Compositions with synergistic permeation enhancers for drug delivery

Abstract

To provide compositions and methods for delivery of therapeutic agents across a barrier.SOLUTION: A composition comprises: (a) a therapeutic agent or a combination of therapeutic agents; (b) a permeation enhancer or a combination of permeation enhancers, wherein the permeation enhancer or combination of permeation enhancers increases the flux of the therapeutic agent or combination of therapeutic agents across a barrier; and (c) a matrix forming agent or a combination of matrix forming agents, wherein the matrix forming agent or combination of matrix forming agents comprises a polymer. The composition forms a gel at temperatures above a phase transition temperature, and the phase transition temperature is less than about 37°C. The composition comprises approximately 0.5-20.0% wt / vol of a permeation enhancer, for example, sodium dodecyl sulfate and the composition comprises approximately 9.0-20.0% wt / vol of a polymer, which is poloxamer 407-poly(butoxy)phosphoester.SELECTED DRAWING: Figure 1

Description

[Technical field]

[0001] Related Applications This application claims priority under 35 U.S.C. § 119(e) to U.S. provisional applications USSN 62 / 726,058, filed August 31, 2018, and USSN 62 / 814,161, filed March 5, 2019, each of which is incorporated herein by reference.

[0002] Government support This invention was made with Government support under Grants DC015050 and DC016644 awarded by the National Institutes of Health. The Government has certain rights in this invention. [Background technology]

[0003] background Between 12 and 16 million office visits per year in the United States are due to otitis media (OM), making it the most common childhood condition specifically treated. [(a) Berman, S., Otitis media in children. N Engl J Med 1995, 332, 1560-5; (b) Fried, VM; Makuc, DM; Rooks, R Ambulatory health care visits by children: principal diagnosis and place of visit.; 137; Washington, DC: Government Printing Office, 1998.: 1998.] Acute otitis media (AOM) has a 90% prevalence within the first 5 years of life [Teele, DW; Klein, JO; Rosner, B., Epidemiology of otitis media during the first seven years of life in children in greater Boston: a prospective, cohort study. The Journal of infectious diseases 1989, 160(1), 83-94], and 90-95% of all children in the United States have at least one documented middle ear effusion by age 2 years [Casselbrant, ML; Mandel, EM, Epidemiology. In Evidence-based otitis media, Rosenfeld, RM; Bluestone, CD, Eds. Decker, Inc.: Hamilton, British Columbia, 1999; pp117-137]. Twenty-five percent of all prescriptions written to children are for the treatment of acute otitis media. Disease recurrence is also significant, with one-third of all children in the United States having six or more episodes of AOM by age 7.[Faden, H.; Duffy, L.; Boeve, M., Otitis media: back to basics. The Pediatric infectious disease journal 1998, 17(12), 1105-12; quiz 1112-3]. Moreover, epidemiological studies suggest that the prevalence of recurrent otitis media among children, particularly among adolescents, is increasing. [Lanphear, BP; Byrd R. S.; Auinger, P.; Hall, CB, Increasing prevalence of recurrent otitis media among children in the United States. Pediatrics 1997, 99(3), E1]. The incidence of OM among children in other developed countries is similar to that in the United States. In the developing world, OM remains a significant cause of child mortality due to the development of chronic suppurative otitis media, which frequently results in permanent hearing loss, and due to intracranial complications that are estimated to cause more than 25,000 deaths worldwide. [Acuin, J. Otitis Media: Burden of Illness and Management Options; World Health Organization: Geneva, Switzerland, 2004].

[0004] Acute OM has become the most common reason for antimicrobial prescriptions in children in the United States due to the high prevalence of the disease, and frequent recurrence is thought to be partially responsible for the continued increase in antibiotic resistance among pathogenic bacteria. Despite the success of reducing antimicrobial use in children by approximately 25% during the past decade, antimicrobial resistance continues to increase. In addition, acute otitis media (AOM) is one of the most common childhood illnesses and is the leading cause of over 20 million doctor's visits annually in the United States. 1,2 Recurrences are also common, with one-third of children having six or more episodes of AOM by age seven. 3 Up to 80% of children with AOM experience mild to severe pain during an infection, and of these, approximately 40% experience severe pain.4,5 The first 24-48 hours are considered the most painful period of AOM, but about 30% of children have pain for 3-7 days. 6 As a result, many AOM guidelines recommend the use of analgesics as part of essential treatment. 7 AOM commonly causes pain and distress in children. Existing ototopical drops of painkillers have limited effectiveness due to the impermeable nature of the tympanic membrane. Oral painkillers are commonly used, but 8 , it is unclear whether they will be useful 9 The efficacy of topical otic products in AOM is also questionable. 10,11 Nevertheless, local topical treatment of pain in AOM remains desirable because side effects from systemic drug distribution can be avoided and pain relief is faster (at onset), more intense, and longer lasting than oral analgesics.

[0005] Current treatment of ear infections consists of systemic oral antibiotics, a treatment that requires multiple doses and systemic exposure to antibiotics over a period of 5-10 days. The rise of antibiotic resistance, coupled with the many multifactorial etiologies of OM, has led to difficulties in diagnosing and treating OM. Furthermore, current treatments present numerous challenges, including patient compliance issues due to gastrointestinal side effects, lack of effective concentrations of drugs at the site of infection, and the possibility of opportunistic infections. Even after the acute signs of infection generally resolve within 72 hours, the underlying cause of the infection may continue for the remainder of the treatment and beyond, even up to two months. Thus, making compliance with the doctor's prescription is important to prevent recurrence of the infection.

[0006] Direct sustained local delivery of active therapeutics to the middle ear for the treatment of OM may allow for much higher concentrations of drugs in the middle ear than systemic administration, while minimizing systemic exposure and its deleterious effects. However, the tympanic membrane (TM), only 10 cells thick, presents a barrier that is largely impermeable to all but the smallest of moderately hydrophobic molecules. Despite being the thinnest layer of skin, it is still a barrier to trans-tympanic membrane diffusion. Thus, direct treatment of middle ear infections remains challenging. The shortcomings of current treatments for ear diseases such as middle ear infections suggest the need for new treatments that are non-invasive and directly acting. In addition, localized local treatment of pain associated with AOM is also desirable. Summary of the Invention

[0007] overview Provided herein are compositions and methods for non-invasive trans-tympanic otitis media (OM) treatment with sustained drug flux across the tympanic membrane (TM). Chemical permeation enhancers (CPEs), commonly employed for transdermal delivery, can enable such transtympanic flux. In some embodiments, a single application of an optimized formulation can provide high concentrations of antibiotics localized to the middle ear resulting in eradication of bacterial otitis without the drawbacks of oral treatment. Such formulations may also be useful for treating other diseases of the ear that require drug delivery across the tympanic membrane.

[0008] A typical OM treatment consists of broad-spectrum oral antibiotics for 10 days. The widespread use of systemic antibiotics for such a high prevalence disease and recurrence is believed to be partially responsible for the ever-increasing antibiotic resistance found in pathogenic bacteria in the nasopharynx. In most cases, antibiotic-resistant infections, such as pneumonia, skin, soft tissue, and gastrointestinal infections, require longer and / or more costly treatments, prolong hospital stays, force additional visits and medical care, and result in greater disability and death compared to infections that are easily treatable with antibiotics. Compliance with multiple dosing regimens can also be difficult in some parts of the world. Compliance and antibiotic resistance can also be more difficult to resolve in the long-term prevention of recurrent OM. Effective sustained topical treatment can address compliance issues, impact the development of drug resistance and chronic suppurative otitis media, and reduce the need for placement of tympanostomy tubes (devices implanted in the TM to facilitate middle ear drainage in recurrent OM). [Khoo, X.; Simons, E.; Chiang, H.; Hickey, J.; Sabharwal, V.; Pelton, S.; Rosowski, J.;

[0009] The TM is a tripartite membrane, the outer layer of which is a stratified squamous keratinizing epithelium that continues to the skin of the external auditory canal. The innermost layer is a simple cuboidal mucosal epithelium. Between these layers of epithelium are layers of elastic fibrous connective tissue and associated blood vessels and nerves. Although the human TM is only about 100 μm thick, the 6-10 cell layers of outer enamel epithelium form a robust barrier against all but the smallest lipophilic molecules due to its keratin- and lipid-rich stratum corneum. [Doyle,WJ;Alper,CM;Seroky,JT;Karnavas,WJ,Exchange rates of gases across the tympanic membrane in rhesus monkeys. Acta oto-laryngologica 1998,118(4),567-73].

[0010] Localized, sustained drug delivery that directly targets tissues has several advantages over systemic application, including fewer systemic side effects, smaller amounts of drug used, potentially better therapeutic outcomes, and reduced costs. The impermeability of the TM is a central challenge to the development of localized treatments.

[0011] Chemical permeation enhancers (CPEs) are used to safely increase the flux of small molecules in transdermal drug delivery. Several have been approved by the FDA for use in humans. These agents are often surfactants, which contain a heterogeneous group of amphiphilic organic molecules with hydrophilic heads and hydrophobic tails. Several classes of surfactants have been studied. Surfactants reversibly modify lipids by adsorption at the interface and removal of water-soluble agents that act as plasticizers. Cationic surfactants are known to increase permeant flux more than anionic surfactants, which in turn increase permeability more than nonionic surfactants. A wide range of non-surfactant chemical enhancers (e.g., terpenes) have also been used, with mechanisms of action that include denaturation of proteins within and between keratinocytes and / or modification or disruption of lipids resulting in increased lipid bilayer fluidity.

[0012] In the compositions provided herein, the therapeutic agent and the permeation enhancer are combined with a matrix-forming agent to form a composition that forms a hydrogel under suitable conditions. Such conditions may include exposure to body temperature during administration (e.g., in the ear canal) or following mixing of the two components of the composition or the matrix-forming agent. The matrix-forming agent is a compound or mixture of compounds that forms a gel after administration. The composition is generally liquid at ambient conditions, however, once administered to a subject, the matrix-forming agent or combination of matrix-forming agents causes a phase transition to a hydrogel. Hydrogels have a highly porous structure that allows loading of drugs and other small molecules, and subsequent drug elution from the gel creates high local concentrations in the surrounding tissue over an extended period of time. In some embodiments, the drug is loaded into the liquid composition. The hydrogel can conform and adhere to the shape of the surface to which it is applied, making it prone to biocompatibility.

[0013] For the compositions provided herein, the combination of a permeation enhancer with a matrix forming agent and a therapeutic agent provides a composition in which the flux of the therapeutic agent is improved and the resulting hydrogel properties are also improved (or not significantly impaired) as compared to hydrogels formed by compositions in the absence of the permeation enhancer. For the compositions provided herein, the combination of a permeation enhancer with a matrix forming agent and a therapeutic agent provides a composition in which the flux of the therapeutic agent is improved and additional properties are improved (including, but not limited to, sustained drug release, adhesion of the composition to the tympanic membrane over time, degradation, or a combination thereof) as compared to hydrogels formed by compositions in the absence of the permeation enhancer, and the resulting hydrogel properties are also improved (or not significantly impaired).

[0014] In addition, it is hypothesized that the lack of efficient analgesic effect from topical ear drops for the treatment of pain associated with AOM was due to an inability to penetrate the TM. The stratum corneum, the outermost layer of the TM, is impermeable to virtually all molecules except small and moderately hydrophobic molecules. The stratum corneum barrier can be disrupted by chemically and biologically active molecules and / or physical means. 12 Chemical permeation enhancers (CPEs), in particular, have emerged as an effective means of promoting the flux of small molecules across the TM. 13,14 CPE can reversibly increase the fluidity of lipid bilayers in the interstitial spaces between non-permeable corneocytes in the stratum corneum, greatly improving transdermal delivery of molecules that would otherwise be poorly permeable. 13,14 Thus, a formulation combining CPE with a known anesthetic may facilitate drug flux into and across the intact TM to achieve effective analgesia for AOM.

[0015] The prior system consisted of a hydrogel compound, a penta-block copolymer, poloxamer 407-polybutylphosphoester (P407-PBP), in combination with three CPEs. 13,14with a transtympanic drug delivery system utilizing sodium dodecyl sulfate (SDS), limonene (LIM), and bupivacaine hydrochloride (BUP). The combination of CPE translocated ciprofloxacin across the intact TM to successfully treat AOM in a chinchilla animal model. 14 The formulation was administered as a single dose directly via the ear canal over the TM of the chinchillas.

[0016] In the present composition, P407-PBP is used due to its robust, reverse thermogelation behavior. 14 The hydrogel-based formulation is an easy-to-apply liquid at room temperature that rapidly and tightly gels upon contact with warm TM, holding the antibiotic and CPE in place (i.e., on the TM). Thus, sustained release and diffusion of the drug into the middle ear can be achieved with a single application of the formulation, resulting in high concentrations of the drug in the middle ear fluid. 14 The compositions and formulations for the treatment of diseases and / or conditions (e.g., AOM and / or pain associated with AOM) disclosed herein also include the therapeutic anesthetic bupivacaine and the sodium channel blocker anesthetic tetrodotoxin, which are also used as CPEs.

[0017] The optimal clinical applicability of such formulations depends on a number of parameters, including, but not limited to, the concentration of a particular permeation enhancer, the flux of the therapeutic agent, the viscosity of the formulation for therapeutic application, rheological properties that affect gelation or persistence on a barrier (e.g., the tympanic membrane), or physiological adverse reactions (e.g., adverse reactions of tissues that make the formulation unsafe or unsuitable for clinical application). Disclosed herein are formulations for clinical applications, including, by way of example, proper flux of the therapeutic agent that are clinically applicable.

[0018] In one aspect, provided herein is a method for treating a pulmonary circulation comprising: (a) a therapeutic agent or combination of therapeutic agents; (b) a permeation enhancer or combination of permeation enhancers, where the permeation enhancer or combination of permeation enhancers increases the flux of a therapeutic agent or combination of therapeutic agents across a barrier; and (c) a matrix-forming agent or combination of matrix-forming agents, wherein the matrix-forming agent or combination of matrix-forming agents comprises a polymer; A composition comprising: The composition forms a gel at a temperature above the phase transition temperature; and The phase transition temperature is less than about 37°C; wherein the composition comprises between about 0.5-20.0% wt / vol of a permeation enhancer which is sodium dodecyl sulfate; wherein the composition comprises between about 0.5-7.5% wt / vol of a permeation enhancer, one of which is bupivacaine; wherein the composition comprises between about 0.5-12.0% wt / vol of a permeation enhancer, which is limonene; and wherein the composition comprises between about 9.0-20.0% wt / vol of a polymer that is poloxamer 407-poly(butoxy) phosphoester; and The compositions herein optionally further comprise between about 0.01-0.50% wt / vol of another therapeutic agent which is a local anesthetic.

[0019] In one aspect, provided herein is a method for treating a pulmonary artery disease comprising administering to a subject a therapeutically effective amount of (a) a therapeutic agent or combination of therapeutic agents; (b) a permeation enhancer or combination of permeation enhancers, where the permeation enhancer or combination of permeation enhancers increases the flux of a therapeutic agent or combination of therapeutic agents across a barrier; and (c) a matrix-forming agent or combination of matrix-forming agents, wherein the matrix-forming agent or combination of matrix-forming agents comprises a polymer; A composition comprising: The composition forms a gel at a temperature above the phase transition temperature; and The phase transition temperature is less than about 37°C; wherein the composition comprises between about 0.5-5.5% wt / vol of a permeation enhancer which is sodium dodecyl sulfate; wherein the composition comprises between about 0.5-7.5% wt / vol of a permeation enhancer, one of which is bupivacaine; wherein the composition comprises between about 0.5-10.0% wt / vol of a permeation enhancer, which is limonene; and wherein the composition comprises between about 9.0-19.0% wt / vol of a polymer that is poloxamer 407-poly(butoxy) phosphoester; and The compositions herein include between about 0.01-0.50% wt / vol of a local anesthetic that is a sodium channel blocker.

[0020] In another aspect, provided herein is a method for treating a pulmonary circulation comprising: (a) a therapeutic agent or combination of therapeutic agents; (b) a permeation enhancer or combination of permeation enhancers, where the permeation enhancer or combination of permeation enhancers increases the flux of a therapeutic agent or combination of therapeutic agents across a barrier; and (c) a matrix-forming agent or combination of matrix-forming agents (wherein the matrix-forming agent or combination of matrix-forming agents comprises a polymer); A composition comprising: The composition forms a gel at a temperature above the phase transition temperature; and The phase transition temperature is less than about 37°C; wherein the composition comprises between about 0.5-5.5% wt / vol of a permeation enhancer which is sodium dodecyl sulfate; wherein the composition comprises between about 0.5-1.5% wt / vol of a permeation enhancer which is bupivacaine; wherein the composition comprises between about 2.0-12.0% wt / vol of a permeation enhancer, which is limonene; and The composition herein comprises between about 9.0-19.0% wt / vol of a polymer that is poloxamer 407-poly(butoxy) phosphoester.

[0021] In an embodiment, conditions (i), (ii), and (iii): (i) the composition can be extruded through soft catheters ranging in size from 10 gauge to 24 gauge and from 1 inch to 5.25 inches, and the composition remains liquid; (ii) the phase transition temperature of the composition is greater than about 15° C. and less than about 37° C.; and (iii) at 37° C., the storage modulus of the composition is greater than about 300 Pa, and the storage modulus is greater than the loss modulus of the composition; At least one of the following is satisfied.

[0022] In some embodiments, at least one of conditions (i), (ii), and (iii) is met. In some embodiments, the composition comprises between about 0.5-5.5% wt / vol of a permeation enhancer that is sodium dodecyl sulfate; the composition comprises between about 0.5-1.5% wt / vol of a permeation enhancer that is bupivacaine; and the composition comprises between about 2.0-12.0% wt / vol of a permeation enhancer that is limonene; and the composition comprises between about 9.0-19.0% wt / vol of a polymer that is poloxamer 407-poly(butoxy)phosphoester.

[0023] In some embodiments, the composition includes two therapeutic agents, including between about 0.01-0.50% wt / vol of another therapeutic agent that is a local anesthetic. In some embodiments, the composition includes between about 0.01-0.50% wt / vol of another therapeutic agent that is a local anesthetic that is a sodium channel blocker. In some embodiments, the composition includes a sodium channel blocker anesthetic (e.g., tetrodotoxin). In some embodiments, the sodium channel blocker is a site 1 sodium channel blocker. In some embodiments, the site 1 sodium channel blocker is tetrodotoxin.

[0024] In certain embodiments, the composition comprises between about 0.5-5.0% wt / vol of a permeation enhancer that is sodium dodecyl sulfate; the composition comprises between about 0.5-7.5% wt / vol of a permeation enhancer that is bupivacaine; and the composition comprises between about 0.5-3.5% wt / vol of a permeation enhancer that is limonene; the composition comprises between about 9.0-15.0% wt / vol of a polymer that is poloxamer 407-poly(butoxy)phosphoester; and the composition optionally comprises between about 0.01-0.50% wt / vol of another therapeutic agent that is the sodium channel blocker anesthetic agent tetrodotoxin. In one embodiment, the composition is: about 1.0% wt / vol sodium dodecyl sulfate; about 2.0% wt / vol bupivacaine; about 2.0% wt / vol limonene; about 12.0% wt / vol poloxamer 407-poly(butoxy)phosphoester; and about 0.3% wt / vol of another therapeutic agent, which is the sodium channel blocker anesthetic agent tetrodotoxin.

[0025] In another aspect, provided herein is a method for treating a disease (e.g., an infectious disease, an ear disease, a bacterial infection) and / or a condition associated with a disease (e.g., pain associated with an infectious disease, an ear disease, a bacterial infection), the method comprising administering to a subject in need thereof a composition comprising a therapeutic agent or combination of therapeutic agents (e.g., an antimicrobial agent, an antibiotic, or an anesthetic agent), a permeation enhancer, and a matrix forming agent, as described herein.

[0026] In another aspect, provided herein is a method for treating an ear disease, the method comprising administering to a subject in need thereof a composition comprising a therapeutic agent or combination of therapeutic agents (e.g., an antimicrobial agent, an antibiotic, or an anesthetic agent), a permeation enhancer, and a matrix forming agent, as described herein. In some embodiments, the composition is administered into the ear canal or to the tympanic membrane. In some embodiments, the disease is otitis media. In some embodiments, the disease is an ear infection. In some embodiments, the disease is a bacterial infection (e.g., an infection with H. influenzae, S. pneumoniae, or M. catarhallis). In some embodiments, the disease is pain. In some embodiments, the disease is pain associated with the disease otitis media. In some embodiments, the disease is pain associated with an ear infection. In some embodiments, the disease is pain associated with a bacterial infection (e.g., an infection with H. influenzae, S. pneumoniae, or M. catarhallis).

[0027] In another aspect, provided herein is a method of eradicating a biofilm, the method comprising administering to a subject in need thereof a composition described herein or contacting a biofilm with a composition described herein.

[0028] In another aspect, provided herein is a method for inhibiting biofilm formation, the method comprising administering to a subject in need thereof a composition described herein or contacting a surface with a composition described herein.

[0029] In another aspect, provided herein is a use of a composition described herein for the treatment and / or prevention of a disease or condition (e.g., infectious disease, ear disease, bacterial infection) and / or a disease-related condition (e.g., pain; pain associated with infectious disease, ear disease, bacterial infection) in a subject in need thereof, said use comprising administering to the subject a therapeutically effective amount of a composition described herein.

[0030] In another aspect, provided herein is a pharmaceutical composition comprising the composition described herein and, optionally, a pharma- ceutical acceptable excipient. In an embodiment, the pharmaceutical composition comprises a therapeutically effective amount of the composition for use in treating a disease in a subject in need thereof. In an additional aspect, provided herein is a method for delivering the composition described herein, comprising administering the composition into the ear canal of a subject, wherein the composition contacts the surface of the tympanic membrane. The composition may be administered with an eye dropper, a syringe, a double barrel syringe, or a catheter (e.g., a vascular catheter).

[0031] In an additional aspect, provided herein is a kit comprising a container, a composition described herein, and instructions for administering the composition to a subject in need thereof. The kit may further comprise a device for administering the composition to the subject, such as a dropper, a syringe, a catheter, a double-barrel syringe, or a combination thereof.

[0032] The compositions, components of the compositions (e.g., matrix-forming agents, therapeutic agents, and permeation enhancers), methods, kits, and uses of the present disclosure may also incorporate any of the features described in the following: Khoo et al., Biomaterials. (2013) 34, 1281-8; U.S. Patent No. 8,822,410; U.S. Patent Application No. 12 / 993,358, filed May 19, 2009; U.S. Patent Application No. 11 / 734,537, filed April 12, 2007; WIPO Patent Application No. PCT / US2009 / 003084, filed May 19, 2009, and WIPO Patent Application No. PCT / US2007 / 009121, filed April 12, 2007, each of which is incorporated herein by reference.

[0033] Details of certain aspects of the present disclosure are presented in the Detailed Description of Certain Aspects, as set forth below. Other features, objects, and advantages of the present disclosure will be apparent from the definition, examples, figures, and claims.

[0034] definition Chemical Definition Definitions of specific functional groups and chemical terms are described in more detail below. Chemical elements are defined in the Handbook of Chemistry and Physics, 75 th Ed., inside cover, Periodic Table of the Elements, CAS version, and specific functional groups are generally defined as described therein. In addition, general principles of organic chemistry and specific functional moieties and reactivities are described in Organic Chemistry, Thomas Sorrell, University Science Books, Sausalito, 1999; Smith and March, March's Advanced Organic Chemistry, 5 thEdition, John Wiley & Sons, Inc., New York, 2001; Larock, Comprehensive Organic Transformations, VCH Publishers, Inc., New York, 1989; and Carruthers, Some Modern Methods of Organic Synthesis, 3 rd Edition, Cambridge University Press, Cambridge, 1987.

[0035] The compounds described herein may contain one or more asymmetric centers, and thus may exist in various stereoisomeric forms, such as enantiomers and / or diastereomers.For example, the compounds described herein may be in the form of individual enantiomers, diastereomers, or geometric isomers, or may be in the form of a mixture of stereoisomers (including racemic mixtures and mixtures enriched in one or more stereoisomers).Isomers can be isolated from mixtures by methods known to those skilled in the art, including chiral high pressure liquid chromatography (HPLC), and the formation and crystallization of chiral salts; or preferred isomers can be prepared by asymmetric synthesis. See, e.g., Jacques et al., Enantiomers, Racemates and Resolutions (Wiley Interscience, New York, 1981); Wilen et al., Tetrahedron 33:2725 (1977); Eliel, ELStereochemistry of Carbon Compounds (McGraw-Hill, NY, 1962); and Wilen, SHTables of Resolving Agents and Optical Resolutions p. 268 (EL Eliel, Ed., Univ. of Notre Dame Press, Notre Dame, IN 1972). Additionally, the present disclosure encompasses the compounds as individual isomers substantially free of other isomers, or alternatively as mixtures of various isomers.

[0036] Unless otherwise stated, structures depicted herein are also meant to include compounds which differ only in the presence of one or more isotopically enriched atoms. For example, compounds having the present structures include those having the replacement of hydrogen with deuterium or tritium, 19 F 18 Replace with F, or 12 C 13 C or 14 It is within the scope of the disclosure, except for the replacement with C. Such compounds are useful, for example, as analytical tools or probes in biological assays.

[0037] When a range of values ​​is listed, it is intended to encompass each value and subrange within the range. For example, "C 1~6 Alkyl" is C1, C2, C3, C4, C5, C6, C 1~6 , C 1~5 , C 1~4 , C 1~3 , C 1~2 , C 2~6 , C 2~5 , C 2~4 , C 2~3 , C 3~6 , C 3~5 , C 3~4 , C 4~6 , C 4~5 , and C 5~6 It is intended to encompass alkyl.

[0038] The term "aliphatic" refers to alkyl, alkenyl, alkynyl, and carbocyclic groups, while the term "heteroaliphatic" refers to heteroalkyl, heteroalkenyl, heteroalkynyl, and heterocyclic groups.

[0039] The term "alkyl" refers to the radical of a straight-chain or branched saturated hydrocarbon group having from 1 to 10 carbon atoms ("C 1~10 In some embodiments, an alkyl group has 1 to 9 carbon atoms ("C 1~9 In some embodiments, an alkyl group has 1 to 8 carbon atoms ("C1~8 In some embodiments, an alkyl group has 1 to 7 carbon atoms ("C 1~7 In some embodiments, an alkyl group has 1 to 6 carbon atoms ("C 1~6 In some embodiments, an alkyl group has 1 to 5 carbon atoms ("C 1~5 In some embodiments, an alkyl group has 1 to 4 carbon atoms ("C 1~4 In some embodiments, an alkyl group has 1 to 3 carbon atoms ("C 1~3 In some embodiments, an alkyl group has 1 to 2 carbon atoms ("C 1~2 In some embodiments, an alkyl group has 1 carbon atom ("C alkyl"). In some embodiments, an alkyl group has 2 to 6 carbon atoms ("C 2~6 "Alkyl"). C 1~6 Examples of alkyl groups include methyl (C1), ethyl (C2), propyl (C3) (e.g., n-propyl, isopropyl), butyl (C4) (e.g., n-butyl, tert-butyl, sec-butyl, isobutyl), pentyl (C5) (e.g., n-pentyl, 3-pentanyl, amyl, neopentyl, 3-methyl-2-butanyl, tertiary amyl), and hexyl (C6) (e.g., n-hexyl). Additional examples of alkyl groups include n-heptyl (C7), n-octyl (C8), and the like. Unless so specified, each instance of an alkyl group is independently unsubstituted ("unsubstituted alkyl") or substituted with one or more substituents (e.g., halogens such as F) ("substituted alkyl"). In certain embodiments, an alkyl group is an unsubstituted C 1~10 Alkyl (unsubstituted C 1~6Alkyl, for example -CH3 (Me), unsubstituted ethyl (Et), unsubstituted propyl (Pr, for example, unsubstituted n-propyl (n-Pr), unsubstituted isopropyl (i-Pr), unsubstituted butyl (Bu, for example, unsubstituted n-butyl (n-Bu), unsubstituted tert-butyl (tert-Bu or t-Bu), unsubstituted sec-butyl (sec-Bu), unsubstituted isobutyl (i-Bu), etc.). In some embodiments, the alkyl group is a substituted C 1~10 Alkyl (substituted C 1~6 Alkyl, for example -CF3, Bn).

[0040] A "counterion" or "anionic counterion" is a negatively charged group associated with a positively charged group to maintain electronic neutrality. Anionic counterions may be monovalent (i.e., containing one formal negative charge). Anionic counterions may also be multivalent, such as divalent or trivalent (i.e., containing more than one formal negative charge). Exemplary counterions are halide ions (e.g., F - , Cl - , Br - , I - ), NO3 - , ClO4 - , O.H. - , H2PO4 - , HCO3 - , HSO4 - , sulfonate ions (e.g., methanesulfonate, trifluoromethanesulfonate, p-toluenesulfonate, benzenesulfonate, 10-camphorsulfonate, naphthalene-2-sulfonate, naphthalene-1-sulfonic acid-5-sulfonate, ethane-1-sulfonic acid-2-sulfonate, etc.), carboxylate ions (e.g., acetate, propanoate, benzoate, glycerate, lactate, tartrate, glycolate, gluconate, etc.), BF4 - , PF4 - , PF6 - , AsF6 - , SbF6 - , B[3,5-(CF3)2C6H3]4] - , B(C6F5)4 -, BPh4 - , Al(OC(CF3)3)4 - , and carborane anions (e.g., CB 11 H 12 - , or (HCB 11 Me5Br6) - Exemplary counterions may be multivalent, such as CO3 2- , HPO4 2- , PO4 3- , B4O7 2- , SO4 2- , S2O3 2- , carboxylate anions (by way of example, tartrate, citrate, fumarate, maleate, malate, malonate, gluconate, succinate, glutarate, adipate, pimellate, suberate, azelate, sebacate, salicylate, phthalate, aspartate, glutamate, and the like), and carboranes.

[0041] As used herein, use of the phrase "at least one instance" refers to 1, 2, 3, 4 or more instances, but also covers ranges (inclusive) of, for example, from 1 to 4, from 1 to 3, from 1 to 2, from 2 to 4, from 2 to 3, or from 3 to 4 instances.

[0042] A "non-hydrogen group" refers to any group defined for a particular variable that is not hydrogen.

[0043] The term "polysaccharide" refers to a polymer composed of long chains of carbohydrate or monosaccharide units or derivatives thereof (e.g., monosaccharides modified to contain crosslinkable functional groups). Exemplary polysaccharides include, but are not limited to, glycans, glucans, starches, glycogen, arabinoxylans, cellulose, hemicelluloses, chitin, pectins, dextran, pullulans, chrysolaminarin, curdlan, laminarin, lentinan, lichenin, pleurans, zymosan, glycosaminoglycans, dextran, hyaluronic acid, chitosan, and chondroitin. The monosaccharide monomers of polysaccharides are typically connected by glycosidic linkages. Polysaccharides may be hydrolyzed to form oligosaccharides, disaccharides, and / or monosaccharides. The term "carbohydrate" or "saccharide" refers to aldehyde or ketone derivatives of polyhydric alcohols. Monosaccharides are the simplest carbohydrates in that they cannot be hydrolyzed into smaller carbohydrates. Most monosaccharides have the general formula C y H 2y O y (For example, C6H 12 O6 (a hexose such as glucose), where y is an integer equal to or greater than 3. Certain polyhydric alcohols not represented by the general formula set forth above may also be considered monosaccharides. For example, deoxyribose has the formula CH 10O4 and are monosaccharides. Monosaccharides are usually composed of 5 or 6 carbon atoms and are called pentoses and hexoses, respectively. If a monosaccharide contains an aldehyde, it is called an aldose; if it contains a ketone, it is called a ketose. Monosaccharides, in either aldose or ketose form, are also composed of 3, 4, or 7 carbon atoms and are called trioses, tetroses, and heptoses, respectively. Glyceraldehyde and dihydroxyacetone are considered aldotriose and ketotriose sugars, respectively. Examples of aldotetrose sugars include erythrose and threose; ketotetrose sugars include erythrulose. Aldopentose sugars include ribose, arabinose, xylose, and lyxose; ketopentose sugars include ribulose, arabulose, xylulose, and lyxulose. Examples of aldohexose sugars include glucose (e.g., dextrose), mannose, galactose, allose, altrose, talose, gulose, and idose; ketohexose sugars include fructose, psicose, sorbose, and tagatose. Ketoheptose sugars include sedoheptulose. Each carbon atom of a monosaccharide bearing a hydroxyl group (-OH), except for the first and last carbon, is asymmetric, making that carbon atom a stereocenter with two possible configurations (R or S). Because of this asymmetry, a number of isomers can exist for any given monosaccharide formula. The aldohexose D-glucose, for example, has the formula CH 12 O6, all but two of its six carbon atoms can be asymmetric (stereogenic), making D-glucose a 16 (i.e., 2 4) species. The D or L assignment is made according to the orientation of the asymmetric carbon furthest from the carbonyl group: if the hydroxyl group is on the right hand side in the standard Fischer projection, the molecule is a D sugar, otherwise it is an L sugar. The aldehyde or ketone groups of linear monosaccharides will react reversibly with hydroxyl groups on different carbon atoms to form hemiacetals or hemiketals, forming heterocyclic rings with an oxygen bridge between the two carbon atoms. Rings with 5 and 6 atoms are called furanose and pyranose forms, respectively, and exist in equilibrium with the linear form. During the conversion from the linear form to the cyclic form, the carbon atom containing the carbonyl oxygen, called the anomeric carbon, becomes the stereogenic center of two possible configurations: the oxygen atom may be either above or below the plane of the ring. The resulting pair of viable stereoisomers is called anomers. In the α anomer, the -OH substituent on the anomeric carbon is on the opposite side of the ring (trans) from the -CHOH side branch. The alternative form, in which the -CHOH substituent and the anomeric hydroxyl are on the same side of the plane of the ring (cis), is called the β anomer. The term carbohydrate also encompasses other naturally occurring or synthetic stereoisomers of the carbohydrates described herein.

[0044] These and other exemplary substituents are described in more detail in the detailed description, examples, and claims. The disclosure is not intended to be limited in any way by the recitation of the above exemplary substituents.

[0045] Other definitions animal: The term animal, as used herein, refers to humans and non-human animals, including, for example, mammals, birds, reptiles, amphibians, and fish.Preferably, the non-human animal is a mammal (e.g., a rodent, a mouse, a rat, a rabbit, a monkey, a dog, a cat, a primate, or a pig).The non-human animal may be a transgenic animal.

[0046] Approximately or about: As used herein, the terms "approximately" or "about" in reference to numbers are generally interpreted to encompass numbers that fall within a range of 5%, 10%, 15%, or 20% in either direction of the number (greater or smaller), unless otherwise stated or otherwise clear from the context (except where such numbers would be less than 0% or more than 100% of the feasible value).

[0047] Biocompatible: As used herein, the term "biocompatible" refers to a substance that is not toxic to cells. In some embodiments, a substance is considered to be "biocompatible" if its addition to cells in vivo does not induce inflammation and / or other adverse effects in vivo. In some embodiments, a substance is considered to be "biocompatible" if its addition to cells in vitro or in vivo results in about 50%, about 45%, about 40%, about 35%, about 30%, about 25%, about 20%, about 15%, about 10%, about 5% or less, or less than about 5% cell death.

[0048] Biodegradable: As used herein, the term "biodegradable" refers to a material that is broken down under physiological conditions. In some embodiments, a biodegradable material is a material that is broken down by cellular mechanisms. In some embodiments, a biodegradable material is a material that is broken down by chemical treatment.

[0049] Optically transparent: As used herein, the term "optically transparent" refers to a material in which little or no light penetrating through the material is absorbed or reflected. In some embodiments, optically transparent refers to a material in which no light penetrating through the material is absorbed or reflected. In some embodiments, optically transparent refers to a material in which little or no light penetrating through the material is absorbed or reflected. In some embodiments, an optically transparent material is substantially clear. In some embodiments, an optically transparent material is crystal clear.

[0050] Effective Dose: Generally, the "effective amount" of an active agent refers to an amount sufficient to induce a desired biological response.It is understood by those skilled in the art that the effective amount of the compound of the present disclosure may vary depending on factors such as the desired biological endpoint, the pharmacokinetics of the compound, the disease being treated, the mode of administration, and the patient.The effective amount of the compound used to treat an infectious disease is the amount required to kill or prevent the growth of the organism(s) causing the infectious disease.

[0051] In vitro: As used herein, the term "in vitro" refers to events that occur in an artificial environment, e.g., in a test tube or reaction vessel, in cell culture, etc., rather than in an organism (e.g., an animal, a plant, and / or a microorganism).

[0052] In vivo: As used herein, the term "in vivo" refers to events that take place within an organism (e.g., an animal, a plant, and / or a microorganism).

[0053] Suffering from: An individual "suffering from" a disease, disorder, and / or condition has been diagnosed with or is exhibiting one or more symptoms of the disease, disorder, and / or condition.

[0054] Treating: As used herein, the term "treating" refers to partially or completely alleviating, improving, alleviating, delaying the onset of, inhibiting the progression of, reducing the severity of, and / or reducing the incidence of, one or more symptoms or features of a particular disease, disorder, and / or condition. For example, "treating" a microbial infection may refer to inhibiting the survival, growth, and / or spread of the microorganism. Treatment may be administered to subjects who do not exhibit symptoms of the disease, disorder, and / or condition and / or to subjects who exhibit only early signs of the disease, disorder, and / or condition, with the aim of reducing the risk of developing pathological conditions associated with the disease, disorder, and / or condition. In some embodiments, treatment includes delivery of an inventive vaccine nanocarrier to a subject.

[0055] Treatment: Also referred to as a "drug," as used herein, refers to an agent administered to a subject to treat a disease, disorder, or other clinically recognized illness that is harmful to the subject, or for prophylactic purposes, and which has a clinically significant effect on the body in treating or preventing the disease, disorder, or illness. Therapeutic agents include, but are not limited to, those described in the United States Pharmacopeia (USP), Goodman and Gilman's The Pharmacological Basis of Therapeutics, 10 th Ed., McGraw Hill, 2001; Katzung, B. (ed.) Basic and Clinical Pharmacology, McGraw-Hill / Appleton & Lange; 8th edition (Sep. 21, 2000); Physician's Desk Reference (Thomson Publishing), and / or The Merck Manual of Diagnosis and Therapy, 17 thed. (1999) or 18th Ed. (2006), subsequently published by Mark H. Beers and Robert Berkow (Eds.), Merck Publishing Group, or in animal cases by The Merck Veterinary Manual, 9 th ed., Kahn, CA (Ed.), Merck Publishing Group, 2005.

[0056] Diagnostics: As used herein, the term "diagnostic agent" refers to an agent administered to a subject to aid in the diagnosis of a disease, disorder, or condition. In some embodiments, diagnostic agents are used to define a pathological process and / or characterize its localization. Diagnostic agents include x-ray contrast agents, radioisotopes, and dyes.

[0057] Surfactants: As used herein, the term "surfactant" refers to any agent that preferentially adsorbs to the interface between two immiscible phases, such as the interface between water and an organic solvent, the water / air interface, or the organic solvent / air interface. Surfactants often possess hydrophilic and hydrophobic portions. Surfactants may also facilitate the flux of therapeutic or diagnostic agents across biological membranes, such as the tympanic membrane.

[0058] Terpenes: As used herein, the term "terpene" refers to any agent that is believed to be derived, for example, biosynthetically or derived from an isoprene unit (5-carbon unit) or units. For example, the isoprene units of a terpene may be linked together to form a linear chain or arranged to form a ring. Typically, the terpenes disclosed herein facilitate the flux of therapeutic or diagnostic agents across biological membranes, for example the tympanic membrane. Terpenes may be naturally derived or synthetically prepared.

[0059] The terms "composition" and "formulation" are used interchangeably. [Brief description of the drawings]

[0060] BRIEF DESCRIPTION OF THE DRAWINGS The accompanying drawings are not intended to be drawn to scale. In the drawings, each identical or nearly identical component illustrated in the various figures is represented by like numerals. For clarity, not every component is labeled on every drawing. The patent or application application contains at least one drawing executed in color. Copies of this patent or patent application publication with color drawing(s) will be provided by the Office upon request and payment of the necessary fee. In the drawings:

[0061] [Figure 1] FIG. 1 shows an exemplary optimization of an exemplary composition described herein that includes a therapeutic agent, a permeation enhancer, and a matrix forming agent (e.g., for synergy in increasing peak efficacy, i.e., maximum drug flux across a barrier such as the tympanic membrane).

[0062] [Diagram 2] Figure 2 shows a summary of the rheological data of possible exemplary compositions. For each composition, the temperature for gelation (°C), the average storage modulus (G'), and the standard deviation of the storage modulus are provided.

[0063] [Diagram 3] Figure 3 shows rheological data for a composition having 12% poloxamer 407-poly(butoxy)phosphoester ("PBP"), 1% sodium dodecyl sulfate ("SDS"), 1% bupivacaine ("BUP"), and 10% limonene ("LIM"). The average storage modulus ("storage") and average loss modulus ("loss") plotted against temperature for the composition are provided. Error bars represent standard deviation.

[0064] [Figure 4]Figure 4 shows the rheology of a composition having 12% PBP-5% SDS-1% BUP-4% LIM. The average storage modulus ("store ave.") and average loss modulus ("loss ave.") plotted against temperature for the composition are provided. Error bars represent standard deviation.

[0065] [Diagram 5] Figure 5 shows rheological data for compositions having 15% PBP-5% SDS-1% BUP-4% LIM. The average storage modulus ("Storage (Avg")) and the average loss modulus ("Loss (Avg")) plotted against temperature for the compositions are provided. Error bars represent standard deviation.

[0066] [Figure 6] Figure 6 shows rheological data for compositions having 10% PBP-5% SDS-0.5% BUP-4% LIM. The average storage modulus ("Storage (Avg")) and the average loss modulus ("Loss (Avg")) plotted against temperature for the compositions are provided. Error bars represent standard deviation.

[0067] [Figure 7] Figures 7A and 7B show the cumulative permeation of bupivacaine hydrochloride (BUP) across the tympanic membrane from formulations containing 2CPE-[P407-PBP]. (Figure 7A) Time course of cumulative permeation of BUP over 48 hours achieved by BUP-2CPE-[P407-PBP] at various BUP concentrations. BUP was not soluble above 4% in 2CPE-[P407-PBP]. Thus, the formulations, 7.5% BUPsusp-2CPE-[P407-PBP] and 15% BUPsusp-2CPE-[P407-PBP], were suspensions, which are indicated by † in the plot. Arrows indicate the data graphed in Figure 7B. (Figure 7B) Effect of bupivacaine concentration on cumulative permeation across the TM at 6 and 48 hours, from data indicated by arrows in Figure 7A. Data are median ± interquartile range (n=4).

[0068] [Figure 8] Figures 8A and 8B show the cumulative permeation of tetrodotoxin (TTX) across the tympanic membrane from formulations containing 2CPE-[P407-PBP]. Figure 8A shows the transtympanic permeation of TTX over 48 hours from formulations containing 0.02, 0.03, 0.16, and 0.32% TTX (which correspond to 0.5, 1, 5, and 10 mM TTX). Figure 8B shows the dependence of TTX permeation on drug concentration of the hydrogel formulation. Data are median ± interquartile range (n=4).

[0069] [Figure 9] Figures 9A and 9B show the cumulative ex vivo permeation of BUP (Figure 9A) and TTX (Figure 9B) across the tympanic membrane from formulations containing both compounds and [P407-PBP]. Data are median ± interquartile range (n=4).

[0070] [Figure 10] Figure 10 shows the cumulative permeation of bupivacaine free base and BUP across the tympanic membrane. BUP is not soluble above 4% in 2CPE-[P407-PBP]. Therefore, 15% BUPsusp-2CPE-[P407-PBP] was a suspension, which is indicated by † in the plots. Data are median ± interquartile range (n=4).

[0071] [Figure 11] Figure 11 shows representative hematoxylin and eosin (H&E)-stained sections of TM treated under various conditions. Scale bar represents 12 μm.

[0072] [Figure 12]Figure 12 shows representative H&E-stained sections of healthy ear canals, ear canals treated for 24 hours after exposure to 10% [bupivacaine free base]-LIM, and ear canals treated for 7 days with 4% BUP-2CPE-[P407-PBP] or 15% BUP-2CPE-[P407-PBP]. Scale bars represent 50 μm. Inset: Magnified image highlights inflammatory cells; black arrows point to neutrophils; white arrows with black outline point to lymphocytes; scale bars in inset represent 10 μm.

[0073] [Figure 13] Figure 13 shows the cumulative in vitro release of Cip from hydrogel formulations under infinite sink conditions. Eight milligrams of Cip was contained in each gel and solution at time zero. Data are means ± SD (n=4).

[0074] [Figure 14] Figures 14A and 14B show the construction of an isobologram. (Figure 14A) Concentration (Conc.)-response curves are used to identify isoboles, i.e. concentrations that achieve the same effect (R). In this work, the main R is VCIP48. (Figure 14B) Analysis of the isobologram. See discussion below for interpretation. Cx and Cy are equivalent doses of drugs X and Y. The diagonal line is the line of additivity, also known as isobol.

[0075] [Figure 15A-B]Figures 15A-15F show the performance of CPE pairs. (Figures 15A-15C) Cumulative Cip permeation (VCIP48) over 48 hours across the TM from CPPB containing varying concentrations of CPE alone (black curves) or in combination with other CPEs (gray dots on graphs). Gray dots represent the same data in all panels. Data means ± SD (n=4). *5% BUP and 30% SDS were suspensions, not homogenous solutions. †p<0.05 comparing CPE combinations to single CPEs of interest in panels;††p<0.1. (Figures 15D-15F) Isobolograms for combinations of SDS and / or LIM that achieved (Figure 15D) VCIP48=0.39 mg, (Figure 15E) SDS and / or BUP that achieved VCIP48=0.24 mg, and (Figure 15F) BUP and / or LIM that achieved VCIP48=0.22 mg. Data are from Figures 15A-15C. [Figure 15C-D] (FIGS. 15A-15C) Cumulative Cip permeation (VCIP48) over 48 h across the TM from CPPB containing varying concentrations of CPE alone (black curves) or in combination with other CPEs (grey dots on graphs). Grey dots represent the same data in all panels. Data means ± SD (n=4). *5% BUP and 30% SDS were suspensions, not homogenous solutions. †p<0.05 comparing CPE combinations to single CPEs of interest in panels;†† p<0.1. (FIGS. 15D-15F) Isobolograms for combinations of SDS and / or LIM that achieved (FIG. 15D) VCIP48=0.39 mg, (FIG. 15E) SDS and / or BUP that achieved VCIP48=0.24 mg, and (FIG. 15F) BUP and / or LIM that achieved VCIP48=0.22 mg. Data from FIGS. 15A-15C. [Fig. 15E-F](FIGS. 15D-15F) Isobolograms for the combination of SDS and / or LIM that achieved (FIG. 15D) VCIP48=0.39 mg, SDS and / or BUP that achieved (FIG. 15E) VCIP48=0.24 mg, and BUP and / or LIM that achieved (FIG. 15F) VCIP48=0.22 mg. Data from FIGS. 15A-15C.

[0076] [Figure 16A-B] Figures 16A-16C show cumulative Cip permeation over 6 hours across the TM from CPPB containing varying concentrations of CPE alone (black curves) or in combination with other CPEs (grey dots on graphs). Grey dots represent the same data in all panels. Data are means ± SD (n=4). *5% BUP and 30% SDS were suspensions, not homogenous solutions. †p<0.05 comparing CPE combinations with single CPEs as panel subjects;††p<0.1. [Figure 16C] Figures 16A-16C show cumulative Cip permeation over 6 hours across the TM from CPPB containing varying concentrations of CPE alone (black curves) or in combination with other CPEs (grey dots on graphs). Grey dots represent the same data in all panels. Data are means ± SD (n=4). *5% BUP and 30% SDS were suspensions, not homogenous solutions. †p<0.05 comparing CPE combinations with single CPEs as panel subjects;††p<0.1.

[0077] [Figure 17A] 17A-17C show concentration-response curves for ciprofloxacin permeation across the TM after 48 hours (i.e., VCIP48) from CPPB containing (FIG. 17A) SDS, (FIG. 17B) LIM, and (FIG. 17C) BUP. Data were fitted to a three-parameter hyperbolic model (black line) using equation (1). Fit parameters are listed in Table 1. Data points (gray dots) originate from FIG. 14. Note that the y-axis scale in FIG. 17C is different from that in FIG. 17A and FIG. 17B. [Fig. 17B-C] 17A-17C show concentration-response curves for ciprofloxacin permeation across the TM after 48 hours (i.e., VCIP48) from CPPB containing (FIG. 17A) SDS, (FIG. 17B) LIM, and (FIG. 17C) BUP. Data were fitted to a three-parameter hyperbolic model (black line) using equation (1). Fit parameters are listed in Table 1. Data points (gray dots) originate from FIG. 14. Note that the y-axis scale in FIG. 17C is different from that in FIG. 17A and FIG. 17B.

[0078] [Figure 18] Figure 18A shows the isobologram plot for the combination of SDS and / or LIM and / or BUP that achieved VCIP48 = 0.4 mg. Surfaces are derived from isobols for the three CPEs in Figures 14A to 14C. Grey dots are VCIP48 measured from all three CPE combinations. Figure 18B shows the effect of CPE combinations on peak VCIP48. Maximum flux of CPE occurred at 4%, 20%, and 1% LIM, SDS, and BUP, respectively; the combination column contained 4% LIM, 1% BUP, and 20% SDS. Data are means ± SD (n = 4).

[0079] [Figure 19] FIG. 19 shows the molecular structures of sodium dodecyl sulfate (SDS), limonene (LIM), bupivacaine hydrochloride (BUP), and poloxamer 407-polybutylphosphoester (P407-PBP).

[0080] [Figure 20A] Figures 20A and 20B show the synthesis of P407-PBP. Figure 20A shows the NMR of the pentablock copolymer. The chemical shifts (δ, in ppm) of the peaks corresponding to the italicized hydrogens in the polymers listed below are provided below. t / m / broad indicates the shape of the peaks (i.e., triplet, multiple, broad). CDCl3 was the solvent. [ka] [Figure 20B] Figure 20B shows the FTIR spectrum of P407 and P407-PBP. Figure 20B shows the FTIR of tri- and penta-block copolymers. Peaks are assigned as follows: 2650-3020 cm-1: CH stretching from CH2 and CH3 groups; 1466 cm-1: CH bending from CH2 and CH3 groups; 1328-1400 cm-1: CH stretching and bending from isopropyl groups; 1279 cm-1: CO and CC stretching (crystalline phase); 1241 cm-1: asymmetric COC stretching; 1144 cm-1: symmetric COC stretching; 1103 cm-1: CO stretching; 1061 cm-1: CO-C axial deformation; 1030 cm-1: PO stretching; 964 cm-1: =CH bending; 845 cm-1: C-CH deformation. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0081] DETAILED DESCRIPTION OF CERTAIN EMBODIMENTS OF THE DISCLOSURE Provided herein are compositions and methods for administering a therapeutic agent to a subject through a barrier. In some embodiments, the composition is for administering a therapeutic agent to the ear of a subject, and the barrier is the tympanic membrane. The compositions and methods provide efficient delivery of the agent to the middle and / or inner ear of a subject. In one aspect, the composition comprises a combination of permeation enhancers, a therapeutic agent or combination of therapeutic agents, and a matrix forming agent. The permeation enhancer increases the flux of the therapeutic agent or combination of therapeutic agents across a barrier (e.g., the tympanic membrane) compared to the flux for a composition lacking the permeation enhancer. In various aspects, the composition is a single application composition for localized sustained delivery of a therapeutic agent or combination of therapeutic agents across the tympanic membrane. In various aspects, the composition is a multiple application composition for localized sustained delivery of a therapeutic agent across the tympanic membrane. The compositions and methods described herein are particularly useful for treating otitis media and / or pain associated with otitis media by providing sustained release and delivery of antibiotics to the middle ear.

[0082] In one aspect, provided herein is a method for treating a pulmonary circulation comprising: (a) a therapeutic agent or combination of therapeutic agents; (b) a permeation enhancer or combination of permeation enhancers, where the permeation enhancer or combination of permeation enhancers increases the flux of a therapeutic agent or combination of therapeutic agents across a barrier; and (c) a matrix-forming agent or combination of matrix-forming agents, wherein the matrix-forming agent or combination of matrix-forming agents comprises a polymer; A composition comprising: The composition forms a gel at a temperature above the phase transition temperature; and The phase transition temperature is less than about 37°C; wherein the composition comprises between about 0.5-20.0% wt / vol of a permeation enhancer which is sodium dodecyl sulfate; wherein the composition comprises between about 0.5-7.5% wt / vol of a permeation enhancer, one of which is bupivacaine; wherein the composition comprises between about 0.5-12.0% wt / vol of a permeation enhancer, which is limonene; and wherein the composition comprises between about 9.0-20.0% wt / vol of a polymer that is poloxamer 407-poly(butoxy) phosphoester; and The compositions herein optionally further comprise between about 0.01-0.50% wt / vol of another therapeutic agent which is a local anesthetic.

[0083] In one aspect, provided herein is a method for treating a pulmonary artery disease comprising administering to a subject a therapeutically effective amount of (a) a therapeutic agent or combination of therapeutic agents; (b) a permeation enhancer or combination of permeation enhancers, where the permeation enhancer or combination of permeation enhancers increases the flux of a therapeutic agent or combination of therapeutic agents across a barrier; and (c) a matrix-forming agent or combination of matrix-forming agents, wherein the matrix-forming agent or combination of matrix-forming agents comprises a polymer; A composition comprising: The composition forms a gel at a temperature above the phase transition temperature; and The phase transition temperature is less than about 37°C; wherein the composition comprises between about 0.5-5.5% wt / vol of a permeation enhancer which is sodium dodecyl sulfate; wherein the composition comprises between about 0.5-7.5% wt / vol of a permeation enhancer, one of which is bupivacaine; wherein the composition comprises between about 0.5-10.0% wt / vol of a permeation enhancer, which is limonene; and wherein the composition comprises between about 9.0-19.0% wt / vol of a polymer that is poloxamer 407-poly(butoxy) phosphoester; and The compositions herein include between about 0.01-0.50% wt / vol of a local anesthetic that is a sodium channel blocker.

[0084] In one aspect, provided herein is a method for treating a pulmonary circulation comprising: (a) a therapeutic agent or combination of therapeutic agents; (b) a permeation enhancer or combination of permeation enhancers, where the permeation enhancer or combination of permeation enhancers increases the flux of a therapeutic agent or combination of therapeutic agents across a barrier; and (c) a matrix-forming agent or combination of matrix-forming agents, wherein the matrix-forming agent or combination of matrix-forming agents comprises a polymer; A composition comprising: The composition forms a gel at a temperature above the phase transition temperature; and The phase transition temperature is less than about 37°C; wherein the composition comprises between about 0.5-5.5% wt / vol of a permeation enhancer which is sodium dodecyl sulfate; wherein the composition comprises between about 0.5-1.5% wt / vol of a permeation enhancer which is bupivacaine; wherein the composition comprises between about 2.0-12.0% wt / vol of a permeation enhancer, which is limonene; and The composition herein comprises between about 9.0-19.0% wt / vol of a polymer that is poloxamer 407-poly(butoxy) phosphoester.

[0085] In an embodiment, conditions (i), (ii), and (iii): (i) the composition can be extruded through soft catheters ranging in size from 16 gauge to 24 gauge and from 1 inch to 5.25 inches, and the composition remains liquid; (ii) the phase transition temperature of the composition is greater than about 15° C. and less than about 37° C.; and (iii) at 37° C., the storage modulus of the composition is greater than about 300 Pa, and the storage modulus is greater than the loss modulus of the composition; At least one of the following is satisfied.

[0086] In some embodiments, the composition may be extruded from a flexible catheter ranging in size from 10 gauge to 24 gauge and from 1 inch to 5.25 inches, and the composition remains liquid, condition (i) is met. In some embodiments, the composition may be extruded from a flexible catheter ranging in size from 16 gauge to 24 gauge and from 1.16 inch to 5.25 inch and the composition remains liquid, condition (i) is met. In some embodiments, the composition may be extruded from a flexible catheter ranging in size from 16 gauge to 24 gauge and from 1 inch to 5.25 inch and the composition remains liquid, condition (i) is met. In some embodiments, the composition may be extruded from a flexible catheter ranging in size from 16 gauge to 18 gauge and from 1.16 inch to 1.88 inch and the composition remains liquid, condition (i) is met. In some embodiments, the flexible catheter is an 18 gauge, 1.88 inch flexible catheter. In an embodiment, condition (i) is met: the soft catheter is a 10 gauge, 1 inch soft catheter. In an embodiment, condition (i) is met: the soft catheter is a 16 gauge, 1.16 inch soft catheter. In an embodiment, condition (i) is met: the soft catheter is a 20 gauge, 3 inch soft catheter. In an embodiment, condition (i) is met: the soft catheter is a 22 gauge, 3.25 inch soft catheter. In an embodiment, condition (i) is met: the soft catheter is a 24 gauge, 5.25 inch soft catheter.

[0087] In some embodiments, condition (ii) is met: the phase transition temperature of the composition is greater than about 15° C. and less than about 37° C. In some embodiments, condition (ii) is met: the phase transition temperature of the composition is greater than about 18° C. and less than about 37° C. In some embodiments, condition (ii) is met: the phase transition temperature of the composition is greater than about 20° C. and less than about 37° C.

[0088] In some embodiments, the condition (iii) is met: at 37° C., the storage modulus of the composition is greater than about 300 Pa, and the storage modulus is greater than the loss modulus of the composition. In some embodiments, the condition (iii) is met: at 37° C., the storage modulus of the composition is greater than about 305 Pa, and the storage modulus is greater than the loss modulus of the composition. In some embodiments, the condition (iii) is met: at 37° C., the storage modulus of the composition is greater than about 310 Pa, and the storage modulus is greater than the loss modulus of the composition. In some embodiments, the condition (iii) is met: at 37° C., the storage modulus of the composition is greater than about 312 Pa, and the storage modulus is greater than the loss modulus of the composition.

[0089] In some embodiments, both conditions (i) and (ii) are met. In some embodiments, both conditions (ii) and (iii) are met. In some embodiments, both conditions (i) and (iii) are met. In some embodiments, each of conditions (i), (ii), and (iii) are met.

[0090] In some embodiments, the therapeutic agent is a single therapeutic agent. In some embodiments, the therapeutic agent is a combination of two or more therapeutic agents (e.g., two, three, four). In some embodiments, the permeation enhancer is a single therapeutic agent. In some embodiments, the therapeutic agent is a combination of two or more therapeutic agents (e.g., two, three, four). In some embodiments, the matrix forming agent is a single matrix forming agent. In some embodiments, the matrix forming agent is a combination of two or more matrix forming agents (e.g., two, three, four). In some embodiments, the therapeutic agent or permeation enhancer may act as both a therapeutic agent and a permeation enhancer. In some embodiments, the therapeutic agent may act as both a therapeutic agent and a permeation enhancer. In some embodiments, the permeation enhancer may act as both a therapeutic agent and a permeation enhancer. In some embodiments, the local anesthetic may act as both a therapeutic agent and a permeation enhancer. In some embodiments, the aminoamide or aminoester local anesthetic may act as both a therapeutic agent and a permeation enhancer. In some embodiments, the aminoamide or aminoester local anesthetic may act as both a therapeutic agent and a permeation enhancer. In some embodiments, the aminoester local anesthetic may act as both a therapeutic agent and a permeation enhancer. In some embodiments, bupivacaine may act as both a therapeutic agent and a permeation enhancer. In some embodiments, tetracaine may act as both a therapeutic agent and a permeation enhancer.

[0091] In some embodiments, the permeation enhancer or combination of permeation enhancers is present in an amount effective to increase the flux of a therapeutic agent across a barrier as compared to a reference composition (e.g., a composition without the permeation enhancer). In some embodiments, the permeation enhancer or combination of permeation enhancers is present in an amount effective to increase the flux of a therapeutic agent across a barrier by at least about 1.05-fold, at least about 1.10-fold, at least about 1.2-fold, at least about, at least about 1.3-fold, at least about 1.4-fold, at least about 1.5-fold, at least about 1.6-fold, at least about 1.7-fold, at least about 1.8-fold, or at least about 1.9-fold as compared to a reference composition (e.g., a composition without the permeation enhancer). In certain embodiments, the permeation enhancer or combination of permeation enhancers is present in an amount effective to increase the flux of the therapeutic agent across the barrier by at least about 2-fold, at least about 2.5-fold, at least about 3-fold, at least about 4-fold, at least about 5-fold, at least about 10-fold, at least about 25-fold, at least about 50-fold, at least about 100-fold, at least about 250-fold, at least about 500-fold, or at least about 1000-fold, as compared to a reference composition. In certain embodiments, the permeation enhancer or combination of permeation enhancers is present in an amount effective to increase the flux of the therapeutic agent across the barrier by between about 1.5-fold and about 100-fold, as compared to a reference composition.

[0092] In some embodiments, the matrix-forming agent or combination of matrix-forming agents includes a polymer that is poloxamer 407-poly(butoxy)phosphoester. In some embodiments, the polymer has the formula: [ka] (Poloxamer 407-poly(butoxy)phosphoester; also referred to as "PBP-P407" or "PBP").

[0093] The composition may be liquid prior to being warmed above the phase transition temperature. In some embodiments, the phase transition temperature is at or below the subject's body temperature (e.g., about 37° C.). Thus, the composition may form a gel when administered to a subject (e.g., when the composition contacts a biological surface).

[0094] In some embodiments, the phase transition temperature is between about 15°C and about 37°C, between about 20°C and about 37°C, between about 25°C, between about 30°C and about 37°C, between about 30°C and about 35°C, or between about 35°C and about 40°C. In some embodiments, the phase transition temperature is between about 20°C and about 37°C. In some embodiments, the phase transition temperature is between about 0°C and about 60°C, between about 10°C and about 50°C, between about 20°C and about 40°C, or between about 25°C and about 35°C. In some embodiments, the phase transition temperature is between about 20°C and 25°C, between about 25°C and about 30°C, between about 30°C and about 35°C, or between about 35°C and about 40°C. In some embodiments, the phase transition temperature is between about 10°C and about 50°C. In some embodiments, the phase transition temperature is between about 20° C. and about 40° C. In some embodiments, the phase transition temperature is between about 15° C. and about 40° C.

[0095] In some embodiments, the composition is applied to a surface at a temperature equal to or above the phase transition temperature. In some embodiments, the surface is a biological surface. In some embodiments, the surface is skin. In some embodiments, the surface is a surface in the ear canal of a subject. In some embodiments, the surface is a tympanic membrane. In some embodiments, the surface is a surface in the respiratory tract of a subject (e.g., in the nasal cavity or in the oral cavity). In some embodiments, the surface is a surface in the mouth of a subject (e.g., or the surface of the gums). The composition may be administered to an internal surface, for example, by intradermal or interdermal delivery, or during a surgical procedure. In some embodiments, the surface is an intradermal surface. In some embodiments, the surface is a surface of an organ (e.g., heart, lung, spleen, pancreas, kidney, liver, stomach, intestine, bladder). In some embodiments, the surface is a connective tissue. In some embodiments, the surface is muscle tissue (e.g., smooth muscle, skeletal muscle, cardiac muscle). In some embodiments, the surface is nerve tissue (e.g., brain, spinal cord). In some embodiments, the surface is an epithelial tissue. In some embodiments, the surface is a surface of the digestive tract (e.g., colon, rectum). In some embodiments, the surface is an epithelial tissue. In some embodiments, the surface is a surface of the reproductive tract (e.g., vagina, cervix). In some embodiments, the surface is a bone. In some embodiments, the surface is vascular tissue. In some embodiments, the surface is a wound bed. In some embodiments, the surface is a biofilm. In some embodiments, the surface is hair or fur. In some embodiments, the surface is a surface of a medical implant.

[0096] In some embodiments, the composition is useful for treating a disease. In some embodiments, the composition is useful for treating an infectious disease. In some embodiments, the composition is useful for treating an ear disease (e.g., the barrier is the eardrum). In some embodiments, the composition is useful for treating otitis media. In some embodiments, the composition is useful for treating pain (e.g., persistently treating pain). In some embodiments, the composition is useful for treating pain associated with a disease (e.g., persistently treating said pain). In some embodiments, the composition is useful for treating pain associated with an infectious disease (e.g., persistently treating said pain). In some embodiments, the composition is useful for treating pain associated with an ear disease (e.g., persistently treating said pain) (e.g., the barrier is the eardrum). In some embodiments, the composition is useful for treating pain associated with otitis media (e.g., persistently treating said pain).

[0097] As described, the gelation temperature (phase transition temperature) of the composition is one factor that determines the suitability of the composition (e.g., to enable sustained delivery to the tympanic membrane). The temperature at which the storage modulus exceeds the loss modulus is considered to be the gelation temperature. The composition herein may have a gelation temperature lower or higher than 37°C, but preferably lower than 37°C to accelerate gelation immediately after administration upon exposure of the composition (especially the matrix forming agent) to body temperature.

[0098] The timing of the sol-gel transition will affect ease of administration. Generally, a faster in situ transition is useful for administration to subjects (e.g., children who are resistant to compliance). In some embodiments, the composition gels within about 5 s, about 10 s, about 20 s, about 30 s, about 1 min, about 5 min, or about 10 min of administration (e.g., into the ear canal). In some embodiments, the composition gels within about 1 s to about 20 s after administration.

[0099] In some embodiments, the composition is stored cool (e.g., refrigerated at about 5° C.) prior to administration. Cool storage may be useful for compositions with gelling temperatures below room temperature to prevent gelling prior to administration or during handling.

[0100] The compositions provided herein include a permeation enhancer (e.g., surfactant, terpene), a therapeutic agent or combination of therapeutic agents (e.g., antibiotic, anesthetic), and a matrix-forming agent (e.g., PBP-poloxamer 407). A permeation enhancer is an agent that increases the flow of a therapeutic agent across the tympanic membrane by altering the stratum corneum of the tympanic membrane. A permeation enhancer facilitates delivery of a therapeutic agent into the middle ear and / or inner ear. A therapeutic agent includes an agent that has a therapeutic benefit in the ear. In some embodiments, the matrix-forming agent is liquid at ambient conditions, but gels (e.g., becomes more viscous) once administered to a subject. In some embodiments, the matrix-forming agent gels upon mixing two components of the composition. In some embodiments, each component includes a matrix-forming agent (e.g., two polysaccharide derivatives that undergo cross-linking upon mixing). In some embodiments, one component includes a matrix-forming agent, and a second component includes an activator or catalyst that causes gelation when mixed with the matrix-forming agent. In certain embodiments, the pharmaceutical composition does not substantially interfere with the subject's hearing.

[0101] Matrix Forming Agent A matrix-forming agent is a compound or mixture of compounds that forms a gel after administration. In some embodiments, the matrix-forming agent forms a gel after administration into the ear canal of a subject. The gel composition behaves like a reservoir containing a therapeutic agent and a permeation enhancer, allowing for sustained release of the therapeutic agent across a barrier (e.g., the tympanic membrane). In some embodiments, the gel maintains contact with the tympanic membrane. In some embodiments, the gel maintains contact for between 0.5 and 1 hour, between 1 and 4 hours, between 1 and 8 hours, between 1 and 16 hours, or between 1 and 24 hours. In some embodiments, the gel maintains contact for between 1 and 3 days, between 1 and 7 days, or between 1 and 14 days. In some embodiments, the gel allows flow of the therapeutic agent across the tympanic membrane for between 0.5 and 1 hour, between 1 and 4 hours, between 1 and 8 hours, between 1 and 16 hours, or between 1 and 24 hours. In some embodiments, the gel maintains contact for between 1 and 3 days, between 1 and 7 days, or between 1 and 14 days. Such a reservoir maintains contact with the tympanic membrane, thereby increasing the time for the therapeutic agent to be delivered across the tympanic membrane to the middle or inner ear. Such a reservoir maximizes exposure of the tympanic membrane to the permeation enhancer and therapeutic agent, facilitating sustained flow of the therapeutic agent into the middle and inner ear.

[0102] In various embodiments, the composition is a sustained release formulation. In various aspects, the sustained release of either the permeation enhancer and / or the therapeutic agent can be at a constant rate to deliver an effective amount of either the permeation enhancer or the therapeutic agent to the surface of the tympanic membrane, the middle ear, or the inner ear. In various embodiments, the sustained release provides sufficient flux of the therapeutic agent for about 1 day, about 2 days, about 3 days, about 4 days, about 5 days, about 6 days, or about 7 days. In various embodiments, the sustained release provides sufficient flux of the therapeutic agent for a range of about 7 days to about 10 days. In various embodiments, the sustained release can be at a constant rate for about 7 days to about 14 days. In various embodiments, the sustained release provides sufficient flux of the therapeutic agent for about 14 days to about 21 days. In various embodiments, the sustained release provides sufficient flux of the therapeutic agent for about 21 days to about 30 days. As used herein, sufficient flux is the flux necessary for the therapeutic agent to be present in a therapeutically effective amount or a prophylactically effective amount in the middle ear. In some embodiments, the sufficient flux is sufficient to provide an antibiotic agent at a concentration equal to or greater than the minimum inhibitory concentration of the infectious microorganism, hi some embodiments, the infectious microorganism is H. influenza, S. pneumoniae, or M. catarrhalis.

[0103] In various aspects, the sustained release profile is obtained by the addition of a matrix-forming agent to the composition. In various embodiments, the composition may further comprise a matrix-forming agent. In various embodiments, the matrix-forming agent may undergo a change in viscosity in situ based on a phase change, a change in solubility, evaporation of a solvent, or mixing of the components including the matrix-forming agent. Such a matrix-forming agent gels in situ after administration into the ear canal of a patient to form a reservoir containing the therapeutic agent and the permeation enhancer, allowing for sustained release of the therapeutic agent. Such a reservoir maintains contact with the tympanic membrane, thereby increasing the time for the therapeutic agent to penetrate the tympanic membrane and be delivered to the middle or inner ear. Such a reservoir maximizes the exposure of the tympanic membrane to the permeation enhancer and the therapeutic agent.

[0104] In some embodiments, the matrix forming agent is a hydrogel or forms a hydrogel upon administration. In some embodiments, the matrix forming agent does not include a polymer. In some embodiments, the matrix forming agent includes a polymer that is a poloxamer 407-poly(butoxy)phosphoester. In some embodiments, the composition includes between about 9.0-19.0% wt / vol of poloxamer 407-poly(butoxy)phosphoester. In some embodiments, the composition includes between about 10.0-15.0% wt / vol of poloxamer 407-poly(butoxy)phosphoester. In certain embodiments, the composition comprises between about 9.0-19.0% wt / vol, between about 9.0-17.0% wt / vol, between about 9.0-16.0% wt / vol, between about 10.0-17.0% wt / vol, between about 10.0-15.0% wt / vol, between about 10.0-14.0% wt / vol, between about 10.0-13.0% wt / vol, between about 10.0-12.0% wt / vol, between about 9.0-12.0% wt / vol, between about 9.0-11.0% wt / vol, or between about 9.0-10.0% wt / vol. In some embodiments, the composition is about 9.0% wt / vol, about 9.5% wt / vol, about 10.0% wt / vol, about 10.5% wt / vol, about 11.0% wt / vol, about 11.5% wt / vol, about 12.0% wt / vol, about 12.5% ​​wt / vol, about 13.0% wt / vol, about 13.5% wt / vol, about 14.0% wt / vol, about 14. The composition comprises about 5% wt / vol, about 15.0% wt / vol, about 15.5% wt / vol, about 16.0% wt / vol, about 16.5% wt / vol, about 17.0% wt / vol, about 17.5% wt / vol, about 18.0% wt / vol, about 18.5% wt / vol, or about 19.0% wt / vol of the poloxamer 407-poly(butoxy)phosphoester. In some embodiments, the composition comprises about 10.0% wt / vol of the poloxamer 407-poly(butoxy)phosphoester. In some embodiments, the composition comprises about 12.0% wt / vol of the poloxamer 407-poly(butoxy)phosphoester.In some embodiments, the composition comprises about 15.0% wt / vol poloxamer 407-poly(butoxy)phosphoester.

[0105] In some embodiments, the composition comprises between about 9.0-19.0% wt / vol of poloxamer 407-poly(butoxy)phosphoester. In some embodiments, the composition comprises between about 9.0-20.0% wt / vol of poloxamer 407-poly(butoxy)phosphoester. In some embodiments, the composition comprises between about 10.0-15.0% wt / vol of poloxamer 407-poly(butoxy)phosphoester. In some embodiments, the composition is between about 9.0-10.0% wt / vol, between about 10.0-12.0% wt / vol, between about 12.0-13.0% wt / vol, between about 13.0-14.0% wt / vol, between about 14.0-15.0% wt / vol, between about 15.0-16.0% wt / vol, between about 16.0-17.0% wt / vol, between about 17.0-18.0% wt / vol, Poloxamer 407-poly(butoxy) phosphoester of between about 18.0-19.0% wt / vol, between about 19.0-20.0% wt / vol, between about 20.0-21.0% wt / vol, between about 21.0-22.0% wt / vol, between about 22.0-23.0% wt / vol, between about 23.0-24.0% wt / vol, or between about 24.0-25.0% wt / vol. In certain embodiments, the composition is about 9.0% wt / vol, about 9.5% wt / vol, about 10.0% wt / vol, about 10.5% wt / vol, about 11.0% wt / vol, about 11.5% wt / vol, about 12.0% wt / vol, about 12.5% ​​wt / vol, about 13.0% wt / vol, about 13.5% wt / vol, about 14.0% wt / vol, about 14.5% wt / vol, about 15. The composition comprises 0% wt / vol, about 15.5% wt / vol, about 16.0% wt / vol, about 16.5% wt / vol, about 17.0% wt / vol, about 17.5% wt / vol, about 18.0% wt / vol, about 18.5% wt / vol, about 19.0% wt / vol, about 19.5% wt / vol, or about 20.0% wt / vol of the poloxamer 407-poly(butoxy)phosphoester. In some embodiments, the composition comprises about 10.0% wt / vol of the poloxamer 407-poly(butoxy)phosphoester. In some embodiments, the composition comprises about 12.0% wt / vol of the poloxamer 407-poly(butoxy)phosphoester.In some embodiments, the composition comprises about 15.0% wt / vol poloxamer 407-poly(butoxy)phosphoester.

[0106] Permeation enhancers A permeation enhancer refers to any agent that increases the flux of a therapeutic agent across a barrier (e.g., a membrane, a layer of cells). In some embodiments, the barrier is skin. In some embodiments, the barrier is a tympanic membrane. In some embodiments, the barrier is a tympanic membrane and is not a nerve. In some embodiments, the barrier is not a nerve. In some embodiments, the permeation enhancer is the surfactant sodium dodecyl sulfate. In some embodiments, the permeation enhancer is the anesthetic bupivacaine. In some embodiments, the permeation enhancer is the terpene limonene. In some embodiments, the permeation enhancer comprises a single permeation enhancer. In some embodiments, the permeation enhancer comprises the surfactant sodium dodecyl sulfate. In some embodiments, the permeation enhancer comprises the anesthetic bupivacaine. In some embodiments, the permeation enhancer comprises the terpene limonene. In some embodiments, the permeation enhancer comprises a surfactant permeation enhancer. In some embodiments, the permeation enhancer comprises an anesthetic permeation enhancer. In some embodiments, the permeation enhancer comprises a terpene permeation enhancer. In some embodiments, the permeation enhancer comprises two permeation enhancers. In some embodiments, the permeation enhancer comprises a surfactant permeation enhancer and an anesthetic permeation enhancer. In some embodiments, the permeation enhancer comprises a surfactant permeation enhancer and a terpene permeation enhancer. In some embodiments, the permeation enhancer comprises an anesthetic permeation enhancer and a terpene permeation enhancer. In some embodiments, the permeation enhancer comprises a surfactant permeation enhancer, an anesthetic permeation enhancer, and a terpene permeation enhancer. In some embodiments, the permeation enhancer comprises three permeation enhancers. In some embodiments, the permeation enhancer comprises the surfactant sodium dodecyl sulfate, the anesthetic bupivacaine, and the terpene limonene.

[0107] In some embodiments, the composition comprises between about 0.5-5.5% wt / vol of a permeation enhancer that is sodium dodecyl sulfate. In some embodiments, the composition comprises between about 0.5-5.5% wt / vol of sodium dodecyl sulfate, between about 0.75-5.5% wt / vol of sodium dodecyl sulfate, between about 1.0-5.25% wt / vol of sodium dodecyl sulfate, between about 1.25-5.25% wt / vol of sodium dodecyl sulfate, or between about 1.0-5.0% wt / vol of sodium dodecyl sulfate. In some embodiments, the composition comprises between about 1.0-5.0% wt / vol of sodium dodecyl sulfate. In some embodiments, the composition comprises about 0.5% wt / vol, about 0.75% wt / vol, about 1.0% wt / vol, about 1.25% wt / vol, about 1.5% wt / vol, about 1.75% wt / vol, about 2.0% wt / vol, about 2.25% wt / vol, about 2.5% wt / vol, about 2.75% wt / vol, about 3.0% wt / vol, about 3.25% wt / vol, about 3.5% wt / vol, about 3.75% wt / vol, about 4.0% wt / vol, about 4.25% wt / vol, about 4.5% wt / vol, about 4.75% wt / vol, about 5.0% wt / vol, or about 5.5% wt / vol of sodium dodecyl sulfate. In some embodiments, the composition comprises about 1.0% wt / vol of sodium dodecyl sulfate. In some embodiments, the composition comprises about 2.0% wt / vol sodium dodecyl sulfate. In some embodiments, the composition comprises about 3.0% wt / vol sodium dodecyl sulfate. In some embodiments, the composition comprises about 4.0% wt / vol sodium dodecyl sulfate. In some embodiments, the composition comprises about 5.0% wt / vol sodium dodecyl sulfate.

[0108] In some embodiments, the composition comprises between about 0.5-20.0% wt / vol of a permeation enhancer that is sodium dodecyl sulfate. In some embodiments, the composition comprises between about 0.5-10.0% wt / vol of a permeation enhancer that is sodium dodecyl sulfate. In some embodiments, the composition comprises between about 10.0-20.0% wt / vol of a permeation enhancer that is sodium dodecyl sulfate. In some embodiments, the composition comprises between about 12.0-20.0% wt / vol of a permeation enhancer that is sodium dodecyl sulfate. In some embodiments, the composition comprises between about 10.0-20.0% wt / vol of a permeation enhancer that is sodium dodecyl sulfate. In some embodiments, the composition comprises between about 12.0-15.0% wt / vol of a permeation enhancer that is sodium dodecyl sulfate. In some embodiments, the composition comprises between about 0.5-5.0% wt / vol of a permeation enhancer that is sodium dodecyl sulfate. In some embodiments, the composition comprises between about 1.0-5.0% wt / vol of a permeation enhancer that is sodium dodecyl sulfate.In some embodiments, the composition comprises about 0.5% wt / vol, about 0.75% wt / vol, about 1.0% wt / vol, about 1.25% wt / vol, about 1.5% wt / vol, about 1.75% wt / vol, about 2.0% wt / vol, about 2.25% wt / vol, about 2.5% wt / vol, about 2.75% wt / vol, about 3.0% wt / vol, about 3.25% wt / vol, about 3.5% wt / vol, about 3.6% wt / vol, about 3.7% wt / vol, about 3.8% wt / vol, about 3.9% wt / vol, about 3.0% wt / vol, about 3.2% wt / vol, about 3.5% wt / vol, about 3.6% wt / vol, about 3.7% wt / vol, about 3.8% wt / vol, about 3.9% wt / vol, about 3.0% wt / vol, about 3.5 ... .5%wt / vol, approx. 3.75%wt / vol, approx. 4.0%wt / vol, approx. 4.25%wt / vol, approx. 4.5%wt / vol, approx. 4.75%wt / vol, approx. 5.0%wt / vo l, approx. 5.5%wt / vol, approx. 6.0%wt / vol, approx. 6.5%wt / vol, approx. 7.0%wt / vol, approx. 7.5%wt / vol, approx. 8.0%wt / vol, approx. 8.5%wt / v ol, about 9.0%wt / vol, about 9.5%wt / vol, about 10.0%wt / vol, about 10.5%wt / vol, about 11.0%wt / vol, about 11.5%wt / vol, about 12. 0%wt / vol, approx. 12.5%wt / vol, approx. 13.0%wt / vol, approx. 13.5%wt / vol, approx. 14.0%wt / vol, approx. 14.5%wt / vol, approx. 15.0%wt / vol, about 15.5% wt / vol, about 16.0% wt / vol, about 16.5% wt / vol, about 17.0% wt / vol, about 17.5% wt / vol, about 18.0% wt / vol, about 18.5% wt / vol, about 19.0% wt / vol, about 19.5% wt / vol, about 20.0% wt / vol, or about 25.5% wt / vol of sodium dodecyl sulfate.

[0109] In certain embodiments, the composition comprises from about 0.5% wt / vol to about 5.0% wt / vol of a permeation enhancer that is sodium dodecyl sulfate, from about 5.0% wt / vol to about 10.0% wt / vol of a permeation enhancer that is sodium dodecyl sulfate, from about 10.0% wt / vol to about 15.0% wt / vol of a permeation enhancer that is sodium dodecyl sulfate, from about 15.0% wt / vol to about 20.0% wt / vol of a permeation enhancer that is sodium dodecyl sulfate. a permeation enhancer that is about 20.0% wt / vol to about 22.5% wt / vol that is sodium dodecyl sulfate, a permeation enhancer that is about 22.5% wt / vol to about 25.0% wt / vol that is sodium dodecyl sulfate, a permeation enhancer that is about 20.0% wt / vol to about 25.0% wt / vol that is sodium dodecyl sulfate, or a permeation enhancer that is about 25.0% wt / vol to about 27.5% wt / vol that is sodium dodecyl sulfate.

[0110] In some embodiments, the composition comprises between about 0.5-1.5% wt / vol, between about 0.75-1.5% wt / vol, between about 1.0-1.5% wt / vol, or between about 1.25-1.5% wt / vol of a permeation enhancer that is bupivacaine. In some embodiments, the composition comprises between about 0.5-1.5% wt / vol of a permeation enhancer that is bupivacaine. In some embodiments, the composition comprises about 0.5% wt / vol, about 0.75% wt / vol, about 1.0% wt / vol, about 1.25% wt / vol, or about 1.5% wt / vol of bupivacaine. In some embodiments, the composition comprises about 0.5% wt / vol of bupivacaine. In some embodiments, the composition comprises about 0.75% wt / vol of bupivacaine. In some embodiments, the composition comprises about 1.0% wt / vol of bupivacaine. In some embodiments, the composition comprises about 1.25% wt / vol bupivacaine.

[0111] In some embodiments, the composition comprises between about 0.5-7.5% wt / vol, between about 0.5-2.5% wt / vol, between about 0.75-2.5% wt / vol, between about 1.0-2.5% wt / vol, between about 1.25-2.5% wt / vol, between about 1.75-7.5% wt / vol, between about 2.5-5.5% wt / vol, between about 2.5-7.5% wt / vol, between about 5.5-7.0% wt / vol, or between about 2.5-7.5% wt / vol. In some embodiments, the composition comprises between about 0.5-2.5% wt / vol of a permeation enhancer that is bupivacaine. In some embodiments, the composition comprises about 0.5% wt / vol, about 0.75% wt / vol, about 1.0% wt / vol, about 1.25% wt / vol, about 1.5% wt / vol, about 2.0% wt / vol, about 2.25% wt / vol, about 2.5% wt / vol, about 3.0% wt / vol, about 3.5% wt / vol, about 4.0% wt / vol, about 4.5% wt / vol, about 5.0% wt / vol, about 5.5% wt / vol, about 6.0% wt / vol, about 6.5% wt / vol, about 7.0% wt / vol, or about 7.5% wt / vol of bupivacaine. In some embodiments, the composition comprises between about 1.75-7.5% wt / vol of bupivacaine. In some embodiments, the composition comprises between about 2.0-7.5% wt / vol bupivacaine. In some embodiments, the composition comprises about 0.5% wt / vol bupivacaine. In some embodiments, the composition comprises about 0.75% wt / vol bupivacaine. In some embodiments, the composition comprises about 1.0% wt / vol bupivacaine. In some embodiments, the composition comprises about 1.25% wt / vol bupivacaine. In some embodiments, the composition comprises about 1.5% wt / vol bupivacaine. In some embodiments, the composition comprises about 1.75% wt / vol bupivacaine. In some embodiments, the composition comprises about 2.0% wt / vol bupivacaine. In some embodiments, the composition comprises about 2.25% wt / vol bupivacaine. In some embodiments, the composition comprises about 2.5% wt / vol bupivacaine. In some embodiments, the composition comprises about 3.0% wt / vol bupivacaine.In some embodiments, the composition comprises about 3.5% wt / vol bupivacaine. In some embodiments, the composition comprises about 4.0% wt / vol bupivacaine. In some embodiments, the composition comprises about 4.5% wt / vol bupivacaine. In some embodiments, the composition comprises about 5.0% wt / vol bupivacaine. In some embodiments, the composition comprises about 5.5% wt / vol bupivacaine. In some embodiments, the composition comprises about 6.0% wt / vol bupivacaine. In some embodiments, the composition comprises about 6.5% wt / vol bupivacaine. In some embodiments, the composition comprises about 7.0% wt / vol bupivacaine. In some embodiments, the composition comprises about 7.5% wt / vol bupivacaine. In some embodiments, the composition does not comprise between 8.0-15.0% wt / vol bupivacaine or between 8.5-15.0% wt / vol bupivacaine.

[0112] In some embodiments, the composition comprises a permeation enhancer of between about 0.5-0.75% wt / vol that is bupivacaine, between about 0.75-1.0% wt / vol that is bupivacaine, between about 1.0-1.25% wt / vol that is bupivacaine, between about 1.25-1.5% wt / vol that is bupivacaine, between about 1.5-1.75% wt / vol that is bupivacaine, between about 1.75-2.25% wt / vol that is bupivacaine, between about 2.25-2. ... a permeation enhancer that is between about 2.5-3.0% wt / vol that is bupivacaine, a permeation enhancer that is between about 3.0-4.0% wt / vol that is bupivacaine, a permeation enhancer that is between about 4.0-5.0% wt / vol that is bupivacaine, a permeation enhancer that is between about 5.0-6.0% wt / vol that is bupivacaine, a permeation enhancer that is between about 6.0-7.0% wt / vol that is bupivacaine, a permeation enhancer that is between about 6.0-7.5% wt / vol that is bupivacaine, or a permeation enhancer that is between about 2.5-7.5% wt / vol that is bupivacaine,

[0113] In some embodiments, the composition comprises between about 0.5-10.0% wt / vol of a permeation enhancer that is limonene. In some embodiments, the composition comprises between about 0.5-12.0% wt / vol of a permeation enhancer that is limonene. In some embodiments, the composition comprises between about 1.5-12.0% wt / vol of a permeation enhancer that is limonene. In some embodiments, the composition comprises between about 1.5-10.0% wt / vol of a permeation enhancer that is limonene. In some embodiments, the composition comprises between about 0.5-3.5% wt / vol of a permeation enhancer that is limonene. In certain embodiments, the composition is between about 0.5-3.5% wt / vol, between about 1.5-5.0% wt / vol, between about 1.5-4.75% wt / vol, between about 1.5-4.5% wt / vol, between about 1.5-4.25% wt / vol, between about 1.5-4.0% wt / vol, between about 1.5-3.75% wt / vol, between about 1.5-3.5% wt / vol between about 1.5-3.25% wt / vol, between about 1.5-3.0% wt / vol, between about 1.5-2.75% wt / vol, between about 1.5-2.5% wt / vol, between about 1.5-2.25% wt / vol, between about 1.5-2.0% wt / vol, between about 1.25-2.25% wt / vol, or between about 1.0-2.5% wt / vol. In some embodiments, the composition comprises about 2.0% wt / vol limonene.

[0114] In some embodiments, the composition includes between about 2.0-12.0% wt / vol of a permeation enhancer that is limonene. In some embodiments, the composition includes between about 1.5-12.0% wt / vol, between about 1.5-11.5% wt / vol, between about 1.5-11.0% wt / vol, between about 1.5-10.0% wt / vol, between about 1.5-9.0% wt / vol, between about 1.5-8.0% wt / vol, between about 2.0-9.0% wt / vol, between about 2.0-10.0% wt / vol, between about 3.0-11.0% wt / vol, between about 4.0-10.0% wt / vol of a permeation enhancer that is limonene. In certain embodiments, the composition is about 2.0% wt / vol, about 2.25% wt / vol, about 2.5% wt / vol, about 2.75% wt / vol, about 3.0% wt / vol, about 3.25% wt / vol, about 3.5% wt / vol, about 3.75% wt / vol, about 4.0% wt / vol, about 4.5% wt / vol, about 5.0% wt / vol, about 5.5% wt / vol, about 6.0% wt / vol, about 7.0% wt / vol, about 8.0% wt / vol, about 9.0% wt / vol, about 10.0% wt / vol, about 11.0% wt / vol, about 12.0% wt / vol, about 13.0% wt / vol, about 14.0% wt / vol, about 15.0% wt / vol, about 16.0% wt / vol, about 17.0% wt / vol, about 18.0% wt / vol, about 19.0% wt / vol, about 20.0% wt / vol, about 21.0% wt / vol, about 22.0% wt / vol, about 23.0% wt / vol, about 24.0% wt / vol, about 25.0% wt / vol, about 26.0% wt / vol, about 27.0% wt / vol, about 28.0% wt / vol, about 29.0% wt / vol, about 30.0% wt / vol, about 31.0% wt / vol, about 32.0% wt / vol, about 33.0% wt / vol, about 34.0% wt / vol, about 35.0% wt / vol, about 36.0% wt / vol, In some embodiments, the composition comprises about 2.0% wt / vol limonene. In some embodiments, the composition comprises about 3.0% wt / vol limonene. In some embodiments, the composition comprises about 4.0% wt / vol limonene. In some embodiments, the composition comprises about 5.0% wt / vol limonene. In some embodiments, the composition comprises about 6.0% wt / vol limonene. In some embodiments, the composition comprises about 7.0% wt / vol limonene. In some embodiments, the composition comprises about 8.0% wt / vol limonene. In some embodiments, the composition comprises about 9.0% wt / vol limonene. In some embodiments, the composition comprises about 10.0% wt / vol limonene.

[0115] In some embodiments, the composition comprises between about 1.5-15.0% wt / vol, between about 1.5-3.0% wt / vol, between about 3.0-5.0% wt / vol, between about 5.0-7.0% wt / vol, between about 7.0-9.0% wt / vol, between about 7.0-11.0% wt / vol, between about 9.0-13.0% wt / vol, between about 11.0-13.0% wt / vol, between about 13.0-14.0% wt / vol, between about 14.0-15.0% wt / vol, between about 8.0-12.5.0% wt / vol, or between about 8.0-15.0% wt / vol of a permeation enhancer that is limonene. In some embodiments, the composition is about 2.0% wt / vol, about 2.25% wt / vol, about 2.5% wt / vol, about 2.75% wt / vol, about 3.0% wt / vol, about 3.25% wt / vol, about 3.5% wt / vol, about 3.75% wt / vol, about 4.0% wt / vol, about 4.5% wt / vol, about 5.0% wt / vol, about 5.5% wt / vol, about 6.0% wt / vol, about 6.5% wt / vol, about The composition comprises 7.0% wt / vol, about 7.5% wt / vol, about 8.0% wt / vol, about 8.5% wt / vol, about 9.0% wt / vol, about 9.5% wt / vol, about 10.0% wt / vol, about 10.5% wt / vol, about 11.0% wt / vol, about 11.5% wt / vol, about 12.0% wt / vol, about 13.0% wt / vol, about 14.0% wt / vol, or about 15.0% wt / vol of limonene. In some embodiments, the composition comprises about 2.0% wt / vol of limonene. In some embodiments, the composition comprises about 3.0% wt / vol of limonene. In some embodiments, the composition comprises about 4.0% wt / vol of limonene. In some embodiments, the composition comprises about 5.0% wt / vol of limonene. In some embodiments, the composition comprises about 6.0% wt / vol limonene. In some embodiments, the composition comprises about 7.0% wt / vol limonene. In some embodiments, the composition comprises about 8.0% wt / vol limonene. In some embodiments, the composition comprises about 9.0% wt / vol limonene. In some embodiments, the composition comprises about 10.0% wt / vol limonene. In some embodiments, the composition comprises about 11.0% wt / vol limonene.In some embodiments, the composition comprises about 12.0% wt / vol limonene. In some embodiments, the composition comprises about 13.0% wt / vol limonene. In some embodiments, the composition comprises about 14.0% wt / vol limonene. In some embodiments, the composition comprises about 15.0% wt / vol limonene.

[0116] In some embodiments, the composition comprises the following: between about 1.0-5.0% wt / vol sodium dodecyl sulfate; between about 0.5-1.0% wt / vol bupivacaine; between about 4.0-10.0% wt / vol limonene; and between about 12.0-15.0% wt / vol poloxamer 407-poly(butoxy)phosphoester.

[0117] In some embodiments, the composition comprises between about 0.5-5.0% wt / vol sodium dodecyl sulfate; between about 0.5-7.5% wt / vol bupivacaine; between about 0.5-3.5% wt / vol limonene; between about 9.0-15.0% wt / vol poloxamer 407-poly(butoxy)phosphoester; and between about 0.01-0.50% wt / vol of another therapeutic agent that is the sodium channel blocker anesthetic agent tetrodotoxin.

[0118] In some embodiments, the composition comprises: and (c) a matrix-forming agent or combination of matrix-forming agents (wherein the matrix-forming agent or combination of matrix-forming agents comprises a polymer); wherein: the composition forms at a temperature above a gel phase transition temperature; and the phase transition temperature is less than about 37° C.; wherein the composition comprises between about 0.5-5.5% wt / vol of a permeation enhancer that is sodium dodecyl sulfate; wherein the composition comprises between about 0.5-1.5% wt / vol of a permeation enhancer that is bupivacaine; wherein the composition comprises between about 2.0-12.0% wt / vol of a permeation enhancer that is limonene; and wherein the composition comprises between about 9.0-20.0% wt / vol of a polymer that is poloxamer 407-poly(butoxy)phosphoester.

[0119] In some embodiments, the composition comprises: (a) a therapeutic agent or combination of therapeutic agents (e.g., an antibiotic (e.g., ciprofloxacin)); (b) a permeation enhancer or combination of permeation enhancers (wherein the permeation enhancer or combination of permeation enhancers increases the flux of the therapeutic agent or combination of therapeutic agents across a barrier); and (c) a matrix forming agent or combination of matrix forming agents (wherein the matrix forming agent or combination of matrix forming agents comprises a polymer); wherein: the composition forms a gel at a temperature above the phase transition temperature; and the phase transition temperature is less than about 37° C.; wherein the composition comprises between about 1.0-5.25% wt / vol of a permeation enhancer that is sodium dodecyl sulfate; wherein the composition comprises between about 0.5-1.25% wt / vol of a permeation enhancer that is bupivacaine; wherein the composition comprises between about 1.5-11.5% wt / vol of a permeation enhancer that is limonene; and wherein the composition comprises between about 9.5-19.5% wt / vol of a polymer that is poloxamer 407-poly(butoxy)phosphoester.

[0120] In some embodiments, the composition comprises: (1) about 1.0% wt / vol sodium dodecyl sulfate; about 0.5% wt / vol bupivacaine; about 2.0% wt / vol limonene; and about 12.0% wt / vol poloxamer 407-poly(butoxy)phosphoester; (2) about 1.0% wt / vol sodium dodecyl sulfate; about 1.0% wt / vol bupivacaine; about 10.0% wt / vol limonene; and about 12.0% wt / vol poloxamer 407-poly(butoxy)phosphoester; (3) about 1.0% wt / vol sodium dodecyl sulfate; about 1.0% wt / vol bupivacaine; about 10.0% wt / vol limonene; and about 15.0% wt / vol poloxamer 407-poly(butoxy)phosphoester; (4) about 5.0% wt / vol sodium dodecyl sulfate; about 1.0% wt / vol bupivacaine; about 4.0% wt / vol limonene; and about 12.0% wt / vol poloxamer 407-poly(butoxy)phosphoester; or (5) about 5.0% wt / vol sodium dodecyl sulfate; about 1.0% wt / vol bupivacaine; about 4.0% wt / vol limonene; and about 15.0% wt / vol poloxamer 407-poly(butoxy)phosphoester. Includes any of the following.

[0121] In some embodiments, the composition comprises: (1) about 1.0% wt / vol sodium dodecyl sulfate; about 0.5% wt / vol bupivacaine; about 2.0% wt / vol limonene; and about 12.0% wt / vol poloxamer 407-poly(butoxy)phosphoester. In some embodiments, the composition comprises: (2) about 1.0% wt / vol sodium dodecyl sulfate; about 1.0% wt / vol bupivacaine; about 10.0% wt / vol limonene; and about 12.0% wt / vol poloxamer 407-poly(butoxy)phosphoester. In some embodiments, the composition comprises: (3) about 1.0% wt / vol sodium dodecyl sulfate; about 1.0% wt / vol bupivacaine; about 10.0% wt / vol limonene; and about 15.0% wt / vol poloxamer 407-poly(butoxy)phosphoester. In some embodiments, the composition comprises: (4) about 5.0% wt / vol sodium dodecyl sulfate; about 1.0% wt / vol bupivacaine; about 4.0% wt / vol limonene; and about 12.0% wt / vol poloxamer 407-poly(butoxy)phosphoester. In some embodiments, the composition comprises the following: (5) about 5.0% wt / vol sodium dodecyl sulfate; about 1.0% wt / vol bupivacaine; about 4.0% wt / vol limonene; and about 15.0% wt / vol poloxamer 407-poly(butoxy)phosphoester.

[0122] In some embodiments, the composition comprises the following: about 1.0% wt / vol sodium dodecyl sulfate; about 2.0% wt / vol bupivacaine; about 2.0% wt / vol limonene; about 12.0% wt / vol poloxamer 407-poly(butoxy)phosphoester; and about 0.03% wt / vol of another therapeutic agent, which is the sodium channel blocker anesthetic agent tetrodotoxin. In some embodiments, the composition comprises the following: about 1.0% wt / vol sodium dodecyl sulfate; about 2.0% wt / vol bupivacaine; about 2.0% wt / vol limonene; about 12.0% wt / vol poloxamer 407-poly(butoxy)phosphoester; and about 0.3% wt / vol of another therapeutic agent, which is the sodium channel blocker anesthetic agent tetrodotoxin.

[0123] Therapeutic Agents The therapeutic agent can be any agent used to treat any ear disease or symptoms of an ear disease or infectious disease (e.g., pain or infectious disease associated with an ear disease). The therapeutic agent can be an agent used to treat pain. The therapeutic agent may include an antimicrobial agent. The therapeutic agent may include, but is not limited to, antimicrobial agents, antibiotics, anesthetics, anti-inflammatory agents, analgesics, anti-fibrotic agents, anti-sclerotics, and anticoagulants. The therapeutic agent may include, but is not limited to, antibiotics, anesthetics, anti-inflammatory agents, analgesics, anti-fibrotic agents, anti-sclerotics, and anticoagulants. In some embodiments, the therapeutic agent is an antimicrobial agent. In some embodiments, the therapeutic agent is an antibiotic formulation. In some embodiments, the therapeutic agent is an anesthetic agent. In some embodiments, the therapeutic agent is an anti-inflammatory agent. In some embodiments, the therapeutic agent is an analgesic agent. In some embodiments, the therapeutic agent is an anti-fibrotic agent. In some embodiments, the therapeutic agent is an anti-sclerotic agent, hi some embodiments, the therapeutic agent is an anticoagulant agent.

[0124] In various aspects, the therapeutic agent may comprise between about 0.01 percent and about 10 percent of the composition. In various embodiments, the therapeutic agent may comprise between about 0.01 percent and about 1 percent of the composition, may comprise between about 1 percent and about 2 percent of the composition, may comprise between about 2 percent and about 3 percent of the composition, may comprise between about 3 percent and about 4 percent of the composition, may comprise between about 4 percent and about 5 percent of the composition, may comprise between about 5 percent and about 6 percent of the composition, may comprise between about 6 percent and about 7 percent of the composition, may comprise between about 7 percent and about 8 percent of the composition, may comprise between about 8 percent and about 9 percent of the composition, or may comprise between about 9 percent and about 10 percent of the composition.

[0125] In various aspects, the therapeutic agent may comprise between about 0.01 percent and about 10 percent wt / vol of the composition. In various aspects, the therapeutic agent may comprise between about 1.0 percent and about 7.0 percent wt / vol of the composition. In various aspects, the therapeutic agent may comprise between about 1.0 percent and about 6.0 percent wt / vol of the composition.

[0126] The exact amount required will vary from subject to subject, depending on the species, age, and general condition of the subject, the specific compound, its mode of administration, its mode of activity, the disease being treated, and the like. The compositions described herein are preferably formulated in unit dosage form for ease of administration and uniformity of dosage. However, it will be understood that the total daily usage of the compounds and compositions will be determined by the attending physician within the scope of sound medical judgment. The specific therapeutically effective dose level for any particular patient or organism will depend on a variety of factors, including the disorder being treated and the severity of the disorder; the activity of the specific compound employed; the specific composition employed; the age, weight, general health, sex, and diet of the patient; the time of administration, route of administration, and excretion rate of the specific compound employed; the duration of treatment; drugs used in combination with or concurrently with the specific compound employed; and the like factors well known in the medical art.

[0127] In some embodiments, the therapeutic agent is an antimicrobial agent. In some embodiments, the therapeutic agent is an antibiotic. Any antibiotic may be used in the system. In some embodiments, the antibiotic is approved for use in humans or other animals. In some embodiments, the antibiotic is approved for use by the U.S. Food and Drug Administration. In some embodiments, the antibiotic may be selected from the group consisting of cephalosporins, quinolones, polypeptides, macrolides, penicillins, and sulfonamides. Exemplary antibiotics include, but are not limited to, ciprofloxacin, cefuroxime, cefadroxil, cefazolin, cephalothin, cephalexin, cefaclor, cefamandole, cefoxitin, cefprozil, cefuroxime, cefixime, cefdinir, ceftidoren, cefoperazone, cefotaxime, cefpodoxime, ceftazidime, ceftibuten, ceftizoxime, ceftriaxone, cefepime, ceftobiprole, enoxacin, gatifloxacin, levofloxacin, lomefloxacin, moxifloxacin, norfloxacin, ofloxacin, trovafloxacin, bacitracin, coli In some embodiments, the medicaments may include sucrose, polymyxin B, azithromycin, clarithromycin, dirithromycin, erythromycin, roxithromycin, troleandomycin, telithromycin, spectinomycin, amoxicillin, ampicillin, azlocillin, carbenicillin, cloxacillin, dicloxacillin, flucloxacillin, mezlocillin, methicillin, nafcillin, oxacillin, penicillin, piperacillin, ticarcillin, mafenide, sulfacetamide, sulfamethizole, sulfasalazine, sulfisoxazole, trimethoprim, and trimethoprim-sulfamethoxazole.

[0128] In certain embodiments, the therapeutic agent is an antibiotic agent, an anesthetic agent, an anti-inflammatory agent, an analgesic agent, an anti-fibrotic agent, an anti-sclerotic agent, an anticoagulant agent, or a diagnostic agent.

[0129] In some embodiments, the antibiotic is a quinolone. In some embodiments, the antibiotic is a carbapenem. In some embodiments, the antibiotic is amoxicillin, azithromycin, cefuroxime, ceftriaxone, trimethoprim, levofloxacin, moxifloxacin, meropenem, or ciprofloxacin. In some embodiments, the antibiotic is ciprofloxacin. In some embodiments, the antibiotic is ciprofloxacin and its pharmaceutically acceptable salts. In some embodiments, the antibiotic is ciprofloxacin hydrochloride. In some embodiments, the antibiotic is levofloxacin.

[0130] Exemplary antibiotics include, but are not limited to, the following: abamectin, actinomycins (e.g., actinomycin A, actinomycin C, actinomycin D, Aurantin), alatrofloxacin mesylate, amikacin sulfate, aminosalicylic acid, anthracyclines (e.g., aclarubicin, adriamycin, doxorubicin, epirubicin, idarubicin), antimycins (e.g., antimycin A), avermectins, BAL 30072, bacitracin, bleomycin, cephalosporins (e.g., 7-aminocephalosporanic acid, 7-aminodeacetoxycephalosporanic acid, cefaclor, cefadroxil, cefamandole, cefazolin, cefepime, cefixime, cefmenoxime, cefmetazole, cefoperazone, cefotaxime, cefotetan, cefotiam, cefoxitin, cefpirome, cefpodoxime proxetil, cefsulodin, cefsulodin sodium , ceftazidime, ceftizoxime, ceftriaxone, cefuroxime, cephalexin, cephaloridine, cephalosporin C, cephalothin, cephalothin sodium, cephapirin, cephradine), ciprofloxacin, enrofloxacin, clarithromycin, clavulanic acid, clindamycin, colicin, cyclosporine (e.g., cyclosporine A), dalfopristin / quinupristin, daunorubicin, doxorubicin, epirubicin, GSK 1322322, geneticin, gentamicin, gentamicin sulfate, gramicidin (e.g., gramicidin A), grepafloxacin hydrochloride, ivermectin, kanamycin (e.g., kanamycin A), lasalocid, leucomycin, levofloxacin, linezolid, lomefloxacin, lovastatin, MK7655, meropenem, mevastatin, mithramycin, mitomycin, monomycin, natamycin, neocarzinostatin, neomycin (e.g., neomycin sulfate), nystatin, oligomycin, olivomycin, pefloxacin, penicillins (e.g., 6-aminopenicillanic acid, amoxicillin, amoxicillin-clavulanic acid, ampicillin, ampicillin sodium, azlocillin, carbenicillin, cefoxitin, cefoxitin, phalloridine, cloxacillin, dicloxacillin, mecillinam, methicillin, mezlocillin, nafcillin, oxacillin, penicillin G, penicillin G potassium, penicillin G procaine, penicillin G sodium, penicillin V, piperacillin, piperacillin-tazobactam, sulbactam, tazobactam, ticarcillin), phleomycin, polymyxins (e.g. colistin, polymyxin B), pyocins (e.g. pyocin R), RPX7009, rapamycin, ristocetin, salinomycin, sparfloxacin, spectinomycin, spiramycin, streptogramin, streptovaricin, tedizolid phosphate, teicoplanin, telithromycin, tetracyclines (e.g., achromycin V, demeclocycline, doxycycline, doxycycline monohydrate, minocycline, oxytetracycline, oxytetracycline hydrochloride, tetracycline, tetracycline hydrochloride), trichostatin A, trovafloxacin, tunicamycin, tyrocidine, valinomycin, (-)-florfenicol, acetylsulfisoxazole, actinonin, amikacin sulfate, ben These include zuethonium chloride, cetrimide, chererythrine, chlorhexidine (e.g., chlorhexidine gluconate), chlorhexidine acetate, chlorhexidine gluconate, chlorothalonil, cotrimoxazole, dichlorophen, didecyldimethylammonium chloride, dihydrostreptomycin, enoxacin, ethambutol, fleroxacin, furazolidone, methylisothiazolinone, monolaurin, oxolinic acid, povidone-iodine, spirochetalicides (e.g., arsphenamine, neoarsphenamine), sulfaquinoxaline, thiamphenicol, tinidazole, triclosan, trovafloxacin, antituberculous drugs (e.g., 4-aminosalicylic acid, AZD 5847, aminosalicylic acid, ethionamide), vidarabine, zinc pyrithione, and zirconium phosphate.

[0131] In certain embodiments, the therapeutic agent is a Food and Drug Administration (FDA) approved drug for treating an infectious disease or infectious disease. Exemplary FDA approved agents include, but are not limited to, the following: Avicaz (ceftazidime-avibactam), Cresemba (isavuconazonium sulfate), Evotaz (atazanavir and cobicistat, Prezcobix (daunavir and cobicistat), Dalvance (dalbavancin), Harvoni (ledipasvir and sovosbuvir), Influenza (influenza), and rivaroxaban (rivaroxaban). Impavido (miltefosine), Jublia (efinaconazole), Kerydin (tavaborole), metronidazole, Orbactiv (oritavancin), Rapivab (peramivir injection), Sivextro (tedizolid phosphate), Triumeq (abacavir, dolutegravir, and lamivudine), Viekira Pak (ombitasvir, paritaprevir, ritonavir, and dasabuvir), Xtoro (finafloxacin), Zerbaxa (ceftolozane plus tazobactam), Luzu (luconazole), Olysio (simeprevir), Sitavig (acyclovir), Sovaldi (sovosbuvir), Abthrax (raxibacumab), Afinitor (everolimus), Cystaran (cysteamine hydrochloride) ), Dymista (azelastine hydrochloride and fluticasone propionate), Fulyzaq (crofelemer), Jetrea (ocriplasmin), Linzess (linaclotide), Qnasl (beclomethasone dipropionate) nasal aerosol, Sirturo (bedaquiline), Sklice (ivermectin), Stribild (elvitegravir, cobicistat, emtricitabine, tenofovir disoproxil fumarate),Tudorza Pressair (aclidinium bromide inhalation powder), Complera (emtricitabine / rilpivirine / tenofovir disoproxil fumarate), Dificid (fidaxomicin), Edurant (rilpivirine), Eylea (aflibercept), Firazyr (icatibant), Gralise (gabapentin), Incivek (telaprevir), Victrelis (boceprevir), Egrifta (tesamorelin), Teflaro (ceftaroline fosamil), Zymaxid (gatifloxacin), Bepreve (bepotastine besylate), Vibativ (televancin), Aptivus (tipranavir), Astepro (azelastine hydrochloride) Nasal spray), Intelence (etravirine), Patanase (olopatadine hydrochloride), Viread (tenofovir disoproxil fumarate), Isentress (raltegravir), Selzentry (maraviroc), Veramyst (fluticasone furoate), Xyzal (levocetirizine dihydrochloride), Eraxis (anidulafungin), Noxafil (posaconazole), Prezista (da Unavir, Tyzeka (telbivudine), Veregen (kunecatechin), Baraclude (entecavir), Fuzeon (enfuvirtide), Lexiva (fosamprenavir calcium), Reyataz (atazanavir sulfate), Clarinex, Hepsera (adefovir dipivoxil), Pegasys (peginterferon alfa-2a), Sustiva, Vfend (voriconazole),Zelnorm (tegaserod maleate), Avelox (moxifloxacin hydrochloride), Cancidas, Invanz, Peg-Intron (peginterferon alpha-2b), Rebetol (ribavirin), Spectracef, Tavist (clemastine fumarate), Twinrix, Valcyte (Valganci) Clovir HCl), Xigris (drotrecogin alfa), ABREVA (docosanol), cefazolin, Kaletra, Lamisil (terbinafine hydrochloride), Lotrisone (clotrimazole / betamethasone dipropionate), Lotronex (alosetron HCL), Trizivir (abacavir sulfate, lamivudine, zidovudine AZT), Synercid, Synergist Synagis, Viroptic, Aldara (Imiquimod), Bactroban, Ceftin (Cefuroxime axetil), Combivir, Condylox (Podofilox), Famvir (Famciclovir), Floxin, Fortovase, INFERGEN (Interferon alfa-con- 1), Intron A (Interferon alpha-2b, recombinant), Mentax (Butenafine HCl), Norvir (Ritonavir), Omnicef, Rescriptor (Delavirdine Mesylate), Taxol, Timentin, Trovan, VIRACEPT (Nelfinavir Mesylate), Zerit (Stavudine), AK-Con-A (Naphazoline eye drops), Allegra (Fexofenadine hydrochloride), Astelin nasal spray,Atrovent (ipratropium bromide), Augmentin (amoxicillin / clavulanic acid), Crixivan (indinavir sulfate), Elmiron (pentosan polysulfate sodium), Havrix, Leukine (sargramostim), Merrem (meropenem), Nasacort AQ (triamcinolone acetonide), Tavist (clemastine fumarate), Vancenase AQ, Videx (didanosine), Viramune (nevirapine), Zithromax (azithromycin), Cedax (ceftibutein), Clavicepidemiol (ceftibutein), Rithromycin (Biaxin), Epivir (lamivudine), Invirase (saquinavir), Valtrex (valaciclovir HCl), Zyrtec (cetirizine HCl), Acyclovir, Penicillin (penicillin g potassium), Cubicin (daptomycin), Factive (gemifloxacin), Albenza (albendazole), Alinia (nitazoxanide), Altabax (retapamulin), AzaSite (azithromycin), Besivance (besifloxacin ophthalmic suspension), Biaxin XL (clarithromycin) Extended release), Cayston (aztreonam), Cleocin (clindamycin phosphate), Doribax (doripenem), Dynabac, Flagyl ER, Ketek (telithromycin), Moxatag (amoxicillin), Rapamune (sirolimus), Restasis (cyclosporine), Tindamax (tinidazole), Tygacil (tigecycline),and Xifaxan (rifaximin). In some embodiments, the antibiotic agent is selected from the group consisting of ciprofloxacin, cefuroxime, cefadroxil, cefazolin, cephalothin, cephalexin, cefaclor, cefamandole, cefoxitin, cefprozil, cefuroxime, cefixime, cefdinir, ceftidoren, cefoperazone, cefotaxime, cefpodoxime, ceftazidime, ceftibuten, ceftizoxime, ceftriaxone, cefepime, ceftobiprole, enoxacin, gatifloxacin, levofloxacin, merofloxacin, moxifloxacin, norfloxacin, ofloxacin, trovafloxacin, bacitracin, colistin, , polymyxin B, azithromycin, clarithromycin, dirithromycin, erythromycin, roxithromycin, troleandomycin, telithromycin, spectinomycin, amoxicillin, ampicillin, azlocillin, carbenicillin, cloxacillin, dicloxacillin, flucloxacillin, mezlocillin, methicillin, nafcillin, oxacillin, penicillin, piperacillin, ticarcillin, mafenide, sulfacetamide, sulfamethizole, sulfasalazine, sulfisoxazole, trimethoprim, and trimethoprim-sulfamethoxazole. In some embodiments, the antibiotic agent is ciprofloxacin. In some embodiments, the composition comprises between about 1.0-5.0% wt / vol ciprofloxacin.

[0132] In some embodiments, the therapeutic agent is an anesthetic. Any anesthetic may be used in the system. In some embodiments, the anesthetic is approved for use in humans or other animals. In some embodiments, the anesthetic is approved for use by the U.S. Food and Drug Administration. Exemplary anesthetics may include, but are not limited to, bupivacaine, tetracaine, procaine, proparacaine, propoxycaine, dimethocaine, cyclomethycaine, chloroprocaine, benzocaine, lidocaine, prilocaine, levobupivacaine, ropivacaine, dibucaine, articaine, carticaine, etidocaine, mepivacaine, piperocaine, and trimecaine. In some embodiments, the anesthetic is bupivacaine. In certain embodiments, the anesthetic agent is selected from the group consisting of bupivacaine, tetracaine, procaine, proparacaine, propoxycaine, dimethocaine, cyclomethycaine, chloroprocaine, benzocaine, lidocaine, prilocaine, levobupivacaine, ropivacaine, dibucaine, articaine, carticaine, etidocaine, mepivacaine, piperocaine, and trimecaine.

[0133] In some embodiments, the therapeutic agent is an anesthetic. In some embodiments, the therapeutic agent is a local anesthetic. In some embodiments, the therapeutic agent is a sodium channel blocker anesthetic. In some embodiments, the therapeutic agent is a site 1 sodium channel blocker anesthetic. In some embodiments, the therapeutic agent is a potent site 1 sodium channel blocker anesthetic. In some embodiments, the sodium channel blocker anesthetic is tetrodotoxin. In some embodiments, the sodium channel blocker anesthetic is saxitoxin (e.g., a member of the saxitoxin family, an analog of saxitoxin). In some embodiments, the sodium channel blocker anesthetic is saxitoxin. In some embodiments, the sodium channel blocker anesthetic is neosaxitoxin. In some embodiments, the sodium channel blocker anesthetic is goniotoxin. In some embodiments, the sodium channel blocker anesthetic is a conotoxin (e.g., μ-conotoxin). In some embodiments, the sodium channel blocker anesthetic is tetrodotoxin, saxitoxin, or a conotoxin. In some embodiments, the sodium channel blocker anesthetic is tetrodotoxin, saxitoxin, or neosaxitoxin. In some embodiments, the therapeutic agent includes bupivacaine and a sodium channel blocker anesthetic. In some embodiments, the therapeutic agent includes bupivacaine and a sodium channel blocker anesthetic that is tetrodotoxin. In some embodiments, the therapeutic agent is a combination of anesthetics and does not include an antibiotic. In some embodiments, the therapeutic agent includes bupivacaine and a sodium channel blocker anesthetic that is tetrodotoxin and does not include ciprofloxacin. In some embodiments, the first therapeutic agent is a local anesthetic. In some embodiments, the first therapeutic agent is an amino-amide local anesthetic (e.g., bupivacaine, lidocaine, mepivacaine, etidocaine). In some embodiments, the first therapeutic agent is an amino-ester local anesthetic (e.g., tetracaine, prilocaine, procaine, chloroprocaine, benzocaine).

[0134] In some embodiments, the composition includes between about 0.01-0.50% wt / vol of a second therapeutic agent that is a local anesthetic. In some embodiments, the composition includes between about 0.01-0.50% wt / vol of a therapeutic agent that is a sodium channel blocker anesthetic. In some embodiments, the composition includes between about 0.01-0.50% wt / vol of a therapeutic agent that is a site 1 sodium channel blocker anesthetic. In some embodiments, the composition includes between about 0.01-0.50% wt / vol of a therapeutic agent that is a sodium channel blocker anesthetic tetrodotoxin. In some embodiments, the composition includes between about 0.01-0.50% wt / vol of a therapeutic agent that is a site 1 sodium channel blocker anesthetic. In some embodiments, the composition includes between about 0.2-0.50% wt / vol of a therapeutic agent that is a sodium channel blocker anesthetic tetodotoxin. In some embodiments, the composition comprises between about 0.1-0.50% wt / vol of a therapeutic agent that is a sodium channel blocker anesthetic agent tetrodotoxin. In some embodiments, the composition comprises between about 0.01-0.50% wt / vol, between about 0.03-0.50% wt / vol, between about 0.03-0.30% wt / vol, between about 0.1-0.50% wt / vol, between about 0.2-0.50% wt / vol, between about 0.1-0.45% wt / vol, between about 0.2-0.45% wt / vol, between about 0.25-0.50% wt / vol, between about 0.25-0.45% wt / vol, or between about 0.25-0.45% wt / vol of a therapeutic agent that is a sodium channel blocker anesthetic agent. In certain embodiments, the composition comprises between about 0.01-0.50% wt / vol, between about 0.03-0.50% wt / vol, between about 0.03-0.30% wt / vol, between about 0.1-0.50% wt / vol, between about 0.2-0.50% wt / vol, between about 0.1-0.45% wt / vol, between about 0.2-0.45% wt / vol, between about 0.25-0.50% wt / vol, between about 0.25-0.45% wt / vol, or between about 0.25-0.45% wt / vol of a Therapeutic Agent that is a Site 1 sodium channel blocker anesthetic agent.In some embodiments, the composition comprises between about 0.01-0.50% wt / vol, between about 0.03-0.50% wt / vol, between about 0.03-0.30% wt / vol, between about 0.2-0.50% wt / vol, between about 0.25-0.50% wt / vol, between about 0.25-0.45% wt / vol, or between about 0.25-0.45% wt / vol of a therapeutic agent that is a sodium channel blocker anesthetic agent, tetrodotoxin. In some embodiments, the composition comprises between about 0.03-0.30% wt / vol of a therapeutic agent that is a sodium channel blocker anesthetic agent. In some embodiments, the composition comprises about 0.03% wt / vol of a sodium channel blocker anesthetic agent. In some embodiments, the composition comprises about 0.3% wt / vol of a sodium channel blocker anesthetic agent. In some embodiments, the composition comprises between about 0.03-0.30% wt / vol of a therapeutic agent that is a sodium channel blocker anesthetic agent tetrodotoxin. In some embodiments, the composition comprises about 0.03% wt / vol of tetrodotoxin. In some embodiments, the composition comprises about 0.3% wt / vol of tetrodotoxin.

[0135] In some embodiments, the therapeutic agent is an anti-inflammatory agent. The anti-inflammatory agent may be a non-steroidal anti-inflammatory agent or a steroidal anti-inflammatory agent. In some embodiments, the therapeutic agent is a steroidal anti-inflammatory agent. In some embodiments, the therapeutic agent is a steroid. Exemplary anti-inflammatory agents include, but are not limited to, acetylsalicylic acid, aloxyprine, benorylate / benorilate, choline magnesium trisalicylate, diflunisal, ethenzamide, faislamine, methyl salicylate, magnesium salicylate, salicylic acid salicylate, salicylamide, diclofenac, aceclofenac, acemetacin, alclofenac, bromfenac, etodolac, indomethacin, nabumetone, oxamethacin, proglumetacin, sulindac, tolmetin, ibroprofen, alminoprofen, benoxaprofen, carprofen, dexibuprofen, dexketoprofen, fenbufen, fenoprofen, flunoxaprofen, flurbiprofen, ibuprofen, In some embodiments, the active ingredient may be sam, indoprofen, ketoprofen, ketorolac, loxoprofen, naproxen, oxaprozin, pirprofen, suprofen, tiaprofenic acid, mefenamic acid, flufenamic acid, meclofenamic acid, tolfenamic acid, phenylbutazone, ampirone, azapropazone, clofezone, kebuzone, metamizole, mofebutazone, oxyphenbutazone, phenazone, phenylbutazone, sulfinpyrazone, piroxicam, droxicam, lornoxicam, meloxicam, tenoxicam, hydrocortisone, cortisone acetate, prednisone, prednisolone, methylprednisolone, dexamethasone, betamethasone, triamcinolone, beclomethasone, fludrocortisone acetate, deoxycorticosterone acetate, and aldosterone.In some embodiments, the anti-inflammatory agent is acetylsalicylic acid, aloxyprine, benorylate, choline magnesium trisalicylate, diflunisal, ethenzamide, physuramine, methyl salicylate, magnesium salicylate, salicylic acid salicylate, salicylamide, diclofenac, aceclofenac, acemetacin, alclofenac, bromfenac, etodolac, indomethacin, nabumetone, oxamethacin, proglumetacin, sulindac, tolmetin, ibroprofen, alminoprofen, benoxaprofen, carprofen, dexibuprofen, dexketoprofen, fenbufen, fenoprofen, flunoxaprofen, flurbiprofen, ibuproxam, indoprofen, keto ... Selected from the group consisting of trolac, loxoprofen, naproxen, oxaprozin, pirprofen, suprofen, tiaprofenic acid, mefenamic acid, flufenamic acid, meclofenamic acid, tolfenamic acid, phenylbutazone, ampirone, azapropazone, clofezone, kebuzone, metamizole, mofebutazone, oxyphenbutazone, phenazone, phenylbutazone, sulfinpyrazone, piroxicam, droxicam, lornoxicam, meloxicam, tenoxicam, hydrocortisone, cortisone acetate, prednisone, prednisolone, methylprednisolone, dexamethasone, betamethasone, triamcinolone, beclomethasone, fludrocortisone acetate, deoxycorticosterone acetate, and aldosterone.

[0136] In various embodiments, combinations of various permeation enhancers and therapeutic agents have been observed to be synergistic and have enhanced efficacy. In various aspects, such combinations may include, but are not limited to, ciprofloxacin and limonene. In various aspects, such combinations may include, but are not limited to, ciprofloxacin and sodium dodecyl sulfate. In various aspects, such combinations may include, but are not limited to, sodium dodecyl sulfate, limonene, bupivacaine, and ciprofloxacin. In various aspects, such combinations may include, but are not limited to, sodium dodecyl sulfate, limonene, and ciprofloxacin.

[0137] In another aspect, provided herein is a pharmaceutical composition comprising at least one of the compositions as described herein, and optionally a pharma- ceutical acceptable excipient. In some embodiments, the pharmaceutical composition comprises a combination of therapeutic agents. In some embodiments, the pharmaceutical composition comprises an antibiotic and an additional therapeutic agent. In some embodiments, the pharmaceutical composition comprises an antibiotic agent and an anti-inflammatory agent. In other embodiments, the pharmaceutical composition comprises an antibiotic agent and an anesthetic agent. In some embodiments, the pharmaceutical composition comprises more than one antibiotic agent. In some embodiments, the pharmaceutical composition comprises a therapeutically effective amount of the composition for use in treating a disease in a subject in need thereof.

[0138] In some embodiments, the additional therapeutic agent is an anti-inflammatory agent (e.g., a steroid). In some embodiments, the first therapeutic agent is an antibiotic and the additional therapeutic agent is an anti-inflammatory agent. In some embodiments, the first therapeutic agent is an antibiotic and the additional therapeutic agent is a steroid. Steroids include, but are not limited to, cortisol, cortisone hydroacetate, cortisone acetate, tixocortol pivalate, prednisolone, methylprednisolone, prednisone, triamcinolone acetonide, triamcinolone alcohol, mometasone, amcinonide, budesonide, desonide, fluocinonide, fluocinolone acetonide, halcinonide, betamethasone, betamethasone sodium phosphate, dexamethasone, dexamethasone sodium phosphate, fluocortol ... Anti-inflammatory agents include 17-hydroxycortisone, 17-hydrocortisone valerate, halometasone, alclometasone dipropionate, betamethasone valerate, betamethasone dipropionate, prednicarbate, clobetasone 17-butyrate, clobetasol 17-propionate, fluocortolone caproate, fluocortolone pivalate, fluprednidene acetate, hydrocortisone 17-butyrate, hydrocortisone 17-aceponate, hydrocortisone 17-buteprate, ciclesonide, and prednicarbate. In some embodiments, the additional anti-inflammatory agent is dexamethasone.

[0139] In some embodiments, the additional therapeutic agent is a β-lactamase inhibitor. In some embodiments, the first therapeutic agent is an antibiotic (e.g., a β-lactam) and the additional therapeutic agent is a β-lactamase inhibitor. β-lactamase inhibitors include, but are not limited to, avibactam, clavulanic acid, tazobactam, and sulbactam. β-lactamase inhibitors may be particularly useful in compositions that include a β-lactam antibiotic. β-lactamase inhibitors may increase the efficacy of the β-lactam antibiotic or allow the β-lactam antibiotic to be present in the composition at a lower concentration than in a composition that does not contain a β-lactamase inhibitor.

[0140] In some embodiments, the additional therapeutic agent is an anesthetic agent. In some embodiments, the additional therapeutic agent is bupivacaine.

[0141] Furthermore, after formulation in a desired dosage with an appropriate pharma- ceutically acceptable carrier, the pharmaceutical compositions can be administered to humans and other animals.

[0142] Dosage forms include, but are not limited to, pharma- ceutically acceptable emulsions, microemulsions, solutions, suspensions, syrups, and elixirs.In addition to the active compound, liquid dosage forms may contain inert diluents commonly used in the art, such as water or other solvents, solubilizers and emulsifiers, such as ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1,3-butylene glycol, dimethylformamide, oils (especially cottonseed oil, peanut oil, corn oil, germ oil, olive oil, castor oil, and sesame oil), glycerol, tetrahydrofurfuryl alcohol, polyethylene glycol, and fatty acid esters of sorbitan, and mixtures thereof.Besides inert diluents, compositions may also contain adjuvants, such as wetting agents, emulsifying and suspending agents, and flavoring agents. In some embodiments, the composition includes a solubilizing agent such as Cremophor, alcohol, oil, modified oil, glycol, polysorbate, cyclodextrin, polymer, and combinations thereof.

[0143] It will also be understood that the compositions described herein can be employed in combination therapy, i.e., the compounds and pharmaceutical compositions can be administered simultaneously, prior to, or subsequent to one or more other desired therapies or medical procedures. The specific combination of therapies (therapies or procedures) employed in a combination regimen will take into account the compatibility of the desired therapies and / or procedures with the desired therapeutic effect to be achieved. It will also be understood that the therapies employed may achieve a desired effect on the same disorder (e.g., the compounds or compositions disclosed herein may be administered simultaneously with another anti-cancer agent), or they may achieve different effects (e.g., the control of either adverse effect).

[0144] In some embodiments, the composition comprises a diagnostic agent. In some embodiments, the diagnostic agent is an X-ray contrast agent. In some embodiments, the diagnostic agent comprises a radioisotope. In some embodiments, the diagnostic agent is a dye.

[0145] Other Additives In some embodiments, the composition includes one or more additional additives. For example, the additional additives may be a diluent, binder, preservative, buffer, lubricant, fragrance, preservative, or oil.

[0146] Exemplary diluents include calcium carbonate, sodium carbonate, calcium phosphate, dicalcium phosphate, calcium sulfate, calcium hydrogen phosphate, sodium phosphate, lactose, sucrose, cellulose, microcrystalline cellulose, kaolin, mannitol, sorbitol, inositol, sodium chloride, dry starch, corn starch, powdered sugar, and mixtures thereof.

[0147] Exemplary binders include starches (e.g., corn starch and starch paste), gelatin, sugars (e.g., sucrose, glucose, dextrose, dextrin, molasses, lactose, lactitol, mannitol, and the like), natural and synthetic gums (e.g., acacia, sodium alginate, extract of Irish moss, panwar gum, ghatti gum, isapol husk mucilage, carboxymethylcellulose, methylcellulose, ethylcellulose, hydroxyethylcellulose, hydroxypropylcellulose, hydroxypropylmethylcellulose, microcrystalline cellulose, cellulose acetate, poly(vinylpyrrolidone), magnesium aluminum silicate (Veegum®), and larch arabogalactan), alginates, polyethylene oxide, polyethylene glycol, inorganic calcium salts, silicic acid, polymethacrylates, waxes, water, alcohol, and / or mixtures thereof.

[0148] Exemplary preservatives include antioxidants, chelating agents, antimicrobial preservatives, antifungal preservatives, antiprotozoan preservatives, alcohol preservatives, acid preservatives, and other preservatives. In some embodiments, the preservative is an antioxidant. In other embodiments, the preservative is a chelating agent. In some embodiments, the preservative is benzalkonium chloride.

[0149] Exemplary antioxidants include alpha tocopherol, ascorbic acid, ascorbyl palmitate, butylated hydroxyanisole, butylated hydroxytoluene, monothioglycerol, potassium metabisulfite, propionic acid, propyl gallate, sodium ascorbate, sodium bisulfite, sodium metabisulfite, and sodium sulfite.

[0150] Exemplary antifungal preservatives include butylparaben, methylparaben, ethylparaben, propylparaben, benzoic acid, hydroxybenzoic acid, potassium benzoate, potassium sorbate, sodium benzoate, sodium propionate, and sorbic acid.

[0151] Exemplary alcohol preservatives include ethanol, polyethylene glycol, phenol, phenolic compounds, bisphenol, chlorobutanol, hydroxybenzoate, and phenylethyl alcohol.

[0152] Exemplary acid preservatives include vitamin A, vitamin C, vitamin E, beta carotene, citric acid, acetic acid, dehydroacetic acid, ascorbic acid, sorbic acid, and phytic acid.

[0153] Other preservatives include tocopherol, tocopherol acetate, deteroxime mesylate, cetrimide, butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), ethylenediamine, sodium lauryl sulfate (SLS), sodium lauryl ether sulfate (SLES), sodium bisulfite, sodium metabisulfite, potassium sulfite, potassium metabisulfite, Glydant® Plus, Phenonip®, methylparaben, Germall® 115, Germaben® II, Neolone®, Kathon®, and Euxyl®.

[0154] Exemplary buffers include citrate buffer, acetate buffer, phosphate buffer, ammonium chloride, calcium carbonate, calcium chloride, calcium citrate, calcium glubionate, calcium gluceptate, calcium gluconate, D-gluconic acid, calcium glycerophosphate, calcium lactate, propanoic acid, calcium levulinate, pentanoic acid, dibasic calcium phosphate, phosphoric acid, tribasic calcium phosphate, calcium hydroxide phosphate, potassium acetate, potassium chloride, potassium gluconate, potassium mixtures, dibasic potassium phosphate, monobasic potassium phosphate, potassium phosphate mixtures, sodium acetate, sodium bicarbonate, sodium chloride, sodium citrate, sodium lactate, dibasic sodium phosphate, monobasic sodium phosphate, sodium phosphate mixtures, tromethamine, magnesium hydroxide, aluminum hydroxide, alginic acid, pyrogen-free water, isotonic saline, Ringer's solution, ethyl alcohol, and mixtures thereof.

[0155] Exemplary lubricants include magnesium stearate, calcium stearate, stearic acid, silica, talc, malt, glyceryl behenate, hydrogenated vegetable oils, polyethylene glycol, sodium benzoate, sodium acetate, sodium chloride, leucine, magnesium lauryl sulfate, sodium lauryl sulfate, and mixtures thereof.

[0156] Exemplary natural oils include almond, apricot kernel, avocado, babassu, bergamot, black current seed, borage, cade, chamomile, canola, caraway, carnauba, castor oil, cinnamon, cocoa butter, coconut, cod liver, coffee, corn, cottonseed, emu, eucalyptus, evening primrose, fish, linseed, geraniol, loofah, grape seed, hazelnut, hyssop, isopropyl myristate, jojoba, kukui nut, lavandin, lavender, lemon. Exemplary synthetic oils include, but are not limited to, butyl stearate, caprylic triglyceride, capric triglyceride, cyclomethicone, diethyl sebacate, dimethicone 360, isopropyl myristate, mineral oil, octyldodecanol, oleyl alcohol, silicone oil, and mixtures thereof.

[0157] In addition to the active ingredient, the liquid dosage forms may contain inert diluents commonly used in the art, such as, for example, water or other solvents, solubilizers and emulsifiers, such as ethyl alcohol, isopropyl alcohol, ethyl acetate carbonate, benzyl alcohol, benzyl benzoate, propylene glycol, 1,3-butylene glycol, dimethylformamide, oils (e.g., cottonseed oil, peanut oil, corn oil, germ oil, olive oil, castor oil, and sesame oil), glycerol, tetrahydrofurfuryl alcohol, polyethylene glycol, and fatty acid esters of sorbitan, and mixtures thereof.

[0158] The compositions may contain water or other solvents, solubilizers and emulsifiers such as ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1,3-butylene glycol, dimethylformamide, oils (e.g., cottonseed oil, peanut oil, corn oil, germ oil, olive oil, castor oil, and sesame oil), glycerol, tetrahydrofurfuryl alcohol, polyethylene glycol, and fatty acid esters of sorbitan, and mixtures thereof.

[0159] Formulations suitable for administration (e.g., to the ear canal) include, but are not limited to, liquid and / or semi-liquid preparations such as liniments, lotions, oil-in-water and / or water-in-oil emulsions such as creams, ointments, and / or pastes, and / or solutions and / or suspensions. Topically administrable formulations may contain, for example, from about 1% to about 10% (w / w) of therapeutic agent, although the concentration of the therapeutic agent is increased up to the solubility limit of the active ingredient in the solvent. Formulations for topical administration may further include one or more additional ingredients as described herein.

[0160] Treatment Methods and Uses Provided herein are methods of the compositions described herein for treating a disease or condition in a subject in need thereof. In some embodiments, the compositions described herein are used to treat pain (e.g., to treat persistent pain). In some embodiments, the compositions described herein are used to treat pain associated with an infectious disease (e.g., to treat persistent pain). In some embodiments, the compositions described herein are used to treat pain associated with an ear disease or bacterial infection (e.g., to treat persistent pain). In some embodiments, the compositions described herein are used to treat persistent pain. In some embodiments, the compositions described herein are used to treat persistent pain for pain associated with an infectious disease, an ear disease, or a bacterial infection.

[0161] The methods of using the compositions described herein in various embodiments are generally directed to methods of treating infectious diseases, ear diseases, and / or diseases associated with infectious diseases and / or ear diseases (e.g., treatment of pain, treatment of persistent pain). In some embodiments, the compositions described herein are used in methods of treating pain. In some embodiments, the compositions described herein are used in methods of treating infectious diseases. In some embodiments, the matrix forming agents described herein are used in methods of treating infectious diseases. In some embodiments, the compositions described herein are used in methods of treating ear diseases. In some embodiments, the compositions described herein are used in methods of treating infectious ear diseases. The methods of using the compositions described herein in various embodiments are generally directed to methods of treating infectious diseases. In various aspects, the compositions may be used to deliver therapeutic or diagnostic agents across the tympanic membrane. Thus, the compositions are specifically useful for treating diseases and / or diseases of the middle and / or inner ear. In some embodiments, the compositions described herein are used in methods of treating diseases and / or diseases of the middle ear. In some embodiments, the compositions described herein are used in methods of treating diseases and / or diseases of the inner ear.

[0162] In some embodiments, the subject described herein is a human. In some embodiments, the subject is a non-human animal. In some embodiments, the subject is a mammal. In some embodiments, the subject is a non-human mammal. In some embodiments, the subject is a domesticated animal, such as a dog, cat, cow, pig, horse, sheep, or goat. In some embodiments, the subject is a companion animal, such as a dog or cat. In some embodiments, the subject is a livestock animal, such as a cow, pig, horse, sheep, or goat. In some embodiments, the subject is a zoo animal. In other embodiments, the subject is a research animal, such as a rodent (e.g., mouse, rat), dog, pig, or a non-human primate animal.

[0163] In various aspects, the compositions described herein may be used to treat ear diseases, including but not limited to ear infection, development of fibroids in the middle ear, or otosclerosis. In some embodiments, the matrix forming agents described herein may be used to treat ear diseases, including but not limited to ear infection, development of fibroids in the middle ear, or otosclerosis. In various other aspects, the compositions described herein may be used to treat vertigo, Meniere's disease, mastoiditis, cholesteatoma, labyrinthitis, perilymphatic fistula, superior canal dehiscence syndrome, otorrhea, ear pain, tinnitus, barotrauma, ear cancer, autoimmune inner ear disease, acoustic neuroma, benign paroxysmal positional vertigo, herpes zoster oticus, purulent labyrinthitis, vestibular neuritis, tympanic membrane perforation, or tympanocytitis. In various other aspects, the compositions described herein may be used to treat vertigo, Meniere's disease, mastoiditis, cholesteatoma, labyrinthitis, perilymphatic fistula, superior semicircular canal dehiscence syndrome, otorrhea, ear pain, tinnitus, barotrauma, cancer of the ear, autoimmune inner ear disease, acoustic neuroma, benign paroxysmal positional vertigo, herpes zoster oticus, suppurative labyrinthitis, vestibular neuritis, tympanic membrane perforation, or tympanocystitis. In some embodiments, the matrix-forming agents described herein may be used to treat vertigo, Meniere's disease, mastoiditis, cholesteatoma, labyrinthitis, perilymphatic fistula, superior semicircular canal dehiscence syndrome, otorrhea, ear pain, tinnitus, barotrauma, cancer of the ear, autoimmune inner ear disease, acoustic neuroma, benign paroxysmal positional vertigo, herpes zoster oticus, suppurative labyrinthitis, vestibular neuritis, tympanic membrane perforation, or tympanocystitis. In some embodiments, the methods disclosed herein are used to treat otitis media (OM). The various forms of OM that may be treated by the methods disclosed herein may be differentiated by the presence of fluid (exudate) and / or by the duration or persistence of inflammation. In some embodiments, the infectious disease is acute otitis media, chronic otitis media, or otitis media with effusion. The exudate, if present, may be of any consistency, from watery (serous) to viscid and mucous-like (mucoid) to purulent (suppurative); the duration is classified as acute, subacute, or chronic.OM with effusion (OME) refers to inflammation with middle ear fluid (MEF) but without any indication of acute infection. Acute OM (AOM) is characterized by the rapid onset of signs and symptoms associated with acute infection of the middle ear (e.g., ear pain, fever), with or without effusion. In some embodiments, the method is used to treat otitis media associated with infection by any of a number of pathogenic bacteria, including, for example, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.

[0164] The infectious disease may be a bacterial infection. In some embodiments, the bacterial infection is a Streptococcus, Haemophilus, or Moraxella infection. In some embodiments, the bacterial infection is a Staphylococcus, Escherichia, or Bacillus infection. In some embodiments, the bacterial infection is an H. influenzae infection. In some embodiments, the bacterial infection is an S. pneumoniae infection. In some embodiments, the bacterial infection is an M. catarrhalis infection. In some embodiments, the infectious disease is an ear infection. In some embodiments, the infectious disease is otitis media.

[0165] In various embodiments, administering the compositions described herein comprises applying the composition into the ear canal of the subject. In some embodiments, applying the composition into the ear canal of the subject comprises spraying the composition into the ear canal of the subject. In some embodiments, administering the compositions described herein comprises applying the composition into the inner ear of the subject. In some embodiments, administering the compositions described herein comprises applying the composition into the middle ear of the subject. In some embodiments, administering the compositions described herein comprises applying the composition into the inner ear, sinus, eye, vagina, or skin of the subject. In some embodiments, administering the compositions described herein comprises applying the composition into the sinus of the subject. In some embodiments, administering the compositions described herein comprises applying the composition into the eye of the subject. In some embodiments, administering the compositions described herein comprises applying the composition into the vagina of the subject. In some embodiments, administering the compositions described herein comprises applying the composition to the skin of the subject. The subject for treatment can be any mammal in need of treatment. In various aspects, the composition is in direct contact with the tympanic membrane for about 1 day to about 30 days. In various aspects, the composition contacts the tympanic membrane for about 1 day to about 3 days, about 3 days to about 7 days, about 7 days to about 14 days, about 14 days to about 21 days, or about 21 days to about 30 days. In various embodiments, the composition forms a sustained release reservoir and contacts the tympanic membrane. In various aspects, the composition is applied as a liquid into the ear canal, and the composition gels in situ on the surface of the tympanic membrane. Upon contact with the tympanic membrane, the therapeutic agent permeates the tympanic membrane and is delivered to the middle ear. In various embodiments, delivery across the tympanic membrane is a sustained release of the therapeutic agent over a period of days. The number of days that the tympanic membrane may be in contact may be, but is not limited to, 5 days, 7 days, 10 days, 14 days, 21 days, or 30 days. The composition may be applied once or repeatedly during the course of treatment. In various aspects, the composition may be administered periodically, from about every day to about every 7 days, from about every day to about every 14 days, or from about every day to about every 30 days. In various embodiments, the composition is naturally extruded from the subject at the end of treatment through a natural process similar to earwax extrusion.In some embodiments, the composition may naturally degrade, and the degradation products may be excreted by the subject. In various embodiments, the administration of the compositions described herein includes adding a matrix-forming agent, a permeation enhancer, and a therapeutic agent into the ear canal; then adding a second therapeutic agent into the ear canal; and mixing the matrix-forming agent, the permeation enhancer, and the therapeutic agent on the ear canal. In some embodiments, the second therapeutic agent is an anesthetic. In some embodiments, the second therapeutic agent is a local anesthetic.

[0166] In various embodiments, administering the compositions described herein includes placing a matrix-forming agent into the ear canal; placing a permeation enhancer into the ear canal; placing a therapeutic agent into the ear canal; and mixing the matrix-forming agent, permeation enhancer, and therapeutic agent on the ear canal. In various embodiments, administering the compositions described herein includes placing a matrix-forming agent into the ear canal; placing a permeation enhancer into the ear canal; placing a therapeutic agent into the ear canal; placing an additional therapeutic agent into the ear canal; and mixing the matrix-forming agent, permeation enhancer, and therapeutic agent on the ear canal. In some embodiments, placing a therapeutic agent and a permeation enhancer into the ear canal includes spraying a therapeutic agent and a permeation enhancer into the ear canal.

[0167] In various embodiments, administering the compositions described herein includes placing a therapeutic agent into the ear canal; placing a permeation enhancer into the ear canal; placing a matrix-forming agent into the ear canal; and mixing the matrix-forming agent, the permeation enhancer, and the therapeutic agent on the ear canal. In various embodiments, administering the compositions described herein includes placing a therapeutic agent into the ear canal; placing an additional therapeutic agent into the ear canal; placing a permeation enhancer into the ear canal; placing a matrix-forming agent into the ear canal; and mixing the matrix-forming agent, the permeation enhancer, and the therapeutic agent on the ear canal. In some embodiments, placing a therapeutic agent and placing a permeation enhancer into the ear canal includes spraying the therapeutic agent and spraying the permeation enhancer into the ear canal. In some embodiments, the therapeutic agent is an antibiotic or an anesthetic. In some embodiments, the therapeutic agent is an antibiotic. In some embodiments, the therapeutic agent is an anesthetic. In some embodiments, the permeation enhancer is bupivacaine.

[0168] In various embodiments, administering the compositions described herein includes placing a composition including one or more therapeutic agents, one or more permeation enhancers, and one or more matrix forming agents into the ear canal; and subsequently placing a composition into the ear canal that is free of a therapeutic agent or that includes one or more therapeutic agents, free of a permeation enhancer or that includes one or more permeation enhancers, and free of a matrix forming agent or that includes one or more matrix forming agents. In some embodiments, the subsequent addition of the one or more therapeutic agents includes the same therapeutic agent as the first addition of the one or more therapeutic agents. In some embodiments, the subsequent addition of the one or more therapeutic agents includes a different therapeutic agent than the first addition of the one or more therapeutic agents. In some embodiments, the subsequent addition of the permeation enhancer includes the same permeation enhancer as the first addition of the permeation enhancer. In some embodiments, the subsequent addition of the permeation enhancer includes a different permeation enhancer than the first addition of the permeation enhancer. In some embodiments, the subsequent addition of the matrix forming agent includes the same matrix forming agent as the first addition of the matrix forming agent. In some embodiments, the subsequent addition of matrix-forming agent contains a different matrix-forming agent than the first addition of matrix-forming agent. In some embodiments, the time interval between the first composition and the second composition is about 1 minute. In some embodiments, the time interval between the first composition and the second composition is less than 1 minute. In some embodiments, the time interval between the first composition and the second composition is more than 1 minute.

[0169] In certain embodiments, the dose is determined based on the minimum inhibitory concentration required at the site of infection. Without being bound to a particular theory, in various aspects, the minimum inhibitory concentration for H. influenzae or S. pneumoniae middle ear infections is about 4 μg / mL of ciprofloxacin. In various aspects, a typical dose would require approximately 12 μg of ciprofloxacin based on an average middle ear volume of 3 mL. In various embodiments, the composition would include a dose sufficient to deliver 12 μg of ciprofloxacin to the middle ear.

[0170] Without being bound by a particular theory, in various aspects, the minimum dosage concentration required to treat pain associated with a middle ear infection with H. influenzae or S. pneumoniae is about 0.36 μg / mL of bupivacaine and / or about 0.32 μg / mL of tetrodotoxin. In various aspects, the minimum dosage concentration at which treatment of pain associated with a middle ear infection with H. influenzae or S. pneumoniae is achieved (e.g., on the middle ear side during a penetration experiment using an incised tympanic membrane or in the middle ear) is about 8 μg / mL (about 25 μM) of bupivacaine and / or about 0.3 ng / mL (about 1 nM) of tetrodotoxin.

[0171] In various aspects, administering the composition comprises a single application. In other aspects, administering the composition comprises multiple applications. For example, the composition may be administered two, three, four, or more times. In some embodiments, the composition is administered repeatedly until a desired clinical outcome is achieved (e.g., the infection is resolved). In some embodiments, administering the composition comprises administering a first composition, followed by administering a second composition after a period of time. In some embodiments, the period between administering the first composition and administering the second composition is one week. In some embodiments, the period between administering the first composition and administering the second composition is more than one week. In some embodiments, the period between administering the first composition and administering the second composition is one month. In some embodiments, the period between administering the first composition and administering the second composition is more than one month. In various embodiments, administering the compositions described herein comprises a first administration of a composition free of a local anesthetic into the ear canal; followed by a second administration of a composition free of a local anesthetic into the ear canal. In some embodiments, administration of the compositions described herein comprises a first administration of the composition free of a local anesthetic to the ear canal; followed by a second administration of the composition free of a local anesthetic to the ear canal.

[0172] In various embodiments, administering the compositions described herein comprises a first administration of a composition free of local anesthetic to the ear canal; followed by a second administration of a composition free of permeation enhancers other than local anesthetic to the ear canal. In some embodiments, administering the compositions described herein comprises a first administration of a composition free of local anesthetic to the ear canal; followed by a second administration of a composition free of permeation enhancers other than local anesthetic to the ear canal. In some embodiments, the first and second administered compositions are the same. In some embodiments, the first and second administered compositions are different.

[0173] Provided herein is a method of delivering the composition of the present disclosure to the surface of the tympanic membrane of a subject. In some embodiments, the subject has an ear disease. In some embodiments, the subject has otitis media. In some embodiments, the subject is a human. In some embodiments, the subject is a domestic animal, such as a dog, cat, cow, pig, horse, sheep, or goat.

[0174] In some embodiments, the method of delivery includes administering the composition into the ear canal via an applicator. In some embodiments, the method of delivery includes placing drops of the composition into the ear canal. In some embodiments, the drops are delivered from a dropper (e.g., a pipette, an eyedropper). In some embodiments, the drops are delivered by a syringe. The syringe may be attached to a needle, a rigid catheter, or a soft catheter. In some embodiments, the method of delivery includes administering the composition onto the round window membrane to deliver the composition to the inner ear.

[0175] In some embodiments, the method of delivery comprises placing a dose of the composition into the ear canal using a catheter. In some embodiments, the catheter is attached to a syringe. In some embodiments, the catheter is rigid. In some embodiments, the catheter is flexible. In some embodiments, the method of delivery comprises placing a dose of the composition into the ear canal using a needle. In some embodiments, the needle is attached to a syringe. In some embodiments, the needle has a blunt tip.

[0176] In some embodiments, the method of delivery includes placing a dose of the composition into the ear canal using a double barrel syringe. The double barrel syringe may be used to keep the two components of the composition together until mixing of the two components occurs during administration (e.g., in situ). In some embodiments, the double barrel syringe is attached to a single catheter or needle. In some embodiments, each barrel of the double barrel syringe is attached to a separate needle or catheter.

[0177] In some embodiments, the method of treating an infectious disease or an ear disease includes instructing a subject to administer a composition or providing instructions to the subject for self-administration of the composition.

[0178] In another aspect, provided herein is a method of eradicating a biofilm in a subject, the method comprising administering to a subject in need thereof a composition described herein. In another aspect, provided herein is a method of eradicating a biofilm, the method comprising contacting the biofilm with a composition described herein. In another aspect, provided herein is a method of inhibiting biofilm formation in a subject, the method comprising administering to a subject in need thereof a composition described herein. In another aspect, provided herein is a method of inhibiting biofilm formation, the method comprising contacting a surface with a composition described herein.

[0179] In another aspect, provided herein is a use of a composition described herein for treating and / or preventing a disease or condition (e.g., infectious disease, ear disease, bacterial infection, pain) and / or a disease-related condition (e.g., pain associated with infectious disease, ear disease, bacterial infection) in a subject in need thereof, the use comprising administering to the subject a therapeutically effective amount of a composition described herein. In one embodiment, provided is a use of a composition described herein for treating pain, the use comprising administering to the subject a therapeutically effective amount of a composition described herein.

[0180] kit Provided herein is a kit that includes any of the compositions described herein, but may additionally include a composition in sterile packaging. Provided herein is a kit that includes any of the compositions or matrix-forming agents described herein, but may additionally include a composition or matrix-forming agent in sterile packaging. The kit may include two containers for the two-part matrix-forming agent. The therapeutic agent may be included in one or both containers of the matrix-forming agent, or the therapeutic agent may be packaged separately. The permeation enhancer may be included in one or both containers of the matrix-forming agent, or the permeation enhancer may be packaged separately. In various aspects, the kit may include a bottle(s) and a dropper or syringe for each bottle. In some embodiments, the kit is used to treat a disease (e.g., ear disease, infectious disease, bacterial infection), disease (e.g., pain), and / or disease-related disease (e.g., ear disease, infectious disease, pain associated with bacterial infection) described herein.

[0181] In some embodiments, the kit includes one or more droppers (e.g., pipettes, eyedroppers). In some embodiments, the kit includes one or more syringes. In some embodiments, the syringes are pre-loaded with the composition or one or more components of the composition. In some embodiments, the kit includes one or more needles (e.g., blunt tip needles). In some embodiments, the kit includes one or more catheters (e.g., soft catheters).

[0182] In some embodiments, the kit includes a double barrel syringe. In some embodiments, the double barrel syringe is pre-filled with two components of the composition. In some embodiments, the double barrel syringe is attached to a single catheter or needle. In some embodiments, each barrel of the double barrel syringe is attached to a separate needle or catheter.

[0183] In some embodiments, the kits described herein further include instructions for using the kit, such as instructions for using the kit in a method of the disclosure (e.g., instructions for administering a compound or pharmaceutical composition described herein to a subject). The kits described herein may also include information as required by regulatory authorities, such as the U.S. Food and Drug Administration (FDA).

[0184] example In order that this disclosure may be more fully understood, the following examples are set forth: The synthetic and biological examples described in this application are offered to illustrate the compounds, pharmaceutical compositions, and methods provided herein, and are not to be construed as in any way limiting the scope thereof.

[0185] Example 1. Rheology. Exemplary compositions were analyzed for favorable properties with respect to gelation and syringeability. Rheological data, including storage modulus (G') and loss modulus (G''), were plotted over the temperature range of the compositions. Transtympanic and biocompatibility experiments were also performed.

[0186] Exemplary workable compositions with reasonable gelling and needleability properties include the following compositions: 12%PBP-1%SDS-0.5%BUP-10%LIM, 12%PBP-1%SDS-1%BUP-10%LIM, 12%PBP-5%SDS-1%BUP-4%LIM, 12%PBP-10%SDS-0.5%BUP-10%LIM, 12%PBP-10%SDS-1%BUP-10%LIM, 12%PBP-20%SDS-1%BUP-4%LIM, 15%PBP-1%SDS-0.5%BUP-10%LIM, 15%PBP-1%SDS-1%BUP-10%LIM, 15%P BP-5%SDS-0.5%BUP-4%LIM, 15%PBP-5%SDS-1%BUP-4%LIM, 15%PBP-10%SDS-0.5%BUP-1%LIM, 15%PBP-10%SDS-1%BUP-1%LIM, 10%PBP-1%SDS-0.5%BUP-4%LIM, 10%PBP-5%SDS-0.5%BUP-4%LIM, 10%PBP-5%SDS-1%BUP-4%LIM, 18%PBP-1%SDS-0.5%BUP-4%LIM, 18%PBP-1%SDS-1%BUP-4%LIM, and 18%PBP-5%SDS-0.5%BUP-4%LIM. Each of the compositions is provided as a percentage weight / vol. See Figures 1-6.

[0187] Example 2. Formulation and properties related to gelation, needleability, storage modulus, and gelation temperature. Table 1. Summary data for formulation optimization of compositions, Group 1. [Table 1-1] [Table 1-2] X: The needleability test results range from 1 to 5, where 1 is good needleability (e.g., can be syringeable as a liquid through a soft catheter without clogging) and 5 is poor needleability (e.g., poor ability to be syringeable as a liquid through a soft catheter without clogging).

[0188] Table 2. Summary data for formulation optimization of exemplary compositions, Group 2. [Table 2-1] [Table 2-2] [Table 2-3] X: The needleability test results range from 1 to 5, where 1 is good needleability (e.g., can be syringeable as a liquid through a soft catheter without clogging) and 5 is poor needleability (e.g., poor ability to be syringeable as a liquid through a soft catheter without clogging).

[0189] Table 3. Data summary for formulation optimization of exemplary compositions, Group 3. [Table 3-1] [Table 3-2] [Table 3-3] X: The needleability test results range from 1 to 5, where 1 is good needleability (e.g., can be syringeable as a liquid through a soft catheter without clogging) and 5 is poor needleability (e.g., poor ability to be syringeable as a liquid through a soft catheter without clogging).

[0190] Table 4. Data summary for formulation optimization of exemplary compositions, Group 4. [Table 4-1] [Table 4-2] [Table 4-3] X: The needleability test results range from 1 to 5, where 1 is good needleability (e.g., can be syringeable as a liquid through a soft catheter without clogging) and 5 is poor needleability (e.g., poor ability to be syringeable as a liquid through a soft catheter without clogging).

[0191] There are 32 exemplary composition formulations in each group (each of groups 1, 2, 3, and 4) that are classified based on their polymer concentration (e.g., 10% PBP, 12% PBP, 15% PBP, 18% PBP; where "PBP" is poloxamer 407-poly(butoxy)phosphoester). Each group contains 32 composition formulations, which are then divided into four subgroups based on SDS concentration (e.g., 1% SDS, 5% SDS, 10% SDS, 20% SDS). Thus, there are eight formulations within each subgroup. These subgroups are then first divided according to their bupivacaine concentration (low to high, sub-subgroups), and then arranged according to their limonene concentration (low to high). Thus, each sub-subgroup is composed of four formulations with the same PBP, SDS, and bupivacaine concentrations, but different limonene concentrations. Within each sub-subgroup, the formulation with the highest limonene concentration and meeting the following criteria for rheology performance was selected.

[0192] The selection criteria are: (A) liquid at room temperature (column 4 in Tables 1-4); (B) solid at body temperature (column 5 in Tables 1-4); and (C) good needle passability at room temperature (column 6 in Tables 1-4). Exemplary compositions that are reasonably viable are displayed in italics in Tables 1-4. The rheological data for these exemplary compositions are provided in the rightmost two columns of the tables.

[0193] Among the samples that underwent rheology, those that met the following criteria were selected for ex vivo experiments (testing transtympanic permeability): (1) gelation temperature above room temperature and below body temperature (last column in Tables 1-4); (2) storage modulus at body temperature is greater than 100 Pa (penultimate column in Tables 1-4). (3) In a subgroup (e.g., two formulations with the same PBP and SDS concentrations), if there are two formulations that meet both (1) and (2) above, only the one with the higher bupivacaine concentration is chosen. The selected exemplary formulations (well-performing formulations) are marked in italics in Tables 1-4. The four well-performing formulations were selected based on the data described herein.

[0194] Experimental procedures for the data in Tables 1-4 The experimental procedures for generating the data in Tables 1-4 above are as follows: To determine the data for column 4 in Tables 1-4, the formulations were kept in vials for 1-5 minutes under ambient laboratory conditions (~20°C to 25°C). The vials were then inverted. If the formulation ran down the side of the vial, then it was considered a liquid. To determine the data for column 5 in Tables 1-4, the vials containing the formulations were submerged in a 37°C water bath for 30 seconds. The vials were then inverted. If the formulation remained at the bottom of the vial (inverted upside down), then it was considered a gel. To determine the data for column 6 in Tables 1-4, the formulations (kept on ice) were drawn into 1 ml syringes. An 18 gauge, 1.88 inch flexible catheter was then attached to each syringe and the formulations were extruded through the catheters onto a glass surface (kept under ambient laboratory conditions). If the extruded material formed droplets on the receiving surface, then it was considered to be needle passable. If the extruded material formed a rod-shaped solid, then the formulation was considered not needle passable.

[0195] The data in the last two columns in Tables 1-4 were calculated from rheological measurements using the following conditions: Storage and loss moduli over the temperature range of 10-40°C were measured in temperature ramp / sweep mode using linear oscillatory shear rheology. An oscillatory rate of 100 rad per second, a deformation strain rate of 1%, and a temperature ramping rate of 1°C / min were used. The gel temperature was taken as the temperature above the loss modulus.

[0196] Example 4 Here, the use of this transtympanic drug delivery system to deliver local anesthetics across the TM was also studied. Bupivacaine, an amphipathic amino-amide local anesthetic in current clinical use that has been found to have intrinsic activity as a CPE, was studied. Tetrodotoxin (TTX), an extremely hydrophilic compound that blocks the same sodium channels as bupivacaine at a different site and has excessively potent local anesthetic activity, was also studied. Bupivacaine and TTX are known to strongly potentiate each other's anesthetic effects when given in combination. 15~17 .

[0197] material 2-Chloro-2-oxo-1,3,2-dioxaphospholane (COP), 1,8-diazabicyclo[5.4.0]undec-7-ene (DBU), n-butanol, diethyl ether, acetic acid, anhydrous dichloromethane, anhydrous tetrahydrofuran, SDS, LIM, and US pharmaceutical grade BUP and bupivacaine free base (BUP-fb) were used as received from Sigma-Aldrich (St. Louis, MO). US pharmaceutical grade TTX was used as received from Abcam Inc. (Boston, MA). US pharmaceutical grade Kolliphor® P407, micro-prilled (pelletized into fine particles), was received from BASF (Florham Park, NJ).

[0198] Animal maintenance Healthy adult male chinchillas weighing 500-650 g were purchased from Ryerson Chinchilla Ranch (Plymouth, OH) and cared for according to institutionally and nationally approved protocols. Experiments were performed in accordance with Boston Children's Hospital animal use guidelines and approved by the Institutional Animal Care and Use Committee.

[0199] Synthesis of butoxy-2-oxo-1,3,2-dioxaphospholane (BP) BP was prepared as previously reported. 14 Briefly, BP was synthesized by the condensation reaction of COP and n-butanol. COP (5.0 g, 35 mmol) in anhydrous THF (50 mL) was added dropwise to a stirred solution of n-butanol (2.6 g, 35 mmol) and trimethylamine (3.9 g, 39 mmol) in anhydrous THF (100 mL) at 0 °C. The reaction mixture was stirred in an ice bath for 12 h upon completion of the addition of COP in THF. Upon completion of the conversion of COP, the reaction mixture was filtered and the filtrate was concentrated. The concentrated filtrate was purified by vacuum distillation under reduced vacuum to yield a viscous colorless liquid.

[0200] Synthesis of P407-PBP P407-PBP was used as previously reported 14 It was synthesized by ring-opening polymerization (ROP) of BP using P407 as a macroinitiator in the presence of organocatalyst DBU at -20 °C. 18P407 (8.1 g, 0.56 mmol) and BP (1.0 g, 5.6 mmol) in anhydrous dichloromethane (DCM, 0.5 mL) were added to a flame dried Schlenk flask (10 mL) equipped with a stir bar. The reaction mixture was flushed with nitrogen gas for 5 minutes while immersed in an ice bath containing saturated NaCl solution. A solution of DBU (0.13 g, 0.84 mmol) in anhydrous DCM was added dropwise via syringe to the stirring solution while maintaining the reaction under a nitrogen gas atmosphere. Upon completion of the reaction, an excess of acetic acid in DCM was added to the reaction mixture to quench the reaction. The product was purified by precipitation into ether (three times) and dried under vacuum to give a white powder product.

[0201] Hydrogel formation Solutions of 12% (w / v) P407-PBP hydrogel formulations were made by adding powdered polymer to distilled deionized water and simple dissolution in a cold room to allow better solubility of P407-PBP. SDS, and / or LIM, and / or BUP, and / or TTX were added to a solution of 12% (w / v) P407-PBP and allowed to dissolve in a cold room for at least 4 hours. TTX hydrogel formulations were made in citrus buffer to enhance TTX solubility.

[0202] In vitro release studies The release of BUP or TTX from each formulation was measured using a diffusion system. Transwell® membrane inserts (0.4 μm pore size, 1.1 cm 2100 μL of each formulation was pipetted directly onto the pre-warmed filter insert to obtain a solid hydrogel. The filter insert containing the formed gel (donor compartment) was suspended in a well (acceptor compartment) filled with pre-warmed phosphate-buffered saline (PBS), and the plate was then kept in a 37° C. incubator. At each time point (0.5, 1, 2, 6, 12, 24, 48 h), 1 mL aliquots of the PBS receiving media were sampled and the inserts were sequentially moved into new wells containing fresh PBS. The aliquots were suspended in 70:30 acetonitrile / PBS to ensure total drug elution. Sample aliquots were analyzed chromatographically using high performance liquid chromatography (HPLC) to determine BUP concentration (absorbance at wavelength λ=254 nm) or using the REAGEN™ TTX Elisa test kit (Reagen LLC. Collingswood, NJ) to quantify TTX concentration. Experiments were performed in quadruplicate.

[0203] Ex vivo permeation experiments Transtympanic permeability of BUP and / or TTX was determined using otic bullae harvested from healthy chinchillas. Chinchillas were placed under deep general anesthesia with intramuscular administration of ketamine (30 mg / kg) and xylazine (4 mg / kg) and then euthanized with intracardiac administration of pentobarbital (100 mg / kg). Euthanized animals were decapitated and the otic bullae were removed intact with the tympanic ring still attached. Their integrity was assessed by measuring their electrical impedance (resistance ≥ 18 kOhm*cm) in a setup in which the TM was placed horizontally in a 12-well plate with donor solution above and recipient solution below. 2 ; indicated by the values ​​determined so far 13) was assessed. Instead of a conventional diffusion cell, which would deform or rupture the TM, the same setup was used to measure drug flux. All formulations were applied in a bone bulla kept at 37°C and allowed to precipitate on the TM. The concentrations of BUP ranged from 0.5 to 15% and the applied volume was 200 μL, which translates to 1 to 30 mg of BUP. The concentrations of TTX were 0.02% to 0.32% (solubility limit of TTX) and the applied volume was 200 μL, which translates to 0.03 to 0.64 mg of TTX. BUP and TX concentrations in the receiving chamber were measured 0.5, 1.0, 2.0, 6.0, 12, 24 and 48 hours after administration of the hydrogel compounds. The permeation of BUP and / or TTX across the TM into the receiving chamber was quantified using HPLC or a TTX Elisa kit. Detailed information regarding the harvesting of TM, the measurement of TM electrical resistance, and the configuration of ex vivo permeability experiments can be found in references. 13 .

[0204] histopathology A hydrogel formulation containing anesthetic and CPE was administered into the ear canals of healthy chinchillas. After 24 hours to 7 days, they were euthanized as described above. Following sacrifice, the bone bulla was excised as described above to obtain TM and ear canal samples. The excised tissues were immediately fixed overnight in 10% formalin, then decalcified, embedded in paraffin, sectioned (10 um thick), and stained with hematoxylin and eosin. All stained specimens were evaluated by light microscopy in a blinded fashion.

[0205] statistical analysis For ex vivo experiments, a sample size of four was selected for each formulation, providing 80% power to detect a 50% difference in flux based on power analysis using the nonparametric Friedman test (version 7.0, nQuery Advisor, Statistical Solutions, Saugus, MA). Statistical analysis was performed using Origin 8 software (version 9.2, SAS Institute, Cary, NC). Data were presented as median (1st quartile - 3rd quartile).

[0206] Calculation of hypothetical drug levels in middle ear fluid The following assumptions were made to calculate the middle ear concentrations of bupivacaine and TTX that would be achieved in vivo: (1) Fluid turnover rate is zero in the middle ear of patients with AOM (i.e., middle ear fluid is not replenished) because in AOM, middle ear fluid drainage is prevented by inflammation of the Eustachian tube mucosa. 19 (2) changes in drug concentration due to absorption by the surrounding middle ear mucosa, bacterial and enzymatic digestion, etc., are negligible; (3) the average volume of the human middle ear is ~0.45 mL. 20 (4) the infinite sink condition applied during ex vivo experiments where the receiving chamber volume was 3 mL still applies to the human middle ear volume of 0.45 mL.

[0207] The measured cumulative mass of drug passing through the TM at any time point was divided by the volume of the human middle ear (0.45 mL) to provide the concentration that could be achieved with a given formulation.

[0208] result Abstract and formulation nomenclature Hydrogel formulations were made in aqueous solutions of the penta-block copolymer P407-PBP at 12% (w / v), with or without added CPE, with or without the local anesthetics BUP [0.5-15% (w / v); concentrations above 4% (w / v) are suspensions, labeled with the subscript susp] and / or TTX [0.02-0.32% (w / v)]. When CPE was added, the composition was 1% (w / v) SDS with 2% (w / v) LIM; this combination was designated 2CPE. The gels were designated x%BUP(susp)-y%TTX-2CPE-[P407-PBP], where x and y are the weight by volume percent concentrations of BUP and TTX, respectively. They are easily extruded from a syringe at room temperature and gel rapidly at body temperature, 14 , 12 percent P407-PBP was used throughout this work. (The latter property will be important when applying the material to toddlers who do not like to stay still. The hydrogel is necessary for CPE of the TM and continuous exposure to anesthetics.) 14 .) If a component is not present in the formulation, it is omitted from the above nomenclature. Unless otherwise specified, all percentages are weight by volume percent.

[0209] Formulations containing BUP dissolved in pure LIM were designated x% BUP-LIM, where x was the weight by volume percent concentration of BUP.

[0210] P407-PBP was synthesized by ring-opening polymerization as reported 14 Nuclear magnetic resonance (NMR) confirmed the presence of the PBP moiety and determined the degree of polymerization of the PBP moiety to be 5. Fourier transform infrared spectroscopy (FTIR) confirmed the successful synthesis of the penta-block copolymer P407-PBP.

[0211] Effect of BUP concentration on transtympanic membrane permeability The transtympanic membrane penetration rate of BUP was assessed using previously reported ex vivo methods. 14Briefly, drug transport across the TM was studied at 37°C using otic bullae excised from healthy chinchillas. 200 μL of anesthetic formulation (donor solution) was placed on the surface of the TM (see Methods for details) and flux into 3 mL of PBS (recipient solution) was measured over time (Figure 7).

[0212] The flux of BUP across the TM from the BUP-2CPE-[P407-PBP] formulation was studied at BUP concentrations ranging from 0.5% to 15% (Figure 7). It is noted that BUP is soluble in water only at concentrations up to 2% and in a 12% [P407-PBP] solution only at concentrations up to 4%. Thus, 7.5% BUP susp -2CPE-[P407-PBP] and 15%BUP susp The -2CPE-[P407-PBP] formulation was a suspension of dissolved and solid BUP. The flux of BUP increased continuously with increasing BUP concentration up to ∼7.5%.

[0213] At 6 h, BUP permeation across the TM in the presence of 2CPE was approximately 1.5 μg (1.1-1.9 μg) for 0.5% BUP-2CPE-[P407-PBP] (Figure 7). Increasing the BUP concentration from 0.5% to 1% improved the transtympanic flux of BUP by approximately 28-fold, resulting in a 6-h BUP cumulative permeation of 42.7 μg (27.4-71.7 μg). Further increasing the BUP concentration to 2% or 4% produced less improvement in BUP flux, with 2% BUP-2CPE-[P407-PBP] achieving 51.0 μg (35.3-68.1 μg) and 4% BUP-2CPE-[P407-PBP] achieving 48.0 μg (43.9-51.2 μg). The 7.5% BUP suspension susp -2CPE-[P407-PBP] further increased the 6-h BUP cumulative permeation to 141.1 μg (85.6-168.8 μg); 15% BUP susp There was no further increase with -2CPE-[P407-PBP] [163.6 μg (74.3 to 223.2 μg)].

[0214] At 48 h, increasing the BUP concentration from 0.5% to 1% increased BUP flux from 27.0 μg (19.4–31.5 μg) to 208.1 μg (127.7–340.8 μg), an 8-fold enhancement (Figure 7B). Further increasing the BUP concentration to 2% produced a small increase in BUP flux to 296.4 μg (206.1–395.7 μg). Doubling the BUP concentration again to 4% achieved another 2-fold increase in BUP flux to 671.9 μg (479.4–820.9 μg). The maximal cumulative permeation of BUP was observed at 7.5% BUP. susp This was achieved with -2CPE-[P407-PBP], resulting in 1251.2 μg (range 971.5-1471.0 μg) of BUP crossing the TM in 48 h. The amount of BUP that permeated across the intact TM represented ~8.3% of the total BUP applied onto the TM. Increasing the BUP concentration from 7.5% to 15% did not result in any further enhancement of 48 h permeation.

[0215] Effect of TTX concentration on transtympanic membrane permeability The flux of TTX across the TM was also assessed by ex vivo methods. Concentration of TTX by enzyme-linked immunosorbent assay (ELISA) (see Methods for details). The concentration of TTX in TTX-2CPE-[P407-PBP] varied from 0.02% (0.5 mM) to 0.32% (10 mM, Figure 8), with 0.32% (10 mM) being the solubility limit of TTX.

[0216] At 6 h, transtympanic permeation of TTX increased roughly linearly with TTX concentration in the formulation (Figure 8B). Increasing the TTX concentration from 0.02% (0.5 mM) to 0.16% (5 mM, i.e., 10-fold) resulted in a six-fold increase in TTX permeability from 0.2 μg (0.2-0.3 μg) to 1.3 μg (0.9-2.0 μg). Doubling the TTX concentration from 0.16% (5 mM) to 0.32% (10 mM) resulted in an additional three-fold increase in TTX permeability from 1.3 μg (0.9-2.0 μg) to 4.4 μg (3.2-5.1 μg). At 48 h, a linear correlation remained between TTX concentration and transtympanic permeability, with 0.02% TTX-2CPE-[P407-PBP] leading to a cumulative permeation of 3.0 μg (range, 2.3-4.4 μg) TTX, and the 0.03%, 0.16%, and 0.32% TTX formulations achieving 3-, 9-, and 16-fold enhancements, respectively.

[0217] Formulation combining BUP and TTX Combining BUP with TTX has been shown to dramatically enhance anesthetic efficacy. 15~17,21 Here, the concentration of BUP in the combined formulation was fixed at 2%. The TTX concentration was kept constant at 0.03% (1 mM) since a similar concentration is used locally. 22,23 The transtympanic membrane permeability of BUP and TTX was studied from 2% BUP-0.03% TTX-[P407-PBP] and 2% BUP-0.03% TTX-2CPE-[P407-PBP] in the ex vivo model described above (Figure 9).

[0218] At 6 h, only 4.3 μg (0.6–10.8 μg) of BUP permeated across the TM from 2% BUP-0.3% TTX-[P407-PBP]. Incorporation of 2CPE within the formulation led to a threefold increase in BUP transtympanic permeation. The enhancing effect of 2CPE on TTX permeation was much greater, 29-fold from 0.1 μg (0–0.2 μg) to 2.9 μg (1.6–4.5 μg).

[0219] At 48 h, the cumulative permeation of BUP achieved by 2% BUP-0.3% TTX-[P407-PBP] was ~80.2 μg (47.7-128.1 μg), ~2.0% of the total BUP applied (Figure 9A); the cumulative permeation for TTX was ~0.9 μg (0.4-1.7 μg), ~1.4% of the total TTX applied (Figure 9B). Incorporating 2CPE increased transtympanic BUP permeation to 350.2 μg (270.1-452.9 μg), ~8.8% of the total amount of BUP (4 mg) applied onto the TM (Figure 9A). During the same period, 9.2 μg (5.2-14.4 μg) TTX permeated across the TM, corresponding to 14.3% of the total amount of TTX applied (63.9 μg, Figure 9B). The combination of 2CPE increased the permeability of BUP 4-fold and TTX 10-fold.

[0220] Terpene-based anesthetic preparations In all of the preceding sections, bupivacaine hydrochloride (BUP) was used to formulate the anesthetic hydrogels due to its hydrophilicity. Nevertheless, the highest soluble concentration was 4%. Increasing the concentrations of SDS and / or LIM(2CPE) to their solubility limits of 20% and 10%, respectively, did not improve the solubility of BUP in water. The solubility of BUP in water was not affected by changing the percentage of bupivacaine in salt form [higher at lower pH] and the percentage of the free base, which is more hydrophobic, by adjusting the pH of the formulation in the range of 3-9.

[0221] To increase the soluble BUP concentration in the formulation, bupivacaine free base (BUP-fb) was used instead and dissolved in pure LIM. 24 , with its proven penetration enhancing effect 13,14,25 It was chosen as the solvent due to its FDA-approved status for topical application. The solubility limit of BUP-fb is ~10% in pure LIM, which is the highest soluble bupivacaine concentration established to date.

[0222] The cumulative amount of BUP-fb delivered into the middle ear using 10% BUP-fb-LIM in the above ex vivo flow model was 63.5 μg (45.3-68.9 μg) after 0.5 h. Middle ear drug levels increased 3- and 27-fold after 6 and 48 h (Figure 10). Transtympanic drug permeability achieved by 10% BUP-fb-LIM [1709.8 μg (1600.1-1742.5 μg)] was significantly higher than that achieved by 15% BUP-fb-LIM. susp This was not significantly different from that of -2CPE-[P407-PBP][1234.5μg (735.5~1633.8μg)].

[0223] In vivo biocompatibility in the ear Biocompatibility in the ear was tested by treating healthy chinchillas with anesthesia containing the formulations, followed by histopathological evaluation of the treated ears (see section 2.8 for experimental details). For the hydrogel formulations, the duration of treatment was set to 7 days, which is a typical treatment duration for acute otitis media. 2 For 10% BUP-fb-LIM, the exposure time was set to 24 hours due to the clinically apparent inflammatory reaction by that time. The inflammatory tissue reaction disappeared after 7 days.

[0224] 4%BUP-2CPE-[P407-PBP] or 15%BUP susp In animals treated with -2CPE-[P407-PBP] for 7 days, hematoxylin-eosin stained sections of the TM appeared similar to normal (Figure 11). No inflammation, necrosis, or tissue damage was observed. Moreover, the ear canals of treated animals appeared similar to healthy canals in hematoxylin-eosin stained sections (Figure 12). Sections showed normal epithelium (outermost layer) without inflammation, covering normal adnexal structures / glands.

[0225] Healthy TMs treated with 10% BUP-fb-LIM for 24 hours appeared similar to normal (Figure 11). However, severe acute and chronic inflammatory responses were observed in the ear canals of treated animals (Figure 12). The inflammatory response consisted of lymphocytes, monocytes, and neutrophils in the epidermal and subepidermal layers of treated animals. In addition, animals receiving 10% BUP-fb-LIM exhibited behavioral abnormalities, such as excessive scratching of their treated ears.

[0226] Consideration The hydrogel drug delivery system achieved transtympanic delivery of bupivacaine and TTX in a sustained manner. A formulation containing both anesthetics, 2% BUP-0.3% TTX-2CPE-[P407-PBP], delivered 350.2±102.7 μg of BUP and 9.2±5.2 μg of TTX across the TM over 48 hours, corresponding to a mean flux of ∼7.3 μg / h for bupivacaine and ∼0.2 μg / h for TTX.

[0227] The drug concentrations that would occur in humans from the above fluxes were calculated as described in the methods. After 6 hours of exposure to 2% BUP-0.3% TTX-2CPE-[P407-PBP], the cumulative flux of the drugs was such that a bupivacaine concentration in the middle ear of 0.03 mg / mL (cumulative flux of 0.013 mg divided by 0.45 mL; i.e. 0.09 mM) and a tetrodotoxin concentration of 6.4 μg / mL (cumulative flux of 2.9 μg divided by 0.45 mL; i.e. 20 μM) TTX could be reached. At 48 hours, the drug concentrations increased to ∼0.8 mg / mL for BUP (cumulative flux of 0.35 mg divided by 0.45 mL; i.e. 3 mM) and ∼0.02 mg / mL for TTX (cumulative flux of 9.2 μg divided by 0.45 mL; i.e. 64 μM).

[0228] The concentrations measured in the receiving chamber are the product of drug permeating through and then exiting the tissue, i.e., they reflect the concentrations in the tissue. In considering whether these concentrations will achieve local pain relief, it is useful to first consider which concentrations will produce local anesthesia in the tissue. In vitro, bupivacaine inhibited most sodium currents with a KI of 25 μM. 26 , and reduces action potential amplitude at a median inhibitory concentration of 180 μM 27 ; the corresponding values ​​for TTX are 1-2 nM 28,29 and 5-6 nM 30 All concentrations in the receiving chambers were higher than the nano- to micromolar concentrations required for nerve block in vitro. For bupivacaine, the concentrations in the receiving chambers were also much higher than the blood (systemic) drug concentrations required to achieve analgesia in animals. A plasma lidocaine concentration of 0.36 μg / mL (1.5 μM) achieved analgesia in a rat neuropathic pain model. 31 this was 1.2% of the bupivacaine concentration achieved here at 6 hours, and 0.05% of the concentration at 48 hours. (In addition, bupivacaine is ~4 times more potent than lidocaine. 32 The concentrations of TTX achieved at 6 and 48 hours are in fact comparable to those used in perineural blocks. 33,34 This is the concentration (several tens of μM) that achieves nerve block.

[0229] The flux of bupivacaine and TTX across the TM may be even greater if tympanic membranes from animals with OM are used here instead of tympanic membranes from healthy animals. In OM, the tympanic membrane also becomes much thicker yet much more permeable to drug flux. 14 The greater drug flux can significantly enhance drug levels in the middle ear.

[0230] Moreover, when bupivacaine and TTX are delivered together, the efficacy of the local anesthetic can be greatly enhanced. 15~17Conventional amino-amide or amino-ester local anesthetics such as bupivacaine are known to have significant synergy with compounds such as tetrodotoxin, which block the same sodium channels at a different site on the surface of the axon, called site 1. Concentrations of either compound that would not be relatively effective independently can become effective in combination. Moreover, CPE is known to enhance the local anesthetic effect of tetrodotoxin, possibly by enhancing its penetration to the axon surface. 35~37 .

[0231] The effectiveness of ear drops containing anesthetics such as lidocaine is controversial and temporary. 38 this poor performance may be due to the well-known barrier function of the tympanic membrane. 12 The permeability barrier was overcome and therapeutic levels of bupivacaine and TTX were delivered across the intact tympanic membrane. In addition, the hydrogel extended the effect over a prolonged period of time that may extend into the time window during which ear pain is at its most severe. This may be even more effective with dual delivery of a conventional local anesthetic and a site 1 sodium channel blocker, as co-delivery may significantly enhance the duration of effect. 15~17,33 .

[0232] Although CPE increased the transtympanic flux of both BUP and TTX, the effect on TTX flux (10-fold increase at 48 h) was much greater than the effect on BUP (4-fold increase at 48 h). This pattern was reminiscent of the effect of co-injecting these compounds with CPE in the sciatic nerve. 35 The nerve blockade from TTX was significantly enhanced by CPE, whereas that from BUP was not. The reason for this difference was thought to be that TTX, being extremely hydrophilic, would have great difficulty penetrating biological barriers and would therefore benefit from CPE. BUP, being amphiphilic, would have less difficulty penetrating biological barriers and would therefore benefit less from CPE.

[0233] Although 10% BUP-fb-LIM had a greater dissolved drug concentration than the hydrogel formulation, transtympanic penetration of BUP was similar. 10% BUP-fb-LIM achieved a BUP concentration of ~0.4 mg / mL (1.2 mM) in the middle ear 6 hours after administration. 10% BUP-fb-LIM caused a 10-degree inflammatory response in the ear canal, which could be the result of the high LIM concentration in the formulation or the high free bupivacaine concentration. No inflammatory response was seen in the TM, possibly because in the absence of hydrogel, 10% BUP-fb-LIM flowed out of the TM into the auditory canal when the animals woke up.

[0234] 7.5% BUP is probably because the concentration of the bupivacaine in the solution is the same. susp It was intriguing to note that hydrogels containing a suspension of bupivacaine, such as -2CPE-[P407-PBP], increased the transtympanic permeation of bupivacaine by 2-fold over 48 hours compared to hydrogel solutions such as 4% BUP-2CPE-[P407-PBP], possibly acting as a drug reservoir to replenish the concentration of free drug on the TM surface when the drug in suspension is depleted by flow.

[0235] Using a similar hydrogel delivery system, it has previously been shown that transtympanic drug delivery does not result in detectable systemic (blood) distribution of the antibiotic ciprofloxacin. 14,39 Presumably, transtympanic delivery of bupivacaine and TTX would also not result in systemic drug distribution, thus eliminating the side effects of local anesthetics. This procedure would also eliminate the need for systemic (oral) analgesics and their potential side effects.

[0236] A temperature-sensitive hydrogel was designed to provide sustained pain relief and allow for easy administration. The hydrogel formulation is a solution at room temperature for administration through the ear canal like other regular ear drops; the formulation gels rapidly in situ upon contact with the warm TM. This is beneficial because only a single application is required to maintain local anesthesia for an extended period of time, and large doses can cause poor compliance among uncooperative young patients.

[0237] A local drug delivery system is delivered to provide sustained pain relief from a single application in patients with AOM. Bupivacaine, a commonly used amino-amide anesthetic, was successfully delivered across the intact TM as was TTX, a highly potent site-1 sodium channel blocker anesthetic. Chemical permeation enhancers incorporated into the hydrogel system significantly increased the permeability of BUP and TTX across the TM.

[0238] Example 3. Chemical permeation enhancers (CPEs) can allow antibiotic flux across the tympanic membrane. Here, we investigated whether combinations of CPEs (sodium dodecyl sulfate, limonene, and bupivacaine hydrochloride) are synergistic and whether they can increase peak drug flux. Synergy was studied by analysis of isobolograms and combination indices. CPE concentration-response (i.e., transtympanic flux of ciprofloxacin) curves were constructed for each CPE, isobolograms constructed for pairs of CPEs, and synergy was demonstrated for all three pairs. Synergy was much greater at earlier (6 hours) and later (48 hours) time points, although effect sizes were larger at later times. Synergy was also demonstrated with the combination of the three drugs. The combination of CPEs also greatly increased the maximum drug flux achievable beyond that achieved by the individual CPEs.

[0239] introduction Auriculotopic drug delivery presents a promising alternative to oral therapies for drug administration to the middle ear. Therapies with local delivery across an intact tympanic membrane (TM) and directly to the middle ear could minimize systemic adverse effects (diarrhea, rash, and possibly antibiotic resistance caused by oral antibiotics for the treatment of otitis media [OM]

[44] ), improve patient adherence to therapy (due to reduced side effects and elimination of the need for prolonged treatment in often uncooperative toddlers), and thus potentially achieve better therapeutic outcomes. However, noninvasive transtympanic delivery has been little explored until recently due to the impermeability of the TM [45,46]. [47,48] The TM is a 100 μm-thick trilaminar membrane, the outer layer of which, the stratum corneum (SC), is a keratinized stratified squamous epithelium that is continuous with the skin of the external auditory canal and is structurally similar to that in the skin.

[0240] Chemical permeation enhancers (CPEs) are an effective means of enhancing the flux of small molecule therapeutics across the TM.[45,46] Moreover, enhancement can be increased by increasing the concentration of CPEs.[49,50] CPEs are known to disrupt the structural integrity of the lipid bilayer in the stratum corneum, enhancing the diffusion of therapeutics.

[49] It has previously been demonstrated that the OM can be treated by transtympanic delivery of ciprofloxacin (Cip), enabled by the combination of CPEs.[45,46] However, the benefit of the combination of CPEs has yet to be formally demonstrated, specifically whether their effects are truly synergistic or merely additive. Synergistic interactions may reduce the amount of CPE required to achieve a given effect, and thus may also reduce toxicity.

[0241] A relevant and important question is whether CPE combinations can be used to maximize peak efficacy, i.e., maximal drug flux across the barrier. The magnitude of drug flux is particularly important in treating OM because relatively high antibiotic concentrations are required to treat some bacteria, such as Streptococcus pneumoniae, a common OM pathogen.[51,52]

[0242] Pioneering studies into CPE interactions have demonstrated the potential to achieve higher than expected permeation enhancement when CPEs are combined.[53-58] Here, we used a formal pharmacological approach to establish whether the CPE interactions noted here are synergistic

[59] and whether CPE combinations could be used to increase the peak efficacy that can be achieved. Potential synergistic effects were investigated between three CPEs delivered in a polymer matrix in enhancing transtympanic permeation using isobol analysis[60,61] and combination indices[59,62,63] (Figure 19).

[0243] The surfactant sodium dodecyl sulfate (SDS) and the terpene limonene (LIM) were chosen because they are both FDA approved CPEs for topical use.

[64] SDS (anionic surfactant) may enhance SC permeability by extracting lipids from the SC and altering the protein structure of keratin in keratinocytes,

[65] while LIM (terpene) may split SC lipids and form a pathway for drug molecules.

[66] Synergistic effects are often found with processes acting on a common phenomenon by different mechanisms.[53,66-68] The clinically used local anesthetic bupivacaine hydrochloride (BUP) was studied because it would reduce pain associated with OM.

[0244] The effects of SDS, LIM, BUP, and their combinations on permeability enhancement were revealed by measuring their effects on the permeability of Cip across the TM of healthy chinchillas. Cip was chosen because it is FDA approved to be administered locally to the middle ear for the treatment of OM.

[69] Cip and CPE were delivered from a previously reported hydrogel, poloxamer 407-polybutylphosphoester (P407-PBP) (Figure 19).

[45] P407-PBP was used here because of its robust reverse thermogelation behavior.

[45] The hydrogel-based formulation is an easily applied liquid at room temperature and gels rapidly and firmly upon contact with the warm TM, keeping the antibiotic and CPE in place (i.e., on the TM) throughout the permeability measurements.

[0245] Chinchilla TM was used here as a model system because of their established structural similarity with human TM

[70] . The main difference between chinchilla and human TM is that the latter is much thicker in humans [45,71]. Nevertheless, the conclusions reached here are still likely to apply to the human TM because a) the TM in the two species is structurally similar, and b) CPEs may have their effects even on much thicker structures such as human skin.

[0246] material and method material 2-Chloro-2-oxo-1,3,2-dioxaphospholane (COP), 1,8-diazabicyclo[5.4.0]undec-7-ene (DBU), n-butanol, diethyl ether, acetic acid, anhydrous dichloromethane, anhydrous tetrahydrofuran, SDS, LIM, and US pharmaceutical grade Cip and BUP were used as received from Sigma-Aldrich (St. Louis, MO). Micronized (pelletized into fine particles) Kolliphor® P407 was received from BASF (Florham Park, NJ).

[0247] Animal maintenance Healthy adult male chinchillas weighing 500-650 g were purchased from Ryerson Chinchilla Ranch (Plymouth, OH) and cared for according to institutionally and nationally approved protocols. Experiments were performed in accordance with Boston Children's Hospital animal use guidelines and approved by the Institutional Animal Care and Use Committee.

[0248] Synthesis of butoxy-2-oxo-1,3,2-dioxaphospholane (BP) BP was synthesized by the condensation reaction of COP and n-butanol. COP (5.0 g, 35 mmol) in anhydrous THF (50 mL) was added dropwise to a stirred solution of n-butanol (2.6 g, 35 mmol) and trimethylamine (3.9 g, 39 mmol) in anhydrous THF (100 mL) at 0° C. The reaction mixture was stirred in an ice bath for 12 h upon completion of the addition of COP in THF. Upon completion of the conversion of COP, the reaction mixture was filtered and the filtrate was concentrated. The concentrated filtrate was purified by vacuum distillation under reduced vacuum to yield a viscous colorless liquid.

[0249] Synthesis of P407-PBP P407-PBP was synthesized by ring-opening polymerization (ROP) of BP with P407 as a macroinitiator in the presence of organocatalyst DBU at -20 °C. P407 (8.1 g, 0.56 mmol) and BP (1.0 g, 5.6 mmol) in anhydrous dichloromethane (DCM, 0.5 mL) were added to a flame dried Schlenk flask (10 mL) equipped with a stir bar. The reaction mixture was flushed with nitrogen gas for 5 min while immersed in an ice bath containing saturated NaCl solution. A solution of DBU (0.13 g, 0.84 mmol) in anhydrous DCM was added dropwise via syringe to the stirred solution while maintaining the reaction under a nitrogen gas atmosphere. Upon completion of the reaction, an excess of acetic acid in DCM was added to the reaction mixture to quench the reaction. The product was purified by precipitation into ether (three times) and dried under vacuum to give a white powder product.

[0250] Hydrogel formation Hydrogel solutions of 12% (w / v) P407-PBP hydrogel formulations were made by adding powdered polymer to an aqueous solution of 4% (w / v) Cip (pH=3.3-3.9) and simple dissolution in a cold room to allow better solubility of P407-PBP. SDS, and / or LIM, and / or BUP were added to a solution of 4% (w / v) Cip and 12% (w / v) P407-PBP and allowed to dissolve in a cold room for at least 4 hours.

[0251] In vitro release studies The release of Cip from each formulation was measured using a diffusion system. Transwell® membrane inserts (0.4 μm pore size, 1.1 cm 2 100 mm area; Costar, Cambridge, MA) and 24-well culture plates were used as donor and acceptor chambers, respectively. 200 μL of each formulation was pipetted directly onto the pre-warmed filter insert to obtain solid hydrogels. The filter inserts containing the formed gels (donor compartment) were suspended in wells (acceptor compartment) filled with pre-warmed phosphate-buffered saline (PBS), and the plates were then kept in a 37° C. incubator. At each time point (0.5, 1, 2, 6, 12, 24, 48 h), 1 mL aliquots of the PBS receiving medium were sampled and the inserts were sequentially transferred into new wells containing fresh PBS. The aliquots were suspended in 70:30 acetonitrile / PBS to ensure total drug dissolution. The sample aliquots were chromatographically analyzed using high performance liquid chromatography (HPLC) to determine Cip concentration (absorbance at wavelength λ=275 nm). More details regarding Cip measurements and HPLC conditions can be found in reference

[46] . Experiments were performed in quadruplicate.

[0252] Ex vivo permeation experiments The transtympanic permeability of Cip was determined using otic bullae harvested from healthy chinchillas. Chinchillas were placed under deep general anesthesia with intramuscular administration of ketamine (30 mg / kg) and xylazine (4 mg / kg) and then euthanized with intracardiac administration of pentobarbital (100 mg / kg). Euthanized animals were decapitated and the otic bullae were removed intact with the tympanic ring still attached. Their integrity was assessed by measuring their electrical impedance (resistance ≥ 18 kOhm*cm) in a setup in which the TM was placed horizontally in a 12-well plate with donor solution above and recipient solution below. 2 The drug flux was assessed by measuring the diffusion coefficient (ΔT) of the TM (ΔT = 0.01; shown by values ​​previously determined

[46] ). The same setup was used to measure drug flux instead of a conventional diffusion cell, which would deform or rupture the TM. All formulations were applied in a bone bulla kept at 37 °C and precipitated onto the TM. The applied volume was 200 μL, which corresponds to 8 mg of Cip. The permeation of Cip across the TM into the receiving chamber was quantified using HPLC. Detailed information on the harvesting of the TM, the measurement of the electrical resistance of the TM, and the configuration of the ex vivo permeation experiment can be found in reference

[46] .

[0253] statistical analysis Data that followed a normal distribution were described using the mean and standard deviation (calculated using Microsoft® Excel®) and compared by unpaired Student's t-test (using Origin®8, OriginLab). Data were otherwise presented as median ± quartiles (using Microsoft® Excel®).

[0254] result Abstract and formulation nomenclature Hydrogel formulations were formulated with the antibiotic Cip at 4% (w / v), the penta-block copolymer P407-PBP at 12% (w / v), and CPE at various concentrations; the gels are designated CPPB-x%LIM-y%SDS-z%BUP, where CPPB stands for constant 4%Cip-12%[P407-PBP]; x, y, and z represent the weight by volume percent concentrations of LIM, SDS, and BUP, respectively. Twelve percent P407-PBP was used throughout the study because it is easily extruded from a syringe at room temperature and gels rapidly at body temperature.

[45] (The latter property may be important when applying the material to toddlers who do not like to stay still. The hydrogel itself will maintain the antibiotic and CPE in the TM in vivo. P407-PBP is necessary for continuous exposure of the TM to CPE and antibiotic.

[45] )

[0255] P407-PBP was synthesized by ring-opening polymerization as reported.

[45] Nuclear magnetic resonance (NMR) confirmed the presence of the PBP moiety and determined the degree of polymerization of the PBP moiety to be 5 (Figure 20A). Fourier transform infrared spectroscopy (FTIR) confirmed the successful synthesis of the penta-block copolymer P407-PBP (Figure 20B).

[0256] If a component is not present in the formulation, it is omitted from the above nomenclature. A previously reported combination of three CPEs,

[45] namely, 2% LIM, 1% SDS, and 0.5% BUP, was designated as 3CPE. Unless otherwise specified, all percentages are weight by volume percent.

[0257] The cumulative amount of Cip that penetrated across the excised TM in the ex vivo experiment was expressed as VCIPt, where t is the time in hours at which the cumulative penetration of Cip was measured. Specifically, VCIP6 and VCIP48 represent the cumulative amount of Cip that penetrated across the TM within 6 and 48 hours, respectively, in the ex vivo experiment.

[0258] In vitro drug release from hydrogels The release of Cip from each formulation was measured using Transwell® membrane inserts. Cip release from 200 μL of CPPB gels containing 8.0 mg of drug with or without CPE was measured at 37° C. (FIG. 13). Drug release slows significantly after approximately 12 hours for Cip solutions and approximately 24 hours for CPPB gels with or without CPE. At 48 hours, CPPB released almost the entire amount of Cip loaded (7.7 mg), while CPPB-3CPE released approximately three-quarters (5.9 mg).

[0259] Synergistic interactions between CPEs Analysis of isobolograms An important concept in comparing drug dose interactions is that of dose equivalence.[60,61] One rigorous way of establishing equivalence is in terms of the dose that affects a given percentage of the population or has a given percentage of maximal effect (both of which are defined, for example, as EC50 [median effective concentration]). In such cases, dose effects can be compared by analysis of isobolograms.

[0260] The following steps are followed to perform the analysis of an isobologram: Concentration-response curves are constructed for drugs X and Y, and the equivalent concentration (or dose) to achieve a given effect (for example, 0.4 mg of VCIP48) is determined for each (Figure 14A). An isobologram (Figure 14B) is constructed in which the concentration of drug X that achieves that given effect is plotted on the X-axis, and the equivalent for drug Y is plotted on the Y-axis. The line connecting the two (isobols) is the line of additivity; the combined effect of fractions of equivalent doses for drugs X and Y is then plotted on the graph. For example, if a combination of 10% of an equivalent dose of X and 90% of an equivalent dose of Y (i.e., a total of 100% equivalent dose) achieves a given effect, then X and Y are simply additive. If only 10% of an equivalent dose of X and only 10% of an equivalent dose of Y (i.e., a 20% equivalent dose) achieves a given effect, then they are synergistic. If the combination of 90% of an equivalent dose of X and 90% of an equivalent dose of Y (ie, 180% of the equivalent dose) has a given effect, then they are antagonistic.

[0261] Concentration-response curves for single CPEs To generate an isobologram analysis, curves relating the effect of single CPE concentrations to transtympanic drug permeation of Cip were generated (similar to Figure 14). These curves were then used to construct isobolograms

[61] to assess whether the effects of CPE combinations were additive, synergistic, or possibly antagonistic.

[0262] Drug transport across the TM was studied ex vivo in otic bullae excised from healthy chinchillas at 37°C. 200 μL of CPPB gel (donor solution) containing 8.0 mg of drug with or without various concentrations of SDS, LIM, or BUP was placed on the surface of the TM (see Methods for details) and flux into 3 mL of PBS (recipient solution) was measured (Figure 15). Curves relating CPE concentration (X-axis) to VCIP6 and VCIP48 were constructed for each CPE.

[0263] Cip flux across the TM from CPPB-SDS was studied at SDS concentrations ranging from 0 to 20%, because the solubility limit for SDS in water is 20%.

[74] (The FDA-approved concentration limit for topical application is 40% for SDS,

[64] but formulations containing more than 20% SDS were suspensions rather than solutions.) Cip flux increased steadily with increasing SDS concentration. At 6 h (Figure 16), Cip permeation across the TM in the absence of CPE was below the detection limit of HPLC (approximately 1 μg / mL). Introducing 1% SDS into the hydrogel (Figure 16A) increased the V CIP6 to approximately 0.001 ± 0.0002 mg (p < 0.001); increasing the SDS concentration from 1% to 20% reduced the V CIP6 (0.002±0.002 mg) roughly doubled (p=0.29). At 48 h (FIG. 15A), increasing the SDS concentration from 1% to 20% significantly reduced V CIP48 Increasing SDS concentration from 0.03 ± 0.004 mg to 0.39 ± 0.11 mg (p < 0.001), a 13-fold enhancement. Further increasing the SDS concentration to 30% reduced V CIP6 and V CIP48 The V from the CPPB-LIM hydrogel did not increase further [0.002 ± 0.001 mg (p = 0.83) and 0.39 ± 0.29 mg (p = 0.94), respectively]. CIP6 and V CIP48 The effect of LIM on V was studied at LIM concentrations ranging from 0 to 10%, with 10% being the highest LIM concentration approved by the US FDA for topical application.

[64] Addition of 1% LIM did not significantly affect V CIP6 remained below the HPLC detection limit (Figure 16B); with 4% LIM it was 0.004 ± 0.001 mg and did not increase further with 10% LIM (0.004 ± 0.001 mg, p = 0.51). As the concentration of LIM was increased from 1% to 4%, V CIP48(Figure 15B) increased ~25-fold (from 0.02±0.004 mg to 0.40±0.13 mg, p=0.001); there was no further increase at 10% LIM (0.42±0.09 mg, p=0.73).

[0264] V CIP6 and V CIP48 Steady state was reached at 1% BUP concentration; at 5% supersaturation, the slurry flow was very similar. CIP6 (Figure 16C) shows that V is approximately 2±2 μg in 0.5% BUP and 5±3 μg in 1% and 5% BUP. CIP6 (Fig. 15C). CIP6 Although the results are comparable to those of other CPEs, the V CIP48 were much smaller than those from LIM or SDS. CIP48 was 0.03 mg at 1% BUP and 0.04±0.01 mg at 5%.

[0265] One interesting finding was that the combined effect between CPEs changed over time. The degree of enhancement from combining CPEs was much greater at 6 hours than at 48 hours, although the net drug permeation rates involved were much smaller. For example, the V achieved by the combination of 3 CPEs was much higher than that achieved by the combination of 1 CPE. CIP6 was 20 times that of 1% SDS, 10 times that of 0.5% BUP, and infinitely more than that of 2% LIM (the latter being below the HPLC detection limit), whereas V with 3CPE was CIP48 were 17, 2, and 37 times higher than those in 1% SDS, 0.5% BUP, and 2% LIM, respectively.

[0266] The net effect of the CPE combination far exceeds the peak effect of the individual CPEs (as determined by concentration-response curves), making it impossible to construct an isobologram.

[0267] The isobologram is CIP48 Constructed using CPE concentration -V CIP48The curves (Figures 15A-15C) were fitted to a three parameter hyperbolic function (the most common logistic function used for concentration-response curves

[73] ) to estimate the E of peak effect using the following equation: max It was determined that:[61,75]

number

[61] The Hill coefficient, derived from a drug's concentration-response curve, represents the number of interacting sites (e.g., the number of ligands bound to a receptor).

[76] In the context of CPEs, the molecular correlate of the Hill coefficient is unclear, but can be determined by fitting the data to equation (1):

[0268] E max Values ​​were calculated using nonlinear least squares regression to determine the CPE concentration-V CIP48 The curves were obtained for SDS, LIM, and BUP by fitting them to Equation (1) (Figure 17 and Table 5). SDS had an E of 0.65 mg. max This means that the maximum V that can be achieved by SDS CIP48 However, the same V CIP48 ~0.4 mg, and the calculated E max SDS at 20% and 30% achieved concentrations at which E = 0.4 mg / ml was obtained. max Used for. Table 5. Concentration-response curves with fitted parameters for SDS, LIM, and BUP. [Table 5] a From equation (1); b Experimentally derived

[0269] LIM is 0.41 mg E max The permeation enhancing effect reached a plateau at a LIM concentration of approximately 4%. BUP had the smallest E max (0.04 mg). max was 9.76% of that of LIM and 6.15% of that of SDS. The effect of BUP on Cip permeation reached a plateau at a concentration of ~1%.

[0270] Combination of two CPEs To assess whether synergy occurs between CPEs, their effect on drug flux across the TM was analyzed by the method of isobolograms. The concentration-response curves above identified two factors that complicate the use of this approach: 1) for some of the CPEs, physicochemical factors (e.g., solubility) limiting the achievable CPE concentration would prevent the determination of the peak effect, and 2) the maximal effects of the individual CPEs were quite different. In such situations, an isobologram could be constructed using a specific absolute effect (e.g., a given drug permeability).

[18] When comparing a drug with a low maximal effect to one with a large maximal effect (e.g., BUP and LIM in this case, or glucosamine and ibroprofen

[34] ), the line of additivity would be parallel to the axis representing the drug with the lower maximal effect[61,77] (i.e., the concentration of that drug would not achieve the given absolute effect).

[0271] V of 0.39 mg CIP48 was used as the "effect" for the isobol analysis of synergy between CPEs. Both CPPB-4%LIM and CPPB-20%SDS had their V CIP48(Fig. 3A and B, p=0.96), therefore 4% LIM and 20% SDS were considered equivalent doses. An isobologram (Fig. 15D) with the concentration of LIM on the X-axis and the concentration of SDS on the Y-axis was constructed as previously discussed, and each equivalent dose (4% LIM and 20% SDS) was plotted on their respective axes. The line connecting the two is the line of additivity (isobol); it can be described using the following equation [60,61]

number

number

[0272] The line connecting the axes in the isobol graph (FIG. 15D), plotted according to equation (3), represents the V CIP48 This represents all combinations of LIM and SDS that would produce a response of 0.39 mg V. Experimentally, CPPB-1%SDS-1%LIM, a combination of a 5% SDS equivalent dose (i.e., 5% of 20% SDS) and a 25% LIM equivalent dose (25% of 4% LIM), produced a V of 0.4 mg V. CIP48 , i.e., a 14-fold response over 1% SDS and a 28-fold response over 1% LIM. The point representing this combination is below the line of additivity (i.e.

number

[0273] SDS and BUP also interacted synergistically (Figure 15E). Calculations similar to equations (1)-(3) were applied to the combination of SDS and BUP (see the discussion below, section "Equations used in the analysis of isobolograms of SDS-BUP and LIM-BUP"). To reduce the number of animals required to identify equivalent doses and combinations, the responses achieved using a formulation of CPPB-1% SDS-1% BUP were first measured, and then equivalent doses were identified using concentration-response curves (Figures 15A and 15C). V for CPPB-1% SDS-1% BUP CIP48 The concentration-response (i.e., CPE-drug flux) curve for SDS (Figure 15A) showed a V of 0.24 ± 0.07 mg for 10% SDS (in CPPB-10% SDS). CIP48 It was added that the results were achieved (Figure 15A). CIP48 The concentration of BUP required to achieve E = 0.24 mg was infinity ( max [BUP]=0.04 mg, Table 5). The combination of 1% SDS and 1% BUP, containing a 10% SDS equivalent dose (10% of 10% SDS) and a 0% BUP equivalent dose, was 8-fold greater than the 1% SDS and 8-fold greater than the 1% BUP, V CIP48 = ~0.24 mg.

[0274] 0.24mg V CIP48 The isobol (i.e., line of additivity) for the combination of SDS and BUP to achieve a V of 0.24 mg was a straight line parallel to the BUP axis and intersected the SDS axis at 10% (Figure 15E). CIP48 The point representing the combination of SDS and BUP that achieved this (CPPB-1% SDS-1% BUP) was well below Isobol, indicating a strong synergistic effect between SDS and BUP.

[0275] LIM and BUP also had a synergistic effect. Calculations similar to equations (1)-(3) were applied to the combination of LIM and BUP (see the discussion below, section "Equations used in the analysis of isobolograms of SDS-BUP and LIM-BUP"). In addition, the response achieved using a formulation of CPPB-1% LIM-1% BUP was first measured, and then the equivalent dose was identified using a concentration-response curve. V for CPPB-1% LIM-1% BUP CIP48 The V was 0.22 mg. CIP48 To achieve a V of 0.22 mg, ∼1.8% LIM was required (Figure 15B). CIP48 The amount of BUP required to achieve this was infinite (E max [BUP]=0.04 mg, Table 5). Thus, the isobol lines for LIM and BUP were parallel to the BUP axis and intersected the LIM axis at 1.8% (FIG. 15F). The CPPB-1% LIM-1% BUP formulation, containing 56% of the LIM equivalent dose (56% of 1.8% LIM) and 0% of the BUP equivalent dose, produced a V CIP48 = 0.22 mg. The dot representing the combination of LIM and BUP fell below the Isobol line, indicating synergy.

[0276] As a further demonstration of synergy, we calculated the combination index (CI), defined as in equations (4)-(7). The CI compares the doses of two drugs (numerator) that produce a given effect in an experimentally measured combination with the doses (denominator) that would be expected to produce the same effect if there was additivity.[16,19,20] A CI<1 indicates synergy; the lower the CI, the greater the synergy.

[0277] Combining SDS and LIM:

number

number

number

number

[0278] Regarding the combination of SDS and BUP:

number

[0279] Regarding the combination of LIM and BUP:

number

[0280] The CIs for all pairs of CPEs indicated strong synergistic effects.

[0281] Discussion. Equations used in the analysis of isobolograms of SDS-BUP and LIM-BUP CPPB-10% SDS is V CIP48= 0.24mg, but its V CIP48 Because the amount of BUP required to achieve this was infinite, CIP48 The isobol for equivalent doses of SDS and BUP that achieved =0.24 mg can be described using equations (S1) and (S2). Thus,

number

number

number

number

[0282] Combination of 3 CPEs Synergy between three components has rarely been analyzed; here, the concept of synergy is extended from a two-component system (e.g., between LIM and BUP) to three components by plotting the isobolograms as planes (Figure 18A). When used alone, a V of 0.4 mg CIP48 The concentrations of CPE required to achieve this were ∼20% for SDS (Figure 15A), ∼4% for LIM (Figure 15B), and infinity for BUP (E max[BUP]=0.04 mg, Table 1). Thus, the isobol plane intersected the axes representing SDS and LIM at 20% and 4%, and was parallel to the BUP axis (FIG. 18A). A combination of three CPEs, CPPB-3CPE (i.e., 2% LIM, 1% SDS, and 0.5% BUP, corresponding to a 5% SDS-equivalent dose (5% of 20% SDS), a 50% LIM-equivalent dose (50% of 4% LIM), and a 0% BUP-equivalent dose), achieved a Cip flux of 0.43±0.02 mg. V CIP48 The point representing CPPB-3CPE at =0.43 mg was well below the isobol plane (Figure 18A), suggesting synergy. The CI for the 3CPE combination was not calculated because a CI value <1 would indicate synergy between two of the three CPEs, rather than synergy between all three CPEs.

[0283] Effect of CPE combinations on peak efficacy The study of synergy by the method of isobolograms is concerned with determining interactions between drugs and establishing, for example, whether a given effect can be achieved with smaller amounts of two drugs rather than one. A related but different question is whether the use of a combination of agents can achieve a greater peak effect than could ever be achieved with either single agent alone. In the context of transtympanic delivery of antibiotics using CPE, the maximum achievable peak effect is of great interest for rapid clearance of infection.

[78]

[0284] To address this issue, we investigated whether combining concentrations of individual CPEs that provided maximal flux (i.e., reached plateau) would increase maximal flux (Figure 18B). From Figure 15, the peak V CIP48 were achieved in 4% LIM (0.40 ± 0.13 mg), 20% SDS (0.39 ± 0.11 mg), and 1% BUP (0.03 ± 0.01 mg), respectively. CIP48The combination of CPPC-4% LIM-1% BUP-20% SDS provided a V of 2.37 ± 0.78 mg. CIP48 It achieves the highest E from any of the individual CPEs. max was six times greater than that of the control (Fig. 18B).

[0285] Consideration It has been formally demonstrated that CPEs have a synergistic effect on drug flux across the TM, and that combinations of CPEs can increase maximal flux beyond that which can be achieved by any single CPE concentration. It is hypothesized that a similar phenomenon will be observed in the structurally similar skin, and in other settings where CPEs have been shown to be effective.

[79]

[0286] There were two major barriers to transport for this transtympanic drug delivery platform: 1) diffusion through the bulk hydrogel matrix and 2) permeation across the TM. The similarity between the release profiles of Cip from aqueous solution and from CPPB (Figure 13) indicated minimal diffusion resistance within the bulk hydrogel matrix. Incorporating 3CPE slowed down the rate of diffusion, suggesting the possibility of additional physical crosslinking as a result of interactions between SDS / LIM and PBP end groups.

[0287] SDS, LIM, and BUP increased TM permeability in proportion to the CPE concentration (Figure 15). Interestingly, the enhancing effect of each CPE relative to the others was different at 6 and 48 hours. For example, BUP increased the maximum V achieved by SDS or LIM. CIP6 However, the maximum V from SDS or LIM was approximately twice as high. CIP48 was roughly 10-fold that of BUP. The contrast between the short-term (6 h) and long-term (48 h) permeation enhancing effects suggested that BUP may have a different mechanism of permeation enhancement from existing CPEs such as SDS and LIM.

[0288] There was significant synergy between the CPEs. Synergy could be used to reduce the total amount of CPE used, which would achieve some desired goal (such as reducing tissue irritation or reducing the viscosity of the formulation) while maintaining the same or greater permeation enhancement. BUP, while not the most effective CPE by itself, dramatically increased the permeation enhancement of SDS and LIM. Interestingly, the synergy of CPEs changed over time, i.e., the combination of 3 CPEs increased drug flux more significantly at 6 hours than at 48 hours. The greatly enhanced drug flux during the early phase of antibiotic treatment is likely important in accelerating the time course of healing. Clinical evidence indicates that early eradication of pathogens from the middle ear improves clinical outcomes.

[80]

[0289] A related but different need is to achieve a greater peak effect than can be achieved with any single agent alone. A greater peak effect is particularly desirable in the context of transtympanic drug delivery of antibiotics to improve therapeutic efficacy. The combination of three CPEs at concentrations that provide the greatest feasible effect when used alone achieved a significant enhancement of drug penetration.

[0290] conclusion In summary, strong synergy between SDS, BUP, and LIM was demonstrated by isobologram analysis and combination index. The analysis was extended to demonstrate strong synergy when all three CPEs were used together. Combination of CPEs may also improve the peak effect on drug flux. References [Table 6-1] [Table 6-2] [Table 6-3] [Table 6-4] [Table 6-5] [Table 6-6] [Table 6-7] [Table 6-8]

[0291] Equivalent and Scope In the claims, articles such as "a," "an," and "the" may mean one or more than one, unless indicated to the contrary or otherwise clear from the context. A claim or description including "or" between one or more members of a group is deemed to be satisfied when one, more than one, or all of the members of the group are present in, employed in, or otherwise relevant to a given product or process, unless indicated to the contrary or otherwise clear from the context. The present disclosure includes embodiments in which exactly one member of a group is present in, employed in, or otherwise relevant to a given product or process. The present disclosure includes embodiments in which more than one or all of the members of a group are present in, employed in, or otherwise relevant to a given product or process.

[0292] Furthermore, the disclosure covers all variations, combinations, and permutations in which one or more limitations, elements, clauses, or descriptive terms from one or more enumerated claims are introduced into another claim. For example, any claim, when dependent on another claim, may be modified to include one or more limitations found in any other claim dependent on the same claim on which it is based. Where elements are presented as a list, for example in Markush group format, each subgroup of elements is also disclosed, and any element(s) may be removed from the group. In general, when the disclosure or aspects of the disclosure are referred to as including specific elements and / or features, it should be understood that certain embodiments of the disclosure or aspects of the disclosure consist of or consist essentially of such elements and / or features. For the sake of brevity, those embodiments have not been specifically described in these terms (in haec verba) herein. It should also be noted that the terms "comprising" and "containing" are intended to be open and allow for the inclusion of additional elements or steps. Where ranges are given, the endpoints are included. Furthermore, unless so indicated or otherwise apparent from the context and / or the understanding of one of ordinary skill in the art, values ​​expressed as ranges can assume any particular value or subrange within the range stated in various aspects of this disclosure down to one tenth of the unit of the lower limit of that range, unless the context clearly dictates otherwise.

[0293] This application refers to various issued patents, published patent applications, academic literature, and other publications, all of which are incorporated herein by reference. If there is a conflict between any of the incorporated references and this specification, this specification will control. In addition, any specific aspects of this disclosure that fall within the scope of the prior art may be expressly excluded from any one or more claims. Such aspects may be excluded even if the exclusion is not expressly expressed herein because they are deemed known to those of skill in the art. Any specific aspects of this disclosure may be excluded from any claim for any reason, whether or not involving the existence of prior art.

[0294] Those skilled in the art will recognize or be able to ascertain, with no more than routine experimentation, many equivalents to the specific embodiments described herein. The embodiments described herein are not intended to be limited to the above description, but rather as set forth in the appended claims. Those skilled in the art will appreciate that various changes and modifications to this description may be made without departing from the spirit or scope of the present disclosure, as defined in the following claims.

Claims

1. The composition comprises: (a) a therapeutic agent or combination of therapeutic agents; (b) a permeation enhancer or combination of permeation enhancers, where the permeation enhancer or combination of permeation enhancers increases the flux of a therapeutic agent or combination of therapeutic agents across a barrier; and (c) a matrix-forming agent or combination of matrix-forming agents, where the matrix-forming agent or combination of matrix-forming agents comprises a polymer; Including, where: The composition forms a gel at a temperature above the phase transition temperature; and The phase transition temperature is less than about 37°C; wherein the composition comprises between about 0.5-20.0% wt / vol of a permeation enhancer which is sodium dodecyl sulfate; wherein the composition comprises between about 0.5-7.5% wt / vol of a permeation enhancer, one of the therapeutic agents being bupivacaine; wherein the composition comprises between about 0.5-12.0% wt / vol of a permeation enhancer, which is limonene; and wherein the composition comprises between about 9.0-20.0% wt / vol of a polymer that is poloxamer 407-poly(butoxy) phosphoester; and wherein the composition optionally further comprises between about 0.01-0.50% wt / vol of another therapeutic agent which is a local anesthetic.

2. below: (a) a therapeutic agent or combination of therapeutic agents; (b) a permeation enhancer or combination of permeation enhancers, where the permeation enhancer or combination of permeation enhancers increases the flux of a therapeutic agent or combination of therapeutic agents across a barrier; and (c) a matrix-forming agent or combination of matrix-forming agents, where the matrix-forming agent or combination of matrix-forming agents comprises a polymer; Including, where: The composition forms a gel at a temperature above the phase transition temperature; and The phase transition temperature is less than about 37°C; wherein the composition comprises between about 0.5-5.5% wt / vol of a permeation enhancer which is sodium dodecyl sulfate; wherein the composition comprises between about 0.5-7.5% wt / vol of a permeation enhancer, one of the therapeutic agents being bupivacaine; wherein the composition comprises between about 0.5-10.0% wt / vol of a permeation enhancer that is limonene; and wherein the composition comprises between about 9.0-19.0% wt / vol of a polymer that is poloxamer 407-poly(butoxy) phosphoester; and 10. The composition of claim 1, wherein the composition comprises between about 0.01-0.50% wt / vol of a local anesthetic that is a sodium channel blocker.

3. below: (a) a therapeutic agent or combination of therapeutic agents; (b) a permeation enhancer or combination of permeation enhancers, where the permeation enhancer or combination of permeation enhancers increases the flux of a therapeutic agent or combination of therapeutic agents across a barrier; and (c) a matrix-forming agent or combination of matrix-forming agents, where the matrix-forming agent or combination of matrix-forming agents comprises a polymer; Contains, where: The composition forms a gel at a temperature above the phase transition temperature; and The phase transition temperature is less than about 37°C; wherein the composition comprises between about 0.5-5.5% wt / vol of a permeation enhancer which is sodium dodecyl sulfate; wherein the composition comprises between about 0.5-1.5% wt / vol of a permeation enhancer which is bupivacaine; wherein the composition comprises between about 2.0-12.0% wt / vol of a permeation enhancer, which is limonene; and 10. The composition of claim 1, wherein the composition comprises between about 9.0-19.0% wt / vol of the polymer that is poloxamer 407-poly(butoxy)phosphoester.

4. Conditions (i), (ii), and (iii): (i) the composition can be extruded through soft catheters ranging in size from 16 gauge to 24 gauge and from 1 inch to 5.25 inches and the composition remains liquid; (ii) the phase transition temperature of the composition is greater than about 15° C. and less than about 37° C.; and (iii) at 37° C., the storage modulus of the composition is greater than about 300 Pa, and the storage modulus is greater than the loss modulus of the composition; The composition according to any one of claims 1 to 3, wherein at least one of the following is satisfied.

5. 2. The composition of claim 1, wherein in condition (i), the flexible catheter is an 18 gauge, 1.88 inch flexible catheter.

6. 6. The composition according to claim 4, wherein condition (i) is met.

7. The composition according to any one of claims 4 to 6, wherein condition (ii) is met.

8. The composition according to any one of claims 4 to 7, wherein condition (iii) is met.

9. The composition of any one of claims 2 or 4 to 8, wherein the sodium channel blocker is a site 1 sodium channel blocker.

10. 10. The composition of claim 9, wherein the site 1 sodium channel blocker is tetrodotoxin.

11. 11. The composition of claim 10, wherein the composition comprises between about 0.03-0.30% wt / vol tetrodotoxin.

12. 12. The composition of claim 10 or 11, wherein the composition comprises about 0.3% wt / vol tetrodotoxin.

13. The composition of any one of claims 1 to 12, wherein the composition comprises between about 0.5 and 5.0% wt / vol sodium dodecyl sulfate.

14. 14. The composition of claim 13, wherein the composition comprises about 1.0% wt / vol sodium dodecyl sulfate.

15. 14. The composition of claim 13, wherein the composition comprises about 5.0% wt / vol sodium dodecyl sulfate.

16. 16. The composition of any one of claims 1 to 15, wherein the composition comprises between about 0.5 and 1.25% wt / vol bupivacaine.

17. 16. The composition of any one of claims 1 to 15, wherein the composition comprises between about 1.75 and 7.5% wt / vol bupivacaine.

18. 18. The composition of any one of claims 1 to 15 or 17, wherein the composition comprises about 2.0 to 7.5% wt / vol bupivacaine.

19. 20. The composition of claim 18, wherein the composition comprises about 2.0% wt / vol bupivacaine.

20. The composition of claims 1-19, wherein the composition comprises about 1.0% wt / vol bupivacaine.

21. 21. The composition of any one of claims 1 to 20, wherein the composition comprises between about 4.0 and 10.0% wt / vol limonene.

22. 21. The composition of any one of claims 1 to 20, wherein the composition comprises about 0.5 to 3.5% wt / vol limonene.

23. 23. The composition of any one of claims 1 to 20 or 22, wherein the composition comprises about 2.0% wt / vol limonene.

24. 22. The composition of any one of claims 1 to 21, wherein the composition comprises about 4.0% wt / vol limonene.

25. 22. The composition of any one of claims 1 to 21, wherein the composition comprises about 10.0% wt / vol limonene.

26. 26. The composition of any one of claims 1 to 25, wherein the composition comprises between about 10.0 and 15.0% wt / vol of poloxamer 407-poly(butoxy)phosphoester.

27. 27. The composition of claim 26, wherein the composition comprises about 10.0% wt / vol of poloxamer 407-poly(butoxy)phosphoester.

28. 27. The composition of claim 26, wherein the composition comprises about 12.0% wt / vol of poloxamer 407-poly(butoxy)phosphoester.

29. 27. The composition of claim 26, wherein the composition comprises about 15.0% wt / vol of poloxamer 407-poly(butoxy)phosphoester.

30. 30. The composition of any one of claims 1 to 29, wherein the therapeutic agent is an antibiotic agent, an anesthetic agent, an anti-inflammatory agent, an analgesic agent, an anti-fibrotic agent, an anti-sclerotic agent, an anticoagulant agent, or a diagnostic agent.

31. Antibiotics include ciprofloxacin, cefuroxime, cefadroxil, cefazolin, cephalothin, cephalexin, cefaclor, cefamandole, cefoxitin, cefprozil, cefuroxime, cefixime, cefdinir, ceftidoren, cefoperazone, cefotaxime, cefpodoxime, ceftazidime, ceftibuten, ceftizoxime, ceftriaxone, cefepime, ceftobiprole, enoxacin, gatifloxacin, levofloxacin, merofloxacin, moxifloxacin, norfloxacin, ofloxacin, trovafloxacin, bacitracin, colistin, polymyxin B, and azithromycin.

31. The composition of claim 30, wherein the medicament is selected from the group consisting of thromycin, clarithromycin, dirithromycin, erythromycin, roxithromycin, troleandomycin, telithromycin, spectinomycin, amoxicillin, ampicillin, azlocillin, carbenicillin, cloxacillin, dicloxacillin, flucloxacillin, mezlocillin, methicillin, nafcillin, oxacillin, penicillin, piperacillin, ticarcillin, mafenide, sulfacetamide, sulfamethizole, sulfasalazine, sulfisoxazole, trimethoprim, and trimethoprim-sulfamethoxazole.

32. 32. The composition of claim 30 or 31, wherein the antibiotic agent is ciprofloxacin.

33. 33. The composition of claim 32, wherein the composition comprises between about 1.0-5.0% wt / vol ciprofloxacin.

34. 31. The composition of claim 30, wherein the anesthetic agent is selected from the group consisting of bupivacaine, tetracaine, procaine, proparacaine, propoxycaine, dimethocaine, cyclomethycaine, chloroprocaine, benzocaine, lidocaine, prilocaine, levobupivacaine, ropivacaine, dibucaine, articaine, carticaine, etidocaine, mepivacaine, piperocaine, and trimecaine.

35. 35. The composition of any one of claims 1, 3-30 or 34, wherein the therapeutic agent comprises the anesthetic agent bupivacaine and a sodium channel blocker anesthetic agent.

36. 36. The composition of claim 35, wherein the anesthetic is tetrodotoxin.

37. Anti-inflammatory agents include acetylsalicylic acid, aloxypurine, benorylate, choline magnesium trisalicylate, diflunisal, ethenzamide, phythramine, methyl salicylate, magnesium salicylate, salicylic acid salicylate, salicylamide, diclofenac, aceclofenac, acemetacin, alclofenac, bromfenac, etodolac, indomethacin, nabumetone, oxamethacin, proglumetacin, sulindac, tolmetin, ibroprofen, aluminoprofen, benoxaprofen, carprofen, dexibuprofen, dexketoprofen, fenbufen, fenoprofen, flunoxaprofen, flurbiprofen, ibuproxam, indoprofen, ketoprofen, ketorolac, loxoprofen 31. The composition of claim 30, wherein the active ingredient is selected from the group consisting of phen, naproxen, oxaprozin, pirprofen, suprofen, tiaprofenic acid, mefenamic acid, flufenamic acid, meclofenamic acid, tolfenamic acid, phenylbutazone, ampirone, azapropazone, clofezone, kebuzone, metamizole, mofebutazone, oxyphenbutazone, phenazone, phenylbutazone, sulfinpyrazone, piroxicam, droxicam, lornoxicam, meloxicam, tenoxicam, hydrocortisone, cortisone acetate, prednisone, prednisolone, methylprednisolone, dexamethasone, betamethasone, triamcinolone, beclomethasone, fludrocortisone acetate, deoxycorticosterone acetate, and aldosterone.

38. The composition of any one of claims 1 to 37, further comprising an additional therapeutic agent.

39. 40. The composition of claim 38, wherein the additional therapeutic agent is an anesthetic agent.

40. 40. The composition of claim 39, wherein the anesthetic is a local anesthetic.

41. 41. The composition of claim 39 or 40, wherein the anesthetic is bupivacaine.

42. 40. The composition of claim 38, wherein the additional therapeutic agent is an anti-inflammatory agent.

43. 43. The composition of claim 42, wherein the anti-inflammatory agent is dexamethasone.

44. 40. The composition of claim 38, wherein the additional therapeutic agent is a beta-lactamase inhibitor.

45. The composition comprises: sodium dodecyl sulfate between about 1.0 and 5.0% wt / vol; bupivacaine between about 0.5 and 1.0% wt / vol; Between about 4.0 and 10.0% wt / vol limonene; and Poloxamer 407-poly(butoxy)phosphoester between about 12.0 and 15.0% wt / vol The composition of any one of claims 1 to 44, comprising:

46. The composition comprises: (1) about 1.0% wt / vol sodium dodecyl sulfate; about 0.5% wt / vol bupivacaine; about 2.0% wt / vol limonene; and about 12.0% wt / vol poloxamer 407-poly(butoxy)phosphoester; (2) about 1.0% wt / vol sodium dodecyl sulfate; about 1.0% wt / vol bupivacaine; about 10.0% wt / vol limonene; and about 12.0% wt / vol poloxamer 407-poly(butoxy)phosphoester; (3) about 1.0% wt / vol sodium dodecyl sulfate; about 1.0% wt / vol bupivacaine; about 10.0% wt / vol limonene; and about 15.0% wt / vol poloxamer 407-poly(butoxy)phosphoester; (4) about 5.0% wt / vol sodium dodecyl sulfate; about 1.0% wt / vol bupivacaine; about 4.0% wt / vol limonene; and about 12.0% wt / vol poloxamer 407-poly(butoxy)phosphoester; or (5) about 5.0% wt / vol sodium dodecyl sulfate; about 1.0% wt / vol bupivacaine; about 4.0% wt / vol limonene; and about 15.0% wt / vol poloxamer 407-poly(butoxy)phosphoester. The composition of any one of claims 1 to 45, comprising:

47. The composition comprises: sodium dodecyl sulfate between about 0.5 and 5.0% wt / vol; bupivacaine between about 0.5 and 7.5% wt / vol; limonene between approximately 0.5 and 3.5% wt / vol; between about 9.0 and 15.0% wt / vol of poloxamer 407-poly(butoxy)phosphoester; and Another therapeutic agent is the sodium channel blocker anesthetic agent tetrodotoxin, between about 0.01-0.50% wt / vol. The composition of any one of claims 1 to 44, comprising:

48. 45. The composition of any one of claims 1-44, wherein the composition comprises the following: about 1.0% wt / vol sodium dodecyl sulfate; about 2.0% wt / vol bupivacaine; about 2.0% wt / vol limonene; about 12.0% wt / vol poloxamer 407-poly(butoxy)phosphoester; and about 0.3% wt / vol of another therapeutic agent that is the sodium channel blocker anesthetic agent tetrodotoxin.

49. A pharmaceutical composition comprising the composition of any one of claims 1 to 48 and, optionally, a pharma- ceutically acceptable excipient.

50. 50. The pharmaceutical composition of claim 49, wherein the pharmaceutical composition comprises a therapeutically effective amount of the composition for use in treating a disease or disorder in a subject in need thereof.

51. 51. A method of treating a disease or disorder in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of a composition according to any one of claims 1 to 48, or a pharma- ceutically acceptable salt, solvate, hydrate, tautomer, or stereoisomer thereof, or a pharmaceutical composition according to claim 49 or 50.

52. 51. The pharmaceutical composition of claim 50, wherein the disease is pain.

53. 53. The pharmaceutical composition of claim 50 or 52, wherein the disease is pain associated with an infectious disease.

54. 53. The pharmaceutical composition of claim 50 or 52, wherein the disease is an ear disease or pain associated with a bacterial infection.

55. 51. The pharmaceutical composition of claim 50, wherein the disease is an infectious disease.

56. 51. The pharmaceutical composition of claim 50, wherein the disease is an ear disease or a bacterial infection.

57. 57. The pharmaceutical composition of any one of claims 54 or 56, wherein the bacterial infection is an infection with H. influenzae, S. pneumoniae, or M. catarrhalis.

58. 56. The pharmaceutical composition of claim 50 or 55, wherein the infectious disease is otitis media.

59. 52. The method of claim 51, wherein the disease is pain.

60. 60. The method of claim 59, wherein the disease is pain associated with an infectious disease.

61. 60. The method of claim 59, wherein the disease is pain associated with an ear disease or a bacterial infection.

62. 62. The method of any one of claims 59 to 61, wherein the method comprises continuous treatment of pain.

63. 52. The method of claim 51, wherein the disease is an infectious disease.

64. 52. The method of claim 51, wherein the disease is an ear disease.

65. 52. The method of claim 51, wherein the disease is a bacterial infection.

66. 66. The method of claim 61 or 65, wherein the bacterial infection is an infection with H. influenzae, S. pneumoniae, or M. catarrhalis.

67. 64. The method of claim 60 or 63, wherein the infectious disease is otitis media.

68. 49. A method of eradicating a biofilm comprising administering to a subject in need thereof a composition according to any one of claims 1 to 48.

69. 50. A method of delivering a composition according to any one of claims 1 to 48, the method comprising administering the composition to the ear canal of a subject.

70. 70. The method of claim 69, wherein the composition contacts the surface of the tympanic membrane.

71. 70. The method of claim 69, wherein administering comprises placing drops of the composition into the ear canal or placing a dose of the composition into the ear canal using a catheter.

72. 70. The method of claim 69, wherein administering comprises placing the composition into the ear canal using an applicator.

73. 70. The method of claim 69, wherein administering comprises administering the composition to the ear canal without a local anesthetic.

74. The following may be administered: administering the composition to the ear canal in the presence of a local anesthetic; and Administering the composition to the ear canal without a local anesthetic 70. The method of claim 69, comprising:

75. 75. The method of any one of claims 69, 73 or 74, wherein administering comprises placing the composition into the ear canal with a double-barrel syringe.

76. 51. Use of a composition for the treatment and / or prevention of a disease or disorder in a subject in need thereof, the use comprising administering to the subject a therapeutically effective amount of the composition according to any one of claims 1 to 48, or a pharma- ceutically acceptable salt, solvate, hydrate, tautomer, or stereoisomer thereof, or a pharmaceutical composition according to claim 49 or 50.

77. 50. A kit for treating an ear disease and / or a condition associated with an ear disease, comprising a container, a composition according to any one of claims 1 to 48, and instructions for administering the composition to a subject in need thereof.

78. 78. The kit of claim 77, further comprising a dropper, syringe, or catheter.

79. 78. The kit of claim 77, further comprising a double-barrel syringe.

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