suppression are negligible and/or enous cortisol production. undetectable by 14 post-administration, for example post 25 injection. In some embodiments, the corticosteroid micropar BACKGROUND OF THE INVENTION ticle formulations provided herein deliver the corticosteroid in a dose and in a controlled or Sustained release manner Such Corticosteroids influence all tissues of the body and pro that the levels of cortisol Suppression are negligible at any duce various cellular effects. These steroids regulate carbo time post-injection. Thus, the corticosteroid microparticle hydrate, lipid, protein biosynthesis and metabolism, and 30 formulations in these embodiments are effective in the water and electrolyte balance. Corticosteroids influencing absence of any significant HPA axis Suppression. Adminis cellular biosynthesis or metabolism are referred to as gluco tration of the corticosteroid microparticle formulations pro corticoids while those affecting water and electrolyte balance vided herein can result in an initial "burst' of HPA axis are mineralocorticoids. Both glucocorticoids and mineralo suppression, for example, within the first few days, within the corticoids are released from the cortex of the adrenal gland. 35 first two days and/or within the first 24 hours post-injection, The administration of corticosteroids, particularly for but by day 14 post-injection, suppression of the HPA axis is extended periods of time, can have a number of unwanted side less than 35%. effects. The interdependent feedback mechanism between the In certain embodiments, a Sustained release form of corti hypothalamus, which is responsible for secretion of corti costeroids is administered locally to treat pain and inflamma cotrophin-releasing factor, the pituitary gland, which is 40 tion. Local administration of a corticosteroid microparticle responsible for secretion of adrenocorticotropic hormone, formulation can occur, for example, by injection into the and the adrenal cortex, which secretes cortisol, is termed the intra-articular space, peri-articular space, soft tissues, lesions, hypothalamic-pituitary-adrenal (HPA) axis. The HPA axis epidural space, perineural space, or the foramenal space at or may be suppressed by the administration of corticosteroids, near the site of a patient’s pain. In certain embodiments, the leading to a variety of unwanted side effects. 45 formulation additionally contains an immediate release com Accordingly, there is a medical need to extend the local ponent. In certain preferred embodiments of the invention, a duration of action of corticosteroids, while reducing the sys Sustained release form of corticosteroids is administered temic side effects associated with that administration. Thus, (e.g., by single injection or as sequential injections) into an there is a need in the art for methods and compositions for the intra-articular space for the treatment of pain, for example, Sustained local treatment of pain and inflammation, Such as 50 due to osteoarthritis, rheumatoid arthritis, gouty arthritis, bur joint pain, with corticosteroids that results in clinically insig sitis, tenosynovitis, epicondylitis, synovitis or other joint dis nificant or no measurable HPA axis Suppression. In addition, order. In certain preferred embodiments of the invention, a there is a medical need to slow, arrest, reverse or otherwise Sustained release form of corticosteroids is administered inhibit structural damage to tissues caused by inflammatory (e.g., by single injection or as sequential injections) into soft diseases such as damage to articular tissues resulting from 55 tissues or lesions for the treatment of inflammatory disorders, osteoarthritis or rheumatoid arthritis. for example, the inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses such as psoriasis. In SUMMARY OF THE INVENTION certain preferred embodiments of the invention, a Sustained release form of corticosteroids is administered (e.g., by single Described herein are compositions and methods for the 60 injection or as sequential injections) into an epidural space, a treatment of pain and inflammation using corticosteroids. The perineural space, a foramenal space or other spinal space for compositions and methods provided herein use one or more the treatment of corticosteroid-responsive degenerative mus corticosteroids in a microparticle formulation. The corticos culoskeletal disorders such as Neurogenic Claudication. In teroid microparticle formulations provided herein are effec certain preferred embodiments of the invention, a Sustained tive at treating pain and/or inflammation with minimal long 65 release form of corticosteroids is administered (e.g., by single term side effects of corticosteroid administration, including injection or as sequential injections) into an intra-articular for example, prolonged suppression of the HPA axis. The space or into soft tissues to slow, arrest, reverse or otherwise US 8,828,440 B2 3 4 inhibit structural damage to tissues associated with progres In some embodiments, a controlled or Sustained-release sive disease such as, for example, the damage to cartilage formulation is provided wherein a microparticle matrix (such associated with progression of osteoarthritis. as PLGA, hydrogels, hyaluronic acid, etc.) incorporates a In certain embodiments of the invention, a combination of corticosteroid, and the formulation may or may not exhibitan an immediate release form and a Sustained release form of 5 initial rapid release, also referred to herein as an initial “burst' corticosteroids is administered (e.g., by single injection or as of the corticosteroid for a first length of time of between 0 and sequential injections) into an intra-articular space for the 14 days, for example, between the beginning of day 1 through treatment of pain, for example, due to osteoarthritis, rheuma the end of day 14, in addition to the Sustained, steady state toid arthritis or other joint disorder(s). In certain embodi release of the corticosteroid for a second length of time of at 10 least two weeks, preferably at least three weeks, including up ments of the invention, a combination of an immediate release to and beyond 30 days, or 60 days, or 90 days. It should be form and a Sustained release form of corticosteroids is admin noted that when corticosteroid levels are measured in vitro, an istered (e.g., by single injection or as sequential injections) occasional initial burst of corticosteroid release from the into an intra-articular space or into soft tissues to slow, arrest, microparticle formulation can be seen, but this initial burst reverse or otherwise inhibit structural damage to tissues asso 15 may or may not be seen in vivo. In another embodiment, a ciated with progressive disease Such as, for example, the controlled or sustained-release formulation is provided damage to cartilage associated with progression of osteoar wherein a microparticle matrix (such as PLGA, hydrogels, thritis. The formulations and methods of embodiments of the hyaluronic acid, etc.) incorporates a corticosteroid, and the invention can achieve immediate relief of the acute symptoms formulation may or may not exhibit an initial rapid release, (e.g., pain and inflammation) of these diseases or conditions also referred to herein as an initial "burst' of the corticoster and additionally provide a Sustained or long term therapy oid for a first length of time of between 0 and 14 days, e.g., (e.g., slowing, arresting, reversing or otherwise inhibiting between the beginning of day 1 through the end of day 14, in structural damage to tissues associated with progressive dis addition to the Sustained, steady state release of the corticos ease), while avoiding long term systemic side effects associ teroid for a second length of time of at least two weeks, ated with corticosteroid administration, including HPA Sup 25 preferably at least three weeks, including up to and beyond 30 pression. days, or 60 days, or 90 days where the sustained, steady state In one aspect, a formulation is provided wherein a micro release of corticosteroid is released at a rate that does not particle matrix (such as PLGA, PLA, hydrogels, hyaluronic suppress the HPA axis at a level greater than 50% at day 14 acid, etc.) incorporates a corticosteroid, and the corticoster post-administration. In some embodiments, the Sustained, oid microparticle formulation provides at least two weeks, 30 steady state release of corticosteroid will not adversely sup preferably at least three weeks, including up to and beyond 30 press the HPA axis, for example, the level of HPA axis Sup days, or 60 days, or 90 days of a sustained, steady state release pressionator less than 35% by day 14 post-administration. In of the corticosteroid. In one aspect, a formulation is provided Some embodiments, the Sustained, steady state release of wherein a microparticle matrix (such as PLGA, PLA, hydro corticosteroid does not significantly suppress the HPA axis, gels, hyaluronic acid, etc.) incorporates a corticosteroid, and 35 for example, the level of HPA axis suppression is negligible the corticosteroid microparticle formulation provides at least and/or undetectable by day 14 post-injection. In some two weeks, preferably at least three weeks, including up to embodiments, the Sustained, steady state release of corticos and beyond 30 days, or 60 days, or 90 days of a sustained, teroid does not significantly suppress the HPA axis, for steady state release of the corticosteroid at a rate that does not example, the level of HPA axis suppression is negligible at all adversely suppress the HPA axis. 40 times post-injection. In some embodiments, the length of The corticosteroid microparticle formulation retains sus sustained release is between 21 days and 90 days. In some tained efficacy even after the corticosteroid is no longer resi embodiments, the length of sustained release is between 21 dent at the site of administration, for example, in the intra days and 60 days. In some embodiments, the length of Sus articular space, and/or after the corticosteroid is no longer tained release is between 14 days and 30 days. In some detected in the systemic circulation. The corticosteroid 45 embodiments, the length of release of the initial “burst’ com microparticle formulation retains Sustained efficacy even ponent is between 0 and 10 days, for example between the after the corticosteroid microparticle formulation is no longer beginning of day 1 through the end of day 10. In some resident at the site of administration, for example, in the embodiments, the length of release of the initial “burst’ com intra-articular space, and/or the corticosteroid microparticle ponent is between 0 and 6 days, for example between the formulation is no longer detected in the systemic circulation. 50 beginning of day 1 through the end of day 6. In some embodi The corticosteroid microparticle formulation retains sus ments, the length of initial “burst, component is between 0 tained efficacy even after the corticosteroid microparticle for and 2 days, for example between the beginning of day 1 mulation ceases to release therapeutically effective amounts through the end of day 2. In some embodiments, the length of of corticosteroid. For example, in Some embodiments, the initial “burst' component is between 0 and 1 day, for example corticosteroid released by the microparticle formulation 55 between the beginning of day 1 through the end of day 1. retains efficacy for at least one week, at least two weeks, at The corticosteroid microparticle formulations provided least three weeks, at least four weeks, at least five weeks, at herein can be used in combination with any of a variety of least six weeks, at least seven weeks, at least eight weeks, at therapeutics, also referred to herein as "co-therapies. For least nine weeks, at least twelve weeks, or more than twelve example, the corticosteroid microparticle formulations can weeks post-administration. In some embodiments, the corti 60 be used in combination with an immediate release corticos costeroid released by the microparticle formulation retains teroid solution or Suspension, which provides high local efficacy for a time period that is at least twice as long, at least exposures for between 1 day and 14 days following adminis three times as long, or more than three times as long as the tration and which produce systemic exposures that may be residency period for the corticosteroid and/or the corticoster associated with transient suppression of the HPA axis. For oid microparticle formulation. In some embodiments, the 65 example, 40 mg of immediate release triamcinolone Sustained, steady state release of corticosteroid will not acetonide co-administered with the corticosteroid micropar adversely suppress the HPA axis. ticle formulation in the intra-articular space would be US 8,828,440 B2 5 6 expected to produce high local concentrations lasting for days. In some embodiments, the length of release of the about 12 days. These high local concentrations would be immediate release form is between 1 day and 10 days. In some associated with peak plasma concentration of triamcinolone embodiments, the length of release of the immediate release acetonide of approximately 10 ng/ml on day 1, and over the form is between 1 day and 8 days. In some embodiments, the course of the first 12 days of release of the triamcinolone length of release of the immediate release form is between 1 acetonide from the intra-articular space would be associated day and 6 days. In some embodiments, the length of release of with transient suppression of the HPA axis with a maximal the immediate release form is between 1 day and 4 days. effect of approximately 60% suppression of cortisol on day The invention provides populations of microparticles 1-2 (Derendorf et al., “Pharmacokinetics and pharmacody including a Class B corticosteroid or a pharmaceutically namics of glucocorticoid Suspensions after intra-articular 10 acceptable salt thereof incorporated in, admixed, encapsu administration.” Clin Pharmacol Ther. 39(3) (1986):313-7). lated or otherwise associated with a lactic acid-glycolic acid By day 12, the contribution of the immediate release compo copolymer matrix, wherein the Class B corticosteroid is nent to the plasma concentration would be Small, less than 0.1 between 22% to 28% of the microparticles. ng/ml, and the contribution to the intra articular concentration The invention also provides controlled or sustained release of the immediate release component would also be Small. 15 preparation of a Class B corticosteroid that include a lactic However at day 12 and beyond, the corticosteroid micropar acid-glycolic acid copolymer microparticle containing the ticle formulation would continue to release corticosteroid in Class B corticosteroid, wherein the Class B corticosteroid is the intra articular space at a rate that extends the duration of between 22% to 28% of the lactic acid-glycolic acid copoly therapeutic effect and does not suppress the HPA axis. In mer microparticle matrix. Some embodiments, the same corticosteroid is used in both The invention also provides formulations that include (a) the immediate release and Sustained release components. In controlled- or Sustained-release microparticles comprising a Some embodiments, the immediate release component con Class B corticosteroid and a lactic acid-glycolic acid copoly tains a corticosteroid that is different from that of the sus mer matrix, wherein the Class B corticosteroid comprises tained release component. In some embodiments, the Sus between 22% to 28% of the microparticles and wherein the tained, steady state release of corticosteroid will not 25 lactic acid-glycolic acid copolymer has one of more of the adversely suppress the HPA axis. In some embodiments, the following characteristics: (i) a molecular weight in the range period of sustained release is between 21 days and 90 days. In of about 40 to 70 kDa; (ii) an inherent viscosity in the range of Some embodiments, the period of Sustained release is 0.3 to 0.5 dL/g; (iii) a lactide:glycolide molar ratio of 80:20 to between 21 days and 60 days. In some embodiments, the 60:40; and/or (iv) the lactic acid-glycolic acid copolymer is period of sustained release is between 14 days and 30 days. In 30 carboxylic acid endcapped. some embodiments, the high local exposure attributable to In some embodiments of these populations, preparations the immediate release component lasts for between 1 day and and/or formulations, the copolymer is biodegradable. In some 14 days. In some embodiments, the high local exposure attrib embodiments, the lactic acid-glycolic acid copolymer is a utable to the immediate release component lasts for between poly(lactic-co-glycolic) acid copolymer (PLGA). In some 1 day and 10 days. In some embodiments, the high local 35 embodiments, the lactic acid-glycolic acid copolymer has a exposure attributable to the immediate release component molar ratio of lactic acid:glycolic acid from the range of about lasts between 1 days and 8 days. In some embodiments, the 80:20 to 60:40. In some embodiments, the lactic acid-glycolic high local exposure attributable to the immediate release acid copolymer has a molar ratio of lactic acid:glycolic acid component lasts between 1 days and 6 days. In some embodi of 75:25. ments, the high local exposure attributable to the immediate 40 The invention also provides populations of microparticles release component lasts for between 1 day and 4 days. including a Class B corticosteroid or a pharmaceutically Upon administration, the corticosteroid microparticle for acceptable salt thereof incorporated in, admixed, encapsu mulation may provide an initial release of corticosteroid at the lated or otherwise associated with a mixed molecular weight site of administration, for example, in the intra-articular space lactic acid-glycolic acid copolymer matrix, wherein the Class and/or peri-articular space. Once the initial release of corti 45 B corticosteroid is between 12% to 28% of the microparticles. costeroid has subsided, the controlled or sustained release of In some embodiments, the corticosteroid microparticle for the corticosteroid microparticle formulations continues to mulation includes a Class B corticosteroid and a micropar provide therapeutic (e.g., intra-articular and/or peri-articular) ticle made using 75:25 PLGA formulation with two PLGA concentrations of corticosteroid to Suppress inflammation, polymers, one of low molecular weight and one of high maintain analgesia, and/or slow, arrest or reverse structural 50 molecular weight in a two to one ratio, respectively. The low damage to tissues for an additional period of therapy follow molecular weight PLGA has a molecular weight of range of ing administration (FIG. 1, top tracings). However, the sys 15-35 kDa and an inherent viscosity range from 0.2 to 0.35 temic exposure associated with the Sustained release compo dL/g and the high molecular weight PLGA has a range of nent does not suppress the HPA axis (FIG. 1, bottom 70-95kDa and an inherent viscosity range of 0.5 to 0.70 dL/g. tracings). Thus, the invention includes therapies and formu 55 In these TCA/75:25 PLGA corticosteroid microparticle for lations that may exhibit an initial release of corticosteroid mulations, the microparticles have a mean diameter in the followed by controlled or sustained release where the therapy range of 10-100 uM. In some embodiments, the micropar comprises a period of therapy wherein the corticosteroid is ticles have a mean diameter in the range of 20-100LLM, 20-90 released from the Sustained release component and the uM, 30-100 uM, 30-90 uM, or 10-90 uM. It is understood that plasma levels of the corticosteroid does not adversely Sup 60 these ranges refer to the mean diameter of all microparticles press the HPA axis. in a given population. The diameter of any given individual In some embodiments, the length of Sustained release is microparticle could be within a standard deviation above or between 21 days and 90 days. In some embodiments, the below the mean diameter. length of sustained release is between 21 days and 60 days. In The invention also provides populations of microparticles Some embodiments, the length of sustained release is between 65 including a Class B corticosteroid or a pharmaceutically 14 days and 30 days. In some embodiments, the length of acceptable salt thereof incorporated in, admixed, encapsu release of the immediate release form is between 1 day and 14 lated or otherwise associated with a lactic acid-glycolic acid US 8,828,440 B2 7 8 copolymer matrix containing 10-20% triblock (PEG-PLGA formulations of the invention do not require the presence of PEG) having an inherent viscosity in the range from 0.6 to 0.8 PEG to exhibit the desired corticosteroid sustained release dL/g, wherein the Class B corticosteroid is between 22% to kinetics and bioavailability profile. 28% of the microparticles. In some embodiments, the corti In one embodiment of these populations, preparations and/ costeroid microparticle formulation includes a Class B corti or formulations, the corticosteroid microparticle formulation costeroid and a microparticle made using 75:25 PLGA for includes triamcinolone acetonide (TCA) and a microparticle mulation and containing 10-20% triblock (PEG-PLGA-PEG) made using 75:25 PLGA formulation having an inherent having an inherent viscosity in the range from 0.6 to 0.8dL/g. viscosity in the range from 0.3 to 0.5 dL/g and/or a molecular In these TCA/75:25 PLGA corticosteroid microparticle for weight in the range of 40-70kDa, for example between 50-60 mulations, the microparticles have a mean diameter in the 10 range of 10-100 uM. In some embodiments, the micropar kDa. In these TCA/75:25 PLGA corticosteroid microparticle ticles have a mean diameter in the range of 20-100 uM, 20-90 formulations, the microparticles have a mean diameter in the uM, 30-100 uM, 30-90 uM, or 10-90 uM. It is understood that range of 10-100 uM. In some embodiments, the micropar these ranges refer to the mean diameter of all microparticles ticles have a mean diameter in the range of 20-100LLM, 20-90 in a given population. The diameter of any given individual 15 uM, 30-100 uM, 30-90 uM, or 10-90 uM. It is understood that microparticle could be within a standard deviation above or these ranges refer to the mean diameter of all microparticles below the mean diameter. in a given population. The diameter of any given individual These Class B corticosteroid microparticle formulations, microparticle could be within a standard deviation above or preparations, and populations thereof, when administered to a below the mean diameter. patient, exhibit reduced undesirable side effects in patient, for For the TCA/75:25 PLGA microparticle formulations, the example, undesirable effects on a patient’s cartilage or other range of TCA load percentage is between 22-28%. In one structural tissue, as compared to the administration, for embodiment, the load percentage of TCA in the micropar example administration into the intra-articular space of a ticles in 25%. joint, of an equivalent amount of the Class B corticosteroid The microparticles in the TCA PLGA microparticle for absent any microparticle or other type of incorporation, 25 mulations can be formulated using PLGA polymers having a admixture, or encapsulation. range of molecular weights from 40 to 70 kDa, most prefer In some embodiments, the Class B corticosteroid is triam ably from 50 to 60kDa and range of inherent viscosities from cinolone acetonide or a commercially available chemical ana 0.5 to 0.5 dL/g, most preferably from 0.38 to 0.42 dL/g. logue or a pharmaceutically-acceptable salt thereof. In some For the TCA/75:25 PLGA microparticle formulations, the embodiments, the total dose of corticosteroid contained in the 30 microparticles is in the range of 10-90 mg, where the Class B total dose of corticosteroid contained in the microparticles is corticosteroid is between 12-28% of the microparticle, for in the range of 10-90 mg, where TCA is between 22-28% of example, between 22-28% of the microparticle (i.e., when the the microparticle (i.e., when TCA is 25% of the microparticle, corticosteroid is 28% of the microparticle, the microparticle the microparticle is in the range of 40-360 mgs, when TCA is is in the range of 35.7-321.4 mgs, and so on for all values 35 22% of the microparticle, the microparticle is in the range of between 22-28% load dose, when the corticosteroid is 25% of 45.5-409.1 mgs, when TCA is 28% of the microparticle, the the microparticle, the microparticle is in the range of 40-360 microparticle is in the range of 35.7-321.4 mgs, and so on for mgs, when the corticosteroid is 22% of the microparticle, the all values between 22-28% load dose). In some embodiments, microparticle is in the range of 45.5-409.1 mgs, when the total dose of corticosteroid contained in the microparticles is corticosteroid is 12% of the microparticle, the microparticle 40 in a range selected from 10-80 mg, 10-70 mg, 10-60 mg. is in the range of 83.3-750 mgs, and so on for all values 10-50 mg, 10-40 mg, 10-30 mg, 10-20 mg, 20-90 mg, 20-80 between 12-28% load dose). In some embodiments, the Class mg, 20-70 mg, 20-60 mg, 20-50 mg, 20-40 mg, 20-30 mg. B corticosteroid contained in the microparticles is 12-28% of 30-90 mg, 30-80 mg, 30-70 mg, 30-60 mg, 30-50 mg, 30-40 the microparticle, for example, between 22-28% of the mg, 40-90 mg, 40-80 mg, 40-70 mg, 40-60 mg, 40-50 mg. microparticle and the total dose of corticosteroid is in a range 45 50-90 mg, 50-80 mg, 50-70 mg, 50-60 mg, 60-90 mg, 60-80 selected from 10-80 mg, 10-70 mg, 10-60 mg, 10-50 mg. mg, 60-70 mg, 70-90 mg, 70-80 mg, and 80-90 mg. 10-40 mg, 10-30 mg, 10-20 mg, 20-90 mg, 20-80 mg, 20-70 In some embodiments of the TCA/75:25 PLGA micropar mg, 20-60 mg, 20-50 mg, 20-40 mg, 20-30 mg, 30-90 mg. ticle formulations, the microparticles further comprise a 30-80 mg, 30-70 mg, 30-60 mg, 30-50 mg, 30-40 mg, 40-90 polyethylene glycol (PEG) moiety, wherein the PEG moiety mg, 40-80 mg, 40-70 mg, 40-60 mg, 40-50 mg, 50-90 mg. 50 comprises between 25% to 0% weight percent of the micro 50-80 mg, 50-70 mg, 50-60 mg, 60-90 mg, 60-80 mg, 60-70 particle. In some embodiments of the microparticles that mg, 70-90 mg, 70-80 mg, and 80-90 mg. In some embodi include a PEG moiety, the populations, preparations and/or ments, the Class B corticosteroid is released for between 14 formulations of the invention do not require the presence of days and 90 days. PEG to exhibit the desired corticosteroid sustained release In some embodiments, the microparticles have a mean 55 kinetics and bioavailability profile. diameter of between 10 um to 100 um, for example, the In one embodiment of these populations, preparations and/ microparticles have a mean diameter in the range of 20-100 or formulations, the corticosteroid microparticle formulation uM, 20-90 uM, 30-100 uM, 30-90 uM, or 10-90 uM. It is includes triamcinolone acetonide (TCA) and a microparticle understood that these ranges refer to the mean diameter of all made using 75:25 PLGA formulation and containing 10-20% microparticles in a given population. The diameter of any 60 triblock (PEG-PLGA-PEG) having an inherent viscosity in given individual microparticle could be within a standard the range from 0.6 to 0.8 dL/g. In these TCA/75:25 PLGA deviation above or below the mean diameter. corticosteroid microparticle formulations, the microparticles In Some embodiments, the microparticles further comprise have a mean diameter in the range of 10-100 uM. In some a polyethylene glycol (PEG) moiety, wherein the PEG moiety embodiments, the microparticles have a mean diameter in the comprises between 25% to 0% weight percent of the micro 65 range of 20-100 uM, 20-90 uM, 30-100 uM, 30-90 uM, or particle. In some embodiments of the microparticles that 10-90 LM. It is understood that these ranges refer to the mean include a PEG moiety, the populations, preparations and/or diameter of all microparticles in a given population. The US 8,828,440 B2 10 diameter of any given individual microparticle could be lated or otherwise associated with a lactic acid-glycolic acid within a standard deviation above or below the mean diam copolymer matrix, wherein the Class A corticosteroid is eter. between 15% to 30% of the microparticles. In one embodiment of these populations, preparations and/ The invention also provides controlled or sustained release or formulations, the corticosteroid microparticle formulation 5 preparations of a Class A corticosteroid including a lactic includes triamcinolone acetonide (TCA) and a microparticle acid-glycolic acid copolymer microparticle containing the made using 75:25 PLGA formulation with two PLGA poly Class A corticosteroid, wherein the Class A corticosteroid is mers, one of low molecular weight and one of high molecular between 10% to 40%, for example between 15% to 30% of weight in a two to one ratio, respectively. The low molecular the lactic acid-glycolic acid copolymer microparticle matrix. weight PLGA has a molecular weight of range of 15-35 kDa 10 The invention provides formulations that include (a) con and an inherent viscosity range from 0.2 to 0.35 dL/g and the trolled- or Sustained-release microparticles including a Class high molecular weight PLGA has a range of 70-95kDa and an A corticosteroid and a lactic acid-glycolic acid copolymer inherent viscosity range of 0.5 to 0.70 dL/g. In these TCA/ matrix, wherein the Class A corticosteroid is between 15% to 75:25 PLGA corticosteroid microparticle formulations, the 30% of the microparticles and wherein the lactic acid-gly microparticles have a mean diameter in the range of 10-100 15 colic acid copolymer has one of more of the following char LM. In some embodiments, the microparticles have a mean acteristics: (i) a molecular weight in the range of about 40 to diameter in the range of 20-100 uM, 20-90 uM, 30-100 uM, 70 kDa; (ii) an inherent viscosity in the range of 0.35 to 0.5 30-90 or 10-90 LM. It is understood that these ranges refer to dL/g; (iii) a lactide:glycolide molar ratio of 60:40 to 45:55: the mean diameter of all microparticles in a given population. and/or (iv) the lactic acid-glycolic acid copolymer is carboxy The diameter of any given individual microparticle could be lic acid endcapped within a standard deviation above or below the mean diam In some embodiments, the copolymer is biodegradable. In eter. Some embodiments, the lactic acid-glycolic acid copolymer These TCA microparticle formulations, preparations, and is a poly(lactic-co-glycolic) acid copolymer (PLGA). 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, 25 has a molar ratio of lactic acid:glycolic acid from the range of undesirable effects on a patient's cartilage or other structural about 60:40 to 45:55. In some embodiments, the lactic acid tissue, as compared to the administration, for example admin glycolic acid copolymer has a molar ratio of lactic acid: istration into the intra-articular space of a joint, of an equiva glycolic acid of 50:50. lent amount of TCA absent any microparticle or other type of In some embodiments, the Class A corticosteroid is pred incorporation, admixture, or encapsulation. 30 nisolone or a commercially available chemical analogue or a In another embodiment, the corticosteroid microparticle pharmaceutically-acceptable salt thereof. In some embodi formulation includes a Class A, C, or D corticosteroid and a ments, total dose of the Class A corticosteroid contained in microparticle made using 50:50 PLGA formulation. For the microparticles is in a range selected from 10-250 mg. example, in some embodiments, the Class A corticosteroid is where the Class A corticosteroid is between 10-40%, for prednisolone. In some embodiments, the Class C corticoster 35 example, between 15-30% of the microparticle (i.e., when the oid is betamethasone. In some embodiments, the Class D corticosteroid is 10% of the microparticle, the microparticle corticosteroid is fluticasone or fluticasone propionate. In is in the range of 100-2500 mgs, when the corticosteroid is these Class A, C, or D corticosteroid microparticle formula 15% of the microparticle, the microparticle is in the range of tions, the microparticles have a mean diameter in the range of 66.7-1666.7 mgs, when the corticosteroid is 20% of the 10-100 uM. In some embodiments, the microparticles have a 40 microparticle, the microparticle is in the range of 50-1250 mean diameter in the range of 20-100 uM, 20-90 LM, 30-100 mgs, when the corticosteroid is 25% of the microparticle, the uM, 30-90 uM, or 10-90 LM. It is understood that these ranges microparticle is in the range of 40-1000 mgs, when the cor refer to the mean diameter of all microparticles in a given ticosteroid is 30% of the microparticle, the microparticle is in population. The diameter of any given individual micropar the range of 33.3-833.3 mgs, when the corticosteroid is 40% ticle could be within a standard deviation above or below the 45 of the microparticle, the microparticle is in the range of mean diameter. 25-625 mgs and so on for all values between 10-40% load For the Class A and/or Class C PLGA microparticle for dose). For example, in some embodiments, the total dose of mulations, the range of corticosteroid load percentage is corticosteroid is in the range of 10-225 mg, 10-200 mg. between 10-40%, for example, between 15%-30%. For the 10-175 mg, 10-150 mg, 10-120 mg, 10-100 mg, 10-75 mg, Class D PLGA microparticle formulations, the range of cor 50 10-50 mg, 10-25 mg, 20-250 mg, 20-225 mg, 20-200 mg. ticosteroid load percentage is between 8-20%. 20-175 mg, 20-150 mg, 20-125 mg, 20-100 mg, 20-75 mg. The microparticles in the Class A, C or DPLGA micropar 20-50 mg, 30-250 mg, 30-225 mg, 30-200 mg, 30-175 mg. ticle formulations can be formulated using PLGA polymers 30-150 mg, 30-120 mg, 30-100 mg, 30-75 mg, 30-50 mg, having a range of inherent viscosities from 0.35 to 0.5 dL/g 40-250 mg, 40-225 mg, 40-200 mg, 40-175 mg, 40-150 mg. and approximated molecular weights from 40 kDa to 70 kDa. 55 40-120 mg, 40-100 mg, 40-75 mg, 50-250 mg, 50-225 mg. These Class A, C or D corticosteroid microparticle formu 50-200 mg, 50-175 mg, 50-150 mg, 50-120 mg, 50-100 mg, lations, preparations, and populations thereof, when admin 50-75 mg, 60-250 mg. 60-225 mg. 60-200 mg, 60-175 mg. istered to a patient, exhibit reduced undesirable side effects in 60-150 mg, 60-120 mg. 60-100 mg, 60-75 mg, 70-250 mg. patient, for example, undesirable effects on a patient’s carti 70-225 mg, 70-200 mg, 70-175 mg, 70-150 mg, 70-120 mg, lage or other structural tissue, as compared to the administra 60 70-100 mg, 80-250 mg, 80-225 mg, 80-200 mg, 80-175 mg, tion, for example administration into the intra-articular space 80-150 mg, 80-120 mg, 80-100 mg, 90-250 mg, 90-225 mg. of a joint, of an equivalent amount of the Class A, C or D 90-200 mg, 90-175 mg, 90-150 mg. or 90-120 mg. In some corticosteroid absent any microparticle or other type of incor embodiments, the Class A corticosteroid is released for poration, admixture, or encapsulation. between 14 days and 90 days. The invention provides populations of microparticles 65 In some embodiments, the microparticles have a mean including a Class A corticosteroid or a pharmaceutically diameter of between 10 um to 100 um, for example, the acceptable salt thereof incorporated in, admixed, encapsu microparticles have a mean diameter in the range of 20-100 US 8,828,440 B2 11 12 uM, 20-90 uM, 30-100 uM, 30-90 uM, or 10-90 uM. It is 60:40 to 45:55. In some embodiments, the lactic acid-glycolic understood that these ranges refer to the mean diameter of all acid copolymer has a molar ratio of lactic acid:glycolic acid microparticles in a given population. The diameter of any Of 50:50. given individual microparticle could be within a standard In some embodiments, the Class C corticosteroid is deviation above or below the mean diameter. betamethasone or a commercially available chemical ana In Some embodiments, the microparticles further comprise logue or a pharmaceutically-acceptable salt thereof. In some a polyethylene glycol (PEG) moiety, wherein the PEG moiety embodiments, total dose of the Class C corticosteroid con comprises between 25% to 0% weight percent of the micro tained in the microparticles is in a range selected from 2-250 particle. In some embodiments of the microparticles that mg, where the Class C corticosteroid is between 10-40%, for 10 example, between 15-30% of the microparticle (i.e., when the include a PEG moiety, the populations, preparations and/or corticosteroid is 10% of the microparticle, the microparticle formulations of the invention do not require the presence of is in the range of 20-2500 mgs, when the corticosteroid is PEG to exhibit the desired corticosteroid sustained release 15% of the microparticle, the microparticle is in the range of kinetics and bioavailability profile. 13.3-1666.7 mgs, when the corticosteroid is 20% of the In one embodiment of these populations, preparations and/ 15 microparticle, the microparticle is in the range of 10-1250 or formulations, the corticosteroid microparticle formulation mgs, when the corticosteroid is 25% of the microparticle, the includes prednisolone and a microparticle made using 50:50 microparticle is in the range of 8-1000 mgs, when the corti PLGA formulation having a molecular weight in the range of costeroid is 30% of the microparticle, the microparticle is in 40 kDa to 70 kDa. In these prednisolone/50:50 PLGA corti the range of 6.67-833.3 mgs, when the corticosteroid is 40% costeroid microparticle formulations, the microparticles have of the microparticle, the microparticle is in the range of 5-625 a mean diameter in the range of 10-100 uM. In some embodi mgs and so on for all values between 10-40% load dose). For ments, the microparticles have a mean diameter in the range example, in some embodiments, the total dose of corticoster of 20-100 uM, 20-90 uM, 30-100 uM, 30-90 uM, or 10-90 oid is in the range of 2-225 mg, 2-200 mg, 2-175 mg, 2-150 uM. mg, 2-120 mg, 2-100 mg, 2-75 mg, 2-60 mg, 2-55 mg, 2-50 For the prednisolone/50:50 PLGA microparticle formula 25 mg, 2-45 mg, 2-40 mg, 2-35 mg, 2-30 mg, 2-25 mg, 2-20 mg. tions, the range of prednisolone load percentage is between 2-15 mg, 2-10 mg, 4-225 mg, 4-200 mg, 4-175 mg, 4-150 mg. 10-40%, for example, between 15-30%. 4-120 mg, 4-100 mg, 4-75 mg, 4-60 mg, 4-55 mg, 4-50 mg. In some embodiments of the prednisolone/50:50 PLGA 4-45 mg, 4-40 mg, 4-35 mg, 4-30 mg, 4-25 mg, 4-20 mg, 4-15 microparticle formulations, the microparticles further com mg, 4-10 mg, 5-225 mg, 5-200 mg, 5-175 mg, 5-150 mg. prise a polyethylene glycol (PEG) moiety, wherein the PEG 30 5-120 mg, 5-100 mg, 5-75 mg, 5-60 mg, 5-55 mg, 5-50 mg. 5-45 mg, 5-40 mg, 5-35 mg, 5-30 mg, 5-25 mg, 5-20 mg, 5-15 moiety comprises between 25% to 0% weight percent of the mg, 5-10 mg, 6-225 mg, 6-200 mg. 6-175 mg, 6-150 mg. microparticle. In some embodiments of the microparticles 6-120 mg. 6-100 mg, 6-75 mg, 6-60 mg. 6-55 mg, 6-50 mg. that include a PEG moiety, the populations, preparations and/ 6-45 mg, 6-40 mg, 6-35 mg, 6-30 mg, 6-25 mg, 6-20 mg. 6-15 or formulations of the invention do not require the presence of 35 mg, 6-10 mg. 8-225 mg. 8-200 mg. 8-175 mg. 8-150 mg. PEG to exhibit the desired corticosteroid sustained release 8-120 mg. 8-100 mg. 8-75 mg. 8-60 mg. 8-55 mg. 8-50 mg. kinetics and bioavailability profile. 8-45 mg. 8-40 mg. 8-35 mg. 8-30 mg. 8-25 mg. 8-20 mg. 8-15 The invention provides populations of microparticles mg. 8-10 mg, 10-225 mg, 10-200 mg, 10-175 mg, 10-150 mg. including a Class C corticosteroid or a pharmaceutically 10-120 mg, 10-100 mg, 10-75 mg, 10-50 mg, 10-25 mg, acceptable salt thereof incorporated in, admixed, encapsu 40 20-250 mg, 20-225 mg, 20-200 mg, 20-175 mg, 20-150 mg. lated or otherwise associated with a lactic acid-glycolic acid 20-125 mg, 20-100 mg, 20-75 mg, 20-50 mg, 30-250 mg. copolymer matrix, wherein the Class C corticosteroid is 30-225 mg, 30-200 mg, 30-175 mg, 30-150 mg, 30-120 mg. between 10% to 40% of the microparticles, for example 30-100 mg, 30-75 mg, 30-50 mg, 40-250 mg, 40-225 mg. between 15% to 30% of the microparticles. 40-200 mg, 40-175 mg, 40-150 mg, 40-120 mg, 40-100 mg. The invention also provides controlled or sustained release 45 40-75 mg, 50-250 mg, 50-225 mg, 50-200 mg, 50-175 mg, preparations of a Class C corticosteroid including a lactic 50-150 mg, 50-120 mg, 50-100 mg, 50-75 mg, 60-250 mg, acid-glycolic acid copolymer microparticle containing the 60-225 mg, 60-200 mg. 60-175 mg, 60-150 mg, 60-120 mg. Class C corticosteroid, wherein the Class C corticosteroid is 60-100 mg, 60-75 mg, 70-250 mg, 70-225 mg, 70-200 mg, between 15% to 30% of the lactic acid-glycolic acid copoly 70-175 mg, 70-150 mg, 70-120 mg, 70-100 mg, 80-250 mg, mer microparticle matrix. 50 80-225 mg, 80-200 mg, 80-175 mg, 80-150 mg, 80-120 mg. The invention provides formulations that include (a) con 80-100 mg,90-250 mg, 90-225 mg,90-200 mg, 90-175 mg, trolled- or Sustained-release microparticles having a Class C 90-150 mg. or 90-120 mg. In some embodiments, the Class C corticosteroid and a lactic acid-glycolic acid copolymer corticosteroid is released for between 14 days and 90 days. matrix, wherein the Class C corticosteroid is between 15% to In some embodiments, the microparticles have a mean 30% of the microparticles and wherein the lactic acid-gly 55 diameter of between 10 um to 100 um, for example, the colic acid copolymer has one of more of the following char microparticles have a mean diameter in the range of 20-100 acteristics: (i) a molecular weight in the range of about 40 to uM, 20-90 uM, 30-100 uM, 30-90 uM, or 10-90 uM. It is 70 kDa; (ii) an inherent viscosity in the range of 0.35 to 0.5 understood that these ranges refer to the mean diameter of all dL/g; (iii) a lactide:glycolide molar ratio of 60:40 to 45:55: microparticles in a given population. The diameter of any and/or (iv) the lactic acid-glycolic acid copolymer is carboxy 60 given individual microparticle could be within a standard lic acid endcapped. deviation above or below the mean diameter. In one embodiment of these populations, preparations and/ In some embodiments, the microparticles further comprise or formulations, the copolymer is biodegradable. In some a polyethylene glycol (PEG) moiety, wherein the PEG moiety embodiments, the lactic acid-glycolic acid copolymer is a comprises between 25% to 0% weight percent of the micro poly(lactic-co-glycolic) acid copolymer (PLGA). In some 65 particle. In some embodiments of the microparticles that embodiments, the lactic acid-glycolic acid copolymer has a include a PEG moiety, the populations, preparations and/or molar ratio of lactic acid:glycolic acid from the range of about formulations of the invention do not require the presence of US 8,828,440 B2 13 14 PEG to exhibit the desired corticosteroid sustained release corticosteroid contained in the microparticles is in a range kinetics and bioavailability profile. selected from 1-250 mg, where the Class D corticosteroid is In one embodiment of these populations, preparations and/ between 8-20% of the microparticle (i.e., when the corticos or formulations, the corticosteroid microparticle formulation teroid is 8% of the microparticle, the microparticle is in the includes betamethasone and a microparticle made using 5 range of 12.5-3125 mgs, when the corticosteroid is 10% of the 50:50 PLGA formulation having a molecular weight in the microparticle, the microparticle is in the range of 10-2500 range of 40 kDa to 70 kDa. In these betamethasone/50:50 mgs, when the corticosteroid is 15% of the microparticle, the PLGA corticosteroid microparticle formulations, the micro microparticle is in the range of 6.67-1666.7 mgs, when the particles have a mean diameter in the range of 10-100 LM. In corticosteroid is 20% of the microparticle, the microparticle Some embodiments, the microparticles have a mean diameter 10 is in the range of 5-1250 mgs, and so on for all values between in the range of 20-100 uM, 20-90 uM, 30-100 uM, 30-90 uM, 10-20% load dose). For example, in some embodiments, the or 10-90 uM. It is understood that these ranges refer to the total dose of corticosteroid is in the range of 1-225 mg, 1-200 mean diameter of all microparticles in a given population. mg, 1-175 mg, 1-150 mg, 1-120 mg, 1-100 mg, 1-75 mg, 1-60 The diameter of any given individual microparticle could be mg, 1-55 mg, 1-50 mg, 1-45 mg, 1-40 mg, 1-35 mg, 1-30 mg. within a standard deviation above or below the mean diam 15 1-25 mg, 1-20 mg, 1-15 mg, 1-10 mg, 2-225 mg, 2-200 mg. eter. 2-175 mg, 2-150 mg, 2-120 mg, 2-100 mg, 2-75 mg, 2-60 mg. For the betamethasone/50:50 PLGA microparticle formu 2-55 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 between mg, 2-20 mg, 2-15 mg, 2-10 mg, 3-225 mg, 3-200 mg. 3-175 10-40%, for example, between 15-30%. mg, 3-150 mg. 3-120 mg. 3-100 mg, 3-75 mg, 3-60 mg. 3-55 In some embodiments of the betamethasone/50:50 PLGA mg, 3-50 mg, 3-45 mg, 3-40 mg, 3-35 mg. 3-30 mg, 3-25 mg. microparticle formulations, the microparticles further com 3-20 mg. 3-15 mg. 3-10 mg, 4-225 mg, 4-200 mg, 4-175 mg. prise a polyethylene glycol (PEG) moiety, wherein the PEG 4-150 mg, 4-120 mg, 4-100 mg, 4-75 mg, 4-60 mg, 4-55 mg. moiety comprises between 25% to 0% weight percent of the 4-50 mg, 4-45 mg, 4-40 mg, 4-35 mg, 4-30 mg, 4-25 mg, 4-20 microparticle. In some embodiments of the microparticles mg, 4-15 mg, 4-10 mg, 5-225 mg, 5-200 mg, 5-175 mg, 5-150 that include a PEG moiety, the populations, preparations and/ 25 mg, 5-120 mg, 5-100 mg, 5-75 mg, 5-60 mg, 5-55 mg, 5-50 or formulations of the invention do not require the presence of mg, 5-45 mg, 5-40 mg, 5-35 mg, 5-30 mg, 5-25 mg, 5-20 mg. PEG to exhibit the desired corticosteroid sustained release 5-15 mg, 5-10 mg, 6-225 mg, 6-200 mg. 6-175 mg. 6-150 mg. kinetics and bioavailability profile. 6-120 mg. 6-100 mg, 6-75 mg, 6-60 mg. 6-55 mg, 6-50 mg. The invention provides populations of microparticles 6-45 mg, 6-40 mg, 6-35 mg, 6-30 mg, 6-25 mg, 6-20 mg. 6-15 including a Class D corticosteroid or a pharmaceutically 30 mg, 6-10 mg. 8-225 mg. 8-200 mg. 8-175 mg. 8-150 mg. acceptable salt thereof incorporated in, admixed, encapsu 8-120 mg. 8-100 mg. 8-75 mg. 8-60 mg. 8-55 mg. 8-50 mg. lated or otherwise associated with a lactic acid-glycolic acid 8-45 mg. 8-40 mg. 8-35 mg. 8-30 mg. 8-25 mg. 8-20 mg. 8-15 copolymer matrix, wherein the Class D corticosteroid is mg. 8-10 mg, 10-225 mg, 10-200 mg, 10-175 mg, 10-150 mg. between 8% to 20% of the microparticles, for example, 10-120 mg, 10-100 mg, 10-75 mg, 10-50 mg, 10-25 mg, between 10% to 20% of the microparticles. 35 20-250 mg, 20-225 mg, 20-200 mg, 20-175 mg, 20-150 mg. The invention also provides controlled or sustained release 20-125 mg, 20-100 mg, 20-75 mg, 20-50 mg, 30-250 mg. preparation of a Class D corticosteroid including a lactic 30-225 mg, 30-200 mg, 30-175 mg, 30-150 mg, 30-120 mg. acid-glycolic acid copolymer microparticle containing the 30-100 mg, 30-75 mg, 30-50 mg, 40-250 mg, 40-225 mg. Class D corticosteroid, wherein the Class D corticosteroid is 40-200 mg, 40-175 mg, 40-150 mg, 40-120 mg, 40-100 mg. between 8% to 20%, for example, between 10% to 20% of the 40 40-75 mg, 50-250 mg, 50-225 mg, 50-200 mg, 50-175 mg, microparticles of the lactic acid-glycolic acid copolymer 50-150 mg, 50-120 mg, 50-100 mg, 50-75 mg, 60-250 mg, microparticle matrix. 60-225 mg, 60-200 mg. 60-175 mg, 60-150 mg, 60-120 mg. The invention provides formulations including (a) con 60-100 mg, 60-75 mg, 70-250 mg, 70-225 mg, 70-200 mg, trolled- or Sustained-release microparticles having a Class D 70-175 mg, 70-150 mg, 70-120 mg, 70-100 mg, 80-250 mg, corticosteroid and a lactic acid-glycolic acid copolymer 45 80-225 mg, 80-200 mg, 80-175 mg, 80-150 mg, 80-120 mg. matrix, wherein the Class D corticosteroid is between 8% to 80-100 mg,90-250 mg, 90-225 mg,90-200 mg, 90-175 mg, 20% of the microparticles, for example, between 10% to 20% 90-150 mg. or 90-120 mg. In some embodiments, the Class D of the microparticles, and wherein the lactic acid-glycolic corticosteroid is released for between 14 days and 90 days. acid copolymer has one of more of the following character In some embodiments, the microparticles have a mean istics: (i) a molecular weight in the range of about 40 to 70 50 diameter of between 10 um to 100 um, for example, the kDa; (ii) an inherent viscosity in the range of 0.35 to 0.5 dL/g: microparticles have a mean diameter in the range of 20-100 (iii) a lactide:glycolide molar ratio of 60:40 to 45:55; and/or uM, 20-90 uM, 30-100 uM, 30-90 uM, or 10-90 uM. It is (iv) the lactic acid-glycolic acid copolymer is carboxylic acid understood that these ranges refer to the mean diameter of all endcapped. microparticles in a given population. The diameter of any In one embodiment of these populations, preparations and/ 55 given individual microparticle could be within a standard or formulations, the copolymer is biodegradable. In some deviation above or below the mean diameter. embodiments, the lactic acid-glycolic acid copolymer is a In some embodiments, the microparticles further comprise poly(lactic-co-glycolic) acid copolymer (PLGA). In some a polyethylene glycol (PEG) moiety, wherein the PEG moiety embodiments, the lactic acid-glycolic acid copolymer has a comprises between 25% to 0% weight percent of the micro molar ratio of lactic acid:glycolic acid from the range of about 60 particle. In some embodiments of the microparticles that 60:40 to 45:55. In some embodiments, the lactic acid-glycolic include a PEG moiety, the populations, preparations and/or acid copolymer has a molar ratio of lactic acid:glycolic acid formulations of the invention do not require the presence of Of 50:50. PEG to exhibit the desired corticosteroid sustained release In some embodiments, the Class D corticosteroid is fluti kinetics and bioavailability profile. casone propionate, fluticasone, or a commercially available 65 In one embodiment of these populations, preparations and/ chemical analogue or a pharmaceutically-acceptable salt or formulations, the corticosteroid microparticle formulation thereof. In some embodiments, total dose of the Class D includes fluticasone propionate or fluticaSone, and a micro US 8,828,440 B2 15 16 particle made using 50:50 PLGA formulation having a Sustained release manner Such that the levels of cortisol Sup molecular weight in the range of 40 kDa to 70 kDa. In these pression are negligible at any time post-administration. fluticasone or fluticasone propionate/50:50 PLGA corticos The invention provides methods of treating pain or inflam teroid microparticle formulations, the microparticles have a mation in a patient comprising administering to said patient a mean diameter in the range of 10-100 uM. In some embodi therapeutically effective amount of a controlled or sustained ments, the microparticles have a mean diameter in the range release preparation selected from the following preparations: of 20-100 uM, 20-90 uM, 30-100 uM, 30-90 or 10-90 uM. It (i) a controlled or Sustained release preparation of a Class B is understood that these ranges refer to the mean diameter of corticosteroid comprising a lactic acid-glycolic acid copoly all microparticles in a given population. The diameter of any mer microparticle containing the Class B corticosteroid, given individual microparticle could be within a standard 10 wherein the Class B corticosteroid comprises between 22% to deviation above or below the mean diameter. 28% of the lactic acid-glycolic acid copolymer microparticle For the fluticasone or fluticasone propionate/50:50 PLGA matrix; (ii) a controlled or Sustained release preparation of a microparticle formulations, the range of prednisolone load Class A corticosteroid comprising a lactic acid-glycolic acid percentage is between 10-20%. copolymer microparticle containing the Class A corticoster In some embodiments of the fluticasone or fluticasone 15 oid, wherein the Class A corticosteroid comprises between propionate/50:50 PLGA microparticle formulations, the 15% to 30% of the lactic acid-glycolic acid copolymer micro microparticles further comprise a polyethylene glycol (PEG) particle matrix; (iii) a controlled or Sustained release prepa moiety, wherein the PEG moiety comprises between 25% to ration of a Class C corticosteroid comprising a lactic acid 0% weight percent of the microparticle. In some embodi glycolic acid copolymer microparticle containing the Class C ments of the microparticles that include a PEG moiety, the corticosteroid, wherein the Class C corticosteroid comprises populations, preparations and/or formulations of the inven between 15% to 30% of the lactic acid-glycolic acid copoly tion do not require the presence of PEG to exhibit the desired mer microparticle matrix; and (iv) a controlled or Sustained corticosteroid sustained release kinetics and bioavailability release preparation of a Class D corticosteroid comprising a profile. lactic acid-glycolic acid copolymer microparticle containing These embodiments of corticosteroid microparticle formu 25 the Class D corticosteroid, wherein the Class D corticosteroid lations have been selected because the combination of class of comprises between 8% to 20% of the lactic acid-glycolic acid corticosteroid, type of microparticle, molecular weight of copolymer microparticle matrix. In some embodiments, the polymers used to create the microparticles lactide:glycolide controlled or Sustained release preparation releases the corti molar ratio, and/or load percentage of the corticosteroid costeroid for at least 14 days at a rate that does not adversely exhibit the desired release kinetics. These embodiments also 30 Suppress the hypothalamic-pituitary-adrenal axis (HPA axis). exhibit the desired release kinetics with minimal prolonged In some embodiments, the controlled or Sustained release HPA axis suppression. preparation releases the corticosteroid in a controlled or sus The invention provides methods of treating pain or inflam tained release manner Such that the levels of cortisol Suppres mation in a patient comprising administering to said patient a sion are at or below 35% by day 14 post-administration, for therapeutically effective amount of a population of micropar 35 example post-administration. In some embodiments, the con ticles selected from the following populations: (i) a popula trolled or Sustained release preparation releases the corticos tion of microparticles comprising a Class B corticosteroid or teroid in a controlled or Sustained release manner Such that the a pharmaceutically acceptable salt thereof incorporated in a levels of cortisol Suppression are negligible and/or undetect lactic acid-glycolic acid copolymer matrix, wherein the Class able by 14 post-administration. In some embodiments, the B corticosteroid comprises between 22% to 28% of the 40 controlled or Sustained release preparation releases the corti microparticles; (ii) a population of microparticles comprising costeroid in a controlled or Sustained release manner Such that a Class A corticosteroid or a pharmaceutically acceptable salt the levels of cortisol Suppression are negligible at any time thereof incorporated in a lactic acid-glycolic acid copolymer post-administration. matrix, wherein the Class A corticosteroid comprises The invention provides methods of treating pain or inflam between 15% to 30% of the microparticles; (iii) a population 45 mation in a patient comprising administering to said patient a of microparticles comprising a Class C corticosteroid or a therapeutically effective amount of a formulation selected pharmaceutically acceptable salt thereof incorporated in a from the following preparations: (i) a formulation comprising lactic acid-glycolic acid copolymer matrix, wherein the Class (a) controlled- or Sustained-release microparticles compris C corticosteroid comprises between 15% to 30% of the ing a Class B corticosteroid and a lactic acid-glycolic acid microparticles; and (iv) a population of microparticles com 50 copolymer matrix, wherein the Class B corticosteroid com prising a Class D corticosteroid or a pharmaceutically accept prises between 22% to 28% of the microparticles and wherein able salt thereof incorporated in a lactic acid-glycolic acid the lactic acid-glycolic acid copolymer has one of more of the copolymer matrix, wherein the Class D corticosteroid com following characteristics: (1) a molecular weight in the range prises between 8% to 20% of the microparticles. In some of about 40 to 70 kDa; (2) an inherent viscosity in the range of embodiments, the population of microparticles releases the 55 0.5 to 0.5 dL/g; or (3) a lactide:glycolide molar ratio of 80:20 corticosteroid for at least 14 days at a rate that does not to 60:40; (ii) a formulation comprising (a) controlled- or adversely suppress the hypothalamic-pituitary-adrenal axis Sustained-release microparticles comprising a Class A corti (HPA axis). In some embodiments, the population of micro costeroid and a lactic acid-glycolic acid copolymer matrix, particles releases the corticosteroid in a controlled or Sus wherein the Class Acorticosteroid comprises between 15% to tained release manner Such that the levels of cortisol Suppres 60 30% of the microparticles and wherein the lactic acid-gly sion are at or below 35% by day 14 post-administration, for colic acid copolymer has one of more of the following char example post-administration. In some embodiments, the acteristics: (1) a molecular weight in the range of about 40 to population of microparticles releases the corticosteroid in a 70 kDa; (2) an inherent viscosity in the range of 0.35 to 0.5 controlled or sustained release manner such that the levels of dL/g; or (3) a lactide:glycolide molar ratio of 60:40 to 45:55: cortisol Suppression are negligible and/or undetectable by 14 65 (iii) a formulation comprising (a) controlled- or Sustained post-administration. In some embodiments, the population of release microparticles comprising a Class C corticosteroid microparticles releases the corticosteroid in a controlled or and a lactic acid-glycolic acid copolymer matrix, wherein the US 8,828,440 B2 17 18 Class C corticosteroid comprises between 15% to 30% of the microparticles have a mass mean diameter of between 10 um microparticles and wherein the lactic acid-glycolic acid to 100 um. In some embodiments, the microparticles are copolymer has one of more of the following characteristics: formed from a hydrogel, hyaluronic acid, PLA or PLGA. For (1) a molecular weight in the range of about 40 to 70 kDa; (2) example, the microparticles are formed from PLGA with a an inherent viscosity in the range of 0.35 to 0.5 dL/g; or (3) a 5 lactide to glycolide co-polymer ratio of about 45:55 to about lactide:glycolide molar ratio of 60:40 to 45:55; and (iv) a 80:20. In some embodiments, the corticosteroid is betametha formulation comprising (a) controlled- or Sustained-release Sone, dexamethasone, triamcinolone acetonide, triamcino microparticles comprising a Class D corticosteroid and a lone hexacetonide, prednisolone, methylprednisolone, bude lactic acid-glycolic acid copolymer matrix, wherein the Class noside, mometasone, ciclesonide, fluticasone, salts thereof, D corticosteroid comprises between 8% to 20% of the micro 10 esters thereof or combinations thereof. particles and wherein the lactic acid-glycolic acid copolymer In yet another aspect, a composition is provided that has one of more of the following characteristics: (1) a molecu includes a population of biodegradable polymer micropar lar weight in the range of about 40 to 70 kDa; (2) an inherent ticles that contain corticosteroid(s). For example, the corti viscosity in the range of 0.35 to 0.5 dL/g; or (3) a lactide: costeroid is betamethasone, dexamethasone, triamcinolone glycolide molar ratio of 60:40 to 45:55. In some embodi 15 acetonide, triamcinolone hexacetonide, prednisolone, meth ments, the formulation releases the corticosteroid for at least ylprednisolone, budenoside, mometasone, ciclesonide, fluti 14 days at a rate that does not adversely Suppress the hypo casone, salts thereof, esters thereof or combinations thereof. thalamic-pituitary-adrenal axis (HPA axis). In some embodi When the composition is administered intra-articularly (e.g., ments, the formulation releases the corticosteroid in a con by one or more injections), a therapeutically effective amount trolled or sustained release manner such that the levels of of corticosteroid(s) is released for a period of time at a rate cortisol suppression are at or below 35% by day 14 post that does not suppress the HPA axis. In some embodiments, administration, for example post-administration. In some the corticosteroid(s) released will not adversely suppress the embodiments, the formulation releases the corticosteroid in a HPA axis. In some embodiments, the corticosteroid(s) controlled or sustained release manner such that the levels of released will not measurably suppress the HPA axis. cortisol Suppression are negligible and/or undetectable by 14 25 In yet a further aspect, a composition is provided that post-administration. In some embodiments, the formulation includes a population of biodegradable polymer micropar releases the corticosteroid in a controlled or Sustained release ticles that contain corticosteroid(s). For example, the corti manner Such that the levels of cortisol Suppression are negli costeroid is betamethasone, dexamethasone, triamcinolone gible at any time post-administration. acetonide, triamcinolone hexacetonide, prednisolone, meth In some embodiments, the population of microparticles, 30 ylprednisolone, budenoside, mometasone, ciclesonide, fluti the controlled or Sustained release preparation or formulation casone, salts thereof, esters thereof or combinations thereof. is administered as one or more intra-articular injections. In When the composition is administered intra-articularly (e.g., Some embodiments, the patient has osteoarthritis, rheumatoid by one or more injections), therapeutically effective amounts arthritis, acute gouty arthritis, and synovitis. In some embodi of corticosteroid(s) are released following administration ments, the patient has acute bursitis, Sub-acute bursitis, acute 35 from a first component for a first length of time and from a nonspecific tenosynovitis, or epicondylitis. Sustained release component for a second length of time. In one aspect, a method of treating pain and/or inflamma Furthermore, the rate of corticosteroid(s) released from the tion in a joint of a patient is provided that includes adminis Sustained release component does not suppress the HPA axis. tering intra-articularly (e.g., by one or more injections) to a In some embodiments, the corticosteroid(s) released from the patient with joint disease (e.g., osteoarthritis or rheumatoid 40 Sustained release component during the second length of time arthritis) a formulation that contains one or more corticoster will not adversely suppress the HPA axis. In some embodi oids, such as those formulations described herein. Therapeu ments, the corticosteroid(s) released from the Sustained tically effective amounts of the one or more corticosteroids release component during the second length of time will not are released for a period of time at a rate that does not suppress measurably suppress the HPA axis. In some embodiments, (e.g., adversely and/or measurably) the HPA axis. 45 the first component comprises a corticosteroid containing In another aspect, a method of treating pain and/or inflam Solution or Suspension. In some embodiments, the first com mation in a joint of a patient is provided that includes admin ponent contains a corticosteroid that is different from that of istering intra-articularly (e.g., by one or more injections) a the Sustained release component. In other embodiments, the therapeutically effective amount of one or more corticoster same corticosteroid is used in both the first and Sustained oids in a formulation to a patient with joint disease (e.g., 50 release components. osteoarthritis or rheumatoid arthritis). The formulation has a According to certain embodiments of the foregoing com Sustained release microparticle formulation that may or may positions, the corticosteroids are 2% to 75% (w/w) of the not release detectable levels of corticosteroid for a length of microparticles, preferably about 5% to 50% (w/w) of the time following administration and that releases a detectable microparticles, and more preferably 5% to 40% (w/w) of the amount of corticosteroid(s) following administration, where 55 microparticles. In some embodiments, the microparticles the rate of corticosteroid release from the sustained release have a mass mean diameter of between 10 um to 100 um. In microparticle formulation does not adversely suppress the Some embodiments, the microparticles are formed from a HPA axis. In some embodiments, corticosteroid released hydrogel, hyaluronic acid, PLA or PLGA. For example, the from the sustained release microparticle formulation will not microparticles are formed from PLGA with a lactide to gly measurably suppress the HPA axis. 60 collide co-polymer ratio of about 45:55 to about 80:20. In According to certain embodiments of the foregoing meth Some embodiments, the compositions further comprise a cor ods, the formulation comprises a population of biodegradable ticosteroid containing Solution or Suspension. In some polymer microparticles that contain the corticosteroids. In embodiments, the corticosteroid containing solution or Sus some embodiments, the corticosteroids are 2% to 75% (w/w) pension contains a corticosteroid that is different from that of the microparticles, preferably about 5% to 50% (w/w) of 65 found in the microparticles. the microparticles, and more preferably 5% to 40% or 10% to The invention also provides methods of slowing, arresting 30% (w/w) of the microparticles. In some embodiments, the or reversing progressive structural tissue damage associated US 8,828,440 B2 19 20 with chronic inflammatory disease in a patient comprising 70 kDa; (2) an inherent viscosity in the range of 0.3 to 0.5 administering to said patient a therapeutically effective dL/g; or (3) a lactide:glycolide molar ratio of 80:20 to 60:40: amount of a population of microparticles selected from the (ii) a formulation comprising (a) controlled- or Sustained following populations: (i) a population of microparticles release microparticles comprising a Class A corticosteroid comprising a Class B corticosteroid or a pharmaceutically and a lactic acid-glycolic acid copolymer matrix, wherein the acceptable salt thereof incorporated in a lactic acid-glycolic Class A corticosteroid comprises between 15% to 30% of the acid copolymer matrix, wherein the Class B corticosteroid microparticles and wherein the lactic acid-glycolic acid comprises between 22% to 28% of the microparticles; (ii) a copolymer has one of more of the following characteristics: population of microparticles comprising a Class A corticos (1) a molecular weight in the range of about 40 to 70 kDa; (2) teroid or a pharmaceutically acceptable salt thereof incorpo 10 an inherent viscosity in the range of 0.35 to 0.5 dL/g; or (3) a rated in a lactic acid-glycolic acid copolymer matrix, wherein lactide:glycolide molar ratio of 60:40 to 50:50; (iii) a formu the Class A corticosteroid comprises between 15% to 30% of lation comprising (a) controlled- or Sustained-release micro the microparticles; (iii) a population of microparticles com particles comprising a Class C corticosteroid and a lactic prising a Class C corticosteroid or a pharmaceutically accept acid-glycolic acid copolymer matrix, wherein the Class C able salt thereof incorporated in a lactic acid-glycolic acid 15 corticosteroid comprises between 15% to 30% of the micro copolymer matrix, wherein the Class C corticosteroid com particles and wherein the lactic acid-glycolic acid copolymer prises between 15% to 30% of the microparticles; and (iv) a has one of more of the following characteristics: (1) a molecu population of microparticles comprising a Class D corticos lar weight in the range of about 40 to 70 kDa; (2) an inherent teroid or a pharmaceutically acceptable salt thereof incorpo viscosity in the range of 0.35 to 0.5 dL/g; or (3) a lactide: rated in a lactic acid-glycolic acid copolymer matrix, wherein glycolide molar ratio of 60:40 to 50:50; and (iv) a formulation the Class D corticosteroid comprises between 8% to 20% of comprising (a) controlled- or Sustained-release micropar the microparticles. In some embodiments, the population of ticles comprising a Class D corticosteroid and a lactic acid microparticles releases the corticosteroid for at least 14 days glycolic acid copolymer matrix, wherein the Class D corti at a rate that does not adversely suppress the hypothalamic costeroid comprises between 8% to 20% of the microparticles pituitary-adrenal axis (HPA axis). 25 and wherein the lactic acid-glycolic acid copolymer has one The invention also provides methods of slowing, arresting of more of the following characteristics: (1) a molecular or reversing progressive structural tissue damage associated weight in the range of about 40 to 70 kDa; (2) an inherent with chronic inflammatory disease in a patient comprising viscosity in the range of 0.35 to 0.5 dL/g; or (3) a lactide: administering to said patient a therapeutically effective glycolide molar ratio of 60:40 to 50:50. In some embodi amount of a controlled or Sustained release preparation 30 ments, the formulation releases the corticosteroid for at least selected from the following preparations: (i) a controlled or 14 days at a rate that does not adversely suppress the hypo sustained release preparation of a Class B corticosteroid com thalamic-pituitary-adrenal axis (HPA'axis). prising a lactic acid-glycolic acid copolymer microparticle In some embodiments, the population of microparticles, containing the Class B corticosteroid, wherein the Class B the controlled or Sustained release preparation or formulation corticosteroid comprises between 22% to 28% of the lactic 35 is administered as one or more intra-articular injections. In acid-glycolic acid copolymer microparticle matrix; (ii) a con Some embodiments, the patient has osteoarthritis, rheumatoid trolled or Sustained release preparation of a Class A corticos arthritis, acute gouty arthritis, and synovitis. In some embodi teroid comprising a lactic acid-glycolic acid copolymer ments, the patient has acute bursitis, Sub-acute bursitis, acute microparticle containing the Class A corticosteroid, wherein nonspecific tenosynovitis, or epicondylitis. the Class A corticosteroid comprises between 15% to 30% of 40 The invention also provides methods to slow, arrest, the lactic acid-glycolic acid copolymer microparticle matrix: reverse or otherwise inhibit progressive structural tissue dam (iii) a controlled or Sustained release preparation of a Class C age associated with chronic inflammatory disease, for corticosteroid comprising a lactic acid-glycolic acid copoly example, damage to cartilage associated with osteoarthritis. mer microparticle containing the Class C corticosteroid, In one embodiment, the method includes the administration wherein the Class C corticosteroid comprises between 15% to 45 to a patient, for example local administration, of a therapeu 30% of the lactic acid-glycolic acid copolymer microparticle tically effective amount of one or more corticosteroids in a matrix; and (iv) a controlled or Sustained release preparation formulation, wherein the formulation releases the corticos of a Class D corticosteroid comprising a lactic acid-glycolic teroid(s) for at least 14 days at a rate that does not adversely acid copolymer microparticle containing the Class D corti Suppress the hypothalamic-pituitary-adrenal axis (HPA axis). costeroid, wherein the Class D corticosteroid comprises 50 The methods to assess the effect of corticosteroid formula between 8% to 20% of the lactic acid-glycolic acid copoly tions on disease progression include controlled clinical stud mer microparticle matrix. In some embodiments, the con ies that assess clinical end points and for employ imaging trolled or Sustained release preparation releases the corticos technologies such as, for example Magnetic Resonance teroid for at least 14 days at a rate that does not adversely Imaging (MRI), to determine effects on the structure in Suppress the hypothalamic-pituitary-adrenal axis (HPA axis). 55 chronically inflamed tissues, for example the effects on car The invention also provides methods of slowing, arresting tilage Volume and other articular and peri-articular structures or reversing progressive structural tissue damage associated in osteoarthritis and rheumatoid arthritis. (See e.g., Eckstein with chronic inflammatory disease in a patient comprising F, et al. “Magnetic resonance imaging (MRI) of articular administering to said patient a therapeutically effective cartilage in knee osteoarthritis (OA): morphological assess amount of a formulation selected from the following prepa 60 ment.” Osteoarthritis Cartilage 14 Suppl A (2006): A46-75; rations: (i) a formulation comprising (a) controlled- or Sus Lo GH, etal. “Bone marrow lesions in the knee areassociated tained-release microparticles comprising a Class B corticos with increased local bone density.” Arthritis Rheum 52 teroid and a lactic acid-glycolic acid copolymer matrix, (2005): 2814-21; and Lo G. H. et al. “The ratio of medial to wherein the Class B corticosteroid comprises between 22% to lateral tibial plateau bone mineral density and compartment 28% of the microparticles and wherein the lactic acid-gly 65 specific tibiofemoral osteoarthritis.” Osteoarthritis Cartilage colic acid copolymer has one of more of the following char 14 (2006): 984-90 the contents of each of which are hereby acteristics: (1) a molecular weight in the range of about 40 to incorporated by reference in their entirety.) The corticoster US 8,828,440 B2 21 22 oid microparticle formulations provided herein appear to articular injection. The systemic glucocorticoid concentra exhibit little to no negative effects, e.g., structural tissue dam tion associated with clinically significant Suppression of the age, and from preliminary data and studies described in the HPA axis is shown as the bottom dotted line. The top dotted Examples below, these corticosteroid microparticle formula line represents the minimal intra-articular concentration tions appear to have a positive effect, e.g., slowing, arresting required to maintain efficacy (defined as relief of pain and or reversing structural tissue damage. inflammation, or slowing, arrest, or reversal of structural The invention also provides methods of treating pain and/ damage to tissues caused by inflammatory diseases. Sus or inflammation of a patient by administering to the patient a tained release of the corticosteroid provides sufficient intra therapeutically effective amount of one or more corticoster articular concentrations to maintain efficacy in the longer oids in a formulation, wherein the formulation releases the 10 term, and has transient, clinically insignificant effect on the corticosteroid(s) for at least 14 days at a rate that does not HPA axis. adversely suppress the hypothalamic-pituitary-adrenal axis FIG. 2 is a graph depicting the change in sensitivity over (HPA axis). The invention also provides methods of manufacturing the time to Suppression of endogenous cortisol production (ECso corticosteroid microparticle formulations. The microparticle 15 (ng/mL) vs. time) for triamcinolone acetonide 40 mg given by formulations provided herein can be manufactured using any intra-articular administration. of a variety of suitable methods. FIG. 3 is a graph depicting the change in sensitivity over For the Class B corticosteroid microparticle formulations, time to suppression of endogenous cortisol production (ECso in Some embodiments, the microparticles are manufactured (ng/mL) vs. time) for various corticosteroids administered as as described in the Examples provided below. For the Class B a single, intra-articular injection in the listed dose. corticosteroid microparticle formulations, in Some embodi FIG. 4 is a graph depicting plasma levels of endogenous ments, the microparticles are manufactured as described in cortisol over time, without (Column 1) adjustment for a U.S. Pat. No. 7,261,529 and U.S. Pat. No. 7,758,778, the change in the sensitivity of the HPA axis after intra-articular contents of each of which are hereby incorporated by refer corticosteroids and with (Column 2) adjustment for a change ence in their entirety. For example, the microparticles are 25 in the sensitivity of the HPA axis after intra-articular corti manufactured using a solvent evaporation process wherein costeroids. These data demonstrate that the sensitivity of the the Class B corticosteroid is dispersed in a lactic acid-glycolic HPA axis varies with corticosteroid, dose, and time with acid copolymer organic Solution and the mixture is treated to clinically important implications for the selection of doses for remove the solvent from the mixture, thereby producing Sustained delivery into an intra-articular space. microparticles. 30 FIG. 5 is a graph depicting the cumulative percent release In some embodiments, the solvent evaporation process of a nominal 25% (w/w) triamcinolone acetonide in PLGA utilizes a spray drying or fluid bed apparatus to remove the 75:25 microparticles. Solvent and produce microparticles. In some embodiments, the solvent evaporation process utilizes a spinning disk. For FIG. 6 is a graph depicting the calculated human dose to example, the spinning disk is the spinning disk as described in 35 achieve transient cortisol Suppression and within 14 days U.S. Pat. No. 7,261,529 and U.S. Pat. No. 7,758,778. achieve less than 35% cortisol Suppression using nominal For the Class B corticosteroid microparticle formulations, 25%TCA PLGA 75:25 microparticles. The dotted lines rep in some embodiments where the Class B corticosteroid is resent, from top to bottom of the graph, 50% cortisol inhibi TCA, the microparticles are manufactured using a solid in oil tion dose, 40% cortisol inhibition dose, 35% cortisol inhibi in water emulsion process wherein TCA is dispersed in a 40 tion dose and 5% cortisol inhibition dose. lactic acid-glycolic acid copolymer organic Solution and FIG. 7 is a graph depicting calculated human dose that does added to an aqueous solvent to produce microparticles. not affect the HPA axis, less than 35% cortisol suppression For the Class A, C and/or D corticosteroid microparticle using nominal 25% TCA PLGA 75:25 microparticles. The formulations, in some embodiments, the microparticles are dotted lines represent, from top to bottom of the graph, 50% manufactured as described in the Examples provided below. 45 cortisol inhibition dose, 40% cortisol inhibition dose, 35% For Class A, C and/or D corticosteroid formulations, in some cortisol inhibition dose and 5% cortisol inhibition dose. embodiments, the microparticles are manufactured as FIG. 8 is a graph depicting cumulative percent release of a described in PCT Publication No. WO95/13799, the contents second preparation of nominal 25% triamcinolone acetonide of which are hereby incorporated by reference in their in PLGA 75:25 microparticles using an alternate preparation. entirety. For example, the microparticles are manufactured 50 FIG. 9 is a graph depicting calculated human dose to using a solid in oil in water emulsion process wherein the achieve transient cortisol Suppression and within 14 days Class A corticosteroid, Class C corticosteroid and/or Class D achieve less than 35% cortisol Suppression using a second corticosteroid is dispersed in a lactic acid-glycolic acid preparation of nominal 25% TCA PLGA 75:25 micropar copolymer organic Solution and added to an aqueous solvent ticles made by an alternate preparation. The dotted lines rep to produce microparticles. 55 resent, from top to bottom of the graph, 50% cortisol inhibi It is contemplated that whenever appropriate, any embodi tion dose, 40% cortisol inhibition dose, 35% cortisol ment of the present invention can be combined with one or inhibition dose and 5% cortisol inhibition dose. more other embodiments of the present invention, even FIG. 10 is a graph depicting: calculated human dose that though the embodiments are described under different does not affect the HPA axis, less than 35% cortisol suppres aspects of the present invention. 60 sion using a second preparation of nominal 25% TCAPLGA 75:25 microparticles made by an alternate preparation. The BRIEF DESCRIPTION OF THE FIGURES dotted lines represent, from top to bottom of the graph, 50% cortisol inhibition dose, 40% cortisol inhibition dose, 35% FIG. 1 is a graph depicting the intra-articular concentra cortisol inhibition dose and 5% cortisol inhibition dose. tions (top solid line) and the systemic concentrations (bottom 65 FIG. 11 is a graph depicting cumulative percent release of Solid line) of the glucocorticoid administered according to nominal 25% triamcinolone acetonide in 5% PEG 1450/ certain embodiments of the present invention following intra PLGA 75:25 microparticles. US 8,828,440 B2 23 24 FIG. 12 is a graph depicting cumulative percent release of microparticles. The dotted lines represent, from top to bottom nominal 25% triamcinolone acetonide in 10% PEG 33507 of the graph, 50% cortisol inhibition dose, 40% cortisol inhi PLGA 75:25 microparticles. bition dose, 35% cortisol inhibition dose and 5% cortisol FIG. 13 is a graph depicting calculated human dose to inhibition dose. achieve transient cortisol Suppression and within 14 days 5 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% achieve transient cortisol Suppression and within 14 days cortisol inhibition dose and 5% cortisol inhibition dose. 10 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 dose, 35% cortisol inhibition dose and 5% cortisol inhibition dotted lines represent, from top to bottom of the graph, 50% 15 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 suppres FIG. 15 is a graph depicting calculated human dose that sion using nominal 16.7% TCA mixed molecular weight does not affect the HPA axis, less than 35% cortisol suppres PLGA 75:25 microparticles. The dotted lines represent, from sion using nominal 25% TCA 5% PEG 1450/PLGA 75:25 top to bottom of the graph, 50% cortisol inhibition dose, 40% microparticles. The dotted lines represent, from top to bottom cortisol inhibition dose, 35% cortisol inhibition dose and 5% of the graph, 50% cortisol inhibition dose, 40% cortisol inhi cortisol inhibition dose. bition dose, 35% cortisol inhibition dose and 5% cortisol FIG. 28 is a graph depicting cumulative percent release of inhibition dose. nominal 28.6% triamcinolone acetonide in various polymer FIG. 16 is a graph depicting calculated human dose that 25 microparticle formulations. does not affect the HPA axis, less than 35% cortisol suppres FIG. 29 is a graph depicting cumulative percent release of sion using nominal 25% TCA 10% PEG 3350/PLGA 75:25 nominal 28.6% Prednisolone in PLGA 50:50 microparticle microparticles. The dotted lines represent, from top to bottom formulation. of the graph, 50% cortisol inhibition dose, 40% cortisol inhi FIG. 30 is a graph depicting calculated human dose to bition dose, 35% cortisol inhibition dose and 5% cortisol 30 achieve transient cortisol Suppression and within 14 days inhibition dose. achieve less than 35% cortisol Suppression using nominal FIG.17 is a graph depicting cumulative percent triamcino 28.6% PRED PLGA 50:50 microparticles. The dotted lines lone acetonide release of nominal 40%, 25%. 20%, 15% and represent, from top to bottom of the graph, 50% cortisol 10% TCA containing PLGA 75:25 microparticles. inhibition dose, 40% cortisol inhibition dose, 35% cortisol FIG. 18 is a graph depicting cumulative percent release of 35 inhibition dose and 5% cortisol inhibition dose. nominal 25% TCA PLGA 75:25 (29 kDa) and PLGA 75:25 FIG. 31 is a graph depicting calculated human dose that (54 kDa) containing microparticles. does not affect the HPA axis, less than 35% cortisol suppres FIG. 19 is a graph depicting cumulative percent release of sion using nominal 28.6% PRED PLGA 50:50 micropar triamcinolone acetonide in PLGA 50:50 microparticle for ticles. The dotted lines represent, from top to bottom of the mulations. 40 graph, 50% cortisol inhibition dose, 40% cortisol inhibition 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. 32 is a graph depicting cumulative percent release of FIG. 21 is a graph depicting calculated human dose to nominal 28.6% Betamethasone PLGA 50:50 microparticle achieve transient cortisol Suppression and within 14 days 45 formulation. achieve less than 35% cortisol Suppression using nominal FIG. 33 is a graph depicting calculated human dose to 28.6% TCA 10% Triblock/PLGA 75:25 microparticles. The achieve transient cortisol Suppression and within 14 days dotted lines represent, from top to bottom of the graph, 50% achieve less than 35% cortisol Suppression using nominal cortisol inhibition dose, 40% cortisol inhibition dose, 35% 28.6% BETA PLGA 50:50 microparticles. The dotted lines cortisol inhibition dose and 5% cortisol inhibition dose. 50 represent, from top to bottom of the graph, 50% cortisol FIG. 22 is a graph depicting calculated human dose to inhibition dose, 40% cortisol inhibition dose, 35% cortisol achieve transient cortisol Suppression and within 14 days inhibition dose and 5% cortisol inhibition dose. achieve less than 35% cortisol Suppression using nominal FIG. 34 is a graph depicting calculated human dose that 28.6% TCA 20% Triblock/PLGA 75:25 microparticles. The does not affect the HPA axis, less than 35% cortisol suppres dotted lines represent, from top to bottom of the graph, 50% 55 sion using nominal 28.6% BETA PLGA 50:50 micropar cortisol inhibition dose, 40% cortisol inhibition dose, 35% ticles. The dotted lines represent, from top to bottom of the cortisol inhibition dose and 5% cortisol inhibition dose. graph, 50% cortisol inhibition dose, 40% cortisol inhibition FIG. 23 is a graph depicting calculated human dose that dose, 35% cortisol inhibition dose and 5% cortisol inhibition does not affect the HPA axis, less than 35% cortisol suppres dose. sion using nominal 28.6% TCA 10% Triblock/PLGA 75:25 60 FIG. 35 is a graph depicting cumulative percent release of microparticles. The dotted lines represent, from top to bottom nominal 16.7% Fluticasone Propionate PLGA 50:50 micro of the graph, 50% cortisol inhibition dose, 40% cortisol inhi particle formulation. bition dose, 35% cortisol inhibition dose and 5% cortisol FIG. 36 is a graph depicting calculated human dose to inhibition dose. achieve transient cortisol Suppression and within 14 days FIG. 24 is a graph depicting calculated human dose that 65 achieve less than 35% cortisol Suppression using nominal does not affect the HPA axis, less than 35% cortisol suppres 16.7% FLUT PLGA 50:50 microparticles. The dotted lines sion using nominal 28.6% TCA 20% Triblock/PLGA 75:25 represent, from top to bottom of the graph, 50% cortisol US 8,828,440 B2 25 26 inhibition dose, 40% cortisol inhibition dose, 35% cortisol DETAILED DESCRIPTION OF THE INVENTION inhibition dose and 5% cortisol inhibition dose. FIG. 37 is a graph depicting calculated human dose that The invention provides compositions and methods for the does not affect the HPA axis, less than 35% cortisol suppres treatment of pain and inflammation using corticosteroids. The sion using nominal 16.7% FLUT PLGA 50:50 micropar- 5 compositions and methods provided herein use one or more ticles. The dotted lines represent, from top to bottom of the corticosteroids in a microparticle formulation. The corticos graph, 50% cortisol inhibition dose, 40% cortisol inhibition teroid microparticle formulations provided herein are effec dose, 35% cortisol inhibition dose and 5% cortisol inhibition tive at treating pain and/or inflammation with minimal pro dose. longed suppression of the HPA axis and/or other long term FIG.38 is a graph depicting cumulative percent release of 10 side effects of corticosteroid administration. The corticoster various Fluticasone Propionate PLGA microparticle formu oid microparticle formulations provided herein are effective lations. in slowing, arresting, reversing or otherwise inhibiting struc FIG. 39 is a graph depicting cumulative percent release of tural damage to tissues associated with progressive disease nominal 28.6% DEX PLGA 50:50 microparticle formula with minimal prolonged suppression of the HPA axis and/or tion. 15 other long term side effects of corticosteroid administration. FIG. 40 is a graph depicting calculated human dose to The corticosteroid microparticle formulations provided achieve transient cortisol Suppression and within 14 days herein deliver the corticosteroid in a dose and in a Sustained achieve less than 35% cortisol suppression and does not affect release manner Such that the levels of cortisol Suppression are the HPA axis, less than 35% cortisol suppression using nomi at or below 35% by day 14 post-injection. In some embodi nal 28.6%DEXPLGA 50:50 microparticles. The dotted lines ments, the corticosteroid microparticle formulations pro represent, from top to bottom of the graph, 50% cortisol vided herein deliver the corticosteroid in a dose and in a inhibition dose, 40% cortisol inhibition dose, 35% cortisol controlled or sustained release manner such that the levels of inhibition dose and 5% cortisol inhibition dose. cortisol Suppression are negligible and/or undetectable by 14 FIGS. 41A-41D are a series of graphs depicting the mean post-injection. Thus, the corticosteroid microparticle formu concentration-time profiles of various doses of TCAIR and 25 lations in these embodiments are effective in the absence of FX006 in rat plasma following single intra-articular doses. A any significant HPA axis Suppression. Administration of the microparticle formulation of TCA in 75:25 PLGA formula corticosteroid microparticle formulations provided herein tion microparticles, referred to as FX006, dosed at 1.125 mg can result in an initial "burst' of HPA axis suppression, for resulted in a very slow absorption of TCA in the systemic example, within the first few days, within the first two days circulation and a markedly lower C, as compared to TCA 30 and/or within the first 24 hours post-injection, but by day 14 IR. Concentrations for the first 72 hr are presented in FIGS. post-injection, suppression of the HPA axis is less than 35%. 41C and 41D on a larger time scale. The use of microparticles to administer corticosteroids is FIG. 42 is a graph depicting corticosteroid inhibition and known (See, e.g., U.S. Patent Application Publication. No. recovery with TCAIR (immediate release) and FX006 (mi 20080317805). In addition, corticosteroids are known to be croparticle formulation) in rats. 35 useful for the symptomatic treatment of inflammation and FIG. 43 is a graph depicting the pharmacokinetic/pharma pain. New data also suggest that synovitis may be associated codynamic (PK/PD) relationship of systemic TCA levels and with the structural damage, for example, the deterioration of corticosterone inhibition. cartilage and other peri-articular associated with the progres FIGS. 44A-44C are a series of graphs depicting the gait sion of osteoarthritis and rheumatoid arthritis. (See e.g., Hill analysis scores, an indicator of pain, in rats injected with 40 CL, et al. “Synovitis detected on magnetic resonance imag doses of either immediate release triamcinolone acetonide ing and its relation to pain and cartilage loss in knee osteoar (TCA IR) or TCA microparticles (FX006) in a model of thritis.” Ann Rheum Dis 66 (2007): 1599–603; van den Berg W osteoarthritis. In FIG. 44A, FX006 at 0.28, 0.12 and 0.03 mg B. etal. “Synovial mediators of cartilage damage and repairin (TCA doses) is expressed as TCA concentrations of the dos osteoarthritis.” In: Brandt KD, Doherty M, Lohmander LS, ing formulation (4.67. 2 and 0.5 mg/ml). In FIG. 44B, FX006 45 eds. Osteoarthritis. Second ed. Oxford: Oxford University at 0.28 mg (TCA dose) is expressed as TCA concentrations of Press (2003): 147-55; Ayral X, et al. “Synovitis: a potential the dosing formulation (4.67 mg/ml). Similarly, TCAIR at predictive factor of structural progression of medial 0.03 mg is expressed as triamcinolone at 0.5 mg/ml. In FIG. tibiofemoral knee osteoarthritis—results of a 1 year longitu 44C, FX006 at 0.28, 0.12 and 0.03 mg (TCA doses) is dinal arthroscopic study in 422 patients.” Osteoarthritis Car expressed as TCA concentrations of the dosing formulation 50 tilage 13 (2005):361-7; and Kirwan J. R. et al. “Effects of (4.67, 2 and 0.5 mg/ml). Similarly, TCAIR at 0.06 and 0.03 glucocorticoids on radiological progression in rheumatoid mg is expressed as triamcinolone at 1 and 0.5 mg/ml. arthritis.” Cochrane Database Syst Rev 2007:CD006356). FIG. 45 is a graph depicting peak pain response following The administration of corticosteroids, particularly for repeated reactivations of arthritis in the right knee. All treat extended periods of time, can have a number of unwanted side ments were administered as a single IA dose in the right knee 55 effects. The HPA axis, the interdependent feedback mecha on Day 0. nism between the hypothalamus, the pituitary gland and the FIG. 46 is a graph depicting the time course of corticoster adrenal cortex, may be Suppressed by the administration of one recovery for various groups in the rat Study in a model of corticosteroids, leading to a variety of unwanted side effects. osteoarthritis. The extent of HPA axis suppression, and related inhibition of FIGS. 47A-47B are a series of graphs depicting the plasma 60 endogenous cortisol production, has been attributed to the TCA concentration-time data for various groups in the rat potency of the corticosteroid, the dose, systemic concentra study in a model of osteoarthritis. Only the groups that tion, protein binding, rate of elimination (Meibohm et al. received injections of TCA microparticles (FX006 groups) “Mechanism-based PK/PD model for the lymphocytopenia are shown in FIG. 47B on an expanded scale. induced by endogenous and exogenous corticosteroids.” IntJ FIG. 48 is a graph depicting the end-of-study histopathol 65 Clin Pharmacol Ther. 37(8) (1999):367-76) and, for one cor ogy scores for various treatment groups in the rat Study in a ticosteroid, a change in sensitivity of the HPA axis (Derendorf model of osteoarthritis. et al. “Clinical PK/PD modelling as a tool in drug develop US 8,828,440 B2 27 28 ment of corticosteroids.” Int J Clin Pharmacol Ther. 35(10) period of the therapy. In some embodiments of the present 1997: 481-8). Furthermore, intra-articular doses of corticos invention, administration of the formulation will not result in teroids associated with only limited anti-inflammatory and any significant level of HPA Suppression, including no detect short-term analgesic benefit (Hepper et al. “The efficacy and able HPA suppression, particularly during the initial release duration of intra-articular corticosteroid injection for knee period of the therapy. During the Subsequent or Sustained osteoarthritis: a systematic review of level I studies. J Am release period of the therapy, additional corticosteroid may be Acad Orthop Surg. 17(10) 2009: 638-46) have been associ released into the plasma. However, the plasma levels during ated with HPA axis suppression (Habib, "Systemic effects of this period will generally be less than those during the initial intra-articular corticosteroids.” Clin Rheumatol. 28(7) release period, if any corticosteroid release occurs, and will (2009): 749-56). 10 not be associated with HPA axis suppression. Further, the The changes in sensitivity to corticosteroid effects over adverse events associated with exogenous corticosteroid time should alter clinical steroid dosing, but prior to the administration, e.g., hyperglycemia, hypertension, altered instant invention, this has not been understood. mood, etc. will generally not be observed. Preferably, the The details of one or more embodiments of the invention number of clinical adverse events during this period will not are set forth in the accompanying description below. 15 substantially exceed the number achieved by an immediate Although any methods and materials similar or equivalent to release formulation alone or by KENALOGTM or its those described herein can be used in the practice or testing of bioequivalent and will, preferably, be fewer than during the the present invention, the methods and materials are now prior, initial release period of the therapy, if any corticosteroid described. Other features, objects, and advantages of the release occurs. Alternatively, one can determine the Suppres invention will be apparent from the description. In the speci sion of the formulation on HPA by measuring endogenous fication, the singular forms also include the plural unless the cortisol production. Thus, the formulation can be considered context clearly dictates otherwise. Unless defined otherwise, as avoiding clinically significant (or adverse) Suppression of all technical and Scientific terms used herein have the same the HPA axis where the endogenous cortisol level is substan meaning as commonly understood by one of ordinary skill in tially the same in the steady state between a patient population the art to which this invention belongs. In the case of conflict, 25 receiving a therapeutically beneficial amount of an immedi the present Specification will control. ate release formulation and those receiving a therapeutically beneficial amount of a Sustained release formulation. Such a DEFINITIONS formulation would be deemed to have no clinically significant effect on the HPA axis. Alternatively or additionally, a small The terms below have the following meanings unless indi 30 but measurable reduction in steady-state glucocorticoid pro cated otherwise. duction can result from the formulation during the Sustained An amount of a corticosteroid that does not "suppress the release period of the therapy with adequate preservation of hypothalamic-pituitary-adrenal axis (HPA axis) refers to the the augmented, stress response needed during infection or amount of the sustained release corticosteroid delivered trauma can be deemed a clinically insignificant Suppression locally to relieve pain due to inflammation, which provides a 35 of the HPA axis. Endogenous glucocorticoid production may systemic concentration that will not have a clinically signifi be assessed by administering various doses of adrenocorti cant effect or “adverse effect” on the HPA axis. Suppression cotropin hormone or by other tests known to those skilled in of the HPA axis is generally manifested by a reduction in the art. Embodiments of the current invention provide for endogenous glucocorticoid production. It is useful to con controlling the release of corticosteroid, as may be desired, to sider both basal and augmented production of endogenous 40 achieve either no measurable effect on endogenous glucocor glucocorticoids. Under ordinary, “unstressed’ conditions, ticoid production or a target, or a measurable effect that is, glucocorticoid production occurs at a normal, basal level. however, without adverse clinical consequence. In this There is some natural variation of production during the regard, it has been found that intra-articular doses of corti course of the 24-hour day. Under extraordinary, “stressed costeroids that suppress cortisol production by 20-35%, and conditions associated with, e.g., infection or trauma and the 45 Sometimes more, provide very useful Sustained anti-inflam like, augmented endogenous production of glucocorticoids matory and analgesic activity. These benefits are achieved occurs. Endogenous cortisol production may be determined without acute risks of hypoadrenalism and without excessive by measuring glucocorticoid concentrations in plasma, risks, after Sustained intra-articular dosing, of developing an saliva, urine or by any other means known in the art. It is adrenal unresponsiveness in times of stress or of developing known that systemic concentrations of corticosteroids can 50 frank adrenal failure. suppress the HPA axis. For example, on day 3 after an intra As shown further below, the studies presented herein have articular injection of 20 mg triamcinolone hexacetonide demonstrated that the HPA axis sensitivity appears to dimin plasma levels, of approximately 3-4 ng/mL have been ish with time, Steroid, and dose. In this regard, it has been observed. These resulted in a transient but highly statistically determined that standard doses of familiar corticosteroids, significant 75% HPA-axis suppression (Derendorf et al., 55 when examined from the viewpoint of steady-state HPA axis "Pharmacokinetics and pharmacodynamics of glucocorticoid Suppression (i.e., after desensitization has occurred), provide suspensions after intra-articular administration.” Clin Phar clinically useful benchmarks. For example, while oral pred macol Ther. 39(3) (1986):313-7) which, however, does not nisolone given at 20 mgQD produces a 73% cortisol Suppres necessarily portend complete HPA failure (Habib, "Systemic sion, even 5 mg QD (considered a “low dose') is associated effects of intra-articular corticosteroids.” Clin Rheumatol 28 60 with a 40% suppression of endogenous cortisol production. (2009): 749-756, see p752 col. 1, para 2, final sentence). Doses at or below 5 mg of prednisolone per day are generally While Such transient Suppression is generally considered to considered to be well tolerated and are not associated with be acceptable without clinically significant effect, more per clinically meaningful HPA axis suppression (La Rochelle et sistent Suppression, i.e., weeks, would be deemed clinically al., “Recovery of the hypothalamic-pituitary-adrenal (HPA) detrimental. In embodiments of the present invention, admin 65 axis in patients with rheumatic diseases receiving low-dose istration of the formulation may result in a clinically accept prednisolone.” Am. J. Med. 95 (1993): 258-264). Therefore, able HPA suppression, particularly during the initial release up to approximately 40% suppression will be clinically well US 8,828,440 B2 29 30 tolerated and very unlikely to be associated with importantly albumin, collagen, gelatin synthetic poly(aminoacids), and adverse clinical events such as hypoadrenalism or soft-tissue prolamines; glycosaminoglycans, such as hyaluronic acid or bony or metabolic changes indicative of long-term gluco and heparin; polysaccharides, such as alginates, chitosan, corticoid excess. starch, and dextrans; and other naturally occurring or chemi “Patient” refers to a human diagnosed with a disease or cally modified biodegradable polymers. Synthetic biocom condition that can be treated in accordance to the inventions patible biodegradable materials include, but are not limited described herein. In some embodiments it is contemplated to, poly(lactide-co-glycolide) (PLGA), polylactide (PLA), that the formulations described herein may also be used in polyglycolide (PG), polyhydroxybutyric acid, poly(trimeth horses. ylene carbonate), polycaprolactone (PCL), polyvalerolac “Delivery” refers to any means used to place the drug into 10 tone, poly(alpha-hydroxy acids), poly(lactones), poly a patient. Such means may include without limitation, placing (amino-acids), poly(anhydrides), polyketals poly(arylates), matrices into a patient that release the drug into a target area. poly(orthoesters), polyurethanes, polythioesters, poly(ortho One of ordinary skill in the art recognizes that the matrices carbonates), poly(phosphoesters), poly(ester-co-amide), may be delivered by a wide variety of methods, e.g., injection poly(lactide-co-urethane, polyethylene glycol (PEG), poly by a syringe, placement into a drill site, catheter or canula 15 vinyl alcohol (PVA), PVA-g-PLGA, PEGT-PBT copolymer assembly, or forceful injection by a gun type apparatus or by (polyactive), methacrylates, poly(N-isopropylacrylamide), placement into a Surgical site in a 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 any combinations thereof. The biocompatible biodegradable symptoms of pain and/or inflammation in a patient. As used material can include a combination of biocompatible biode herein, “treatment” and “treating includes partial alleviation gradable materials. For example, the biocompatible biode of symptoms as well as complete alleviation of the symptoms gradable material can be a triblock, or other multi-block, for a time period. The time period can be hours, days, months, formation where a combination of biocompatible biodegrad or even years. able polymers are joined together. For example, the triblock By an “effective” amount or a “therapeutically effective 25 can be PLGA-PEG-PLGA. amount of a drug orpharmacologically active agentis meant Diseases that May be Treated Using the Formulations of a nontoxic but Sufficient amount of the drug or agent to this Invention provide the desired effect, e.g., analgesia. An appropriate Descriptions of various embodiments of the invention are “effective” amount in any individual case may be determined given below. Although these embodiments are exemplified by one of ordinary skill in the art using routine experimenta 30 with reference to treat joint pain associated with osteoarthri tion. tis, rheumatoid arthritis and other joint disorders, it should not “Site of a patient’s pain” refers to any area within a body be inferred that the invention is only for these uses. Rather, it causing pain, e.g., a knee joint with osteoarthritis, nerve root is contemplated that embodiments of the present invention causing sciatic pain, nerve fibers growing into annular tears in will be useful for treating other forms of joint pain by admin discs causing back pain, temporomandibular joint (TMJ) 35 istration into articular and periarticular spaces. In addition, it pain, for example TMJ pain associated with temporoman will be understood that for some embodiments injection near dibular joint disorder (TMD) or pain radiating from epidural a joint may be equivalent to injections in that joint. It is also or perineural spaces. The pain perceived by the patient may contemplated that embodiments of the present invention may result from inflammatory responses, mechanical stimuli, be useful for injection or administration into soft tissues or chemical stimuli, thermal stimuli, as well as allodynia. 40 lesions. Any and all uses of specific words and references are Additionally, the site of a patient’s pain can comprise one simply to detail different embodiments of the present inven or multiple sites in the spine. Such as between the cervical, tion. thoracic, or lumbar vertebrae, or can comprise one or multiple Local administration of a corticosteroid microparticle for sites located within the immediate area of inflamed or injured mulation can occur, for example, by injection into the intra joints such as the shoulder, hip, or other joints. 45 articular space, peri-articular space, soft tissues, lesions, epi A “biocompatible' material refers to a material that is not dural space, perineural space, or the foramenal space at or toxic to the human body, it is not carcinogenic and it should near the site of a patient’s pain and/or structural tissue dam induce limited or no inflammation in body tissues. A “biode age. Local injection of the formulations described herein into gradable' material refers to a material that is degraded by articular or periarticular spaces may be useful in the treatment bodily processes (e.g., enzymatic) to products readily dispos 50 of for example, juvenile rheumatoid arthritis, Sciatica and able by the body or absorbed into body tissue. The biode otherforms of radicular pain (e.g., arm, neck, lumbar, thorax), graded products should also be biocompatible with the body. psoriatic arthritis, acute gouty arthritis, Morton's neuroma, In the context of intra-articular drug delivery systems for acute and Subacute bursitis, acute and Subacute nonspecific corticosteroids, such polymers may be used to fabricate, tenosynovitis and epicondylitis, acute rheumatic carditis and without limitation: microparticles, micro-spheres, matrices, 55 ankylosing spondylitis. Injection of the microparticles microparticle matrices, micro-sphere matrices, capsules, described herein into soft tissues or lesions may be useful in hydrogels, rods, wafers, pills, liposomes, fibers, pellets, or the treatment of for example, alopecia greata, discoid lupus, other appropriate pharmaceutical delivery compositions that erythematosus; keloids, localized hypertrophic, infiltrated a physician can administer into the joint. The biodegradable inflammatory lesions of granuloma annulare, lichen planus, polymers degrade into non-toxic residues that the body easily 60 lichen simplex chronicus (neurodermatitis), psoriasis and removes or break down or dissolve slowly and are cleared psoriatic plaques; necrobiosis lipoidica diabeticorum, and from the body intact. The polymers may be cured ex-vivo psoriatic arthritis. Injection of the microparticles described forming a solid matrix that incorporates the drug for con herein into epidural spaces may be useful in the treatment of trolled release to an inflammatory region. Suitable biodegrad for example, neurogenic claudication. Intramuscular or other able polymers may include, without limitation natural or 65 Soft tissues or lesions injections may also be useful in provid synthetic biocompatible biodegradable material. Natural ing systemic exposures that are effective in the control of polymers include, but are not limited to, proteins such as incapacitating allergic conditions (including but not limited US 8,828,440 B2 31 32 to asthma, atopic dermatitis, contact dermatitis, drug hyper Also, any and all alterations and further modifications of sensitivity reactions, seasonal or perennial allergic rhinitis, the invention, as would occur to one of ordinary skill in the serum sickness, transfusion reactions), bullous dermatitis art, are intended to be within the scope of the invention herpetiformis, exfoliative dermatitis, mycosis fungoides, Selection of Corticosteroids and Drug Dosage pemphigus, severe erythema multiforme (Stevens-Johnson 5 Corticosteroids associated with embodiments of the syndrome), Primary or secondary adrenocortical insuffi present invention can be any naturally occurring or synthetic ciency in conjunction with mineralocorticoids where appli steroid hormone. Naturally occurring corticosteroids are cable; congenital adrenal hyperplasia, hypercalcemia associ secreted by the adrenal cortex or generally the human body. ated with cancer, nonSupportive thyroiditis, exacerbations of Corticosteroid molecules have the following basic struc 10 regional enteritis and ulcerative colitis, acquired (autoim ture: mune) hemolytic anemia, congenital (erythroid) hypoplastic anemia (Diamond blackfan anemia), pure red cell aplasia, (I) select cases of secondary thrombocytopenia, trichinosis with neurologic or myocardial involvement, tuberculous meningi 15 tis with subarachnoid block or impending block when used concurrently with appropriate antituberculous chemotherapy, palliative management of leukemias and lymphomas, acute exacerbations of multiple Sclerosis, cerebral edema associ ated with primary or metastatic brain tumor or craniotomy, to induce diuresis or remission of proteinuria in idiopathic neph rotic syndrome, or to induce diuresis or remission of pro teinuria in lupus erythematosus, berylliosis, symptomatic sar coidosis, fulminating or disseminated pulmonary tuberculosis (when used concurrently with appropriate anti 25 Corticosteroids have been classified into four different tuberculous chemotherapy), idiopathic eosinophilic pneumo groups (A, B, C, and D). (See e.g., Foti et al. “Contact Allergy nias, symptomatic sarcoidosis, dermatomyositis, polymyosi to Topical Corticosteroids: Update and Review on Cross tis, and systemic lupus erythematosus, post-operative pain Sensitization. Recent Patents on Inflammation & Allergy and Swelling. Drug Discovery 3 (2009): 33-39; Coopman et al., “Identifi In one embodiment, the corticosteroid microparticle for 30 cation of cross-reaction patterns in allergic contact dermatitis mulations provided herein are useful in treating, alleviating a to topical corticosteroids.” BrJ Dermatol 121 (1989): 27-34). symptom of ameliorating and/or delaying the progression of Class A corticosteroids are hydrocortisone types with no modification of the Dring or C20-C21 or short chain esters on sciatica. In one embodiment, corticosteroid microparticle for C20-C21. Main examples of Class A corticosteroids include mulations provided herein are useful in treating, alleviating a 35 prednisolone, hydrocortisone and methylprednisolone and symptom of ameliorating and/or delaying the progression of their ester acetate, sodium phosphate and Succinate, corti temporomandibular joint disorder (TMD). Sone, prednisone, and tiXocortol pivalate. Class B corticos In one embodiment, the corticosteroid microparticle for teroids are triamcinolone acetonide (TCA) types with cis/ mulations provided herein are useful in treating, alleviating a ketalic or diolic modifications on C16-C17. Main examples symptom of ameliorating and/or delaying the progression of 40 of Class B corticosteroids include triamcinolone acetonide neurogenic claudication secondary to lumbar spinal Stenosis (TCA), fluocinolone acetonide, amcinonide, desonide, fluo (LSS). LSS implies spinal canal narrowing with possible cinonide, halcinonide, budesonide, and flunisolide. Class C Subsequent neural compression (classified by anatomy or corticosteroids are betamethasone types with a —CH3 muti etiology). Neurogenic Claudication (NC) is a hallmark Symp lation on C16, but no esterification on C17-C21. Main tom of lumbar stenosis, in which the column of the spinal cord 45 examples of Class C corticosteroids include betamethasone, (or the canals that protect the nerve roots) narrows at the lower dexamethasone, desoxymethasone, fluocortolone, and back. This narrowing can also occur in the spaces between the halomethasone. Class D corticosteroids are clobetasone or vertebrae where the nerves leave the spine to travel to other hydrocortisone esterified types with a long chain on C17 parts of the body. and/or C21 and with no methyl group on C16. Main examples The microparticles of the invention are used to treat, alle 50 of Class D corticosteroids include fluticasone, clobetasone viate a symptom of ameliorate and/or delay the progression butyrate, clobetasol propionate, hydrocortisone-17-ace patients suffering from NC secondary to LSS. The corticos ponate, hydrocortisone-17-butyrate, beclomethasone dipro teroid microparticle formulations can be administered, for pionate, betamethasone-17-Valerate, betamethasone dipropi example, by epidural steroid injection (ESI). onate, methylprednisolone aceponate, and prednicarbate. Administration of a corticosteroid microparticle formula 55 For the present invention non-limiting examples of corti tion, e.g., a TCA microparticle formulation, to a patient Suf costeroids may include: betamethasone, betamethasone fering from an inflammatory disease Such as osteoarthritis or acetate, betamethasone dipropionate, betamethasone 17-val rheumatoid arthritis, is considered successful if any of a vari erate, cortivaZol, dexamethasone, dexamethasone acetate, ety of laboratory or clinical results is achieved. For example, dexamethasone sodium phosphate, hydrocortisone, hydro administration of a corticosteroid microparticle formulation 60 cortisone aceponate, hydrocortisone acetate, hydrocortisone is considered Successful if one or more of the symptoms butyrate, hydrocortisone cypionate, hydrocortisone probu associated with the disease is alleviated, reduced, inhibited or tate, hydrocortisone sodium phosphate, hydrocortisone does not progress to a further, i.e., worse, state. Administra Sodium Succinate, hydrocortisone Valerate, methylpredniso tion of a corticosteroid microparticle formulation is consid lone, methylprednisolone aceponate, methylprednisolone ered Successful if the disease, e.g., anarthritic or otherinflam 65 acetate, methylprednisolone sodium Succinate, prednisolone, matory disease, enters remission or does not progress to a prednisolone acetate, prednisolone metasulphobenzoate, further, i.e., worse, State. prednisolone sodium phosphate, prednisolone steaglate, US 8,828,440 B2 33 34 prednisolone tebutate, triamcinolone, triamcinolone TABLE 1 acetonide, triamcinolone acetonide 21-palmitate, triamcino HPA Axis Change-in-Sensitivity Decay-Parameter lone benetonide, triamcinolone diacetate, triamcinolone 8 vs. Corticosteroid and Dose * hexacetonide, alclometaSone, alclometaSone dipropionate, amcinonide, amelometaSone, beclomethasone, beclometha Corticosteroid Decay Parameter ö (time') Sone dipropionate, beclomethasone dipropionate monohy Betamethasone Phosphate? Acetate (7 mg) O.O24 Triamcinolone Acetonide (40 mg) O.OOS drate, budesonide, butiXocort, butiXocort propionate, Triamcinolone Hexacetonide (20 mg) O.O70 ciclesonide, ciprocinonide, clobetasol, clobetasol propionate, 10 * The inhibition of endogenous cortisol synthesis can be related to the exogenous corticos clocortolone, clobetaSone, clobetaSone butyrate, clocor teroid concentration by the following equations: '.E=(E - C')/((EC50)"+C"wherein E = effect, E = maximal effect, C = concentration tolone pivalate, cloprednol, cortisone, cortisone acetate, of exogenous corticosteroid, EC50 = concentration at /2 E, and n = the Hill (“shape', or deflazacort, domoprednate, deprodone, deprodone propi slope”) factor; and onate, desonide, desoximethasone, desoxycortone, desoxy 2. EC50 final = EC50-initial + (EC50 final - EC50-initial 1 - e-8 time cortone acetate, dichlorisone, diflorasone, diflorasone diac 15 Using this approach permits the determination of “6”, the etate, diflucortolone, difluprednate, fluclorolone, parameter describing the exponential decay from the initial to the final ECso. Minimization of least-squares differences was fluclorolone acetonide, fludrocortisone, fludrocortisone utilized to obtain the best-fit Ö. acetate, fludroxycortide, flumethasone, flumethasone piv These new findings regarding the rate and pattern of alate, flunisolide, fluocinolone, fluocinolone acetonide, fluo change of sensitivity to inhibition and the lack of predictabil cortin, fluocortolone, fluorometholone, fluticasone, flutica ity of Such rates and patterns on the basis of for example, Sone furoate, fluticaSone propionate, fluorometholone steroid potency, have significant implications for clinically acetate, fluoxymesterone, fluperolone, fluprednidene, flu appropriate dose-selection. Those skilled in the art will appre prednidene acetate, fluprednisolone, formocortal, halcinon ciate the importance of a changing sensitivity to HPA axis ide, halobetasol propionate, halometasone, halopredone, 25 Suppression and will also appreciate both the complexity and halopredone acetate, hydrocortamate, isoflupredone, isoflu counterintuitive aspects of several of these new findings predone acetate, itrocinonide, loteprednol etabonate, (Table 1). As a result of these clinical findings, the dose range to maZipredone, meclorisone, meclorisone dibutyrate, achieve clinically useful analgesia, with minimal or con medrysone, meprednisone, mometasone, mometasone 30 trolled modulation of the HPA axis, at steady state concen furoate, mometasone furoate monohydrate, nivacortol, trations of various corticosteroids has been determined (Table paramethasone, paramethasone acetate, prednazoline, pred 2). In particular, it appears that the daily corticosteroid doses nicarbate, prednisolone, prednylidene, procinonide, rofile at steady state concentrations, are approximately 3- to 7-times ponide, rimexolone, timobesone, tipredane, tiXocortol, tiXo greater than are predicted by prior art (Meibohm, 1999). cortol pivalate and tralonide. 35 Embodiments of the invention include using Sustained TABLE 2 release corticosteroids delivered to treat pain at dosages that Dose (mg/d), adjusted for individual intra-articular do not adversely suppress the HPA axis. Such amounts deliv corticosteroid characteristics, for expected Suppression of endogenous cortisol production at steady state. ered locally to relieve pain due to inflammation, will provide 40 a systemic concentration that does not have a measurable Cortisol Inhibition (% adverse effect on the HPA axis (differences if any are not significant because any such differences are within normal Corticosteroid 59% 10% 20% 35% 50% assay variability) or, as desired, may have a measurable but betamethasone (mg/d) O.1 O.2 O.S 1.O 1.8 clinically insignificant effect on the HPA axis (basal cortisol 45 budesonide (mg/d) O.1 O.2 O6 1.2 2.2 des-ciclesonide (mg/d) 3.0 6.3 14.3 30.7 57.0 is Suppressed to some measurable extent but stress responses dexamethasone (mg/d) O.1 O.2 0.4 O.9 1.6 are adequately preserved). Further embodiments of the inven flunisonide (mg/d) O.3 O.S 1.2 2.6 4.8 tion include doses during a second period of time selected to fluticaSone (mg/d) O.1 O.1 O.3 O.6 1.1 adjust for a change in sensitivity of the HPA axis to Suppres mometaSone (mg/d) O.2 0.4 O.9 2.0 3.7 50 methylprednisolone (mg/d) O.3 0.7 1.6 3.5 6.5 sion following exposure during a first period of time to the prednisolone (mg/d) 0.4 O.8 1.9 4.0 7.5 corticosteroid (FIG. 1). triamcinolone acetonide O.2 0.4 O.8 1.7 3.2 (mg/d) Additional embodiments include doses during first and/or triamcinolone hexacetonide O.1 O.2 0.4 O.9 1.6 the second period of time selected to adjust for corticosteroid (mg/d) specific (or corticosteroid- and potentially dose-specific) changes in the rate of change of sensitivity of the HPA axis to 55 Suppression that begin with initial exposure. For clinically effective corticosteroids, the rate of change of the sensitivity TABLE 2A of the HPA axis to exogenous corticosteroids is both non Total Dose Delivered (mg/month), adjusted for individual intra uniform and non-linear (FIG. 2). The rate and pattern of 60 articular corticosteroid characteristics, for expected Suppression change in Such sensitivity varies widely as a function of the of endogenous cortisol production at steady state. particular corticosteroid that is selected (FIG. 3). Cortisol Inhibition (% Finally, it is possible to usefully characterize the change in sensitivity vs. time mathematically as the (non-linear, expo Corticosteroid 59% 10% 20% 35% SO% nential) “decay” of the sensitivity from the initial to final 65 betamethasone 3.0 6.0 1S.O 3O.O 54.O value, wherein the decay parameters (Table 1) has been deter budesonide 3.0 6.0 18.0 36.0 66.O mined from the data further described herein. US 8,828,440 B2 35 36 TABLE 2A-continued the HPA axis to exogenous corticosteroids. In addition, both the mean doses and mean plasma levels shown in Tables 2 and Total Dose Delivered (mg/month), adjusted for individual intra articular corticosteroid characteristics, for expected Suppression 3 above are those after steady state has been achieved, requir of endogenous cortisol production at steady state. ing approximately 4 to 24 days depending upon the corticos 5 teroid in question. The companion post-dose but pre-steady Cortisol Inhibition (% state transients for several corticosteroids have been Corticosteroid 59% 10% 20% 35% SO% described in FIGS. 2, 3, and 4. It is also important to note that the data suggest that the carefully controlled benefits from the des-ciclesonide 90.0 1890 429.O 921.O. 1710.0 intra-articular, Sustained release of a corticosteroid of interest dexamethasone 3.0 6.O 12.0 27.0 48.0 10 flunisonide 9.0 1S.O 36.0 78.O 144.0 will persist as long as release continues. fluticaSone 3.0 3.0 9.0 18.0 33.0 In one preferred embodiment, a single component Sus nonetaSone 6.O 12.0 27.0 6O.O 111.0 tained release formulation releases a dose (in mg/day) that methylprednisolone 9.0 21.0 48.O 105.0 195.0 suppresses the HPA axis by no more than between 5-40% at prednisolone 12.0 24.0 57.O. 12O.O 225.0 steady state as shown in Table 2, more preferably no more triamcinolone acetonide 6.O 12.0 24.0 S1.O 96.O 15 triamcinolone hexacetonide 3.0 6.O 12.0 27.0 48.0 than between 10-35% at steady state as shown in Table 2. These doses are therapeutically effective without adverse side effects. That higher doses of corticosteroids can be administered In another preferred embodiment, a single component Sus Successfully by intra-articular injection, maximizing the like tained release formulation releases a dose (in mg/day) that lihood of observing anti-inflammatory and analgesic does not measurably suppress the HPA axis at steady state. responses while minimizing or eliminating adverse events These doses are therapeutically effective without adverse side from HPA axis suppression or otherwise excessive tissue effects. exposure, is of profound clinical consequence for improving In another embodiment where both an immediate release the treatment of patients with arthritis. component and Sustained release component of the formula In addition, with these continuous daily doses of intra 25 tion are present, immediate release dose would be as shown in articular corticosteroids, it is possible to determine the related Table 4 and the sustained release dose would be a dose (in systemic plasma level concentrations (Table 3) that will pro mg/day) that Suppresses the HPA axis by no more than duce the target cortisol inhibition and not beyond, this while between 5-40% as shown in Table 2, more preferably no more retaining clinically important anti-inflammatory and analge than between 10-35% as shown in Table 2. In addition, it is sic activity within the joint. These plasma concentrations 30 expected that Sustained release doses described previously were predicted on the basis of data from short term (i.e., less will follow immediate release doses as shown in Table 4. than 8 days) exposure to corticosteroids. With longer expo sure to corticosteroids, the “decay” (i.e., decline) of the sen TABLE 4 sitivity to corticosteroids may continue resulting in values higher than those listed in Table 3. The levels calculated in 35 Immediate release relative doses (ng Table 3 were purely hypothetical calculations based on Immediate Release Dose human data with immediate release-level doses from the lit Corticosteroid (mg) erature. With Sustained release dosages, more drug may be able to be delivered without seeing an increased level of betamethasone' S-20 40 budesonide? 7-28 cortisol inhibition after the initial burst period. A given level des-ciclesonide 177-713 of plasma concentration may actually provide less inhibition dexamethasone’ S-20 that would have been predicted or calculated using the human flunisonide? 15-60 IR levels from the literature. fluticasone’ 3-12 mometasone’ 11-44 methylprednisolone' 40-160 TABLE 3 45 prednisolone' 2S-100 triamcinolone acetonide' 1O-40 Plasma corticosteroid concentrations associated with triamcinolone hexacetonide' 1O-40 target levels of cortisol inhibition at steady state. 'clinical doses Corticosteroid Concentration in 'calculated doses Plasma (ng/mL) associated with the 50 Target Levels of Cortisol Inhibition (% Sustained Release Delivery Platforms The manufacture of microparticles or methods of making Corticosteroid 59% 10% 20%. 35% 50% biodegradable polymer microparticles are known in the art. betamethasone (ng mL) O.33 O.70 1.57 3.38 6.27 Microparticles from any of the biodegradable polymers listed budesonide (ng mL) O.60 1.27 2.85 6.14 11.40 55 below can be made by, but not limited to, spray drying, 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 Solvent evaporation, phase separation, spray drying, fluidized flunisonide (ng/mL) O.18 O.38 O.86 1.84 3.42 bed coating or combinations thereof. fluticaSone (ng mL) O.04 O.O8 O.19 O41 O.76 In certain embodiments of the invention, the microparticles mometaSone (ng mL) O.15 O.32 O.71 1.54 2.85 are made from a biodegradable polymer that may include, methylprednisolone (ng mL) O.68 1.44 3.23 6.96 12.92 prednisolone (ng/mL) 1.64 3.46 7.79 16.79 31.16 60 without limitation, natural or synthetic biocompatible biode triamcinolone acetonide O.19 O40 O.90 1.9S 3.61 gradable materials. Natural polymers include, but are not (ng/mL) limited to, proteins such as albumin, collagen, gelatin Syn triamcinolone hexacetonide O.10 O.21 O48 1.02 1.90 thetic poly(aminoacids), and prolamines; glycosaminogly (ng/mL) cans, such as hyaluronic acid and heparin; polysaccharides, 65 Such as alginates, chitosan, Starch, and dextrans; and other The studies presented herein demonstrate for the first time naturally occurring or chemically modified biodegradable the discovery of the time-course of changes in sensitivity of polymers. Synthetic biocompatible biodegradable materials US 8,828,440 B2 37 38 include, but are not limited to the group comprising of poly lected and dried. Process parameters such as solvent and salt (lactide-co-glycolide) (PLGA), polylactide (PLA), polygly selection, polymer/solvent ratio, temperatures, stirring speed collide (PG), polyhydroxybutyric acid, poly(trimethylene car and drying cycles are adjusted to achieve the desired particle bonate), polycaprolactone (PCL), polyvalerolactone, poly size, Surface Smoothness, and narrow particle size distribu (alpha-hydroxy acids), poly(lactones), poly(amino-acids), tion. poly(anhydrides), polyketals poly(arylates), poly(orthoe Alternatively, the microparticles may be prepared by the sters), poly(orthocarbonates), poly(phosphoesters), poly(es process of Ramstack et al., 1995, described in published ter-co-amide), poly(lactide-co-urethane, polyethylene glycol international patent application WO95/13799, the disclosure (PEG), polyvinyl alcohol (PVA), PVA-g-PLGA, PEGT-PBT of which is incorporated herein in its entirety. The Ramstack copolymer(polyactive), polyurethanes, polythioesters, meth 10 acrylates, poly(N-isopropylacrylamide), PEO-PPO-PEO et al. process essentially provides for a first phase, including (pluronics), PEO-PPO-PAA copolymers, and PLGA-PEO an active agent and a polymer, and a second phase, that are PLGA blends and copolymers thereof, multi-block polymer pumped through a static mixer into a quench liquid to form configurations such as PLGA-PEG-PLGA, and any combi microparticles containing the active agent. The first and sec nations thereof. These polymers may be used in making con 15 ond phases can optionally be substantially immiscible and the trolled release or Sustained release compositions disclosed second phase is preferably free from solvents for the polymer herein. and the active agent and includes an aqueous Solution of an In a preferred embodiment, the microparticles are formed emulsifier. from poly(d.1-lactic-co-glycolic acid) (PLGA), which is com In the spray drying process, a suitable biodegradable poly mercially available from a number of sources. Biodegradable mer is dissolved in an organic solvent and then sprayed PLGA copolymers are available in a wide range of molecular through nozzles into a drying environment provided with weights and ratios of lactic to glycolic acid. If not purchased sufficient elevated temperature and/or flowing air to effec from a supplier, then the biodegradable PLGA copolymers tively extract the Solvent. Adding Surfactants, such as Sodium may be prepared by the procedure set forth in U.S. Pat. No. lauryl Sulfate can improve the Surface Smoothness of the 4.293,539 (Ludwig, et al.), the disclosure of which is hereby 25 microparticles. incorporated by reference in its entirety. Ludwig prepares Alternatively, a suitable biodegradable polymer can be dis Such copolymers by condensation of lactic acid and glycolic Solved or dispersed in Supercritical fluid, such as carbon diox acid in the presence of a readily removable polymerization ide. The polymer is either dissolved in a suitable organic catalyst (e.g., a strong acidion-exchange resin Such as DoweX Solvent, such as methylene chloride, prior to mixing in a HCR-W2-H). However, any suitable method known in the art 30 of making the polymer can be used. suitable supercritical fluid or directly mixed in the supercriti In the coacervation process, a suitable biodegradable poly cal fluid and then sprayed through a nozzle. Process param mer is dissolved in an organic solvent. Suitable organic Sol eters such as spray rate, nozzle diameter, polymer/solvent vents for the polymeric materials include, but are not limited ratio, and temperatures, are adjusted to achieve the desired to acetone, halogenated hydrocarbons such as chloroform 35 particle size, Surface Smoothness, and narrow particle size and methylene chloride, aromatic hydrocarbons such as tolu distribution. ene, halogenated aromatic hydrocarbons such as chloroben In a fluidized bed coating, the drug is dissolved in an Zene, and cyclic ethers such as dioxane. The organic solvent organic solvent along with the polymer. The Solution is then containing a suitable biodegradable polymer is then mixed processed, e.g., through a Wurster air Suspension coating with a non-solvent such as silicone based solvent. By mixing 40 apparatus to form the final microcapsule product. the miscible non-solvent in the organic solvent, the polymer The microparticles can be prepared in a size distribution precipitates out of solution in the form of liquid droplets. The range suitable for local infiltration or injection. The diameter liquid droplets are then mixed with another non-solvent. Such and shape of the microparticles can be manipulated to modify as heptane or petroleum ether, to form the hardened micro the release characteristics. In addition, other particle shapes, particles. The microparticles are then collected and dried. 45 Such as, for example, cylindrical shapes, can also modify Process parameters such as solvent and non-solvent selec release rates of a sustained release corticosteroid by virtue of tions, polymer/solvent ratio, temperatures, stirring speed and the increased ratio of Surface area to mass inherent to Such drying cycles are adjusted to achieve the desired particle size, alternative geometrical shapes, relative to a spherical shape. Surface Smoothness, and narrow particle size distribution. The microparticles have a mass mean diameter ranging In the phase separation or phase inversion procedures 50 between about 0.5 to 500 microns. In a preferred embodi entrap dispersed agents in the polymer to prepare micropar ment, the microparticles have a mass mean diameter of ticles. Phase separation is similar to coacervation of a biode between 10 to about 100 microns. gradable polymer. By addition of a nonsolvent Such as petro Biodegradable polymer microparticles that deliver sus leum ether, to the organic solvent containing a suitable tained release corticosteroids may be suspended in Suitable biodegradable polymer, the polymer is precipitates from the 55 aqueous or non-aqueous carriers which may include, but is organic solvent to form microparticles. not limited to water, Saline, pharmaceutically acceptable oils, In the salting out process, a suitable biodegradable polymer low melting waxes, fats, lipids, liposomes and any other phar is dissolved in an aqueous miscible organic solvent. Suitable maceutically acceptable Substance that is lipophilic, Substan water miscible organic solvents for the polymeric materials tially insoluble in water, and is biodegradable and/or elimi include, but are not limited to acetone, as acetone, acetoni 60 natable by natural processes of a patient’s body. Oils of plants trile, and tetrahydrofuran. The water miscible organic solvent Such as Vegetables and seeds are included. Examples include containing a suitable biodegradable polymer is then mixed oils made from corn, Sesame, cannoli, soybean, castor, pea with an aqueous Solution containing salt. Suitable salts nut, olive, arachis, maize, almond, flax, safflower, Sunflower, include, but are not limited to electrolytes such as magnesium rape, coconut, palm, babassu, and cottonseed oil; waxes such chloride, calcium chloride, or magnesium acetate and non 65 as carnoba wax, beeswax, and tallow; fats Such as triglycer electrolytes Such as Sucrose. The polymer precipitates from ides, lipids such as fatty acids and esters, and liposomes Such the organic solvent to form microparticles, which are col as red cell ghosts and phospholipid layers. US 8,828,440 B2 39 40 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 incor an ester or acid end group plus either the corticosteroid porated into a biodegradable polymer for Sustained release betamethasone or triamcinolone acetonide. If betamethasone into a joint at a dosage that does not suppress the HPA axis, preferred loadings of said corticosteroid are from about 5% to is used, then the betamethasone is in the form of either about 40% (w/w) of the polymer, preferably about 5% to betamethasone acetate, betamethasone diproprionate or a about 30%, more preferably about 5% to about 28% of the combination thereof. The total amount of betamethasone or polymer. triamcinolone acetonide incorporated into the microparticle As the biodegradable polymers undergo gradual bio-ero ranges from 10% to 30% (w/w). The microparticles are for sion within the joint, the corticosteroid is released to the 10 mulated to mean mass range in size from 10 to 100 microns. inflammatory site. The pharmacokinetic release profile of the The population of microparticles is formulated to be deliv corticosteroid by the biodegradable polymer may be first ered through a 19 gauge or higher needle. Additional excipi order, Zero order, bi- or multi-phasic, to provide desired treat ents may be added such as, but not limited to, carboxymeth ment of inflammatory related pain. In any pharmacokinetic ylcellulose Sodium, mannitol, polysorbate-80, sodium event, the bio-erosion of the polymer and Subsequent release 15 phosphate, sodium chloride, polyethylene glycol to achieve of the corticosteroid may result in a controlled release of a isotonicity and promote Syringeability. If betamethasone is corticosteroid from the polymer matrix. The rate of release at used, then the betamethasone incorporated into the micropar dosages that do not suppress the HPA axis are described ticle population provides an initial release (burst) of about above. 5-20 mg of drug over a period of 1 to 12 hours, followed by a Excipients steady state release of drugata rate of about 0.1 to 1.0 mg/day The release rate of the corticosteroid from a biodegradable over a period of 14 to 90 days. If triamcinolone acetonide is polymer matrix can be modulated or stabilized by adding a used, then the drug incorporated into the microparticle popu pharmaceutically acceptable excipient to the formulation. An lation provides an initial release (burst) of about 10-40 mg of excipient may include any useful ingredient added to the drug over a period of 1 to 12 hours, followed by a steady state biodegradable polymer depot that is not a corticosteroid or a 25 release of drug at a rate of about 0.2 to 1.7 mg/day over a biodegradable polymer. Pharmaceutically acceptable excipi period of 14 to 90 days. ents may include without limitation lactose, dextrose, Sucrose, Sorbitol, mannitol, starches, gum acacia, calcium Example 2 phosphate, alginates, tragacanth, gelatin, calcium silicate, microcrystalline cellulose, PEG, polysorbate 20, polysorbate 30 Sustained-Release Betamethasone or Triamcinolone 80, polyvinylpyrrolidone, cellulose, water, Saline, syrup, Acetonide Microparticles with an Immediate Release methyl cellulose, and carboxymethyl cellulose. An excipient Form for modulating the release rate of a corticosteroid from the biodegradable drug depot may also include without limitation In another embodiment, the microparticle formulation of pore formers, pH modifiers, reducing agents, antioxidants, 35 Example 1 is further admixed with an immediate release and free radical scavengers. betamethasone or triamcinolone acetonide component, Such Delivery of Corticosteroid Microparticles as a betamethasone or triamcinolone acetonide containing Parenteral administration of formulations of the invention Solution. If betamethasone is used, then the betamethasone in can be effected by intra-articular injection or other injection the immediate release component is in the form of either using a needle. To inject the microparticles into a joint, 40 betamethasone acetate, betamethasone diproprionate or a needles having a gauge of about 14-28 gauge are suitable. It combination thereof. If betamethasone is used, then the will be appreciated by those skilled in the art that formula immediate release component provides an initial release of a tions of the present invention may be delivered to a treatment total of about 5 to 20 mg of betamethasone over the first 1-10 site by other conventional methods, including catheters, influ days, while the Sustained release component releases sion pumps, pens devices, injection guns and the like. 45 betamethasone at a rate of about 0.1 to 1.0 mg/day over the All references, patents, patent applications or other docu first 14 to 90 days following administration. If triamcinolone ments cited are hereby incorporated by reference. acetonide is used, then the immediate release component provides an initial release of a total of 10 to 40 mg of drug over EXAMPLES the first 1-10 days, while the sustained release component 50 releases drug at a rate of about 0.2 to 1.7 mg/day over the first The present invention is further defined in the following 14 to 90 days following administration. Examples. It should be understood that these Examples, while indicating preferred embodiments of the invention, are Example 3 given by way of illustration only. From the above discussion and these Examples, one skilled in the art can ascertain the 55 Determination of Time-Variance in HPA Axis essential characteristics of this invention, and without depart Sensitivity ing from the spirit and scope thereof, can make various changes and modifications of the invention to adapt it to Adult volunteers (N=4 to 9 per group) give appropriate various uses and conditions. informed consent. Each individual in each group receives a 60 single intra-articular administration of an exogenous corti Example 1 costeroid (triamcinolone acetonide 40 mg. triamcinolone hexacetonide 20; betamethasone 7 mg (disodium phosphate 4 Sustained-Release Betamethasone or Triamcinolone mg/acetate 3 mg). Blood samples for measurement of corti Acetonide Microparticles costeroid concentrations and/or cortisol concentrations are 65 drawn at 8 AM at baseline and on days 1, 7, 9, 10, 12, 14, 18, In one embodiment, the microparticle formulation con and 21. The extent of suppression of endogenous cortisol was tains a copolymer of DL-lactide (or L-lactide) and glycolide measured in each Subject in each group. The extent of cortisol US 8,828,440 B2 41 42 suppression predicted by previously published models (Mei TABLE 5-continued bohm, 1999) was determined and compared to observations (FIG. 4 Column 1). The change (decrease) in HPA axis sen Analytical Results for 25% Triamcinolone sitivity vs. time is then determined on a day-by-day and final Acetonide PLGA 75:25 Microparticles basis (FIG. 4, Column 2), permitting determination of the PLGA(lactide: glycolide molar correct steady-state intra-articular doses of corticosteroid to ratio Incor achieve, or limit, HPA axis suppression to the desired level. ratio inherent Drug load poration viscosity/molecular (% eff- In vitro Example 4 weight target TCA by ciency Particle size release 10 % TCA weight) (%) (Dv, Im) (%) Preparation of Triamcinolone Acetonide 54 kDa 14 day 70.9 Microparticles by Spinning Disk 25% 21 day: 76.4 28 day: 79.1 A pharmaceutical depot was prepared comprised of the corticosteroid, triamcinolone acetonide (TCA, 9C.-Fluoro 15 The in vitro cumulative release profile is graphed in FIG. 5. 113,16C, 17O.21-tetrahydroxy-1,4-pregnadiene-3,20-dione In one iteration of these data, the amount of TCA released 16,17-acetonide; 9C-Fluoro-16C.-hydroxyprednisolone 16C. per day was calculated based on a human dose, as exemplified 17O-acetonide) incorporated into PLGA microparticles. in Table 2, that would achieve a transient suppression of In one suitable thirty day formulation, 250 mg of triamci endogenous cortisol (greater than 50%) and, within 14 days, nolone acetonide and 750 mg of PLGA (lactide:glycolide achieve cortisol Suppression of endogenous cortisol of less molar ratio of 75:25, inherent viscosity of 0.4 dL/g and than 35% as shown in FIG. 6. In a second iteration of these molecular weight of 54 kDa) were dispersed in 14.25 grams data, the amount of triamcinolone acetonide released per day ofdichloromethane. The dispersion was atomized into micro was calculated based on a human dose, as exemplified in droplets by adding the dispersion to the feed well of a rotating 25 Table 2 that would not suppress the HPA axis, i.e. endogenous disk, rotating at a speed of approximately 3300 rpm inside a cortisol suppression never exceeding 35% as shown in FIG.7. temperature controlled chamber maintained at 38-45° C. The These calculated doses equal 376 mg of microparticles con Solvent was evaporated to produce Solid microparticles. The taining 94 mg of TCA and 80 mg of microparticles containing microparticles were collected using a cyclone separator and, 20 mg of TCA, respectively. Subsequently, sieved through a 150 um sieve. 30 In a second preparation of the same formulation, analyzed Particle size of the TCA incorporated microparticles was and in vitro release plotted in the same manner, the results are determined using laser diffraction (Malvern Mastersizer equivalent as shown in Table 6, and FIGS. 8, 9 and 10. The 2000) by dispersing a 250 mg aliquot in water, with the calculated human dose, as exemplified in Table 2 that would refractive index (RI) for water and PLGA, set at 1.33 and 1.46 achieve a transient Suppression of endogenous cortisol respectively. Sonication was maintained as the sample was 35 (greater than 50%) and, within 14 days, achieve cortisol Sup stirred at 2500 rpm and measurements taken every 15 sec pression of endogenous cortisol of less than 35% equals 280 onds, with the average of three measurements reported. 10 mg mg of microparticles containing 70 mg of TCA. The calcu of TCA containing microparticles were added to 10 mL of lated human dose, as exemplified in Table 2 that would not dimethylsulfoxide (DMSO), mixed until dissolved and an Suppress the HPA axis, i.e. endogenous cortisol Suppression aliquot analyzed by HPLC to determine the microparticle 40 never exceeding 35% equals 68 mg of microparticles contain drug load. Another 4 mg of TCA containing microparticles ing 17 mg of TCA. were suspended in 20 mL of phosphate buffered saline (PBS) containing 0.5% sodium dodecyl sulfate (SDS) maintained at TABLE 6 37°C. 0.5 mL of the media was removed at regular intervals, replaced at each interval with an equivalent amount of fresh 45 Analytical Results for Alternate Preparation of a Nominal media to maintain a constant Volume, and analyzed by HPLC 25% Triancinolone Acetonide PLGA 75:25 Microparticles to determine microparticle invitro release. Analysis by HPLC PLGA(lactide: was conducted using a C18 (Waters Nova-Pack C-18, 3.9x glycolide molar 150 mm) and 35% acetonitrile mobile phase at 1 mL/min flow ratio Incor rate with UV detection at 240 nm. The results are shown in 50 ratio inherent Drug load poration viscosity/molecular (% eff- In vitro Table 5. weight target TCA by ciency Particle size release % TCA weight) (%) (Dv, Im) (%) TABLE 5 75:25 27.5 110 D0.1: 30.9 m 0.2 day: 4.8 carboxylic D0.5:48.2 m 1 day: 15 Analytical Results for 25% Triamcinolone 55 acid end-capped D0.9: 71.0 m 3 day: 28.5 Acetonide PLGA 75:25 Microparticles 0.4 dLig 7 day: 50.2 PLGA(lactide: 54 kDa 14 day 67.1 glycolide molar 25% 21 day: 74.2 ratio Incor 28 day: 75.7 ratio inherent Drug load poration 60 viscosity/molecular (% eff- In vitro weight target TCA by ciency Particle size release Influence of PEG on PLGA 75:25 Formulations % TCA weight) (%) (Dv, Im) (%) In other Suitable formulations, polyethylene glycol was added to the PLGA 75:25 polymers while keeping the target 75:25 24 96 D0.1: 32 m 0.2 day: 5.1 carboxylic D0.5:49 lim 1 day: 13.5 amount of triamcinolone acetonide constant. PEG/PLGA acid end-capped D0.9: 73 m 3 day: 29.6 65 blends are known to allow for more complete and faster 0.4 dLig 7 day: 52.6 release of pharmaceutical agents incorporated into micropar ticles than PLGA alone (Cleek et al. “Microparticles of poly US 8,828,440 B2 43 44 (DL-lactic-coglycolic acid)/poly(ethylene glycol) blends for ing 79 mg of TCA, respectively. In a second iteration of these controlled drug delivery.”J Control Release 48 (1997): 259 data, the amount of triamcinolone acetonide released per day 268; Morlock, et al. “Erythropoietin loaded microspheres was calculated based on a human dose, as exemplified in prepared from biodegradable LPLG-PEO-LPLG triblock Table 2 that would not suppress the HPA axis, i.e. endogenous copolymers: protein stabilization and in-vitro release proper cortisol suppression never exceeding 35% as shown in FIGS. ties.” J Control Release, 56 (1-3) (1998): 105-15; Yeh, “The 15 and 16. These calculated doses equal 68 mg of micropar stability of insulin in biodegradable microparticles based on ticles containing 17 mg of TCA and 88 mg of microparticles blends of lactide polymers and polyethylene glycol J containing 22 mg of TCA, respectively. Microencapsul, 17(6) (2000): 743-56). Other TCA containing formulations were tried with PEG In one iteration, 250 mg of triamcinolone acetonide, 50 mg 10 of polyethylene glycol (PEG 1450) and 700 mg of PLGA and PLGA 75:25 without success. A PLGA microparticle (lactide:glycolide molar ratio of 75:25, inherent viscosity of formulation containing 25% TCA and 25% PEG 1450 0.4 dL/g and molecular weight of 54 kDa) were dispersed in agglomerated during manufacture and storage. Another 14 grams of dichloromethane. In anotheriteration, 250 mg of PLGA formulation containing 40%TCA and 15% PEG 1450 triamcinolone acetonide, 100 mg of polyethylene glycol 15 gave similar results to the microparticles containing 40% (PEG 3350) and 650 mg of PLGA (lactide:glycolide molar TCA and no PEG. ratio of 75:25, inherent viscosity of 0.4 dL/g and molecular Influence of Triamcinolone Acetonide Content in PLGA weight of 54 kDa) were dispersed in 13 grams of dichlo 75:25 Microparticles: romethane. The dispersions were atomized into micro-drop Triamcinolone acetonide containing microparticle depots lets by adding the dispersion to the feed wellofa rotating disk, were prepared and analyzed, as described above, with the rotating at a speed of approximately 3300 rpm inside a tem exception of using 100 mg, 150 mg, 200 mg and 400 mg perature controlled chamber maintained at 38-45° C. The triamcinolone acetonide and adding to a 5% PLGA dichlo Solvent was evaporated to produce Solid microparticles. The romethane solution. The physical characteristics of these for microparticles were collected using a cyclone separator and, mulations are shown in Table 8. Subsequently, sieved through a 150 um sieve. 25 The microparticles were analyzed as described above and TABLE 8 the data is shown in Table 7. Analytical Results of PLGA 75:25 Microparticles containing varying amounts of Triancinolone Acetonide TABLE 7 30 PLGA(lactide: Analytical Results of Nominal 25% Triamcinolone glycolide molar Acetonide PLGA 75:25 Microparticles containing ratio Incor Polyethylene Glycol (PEG) Additive ratio inherent Drug load poration viscosity/molecular (% eff- In vitro PLGA(lactide: weight target TCA by ciency Particle size (8Se. % TCA weight) (%) (Dv, Im) (%) glycolide molar 35 ratio Incor ratio inherent Drug load poration 75:25 43.4 109 D0.1:40.7 m 0.2 day: 6.6 viscosity/molecular (% eff- In vitro carboxylic D0.5: 70.7 m ay: 24.2 weight target TCA by ciency Particle size (8Se. acid end-capped D0.9: 167 lm 3 day: 53.8 % TCA% PEG weight) (%) (Dv, Im) (%) 0.4 dLig 7 day: 82.5 54 kDa 14 day 89.4 75:25 29.4 118 D0.1: 36.2 m 0.2 day: 3.6 40 40% 21 day: 89.6 carboxylic D0.5:59.0 m day: 13.8 28 day: 87.5 acid end-capped D0.9: 95.5 m 3 day: 30.1 75:25 2O2 101 D0.1: 28.7 m 0.2 day: 5.3 0.4 dLig 7 day: 49.5 carboxylic D0.5:45.2 m ay: 13.5 54 kDa 14 day 65.5 acid end-capped D0.9: 70.5 m 3 day: 23.7 25% 21 day: 74.0 0.4 dLig 7 day: 35.3 5% PEG 1450 28 day: 78.5 45 54 kDa 14 day 44.4 75:25 24.5 98 D0.1:32.0 m 0.2 day: 4.1 20% 21 day: 48.1 carboxylic D0.5: 52.4 lim day: 11.7 28 day: 50.6 acid end-capped D0.9: 79.0 m 3 day: 24.5 75:25 15.9 106 D0.1: 30.7 m 0.2 day: 3.9 0.4 dLig 7 day: 40.8 carboxylic D0.5:47.8 m ay: 9.0 54 kDa 14 day: 55.8 acid end-capped D0.9: 74.8 m 3 day: 14.2 25% 21 day: 63.7 50 0.4 dLig 7 day: 19.3 10% PEG 3350 28 day: 69.5 54 kDa 14 day 22.7 15% 21 day: 24.6 28 day: 27.6 The in vitro cumulative release profile is graphed in FIG. 75:25 11.7 117 D0.1: 31.0 m 0.2 day: 2.3 carboxylic D0.5: 57.9 m ay: 4.4 11 and FIG. 12. PEG did not seem to enhance the release of acid end-capped D0.9: 118 um 3 day: 5.9 the TCA in either formulation, as would be expected. In fact, 55 0.4 dLig 7 day: 7.5 at higher percentages of PEG, albeit a different molecular 54 kDa 14 day 9.9 weight (higher percentages of PEG 1350 were unmanageable 10% 21 day: 11.7 due to the agglomeration of microparticles), the release rate 28 day: 15.8 was slower. In one iteration of these in vitro release data, the amount of 60 The in vitro cumulative release profiles for these four other TCA released per day was calculated based on a human dose, TCA containing PLGA 75:25 microparticle depots are as exemplified in Table 2, that would achieve a temporary graphed in FIG. 17, along with the preferred formulation Suppression of endogenous cortisol (greater than 50%) and, (25%TCA). The tabulated data and graph show the impact of within 14 days, achieve cortisol Suppression of endogenous the percent TCA incorporated in the PLGA microparticles on cortisol of less than 35% as shown in FIG. 13 and FIG. 14. 65 the in vitro release profile. The 10%, 15% and 20% TCA These calculated doses equal 296 mg of microparticles con containing PLGA microparticles exhibit a slower release pro taining 74 mg of TCA and 316 mg of microparticles contain file, with a significant less cumulative release over 28 days, US 8,828,440 B2 45 46 less than 20%, 30% and 55% respectively, than the 25%TCA TABLE 9-continued PLGA depot exemplified in Example 4. The 40% TCA con taining depot exhibits a faster release profile, with greater Analytical Results of a Nominal 25% Triamcinolone than 80% of the triamcinolone released by day 7 with a Acetonide PLGA 75:25 (29 kDa) Microparticles similar total cumulative release, than the 25% TCA PLGA 5 PLGA(lactide: depot exemplified in Example 4. glycolide molar ratio Incor Influence of Molecular Weight on TCA PLGA 75:25 ratio inherent Drug load poration Microparticle Formulations: viscosity/molecular (% eff- In vitro In another microparticle formulation, triamcinolone weight target TCA by ciency Particle size release acetonide was incorporated in PLGA of the same lactide to 10 % TCA% PEG weight) (%) (Dv, Im) (%) glycolide molar ratio as cited in Example 4 but of a lower 29 kDa 14 day: 48.3 molecular weight. Low molecular weight PLGA is known to 25% 21 day: 53.4 allow for more complete and faster release of pharmaceutical 28 day: 56.5 agents incorporated into microparticles than their higher molecular weight counterparts. (Anderson et al. "Biodegra 15 In vitro cumulative release data is graphed in FIG. 18, dation and biocompatibility of PLA and PLGA micro spheres.” Advanced Drug Delivery Reviews 28 (1997): 5-24: along with the preferred formulation using a higher molecular Bouissou et al., “Poly(lactic-co-glycolicacid) Microspheres.” PLGA 75:25. The use of lower molecular weight PLGA (29 Polymer in Drug Delivery (2006): Chapter 7). kDa) did not improve the release of the triamcinolone 250 mg of triamcinolone acetonide and 750 mg of PLGA acetonide from the microparticles as expected, in fact the rate (lactide:glycolide molar ratio of 75:25, inherent viscosity of of release decreased and the release was incomplete as com 0.27 dL/g and molecular weight of 29 kDa) were dispersed in pared to higher molecular weight PLGA (PLGA, 54 kDa). 14.25 grams of dichloromethane. The dispersion was atom In another formulation of low molecular weight PLGA ized into micro-droplets by adding the dispersion to the feed 75:25(29 kDa), polyethylene glycol, 10% PEG 3350, was well of a rotating disk, rotating at a speed of approximately 25 added while maintaining the same amount of triamcinolone 3300 rpm inside a temperature controlled chamber main acetonide. As shown with other PEG containing formula tained at 38-45° C. The solvent was evaporated to produce tions, there was no impact of this additive on the cumulative Solid microparticles. The microparticles were collected using percent in vitro release profile as compared to the formulation a cyclone separator and, Subsequently, sieved through a 150 not containing PEG (data not shown). um sieve. 30 Influence of PLGA Lactide to Glycolide Ratio: Particle size of the TCA incorporated microparticles was In other triamcinolone acetonide microparticle formula determined using laser diffraction (Malvern Mastersizer tions, PLGA of equimolar lactide to glycolide ratio were 2000) by dispersing a 250 mg aliquot in water, with the employed instead of PLGA (75:25). PLGA (50:50) is known refractive index (RI) for water and PLGA, set at 1.33 and 1.46 to allow for faster degradation and release of pharmaceutical respectively. Sonication was maintained as the sample was 35 agents incorporated into microparticles than PLGAs with stirred at 2500 rpm and measurements taken every 15 sec greater lactide versus glycolide content (Anderson etal. "Bio onds, with the average of three measurements reported. 10 mg of TCA containing microparticles were added to 10 mL of degradation and biocompatibility of PLA and PLGA micro dimethylsulfoxide (DMSO), mixed until dissolved and an spheres.” Advanced Drug Delivery Reviews 28 (1997): 5-24: aliquot analyzed by HPLC to determine the microparticle 40 Bouissou et al., “Poly(lactic-co-glycolicacid) Microspheres.” drug load. Another 4 mg of TCA containing microparticles Polymer in Drug Delivery (2006): Chapter 7). Multiple for were suspended in 20 mL of phosphate buffered saline (PBS) mulations using PLGA 50:50 with differing amounts of tri containing 0.5% sodium dodecyl sulfate (SDS) maintained at amcinolone acetonide, with and without PEG, different 37°C. 0.5 mL of the media was removed at regular intervals, PLGA molecular weights and different PLGA endcaps were replaced at each interval with an equivalent amount of fresh 45 exemplified. media to maintain a constant Volume, and analyzed by HPLC Formulations were prepared with 200 mg, 250 mg,300 mg to determine microparticle invitro release. Analysis by HPLC and 350 mg of triamcinolone acetonide and corresponding was conducted using a C18 (Waters Nova-Pack C-18, 3.9x amount of PLGA (lactide:glycolide molar ratio of 50:50, 150 mm) and 35% acetonitrile mobile phase at 1 ml/min flow inherent viscosity of 0.48 dL/g and molecular weight of 66 rate with UV detection at 240 nm. The results are shown in 50 kDa) to yield 1000 mg total solids were dispersed into a Table 9. quantity of dichloromethane to a achieve a 5% PLGA solu tion. In anotheriteration, 300 mg of triamcinolone acetonide, TABLE 9 100 mg of polyethylene glycol (PEG 3350) and 650 mg of PLGA (lactide:glycolide molar ratio of 50:50, inherent vis Analytical Results of a Nominal 25% Triamcinolone 55 cosity of 0.48 dL/g and molecular weight of 66 kDa) were Acetonide PLGA 75:25 (29 kDa) Microparticles dispersed in 14.25 grams of dichloromethane. In another PLGA(lactide: iteration, 300 mg of triamcinolone acetonide and 700 mg of glycolide molar PLGA (lactide:glycolide molar ratio of 50:50, inherent vis ratio Incor cosity of 0.18 dL/g and molecular weight of 18 kDa) to yield ratio inherent Drug load poration 60 viscosity/molecular (% eff- In vitro 1000 mg total solids were dispersed in 14.25 grams of dichlo weight target TCA by ciency Particle size release romethane. The dispersions were atomized into micro-drop % TCA% PEG weight) (%) (Dv, Im) (%) lets by adding the dispersion to the feed wellofa rotating disk, rotating at a speed of approximately 3300 rpm inside a tem 75:25 29.4 118 D0.1:34.1 m 0.2 day: 4.0 carboxylic D0.5: 56.5 m 1 day: 11.3 perature controlled chamber maintained at 38-45° C. The acid end-capped D0.9: 95.2 m 3 day: 22.5 65 Solvent was evaporated to produce Solid microparticles. The 0.27 dLig 7 day: 35.9 microparticles were collected using a cyclone separator and, Subsequently, sieved through a 150 um sieve. US 8,828,440 B2 47 48 Particle size of the TCA incorporated microparticles was TABLE 10-continued determined using laser diffraction (Malvern Mastersizer 2000) by dispersing a 250 mg aliquot in water, with the Analytical Results of Triamcinolone Acetonide refractive index (RI) for water and PLGA, set at 1.33 and 1.46 PLGA 50:50 Microparticle Formulations respectively. Sonication was maintained as the sample was PLGA(lactide: stirred at 2500 rpm and measurements taken every 15 sec glycolide molar onds, with the average of three measurements reported. 10 mg ratio Incor of TCA containing microparticles were added to 10 mL of ratio inherent Drug load poration dimethylsulfoxide (DMSO), mixed until dissolved and an viscosity/molecular (% eff- In vitro 10 weight target TCA by ciency Particle size (8Se. aliquot analyzed by HPLC to determine the microparticle % TCA% PEG weight) (%) (Dv, Im) (%) drug load. Another 4 mg of TCA containing microparticles 50:50 34.4 98.3 D0.1: 35.1 Im 0.2 day: 7.1 were suspended in 20 mL of phosphate buffered saline (PBS) carboxylic D0.5: 52.3 lim day: 23.3 containing 0.5% sodium dodecyl sulfate (SDS) maintained at acid end-capped D0.9: 75.6 m 3 day: 47.6 37°C. 0.5 mL of the media was removed at regular intervals, 15 0.48 dLig 7 day: 66.9 replaced at each interval with an equivalent amount of fresh 66 kDa 14 day: 69.3 35% TCA 21 day: 68.3 media to maintain a constant Volume, and analyzed by HPLC 28 day: 66.7 to determine microparticle invitro release. Analysis by HPLC 50:50 ester 23.2 93 D0.1: 34.2 m 0.2 day: 3.1 was conducted using a C18 (Waters Nova-Pack C-18, 3.9x endcapped D0.5:51.7 m day: 7.8 150 mm) and 35% acetonitrile mobile phase at 1 ml/min flow 0.4 dLig D0.9: 77.4 m 3 day: 12.5 rate with UV detection at 240 nm. The results are shown in 66 kDa 7 day: 15.4 Table 10. 25% TCA 14 day: 16.2 21 day: 16.0 TABLE 10 28 day: 16.4 25 Analytical Results of Triamcinolone Acetonide PLGA 50:50 Microparticle Formulations In-vitro release profiles of the various PLGA (50:50) for mulations are shown in the FIG. 19. The use of PLGA (50:50) PLGA(lactide: glycolide molar did not improve the release kinetics of the triamcinolone ratio Incor 30 acetonide as compared to the PLGA (75:25). Unexpectedly, ratio inherent Drug load poration 25% triamcinolone acetonide microparticles in PLGA (50: viscosity/molecular (% eff- In vitro 50) release the corticosteroid at a slower rate and give an weight target TCA by ciency Particle size (8Se. incomplete release as compared to the equivalent amount of % TCA% PEG weight) (%) (Dv, Im) (%) triamcinolone acetonide incorporated in PLGA 75:25. All the 50:50 19.2 96 D0.1:30.0 m 0.2 day: 2.1 35 PLGA 50:50 formulation show a substantial lag phase, where carboxylic D0.5:48.5 m ay: 3.3 little or any TCA is being released after 7 days, which con acid end-capped D0.9: 77.0 m 3 day: 17.0 tinues to about day 50. As observed with TCA PLGA 75:25 0.48 dLig 7 day: 18.7 formulations, increasing the amount of TCA increases the 66 kDa 14 day: 21.0 rate of release and allows for more TCA to be released before 20% TCA 21 day: 23.5 40 entering the lag phase. Similarly, the addition of PEG has 28 day: 25.6 50:50 23.9 95.6 D0.1: 30.2 m 0.2 day: 4.0 minimal influence on the release rate of TCA, while lower carboxylic D0.5:48.2 m ay: 7.8 molecular weight PLGA 50:50 decrease the release rate as acid end-capped D0.9: 75.8 m 3 day: 21.1 observed with PLGA 75:25 formulations. 0.48 dLig 7 day: 32.1 Based on the studies described herein, the Class B corti 66 kDa 14 day: 39.2 45 25% TCA 21 day: 40.0 costeroid microparticle formulations, for example, the TCA 28 day: 40.8 microparticle formulations, exhibiting the desired release 50:50 29.3 97.6 D0.1: 31.5 m 0.2 day: 5.1 kinetics have the following characteristics: (i) the corticoster carboxylic D0.5:48.0 m ay: 16.0 oid is between 22%-28% of the microparticle; and (ii) the acid end-capped D0.9: 68.9 m 3 day: 33.6 50 polymer is PLGA having a molecular weight in the range of 0.48 dLig 7 day: 49.9 about 40 to 70 kDa, having an inherent viscosity in the range 66 kDa 14 day: 54.0 30% TCA 21 day: 53.2 of 0.3 to 0.5 dL/g, and or having a lactide:glycolide molar 28 day: 52.2 ratio of 80:20 to 60:40. 50:50 27.2 91 D0.1:37.6 m 0.2 day: 4.4 carboxylic D0.5: 59.8 m ay: 9.8 55 Example 5 acid end-capped D0.9: 93.9 m 3 day: 13.8 0.18 dLig 7 day: 17.7 18 kDa 14 day: 21.9 Preparation of Triamcinolone Acetonide PLGA 30% TCA 21 day: 26.3 Microparticles by Solid in Oil in Water (S/O/W) 28 day: 36.6 60 50:50 30.4 101 D0.1: 38.1 m 0.2 day: 4.2 Emulsion carboxylic D0.5: 56.6 m ay: 14.6 acid end-capped D0.9:82.1 lim 3 day: 32.2 0.48 dLig 7 day: 51.0 A pharmaceutical depot was prepared comprised of the 66 kDa 14 day: 60.1 corticosteroid, triamcinolone acetonide (TCA, 9C.-Fluoro 30% TCA 21 day: 61.1 65 11B,16C, 17O.21-tetrahydroxy-14-pregnadiene-320-dione 10% PEG 3350 28 day: 60.1 16, 17-acetonide; 9C-Fluoro-16C.-hydroxyprednisolone 16C. 17C.-acetonide) incorporated into microparticles. US 8,828,440 B2 49 50 Formulations were prepared by dissolving approximately TABLE 11 1 gram of PLGA in 6.67 mL of dichloromethane (DCM). To Analytical Results of Nominal 28.6% Triamcinolone Acetonide the polymer Solution, 400 mg of triamcinolone acetonide was in PLGA 75:25 plus Triblock Microparticle Formulations added and Sonicated. Subsequently, the corticosteroid con PLGA(lactide: taining dispersion was poured into 200 mL of 0.3% polyvinyl glycolide molar alcohol (PVA) solution while homogenizing with a Silverson ratio Incor ratio inherent Drug load poration homogenizer using a rotor fixed with a Silverson Square Hole viscosity/molecular (% eff- In vitro High Shear ScreenTM, set to rotate at approximately 2,000 weight target TCA by ciency Particle size release rpm to form the microparticles. After two minutes, the beaker 10 % TCA% PEG weight) (%) (Dv, Im) (%) was removed, and a glass magnetic stirrer) added to the bea 75:25 ester 23.8 83.2 D0.1: 38.9 m 1 day: 8.2 ker, which was then placed onto a multi-way magnetic stirrer endcapped D0.5: 74.7 m 2 day: 14.2 0.71 dLig D0.9: 103.0 m 3 day: 15.7 and stirred for four hours at 300 rpm to evaporate the DCM. 114 kDa 4 day 18.2 The microparticles were then washed with 2 liters of distilled 15 28.6% TCA 6 day: 28.8 10% Triblock 9 day: 38.9 water, sieved through a 100 micron screen. The micropar 12 day: 49.8 ticles were then lyophilized for greater than 96 hours and 16 day: 61.6 20 day: 66.4 vacuum packed. 24 day: 68.7 Particle size of the TCA incorporated microparticles was 30 day: 72:3 35 day: 72.8 determined using laser diffraction (Beckman Coulter LS 230) 75:25 ester 24.8 86.7 D0.1: 39.5 m 1 day: 5.5 by dispersing a 50 mg aliquot in water, with the refractive endcapped D0.5: 74.6 m 2 day: 8.9 index (RI) for water and PLGA, set at 1.33 and 1.46 respec 0.71 dLig D0.9: 104.2 m 3 day: 12.8 114 kDa 4 day 14.5 tively. The sample was stirred at the particle size measure 28.6% TCA 6 day: 28.4 ment measurements taken and the results reported. Drug load 25 20% Triblock 9 day: 35.6 (TB) 12 day: 47.8 was determined by Suspending a nominal 10 mg of micropar 16 day: 53.0 ticles in 8 ml HPLC grade methanol and sonicating for 2 20 day: 64.3 24 day: 67.3 hours. Samples were then centrifuged at 14,000 g for 15 mins 30 day: 73.0 beforean aliquot of the supernatant was assayed via HPLC as 30 35 day: 73.0 described below. Corticosteroid-loaded microparticle samples, nominally 1 g were placed in 22 ml glass vials in 8-20 ml of 0.5% v/v Tween 20 in 100 mM phosphate buffered The in vitro cumulative release profiles for both triblock saline and stored in a 37°C. incubator with magnetic stirring containing formulations are shown in FIG. 20. The amount of 35 triblock in the tested formulations did not influence the cumu at 130 rpm. Each test sample was prepared and analyzed in lative percent release. duplicate to monitor possible variability. At each time point in In one iteration of these data, the amount of TCA released the release study, microparticles were allowed to settle, and per day was calculated based on a human dose, as exemplified an aliquot of between 4-16 ml of Supernatant were taken, and in Table 2, that may achieve a temporary Suppression of replaced with an equal volume of fresh 0.5% V/v Tween 20 in 40 endogenous cortisol (greater than 50%) and, within 14 days, 100 mM phosphate buffered saline. Drug load and in vitro achieve cortisol Suppression of endogenous cortisol of less release samples were analyzed by HPLC using a Hypersil than 35%. These calculated doses equal 149 mg of micropar C18 column (100 mm, i.d. 5 mm, particle size 5 um; Ther ticles containing 35 mg of TCA and 252 microparticles con moFisher) and Beckman HPLC. All samples were run using 45 taining 62 mg of TCA, for the 10% and 20% triblock formu a sample injection Volume of 5um, and column temperature lations respectively (FIG. 21 and FIG. 22). In a second of 40° C. An isocratic mobile phase of 60% methanol and iteration of these data, the amount of TCA released per day 40% water was used at a flow rate of 1 ml/min, with detection was calculated based on a human dose, as exemplified in at a wavelength of 254 nm. Table 2, that would not have an suppress the HPA axis, i.e. In one group of suitable thirty day formulations, the PLGA 50 endogenous cortisol Suppression more than 35%. These cal is an ester end capped PLGA (lactide:glycolide molar ratio of culated doses equal 66 mg of microparticles containing 16 mg 75:25, inherent viscosity of 0.71 dI/g and molecular weight of TCA and 47 microparticles containing 12 mg of TCA, for of 114 kDa) with 10% or 20% triblock (TB) polymer (PLGA the 10% and 20% triblock formulations respectively (FIG.23 PEG-PLGA). Triblock polymer was synthesized using a and FIG. 24). method described by Zentner et al 2001 (Zentner et al. “Bio In another Suitable formulation lasting greater than 30 days degradable block copolymers for delivery of proteins and and up to 90 days, the PLGA polymer consists of two differ water-insoluble drugs.”J Control Release 72 (2001): 203-15) ent molecular weight PLGA 75:25 polymers in a two to one and refined by Hou et al 2008 (Hou et al., “In situ gelling ratio, PLGA 75:25 (lactide:glycolide molar ratio of 75:25, hydrogels incorporating microparticles as drug delivery car 60 inherent viscosity of 0.27 dL/g and molecular weight of 29 riers for regenerative medicine.”J Pharm Sci 97(9) (2008): kDa) and ester end capped PLGA 5.5E (lactide:glycolide 3972-80). It is synthesized using a ring opening polymeriza molar ratio of 75:25, inherent viscosity of 0.58 dL/g and tion of cyclic dimmers of D.L-lactide and glycolide with PEG molecular weight of 86 kDa), respectively. The formulation 1,500kDa in the presence of stannous octoate. In vitro release was processed as described above with the exception that 200 (lactide:glycolide molar ratio of 50:50, inherent viscosity of 65 mg of triamcinolone acetonide was used in the formulation 0.40 dL/g and molecular weight of 66 kDa). The analytical instead of 400 mg and similarly analyzed as describe for other results for these formulations are shown in Table 11. formulations. The results are shown in the Table 12. US 8,828,440 B2 51 52 TABLE 12 polymer is (1) PLGA having a molecular weight in the range of about 40 to 70 kDa, having an inherent viscosity in the Analytical Results of a Nominal 16.7% Triamcinolone Acetonide range of 0.3 to 0.5 dI/g, containing 10%-20% Triblock and/or in Mixed Molecular Weight PLGA 75:25 Microparticle Formulation having a lactide:glycolide molar ratio of 80:20 to 60:40 or (2) PLGA (lactide: a mixture of low and high molecular weight PLGAs in a two glycolide molar ratio Incor to one ratio. The low molecular weight PLGA has a molecular ratio inherent Drug load poration weight of range of 15-35 kDa and an inherent viscosity range viscosity/molecular (% eff- In vitro from 0.2 to 0.35 dL/g, and the high molecular weight PLGA weight target TCA by ciency Particle size release has a range of 70-95 kDa and an inherent viscosity range of % TCA% PEG weight) (%) (Dv, Im) (%) 10 0.5 to 0.70 dL/g. 75:25 ester 14.6 87.7 D0.1: 36.5 m 1 day: 12.4 endcapped D0.5:54.0 m 2 day: 21.6 Example 6 0.58 dLig D0.9: 69.4 m 3 day: 27.3 86 kDa 4 day 33.6 And 6 day: 41.2 15 Preparation of Prednisolone PLGA Microparticles 75:25 9 day: 50.7 by Solid in Oil in Water (S/O/W) Emulsion carboxylic 12 day: 54.3 acid end-capped 17 day: 62.0 0.27 dLig 20 day: 73.1 A pharmaceutical depot was prepared comprised of the 29 kDa 25 day: 75.5 corticosteroid, prednisolone (PRED, 11B, 17.21-trihydrox 16.7% TCA 30 day: 82.9 ypregna-1,4-diene-320-dione) incorporated into micropar 35 day: 84.6 42 day: 87.4 ticles in PLGA 50:50. 49 day: 89.2 Formulations were prepared by dissolving approximately 1 gram of PLGA 50:50 (lactide:glycolide molar ratio of In Vitro Cumulative Percent TCA Release Data is Graphed 50:50, inherent viscosity 0.44 dL/g, MW 56 kDa) in 6.67 mL in FIG. 25. 25 ofdichloromethane (DCM). To the polymer solution, 400 mg In one iteration of these in vitro release data, the amount of of prednisolone was added and Sonicated. Subsequently, the TCA released per day was calculated based on a human dose, corticosteroid containing dispersion was poured into 200 mL as exemplified in Table 2, which may achieve a temporary of 0.3% polyvinyl alcohol (PVA) solution while homogeniz Suppression of endogenous cortisol (greater than 50%) and, ing with a Silverson homogenizer using a rotor fixed with a within 14 days, achieve cortisol Suppression of endogenous 30 Silverson Square Hole High Shear ScreenTM, set to spin at cortisol of less than 35%. This calculated dose equals 317 mg 2,000 rpm to form the microparticles. After two minutes, the of microparticles containing 46 mg of TCA. In a second beaker was removed, and a glass magnetic stirrer) added to iteration of these data, the amount of TCA released per day the beaker, which was then placed onto a multi-way magnetic stirrer and stirred for four hours at 300 rpm to evaporate the was calculated based on a human dose, as exemplified in 35 Table 2, that would not have an suppress the HPA axis, i.e. DCM. The microparticles were then washed with 2 liters of endogenous cortisol Suppression more than 35%. This calcu distilled water, sieved through a 100 micron screen. The lated dose equals 93 mg of microparticles containing 14 mg of microparticles were then lyophilized for greater than 96 hours TCA and vacuum packed. Several other triamcinolone acetonide PLGA depots were 40 Particle size of the PRED incorporated microparticles was formulated in the same manner as described above with dif determined using laser diffraction (Beckman Coulter LS 230) ferent polymers including polycaprolactone (14 kDa), PLGA by dispersing a 50 mg aliquot in water, with the refractive 50:50 (carboxylic acid end-capped, 0.44 dL/g, MW 56 kDa), index (RI) for water and PLGA, set at 1.33 and 1.46 respec PLGA 85:15 (carboxylic acid end-capped, 0.43 dL/g, 56 tively. The sample was stirred at the particle size measure kDa) and a mixed molecular weightformulation using PLGA 45 ment measurements taken and the results reported. Drug load 75:25 (carboxylic acid end capped, 0.27 dL/g, MW 29 kDa) was determined by Suspending a nominal 10 mg of micropar and PLGA 75:25 (ester end-capped, 0.57 dL/g, MW 86 kDa) ticles in 8 ml HPLC grade methanol and sonicating for 2 in a two to one ratio. The in vitro cumulative percent release hours. Samples were then centrifuged at 14,000 g for 15 mins of triamcinolone acetonide is shown in FIG. 28. None of these beforean aliquot of the supernatant was assayed via HPLC as formulations were suitable for a nominal thirty day or longer 50 described below. Corticosteroid-loaded microparticle duration pharmaceutical depot. Polycaprolactone release all samples, nominally 1 g were placed in 22 ml glass vials in the triamcinolone acetonide prior to 14 days. The PLGA 8-20 ml of 0.5% v/v Tween 20 in 100 mM phosphate buffered 50:50 microparticles released about 35% of its content by day saline and stored in a 37°C. incubator with magnetic stirring 12 and then entered a lag phase where no drug was released up at 130 rpm. Each test sample was prepared and analyzed in to 30 days. The PLGA85:15 microparticles exhibited similar 55 duplicate to monitor possible variability. At each time point in in vitro release kinetics as the PLGA 50:50, releasing about the release study, microparticles were allowed to settle, and 30% of its content by day 12 and then entered a lag phase an aliquot of between 4-16 ml of Supernatant were taken, and where no drug was released up to 30 days (See FIG. 28). A replaced with an equal volume of fresh 0.5% V/v Tween 20 in similar phenomenon is seen as shown in Example 4, where 100 mM phosphate buffered saline. Drug load and in vitro the mixed molecular weight PLGA 75:25 unexpectedly 60 release samples were analyzed by HPLC using a Hypersil exhibits faster initial release of the triamcinolone acetonide C18 column (100 mm, i.d. 5 mm, particle size 5 um; Ther than PLGA 50:50. moFisher) and Beckman HPLC. All samples were run using Based on the studies described herein, the Class B corti a sample injection Volume of 5um, and column temperature costeroid microparticle formulations, for example, the TCA of 40° C. An isocratic mobile phase of 60% methanol and microparticle formulations, exhibiting the desired release 65 40% water was used at a flow rate of 1 ml/min, with detection kinetics have the following characteristics: (i) the corticoster at a wavelength of 254 nm. The analytical results are shown in oid is between 12%-28% of the microparticle; and (ii) the the Table 13. US 8,828,440 B2 53 54 TABLE 13 of 0.3% polyvinyl alcohol (PVA) solution while homogeniz ing with a Silverson homogenizer using a rotor fixed with a Analytical Results of a Nominal 28.6% Prednisolone Silverson Square Hole High Shear ScreenTM, set to spin at in PLGA 50:50 Microparticle Formulation 2,000 rpm to form the microparticles. After two minutes, the PLGA(lactide: beaker was removed, and a glass magnetic stirrer) added to glycolide molar the beaker, which was then placed onto a multi-way magnetic ratio Incor ratio inherent Drug load poration stirrer and stirred for four hours at 300 rpm to evaporate the viscosity/molecular (% eff- In vitro DCM. The microparticles were then washed with 2 liters of weight target PRED ciency Particle size release distilled water, sieved through a 100 micron screen. The % TCA% PEG by weight) (%) (Dv, Im) (%) 10 microparticles were then lyophilized for greater than 96 hours 50:50 19.0 66.4 D0.1: 34.4 m 1 day: 7.2 and vacuum packed. carboxylic D0.5: 66.9 m 2 day: 11.5 Particle size of the BETA incorporated microparticles was acid end-capped D0.9:87.5 m 3 day: 15.6 0.44 dLig 4 day: 20.2 determined using laser diffraction (Beckman Coulter LS 230) 56 kDa 5 day: 24.0 15 by dispersing a 50 mg aliquot in water, with the refractive 28.6% PRED 6 day: 28.4 7 day: 32.7 index (RI) for water and PLGA, set at 1.33 and 1.46 respec 9 day: 36.5 tively. The sample was stirred at the particle size measure 11 day: 41.4 ment measurements taken and the results reported. Drug load 13 day: 45.0 was determined by Suspending a nominal 10 mg of micropar 15 day: 49.3 18 day: 52.0 ticles in 8 ml HPLC grade methanol and sonicating for 2 21 day: 55.2 hours. Samples were then centrifuged at 14,000 g for 15 mins 24 day: 58.3 beforean aliquot of the supernatant was assayed via HPLC as 27 day: 62.3 described below. Corticosteroid-loaded microparticle 30 day: 65.9 samples, nominally 1 g were placed in 22 ml glass vials in 25 8-20 ml of 0.5% v/v Tween 20 in 100 mM phosphate buffered In vitro release profile of the prednisolone PLGA micro saline and stored in a 37°C. incubator with magnetic stirring particles is shown in FIG. 29. This formulation is suitable for at 130 rpm. Each test sample was prepared and analyzed in a 30 day formulation or greater. duplicate to monitor possible variability. At each time point in In one iteration of the cumulative percent in vitro release the release study, microparticles were allowed to settle, and data, the amount of prednisolone released per day was calcu 30 an aliquot of between 4-16 ml of Supernatant were taken, and lated based on a human dose, as exemplified in Table 2, which replaced with an equal volume of fresh 0.5% V/v Tween 20 in may achieve a temporary suppression of endogenous cortisol 100 mM phosphate buffered saline. Drug load and in vitro (greater than 50%) and, within 14 days, achieve cortisol Sup release samples were analyzed by HPLC using a Hypersil pression of endogenous cortisol of less than 35% (FIG. 30). C18 column (100 mm, i.d. 5 mm, particle size 5 um; Ther The calculated dose equals 699 mg of microparticles contain 35 moFisher) and Beckman HPLC. All samples were run using ing 133 mg of PRED. In a second iteration of these data, the a sample injection Volume of 5um, and column temperature amount of PRED released per day was calculated based on a of 40° C. An isocratic mobile phase of 60% methanol and human dose, as exemplified in Table 2 that would not suppress 40% water was used at a flow rate of 1 ml/min, with detection the HPA axis, i.e. endogenous cortisol Suppression of less at a wavelength of 254 nm. The analytical characteristics of than 35% (FIG. 31). This calculated dose equals 377 mg of 40 the betamethasone PLGA microparticles are shown in the microparticles containing 72 mg of PRED. Table 14. Based on the studies described herein, the Class A corti costeroid microparticle formulations, for example, the pred TABLE 1.4 nisolone microparticle formulations, exhibiting the desired Analytical Results of a Nominal 28.6% Betamethasone release kinetics have the following characteristics: (i) the 45 PLGA 50:50 Microparticle Formulation corticosteroid is between 10%-40% of the microparticle, for example, between 15%-30% of the microparticle; and (ii) the PLGA(lactide: glycolide molar polymer is PLGA having a molecular weight in the range of ratio Incor about 45 to 75 kDa, having an inherent viscosity in the range ratio inherent Drug load poration of 0.35 to 0.5 dL/g, and or having a lactide:glycolide molar 50 viscosity/molecular (% eff- In vitro ratio of 60:40 to 45:55. weight target BETA ciency Particle size release % TCA% PEG by weight) (%) (Dv, Im) (%) Example 7 50:50 22.8 79.7 D0.1:42.1 Im 1 day: 2.0 carboxylic D0.5: 71.7 m 2 day: 3.1 Preparation of Betamethasone PLGA Microparticles 55 acid endcapped D0.9: 102.7 m 3 day: 4.8 0.44 dLig 4 day: 7.7 by Solid in Oil in Water (S/O/W) Emulsion 56 kDa 5 day: 12.5 28.6% BETA 6 day: 21.4 A pharmaceutical depot was prepared comprised of the 7 day: 30.8 9 day: 38.6 corticosteroid, betamethasone (BETA, 9-Fluoro-113, 17.21 11 day: 43.9 trihydroxy-16? 3-methylpregna-1,4-diene-320-dione) incor 60 13 day: 49.6 porated into microparticles in PLGA 50:50. 15 day: 55.5 A formulation was prepared by dissolving approximately 1 18 day: 57.5 gram of PLGA 50:50 (lactide:glycolide molar ratio of 50:50, 21 day: 59.2 24 day: 60.8 inherent viscosity 0.44 dL/g, MW 56 kDa) in 6.67 mL of 27 day: 62.9 dichloromethane (DCM). To the polymer solution, 400 mg of 65 30 day: 72.4 betamethasone was added and Sonicated. Subsequently, the corticosteroid containing dispersion was poured into 200 mL US 8,828,440 B2 55 56 In vitro release profile of the betamethasone PLGA micro samples, nominally 1 g were placed in 22 ml glass vials in particles is shown in FIG. 32. This formulation is suitable for 8-20 ml of 0.5% v/v Tween 20 in 100 mM phosphate buffered a 30 day formulation or greater. saline and stored in a 37°C. incubator with magnetic stirring In one iteration of the in vitro release data, the amount of at 130 rpm. Each test sample was prepared and analyzed in betamethasone released per day was calculated based on a 5 duplicate to monitor possible variability. At each time point in human dose, as exemplified in Table 2, which may achieve a the release study, microparticles were allowed to settle, and temporary Suppression of endogenous cortisol (greater than an aliquot of between 4-16 ml of Supernatant were taken, and 50%) and, within 14 days, achieve cortisol suppression of replaced with an equal volume of fresh 0.5% V/v Tween 20 in endogenous cortisol of less than 35%. This calculated dose 100 mM phosphate buffered saline. Drug load and in vitro equals 111 mg of microparticles containing 25 mg of 10 release samples were analyzed by HPLC using a Hypersil betamethasone. In a seconditeration of these data, the amount C18 column (100 mm, i.d. 5 mm, particle size 5 um; Ther of betamethasone released per day was calculated based on a moFisher) and Beckman HPLC. All samples were run using human dose, as exemplified in Table 2 that would not suppress a sample injection Volume of 5um, and column temperature the HPA axis, i.e. endogenous cortisol Suppression never of 40° C. An isocratic mobile phase of 60% methanol and exceeding 35%. This calculated dose equals 38 mg of micro 15 40% water was used at a flow rate of 1 ml/min, with detection particles containing 9 mg of betamethasone. These doses are at a wavelength of 254 nm. The analytical results of the both graphically represented in FIGS. 33 and 34. fluticasone propionate PLGA microparticles are shown in Based on the studies described herein, the Class C corti Table 15. costeroid microparticle formulations, for example, the betamethasone microparticle formulations, exhibiting the TABLE 1.5 desired release kinetics have the following characteristics: (i) the corticosteroid is between 10%-40% of the microparticle, Analytical Results of a Nominal 16.7% Fluticasone for example, between 15%-30% of the microparticle; and (ii) PLGA 50:50 Microparticle Formulation the polymer is PLGA having a molecular weight in the range PLGA(lactide: of about 40 to 70 kDa, having an inherent viscosity in the 25 glycolide molar range of 0.35 to 0.5 dL/g, and or having a lactide:glycolide ratio Incor molar ratio of 60:40 to 45:55. ratio inherent Drug load poration viscosity/molecular (% eff- In vitro weight target FLUT ciency Particle size release Example 8 96 FLUT by weight) (%) (Dv, Im) (%) 30 Preparation of Fluticasone Propionate PLGA 50:50 8.5 51.1 D0.1: 34.1 Im 1 day: 29.5 carboxylic D0.5: 65.5 m 2 day: 43.5 Microparticles by Solid in Oil in Water (S/O/W) acid endcapped D0.9: 95.0 m 3 day: 46.7 Emulsion 0.45 dLig 4 day: 50.9 66 kDa 5 day: 55.5 A pharmaceutical depot was prepared comprised of the 35 16.7% 6 day: 58.6 FLUT 7 day: 60.1 corticosteroid, fluticasone propionate (FLUT, S-(fluorom 9 day: 63 ethyl) 6C.9-difluoro-11B,17-dihydroxy-16C.-methyl-3- 11 day: 66.8 oxoandrosta-1,4-diene-173-carbothioate, 17-propionate) 13 day: 67.8 incorporated into microparticles in PLGA 50:50. 15 day: 68.7 18 day: 73.7 A formulation was prepared by dissolving approximately 1 40 21 day: 81.8 gram of PLGA 50:50 (lactide:glycolide molar ratio of 50:50, 24 day: 93.7 inherent viscosity 0.45 dL/g, molecular weight 66 kDa) in 26 day: 97.1 6.67 mL of dichloromethane (DCM). To the polymer solu 31 day: tion, 200 mg of fluticasone propionate was added and Soni 100.8 cated. Subsequently, the corticosteroid containing dispersion 45 was poured into 200 mL of 0.3% polyvinyl alcohol (PVA) In vitro release profile of the fluticasone propionate PLGA Solution while homogenizing with a Silverson homogenizer microparticles is shown in FIG. 35. This formulation is suit using a rotor fixed with a Silverson Square Hole High Shear able for a 30 day formulation or greater. ScreenTM, set to spin at 2,000 rpm to form the microparticles. In one iteration of the in vitro release data, the amount of After two minutes, the beaker was removed, and a glass 50 fluticasone propionate released per day was calculated based magnetic stirrer) added to the beaker, which was then placed on a human dose, as exemplified in Table 2, which may onto a multi-way magnetic stirrer and stirred for four hours at achieve a temporary Suppression of endogenous cortisol 300 rpm to evaporate the DCM. The microparticles were then (greater than 50%) and, within 14 days, achieve cortisol Sup washed with 2 liters of distilled water, sieved through a 100 pression of endogenous cortisol of less than 35%. This cal micron screen. The microparticles were then lyophilized for 55 culated dose equals 178 mg of microparticles containing 15 greater than 96 hours and vacuum packed. mg of fluticaSone propionate. In a second iteration of these Particle size of the FLUT incorporated microparticles was data, the amount of fluticasone propionate released per day determined using laser diffraction (Beckman Coulter LS 230) was calculated based on a human dose, as exemplified in by dispersing a 50 mg aliquot in water, with the refractive Table 2 that would not suppress the HPA axis, i.e. endogenous index (RI) for water and PLGA, set at 1.33 and 1.46 respec 60 cortisol suppression never exceeding 35%. This calculated tively. The sample was stirred at the particle size measure dose equals 24 mg of microparticles containing 2 mg of ment measurements taken and the results reported. Drug load fluticasone propionate. These doses are both graphically rep was determined by Suspending a nominal 10 mg of micropar resented in FIGS. 36 and 37. ticles in 8 ml HPLC grade methanol and sonicating for 2 Other fluticasone propionate PLGA depots were formu hours. Samples were then centrifuged at 14,000 g for 15 mins 65 lated in the same manner as described above with different beforean aliquot of the supernatant was assayed via HPLC as PLGA polymers or amounts fluticasone propionate. In one described below. Corticosteroid-loaded microparticle formulation, a PLGA polymer with a higher lactide to gly US 8,828,440 B2 57 58 colide ratio (PLGA 75:25 (ester end-capped PLGA 75:25, 8-20 ml of 0.5% v/v Tween 20 in 100 mM phosphate buffered lactide:glycolide molar ratio of 75:25, 0.58 dL/g, MW 86 saline and stored in a 37°C. incubator with magnetic stirring kDa) was used instead of the PLGA 50:50 as previously at 130 rpm. Each test sample was prepared and analyzed in described. Unlike the triamcinolone acetonide preparations duplicate to monitor possible variability. At each time point in described in Example 5, but typically expected as described in 5 the release study, microparticles were allowed to settle, and the literature, the higher lactide to glycolide ratio resulted in a slower release, where 30% release in 14 days, followed by an aliquot of between 4-16 ml of Supernatant were taken, and a Substantial lag phase where little drug is released for a replaced with an equal volume of fresh 0.5% V/v Tween 20 in minimum of thirty days. In another example, 400 mg of 100 mM phosphate buffered saline. Drug load and in vitro fluticasone propionate instead of 200 mg was used in prepa 10 release samples were analyzed by HPLC using a Hypersil ration of PLGA 50:50 microparticles (target drug load C18 column (100 mm, i.d. 5 mm, particle size 5 um; Ther 28.6%). Unlike triamcinolone acetonide microparticle prepa moFisher) and Beckman HPLC. All samples were run using rations, the higher drug load did not result in a significantly a sample injection Volume of 5um, and column temperature different release of fluticasone propionate; FIG.38 shows the in vitro release of all three fluticasone propionate formula 15 of 40° C. An isocratic mobile phase of 60% methanol and tions. 40% water was used at a flow rate of 1 ml/min, with detection Based on the studies described herein, the Class D corti at a wavelength of 254 nm. The analytical results for the costeroid microparticle formulations, for example, the fluti dexamethasone PLGA microparticles are shown in Table 16. casone or fluticasone propionate microparticle formulations, exhibiting the desired release kinetics have the following TABLE 16 characteristics: (i) the corticosteroid is between 8%-20% of the microparticle, and (ii) the polymer is PLGA having a Analytical Results of a Nominal 28.6% Dexamethasone molecular weight in the range of about 40 to 70 kDa, having PLGA 50:50 Microparticle Formulation an inherent viscosity in the range of 0.35 to 0.5 dI/g, and or 25 PLGA(lactide: having a lactide:glycolide molar ratio of 60:40 to 45:55. glycolide molar ratio Incor Example 9 ratio inherent Drug load poration viscosity/molecular (% eff- In vitro Preparation of Dexamethasone Microparticles by weight target DEX ciency Particle size release Solvent Dispersion in PLGA 30 96 FLUT by weight) (%) (Dv, Im) (%) A pharmaceutical depot was prepared comprised of the 50:50 22.1 77.2 D0.1:41.2 Im 1 day: 2.9 corticosteroid, dexamethasone (DEX, 9-Fluoro-113, 17.21 carboxylic D0.5: 71.9 m 2 day: 4.6 trihydroxy-16C.-methylpregna-1,4-diene-320-dione) incor acid endcapped D0.9: 99.1 m 3 day: 6.3 35 0.45 dLig 4 day: 8.7 porated into microparticles in PLGA 50:50. 66 kDa 5 day: 10.9 A formulation was prepared by dissolving approximately 1 28.6% DEX 6 day: 12.7 gram of PLGA 50:50 (lactide:glycolide molar ratio of 50:50, 7 day: 15.0 inherent viscosity 0.45 dL/g, molecular weight 66 kDa) in 9 day: 16.4 6.67 mL of dichloromethane (DCM). To the polymer solu 11 day: 18.0 40 13 day: 20.7 tion, 200 mg of dexamethasone was added and Sonicated. 15 day: 24.6 Subsequently, the corticosteroid containing dispersion was 18 day: 26.2 poured into 200 mL of 0.3% polyvinyl alcohol (PVA) solution 21 day: 28.1 while homogenizing with a Silverson homogenizer using a 24 day: 30.3 rotor fixed with a Silverson Square Hole High Shear 45 27 day: 34.0 ScreenTM, set to spin at 2,000 rpm to form the microparticles. 30 day: 46.3 After two minutes, the beaker was removed, and a glass magnetic stirrer) added to the beaker, which was then placed onto a multi-way magnetic stirrer and stirred for four hours at In vitro cumulative percent release of the dexamethasone is 50 shown in 39, and results in suitable formulation for a mini 300 rpm to evaporate the DCM. The microparticles were then mum of thirty days and, assuming linear release, likely up to washed with 2 liters of distilled water, sieved through a 100 60 days. micron screen. The microparticles were then lyophilized for greater than 96 hours and vacuum packed. In one iteration of the in vitro release data, the amount of dexamethasone released per day was calculated based on a Particle size of the DEX incorporated microparticles was 55 human dose, as exemplified in Table 2, which may achieve a determined using laser diffraction (Beckman Coulter LS 230) temporary Suppression of endogenous cortisol (greater than by dispersing a 50 mg aliquot in water, with the refractive 50%) and, within 14 days, achieve cortisol suppression of index (RI) for water and PLGA, set at 1.33 and 1.46 respec endogenous cortisol of less than 35%. In a seconditeration of tively. The sample was stirred at the particle size measure 60 these data, the amount of dexamethasone released per day ment measurements taken and the results reported. Drug load was calculated based on a human dose, as exemplified in was determined by Suspending a nominal 10 mg of micropar Table 2 that would not suppress the HPA axis, i.e. endogenous ticles in 8 ml HPLC grade methanol and sonicating for 2 cortisol Suppression never exceeding 35%. In the case of hours. Samples were then centrifuged at 14,000 g for 15 mins dexamethasone, where the data is truncated, both calculated beforean aliquot of the supernatant was assayed via HPLC as 65 human doses are the same; 36 mg of microparticles contain described below. Corticosteroid-loaded microparticle ing 8 mg of dexamethasone. The doses are graphically rep samples, nominally 1 g were placed in 22 ml glass vials in resented in FIG. 40. US 8,828,440 B2 59 60 Example 10 Bioavailability of TCA in the systemic circulation follow ing administration of FX006 was 3-fold lower than that Pharmacology, Pharmacokinetics and Exploratory observed for TCAIR, as shown in Table 18. Safety Study of Corticosteroid Formulations 5 TABLE 1.8 In an exploratory safety study in rats, single intra-articular (IA) doses of TCA immediate release (TCAIR) (0.18 and Bioavailability of TCA in Plasma 1.125 mg) and doses of TCA in 75:25 PLGA formulation microparticles (FX006) (0.28, 0.56 and 1.125 mg (i.e., the 10 Absolute Bioavailability Comparison maximum feasible dose) of TCA) were evaluated. Blood samples were collected at various time points for determina FX006 (0.28 mg) TCAIR (0.18 mg) tion of plasma concentrations. Plasma concentration-time data from this study and pharmacokinetic (PK) analysis 15 F (%) 17.9 58.6 thereofare shown in FIGS. 41-43 and Tables 17-20. As seen in FIGS. 41A-41D, FX006 dosed at 1.125 mg resulted in a very slow absorption of TCA in the systemic For the 0.56 and 1.125 mg dose levels of FX006, apparent circulation and a markedly lower C, as compared to TCA F% were 23.1% and 58.1%, respectively. The IV data in rats IR. 20 shown in Table 19 was used as a reference to calculate F. As shown in Table 17, the mean AUC, values of TCA following 1.125 mg administration of FX006 were 2.1-fold TABLE 19 lower than those observed for TCAIR (i.e., 2856 vs. 6065 ngth/mL, respectively). The mean C. values of TCA fol Pharmacokinetic Parameters of TCA in Rat Plasma. After lowing 1.125 mg administration of FX006 were 15-fold i.V. (50 mg/kg bolus + 23 mg/kg/h Infusion) lower than those observed for TCA IR (i.e., 125 vs. 8.15 25 Administration of Triancinolone Acetonide Phosphate ng/mL, respectively). The absorption of TCA following Parameter Rat 1 Rat 2 Rat 3 Mean SD administration of FX006 was slower than that observed for V (L/kg) O.684 O.856 1.29 O.944 - 0.314 TCAIR, with mean T values observed at 3.33 and 1.00 h. CL (L/h/kg) 1.15 O.790 O.872 O.937 0.188 respectively. The elimination half-life of TCA following 30 k12 (h') 1.64 1.79 1.59 11.67 + 0.102 administration of 1.125 mg FX006 and TCAIR were 451 and k2 (h') 1.04 O.640 1.13 O.937 0.261 107 h, respectively. TABLE 17 Summary of TCA Plasma Pharmacokinetic Parameters Treatment

FXOO6 FXOO6 FXOO6 TCAIR TCAIR 0.28 mg OSO Ing Ll2S ing 0.18 mg Ll2S ing Variable Mean (CV9%) Mean (CV9%) Mean (CV9%) Mean (CV9%) Mean (CV9%) 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) 606S (3.7) (ng himL) AUCo. 335 (66.5) 532 (23.8) 2142 (14.4) 456 (31.3) 6O13 (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) 18O (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) (mL)

The above results suggest a slower distribution and bio TABLE 19-continued availability of TCA in the systemic circulation following Pharmacokinetic Parameters of TCA in Rat Plasma. After administration of FX006 as compared to TCA IR. Without 60 i.V. (50 mg/kg bolus + 23 mg/kg/h Infusion) wishing to be bound by theory, the slower distribution FX006 Administration of Triancinolone Acetonide Phosphate into the systemic circulation may be related to the longer residence time of FX006 at the site of injection. This is sup- Parameter Rat 1 Rat 2 Rat 3 Mean SD ported by the lesser availability of the FX006 microparticle T12 (h) 1.55 3.71 2.87 2.71 - 1.09 formulation in the early “burst' phase, where only 4-9% of 65 f, O.O84 0.11O O.O85 O.093 OO15 product is released, compared to at least 23% of the IR prod from Rojas et al., “Microdialysis of triamcinolone acetonide in rat muscle.”J Pharm Sci uct. 92(2) (2003): 394-397. US 8,828,440 B2 61 62 The initial “burst' (i.e., exposure up to 24 h) accounted for A PK-PD analysis demonstrated that inhibition of corti less than 10% of the total systemic exposure of FX006. The costerone was correlated with systemic TCA levels and fol initial burst accounted for ~23-62% of the total exposure for lowed a classical inhibitory model as shown in FIG. 43. The the TCAIR product, as shown in Table 20. ICso was about 1 ng/mL and the E was achieved at 50-80 ng/mL. TABLE 20 Example 11 Relative Availability of TCA in Plasma Initial Burst vs. Delayed Release Evaluation of Efficacy of Single Doses of TCA Treatment 10 Immediate Release and TCA Microparticle Formulation in Animal Model of Osteoarthritis FXOO6 FXOO6 FXOO6 TCAIR TCAIR (0.28 (0.56 (1.125 (0.18 (1.125 mg) mg) mg) mg) mg) The studies described herein were designed to test and Variable Mean Mean Mean Mean Mean evaluate the efficacy of the corticosteroid microparticle for 15 mulations provided herein as compared to immediate release AUCo. 24 31.0 33.0 136 297 1403 corticosteroid formulations. While the studies herein use (ng himL) AUCo. 356 572 2856 479 606S TCA, it is understood that other corticosteroids, including (ng himL) other Class B corticosteroids, Class A corticosteroids, Class AUC24. 325 539 2720 182 4662 C corticosteroids, and Class D corticosteroids, can be evalu (ng himL) ated using these materials, methods and animal models. %. Initial Burst 8.69 5.76 4.76 62.1 23.1 Efficacy of single intra-articular (IA) doses of FX006 (TCA in 75:25 PLGA formulation microparticles) and TCA In this same study, groups of animals were sacrificed 28 IR (immediate release) was evaluated in a rat model of days after dosing, and the remaining were terminated on Day osteoarthritis of the knee via sensitization and challenge by 42. Body weights were monitored throughout the study and 25 peptidoglycan polysaccharide (PGPS). The model involves key organs (spleen, adrenal glands, thymus) were weighed priming the animals with an intra-articular injection of PGPS upon necropsy. The injected knee and the contralateral con in the right knee. The following day, any animals with no knee trol joints were prepared for histological assessment. Tolui discomfort were eliminated from the test article groups and dine blue stained sections of joints were evaluated for treat placed into the baseline group. Two weeks later, knee inflam ment-related alterations. Histologic changes were described, 30 mation was reactivated by a tail vein injection of PGPS, 2.5 hr wherever possible, according to their distribution, severity, following IA dosing with FX006 or TCA IR at the doses and morphologic character. selected (n=10/group). Differences in weight-bearing and Histological analysis demonstrated the following observa gait (as a measure of joint pain experienced by the animals), tions. First, injected joints from placebo (blank PLGA micro histopathology, plasma PK etc. were evaluated. 35 Doses of FX006 (0.28, 0.12, 0.03 mg) and TCAIR (0.06, spheres)-treated animals had minimal multifocal macroph 0.03 mg) for this study were selected based on data from the age infiltration in associated with 20-130 um diameter study described above in Example 10 and an initial run of the microspheres, whereas none of the active FX006-injected PGPS model in which only TCAIR was evaluated at two IA joints showed the presence of any microspheres at Day 28. dose levels. The goals of the present study were to demon Placebo-treated rat joints had no cartilage or joint changes 40 strate the following: save for the presence of spontaneous cartilage cysts in a few FX006 is efficacious at doses that do not inhibit the HPA joints (1 at Day 28, 2 at Day 42) in the right (injected) knees. aX1S The left knees in the placebo-treated ratjoints were normal. In The duration of efficacy is a function of dose comparison, both knees in the high dose TCAIR and the high FX006 provides more prolonged pain reliefas compared to and mid-dose FX006-groups showed some mild bone mar 45 TCAIR Since only about 10% of the TCA payload is row hypocellularity and growth plate atrophy (dose depen expected to be released from FX006 in the first 24 hr, one dent for FX006). Both knees in the low dose TCA JR and TCAIR dose group (0.03 mg) was chosen to match 10% FX006 animals were normal. Spontaneous cartilage cysts of the TCA in FX006 at a dose of 0.28 mg noted in placebo animals were also noted in all groups dosed Effects of matched doses of FX006 and TCAIR (0.03 mg) with FX006 with no increase in incidence or severity. High 50 The duration of efficacy was assessed by 3 different reac dose TCAIR increased cartilage cysts at Day 42 but not at tivations, 2 weeks apart. After that point, the arthritis Day 28. In general, FX006-treated animals had normal articu observed in the animals becomes more wide-spread making lar cartilage despite the presence of catabolic effects on other the efficacy in the index knee more difficult to assess. joint structures, which was likely more readily observed on At the first reactivation, vehicle treated animals demon account of the young age of the animals. 55 strate painful gait as demonstrated by high pain scores (3.5 Overall, all observed effects of FX006, especially at the out of a maximum of 4 possible) as shown in FIGS. 44A, 44B, high dose. Such as body weight loss and reduced organ and 44C. FX006 at 0.28 mg (squares) showed good efficacy. weights were also seen with TCA IR. The time course of In the previous study described in Example 10, this dose was inhibition of the HPA axis (measured as corticosterone levels) demonstrated to inhibit the HPA axis immediately after dos is shown in FIG. 42. It should be noted that at the lowest dose 60 ing but a return to baseline function was demonstrated by Day of FX006 (0.28 mg; circles) corticosterone levels were ini 14. Interestingly, this dose of FX006 continued to be effica tially inhibited but recovered back to near baseline by Day 14 cious upon the 2" and 3" reactivations on Days 14 and 28 post-dose. Similarly, with TCAIR at the lowest dose (0.18 when the HPA axis function was presumably normal. It mg), corticosterone levels recovered by Day 7 (squares). With should also be noted that since HPA axis function returned to the mid (0.56 mg) and high (1.125 mg) doses of FX006 and 65 baseline by Day 7 at a 0.18 mg dose ofTCAIR in the previous the high dose of TCA IR (1.125 mg), corticosterone levels study described in Example 10, the effects of the doses of were inhibited longer as shown in FIG. 42. TCAIR used in the present study (0.06 and 0.03 mg) were US 8,828,440 B2 63 64 also in the presence of normal HPA axis function following an The duration of efficacy of sustained release of intra-ar initial transient inhibition. Corticosterone measurements ticular corticosteroid microparticle formulations is a from the present study (as an indicator of HPA axis function) function of dose. are presented as change from baseline for each treatment Intra-articular injection of Sustained release corticosteroid group in FIG. 46. As demonstrated from these data, corticos microparticle formulations slows, arrests, reverses, or terone levels for all groups recovered by Day 14; hence the otherwise inhibits structural damage to tissues caused by goal of prolonged efficacy with FX006 in the presence of inflammation. normal HPA axis function was achieved. Although particular embodiments have been disclosed Overall, a clear dose-dependence of response was noted for herein in detail, this has been done by way of example for both FX006 and TCAIR. Also, if less than 10% of this dose 10 is available by the day after dosing (Day 1), it should be noted purposes of illustration only, and is not intended to be limiting in FIG. 44B that the efficacy of FX006 at 0.28 mg (squares) is with respect to the scope of the appended claims, which greater than TCAIR at 0.03 mg (triangles) at all evaluations. follow. In particular, it is contemplated by the inventors that Further, the duration of efficacy of TCA (both FX006 and IR) various Substitutions, alterations, and modifications may be appears to be a function of dose, however, the prolonged 15 made to the invention without departing from the spirit and release of TCA from the PLGA microspheres in FX006 scope of the invention as defined by the claims. Other aspects, results in more Sustained efficacy. This is more clearly advantages, and modifications are considered to be within the depicted in another representation of the data in FIG. 45 in Scope of the following claims. The claims presented are rep which peak response for each dose as determined by gait/pain resentative of the inventions disclosed herein. Other, scores on Day 1 following each reactivation (Days 1, 15 and unclaimed inventions are also contemplated. Applicants 29) are plotted. FIG. 46 plots the time course of corticosterone reserve the right to pursue such inventions in later claims. recovery for all study groups. On balance, across all groups that received the corticosteroid, there was recovery. What is claimed is: Plasma levels of TCA were measured in samples taken 1. An injectable formulation comprising (a) controlled- or from all rats at baseline (Day -4), Days 0 (2 hr post dosing), 25 Sustained-release microparticles comprising triamcinolone 1, 3, 8, 14, 17, 21, 28, and 31. Concentration-time curves for acetonide (TCA) or a pharmaceutically-acceptable salt all treatment groups are shown in FIG. 47A. FIG. 47B shows thereof and a poly(lactic-co-glycolic) acid copolymer only the FX006 dose groups on a larger scale since maximal (PLGA) matrix, wherein the TCA comprises between 22% to plasma concentrations with FX006 were far lower than those 28% of the microparticles and wherein the PLGA has the with TCAIR 30 following characteristics: (i) a molecular weight in the range Histopathological evaluation of the knees taken from all of about 40 to 70 kDa; and (ii) a lactic acid:glycolic acid animals at the end of the study (Day 32 at the end of the 3' molar ratio of 80:20 to 60:40, and wherein the TCA is reactivation of arthritis) demonstrated Statistically significant released for between at least 14 days and 90 days upon admin improvement by FX006 at the high and mid-range doses istration to a joint. (0.28 and 0.12 mg) in the composite histological score and 35 2. The formulation of claim 1, wherein the PLGA copoly each component score (inflammation, pannus, cartilage dam mer has a molar ratio of lactic acid:glycolic acid of 75:25. age and bone resorption) as shown in FIG. 48. As described 3. The formulation of claim 1, wherein the microparticles above, the dose of 0.28 mg FX006 demonstrated strong effi further comprise a polyethylene glycol (PEG) moiety, cacy (i.e. analgesic activity) throughout all 3 reactivations, wherein the PEG moiety comprises between 25% to 0% whereas the dose of 0.12 mg was active but to a lesser degree 40 weight percent of the microparticle. through all 3 reactivations. At the doses of TCAIR used, the 4. The formulation of claim 1, wherein the 22% to 28% of duration of efficacy was mostly through the first reactivation TCA in the microparticles comprises a total TCA load dose of arthritis, with partial efficacy of the higher (0.06 mg) dose between 10 to 50 mg. in the second reactivation, and this also translated into a much 5. The formulation of claim 1, wherein the lactic acid Smaller non-significant improvement in histological scores. 45 glycolic acid copolymer has an inherent viscosity in the range Importantly, these data demonstrate that TCA has no delete of 0.3 to 0.5 dL/g. rious effect on cartilage and as has been described in other 6. An injectable formulation comprising (a) controlled- or settings, it actually reduces cartilage damage in an inflamma Sustained-release microparticles comprising triamcinolone tory milieu. acetonide (TCA) or a pharmaceutically-acceptable salt In conclusion, the prolonged residence of TCA in the joint 50 thereof and a poly(lactic-co-glycolic) acid copolymer upon IA dosing with FX006 resulted in extending the dura (PLGA) matrix, wherein the TCA comprises between 22% to tion of efficacy in the rat PGPS model of arthritis with a 28% of the microparticles, wherein the microparticles have a significant histological improvement in inflammation, pan mean diameter of between 10 um to 100 um, and wherein the nus formation, cartilage damage and bone resorption. FX006 PLGA has the following characteristics: (i) a molecular had these effects without inhibiting HPA axis function as 55 weight in the range of about 40 to 70 kDa; and (ii) a lactic demonstrated by the return to baseline of corticosterone lev acid:glycolic acid molar ratio of 80:20 to 60:40, wherein the els within 14 days after dosing. The clinical implications for TCA is released for between at least 14 days and 90 days upon the treatment of patients with osteoarthritis, rheumatoid administration to a joint. arthritis and other inflammatory joint disorders areas follows: 7. The formulation of claim 6, wherein the PLGA copoly Intra-articular injection of Sustained release corticosteroid 60 mer has a molar ratio of lactic acid:glycolic acid of 75:25. microparticle formulations provides prolonged pain 8. The formulation of claim 6, wherein the microparticles relief relative to intra-articular injection of immediate further comprise a polyethylene glycol (PEG) moiety, release steroids. wherein the PEG moiety comprises between 25% to 0% Intra-articular injection of Sustained release corticosteroid weight percent of the microparticle. microparticle formulations is efficacious in reducing 65 9. The formulation of claim 6, wherein the 22 to 28% of pain and inflammation at doses that do not inhibit the TCA in the microparticles comprises a total TCA load dose HPA axis. between 10 to 50 mg. US 8,828,440 B2 65 66 10. The formulation of claim 6, wherein the lactic acid glycolic acid copolymer has an inherent viscosity in the range of 0.3 to 0.5 dL/g.