UNI SYDNEY LOGO INHALED ANTI-TUBERCULAR THERAPY: DRY POWDER FORMULATIONS, DEVICE AND TOXICITY CHALLENGES Thaigarajan Parumasivam A thesis submitted in fulfillment of the requirements for the degree of Doctor of Philosophy Faculty of Pharmacy The University of Sydney 2017 STATEMENT OF AUTHENTICITY This thesis is submitted to the University of Sydney in fulfilment of the requirements for the Degree of Doctor of Philosophy. The work described was carried out in the Faculty of Pharmacy and Centenary Institute under the supervision of Professor Hak-Kim Chan and Professor Warwick Britton The work presented in this thesis, is to the best of my knowledge and belief, original except as acknowledged in the text. The contributions of all co-authors in publications included in the body of the thesis have been declared, signed by each co-author and attached as an appendix. I hereby declare that I have not previously or concurrently submitted this material, either in full or in part, for a degree at this or any other institution. Thaigarajan Parumasivam Oct 2016 ii CONTENTS Acknowledgement ................................................................................................................. viii Glossary .................................................................................................................................... x Thesis abstract .......................................................................................................................... 1 Chapter 1 ........................................................................................................................ 1 Chapter 2 ........................................................................................................................ 1 Chapter 3 ........................................................................................................................ 2 Chapter 4 ........................................................................................................................ 3 Chapter 5 ........................................................................................................................ 4 Chapter 6 ........................................................................................................................ 5 Chapter 7 ........................................................................................................................ 6 Introduction .............................................................................................................................. 7 Objectives and aims ..................................................................................................... 10 Chapter 1: Dry powder inhalable formulations for anti-tubercular therapy .................. 14 Abstract ........................................................................................................................ 15 1. Introduction .............................................................................................................. 16 2. Powder formulation approaches using particle engineering techniques .................. 20 2.1 Formulations by spray drying .................................................................... 35 2.1.1 Capreomycin sulphate ................................................................. 36 2.1.2 Rifamycins (rifampicin and rifapentine) ..................................... 37 2.1.3 Para-aminosalicylic acid (PAS) .................................................. 39 2.1.4 Pretomanid (PA-824) .................................................................. 40 iii 2.1.5 Isoniazid ...................................................................................... 41 2.1.6 Combination formulations .......................................................... 41 2.1.7 Vaccine candidates...................................................................... 42 2.1.8 Bacteriophage formulations ........................................................ 43 2.2 Formulations by freeze drying and spray freeze drying ............................ 46 2.3 Formulations by supercritical fluid precipitation ....................................... 47 3. Other inhalable dry powder production approaches ................................................ 48 3.1 Liposomal formulations ............................................................................. 48 3.2 Polymeric formulations .............................................................................. 50 4. Dry powder delivery devices ................................................................................... 53 5. Pre-clinical and clinical trial evaluations of inhaled TB drug powders ................... 57 5.1 In vitro studies............................................................................................ 57 5.2 In vivo studies ............................................................................................ 58 5.3 Clinical trial ............................................................................................... 60 6. Risk related to inhaled regimen in the treatment of TB ........................................... 61 7. Expert opinion on future development .................................................................... 64 8. Conclusions .............................................................................................................. 66 Acknowledgement ....................................................................................................... 67 References .................................................................................................................... 68 Chapter 2: In vitro evaluation of inhalable verapamil-rifapentine particles for tuberculosis therapy ............................................................................................................. 83 Abstract ........................................................................................................................ 84 1. Introduction .............................................................................................................. 85 2. Materials and methods ............................................................................................. 89 3. Results ...................................................................................................................... 98 iv 4. Discussion .............................................................................................................. 117 5. Conclusion ............................................................................................................. 122 Acknowledgement ..................................................................................................... 123 References .................................................................................................................. 124 Chapter 3: In vitro evaluation of novel inhalable dry powders consisting of thioridazine and rifapentine for rapid tuberculosis treatment ............................................................ 128 Abstract ...................................................................................................................... 129 1. Introduction ............................................................................................................ 130 2. Materials and methods ........................................................................................... 134 3. Results .................................................................................................................... 142 4. Discussion .............................................................................................................. 156 5. Conclusion ............................................................................................................. 161 Acknowledgement ..................................................................................................... 162 References .................................................................................................................. 163 Chapter 4: Rifapentine-loaded PLGA microparticles for tuberculosis inhaled therapy: preparation and in vitro aerosol characterisation ............................................................. 167 Abstract ...................................................................................................................... 168 1. Introduction ............................................................................................................ 169 2. Materials and methods ........................................................................................... 172 3. Results and discussion .......................................................................................... 182 4. Conclusion ............................................................................................................. 203 Acknowledgement ..................................................................................................... 204 References .................................................................................................................. 205 v Chapter 5: The delivery of high dose dry powder antibiotics by a low-cost generic inhaler ................................................................................................................................................ 209 Abstract .....................................................................................................................