Ophthalmic composition for use for the prevention and treatment of eye infection and inflammation

Abstract

The present invention relates to an ophthalmic composition in the form of an aqueous solution containing levofloxacin or salt or derivative thereof and ketorolac or salt or derivative. The present invention relates to an ophthalmic composition in the form of an aqueous solution containing levofloxacin or salt or derivative thereof and ketorolac or salt or derivative thereof, for use in a method for the treatment of conjunctivitis and for the prevention or treatment of inflammation or prevention of infection after cataract surgery in a subject, according to a dosage regimen that improves patient compliance and tolerability and enables the prevention and treatment of intermediate / antibiotic-resistant infections.

Description

[0001] OPHTHALMIC COMPOSITION FOR USE FOR THE PREVENTION AND TREATMENT OF EYE INFECTION AND INFLAMMATION

[0002] TECHNICAL FIELD OF THE INVENTION

[0003] The present invention relates to an ophthalmic composition comprising a therapeutically effective amount of levofloxacin or a pharmaceutically acceptable salt or derivative thereof and a therapeutically effective amount of ketorolac or a pharmaceutically acceptable salt or derivative thereof for the prevention or treatment of ocular infections. More specifically, the invention relates to a fixed-dose levofloxacin-ketorolac dosage regimen that is improved in terms of patient compliance and particularly effective in treating conjunctivitis caused by bacteria resistant to the antibiotic levofloxacin, and in preventing and treating inflammation and infections associated with cataract surgery.

[0004] BACKROUND OF THE INVENTION

[0005] Eye infections can be superficial (conjunctivitis) or deep (keratitis) and require the use of antibiotics, anti-inflammatories and sometimes analgesics.

[0006] Conjunctivitis is a well-known eye disease that involves redness, purulent secretions and swelling due to infection of the external tissues of the eye district. These manifestations determine a painful symptomatology of burning that in severe cases can last several days, even in the presence of pharmacological treatments. Conjunctivitis is associated with infections which can be either bacterial or viral, and the severity of this pathology ranges from mild to very serious.

[0007] Conjunctivitis affects many people and imposes economic and social burdens. Bacterial conjunctivitis is responsible approximately for 32% of acute infectious conjunctivitis cases in adult patients who presented to their general practitioner (GP) with a red eye and either mucopurulent discharge or glued eyelids. Acute bacterial conjunctivitis is characterized by a rapid onset of conjunctival redness (hyperaemia), purulent or mucopurulent discharge and chemosis, as most classical signs.

[0008] The clinical presentation is often nonspecific and there is a cross-over between conjunctivitis symptoms of different aetiologies. A diagnosis of bacterial conjunctivitis can be further supported by positive bacterial culture results, which allow to identify the pathogenic bacterial species. However, obtaining conjunctival cultures is neither recommended as a routine practice nor common in normal clinical practice. Thus, topical antibiotic treatment usually starts after the clinical diagnosis of bacterial conjunctivitis. Controlled clinical studies have shown that topical antibiotic treatment has a greater efficacy than placebo, reduces the duration of the disease and is more effective in patients who have positive bacterial culture results.

[0009] Cataract is an ocular condition that causes vision impairment due to changes in the opacity of the ocular lens. Cataract is an age-related condition, and lens opacification is negatively influenced by smoking, ocular trauma, exposure to ultraviolet light, diabetes, and drug-induced metabolic changes.

[0010] The only cure for cataract is a surgical procedure, particularly phacoemulsification with intraocular lens implantation, requiring a small (3 mm or less) corneal incision.

[0011] Although surgical success is common in patients who receive cataract surgery, complications can still develop. The complications after cataract surgery include intraocular inflammation, corneal trauma, and ocular dryness, which can result in ocular irritation during the recovery period. Intraocular inflammation may derive by the intraoperative damage of ocular structure and occurs in nearly all ocular surgeries [Aptel et al., 2017], If left untreated, the intraocular inflammation may cause cystoid macular oedema and visual loss [Donnenfeld et al., 2023],

[0012] A sight-threatening complication that may occur following any intraocular procedure, including cataract surgery, is infectious endophthalmitis [Lee et al., 2025], Most cases of bacterial endophthalmitis are caused by Gram-positive bacteria, such as S. epidermidis and S. aureus.

[0013] The persistence of surgical corneal lesion and repair times may impact the postoperative endophthalmitis rate, and an antibiotic treatment after the surgery is needed to prevent the passage of pathogens into the anterior chamber through the surgical incision until its complete closure. To increase the efficacy of this treatment, a broad antibacterial spectrum antibiotic together with an agent able to reduce inflammation should be chosen.

[0014] In clinical practice a treatment to prevent any infectious complications, like endophthalmitis, due to the incision in the cornea, is widely applied before, during and after cataract surgery.

[0015] Among the classes of antibiotics available for ophthalmic use, fluoroquinolones feature a broad spectrum of action that includes both the Gram-positive and Gram-negative bacteria that are most frequently responsible for ocular infections.

[0016] Levofloxacin is a fluoroquinolone antibiotic. It has a molecular weight of 361.4 g / mol and is poorly soluble in water, but sufficiently lipophilic to penetrate the eyes. Levofloxacin has a broad spectrum of activity and a fairly long duration of action. Recent studies showed that it remains in the eye at levels above the minimum inhibitory concentration (MIC) for more than six hours. The dosage of levofloxacin (as hemihydrate form) eye drops currently on the market (Oftaquix® by Santen) generally involves the administration of a 0.5% solution in an amount of one to two drops 8 times a day approximately every 2 hours while awake, on days 1 and 2, and thereafter, one to two drops 4 times a day approximately every 4 hours while awake on days 3-5.

[0017] In patients affected by conjunctivitis or by inflammation or at risk of infectious complications such as after cataract surgery, the ophthalmologists generally prescribe a fixed dose combination (FDC). Currently, the only fixed dose combination available on the market are those comprising an antibiotic and a corticosteroid, such as TobraDex® by Alcon containing tobramycin and dexamethasone and Blephamide® by Allergan containing sulfacetamide sodium and prednisolone acetate.

[0018] However, in case of ocular infection such as conjunctivitis, the administration of a combination comprising an antibiotic and a corticosteroid can lead to significant risks in case of viral conjunctivitis, due to suppressive effect of the corticosteroid on the immune system, ranging from worsening of symptoms up to permanent damages. Considering that the conjunctival swab for confirmation of the bacterial aetiology of the conjunctivitis is not routinely done and that, when performed, it is confirmed in only 50% of cases, the combination of a nonsteroidal anti-inflammatory drug with an antibiotic may be a valid alternative in the treatment of conjunctivitis, by avoiding the use of the corticosteroid.

[0019] On the other side, in case of cataract surgery, the administration of a combination comprising an antibiotic and a corticosteroid can be linked to potential side effects, recognized to be associated to steroids, such as: risk of increasing IOP, delay in healing the surgical wound and increased susceptibility to microbial infection.

[0020] There are several non-steroidal anti-inflammatory drugs used in the prevention and treatment of eye-inflammation, with a greater or lesser pain-relieving ability, but none except ketorolac possess a strong analgesic effect that acts centrally at the level of neural pathways of pain perception, which is particularly beneficial since the eye is a highly innervated tissue.

[0021] Ketorolac is a molecule belonging to the category of NSAIDs, non-steroidal antiinflammatory drugs, and is generally used in salified form with trometamol. Ketorolac trometamol is a white or almost white crystalline powder with a molecular weight of 376.4 g / mol. Its solubility profile shows a pH dependent trend, significantly increasing at pH value > 6.0.

[0022] W02022 / 096702 discloses a stable ophthalmic composition for ophthalmic administration comprising levofloxacin or salt thereof and ketorolac or salt thereof, which remains stable upon storage for extended periods of time while preserving the physicochemical properties of the active ingredients. Furthermore, a process for the preparation of the ophthalmic composition is also described.

[0023] Thus, there still exists a need to provide an effective fixed-dose ophthalmic combination against conjunctivitis with improved patient compliance that also prevents the triggering of antibiotic resistance due to prolonged treatment. There still exists also a need to provide an effective fixed-dose ophthalmic combination to be used after cataract surgery, characterized by better tolerability and specific pharmacological effect not exerted by fixed-dose combination with steroids: analgesic effect and more effective prevention of cystoid macular oedema.

[0024] SUMMARY OF THE INVENTION

[0025] It is therefore an object of the present invention to provide a pharmaceutical composition for ophthalmic administration containing levofloxacin or pharmaceutically acceptable salt or derivative thereof, and ketorolac or a pharmaceutically acceptable salt or derivative thereof for the treatment of ocular infections, especially conjunctivitis, and for the prevention or treatment of inflammation or infections occurring after cataract surgery, which overcomes the deficiencies of the prior art.

[0026] It is another object of the present invention to provide a fixed-dose ophthalmic combination containing levofloxacin or a pharmaceutically acceptable salt or derivative thereof, as a first active ingredient, and ketorolac or a pharmaceutically acceptable salt or derivative thereof, as a second active ingredient, for the treatment of conjunctivitis and for the treatment or prevention of inflammation or infections associated with cataract surgery, which is safe and effective and prevents the triggering of antibiotic resistance.

[0027] In accordance with the above objects, the present invention provides an ophthalmic composition, preferably in the form of an aqueous solution, comprising a 0.4% to 0.9% w / v, preferably 0.5% w / v of levofloxacin or a pharmaceutically acceptable salt or derivative thereof, and 0.4% to 0.9% w / v, preferably 0.5% w / v of ketorolac or a pharmaceutically acceptable salt or derivative thereof, for use in a method for the treatment of conjunctivitis and for the treatment and prevention of inflammation or infection after cataract surgery in a subject, wherein said method comprises ocular topical administration of said ophthalmic composition to the affected eye four times a day.

[0028] Further preferred embodiments of the present invention are disclosed in the dependent claims.

[0029] Other objects and advantages of the present invention will become apparent to those skilled in the art in view of the following detailed description. BRIEF DESCRIPTION OF THE DRAWINGS

[0030] Fig. 1(A) and Fig. 1(B) show graphical representation of the results of Table 2 of the present invention.

[0031] Fig. 2 shows graphical representation of the results of Table 4 of the present invention.

[0032] Fig. 3 shows graphical representation of the results of Table 5 of the present invention.

[0033] DETAILED DESCRIPTION OF THE INVENTION

[0034] Aim of the present invention was the development of an ophthalmic composition comprising a combination of levofloxacin or salt or derivative thereof and ketorolac or salt or derivative thereof, to be administered according to a dosage regimen ensuring patient compliance and convenience in the treatment and prevention of eye infection and / or inflammation. Under this scope, several different ophthalmic solutions were prepared and studied for the treatment of conjunctivitis and for the treatment and prevention of inflammation or infection after cataract surgery. It was surprisingly found that an ophthalmic composition comprising levofloxacin or salt or derivative thereof and ketorolac or salt or derivative thereof can be effectively used in the treatment of conjunctivitis according to a dosage regimen which (i) is effective in the treatment of conjunctivitis of bacterial origin, possibly caused by an underlying viral infection, or in the treatment or prevention of inflammation or bacterial infection after cataract surgery, (ii) improves patient compliance and tolerability, thereby ensuring maximum therapeutic efficacy, and (iii) enables treating infections caused by pathogens resistant to levofloxacin.

[0035] Accordingly, the invention provides an ophthalmic composition comprising 0.4% to 0.9% w / v of levofloxacin or a pharmaceutically acceptable salt or derivative thereof, and 0.4% to 0.9% w / v of ketorolac or a pharmaceutically acceptable salt or derivative thereof, for use in a method for the treatment of conjunctivitis in a subject, or for the prevention or treatment of inflammation or prevention of bacterial infection after cataract surgery in a subject, wherein said method comprises ocular topical administration of said ophthalmic composition to the affected eye four times a day.

[0036] In preferred and independent embodiments, the ophthalmic composition comprises 0.5%w / v of levofloxacin or a pharmaceutically acceptable salt or derivative thereof, and 0.5%w / v of ketorolac or a pharmaceutically acceptable salt or derivative thereof.

[0037] In further preferred and independent embodiments of the invention, levofloxacin is levofloxacin hemihydrate and ketorolac salt is ketorolac trometamol.

[0038] In a further preferred embodiment, the ophthalmic composition is in the form of an aqueous solution. Preferably, the ophthalmic composition for use according to the present invention is in the form of eye drops or eyewash; said composition has a pH ranging from 7.5 to 8.5, preferably 7.7 to 8.3, more preferably 7.9 to 8.3. Furthermore, the composition may contain one or more excipients selected from preservatives, pH adjusting agents, pH buffers, solubilizing agents, chelating agents, tonicity agents and solvents or combination thereof. The ophthalmic composition and its method of preparation are disclosed in W02022 / 096702, which is herein incorporated by reference (see in particular Example 1, Table 1; Example 2, Table 3 (Composition 2); Example 3, Table 4 (Composition 3, 3a or 3b); Example 4, Table 7 (Composition 4); or Example 5, Table 9 (Composition 5)).

[0039] In a preferred embodiment of the invention, a dosage unit of the ophthalmic composition delivers to the affected eye an amount of 60mcg to 630mcg, preferably 104mcg to 288mcg, more preferably 150mcg of levofloxacin or a pharmaceutically acceptable salt or derivative thereof, and an amount of 60mcg to 630mcg, preferably 104mcg to 288mcg, more preferably 150mcg of ketorolac or a pharmaceutically acceptable salt or derivative thereof. Preferably, the ophthalmic composition delivers equal amounts of levofloxacin and ketorolac, or of their salts or derivatives. The indicated amounts of levofloxacin and ketorolac, salts or derivative thereof, are delivered to the affected eye four times a day.

[0040] In a preferred alternative embodiment, the ophthalmic composition is in the form of an aqueous solution and it is used in a method for the treatment of conjunctivitis in a subject, or for the treatment or prevention of inflammation or prevention of infection after cataract surgery in a subject, which comprises ocular topical administration of 1 drop to the affected eye 4 times daily of said ophthalmic composition.

[0041] In a more preferred embodiment, said drop has a volume between about 15 - 70pl, preferably about 26-32 pl, more preferably about 30 pl.

[0042] According to the invention, the four administrations of the ophthalmic composition are preferably uniformly distributed across the day, that is, one administration approximately every 4 hours while awake, but shorter or longer intervals are also possible. In another preferred embodiment, the therapeutic treatment has a duration of 5 to 7 days, more preferably 5 days for treatment of conjunctivitis and 7 days for prevention or treatment of inflammation or prevention of infection after cataract surgery.

[0043] In another preferred embodiment, the conjunctivitis is caused by bacteria resistant to treatment with levofloxacin. The bacterial infection may result from a previous or concomitant viral infection.

[0044] In another preferred embodiment, said bacteria show intermediate or total resistance to the antibiotic levofloxacin.

[0045] The term "Intermediate resistance" means that the treatment, in order to be effective, requires an increase in the antibiotic dosage from the amount initially intended; and the term "total resistance" means that the antibiotic is not effective at any dosage.

[0046] To assess the efficacy and tolerability of an ophthalmic composition comprising levofloxacin and ketorolac in the treatment of bacterial conjunctivitis in adults, a multicentre, randomized, blinded-assessor, parallel-group, clinical phase II study was conducted.

[0047] In said clinical study the non-inferiority of the treatment based on an ophthalmic composition according to the present invention (fixed dose combination of levofloxacin and ketorolac composition) was evaluated versus a standard treatment (levofloxacin alone composition).

[0048] A fixed-dose ophthalmic solution comprising 0.5% w / v levofloxacin and 0.5% w / v ketorolac trometamol was dropwise administered to the eye of the patients, using a range drop volume of 26-32 pl. The ophthalmic solution further comprised the following inactive excipients: sodium chloride as tonicity agent; disodium EDTA as chelating agent; benzalkonium chloride as preservative; sodium hydroxide or hydrochloric acid to adjust the pH value, and water for injection.

[0049] The tested combination is shown in Table A below and it was prepared according to the method described in W02022 / 096702, in the name of the same applicants, the content of which is incorporated herein by reference.

[0050] Table A: Fixed-dose composition of the present invention containing 0.5% levofloxacin and 0.5% ketorolac trometamol

[0051] The dosage regimen investigated for the ophthalmic composition is one drop 4 times daily for 5 days, which is lower and simpler in terms of antibiotic content than the current treatment approved in Europe for levofloxacin alone, i.e., one to two drops 8 times daily for the first two days and one to two drop 4 times daily on days 3 through 5.

[0052] In patients with clinical diagnosis of bacterial conjunctivitis or of inflammation or at risk of infection after cataract surgery, and in the presence of moderate / severe signs and symptoms requiring an effective antibiotic treatment and an anti-inflammatory treatment for rapid symptomatic improvement, the use of a fixed-dose combination of levofloxacin and ketorolac trometamol according to the present invention, compared with levofloxacin alone, lead to a substantial simplification of the therapeutic regimen, with an improvement in patient compliance, a more rapid and complete resolution of signs and symptoms, and a high rate of microbiological eradication. The fixed-dose combination of levofloxacin and ketorolac according to the present invention treatment, containing a lower dose of levofloxacin, has the further advantage to reduce the bacterial resistance which affects the whole population.

[0053] The main purpose of the Phase II study was to obtain a first evidence-based microbiological confirmation of the efficacy of the fixed-dose combination of the present invention, that is, to verify whether the reduced dose of levofloxacin administered with fixed- dose combination of the present invention was at least as effective as a higher dose of levofloxacin administered alone and whether or not the presence of ketorolac trometamol could have an influence in vivo on the antibacterial activity of levofloxacin.

[0054] Additional purposes of the Phase II study were to explore the efficacy of the fixed-dose combination of the present invention on signs and symptoms of bacterial conjunctivitis and to collect data to estimate study feasibility in terms of patient recruitment and safety and acceptability of the study drug.

[0055] Moreover, in this study, a new method of clinical evaluation of the affected eye through photographs was implemented to continuously monitor the clinical course of bacterial conjunctivitis remotely.

[0056] In the controlled clinical trial, the ophthalmic composition comprising levofloxacin and ketorolac was shown to completely (100%) eradicate sensitive to levofloxacin pathogens compared to levofloxacin alone, which showed lower efficacy (90.74%). In addition, the levofloxacin antibiotic was able to eradicate even the entirety (100%) of intermediate / antibiotic-resistant levofloxacin pathogens by effectively treating all patients with these pathogens. These results were made possible through the identification of a specific dosage regimen that not only increases the effectiveness of treatment in eradicating the pathogens responsible for bacterial conjunctivitis, but also improves patient compliance and contributes to decreasing the development of bacterial resistance. In fact, patients resolve the disease condition with a lower dosage compared to current levofloxacin-based treatments, thus reducing their exposure to the antibiotic.

[0057] The invention is further illustrated by the following examples.

[0058] EXAMPLES

[0059] 1. Clinical study protocol

[0060] 252 patients with clinical diagnosis of acute bacterial conjunctivitis with moderate to severe signs and symptoms were selected for the clinical study. The patients were randomized in a 1 : 1 ratio to one of the following two treatment groups:

[0061] First group: treatment with eye drops of a fixed-dose combination of levofloxacin and ketorolac trometamol according to the present invention, 1 drop 4 times a day on days 1-5.

[0062] Second group: treatment with Oftaquix® 5 mg / ml eye drops solution, 1 drop 8 times a day on days 1 and 2, and 1 drop 4 times a day on days 3-5.

[0063] A total of one hundred twenty-five (125) patients were randomized and assigned to the first group treated with levofloxacin + ketorolac trometamol of the present invention and 127 to the second group treated with levofloxacin alone. Out of the 252 randomized patients, 2 patients were not treated (both said patients were randomized to receive levofloxacin alone). Of the two hundred fifty (250) patients that were treated, two hundred forty (240) patients completed the treatment (119 randomized to the first group and 121 to second group), and 10 patients discontinued the treatment (6 in the first group and 4 in the second group). Overall, 239 patients completed the study (118 randomized to first group and 121 to second group), while 13 discontinued the study.

[0064] Patient population consisted of both males and females, with an average age of 52 years. All patients performed the baseline (first visit) assessment of cardinal signs of bacterial conjunctivitis through an ocular visit. Three cardinal signs were considered: “conjunctival discharge”, “bulbar conjunctival injection”, and “palpebral conjunctival injection”. Further, all patients performed the baseline (first visit) bacteriological culture, and all reported at least one isolated pathogenic bacterial species, and at least one bacterial species that was susceptible to levofloxacin.

[0065] The fixed-dose ophthalmic composition (eye drops) according to the present invention used in the first group of said clinical study (see Table A) comprises 0.5% w / v levofloxacin and 0.5% w / v ketorolac trometamol. Said composition further contains the following inactive excipients: sodium chloride as tonicity agent; disodium EDTA as chelating agent; benzalkonium chloride as preservative (approximately 0.1 Omg benzalkonium chloride in 1 mL eye drop); sodium hydroxide or hydrochloric acid to adjust the pH value, and water for injection and with a pH 7.7 to 8.3.Oftaquix® 5 mg / ml eye drops solution used in the second group of the clinical study contains 0.5% Levofloxacin, approximately 0.05mg benzalkonium chloride in 1 mL eye drop, sodium chloride, sodium hydroxide or Hydrochloric acid and water for injection.

[0066] 2. Microbiological eradication endpoints

[0067] The primary objective of the study was to demonstrate the non-inferiority of the levofloxacin-ketorolac combination of the present invention compared with levofloxacin alone in the microbiological eradication of levofloxacin-sensitive bacteria per patient.

[0068] In order to evaluate the primary efficacy endpoint, the Microbiological eradication rate of levofloxacin-sensitive bacteria, assessed per individual patient, was considered in terms of proportion of patients with microbiological eradication (i.e., reduced or no growth of microorganisms) at the last visit of levofloxacin-sensitive bacteria identified during the initial visit (baseline).

[0069] The terms and definitions used to classify bacteriological culture outcomes are described in Table 1 according to the criteria described by Hwang's research group in 2003.

[0070] Table 1 - Scoring description for microbiological eradication degree of Levofloxacinsensitive bacteria, eradicated / re solved case.

[0071] Microbiological eradication was defined as a bacteriological culture outcome at final visit equal to “Resolved - Absence of baseline organisms, no growth” or “Improved-Reduction below pathogenic criteria” for all the pathogens identified at baseline (first visit); patients without bacteriological outcome assessment at final visit were considered as failures (i.e. Unresolved) for what concerns the microbiological eradication. If at least one pathogenic bacterial species sensitive to Levofloxacin was detected, the bacteriological culture should be considered positive. Note that bacterial organisms that are part of the normal ocular microbiota should be considered pathogenic only if detected at concentrations greater than or equal to predefined threshold values based on colony-forming unit counts [CFU],

[0072] The results of microbiological eradication rate of susceptible to levofloxacin pathogens for the patients analysed are shown in Table 2 below and Fig. 1(A) and Fig. 1(B).

[0073] All 53 patients analyzed (100%) in the first group of levofloxacin-ketorolac according to the present invention achieved pathogen eradication compared with 50 patients (92.59%) in the second group of levofloxacin alone. Furthermore, out of the 54 patients analyzed in second group, one showed a reduction below pathogenic criteria (‘improved’) and 4 patients did not show any change.

[0074] According to the study design, non-inferiority was to be met if the 95% Confidence Interval (CI) of the difference between the proportion of patients with microbiological eradication in the first group and the second group did not cross the predefined non-inferiority margin d = -0.15 and lied entirely to the right of the margin.

[0075] The difference between these proportions (i.e., per-patient microbiological eradication rates) in the first group versus the second group was 0.0741 (95% CI 0.0042; 0.1439). The non-inferiority of the first group versus the second group was met, as the 95% CI did not cross the non-inferiority margin of 0.15. Furthermore, as the 95% CI was entirely above zero, also the superiority of the first group versus the second group was met.

[0076] Therefore, the fixed-dose combination of levofloxacin-ketorolac of the present invention demonstrated superiority to levofloxacin alone in microbiological eradication of levofloxacin-susceptible pathogenic bacteria detected at baseline (first visit).

[0077] Table 2 - Results of microbiological eradication rate of levofloxacin-susceptible pathogens in patients; comparison between levofloxacin-ketorolac of the present invention (first group) and levofloxacin alone (second group). In order to consider the most unfavorable conditions, a further analysis was conducted in which the classification of bacterial culture outcome was considered successful only in the case of complete absence of microorganisms. This different classification is described in Table 3.

[0078] Table 3 - Description of the most unfavorable scoring for the degree of microbiological eradication of levofloxacin-susceptible bacteria, "complete / not complete" case. Complete microbiological eradication was defined as a bacteriological culture outcome at final visit equal to “Resolved - Absence of baseline organisms, no growth” for all the pathogens identified at baseline (first visit); patients without bacteriological outcome assessment at final visit were considered as failures (i.e. Unresolved) for what concerns the complete microbiological eradication.

[0079] The results of complete microbiological eradication rate of susceptible to levofloxacin pathogens for the patients analysed are shown in Table 4 below and Fig. 2.

[0080] All 53 patients analyzed (100%) showed a complete eradication of bacteria in the first group of levofloxacin-ketorolac according to the present invention versus 49 patients (90.74%) in the second group of levofloxacin alone.

[0081] According to the study design, non-inferiority was to be met if the 95% Confidence Interval (CI) of the difference between the proportion of patients with microbiological eradication in the first group and the second group did not cross the predefined non-inferiority margin d = -0.15 and lied entirely to the right of the margin.

[0082] The difference between the complete microbiological eradication rates in the first group versus the second group was 0.0926, with a corresponding 95% CI ranging between 0.0153 and 0.1699. The non-inferiority of the first group versus the second group was met, as the 95% CI was entirely above the non-inferiority margin of -0.15. Furthermore, as the 95% CI was entirely above zero, the superiority of the first group versus the second group was met also in terms of complete microbiological eradication.

[0083] Table 4 - Results of complete microbiological eradication of levofloxacin-susceptible pathogens in patients: comparison between levofloxacin-ketorolac of the present invention (first group) and Levofloxacin alone (second group). Thus, it has been shown how the superiority of Levofloxacin-Ketorolac (first group) over Levofloxacin alone (second group) was confirmed even in the most unfavorable analysis, in which complete eradication, defined as no growth at the final visit of bacteria present at baseline (first visit) even for potential nonpathogenic microorganisms, was considered.

[0084] 3 , Secondary study endpoints:

[0085] The following secondary microbiological efficacy endpoints were analysed: a. To evaluate the percentage of eradicated levofloxacin-susceptible pathogenic bacteria per treatment group in order to assess the non-inferiority of the fixed-dose levofloxacin-ketorolac combination (first group) compared to levofloxacin alone (second group).

[0086] In order to evaluate this secondary efficacy endpoint, the Microbiological eradication rate of Levofloxacin-susceptible bacteria assessed by individual pathogen was considered: percentage of eradicated pathogens (i.e., reduced or no growth of microorganisms) of Levofloxacin-susceptible bacteria detected during the first visit.

[0087] The scoring criteria for the microbiological eradication degree of Levofloxacinsensitive bacteria, eradicated / unresolved case, are described in Table 1.

[0088] In the patients included in both groups (53 in the first group and 54 in the second group) 61 and 62 pathogens were susceptible to levofloxacin at baseline (first visit), respectively. All 61 different pathogenic bacterial species isolated in the first group (100%) were eradicated at the final visit. Whereas, among the 62 different pathogenic bacterial species isolated in the second group, 56 (90.32%) were eradicated at the final visit; for 2 bacterial species (3.23%) there was a reduction below pathogenic criteria, and 4 bacterial species (6.45%) reported no change. Therefore, the number of eradicated pathogens was 61 in the first group versus 58 in the second group.

[0089] Non-inferiority was to be met if the 95% Confidence Interval (CI) of the difference between the two groups did not cross the predefined non-inferiority margin d = -0.15 and lied entirely to the right of the margin.

[0090] The difference between the by-pathogen microbiological eradication rates in the first group versus the second group was 0.0645, with a corresponding 95% CI ranging between 0.0034 and 0.1257. Thus, non-inferiority of the first group versus the second group was met, as the 95% CI was entirely on the right of the non-inferiority margin of -0.15. Furthermore, as the 95% CI lied entirely above zero, also the superiority of the treatment of the first group versus the treatment of the second group was met.

[0091] The results of microbiological eradication rate of susceptible to levofloxacin pathogens by pathogens analysed are shown in Table 5 and Fig. 3.

[0092] Table 5 - Results of microbiological eradication of levofloxacin-sensitive pathogens in patients

[0093] The fixed-dose combination of levofloxacin-ketorolac of the present invention was effective in eradicating levofloxacin-sensitive bacteria even when considering each individual pathogen, rather than each individual patient. b. b. To evaluate the overall efficacy by considering the proportion of patients (considering both treatment groups) with microbiological eradication of intermediate or levofloxacin-resistant bacteria identified at baseline (first visit).

[0094] In order to evaluate this secondary efficacy objective, the Microbiological Eradication Rate of Intermediate or levofloxacin-Resistant Bacteria assessed on a per-patient basis was considered: percentage of eradicated pathogens (i.e., absence or reduction) of intermediate / levofloxacin-resistant bacteria detected at the first visit.

[0095] Pathogen susceptibility / resistance scoring criteria are established in accordance with EUCAST (European Committee on Antimicrobial Susceptibility Testing) criteria, as described in Table 6. Table 6 - EUCAST susceptibility / resistance assessment of pathogens.

[0096] The results of the overall per-patient microbiological eradication rate of pathogens that were intermediate / resistant to levofloxacin for the patients analyzed are shown in Table 7.

[0097] This analysis considered the 140 patients who were enrolled in the clinical study, among whom 16 had intermediate / resistant pathogens at baseline (first visit).

[0098] The results of the per-patient analysis of microbiological eradication were equal to those by-pathogens (see below) because no more than one species of intermediate / resistant pathogens was reported per each patient. Overall, the two studied groups were effective, treating all patients with intermediate / levofloxacin-resistant pathogens. Table 7 - Results of microbiological eradication of intermediate / levofloxacin-resistant pathogens in patients c. Measure overall efficacy by assessing the percentage of intermediate- or Levofloxacin-resistant bacteria that have been eradicated, considering pathogens.

[0099] In order to evaluate this secondary efficacy objective, the Microbiological Eradication Rate of Intermediate or levofloxacin-resistant Bacteria assessed by individual pathogen was considered: percentage of eradicated pathogens (i.e., absence or reduction in growth of microorganisms) of Levofloxacin-intermediate / resistant bacteria detected at the first visit.

[0100] The scoring criteria for the degree of microbiological eradication of Levofloxacin intermediate / resistant bacteria, eradicated / resolved case, are described in Table 1.

[0101] The results of the overall microbiological eradication rate of levofloxacin-intermediate or resistant pathogens are shown in Table 8.

[0102] Sixteen (16) pathogenic bacterial species that were intermediate / resistant to levofloxacin were isolated in the patients of both groups at the first visit. All these pathogens were eradicated at the final visit, leading to a by-pathogen microbiological eradication rate 100% eradicated.

[0103] Overall, the two study treatments were effective in eradicating all 16 intermediate / levofloxacin-resistant pathogens isolated among the patients considered.

[0104] Table 8 - Results of microbiological eradication of intermediate / levofloxacin-resistant pathogens in pathogens population

[0105] The species of intermediate or resistant to levofloxacin pathogenic bacteria eradicated, according to eradication at the final visit, were staphylococcus aureus, staphylococcus epidermidis, staphylococcus coagulase negative and streptococcus viridans.

[0106] Therefore, the fixed-dose levofloxacin - ketorolac combination of the present invention showed to be not only not inferior, but also superior to levofloxacin alone in the microbiological eradication of pathogenic bacteria in terms of absence or reduction below pathogenic criteria at the final visit of baseline bacteria that were susceptible to levofloxacin.

[0107] Therefore, the primary objective of this study was achieved: the fixed-dose levofloxacin - ketorolac combination of the present invention showed to be not only not inferior but also superior to levofloxacin alone in the microbiological eradication of pathogenic bacteria in terms of absence / no growth or reduction below pathogenic criteria for potential opportunistic microorganisms at the final visit of baseline bacteria that were susceptible to levofloxacin. The superiority of the fixed-dose levofloxacin - ketorolac combination of the present invention was confirmed by evaluating the eradication rate both per patient and per pathogen.

[0108] Moreover, the fixed-dose levofloxacin - ketorolac combination of the present invention was more effective than levofloxacin alone despite being administered with a simplified dosing regimen which resulted in the instillation of a smaller total quantity of antibiotic compared to the treatment group with levofloxacin alone. This allows to hypothesize the presence of a positive interaction in terms of antibacterial activity between levofloxacin and ketorolac, the two active drugs present in the fixed-dose levofloxacin - ketorolac combination of the present invention.

[0109] This phase II study aimed to obtain a first evidence-based microbiological confirmation of the efficacy and the tolerability of a fixed-dose combination of levofloxacin 0.5% and ketorolac 0.5% according to the present invention in the treatment of moderate-severe conjunctivitis. The first fixed-dose combination of a largely used ocular antibiotic and a highly effective NS AID was investigated to treat moderate-severe conjunctivitis, as this kind of conjunctivitis requires the rapid control of infection and the acute inflammatory manifestations that can be very intense and disabling.

[0110] Therefore, the fixed-dose levofloxacin-ketorolac combination of the present invention was tested at the dosage of one drop 4 times a day for 5 days, with an overall use of antibiotic lower than what currently used (i.e. levofloxacin alone is approved in Europe for treating conjunctivitis at the dosage of one drop 8 times per day for the first two days and one drop 4 times daily on days 3 through 5) and with a simpler administration schedule, thus likely increasing patient compliance. In this perspective, a non-inferiority study against levofloxacin alone, which is largely used in clinical practice, was conducted.

[0111] The combination of levofloxacin and ketorolac trometamol of the present invention, despite the reduction in the total amount of antibiotic administered, was not inferior to levofloxacin from a microbiological point of view and effective on signs and symptoms also thanks to the action of ketorolac trometamol. The present study met its primary objective, namely that the fixed-dose levofloxacin and ketorolac trometamol combination of the present invention showed to be not only not inferior to, but also superior to levofloxacin alone in the microbiological eradication of levofloxacin-susceptible bacteria, in terms of their absence or reduction below pathogenic criteria at the final visit.

[0112] When analysing secondary microbiological endpoints considering each pathogen, rather than each patient, the fixed-dose levofloxacin - ketorolac combination of the present invention also showed to be superior to levofloxacin alone in eradicating levofloxacin-susceptible pathogens, as the fixed-dose levofloxacin - ketorolac combination of the present invention eradicated all pathogenic bacteria at the final visit.

[0113] The present clinical study shows that:

[0114] The levofloxacin-ketorolac combination with a reduced dose of the antibiotic was able to eradicate levofloxacin-sensitive pathogens at baseline to a greater extent than levofloxacin alone. In fact, the levofloxacin-ketorolac combination resulted in the complete eradication of 100% of levofloxacin-sensitive pathogens compared with Levofloxacin alone (92,59%).

[0115] In both groups, the treatment regimen was also able to eradicate 100% of pathogens intermediate or resistant to Levofloxacin according to the EUCAST antibiotic susceptibility criteria, effectively treating all patients with these pathogens.

[0116] The reduced dosage regimen of levofloxacin-ketorolac: (i) demonstrates greater efficacy in eradicating the pathogens responsible for bacterial conjunctivitis; (ii) promotes greater adherence / compliance to treatment by patients; and (iii) contributes to the containment of antibiotic resistance as it exposes patients to reduced doses of antibiotic.

[0117] Levofloxacin-ketorolac has also been shown to be the safest treatment approach even in cases of non-confirmed bacterial aetiology, which often occurs in clinical practice as microbiological evaluation is not routinely performed. In conclusion, this phase-II randomized controlled clinical trial indicated that the fixed-dose levofloxacin - ketorolac combination of the present invention was not only not-inferior, but also superior to levofloxacin alone when considering microbiological eradication of pathogenic bacteria. The superiority of the fixed- dose levofloxacin - ketorolac combination of the present invention was confirmed by evaluating the eradication rate both per patient and per pathogen. These results allow us to hypothesize the presence of a positive interaction between levofloxacin and ketorolac trometamol in terms of antibacterial activity.

[0118] Moreover, the present invention has overcome problems not only related to antibiotic resistance due to prolonged treatment of antibiotic monotherapy but also related to the suppressive effect of corticosteroids on the immune system in the treatment of conjunctivitis.

[0119] 4. Multicenter, randomized, parallel-group clinical study comparing RD03 / 2016 (levofloxacin and ketorolac tromethamine composition according to the invention) eye drops vs antibiotic and steroid eye drops for 7 days for the prevention and treatment of inflammation and prevention of infection associated with cataract surgery.

[0120] Patients scheduled for cataract surgery who have provided written informed consent undergo screening procedures to verify eligibility. Immediately following phacoemulsification performed by an experienced surgeon, patients who complete surgery are assigned to levofloxacin +ketorolac or antibiotic+ steroid in a 1 : 1 ratio according to a randomization list stratified by center for 7 days after cataract surgery.

[0121] Treatment begins either immediately after randomization according to local routine clinical practice (in those patients who are not bandaged after surgery), or immediately after removal of dressing of operated eye..

[0122] After the day of surgery, patients undergo visit on Day 8 (end of study: EOS) to evaluate efficacy, safety and local tolerability.

[0123] Primary endpoint: The proportion of patients with «absence of signs of anterior chamber inflammation (cells and flare)» after 7 days of treatment are calculated to evaluate the noninferiority of the test treatment vs. the standard therapy.

[0124] Secondary endpoints: Descriptive statistics and corresponding two-sided 95% Cis of the difference in proportions or in means (as appropriate according to the specific endpoint) between treatments are computed for the secondary efficacy endpoints regarding the assessment of postoperative ocular inflammation (conjunctival hyperemia, TOSS, pain / discomfort, rescue, endophthalmitis).

Claims

CLAIMS1. An ophthalmic composition comprising 0.4% to 0.9% w / v of levofloxacin or a pharmaceutically acceptable salt or derivative thereof, and 0.4% to 0.9% w / v of ketorolac or a pharmaceutically acceptable salt or derivative thereof, for use in a method for the treatment of conjunctivitis in a subject, or for the treatment and prevention of inflammation or for prevention of infections after cataract surgery in a subject, wherein said method comprises ocular topical administration of said ophthalmic composition to the affected eye 4 times dailyand wherein said method of treatment or prevention has a duration of 5 to 7 days.

2. The ophthalmic composition for use according to claim 1, comprising 0.5% w / v of levofloxacin or a pharmaceutically acceptable salt or derivative thereof, and 0.5% w / v of ketorolac or a pharmaceutically acceptable salt or derivative thereof.

3. The ophthalmic composition for use according to claims 1-2, which is in the form of an aqueous solution, preferably in the form of eye drops.

4. The ophthalmic composition for use according to claims 1-3, wherein a dosage unit of said composition delivers to the affected eye an amount of 60mcg to 630mcg, preferably 104mcg to 288mcg, more preferably 150mcg of levofloxacin or a pharmaceutically acceptable salt or derivative thereof, and an amount of 60mcg to 630mcg, preferably 104mcg to 288mcg, more preferably 150mcg of ketorolac or a pharmaceutically acceptable salt or derivative thereof.

5. The ophthalmic composition for use in a method according to claims 1-3, said method comprising ocular topical administration of 1 drop of said ophthalmic composition to the affected eye 4 times daily, wherein said drop has a volume from about 15 to about 70pl, preferably about 26-32 pl, more preferably about 30 pl.

6. The ophthalmic composition for use according to claims 1-5, wherein Levofloxacin is Levofloxacin hemihydrate.

7. The ophthalmic composition for use according to claims 1-5, wherein ketorolac salt is ketorolac trometamol.

8. The ophthalmic composition for use according to claims 1-7, wherein said composition comprises 0.5% w / v Levofloxacin and 0.5% w / v ketorolac trometamol.

9. The ophthalmic composition for use according to claim 1, wherein the conjunctivitis treatment has a duration of 5 days.

10. The ophthalmic composition for use according to claim 1, wherein the prevention or treatment of inflammation or the prevention of infection after cataract surgery has aduration of 7 days.

11. The ophthalmic composition for use according to claim 1 , wherein said conjunctivitis or said infection after cataract surgery is caused by bacteria and / or viruses.

12. The ophthalmic composition for use according to claim 11, wherein said bacteria show intermediate or total resistance.

13. The ophthalmic composition for use according to claims 11-12, wherein said bacteria are sensitive to treatment with Levofloxacin.

14. The ophthalmic composition for use according to claims 1-13, wherein said composition has a pH ranging from 7.5 to 8.5, preferably from 7.7 to 8.3, more preferably from 7.9 to 8.3.

15. The ophthalmic composition for use according to claims 1-14, wherein said composition further comprises one or more excipients selected from preservatives, pH buffers, pH adjusting agents, solubilizing agents, chelating agents, tonicity agents and solvents or combination thereof.

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