Sustained-release biodegradable intraductal insert comprising a hydrogel and cyclosporine

Abstract

Provided herein are sustained-release biodegradable intracanalicular inserts comprising a hydrogel and cyclosporine, methods of treating or preventing ocular diseases in subjects in need thereof by administering such inserts, and methods of making such inserts.

Description

Technical Field

[0001] The present invention relates to the treatment of ocular diseases, e.g., diseases affecting the ocular surface such as dry eye or dry eye disease "DED". According to the invention, ocular diseases are treated by, e.g., intraductal administration of an insert that is biodegradable and provides sustained release of cyclosporine. Background Art

[0002] Eye diseases and conditions, particularly those affecting the ocular surface, are extremely common. For example, dry eye disease (DED), also known as keratoconjunctivitis sicca (KCS), is one of the most common ophthalmic conditions. Patients who visit ophthalmology clinics often report symptoms of dry eye, making it a growing public health problem and one of the most common ailments seen by eye care physicians. The prevalence increases significantly with age and is higher in women. It is estimated that more than 16 million adults in the United States (US) have been diagnosed with the condition, with 9 million of them being classified as moderate to severe.

[0003] DED is a multifactorial disorder of the tear film and ocular surface that can cause ocular discomfort symptoms such as dryness, burning, itching, redness, stinging, blurred vision, gritty sensation, pain, foreign body sensation, visual disturbances, tear film instability, eye fatigue, and general ocular surface damage. DED may also make it difficult or impossible for patients to wear contact lenses, read, work on a computer, or drive at night.

[0004] It has been shown that lacrimal glands and ocular surface inflammation play a role in dry eye. Factors that adversely affect tear film stability and permeability can cause ocular surface damage and trigger an inflammatory cascade, thereby producing innate and adaptive immune responses. These immune inflammatory responses lead to further ocular surface damage and the development of a self-sustaining inflammatory cycle. For example, ocular surface inflammation leads to a reduction in tear production, which further worsens the condition and may in turn lead to ocular surface inflammation and epithelial cell damage. In animal models, T cell-mediated inflammation is indeed the cause and result of dry eye. In humans, it was found that dry eye was associated with the presence of conjunctival T cells and increased levels of inflammatory cytokines in tears compared to controls, thus confirming that inflammation is the driving source of the disease.

[0005] DED can be classified as acute, paroxysmal or chronic. In some cases, DED can be classified as a chronic disease with acute attacks. Chronic DED may require year-round attention. Several pharmacological treatments for DED have been explored, and the treatments include a stepwise approach that starts with over-the-counter lubricants and artificial tear substitutes (delivered in the form of drops), progresses to topical anti-inflammatory therapy and tear duct occlusion using punctal plugs to prevent tear drainage.

[0006] Artificial tears increase tear volume, but tear volume may return to its original state as tears drain and fluid is lost, for example, by evaporation or absorption through the ocular epithelium, so frequent applications are required. Although retention time can be increased by adding viscosity enhancers, high-viscosity tear substitutes may cause blurred vision. Although punctal plugs have been shown to be effective in patients with DED, plugs may be lost (showing poor retention) and may rarely migrate into the nasolacrimal duct, thereby causing inflammation or other critical conditions. In some cases, DED can be treated by surgical closure of the punctum with high-temperature cautery. Other therapies approved for patients with DED in the United States are to increase tear production. (cyclosporine), increases tear production (cyclosporine) and for the signs and symptoms of DED (lifitegrast). Recently, Eysuvis TM (loteprednol) is approved for the acute treatment of DED.

[0007] Cyclosporin A is a cyclic polypeptide calcineurin inhibitor immunosuppressant / immunomodulator found in soil fungi, and its immunomodulatory activity can be used to treat immune disorders such as transplant rejection, psoriasis, ulcerative colitis, and rheumatoid arthritis. Calcineurin is an enzyme that activates T cells, which plays a key role in cell-mediated immunity. Because calcineurin inhibitors suppress the immune system, they are called immunosuppressants.

[0008] The exact mechanism by which cyclosporin is used to improve the signs and symptoms of keratoconjunctivitis sicca (KCS) has not been fully determined, but it is believed that it can be used as a partial immunomodulator. In DED, cyclosporin can inhibit lymphocyte infiltration, reduce immune inflammatory reactions, and inhibit apoptosis of lacrimal gland and conjunctival epithelial cells. Cyclosporin interferes with the activity and growth of T cells by entering T cells and binding to cyclophilin, thereby affecting immune function. The complex affects T cell activity by blocking the action of calcineurin and preventing NFATc dephosphorylation and the regulation of the production of proinflammatory cytokines such as IL-2, IL-4, interferon-γ and TNF-α.

[0009] Topical administration of cyclosporine A has been shown to increase tear secretion, possibly by promoting the local release of neurotransmitters associated with the parasympathetic nervous system. Veterinary ophthalmologists conducted a clinical field trial in 124 dogs with KCS to evaluate the effects of twice daily administration of 2.0 mg / mL cyclosporine ( Eye ointment, Intervet Inc.) or vehicle eye ointment after approximately 90 days of treatment, which resulted in increased tear production, however, some dogs showed improvement in clinical signs without an increase in tears.

[0010] This is thought to occur as a result of cyclosporine suppressing ocular surface inflammation. Global improvement was observed in eyes treated with ophthalmic ointment and discontinuation of therapy resulted in rapid clinical regression in all but one of the tested eyes, suggesting the need for long-term continued therapy. In the management of canine KCS, little is known about the mechanism of increased tearing caused by cyclosporine, but clinical improvement is not necessarily dependent on increased tear production. In humans, the beneficial effects of cyclosporine A therapy for DED are better established, and findings from several clinical trials suggest that long-term treatment with topical cyclosporine results in positive outcomes in measures such as corneal surface staining, Schirmer test, blurred vision, frequency of artificial tear application, and cellular and molecular markers of disease severity.

[0011] Cyclosporine was first approved for ophthalmic use in dogs in 1995 for the treatment of KCS. In 2003, cyclosporine was approved as a (0.5 mg / mL cyclosporine ophthalmic emulsion, Allergan) is approved for human ophthalmology and is indicated for increasing tear production in patients whose tear production is presumed to be suppressed due to KCS-related ocular inflammation. Topical cyclosporine eye drops have been shown to reduce inflammatory mediators and increase tear production. Commercially available and marketed topical cyclosporine eye drops are available worldwide for the treatment of DED / KCS, vernal keratoconjunctivitis (VKC), and ocular inflammation. Cyclosporine ophthalmic solutions are currently on the market for topical use in a variety of products in multiple jurisdictions, as listed below.

[0012]

[0013] However, there are limitations to the administration of topical drops that can affect patient management. These limitations include difficult bottle handling, limited instillation accuracy, possible washout of the drops, and limited bioavailability of topical eye drops (Aldrich et al., 2013, Ophthalmic preparations, USP, 39(5), pp. 1-21). Specific issues with currently available cyclosporine eye drop formulations are tolerability issues, such as burning and stinging, and a slow onset of action that can last weeks to months. A higher frequency of application (e.g., several times a day) can severely impact a patient's daily life. In humans, the bioavailability of topical eye drops that reach ocular tissue is less than 5%. Other limitations include a delayed onset of action (weeks to months), and high drug doses in the drops, which can be a cause of adverse reactions, such as side effects with topical cyclosporine eye drops ( NDA#021023)-related ocular burning.

[0014] Therefore, there is an unmet need for a cyclosporin A therapeutic form that overcomes the shortcomings of currently available topical formulations, in particular for a dosage form that allows for a sustained release of cyclosporin A and an associated reduced frequency of administration, which may improve quality of life and patient compliance, with a lower risk of infection and fewer adverse effects, such as eye burning and stinging.

[0015] Drug delivery by punctal plugs is superior to topical drops because the punctal plugs achieve sustained release of the drug over time by forming a reservoir for slow-release drug. Administration consists of a one-time application of the punctal plug, which addresses the limitations inherent in long-term administration of topical eye drops mentioned above.

[0016] However, intracanalicular plugs are also associated with challenges. The intracanalicular route of administration has some potential anatomical limitations (the plug needs to be small enough to enter the lacrimal punctum), and it is difficult to develop an ophthalmic intracanalicular plug that is easy to apply and, if necessary, removable after the drug reservoir is depleted, fits well, i.e., provides adequate retention so that it is not inadvertently lost, and at the same time does not cause any discomfort or unexpected application site reactions such as inflammation.

[0017] In addition, there is a need for adequate and consistent drug release over a sustained period of time. Given the small size of the plug, it is challenging to formulate it to include adequate drug loading and sustained release properties.

[0018] Against this background, it is clear that there is a need for alternative cyclosporine dosage forms that are effective in treating ocular diseases such as DED.

[0019] All references disclosed herein are incorporated by reference in their entirety for all purposes. Summary of the invention

[0020] It is an object of certain embodiments of the present invention to provide an intraductal insert comprising cyclosporine that is effective in treating ocular diseases, particularly DED, in a patient over an extended period of time.

[0021] It is another object of certain embodiments of the present invention to provide an intraductal insert comprising cyclosporine that is effective in treating ocular diseases, particularly blepharitis, in a patient over an extended period of time.

[0022] Another object of certain embodiments of the present invention is to provide an intraductal insert comprising cyclosporine that can effectively treat ocular diseases in patients over an extended period of time, particularly blepharitis, allergic conjunctivitis, and particularly atopic keratoconjunctivitis and vernal keratoconjunctivitis.

[0023] As mentioned above, a major drawback of currently available cyclosporin formulations, such as topical eye drops, is the need for frequent application. The present invention seeks to address this problem by providing a single insert that delivers continuous release of the active agent over an extended period of time, such as weeks, to achieve effective long-term therapy.

[0024] It is therefore another object of certain embodiments of the present invention to provide an intraductal insert comprising cyclosporine that provides sustained release of the cyclosporine on the ocular surface.

[0025] To ensure effective therapy is provided during the period of wear of the insert, the release of cyclosporine should be maintained at a substantially constant level (eg, within a therapeutic window) to provide a therapeutic effect.

[0026] Therefore, another object of certain embodiments of the present invention is to provide an intraductal insert comprising cyclosporine that provides a sustained release and in particular a constant release of cyclosporine on the ocular surface.

[0027] It is also an object of certain embodiments of the present invention to provide an intraductal insert comprising cyclosporine that has a more rapid onset of action, such as within days or even hours.

[0028] Furthermore, the present invention is also intended to maintain and improve patient compliance, which still has room for improvement in current commercial products.

[0029] It is therefore another object of certain embodiments of the present invention to provide an intracanalicular insert comprising cyclosporine that is well tolerated and does not provide intolerable discomfort during or after insertion into the canaliculus.

[0030] It is also another object of certain embodiments of the present invention to provide an intracanalicular insert comprising cyclosporine that is easy to administer, ie, easy to insert into the canaliculus.

[0031] It is another object of certain embodiments of the present invention to provide an intraductal insert comprising cyclosporine that is easy to handle and does not spill like eye drops, or break easily.

[0032] It is another object of certain embodiments of the present invention to provide an intracanalicular insert comprising cyclosporine that is less susceptible to misapplication by a patient and thus avoids overdosing and underdosing.

[0033] It is another object of certain embodiments of the present invention to provide an intracanalicular insert comprising cyclosporine that, once inserted, fits well within the canaliculus and is not easily lost or inadvertently expelled via the tear duct.

[0034] It is another object of certain embodiments of the present invention to provide an intraductal insert comprising cyclosporine that is easily removable or replaceable, or that does not require removal.

[0035] It is therefore another object of certain embodiments of the present invention to provide an intraductal insert comprising cyclosporine that has fewer side effects such as eye burning, stinging or itching when compared to common treatments such as eye drops.

[0036] It is therefore another object of certain embodiments of the present invention to provide an intracanalicular insert comprising cyclosporine that has reduced associated risks such as ocular infection or systemic toxicity when compared to common treatments such as eye drops.

[0037] It is therefore another object of certain embodiments of the present invention to provide an intraductal insert comprising cyclosporine that has little impairment of quality of life, e.g. via therapy-related restrictions such as the inability or only limited possibility to perform contact lens wear, or to read, work on a computer or drive at night.

[0038] It is another object of certain embodiments of the present invention to provide an intraductal insert comprising cyclosporine that is simple to manufacture.

[0039] It is another object of certain embodiments of the present invention to provide an intraductal insert comprising cyclosporine that is easy to store and stable during storage.

[0040] It is another object of certain embodiments of the present invention to provide an intraductal insert comprising cyclosporine that increases tear production and provides a suitable tear volume to a patient over a longer period of time.

[0041] Another object of certain embodiments of the present invention is to provide an intraductal insert comprising cyclosporine that resolves or alleviates symptoms of ocular surface diseases, particularly DED, such as dry eyes, burning, itching, redness, stinging, gritty sensation, pain, foreign body sensation, visual disturbances, tear film instability, eye fatigue, and ocular surface damage in patients over a prolonged period of time.

[0042] Another object of certain embodiments of the present invention is to provide a method for treating or preventing an eye disease, particularly DED, in a patient over a prolonged period of time, which method solves one or more of the problems mentioned in the above-listed objects.

[0043] Another object of certain embodiments of the present invention is to provide a method of treating an ocular disease, particularly blepharitis, in a patient over an extended period of time, which method solves one or more of the problems mentioned in the above-listed objects.

[0044] Another object of certain embodiments of the present invention is to provide a method for treating eye diseases in patients over a longer period of time, particularly blepharitis, allergic conjunctivitis, and particularly atopic keratoconjunctivitis and vernal keratoconjunctivitis, which method can solve one or more of the problems mentioned in the above-listed objects.

[0045] It is another object of certain embodiments of the present invention to provide a method of treating or preventing DED, the method comprising inserting a biodegradable insert comprising a hydrogel and cyclosporine into a patient's canaliculus, wherein the method solves one or more of the problems listed above with respect to the purpose of providing an intracanalicular insert.

[0046] Another object of certain embodiments of the present invention is to provide a method of treating or preventing DED, the method comprising inserting a biodegradable insert comprising a hydrogel and cyclosporine into a patient's canaliculus, and after a longer period of time, such as at least about 2 months, inserting a second biodegradable insert comprising a hydrogel and cyclosporine into the same canaliculus, wherein the method solves one or more of the problems listed above with respect to the purpose of providing an intracanalicular insert.

[0047] It is another object of certain embodiments of the present invention to provide a method for treating or preventing an ocular disease, particularly DED, in a patient over an extended period of time, wherein the therapeutic effect achieved exceeds that achieved by treatment with a combination of punctal occlusion with a drug-free punctal plug and administration of cyclosporine eye drops.

[0048] Another object of certain embodiments of the present invention is to provide a method of manufacturing an intracanalicular insert that solves one or more of the problems mentioned in the above-listed objects related to intracanalicular inserts.

[0049] One or more of these objects, as well as other objects, of the present invention are addressed by one or more embodiments disclosed and claimed herein.

[0050] Various aspects of the invention are disclosed in this specification and claimed in the independent claims, while the dependent claims claim specific embodiments and variations of these aspects of the invention.The following detailed description will provide details of various aspects of the invention. BRIEF DESCRIPTION OF THE DRAWINGS

[0051] Figure 1 is a schematic diagram of the eye and tear system.

[0052] Figure 1.2A Depicted are dry insert fibers and hydrated insert fibers prepared in Example 1.2 (Run 1 and Run 2).

[0053] Figure 1.2B Depicted are dry insert fibers and hydrated insert fibers prepared in Example 1.2 (Run 3).

[0054] Figure 1.2C Depicted are dry insert fibers and hydrated insert fibers produced in Example 1.2 (low, medium, and high doses). The major portion of the dry insert fibers produced, independent of the dose, are particulate, cylindrical, and free of any noticeable surface defects (left). In addition, the insert with the highest surface deformation for each dose is shown (right).

[0055] Figure 1.3 Depicted are the dry insert fibers and hydrated insert fibers prepared in Example 1.3.

[0056] Figures 1.4A to 1.4E Depicted are the insert dry density and drug loading of each insert, dry diameter, dry density, microscopic images, and a graph showing the change in dry diameter and hydrated diameter, respectively, of the insert fibers prepared in Example 1.4 as a function of hydration time.

[0057] Figure 2 A chromatogram showing the conversion of NHS-fluorescein to fluorescein-trilysine conjugate is depicted.

[0058] Figure 3.1 Depicted are the results of tear production as measured by the Schirmer tear test of Example 3.4 over time.

[0059] Figure 3.2A and 3.2B Depicted is the change in cyclosporine A (CsA) concentration over time as measured in beagle tears in Example 3.5.

[0060] Figure 3.3Depicted is the change in cyclosporine A (CsA) concentration over time as measured in beagle dog tears in Example 3.6.

[0061] Figure 4A A general schematic diagram depicting the human clinical study outline of Example 4 is shown.

[0062] Figure 4B An exemplary general schematic diagram of placement of an insert into a human tear canaliculus is depicted.

[0063] FIG. 5A to FIG. 5D An exemplary schematic diagram depicting the steps required to place an insert into a human tear canaliculus.

[0064] Fig. 6A and Figure 6B Depicted is the study eye measured by the Schirmer tear test of Example 4.1 ( Fig. 6A ) and non-study eye ( Figure 6B The black solid line represents the average Schirmer score of all analyzed individuals, while the dotted line represents the Schirmer score of a single individual.

[0065] Fig. 7A and Figure 7B Depicted are the total corneal fluorescein staining (tCFS) values ​​(mean of all eyes) from Example 4.1 expressed as absolute values ​​over time and as changes from baseline

[0066] Fig. 8A and Figure 8B The results of Example 4.1 for dry eye severity scores on the visual analogue scale (VAS) are depicted as absolute values ​​over time and as changes from baseline.

[0067] Fig. 9 The results of dry eye frequency scores on the visual analogue scale (VAS) in Example 4.1 are depicted as absolute values ​​over time.

[0068] Fig.10 The results of OSDI in Example 4.1 are depicted as mean absolute values ​​over time.

[0069] Fig.11 The results of the SPEED score in Example 4.1 are depicted as absolute values ​​over time.

[0070] definition

[0071] As used herein, the term "intra-canalicular insert" refers to an object containing an active agent, specifically cyclosporin, that is administered, i.e., inserted into the canaliculus, where it remains for a period of time while it releases the active agent into the surrounding environment. The insert may be of any predetermined shape, most commonly in the shape of a rod prior to insertion, which shape may be maintained to a certain extent when the insert is placed in the desired position, although the size of the insert (e.g., length and / or diameter) may change after administration due to hydration, as further disclosed herein. In other words, what is inserted into the eye is not a solution or suspension, but an already formed, attached object. Thus, prior to administration, the insert has been fully formed, for example, according to the methods disclosed herein. The intra-canalicular insert may be designed to be biodegradable over time (as disclosed below), and may therefore soften, change its shape and / or reduce its size, and may eventually be eliminated by dissolving or disintegrating, at which point the remainder of the insert will be discharged along the canaliculus. In the present invention, the term "insert" is used to refer to an insert in a hydrated (also called "swollen") state when containing water (e.g., after (re)hydration of the insert after application to the eye or otherwise immersed in an aqueous environment) and in a dry (dry / dehydrated) state, e.g., when dried to a low water content, e.g., not more than 1% by weight.

[0072] The term "ocular" as used herein generally refers to the eye, or any component or part of the eye ("ocular insert" can in principle be applied to any component or part of the eye). In certain embodiments, the present invention relates to intraductal injection of an ocular insert, and treatment of dry eye disease (DED), as further disclosed below.

[0073] The term "biodegradable" refers to a material or object (e.g., an intracanalicular insert according to the present invention) that degrades in vivo, i.e., when placed in a human or animal body. In the context of certain embodiments of the present invention, as disclosed in detail below, an insert comprising a hydrogel containing cyclosporin slowly biodegrades over time after being applied to the canaliculus of the eye. In certain embodiments, biodegradation occurs at least in part via ester hydrolysis in the aqueous environment of the canaliculus. The insert slowly softens and disintegrates, resulting in clearance via the nasolacrimal duct.

[0074] A "hydrogel" is a three-dimensional network structure composed of one or more hydrophilic natural or synthetic polymers (as disclosed herein) that can swell in water and retain a certain amount of water while maintaining or substantially maintaining its structure due to, for example, chemical or physical crosslinking of individual polymer chains. Due to the high water content, the hydrogel is soft and flexible, which makes it very similar to natural tissue. In the present invention, the term "hydrogel" is used to refer to a hydrogel in a hydrated state when it contains water (e.g., after forming the hydrogel in an aqueous solution, or after hydration or (re)hydration after the hydrogel is inserted into the eye or otherwise immersed in an aqueous environment) and in a dry (dry / dehydrated) state when, for example, dried to a low water content of, for example, not more than 1% by weight. In the present invention, when an active ingredient is contained (e.g., dispersed) in the hydrogel, the hydrogel may also be referred to as a "matrix."

[0075] The term "polymer network" describes a structure formed by polymer chains (polymer chains with the same or different molecular structure and the same or different molecular weight) cross-linked to each other. Types of polymers suitable for the purposes of the present invention are disclosed below.

[0076] The term "amorphous" refers to a polymer or polymer network that does not exhibit a crystalline structure in X-ray or electron scattering experiments.

[0077] The term "semicrystalline" refers to a polymer or polymer network that has some crystalline properties, ie, exhibits some crystalline characteristics in X-ray or electron scattering experiments.

[0078] The term "precursor" herein refers to those molecules or compounds that react with each other and thereby form a polymer network via cross-linking and thereby form a hydrogel matrix. Although other materials may be present in the hydrogel, such as active agents or buffers, such materials are not referred to as "precursors".

[0079] The parts of the precursor molecules that are still present in the final polymer network are also referred to herein as "units". Thus, a "unit" is a structural unit or component of a polymer network that forms a hydrogel. For example, a polymer network suitable for use in the present invention may contain the same or different polyethylene glycol units, as will be further disclosed herein.

[0080] For the purposes of the present invention, the term "sustained release" is intended to characterize a class of products that are formulated to make cyclosporin available over a longer period of time, thereby reducing the frequency of dosing compared to an immediate release dosage form, such as a cyclosporin solution applied topically to the eye (i.e., eye drops containing cyclosporin). Other terms that may be used interchangeably with "sustained release" herein are "extended release" or "controlled release". Within the meaning of the present invention, the term "sustained release" encompasses a constant release of cyclosporin, a decreasing release of cyclosporin, and any combination thereof, such as a constant release of cyclosporin followed by a decreasing release of cyclosporin. Within the meaning of the present invention, the term "tapered" or "tapering" refers to a decrease in the amount of cyclosporin released over time.

[0081] As used herein, the term "prolonged period of time" refers to any period of time that one of ordinary skill in the art would consider to be extended for the treatment of a disease, and in particular refers to, for example, a period of time of at least about 1 week, or at least about 1 month or longer, such as up to about 12 months, or any intermediate period, such as about 1 to about 6 months, about 2 to about 4 months, about 2 to about 3 months, or about 3 to about 4 months.

[0082] As used herein, the term "wearing time" refers to the period of time during which the intracanalicular insert is present in the canaliculus, i.e., the period from the application of the insert until the insert is eliminated from the canaliculus. In certain embodiments, the elimination of the insert can be achieved by removing the insert (which may be intentional or unintentional, but does not occur spontaneously without the application of external force) or by spontaneous removal after a longer period of time after the insert is completely biodegraded, completely disintegrated, or substantially disintegrated, thereby discharging the remainder of the insert. In certain embodiments, the wearing time is at least about 1 week, or at least about 1 month or longer, such as up to about 12 months, or any intermediate period, such as about 1 to about 6 months, about 2 to about 4 months, about 2 to about 3 months, or about 3 to about 4 months.

[0083] As used herein, the term "chromogenic agent" refers to a molecule or composition contained within the hydrogel of an insert that can make the insert easily visible when inserted into the tear canaliculus of the eye. The chromogenic agent can be a fluorophore such as fluorescein, rhodamine, coumarin, and cyanine. In certain embodiments, the chromogenic agent is fluorescein or includes a fluorescein moiety.

[0084] As used herein, "ocular surface" includes the conjunctiva and / or cornea, as well as components such as the lacrimal apparatus, including the puncta, and the canaliculi and associated eyelid structures.

[0085] As used herein, the term "tears" or "tears" refers to the liquid secreted by the lacrimal glands, which lubricates the eyes and thereby forms the tear film. Tears are composed of water, electrolytes, proteins, lipids, and mucins.

[0086] As used herein, in the context of the present invention, the terms "administration", "insertion", "administering" and "inserting" are used synonymously and refer to the placement of an insert into the canaliculus, and in particular placement into the vertical portion of the canaliculus, for example according to the procedure described in Example 4.II (Insert Placement).

[0087] As used herein, the term "bilaterally" or "bilaterally" in the context of administering the insert of the present invention means administering the insert into both eyes of the patient. For each eye, the insert may be inserted into the upper canaliculus or the lower canaliculus of the eye, or into both the upper canaliculus and the lower canaliculus of the eye.

[0088] The term "plug" refers to a device that can occlude, substantially occlude or partially occlude the tear duct ("tear duct occlusion"), thereby preventing or reducing the discharge of tears, which helps to keep the eyes moist. Plugs can be divided into "punctal plugs" and "canalicular plugs". Canalicular plugs are also referred to as "canalicular plugs" in the literature. Both types of plugs are inserted via the upper and / or lower puncta of the eye. Punctal plugs are placed at the opening of the punctum, making them easy to see and therefore can be removed without any effort. However, punctal plugs show poor retention rates and are contaminated by microorganisms due to exposure of their composition, which can lead to infection in rare cases. In contrast, canalicular plugs are invisible and provide better retention rates compared to punctal plugs because they are placed in vertical or horizontal canaliculi. However, canalicular plugs are not easy to remove and the risk of their migration increases. Commercially available plugs are usually made of collagen, acrylic or silicone.

[0089] As used herein, the term "canaliculus" (plural "canaliculi") or "tear duct" refers to the canaliculus, a small channel in each eyelid that drains tears from the lacrimal punctum to the nasolacrimal duct (see also Figure 1 ). Thus, the canaliculi form part of the lacrimal apparatus, which drains tears from the surface of the eye to the nasal cavity. The canaliculi in the upper eyelid are called "upper canaliculi" or "upper canaliculi", while the canaliculi in the lower eyelid are called "lower canaliculi" or "lower canaliculi". Each canaliculus contains a vertical region along the lacrimal punctum, called the "vertical canaliculi"; and a horizontal region along the vertical canaliculi, called the "horizontal canaliculi", wherein the horizontal canaliculi merge into the nasolacrimal duct.

[0090] The term "punctum" (plural "puncta") refers to the lacrimal punctum, a tiny opening at the edge of the eyelid that represents the entrance to the lacrimal canaliculus. When tears are produced, some evaporates between each blink and some is drained via the punctum. Both the upper and lower eyelids display puncta, and the puncta are therefore referred to as the "upper punctum" or "upper punctum" and the "lower punctum" or "lower punctum", respectively (see also Figure 1 ).

[0091] The term "intra-canalicular insert" refers to an insert that can be applied into the upper or lower canaliculus of the eye or both of the upper and lower canaliculus of the eye, particularly into the upper vertical canaliculus or lower vertical canaliculus of the eye or into the upper and lower vertical canaliculus of the eye, via the upper or lower punctum or via both the upper and lower punctum. Since the insert is positioned in the canaliculus, the insert prevents tear drainage by means of tear duct occlusion, as observed with canaliculus intraplugs. In certain embodiments, the canaliculus intraplug of the present invention is inserted bilaterally into the lower vertical canaliculus of the eye. According to certain embodiments of the present invention, the canaliculus intraplug is a sustained release biodegradable insert.

[0092] The terms "API", "active (pharmaceutical) ingredient (ingredient)", "active (pharmaceutical) agent", "active (pharmaceutical) principle" "(active) therapeutic agent", "active agent" and "drug" are used interchangeably herein and refer to substances used in finished pharmaceutical products (FPPs) and substances used to prepare such finished pharmaceutical products, which are intended to provide pharmacological activity or otherwise have a direct effect on the diagnosis, cure, mitigation, treatment or prevention of disease, or to restore, correct or modify the physiological function of a patient.

[0093] The API used according to the present invention is cyclosporin A. As used herein, the term "cyclosporin" refers to cyclosporin A, and specifically does not refer to cyclosporin B, C, D, E, H and L, which are metabolites of cyclosporin A; nor does it refer to cyclosporin U, G, dihydrocyclosporin A or isocyclosporin A, which may be contained in cyclosporin A as impurities. In certain embodiments, cyclosporin A may contain cyclosporin B, C, D, E, G, H, L and U, dihydrocyclosporin A and isocyclosporin A as impurities at a concentration of no more than 1.0% each or a concentration of no more than 0.7% each; may also contain unknown impurities at a concentration of no more than 0.3% each or a concentration of no more than 0.1% each, and may contain impurities in a total amount of no more than 2.5% or no more than 1.5%.

[0094] The molecular formula of cyclosporine A is C 62H 111 N 11 O 12 And its IUPAC name is 30-ethyl-33-(1-hydroxy-2-methylhex-4-enyl)-1,4,7,10,12,15,19,25,28-nonamethyl-6,9,18,24-tetrakis(2-methylpropyl)-3,21-di(propan-2-yl)-1,4,7,10,13,16,19,22,25,28,31-undecazacyclotriacontane-2,5,8,11,14,17,20,23,26,29,32-undecanone (CAS No. 59865-13-3). Its molecular weight is 1203 Daltons. It has the following chemical structure:

[0095]

[0096] Cyclosporin is a white to almost white powder that is soluble in various organic solvents, such as acetone, methanol, and ethanol (96% v / v), but is virtually insoluble in water. In certain embodiments, cyclosporin is micronized.

[0097] For the purposes of the present invention, all possible forms of cyclosporin can be used, including polymorphs or any pharmaceutically acceptable salts, anhydrates, hydrates, other solvates or derivatives. When cyclosporin is mentioned in the specification or claims and is not further specified, even if not explicitly stated, it refers to cyclosporin A (see above) in the form of any such polymorph, pharmaceutically acceptable salt, anhydrate, solvate (including hydrate) or derivative of cyclosporin. For cyclosporin, suitable solid forms include, but are not limited to, pure substance forms in any physical form known to those of ordinary skill in the art. For example, cyclosporin can be in the form of particles. The particles can be amorphous or crystalline, or present a mixture of the two forms, and can be made of any size, which can be classified as coarse particles, fine particles or ultrafine particles, but not limited thereto, and the size of the particles can be particularly visible to the naked eye or visible under a microscope, and have, for example, the shape of single crystals and aggregates. The particles can also be micronized. As used herein, the term "micronized" refers to small-sized particles, particularly microscopic-scale particles, which are reduced in size by, for example, but not limited to, jet milling, jaw crushing, hammer milling, wet milling, precipitation in a non-solvent, cryogenic grinding (grinding under liquid nitrogen or dry ice), and ball milling. The cyclosporin may also be in a dissolved or dispersed state, such as dissolved or dispersed in a solvent or in an aqueous medium, for example in the form of particles dispersed in an aqueous suspension, which may optionally include other excipients such as surfactants.

[0098] As used herein, the term "therapeutically effective" refers to the amount of cyclosporine required to produce the desired therapeutic outcome after administration. For example, in the context of the present invention, a desired therapeutic outcome would be a reduction in DED-related symptoms, such as measured by in vivo tests known to those of ordinary skill in the art, such as an increase in Schirmer tear test scores; a decrease in staining values ​​as measured by conjunctival lissamine green staining or corneal fluorescein staining; a decrease in dry eye severity and / or dry eye frequency scores on a visual analog scale (VAS); a decrease in the ocular surface disease index and / or standard patient dry eye assessment scores; and a decrease in best corrected visual acuity. In one embodiment, "therapeutically effective" refers to sustained release of cyclosporine in an intracanalicular insert that is capable of achieving a tear concentration of 0.236 μg / mL over an extended period of time (which is considered necessary for immunomodulation; Tang-Liu and Acheampong, Clin. Pharmacokinet. 44(3), pp. 247-261), and in particular, after achieving that tear concentration, such that the insert remains substantially intact during wear.

[0099] As used herein, the values ​​"d10", "d50", "d90" and "d100" refer to values ​​that characterize the amount of particles that meet a specific particle size in a particle size distribution. In a given particle size distribution, 10% of the particles present a particle size of d10 or less, 50% of the particles present a particle size of d50 or less, 90% of the particles present a particle size of d90 or less, and substantially all of the particles present a particle size of d100 or less. The percentages may be given by different parameters known to those of ordinary skill in the art, for example, the percentages may be based on the volume, weight or number of particles. Thus, d50 may be illustratively a median particle size based on volume, weight or number. For example, a volume-based d90 of 43 μm means that 90% of the particles by volume have a particle size of 43 μm or less. In certain embodiments, d10, d50 and d90 are volume-based values. The particle size distribution PSD can generally be measured by methods known to those of ordinary skill in the art, and include sieving methods and laser diffraction methods. In certain embodiments, PSD is measured according to USP <429> Laser diffraction measurement in light diffraction particle size measurement In certain embodiments, PSD is measured by laser diffraction using a Beckman Coulter LS 13 320 based on the optical model "Fraunhofer.rf780z" with an obscuration value in the range of 7% to 9%.

[0100] As used herein, the term "about" in connection with a measured quantity refers to the normal variation in the measured quantity that one of ordinary skill in the art would expect when making the measurements and exercising a degree of care commensurate with the precision of the object being measured and the measuring equipment.

[0101] The term "at least about" in connection with a measured quantity refers to the normal variation in the measured quantity that one of ordinary skill in the art would expect when making the measurements and exercising a degree of care commensurate with the precision of the object being measured and the measuring equipment, and any amount above the stated quantity.

[0102] As used herein, the singular forms "a," "an," and "the" include plural references unless the context clearly dictates otherwise.

[0103] The term "and / or" used in phrases such as "A and / or B" is intended herein to include "A and B" and "A or B."

[0104] Open-ended terms such as “include / including”, “contain / containing”, etc. mean “comprsing”. These open transition phrases are used to describe an open list of elements, method steps, etc., and do not exclude additional, unlisted elements or method steps. DETAILED DESCRIPTION

[0105] I. Intraductal Insert

[0106] According to certain embodiments, the intracanalicular insert of the present invention is characterized in that the insert provides sustained release, is biodegradable and comprises a hydrogel and cyclosporine.

[0107] As also outlined in the definitions section above, providing sustained release in the context of the present invention means that the insert is able to make the cyclosporin available for an extended period of time. The insert is applied to the eye and slowly releases the cyclosporin into the tear fluid. As the tear fluid is slowly renewed by the production of new tears from the tear glands, replacing the tears already present on the ocular surface that are drained via the tear ducts, the cyclosporin present in the insert is slowly released into the tear fluid with each blink, without any action by the patient. Thus, the insert provides an advantageous, hands-free alternative to traditional eye drops.

[0108] Typically, sustained release is maintained for example for several weeks, thereby significantly reducing the multiple daily dosing frequency of current products (since the products are in the form of topical eye drops that are easily and rapidly washed out). This means that patients can benefit from the therapeutic effects of the insert without having to remind themselves to apply eye drops several times a day, which is a huge advantage in itself, but also reduces the risk of incorrect dosing due to inaccurate instillation or incorrect handling / application and the risk of infection due to reusing eye drop bottles.

[0109] In addition, as outlined again in the definition section above, in certain embodiments, the insert of the present invention is designed to slowly biodegrade over a pre-specified time after administration. This means that the insert can remain in the canaliculus and does not need to be explanted. Typically, the insert does not need to be removed, but the patient can simply leave the insert until it is cleared. On the other hand, in unexpected events such as allergic reactions, discomfort in wearing, or other adverse events such as irritation, the (partially biodegradable) insert can be removed by applying slight pressure to expel the insert to the outside through the lacrimal punctum or to move the insert further down the canaliculus to be cleared via the nasolacrimal duct. At the end of the wearing time, the cyclosporin in the insert is exhausted, and thus the insert needs to be replaced with a new insert to maintain the therapeutic effect, the ability to remove and / or easily remove is also advantageous.

[0110] The intracanalicular insert of the present invention also comprises a hydrogel. As explained in detail in the definition section, the hydrogel is capable of absorbing water and transitioning from a dry state to a hydrated state. In certain embodiments, the hydration of the hydrogel causes the insert to change its shape. In a specific embodiment, the diameter of the insert expands and the length contracts, so that a thin rod-shaped insert can be easily inserted into the canaliculus in a dry state, and after application and correct positioning, its diameter expands in the canaliculus, thereby making it fit securely and reducing the risk of migration or loss of the insert. Although firmly fixed in place, the hydrated insert is soft and therefore comfortable to wear.

[0111] In certain embodiments, the hydrogel comprises a polymer network. Further details on the polymer network are provided below.

[0112] For example, compositions of such highly swellable to securely hold hydrogel plugs have been disclosed in US Pat. No. 8,409,606 (hereby incorporated by reference for all purposes; the present specification controls in the event of a conflict).

[0113] Active ingredients:

[0114] Details regarding cyclosporin, its chemical structure and its properties are provided in the definitions section above. As outlined therein, cyclosporin is virtually insoluble in water, and therefore, without wishing to be bound by theory, it is hypothesized that upon contact with tear fluid, the low drug solubility under physiological conditions (approximately 10 μg / mL) combined with the cross-sectional area of ​​the insert contacting the tear fluid and the limited volume of tear fluid are believed to modulate the release rate of the drug.

[0115] On the other hand, the form and amount of cyclosporine embedded in the hydrogel may also affect the dissolution of cyclosporine and the achievement of a therapeutically effective release rate.

[0116] An aspect of certain embodiments of the present invention is a sustained release biodegradable intraductal insert comprising a hydrogel and cyclosporine, wherein the cyclosporine is in particulate form and wherein the cyclosporine particles are dispersed within the hydrogel.

[0117] In certain embodiments of the present invention, the cyclosporin particles are uniformly dispersed in the hydrogel. As used herein, dispersed in the hydrogel means that the cyclosporin particles are present in the form of a substantially pure substance embedded in the matrix, but it is not excluded that a small amount of cyclosporin will be found on the surface of the matrix. In certain embodiments, the cyclosporin particles form an independent hydrophobic phase, which does not contain other excipients other than cyclosporin and any impurities that may be present in the active material used, and in particular does not refer to any microspheres, microparticles or hydrophobic microdomains that entrap drugs and contain other materials such as oils, fats, fatty acids, waxes, fluorocarbons or other previously proposed non-water-miscible microspheres. Cyclosporin in a substantially pure form has the advantage of being easy to manufacture because no further processing of the active material is required to prepare, for example, microspheres, microparticles or hydrophobic microdomains.

[0118] In certain embodiments, the cyclosporin may have: a loss on drying of no more than 1.5% w / w as measured at 60°C and a pressure of no more than 5 mmHg in a capillary stopper vial at 100 mg; a heavy metal content of no more than 0.002%; organic impurities as defined in the product specifications section of Example 2, and in particular, no more than 1.5% of the sum of all impurities as measured by HPLC; a cyclosporin content of no less than 97.0% and no more than 101.5% as measured by HPLC; and no more than 4500 ppm of residual acetone and no more than 2000 ppm of residual ethyl acetate as measured by GC headspace.

[0119] In certain embodiments and as also shown in the Examples (see in particular Example 2), the inserts of the invention are stable upon storage and the cyclosporine content does not substantially change after long-term storage.

[0120] Thus, in certain embodiments, the cyclosporin content measured by HPLC after storage at a temperature of 2 to 8°C for at least 3 months, at least 6 months, or at least 12 months and the initial cyclosporin content measured by HPLC directly before storage is about 300 to about 410 μg.

[0121] In certain embodiments, the cyclosporine content measured by HPLC after storage for at least 3 months, at least 6 months, or at least 12 months at a temperature of 2 to 8°C is in the range of 90% to 110% by weight, or in the range of 95% to 105% by weight, or in the range of 98% to 102% by weight of the initial cyclosporine content measured by HPLC directly before storage.

[0122] In certain embodiments, the amount of impurities measured by HPLC after storage at a temperature of 2 to 8°C for at least 3 months, at least 6 months, or at least 12 months does not exceed 3.0%.

[0123] In certain embodiments of the invention, the cyclosporin is in particulate form. In certain embodiments, the particles are micronized particles. Without wishing to be bound by theory, it is believed that the cyclosporin particles, and particularly small cyclosporin particles, in a dispersed state enable the active agent to dissolve quickly enough to allow for rapid onset of action.

[0124] In certain embodiments of the invention, the cyclosporin particles have a d50 value of less than about 50 μm, or a d90 value of less than about 43 μm, or a d100 value of less than about 45 μm, as measured by laser diffraction. As shown in the Examples (see Example 1.4), it is believed that large particles have an effect on the mechanical properties of the intracanalicular insert. In addition, large particles also tend to clog the tube, thereby making casting the precursor mixture (as further outlined below) difficult or even impossible.

[0125] In certain embodiments of the invention, the d50 value of the cyclosporin particles ranges from about 3 to about 17 μm, or from about 4 to about 12 μm, or from about 5 to about 8 μm. As shown in the examples (see Example 1.4), the particle size has a large impact on the density, swelling behavior and surface quality of the insert, and a trade-off needs to be made between the high density and smoother insert surface achievable with smaller particles and the preferred hydration and swelling behavior of larger particles.

[0126] In certain embodiments, the d50, d90, and d100 values ​​refer to the values ​​of the cyclosporine particles used to make the insert, or the values ​​of the cyclosporine particles present in the insert.

[0127] In terms of the amount of cyclosporin contained in the insert, in certain embodiments, it is desirable to have a high concentration of active agent in the insert, as it will allow a high dose of active agent (resulting in sustained release for a longer time and / or at a constant rate, as will be further discussed below) at the same insert size, or at the same dose but in a smaller product size, while the same dose but in a smaller product size is preferred in terms of ease of administration and wearing comfort. On the other hand, the concentration has a non-negligible effect on the quality of the insert, as shown in Example 1.1. That is, too high or too low concentrations tend to result in the manufacture of inserts that are "strawed", with a large stem diameter and hollow pores. In addition, lower drug concentrations appear to improve swelling / hydration behavior.

[0128] In certain embodiments of the invention, the insert contains from about 15 wt % to about 80 wt %, or from about 30 wt % to about 65 wt %, or from about 45 wt % to about 55 wt % cyclosporin in the dry state, based on the total weight of the insert.

[0129] One aspect of the present invention is a sustained release biodegradable intracanalicular insert comprising a hydrogel and cyclosporine, wherein the insert in a dry state contains from about 40 wt % to about 80 wt % cyclosporine based on the total weight of the insert.

[0130] Dosage, in terms of the absolute amount of active agent, is an important factor in achieving sustained release.

[0131] In certain embodiments of the invention, the insert comprises cyclosporine in an amount ranging from about 100 μg to about 800 μg.

[0132] Cyclosporin is included in the insert of the invention in a dosage range, such as about 100 μg to about 800 μg, about 100 μg to about 300 μg, about 300 μg to about 450 μg, or about 500 μg to about 800 μg. Any amount within these ranges may be used, such as about 250 μg, about 360 μg, about 600 μg, or about 670 μg, all values ​​also including deviations of +25% and -20%, or + / -15%, or + / -10%.

[0133] The disclosed amounts of cyclosporin, including the deviations mentioned, refer to the final content of the active ingredient in the insert, as well as the amount of active ingredient used as a starting component in the manufacture of the insert.

[0134] Polymer Network:

[0135] As described above, in certain embodiments, the hydrogel comprises a polymer network. The hydrogel can be formed from precursors having functional groups that form crosslinks to produce such polymer networks. These crosslinks between polymer chains or arms can be chemical (i.e., covalent bonds) and / or physical (e.g., ionic bonds, hydrophobic associations, hydrogen bridges, etc.).

[0136] The polymer network can be prepared from precursors, which are from one type of precursor or from two or more types of precursors that can react. The precursor is selected taking into account the desired properties of the resulting hydrogel. There are a variety of suitable precursors that can be used to make hydrogels. Generally, any pharmaceutically acceptable and cross-linkable polymer that forms a hydrogel can be used for the purpose of the present invention. The hydrogel and the components thus incorporated therein, including the polymers used to make the polymer network, should be physiologically safe so that they do not cause, for example, an immune response or other adverse effects. The hydrogel can be formed by natural, synthetic or biosynthetic polymers.

[0137] Natural polymers may include glycosaminoglycans, polysaccharides (eg, polydextrose), polyamino acids, and proteins, or mixtures or combinations thereof.

[0138] Synthetic polymers can generally be any polymer synthesized from a variety of raw materials by different types of polymerization reactions, including free radical polymerization, anionic or cationic polymerization, chain growth or addition polymerization, condensation polymerization, ring opening polymerization, etc. The polymerization reaction can be initiated by certain initiators, by light and / or heat, and can be mediated by catalysts.

[0139] Generally, for the purposes of the present invention, one or more synthetic polymers from the group comprising one or more units of polyethylene glycol (PEG), polyethylene oxide, polypropylene oxide, polyvinyl alcohol, poly(vinyl pyrrolidone), polylactic acid, polylactic-co-glycolic acid, random or block copolymers, or combinations / mixtures of any of these may be used, although this list is not intended to be limiting.

[0140] To form a covalently crosslinked polymer network, the precursors can be covalently crosslinked with each other. In certain embodiments, precursors having at least two reactive centers (eg, in free radical polymerization) can be used as crosslinkers because each reactive group can participate in the formation of a different growing polymer chain.

[0141] Precursors may have a bioinert and hydrophilic portion, such as a core. In the case of a branched polymer, a core refers to a continuous portion of a molecule that is engaged with an arm extending from the core, wherein the arm carries a functional group that is typically located at the end of the arm or branch. Multi-arm PEG precursors are examples of such precursors and will be further disclosed below.

[0142] Therefore, the hydrogel for the present invention can be made of, for example, a multi-arm precursor with a first (group) functional group and another multi-arm precursor with a second (group) functional group. For example, the multi-arm precursor can have a hydrophilic arm, such as a polyethylene glycol unit, terminated with a primary amine (nucleophilic reagent), or can have an active ester end group (electrophilic reagent). The polymer network according to the present invention can contain the same or different polymer units cross-linked to each other. The precursor can be a high molecular weight component (e.g., a polymer with a functional group) or a low molecular weight component (e.g., a low molecular weight amine, thiol, ester, etc.).

[0143] Certain functional groups can be made more reactive by using activating groups. Such activating groups include, but are not limited to, carbonyldiimidazole, sulfonyl chloride, aryl halide, sulfosuccinimide esters, N-hydroxysuccinimide (NHS) esters, succinimide esters, epoxides, aldehydes, maleimides, imide esters, acrylates, and the like. NHS esters are useful groups for crosslinking nucleophilic polymers, such as primary amine-terminated or thiol-terminated polyethylene glycols. The NHS-amine crosslinking reaction can be carried out in aqueous solution and in the presence of a buffer, such as phosphate buffer (pH 5.0-7.5), triethanolamine buffer (pH 7.5-9.0), borate buffer (pH 9.0-12), or sodium bicarbonate buffer (pH 9.0-10.0).

[0144] In certain embodiments, each precursor may contain only nucleophilic functional groups or only electrophilic functional groups, as long as both nucleophilic precursors and electrophilic precursors are used in the cross-linking reaction. Thus, for example, if the cross-linking agent has only nucleophilic functional groups, such as amines, the precursor polymer may have electrophilic functional groups, such as N-hydroxysuccinimide. On the other hand, if the cross-linking agent has electrophilic functional groups, such as sulfosuccinimide, the functional polymer may have nucleophilic functional groups, such as amines or thiols. Thus, functional polymers, such as proteins, poly(allylamine)s or amine-terminated bifunctional or multifunctional poly(ethylene glycol), may also be used to prepare the polymer networks of the present invention.

[0145] In one embodiment of the invention, the precursors forming the polymer network of the hydrogel in which the cyclosporin is dispersed to form the insert according to the invention each have from about 2 to about 16 nucleophilic functional groups (referred to as functionality), and in another embodiment, the precursors each have from about 2 to about 16 electrophilic functional groups (referred to as functionality). Reactive precursors having multiples of 4 reactive (nucleophilic or electrophilic) groups, thus for example having 4, 8 and 16 reactive groups, are particularly suitable for use in the present invention. Precursors used according to the present invention may have any number of functional groups, for example including any number of 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 or 16 groups, while ensuring that the functionality is sufficient to form a sufficiently cross-linked network.

[0146] PEG hydrogel:

[0147] In a certain embodiment of the invention, the polymer network forming the hydrogel contains polyethylene glycol (PEG) units. It is known in the art that PEG forms hydrogels when cross-linked, and these PEG hydrogels are suitable for medical applications, for example as a matrix for drugs intended to be administered to all parts of the human or animal body.

[0148] The polymer network of the hydrogel insert of the present invention may comprise one or more multi-arm PEG units having 2 to 10 arms, or 4 to 8 arms, or 4, 5, 6, 7, or 8 arms. In certain embodiments, the PEG units used in the hydrogels of the present invention have 4 and / or 8 arms. In certain specific embodiments, a 4-arm PEG is used.

[0149] The number of arms of the PEG used helps control the flexibility or softness of the resulting hydrogel. For example, a hydrogel formed by crosslinking a 4-arm PEG is generally softer and more flexible than a hydrogel formed by an 8-arm PEG of the same molecular weight. In particular, if it is desired to stretch the hydrogel before (or after) drying, as disclosed below in the section related to the manufacture of the insert, a more flexible PEG unit, such as a 4-arm PEG, can be used, optionally in combination with another multi-arm PEG, such as the 8-arm PEG disclosed above, or another (different) 4-arm PEG.

[0150] In certain embodiments of the invention, the average molecular weight of the polyethylene glycol units used as precursors is in the range of about 2,000 to about 100,000 Daltons, or in the range of about 10,000 to about 60,000 Daltons. In certain specific embodiments, the average molecular weight of the polyethylene glycol units is in the range of about 10,000 to about 40,000 Daltons. In a specific embodiment, the polyethylene glycol units used to make the hydrogel according to the invention have a molecular weight of about 20,000 Daltons.

[0151] The molecular weight of polyethylene glycol and polyethylene glycol derivatives can be determined by several methods, including gel electrophoresis, such as SDS-PAGE (sodium dodecyl sulfate-polyacrylamide gel electrophoresis); Gel permeation chromatography (GPC); GPC combined with dynamic light scattering (DLS); and matrix-assisted laser desorption / ionization time of flight (MALDI-TOF) spectroscopy. The molecular weight of the polyethylene glycol precursor as disclosed herein can be determined by any method known to those of ordinary skill in the art, including SDS-PAGE, GPC and MALDI-TOF, and in particular, using PEG standards of known molecular weight (e.g., determined by MALDI-TOF) and polydispersity (e.g., determined by GPC), determined by GPC. If high precision is required, MALDI-TOF can be used.

[0152] The molecular weight of polyethylene glycol refers to an average molecular weight, which can be selected from various average values ​​known to those of ordinary skill in the art, including number average molecular weight (Mn), weight average molecular weight (Mw) and peak average molecular weight. In the context of the present invention, any such average value can be used, and in particular the above three average molecular weights. In certain embodiments, the average molecular weight of polyethylene glycol units and precursors as disclosed herein is given in terms of number average molecular weight.

[0153] As used herein, a multi-arm PEG unit of a specified molecular weight may be abbreviated as, for example, 4a20kPEG, meaning a 4-arm PEG unit with a molecular weight of 20,000.

[0154] In a 4-arm PEG, the average arm length (or molecular weight) of each arm can be the total molecular weight of the PEG divided by 4. Therefore, as a precursor particularly suitable for use in the present invention, the 4a20kPEG precursor has 4 arms with an average molecular weight of about 5,000 Daltons each. Therefore, the 8a20k PEG precursor that can be used in combination with the 4a20kPEG precursor or as an alternative to it in the present invention has 8 arms with an average molecular weight of 2,500 Daltons each. Compared with shorter arms, longer arms can provide higher flexibility. Compared with PEG with shorter arms, PEG with longer arms can swell more. Compared with PEG with more arms, PEG with fewer arms may also swell more and may be more flexible. In certain specific embodiments, the present invention uses only 4-arm PEG precursors. In certain specific embodiments, the present invention uses two different 4-arm PEG precursors. In certain other embodiments, the present invention uses a combination of 4-arm PEG precursors and 8-arm precursors. In addition, longer PEG arms have higher melting temperatures when dry, thereby providing higher dimensional stability during storage.

[0155] In certain embodiments, the electrophilic end group used with the PEG precursors used to prepare the hydrogels of the present invention is an N-hydroxysuccinimide (NHS) ester, including but not limited to NHS dicarboxylates, such as a succinimidyl malonate group, a succinimidyl maleate group, a succinimidyl fumarate group, "SAZ" for a succinimidyl azelate end group, "SAP" for a succinimidyl adipate end group, "SG" for a succinimidyl glutarate end group, and "SS" for a succinimidyl succinate end group.

[0156] Thus, in certain embodiments, the PEG precursor is an NHS dicarboxylate-terminated multi-arm PEG precursor, which can be represented by the following formula:

[0157]

[0158] Where n is determined by the molecular weight of each PEG arm, m is an integer from 0 to 10, and specifically 1, 2, 3, 4, 5, 6, 7, 8, 9 or 10, and x is the number of arms (and thus can be, for example, 2, 4, 8, etc., see above). When m is 1, each arm is terminated with a succinimidyl succinate (SS) end group; when m is 2, each arm is terminated with a succinimidyl glutarate (SG) group; when m is 3, each arm is terminated with a succinimidyl adipate (SAP) group; and when m is 6, each arm is terminated with a succinimidyl azelate (SAZ) group. In the presence of these specific electrophilic end groups, the multi-arm PEG unit can be abbreviated, for example, to the form 4a20kPEG-SAP, meaning a 4-arm PEG with succinimidyl adipate end groups and a molecular weight of 20,000 (4 arms, each about 5,000 Daltons). In the above formula, R is a core structure suitable for providing the desired number of arms. For 4-arm PEG units and precursors, R can be a pentaerythritol structure, while for 8-arm PEG units and precursors, R can be a hexaglycerol structure.

[0159] In certain embodiments, the PEG precursor is 4a20kPEG-SG or 4a20kPEG-SAP.

[0160] In certain embodiments, the nucleophilic end group used with the electrophilic group-containing PEG precursors used to prepare the hydrogels of the present invention is an amine (denoted as "NH 2 ”) end groups. Thiol (-SH) end groups or other nucleophilic end groups are also possible.

[0161] In certain embodiments, 4-arm PEGs having an average molecular weight of about 20,000 Daltons and electrophilic end groups as disclosed above (eg, SAZ, SAP, SG, and SS end groups) are cross-linked to form a polymer network and thus a hydrogel according to the invention.

[0162] For example, a cross-linking agent containing a nucleophilic group reacts with a PEG unit containing an electrophilic group, such as a cross-linking agent containing an amine group reacts with a PEG unit containing an active ester group, to produce multiple PEG units cross-linked by the cross-linking agent via the amide group.

[0163] In the case of PEGs with NHS-ester end groups, such as succinimidyl azelate (SAZ)-capped, succinimidyl adipate (SAP)-capped, or succinimidyl glutarate (SG)-capped PEG units (see above), the reaction with an amine group-containing cross-linking agent produces a plurality of PEG units cross-linked by the cross-linking agent via a hydrolyzable linking group having the formula: wherein m is an integer from 0 to 10, and specifically 1, 2, 3, 4, 5, 6, 7, 8, 9 or 10. For SAZ end groups, m is 6. For SAP end groups, m is 3; for SG end groups, m is 2; and for SS end groups, m is 1.

[0164] In certain embodiments, the present invention uses SG or SAP end groups. SG end groups can persist for a shorter time before the hydrogel biodegrades when compared to using other succinimide end groups (except SS groups) such as SAZ end groups, while SAZ end groups have a greater number of carbon atoms in the linking group and thus may have a higher hydrophobicity and therefore are less susceptible to ester hydrolysis than SG end groups.

[0165] In certain embodiments, the multi-arm polymer precursor containing electrophilic groups, and in particular the multi-arm PEG precursor having SG or SAP end groups (as defined above) is cross-linked with a cross-linking agent containing a nucleophilic group. The nucleophilic group may be an amine, and in particular a primary amine.

[0166] In certain embodiments, the cross-linking agent containing a nucleophilic group is a multi-arm polymer precursor containing a nucleophilic group.

[0167] In certain other embodiments, the cross-linking agent used is a low molecular weight component containing a nucleophilic end group such as an amine or thiol end group. In certain embodiments, the cross-linking agent containing a nucleophilic group is a small molecule amine with a molecular weight lower than 1,000Da, which includes two or more aliphatic primary amine groups. The specific cross-linking agent used in the present invention is, for example, dilysine, trilysine, tetralysine, ethylenediamine, 1,3-diaminopropane, 1,3-diaminopropane, diethylenetriamine, trimethylhexamethylenediamine, its pharmaceutically acceptable salt, hydrate, and derivative, such as conjugate (as long as there are enough nucleophilic groups for cross-linking), and any mixture thereof. In certain preferred embodiments, trilysine is used as a cross-linking agent. It should be understood that trilysine used herein refers to any form of trilysine, including trilysine salts, such as trilysine acetate or trilysine derivatives, such as labeled trilysine.

[0168] In certain embodiments, the cross-linking agent containing a nucleophilic group is a labeled cross-linking agent, and in particular a labeled trilysine. The cross-linking agent can be labeled with a developer to help physicians confirm the presence of the insert during, for example, a control examination. Fluorophores such as fluorescein, rhodamine, coumarin and cyanine can be used as developers for labeling cross-linking agents. Labeling can be achieved, for example, by chemical conjugation, and in particular by conjugating the nucleophilic group of the cross-linking agent with the label. Since cross-linking requires a sufficient amount of nucleophilic groups (at least more than one molar equivalent), "conjugated / conjugation" generally includes partial conjugation, meaning that only a portion of the nucleophilic groups are used for conjugation with the label. Therefore, in certain embodiments, the cross-linking agent is a trilysine labeled by partial conjugation with a developer, wherein in particular, about 1% to about 20%, or about 5% to about 10%, or about 8% of the trilysine amine groups are conjugated with the developer.

[0169] In certain embodiments, the cross-linking agent containing a nucleophilic group is fluorescein-conjugated trilysine. Fluorescein-conjugated trilysine can be obtained by reacting trilysine acetate with N-hydroxysuccinimide (NHS)-fluorescein.

[0170] In certain embodiments, the multi-arm polymer unit comprises a 4a20kPEG unit and the cross-linking unit comprises a fluorescein-conjugated trilysine amide unit.

[0171] In certain embodiments, the polymer network is obtained by reacting 4a20kPEG-SG with fluorescein-conjugated trilysine at a molar ratio ranging from about 1:2 to about 2: 1. In certain other embodiments, the polymer network is obtained by reacting 4a20kPEG-SS or 4a20kPEG-SAZ with fluorescein-conjugated trilysine at a molar ratio ranging from about 1:2 to about 2:1.

[0172] In certain embodiments, the molar ratio of nucleophilic end groups to electrophilic end groups that react with each other is about 1:1, i.e., each electrophilic group, such as SG or SAP end group, provides one amine group. In the case of trilysine conjugated to fluorescein and 4a20kPEG-SG or 4a20kPEG-SAP as a polymer unit containing an electrophilic group, assuming that trilysine uses one of the four primary amines for partial conjugation on average, trilysine has three primary amine groups that can react with the electrophilic SG or SAP ester group, so that the molar ratio of the two components is about 1:1. However, an excess of electrophilic (e.g., NHS end groups, such as SG) end group precursors or nucleophilic (e.g., amine) end group precursors can be used.

[0173] Thus, in certain embodiments, the polymer network is obtained by reacting 4a20kPEG-SG with fluorescein-conjugated trilysine at a molar ratio ranging from about 1:2 to about 2:1, and particularly at about 1:1.

[0174] In certain embodiments, the polymer network is obtained by reacting 4a20kPEG-SAP with fluorescein-conjugated trilysine at a molar ratio ranging from about 1:2 to about 2:1, and particularly at a molar ratio of about 1:1.

[0175] Surfactants:

[0176] One aspect of the invention is a sustained release biodegradable intracanalicular insert comprising a hydrogel and cyclosporine, wherein the insert contains a surfactant.

[0177] As further outlined above, cyclosporin is a hydrophobic active agent that is virtually immiscible with the hydrophilic hydrogel material and, in certain embodiments, is present in the form of dispersed particles having a particular particle size. It has been shown that a certain particle size is advantageous in terms of insert properties. However, small particles are also prone to aggregation. Without wishing to be bound by theory, it is believed that the presence of a surfactant prevents aggregation and improves the content uniformity of the hydrogel.

[0178] Furthermore, experimental results indicate that the presence of a surfactant helps prevent unwanted tube adhesion of the cast hydrogel during insert fabrication (see Example 1.2) and improves the quality of the insert.

[0179] Thus, in certain embodiments, the insert contains a surfactant.

[0180] In certain embodiments, the insert contains from about 0.01 wt % to about 5 wt %, or from about 0.01 wt % to about 2 wt %, or from about 0.2 wt % to about 2 wt %, or from about 0.05 wt % to about 0.5 wt % of a surfactant in a dry state, based on the total weight of the insert.

[0181] As shown in Example 1.2, the type of surfactant may be important in view of the ability to prevent cyclosporin particles from aggregating. In certain embodiments, the insert contains a nonionic surfactant. The nonionic surfactant may comprise a poly(ethylene glycol) chain. Exemplary nonionic surfactants useful herein are Commercially available poly(ethylene glycol) sorbitan monolaurate (and especially 20, i.e. PEG-20-sorbitan monolaurate; or 80, which is PEG-80-sorbitan monolaurate); poly(ethylene glycol) esters of castor oil sold as Cremophor (and particularly Cremophor 40, which is PEG-40-castor oil); and ethoxylated 4-tert-octylphenol / formaldehyde polycondensate sold as Tyloxapol.

[0182] Additional Ingredients:

[0183] In addition to the polymer units, active ingredients and surfactants forming the polymer network as disclosed above, the insert of the present invention may also contain other additional ingredients. Such additional ingredients are, for example, salts derived from the buffer used during the preparation of the hydrogel, such as phosphates, borates, bicarbonates or other buffers such as triethanolamine. In certain embodiments of the present invention, sodium phosphate buffers (particularly sodium dihydrogen phosphate and disodium hydrogen phosphate) are used.

[0184] Optionally, preservatives may be used in the inserts of the invention. However, as demonstrated in the examples, also with the aid of storage stability test data and clinical results showing that the inserts remain safe, the inserts of the invention do not require the presence of preservatives, in contrast to, for example, certain eye drops. Since preservatives are also believed to be responsible for causing discomfort to the subject, such as stinging and irritation of the eyes, in one embodiment of the invention, the inserts are free or substantially free of preservatives.

[0185] preparation:

[0186] In certain embodiments, the insert according to the present invention comprises cyclosporine; a polymer network in the form of a hydrogel made from one or more polymer precursors as disclosed above; and optional additional components, such as surfactants, and also salts and the like remaining in the insert from the manufacturing process (e.g., phosphates used as buffers, etc.).

[0187] In certain embodiments, the insert according to the present invention contains, in the dry state, from about 15 wt % to about 80 wt % of cyclosporin, based on the total weight of the insert, and from about 20 wt % to about 60 wt % of polymer units, based on the total weight of the insert; or from about 30 wt % to about 65 wt % of cyclosporin, based on the total weight of the insert, and from about 25 wt % to about 50 wt % of polymer units, based on the total weight of the insert; or from about 45 wt % to about 55 wt % of cyclosporin, based on the total weight of the insert, and from about 37 wt % to about 47 wt % of polymer units, based on the total weight of the insert.

[0188] In another specific embodiment, the ratio of cyclosporine to PEG on a dry weight basis is about 50 to 60 wt % cyclosporine to about 40 wt % PEG, with the balance being phosphate and other excipients, based on the total weight of the insert.

[0189] In certain embodiments, the balance of the insert in the dry state (i.e., the remainder of the formulation when the cyclosporin, polymer hydrogel such as PEG hydrogel, and optional surfactant have been accounted for) may be salts remaining from a buffer solution as disclosed above. In certain embodiments, such salts are phosphates, borates, or (bi)carbonates. In one embodiment, the buffer salt is sodium phosphate (monobasic sodium phosphate and / or dibasic sodium phosphate).

[0190] The amounts of cyclosporin and polymer may vary, and other amounts of cyclosporin and polymer hydrogel may be used to prepare inserts according to the invention.

[0191] In certain embodiments, the amount of drug in the formulation is less than about twice the amount of polymer (e.g., PEG) units, but may be higher in some cases, and it is desirable that the mixture comprising, for example, precursor, buffer, and drug (in a state before the hydrogel is fully gelled) can be uniformly cast into a mold or tube.

[0192] In one embodiment of the invention, the hydrogel, after formation and prior to drying, i.e., in the wet state, comprises from about 3% to about 20% polyethylene glycol, expressed as the weight of polyethylene glycol divided by the weight of the fluid x 100. In one embodiment, the hydrogel comprises from about 7.5% to about 15% polyethylene glycol in the wet state, expressed as the weight of polyethylene glycol divided by the weight of the fluid x 100.

[0193] In certain embodiments, hydrogels for inserts according to the invention are formed using a solids content of about 10% to about 30% (w / v) (where "solids" refers to the total weight of the one or more polymer precursors, salt, and drug in solution).

[0194] In certain embodiments, the water content of the hydrogel in the dry (dehydrated / dried) state, such as the water content prior to insertion into the tear canaliculus of the eye, may be extremely low, such as no more than 1 wt % water. In other words, in certain embodiments, the insert contains no more than about 1 wt % water in the dry state. In certain embodiments, the water content may also be lower than the stated values, such as no more than 0.25 wt % or no more than 0.1 wt %, based on the total weight of the insert.

[0195] Insert dimensions and dimensional changes after hydration due to stretching:

[0196] The dried insert may have different geometric shapes depending on the manufacturing method, such as the use of a mold or tube into which the mixture containing the hydrogel precursor including cyclosporin is cast before complete gelation. In one embodiment, the insert has a cylindrical or substantially cylindrical shape with a circular or substantially circular cross-section. The shape of the insert may also be described as fibrous (because the length of the cylinder is much greater than the diameter) or rod-like.

[0197] The polymer network of the hydrogel insert according to certain embodiments of the present invention, such as a PEG network, can be semi-crystalline in a dry state at or below room temperature, and can be amorphous in a wet state. Even in a stretched form, the dry insert can be dimensionally stable at or below room temperature, which can facilitate insertion of the insert into the canaliculus.

[0198] After the insert has been hydrated in the eye (which can be simulated by immersing the insert in pH 7.4 PBS at 37°C), the dimensions of the insert according to the invention may change: typically, the diameter of the insert may increase, while its length may decrease or at least may remain the same or substantially unchanged. One advantage of this dimensional change is that, although the insert is thin enough in the dry state to be easily inserted into the canaliculus, once it has been placed in the canaliculus, the insert not only becomes shorter, improving the wearing comfort in the shorter vertical portion of the canaliculus and the corresponding limited available space, but also its diameter becomes larger, thereby making it fit tightly against the canaliculus wall, locking the insert in place and thereby preventing accidental migration and loss of the insert. Since the insert may also become soft, it is comfortable to wear despite the tight fit. In certain embodiments, the dimensional change is achieved at least in part by a "shape memory" effect introduced into the insert by stretching the insert in the longitudinal direction during manufacture (also disclosed in the "Manufacturing Methods" section below). In certain embodiments, the stretching may be performed in the dry state or in the wet state, i.e., after drying the hydrogel insert, or before drying. It should be noted that if no stretching is performed, and the hydrogel insert is simply dried and cut to the desired length, the insert may not substantially change in size, or the insert may increase in diameter and length upon hydration. If this is not desired, the hydrogel fibers may be dry stretched or wet stretched, i.e., stretched before or after drying. In particular, the fibers may be stretched before drying.

[0199] In a preformed dry hydrogel, a certain degree of molecular orientation can be imparted by dry stretching the material and then solidifying it to lock the molecular orientation. In certain embodiments, this can be achieved by pulling the material (optionally while heating the material to a temperature above the melting point of the crystallizable region of the material) and then crystallizing the crystallizable region. Alternatively, in certain embodiments, the glass transition temperature of the dry hydrogel can be used to lock the molecular orientation of a polymer such as PVA with a suitable glass transition temperature. Another alternative is to stretch the gel before complete drying (also known as "wet stretching") and then dry the material under tension. Molecular orientation provides a mechanism for anisotropic swelling after introduction into a hydrating medium such as a vitreous body. Upon hydration, the insert of certain embodiments will swell only in the radial dimension, while the length will decrease or remain or remain essentially unchanged. The term "anisotropic swelling" refers to swelling in one direction preferentially relative to another direction, such as swelling in a cylinder mainly in the diameter, but not significantly expanding (or even shrinking) in the longitudinal dimension.

[0200] The degree of dimensional change upon hydration may depend, among other things, on the stretch factor. As used herein, the stretch factor refers to the factor by which the hydrogel is stretched, measured in the stretch direction, i.e., the change in length, not diameter, before and after stretching, without taking into account any final further dimensional change (e.g., dimensional change caused by drying or rehydration). For example, stretching (e.g., by wet stretching) with a stretch factor of, for example, about 1.3 may have a less pronounced effect or may not substantially change the length during hydration. In contrast, stretching (e.g., by wet stretching) with a stretch factor of, for example, about 1.8 may significantly shorten the length during hydration. Stretching (e.g., by dry stretching) with a stretch factor of, for example, 4 may shorten the length (e.g., the length is reduced from 15 mm to 8 mm) upon hydration. It will be appreciated by those skilled in the art that other factors besides stretching may also affect swelling behavior.

[0201] One aspect of the present invention is a sustained-release biodegradable intraductal insert comprising a hydrogel and cyclosporine, the insert being in the form of a fiber, wherein the fiber is stretched.

[0202] In certain embodiments, the fibers are stretched in the longitudinal direction by a stretch factor of about 1.0 to about 4.0, or about 1.5 to about 3.0, or about 2.7.

[0203] Factors that influence the likelihood of stretching the hydrogel and causing dimensional changes in the insert upon hydration include the composition of the polymer network. In the case of using PEG precursors, PEG precursors with fewer arms (e.g., 4-arm PEG precursors) contribute to a higher flexibility of the hydrogel compared to PEG precursors with more arms (e.g., 8-arm PEG precursors). If the hydrogel contains more components with lower flexibility (e.g., a higher amount of PEG precursors with more arms, such as 8-arm PEG units), the hydrogel may be harder and less easy to stretch without causing rupture. On the other hand, hydrogels containing components with higher flexibility (e.g., PEG precursors with fewer arms, such as 4-arm PEG units) may be easier to stretch and softer, and swell to a greater extent upon hydration. Therefore, once the insert is placed in the eye (i.e., once the hydrogel becomes (re)hydrated), the behavior and properties of the insert can be customized by changing the structural features and by changing the processing of the insert after the insert is initially formed.

[0204] Exemplary dimensions of the inserts used in the examples below are provided in Table 2.1 of the Examples section. The dimensions of the dry insert depend, among other things, on the amount of cyclosporin incorporated and the ratio of cyclosporin to polymer units, and may also be controlled by the diameter and shape of the mold or tube that allows the hydrogel to gel. Furthermore, after the insert is formed, the diameter of the insert is further determined, among other things, by (wet or dry) stretching the hydrogel fibers. The dry fibers (after stretching) are cut into segments of the desired length to form the insert. Thus, the diameter and length of the insert may be adjusted as desired. On the other hand, the anatomical dimensions of the canaliculus provide certain size requirements for the intracanaliculus insert to be met.

[0205] In certain embodiments, the insert is in the form of fibers. The fibers may have an average length of about 1.5 mm to about 4.0 mm and an average diameter of no more than 0.8 mm in their dry state; an average length of about 2.0 mm to about 2.5 mm and an average diameter of no more than 0.62 mm in their dry state; or an average length of about 2.5 mm to about 2.9 mm and an average diameter of no more than 0.62 mm in their dry state.

[0206] In certain embodiments, and as shown in the Examples (see in particular Example 2), the inserts of the present invention are stable upon storage, and the product dimensions do not change or do not substantially change upon long-term storage.

[0207] Thus, in certain embodiments, after storage at a temperature of 2 to 8°C for at least 3 months, at least 6 months, or at least 12 months, the insert is in the form of fibers having an average length of about 2.5 mm to about 2.9 mm and an average diameter in the dry state of no more than 0.62 mm.

[0208] The size of the insert can be adjusted, for example, by selecting an appropriate active agent concentration, depending on the dose of cyclosporine to be incorporated into the insert. By increasing the active agent concentration, the size of the insert can be reduced. On the other hand, the active agent concentration also affects the release behavior and the properties and quality of the insert, such as the swelling behavior or the diameter after drying (see Example 1.1 for details). In certain embodiments, the inventors unexpectedly found that certain combinations of insert size, active agent concentration and / or dose not only produce high-quality inserts with appropriate swelling behavior, easy manufacturing, easy application and high wearing comfort, but also provide effective release over a longer period of time.

[0209] In view of the above, one aspect of the present invention is a sustained-release biodegradable intraductal insert, the insert comprising a hydrogel and cyclosporin in an amount of about 360 μg, the insert being in the form of a fiber (or cylinder) having an average length of about 2.5 mm to about 2.9 mm and an average diameter of no more than about 0.62 mm in its dry state. Another aspect of the present invention is a sustained-release biodegradable intraductal insert, the insert comprising a hydrogel and cyclosporin in an amount of about 45% to about 55% by weight based on the total weight of the insert, the insert being in the form of a fiber (or cylinder) having an average length of about 2.5 mm to about 2.9 mm and an average diameter of no more than about 0.62 mm in its dry state.

[0210] Such inserts, and in certain other embodiments, inserts of the invention, can decrease in length and increase in diameter upon hydration in vivo in the eye, i.e., in the lacrimal canaliculus, or in vitro (where in vitro hydration is measured after 24 hours at 37° C. in phosphate buffered saline, pH 7.4), i.e., an average diameter of at least 1.0 mm in the expanded state after hydration for 10 minutes in vitro in phosphate buffered saline, pH 7.4, or an average diameter of at least 1.3 mm in the equilibrium state after hydration for 24 hours in vitro in phosphate buffered saline, pH 7.4, at 37° C. In one embodiment, such a dimensional change can be achieved by dry stretching the hydrogel fiber by a stretch factor of about 1 to about 4, or a factor of about 1.5 to about 3.0, or a factor of about 2.7.

[0211] In certain embodiments, stretching thereby creates shape memory, meaning that the insert, upon hydration when applied to the canaliculus, will shrink in length (also referred to as rebound) and widen in diameter until it approaches (more or less) its equilibrium size, which is determined by the original molded dimensions and compositional variables. While the narrow stem dimensions facilitate insertion of the product into the canaliculus, the widened diameter and shortened length after application create a shorter and thicker insert that is comfortable to wear and still securely locked in place, thereby minimizing the risk of accidental migration. Thus, in one aspect, the present invention also relates to a method of imparting shape memory to hydrogel mixture fibers by stretching the hydrogel mixture fibers in a longitudinal direction, the hydrogel mixture fibers comprising cyclosporine particles dispersed in a hydrogel.

[0212] In vitro release:

[0213] The in vitro release of cyclosporin from the insert of the invention can be determined by various methods and for example at 37°C in a non-sink mimicking physiological conditions in PBS (phosphate buffered saline, pH 7.4) with daily replacement of a volume of PBS equivalent to the tear volume in the human eye.

[0214] In vitro release testing can be used to compare different inserts (eg, from different manufacturing batches, with different compositions and different dosage concentrations, etc.), for example, for the purpose of quality control or other qualitative assessment.

[0215] In vivo release and durability:

[0216] In one embodiment of the invention, when a dry insert of the invention is inserted into a lacrimal canaliculus, as disclosed above, the insert becomes hydrated and changes its size, and then undergoes biodegradation and disintegration over time until it completely disintegrates and any residue is expelled from the lacrimal canaliculus. As the insert biodegrades, e.g., via ester hydrolysis, it may gradually swell and soften. The inventors will recognize from clinical studies presented in the Examples section below that inserts according to certain embodiments of the invention can be maintained for months, e.g., from about 2 to about 4 months or longer, also enabling sustained release of cyclosporin over months.

[0217] After the insert is completely disintegrated, any remaining undissolved cyclosporin particles can be excreted via the tear drainage system. Thus, if a sufficient amount of cyclosporin is included to last for the time required for the insert to completely disintegrate, the length of time for sustained release can be designed, among other things, by adjusting the disintegration time. If, in certain embodiments, two inserts are used to treat one eye, e.g., one insert for each lower and upper canaliculus to achieve a desired total dose, the inserts can be designed to disintegrate over the same or substantially the same time.

[0218] In certain embodiments, in the canaliculus, the insert of the invention disintegrates over a longer period of time, such as within about 1 to about 6 months after insertion, or within about 2 to about 4 months after insertion, or within about 2 to about 3 months after insertion, or within about 3 to about 4 months after insertion. This has been demonstrated in clinical trials, see the Examples section, particularly Example 4.

[0219] In one embodiment, after insertion into the canaliculus, the insert releases a therapeutically effective amount of cyclosporine over a period of at least about 1 month, at least about 2 months, at least about 3 months, or at least 4 months after insertion.

[0220] In one embodiment of the invention, after insertion of the insert, cyclosporine is released from the insert at an average rate of about 0.1 μg per day to about 10 μg per day, or about 1 μg per day to about 5 μg per day, or about 2 μg per day to about 4 μg per day.

[0221] In one embodiment of the invention, after insertion of the insert into a human subject, cyclosporine is released from the insert at an average rate of about 0.1 μg per day to about 10 μg per day, or about 1 μg per day to about 5 μg per day, or about 2 μg per day to about 4 μg per day.

[0222] As shown in the Examples section herein, preclinical studies in animals and clinical studies in humans have shown that inserts of certain embodiments of the present invention can continuously release therapeutically effective amounts of cyclosporine over an extended period of time until the insert is completely disintegrated. However, in certain embodiments, the entire amount of cyclosporine contained in the insert is released from the insert before the insert is completely biodegraded.

[0223] One aspect of the invention is a sustained release biodegradable intracanalicular insert comprising a hydrogel and an amount of about 360 μg of cyclosporine dispersed within the hydrogel, wherein upon insertion into the canaliculus, the insert releases a therapeutically effective amount of cyclosporine over a period of at least about 3 months after insertion.

[0224] In certain embodiments, the tear concentration of cyclosporine is in the range of about 0.1 μg / mL to about 10 μg / mL following insertion into a human subject.

[0225] In certain embodiments, following insertion of the insert, the tear concentration of cyclosporine is in the range of about 0.1 μg / mL to about 10 μg / mL, or in the range of about 1 μg / mL to about 5 μg / mL.

[0226] In certain embodiments, the insert disintegrates in the canaliculus before the cyclosporine particles contained in the insert are completely dissolved.

[0227] In certain embodiments, the inserts of the present invention may be designed to disintegrate within the lacrimal canaliculus within about 1 to about 6 months after insertion, or within about 2 to about 4 months after insertion, or within about 2 to about 3 months after insertion, or within about 3 to about 4 months after insertion.

[0228] In one embodiment, where the polymer network of the hydrogel is cross-linked based on linking groups derived from NHS ester end groups, such as SG end groups, SAP end groups, or similar groups as disclosed above, the durability of the hydrogel in an aqueous environment and within the canaliculus depends, among other things, on the hydrophobicity of the carbon chain near the degradable ester group. In the inserts used in the examples herein, this carbon chain contains 3 or 4 carbon atoms because the carbon chain is derived from the SG and SAP functional groups of the 4a20k PEG precursor. This can provide a longer durability of about 2 to about 3 months or about 3 to about 4 months, respectively, in the human eye. In other embodiments, precursors other than 4a20kPEG-SG- / -SAP and the cross-linker trilysine can be used to prepare hydrogel inserts that biodegrade in the human eye and have a durability similar to or different from that of the inserts illustrated in the examples.

[0229] In certain embodiments, the hydrogel insert softens over time as it degrades, which may depend, among other things, on the structure of the linking groups that cross-link the PEG units in the hydrogel. 2 The formed insert softens rather slowly over time.

[0230] Release mechanism:

[0231] Without wishing to be bound by theory, the mechanism of release of cyclosporine from the insert of the present invention may be explained as follows:

[0232] As outlined above, the hydrophobic active agent cyclosporin is virtually immiscible with the hydrophilic hydrogel material. Once the insert is inserted and placed in the canaliculus, the insert comes into contact with tears, which slowly absorb and penetrate the hydrophilic hydrogel. Biodegradation, i.e., hydrolytic degradation of the hydrogel matrix causes the hydrogel to soften and allows tears to penetrate further, but the hydrophobic active agent, particularly in the form of uniformly dispersed cyclosporin particles, remains trapped in the hydrogel matrix and is released by slowly partitioning into the hydrogel due to its low solubility in aqueous solution.

[0233] In addition, without wishing to be bound by a particular theory, it is believed that the tear fluid provides a fluid column at the top of the intraductal insert that tends to limit the release of the active agent to the cross-sectional area of ​​the proximal portion of the plunger. The canaliculus wall appears to release the drug at a much slower rate than the therapeutic agent is depleted via the fluid column, and / or the canaliculus wall may be filled with the drug, thereby slowing down the release through the wall. Therefore, in certain embodiments, as previously proposed, the canaliculus insert of the present invention does not require and particularly does not include any complex and more difficult to manufacture barrier or reservoir system (e.g., a coating on the sidewall of the insert prevents and limits the release of the active agent to the release from the cross-sectional area).

[0234] The release of the drug from the cross-sectional area of ​​the insert into the tear fluid may occur first in the outer region of the hydrogel that is in contact with the liquid environment (i.e., drug particles located in the region of the hydrogel near the punctum are first dissolved and diffused, while drug particles near the other end of the insert, i.e., near the tear duct, diffuse last). Therefore, in certain embodiments, the region of the hydrogel closer to the punctum becomes free of drug particles. Therefore, this region is also referred to as the "clearance zone" and is limited to dissolved drug, and the drug concentration is equal to or lower than the solubility of the drug.

[0235] In certain embodiments where the clearance zone has been formed when the drug dissolves and diffuses out of the hydrogel, this area of ​​the hydrogel forms voids and becomes soft and breakable. While the drug diffuses out of the hydrogel, the hydrogel may also slowly degrade by means of ester hydrolysis in, for example, the aqueous environment of the eye. This degradation occurs uniformly throughout the hydrogel. In the late stages of degradation, the hydrogel begins to deform and erode (also referred to as disintegration as used herein). When this happens, the hydrogel softens and becomes more fluid (and therefore its shape becomes distorted) until the hydrogel eventually disintegrates completely and any remaining portions of the hydrogel and / or active agent are cleared by the tear drainage system.

[0236] Since cyclosporine is a relatively low solubility drug, undissolved cyclosporine particles may remain upon complete disintegration of the insert, i.e., the insert may disintegrate in the canaliculus before the cyclosporine particles contained therein are completely dissolved, but as outlined above, in such cases any remaining active agent particles are cleared away by the tear drainage system.

[0237] However, in one embodiment, the entire amount of cyclosporin is released before the hydrogel completely disintegrates.Since the hydrogel can hold the cyclosporin particles in place and prevent them from aggregating, the release of cyclosporin from the hydrogel can be maintained at a relatively constant rate.

[0238] II. Fabrication of the Insert

[0239] In certain embodiments, the present invention also relates to a method for manufacturing a sustained release biodegradable intraductal insert disclosed herein, the insert comprising a hydrogel and cyclosporin. In certain embodiments, the method comprises the following steps:

[0240] a) preparing a precursor mixture containing a hydrogel precursor and cyclosporine particles dispersed in the precursor mixture,

[0241] b) shaping the precursor mixture and crosslinking the hydrogel precursor to form a polymer network and obtain a shaped hydrogel mixture comprising the polymer network, and

[0242] c) drying the hydrogel mixture to provide the insert.

[0243] In one embodiment, the insert may be prepared using cyclosporin particles in micronized form, i.e., the cyclosporin particles are used and dispersed in the form of micronized particles to prepare the precursor mixture, the micronized particles being uniformly dispersed in the precursor mixture. In another embodiment, the insert may be prepared using cyclosporin in non-micronized form. Further details regarding the active ingredient cyclosporin have been disclosed in detail above and are applicable in all respects to the active agent used in the manufacture.

[0244] Precursors used to form the hydrogels of certain embodiments have been disclosed in detail above in the section concerning the inserts themselves.

[0245] In certain embodiments, in step a), the precursor mixture is prepared by mixing a multi-arm polymer precursor containing electrophilic groups with a cross-linking agent containing nucleophilic groups in a buffered aqueous solution in the presence of micronized cyclosporin particles.

[0246] In certain embodiments, in step a), a buffered aqueous precursor solution is prepared by dissolving the multi-arm polymer precursor in an aqueous buffer solution, and then mixed with a buffered aqueous precursor suspension comprising a nucleophilic group-containing crosslinker and micronized cyclosporin particles, for example within 60 minutes.

[0247] In the case of using a PEG precursor to prepare a cross-linked PEG network, in certain embodiments, a method of making an insert may include mixing a multi-arm polyethylene glycol containing an electrophilic group, such as 4a20kPEG-SG or 4a20kPEG-SAP, with a cross-linker containing a nucleophilic group, such as trilysine, in a buffered aqueous solution in the presence of micronized cyclosporine particles.

[0248] In certain embodiments, the molar ratio of electrophilic groups to nucleophilic groups in the PEG precursor is about 1: 1, but nucleophilic groups (e.g., amine groups) can also be used with an excess of electrophilic groups, or vice versa, such as a molar ratio ranging from about 1: 2 to 2: 1. In certain embodiments, the method comprises reacting 4a20kPEG-SG or 4a20kPEG-SAP with fluorescein-conjugated trilysine at a weight ratio ranging from about 30: 1 to about 50: 1.

[0249] As shown in Example 1.4, degassing the precursor mixture by vacuum has a great influence on the quality of the insert. In particular, aggregation of cyclosporin particles can be prevented. Therefore, in certain embodiments, in step a), after mixing the components of the precursor mixture containing cyclosporin particles, it is degassed under vacuum.

[0250] In certain embodiments, after the precursor mixture is prepared as outlined in step a) above, it can be shaped in step b) by casting the mixture into a suitable mold or tube and then allowing it to fully gel so as to provide a hydrogel of the desired final shape, that is, in step b), the shaping of the precursor mixture consists of filling the precursor mixture into a mold or tube before fully cross-linking so as to provide a hydrogel mixture of the desired final shape and cross-linking the hydrogel precursor.

[0251] In the case where the insert should have a fiber shape, the reaction mixture can be filled into a thin diameter tube, such as a polyurethane (PU) tube, so as to provide an extended cylindrical shape. Tubes of different geometries and diameters can be used depending on the desired final cross-sectional geometry of the hydrogel fiber, its initial diameter (which can also be reduced by stretching), and also on the ability of the reaction mixture to uniformly fill the tube.

[0252] Thus, the interior of the tube may have a circular geometry or a non-circular geometry, such as a cruciform geometry.The tube may have a circular geometry with an inner diameter of, for example, about 1 mm to about 3 mm or about 2.0 mm.

[0253] In certain embodiments, after the hydrogel has been formed and has solidified to complete gelation, the hydrogel can be stretched longitudinally in a wet state or a dry state, as has been disclosed in detail above in the section on the dimensional changes of the insert after hydration. In certain embodiments, the stretch factor can be in the range of about 1 to about 4.5, or in other ranges as also disclosed above. When dry stretching is performed in certain embodiments, the hydrogel is first dried and then stretched. When wet stretching is performed in certain embodiments, the hydrogel is stretched in a wet (substantially undried) state and then dried under tension. Optionally, heat can be applied during stretching. Also optionally, the fibers can be additionally twisted.

[0254] In certain embodiments, the insert may be obtained by preparing a precursor mixture containing a hydrogel precursor and cyclosporin, filling the precursor mixture into a tube, cross-linking the hydrogel precursor in the tube to provide a hydrogel mixture in a fibrous form, and stretching the hydrogel mixture fibers to provide an insert.

[0255] In certain embodiments, the insert maintains its dimensions even after stretching as long as it remains dry at or below room temperature.

[0256] In certain embodiments, the inserts are individually packaged and sterilized, for example, by means of gamma irradiation.

[0257] The stretched shape memory effect has been disclosed in detail above with respect to the properties of the insert. In certain embodiments, the extent of contraction upon hydration depends inter alia on the stretch factor disclosed above.

[0258] In certain embodiments, the present invention is also directed to a method of imparting shape memory to a hydrogel mixture fiber by stretching the hydrogel mixture fiber in a longitudinal direction, the hydrogel mixture fiber comprising cyclosporine particles dispersed in a hydrogel.

[0259] The stretch factors used in these methods of the invention can be used as disclosed above.

[0260] III. Therapy

[0261] In certain embodiments, the present invention further relates to a method of treating or preventing an ocular disease in a patient in need thereof, the method comprising administering to the patient a first sustained release biodegradable intraductal insert as disclosed above, the insert comprising a hydrogel and cyclosporine.

[0262] In certain embodiments, the first insert is left in the canaliculus until completely disintegrated, or is removed before completely disintegrating. In certain embodiments, the first insert may be designed to disintegrate in the canaliculus over a long period of time after insertion, such as within about 1 to about 6 months, within about 2 to about 4 months, or within about 2 to about 3 months, or within about 3 to about 4 months, but in some cases, it will take longer to disintegrate. Under normal circumstances, since the disintegration of the insert does not require any action on the part of the patient, the insert may be retained in the canaliculus until completely disintegrated. This is advantageous because the patient does not need to consult a physician or optician in order to remove the insert. On the other hand, continuous biodegradation will soften the insert, and if an unexpected event such as an allergic reaction, discomfort in wearing, or other adverse events such as irritation occurs, the insert may be discharged to the outside via the lacrimal point by applying slight pressure or the insert may be further moved downward along the canaliculus to be cleared via the nasolacrimal duct, thereby promoting premature removal. In addition, the softness of the first insert allows the second insert to be inserted without removing the first insert in advance. By inserting the second insert, the first insert is pushed further into the canaliculus and retained there without discomfort until it is completely disintegrated or pushed down the tear drainage system. For example, once the intended treatment period of the first insert has passed, or if the patient feels that the treatment effect has worn off, the second insert may be inserted.

[0263] Thus, in certain embodiments, a second insert may be inserted after at least 1 month or at least 2 months without prior removal of the first insert. In other embodiments, the first insert is removed prior to complete disintegration and a second insert is administered to replace the removed first insert.

[0264] One aspect of the present invention is a method of treating dry eye in a subject, the method comprising the steps of:

[0265] (a) inserting a first biodegradable insert into a first lacrimal canaliculus of a first eye of the subject, wherein the insert comprises:

[0266] (1) Biodegradable hydrogel;

[0267] (2) about 100 μg to about 800 μg of cyclosporine dispersed in the hydrogel;

[0268] (3) wherein the cyclosporine is released from the insert at an average rate of about 0.1 μg per day to about 10 μg per day over a period of at least about 2 months from the date the first insert is inserted into the subject; and

[0269] (b) inserting a second insert into the first canaliculus of the first eye of the subject at least about 2 months from the date of inserting the first insert, wherein the second insert is similar or substantially similar to the first insert.

[0270] In certain embodiments, the first insert is designed to disintegrate in the lacrimal canaliculus within about 2 to about 3 months after insertion and the first insert is removed within 2 months after administration.

[0271] In certain embodiments, the dose of cyclosporine administered once per eye over a treatment period of at least 2 months is about 300 μg to about 400 μg cyclosporine. Other suitable doses are further disclosed above.

[0272] In certain embodiments, the ocular disease is a disorder of the tear film and ocular surface.

[0273] In certain embodiments, the ocular disease is dry eye.In alternative embodiments, the inserts and methods of the invention can be used to treat other ocular surface diseases, such as blepharitis, allergic conjunctivitis, and in particular atopic keratoconjunctivitis and vernal keratoconjunctivitis.

[0274] In some embodiments, the ocular disease is associated with one or more conditions selected from the group consisting of burning, itching, redness, stinging, pain, foreign body sensation, visual disturbances, lacrimal gland inflammation, ocular surface inflammation, T cell-mediated inflammation, the presence of conjunctival T cells in tears, and elevated levels of inflammatory cytokines in tears.

[0275] In some embodiments, the sustained-release biodegradable intraductal inserts of the present invention comprising a hydrogel and cyclosporine can be used to prevent dry eye disease or any related disorder in subjects at risk for developing such ocular disorders, such as subjects who wear contact lenses.

[0276] In some embodiments, the treatment is effective to improve tear production in patients with a Schirmer score of less than 10 mm prior to administration, as measured by the Schirmer tear test; and / or is effective to reduce dry eye symptoms, as determined by one or more assessments selected from the group consisting of: rating the severity of dry eye symptoms on a visual analog scale; rating the frequency of dry eye symptoms on a visual analog scale; determination of tear breakup time; corneal fluorescein staining; conjunctival lissamine green staining; best corrected visual acuity; determination of the ocular surface disease index; and a standard patient dry eye assessment.

[0277] In some embodiments, the treatment is effective to improve tear production in a patient having a Schirmer score of less than 10 mm prior to administration, as measured by the Schirmer tear test.

[0278] In certain embodiments, the dose administered to each eye at one time during the treatment period is contained in one insert or two inserts.

[0279] In certain embodiments, the insert is inserted into the lower canaliculus, or the insert is inserted into the upper canaliculus, or one insert is inserted into each of the lower canaliculus and the upper canaliculus. The insert may be inserted into the vertical portion of the canaliculus.

[0280] Cyclosporine administered once to each eye during treatment may be contained in one or two inserts.

[0281] In certain embodiments, the dose administered to each eye at one time during treatment is contained in one insert, for example, contained in one insert containing a dose of about 250 μg or about 360 μg of cyclosporine.

[0282] In certain embodiments, the insert is insertable into the canaliculus with the aid of a grasping device selected from the group consisting of forceps, tweezers, and an applicator.

[0283] In embodiments where two inserts are administered, the inserts are inserted simultaneously as disclosed above. The simultaneously inserted inserts may be the same or different.

[0284] In certain embodiments, the treatment period is at least 1 month, at least 2 months, or at least 3 months. According to one embodiment of the present invention, "treatment period" means that the insert of the present invention maintains or substantially maintains the treatment effect during the time period after insertion. In other words, in certain embodiments, only one insertion (of the insert of the present invention) is required to maintain the treatment effect for a longer period of time referred to herein as the "treatment period". This is a considerable advantage compared to the current eye drops for treating dry eye disease, which need to be applied more frequently several times a day, and thus significantly improves the quality of life of patients.

[0285] One aspect of the invention is a method of treating dry eye disease in a patient in need thereof, the method comprising administering to the patient a sustained release biodegradable intracanalicular insert comprising a hydrogel and cyclosporine, wherein punctal occlusion and cyclosporine release in the eye provide a synergistic effect.

[0286] Such synergistic effects may result from the higher bioavailability of cyclosporin when compared to administration of an eye drop solution containing cyclosporin and designed to provide the same daily release of cyclosporin, which can be determined, for example, by the amount of cyclosporin released into the tears calculated based on the change in tear concentration of cyclosporin over time.

[0287] In certain embodiments, the systemic concentration of cyclosporin is below a quantifiable amount. Since the systemic concentration of cyclosporin is kept to a minimum, the risk of drug-drug interactions or systemic toxicity is also kept to a minimum. Thus, in one embodiment, the additional medications taken by the patient do not provide a significant risk. This is particularly beneficial for elderly patients who often have eye diseases and are also taking other medications.

[0288] One aspect of the present invention is the use of a sustained-release biodegradable intraductal insert comprising a hydrogel and cyclosporine as disclosed above in the preparation of a medicament for treating an ocular disease as disclosed above in a patient in need thereof, or for treating dry eye / keratoconjunctivitis sicca as disclosed above in a patient in need thereof.

[0289] One aspect of the present invention is a sustained release biodegradable intraductal insert comprising a hydrogel and cyclosporine as disclosed above for use in treating an ocular disease as disclosed above in a patient in need thereof, or for treating dry eye / keratoconjunctivitis sicca as disclosed above in a patient in need thereof.

[0290] One aspect of the invention is a method of increasing tear production in a patient having a Schirmer score less than 10 mm prior to administration, as measured by the Schirmer tear test, the method comprising administering to the patient a sustained-release biodegradable intracanalicular insert comprising a hydrogel and cyclosporine as disclosed above.

[0291] In certain embodiments, in such methods, the Schirmer score may be increased by at least 2 mm at 6 weeks or by at least 3 mm at 12 weeks following insertion of the insert.

[0292] One aspect of the invention is a method of reducing dry eye symptoms, the reduction of dry eye symptoms being determined by one or more assessments selected from the group consisting of: rating the severity of dry eye symptoms on a visual analog scale; rating the frequency of dry eye symptoms on a visual analog scale; determination of tear breakup time; corneal fluorescein staining; conjunctival lissamine green staining; best corrected visual acuity; determination of the Ocular Surface Disease Index OSDI; and a standard patient dry eye assessment SPEED, the method comprising administering to the patient a sustained release biodegradable intraductal insert comprising a hydrogel and cyclosporine as disclosed above.

[0293] In certain embodiments, in such methods, the total corneal fluorescein staining value, tCFS, may be reduced by at least 1.5 at 6 weeks or by at least 3 at 12 weeks following insertion of the insert.

[0294] In certain embodiments, in such methods, ratings of the severity of dry eye symptoms on a visual analog scale may be reduced by at least 10 at 2 weeks, or by at least 15 at 6 weeks following insertion of the insert.

[0295] Example

[0296] The following examples are included to demonstrate certain aspects and embodiments of the invention as described in the claims. However, those skilled in the art will appreciate that the following description is merely exemplary and should in no way be considered as limiting the invention.

[0297] Example 1: Preparation of Cyclosporine Inserts

[0298] The cyclosporine insert of the present application is substantially cylindrical (shaped into fibers) in which cyclosporine is uniformly dispersed and entrapped in a PEG-based hydrogel matrix, which provides sustained release of cyclosporine based on the low solubility of the hydrogel matrix in tear fluid.

[0299] I. Example 1.1: Drug Concentration Assessment

[0300] To evaluate the effect of drug concentration, three different formulations with low, medium and high doses of cyclosporin were prepared. The composition of the three formulations is shown in Table 1.1.1 below.

[0301] Table 1.1.1: Composition of Cyclosporine Insert Formulations

[0302]

[0303]

[0304]

[0305] The low, medium and high dose inserts were prepared essentially according to the manufacturing process outlined for the investigational product inserts (see Example 1.5 below). However, tyloxapol was not used, the syringe containing cyclosporine was first mixed with the syringe containing the multi-arm PEG solution, and then mixed with the syringe containing the trilysine acetate (TLA) / fluorescein solution, and no vacuum degassing was performed.

[0306] After casting, the hydrogel immediately solidifies, i.e., cross-linking occurs, and the bundle is then stretched and dried in an incubator under a stream of nitrogen. The dried bundle is removed from the flexible tube and cut into lengths. The dimensions and physical properties are as follows:

[0307] Table 1.1.2: Dimensions and physical properties of low, medium, and high dose inserts

[0308]

[0309] The low-dose and high-dose formulations produced fibers with an undesirable "straw shape," i.e., the fibers had a larger stem diameter and exhibited a hollow hole in the middle of the fiber. Thus, the density of the straw-shaped fibers was relatively low.

[0310] To determine the "roundness" of the fiber, the cross-sectional diameters at the thick end and the thin end are measured, the lower diameter value is designated as Diameter 1, the higher diameter value is designated as Diameter 2, and the aspect ratio is calculated as follows:

[0311] Aspect ratio = diameter 1 / diameter 2

[0312] While the medium dose formulation did not show strawing, it produced flat fibers with a very low aspect ratio. The aspect ratio was 0.7, indicating a lack of roundness. Although the straw-shaped fibers formed by the low and high dose formulations were rounder, the low density produced fibers that were much larger than desired. Drug concentration also had an effect on the hydration characteristics of the inserts as summarized in Table 1.1.3 below:

[0313] Table 1.1.3: Hydration characteristics of low, medium and high dose inserts

[0314]

[0315] It can be seen that the hydrated diameters were all significantly higher than the target of 1.45 mm and decreased with increasing dose, and the shrinkage factor also decreased with increasing dose.

[0316] II. Example 1.2: Evaluation of surfactants

[0317] The presence of surfactant

[0318] To evaluate the effect of the presence of surfactant in the insert, three different formulations were prepared, one containing no surfactant (control, run 1), one containing 0.05% 20 (Run 2), and the third contained no surfactant but was prepared using ethanol (Run 3). The compositions of the three formulations are shown in Table 1.2.1 below.

[0319] Table 1.2.1: Composition of cyclosporine insert formulations with and without surfactant

[0320]

[0321]

[0322]

[0323] Inserts for Runs 1 to 3 were prepared essentially according to the manufacturing process outlined for the investigational product inserts (see Example 1.5 below), i.e., by preparing a hydrogel suspension precursor syringe containing a suspension of cyclosporin in an aqueous trilysine acetate (TLA) / fluorescein solution (Run 1: without tyloxapol; Run 2: with 20 instead of tyloxapol; Operation 3: without tyloxapol, but dissolved in ethanol instead of water) and a second syringe of hydrogel solution precursor containing a multi-arm PEG aqueous solution, the two syringes are mixed and then cast into a set of flexible tubing by injecting the liquid suspension, followed by crosslinking and solidification of the material. No vacuum degassing is performed. After casting, the hydrogel immediately solidifies, i.e., crosslinking occurs, and the bundle is then stretched and dried in an incubator under a stream of nitrogen. The dried bundle is removed from the flexible tube and cut into a certain length. The dimensions and physical properties are as follows:

[0324] Table 1.2.2: Dimensions and physical properties of inserts with and without surfactant

[0325]

[0326] To determine the "roundness" of the fiber, the cross-sectional diameters at the thick end and the thin end are measured, the lower diameter value is designated as Diameter 1, the higher diameter value is designated as Diameter 2, and the aspect ratio is calculated as follows:

[0327] Aspect ratio = diameter 1 / diameter 2

[0328] It can be seen that adding 20 produced a high aspect ratio, indicating that the fibers were round. Its average diameter was smaller than the control and the density was higher, which facilitated easy insertion into the product. The control fibers from Run 1 stuck to the tube during drying and had a low aspect ratio, indicating that the fibers were flat (see Figure 1.2A ).

[0329] Operation 3 investigated the use of ethanol and encountered major problems. The solution began to evaporate within 1 minute after the start of curing, producing bubbles in the fibers. When removed from the incubator, the fibers were all broken and deformed, such as Figure 1.2B as shown in .

[0330] Drug concentration in the presence of surfactant

[0331] To evaluate the effect of drug concentration in the presence of surfactant, 0.05% Three different formulations were prepared with low, medium and high doses of cyclosporin in the presence of 20. The compositions of the three formulations are shown in Table 1.2.3 below.

[0332] Table 1.2.3: Composition of cyclosporine insert formulations containing surfactant

[0333]

[0334]

[0335] The three inserts for Runs 1 to 3 were prepared essentially according to the manufacturing process outlined for the investigational product insert (see Example 1.5 below), but using 20 instead of tyloxapol. No vacuum degassing was performed. Immediately after casting, the hydrogel solidified, i.e., cross-linking occurred, and the bundle was then stretched and dried in an incubator under a stream of nitrogen. The dried bundle was removed from the flexible tube and cut to length. No sterilization was performed. The dimensions and physical properties were as follows:

[0336] Table 1.2.4: Dimensions and physical properties of inserts containing surfactants

[0337]

[0338] The aspect ratios were all above 0.9, indicating that the fibers were round. The dry fiber diameter increased with increasing dose. However, the dry fiber diameter increased slightly, which may be related to the fiber density, which decreased with increasing dose.

[0339] Figure 1.2C Shown are dry and hydrated inserts made in this run. As can be seen, the higher the drug concentration, the more aggregation appears to occur.

[0340] Table 1.2.5 below shows the characteristics of the hydrated inserts after hydration with PBS at 37°C for 10 minutes and 24 hours. It can be seen that both the hydrated diameter and the shrinkage factor decrease with increasing dose. This indicates that the drug content has a significant adverse effect on the rehydration rate.

[0341] Table 1.2.5: Hydration characteristics of low, medium and high dose inserts

[0342]

[0343]

[0344] Surfactant Type

[0345] To address the issue of aggregation, the effect of various surfactants on cyclosporin particle size was determined. Surfactants were tested at maximum surfactant concentrations according to FDA guidelines.

[0346] In a glass vial, prepare a solution containing 0.05% 20 (PEG-20 sorbitan monolaurate), 4% 80 (PEG-80 sorbitan monolaurate), 0.5% Cremophor RH 40 (PEG-40 hydrogenated castor oil), and 0.3% Tyloxapol (ethoxylated 4-tert-octylphenol / formaldehyde condensate). The surfactant solution was then vortexed and sonicated. In a vial, a solution containing about 9-10% (w / w) cyclosporin was prepared by adding about 1 mL of the surfactant / buffer stock solution to about 100 mg of cyclosporin. Controls were prepared with distilled water (DIW) or phosphate buffered saline (PBS) and contained no surfactant. This solution was then vortexed and the particle size was measured by laser diffraction using a BeckmanCoulter LS 13 320 based on the optical model "Fraunhofer.rf780z", with obscuration values ​​ranging from 7% to 9%.

[0347] Table 1.2.6 shows the solution concentrations and particle sizes. It can be seen that the use of surfactants resulted in a significant reduction in particle size, indicating reduced aggregation. Among the surfactants tested, Tyloxapol showed the greatest reduction in particle size. In addition, the particle size measured using tyloxapol was closest to the particle size provided by the supplier, who stated that D10, D50, and D90 were 0.5, 2.1, and 7.5 μm, respectively.

[0348] Table 1.2.6: Effect of surfactants on cyclosporin particle size

[0349]

[0350]

[0351] I. Example 1.3: Vacuum Degassing Evaluation

[0352] To evaluate the effect of vacuum degassing, 600 μg doses of cyclosporin inserts were prepared using a 0.3% (w / w) concentration for Tyloxapol and a 9% (w / v) concentration for 4a20kPEG-SG of the hydrogel precursor mixture. The composition of the insert formulations is shown in Table 1.3.1 below.

[0353] Table 1.3.1 Composition of Cyclosporine Insert Formulations Used to Evaluate Vacuum Degassing

[0354]

[0355]

[0356]

[0357] Three different sets of inserts were prepared using the same fabrication process except for the following details regarding the handling of the syringe containing the hydrogel suspension precursor containing cyclosporine, tyloxapol, and trilysine acetate / fluorescein after mixing the components and prior to further mixing with the PEG-containing hydrogel solution precursor.

[0358] For the first set of inserts, the hydrogel suspension contained in the syringe was processed in the following manner: (i) the syringe was filled (following the convention for all formulations), the suspension was vortexed for 3 minutes and manually degassed. Manual degassing was performed by pulling back the plunger of the syringe closed with a cap to create a vacuum, and then opening the syringe, thereby releasing the vacuum and bursting large bubbles. As a next step (ii), the hydrogel suspension precursor was placed in a vacuum chamber and degassed, and then mixed with the hydrogel solution precursor. The hydrogel suspension precursor for the second set of inserts was processed in essentially the same manner, except that the hydrogel suspension precursor was further sonicated in a step (iii) after step (ii). The hydrogel suspension precursor for the third set of inserts was prepared in the same manner as the second set, but step (ii) of degassing in a vacuum chamber was omitted. An overview of the preparation steps is given in Table 1.3.2 below.

[0359] Table 1.3.2: Vacuum degassing evaluation

[0360]

[0361] The first set of inserts obtained by vacuum degassing only had almost no aggregates. The second set of inserts obtained by vacuum degassing and sonication had many larger aggregates and could not fit into the cutting device. The third set of inserts obtained by sonication but without vacuum degassing had some aggregates but otherwise appeared to be in good condition ( Figure 1.3 ).

[0362] II. Example 1.4: Evaluation of drug particle size

[0363] Other inserts have been prepared to evaluate and determine the optimal particle size of the drug substance.

[0364] Effect of Sieving Large Particles of Cyclosporine

[0365] To evaluate the effect of sieving to exclude larger particles, 400 μg doses of cyclosporin inserts were prepared using a 0.3% (w / w) concentration for Tyloxapol and a 9% (w / v) concentration for 4a20k PEG-SG of the hydrogel precursor mixture. The composition of the formulations is shown in Table 1.4.1 below.

[0366] Table 1.4.1 Composition of cyclosporine insert formulations used to evaluate sieving

[0367]

[0368]

[0369] The cyclosporin used was sieved and the particle size fractions shown in Table 1.4.1 below were used. During manufacturing, some of the cast tube bundles broke and could not be used, which is also summarized in Table 1.4.2 below. The dry density and drug loading of each insert are shown in Figure 1.4A middle.

[0370] Table 1.4.2 Particle size fractions used and fracture failures of cast tube bundles

[0371]

[0372] *Other causes of fracture failure were identified, such as air entrapment in the gel during casting

[0373] From this we can conclude that high granularity has serious negative effects.

[0374] Effect of cyclosporine particle size on hydration, dry density and mechanical failure

[0375] To evaluate the effect of different particle sizes, inserts were prepared using micronized cyclosporine particles with five different particle size distributions (PSDs). The compositions of the five formulations are shown in Table 1.4.3 below.

[0376] Table 1.4.3: Composition of Cyclosporine Insert Formulations

[0377]

[0378]

[0379] The d10, d50 and d90 values ​​of the cyclosporins used are shown in Table 1.4.4 below.

[0380] Table 1.4.4: Particle sizes of cyclosporins used

[0381] Small 1 Small 2 Medium-Small medium big d10[μm] 1.0 1.1 1.3 1.5 1.8 d50[μm] 4.4 5.57 8.7 12.3 17.9 d90[μm] 28.9 37.6 34.8 38.4 43.2

[0382] After fabrication, the following was observed: inserts prepared with larger CSI particles tended to have larger stem diameters (see Figure 1.4B ), while the density decreases with increasing CSI particle size (see Figure 1.4C ). Smaller CSI particles produce smoother insert surfaces (see Figure 1.4D, showing microscopic images taken under a stereomicroscope with a camera). Inserts with small particles and small / medium particles on the surface appear to be covered with PEG. Rough surfaces with noticeable irregularities and deformations were found on inserts prepared with medium and large particles. Medium particles induced the highest rate of breakage during drying. Larger particles resulted in better hydration behavior and swelling (see Figure 1.4E ).

[0383] In summary, while larger particles improve swelling and rebound, they also lead to more bundle breakage. In addition, the high-dose formulation exhibited a higher breakage rate than the low-dose and medium-dose formulations, and the removal of very large particles (>45 microns) by sieving significantly improved the breakage rate.

[0384] In summary, a particle size between "small particle size" and "medium particle size" balances the density gain and fiber smoothness of small particles with the rehydration rate of medium particles, thereby achieving reduced bundle breakage.

[0385] III. Example 1.5: Preparation of inserts to support clinical trials

[0386] Hereinafter, the preparation process of the investigational product inserts used for human clinical studies (Formulations 1, 2A, 2B and 3, see Example 4) and high-dose beagle studies (Formulations 4A and 4B, see Example 3.6) will be described. The investigational product inserts were based on: medium-durability cyclosporine / hydrogel formulations based on PEG-SG (Formulations 1 and 4A, designed to last about 2 to 3 months); long-durability cyclosporine / hydrogel formulations based on PEG-SAP (Formulations 2A and 4B, designed to last about 3 to 4 months); and two hydrogel vehicle (HV) formulations without cyclosporine as placebos, a long-durability formulation based on PEG-SAP (Formulation 2B, designed to last about 3 to 4 months) and a short-durability formulation based on PEG-SS (Formulation 3, designed to last about 1 week).

[0387] The target diameter of the cyclosporine-containing insert was 0.55 mm ± 0.03 mm and the target length was 2.72 mm ± 0.08 mm, while the target diameter of the HV insert was 0.41 mm ± 0.05 mm and the target length was 2.72 mm ± 0.08 mm. The composition of the formulations is shown in Table 1.5 below.

[0388] Table 1.5 Composition of Cyclosporine Investigational Product Insert Formulations

[0389]

[0390] I. Brief description of preparation process

[0391] To form a polymer network containing an insert of cyclosporin, two precursor syringes were prepared: one hydrogel suspension precursor syringe containing a suspension of cyclosporin in a tyloxapol and trilysine acetate (TLA) / fluorescein solution, and a second hydrogel solution precursor syringe containing a multi-arm PEG (4-arm 20K PEG based on a pentaerythritol core structure, containing amine-reactive NHS groups) solution. The two syringes were mixed and then the liquid suspension was cast into a subset of flexible tubing by injection, and the material was then cross-linked and solidified. After casting, the hydrogel immediately solidified, i.e., cross-linking occurred. The bundle of tubing containing cyclosporin trapped in the hydrogel network was then stretched and dried in an incubator under a stream of nitrogen. The dried bundle of tubing was removed from the flexible tube, cut into a certain length, and stored in a vial. The drug was then packaged in a protective foam carrier, which was heat-sealed into a laminated foil bag under a nitrogen environment. Drug products were sterilized using electron beam irradiation for cyclosporine-containing formulations and gamma irradiation for HV formulations.

[0392] The HV placebo insert was prepared in the same manner, except that the amounts of excipients used were adjusted according to the composition of Table 1 (multi-arm PEG variations), and in particular, cyclosporine was not used.

[0393] II. Preparation of Hydrogel Suspension Precursor Syringes

[0394] The same procedure and quantities were used for Formulations 1 and 2A, except for the type of multi-arm PEG and the amount of disodium hydrogen phosphate used. For Formulations 4 and 5, the amount of cyclosporin was also adjusted according to the composition given in Table 1.5 above.

[0395] The hydrogel suspension precursor syringe consisted of a mixture of two different additional precursor syringes.

[0396] One syringe contained micronized cyclosporin suspended in a tyloxapol solution, which was prepared by weighing 704.8 mg ± 5.0 mg of micronized cyclosporin (d50: 5-8 μm; d100: ≤ 45 μm) and suspending it in 2,775.0 mg ± 20.0 mg of a 0.8 wt % tyloxapol solution in water for injection (WFI). For the HV formulations (Formulations 2B and 3), the syringe contained only the 0.8 wt % tyloxapol solution.

[0397] Another syringe contained a solution of trilysine-fluorescein conjugate buffered with disodium hydrogen phosphate, which was prepared by: (i) mixing 25.0 mg ± 0.5 mg NHS-fluorescein with 8,025.0 mg ± 5.0 mg of a solution containing 97.5 mg ± 2.5 mg trilysine acetate and 243.75 mg ± 2.5 mg (Formulations 1 and 3) or 690 mg ± 5.0 mg (Formulations 2A and 2B) disodium hydrogen phosphate in 9,750.0 ± 10.0 mg WFI; (ii) reacting the resulting mixture at room temperature for 1 to 24 hours; (iii) filtering the solution; and (iv) filling syringes, wherein each syringe was filled with a 1,575.0 mg ± 10.0 mg portion of the resulting solution. Completion of the reaction in step (ii) was confirmed by a reverse phase (RP) HPLC method using UV detection, which allows the unreacted components to be distinguished from the product amide by retention time (RT). After step (ii), no quantifiable peak remained with a RT consistent with NHS-fluorescein (RT≈6.6 min), and a new peak appeared at a higher RT (RT of about 8.2 min) resulting from the formation of the product amide. In initial studies, the results indicated conversion to the amide after 1 h, and the reaction product was shown to be stable in solution for up to 7 days ( Figure 2 ).

[0398] Two additional precursor syringes were connected together with a female-to-female luer lock connector and their contents were mixed together by passing back and forth between each syringe a total of 25 times, thereby forming a hydrogel suspension precursor syringe. Tyloxapol USP was added to the solution used to suspend cyclosporin to help disperse the cyclosporin and reduce any aggregation, as cyclosporin is very poorly soluble in water and tends to aggregate, and also to help prevent the hydrogel mixture from sticking to the inner wall of the tube, which is believed to be the cause of the flat shape of the insert with a low aspect ratio.

[0399] III. Preparation of Hydrogel Solution Precursor Syringe

[0400] The hydrogel solution precursor syringe contained a buffered solution of PEG prepared by combining 1,565.0 mg ± 10.0 mg of a solution containing 24.5 mg ± 1.0 mg sodium dihydrogen phosphate in 7,985.0 mg ± 50.0 mg WFI with 542.0 mg ± 5.0 mg of 4a20K PEG-SG (4-arm 20 kDa PEG with N-hydroxysuccinimidyl glutarate end groups, used in Formulation 1) or 4a20K PEG-SAP (4-arm 20 kDa PEG with N-hydroxysuccinimidyl adipate end groups, used in Formulation 2A).

[0401] IV. Casting, Stretching and Drying

[0402] To form the hydrogel / cyclosporin suspension, a hydrogel suspension precursor syringe containing cyclosporin, tyloxapol, and trilysine-fluorescein conjugate, and a hydrogel solution precursor syringe containing 4a20k PEG-SG, 4a20k PEG-SAP, or 4a20k PEG-SS were first degassed by placing them into a vacuum chamber and exposed to a programmed vacuum cycle, and then connected with a female-to-female Luer lock connector. The contents of the precursor syringes were mixed together by passing back and forth between each syringe a total of 25 times, and the resulting hydrogel / cyclosporin suspension was transferred to a single syringe.

[0403] The hydrogel / cyclosporine suspension syringe was then connected to a barbed fitting on autoclaved polyurethane tubing with an inner diameter of 2.0 mm and an outer diameter of 2.8 mm, cut to the appropriate length, and the suspension was cast through the prepared tubing, and the material was then allowed to crosslink and solidify.

[0404] Once the tube was filled, the tube was removed from the syringe and the barb fitting on the tube was capped. The gel time was confirmed by performing a gel tapping test. For the gel tapping test, a small amount of residual hydrogel / cyclosporin suspension was placed on a glass slide and tapped with a pipette tip until the suspension began to strand, indicating that when the suspension gelled, polymerization began in about 2-8 minutes (i.e., remained attached to the pipette tip during a complete tapping cycle).

[0405] The tubes filled with the hydrogel / cyclosporin suspension, hereinafter referred to as "casted strands", were placed vertically and stored in a curing chamber (ambient temperature and humidity) for 3 to 6 hours to allow the gel to cure.

[0406] After the curing time is over, the cast bundle is placed in a stretching fixture and fixed in place with a dynamic clamp. The cast bundle is stretched to a fixed length of the stretching fixture, which is about 2.7 times the original tube length. The stretching fixture is then moved and placed vertically in an incubator set at 32.0±2.0°C and a nitrogen flow rate of 53±3 SCFH (standard cubic feet per hour) for drying. The cast bundle is kept in the incubator for several days to allow it to dry completely.

[0407] V. Cutting, packaging, sterilization and inspection

[0408] The dried cast bundle was removed from the tube and cut into approximately 2.7 mm lengths. The inserts were 100% in-process visually and dimensionally inspected using a Vision System at 10X magnification (acceptance criteria: particulate, cylindrical, no visible surface defects, 0.55 mm ± 0.03 mm diameter for cyclosporin-containing inserts, 0.41 mm ± 0.05 mm diameter for HV inserts, and 2.72 mm ± 0.08 mm length for all inserts).

[0409] Inserts that meet all in-process specifications are packaged as individual inserts in a foam carrier and sealed in an aluminum-LDPE foil bag that can be torn open by the user. To hold the insert, the foam carrier has a V-shaped notch with an opening at the bottom, into which the insert is placed with pliers, with a portion of the insert sticking out to facilitate removal. The foam carrier with the insert is placed in the foil bag. The unsealed foil bag is transferred to a glove box provided with an inert nitrogen environment to reduce residual moisture from the foam and bag materials, stored therein for a duration of at least 16 hours but not more than 96 hours, and then sealed in the glove box using a bag sealer to form a complete, continuous seal on the bag. The bag seal is checked and the package is stored at 2-8°C until sterilized.

[0410] Packaged inserts are sterilized by electron beam or gamma irradiation and stored at 2–8°C until final quality inspection.

[0411] After the bag insert has been sterilized, a final quality check of the drug product is performed.

[0412] Example 2: Insert Specifications

[0413] The obtained inserts were characterized by means of visibility tests, microscopy analysis, HPLC analysis and storage stability tests.

[0414] I. Visibility Test

[0415] The inserts were visually inspected to confirm that the inserts were visually observable through the surrogate test model when illuminated with blue light.

[0416] II. Microscopic Examination and Analysis

[0417] Inserts were examined microscopically using a Unitron Z850 / NSZ-606 microscope to confirm the dimensions of the product in the dry state and in the hydrated state after hydration in phosphate buffered saline, pH 7.4 at 37°C for 10 minutes (swollen state) and 24 hours (equilibrium state) (Table 2.1).

[0418] Table 2.1 Results of microscopic analysis of different preparations

[0419]

[0420] III. Other product specification tests

[0421] Other product specifications are tested and reported according to Table 2.2 below.

[0422] Table 2.2 Results of other product specification tests

[0423]

[0424]

[0425] *The RT (retention time) of the cyclosporine peak corresponds to the reference standard ± 0.5 minutes

[0426] **The target specifications for impurities are as follows:

[0427] - Cyclosporine A, ≤ 1.0%

[0428] - Cyclosporine C, ≤ 1.0%

[0429] - Cyclosporine B, ≤ 1.0%

[0430] -Dihydrocyclosporine A / Geclosporine, ≤ 1.4%

[0431] - Cyclosporine D, ≤ 1.0%

[0432] -Any individual impurity: ≤1.0%

[0433] -Total impurities: ≤6.0%

[0434] IV. Storage stability test

[0435] The stability of cyclosporine-containing inserts according to Formulations 1 and 2A has been evaluated under refrigerated conditions (2-8°C) over 12 months.

[0436] The results of the storage stability testing can be found in Tables 2.3.1 and 2.3.2 (Formulation 1) and Tables 2.3.3 and 2.3.4 (Formulation 2A).

[0437] Table 2.3.1 Storage stability test results: appearance, dimensions, measurements and properties (Formulation 1)

[0438]

[0439]

[0440]

[0441] Table 2.3.2 Storage stability test results: impurities and other specifications (Formulation 1)

[0442]

[0443]

[0444]

[0445]

[0446] 1 T=0 and T=3 data reported prior to label finalization; T=3, 4-hour interval and 9-day samples not extracted *Data not available, samples inadvertently not tested at 6 months

[0447] NMT: Not More Than NR: Not Reportable ND: Not Detected TBD: To Be Determined

[0448] --: Not tested yet

[0449] Table 2.3.3 Storage stability test results: appearance, dimensions, measurements and properties (Formulation 2A)

[0450]

[0451]

[0452]

[0453] Table 2.3.4 Storage stability test results: impurities and other specifications (Formulation 2A)

[0454]

[0455]

[0456]

[0457] 1 T=0 and T=3 data reported before label finalization; *data not available, samples inadvertently not tested at 6 months

[0458] NMT: not more than, NR: not reportable, ND: not detected, TBD: to be determined, --: not tested yet

[0459] The stability data obtained after 12 months still meet the predetermined stability specifications. According to ICH Q1E, for refrigerated products, if the long-term data show little change over time and show little change, the proposed shelf life can be up to twice, but should not exceed 12 months, and the proposal is supported by analytical results and relevant supporting data. Real-time long-term stability data follow the upper and lower limits of the stability specifications under the 95% confidence interval (CI). Overall, there are few or even no trends observed in the quantitative data. Statistical analysis shows that based on the degradation analysis of the assay showing a possible intercept at 23 months, the product will meet a shelf life of 23 months. All other stability-indicating parameters show a possible intercept of more than 36 months. Therefore, a shelf life of at least 23 months can be expected.

[0460] Example 3: Evaluation of Cyclosporine Insertion in Beagle Dogs

[0461] To investigate the pharmacokinetics of the cyclosporine-containing inserts, different formulations were tested in a beagle dog pharmacokinetic study.

[0462] Six different beagle dog studies were conducted in which the amount of drug released from the insert and / or the concentration of cyclosporine in the tear fluid was determined over the duration of the study. An overview of the studies and formulations is given in Table 3.

[0463] Table 3 Overview of beagle studies

[0464]

[0465]

[0466] Example 3.1: Proof-of-Concept PK Study

[0467] Inserts containing a nominal dose of 0.7 mg cyclosporine were administered to beagle dogs as outlined in Table 3.

[0468] The amount of drug released from the insert was assessed over time, and the concentration of cyclosporine in tears was determined for the duration of the study.

[0469] The median tear concentrations of cyclosporine ranged from 1.1 to 1.9 μg over the duration of the study, see Table 3.1 below. A subset of inserts were removed at 6 weeks to determine the amount of residual drug compared to the administered dose. The average amount of cyclosporine released over 6 weeks was 0.37 mg. Assuming a consistent daily release rate over the dosing period (as evidenced by tear concentrations remaining relatively constant), the estimated daily delivered dose was calculated to be 8.8 μg per day.

[0470] Table 3.1: Cyclosporine tear concentrations in beagle dogs

[0471]

[0472]

[0473] Example 3.2: Proof-of-Concept PK Study

[0474] Inserts containing a nominal dose of 0.44 mg of cyclosporine were administered to beagle dogs as summarized in Table 3.

[0475] The amount of drug released from the insert was assessed over time, and the concentration of cyclosporine in tears was determined for the duration of the study.

[0476] The mean tear concentrations of cyclosporine ranged from 1.1 to 2.8 μg over the duration of the study, see Table 3.2 below. The inserts were removed at 32 days to determine the amount of residual drug compared to the administered dose. The mean amount of cyclosporine released over 32 days was 0.2 mg. Assuming a consistent daily release rate over the dosing period, the estimated daily delivered dose was calculated to be 6.3 μg per day.

[0477] Table 3.2: Cyclosporine tear concentrations in beagle dogs

[0478]

[0479] Example 3.3: Proof-of-Concept PK Study

[0480] For n=10 samples in total, the initial cyclosporin dose in the insert prior to administration was 671±13 μg (mean plus standard deviation). Four and five inserts were removed at 28 and 50 days, respectively, and analyzed for cyclosporin content. The left and right eyes provided similar results, from which the average of all removed inserts was calculated to give release amounts (initial amount minus the amount remaining in the removed inserts, which were 576±18 μg and 494±32 μg, respectively) of 3.4 and 3.5 μg, respectively, as shown in Table 3.3. The average daily release rate was determined by comparing the initial dose with the released dose. The results of the study indicate that the estimated daily delivered dose within 28 and 50 days was approximately 3.5 μg per day. The drug release from the inserts during the study ranged from as low as 2.7 μg per day to as high as 4.4 μg per day.

[0481] 3.3: Cyclosporine Release from Inserts in Beagle Dogs

[0482]

[0483] Example 3.4: Dry eye model study

[0484] Inserts containing a nominal dose of 0.36 mg of cyclosporine and having a hydrated diameter of 1.5 mm and a hydrated length of 2.5 mm were administered to beagle dogs as outlined in Table 3.

[0485] The tear glands of the right eye of the beagle dog were surgically removed in advance to establish an artificial dry eye model. The left eye was not treated and thus used as a healthy control. Tear production was tracked over time by the Schirmer tear test, and the test showed that tear production in the right eye was reduced to near zero, providing proof of concept for the dry eye model (see Figure 3.1 ). The amount of drug released from the insert was assessed over time, and the concentration of cyclosporine in tears was determined for the duration of the study.

[0486] The mean tear concentrations of cyclosporine ranged from 0.8 to 1.4 μg / mL in healthy eyes and from 1.4 to 4.8 μg / mL in dry eyes, see Table 3.4 below. The higher tear cyclosporine concentrations in the beagle dry eye model (compared to healthy eyes) suggest that cyclosporine can be successfully transported into the tears and is likely transported from the insert to the ocular surface under dry eye conditions, and that cyclosporine concentrations on the ocular surface may be higher under dry eye conditions due to reduced tear volume (caused by reduced tear production) and thus lower drug dilution when compared to cyclosporine concentrations observed in healthy eyes.

[0487] Table 3.4: Cyclosporine tear concentrations in dry and healthy eyes of beagle dogs

[0488]

[0489] Example 3.5: Pharmacokinetic studies

[0490] As summarized in Table 3, inserts of Formulations 1 and 2A (PEG-SG and PEG-SAP hydrogels, 0.36 mg cyclosporin) were administered bilaterally to 24 beagle dogs. Tear samples were obtained at 1 hour, 3 hours and 6 hours after dosing, 1 day and 3 days, 1 week, 2 weeks, 4 weeks, 6 weeks, 8 weeks, 10 weeks and 12 weeks. The results are shown in Table 3.5 and Table 3.5 below. Figure 3.2A and Figure 3.2B Cyclosporine was released from the insert into the tears of beagle dogs over 12 weeks for Formulation 1 (Group 1) and Formulation 2A (Group 2). The results showed that the maximum tear concentration occurring at about 3 hours for the two formulations was comparable, at 2.7 μg / mL. During the first six weeks, the drug release profiles and tear concentrations for the two formulations appeared comparable (within the 95% confidence interval).

[0491] Potential decreases in cyclosporine tear concentrations in beagle dogs were observed with the SG hydrogel formulation relative to the SAP hydrogel formulation between weeks 8 and 12. This difference may be caused by faster degradation of the SG hydrogel than the SAP hydrogel.

[0492] 3.5 Cyclosporine tear concentration in beagles

[0493]

[0494] Example 3.6: High-dose study

[0495] As summarized in Table 3, the pharmacokinetics of the inserts with a higher dose (0.7 mg cyclosporin) according to two hydrogel formulations 4A and 4B (PEG-SG and PEG-SAP) were evaluated in a GLP-compliant toxicology study.

[0496] Tear samples were obtained before dosing and at 1 hour, 2 hours, 4 hours, 24 hours and on days 7, 30, 60, 90 and 104 after dosing. The concentrations of cyclosporine in tears are shown in Table 3.6.1 and Figure 3.3 Results showed that tear concentrations of the two formulations were comparable (within 95% confidence intervals) for the duration of the study in this beagle dog study, and drug levels were below the lower limit of quantitation (LLOQ = 30 ng / mL) in the recovery animals (test article was removed two weeks prior to the 104 day sampling).

[0497] The pharmacokinetic profiles of the two formulations were comparable and demonstrated sustained steady-state dose exposure over the duration of the study. Because tear concentrations reached an apparent steady state within the one-hour dose exposure during dosing over the duration of the study, the true maximum concentration was not apparent.

[0498] Table 3.6.1 Cyclosporine tear concentrations in beagle dogs

[0499]

[0500] Example 4: Randomized, multicenter, double-blind, vehicle-controlled human phase 1 / 2 clinical study

[0501] A randomized, multicenter, double-blind, vehicle-controlled, Phase 1 / 2 clinical study was designed to evaluate the safety, tolerability, and efficacy of cyclosporine inserts for use in the canaliculus to treat subjects with DED, including 145 subjects (290 eyes), recruited in two cohorts, i.e., Cohort 1, an open-label group consisting of approximately 5 subjects (10 eyes) treated with Formulation 2A hydrogel / cyclosporine inserts; and Cohort 2, a randomized, double-blind group consisting of approximately 140 subjects treated with 2 different Formulations 1 and 2A hydrogel / cyclosporine inserts and 2 different Formulations 2B and 3HV inserts.

[0502] Both eyes were treated with the same treatment / formulation. If both eyes met the symptoms of dry eye, the eye with the higher total corneal fluorescein staining score was designated as the study eye, and the other eye was designated as the non-study eye. If the total corneal fluorescein staining score was the same for both eyes, the study eye was determined by the biostatistician prior to analysis. If only one eye met the criteria, that eye would be the study eye, but both eyes would still receive the same treatment / formulation.

[0503] Treatments are summarized in Table 4 below.

[0504] Table 4: Treatment Overview (HV = Hydrogel Vehicle)

[0505]

[0506] I. Research Schedule

[0507] Both cohort groups followed essentially the same study schedule. Subjects were enrolled if:

[0508] Self-reported history of dry eye or clinically confirmed dry eye disease in both eyes for ≥ 6 months by an eye care professional,

[0509] Persistent dry eye disease in the study eye as defined by a visual analogue scale (VAS) dry eye severity score ≥ 30 during the screening visit, and

[0510] Total corneal fluorescein staining (tCFS) score ≥6 and ≤15 (NEI scale, see Assessment section below) and Schirmer score (unanesthetized) >0 mm and ≤10 mm wetting (at 5 minutes) in the same eligible eye or in both eyes, where

[0511] Other inclusion and exclusion criteria apply.

[0512] Subjects underwent screening 14 days / day 1 before insertion (visit 2) and eligibility was confirmed at visit 2. At visit 2, subjects in cohort 2 were randomized to one of four treatment groups in a 2:2:2:1 ratio. Further treatment follow-up (visits 3 to 8) were scheduled for all subjects at regular intervals from week 2 to week 16 to determine, inter alia, the presence of the insert, which was assessed non-invasively by illuminating the corresponding area with blue light and using a yellow light filter.

[0513] For both cohorts, if the insert was visible at Week 16 (Visit 8), the subject returned to the clinic within 30 days (±10 days; Visit 9) and continued to return every 30 days as needed until the insert was no longer visible and the physician had determined that there was no evidence of biological activity. If the insert could not be seen at Week 16 (Visit 8) and the physician had determined that there was no evidence of biological activity, the subject was withdrawn from the study.

[0514] A general schematic diagram of the study is shown in Figure 4A as shown in .

[0515] Various assessments were performed at each visit. In particular, all ophthalmologic assessments outlined in point III below were performed at all visits 1 to 8 and at visit 9 in the event that a visit 9 was performed for individual patients, with the exception of the TBUT assessment, which occurred only at visits 1, 2, 5, and 7.

[0516] According to point III below, the occurrence of any adverse events was also assessed at each visit starting from the insertion day / Day 1 (any signs, symptoms and conditions present before insertion on Day 1 were recorded as medical history).

[0517] II. Insert Placement

[0518] The ophthalmic insert is placed in the vertical portion of the lacrimal canaliculus (see Figure 5B ). In the clinical studies disclosed herein, the insert was placed in the lower punctum.

[0519] To place the insert in the canaliculus, lateral pressure is applied to stretch the canaliculus system and temporarily pull down the skin near the punctum ( Figure 5A ). Use the punctal dilator to dilate the lower punctum toward the nose, ensuring that the system is elongated and the canaliculus is dilated deeper through the punctum to a certain depth and width. If necessary, rotate the dilator in a rotational motion to assist the dilation procedure ( Figure 5B ).

[0520] Use an ophthalmic sponge to dry the surface around the punctal opening ( Figure 5C ).

[0521] Using forceps, insert the hydrogel / cyclosporine or HV insert at a shallow angle toward the nose ( Figure 5D ), aim to insert 70% in the first movement and use forceps to tap or push the rest of the insert in, thus avoiding over-compression of the insert to prevent deformation. Confirm that the insert is positioned just below the punctal opening.

[0522] If the insert hydrates before placement below the punctal opening (similar to a trumpet shape), hydrates before ideal positioning, or if a portion of the insert protrudes and cannot be inserted, the insert is discarded and a new insert is used.

[0523] The ease of insertion of ophthalmic inserts was graded as "easy" (1), "moderate" (2), or "difficult" (3).

[0524] III. Assessment

[0525] The study used the following assessment:

[0526] Schirmer tear test

[0527] The Schirmer test determines the amount of tears produced and works by capillary action, thereby allowing tears to travel along the length of a paper test strip. The rate of travel along the test strip is proportional to the rate of tear production. The subject is asked to raise his head and apply the curved end of the test strip so that it is located between the inferior conjunctiva of the lower eyelid and the bulbar conjunctiva of the eye. After five minutes, the patient is asked to open both eyes and look upward, and the test strip is removed. The Schirmer test score is determined by the length of the wet area of ​​the test strip. Both eyes are tested at the same time. Under anesthesia, only basal tear secretion is measured.

[0528] A Schirmer score of ≥10 mm wetting is considered normal, whereas a score <5 mm indicates insufficient tear production.

[0529] Tear film breakup time (TBUT) and total corneal fluorescein staining (tCFS)

[0530] The time it takes for the tear film to break up after blinking is known as TBUT. It is a quantitative test to measure the stability of the tear film. Normal tear film breakup time is more than 15 seconds. To assess TBUT, a fluorescein strip is moistened with saline and applied to the inferior ductus. After blinking several times, the tear film is examined using a wide beam slit lamp with a blue light filter to identify the appearance of the first dry spot on the cornea.

[0531] TBUT values ​​less than 5-10 seconds indicate tear instability and are observed in patients with mild to moderate dry eye.

[0532] Total corneal fluorescein staining (tCFS) values ​​are measured to assess corneal condition. Damage such as corneal surface abrasions that may be caused, for example, by dry eye disease are made visible by staining with fluorescein dye.

[0533] To assess tCFS, the fluorescein strip was moistened with saline solution / eyewash, and the subject was asked to raise his head and apply the moistened test strip to the lower eyelid conjunctiva, without the test strip touching the bulbar conjunctiva. Since TBUT is also assessed by applying fluorescein, if the tCFS measurement is performed immediately after TBUT, no additional application of fluorescein dye is required. The subject was asked to blink several times to distribute the fluorescein dye, and after waiting for 2 to 3 minutes, corneal staining in each of the five areas of the cornea, central, inferior, nasal, temporal, and superior, was assessed using cobalt blue illumination and a Wratten yellow light filter using the NEI (National Eye Institute) 0-3 grading scale (0 = no staining, 1 = mild staining, 2 = moderate staining, 3 = severe staining), where the total CFS score is the sum of the five areas (0 to 15).

[0534] The higher the tCFS score, the greater the damage to the corneal surface.

[0535] Conjunctival lissamine green staining (LGS)

[0536] The LGS value is measured to assess the condition of the conjunctiva. The Lissamine strip is moistened with saline solution / eyewash, and the subject is asked to raise his head and apply the moistened test strip to the lower eyelid conjunctiva, without the test strip touching the bulbar conjunctiva. The subject is asked to blink several times to distribute the Lissamine dye, and after waiting for 1 to 4 minutes, the conjunctiva is assessed for conjunctival staining in 6 areas, namely, temporal, superior temporal, inferior temporal, and superior nasal, inferior nasal, and mid-nasal, using a moderate light, using the NEI 0-3 scoring scale, where the total LGS score is the sum of the six areas (0 to 18).

[0537] Staining produced by elevated piñas may not improve. Staining associated with piñas may always be excluded from the total lissamine score.

[0538] The higher the LGS score, the greater the degree of damage to the conjunctival surface.

[0539] Best corrected visual acuity BCVA

[0540] Visual acuity testing should be performed before any examination requiring contact with the eye or instillation of study dye. LogMAR visual acuity must be assessed using the Early Treatment Diabetic Retinopathy Study (ETDRS) or Modified ETDRS chart, which consists of five letters per line, each representing 0.1× the log unit of the minimum angle of resolution (logMAR) at a given test distance.

[0541] Visual acuity testing was performed using the Early Treatment Diabetic Retinopathy Study (ETDRS) or modified ETDRS chart with best correction using the subject's own corrective lenses (glasses only) or pinhole refraction. The ETDRS or modified ETDRS chart consists of five letters per line, with each line representing 0.1× the logarithm of the minimum angle of resolution (logMAR) at a given testing distance.

[0542] Visual acuity (VA) is scored as a logMAR value, where the correct reading of the letters in the last row is considered the base logMAR reading, to which N×0.02 is added, where N is the total number of letters missed and included in the last row reading. This sum (base logMAR+N×0.02) represents the BCVA of the eye.

[0543] The lower the BCVA score, the better the visual acuity.

[0544] Dry eye score / Visual Analogue Scale (VAS)

[0545] To assess the dry eye score, subjects were asked to rate the severity and frequency of dry eye symptoms based on vertical marks placed on a horizontal line (representing values ​​from 0 to 100%) to indicate the degree of eye discomfort currently experienced by the subject's eyes and the frequency of dry eye experienced, where 0% corresponds to "no discomfort" and 100% corresponds to "maximum (worst) discomfort".

[0546] Ocular Surface Disease Index

[0547] The OSDI allows for rapid assessment of ocular irritation symptoms in dry eye patients based on a 12-item questionnaire that assesses symptoms of dry eye and its impact on vision-related function in the subject's life over the past week (see, e.g., RM Schiffman et al., Arch Ophthalmol. 2000; 118(5):615-621, hereby incorporated by reference).

[0548] The higher the final score, the greater the degree of disability.

[0549] Standardized Patient Evaluation of Dry Eyes (SPEED) Assessment

[0550] The SPEED questionnaire (see Korb and Blackie, Ocular Surgery News European edition, 2012, hereby incorporated by reference) is another assessment that monitors symptoms of dry eye over time and consists of 8 items ranging from 0 to 28 points that assess the frequency and severity of symptoms including dryness, gritty sensation, itching, irritation, burning, tearing, soreness, and eye fatigue.

[0551] Higher scores indicate a higher degree of disability.

[0552] IV. Adverse Events

[0553] An adverse event (AE) is any untoward medical occurrence in a patient or clinical investigation subject administered a medicinal product and not necessarily causally related to such treatment. Thus, an AE may be any unfavorable and unexpected sign (including abnormal laboratory findings), symptom or disease temporally associated with the use of a medicinal (investigational) product, whether or not related to the medicinal (investigational) product.

[0554] A serious adverse event (SAE) is any unfortunate medical occurrence at any dose that:

[0555] Cause death

[0556] Life-threatening (an event in which the subject is at risk of death at the time of the event, but not an event that would result in death if a more serious condition were assumed)

[0557] · Requires hospitalization or prolongation of existing hospitalization. (Hospitalization for elective surgery does not constitute an SAE)

[0558] Causing persistent or significant loss of ability / incapacity.

[0559] Congenital anomalies / birth defects.

[0560] During each visit, subjects were asked about adverse events using open-ended questions, taking care not to influence the subjects' responses.

[0561] Any AEs as well as SAEs experienced by subjects from Visit 2 (Insertion / Day 1) to Visit 9 (30-day follow-up) were recorded, regardless of the severity of the event or its relationship to study treatment.

[0562] If necessary, any AEs noted in a previous assessment and indicated as ongoing will be reviewed at a follow-up visit and recorded if resolved.

[0563] Changes in AE intensity or frequency were recorded as independent events (ie, the start of a new recording).

[0564] Any SAE that a subject is experiencing when they complete the study or discontinue the study will be followed until the event resolves, stabilizes, or returns to baseline.

[0565] All events were assessed to determine whether the event met the criteria for an SAE, the severity of the event, and the relationship of the event to study treatment.

[0566] Example 4.1: Cohort 1—Open-label, single-center phase 1 study

[0567] Cohort 1 was an open-label, Phase 1 study designed to evaluate the safety, tolerability, durability, and bioactivity of the hydrogel / cyclosporine insert, with the Sponsor, Investigator, and Subjects aware of treatment assignment, and the study schedule was as outlined above under I. The study schedule was followed. All 5 enrolled subjects in Cohort 1 (10 eyes) received Formulation 2A inserts at Visit 2 according to the schedule outlined above under II. Inserts were placed after confirmation of eligibility.

[0568] I. Safety and Tolerability

[0569] All subjects completed the 16-week study period and no subjects withdrew. No serious adverse events were reported. The insert was observed to be well tolerated, and no adverse events of stinging, irritation, blurred vision, or tearing were reported or observed. No insert replacement was required. The ease of insertion of the insert was rated as follows:

[0570] 8 eyes: simple

[0571] 1 eye: medium

[0572] 1 eye: difficult

[0573] The moderate and difficult ratings are for the right and left eyes of the same subject. This shows that the overall size and swelling behavior of the insert are very well adjusted to facilitate its administration.

[0574] II. Durability

[0575] All inserts were last visible at Visit 8.

[0576] III. Biological Activity / Efficacy

[0577] The efficacy of insert treatment was assessed based on ophthalmologic assessments performed at each visit.

[0578] Tear production, as measured by the Schirmer test (without anesthesia), increased from a mean of 4.2 mm at baseline to 8.2 mm at Week 12, with one of five subjects (20%) having an increase of ≥10 mm in Schirmer score at Week 12 relative to baseline (see Fig. 6A and Figure 6B ).

[0579] Subjects demonstrated improvement in symptoms of dry eye disease (DED) as measured by tCFS. tCFS increased from a mean of 6.7 at baseline to a mean of 2.7 at Week 12 (see Fig. 7A ), resulting in a change from baseline (CFB) of -4.0 at Week 12 (see Figure 7B ).

[0580] Symptoms of DED also improved, as measured by:

[0581] (i) Visual Analog Scale (VAS) dry eye severity scores, which improved from a mean of 51 at baseline to a mean of 33 at Week 12 (see Fig. 8A and Figure 8B );and

[0582] (ii) VAS dry eye frequency score, which improved from a mean of 51 at baseline to a mean of 31 at Week 12 (see Fig. 9 ).

[0583] The inserts provided an effect on signs and symptoms of DED as early as two weeks (as measured by VAS dry eye severity and frequency scores) and continued over the 16-week study period.

[0584] In addition, both the Ocular Surface Disease Index (OSDI) and Standardized Patient Evaluation of Dry Eyes (SPEED) scores decreased over the 16-week period (see Fig.10 and Fig.11 ).

[0585] Example 4.2: Cohort 2 - Randomized, Multicenter, Double-Blind, Vehicle-Controlled Phase 2 Study

[0586] Cohort 2 is an ongoing randomized, double-blind, vehicle-controlled Phase 2 study designed to evaluate the safety, tolerability, and efficacy of the hydrogel / cyclosporine insert, with subjects and investigators and their staff and sponsors blinded to treatment assignment, and the study schedule is as outlined above under I. The study schedule was followed.

[0587] The randomization schedule was computer generated by a qualified biostatistician independent of the study implementation or planning team, and the hydrogel / cyclosporine and HV inserts administered to subjects at randomization during the double-blind treatment period were identical in appearance. Study subjects and investigators and their staff were masked to treatment identity until the final database was locked, and sponsor personnel involved in study implementation and monitoring remained masked until study and database locks were completed.

[0588] At Visit 2, 140 subjects enrolled in Cohort 2 received one insert (Formulations 1, 2A, 2B, and 3) according to the randomization schedule at Visit 2 after confirmation of eligibility. The procedure was as outlined above under II. Insert placement followed insert administration.

[0589] If disclosure is necessary, the integrity of the study assessment and objectives will be maintained by limiting access to the public data to two persons not involved in the conduct of the study (the sponsor's medical monitor and the sponsor's statistician) or, in emergency situations, directly to the investigator.

[0590] IV. Safety and Tolerability

[0591] Adverse events that were assessed continuously included the occurrence of stinging, irritation, blurred vision, or tearing.

[0592] V. Durability

[0593] The durability of the insert was assessed by monitoring the presence of the insert.

[0594] VI. Biological Activity / Efficacy

[0595] The efficacy of the insert treatment was assessed based on ophthalmologic assessments performed at each visit. Efficacy endpoints were determined as follows:

[0596] Primary End Point

[0597] Change from baseline (CFB) and absolute values ​​at week 12 in the Schirmer test (without anesthesia)

[0598] Secondary End Points

[0599] Symptoms:

[0600] Percentage of subjects with an increase in Schirmer score ≥10 mm at Week 12

[0601] CFB and absolute values ​​of total corneal fluorescein staining (tCFS) using the NEI scale at each post-baseline study visit

[0602] • CFB and absolute values ​​of corneal fluorescein staining subareas obtained using the NEI scale at each post-baseline visit.

[0603] CFB and absolute values ​​of conjunctival lissamine green staining using the NEI scale at each post-baseline visit.

[0604] Symptoms (subject reported):

[0605] CFB and absolute value of the dry eye score (VAS) at each post-baseline study visit

[0606] At each post-baseline visit, the ocular surface disease index ( total score, CFB and absolute values ​​for each of the three domains and individual questions).

[0607] CFB of the SPEED questionnaire (overall score and individual questions) at each post-baseline visit.

[0608] Exploratory :

[0609] CFB of tear breakup time (TBUT) at week 12

[0610] Presence of insert at all post-baseline visits

[0611] Investigator-rated ease of insertion

[0612] Visualization difficulty as rated by researchers

[0613] Although many embodiments have been described, it is apparent that the basic examples can be altered to provide other embodiments utilizing the compounds and methods of the present disclosure. It should be understood, therefore, that the scope of the present disclosure is to be limited by the appended claims rather than by the specific embodiments represented by way of example.

[0614] Various references are cited throughout this application. The disclosures of these references are hereby incorporated by reference into this disclosure.

[0615] The present invention particularly relates to the following other embodiments:

[0616] 1. A sustained-release biodegradable intraductal insert comprising a hydrogel and cyclosporine, wherein the cyclosporine is in the form of particles and wherein the cyclosporine particles are dispersed within the hydrogel.

[0617] 2. The sustained-release biodegradable intraductal insert according to embodiment 1, wherein the cyclosporine particles are uniformly dispersed in the hydrogel.

[0618] 3. The sustained release biodegradable intraductal insert of embodiment 1 or 2, wherein the cyclosporine particles have a d50 value of less than about 50 μm.

[0619] 4. The sustained release biodegradable intraductal insert of embodiment 3, wherein the cyclosporine particles have a d50 value in the range of 3 to 17 μm.

[0620] 5. The sustained release biodegradable intraductal insert of embodiment 4, wherein the cyclosporine particles have a d50 value in the range of 4 to 12 μm.

[0621] 6. The sustained release biodegradable intraductal insert of embodiment 5, wherein the cyclosporine particles have a d50 value in the range of 5 to 8 μm.

[0622] 7. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 6, wherein the cyclosporine particles have a d90 value of less than 43 μm.

[0623] 8. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 7, wherein the cyclosporine particles have a d100 value of less than 45 μm.

[0624] 9. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 8, comprising the cyclosporine in an amount ranging from about 100 μg to about 800 μg.

[0625] 10. The sustained release biodegradable intraductal insert of embodiment 9, comprising the cyclosporine in an amount ranging from 100 μg to 300 μg.

[0626] 11. The sustained release biodegradable intraductal insert of embodiment 9, comprising the cyclosporine in an amount ranging from 300 μg to 450 μg.

[0627] 12. The sustained release biodegradable intraductal insert of embodiment 9, comprising the cyclosporine in an amount ranging from about 500 μg to about 800 μg.

[0628] 13. The sustained release biodegradable intraductal insert of embodiment 9, comprising the cyclosporine in an amount of about 250 μg.

[0629] 14. The sustained release biodegradable intraductal insert of embodiment 9, comprising the cyclosporine in an amount of about 360 μg.

[0630] 15. The sustained release biodegradable intraductal insert of embodiment 9, comprising the cyclosporine in an amount of about 600 μg.

[0631] 16. The sustained release biodegradable intraductal insert of embodiment 9, comprising the cyclosporine in an amount of about 670 μg.

[0632] 17. The sustained release biodegradable intracanalicular insert of any one of embodiments 1 to 16, wherein the insert is for insertion into the lower canaliculus and the upper canaliculus.

[0633] 18. The sustained release biodegradable intracanalicular insert of any one of embodiments 1 to 16, wherein the insert is for insertion into the lower canaliculus.

[0634] 19. The sustained release biodegradable intracanalicular insert of any one of embodiments 1 to 16, wherein the insert is for insertion into the upper canaliculus.

[0635] 20. The sustained release biodegradable intracanalicular insert of any one of embodiments 17 to 19, wherein the insert is for insertion into a vertical portion of the canaliculus.

[0636] 21. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 20, wherein the insert is in a dry state prior to insertion and becomes hydrated after insertion into the eye.

[0637] 22. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 21, wherein the hydrogel comprises a polymer network.

[0638] 23. The sustained release biodegradable intraductal insert of embodiment 22, wherein the hydrogel comprises a polymer network comprising one or more units of polyethylene glycol, polyethylene oxide, polypropylene oxide, polyvinyl alcohol, poly(vinyl pyrrolidone), polylactic acid, polylactic acid-co-glycolic acid, a random or block copolymer, or a combination or mixture of any of them, or one or more units of polyamino acids, glycosaminoglycans, polysaccharides, or proteins.

[0639] 24. The sustained release biodegradable intraductal insert of embodiment 22 or 23, wherein the hydrogel comprises a polymer network comprising the same or different cross-linked polymer units.

[0640] 25. The sustained-release biodegradable intraductal insert of embodiment 24, wherein the cross-linked polymer unit is one or more cross-linked polyethylene glycol units.

[0641] 26. The sustained release biodegradable intraductal insert of any one of embodiments 22 to 25, wherein the polymer network comprises polyethylene glycol units having an average molecular weight ranging from about 2,000 to about 100,000 Daltons.

[0642] 27. The sustained release biodegradable intraductal insert of embodiment 26, wherein the average molecular weight of the polyethylene glycol unit is in the range of about 10,000 to about 60,000 Daltons.

[0643] 28. The sustained release biodegradable intraductal insert of embodiment 27, wherein the average molecular weight of the polyethylene glycol unit is in the range of about 20,000 to about 40,000 Daltons.

[0644] 29. The sustained release biodegradable intraductal insert of embodiment 28, wherein the average molecular weight of the polyethylene glycol unit is about 20,000 Daltons.

[0645] 30. The sustained release biodegradable intraductal insert of any one of embodiments 22 to 29, wherein the polymer network comprises one or more cross-linked multi-arm polymer units.

[0646] 31. The sustained-release biodegradable intraductal insert of embodiment 30, wherein the multi-arm polymer unit comprises one or more 2-arm to 10-arm polyethylene glycol units.

[0647] 32. The sustained-release biodegradable intraductal insert of embodiment 31, wherein the multi-arm polymer unit comprises one or more 4-arm to 8-arm polyethylene glycol units.

[0648] 33. The sustained-release biodegradable intraductal insert of embodiment 32, wherein the multi-arm polymer unit comprises a 4-arm polyethylene glycol unit.

[0649] 34. The sustained-release biodegradable intraductal insert of embodiment 33, wherein four arms of the 4-arm polyethylene glycol unit are attached to a core pentaerythritol molecule.

[0650] 35. The sustained release biodegradable intraductal insert of any one of embodiments 22 to 34, wherein the polymer network further comprises one or more cross-linking units.

[0651] 36. The sustained-release biodegradable intraductal insert of any one of embodiments 22 to 35, wherein the polymer network is formed by reacting a multi-arm polymer precursor containing an electrophilic group with a cross-linking agent containing a nucleophilic group.

[0652] 37. The sustained-release biodegradable intraductal insert of embodiment 36, wherein the electrophilic group is an active ester group.

[0653] 38. The sustained release biodegradable intraductal insert of embodiment 37, wherein the electrophilic group is an N-hydroxysuccinimide (NHS) ester group.

[0654] 39. The sustained-release biodegradable intraductal insert of embodiment 38, wherein the electrophilic group is selected from the group consisting of a succinimidyl malonate group, a succinimidyl succinate (SS) group, a succinimidyl maleate group, a succinimidyl fumarate group, a succinimidyl glutarate (SG) group, a succinimidyl adipate (SAP) group, a succinimidyl pimelate group, a succinimidyl suberate group, and a succinimidyl azelate (SAZ) group.

[0655] 40. The sustained-release biodegradable intraductal insert of any one of embodiments 36 to 39, wherein the cross-linking agent containing a nucleophilic group is a multi-arm polymer precursor containing a nucleophilic group.

[0656] 41. The sustained release biodegradable intraductal insert of any one of embodiments 36 to 39, wherein the cross-linking agent containing a nucleophilic group is an amine.

[0657] 42. The sustained-release biodegradable intraductal insert of embodiment 41, wherein the cross-linking agent containing a nucleophilic group is a small molecule amine having a molecular weight of less than 1,000 Da and comprising two or more aliphatic primary amine groups.

[0658] 43. The sustained-release biodegradable intraductal insert of embodiment 42, wherein the cross-linking agent containing a nucleophilic group is a small molecule amine selected from the group consisting of dilysine, trilysine, tetralysine, ethylenediamine, 1,3-diaminopropane, 1,3-diaminopropane, diethylenetriamine and trimethylhexamethylenediamine.

[0659] 44. The sustained-release biodegradable intraductal insert of embodiment 43, wherein the cross-linking agent containing a nucleophilic group is trilysine.

[0660] 45. The sustained-release biodegradable intraductal insert of embodiment 44, wherein the cross-linking agent containing a nucleophilic group is trilysine acetate.

[0661] 46. ​​The sustained-release biodegradable intraductal insert of embodiment 44, wherein the cross-linking agent containing a nucleophilic group is labeled trilysine.

[0662] 47. The sustained-release biodegradable intraductal insert of embodiment 46, wherein the trilysine is labeled with a color developing agent.

[0663] 48. The sustained release biodegradable intraductal insert of embodiment 47, wherein the trilysine is labeled with a chromogenic agent selected from the group consisting of a fluorophore such as fluorescein, rhodamine, coumarin, and cyanine.

[0664] 49. The sustained-release biodegradable intraductal insert of embodiment 48, wherein the cross-linking agent containing a nucleophilic group is fluorescein-conjugated trilysine.

[0665] 50. The sustained-release biodegradable intraductal insert of embodiment 49, wherein the fluorescein-conjugated trilysine is obtained by reacting trilysine acetate with N-hydroxysuccinimide (NHS)-fluorescein.

[0666] 51. The sustained release biodegradable intraductal insert of any one of embodiments 46 to 50, wherein the trilysine is labeled by partial conjugation with a chromogenic agent.

[0667] 52. The sustained release biodegradable intraductal insert of embodiment 51, wherein about 1% to about 20% of the trilysine amine groups are conjugated to a color developing agent.

[0668] 53. The sustained release biodegradable intraductal insert of embodiment 52, wherein 5% to 10% of the trilysine amine groups are conjugated to a color developing agent.

[0669] 54. The sustained release biodegradable intraductal insert of embodiment 53, wherein 8% of the trilysine amine groups are conjugated with a color developing agent.

[0670] 55. The sustained-release biodegradable intraductal insert of any one of embodiments 30 to 54, wherein the multi-arm polymer unit comprises a 4a20kPEG unit and the cross-linking unit comprises a fluorescein-conjugated trilysine amide unit.

[0671] 56. The sustained release biodegradable intraductal insert of any one of embodiments 22 to 55, wherein the polymer network is obtained by reacting 4a20kPEG-SG with fluorescein-conjugated trilysine at a molar ratio ranging from about 1:2 to about 2:1.

[0672] 57. The sustained-release biodegradable intraductal insert of embodiment 56, wherein the polymer network is obtained by reacting 4a20kPEG-SG with fluorescein-conjugated trilysine at a molar ratio of about 1:1.

[0673] 58. The sustained release biodegradable intraductal insert of any one of embodiments 22 to 55, wherein the polymer network is obtained by reacting 4a20kPEG-SAP with fluorescein-conjugated trilysine at a molar ratio ranging from about 1:2 to about 2:1.

[0674] 59. The sustained-release biodegradable intraductal insert of embodiment 58, wherein the polymer network is obtained by reacting 4a20kPEG-SAP with fluorescein-conjugated trilysine at a molar ratio of about 1:1.

[0675] 60. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 59, wherein the insert comprises, in a dry state, from about 15 wt % to about 80 wt % of the cyclosporine based on the total weight of the insert and from about 20 wt % to about 60 wt % of polymer units based on the total weight of the insert.

[0676] 61. The sustained-release biodegradable intraductal insert of embodiment 60, wherein the insert comprises, in a dry state, 30 wt % to 65 wt % of the cyclosporine based on the total weight of the insert and 25 wt % to 50 wt % of polymer units based on the total weight of the insert.

[0677] 62. The sustained-release biodegradable intraductal insert of embodiment 61, wherein the insert comprises, in a dry state, 45 to 55 wt% of the cyclosporine based on the total weight of the insert and 37 to 47 wt% of polymer units based on the total weight of the insert.

[0678] 63. A sustained release biodegradable intraductal insert comprising a hydrogel and cyclosporine, wherein the insert in a dry state contains from about 40% to about 80% by weight of the cyclosporine based on the total weight of the insert.

[0679] 64. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 63, wherein the insert contains 45 wt% to 55 wt% of the cyclosporin in a dry state based on the total weight of the insert.

[0680] 65. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 64, wherein the insert contains from about 20 wt% to about 60 wt% of polymer units in a dry state, based on the total weight of the insert.

[0681] 66. The sustained release biodegradable intraductal insert of embodiment 65, wherein the insert contains 25 wt% to 50 wt% of polymer units in a dry state based on the total weight of the insert.

[0682] 67. The sustained release biodegradable intraductal insert of embodiment 66, wherein the insert contains 37 wt% to 47 wt% of polymer units in a dry state based on the total weight of the insert.

[0683] 68. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 67, wherein the insert contains a surfactant.

[0684] 69. A sustained release biodegradable intraductal insert comprising a hydrogel and cyclosporine, wherein the insert contains a surfactant.

[0685] 70. The sustained release biodegradable intraductal insert of embodiment 68 or 69, wherein the insert contains from about 0.01 wt % to about 5 wt % of a surfactant in a dry state, based on the total weight of the insert.

[0686] 71. The sustained release biodegradable intraductal insert of embodiment 70, wherein the insert contains 0.2 wt % to 2 wt % of a surfactant in a dry state, based on the total weight of the insert.

[0687] 72. The sustained release biodegradable intraductal insert of any one of embodiments 68 to 71, wherein the insert contains a non-ionic surfactant.

[0688] 73. The sustained release biodegradable intraductal insert of embodiment 72, wherein the insert contains a nonionic surfactant comprising a poly(ethylene glycol) chain.

[0689] 74. The sustained release biodegradable intraductal insert of embodiment 73, wherein the insert contains a surfactant selected from the group consisting of poly(ethylene glycol) sorbitan monolaurate, poly(ethylene glycol) esters of castor oil, and ethoxylated 4-tert-octylphenol / formaldehyde condensate.

[0690] 75. The sustained release biodegradable intraductal insert of embodiment 74, wherein the surfactant is selected from the group consisting of poly(ethylene glycol)-20-sorbitan monolaurate, poly(ethylene glycol)-80-sorbitan monolaurate, poly(ethylene glycol)-35 ester of castor oil, and ethoxylated 4-tert-octylphenol / formaldehyde condensate.

[0691] 76. The sustained release biodegradable intraductal insert of embodiment 75, wherein the insert comprises ethoxylated 4-tert-octylphenol / formaldehyde condensate.

[0692] 77. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 76, wherein the insert contains one or more phosphates, borates, or carbonates.

[0693] 78. The sustained release biodegradable intraductal insert of embodiment 77, wherein the insert contains phosphate derived from a phosphate buffer used during preparation of the hydrogel.

[0694] 79. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 78, wherein the insert contains no more than about 1 wt % water in a dry state, based on the total weight of the insert.

[0695] 80. The sustained release biodegradable intracanalicular insert of any one of embodiments 1 to 79, wherein the insert has a substantially cylindrical shape with a substantially circular cross-section.

[0696] 81. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 80, wherein the content of cyclosporin is about 300 to about 410 μg as measured by HPLC after storage at a temperature of 2 to 8°C for at least 3 months.

[0697] 82. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 81, wherein the content of cyclosporin is about 300 to about 410 μg as measured by HPLC after storage at a temperature of 2 to 8°C for at least 6 months.

[0698] 83. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 82, wherein the content of cyclosporin is about 300 to about 410 μg as measured by HPLC after storage at a temperature of 2 to 8°C for at least 12 months.

[0699] 84. The sustained-release biodegradable intraductal insert of any one of embodiments 1 to 83, wherein the content of cyclosporin is about 90 wt % to about 110 wt % as measured by HPLC after storage at a temperature of 2 to 8°C for at least 3 months. [More ranges reserved in the specification]

[0700] 85. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 84, wherein the content of cyclosporin is about 90 wt % to about 110 wt % as measured by HPLC after storage at a temperature of 2 to 8°C for at least 6 months.

[0701] 86. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 85, wherein the content of cyclosporin is about 90 wt % to about 110 wt % as measured by HPLC after storage at a temperature of 2 to 8°C for at least 12 months.

[0702] 87. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 86, wherein the amount of impurities does not exceed 3.0% as measured by HPLC after storage at a temperature of 2 to 8°C for at least 3 months.

[0703] 88. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 87, wherein the amount of impurities does not exceed 3.0% as measured by HPLC after storage at a temperature of 2 to 8°C for at least 6 months.

[0704] 89. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 88, wherein the amount of impurities does not exceed 3.0% as measured by HPLC after storage at a temperature of 2 to 8°C for at least 12 months.

[0705] 90. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 89, wherein the insert is in the form of a fiber.

[0706] 91. The sustained release biodegradable intraductal insert of embodiment 90, wherein the insert is in the form of fibers having an average length of about 1.5 mm to about 4.0 mm and an average diameter of no more than 0.8 mm in its dry state.

[0707] 92. The sustained-release biodegradable intraductal insert of embodiment 91, wherein the insert is in the form of fibers having an average length of 2.0 mm to 2.5 mm and an average diameter of no more than 0.62 mm in its dry state.

[0708] 93. The sustained release biodegradable intraductal insert of embodiment 92, wherein the insert is in the form of fibers having an average length of 2.5 mm to 2.9 mm and an average diameter of no more than 0.62 mm in its dry state.

[0709] 94. The sustained-release biodegradable intraductal insert of any one of embodiments 1 to 93, wherein after storage at a temperature of 2 to 8°C for at least 3 months, the insert is in the form of fibers having an average length of about 2.5 mm to about 2.9 mm and an average diameter of no more than 0.62 mm in its dry state.

[0710] 95. The sustained-release biodegradable intraductal insert of any one of embodiments 1 to 94, wherein after storage at a temperature of 2 to 8°C for at least 6 months, the insert is in the form of fibers having an average length of about 2.5 mm to about 2.9 mm and an average diameter of no more than 0.62 mm in its dry state.

[0711] 96. The sustained-release biodegradable intraductal insert of any one of embodiments 1 to 95, wherein after storage at a temperature of 2 to 8°C for at least 12 months, the insert is in the form of fibers having an average length of about 2.5 mm to about 2.9 mm and an average diameter of no more than 0.62 mm in its dry state.

[0712] 97. The sustained-release biodegradable intraductal insert of any one of embodiments 1 to 96, wherein the insert is in the form of fibers having an average diameter of at least 1.0 mm in a swollen state after hydration in phosphate-buffered saline, pH 7.4, at 37°C for 10 minutes in vitro.

[0713] 98. The sustained-release biodegradable intraductal insert of any one of embodiments 1 to 97, wherein the insert is in the form of fibers having an average diameter of at least 1.3 mm at equilibrium after hydration in phosphate-buffered saline, pH 7.4, at 37°C for 24 hours in vitro.

[0714] 99. The sustained release biodegradable intracanalicular insert of any one of embodiments 1 to 98, wherein the insert is inserted into the canaliculus with the aid of a grasping device selected from the group consisting of forceps, tweezers, and an applicator.

[0715] 100. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 99, wherein upon hydration in vivo in the eye or in vitro, the diameter of the insert increases, or the length of the insert decreases while the diameter of the insert increases.

[0716] 101. The sustained release biodegradable intraductal insert of embodiment 100, wherein hydration is measured after 24 hours in vitro at 37°C in phosphate buffered saline, pH 7.4.

[0717] 102. The sustained release biodegradable intracanalicular insert of any one of embodiments 1 to 101, wherein the insert disintegrates in the canaliculus within about 1 to about 6 months after insertion.

[0718] 103. The sustained release biodegradable intracanalicular insert of embodiment 102, wherein the insert disintegrates in the canaliculus within 2 to 4 months after insertion.

[0719] 104. The sustained release biodegradable intracanalicular insert of embodiment 103, wherein the insert disintegrates in the canaliculus within 2 to 3 months after insertion.

[0720] 105. The sustained release biodegradable intracanalicular insert of embodiment 103, wherein the insert disintegrates in the canaliculus within 3 to 4 months after insertion.

[0721] 106. The sustained release biodegradable intracanalicular insert of any one of embodiments 1 to 105, wherein upon insertion into the canaliculus, the insert releases a therapeutically effective amount of cyclosporine over a period of at least about 1 month after insertion.

[0722] 107. The sustained release biodegradable intracanalicular insert of embodiment 106, wherein after insertion into the canaliculus, the insert releases a therapeutically effective amount of cyclosporine over a period of at least 2 months after insertion.

[0723] 108. The sustained release biodegradable intracanalicular insert of embodiment 107, wherein after insertion into the canaliculus, the insert releases a therapeutically effective amount of cyclosporine over a period of at least 3 months after insertion.

[0724] 109. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 108, wherein cyclosporine is released from the insert at an average rate of about 0.1 μg per day to about 10 μg per day after the insert is inserted into a human subject.

[0725] 110. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 108, wherein cyclosporine is released from the insert at an average rate of about 0.1 μg per day to about 10 μg per day after insertion of the insert.

[0726] 111. The sustained release biodegradable intraductal insert of embodiment 109 or 110, wherein after insertion of the insert, cyclosporine is released from the insert at an average rate of 1 μg per day to 5 μg per day.

[0727] 112. The sustained release biodegradable intraductal insert of embodiment 111, wherein after insertion of the insert, cyclosporine is released from the insert at an average rate of 2 μg per day to 4 μg per day.

[0728] 113. The sustained release biodegradable intracanalicular insert of any one of embodiments 1 to 112, wherein the tear concentration of cyclosporine is in the range of about 0.1 μg / mL to about 10 μg / mL after insertion into a human subject.

[0729] 114. The sustained release biodegradable intracanalicular insert of any one of embodiments 1 to 112, wherein the tear concentration of cyclosporine after insertion of the insert is in the range of about 0.1 μg / mL to about 10 μg / mL.

[0730] 115. The sustained release biodegradable intracanalicular insert of embodiment 113 or 114, wherein the tear concentration of cyclosporine after insertion of the insert is in the range of about 1 μg / mL to about 5 μg / mL.

[0731] 116. The sustained release biodegradable intracanalicular insert of any one of embodiments 1 to 115, wherein the insert disintegrates in the canaliculus before the cyclosporine particles contained in the insert are completely dissolved.

[0732] 117. The sustained-release biodegradable intraductal insert of any one of embodiments 1 to 116, wherein the insert can be obtained by preparing a precursor mixture containing a hydrogel precursor and cyclosporin, filling the precursor mixture into a tube, cross-linking the hydrogel precursor in the tube to provide a hydrogel mixture in a fibrous form, and stretching the hydrogel mixture fibers to provide the insert.

[0733] 118. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 117, wherein the fibers have been stretched before or after drying.

[0734] 119. The sustained release biodegradable intraductal insert of embodiment 118, wherein the fibers have been stretched prior to drying.

[0735] 120. A sustained release biodegradable intraductal insert comprising a hydrogel and cyclosporine, said insert being in the form of a fiber, wherein said fiber is stretched.

[0736] 121. The sustained release biodegradable intraductal insert of any one of embodiments 118 to 120, wherein the fibers have been stretched in the longitudinal direction by a stretch factor of about 1.0 to about 4.0.

[0737] 122. The sustained release biodegradable intraductal insert of embodiment 121, wherein the fibers have been stretched in the longitudinal direction by a stretch factor of about 1.5 to about 3.0.

[0738] 123. The sustained release biodegradable intraductal insert of embodiment 122, wherein the fibers have been stretched in the longitudinal direction by a stretch factor of about 2.7.

[0739] 124. A sustained release biodegradable intraductal insert, the insert comprising a hydrogel and cyclosporine in an amount of about 360 μg dispersed in the hydrogel, wherein the hydrogel comprises a polymer network comprising polyethylene glycol units, and wherein the insert is in a dry state prior to insertion.

[0740] 125. A sustained release biodegradable intraductal insert comprising a hydrogel and cyclosporine in an amount of about 360 μg, the insert being in the form of fibers having an average length of about 2.5 mm to about 2.9 mm and an average diameter in its dry state of no more than 0.62 mm.

[0741] 126. A sustained release biodegradable intraductal insert comprising a hydrogel and from about 45% to about 55% by weight of cyclosporine, based on the total weight of the insert, the insert being in the form of fibers having an average length of from about 2.5 mm to about 2.9 mm and an average diameter in its dry state of not more than 0.62 mm.

[0742] 127. A sustained release biodegradable intracanalicular insert, the insert comprising a hydrogel and cyclosporine in an amount of about 360 μg dispersed within the hydrogel, wherein upon insertion into the canaliculus, the insert releases a therapeutically effective amount of cyclosporine over a period of at least about 3 months after insertion.

[0743] 128. A sustained-release biodegradable intraductal insert comprising a hydrogel and cyclosporine, wherein

[0744] The cyclosporine is in the form of particles

[0745] The cyclosporine particles are dispersed within the hydrogel and have a d50 value of less than about 50 μm, and wherein

[0746] After insertion of the insert into a human subject, the cyclosporine is released from the insert at an average rate of about 0.1 μg per day to about 10 μg per day.

[0747] 129. A sustained release biodegradable intraductal insert, the insert comprising:

[0748] A hydrogel comprising a polymer network comprising

[0749] one or more cross-linked multi-arm polymer units comprising about 300 μg of 4a20K PEG units, and

[0750] a cross-linking unit comprising a fluorescein-conjugated trilysine amide unit, and

[0751] Cyclosporine in an amount of about 360 μg,

[0752] The inserts are in the form of fibers having an average length of about 2.5 mm to about 2.9 mm and an average diameter in their dry state of no more than 0.62 mm.

[0753] 130. A sustained release biodegradable intraductal insert, the insert comprising:

[0754] A hydrogel comprising a polymer network obtained by reacting 4a20kPEG-SG with fluorescein-conjugated trilysine at a molar ratio of about 1:1,

[0755] and cyclosporine in an amount of about 360 μg,

[0756] The inserts are in the form of fibers having an average length of about 2.5 mm to about 2.9 mm and an average diameter in their dry state of no more than 0.62 mm.

[0757] 131. A sustained release biodegradable intraductal insert, the insert comprising:

[0758] A hydrogel comprising a polymer network obtained by reacting 4a20kPEG-SAP with fluorescein-conjugated trilysine at a molar ratio of about 1:1,

[0759] and cyclosporine in an amount of about 360 μg,

[0760] The inserts are in the form of fibers having an average length of about 2.5 mm to about 2.9 mm and an average diameter in their dry state of no more than 0.62 mm.

[0761] 132. The sustained release biodegradable intraductal insert of any one of embodiments 1 to 131, wherein the hydrogel comprises a polymer network that is semi-crystalline in a dry state and amorphous in a wet state at or below room temperature.

[0762] 133. The sustained-release biodegradable intraductal insert of any one of embodiments 1 to 132, wherein the insert undergoes wet stretching or dry stretching during manufacture, and wherein the insert in a stretched form is dimensionally stable when in a dry state at or below room temperature.

[0763] 134. A method of treating or preventing an ocular disease in a subject in need thereof, the method comprising inserting a first sustained-release biodegradable intracanalicular insert comprising a hydrogel and cyclosporine according to any one of embodiments 1 to 132 into a canaliculus of the subject.

[0764] 135. The method of embodiment 134, wherein the first insert remains in the canaliculus until completely disintegrated.

[0765] 136. The method of embodiment 134 or 135, wherein the first insert is designed to disintegrate in the canaliculus within about 3 to about 4 months after insertion.

[0766] 137. The method of any one of embodiments 134 to 136, wherein the second insert is inserted at least 2 months later without prior removal of the first insert.

[0767] 138. A method of treating dry eye in a subject, the method comprising the steps of:

[0768] (a) inserting a first biodegradable insert into a first lacrimal canaliculus of a first eye of the subject, wherein the insert comprises:

[0769] (1) Hydrogel;

[0770] (2) about 100 μg to about 800 μg of cyclosporine dispersed in the hydrogel;

[0771] (3) wherein the cyclosporine is released from the insert at an average rate of about 0.1 μg per day to about 10 μg per day over a period of at least about 2 months from the date the first insert is inserted into the subject; and

[0772] (b) inserting a second insert into the first canaliculus of the first eye of the subject at least about 2 months from the date of inserting the first insert, wherein the second insert is substantially similar to the first insert.

[0773] 139. The method of embodiment 138, wherein the first insert is removed prior to complete disintegration.

[0774] 140. The method of embodiment 139, wherein the first insert is removed prior to complete disintegration and a second insert is inserted to replace the removed first insert.

[0775] 141. The method of any one of embodiments 138 to 140, wherein the first insert is designed to disintegrate in the canaliculus within about 2 to about 3 months after insertion.

[0776] 142. The method of any one of embodiments 134 to 141, wherein the first insert remains in the canaliculus until completely disintegrated.

[0777] 143. The method of any one of embodiments 134 to 142, wherein the second insert is inserted at least 2 months later without prior removal of the first insert.

[0778] 144. The method of any one of embodiments 134 to 142, wherein the first insert is removed prior to complete disintegration and a second insert is inserted to replace the removed first insert.

[0779] 145. The method of any one of embodiments 134 to 142, wherein the first insert is designed to disintegrate in the canaliculus within about 2 to about 3 months after insertion, and wherein the first insert is removed within 2 months after insertion.

[0780] 146. The method of any one of embodiments 134 to 145, wherein a dose of about 300 μg to about 400 μg of the cyclosporine is administered once per eye over a treatment period of at least 2 months.

[0781] 147. The method of any one of embodiments 134 to 146, wherein the eye disease is a disorder of the tear film and ocular surface.

[0782] 148. The method of any one of embodiments 134 to 146, wherein the eye disease is dry eye.

[0783] 149. The method of any one of embodiments 134 to 146, wherein the eye disease is associated with one or more conditions selected from the group consisting of burning, itching, redness, stinging, pain, foreign body sensation, visual disturbances, lacrimal gland inflammation, ocular surface inflammation, T cell-mediated inflammation, the presence of conjunctival T cells in tears, and elevated levels of inflammatory cytokines in tears.

[0784] 150. The method of any one of embodiments 134 to 149, wherein the treatment is effective to improve tear production as measured by the Schirmer tear test in a subject having a Schirmer score of less than 10 mm prior to insertion of the insert.

[0785] 151. The method of any one of embodiments 134 to 150, wherein the treatment is effective in reducing dry eye symptoms as determined by one or more assessments selected from the group consisting of: rating the severity of dry eye symptoms on a visual analog scale; rating the frequency of dry eye symptoms on a visual analog scale; determination of tear breakup time; corneal fluorescein staining; conjunctival lissamine green staining; best corrected visual acuity; determination of the ocular surface disease index; and a standard patient dry eye assessment.

[0786] 152. The method of any one of embodiments 134 to 151, wherein the dose for each eye administered once during the treatment period is contained in one insert.

[0787] 153. The method of any one of embodiments 134 to 151, wherein the dose administered to each eye once during the treatment period is contained in two inserts.

[0788] 154. The method of any one of embodiments 134 to 153, wherein the insert is inserted into the inferior canaliculus.

[0789] 155. The method of any one of embodiments 134 to 154, wherein the treatment period is at least 1 month, at least 2 months, or at least 3 months.

[0790] 156. A method of treating dry eye disease in a subject in need thereof, the method comprising inserting a sustained release biodegradable intracanalicular insert comprising a hydrogel and cyclosporine into a canaliculus of the subject, wherein punctal occlusion and cyclosporine release in the eye provide a synergistic effect.

[0791] 157. The method of embodiment 156, wherein the synergistic effect is that the cyclosporin has a higher bioavailability when compared to the administration of an eye drop solution containing the cyclosporin designed to provide the same daily release of the cyclosporin.

[0792] 158. The method of embodiment 157, wherein the higher bioavailability is measured by the amount of cyclosporine released into the tears calculated as cyclosporine tear concentration over time.

[0793] 159. A method of manufacturing a sustained-release biodegradable intraductal insert comprising a hydrogel and cyclosporine according to any one of embodiments 1 to 133, the method comprising the steps of:

[0794] a) preparing a precursor mixture containing a hydrogel precursor and cyclosporine particles dispersed in the precursor mixture,

[0795] b) shaping the precursor mixture and crosslinking the hydrogel precursor to form a polymer network and obtain a shaped hydrogel mixture comprising the polymer network, and

[0796] c) drying the hydrogel mixture to provide the insert.

[0797] 160. The method of embodiment 159, wherein the cyclosporine particles are micronized particles uniformly dispersed in the precursor mixture.

[0798] 161. The method of embodiment 159 or 160, wherein in step a), the precursor mixture is prepared by mixing a multi-arm polymer precursor containing an electrophilic group with a cross-linking agent containing a nucleophilic group in a buffered aqueous solution in the presence of micronized cyclosporine particles.

[0799] 162. The method of embodiment 161, wherein in step a), the multi-arm polymer precursor containing electrophilic groups is provided in a buffered aqueous precursor solution and the cross-linking agent containing nucleophilic groups is provided in a buffered aqueous precursor suspension containing the micronized cyclosporine particles.

[0800] 163. A method as described in embodiment 161 or 162, wherein in step a), the buffered aqueous precursor solution is prepared by dissolving the multi-arm polymer precursor in an aqueous buffer solution, and then mixing it with the buffered aqueous precursor suspension containing the nucleophilic group-containing cross-linker and the micronized cyclosporine particles within 60 minutes.

[0801] 164. The method of any one of embodiments 159 to 163, wherein in step a), after mixing the components of the precursor mixture containing cyclosporine particles, it is degassed under vacuum.

[0802] 165. The method of any one of embodiments 159 to 164, comprising reacting 4a20kPEG-SAP with fluorescein-conjugated trilysine at a weight ratio ranging from about 30:1 to about 50:1.

[0803] 166. The method of any one of embodiments 159 to 164, comprising reacting 4a20kPEG-SG with fluorescein-conjugated trilysine at a weight ratio ranging from about 30:1 to about 50:1.

[0804] 167. A method as described in any one of embodiments 159 to 166, wherein in step b), shaping the precursor mixture consists of filling the precursor mixture into a mold or tube to provide the desired final shape of the hydrogel mixture and cross-linking the hydrogel precursor before complete cross-linking.

[0805] 168. The method of any one of embodiments 159 to 167, wherein in step b), the precursor mixture is filled into a thin diameter tube to prepare a hydrogel mixture fiber.

[0806] 169. A method as described in embodiment 168, wherein the interior of the tube has a circular geometry.

[0807] 170. The method of embodiment 169, wherein the interior of the tube has a circular geometry with an inner diameter of approximately 2.0 mm.

[0808] 171. The method of embodiment 169, wherein the interior of the tube has a non-circular geometry.

[0809] 172. The method of any one of embodiments 159 to 171, wherein the method further comprises stretching the hydrogel mixture fiber.

[0810] 173. A method as described in embodiment 172, wherein the stretching is performed before or after drying the hydrogel mixture.

[0811] 174. A method as described in embodiment 172 or 173, wherein the fiber is stretched with a stretch factor of about 1 to about 4.5.

[0812] 175. A sustained release biodegradable intraductal insert obtainable by the method of any one of embodiments 159 to 174.

[0813] 176. A method of imparting shape memory to a hydrogel mixture fiber by stretching the hydrogel mixture fiber in a longitudinal direction, the hydrogel mixture fiber comprising cyclosporine particles dispersed in a hydrogel.

[0814] 177. Use of a sustained-release biodegradable intraductal insert comprising a hydrogel and cyclosporine according to any one of embodiments 1 to 133 for the preparation of a medicament for treating an ocular disease in a subject in need thereof according to any one of embodiments 134 to 158.

[0815] 178. The sustained-release biodegradable intraductal insert comprising a hydrogel and cyclosporine according to any one of embodiments 1 to 133, for use in treating an ocular disease in a subject in need thereof according to any one of embodiments 134 to 158.

[0816] 179. A method of increasing tear production in a subject having a Schirmer score of less than 10 mm prior to insertion of an intracanalicular insert, wherein tear production is measured by the Schirmer tear test, the method comprising administering to the subject a sustained release biodegradable intracanalicular insert comprising a hydrogel and cyclosporine according to any one of embodiments 1 to 133.

[0817] 180. The method of embodiment 179, wherein the Schirmer score increases by at least 2 mm 6 weeks after insertion.

[0818] 181. The method of embodiment 180, wherein the Schirmer score increases by at least 3 mm 12 weeks after insertion.

[0819] 182. A method of reducing dry eye symptoms, the reduction in dry eye symptoms being determined by one or more assessments selected from the group consisting of: rating the severity of dry eye symptoms on a visual analog scale; rating the frequency of dry eye symptoms on a visual analog scale; determination of tear breakup time; corneal fluorescein staining; conjunctival lissamine green staining; best corrected visual acuity; determination of the ocular surface disease index OSDI; and a standard patient dry eye assessment SPEED, the method comprising administering to the subject a sustained release biodegradable intraductal insert comprising a hydrogel and cyclosporine according to any one of embodiments 1 to 133.

[0820] 183. The method of claim 182, wherein the total corneal fluorescein staining value tCFS is reduced by at least 1.5 6 weeks after insertion.

[0821] 184. The method of claim 183, wherein the total corneal fluorescein staining value tCFS is reduced by at least 3 12 weeks after insertion.

[0822] 185. The method of any one of claims 182 to 184, wherein the rating of severity of dry eye symptoms on a visual analog scale is reduced by at least 10 2 weeks after insertion.

[0823] 186. The method of claim 185, wherein the rating of severity of dry eye symptoms on a visual analog scale is reduced by at least 15 6 weeks after insertion.

Claims

1. A sustained release biodegradable intraductal insert comprising a hydrogel and cyclosporine, wherein the cyclosporine is in the form of particles and wherein the cyclosporine particles are dispersed in the hydrogel, wherein The hydrogel comprises a polymer network, wherein the polymer network comprises one or more cross-linked multi-arm polymer units, wherein the multi-arm polymer units comprise one or more 2-arm to 10-arm polyethylene glycol units, and The cyclosporine particles have a d50 value of less than 50 μm, which according to USP <429> Laser diffraction measurement.

2. The sustained release biodegradable intraductal insert of claim 1, wherein the cyclosporine particles have a d50 value in the range of 3 to 17 μm.

3. The sustained release biodegradable intraductal insert of claim 1, wherein the polymer network comprises identical or different cross-linked polymer units. 4 . The sustained-release biodegradable intraductal insert according to claim 3 , wherein the cross-linked polymer unit is one or more cross-linked polyethylene glycol units.

5. The sustained release biodegradable intraductal insert of claim 1, wherein the polymer network comprises polyethylene glycol units having an average molecular weight ranging from 2,000 to 100,000 Daltons. 6 . The sustained-release biodegradable intraductal insert of claim 1 , wherein the multi-arm polymer unit comprises one or more 4-arm to 8-arm polyethylene glycol units.

7. The sustained-release biodegradable intraductal insert of claim 6, wherein the multi-arm polymer unit comprises a 4-arm polyethylene glycol unit.

8. The sustained release biodegradable intraductal insert of claim 7, wherein four arms of the 4-arm polyethylene glycol unit are linked to a core pentaerythritol molecule.

9. The sustained-release biodegradable intraductal insert of claim 1, wherein the polymer network is formed by reacting a multi-arm polymer precursor containing an electrophilic group with a cross-linking agent containing a nucleophilic group.

10. The sustained-release biodegradable intraductal insert of claim 9, wherein the electrophilic group is an active ester group.

11. The sustained-release biodegradable intraductal insert of claim 10, wherein the electrophilic group is an N-hydroxysuccinimide (NHS) ester group.

12. The sustained release biodegradable intraductal insert of claim 11, wherein the electrophilic group is selected from the group consisting of a succinimidyl malonate group, a succinimidyl succinate (SS) group, a succinimidyl maleate group, a succinimidyl fumarate group, a succinimidyl glutarate (SG) group, a succinimidyl adipate (SAP) group, a succinimidyl pimelate group, a succinimidyl suberate group, and a succinimidyl azelate (SAZ) group.

13. The sustained-release biodegradable intraductal insert of claim 9, wherein the cross-linking agent containing a nucleophilic group is an amine. 14 . The sustained-release biodegradable intraductal insert of claim 13 , wherein the cross-linking agent containing a nucleophilic group is a small molecule amine having a molecular weight of less than 1,000 Da and containing two or more aliphatic primary amine groups.

15. The sustained-release biodegradable intraductal insert of claim 14, wherein the cross-linking agent containing a nucleophilic group is a small molecule amine selected from the group consisting of dilysine, trilysine, tetralysine, ethylenediamine, 1,3-diaminopropane, diethylenetriamine, and trimethylhexamethylenediamine. 16 . The sustained-release biodegradable intraductal insert of claim 15 , wherein the cross-linking agent containing a nucleophilic group is trilysine, wherein the trilysine is trilysine acetate.

17. The sustained-release biodegradable intraductal insert of claim 9, wherein the cross-linking agent containing a nucleophilic group is labeled trilysine.

18. The sustained-release biodegradable intraductal insert of claim 17, wherein the labeled trilysine is labeled with a color developing agent.

19. The sustained release biodegradable intraductal insert of claim 18, wherein the color developing agent is selected from fluorophores.

20. The sustained release biodegradable intraductal insert of claim 19, wherein the fluorophore is selected from the group consisting of fluorescein, rhodamine, coumarin, and cyanine.

21. The sustained-release biodegradable intraductal insert of claim 9, wherein the cross-linking agent containing a nucleophilic group is fluorescein-conjugated trilysine.

22. The sustained-release biodegradable intraductal insert of claim 21, wherein the fluorescein-conjugated trilysine is obtained by reacting trilysine acetate with N-hydroxysuccinimide (NHS)-fluorescein.

23. The sustained release biodegradable intraductal insert of claim 1, wherein the insert contains, in a dry state, 15 to 80 wt% of the cyclosporin based on the total weight of the insert and 20 to 60 wt% of polymer units based on the total weight of the insert.

24. The sustained release biodegradable intraductal insert of claim 1, wherein the insert contains 40 wt% to 80 wt% of the cyclosporin in a dry state based on the total weight of the insert.

25. The sustained release biodegradable intraductal insert of claim 24, wherein the insert contains 45 wt% to 55 wt% of the cyclosporin in a dry state based on the total weight of the insert.

26. The sustained release biodegradable intraductal insert of claim 1, wherein the insert contains a surfactant.

27. The sustained release biodegradable intraductal insert of claim 26, wherein the insert contains 0.01 wt% to 5 wt% of a surfactant in a dry state based on the total weight of the insert.

28. The sustained release biodegradable intraductal insert of claim 26, wherein the insert contains a nonionic surfactant.

29. The sustained release biodegradable intraductal insert of claim 28, wherein the nonionic surfactant comprises a poly(ethylene glycol) chain.

30. The sustained release biodegradable intraductal insert of claim 29, wherein the surfactant is selected from the group consisting of poly(ethylene glycol) sorbitan monolaurate, poly(ethylene glycol) esters of castor oil, and ethoxylated 4-tert-octylphenol / formaldehyde condensate.

31. The sustained release biodegradable intraductal insert of claim 30, wherein the surfactant is selected from the group consisting of poly(ethylene glycol)-20-sorbitan monolaurate, poly(ethylene glycol)-80-sorbitan monolaurate, poly(ethylene glycol)-35 ester of castor oil, and ethoxylated 4-tert-octylphenol / formaldehyde condensate.

32. The sustained release biodegradable intraductal insert of claim 1, wherein the insert is in the form of a fiber.

33. The sustained release biodegradable intraductal insert of claim 32, wherein the fibers have an average length of 1.5 mm to 4.0 mm and an average diameter of no more than 0.8 mm in their dry state.

34. The sustained release biodegradable intraductal insert of claim 32, wherein the fibers have an average diameter of at least 1.0 mm in a swollen state after hydration in vitro in phosphate buffered saline, pH 7.4 at 37°C for 10 minutes or an average diameter of at least 1.3 mm in an equilibrium state after hydration for 24 hours.

35. The sustained release biodegradable intracanalicular insert of claim 1, wherein the insert disintegrates in the canaliculus within 1 to 6 months or within 3 to 4 months after insertion.

36. The sustained release biodegradable intracanalicular insert of claim 1, wherein the insert disintegrates in the canaliculus before the cyclosporine particles contained in the insert are completely dissolved.

37. The sustained release biodegradable intracanalicular insert of claim 1, wherein the tear concentration of cyclosporine is in the range of 0.1 μg / mL to 10 μg / mL after insertion into a human subject.

38. The sustained release biodegradable intraductal insert of claim 1, which is in the form of fibers, wherein the fibers have been stretched.

39. The sustained release biodegradable intraductal insert of claim 38, wherein the fibers have been stretched before or after drying.

40. The sustained release biodegradable intraductal insert of claim 39, wherein the fibers have been stretched in the machine direction by a stretch factor of 1.0 to 4.

0.

41. The sustained release biodegradable intraductal insert of claim 1, comprising: A hydrogel comprising a polymer network obtained by reacting 4a20kPEG-SG with fluorescein-conjugated trilysine at a molar ratio of 1:1, and 360 μg of cyclosporine, The inserts are in the form of fibres having an average length of 2.5 to 2.9 mm and an average diameter in their dry state not exceeding 0.62 mm.

42. The sustained release biodegradable intraductal insert of claim 1, comprising: A hydrogel comprising a polymer network obtained by reacting 4a20kPEG-SAP with fluorescein-conjugated trilysine at a molar ratio of 1:1, and 360 μg of cyclosporine, The inserts are in the form of fibres having an average length of 2.5 to 2.9 mm and an average diameter in their dry state not exceeding 0.62 mm.

43. Use of a sustained-release biodegradable intraductal insert comprising a hydrogel and cyclosporine as claimed in any one of claims 1 to 42 for the preparation of a medicament for treating or preventing dry eye disease in a human subject in need thereof.

44. The use of claim 43, wherein the dry eye disease is associated with one or more conditions selected from the group consisting of burning, itching, redness, stinging, pain, foreign body sensation, visual disturbances, lacrimal gland inflammation, ocular surface inflammation, T cell-mediated inflammation, the presence of conjunctival T cells in tears and elevated levels of inflammatory cytokines in tears, and / or wherein the treatment is effective to improve tear production as measured by the Schirmer tear test in subjects having a Schirmer score of less than 10 mm prior to insertion of the insert, and / or wherein the treatment is effective to reduce dry eye symptoms as measured by a measure selected from the group consisting of: rating the severity of dry eye symptoms on a visual analog scale; rating the frequency of dry eye symptoms on a visual analog scale; measurement of tear breakup time; corneal fluorescein staining; conjunctival lissamine green staining; best corrected visual acuity; measurement of the Ocular Surface Disease Index; and a standard patient dry eye assessment, and / or The treatment period is at least 1 month, at least 2 months or at least 3 months.

45. A method for manufacturing a sustained-release biodegradable intraductal insert comprising a hydrogel and cyclosporine according to any one of claims 1 to 42, the method comprising the steps of: a) preparing a precursor mixture containing a hydrogel precursor and cyclosporine particles dispersed in the precursor mixture, b) shaping the precursor mixture and crosslinking the hydrogel precursor to form a polymer network and obtain a shaped hydrogel mixture comprising the polymer network, and c) drying the hydrogel mixture to provide the insert.

46. ​​The method of claim 45, wherein in step a), the precursor mixture is prepared by mixing a multi-arm polymer precursor containing electrophilic groups with a cross-linking agent containing nucleophilic groups in a buffered aqueous solution in the presence of micronized cyclosporin particles, In step a), after mixing the components of the precursor mixture containing the cyclosporin particles, it is degassed under vacuum, and / or The method further comprises stretching the hydrogel mixture fiber, and the stretching is performed before or after drying the hydrogel mixture.

47. The method of claim 46, wherein the fibers are stretched with a stretch factor of 1 to 4.5.

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