Compositions for treating vaginal candida (biofilm) infections with improved relapse prevention

Abstract

The present invention provides a topical pharmaceutical formulation comprising a combination of miconazole or a pharmaceutically acceptable salt thereof and domiphen bromide, a formulation vehicle and a viscosity modifier; wherein the ratio of w / w% miconazole (salt) to w / w% domiphen bromide is between 6 to 20 endpoints included and wherein the amount of viscosity modifier is sufficient to adjust the viscosity of the topical formulation to a value of 1000-4600 mPa.s measured at 25°C. The invention further provides use of said formulation in a treatment of vaginal Candida (biofilm) infections, wherein once daily use of 4.5-5.5 g of the formulation for a duration of 7 days performed better than a reference product and unexpectedly also performed better than a formulation with a double domiphen bromide dose. Improved performance was the relapse prevention for a duration of at least 28 days in human patients treated for a vulvovaginal Candida (biofilm) infection.

Description

[0001] COMPOSITIONS FOR TREATING VAGINAL CANDIDA (BIOFILM) INFECTIONS WITH IMPROVED RELAPSE PREVENTION

[0002] FIELD OF THE INVENTION

[0003] The invention relates to compositions for treating vaginal Candida infections and vaginal Candida biofilms. A composition according to the invention has the advantage that it provides infection control with improved protection against relapse of the vaginal Candida (biofilm) infection. A lower amount of the antiseptic domiphen bromide was used. The formulation is preservative-free. The composition is advantageous for use in a vaginal applicator and to prevent product loss during the treatment.

[0004] BACKGROUND

[0005] Over the past two decades, there has been a dramatic increase in the rate of vulvovaginal candidiasis (VVC). It is a common fungal infection caused by abnormal growth of yeast-like fungi, especially Candida albicans, on the female genital tract mucosa. A vulvovaginal candidiasis infection is often characterized by painful and uncomfortable manifestations such as intense itching, irritation, vaginal discharge, erythema, and dysuria. Associated with vaginal Candida (biofilm) infections comes a diminished quality of life of many women. Approximately 75 % of all women experience at least one episode of VVC during their lifetime. The infection may reoccur leading to a therapy over a long period of time, with associated costs.

[0006] In addition, woman under treatment for VVC may initially experience an improvement in symptoms but relapse. This is different from a recurrent VVC in that relapse is a re-emergence of the Candida sp. during treatment, whereas a recurrent VVC is an often or repeated occurrence of new Candida sp. infections. A relapse is an infection that resurfaces, presumably because it was not completely irradicated. The presence of a biofilm, presenting a thicker layer to be treated, may prevent full access to the infection and may allow a reemergence. A recurrent VVC involves a re-infection.

[0007] The high incidence of VVC, relapse, and associated healthcare cost of VVC highlight the need for the development of more effective formulations. Miconazole is a well-known imidazole antifungal. It is mostly used in its nitrate salt form. Miconazole nitrate has a dual mechanism of action. It inhibits ergosterol biosynthesis and it inhibits peroxidases, which cause the accumulation of peroxide within the cell, leading to cell death.

[0008] Deep-seated fungal infections, e.g. in case of biofilm involvement, may be more difficult to treat because the active ingredient released from the topical formulation may not be able to fully reach the target site. For miconazole nitrate, its poor aqueous solubility (< 1 ^g / ml) may pose difficulties in the formulation design and lead to therapeutic failure.

[0009] Domiphen bromide was recently shown to be a potentiator of miconazole nitrate. By itself it does not provide a fungicidal action. It is known as an anti-septic and preservative.

[0010] In WO2019 / 015975 compositions for topical use comprising miconazole nitrate and domiphen bromide were disclosed, for use in treating a vulvovaginal Candida (biofilm) infection. From a checkerboard experiment, synergistic combinations were found for miconazole - domiphen bromide combinations in a ratio of 2.3 to 9. In Example 6, Table 2, formulations of miconazole nitrate are listed. A 2% miconazole nitrate + 1 / 3 domiphen bromide (w / w%) composition is disclosed. The miconazole nitrate is present in a 3-fold molar excess over domiphen bromide. The composition was used in an animal model for vaginal Candida infection (Example 7). A significant effect was seen when the potentiator domiphen bromide was added, although domiphen bromide itself was reported not to influence the outcome of the infection.

[0011] In view of the above, there is a need in the art for improved pharmaceutical products. There is a need for improved therapeutic options, especially in view of the experience that Candida infections often relapse.

[0012] It is the objective of the present invention, to provide a solution to at least one of the problems mentioned above.

[0013] In particular, the invention aims to provide a topical pharmaceutical formulation that is better suited for use in the treatment of an acute vulvovaginal candidiasis. In particular, the invention aims to provide a reduction or prevention of relapse. BRIEF DESCRIPTION OF THE INVENTION

[0014] In a first aspect, the invention provides a topical pharmaceutical formulation comprising a combination of miconazole or a pharmaceutically acceptable salt thereof and domiphen bromide, a formulation vehicle and a viscosity modifier; wherein the ratio of w / w% miconazole (salt) to w / w% domiphen bromide is between 6 to 20, endpoints included; and wherein the amount of viscosity modifier is sufficient to adjust the viscosity of the topical formulation to a value of 1000-4600 mPa (centipoise) measured at 25°C; with the proviso that the topical pharmaceutical formulation does not contain an anti-oxidant.

[0015] In a second aspect the invention provides a medical use for a topical pharmaceutical formulation according to an embodiment of the invention.

[0016] In a further aspect, the invention provides a container comprising the topical pharmaceutical formulation according to an embodiment of the invention, said container comprising an amount of miconazole (salt) and domiphen bromide for a once-a-day application of the topical pharmaceutical formulation for a duration of seven days, wherein said amount of topical formulation in the container is 35- 100 g.

[0017] In another aspect, the invention provides an applicator comprising a topical pharmaceutical formulation according to an embodiment of the invention, wherein the applicator comprises a unit dose of 5 g of said topical pharmaceutical formulation. Preferably said applicator is a pre-filled vaginal applicator.

[0018] In a final aspect the invention provides a kit of parts comprising a topical pharmaceutical formulation according to an embodiment of the invention, an applicator according to an embodiment of the invention suitable for application of the topical formulation on a vulvovaginal surface area and a product leaflet, wherein the product leaflet prescribes application of 4, 5-5, 5 g of the topical formulation and use of the applicator once a day for a period of seven days. More preferably use of 4, 8-5, 4 g of the topical formulation is prescribed in the product leaflet. Most preferably 5 g application is prescribed in the product leaflet.

[0019] Further improvements are worked out in the dependent claims. The invention has the advantage that it provides an improved protection against relapse of the vaginal Candida (biofilm) infection. A low amount of the antiseptic domiphen bromide was used. The formulation is preservative-free, not taking account domiphen bromide. The formulation has a viscosity that is suitable for application on a vulvovaginal candidiasis. The formulation is suitable for application by (prefilled) vaginal syringe and for avoidance of product loss during the treatment.

[0020] DETAILED DESCRIPTION OF THE INVENTION

[0021] Exemplary aspects of the invention are described herein. Although the following detailed description contains many specifics for purposes of illustration, a person of ordinary skill in the art will appreciate that variations and alterations to the following details are within the scope of the invention. Accordingly, the following aspects of the invention are set forth without any loss of generality to, and without imposing limitations upon, the claimed invention.

[0022] In a first aspect, the invention provides a topical pharmaceutical formulation comprising a combination of miconazole or a pharmaceutically acceptable salt thereof and domiphen bromide, a formulation vehicle and a viscosity modifier.

[0023] The inventors have found a formulation with a reduced amount of domiphen bromide which may treat an acute vulvovaginal candidiasis and at the same time may provide improved relapse control. An amount of miconazole (salt) to domiphen bromide, expressed as the ratio of w / w% miconazole (salt) to w / w% domiphen bromide, of 6 to 20 was found effective.

[0024] In a preferred embodiment of a topical pharmaceutical formulation according to the invention, said ratio of miconazole-nitrate to domiphen bromide is 14 to 20; preferably 14.2 to 18; more preferably 14.4 to 16; most preferably 14.5 to 15.

[0025] Pharmaceutical compositions of the present invention preferably comprise 1 % (w / w) to 5% (w / w / ) miconazole or a salt thereof, most preferably miconazole nitrate. Specific embodiments comprise 1 w / w %, 1.5 w / w %, 2 w / w %, 2.5 w / w%, 3 w / w%, 4 w / w %, or 5 w / w % miconazole nitrate. Most preferably the pharmaceutical composition of the present invention comprises 2 w / w % miconazole nitrate in combination with domiphen bromide. It was found that the presence of domiphen bromide significantly impacted the viscosity of a formulation. The viscosity of the formulation was raised to avoid product loss, both from an applicator as from a treated surface during therapy. In addition, the viscosity still must allow for easy removal from the packaging.

[0026] A topical pharmaceutical formulation according to an embodiment of the invention has a viscosity between 1000-4000 mPa.s (centipoise), more preferably between 1200-3700 mPa.s (centipoise), even more preferably between 1500-3600 mPa.s (centipoise), most preferably between 2000-3500 mPa.s (centipoise). The viscosity is measured at 25°C with a method known to a person skilled in the art, preferably as per ICH Q6A guideline.

[0027] It was found that the inventive formulation provides a dosage form for topical application in the vagina that will not leak during application, making dosing reliable and which provides sufficient exposure time.

[0028] In addition, it was found that an antioxidant can be abandoned and the presence of domiphen bromide is sufficient to provide microbial control, even at low amounts of domiphen bromide as used in formulations according to the present invention.

[0029] A topical pharmaceutical formulation according to an embodiment of the invention does not contain an antioxidant and does not contain a preservative other than domiphen bromide.

[0030] The absence of antioxidant and preservative, other than domiphen bromide, is advantageous to provide a skin friendly topical composition. The irritation potential is kept low.

[0031] In a preferred embodiment of a topical pharmaceutical formulation according to the invention, the viscosity modifier is cetostearyl alcohol. Cetostearyl alcohol, also called cetearyl alcohol or cetylstearyl alcohol, is a mixture of fatty alcohols, consisting predominantly of cetyl (16 carbon atoms) and stearyl alcohol (18 carbon atoms). It is classified as a fatty alcohol. Cetostearyl may be used as an emulsion stabilizer, opacifying agent, foam boosting surfactant, and as a viscosity-increasing agent. It may be used in emulsions. In a preferred embodiment of a topical pharmaceutical formulation according to the invention, said formulation comprises 2-6 w / w% cetostearyl alcohol; more preferably 4.0-5.9 w / w% cetostearyl alcohol; even more preferably 4.1-5.8 w / w% cetostearyl alcohol; most preferably 4.2-4.8 w / w% cetostearyl alcohol.

[0032] Without being bound to theory, it is contemplated that the increased amount of viscosity enhancer by means of the non-ionic surfactant cetostearyl alcohol, provided better wicking behavior of the formulation on a biofilm, often a hydrophobic environment. In combination with the absence of antioxidants, it is believed that a suppression of reactive oxygen species (ROS) generated by Candida treated with miconazole, is reduced. This contributes to a more effective formulation.

[0033] In a preferred embodiment of a topical pharmaceutical formulation according to the invention, the formulation has a density of 0.9-1.1 g / ml; more preferably 0.95-1.05 g / ml; most preferably 0.97-1.03; most preferably 1.00 g / ml. This density is advantageous for the formulation to be used with commercially available syringes.

[0034] In a preferred embodiment of a topical pharmaceutical formulation according to the invention, the topical formulation is provided for application on a vulvovaginal surface area, wherein the topical pharmaceutical formulation has a pH 2.5-3.5; more preferably 2.7-3.2; most preferably 3.0.

[0035] In a preferred embodiment of a topical pharmaceutical formulation according to the invention, the topical formulation comprises a mucoadhesive. A mucoadhesive may provide optimal attachment to the site of application. Suitable mucoadhesives for vulvovaginal application include polymers that are capable of forming hydrogels such as synthetic polycarbophil, chitosan, cellulose derivatives (hydroxyethycellulose, hydroxypropylcellulose and hydroxypropyl methylcellulose), pectin, hyaluronic acid derivatives, polyacrylates, tragacanth, carrageenan and sodium alginate, thiolated polymers.

[0036] Preferably the mucoadhesive is selected from the list of polycarbophil, chitosan, Hydroxyethylcellulose, hydroxypropylcellulose, hydroxypropylmethylcellulose, pectin, polyacrylates, tragacanth, carrageenan, sodium alginate, and combinations thereof. The topical pharmaceutical formulation of the present invention can applied as a gel or cream.

[0037] Creams are know in the art as oil in water (o / w) or water in oil (w / o) emulsions. They typically contain an emulsifier (formulation vehicle) and a viscosity modifier.

[0038] Gels are known in the art as preparations containing cellulose ethers or carbomer (viscosity modifier) in water or a water-alcohol mixture (formulation vehicle).

[0039] Preferably the topical pharmaceutical formulation of the present invention is a cream.

[0040] Preferably the cream is comprising liquid paraffin and lauroyl macrogol-6 glycerides as oily phase. Preferably water is used in combination with the aforementioned oily phase to provide an oil in water emulsion.

[0041] Emulsifiers may be used for the stabilisation of the emulsion. Preferably an emulsifier is selected from polyethylene glycol-6, palmitostearate, ethylene glycol stereate, PEG-32 stereate, and mixtures thereof.

[0042] The packaging for the topical pharmaceutical formulation may comprise a tube or syringe. Preferably the packaging is a vaginal syringe. More preferably the packaging is a prefilled vaginal syringe. In an alternative embodiment, the packaging is an aluminium lined tube.

[0043] In a preferred embodiment the storage stability of the formulation of a 2 w / w% miconazole nitrate and 0.14 w / w% domiphen bromide composition in absence of anti-oxidant and preservative auxiliary ingredients, is at least 6 months as measured in a stability test at 25°C / 60% Relative Humidity and in an accelerated storage stability test at 40°C / 75% Relative Humidity.

[0044] In a second aspect the invention provides a medical use for a topical pharmaceutical formulation according to an embodiment of the invention.

[0045] Particularly, the invention provides a topical pharmaceutical formulation according to an embodiment of the invention, for use in the treatment of an acute vulvovaginal Candida sp. infection (VVC) and improved suppression or prevention of a relapse of said Candida sp. infection in a human patient in need thereof, for at least 28 days. Preferably the improved suppression or prevention is for a period of at least 35 days, more preferably 42 days, even more preferably for 49 days, most preferably for 54 days or more.

[0046] Treatment in the context of the present invention refers to a complete or partial reduction of yeast and / or a reduction in the symptoms of a fungal infection such as itching, burning with urination, and vaginal discharge.

[0047] Suppression or prevention is measured compared to the treatment of an acute vulvovaginal Candida sp. infection, using the same length of treatment and amount of miconazole (or a salt thereof), but in absence of domiphen bromide.

[0048] The pharmaceutical formulation of the invention will be used upon signs of a fungal infection. Application of the pharmaceutical composition on the infected region, wherein the acute infection is treated, and relapse is prevented for a period of 28 days or more, provides much needed patient relieve.

[0049] Candida is a genus of yeasts. Candidiasis is a fungal infection caused by an overgrowth of a Candida yeast. Candida sp. comprise Candida albicans, Candida glabrata, Candida auris. Candida albicans are responsible for most vaginal yeast infections. Candida auris is a strain of Candida fungus first identified in 2009. It is difficult to treat because it is resistant to many drugs typically used for fungal infections.

[0050] In a preferred embodiment of the invention, the acute Candida sp. infection comprises a vaginal biofilm.

[0051] Biofilm refers to a mode of microbial growth comprising sessile cells, usually within a complex and highly heterogeneous matrix of extracellular polymers, and characterized by a reduced sensitivity to antifungal agents. Biofilms can contain single species (e.g. a fungi / yeast such as C. albicans) or multiple species microorganisms (such as C. albicans, C. glabrata and other microorganisms, preferably yeasts and / or fungi or even prokaryotes). In a preferred embodiment said biofilm is a fungal biofilm, more preferably a Candida species biofilm, comprising one or more of C. albicans, C. glabrata, and / or C. cruse. Biofilms may also comprise or consist of an Aspergillus species (e.g. A. flavus, A. fumigatus, A. clavatus) biofilm or a Fusarium species (e.g. F. oxysporum, F. culmorum). In the context of the present invention biofilm typically refers to a Candida sp. biofilm, preferably to a Candida albicans biofilm. Biofilm-associated Candida infections exhibit decreased susceptibility to antimicrobial agents. This is potentially due to cell surface hydrophobicity, adhesion performance and the susceptibility profile. Without being bound to theory, it is hypothesized this may also be the case for antifungals / antimycotics. Miconazole with its low solubility is difficult to formulate for improved performance in these situations. Although domiphen bromide has recently become known as a potentiator for miconazole, it was surprising to find that a 14: 1 miconazole nitrate domiphen bromide combination was performing better than a miconazole nitrate double dose domiphen bromide combination (7: 1). It is hypothesized that the increased amount of surfactant provides for improved distribution of the miconazole (nitrate). It is also believed that leaving out an anti-oxidant may avoid the potential supression of reactive oxygen species (ROS) that are formed by yeast exposed to miconazole. A low dose of domiphen bromide was found sufficient to prevent microbial growth in a packaged formulation. A higher dose of domiphen bromide could potentially allow the yeast to dig deaper into the vulvovaginal tissue, making it more likely that the infection will relapse despite of the higher dose.

[0052] In a preferred embodiment of the invention, said treatment comprises a once daily application of 4, 5-5, 5 g of the topical formulation for a period of seven days. A once daily application provides more comfort than a multiple times a day treatment. The formulation of the present invention is advantageous to use before going to bed. Patient comfort is improved. Leaks during the day need not be feared. A period of seven consecutive days was found effective for the intended treatment, with both infection control and improved relapse prevention.

[0053] The compositions of the present invention comprise miconazole and domiphen bromide in concentrations that provide a synergistic effect. Synergism was determined by FICI (fractional inhibitory concentration index) calculations.

[0054] The FICI was calculated by the formula FICI = [C(BEC-2A ) / BEC-2A ] + [C(BEC- 2B) / BEC-2b ], in which C(BEC-2A ) and C(BEC-2B ) are the BEC-2 values of the antifungal drugs in combination, and BEC-2A and BEC-2B are the BEC-2 values of antifungal drugs A and B alone. BEC-2 stands for biofilm eradication concentration 2 which is the minimal concentration of a compound that causes a 2-fold decrease in biofilm metabolic activity. The interaction was defined as synergistic for a FICI value of 0.5 or less, indifferent for 0.5<FICI<4 and antagonistic for FICI>4. Preferably the FICI value of the present miconazole nitrate with domiphen bromide combination is less than 0.5; more preferably less than 0.45; even more preferably less than 0.4.

[0055] In a preferred embodiment of the invention 2.0 w / w % miconazole nitrate and 0.14 w / w % domiphen bromide are applied.

[0056] The inventors have surprisingly found that 0.14 w / w % domiphen bromide in combination with 2.0 w / w % miconazole nitrate was more effective than a reference product with 2.0 w / w % miconazole nitrate and more effective than a 0.28 w / w % domiphen bromide in combination with 2.0 w / w % miconazole nitrate.

[0057] In a further aspect, the invention provides a container comprising the topical pharmaceutical formulation according to an embodiment of the invention, said container comprising an amount of miconazole (salt) and domiphen bromide for a once-a-day application of the topical pharmaceutical formulation for a duration of seven days, wherein said amount of topical formulation in the container is 35- 100 g. Preferably the amount of topical formulation in the container is 40-90 g, more preferably 45-85 g, more preferably 50-75 g. Preferably the packaging is a tube, preferably an aluminum lined tube. In an alternative embodiment, the packaging is provided for application of the topical pharmaceutical formulation of the invention.

[0058] In another aspect, the invention provides an applicator comprising a topical pharmaceutical formulation according to an embodiment of the invention, wherein the applicator comprises a unit dose of 5 g of said topical pharmaceutical formulation. Preferably said applicator is a vaginal applicator, most preferably a pre-filled vaginal applicator.

[0059] Preferably the vaginal applicator comprises a barrel, wherein said barrel is tubular; a tip; wherein said tip is attached to, attachable to, or connected with said barrel, wherein said barrel allows for the insertion and / or expulsion of a topical pharmaceutical formulation according to an embodiment of the invention; and a plunger, wherein said plunger is circular in cross-section and wherein the cross section of said plunger fits inside said barrel. Preferably the barrel has an outer surface and outer surface is provided with markings to indicate the amount of formulation held in the barrel. This is advantageous for correct dose administration.

[0060] Preferably said topical pharmaceutical formulation comprised in the applicator, has a density of 0.9-1.1 g / ml; more preferably 0.95-1.05 g / ml; most preferably 0.97-1.03; most preferably 1.00 g / ml. This is advantageous for simple dose calculations, as the volume expelled from the barrel corresponds with the amount of product.

[0061] In a final aspect the invention provides, a kit of parts comprising a topical pharmaceutical formulation according to an embodiment of the invention, an applicator according to an embodiment of the invention suitable for application of the topical formulation on a vulvovaginal surface area and a product leaflet, wherein the product leaflet prescribes application of 5 g of the topical formulation and use of the applicator once a day for a period of seven days.

[0062] EXAMPLES

[0063] It is important for commercial products that the viscosity is not so low that the product will run too much, leading to loss of product and underperformance. It is also important that the product is not too thick, so there are difficulties applying it, e.g. using a syringe. Product properties were tested according to ICH Q6A guideline requirements.

[0064] EXAMPLE 1 : Prior art compositions

[0065] The following compositions are known in the art from EP3654973. They were used in mycological screenings. The viscosity was reported as 300 mPa.s (centipoise).

[0066] Table 1: Prior art compositions

[0067] In F5 miconazole is present in a 3-fold molar excess over domiphen bromide (ratio 3: 1). The viscosity was reported as 300 mPa.s (centipoise). EXAMPLE 2: Comparison of physical properties

[0068] From a comparison of compositions, it was found that domiphen bromide lowers product viscosity. This can be significant especially at room temperature of around 25°C.

[0069] Table 2:

[0070] EXAMPLE 3: compositions according to an embodiment of the invention

[0071] Compositions were made with miconazole nitrate and domiphen bromide as active ingredients. Cetostearyl alcohol was used in an amount to provide a product viscosity of 1000-4000 mPas at 25°C. Density of the formulation was around 1.0 g / ml. No antioxidant or preservative were added.

[0072] The formulations were found vaginal tissue-friendly and stable for at least 6 months based on storage stability testing. Stability comprises active ingredient assay, a preservative efficacy test (absence of microbial growth) and a screening for the absence of vaginal irritation in an in vivo model.

[0073] Table 3A - Cream 2 w / w % miconazole nitrate and 0.29 w / w% domiphen bromide (ratio 7: 1) / high dose cream (Composition 3A)

[0074] Table 3B — Cream 2 w / w % miconazole nitrate and 0.144 w / w% domiphen bromide (ratio 14: 1) / low dose cream (Composition 3B) Table 3C: Comparison of physical properties -compositions according to invention

[0075] EXAMPLE 4: Preservative Efficacy Test

[0076] Table 4 provides a comparison of prior art compositions with a preferred composition according to the invention with respect to viscosity modifier and antioxidant / preservative.

[0077] Table 4: Comparative data compositions

[0078] + = present; - = not present EXAMPLE 5

[0079] A 2 w / w % miconazole nitrate - 0.14 w / w% domiphen bromide vaginal cream according to an embodiment of the invention was stored at 25°C, 60% relative humidity and at 40°C, 75% relative humidity. Appearance, assay of miconazole nitrate and domiphen bromide, impurities, and viscosity were followed at monthly intervals for at least 6 months. The formulation was found stable for at least 6 months under both test conditions used.

[0080] EXAMPLE 6: Clinical trial

[0081] A first-in-human clinical trial was conducted. A phase 2, randomized, doubleblind, active-controlled study to evaluate the efficacy and safety of miconazole nitrate 2 w / w% in combination with domiphen bromide was conducted. The study involved the use of a vaginal cream for the treatment of human patients with confirmed acute vulvovaginal candidiasis.

[0082] The study was a multicenter, randomized, double-blind, active-controlled, parallel-group study with three treatment groups. Subjects were randomized in a ratio of 1: 1 : 1 to one of the three treatment groups. One group received the miconazole nitrate 2 w / w% + domiphen bromide 0.14 w / w% vaginal cream. A second group received the miconazole nitrate 2 w / w% + domiphen bromide 0.288 w / w% vaginal cream and the last group received Gyno-Daktarin®, a commercially available product with 2 w / w% miconazole nitrate. The creams were applied for 7 days.

[0083] The study was conducted in multiple study sites in Belgium. The study consisted of 5 visits: screening visit (baseline) at day 1, a follow-up visit at day 15 (+ / - 2 days), a follow-up visit at day 29 (+ / - 7days), a follow-up visit a day 57 (+ / - 7 days), and a follow-up visit at day 85 (+ / - 7 days). Eligible subjects were females aged 18 - 50 years with a clinical diagnosis of an acute vulvovaginal candidiasis (VVC) at the study visit, defined as: a total signs and symptoms score equal to or above 3. Each of the following vulvovaginal signs and symptoms were scored and the individual scores combined, for a maximum score of 18, using the following scale: a. Signs: erythema, edema, and excoriation b. Symptoms: itching, burning, and irritation

[0084] Scoring scale: each score should be graded on a scale of 0 to 3. as follows: 0 = none (complete absence of any sign or symptom)

[0085] 1 = mild (slight)

[0086] 2 = moderate (present)

[0087] 3 = severe (marked, intense)

[0088] Documented positive potassium hydroxide (KOH) wet mount or Gram stain performed at the investigative site from a vaginal smear revealing filamentous hyphae / pseudohyphae and / or budding yeast cells.

[0089] 75 randomized female patients, 25 per study group, completed the study. Subjects were suitable candidates for vaginal therapy and were able to introduce the cream. Subjects provided written informed consent in compliance with ICH- GCP.

[0090] In the study there were 2 test products and one active comparator:

[0091] 1. 2 w / w% miconazole nitrate + 0.288 w / w% domiphen bromide (i.e. 7: 1 ratio) cream

[0092] 2. 2 w / w% miconazole nitrate + 0.144 w / w% domiphen bromide (i.e. 14: 1 ratio) cream

[0093] 3. Gyno-Daktarin®

[0094] At the Screening Visit, the subjects were assigned to one of the three treatment groups, according to a double-blind 1 : 1: 1 randomized allocation. Each subject was issued with 1 tube cream for 1 week, containing 50 g of cream, and were instructed how to use the cream. The instructions included the dosing, the use of an applicator and discarding of the applicator. The cream had to be applied at night, after urination, through vaginal administration in a recumbent position. The tubes (used and unused) had to be kept and were brought back the next visit.

[0095] At the follow-up visits, the effect of the treatment was assessed (clinical and antimycotic efficacy and safety), the diary (treatment compliance) evaluated, the cream usage verified (by reviewing returned tubes) with physical / vaginal examinations. Assessment of ical Outcome

[0096] Mycological outcomes will be assessed at the follow-up visits according to the following definitions:

[0097] Mycological eradiation

[0098] At Day 15- a culture negative vaginal swab for growth of baseline Candida species

[0099] On the other follow-up visits - a culture and PCR negative vaginal swab for growth of baseline Candida species.

[0100] Mycological persistence

[0101] At Day 15 - a culture positive vaginal swab for the growth of baseline Candida species. On the other follow-up visits - a culture or PCR positive vaginal swab for the growth of baseline Candida species.

[0102] Mycological indeterminate

[0103] At Day 15 - no vaginal swab culture is available, or the culture cannot be interpreted for any reason, or the culture is considered contaminated. On the other follow-up visits - no vaginal swab culture or PCR is available, or the culture / PCR test cannot be interpreted for any reason, or the culture / PCR test is considered contaminated.

[0104] Assessment of Overall

[0105] Overall therapeutic response will be assessed at the follow-up visits according to the following definitions:

[0106] Overall therapeutic success - achievement of both a clinical cure AND mycological eradication

[0107] Overall therapeutic failure - clinical failure OR mycological persistence

[0108] Overall therapeutic indeterminate - insufficient data are available to determine if the subject is an overall success or failure.

[0109] At the end of the study period, statistical data analyses were performed.

[0110] Both active ingredients, miconazole nitrate and domiphen bromide were found stable and safe. Both test products showed an absence of irritation. Test with the low dose domiphen bromide showed clear positive results over a period of 29 days after a 7-day treatment: clinically (improvement of symptoms) and mycologically (absence of Candida sp. as determined by a PCR test). In the post-hoc analyses. It was unexpectedly found that the low dose group (0.14 w / w%) did significantly better than the high dose group (0.29 w / w%) on Day 29 after a 7-day treatment.

[0111] At Day 57 the difference was smaller, yet still present. The treatment with low dose was better than the GynoDaktarin® comparison.

[0112] Without being bound to theory, it is hypothesized that domiphen bromide impacts the vaginal wall and allows the fungus to dig in. It would then be protected against miconazole and more difficult to treat.

[0113] Efficacy Analysis - Day 29 visit

[0114] Table 5: patients with VVC confirmed by vaginal swab -objective clinical outcome CI: confidence interval

[0115] Table 6: patients with VVC confirmed by vaginal swab -modified mycological outcome Table 7: patients with VVC confirmed by vaginal swab -modified overall therapeutic outcome Efficacy Analysis - Day 57 visit

[0116] Table 8: Patients with WC confirmed by vaginal swab -objective clinical outcome Table 9: Patients with WC confirmed by vaginal swab -modified mycological outcome

[0117] Table 10: Patients with WC confirmed by vaginal swab -modified overall therapeutic outcome

[0118] Efficacy Analysis - Day 86 visit

[0119] Table 11 : Patients with VVC confirmed by vaginal swab -objective clinical outcome Table 12: Patients with VVC confirmed by vaginal swab -modified mycological outcome

[0120] Table 13: Patients with VVC confirmed by vaginal swab -modified overall therapeutic outcome

[0121] Table 14: Efficacy Analysis - modified as per protocol analysis set - analysis of reported data - Modified overall therapeutic outcome

Claims

CLAIMS1. A topical pharmaceutical formulation comprising a combination of miconazole or a pharmaceutically acceptable salt thereof and domiphen bromide, a formulation vehicle and a viscosity modifier; wherein the ratio of w / w% miconazole (salt) to w / w% domiphen bromide is between 6 to 20, endpoints included; and wherein the amount of viscosity modifier is sufficient to adjust the viscosity of the topical formulation to a value of 1000-4600 mPa.s (centipoise) measured at 25°C; with the proviso that the topical pharmaceutical formulation does not contain an anti-oxidant.

2. Topical pharmaceutical formulation according to claim 1, wherein the viscosity is 1300-3900 mPa.s (centipoise) at 25°C.

3. Topical pharmaceutical formulation according to claim 1 or 2, wherein the formulation comprises miconazole nitrate and said ratio of miconazolenitrate to domiphen bromide is 14 tol5.

4. Topical pharmaceutical formulation according to any of claims 1 to 3, wherein the viscosity modifier cetostearyl alcohol.

5. Topical pharmaceutical formulation according to claim 4, wherein said formulation comprises 4.0-6.0 w / w% cetostearyl alcohol.

6. Topical pharmaceutical formulation according to any of claims 1 to 5, wherein the formulation has a density of 0.9-1.1 g / ml; preferably 1.00 g / ml.

7. Topical pharmaceutical formulation according to claim 5 or 6, wherein the topical formulation is provided for application on a vulvovaginal surface area, having a pH 2.5-3.5; optionally comprising a mucoadhesive.

8. Topical pharmaceutical formulation according to any of claims 1 to 7, comprising 2 w / w% miconazole nitrate in combination with 0.14 w / w% domiphen bromide, a formulation vehicle. 4 w / w% cetostearyl alcohol, pH 2.5-3.5; with the proviso that the formulation does not contain an antioxidant.

9. Topical pharmaceutical formulation according to claim 8, wherein the storage stability of the formulation is at least 6 months as measured in a storage stability test at 25°C / 60% Relative Humidity and in an accelerated storage stability test at 40°C / 75% Relative Humidity.

10. Topical pharmaceutical formulation according to any of claims 1 to 9, comprising a therapeutically effective concentration of miconazole or a pharmaceutically acceptable salt thereof and domiphen bromide for use in the treatment of an acute vulvovaginal Candida sp. infection (VVC) in a human patient in need thereof and prevention of a relapse of said Candida sp. infection for at least 28 days.

11. Topical pharmaceutical formulation according to claim 10, wherein the acute Candida sp. infection comprises a vaginal biofilm.

12. Topical pharmaceutical formulation according to claim 10 or 11, comprising an application of 4.5-5.5 g of the topical formulation once daily for a period of seven days.

13. A container comprising the topical pharmaceutical formulation according to any of claims 1 to 12, said container comprising an amount of miconazole (salt) and domiphen bromide for a once-a-day application of the topical pharmaceutical formulation for a duration of seven days, wherein said amount of topical formulation in the container is 35-100 g.

14. An applicator comprising a topical pharmaceutical formulation according to any of claims 1 to 12, wherein the applicator comprises a unit dose of 4.5- 5.5 g of said topical pharmaceutical formulation.

15. The applicator according to claim 14, wherein the applicator is a vaginal applicator.

16. The applicator according to claim 14 or 15, wherein the density of the topical formulation is 0.9-1.1 g / ml.

17. A kit of parts comprising a topical pharmaceutical formulation according to any of claims 1 to 12, an applicator according to any of claims 14 to 16suitable for application of the topical formulation on a vulvovaginal surface area and a product leaflet, wherein the product leaflet prescribes application of 4.5-5.5 g of the topical formulation and use of the applicator once a day for a period of seven days.

Images